1
HMSA QUEST Integration Managed Medicaid
Formulary
(Effective 02/01/2020)
LEGEND
AL Age Limit
OB7 Initial prescriptions for opioids and benzodiazepines being filled
concurrently will be limited to a 7 day supply
OTC Over the Counter
PA Prior Authorization
QL Quantity Limit
SP Specialty Drug
ST Step Therapy
120 MME Cumulative morphine milligram equivalent (MME) opioid threshold is 120 MME per day
+ Indicates both the generic is covered as well as the brand-name product equivalent, with dispense as written code 1 (DAW 1). This
includes State-mandated drug classes (HIV and AIDS, Antidepressants, Antipsychotics, Antianxiety Agents, and
Immunosuppressants).
lowercase lowercase type indicates generic availability
UPPERCASE UPPERCASE type indicates brand availability
NOTE
The status of a drug on this list is current as of the date of this publication.
The list serves as a guide to product selection for our providers and members. The list is subject to change. Participating pharmacies have the most
up-to-date formulary information at the time prescriptions are filled. New drugs, strengths, forms, and/or therapeutic categories introduced in the
marketplace will be reflected in the formulary, as applicable, following the completion of HMSA’s review process.
Not all generic drugs may be listed.
Coverage of a drug will depend on your drug plan.
HMSA's mission is to provide the people of Hawaii access to a sustainable, quality health care
system that improves the overall health and well-being of our state.
2
HMSA CENTERS
Convenient evening and Saturday hours:
HMSA Center @ Honolulu 818 Keeaumoku St.
Monday through Friday, 8 a.m. - 6 p.m. | Saturday, 9 a.m. - 2 p.m.
HMSA Center @ Pearl City
Pearl City Gateway | 1132 Kuala St., Suite 400 Monday through Friday, 9 a.m. - 7 p.m. | Saturday, 9 a.m. - 2 p.m.
HMSA Center @ Hilo
Waiakea Center | 303A E. Makaala St. Monday through Friday, 9 a.m. - 7 p.m. | Saturday, 9 a.m. - 2 p.m.
OFFICES Visit your local HMSA office Monday through Friday, 8 a.m. - 4 p.m.:
Kailua-Kona, Hawaii Island | 75-1029 Henry St., Suite 301 |
Phone: 329-5291
Kahului, Maui | 33 Lono Ave., Suite 350 | Phone: 871-6295
Lihue, Kauai | 4366 Kukui Grove St., Suite 103 | Phone: 245-3393
PHONE
948-6372 on Oahu
If you are calling from the U.S. Mainland, please call 1 (800) 776-4672. If you need to call a local Hawaii telephone number from the Mainland, the area code
is 808.
Check hmsa.com/contact for our holiday schedule.
The information contained in this document is proprietary. The information may
not be copied in whole or in part without written permission. ©2019. All rights reserved.
This document contains references to brand-name prescription drugs that are
trademarks or registered trademarks of pharmaceutical manufacturers.
Plan member privacy is important to us. Our employees are trained regarding the
appropriate way to handle members' private health information.
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
3
Drug Name Requirements/Limits
ANALGESICS COX-II INHIBITORS
celecoxib cap 50 mg ST (Must have recently been
on 30 days supply of NSAID
or GI protectant OR be
taking a drug that could
cause adverse GI events)
celecoxib cap 100 mg ST (Must have recently been
on 30 days supply of NSAID or GI protectant OR be
taking a drug that could
cause adverse GI events)
celecoxib cap 200 mg ST (Must have recently been
on 30 days supply of NSAID
or GI protectant OR be
taking a drug that could
cause adverse GI events)
celecoxib cap 400 mg ST (Must have recently been
on 30 days supply of NSAID
or GI protectant OR be taking a drug that could
cause adverse GI events)
GOUT allopurinol tab 100 mg
allopurinol tab 300 mg
colchicine tab 0.6 mg QL (30 per month)
probenecid tab 500 mg
NON-OPIOID ANALGESICS acetaminophen cap 500 mg OTC
acetaminophen chew tab 80 mg OTC
acetaminophen chew tab 160 mg OTC
acetaminophen disintegrating tab 80 mg OTC
acetaminophen disintegrating tab 160 mg OTC
acetaminophen elixir 160 mg/5ml OTC
acetaminophen liquid 160 mg/5ml OTC
acetaminophen liquid 167 mg/5ml OTC
acetaminophen soln 160 mg/5ml OTC
acetaminophen suppos 120 mg OTC
acetaminophen suppos 325 mg OTC
acetaminophen suppos 650 mg OTC
acetaminophen susp 80 mg/0.8ml OTC
acetaminophen susp 160 mg/5ml OTC
acetaminophen tab 325 mg OTC
acetaminophen tab 500 mg OTC
acetaminophen tab er 650 mg OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
4
Drug Name Requirements/Limits
butalbital-acetaminophen-caffeine cap 50-325-40
mg
QL (60 per month)
butalbital-acetaminophen-caffeine tab 50-325-40
mg
QL (60 per month)
butalbital-aspirin-caffeine cap 50-325-40 mg QL (60 per month)
FEVERALL INF SUP 80MG OTC
FEVERALL SUP 325MG OTC
NSAIDS diclofenac potassium tab 50 mg
diclofenac sodium tab delayed release 25 mg
diclofenac sodium tab delayed release 50 mg
diclofenac sodium tab delayed release 75 mg
diclofenac sodium tab er 24hr 100 mg
diflunisal tab 500 mg
etodolac cap 200 mg
etodolac cap 300 mg
etodolac tab 400 mg
etodolac tab 500 mg
etodolac tab er 24hr 400 mg
etodolac tab er 24hr 500 mg
etodolac tab er 24hr 600 mg
flurbiprofen tab 50 mg
flurbiprofen tab 100 mg
ibuprofen cap 200 mg OTC
ibuprofen chew tab 100 mg OTC
ibuprofen susp 40 mg/ml OTC
ibuprofen susp 100 mg/5ml
ibuprofen susp 100 mg/5ml OTC
ibuprofen tab 100 mg OTC
ibuprofen tab 200 mg OTC
ibuprofen tab 400 mg
ibuprofen tab 600 mg
ibuprofen tab 800 mg
ketorolac tromethamine tab 10 mg QL (20 per month)
meloxicam tab 7.5 mg
meloxicam tab 15 mg
nabumetone tab 500 mg
nabumetone tab 750 mg
naproxen sodium cap 220 mg OTC
