Preferred Drug List - Passportpassporthealthplan.com/wp-content/uploads/2014/12/Evolent-Passport... · If a drug is not covered by Passport or is not listed on our Preferred Drug

PASS-13169 APP_2/10/2014

Preferred Drug List (List of Covered Drugs)

This document includes Passport Health Plan’s complete 2017 formulary.

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

• Be a Passport member;

• Need a drug that is medically necessary;

• GettheprescriptionfilledataPassportHealthPlannetworkpharmacy.AnetworkpharmacyisonethatissignedupwithPassport;and

• FollowallPassportrules(seelimitsbelow).

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

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

www.passporthealthplan.com.

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

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

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

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

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

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

1. Workwithyourpharmacyorprovidertofindthepreferreddrug.

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

3. IfadrugisnotcoveredbyPassportorisnotlistedonourPreferredDrugList,yourdoctorcanrequestapproval for it.

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

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

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

DRUG TIERTier 1 = Generic

Tier 2 = Preferred Brand

Tier 3 = Non-Preferred Brand

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

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

print, audio, accessible electronic formats)

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

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

race, color, national origin, age, disability or sex

• Exclude people or treat them differently because of race, color, national origin, age, disability or sex

If you need any of these services listed above, you may contact:Tracy Bertram, Director of Compliance5100 Commerce Crossings DriveLouisville, KY 40229(502) 212-6767 | Fax: (502) 585-7985 | [email protected]

If you believe Passport has not provided these services or has discriminated against you, you may file a grievance. You can file a grievance by contacting Tracy Bertram. You may file in person or by mail, fax or email. If you need help filing a grievance, Tracy Bertram can help you.

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

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

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

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

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

PASS73355 APP_3/3/2017

PASS73355 APP_3/3/2017

PASS73355 APP_3/3/2017

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

1

LIST OF COVERED PRESCRIPTION MEDICATIONS Effective 10/01/2017 Drug Name Drug Tier Requirements/LimitsANALGESICS ANALGESICS, OTHER acetaminophen suppos 650 mg 1 OTC apap rapid tab tab 80mg 1 OTC chld asafree elx 80/2.5ml 1 OTC eql acetamin tab 160mg 1 OTC fever reduce sup 120mg 1 OTC FEVERALL INF SUP 80MG 2 OTC feverall sup 325mg 1 OTC 8 hour pain tab 650mg 1 OTC inf silapap dro 80/0.8ml 1 OTC little remed liq 160/5ml 1 OTC OFIRMEV INJ 10MG/ML 3 PA pain relief dro 80/0.8ml 1 OTC pain relief liq 500/15ml 1 OTC pain relief sus 160/5ml 1 OTC pain relief tab 325mg 1 OTC pain relief tab 500mg 1 OTC pain relieve chw 160mg jr 1 OTC pain relievr chw 80mg 1 OTC sm pain rel cap 500mg 1 OTC COX-II INHIBITORS CELEBREX CAP 50MG 3 PA, ST CELEBREX CAP 100MG 3 PA, ST CELEBREX CAP 200MG 3 PA, ST CELEBREX CAP 400MG 3 PA, ST celecoxib cap 50 mg 1 PA, ST celecoxib cap 100 mg 1 PA, ST celecoxib cap 200 mg 1 PA, ST celecoxib cap 400 mg 1 PA, ST GOUT allopurinol tab 100 mg 1 allopurinol tab 300 mg 1 ALOPRIM INJ 500MG 3 colchicine cap 0.6 mg 1 QL (60 caps / 30 days) colchicine tab 0.6 mg 1 QL (60 tabs / 30 days) colchicine w/ probenecid tab 0.5-500 mg 1 probenecid tab 500 mg 1 ULORIC TAB 40MG 2 QL (30 tabs / 30 days) ULORIC TAB 80MG 2 ZURAMPIC TAB 200MG 3 QL (30 tabs / 30 days),

ST


2

Drug Name Drug Tier Requirements/Limits MISCELLANEOUS CARTICEL IMP 3 PA clonidine hcl inj (for epidural infusion) 100

mcg/ml 1

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

1

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

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

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

1 QL (180 caps / 25 days)

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

1 QL (180 tabs / 25 days)

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

1

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

PA FIORICET CAP 3 QL (180 caps / 25

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

mg/5ml 1

choline & magnesium salicylates tab 1000 mg

1

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

mg 1

diclofenac sodium tab delayed release 50 mg

1

diclofenac sodium tab delayed release 75 mg

1

diclofenac sodium tab er 24hr 100 mg 1


3

Drug Name Drug Tier Requirements/Limits diflunisal tab 500 mg 1 DYLOJECT INJ 37.5MG/M 3 PA EC-NAPROSYN TAB 375MG 3 PA, ST EC-NAPROSYN TAB 500MG 3 PA, ST etodolac cap 200 mg 1 etodolac cap 300 mg 1 etodolac tab 400 mg 1 etodolac tab 500 mg 1 etodolac tab er 24hr 400 mg 1 etodolac tab er 24hr 500 mg 1 etodolac tab er 24hr 600 mg 1 FELDENE CAP 10MG 3 PA, ST FELDENE CAP 20MG 3 PA, ST fenoprofen calcium cap 400 mg 1 fenoprofen calcium tab 600 mg 1 FENORTHO CAP 200MG 3 PA flurbiprofen tab 50 mg 1 flurbiprofen tab 100 mg 1 ibuprofen cap 200 mg 1 OTC ibuprofen dro 50/1.25 1 OTC ibuprofen jr chw 100mg 1 OTC ibuprofen susp 100 mg/5ml 1 ibuprofen tab 200 mg 1 OTC ibuprofen tab 400 mg 1 ibuprofen tab 600 mg 1 ibuprofen tab 800 mg 1 INDOCIN SUP 50MG 3 ST indomethacin cap 25 mg 1 indomethacin cap 50 mg 1 indomethacin cap er 75 mg 1 QL (90 caps / 30 days) ketoprofen cap 50 mg 1 ketoprofen cap 75 mg 1 ketoprofen cap er 24hr 200 mg 1 ketorolac tromethamine tab 10 mg 1 QL (5 days per fill) meclofenamate sodium cap 50 mg 1 meclofenamate sodium cap 100 mg 1 mefenamic acid cap 250 mg 1 meloxicam tab 7.5 mg 1 meloxicam tab 15 mg 1 MOBIC TAB 7.5MG 3 PA, ST MOBIC TAB 15MG 3 PA, ST nabumetone tab 500 mg 1 nabumetone tab 750 mg 1 NALFON CAP 400MG 3 ST NAPRELAN TAB 375MG CR 3 PA, ST NAPRELAN TAB 500MG CR 3 PA, ST


4

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

(base equiv) 1

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

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

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

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

PA diclofenac w/ misoprostol tab delayed

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

PA diclofenac w/ misoprostol tab delayed

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

PA DUEXIS TAB 800-26.6 3 ST inflammacin mis 75-0.025 1 PA


5

Drug Name Drug Tier Requirements/Limits MELOXICAM KIT COMFORT 3 PA NAPROXEN KIT COMFORT 3 PA VIMOVO TAB 375-20MG 3 ST VIMOVO TAB 500-20MG 3 ST NSAIDS, TOPICAL diclofenac sodium gel 1% 1 diclofenac sodium soln 1.5% 1 DS PREP PAK PAK 1%-0.13% 3 PA FLECTOR DIS 1.3% 3 QL (30 ptch / 25 days),

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

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





ST acetaminophen w/ codeine soln 120-12

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

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

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

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






alfentanil inj 500 mcg/ml 1 ALFENTANIL INJ 500/ML 3 PA ascomp/cod cap 30mg 1 QL (180 caps / 30 days)


6

Drug Name Drug Tier Requirements/Limits aspirin-caffeine-dihydrocodeine cap 356.4-

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

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







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

equiv) 1

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

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

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


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

ST codeine sulfate tab 15 mg 1 QL (720 tabs / 30 days) codeine sulfate tab 30 mg 1 QL (360 tabs / 30 days) codeine sulfate tab 60 mg 1 QL (180 tabs / 30 days) CONZIP CAP 100MG 3 QL (90 caps / 25 days),

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

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

PA DEMEROL INJ 25MG/0.5 3 ST DEMEROL INJ 25MG/ML 3 PA, ST


7

Drug Name Drug Tier Requirements/Limits DEMEROL INJ 50MG/ML 3 PA, ST DEMEROL INJ 75MG/1.5 3 ST DEMEROL INJ 75MG/ML 3 ST DEMEROL INJ 100/2ML 3 ST DEMEROL INJ 100MG/ML 3 PA, ST DEMEROL TAB 100MG 3 QL (180 tabs / 30 days),

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

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



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

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

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

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



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

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

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

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



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

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

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

PA


8

Drug Name Drug Tier Requirements/Limits EXALGO TAB 16MG 3 QL (60 tabs / 30 days),

PA EXALGO TAB 32MG 3 QL (30 tabs / 30 days),

PA fentanyl citrate lozenge on a handle 200

mcg 1 QL (180 lpop / 25 days)

fentanyl citrate lozenge on a handle 400 mcg

1 QL (90 lpop / 25 days)









fentanyl citrate pf soln cartridge 100 mcg/2ml

1

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

1


1


1


1


1

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



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





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

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


9

Drug Name Drug Tier Requirements/Limits FENTORA TAB 400MCG 3 QL (90 tabs / 25 days),

ST FENTORA TAB 600MCG 3 QL (60 tabs / 25 days),

ST FENTORA TAB 800MCG 3 QL (30 tabs / 25 days),

ST FIORICET CAP CODEINE 3 QL (360 caps / 25

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

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

PA, ST hydrocodone-acetaminophen soln 7.5-325

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

hydrocodone-acetaminophen soln 10-325 mg/15ml

1 PA

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

mg 1 QL (360 tabs / 25 days)

hydrocodone-acetaminophen tab 7.5-325 mg


hydrocodone-acetaminophen tab 10-300 mg


hydrocodone-acetaminophen tab 10-325 mg


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

inj 10 mg/ml 1

hydromorphone hcl tab 2 mg 1 QL (480 tabs / 30 days) hydromorphone hcl tab 4 mg 1 QL (240 tabs / 30 days) hydromorphone hcl tab 8 mg 1 QL (120 tabs / 30 days) hydromorphone hcl tab er 24hr deter 8 mg 1 QL (120 tabs / 30 days) hydromorphone hcl tab er 24hr deter 12


hydromorphone hcl tab er 24hr deter 16 mg


hydromorphone hcl tab er 24hr deter 32 mg


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

HYSINGLA ER TAB 30 MG 3 QL (120 tabs / 25 days), PA


10

Drug Name Drug Tier Requirements/Limits HYSINGLA ER TAB 40 MG 3 QL (90 tabs / 25 days),

PA HYSINGLA ER TAB 60 MG 3 QL (60 tabs / 25 days),




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

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

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

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

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





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

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

days), ST LAZANDA SPR 400MCG 3 QL (120 sprays / 25

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

ST meperidine hcl inj 10 mg/ml 1 meperidine hcl inj 25 mg/ml 1 meperidine hcl inj 50 mg/ml 1 meperidine hcl inj 100 mg/ml 1 meperidine hcl oral soln 50 mg/5ml 1 QL (1800 ml / 30 days) meperidine hcl tab 50 mg 1 QL (360 tabs / 30 days)


11

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

mg 1 QL (30 caps / 25 days)

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

PA morphine sulfate cap er 24hr 80 mg 1 QL (30 caps / 25 days) morphine sulfate cap er 24hr 100 mg 1 QL (30 caps / 25 days) morphine sulfate inj 8 mg/ml 1 morphine sulfate inj 10 mg/ml 1 morphine sulfate inj 15 mg/ml 1 morphine sulfate inj pf 0.5 mg/ml 1 PA morphine sulfate inj pf 1 mg/ml 1 PA morphine sulfate iv soln 1 mg/ml 1 morphine sulfate iv soln 25 mg/ml 1 morphine sulfate iv soln 50 mg/ml 1 morphine sulfate iv soln pf 4 mg/ml 1 morphine sulfate iv soln pf 8 mg/ml 1 morphine sulfate iv soln pf 10 mg/ml 1 morphine sulfate iv soln pf 15 mg/ml 1 morphine sulfate oral soln 10 mg/5ml 1 QL (1800 ml / 30 days) morphine sulfate oral soln 20 mg/5ml 1 QL (900 ml / 30 days) morphine sulfate oral soln 100 mg/5ml (20

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

PA


12

Drug Name Drug Tier Requirements/Limits morphine sulfate suppos 5 mg 1 morphine sulfate suppos 10 mg 1 morphine sulfate suppos 20 mg 1 morphine sulfate tab 15 mg 1 QL (240 tabs / 30 days) morphine sulfate tab 30 mg 1 QL (120 tabs / 30 days) morphine sulfate tab er 15 mg 1 QL (240 tabs / 25 days),

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




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





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

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

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

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

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




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

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

ST


13

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

ST OPANA ER TAB 5MG 3 QL (240 tabs / 30 days),

PA OPANA ER TAB 7.5MG 3 QL (150 tabs / 30 days),

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





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

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

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

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

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

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

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

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



PA oxycodone w/ acetaminophen soln 5-325

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


14

Drug Name Drug Tier Requirements/Limits oxycodone w/ acetaminophen tab 5-325


oxycodone w/ acetaminophen tab 7.5-325 mg


oxycodone w/ acetaminophen tab 10-325 mg


oxycodone-aspirin tab 4.8355-325 mg 1 QL (360 tabs / 30 days) oxycodone-ibuprofen tab 5-400 mg 1 QL (240 tabs / 30 days) OXYCONTIN TAB 10MG CR 2 QL (240 tabs / 30 days),

PA OXYCONTIN TAB 15MG CR 2 QL (150 tabs / 30 days),






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

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

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





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

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

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

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

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

ST


15

Drug Name Drug Tier Requirements/Limits PRIMLEV TAB 7.5-300 3 QL (300 tabs / 25 days),

ST PRIMLEV TAB 10-300MG 3 QL (240 tabs / 25 days),

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

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

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

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

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




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

mcg/ml) 1 PA

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

1 PA

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

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

100 mg 1 QL (90 caps / 25 days)

tramadol hcl cap er 24hr biphasic release 200 mg


tramadol hcl cap er 24hr biphasic release 300 mg


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

100 mg 1 QL (90 tabs / 25 days)

tramadol hcl tab er 24hr biphasic release 200 mg


tramadol hcl tab er 24hr biphasic release 300 mg


tramadol-acetaminophen tab 37.5-325 mg 1 QL (300 tabs / 30 days)


16

Drug Name Drug Tier Requirements/Limits TYLENOL/COD TAB #3 3 QL (360 tabs / 30 days),

PA, ST TYLENOL/COD TAB #4 3 QL (180 tabs / 30 days),

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

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

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

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

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

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

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

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

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

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

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

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

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



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

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

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


17

Drug Name Drug Tier Requirements/Limits SUPARTZ INJ 25/2.5ML 3 PA ANTI-INFECTIVES AMINOGLYCOSIDES amikacin sulfate inj 1 gm/4ml (250 mg/ml)1 amikacin sulfate inj 500 mg/2ml (250

mg/ml) 1

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

mg/ml) (base equiv) 1

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

1

tobramycin sulfate inj 10 mg/ml (base equivalent)

1

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

1

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

250 mg 1

imipenem-cilastatin intravenous for soln 500 mg

1

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


18

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


19

Drug Name Drug Tier Requirements/Limits cefuroxime axetil tab 250 mg 1 cefuroxime axetil tab 500 mg 1 CEFUROXIME INJ 7.5GM 2 CEFUROXIME INJ 75GM 3 cefuroxime sodium for inj 1.5 gm 1 cefuroxime sodium for inj 7.5 gm 1 cefuroxime sodium for inj 750 mg 1 cefuroxime sodium for iv soln 1.5 gm 1 ZINACEF INJ 1.5GM 3 PA ZINACEF INJ 7.5GM 3 PA ZINACEF INJ 750MG 3 PA ZINACEF/H20 INJ 1.5GM PB 3 PA ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN cefdinir cap 300 mg 1 cefdinir for susp 125 mg/5ml 1 cefdinir for susp 250 mg/5ml 1 cefditoren pivoxil tab 200 mg (base

equivalent) 1

cefditoren pivoxil tab 400 mg (base equivalent)

1

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


20

Drug Name Drug Tier Requirements/Limits ceftriaxone sodium in dextrose inj 20

mg/ml 1

ceftriaxone sodium in dextrose inj 40 mg/ml

1

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

ST


21

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

SUSP 200 MG/5ML 1

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

cap 250 mg 1

PCE TAB 333MG EC 3 PA PCE TAB 500MG EC 3 PA ZMAX SUS 2GM 3 ANTIBACTERIALS, FLUOROQUINOLONES AVELOX INJ 2 ciprofloxacin 200 mg/100ml in d5w 1 ciprofloxacin 400 mg/200ml in d5w 1 ciprofloxacin hcl tab 100 mg (base equiv) 1 QL (60 tabs / 30 days) ciprofloxacin hcl tab 250 mg (base equiv) 1 QL (60 tabs / 30 days) ciprofloxacin hcl tab 500 mg (base equiv) 1 QL (60 tabs / 30 days) ciprofloxacin hcl tab 750 mg (base equiv) 1 QL (60 tabs / 30 days) ciprofloxacin iv soln 200 mg/20ml (1%) 1 ciprofloxacin iv soln 400 mg/40ml (1%) 1 ciprofloxacin-ciprofloxacin hcl tab er 24hr

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

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


FACTIVE TAB 320MG 3 QL (7 tabs per fill) levofloxacin in d5w iv soln 250 mg/50ml 1 levofloxacin in d5w iv soln 500 mg/100ml 1 levofloxacin in d5w iv soln 750 mg/150ml 1 levofloxacin iv soln 25 mg/ml 1 levofloxacin oral soln 25 mg/ml 1 levofloxacin tab 250 mg 1 QL (30 tabs / 30 days) levofloxacin tab 500 mg 1 QL (30 tabs / 30 days) levofloxacin tab 750 mg 1 QL (30 tabs / 30 days) moxifloxacin hcl tab 400 mg (base equiv) 1 QL (30 tabs / 30 days) MOXIFLOXACIN INJ 3 ofloxacin tab 400 mg 1 ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab 200-

28.5 mg 1


22

Drug Name Drug Tier Requirements/Limits amoxicillin & k clavulanate chew tab 400-

57 mg 1

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

1


1

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

1


1

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

1000-62.5 mg 1

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

mg/5ml 1

amoxicillin (trihydrate) for susp 200 mg/5ml

1


1


1

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

(1-0.5) gm 1

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

1

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

1

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

1

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


23

Drug Name Drug Tier Requirements/Limits ampicillin sodium for iv soln 1 gm 1 ampicillin sodium for iv soln 10 gm 1 AUGMENTIN SUS 125/5ML 3 BACTOCILL INJ DEX 1GM 3 BACTOCILL INJ DEX 2GM 3 BICILLIN C-R INJ 900/300 3 PA BICILLIN C-R INJ 1200000 3 PA BICILLIN L-A INJ 600000 3 PA BICILLIN L-A INJ 1200000 3 PA BICILLIN L-A INJ 2400000 3 PA dicloxacillin sodium cap 250 mg 1 dicloxacillin sodium cap 500 mg 1 MOXATAG TAB 775MG 3 PA NAFCILLIN INJ 1GM/50ML 3 NAFCILLIN INJ 2GM/100 3 nafcillin sodium for inj 1 gm 1 nafcillin sodium for inj 2 gm 1 nafcillin sodium for inj 10 gm 1 nafcillin sodium for iv soln 1 gm 1 nafcillin sodium for iv soln 2 gm 1 oxacillin sodium for inj 1 gm 1 oxacillin sodium for inj 2 gm 1 oxacillin sodium for inj 10 gm 1 PEN G PROC INJ 600000 3 PENICILL GK/ INJ DEX 1MU 3 PA PENICILL GK/ INJ DEX 2MU 3 PA PENICILL GK/ INJ DEX 3MU 3 PA penicillin g potassium for inj 5000000 unit 1 penicillin g potassium for inj 20000000 unit1 penicillin g sodium for inj 5000000 unit 1 penicillin v potassium for soln 125 mg/5ml 1 penicillin v potassium for soln 250 mg/5ml 1 penicillin v potassium tab 250 mg 1 penicillin v potassium tab 500 mg 1 piperacillin sod-tazobactam na for inj 3.375

gm (3-0.375 gm) 1

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

1


1


1

UNASYN INJ 1.5GM 3 PA UNASYN INJ 3GM 3 PA UNASYN INJ 15GM 3 PA ZOSYN INJ 2-0.25GM 3 PA


24

Drug Name Drug Tier Requirements/Limits ZOSYN INJ 3-0.375G 3 PA ZOSYN INJ 4-0.5GM 3 PA ZOSYN INJ 36-4.5GM 3 PA ZOSYN SOL 2-0.25GM 3 PA ZOSYN SOL 3-0.375G 3 PA ZOSYN SOL 4-0.50GM 3 PA ANTIBACTERIALS, SULFONAMIDES BACTRIM DS TAB 800-160 3 PA BACTRIM TAB 400-80MG 3 PA sulfamethoxazole-trimethoprim iv soln

400-80 mg/5ml 1

sulfamethoxazole-trimethoprim susp 200-40 mg/5ml

1

sulfamethoxazole-trimethoprim tab 400-80 mg

1

sulfamethoxazole-trimethoprim tab 800-160 mg

1

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

mg 1 PA

doxycycline hyclate tab delayed release 100 mg

1 PA

doxycycline hyclate tab delayed release 150 mg

1 PA

doxycycline monohydrate cap 50 mg 1 doxycycline monohydrate cap 75 mg 1 doxycycline monohydrate cap 100 mg 1 doxycycline monohydrate cap 150 mg 1


25

Drug Name Drug Tier Requirements/Limits doxycycline monohydrate for susp 25

mg/5ml 1

doxycycline monohydrate tab 50 mg 1 doxycycline monohydrate tab 75 mg 1 doxycycline monohydrate tab 150 mg 1 MINOCIN CAP 50MG 3 PA MINOCIN CAP 75MG 3 PA MINOCIN CAP 100MG 3 PA MINOCIN INJ 100MG 3 PA minocycline hcl cap 50 mg 1 minocycline hcl cap 75 mg 1 minocycline hcl cap 100 mg 1 minocycline hcl tab 50 mg 1 minocycline hcl tab 75 mg 1 minocycline hcl tab 100 mg 1 minocycline hcl tab er 24hr 45 mg 1 minocycline hcl tab er 24hr 90 mg 1 minocycline hcl tab er 24hr 135 mg 1 MONODOX CAP 75MG 3 PA MONODOX CAP 100MG 3 PA MORGIDOX KIT 1X100MG 3 ST MORGIDOX KIT 2X100MG 3 ST SOLODYN TAB 55MG 3 ST SOLODYN TAB 65MG 3 ST SOLODYN TAB 80MG 3 ST SOLODYN TAB 105MG 3 ST SOLODYN TAB 115MG 3 ST tetracycline hcl cap 250 mg 1 tetracycline hcl cap 500 mg 1 VIBRAMYCIN CAP 100MG 3 PA, ST VIBRAMYCIN SUS 25MG/5ML 3 PA, ST VIBRAMYCIN SYP 50MG/5ML 3 ST ANTIFUNGALS ABELCET INJ 5MG/ML 3 PA AMBISOME INJ 50MG 3 PA amphotericin b for inj 50 mg 1 CANCIDAS INJ 50MG 2 CANCIDAS INJ 70MG 2 clotrimazole troche 10 mg 1 CRESEMBA CAP 186 MG 3 QL (100 days per 365

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

days), PA DIFLUCAN SUS 10MG/ML 3 PA, ST DIFLUCAN SUS 40MG/ML 3 PA, ST


26

Drug Name Drug Tier Requirements/Limits DIFLUCAN TAB 50MG 3 QL (10 tabs / 25 days),

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



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

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

ST nystatin oral powder 1 nystatin susp 100000 unit/ml 1 nystatin tab 500000 unit 1 ONMEL TAB 200MG 3 QL (30 tabs / 30 days),

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

ST


27

Drug Name Drug Tier Requirements/Limits SPORANOX CAP 100MG 3 QL (60 caps / 30 days),

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

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

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

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

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

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

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

mg 1

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

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

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

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

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

ATRIPLA TAB 2 QL (30 tabs / 30 days) COMBIVIR TAB 150-300 3 QL (60 tabs / 30 days),

PA COMPLERA TAB 2 QL (30 tabs / 30 days) GENVOYA TAB 2 PA lamivudine-zidovudine tab 150-300 mg 1 QL (60 tabs / 30 days)


28

Drug Name Drug Tier Requirements/Limits ODEFSEY TAB 2 STRIBILD TAB 2 QL (30 tabs / 30 days) TRIUMEQ TAB 3 QL (30 tabs / 30 days) TRIZIVIR TAB 3 QL (60 tabs / 30 days),

PA TRUVADA TAB 200-300 2 QL (30 tabs / 30 days) ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY TAB 150MG 2 QL (60 tabs / 30 days),

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

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

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

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

PA TIVICAY TAB 10MG 2 QL (60 tabs / 30 days) TIVICAY TAB 25MG 2 QL (60 tabs / 30 days) TIVICAY TAB 50MG 2 QL (60 tabs / 30 days) ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG 2 QL (120 caps / 30 days) APTIVUS SOL 2 QL (300 / 30 days) CRIXIVAN CAP 200MG 2 QL (90 caps / 30 days) CRIXIVAN CAP 400MG 2 QL (180 caps / 30 days) INVIRASE CAP 200MG 2 QL (300 caps / 30 days) INVIRASE TAB 500MG 2 QL (120 tabs / 30 days) KALETRA SOL 3 QL (480 ml / 30 days) KALETRA TAB 100-25MG 2 QL (30 tabs / 30 days) KALETRA TAB 200-50MG 2 QL (120 tabs / 30 days) LEXIVA SUS 50MG/ML 2 QL (1680 ml / 25 days) LEXIVA TAB 700MG 2 QL (120 tabs / 30 days) lopinavir-ritonavir soln 400-100 mg/5ml

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

NORVIR CAP 100MG 2 QL (360 caps / 30 days) NORVIR SOL 80MG/ML 2 QL (480 ml / 25 days) NORVIR TAB 100MG 2 QL (360 tabs / 30 days) PREZISTA SUS 100MG/ML 2 QL (400 ml / 25 days) PREZISTA TAB 75MG 2 QL (60 tabs / 30 days) PREZISTA TAB 150MG 2 QL (60 tabs / 30 days) PREZISTA TAB 600MG 2 QL (60 tabs / 30 days) PREZISTA TAB 800MG 2 QL (60 tabs / 30 days)


29

Drug Name Drug Tier Requirements/Limits REYATAZ CAP 150MG 2 QL (30 caps / 30 days) REYATAZ CAP 200MG 2 QL (30 caps / 30 days) REYATAZ CAP 300MG 2 QL (30 caps / 30 days) VIRACEPT TAB 250MG 2 QL (270 tabs / 30 days) VIRACEPT TAB 625MG 2 QL (120 tabs / 30 days) ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NON-

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

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

PA ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS -

NUCLEOSIDE abacavir sulfate tab 300 mg (base equiv) 1 QL (60 tabs / 30 days) didanosine delayed release capsule 125 mg1 QL (60 caps / 30 days) didanosine delayed release capsule 200 mg1 QL (60 caps / 30 days) didanosine delayed release capsule 250 mg1 QL (30 caps / 30 days) didanosine delayed release capsule 400 mg1 QL (30 caps / 30 days) EMTRIVA CAP 200MG 2 QL (30 caps / 30 days) EMTRIVA SOL 10MG/ML 2 QL (720 / 25 days) EPIVIR TAB 150MG 3 QL (60 tabs / 30 days),

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

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

days), PA RETROVIR SYP 50MG/5ML 3 QL (1800 / 30 days), PA stavudine cap 15 mg 1 QL (60 caps / 30 days) stavudine cap 20 mg 1 QL (60 caps / 30 days) stavudine cap 30 mg 1 QL (60 caps / 30 days)


30

Drug Name Drug Tier Requirements/Limits stavudine cap 40 mg 1 QL (60 caps / 30 days) stavudine for oral soln 1 mg/ml 1 QL (2400 / 30 days) VIDEX EC CAP 125MG 3 QL (60 caps / 30 days),

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



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

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



PA ZERIT SOL 1MG/ML 3 QL (2400 / 30 days), PA ZIAGEN SOL 20MG/ML 2 QL (900 ml / 30 days) ZIAGEN TAB 300MG 3 QL (60 tabs / 30 days),

PA zidovudine cap 100 mg 1 QL (180 caps / 30 days) zidovudine syrup 10 mg/ml 1 QL (1800 / 30 days) zidovudine tab 300 mg 1 QL (60 tabs / 30 days) ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS -

NUCLEOTIDE VIREAD POW 40MG/GM 2 QL (240 / 30 days) VIREAD TAB 150MG 2 QL (30 tabs / 30 days) VIREAD TAB 200MG 2 QL (30 tabs / 30 days) VIREAD TAB 250MG 2 QL (30 tabs / 30 days) VIREAD TAB 300MG 2 QL (30 tabs / 30 days) ANTITUBERCULAR AGENTS CAPASTAT SUL INJ 1GM 3 PA cycloserine cap 250 mg 1 PA ethambutol hcl tab 100 mg 1 ethambutol hcl tab 400 mg 1 isoniazid inj 100 mg/ml 1 isoniazid syrup 50 mg/5ml 1 isoniazid tab 100 mg 1 isoniazid tab 300 mg 1 MYAMBUTOL TAB 400MG 3 PA PASER GRA 4GM 3 PA PRIFTIN TAB 150MG 2


31

Drug Name Drug Tier Requirements/Limits pyrazinamide tab 500 mg 1 RIFADIN CAP 150MG 3 PA RIFADIN CAP 300MG 3 PA RIFADIN INJ 600 MG 3 PA RIFAMATE CAP 3 PA rifampin cap 150 mg 1 rifampin cap 300 mg 1 rifampin for inj 600 mg 1 RIFATER TAB 3 PA SIRTURO TAB 100MG 2 TRECATOR TAB 250MG 3 PA ANTIVIRALS, CMV AGENTS cidofovir iv inj 75 mg/ml 1 CYTOVENE INJ 500MG 2 PA FOSCAVIR INJ 24MG/ML 3 PA ganciclovir sodium for inj 500 mg 1 valganciclovir hcl for soln 50 mg/ml (base

equiv) 1

valganciclovir hcl tab 450 mg (base equivalent)

1

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

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

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

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



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

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

PA


32

Drug Name Drug Tier Requirements/Limits MODERIBA PAK 600/DAY 3 QL (56 tabs / 25 days),

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



PA OLYSIO CAP 150MG 3 QL (30 caps / 30 days),

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

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

PA RIBAPAK PAK 600/DAY 2 QL (56 tabs / 25 days),




PA ribasphere tab 400mg 1 QL (56 tabs / 25 days) ribasphere tab 600mg 1 QL (56 tabs / 25 days) ribavirin cap 200 mg 1 QL (180 caps / 30 days) ribavirin tab 200 mg 1 QL (180 tabs / 30 days) SOVALDI TAB 400MG 3 QL (30 tabs / 30 days),

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

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

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

PA ZEPATIER TAB 50-100MG 2 QL (30 tabs / 30 days),

PA; Preferred for genotypes 1 and 4

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


33

Drug Name Drug Tier Requirements/Limits famciclovir tab 500 mg 1 QL (21 tabs / 25 days) FAMVIR TAB 125MG 3 QL (21 tabs / 25 days),

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

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

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

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

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

equiv) 1 QL (10 caps / 180 days)

oseltamivir phosphate cap 45 mg (base equiv)


oseltamivir phosphate cap 75 mg (base equiv)


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

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

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


34

Drug Name Drug Tier Requirements/Limits BILTRICIDE TAB 600MG 3 PA chloramphenicol sodium succinate for iv inj

1 gm 1

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

mg/5ml (base equiv) 1

clindamycin phosphate in d5w iv soln 300 mg/50ml

1


1


1

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


35

Drug Name Drug Tier Requirements/Limits linezolid in sodium chloride iv soln 600

mg/300ml-0.9% 1

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

mg/100ml 1

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

macrocrystalline cap 100 mg 1

nitrofurantoin susp 25 mg/5ml 1 PENTAM 300 INJ 300MG 3 PA PIN-X CHW 250MG 2 OTC polymyxin b sulfate for inj 500000 unit 1 PRIMSOL SOL 50MG/5ML 3 PA reeses med sus pinworm 1 OTC rifabutin cap 150 mg 1 SIVEXTRO INJ 200MG 3 QL (6 / 25 days), PA SIVEXTRO TAB 200MG 3 QL (6 tabs / 25 days),

PA SYNERCID INJ 500MG 3 PA TINDAMAX TAB 500MG 3 PA tinidazole tab 250 mg 1 tinidazole tab 500 mg 1 trimethoprim tab 100 mg 1 TYGACIL INJ 50MG 2 VANCOCIN HCL CAP 125MG 3 PA, ST VANCOCIN HCL CAP 250MG 3 PA, ST VANCOMYC/DEX INJ 1GM 2 VANCOMYC/DEX INJ 500MG 2 VANCOMYC/DEX INJ 750MG 2 vancomycin hcl cap 125 mg 1 vancomycin hcl cap 250 mg 1 vancomycin hcl for inj 10 gm 1 vancomycin hcl for inj 500 mg 1


36

Drug Name Drug Tier Requirements/Limits vancomycin hcl for inj 1000 mg 1 vancomycin hcl for inj 5000 mg 1 VANCOMYCIN INJ 750MG 1 VIBATIV INJ 250MG 3 PA VIRAZOLE INH 6GM 3 PA XIFAXAN TAB 200MG 3 QL (9 tabs / 30 days),

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

PA ZYVOX SOL 2MG/ML 3 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN INJ 50MG 3 PA ALKERAN TAB 2MG 3 BENDEKA INJ 100/4ML 3 PA BICNU INJ 100MG 2 BUSULFEX INJ 6MG/ML 2 carboplatin iv soln 50 mg/5ml 1 carboplatin iv soln 150 mg/15ml 1 carboplatin iv soln 450 mg/45ml 1 carboplatin iv soln 600 mg/60ml 1 cisplatin inj 50 mg/50ml (1 mg/ml) 1 cisplatin inj 100 mg/100ml (1 mg/ml) 1 cisplatin inj 200 mg/200ml (1 mg/ml) 1 cyclophosphamide for inj 1 gm 1 cyclophosphamide for inj 2 gm 1 cyclophosphamide for inj 500 mg 1 dacarbazine for inj 100 mg 1 dacarbazine for inj 200 mg 1 EMCYT CAP 140MG 2 GLEOSTINE CAP 5MG 2 GLEOSTINE CAP 10MG 2 GLEOSTINE CAP 40MG 2 GLEOSTINE CAP 100MG 2 GLIADEL WAF 7.7MG 3 PA HEXALEN CAP 50MG 2 IFEX INJ 1GM 3 PA IFEX INJ 3GM 3 PA ifosfamide for inj 1 gm 1 ifosfamide iv inj 1 gm/20ml (50 mg/ml) 1 ifosfamide iv inj 3 gm/60ml (50 mg/ml) 1 LEUKERAN TAB 2MG 2 melphalan hcl for inj 50 mg (base equiv) 1 melphalan tab 2 mg 1 MYLERAN TAB 2MG 2 oxaliplatin for iv inj 50 mg 1


37

Drug Name Drug Tier Requirements/Limits oxaliplatin for iv inj 100 mg 1 oxaliplatin iv soln 50 mg/10ml 1 oxaliplatin iv soln 100 mg/20ml 1 TEMODAR CAP 5MG 3 PA TEMODAR CAP 20MG 3 PA TEMODAR CAP 100MG 3 PA TEMODAR CAP 140MG 3 PA TEMODAR CAP 180MG 3 PA TEMODAR CAP 250MG 3 PA TEMODAR INJ 100MG 2 temozolomide cap 5 mg 1 temozolomide cap 20 mg 1 temozolomide cap 100 mg 1 temozolomide cap 140 mg 1 temozolomide cap 180 mg 1 temozolomide cap 250 mg 1 thiotepa for inj 15 mg 1 PA TREANDA INJ 25MG 2 TREANDA INJ 100MG 2 VALCHLOR GEL 0.016% 2 ZANOSAR INJ 1GM 2 ANTIMETABOLITES ALIMTA INJ 100MG 2 ALIMTA INJ 500MG 2 capecitabine tab 150 mg 1 capecitabine tab 500 mg 1 cladribine iv soln 10 mg/10ml (1 mg/ml) 1 cytarabine inj 20 mg/ml 1 cytarabine inj pf 20 mg/ml 1 cytarabine inj pf 100 mg/ml 1 DACOGEN INJ 50MG 3 PA decitabine for inj 50 mg 1 FLUDARA INJ 50MG 3 PA fludarabine phosphate for inj 50 mg 1 fludarabine phosphate inj 25 mg/ml 1 fluorouracil inj 1 gm/20ml (50 mg/ml) 1 fluorouracil inj 2.5 gm/50ml (50 mg/ml) 1 fluorouracil inj 5 gm/100ml (50 mg/ml) 1 fluorouracil inj 500 mg/10ml (50 mg/ml) 1 FOLOTYN INJ 20MG/ML 2 FOLOTYN INJ 40MG/2ML 2 gemcitabine hcl for inj 1 gm 1 gemcitabine hcl for inj 2 gm 1 gemcitabine hcl for inj 200 mg 1


38

Drug Name Drug Tier Requirements/Limits gemcitabine hcl inj 1 gm/26.3ml (38

mg/ml) (base equiv) 1

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

1

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

1

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

mg/ml) 1

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

1

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

1


1


1


1


1

methotrexate sodium tab 2.5 mg (base equiv)

1

PURIXAN SUS 20MG/ML 3 PA TABLOID TAB 40MG 2 TREXALL TAB 5MG 2 TREXALL TAB 7.5MG 2 TREXALL TAB 10MG 2 TREXALL TAB 15MG 2 XELODA TAB 150MG 3 PA XELODA TAB 500MG 3 PA HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide tab 50 mg 1 CASODEX TAB 50MG 3 PA flutamide cap 125 mg 1 nilutamide tab 150 mg 1 XTANDI CAP 40MG 2 QL (120 caps / 30 days) ZYTIGA TAB 250MG 2 QL (120 tabs / 30 days) HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FARESTON TAB 60MG 2 SOLTAMOX SOL 10MG/5ML 3 PA tamoxifen citrate tab 10 mg (base

equivalent) 1


39

Drug Name Drug Tier Requirements/Limits tamoxifen citrate tab 20 mg (base

equivalent) 1

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

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

PA TRELSTAR INJ 11.25MG 3 PA VANTAS KIT 50MG 2 QL (1 box / year), PA HORMONAL ANTINEOPLASTICS, PROGESTINS DEPO-PROVERA INJ 400/ML 2 MEGACE ORAL SUS 40MG/ML 3 PA megestrol acetate susp 40 mg/ml 1 megestrol acetate tab 20 mg 1 megestrol acetate tab 40 mg 1 IMMUNOMODULATORS POMALYST CAP 1MG 2 QL (21 caps / 21 days) POMALYST CAP 2MG 2 QL (21 caps / 21 days) POMALYST CAP 3MG 2 QL (21 caps / 21 days) POMALYST CAP 4MG 2 QL (21 caps / 21 days) REVLIMID CAP 2.5MG 2 QL (30 caps / 30 days) REVLIMID CAP 5MG 2 QL (30 caps / 30 days) REVLIMID CAP 10MG 2 QL (30 caps / 30 days) REVLIMID CAP 15MG 2 QL (30 caps / 30 days) REVLIMID CAP 20MG 2 QL (30 caps / 30 days) REVLIMID CAP 25MG 2 QL (30 caps / 30 days) THALOMID CAP 50MG 2 QL (30 caps / 30 days) THALOMID CAP 100MG 2 QL (30 caps / 30 days) THALOMID CAP 150MG 2 QL (60 caps / 30 days) THALOMID CAP 200MG 2 QL (60 caps / 30 days) KINASE INHIBITOR /AROMATASE INHIBITOR COMBINATIONS KISQALI 200 PAK FEMARA 2 QL (63 / 28), PA


40

Drug Name Drug Tier Requirements/Limits KISQALI 400 PAK FEMARA 2 QL (63 / 28), PA KISQALI 600 PAK FEMARA 2 QL (63 / 28), PA KINASE INHIBITORS AFINITOR DIS TAB 2MG 2 QL (30 / 30 days) AFINITOR DIS TAB 3MG 2 QL (30 / 30 days) AFINITOR DIS TAB 5MG 2 QL (30 / 30 days) AFINITOR TAB 2.5MG 2 QL (30 tabs / 30 days) AFINITOR TAB 5MG 2 QL (30 tabs / 30 days) AFINITOR TAB 7.5MG 2 QL (30 tabs / 30 days) AFINITOR TAB 10MG 2 QL (30 tabs / 30 days) ALECENSA CAP 150MG 2 QL (240 caps / 30

days), PA ALUNBRIG TAB 30MG 2 QL (180 / 30), PA BOSULIF TAB 100MG 2 QL (120 tabs / 30 days) BOSULIF TAB 500MG 2 QL (30 tabs / 30 days) CABOMETYX TAB 20MG 3 QL (30 tabs / 30 days),

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

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

PA CAPRELSA TAB 100MG 2 QL (60 tabs / 30 days) CAPRELSA TAB 300MG 2 QL (30 tabs / 30 days) COMETRIQ KIT 60MG 3 QL (1 box / 21 days), PA COMETRIQ KIT 100MG 3 QL (1 box / 21 days), PA COMETRIQ KIT 140MG 3 QL (1 box / 21 days), PA COTELLIC TAB 20MG 2 QL (63 tabs / 30 days),

PA GILOTRIF TAB 20MG 2 QL (30 tabs / 30 days) GILOTRIF TAB 30MG 2 QL (30 tabs / 30 days) GILOTRIF TAB 40MG 2 QL (30 tabs / 30 days) IBRANCE CAP 75MG 3 PA IBRANCE CAP 100MG 3 PA IBRANCE CAP 125MG 3 PA ICLUSIG TAB 15MG 2 QL (60 tabs / 30 days) ICLUSIG TAB 45MG 2 QL (30 tabs / 30 days) imatinib mesylate tab 100 mg (base

equivalent) 1 QL (90 tabs / 30 days)

imatinib mesylate tab 400 mg (base equivalent)


IMBRUVICA CAP 140MG 2 QL (120 caps / 30 days) INLYTA TAB 1MG 2 QL (180 tabs / 30 days) INLYTA TAB 5MG 2 QL (120 tabs / 30 days) IRESSA TAB 250MG 2 QL (30 tabs / 30 days) JAKAFI TAB 5MG 2 QL (60 tabs / 30 days) JAKAFI TAB 10MG 2 QL (60 tabs / 30 days)


41

Drug Name Drug Tier Requirements/Limits JAKAFI TAB 15MG 2 QL (60 tabs / 30 days) JAKAFI TAB 20MG 2 QL (60 tabs / 30 days) JAKAFI TAB 25MG 2 QL (60 tabs / 30 days) KISQALI TAB 200DOSE 2 QL (63 / 28), PA KISQALI TAB 400DOSE 2 QL (63 / 28), PA KISQALI TAB 600DOSE 2 QL (63 / 28), PA LENVIMA CAP 10 MG 3 QL (5 / 25 days), PA LENVIMA CAP 14 MG 3 QL (10 / 25 days), PA LENVIMA CAP 20 MG 3 QL (10 / 25 days), PA LENVIMA CAP 24 MG 3 QL (15 / 25 days), PA MEKINIST TAB 0.5MG 2 QL (30 tabs / 30 days) MEKINIST TAB 2MG 2 QL (30 tabs / 30 days) NEXAVAR TAB 200MG 2 QL (120 tabs / 30 days) RYDAPT CAP 25MG 2 QL (224 / 28), PA SPRYCEL TAB 20MG 2 QL (30 tabs / 30 days) SPRYCEL TAB 50MG 2 QL (30 tabs / 30 days) SPRYCEL TAB 70MG 2 QL (30 tabs / 30 days) SPRYCEL TAB 80MG 2 QL (30 tabs / 30 days) SPRYCEL TAB 100MG 2 QL (30 tabs / 30 days) SPRYCEL TAB 140MG 2 QL (30 tabs / 30 days) STIVARGA TAB 40MG 2 QL (84 tabs / 25 days) SUTENT CAP 12.5MG 2 QL (90 caps / 30 days) SUTENT CAP 25MG 2 QL (30 caps / 30 days) SUTENT CAP 50MG 2 QL (30 caps / 30 days) TAFINLAR CAP 50MG 2 QL (120 caps / 30 days) TAFINLAR CAP 75MG 2 QL (120 caps / 30 days) TAGRISSO TAB 40MG 2 QL (30 tabs / 30 days),

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

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

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

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

PA


42

Drug Name Drug Tier Requirements/Limits ZYKADIA CAP 150MG 2 QL (150 caps / 30

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

mg/ml) 1

DOCETAXEL INJ 20/0.5ML 3 PA DOCETAXEL INJ 20MG/2ML 3 DOCETAXEL INJ 80MG/2ML 3 PA DOCETAXEL INJ 80MG/8ML 3 DOCETAXEL INJ 140/7ML 3 DOCETAXEL INJ 160/8ML 3 DOCETAXEL INJ 160/16ML 3 DOCETAXEL INJ 200MG/20 3 DOCETAXEL INJ NON-ALCO 3 doxorubicin hcl for inj 10 mg 1 doxorubicin hcl for inj 50 mg 1 doxorubicin hcl inj 2 mg/ml 1 doxorubicin hcl liposomal inj (for iv

infusion) 2 mg/ml 1

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

mg/ml) 1

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

1

ERBITUX INJ 100MG 2 ERBITUX INJ 200MG 2 ERIVEDGE CAP 150MG 2 QL (30 caps / 30 days) ETHYOL INJ 500MG 2 PA


43

Drug Name Drug Tier Requirements/Limits etoposide cap 50 mg 1 etoposide inj 1 gm/50ml (20 mg/ml) 1 etoposide inj 100 mg/5ml (20 mg/ml) 1 etoposide inj 500 mg/25ml (20 mg/ml) 1 FARYDAK CAP 10MG 3 PA FARYDAK CAP 15MG 3 PA FARYDAK CAP 20MG 3 PA HALAVEN INJ 1MG/2ML 3 PA HERCEPTIN INJ 440MG 2 PA HYDREA CAP 500MG 3 PA hydroxyurea cap 500 mg 1 IDAMYCIN PFS INJ 5MG/5ML 3 PA IDAMYCIN PFS INJ 10/10ML 3 PA IDAMYCIN PFS INJ 20/20ML 3 PA idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 1 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 1 idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 1 ISTODAX INJ 10MG 2 IXEMPRA KIT INJ 15MG 2 IXEMPRA KIT INJ 45MG 2 JEVTANA INJ 60/1.5ML 3 PA KADCYLA INJ 100MG 2 PA KADCYLA INJ 160MG 2 PA KEYTRUDA INJ 100MG/4M 3 PA KEYTRUDA SOL 50MG 3 PA KYPROLIS SOL 60MG 3 PA leucovorin calcium for inj 50 mg 1 leucovorin calcium for inj 100 mg 1 leucovorin calcium for inj 200 mg 1 leucovorin calcium for inj 350 mg 1 leucovorin calcium for inj 500 mg 1 leucovorin calcium tab 5 mg 1 leucovorin calcium tab 10 mg 1 leucovorin calcium tab 15 mg 1 leucovorin calcium tab 25 mg 1 LEVOLEUCOVOR SOL 250MG/25 2 levoleucovorin calcium for iv inj 50 mg

(base equiv) 1

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

1

LONSURF TAB 15-6.14 3 PA LONSURF TAB 20-8.19 3 PA LYNPARZA CAP 50MG 3 QL (480 caps / 30

days), PA LYSODREN TAB 500MG 2 MARQIBO INJ 5MG/31ML 2


44

Drug Name Drug Tier Requirements/Limits MATULANE CAP 50MG 2 mesna inj 100 mg/ml 1 MESNEX INJ 1GM 3 PA MESNEX TAB 400MG 2 METASTRON INJ 3 PA mitomycin for iv soln 5 mg 1 mitomycin for iv soln 20 mg 1 mitomycin for iv soln 40 mg 1 mitoxantrone hcl inj conc 20 mg/10ml (2

mg/ml) 1

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

1

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

1

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

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

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

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

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

mg/ml) 1

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

PA RUBRACA TAB 300MG 3 QL (120 tabs / 30 days),

PA SYNRIBO INJ 3.5MG 3 PA TARGRETIN GEL 1% 2 TAXOTERE INJ 20MG/ML 3 PA TAXOTERE INJ 80MG/4ML 3 PA TENIPOSIDE INJ 50MG/5ML 2 tretinoin cap 10 mg 1


45

Drug Name Drug Tier Requirements/Limits TRISENOX SOL 10MG/10M 2 UNITUXIN INJ 3 PA VECTIBIX INJ 100MG 2 VECTIBIX INJ 400MG 2 VENCLEXTA TAB 10MG 2 QL (60 tabs / 30 days),

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

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

PA VENCLEXTA TAB START PK 2 QL (1 box in lifetime),

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

equiv) 1

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

1

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

10 mg 1

amlodipine besylate-benazepril hcl cap 5-10 mg

1


1


1


1


46

Drug Name Drug Tier Requirements/Limits amlodipine besylate-benazepril hcl cap 10-

40 mg 1

LOTREL CAP 5-10MG 3 PA, ST LOTREL CAP 5-20MG 3 PA, ST LOTREL CAP 10-20MG 3 PA, ST LOTREL CAP 10-40MG 3 PA, ST PRESTALIA TAB 3.5-2.5 3 ST PRESTALIA TAB 7-5MG 3 ST PRESTALIA TAB 14-10MG 3 ST TARKA TAB 1-240 CR 3 PA, ST TARKA TAB 2-180 CR 3 PA, ST TARKA TAB 2-240 CR 3 PA, ST TARKA TAB 4-240 CR 3 PA, ST trandolapril-verapamil hcl tab er 1-240 mg 1 trandolapril-verapamil hcl tab er 2-180 mg 1 trandolapril-verapamil hcl tab er 2-240 mg 1 trandolapril-verapamil hcl tab er 4-240 mg 1 ACE INHIBITOR/DIURETIC COMBINATIONS ACCURETIC TAB 10-12.5 3 PA, ST ACCURETIC TAB 20-12.5 3 PA, ST ACCURETIC TAB 20-25MG 3 PA, ST benazepril & hydrochlorothiazide tab 5-

6.25 mg 1

benazepril & hydrochlorothiazide tab 10-12.5 mg

1

benazepril & hydrochlorothiazide tab 20-12.5 mg

1

benazepril & hydrochlorothiazide tab 20-25 mg

1

captopril & hydrochlorothiazide tab 25-15 mg

1


1


1


1

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg

1

enalapril maleate & hydrochlorothiazide tab 10-25 mg

1

fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg

1

fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg

1

lisinopril & hydrochlorothiazide tab 10-12.5 mg

1


47

Drug Name Drug Tier Requirements/Limits lisinopril & hydrochlorothiazide tab 20-12.5

mg 1

lisinopril & hydrochlorothiazide tab 20-25 mg

1

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

mg 1

moexipril-hydrochlorothiazide tab 15-12.5 mg

1

moexipril-hydrochlorothiazide tab 15-25 mg

1

quinapril-hydrochlorothiazide tab 10-12.5 mg

1

quinapril-hydrochlorothiazide tab 20-12.5 mg

1

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


48

Drug Name Drug Tier Requirements/Limits EPANED SOL 1MG/ML 3 PA fosinopril sodium tab 10 mg 1 fosinopril sodium tab 20 mg 1 fosinopril sodium tab 40 mg 1 lisinopril tab 2.5 mg 1 lisinopril tab 5 mg 1 lisinopril tab 10 mg 1 lisinopril tab 20 mg 1 lisinopril tab 30 mg 1 lisinopril tab 40 mg 1 LOTENSIN TAB 10MG 3 PA, ST LOTENSIN TAB 20MG 3 PA, ST LOTENSIN TAB 40MG 3 PA, ST MAVIK TAB 1MG 3 PA, ST MAVIK TAB 2MG 3 PA, ST moexipril hcl tab 7.5 mg 1 moexipril hcl tab 15 mg 1 perindopril erbumine tab 2 mg 1 perindopril erbumine tab 4 mg 1 perindopril erbumine tab 8 mg 1 quinapril hcl tab 5 mg 1 quinapril hcl tab 10 mg 1 quinapril hcl tab 20 mg 1 quinapril hcl tab 40 mg 1 ramipril cap 1.25 mg 1 ramipril cap 2.5 mg 1 ramipril cap 5 mg 1 ramipril cap 10 mg 1 trandolapril tab 1 mg 1 trandolapril tab 2 mg 1 trandolapril tab 4 mg 1 VASOTEC TAB 2.5MG 3 PA, ST VASOTEC TAB 5MG 3 PA, ST VASOTEC TAB 10MG 3 PA, ST VASOTEC TAB 20MG 3 PA, ST ZESTRIL TAB 2.5MG 3 PA, ST ZESTRIL TAB 5MG 3 PA, ST ZESTRIL TAB 10MG 3 PA, ST ZESTRIL TAB 20MG 3 PA, ST ZESTRIL TAB 30MG 3 PA, ST ZESTRIL TAB 40MG 3 PA, ST ADRENOLYTICS, CENTRAL CATAPRES TAB 0.1MG 3 PA, ST CATAPRES TAB 0.2MG 3 PA, ST CATAPRES TAB 0.3MG 3 PA, ST


49

Drug Name Drug Tier Requirements/Limits CATAPRES-TTS DIS 0.1/24HR 3 PA, ST CATAPRES-TTS DIS 0.2/24HR 3 PA, ST CATAPRES-TTS DIS 0.3/24HR 3 PA, ST clonidine hcl tab 0.1 mg 1 clonidine hcl tab 0.2 mg 1 clonidine hcl tab 0.3 mg 1 clonidine hcl td patch weekly 0.1 mg/24hr 1 clonidine hcl td patch weekly 0.2 mg/24hr 1 clonidine hcl td patch weekly 0.3 mg/24hr 1 guanfacine hcl tab 1 mg 1 guanfacine hcl tab 2 mg 1 TENEX TAB 1MG 3 PA, ST TENEX TAB 2MG 3 PA, ST AGENTS FOR PHEOCHROMOCYTOMA DEMSER CAP 250MG 2 phenoxybenzamine hcl cap 10 mg 1 PHENTOLAMINE INJ 5MG 2 ALDOSTERONE RECEPTOR ANTAGONISTS ALDACTONE TAB 25MG 3 PA ALDACTONE TAB 50MG 3 PA ALDACTONE TAB 100MG 3 PA eplerenone tab 25 mg 1 eplerenone tab 50 mg 1 INSPRA TAB 25MG 3 PA INSPRA TAB 50MG 3 PA spironolactone tab 25 mg 1 spironolactone tab 50 mg 1 spironolactone tab 100 mg 1 ALPHA BLOCKERS CARDURA TAB 1MG 3 PA, ST CARDURA TAB 2MG 3 PA, ST CARDURA TAB 4MG 3 PA, ST CARDURA TAB 8MG 3 PA, ST doxazosin mesylate tab 1 mg 1 doxazosin mesylate tab 2 mg 1 doxazosin mesylate tab 4 mg 1 doxazosin mesylate tab 8 mg 1 MINIPRESS CAP 1MG 3 PA MINIPRESS CAP 2MG 3 PA MINIPRESS CAP 5MG 3 PA prazosin hcl cap 1 mg 1 prazosin hcl cap 2 mg 1 prazosin hcl cap 5 mg 1 terazosin hcl cap 1 mg 1 terazosin hcl cap 2 mg 1


50

Drug Name Drug Tier Requirements/Limits terazosin hcl cap 5 mg 1 terazosin hcl cap 10 mg 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER COMBINATIONS amlodipine besylate-olmesartan medoxomil

tab 5-20 mg 1 ST

amlodipine besylate-olmesartan medoxomil tab 5-40 mg

1 ST


1 ST


1 ST

amlodipine besylate-valsartan tab 5-160 mg








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

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



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

BLOCKER/DIURETIC COMBINATIONS amlodipine-valsartan-hydrochlorothiazide

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

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



51

Drug Name Drug Tier Requirements/Limits amlodipine-valsartan-hydrochlorothiazide

tab 10-160-12.5 mg 1 QL (30 tabs / 30 days)





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

EXFORGEH/5- TAB 160-25 3 QL (30 tabs / 30 days), PA, ST

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



olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg

1 ST

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

1 ST

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

1 ST

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

1 ST

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

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

tab 16-12.5 mg 1

candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg

1

candesartan cilexetil-hydrochlorothiazide tab 32-25 mg

1

DIOVAN HCT TAB 80/12.5 3 PA, ST DIOVAN HCT TAB 160-12.5 3 PA, ST


52

Drug Name Drug Tier Requirements/Limits DIOVAN HCT TAB 160-25MG 3 PA, ST DIOVAN HCT TAB 320-12.5 3 PA, ST DIOVAN HCT TAB 320-25MG 3 PA, ST EDARBYCLOR TAB 40-12.5 3 ST EDARBYCLOR TAB 40-25MG 3 ST HYZAAR TAB 50-12.5 3 PA, ST HYZAAR TAB 100-12.5 3 PA, ST HYZAAR TAB 100-25 3 PA, ST irbesartan-hydrochlorothiazide tab 150-

12.5 mg 1

irbesartan-hydrochlorothiazide tab 300-12.5 mg

1

losartan potassium & hydrochlorothiazide tab 50-12.5 mg

1

losartan potassium & hydrochlorothiazide tab 100-12.5 mg

1

losartan potassium & hydrochlorothiazide tab 100-25 mg

1

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

tab 20-12.5 mg 1 ST

olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg

1 ST

olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg

1 ST

telmisartan-hydrochlorothiazide tab 40-12.5 mg

1

telmisartan-hydrochlorothiazide tab 80-12.5 mg

1

telmisartan-hydrochlorothiazide tab 80-25 mg

1

valsartan-hydrochlorothiazide tab 80-12.5 mg

1


1

valsartan-hydrochlorothiazide tab 160-25 mg

1


1

valsartan-hydrochlorothiazide tab 320-25 mg

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND TAB 4MG 3 PA, ST ATACAND TAB 8MG 3 PA, ST ATACAND TAB 16MG 3 PA, ST


53

Drug Name Drug Tier Requirements/Limits ATACAND TAB 32MG 3 PA, ST AVAPRO TAB 75MG 3 PA, ST AVAPRO TAB 150MG 3 PA, ST AVAPRO TAB 300MG 3 PA, ST BENICAR TAB 5MG 3 PA, ST BENICAR TAB 20MG 3 PA, ST BENICAR TAB 40MG 3 PA, ST candesartan cilexetil tab 4 mg 1 candesartan cilexetil tab 8 mg 1 candesartan cilexetil tab 16 mg 1 candesartan cilexetil tab 32 mg 1 COZAAR TAB 25MG 3 PA, ST COZAAR TAB 50MG 3 PA, ST COZAAR TAB 100MG 3 PA, ST DIOVAN TAB 40MG 3 QL (60 tabs / 30 days),

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



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


54

Drug Name Drug Tier Requirements/Limits ADENOCARD INJ 12MG/4ML 3 PA adenosine iv soln 6 mg/2ml 1 adenosine iv soln 12 mg/4ml 1 amiodarone hcl inj 150 mg/3ml (50

mg/ml) 1 PA

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

1

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

1

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


55

Drug Name Drug Tier Requirements/Limits RYTHMOL SR CAP 325MG 3 PA RYTHMOL SR CAP 425MG 3 PA RYTHMOL TAB 225MG 3 PA sotalol hcl (afib/afl) tab 80 mg 1 sotalol hcl (afib/afl) tab 120 mg 1 sotalol hcl (afib/afl) tab 160 mg 1 SOTALOL HCL INJ 150/10ML 3 PA sotalol hcl tab 80 mg 1 sotalol hcl tab 120 mg 1 sotalol hcl tab 160 mg 1 sotalol hcl tab 240 mg 1 SOTYLIZE SOL 5MG/ML 3 PA XYLOCAINE INJ 2% 3 PA ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose 1 cholestyramine light powder packets 4 gm 1 cholestyramine powder 4 gm/dose 1 cholestyramine powder packets 4 gm 1 COLESTID GRA 5GM 3 PA, ST COLESTID POW 5GM 3 PA, ST COLESTID TAB 1GM 3 PA, ST colestipol hcl granule packets 5 gm 1 colestipol hcl granules 5 gm 1 colestipol hcl tab 1 gm 1 QUESTRAN POW 4GM 3 PA, ST QUESTRAN POW 4GM LITE 3 PA, ST WELCHOL PAK 3.75GM 3 ST WELCHOL TAB 625MG 3 ST ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg 1 PA ZETIA TAB 10MG 3 PA ANTILIPEMICS, FIBRATES ANTARA CAP 30MG 3 ST ANTARA CAP 90MG 3 ST choline fenofibrate cap dr 45 mg (fenofibric

acid equiv) 1

choline fenofibrate cap dr 135 mg (fenofibric acid equiv)

1

fenofibrate cap 50 mg 1 fenofibrate cap 150 mg 1 fenofibrate micronized cap 43 mg 1 fenofibrate micronized cap 67 mg 1 fenofibrate micronized cap 130 mg 1 fenofibrate micronized cap 134 mg 1 fenofibrate micronized cap 200 mg 1


56

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

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

equivalent) 1

atorvastatin calcium tab 20 mg (base equivalent)

1


1


1

CRESTOR TAB 5MG 3 PA, ST CRESTOR TAB 10MG 3 PA, ST CRESTOR TAB 20MG 3 PA, ST CRESTOR TAB 40MG 3 PA, ST ezetimibe-simvastatin tab 10-10 mg 1 PA ezetimibe-simvastatin tab 10-20 mg 1 PA ezetimibe-simvastatin tab 10-40 mg 1 PA


57

Drug Name Drug Tier Requirements/Limits ezetimibe-simvastatin tab 10-80 mg 1 PA fluvastatin sodium cap 20 mg 1 fluvastatin sodium cap 40 mg 1 fluvastatin sodium tab er 24 hr 80 mg 1 LESCOL XL TAB 80MG 3 PA, ST LIPITOR TAB 10MG 3 PA, ST LIPITOR TAB 20MG 3 PA, ST LIPITOR TAB 40MG 3 PA, ST LIPITOR TAB 80MG 3 PA, ST LIVALO TAB 1MG 3 ST LIVALO TAB 2MG 3 ST LIVALO TAB 4MG 3 ST lovastatin tab 10 mg 1 lovastatin tab 20 mg 1 lovastatin tab 40 mg 1 PRAVACHOL TAB 20MG 3 PA, ST PRAVACHOL TAB 40MG 3 PA, ST PRAVACHOL TAB 80MG 3 PA, ST pravastatin sodium tab 10 mg 1 pravastatin sodium tab 20 mg 1 pravastatin sodium tab 40 mg 1 pravastatin sodium tab 80 mg 1 rosuvastatin calcium tab 5 mg 1 ST rosuvastatin calcium tab 10 mg 1 ST rosuvastatin calcium tab 20 mg 1 ST rosuvastatin calcium tab 40 mg 1 ST simvastatin tab 5 mg 1 simvastatin tab 10 mg 1 simvastatin tab 20 mg 1 simvastatin tab 40 mg 1 simvastatin tab 80 mg 1 VYTORIN TAB 10-10MG 3 PA VYTORIN TAB 10-20MG 3 PA VYTORIN TAB 10-40MG 3 PA VYTORIN TAB 10-80MG 3 PA ZOCOR TAB 5MG 3 PA, ST ZOCOR TAB 10MG 3 PA, ST ZOCOR TAB 20MG 3 PA, ST ZOCOR TAB 40MG 3 PA, ST ZOCOR TAB 80MG 3 PA, ST ANTILIPEMICS, MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN

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

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

PA


58

Drug Name Drug Tier Requirements/Limits JUXTAPID CAP 20MG 2 QL (30 caps / 30 days),




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

6.25 mg 1

bisoprolol & hydrochlorothiazide tab 5-6.25 mg

1

bisoprolol & hydrochlorothiazide tab 10-6.25 mg

1

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

25 mg 1


59

Drug Name Drug Tier Requirements/Limits metoprolol & hydrochlorothiazide tab 100-

25 mg 1

metoprolol & hydrochlorothiazide tab 100-50 mg

1

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

25 mg 1

propranolol & hydrochlorothiazide tab 80-25 mg

1

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


60

Drug Name Drug Tier Requirements/Limits CORGARD TAB 80MG 3 PA, ST esmolol hcl inj 100 mg/10ml 1 HEMANGEOL SOL 4.28/ML 3 PA INDERAL LA CAP 60MG 3 PA, ST INDERAL LA CAP 80MG 3 PA, ST INDERAL LA CAP 120MG 3 PA, ST INDERAL LA CAP 160MG 3 PA, ST INDERAL XL CAP 80MG 3 ST INDERAL XL CAP 120MG 3 ST KERLONE TAB 10MG 3 PA, ST KERLONE TAB 20MG 3 PA, ST labetalol hcl iv soln 5 mg/ml 1 labetalol hcl tab 100 mg 1 labetalol hcl tab 200 mg 1 labetalol hcl tab 300 mg 1 LEVATOL TAB 20MG 3 ST LOPRESSOR TAB 50MG 3 PA, ST LOPRESSOR TAB 100MG 3 PA, ST metoprolol succinate tab er 24hr 25 mg

(tartrate equiv) 1

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

1


1


1

metoprolol tartrate iv soln 5 mg/5ml 1 metoprolol tartrate tab 25 mg 1 metoprolol tartrate tab 50 mg 1 metoprolol tartrate tab 75 mg 1 metoprolol tartrate tab 100 mg 1 nadolol tab 20 mg 1 nadolol tab 40 mg 1 nadolol tab 80 mg 1 pindolol tab 5 mg 1 pindolol tab 10 mg 1 propranolol hcl cap er 24hr 60 mg 1 propranolol hcl cap er 24hr 80 mg 1 propranolol hcl cap er 24hr 120 mg 1 propranolol hcl cap er 24hr 160 mg 1 propranolol hcl inj 1 mg/ml 1 propranolol hcl oral soln 20 mg/5ml 1 propranolol hcl oral soln 40 mg/5ml 1 propranolol hcl tab 10 mg 1 propranolol hcl tab 20 mg 1 propranolol hcl tab 40 mg 1


61

Drug Name Drug Tier Requirements/Limits propranolol hcl tab 60 mg 1 propranolol hcl tab 80 mg 1 SECTRAL CAP 200MG 3 PA, ST SECTRAL CAP 400MG 3 PA, ST TENORMIN TAB 25MG 3 PA, ST TENORMIN TAB 50MG 3 PA, ST TENORMIN TAB 100MG 3 PA, ST timolol maleate tab 5 mg 1 timolol maleate tab 10 mg 1 timolol maleate tab 20 mg 1 TOPROL XL TAB 25MG 3 PA, ST TOPROL XL TAB 50MG 3 PA, ST TOPROL XL TAB 100MG 3 PA, ST TOPROL XL TAB 200MG 3 PA, ST ZEBETA TAB 5MG 3 PA, ST CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin calcium

tab 2.5-10 mg 1

amlodipine besylate-atorvastatin calcium tab 2.5-20 mg

1

amlodipine besylate-atorvastatin calcium tab 2.5-40 mg

1

amlodipine besylate-atorvastatin calcium tab 5-10 mg

1 PA


1


1


1


1


1


1


1

CADUET TAB 2.5-10MG 3 PA CADUET TAB 2.5-20MG 3 PA CADUET TAB 2.5-40MG 3 PA CADUET TAB 5-10MG 3 PA CADUET TAB 5-20MG 3 PA CADUET TAB 5-40MG 3 PA CADUET TAB 5-80MG 3 PA CADUET TAB 10-10MG 3 PA CADUET TAB 10-20MG 3 PA


62

Drug Name Drug Tier Requirements/Limits CADUET TAB 10-40MG 3 PA CADUET TAB 10-80MG 3 PA CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES ADALAT CC TAB 30MG ER 3 PA, ST ADALAT CC TAB 60MG ER 3 PA, ST ADALAT CC TAB 90MG ER 3 PA, ST amlodipine besylate tab 2.5 mg 1 amlodipine besylate tab 5 mg 1 amlodipine besylate tab 10 mg 1 CARDENE IV INJ 40/200ML 3 PA CARDENE IV SOL 20/200ML 3 PA CLEVIPREX EMU 0.5MG/ML 3 PA felodipine tab er 24hr 2.5 mg 1 felodipine tab er 24hr 5 mg 1 felodipine tab er 24hr 10 mg 1 isradipine cap 2.5 mg 1 isradipine cap 5 mg 1 nicardipine hcl cap 20 mg 1 nicardipine hcl cap 30 mg 1 nicardipine hcl iv soln 2.5 mg/ml 1 nifedipine tab er 24hr 30 mg 1 nifedipine tab er 24hr 60 mg 1 nifedipine tab er 24hr 90 mg 1 nifedipine tab er 24hr osmotic release 30

mg 1

nifedipine tab er 24hr osmotic release 60 mg

1

nifedipine tab er 24hr osmotic release 90 mg

1

nimodipine cap 30 mg 1 nisoldipine tab er 24hr 8.5 mg 1 nisoldipine tab er 24hr 17 mg 1 nisoldipine tab er 24hr 20 mg 1 nisoldipine tab er 24hr 25.5 mg 1 nisoldipine tab er 24hr 30 mg 1 nisoldipine tab er 24hr 34 mg 1 nisoldipine tab er 24hr 40 mg 1 NORVASC TAB 2.5MG 3 PA, ST NORVASC TAB 5MG 3 PA, ST NORVASC TAB 10MG 3 PA, ST NYMALIZE SOL 60/20ML 3 ST PROCARDIA XL TAB 30MG CR 3 PA, ST PROCARDIA XL TAB 60MG CR 3 PA, ST PROCARDIA XL TAB 90MG CR 3 PA, ST SULAR TAB 8.5MG 3 PA, ST SULAR TAB 17MG 3 PA, ST


63

Drug Name Drug Tier Requirements/Limits SULAR TAB 34MG 3 PA, ST CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES CALAN SR TAB 120MG 3 PA, ST CALAN SR TAB 180MG 3 PA, ST CALAN SR TAB 240MG 3 PA, ST CALAN TAB 80MG 3 PA, ST CALAN TAB 120MG 3 PA, ST CARDIZEM CD CAP 120MG/24 3 PA, ST CARDIZEM CD CAP 180MG/24 3 PA, ST CARDIZEM CD CAP 240MG/24 3 PA, ST CARDIZEM CD CAP 300MG/24 3 PA, ST CARDIZEM CD CAP 360MG/24 3 PA, ST CARDIZEM LA TAB 120MG 3 ST CARDIZEM LA TAB 180MG 3 PA, ST CARDIZEM LA TAB 240MG 3 PA, ST CARDIZEM LA TAB 300MG/24 3 PA, ST CARDIZEM LA TAB 360MG 3 PA, ST CARDIZEM LA TAB 420MG/24 3 PA, ST CARDIZEM TAB 30MG 3 PA, ST CARDIZEM TAB 60MG 3 PA, ST CARDIZEM TAB 120MG 3 PA, ST diltiazem cap 240mg cd 1 diltiazem cap 300mg cd 1 diltiazem hcl cap er 12hr 60 mg 1 diltiazem hcl cap er 12hr 90 mg 1 diltiazem hcl cap er 12hr 120 mg 1 diltiazem hcl cap er 24hr 120 mg 1 diltiazem hcl cap er 24hr 180 mg 1 diltiazem hcl cap er 24hr 240 mg 1 diltiazem hcl coated beads cap er 24hr 120

mg 1

diltiazem hcl coated beads cap er 24hr 180 mg

1

diltiazem hcl coated beads cap er 24hr 360 mg

1

diltiazem hcl extended release beads cap er 24hr 120 mg

1


1


1


1


1


64

Drug Name Drug Tier Requirements/Limits diltiazem hcl extended release beads cap

er 24hr 420 mg 1

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

mg/ml) 1

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

1

diltiazem hcl tab 30 mg 1 diltiazem hcl tab 60 mg 1 diltiazem hcl tab 90 mg 1 diltiazem hcl tab 120 mg 1 DILTIAZEM INJ 100MG 3 matzim la tab 180mg/24 1 matzim la tab 240mg/24 1 matzim la tab 300mg/24 1 matzim la tab 360mg/24 1 matzim la tab 420mg/24 1 TIAZAC CAP 120MG/24 3 PA, ST TIAZAC CAP 180MG/24 3 PA, ST TIAZAC CAP 240MG/24 3 PA, ST TIAZAC CAP 300MG/24 3 PA, ST TIAZAC CAP 360MG/24 3 PA, ST TIAZAC CAP 420MG/24 3 PA, ST verapamil hcl cap er 24hr 100 mg 1 verapamil hcl cap er 24hr 120 mg 1 verapamil hcl cap er 24hr 180 mg 1 verapamil hcl cap er 24hr 200 mg 1 verapamil hcl cap er 24hr 240 mg 1 verapamil hcl cap er 24hr 300 mg 1 verapamil hcl cap er 24hr 360 mg 1 verapamil hcl iv soln 2.5 mg/ml 1 verapamil hcl tab 40 mg 1 verapamil hcl tab 80 mg 1 verapamil hcl tab 120 mg 1 verapamil hcl tab er 120 mg 1 verapamil hcl tab er 180 mg 1 verapamil hcl tab er 240 mg 1 VERELAN CAP 120MG SR 3 PA, ST VERELAN CAP 180MG SR 3 PA, ST VERELAN CAP 240MG SR 3 PA, ST VERELAN CAP 360MG SR 3 PA, ST VERELAN PM CAP 100MG ER 3 PA, ST VERELAN PM CAP 200MG ER 3 PA, ST VERELAN PM CAP 300MG ER 3 PA, ST DIGITALIS GLYCOSIDES digitek tab 0.25mg 1


65

Drug Name Drug Tier Requirements/Limits digitek tab 0.125mg 1 digoxin inj 0.25 mg/ml 1 digoxin oral soln 0.05 mg/ml 1 LANOXIN INJ 0.25MG/1 3 PA LANOXIN PED INJ 0.1MG/ML 3 PA LANOXIN TAB 0.25MG 3 PA LANOXIN TAB 0.125MG 3 PA LANOXIN TAB 0.0625MG 3 PA LANOXIN TAB 0.1875MG 3 PA DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS TEKTURNA HCT TAB 150-12.5 3 PA TEKTURNA HCT TAB 150-25MG 3 PA TEKTURNA HCT TAB 300-12.5 3 PA TEKTURNA HCT TAB 300-25MG 3 PA TEKTURNA TAB 150MG 3 PA TEKTURNA TAB 300MG 3 PA DIURETICS ALDACTAZIDE TAB 25/25 3 PA ALDACTAZIDE TAB 50/50 3 PA amiloride & hydrochlorothiazide tab 5-50

mg 1

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


66

Drug Name Drug Tier Requirements/Limits furosemide tab 80 mg 1 hydrochlorothiazide cap 12.5 mg 1 hydrochlorothiazide tab 12.5 mg 1 hydrochlorothiazide tab 25 mg 1 hydrochlorothiazide tab 50 mg 1 indapamide tab 1.25 mg 1 indapamide tab 2.5 mg 1 LASIX TAB 20MG 3 PA LASIX TAB 40MG 3 PA LASIX TAB 80MG 3 PA MAXZIDE TAB 75-50 3 PA MAXZIDE-25 TAB 3 PA methyclothiazide tab 5 mg 1 metolazone tab 2.5 mg 1 metolazone tab 5 mg 1 metolazone tab 10 mg 1 MICROZIDE CAP 12.5MG 3 PA SOD DIURIL INJ 500MG 3 PA SOD EDECRIN INJ 50MG 3 PA spironolactone & hydrochlorothiazide tab

25-25 mg 1

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

37.5-25 mg 1

triamterene & hydrochlorothiazide cap 50-25 mg

1

triamterene & hydrochlorothiazide tab 37.5-25 mg

1

triamterene & hydrochlorothiazide tab 75-50 mg

1

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

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

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



PA MISCELLANEOUS


67

Drug Name Drug Tier Requirements/Limits alprostadil inj 500 mcg/ml 1 ASCLERA INJ 0.5% 3 PA ASCLERA INJ 1% 3 PA atropine sulfate inj 1 mg/ml 1 atropine sulfate inj 8 mg/20ml (0.4 mg/ml)1 atropine sulfate preservative free (pf) inj

0.4 mg/0.5ml 1

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

1

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

1

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

(base equiv) 1

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

1

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

15 mg 1

methyldopa & hydrochlorothiazide tab 250-25 mg

1

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

mg/100ml 1

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

1

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

1


1


1

minoxidil tab 2.5 mg 1


68

Drug Name Drug Tier Requirements/Limits minoxidil tab 10 mg 1 NATRECOR INJ 1.5MG 3 PA NEOPROFEN SOL 10MG/ML 3 PA niacin cap 500mg 1 OTC NIACIN FLUSH CAP FREE 2 OTC NITROPRESS INJ 25MG/ML 3 PA NORTHERA CAP 100MG 2 QL (540 caps in

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

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

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


69

Drug Name Drug Tier Requirements/Limits nitroglycerin sl tab 0.3 mg 1 nitroglycerin sl tab 0.4 mg 1 nitroglycerin sl tab 0.6 mg 1 nitroglycerin tl soln 0.4 mg/spray (400

mcg/spray) 1

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

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

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

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

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

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

PA PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE

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

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

PA sildenafil citrate iv soln 10 mg/12.5ml

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

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

PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN RECEPTOR AGONISTS

UPTRAVI TAB 200/800 3 PA UPTRAVI TAB 200MCG 3 PA UPTRAVI TAB 400MCG 3 PA UPTRAVI TAB 600MCG 3 PA UPTRAVI TAB 800MCG 3 PA


70

Drug Name Drug Tier Requirements/Limits UPTRAVI TAB 1000MCG 3 PA UPTRAVI TAB 1200MCG 3 PA UPTRAVI TAB 1400MCG 3 PA UPTRAVI TAB 1600MCG 3 PA PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN

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

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

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

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

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

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

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

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

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

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

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


71

Drug Name Drug Tier Requirements/Limits dopamine hcl inj 160 mg/ml 1 dopamine inj 0.8 mg/ml in d5w 1 dopamine inj 1.6 mg/ml in d5w 1 dopamine inj 3.2 mg/ml in d5w 1 ephedrine sulfate inj 50 mg/ml 1 EPINEPHRINE INJ 1MG/ML 3 LEVOPHED INJ 1MG/ML 3 PA norepinephrine bitartrate iv soln 1 mg/ml 1 PHENYL/NACL INJ 1MG/10ML 2 PHENYLEPHRIN INJ 10MG/ML 3 PA phenylephrine hcl inj 10 mg/ml 1 VAZCULEP INJ 10MG/ML 3 PA CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES ALPRAZOLAM CON 1 MG/ML 3 alprazolam orally disintegrating tab 0.5 mg 1 alprazolam orally disintegrating tab 0.25

mg 1

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

mg 1

clonazepam orally disintegrating tab 0.25 mg

1

clonazepam orally disintegrating tab 0.125 mg

1

clonazepam orally disintegrating tab 1 mg 1 clonazepam orally disintegrating tab 2 mg 1 clonazepam tab 0.5 mg 1 clonazepam tab 1 mg 1


72

Drug Name Drug Tier Requirements/Limits clonazepam tab 2 mg 1 clorazepate dipotassium tab 3.75 mg 1 clorazepate dipotassium tab 7.5 mg 1 clorazepate dipotassium tab 15 mg 1 diazepam con 5mg/ml 1 diazepam inj 5 mg/ml 1 DIAZEPAM INJ 10MG/2ML 3 diazepam oral soln 1 mg/ml 1 diazepam tab 2 mg 1 diazepam tab 5 mg 1 diazepam tab 10 mg 1 KLONOPIN TAB 0.5MG 3 PA, ST KLONOPIN TAB 1MG 3 PA, ST KLONOPIN TAB 2MG 3 PA, ST lorazepam conc 2 mg/ml 1 lorazepam inj 2 mg/ml 1 PA lorazepam inj 4 mg/ml 1 PA lorazepam tab 0.5 mg 1 lorazepam tab 1 mg 1 lorazepam tab 2 mg 1 oxazepam cap 10 mg 1 oxazepam cap 15 mg 1 oxazepam cap 30 mg 1 TRANXENE T TAB 7.5MG 3 PA VALIUM TAB 2MG 3 PA VALIUM TAB 5MG 3 PA VALIUM TAB 10MG 3 PA XANAX TAB 0.5MG 3 PA XANAX TAB 0.25MG 3 PA XANAX TAB 1MG 3 PA XANAX TAB 2MG 3 PA XANAX XR TAB 0.5MG 3 PA XANAX XR TAB 1MG 3 PA XANAX XR TAB 2MG 3 PA XANAX XR TAB 3MG 3 PA ANTIANXIETY, MISCELLANEOUS buspirone hcl tab 5 mg 1 buspirone hcl tab 7.5 mg 1 buspirone hcl tab 10 mg 1 buspirone hcl tab 15 mg 1 buspirone hcl tab 30 mg 1 clomipramine hcl cap 25 mg 1 clomipramine hcl cap 50 mg 1 clomipramine hcl cap 75 mg 1 fluvoxamine maleate cap er 24hr 100 mg 1


73

Drug Name Drug Tier Requirements/Limits fluvoxamine maleate cap er 24hr 150 mg 1 fluvoxamine maleate tab 25 mg 1 fluvoxamine maleate tab 50 mg 1 fluvoxamine maleate tab 100 mg 1 meprobamate tab 200 mg 1 PA meprobamate tab 400 mg 1 PA ANTICONVULSANTS APTIOM TAB 200MG 3 QL (30 tabs / 30 days),

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



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

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




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


74

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

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

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

ST diazepam rectal gel delivery system 2.5

mg 1 QL (2 ea / 25 days)

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

sprinkle 125 mg 1

divalproex sodium tab delayed release 125 mg

1


1


1

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

(phenytoin equiv) 1

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

1

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

FYCOMPA TAB 4MG 3 QL (30 tabs / 30 days), ST


75

Drug Name Drug Tier Requirements/Limits FYCOMPA TAB 6MG 3 QL (30 tabs / 30 days),

ST FYCOMPA TAB 8MG 3 QL (30 tabs / 30 days),



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

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

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

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




PA, ST LAMICTAL TAB 25MG 3 PA, ST LAMICTAL TAB 100MG 3 PA, ST LAMICTAL TAB 150MG 3 PA, ST LAMICTAL TAB 200MG 3 PA, ST


76

Drug Name Drug Tier Requirements/Limits LAMICTAL XR KIT 3 QL (1 box in lifetime),

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

PA, ST LAMICTAL XR TAB 50MG 3 QL (90 tabs / 30 days),



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


lamotrigine orally disintegrating tab 200 mg


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

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

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

1 QL (1 box in lifetime)

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

1 QL (1 box in lifetime)

lamotrigine tab er 24hr 25 mg 1 QL (90 tabs / 30 days) lamotrigine tab er 24hr 50 mg 1 QL (90 tabs / 30 days) lamotrigine tab er 24hr 100 mg 1 QL (60 tabs / 30 days) lamotrigine tab er 24hr 200 mg 1 QL (60 tabs / 30 days) lamotrigine tab er 24hr 250 mg 1 lamotrigine tab er 24hr 300 mg 1 LEVETIRACETA INJ 5MG/ML 3 PA LEVETIRACETA INJ 10MG/ML 3 PA LEVETIRACETA INJ 15MG/ML 3 PA levetiracetam inj 500 mg/5ml (100 mg/ml) 1 levetiracetam oral soln 100 mg/ml 1 levetiracetam tab 250 mg 1 levetiracetam tab 500 mg 1 levetiracetam tab 750 mg 1 levetiracetam tab 1000 mg 1 levetiracetam tab er 24hr 500 mg 1 QL (180 tabs / 30 days) levetiracetam tab er 24hr 750 mg 1 QL (120 tabs / 30 days)


77

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

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

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

PA oxcarbazepine susp 300 mg/5ml (60

mg/ml) 1

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

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

PA


78

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

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

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

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




ST SABRIL POW 500MG 2 QL (180 packets / 30

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

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

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

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


79

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

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



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

(base equiv) 1

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

disintegrating tab 5 mg 1

donepezil hydrochloride orally disintegrating tab 10 mg

1

donepezil hydrochloride tab 5 mg 1 donepezil hydrochloride tab 10 mg 1 donepezil hydrochloride tab 23 mg 1 EXELON CAP 1.5MG 3 ST EXELON CAP 3MG 3 ST EXELON CAP 4.5MG 3 ST EXELON CAP 6MG 3 ST EXELON DIS 4.6MG/24 3 ST EXELON DIS 9.5MG/24 3 ST EXELON DIS 13.3/24 3 ST


80

Drug Name Drug Tier Requirements/Limits galantamine hydrobromide cap er 24hr 8

mg 1

galantamine hydrobromide cap er 24hr 16 mg

1

galantamine hydrobromide cap er 24hr 24 mg

1

galantamine hydrobromide oral soln 4 mg/ml

1

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

(21) titration pak 1

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

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



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

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




ST RAZADYNE ER CAP 8MG 3 ST RAZADYNE ER CAP 16MG 3 ST RAZADYNE ER CAP 24MG 3 ST RAZADYNE TAB 4MG 3 ST RAZADYNE TAB 8MG 3 ST RAZADYNE TAB 12MG 3 ST rivastigmine tartrate cap 1.5 mg 1 rivastigmine tartrate cap 3 mg 1 rivastigmine tartrate cap 4.5 mg 1 rivastigmine tartrate cap 6 mg 1 rivastigmine td patch 24hr 4.6 mg/24hr 1 rivastigmine td patch 24hr 9.5 mg/24hr 1 rivastigmine td patch 24hr 13.3 mg/24hr 1


81

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

mg 1

chlordiazepoxide-amitriptyline tab 10-25 mg

1

FORFIVO XL TAB 450MG 3 ST maprotiline hcl tab 25 mg 1 maprotiline hcl tab 50 mg 1 maprotiline hcl tab 75 mg 1 mirtazapine orally disintegrating tab 15 mg1 mirtazapine orally disintegrating tab 30 mg1 mirtazapine orally disintegrating tab 45 mg1 mirtazapine tab 7.5 mg 1 mirtazapine tab 15 mg 1 mirtazapine tab 30 mg 1 mirtazapine tab 45 mg 1 REMERON SLTB TAB 15MG 3 PA, ST REMERON SLTB TAB 30MG 3 PA, ST REMERON SLTB TAB 45MG 3 PA, ST REMERON TAB 15MG 3 PA, ST REMERON TAB 30MG 3 PA, ST REMERON TAB 45MG 3 PA, ST trazodone hcl tab 50 mg 1 trazodone hcl tab 100 mg 1 trazodone hcl tab 150 mg 1 trazodone hcl tab 300 mg 1 WELLBUTRIN TAB 100MG SR 3 PA, ST


82

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

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

ST desvenlafaxine succinate tab er 24hr 25

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





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

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

ST duloxetine hcl enteric coated pellets cap 20

mg 1 QL (60 ea / 30 days)

duloxetine hcl enteric coated pellets cap 30 mg

1 QL (30 ea / 30 days)


1 QL (30 ea / 30 days)


1 QL (60 / 30)

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

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

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

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




FETZIMA CAP TITRATIO 3 QL (1 kit in lifetime), PA KHEDEZLA TAB 50MG ER 3 QL (30 tabs / 30 days),

ST


83

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

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



ST venlafaxine hcl cap er 24hr 37.5 mg (base

equivalent) 1 QL (30 caps / 30 days)

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


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


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

equivalent) 1 QL (30 tabs / 30 days)

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






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

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

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

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

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

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

PA, ST citalopram hydrobromide oral soln 10

mg/5ml 1

citalopram hydrobromide tab 10 mg (base equiv)







84

Drug Name Drug Tier Requirements/Limits escitalopram oxalate soln 5 mg/5ml (base

equiv) 1 QL (600 / 30 days)

escitalopram oxalate tab 5 mg (base equiv)






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

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



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

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

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

PA, ST PAXIL SUS 10MG/5ML 3 ST PAXIL TAB 10MG 3 PA, ST PAXIL TAB 20MG 3 PA, ST PAXIL TAB 30MG 3 PA, ST PAXIL TAB 40MG 3 PA, ST PEXEVA TAB 10MG 3 QL (30 tabs / 30 days),

ST


85

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

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

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

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

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

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

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

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

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



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


86

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

equivalent) 1

bromocriptine mesylate tab 2.5 mg (base equivalent)

1


87

Drug Name Drug Tier Requirements/Limits carbidopa & levodopa orally disintegrating

tab 10-100 mg 1

carbidopa & levodopa orally disintegrating tab 25-100 mg

1

carbidopa & levodopa orally disintegrating tab 25-250 mg

1

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

50-200 mg 1

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

1

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

1


1


1

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

1

COGENTIN INJ 1MG/ML 3 PA COMTAN TAB 200MG 3 PA ELDEPRYL CAP 5MG 3 PA entacapone tab 200 mg 1 PA LODOSYN TAB 25MG 3 PA MIRAPEX ER TAB 0.75MG 3 PA, ST MIRAPEX ER TAB 0.375MG 3 PA, ST MIRAPEX ER TAB 1.5MG 3 PA, ST MIRAPEX ER TAB 2.25MG 3 PA, ST MIRAPEX ER TAB 3.75MG 3 PA, ST MIRAPEX ER TAB 3MG 3 PA, ST MIRAPEX ER TAB 4.5MG 3 PA, ST MIRAPEX TAB 0.5MG 3 PA, ST MIRAPEX TAB 0.25MG 3 PA, ST MIRAPEX TAB 0.75MG 3 PA, ST MIRAPEX TAB 0.125MG 3 PA, ST MIRAPEX TAB 1.5MG 3 PA, ST MIRAPEX TAB 1MG 3 PA, ST NEUPRO DIS 1MG/24HR 3 ST NEUPRO DIS 2MG/24HR 3 ST NEUPRO DIS 3MG/24HR 3 ST NEUPRO DIS 4MG/24HR 3 ST NEUPRO DIS 6MG/24HR 3 ST


88

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

0.75 mg 1 ST

pramipexole dihydrochloride tab er 24hr 0.375 mg

1


1 ST


1

pramipexole dihydrochloride tab er 24hr 3 mg

1


1

rasagiline mesylate tab 0.5 mg (base equiv)

1

rasagiline mesylate tab 1 mg (base equiv) 1 REQUIP TAB 0.5MG 3 PA, ST REQUIP TAB 0.25MG 3 PA, ST REQUIP TAB 1MG 3 PA, ST REQUIP TAB 2MG 3 PA, ST REQUIP TAB 3MG 3 PA, ST REQUIP TAB 4MG 3 PA, ST REQUIP TAB 5MG 3 PA, ST REQUIP XL TAB 2MG 3 PA, ST REQUIP XL TAB 4MG 3 PA, ST REQUIP XL TAB 6MG 3 PA, ST REQUIP XL TAB 8MG 3 PA, ST REQUIP XL TAB 12MG 3 PA, ST ropinirole hydrochloride tab 0.5 mg 1 ropinirole hydrochloride tab 0.25 mg 1 ropinirole hydrochloride tab 1 mg 1 ropinirole hydrochloride tab 2 mg 1 ropinirole hydrochloride tab 3 mg 1 ropinirole hydrochloride tab 4 mg 1 ropinirole hydrochloride tab 5 mg 1 ropinirole hydrochloride tab er 24hr 2 mg

(base equivalent) 1

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

1


89

Drug Name Drug Tier Requirements/Limits ropinirole hydrochloride tab er 24hr 6 mg

(base equivalent) 1


1


1

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

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

PA ZELAPAR TAB 1.25MG 3 PA ANTIPSYCHOTICS, ATYPICALS ABILIFY MAIN INJ 300MG 2 QL (1 vial / 21 days), PA ABILIFY MAIN INJ 400MG 2 QL (1 vial / 21 days), PA ADASUVE INH 10MG 3 PA aripiprazole oral solution 1 mg/ml 1 QL (750 per 25 days) aripiprazole orally disintegrating tab 10 mg 1 QL (60 tabs / 30 days) aripiprazole orally disintegrating tab 15 mg 1 QL (60 tabs / 30 days) aripiprazole tab 2 mg 1 QL (30 tabs / 30 days) aripiprazole tab 5 mg 1 QL (30 tabs / 30 days) aripiprazole tab 10 mg 1 QL (30 tabs / 30 days) aripiprazole tab 15 mg 1 QL (30 tabs / 30 days) aripiprazole tab 20 mg 1 QL (30 tabs / 30 days) aripiprazole tab 30 mg 1 QL (30 tabs / 30 days) ARISTADA INJ 441MG/1. 3 QL (1 / 25 days), PA


90

Drug Name Drug Tier Requirements/Limits ARISTADA INJ 662MG/2 3 QL (1 syringe / 25

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

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

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







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

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

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



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



PA, ST


91

Drug Name Drug Tier Requirements/Limits GEODON CAP 80MG 3 QL (60 caps / 30 days),

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

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

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

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



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

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



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

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




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

PA olanzapine for im inj 10 mg 1 QL (30 / 30 days) olanzapine orally disintegrating tab 5 mg 1 QL (30 tabs / 30 days) olanzapine orally disintegrating tab 10 mg 1 QL (30 tabs / 30 days) olanzapine orally disintegrating tab 15 mg 1 QL (30 tabs / 30 days) olanzapine orally disintegrating tab 20 mg 1 QL (30 tabs / 30 days)


92

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

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

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




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

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




PA, ST


93

Drug Name Drug Tier Requirements/Limits RISPERDAL SOL 1MG/ML 3 QL (240 ml / 30 days),

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

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

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




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


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

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





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


PA


94

Drug Name Drug Tier Requirements/Limits SEROQUEL XR TAB 200MG 3 QL (30 tabs / 30 days),



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

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

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

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

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

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




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




PA, ST ANTIPSYCHOTICS, MISCELLANEOUS CHLORPROMAZ INJ 25MG/ML 3 CHLORPROMAZ INJ 50MG/2ML 3 chlorpromazine hcl tab 10 mg 1


95

Drug Name Drug Tier Requirements/Limits chlorpromazine hcl tab 25 mg 1 chlorpromazine hcl tab 50 mg 1 chlorpromazine hcl tab 100 mg 1 chlorpromazine hcl tab 200 mg 1 fluphenazine decanoate inj 25 mg/ml 1 fluphenazine hcl elixir 2.5 mg/5ml 1 fluphenazine hcl inj 2.5 mg/ml 1 fluphenazine hcl oral conc 5 mg/ml 1 fluphenazine hcl tab 1 mg 1 fluphenazine hcl tab 2.5 mg 1 fluphenazine hcl tab 5 mg 1 fluphenazine hcl tab 10 mg 1 HALDOL DECAN INJ 50MG/ML 3 PA HALDOL DECAN INJ 100MG/ML 3 PA HALDOL INJ 5MG/ML 3 PA haloperidol decanoate im soln 50 mg/ml 1 haloperidol decanoate im soln 100 mg/ml 1 haloperidol lactate inj 5 mg/ml 1 haloperidol lactate oral conc 2 mg/ml 1 haloperidol tab 0.5 mg 1 haloperidol tab 1 mg 1 haloperidol tab 2 mg 1 haloperidol tab 5 mg 1 haloperidol tab 10 mg 1 haloperidol tab 20 mg 1 ORAP TAB 1MG 3 PA ORAP TAB 2MG 3 PA perphenazine tab 2 mg 1 perphenazine tab 4 mg 1 perphenazine tab 8 mg 1 perphenazine tab 16 mg 1 perphenazine-amitriptyline tab 2-10 mg 1 perphenazine-amitriptyline tab 2-25 mg 1 perphenazine-amitriptyline tab 4-10 mg 1 perphenazine-amitriptyline tab 4-25 mg 1 perphenazine-amitriptyline tab 4-50 mg 1 pimozide tab 1 mg 1 pimozide tab 2 mg 1 thioridazine hcl tab 10 mg 1 thioridazine hcl tab 25 mg 1 thioridazine hcl tab 50 mg 1 thioridazine hcl tab 100 mg 1 thiothixene cap 1 mg 1 thiothixene cap 2 mg 1 thiothixene cap 5 mg 1 thiothixene cap 10 mg 1