naproxen sodium tab 220 mg OTC
naproxen sodium tab 275 mg
naproxen sodium tab 550 mg
naproxen susp 125 mg/5ml
naproxen tab 250 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
5
Drug Name Requirements/Limits
naproxen tab 375 mg
naproxen tab 500 mg
naproxen tab ec 375 mg
naproxen tab ec 500 mg
oxaprozin tab 600 mg
sulindac tab 150 mg
sulindac tab 200 mg
NSAIDS, TOPICAL diclofenac sodium gel 1% QL (500 grams per month)
OPIOID ANALGESICS acetaminophen w/ codeine soln 120-12 mg/5ml OB7, 120 MME, QL (5000
mL per month)
acetaminophen w/ codeine tab 300-15 mg OB7, 120 MME, QL (400 per
month)
acetaminophen w/ codeine tab 300-30 mg OB7, 120 MME, QL (400 per
month)
acetaminophen w/ codeine tab 300-60 mg OB7, 120 MME, QL (400 per month)
fentanyl td patch 72hr 12 mcg/hr OB7, 120 MME, QL (20 per month)
fentanyl td patch 72hr 25 mcg/hr OB7, 120 MME, QL (20 per
month)
fentanyl td patch 72hr 50 mcg/hr OB7, 120 MME, QL (20 per
month)
fentanyl td patch 72hr 75 mcg/hr OB7, 120 MME
fentanyl td patch 72hr 100 mcg/hr OB7, 120 MME
hydrocodone-acetaminophen soln 7.5-325
mg/15ml
OB7, 120 MME, QL (5540
mL per month)
hydrocodone-acetaminophen tab 5-325 mg OB7, 120 MME, QL (375 per
month)
hydrocodone-acetaminophen tab 7.5-325 mg OB7, 120 MME, QL (375 per
month)
hydrocodone-acetaminophen tab 10-325 mg OB7, 120 MME, QL (240 per
month)
hydromorphone hcl tab 2 mg OB7, 120 MME, QL (180 per
month)
hydromorphone hcl tab 4 mg OB7, 120 MME, QL (180 per month)
hydromorphone hcl tab 8 mg OB7, 120 MME, QL (90 per month)
methadone hcl tab 5 mg OB7, 120 MME
methadone hcl tab 10 mg OB7, 120 MME
morphine sulfate oral soln 10 mg/5ml OB7, 120 MME, QL (900 mL
per month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
6
Drug Name Requirements/Limits
morphine sulfate oral soln 20 mg/5ml OB7, 120 MME, QL (900 mL
per month)
morphine sulfate oral soln 100 mg/5ml (20 mg/ml) OB7, 120 MME, QL (180 mL
per month)
morphine sulfate tab 15 mg OB7, 120 MME, QL (180 per
month)
morphine sulfate tab 30 mg OB7, 120MME, QL (120 per
month)
morphine sulfate tab er 15 mg OB7, 120 MME, QL (120 per
month)
morphine sulfate tab er 30 mg OB7, 120 MME, QL (120 per month)
morphine sulfate tab er 60 mg OB7, 120 MME, QL (60 per month)
morphine sulfate tab er 100 mg OB7, 120 MME
morphine sulfate tab er 200 mg OB7, 120 MME
oxycodone hcl cap 5 mg OB7, 120 MME, QL (180 per
month)
oxycodone hcl conc 100 mg/5ml (20 mg/ml) OB7, 120 MME, QL (120 mL
per month)
oxycodone hcl soln 5 mg/5ml OB7, 120 MME, QL (180 mL
per month)
oxycodone hcl tab 5 mg OB7, 120 MME, QL (180 per
month)
oxycodone hcl tab 10 mg OB7, 120 MME, QL (180 per
month)
oxycodone hcl tab 15 mg OB7, 120 MME, QL (150 per
month)
oxycodone hcl tab 20 mg OB7, 120 MME, QL (120 per month)
oxycodone hcl tab 30 mg OB7, 120 MME, QL (60 per month)
oxycodone w/ acetaminophen tab 2.5-325 mg OB7, 120 MME, QL (375 per
month)
oxycodone w/ acetaminophen tab 5-325 mg OB7, 120 MME, QL (375 per
month)
oxycodone w/ acetaminophen tab 7.5-325 mg OB7, 120 MME, QL (300 per
month)
oxycodone w/ acetaminophen tab 10-325 mg OB7, 120 MME, QL (240 per
month)
oxycodone-aspirin tab 4.8355-325 mg OB7, 120 MME, QL (308 per
month)
tramadol hcl tab 50 mg OB7, 120 MME, QL (240 per
month)
tramadol hcl tab er 24hr 100 mg OB7, 120 MME, QL (30 per
month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
7
Drug Name Requirements/Limits
tramadol hcl tab er 24hr 200 mg OB7, 120 MME, QL (30 per
month)
tramadol hcl tab er 24hr 300 mg OB7, 120 MME, QL (30 per
month)
tramadol hcl tab er 24hr biphasic release 300 mg OB7, 120 MME, QL (30 per
month)
tramadol-acetaminophen tab 37.5-325 mg OB7, 120 MME, QL (240 per
month)
ANTI-INFECTIVES AMINOGLYCOSIDES
neomycin sulfate tab 500 mg
ANTIBACTERIALS, CEPHALOSPORINS, First Generation cefadroxil cap 500 mg
cefadroxil for susp 250 mg/5ml
cefadroxil for susp 500 mg/5ml
cefadroxil tab 1 gm
cephalexin cap 250 mg
cephalexin cap 500 mg
cephalexin cap 750 mg
cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
cephalexin tab 250 mg
cephalexin tab 500 mg
ANTIBACTERIALS, CEPHALOSPORINS, Second Generation cefprozil for susp 125 mg/5ml
cefprozil for susp 250 mg/5ml
cefprozil tab 250 mg
cefprozil tab 500 mg
cefuroxime axetil tab 250 mg
cefuroxime axetil tab 500 mg
ANTIBACTERIALS, CEPHALOSPORINS, Third Generation cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml
azithromycin for susp 200 mg/5ml
azithromycin powd pack for susp 1 gm
azithromycin tab 250 mg
azithromycin tab 500 mg
azithromycin tab 600 mg
clarithromycin for susp 125 mg/5ml
clarithromycin for susp 250 mg/5ml
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
8
Drug Name Requirements/Limits
clarithromycin tab 250 mg
clarithromycin tab 500 mg
clarithromycin tab er 24hr 500 mg
erythromycin ethylsuccinate for susp 200 mg/5ml
erythromycin ethylsuccinate tab 400 mg
erythromycin stearate tab 250 mg
erythromycin tab 250 mg
erythromycin tab 500 mg
erythromycin tab delayed release 250 mg
erythromycin tab delayed release 333 mg
erythromycin tab delayed release 500 mg
erythromycin w/ delayed release particles cap 250
mg
ANTIBACTERIALS, FLUOROQUINOLONES ciprofloxacin hcl tab 100 mg (base equiv)
ciprofloxacin hcl tab 250 mg (base equiv)
ciprofloxacin hcl tab 500 mg (base equiv)
ciprofloxacin hcl tab 750 mg (base equiv)
levofloxacin oral soln 25 mg/ml
levofloxacin tab 250 mg
levofloxacin tab 500 mg
levofloxacin tab 750 mg
ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab 200-28.5 mg
amoxicillin & k clavulanate chew tab 400-57 mg
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
amoxicillin & k clavulanate for susp 400-57
mg/5ml
amoxicillin & k clavulanate for susp 600-42.9
mg/5ml
amoxicillin & k clavulanate tab 250-125 mg
amoxicillin & k clavulanate tab 500-125 mg
amoxicillin & k clavulanate tab 875-125 mg
amoxicillin (trihydrate) cap 250 mg
amoxicillin (trihydrate) cap 500 mg
amoxicillin (trihydrate) chew tab 125 mg
amoxicillin (trihydrate) chew tab 250 mg
amoxicillin (trihydrate) for susp 125 mg/5ml
amoxicillin (trihydrate) for susp 200 mg/5ml
amoxicillin (trihydrate) for susp 250 mg/5ml
amoxicillin (trihydrate) for susp 400 mg/5ml
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
9
Drug Name Requirements/Limits
amoxicillin (trihydrate) tab 500 mg
amoxicillin (trihydrate) tab 875 mg
ampicillin cap 500 mg
AUGMENTIN SUS 125/5ML
dicloxacillin sodium cap 250 mg
dicloxacillin sodium cap 500 mg
penicillin v potassium for soln 125 mg/5ml
penicillin v potassium for soln 250 mg/5ml
penicillin v potassium tab 250 mg
penicillin v potassium tab 500 mg
ANTIBACTERIALS, SULFONAMIDES SULFADIAZINE TAB 500MG
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml
sulfamethoxazole-trimethoprim tab 400-80 mg
sulfamethoxazole-trimethoprim tab 800-160 mg
ANTIBACTERIALS, TETRACYCLINES demeclocycline hcl tab 150 mg
demeclocycline hcl tab 300 mg
doxycycline hyclate cap 50 mg
doxycycline hyclate cap 100 mg
doxycycline hyclate tab 20 mg
doxycycline hyclate tab 100 mg
doxycycline monohydrate for susp 25 mg/5ml
minocycline hcl cap 50 mg
minocycline hcl cap 75 mg
minocycline hcl cap 100 mg
tetracycline hcl cap 250 mg
tetracycline hcl cap 500 mg
ANTIFUNGALS clotrimazole troche 10 mg
fluconazole for susp 10 mg/ml
fluconazole for susp 40 mg/ml
fluconazole tab 50 mg
fluconazole tab 100 mg
fluconazole tab 150 mg
fluconazole tab 200 mg
griseofulvin microsize susp 125 mg/5ml
griseofulvin ultramicrosize tab 125 mg
griseofulvin ultramicrosize tab 250 mg
itraconazole cap 100 mg PA
nystatin oral powder
nystatin susp 100000 unit/ml
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
10
Drug Name Requirements/Limits
nystatin tab 500000 unit
terbinafine hcl tab 250 mg QL (1 tab per day; 90 days
per year)
voriconazole for susp 40 mg/ml PA
voriconazole tab 50 mg PA
voriconazole tab 200 mg PA
ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg QL (23 per 6 months)
atovaquone-proguanil hcl tab 250-100 mg QL (23 per 6 months)
chloroquine phosphate tab 250 mg QL (8 per 6 months)
chloroquine phosphate tab 500 mg QL (8 per 6 months)
mefloquine hcl tab 250 mg QL (8 per 6 months)
ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST TAB 150MG SP
ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine tab 600-300 mg SP
abacavir sulfate-lamivudine-zidovudine tab 300-
150-300 mg
SP
ATRIPLA TAB SP
BIKTARVY TAB SP
CIMDUO TAB 300-300 SP
COMBIVIR TAB 150-300 SP; +
COMPLERA TAB SP
DESCOVY TAB 200/25 SP
EPZICOM TAB 600-300 SP; +
EVOTAZ TAB 300-150 SP
GENVOYA TAB SP
lamivudine-zidovudine tab 150-300 mg SP
ODEFSEY TAB SP
PREZCOBIX TAB 800-150 SP
STRIBILD TAB SP
SYMFI LO TAB SP
SYMFI TAB SP
SYMTUZA TAB SP
TRIUMEQ TAB SP
TRIZIVIR TAB SP; +
TRUVADA TAB 100-150 SP
TRUVADA TAB 133-200 SP
TRUVADA TAB 167-250 SP
TRUVADA TAB 200-300 SP
ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML SP
SELZENTRY TAB 25MG SP
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
11
Drug Name Requirements/Limits
SELZENTRY TAB 75MG SP
SELZENTRY TAB 150MG SP
SELZENTRY TAB 300MG SP
ANTIRETROVIRALS, FUSION INHIBITORS FUZEON INJ 90MG SP
ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG SP
ISENTRESS CHW 100MG SP
ISENTRESS HD TAB 600MG SP
ISENTRESS POW 100MG SP
ISENTRESS TAB 400MG SP
TIVICAY TAB 10MG SP
TIVICAY TAB 25MG SP
TIVICAY TAB 50MG SP
ANTIRETROVIRALS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE
INHIBITORS EDURANT TAB 25MG SP
efavirenz cap 50 mg SP
efavirenz cap 200 mg SP
efavirenz tab 600 mg SP
INTELENCE TAB 25MG SP
INTELENCE TAB 100MG SP
INTELENCE TAB 200MG SP
nevirapine susp 50 mg/5ml SP
nevirapine tab 200 mg SP
nevirapine tab er 24hr 100 mg SP
nevirapine tab er 24hr 400 mg SP
RESCRIPTOR TAB 200MG SP
SUSTIVA CAP 50MG SP; +
SUSTIVA CAP 200MG SP; +
SUSTIVA TAB 600MG SP; +
VIRAMUNE SUS 50MG/5ML SP; +
VIRAMUNE TAB 200MG SP; +
VIRAMUNE XR TAB 400MG SP; +
ANTIRETROVIRALS, NUCLEOSIDE REVERSE TRANSCRIPTASE
INHIBITORS abacavir sulfate soln 20 mg/ml (base equiv) SP
abacavir sulfate tab 300 mg (base equiv) SP
didanosine delayed release capsule 200 mg SP
didanosine delayed release capsule 250 mg SP
didanosine delayed release capsule 400 mg SP
EMTRIVA CAP 200MG SP
EMTRIVA SOL 10MG/ML SP
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
12
Drug Name Requirements/Limits
EPIVIR SOL 10MG/ML SP; +
EPIVIR TAB 150MG SP; +
EPIVIR TAB 300MG SP; +
lamivudine oral soln 10 mg/ml SP
lamivudine tab 150 mg SP
lamivudine tab 300 mg SP
RETROVIR CAP 100MG SP; +
RETROVIR SYP 50MG/5ML SP; +
stavudine cap 15 mg SP
stavudine cap 20 mg SP
stavudine cap 30 mg SP
stavudine cap 40 mg SP
VIDEX EC CAP 125MG SP
VIDEX EC CAP 200MG SP; +
VIDEX EC CAP 250MG SP; +
VIDEX EC CAP 400MG SP; +
VIDEX SOL 2GM SP
ZIAGEN SOL 20MG/ML SP; +
ZIAGEN TAB 300MG SP; +
zidovudine cap 100 mg SP
zidovudine syrup 10 mg/ml SP
zidovudine tab 300 mg SP
ANTIRETROVIRALS, NUCLEOTIDE REVERSE TRANSCRIPTASE
INHIBITORS tenofovir disoproxil fumarate tab 300 mg SP
VIREAD POW 40MG/GM SP
VIREAD TAB 150MG SP
VIREAD TAB 200MG SP
VIREAD TAB 250MG SP
VIREAD TAB 300MG SP; +
ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG SP
APTIVUS SOL SP
atazanavir sulfate cap 150 mg (base equiv) SP
atazanavir sulfate cap 200 mg (base equiv) SP