96

Drug Name Drug Tier Requirements/Limits trifluoperazine hcl tab 1 mg 1 trifluoperazine hcl tab 2 mg 1 trifluoperazine hcl tab 5 mg 1 trifluoperazine hcl tab 10 mg 1 ATTENTION DEFICIT HYPERACTIVITY DISORDER ADDERALL TAB 5MG 3 QL (90 tabs / 30 days),

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

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

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




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




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

PA, ST amphetamine-dextroamphetamine cap er

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

amphetamine-dextroamphetamine cap er 24hr 10 mg







1



amphetamine-dextroamphetamine tab 5 mg


amphetamine-dextroamphetamine tab 7.5 mg





97

Drug Name Drug Tier Requirements/Limits amphetamine-dextroamphetamine tab

12.5 mg 1 QL (90 tabs / 30 days)







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







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







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

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



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

PA


98

Drug Name Drug Tier Requirements/Limits DAYTRANA DIS 15MG/9HR 3 QL (30 ptch / 30 days),

PA DAYTRANA DIS 20MG/9HR 3 QL (30 ptch / 30 days),

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

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

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

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

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


dexmethylphenidate hcl cap er 24 hr 15 mg












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


dextroamphetamine sulfate cap er 24hr 10 mg


dextroamphetamine sulfate cap er 24hr 15 mg


dextroamphetamine sulfate oral solution 5 mg/5ml

1

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

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

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

PA, ST


99

Drug Name Drug Tier Requirements/Limits FOCALIN TAB 5MG 3 QL (60 tabs / 30 days),

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

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




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

equiv) 1 QL (30 tabs / 30 days)

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






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




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

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






methamphetamine hcl tab 5 mg 1 QL (150 tabs / 30 days), PA


100

Drug Name Drug Tier Requirements/Limits METHYLIN CHW 2.5MG 3 QL (90 ea / 30 days),

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

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

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

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

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

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

methylphenidate hcl cap er 24hr 30 mg (la)


methylphenidate hcl cap er 24hr 40 mg (la)


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

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

methylphenidate hcl tab er osmotic release (osm) 27 mg






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


101

Drug Name Drug Tier Requirements/Limits QUILLICHEW CHW 30MG ER 3 QL (30 / 30 days), PA,

ST QUILLICHEW CHW 40MG ER 3 QL (30 / 30 days), PA,

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

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

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



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

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

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

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

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






PA VYVANSE CAP 10MG 2 VYVANSE CAP 20MG 2 QL (30 caps / 30 days) VYVANSE CAP 30MG 2 QL (30 caps / 30 days) VYVANSE CAP 40MG 2 QL (30 caps / 30 days) VYVANSE CAP 50MG 2 VYVANSE CAP 60MG 2 QL (30 caps / 30 days) VYVANSE CAP 70MG 2 QL (30 caps / 30 days) zenzedi tab 2.5mg 1 QL (480 tabs / 25 days),

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

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

ST


102

Drug Name Drug Tier Requirements/Limits zenzedi tab 20mg 1 QL (90 tabs / 30 days),

ST zenzedi tab 30mg 1 QL (60 tabs / 30 days),

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

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







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

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

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



PA HYPNOTICS, BENZODIAZEPINES DORAL TAB 15MG 3 PA, ST estazolam tab 1 mg 1 estazolam tab 2 mg 1 HALCION TAB 0.25MG 3 PA, ST midazolam hcl inj 2 mg/2ml (base

equivalent) 1 PA

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

1 PA

midazolam hcl inj 5 mg/ml (base equivalent)

1 PA


1 PA


1


103

Drug Name Drug Tier Requirements/Limits midazolam hcl inj 25 mg/5ml (base

equivalent) 1


1

midazolam hcl syrup 2 mg/ml (base equivalent)

1 PA

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

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

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

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

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

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



PA BUTISOL SOD TAB 30MG 3 PA dexmedetomidine hcl inj 200 mcg/2ml (for

iv infusion) 1

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

PA INTERMEZZO SUB 1.75MG 3 QL (30 ea / 30 days), PA


104

Drug Name Drug Tier Requirements/Limits INTERMEZZO SUB 3.5MG 3 QL (30 ea / 30 days), PA LUNESTA TAB 1MG 3 QL (30 tabs / 30 days),

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

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

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

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

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

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

PA ZZZQUIL CAP 25MG 3 PA; OTC ZZZQUIL LIQ 50MG/30 2 PA; OTC HYPNOTICS, TRICYCLICS SILENOR TAB 3MG 3 PA SILENOR TAB 6MG 3 PA MIGRAINE, ERGOTAMINE DERIVATIVES CAFERGOT TAB 1-100MG 3 PA D.H.E. 45 INJ 1MG/ML 3 PA dihydroergotamine mesylate inj 1 mg/ml 1 dihydroergotamine mesylate nasal spray 4

mg/ml 1

ERGOMAR SUB 2MG 3 PA migergot sup 2/100 1 MIGRANAL SPR 4MG/ML 3 PA


105

Drug Name Drug Tier Requirements/Limits MIGRAINE, SELECTIVE SEROTONIN AGONIST/NSAID TREXIMET TAB 85-500MG 3 QL (9 tabs / 25 days),

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

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

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

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

PA, ST eletriptan hydrobromide tab 20 mg (base

equivalent) 1 QL (6 / 30)

eletriptan hydrobromide tab 40 mg (base equivalent)

1 QL (6 / 30)

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

frovatriptan succinate tab 2.5 mg (base equivalent)


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

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

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

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

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

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

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

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

ST


106

Drug Name Drug Tier Requirements/Limits RELPAX TAB 40MG 3 QL (6 tabs / 25 days),

ST rizatriptan benzoate oral disintegrating tab

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

rizatriptan benzoate oral disintegrating tab 10 mg (base eq)


rizatriptan benzoate tab 5 mg (base equivalent)


rizatriptan benzoate tab 10 mg (base equivalent)


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

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

sumatriptan succinate solution auto-injector 6 mg/0.5ml

1 QL (4 / 25 days)

sumatriptan succinate solution cartridge 4 mg/0.5ml

1

sumatriptan succinate solution cartridge 6 mg/0.5ml

1

sumatriptan succinate solution prefilled syringe 6 mg/0.5ml

1 QL (8 / 25 days)

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


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

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

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

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

PA, ST MISCELLANEOUS BLOXIVERZ INJ 5MG/10ML 3 PA BLOXIVERZ INJ 10/10ML 3 PA


107

Drug Name Drug Tier Requirements/Limits caffeine & sodium benzoate inj 125-125

mg/ml (500 mg/2ml) 1

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

(1:2000) 1

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

ml (0.5 mg/ml) 1

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

1

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

PA riluzole tab 50 mg 1 QL (60 tabs / 30 days) VITRASE INJ 200/ML 3 PA MOOD STABILIZERS EQUETRO CAP 100MG 3 ST EQUETRO CAP 200MG 3 ST EQUETRO CAP 300MG 3 ST lithium carbonate cap 150 mg 1 lithium carbonate cap 300 mg 1 lithium carbonate cap 600 mg 1 lithium carbonate tab 300 mg 1 lithium carbonate tab er 300 mg 1 lithium carbonate tab er 450 mg 1 LITHIUM SOL 8MEQ/5ML 3 LITHOBID TAB 300MG CR 3 PA MOVEMENT DISORDER DRUGS AUSTEDO TAB 6MG 3 QL (60 / 30), PA AUSTEDO TAB 9MG 3 QL (60 / 30), PA AUSTEDO TAB 12MG 3 QL (120 / 30), PA INGREZZA CAP 40MG 3 QL (60 / 30), PA tetrabenazine tab 12.5 mg 1 QL (90 tabs / 30 days) tetrabenazine tab 25 mg 1 QL (120 tabs / 30 days) MULTIPLE SCLEROSIS AMPYRA TAB 10MG 2 QL (60 tabs / 30 days),

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

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

PA


108

Drug Name Drug Tier Requirements/Limits AVONEX KIT 30MCG 2 QL (4 boxes / 25 days),

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

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

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

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

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

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

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

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

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

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

PA ZINBRYTA INJ 150MG/ML 3 QL (1 syringe / 28

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

325-16 mg 1 PA

carisoprodol w/ aspirin tab 200-325 mg 1 ST chlorzoxazone tab 500 mg 1


109

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

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

PA, ST tizanidine hcl cap 2 mg (base equivalent) 1 tizanidine hcl cap 4 mg (base equivalent) 1 tizanidine hcl cap 6 mg (base equivalent) 1 tizanidine hcl tab 2 mg (base equivalent) 1 tizanidine hcl tab 4 mg (base equivalent) 1 ZANAFLEX CAP 2MG 3 PA, ST ZANAFLEX CAP 4MG 3 PA, ST ZANAFLEX CAP 6MG 3 PA, ST ZANAFLEX TAB 4MG 3 PA, ST MYASTHENIA GRAVIS ENLON INJ 150/15ML 3 MESTINON SYP 60MG/5ML 2 MESTINON TAB 60MG 3 PA


110

Drug Name Drug Tier Requirements/Limits pyridostigmine bromide tab 60 mg 1 pyridostigmine bromide tab er 180 mg 1 NARCOLEPSY/CATAPLEXY armodafinil tab 50 mg 1 QL (30 tabs / 30 days) armodafinil tab 150 mg 1 QL (30 tabs / 30 days) armodafinil tab 200 mg 1 QL (30 tabs / 30 days),

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

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

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

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



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

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

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

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

mg/ml) 1

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

1

vecuronium bromide for inj 10 mg 1 vecuronium bromide for inj 20 mg 1 POSTHERPETIC NEURALGIA GRALISE STAR MIS 300/600 3 QL (1 in lifetime), PA GRALISE TAB 300MG 3 QL (30 tabs / 30 days),

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

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

333 mg 1

ANTABUSE TAB 250MG 3 PA ANTABUSE TAB 500MG 3 PA disulfiram tab 250 mg 1


111

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

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

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

Copay PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONIST/OPIOID

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

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

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

1 QL (60 ea / 30 days), PA

SUBOXONE MIS 2-0.5MG 3 QL (60 / 30 days), PA SUBOXONE MIS 4-1MG 3 QL (60 / 30 days), PA SUBOXONE MIS 8-2MG 3 QL (60 / 30 days), PA SUBOXONE MIS 12-3MG 3 QL (30 / 30 days), PA ZUBSOLV SUB 0.7-0.18 3 QL (30 ea / 30 days), PA ZUBSOLV SUB 1.4-0.36 3 QL (60 ea / 30 days), PA ZUBSOLV SUB 2.9-0.71 3 QL (60 ea / 30 days), PA ZUBSOLV SUB 5.7-1.4 3 QL (60 ea / 30 days), PA ZUBSOLV SUB 8.6-2.1 3 QL (30 ea / 30 days), PA ZUBSOLV SUB 11.4-2.9 3 QL (30 ea / 30 days), PA PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONISTS buprenorphine hcl sl tab 2 mg (base equiv)1 QL (60 ea / 30 days), PA buprenorphine hcl sl tab 8 mg (base equiv)1 QL (60 ea / 30 days), PA PSYCHOTHERAPEUTIC-MISC, PSEUDOBULBAR AFFECT NUEDEXTA CAP 20-10MG 2 QL (60 caps / 30 days) PSYCHOTHERAPEUTIC-MISC, SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab er

12hr 150 mg 1

CHANTIX PAK 0.5& 1MG 2 CHANTIX PAK 1MG 2 CHANTIX TAB 0.5MG 2 nicotine polacrilex gum 2 mg 1 OTC nicotine polacrilex gum 4 mg 1 OTC nicotine polacrilex lozenge 2 mg 1 OTC


112

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

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

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

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

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

PA ANDROGEL GEL 1.62% 3 PA AXIRON SOL 30MG/ACT 3 PA DEPO-TESTOST INJ 100MG/ML 3 PA DEPO-TESTOST INJ 200MG/ML 3 PA FORTESTA GEL 10MG/ACT 3 PA NATESTO GEL 5.5MG 3 PA OXANDRIN TAB 2.5MG 3 PA, ST OXANDRIN TAB 10MG 3 PA, ST oxandrolone tab 2.5 mg 1 oxandrolone tab 10 mg 1 STRIANT MIS 30MG 3 PA TESTIM GEL 1%(50MG) 3 QL (150 gm / 30 days),

PA TESTONE CIK KIT 200MG/ML 3 PA testosterone cypionate im inj in oil 100

mg/ml 1

testosterone cypionate im inj in oil 200 mg/ml

1

testosterone enanthate im inj in oil 200 mg/ml

1

testosterone td gel 10mg/act (2%) 1 PA


113

Drug Name Drug Tier Requirements/Limits testosterone td gel 12.5 mg/act (1%) 1 QL (150 gm / 30 days),

PA testosterone td gel 25 mg/2.5gm (1%) 1 QL (150 gm / 30 days),

PA testosterone td gel 50 mg/5gm (1%) 1 QL (150 gm / 30 days),

PA testosterone td soln 30 mg/act 1 ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITOR acarbose tab 25 mg 1 acarbose tab 50 mg 1 acarbose tab 100 mg 1 GLYSET TAB 25MG 1 ST GLYSET TAB 50MG 1 ST GLYSET TAB 100MG 1 ST ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG 2 QL (4 / 25 days) SYMLNPEN 120 INJ 1000MCG 2 QL (4 / 25 days) ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS glipizide-metformin hcl tab 2.5-250 mg 1 glipizide-metformin hcl tab 2.5-500 mg 1 glipizide-metformin hcl tab 5-500 mg 1 glyburide-metformin tab 1.25-250 mg 1 glyburide-metformin tab 2.5-500 mg 1 glyburide-metformin tab 5-500 mg 1 ANTIDIABETICS, BIGUANIDES FORTAMET TAB 500MG 3 ST FORTAMET TAB 1000MG 3 ST GLUMETZA TAB 500MG 3 ST GLUMETZA TAB 1000MG 3 ST metformin hcl tab 500 mg 1 metformin hcl tab 850 mg 1 metformin hcl tab 1000 mg 1 metformin hcl tab er 24hr 500 mg 1 metformin hcl tab er 24hr 750 mg 1 metformin hcl tab er 24hr modified release

500 mg 3 ST

metformin hcl tab er 24hr modified release 1000 mg

3 ST

metformin hcl tab er 24hr osmotic 500 mg 3 ST metformin hcl tab er 24hr osmotic 1000

mg 1

RIOMET SOL 2 ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)

INHIBITOR/BIGUANIDE COMBINATIONS JANUMET TAB 50-500MG 2 ST


114

Drug Name Drug Tier Requirements/Limits JANUMET TAB 50-1000 2 ST JANUMET XR TAB 50-500MG 2 ST JANUMET XR TAB 50-1000 2 ST JANUMET XR TAB 100-1000 2 ST JENTADUETO TAB 2.5-500 2 PA JENTADUETO TAB 2.5-850 2 PA JENTADUETO TAB 2.5-1000 2 PA JENTADUETO TAB XR 2 QL (30 tabs / 30 days),

PA, ST KAZANO 12.5- TAB 500MG 3 PA KAZANO 12.5- TAB 1000MG 3 PA KOMBIGLYZ XR TAB 2.5-1000 3 PA KOMBIGLYZ XR TAB 5-500MG 3 PA KOMBIGLYZ XR TAB 5-1000MG 3 PA ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)

INHIBITOR/INSULIN SENSITIZER COMBINATIONS OSENI TAB 12.5-15 3 PA OSENI TAB 12.5-30 3 PA OSENI TAB 12.5-45 3 PA OSENI TAB 25-15MG 3 PA OSENI TAB 25-30MG 3 PA OSENI TAB 25-45MG 3 PA ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TAB 25MG 2 ST JANUVIA TAB 50MG 2 ST JANUVIA TAB 100MG 2 ST NESINA TAB 6.25MG 3 PA NESINA TAB 12.5MG 3 PA NESINA TAB 25MG 3 PA ONGLYZA TAB 2.5MG 3 PA ONGLYZA TAB 5MG 3 PA TRADJENTA TAB 5MG 2 PA ANTIDIABETICS, INCRETIN MIMETIC AGENT/INSULIN

COMBINATIONS SOLIQUA INJ 100/33 3 QL (30 ml / 30 days),

ST XULTOPHY INJ 100/3.6 3 QL (15 / 28), PA ANTIDIABETICS, INCRETIN MIMETIC AGENTS ADLYXIN INJ 10/20MCG 3 QL (1 per lifetime), PA,

ST ADLYXIN INJ 20MCG 3 QL (2 pens / 30), PA, ST BYDUREON INJ 2MG 3 QL (4 / 21 days), PA, ST BYDUREON PEN INJ 2MG 3 QL (4 / 21 days), PA, ST BYETTA INJ 5MCG 3 QL (1 pen / 25 days),

PA, ST


115

Drug Name Drug Tier Requirements/Limits BYETTA INJ 10MCG 3 QL (1 pen / 25 days),

PA, ST TANZEUM INJ 30MG 2 QL (4.5 ml / 30 days),

ST TANZEUM INJ 50MG 2 QL (4.5 ml / 30 days),

ST TRULICITY INJ 0.75/0.5 2 QL (6 / 30 days), ST TRULICITY INJ 1.5/0.5 2 QL (6 / 30 days), ST VICTOZA INJ 18MG/3ML 2 QL (3 / 30 days), ST ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION ACTOPLUS MET TAB XR 2 pioglitazone hcl-metformin hcl tab 15-500

mg 1

pioglitazone hcl-metformin hcl tab 15-850 mg

1

ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBO pioglitazone hcl-glimepiride tab 30-2 mg 1 pioglitazone hcl-glimepiride tab 30-4 mg 1 ANTIDIABETICS, INSULIN SENSITIZERS AVANDIA TAB 2MG 3 AVANDIA TAB 4MG 3 pioglitazone hcl tab 15 mg (base equiv) 1 pioglitazone hcl tab 30 mg (base equiv) 1 pioglitazone hcl tab 45 mg (base equiv) 1 ANTIDIABETICS, INSULINS AFREZZA POW 4&8 UNIT 3 QL (3 boxes / 30 days),

ST AFREZZA POW 4&8 UNIT 3 QL (90 / 30 days), ST AFREZZA POW 4/8/12UN 3 Refers to 4 & 8 & 12

UNIT pack; ST AFREZZA POW 4UNIT 3 QL (90 / 30 days), ST AFREZZA POW 8 UNIT 3 QL (90 / 30), ST AFREZZA POW 8&12UNIT 3 QL (3 boxes / 30 days),

ST AFREZZA POW 12 UNIT 3 QL (90 / 30), ST APIDRA INJ SOLOSTAR 3 ST APIDRA INJ U-100 3 ST BASAGLAR INJ 100UNIT 2 QL (45 ml / 30 days) HUMALOG INJ 100/ML 2 QL (50 ml / 30 days) HUMALOG KWIK INJ 100/ML 2 QL (45 ml / 30 days) HUMALOG KWIK INJ 200/ML 2 QL (24 ml / 30 days) HUMALOG MIX INJ 50/50 2 QL (50 ml / 30 days) HUMALOG MIX INJ 50/50KWP 2 QL (45 ml / 30 days) HUMALOG MIX INJ 75/25KWP 2 QL (45 ml / 30 days) HUMALOG MIX SUS 75/25 2 QL (50 ml / 30 days)


116

Drug Name Drug Tier Requirements/Limits HUMULIN INJ 70/30 2 QL (50 ml / 30 days);

OTC HUMULIN INJ 70/30KWP 2 QL (45 ml / 30 days);

OTC HUMULIN N INJ U-100 2 QL (50 ml / 30 days);

OTC HUMULIN N INJ U-100KWP 2 QL (45 ml / 30 days);

OTC HUMULIN R INJ U-100 2 QL (50 ml / 30 days);

OTC HUMULIN R INJ U-500 2 HUMULIN R INJ U-500 2 QL (1 vial / 30 days) LANTUS INJ 100/ML 3 QL (50 ml / 30 days),

ST LANTUS INJ SOLOSTAR 3 QL (45 ml / 30 days),

ST LEVEMIR INJ 3 QL (50 ml / 30 days),

ST LEVEMIR INJ FLEXTOUC 3 QL (45 ml / 30 days),

ST NOVOLIN INJ 70/30 3 QL (50 ml / 30 days),

ST; OTC NOVOLIN N INJ U-100 3 QL (50 ml / 30 days),

ST; OTC NOVOLIN R INJ U-100 3 QL (50 ml / 30 days),

ST; OTC NOVOLOG INJ 100/ML 3 QL (50 ml / 30 days),

ST NOVOLOG INJ FLEXPEN 3 QL (45 ml / 30 days),

ST NOVOLOG INJ PENFILL 3 QL (45 ml / 30 days),

ST NOVOLOG MIX INJ 70/30 3 QL (50 ml / 30 days),

ST NOVOLOG MIX INJ FLEXPEN 3 QL (45 ml / 30 days),

ST TOUJEO SOLO INJ 300IU/ML 3 QL (9 ml / 30 days), ST TRESIBA FLEX INJ 100UNIT 2 QL (45 ml / 30 days) TRESIBA FLEX INJ 200UNIT 2 QL (27 ml / 30 days) ANTIDIABETICS, MEGLITINIDE nateglinide tab 60 mg 1 nateglinide tab 120 mg 1 repaglinide tab 0.5 mg 1 repaglinide tab 1 mg 1 repaglinide tab 2 mg 1 ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATIONS repaglinide-metformin hcl tab 1-500 mg 1


117

Drug Name Drug Tier Requirements/Limits repaglinide-metformin hcl tab 2-500 mg 1 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)

INHIBITOR/BIGUANIDE COMBINATIONS INVOKAMET TAB 50-500MG 2 QL (60 tabs / 30 days),

ST (step through metformin)

INVOKAMET TAB 50-1000 2 QL (60 tabs / 30 days), ST (step through metformin)



INVOKAMET XR TAB 50-500MG 2 QL (60 tabs / 30 days), ST (step through metformin)

INVOKAMET XR TAB 50-1000 2 QL (60 tabs / 30 days), ST (step through metformin)



SYNJARDY TAB 2 ST (step through metformin)

SYNJARDY TAB 5-500MG 2 ST (step through metformin)

SYNJARDY TAB 5-1000MG 2 ST (step through metformin)

SYNJARDY TAB 12.5-500 2 ST (step through metformin)

SYNJARDY XR TAB 2 ST (step through metformin)

SYNJARDY XR TAB 5-1000MG 2 ST (step through metformin)

SYNJARDY XR TAB 10-1000 2 ST (step through metformin)

SYNJARDY XR TAB 25-1000 2 ST (step through metformin)

XIGDUO XR TAB 5-500MG 3 ST XIGDUO XR TAB 5-1000MG 3 ST XIGDUO XR TAB 10-500MG 3 ST XIGDUO XR TAB 10-1000 3 ST


118

Drug Name Drug Tier Requirements/Limits ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)

INHIBITORS FARXIGA TAB 5MG 3 QL (30 tabs / 30 days),

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

ST INVOKANA TAB 100MG 2 QL (60 tabs / 30 days),

ST (step through metformin)

INVOKANA TAB 300MG 2 QL (30 tabs / 30 days), ST (step through metformin)

JARDIANCE TAB 10MG 2 QL (60 / 30), ST (step through metformin)

JARDIANCE TAB 25MG 2 QL (30 / 30), ST (step through metformin)

ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR/DPP-4 INHIBITOR COMBINATIONS

GLYXAMBI TAB 10-5 MG 3 QL (30 tabs / 30 days), ST

GLYXAMBI TAB 25-5 MG 3 QL (30 tabs / 30 days), ST

ANTIDIABETICS, SULFONYLUREAS chlorpropamide tab 100 mg 1 chlorpropamide tab 250 mg 1 glimepiride tab 1 mg 1 glimepiride tab 2 mg 1 glimepiride tab 4 mg 1 glipizide tab 5 mg 1 glipizide tab 10 mg 1 glipizide tab er 24hr 5 mg 1 glipizide tab er 24hr 10 mg 1 glipizide xl tab 2.5mg 1 glyburide micronized tab 1.5 mg 1 glyburide micronized tab 3 mg 1 glyburide micronized tab 6 mg 1 glyburide tab 1.25 mg 1 glyburide tab 2.5 mg 1 glyburide tab 5 mg 1 tolazamide tab 250 mg 1 tolazamide tab 500 mg 1 tolbutamide tab 500 mg 1 ANTIDIABETICS, SUPPLIES ACCU-CHEK IN LIQ CONTROL 2 OTC ACCU-CHEK KIT AVA CONN 2 QL (1 kit / year); OTC ACCU-CHEK KIT AVIVA PL 2 QL (1 kit / year); OTC


119

Drug Name Drug Tier Requirements/Limits ACCU-CHEK KIT COMBO 2 ACCU-CHEK KIT COMPACT 2 QL (1 kit / year); OTC ACCU-CHEK KIT FASTCLIX 2 OTC ACCU-CHEK KIT MLTICLIX 2 OTC ACCU-CHEK KIT NANO 2 QL (1 kit / year); OTC ACCU-CHEK KIT SOFTCLIX 2 OTC ACCU-CHEK KIT VOICEMAT 2 QL (1 kit / year); OTC ACCU-CHEK LIQ COMPACT 2 OTC ACCU-CHEK LIQ SMART 2 OTC ACCU-CHEK SOL 2 OTC ACCU-CHEK SOL COMPACT 2 OTC ACCU-CHEK TES AVIVA PL 2 QL (210 strips / 30

days); OTC ACCU-CHEK TES COMPACT 2 QL (210 strips / 30

days); OTC ACCU-CHEK TES SMART 2 QL (210 strips / 30

days); OTC ACCUTREND TES GLUCOSE 2 QL (210 strips / 30

days); OTC ACETEST TAB TABLETS 2 OTC ADVOCATE ARM MIS BPM LRG 3 QL (1 kit / year), PA;

OTC ALCOH-WIPE PAD 12"X12" 3 QL (300 pads / 30 days) AUTOSHIELD MIS 29X3/16" 2 OTC AUTOSHIELD MIS 29X5/16" 2 OTC AUTOSHIELD MIS 30GX3/16 2 OTC CAREFINE MIS 32GX5MM 2 OTC CARTRIDGE MIS PUMP 3 CHEMSTRIP TES STRIPS 2 OTC CLINITEST TAB 2 DROP 2 OTC COMFORT EZ MIS 33GX5MM 2 OTC COMFORT EZ MIS 33GX6MM 2 OTC COMFORT EZ MIS 33GX8MM 2 OTC CVS KETONE TES CARE 2 QL (210 strips / 30

days); OTC DELTEC COZMO MIS INL PUMP 2 DIASTIX TES STRIPS 2 QL (210 strips / 30

days); OTC FREESTYLE KIT FREEDOM 2 QL (1 kit / year); OTC FREESTYLE KIT INSULINX 2 QL (1 kit / year); OTC FREESTYLE KIT SIDEKICK 2 QL (1 kit / year); OTC FREESTYLE KIT SYSTEM 2 QL (1 kit / year); OTC FREESTYLE LIQ CONTROL 2 OTC FREESTYLE MIS LITE 2 QL (1 kit / year); OTC FREESTYLE TES 2 QL (210 strips / 30

days); OTC


120

Drug Name Drug Tier Requirements/Limits FREESTYLE TES INSULINX 2 QL (210 strips / 30

days); OTC FREESTYLE TES LITE 2 QL (210 strips / 30

days); OTC G4 SENSOR MIS 3 QL (1 kit / year), PA GENTLE-LET MIS PLATFORM 2 QL (210 lancets / 30

days); OTC GUARDIAN RT MIS REPLACE 3 QL (1 kit / year), PA H-TRON PLUS MIS INS PUMP 2 OTC HUMAPEN MIS LUXURA 3 PA INFUSION SET MIS 23" 6MM 2 INFUSION SET MIS 23" 8MM 2 INFUSION SET MIS 23"/6MM 2 INFUSION SET MIS 23"/9MM 2 INFUSION SET MIS 24" 6MM 2 INFUSION SET MIS 24" 9MM 2 INFUSION SET MIS 31" 9MM 2 INFUSION SET MIS 32" 8MM 2 INFUSION SET MIS 43"/6MM 2 INFUSION SET MIS 43"/9MM 2 INSUL-TRAY MIS 3 PA; OTC INSULIN PEN MIS 31GX4MM 2 OTC INSULIN PUMP KIT IR2020 2 INSULIN PUMP KIT IR2020 2 PA INSULIN SYR MIS 0.3/31G 2 QL (210 syringes / 30

days); OTC INSULIN SYR MIS 0.5/31G 2 QL (210 syringes / 30

days); OTC INSULIN SYR MIS 1ML/31G 2 QL (210 syringes / 30

days); OTC INSULIN SYRG MIS 0.3/28G 2 QL (210 syringes / 30


days) INSULIN SYRG MIS 0.3/29G 2 QL (210 syringes / 30






days)


121

Drug Name Drug Tier Requirements/Limits INSULIN SYRG MIS 0.5/28G 2 QL (210 syringes / 30






days); OTC INSULIN SYRG MIS 1ML 2 QL (210 syringes / 30

days) INSULIN SYRG MIS 1ML/25G 2 QL (210 syringes / 30

days); OTC INSULIN SYRG MIS 1ML/26G 2 QL (210 syringes / 30










days); OTC INSULIN SYRG MIS 2/27.5G 2 QL (210 syringes / 30


days); OTC INSUPEN MIS 32GX4MM 2 OTC INSUPEN MIS 33GX4MM 2 OTC INSUPEN SENS MIS 32GX6MM 2 OTC INSUPEN SENS MIS 32GX8MM 2 OTC INSUPEN ULTR MIS 30GX8MM 2 OTC KETONE TEST TES 3 OTC LANCETS MIS 2 QL (210 lancets / 30

days); OTC


122

Drug Name Drug Tier Requirements/Limits LANCING DEVI MIS 2 OTC LITETOUCH MIS 29GX12.7 2 OTC MICRO-BUMIN KIT 3 PA; OTC MINILINK RT KIT STARTER 3 PA NOVOTWIST MIS 32GX5MM 2 OMNIPOD KIT STARTER 2 OMNIPOD MIS 2 ONETOUCH PNG KIT INS PUMP 2 PA PEN NEEDLES MIS 29GX1/2" 2 OTC PEN NEEDLES MIS 29GX10MM 2 OTC PEN NEEDLES MIS 31GX1/4" 2 OTC PEN NEEDLES MIS 31GX5/16 2 OTC SOF-SENSOR MIS 3 PA UNIFINE PNTP MIS 31GX3/16 2 OTC ANTIDOTES ACETADOTE INJ 200MG/ML 3 PA acetylcysteine inj 200 mg/ml 1 PA ATROPEN INJ 0.5MG 3 PA ATROPEN INJ 1MG 3 PA ATROPEN INJ 2MG 3 PA BAL IN OIL INJ 100MG/ML 3 PA CA-DTPA SOL 1000MG 3 PA CALCIUM DISO INJ 1GM/5ML 3 PA CYANOKIT INJ 5GM 3 PA DIGIFAB INJ 40MG 3 PA DUODOTE INJ 3 PA flumazenil iv soln 0.5 mg/5ml (0.1 mg/ml) 1 flumazenil iv soln 1 mg/10ml (0.1 mg/ml) 1 fomepizole inj 1 gm/ml (for iv infusion) 1 methylene blue inj 1% 1 NITHIODOTE KIT 3 PA PHYSOS SALIC INJ 1MG/ML 3 PRALIDOXIME INJ 600/2ML 3 PA PROTOPAM CHL INJ 1GM 2 SOD NITRITE INJ 30MG/ML 3 PA sodium thiosulfate inj 25% 1 ZN-DTPA SOL 1000MG 3 PA ANTIOBESITY AGENTS, INJECTABLE SAXENDA INJ 6MG/ML 3 PA ANTIOBESITY AGENTS, ORAL ADIPEX-P CAP 37.5MG 3 PA ADIPEX-P TAB 37.5MG 3 PA ALLI CAP 60MG 1 PA; OTC, $0 copay BELVIQ TAB 10MG 3 QL (60 tabs / 30 days),

PA


123

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

PA benzphetamine hcl tab 50 mg 1 PA CONTRAVE TAB 8-90MG 3 QL (120 tabs / 30 days),

PA diethylpropion hcl tab 25 mg 1 PA diethylpropion hcl tab er 24hr 75 mg 1 PA phendimetrazine tartrate cap er 24hr 105

mg 1 PA

phendimetrazine tartrate tab 35 mg 1 PA phentermine hcl cap 15 mg 1 PA phentermine hcl cap 30 mg 1 PA phentermine hcl cap 37.5 mg 1 PA phentermine hcl tab 37.5 mg 1 PA QSYMIA CAP 3.75-23 3 PA QSYMIA CAP 7.5-46MG 3 PA QSYMIA CAP 11.25-69 3 PA QSYMIA CAP 15-92MG 3 PA REGIMEX TAB 25MG 3 PA XENICAL CAP 120MG 3 PA CALCIUM RECEPTOR ANTAGONISTS SENSIPAR TAB 30MG 2 QL (60 tabs / 30 days),

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

PA SENSIPAR TAB 90MG 2 QL (120 tabs / 30 days),

PA CALCIUM REGULATORS, BISPHOSPHONATES ACTONEL TAB 5MG 3 PA, ST ACTONEL TAB 30MG 3 PA, ST ACTONEL TAB 35MG 3 QL (4 tabs / 25 days),

PA, ST ACTONEL TAB 150MG 3 QL (1 tab / 25 days),

PA, ST alendronate sodium oral soln 70 mg/75ml 1 QL (300 / 30 days) alendronate sodium tab 5 mg 1 alendronate sodium tab 10 mg 1 alendronate sodium tab 35 mg 1 alendronate sodium tab 40 mg 1 alendronate sodium tab 70 mg 1 ATELVIA TAB 3 QL (4 tab / 25 days),

PA, ST BINOSTO TAB 70MG 3 ST BONIVA TAB 150MG 3 QL (1 tab / 25 days),

PA, ST etidronate disodium tab 200 mg 1


124

Drug Name Drug Tier Requirements/Limits etidronate disodium tab 400 mg 1 FOSAMAX + D TAB 70-2800 3 QL (4 tabs / 25 days),

ST FOSAMAX + D TAB 70-5600 3 QL (4 tabs / 25 days),

ST FOSAMAX TAB 70MG 3 PA, ST ibandronate sodium tab 150 mg (base

equivalent) 1 QL (1 tab / 25 days)

risedronate sodium tab 5 mg 1 risedronate sodium tab 30 mg 1 risedronate sodium tab 35 mg 1 QL (4 tabs / 25 days) risedronate sodium tab 150 mg 1 QL (1 tab / 25 days) risedronate sodium tab delayed release 35


CALCIUM REGULATORS, CALCITONINS calcitonin (salmon) nasal soln 200 unit/act 1 MIACALCIN SPR 200/ACT 3 PA, ST CALCIUM REGULATORS, PARATHYROID HORMONES FORTEO SOL 600/2.4 2 QL (1 pen / 28 days), PA NATPARA INJ 25MCG 3 QL (2 pens / 28 days),

PA NATPARA INJ 50MCG 3 QL (2 pens / 28 days),



PA TYMLOS INJ 2 QL (1 pen / 30 days), PA CALCIUM REGULATORS, RANK LIGAND INHIBITORS PROLIA SOL 60MG/ML 3 QL (1 syringe / 180

days), PA CONTRACEPTIVES, BIPHASIC azurette tab 28 day 1 MIRCETTE TAB 28 DAY 3 PA NECON TAB 10/11-28 3 PA CONTRACEPTIVES, EMERGENCY CONTRACEPTION ELLA TAB 30MG 3 PA levonorgestrel tab 1.5 mg 1 my way tab 1.5mg 1 OTC PLAN B TAB 1.5MG 3 PA; OTC CONTRACEPTIVES, EXTENDED CYCLE amethia tab 1 QL (91 tabs / 91 days) fayosim tab 1 QL (91 tabs / 91 days) levonorg-eth est tab 0.1-0.02mg(84) & eth

est tab 0.01mg(7) 1 QL (91 tabs / 91 days)


125

Drug Name Drug Tier Requirements/Limits LOSEASONIQUE TAB 3 QL (91 tabs / 91 days),

PA QUARTETTE TAB 3 QL (91 tabs / 91 days),

PA quasense tab 1 QL (91 tabs / 91 days) rivelsa tab 1 QL (91 tabs / 91 days) SEASONIQUE TAB 3 QL (91 tabs / 91 days),

PA CONTRACEPTIVES, FOUR PHASE NATAZIA TAB 3 PA CONTRACEPTIVES, IMPLANT NEXPLANON IMP 68MG 2 CONTRACEPTIVES, INJECTABLE DEPO-PROVERA INJ 150MG/ML 3 QL (1 syringe / 75

days), PA DEPO-PROVERA INJ 150MG/ML 3 QL (1 vial / 75 days), PA DEPO-SQ PROV INJ 104 3 PA medroxyprogesterone acetate im susp 150

mg/ml 1 QL (1 vial / 75 days)

medroxyprogesterone acetate im susp prefilled syr 150 mg/ml

1 QL (1 syringe / 75 days)

CONTRACEPTIVES, INTRAUTERINE DEVICE PARAGARD IUD T380A 2 CONTRACEPTIVES, MISCELLANEOUS CONCEPTION KIT 2 FEMCAP MIS 22MM 3 FEMCAP MIS 26MM 2 FEMCAP MIS 30MM 2 WIDE-SEAL DPR KIT 60 3 PA WIDE-SEAL DPR KIT 65 3 PA WIDE-SEAL DPR KIT 70 3 PA WIDE-SEAL DPR KIT 75 3 PA WIDE-SEAL DPR KIT 80 3 PA WIDE-SEAL DPR KIT 85 3 PA WIDE-SEAL DPR KIT 90 3 PA WIDE-SEAL DPR KIT 95 3 PA CONTRACEPTIVES, MONOPHASIC aubra tab 0.1-0.02 1 QL (30 tabs / 30 days) BEYAZ TAB 3 QL (30 tabs / 30 days),

PA chateal tab 0.15/30 1 QL (30 tabs / 30 days) cyred tab 1 QL (30 tabs / 30 days) DESOGEN-28 TAB 3 QL (30 tabs / 30 days),

PA drospirenone-ethinyl estrad-levomefolate

tab 3-0.02-0.451 mg 1 QL (30 tabs / 30 days)


126

Drug Name Drug Tier Requirements/Limits drospirenone-ethinyl estradiol tab 3-0.03


FEMCON FE CHW 3 QL (30 ea / 30 days), PA GENERESS FE CHW 3 QL (30 ea / 30 days), PA layolis fe chw 1 QL (30 ea / 30 days) LO LOESTRIN TAB 3 PA LOESTRIN 21 TAB 1.5/30 3 QL (30 tabs / 30 days),

PA LOESTRIN FE TAB 1.5/30 3 QL (30 tabs / 30 days),

PA LOESTRIN FE TAB 1/20 3 QL (30 tabs / 30 days),

PA LOESTRIN TAB 1/20-21 3 QL (30 tabs / 30 days),

PA low-ogestrel tab 1 QL (30 tabs / 30 days) micrgstin 24 tab fe 1/20 1 QL (30 tabs / 30 days) microgestin tab 1.5/30 1 QL (30 tabs / 30 days) microgestin tab 1/20 1 QL (30 tabs / 30 days) microgestin tab fe1.5/30 1 QL (30 tabs / 30 days) MINASTRIN 24 CHW FE 3 QL (30 ea / 30 days), PA MODICON TAB 0.5/35 3 QL (30 tabs / 30 days),

PA mononessa tab 1 QL (30 tabs / 30 days) necon tab 0.5/35 1 QL (30 tabs / 30 days) necon tab 1/35 1 QL (30 tabs / 30 days) necon tab 1/50-28 1 QL (30 tabs / 30 days) ogestrel tab 1 QL (30 tabs / 30 days) ORTHO-CYCLEN TAB 0.25/35 3 QL (30 tabs / 30 days),

PA ORTHO-NOVUM TAB 1/35 3 QL (30 tabs / 30 days),

PA OVCON-35 TAB 3 QL (30 tabs / 30 days),

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

PA tarina fe tab 1/20 1 QL (30 tabs / 30 days) vestura tab 3-0.02mg 1 QL (30 tabs / 30 days) YASMIN 28 TAB 3-0.03MG 3 QL (30 tabs / 30 days),

PA YAZ TAB 3-0.02MG 3 QL (30 tabs / 30 days),

PA zenchent fe chw 0.4mg-35 1 QL (30 ea / 30 days) zenchent tab 1 QL (30 tabs / 30 days) zovia 1/35e tab 1 QL (30 tabs / 30 days) zovia 1/50e tab 1 QL (30 tabs / 30 days) CONTRACEPTIVES, PROGESTIN INTRAUTERINE DEVICE LILETTA IUD 52MG 2


127

Drug Name Drug Tier Requirements/Limits MIRENA IUD SYSTEM 2 SKYLA IUD 13.5MG 2 CONTRACEPTIVES, PROGESTIN ONLY lyza tab 0.35mg 1 ORTHO MICRON TAB 0.35MG 3 PA CONTRACEPTIVES, TRANSDERMAL xulane dis 150-35 1 QL (3 ea / 25 days) CONTRACEPTIVES, TRIPHASIC caziant pak 1 CYCLESSA PAK 3 PA enpresse-28 tab 1 ESTROSTEP FE TAB 3 PA leena tab 1 necon tab 7/7/7 1 ORTHO TRI- TAB CYCLEN 3 PA ORTHO TRI- TAB CYCLN LO 3 PA ORTHO-NOVUM TAB 7/7/7 3 PA tilia fe tab 1 TRI-NORINYL TAB 28 3 PA trinessa lo tab 1 trinessa tab 1 CONTRACEPTIVES, VAGINAL NUVARING MIS 3 QL (1 ring / 21 days) ENDOMETRIOSIS danazol cap 50 mg 1 danazol cap 100 mg 1 danazol cap 200 mg 1 SYNAREL SOL 2MG/ML 3 QL (40 / 25 days), PA ESTROGEN/PROGESTIN, ORAL ACTIVELLA TAB 0.5-0.1 3 PA, ST ACTIVELLA TAB 1-0.5MG 3 PA, ST estradiol & norethindrone acetate tab 0.5-

0.1 mg 1

estradiol & norethindrone acetate tab 1-0.5 mg

1

FEMHRT TAB 0.5-2.5 3 PA, ST fyavolv tab 1-5 1 jevantique l tab 0.5-2.5 1 PREFEST TAB 3 ST PREMPHASE TAB 2 PREMPRO TAB 0.3-1.5 2 PREMPRO TAB 0.45-1.5 2 PREMPRO TAB 0.625-5 2 PREMPRO TAB .625-2.5 2 ESTROGEN/PROGESTIN, TRANSDERMAL


128

Drug Name Drug Tier Requirements/Limits CLIMARA PRO DIS WEEKLY 3 ST COMBIPATCH DIS .05/.14 3 QL (8 ea / 25 days), ST COMBIPATCH DIS .05/.25 3 QL (84 per 365 days),

ST ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR

COMBINATIONS DUAVEE TAB 0.45-20 3 ST ESTROGENS, INJECTABLE DELESTROGEN INJ 10MG/ML 3 PA DELESTROGEN INJ 20MG/ML 3 PA DELESTROGEN INJ 40MG/ML 3 PA DEPO-ESTRADI INJ 5MG/ML 3 PA estradiol valerate im in oil 20 mg/ml 1 estradiol valerate im in oil 40 mg/ml 1 PREMARIN INJ 25MG 3 PA ESTROGENS, ORAL ESTRACE TAB 0.5MG 3 PA, ST ESTRACE TAB 1MG 3 PA, ST ESTRACE TAB 2MG 3 PA, ST estradiol tab 0.5 mg 1 estradiol tab 1 mg 1 estradiol tab 2 mg 1 estropipate tab 0.75 mg 1 estropipate tab 1.5 mg 1 estropipate tab 3 mg 1 MENEST TAB 0.3MG 2 MENEST TAB 0.625MG 2 MENEST TAB 1.25MG 2 MENEST TAB 2.5MG 2 PREMARIN TAB 0.3MG 3 ST PREMARIN TAB 0.9MG 3 ST PREMARIN TAB 0.45MG 3 ST PREMARIN TAB 0.625MG 3 ST PREMARIN TAB 1.25MG 3 ST ESTROGENS, TRANSDERMAL ALORA DIS 0.1MG 3 QL (8 ea / 25 days), ST ALORA DIS 0.05MG 3 QL (8 ea / 25 days), ST ALORA DIS 0.025MG 3 QL (8 ea / 25 days), ST ALORA DIS 0.075MG 3 QL (8 ea / 25 days), ST CLIMARA DIS 0.1MG 3 PA, ST CLIMARA DIS 0.05MG 3 PA, ST CLIMARA DIS 0.06MG 3 QL (4 ea / 25 days), PA,

ST CLIMARA DIS 0.025MG 3 QL (4 ea / 25 days), PA,

ST


129

Drug Name Drug Tier Requirements/Limits CLIMARA DIS 0.075MG 3 QL (4 ea / 25 days), PA,

ST CLIMARA DIS 0.0375MG 3 QL (4 ea / 25 days), PA,

ST DIVIGEL GEL 0.5MG 3 ST DIVIGEL GEL 0.25MG 3 ST DIVIGEL GEL 1MG/GM 3 ST ELESTRIN GEL 0.06% 3 QL (26 gm / 25 days),

ST estradiol td patch twice weekly 0.1

mg/24hr 1 QL (8 ea / 25 days)

estradiol td patch twice weekly 0.05 mg/24hr

1 QL (8 ea / 25 days)


1 QL (8 ea / 25 days)


1 QL (8 ea / 25 days)


1 QL (8 ea / 25 days)

estradiol td patch weekly 0.1 mg/24hr 1 QL (4 ea / 25 days) estradiol td patch weekly 0.05 mg/24hr 1 QL (4 ea / 25 days) estradiol td patch weekly 0.06 mg/24hr 1 QL (4 ea / 25 days) estradiol td patch weekly 0.025 mg/24hr 1 QL (4 ea / 25 days) estradiol td patch weekly 0.075 mg/24hr 1 QL (4 ea / 25 days) estradiol td patch weekly 0.0375 mg/24hr

(37.5 mcg/24hr) 1 QL (4 ea / 25 days)

ESTROGEL GEL 3 QL (50 gm / 25 days), ST

EVAMIST SPR 1.53MG 3 ST MENOSTAR DIS 14MCG 3 QL (4 ea / 25 days), ST MINIVELLE DIS 0.0375MG 3 QL (8 ea / 25 days), ST VIVELLE-DOT DIS 0.1MG 3 QL (8 ea / 25 days), PA,

ST VIVELLE-DOT DIS 0.05MG 3 QL (8 ea / 25 days), PA,




ST ESTROGENS, VAGINAL ESTRACE VAG CRE 0.1MG/GM 3 PA ESTRING MIS 2MG 3 QL (1 ring / 91 days),

ST FEMRING MIS 0.1MG/24 3 ST FEMRING MIS 0.05/24H 3 ST


130

Drug Name Drug Tier Requirements/Limits PREMARIN VAG CRE 0.625MG 3 PA yuvafem tab 10mcg 1 FERTILITY REGULATORS, GNRH / LHRH ANTAGONISTS CETROTIDE KIT 0.25MG 3 PA FERTILITY REGULATORS, OVULATION STIMULANTS,

GONADOTROPINS novarel inj 10000unt 1 PA OVIDREL INJ 3 PA GLUCOCORTICOID COMBINATIONS ACTIVE INJEC KIT KL-3 3 PA betamethasone sod phosphate & acetate

inj susp 6 (3-3) mg/ml 1

CELESTONE INJ SOLUSPAN 3 PA PHYS EZ USE KIT M-PRED 3 PA GLUCOCORTICOIDS CORTEF TAB 5MG 3 PA, ST CORTEF TAB 10MG 3 PA, ST CORTEF TAB 20MG 3 PA, ST cortisone acetate tab 25 mg 1 DEPO-MEDROL INJ 20MG/ML 3 PA DEPO-MEDROL INJ 40MG/ML 3 PA DEPO-MEDROL INJ 80MG/ML 3 PA dexamethasone elixir 0.5 mg/5ml 1 dexamethasone sod phosphate

preservative free inj 10 mg/ml 1

dexamethasone sodium phosphate inj 4 mg/ml

1

dexamethasone sodium phosphate inj 10 mg/ml

1

dexamethasone sodium phosphate inj 20 mg/5ml

1


1


1

dexamethasone soln 0.5 mg/5ml 1 dexamethasone tab 0.5 mg 1 dexamethasone tab 0.75 mg 1 dexamethasone tab 1 mg 1 dexamethasone tab 1.5 mg 1 dexamethasone tab 2 mg 1 dexamethasone tab 4 mg 1 dexamethasone tab 6 mg 1 DEXPAK PAK 6 DAY 3 ST DEXPAK PAK 10 DAY 3 ST DEXPAK PAK 13 DAY 3 ST


131

Drug Name Drug Tier Requirements/Limits EMFLAZA TAB 6MG 3 PA EMFLAZA TAB 18MG 3 PA EMFLAZA TAB 30MG 3 PA EMFLAZA TAB 36MG 3 PA fludrocortisone acetate tab 0.1 mg 1 hydrocortisone tab 5 mg 1 hydrocortisone tab 10 mg 1 hydrocortisone tab 20 mg 1 KENALOG-10 INJ 10MG/ML 3 PA KENALOG-40 INJ 40MG/ML 3 PA MEDROL TAB 2MG 3 ST MEDROL TAB 4MG 3 PA, ST MEDROL TAB 8MG 3 PA, ST MEDROL TAB 16MG 3 PA, ST MEDROL TAB 32MG 3 PA, ST methylprednisolone acetate inj susp 40

mg/ml 1

methylprednisolone acetate inj susp 80 mg/ml

1

methylprednisolone sodium succinate for inj 40 mg

1


1


1

methylprednisolone tab 4 mg 1 methylprednisolone tab 8 mg 1 methylprednisolone tab 16 mg 1 methylprednisolone tab 32 mg 1 methylprednisolone tab therapy pack 4 mg

(21) 1

MILLIPRED DP PAK 5MG 3 MILLIPRED SOL 10MG/5ML 3 ST MILLIPRED TAB 5MG 3 PA ORAPRED ODT TAB 10MG 3 PA, ST ORAPRED ODT TAB 15MG 3 PA, ST ORAPRED ODT TAB 30MG 3 PA, ST PEDIAPRED SOL 6.7/5ML 3 PA, ST prednisolone sod phos orally disintegr tab

10 mg (base eq) 1

prednisolone sod phos orally disintegr tab 15 mg (base eq)

1

prednisolone sod phos orally disintegr tab 30 mg (base eq)

1

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

1


132

Drug Name Drug Tier Requirements/Limits prednisolone sod phosphate oral soln 15

mg/5ml (base equiv) 1

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

1

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

1

prednisone oral soln 5 mg/5ml 1 prednisone tab 1 mg 1 prednisone tab 2.5 mg 1 prednisone tab 5 mg 1 prednisone tab 10 mg 1 prednisone tab 20 mg 1 prednisone tab 50 mg 1 prednisone tab therapy pack 5 mg (21) 1 prednisone tab therapy pack 5 mg (48) 1 prednisone tab therapy pack 10 mg (21) 1 prednisone tab therapy pack 10 mg (48) 1 RAYOS TAB 1MG 3 ST RAYOS TAB 2MG 3 ST RAYOS TAB 5MG 3 ST SOLU-CORTEF INJ 100MG 3 PA SOLU-CORTEF INJ 250MG 3 PA SOLU-CORTEF INJ 500MG 3 PA SOLU-CORTEF INJ 1000MG 3 PA SOLU-MEDROL INJ 1GM 3 PA SOLU-MEDROL INJ 2GM 3 PA SOLU-MEDROL INJ 40MG 3 PA SOLU-MEDROL INJ 125MG 3 PA SOLU-MEDROL INJ 500MG 3 PA GLUCOSE ELEVATING AGENT GLUCAGEN INJ 1MG 2 GLUCAGEN INJ HYPOKIT 2 QL (2 boxes / 25 days) GLUCAGON KIT 1MG 2 QL (2 boxes / 25 days) glucose drnk liq 15/59ml 1 OTC glucose gel 40% 1 OTC PROGLYCEM SUS 50MG/ML 2 SM GLUCOSE CHW SOUR APP 3 OTC HUMAN GROWTH HORMONES GENOTROPIN INJ 0.2MG 3 PA GENOTROPIN INJ 0.4MG 3 PA GENOTROPIN INJ 0.6MG 3 PA GENOTROPIN INJ 0.8MG 3 PA GENOTROPIN INJ 1.2MG 3 PA GENOTROPIN INJ 1.4MG 3 PA GENOTROPIN INJ 1.6MG 3 PA GENOTROPIN INJ 1.8MG 3 PA


133

Drug Name Drug Tier Requirements/Limits GENOTROPIN INJ 1MG 3 PA GENOTROPIN INJ 2MG 3 PA GENOTROPIN INJ 12MG 3 PA HUMATROPE INJ 5MG 3 PA HUMATROPE INJ 6MG 3 PA HUMATROPE INJ 12MG 3 PA HUMATROPE INJ 24MG 3 PA NORDITROPIN INJ 5/1.5ML 2 PA NORDITROPIN INJ 10/1.5ML 2 PA NORDITROPIN INJ 15/1.5ML 2 PA NORDITROPIN INJ 30/3ML 2 PA NUTROPIN AQ INJ 10MG/2ML 3 PA NUTROPIN AQ INJ 20MG/2ML 3 PA NUTROPIN AQ INJ NUSPIN 5 3 PA OMNITROPE INJ 5.8MG 3 PA OMNITROPE INJ 10/1.5ML 3 PA SAIZEN INJ 5MG 3 PA SAIZEN INJ 8.8MG 3 PA SEROSTIM INJ 4MG 2 PA SEROSTIM INJ 5MG 3 PA SEROSTIM INJ 6MG 3 PA ZOMACTON INJ 5MG 3 PA ZOMACTON INJ 10MG 3 PA ZORBTIVE INJ 8.8MG 3 PA HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol cap 0.5 mcg 1 calcitriol cap 0.25 mcg 1 calcitriol inj 1 mcg/ml 1 calcitriol oral soln 1 mcg/ml 1 doxercalciferol cap 0.5 mcg 1 doxercalciferol cap 1 mcg 1 doxercalciferol cap 2.5 mcg 1 HECTOROL CAP 0.5MCG 3 PA HECTOROL CAP 1MCG 3 PA HECTOROL CAP 2.5MCG 3 PA HECTOROL INJ 2MCG/ML 2 paricalcitol cap 1 mcg 1 paricalcitol cap 2 mcg 1 paricalcitol cap 4 mcg 1 paricalcitol iv soln 5 mcg/ml 1 ROCALTROL CAP 0.5MCG 3 PA ROCALTROL CAP 0.25MCG 3 PA ROCALTROL SOL 1MCG/ML 3 PA ZEMPLAR CAP 1MCG 3 PA ZEMPLAR CAP 2MCG 3 PA


134

Drug Name Drug Tier Requirements/Limits ZEMPLAR INJ 5MCG/ML 2 PA INSULIN-LIKE GROWTH FACTOR INCRELEX INJ 40MG/4ML 2 LYSOSOMAL STORAGE DISORDERS ALDURAZYME INJ 2.9MG/5M 2 CERDELGA CAP 84MG 3 QL (30 caps / 30 days),

PA ELAPRASE INJ 6MG/3ML 2 ELELYSO INJ 200UNIT 2 PA FABRAZYME INJ 5MG 2 FABRAZYME INJ 35MG 2 LUMIZYME INJ 50MG 2 NAGLAZYME INJ 1MG/ML 2 VPRIV INJ 400UNIT 2 ZAVESCA CAP 100MG 2 MISCELLANEOUS AMMONUL INJ 10% 3 PA cabergoline tab 0.5 mg 1 CARBAGLU TAB 200MG 2 CERVIDIL VAG MIS 10MG INS 3 PA CYSTADANE POW 2 EGRIFTA SOL 1MG 2 QL (60 / 30 days), PA EGRIFTA SOL 2MG 2 QL (60 / 30 days), PA H.P. ACTHAR INJ 80UNIT 2 QL (15 ml / 25 days),

PA HEMABATE INJ 250MCG 2 LUPR DEP-PED INJ 3M 30MG 2 QL (1 box / 84 days), PA LUPR DEP-PED INJ 7.5MG 2 QL (1 box / 21 days), PA LUPR DEP-PED INJ 11.25MG 2 QL (1 box / 21 days), PA LUPR DEP-PED INJ 11.25MG 2 QL (1 box / 70 days), PA LUPR DEP-PED INJ 15MG 2 QL (1 box / 21 days), PA methylergonovine maleate inj 0.2 mg/ml 1 PA methylergonovine maleate tab 0.2 mg 1 MYALEPT INJ 11.3MG 3 QL (30 / 30 days), PA octreotide acetate inj 50 mcg/ml (0.05

mg/ml) 1 PA

octreotide acetate inj 100 mcg/ml (0.1 mg/ml)

1 PA

octreotide acetate inj 500 mcg/ml (0.5 mg/ml)

1 PA

ORFADIN CAP 2MG 2 QL (600 caps / 30 days), PA




135

Drug Name Drug Tier Requirements/Limits ORFADIN CAP 20MG 2 QL (300 caps / 30

days), PA ORFADIN SUS 4MG/ML 2 PA oxytocin inj 10 unit/ml 1 PITOCIN INJ 10UNT/ML 3 PA PREPIDIL GEL 0.5MG/3G 3 PA PROSTIN E2 SUP 20MG 3 PA RAVICTI LIQ 1.1GM/ML 2 QL (525 / 25 days) SIGNIFOR INJ 0.3MG/ML 2 QL (60 / 30 days) SIGNIFOR INJ 0.6MG/ML 2 QL (60 / 30 days) SIGNIFOR INJ 0.9MG/ML 2 QL (60 / 30 days) STRENSIQ INJ 18/0.45 2 PA STRENSIQ INJ 28/0.7ML 2 PA STRENSIQ INJ 40MG/ML 2 PA STRENSIQ INJ 80/0.8ML 2 PA SYPRINE CAP 250MG 3 PA XURIDEN POW 2GM 3 PA PHENYLKETONURIA TREATMENT AGENTS KUVAN POW 100MG 2 PA KUVAN POW 500MG 2 PA KUVAN TAB 100MG 2 PA PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) cap

667 mg (169 mg ca) 1

calcium acetate (phosphate binder) tab 667 mg

1

FOSRENOL CHW 500MG 3 ST FOSRENOL CHW 750MG 3 ST FOSRENOL CHW 1000MG 3 ST PHOSLO CAP 667MG 3 PA, ST PHOSLYRA SOL 3 ST RENAGEL TAB 400MG 3 ST RENAGEL TAB 800MG 3 ST RENVELA PAK 0.8GM 3 RENVELA PAK 2.4GM 3 RENVELA TAB 800MG 3 sevelamer carbonate packet 0.8 gm 1 sevelamer carbonate packet 2.4 gm 1 VELPHORO CHW 500MG 3 ST POTASSIUM-REMOVING AGENTS KAYEXALATE POW 3 PA sodium polystyrene sulfonate powder 1 sodium polystyrene sulfonate rectal susp

30 gm/120ml 1

sps sus 15gm/60 1 VELTASSA POW 8.4GM 3 PA


136

Drug Name Drug Tier Requirements/Limits VELTASSA POW 16.8GM 3 PA VELTASSA POW 25.2GM 3 PA PROGESTINS, INJECTABLE MAKENA INJ 250MG/ML 2 PA progesterone im in oil 50 mg/ml 1 PROGESTINS, ORAL AYGESTIN TAB 5MG 3 PA medroxyprogesterone acetate tab 2.5 mg 1 medroxyprogesterone acetate tab 5 mg 1 medroxyprogesterone acetate tab 10 mg 1 MEGACE ES SUS 625/5ML 3 PA megestrol acetate susp 625 mg/5ml 1 norethindrone acetate tab 5 mg 1 progesterone micronized cap 100 mg 1 progesterone micronized cap 200 mg 1 PROMETRIUM CAP 100MG 3 PA PROMETRIUM CAP 200MG 3 PA PROVERA TAB 2.5MG 3 PA PROVERA TAB 5MG 3 PA PROVERA TAB 10MG 3 PA PROGESTINS, VAGINAL CRINONE GEL 4% VAG 3 PA SELECTIVE ESTROGEN RECEPTOR MODULATOR EVISTA TAB 60MG 3 PA OSPHENA TAB 60MG 3 QL (30 tabs / 30 days),

PA raloxifene hcl tab 60 mg 1 THYROID AGENTS, ANTITHYROID AGENTS iodine solution strong 5% (lugol's) 1 methimazole tab 5 mg 1 methimazole tab 10 mg 1 propylthiouracil tab 50 mg 1 SSKI SOL 1GM/ML 3 PA TAPAZOLE TAB 5MG 3 PA TAPAZOLE TAB 10MG 3 PA THYROID SUPPLEMENTS ARMOUR THYRO TAB 15MG 2 PA ARMOUR THYRO TAB 120MG 2 ARMOUR THYRO TAB 180MG 2 ARMOUR THYRO TAB 240MG 2 ARMOUR THYRO TAB 300MG 2 CYTOMEL TAB 5MCG 3 PA, ST CYTOMEL TAB 25MCG 3 PA, ST CYTOMEL TAB 50MCG 3 PA, ST levo-t tab 88mcg 1


137

Drug Name Drug Tier Requirements/Limits levo-t tab 112mcg 1 levo-t tab 137mcg 1 levo-t tab 175mcg 1 levo-t tab 200 mcg 1 levo-t tab 300 mcg 1 levothyroxine sodium tab 25 mcg 1 levothyroxine sodium tab 50 mcg 1 levothyroxine sodium tab 75 mcg 1 levothyroxine sodium tab 100 mcg 1 levothyroxine sodium tab 125 mcg 1 levothyroxine sodium tab 150 mcg 1 liothyronine sodium iv soln 10 mcg/ml 1 liothyronine sodium tab 5 mcg 1 liothyronine sodium tab 25 mcg 1 liothyronine sodium tab 50 mcg 1 NATURE THROI TAB 162.5MG 2 NATURE-THROI TAB 16.25MG 2 PA NATURE-THROI TAB 32.5MG 2 PA NATURE-THROI TAB 48.75MG 2 PA NATURE-THROI TAB 65MG 2 PA NATURE-THROI TAB 81.25MG 2 PA NATURE-THROI TAB 97.5MG 2 PA NATURE-THROI TAB 113.75MG 2 PA NATURE-THROI TAB 130MG 2 PA NATURE-THROI TAB 146.25MG 2 NATURE-THROI TAB 195MG 2 NATURE-THROI TAB 260MG 2 NATURE-THROI TAB 325MG 2 np thyroid tab 15mg 1 np thyroid tab 30mg 1 np thyroid tab 60mg 1 np thyroid tab 90mg 1 SYNTHROID TAB 25MCG 3 PA, ST SYNTHROID TAB 50MCG 3 PA, ST SYNTHROID TAB 75MCG 3 PA, ST SYNTHROID TAB 88MCG 3 PA, ST SYNTHROID TAB 100MCG 3 PA, ST SYNTHROID TAB 112MCG 3 PA, ST SYNTHROID TAB 125MCG 3 PA, ST SYNTHROID TAB 137MCG 3 PA, ST SYNTHROID TAB 150MCG 3 PA, ST SYNTHROID TAB 175MCG 3 PA, ST SYNTHROID TAB 200MCG 3 PA, ST SYNTHROID TAB 300MCG 3 PA, ST THYROLAR-1 TAB 60MG 2 THYROLAR-1/2 TAB 30MG 2


138

Drug Name Drug Tier Requirements/Limits THYROLAR-1/4 TAB 15MG 2 THYROLAR-2 TAB 120MG 2 THYROLAR-3 TAB 180MG 2 TIROSINT CAP 13MCG 3 ST TIROSINT CAP 25MCG 3 ST TIROSINT CAP 50MCG 3 ST TIROSINT CAP 75MCG 3 ST TIROSINT CAP 88MCG 3 ST TIROSINT CAP 100MCG 3 ST TIROSINT CAP 112MCG 3 ST TIROSINT CAP 125MCG 3 ST TIROSINT CAP 137MCG 3 ST TIROSINT CAP 150MCG 3 ST TRIOSTAT INJ 10MCG/ML 3 PA WESTHROID TAB 32.5MG 2 PA WESTHROID TAB 65MG 2 PA WESTHROID TAB 97.5MG 2 PA WESTHROID TAB 130MG 2 PA VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA TAB 15MG 2 QL (30 tabs / 30 days) SAMSCA TAB 30MG 2 QL (60 tabs / 30 days) VAPRISOL INJ 20/100ML 3 PA VASOPRESSINS DDAVP INJ 4MCG/ML 3 PA DDAVP SOL 0.01% 3 PA DDAVP SPR 0.01% 3 PA DDAVP TAB 0.1MG 3 PA DDAVP TAB 0.2MG 3 PA desmopressin acetate inj 4 mcg/ml 1 desmopressin acetate nasal soln 0.01%

(refrigerated) 1

desmopressin acetate nasal spray soln 0.01%

1

desmopressin acetate nasal spray soln 0.01% (refrigerated)

1

desmopressin acetate tab 0.1 mg 1 desmopressin acetate tab 0.2 mg 1 STIMATE SOL 1.5MG/ML 2 GASTROINTESTINAL ANTACIDS alamag-plus chw 1 OTC ALUM HYDROX SUS 320/5ML 3 OTC ant/anti-gas chw 1000-60 1 OTC antacid chw 500mg 1 OTC antacid chw 550-110 1 OTC


139

Drug Name Drug Tier Requirements/Limits antacid chw 750mg 1 OTC antacid extr chw 675-135 1 OTC antacid mult chw -symptom 1 OTC antacid plus sus anti-gas 1 OTC antacid plus sus gas rel 1 OTC ANTACID ULTR CHW 1000-200 3 OTC calcium carbonate (antacid) tab 648 mg 1 OTC childrens chw pepto 1 OTC cvs antacid sus supreme 1 OTC DI-GEL SUS 3 OTC foam antacid chw 80-20mg 1 OTC foam antacid sus 1 OTC GAVISCON CHW 2 OTC GAVISCON SUS CHERRY 2 OTC GELUSIL CHW 3 PA; OTC MAG OXIDE CAP 400MG 3 PA; OTC magnesium oxide tab 250 mg 1 OTC magnesium oxide tab 400 mg 1 OTC magnesium oxide tab 420 mg 1 OTC sm antacid chw ex-str 1 OTC sodium bicarbonate tab 325 mg 1 OTC sodium bicarbonate tab 650 mg 1 OTC tgt antacid chw 1000mg 1 OTC titralac chw 420mg 1 OTC TUMS CHW 500MG 2 PA; OTC URO-MAG CAP 140MG 2 OTC ANTIDIARRHEALS anti-diarrhe liq 1mg/5ml 1 OTC anti-diarrhe tab 2mg 1 OTC diphenoxylate w/ atropine liq 2.5-0.025

mg/5ml 1

diphenoxylate w/ atropine tab 2.5-0.025 mg

1

LOMOTIL TAB 2.5MG 3 PA loperamide hcl cap 2 mg 1 loperamide sus 1mg/7.5 1 OTC MOTOFEN TAB 3 PA MYTESI TAB 125MG 3 QL (60 tabs / 30 days),

PA paregoric tincture 2 mg/5ml (morphine

equivalent) 1

stomach relf chw 262mg 1 OTC stomach relf sus 262/15ml 1 OTC stomach relf sus 525/15ml 1 OTC stomach relf tab 262mg 1 OTC ANTIEMETICS


140

Drug Name Drug Tier Requirements/Limits AKYNZEO CAP 300-0.5 3 QL (2 caps / 25 days),

ST aprepitant capsule 40 mg 1 QL (1 cap / 30 days) aprepitant capsule 80 mg 1 QL (4 caps / 30 days) aprepitant capsule 125 mg 1 QL (2 caps / 30 days) aprepitant capsule therapy pack 80 & 125

mg 1 QL (2 paks / 30 days)

CESAMET CAP 1MG 3 PA compro sup 25mg 1 PA DICLEGIS TAB 10-10MG 3 QL (60 tabs / 30 days),

ST dronabinol cap 2.5 mg 1 dronabinol cap 5 mg 1 dronabinol cap 10 mg 1 EMEND CAP 40MG 3 QL (1 cap / 30 days) EMEND CAP 80MG 3 QL (4 caps / 30 days) EMEND CAP 125MG 3 QL (2 caps / 30 days) EMEND SOL 150MG 2 EMEND SUS 125MG 2 EMEND TRIPAC PAK 80 & 125 3 QL (2 paks / 30 days) granisetron hcl inj 0.1 mg/ml 1 PA granisetron hcl inj 1 mg/ml 1 PA granisetron hcl inj 4 mg/4ml (1 mg/ml) 1 PA granisetron hcl tab 1 mg 1 QL (14 tabs / 25 days) MARINOL CAP 2.5MG 3 PA MARINOL CAP 5MG 3 PA MARINOL CAP 10MG 3 PA meclizine hcl tab 12.5 mg 1 meclizine hcl tab 25 mg 1 METOCLOPRAMI TAB 10MG ODT 3 ST metoclopramide hcl inj 5 mg/ml 1 metoclopramide hcl orally disintegrating

tab 5 mg 1

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

1

metoclopramide hcl tab 5 mg 1 metoclopramide hcl tab 10 mg 1 ondansetron hcl inj 4 mg/2ml (2 mg/ml) 1 PA ondansetron hcl inj 40 mg/20ml (2 mg/ml) 1 PA ondansetron hcl oral soln 4 mg/5ml 1 ondansetron hcl tab 4 mg 1 QL (90 tabs / 30 days) ondansetron hcl tab 8 mg 1 QL (90 tabs / 30 days) ondansetron hcl tab 24 mg 1 QL (15 tabs / 30 days) ondansetron orally disintegrating tab 4 mg 1 QL (90 tabs / 30 days) ondansetron orally disintegrating tab 8 mg 1 QL (90 tabs / 30 days) PHENERGAN INJ 25MG/ML 3 PA


141

Drug Name Drug Tier Requirements/Limits PHENERGAN INJ 50MG/ML 3 PA phenergan sup 12.5mg 1 phenergan sup 25mg 1 phenergan sup 50mg 1 prochlorperazine edisylate inj 5 mg/ml 1 prochlorperazine maleate tab 5 mg (base

equivalent) 1

prochlorperazine maleate tab 10 mg (base equivalent)

1

promethazine hcl inj 25 mg/ml 1 promethazine hcl inj 50 mg/ml 1 promethazine hcl syrup 6.25 mg/5ml 1 promethazine hcl tab 12.5 mg 1 promethazine hcl tab 25 mg 1 promethazine hcl tab 50 mg 1 REGLAN TAB 5MG 3 PA REGLAN TAB 10MG 3 PA SANCUSO DIS 3.1MG 3 QL (1 ptch / 5 days), PA scopolamine td patch 72hr 1 mg/3days 1 TIGAN CAP 300MG 3 PA, ST TIGAN INJ 100MG/ML 3 ST TRANSDERM-SC DIS 1.5MG 3 ST trimethobenzamide hcl cap 300 mg 1 VARUBI TAB 90MG 3 QL (4 tabs / 25 days),

ST ZOFRAN INJ 40/20ML 3 PA ZOFRAN SOL 4MG/5ML 3 PA, ST ZOFRAN TAB 4MG 3 QL (90 tabs / 30 days),

PA, ST ZOFRAN TAB 4MG ODT 3 QL (90 tabs / 30 days),

PA, ST ZOFRAN TAB 8MG 3 QL (90 tabs / 30 days),

PA, ST ZOFRAN TAB 8MG ODT 3 QL (90 tabs / 30 days),

PA, ST ZUPLENZ MIS 4MG 3 ST ZUPLENZ MIS 8MG 3 ST ANTISPASMODICS BENTYL CAP 10MG 3 PA, ST BENTYL INJ 10MG/ML 3 PA, ST BENTYL TAB 20MG 3 PA, ST chlordiazepoxide hcl-clidinium bromide cap

5-2.5 mg 1

CUVPOSA SOL 1MG/5ML 3 PA dicyclomine hcl cap 10 mg 1 dicyclomine hcl inj 10 mg/ml 1


142

Drug Name Drug Tier Requirements/Limits dicyclomine hcl oral soln 10 mg/5ml 1 dicyclomine hcl tab 20 mg 1 glycopyrrolate inj 0.2 mg/ml 1 glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) 1 glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) 1 glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) 1 glycopyrrolate tab 1 mg 1 glycopyrrolate tab 2 mg 1 hyoscyamine sulfate elixir 0.125 mg/5ml 1 hyoscyamine sulfate soln 0.125 mg/ml 1 hyoscyamine sulfate tab 0.125 mg 1 hyoscyamine sulfate tab disint 0.125 mg 1 ST hyoscyamine sulfate tab er 12hr 0.375 mg 1 hyoscyamine sulfate tab sl 0.125 mg 1 LEVBID TAB 0.375 ER 3 PA LEVSIN INJ 0.5MG/ML 3 PA LEVSIN TAB 0.125MG 3 PA LEVSIN/SL SUB 0.125MG 3 PA LIBRAX CAP 5-2.5MG 3 PA methscopolamine bromide tab 2.5 mg 1 ST methscopolamine bromide tab 5 mg 1 ST PAMINE FORTE TAB 5MG 3 PA, ST PAMINE TAB 2.5MG 3 PA, ST propantheline bromide tab 15 mg 1 ST ROBINUL FORT TAB 2MG 3 PA, ST ROBINUL INJ 0.2MG/ML 3 PA, ST ROBINUL INJ 0.4/2ML 3 PA, ST ROBINUL TAB 1MG 3 PA, ST SYMAX DUOTAB TAB 3 ST CHOLELITHOLYTICS ACTIGALL CAP 300MG 3 PA CHENODAL TAB 250MG 2 URSO 250 TAB 250MG 3 PA URSO FORTE TAB 500MG 3 PA ursodiol cap 300 mg 1 ursodiol tab 250 mg 1 ursodiol tab 500 mg 1 H2-RECEPTOR ANTAGONISTS acid reducer tab 10mg 1 OTC cimetidine hcl soln 300 mg/5ml 1 cimetidine tab 200 mg 1 cimetidine tab 300 mg 1 cimetidine tab 400 mg 1 cimetidine tab 800 mg 1 famotidine for susp 40 mg/5ml 1


143

Drug Name Drug Tier Requirements/Limits famotidine in nacl 0.9% iv soln 20

mg/50ml 1

famotidine inj 20 mg/2ml 1 famotidine inj 40 mg/4ml 1 famotidine inj 200 mg/20ml 1 famotidine inj 500 mg/50ml 1 famotidine tab 20 mg 1 QL (30 tabs / 30 days) famotidine tab 40 mg 1 heartbrn rel tab 75mg 1 OTC nizatidine cap 150 mg 1 nizatidine cap 300 mg 1 nizatidine oral soln 15 mg/ml 1 PEPCID AC CHW MAX ST 3 OTC PEPCID SUS 40MG/5ML 3 PA, ST PEPCID TAB 20MG 3 QL (30 tabs / 30 days),

PA, ST PEPCID TAB 40MG 3 PA, ST ranitidine hcl cap 150 mg 1 ranitidine hcl cap 300 mg 1 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1 ranitidine hcl tab 150 mg 1 ranitidine hcl tab 300 mg 1 ZANTAC INJ 25MG/ML 3 ST ZANTAC INJ 50MG/2ML 3 ST ZANTAC TAB 150MG 3 PA, ST ZANTAC TAB 300MG 3 PA, ST INFLAMMATORY BOWEL DISEASE, ORAL AGENTS APRISO CAP 0.375GM 2 ASACOL HD TAB 800MG 3 ST AZULFIDINE TAB 500MG 3 ST AZULFIDINE TAB 500MG EN 3 ST balsalazide disodium cap 750 mg 1 budesonide delayed release particles cap 3

mg 1

COLAZAL CAP 750MG 3 ST DELZICOL CAP 400MG 3 ST DIPENTUM CAP 250MG 3 ST GIAZO TAB 1.1GM 3 ST LIALDA TAB 1.2GM 3 mesalamine tab delayed release 1.2 gm 1 mesalamine tab delayed release 800 mg 1 PENTASA CAP 250MG CR 3 ST PENTASA CAP 500MG CR 3 ST sulfasalazine tab 500 mg 1 sulfasalazine tab delayed release 500 mg 1 UCERIS TAB 9MG 3 ST


144

Drug Name Drug Tier Requirements/Limits INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS CANASA SUP 1000MG 2 CORTENEMA ENE 100MG 3 PA CORTIFOAM AER 90MG 2 hydrocortisone enema 100 mg/60ml 1 mesalamine enema 4 gm 1 mesalamine rectal enema 4 gm & cleanser

wipe kit 1

ROWASA KIT 4GM 3 PA, ST SFROWASA ENE 4GM 3 ST UCERIS AER 2MG/ACT 3 ST IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA CAP 8MCG 3 QL (60 caps / 30 days),

ST AMITIZA CAP 24MCG 3 QL (60 caps / 30 days),

PA LINZESS CAP 72MCG 2 QL (30 caps / 30 days) LINZESS CAP 145MCG 2 QL (30 caps / 30 days) LINZESS CAP 290MCG 2 QL (30 caps / 30 days) IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl tab 0.5 mg (base equiv) 1 PA alosetron hcl tab 1 mg (base equiv) 1 PA LOTRONEX TAB 0.5MG 2 PA LOTRONEX TAB 1MG 2 PA VIBERZI TAB 75MG 3 QL (60 tabs / 30 days),

PA VIBERZI TAB 100MG 3 QL (60 tabs / 30 days),

PA LAXATIVES/STOOL SOFTENERS CEO-TWO SUP 3 PA; OTC COLYTE/FLAVR SOL PACKS 3 PA, ST constulose sol 10gm/15 1 docusate cal cap 240mg 1 OTC docusate sodium liquid 150 mg/15ml 1 OTC docusate sodium syrup 60 mg/15ml 1 OTC ENEMEEZ MINI ENE 2 OTC epsom salt gra 1 OTC eql castor oil 100% 1 OTC EQUALACTIN CHW 625MG 3 OTC EVAC POW 3 PA; OTC FIBER CHOICE CHW 1.5GM 3 PA; OTC fiber laxatv tab 625mg 1 OTC fiber laxtiv cap 0.52gm 1 OTC fiber select chw gummies 1 OTC FLEET LIQUID ENE GLYCERIN 2 OTC gavilyte-c sol 1


145

Drug Name Drug Tier Requirements/Limits gavilyte-g sol 1 gavilyte-h kit 1 gavilyte-n sol flav pk 1 geri-mucil pow 68% 1 OTC glycerin ped sup 1.2gm 1 OTC glycerin sup 1gm 1 OTC glycerin sup 2.1gm 1 OTC glycerin sup 2gm 1 OTC GOLYTELY SOL 3 PA, ST GOLYTELY SOL 3 ST HYDROCIL INS POW 95% 3 OTC KONDREMUL EMU 50% 3 OTC KONSYL POW 28.3% 2 OTC KONSYL POW 60.3% 3 OTC KONSYL POW 60.3% 3 PA; OTC KONSYL POW 71.67% 3 OTC KONSYL POW 100% 3 OTC KRISTALOSE PAK 10GM 3 ST KRISTALOSE PAK 20GM 3 ST lax diet sup tab 500mg 1 OTC laxative chw 15mg 1 OTC laxative tab 5mg ec 1 OTC laxative tab 15mg 1 OTC laxative tab 25mg 1 OTC magnesium citrate soln 1 OTC METAMUCIL POW 28% 3 OTC metamucil pow 28.3%org 1 OTC METAMUCIL POW 55.46% 3 OTC metamucil pow 58.6%org 1 OTC METAMUCIL POW 58.12% 3 OTC METAMUCIL POW 63% 3 OTC MILK OF MAGN SUS 800/5ML 3 ST; OTC milk of magn sus 1200/15 1 OTC mineral oil enema 1 OTC MIRALAX POW 3350 NF 3 PA, ST; OTC move along tab 100mg 1 OTC MOVIPREP SOL 3 ST NAT FIBER POW 58.6% 3 OTC naturl fiber pow 30.9% 1 OTC NULYTELY SOL FLAV PKS 3 PA, ST oral saline sol laxative 1 OTC OSMOPREP TAB 1.5GM 3 ST PEDIA-LAX LIQ 50MG 3 OTC PEDIA-LAX SUP 2.8GM 2 OTC polyethylene glycol 3350 oral packet 1 polyethylene glycol 3350 oral powder 1


146

Drug Name Drug Tier Requirements/Limits PREPOPIK PAK 3 QL (30 boxes / 30

days), ST qc natural pow vegetabl 1 OTC ra col-rite cap 50mg 1 OTC sb fib lax pow 30% 1 OTC sb fib lax pow 33% 1 OTC sb nat fiber pow 49% 1 OTC SENNA PROMPT CAP 9-500MG 3 OTC senna tab 8.6mg 1 OTC senna-extra tab 17.2mg 1 OTC sennosides cap 8.6 mg 1 OTC sennosides syrup 8.8 mg/5ml 1 OTC sm fiber lax tab 500mg 1 OTC sm fiber pow 48.57% 1 OTC sm glycerin sup 80.7% 1 OTC sm laxative sup 10mg 1 OTC sodium phosphates - enema 1 OTC soluble fib pow therapy 1 OTC stool softnr cap 100mg 1 OTC stool softnr cap 250mg 1 OTC stool softnr tab 8.6-50mg 1 OTC SUPREP BOWEL SOL PREP KIT 3 PA total fiber pow 1 OTC UNIFIBER POW 3 OTC wal-mucil cap plus ca 1 OTC wal-mucil pow 100% 1 OTC MISCELLANEOUS ACIDOPH/PROB TAB FORMULA 3 PA; OTC ACIDOPHILUS CAP 2 OTC ACIDOPHILUS/ WAF BIFIDUS 3 OTC BIOGAIA DRO PROBIOTI 3 PA; OTC BIOGAIA MIS PROBIOTI 3 PA; OTC CARAFATE SUS 1GM/10ML 3 CARAFATE TAB 1GM 3 PA CHOLBAM CAP 50MG 3 PA CHOLBAM CAP 250MG 3 PA cromolyn sodium oral conc 100 mg/5ml 1 CULTURELLE CHW KIDS 3 OTC CULTURELLE PAK KIDS 3 OTC digestive chw advantag 1 OTC ENTEREG CAP 12MG 3 PA enulose sol 10gm/15 1 floranex tab 1 OTC FLORASTOR CAP 250MG 2 PA; OTC FLORASTOR PAK KIDS 2 OTC


147

Drug Name Drug Tier Requirements/Limits gas relief cap 125mg 1 OTC gas relief cap 180mg 1 OTC gas relief chw 80mg 1 OTC gas relief dro 40/0.6ml 1 OTC gas relief liq infants 1 OTC GAS-X EX-STR MIS 62.5MG 3 OTC GASTROCROM CON 100/5ML 3 PA GATTEX KIT 5MG 3 QL (30 boxes / 30

days), PA hemorrhoidal sup 1 OTC hemorrhoidal sup 0.25% 1 OTC KEPIVANCE INJ 6.25MG 2 LACTINEX CHW 3 PA; OTC lactobacillus acidophilus-pectin cap 1 OTC lidocaine anorectal cream 5% 1 OTC MORE-DOPHILU POW ACIDOPHI 2 PA; OTC OCALIVA TAB 5MG 3 QL (30 tabs / 30 days),

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

PA PREB-2 PAK 2 PA; OTC probiotic cap 1 OTC PROBIOTIC CAP 2 PA; OTC probiotic cap gold 1 OTC probiotic pak children 1 OTC PROBIOTIC TAB 2 OTC probiotic w/ cap prebioti 1 OTC RECTIV OIN 0.4% 2 sm gas rel chw 125mg 1 OTC sm hemorrhoi oin 1 OTC sm probiotic cap 250mg 1 OTC SUCRAID SOL 8500/ML 2 sucralfate tab 1 gm 1 TRULANCE TAB 3MG 3 QL (30 / 30 days), PA VSL#3 DS PAK 3 XERMELO TAB 250MG 3 QL (90 / 30 days), PA OPIOID-INDUCED CONSTIPATION MOVANTIK TAB 12.5MG 2 QL (30 tabs / 30 days) MOVANTIK TAB 25MG 2 QL (30 tabs / 30 days) RELISTOR INJ 8/0.4ML 3 QL (12 / 30 days), PA RELISTOR INJ 12/0.6ML 3 QL (18 / 30 days), PA RELISTOR TAB 150MG 3 QL (90 tabs / 30 days),

PA PANCREATIC ENZYMES CREON CAP 3000UNIT 2 CREON CAP 6000UNIT 2


148

Drug Name Drug Tier Requirements/Limits CREON CAP 12000UNT 2 CREON CAP 24000UNT 2 CREON CAP 36000UNT 2 PANCREAZE CAP 4200UNIT 3 ST PANCREAZE CAP 10500UNT 3 ST PANCREAZE CAP 16800UNT 3 ST PANCREAZE CAP 21000UNT 3 ST PERTZYE CAP 3 ST VIOKACE TAB 2 VIOKACE TAB 20880 2 ZENPEP CAP 3000UNIT 2 ZENPEP CAP 5000UNIT 2 ZENPEP CAP 10000UNT 2 ZENPEP CAP 15000UNT 2 ZENPEP CAP 20000UNT 2 ZENPEP CAP 25000UNT 2 ZENPEP CAP 40000UNT 2 PROSTAGLANDINS CYTOTEC TAB 100MCG 3 PA CYTOTEC TAB 200MCG 3 PA misoprostol tab 100 mcg 1 misoprostol tab 200 mcg 1 PROTON PUMP INHIBITORS (PPI) ACIPHEX SPR CAP 5MG 3 QL (30 / 30 days), ST ACIPHEX SPR CAP 10MG 3 QL (30 / 30 days), ST ACIPHEX TAB 20MG 3 QL (30 tabs / 30 days),

PA, ST DEXILANT CAP 30MG DR 3 QL (30 caps / 30 days),

ST DEXILANT CAP 60MG DR 3 QL (30 caps / 30 days),

ST esomeprazole magnesium cap delayed

release 20 mg (base eq) 1 QL (30 caps / 30 days),

ST esomeprazole magnesium cap delayed

release 40 mg (base eq) 1 QL (30 caps / 30 days),

ST esomeprazole sodium for intravenous soln

20 mg (base equiv) 1 QL (30 / 30 days)

esomeprazole sodium for intravenous soln 40 mg (base equiv)

1 QL (30 / 30 days)

lansoprazole cap delayed release 15 mg 1 QL (30 caps / 30 days), ST

lansoprazole cap delayed release 15 mg 1 QL (30 caps / 30 days), ST; OTC

lansoprazole cap delayed release 30 mg 1 QL (30 caps / 30 days), ST


149

Drug Name Drug Tier Requirements/Limits NEXIUM 24HR CAP 20MG 1 QL (30 caps / 30 days),

ST; OTC NEXIUM CAP 20MG 3 QL (30 caps / 30 days),

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

PA, ST NEXIUM GRA 2.5MG DR 3 QL (1 box / 30 days), ST NEXIUM GRA 5MG DR 3 QL (1 box / 30 days), ST NEXIUM GRA 10MG DR 3 QL (1 box / 30 days), ST NEXIUM GRA 20MG DR 3 QL (1 box / 30 days), ST NEXIUM GRA 40MG DR 3 QL (1 box / 30 days), ST NEXIUM I.V. INJ 40MG 3 QL (30 / 30 days), PA omeprazole cap delayed release 10 mg 1 QL (60 caps / 30 days) omeprazole cap delayed release 20 mg 1 QL (60 caps / 30 days) omeprazole cap delayed release 40 mg 1 QL (60 caps / 30 days) omeprazole magnesium cap dr 20.6 mg

(20 mg base equiv) 1 QL (30 caps / 30 days);

OTC OMEPRAZOLE TAB 20MG 3 QL (30 tabs / 30 days);

OTC omeprazole-sodium bicarbonate cap 20-

1100 mg 1 QL (30 caps / 30 days),

ST omeprazole-sodium bicarbonate cap 20-

1100 mg 1 QL (30 caps / 30 days),

ST; OTC omeprazole-sodium bicarbonate cap 40-

1100 mg 1 QL (30 caps / 30 days),

ST pantoprazole sodium ec tab 20 mg (base


pantoprazole sodium ec tab 40 mg (base equiv)


pantoprazole sodium for iv soln 40 mg (base equiv)

1 QL (30 / 30 days)

PREVACID CAP 15MG DR 3 QL (30 caps / 30 days), PA, ST

PREVACID CAP 30MG DR 3 QL (30 caps / 30 days), PA, ST

PREVACID TAB 15MG STB 3 QL (30 tabs / 30 days), ST

PREVACID TAB 30MG STB 3 QL (30 tabs / 30 days), ST

PRILOSEC CAP 10MG 3 QL (60 caps / 30 days), PA, ST



PRILOSEC OTC TAB 20MG 3 OTC PRILOSEC POW 2.5MG 3 QL (2 / 30 days), ST PRILOSEC POW 10MG 3 QL (2 / 30 days), ST


150

Drug Name Drug Tier Requirements/Limits PROTONIX INJ 40MG 3 QL (30 / 30 days), PA PROTONIX PAK 3 QL (30 / 30 days), ST PROTONIX TAB 20MG 3 QL (60 tabs / 30 days),

PA, ST PROTONIX TAB 40MG 3 QL (60 tabs / 30 days),

PA, ST rabeprazole sodium ec tab 20 mg 1 QL (30 tabs / 30 days),

ST ZEGERID CAP 20-1100 3 QL (30 caps / 30 days),

PA, ST ZEGERID CAP 40-1100 3 QL (30 caps / 30 days),

PA, ST ZEGERID OTC CAP 20-1100 3 QL (30 caps / 30 days),

PA, ST; OTC ZEGERID POW 20-1680 3 QL (30 / 30 days), PA,

ST ZEGERID POW 40-1680 3 QL (30 / 30 days), PA,

ST SALIVA STIMULANTS cevimeline hcl cap 30 mg 1 EVOXAC CAP 30MG 3 PA pilocarpine hcl tab 5 mg 1 pilocarpine hcl tab 7.5 mg 1 SALAGEN TAB 5MG 3 PA SALAGEN TAB 7.5MG 3 PA STEROIDS, RECTAL ANALPRAM KIT ADVANCED 3 PA EPIFOAM AER 1% 3 PA hydrocortisone acetate w/ pramoxine rectal

cream 1-1% 1

hydrocortisone rectal cream 1% 1 hydrocortisone rectal cream 2.5% 1 LIDO-HYDRO GEL 2.8-0.55 3 lidocaine-hydrocortisone acetate rectal

cream 3-0.5% 1

lidocaine-hydrocortisone acetate rectal cream kit 2-2%

1

lidocaine-hydrocortisone acetate rectal cream kit 3-0.5%

1

lidocaine-hydrocortisone acetate rectal cream kit 3-1%

1 PA

lidocaine-hydrocortisone acetate rectal gel kit 3-2.5%

1 PA

PROCORT CRE 3 PA PROCTOCORT CRE 1% 3 PA PROCTOFOAM AER HC 1% 3 PA ULCER THERAPY COMBINATION


151

Drug Name Drug Tier Requirements/Limits amoxicillin cap-clarithro tab-lansopraz cap

dr therapy pack 1

dual action chw complete 1 OTC OMECLAMOX- MIS PAK 3 PA PREVPAC MIS 3 PA PYLERA CAP 3 PA GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl tab er 24hr 10 mg 1 AVODART CAP 0.5MG 3 QL (30 caps / 30 days),

PA, ST CARDURA XL TAB 4MG 3 QL (30 tabs / 30 days),

ST CARDURA XL TAB 8MG 3 QL (30 tabs / 30 days),

ST dutasteride cap 0.5 mg 1 QL (30 caps / 30 days) dutasteride-tamsulosin hcl cap 0.5-0.4 mg 1 finasteride tab 5 mg 1 FLOMAX CAP 0.4MG 3 PA, ST JALYN CAP 3 PA, ST PROSCAR TAB 5MG 3 PA, ST RAPAFLO CAP 4MG 3 ST RAPAFLO CAP 8MG 3 ST tamsulosin hcl cap 0.4 mg 1 UROXATRAL TAB 10MG 3 PA, ST GENITOURINARY IRRIGANTS acetic acid irrigation soln 0.25% 1 argyl saline sol 0.9% 1 neomycin-polymyxin b gu irrigation soln 1 NEOSPORIN GU SOL 40/ML IR 3 PA RENACIDIN SOL 2 RESECTISOL SOL 5% 3 PA SORBITOL SOL 3% IRR 3 PA SORBITOL SOL 3.3% IRR 3 PA SORBITOL-MAN SOL 3 PA MISCELLANEOUS anti-itch cre 5-2% 1 OTC azuphen mb cap 120mg 1 PA bethanechol chloride tab 5 mg 1 bethanechol chloride tab 10 mg 1 bethanechol chloride tab 25 mg 1 bethanechol chloride tab 50 mg 1 CYSTAGON CAP 50MG 2 CYSTAGON CAP 150MG 2 cytra k gra crystals 1


152

Drug Name Drug Tier Requirements/Limits cytra-3 syp 1 ELMIRON CAP 100MG 2 HIPREX TAB 1GM 3 PA hyolev mb tab 81mg 1 PA indiomin mb cap 120mg 1 PA INTRAROSA SUP 6.5MG 3 QL (30 ea / 30 days), PA LITHOSTAT TAB 250MG 3 PA mannitol iv soln 20% 1 mannitol iv soln 25% 1 methenamine hippurate tab 1 gm 1 methenamine mandelate tab 0.5 gm 1 methenamine mandelate tab 1 gm 1 ORACIT SOL 3 PA osmitrol inj 5% 1 PA osmitrol inj 10% 1 PA osmitrol inj 15% 1 phenazopyridine hcl tab 100 mg 1 phenazopyridine hcl tab 200 mg 1 pot & sod citrates w/ cit ac soln 550-500-

334 mg/5ml 1

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

1

potassium citrate tab er 5 meq (540 mg) 1 potassium citrate tab er 10 meq (1080 mg)1 potassium citrate tab er 15 meq (1620 mg)1 PRO-CEPTION MIS 3 PA; OTC PROCYSBI CAP 25MG 3 QL (900 caps / 30

days), PA PROCYSBI CAP 75MG 3 QL (900 caps / 30

days), PA PYRIDIUM TAB 100MG 3 PA PYRIDIUM TAB 200MG 3 PA relagard gel 1 PA RIMSO-50 SOL 50% 3 PA SHOHLS SOL MODIFIED 3 PA sodium citrate & citric acid soln 500-334

mg/5ml 1

THIOLA TAB 100MG 3 PA ur n-c tab 1 uramit mb cap 118mg 1 QL (120 caps / 30

days), PA URECHOLINE TAB 5MG 3 PA URECHOLINE TAB 10MG 3 PA URECHOLINE TAB 25MG 3 PA URECHOLINE TAB 50MG 3 PA urimar-t tab 1