atazanavir sulfate cap 300 mg (base equiv) SP
CRIXIVAN CAP 200MG SP
CRIXIVAN CAP 400MG SP
fosamprenavir calcium tab 700 mg (base equiv) SP
INVIRASE TAB 500MG SP
KALETRA SOL SP; +
KALETRA TAB 100-25MG SP
KALETRA TAB 200-50MG SP
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
13
Drug Name Requirements/Limits
LEXIVA SUS 50MG/ML SP
LEXIVA TAB 700MG SP; +
lopinavir-ritonavir soln 400-100 mg/5ml (80-20
mg/ml)
SP
NORVIR POW 100MG SP
NORVIR SOL 80MG/ML SP
NORVIR TAB 100MG SP; +
PREZISTA SUS 100MG/ML SP
PREZISTA TAB 75MG SP
PREZISTA TAB 150MG SP
PREZISTA TAB 600MG SP
PREZISTA TAB 800MG SP
REYATAZ CAP 150MG SP; +
REYATAZ CAP 200MG SP; +
REYATAZ CAP 300MG SP; +
REYATAZ POW 50MG SP
ritonavir tab 100 mg SP
VIRACEPT TAB 250MG SP
VIRACEPT TAB 625MG SP
ANTITUBERCULAR AGENTS ethambutol hcl tab 100 mg
ethambutol hcl tab 400 mg
isoniazid syrup 50 mg/5ml AL (covered for ages 18 and
under; refer to Dept of
Health if > 18 years old)
isoniazid tab 100 mg AL (covered for ages 18 and
under; refer to Dept of
Health if > 18 years old)
isoniazid tab 300 mg AL (covered for ages 18 and
under; refer to Dept of
Health if > 18 years old)
pyrazinamide tab 500 mg
rifampin cap 150 mg
rifampin cap 300 mg
ANTIVIRALS, CYTOMEGALOVIRUS AGENTS valganciclovir hcl for soln 50 mg/ml (base equiv)
valganciclovir hcl tab 450 mg (base equivalent)
ANTIVIRALS, HEPATITIS AGENTS, Hepatitis B adefovir dipivoxil tab 10 mg
BARACLUDE SOL
entecavir tab 0.5 mg
entecavir tab 1 mg
lamivudine tab 100 mg (hbv)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
14
Drug Name Requirements/Limits
ANTIVIRALS, HEPATITIS AGENTS, Hepatitis C MAVYRET TAB 100-40MG SP, PA; for genotypes 1, 2,
3, 4, 5, 6
RIBAPAK PAK 800/DAY SP, PA
RIBAPAK PAK 1200/DAY SP, PA
RIBAPAK TAB 600/DAY SP, PA
RIBAPAK TAB 1000/DAY SP, PA
ribasphere cap 200mg SP, PA
ribasphere tab 200mg SP, PA
RIBASPHERE TAB 400MG SP, PA
ribasphere tab 600mg SP, PA
ribavirin cap 200 mg SP, PA
ribavirin tab 200 mg SP, PA
ANTIVIRALS, HERPES AGENTS acyclovir cap 200 mg
acyclovir susp 200 mg/5ml
acyclovir tab 400 mg
acyclovir tab 800 mg
famciclovir tab 125 mg
famciclovir tab 250 mg
famciclovir tab 500 mg
valacyclovir hcl tab 1 gm
valacyclovir hcl tab 500 mg
ANTIVIRALS, INFLUENZA AGENTS oseltamivir phosphate cap 30 mg (base equiv) QL (56 caps per 6 months)
oseltamivir phosphate cap 45 mg (base equiv) QL (28 caps per 6 months)
oseltamivir phosphate cap 75 mg (base equiv) QL (28 caps per 6 months)
oseltamivir phosphate for susp 6 mg/ml (base equiv)
QL (360 mL per 6 months)
MISCELLANEOUS atovaquone susp 750 mg/5ml
clindamycin hcl cap 150 mg
clindamycin hcl cap 300 mg
clindamycin palmitate hcl for soln 75 mg/5ml
(base equiv)
dapsone tab 25 mg
dapsone tab 100 mg
DARAPRIM TAB 25MG
EMVERM CHW 100MG QL (12 tabs per 365 days)
ivermectin tab 3 mg
linezolid for susp 100 mg/5ml PA
linezolid tab 600 mg PA
metronidazole cap 375 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
15
Drug Name Requirements/Limits
metronidazole tab 250 mg
metronidazole tab 500 mg
nitrofurantoin macrocrystalline cap 25 mg
nitrofurantoin macrocrystalline cap 50 mg
nitrofurantoin macrocrystalline cap 100 mg
nitrofurantoin monohydrate macrocrystalline cap
100 mg
nitrofurantoin susp 25 mg/5ml
PINWORM TAB MEDICINE OTC
pyrantel pamoate susp 144 mg/ml (50 mg/ml base
equiv)
OTC
rifabutin cap 150 mg
trimethoprim tab 100 mg
vancomycin hcl cap 125 mg (base equivalent) QL (80 caps per 10 days)
vancomycin hcl cap 250 mg (base equivalent) QL (80 caps per 10 days)
ANTINEOPLASTIC AGENTS ALKYLATING AGENTS
cyclophosphamide cap 25 mg
cyclophosphamide cap 50 mg
GLEOSTINE CAP 10MG
GLEOSTINE CAP 40MG
GLEOSTINE CAP 100MG
LEUKERAN TAB 2MG
melphalan tab 2 mg
MYLERAN TAB 2MG
temozolomide cap 5 mg SP, PA
temozolomide cap 20 mg SP, PA
temozolomide cap 100 mg SP, PA
temozolomide cap 140 mg SP, PA
temozolomide cap 180 mg SP, PA
temozolomide cap 250 mg SP, PA
ANTIMETABOLITES capecitabine tab 150 mg SP, PA
capecitabine tab 500 mg SP, PA
mercaptopurine tab 50 mg
methotrexate sodium tab 2.5 mg (base equiv)
HORMONAL ANTINEOPLASTICS, ANTIANDROGENS abiraterone acetate tab 250 mg SP, PA
bicalutamide tab 50 mg
flutamide cap 125 mg
HORMONAL ANTINEOPLASTICS, ANTIESTROGENS tamoxifen citrate tab 10 mg (base equivalent)
tamoxifen citrate tab 20 mg (base equivalent)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
16
Drug Name Requirements/Limits
toremifene citrate tab 60 mg (base equivalent)
HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole tab 1 mg
exemestane tab 25 mg
letrozole tab 2.5 mg
HORMONAL ANTINEOPLASTICS, PROGESTINS megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
IMMUNOMODULATORS REVLIMID CAP 2.5MG SP, PA
REVLIMID CAP 5MG SP, PA
REVLIMID CAP 10MG SP, PA
REVLIMID CAP 15MG SP, PA
REVLIMID CAP 20MG SP, PA
REVLIMID CAP 25MG SP, PA
KINASE INHIBITORS AFINITOR TAB 2.5MG SP, PA
AFINITOR TAB 5MG SP, PA
AFINITOR TAB 7.5MG SP, PA
AFINITOR TAB 10MG SP, PA
ALECENSA CAP 150MG SP, PA
CABOMETYX TAB 20MG SP, QL (30 per month), PA
CABOMETYX TAB 40MG SP, QL (30 per month), PA
CABOMETYX TAB 60MG SP, QL (30 per month), PA
CALQUENCE CAP 100MG SP, PA
CAPRELSA TAB 100MG SP, PA
CAPRELSA TAB 300MG SP, PA
COMETRIQ KIT 60MG SP, PA
COMETRIQ KIT 100MG SP, PA
COMETRIQ KIT 140MG SP, PA
erlotinib hcl tab 25 mg (base equivalent) SP, PA
erlotinib hcl tab 100 mg (base equivalent) SP, PA
erlotinib hcl tab 150 mg (base equivalent) SP, PA
GILOTRIF TAB 20MG SP, PA
GILOTRIF TAB 30MG SP, PA
GILOTRIF TAB 40MG SP, PA
IBRANCE CAP 75MG SP, PA
IBRANCE CAP 100MG SP, PA
IBRANCE CAP 125MG SP, PA
IMBRUVICA CAP 70MG SP, PA
IMBRUVICA CAP 140MG SP, PA
IMBRUVICA TAB 140MG SP, PA
IMBRUVICA TAB 280MG SP, PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
17
Drug Name Requirements/Limits
IMBRUVICA TAB 420MG SP, PA
IMBRUVICA TAB 560MG SP, PA
INLYTA TAB 1MG SP, PA
INLYTA TAB 5MG SP, PA
JAKAFI TAB 5MG SP, PA
JAKAFI TAB 10MG SP, PA
JAKAFI TAB 15MG SP, PA
JAKAFI TAB 20MG SP, PA
JAKAFI TAB 25MG SP, PA
LENVIMA CAP 4MG SP, PA
LENVIMA CAP 8 MG SP, PA
LENVIMA CAP 10 MG SP, PA
LENVIMA CAP 12MG SP, PA
LENVIMA CAP 14 MG SP, PA
LENVIMA CAP 18 MG SP, PA
LENVIMA CAP 20 MG SP, PA
LENVIMA CAP 24 MG SP, PA
LORBRENA TAB 25MG SP, PA
LORBRENA TAB 100MG SP, PA
MEKINIST TAB 0.5MG SP, PA
MEKINIST TAB 2MG SP, PA
NEXAVAR TAB 200MG SP, PA
RYDAPT CAP 25MG SP, PA
STIVARGA TAB 40MG SP, PA
SUTENT CAP 12.5MG SP, PA
SUTENT CAP 25MG SP, PA
SUTENT CAP 37.5MG SP, PA
SUTENT CAP 50MG SP, PA
TAFINLAR CAP 50MG SP, PA
TAFINLAR CAP 75MG SP, PA
TYKERB TAB 250MG SP, PA
VITRAKVI CAP 25MG SP, PA
VITRAKVI CAP 100MG SP, PA
VITRAKVI SOL 20MG/ML SP, PA
VOTRIENT TAB 200MG SP, PA
ZELBORAF TAB 240MG SP, PA
ZYDELIG TAB 100MG SP, PA
ZYDELIG TAB 150MG SP, PA
ZYKADIA CAP 150MG SP, PA
ZYKADIA TAB 150MG SP, PA
KINASE INHIBITORS FOR CML imatinib mesylate tab 100 mg (base equivalent) SP, PA
imatinib mesylate tab 400 mg (base equivalent) SP, PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
18
Drug Name Requirements/Limits
MISCELLANEOUS bexarotene cap 75 mg SP, PA
ERIVEDGE CAP 150MG SP, PA
etoposide cap 50 mg
FARYDAK CAP 10MG SP, PA
FARYDAK CAP 15MG SP, PA
FARYDAK CAP 20MG SP, PA
hydroxyurea cap 500 mg
IDHIFA TAB 50MG SP, PA
IDHIFA TAB 100MG SP, PA
leucovorin calcium tab 5 mg
leucovorin calcium tab 10 mg
leucovorin calcium tab 15 mg
leucovorin calcium tab 25 mg
LYNPARZA TAB 100MG SP, PA
LYNPARZA TAB 150MG SP, PA
LYSODREN TAB 500MG
MATULANE CAP 50MG
RUBRACA TAB 200MG SP, PA
RUBRACA TAB 250MG SP, PA
RUBRACA TAB 300MG SP, PA
tretinoin cap 10 mg
VENCLEXTA TAB 10MG SP, PA
VENCLEXTA TAB 50MG SP, PA
VENCLEXTA TAB 100MG SP, PA
VENCLEXTA TAB START PK SP, PA
VISTOGARD PAK 10GM
ZEJULA CAP 100MG SP, PA
ZOLINZA CAP 100MG SP, PA
CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS
amlodipine besylate-benazepril hcl cap 2.5-10 mg
amlodipine besylate-benazepril hcl cap 5-10 mg
amlodipine besylate-benazepril hcl cap 5-20 mg
amlodipine besylate-benazepril hcl cap 5-40 mg
amlodipine besylate-benazepril hcl cap 10-20 mg
amlodipine besylate-benazepril hcl cap 10-40 mg
ACE INHIBITOR/DIURETIC COMBINATIONS benazepril & hydrochlorothiazide tab 5-6.25 mg
benazepril & hydrochlorothiazide tab 10-12.5 mg
benazepril & hydrochlorothiazide tab 20-12.5 mg
benazepril & hydrochlorothiazide tab 20-25 mg
captopril & hydrochlorothiazide tab 25-15 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
19
Drug Name Requirements/Limits
captopril & hydrochlorothiazide tab 25-25 mg
captopril & hydrochlorothiazide tab 50-15 mg
captopril & hydrochlorothiazide tab 50-25 mg
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg
enalapril maleate & hydrochlorothiazide tab 10-25 mg
fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg
fosinopril sodium & hydrochlorothiazide tab 20-
12.5 mg
lisinopril & hydrochlorothiazide tab 10-12.5 mg
lisinopril & hydrochlorothiazide tab 20-12.5 mg
lisinopril & hydrochlorothiazide tab 20-25 mg
quinapril-hydrochlorothiazide tab 10-12.5 mg
quinapril-hydrochlorothiazide tab 20-12.5 mg
quinapril-hydrochlorothiazide tab 20-25 mg
ACE INHIBITORS benazepril hcl tab 5 mg
benazepril hcl tab 10 mg
benazepril hcl tab 20 mg
benazepril hcl tab 40 mg
captopril tab 12.5 mg
captopril tab 25 mg
captopril tab 50 mg
captopril tab 100 mg
enalapril maleate tab 2.5 mg
enalapril maleate tab 5 mg
enalapril maleate tab 10 mg
enalapril maleate tab 20 mg
fosinopril sodium tab 10 mg
fosinopril sodium tab 20 mg
fosinopril sodium tab 40 mg
lisinopril tab 2.5 mg
lisinopril tab 5 mg
lisinopril tab 10 mg
lisinopril tab 20 mg
lisinopril tab 30 mg
lisinopril tab 40 mg
quinapril hcl tab 5 mg
quinapril hcl tab 10 mg
quinapril hcl tab 20 mg
quinapril hcl tab 40 mg
ramipril cap 1.25 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
20
Drug Name Requirements/Limits
ramipril cap 2.5 mg
ramipril cap 5 mg
ramipril cap 10 mg
trandolapril tab 1 mg
trandolapril tab 2 mg
trandolapril tab 4 mg
ADRENOLYTICS, CENTRAL clonidine hcl tab 0.1 mg
clonidine hcl tab 0.2 mg
clonidine hcl tab 0.3 mg
clonidine td patch weekly 0.1 mg/24hr
clonidine td patch weekly 0.2 mg/24hr
clonidine td patch weekly 0.3 mg/24hr
guanfacine hcl tab 1 mg
guanfacine hcl tab 2 mg
methyldopa tab 250 mg
methyldopa tab 500 mg
ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 mg
eplerenone tab 50 mg
spironolactone tab 25 mg
spironolactone tab 50 mg
spironolactone tab 100 mg
ALPHA BLOCKERS doxazosin mesylate tab 1 mg
doxazosin mesylate tab 2 mg
doxazosin mesylate tab 4 mg
doxazosin mesylate tab 8 mg
prazosin hcl cap 1 mg
prazosin hcl cap 2 mg
prazosin hcl cap 5 mg
terazosin hcl cap 1 mg (base equivalent)
terazosin hcl cap 2 mg (base equivalent)
terazosin hcl cap 5 mg (base equivalent)
terazosin hcl cap 10 mg (base equivalent)
ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC
COMBINATIONS irbesartan-hydrochlorothiazide tab 150-12.5 mg
irbesartan-hydrochlorothiazide tab 300-12.5 mg
losartan potassium & hydrochlorothiazide tab 50-12.5 mg
losartan potassium & hydrochlorothiazide tab 100-
12.5 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
21
Drug Name Requirements/Limits
losartan potassium & hydrochlorothiazide tab 100-
25 mg
valsartan-hydrochlorothiazide tab 80-12.5 mg
valsartan-hydrochlorothiazide tab 160-12.5 mg