153

Drug Name Drug Tier Requirements/Limits UROCIT-K 5 TAB 3 PA UROCIT-K 10 TAB 3 PA UROCIT-K 15 TAB 3 PA urolet mb tab 1 urophen mb tab 81.6mg 1 PERITONEAL DIALYSIS SOLUTION DELFLEX-LC/ SOL 2.5% DEX 3 URINARY ANTISPASMODICS DETROL LA CAP 2MG 3 PA, ST DETROL LA CAP 4MG 3 PA, ST DETROL TAB 1MG 3 PA, ST DETROL TAB 2MG 3 PA, ST DITROPAN XL TAB 5MG 3 PA, ST DITROPAN XL TAB 10MG 3 PA, ST DITROPAN XL TAB 15MG 3 PA, ST ENABLEX TAB 7.5MG 3 PA, ST ENABLEX TAB 15MG 3 PA, ST flavoxate hcl tab 100 mg 1 GELNIQUE GEL 10% 3 ST MYRBETRIQ TAB 25MG 3 QL (30 tabs / 30 days),

ST MYRBETRIQ TAB 50MG 3 QL (30 tabs / 30 days),

ST oxybutynin chloride syrup 5 mg/5ml 1 oxybutynin chloride tab 5 mg 1 oxybutynin chloride tab er 24hr 5 mg 1 oxybutynin chloride tab er 24hr 10 mg 1 oxybutynin chloride tab er 24hr 15 mg 1 OXYTROL DIS 3.9MG/24 3 ST OXYTROL/WOMN DIS 3.9MG/24 3 OTC tolterodine tartrate cap er 24hr 2 mg 1 tolterodine tartrate cap er 24hr 4 mg 1 tolterodine tartrate tab 1 mg 1 tolterodine tartrate tab 2 mg 1 TOVIAZ TAB 4MG 3 ST TOVIAZ TAB 8MG 3 ST trospium chloride cap er 24hr 60 mg 1 trospium chloride tab 20 mg 1 VESICARE TAB 5MG 3 ST VESICARE TAB 10MG 3 ST VAGINAL ANTI-INFECTIVES AVC CRE 15% 3 PA CLEOCIN CRE 2% VAG 3 PA CLEOCIN SUP 100MG 3 PA clindamycin phosphate vaginal cream 2% 1


154

Drug Name Drug Tier Requirements/Limits CLINDESSE CRE 2% 3 PA clotrimazole cre 1% vag 1 OTC clotrimazole cre 2% 1 OTC GYNAZOLE-1 CRE 2% 3 PA METROGEL-VAG GEL 0.75% 3 PA metronidazole vaginal gel 0.75% 1 miconazole 3 kit combinat 1 OTC miconazole 3 kit combo pk 1 OTC miconazole 3 sup 200mg 1 miconazole 7 cre 2% 1 OTC miconazole nitrate vaginal supp 1200 mg &

2% cream kit 1 OTC

MONISTAT 3 KIT COMBO PK 3 PA; OTC NUVESSA GEL 1.3% 3 PA sm micon 7 sup 100mg 1 OTC TERAZOL 3 CRE 0.8% 3 PA TERAZOL 7 CRE 0.4% 3 PA terconazole vaginal cream 0.4% 1 terconazole vaginal cream 0.8% 1 terconazole vaginal suppos 80 mg 1 HEMATOLOGIC ANTICOAGULANTS, INJECTABLE ANGIOMAX INJ 250MG 3 PA ARGATROBAN INJ 50MG/50M 2 PA ARGATROBAN INJ 125/125 3 PA argatroban inj 250 mg/2.5ml (concentrate

for iv infusion) 1 PA

ARIXTRA INJ 2.5/0.5 3 QL (60 per 365 days), PA

ARIXTRA INJ 5/0.4ML 3 QL (60 per 365 days), PA

ARIXTRA INJ 7.5/0.6 3 QL (60 per 365 days), PA

ARIXTRA INJ 10/0.8ML 3 QL (60 per 365 days), PA

bivalirudin for iv soln 250 mg 1 enoxaparin sodium inj 30 mg/0.3ml 1 QL (60 per 365 days) enoxaparin sodium inj 40 mg/0.4ml 1 QL (60 per 365 days) enoxaparin sodium inj 60 mg/0.6ml 1 QL (60 per 365 days) enoxaparin sodium inj 80 mg/0.8ml 1 QL (60 per 365 days) enoxaparin sodium inj 100 mg/ml 1 QL (60 per 365 days) enoxaparin sodium inj 120 mg/0.8ml 1 QL (60 per 365 days) enoxaparin sodium inj 150 mg/ml 1 QL (60 per 365 days) enoxaparin sodium inj 300 mg/3ml 1 QL (60 per 365 days) fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml 1 QL (60 per 365 days),

PA


155

Drug Name Drug Tier Requirements/Limits fondaparinux sodium subcutaneous inj 5


PA fondaparinux sodium subcutaneous inj 7.5


PA fondaparinux sodium subcutaneous inj 10


PA FRAGMIN INJ 2500/0.2 3 QL (60 per 365 days),



PA FRAGMIN INJ 10000/ML 3 QL (60 per 365 days),

PA FRAGMIN INJ 12500UNT 3 QL (60 per 365 days),




PA HEP SOD/NACL INJ 25000UNT 3 PA HEPARIN SOD INJ 2000/ML 3 heparin sodium (porcine) inj 1000 unit/ml 1 heparin sodium (porcine) inj 5000 unit/ml 1 heparin sodium (porcine) inj 10000 unit/ml1 heparin sodium (porcine) inj 20000 unit/ml1 heparin sodium (porcine) pf inj 5000

unit/0.5ml 1

IPRIVASK INJ 15MG 3 QL (10 days per 365 days), PA

LOVENOX INJ 30/0.3ML 3 QL (60 per 365 days), PA




LOVENOX INJ 100MG/ML 3 QL (60 per 365 days), PA

LOVENOX INJ 120/0.8 3 QL (60 per 365 days), PA

LOVENOX INJ 150MG/ML 3 QL (60 per 365 days), PA

LOVENOX INJ 300/3ML 3 QL (60 per 365 days), PA


156

Drug Name Drug Tier Requirements/Limits ANTICOAGULANTS, ORAL COUMADIN TAB 1MG 3 PA, ST COUMADIN TAB 2.5MG 3 PA, ST COUMADIN TAB 2MG 3 PA, ST COUMADIN TAB 3MG 3 PA, ST COUMADIN TAB 4MG 3 PA, ST COUMADIN TAB 5MG 3 PA, ST COUMADIN TAB 6MG 3 PA, ST COUMADIN TAB 7.5MG 3 PA, ST COUMADIN TAB 10MG 3 PA, ST ELIQUIS TAB 2.5MG 2 QL (60 tabs / 30 days) ELIQUIS TAB 5MG 2 QL (74 tabs / 25 days) PRADAXA CAP 75MG 3 QL (60 caps / 30 days),

PA PRADAXA CAP 110MG 3 QL (120 caps / 365

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

PA SAVAYSA TAB 15MG 3 QL (30 tabs / 30 days),

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

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

ST warfarin sodium tab 1 mg 1 warfarin sodium tab 2 mg 1 warfarin sodium tab 2.5 mg 1 warfarin sodium tab 3 mg 1 warfarin sodium tab 4 mg 1 warfarin sodium tab 5 mg 1 warfarin sodium tab 6 mg 1 warfarin sodium tab 7.5 mg 1 warfarin sodium tab 10 mg 1 XARELTO STAR TAB 15/20MG 2 QL (1 kit / year) XARELTO TAB 10MG 2 QL (60 tabs / year) XARELTO TAB 15MG 2 QL (42 tabs / 25 days) XARELTO TAB 20MG 2 QL (30 tabs / 30 days) ANTIHEMOPHILIC AGENTS ADVATE INJ 250UNIT 2 ADVATE INJ 500UNIT 2 ADVATE INJ 1000UNIT 2 ADVATE INJ 1500UNIT 2 ADVATE INJ 2000UNIT 2 ADVATE INJ 3000UNIT 2 ADVATE INJ 4000UNIT 2 ADYNOVATE INJ 250UNIT 3 ST


157

Drug Name Drug Tier Requirements/Limits ADYNOVATE INJ 500UNIT 3 ST ADYNOVATE INJ 1000UNIT 3 ST ADYNOVATE INJ 2000UNIT 3 ST ALPHANATE INJ VWF/HUM 2 ALPHANINE SD INJ 1000UNIT 3 PA ALPHANINE SD INJ 1500UNIT 3 PA ALPROLIX INJ 500UNIT 3 PA ALPROLIX INJ 1000UNIT 3 PA ALPROLIX INJ 2000UNIT 3 PA ALPROLIX INJ 3000UNIT 3 PA BEBULIN INJ 200-1200 2 BENEFIX INJ 250UNIT 2 PA BENEFIX INJ 500UNIT 2 PA BENEFIX INJ 1000UNIT 2 PA BENEFIX INJ 2000UNIT 2 PA BENEFIX INJ 3000UNIT 2 PA COAGADEX INJ 250UNIT 3 ST COAGADEX INJ 500UNIT 3 ST CORIFACT KIT 2 ELOCTATE INJ 250UNIT 3 PA ELOCTATE INJ 500UNIT 3 PA ELOCTATE INJ 750UNIT 3 PA ELOCTATE INJ 1000UNIT 3 PA ELOCTATE INJ 1500UNIT 3 PA ELOCTATE INJ 2000UNIT 3 PA ELOCTATE INJ 3000UNIT 3 PA FEIBA INJ 2 HELIXATE FS INJ 250UNIT 2 HELIXATE FS INJ 500UNIT 2 HELIXATE FS INJ 1000UNIT 2 HELIXATE FS INJ 2000UNIT 2 HELIXATE FS INJ 3000UNIT 2 HEMOFIL M INJ 250UNIT 3 ST HEMOFIL M INJ 500UNIT 3 ST HEMOFIL M INJ 1000UNIT 3 ST HEMOFIL M INJ 1700UNIT 3 ST HUMATE-P SOL 250-600 2 HUMATE-P SOL 500-1200 2 HUMATE-P SOL 2400UNIT 2 IXINITY INJ 500UNIT 2 PA IXINITY INJ 1000UNIT 2 PA IXINITY INJ 1500UNIT 2 KOATE-DVI INJ 250UNIT 2 KOATE-DVI INJ 500UNIT 2 KOATE-DVI INJ 1000UNIT 2 KOGENATE FS INJ 250/BS 3 ST


158

Drug Name Drug Tier Requirements/Limits KOGENATE FS INJ 250UNIT 3 ST KOGENATE FS INJ 500/BS 3 ST KOGENATE FS INJ 500UNIT 3 ST KOGENATE FS INJ 1000/BS 3 ST KOGENATE FS INJ 1000UNIT 3 ST KOGENATE FS INJ 2000/BS 3 ST KOGENATE FS INJ 2000UNIT 3 ST KOGENATE FS INJ 3000/BS 3 ST KOGENATE FS INJ 3000UNIT 3 ST KOVALTRY INJ 250UNIT 2 KOVALTRY INJ 500UNIT 2 KOVALTRY INJ 1000UNIT 2 KOVALTRY INJ 2000UNIT 3 KOVALTRY INJ 3000UNIT 2 MONOCLATE-P INJ 1000UNIT 3 ST MONOCLATE-P INJ 1500UNIT 3 ST MONONINE INJ 500UNIT 3 PA MONONINE INJ 1000UNIT 2 PA NOVOEIGHT INJ 250UNIT 2 NOVOEIGHT INJ 500UNIT 2 NOVOEIGHT INJ 1000UNIT 2 NOVOEIGHT INJ 1500UNIT 2 NOVOEIGHT INJ 2000UNIT 2 NOVOSEVEN RT INJ 1MG 2 NOVOSEVEN RT INJ 2MG 2 NOVOSEVEN RT INJ 5MG 2 NOVOSEVEN RT INJ 8MG 2 NUWIQ INJ 250UNIT 3 ST NUWIQ INJ 500UNIT 3 ST NUWIQ INJ 1000UNIT 3 ST NUWIQ INJ 2000UNIT 2 ST NUWIQ KIT 250UNIT 3 ST NUWIQ KIT 500UNIT 3 ST NUWIQ KIT 1000UNIT 3 ST NUWIQ KIT 2000UNIT 3 ST OBIZUR INJ 500 UNIT 3 PA PROFILNINE INJ 500UNIT 2 PA PROFILNINE INJ 1000UNIT 2 PA PROFILNINE INJ 1500UNIT 2 PA RECOMBINATE INJ 2 RECOMBINATE INJ 220-400 2 PA RECOMBINATE INJ 401-800 2 PA RECOMBINATE INJ 801-1240 2 PA RIASTAP SOL 1GM 2 RIXUBIS INJ 250 UNIT 3 PA RIXUBIS INJ 500UNIT 3 PA


159

Drug Name Drug Tier Requirements/Limits RIXUBIS INJ 1000UNIT 3 PA RIXUBIS INJ 2000UNIT 3 PA RIXUBIS INJ 3000UNIT 3 PA TRETTEN INJ 2 XYNTHA INJ 250UNIT 2 XYNTHA INJ 500UNIT 2 XYNTHA INJ 1000UNIT 2 XYNTHA INJ 2000UNIT 2 XYNTHA SOLOF INJ 3000UNIT 2 HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 10MCG 3 PA ARANESP INJ 25MCG 3 PA ARANESP INJ 40MCG 3 PA ARANESP INJ 60MCG 3 PA ARANESP INJ 100MCG 3 PA ARANESP INJ 150MCG 3 PA ARANESP INJ 200MCG 3 PA ARANESP INJ 300MCG 3 PA ARANESP INJ 500MCG 3 PA EPOGEN INJ 2000/ML 3 PA EPOGEN INJ 3000/ML 3 PA EPOGEN INJ 4000/ML 3 PA EPOGEN INJ 10000/ML 3 PA EPOGEN INJ 20000/ML 3 PA GRANIX INJ 300/0.5 3 PA GRANIX INJ 480/0.8 3 PA LEUKINE INJ 250MCG 2 PA MIRCERA INJ 50MCG 3 PA MIRCERA INJ 75MCG 3 PA MIRCERA INJ 100MCG 3 PA MIRCERA INJ 200MCG 3 PA NEULASTA KIT 6MG/0.6M 3 PA NEUPOGEN INJ 300/0.5 3 PA NEUPOGEN INJ 300MCG 3 PA NEUPOGEN INJ 480/0.8 3 PA NEUPOGEN INJ 480MCG 3 PA PROCRIT INJ 2000/ML 2 PA PROCRIT INJ 3000/ML 2 PA PROCRIT INJ 4000/ML 2 PA PROCRIT INJ 10000/ML 2 PA PROCRIT INJ 20000/ML 2 PA PROCRIT INJ 40000/ML 2 PA ZARXIO INJ 300/0.5 2 PA ZARXIO INJ 480/0.8 2 PA HEMOSTATICS, SYSTEMIC


160

Drug Name Drug Tier Requirements/Limits AMICAR SOL 0.25/ML 3 PA AMICAR TAB 500MG 2 PA AMICAR TAB 1000MG 2 PA aminocaproic acid inj 250 mg/ml 1 CYKLOKAPRON INJ 100MG/ML 3 PA LYSTEDA TAB 650MG 3 QL (30 tabs / 21 days),

PA tranexamic acid iv soln 1000 mg/10ml

(100 mg/ml) 1

tranexamic acid tab 650 mg 1 QL (30 tabs / 21 days) HEMOSTATICS, TOPICAL AVITENE PAD 35X35MM 3 PA AVITENE POW FLOUR 3 PA ENDO AVITENE MIS 5MM DIA 3 PA EVICEL KIT 2ML 3 PA GELFILM MIS ENVELOPE 3 PA GELFOAM MIS DENTAL 4 3 PA GELFOAM MIS SPON COM 3 PA GELFOAM MIS SPONG200 3 PA GELFOAM MIS SPONG 50 3 PA GELFOAM POW 3 PA RECOTHROM SOL 5000UNIT 3 PA RECOTHROM SOL 20000UNT 3 PA SURGICEL PAD 3"X4" 3 PA SURGIFOAM MIS 12-7MM 3 PA SURGIFOAM MIS SIZE 100 3 PA TACHOSIL PAD 3 PA THROMBI-GEL PAD 10 3 PA THROMBI-PAD PAD 3"X3" 3 PA THROMBIN KIT 5000UNIT 3 PA THROMBIN-JMI KIT 20000UNT 3 PA THROMBIN-JMI SOL 5000UNIT 3 PA THROMBIN-JMI SOL 20000UNT 3 PA TISSEEL SOL 3 PA TISSEEL VH KIT 4ML 3 PA TISSEEL VH KIT 10ML 3 PA ULTRAFOAM MIS 2X6.25X7 3 PA ULTRAFOAM MIS 8X6.25X1 3 PA ULTRAFOAM MIS 8X12.5X1 3 PA ULTRAFOAM MIS 8X12.5X3 3 PA HEREDITARY ANGIOEDEMA AGENTS BERINERT INJ 500UNIT 3 ST CINRYZE SOL 500 UNIT 2 QL (16 / 25 days) FIRAZYR INJ 30MG/3ML 2 QL (3 / 25 days) HAEGARDA INJ 2000UNIT 2 QL (16 vials / 30)


161

Drug Name Drug Tier Requirements/Limits HAEGARDA INJ 3000UNIT 2 QL (16 vials / 30) RUCONEST INJ 2100UNIT 3 PA IDIOPATHIC THROMBOCYTOPENIC PURPURA PROMACTA TAB 25MG 2 QL (30 tabs / 30 days) PROMACTA TAB 50MG 2 QL (60 tabs / 30 days) PROMACTA TAB 75MG 2 QL (60 tabs / 30 days) MISCELLANEOUS ACD FORMULA SOL A 2 albumin, human inj 25% 1 alburx inj 5% 1 PA ANTICOAG CPD SOL 2 ANTICOAGULNT SOL SOD CITR 3 PA CATHFLO ACTI INJ VASE 3 PA CEPROTIN INJ 500 UNIT 3 PA CEPROTIN INJ 1000UNIT 3 PA CHEMET CAP 100MG 2 cilostazol tab 50 mg 1 cilostazol tab 100 mg 1 deferoxamine mesylate for inj 2 gm 1 deferoxamine mesylate for inj 500 mg 1 DESFERAL INJ 500MG 3 PA EXJADE TAB 125MG 2 PA EXJADE TAB 250MG 2 PA EXJADE TAB 500MG 2 PA FERRIPROX SOL 100MG/ML 3 PA FERRIPROX TAB 500MG 2 JADENU TAB 90MG 3 PA JADENU TAB 180MG 3 PA JADENU TAB 360MG 3 PA lmd 10%/d5w inj 1 lmd 10%/nacl inj 0.9% 1 PANHEMATIN INJ 313MG 2 PANHEMATIN INJ 350MG 2 pentoxifylline tab er 400 mg 1 protamine sulfate inj 10 mg/ml 1 THROMBAT III INJ 500UNIT 3 PA THROMBAT III INJ 1000UNIT 3 PA TNKASE KIT 50MG 3 PA TRICITRASOL CON 2 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS SOLIRIS INJ 10MG/ML 2 PA PLATELET AGGREGATION INHIBITORS AGGRASTAT INJ 5/100ML 3 PA AGGRASTAT INJ 12.5/250 3 PA


162

Drug Name Drug Tier Requirements/Limits AGGRENOX CAP 25-200MG 3 QL (60 caps / 30 days),

PA, ST aspirin chw 81mg 1 OTC aspirin low tab 81mg ec 1 OTC aspirin tab 325 mg 1 OTC aspirin tab delayed release 325 mg 1 OTC aspirin-dipyridamole cap er 12hr 25-200


bayer adv tab 500mg 1 OTC BRILINTA TAB 60MG 2 QL (60 tabs / 30 days) BRILINTA TAB 90MG 2 QL (60 tabs / 30 days) clopidogrel bisulfate tab 75 mg (base

equiv) 1

clopidogrel bisulfate tab 300 mg (base equiv)

1

dipyridamole tab 25 mg 1 dipyridamole tab 50 mg 1 dipyridamole tab 75 mg 1 DURLAZA CAP 162.5MG 3 QL (30 caps / 30 days),

PA EFFIENT TAB 5MG 3 QL (30 tabs / 30 days) EFFIENT TAB 10MG 3 QL (30 tabs / 30 days) eptifibatide iv soln 20 mg/10ml (2 mg/ml) 1 PA eptifibatide iv soln 75 mg/100ml (0.75

mg/ml) 1 PA

eptifibatide iv soln 200 mg/100ml (2 mg/ml)

1 PA

eq aspirin tab 500mg ec 1 OTC INTEGRILIN INJ 3 PA INTEGRILIN INJ 0.75MG/1 3 PA INTEGRILIN INJ 20/10ML 3 PA KCENTRA KIT 500UNIT 3 PA KCENTRA KIT 1000UNIT 3 PA PLAVIX TAB 75MG 3 PA, ST PLAVIX TAB 300MG 3 PA, ST prasugrel hcl tab 5 mg (base equiv) 1 QL (30 / 30) prasugrel hcl tab 10 mg (base equiv) 1 QL (30 / 30) REOPRO INJ 2MG/ML 3 PA ZONTIVITY TAB 2.08MG 2 QL (30 tabs / 30 days),

PA PLATELET SYNTHESIS INHIBITOR AGRYLIN CAP 0.5MG 3 PA anagrelide hcl cap 0.5 mg 1 anagrelide hcl cap 1 mg 1 STEM CELL MOBILIZERS MOZOBIL INJ 2 QL (8 / 3 days)


163

Drug Name Drug Tier Requirements/LimitsIMMUNOLOGIC AGENTS ANTITOXINS/ANTIVENINS ANASCORP INJ 3 PA ANTIVENIN KIT LAT MACT 3 PA CROFAB INJ 3 PA BIOLOGIC DISEASE-MODIFYING AGENTS ACTEMRA INJ 162/0.9 2 QL (4 / 21 days), PA CIMZIA KIT 3 QL (2 boxes / 25 days),

PA CIMZIA KIT STARTER 3 QL (1 box in lifetime),

PA CIMZIA PREFL KIT 200MG/ML 3 QL (2 boxes / 25 days),

PA ENBREL INJ 25/0.5ML 2 PA ENBREL INJ 25MG 2 QL (8 boxes / 25 days),

PA ENBREL INJ 50MG/ML 2 QL (4 / 25 days), PA ENBREL SRCLK INJ 50MG/ML 2 QL (4 / 25 days), PA HUMIRA INJ 10MG/0.2 2 PA HUMIRA KIT 20MG/0.4 2 QL (2 boxes / 25 days),

PA HUMIRA KIT 40MG/0.8 2 QL (2 boxes / 25 days),

PA HUMIRA PEN INJ 40MG/0.8 2 QL (2 boxes / 25 days),

PA INFLECTRA INJ 100MG 2 PA KINERET INJ 3 QL (30 / 25 days), PA ORENCIA CLCK INJ 125MG/ML 3 QL (4 / 30 days), PA ORENCIA INJ 125MG/ML 3 QL (4 / 30 days), PA REMICADE INJ 100MG 2 SIMPONI ARIA SOL 50MG/4ML 3 PA SIMPONI INJ 50/0.5ML 3 PA SIMPONI INJ 50/0.5ML 3 QL (0.5 ml / 21 days),

PA SIMPONI INJ 100MG/ML 3 PA SIMPONI INJ 100MG/ML 3 QL (1 syringe / 21

days), PA DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS) ARAVA TAB 10MG 3 PA ARAVA TAB 20MG 3 PA hydroxychloroquine sulfate tab 200 mg 1 leflunomide tab 10 mg 1 leflunomide tab 20 mg 1 OTREXUP INJ 7.5/0.4 3 QL (4 / 21 days), PA OTREXUP INJ 10MG 3 QL (4 / 21 days), PA OTREXUP INJ 15MG 3 QL (4 / 21 days), PA


164

Drug Name Drug Tier Requirements/Limits OTREXUP INJ 20MG 3 QL (4 / 21 days), PA OTREXUP INJ 25MG 3 QL (4 / 21 days), PA RASUVO INJ 7.5MG 3 QL (4 / 21 days), PA RASUVO INJ 10MG 3 QL (4 / 21 days), PA RASUVO INJ 12.5MG 3 QL (4 / 21 days), PA RASUVO INJ 15MG 3 QL (4 / 21 days), PA RASUVO INJ 17.5MG 3 QL (4 / 21 days), PA RASUVO INJ 22.5MG 3 QL (4 / 21 days), PA RASUVO INJ 25MG 3 QL (4 / 21 days), PA RASUVO INJ 27.5MG 3 QL (4 / 21 days), PA RASUVO INJ 30MG 3 QL (4 / 21 days), PA XELJANZ TAB 5MG 3 QL (60 tabs / 30 days),

PA IMMUNE GLOBULINS BIVIGAM INJ 10% 2 PA CARIMUNE NF INJ 6GM 3 PA CARIMUNE NF INJ 12GM 3 PA CYTOGAM INJ 3 PA FLEBOGAMMA INJ 5GM/50ML 2 PA FLEBOGAMMA INJ 10/100ML 2 PA FLEBOGAMMA INJ 10/200ML 2 PA FLEBOGAMMA INJ 20/200ML 2 PA FLEBOGAMMA INJ 20/400ML 2 PA FLEBOGAMMA INJ DIF 5% 2 PA GAMASTAN S/D INJ 3 PA GAMMAGARD INJ 1GM/10ML 2 PA GAMMAGARD INJ 2.5GM/25 2 PA GAMMAGARD INJ 5GM/50ML 2 PA GAMMAGARD INJ 10GM/100 2 PA GAMMAGARD INJ 20GM/200 2 PA GAMMAGARD INJ 30GM/300 2 PA GAMMAGARD SD INJ 5GM HU 3 PA GAMMAGARD SD INJ 10GM HU 3 PA GAMMAKED INJ 1GM/10ML 3 PA GAMMAKED INJ 2.5GM/25 3 PA GAMMAKED INJ 5GM/50ML 3 PA GAMMAKED INJ 10GM/100 3 PA GAMMAKED INJ 20GM/200 3 PA GAMMAPLEX INJ 5% 2 PA GAMUNEX-C INJ 1GM/10ML 2 PA GAMUNEX-C INJ 2.5GM/25 2 PA GAMUNEX-C INJ 5GM/50ML 2 PA GAMUNEX-C INJ 10GM/100 2 PA GAMUNEX-C INJ 20GM/200 2 PA HEPAGAM B INJ 3 PA


165

Drug Name Drug Tier Requirements/Limits HIZENTRA INJ 1GM/5ML 2 HIZENTRA INJ 2GM/10ML 2 HIZENTRA INJ 4GM/20ML 2 HIZENTRA INJ 10/50ML 2 HYQVIA INJ 2.5-200 3 PA HYQVIA INJ 5-400 3 PA HYQVIA INJ 10-800 3 PA HYQVIA INJ 20-1600 3 PA HYQVIA INJ 30-2400 3 PA OCTAGAM INJ 1GM 3 PA OCTAGAM INJ 2.5GM 3 PA OCTAGAM INJ 2GM/20ML 3 PA OCTAGAM INJ 5GM 3 PA OCTAGAM INJ 5GM/50ML 3 PA OCTAGAM INJ 10/100ML 3 PA OCTAGAM INJ 10GM 3 PA OCTAGAM INJ 20/200ML 3 PA OCTAGAM INJ 25GM 3 PA PRIVIGEN INJ 5 GRAMS 2 PA PRIVIGEN INJ 10GRAMS 2 PA PRIVIGEN INJ 20GRAMS 2 PA PRIVIGEN INJ 40GRAMS 2 PA RHOPHYLAC INJ 1500/2ML 3 PA THYMOGLOBULN INJ 25MG 3 PA VARIZIG INJ 125UNIT 2 IMMUNOMODULATORS, INTERFERONS ACTIMMUNE INJ 2MU/0.5 2 INTRON A INJ 10MU 2 INTRON A INJ 18MU 2 INTRON A INJ 25MU 2 INTRON A INJ 50MU 2 PEG-INTRON KIT 50MCG RP 3 QL (4 boxes / 25 days),

PA PEG-INTRON KIT 80MCG RP 3 QL (4 boxes / 25 days),

PA PEG-INTRON KIT 120 RP 3 QL (4 boxes / 25 days),

PA PEG-INTRON KIT 150 RP 3 QL (4 boxes / 25 days),

PA PEGASYS INJ 2 QL (2 / 25 days), PA PEGASYS INJ 180MCG/M 2 QL (4 / 25 days), PA PEGASYS INJ PROCLICK 2 QL (2 / 25 days), PA SYLATRON KIT 200MCG 2 SYLATRON KIT 300MCG 2 SYLATRON KIT 600MCG 2 IMMUNOMODULATORS, MISCELLANEOUS


166

Drug Name Drug Tier Requirements/Limits ARCALYST INJ 220MG 2 QL (4 / 30 days) ILARIS (150) INJ 180MG 2 QL (2 / 30 days) ILARIS INJ 150MG/ML 2 QL (2 / 30 days) OTEZLA TAB 10/20/30 3 QL (1 in lifetime), PA OTEZLA TAB 30MG 3 QL (60 tabs / 30 days),

PA IMMUNOSUPPRESSANTS, ANTIMETABOLITES AZASAN TAB 75 MG 2 AZASAN TAB 100MG 2 azathioprine tab 50 mg 1 CELLCEPT IV INJ 500MG 3 mycophenolate mofetil cap 250 mg 1 mycophenolate mofetil for oral susp 200

mg/ml 1

MYCOPHENOLATE MOFETIL HCL FOR IV SOLN 500 MG (BASE EQUIV)

1

mycophenolate mofetil tab 500 mg 1 mycophenolate sodium tab dr 180 mg

(mycophenolic acid equiv) 1

mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)

1

IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS ASTAGRAF XL CAP 0.5MG 3 ASTAGRAF XL CAP 1MG 3 ASTAGRAF XL CAP 5MG 3 cyclosporine cap 25 mg 1 cyclosporine cap 100 mg 1 cyclosporine iv soln 50 mg/ml 1 cyclosporine modified cap 25 mg 1 cyclosporine modified cap 100 mg 1 ENVARSUS XR TAB 0.75MG 3 ST ENVARSUS XR TAB 1MG 3 ST ENVARSUS XR TAB 4MG 3 ST gengraf cap 50mg 1 gengraf sol 100mg/ml 1 PROGRAF INJ 5MG/ML 2 SANDIMMUNE SOL 100MG/ML 3 tacrolimus cap 0.5 mg 1 tacrolimus cap 1 mg 1 tacrolimus cap 5 mg 1 IMMUNOSUPPRESSANTS, MISCELLANEOUS BENLYSTA INJ 120MG 2 BENLYSTA INJ 200MG/ML 2 BENLYSTA INJ 400MG 2 NULOJIX INJ 250MG 2 IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE


167

Drug Name Drug Tier Requirements/Limits RAPAMUNE SOL 1MG/ML 2 sirolimus tab 0.5 mg 1 sirolimus tab 1 mg 1 ZORTRESS TAB 0.5MG 2 ZORTRESS TAB 0.25MG 2 ZORTRESS TAB 0.75MG 2 MONOCLONAL ANTIBODIES SYNAGIS INJ 50MG 2 QL (1 / 25 days), PA SYNAGIS INJ 100MG/ML 2 QL (1 vial / 25 days), PAMISCELLANEOUS MEDICAL SUPPLIES ANESTH NEEDL MIS 20GX6" 2 OTC ANESTH NEEDL MIS 22GX2" 2 OTC AXILLARY NDL MIS 22GX1" 2 OTC AXILLARY NDL MIS 25GX1" 2 OTC BD ECLIPSE MIS 1ML/30G 2 OTC BD ECLIPSE MIS 25GX5/8" 2 OTC BP ARM CUFF MIS LARGE 2 OTC 5ML CONTROL MIS SANA-LOK 2 OTC 3ML CTRL SYR MIS LL ZONE1 2 OTC HUBER NEEDLE MIS 20GX1" 2 OTC HYPO NEEDLE MIS 18GX1" 3 HYPO NEEDLE MIS 19GX1.5" 3 HYPO NEEDLE MIS 21GX1" 3 HYPO NEEDLE MIS 22GX1.5" 3 HYPO NEEDLE MIS 23GX1" 3 HYPO NEEDLE MIS 23GX1.5" 2 OTC HYPO NEEDLE MIS 23GX1/2" 2 HYPO NEEDLE MIS 25GX1" 2 HYPO NEEDLE MIS 25GX1.5" 3 HYPO NEEDLE MIS 25GX5/8" 3 HYPO NEEDLE MIS 26GX1.5" 2 HYPO NEEDLE MIS 26GX1/2" 3 HYPO NEEDLE MIS 27GX1/2" 3 HYPO NEEDLE MIS 30GX3/4" 2 INFUS SYRING MIS 100ML 2 OTC 3ML LL SYRNG MIS 20GX1" 2 OTC 6ML LL SYRNG MIS 20GX1.5" 2 OTC 3ML LL SYRNG MIS 21GX1.25 2 OTC 3ML LL SYRNG MIS 22GX1.25 3 OTC 3ML LL SYRNG MIS 22GX3/4" 3 OTC 3ML LL SYRNG MIS 23GX1.25 2 OTC 3ML LL SYRNG MIS 24GX1" 3 OTC MULIT-DRAW MIS 22GX1.5" 2 OTC MULTI-DRAW MIS 20GX1.5 2 OTC


168

Drug Name Drug Tier Requirements/Limits MULTI-DRAW MIS 21GX1.5" 2 OTC NEEDLES MIS 19GX1" 2 OTC NEEDLES MIS 25GX1.5" 2 OTC NEEDLES MIS 26X1/2" 2 OTC NEEDLES MIS 27GX1/2" 2 OTC OSGOOD BIOPS MIS 18GX1" 3 SAFETYGLIDE MIS 27GX5/8" 3 OTC SPINAL NEEDL MIS 22GX3.5" 2 OTC 5-6ML SYRING MIS LUER SLP 2 OTC 3ML SYRINGE MIS 20GX1" 3 3ML SYRINGE MIS 20GX1.5" 2 12ML SYRINGE MIS 20GX1.5" 2 OTC 6ML SYRINGE MIS 20GX1.5" 3 3ML SYRINGE MIS 21GX1" 2 3ML SYRINGE MIS 21GX1" 2 OTC 3ML SYRINGE MIS 21GX1.5" 2 12ML SYRINGE MIS 21GX1.5" 2 OTC 3ML SYRINGE MIS 22GX1" 3 3ML SYRINGE MIS 22GX1" 3 PA; OTC 6ML SYRINGE MIS 22GX1.5" 2 3ML SYRINGE MIS 22GX1.5" 3 3 ML SYRINGE MIS 22X1-1/2 2 OTC 3ML SYRINGE MIS 23GX1" 2 3ML SYRINGE MIS 23GX1" 2 OTC 3ML SYRINGE MIS 23GX1.5" 3 OTC 3ML SYRINGE MIS 25GX1" 2 1ML SYRINGE MIS 25GX1" 2 OTC 3ML SYRINGE MIS 25GX5/8" 2 1ML SYRINGE MIS 25GX5/8" 2 OTC 1ML SYRINGE MIS 26GX3/8" 2 OTC 30ML SYRINGE MIS GL ZONE1 2 OTC 20ML SYRINGE MIS LL ZONE1 2 OTC 30ML SYRINGE MIS LUER LOC 3 5ML SYRINGE MIS LUER SLP 2 OTC 1ML SYRINGE MIS LUER SLP 3 50ML SYRINGE MIS ML ZONE1 2 OTC 3ML SYRINGE MIS REG TIP 3 10-12ML SYRN MIS LUER SLP 2 OTC 1.5 ML SYRNG MIS 22X1-1/2 3 PA; OTC 2ML TB SYRNG MIS LL ZONE1 2 OTC 1ML TB SYRNG MIS LUER SLP 3 TOOMEY SYRIN MIS 70ML 2 VENT NEEDLE MIS 18GX1.5" 2 OTC YALE NEEDLE MIS 15GX1.5" 3 OTC YALE NEEDLE MIS 15GX2" 3 OTC YALE NEEDLE MIS 16GX2" 3 OTC


169

Drug Name Drug Tier Requirements/Limits YALE NEEDLES MIS 13X3-1/2 3 OTC YALE NEEDLES MIS 15X3-1/2 3 OTC YALE NEEDLES MIS 17G X 2" 3 OTC YALE NEEDLES MIS 18G X 2" 3 OTC YALE NEEDLES MIS 18X1-1/2 3 OTC YALE NEEDLES MIS 19X1-1/2 3 OTC YALE NEEDLES MIS 20G X 1" 3 OTC YALE NEEDLES MIS 20G X 2" 3 OTC YALE NEEDLES MIS 20X1-1/2 3 OTC YALE NEEDLES MIS 21G X 1" 3 OTC YALE NEEDLES MIS 21X1-1/2 3 OTC YALE NEEDLES MIS 22G X 1" 3 OTC YALE NEEDLES MIS 22G X 2" 3 OTC YALE NEEDLES MIS 22G X 3" 3 OTC YALE NEEDLES MIS 22X1-1/2 3 OTC YALE NEEDLES MIS 23G X 1" 3 OTC YALE NEEDLES MIS 23G X 2" 3 OTC YALE NEEDLES MIS 23GX1/2" 3 OTC YALE NEEDLES MIS 23X1-1/2 3 OTC YALE NEEDLES MIS 24G X 1" 3 OTC YALE NEEDLES MIS 24GX1/2" 3 OTC YALE NEEDLES MIS 24GX3/4" 3 OTC YALE NEEDLES MIS 24X1-1/2 3 OTC YALE NEEDLES MIS 25G X 1" 3 OTC YALE NEEDLES MIS 25GX1/2" 3 OTC YALE NEEDLES MIS 25GX3/8" 3 OTC YALE NEEDLES MIS 25GX5/8" 3 OTC YALE NEEDLES MIS 25X1-1/2 3 OTC YALE NEEDLES MIS 26G X 1" 3 OTC YALE NEEDLES MIS 26GX1/2" 3 OTC YALE NEEDLES MIS 26GX3/8" 3 OTC YALE NEEDLES MIS 26GX5/8" 3 OTC YALE NEEDLES MIS 26X1-1/2 3 OTC YALE NEEDLES MIS 27G X 1" 3 OTC YALE NEEDLES MIS 27GX1/2" 3 OTC YALE NEEDLES MIS 27GX1/4" 3 OTC YALE NEEDLES MIS 27GX3/8" 3 OTC YALE NEEDLES MIS 30G X 1" 3 OTC YALE NEEDLES MIS 30X1-1/2 3 OTC YALE TB SYRN MIS GL 1/4ML 2 OTC YALE TB SYRN MIS GL 1ML 2 OTC NUTRITIONAL / SUPPLEMENTS DIETARY MANAGEMENT PRODUCTS BLADDER 2.2 TAB 2 OTC ELFOLATE TAB 7.5MG 3 ST


170

Drug Name Drug Tier Requirements/Limits ELFOLATE TAB 15MG 3 ST ELFOLATE TAB PLUS 3 ST estro supprt tab es 1 OTC FALESSA TAB 1MG 3 PA L-METHYL- TAB B6-B12 3 PA L-METHYL-MC TAB NAC 3 METAFOLBIC TAB 3 METAFOLBIC TAB PLUS RF 3 NUTR DRINK POW MIX VAN 2 OTC PODIAPN CAP 3 PURALOR CI TAB 3 PA TEARS AGAIN CAP HYDRATE 3 OTC VASCAZEN CAP 1GM 3 VAYAROL CAP 3 vp-precip cap 1 ELECTROLYTES, MISCELLANEOUS av-phos 250 tab neutral 1 CERALYTE 70 LIQ 2 QL (5000 / 30 days);

OTC K-PHOS TAB 2 K-PHOS TAB NO 2 2 oral electrolyte solution 1 QL (5000 ml / 30 days);

OTC ELECTROLYTES, POTASSIUM EFFER-K TAB 10MEQ 3 PA EFFER-K TAB 20MEQ 3 PA K-TAB TAB 10MEQ CR 3 PA K-TAB TAB 20MEQ 3 PA klor-con 8 tab 8meq er 1 KLOR-CON M15 TAB 15MEQ ER 3 MICRO-K CAP 8MEQ CR 3 PA MICRO-K CAP 10MEQ CR 3 PA pot bicarbonate & chloride effer tab 25

meq 1

potassium bicarbonate effer tab 25 meq 1 potassium chloride cap er 8 meq 1 potassium chloride cap er 10 meq 1 potassium chloride microencapsulated crys

er tab 10 meq 1

potassium chloride microencapsulated crys er tab 20 meq

1

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

1

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

1

potassium chloride powder packet 20 meq 1


171

Drug Name Drug Tier Requirements/Limits potassium chloride tab er 10 meq 1 potassium chloride tab er 20 meq (1500

mg) 1

INTRAVENOUS NUTRITION, CALORIC AGENTS AMINOSYN 7% INJ /LYTES 3 PA AMINOSYN II INJ 7% 3 PA AMINOSYN II INJ 8.5% 3 PA aminosyn ii inj 8.5/lyte 1 PA AMINOSYN II INJ 15% 3 PA AMINOSYN M INJ 3.5% 3 PA AMINOSYN-RF INJ 5.2% 3 PA CLINIMIX E INJ 2.75/D5W 3 PA CLINIMIX E INJ 2.75/D10 3 PA CLINIMIX E INJ 4.25/D5W 3 PA CLINIMIX E INJ 4.25/D10 3 PA CLINIMIX E INJ 4.25/D25 3 PA CLINIMIX E INJ 5%/D15W 3 PA CLINIMIX E INJ 5%/D20W 3 PA CLINIMIX E INJ 5%/D25W 3 PA CLINIMIX INJ 2.75/D5W 3 PA CLINIMIX INJ 4.25/D5W 3 PA CLINIMIX INJ 4.25/D10 3 PA CLINIMIX INJ 4.25/D20 3 PA CLINIMIX INJ 4.25/D25 3 PA CLINIMIX INJ 5%/D15W 3 PA CLINIMIX INJ 5%/D20W 3 PA CLINIMIX INJ 5%/D25W 3 PA cysteine hcl inj 50 mg/ml 1 dextrose inj 5% 1 dextrose inj 10% 1 PA DEXTROSE INJ 20% 3 dextrose inj 25% 1 dextrose inj 30% 1 DEXTROSE INJ 40% 3 dextrose inj 50% 1 dextrose inj 70% 1 FREAMINE HBC INJ 6.9% 3 PA FREAMINE III INJ 10% 3 PA gluco shot liq 1 OTC hepatamine sol 8% 1 PA INTRALIPID INJ 30% 3 PA LIPOCHOL TAB PLUS 3 PA; OTC MICROLIPID EMU 50% 2 OTC NEPHRAMINE INJ 5.4% 3 PA nutrilipid emu 20% 1 PA


172

Drug Name Drug Tier Requirements/Limits plenamine inj 15% 1 PA premasol sol 6% 1 PA PROCALAMINE INJ 3% 3 PA PROSOL INJ 20% 3 PA TROPHAMINE INJ 6% 3 PA INTRAVENOUS NUTRITION, ELECTROLYTES alcohol absolute inj 98% 1 PA D5W/LYTES INJ #48 3 D5W/NACL INJ 0.3% 3 D10W/NACL INJ 0.2% 3 D10W/NACL INJ 0.225% 2 dextrose 2.5% w/ sodium chloride 0.45% 1 dextrose 5% in lactated ringers 1 dextrose 5% w/ sodium chloride 0.2% 1 dextrose 5% w/ sodium chloride 0.9% 1 dextrose 5% w/ sodium chloride 0.33% 1 dextrose 5% w/ sodium chloride 0.45% 1 dextrose 5% w/ sodium chloride 0.225% 1 dextrose 10% w/ sodium chloride 0.45% 1 ELLIOTTS B INJ 3 PA hyperlyte-cr inj 1 PA IONOSOL-B/ INJ D5W 3 PA IONOSOL-MB INJ /D5W 3 PA ISOLYTE-P INJ /D5W 3 PA ISOLYTE-S INJ 3 PA ISOLYTE-S INJ PH 7.4 3 PA kcl 10 meq/l (0.075%) in dextrose 5% &

nacl 0.45% inj 1

kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj

1


1


1


1

kcl 20 meq/l (0.15%) in nacl 0.9% inj 1 kcl 20 meq/l (0.15%) in nacl 0.45% inj 1 kcl 30 meq/l (0.224%) in dextrose 5% &

nacl 0.45% inj 1


1

kcl 40 meq/l (0.3%) in nacl 0.9% inj 1 KCL/D5W/LACT INJ 20MEQ/L 3 KCL/D5W/LACT INJ 40MEQ/L 3 KCL/D5W/NACL INJ 0.3/0.9% 3


173

Drug Name Drug Tier Requirements/Limits KCL/D5W/NACL INJ 0.15/0.2 3 lactated ringer's solution 1 NORMOSOL -M INJ /D5W 3 PA NORMOSOL -R INJ 3 PA NORMOSOL -R INJ /D5W 3 PA NORMOSOL-R INJ PH 7.4 3 PA PLASMA-LYTE INJ 56/D5W 3 PA PLASMA-LYTE INJ -148 3 PA PLASMA-LYTE INJ -A 3 PA potassium acetate inj 2 meq/ml 1 potassium acetate inj 4 meq/ml 1 potassium chloride 20 meq/l (0.15%) in

dextrose 5% inj 1

potassium chloride 40 meq/l (0.3%) in dextrose 5% inj

1

potassium chloride inj 2 meq/ml 1 PA potassium chloride inj 10 meq/50ml 1 potassium chloride inj 10 meq/100ml 1 potassium chloride inj 20 meq/50ml 1 potassium chloride inj 20 meq/100ml 1 potassium chloride inj 40 meq/100ml 1 ringer's solution 1 sodium chloride inj 0.9% 1 sodium chloride inj 0.45% 1 sodium chloride inj 2.5 meq/ml (14.6%) 1 sodium chloride inj 3% 1 sodium chloride inj 4 meq/ml (23.4%) 1 sodium chloride inj 5% 1 sodium chloride iv soln 0.9% 1 sodium chloride tab 1 gm 1 OTC tpn electrol inj 1 PA INTRAVENOUS NUTRITION, VITAMINS AND MINERALS ADDAMEL N INJ 3 PA ascorbic acid inj 500 mg/ml 1 calcium chloride inj 10% 1 calcium gluconate inj 10% 1 chromic chloride inj 40 mcg/10ml (4

mcg/ml) (elemental cr) 1

cupric chloride inj 0.4 mg/ml 1 GLYCOPHOS SOL 1MM/ML 3 PA INFUVITE INJ 1 PA IODOPEN INJ 100MCG 3 PA magnesium chloride inj 200 mg/ml 1 magnesium sulfate inj 50% 1 manganese chloride inj 0.1 mg/ml 1 manganese sulfate inj 0.1 mg/ml 1


174

Drug Name Drug Tier Requirements/Limits MANGANESE TAB 50MG 3 PA; OTC MG SO4/D5W INJ 10MG/ML 3 PA MULTITRACE-4 INJ 2 multitrace-4 inj conc 1 MULTITRACE-4 INJ NEONATAL 3 PA MULTITRACE-4 INJ PED 3 multitrace-5 inj conc 1 MULTITRACE-5 INJ REGULAR 3 PA PEDITRACE INJ 3 PA potassium phosphates inj 15 mm/5ml

(phos) 22 meq/5ml (k) 1

potassium phosphates inj 45 mm/15ml (phos) 66 meq/15ml (k)

1

potassium phosphates inj 150 mm/50ml (phos) 220 meq/50ml (k)

1

selenious acid inj 40 mcg/ml 1 sodium phosphates inj 15 mm/5ml (phos)

20 meq/5ml (na) 1

TRACE ELEM 4 INJ PED 3 PA zinc chloride inj 1 mg/ml 1 zinc sulfate inj 1 mg/ml 1 zinc sulfate inj 5 mg/ml 1 VITAMINS AND MINERALS, FOLIC ACID / COMBINATIONS ANIMI-3 CAP VIT D 3 PA DIVISTA CAP 3 PA DURACHOL CAP 1-3775IU 2 folic acid inj 5 mg/ml 1 folic acid tab 1 mg 1 folic acid tab 400 mcg 1 PA; OTC folic acid tab 800 mcg 1 PA; OTC PUREFOLIX TAB 1-5000 3 PA REVESTA CAP 1MG-5750 3 PA VITAMINS AND MINERALS, MISCELLANEOUS ABANEU-SL SUB 2 abatron af tab 1 PA; OTC abatron liq 1 OTC ACTIVE FE TAB 75-1.25 3 PA ACTIVE OB CAP 2 ADVANCED MIS AM/PM 3 AMMONIUM CHL INJ 5MEQ/ML 3 PA animal shape chw complete 1 OTC AP-ZEL TAB 3 ascorbic acid cap er 500 mg 1 OTC ascorbic acid chew tab 250 mg 1 OTC ascorbic acid chew tab 500 mg 1 OTC ascorbic acid tab 250 mg 1 OTC


175

Drug Name Drug Tier Requirements/Limits ascorbic acid tab 1000 mg 1 OTC ascorbic acid tab er 500 mg 1 OTC ascorbic acid tab er 1000 mg 1 OTC ascorbic acid tab er 1500 mg 1 OTC ATABEX CHW PRENATAL 2 OTC ATABEX EC TAB 2 B12 COMPLNCE KIT INJ KIT 3 PA b-100 tab tr 1 OTC b-complex tab 1 OTC B-COMPLEX TAB C/FA/BIO 3 OTC b-complex vitamin cap 1 OTC b-complex vitamin tab 1 OTC b-complex w/ c & calcium tab 1 OTC b-complex w/ c cap 1 OTC b-complex w/ folic acid cap 1 OTC b-plex tab 1 BAL-CARE MIS DHA 2 balance b-50 tab tr 1 OTC balanced b tab complex 1 OTC balanced tab b-100 tr 1 OTC bdy/hair/skn cap nails 1 PA; OTC BE WELL PAK ROUNDED 2 OTC berocca tab 1 OTC BIFERARX TAB 3 PA bio-d-mulsio liq 400unit 1 OTC bio-d-mulsio liq 2000unit 1 OTC biocel tab 1 BIOSUPP LIQ 3 PA; OTC BIOVOL SYP 3 OTC BONE DENSITY TAB BUILDER 2 OTC bp folinatal tab plus b 1 bp multinatl chw plus 1 bp multinatl tab plus 1 bprotected sol tri-vite 1 OTC BRAINSTRONG MIS PRENATAL 2 OTC c complex tab 1000mg 1 OTC ca citrate tab plus 1 OTC CA HI-CAL/D TAB 500MG 2 OTC CADEAU DHA CAP 2 OTC CAL-QUICK LIQ 500-400 3 PA; OTC calc citr/d3 tab 200-250 1 OTC calc citrate tab +d 1 OTC CALCET BITES CHW 500-400 3 PA; OTC calcidol dro 8000/ml 1 OTC calcium 500 tab +d 1 OTC calcium 600 chw +d/miner 1 OTC


176

Drug Name Drug Tier Requirements/Limits calcium 600 chw w/vit d 1 OTC calcium 600 tab + d 1 OTC calcium 600 tab +d 1 OTC calcium 600 tab +d3 1 OTC calcium 600/ tab vit d 1 OTC CALCIUM 1000 TAB + D 2 OTC calcium 1200 chw 1 OTC calcium + d chw 1 OTC CALCIUM CARB CHW 260MG 3 PA; OTC CALCIUM CARB POW 800/2GM 3 PA; OTC calcium carbonate susp 1250 mg/5ml (500

mg/5ml elemental ca) 1 OTC

calcium carbonate tab 600 mg 1 OTC calcium carbonate tab 1250 mg (500 mg

elemental ca) 1 OTC

calcium carbonate tab 1500 mg (600 mg elemental ca)

1 OTC

calcium carbonate-cholecalciferol chew tab 500 mg-100 unit

1 OTC

calcium carbonate-vitamin d tab 250 mg-125 unit

1 OTC


1 OTC


1 OTC

CALCIUM CHW GUMMIES 3 OTC CALCIUM CIT/ TAB VIT D 3 OTC calcium citr tab +d 1 OTC calcium citrate-vitamin d tab 315 mg-200

unit (elemental ca) 1 OTC

calcium plus cap d3 1 OTC calcium tab 500/d 1 OTC calcium tab 600mg 1 OTC calcium+d3 tab 600-800 1 OTC calcium+d3 tab grad rel 1 OTC CALCIUM-FA WAF PLUS D 3 PA calcium-magnesium-zinc tab 333-133-5

mg 1 OTC

CALCIUM/C/D CHW 500MG 3 OTC calcium/d3 tab 1 OTC calcium/d3 tab 600-800 1 OTC CALCIUM/VITD CAP 600-400 3 OTC CALNA TAB 2 OTC CALTRATE 600 CHW 600-800 2 OTC CALTRATE 600 CHW +D PLUS 2 PA; OTC CALTRATE + D TAB 300-800 2 OTC CELLULAR CAP SECURITY 3 PA; OTC


177

Drug Name Drug Tier Requirements/Limits CENTRUM LIQ 3 PA; OTC CHEWABLE CHW IRON 3 OTC cholecalciferol cap 400 unit 1 OTC cholecalciferol cap 5000 unit 1 OTC cholecalciferol oral liquid 400 unit/ml 1 OTC cholecalciferol tab 2000 unit 1 OTC cholecalciferol tab 50000 unit 1 OTC CITRACAL+D3 CHW 250-500 3 PA; OTC CITRANATAL CAP HARMONY 2 CITRANATAL TAB RX 2 cod liver chw w/vit 1 OTC COMP PRNATAL MIS DHA 2 OTC COMPLETE NAT PAK DHA 2 CONCEPT DHA CAP 2 CONCEPT OB CAP 2 corvita 150 tab 1 corvita tab 1 CORVITE 150 TAB 3 PA CORVITE FE TAB 3 PA CORVITE TAB 3 PA CVS PRENATAL CHW GUMMY 2 OTC cyanocobalamin inj 1000 mcg/ml 1 d3 cap 1000unit 1 OTC d3 max st dro 5000unit 1 OTC d3 super str cap 2000unit 1 OTC d 400 chw 400unit 1 OTC d 400 tab 400unit 1 OTC DDROPS LIQ 1000UNIT 2 OTC DECARA CAP 25000UNT 2 OTC DIABETIC CAP VITAMIN 3 PA DIALYVITE TAB 800/IRON 3 PA; OTC DIALYVITE TAB 3000 3 PA DUET DHA 400 MIS 25-1-400 2 DUET DHA MIS BALANCED 2 elite-ob tab 1 ENBRACE HR CAP 2 EQL CALCIUM CAP VIT D 3 PA; OTC ergocalciferol cap 50000 unit 1 essent one tab daily 1 OTC ezfe 200 cap 200mg 1 OTC fe c plus tab 1 OTC fe gluconate tab 325mg 1 OTC FE PLUS TAB PROTEIN 3 OTC fe tabs tab 325mg ec 1 OTC FER-IN-SOL DRO 15MG/ML 2 PA; OTC FERIVA CAP 75-1MG 3 PA


178

Drug Name Drug Tier Requirements/Limits FERIVAFA CAP 110-1MG 3 PA ferocon cap 1 ferrex 28 mis 1 ferrex 150 cap 150mg 1 OTC ferrex 150 cap forte pl 1 FERRIMIN 150 TAB 2 OTC ferrocite tab 324mg 1 OTC ferrocite tab plus 1 ferrogels fo cap forte 1 FERROUS SULF TAB 140MG 2 OTC ferrous sulfate elixir 220 mg/5ml (44

mg/5ml elemental fe) 1 OTC

ferrous sulfate tab 325 mg (65 mg elemental fe)

1 OTC

ferrous sulfate tab er 142 mg (45 mg fe equivalent)

1 OTC

FLINTSTONES CHW COMPLETE 3 PA; OTC FLINTSTONES CHW GUMMIES 3 PA; OTC FLORICAL CAP 2 OTC FLORICAL TAB 2 OTC FLORIVA CHW 0.25MG 3 PA FLUOR-A-DAY CHW 0.25MG F 3 FLUOR-A-DAY CHW 1MG F 3 FLUORABON DRO 3 PA flura-drops dro 0.25mg f 1 PA flura-drops dro 0.125mg 1 PA FOCALGIN 90 MIS DHA 2 FOCALGIN CA MIS 2 FOCALGIN DSS TAB 90-1MG 3 PA folbee plus tab 1 FOLCAPS CAP OMEGA 3 2 FOLET DHA PAK 2 FOLET ONE CAP 38-1-225 2 FOLGARD OS TAB 3 PA FORTAVIT CAP 3 PA FUSION PLUS CAP 3 PA GALZIN CAP 25MG 3 PA GALZIN CAP 50MG 3 PA gnp iron tab 65mg 1 OTC healthy kids chw overall 1 OTC hematogen cap 1 HEMATOGEN FA CAP 2 HEMATRON-AF TAB 3 PA HEMENATAL OB MIS + DHA 2 hemocyte-f tab 1 PA HONEY BEARS CHW 3 OTC


179

Drug Name Drug Tier Requirements/Limits HONEY BEARS CHW IRON-ZIN 3 OTC icar-c plus tab 1 PA inatal adv tab 1 INFANATE CAP BALANCE 2 INTEGRA F CAP 3 PA INTEGRA PLUS CAP 3 PA iron slow tab 45mg 1 OTC iron supplmt dro 15mg/ml 1 OTC IRON UP LIQ 3 PA; OTC IS 24/6 MIS 3 PA KOSHR PRENAT TAB 30-1MG 2 KPN PRENATAL TAB 2 OTC LEVOMEFOLATE CAP DHA 2 liq ca/vit d cap 600mg 1 OTC LIQUID CALCI CAP WITH D3 3 PA; OTC LOZI-FLUR LOZ 1MG F 2 ludent chw 0.5mg f 1 ludent chw 0.25mg f 1 ludent chw 1mg f 1 mag64 tab 64mg 1 OTC MAGNEBIND TAB 400 3 PA MAGNESIUM CAP 400MG 3 PA; OTC magnesium oxide cap 500 mg (elemental

mg) 1 OTC

magnesium oxide tab 400 mg (240 mg elemental mg)

1 OTC

magnesium oxide tab 500 mg (mg supplement)

1 OTC

magnesium tab 250 mg 1 OTC MARNATAL-F CAP 2 MAXFE LIQ 3 PA; OTC MEGA MULTIVI TAB WOMEN 3 OTC MEPHYTON TAB 5MG 2 methacholine cap /liver 1 OTC mgo tab 400mg 1 OTC MISSION PREN TAB 2 OTC MISSION PREN TAB HP 2 OTC MTERYTI TAB 2 OTC MTERYTI TAB FOLIC 5 2 OTC MULTI PRENAT TAB 2 OTC multi-delyn liq 1 OTC MULTI-DELYN LIQ /IRON 3 OTC multi-vit/fe dro /fl 0.25 1 PA multi-vit/fl dro 0.5mg/ml 1 PA multi-vit/fl dro 0.25mg 1 PA MULTIGEN PLS TAB 3


180

Drug Name Drug Tier Requirements/Limits MULTIGEN TAB 3 multiple minerals tab 1 OTC multivitamin dro pediatrc 1 OTC multivitamin liq mineral 1 PA; OTC mv-one cap 1 OTC myferon 150 cap forte 1 MYKIDZ IRON SUS 10MG/2ML 2 OTC MYNATAL CAP 2 MYNATAL TAB 2 MYNATAL-Z TAB 2 MYNATE 90 TAB PLUS 2 mynephrocaps cap 1 PA NANOVM T/F LIQ 2 OTC NANOVM T/F POW 2 OTC NATACHEW CHW 2 NATALVIT TAB 75-1MG 2 NATELLE ONE CAP 2 NEPHROCAPS CAP 3 PA NEPHRON FA TAB 3 PA nephronex tab 1mg 1 NESTABS ABC MIS 2 NESTABS DHA PAK 2 NEUT INJ 4% 3 PA NEWGEN TAB 32-1MG 2 NEXA PLUS CAP 2 niacin cap 400mg 1 OTC niacin cap er 250 mg 1 OTC niacin cap er 500 mg 1 OTC niacin tab 50 mg 1 OTC niacin tab 100 mg 1 OTC niacin tab 250 mg 1 OTC niacin tab 500 mg 1 OTC niacin tab er 500 mg 1 OTC niacin tab er 750 mg 1 OTC NIACIN TR TAB 1000MG 3 OTC niacinamide tab 100 mg 1 OTC niacinamide tab 500 mg 1 OTC NIACINAMIDE TAB 500MG PR 3 PA; OTC NOVAFERRUM CAP 50MG 2 OTC novaferrum dro 10mg/ml 1 OTC NOVAFERRUM DRO 15MG/ML 2 OTC NOVAFERRUM LIQ 125 2 OTC NUTRICION TAB PORVIDA 2 OTC NUTRIENTS TAB PRENATAL 2 OTC NUTRIVIT LIQ 800-15-1 2 O-CAL TAB PRENATAL 2


181

Drug Name Drug Tier Requirements/Limits OB COMPLETE CAP GOLD 2 OB COMPLETE CAP ONE 2 OB COMPLETE CAP PETITE 2 OB COMPLETE TAB 2 OB COMPLETE TAB PREMIER 2 OB COMPLETE/ CAP DHA 2 OBSTETRIX EC TAB 2 OBSTETRIX PAK DHA 2 OBTREX DHA PAK 2 OTC OBTREX TAB 2 OTC ONE A DAY CAP PRENATAL 2 OTC ONE A DAY MIS PRENATAL 2 OTC one daily tab 1 OTC one daily tab plus iro 1 OTC ONE-A-DAY TAB WOMENS 3 PA; OTC optimal-d cap 50000unt 1 OTC OSTEO-PORETI TAB 3 PA; OTC oys shell+d chw 500-400 1 OTC oys shell+d tab 250-125 1 OTC oysco 500+d tab 1 OTC oyst shell/d tab 500mg 1 OTC oyster shell calcium tab 500 mg 1 OTC oyster-cal tab 500mg 1 OTC PERRY PRENAT CAP 2 OTC phytonadione inj 1 mg/0.5ml (2 mg/ml) 1 PA phytonadione inj 10 mg/ml 1 PNV OB+DHA PAK 2 pnv-dha cap 1 PNV-DHA CAP DOCUSATE 2 PNV-OMEGA CAP 2 pnv-select tab 1 PNV-TOTAL CAP 2 poly-vite dro 1 OTC PR NATAL 400 PAK 2 PR NATAL 400 PAK EC 2 PR NATAL 430 PAK 2 PR NATAL 430 PAK EC 2 PREFERA OB TAB 2 PREFERAOB CAP ONE 2 PREFERAOB MIS +DHA 2 PRENA1 CHW 2 PRENA1 PEARL CAP 2 PRENA 1 TRUE MIS 2 PRENAISSANCE CAP 2 PRENAISSANCE CAP BALANCE 2 PRENAISSANCE CAP PLUS 2


182

Drug Name Drug Tier Requirements/Limits PRENAISSANCE MIS HARMONY 2 PRENAISSANCE TAB NEXT 2 PRENAISSANCE TAB NEXT-B 2 PRENATA CHW 29-1MG 2 prenatabs rx tab 1 PRENATAL 1 CAP 2 OTC PRENATAL 19 CHW 29-1MG 2 prenatal 19 chw tab 1 prenatal 19 tab 1 PRENATAL 19 TAB 29-1MG 2 PRENATAL CAP FORMULA 2 OTC PRENATAL CAP OMEGA-3 2 OTC PRENATAL FRM TAB A-FREE 2 OTC PRENATAL MIS COMPLEAT 2 PRENATAL MUL CAP +DHA 2 OTC PRENATAL MV MIS + DHA 2 OTC PRENATAL TAB 2 OTC PRENATAL TAB 27-1MG 2 PRENATAL TAB COMPLETE 2 OTC PRENATAL TAB FORMULA 2 OTC PRENATAL+DHA MIS 2 OTC PRENATAL+FE TAB 29-1MG 2 PRENATAL-U CAP 106.5-1 2 PRENATE AM TAB 1MG 2 PRENATE CAP ENHANCE 2 PRENATE CAP ESSENTIA 2 PRENATE CAP PIXIE 2 PRENATE CAP RESTORE 2 PRENATE CHW 0.6-0.4 2 PRENATE DHA CAP 2 PRENATE MINI CAP 2 PRENATE TAB ELITE 2 PRENATL MULT CAP + DHA 2 OTC PRETAB TAB 29-1MG 2 PROFE CAP 180MG 2 OTC PROFE FORTE CAP 155-1MG 2 OTC PROFERRIN- TAB FORTE 2 PRONUTRIENTS TAB SUPER B 2 OTC PROTECTIRON TAB 3 PA PROVIDA DHA CAP 2 PROVIDA OB CAP 2 PUREFE CAP PLUS 2 PUREFE OB CAP PLUS 2 purevit dual cap fe plus 1 px iron tab 27mg 1 OTC pyridoxine hcl tab 25 mg 1 OTC


183

Drug Name Drug Tier Requirements/Limits pyridoxine hcl tab 50 mg 1 OTC pyridoxine hcl tab 100 mg 1 OTC QUINTABS TAB 3 OTC RA OYS SHL/D TAB 250MG 3 OTC rabano liq yodado 1 OTC RAYALDEE CAP 30MCG 3 ST RELNATE DHA CAP 2 REPLESTA NX WAF 14000UNT 2 OTC REPLESTA WAF 50000UNT 3 OTC RULAVITE DHA CAP 2 s.s.s. tonic tab 1 OTC SCOOBY-DOO CHW 2 OTC SE-TAN DHA CAP 2 SELECT-OB CHW 2 SELECT-OB+ PAK DHA 2 SIMILAC PREN PAK EARLY SH 2 OTC slow release tab 47.5mg 1 OTC sm b super tab vita com 1 OTC sm b-complex tab 1 OTC SM B-COMPLEX TAB /VIT C 3 OTC sm balanced tab b-100 1 OTC SM CORAL CAL TAB 1000MG 3 PA; OTC sm iron slow tab 160mg cr 1 OTC sm iron tab 1 OTC sm magnesium tab 250mg 1 OTC sm multiple tab vit/iron 1 OTC sm niacin tab 250mg cr 1 OTC SM ONE DAILY MIS PRENATAL 2 OTC SM ONE DAILY TAB ESSENTIA 3 PA; OTC sm vit b-1 tab 100mg 1 OTC SOD LACTATE INJ 5MEQ/ML 3 sodium acetate inj 2 meq/ml 1 sodium acetate inj 4 meq/ml 1 sodium bicarbonate inj 4.2% 1 sodium bicarbonate inj 7.5% 1 sodium bicarbonate inj 8.4% 1 sodium fluoride soln 0.5 mg/ml f (from 1.1

mg/ml naf) 1

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

1

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

1

stress b com tab vit c/zn 1 OTC STUART ONE CAP 2 OTC super b comp tab vit c 1 OTC superior 35 tab 1 OTC


184

Drug Name Drug Tier Requirements/Limits SUPPORT LIQ 3 PA TANDEM F CAP 3 PA TANDEM PLUS CAP 3 PA TARON-BC MIS 2 TARON-PREX CAP 2 THERA-D TAB 4000UNIT 3 PA; OTC THERAMILL CAP FORTE 3 PA; OTC THERANATAL CAP ONE 2 OTC THERANATAL MIS COMPLETE 2 OTC THERANATAL PAK OVAVITE 2 OTC THERANATAL TAB 27-1 2 OTC thiamine hcl inj 100 mg/ml 1 thiamine hcl tab 100 mg 1 OTC TL FOLATE TAB 2 tl-hem 150 tab 1 PA TRI-VI-SOL SOL 3 PA; OTC TRICARE PAK PRENATAL 2 TRICARE PRE CAP 27-1-500 2 TRIFERIC SOL 3 PA trinate tab 1 TRISTART DHA CAP 2 UDAMIN SP TAB 3 PA ULTIMATECARE CAP ONE NF 2 ultra b-100 tab complex 1 OTC ULTRA MAN TAB 2 OTC UPCAL D POW 3 PA; OTC urosex tab 1 PA v-c forte cap 1 PA vigor cap 1 OTC VINACAL B MIS 2 VINATE C TAB 2 VINATE CAL TAB 2 VINATE CARE CHW 40-1MG 2 VINATE DHA CAP 27-1.13 2 VINATE II TAB 2 VINATE M TAB 2 VINATE ONE TAB 2 VIRT NATE TAB 2 VIRT-PN TAB 2 VIRTPREX CAP 2 vit c gummie chw 125mg 1 OTC VITA-PREN TAB 2 VITACRAVES CHW +OMEGA-3 3 PA; OTC VITAFOL CAP ULTRA 2 VITAFOL CHW GUMMIES 2 VITAFOL FE+ CAP 2


185

Drug Name Drug Tier Requirements/Limits VITAFOL TAB 3 PA VITAFOL-NANO TAB 2 VITAFOL-OB PAK +DHA 2 VITAFOL-ONE CAP 2 VITAL-D RX TAB 3 PA VITALETS CHW 3 OTC VITAMAX CHW 3 PA; OTC vitamax ped dro 1 VITAMEDMD CAP ONE RX 2 VITAMEDMD MIS PLUS RX 2 vitamin c + tab echinace 1 OTC vitamin c tab 500mg 1 OTC vitamin c tab plus 1 OTC VITAMIN D2 TAB 400UNIT 3 OTC VITAMIN D2 TAB 2000UNIT 2 OTC VITAMIN D3 CAP 4000UNIT 3 PA; OTC vitamin d3 cap 10000unt 1 OTC VITAMIN D3 LIQ 1200UNIT 3 PA; OTC VITAMIN D3 SPR 1000UNIT 3 PA; OTC VITAMIN D3 TAB 3000UNIT 3 PA; OTC vitamin d chw 1000unit 1 OTC VITAMIN D TAB 400 3 OTC vitamin d tab 1000unit 1 OTC vitamin d-3 tab 5000unit 1 OTC vitamins a & d cap 1 OTC vitatrum chw 1 OTC VP-HEME OB TAB 2 VP-PNV-DHA CAP 2 weight loss tab multi 1 PA; OTC ZATEAN-CH CAP 2 zoo friends chw extra c 1 OTC zoo friends chw gummies 1 OTC zoo friends chw pls iron 1 OTC RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS ADRENALIN INJ 1MG/ML 3 epinephrine hcl inj 1 mg/ml 1 epinephrine hcl soln prefilled syringe 0.1

mg/ml 1

epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)

1 QL (2 pens / 30 days)

epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000)

1 QL (2 pens / 30 days)

EPIPEN 2-PAK INJ 0.3MG 2 QL (2 pens / 30 days) EPIPEN-JR INJ 2-PAK 2 QL (2 pens / 30 days) EPISNAP KIT 3 PA


186

Drug Name Drug Tier Requirements/Limits ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, LONG ACTING ANORO ELLIPT AER 62.5-25 2 QL (1 / 30 days) STIOLTO AER 2.5-2.5 2 QL (1 / 30 days) UTIBRON CAP NEOHALER 3 ST ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, SHORT

ACTING COMBIVENT AER 20-100 2 ipratropium-albuterol nebu soln 0.5-2.5(3)

mg/3ml 1

ANTICHOLINERGICS ATROVENT HFA AER 17MCG 2 INCRUSE ELPT INH 62.5MCG 2 ipratropium bromide inhal soln 0.02% 1 SPIRIVA AER 1.25MCG 2 SPIRIVA CAP HANDIHLR 3 ST SPIRIVA SPR 2.5MCG 2 TUDORZA PRES AER 400/ACT 3 ST ANTIHISTAMINE/DECONGESTANT COMBINATIONS ALLEGRA-D TAB 24 HOUR 2 PA; OTC allergy d tab 5-120mg 1 OTC allergy tab multi-sy 1 OTC allrgy rel-d tab 10-240mg 1 OTC allrgy rlf-d tab 5-120mg 1 OTC CLARINEX-D TAB 2.5-120 3 PA cold & flu liq nighttim 1 OTC cold/allergy elx children 1 OTC entre-b sus 6-10mg/5 1 OTC fexofenadine-pseudoephedrine tab er 12hr

60-120 mg 1 PA

GLENAX PEB LIQ 3 PA; OTC promethazine & phenylephrine syrup 6.25-

5 mg/5ml 1

pyrilamine mal-phenylephrine hcl tann susp 16-5 mg/5ml

1 OTC

RELHIST CHW 3 SEMPREX-D CAP 8-60MG 3 PA sinus/allrgy tab max st 1 OTC TRIAMINIC NT MIS COLD/CGH 3 PA; OTC TRIAMINIC SYP CLD/ALRG 2 OTC wal-fex d tab 24 hour 1 PA; OTC ANTIHISTAMINES, LOW-SEDATING all day allg cap 10mg 1 OTC all day allg tab 10mg 1 OTC allergy relf chw 10mg 1 OTC cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) 1


187

Drug Name Drug Tier Requirements/Limits cetirizine hcl tab 5 mg 1 OTC CLARITIN CAP 10MG 2 OTC levocetirizine dihydrochloride soln 2.5

mg/5ml (0.5 mg/ml) 1 ST

levocetirizine dihydrochloride tab 5 mg 1 ST wal-zyr chw 5mg 1 OTC XYZAL SOL 2.5/5ML 3 PA, ST XYZAL TAB 5MG 3 PA, ST ZYRTEC ALLGY TAB 10MG 2 OTC ZYRTEC ALLGY TAB 10MG 3 PA; OTC ANTIHISTAMINES, NONSEDATING ALLEGRA ALRG TAB 30MG 3 OTC ALLEGRA ALRG TAB 30MG 3 PA; OTC allergy relf tab 10mg 1 OTC CLARINEX SYP 0.5MG/ML 3 ST CLARINEX TAB 5MG 3 PA, ST CLARITIN CHW 5MG 2 OTC CLARITIN RDT TAB 5MG 2 OTC desloratadine tab 5 mg 1 ST desloratadine tab orally disintegrating 2.5

mg 1 ST

desloratadine tab orally disintegrating 5 mg

1 ST

fexofenadine hcl tab 60 mg 1 ST; OTC fexofenadine hcl tab 180 mg 1 ST; OTC loratadine sol 5mg/5ml 1 OTC wal-fex chld sus 30mg/5ml 1 ST; OTC ANTIHISTAMINES, SEDATING allergy cap 25mg 1 OTC allergy tab 4mg 1 OTC allergy tab 12mg cr 1 OTC allergy tab 25mg 1 OTC allrgy relf tab 12.5mg 1 OTC brompheniramine tannate chew tab 12 mg 1 carbinoxamine maleate soln 4 mg/5ml 1 carbinoxamine maleate tab 4 mg 1 chld allergy liq 12.5/5ml 1 OTC clemastine fumarate tab 2.68 mg 1 cvs allergy chw 12.5mg 1 OTC cyproheptadine hcl syrup 2 mg/5ml 1 cyproheptadine hcl tab 4 mg 1 dayhist alrg tab 12 hour 1 OTC diabet tuss syp allergy 1 PA; OTC diphenhydramine hcl cap 50 mg 1 OTC diphenhydramine hcl elixir 12.5 mg/5ml 1 diphenhydramine hcl inj 50 mg/ml 1


188

Drug Name Drug Tier Requirements/Limits ED CHLORPED LIQ 2MG/ML 2 OTC hydroxyzine hcl im soln 25 mg/ml 1 hydroxyzine hcl im soln 50 mg/ml 1 hydroxyzine hcl syrup 10 mg/5ml 1 hydroxyzine hcl tab 10 mg 1 hydroxyzine hcl tab 25 mg 1 hydroxyzine hcl tab 50 mg 1 hydroxyzine pamoate cap 25 mg 1 hydroxyzine pamoate cap 50 mg 1 hydroxyzine pamoate cap 100 mg 1 J-TAN PD DRO 1MG/ML 3 PA; OTC KARBINAL ER SUS 4MG/5ML 3 PA RESPA-BR TAB 11MG 3 PA silphen coug syp 12.5/5ml 1 OTC VISTARIL CAP 25MG 3 PA VISTARIL CAP 50MG 3 PA ANTITUSSIVE COMBINATIONS a-s pls nght cap cld/flu 1 OTC ALDEX GS TAB 30-190MG 2 OTC ambi 60pse/ tab 400gfn 1 OTC bio t pres-b liq 10-4-20 1 OTC bio-rytuss liq 5-2-10/5 1 OTC BIONEL LIQ PEDIATRC 3 PA; OTC BIOSPEC DMX LIQ 3 PA; OTC BROVEX PEB LIQ DM 3 PA; OTC CARBAPHEN 12 LIQ 3 PA CARBAPHEN 12 SUS PED 3 PA cgh control syp pe 1 OTC CHERACOL-D LIQ 100-10/5 3 PA; OTC chest conges tab 20-400mg 1 OTC CODAR AR LIQ 2-8/5ML 3 CODAR D LIQ 30-8/5ML 2 OTC codar gf liq 200-8/5 1 OTC cold & flu liq day/nght 1 OTC cold head tab cong dt 1 OTC cold mult-sy tab daytime 1 OTC cold/cough elx child 1 OTC cold/cough elx children 1 OTC CONGESTAC TAB 60-400MG 3 PA; OTC cough & sore liq thrt day 1 OTC day time liq cold/flu 1 OTC dayquil sev liq cold/flu 1 OTC desgen dm tab 1 OTC dibromm chld liq 2.5-1-5 1 OTC DOUBLE-TUSSN LIQ DM 3 PA; OTC


189

Drug Name Drug Tier Requirements/Limits ED BRON GP LIQ 2 OTC ENTEX T TAB 60-375MG 2 OTC GNP DAY TIME LIQ MUCUS DM 3 PA; OTC gnp tussin syp cf 1 OTC guaiatussin syp 100-10/5 1 OTC HYCOFENIX SOL 3 PA hydrocod polst-chlorphen polst er susp 10-

8 mg/5ml 1

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

1

hydrocodone w/ homatropine tab 5-1.5 mg 1 intense coug liq reliever 1 OTC lohist-dm syp 5-2-10mg 1 OTC MUCINEX CGH GRA 5-100MG 2 OTC mucus & cong cap 10-200 1 OTC mucus d tab 120/1200 1 OTC mucus relief liq 5-100mg 1 OTC mucus relief tab d 1 OTC mucus rlf d tab 60-600mg 1 OTC mucus-dm max tab 60-1200 1 OTC mucus-dm tab 30-600mg 1 OTC OBREDON SOL 2.5-200 3 QL (1800 ml / 30 days),

PA PECGEN DMX LIQ 10-187MG 3 PA; OTC PECGEN DMX LIQ 15-125MG 2 OTC pecgen liq pse 1 OTC POLY-VENT IR TAB 60-380MG 3 PA; OTC promethazine w/ codeine syrup 6.25-10

mg/5ml 1

promethazine-dm syrup 6.25-15 mg/5ml 1 45PSE/400GFN TAB 3 PA; OTC 60PSE/400GFN TAB /20DM 3 PA; OTC pseudoephed-bromphen-dm syrup 30-2-10

mg/5ml 1

pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml

1 OTC

relcof c sol 100-6.3 1 OTC relcof dm liq 1 OTC RESPA C&C IR TAB 3 PA; OTC RESPAIRE-30 CAP 3 PA; OTC REZIRA SOL 60-5/5ML 3 PA ROBITUSSIN LIQ CGH/CLD 3 PA; OTC ROBITUSSIN LIQ DM MAX 3 PA; OTC ROBITUSSN DM SYP 3 PA; OTC RYDEX G TAB 38.5-398 2 OTC SCOT-TUSSIN LIQ SENIOR 2 OTC


190

Drug Name Drug Tier Requirements/Limits sm tussin cf liq 1 OTC stuffy nose liq & cold 1 OTC supress dm dro 5-50/ml 1 OTC TGQ 15DM/5PE SYP H/2CPM 3 TGQ 30/ SYP 150/15 3 TGQ 30/PSE/3 SYP BRM/15DM 3 tgq 50pse/3 syp brm/30dm 1 TRIAMINIC CHW 3 PA; OTC TRICODE AR LIQ 30-2-8 2 OTC TRICODE GF LIQ 30-8-200 2 OTC trymine cg liq 225-7.5 1 OTC TUSNEL PED DRO 7.5-50 3 OTC tussin cf liq 1 OTC tussin cf liq max/m-s 1 OTC tussin dm liq 100-10/5 1 OTC tussin dm liq max 1 OTC tussin dm syp 100-10/5 1 OTC TUSSIONEX SUS 10-8/5ML 3 PA TUZISTRA XR SUS 3 PA vcks dayquil liq mucus dm 1 OTC VICKS NATURE LIQ COLD/FLU 3 OTC VICKS NATURE LIQ CONGEST 3 PA; OTC virtussin sol dac 1 OTC ZYNCOF SYP 20-400/5 2 OTC ANTITUSSIVES benzonatate cap 100 mg 1 benzonatate cap 150 mg 1 benzonatate cap 200 mg 1 BUCKLEYS LIQ COUGH 2 OTC cough dm sus 30mg/5ml 1 OTC CREO-TERPIN SYP 10/15ML 3 PA; OTC day time liq cough 1 OTC HOLD LOZ 5MG ORIG 3 PA; OTC SCOT-TUSSIN LIQ DIBTS/CF 2 PA; OTC st joseph co syp 7.5/5ml 1 OTC TESSALON PER CAP 100MG 3 PA tussin cough syp 15mg/5ml 1 OTC wal-tussin cap cough 1 OTC WAL-TUSSIN CHW 7.5MG 3 OTC wal-tussin liq 15mg/5ml 1 OTC BETA AGONISTS, INHALANTS, LONG ACTING, Hand-held Active

Inhalation ARCAPTA CAP 75MCG 3 ST SEREVENT DIS AER 50MCG 3 ST STRIVERDI AER 2.5MCG 2 QL (1 / 30 days), PA


191

Drug Name Drug Tier Requirements/Limits BETA AGONISTS, INHALANTS, LONG ACTING, Nebulized Passive

Inhalation BROVANA NEB 15MCG 3 ST PERFOROMIST NEB 20MCG 2 BETA AGONISTS, INHALANTS, SHORT ACTING albuterol sulfate soln nebu 0.5% (5 mg/ml)1 albuterol sulfate soln nebu 0.63 mg/3ml

(base equiv) 1

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

1

albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)

1

levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)

1


1


1

levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv)

1

levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv)

1

metaproterenol sulfate syrup 10 mg/5ml 1 metaproterenol sulfate tab 10 mg 1 metaproterenol sulfate tab 20 mg 1 PROAIR HFA AER 3 QL (2 / 30 days), ST PROAIR RESPI AER 3 ST VENTOLIN HFA AER 2 VENTOLIN HFA AER 2 QL (2 / 30 days) XOPENEX CONC NEB 1.25/0.5 3 PA, ST XOPENEX HFA AER 3 QL (1 inhaler / 25 days),

PA, ST XOPENEX NEB 0.31MG 3 PA, ST XOPENEX NEB 0.63MG 3 PA, ST XOPENEX NEB 1.25/3ML 3 PA, ST BETA AGONISTS, INJECTABLE ISUPREL INJ 0.2MG/ML 3 PA terbutaline sulfate inj 1 mg/ml 1 BETA AGONISTS, ORAL AGENTS albuterol sulfate syrup 2 mg/5ml 1 albuterol sulfate tab 2 mg 1 albuterol sulfate tab 4 mg 1 albuterol sulfate tab er 12hr 4 mg 1 albuterol sulfate tab er 12hr 8 mg 1 terbutaline sulfate tab 2.5 mg 1 terbutaline sulfate tab 5 mg 1


192

Drug Name Drug Tier Requirements/Limits VOSPIRE ER TAB 4MG 3 PA, ST VOSPIRE ER TAB 8MG 3 PA, ST CYSTIC FIBROSIS BETHKIS NEB 300/4ML 3 QL (60 / 30 days), PA CAYSTON INH 75MG 2 QL (84 / 60) KALYDECO PAK 50MG 2 QL (60 / 30 days), PA KALYDECO PAK 75MG 2 QL (60 / 30 days), PA KALYDECO TAB 150MG 2 QL (60 tabs / 30 days),

PA KITABIS PAK NEB 300/5ML 3 QL (56 / 56 days), PA ORKAMBI TAB 100-125 3 QL (120 tabs / 30 days),

PA ORKAMBI TAB 200-125 3 QL (120 tabs / 30 days),

PA PULMOZYME SOL 1MG/ML 2 QL (30 / 25 days), PA TOBI NEB 300/5ML 2 QL (56 / 56 days) TOBI PODHALR CAP 28MG 2 QL (240 caps / 30 days) tobramycin nebu soln 300 mg/5ml 1 QL (56 / 56 days) DECONGESTANTS child silfed liq 15mg/5ml 1 OTC decongestant tab 120mg er 1 OTC nasal decon syp 30mg/5ml 1 OTC nasal decong tab 10mg 1 OTC nasal decong tab 30mg 1 OTC nexafed tab 30mg 1 OTC pseudoephedrine hcl tab 60 mg 1 OTC SUDAFED 24HR TAB 240MG 2 OTC EXPECTORANTS chest conges tab 400mg 1 OTC coughtab tab 200mg 1 OTC guaifenesin tab er 12hr 1200 mg 1 OTC mucus relief liq 100/5ml 1 OTC mucus-er tab 600mg 1 OTC tussin chest syp 100/5ml 1 OTC yodefan-nf liq 200-5ml 1 OTC LEUKOTRIENE MODIFIERS ACCOLATE TAB 10MG 3 PA ACCOLATE TAB 20MG 3 PA montelukast sodium chew tab 4 mg (base


montelukast sodium chew tab 5 mg (base equiv)


montelukast sodium oral granules packet 4 mg (base equiv)

1 QL (1 box / 30 days)

montelukast sodium tab 10 mg (base equiv)



193

Drug Name Drug Tier Requirements/Limits SINGULAIR CHW 4MG 3 QL (30 tabs / 30 days),

ST SINGULAIR CHW 5MG 3 QL (30 tabs / 30 days),

ST SINGULAIR GRA 4MG 3 QL (1 box / 30 days), ST SINGULAIR TAB 10MG 3 QL (30 tabs / 30 days),

ST zafirlukast tab 10 mg 1 zafirlukast tab 20 mg 1 zileuton tab er 12hr 600 mg 1 ST ZYFLO CR TAB 600MG 3 ST ZYFLO TAB 600MG 3 ST MAST CELL STABILIZERS cromolyn sodium soln nebu 20 mg/2ml 1 MEDICAL SUPPLIES AERCHMBR Z- MIS STAT PLS 2 QL (1 / year for

members > 18 yo; 2 / year for members < 18 yo)

AEROCHAMBER KIT ACTION 3 AIRZONE PEAK MIS FLOW MTR 2 OTC ASSESS METER MIS FULL RNG 2 OTC ASSESS METER MIS LOW RANG 2 OTC ASTHMA CHECK MIS SYSTEM 2 OTC ASTHMAMENTOR MIS 2 OTC ASTHMAPACK KIT CHILD 2 OTC FACE MASK MIS EARLOOP 3 FLEXICHAMBER MIS MASK SM 3 QL (1 / year for

members > 18 yo; 2 / year for members < 18 yo)

INSPIREASE MIS RES BAG 2 QL (1 / year for members > 18 yo; 2 / year for members < 18 yo)

MICROLIFE MIS PEAK FLO 2 OTC MINI WRIGHT MIS PFM 3 OTC MINI WRIGHT MIS PFM 3 PA; OTC MINI WRIGHT MIS PFM LOW 3 PA; OTC NASONEB NSL MIS STARTER 2 PA NEBULIZER MIS COMPRESS 3 PARI LC MIS SPRINT 2 PEAK AIR FLO MIS ADLT/PED 2 OTC PERSONAL BES MIS FULL RNG 2 OTC PERSONAL BES MIS LOW RANG 2 OTC PIKO 1 MIS ELECTRON 2 OTC


194

Drug Name Drug Tier Requirements/Limits POCKET PEAK MIS METER 2 OTC POCKETPEAK MIS UNIVERSA 3 OTC SINUSTAR MIS NEBULIZE 2 PA TRUZONE PEAK MIS FLOW MTR 3 PA VIOS LC MIS SPRINT 2 MISCELLANEOUS acetylcysteine inhal soln 10% 1 acetylcysteine inhal soln 20% 1 ARALAST NP INJ 500MG 2 AYR ALLERGY SPR & SINUS 3 PA; OTC AYR NASAL DRO 0.65% 3 OTC CAFCIT INJ 60MG/3ML 3 PA caffeine citrate inj 60 mg/3ml (10 mg/ml

base equiv) 1

caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)

1

CUROSURF SUS 120/1.5 3 PA GLASSIA INJ 3 PA HYPER-SAL NEB 7% 3 PA HYPERSAL NEB 3.5% 3 PA INFASURF SUS 35MG/ML 3 PA ipratropium bromide nasal soln 0.03% (21

mcg/spray) 1

ipratropium bromide nasal soln 0.06% (42 mcg/spray)

1

NASADROPS DRO 0.9% 3 PA; OTC nasal moist spr 0.65% 1 OTC nebusal neb 3% 1 NEBUSAL NEB 6% 3 PA RHINARIS SPR 0.2% 2 OTC SCLEROSOL AER INTRAPLE 3 PA sinus congst tab /pain dt 1 OTC sodium chloride soln nebu 0.9% 1 sodium chloride soln nebu 7% 1 sodium chloride soln nebu 10% 1 STERIL TALC SUS 5GM 3 PA SURVANTA INH 3 PA tgt cough oin suppress 2 OTC VICKS OIN VAPORUB 2 OTC XOLAIR SOL 150MG 2 QL (6 / 28 days), PA ZEMAIRA INJ 1000MG 2 NASAL ANTIHISTAMINES ASTEPRO SPR 0.15% 3 PA, ST azelastine hcl nasal spray 0.1% (137

mcg/spray) 1


195

Drug Name Drug Tier Requirements/Limits azelastine hcl nasal spray 0.15% (205.5

mcg/spray) 1

olopatadine hcl nasal soln 0.6% 1 QL (31 / 25 days) PATANASE SPR 0.6% 3 QL (31 / 25 days), PA,

ST NASAL STEROIDS / COMBINATIONS BECONASE AQ SUS 0.042% 3 ST budesonide nasal susp 32 mcg/act 1 budesonide nasal susp 32 mcg/act 1 OTC DYMISTA SPR 137-50 3 ST flunisolide nasal soln 25 mcg/act (0.025%) 1 fluticasone propionate nasal susp 50

mcg/act 1 QL (1 bottle / 25 days)

mometasone furoate nasal susp 50 mcg/act

1 PA

NASACORT ALR SPR 55MCG/AC 3 PA, ST; OTC NASONEX SPR 50MCG/AC 3 PA OMNARIS SPR 3 ST QNASL AER 80MCG 3 ST QNASL CHILD SPR 40MCG 3 ST RHINOCORT SUS AQUA 3 PA, ST triamcinolone acetonide nasal aerosol

suspension 55 mcg/act 1

triamcinolone acetonide nasal aerosol suspension 55 mcg/act

1 OTC

VERAMYST SPR 27.5MCG 3 ST ZETONNA AER 37MCG 3 ST PHOSPHODIESTERASE-4 INHIBITORS DALIRESP TAB 500MCG 3 PA PULMONARY FIBROSIS AGENTS ESBRIET CAP 267MG 3 QL (270 caps / 30

days), PA OFEV CAP 100MG 3 QL (60 caps / 30 days),

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

PA STEROID INHALANTS AEROSPAN AER 80MCG 2 QL (2 / 25 days) ALVESCO AER 80MCG 3 ST ALVESCO AER 160MCG 3 ST ARNUITY ELPT INH 100MCG 2 QL (1 inhaler / 30 days) ARNUITY ELPT INH 200MCG 2 QL (1 inhaler / 30 days) ASMANEX 14 AER 220MCG 2 QL (1 inhaler / 25 days) ASMANEX 30 AER 110MCG 2 QL (1 inhaler / 25 days) ASMANEX HFA AER 100 MCG 2 QL (1 inhaler / 25 days) ASMANEX HFA AER 200 MCG 2 QL (1 inhaler / 25 days)


196

Drug Name Drug Tier Requirements/Limits budesonide inhalation susp 0.5 mg/2ml 1 QL (60 / 30 days) budesonide inhalation susp 0.25 mg/2ml 1 QL (60 / 30 days) budesonide inhalation susp 1 mg/2ml 1 QL (60 / 30 days) FLOVENT DISK AER 50MCG 2 FLOVENT DISK AER 100MCG 2 FLOVENT DISK AER 250MCG 2 FLOVENT HFA AER 44MCG 2 QL (2 inhalers / 25

days) FLOVENT HFA AER 110MCG 2 QL (2 inhalers / 25

days) FLOVENT HFA AER 220MCG 2 QL (2 inhalers / 25

days) PULMICORT INH 90MCG 3 ST PULMICORT INH 180MCG 3 ST PULMICORT SUS 0.5MG/2 3 QL (60 / 30 days), PA,

ST PULMICORT SUS 0.25MG/2 3 QL (60 / 30 days), PA,

ST PULMICORT SUS 1MG/2ML 3 QL (60 / 30 days), PA,

ST QVAR AER 40MCG 3 PA; No UM required for

members under age 12 QVAR AER 80MCG 3 PA; No UM required for

members under age 12 STEROID/BETA AGONIST COMBINATIONS ADVAIR DISKU AER 100/50 2 ST; No UM required for

members under age 12 ADVAIR DISKU AER 250/50 3 ST ADVAIR DISKU AER 500/50 3 ST ADVAIR HFA AER 45/21 3 ST ADVAIR HFA AER 115/21 3 ST ADVAIR HFA AER 230/21 3 ST BEVESPI AER 9-4.8MCG 3 ST BREO ELLIPTA INH 100-25 2 BREO ELLIPTA INH 200-25 2 DULERA AER 100-5MCG 2 DULERA AER 200-5MCG 2 SYMBICORT AER 80-4.5 3 ST SYMBICORT AER 160-4.5 3 ST TOPICAL DECONGESTANTS ADRENALIN SOL 1:1000 3 PA nasal 12 hr spr 0.05% 1 PA; OTC nose dro 1% 1 OTC TYZINE SOL 0.1% 3 PA XANTHINES aminophylline inj 25 mg/ml 1 PA


197

Drug Name Drug Tier Requirements/Limits ELIXOPHYLLIN ELX 80/15ML 3 PA THEO-24 CAP 100MG CR 3 ST THEO-24 CAP 200MG CR 3 ST THEO-24 CAP 300MG CR 3 ST THEO-24 CAP 400MG ER 3 ST THEOPHYL/D5W INJ 0.8MG/ML 3 theophylline soln 80 mg/15ml 1 theophylline tab er 12hr 100 mg 1 theophylline tab er 12hr 200 mg 1 theophylline tab er 12hr 300 mg 1 theophylline tab er 12hr 450 mg 1 theophylline tab er 24hr 400 mg 1 theophylline tab er 24hr 600 mg 1 TOPICAL DERMATOLOGY, ACNE, ORAL ABSORICA CAP 10MG 2 ABSORICA CAP 20MG 2 ABSORICA CAP 25MG 2 ABSORICA CAP 30MG 2 ABSORICA CAP 35MG 2 ABSORICA CAP 40MG 2 zenatane cap 10mg 1 zenatane cap 20mg 1 zenatane cap 30mg 1 zenatane cap 40mg 1 DERMATOLOGY, ACNE, TOPICAL ACANYA GEL 1.2-2.5% 3 ST acne cleansi bar 10% 1 OTC ACNE MEDICAT LOT 10% 3 PA; OTC acne treatme cre 10% 1 OTC ACZONE GEL 5% 3 PA adapalene cream 0.1% 1 adapalene gel 0.1% 1 QL (48 gm / 30 days) adapalene gel 0.3% 1 QL (48 gm / 30 days) adapalene lotion 0.1% 1 adapalene-benzoyl peroxide gel 0.1-2.5% 1 ST ADV ACNE WSH LIQ 4.4% 3 PA; OTC ATRALIN GEL 0.05% 3 QL (48 gm / 30 days),