valsartan-hydrochlorothiazide tab 160-25 mg
valsartan-hydrochlorothiazide tab 320-12.5 mg
valsartan-hydrochlorothiazide tab 320-25 mg
ANGIOTENSIN II RECEPTOR ANTAGONISTS irbesartan tab 75 mg
irbesartan tab 150 mg
irbesartan tab 300 mg
losartan potassium tab 25 mg
losartan potassium tab 50 mg
losartan potassium tab 100 mg
valsartan tab 40 mg
valsartan tab 80 mg
valsartan tab 160 mg
valsartan tab 320 mg
ANTIARRHYTHMICS amiodarone hcl tab 100 mg
amiodarone hcl tab 200 mg
amiodarone hcl tab 400 mg
BETAPACE AF TAB 80MG +
BETAPACE AF TAB 120MG +
BETAPACE AF TAB 160MG +
BETAPACE TAB 80MG +
BETAPACE TAB 120MG +
BETAPACE TAB 160MG +
disopyramide phosphate cap 100 mg
disopyramide phosphate cap 150 mg
dofetilide cap 125 mcg (0.125 mg) SP, PA
dofetilide cap 250 mcg (0.25 mg) SP, PA
dofetilide cap 500 mcg (0.5 mg) SP, PA
flecainide acetate tab 50 mg
flecainide acetate tab 100 mg
flecainide acetate tab 150 mg
MULTAQ TAB 400MG
NORPACE CAP 100MG +
NORPACE CAP 100MG CR
NORPACE CAP 150MG +
NORPACE CAP 150MG CR
propafenone hcl cap er 12hr 225 mg
propafenone hcl cap er 12hr 325 mg
propafenone hcl cap er 12hr 425 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
22
Drug Name Requirements/Limits
propafenone hcl tab 150 mg
propafenone hcl tab 225 mg
propafenone hcl tab 300 mg
RYTHMOL SR CAP 225MG +
RYTHMOL SR CAP 325MG +
RYTHMOL SR CAP 425MG +
sotalol hcl (afib/afl) tab 80 mg
sotalol hcl (afib/afl) tab 120 mg
sotalol hcl (afib/afl) tab 160 mg
sotalol hcl tab 80 mg
sotalol hcl tab 120 mg
sotalol hcl tab 160 mg
sotalol hcl tab 240 mg
TIKOSYN CAP 125MCG SP, PA; +
TIKOSYN CAP 250MCG SP, PA; +
TIKOSYN CAP 500MCG SP, PA; +
ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose
cholestyramine light powder packets 4 gm
cholestyramine powder 4 gm/dose
cholestyramine powder packets 4 gm
colestipol hcl granule packets 5 gm
colestipol hcl granules 5 gm
colestipol hcl tab 1 gm
ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg QL (30 per month)
ANTILIPEMICS, FIBRATES fenofibrate micronized cap 67 mg
fenofibrate micronized cap 134 mg
fenofibrate micronized cap 200 mg
fenofibrate tab 48 mg
fenofibrate tab 54 mg
fenofibrate tab 145 mg
fenofibrate tab 160 mg
gemfibrozil tab 600 mg
ANTILIPEMICS, HMG-COA REDUCTASE
INHIBITORS/COMBINATIONS atorvastatin calcium tab 10 mg (base equivalent) QL (30 per month)
atorvastatin calcium tab 20 mg (base equivalent) QL (30 per month)
atorvastatin calcium tab 40 mg (base equivalent) QL (30 per month)
atorvastatin calcium tab 80 mg (base equivalent) QL (30 per month)
lovastatin tab 10 mg QL (30 per month)
lovastatin tab 20 mg QL (30 per month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
23
Drug Name Requirements/Limits
lovastatin tab 40 mg QL (30 per month)
pravastatin sodium tab 10 mg QL (30 per month)
pravastatin sodium tab 20 mg QL (30 per month)
pravastatin sodium tab 40 mg QL (30 per month)
pravastatin sodium tab 80 mg QL (30 per month)
simvastatin tab 5 mg QL (30 per month)
simvastatin tab 10 mg QL (30 per month)
simvastatin tab 20 mg QL (30 per month)
simvastatin tab 40 mg QL (30 per month)
simvastatin tab 80 mg QL (30 per month)
ANTILIPEMICS, NIACINS niacin tab er 500 mg (antihyperlipidemic)
niacin tab er 750 mg (antihyperlipidemic)
niacin tab er 1000 mg (antihyperlipidemic)
BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab 50-25 mg
atenolol & chlorthalidone tab 100-25 mg
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
metoprolol & hydrochlorothiazide tab 50-25 mg
metoprolol & hydrochlorothiazide tab 100-25 mg
metoprolol & hydrochlorothiazide tab 100-50 mg
BETA-BLOCKERS atenolol tab 25 mg
atenolol tab 50 mg
atenolol tab 100 mg
bisoprolol fumarate tab 5 mg
bisoprolol fumarate tab 10 mg
carvedilol tab 3.125 mg
carvedilol tab 6.25 mg
carvedilol tab 12.5 mg
carvedilol tab 25 mg
labetalol hcl tab 100 mg
labetalol hcl tab 200 mg
labetalol hcl tab 300 mg
metoprolol succinate tab er 24hr 25 mg (tartrate
equiv)
metoprolol succinate tab er 24hr 50 mg (tartrate
equiv)
metoprolol succinate tab er 24hr 100 mg (tartrate equiv)
metoprolol succinate tab er 24hr 200 mg (tartrate equiv)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
24
Drug Name Requirements/Limits
metoprolol tartrate tab 25 mg
metoprolol tartrate tab 50 mg
metoprolol tartrate tab 100 mg
nadolol tab 20 mg
nadolol tab 40 mg
nadolol tab 80 mg
pindolol tab 5 mg
pindolol tab 10 mg
propranolol hcl cap er 24hr 60 mg
propranolol hcl cap er 24hr 80 mg
propranolol hcl cap er 24hr 120 mg
propranolol hcl cap er 24hr 160 mg
propranolol hcl oral soln 20 mg/5ml
propranolol hcl oral soln 40 mg/5ml
propranolol hcl tab 10 mg
propranolol hcl tab 20 mg
propranolol hcl tab 40 mg
propranolol hcl tab 60 mg
propranolol hcl tab 80 mg
timolol maleate tab 5 mg
timolol maleate tab 10 mg
timolol maleate tab 20 mg
CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES amlodipine besylate tab 2.5 mg (base equivalent)
amlodipine besylate tab 5 mg (base equivalent)
amlodipine besylate tab 10 mg (base equivalent)
felodipine tab er 24hr 2.5 mg
felodipine tab er 24hr 5 mg
felodipine tab er 24hr 10 mg
nifedipine tab er 24hr 30 mg
nifedipine tab er 24hr 60 mg
nifedipine tab er 24hr 90 mg
nifedipine tab er 24hr osmotic release 30 mg
nifedipine tab er 24hr osmotic release 60 mg
nifedipine tab er 24hr osmotic release 90 mg
CALCIUM CHANNEL BLOCKERS, NON-DIHYDROPYRIDINES diltiazem hcl cap er 12hr 60 mg
diltiazem hcl cap er 12hr 90 mg
diltiazem hcl cap er 12hr 120 mg
diltiazem hcl cap er 24hr 120 mg
diltiazem hcl cap er 24hr 180 mg
diltiazem hcl cap er 24hr 240 mg