PA AZELEX CRE 20% 3 ST BENZAC AC LIQ 5% WASH 3 PA, ST BENZACLIN GEL 1-5% 3 PA, ST BENZAMYCIN GEL 5-3% 3 PA BENZAMYCIN GEL PAK 3 PA BENZEFOAM AER 5.3% 3 PA


198

Drug Name Drug Tier Requirements/Limits BENZEFOAM AER 9.8% 3 PA benzepro liq creamy 1 PA benzepro sc aer 9.8% 1 BENZIQ GEL 5.25% 3 PA BENZIQ LS GEL 2.75% 3 PA benziq wash liq 5.25% 1 PA BENZOYL PER GEL 2.5% 3 OTC benzoyl per liq 5% wash 1 OTC benzoyl per liq 10% wash 1 OTC benzoyl pero kit acne pck 1 OTC benzoyl peroxide foam 5.3% 1 OTC benzoyl peroxide gel 10% 1 OTC benzoyl peroxide-erythromycin gel 5-3% 1 BENZYL PEROX LOT CLNSR 3% 3 OTC benzyl perox lot clnsr 6% 1 OTC bp 10-1 emu 1 bp cleansing emu 10-4% 1 bp foaming liq wash 10% 1 BP GEL GEL 5.5% 3 OTC bp wash liq 5.25% 1 OTC bpo cloths mis 6% 1 bpo creamy kit 4% wash 1 OTC BPO GEL 4% 3 PA BPO GEL 8% 3 PA clearplex v gel 5% 1 OTC CLEOCIN-T GEL 1% 3 PA, ST CLEOCIN-T LOT 1% 3 PA, ST CLEOCIN-T PAD 1% 3 PA, ST CLEOCIN-T SOL 1% 3 PA, ST CLINDACIN KIT PAC 1% 3 PA clindacin-p pad 1% 1 CLINDAGEL GEL 1% 3 ST clindamycin phosphate foam 1% 1 clindamycin phosphate gel 1% 1 clindamycin phosphate lotion 1% 1 clindamycin phosphate soln 1% 1 clindamycin phosphate-benzoyl peroxide

gel 1-5% 1

clindamycin phosphate-tretinoin gel 1.2-0.025%

1

creamy face liq wash 4% 1 OTC DIFFERIN CRE 0.1% 3 PA, ST DIFFERIN GEL 0.1% 3 QL (48 gm / 30 days),

PA, ST DIFFERIN GEL 0.3% 3 QL (48 gm / 30 days),

PA, ST


199

Drug Name Drug Tier Requirements/Limits DIFFERIN LOT 0.1% 3 PA DUAC GEL 1.2-5% 3 PA, ST EPIDUO FORTE GEL 0.3-2.5% 3 ST EPIDUO GEL 0.1-2.5% 3 ST ery pad 2% 1 erythromycin gel 2% 1 erythromycin soln 2% 1 EVOCLIN AER 1% 3 PA, ST FABIOR AER 0.1% 3 PA INOVA 4/1 KIT ACNE CON 3 PA INOVA 8/2 KIT ACNE CON 3 PA INOVA KIT 4% 3 PA INOVA KIT 8% 3 PA KLARON LOT 10% 3 PA neuac gel 1.2-5% 1 NUOX GEL 6-3% 3 ST OC8 GEL 7% 3 OTC ONEXTON GEL 1.2-3.75 3 ST oscion clnsr lot 6% 1 PANOXYL GEL 3% 2 OTC PANOXYL-4 LIQ CREM WSH 3 PA; OTC PRASCION RA CRE 10-5% 2 RETIN-A CRE 0.1% 3 QL (48 gm / 30 days),

PA RETIN-A CRE 0.05% 3 QL (48 gm / 30 days),

PA RETIN-A CRE 0.025% 3 QL (48 gm / 30 days),

PA RETIN-A GEL 0.01% 3 QL (48 gm / 30 days),

PA RETIN-A GEL 0.025% 3 QL (48 gm / 30 days),

PA RETIN-A MICR GEL 0.1% 3 PA RETIN-A MICR GEL 0.04% 3 PA RIAX AER 5.5% 3 PA RIAX AER 9.5% 3 PA SOD SUL/SULF EMU 10-5% 3 PA SOD SUL/SULF SUS 10-5% 3 sss 10-5 aer 10-5% 1 sss cre 10%-5% 1 sulfacetamide sod-sulfur wash 9-4.5% &

skin cleanser kit 1

sulfacetamide sodium lotion 10% (acne) 1 sulfacetamide sodium w/ sulfur cleanser

9.8-4.8% 1


200

Drug Name Drug Tier Requirements/Limits sulfacetamide sodium w/ sulfur cleanser

10-2% 1

sulfacetamide sodium w/ sulfur cleansing pad 10-4%

1

sulfacetamide sodium w/ sulfur cream 10-2%

1

sulfacetamide sodium w/ sulfur emulsion 10-5%

1

sulfacetamide sodium w/ sulfur lotion 10-5%

1

sulfacetamide sodium w/ sulfur susp 8-4% 1 sulfacetamide sodium w/ sulfur wash 9-4%1 sulfacetamide sodium w/ sulfur wash 9-

4.5% 1

sulfacetamide sodium-sulfur in urea gel 10-5%

1 PA

SUMADAN KIT 3 PA SUMADAN WASH LIQ 9-4.5% 3 PA SUMADAN XLT KIT 9-4.5% 3 PA targetd acne cre 2.5% 1 OTC tazarotene cream 0.1% 1 ST TAZORAC CRE 0.1% 3 PA TAZORAC CRE 0.05% 2 TAZORAC GEL 0.1% 2 TAZORAC GEL 0.05% 2 TRETIN-X CRE 0.075% 3 PA TRETIN-X CRE 0.0375% 3 PA TRETIN-X CRE KIT 0.05% 3 PA tretinoin cream 0.1% 1 QL (48 gm / 30 days) tretinoin cream 0.05% 1 QL (48 gm / 30 days) tretinoin cream 0.025% 1 QL (48 gm / 30 days) tretinoin gel 0.01% 1 QL (48 gm / 30 days) tretinoin gel 0.05% 1 QL (48 gm / 30 days),

PA tretinoin gel 0.025% 1 QL (48 gm / 30 days),

PA tretinoin microsphere gel 0.1% 1 tretinoin microsphere gel 0.04% 1 VELTIN GEL 3 ST ZACARE KIT KIT 4% 3 PA ZIANA GEL 3 PA, ST DERMATOLOGY, ACTINIC KERATOSIS CARAC CRE 0.5% 3 PA diclofenac sodium (actinic keratoses) gel

3% 1

EFUDEX CRE 5% 3 PA


201

Drug Name Drug Tier Requirements/Limits EUCRISA OIN 2% 3 QL (60 gm / 30 days),

PA FLUOROPLEX CRE 1% 3 PA fluorouracil cream 5% 1 fluorouracil soln 2% 1 fluorouracil soln 5% 1 LEVULAN KERA SOL 20% 3 PA PICATO GEL 0.05% 3 PA PICATO GEL 0.015% 3 PA SOLARAZE GEL 3% W/W 3 PA TOLAK CRE 4% 3 PA ZYCLARA CRE 3.75% 3 PA ZYCLARA PUMP CRE 2.5% 3 PA DERMATOLOGY, ANTI-INFECTIVE/ANTI-INFLAMMATORY

COMBINATIONS CORTISPORIN CRE 0.5% 3 PA CORTISPORIN OIN 1% 3 PA DERMATOLOGY, ANTI-INFLAMMATORY COMBINATIONS DERMACINRX PAK LEXITRAL 3 PA NAPROXENPAX MIS 3 ST DERMATOLOGY, ANTIBIOTICS ALTABAX OIN 1% 3 bacitracin oint 500 unit/gm 1 OTC bacitracin zinc oint 500 unit/gm 1 OTC BACTROBAN OIN NASAL 2% 2 CENTANY AT KIT 2% 3 CENTANY OIN 2% 3 double antib oin 1 OTC gentamicin sulfate cream 0.1% 1 gentamicin sulfate oint 0.1% 1 mupirocin calcium cream 2% 1 mupirocin oint 2% 1 NEOSPORIN CRE PLUS 2 PA; OTC NEOSPORIN OIN ORIGINAL 3 PA; OTC sb triple oin antibiot 1 OTC SILVADENE CRE 1% 3 PA sm antibioti cre plus 1 OTC ssd cre 1% 1 triple antib oin 1 OTC triple antib oin plus 1 OTC DERMATOLOGY, ANTIFUNGALS antifungal aer 1% 1 OTC antifungal cre 1% 1 OTC ath foot pow aer 1% 1 OTC athlete foot cre af 1 OTC


202

Drug Name Drug Tier Requirements/Limits AZOLEN TINC SOL 2% 2 OTC blis-to-sol liq 1% 1 OTC ciclodan cre 0.77% 1 CICLODAN CRE KIT 0.77% 3 ST ciclodan sol 8% 1 CICLODAN SOL KIT 8% 3 PA, ST ciclopirox gel 0.77% 1 ciclopirox kit 8% 1 ciclopirox olamine susp 0.77% (base

equiv) 1

ciclopirox shampoo 1% 1 clotrimazole cream 1% 1 clotrimazole soln 1% 1 clotrimazole soln 1% 1 OTC clotrimazole w/ betamethasone cream 1-

0.05% 1

clotrimazole w/ betamethasone lotion 1-0.05%

1

econazole nitrate cream 1% 1 ECOZA AER 1% 3 PA ERTACZO CRE 2% 3 ST EXELDERM CRE 1% 3 ST EXELDERM SOL 1% 3 ST EXODERM LOT 25-1% 3 PA EXTINA AER 2% 3 PA, ST JUBLIA SOL 10% 3 QL (12 / 30 days), ST ketoconazole cream 2% 1 ketoconazole shampoo 2% 1 ketodan aer 2% 1 LAMISIL ADV GEL 1% 2 OTC LOPROX SHA 1% 3 PA, ST lotrimin af aer 2% 1 OTC LUZU CRE 1% 3 ST MENTAX CRE 1% 3 ST miconazole nitrate aerosol pow 2% 1 OTC miconazorb pow af 2% 1 OTC NAFTIN CRE 2% 3 PA, ST NAFTIN GEL 1% 3 ST NAFTIN GEL 2% 3 ST NIZORAL A-D SHA 1% 2 OTC NIZORAL SHA 2% 3 PA, ST nystatin cream 100000 unit/gm 1 nystatin oint 100000 unit/gm 1 nystatin topical powder 100000 unit/gm 1 nystatin-triamcinolone cream 100000-0.1

unit/gm-% 1


203

Drug Name Drug Tier Requirements/Limits nystatin-triamcinolone oint 100000-0.1

unit/gm-% 1

odor eaters pow 1% 1 OTC OXISTAT CRE 1% 3 PA, ST OXISTAT LOT 1% 3 ST sm antifungl cre 2% 1 OTC tetterine oin 2% 1 OTC VUSION OIN 3 ST XOLEGEL GEL 2% 3 ST DERMATOLOGY, ANTIPSORIATICS, INJECTABLE COSENTYX INJ 150MG/ML 3 QL (2 / 30 days), PA COSENTYX PEN INJ 300DOSE 3 QL (2 / 30 days), PA SILIQ INJ 210/1.5 3 QL (2 / 28 days), PA STELARA INJ 5MG/ML 3 QL (104 mL vial per

lifetime), PA STELARA INJ 45MG/0.5 3 QL (0.5 mL / 63 days),

PA STELARA INJ 90MG/ML 3 QL (1 mL / 63 days), PA DERMATOLOGY, ANTIPSORIATICS, ORAL acitretin cap 10 mg 1 acitretin cap 17.5 mg 1 acitretin cap 25 mg 1 METHOXSALEN CAP 10 MG 1 SORIATANE CAP 10MG 3 PA SORIATANE CAP 17.5MG 3 PA SORIATANE CAP 25MG 3 PA DERMATOLOGY, ANTIPSORIATICS, TOPICAL calcipotriene cream 0.005% 1 calcipotriene oint 0.005% 1 calcipotriene soln 0.005% (50 mcg/ml) 1 calcipotriene-betamethasone dipropionate

oint 0.005-0.064% 1

calcitriol oint 3 mcg/gm 1 QL (800 gm / 25 days) DOVONEX CRE 0.005% 3 PA, ST ENSTILAR AER 3 ST SORILUX AER 0.005% 3 ST TACLONEX OIN 3 PA, ST TACLONEX SUS 3 ST VECTICAL OIN 3MCG/GM 3 QL (800 gm / 25 days),

PA, ST ZITHRANOL SHA 1% 3 PA DERMATOLOGY, ANTISEBORRHEICS dandruff sha 1% 1 OTC LOUTREX CRE 3 PA PROMISEB KIT COMPLETE 3 PA


204

Drug Name Drug Tier Requirements/Limits selenium sulfide lotion 2.5% 1 selenium sulfide-pyrithione zinc in urea

shampoo 2.25% 1

SODIUM SULFA LIQ 10% WASH 3 sulfacetamide sodium cleansing gel 10% 1 sulfacetamide sodium liquid 10% 1 sulfacetamide sodium shampoo 10% 1 TERSI FOAM AER 2.25% 3 PA DERMATOLOGY, ANTISEPTICS/DISINFECTANTS DI-DAK-SOL SOL 0.0125% 2 OTC forma-ray sol 20% 1 formaldehyde solution 10% 1 PA GLUTARALDEHY SOL 25% 2 h-chlor 12 sol 0.125% 1 OTC hysept sol 0.5% 1 OTC hysept sol 0.25% 1 OTC IODOFLEX PAD PAD 3 PA IODOSORB GEL 3 PA; OTC KERR TRIPLE MIS DYE SWAB 3 PA triple dye solution 1 PA DERMATOLOGY, ATOPIC DERMATITIS, INJECTABLE DUPIXENT INJ 300/2ML 3 QL (4 mL / 28 days, 6

mL allowed first month of therapy), PA

DERMATOLOGY, ATOPIC DERMATITIS, TOPICAL ELIDEL CRE 1% 3 QL (30 gm / 30 days),

PA PROTOPIC OIN 0.1% 3 QL (30 gm / 30 days),

PA PROTOPIC OIN 0.03% 3 QL (30 gm / 30 days),

PA tacrolimus oint 0.1% 1 QL (30 gm / 30 days),

PA tacrolimus oint 0.03% 1 QL (30 gm / 30 days),

PA DERMATOLOGY, CORTICOSTEROID COMBINATIONS DERMACINRX KIT SILAPAK 3 PA, ST HALAC KIT 3 PA hydrocortisone-aloe vera cream 0.5% 1 OTC hydrocortisone-aloe vera cream 1% 1 OTC PRAMOSONE CRE 1-1% 3 PA PRAMOSONE LOT 1% 3 PA PRAMOSONE LOT 2.5% 3 PA SCALACORT DK KIT 3 PA SILAZONE PAK PHARMAPA 3 ST SYNALAR KIT 0.025% 3 ST


205

Drug Name Drug Tier Requirements/Limits SYNALAR TS KIT 0.01% 3 ST DERMATOLOGY, CORTICOSTEROIDS, HIGH POTENCY amcinonide cream 0.1% 1 amcinonide lotion 0.1% 1 APEXICON E CRE 0.05% 3 betamethasone dipropionate augmented

cream 0.05% 1

betamethasone dipropionate augmented lotion 0.05%

1

betamethasone dipropionate cream 0.05% 1 betamethasone dipropionate lotion 0.05% 1 betamethasone dipropionate oint 0.05% 1 desoximetasone cream 0.25% 1 desoximetasone gel 0.05% 1 desoximetasone oint 0.25% 1 diflorasone diacetate cream 0.05% 1 DIPROLENE AF CRE 0.05% 3 PA, ST DIPROLENE LOT 0.05% 3 PA, ST fluocinonide cream 0.1% 1 fluocinonide cream 0.05% 1 fluocinonide emulsified base cream 0.05% 1 fluocinonide gel 0.05% 1 fluocinonide oint 0.05% 1 fluocinonide soln 0.05% 1 HALOG CRE 0.1% 3 ST HALOG OIN 0.1% 3 ST PSORCON CRE 0.05% 3 ST TOPICORT CRE 0.25% 3 PA, ST TOPICORT GEL 0.05% 3 PA, ST TOPICORT OIN 0.25% 3 PA, ST TOPICORT SPR 0.25% 3 ST triamcinolone acetonide cream 0.5% 1 triamcinolone acetonide oint 0.5% 1 VANOS CRE 0.1% 3 PA, ST DERMATOLOGY, CORTICOSTEROIDS, LOW POTENCY ADV ALLERGY KIT COLLECTI 3 PA ALA SCALP LOT 2% 3 PA alclometasone dipropionate cream 0.05% 1 alclometasone dipropionate oint 0.05% 1 anti-itch lot 1% 1 OTC CAPEX SHA 0.01% 3 ST DERMA-SMOOTH OIL /FS BODY 3 PA, ST DERMA-SMOOTH OIL /FS SCLP 3 PA, ST DERMASORB HC KIT 2% 3 PA DESONATE GEL 0.05% 3 ST


206

Drug Name Drug Tier Requirements/Limits desonide cream 0.05% 1 desonide lotion 0.05% 1 desonide oint 0.05% 1 DESOWEN CRE 0.05% 3 PA, ST DESOWEN LOT 0.05% 3 PA, ST fluocin acet oil 0.01% sc 1 fluocin acet oil body 1 fluocinolone acetonide cream 0.01% 1 fluocinolone acetonide soln 0.01% 1 hydrocort cre 0.5% 1 OTC hydrocort oin 0.5% 1 OTC hydrocortisone cream 1% 1 hydrocortisone cream 1% 1 OTC hydrocortisone cream 2.5% 1 hydrocortisone lotion 2.5% 1 hydrocortisone oint 1% 1 hydrocortisone oint 2.5% 1 lanacort 10 cre 1% 1 OTC scalacort lot 2% 1 SYNALAR SOL 0.01% 3 PA, ST TEXACORT SOL 2.5% 3 PA VERDESO AER 0.05% 3 ST DERMATOLOGY, CORTICOSTEROIDS, MEDIUM POTENCY betamethasone valerate aerosol foam

0.12% 1

betamethasone valerate cream 0.1% 1 betamethasone valerate lotion 0.1% 1 betamethasone valerate oint 0.1% 1 clocortolone pivalate cream 0.1% 1 CLODERM CRE 0.1% PMP 3 PA, ST CORDRAN CRE 0.05% 3 QL (120 gm / 30 days),

PA, ST CORDRAN LOT 0.05% 3 PA, ST CUTIVATE CRE 0.05% 3 PA, ST CUTIVATE LOT 0.05% 3 PA, ST DERMASORB TA KIT 0.1% 3 PA DERMATOP CRE 0.1% 3 PA, ST DERMATOP OIN 0.1% 3 PA, ST desoximetasone cream 0.05% 1 desoximetasone oint 0.05% 1 ELOCON CRE 0.1% 3 PA, ST ELOCON LOT 0.1% 3 PA, ST ELOCON OIN 0.1% 3 PA, ST fluocinolone acetonide cream 0.025% 1 fluocinolone acetonide oint 0.025% 1 flurandrenolide cream 0.05% 1 ST


207

Drug Name Drug Tier Requirements/Limits flurandrenolide lotion 0.05% 1 ST flurandrenolide oint 0.05% 1 ST fluticasone propionate cream 0.05% 1 fluticasone propionate lotion 0.05% 1 fluticasone propionate oint 0.005% 1 hydrocortisone butyrate cream 0.1% 1 hydrocortisone butyrate hydrophilic lipo

base cream 0.1% 1

hydrocortisone butyrate oint 0.1% 1 hydrocortisone butyrate soln 0.1% 1 hydrocortisone valerate cream 0.2% 1 hydrocortisone valerate oint 0.2% 1 KENALOG AER SPRAY 3 PA, ST LOCOID CRE 0.1% 3 PA LOCOID LIPO CRE 0.1% 3 PA LOCOID LOT 0.1% 3 PA LOCOID OIN 0.1% 3 PA LOCOID SOL 0.1% 3 PA LUXIQ AER 0.12% 3 PA, ST mometasone furoate cream 0.1% 1 mometasone furoate oint 0.1% 1 mometasone furoate solution 0.1% (lotion)1 PANDEL CRE 0.1% 3 ST prednicarbate cream 0.1% 1 prednicarbate oint 0.1% 1 SYNALAR CRE 0.025% 3 PA, ST SYNALAR OIN 0.025% 3 PA, ST TOPICORT CRE 0.05% 3 PA, ST TOPICORT OIN 0.05% 3 PA, ST triamcinolone acetonide aerosol soln 0.147

mg/gm 1

triamcinolone acetonide cream 0.1% 1 triamcinolone acetonide cream 0.025% 1 triamcinolone acetonide lotion 0.1% 1 triamcinolone acetonide lotion 0.025% 1 triamcinolone acetonide oint 0.1% 1 triamcinolone acetonide oint 0.025% 1 TRIANEX OIN 0.05% 3 DERMATOLOGY, CORTICOSTEROIDS, VERY HIGH POTENCY betamethasone dipropionate augmented

gel 0.05% 1

betamethasone dipropionate augmented oint 0.05%

1

clobetasol e cre 0.05% 1 clobetasol propionate cream 0.05% 1


208

Drug Name Drug Tier Requirements/Limits clobetasol propionate emulsion foam

0.05% 1 QL (1 can / 25 days)

clobetasol propionate foam 0.05% 1 clobetasol propionate gel 0.05% 1 clobetasol propionate lotion 0.05% 1 clobetasol propionate oint 0.05% 1 clobetasol propionate soln 0.05% 1 clobetasol propionate spray 0.05% 1 CLOBEX LOT 0.05% 3 PA, ST CLOBEX SHA 0.05% 3 PA, ST CLOBEX SPR 0.05% 3 PA, ST clodan sha 0.05% 1 diflorasone diacetate oint 0.05% 1 PA DIPROLENE OIN 0.05% 3 PA, ST halobetasol propionate cream 0.05% 1 halobetasol propionate oint 0.05% 1 OLUX AER 0.05% 3 PA, ST OLUX-E AER 0.05% 3 QL (1 can / 25 days),

PA, ST TEMOVATE CRE 0.05% 3 PA, ST TEMOVATE GEL 0.05% 3 PA, ST TEMOVATE OIN 0.05% 3 PA, ST ULTRAVATE CRE 0.05% 3 PA, ST ULTRAVATE OIN 0.05% 3 PA, ST DERMATOLOGY, EMOLLIENTS DERMASORB XM KIT 39% 3 PA glycerin topical liquid 1 OTC gnp glycerin sol rosewatr 1 OTC GORDONS UREA OIN 22% 3 PA; OTC GORDONS UREA OIN 40% 3 PA hyaluronate sodium (emollient) gel 0.2% 1 LAC-HYDRIN CRE 12% 2 PA LAC-HYDRIN LOT 12% 3 PA LAC-HYDRIN LOT 12% 3 PA; OTC lactic acid (ammonium lactate) cream 12% 1 lactic acid (ammonium lactate) cream 12% 1 OTC lactic acid (ammonium lactate) lotion 12% 1 lactic acid (ammonium lactate) lotion 12% 1 OTC LATRIX XM EMU 45% 3 PA sm dry skin lot therapy 1 OTC TROPAZONE LOT 3 UREVAZ CRE 44% 3 PA DERMATOLOGY, LOCAL ANALGESIC lidocaine patch 5% 1 PA LIDODERM DIS 5% 3 PA


209

Drug Name Drug Tier Requirements/Limits DERMATOLOGY, LOCAL ANESTHETICS ANACAINE OIN 3 PA BACTINE SPR 3 PA; OTC capsaicin cream 0.1% 1 OTC capsaicin cream 0.025% 1 OTC CAPSAICIN LIQ 0.15% 3 PA; OTC capsaicin pad hot ptch 1 OTC CAPSIDERM PAD .0375-5% 2 OTC CAPZASIN GEL RELIEF 2 OTC CAPZASIN-P CRE 0.035% 3 OTC cocaine hcl soln 4% 1 cooling burn spr relief 1 OTC dermacinrx kit prizopak 1 PA endoxcin pad 4-1% 1 OTC first aid spr 1 PA; OTC LDO PLUS GEL 4% 3 PA LIDO-K LOT 3% 3 PA lidocaine cream 4% 1 OTC lidocaine cream 4% & transparent dressing

kit 1 OTC

lidocaine hcl cream 3% 1 PA lidocaine hcl gel 2% 1 lidocaine hcl lotion 3% 1 lidocaine hcl soln 4% 1 lidocaine oint 5% 1 lidocaine-prilocaine cream 2.5-2.5% 1 LIDORX GEL 3% 3 PA LIDOVEX CRE 3.75% 3 PA NEO TO GO SPR 1-0.13% 3 PA; OTC PLIAGLIS CRE 7-7% 3 PA QUTENZA KIT 8% 1-PCH 3 QL (4 boxes / 91 days),

PA SYNERA DIS 70-70MG 3 PA tgt cold/hot cre pain rel 1 OTC theragen hp cre 0.075% 1 OTC XYLOCAINE SOL 4% 3 PA zeruvia pad 4-1% 1 PA DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ABREVA CRE 10% 2 QL (2 gm / 30 days);

OTC ACLARO EMU 3 PA acyclovir oint 5% 1 QL (30 gm / 30 days) ALDARA CRE 5% 3 PA anti-itch cre 1-01% 1 OTC anti-itch cre 2-0.1% 1 OTC anti-itch spr 2% 1 OTC


210

Drug Name Drug Tier Requirements/Limits APLIGRAF MIS 2 benadryl itc gel 2% 1 OTC BENSAL HP OIN 3 PA BOUDREAUXS OIN 16% 3 OTC BUCALSEP SOL 3 PA BUCALSEP SPR 3 PA calamine med lot 1-8% 1 OTC ceramax cre 1 clear away liq 17% 1 OTC CONDYLOX GEL 0.5% 3 PA CONDYLOX SOL 0.5% 3 PA corn&callus kit 17% 1 OTC DENAVIR CRE 1% 3 QL (5 gm / 30 days), ST DERMAGRAFT MIS 3 PA DERMAWERX KIT SURGICAL 3 PA diaper rash cre 10% 1 OTC diaper rash cre 13% 1 OTC diaper rash oin 40% 1 OTC diaper rash oin creamy 1 OTC DR SMITHS OIN DIAPER 2 PA; OTC DRYSOL SOL 20% 2 duofilm sol 17% 1 OTC EMULSION SB EMU 3 PA GENADUR LIQ 3 PA GENTIAN VIOL SOL 2% 3 OTC grafco silvr mis nit appl 1 high power liq body wsh 1 OTC HPR PLUS CRE 3 PA hydrocerin cre plus 1 OTC imiquimod cream 5% 1 IV PREP WIPE PAD 3 QL (300 pads / 30

days); OTC KERALYT GEL 6% 3 PA KERALYT KIT SCALP 6% 3 PA lip balm oin strawber 1 OTC MB HYDROGEL KIT 3 PA MEXSANA POW 2 OTC neutrogena gel rainbath 1 OTC NONYX GEL 3 OTC OXSORALEN LOT 1% 3 PA PALOMAR E OIN 2 OTC PANRETIN GEL 0.1% 3 PA PHARMABASE OIN BARRIER 2 OTC PODOCON SOL 25% 3 PA podofilox soln 0.5% 1 PRUDOXIN CRE 5% 3 PA


211

Drug Name Drug Tier Requirements/Limits PYROGALL ACD OIN 3 PA REGRANEX GEL 0.01% 2 QL (45 gm / year) RENOVA CRE 0.02% 3 PA SALEX CREAM KIT 6% 3 PA SALEX LOTION KIT 6% 3 PA SALEX SHA 6% 3 PA salicylic ac liq 27.5% 1 salicylic acid cream 6% 1 salicylic acid cream 6% & cleanser liqd kit 1 salicylic acid foam 6% 1 salicylic acid gel 6% 1 salicylic acid in ammonium lactate vehicle

foam 6% 1

salicylic acid lotion 6% 1 salicylic acid lotion 6% & cleanser liqd kit 1 salicylic acid shampoo 6% 1 SALICYLIC ACID SOLN 26% 3 PA SANTYL OIN 250/GM 2 SECURA CRE 30.6% 2 OTC SENSI-CARE CRE MOISTURI 3 OTC SILVER NITRA OIN 10% 3 SKIN PROTECT CRE 12% 3 PA; OTC sm allergy cre 2% 1 OTC strip ease liq adh remv 1 OTC SULFAMYLON CRE 85MG/GM 2 SULFAMYLON PAK 5% 3 PA TERSASEPTIC LIQ 3 OTC therapeutic gel 2% 1 OTC TRI-LUMA CRE 3 PA TRIPLE PASTE OIN 12.8% 2 OTC ultra-derm lot 1 OTC VIRASAL LIQ 27.5% 3 PA wal-dryl spr 1 OTC XERAC-AC SOL 6.25% 3 PA XERESE CRE 5-1% 3 ST YALE CLEANER POW 3 PA; OTC zinc oxide oin 20% 1 OTC ZINC OXIDE PST 25% 2 OTC ZOVIRAX CRE 5% 2 QL (5 gm / 30 days) ZOVIRAX OIN 5% 3 QL (30 gm / 30 days),

PA, ST DERMATOLOGY, ROSACEA doxycycline (rosacea) cap delayed release

40 mg 1 QL (30 caps / 30 days)

FINACEA AER 15% 3 ST FINACEA GEL 15% 3 ST


212

Drug Name Drug Tier Requirements/Limits METROCREAM CRE 0.75% 3 PA METROGEL GEL 1% 3 PA, ST METROLOTION LOT 0.75% 3 PA metronidazole gel 0.75% 1 metronidazole gel 1% 1 metronidazole lotion 0.75% 1 MIRVASO GEL 0.33% 3 ST NORITATE CRE 1% 3 ST ORACEA CAP 40MG 3 QL (30 caps / 30 days),

PA, ST RHOFADE CRE 1% 3 PA rosadan cre 0.75% 1 ROSADAN KIT 0.75% 3 PA DERMATOLOGY, SCABICIDES AND PEDICULICIDES bedding spra aer 0.5% 1 OTC complete kit lice 1 OTC ELIMITE CRE 5% 3 PA eql lice kit solution 1 OTC EURAX CRE 10% 2 EURAX LOT 10% 2 lice killing sha 1 OTC lice md gel 1 PA; OTC lice trtmnt liq 1% 1 QL (120 / 30 days); OTC lice trtmnt liq crm rnse 1 QL (120 / 30 days); OTC LYCELLE GEL 3 PA; OTC malathion lotion 0.5% 1 NATROBA SUS 0.9% 3 QL (1420 ml per fill),

PA, ST OVIDE LOT 0.5% 3 PA, ST permethrin cream 5% 1 RID COMPLETE KIT LICE 2 PA; OTC SKLICE LOT 0.5% 3 ST sm lice lot treatmnt 1 OTC spinosad susp 0.9% 1 QL (1420 ml per fill) ULESFIA LOT 5% 3 ST DERMATOLOGY, WOUND CARE PRODUCTS ACTICOAT 7 MIS 1"X24" 3 PA ACTICOAT 7 MIS 2"X2" 3 ACTICOAT 7 MIS 4"X5" 3 PA ACTICOAT 7 MIS 6"X6" 3 PA ACTICOAT MIS 5"X5" 3 PA ALGICELL AG PAD 4"X5" 3 OTC ALLEVYN AG PAD 3"X3" 3 PA ATRAPRO DERM SPR 3 PA ATRAPRO GEL HYDROGEL 3 PA


213

Drug Name Drug Tier Requirements/Limits BIOSTEP AG MIS 2"X2" 3 PA BIOSTEP AG MIS 4"X4" 3 PA BIOSTEP MIS 2"X2" 3 PA BIOSTEP MIS 4"X4" 3 PA carracolloid pad 4"x4" 1 OTC CURITY HYPER MIS 1/2"X15' 3 DIAB CRE 3 OTC ENDO DERMAL MIS 5X5 CM 3 PA ENDO DERMAL MIS 10X12.7 3 PA HYDROGEL DRE PAD 2"X3" 3 PA HYDROGEL DRE PAD 4"X5" 3 PA HYGEL GEL 2.5% 3 PA LUXAMEND CRE 3 PA OASIS MATRIX MIS 3X7CM 3 PA OASIS ULTRA MIS 3X3.5CM 3 PA OASIS ULTRA MIS 5 X 7CM 3 PA OASIS ULTRA MIS TRI MESH 3 PICO WOUND KIT THER SYS 3 PA PRUTECT EMU 3 PA REGENECARE GEL 3 PA SILVER GEL HYDROGEL 3 OTC SILVRSTAT GEL DRESSING 3 PA vashe wound sol therapy 1 OTC VENELEX OIN 3 PA wound wash liq advanced 1 PA; OTC XEROFRM GAUZ MIS 1"X8" 2 XEROFRM PETR PAD 2"X2" 2 IRRIGATION SOLUTIONS argyl saline sol 100ml 1 lactated ringer's for irrigation 1 PA physiolyte sol 1 PA ringer's solution for irrigation 1 MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS act dry loz mouth 1 OTC ANTI-SNORE LIQ THROAT 2 OTC antiseptic liq original 1 OTC AQUORAL AER 3 PA ARESTIN MIS 1MG 3 PA CAPHOSOL SOL 3 PA cavarest gel 1.1% 1 CEPACOL SORE LOZ COATING 2 OTC CHLORASEPTIC LOZ TOTAL 3 OTC clinpro 5000 pst 1.1% 1 controlrx cre 1.1% 1 cough drops loz 5.4mg 1 OTC


214

Drug Name Drug Tier Requirements/Limits cough drops loz menthol 1 OTC cvs sore loz throat 1 OTC DEBACTEROL SOL 30-50% 2 easygel gel 0.4%citr 1 fluorid sens pst 1.1-5% 1 fluoridex dd pst sensitiv 1 PA GEL-KAM CON 0.63% 3 PA GELCLAIR GEL 3 PA just for kid gel 0.4% grp 1 OTC lidocaine hcl laryngotracheal soln 4% 1 lidocaine hcl viscous soln 2% 1 NAFRINSE DLY SOL /NEUTRAL 2 NAFRINSE SOL DAILY 2 NAFRINSE WK SOL 0.2% 3 PA NEUTRASAL POW 3 PA NUMOISYN LOZ 3 PA OASIS MOUTH SPR 35% 2 OTC ORAFATE PST 10% 3 PA PERIDEX SOL 0.12% 3 PA periogard sol 0.12% 1 periomed con 0.63% 1 OTC PHOS-FLUR SOL 0.044% 2 OTC PREVDNT 5000 PST 1.1-5% 3 PA PREVIDENT GEL 1.1% MIN 3 PA PREVIDENT PST 5000 BST 3 PA Q4 ORAL CLEA KIT SYSTEM 3 PA sod fluoride sol 0.2% 1 PA sore throat loz 15-3.6mg 1 OTC sore throat loz cherry 1 OTC sore throat spr 1.4% 1 OTC triamcinolone acetonide dental paste 0.1% 1 MOUTH/THROAT/DENTAL AGENTS, PROTECTANTS EPISIL LIQ 3 PA MUCOTROL WAF 3 PA MUGARD LIQ 3 PA SALICEPT SUS 3 PA OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY

COMBINATIONS BLEPHAMIDE OIN S.O.P. 3 ST BLEPHAMIDE SUS OP 3 ST MAXITROL OIN 0.1% OP 3 PA, ST MAXITROL SUS 0.1% OP 3 PA, ST neo-polycin oin hc 1%op 1 neomycin-polymyxin-dexamethasone

ophth oint 0.1% 1


215

Drug Name Drug Tier Requirements/Limits neomycin-polymyxin-dexamethasone

ophth susp 0.1% 1

neomycin-polymyxin-hc ophth susp 1 PRED-G S.O.P OIN OP 3 ST PRED-G SUS OP 3 ST sulfacetamide sodium-prednisolone ophth

soln 10-0.23(0.25)% 1

TOBRADEX OIN 0.3-0.1% 3 ST TOBRADEX ST SUS 0.3-0.05 3 ST TOBRADEX SUS 0.3-0.1% 3 PA, ST tobramycin-dexamethasone ophth susp

0.3-0.1% 1

ZYLET SUS 0.5-0.3% 3 PA OPHTHALMIC, ANTI-INFECTIVES AZASITE SOL 1% 3 ST bacitracin ophth oint 500 unit/gm 1 BESIVANCE SUS 0.6% 3 ST BETADINE SOL 5% OP 3 PA BLEPH-10 SOL 10% OP 3 PA, ST CILOXAN OIN 0.3% OP 3 ST CILOXAN SOL 0.3% OP 3 PA, ST ciprofloxacin hcl ophth soln 0.3% 1 gatifloxacin ophth soln 0.5% 1 gentamicin sulfate ophth oint 0.3% 1 gentamicin sulfate ophth soln 0.3% 1 ilotycin oin op 1 levofloxacin ophth soln 0.5% 1 MITOSOL KIT 0.2MG 3 PA MOXEZA SOL 0.5% 2 moxifloxacin hcl ophth soln 0.5% (base

equiv) 1 ST

neo-polycin oin op 1 neomycin-polymy-gramicid op sol 1.75-

10000-0.025mg-unt-mg/ml 1

NEOSPORIN SOL OP 3 PA, ST OCUFLOX DRO 0.3% OP 3 PA, ST ofloxacin ophth soln 0.3% 1 polycin oin op 1 polymyxin b-trimethoprim ophth soln

10000 unit/ml-0.1% 1

POLYTRIM SOL OP 3 PA, ST sulfacetamide sodium ophth oint 10% 1 sulfacetamide sodium ophth soln 10% 1 tobramycin ophth soln 0.3% 1 TOBREX OIN 0.3% OP 3 ST TOBREX SOL 0.3% OP 3 PA, ST


216

Drug Name Drug Tier Requirements/Limits VIGAMOX DRO 0.5% 3 ST ZYMAXID SOL 0.5% 3 PA, ST OPHTHALMIC, ANTI-INFLAMMATORY, NONSTEROIDAL ACULAR LS SOL 0.4% 3 PA, ST ACULAR SOL 0.5% OP 3 PA ACUVAIL SOL 0.45% 3 QL (30 / 365 days), ST bromfenac sodium ophth soln 0.09% (base

equiv) (once-daily) 1

bromfenac sodium ophth soln 0.09% (base equivalent)

1

diclofenac sodium ophth soln 0.1% 1 flurbiprofen sodium ophth soln 0.03% 1 ILEVRO DRO 0.3% OP 3 ST ketorolac tromethamine ophth soln 0.4% 1 ketorolac tromethamine ophth soln 0.5% 1 NEVANAC SUS 0.1% 3 ST OCUFEN SOL 0.03% OP 3 PA, ST PROLENSA SOL 0.07% 3 ST OPHTHALMIC, ANTI-INFLAMMATORY, STEROIDAL ALREX SUS 0.2% 3 PA dexamethasone sodium phosphate ophth

soln 0.1% 1

DUREZOL EMU 0.05% 3 PA FLAREX SUS 0.1% OP 3 PA fluorometholone ophth susp 0.1% 1 FML FORTE SUS 0.25% OP 3 PA FML LIQUIFLM SUS 0.1% OP 3 PA FML OIN 0.1% OP 3 PA LOTEMAX GEL 0.5% 3 ST LOTEMAX OIN 0.5% 3 ST LOTEMAX SUS 0.5% 3 ST MAXIDEX SUS 0.1% OP 3 PA OMNIPRED SUS 1% OP 3 PA PRED MILD SUS 0.12% OP 2 PRED SOD PHO SOL 1% OP 3 prednisolone acetate ophth susp 1% 1 TRIESENCE INJ 40MG/ML 3 PA OPHTHALMIC, ANTIALLERGICS alaway dro 0.025%op 1 OTC ALOCRIL SOL 2% 3 ST ALOMIDE SOL 0.1% OP 3 ST azelastine hcl ophth soln 0.05% 1 BEPREVE DRO 1.5% 3 ST cromolyn sodium ophth soln 4% 1 ELESTAT DRO 0.05% 3 PA, ST


217

Drug Name Drug Tier Requirements/Limits EMADINE SOL 0.05% OP 3 ST epinastine hcl ophth soln 0.05% 1 LASTACAFT SOL 0.25% 3 ST olopatadine hcl ophth soln 0.1% (base

equivalent) 1

olopatadine hcl ophth soln 0.2% (base equivalent)

1

PATADAY SOL 0.2% 3 ST PATANOL SOL 0.1% OP 3 ST PAZEO DRO 0.7% 3 PA OPHTHALMIC, ANTIFUNGALS NATACYN SUS 5% OP 2 OPHTHALMIC, ANTIVIRAL trifluridine ophth soln 1% 1 VIROPTIC SOL 1% OP 3 PA, ST ZIRGAN GEL 0.15% 3 ST OPHTHALMIC, BETA-BLOCKERS, NONSELECTIVE BETAGAN SOL 0.5% OP 3 PA, ST BETIMOL SOL 0.5% 3 ST BETIMOL SOL 0.25% 3 ST carteolol hcl ophth soln 1% 1 ISTALOL SOL 0.5% OP 3 ST levobunolol hcl ophth soln 0.5% 1 metipranolol ophth soln 0.3% 1 timolol maleate ophth gel forming soln

0.5% 1

timolol maleate ophth gel forming soln 0.25%

1

timolol maleate ophth soln 0.5% 1 timolol maleate ophth soln 0.25% 1 TIMOPTIC OCU SOL 0.5% OP 3 ST TIMOPTIC OCU SOL 0.25% OP 3 ST TIMOPTIC SOL 0.5% OP 3 PA, ST TIMOPTIC SOL 0.25% OP 3 PA, ST TIMOPTIC-XE SOL 0.5% OP 3 PA, ST TIMOPTIC-XE SOL 0.25% OP 3 PA, ST OPHTHALMIC, BETA-BLOCKERS, SELECTIVE betaxolol hcl ophth soln 0.5% 1 BETOPTIC-S SUS 0.25% OP 3 ST OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER

COMBINATIONS COSOPT PF SOL 3 ST COSOPT SOL 22.3-6.8 3 PA, ST dorzolamide hcl-timolol maleate ophth soln

22.3-6.8 mg/ml 1


218

Drug Name Drug Tier Requirements/Limits OPHTHALMIC, CARBONIC ANHYDRASE

INHIBITOR/SYMPATHOMIMETIC COMBINATIONS SIMBRINZA SUS 1-0.2% 3 ST OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS, INJECTABLE acetazolamide sodium for inj 500 mg 1 KEVEYIS TAB 50MG 3 QL (120 tabs / 30 days),

PA OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS, ORAL acetazolamide cap er 12hr 500 mg 1 acetazolamide tab 125 mg 1 acetazolamide tab 250 mg 1 DIAMOX SEQUE CAP 500MG CR 3 PA methazolamide tab 25 mg 1 methazolamide tab 50 mg 1 NEPTAZANE TAB 25MG 3 PA NEPTAZANE TAB 50MG 3 PA OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS, TOPICAL AZOPT SUS 1% OP 3 ST dorzolamide hcl ophth soln 2% 1 TRUSOPT SOL 2% OP 3 PA, ST OPHTHALMIC, DIAGNOSTIC PRODUCTS ak-fluor inj 10% op 1 PA AK-FLUOR INJ 25% OP 3 PA bio glo tes 1mg op 1 flucaine sol 0.25-0.5 1 FLURA-SAFE SOL 3 PA flurox sol op 1 PA FUL-GLO TES 0.6MG OP 3 PA PAREMYD SOL 1-0.25% 3 PA OPHTHALMIC, DRY EYE DISEASE RESTASIS EMU 0.05% 2 QL (60 ea / 30 days) XIIDRA DRO 5% 3 QL (12 / 30 days), PA OPHTHALMIC, LOCAL ANESTHETIC AKTEN GEL 3.5% 3 QL (1 ml / year), PA OPHTHALMIC, MISCELLANEOUS adv formula dro eye 1 OTC advanced sol lubrican 1 OTC ALCAINE SOL 0.5% OP 3 PA AMVISC INJ 12MG/ML 3 PA AMVISC PLUS INJ 16MG/ML 3 PA artificial dro tears 1 OTC artificial sol tears 1 OTC artificial sol tears op 1 OTC bal salt sol op 1


219

Drug Name Drug Tier Requirements/Limits BSS PLUS SOL OP 3 PA CELLUGEL SOL 2% 3 PA CYSTARAN SOL 0.44% 2 QL (60 / 30 days) DISCOVISC SOL 3 PA DUOVISC KIT 0.5/0.55 3 PA DUOVISC KIT 0.35/0.4 3 PA eq gentle dro 0.3% 1 OTC eye drops dro 0.5-0.9% 1 OTC eye drops sol 0.05% op 1 OTC eye drops sol a/r 1 OTC GELFILM MIS OP 3 PA GENTEAL MILD DRO 0.2% 3 OTC HYPOTEARS SOL 1-1% 2 OTC ISOPTO TEARS SOL 0.5% OP 3 OTC LACRISERT MIS 5MG OP 3 PA lubricant dro eye 0.6% 1 OTC lubricnt eye dro 0.4-0.3% 1 OTC lubricnt eye dro 0.5% op 1 OTC lubricnt eye oin fast act 1 OTC lubricnt gel dro 0.25-0.3 1 OTC lubricnt gel dro 1% 1 OTC MEMBRANEBLUE SOL 0.15% 3 PA ocucoat sol 2% op 1 phenylephrine hcl ophth soln 2.5% 1 phenylephrine hcl ophth soln 10% 1 polyvinyl alcohol ophth soln 1.4% 1 OTC proparacaine hcl ophth soln 0.5% 1 PROVISC INJ 1% 3 PA REFRESH CELL DRO 1% OP 3 OTC REFRESH GEL OPTIVE 2 OTC REFRESH OPTI DRO 0.5-0.9% 2 PA; OTC REFRESH PLUS DRO 0.5% OP 3 PA; OTC REFRESH SOL OPTIVE 3 OTC ROSE BENGAL TES 1.3MG 3 OTC sm dry eye sol relief 1 OTC sm multi-pur sol 1 OTC sm redness dro relief 1 OTC soothe night oin time 1 OTC STERILE LUBR DRO 0.7% 3 PA; OTC SYSTANE GEL 0.3% 3 OTC SYSTANE GEL DRO 0.4-0.3% 3 OTC tears pure sol 1 OTC tetcaine sol 0.5% op 1 PA THERATEARS GEL 1% 3 PA; OTC THERATEARS SOL OP 3 OTC VISCOAT SOL 3 PA


220

Drug Name Drug Tier Requirements/Limits VISIONBLUE SOL 0.06% 3 PA OPHTHALMIC, MYDRIATICS ATROPINE SUL OIN 1% OP 3 atropine sulfate ophth soln 1% 1 CYCLOGYL SOL 0.5% OP 3 PA CYCLOGYL SOL 1% OP 3 PA CYCLOGYL SOL 2% OP 3 PA CYCLOMYDRIL SOL OP 3 PA cyclopentolate hcl ophth soln 1% 1 cyclopentolate hcl ophth soln 2% 1 homatropine hbr ophth soln 5% 1 MYDRIACYL SOL 1% OP 3 PA tropicamide ophth soln 0.5% 1 tropicamide ophth soln 1% 1 OPHTHALMIC, PARASYMPATHOMIMETICS ISOPTO CARP SOL 1% OP 3 PA, ST ISOPTO CARP SOL 2% OP 3 PA, ST ISOPTO CARP SOL 4% OP 3 PA, ST MIOCHOL-E SOL 1:100 3 PA MIOSTAT INJ 0.01% OP 3 pilocarpine hcl ophth soln 1% 1 pilocarpine hcl ophth soln 2% 1 pilocarpine hcl ophth soln 4% 1 OPHTHALMIC, PROSTAGLANDINS bimatoprost ophth soln 0.03% 1 latanoprost ophth soln 0.005% 1 LUMIGAN SOL 0.01% 3 ST TRAVATAN Z DRO 0.004% 3 ST XALATAN SOL 0.005% 3 PA, ST ZIOPTAN DRO 0.0015% 3 ST OPHTHALMIC, SYMPATHOMIMETIC/BETA-BLOCKER COMBINATIONS COMBIGAN SOL 0.2/0.5% 3 ST OPHTHALMIC, SYMPATHOMIMETICS ALPHAGAN P SOL 0.1% 2 ALPHAGAN P SOL 0.15% 3 PA, ST apraclonidine hcl ophth soln 0.5% (base

equivalent) 1

brimonidine tartrate ophth soln 0.2% 1 brimonidine tartrate ophth soln 0.15% 1 PHOSPHOLINE SOL 0.125%OP 2 OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CIPRO HC SUS OTIC 3 CIPRODEX SUS 0.3-0.1% 2 COLY-MYCIN S SUS OTIC 3


221

Drug Name Drug Tier Requirements/Limits hydrocortisone w/ acetic acid otic soln 1-

2% 1

neomycin-polymyxin-hc otic soln 1% 1 neomycin-polymyxin-hc otic susp 3.5

mg/ml-10000 unit/ml-1% 1

OTIC, ANTI-INFECTIVES acetic acid 2% in aluminum acetate otic

soln 1

acetic acid otic soln 2% 1 ciprofloxacin hcl otic soln 0.2% (base

equivalent) 1

ofloxacin otic soln 0.3% 1 OTIC, MISCELLANEOUS DERMOTIC OIL 0.01% 3 PA fluocinolone acetonide (otic) oil 0.01% 1 PRAMOTIC DRO 1-0.1% 3 PA

222

Index 1 1.5 ML SYRNG MIS 22X1-1/2 ........... 168 10-12ML SYRN MIS LUER SLP .......... 168 12ML SYRINGE MIS 20GX1.5" .......... 168 12ML SYRINGE MIS 21GX1.5" .......... 168 1ML SYRINGE MIS 25GX1" .............. 168 1ML SYRINGE MIS 25GX5/8"............ 168 1ML SYRINGE MIS 26GX3/8"............ 168 1ML SYRINGE MIS LUER SLP ............ 168 1ML TB SYRNG MIS LUER SLP .......... 168 2 20ML SYRINGE MIS LL ZONE1 .......... 168 2ML TB SYRNG MIS LL ZONE1 .......... 168 3 3 ML SYRINGE MIS 22X1-1/2 ........... 168 30ML SYRINGE MIS GL ZONE1 ......... 168 30ML SYRINGE MIS LUER LOC ......... 168 3ML CTRL SYR MIS LL ZONE1 .......... 167 3ML LL SYRNG MIS 20GX1" ............. 167 3ML LL SYRNG MIS 21GX1.25 .......... 167 3ML LL SYRNG MIS 22GX1.25 .......... 167 3ML LL SYRNG MIS 22GX3/4" .......... 167 3ML LL SYRNG MIS 23GX1.25 .......... 167 3ML LL SYRNG MIS 24GX1" ............. 167 3ML SYRINGE MIS 20GX1" .............. 168 3ML SYRINGE MIS 20GX1.5" ............ 168 3ML SYRINGE MIS 21GX1" .............. 168 3ML SYRINGE MIS 21GX1.5" ............ 168 3ML SYRINGE MIS 22GX1" .............. 168 3ML SYRINGE MIS 22GX1.5" ............ 168 3ML SYRINGE MIS 23GX1" .............. 168 3ML SYRINGE MIS 23GX1.5" ............ 168 3ML SYRINGE MIS 25GX1" .............. 168 3ML SYRINGE MIS 25GX5/8"............ 168 3ML SYRINGE MIS REG TIP .............. 168 4 45PSE/400GFN TAB ........................ 189 5 50ML SYRINGE MIS ML ZONE1 ......... 168 5-6ML SYRING MIS LUER SLP ........... 168 5ML CONTROL MIS SANA-LOK .......... 167 5ML SYRINGE MIS LUER SLP ............ 168 6 60PSE/400GFN TAB /20DM .............. 189 6ML LL SYRNG MIS 20GX1.5" ........... 167 6ML SYRINGE MIS 20GX1.5" ............ 168 6ML SYRINGE MIS 22GX1.5" ............ 168

8 8 hour pain tab 650mg ....................... 1 A abacavir sulfate tab 300 mg (base equiv) ..................................................... 29 abacavir sulfate-lamivudine tab 600-300 mg ................................................ 27 abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg ........................ 27 ABANEU-SL SUB ............................. 174 abatron af tab ................................ 174 abatron liq ..................................... 174 ABELCET INJ 5MG/ML ....................... 25 ABILIFY MAIN INJ 300MG ................. 89 ABILIFY MAIN INJ 400MG ................. 89 ABRAXANE INJ 100MG ..................... 42 ABREVA CRE 10% .......................... 209 ABSORICA CAP 10MG ...................... 197 ABSORICA CAP 20MG ...................... 197 ABSORICA CAP 25MG ...................... 197 ABSORICA CAP 30MG ...................... 197 ABSORICA CAP 35MG ...................... 197 ABSORICA CAP 40MG ...................... 197 ABSTRAL SUB 100MCG ....................... 5 ABSTRAL SUB 200MCG ....................... 5 ABSTRAL SUB 300MCG ....................... 5 ABSTRAL SUB 400MCG ....................... 5 ABSTRAL SUB 600MCG ....................... 5 ABSTRAL SUB 800MCG ....................... 5 acamprosate calcium tab delayed release 333 mg ......................................... 110 ACANYA GEL 1.2-2.5% .................... 197 acarbose tab 100 mg ...................... 113 acarbose tab 25 mg ........................ 113 acarbose tab 50 mg ........................ 113 ACCOLATE TAB 10MG ...................... 192 ACCOLATE TAB 20MG ...................... 192 ACCU-CHEK IN LIQ CONTROL ........... 118 ACCU-CHEK KIT AVA CONN .............. 118 ACCU-CHEK KIT AVIVA PL ................ 118 ACCU-CHEK KIT COMBO .................. 119 ACCU-CHEK KIT COMPACT ............... 119 ACCU-CHEK KIT FASTCLIX ............... 119 ACCU-CHEK KIT MLTICLIX ............... 119 ACCU-CHEK KIT NANO .................... 119 ACCU-CHEK KIT SOFTCLIX ............... 119 ACCU-CHEK KIT VOICEMAT .............. 119

223

ACCU-CHEK LIQ COMPACT .............. 119 ACCU-CHEK LIQ SMART .................. 119 ACCU-CHEK SOL ............................ 119 ACCU-CHEK SOL COMPACT .............. 119 ACCU-CHEK TES AVIVA PL ............... 119 ACCU-CHEK TES COMPACT .............. 119 ACCU-CHEK TES SMART .................. 119 ACCUPRIL TAB 10MG ........................ 47 ACCUPRIL TAB 20MG ........................ 47 ACCUPRIL TAB 40MG ........................ 47 ACCUPRIL TAB 5MG .......................... 47 ACCURETIC TAB 10-12.5 ................... 46 ACCURETIC TAB 20-12.5 ................... 46 ACCURETIC TAB 20-25MG ................. 46 ACCUTREND TES GLUCOSE .............. 119 ACD FORMULA SOL A ...................... 161 acebutolol hcl cap 200 mg ................. 59 acebutolol hcl cap 400 mg ................. 59 ACEON TAB 4MG .............................. 47 ACEON TAB 8MG .............................. 47 ACETADOTE INJ 200MG/ML ............. 122 acetaminophen suppos 650 mg ........... 1 acetaminophen w/ codeine soln 120-12 mg/5ml ............................................ 5 acetaminophen w/ codeine tab 300-15 mg .................................................. 5 acetaminophen w/ codeine tab 300-30 mg .................................................. 5 acetaminophen w/ codeine tab 300-60 mg .................................................. 5 acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg .......................... 5 acetazolamide cap er 12hr 500 mg ... 218 acetazolamide sodium for inj 500 mg 218 acetazolamide tab 125 mg ............... 218 acetazolamide tab 250 mg ............... 218 ACETEST TAB TABLETS ................... 119 acetic acid 2% in aluminum acetate otic soln .............................................. 221 acetic acid irrigation soln 0.25% ....... 151 acetic acid otic soln 2% ................... 221 acetylcysteine inhal soln 10% .......... 194 acetylcysteine inhal soln 20% .......... 194 acetylcysteine inj 200 mg/ml ........... 122 acid reducer tab 10mg .................... 142 ACIDOPH/PROB TAB FORMULA ......... 146 ACIDOPHILUS CAP ......................... 146 ACIDOPHILUS/ WAF BIFIDUS ........... 146

ACIPHEX SPR CAP 10MG .................. 148 ACIPHEX SPR CAP 5MG ................... 148 ACIPHEX TAB 20MG ........................ 148 acitretin cap 10 mg ......................... 203 acitretin cap 17.5 mg ...................... 203 acitretin cap 25 mg ......................... 203 ACLARO EMU ................................. 209 acne cleansi bar 10% ...................... 197 ACNE MEDICAT LOT 10% ................ 197 acne treatme cre 10% ..................... 197 act dry loz mouth ........................... 213 ACTEMRA INJ 162/0.9 ..................... 163 ACTICOAT 7 MIS 1"X24" .................. 212 ACTICOAT 7 MIS 2"X2" ................... 212 ACTICOAT 7 MIS 4"X5" ................... 212 ACTICOAT 7 MIS 6"X6" ................... 212 ACTICOAT MIS 5"X5" ...................... 212 ACTIGALL CAP 300MG ..................... 142 ACTIMMUNE INJ 2MU/0.5 ................ 165 ACTIQ LOZ 1200MCG ......................... 5 ACTIQ LOZ 1600MCG ......................... 5 ACTIQ LOZ 200MCG ........................... 5 ACTIQ LOZ 400MCG ........................... 5 ACTIQ LOZ 600MCG ........................... 5 ACTIQ LOZ 800MCG ........................... 5 ACTIVE FE TAB 75-1.25 ................... 174 ACTIVE INJEC KIT KL-3 ................... 130 ACTIVE OB CAP .............................. 174 ACTIVELLA TAB 0.5-0.1 ................... 127 ACTIVELLA TAB 1-0.5MG ................. 127 ACTONEL TAB 150MG ...................... 123 ACTONEL TAB 30MG ....................... 123 ACTONEL TAB 35MG ....................... 123 ACTONEL TAB 5MG ......................... 123 ACTOPLUS MET TAB XR ................... 115 ACULAR LS SOL 0.4% ..................... 216 ACULAR SOL 0.5% OP ..................... 216 ACUVAIL SOL 0.45% ....................... 216 acyclovir cap 200 mg ....................... 32 acyclovir oint 5% ............................ 209 acyclovir sodium for inj 1000 mg ....... 32 acyclovir sodium for inj 500 mg ......... 32 acyclovir sodium iv soln 50 mg/ml ..... 32 acyclovir susp 200 mg/5ml ............... 32 acyclovir tab 400 mg ........................ 32 acyclovir tab 800 mg ........................ 32 ACZONE GEL 5% ............................ 197 ADALAT CC TAB 30MG ER ................. 62

224

ADALAT CC TAB 60MG ER .................. 62 ADALAT CC TAB 90MG ER .................. 62 adapalene cream 0.1% ................... 197 adapalene gel 0.1% ........................ 197 adapalene gel 0.3% ........................ 197 adapalene lotion 0.1% .................... 197 adapalene-benzoyl peroxide gel 0.1-2.5% ............................................ 197 ADASUVE INH 10MG ......................... 89 ADCIRCA TAB 20MG ......................... 69 ADDAMEL N INJ ............................. 173 ADDERALL TAB 10MG ....................... 96 ADDERALL TAB 12.5MG ..................... 96 ADDERALL TAB 15MG ....................... 96 ADDERALL TAB 20MG ....................... 96 ADDERALL TAB 30MG ....................... 96 ADDERALL TAB 5MG ......................... 96 ADDERALL TAB 7.5MG ...................... 96 ADDERALL XR CAP 10MG ................... 96 ADDERALL XR CAP 15MG ................... 96 ADDERALL XR CAP 20MG ................... 96 ADDERALL XR CAP 25MG ................... 96 ADDERALL XR CAP 30MG ................... 96 ADDERALL XR CAP 5MG .................... 96 adefovir dipivoxil tab 10 mg ............... 31 ADEMPAS TAB 0.5MG ........................ 70 ADEMPAS TAB 1.5MG ........................ 70 ADEMPAS TAB 1MG .......................... 70 ADEMPAS TAB 2.5MG ........................ 70 ADEMPAS TAB 2MG .......................... 70 ADENOCARD INJ 12MG/4ML .............. 54 ADENOCARD INJ 3MG/ML .................. 53 adenosine iv soln 12 mg/4ml ............. 54 adenosine iv soln 6 mg/2ml ............... 54 ADIPEX-P CAP 37.5MG .................... 122 ADIPEX-P TAB 37.5MG .................... 122 ADLYXIN INJ 10/20MCG .................. 114 ADLYXIN INJ 20MCG ....................... 114 ADOXA CAP 150MG .......................... 24 ADRENALIN INJ 1MG/ML ................. 185 ADRENALIN SOL 1:1000 .................. 196 ADV ACNE WSH LIQ 4.4% ............... 197 ADV ALLERGY KIT COLLECTI ............ 205 adv formula dro eye ....................... 218 ADVAIR DISKU AER 100/50 ............. 196 ADVAIR DISKU AER 250/50 ............. 196 ADVAIR DISKU AER 500/50 ............. 196 ADVAIR HFA AER 115/21 ................. 196

ADVAIR HFA AER 230/21 ................. 196 ADVAIR HFA AER 45/21 ................... 196 ADVANCED MIS AM/PM ................... 174 advanced sol lubrican ...................... 218 ADVATE INJ 1000UNIT .................... 156 ADVATE INJ 1500UNIT .................... 156 ADVATE INJ 2000UNIT .................... 156 ADVATE INJ 250UNIT ...................... 156 ADVATE INJ 3000UNIT .................... 156 ADVATE INJ 4000UNIT .................... 156 ADVATE INJ 500UNIT ...................... 156 ADVOCATE ARM MIS BPM LRG .......... 119 ADYNOVATE INJ 1000UNIT .............. 157 ADYNOVATE INJ 2000UNIT .............. 157 ADYNOVATE INJ 250UNIT ................ 156 ADYNOVATE INJ 500UNIT ................ 157 AERCHMBR Z- MIS STAT PLS ........... 193 AEROCHAMBER KIT ACTION ............. 193 AEROSPAN AER 80MCG ................... 195 AFINITOR DIS TAB 2MG ................... 40 AFINITOR DIS TAB 3MG ................... 40 AFINITOR DIS TAB 5MG ................... 40 AFINITOR TAB 10MG ........................ 40 AFINITOR TAB 2.5MG ....................... 40 AFINITOR TAB 5MG ......................... 40 AFINITOR TAB 7.5MG ....................... 40 AFREZZA POW 12 UNIT ................... 115 AFREZZA POW 4&8 UNIT ................. 115 AFREZZA POW 4/8/12UN ................. 115 AFREZZA POW 4UNIT ...................... 115 AFREZZA POW 8 UNIT ..................... 115 AFREZZA POW 8&12UNIT ................ 115 AGGRASTAT INJ 12.5/250 ............... 161 AGGRASTAT INJ 5/100ML ................ 161 AGGRENOX CAP 25-200MG .............. 162 AGRYLIN CAP 0.5MG ....................... 162 AIRZONE PEAK MIS FLOW MTR ......... 193 ak-fluor inj 10% op ......................... 218 AK-FLUOR INJ 25% OP .................... 218 AKTEN GEL 3.5% ............................ 218 AKYNZEO CAP 300-0.5 .................... 140 ALA SCALP LOT 2% ........................ 205 alamag-plus chw ............................ 138 alaway dro 0.025%op ..................... 216 ALBENZA TAB 200MG ....................... 33 albumin, human inj 25% ................. 161 alburx inj 5% ................................. 161 albuterol sulfate soln nebu 0.083% (2.5

225

mg/3ml) ....................................... 191 albuterol sulfate soln nebu 0.5% (5 mg/ml) ......................................... 191 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) .................................. 191 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) .................................. 191 albuterol sulfate syrup 2 mg/5ml ...... 191 albuterol sulfate tab 2 mg ................ 191 albuterol sulfate tab 4 mg ................ 191 albuterol sulfate tab er 12hr 4 mg .... 191 albuterol sulfate tab er 12hr 8 mg .... 191 ALCAINE SOL 0.5% OP ................... 218 alclometasone dipropionate cream 0.05% ................................................... 205 alclometasone dipropionate oint 0.05% ................................................... 205 alcohol absolute inj 98% ................. 172 ALCOH-WIPE PAD 12"X12" .............. 119 ALDACTAZIDE TAB 25/25 .................. 65 ALDACTAZIDE TAB 50/50 .................. 65 ALDACTONE TAB 100MG ................... 49 ALDACTONE TAB 25MG ..................... 49 ALDACTONE TAB 50MG ..................... 49 ALDARA CRE 5% ............................ 209 ALDEX GS TAB 30-190MG ............... 188 ALDURAZYME INJ 2.9MG/5M ............ 134 ALECENSA CAP 150MG ...................... 40 alendronate sodium oral soln 70 mg/75ml ....................................... 123 alendronate sodium tab 10 mg ......... 123 alendronate sodium tab 35 mg ......... 123 alendronate sodium tab 40 mg ......... 123 alendronate sodium tab 5 mg ........... 123 alendronate sodium tab 70 mg ......... 123 alfentanil inj 500 mcg/ml .................... 5 ALFENTANIL INJ 500/ML ..................... 5 alfuzosin hcl tab er 24hr 10 mg ........ 151 ALGICELL AG PAD 4"X5" .................. 212 ALIMTA INJ 100MG ........................... 37 ALIMTA INJ 500MG ........................... 37 ALINIA SUS 100/5ML ........................ 33 ALINIA TAB 500MG ........................... 33 ALKERAN INJ 50MG .......................... 36 ALKERAN TAB 2MG ........................... 36 all day allg cap 10mg ...................... 186 all day allg tab 10mg ...................... 186 all day pain tab 220mg ...................... 2

ALLEGRA ALRG TAB 30MG ............... 187 ALLEGRA-D TAB 24 HOUR ................ 186 allergy cap 25mg ............................ 187 allergy d tab 5-120mg ..................... 186 allergy relf chw 10mg ...................... 186 allergy relf tab 10mg ....................... 187 allergy tab 12mg cr ........................ 187 allergy tab 25mg ............................ 187 allergy tab 4mg .............................. 187 allergy tab multi-sy ......................... 186 ALLEVYN AG PAD 3"X3" ................... 212 ALLI CAP 60MG .............................. 122 allopurinol tab 100 mg ....................... 1 allopurinol tab 300 mg ....................... 1 allrgy rel-d tab 10-240mg ................ 186 allrgy relf tab 12.5mg ..................... 187 allrgy rlf-d tab 5-120mg .................. 186 almotriptan malate tab 12.5 mg ....... 105 almotriptan malate tab 6.25 mg ....... 105 ALOCRIL SOL 2% ........................... 216 ALOMIDE SOL 0.1% OP ................... 216 ALOPRIM INJ 500MG .......................... 1 ALORA DIS 0.025MG ....................... 128 ALORA DIS 0.05MG ........................ 128 ALORA DIS 0.075MG ....................... 128 ALORA DIS 0.1MG .......................... 128 alosetron hcl tab 0.5 mg (base equiv) 144 alosetron hcl tab 1 mg (base equiv) .. 144 ALPHAGAN P SOL 0.1% ................... 220 ALPHAGAN P SOL 0.15% ................. 220 ALPHANATE INJ VWF/HUM ............... 157 ALPHANINE SD INJ 1000UNIT .......... 157 ALPHANINE SD INJ 1500UNIT .......... 157 ALPRAZOLAM CON 1 MG/ML .............. 71 alprazolam orally disintegrating tab 0.25 mg ................................................ 71 alprazolam orally disintegrating tab 0.5 mg ................................................ 71 alprazolam orally disintegrating tab 1 mg ..................................................... 71 alprazolam orally disintegrating tab 2 mg ..................................................... 71 alprazolam tab 0.25 mg .................... 71 alprazolam tab 0.5 mg ..................... 71 alprazolam tab 0.5mg xr .................. 71 alprazolam tab 1 mg ........................ 71 alprazolam tab 1mg xr ..................... 71 alprazolam tab 2 mg ........................ 71

226

alprazolam tab 2mg xr ...................... 71 alprazolam tab 3mg xr ...................... 71 ALPROLIX INJ 1000UNIT ................. 157 ALPROLIX INJ 2000UNIT ................. 157 ALPROLIX INJ 3000UNIT ................. 157 ALPROLIX INJ 500UNIT ................... 157 alprostadil inj 500 mcg/ml ................. 67 ALREX SUS 0.2% ........................... 216 ALTABAX OIN 1% ........................... 201 ALTACE CAP 1.25MG ......................... 47 ALTACE CAP 10MG ........................... 47 ALTACE CAP 2.5MG .......................... 47 ALTACE CAP 5MG ............................. 47 ALTOPREV TAB 20MG ER ................... 56 ALTOPREV TAB 40MG ER ................... 56 ALTOPREV TAB 60MG ER ................... 56 ALUM HYDROX SUS 320/5ML ........... 138 ALUNBRIG TAB 30MG ....................... 40 ALVESCO AER 160MCG ................... 195 ALVESCO AER 80MCG ..................... 195 amantadine hcl cap 100 mg ............... 86 amantadine hcl syrup 50 mg/5ml ....... 86 amantadine hcl tab 100 mg ............... 86 ambi 60pse/ tab 400gfn .................. 188 AMBIEN CR TAB 12.5MG ................. 103 AMBIEN CR TAB 6.25MG ................. 103 AMBIEN TAB 10MG ......................... 103 AMBIEN TAB 5MG ........................... 103 AMBISOME INJ 50MG ........................ 25 amcinonide cream 0.1% .................. 205 amcinonide lotion 0.1% ................... 205 AMERGE TAB 1MG .......................... 105 AMERGE TAB 2.5MG ....................... 105 amethia tab ................................... 124 AMICAR SOL 0.25/ML ..................... 160 AMICAR TAB 1000MG...................... 160 AMICAR TAB 500MG ....................... 160 amifostine for inj 500 mg .................. 42 amikacin sulfate inj 1 gm/4ml (250 mg/ml) ........................................... 17 amikacin sulfate inj 500 mg/2ml (250 mg/ml) ........................................... 17 amiloride & hydrochlorothiazide tab 5-50 mg ................................................. 65 amiloride hcl tab 5 mg ...................... 65 aminocaproic acid inj 250 mg/ml ...... 160 aminophylline inj 25 mg/ml ............. 196 AMINOSYN 7% INJ /LYTES .............. 171

AMINOSYN II INJ 15% .................... 171 AMINOSYN II INJ 7% ...................... 171 AMINOSYN II INJ 8.5% ................... 171 aminosyn ii inj 8.5/lyte .................... 171 AMINOSYN M INJ 3.5% ................... 171 AMINOSYN-RF INJ 5.2% .................. 171 amiodarone hcl inj 150 mg/3ml (50 mg/ml) .......................................... 54 amiodarone hcl inj 450 mg/9ml (50 mg/ml) .......................................... 54 amiodarone hcl inj 900 mg/18ml (50 mg/ml) .......................................... 54 amiodarone hcl tab 100 mg .............. 54 amiodarone hcl tab 200 mg .............. 54 amiodarone hcl tab 400 mg .............. 54 AMITIZA CAP 24MCG ...................... 144 AMITIZA CAP 8MCG ........................ 144 amitriptyline hcl tab 10 mg ............... 85 amitriptyline hcl tab 100 mg ............. 85 amitriptyline hcl tab 150 mg ............. 85 amitriptyline hcl tab 25 mg ............... 85 amitriptyline hcl tab 50 mg ............... 85 amitriptyline hcl tab 75 mg ............... 85 amlodipine besylate tab 10 mg .......... 62 amlodipine besylate tab 2.5 mg ......... 62 amlodipine besylate tab 5 mg ............ 62 amlodipine besylate-atorvastatin calcium tab 10-10 mg .................................. 61 amlodipine besylate-atorvastatin calcium tab 10-20 mg .................................. 61 amlodipine besylate-atorvastatin calcium tab 10-40 mg .................................. 61 amlodipine besylate-atorvastatin calcium tab 10-80 mg .................................. 61 amlodipine besylate-atorvastatin calcium tab 2.5-10 mg ................................. 61 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg ................................. 61 amlodipine besylate-atorvastatin calcium tab 2.5-40 mg ................................. 61 amlodipine besylate-atorvastatin calcium tab 5-10 mg ................................... 61 amlodipine besylate-atorvastatin calcium tab 5-20 mg ................................... 61 amlodipine besylate-atorvastatin calcium tab 5-40 mg ................................... 61 amlodipine besylate-atorvastatin calcium tab 5-80 mg ................................... 61

227

amlodipine besylate-benazepril hcl cap 10-20 mg ........................................ 45 amlodipine besylate-benazepril hcl cap 10-40 mg ........................................ 46 amlodipine besylate-benazepril hcl cap 2.5-10 mg ....................................... 45 amlodipine besylate-benazepril hcl cap 5-10 mg ............................................ 45 amlodipine besylate-benazepril hcl cap 5-20 mg ............................................ 45 amlodipine besylate-benazepril hcl cap 5-40 mg ............................................ 45 amlodipine besylate-olmesartan medoxomil tab 10-20 mg .................. 50 amlodipine besylate-olmesartan medoxomil tab 10-40 mg .................. 50 amlodipine besylate-olmesartan medoxomil tab 5-20 mg .................... 50 amlodipine besylate-olmesartan medoxomil tab 5-40 mg .................... 50 amlodipine besylate-valsartan tab 10-160 mg ........................................... 50 amlodipine besylate-valsartan tab 10-320 mg ........................................... 50 amlodipine besylate-valsartan tab 5-160 mg ................................................. 50 amlodipine besylate-valsartan tab 5-320 mg ................................................. 50 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg ......................... 51 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg ............................ 51 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg ............................ 51 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg ........................... 50 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg .............................. 50 AMMONIUM CHL INJ 5MEQ/ML ......... 174 AMMONUL INJ 10% ........................ 134 amoxapine tab 100 mg ..................... 85 amoxapine tab 150 mg ..................... 85 amoxapine tab 25 mg ....................... 85 amoxapine tab 50 mg ....................... 85 amoxicillin & k clavulanate chew tab 200-28.5 mg .......................................... 21 amoxicillin & k clavulanate chew tab 400-57 mg ............................................ 22

amoxicillin & k clavulanate for susp 200-28.5 mg/5ml ................................... 22 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml ................................... 22 amoxicillin & k clavulanate for susp 400-57 mg/5ml ..................................... 22 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml ................................... 22 amoxicillin & k clavulanate tab 250-125 mg ................................................ 22 amoxicillin & k clavulanate tab 500-125 mg ................................................ 22 amoxicillin & k clavulanate tab 875-125 mg ................................................ 22 amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg ................................. 22 amoxicillin (trihydrate) cap 250 mg .... 22 amoxicillin (trihydrate) cap 500 mg .... 22 amoxicillin (trihydrate) chew tab 125 mg ..................................................... 22 amoxicillin (trihydrate) chew tab 250 mg ..................................................... 22 amoxicillin (trihydrate) for susp 125 mg/5ml .......................................... 22 amoxicillin (trihydrate) for susp 200 mg/5ml .......................................... 22 amoxicillin (trihydrate) for susp 250 mg/5ml .......................................... 22 amoxicillin (trihydrate) for susp 400 mg/5ml .......................................... 22 amoxicillin (trihydrate) tab 500 mg .... 22 amoxicillin (trihydrate) tab 875 mg .... 22 amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack ........................ 151 amphetamine-dextroamphetamine cap er 24hr 10 mg .................................... 96 amphetamine-dextroamphetamine cap er 24hr 15 mg .................................... 96 amphetamine-dextroamphetamine cap er 24hr 20 mg .................................... 96 amphetamine-dextroamphetamine cap er 24hr 25 mg .................................... 96 amphetamine-dextroamphetamine cap er 24hr 30 mg .................................... 96 amphetamine-dextroamphetamine cap er 24hr 5 mg ...................................... 96 amphetamine-dextroamphetamine tab 10 mg ............................................ 96

228

amphetamine-dextroamphetamine tab 12.5 mg .......................................... 97 amphetamine-dextroamphetamine tab 15 mg ............................................ 97 amphetamine-dextroamphetamine tab 20 mg ............................................ 97 amphetamine-dextroamphetamine tab 30 mg ............................................ 97 amphetamine-dextroamphetamine tab 5 mg ................................................. 96 amphetamine-dextroamphetamine tab 7.5 mg ........................................... 96 amphotericin b for inj 50 mg .............. 25 ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm ...................................... 22 ampicillin & sulbactam sodium for inj 15 (10-5) gm ....................................... 22 ampicillin & sulbactam sodium for inj 3 (2-1) gm ......................................... 22 ampicillin & sulbactam sodium for iv soln 15 (10-5) gm ................................... 22 ampicillin cap 250 mg ....................... 22 ampicillin cap 500 mg ....................... 22 ampicillin for susp 125 mg/5ml .......... 22 ampicillin for susp 250 mg/5ml .......... 22 ampicillin sodium for inj 1 gm ............ 22 ampicillin sodium for inj 10 gm........... 22 ampicillin sodium for inj 125 mg ......... 22 ampicillin sodium for inj 2 gm ............ 22 ampicillin sodium for inj 250 mg ......... 22 ampicillin sodium for inj 500 mg ......... 22 ampicillin sodium for iv soln 1 gm ....... 23 ampicillin sodium for iv soln 10 gm ..... 23 AMPYRA TAB 10MG ......................... 107 AMRIX CAP 15MG ........................... 108 AMRIX CAP 30MG ........................... 108 AMVISC INJ 12MG/ML ..................... 218 AMVISC PLUS INJ 16MG/ML ............. 218 AMYTAL SOD INJ 500MG ................. 103 ANACAINE OIN .............................. 209 anagrelide hcl cap 0.5 mg ................ 162 anagrelide hcl cap 1 mg .................. 162 ANALPRAM KIT ADVANCED .............. 150 ANAPROX DS TAB 550MG ................... 2 ANASCORP INJ ............................... 163 anastrozole tab 1 mg ........................ 39 ANDRODERM DIS 2MG/24HR ........... 112 ANDRODERM DIS 4MG/24HR ........... 112

ANDROGEL GEL 1%(25MG) .............. 112 ANDROGEL GEL 1%(50MG) .............. 112 ANDROGEL GEL 1.62% .................... 112 ANESTH NEEDL MIS 20GX6" ............ 167 ANESTH NEEDL MIS 22GX2" ............ 167 ANGIOMAX INJ 250MG .................... 154 animal shape chw complete ............. 174 ANIMI-3 CAP VIT D ......................... 174 ANORO ELLIPT AER 62.5-25 ............. 186 ant/anti-gas chw 1000-60 ................ 138 ANTABUSE TAB 250MG .................... 110 ANTABUSE TAB 500MG .................... 110 antacid chw 500mg ......................... 138 antacid chw 550-110....................... 138 antacid chw 750mg ......................... 139 antacid extr chw 675-135 ................ 139 antacid mult chw -symptom ............. 139 antacid plus sus anti-gas ................. 139 antacid plus sus gas rel ................... 139 ANTACID ULTR CHW 1000-200 ......... 139 ANTARA CAP 30MG .......................... 55 ANTARA CAP 90MG .......................... 55 ANTICOAG CPD SOL ........................ 161 ANTICOAGULNT SOL SOD CITR ........ 161 anti-diarrhe liq 1mg/5ml .................. 139 anti-diarrhe tab 2mg ....................... 139 antifungal aer 1% ........................... 201 antifungal cre 1% ........................... 201 anti-itch cre 1-01%......................... 209 anti-itch cre 2-0.1%........................ 209 anti-itch cre 5-2% .......................... 151 anti-itch lot 1% .............................. 205 anti-itch spr 2% ............................. 209 antiseptic liq original ....................... 213 ANTI-SNORE LIQ THROAT ................ 213 ANTIVENIN KIT LAT MACT ............... 163 apap rapid tab tab 80mg .................... 1 APEXICON E CRE 0.05% .................. 205 APIDRA INJ SOLOSTAR .................... 115 APIDRA INJ U-100 .......................... 115 APLENZIN TAB 174MG ...................... 81 APLENZIN TAB 348MG ...................... 81 APLENZIN TAB 522MG ...................... 81 APLIGRAF MIS ................................ 210 APOKYN INJ 10MG/ML ...................... 86 apraclonidine hcl ophth soln 0.5% (base equivalent) .................................... 220 aprepitant capsule 125 mg ............... 140

229

aprepitant capsule 40 mg ................ 140 aprepitant capsule 80 mg ................ 140 aprepitant capsule therapy pack 80 & 125 mg ......................................... 140 APRISO CAP 0.375GM ..................... 143 APTENSIO XR CAP 10MG ................... 97 APTENSIO XR CAP 15MG ................... 97 APTENSIO XR CAP 20MG ................... 97 APTENSIO XR CAP 30MG ................... 97 APTENSIO XR CAP 40MG ................... 97 APTENSIO XR CAP 50MG ................... 97 APTENSIO XR CAP 60MG ................... 97 APTIOM TAB 200MG ......................... 73 APTIOM TAB 400MG ......................... 73 APTIOM TAB 600MG ......................... 73 APTIOM TAB 800MG ......................... 73 APTIVUS CAP 250MG ........................ 28 APTIVUS SOL ................................... 28 AP-ZEL TAB ................................... 174 AQUORAL AER ............................... 213 ARALAST NP INJ 500MG .................. 194 ARANESP INJ 100MCG .................... 159 ARANESP INJ 10MCG ...................... 159 ARANESP INJ 150MCG .................... 159 ARANESP INJ 200MCG .................... 159 ARANESP INJ 25MCG ...................... 159 ARANESP INJ 300MCG .................... 159 ARANESP INJ 40MCG ...................... 159 ARANESP INJ 500MCG .................... 159 ARANESP INJ 60MCG ...................... 159 ARAVA TAB 10MG ........................... 163 ARAVA TAB 20MG ........................... 163 ARCALYST INJ 220MG ..................... 166 ARCAPTA CAP 75MCG ..................... 190 ARESTIN MIS 1MG .......................... 213 ARGATROBAN INJ 125/125 .............. 154 argatroban inj 250 mg/2.5ml (concentrate for iv infusion) ............. 154 ARGATROBAN INJ 50MG/50M ........... 154 argyl saline sol 0.9% ...................... 151 argyl saline sol 100ml ..................... 213 ARICEPT TAB 10MG .......................... 79 ARICEPT TAB 23MG .......................... 79 ARICEPT TAB 5MG ............................ 79 ARIMIDEX TAB 1MG .......................... 39 aripiprazole oral solution 1 mg/ml ....... 89 aripiprazole orally disintegrating tab 10 mg ................................................. 89

aripiprazole orally disintegrating tab 15 mg ................................................ 89 aripiprazole tab 10 mg ..................... 89 aripiprazole tab 15 mg ..................... 89 aripiprazole tab 2 mg ....................... 89 aripiprazole tab 20 mg ..................... 89 aripiprazole tab 30 mg ..................... 89 aripiprazole tab 5 mg ....................... 89 ARISTADA INJ 1064MG .................... 90 ARISTADA INJ 441MG/1. .................. 89 ARISTADA INJ 662MG/2 ................... 90 ARISTADA INJ 882MG/3 ................... 90 ARIXTRA INJ 10/0.8ML .................... 154 ARIXTRA INJ 2.5/0.5 ....................... 154 ARIXTRA INJ 5/0.4ML ...................... 154 ARIXTRA INJ 7.5/0.6 ....................... 154 armodafinil tab 150 mg ................... 110 armodafinil tab 200 mg ................... 110 armodafinil tab 250 mg ................... 110 armodafinil tab 50 mg ..................... 110 ARMOUR THYRO TAB 120MG ............ 136 ARMOUR THYRO TAB 15MG .............. 136 ARMOUR THYRO TAB 180MG ............ 136 ARMOUR THYRO TAB 240MG ............ 136 ARMOUR THYRO TAB 300MG ............ 136 ARNUITY ELPT INH 100MCG ............. 195 ARNUITY ELPT INH 200MCG ............. 195 AROMASIN TAB 25MG ...................... 39 ARTHROTEC 50 TAB ........................... 4 ARTHROTEC 75 TAB ........................... 4 artificial dro tears ........................... 218 artificial sol tears ............................ 218 artificial sol tears op ........................ 218 ARZERRA CON 100/5ML ................... 42 a-s pls nght cap cld/flu .................... 188 ASACOL HD TAB 800MG .................. 143 ASCLERA INJ 0.5% .......................... 67 ASCLERA INJ 1% ............................. 67 ascomp/cod cap 30mg ....................... 5 ascorbic acid cap er 500 mg ............. 174 ascorbic acid chew tab 250 mg ......... 174 ascorbic acid chew tab 500 mg ......... 174 ascorbic acid inj 500 mg/ml ............. 173 ascorbic acid tab 1000 mg ............... 175 ascorbic acid tab 250 mg ................. 174 ascorbic acid tab er 1000 mg ........... 175 ascorbic acid tab er 1500 mg ........... 175 ascorbic acid tab er 500 mg ............. 175

230

ASMANEX 14 AER 220MCG .............. 195 ASMANEX 30 AER 110MCG .............. 195 ASMANEX HFA AER 100 MCG ........... 195 ASMANEX HFA AER 200 MCG ........... 195 aspirin chw 81mg ........................... 162 aspirin low tab 81mg ec .................. 162 aspirin suppos 300 mg ....................... 2 aspirin suppos 600 mg ....................... 2 aspirin tab 325 mg ......................... 162 aspirin tab delayed release 325 mg ... 162 aspirin-caffeine-dihydrocodeine cap 356.4-30-16 mg ................................ 6 aspirin-dipyridamole cap er 12hr 25-200 mg ............................................... 162 ASSESS METER MIS FULL RNG ......... 193 ASSESS METER MIS LOW RANG ....... 193 ASTAGRAF XL CAP 0.5MG ................ 166 ASTAGRAF XL CAP 1MG ................... 166 ASTAGRAF XL CAP 5MG ................... 166 ASTEPRO SPR 0.15% ...................... 194 ASTHMA CHECK MIS SYSTEM ........... 193 ASTHMAMENTOR MIS ..................... 193 ASTHMAPACK KIT CHILD ................. 193 ATABEX CHW PRENATAL ................. 175 ATABEX EC TAB ............................. 175 ATACAND HCT TAB 16-12.5 ............... 51 ATACAND HCT TAB 32-12.5 ............... 51 ATACAND HCT TAB 32-25MG ............. 51 ATACAND TAB 16MG ......................... 52 ATACAND TAB 32MG ......................... 53 ATACAND TAB 4MG .......................... 52 ATACAND TAB 8MG .......................... 52 ATELVIA TAB ................................. 123 atenolol & chlorthalidone tab 100-25 mg ..................................................... 58 atenolol & chlorthalidone tab 50-25 mg ..................................................... 58 atenolol tab 100 mg ......................... 59 atenolol tab 25 mg ........................... 59 atenolol tab 50 mg ........................... 59 ath foot pow aer 1% ....................... 201 athlete foot cre af ........................... 201 ATIVAN INJ 2MG/ML ......................... 71 ATIVAN INJ 4MG/ML ......................... 71 ATIVAN TAB 0.5MG .......................... 71 ATIVAN TAB 1MG ............................. 71 ATIVAN TAB 2MG ............................. 71 atomoxetine hcl cap 10 mg (base equiv)

..................................................... 97 atomoxetine hcl cap 100 mg (base equiv) ............................................ 97 atomoxetine hcl cap 18 mg (base equiv) ..................................................... 97 atomoxetine hcl cap 25 mg (base equiv) ..................................................... 97 atomoxetine hcl cap 40 mg (base equiv) ..................................................... 97 atomoxetine hcl cap 60 mg (base equiv) ..................................................... 97 atomoxetine hcl cap 80 mg (base equiv) ..................................................... 97 atorvastatin calcium tab 10 mg (base equivalent) ..................................... 56 atorvastatin calcium tab 20 mg (base equivalent) ..................................... 56 atorvastatin calcium tab 40 mg (base equivalent) ..................................... 56 atorvastatin calcium tab 80 mg (base equivalent) ..................................... 56 atovaquone susp 750 mg/5ml ........... 33 atovaquone-proguanil hcl tab 250-100 mg ................................................ 27 atovaquone-proguanil hcl tab 62.5-25 mg ................................................ 27 ATRALIN GEL 0.05% ....................... 197 ATRAPRO DERM SPR ....................... 212 ATRAPRO GEL HYDROGEL ................ 212 ATRIPLA TAB .................................. 27 ATROPEN INJ 0.5MG ....................... 122 ATROPEN INJ 1MG .......................... 122 ATROPEN INJ 2MG .......................... 122 ATROPINE SUL OIN 1% OP .............. 220 atropine sulfate inj 1 mg/ml .............. 67 atropine sulfate inj 8 mg/20ml (0.4 mg/ml) .......................................... 67 atropine sulfate ophth soln 1% ......... 220 atropine sulfate preservative free (pf) inj 0.4 mg/0.5ml .................................. 67 atropine sulfate soln prefill syr 0.25 mg/5ml (0.05 mg/ml) ...................... 67 atropine sulfate soln prefill syr 1 mg/10ml (0.1 mg/ml) ...................... 67 ATROVENT HFA AER 17MCG ............. 186 AUBAGIO TAB 14MG ....................... 107 AUBAGIO TAB 7MG ......................... 107 aubra tab 0.1-0.02 ......................... 125

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AUGMENTIN SUS 125/5ML ................. 23 AUSTEDO TAB 12MG ....................... 107 AUSTEDO TAB 6MG ........................ 107 AUSTEDO TAB 9MG ........................ 107 AUTOSHIELD MIS 29X3/16" ............. 119 AUTOSHIELD MIS 29X5/16" ............. 119 AUTOSHIELD MIS 30GX3/16 ............ 119 AVALIDE TAB 150-12.5 ..................... 51 AVALIDE TAB 300-12.5 ..................... 51 AVANDIA TAB 2MG ......................... 115 AVANDIA TAB 4MG ......................... 115 AVAPRO TAB 150MG ......................... 53 AVAPRO TAB 300MG ......................... 53 AVAPRO TAB 75MG ........................... 53 AVASTIN INJ ................................... 42 AVASTIN INJ 400/16ML ..................... 42 AVC CRE 15% ................................ 153 AVELOX INJ ..................................... 21 AVIDOXY DK KIT .............................. 24 avidoxy tab 100mg ........................... 24 AVITENE PAD 35X35MM .................. 160 AVITENE POW FLOUR ...................... 160 AVODART CAP 0.5MG ...................... 151 AVONEX KIT 30MCG ....................... 108 AVONEX PEN KIT 30MCG ................. 108 AVONEX PREFL KIT 30MCG .............. 108 av-phos 250 tab neutral .................. 170 AVYCAZ INJ 2-0.5GM ........................ 17 AXERT TAB 12.5MG ........................ 105 AXERT TAB 6.25MG ........................ 105 AXILLARY NDL MIS 22GX1" ............. 167 AXILLARY NDL MIS 25GX1" ............. 167 AXIRON SOL 30MG/ACT .................. 112 AYGESTIN TAB 5MG ........................ 136 AYR ALLERGY SPR & SINUS ............. 194 AYR NASAL DRO 0.65% .................. 194 AZACTAM INJ 1GM ........................... 33 AZACTAM INJ 2GM ........................... 33 AZACTAM/DEX INJ 1GM .................... 33 AZACTAM/DEX INJ 2GM .................... 33 AZASAN TAB 100MG ....................... 166 AZASAN TAB 75 MG ........................ 166 AZASITE SOL 1% ........................... 215 azathioprine tab 50 mg ................... 166 azelastine hcl nasal spray 0.1% (137 mcg/spray) ................................... 194 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) ................................... 195

azelastine hcl ophth soln 0.05% ....... 216 AZELEX CRE 20% ........................... 197 AZILECT TAB 0.5MG ........................ 86 AZILECT TAB 1MG ........................... 86 azithromycin for susp 100 mg/5ml ..... 20 azithromycin for susp 200 mg/5ml ..... 20 azithromycin iv for soln 500 mg ......... 20 azithromycin powd pack for susp 1 gm 20 azithromycin tab 250 mg .................. 20 azithromycin tab 500 mg .................. 20 azithromycin tab 600 mg .................. 20 AZOLEN TINC SOL 2% .................... 202 AZOPT SUS 1% OP ......................... 218 AZOR TAB 10-20MG ......................... 50 AZOR TAB 10-40MG ......................... 50 AZOR TAB 5-20MG .......................... 50 AZOR TAB 5-40MG .......................... 50 aztreonam for inj 1 gm ..................... 33 aztreonam for inj 2 gm ..................... 33 AZULFIDINE TAB 500MG ................. 143 AZULFIDINE TAB 500MG EN ............. 143 azuphen mb cap 120mg .................. 151 azurette tab 28 day ........................ 124 B b-100 tab tr ................................... 175 B12 COMPLNCE KIT INJ KIT ............. 175 baciim inj 50000unt ......................... 33 bacitracin oint 500 unit/gm .............. 201 bacitracin ophth oint 500 unit/gm ..... 215 bacitracin zinc oint 500 unit/gm ........ 201 baclofen tab 10 mg ......................... 108 baclofen tab 20 mg ......................... 108 BACTINE SPR ................................. 209 BACTOCILL INJ DEX 1GM .................. 23 BACTOCILL INJ DEX 2GM .................. 23 BACTRIM DS TAB 800-160 ................ 24 BACTRIM TAB 400-80MG .................. 24 BACTROBAN OIN NASAL 2% ............ 201 BAL IN OIL INJ 100MG/ML ............... 122 bal salt sol op ................................ 218 balance b-50 tab tr ......................... 175 balanced b tab complex ................... 175 balanced tab b-100 tr ...................... 175 BAL-CARE MIS DHA ........................ 175 balsalazide disodium cap 750 mg ...... 143 BANZEL SUS 40MG/ML ..................... 73 BANZEL TAB 200MG ......................... 73 BANZEL TAB 400MG ......................... 73

232

BARACLUDE SOL .05MG/ML ............... 31 BARACLUDE TAB 0.5MG .................... 31 BARACLUDE TAB 1MG ....................... 31 BASAGLAR INJ 100UNIT .................. 115 bayer adv tab 500mg ...................... 162 b-complex tab ............................... 175 B-COMPLEX TAB C/FA/BIO ............... 175 b-complex vitamin cap .................... 175 b-complex vitamin tab .................... 175 b-complex w/ c & calcium tab .......... 175 b-complex w/ c cap ........................ 175 b-complex w/ folic acid cap .............. 175 BD ECLIPSE MIS 1ML/30G ............... 167 BD ECLIPSE MIS 25GX5/8" .............. 167 bdy/hair/skn cap nails ..................... 175 BE WELL PAK ROUNDED .................. 175 BEBULIN INJ 200-1200 ................... 157 BECONASE AQ SUS 0.042% ............ 195 bedding spra aer 0.5% .................... 212 BELBUCA MIS 150MCG ....................... 6 BELBUCA MIS 300MCG ....................... 6 BELBUCA MIS 450MCG ....................... 6 BELBUCA MIS 600MCG ....................... 6 BELBUCA MIS 750MCG ....................... 6 BELBUCA MIS 75MCG ........................ 6 BELBUCA MIS 900MCG ....................... 6 BELSOMRA TAB 10MG ..................... 103 BELSOMRA TAB 15MG ..................... 103 BELSOMRA TAB 20MG ..................... 103 BELSOMRA TAB 5MG ...................... 103 BELVIQ TAB 10MG .......................... 122 BELVIQ XR TAB 20MG ..................... 123 benadryl itc gel 2% ........................ 210 benazepril & hydrochlorothiazide tab 10-12.5 mg .......................................... 46 benazepril & hydrochlorothiazide tab 20-12.5 mg .......................................... 46 benazepril & hydrochlorothiazide tab 20-25 mg ............................................ 46 benazepril & hydrochlorothiazide tab 5-6.25 mg .......................................... 46 benazepril hcl tab 10 mg ................... 47 benazepril hcl tab 20 mg ................... 47 benazepril hcl tab 40 mg ................... 47 benazepril hcl tab 5 mg ..................... 47 BENDEKA INJ 100/4ML ...................... 36 BENEFIX INJ 1000UNIT ................... 157 BENEFIX INJ 2000UNIT ................... 157

BENEFIX INJ 250UNIT ..................... 157 BENEFIX INJ 3000UNIT ................... 157 BENEFIX INJ 500UNIT ..................... 157 BENICAR HCT TAB 20-12.5 ............... 51 BENICAR HCT TAB 40-12.5 ............... 51 BENICAR HCT TAB 40-25MG ............. 51 BENICAR TAB 20MG ......................... 53 BENICAR TAB 40MG ......................... 53 BENICAR TAB 5MG .......................... 53 BENLYSTA INJ 120MG ..................... 166 BENLYSTA INJ 200MG/ML ................ 166 BENLYSTA INJ 400MG ..................... 166 BENSAL HP OIN .............................. 210 BENTYL CAP 10MG .......................... 141 BENTYL INJ 10MG/ML ...................... 141 BENTYL TAB 20MG .......................... 141 BENZAC AC LIQ 5% WASH ............... 197 BENZACLIN GEL 1-5% .................... 197 BENZAMYCIN GEL 5-3% .................. 197 BENZAMYCIN GEL PAK .................... 197 BENZEFOAM AER 5.3% ................... 197 BENZEFOAM AER 9.8% ................... 198 benzepro liq creamy ........................ 198 benzepro sc aer 9.8% ..................... 198 BENZIQ GEL 5.25% ........................ 198 BENZIQ LS GEL 2.75% .................... 198 benziq wash liq 5.25% .................... 198 BENZODOX 30 MIS .......................... 24 BENZODOX 60 MIS .......................... 24 benzonatate cap 100 mg ................. 190 benzonatate cap 150 mg ................. 190 benzonatate cap 200 mg ................. 190 BENZOYL PER GEL 2.5% .................. 198 benzoyl per liq 10% wash ................ 198 benzoyl per liq 5% wash .................. 198 benzoyl pero kit acne pck ................ 198 benzoyl peroxide foam 5.3% ............ 198 benzoyl peroxide gel 10% ................ 198 benzoyl peroxide-erythromycin gel 5-3% .................................................... 198 benzphetamine hcl tab 50 mg .......... 123 benztropine mesylate inj 1 mg/ml ...... 86 benztropine mesylate tab 0.5 mg ....... 86 benztropine mesylate tab 1 mg ......... 86 benztropine mesylate tab 2 mg ......... 86 BENZYL PEROX LOT CLNSR 3% ........ 198 benzyl perox lot clnsr 6% ................ 198 BEPREVE DRO 1.5% ....................... 216

233

BERINERT INJ 500UNIT ................... 160 berocca tab ................................... 175 BESIVANCE SUS 0.6% .................... 215 BETADINE SOL 5% OP .................... 215 BETAGAN SOL 0.5% OP .................. 217 betamethasone dipropionate augmented cream 0.05% ................................. 205 betamethasone dipropionate augmented gel 0.05% ..................................... 207 betamethasone dipropionate augmented lotion 0.05% .................................. 205 betamethasone dipropionate augmented oint 0.05% .................................... 207 betamethasone dipropionate cream 0.05% .......................................... 205 betamethasone dipropionate lotion 0.05% .......................................... 205 betamethasone dipropionate oint 0.05% ................................................... 205 betamethasone sod phosphate & acetate inj susp 6 (3-3) mg/ml .................... 130 betamethasone valerate aerosol foam 0.12% .......................................... 206 betamethasone valerate cream 0.1% 206 betamethasone valerate lotion 0.1% . 206 betamethasone valerate oint 0.1% ... 206 BETAPACE AF TAB 120MG .................. 54 BETAPACE AF TAB 160MG .................. 54 BETAPACE AF TAB 80MG ................... 54 BETAPACE TAB 120MG ...................... 54 BETAPACE TAB 160MG ...................... 54 BETAPACE TAB 80MG ........................ 54 BETASERON INJ 0.3MG ................... 108 betaxolol hcl ophth soln 0.5% .......... 217 betaxolol hcl tab 10 mg ..................... 59 betaxolol hcl tab 20 mg ..................... 59 bethanechol chloride tab 10 mg ........ 151 bethanechol chloride tab 25 mg ........ 151 bethanechol chloride tab 5 mg ......... 151 bethanechol chloride tab 50 mg ........ 151 BETHKIS NEB 300/4ML ................... 192 BETIMOL SOL 0.25% ...................... 217 BETIMOL SOL 0.5% ........................ 217 BETOPTIC-S SUS 0.25% OP ............. 217 BEVESPI AER 9-4.8MCG .................. 196 bexarotene cap 75 mg ...................... 42 BEYAZ TAB .................................... 125 bicalutamide tab 50 mg ..................... 38

BICILLIN C-R INJ 1200000 ................ 23 BICILLIN C-R INJ 900/300 ................ 23 BICILLIN L-A INJ 1200000 ................ 23 BICILLIN L-A INJ 2400000 ................ 23 BICILLIN L-A INJ 600000 .................. 23 BICNU INJ 100MG ........................... 36 BIDIL TAB ...................................... 66 BIFERARX TAB ............................... 175 BILTRICIDE TAB 600MG ................... 34 bimatoprost ophth soln 0.03% ......... 220 BINOSTO TAB 70MG ....................... 123 bio glo tes 1mg op .......................... 218 bio t pres-b liq 10-4-20 ................... 188 biocel tab ...................................... 175 bio-d-mulsio liq 2000unit ................. 175 bio-d-mulsio liq 400unit ................... 175 BIOGAIA DRO PROBIOTI ................. 146 BIOGAIA MIS PROBIOTI .................. 146 BIONEL LIQ PEDIATRC .................... 188 bio-rytuss liq 5-2-10/5 .................... 188 BIOSPEC DMX LIQ .......................... 188 BIOSTEP AG MIS 2"X2" ................... 213 BIOSTEP AG MIS 4"X4" ................... 213 BIOSTEP MIS 2"X2" ........................ 213 BIOSTEP MIS 4"X4" ........................ 213 BIOSUPP LIQ ................................. 175 BIOVOL SYP ................................... 175 bisoprolol & hydrochlorothiazide tab 10-6.25 mg ......................................... 58 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg ......................................... 58 bisoprolol & hydrochlorothiazide tab 5-6.25 mg ......................................... 58 bisoprolol fumarate tab 10 mg ........... 59 bisoprolol fumarate tab 5 mg ............ 59 bivalirudin for iv soln 250 mg ........... 154 BIVIGAM INJ 10% .......................... 164 BLADDER 2.2 TAB ........................... 169 BLEPH-10 SOL 10% OP ................... 215 BLEPHAMIDE OIN S.O.P. .................. 214 BLEPHAMIDE SUS OP ...................... 214 blis-to-sol liq 1% ............................ 202 BLOXIVERZ INJ 10/10ML ................. 106 BLOXIVERZ INJ 5MG/10ML .............. 106 BONE DENSITY TAB BUILDER ........... 175 BONIVA TAB 150MG ........................ 123 BOSULIF TAB 100MG ....................... 40 BOSULIF TAB 500MG ....................... 40

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BOUDREAUXS OIN 16% .................. 210 bp 10-1 emu ................................. 198 BP ARM CUFF MIS LARGE ................ 167 bp cleansing emu 10-4% ................. 198 bp foaming liq wash 10% ................ 198 bp folinatal tab plus b ..................... 175 BP GEL GEL 5.5% ........................... 198 bp multinatl chw plus ...................... 175 bp multinatl tab plus ....................... 175 bp wash liq 5.25% .......................... 198 b-plex tab ..................................... 175 bpo cloths mis 6% .......................... 198 bpo creamy kit 4% wash ................. 198 BPO GEL 4% .................................. 198 BPO GEL 8% .................................. 198 bprotected sol tri-vite ..................... 175 BRAINSTRONG MIS PRENATAL ......... 175 BREO ELLIPTA INH 100-25 .............. 196 BREO ELLIPTA INH 200-25 .............. 196 BREVIBLOC INJ 10MG/ML .................. 59 BREVIBLOC SOL ............................... 59 BREVIBLOC SOL 10MG/ML ................. 59 BRILINTA TAB 60MG ....................... 162 BRILINTA TAB 90MG ....................... 162 brimonidine tartrate ophth soln 0.15% ................................................... 220 brimonidine tartrate ophth soln 0.2% 220 BRISDELLE CAP 7.5MG .................... 112 BRIVIACT SOL 10MG/ML ................... 73 BRIVIACT TAB 100MG ....................... 73 BRIVIACT TAB 10MG ......................... 73 BRIVIACT TAB 25MG ......................... 73 BRIVIACT TAB 50MG ......................... 73 BRIVIACT TAB 75MG ......................... 73 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) ................ 216 bromfenac sodium ophth soln 0.09% (base equivalent) ........................... 216 bromocriptine mesylate cap 5 mg (base equivalent) ...................................... 86 bromocriptine mesylate tab 2.5 mg (base equivalent) ...................................... 86 brompheniramine tannate chew tab 12 mg ............................................... 187 BROVANA NEB 15MCG .................... 191 BROVEX PEB LIQ DM ...................... 188 BSS PLUS SOL OP .......................... 219 BUCALSEP SOL .............................. 210

BUCALSEP SPR ............................... 210 BUCKLEYS LIQ COUGH .................... 190 budesonide delayed release particles cap 3 mg ............................................ 143 budesonide inhalation susp 0.25 mg/2ml .................................................... 196 budesonide inhalation susp 0.5 mg/2ml .................................................... 196 budesonide inhalation susp 1 mg/2ml 196 budesonide nasal susp 32 mcg/act .... 195 bumetanide inj 0.25 mg/ml ............... 65 bumetanide tab 0.5 mg .................... 65 bumetanide tab 1 mg ....................... 65 bumetanide tab 2 mg ....................... 65 BUNAVAIL MIS 2.1-0.3 .................... 111 BUNAVAIL MIS 4.2-0.7 .................... 111 BUNAVAIL MIS 6.3-1MG .................. 111 BUPAP TAB 50-300MG ........................ 2 BUPRENEX INJ 0.3MG/ML ................... 6 buprenorphine hcl inj 0.3 mg/ml (base equiv) .............................................. 6 buprenorphine hcl sl tab 2 mg (base equiv) ........................................... 111 buprenorphine hcl sl tab 8 mg (base equiv) ........................................... 111 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) ....................... 111 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) .......................... 111 buprenorphine td patch weekly 10 mcg/hr ............................................. 6 buprenorphine td patch weekly 15 mcg/hr ............................................. 6 buprenorphine td patch weekly 20 mcg/hr ............................................. 6 buprenorphine td patch weekly 5 mcg/hr ....................................................... 6 bupropion hcl (smoking deterrent) tab er 12hr 150 mg .................................. 111 bupropion hcl tab 100 mg ................. 81 bupropion hcl tab 75 mg ................... 81 bupropion hcl tab er 12hr 100 mg ...... 81 bupropion hcl tab er 12hr 150 mg ...... 81 bupropion hcl tab er 12hr 200 mg ...... 81 bupropion hcl tab er 24hr 150 mg ...... 81 bupropion hcl tab er 24hr 300 mg ...... 81 buspirone hcl tab 10 mg ................... 72 buspirone hcl tab 15 mg ................... 72

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buspirone hcl tab 30 mg .................... 72 buspirone hcl tab 5 mg ..................... 72 buspirone hcl tab 7.5 mg ................... 72 BUSULFEX INJ 6MG/ML ..................... 36 butalbital-acetaminophen tab 50-325 mg ...................................................... 2 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg .............................. 6 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg .............................. 6 butalbital-acetaminophen-caffeine cap 50-300-40 mg .................................. 2 butalbital-acetaminophen-caffeine cap 50-325-40 mg .................................. 2 butalbital-acetaminophen-caffeine tab 50-325-40 mg .................................. 2 butalbital-aspirin-caffeine cap 50-325-40 mg .................................................. 2 BUTISOL SOD TAB 30MG ................. 103 butorphanol tartrate inj 1 mg/ml ......... 6 butorphanol tartrate inj 2 mg/ml ......... 6 butorphanol tartrate nasal soln 10 mg/ml ...................................................... 6 BUTRANS DIS 10MCG/HR ................... 6 BUTRANS DIS 15MCG/HR ................... 6 BUTRANS DIS 20MCG/HR ................... 6 BUTRANS DIS 5MCG/HR ..................... 6 BYDUREON INJ 2MG ....................... 114 BYDUREON PEN INJ 2MG ................. 114 BYETTA INJ 10MCG ......................... 115 BYETTA INJ 5MCG .......................... 114 BYSTOLIC TAB 10MG ........................ 59 BYSTOLIC TAB 2.5MG ....................... 59 BYSTOLIC TAB 20MG ........................ 59 BYSTOLIC TAB 5MG .......................... 59 C c complex tab 1000mg .................... 175 ca citrate tab plus .......................... 175 CA HI-CAL/D TAB 500MG ................ 175 cabergoline tab 0.5 mg ................... 134 CABOMETYX TAB 20MG ..................... 40 CABOMETYX TAB 40MG ..................... 40 CABOMETYX TAB 60MG ..................... 40 CADEAU DHA CAP .......................... 175 CA-DTPA SOL 1000MG .................... 122 CADUET TAB 10-10MG ...................... 61 CADUET TAB 10-20MG ...................... 61 CADUET TAB 10-40MG ...................... 62

CADUET TAB 10-80MG ..................... 62 CADUET TAB 2.5-10MG .................... 61 CADUET TAB 2.5-20MG .................... 61 CADUET TAB 2.5-40MG .................... 61 CADUET TAB 5-10MG ....................... 61 CADUET TAB 5-20MG ....................... 61 CADUET TAB 5-40MG ....................... 61 CADUET TAB 5-80MG ....................... 61 CAFCIT INJ 60MG/3ML .................... 194 CAFERGOT TAB 1-100MG ................. 104 caffeine & sodium benzoate inj 125-125 mg/ml (500 mg/2ml) ...................... 107 caffeine citrate inj 60 mg/3ml (10 mg/ml base equiv) ................................... 194 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) ......................... 194 calamine med lot 1-8% ................... 210 CALAN SR TAB 120MG ...................... 63 CALAN SR TAB 180MG ...................... 63 CALAN SR TAB 240MG ...................... 63 CALAN TAB 120MG .......................... 63 CALAN TAB 80MG ............................ 63 calc citr/d3 tab 200-250 .................. 175 calc citrate tab +d .......................... 175 CALCET BITES CHW 500-400 ........... 175 calcidol dro 8000/ml ....................... 175 calcipotriene cream 0.005% ............. 203 calcipotriene oint 0.005% ................ 203 calcipotriene soln 0.005% (50 mcg/ml) .................................................... 203 calcipotriene-betamethasone dipropionate oint 0.005-0.064% ....... 203 calcitonin (salmon) nasal soln 200 unit/act ......................................... 124 calcitriol cap 0.25 mcg .................... 133 calcitriol cap 0.5 mcg ...................... 133 calcitriol inj 1 mcg/ml ...................... 133 calcitriol oint 3 mcg/gm ................... 203 calcitriol oral soln 1 mcg/ml ............. 133 calcium + d chw ............................. 176 CALCIUM 1000 TAB + D .................. 176 calcium 1200 chw ........................... 176 calcium 500 tab +d ......................... 175 calcium 600 chw +d/miner .............. 175 calcium 600 chw w/vit d .................. 176 calcium 600 tab + d ........................ 176 calcium 600 tab +d ......................... 176 calcium 600 tab +d3 ....................... 176

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calcium 600/ tab vit d ..................... 176 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) ....................... 135 calcium acetate (phosphate binder) tab 667 mg ......................................... 135 CALCIUM CARB CHW 260MG ............ 176 CALCIUM CARB POW 800/2GM ......... 176 calcium carbonate (antacid) tab 648 mg ................................................... 139 calcium carbonate susp 1250 mg/5ml (500 mg/5ml elemental ca) ............. 176 calcium carbonate tab 1250 mg (500 mg elemental ca) ................................ 176 calcium carbonate tab 1500 mg (600 mg elemental ca) ................................ 176 calcium carbonate tab 600 mg ......... 176 calcium carbonate-cholecalciferol chew tab 500 mg-100 unit ....................... 176 calcium carbonate-vitamin d tab 250 mg-125 unit ........................................ 176 calcium carbonate-vitamin d tab 500 mg-400 unit ........................................ 176 calcium carbonate-vitamin d tab 600 mg-125 unit ........................................ 176 calcium chloride inj 10% ................. 173 CALCIUM CHW GUMMIES ................ 176 CALCIUM CIT/ TAB VIT D ................ 176 calcium citr tab +d ......................... 176 calcium citrate-vitamin d tab 315 mg-200 unit (elemental ca) ................... 176 CALCIUM DISO INJ 1GM/5ML ........... 122 calcium gluconate inj 10% ............... 173 calcium plus cap d3 ........................ 176 calcium tab 500/d .......................... 176 calcium tab 600mg ......................... 176 CALCIUM/C/D CHW 500MG .............. 176 calcium/d3 tab ............................... 176 calcium/d3 tab 600-800 .................. 176 CALCIUM/VITD CAP 600-400 ........... 176 calcium+d3 tab 600-800 ................. 176 calcium+d3 tab grad rel .................. 176 CALCIUM-FA WAF PLUS D ................ 176 calcium-magnesium-zinc tab 333-133-5 mg ............................................... 176 CALDOLOR INJ 400/4ML ..................... 2 CALDOLOR INJ 800/8ML ..................... 2 CALNA TAB .................................... 176 CAL-QUICK LIQ 500-400 ................. 175

CALTRATE + D TAB 300-800 ............ 176 CALTRATE 600 CHW +D PLUS .......... 176 CALTRATE 600 CHW 600-800 ........... 176 CAMPTOSAR INJ 100/5ML ................. 45 CAMPTOSAR INJ 300/15ML ............... 45 CAMPTOSAR INJ 40MG/2ML .............. 45 CANASA SUP 1000MG ..................... 144 CANCIDAS INJ 50MG ....................... 25 CANCIDAS INJ 70MG ....................... 25 candesartan cilexetil tab 16 mg ......... 53 candesartan cilexetil tab 32 mg ......... 53 candesartan cilexetil tab 4 mg ........... 53 candesartan cilexetil tab 8 mg ........... 53 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg ............................... 51 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg ............................... 51 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg .................................. 51 CAPASTAT SUL INJ 1GM ................... 30 capecitabine tab 150 mg .................. 37 capecitabine tab 500 mg .................. 37 CAPEX SHA 0.01% .......................... 205 CAPHOSOL SOL .............................. 213 CAPITAL/COD SUS 120-12/5 ............... 6 CAPRELSA TAB 100MG ..................... 40 CAPRELSA TAB 300MG ..................... 40 capsaicin cream 0.025% .................. 209 capsaicin cream 0.1% ..................... 209 CAPSAICIN LIQ 0.15% .................... 209 capsaicin pad hot ptch ..................... 209 CAPSIDERM PAD .0375-5% .............. 209 captopril & hydrochlorothiazide tab 25-15 mg ................................................ 46 captopril & hydrochlorothiazide tab 25-25 mg ................................................ 46 captopril & hydrochlorothiazide tab 50-15 mg ................................................ 46 captopril & hydrochlorothiazide tab 50-25 mg ................................................ 46 captopril tab 100 mg ........................ 47 captopril tab 12.5 mg ....................... 47 captopril tab 25 mg ......................... 47 captopril tab 50 mg ......................... 47 CAPZASIN GEL RELIEF .................... 209 CAPZASIN-P CRE 0.035% ................ 209 CARAC CRE 0.5% ........................... 200 CARAFATE SUS 1GM/10ML ............... 146

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CARAFATE TAB 1GM ....................... 146 CARBAGLU TAB 200MG ................... 134 carbamazepine cap er 12hr 100 mg .... 73 carbamazepine cap er 12hr 200 mg .... 73 carbamazepine cap er 12hr 300 mg .... 73 carbamazepine chew tab 100 mg ........ 73 carbamazepine susp 100 mg/5ml ....... 73 carbamazepine tab 200 mg ................ 73 carbamazepine tab er 12hr 200 mg .... 73 carbamazepine tab er 12hr 400 mg .... 73 CARBAPHEN 12 LIQ ........................ 188 CARBAPHEN 12 SUS PED ................. 188 CARBATROL CAP 100MG .................... 73 CARBATROL CAP 200MG .................... 73 CARBATROL CAP 300MG .................... 73 carbidopa & levodopa orally disintegrating tab 10-100 mg ............. 87 carbidopa & levodopa orally disintegrating tab 25-100 mg ............. 87 carbidopa & levodopa orally disintegrating tab 25-250 mg ............. 87 carbidopa & levodopa tab 10-100 mg .. 87 carbidopa & levodopa tab 25-100 mg .. 87 carbidopa & levodopa tab 25-250 mg .. 87 carbidopa & levodopa tab er 25-100 mg ..................................................... 87 carbidopa & levodopa tab er 50-200 mg ..................................................... 87 carbidopa tab 25 mg ......................... 87 carbidopa-levodopa-entacapone tabs 12.5-50-200 mg ............................... 87 carbidopa-levodopa-entacapone tabs 18.75-75-200 mg ............................. 87 carbidopa-levodopa-entacapone tabs 25-100-200 mg .................................... 87 carbidopa-levodopa-entacapone tabs 31.25-125-200 mg ........................... 87 carbidopa-levodopa-entacapone tabs 37.5-150-200 mg ............................. 87 carbidopa-levodopa-entacapone tabs 50-200-200 mg .................................... 87 carbinoxamine maleate soln 4 mg/5ml ................................................... 187 carbinoxamine maleate tab 4 mg ...... 187 carboplatin iv soln 150 mg/15ml ........ 36 carboplatin iv soln 450 mg/45ml ........ 36 carboplatin iv soln 50 mg/5ml ............ 36 carboplatin iv soln 600 mg/60ml ........ 36

CARDENE IV INJ 40/200ML ............... 62 CARDENE IV SOL 20/200ML .............. 62 cardioplegic soln .............................. 67 CARDIZEM CD CAP 120MG/24 ........... 63 CARDIZEM CD CAP 180MG/24 ........... 63 CARDIZEM CD CAP 240MG/24 ........... 63 CARDIZEM CD CAP 300MG/24 ........... 63 CARDIZEM CD CAP 360MG/24 ........... 63 CARDIZEM LA TAB 120MG ................ 63 CARDIZEM LA TAB 180MG ................ 63 CARDIZEM LA TAB 240MG ................ 63 CARDIZEM LA TAB 300MG/24 ............ 63 CARDIZEM LA TAB 360MG ................ 63 CARDIZEM LA TAB 420MG/24 ............ 63 CARDIZEM TAB 120MG ..................... 63 CARDIZEM TAB 30MG ...................... 63 CARDIZEM TAB 60MG ...................... 63 CARDURA TAB 1MG ......................... 49 CARDURA TAB 2MG ......................... 49 CARDURA TAB 4MG ......................... 49 CARDURA TAB 8MG ......................... 49 CARDURA XL TAB 4MG .................... 151 CARDURA XL TAB 8MG .................... 151 CAREFINE MIS 32GX5MM ................ 119 CARIMUNE NF INJ 12GM .................. 164 CARIMUNE NF INJ 6GM ................... 164 carisoprodol tab 250 mg .................. 108 carisoprodol tab 350 mg .................. 108 carisoprodol w/ aspirin & codeine tab 200-325-16 mg .............................. 108 carisoprodol w/ aspirin tab 200-325 mg .................................................... 108 carracolloid pad 4"x4" ..................... 213 carteolol hcl ophth soln 1% .............. 217 CARTICEL IMP ................................... 2 CARTRIDGE MIS PUMP .................... 119 carvedilol tab 12.5 mg ..................... 59 carvedilol tab 25 mg ........................ 59 carvedilol tab 3.125 mg .................... 59 carvedilol tab 6.25 mg ..................... 59 CASODEX TAB 50MG ........................ 38 CATAPRES TAB 0.1MG ...................... 48 CATAPRES TAB 0.2MG ...................... 48 CATAPRES TAB 0.3MG ...................... 48 CATAPRES-TTS DIS 0.1/24HR ........... 49 CATAPRES-TTS DIS 0.2/24HR ........... 49 CATAPRES-TTS DIS 0.3/24HR ........... 49 CATHFLO ACTI INJ VASE ................. 161

238

cavarest gel 1.1% .......................... 213 CAYSTON INH 75MG ....................... 192 caziant pak .................................... 127 cefaclor cap 250 mg ......................... 18 cefaclor cap 500 mg ......................... 18 CEFACLOR ER TAB 500MG ................. 18 cefaclor for susp 125 mg/5ml ............. 18 cefaclor for susp 250 mg/5ml ............. 18 cefaclor for susp 375 mg/5ml ............. 18 cefadroxil cap 500 mg ....................... 18 cefadroxil for susp 250 mg/5ml .......... 18 cefadroxil for susp 500 mg/5ml .......... 18 cefadroxil tab 1 gm ........................... 18 CEFAZOL/DEX SOL 1GM .................... 18 CEFAZOL/DEX SOL 2GM .................... 18 CEFAZOLIN INJ 100GM ..................... 18 CEFAZOLIN INJ 1GM/10ML ................ 18 CEFAZOLIN INJ 1GM/50ML ................ 18 CEFAZOLIN INJ 300GM ..................... 18 cefazolin sodium for inj 1 gm ............. 18 cefazolin sodium for inj 10 gm ........... 18 cefazolin sodium for inj 20 gm ........... 18 cefazolin sodium for inj 500 mg .......... 18 cefazolin sodium for iv soln 1 gm ........ 18 cefdinir cap 300 mg .......................... 19 cefdinir for susp 125 mg/5ml ............. 19 cefdinir for susp 250 mg/5ml ............. 19 cefditoren pivoxil tab 200 mg (base equivalent) ...................................... 19 cefditoren pivoxil tab 400 mg (base equivalent) ...................................... 19 cefepime hcl for inj 1 gm ................... 20 cefepime hcl for inj 2 gm ................... 20 CEFEPIME INJ 1GM ........................... 20 CEFEPIME INJ 2GM ........................... 20 CEFEPIME/DEX INJ 1GM .................... 20 CEFEPIME/DEX INJ 2GM .................... 20 cefixime for susp 100 mg/5ml ............ 19 cefixime for susp 200 mg/5ml ............ 19 cefotaxime sodium for inj 1 gm .......... 19 cefotaxime sodium for inj 10 gm ........ 19 cefotaxime sodium for inj 2 gm .......... 19 cefotaxime sodium for inj 500 mg ....... 19 CEFOTET/DEX INJ 1-3.58% ............... 18 CEFOTET/DEX INJ 2-2.08% ............... 18 cefotetan disodium for inj 1 gm .......... 18 cefotetan disodium for inj 10 gm ........ 18 cefotetan disodium for inj 2 gm .......... 18

CEFOXITIN INJ 1GM ......................... 18 CEFOXITIN INJ 2GM ......................... 18 cefoxitin sodium for inj 10 gm ........... 18 cefoxitin sodium for iv soln 1 gm ....... 18 cefoxitin sodium for iv soln 2 gm ....... 18 cefpodoxime proxetil for susp 100 mg/5ml .......................................... 19 cefpodoxime proxetil for susp 50 mg/5ml ..................................................... 19 cefpodoxime proxetil tab 100 mg ....... 19 cefpodoxime proxetil tab 200 mg ....... 19 cefprozil for susp 125 mg/5ml ........... 18 cefprozil for susp 250 mg/5ml ........... 18 cefprozil tab 250 mg ........................ 18 cefprozil tab 500 mg ........................ 18 ceftazidime for inj 1 gm .................... 19 ceftazidime for inj 2 gm .................... 19 ceftazidime for inj 6 gm .................... 19 CEFTAZIDIME/ SOL D5W 1GM ........... 19 CEFTAZIDIME/ SOL D5W 2GM ........... 19 ceftibuten cap 400 mg ...................... 19 ceftibuten for susp 180 mg/5ml ......... 19 CEFTIN SUS 125/5ML ....................... 18 CEFTIN SUS 250/5ML ....................... 18 CEFTRIAX/DEX INJ 1GM ................... 19 CEFTRIAX/DEX INJ 2GM ................... 19 ceftriaxone sodium for inj 1 gm ......... 19 ceftriaxone sodium for inj 10 gm ....... 19 ceftriaxone sodium for inj 2 gm ......... 19 ceftriaxone sodium for inj 250 mg ...... 19 ceftriaxone sodium for inj 500 mg ...... 19 ceftriaxone sodium for iv soln 1 gm .... 19 ceftriaxone sodium for iv soln 2 gm .... 19 ceftriaxone sodium in dextrose inj 20 mg/ml ........................................... 20 ceftriaxone sodium in dextrose inj 40 mg/ml ........................................... 20 cefuroxime axetil tab 250 mg ............ 19 cefuroxime axetil tab 500 mg ............ 19 CEFUROXIME INJ 7.5GM ................... 19 CEFUROXIME INJ 75GM .................... 19 cefuroxime sodium for inj 1.5 gm ...... 19 cefuroxime sodium for inj 7.5 gm ...... 19 cefuroxime sodium for inj 750 mg ...... 19 cefuroxime sodium for iv soln 1.5 gm . 19 CELEBREX CAP 100MG ....................... 1 CELEBREX CAP 200MG ....................... 1 CELEBREX CAP 400MG ....................... 1

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CELEBREX CAP 50MG ......................... 1 celecoxib cap 100 mg ........................ 1 celecoxib cap 200 mg ........................ 1 celecoxib cap 400 mg ........................ 1 celecoxib cap 50 mg .......................... 1 CELESTONE INJ SOLUSPAN.............. 130 CELEXA TAB 10MG ........................... 83 CELEXA TAB 20MG ........................... 83 CELEXA TAB 40MG ........................... 83 CELLCEPT IV INJ 500MG .................. 166 CELLUGEL SOL 2% ......................... 219 CELLULAR CAP SECURITY ................ 176 CELONTIN CAP 300MG ...................... 73 CENTANY AT KIT 2% ...................... 201 CENTANY OIN 2% .......................... 201 CENTRUM LIQ ................................ 177 CEO-TWO SUP ............................... 144 CEPACOL SORE LOZ COATING ......... 213 cephalexin cap 250 mg ..................... 18 cephalexin cap 500 mg ..................... 18 cephalexin cap 750 mg ..................... 18 cephalexin for susp 125 mg/5ml ......... 18 cephalexin for susp 250 mg/5ml ......... 18 cephalexin tab 250 mg ...................... 18 cephalexin tab 500 mg ...................... 18 CEPROTIN INJ 1000UNIT ................. 161 CEPROTIN INJ 500 UNIT .................. 161 CERALYTE 70 LIQ ........................... 170 ceramax cre .................................. 210 CERDELGA CAP 84MG ..................... 134 CEREBYX INJ 100/2ML ...................... 73 CEREBYX INJ 500/10ML .................... 73 CERVIDIL VAG MIS 10MG INS .......... 134 CESAMET CAP 1MG ......................... 140 cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) ....................................... 186 cetirizine hcl tab 5 mg ..................... 187 CETROTIDE KIT 0.25MG .................. 130 cevimeline hcl cap 30 mg ................ 150 cgh control syp pe .......................... 188 CHANTIX PAK 0.5& 1MG .................. 111 CHANTIX PAK 1MG ......................... 111 CHANTIX TAB 0.5MG ...................... 111 chateal tab 0.15/30 ........................ 125 CHEMET CAP 100MG ....................... 161 CHEMSTRIP TES STRIPS .................. 119 CHENODAL TAB 250MG ................... 142 CHERACOL-D LIQ 100-10/5 ............. 188

chest conges tab 20-400mg ............. 188 chest conges tab 400mg .................. 192 CHEWABLE CHW IRON .................... 177 child silfed liq 15mg/5ml .................. 192 childrens chw pepto ........................ 139 chld allergy liq 12.5/5ml .................. 187 chld asafree elx 80/2.5ml ................... 1 chloramphenicol sodium succinate for iv inj 1 gm ......................................... 34 CHLORASEPTIC LOZ TOTAL .............. 213 chlordiazepoxide hcl cap 10 mg ......... 71 chlordiazepoxide hcl cap 25 mg ......... 71 chlordiazepoxide hcl cap 5 mg ........... 71 chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg ................................. 141 chlordiazepoxide-amitriptyline tab 10-25 mg ................................................ 81 chlordiazepoxide-amitriptyline tab 5-12.5 mg ................................................ 81 chloroquine phosphate tab 250 mg .... 27 chloroquine phosphate tab 500 mg .... 27 chlorothiazide sodium for inj 500 mg .. 65 chlorothiazide tab 250 mg ................ 65 chlorothiazide tab 500 mg ................ 65 CHLORPROMAZ INJ 25MG/ML ............ 94 CHLORPROMAZ INJ 50MG/2ML .......... 94 chlorpromazine hcl tab 10 mg ........... 94 chlorpromazine hcl tab 100 mg .......... 95 chlorpromazine hcl tab 200 mg .......... 95 chlorpromazine hcl tab 25 mg ........... 95 chlorpromazine hcl tab 50 mg ........... 95 chlorpropamide tab 100 mg ............. 118 chlorpropamide tab 250 mg ............. 118 chlorthalidone tab 25 mg .................. 65 chlorthalidone tab 50 mg .................. 65 chlorzoxazone tab 500 mg ............... 108 CHOLBAM CAP 250MG ..................... 146 CHOLBAM CAP 50MG ....................... 146 cholecalciferol cap 400 unit .............. 177 cholecalciferol cap 5000 unit ............ 177 cholecalciferol oral liquid 400 unit/ml 177 cholecalciferol tab 2000 unit ............. 177 cholecalciferol tab 50000 unit ........... 177 cholestyramine light powder 4 gm/dose ..................................................... 55 cholestyramine light powder packets 4 gm ................................................ 55 cholestyramine powder 4 gm/dose ..... 55

240

cholestyramine powder packets 4 gm .. 55 choline & magnesium salicylates liq 500 mg/5ml ............................................ 2 choline & magnesium salicylates tab 1000 mg .......................................... 2 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) ....................... 55 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) ....................... 55 chromic chloride inj 40 mcg/10ml (4 mcg/ml) (elemental cr) ................... 173 ciclodan cre 0.77% ......................... 202 CICLODAN CRE KIT 0.77% .............. 202 ciclodan sol 8% .............................. 202 CICLODAN SOL KIT 8% ................... 202 ciclopirox gel 0.77% ....................... 202 ciclopirox kit 8% ............................ 202 ciclopirox olamine susp 0.77% (base equiv) ........................................... 202 ciclopirox shampoo 1% ................... 202 cidofovir iv inj 75 mg/ml ................... 31 cilostazol tab 100 mg ...................... 161 cilostazol tab 50 mg ........................ 161 CILOXAN OIN 0.3% OP ................... 215 CILOXAN SOL 0.3% OP ................... 215 cimetidine hcl soln 300 mg/5ml ........ 142 cimetidine tab 200 mg .................... 142 cimetidine tab 300 mg .................... 142 cimetidine tab 400 mg .................... 142 cimetidine tab 800 mg .................... 142 CIMZIA KIT ................................... 163 CIMZIA KIT STARTER ...................... 163 CIMZIA PREFL KIT 200MG/ML .......... 163 CINRYZE SOL 500 UNIT .................. 160 CIPRO HC SUS OTIC ....................... 220 CIPRODEX SUS 0.3-0.1% ................ 220 ciprofloxacin 200 mg/100ml in d5w ..... 21 ciprofloxacin 400 mg/200ml in d5w ..... 21 ciprofloxacin hcl ophth soln 0.3% ..... 215 ciprofloxacin hcl otic soln 0.2% (base equivalent) .................................... 221 ciprofloxacin hcl tab 100 mg (base equiv) ..................................................... 21 ciprofloxacin hcl tab 250 mg (base equiv) ..................................................... 21 ciprofloxacin hcl tab 500 mg (base equiv) ..................................................... 21 ciprofloxacin hcl tab 750 mg (base equiv)

..................................................... 21 ciprofloxacin iv soln 200 mg/20ml (1%) ..................................................... 21 ciprofloxacin iv soln 400 mg/40ml (1%) ..................................................... 21 ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq) ........................... 21 ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq) ............................ 21 cisplatin inj 100 mg/100ml (1 mg/ml) 36 cisplatin inj 200 mg/200ml (1 mg/ml) 36 cisplatin inj 50 mg/50ml (1 mg/ml) .... 36 citalopram hydrobromide oral soln 10 mg/5ml .......................................... 83 citalopram hydrobromide tab 10 mg (base equiv) ................................... 83 citalopram hydrobromide tab 20 mg (base equiv) ................................... 83 citalopram hydrobromide tab 40 mg (base equiv) ................................... 83 CITRACAL+D3 CHW 250-500 ........... 177 CITRANATAL CAP HARMONY ............. 177 CITRANATAL TAB RX ....................... 177 cladribine iv soln 10 mg/10ml (1 mg/ml) ..................................................... 37 CLAFORAN INJ 10GM ....................... 20 CLAFORAN INJ 1GM ......................... 20 CLAFORAN INJ 2GM ......................... 20 CLAFORAN INJ 500MG ...................... 20 CLARINEX SYP 0.5MG/ML ................ 187 CLARINEX TAB 5MG ........................ 187 CLARINEX-D TAB 2.5-120 ................ 186 clarithromycin for susp 125 mg/5ml ... 20 clarithromycin for susp 250 mg/5ml ... 20 clarithromycin tab 250 mg ................ 20 clarithromycin tab 500 mg ................ 20 clarithromycin tab er 24hr 500 mg ..... 20 CLARITIN CAP 10MG ....................... 187 CLARITIN CHW 5MG ....................... 187 CLARITIN RDT TAB 5MG .................. 187 clear away liq 17% ......................... 210 clearplex v gel 5% .......................... 198 clemastine fumarate tab 2.68 mg ..... 187 CLEOCIN CAP 150MG ....................... 34 CLEOCIN CAP 300MG ....................... 34 CLEOCIN CAP 75MG ......................... 34 CLEOCIN CRE 2% VAG .................... 153 CLEOCIN PED SOL 75MG/5ML ........... 34

241

CLEOCIN PHOS INJ 300MG ................ 34 CLEOCIN PHOS INJ 600MG ................ 34 CLEOCIN PHOS INJ 900MG ................ 34 CLEOCIN PHOS INJ 9GM/60ML ........... 34 CLEOCIN SUP 100MG ...................... 153 CLEOCIN/D5W INJ 300MG ................. 34 CLEOCIN/D5W INJ 600MG ................. 34 CLEOCIN/D5W INJ 900MG ................. 34 CLEOCIN-T GEL 1% ........................ 198 CLEOCIN-T LOT 1% ........................ 198 CLEOCIN-T PAD 1% ........................ 198 CLEOCIN-T SOL 1% ........................ 198 CLEVIPREX EMU 0.5MG/ML ................ 62 CLIMARA DIS 0.025MG ................... 128 CLIMARA DIS 0.0375MG .................. 129 CLIMARA DIS 0.05MG ..................... 128 CLIMARA DIS 0.06MG ..................... 128 CLIMARA DIS 0.075MG ................... 129 CLIMARA DIS 0.1MG ....................... 128 CLIMARA PRO DIS WEEKLY .............. 128 CLIN SINGLE KIT USE ....................... 34 CLINDACIN KIT PAC 1% .................. 198 clindacin-p pad 1% ......................... 198 CLINDAGEL GEL 1% ....................... 198 clindamycin hcl cap 150 mg ............... 34 clindamycin hcl cap 300 mg ............... 34 clindamycin hcl cap 75 mg ................. 34 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) ........................ 34 clindamycin phosphate foam 1% ...... 198 clindamycin phosphate gel 1% ......... 198 clindamycin phosphate in d5w iv soln 300 mg/50ml ................................... 34 clindamycin phosphate in d5w iv soln 600 mg/50ml ................................... 34 clindamycin phosphate in d5w iv soln 900 mg/50ml ................................... 34 clindamycin phosphate inj 300 mg/2ml 34 clindamycin phosphate inj 600 mg/4ml 34 clindamycin phosphate inj 9 gm/60ml . 34 clindamycin phosphate inj 900 mg/6ml 34 clindamycin phosphate iv soln 300 mg/2ml ........................................... 34 clindamycin phosphate iv soln 900 mg/6ml ........................................... 34 clindamycin phosphate lotion 1% ...... 198 clindamycin phosphate soln 1% ........ 198 clindamycin phosphate vaginal cream 2%

.................................................... 153 clindamycin phosphate-benzoyl peroxide gel 1-5% ....................................... 198 clindamycin phosphate-tretinoin gel 1.2-0.025% ......................................... 198 CLINDESSE CRE 2% ....................... 154 CLINIMIX E INJ 2.75/D10 ................ 171 CLINIMIX E INJ 2.75/D5W ............... 171 CLINIMIX E INJ 4.25/D10 ................ 171 CLINIMIX E INJ 4.25/D25 ................ 171 CLINIMIX E INJ 4.25/D5W ............... 171 CLINIMIX E INJ 5%/D15W ............... 171 CLINIMIX E INJ 5%/D20W ............... 171 CLINIMIX E INJ 5%/D25W ............... 171 CLINIMIX INJ 2.75/D5W .................. 171 CLINIMIX INJ 4.25/D10 ................... 171 CLINIMIX INJ 4.25/D20 ................... 171 CLINIMIX INJ 4.25/D25 ................... 171 CLINIMIX INJ 4.25/D5W .................. 171 CLINIMIX INJ 5%/D15W .................. 171 CLINIMIX INJ 5%/D20W .................. 171 CLINIMIX INJ 5%/D25W .................. 171 CLINITEST TAB 2 DROP ................... 119 clinpro 5000 pst 1.1% ..................... 213 clobetasol e cre 0.05% .................... 207 clobetasol propionate cream 0.05% .. 207 clobetasol propionate emulsion foam 0.05% .......................................... 208 clobetasol propionate foam 0.05% .... 208 clobetasol propionate gel 0.05% ....... 208 clobetasol propionate lotion 0.05% ... 208 clobetasol propionate oint 0.05% ...... 208 clobetasol propionate soln 0.05% ..... 208 clobetasol propionate spray 0.05% ... 208 CLOBEX LOT 0.05% ........................ 208 CLOBEX SHA 0.05% ........................ 208 CLOBEX SPR 0.05% ........................ 208 clocortolone pivalate cream 0.1% ..... 206 clodan sha 0.05% ........................... 208 CLODERM CRE 0.1% PMP ................ 206 clomipramine hcl cap 25 mg .............. 72 clomipramine hcl cap 50 mg .............. 72 clomipramine hcl cap 75 mg .............. 72 clonazepam orally disintegrating tab 0.125 mg ....................................... 71 clonazepam orally disintegrating tab 0.25 mg ................................................ 71 clonazepam orally disintegrating tab 0.5

242

mg ................................................. 71 clonazepam orally disintegrating tab 1 mg ................................................. 71 clonazepam orally disintegrating tab 2 mg ................................................. 71 clonazepam tab 0.5 mg ..................... 71 clonazepam tab 1 mg ........................ 71 clonazepam tab 2 mg ........................ 72 clonidine hcl inj (for epidural infusion) 100 mcg/ml ...................................... 2 clonidine hcl inj (for epidural infusion) 500 mcg/ml ...................................... 2 clonidine hcl tab 0.1 mg .................... 49 clonidine hcl tab 0.2 mg .................... 49 clonidine hcl tab 0.3 mg .................... 49 clonidine hcl tab er 12hr 0.1 mg ......... 97 clonidine hcl td patch weekly 0.1 mg/24hr ......................................... 49 clonidine hcl td patch weekly 0.2 mg/24hr ......................................... 49 clonidine hcl td patch weekly 0.3 mg/24hr ......................................... 49 clopidogrel bisulfate tab 300 mg (base equiv) ........................................... 162 clopidogrel bisulfate tab 75 mg (base equiv) ........................................... 162 clorazepate dipotassium tab 15 mg ..... 72 clorazepate dipotassium tab 3.75 mg .. 72 clorazepate dipotassium tab 7.5 mg .... 72 clorpres tab 0.1-15mg ...................... 67 clorpres tab 0.2-15mg ...................... 67 clorpres tab 0.3-15mg ...................... 67 clotrimazole cre 1% vag .................. 154 clotrimazole cre 2% ........................ 154 clotrimazole cream 1% ................... 202 clotrimazole soln 1% ...................... 202 clotrimazole troche 10 mg ................. 25 clotrimazole w/ betamethasone cream 1-0.05% .......................................... 202 clotrimazole w/ betamethasone lotion 1-0.05% .......................................... 202 clozapine orally disintegrating tab 100 mg ................................................. 90 clozapine orally disintegrating tab 12.5 mg ................................................. 90 clozapine orally disintegrating tab 150 mg ................................................. 90 clozapine orally disintegrating tab 200

mg ................................................ 90 clozapine orally disintegrating tab 25 mg ..................................................... 90 clozapine tab 100 mg ....................... 90 clozapine tab 200 mg ....................... 90 clozapine tab 25 mg ......................... 90 clozapine tab 50 mg ......................... 90 CLOZARIL TAB 100MG ...................... 90 CLOZARIL TAB 25MG ....................... 90 COAGADEX INJ 250UNIT ................. 157 COAGADEX INJ 500UNIT ................. 157 COARTEM TAB 20-120MG ................. 27 cocaine hcl soln 4% ........................ 209 cod liver chw w/vit .......................... 177 CODAR AR LIQ 2-8/5ML................... 188 CODAR D LIQ 30-8/5ML .................. 188 codar gf liq 200-8/5 ........................ 188 codeine sulfate tab 15 mg ................... 6 codeine sulfate tab 30 mg ................... 6 codeine sulfate tab 60 mg ................... 6 COGENTIN INJ 1MG/ML .................... 87 COLAZAL CAP 750MG ...................... 143 colchicine cap 0.6 mg ......................... 1 colchicine tab 0.6 mg ......................... 1 colchicine w/ probenecid tab 0.5-500 mg ....................................................... 1 cold & flu liq day/nght ..................... 188 cold & flu liq nighttim ...................... 186 cold head tab cong dt ...................... 188 cold mult-sy tab daytime ................. 188 cold/allergy elx children ................... 186 cold/cough elx child ........................ 188 cold/cough elx children .................... 188 COLESTID GRA 5GM ........................ 55 COLESTID POW 5GM ........................ 55 COLESTID TAB 1GM ......................... 55 colestipol hcl granule packets 5 gm .... 55 colestipol hcl granules 5 gm .............. 55 colestipol hcl tab 1 gm ..................... 55 colistimethate sodium for inj 150 mg .. 34 COLY-MYCIN M INJ 150MG ................ 34 COLY-MYCIN S SUS OTIC ................ 220 COLYTE/FLAVR SOL PACKS .............. 144 COMBIGAN SOL 0.2/0.5% ............... 220 COMBIPATCH DIS .05/.14 ................ 128 COMBIPATCH DIS .05/.25 ................ 128 COMBIVENT AER 20-100 ................. 186 COMBIVIR TAB 150-300 ................... 27

243

COMETRIQ KIT 100MG ...................... 40 COMETRIQ KIT 140MG ...................... 40 COMETRIQ KIT 60MG ........................ 40 COMFORT EZ MIS 33GX5MM ............ 119 COMFORT EZ MIS 33GX6MM ............ 119 COMFORT EZ MIS 33GX8MM ............ 119 COMP PRNATAL MIS DHA ................ 177 COMPLERA TAB ................................ 27 complete kit lice ............................. 212 COMPLETE NAT PAK DHA ................. 177 compro sup 25mg .......................... 140 COMTAN TAB 200MG ........................ 87 CONCEPT DHA CAP ......................... 177 CONCEPT OB CAP ........................... 177 CONCEPTION KIT ........................... 125 CONCERTA TAB 18MG ....................... 97 CONCERTA TAB 27MG ....................... 97 CONCERTA TAB 36MG ....................... 97 CONCERTA TAB 54MG ....................... 97 CONDYLOX GEL 0.5% ..................... 210 CONDYLOX SOL 0.5% ..................... 210 CONGESTAC TAB 60-400MG ............ 188 constulose sol 10gm/15 .................. 144 CONTRAVE TAB 8-90MG .................. 123 controlrx cre 1.1% ......................... 213 CONZIP CAP 100MG .......................... 6 CONZIP CAP 200MG .......................... 6 CONZIP CAP 300MG .......................... 6 cooling burn spr relief ..................... 209 COPAXONE INJ 20MG/ML................. 108 COPAXONE INJ 40MG/ML................. 108 COPEGUS TAB 200MG ....................... 31 CORDARONE TAB 200MG .................. 54 CORDRAN CRE 0.05% ..................... 206 CORDRAN LOT 0.05% ..................... 206 COREG CR CAP 10MG ....................... 59 COREG CR CAP 20MG ....................... 59 COREG CR CAP 40MG ....................... 59 COREG CR CAP 80MG ....................... 59 COREG TAB 12.5MG ......................... 59 COREG TAB 25MG ............................ 59 COREG TAB 3.125MG ........................ 59 COREG TAB 6.25MG ......................... 59 CORGARD TAB 20MG ........................ 59 CORGARD TAB 40MG ........................ 59 CORGARD TAB 80MG ........................ 60 CORIFACT KIT ............................... 157 CORLANOR TAB 5MG ........................ 66

CORLANOR TAB 7.5MG ..................... 66 CORLOPAM INJ 10MG/ML .................. 67 corn&callus kit 17% ........................ 210 CORTEF TAB 10MG ......................... 130 CORTEF TAB 20MG ......................... 130 CORTEF TAB 5MG ........................... 130 CORTENEMA ENE 100MG ................. 144 CORTIFOAM AER 90MG ................... 144 cortisone acetate tab 25 mg ............. 130 CORTISPORIN CRE 0.5% ................. 201 CORTISPORIN OIN 1% .................... 201 CORVERT INJ 1MG/10ML .................. 54 corvita 150 tab ............................... 177 corvita tab ..................................... 177 CORVITE 150 TAB........................... 177 CORVITE FE TAB ............................ 177 CORVITE TAB ................................. 177 CORZIDE TAB 40-5MG ..................... 58 CORZIDE TAB 80-5MG ..................... 58 COSENTYX INJ 150MG/ML ............... 203 COSENTYX PEN INJ 300DOSE ........... 203 COSMEGEN INJ 0.5MG ..................... 42 COSOPT PF SOL ............................. 217 COSOPT SOL 22.3-6.8 ..................... 217 COTELLIC TAB 20MG ........................ 40 cough & sore liq thrt day ................. 188 cough dm sus 30mg/5ml ................. 190 cough drops loz 5.4mg .................... 213 cough drops loz menthol .................. 214 coughtab tab 200mg ....................... 192 COUMADIN TAB 10MG ..................... 156 COUMADIN TAB 1MG ...................... 156 COUMADIN TAB 2.5MG .................... 156 COUMADIN TAB 2MG ...................... 156 COUMADIN TAB 3MG ...................... 156 COUMADIN TAB 4MG ...................... 156 COUMADIN TAB 5MG ...................... 156 COUMADIN TAB 6MG ...................... 156 COUMADIN TAB 7.5MG .................... 156 COZAAR TAB 100MG ........................ 53 COZAAR TAB 25MG .......................... 53 COZAAR TAB 50MG .......................... 53 creamy face liq wash 4% ................. 198 CREON CAP 12000UNT .................... 148 CREON CAP 24000UNT .................... 148 CREON CAP 3000UNIT ..................... 147 CREON CAP 36000UNT .................... 148 CREON CAP 6000UNIT ..................... 147

244

CREO-TERPIN SYP 10/15ML ............. 190 CRESEMBA CAP 186 MG .................... 25 CRESEMBA INJ 372MG ...................... 25 CRESTOR TAB 10MG ......................... 56 CRESTOR TAB 20MG ......................... 56 CRESTOR TAB 40MG ......................... 56 CRESTOR TAB 5MG ........................... 56 CRINONE GEL 4% VAG ................... 136 CRIXIVAN CAP 200MG ...................... 28 CRIXIVAN CAP 400MG ...................... 28 CROFAB INJ ................................... 163 cromolyn sodium ophth soln 4% ....... 216 cromolyn sodium oral conc 100 mg/5ml ................................................... 146 cromolyn sodium soln nebu 20 mg/2ml ................................................... 193 CUBICIN SOL 500MG ........................ 34 CULTURELLE CHW KIDS .................. 146 CULTURELLE PAK KIDS ................... 146 cupric chloride inj 0.4 mg/ml ........... 173 CURITY HYPER MIS 1/2"X15' ............ 213 CUROSURF SUS 120/1.5 ................. 194 CUTIVATE CRE 0.05% ..................... 206 CUTIVATE LOT 0.05% ..................... 206 CUVPOSA SOL 1MG/5ML ................. 141 cvs allergy chw 12.5mg ................... 187 cvs antacid sus supreme ................. 139 CVS KETONE TES CARE ................... 119 CVS PRENATAL CHW GUMMY ........... 177 cvs sore loz throat .......................... 214 cyanocobalamin inj 1000 mcg/ml ..... 177 CYANOKIT INJ 5GM ........................ 122 CYCLESSA PAK............................... 127 CYCLOBENZAPR PAK PAX ................ 109 cyclobenzaprine hcl tab 10 mg ......... 109 cyclobenzaprine hcl tab 5 mg ........... 109 cyclobenzaprine hcl tab 7.5 mg ........ 109 CYCLOGYL SOL 0.5% OP ................. 220 CYCLOGYL SOL 1% OP .................... 220 CYCLOGYL SOL 2% OP .................... 220 CYCLOMYDRIL SOL OP .................... 220 cyclopentolate hcl ophth soln 1% ...... 220 cyclopentolate hcl ophth soln 2% ...... 220 cyclophosphamide for inj 1 gm ........... 36 cyclophosphamide for inj 2 gm ........... 36 cyclophosphamide for inj 500 mg ....... 36 cycloserine cap 250 mg ..................... 30 cyclosporine cap 100 mg ................. 166

cyclosporine cap 25 mg ................... 166 cyclosporine iv soln 50 mg/ml .......... 166 cyclosporine modified cap 100 mg .... 166 cyclosporine modified cap 25 mg ...... 166 CYKLOKAPRON INJ 100MG/ML .......... 160 CYMBALTA CAP 20MG ...................... 82 CYMBALTA CAP 30MG ...................... 82 CYMBALTA CAP 60MG ...................... 82 cyproheptadine hcl syrup 2 mg/5ml .. 187 cyproheptadine hcl tab 4 mg ............ 187 cyred tab ....................................... 125 CYSTADANE POW ........................... 134 CYSTAGON CAP 150MG ................... 151 CYSTAGON CAP 50MG ..................... 151 CYSTARAN SOL 0.44% .................... 219 cysteine hcl inj 50 mg/ml................. 171 cytarabine inj 20 mg/ml ................... 37 cytarabine inj pf 100 mg/ml .............. 37 cytarabine inj pf 20 mg/ml ................ 37 CYTOGAM INJ ................................ 164 CYTOMEL TAB 25MCG ..................... 136 CYTOMEL TAB 50MCG ..................... 136 CYTOMEL TAB 5MCG ....................... 136 CYTOTEC TAB 100MCG .................... 148 CYTOTEC TAB 200MCG .................... 148 CYTOVENE INJ 500MG ...................... 31 cytra k gra crystals ......................... 151 cytra-3 syp .................................... 152 D d 400 chw 400unit .......................... 177 d 400 tab 400unit ........................... 177 D.H.E. 45 INJ 1MG/ML ..................... 104 D10W/NACL INJ 0.2% ..................... 172 D10W/NACL INJ 0.225% ................. 172 d3 cap 1000unit ............................. 177 d3 max st dro 5000unit ................... 177 d3 super str cap 2000unit ................ 177 D5W/LYTES INJ #48 ....................... 172 D5W/NACL INJ 0.3% ....................... 172 dacarbazine for inj 100 mg ............... 36 dacarbazine for inj 200 mg ............... 36 DACOGEN INJ 50MG ........................ 37 DAKLINZA TAB 30MG ....................... 31 DAKLINZA TAB 60MG ....................... 31 DAKLINZA TAB 90MG ....................... 31 DALIRESP TAB 500MCG ................... 195 danazol cap 100 mg ........................ 127 danazol cap 200 mg ........................ 127

245

danazol cap 50 mg ......................... 127 dandruff sha 1% ............................ 203 DANTRIUM CAP 25MG ..................... 109 DANTRIUM CAP 50MG ..................... 109 DANTRIUM IV INJ 20MG .................. 109 dantrolene sodium cap 100 mg ........ 109 dantrolene sodium cap 25 mg .......... 109 dantrolene sodium cap 50 mg .......... 109 dapsone tab 100 mg ......................... 34 dapsone tab 25 mg ........................... 34 DARAPRIM TAB 25MG ....................... 27 daunorubicin hcl inj 5 mg/ml (base equiv) ............................................. 42 day time liq cold/flu ........................ 188 day time liq cough .......................... 190 dayhist alrg tab 12 hour .................. 187 DAYPRO TAB 600MG .......................... 2 dayquil sev liq cold/flu .................... 188 DAYTRANA DIS 10MG/9HR ................ 97 DAYTRANA DIS 15MG/9HR ................ 98 DAYTRANA DIS 20MG/9HR ................ 98 DAYTRANA DIS 30MG/9HR ................ 98 DDAVP INJ 4MCG/ML ...................... 138 DDAVP SOL 0.01% ......................... 138 DDAVP SPR 0.01% ......................... 138 DDAVP TAB 0.1MG ......................... 138 DDAVP TAB 0.2MG ......................... 138 DDROPS LIQ 1000UNIT ................... 177 DEBACTEROL SOL 30-50% .............. 214 DECARA CAP 25000UNT .................. 177 decitabine for inj 50 mg .................... 37 decongestant tab 120mg er ............. 192 deferoxamine mesylate for inj 2 gm .. 161 deferoxamine mesylate for inj 500 mg ................................................... 161 DELESTROGEN INJ 10MG/ML ........... 128 DELESTROGEN INJ 20MG/ML ........... 128 DELESTROGEN INJ 40MG/ML ........... 128 DELFLEX-LC/ SOL 2.5% DEX ............ 153 DELTEC COZMO MIS INL PUMP ......... 119 DELZICOL CAP 400MG .................... 143 DEMADEX TAB 10MG ........................ 65 DEMADEX TAB 20MG ........................ 65 demeclocycline hcl tab 150 mg ........... 24 demeclocycline hcl tab 300 mg ........... 24 DEMEROL INJ 100/2ML ...................... 7 DEMEROL INJ 100MG/ML .................... 7 DEMEROL INJ 25MG/0.5 ..................... 6

DEMEROL INJ 25MG/ML ...................... 6 DEMEROL INJ 50MG/ML ...................... 7 DEMEROL INJ 75MG/1.5 ..................... 7 DEMEROL INJ 75MG/ML ...................... 7 DEMEROL TAB 100MG ........................ 7 DEMSER CAP 250MG ........................ 49 DENAVIR CRE 1% ........................... 210 DEPACON INJ 100MG/ML .................. 73 DEPAKENE CAP 250MG ..................... 73 DEPAKENE SOL 250/5ML .................. 73 DEPAKOTE ER TAB 250MG ................ 74 DEPAKOTE ER TAB 500MG ................ 74 DEPAKOTE SPR CAP 125MG .............. 74 DEPAKOTE TAB 125MG DR ................ 74 DEPAKOTE TAB 250MG DR ................ 74 DEPAKOTE TAB 500MG DR ................ 74 DEPODUR INJ 10MG/ML ..................... 7 DEPODUR INJ 15/1.5ML ..................... 7 DEPO-ESTRADI INJ 5MG/ML ............. 128 DEPO-MEDROL INJ 20MG/ML ............ 130 DEPO-MEDROL INJ 40MG/ML ............ 130 DEPO-MEDROL INJ 80MG/ML ............ 130 DEPO-PROVERA INJ 150MG/ML ........ 125 DEPO-PROVERA INJ 400/ML .............. 39 DEPO-SQ PROV INJ 104 .................. 125 DEPO-TESTOST INJ 100MG/ML ......... 112 DEPO-TESTOST INJ 200MG/ML ......... 112 dermacinrx kit prizopak ................... 209 DERMACINRX KIT SILAPAK .............. 204 DERMACINRX PAK LEXITRAL ............ 201 DERMAGRAFT MIS .......................... 210 DERMA-SMOOTH OIL /FS BODY ........ 205 DERMA-SMOOTH OIL /FS SCLP ......... 205 DERMASORB HC KIT 2% ................. 205 DERMASORB TA KIT 0.1% ............... 206 DERMASORB XM KIT 39% ................ 208 DERMATOP CRE 0.1% ..................... 206 DERMATOP OIN 0.1% ..................... 206 DERMAWERX KIT SURGICAL ............ 210 DERMOTIC OIL 0.01% ..................... 221 DESCOVY TAB 200/25 ...................... 27 DESFERAL INJ 500MG ..................... 161 desgen dm tab ............................... 188 desipramine hcl tab 10 mg ................ 85 desipramine hcl tab 100 mg .............. 86 desipramine hcl tab 150 mg .............. 86 desipramine hcl tab 25 mg ................ 86 desipramine hcl tab 50 mg ................ 86

246

desipramine hcl tab 75 mg ................ 86 desloratadine tab 5 mg ................... 187 desloratadine tab orally disintegrating 2.5 mg ......................................... 187 desloratadine tab orally disintegrating 5 mg ............................................... 187 desmopressin acetate inj 4 mcg/ml ... 138 desmopressin acetate nasal soln 0.01% (refrigerated) ................................. 138 desmopressin acetate nasal spray soln 0.01% .......................................... 138 desmopressin acetate nasal spray soln 0.01% (refrigerated) ...................... 138 desmopressin acetate tab 0.1 mg ..... 138 desmopressin acetate tab 0.2 mg ..... 138 DESOGEN-28 TAB .......................... 125 DESONATE GEL 0.05% .................... 205 desonide cream 0.05% ................... 206 desonide lotion 0.05% .................... 206 desonide oint 0.05% ....................... 206 DESOWEN CRE 0.05% .................... 206 DESOWEN LOT 0.05% .................... 206 desoximetasone cream 0.05% ......... 206 desoximetasone cream 0.25% ......... 205 desoximetasone gel 0.05% .............. 205 desoximetasone oint 0.05% ............. 206 desoximetasone oint 0.25% ............. 205 DESVENLAFAX TAB 100MG ER ............ 82 DESVENLAFAX TAB 50MG ER ............. 82 desvenlafaxine succinate tab er 24hr 100 mg (base equiv) ............................... 82 desvenlafaxine succinate tab er 24hr 25 mg (base equiv) ............................... 82 desvenlafaxine succinate tab er 24hr 50 mg (base equiv) ............................... 82 desvenlafaxine tab er 24hr 100 mg ..... 82 desvenlafaxine tab er 24hr 50 mg ....... 82 DETROL LA CAP 2MG ...................... 153 DETROL LA CAP 4MG ...................... 153 DETROL TAB 1MG ........................... 153 DETROL TAB 2MG ........................... 153 dexamethasone elixir 0.5 mg/5ml ..... 130 dexamethasone sod phosphate preservative free inj 10 mg/ml ......... 130 dexamethasone sodium phosphate inj 10 mg/ml .......................................... 130 dexamethasone sodium phosphate inj 100 mg/10ml ................................. 130

dexamethasone sodium phosphate inj 120 mg/30ml ................................. 130 dexamethasone sodium phosphate inj 20 mg/5ml ......................................... 130 dexamethasone sodium phosphate inj 4 mg/ml .......................................... 130 dexamethasone sodium phosphate ophth soln 0.1% ...................................... 216 dexamethasone soln 0.5 mg/5ml ...... 130 dexamethasone tab 0.5 mg .............. 130 dexamethasone tab 0.75 mg ............ 130 dexamethasone tab 1 mg ................ 130 dexamethasone tab 1.5 mg .............. 130 dexamethasone tab 2 mg ................ 130 dexamethasone tab 4 mg ................ 130 dexamethasone tab 6 mg ................ 130 DEXEDRINE CAP 10MG CR ................ 98 DEXEDRINE CAP 15MG CR ................ 98 DEXEDRINE CAP 5MG CR .................. 98 DEXILANT CAP 30MG DR ................. 148 DEXILANT CAP 60MG DR ................. 148 dexmedetomidine hcl inj 200 mcg/2ml (for iv infusion) .............................. 103 dexmethylphenidate hcl cap er 24 hr 10 mg ................................................ 98 dexmethylphenidate hcl cap er 24 hr 15 mg ................................................ 98 dexmethylphenidate hcl cap er 24 hr 20 mg ................................................ 98 dexmethylphenidate hcl cap er 24 hr 25 mg ................................................ 98 dexmethylphenidate hcl cap er 24 hr 30 mg ................................................ 98 dexmethylphenidate hcl cap er 24 hr 35 mg ................................................ 98 dexmethylphenidate hcl cap er 24 hr 40 mg ................................................ 98 dexmethylphenidate hcl cap er 24 hr 5 mg ................................................ 98 dexmethylphenidate hcl tab 10 mg .... 98 dexmethylphenidate hcl tab 2.5 mg ... 98 dexmethylphenidate hcl tab 5 mg ...... 98 DEXPAK PAK 10 DAY ....................... 130 DEXPAK PAK 13 DAY ....................... 130 DEXPAK PAK 6 DAY ......................... 130 dexrazoxane for inj 250 mg .............. 42 dexrazoxane for inj 500 mg .............. 42 dextroamphetamine sulfate cap er 24hr

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10 mg ............................................ 98 dextroamphetamine sulfate cap er 24hr 15 mg ............................................ 98 dextroamphetamine sulfate cap er 24hr 5 mg ................................................. 98 dextroamphetamine sulfate oral solution 5 mg/5ml ........................................ 98 dextroamphetamine sulfate tab 10 mg 98 dextroamphetamine sulfate tab 5 mg .. 98 dextrose 10% w/ sodium chloride 0.45% ................................................... 172 dextrose 2.5% w/ sodium chloride 0.45% .......................................... 172 dextrose 5% in lactated ringers ........ 172 dextrose 5% w/ sodium chloride 0.2% ................................................... 172 dextrose 5% w/ sodium chloride 0.225% ................................................... 172 dextrose 5% w/ sodium chloride 0.33% ................................................... 172 dextrose 5% w/ sodium chloride 0.45% ................................................... 172 dextrose 5% w/ sodium chloride 0.9% ................................................... 172 dextrose inj 10% ............................ 171 DEXTROSE INJ 20% ....................... 171 dextrose inj 25% ............................ 171 dextrose inj 30% ............................ 171 DEXTROSE INJ 40% ....................... 171 dextrose inj 5% ............................. 171 dextrose inj 50% ............................ 171 dextrose inj 70% ............................ 171 DIAB CRE ...................................... 213 diabet tuss syp allergy .................... 187 DIABETIC CAP VITAMIN .................. 177 DIALYVITE TAB 3000 ...................... 177 DIALYVITE TAB 800/IRON ............... 177 DIAMOX SEQUE CAP 500MG CR ........ 218 diaper rash cre 10% ....................... 210 diaper rash cre 13% ....................... 210 diaper rash oin 40% ....................... 210 diaper rash oin creamy ................... 210 DIASTAT ACDL GEL 12.5-20 .............. 74 DIASTAT ACDL GEL 5-10MG .............. 74 DIASTAT PED GEL 2.5M GEL .............. 74 DIASTIX TES STRIPS ...................... 119 diazepam con 5mg/ml ....................... 72 DIAZEPAM INJ 10MG/2ML .................. 72

diazepam inj 5 mg/ml ...................... 72 diazepam oral soln 1 mg/ml .............. 72 diazepam rectal gel delivery system 10 mg ................................................ 74 diazepam rectal gel delivery system 2.5 mg ................................................ 74 diazepam rectal gel delivery system 20 mg ................................................ 74 diazepam tab 10 mg ........................ 72 diazepam tab 2 mg .......................... 72 diazepam tab 5 mg .......................... 72 dibromm chld liq 2.5-1-5 ................. 188 DICLEGIS TAB 10-10MG .................. 140 diclofenac potassium tab 50 mg ........... 2 diclofenac sodium (actinic keratoses) gel 3% ............................................... 200 diclofenac sodium gel 1% ................... 5 diclofenac sodium ophth soln 0.1% ... 216 diclofenac sodium soln 1.5% ............... 5 diclofenac sodium tab delayed release 25 mg .................................................. 2 diclofenac sodium tab delayed release 50 mg .................................................. 2 diclofenac sodium tab delayed release 75 mg .................................................. 2 diclofenac sodium tab er 24hr 100 mg .. 2 diclofenac w/ misoprostol tab delayed release 50-0.2 mg ............................. 4 diclofenac w/ misoprostol tab delayed release 75-0.2 mg ............................. 4 dicloxacillin sodium cap 250 mg ......... 23 dicloxacillin sodium cap 500 mg ......... 23 dicyclomine hcl cap 10 mg ............... 141 dicyclomine hcl inj 10 mg/ml ............ 141 dicyclomine hcl oral soln 10 mg/5ml .. 142 dicyclomine hcl tab 20 mg ............... 142 DI-DAK-SOL SOL 0.0125% .............. 204 didanosine delayed release capsule 125 mg ................................................ 29 didanosine delayed release capsule 200 mg ................................................ 29 didanosine delayed release capsule 250 mg ................................................ 29 didanosine delayed release capsule 400 mg ................................................ 29 diethylpropion hcl tab 25 mg ............ 123 diethylpropion hcl tab er 24hr 75 mg . 123 DIFFERIN CRE 0.1% ....................... 198

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DIFFERIN GEL 0.1% ....................... 198 DIFFERIN GEL 0.3% ....................... 198 DIFFERIN LOT 0.1% ....................... 199 DIFICID TAB 200MG ......................... 20 diflorasone diacetate cream 0.05% ... 205 diflorasone diacetate oint 0.05% ...... 208 DIFLUCAN SUS 10MG/ML .................. 25 DIFLUCAN SUS 40MG/ML .................. 25 DIFLUCAN TAB 100MG ...................... 26 DIFLUCAN TAB 150MG ...................... 26 DIFLUCAN TAB 200MG ...................... 26 DIFLUCAN TAB 50MG ........................ 26 diflunisal tab 500 mg ......................... 3 DI-GEL SUS ................................... 139 digestive chw advantag ................... 146 DIGIFAB INJ 40MG ......................... 122 digitek tab 0.125mg ......................... 65 digitek tab 0.25mg ........................... 64 digoxin inj 0.25 mg/ml ...................... 65 digoxin oral soln 0.05 mg/ml ............. 65 dihydroergotamine mesylate inj 1 mg/ml ................................................... 104 dihydroergotamine mesylate nasal spray 4 mg/ml ........................................ 104 DILANTIN CAP 100MG ....................... 74 DILANTIN CAP 30MG ........................ 74 DILANTIN CHW 50MG ....................... 74 DILANTIN-125 SUS 125/5ML ............. 74 DILATRATE SR CAP 40MG .................. 68 DILAUDID LIQ 1MG/ML ...................... 7 DILAUDID TAB 2MG ........................... 7 DILAUDID TAB 4MG ........................... 7 DILAUDID TAB 8MG ........................... 7 diltiazem cap 240mg cd .................... 63 diltiazem cap 300mg cd .................... 63 diltiazem hcl cap er 12hr 120 mg ........ 63 diltiazem hcl cap er 12hr 60 mg ......... 63 diltiazem hcl cap er 12hr 90 mg ......... 63 diltiazem hcl cap er 24hr 120 mg ........ 63 diltiazem hcl cap er 24hr 180 mg ........ 63 diltiazem hcl cap er 24hr 240 mg ........ 63 diltiazem hcl coated beads cap er 24hr 120 mg ........................................... 63 diltiazem hcl coated beads cap er 24hr 180 mg ........................................... 63 diltiazem hcl coated beads cap er 24hr 360 mg ........................................... 63 diltiazem hcl extended release beads cap

er 24hr 120 mg ............................... 63 diltiazem hcl extended release beads cap er 24hr 180 mg ............................... 63 diltiazem hcl extended release beads cap er 24hr 240 mg ............................... 63 diltiazem hcl extended release beads cap er 24hr 300 mg ............................... 63 diltiazem hcl extended release beads cap er 24hr 360 mg ............................... 63 diltiazem hcl extended release beads cap er 24hr 420 mg ............................... 64 diltiazem hcl iv soln 125 mg/25ml (5 mg/ml) .......................................... 64 diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) .......................................... 64 diltiazem hcl iv soln 50 mg/10ml (5 mg/ml) .......................................... 64 diltiazem hcl tab 120 mg .................. 64 diltiazem hcl tab 30 mg .................... 64 diltiazem hcl tab 60 mg .................... 64 diltiazem hcl tab 90 mg .................... 64 DILTIAZEM INJ 100MG ..................... 64 DIOVAN HCT TAB 160-12.5 ............... 51 DIOVAN HCT TAB 160-25MG ............. 52 DIOVAN HCT TAB 320-12.5 ............... 52 DIOVAN HCT TAB 320-25MG ............. 52 DIOVAN HCT TAB 80/12.5 ................ 51 DIOVAN TAB 160MG ........................ 53 DIOVAN TAB 320MG ........................ 53 DIOVAN TAB 40MG .......................... 53 DIOVAN TAB 80MG .......................... 53 DIPENTUM CAP 250MG .................... 143 diphenhydramine hcl (sleep) tab 50 mg .................................................... 103 diphenhydramine hcl cap 50 mg ....... 187 diphenhydramine hcl elixir 12.5 mg/5ml .................................................... 187 diphenhydramine hcl inj 50 mg/ml .... 187 diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml ......................................... 139 diphenoxylate w/ atropine tab 2.5-0.025 mg ............................................... 139 DIPROLENE AF CRE 0.05% .............. 205 DIPROLENE LOT 0.05% ................... 205 DIPROLENE OIN 0.05% ................... 208 dipyridamole tab 25 mg ................... 162 dipyridamole tab 50 mg ................... 162 dipyridamole tab 75 mg ................... 162

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DISCOVISC SOL ............................. 219 disopyramide phosphate cap 100 mg .. 54 disopyramide phosphate cap 150 mg .. 54 disulfiram tab 250 mg ..................... 110 disulfiram tab 500 mg ..................... 111 DITROPAN XL TAB 10MG ................. 153 DITROPAN XL TAB 15MG ................. 153 DITROPAN XL TAB 5MG ................... 153 DIURIL SUS 250/5ML ........................ 65 divalproex sodium cap delayed release sprinkle 125 mg ............................... 74 divalproex sodium tab delayed release 125 mg ........................................... 74 divalproex sodium tab delayed release 250 mg ........................................... 74 divalproex sodium tab delayed release 500 mg ........................................... 74 divalproex sodium tab er 24 hr 250 mg ..................................................... 74 divalproex sodium tab er 24 hr 500 mg ..................................................... 74 DIVIGEL GEL 0.25MG ...................... 129 DIVIGEL GEL 0.5MG ....................... 129 DIVIGEL GEL 1MG/GM .................... 129 DIVISTA CAP ................................. 174 dobutamine hcl inj 12.5 mg/ml........... 70 dobutamine inj 1 mg/ml in d5w .......... 70 dobutamine inj 2 mg/ml in d5w .......... 70 dobutamine inj 4 mg/ml in d5w .......... 70 docetaxel for inj conc 20 mg/ml ......... 42 docetaxel for inj conc 80 mg/4ml (20 mg/ml) ........................................... 42 DOCETAXEL INJ 140/7ML .................. 42 DOCETAXEL INJ 160/16ML ................. 42 DOCETAXEL INJ 160/8ML .................. 42 DOCETAXEL INJ 20/0.5ML ................. 42 DOCETAXEL INJ 200MG/20 ................ 42 DOCETAXEL INJ 20MG/2ML ................ 42 DOCETAXEL INJ 80MG/2ML ................ 42 DOCETAXEL INJ 80MG/8ML ................ 42 DOCETAXEL INJ NON-ALCO ............... 42 docusate cal cap 240mg .................. 144 docusate sodium liquid 150 mg/15ml 144 docusate sodium syrup 60 mg/15ml .. 144 dofetilide cap 125 mcg (0.125 mg) ..... 54 dofetilide cap 250 mcg (0.25 mg) ....... 54 dofetilide cap 500 mcg (0.5 mg) ......... 54 DOLOPHINE TAB 10MG ...................... 7

DOLOPHINE TAB 5MG ........................ 7 donepezil hydrochloride orally disintegrating tab 10 mg .................. 79 donepezil hydrochloride orally disintegrating tab 5 mg .................... 79 donepezil hydrochloride tab 10 mg ..... 79 donepezil hydrochloride tab 23 mg ..... 79 donepezil hydrochloride tab 5 mg ...... 79 dopamine hcl inj 160 mg/ml .............. 71 dopamine hcl inj 40 mg/ml ............... 70 dopamine hcl inj 80 mg/ml ............... 70 dopamine inj 0.8 mg/ml in d5w ......... 71 dopamine inj 1.6 mg/ml in d5w ......... 71 dopamine inj 3.2 mg/ml in d5w ......... 71 DOPRAM INJ 20MG/ML .................... 107 DORAL TAB 15MG ........................... 102 DORIBAX INJ 250MG ........................ 17 DORIBAX INJ 500MG ........................ 17 DORYX TAB 200MG .......................... 24 DORYX TAB 50MG............................ 24 dorzolamide hcl ophth soln 2% ......... 218 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml ....................... 217 double antib oin ............................. 201 DOUBLE-TUSSN LIQ DM .................. 188 DOVONEX CRE 0.005% ................... 203 doxapram hcl inj 20 mg/ml .............. 107 doxazosin mesylate tab 1 mg ............ 49 doxazosin mesylate tab 2 mg ............ 49 doxazosin mesylate tab 4 mg ............ 49 doxazosin mesylate tab 8 mg ............ 49 doxepin hcl cap 10 mg ..................... 86 doxepin hcl cap 100 mg .................... 86 doxepin hcl cap 150 mg .................... 86 doxepin hcl cap 25 mg ..................... 86 doxepin hcl cap 50 mg ..................... 86 doxepin hcl cap 75 mg ..................... 86 doxepin hcl conc 10 mg/ml ............... 86 doxercalciferol cap 0.5 mcg .............. 133 doxercalciferol cap 1 mcg ................ 133 doxercalciferol cap 2.5 mcg .............. 133 doxorubicin hcl for inj 10 mg ............. 42 doxorubicin hcl for inj 50 mg ............. 42 doxorubicin hcl inj 2 mg/ml ............... 42 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ............................ 42 doxy 100 inj 100mg ......................... 24 doxycycline (rosacea) cap delayed

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release 40 mg ................................ 211 doxycycline hyclate cap 100 mg ......... 24 doxycycline hyclate cap 50 mg ........... 24 doxycycline hyclate tab 100 mg .......... 24 doxycycline hyclate tab 150 mg .......... 24 doxycycline hyclate tab 20 mg ........... 24 doxycycline hyclate tab 75 mg ........... 24 doxycycline hyclate tab delayed release 100 mg ........................................... 24 doxycycline hyclate tab delayed release 150 mg ........................................... 24 doxycycline hyclate tab delayed release 75 mg ............................................ 24 doxycycline monohydrate cap 100 mg . 24 doxycycline monohydrate cap 150 mg . 24 doxycycline monohydrate cap 50 mg ... 24 doxycycline monohydrate cap 75 mg ... 24 doxycycline monohydrate for susp 25 mg/5ml ........................................... 25 doxycycline monohydrate tab 150 mg . 25 doxycycline monohydrate tab 50 mg ... 25 doxycycline monohydrate tab 75 mg ... 25 DR SMITHS OIN DIAPER .................. 210 dronabinol cap 10 mg ..................... 140 dronabinol cap 2.5 mg .................... 140 dronabinol cap 5 mg ....................... 140 drospirenone-ethinyl estradiol tab 3-0.03 mg ............................................... 126 drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg ...................... 125 DROXIA CAP 200MG ......................... 42 DROXIA CAP 300MG ......................... 42 DROXIA CAP 400MG ......................... 42 DRYSOL SOL 20% .......................... 210 DS PREP PAK PAK 1%-0.13% .............. 5 DUAC GEL 1.2-5% .......................... 199 dual action chw complete ................ 151 DUAVEE TAB 0.45-20 ...................... 128 DUET DHA 400 MIS 25-1-400 .......... 177 DUET DHA MIS BALANCED ............... 177 DUEXIS TAB 800-26.6 ....................... 4 DULERA AER 100-5MCG .................. 196 DULERA AER 200-5MCG .................. 196 duloxetine hcl enteric coated pellets cap 20 mg ............................................ 82 duloxetine hcl enteric coated pellets cap 30 mg ............................................ 82 duloxetine hcl enteric coated pellets cap

40 mg ............................................ 82 duloxetine hcl enteric coated pellets cap 60 mg ............................................ 82 DUODOTE INJ ................................ 122 duofilm sol 17% ............................. 210 DUOVISC KIT 0.35/0.4 .................... 219 DUOVISC KIT 0.5/0.55 .................... 219 DUPIXENT INJ 300/2ML ................... 204 DURACHOL CAP 1-3775IU................ 174 DURACLON INJ .................................. 2 DURAGESIC DIS 100MCG/H ................ 7 DURAGESIC DIS 12MCG/HR ................ 7 DURAGESIC DIS 25MCG/HR ................ 7 DURAGESIC DIS 50MCG/HR ................ 7 DURAGESIC DIS 75MCG/HR ................ 7 duraxin cap ...................................... 2 DUREZOL EMU 0.05% ..................... 216 DURLAZA CAP 162.5MG ................... 162 dutasteride cap 0.5 mg ................... 151 dutasteride-tamsulosin hcl cap 0.5-0.4 mg ............................................... 151 DUTOPROL TAB 100-12.5 ................. 58 DUTOPROL TAB 25-12.5 ................... 58 DUTOPROL TAB 50-12.5 ................... 58 DYANAVEL XR SUS 2.5MG/ML ........... 98 DYAZIDE CAP 37.5-25 ...................... 65 DYLOJECT INJ 37.5MG/M .................... 3 DYMISTA SPR 137-50 ...................... 195 DYRENIUM CAP 100MG ..................... 65 DYRENIUM CAP 50MG ...................... 65 E e.e.s. 400 tab 400mg ....................... 21 easygel gel 0.4%citr ....................... 214 EC-NAPROSYN TAB 375MG ................. 3 EC-NAPROSYN TAB 500MG ................. 3 econazole nitrate cream 1% ............. 202 ECOZA AER 1% .............................. 202 ED BRON GP LIQ ............................ 189 ED CHLORPED LIQ 2MG/ML .............. 188 EDARBI TAB 40MG ........................... 53 EDARBI TAB 80MG ........................... 53 EDARBYCLOR TAB 40-12.5 ................ 52 EDARBYCLOR TAB 40-25MG .............. 52 EDECRIN TAB 25MG ......................... 65 EDLUAR SUB 10MG ......................... 103 EDLUAR SUB 5MG........................... 103 EDURANT TAB 25MG ........................ 29 EFFER-K TAB 10MEQ ....................... 170

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EFFER-K TAB 20MEQ ....................... 170 EFFEXOR XR CAP 150MG ................... 82 EFFEXOR XR CAP 37.5MG .................. 82 EFFEXOR XR CAP 75MG ..................... 82 EFFIENT TAB 10MG......................... 162 EFFIENT TAB 5MG .......................... 162 EFUDEX CRE 5% ............................ 200 EGRIFTA SOL 1MG .......................... 134 EGRIFTA SOL 2MG .......................... 134 ELAPRASE INJ 6MG/3ML .................. 134 ELDEPRYL CAP 5MG .......................... 87 ELELYSO INJ 200UNIT ..................... 134 ELESTAT DRO 0.05% ...................... 216 ELESTRIN GEL 0.06% ..................... 129 eletriptan hydrobromide tab 20 mg (base equivalent) .................................... 105 eletriptan hydrobromide tab 40 mg (base equivalent) .................................... 105 ELFOLATE TAB 15MG ...................... 170 ELFOLATE TAB 7.5MG ..................... 169 ELFOLATE TAB PLUS ....................... 170 ELIDEL CRE 1% ............................. 204 ELIGARD INJ 22.5MG ........................ 39 ELIMITE CRE 5% ............................ 212 ELIQUIS TAB 2.5MG ....................... 156 ELIQUIS TAB 5MG .......................... 156 ELITEK INJ 1.5MG ............................ 42 ELITEK INJ 7.5MG ............................ 42 elite-ob tab ................................... 177 ELIXOPHYLLIN ELX 80/15ML ............ 197 ELLA TAB 30MG ............................. 124 ELLENCE INJ 2MG/ML ....................... 42 ELLIOTTS B INJ .............................. 172 ELMIRON CAP 100MG ..................... 152 ELOCON CRE 0.1% ......................... 206 ELOCON LOT 0.1% ......................... 206 ELOCON OIN 0.1% ......................... 206 ELOCTATE INJ 1000UNIT ................. 157 ELOCTATE INJ 1500UNIT ................. 157 ELOCTATE INJ 2000UNIT ................. 157 ELOCTATE INJ 250UNIT .................. 157 ELOCTATE INJ 3000UNIT ................. 157 ELOCTATE INJ 500UNIT .................. 157 ELOCTATE INJ 750UNIT .................. 157 EMADINE SOL 0.05% OP ................. 217 EMBEDA CAP 100-4MG ....................... 7 EMBEDA CAP 20-0.8MG ...................... 7 EMBEDA CAP 30-1.2MG ...................... 7

EMBEDA CAP 50-2MG ......................... 7 EMBEDA CAP 60-2.4MG ...................... 7 EMBEDA CAP 80-3.2MG ...................... 7 EMCYT CAP 140MG .......................... 36 EMEND CAP 125MG ......................... 140 EMEND CAP 40MG .......................... 140 EMEND CAP 80MG .......................... 140 EMEND SOL 150MG ........................ 140 EMEND SUS 125MG ........................ 140 EMEND TRIPAC PAK 80 & 125 .......... 140 EMFLAZA TAB 18MG ....................... 131 EMFLAZA TAB 30MG ....................... 131 EMFLAZA TAB 36MG ....................... 131 EMFLAZA TAB 6MG ......................... 131 EMPLICITI INJ 300MG ...................... 42 EMPLICITI INJ 400MG ...................... 42 EMSAM DIS 12MG/24H ..................... 81 EMSAM DIS 6MG/24HR..................... 81 EMSAM DIS 9MG/24HR..................... 81 EMTRIVA CAP 200MG ....................... 29 EMTRIVA SOL 10MG/ML.................... 29 EMULSION SB EMU ......................... 210 ENABLEX TAB 15MG ........................ 153 ENABLEX TAB 7.5MG ....................... 153 enalapril maleate & hydrochlorothiazide tab 10-25 mg .................................. 46 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg ................................. 46 enalapril maleate tab 10 mg .............. 47 enalapril maleate tab 2.5 mg ............. 47 enalapril maleate tab 20 mg .............. 47 enalapril maleate tab 5 mg ............... 47 enalaprilat iv inj 1.25 mg/ml ............. 47 ENBRACE HR CAP ........................... 177 ENBREL INJ 25/0.5ML ..................... 163 ENBREL INJ 25MG .......................... 163 ENBREL INJ 50MG/ML ..................... 163 ENBREL SRCLK INJ 50MG/ML ........... 163 ENDO AVITENE MIS 5MM DIA ........... 160 ENDO DERMAL MIS 10X12.7 ............ 213 ENDO DERMAL MIS 5X5 CM ............. 213 endocet tab 2.5-325 .......................... 7 endoxcin pad 4-1% ......................... 209 ENEMEEZ MINI ENE ........................ 144 ENLON INJ 150/15ML ...................... 109 enoxaparin sodium inj 100 mg/ml ..... 154 enoxaparin sodium inj 120 mg/0.8ml 154 enoxaparin sodium inj 150 mg/ml ..... 154

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enoxaparin sodium inj 30 mg/0.3ml .. 154 enoxaparin sodium inj 300 mg/3ml ... 154 enoxaparin sodium inj 40 mg/0.4ml .. 154 enoxaparin sodium inj 60 mg/0.6ml .. 154 enoxaparin sodium inj 80 mg/0.8ml .. 154 enpresse-28 tab ............................. 127 ENSTILAR AER ............................... 203 entacapone tab 200 mg .................... 87 entecavir tab 0.5 mg ........................ 31 entecavir tab 1 mg ........................... 31 ENTEREG CAP 12MG ....................... 146 ENTEX T TAB 60-375MG .................. 189 entre-b sus 6-10mg/5 ..................... 186 ENTRESTO TAB 24-26MG .................. 66 ENTRESTO TAB 49-51MG .................. 66 ENTRESTO TAB 97-103MG ................. 66 enulose sol 10gm/15 ...................... 146 ENVARSUS XR TAB 0.75MG ............. 166 ENVARSUS XR TAB 1MG .................. 166 ENVARSUS XR TAB 4MG .................. 166 EPANED SOL 1MG/ML ....................... 48 EPCLUSA TAB 400-100 ...................... 31 ephedrine sulfate inj 50 mg/ml ........... 71 EPIDUO FORTE GEL 0.3-2.5% .......... 199 EPIDUO GEL 0.1-2.5% .................... 199 EPIFOAM AER 1% ........................... 150 epinastine hcl ophth soln 0.05% ....... 217 epinephrine hcl inj 1 mg/ml ............. 185 epinephrine hcl soln prefilled syringe 0.1 mg/ml .......................................... 185 EPINEPHRINE INJ 1MG/ML ................. 71 epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) ....................... 185 epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) ........................ 185 EPIPEN 2-PAK INJ 0.3MG ................. 185 EPIPEN-JR INJ 2-PAK ...................... 185 epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) ........................................... 42 epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) ........................................... 42 EPISIL LIQ .................................... 214 EPISNAP KIT .................................. 185 EPIVIR HBV SOL 5MG/ML .................. 31 EPIVIR HBV TAB 100MG .................... 31 EPIVIR TAB 150MG ........................... 29 EPIVIR TAB 300MG ........................... 29 eplerenone tab 25 mg ....................... 49

eplerenone tab 50 mg ...................... 49 EPOGEN INJ 10000/ML .................... 159 EPOGEN INJ 2000/ML ...................... 159 EPOGEN INJ 20000/ML .................... 159 EPOGEN INJ 3000/ML ...................... 159 EPOGEN INJ 4000/ML ...................... 159 epoprostenol sodium for inj 0.5 mg .... 70 epoprostenol sodium for inj 1.5 mg .... 70 eprosartan mesylate tab 600 mg ....... 53 epsom salt gra ............................... 144 eptifibatide iv soln 20 mg/10ml (2 mg/ml) ......................................... 162 eptifibatide iv soln 200 mg/100ml (2 mg/ml) ......................................... 162 eptifibatide iv soln 75 mg/100ml (0.75 mg/ml) ......................................... 162 eq aspirin tab 500mg ec .................. 162 eq gentle dro 0.3% ......................... 219 eql acetamin tab 160mg ..................... 1 EQL CALCIUM CAP VIT D ................. 177 eql castor oil 100% ......................... 144 eql lice kit solution .......................... 212 EQUALACTIN CHW 625MG ............... 144 EQUETRO CAP 100MG ..................... 107 EQUETRO CAP 200MG ..................... 107 EQUETRO CAP 300MG ..................... 107 ERAXIS INJ 100MG .......................... 26 ERAXIS INJ 50MG ............................ 26 ERBITUX INJ 100MG ........................ 42 ERBITUX INJ 200MG ........................ 42 ergocalciferol cap 50000 unit ........... 177 ERGOMAR SUB 2MG ........................ 104 ERIVEDGE CAP 150MG ..................... 42 ERTACZO CRE 2% .......................... 202 ery pad 2% ................................... 199 ERYPED SUS 400/5ML ...................... 21 ery-tab tab 250mg ec ...................... 21 ery-tab tab 333mg ec ...................... 21 ery-tab tab 500mg ec ...................... 21 ERYTHROCIN INJ 500MG .................. 21 erythrocin tab 250mg ....................... 21 ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 200 MG/5ML ........................... 21 erythromycin gel 2% ....................... 199 erythromycin soln 2% ..................... 199 erythromycin tab 250 mg ................. 21 erythromycin tab 500 mg ................. 21 erythromycin w/ delayed release

253

particles cap 250 mg ........................ 21 ESBRIET CAP 267MG ...................... 195 escitalopram oxalate soln 5 mg/5ml (base equiv) .................................... 84 escitalopram oxalate tab 10 mg (base equiv) ............................................. 84 escitalopram oxalate tab 20 mg (base equiv) ............................................. 84 escitalopram oxalate tab 5 mg (base equiv) ............................................. 84 ESGIC TAB ....................................... 2 esmolol hcl inj 100 mg/10ml .............. 60 esomeprazole magnesium cap delayed release 20 mg (base eq) ................. 148 esomeprazole magnesium cap delayed release 40 mg (base eq) ................. 148 esomeprazole sodium for intravenous soln 20 mg (base equiv) .................. 148 esomeprazole sodium for intravenous soln 40 mg (base equiv) .................. 148 essent one tab daily ........................ 177 estazolam tab 1 mg ........................ 102 estazolam tab 2 mg ........................ 102 ESTRACE TAB 0.5MG ...................... 128 ESTRACE TAB 1MG ......................... 128 ESTRACE TAB 2MG ......................... 128 ESTRACE VAG CRE 0.1MG/GM .......... 129 estradiol & norethindrone acetate tab 0.5-0.1 mg .................................... 127 estradiol & norethindrone acetate tab 1-0.5 mg ......................................... 127 estradiol tab 0.5 mg ....................... 128 estradiol tab 1 mg .......................... 128 estradiol tab 2 mg .......................... 128 estradiol td patch twice weekly 0.025 mg/24hr ....................................... 129 estradiol td patch twice weekly 0.0375 mg/24hr ....................................... 129 estradiol td patch twice weekly 0.05 mg/24hr ....................................... 129 estradiol td patch twice weekly 0.075 mg/24hr ....................................... 129 estradiol td patch twice weekly 0.1 mg/24hr ....................................... 129 estradiol td patch weekly 0.025 mg/24hr ................................................... 129 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) ............... 129

estradiol td patch weekly 0.05 mg/24hr .................................................... 129 estradiol td patch weekly 0.06 mg/24hr .................................................... 129 estradiol td patch weekly 0.075 mg/24hr .................................................... 129 estradiol td patch weekly 0.1 mg/24hr .................................................... 129 estradiol valerate im in oil 20 mg/ml . 128 estradiol valerate im in oil 40 mg/ml . 128 ESTRING MIS 2MG .......................... 129 estro supprt tab es ......................... 170 ESTROGEL GEL .............................. 129 estropipate tab 0.75 mg .................. 128 estropipate tab 1.5 mg .................... 128 estropipate tab 3 mg ....................... 128 ESTROSTEP FE TAB ......................... 127 eszopiclone tab 1 mg ...................... 103 eszopiclone tab 2 mg ...................... 103 eszopiclone tab 3 mg ...................... 103 ethacrynate sodium for inj 50 mg ...... 65 ethacrynic acid tab 25 mg ................. 65 ethambutol hcl tab 100 mg ............... 30 ethambutol hcl tab 400 mg ............... 30 ETHAMOLIN INJ 5% ......................... 67 ethosuximide cap 250 mg ................. 74 ethosuximide soln 250 mg/5ml .......... 74 ETHYOL INJ 500MG .......................... 42 etidronate disodium tab 200 mg ....... 123 etidronate disodium tab 400 mg ....... 124 etodolac cap 200 mg .......................... 3 etodolac cap 300 mg .......................... 3 etodolac tab 400 mg .......................... 3 etodolac tab 500 mg .......................... 3 etodolac tab er 24hr 400 mg ............... 3 etodolac tab er 24hr 500 mg ............... 3 etodolac tab er 24hr 600 mg ............... 3 etoposide cap 50 mg ........................ 43 etoposide inj 1 gm/50ml (20 mg/ml) .. 43 etoposide inj 100 mg/5ml (20 mg/ml) 43 etoposide inj 500 mg/25ml (20 mg/ml) ..................................................... 43 EUCRISA OIN 2% ........................... 201 EUFLEXXA INJ 10MG/ML ................... 16 EURAX CRE 10% ............................ 212 EURAX LOT 10% ............................ 212 EVAC POW ..................................... 144 EVAMIST SPR 1.53MG ..................... 129