diltiazem hcl coated beads cap er 24hr 120 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
25
Drug Name Requirements/Limits
diltiazem hcl coated beads cap er 24hr 180 mg
diltiazem hcl coated beads cap er 24hr 240 mg
diltiazem hcl coated beads cap er 24hr 300 mg
diltiazem hcl coated beads cap er 24hr 360 mg
diltiazem hcl coated beads tab er 24hr 180 mg
diltiazem hcl coated beads tab er 24hr 240 mg
diltiazem hcl coated beads tab er 24hr 300 mg
diltiazem hcl coated beads tab er 24hr 360 mg
diltiazem hcl coated beads tab er 24hr 420 mg
diltiazem hcl extended release beads cap er 24hr
120 mg
diltiazem hcl extended release beads cap er 24hr
180 mg
diltiazem hcl extended release beads cap er 24hr 240 mg
diltiazem hcl extended release beads cap er 24hr 300 mg
diltiazem hcl extended release beads cap er 24hr
360 mg
diltiazem hcl extended release beads cap er 24hr
420 mg
diltiazem hcl tab 30 mg
diltiazem hcl tab 60 mg
diltiazem hcl tab 90 mg
diltiazem hcl tab 120 mg
verapamil hcl tab er 120 mg
verapamil hcl tab er 180 mg
verapamil hcl tab er 240 mg
DIGITALIS GLYCOSIDES digoxin oral soln 0.05 mg/ml
digoxin tab 125 mcg (0.125 mg)
digoxin tab 250 mcg (0.25 mg)
LANOXIN TAB 0.0625MG
DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide cap er 12hr 500 mg
acetazolamide tab 125 mg
acetazolamide tab 250 mg
methazolamide tab 25 mg
methazolamide tab 50 mg
DIURETICS, DIURETIC COMBINATIONS ALDACTAZIDE TAB 50/50
amiloride & hydrochlorothiazide tab 5-50 mg
spironolactone & hydrochlorothiazide tab 25-25 mg
triamterene & hydrochlorothiazide cap 37.5-25 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
26
Drug Name Requirements/Limits
triamterene & hydrochlorothiazide tab 37.5-25 mg
triamterene & hydrochlorothiazide tab 75-50 mg
DIURETICS, LOOP DIURETICS bumetanide tab 0.5 mg
bumetanide tab 1 mg
bumetanide tab 2 mg
furosemide oral soln 10 mg/ml
furosemide tab 20 mg
furosemide tab 40 mg
furosemide tab 80 mg
torsemide tab 5 mg
torsemide tab 10 mg
torsemide tab 20 mg
torsemide tab 100 mg
DIURETICS, POTASSIUM-SPARING DIURETICS amiloride hcl tab 5 mg
DIURETICS, THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorthalidone tab 25 mg
chlorthalidone tab 50 mg
hydrochlorothiazide cap 12.5 mg
hydrochlorothiazide tab 12.5 mg
hydrochlorothiazide tab 25 mg
hydrochlorothiazide tab 50 mg
indapamide tab 1.25 mg
indapamide tab 2.5 mg
metolazone tab 2.5 mg
metolazone tab 5 mg
metolazone tab 10 mg
HEART FAILURE CORLANOR TAB 5MG
CORLANOR TAB 7.5MG
ENTRESTO TAB 24-26MG
ENTRESTO TAB 49-51MG
ENTRESTO TAB 97-103MG
MISCELLANEOUS hydralazine hcl tab 10 mg
hydralazine hcl tab 25 mg
hydralazine hcl tab 50 mg
hydralazine hcl tab 100 mg
NITRATES, ORAL ISORDIL TAB 40MG
isosorbide dinitrate tab 5 mg
isosorbide dinitrate tab 10 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
27
Drug Name Requirements/Limits
isosorbide dinitrate tab 20 mg
isosorbide dinitrate tab 30 mg
isosorbide dinitrate tab er 40 mg
isosorbide mononitrate tab 10 mg
isosorbide mononitrate tab 20 mg
isosorbide mononitrate tab er 24hr 30 mg
isosorbide mononitrate tab er 24hr 60 mg
isosorbide mononitrate tab er 24hr 120 mg
nitroglycerin cap er 2.5 mg
nitroglycerin cap er 6.5 mg
nitroglycerin cap er 9 mg
NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin sl tab 0.3 mg
nitroglycerin sl tab 0.4 mg
nitroglycerin sl tab 0.6 mg
NITRATES, TRANSDERMAL NITRO-BID OIN 2%
NITRO-DUR DIS 0.3MG/HR
NITRO-DUR DIS 0.8MG/HR
nitroglycerin td patch 24hr 0.1 mg/hr
nitroglycerin td patch 24hr 0.2 mg/hr
nitroglycerin td patch 24hr 0.4 mg/hr
nitroglycerin td patch 24hr 0.6 mg/hr
PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR
ANTAGONISTS ambrisentan tab 5 mg SP, PA
ambrisentan tab 10 mg SP, PA
bosentan tab 62.5 mg SP, PA
bosentan tab 125 mg SP, PA
OPSUMIT TAB 10MG SP, PA
TRACLEER TAB 32MG SP, PA
PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE
INHIBITORS sildenafil citrate for suspension 10 mg/ml SP, QL (90 mL per month),
PA
sildenafil citrate tab 20 mg SP, PA
PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN RECEPTOR
AGONISTS UPTRAVI TAB 200/800 SP, PA
UPTRAVI TAB 200MCG SP, PA
UPTRAVI TAB 400MCG SP, PA
UPTRAVI TAB 600MCG SP, PA
UPTRAVI TAB 800MCG SP, PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
28
Drug Name Requirements/Limits
UPTRAVI TAB 1000MCG SP, PA
UPTRAVI TAB 1200MCG SP, PA
UPTRAVI TAB 1400MCG SP, PA
UPTRAVI TAB 1600MCG SP, PA
PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN
VASODILATORS ORENITRAM TAB 0.25MG SP, PA
ORENITRAM TAB 0.125MG SP, PA
ORENITRAM TAB 1MG SP, PA
ORENITRAM TAB 2.5MG SP, PA
ORENITRAM TAB 5MG SP, PA
TYVASO REFIL SOL 0.6MG/ML SP, PA
TYVASO SOL 0.6MG/ML SP, PA
TYVASO START SOL 0.6MG/ML SP, PA
VASOPRESSORS midodrine hcl tab 2.5 mg
midodrine hcl tab 5 mg
midodrine hcl tab 10 mg
CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES
ALPRAZOLAM CON 1 MG/ML OB7
alprazolam orally disintegrating tab 0.5 mg OB7
alprazolam orally disintegrating tab 0.25 mg OB7
alprazolam orally disintegrating tab 1 mg OB7
alprazolam orally disintegrating tab 2 mg OB7
alprazolam tab 0.5 mg OB7
alprazolam tab 0.25 mg OB7
alprazolam tab 1 mg OB7
alprazolam tab 2 mg OB7
alprazolam tab er 24hr 0.5 mg OB7
alprazolam tab er 24hr 1 mg OB7
alprazolam tab er 24hr 2 mg OB7
alprazolam tab er 24hr 3 mg OB7
ATIVAN INJ 2MG/ML +, OB7
ATIVAN INJ 4MG/ML +, OB7
ATIVAN TAB 0.5MG +, OB7
ATIVAN TAB 1MG +, OB7
ATIVAN TAB 2MG +, OB7
chlordiazepoxide hcl cap 5 mg OB7
chlordiazepoxide hcl cap 10 mg OB7
chlordiazepoxide hcl cap 25 mg OB7
clonazepam orally disintegrating tab 0.5 mg OB7
clonazepam orally disintegrating tab 0.25 mg OB7