254

EVEKEO TAB 10MG ........................... 98 EVEKEO TAB 5MG ............................. 98 EVICEL KIT 2ML ............................. 160 EVISTA TAB 60MG .......................... 136 EVOCLIN AER 1% ........................... 199 EVOTAZ TAB 300-150 ....................... 27 EVOXAC CAP 30MG ......................... 150 EVZIO INJ ..................................... 111 EXALGO TAB 12MG ............................ 7 EXALGO TAB 16MG ............................ 8 EXALGO TAB 32MG ............................ 8 EXALGO TAB 8MG ............................. 7 EXELDERM CRE 1% ........................ 202 EXELDERM SOL 1% ........................ 202 EXELON CAP 1.5MG .......................... 79 EXELON CAP 3MG ............................. 79 EXELON CAP 4.5MG .......................... 79 EXELON CAP 6MG ............................. 79 EXELON DIS 13.3/24 ........................ 79 EXELON DIS 4.6MG/24...................... 79 EXELON DIS 9.5MG/24...................... 79 exemestane tab 25 mg ..................... 39 EXFORGE TAB 10-160MG .................. 50 EXFORGE TAB 10-320MG .................. 50 EXFORGE TAB 5-160MG .................... 50 EXFORGE TAB 5-320MG .................... 50 EXFORGEH/10- TAB 160-12.5 ............ 51 EXFORGEH/10- TAB 160-25 ............... 51 EXFORGEH/10- TAB 320-25 ............... 51 EXFORGEH/5- TAB 160-12.5 .............. 51 EXFORGEH/5- TAB 160-25 ................. 51 EXJADE TAB 125MG ........................ 161 EXJADE TAB 250MG ........................ 161 EXJADE TAB 500MG ........................ 161 EXODERM LOT 25-1% ..................... 202 EXTAVIA INJ 0.3MG ........................ 108 EXTINA AER 2% ............................. 202 eye drops dro 0.5-0.9% .................. 219 eye drops sol 0.05% op .................. 219 eye drops sol a/r ............................ 219 ezetimibe tab 10 mg ......................... 55 ezetimibe-simvastatin tab 10-10 mg ... 56 ezetimibe-simvastatin tab 10-20 mg ... 56 ezetimibe-simvastatin tab 10-40 mg ... 56 ezetimibe-simvastatin tab 10-80 mg ... 57 ezfe 200 cap 200mg ....................... 177 F FABIOR AER 0.1% .......................... 199

FABRAZYME INJ 35MG..................... 134 FABRAZYME INJ 5MG ...................... 134 FACE MASK MIS EARLOOP ............... 193 FACTIVE TAB 320MG ........................ 21 FALESSA TAB 1MG .......................... 170 famciclovir tab 125 mg ..................... 32 famciclovir tab 250 mg ..................... 32 famciclovir tab 500 mg ..................... 33 famotidine for susp 40 mg/5ml ......... 142 famotidine in nacl 0.9% iv soln 20 mg/50ml ....................................... 143 famotidine inj 20 mg/2ml ................ 143 famotidine inj 200 mg/20ml ............. 143 famotidine inj 40 mg/4ml ................ 143 famotidine inj 500 mg/50ml ............. 143 famotidine tab 20 mg ...................... 143 famotidine tab 40 mg ...................... 143 FAMVIR TAB 125MG ......................... 33 FAMVIR TAB 250MG ......................... 33 FAMVIR TAB 500MG ......................... 33 FANAPT PAK ................................... 90 FANAPT TAB 10MG ........................... 90 FANAPT TAB 12MG ........................... 90 FANAPT TAB 1MG ............................ 90 FANAPT TAB 2MG ............................ 90 FANAPT TAB 4MG ............................ 90 FANAPT TAB 6MG ............................ 90 FANAPT TAB 8MG ............................ 90 FARESTON TAB 60MG ...................... 38 FARXIGA TAB 10MG ........................ 118 FARXIGA TAB 5MG .......................... 118 FARYDAK CAP 10MG ........................ 43 FARYDAK CAP 15MG ........................ 43 FARYDAK CAP 20MG ........................ 43 fayosim tab ................................... 124 FAZACLO TAB 100 ODT .................... 90 FAZACLO TAB 12.5 ODT ................... 90 FAZACLO TAB 150 ODT .................... 90 FAZACLO TAB 200 ODT .................... 90 FAZACLO TAB 25MG ODT .................. 90 fe c plus tab ................................... 177 fe gluconate tab 325mg ................... 177 FE PLUS TAB PROTEIN .................... 177 fe tabs tab 325mg ec ...................... 177 FEIBA INJ ...................................... 157 felbamate susp 600 mg/5ml .............. 74 felbamate tab 400 mg ...................... 74 felbamate tab 600 mg ...................... 74

255

FELBATOL SUS 600/5ML .................... 74 FELBATOL TAB 400MG ...................... 74 FELBATOL TAB 600MG ...................... 74 FELDENE CAP 10MG ........................... 3 FELDENE CAP 20MG ........................... 3 felodipine tab er 24hr 10 mg .............. 62 felodipine tab er 24hr 2.5 mg ............. 62 felodipine tab er 24hr 5 mg ............... 62 FEMARA TAB 2.5MG .......................... 39 FEMCAP MIS 22MM ......................... 125 FEMCAP MIS 26MM ......................... 125 FEMCAP MIS 30MM ......................... 125 FEMCON FE CHW ............................ 126 FEMHRT TAB 0.5-2.5 ...................... 127 FEMRING MIS 0.05/24H .................. 129 FEMRING MIS 0.1MG/24 .................. 129 fenofibrate cap 150 mg ..................... 55 fenofibrate cap 50 mg ....................... 55 fenofibrate micronized cap 130 mg ..... 55 fenofibrate micronized cap 134 mg ..... 55 fenofibrate micronized cap 200 mg ..... 55 fenofibrate micronized cap 43 mg ....... 55 fenofibrate micronized cap 67 mg ....... 55 fenofibrate tab 120 mg ..................... 56 fenofibrate tab 145 mg ..................... 56 fenofibrate tab 160 mg ..................... 56 fenofibrate tab 40 mg ....................... 56 fenofibrate tab 48 mg ....................... 56 fenofibrate tab 54 mg ....................... 56 fenofibric acid tab 105 mg ................. 56 fenofibric acid tab 35 mg ................... 56 FENOGLIDE TAB 120MG .................... 56 FENOGLIDE TAB 40MG ...................... 56 fenoldopam mesylate iv inj 10 mg/ml (base equiv) .................................... 67 fenoldopam mesylate iv inj 20 mg/2ml (base equiv) .................................... 67 fenoprofen calcium cap 400 mg ........... 3 fenoprofen calcium tab 600 mg ........... 3 FENORTHO CAP 200MG ...................... 3 fentanyl citrate lozenge on a handle 1200 mcg ................................................ 8 fentanyl citrate lozenge on a handle 1600 mcg ................................................ 8 fentanyl citrate lozenge on a handle 200 mcg ................................................ 8 fentanyl citrate lozenge on a handle 400 mcg ................................................ 8

fentanyl citrate lozenge on a handle 600 mcg ................................................. 8 fentanyl citrate lozenge on a handle 800 mcg ................................................. 8 fentanyl citrate pf soln cartridge 100 mcg/2ml .......................................... 8 fentanyl citrate preservative free (pf) inj 100 mcg/2ml .................................... 8 fentanyl citrate preservative free (pf) inj 1000 mcg/20ml ................................. 8 fentanyl citrate preservative free (pf) inj 250 mcg/5ml .................................... 8 fentanyl citrate preservative free (pf) inj 2500 mcg/50ml ................................. 8 fentanyl citrate preservative free (pf) inj 500 mcg/10ml .................................. 8 FENTANYL DIS 37.5MCG ..................... 8 FENTANYL DIS 62.5MCG ..................... 8 FENTANYL DIS 87.5MCG ..................... 8 fentanyl td patch 72hr 100 mcg/hr ....... 8 fentanyl td patch 72hr 12 mcg/hr ........ 8 fentanyl td patch 72hr 25 mcg/hr ........ 8 fentanyl td patch 72hr 50 mcg/hr ........ 8 fentanyl td patch 72hr 75 mcg/hr ........ 8 FENTORA TAB 100MCG ....................... 8 FENTORA TAB 200MCG ....................... 8 FENTORA TAB 400MCG ....................... 9 FENTORA TAB 600MCG ....................... 9 FENTORA TAB 800MCG ....................... 9 FER-IN-SOL DRO 15MG/ML .............. 177 FERIVA CAP 75-1MG ....................... 177 FERIVAFA CAP 110-1MG .................. 178 ferocon cap .................................... 178 ferrex 150 cap 150mg ..................... 178 ferrex 150 cap forte pl..................... 178 ferrex 28 mis ................................. 178 FERRIMIN 150 TAB ......................... 178 FERRIPROX SOL 100MG/ML ............. 161 FERRIPROX TAB 500MG ................... 161 ferrocite tab 324mg ........................ 178 ferrocite tab plus ............................ 178 ferrogels fo cap forte ....................... 178 FERROUS SULF TAB 140MG ............. 178 ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ..................... 178 ferrous sulfate tab 325 mg (65 mg elemental fe) ................................. 178 ferrous sulfate tab er 142 mg (45 mg fe

256

equivalent) .................................... 178 FETZIMA CAP 120MG ........................ 82 FETZIMA CAP 20MG .......................... 82 FETZIMA CAP 40MG .......................... 82 FETZIMA CAP 80MG .......................... 82 FETZIMA CAP TITRATIO .................... 82 fever reduce sup 120mg ..................... 1 FEVERALL INF SUP 80MG ................... 1 feverall sup 325mg ............................ 1 FEXMID TAB 7.5MG ........................ 109 fexofenadine hcl tab 180 mg ............ 187 fexofenadine hcl tab 60 mg .............. 187 fexofenadine-pseudoephedrine tab er 12hr 60-120 mg ............................. 186 FIBER CHOICE CHW 1.5GM .............. 144 fiber laxatv tab 625mg .................... 144 fiber laxtiv cap 0.52gm ................... 144 fiber select chw gummies ................ 144 FIBRICOR TAB 105MG ....................... 56 FIBRICOR TAB 35MG ........................ 56 FINACEA AER 15% ......................... 211 FINACEA GEL 15% ......................... 211 finasteride tab 5 mg ....................... 151 FIORICET CAP ................................... 2 FIORICET CAP CODEINE ..................... 9 FIORINAL CAP................................... 2 FIORINAL/COD CAP 30MG .................. 9 FIRAZYR INJ 30MG/3ML .................. 160 first aid spr .................................... 209 FLAGYL CAP 375MG .......................... 34 FLAGYL ER TAB 750MG ..................... 34 FLAGYL TAB 250MG .......................... 34 FLAGYL TAB 500MG .......................... 34 FLAREX SUS 0.1% OP ..................... 216 flavoxate hcl tab 100 mg ................. 153 FLEBOGAMMA INJ 10/100ML ............ 164 FLEBOGAMMA INJ 10/200ML ............ 164 FLEBOGAMMA INJ 20/200ML ............ 164 FLEBOGAMMA INJ 20/400ML ............ 164 FLEBOGAMMA INJ 5GM/50ML ........... 164 FLEBOGAMMA INJ DIF 5% ............... 164 flecainide acetate tab 100 mg ............ 54 flecainide acetate tab 150 mg ............ 54 flecainide acetate tab 50 mg .............. 54 FLECTOR DIS 1.3% ........................... 5 FLEET LIQUID ENE GLYCERIN .......... 144 FLEXICHAMBER MIS MASK SM ......... 193 FLINTSTONES CHW COMPLETE ......... 178

FLINTSTONES CHW GUMMIES .......... 178 FLOLAN INJ 0.5MG ........................... 70 FLOLAN INJ 1.5MG ........................... 70 FLOMAX CAP 0.4MG ........................ 151 floranex tab ................................... 146 FLORASTOR CAP 250MG .................. 146 FLORASTOR PAK KIDS .................... 146 FLORICAL CAP ............................... 178 FLORICAL TAB ............................... 178 FLORIVA CHW 0.25MG .................... 178 FLOVENT DISK AER 100MCG ............ 196 FLOVENT DISK AER 250MCG ............ 196 FLOVENT DISK AER 50MCG .............. 196 FLOVENT HFA AER 110MCG ............. 196 FLOVENT HFA AER 220MCG ............. 196 FLOVENT HFA AER 44MCG ............... 196 flucaine sol 0.25-0.5 ....................... 218 fluconazole for susp 10 mg/ml ........... 26 fluconazole for susp 40 mg/ml ........... 26 fluconazole in dextrose inj 200 mg/100ml ...................................... 26 fluconazole in dextrose inj 400 mg/200ml ...................................... 26 fluconazole in nacl 0.9% inj 200 mg/100ml ...................................... 26 fluconazole in nacl 0.9% inj 400 mg/200ml ...................................... 26 fluconazole tab 100 mg .................... 26 fluconazole tab 150 mg .................... 26 fluconazole tab 200 mg .................... 26 fluconazole tab 50 mg ...................... 26 FLUCONAZOLE/ INJ NACL 100 ........... 26 flucytosine cap 250 mg .................... 26 flucytosine cap 500 mg .................... 26 FLUDARA INJ 50MG ......................... 37 fludarabine phosphate for inj 50 mg ... 37 fludarabine phosphate inj 25 mg/ml ... 37 fludrocortisone acetate tab 0.1 mg .... 131 FLUMADINE TAB 100MG ................... 33 flumazenil iv soln 0.5 mg/5ml (0.1 mg/ml) ......................................... 122 flumazenil iv soln 1 mg/10ml (0.1 mg/ml) ......................................... 122 flunisolide nasal soln 25 mcg/act (0.025%) ...................................... 195 fluocin acet oil 0.01% sc .................. 206 fluocin acet oil body ........................ 206 fluocinolone acetonide (otic) oil 0.01%

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................................................... 221 fluocinolone acetonide cream 0.01% . 206 fluocinolone acetonide cream 0.025% 206 fluocinolone acetonide oint 0.025% ... 206 fluocinolone acetonide soln 0.01% .... 206 fluocinonide cream 0.05% ............... 205 fluocinonide cream 0.1% ................. 205 fluocinonide emulsified base cream 0.05% .......................................... 205 fluocinonide gel 0.05% .................... 205 fluocinonide oint 0.05% .................. 205 fluocinonide soln 0.05% .................. 205 FLUORABON DRO ........................... 178 FLUOR-A-DAY CHW 0.25MG F .......... 178 FLUOR-A-DAY CHW 1MG F ............... 178 fluorid sens pst 1.1-5% ................... 214 fluoridex dd pst sensitiv .................. 214 fluorometholone ophth susp 0.1% .... 216 FLUOROPLEX CRE 1% ..................... 201 fluorouracil cream 5% ..................... 201 fluorouracil inj 1 gm/20ml (50 mg/ml) 37 fluorouracil inj 2.5 gm/50ml (50 mg/ml) ..................................................... 37 fluorouracil inj 5 gm/100ml (50 mg/ml) ..................................................... 37 fluorouracil inj 500 mg/10ml (50 mg/ml) ..................................................... 37 fluorouracil soln 2% ........................ 201 fluorouracil soln 5% ........................ 201 fluoxetine hcl (pmdd) cap 10 mg ........ 84 fluoxetine hcl (pmdd) cap 20 mg ........ 84 fluoxetine hcl cap 10 mg ................... 84 fluoxetine hcl cap 20 mg ................... 84 fluoxetine hcl cap 40 mg ................... 84 fluoxetine hcl cap delayed release 90 mg ..................................................... 84 fluoxetine hcl solution 20 mg/5ml ....... 84 fluoxetine hcl tab 10 mg .................... 84 fluoxetine hcl tab 20 mg .................... 84 FLUOXETINE TAB 60MG..................... 84 fluphenazine decanoate inj 25 mg/ml .. 95 fluphenazine hcl elixir 2.5 mg/5ml ...... 95 fluphenazine hcl inj 2.5 mg/ml ........... 95 fluphenazine hcl oral conc 5 mg/ml ..... 95 fluphenazine hcl tab 1 mg .................. 95 fluphenazine hcl tab 10 mg ................ 95 fluphenazine hcl tab 2.5 mg ............... 95 fluphenazine hcl tab 5 mg .................. 95

flura-drops dro 0.125mg .................. 178 flura-drops dro 0.25mg f ................. 178 flurandrenolide cream 0.05% ........... 206 flurandrenolide lotion 0.05% ............ 207 flurandrenolide oint 0.05% .............. 207 FLURA-SAFE SOL ............................ 218 flurbiprofen sodium ophth soln 0.03% .................................................... 216 flurbiprofen tab 100 mg ...................... 3 flurbiprofen tab 50 mg ....................... 3 flurox sol op .................................. 218 flutamide cap 125 mg ...................... 38 fluticasone propionate cream 0.05% . 207 fluticasone propionate lotion 0.05% .. 207 fluticasone propionate nasal susp 50 mcg/act ........................................ 195 fluticasone propionate oint 0.005% ... 207 fluvastatin sodium cap 20 mg ............ 57 fluvastatin sodium cap 40 mg ............ 57 fluvastatin sodium tab er 24 hr 80 mg 57 fluvoxamine maleate cap er 24hr 100 mg ..................................................... 72 fluvoxamine maleate cap er 24hr 150 mg ..................................................... 73 fluvoxamine maleate tab 100 mg ....... 73 fluvoxamine maleate tab 25 mg ......... 73 fluvoxamine maleate tab 50 mg ......... 73 FML FORTE SUS 0.25% OP .............. 216 FML LIQUIFLM SUS 0.1% OP ............ 216 FML OIN 0.1% OP ........................... 216 foam antacid chw 80-20mg .............. 139 foam antacid sus ............................ 139 FOCALGIN 90 MIS DHA ................... 178 FOCALGIN CA MIS .......................... 178 FOCALGIN DSS TAB 90-1MG ............ 178 FOCALIN TAB 10MG ......................... 99 FOCALIN TAB 2.5MG ........................ 98 FOCALIN TAB 5MG ........................... 99 FOCALIN XR CAP 10MG .................... 99 FOCALIN XR CAP 15MG .................... 99 FOCALIN XR CAP 20MG .................... 99 FOCALIN XR CAP 25MG .................... 99 FOCALIN XR CAP 30MG .................... 99 FOCALIN XR CAP 35MG .................... 99 FOCALIN XR CAP 40MG .................... 99 FOCALIN XR CAP 5MG ...................... 99 folbee plus tab ............................... 178 FOLCAPS CAP OMEGA 3 ................... 178

258

FOLET DHA PAK ............................. 178 FOLET ONE CAP 38-1-225 ............... 178 FOLGARD OS TAB ........................... 178 folic acid inj 5 mg/ml ...................... 174 folic acid tab 1 mg .......................... 174 folic acid tab 400 mcg ..................... 174 folic acid tab 800 mcg ..................... 174 FOLOTYN INJ 20MG/ML ..................... 37 FOLOTYN INJ 40MG/2ML ................... 37 fomepizole inj 1 gm/ml (for iv infusion) ................................................... 122 fondaparinux sodium subcutaneous inj 10 mg/0.8ml ................................. 155 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml ................................ 154 fondaparinux sodium subcutaneous inj 5 mg/0.4ml ...................................... 155 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml ................................ 155 FORFIVO XL TAB 450MG.................... 81 formaldehyde solution 10% ............. 204 forma-ray sol 20% ......................... 204 FORTAMET TAB 1000MG .................. 113 FORTAMET TAB 500MG ................... 113 FORTAVIT CAP ............................... 178 FORTAZ INJ 1GM .............................. 20 FORTAZ INJ 2GM .............................. 20 FORTAZ INJ 500MG .......................... 20 FORTAZ INJ 6GM .............................. 20 FORTEO SOL 600/2.4 ...................... 124 FORTESTA GEL 10MG/ACT ............... 112 FOSAMAX + D TAB 70-2800 ............ 124 FOSAMAX + D TAB 70-5600 ............ 124 FOSAMAX TAB 70MG ...................... 124 FOSCAVIR INJ 24MG/ML .................... 31 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg ................................ 46 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg ................................ 46 fosinopril sodium tab 10 mg ............... 48 fosinopril sodium tab 20 mg ............... 48 fosinopril sodium tab 40 mg ............... 48 fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) ............................. 74 fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) ............................. 74 FOSRENOL CHW 1000MG ................ 135 FOSRENOL CHW 500MG .................. 135

FOSRENOL CHW 750MG .................. 135 FRAGMIN INJ 10000/ML .................. 155 FRAGMIN INJ 12500UNT .................. 155 FRAGMIN INJ 15000UNT .................. 155 FRAGMIN INJ 18000UNT .................. 155 FRAGMIN INJ 2500/0.2 ................... 155 FRAGMIN INJ 5000/0.2 ................... 155 FRAGMIN INJ 7500/0.3 ................... 155 FRAGMIN INJ 95000UNT .................. 155 FREAMINE HBC INJ 6.9% ................. 171 FREAMINE III INJ 10% .................... 171 FREESTYLE KIT FREEDOM ................ 119 FREESTYLE KIT INSULINX ................ 119 FREESTYLE KIT SIDEKICK ................ 119 FREESTYLE KIT SYSTEM .................. 119 FREESTYLE LIQ CONTROL ................ 119 FREESTYLE MIS LITE ....................... 119 FREESTYLE TES .............................. 119 FREESTYLE TES INSULINX ............... 120 FREESTYLE TES LITE ....................... 120 FROVA TAB 2.5MG .......................... 105 frovatriptan succinate tab 2.5 mg (base equivalent) .................................... 105 FUL-GLO TES 0.6MG OP .................. 218 FURADANTIN SUS 25MG/5ML ............ 34 furosemide inj 10 mg/ml .................. 65 furosemide oral soln 10 mg/ml .......... 65 furosemide oral soln 8 mg/ml ............ 65 furosemide tab 20 mg ...................... 65 furosemide tab 40 mg ...................... 65 furosemide tab 80 mg ...................... 66 FUSION PLUS CAP .......................... 178 FUZEON INJ 90MG ........................... 28 fyavolv tab 1-5 ............................... 127 FYCOMPA TAB 10MG ........................ 75 FYCOMPA TAB 12MG ........................ 75 FYCOMPA TAB 2MG .......................... 74 FYCOMPA TAB 4MG .......................... 74 FYCOMPA TAB 6MG .......................... 75 FYCOMPA TAB 8MG .......................... 75 G G4 SENSOR MIS ............................. 120 gabapentin cap 100 mg .................... 75 gabapentin cap 300 mg .................... 75 gabapentin cap 400 mg .................... 75 gabapentin oral soln 250 mg/5ml ....... 75 gabapentin tab 600 mg .................... 75 gabapentin tab 800 mg .................... 75

259

GABITRIL TAB 12MG ......................... 75 GABITRIL TAB 16MG ......................... 75 GABITRIL TAB 2MG .......................... 75 GABITRIL TAB 4MG .......................... 75 GABLOFEN INJ 10000/20 ................. 109 GABLOFEN INJ 20000/20 ................. 109 GABLOFEN INJ 40000/20 ................. 109 GABLOFEN INJ 50MCG/ML ............... 109 galantamine hydrobromide cap er 24hr 16 mg ............................................ 80 galantamine hydrobromide cap er 24hr 24 mg ............................................ 80 galantamine hydrobromide cap er 24hr 8 mg ................................................. 80 galantamine hydrobromide oral soln 4 mg/ml ............................................ 80 galantamine hydrobromide tab 12 mg . 80 galantamine hydrobromide tab 4 mg ... 80 galantamine hydrobromide tab 8 mg ... 80 GALZIN CAP 25MG ......................... 178 GALZIN CAP 50MG ......................... 178 GAMASTAN S/D INJ ........................ 164 GAMMAGARD INJ 10GM/100 ............ 164 GAMMAGARD INJ 1GM/10ML ............ 164 GAMMAGARD INJ 2.5GM/25 ............. 164 GAMMAGARD INJ 20GM/200 ............ 164 GAMMAGARD INJ 30GM/300 ............ 164 GAMMAGARD INJ 5GM/50ML ............ 164 GAMMAGARD SD INJ 10GM HU ......... 164 GAMMAGARD SD INJ 5GM HU .......... 164 GAMMAKED INJ 10GM/100 .............. 164 GAMMAKED INJ 1GM/10ML .............. 164 GAMMAKED INJ 2.5GM/25 ............... 164 GAMMAKED INJ 20GM/200 .............. 164 GAMMAKED INJ 5GM/50ML .............. 164 GAMMAPLEX INJ 5% ....................... 164 GAMUNEX-C INJ 10GM/100 ............. 164 GAMUNEX-C INJ 1GM/10ML ............. 164 GAMUNEX-C INJ 2.5GM/25 .............. 164 GAMUNEX-C INJ 20GM/200 ............. 164 GAMUNEX-C INJ 5GM/50ML ............. 164 ganciclovir sodium for inj 500 mg ....... 31 gas relief cap 125mg ...................... 147 gas relief cap 180mg ...................... 147 gas relief chw 80mg ....................... 147 gas relief dro 40/0.6ml .................... 147 gas relief liq infants ........................ 147 GASTROCROM CON 100/5ML ........... 147

GAS-X EX-STR MIS 62.5MG ............. 147 gatifloxacin ophth soln 0.5% ............ 215 GATTEX KIT 5MG ............................ 147 gavilyte-c sol ................................. 144 gavilyte-g sol ................................. 145 gavilyte-h kit ................................. 145 gavilyte-n sol flav pk ....................... 145 GAVISCON CHW ............................. 139 GAVISCON SUS CHERRY .................. 139 GELCLAIR GEL ............................... 214 GELFILM MIS ENVELOPE .................. 160 GELFILM MIS OP............................. 219 GELFOAM MIS DENTAL 4 ................. 160 GELFOAM MIS SPON COM ................ 160 GELFOAM MIS SPONG 50 ................. 160 GELFOAM MIS SPONG200 ................ 160 GELFOAM POW ............................... 160 GEL-KAM CON 0.63% ...................... 214 GELNIQUE GEL 10% ....................... 153 GELUSIL CHW ................................ 139 gemcitabine hcl for inj 1 gm .............. 37 gemcitabine hcl for inj 2 gm .............. 37 gemcitabine hcl for inj 200 mg .......... 37 gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) (base equiv) ........................ 38 gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) (base equiv) ........................ 38 gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) (base equiv) ........................ 38 gemfibrozil tab 600 mg .................... 56 GEMZAR INJ 1GM ............................ 38 GEMZAR INJ 200MG ......................... 38 GENADUR LIQ ................................ 210 GENERESS FE CHW ......................... 126 gengraf cap 50mg .......................... 166 gengraf sol 100mg/ml ..................... 166 GENOTROPIN INJ 0.2MG .................. 132 GENOTROPIN INJ 0.4MG .................. 132 GENOTROPIN INJ 0.6MG .................. 132 GENOTROPIN INJ 0.8MG .................. 132 GENOTROPIN INJ 1.2MG .................. 132 GENOTROPIN INJ 1.4MG .................. 132 GENOTROPIN INJ 1.6MG .................. 132 GENOTROPIN INJ 1.8MG .................. 132 GENOTROPIN INJ 12MG ................... 133 GENOTROPIN INJ 1MG .................... 133 GENOTROPIN INJ 2MG .................... 133 GENTAM/NACL INJ 0.9MG/ML ............ 17

260

gentamicin in saline inj 0.8 mg/ml ...... 17 gentamicin in saline inj 1 mg/ml ......... 17 gentamicin in saline inj 1.2 mg/ml ...... 17 gentamicin in saline inj 1.6 mg/ml ...... 17 gentamicin in saline inj 2 mg/ml ......... 17 gentamicin sulfate cream 0.1% ........ 201 gentamicin sulfate inj 10 mg/ml ......... 17 gentamicin sulfate inj 40 mg/ml ......... 17 gentamicin sulfate iv soln 10 mg/ml .... 17 gentamicin sulfate oint 0.1% ........... 201 gentamicin sulfate ophth oint 0.3%... 215 gentamicin sulfate ophth soln 0.3% .. 215 GENTEAL MILD DRO 0.2% ............... 219 GENTIAN VIOL SOL 2% ................... 210 GENTLE-LET MIS PLATFORM ............ 120 GENVISC 850 INJ 25/2.5 ................... 16 GENVOYA TAB ................................. 27 GEODON CAP 20MG .......................... 90 GEODON CAP 40MG .......................... 90 GEODON CAP 60MG .......................... 90 GEODON CAP 80MG .......................... 91 GEODON INJ 20MG ........................... 91 geri-mucil pow 68% ....................... 145 GIAZO TAB 1.1GM .......................... 143 GILENYA CAP 0.5MG ....................... 108 GILOTRIF TAB 20MG ......................... 40 GILOTRIF TAB 30MG ......................... 40 GILOTRIF TAB 40MG ......................... 40 GLASSIA INJ .................................. 194 glatopa inj 20mg/ml ....................... 108 GLENAX PEB LIQ ............................ 186 GLEOSTINE CAP 100MG .................... 36 GLEOSTINE CAP 10MG ...................... 36 GLEOSTINE CAP 40MG ...................... 36 GLEOSTINE CAP 5MG ........................ 36 GLIADEL WAF 7.7MG ........................ 36 glimepiride tab 1 mg ....................... 118 glimepiride tab 2 mg ....................... 118 glimepiride tab 4 mg ....................... 118 glipizide tab 10 mg ......................... 118 glipizide tab 5 mg ........................... 118 glipizide tab er 24hr 10 mg .............. 118 glipizide tab er 24hr 5 mg ................ 118 glipizide xl tab 2.5mg ...................... 118 glipizide-metformin hcl tab 2.5-250 mg ................................................... 113 glipizide-metformin hcl tab 2.5-500 mg ................................................... 113

glipizide-metformin hcl tab 5-500 mg 113 GLUCAGEN INJ 1MG ........................ 132 GLUCAGEN INJ HYPOKIT.................. 132 GLUCAGON KIT 1MG ....................... 132 gluco shot liq ................................. 171 glucose drnk liq 15/59ml ................. 132 glucose gel 40% ............................. 132 GLUMETZA TAB 1000MG .................. 113 GLUMETZA TAB 500MG ................... 113 GLUTARALDEHY SOL 25%................ 204 glyburide micronized tab 1.5 mg ....... 118 glyburide micronized tab 3 mg ......... 118 glyburide micronized tab 6 mg ......... 118 glyburide tab 1.25 mg ..................... 118 glyburide tab 2.5 mg ....................... 118 glyburide tab 5 mg ......................... 118 glyburide-metformin tab 1.25-250 mg .................................................... 113 glyburide-metformin tab 2.5-500 mg . 113 glyburide-metformin tab 5-500 mg ... 113 glycerin ped sup 1.2gm ................... 145 glycerin sup 1gm ............................ 145 glycerin sup 2.1gm ......................... 145 glycerin sup 2gm ............................ 145 glycerin topical liquid ...................... 208 GLYCOPHOS SOL 1MM/ML ............... 173 glycopyrrolate inj 0.2 mg/ml ............ 142 glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) ......................................... 142 glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) .................................................... 142 glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) ......................................... 142 glycopyrrolate tab 1 mg................... 142 glycopyrrolate tab 2 mg................... 142 GLYSET TAB 100MG ........................ 113 GLYSET TAB 25MG .......................... 113 GLYSET TAB 50MG .......................... 113 GLYXAMBI TAB 10-5 MG .................. 118 GLYXAMBI TAB 25-5 MG .................. 118 GNP DAY TIME LIQ MUCUS DM ......... 189 gnp glycerin sol rosewatr ................. 208 gnp iron tab 65mg .......................... 178 gnp tussin syp cf ............................ 189 GOLYTELY SOL ............................... 145 GORDONS UREA OIN 22% ............... 208 GORDONS UREA OIN 40% ............... 208 grafco silvr mis nit appl ................... 210

261

GRALISE STAR MIS 300/600 ............ 110 GRALISE TAB 300MG ...................... 110 GRALISE TAB 600MG ...................... 110 granisetron hcl inj 0.1 mg/ml ........... 140 granisetron hcl inj 1 mg/ml .............. 140 granisetron hcl inj 4 mg/4ml (1 mg/ml) ................................................... 140 granisetron hcl tab 1 mg ................. 140 GRANIX INJ 300/0.5 ....................... 159 GRANIX INJ 480/0.8 ....................... 159 griseofulvin microsize susp 125 mg/5ml ..................................................... 26 griseofulvin microsize tab 500 mg ....... 26 griseofulvin ultramicrosize tab 125 mg 26 griseofulvin ultramicrosize tab 250 mg 26 GRIS-PEG TAB 125MG ...................... 26 GRIS-PEG TAB 250MG ...................... 26 guaiatussin syp 100-10/5 ................ 189 guaifenesin tab er 12hr 1200 mg ...... 192 guanfacine hcl tab 1 mg .................... 49 guanfacine hcl tab 2 mg .................... 49 guanfacine hcl tab er 24hr 1 mg (base equiv) ............................................. 99 guanfacine hcl tab er 24hr 2 mg (base equiv) ............................................. 99 guanfacine hcl tab er 24hr 3 mg (base equiv) ............................................. 99 guanfacine hcl tab er 24hr 4 mg (base equiv) ............................................. 99 GUANIDINE TAB 125MG .................. 107 GUARDIAN RT MIS REPLACE ............ 120 GYNAZOLE-1 CRE 2% ..................... 154 H H.P. ACTHAR INJ 80UNIT ................. 134 HAEGARDA INJ 2000UNIT................ 160 HAEGARDA INJ 3000UNIT................ 161 HALAC KIT .................................... 204 HALAVEN INJ 1MG/2ML ..................... 43 HALCION TAB 0.25MG ..................... 102 HALDOL DECAN INJ 100MG/ML .......... 95 HALDOL DECAN INJ 50MG/ML ............ 95 HALDOL INJ 5MG/ML ........................ 95 halobetasol propionate cream 0.05% 208 halobetasol propionate oint 0.05% .... 208 HALOG CRE 0.1% ........................... 205 HALOG OIN 0.1% ........................... 205 haloperidol decanoate im soln 100 mg/ml ..................................................... 95

haloperidol decanoate im soln 50 mg/ml ..................................................... 95 haloperidol lactate inj 5 mg/ml .......... 95 haloperidol lactate oral conc 2 mg/ml . 95 haloperidol tab 0.5 mg ..................... 95 haloperidol tab 1 mg ........................ 95 haloperidol tab 10 mg ...................... 95 haloperidol tab 2 mg ........................ 95 haloperidol tab 20 mg ...................... 95 haloperidol tab 5 mg ........................ 95 HARVONI TAB 90-400MG .................. 31 h-chlor 12 sol 0.125% ..................... 204 healthy kids chw overall .................. 178 heartbrn rel tab 75mg ..................... 143 HECTOROL CAP 0.5MCG .................. 133 HECTOROL CAP 1MCG ..................... 133 HECTOROL CAP 2.5MCG .................. 133 HECTOROL INJ 2MCG/ML ................. 133 HELIXATE FS INJ 1000UNIT ............. 157 HELIXATE FS INJ 2000UNIT ............. 157 HELIXATE FS INJ 250UNIT ............... 157 HELIXATE FS INJ 3000UNIT ............. 157 HELIXATE FS INJ 500UNIT ............... 157 HEMABATE INJ 250MCG .................. 134 HEMANGEOL SOL 4.28/ML ................ 60 hematogen cap .............................. 178 HEMATOGEN FA CAP ....................... 178 HEMATRON-AF TAB ......................... 178 HEMENATAL OB MIS + DHA ............. 178 hemocyte-f tab .............................. 178 HEMOFIL M INJ 1000UNIT................ 157 HEMOFIL M INJ 1700UNIT................ 157 HEMOFIL M INJ 250UNIT ................. 157 HEMOFIL M INJ 500UNIT ................. 157 hemorrhoidal sup ........................... 147 hemorrhoidal sup 0.25% ................. 147 HEP SOD/NACL INJ 25000UNT .......... 155 HEPAGAM B INJ .............................. 164 HEPARIN SOD INJ 2000/ML .............. 155 heparin sodium (porcine) inj 1000 unit/ml .......................................... 155 heparin sodium (porcine) inj 10000 unit/ml .......................................... 155 heparin sodium (porcine) inj 20000 unit/ml .......................................... 155 heparin sodium (porcine) inj 5000 unit/ml .......................................... 155 heparin sodium (porcine) pf inj 5000

262

unit/0.5ml ..................................... 155 hepatamine sol 8% ......................... 171 HEPSERA TAB 10MG ......................... 31 HERCEPTIN INJ 440MG ..................... 43 HETLIOZ CAP 20MG ........................ 103 HEXALEN CAP 50MG ......................... 36 high power liq body wsh .................. 210 HIPREX TAB 1GM ........................... 152 HIZENTRA INJ 10/50ML ................... 165 HIZENTRA INJ 1GM/5ML .................. 165 HIZENTRA INJ 2GM/10ML ................ 165 HIZENTRA INJ 4GM/20ML ................ 165 HOLD LOZ 5MG ORIG ..................... 190 homatropine hbr ophth soln 5% ....... 220 HONEY BEARS CHW ........................ 178 HONEY BEARS CHW IRON-ZIN ......... 179 HORIZANT TAB 300MG.................... 112 HORIZANT TAB 600MG.................... 112 HPR PLUS CRE ............................... 210 H-TRON PLUS MIS INS PUMP ........... 120 HUBER NEEDLE MIS 20GX1" ............ 167 HUMALOG INJ 100/ML ..................... 115 HUMALOG KWIK INJ 100/ML ............ 115 HUMALOG KWIK INJ 200/ML ............ 115 HUMALOG MIX INJ 50/50 ................ 115 HUMALOG MIX INJ 50/50KWP .......... 115 HUMALOG MIX INJ 75/25KWP .......... 115 HUMALOG MIX SUS 75/25 ............... 115 HUMAPEN MIS LUXURA ................... 120 HUMATE-P SOL 2400UNIT ............... 157 HUMATE-P SOL 250-600 .................. 157 HUMATE-P SOL 500-1200 ................ 157 HUMATROPE INJ 12MG .................... 133 HUMATROPE INJ 24MG .................... 133 HUMATROPE INJ 5MG ..................... 133 HUMATROPE INJ 6MG ..................... 133 HUMIRA INJ 10MG/0.2 .................... 163 HUMIRA KIT 20MG/0.4 .................... 163 HUMIRA KIT 40MG/0.8 .................... 163 HUMIRA PEN INJ 40MG/0.8 .............. 163 HUMULIN INJ 70/30 ........................ 116 HUMULIN INJ 70/30KWP ................. 116 HUMULIN N INJ U-100 .................... 116 HUMULIN N INJ U-100KWP .............. 116 HUMULIN R INJ U-100 .................... 116 HUMULIN R INJ U-500 .................... 116 HYALGAN INJ 20MG/2ML ................... 16 hyaluronate sodium (emollient) gel 0.2%

.................................................... 208 HYCET SOL 7.5-325 ........................... 9 HYCOFENIX SOL ............................. 189 hydralazine hcl inj 20 mg/ml ............. 67 hydralazine hcl tab 10 mg ................. 67 hydralazine hcl tab 100 mg ............... 67 hydralazine hcl tab 25 mg ................. 67 hydralazine hcl tab 50 mg ................. 67 HYDREA CAP 500MG ........................ 43 hydrocerin cre plus ......................... 210 hydrochlorothiazide cap 12.5 mg ....... 66 hydrochlorothiazide tab 12.5 mg ........ 66 hydrochlorothiazide tab 25 mg .......... 66 hydrochlorothiazide tab 50 mg .......... 66 HYDROCIL INS POW 95% ................ 145 hydrocod polst-chlorphen polst er susp 10-8 mg/5ml ................................. 189 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml ................................... 189 hydrocodone w/ homatropine tab 5-1.5 mg ............................................... 189 hydrocodone-acetaminophen soln 10-325 mg/15ml .......................................... 9 hydrocodone-acetaminophen soln 7.5-325 mg/15ml .................................... 9 hydrocodone-acetaminophen tab 10-300 mg .................................................. 9 hydrocodone-acetaminophen tab 10-325 mg .................................................. 9 hydrocodone-acetaminophen tab 5-300 mg .................................................. 9 hydrocodone-acetaminophen tab 5-325 mg .................................................. 9 hydrocodone-acetaminophen tab 7.5-300 mg .................................................. 9 hydrocodone-acetaminophen tab 7.5-325 mg .................................................. 9 hydrocodone-ibuprofen tab 7.5-200 mg 9 hydrocort cre 0.5% ......................... 206 hydrocort oin 0.5% ......................... 206 hydrocortisone acetate w/ pramoxine rectal cream 1-1% .......................... 150 hydrocortisone butyrate cream 0.1% . 207 hydrocortisone butyrate hydrophilic lipo base cream 0.1% ........................... 207 hydrocortisone butyrate oint 0.1% .... 207 hydrocortisone butyrate soln 0.1% .... 207 hydrocortisone cream 1% ................ 206

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hydrocortisone cream 2.5% ............. 206 hydrocortisone enema 100 mg/60ml . 144 hydrocortisone lotion 2.5% .............. 206 hydrocortisone oint 1% ................... 206 hydrocortisone oint 2.5% ................ 206 hydrocortisone rectal cream 1% ....... 150 hydrocortisone rectal cream 2.5% .... 150 hydrocortisone tab 10 mg ................ 131 hydrocortisone tab 20 mg ................ 131 hydrocortisone tab 5 mg ................. 131 hydrocortisone valerate cream 0.2% . 207 hydrocortisone valerate oint 0.2% .... 207 hydrocortisone w/ acetic acid otic soln 1-2% ............................................... 221 hydrocortisone-aloe vera cream 0.5%204 hydrocortisone-aloe vera cream 1% .. 204 HYDROGEL DRE PAD 2"X3" .............. 213 HYDROGEL DRE PAD 4"X5" .............. 213 hydromorphone hcl inj 1 mg/ml .......... 9 hydromorphone hcl inj 2 mg/ml .......... 9 hydromorphone hcl inj 4 mg/ml .......... 9 hydromorphone hcl liqd 1 mg/ml ......... 9 hydromorphone hcl preservative free (pf) inj 10 mg/ml .................................... 9 hydromorphone hcl tab 2 mg .............. 9 hydromorphone hcl tab 4 mg .............. 9 hydromorphone hcl tab 8 mg .............. 9 hydromorphone hcl tab er 24hr deter 12 mg .................................................. 9 hydromorphone hcl tab er 24hr deter 16 mg .................................................. 9 hydromorphone hcl tab er 24hr deter 32 mg .................................................. 9 hydromorphone hcl tab er 24hr deter 8 mg .................................................. 9 hydroxychloroquine sulfate tab 200 mg ................................................... 163 hydroxyurea cap 500 mg ................... 43 hydroxyzine hcl im soln 25 mg/ml .... 188 hydroxyzine hcl im soln 50 mg/ml .... 188 hydroxyzine hcl syrup 10 mg/5ml ..... 188 hydroxyzine hcl tab 10 mg ............... 188 hydroxyzine hcl tab 25 mg ............... 188 hydroxyzine hcl tab 50 mg ............... 188 hydroxyzine pamoate cap 100 mg .... 188 hydroxyzine pamoate cap 25 mg ...... 188 hydroxyzine pamoate cap 50 mg ...... 188 HYGEL GEL 2.5% ........................... 213

HYLENEX INJ 150 UNIT ................... 107 hyolev mb tab 81mg ....................... 152 hyoscyamine sulfate elixir 0.125 mg/5ml .................................................... 142 hyoscyamine sulfate soln 0.125 mg/ml .................................................... 142 hyoscyamine sulfate tab 0.125 mg .... 142 hyoscyamine sulfate tab disint 0.125 mg .................................................... 142 hyoscyamine sulfate tab er 12hr 0.375 mg ............................................... 142 hyoscyamine sulfate tab sl 0.125 mg . 142 hyperlyte-cr inj .............................. 172 HYPERSAL NEB 3.5% ...................... 194 HYPER-SAL NEB 7% ........................ 194 HYPO NEEDLE MIS 18GX1" .............. 167 HYPO NEEDLE MIS 19GX1.5" ............ 167 HYPO NEEDLE MIS 21GX1" .............. 167 HYPO NEEDLE MIS 22GX1.5" ............ 167 HYPO NEEDLE MIS 23GX1" .............. 167 HYPO NEEDLE MIS 23GX1.5" ............ 167 HYPO NEEDLE MIS 23GX1/2" ........... 167 HYPO NEEDLE MIS 25GX1" .............. 167 HYPO NEEDLE MIS 25GX1.5" ............ 167 HYPO NEEDLE MIS 25GX5/8" ........... 167 HYPO NEEDLE MIS 26GX1.5" ............ 167 HYPO NEEDLE MIS 26GX1/2" ........... 167 HYPO NEEDLE MIS 27GX1/2" ........... 167 HYPO NEEDLE MIS 30GX3/4" ........... 167 HYPOTEARS SOL 1-1% .................... 219 HYQVIA INJ 10-800 ........................ 165 HYQVIA INJ 2.5-200 ....................... 165 HYQVIA INJ 20-1600 ....................... 165 HYQVIA INJ 30-2400 ....................... 165 HYQVIA INJ 5-400 .......................... 165 hysept sol 0.25% ........................... 204 hysept sol 0.5% ............................. 204 HYSINGLA ER TAB 100 MG ................ 10 HYSINGLA ER TAB 120 MG ................ 10 HYSINGLA ER TAB 20 MG ................... 9 HYSINGLA ER TAB 30 MG ................... 9 HYSINGLA ER TAB 40 MG ................. 10 HYSINGLA ER TAB 60 MG ................. 10 HYSINGLA ER TAB 80 MG ................. 10 HYZAAR TAB 100-12.5 ..................... 52 HYZAAR TAB 100-25 ........................ 52 HYZAAR TAB 50-12.5 ....................... 52

264

I ibandronate sodium tab 150 mg (base equivalent) .................................... 124 IBRANCE CAP 100MG ........................ 40 IBRANCE CAP 125MG ........................ 40 IBRANCE CAP 75MG.......................... 40 ibudone tab 10-200mg ...................... 10 ibudone tab 5-200mg ....................... 10 ibuprofen cap 200 mg ........................ 3 ibuprofen dro 50/1.25 ........................ 3 ibuprofen jr chw 100mg ..................... 3 ibuprofen susp 100 mg/5ml ................ 3 ibuprofen tab 200 mg ........................ 3 ibuprofen tab 400 mg ........................ 3 ibuprofen tab 600 mg ........................ 3 ibuprofen tab 800 mg ........................ 3 ibutilide fumarate inj 1 mg/10ml ........ 54 icar-c plus tab ................................ 179 ICLUSIG TAB 15MG .......................... 40 ICLUSIG TAB 45MG .......................... 40 IDAMYCIN PFS INJ 10/10ML ............... 43 IDAMYCIN PFS INJ 20/20ML ............... 43 IDAMYCIN PFS INJ 5MG/5ML .............. 43 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) ........................................... 43 idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) ........................................... 43 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) ..................................................... 43 IFEX INJ 1GM .................................. 36 IFEX INJ 3GM .................................. 36 ifosfamide for inj 1 gm ...................... 36 ifosfamide iv inj 1 gm/20ml (50 mg/ml) ..................................................... 36 ifosfamide iv inj 3 gm/60ml (50 mg/ml) ..................................................... 36 ILARIS (150) INJ 180MG ................. 166 ILARIS INJ 150MG/ML ..................... 166 ILEVRO DRO 0.3% OP ..................... 216 ilotycin oin op ................................ 215 imatinib mesylate tab 100 mg (base equivalent) ...................................... 40 imatinib mesylate tab 400 mg (base equivalent) ...................................... 40 IMBRUVICA CAP 140MG .................... 40 imipenem-cilastatin intravenous for soln 250 mg ........................................... 17 imipenem-cilastatin intravenous for soln

500 mg .......................................... 17 imipramine hcl tab 10 mg ................. 86 imipramine hcl tab 25 mg ................. 86 imipramine hcl tab 50 mg ................. 86 imipramine pamoate cap 100 mg ....... 86 imipramine pamoate cap 125 mg ....... 86 imipramine pamoate cap 150 mg ....... 86 imipramine pamoate cap 75 mg ......... 86 imiquimod cream 5% ...................... 210 IMITREX INJ 4MG/0.5 ..................... 105 IMITREX INJ 6MG/0.5 ..................... 105 IMITREX SPR 20MG/ACT .................. 105 IMITREX SPR 5MG/ACT ................... 105 IMITREX TAB 100MG ....................... 105 IMITREX TAB 25MG ........................ 105 IMITREX TAB 50MG ........................ 105 inatal adv tab ................................. 179 INCRELEX INJ 40MG/4ML ................. 134 INCRUSE ELPT INH 62.5MCG ............ 186 indapamide tab 1.25 mg ................... 66 indapamide tab 2.5 mg .................... 66 INDERAL LA CAP 120MG ................... 60 INDERAL LA CAP 160MG ................... 60 INDERAL LA CAP 60MG ..................... 60 INDERAL LA CAP 80MG ..................... 60 INDERAL XL CAP 120MG ................... 60 INDERAL XL CAP 80MG ..................... 60 indiomin mb cap 120mg .................. 152 INDOCIN SUP 50MG ........................... 3 indomethacin cap 25 mg .................... 3 indomethacin cap 50 mg .................... 3 indomethacin cap er 75 mg ................. 3 inf silapap dro 80/0.8ml ..................... 1 INFANATE CAP BALANCE ................. 179 INFASURF SUS 35MG/ML ................. 194 inflammacin mis 75-0.025 .................. 4 INFLECTRA INJ 100MG .................... 163 INFUMORPH INJ 10MG/ML ................ 10 INFUMORPH INJ 25MG/ML ................ 10 INFUS SYRING MIS 100ML ............... 167 INFUSION SET MIS 23" 6MM ............ 120 INFUSION SET MIS 23" 8MM ............ 120 INFUSION SET MIS 23"/6MM ............ 120 INFUSION SET MIS 23"/9MM ............ 120 INFUSION SET MIS 24" 6MM ............ 120 INFUSION SET MIS 24" 9MM ............ 120 INFUSION SET MIS 31" 9MM ............ 120 INFUSION SET MIS 32" 8MM ............ 120

265

INFUSION SET MIS 43"/6MM ........... 120 INFUSION SET MIS 43"/9MM ........... 120 INFUVITE INJ ................................. 173 INGREZZA CAP 40MG ..................... 107 INLYTA TAB 1MG .............................. 40 INLYTA TAB 5MG .............................. 40 INOVA 4/1 KIT ACNE CON ............... 199 INOVA 8/2 KIT ACNE CON ............... 199 INOVA KIT 4% ............................... 199 INOVA KIT 8% ............................... 199 INSPIREASE MIS RES BAG ............... 193 INSPRA TAB 25MG............................ 49 INSPRA TAB 50MG............................ 49 INSULIN PEN MIS 31GX4MM ............ 120 INSULIN PUMP KIT IR2020 .............. 120 INSULIN SYR MIS 0.3/31G .............. 120 INSULIN SYR MIS 0.5/31G .............. 120 INSULIN SYR MIS 1ML/31G ............. 120 INSULIN SYRG MIS 0.3/28G ............ 120 INSULIN SYRG MIS 0.3/29G ............ 120 INSULIN SYRG MIS 0.3/30G ............ 120 INSULIN SYRG MIS 0.3/31G ............ 120 INSULIN SYRG MIS 0.5/27G ............ 120 INSULIN SYRG MIS 0.5/28G ..... 120, 121 INSULIN SYRG MIS 0.5/29G ............ 121 INSULIN SYRG MIS 0.5/30G ............ 121 INSULIN SYRG MIS 0.5/31G ............ 121 INSULIN SYRG MIS 1ML .................. 121 INSULIN SYRG MIS 1ML/25G ........... 121 INSULIN SYRG MIS 1ML/26G ........... 121 INSULIN SYRG MIS 1ML/27G ........... 121 INSULIN SYRG MIS 1ML/28G ........... 121 INSULIN SYRG MIS 1ML/29G ........... 121 INSULIN SYRG MIS 1ML/30G ........... 121 INSULIN SYRG MIS 1ML/31G ........... 121 INSULIN SYRG MIS 2/27.5G ............ 121 INSULIN SYRG MIS 2ML/29G ........... 121 INSUL-TRAY MIS ............................ 120 INSUPEN MIS 32GX4MM .................. 121 INSUPEN MIS 33GX4MM .................. 121 INSUPEN SENS MIS 32GX6MM ......... 121 INSUPEN SENS MIS 32GX8MM ......... 121 INSUPEN ULTR MIS 30GX8MM .......... 121 INTEGRA F CAP .............................. 179 INTEGRA PLUS CAP ........................ 179 INTEGRILIN INJ ............................. 162 INTEGRILIN INJ 0.75MG/1 ............... 162 INTEGRILIN INJ 20/10ML ................ 162

INTELENCE TAB 100MG .................... 29 INTELENCE TAB 200MG .................... 29 INTELENCE TAB 25MG ...................... 29 intense coug liq reliever ................... 189 INTERMEZZO SUB 1.75MG ............... 103 INTERMEZZO SUB 3.5MG ................ 104 INTRALIPID INJ 30% ...................... 171 INTRAROSA SUP 6.5MG ................... 152 INTRON A INJ 10MU ........................ 165 INTRON A INJ 18MU ........................ 165 INTRON A INJ 25MU ........................ 165 INTRON A INJ 50MU ........................ 165 INTUNIV TAB 1MG ........................... 99 INTUNIV TAB 2MG ........................... 99 INTUNIV TAB 3MG ........................... 99 INTUNIV TAB 4MG ........................... 99 INVANZ INJ 1GM ............................. 17 INVEGA SUST INJ 117/0.75 .............. 91 INVEGA SUST INJ 156MG/ML ............ 91 INVEGA SUST INJ 234/1.5 ................ 91 INVEGA SUST INJ 39/0.25 ................ 91 INVEGA SUST INJ 78/0.5ML .............. 91 INVEGA TAB 1.5MG ......................... 91 INVEGA TAB 3MG ............................ 91 INVEGA TAB 6MG ............................ 91 INVEGA TAB 9MG ............................ 91 INVEGA TRINZ INJ 273MG ................ 91 INVEGA TRINZ INJ 410MG ................ 91 INVEGA TRINZ INJ 546MG ................ 91 INVEGA TRINZ INJ 819MG ................ 91 INVIRASE CAP 200MG ...................... 28 INVIRASE TAB 500MG ...................... 28 INVOKAMET TAB 150-1000 .............. 117 INVOKAMET TAB 150-500 ................ 117 INVOKAMET TAB 50-1000 ................ 117 INVOKAMET TAB 50-500MG ............. 117 INVOKAMET XR TAB 150-1000 ......... 117 INVOKAMET XR TAB 150-500 ........... 117 INVOKAMET XR TAB 50-1000 ........... 117 INVOKAMET XR TAB 50-500MG ........ 117 INVOKANA TAB 100MG .................... 118 INVOKANA TAB 300MG .................... 118 iodine solution strong 5% (lugol's) .... 136 IODOFLEX PAD PAD ........................ 204 IODOPEN INJ 100MCG ..................... 173 IODOSORB GEL .............................. 204 IONOSOL-B/ INJ D5W ..................... 172 IONOSOL-MB INJ /D5W ................... 172

266

IONSYS PAD 40MCG/AC .................... 10 ipratropium bromide inhal soln 0.02% ................................................... 186 ipratropium bromide nasal soln 0.03% (21 mcg/spray) .............................. 194 ipratropium bromide nasal soln 0.06% (42 mcg/spray) .............................. 194 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml ............................... 186 IPRIVASK INJ 15MG ........................ 155 irbesartan tab 150 mg ...................... 53 irbesartan tab 300 mg ...................... 53 irbesartan tab 75 mg ........................ 53 irbesartan-hydrochlorothiazide tab 150-12.5 mg .......................................... 52 irbesartan-hydrochlorothiazide tab 300-12.5 mg .......................................... 52 IRESSA TAB 250MG .......................... 40 irinotecan hcl inj 100 mg/5ml (20 mg/ml) ........................................... 45 irinotecan hcl inj 40 mg/2ml (20 mg/ml) ..................................................... 45 irinotecan hcl inj 500 mg/25ml (20 mg/ml) ........................................... 45 iron slow tab 45mg ......................... 179 iron supplmt dro 15mg/ml ............... 179 IRON UP LIQ .................................. 179 IS 24/6 MIS ................................... 179 ISENTRESS CHW 100MG ................... 28 ISENTRESS CHW 25MG ..................... 28 ISENTRESS POW 100MG ................... 28 ISENTRESS TAB 400MG .................... 28 ISOLYTE-P INJ /D5W ...................... 172 ISOLYTE-S INJ ............................... 172 ISOLYTE-S INJ PH 7.4 ..................... 172 isoniazid inj 100 mg/ml ..................... 30 isoniazid syrup 50 mg/5ml ................. 30 isoniazid tab 100 mg......................... 30 isoniazid tab 300 mg......................... 30 ISOPTO CARP SOL 1% OP ............... 220 ISOPTO CARP SOL 2% OP ............... 220 ISOPTO CARP SOL 4% OP ............... 220 ISOPTO TEARS SOL 0.5% OP ........... 219 ISORDIL TAB 40MG .......................... 68 ISORDIL TAB 5MG ............................ 68 isosorbide dinitrate tab 10 mg ............ 68 isosorbide dinitrate tab 20 mg ............ 68 isosorbide dinitrate tab 30 mg ............ 68

isosorbide dinitrate tab 5 mg ............. 68 isosorbide dinitrate tab er 40 mg ....... 68 isosorbide mononitrate tab 10 mg ...... 68 isosorbide mononitrate tab 20 mg ...... 68 isosorbide mononitrate tab er 24hr 120 mg ................................................ 68 isosorbide mononitrate tab er 24hr 30 mg ................................................ 68 isosorbide mononitrate tab er 24hr 60 mg ................................................ 68 isradipine cap 2.5 mg ....................... 62 isradipine cap 5 mg ......................... 62 ISTALOL SOL 0.5% OP .................... 217 ISTODAX INJ 10MG ......................... 43 ISUPREL INJ 0.2MG/ML ................... 191 itraconazole cap 100 mg ................... 26 IV PREP WIPE PAD .......................... 210 IXEMPRA KIT INJ 15MG .................... 43 IXEMPRA KIT INJ 45MG .................... 43 IXINITY INJ 1000UNIT ..................... 157 IXINITY INJ 1500UNIT ..................... 157 IXINITY INJ 500UNIT ...................... 157 J JADENU TAB 180MG ....................... 161 JADENU TAB 360MG ....................... 161 JADENU TAB 90MG ......................... 161 JAKAFI TAB 10MG ............................ 40 JAKAFI TAB 15MG ............................ 41 JAKAFI TAB 20MG ............................ 41 JAKAFI TAB 25MG ............................ 41 JAKAFI TAB 5MG ............................. 40 JALYN CAP ..................................... 151 JANUMET TAB 50-1000 .................... 114 JANUMET TAB 50-500MG ................. 113 JANUMET XR TAB 100-1000 ............. 114 JANUMET XR TAB 50-1000 ............... 114 JANUMET XR TAB 50-500MG ............ 114 JANUVIA TAB 100MG ...................... 114 JANUVIA TAB 25MG ........................ 114 JANUVIA TAB 50MG ........................ 114 JARDIANCE TAB 10MG .................... 118 JARDIANCE TAB 25MG .................... 118 JENTADUETO TAB 2.5-1000 ............. 114 JENTADUETO TAB 2.5-500 ............... 114 JENTADUETO TAB 2.5-850 ............... 114 JENTADUETO TAB XR ...................... 114 jevantique l tab 0.5-2.5 ................... 127 JEVTANA INJ 60/1.5ML ..................... 43

267

J-TAN PD DRO 1MG/ML ................... 188 JUBLIA SOL 10% ............................ 202 just for kid gel 0.4% grp ................. 214 JUXTAPID CAP 10MG ........................ 57 JUXTAPID CAP 20MG ........................ 58 JUXTAPID CAP 30MG ........................ 58 JUXTAPID CAP 40MG ........................ 58 JUXTAPID CAP 5MG .......................... 57 JUXTAPID CAP 60MG ........................ 58 K KADCYLA INJ 100MG ........................ 43 KADCYLA INJ 160MG ........................ 43 KADIAN CAP 100MG ER ..................... 10 KADIAN CAP 10MG ER ...................... 10 KADIAN CAP 200MG ER ..................... 10 KADIAN CAP 20MG ER ...................... 10 KADIAN CAP 30MG ER ...................... 10 KADIAN CAP 40MG ER ...................... 10 KADIAN CAP 50MG ER ...................... 10 KADIAN CAP 60MG ER ...................... 10 KADIAN CAP 80MG ER ...................... 10 KALETRA SOL .................................. 28 KALETRA TAB 100-25MG ................... 28 KALETRA TAB 200-50MG ................... 28 KALYDECO PAK 50MG ..................... 192 KALYDECO PAK 75MG ..................... 192 KALYDECO TAB 150MG ................... 192 KAPVAY TAB 0.1 MG ......................... 99 KARBINAL ER SUS 4MG/5ML ............ 188 KAYEXALATE POW .......................... 135 KAZANO 12.5- TAB 1000MG ............ 114 KAZANO 12.5- TAB 500MG .............. 114 KCENTRA KIT 1000UNIT .................. 162 KCENTRA KIT 500UNIT ................... 162 kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj ............................... 172 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj ................................. 172 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj ............................... 172 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj ............................... 172 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.9% inj ................................. 172 kcl 20 meq/l (0.15%) in nacl 0.45% inj ................................................... 172 kcl 20 meq/l (0.15%) in nacl 0.9% inj ................................................... 172

kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj ............................... 172 kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj ............................... 172 kcl 40 meq/l (0.3%) in nacl 0.9% inj . 172 KCL/D5W/LACT INJ 20MEQ/L ........... 172 KCL/D5W/LACT INJ 40MEQ/L ........... 172 KCL/D5W/NACL INJ 0.15/0.2 ........... 173 KCL/D5W/NACL INJ 0.3/0.9% .......... 172 KENALOG AER SPRAY ...................... 207 KENALOG-10 INJ 10MG/ML .............. 131 KENALOG-40 INJ 40MG/ML .............. 131 KEPIVANCE INJ 6.25MG ................... 147 KEPPRA INJ 500/5ML ....................... 75 KEPPRA SOL 100MG/ML .................... 75 KEPPRA TAB 1000MG ....................... 75 KEPPRA TAB 250MG ......................... 75 KEPPRA TAB 500MG ......................... 75 KEPPRA TAB 750MG ......................... 75 KEPPRA XR TAB 500MG .................... 75 KEPPRA XR TAB 750MG .................... 75 KERALYT GEL 6% ........................... 210 KERALYT KIT SCALP 6% .................. 210 KERLONE TAB 10MG ........................ 60 KERLONE TAB 20MG ........................ 60 KERR TRIPLE MIS DYE SWAB ........... 204 ketoconazole cream 2% .................. 202 ketoconazole shampoo 2% .............. 202 ketoconazole tab 200 mg .................. 26 ketodan aer 2% ............................. 202 KETONE TEST TES .......................... 121 ketoprofen cap 50 mg ........................ 3 ketoprofen cap 75 mg ........................ 3 ketoprofen cap er 24hr 200 mg ........... 3 ketorolac tromethamine ophth soln 0.4% .................................................... 216 ketorolac tromethamine ophth soln 0.5% .................................................... 216 ketorolac tromethamine tab 10 mg ...... 3 KEVEYIS TAB 50MG ........................ 218 KEYTRUDA INJ 100MG/4M ................ 43 KEYTRUDA SOL 50MG ...................... 43 KHEDEZLA TAB 100MG ER ................ 83 KHEDEZLA TAB 50MG ER .................. 82 KINERET INJ .................................. 163 KISQALI 200 PAK FEMARA ................ 39 KISQALI 400 PAK FEMARA ................ 40 KISQALI 600 PAK FEMARA ................ 40

268

KISQALI TAB 200DOSE ..................... 41 KISQALI TAB 400DOSE ..................... 41 KISQALI TAB 600DOSE ..................... 41 KITABIS PAK NEB 300/5ML .............. 192 KLARON LOT 10% .......................... 199 KLONOPIN TAB 0.5MG ...................... 72 KLONOPIN TAB 1MG ......................... 72 KLONOPIN TAB 2MG ......................... 72 klor-con 8 tab 8meq er ................... 170 KLOR-CON M15 TAB 15MEQ ER ........ 170 KOATE-DVI INJ 1000UNIT ............... 157 KOATE-DVI INJ 250UNIT ................. 157 KOATE-DVI INJ 500UNIT ................. 157 KOGENATE FS INJ 1000/BS ............. 158 KOGENATE FS INJ 1000UNIT ........... 158 KOGENATE FS INJ 2000/BS ............. 158 KOGENATE FS INJ 2000UNIT ........... 158 KOGENATE FS INJ 250/BS ............... 157 KOGENATE FS INJ 250UNIT ............. 158 KOGENATE FS INJ 3000/BS ............. 158 KOGENATE FS INJ 3000UNIT ........... 158 KOGENATE FS INJ 500/BS ............... 158 KOGENATE FS INJ 500UNIT ............. 158 KOMBIGLYZ XR TAB 2.5-1000 .......... 114 KOMBIGLYZ XR TAB 5-1000MG ........ 114 KOMBIGLYZ XR TAB 5-500MG .......... 114 KONDREMUL EMU 50% ................... 145 KONSYL POW 100% ....................... 145 KONSYL POW 28.3% ...................... 145 KONSYL POW 60.3% ...................... 145 KONSYL POW 71.67% ..................... 145 KOSHR PRENAT TAB 30-1MG ........... 179 KOVALTRY INJ 1000UNIT ................ 158 KOVALTRY INJ 2000UNIT ................ 158 KOVALTRY INJ 250UNIT .................. 158 KOVALTRY INJ 3000UNIT ................ 158 KOVALTRY INJ 500UNIT .................. 158 K-PHOS TAB .................................. 170 K-PHOS TAB NO 2 .......................... 170 KPN PRENATAL TAB ........................ 179 KRISTALOSE PAK 10GM .................. 145 KRISTALOSE PAK 20GM .................. 145 K-TAB TAB 10MEQ CR ..................... 170 K-TAB TAB 20MEQ .......................... 170 KUVAN POW 100MG ....................... 135 KUVAN POW 500MG ....................... 135 KUVAN TAB 100MG ......................... 135 KYNAMRO INJ 200MG/ML .................. 58

KYPROLIS SOL 60MG ....................... 43 L labetalol hcl iv soln 5 mg/ml ............. 60 labetalol hcl tab 100 mg ................... 60 labetalol hcl tab 200 mg ................... 60 labetalol hcl tab 300 mg ................... 60 LAC-HYDRIN CRE 12% .................... 208 LAC-HYDRIN LOT 12% .................... 208 LACRISERT MIS 5MG OP .................. 219 lactated ringer's for irrigation ........... 213 lactated ringer's solution.................. 173 lactic acid (ammonium lactate) cream 12% ............................................. 208 lactic acid (ammonium lactate) lotion 12% ............................................. 208 LACTINEX CHW .............................. 147 lactobacillus acidophilus-pectin cap ... 147 LAMICTAL CHW 25MG ...................... 75 LAMICTAL CHW 5MG ........................ 75 LAMICTAL KIT START 35 ................... 75 LAMICTAL KIT START 49 ................... 75 LAMICTAL KIT START 98 ................... 75 LAMICTAL ODT KIT .......................... 75 LAMICTAL ODT TAB 100MG ............... 75 LAMICTAL ODT TAB 200MG ............... 75 LAMICTAL ODT TAB 25MG ................ 75 LAMICTAL ODT TAB 50MG ................ 75 LAMICTAL TAB 100MG ...................... 75 LAMICTAL TAB 150MG ...................... 75 LAMICTAL TAB 200MG ...................... 75 LAMICTAL TAB 25MG ....................... 75 LAMICTAL XR KIT ............................ 76 LAMICTAL XR TAB 100MG ................. 76 LAMICTAL XR TAB 200MG ................. 76 LAMICTAL XR TAB 250MG ................. 76 LAMICTAL XR TAB 25MG ................... 76 LAMICTAL XR TAB 300MG ................. 76 LAMICTAL XR TAB 50MG ................... 76 LAMISIL ADV GEL 1% ..................... 202 LAMISIL TAB 250MG ........................ 26 lamivudine oral soln 10 mg/ml .......... 29 lamivudine tab 100 mg (hbv) ............ 31 lamivudine tab 150 mg ..................... 29 lamivudine tab 300 mg ..................... 29 lamivudine-zidovudine tab 150-300 mg ..................................................... 27 lamotrigine orally disintegrating tab 100 mg ................................................ 76

269

lamotrigine orally disintegrating tab 200 mg ................................................. 76 lamotrigine orally disintegrating tab 25 mg ................................................. 76 lamotrigine orally disintegrating tab 50 mg ................................................. 76 lamotrigine tab 100 mg ..................... 76 lamotrigine tab 150 mg ..................... 76 lamotrigine tab 200 mg ..................... 76 lamotrigine tab 25 mg ....................... 76 lamotrigine tab chewable dispersible 25 mg ................................................. 76 lamotrigine tab chewable dispersible 5 mg ................................................. 76 lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg (7) kit ....................... 76 lamotrigine tab disint 25 mg (21) & 50 mg (7) titration kit ........................... 76 lamotrigine tab disint 50 mg (42)- 100 mg(14) titration kit ........................... 76 lamotrigine tab er 24hr 100 mg .......... 76 lamotrigine tab er 24hr 200 mg .......... 76 lamotrigine tab er 24hr 25 mg ........... 76 lamotrigine tab er 24hr 250 mg .......... 76 lamotrigine tab er 24hr 300 mg .......... 76 lamotrigine tab er 24hr 50 mg ........... 76 lanacort 10 cre 1% ......................... 206 LANCETS MIS ................................ 121 LANCING DEVI MIS ........................ 122 LANOXIN INJ 0.25MG/1 ..................... 65 LANOXIN PED INJ 0.1MG/ML .............. 65 LANOXIN TAB 0.0625MG ................... 65 LANOXIN TAB 0.125MG ..................... 65 LANOXIN TAB 0.1875MG ................... 65 LANOXIN TAB 0.25MG ....................... 65 lansoprazole cap delayed release 15 mg ................................................... 148 lansoprazole cap delayed release 30 mg ................................................... 148 LANTUS INJ 100/ML ........................ 116 LANTUS INJ SOLOSTAR ................... 116 LASIX TAB 20MG .............................. 66 LASIX TAB 40MG .............................. 66 LASIX TAB 80MG .............................. 66 LASTACAFT SOL 0.25% ................... 217 latanoprost ophth soln 0.005% ........ 220 LATRIX XM EMU 45% ...................... 208 LATUDA TAB 120MG ......................... 91

LATUDA TAB 20MG .......................... 91 LATUDA TAB 40MG .......................... 91 LATUDA TAB 60MG .......................... 91 LATUDA TAB 80MG .......................... 91 lax diet sup tab 500mg .................... 145 laxative chw 15mg .......................... 145 laxative tab 15mg ........................... 145 laxative tab 25mg ........................... 145 laxative tab 5mg ec ........................ 145 layolis fe chw ................................. 126 LAZANDA SPR 100MCG .................... 10 LAZANDA SPR 300MCG .................... 10 LAZANDA SPR 400MCG .................... 10 LDO PLUS GEL 4% .......................... 209 leena tab ....................................... 127 leflunomide tab 10 mg .................... 163 leflunomide tab 20 mg .................... 163 LENVIMA CAP 10 MG ........................ 41 LENVIMA CAP 14 MG ........................ 41 LENVIMA CAP 20 MG ........................ 41 LENVIMA CAP 24 MG ........................ 41 LESCOL XL TAB 80MG ...................... 57 LETAIRIS TAB 10MG ........................ 69 LETAIRIS TAB 5MG .......................... 69 letrozole tab 2.5 mg ......................... 39 leucovorin calcium for inj 100 mg ...... 43 leucovorin calcium for inj 200 mg ...... 43 leucovorin calcium for inj 350 mg ...... 43 leucovorin calcium for inj 50 mg ........ 43 leucovorin calcium for inj 500 mg ...... 43 leucovorin calcium tab 10 mg ............ 43 leucovorin calcium tab 15 mg ............ 43 leucovorin calcium tab 25 mg ............ 43 leucovorin calcium tab 5 mg .............. 43 LEUKERAN TAB 2MG ........................ 36 LEUKINE INJ 250MCG ..................... 159 leuprolide acetate inj kit 5 mg/ml ...... 39 LEVACET TAB .................................... 2 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) .................................. 191 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) .................................. 191 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) .................................. 191 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) .................... 191 levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv) ...................... 191

270

LEVATOL TAB 20MG .......................... 60 LEVBID TAB 0.375 ER ..................... 142 LEVEMIR INJ .................................. 116 LEVEMIR INJ FLEXTOUC .................. 116 LEVETIRACETA INJ 10MG/ML ............. 76 LEVETIRACETA INJ 15MG/ML ............. 76 LEVETIRACETA INJ 5MG/ML ............... 76 levetiracetam inj 500 mg/5ml (100 mg/ml) ........................................... 76 levetiracetam oral soln 100 mg/ml ...... 76 levetiracetam tab 1000 mg ................ 76 levetiracetam tab 250 mg .................. 76 levetiracetam tab 500 mg .................. 76 levetiracetam tab 750 mg .................. 76 levetiracetam tab er 24hr 500 mg ....... 76 levetiracetam tab er 24hr 750 mg ....... 76 levobunolol hcl ophth soln 0.5% ....... 217 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) ....................... 187 levocetirizine dihydrochloride tab 5 mg ................................................... 187 levofloxacin in d5w iv soln 250 mg/50ml ..................................................... 21 levofloxacin in d5w iv soln 500 mg/100ml ....................................... 21 levofloxacin in d5w iv soln 750 mg/150ml ....................................... 21 levofloxacin iv soln 25 mg/ml ............. 21 levofloxacin ophth soln 0.5% ........... 215 levofloxacin oral soln 25 mg/ml .......... 21 levofloxacin tab 250 mg .................... 21 levofloxacin tab 500 mg .................... 21 levofloxacin tab 750 mg .................... 21 LEVOLEUCOVOR SOL 250MG/25 ......... 43 levoleucovorin calcium for iv inj 50 mg (base equiv) .................................... 43 levoleucovorin calcium inj 175 mg/17.5ml (base equiv) .................... 43 LEVOMEFOLATE CAP DHA ................ 179 levonorgestrel tab 1.5 mg ............... 124 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) ..................... 124 LEVOPHED INJ 1MG/ML ..................... 71 levorphanol tartrate tab 2 mg ............ 10 levo-t tab 112mcg .......................... 137 levo-t tab 137mcg .......................... 137 levo-t tab 175mcg .......................... 137 levo-t tab 200 mcg ......................... 137

levo-t tab 300 mcg ......................... 137 levo-t tab 88mcg ............................ 136 levothyroxine sodium tab 100 mcg .... 137 levothyroxine sodium tab 125 mcg .... 137 levothyroxine sodium tab 150 mcg .... 137 levothyroxine sodium tab 25 mcg ..... 137 levothyroxine sodium tab 50 mcg ..... 137 levothyroxine sodium tab 75 mcg ..... 137 LEVSIN INJ 0.5MG/ML ..................... 142 LEVSIN TAB 0.125MG ...................... 142 LEVSIN/SL SUB 0.125MG ................. 142 LEVULAN KERA SOL 20% ................. 201 LEXAPRO SOL 5MG/5ML ................... 84 LEXAPRO TAB 10MG ......................... 84 LEXAPRO TAB 20MG ......................... 84 LEXAPRO TAB 5MG .......................... 84 LEXIVA SUS 50MG/ML ...................... 28 LEXIVA TAB 700MG ......................... 28 LIALDA TAB 1.2GM ......................... 143 LIBRAX CAP 5-2.5MG ...................... 142 lice killing sha ................................ 212 lice md gel ..................................... 212 lice trtmnt liq 1% ........................... 212 lice trtmnt liq crm rnse .................... 212 lidocaine anorectal cream 5% ........... 147 lidocaine cream 4% ........................ 209 lidocaine cream 4% & transparent dressing kit .................................... 209 lidocaine hcl cream 3% ................... 209 lidocaine hcl gel 2% ........................ 209 lidocaine hcl iv inj 10 mg/ml ............. 54 lidocaine hcl iv inj 20 mg/ml ............. 54 lidocaine hcl laryngotracheal soln 4% 214 lidocaine hcl lotion 3% .................... 209 lidocaine hcl soln 4% ...................... 209 lidocaine hcl viscous soln 2% ........... 214 lidocaine iv infusion in d5w inj 4 mg/ml ..................................................... 54 lidocaine iv infusion in d5w inj 8 mg/ml ..................................................... 54 lidocaine oint 5% ............................ 209 lidocaine patch 5% ......................... 208 lidocaine-hydrocortisone acetate rectal cream 3-0.5% ................................ 150 lidocaine-hydrocortisone acetate rectal cream kit 2-2% .............................. 150 lidocaine-hydrocortisone acetate rectal cream kit 3-0.5% ........................... 150

271

lidocaine-hydrocortisone acetate rectal cream kit 3-1% .............................. 150 lidocaine-hydrocortisone acetate rectal gel kit 3-2.5% ............................... 150 lidocaine-prilocaine cream 2.5-2.5% . 209 LIDODERM DIS 5% ......................... 208 LIDO-HYDRO GEL 2.8-0.55 .............. 150 LIDO-K LOT 3% ............................. 209 LIDORX GEL 3% ............................. 209 LIDOVEX CRE 3.75% ...................... 209 LILETTA IUD 52MG ......................... 126 LINCOCIN INJ 300MG/ML .................. 34 lincomycin hcl inj 300 mg/ml ............. 34 linezolid for susp 100 mg/5ml ............ 34 linezolid in sodium chloride iv soln 600 mg/300ml-0.9% .............................. 35 linezolid iv soln 600 mg/300ml (2 mg/ml) ........................................... 35 linezolid tab 600 mg ......................... 35 LINZESS CAP 145MCG .................... 144 LINZESS CAP 290MCG .................... 144 LINZESS CAP 72MCG ...................... 144 liothyronine sodium iv soln 10 mcg/ml ................................................... 137 liothyronine sodium tab 25 mcg ....... 137 liothyronine sodium tab 5 mcg ......... 137 liothyronine sodium tab 50 mcg ....... 137 lip balm oin strawber ...................... 210 LIPITOR TAB 10MG ........................... 57 LIPITOR TAB 20MG ........................... 57 LIPITOR TAB 40MG ........................... 57 LIPITOR TAB 80MG ........................... 57 LIPOCHOL TAB PLUS ....................... 171 LIPOFEN CAP 150MG ........................ 56 LIPOFEN CAP 50MG .......................... 56 liq ca/vit d cap 600mg .................... 179 LIQUID CALCI CAP WITH D3 ............ 179 lisinopril & hydrochlorothiazide tab 10-12.5 mg .......................................... 46 lisinopril & hydrochlorothiazide tab 20-12.5 mg .......................................... 47 lisinopril & hydrochlorothiazide tab 20-25 mg ................................................. 47 lisinopril tab 10 mg ........................... 48 lisinopril tab 2.5 mg .......................... 48 lisinopril tab 20 mg ........................... 48 lisinopril tab 30 mg ........................... 48 lisinopril tab 40 mg ........................... 48

lisinopril tab 5 mg ............................ 48 LITETOUCH MIS 29GX12.7 ............... 122 lithium carbonate cap 150 mg .......... 107 lithium carbonate cap 300 mg .......... 107 lithium carbonate cap 600 mg .......... 107 lithium carbonate tab 300 mg .......... 107 lithium carbonate tab er 300 mg ....... 107 lithium carbonate tab er 450 mg ....... 107 LITHIUM SOL 8MEQ/5ML ................. 107 LITHOBID TAB 300MG CR ................ 107 LITHOSTAT TAB 250MG ................... 152 little remed liq 160/5ml ...................... 1 LIVALO TAB 1MG ............................. 57 LIVALO TAB 2MG ............................. 57 LIVALO TAB 4MG ............................. 57 lmd 10%/d5w inj ............................ 161 lmd 10%/nacl inj 0.9% ................... 161 L-METHYL- TAB B6-B12 ................... 170 L-METHYL-MC TAB NAC ................... 170 LO LOESTRIN TAB .......................... 126 LOCOID CRE 0.1% .......................... 207 LOCOID LIPO CRE 0.1% .................. 207 LOCOID LOT 0.1% .......................... 207 LOCOID OIN 0.1% .......................... 207 LOCOID SOL 0.1% .......................... 207 LODOSYN TAB 25MG ........................ 87 LOESTRIN 21 TAB 1.5/30 ................ 126 LOESTRIN FE TAB 1.5/30 ................. 126 LOESTRIN FE TAB 1/20 ................... 126 LOESTRIN TAB 1/20-21 ................... 126 LOFIBRA CAP 134MG ....................... 56 LOFIBRA CAP 200MG ....................... 56 LOFIBRA CAP 67MG ......................... 56 LOFIBRA TAB 160MG ....................... 56 LOFIBRA TAB 54MG ......................... 56 lohist-dm syp 5-2-10mg .................. 189 LOMOTIL TAB 2.5MG ....................... 139 LONSURF TAB 15-6.14 ..................... 43 LONSURF TAB 20-8.19 ..................... 43 loperamide hcl cap 2 mg .................. 139 loperamide sus 1mg/7.5 .................. 139 LOPID TAB 600MG ........................... 56 lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) ................................ 28 LOPRESS HCT TAB 100-25MG ........... 58 LOPRESS HCT TAB 50-25MG ............. 58 LOPRESSOR TAB 100MG ................... 60 LOPRESSOR TAB 50MG .................... 60

272

LOPROX SHA 1% ............................ 202 loratadine sol 5mg/5ml ................... 187 lorazepam conc 2 mg/ml ................... 72 lorazepam inj 2 mg/ml ...................... 72 lorazepam inj 4 mg/ml ...................... 72 lorazepam tab 0.5 mg ....................... 72 lorazepam tab 1 mg .......................... 72 lorazepam tab 2 mg .......................... 72 LORTAB ELX 10-300MG ..................... 10 LORZONE TAB 375MG ..................... 109 LORZONE TAB 750MG ..................... 109 losartan potassium & hydrochlorothiazide tab 100-12.5 mg .............................. 52 losartan potassium & hydrochlorothiazide tab 100-25 mg ................................. 52 losartan potassium & hydrochlorothiazide tab 50-12.5 mg ................................ 52 losartan potassium tab 100 mg .......... 53 losartan potassium tab 25 mg ............ 53 losartan potassium tab 50 mg ............ 53 LOSEASONIQUE TAB ....................... 125 LOTEMAX GEL 0.5% ....................... 216 LOTEMAX OIN 0.5% ....................... 216 LOTEMAX SUS 0.5% ....................... 216 LOTENSIN HCT TAB 10-12.5 .............. 47 LOTENSIN HCT TAB 20-12.5 .............. 47 LOTENSIN HCT TAB 20-25MG ............ 47 LOTENSIN TAB 10MG ........................ 48 LOTENSIN TAB 20MG ........................ 48 LOTENSIN TAB 40MG ........................ 48 LOTREL CAP 10-20MG ....................... 46 LOTREL CAP 10-40MG ....................... 46 LOTREL CAP 5-10MG ........................ 46 LOTREL CAP 5-20MG ........................ 46 lotrimin af aer 2% .......................... 202 LOTRONEX TAB 0.5MG .................... 144 LOTRONEX TAB 1MG ....................... 144 LOUTREX CRE ................................ 203 lovastatin tab 10 mg ......................... 57 lovastatin tab 20 mg ......................... 57 lovastatin tab 40 mg ......................... 57 LOVAZA CAP 1GM ............................. 58 LOVENOX INJ 100MG/ML ................. 155 LOVENOX INJ 120/0.8 ..................... 155 LOVENOX INJ 150MG/ML ................. 155 LOVENOX INJ 30/0.3ML................... 155 LOVENOX INJ 300/3ML ................... 155 LOVENOX INJ 40/0.4ML................... 155

LOVENOX INJ 60/0.6ML ................... 155 LOVENOX INJ 80/0.8ML ................... 155 low-ogestrel tab ............................. 126 loxapine succinate cap 10 mg ............ 91 loxapine succinate cap 25 mg ............ 91 loxapine succinate cap 5 mg ............. 91 loxapine succinate cap 50 mg ............ 91 LOZI-FLUR LOZ 1MG F .................... 179 lubricant dro eye 0.6% .................... 219 lubricnt eye dro 0.4-0.3% ................ 219 lubricnt eye dro 0.5% op ................. 219 lubricnt eye oin fast act ................... 219 lubricnt gel dro 0.25-0.3 .................. 219 lubricnt gel dro 1% ......................... 219 ludent chw 0.25mg f ....................... 179 ludent chw 0.5mg f ......................... 179 ludent chw 1mg f............................ 179 LUMIGAN SOL 0.01% ...................... 220 LUMIZYME INJ 50MG ....................... 134 LUNESTA TAB 1MG ......................... 104 LUNESTA TAB 2MG ......................... 104 LUNESTA TAB 3MG ......................... 104 LUPR DEP-PED INJ 11.25MG ............ 134 LUPR DEP-PED INJ 15MG ................. 134 LUPR DEP-PED INJ 3M 30MG ............ 134 LUPR DEP-PED INJ 7.5MG ................ 134 LUPRON DEPOT INJ 11.25MG ............ 39 LUPRON DEPOT INJ 22.5MG .............. 39 LUPRON DEPOT INJ 3.75MG .............. 39 LUPRON DEPOT INJ 30MG ................. 39 LUPRON DEPOT INJ 45MG ................. 39 LUPRON DEPOT INJ 7.5MG ................ 39 LUXAMEND CRE .............................. 213 LUXIQ AER 0.12% .......................... 207 LUZU CRE 1% ................................ 202 LYCELLE GEL .................................. 212 LYNPARZA CAP 50MG ....................... 43 LYRICA CAP 100MG ........................ 102 LYRICA CAP 150MG ........................ 102 LYRICA CAP 200MG ........................ 102 LYRICA CAP 225MG ........................ 102 LYRICA CAP 25MG .......................... 102 LYRICA CAP 300MG ........................ 102 LYRICA CAP 50MG .......................... 102 LYRICA CAP 75MG .......................... 102 LYRICA SOL 20MG/ML ..................... 102 LYSODREN TAB 500MG .................... 43 LYSTEDA TAB 650MG ...................... 160

273

lyza tab 0.35mg ............................. 127 M MACROBID CAP 100MG ..................... 35 MACRODANTIN CAP 100MG ............... 35 MACRODANTIN CAP 25MG ................. 35 MACRODANTIN CAP 50MG ................. 35 MAG OXIDE CAP 400MG .................. 139 mag64 tab 64mg ............................ 179 MAGNEBIND TAB 400 ..................... 179 MAGNESIUM CAP 400MG ................. 179 magnesium chloride inj 200 mg/ml ... 173 magnesium citrate soln ................... 145 magnesium oxide cap 500 mg (elemental mg) .............................................. 179 magnesium oxide tab 250 mg .......... 139 magnesium oxide tab 400 mg .......... 139 magnesium oxide tab 400 mg (240 mg elemental mg) ............................... 179 magnesium oxide tab 420 mg .......... 139 magnesium oxide tab 500 mg (mg supplement) .................................. 179 magnesium sulfate inj 50% ............. 173 magnesium tab 250 mg .................. 179 MAKENA INJ 250MG/ML .................. 136 malathion lotion 0.5% ..................... 212 manganese chloride inj 0.1 mg/ml .... 173 manganese sulfate inj 0.1 mg/ml ..... 173 MANGANESE TAB 50MG .................. 174 mannitol iv soln 20% ...................... 152 mannitol iv soln 25% ...................... 152 maprotiline hcl tab 25 mg .................. 81 maprotiline hcl tab 50 mg .................. 81 maprotiline hcl tab 75 mg .................. 81 MARINOL CAP 10MG ....................... 140 MARINOL CAP 2.5MG ...................... 140 MARINOL CAP 5MG ......................... 140 MARNATAL-F CAP ........................... 179 MARPLAN TAB 10MG ......................... 81 MARQIBO INJ 5MG/31ML ................... 43 MATULANE CAP 50MG ....................... 44 matzim la tab 180mg/24 ................... 64 matzim la tab 240mg/24 ................... 64 matzim la tab 300mg/24 ................... 64 matzim la tab 360mg/24 ................... 64 matzim la tab 420mg/24 ................... 64 MAVIK TAB 1MG ............................... 48 MAVIK TAB 2MG ............................... 48 MAXALT TAB 10MG ......................... 105

MAXALT TAB 5MG ........................... 105 MAXALT-MLT TAB 10MG .................. 105 MAXALT-MLT TAB 5MG .................... 105 MAXFE LIQ .................................... 179 MAXIDEX SUS 0.1% OP ................... 216 MAXIPIME INJ 1GM .......................... 20 MAXIPIME INJ 2GM .......................... 20 MAXITROL OIN 0.1% OP .................. 214 MAXITROL SUS 0.1% OP ................. 214 MAXZIDE TAB 75-50 ........................ 66 MAXZIDE-25 TAB ............................ 66 MB HYDROGEL KIT ......................... 210 meclizine hcl tab 12.5 mg ................ 140 meclizine hcl tab 25 mg ................... 140 meclofenamate sodium cap 100 mg ..... 3 meclofenamate sodium cap 50 mg ....... 3 MEDROL TAB 16MG......................... 131 MEDROL TAB 2MG .......................... 131 MEDROL TAB 32MG......................... 131 MEDROL TAB 4MG .......................... 131 MEDROL TAB 8MG .......................... 131 medroxyprogesterone acetate im susp 150 mg/ml .................................... 125 medroxyprogesterone acetate im susp prefilled syr 150 mg/ml ................... 125 medroxyprogesterone acetate tab 10 mg .................................................... 136 medroxyprogesterone acetate tab 2.5 mg ............................................... 136 medroxyprogesterone acetate tab 5 mg .................................................... 136 mefenamic acid cap 250 mg ................ 3 mefloquine hcl tab 250 mg ............... 27 MEGA MULTIVI TAB WOMEN ............ 179 MEGACE ES SUS 625/5ML ................ 136 MEGACE ORAL SUS 40MG/ML ............ 39 megestrol acetate susp 40 mg/ml ...... 39 megestrol acetate susp 625 mg/5ml .. 136 megestrol acetate tab 20 mg............. 39 megestrol acetate tab 40 mg............. 39 MEKINIST TAB 0.5MG ...................... 41 MEKINIST TAB 2MG ......................... 41 MELOXICAM KIT COMFORT ................. 5 meloxicam tab 15 mg ......................... 3 meloxicam tab 7.5 mg ........................ 3 melphalan hcl for inj 50 mg (base equiv) ..................................................... 36 melphalan tab 2 mg ......................... 36

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memantine hcl oral solution 2 mg/ml .. 80 memantine hcl tab 10 mg .................. 80 memantine hcl tab 5 mg ................... 80 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak ............................. 80 MEMBRANEBLUE SOL 0.15% ............ 219 MENEST TAB 0.3MG ........................ 128 MENEST TAB 0.625MG .................... 128 MENEST TAB 1.25MG ...................... 128 MENEST TAB 2.5MG ........................ 128 MENOSTAR DIS 14MCG ................... 129 MENTAX CRE 1% ............................ 202 meperidine hcl inj 10 mg/ml .............. 10 meperidine hcl inj 100 mg/ml ............ 10 meperidine hcl inj 25 mg/ml .............. 10 meperidine hcl inj 50 mg/ml .............. 10 meperidine hcl oral soln 50 mg/5ml .... 10 meperidine hcl tab 100 mg ................ 11 meperidine hcl tab 50 mg .................. 10 MEPHYTON TAB 5MG ...................... 179 meprobamate tab 200 mg ................. 73 meprobamate tab 400 mg ................. 73 MEPRON SUS ................................... 35 mercaptopurine tab 50 mg ................ 38 MEROP/NACL INJ 1GM/50ML .............. 17 MEROP/NACL INJ 500/50ML ............... 17 meropenem iv for soln 1 gm .............. 17 meropenem iv for soln 500 mg ........... 17 MERREM INJ 1GM ............................. 17 MERREM INJ 500MG ......................... 17 mesalamine enema 4 gm ................ 144 mesalamine rectal enema 4 gm & cleanser wipe kit ............................ 144 mesalamine tab delayed release 1.2 gm ................................................... 143 mesalamine tab delayed release 800 mg ................................................... 143 mesna inj 100 mg/ml ........................ 44 MESNEX INJ 1GM ............................. 44 MESNEX TAB 400MG ......................... 44 MESTINON SYP 60MG/5ML .............. 109 MESTINON TAB 60MG ..................... 109 METADATE CD CAP 10MG .................. 99 METADATE CD CAP 20MG .................. 99 METADATE CD CAP 30MG .................. 99 METADATE CD CAP 40MG .................. 99 METADATE CD CAP 50MG .................. 99 METADATE CD CAP 60MG .................. 99

METAFOLBIC TAB ........................... 170 METAFOLBIC TAB PLUS RF ............... 170 METAMUCIL POW 28% .................... 145 metamucil pow 28.3%org ................ 145 METAMUCIL POW 55.46% ................ 145 METAMUCIL POW 58.12% ................ 145 metamucil pow 58.6%org ................ 145 METAMUCIL POW 63% .................... 145 metaproterenol sulfate syrup 10 mg/5ml .................................................... 191 metaproterenol sulfate tab 10 mg ..... 191 metaproterenol sulfate tab 20 mg ..... 191 METASTRON INJ .............................. 44 metaxalone tab 400 mg ................... 109 metaxalone tab 800 mg ................... 109 metformin hcl tab 1000 mg .............. 113 metformin hcl tab 500 mg ............... 113 metformin hcl tab 850 mg ............... 113 metformin hcl tab er 24hr 500 mg .... 113 metformin hcl tab er 24hr 750 mg .... 113 metformin hcl tab er 24hr modified release 1000 mg ............................ 113 metformin hcl tab er 24hr modified release 500 mg .............................. 113 metformin hcl tab er 24hr osmotic 1000 mg ............................................... 113 metformin hcl tab er 24hr osmotic 500 mg ............................................... 113 methacholine cap /liver ................... 179 methadone hcl conc 10 mg/ml .......... 11 methadone hcl soln 10 mg/5ml ......... 11 methadone hcl soln 5 mg/5ml ........... 11 methadone hcl tab 10 mg ................. 11 methadone hcl tab 5 mg ................... 11 methadone hcl tab for oral susp 40 mg 11 METHADONE INJ 10MG/ML ............... 11 methamphetamine hcl tab 5 mg ........ 99 methazolamide tab 25 mg ............... 218 methazolamide tab 50 mg ............... 218 methenamine hippurate tab 1 gm ..... 152 methenamine mandelate tab 0.5 gm . 152 methenamine mandelate tab 1 gm .... 152 methimazole tab 10 mg ................... 136 methimazole tab 5 mg .................... 136 methocarbamol tab 500 mg ............. 109 methocarbamol tab 750 mg ............. 109 methotrexate sodium for inj 1 gm ...... 38 methotrexate sodium inj 250 mg/10ml

275

(25 mg/ml) ..................................... 38 methotrexate sodium inj 50 mg/2ml (25 mg/ml) ........................................... 38 methotrexate sodium inj pf 100 mg/4ml (25 mg/ml) ..................................... 38 methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) ........................ 38 methotrexate sodium inj pf 200 mg/8ml (25 mg/ml) ..................................... 38 methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) ..................................... 38 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) ..................................... 38 methotrexate sodium tab 2.5 mg (base equiv) ............................................. 38 METHOXSALEN CAP 10 MG .............. 203 methscopolamine bromide tab 2.5 mg ................................................... 142 methscopolamine bromide tab 5 mg . 142 methyclothiazide tab 5 mg ................. 66 methyldopa & hydrochlorothiazide tab 250-15 mg ...................................... 67 methyldopa & hydrochlorothiazide tab 250-25 mg ...................................... 67 methyldopa tab 250 mg .................... 67 methyldopa tab 500 mg .................... 67 methyldopate hcl inj 250 mg/5ml ....... 67 methylene blue inj 1% .................... 122 methylergonovine maleate inj 0.2 mg/ml ................................................... 134 methylergonovine maleate tab 0.2 mg ................................................... 134 METHYLIN CHW 10MG ..................... 100 METHYLIN CHW 2.5MG .................... 100 METHYLIN CHW 5MG ...................... 100 METHYLIN SOL 10MG/5ML ............... 100 METHYLIN SOL 5MG/5ML ................. 100 methylphenidate hcl cap er 10 mg (cd) ................................................... 100 methylphenidate hcl cap er 20 mg (cd) ................................................... 100 methylphenidate hcl cap er 24hr 20 mg (la) .............................................. 100 methylphenidate hcl cap er 24hr 30 mg (la) .............................................. 100 methylphenidate hcl cap er 24hr 40 mg (la) .............................................. 100 methylphenidate hcl cap er 30 mg (cd)

.................................................... 100 methylphenidate hcl cap er 40 mg (cd) .................................................... 100 methylphenidate hcl cap er 50 mg (cd) .................................................... 100 methylphenidate hcl cap er 60 mg (cd) .................................................... 100 methylphenidate hcl chew tab 10 mg 100 methylphenidate hcl chew tab 2.5 mg 100 methylphenidate hcl chew tab 5 mg .. 100 methylphenidate hcl soln 10 mg/5ml . 100 methylphenidate hcl soln 5 mg/5ml ... 100 methylphenidate hcl tab 10 mg ........ 100 methylphenidate hcl tab 20 mg ........ 100 methylphenidate hcl tab 5 mg .......... 100 methylphenidate hcl tab er 10 mg ..... 100 methylphenidate hcl tab er 20 mg ..... 100 methylphenidate hcl tab er 24hr 18 mg .................................................... 100 methylphenidate hcl tab er 24hr 27 mg .................................................... 100 methylphenidate hcl tab er 24hr 36 mg .................................................... 100 methylphenidate hcl tab er 24hr 54 mg .................................................... 100 methylphenidate hcl tab er osmotic release (osm) 18 mg ....................... 100 methylphenidate hcl tab er osmotic release (osm) 27 mg ....................... 100 methylphenidate hcl tab er osmotic release (osm) 36 mg ....................... 100 methylphenidate hcl tab er osmotic release (osm) 54 mg ....................... 100 methylprednisolone acetate inj susp 40 mg/ml .......................................... 131 methylprednisolone acetate inj susp 80 mg/ml .......................................... 131 methylprednisolone sodium succinate for inj 1000 mg ................................... 131 methylprednisolone sodium succinate for inj 125 mg ..................................... 131 methylprednisolone sodium succinate for inj 40 mg ...................................... 131 methylprednisolone tab 16 mg ......... 131 methylprednisolone tab 32 mg ......... 131 methylprednisolone tab 4 mg ........... 131 methylprednisolone tab 8 mg ........... 131 methylprednisolone tab therapy pack 4

276

mg (21) ........................................ 131 metipranolol ophth soln 0.3% .......... 217 METOCLOPRAMI TAB 10MG ODT ....... 140 metoclopramide hcl inj 5 mg/ml ....... 140 metoclopramide hcl orally disintegrating tab 5 mg ....................................... 140 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) ...................................... 140 metoclopramide hcl tab 10 mg ......... 140 metoclopramide hcl tab 5 mg ........... 140 metolazone tab 10 mg ...................... 66 metolazone tab 2.5 mg ..................... 66 metolazone tab 5 mg ........................ 66 metoprolol & hydrochlorothiazide tab 100-25 mg ...................................... 59 metoprolol & hydrochlorothiazide tab 100-50 mg ...................................... 59 metoprolol & hydrochlorothiazide tab 50-25 mg ............................................ 58 metoprolol succinate tab er 24hr 100 mg (tartrate equiv) ................................ 60 metoprolol succinate tab er 24hr 200 mg (tartrate equiv) ................................ 60 metoprolol succinate tab er 24hr 25 mg (tartrate equiv) ................................ 60 metoprolol succinate tab er 24hr 50 mg (tartrate equiv) ................................ 60 metoprolol tartrate iv soln 5 mg/5ml ... 60 metoprolol tartrate tab 100 mg .......... 60 metoprolol tartrate tab 25 mg ............ 60 metoprolol tartrate tab 50 mg ............ 60 metoprolol tartrate tab 75 mg ............ 60 METRO IV INJ 5MG/ML ...................... 35 METROCREAM CRE 0.75% ............... 212 METROGEL GEL 1% ........................ 212 METROGEL-VAG GEL 0.75% ............. 154 METROLOTION LOT 0.75% .............. 212 metronidazole cap 375 mg ................ 35 metronidazole gel 0.75% ................. 212 metronidazole gel 1% ..................... 212 metronidazole in nacl 0.79% iv soln 500 mg/100ml ....................................... 35 metronidazole lotion 0.75% ............. 212 metronidazole tab 250 mg ................. 35 metronidazole tab 500 mg ................. 35 metronidazole vaginal gel 0.75% ...... 154 MEXSANA POW .............................. 210 MG SO4/D5W INJ 10MG/ML ............. 174

mgo tab 400mg .............................. 179 MIACALCIN SPR 200/ACT ................ 124 MICARDIS HCT TAB 40/12.5 ............. 52 MICARDIS HCT TAB 80/12.5 ............. 52 MICARDIS HCT TAB 80-25MG ............ 52 MICARDIS TAB 20MG ....................... 53 MICARDIS TAB 40MG ....................... 53 MICARDIS TAB 80MG ....................... 53 miconazole 3 kit combinat ............... 154 miconazole 3 kit combo pk ............... 154 miconazole 3 sup 200mg ................. 154 miconazole 7 cre 2% ....................... 154 miconazole nitrate aerosol pow 2% ... 202 miconazole nitrate vaginal supp 1200 mg & 2% cream kit .............................. 154 miconazorb pow af 2% .................... 202 micrgstin 24 tab fe 1/20 .................. 126 MICRO-BUMIN KIT .......................... 122 microgestin tab 1.5/30 .................... 126 microgestin tab 1/20 ....................... 126 microgestin tab fe1.5/30 ................. 126 MICRO-K CAP 10MEQ CR ................. 170 MICRO-K CAP 8MEQ CR ................... 170 MICROLIFE MIS PEAK FLO ............... 193 MICROLIPID EMU 50% .................... 171 MICROZIDE CAP 12.5MG .................. 66 midazolam hcl inj 10 mg/10ml (base equivalent) .................................... 102 midazolam hcl inj 10 mg/2ml (base equivalent) .................................... 102 midazolam hcl inj 2 mg/2ml (base equivalent) .................................... 102 midazolam hcl inj 25 mg/5ml (base equivalent) .................................... 103 midazolam hcl inj 5 mg/5ml (base equivalent) .................................... 102 midazolam hcl inj 5 mg/ml (base equivalent) .................................... 102 midazolam hcl inj 50 mg/10ml (base equivalent) .................................... 103 midazolam hcl syrup 2 mg/ml (base equivalent) .................................... 103 midodrine hcl tab 10 mg ................... 67 midodrine hcl tab 2.5 mg .................. 67 midodrine hcl tab 5 mg .................... 67 migergot sup 2/100 ........................ 104 migraine tab formula .......................... 2 MIGRANAL SPR 4MG/ML .................. 104

277

milk of magn sus 1200/15 ............... 145 MILK OF MAGN SUS 800/5ML ........... 145 MILLIPRED DP PAK 5MG .................. 131 MILLIPRED SOL 10MG/5ML .............. 131 MILLIPRED TAB 5MG ....................... 131 milrinone lactate in dextrose 5% iv soln 20 mg/100ml ................................... 67 milrinone lactate in dextrose 5% iv soln 40 mg/200ml ................................... 67 milrinone lactate iv soln 10 mg/10ml (base equivalent) ............................. 67 milrinone lactate iv soln 20 mg/20ml (base equivalent) ............................. 67 milrinone lactate iv soln 50 mg/50ml (base equivalent) ............................. 67 MINASTRIN 24 CHW FE ................... 126 mineral oil enema ........................... 145 MINI WRIGHT MIS PFM ................... 193 MINI WRIGHT MIS PFM LOW ............ 193 MINILINK RT KIT STARTER .............. 122 MINIPRESS CAP 1MG ........................ 49 MINIPRESS CAP 2MG ........................ 49 MINIPRESS CAP 5MG ........................ 49 MINIVELLE DIS 0.0375MG ............... 129 MINOCIN CAP 100MG ....................... 25 MINOCIN CAP 50MG ......................... 25 MINOCIN CAP 75MG ......................... 25 MINOCIN INJ 100MG ........................ 25 minocycline hcl cap 100 mg ............... 25 minocycline hcl cap 50 mg ................. 25 minocycline hcl cap 75 mg ................. 25 minocycline hcl tab 100 mg ............... 25 minocycline hcl tab 50 mg ................. 25 minocycline hcl tab 75 mg ................. 25 minocycline hcl tab er 24hr 135 mg .... 25 minocycline hcl tab er 24hr 45 mg ...... 25 minocycline hcl tab er 24hr 90 mg ...... 25 minoxidil tab 10 mg .......................... 68 minoxidil tab 2.5 mg ......................... 67 MIOCHOL-E SOL 1:100 ................... 220 MIOSTAT INJ 0.01% OP .................. 220 MIRALAX POW 3350 NF ................... 145 MIRAPEX ER TAB 0.375MG ................ 87 MIRAPEX ER TAB 0.75MG .................. 87 MIRAPEX ER TAB 1.5MG .................... 87 MIRAPEX ER TAB 2.25MG .................. 87 MIRAPEX ER TAB 3.75MG .................. 87 MIRAPEX ER TAB 3MG ....................... 87

MIRAPEX ER TAB 4.5MG ................... 87 MIRAPEX TAB 0.125MG .................... 87 MIRAPEX TAB 0.25MG ...................... 87 MIRAPEX TAB 0.5MG ........................ 87 MIRAPEX TAB 0.75MG ...................... 87 MIRAPEX TAB 1.5MG ........................ 87 MIRAPEX TAB 1MG .......................... 87 MIRCERA INJ 100MCG ..................... 159 MIRCERA INJ 200MCG ..................... 159 MIRCERA INJ 50MCG ....................... 159 MIRCERA INJ 75MCG ....................... 159 MIRCETTE TAB 28 DAY .................... 124 MIRENA IUD SYSTEM ...................... 127 mirtazapine orally disintegrating tab 15 mg ................................................ 81 mirtazapine orally disintegrating tab 30 mg ................................................ 81 mirtazapine orally disintegrating tab 45 mg ................................................ 81 mirtazapine tab 15 mg ..................... 81 mirtazapine tab 30 mg ..................... 81 mirtazapine tab 45 mg ..................... 81 mirtazapine tab 7.5 mg .................... 81 MIRVASO GEL 0.33% ...................... 212 misoprostol tab 100 mcg ................. 148 misoprostol tab 200 mcg ................. 148 MISSION PREN TAB ........................ 179 MISSION PREN TAB HP .................... 179 mitomycin for iv soln 20 mg .............. 44 mitomycin for iv soln 40 mg .............. 44 mitomycin for iv soln 5 mg ............... 44 MITOSOL KIT 0.2MG ....................... 215 mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) .......................................... 44 mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) ...................................... 44 mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) .......................................... 44 MOBIC TAB 15MG .............................. 3 MOBIC TAB 7.5MG ............................. 3 modafinil tab 100 mg ...................... 110 modafinil tab 200 mg ...................... 110 MODERIBA PAK 1000/DAY ................ 32 MODERIBA PAK 1200/DAY ................ 32 MODERIBA PAK 600/DAY .................. 32 MODERIBA PAK 800/DAY .................. 32 MODICON TAB 0.5/35 ..................... 126 moexipril hcl tab 15 mg .................... 48

278

moexipril hcl tab 7.5 mg .................... 48 moexipril-hydrochlorothiazide tab 15-12.5 mg .......................................... 47 moexipril-hydrochlorothiazide tab 15-25 mg ................................................. 47 moexipril-hydrochlorothiazide tab 7.5-12.5 mg .......................................... 47 mometasone furoate cream 0.1% ..... 207 mometasone furoate nasal susp 50 mcg/act ........................................ 195 mometasone furoate oint 0.1% ........ 207 mometasone furoate solution 0.1% (lotion) ......................................... 207 MONISTAT 3 KIT COMBO PK ............ 154 MONOCLATE-P INJ 1000UNIT ........... 158 MONOCLATE-P INJ 1500UNIT ........... 158 MONODOX CAP 100MG ..................... 25 MONODOX CAP 75MG ....................... 25 mononessa tab .............................. 126 MONONINE INJ 1000UNIT ............... 158 MONONINE INJ 500UNIT ................. 158 montelukast sodium chew tab 4 mg (base equiv) .................................. 192 montelukast sodium chew tab 5 mg (base equiv) .................................. 192 montelukast sodium oral granules packet 4 mg (base equiv) .......................... 192 montelukast sodium tab 10 mg (base equiv) ........................................... 192 MORE-DOPHILU POW ACIDOPHI ....... 147 MORGIDOX KIT 1X100MG .................. 25 MORGIDOX KIT 2X100MG .................. 25 MORPHINE SUL INJ 10/0.7ML ............ 11 MORPHINE SUL INJ 150/30ML ............ 11 MORPHINE SUL INJ 2MG/ML .............. 11 MORPHINE SUL INJ 4MG/ML .............. 11 MORPHINE SUL INJ 5MG/ML .............. 11 MORPHINE SUL INJ 8MG/ML .............. 11 MORPHINE SUL SUP 30MG ................. 11 morphine sulfate beads cap er 24hr 120 mg ................................................. 11 morphine sulfate beads cap er 24hr 30 mg ................................................. 11 morphine sulfate beads cap er 24hr 45 mg ................................................. 11 morphine sulfate beads cap er 24hr 60 mg ................................................. 11 morphine sulfate beads cap er 24hr 75

mg ................................................ 11 morphine sulfate beads cap er 24hr 90 mg ................................................ 11 morphine sulfate cap er 24hr 10 mg ... 11 morphine sulfate cap er 24hr 100 mg . 11 morphine sulfate cap er 24hr 20 mg ... 11 morphine sulfate cap er 24hr 30 mg ... 11 morphine sulfate cap er 24hr 50 mg ... 11 morphine sulfate cap er 24hr 60 mg ... 11 morphine sulfate cap er 24hr 80 mg ... 11 morphine sulfate inj 10 mg/ml .......... 11 morphine sulfate inj 15 mg/ml .......... 11 morphine sulfate inj 8 mg/ml ............ 11 morphine sulfate inj pf 0.5 mg/ml ...... 11 morphine sulfate inj pf 1 mg/ml ......... 11 morphine sulfate iv soln 1 mg/ml ....... 11 morphine sulfate iv soln 25 mg/ml ..... 11 morphine sulfate iv soln 50 mg/ml ..... 11 morphine sulfate iv soln pf 10 mg/ml . 11 morphine sulfate iv soln pf 15 mg/ml . 11 morphine sulfate iv soln pf 4 mg/ml ... 11 morphine sulfate iv soln pf 8 mg/ml ... 11 morphine sulfate oral soln 10 mg/5ml 11 morphine sulfate oral soln 100 mg/5ml (20 mg/ml) ..................................... 11 morphine sulfate oral soln 20 mg/5ml 11 morphine sulfate suppos 10 mg ......... 12 morphine sulfate suppos 20 mg ......... 12 morphine sulfate suppos 5 mg ........... 12 morphine sulfate tab 15 mg .............. 12 morphine sulfate tab 30 mg .............. 12 morphine sulfate tab er 100 mg ......... 12 morphine sulfate tab er 15 mg .......... 12 morphine sulfate tab er 200 mg ......... 12 morphine sulfate tab er 30 mg .......... 12 morphine sulfate tab er 60 mg .......... 12 MOTOFEN TAB ............................... 139 MOVANTIK TAB 12.5MG................... 147 MOVANTIK TAB 25MG ..................... 147 move along tab 100mg .................... 145 MOVIPREP SOL ............................... 145 MOXATAG TAB 775MG ...................... 23 MOXEZA SOL 0.5% ......................... 215 moxifloxacin hcl ophth soln 0.5% (base equiv) ........................................... 215 moxifloxacin hcl tab 400 mg (base equiv) ..................................................... 21 MOXIFLOXACIN INJ ......................... 21

279

MOZOBIL INJ ................................. 162 MS CONTIN TAB 100MG ER................ 12 MS CONTIN TAB 15MG ER ................. 12 MS CONTIN TAB 200MG ER................ 12 MS CONTIN TAB 30MG ER ................. 12 MS CONTIN TAB 60MG ER ................. 12 MTERYTI TAB ................................. 179 MTERYTI TAB FOLIC 5 ..................... 179 MUCINEX CGH GRA 5-100MG ........... 189 MUCOTROL WAF ............................. 214 mucus & cong cap 10-200 ............... 189 mucus d tab 120/1200 .................... 189 mucus relief liq 100/5ml .................. 192 mucus relief liq 5-100mg ................. 189 mucus relief tab d .......................... 189 mucus rlf d tab 60-600mg ............... 189 mucus-dm max tab 60-1200 ............ 189 mucus-dm tab 30-600mg ................ 189 mucus-er tab 600mg ...................... 192 MUGARD LIQ ................................. 214 MULIT-DRAW MIS 22GX1.5" ............ 167 MULTAQ TAB 400MG ......................... 54 MULTI PRENAT TAB ........................ 179 multi-delyn liq ............................... 179 MULTI-DELYN LIQ /IRON ................. 179 MULTI-DRAW MIS 20GX1.5 .............. 167 MULTI-DRAW MIS 21GX1.5" ............ 168 MULTIGEN PLS TAB ........................ 179 MULTIGEN TAB .............................. 180 multiple minerals tab ...................... 180 MULTITRACE-4 INJ ......................... 174 multitrace-4 inj conc ....................... 174 MULTITRACE-4 INJ NEONATAL ......... 174 MULTITRACE-4 INJ PED ................... 174 multitrace-5 inj conc ....................... 174 MULTITRACE-5 INJ REGULAR ........... 174 multi-vit/fe dro /fl 0.25 ................... 179 multi-vit/fl dro 0.25mg .................... 179 multi-vit/fl dro 0.5mg/ml ................. 179 multivitamin dro pediatrc ................ 180 multivitamin liq mineral ................... 180 mupirocin calcium cream 2% ........... 201 mupirocin oint 2% .......................... 201 mv-one cap ................................... 180 my way tab 1.5mg ......................... 124 MYALEPT INJ 11.3MG ...................... 134 MYAMBUTOL TAB 400MG ................... 30 MYCAMINE INJ 100MG ...................... 26

MYCAMINE INJ 50MG ....................... 26 mycophenolate mofetil cap 250 mg ... 166 mycophenolate mofetil for oral susp 200 mg/ml .......................................... 166 MYCOPHENOLATE MOFETIL HCL FOR IV SOLN 500 MG (BASE EQUIV) ............ 166 mycophenolate mofetil tab 500 mg ... 166 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) ............... 166 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) ............... 166 MYDRIACYL SOL 1% OP .................. 220 myferon 150 cap forte ..................... 180 MYKIDZ IRON SUS 10MG/2ML .......... 180 MYLERAN TAB 2MG .......................... 36 MYNATAL CAP ................................ 180 MYNATAL TAB ................................ 180 MYNATAL-Z TAB ............................. 180 MYNATE 90 TAB PLUS ..................... 180 mynephrocaps cap .......................... 180 MYRBETRIQ TAB 25MG .................... 153 MYRBETRIQ TAB 50MG .................... 153 MYSOLINE TAB 250MG ..................... 77 MYSOLINE TAB 50MG ....................... 77 MYTESI TAB 125MG ........................ 139 N nabumetone tab 500 mg .................... 3 nabumetone tab 750 mg .................... 3 nadolol & bendroflumethiazide tab 40-5 mg ................................................ 59 nadolol & bendroflumethiazide tab 80-5 mg ................................................ 59 nadolol tab 20 mg ........................... 60 nadolol tab 40 mg ........................... 60 nadolol tab 80 mg ........................... 60 NAFCILLIN INJ 1GM/50ML ................. 23 NAFCILLIN INJ 2GM/100 ................... 23 nafcillin sodium for inj 1 gm .............. 23 nafcillin sodium for inj 10 gm ............ 23 nafcillin sodium for inj 2 gm .............. 23 nafcillin sodium for iv soln 1 gm ........ 23 nafcillin sodium for iv soln 2 gm ........ 23 NAFRINSE DLY SOL /NEUTRAL .......... 214 NAFRINSE SOL DAILY ..................... 214 NAFRINSE WK SOL 0.2% ................. 214 NAFTIN CRE 2% ............................. 202 NAFTIN GEL 1% ............................. 202 NAFTIN GEL 2% ............................. 202

280

NAGLAZYME INJ 1MG/ML ................. 134 nalbuphine hcl inj 10 mg/ml .............. 12 nalbuphine hcl inj 20 mg/ml .............. 12 NALFON CAP 400MG .......................... 3 naloxone hcl inj 0.4 mg/ml .............. 111 naloxone hcl inj 4 mg/10ml ............. 111 naloxone hcl soln cartridge 0.4 mg/ml ................................................... 111 naloxone hcl soln prefilled syringe 2 mg/2ml ......................................... 111 naltrexone hcl tab 50 mg ................. 111 NAMENDA XR CAP 14MG ................... 80 NAMENDA XR CAP 21MG ................... 80 NAMENDA XR CAP 28MG ................... 80 NAMENDA XR CAP 7MG ..................... 80 NAMENDA XR CAP TITRATIO .............. 80 NAMZARIC CAP 14-10MG .................. 80 NAMZARIC CAP 21-10MG .................. 80 NAMZARIC CAP 28-10MG .................. 80 NAMZARIC CAP 7-10MG .................... 80 NANOVM T/F LIQ ............................ 180 NANOVM T/F POW .......................... 180 NAPRELAN TAB 375MG CR .................. 3 NAPRELAN TAB 500MG CR .................. 3 NAPRELAN TAB 750MG CR .................. 4 NAPROSYN SUS 125/5ML ................... 4 NAPROSYN TAB 500MG ...................... 4 naproxen dr tab 375mg ...................... 4 naproxen dr tab 500mg ...................... 4 NAPROXEN KIT COMFORT ................... 5 naproxen sodium cap 220 mg ............. 4 naproxen sodium tab 275 mg .............. 4 naproxen sodium tab 550 mg .............. 4 naproxen sodium tab er 24hr 375 mg (base equiv) ..................................... 4 naproxen susp 125 mg/5ml ................ 4 naproxen tab 250 mg ........................ 4 naproxen tab 375 mg ........................ 4 naproxen tab 500 mg ........................ 4 NAPROXENPAX MIS ........................ 201 naratriptan hcl tab 1 mg (base equiv) 105 naratriptan hcl tab 2.5 mg (base equiv) ................................................... 105 NARCAN SPR ................................. 111 NARDIL TAB 15MG ........................... 81 NASACORT ALR SPR 55MCG/AC ....... 195 NASADROPS DRO 0.9% .................. 194 nasal 12 hr spr 0.05% .................... 196

nasal decon syp 30mg/5ml .............. 192 nasal decong tab 10mg ................... 192 nasal decong tab 30mg ................... 192 nasal moist spr 0.65% .................... 194 NASONEB NSL MIS STARTER ............ 193 NASONEX SPR 50MCG/AC ................ 195 NAT FIBER POW 58.6% ................... 145 NATACHEW CHW ............................ 180 NATACYN SUS 5% OP ..................... 217 NATALVIT TAB 75-1MG .................... 180 NATAZIA TAB ................................. 125 nateglinide tab 120 mg ................... 116 nateglinide tab 60 mg ..................... 116 NATELLE ONE CAP .......................... 180 NATESTO GEL 5.5MG ...................... 112 NATPARA INJ 100MCG ..................... 124 NATPARA INJ 25MCG ...................... 124 NATPARA INJ 50MCG ...................... 124 NATPARA INJ 75MCG ...................... 124 NATRECOR INJ 1.5MG ...................... 68 NATROBA SUS 0.9% ....................... 212 NATURE THROI TAB 162.5MG ........... 137 NATURE-THROI TAB 113.75MG ......... 137 NATURE-THROI TAB 130MG ............. 137 NATURE-THROI TAB 146.25MG ......... 137 NATURE-THROI TAB 16.25MG .......... 137 NATURE-THROI TAB 195MG ............. 137 NATURE-THROI TAB 260MG ............. 137 NATURE-THROI TAB 32.5MG ............ 137 NATURE-THROI TAB 325MG ............. 137 NATURE-THROI TAB 48.75MG .......... 137 NATURE-THROI TAB 65MG ............... 137 NATURE-THROI TAB 81.25MG .......... 137 NATURE-THROI TAB 97.5MG ............ 137 naturl fiber pow 30.9% .................... 145 NAVELBINE INJ 10MG/ML ................. 44 NAVELBINE INJ 50MG/5ML ................ 44 NEBULIZER MIS COMPRESS ............. 193 NEBUPENT INH 300MG ..................... 35 nebusal neb 3% ............................. 194 NEBUSAL NEB 6% .......................... 194 necon tab 0.5/35 ............................ 126 necon tab 1/35 .............................. 126 necon tab 1/50-28 .......................... 126 NECON TAB 10/11-28 ..................... 124 necon tab 7/7/7 ............................. 127 NEEDLES MIS 19GX1" ..................... 168 NEEDLES MIS 25GX1.5" .................. 168

281

NEEDLES MIS 26X1/2" .................... 168 NEEDLES MIS 27GX1/2" .................. 168 NEMBUTAL SOD INJ 50MG/ML .......... 104 NEO TO GO SPR 1-0.13% ................ 209 neomycin sulfate tab 500 mg ............. 17 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml ............. 215 neomycin-polymyxin b gu irrigation soln ................................................... 151 neomycin-polymyxin-dexamethasone ophth oint 0.1% ............................. 214 neomycin-polymyxin-dexamethasone ophth susp 0.1% ............................ 215 neomycin-polymyxin-hc ophth susp .. 215 neomycin-polymyxin-hc otic soln 1% 221 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ............... 221 neo-polycin oin hc 1%op ................. 214 neo-polycin oin op .......................... 215 NEOPROFEN SOL 10MG/ML ................ 68 NEOSPORIN CRE PLUS .................... 201 NEOSPORIN GU SOL 40/ML IR ......... 151 NEOSPORIN OIN ORIGINAL ............. 201 NEOSPORIN SOL OP ....................... 215 NEOSTIG METH INJ 10/10ML ........... 107 NEOSTIGMINE INJ 5MG/10ML .......... 107 neostigmine methylsulfate inj 0.5 mg/ml (1:2000) ....................................... 107 neostigmine methylsulfate inj 1 mg/ml ................................................... 107 neostigmine methylsulfate iv soln 10 mg/10 ml (1 mg/ml) ....................... 107 neostigmine methylsulfate iv soln 5 mg/10 ml (0.5 mg/ml) .................... 107 NEPHRAMINE INJ 5.4% ................... 171 NEPHROCAPS CAP .......................... 180 NEPHRON FA TAB ........................... 180 nephronex tab 1mg ........................ 180 NEPTAZANE TAB 25MG ................... 218 NEPTAZANE TAB 50MG ................... 218 NESINA TAB 12.5MG ....................... 114 NESINA TAB 25MG ......................... 114 NESINA TAB 6.25MG ....................... 114 NESTABS ABC MIS ......................... 180 NESTABS DHA PAK ......................... 180 neuac gel 1.2-5% ........................... 199 NEULASTA KIT 6MG/0.6M ................ 159 NEUPOGEN INJ 300/0.5 .................. 159

NEUPOGEN INJ 300MCG .................. 159 NEUPOGEN INJ 480/0.8 ................... 159 NEUPOGEN INJ 480MCG .................. 159 NEUPRO DIS 1MG/24HR ................... 87 NEUPRO DIS 2MG/24HR ................... 87 NEUPRO DIS 3MG/24HR ................... 87 NEUPRO DIS 4MG/24HR ................... 87 NEUPRO DIS 6MG/24HR ................... 87 NEUPRO DIS 8MG/24HR ................... 88 NEURONTIN CAP 100MG ................... 77 NEURONTIN CAP 300MG ................... 77 NEURONTIN CAP 400MG ................... 77 NEURONTIN SOL 250/5ML ................ 77 NEURONTIN TAB 600MG ................... 77 NEURONTIN TAB 800MG ................... 77 NEUT INJ 4% ................................. 180 NEUTRASAL POW ............................ 214 neutrogena gel rainbath .................. 210 NEVANAC SUS 0.1% ....................... 216 nevirapine susp 50 mg/5ml ............... 29 nevirapine tab 200 mg ..................... 29 nevirapine tab er 24hr 100 mg .......... 29 nevirapine tab er 24hr 400 mg .......... 29 NEWGEN TAB 32-1MG ..................... 180 NEXA PLUS CAP .............................. 180 nexafed tab 30mg .......................... 192 NEXAVAR TAB 200MG ...................... 41 NEXIUM 24HR CAP 20MG ................. 149 NEXIUM CAP 20MG ......................... 149 NEXIUM CAP 40MG ......................... 149 NEXIUM GRA 10MG DR .................... 149 NEXIUM GRA 2.5MG DR ................... 149 NEXIUM GRA 20MG DR .................... 149 NEXIUM GRA 40MG DR .................... 149 NEXIUM GRA 5MG DR ..................... 149 NEXIUM I.V. INJ 40MG .................... 149 NEXPLANON IMP 68MG .................... 125 NEXTERONE INJ .............................. 54 niacin cap 400mg ........................... 180 niacin cap 500mg ............................ 68 niacin cap er 250 mg ...................... 180 niacin cap er 500 mg ...................... 180 NIACIN FLUSH CAP FREE .................. 68 niacin tab 100 mg ........................... 180 niacin tab 250 mg ........................... 180 niacin tab 50 mg ............................ 180 niacin tab 500 mg ........................... 180 niacin tab er 1000 mg

282

(antihyperlipidemic) .......................... 58 niacin tab er 500 mg ....................... 180 niacin tab er 500 mg (antihyperlipidemic) ..................................................... 58 niacin tab er 750 mg ....................... 180 niacin tab er 750 mg (antihyperlipidemic) ..................................................... 58 NIACIN TR TAB 1000MG .................. 180 niacinamide tab 100 mg .................. 180 niacinamide tab 500 mg .................. 180 NIACINAMIDE TAB 500MG PR .......... 180 niacor tab 500mg ............................. 58 NIASPAN TAB 1000 ER ...................... 58 NIASPAN TAB 500MG ER ................... 58 NIASPAN TAB 750MG ER ................... 58 nicardipine hcl cap 20 mg .................. 62 nicardipine hcl cap 30 mg .................. 62 nicardipine hcl iv soln 2.5 mg/ml ........ 62 nicotine polacrilex gum 2 mg ........... 111 nicotine polacrilex gum 4 mg ........... 111 nicotine polacrilex lozenge 2 mg ....... 111 nicotine polacrilex lozenge 4 mg ....... 112 NICOTINE SYS KIT TRANSDER ......... 112 nicotine td patch 24hr 14 mg/24hr ... 112 NICOTROL INH............................... 112 NICOTROL NS SPR 10MG/ML ........... 112 nifedipine tab er 24hr 30 mg .............. 62 nifedipine tab er 24hr 60 mg .............. 62 nifedipine tab er 24hr 90 mg .............. 62 nifedipine tab er 24hr osmotic release 30 mg ................................................. 62 nifedipine tab er 24hr osmotic release 60 mg ................................................. 62 nifedipine tab er 24hr osmotic release 90 mg ................................................. 62 nilutamide tab 150 mg ...................... 38 nimodipine cap 30 mg ....................... 62 NINLARO CAP 2.3MG ........................ 44 NINLARO CAP 3MG ........................... 44 NINLARO CAP 4MG ........................... 44 NIPENT INJ 10MG ............................. 44 nisoldipine tab er 24hr 17 mg ............ 62 nisoldipine tab er 24hr 20 mg ............ 62 nisoldipine tab er 24hr 25.5 mg .......... 62 nisoldipine tab er 24hr 30 mg ............ 62 nisoldipine tab er 24hr 34 mg ............ 62 nisoldipine tab er 24hr 40 mg ............ 62 nisoldipine tab er 24hr 8.5 mg ........... 62

NITHIODOTE KIT ............................ 122 NITRO-BID OIN 2% ......................... 69 NITRO-DUR DIS 0.3MG/HR ............... 69 NITRO-DUR DIS 0.8MG/HR ............... 69 nitrofurantoin macrocrystalline cap 100 mg ................................................ 35 nitrofurantoin macrocrystalline cap 25 mg ................................................ 35 nitrofurantoin macrocrystalline cap 50 mg ................................................ 35 nitrofurantoin monohydrate macrocrystalline cap 100 mg ............. 35 nitrofurantoin susp 25 mg/5ml .......... 35 NITROGLYCER INJ 5MG/ML ............... 68 nitroglycerin iv soln 100 mcg/ml in d5w ..................................................... 68 nitroglycerin iv soln 200 mcg/ml in d5w ..................................................... 68 nitroglycerin iv soln 400 mcg/ml in d5w ..................................................... 68 nitroglycerin lingual aerosol 400 mcg/spray ...................................... 68 nitroglycerin sl tab 0.3 mg ................ 69 nitroglycerin sl tab 0.4 mg ................ 69 nitroglycerin sl tab 0.6 mg ................ 69 nitroglycerin td patch 24hr 0.1 mg/hr . 69 nitroglycerin td patch 24hr 0.2 mg/hr . 69 nitroglycerin td patch 24hr 0.4 mg/hr . 69 nitroglycerin td patch 24hr 0.6 mg/hr . 69 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) ..................................... 69 NITROLINGUAL SPR PUMPSPRA ......... 69 NITROMIST AER 400MCG .................. 69 NITRONAL SOL 1MG/ML ................... 68 NITROPRESS INJ 25MG/ML ............... 68 nitro-time cap 2.5mg cr .................... 68 nitro-time cap 6.5mg cr .................... 68 nitro-time cap 9mg cr ...................... 68 nizatidine cap 150 mg ..................... 143 nizatidine cap 300 mg ..................... 143 nizatidine oral soln 15 mg/ml ........... 143 NIZORAL A-D SHA 1% .................... 202 NIZORAL SHA 2% ........................... 202 NONYX GEL ................................... 210 NORCO TAB 10-325MG ..................... 12 NORCO TAB 5-325MG ...................... 12 NORCO TAB 7.5-325 ........................ 12 NORDITROPIN INJ 10/1.5ML ............ 133

283

NORDITROPIN INJ 15/1.5ML ............ 133 NORDITROPIN INJ 30/3ML ............... 133 NORDITROPIN INJ 5/1.5ML .............. 133 norepinephrine bitartrate iv soln 1 mg/ml ..................................................... 71 norethindrone acetate tab 5 mg ....... 136 NORITATE CRE 1% ......................... 212 NORMOSOL -M INJ /D5W ................ 173 NORMOSOL -R INJ .......................... 173 NORMOSOL -R INJ /D5W ................. 173 NORMOSOL-R INJ PH 7.4 ................ 173 NORPACE CAP 100MG ....................... 54 NORPACE CAP 100MG CR .................. 54 NORPACE CAP 150MG ....................... 54 NORPACE CAP 150MG CR .................. 54 NORTHERA CAP 100MG ..................... 68 NORTHERA CAP 200MG ..................... 68 NORTHERA CAP 300MG ..................... 68 nortriptyline hcl cap 10 mg ................ 86 nortriptyline hcl cap 25 mg ................ 86 nortriptyline hcl cap 50 mg ................ 86 nortriptyline hcl cap 75 mg ................ 86 nortriptyline hcl soln 10 mg/5ml ......... 86 NORVASC TAB 10MG ........................ 62 NORVASC TAB 2.5MG ....................... 62 NORVASC TAB 5MG .......................... 62 NORVIR CAP 100MG ......................... 28 NORVIR SOL 80MG/ML ...................... 28 NORVIR TAB 100MG ......................... 28 nose dro 1% .................................. 196 NOVAFERRUM CAP 50MG ................. 180 novaferrum dro 10mg/ml ................ 180 NOVAFERRUM DRO 15MG/ML ........... 180 NOVAFERRUM LIQ 125 .................... 180 novarel inj 10000unt ...................... 130 NOVOEIGHT INJ 1000UNIT .............. 158 NOVOEIGHT INJ 1500UNIT .............. 158 NOVOEIGHT INJ 2000UNIT .............. 158 NOVOEIGHT INJ 250UNIT ................ 158 NOVOEIGHT INJ 500UNIT ................ 158 NOVOLIN INJ 70/30 ........................ 116 NOVOLIN N INJ U-100 .................... 116 NOVOLIN R INJ U-100 ..................... 116 NOVOLOG INJ 100/ML ..................... 116 NOVOLOG INJ FLEXPEN ................... 116 NOVOLOG INJ PENFILL .................... 116 NOVOLOG MIX INJ 70/30 ................ 116 NOVOLOG MIX INJ FLEXPEN ............ 116

NOVOSEVEN RT INJ 1MG ................. 158 NOVOSEVEN RT INJ 2MG ................. 158 NOVOSEVEN RT INJ 5MG ................. 158 NOVOSEVEN RT INJ 8MG ................. 158 NOVOTWIST MIS 32GX5MM ............. 122 NOXAFIL INJ 300/16.7 ..................... 26 NOXAFIL SUS 40MG/ML .................... 26 NOXAFIL TAB 100MG ....................... 26 np thyroid tab 15mg ....................... 137 np thyroid tab 30mg ....................... 137 np thyroid tab 60mg ....................... 137 np thyroid tab 90mg ....................... 137 NUCYNTA ER TAB 100MG .................. 12 NUCYNTA ER TAB 150MG .................. 12 NUCYNTA ER TAB 200MG .................. 12 NUCYNTA ER TAB 250MG .................. 12 NUCYNTA ER TAB 50MG ................... 12 NUCYNTA TAB 100MG ...................... 13 NUCYNTA TAB 50MG ........................ 12 NUCYNTA TAB 75MG ........................ 12 NUEDEXTA CAP 20-10MG ................ 111 NULOJIX INJ 250MG ....................... 166 NULYTELY SOL FLAV PKS ................. 145 NUMOISYN LOZ .............................. 214 NUOX GEL 6-3% ............................ 199 NUPLAZID TAB 17MG ....................... 91 NUTR DRINK POW MIX VAN ............. 170 NUTRICION TAB PORVIDA ............... 180 NUTRIENTS TAB PRENATAL .............. 180 nutrilipid emu 20% ......................... 171 NUTRIVIT LIQ 800-15-1 .................. 180 NUTROPIN AQ INJ 10MG/2ML ........... 133 NUTROPIN AQ INJ 20MG/2ML ........... 133 NUTROPIN AQ INJ NUSPIN 5 ............ 133 NUVARING MIS .............................. 127 NUVESSA GEL 1.3%........................ 154 NUVIGIL TAB 150MG ....................... 110 NUVIGIL TAB 200MG ....................... 110 NUVIGIL TAB 250MG ....................... 110 NUVIGIL TAB 50MG ........................ 110 NUWIQ INJ 1000UNIT ..................... 158 NUWIQ INJ 2000UNIT ..................... 158 NUWIQ INJ 250UNIT ....................... 158 NUWIQ INJ 500UNIT ....................... 158 NUWIQ KIT 1000UNIT ..................... 158 NUWIQ KIT 2000UNIT ..................... 158 NUWIQ KIT 250UNIT ....................... 158 NUWIQ KIT 500UNIT ....................... 158

284

NYMALIZE SOL 60/20ML .................... 62 nystatin cream 100000 unit/gm ....... 202 nystatin oint 100000 unit/gm ........... 202 nystatin oral powder ......................... 26 nystatin susp 100000 unit/ml ............. 26 nystatin tab 500000 unit ................... 26 nystatin topical powder 100000 unit/gm ................................................... 202 nystatin-triamcinolone cream 100000-0.1 unit/gm-% ............................... 202 nystatin-triamcinolone oint 100000-0.1 unit/gm-% .................................... 203 O OASIS MATRIX MIS 3X7CM .............. 213 OASIS MOUTH SPR 35% ................. 214 OASIS ULTRA MIS 3X3.5CM ............. 213 OASIS ULTRA MIS 5 X 7CM .............. 213 OASIS ULTRA MIS TRI MESH ........... 213 OB COMPLETE CAP GOLD ................ 181 OB COMPLETE CAP ONE .................. 181 OB COMPLETE CAP PETITE ............... 181 OB COMPLETE TAB ......................... 181 OB COMPLETE TAB PREMIER ............ 181 OB COMPLETE/ CAP DHA ................. 181 OBIZUR INJ 500 UNIT ..................... 158 OBREDON SOL 2.5-200 ................... 189 OBSTETRIX EC TAB ........................ 181 OBSTETRIX PAK DHA ...................... 181 OBTREX DHA PAK ........................... 181 OBTREX TAB .................................. 181 OC8 GEL 7% ................................. 199 O-CAL TAB PRENATAL ..................... 180 OCALIVA TAB 10MG ........................ 147 OCALIVA TAB 5MG ......................... 147 OCTAGAM INJ 10/100ML ................. 165 OCTAGAM INJ 10GM ....................... 165 OCTAGAM INJ 1GM ......................... 165 OCTAGAM INJ 2.5GM ...................... 165 OCTAGAM INJ 20/200ML ................. 165 OCTAGAM INJ 25GM ....................... 165 OCTAGAM INJ 2GM/20ML ................ 165 OCTAGAM INJ 5GM ......................... 165 OCTAGAM INJ 5GM/50ML ................ 165 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) ......................................... 134 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) ......................................... 134 octreotide acetate inj 500 mcg/ml (0.5

mg/ml) ......................................... 134 ocucoat sol 2% op .......................... 219 OCUFEN SOL 0.03% OP ................... 216 OCUFLOX DRO 0.3% OP .................. 215 ODEFSEY TAB ................................. 28 ODOMZO CAP 200MG ....................... 44 odor eaters pow 1% ........................ 203 OFEV CAP 100MG ........................... 195 OFEV CAP 150MG ........................... 195 OFIRMEV INJ 10MG/ML ...................... 1 ofloxacin ophth soln 0.3% ............... 215 ofloxacin otic soln 0.3% .................. 221 ofloxacin tab 400 mg ....................... 21 ogestrel tab ................................... 126 olanzapine for im inj 10 mg ............... 91 olanzapine orally disintegrating tab 10 mg ................................................ 91 olanzapine orally disintegrating tab 15 mg ................................................ 91 olanzapine orally disintegrating tab 20 mg ................................................ 91 olanzapine orally disintegrating tab 5 mg ..................................................... 91 olanzapine tab 10 mg ....................... 92 olanzapine tab 15 mg ....................... 92 olanzapine tab 2.5 mg ...................... 92 olanzapine tab 20 mg ....................... 92 olanzapine tab 5 mg ........................ 92 olanzapine tab 7.5 mg ...................... 92 olmesartan medoxomil tab 20 mg ...... 53 olmesartan medoxomil tab 40 mg ...... 53 olmesartan medoxomil tab 5 mg ........ 53 olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg ... 52 olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg ... 52 olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg ...... 52 olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg ..................................................... 51 olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg . 51 olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg 51 olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg ... 51 olopatadine hcl nasal soln 0.6% ........ 195

285

olopatadine hcl ophth soln 0.1% (base equivalent) .................................... 217 olopatadine hcl ophth soln 0.2% (base equivalent) .................................... 217 OLUX AER 0.05% ........................... 208 OLUX-E AER 0.05% ........................ 208 OLYSIO CAP 150MG .......................... 32 OMECLAMOX- MIS PAK.................... 151 omega-3-acid ethyl esters cap 1 gm ... 58 omeprazole cap delayed release 10 mg ................................................... 149 omeprazole cap delayed release 20 mg ................................................... 149 omeprazole cap delayed release 40 mg ................................................... 149 omeprazole magnesium cap dr 20.6 mg (20 mg base equiv) ........................ 149 OMEPRAZOLE TAB 20MG ................. 149 omeprazole-sodium bicarbonate cap 20-1100 mg ....................................... 149 omeprazole-sodium bicarbonate cap 40-1100 mg ....................................... 149 OMNARIS SPR ................................ 195 OMNIPOD KIT STARTER .................. 122 OMNIPOD MIS ............................... 122 OMNIPRED SUS 1% OP ................... 216 OMNITROPE INJ 10/1.5ML ............... 133 OMNITROPE INJ 5.8MG ................... 133 ondansetron hcl inj 4 mg/2ml (2 mg/ml) ................................................... 140 ondansetron hcl inj 40 mg/20ml (2 mg/ml) ......................................... 140 ondansetron hcl oral soln 4 mg/5ml .. 140 ondansetron hcl tab 24 mg .............. 140 ondansetron hcl tab 4 mg ................ 140 ondansetron hcl tab 8 mg ................ 140 ondansetron orally disintegrating tab 4 mg ............................................... 140 ondansetron orally disintegrating tab 8 mg ............................................... 140 ONE A DAY CAP PRENATAL .............. 181 ONE A DAY MIS PRENATAL .............. 181 one daily tab ................................. 181 one daily tab plus iro ...................... 181 ONE-A-DAY TAB WOMENS ............... 181 ONETOUCH PNG KIT INS PUMP ........ 122 ONEXTON GEL 1.2-3.75 .................. 199 ONFI SUS 2.5MG/ML ......................... 77

ONFI TAB 10MG .............................. 77 ONFI TAB 20MG .............................. 77 ONGLYZA TAB 2.5MG ...................... 114 ONGLYZA TAB 5MG ......................... 114 ONIVYDE INJ 4.3MG/ML ................... 45 ONMEL TAB 200MG .......................... 26 OPANA ER TAB 10MG ....................... 13 OPANA ER TAB 15MG ....................... 13 OPANA ER TAB 20MG ....................... 13 OPANA ER TAB 30MG ....................... 13 OPANA ER TAB 40MG ....................... 13 OPANA ER TAB 5MG ......................... 13 OPANA ER TAB 7.5MG ...................... 13 OPANA INJ 1MG/ML ......................... 13 OPANA TAB 10MG ............................ 13 OPANA TAB 5MG ............................. 13 OPSUMIT TAB 10MG ........................ 69 optimal-d cap 50000unt .................. 181 ORACEA CAP 40MG ......................... 212 ORACIT SOL .................................. 152 ORAFATE PST 10% ......................... 214 oral electrolyte solution ................... 170 oral saline sol laxative ..................... 145 ORAP TAB 1MG ............................... 95 ORAP TAB 2MG ............................... 95 ORAPRED ODT TAB 10MG ................ 131 ORAPRED ODT TAB 15MG ................ 131 ORAPRED ODT TAB 30MG ................ 131 ORAVIG TAB 50MG .......................... 26 ORENCIA CLCK INJ 125MG/ML ......... 163 ORENCIA INJ 125MG/ML .................. 163 ORENITRAM TAB 0.125MG ................ 70 ORENITRAM TAB 0.25MG .................. 70 ORENITRAM TAB 1MG ...................... 70 ORENITRAM TAB 2.5MG ................... 70 ORFADIN CAP 10MG ....................... 134 ORFADIN CAP 20MG ....................... 135 ORFADIN CAP 2MG ......................... 134 ORFADIN CAP 5MG ......................... 134 ORFADIN SUS 4MG/ML .................... 135 ORKAMBI TAB 100-125 ................... 192 ORKAMBI TAB 200-125 ................... 192 orphenadrine citrate inj 30 mg/ml ..... 109 orphenadrine citrate tab er 12hr 100 mg .................................................... 109 ORTHO MICRON TAB 0.35MG ........... 127 ORTHO TRI- TAB CYCLEN ................ 127 ORTHO TRI- TAB CYCLN LO.............. 127

286

ORTHO-CYCLEN TAB 0.25/35 ........... 126 ORTHO-NOVUM TAB 1/35 ................ 126 ORTHO-NOVUM TAB 7/7/7 ............... 127 oscion clnsr lot 6% ......................... 199 oseltamivir phosphate cap 30 mg (base equiv) ............................................. 33 oseltamivir phosphate cap 45 mg (base equiv) ............................................. 33 oseltamivir phosphate cap 75 mg (base equiv) ............................................. 33 OSENI TAB 12.5-15 ........................ 114 OSENI TAB 12.5-30 ........................ 114 OSENI TAB 12.5-45 ........................ 114 OSENI TAB 25-15MG ...................... 114 OSENI TAB 25-30MG ...................... 114 OSENI TAB 25-45MG ...................... 114 OSGOOD BIOPS MIS 18GX1" ........... 168 osmitrol inj 10% ............................ 152 osmitrol inj 15% ............................ 152 osmitrol inj 5% .............................. 152 OSMOPREP TAB 1.5GM .................... 145 OSPHENA TAB 60MG ....................... 136 OSTEO-PORETI TAB ........................ 181 OTEZLA TAB 10/20/30 .................... 166 OTEZLA TAB 30MG ......................... 166 OTREXUP INJ 10MG ........................ 163 OTREXUP INJ 15MG ........................ 163 OTREXUP INJ 20MG ........................ 164 OTREXUP INJ 25MG ........................ 164 OTREXUP INJ 7.5/0.4 ...................... 163 OVCON-35 TAB .............................. 126 OVIDE LOT 0.5% ............................ 212 OVIDREL INJ ................................. 130 oxacillin sodium for inj 1 gm .............. 23 oxacillin sodium for inj 10 gm ............ 23 oxacillin sodium for inj 2 gm .............. 23 oxaliplatin for iv inj 100 mg ............... 37 oxaliplatin for iv inj 50 mg ................. 36 oxaliplatin iv soln 100 mg/20ml .......... 37 oxaliplatin iv soln 50 mg/10ml ........... 37 OXANDRIN TAB 10MG ..................... 112 OXANDRIN TAB 2.5MG .................... 112 oxandrolone tab 10 mg ................... 112 oxandrolone tab 2.5 mg .................. 112 oxaprozin tab 600 mg ........................ 4 OXAYDO TAB 5MG ............................ 13 OXAYDO TAB 7.5MG ......................... 13 oxazepam cap 10 mg ........................ 72

oxazepam cap 15 mg ....................... 72 oxazepam cap 30 mg ....................... 72 oxcarbazepine susp 300 mg/5ml (60 mg/ml) .......................................... 77 oxcarbazepine tab 150 mg ................ 77 oxcarbazepine tab 300 mg ................ 77 oxcarbazepine tab 600 mg ................ 77 OXISTAT CRE 1% ........................... 203 OXISTAT LOT 1% ........................... 203 OXSORALEN LOT 1% ...................... 210 OXTELLAR XR TAB 150MG ................ 77 OXTELLAR XR TAB 300MG ................ 77 OXTELLAR XR TAB 600MG ................ 77 oxybutynin chloride syrup 5 mg/5ml . 153 oxybutynin chloride tab 5 mg ........... 153 oxybutynin chloride tab er 24hr 10 mg .................................................... 153 oxybutynin chloride tab er 24hr 15 mg .................................................... 153 oxybutynin chloride tab er 24hr 5 mg 153 oxycodone hcl cap 5 mg ................... 13 oxycodone hcl conc 100 mg/5ml (20 mg/ml) .......................................... 13 oxycodone hcl soln 5 mg/5ml ............ 13 oxycodone hcl tab 10 mg .................. 13 oxycodone hcl tab 15 mg .................. 13 oxycodone hcl tab 20 mg .................. 13 oxycodone hcl tab 30 mg .................. 13 oxycodone hcl tab 5 mg ................... 13 oxycodone hcl tab er 12hr deter 10 mg ..................................................... 13 oxycodone hcl tab er 12hr deter 15 mg ..................................................... 13 oxycodone hcl tab er 12hr deter 20 mg ..................................................... 13 oxycodone hcl tab er 12hr deter 30 mg ..................................................... 13 oxycodone hcl tab er 12hr deter 40 mg ..................................................... 13 oxycodone hcl tab er 12hr deter 60 mg ..................................................... 13 oxycodone hcl tab er 12hr deter 80 mg ..................................................... 13 oxycodone w/ acetaminophen soln 5-325 mg/5ml .......................................... 13 oxycodone w/ acetaminophen tab 10-325 mg ................................................ 14 oxycodone w/ acetaminophen tab 5-325

287

mg ................................................. 14 oxycodone w/ acetaminophen tab 7.5-325 mg ........................................... 14 oxycodone-aspirin tab 4.8355-325 mg 14 oxycodone-ibuprofen tab 5-400 mg .... 14 OXYCONTIN TAB 10MG CR ................ 14 OXYCONTIN TAB 15MG CR ................ 14 OXYCONTIN TAB 20MG CR ................ 14 OXYCONTIN TAB 30MG CR ................ 14 OXYCONTIN TAB 40MG CR ................ 14 OXYCONTIN TAB 60MG CR ................ 14 OXYCONTIN TAB 80MG CR ................ 14 oxymorphone hcl tab 10 mg .............. 14 oxymorphone hcl tab 5 mg ................ 14 oxymorphone hcl tab er 12hr 10 mg ... 14 oxymorphone hcl tab er 12hr 15 mg ... 14 oxymorphone hcl tab er 12hr 20 mg ... 14 oxymorphone hcl tab er 12hr 30 mg ... 14 oxymorphone hcl tab er 12hr 40 mg ... 14 oxymorphone hcl tab er 12hr 5 mg ..... 14 oxymorphone hcl tab er 12hr 7.5 mg .. 14 oxytocin inj 10 unit/ml .................... 135 OXYTROL DIS 3.9MG/24 .................. 153 OXYTROL/WOMN DIS 3.9MG/24 ....... 153 oys shell+d chw 500-400 ................ 181 oys shell+d tab 250-125 ................. 181 oysco 500+d tab ............................ 181 oyst shell/d tab 500mg ................... 181 oyster shell calcium tab 500 mg ....... 181 oyster-cal tab 500mg ...................... 181 P paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) ........................................... 44 paclitaxel iv conc 150 mg/25ml (6 mg/ml) ........................................... 44 paclitaxel iv conc 30 mg/5ml (6 mg/ml) ..................................................... 44 paclitaxel iv conc 300 mg/50ml (6 mg/ml) ........................................... 44 pain relief dro 80/0.8ml ..................... 1 pain relief liq 500/15ml ...................... 1 pain relief sus 160/5ml ...................... 1 PAIN RELIEF TAB ............................... 2 pain relief tab 325mg ......................... 1 pain relief tab 500mg ......................... 1 pain relieve chw 160mg jr .................. 1 pain relievr chw 80mg ........................ 1 paliperidone tab er 24hr 1.5 mg ......... 92

paliperidone tab er 24hr 3 mg ........... 92 paliperidone tab er 24hr 6 mg ........... 92 paliperidone tab er 24hr 9 mg ........... 92 PALOMAR E OIN ............................. 210 PAMINE FORTE TAB 5MG ................. 142 PAMINE TAB 2.5MG ........................ 142 PANCREAZE CAP 10500UNT ............. 148 PANCREAZE CAP 16800UNT ............. 148 PANCREAZE CAP 21000UNT ............. 148 PANCREAZE CAP 4200UNIT .............. 148 pancuronium bromide inj 1 mg/ml .... 110 PANDEL CRE 0.1% .......................... 207 PANHEMATIN INJ 313MG ................. 161 PANHEMATIN INJ 350MG ................. 161 PANOXYL GEL 3% ........................... 199 PANOXYL-4 LIQ CREM WSH ............. 199 PANRETIN GEL 0.1% ....................... 210 pantoprazole sodium ec tab 20 mg (base equiv) ........................................... 149 pantoprazole sodium ec tab 40 mg (base equiv) ........................................... 149 pantoprazole sodium for iv soln 40 mg (base equiv) .................................. 149 papaverine hcl inj 30 mg/ml .............. 68 PARAFON FORT TAB 500MG ............. 109 PARAGARD IUD T380A .................... 125 paregoric tincture 2 mg/5ml (morphine equivalent) .................................... 139 PAREMYD SOL 1-0.25% ................... 218 PARI LC MIS SPRINT ....................... 193 paricalcitol cap 1 mcg ...................... 133 paricalcitol cap 2 mcg ...................... 133 paricalcitol cap 4 mcg ...................... 133 paricalcitol iv soln 5 mcg/ml ............. 133 PARLODEL CAP 5MG ........................ 88 PARNATE TAB 10MG ........................ 81 paromomycin sulfate cap 250 mg ...... 17 paroxetine hcl tab 10 mg .................. 84 paroxetine hcl tab 20 mg .................. 84 paroxetine hcl tab 30 mg .................. 84 paroxetine hcl tab 40 mg .................. 84 paroxetine hcl tab er 24hr 12.5 mg .... 84 paroxetine hcl tab er 24hr 25 mg ....... 84 paroxetine hcl tab er 24hr 37.5 mg .... 84 PASER GRA 4GM ............................. 30 PATADAY SOL 0.2% ........................ 217 PATANASE SPR 0.6% ...................... 195 PATANOL SOL 0.1% OP ................... 217

288

PAXIL CR TAB 12.5MG ...................... 84 PAXIL CR TAB 25MG ......................... 84 PAXIL CR TAB 37.5MG ...................... 84 PAXIL SUS 10MG/5ML ....................... 84 PAXIL TAB 10MG .............................. 84 PAXIL TAB 20MG .............................. 84 PAXIL TAB 30MG .............................. 84 PAXIL TAB 40MG .............................. 84 PAZEO DRO 0.7% .......................... 217 PCE TAB 333MG EC .......................... 21 PCE TAB 500MG EC .......................... 21 PEAK AIR FLO MIS ADLT/PED ........... 193 PECGEN DMX LIQ 10-187MG ............ 189 PECGEN DMX LIQ 15-125MG ............ 189 pecgen liq pse ................................ 189 PEDIA-LAX LIQ 50MG ...................... 145 PEDIA-LAX SUP 2.8GM .................... 145 PEDIAPRED SOL 6.7/5ML ................. 131 PEDITRACE INJ .............................. 174 PEGANONE TAB 250MG ..................... 77 PEGASYS INJ ................................. 165 PEGASYS INJ 180MCG/M ................. 165 PEGASYS INJ PROCLICK .................. 165 PEG-INTRON KIT 120 RP ................. 165 PEG-INTRON KIT 150 RP ................. 165 PEG-INTRON KIT 50MCG RP ............. 165 PEG-INTRON KIT 80MCG RP ............. 165 PEN G PROC INJ 600000 ................... 23 PEN NEEDLES MIS 29GX1/2" ........... 122 PEN NEEDLES MIS 29GX10MM ......... 122 PEN NEEDLES MIS 31GX1/4" ........... 122 PEN NEEDLES MIS 31GX5/16 ........... 122 PENICILL GK/ INJ DEX 1MU ............... 23 PENICILL GK/ INJ DEX 2MU ............... 23 PENICILL GK/ INJ DEX 3MU ............... 23 penicillin g potassium for inj 20000000 unit ................................................ 23 penicillin g potassium for inj 5000000 unit ................................................ 23 penicillin g sodium for inj 5000000 unit ..................................................... 23 penicillin v potassium for soln 125 mg/5ml ........................................... 23 penicillin v potassium for soln 250 mg/5ml ........................................... 23 penicillin v potassium tab 250 mg ....... 23 penicillin v potassium tab 500 mg ....... 23 PENNSAID SOL 2% ............................ 5

PENTAM 300 INJ 300MG ................... 35 PENTASA CAP 250MG CR ................. 143 PENTASA CAP 500MG CR ................. 143 pentoxifylline tab er 400 mg ............ 161 PEPCID AC CHW MAX ST ................. 143 PEPCID SUS 40MG/5ML ................... 143 PEPCID TAB 20MG .......................... 143 PEPCID TAB 40MG .......................... 143 PERCOCET TAB 10-325MG ................ 14 PERCOCET TAB 2.5-325 .................... 14 PERCOCET TAB 5-325MG .................. 14 PERCOCET TAB 7.5-325 .................... 14 PERFOROMIST NEB 20MCG .............. 191 PERIDEX SOL 0.12% ....................... 214 perindopril erbumine tab 2 mg .......... 48 perindopril erbumine tab 4 mg .......... 48 perindopril erbumine tab 8 mg .......... 48 periogard sol 0.12% ....................... 214 periomed con 0.63% ....................... 214 PERJETA INJ 420/14ML ..................... 44 permethrin cream 5% ..................... 212 perphenazine tab 16 mg ................... 95 perphenazine tab 2 mg ..................... 95 perphenazine tab 4 mg ..................... 95 perphenazine tab 8 mg ..................... 95 perphenazine-amitriptyline tab 2-10 mg ..................................................... 95 perphenazine-amitriptyline tab 2-25 mg ..................................................... 95 perphenazine-amitriptyline tab 4-10 mg ..................................................... 95 perphenazine-amitriptyline tab 4-25 mg ..................................................... 95 perphenazine-amitriptyline tab 4-50 mg ..................................................... 95 PERRY PRENAT CAP ........................ 181 PERSONAL BES MIS FULL RNG ......... 193 PERSONAL BES MIS LOW RANG ........ 193 PERTZYE CAP ................................. 148 PEXEVA TAB 10MG .......................... 84 PEXEVA TAB 20MG .......................... 85 PEXEVA TAB 30MG .......................... 85 PEXEVA TAB 40MG .......................... 85 PHARMABASE OIN BARRIER ............. 210 phenazopyridine hcl tab 100 mg ....... 152 phenazopyridine hcl tab 200 mg ....... 152 phendimetrazine tartrate cap er 24hr 105 mg ............................................... 123

289

phendimetrazine tartrate tab 35 mg .. 123 phenelzine sulfate tab 15 mg ............. 81 PHENERGAN INJ 25MG/ML ............... 140 PHENERGAN INJ 50MG/ML ............... 141 phenergan sup 12.5mg ................... 141 phenergan sup 25mg ...................... 141 phenergan sup 50mg ...................... 141 phenobarbital elixir 20 mg/5ml ........... 77 phenobarbital sodium inj 130 mg/ml ... 77 phenobarbital tab 100 mg ................. 77 phenobarbital tab 15 mg ................... 77 phenobarbital tab 16.2 mg ................ 77 phenobarbital tab 30 mg ................... 77 phenobarbital tab 32.4 mg ................ 77 phenobarbital tab 60 mg ................... 77 phenobarbital tab 64.8 mg ................ 77 phenobarbital tab 97.2 mg ................ 77 phenoxybenzamine hcl cap 10 mg ...... 49 phentermine hcl cap 15 mg ............. 123 phentermine hcl cap 30 mg ............. 123 phentermine hcl cap 37.5 mg ........... 123 phentermine hcl tab 37.5 mg ........... 123 PHENTOLAMINE INJ 5MG ................... 49 PHENYL/NACL INJ 1MG/10ML ............. 71 PHENYLEPHRIN INJ 10MG/ML ............. 71 phenylephrine hcl inj 10 mg/ml .......... 71 phenylephrine hcl ophth soln 10% .... 219 phenylephrine hcl ophth soln 2.5% ... 219 PHENYTEK CAP 200MG ...................... 77 PHENYTEK CAP 300MG ...................... 77 phenytoin chew tab 50 mg ................ 77 phenytoin sodium extended cap 100 mg ..................................................... 77 phenytoin sodium extended cap 200 mg ..................................................... 77 phenytoin sodium extended cap 300 mg ..................................................... 77 phenytoin sodium inj 50 mg/ml .......... 77 phenytoin susp 125 mg/5ml .............. 77 PHOS-FLUR SOL 0.044% ................. 214 PHOSLO CAP 667MG ....................... 135 PHOSLYRA SOL .............................. 135 PHOSPHOLINE SOL 0.125%OP ......... 220 PHOTOFRIN INJ 75MG ....................... 44 PHYS EZ USE KIT M-PRED ............... 130 physiolyte sol ................................ 213 PHYSOS SALIC INJ 1MG/ML ............. 122 phytonadione inj 1 mg/0.5ml (2 mg/ml)

.................................................... 181 phytonadione inj 10 mg/ml .............. 181 PICATO GEL 0.015% ....................... 201 PICATO GEL 0.05% ......................... 201 PICO WOUND KIT THER SYS ............ 213 PIKO 1 MIS ELECTRON .................... 193 pilocarpine hcl ophth soln 1% ........... 220 pilocarpine hcl ophth soln 2% ........... 220 pilocarpine hcl ophth soln 4% ........... 220 pilocarpine hcl tab 5 mg .................. 150 pilocarpine hcl tab 7.5 mg ................ 150 pimozide tab 1 mg ........................... 95 pimozide tab 2 mg ........................... 95 pindolol tab 10 mg ........................... 60 pindolol tab 5 mg ............................ 60 PIN-X CHW 250MG .......................... 35 pioglitazone hcl tab 15 mg (base equiv) .................................................... 115 pioglitazone hcl tab 30 mg (base equiv) .................................................... 115 pioglitazone hcl tab 45 mg (base equiv) .................................................... 115 pioglitazone hcl-glimepiride tab 30-2 mg .................................................... 115 pioglitazone hcl-glimepiride tab 30-4 mg .................................................... 115 pioglitazone hcl-metformin hcl tab 15-500 mg ......................................... 115 pioglitazone hcl-metformin hcl tab 15-850 mg ......................................... 115 piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) ................... 23 piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) ....................... 23 piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) .......................... 23 piperacillin sod-tazobactam sod for inj 40.5 gm (36-4.5 gm) ....................... 23 piroxicam cap 10 mg .......................... 4 piroxicam cap 20 mg .......................... 4 PITOCIN INJ 10UNT/ML ................... 135 PLAN B TAB 1.5MG ......................... 124 PLASMA-LYTE INJ -148 .................... 173 PLASMA-LYTE INJ 56/D5W ............... 173 PLASMA-LYTE INJ -A ....................... 173 PLAVIX TAB 300MG ......................... 162 PLAVIX TAB 75MG .......................... 162 PLEGISOL SOL ................................ 68

290

PLEGRIDY INJ ................................ 108 PLEGRIDY INJ PEN .......................... 108 PLEGRIDY INJ STARTER .................. 108 PLEGRIDY PEN INJ STARTER ............ 108 plenamine inj 15% ......................... 172 PLIAGLIS CRE 7-7% ....................... 209 PNV OB+DHA PAK .......................... 181 pnv-dha cap .................................. 181 PNV-DHA CAP DOCUSATE ................ 181 PNV-OMEGA CAP ............................ 181 pnv-select tab ................................ 181 PNV-TOTAL CAP ............................. 181 POCKET PEAK MIS METER ............... 194 POCKETPEAK MIS UNIVERSA ........... 194 PODIAPN CAP ................................ 170 PODOCON SOL 25% ....................... 210 podofilox soln 0.5% ........................ 210 polycin oin op ................................ 215 polyethylene glycol 3350 oral packet . 145 polyethylene glycol 3350 oral powder 145 polymyxin b sulfate for inj 500000 unit 35 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% ....................... 215 POLYTRIM SOL OP .......................... 215 POLY-VENT IR TAB 60-380MG .......... 189 polyvinyl alcohol ophth soln 1.4% ..... 219 poly-vite dro .................................. 181 POMALYST CAP 1MG ......................... 39 POMALYST CAP 2MG ......................... 39 POMALYST CAP 3MG ......................... 39 POMALYST CAP 4MG ......................... 39 PONSTEL CAP 250MG ......................... 4 PORTRAZZA INJ 800/50ML ................ 44 pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml .................................. 152 pot bicarbonate & chloride effer tab 25 meq ............................................. 170 potassium acetate inj 2 meq/ml ....... 173 potassium acetate inj 4 meq/ml ....... 173 potassium bicarbonate effer tab 25 meq ................................................... 170 potassium chloride 20 meq/l (0.15%) in dextrose 5% inj ............................. 173 potassium chloride 40 meq/l (0.3%) in dextrose 5% inj ............................. 173 potassium chloride cap er 10 meq .... 170 potassium chloride cap er 8 meq ...... 170 potassium chloride inj 10 meq/100ml 173

potassium chloride inj 10 meq/50ml .. 173 potassium chloride inj 2 meq/ml ....... 173 potassium chloride inj 20 meq/100ml 173 potassium chloride inj 20 meq/50ml .. 173 potassium chloride inj 40 meq/100ml 173 potassium chloride microencapsulated crys er tab 10 meq ......................... 170 potassium chloride microencapsulated crys er tab 20 meq ......................... 170 potassium chloride oral soln 10% (20 meq/15ml) .................................... 170 potassium chloride oral soln 20% (40 meq/15ml) .................................... 170 potassium chloride powder packet 20 meq .............................................. 170 potassium chloride tab er 10 meq ..... 171 potassium chloride tab er 20 meq (1500 mg) .............................................. 171 potassium citrate & citric acid soln 1100-334 mg/5ml ................................... 152 potassium citrate tab er 10 meq (1080 mg) .............................................. 152 potassium citrate tab er 15 meq (1620 mg) .............................................. 152 potassium citrate tab er 5 meq (540 mg) .................................................... 152 potassium phosphates inj 15 mm/5ml (phos) 22 meq/5ml (k) .................... 174 potassium phosphates inj 150 mm/50ml (phos) 220 meq/50ml (k) ................ 174 potassium phosphates inj 45 mm/15ml (phos) 66 meq/15ml (k) .................. 174 POTIGA TAB 200MG ......................... 77 POTIGA TAB 300MG ......................... 78 POTIGA TAB 400MG ......................... 78 POTIGA TAB 50MG ........................... 77 PR NATAL 400 PAK ......................... 181 PR NATAL 400 PAK EC ..................... 181 PR NATAL 430 PAK ......................... 181 PR NATAL 430 PAK EC ..................... 181 PRADAXA CAP 110MG ..................... 156 PRADAXA CAP 150MG ..................... 156 PRADAXA CAP 75MG ....................... 156 PRALIDOXIME INJ 600/2ML .............. 122 PRALUENT INJ 150MG/ML ................. 58 PRALUENT INJ 75MG/ML ................... 58 pramipexole dihydrochloride tab 0.125 mg ................................................ 88

291

pramipexole dihydrochloride tab 0.25 mg ..................................................... 88 pramipexole dihydrochloride tab 0.5 mg ..................................................... 88 pramipexole dihydrochloride tab 0.75 mg ..................................................... 88 pramipexole dihydrochloride tab 1 mg . 88 pramipexole dihydrochloride tab 1.5 mg ..................................................... 88 pramipexole dihydrochloride tab er 24hr 0.375 mg ........................................ 88 pramipexole dihydrochloride tab er 24hr 0.75 mg .......................................... 88 pramipexole dihydrochloride tab er 24hr 1.5 mg ........................................... 88 pramipexole dihydrochloride tab er 24hr 2.25 mg .......................................... 88 pramipexole dihydrochloride tab er 24hr 3 mg .............................................. 88 pramipexole dihydrochloride tab er 24hr 4.5 mg ........................................... 88 PRAMOSONE CRE 1-1% .................. 204 PRAMOSONE LOT 1% ...................... 204 PRAMOSONE LOT 2.5% ................... 204 PRAMOTIC DRO 1-0.1% .................. 221 PRASCION RA CRE 10-5% ............... 199 prasugrel hcl tab 10 mg (base equiv) 162 prasugrel hcl tab 5 mg (base equiv) .. 162 PRAVACHOL TAB 20MG ..................... 57 PRAVACHOL TAB 40MG ..................... 57 PRAVACHOL TAB 80MG ..................... 57 pravastatin sodium tab 10 mg ............ 57 pravastatin sodium tab 20 mg ............ 57 pravastatin sodium tab 40 mg ............ 57 pravastatin sodium tab 80 mg ............ 57 prazosin hcl cap 1 mg ....................... 49 prazosin hcl cap 2 mg ....................... 49 prazosin hcl cap 5 mg ....................... 49 PREB-2 PAK ................................... 147 PRECEDEX INJ 100MCG ................... 104 PRECEDEX INJ 200/50ML ................ 104 PRECEDEX INJ 400/100 ................... 104 PRECEDEX INJ 80/20ML .................. 104 PRED MILD SUS 0.12% OP .............. 216 PRED SOD PHO SOL 1% OP ............. 216 PRED-G S.O.P OIN OP ..................... 215 PRED-G SUS OP ............................. 215 prednicarbate cream 0.1% .............. 207

prednicarbate oint 0.1% .................. 207 prednisolone acetate ophth susp 1% . 216 prednisolone sod phos orally disintegr tab 10 mg (base eq) ....................... 131 prednisolone sod phos orally disintegr tab 15 mg (base eq) ....................... 131 prednisolone sod phos orally disintegr tab 30 mg (base eq) ....................... 131 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) ................ 131 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) ...................... 132 prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) ...................... 132 prednisolone syrup 15 mg/5ml (usp solution equivalent) ........................ 132 prednisone oral soln 5 mg/5ml ......... 132 prednisone tab 1 mg ....................... 132 prednisone tab 10 mg ..................... 132 prednisone tab 2.5 mg .................... 132 prednisone tab 20 mg ..................... 132 prednisone tab 5 mg ....................... 132 prednisone tab 50 mg ..................... 132 prednisone tab therapy pack 10 mg (21) .................................................... 132 prednisone tab therapy pack 10 mg (48) .................................................... 132 prednisone tab therapy pack 5 mg (21) .................................................... 132 prednisone tab therapy pack 5 mg (48) .................................................... 132 PREFERA OB TAB ............................ 181 PREFERAOB CAP ONE ...................... 181 PREFERAOB MIS +DHA .................... 181 PREFEST TAB ................................. 127 PREMARIN INJ 25MG ....................... 128 PREMARIN TAB 0.3MG ..................... 128 PREMARIN TAB 0.45MG ................... 128 PREMARIN TAB 0.625MG ................. 128 PREMARIN TAB 0.9MG ..................... 128 PREMARIN TAB 1.25MG ................... 128 PREMARIN VAG CRE 0.625MG .......... 130 premasol sol 6% ............................ 172 PREMPHASE TAB ............................ 127 PREMPRO TAB .625-2.5 ................... 127 PREMPRO TAB 0.3-1.5 ..................... 127 PREMPRO TAB 0.45-1.5 ................... 127 PREMPRO TAB 0.625-5 .................... 127

292

PRENA 1 TRUE MIS ......................... 181 PRENA1 CHW ................................. 181 PRENA1 PEARL CAP ........................ 181 PRENAISSANCE CAP ....................... 181 PRENAISSANCE CAP BALANCE ......... 181 PRENAISSANCE CAP PLUS ............... 181 PRENAISSANCE MIS HARMONY ........ 182 PRENAISSANCE TAB NEXT ............... 182 PRENAISSANCE TAB NEXT-B ............ 182 PRENATA CHW 29-1MG ................... 182 prenatabs rx tab ............................ 182 PRENATAL 1 CAP ............................ 182 PRENATAL 19 CHW 29-1MG ............. 182 prenatal 19 chw tab ........................ 182 prenatal 19 tab .............................. 182 PRENATAL 19 TAB 29-1MG .............. 182 PRENATAL CAP FORMULA ................ 182 PRENATAL CAP OMEGA-3 ................ 182 PRENATAL FRM TAB A-FREE ............. 182 PRENATAL MIS COMPLEAT ............... 182 PRENATAL MUL CAP +DHA ............... 182 PRENATAL MV MIS + DHA ............... 182 PRENATAL TAB ............................... 182 PRENATAL TAB 27-1MG ................... 182 PRENATAL TAB COMPLETE ............... 182 PRENATAL TAB FORMULA ................ 182 PRENATAL+DHA MIS ...................... 182 PRENATAL+FE TAB 29-1MG ............. 182 PRENATAL-U CAP 106.5-1 ............... 182 PRENATE AM TAB 1MG .................... 182 PRENATE CAP ENHANCE .................. 182 PRENATE CAP ESSENTIA ................. 182 PRENATE CAP PIXIE ........................ 182 PRENATE CAP RESTORE .................. 182 PRENATE CHW 0.6-0.4 .................... 182 PRENATE DHA CAP ......................... 182 PRENATE MINI CAP ......................... 182 PRENATE TAB ELITE ....................... 182 PRENATL MULT CAP + DHA .............. 182 PREPIDIL GEL 0.5MG/3G ................. 135 PREPOPIK PAK ............................... 146 PRESTALIA TAB 14-10MG .................. 46 PRESTALIA TAB 3.5-2.5 .................... 46 PRESTALIA TAB 7-5MG ..................... 46 PRETAB TAB 29-1MG ...................... 182 PREVACID CAP 15MG DR ................. 149 PREVACID CAP 30MG DR ................. 149 PREVACID TAB 15MG STB ............... 149

PREVACID TAB 30MG STB ................ 149 PREVDNT 5000 PST 1.1-5% ............. 214 PREVIDENT GEL 1.1% MIN .............. 214 PREVIDENT PST 5000 BST ............... 214 PREVPAC MIS ................................. 151 PREZCOBIX TAB 800-150 ................. 27 PREZISTA SUS 100MG/ML ................ 28 PREZISTA TAB 150MG ...................... 28 PREZISTA TAB 600MG ...................... 28 PREZISTA TAB 75MG ....................... 28 PREZISTA TAB 800MG ...................... 28 PRIFTIN TAB 150MG ........................ 30 PRILOSEC CAP 10MG ...................... 149 PRILOSEC CAP 20MG ...................... 149 PRILOSEC CAP 40MG ...................... 149 PRILOSEC OTC TAB 20MG ................ 149 PRILOSEC POW 10MG ..................... 149 PRILOSEC POW 2.5MG .................... 149 PRIMAQUINE TAB 26.3MG................. 27 PRIMAXIN IV INJ 250MG ................... 17 PRIMAXIN IV INJ 500MG ................... 17 primidone tab 250 mg ...................... 78 primidone tab 50 mg ........................ 78 PRIMLEV TAB 10-300MG ................... 15 PRIMLEV TAB 5-300MG .................... 14 PRIMLEV TAB 7.5-300 ...................... 15 PRIMSOL SOL 50MG/5ML .................. 35 PRISTIQ TAB 100MG ........................ 83 PRISTIQ TAB 25MG .......................... 83 PRISTIQ TAB 50MG .......................... 83 PRIVIGEN INJ 10GRAMS .................. 165 PRIVIGEN INJ 20GRAMS .................. 165 PRIVIGEN INJ 40GRAMS .................. 165 PRIVIGEN INJ 5 GRAMS ................... 165 PROAIR HFA AER ............................ 191 PROAIR RESPI AER ......................... 191 probenecid tab 500 mg ...................... 1 probiotic cap .................................. 147 PROBIOTIC CAP ............................. 147 probiotic cap gold ........................... 147 probiotic pak children ...................... 147 PROBIOTIC TAB ............................. 147 probiotic w/ cap prebioti .................. 147 PROCALAMINE INJ 3% .................... 172 PROCARDIA XL TAB 30MG CR ............ 62 PROCARDIA XL TAB 60MG CR ............ 62 PROCARDIA XL TAB 90MG CR ............ 62 PRO-CEPTION MIS .......................... 152

293

prochlorperazine edisylate inj 5 mg/ml ................................................... 141 prochlorperazine maleate tab 10 mg (base equivalent) ........................... 141 prochlorperazine maleate tab 5 mg (base equivalent) .................................... 141 PROCORT CRE ............................... 150 PROCRIT INJ 10000/ML ................... 159 PROCRIT INJ 2000/ML..................... 159 PROCRIT INJ 20000/ML ................... 159 PROCRIT INJ 3000/ML..................... 159 PROCRIT INJ 4000/ML..................... 159 PROCRIT INJ 40000/ML ................... 159 PROCTOCORT CRE 1% .................... 150 PROCTOFOAM AER HC 1% ............... 150 PROCYSBI CAP 25MG ...................... 152 PROCYSBI CAP 75MG ...................... 152 PROFE CAP 180MG ......................... 182 PROFE FORTE CAP 155-1MG ............ 182 PROFERRIN- TAB FORTE .................. 182 PROFILNINE INJ 1000UNIT .............. 158 PROFILNINE INJ 1500UNIT .............. 158 PROFILNINE INJ 500UNIT ................ 158 progesterone im in oil 50 mg/ml ....... 136 progesterone micronized cap 100 mg 136 progesterone micronized cap 200 mg 136 PROGLYCEM SUS 50MG/ML .............. 132 PROGRAF INJ 5MG/ML .................... 166 PROLENSA SOL 0.07% .................... 216 PROLIA SOL 60MG/ML ..................... 124 PROMACTA TAB 25MG ..................... 161 PROMACTA TAB 50MG ..................... 161 PROMACTA TAB 75MG ..................... 161 promethazine & phenylephrine syrup 6.25-5 mg/5ml .............................. 186 promethazine hcl inj 25 mg/ml ......... 141 promethazine hcl inj 50 mg/ml ......... 141 promethazine hcl syrup 6.25 mg/5ml 141 promethazine hcl tab 12.5 mg .......... 141 promethazine hcl tab 25 mg ............ 141 promethazine hcl tab 50 mg ............ 141 promethazine w/ codeine syrup 6.25-10 mg/5ml ......................................... 189 promethazine-dm syrup 6.25-15 mg/5ml ................................................... 189 PROMETRIUM CAP 100MG ............... 136 PROMETRIUM CAP 200MG ............... 136 PROMISEB KIT COMPLETE ............... 203

PRONUTRIENTS TAB SUPER B .......... 182 propafenone hcl cap er 12hr 225 mg .. 54 propafenone hcl cap er 12hr 325 mg .. 54 propafenone hcl cap er 12hr 425 mg .. 54 propafenone hcl tab 150 mg ............. 54 propafenone hcl tab 225 mg ............. 54 propafenone hcl tab 300 mg ............. 54 propantheline bromide tab 15 mg ..... 142 proparacaine hcl ophth soln 0.5% ..... 219 propranolol & hydrochlorothiazide tab 40-25 mg ....................................... 59 propranolol & hydrochlorothiazide tab 80-25 mg ....................................... 59 propranolol hcl cap er 24hr 120 mg .... 60 propranolol hcl cap er 24hr 160 mg .... 60 propranolol hcl cap er 24hr 60 mg ..... 60 propranolol hcl cap er 24hr 80 mg ..... 60 propranolol hcl inj 1 mg/ml ............... 60 propranolol hcl oral soln 20 mg/5ml ... 60 propranolol hcl oral soln 40 mg/5ml ... 60 propranolol hcl tab 10 mg ................. 60 propranolol hcl tab 20 mg ................. 60 propranolol hcl tab 40 mg ................. 60 propranolol hcl tab 60 mg ................. 61 propranolol hcl tab 80 mg ................. 61 propylthiouracil tab 50 mg ............... 136 PROSCAR TAB 5MG ......................... 151 PROSOL INJ 20% ........................... 172 PROSTIN E2 SUP 20MG ................... 135 PROSTIN VR INJ 500MCG ................. 68 protamine sulfate inj 10 mg/ml ........ 161 PROTECTIRON TAB ......................... 182 PROTONIX INJ 40MG ....................... 150 PROTONIX PAK .............................. 150 PROTONIX TAB 20MG ...................... 150 PROTONIX TAB 40MG ...................... 150 PROTOPAM CHL INJ 1GM ................. 122 PROTOPIC OIN 0.03% ..................... 204 PROTOPIC OIN 0.1% ....................... 204 protriptyline hcl tab 10 mg ................ 86 protriptyline hcl tab 5 mg ................. 86 PROVERA TAB 10MG ....................... 136 PROVERA TAB 2.5MG ...................... 136 PROVERA TAB 5MG ......................... 136 PROVIDA DHA CAP ......................... 182 PROVIDA OB CAP ........................... 182 PROVIGIL TAB 100MG ..................... 110 PROVIGIL TAB 200MG ..................... 110

294

PROVISC INJ 1% ............................ 219 PROZAC CAP 10MG ........................... 85 PROZAC CAP 20MG ........................... 85 PROZAC CAP 40MG ........................... 85 PROZAC WEEKL CAP 90MG ................ 85 PRUDOXIN CRE 5% ........................ 210 PRUTECT EMU ................................ 213 pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml .................................... 189 pseudoephedrine hcl tab 60 mg ........ 192 PSORCON CRE 0.05% ..................... 205 PULMICORT INH 180MCG ................ 196 PULMICORT INH 90MCG .................. 196 PULMICORT SUS 0.25MG/2 .............. 196 PULMICORT SUS 0.5MG/2 ............... 196 PULMICORT SUS 1MG/2ML .............. 196 PULMOZYME SOL 1MG/ML ............... 192 PURALOR CI TAB ............................ 170 PUREFE CAP PLUS .......................... 182 PUREFE OB CAP PLUS ..................... 182 PUREFOLIX TAB 1-5000 .................. 174 purevit dual cap fe plus ................... 182 PURIXAN SUS 20MG/ML .................... 38 px iron tab 27mg ........................... 182 PYLERA CAP ................................... 151 pyrazinamide tab 500 mg .................. 31 PYRIDIUM TAB 100MG .................... 152 PYRIDIUM TAB 200MG .................... 152 pyridostigmine bromide tab 60 mg ... 110 pyridostigmine bromide tab er 180 mg ................................................... 110 pyridoxine hcl tab 100 mg ............... 183 pyridoxine hcl tab 25 mg ................. 182 pyridoxine hcl tab 50 mg ................. 183 pyrilamine mal-phenylephrine hcl tann susp 16-5 mg/5ml .......................... 186 PYROGALL ACD OIN ........................ 211 Q Q4 ORAL CLEA KIT SYSTEM ............. 214 qc natural pow vegetabl .................. 146 QNASL AER 80MCG ......................... 195 QNASL CHILD SPR 40MCG ............... 195 QSYMIA CAP 11.25-69 .................... 123 QSYMIA CAP 15-92MG .................... 123 QSYMIA CAP 3.75-23 ...................... 123 QSYMIA CAP 7.5-46MG ................... 123 QUADRAMET INJ .............................. 44 QUARTETTE TAB ............................ 125

quasense tab ................................. 125 quazepam tab 15 mg ...................... 103 QUDEXY XR CAP 100/24HR ............... 78 QUDEXY XR CAP 150/24HR ............... 78 QUDEXY XR CAP 200/24HR ............... 78 QUDEXY XR CAP 25/24HR ................. 78 QUDEXY XR CAP 50/24HR ................. 78 QUELICIN INJ 20MG/ML .................. 110 QUESTRAN POW 4GM ....................... 55 QUESTRAN POW 4GM LITE ................ 55 quetiapine fumarate tab 100 mg ........ 92 quetiapine fumarate tab 200 mg ........ 92 quetiapine fumarate tab 25 mg ......... 92 quetiapine fumarate tab 300 mg ........ 92 quetiapine fumarate tab 400 mg ........ 92 quetiapine fumarate tab 50 mg ......... 92 quetiapine fumarate tab er 24hr 150 mg ..................................................... 92 quetiapine fumarate tab er 24hr 200 mg ..................................................... 92 quetiapine fumarate tab er 24hr 300 mg ..................................................... 92 quetiapine fumarate tab er 24hr 400 mg ..................................................... 92 quetiapine fumarate tab er 24hr 50 mg ..................................................... 92 QUILLICHEW CHW 20MG ER ............ 100 QUILLICHEW CHW 30MG ER ............ 101 QUILLICHEW CHW 40MG ER ............ 101 QUILLIVANT SUS 25MG/5ML ............ 101 quinapril hcl tab 10 mg ..................... 48 quinapril hcl tab 20 mg ..................... 48 quinapril hcl tab 40 mg ..................... 48 quinapril hcl tab 5 mg ...................... 48 quinapril-hydrochlorothiazide tab 10-12.5 mg ................................................ 47 quinapril-hydrochlorothiazide tab 20-12.5 mg ................................................ 47 quinapril-hydrochlorothiazide tab 20-25 mg ................................................ 47 quinine sulfate cap 324 mg ............... 27 QUINTABS TAB .............................. 183 QUTENZA KIT 8% 1-PCH ................. 209 QVAR AER 40MCG .......................... 196 QVAR AER 80MCG .......................... 196 R ra col-rite cap 50mg ....................... 146 RA OYS SHL/D TAB 250MG .............. 183

295

rabano liq yodado ........................... 183 rabeprazole sodium ec tab 20 mg ..... 150 raloxifene hcl tab 60 mg .................. 136 ramipril cap 1.25 mg ........................ 48 ramipril cap 10 mg ........................... 48 ramipril cap 2.5 mg .......................... 48 ramipril cap 5 mg ............................. 48 RANEXA TAB 1000MG ....................... 68 RANEXA TAB 500MG ......................... 68 ranitidine hcl cap 150 mg ................ 143 ranitidine hcl cap 300 mg ................ 143 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ....................................... 143 ranitidine hcl tab 150 mg ................. 143 ranitidine hcl tab 300 mg ................. 143 RAPAFLO CAP 4MG ......................... 151 RAPAFLO CAP 8MG ......................... 151 RAPAMUNE SOL 1MG/ML ................. 167 rasagiline mesylate tab 0.5 mg (base equiv) ............................................. 88 rasagiline mesylate tab 1 mg (base equiv) ............................................. 88 RASUVO INJ 10MG ......................... 164 RASUVO INJ 12.5MG ....................... 164 RASUVO INJ 15MG ......................... 164 RASUVO INJ 17.5MG ....................... 164 RASUVO INJ 22.5MG ....................... 164 RASUVO INJ 25MG ......................... 164 RASUVO INJ 27.5MG ....................... 164 RASUVO INJ 30MG ......................... 164 RASUVO INJ 7.5MG ........................ 164 RAVICTI LIQ 1.1GM/ML ................... 135 RAYALDEE CAP 30MCG .................... 183 RAYOS TAB 1MG ............................ 132 RAYOS TAB 2MG ............................ 132 RAYOS TAB 5MG ............................ 132 RAZADYNE ER CAP 16MG .................. 80 RAZADYNE ER CAP 24MG .................. 80 RAZADYNE ER CAP 8MG .................... 80 RAZADYNE TAB 12MG ....................... 80 RAZADYNE TAB 4MG ......................... 80 RAZADYNE TAB 8MG ......................... 80 REBETOL CAP 200MG ........................ 32 REBETOL SOL 40MG/ML .................... 32 REBIF INJ 22/0.5 ........................... 108 REBIF INJ 44/0.5 ........................... 108 REBIF REBIDO INJ 22/0.5 ................ 108 REBIF REBIDO INJ 44/0.5 ................ 108

REBIF REBIDO INJ TITRATN ............. 108 REBIF TITRTN INJ PACK .................. 108 RECOMBINATE INJ .......................... 158 RECOMBINATE INJ 220-400 ............. 158 RECOMBINATE INJ 401-800 ............. 158 RECOMBINATE INJ 801-1240 ........... 158 RECOTHROM SOL 20000UNT ............ 160 RECOTHROM SOL 5000UNIT ............ 160 RECTIV OIN 0.4% ........................... 147 reeses med sus pinworm .................. 35 REFRESH CELL DRO 1% OP .............. 219 REFRESH GEL OPTIVE ..................... 219 REFRESH OPTI DRO 0.5-0.9% .......... 219 REFRESH PLUS DRO 0.5% OP .......... 219 REFRESH SOL OPTIVE ..................... 219 REGENECARE GEL .......................... 213 REGIMEX TAB 25MG ....................... 123 REGLAN TAB 10MG ......................... 141 REGLAN TAB 5MG ........................... 141 REGONOL INJ 5MG/ML .................... 107 REGRANEX GEL 0.01% .................... 211 relagard gel ................................... 152 relcof c sol 100-6.3 ......................... 189 relcof dm liq .................................. 189 RELENZA MIS DISKHALE .................. 33 RELHIST CHW ................................ 186 RELISTOR INJ 12/0.6ML .................. 147 RELISTOR INJ 8/0.4ML .................... 147 RELISTOR TAB 150MG ..................... 147 RELNATE DHA CAP .......................... 183 RELPAX TAB 20MG .......................... 105 RELPAX TAB 40MG .......................... 106 REMERON SLTB TAB 15MG ................ 81 REMERON SLTB TAB 30MG ................ 81 REMERON SLTB TAB 45MG ................ 81 REMERON TAB 15MG ....................... 81 REMERON TAB 30MG ....................... 81 REMERON TAB 45MG ....................... 81 REMICADE INJ 100MG ..................... 163 REMODULIN INJ 10MG/ML ................ 70 REMODULIN INJ 1MG/ML .................. 70 REMODULIN INJ 2.5MG/ML ............... 70 REMODULIN INJ 5MG/ML .................. 70 RENACIDIN SOL ............................. 151 RENAGEL TAB 400MG ...................... 135 RENAGEL TAB 800MG ...................... 135 RENOVA CRE 0.02% ....................... 211 RENVELA PAK 0.8GM ....................... 135

296

RENVELA PAK 2.4GM ...................... 135 RENVELA TAB 800MG ...................... 135 REOPRO INJ 2MG/ML ...................... 162 repaglinide tab 0.5 mg .................... 116 repaglinide tab 1 mg ....................... 116 repaglinide tab 2 mg ....................... 116 repaglinide-metformin hcl tab 1-500 mg ................................................... 116 repaglinide-metformin hcl tab 2-500 mg ................................................... 117 REPATHA INJ 140MG/ML ................... 58 REPATHA SURE INJ 140MG/ML ........... 58 REPLESTA NX WAF 14000UNT .......... 183 REPLESTA WAF 50000UNT ............... 183 REQUIP TAB 0.25MG ......................... 88 REQUIP TAB 0.5MG .......................... 88 REQUIP TAB 1MG ............................. 88 REQUIP TAB 2MG ............................. 88 REQUIP TAB 3MG ............................. 88 REQUIP TAB 4MG ............................. 88 REQUIP TAB 5MG ............................. 88 REQUIP XL TAB 12MG ....................... 88 REQUIP XL TAB 2MG ......................... 88 REQUIP XL TAB 4MG ......................... 88 REQUIP XL TAB 6MG ......................... 88 REQUIP XL TAB 8MG ......................... 88 RESCRIPTOR TAB 100 MG ................. 29 RESCRIPTOR TAB 200MG .................. 29 RESECTISOL SOL 5% ...................... 151 RESPA C&C IR TAB ......................... 189 RESPA-BR TAB 11MG ...................... 188 RESPAIRE-30 CAP .......................... 189 RESTASIS EMU 0.05% .................... 218 RESTORIL CAP 15MG ...................... 103 RESTORIL CAP 22.5MG ................... 103 RESTORIL CAP 30MG ...................... 103 RESTORIL CAP 7.5MG ..................... 103 RETIN-A CRE 0.025% ..................... 199 RETIN-A CRE 0.05% ....................... 199 RETIN-A CRE 0.1% ......................... 199 RETIN-A GEL 0.01% ....................... 199 RETIN-A GEL 0.025% ..................... 199 RETIN-A MICR GEL 0.04% ............... 199 RETIN-A MICR GEL 0.1% ................. 199 RETROVIR CAP 100MG ...................... 29 RETROVIR SYP 50MG/5ML ................. 29 REVATIO INJ ................................... 69 REVATIO SUS 10MG/ML .................... 69

REVATIO TAB 20MG ......................... 69 REVESTA CAP 1MG-5750 ................. 174 REVLIMID CAP 10MG ....................... 39 REVLIMID CAP 15MG ....................... 39 REVLIMID CAP 2.5MG ...................... 39 REVLIMID CAP 20MG ....................... 39 REVLIMID CAP 25MG ....................... 39 REVLIMID CAP 5MG ......................... 39 revonto inj 20mg ............................ 109 REXULTI TAB 0.25MG ....................... 92 REXULTI TAB 0.5MG ........................ 92 REXULTI TAB 1MG ........................... 92 REXULTI TAB 2MG ........................... 92 REXULTI TAB 3MG ........................... 92 REXULTI TAB 4MG ........................... 92 REYATAZ CAP 150MG ....................... 29 REYATAZ CAP 200MG ....................... 29 REYATAZ CAP 300MG ....................... 29 REZIRA SOL 60-5/5ML .................... 189 RHINARIS SPR 0.2% ....................... 194 RHINOCORT SUS AQUA ................... 195 RHOFADE CRE 1% .......................... 212 RHOPHYLAC INJ 1500/2ML ............... 165 RIASTAP SOL 1GM .......................... 158 RIAX AER 5.5% .............................. 199 RIAX AER 9.5% .............................. 199 RIBAPAK PAK 1000/DAY ................... 32 RIBAPAK PAK 1200/DAY ................... 32 RIBAPAK PAK 600/DAY ..................... 32 RIBAPAK PAK 800/DAY ..................... 32 ribasphere tab 400mg ...................... 32 ribasphere tab 600mg ...................... 32 ribavirin cap 200 mg ........................ 32 ribavirin tab 200 mg ........................ 32 RID COMPLETE KIT LICE .................. 212 rifabutin cap 150 mg ........................ 35 RIFADIN CAP 150MG ........................ 31 RIFADIN CAP 300MG ........................ 31 RIFADIN INJ 600 MG ........................ 31 RIFAMATE CAP ................................ 31 rifampin cap 150 mg ........................ 31 rifampin cap 300 mg ........................ 31 rifampin for inj 600 mg .................... 31 RIFATER TAB .................................. 31 RILUTEK TAB 50MG ........................ 107 riluzole tab 50 mg .......................... 107 rimantadine hydrochloride tab 100 mg 33 RIMSO-50 SOL 50% ....................... 152

297

ringer's solution ............................. 173 ringer's solution for irrigation ........... 213 RIOMET SOL .................................. 113 risedronate sodium tab 150 mg ........ 124 risedronate sodium tab 30 mg .......... 124 risedronate sodium tab 35 mg .......... 124 risedronate sodium tab 5 mg ........... 124 risedronate sodium tab delayed release 35 mg .......................................... 124 RISPERDAL INJ 12.5MG ..................... 92 RISPERDAL INJ 25MG ....................... 92 RISPERDAL INJ 37.5MG ..................... 92 RISPERDAL INJ 50MG ....................... 92 RISPERDAL M TAB 0.5MG .................. 92 RISPERDAL M TAB 1MG ..................... 92 RISPERDAL M TAB 2MG ..................... 92 RISPERDAL M TAB 3MG ..................... 92 RISPERDAL M TAB 4MG ..................... 92 RISPERDAL SOL 1MG/ML ................... 93 RISPERDAL TAB 0.25MG .................... 93 RISPERDAL TAB 0.5MG ..................... 93 RISPERDAL TAB 1MG ........................ 93 RISPERDAL TAB 2MG ........................ 93 RISPERDAL TAB 3MG ........................ 93 RISPERDAL TAB 4MG ........................ 93 risperidone orally disintegrating tab 0.25 mg ................................................. 93 risperidone orally disintegrating tab 0.5 mg ................................................. 93 risperidone orally disintegrating tab 1 mg ..................................................... 93 risperidone orally disintegrating tab 2 mg ..................................................... 93 risperidone orally disintegrating tab 3 mg ..................................................... 93 risperidone orally disintegrating tab 4 mg ..................................................... 93 risperidone soln 1 mg/ml ................... 93 risperidone tab 0.25 mg .................... 93 risperidone tab 0.5 mg ...................... 93 risperidone tab 1 mg ......................... 93 risperidone tab 2 mg ......................... 93 risperidone tab 3 mg ......................... 93 risperidone tab 4 mg ......................... 93 RITALIN LA CAP 10MG .................... 101 RITALIN LA CAP 20MG .................... 101 RITALIN LA CAP 30MG .................... 101 RITALIN LA CAP 40MG .................... 101

RITALIN LA CAP 60MG ..................... 101 RITALIN TAB 10MG ......................... 101 RITALIN TAB 20MG ......................... 101 RITALIN TAB 5MG ........................... 101 RITUXAN INJ 100MG ........................ 44 RITUXAN INJ 500MG ........................ 44 RITUXAN INJ HYCELA ....................... 44 rivastigmine tartrate cap 1.5 mg ........ 80 rivastigmine tartrate cap 3 mg .......... 80 rivastigmine tartrate cap 4.5 mg ........ 80 rivastigmine tartrate cap 6 mg .......... 80 rivastigmine td patch 24hr 13.3 mg/24hr ..................................................... 80 rivastigmine td patch 24hr 4.6 mg/24hr ..................................................... 80 rivastigmine td patch 24hr 9.5 mg/24hr ..................................................... 80 rivelsa tab ..................................... 125 RIXUBIS INJ 1000UNIT ................... 159 RIXUBIS INJ 2000UNIT ................... 159 RIXUBIS INJ 250 UNIT .................... 158 RIXUBIS INJ 3000UNIT ................... 159 RIXUBIS INJ 500UNIT ..................... 158 rizatriptan benzoate oral disintegrating tab 10 mg (base eq) ....................... 106 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) ......................... 106 rizatriptan benzoate tab 10 mg (base equivalent) .................................... 106 rizatriptan benzoate tab 5 mg (base equivalent) .................................... 106 ROBAXIN INJ 100MG/ML .................. 109 ROBAXIN TAB 500MG ...................... 109 ROBAXIN-750 TAB 750MG ............... 109 ROBINUL FORT TAB 2MG ................. 142 ROBINUL INJ 0.2MG/ML .................. 142 ROBINUL INJ 0.4/2ML ..................... 142 ROBINUL TAB 1MG ......................... 142 ROBITUSSIN LIQ CGH/CLD .............. 189 ROBITUSSIN LIQ DM MAX ................ 189 ROBITUSSN DM SYP ....................... 189 ROCALTROL CAP 0.25MCG ............... 133 ROCALTROL CAP 0.5MCG ................. 133 ROCALTROL SOL 1MCG/ML .............. 133 rocuronium bromide iv soln 100 mg/10ml (10 mg/ml) .................................... 110 rocuronium bromide iv soln 50 mg/5ml (10 mg/ml) .................................... 110

298

ropinirole hydrochloride tab 0.25 mg ... 88 ropinirole hydrochloride tab 0.5 mg .... 88 ropinirole hydrochloride tab 1 mg ....... 88 ropinirole hydrochloride tab 2 mg ....... 88 ropinirole hydrochloride tab 3 mg ....... 88 ropinirole hydrochloride tab 4 mg ....... 88 ropinirole hydrochloride tab 5 mg ....... 88 ropinirole hydrochloride tab er 24hr 12 mg (base equivalent) ........................ 89 ropinirole hydrochloride tab er 24hr 2 mg (base equivalent) ............................. 88 ropinirole hydrochloride tab er 24hr 4 mg (base equivalent) ............................. 88 ropinirole hydrochloride tab er 24hr 6 mg (base equivalent) ............................. 89 ropinirole hydrochloride tab er 24hr 8 mg (base equivalent) ............................. 89 rosadan cre 0.75% ......................... 212 ROSADAN KIT 0.75% ...................... 212 ROSE BENGAL TES 1.3MG ............... 219 rosuvastatin calcium tab 10 mg .......... 57 rosuvastatin calcium tab 20 mg .......... 57 rosuvastatin calcium tab 40 mg .......... 57 rosuvastatin calcium tab 5 mg ............ 57 ROWASA KIT 4GM .......................... 144 ROXICODONE TAB 15MG ................... 15 ROXICODONE TAB 30MG ................... 15 ROXICODONE TAB 5MG ..................... 15 ROZEREM TAB 8MG ........................ 104 RUBRACA TAB 200MG ....................... 44 RUBRACA TAB 300MG ....................... 44 RUCONEST INJ 2100UNIT ................ 161 RULAVITE DHA CAP ........................ 183 RYDAPT CAP 25MG ........................... 41 RYDEX G TAB 38.5-398 ................... 189 RYTARY CAP 145MG .......................... 89 RYTARY CAP 195MG .......................... 89 RYTARY CAP 245MG .......................... 89 RYTARY CAP 95MG ........................... 89 RYTHMOL SR CAP 225MG .................. 54 RYTHMOL SR CAP 325MG .................. 55 RYTHMOL SR CAP 425MG .................. 55 RYTHMOL TAB 225MG ....................... 55 S s.s.s. tonic tab ............................... 183 SABRIL POW 500MG ......................... 78 SABRIL TAB 500MG .......................... 78 SAFETYGLIDE MIS 27GX5/8" ........... 168

SAFYRAL TAB ................................. 126 SAIZEN INJ 5MG ............................ 133 SAIZEN INJ 8.8MG .......................... 133 SALAGEN TAB 5MG ......................... 150 SALAGEN TAB 7.5MG ...................... 150 SALEX CREAM KIT 6% ..................... 211 SALEX LOTION KIT 6% .................... 211 SALEX SHA 6% .............................. 211 SALICEPT SUS ............................... 214 salicylic ac liq 27.5% ....................... 211 salicylic acid cream 6% ................... 211 salicylic acid cream 6% & cleanser liqd kit ................................................ 211 salicylic acid foam 6% ..................... 211 salicylic acid gel 6% ........................ 211 salicylic acid in ammonium lactate vehicle foam 6% ............................ 211 salicylic acid lotion 6% .................... 211 salicylic acid lotion 6% & cleanser liqd kit .................................................... 211 salicylic acid shampoo 6% ............... 211 SALICYLIC ACID SOLN 26% ............. 211 SAMSCA TAB 15MG ......................... 138 SAMSCA TAB 30MG ......................... 138 SANCUSO DIS 3.1MG ...................... 141 SANDIMMUNE SOL 100MG/ML .......... 166 SANTYL OIN 250/GM ....................... 211 SAPHRIS SUB 10MG ......................... 93 SAPHRIS SUB 2.5MG ........................ 93 SAPHRIS SUB 5MG .......................... 93 SARAFEM TAB 10MG ........................ 85 SARAFEM TAB 20MG ........................ 85 SAVAYSA TAB 15MG ....................... 156 SAVAYSA TAB 30MG ....................... 156 SAVAYSA TAB 60MG ....................... 156 SAVELLA MIS TITR PAK ................... 102 SAVELLA TAB 100MG ...................... 102 SAVELLA TAB 12.5MG ..................... 102 SAVELLA TAB 25MG ........................ 102 SAVELLA TAB 50MG ........................ 102 SAXENDA INJ 6MG/ML..................... 122 sb fib lax pow 30% ......................... 146 sb fib lax pow 33% ......................... 146 sb nat fiber pow 49% ...................... 146 sb triple oin antibiot ........................ 201 SCALACORT DK KIT ........................ 204 scalacort lot 2% ............................. 206 SCLEROSOL AER INTRAPLE .............. 194

299

SCOOBY-DOO CHW ........................ 183 scopolamine td patch 72hr 1 mg/3days ................................................... 141 SCOT-TUSSIN LIQ DIBTS/CF ............ 190 SCOT-TUSSIN LIQ SENIOR .............. 189 SEASONIQUE TAB .......................... 125 SECTRAL CAP 200MG ........................ 61 SECTRAL CAP 400MG ........................ 61 SECURA CRE 30.6% ....................... 211 SELECT-OB CHW ............................ 183 SELECT-OB+ PAK DHA .................... 183 selegiline hcl cap 5 mg ...................... 89 selegiline hcl tab 5 mg ...................... 89 selenious acid inj 40 mcg/ml ............ 174 selenium sulfide lotion 2.5% ............ 204 selenium sulfide-pyrithione zinc in urea shampoo 2.25% ............................. 204 SELZENTRY TAB 150MG .................... 28 SELZENTRY TAB 300MG .................... 28 SEMPREX-D CAP 8-60MG ................. 186 SENNA PROMPT CAP 9-500MG ......... 146 senna tab 8.6mg ............................ 146 senna-extra tab 17.2mg .................. 146 sennosides cap 8.6 mg .................... 146 sennosides syrup 8.8 mg/5ml .......... 146 SENSI-CARE CRE MOISTURI ............ 211 SENSIPAR TAB 30MG ...................... 123 SENSIPAR TAB 60MG ...................... 123 SENSIPAR TAB 90MG ...................... 123 SEREVENT DIS AER 50MCG ............. 190 SEROQUEL TAB 100MG ..................... 93 SEROQUEL TAB 200MG ..................... 93 SEROQUEL TAB 25MG ....................... 93 SEROQUEL TAB 300MG ..................... 93 SEROQUEL TAB 400MG ..................... 93 SEROQUEL TAB 50MG ....................... 93 SEROQUEL XR TAB 150MG ................ 93 SEROQUEL XR TAB 200MG ................ 94 SEROQUEL XR TAB 300MG ................ 94 SEROQUEL XR TAB 400MG ................ 94 SEROQUEL XR TAB 50MG .................. 93 SEROSTIM INJ 4MG ........................ 133 SEROSTIM INJ 5MG ........................ 133 SEROSTIM INJ 6MG ........................ 133 sertraline hcl oral conc 20 mg/ml ........ 85 sertraline hcl tab 100 mg................... 85 sertraline hcl tab 25 mg .................... 85 sertraline hcl tab 50 mg .................... 85

SE-TAN DHA CAP ............................ 183 sevelamer carbonate packet 0.8 gm .. 135 sevelamer carbonate packet 2.4 gm .. 135 SFROWASA ENE 4GM ...................... 144 SHOHLS SOL MODIFIED .................. 152 SIGNIFOR INJ 0.3MG/ML ................. 135 SIGNIFOR INJ 0.6MG/ML ................. 135 SIGNIFOR INJ 0.9MG/ML ................. 135 SILAZONE PAK PHARMAPA ............... 204 sildenafil citrate iv soln 10 mg/12.5ml (base equivalent) ............................ 69 sildenafil citrate tab 20 mg ............... 69 SILENOR TAB 3MG .......................... 104 SILENOR TAB 6MG .......................... 104 SILIQ INJ 210/1.5 .......................... 203 silphen coug syp 12.5/5ml ............... 188 SILVADENE CRE 1% ....................... 201 SILVER GEL HYDROGEL ................... 213 SILVER NITRA OIN 10% .................. 211 SILVRSTAT GEL DRESSING .............. 213 SIMBRINZA SUS 1-0.2% ................. 218 SIMILAC PREN PAK EARLY SH .......... 183 SIMPONI ARIA SOL 50MG/4ML ......... 163 SIMPONI INJ 100MG/ML .................. 163 SIMPONI INJ 50/0.5ML .................... 163 simvastatin tab 10 mg ...................... 57 simvastatin tab 20 mg ...................... 57 simvastatin tab 40 mg ...................... 57 simvastatin tab 5 mg ....................... 57 simvastatin tab 80 mg ...................... 57 SINEMET CR TAB 25-100MG ............. 89 SINEMET CR TAB 50-200MG ............. 89 SINEMET TAB 10-100MG .................. 89 SINEMET TAB 25-100MG .................. 89 SINEMET TAB 25-250MG .................. 89 SINGULAIR CHW 4MG ..................... 193 SINGULAIR CHW 5MG ..................... 193 SINGULAIR GRA 4MG ...................... 193 SINGULAIR TAB 10MG ..................... 193 sinus congst tab /pain dt ................. 194 sinus/allrgy tab max st .................... 186 SINUSTAR MIS NEBULIZE ................ 194 sirolimus tab 0.5 mg ....................... 167 sirolimus tab 1 mg .......................... 167 SIRTURO TAB 100MG ....................... 31 SITAVIG TAB 50MG.......................... 33 SIVEXTRO INJ 200MG ...................... 35 SIVEXTRO TAB 200MG ..................... 35

300

SKELAXIN TAB 800MG .................... 109 SKIN PROTECT CRE 12% ................. 211 SKLICE LOT 0.5% .......................... 212 SKYLA IUD 13.5MG ......................... 127 sleep aid tab 25mg ......................... 104 slow release tab 47.5mg ................. 183 sm allergy cre 2% .......................... 211 sm antacid chw ex-str ..................... 139 sm antibioti cre plus ....................... 201 sm antifungl cre 2% ....................... 203 sm b super tab vita com .................. 183 sm balanced tab b-100 ................... 183 sm b-complex tab .......................... 183 SM B-COMPLEX TAB /VIT C .............. 183 SM CORAL CAL TAB 1000MG ............ 183 sm dry eye sol relief ....................... 219 sm dry skin lot therapy ................... 208 sm fiber lax tab 500mg ................... 146 sm fiber pow 48.57% ...................... 146 sm gas rel chw 125mg .................... 147 SM GLUCOSE CHW SOUR APP .......... 132 sm glycerin sup 80.7% ................... 146 sm hemorrhoi oin ........................... 147 sm ibuprofen tab 100mg jr ................. 4 sm iron slow tab 160mg cr .............. 183 sm iron tab .................................... 183 sm laxative sup 10mg ..................... 146 sm lice lot treatmnt ........................ 212 sm magnesium tab 250mg .............. 183 sm micon 7 sup 100mg ................... 154 sm multiple tab vit/iron ................... 183 sm multi-pur sol ............................. 219 sm niacin tab 250mg cr ................... 183 sm nicotine dis 21mg ...................... 112 sm nicotine dis 7mg/24hr ................ 112 SM ONE DAILY MIS PRENATAL ......... 183 SM ONE DAILY TAB ESSENTIA .......... 183 sm pain rel cap 500mg ....................... 1 sm probiotic cap 250mg .................. 147 sm redness dro relief ...................... 219 sm sleep aid cap 50mg ................... 104 sm tussin cf liq ............................... 190 sm vit b-1 tab 100mg ..................... 183 sm z-sleep cap 25mg ...................... 104 sm z-sleep liq 50mg/30 ................... 104 SOD DIURIL INJ 500MG .................... 66 SOD EDECRIN INJ 50MG ................... 66 sod fluoride sol 0.2% ...................... 214

SOD LACTATE INJ 5MEQ/ML ............. 183 SOD NITRITE INJ 30MG/ML .............. 122 SOD SUL/SULF EMU 10-5% ............. 199 SOD SUL/SULF SUS 10-5% .............. 199 sodium acetate inj 2 meq/ml ............ 183 sodium acetate inj 4 meq/ml ............ 183 sodium bicarbonate inj 4.2% ............ 183 sodium bicarbonate inj 7.5% ............ 183 sodium bicarbonate inj 8.4% ............ 183 sodium bicarbonate tab 325 mg ........ 139 sodium bicarbonate tab 650 mg ........ 139 sodium chloride inj 0.45% ............... 173 sodium chloride inj 0.9% ................. 173 sodium chloride inj 2.5 meq/ml (14.6%) .................................................... 173 sodium chloride inj 3% .................... 173 sodium chloride inj 4 meq/ml (23.4%) .................................................... 173 sodium chloride inj 5% .................... 173 sodium chloride iv soln 0.9%............ 173 sodium chloride soln nebu 0.9% ....... 194 sodium chloride soln nebu 10% ........ 194 sodium chloride soln nebu 7% .......... 194 sodium chloride tab 1 gm ................ 173 sodium citrate & citric acid soln 500-334 mg/5ml ......................................... 152 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) .............................. 183 sodium fluoride tab 0.5 mg f (from 1.1 mg naf) ......................................... 183 sodium fluoride tab 1 mg f (from 2.2 mg naf) .............................................. 183 sodium phosphates - enema ............ 146 sodium phosphates inj 15 mm/5ml (phos) 20 meq/5ml (na) .................. 174 sodium polystyrene sulfonate powder 135 sodium polystyrene sulfonate rectal susp 30 gm/120ml ................................. 135 SODIUM SULFA LIQ 10% WASH ....... 204 sodium thiosulfate inj 25% .............. 122 SOF-SENSOR MIS ........................... 122 SOLARAZE GEL 3% W/W ................. 201 SOLIQUA INJ 100/33 ...................... 114 SOLIRIS INJ 10MG/ML..................... 161 SOLODYN TAB 105MG ...................... 25 SOLODYN TAB 115MG ...................... 25 SOLODYN TAB 55MG ........................ 25 SOLODYN TAB 65MG ........................ 25

301

SOLODYN TAB 80MG ........................ 25 SOLTAMOX SOL 10MG/5ML ................ 38 soluble fib pow therapy ................... 146 SOLU-CORTEF INJ 1000MG .............. 132 SOLU-CORTEF INJ 100MG ............... 132 SOLU-CORTEF INJ 250MG ............... 132 SOLU-CORTEF INJ 500MG ............... 132 SOLU-MEDROL INJ 125MG ............... 132 SOLU-MEDROL INJ 1GM .................. 132 SOLU-MEDROL INJ 2GM .................. 132 SOLU-MEDROL INJ 40MG ................ 132 SOLU-MEDROL INJ 500MG ............... 132 SOMA TAB 250MG .......................... 109 SOMA TAB 350MG .......................... 109 SONATA CAP 10MG ........................ 104 SONATA CAP 5MG .......................... 104 soothe night oin time ...................... 219 SORBITOL SOL 3% IRR ................... 151 SORBITOL SOL 3.3% IRR ................ 151 SORBITOL-MAN SOL ....................... 151 sore throat loz 15-3.6mg ................. 214 sore throat loz cherry ...................... 214 sore throat spr 1.4% ...................... 214 SORIATANE CAP 10MG .................... 203 SORIATANE CAP 17.5MG ................. 203 SORIATANE CAP 25MG .................... 203 SORILUX AER 0.005% .................... 203 sotalol hcl (afib/afl) tab 120 mg ......... 55 sotalol hcl (afib/afl) tab 160 mg ......... 55 sotalol hcl (afib/afl) tab 80 mg ........... 55 SOTALOL HCL INJ 150/10ML .............. 55 sotalol hcl tab 120 mg....................... 55 sotalol hcl tab 160 mg....................... 55 sotalol hcl tab 240 mg....................... 55 sotalol hcl tab 80 mg ........................ 55 SOTRADECOL INJ 1% ....................... 68 SOTRADECOL INJ 3% ....................... 68 SOTYLIZE SOL 5MG/ML ..................... 55 SOVALDI TAB 400MG ........................ 32 SPINAL NEEDL MIS 22GX3.5" ........... 168 spinosad susp 0.9% ........................ 212 SPIRIVA AER 1.25MCG .................... 186 SPIRIVA CAP HANDIHLR .................. 186 SPIRIVA SPR 2.5MCG ...................... 186 spironolactone & hydrochlorothiazide tab 25-25 mg ........................................ 66 spironolactone tab 100 mg ................ 49 spironolactone tab 25 mg .................. 49

spironolactone tab 50 mg ................. 49 SPORANOX CAP 100MG .................... 27 SPORANOX SOL 10MG/ML................. 27 SPRIX SPR 15.75MG .......................... 4 SPRYCEL TAB 100MG ....................... 41 SPRYCEL TAB 140MG ....................... 41 SPRYCEL TAB 20MG ......................... 41 SPRYCEL TAB 50MG ......................... 41 SPRYCEL TAB 70MG ......................... 41 SPRYCEL TAB 80MG ......................... 41 sps sus 15gm/60 ............................ 135 ssd cre 1% .................................... 201 SSKI SOL 1GM/ML .......................... 136 sss 10-5 aer 10-5% ........................ 199 sss cre 10%-5% ............................. 199 st joseph co syp 7.5/5ml ................. 190 STALEVO 100 TAB ........................... 89 STALEVO 125 TAB ........................... 89 STALEVO 150 TAB ........................... 89 STALEVO 200 TAB ........................... 89 STALEVO 50 TAB ............................. 89 STALEVO 75 TAB ............................. 89 stavudine cap 15 mg ........................ 29 stavudine cap 20 mg ........................ 29 stavudine cap 30 mg ........................ 29 stavudine cap 40 mg ........................ 30 stavudine for oral soln 1 mg/ml ......... 30 STELARA INJ 45MG/0.5 ................... 203 STELARA INJ 5MG/ML ..................... 203 STELARA INJ 90MG/ML .................... 203 STERIL TALC SUS 5GM .................... 194 STERILE LUBR DRO 0.7% ................ 219 STIMATE SOL 1.5MG/ML .................. 138 STIOLTO AER 2.5-2.5 ...................... 186 STIVARGA TAB 40MG ....................... 41 stomach relf chw 262mg ................. 139 stomach relf sus 262/15ml............... 139 stomach relf sus 525/15ml............... 139 stomach relf tab 262mg .................. 139 stool softnr cap 100mg .................... 146 stool softnr cap 250mg .................... 146 stool softnr tab 8.6-50mg ................ 146 STRATTERA CAP 100MG .................. 101 STRATTERA CAP 10MG .................... 101 STRATTERA CAP 18MG .................... 101 STRATTERA CAP 25MG .................... 101 STRATTERA CAP 40MG .................... 101 STRATTERA CAP 60MG .................... 101

302

STRATTERA CAP 80MG .................... 101 STRENSIQ INJ 18/0.45 .................... 135 STRENSIQ INJ 28/0.7ML ................. 135 STRENSIQ INJ 40MG/ML ................. 135 STRENSIQ INJ 80/0.8ML ................. 135 streptomycin sulfate for inj 1 gm ........ 17 stress b com tab vit c/zn ................. 183 STRIANT MIS 30MG ........................ 112 STRIBILD TAB .................................. 28 strip ease liq adh remv .................... 211 STRIVERDI AER 2.5MCG .................. 190 STUART ONE CAP ........................... 183 stuffy nose liq & cold ...................... 190 SUBOXONE MIS 12-3MG ................. 111 SUBOXONE MIS 2-0.5MG ................ 111 SUBOXONE MIS 4-1MG ................... 111 SUBOXONE MIS 8-2MG ................... 111 SUBSYS SPR 100MCG ....................... 15 SUBSYS SPR 1200MCG ..................... 15 SUBSYS SPR 1600MCG ..................... 15 SUBSYS SPR 200MCG ....................... 15 SUBSYS SPR 400MCG ....................... 15 SUBSYS SPR 600MCG ....................... 15 SUBSYS SPR 800MCG ....................... 15 SUCRAID SOL 8500/ML ................... 147 sucralfate tab 1 gm ........................ 147 SUDAFED 24HR TAB 240MG ............. 192 sufentanil citrate inj 100 mcg/2ml (50 mcg/ml) .......................................... 15 sufentanil citrate inj 250 mcg/5ml (50 mcg/ml) .......................................... 15 sufentanil citrate inj 50 mcg/ml .......... 15 SULAR TAB 17MG ............................. 62 SULAR TAB 34MG ............................. 63 SULAR TAB 8.5MG ............................ 62 sulfacetamide sodium cleansing gel 10% ................................................... 204 sulfacetamide sodium liquid 10% ...... 204 sulfacetamide sodium lotion 10% (acne) ................................................... 199 sulfacetamide sodium ophth oint 10% ................................................... 215 sulfacetamide sodium ophth soln 10% ................................................... 215 sulfacetamide sodium shampoo 10% 204 sulfacetamide sodium w/ sulfur cleanser 10-2% .......................................... 200 sulfacetamide sodium w/ sulfur cleanser

9.8-4.8% ...................................... 199 sulfacetamide sodium w/ sulfur cleansing pad 10-4% .................................... 200 sulfacetamide sodium w/ sulfur cream 10-2% .......................................... 200 sulfacetamide sodium w/ sulfur emulsion 10-5% .......................................... 200 sulfacetamide sodium w/ sulfur lotion 10-5% ............................................... 200 sulfacetamide sodium w/ sulfur susp 8-4% ............................................... 200 sulfacetamide sodium w/ sulfur wash 9-4% ............................................... 200 sulfacetamide sodium w/ sulfur wash 9-4.5% ............................................ 200 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% ............. 215 sulfacetamide sodium-sulfur in urea gel 10-5% .......................................... 200 sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser kit ............................. 199 sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml ............................... 24 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml ............................... 24 sulfamethoxazole-trimethoprim tab 400-80 mg ............................................ 24 sulfamethoxazole-trimethoprim tab 800-160 mg .......................................... 24 SULFAMYLON CRE 85MG/GM ............ 211 SULFAMYLON PAK 5% ..................... 211 sulfasalazine tab 500 mg ................. 143 sulfasalazine tab delayed release 500 mg .................................................... 143 sulindac tab 150 mg .......................... 4 sulindac tab 200 mg .......................... 4 SUMADAN KIT ................................ 200 SUMADAN WASH LIQ 9-4.5% ........... 200 SUMADAN XLT KIT 9-4.5% .............. 200 sumatriptan nasal spray 20 mg/act ... 106 sumatriptan nasal spray 5 mg/act ..... 106 sumatriptan succinate inj 6 mg/0.5ml 106 sumatriptan succinate solution auto-injector 4 mg/0.5ml ........................ 106 sumatriptan succinate solution auto-injector 6 mg/0.5ml ........................ 106 sumatriptan succinate solution cartridge 4 mg/0.5ml ................................... 106

303

sumatriptan succinate solution cartridge 6 mg/0.5ml ................................... 106 sumatriptan succinate solution prefilled syringe 6 mg/0.5ml ........................ 106 sumatriptan succinate tab 100 mg .... 106 sumatriptan succinate tab 25 mg ...... 106 sumatriptan succinate tab 50 mg ...... 106 SUMAVEL DOSE INJ 4MG/0.5 ........... 106 SUMAVEL DOSE INJ 6MG/0.5 ........... 106 SUPARTZ FX INJ 25/2.5ML ................. 16 SUPARTZ INJ 25/2.5ML ..................... 17 super b comp tab vit c .................... 183 superior 35 tab .............................. 183 SUPPORT LIQ ................................. 184 SUPRAX CAP 400MG ......................... 20 SUPRAX CHW 100MG ........................ 20 SUPRAX CHW 200MG ........................ 20 SUPRAX SUS 500/5ML ...................... 20 SUPREP BOWEL SOL PREP KIT ......... 146 supress dm dro 5-50/ml .................. 190 SURGICEL PAD 3"X4" ...................... 160 SURGIFOAM MIS 12-7MM ................ 160 SURGIFOAM MIS SIZE 100 .............. 160 SURMONTIL CAP 25MG ..................... 86 SURMONTIL CAP 50MG ..................... 86 SURVANTA INH .............................. 194 SUSTIVA CAP 200MG ........................ 29 SUSTIVA CAP 50MG .......................... 29 SUSTIVA TAB 600MG ........................ 29 SUTENT CAP 12.5MG ........................ 41 SUTENT CAP 25MG ........................... 41 SUTENT CAP 50MG ........................... 41 SYLATRON KIT 200MCG .................. 165 SYLATRON KIT 300MCG .................. 165 SYLATRON KIT 600MCG .................. 165 SYMAX DUOTAB TAB ....................... 142 SYMBICORT AER 160-4.5 ................ 196 SYMBICORT AER 80-4.5 .................. 196 SYMLINPEN 60 INJ 1000MCG ........... 113 SYMLNPEN 120 INJ 1000MCG ........... 113 SYNAGIS INJ 100MG/ML .................. 167 SYNAGIS INJ 50MG ........................ 167 SYNALAR CRE 0.025% .................... 207 SYNALAR KIT 0.025% ..................... 204 SYNALAR OIN 0.025% .................... 207 SYNALAR SOL 0.01% ...................... 206 SYNALAR TS KIT 0.01% .................. 205 SYNALGOS-DC CAP .......................... 15

SYNAREL SOL 2MG/ML .................... 127 SYNERA DIS 70-70MG ..................... 209 SYNERCID INJ 500MG ...................... 35 SYNJARDY TAB ............................... 117 SYNJARDY TAB 12.5-500 ................. 117 SYNJARDY TAB 5-1000MG ............... 117 SYNJARDY TAB 5-500MG ................. 117 SYNJARDY XR TAB .......................... 117 SYNJARDY XR TAB 10-1000 ............. 117 SYNJARDY XR TAB 25-1000 ............. 117 SYNJARDY XR TAB 5-1000MG ........... 117 SYNRIBO INJ 3.5MG ......................... 44 SYNTHROID TAB 100MCG ................ 137 SYNTHROID TAB 112MCG ................ 137 SYNTHROID TAB 125MCG ................ 137 SYNTHROID TAB 137MCG ................ 137 SYNTHROID TAB 150MCG ................ 137 SYNTHROID TAB 175MCG ................ 137 SYNTHROID TAB 200MCG ................ 137 SYNTHROID TAB 25MCG .................. 137 SYNTHROID TAB 300MCG ................ 137 SYNTHROID TAB 50MCG .................. 137 SYNTHROID TAB 75MCG .................. 137 SYNTHROID TAB 88MCG .................. 137 SYPRINE CAP 250MG ...................... 135 SYSTANE GEL 0.3% ........................ 219 SYSTANE GEL DRO 0.4-0.3% ........... 219 T TABLOID TAB 40MG ......................... 38 TACHOSIL PAD ............................... 160 TACLONEX OIN .............................. 203 TACLONEX SUS .............................. 203 tacrolimus cap 0.5 mg ..................... 166 tacrolimus cap 1 mg ....................... 166 tacrolimus cap 5 mg ....................... 166 tacrolimus oint 0.03% ..................... 204 tacrolimus oint 0.1% ....................... 204 TAFINLAR CAP 50MG ........................ 41 TAFINLAR CAP 75MG ........................ 41 TAGRISSO TAB 40MG ....................... 41 TAGRISSO TAB 80MG ....................... 41 TALWIN INJ 30MG/ML ...................... 15 TAMIFLU CAP 30MG ......................... 33 TAMIFLU CAP 45MG ......................... 33 TAMIFLU CAP 75MG ......................... 33 TAMIFLU SUS 6MG/ML ..................... 33 tamoxifen citrate tab 10 mg (base equivalent) ..................................... 38

304

tamoxifen citrate tab 20 mg (base equivalent) ...................................... 39 tamsulosin hcl cap 0.4 mg ............... 151 TANDEM F CAP ............................... 184 TANDEM PLUS CAP ......................... 184 TANZEUM INJ 30MG ....................... 115 TANZEUM INJ 50MG ....................... 115 TAPAZOLE TAB 10MG ...................... 136 TAPAZOLE TAB 5MG ....................... 136 TARCEVA TAB 100MG ....................... 41 TARCEVA TAB 150MG ....................... 41 TARCEVA TAB 25MG ......................... 41 targetd acne cre 2.5% .................... 200 TARGRETIN GEL 1% ......................... 44 tarina fe tab 1/20 ........................... 126 TARKA TAB 1-240 CR ........................ 46 TARKA TAB 2-180 CR ........................ 46 TARKA TAB 2-240 CR ........................ 46 TARKA TAB 4-240 CR ........................ 46 TARON-BC MIS .............................. 184 TARON-PREX CAP ........................... 184 TASIGNA CAP 150MG ........................ 41 TASIGNA CAP 200MG ........................ 41 TAXOTERE INJ 20MG/ML ................... 44 TAXOTERE INJ 80MG/4ML .................. 44 tazarotene cream 0.1% ................... 200 tazicef inj 1gm ................................. 20 tazicef inj 2gm ................................. 20 TAZORAC CRE 0.05% ..................... 200 TAZORAC CRE 0.1% ....................... 200 TAZORAC GEL 0.05% ...................... 200 TAZORAC GEL 0.1% ....................... 200 TEARS AGAIN CAP HYDRATE ............ 170 tears pure sol ................................ 219 TECFIDERA CAP 120MG ................... 108 TECFIDERA CAP 240MG ................... 108 TECFIDERA MIS STARTER ................ 108 TECHNIVIE TAB ................................ 32 TEFLARO INJ 400MG ......................... 20 TEFLARO INJ 600MG ......................... 20 TEGRETOL SUS 100/5ML ................... 78 TEGRETOL TAB 200MG ...................... 78 TEGRETOL-XR TAB 200MG ................. 78 TEGRETOL-XR TAB 400MG ................. 78 TEKTURNA HCT TAB 150-12.5 ............ 65 TEKTURNA HCT TAB 150-25MG .......... 65 TEKTURNA HCT TAB 300-12.5 ............ 65 TEKTURNA HCT TAB 300-25MG .......... 65

TEKTURNA TAB 150MG ..................... 65 TEKTURNA TAB 300MG ..................... 65 telmisartan tab 20 mg ...................... 53 telmisartan tab 40 mg ...................... 53 telmisartan tab 80 mg ...................... 53 telmisartan-amlodipine tab 40-10 mg . 50 telmisartan-amlodipine tab 40-5 mg ... 50 telmisartan-amlodipine tab 80-10 mg . 50 telmisartan-amlodipine tab 80-5 mg ... 50 telmisartan-hydrochlorothiazide tab 40-12.5 mg ......................................... 52 telmisartan-hydrochlorothiazide tab 80-12.5 mg ......................................... 52 telmisartan-hydrochlorothiazide tab 80-25 mg ............................................ 52 temazepam cap 15 mg .................... 103 temazepam cap 22.5 mg ................. 103 temazepam cap 30 mg .................... 103 temazepam cap 7.5 mg ................... 103 TEMODAR CAP 100MG ...................... 37 TEMODAR CAP 140MG ...................... 37 TEMODAR CAP 180MG ...................... 37 TEMODAR CAP 20MG ....................... 37 TEMODAR CAP 250MG ...................... 37 TEMODAR CAP 5MG ......................... 37 TEMODAR INJ 100MG ....................... 37 TEMOVATE CRE 0.05% .................... 208 TEMOVATE GEL 0.05% .................... 208 TEMOVATE OIN 0.05% .................... 208 temozolomide cap 100 mg ................ 37 temozolomide cap 140 mg ................ 37 temozolomide cap 180 mg ................ 37 temozolomide cap 20 mg .................. 37 temozolomide cap 250 mg ................ 37 temozolomide cap 5 mg ................... 37 TENEX TAB 1MG .............................. 49 TENEX TAB 2MG .............................. 49 TENIPOSIDE INJ 50MG/5ML .............. 44 TENORETIC TAB 100 ........................ 59 TENORETIC TAB 50 .......................... 59 TENORMIN TAB 100MG .................... 61 TENORMIN TAB 25MG ...................... 61 TENORMIN TAB 50MG ...................... 61 TERAZOL 3 CRE 0.8% ..................... 154 TERAZOL 7 CRE 0.4% ..................... 154 terazosin hcl cap 1 mg ..................... 49 terazosin hcl cap 10 mg .................... 50 terazosin hcl cap 2 mg ..................... 49

305

terazosin hcl cap 5 mg ...................... 50 terbinafine hcl tab 250 mg ................. 27 terbutaline sulfate inj 1 mg/ml ......... 191 terbutaline sulfate tab 2.5 mg .......... 191 terbutaline sulfate tab 5 mg ............. 191 terconazole vaginal cream 0.4% ....... 154 terconazole vaginal cream 0.8% ....... 154 terconazole vaginal suppos 80 mg .... 154 TERSASEPTIC LIQ .......................... 211 TERSI FOAM AER 2.25% ................. 204 TESSALON PER CAP 100MG ............. 190 TESTIM GEL 1%(50MG) .................. 112 TESTONE CIK KIT 200MG/ML ........... 112 testosterone cypionate im inj in oil 100 mg/ml .......................................... 112 testosterone cypionate im inj in oil 200 mg/ml .......................................... 112 testosterone enanthate im inj in oil 200 mg/ml .......................................... 112 testosterone td gel 10mg/act (2%) ... 112 testosterone td gel 12.5 mg/act (1%) 113 testosterone td gel 25 mg/2.5gm (1%) ................................................... 113 testosterone td gel 50 mg/5gm (1%) 113 testosterone td soln 30 mg/act ......... 113 tetcaine sol 0.5% op ....................... 219 tetrabenazine tab 12.5 mg .............. 107 tetrabenazine tab 25 mg ................. 107 tetracycline hcl cap 250 mg ............... 25 tetracycline hcl cap 500 mg ............... 25 tetterine oin 2% ............................. 203 TEXACORT SOL 2.5% ...................... 206 TGQ 15DM/5PE SYP H/2CPM ............ 190 TGQ 30/ SYP 150/15 ....................... 190 TGQ 30/PSE/3 SYP BRM/15DM ......... 190 tgq 50pse/3 syp brm/30dm ............. 190 tgt antacid chw 1000mg .................. 139 tgt cold/hot cre pain rel ................... 209 tgt cough oin suppress .................... 194 THALOMID CAP 100MG ..................... 39 THALOMID CAP 150MG ..................... 39 THALOMID CAP 200MG ..................... 39 THALOMID CAP 50MG ....................... 39 THEO-24 CAP 100MG CR ................. 197 THEO-24 CAP 200MG CR ................. 197 THEO-24 CAP 300MG CR ................. 197 THEO-24 CAP 400MG ER ................. 197 THEOPHYL/D5W INJ 0.8MG/ML ......... 197

theophylline soln 80 mg/15ml .......... 197 theophylline tab er 12hr 100 mg ....... 197 theophylline tab er 12hr 200 mg ....... 197 theophylline tab er 12hr 300 mg ....... 197 theophylline tab er 12hr 450 mg ....... 197 theophylline tab er 24hr 400 mg ....... 197 theophylline tab er 24hr 600 mg ....... 197 THERA-D TAB 4000UNIT .................. 184 theragen hp cre 0.075% .................. 209 THERAMILL CAP FORTE ................... 184 THERANATAL CAP ONE .................... 184 THERANATAL MIS COMPLETE ........... 184 THERANATAL PAK OVAVITE .............. 184 THERANATAL TAB 27-1 ................... 184 therapeutic gel 2% ......................... 211 THERATEARS GEL 1% ..................... 219 THERATEARS SOL OP ...................... 219 thiamine hcl inj 100 mg/ml .............. 184 thiamine hcl tab 100 mg .................. 184 THIOLA TAB 100MG ........................ 152 thioridazine hcl tab 10 mg ................ 95 thioridazine hcl tab 100 mg ............... 95 thioridazine hcl tab 25 mg ................ 95 thioridazine hcl tab 50 mg ................ 95 thiotepa for inj 15 mg ...................... 37 thiothixene cap 1 mg ....................... 95 thiothixene cap 10 mg ...................... 95 thiothixene cap 2 mg ....................... 95 thiothixene cap 5 mg ....................... 95 THROMBAT III INJ 1000UNIT ........... 161 THROMBAT III INJ 500UNIT ............. 161 THROMBI-GEL PAD 10 ..................... 160 THROMBIN KIT 5000UNIT ................ 160 THROMBIN-JMI KIT 20000UNT ......... 160 THROMBIN-JMI SOL 20000UNT ........ 160 THROMBIN-JMI SOL 5000UNIT ......... 160 THROMBI-PAD PAD 3"X3" ................ 160 THYMOGLOBULN INJ 25MG .............. 165 THYROLAR-1 TAB 60MG .................. 137 THYROLAR-1/2 TAB 30MG ............... 137 THYROLAR-1/4 TAB 15MG ............... 138 THYROLAR-2 TAB 120MG ................. 138 THYROLAR-3 TAB 180MG ................. 138 tiagabine hcl tab 2 mg ...................... 78 tiagabine hcl tab 4 mg ...................... 78 TIAZAC CAP 120MG/24 .................... 64 TIAZAC CAP 180MG/24 .................... 64 TIAZAC CAP 240MG/24 .................... 64

306

TIAZAC CAP 300MG/24 ..................... 64 TIAZAC CAP 360MG/24 ..................... 64 TIAZAC CAP 420MG/24 ..................... 64 TIGAN CAP 300MG ......................... 141 TIGAN INJ 100MG/ML ..................... 141 tilia fe tab ..................................... 127 timolol maleate ophth gel forming soln 0.25% .......................................... 217 timolol maleate ophth gel forming soln 0.5% ............................................ 217 timolol maleate ophth soln 0.25% .... 217 timolol maleate ophth soln 0.5% ...... 217 timolol maleate tab 10 mg ................. 61 timolol maleate tab 20 mg ................. 61 timolol maleate tab 5 mg................... 61 TIMOPTIC OCU SOL 0.25% OP ......... 217 TIMOPTIC OCU SOL 0.5% OP ........... 217 TIMOPTIC SOL 0.25% OP ................ 217 TIMOPTIC SOL 0.5% OP .................. 217 TIMOPTIC-XE SOL 0.25% OP ........... 217 TIMOPTIC-XE SOL 0.5% OP ............. 217 TINDAMAX TAB 500MG ..................... 35 tinidazole tab 250 mg ....................... 35 tinidazole tab 500 mg ....................... 35 TIROSINT CAP 100MCG ................... 138 TIROSINT CAP 112MCG ................... 138 TIROSINT CAP 125MCG ................... 138 TIROSINT CAP 137MCG ................... 138 TIROSINT CAP 13MCG .................... 138 TIROSINT CAP 150MCG ................... 138 TIROSINT CAP 25MCG .................... 138 TIROSINT CAP 50MCG .................... 138 TIROSINT CAP 75MCG .................... 138 TIROSINT CAP 88MCG .................... 138 TISSEEL SOL ................................. 160 TISSEEL VH KIT 10ML ..................... 160 TISSEEL VH KIT 4ML ....................... 160 titralac chw 420mg ......................... 139 TIVICAY TAB 10MG ........................... 28 TIVICAY TAB 25MG ........................... 28 TIVICAY TAB 50MG ........................... 28 TIVORBEX CAP 20MG ......................... 4 TIVORBEX CAP 40MG ......................... 4 tizanidine hcl cap 2 mg (base equivalent) ................................................... 109 tizanidine hcl cap 4 mg (base equivalent) ................................................... 109 tizanidine hcl cap 6 mg (base equivalent)

.................................................... 109 tizanidine hcl tab 2 mg (base equivalent) .................................................... 109 tizanidine hcl tab 4 mg (base equivalent) .................................................... 109 TL FOLATE TAB .............................. 184 tl-hem 150 tab ............................... 184 TNKASE KIT 50MG .......................... 161 TOBI NEB 300/5ML ......................... 192 TOBI PODHALR CAP 28MG ............... 192 TOBRADEX OIN 0.3-0.1% ................ 215 TOBRADEX ST SUS 0.3-0.05 ............ 215 TOBRADEX SUS 0.3-0.1% ............... 215 tobramycin nebu soln 300 mg/5ml .... 192 tobramycin ophth soln 0.3% ............ 215 tobramycin sulfate for inj 1.2 gm ....... 17 tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) (base equiv) ........................ 17 tobramycin sulfate inj 10 mg/ml (base equivalent) ..................................... 17 tobramycin sulfate inj 2 gm/50ml (40 mg/ml) (base equiv) ........................ 17 tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv) ........................ 17 tobramycin-dexamethasone ophth susp 0.3-0.1% ...................................... 215 TOBREX OIN 0.3% OP ..................... 215 TOBREX SOL 0.3% OP ..................... 215 TOLAK CRE 4% .............................. 201 tolazamide tab 250 mg .................... 118 tolazamide tab 500 mg .................... 118 tolbutamide tab 500 mg .................. 118 tolcapone tab 100 mg ...................... 89 tolmetin sodium cap 400 mg ............... 4 tolmetin sodium tab 200 mg ............... 4 tolmetin sodium tab 600 mg ............... 4 tolterodine tartrate cap er 24hr 2 mg 153 tolterodine tartrate cap er 24hr 4 mg 153 tolterodine tartrate tab 1 mg ............ 153 tolterodine tartrate tab 2 mg ............ 153 TOOMEY SYRIN MIS 70ML ................ 168 TOPAMAX SPR CAP 15MG ................. 78 TOPAMAX SPR CAP 25MG ................. 78 TOPAMAX TAB 100MG ...................... 78 TOPAMAX TAB 200MG ...................... 78 TOPAMAX TAB 25MG ........................ 78 TOPAMAX TAB 50MG ........................ 78 TOPICORT CRE 0.05% ..................... 207

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TOPICORT CRE 0.25% .................... 205 TOPICORT GEL 0.05% .................... 205 TOPICORT OIN 0.05% ..................... 207 TOPICORT OIN 0.25% ..................... 205 TOPICORT SPR 0.25% .................... 205 topiramate cap er 24hr sprinkle 100 mg ..................................................... 78 topiramate cap er 24hr sprinkle 150 mg ..................................................... 78 topiramate cap er 24hr sprinkle 200 mg ..................................................... 78 topiramate cap er 24hr sprinkle 25 mg 78 topiramate cap er 24hr sprinkle 50 mg 78 topiramate sprinkle cap 15 mg ........... 78 topiramate sprinkle cap 25 mg ........... 78 topiramate tab 100 mg ..................... 78 topiramate tab 200 mg ..................... 78 topiramate tab 25 mg ....................... 78 topiramate tab 50 mg ....................... 78 TOPROL XL TAB 100MG ..................... 61 TOPROL XL TAB 200MG ..................... 61 TOPROL XL TAB 25MG ....................... 61 TOPROL XL TAB 50MG ....................... 61 TORISEL SOL 25MG/ML ..................... 41 torsemide tab 10 mg ........................ 66 torsemide tab 100 mg ....................... 66 torsemide tab 20 mg ........................ 66 torsemide tab 5 mg .......................... 66 total fiber pow ............................... 146 TOUJEO SOLO INJ 300IU/ML ............ 116 TOVIAZ TAB 4MG ........................... 153 TOVIAZ TAB 8MG ........................... 153 tpn electrol inj ............................... 173 TRACE ELEM 4 INJ PED ................... 174 TRACLEER TAB 125MG ...................... 69 TRACLEER TAB 62.5MG ..................... 69 TRADJENTA TAB 5MG ...................... 114 TRAMADOL HCL CAP 150MG ER .......... 15 tramadol hcl cap er 24hr biphasic release 100 mg ........................................... 15 tramadol hcl cap er 24hr biphasic release 200 mg ........................................... 15 tramadol hcl cap er 24hr biphasic release 300 mg ........................................... 15 tramadol hcl tab 50 mg ..................... 15 tramadol hcl tab er 24hr 100 mg ........ 15 tramadol hcl tab er 24hr 200 mg ........ 15 tramadol hcl tab er 24hr 300 mg ........ 15

tramadol hcl tab er 24hr biphasic release 100 mg .......................................... 15 tramadol hcl tab er 24hr biphasic release 200 mg .......................................... 15 tramadol hcl tab er 24hr biphasic release 300 mg .......................................... 15 tramadol-acetaminophen tab 37.5-325 mg ................................................ 15 trandolapril tab 1 mg ....................... 48 trandolapril tab 2 mg ....................... 48 trandolapril tab 4 mg ....................... 48 trandolapril-verapamil hcl tab er 1-240 mg ................................................ 46 trandolapril-verapamil hcl tab er 2-180 mg ................................................ 46 trandolapril-verapamil hcl tab er 2-240 mg ................................................ 46 trandolapril-verapamil hcl tab er 4-240 mg ................................................ 46 tranexamic acid iv soln 1000 mg/10ml (100 mg/ml) .................................. 160 tranexamic acid tab 650 mg ............. 160 TRANSDERM-SC DIS 1.5MG ............. 141 TRANXENE T TAB 7.5MG ................... 72 tranylcypromine sulfate tab 10 mg ..... 81 TRAVATAN Z DRO 0.004% ............... 220 trazodone hcl tab 100 mg ................. 81 trazodone hcl tab 150 mg ................. 81 trazodone hcl tab 300 mg ................. 81 trazodone hcl tab 50 mg ................... 81 TREANDA INJ 100MG ....................... 37 TREANDA INJ 25MG ......................... 37 TRECATOR TAB 250MG ..................... 31 TRELSTAR INJ 11.25MG .................... 39 TRESIBA FLEX INJ 100UNIT ............. 116 TRESIBA FLEX INJ 200UNIT ............. 116 tretinoin cap 10 mg ......................... 44 tretinoin cream 0.025% ................... 200 tretinoin cream 0.05% .................... 200 tretinoin cream 0.1% ...................... 200 tretinoin gel 0.01% ......................... 200 tretinoin gel 0.025% ....................... 200 tretinoin gel 0.05% ......................... 200 tretinoin microsphere gel 0.04% ....... 200 tretinoin microsphere gel 0.1% ......... 200 TRETIN-X CRE 0.0375% .................. 200 TRETIN-X CRE 0.075% .................... 200 TRETIN-X CRE KIT 0.05% ................ 200

308

TRETTEN INJ ................................. 159 TREXALL TAB 10MG .......................... 38 TREXALL TAB 15MG .......................... 38 TREXALL TAB 5MG ............................ 38 TREXALL TAB 7.5MG ......................... 38 TREXIMET TAB 85-500MG ............... 105 triamcinolone acetonide aerosol soln 0.147 mg/gm ................................ 207 triamcinolone acetonide cream 0.025% ................................................... 207 triamcinolone acetonide cream 0.1% 207 triamcinolone acetonide cream 0.5% 205 triamcinolone acetonide dental paste 0.1% ............................................ 214 triamcinolone acetonide lotion 0.025% ................................................... 207 triamcinolone acetonide lotion 0.1% . 207 triamcinolone acetonide nasal aerosol suspension 55 mcg/act ................... 195 triamcinolone acetonide oint 0.025% 207 triamcinolone acetonide oint 0.1% .... 207 triamcinolone acetonide oint 0.5% .... 205 TRIAMINIC CHW ............................ 190 TRIAMINIC NT MIS COLD/CGH ......... 186 TRIAMINIC SYP CLD/ALRG ............... 186 triamterene & hydrochlorothiazide cap 37.5-25 mg ..................................... 66 triamterene & hydrochlorothiazide cap 50-25 mg ........................................ 66 triamterene & hydrochlorothiazide tab 37.5-25 mg ..................................... 66 triamterene & hydrochlorothiazide tab 75-50 mg ........................................ 66 TRIANEX OIN 0.05% ....................... 207 triazolam tab 0.125 mg ................... 103 triazolam tab 0.25 mg ..................... 103 TRIBENZOR20- TAB 5-12.5MG ........... 51 TRIBENZOR40- TAB 10-12.5 .............. 51 TRIBENZOR40- TAB 10-25MG ............ 51 TRIBENZOR40- TAB 5-12.5MG ........... 51 TRIBENZOR40- TAB 5-25MG .............. 51 tri-buff asa tab 325mg ....................... 4 TRICARE PAK PRENATAL ................. 184 TRICARE PRE CAP 27-1-500 ............. 184 TRICITRASOL CON ......................... 161 TRICODE AR LIQ 30-2-8 .................. 190 TRICODE GF LIQ 30-8-200 .............. 190 TRICOR TAB 145MG .......................... 56

TRICOR TAB 48MG ........................... 56 TRIESENCE INJ 40MG/ML ................ 216 TRIFERIC SOL ................................ 184 trifluoperazine hcl tab 1 mg .............. 96 trifluoperazine hcl tab 10 mg ............. 96 trifluoperazine hcl tab 2 mg .............. 96 trifluoperazine hcl tab 5 mg .............. 96 trifluridine ophth soln 1% ................ 217 TRIGLIDE TAB 160MG ...................... 56 trihexyphenidyl hcl elixir 0.4 mg/ml ... 89 trihexyphenidyl hcl tab 2 mg ............. 89 trihexyphenidyl hcl tab 5 mg ............. 89 TRILEPTAL SUS 300MG/5M ............... 78 TRILEPTAL TAB 150MG ..................... 78 TRILEPTAL TAB 300MG ..................... 79 TRILEPTAL TAB 600MG ..................... 79 TRILIPIX CAP 135MG ....................... 56 TRILIPIX CAP 45MG ......................... 56 TRI-LUMA CRE ............................... 211 trimethobenzamide hcl cap 300 mg ... 141 trimethoprim tab 100 mg .................. 35 trimipramine maleate cap 100 mg ...... 86 trimipramine maleate cap 25 mg ....... 86 trimipramine maleate cap 50 mg ....... 86 trinate tab ..................................... 184 trinessa lo tab ................................ 127 trinessa tab ................................... 127 TRI-NORINYL TAB 28 ...................... 127 TRINTELLIX TAB 10MG ..................... 85 TRINTELLIX TAB 20MG ..................... 85 TRINTELLIX TAB 5MG ....................... 85 TRIOSTAT INJ 10MCG/ML ................ 138 triple antib oin ............................... 201 triple antib oin plus ......................... 201 triple dye solution ........................... 204 TRIPLE PASTE OIN 12.8% ................ 211 TRISENOX SOL 10MG/10M ................ 45 TRISTART DHA CAP ........................ 184 TRIUMEQ TAB ................................. 28 TRI-VI-SOL SOL ............................. 184 TRIZIVIR TAB ................................. 28 TROKENDI XR CAP 100MG ................ 79 TROKENDI XR CAP 200MG ................ 79 TROKENDI XR CAP 25MG .................. 79 TROKENDI XR CAP 50MG .................. 79 TROPAZONE LOT ............................ 208 TROPHAMINE INJ 6% ...................... 172 tropicamide ophth soln 0.5%............ 220

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tropicamide ophth soln 1% .............. 220 trospium chloride cap er 24hr 60 mg . 153 trospium chloride tab 20 mg ............ 153 TRULANCE TAB 3MG ....................... 147 TRULICITY INJ 0.75/0.5 .................. 115 TRULICITY INJ 1.5/0.5 .................... 115 TRUSOPT SOL 2% OP ..................... 218 TRUVADA TAB 200-300 ..................... 28 TRUZONE PEAK MIS FLOW MTR ........ 194 trymine cg liq 225-7.5 .................... 190 TUDORZA PRES AER 400/ACT .......... 186 TUMS CHW 500MG ......................... 139 TUSNEL PED DRO 7.5-50 ................. 190 tussin cf liq .................................... 190 tussin cf liq max/m-s ...................... 190 tussin chest syp 100/5ml ................. 192 tussin cough syp 15mg/5ml ............. 190 tussin dm liq 100-10/5 .................... 190 tussin dm liq max ........................... 190 tussin dm syp 100-10/5 .................. 190 TUSSIONEX SUS 10-8/5ML .............. 190 TUZISTRA XR SUS .......................... 190 TWYNSTA TAB 40-10MG .................... 50 TWYNSTA TAB 40-5MG ..................... 50 TWYNSTA TAB 80-10MG .................... 50 TWYNSTA TAB 80-5MG ..................... 50 TYBOST TAB 150MG ......................... 27 TYGACIL INJ 50MG ........................... 35 TYKERB TAB 250MG ......................... 41 TYLENOL/COD TAB #3 ...................... 16 TYLENOL/COD TAB #4 ...................... 16 TYMLOS INJ ................................... 124 TYVASO START SOL 0.6MG/ML ........... 70 TYZINE SOL 0.1% .......................... 196 U UCERIS AER 2MG/ACT .................... 144 UCERIS TAB 9MG ........................... 143 UDAMIN SP TAB ............................. 184 ULESFIA LOT 5% ............................ 212 ULORIC TAB 40MG ............................ 1 ULORIC TAB 80MG ............................ 1 ULTIMATECARE CAP ONE NF ............ 184 ULTIVA INJ 1MG ............................... 16 ULTIVA INJ 2MG ............................... 16 ULTIVA INJ 5MG ............................... 16 ultra b-100 tab complex .................. 184 ULTRA MAN TAB ............................. 184 ULTRACET TAB 37.5-325 ................... 16

ultra-derm lot ................................ 211 ULTRAFOAM MIS 2X6.25X7 .............. 160 ULTRAFOAM MIS 8X12.5X1 .............. 160 ULTRAFOAM MIS 8X12.5X3 .............. 160 ULTRAFOAM MIS 8X6.25X1 .............. 160 ULTRAM ER TAB 300MG .................... 16 ULTRAM TAB 50MG .......................... 16 ULTRAVATE CRE 0.05% ................... 208 ULTRAVATE OIN 0.05% ................... 208 UNASYN INJ 1.5GM .......................... 23 UNASYN INJ 15GM ........................... 23 UNASYN INJ 3GM ............................ 23 UNIFIBER POW ............................... 146 UNIFINE PNTP MIS 31GX3/16 ........... 122 UNISOM SLEEP TAB 25MG ............... 104 UNITUXIN INJ ................................. 45 UPCAL D POW ................................ 184 UPTRAVI TAB 1000MCG .................... 70 UPTRAVI TAB 1200MCG .................... 70 UPTRAVI TAB 1400MCG .................... 70 UPTRAVI TAB 1600MCG .................... 70 UPTRAVI TAB 200/800 ..................... 69 UPTRAVI TAB 200MCG ..................... 69 UPTRAVI TAB 400MCG ..................... 69 UPTRAVI TAB 600MCG ..................... 69 UPTRAVI TAB 800MCG ..................... 69 ur n-c tab ...................................... 152 uramit mb cap 118mg ..................... 152 URECHOLINE TAB 10MG .................. 152 URECHOLINE TAB 25MG .................. 152 URECHOLINE TAB 50MG .................. 152 URECHOLINE TAB 5MG .................... 152 UREVAZ CRE 44% .......................... 208 urimar-t tab ................................... 152 UROCIT-K 10 TAB ........................... 153 UROCIT-K 15 TAB ........................... 153 UROCIT-K 5 TAB ............................ 153 urolet mb tab ................................. 153 URO-MAG CAP 140MG ..................... 139 urophen mb tab 81.6mg .................. 153 urosex tab ..................................... 184 UROXATRAL TAB 10MG ................... 151 URSO 250 TAB 250MG .................... 142 URSO FORTE TAB 500MG ................. 142 ursodiol cap 300 mg ....................... 142 ursodiol tab 250 mg ........................ 142 ursodiol tab 500 mg ........................ 142 UTIBRON CAP NEOHALER ................ 186

310

V valacyclovir hcl tab 1 gm ................... 33 valacyclovir hcl tab 500 mg ............... 33 VALCHLOR GEL 0.016% .................... 37 valganciclovir hcl for soln 50 mg/ml (base equiv) .................................... 31 valganciclovir hcl tab 450 mg (base equivalent) ...................................... 31 VALIUM TAB 10MG ........................... 72 VALIUM TAB 2MG ............................. 72 VALIUM TAB 5MG ............................. 72 valproate sodium inj 100 mg/ml ......... 79 valproate sodium oral soln 250 mg/5ml (base equiv) .................................... 79 valproic acid cap 250 mg ................... 79 valsartan tab 160 mg ........................ 53 valsartan tab 320 mg ........................ 53 valsartan tab 40 mg ......................... 53 valsartan tab 80 mg ......................... 53 valsartan-hydrochlorothiazide tab 160-12.5 mg .......................................... 52 valsartan-hydrochlorothiazide tab 160-25 mg ................................................. 52 valsartan-hydrochlorothiazide tab 320-12.5 mg .......................................... 52 valsartan-hydrochlorothiazide tab 320-25 mg ................................................. 52 valsartan-hydrochlorothiazide tab 80-12.5 mg .......................................... 52 VALTREX TAB 1GM ........................... 33 VALTREX TAB 500MG ........................ 33 VANCOCIN HCL CAP 125MG ............... 35 VANCOCIN HCL CAP 250MG ............... 35 VANCOMYC/DEX INJ 1GM .................. 35 VANCOMYC/DEX INJ 500MG ............... 35 VANCOMYC/DEX INJ 750MG ............... 35 vancomycin hcl cap 125 mg ............... 35 vancomycin hcl cap 250 mg ............... 35 vancomycin hcl for inj 10 gm ............. 35 vancomycin hcl for inj 1000 mg .......... 36 vancomycin hcl for inj 500 mg ........... 35 vancomycin hcl for inj 5000 mg .......... 36 VANCOMYCIN INJ 750MG .................. 36 VANOS CRE 0.1% ........................... 205 VANTAS KIT 50MG ........................... 39 VAPRISOL INJ 20/100ML ................. 138 VARITHENA AER 10MG/ML ................. 68 VARIZIG INJ 125UNIT ..................... 165

VARUBI TAB 90MG .......................... 141 VASCAZEN CAP 1GM ....................... 170 VASCEPA CAP 0.5GM ....................... 58 VASCEPA CAP 1GM .......................... 58 VASERETIC TAB 10-25MG ................. 47 vashe wound sol therapy ................. 213 VASOTEC TAB 10MG ........................ 48 VASOTEC TAB 2.5MG ....................... 48 VASOTEC TAB 20MG ........................ 48 VASOTEC TAB 5MG .......................... 48 VAYAROL CAP ................................ 170 VAZCULEP INJ 10MG/ML ................... 71 v-c forte cap .................................. 184 vcks dayquil liq mucus dm ............... 190 VECTIBIX INJ 100MG ....................... 45 VECTIBIX INJ 400MG ....................... 45 VECTICAL OIN 3MCG/GM ................. 203 vecuronium bromide for inj 10 mg .... 110 vecuronium bromide for inj 20 mg .... 110 VELETRI INJ 0.5MG .......................... 70 VELETRI INJ 1.5MG .......................... 70 VELPHORO CHW 500MG .................. 135 VELTASSA POW 16.8GM .................. 136 VELTASSA POW 25.2GM .................. 136 VELTASSA POW 8.4GM .................... 135 VELTIN GEL ................................... 200 VENCLEXTA TAB 100MG ................... 45 VENCLEXTA TAB 10MG ..................... 45 VENCLEXTA TAB 50MG ..................... 45 VENCLEXTA TAB START PK ............... 45 VENELEX OIN ................................. 213 venlafaxine hcl cap er 24hr 150 mg (base equivalent) ............................ 83 venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) ............................ 83 venlafaxine hcl cap er 24hr 75 mg (base equivalent) ..................................... 83 venlafaxine hcl tab 100 mg ............... 83 venlafaxine hcl tab 25 mg ................. 83 venlafaxine hcl tab 37.5 mg .............. 83 venlafaxine hcl tab 50 mg ................. 83 venlafaxine hcl tab 75 mg ................. 83 venlafaxine hcl tab er 24hr 150 mg (base equivalent) ..................................... 83 venlafaxine hcl tab er 24hr 225 mg (base equivalent) ..................................... 83 venlafaxine hcl tab er 24hr 37.5 mg (base equivalent) ............................ 83

311

venlafaxine hcl tab er 24hr 75 mg (base equivalent) ...................................... 83 VENLAFAXINE TAB 150MG ER ............ 83 VENLAFAXINE TAB 37.5 ER ................ 83 VENLAFAXINE TAB 75MG ER .............. 83 VENT NEEDLE MIS 18GX1.5" ............ 168 VENTAVIS SOL 10MCG/ML ................. 70 VENTAVIS SOL 20MCG/ML ................. 70 VENTOLIN HFA AER ........................ 191 VERAMYST SPR 27.5MCG ................ 195 verapamil hcl cap er 24hr 100 mg ...... 64 verapamil hcl cap er 24hr 120 mg ...... 64 verapamil hcl cap er 24hr 180 mg ...... 64 verapamil hcl cap er 24hr 200 mg ...... 64 verapamil hcl cap er 24hr 240 mg ...... 64 verapamil hcl cap er 24hr 300 mg ...... 64 verapamil hcl cap er 24hr 360 mg ...... 64 verapamil hcl iv soln 2.5 mg/ml.......... 64 verapamil hcl tab 120 mg .................. 64 verapamil hcl tab 40 mg .................... 64 verapamil hcl tab 80 mg .................... 64 verapamil hcl tab er 120 mg .............. 64 verapamil hcl tab er 180 mg .............. 64 verapamil hcl tab er 240 mg .............. 64 VERDESO AER 0.05% ..................... 206 verdrocet tab 2.5-325 ....................... 16 VERELAN CAP 120MG SR ................... 64 VERELAN CAP 180MG SR ................... 64 VERELAN CAP 240MG SR ................... 64 VERELAN CAP 360MG SR ................... 64 VERELAN PM CAP 100MG ER .............. 64 VERELAN PM CAP 200MG ER .............. 64 VERELAN PM CAP 300MG ER .............. 64 VERSACLOZ SUS 50MG/ML ................ 94 VESICARE TAB 10MG ...................... 153 VESICARE TAB 5MG ........................ 153 vestura tab 3-0.02mg ..................... 126 VFEND IV INJ 200MG ........................ 27 VFEND SUS 40MG/ML ....................... 27 VFEND TAB 200MG ........................... 27 VFEND TAB 50MG ............................. 27 VIBATIV INJ 250MG .......................... 36 VIBERZI TAB 100MG ....................... 144 VIBERZI TAB 75MG ........................ 144 VIBRAMYCIN CAP 100MG .................. 25 VIBRAMYCIN SUS 25MG/5ML ............. 25 VIBRAMYCIN SYP 50MG/5ML .............. 25 VICKS NATURE LIQ COLD/FLU .......... 190

VICKS NATURE LIQ CONGEST .......... 190 VICKS OIN VAPORUB ...................... 194 VICTOZA INJ 18MG/3ML .................. 115 VIDEX EC CAP 125MG ...................... 30 VIDEX EC CAP 200MG ...................... 30 VIDEX EC CAP 250MG ...................... 30 VIDEX EC CAP 400MG ...................... 30 VIDEX SOL 2GM .............................. 30 VIDEX SOL 4GM .............................. 30 VIEKIRA PAK TAB ............................ 32 VIEKIRA XR TAB .............................. 32 VIGAMOX DRO 0.5% ....................... 216 vigor cap ....................................... 184 VIIBRYD KIT STARTER ..................... 85 VIIBRYD TAB 10MG ......................... 85 VIIBRYD TAB 20MG ......................... 85 VIIBRYD TAB 40MG ......................... 85 VIMOVO TAB 375-20MG ..................... 5 VIMOVO TAB 500-20MG ..................... 5 VIMPAT INJ 200MG/20 ..................... 79 VIMPAT SOL 10MG/ML ..................... 79 VIMPAT TAB 100MG ......................... 79 VIMPAT TAB 150MG ......................... 79 VIMPAT TAB 200MG ......................... 79 VIMPAT TAB 50MG ........................... 79 VINACAL B MIS .............................. 184 VINATE C TAB ................................ 184 VINATE CAL TAB ............................ 184 VINATE CARE CHW 40-1MG ............. 184 VINATE DHA CAP 27-1.13 ................ 184 VINATE II TAB ............................... 184 VINATE M TAB ............................... 184 VINATE ONE TAB ............................ 184 vinblastine sulfate inj 1 mg/ml .......... 45 vincristine sulfate iv soln 1 mg/ml ...... 45 vinorelbine tartrate inj 10 mg/ml (base equiv) ............................................ 45 vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv) ........................ 45 VIOKACE TAB ................................. 148 VIOKACE TAB 20880 ....................... 148 VIOS LC MIS SPRINT ...................... 194 VIRACEPT TAB 250MG ...................... 29 VIRACEPT TAB 625MG ...................... 29 VIRAMUNE SUS 50MG/5ML ............... 29 VIRAMUNE TAB 200MG ..................... 29 VIRASAL LIQ 27.5% ........................ 211 VIRAZOLE INH 6GM ......................... 36

312

VIREAD POW 40MG/GM ..................... 30 VIREAD TAB 150MG .......................... 30 VIREAD TAB 200MG .......................... 30 VIREAD TAB 250MG .......................... 30 VIREAD TAB 300MG .......................... 30 VIROPTIC SOL 1% OP ..................... 217 VIRT NATE TAB .............................. 184 VIRT-PN TAB ................................. 184 VIRTPREX CAP ............................... 184 virtussin sol dac ............................. 190 VISCOAT SOL ................................ 219 VISIONBLUE SOL 0.06% ................. 220 VISTARIL CAP 25MG ....................... 188 VISTARIL CAP 50MG ....................... 188 vit c gummie chw 125mg ................ 184 VITACRAVES CHW +OMEGA-3.......... 184 VITAFOL CAP ULTRA ....................... 184 VITAFOL CHW GUMMIES ................. 184 VITAFOL FE+ CAP ........................... 184 VITAFOL TAB ................................. 185 VITAFOL-NANO TAB ........................ 185 VITAFOL-OB PAK +DHA ................... 185 VITAFOL-ONE CAP .......................... 185 VITAL-D RX TAB ............................. 185 VITALETS CHW .............................. 185 VITAMAX CHW ............................... 185 vitamax ped dro ............................. 185 VITAMEDMD CAP ONE RX ................ 185 VITAMEDMD MIS PLUS RX ............... 185 vitamin c + tab echinace ................. 185 vitamin c tab 500mg ....................... 185 vitamin c tab plus ........................... 185 vitamin d chw 1000unit ................... 185 vitamin d tab 1000unit .................... 185 VITAMIN D TAB 400 ........................ 185 VITAMIN D2 TAB 2000UNIT ............. 185 VITAMIN D2 TAB 400UNIT ............... 185 vitamin d3 cap 10000unt ................. 185 VITAMIN D3 CAP 4000UNIT ............. 185 VITAMIN D3 LIQ 1200UNIT .............. 185 VITAMIN D3 SPR 1000UNIT ............. 185 VITAMIN D3 TAB 3000UNIT ............. 185 vitamin d-3 tab 5000unit ................. 185 vitamins a & d cap .......................... 185 VITA-PREN TAB .............................. 184 vitatrum chw ................................. 185 VITRASE INJ 200/ML ....................... 107 VIVELLE-DOT DIS 0.025MG ............. 129

VIVELLE-DOT DIS 0.0375MG ............ 129 VIVELLE-DOT DIS 0.05MG ............... 129 VIVELLE-DOT DIS 0.075MG ............. 129 VIVELLE-DOT DIS 0.1MG ................. 129 VIVITROL INJ 380MG ...................... 111 VIVLODEX CAP 10MG ......................... 4 VIVLODEX CAP 5MG ........................... 4 VOLTAREN GEL 1% ............................ 5 voriconazole for inj 200 mg ............... 27 voriconazole for susp 40 mg/ml ......... 27 voriconazole tab 200 mg .................. 27 voriconazole tab 50 mg .................... 27 VOSPIRE ER TAB 4MG ..................... 192 VOSPIRE ER TAB 8MG ..................... 192 VOTRIENT TAB 200MG ..................... 41 VP-HEME OB TAB ............................ 185 VP-PNV-DHA CAP ........................... 185 vp-precip cap ................................. 170 VPRIV INJ 400UNIT ......................... 134 VRAYLAR CAP 1.5-3MG ..................... 94 VRAYLAR CAP 1.5MG ........................ 94 VRAYLAR CAP 3MG .......................... 94 VRAYLAR CAP 4.5MG ........................ 94 VRAYLAR CAP 6MG .......................... 94 VSL#3 DS PAK ............................... 147 VUSION OIN .................................. 203 VYTORIN TAB 10-10MG .................... 57 VYTORIN TAB 10-20MG .................... 57 VYTORIN TAB 10-40MG .................... 57 VYTORIN TAB 10-80MG .................... 57 VYVANSE CAP 10MG ....................... 101 VYVANSE CAP 20MG ....................... 101 VYVANSE CAP 30MG ....................... 101 VYVANSE CAP 40MG ....................... 101 VYVANSE CAP 50MG ....................... 101 VYVANSE CAP 60MG ....................... 101 VYVANSE CAP 70MG ....................... 101 W wal-dryl spr ................................... 211 wal-fex chld sus 30mg/5ml .............. 187 wal-fex d tab 24 hour ...................... 186 wal-mucil cap plus ca ...................... 146 wal-mucil pow 100% ....................... 146 wal-som tab 25mg .......................... 104 wal-tussin cap cough ....................... 190 WAL-TUSSIN CHW 7.5MG ................ 190 wal-tussin liq 15mg/5ml .................. 190 wal-zyr chw 5mg ............................ 187

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warfarin sodium tab 1 mg ................ 156 warfarin sodium tab 10 mg .............. 156 warfarin sodium tab 2 mg ................ 156 warfarin sodium tab 2.5 mg ............. 156 warfarin sodium tab 3 mg ................ 156 warfarin sodium tab 4 mg ................ 156 warfarin sodium tab 5 mg ................ 156 warfarin sodium tab 6 mg ................ 156 warfarin sodium tab 7.5 mg ............. 156 weight loss tab multi ....................... 185 WELCHOL PAK 3.75GM ...................... 55 WELCHOL TAB 625MG ....................... 55 WELLBUTRIN TAB 100MG SR ............. 81 WELLBUTRIN TAB 150MG SR ............. 82 WELLBUTRIN TAB 200MG SR ............. 82 WELLBUTRIN TAB XL 150MG .............. 82 WELLBUTRIN TAB XL 300MG .............. 82 WESTHROID TAB 130MG ................. 138 WESTHROID TAB 32.5MG ................ 138 WESTHROID TAB 65MG ................... 138 WESTHROID TAB 97.5MG ................ 138 WIDE-SEAL DPR KIT 60 ................... 125 WIDE-SEAL DPR KIT 65 ................... 125 WIDE-SEAL DPR KIT 70 ................... 125 WIDE-SEAL DPR KIT 75 ................... 125 WIDE-SEAL DPR KIT 80 ................... 125 WIDE-SEAL DPR KIT 85 ................... 125 WIDE-SEAL DPR KIT 90 ................... 125 WIDE-SEAL DPR KIT 95 ................... 125 wound wash liq advanced ................ 213 X XADAGO TAB 100MG ........................ 89 XADAGO TAB 50MG .......................... 89 XALATAN SOL 0.005% .................... 220 XALKORI CAP 200MG ........................ 41 XALKORI CAP 250MG ........................ 41 XANAX TAB 0.25MG .......................... 72 XANAX TAB 0.5MG ........................... 72 XANAX TAB 1MG .............................. 72 XANAX TAB 2MG .............................. 72 XANAX XR TAB 0.5MG ....................... 72 XANAX XR TAB 1MG ......................... 72 XANAX XR TAB 2MG ......................... 72 XANAX XR TAB 3MG ......................... 72 XARELTO STAR TAB 15/20MG .......... 156 XARELTO TAB 10MG ....................... 156 XARELTO TAB 15MG ....................... 156 XARELTO TAB 20MG ....................... 156

XELJANZ TAB 5MG .......................... 164 XELODA TAB 150MG ........................ 38 XELODA TAB 500MG ........................ 38 XENICAL CAP 120MG ...................... 123 XERAC-AC SOL 6.25% ..................... 211 XERESE CRE 5-1% .......................... 211 XERMELO TAB 250MG ..................... 147 XEROFRM GAUZ MIS 1"X8" .............. 213 XEROFRM PETR PAD 2"X2" ............... 213 XIFAXAN TAB 200MG ....................... 36 XIFAXAN TAB 550MG ....................... 36 XIGDUO XR TAB 10-1000 ................ 117 XIGDUO XR TAB 10-500MG .............. 117 XIGDUO XR TAB 5-1000MG .............. 117 XIGDUO XR TAB 5-500MG ............... 117 XIIDRA DRO 5% ............................. 218 XODOL TAB 10-300MG ..................... 16 XODOL TAB 5-300MG ....................... 16 XODOL TAB 7.5-300 ........................ 16 XOLAIR SOL 150MG ........................ 194 XOLEGEL GEL 2% ........................... 203 XOPENEX CONC NEB 1.25/0.5 .......... 191 XOPENEX HFA AER ......................... 191 XOPENEX NEB 0.31MG .................... 191 XOPENEX NEB 0.63MG .................... 191 XOPENEX NEB 1.25/3ML .................. 191 XTAMPZA ER CAP 13.5MG ................. 16 XTAMPZA ER CAP 18MG ................... 16 XTAMPZA ER CAP 27MG ................... 16 XTAMPZA ER CAP 36MG ................... 16 XTAMPZA ER CAP 9MG ..................... 16 XTANDI CAP 40MG .......................... 38 xulane dis 150-35 ........................... 127 XULTOPHY INJ 100/3.6 .................... 114 XURIDEN POW 2GM ........................ 135 XYLOCAINE INJ 2% ......................... 55 XYLOCAINE SOL 4% ....................... 209 XYNTHA INJ 1000UNIT .................... 159 XYNTHA INJ 2000UNIT .................... 159 XYNTHA INJ 250UNIT ...................... 159 XYNTHA INJ 500UNIT ...................... 159 XYNTHA SOLOF INJ 3000UNIT .......... 159 XYREM SOL 500MG/ML .................... 110 XYZAL SOL 2.5/5ML ........................ 187 XYZAL TAB 5MG ............................. 187 Y YALE CLEANER POW ........................ 211 YALE NEEDLE MIS 15GX1.5" ............ 168

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YALE NEEDLE MIS 15GX2" ............... 168 YALE NEEDLE MIS 16GX2" ............... 168 YALE NEEDLES MIS 13X3-1/2 .......... 169 YALE NEEDLES MIS 15X3-1/2 .......... 169 YALE NEEDLES MIS 17G X 2" ........... 169 YALE NEEDLES MIS 18G X 2" ........... 169 YALE NEEDLES MIS 18X1-1/2 .......... 169 YALE NEEDLES MIS 19X1-1/2 .......... 169 YALE NEEDLES MIS 20G X 1" ........... 169 YALE NEEDLES MIS 20G X 2" ........... 169 YALE NEEDLES MIS 20X1-1/2 .......... 169 YALE NEEDLES MIS 21G X 1" ........... 169 YALE NEEDLES MIS 21X1-1/2 .......... 169 YALE NEEDLES MIS 22G X 1" ........... 169 YALE NEEDLES MIS 22G X 2" ........... 169 YALE NEEDLES MIS 22G X 3" ........... 169 YALE NEEDLES MIS 22X1-1/2 .......... 169 YALE NEEDLES MIS 23G X 1" ........... 169 YALE NEEDLES MIS 23G X 2" ........... 169 YALE NEEDLES MIS 23GX1/2" .......... 169 YALE NEEDLES MIS 23X1-1/2 .......... 169 YALE NEEDLES MIS 24G X 1" ........... 169 YALE NEEDLES MIS 24GX1/2" .......... 169 YALE NEEDLES MIS 24GX3/4" .......... 169 YALE NEEDLES MIS 24X1-1/2 .......... 169 YALE NEEDLES MIS 25G X 1" ........... 169 YALE NEEDLES MIS 25GX1/2" .......... 169 YALE NEEDLES MIS 25GX3/8" .......... 169 YALE NEEDLES MIS 25GX5/8" .......... 169 YALE NEEDLES MIS 25X1-1/2 .......... 169 YALE NEEDLES MIS 26G X 1" ........... 169 YALE NEEDLES MIS 26GX1/2" .......... 169 YALE NEEDLES MIS 26GX3/8" .......... 169 YALE NEEDLES MIS 26GX5/8" .......... 169 YALE NEEDLES MIS 26X1-1/2 .......... 169 YALE NEEDLES MIS 27G X 1" ........... 169 YALE NEEDLES MIS 27GX1/2" .......... 169 YALE NEEDLES MIS 27GX1/4" .......... 169 YALE NEEDLES MIS 27GX3/8" .......... 169 YALE NEEDLES MIS 30G X 1" ........... 169 YALE NEEDLES MIS 30X1-1/2 .......... 169 YALE TB SYRN MIS GL 1/4ML ........... 169 YALE TB SYRN MIS GL 1ML .............. 169 YASMIN 28 TAB 3-0.03MG ............... 126 YAZ TAB 3-0.02MG ......................... 126 YERVOY INJ 200MG .......................... 45 YERVOY INJ 50MG ............................ 45 yodefan-nf liq 200-5ml .................... 192

yuvafem tab 10mcg ........................ 130 Z ZACARE KIT KIT 4% ....................... 200 zafirlukast tab 10 mg ...................... 193 zafirlukast tab 20 mg ...................... 193 zaleplon cap 10 mg ......................... 104 zaleplon cap 5 mg .......................... 104 ZALTRAP INJ 100/4ML ...................... 45 ZALTRAP INJ 200/8ML ...................... 45 ZANAFLEX CAP 2MG ........................ 109 ZANAFLEX CAP 4MG ........................ 109 ZANAFLEX CAP 6MG ........................ 109 ZANAFLEX TAB 4MG ........................ 109 ZANOSAR INJ 1GM .......................... 37 ZANTAC INJ 25MG/ML ..................... 143 ZANTAC INJ 50MG/2ML ................... 143 ZANTAC TAB 150MG ....................... 143 ZANTAC TAB 300MG ....................... 143 ZARONTIN CAP 250MG ..................... 79 ZARONTIN SOL 250/5ML .................. 79 ZARXIO INJ 300/0.5 ....................... 159 ZARXIO INJ 480/0.8 ....................... 159 ZATEAN-CH CAP ............................. 185 ZAVESCA CAP 100MG ..................... 134 ZEBETA TAB 5MG ............................ 61 ZEGERID CAP 20-1100 .................... 150 ZEGERID CAP 40-1100 .................... 150 ZEGERID OTC CAP 20-1100 ............. 150 ZEGERID POW 20-1680 ................... 150 ZEGERID POW 40-1680 ................... 150 ZELAPAR TAB 1.25MG ...................... 89 ZELBORAF TAB 240MG ..................... 41 ZEMAIRA INJ 1000MG ..................... 194 ZEMPLAR CAP 1MCG ....................... 133 ZEMPLAR CAP 2MCG ....................... 133 ZEMPLAR INJ 5MCG/ML ................... 134 zenatane cap 10mg ........................ 197 zenatane cap 20mg ........................ 197 zenatane cap 30mg ........................ 197 zenatane cap 40mg ........................ 197 zenchent fe chw 0.4mg-35 ............... 126 zenchent tab .................................. 126 ZENPEP CAP 10000UNT ................... 148 ZENPEP CAP 15000UNT ................... 148 ZENPEP CAP 20000UNT ................... 148 ZENPEP CAP 25000UNT ................... 148 ZENPEP CAP 3000UNIT .................... 148 ZENPEP CAP 40000UNT ................... 148

315

ZENPEP CAP 5000UNIT ................... 148 zenzedi tab 15mg ........................... 101 zenzedi tab 2.5mg .......................... 101 zenzedi tab 20mg ........................... 102 zenzedi tab 30mg ........................... 102 zenzedi tab 7.5mg .......................... 101 ZEPATIER TAB 50-100MG .................. 32 ZERIT CAP 15MG .............................. 30 ZERIT CAP 20MG .............................. 30 ZERIT CAP 30MG .............................. 30 ZERIT CAP 40MG .............................. 30 ZERIT SOL 1MG/ML .......................... 30 zeruvia pad 4-1% ........................... 209 ZESTORETIC TAB 10-12.5 ................. 47 ZESTORETIC TAB 20-12.5 ................. 47 ZESTORETIC TAB 20-25MG ................ 47 ZESTRIL TAB 10MG .......................... 48 ZESTRIL TAB 2.5MG ......................... 48 ZESTRIL TAB 20MG .......................... 48 ZESTRIL TAB 30MG .......................... 48 ZESTRIL TAB 40MG .......................... 48 ZESTRIL TAB 5MG ............................ 48 ZETIA TAB 10MG .............................. 55 ZETONNA AER 37MCG ..................... 195 ZEVALIN KIT Y-90 ............................ 45 ZIAC TAB 10/6.25 ............................ 59 ZIAC TAB 2.5/6.25 ........................... 59 ZIAC TAB 5-6.25MG ......................... 59 ZIAGEN SOL 20MG/ML ...................... 30 ZIAGEN TAB 300MG ......................... 30 ZIANA GEL .................................... 200 zidovudine cap 100 mg ..................... 30 zidovudine syrup 10 mg/ml ............... 30 zidovudine tab 300 mg ...................... 30 zileuton tab er 12hr 600 mg ............ 193 ZINACEF INJ 1.5GM .......................... 19 ZINACEF INJ 7.5GM .......................... 19 ZINACEF INJ 750MG ......................... 19 ZINACEF/H20 INJ 1.5GM PB ............... 19 ZINBRYTA INJ 150MG/ML ................ 108 zinc chloride inj 1 mg/ml ................. 174 zinc oxide oin 20% ......................... 211 ZINC OXIDE PST 25% ..................... 211 zinc sulfate inj 1 mg/ml ................... 174 zinc sulfate inj 5 mg/ml ................... 174 ZINECARD INJ 250MG ....................... 45 ZINECARD INJ 500MG ....................... 45 ZIOPTAN DRO 0.0015% .................. 220

ziprasidone hcl cap 20 mg ................ 94 ziprasidone hcl cap 40 mg ................ 94 ziprasidone hcl cap 60 mg ................ 94 ziprasidone hcl cap 80 mg ................ 94 ZIPSOR CAP 25MG ............................. 4 ZIRGAN GEL 0.15% ........................ 217 ZITHRANOL SHA 1% ....................... 203 ZMAX SUS 2GM ............................... 21 ZN-DTPA SOL 1000MG .................... 122 ZOCOR TAB 10MG ........................... 57 ZOCOR TAB 20MG ........................... 57 ZOCOR TAB 40MG ........................... 57 ZOCOR TAB 5MG ............................. 57 ZOCOR TAB 80MG ........................... 57 ZOFRAN INJ 40/20ML ...................... 141 ZOFRAN SOL 4MG/5ML .................... 141 ZOFRAN TAB 4MG ........................... 141 ZOFRAN TAB 4MG ODT .................... 141 ZOFRAN TAB 8MG ........................... 141 ZOFRAN TAB 8MG ODT .................... 141 ZOHYDRO ER CAP 10MG ................... 16 ZOHYDRO ER CAP 15MG ................... 16 ZOHYDRO ER CAP 20MG ................... 16 ZOHYDRO ER CAP 30MG ................... 16 ZOHYDRO ER CAP 40MG ................... 16 ZOHYDRO ER CAP 50MG ................... 16 ZOLINZA CAP 100MG ....................... 45 zolmitriptan orally disintegrating tab 2.5 mg ............................................... 106 zolmitriptan orally disintegrating tab 5 mg ............................................... 106 zolmitriptan tab 2.5 mg ................... 106 zolmitriptan tab 5 mg ...................... 106 ZOLOFT CON 20MG/ML..................... 85 ZOLOFT TAB 100MG ......................... 85 ZOLOFT TAB 25MG .......................... 85 ZOLOFT TAB 50MG .......................... 85 zolpidem tartrate tab 10 mg ............. 104 zolpidem tartrate tab 5 mg .............. 104 zolpidem tartrate tab er 12.5 mg ...... 104 zolpidem tartrate tab er 6.25 mg ...... 104 ZOLPIMIST SPR 5MG ....................... 104 ZOMACTON INJ 10MG ..................... 133 ZOMACTON INJ 5MG ....................... 133 ZOMIG SPR 2.5MG .......................... 106 ZOMIG SPR 5MG ............................ 106 ZOMIG TAB 2.5MG .......................... 106 ZOMIG TAB 5MG ............................ 106

316

ZOMIG ZMT TAB 2.5 MG .................. 106 ZOMIG ZMT TAB 5MG ..................... 106 ZONEGRAN CAP 100MG..................... 79 ZONEGRAN CAP 25MG ...................... 79 zonisamide cap 100 mg ..................... 79 zonisamide cap 25 mg ...................... 79 zonisamide cap 50 mg ...................... 79 ZONTIVITY TAB 2.08MG .................. 162 zoo friends chw extra c ................... 185 zoo friends chw gummies ................ 185 zoo friends chw pls iron ................... 185 ZORBTIVE INJ 8.8MG ...................... 133 ZORTRESS TAB 0.25MG .................. 167 ZORTRESS TAB 0.5MG .................... 167 ZORTRESS TAB 0.75MG .................. 167 ZORVOLEX CAP 18MG ........................ 4 ZORVOLEX CAP 35MG ........................ 4 ZOSYN INJ 2-0.25GM ........................ 23 ZOSYN INJ 3-0.375G ........................ 24 ZOSYN INJ 36-4.5GM ........................ 24 ZOSYN INJ 4-0.5GM ......................... 24 ZOSYN SOL 2-0.25GM ....................... 24 ZOSYN SOL 3-0.375G ....................... 24 ZOSYN SOL 4-0.50GM ....................... 24 zovia 1/35e tab .............................. 126 zovia 1/50e tab .............................. 126 ZOVIRAX CAP 200MG ........................ 33 ZOVIRAX CRE 5% .......................... 211 ZOVIRAX OIN 5% ........................... 211 ZOVIRAX SUS 200/5ML ..................... 33 ZOVIRAX TAB 400MG ........................ 33 ZOVIRAX TAB 800MG ........................ 33 ZUBSOLV SUB 0.7-0.18 .................. 111 ZUBSOLV SUB 1.4-0.36 .................. 111 ZUBSOLV SUB 11.4-2.9 .................. 111 ZUBSOLV SUB 2.9-0.71 .................. 111

ZUBSOLV SUB 5.7-1.4 .................... 111 ZUBSOLV SUB 8.6-2.1 .................... 111 ZUPLENZ MIS 4MG ......................... 141 ZUPLENZ MIS 8MG ......................... 141 ZURAMPIC TAB 200MG ....................... 1 ZYBAN TAB 150MG SR .................... 112 ZYCLARA CRE 3.75% ...................... 201 ZYCLARA PUMP CRE 2.5% ............... 201 ZYDELIG TAB 100MG ....................... 41 ZYDELIG TAB 150MG ....................... 41 ZYFLO CR TAB 600MG ..................... 193 ZYFLO TAB 600MG .......................... 193 ZYKADIA CAP 150MG ....................... 42 ZYLET SUS 0.5-0.3% ...................... 215 ZYMAXID SOL 0.5% ........................ 216 ZYNCOF SYP 20-400/5 .................... 190 ZYPREXA INJ 10MG .......................... 94 ZYPREXA RELP INJ 210MG ................ 94 ZYPREXA RELP INJ 300MG ................ 94 ZYPREXA RELP INJ 405MG ................ 94 ZYPREXA TAB 10MG ......................... 94 ZYPREXA TAB 15MG ......................... 94 ZYPREXA TAB 2.5MG ........................ 94 ZYPREXA TAB 20MG ......................... 94 ZYPREXA TAB 5MG .......................... 94 ZYPREXA TAB 7.5MG ........................ 94 ZYPREXA ZYDI TAB 10MG ................. 94 ZYPREXA ZYDI TAB 15MG ................. 94 ZYPREXA ZYDI TAB 20MG ................. 94 ZYPREXA ZYDI TAB 5MG ................... 94 ZYRTEC ALLGY TAB 10MG ................ 187 ZYTIGA TAB 250MG ......................... 38 ZYVOX SOL 2MG/ML ........................ 36 ZZZQUIL CAP 25MG ........................ 104 ZZZQUIL LIQ 50MG/30 .................... 104

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Preferred Drug List - Passportpassporthealthplan.com/wp-content/uploads/2014/12/Evolent-Passport... · If a drug is not covered by Passport or is not listed on our Preferred Drug