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
29
Drug Name Requirements/Limits
clonazepam orally disintegrating tab 0.125 mg OB7
clonazepam orally disintegrating tab 1 mg OB7
clonazepam orally disintegrating tab 2 mg OB7
clonazepam tab 0.5 mg OB7
clonazepam tab 1 mg OB7
clonazepam tab 2 mg OB7
clorazepate dipotassium tab 3.75 mg OB7
clorazepate dipotassium tab 7.5 mg OB7
clorazepate dipotassium tab 15 mg OB7
diazepam conc 5 mg/ml OB7
diazepam inj 5 mg/ml OB7
DIAZEPAM INJ 10MG/2ML OB7
diazepam oral soln 1 mg/ml OB7
diazepam tab 2 mg OB7
diazepam tab 5 mg OB7
diazepam tab 10 mg OB7
KLONOPIN TAB 0.5MG +, OB7
KLONOPIN TAB 1MG +, OB7
KLONOPIN TAB 2MG +, OB7
lorazepam conc 2 mg/ml OB7
lorazepam inj 2 mg/ml OB7
lorazepam inj 4 mg/ml OB7
lorazepam tab 0.5 mg OB7
lorazepam tab 1 mg OB7
lorazepam tab 2 mg OB7
oxazepam cap 10 mg OB7
oxazepam cap 15 mg OB7
oxazepam cap 30 mg OB7
TRANXENE T TAB 7.5MG +, OB7
VALIUM TAB 2MG +, OB7
VALIUM TAB 5MG +, OB7
VALIUM TAB 10MG +, OB7
XANAX TAB 0.5MG +, OB7
XANAX TAB 0.25MG +, OB7
XANAX TAB 1MG +, OB7
XANAX TAB 2MG +, OB7
XANAX XR TAB 0.5MG +, OB7
XANAX XR TAB 1MG +, OB7
XANAX XR TAB 2MG +, OB7
XANAX XR TAB 3MG +, OB7
ANTIANXIETY, MISCELLANEOUS ANAFRANIL CAP 25MG +
ANAFRANIL CAP 50MG +
ANAFRANIL CAP 75MG +
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
30
Drug Name Requirements/Limits
buspirone hcl tab 5 mg
buspirone hcl tab 7.5 mg
buspirone hcl tab 10 mg
buspirone hcl tab 15 mg
buspirone hcl tab 30 mg
clomipramine hcl cap 25 mg
clomipramine hcl cap 50 mg
clomipramine hcl cap 75 mg
fluvoxamine maleate cap er 24hr 100 mg
fluvoxamine maleate cap er 24hr 150 mg
fluvoxamine maleate tab 25 mg
fluvoxamine maleate tab 50 mg
fluvoxamine maleate tab 100 mg
meprobamate tab 200 mg
meprobamate tab 400 mg
ANTICONVULSANTS APTIOM TAB 200MG
APTIOM TAB 400MG
APTIOM TAB 600MG
APTIOM TAB 800MG
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
BRIVIACT SOL 10MG/ML
BRIVIACT TAB 10MG
BRIVIACT TAB 25MG
BRIVIACT TAB 50MG
BRIVIACT TAB 75MG
BRIVIACT TAB 100MG
carbamazepine cap er 12hr 100 mg
carbamazepine cap er 12hr 200 mg
carbamazepine cap er 12hr 300 mg
carbamazepine chew tab 100 mg
carbamazepine susp 100 mg/5ml
carbamazepine tab 200 mg
carbamazepine tab er 12hr 100 mg
carbamazepine tab er 12hr 200 mg
carbamazepine tab er 12hr 400 mg
CARBATROL CAP 100MG +
CARBATROL CAP 200MG +
CARBATROL CAP 300MG +
CELONTIN CAP 300MG
clobazam suspension 2.5 mg/ml
clobazam tab 10 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
31
Drug Name Requirements/Limits
clobazam tab 20 mg
DEPAKENE CAP 250MG +
DEPAKOTE ER TAB 250MG +
DEPAKOTE ER TAB 500MG +
DEPAKOTE SPR CAP 125MG +
DEPAKOTE TAB 125MG DR +
DEPAKOTE TAB 250MG DR +
DEPAKOTE TAB 500MG DR +
DIASTAT ACDL GEL 5-10MG +
DIASTAT ACDL GEL 12.5-20 +
DIASTAT PED GEL 2.5M GEL +
diazepam rectal gel delivery system 2.5 mg
diazepam rectal gel delivery system 10 mg
diazepam rectal gel delivery system 20 mg
DILANTIN CAP 30MG
DILANTIN CAP 100MG +
DILANTIN CHW 50MG +
DILANTIN-125 SUS 125/5ML +
divalproex sodium cap delayed release sprinkle 125 mg
divalproex sodium tab delayed release 125 mg
divalproex sodium tab delayed release 250 mg
divalproex sodium tab delayed release 500 mg
divalproex sodium tab er 24 hr 250 mg
divalproex sodium tab er 24 hr 500 mg
epitol tab 200mg
ethosuximide cap 250 mg
ethosuximide soln 250 mg/5ml
FANATREX SUS 25MG/ML
felbamate susp 600 mg/5ml
felbamate tab 400 mg
felbamate tab 600 mg
FELBATOL SUS 600/5ML +
FELBATOL TAB 400MG +
FELBATOL TAB 600MG +
FYCOMPA SUS 0.5MG/ML
FYCOMPA TAB 2MG
FYCOMPA TAB 4MG
FYCOMPA TAB 6MG
FYCOMPA TAB 8MG
FYCOMPA TAB 10MG
FYCOMPA TAB 12MG
gabapentin cap 100 mg QL (1080 per month)
gabapentin cap 300 mg QL (360 per month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
32
Drug Name Requirements/Limits
gabapentin cap 400 mg QL (270 per month)
gabapentin oral soln 250 mg/5ml QL (2100 mL per month)
gabapentin tab 600 mg QL (180 per month)
gabapentin tab 800 mg QL (120 per month)
GABITRIL TAB 2MG +
GABITRIL TAB 4MG +
GABITRIL TAB 12MG +
GABITRIL TAB 16MG +
KEPPRA SOL 100MG/ML +
KEPPRA TAB 250MG +
KEPPRA TAB 500MG +
KEPPRA TAB 750MG +
KEPPRA TAB 1000MG +
KEPPRA XR TAB 500MG +
KEPPRA XR TAB 750MG +
LAMICTAL CHW 5MG +
LAMICTAL CHW 25MG +
LAMICTAL KIT START 35 +
LAMICTAL KIT START 49 +
LAMICTAL KIT START 98 +
LAMICTAL ODT KIT
LAMICTAL ODT TAB 25MG +
LAMICTAL ODT TAB 50MG +
LAMICTAL ODT TAB 100MG +
LAMICTAL ODT TAB 200MG +
LAMICTAL TAB 25MG +
LAMICTAL TAB 100MG +
LAMICTAL TAB 150MG +
LAMICTAL TAB 200MG +
LAMICTAL XR KIT
LAMICTAL XR TAB 25MG +
LAMICTAL XR TAB 50MG +
LAMICTAL XR TAB 100MG +
LAMICTAL XR TAB 200MG +
LAMICTAL XR TAB 250MG +
LAMICTAL XR TAB 300MG +
lamotrigine orally disintegrating tab 25 mg
lamotrigine orally disintegrating tab 50 mg
lamotrigine orally disintegrating tab 100 mg
lamotrigine orally disintegrating tab 200 mg
lamotrigine tab 25 mg
lamotrigine tab 25 mg (35) starter kit
lamotrigine tab 25 mg (42) & 100 mg (7) starter
kit
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
33
Drug Name Requirements/Limits
lamotrigine tab 25 mg (84) & 100 mg (14) starter
kit
lamotrigine tab 100 mg
lamotrigine tab 150 mg
lamotrigine tab 200 mg
lamotrigine tab chewable dispersible 5 mg
lamotrigine tab chewable dispersible 25 mg
lamotrigine tab er 24hr 25 mg
lamotrigine tab er 24hr 50 mg
lamotrigine tab er 24hr 100 mg
lamotrigine tab er 24hr 200 mg
lamotrigine tab er 24hr 250 mg
lamotrigine tab er 24hr 300 mg
levetiracetam oral soln 100 mg/ml
levetiracetam tab 250 mg
levetiracetam tab 500 mg
levetiracetam tab 750 mg
levetiracetam tab 1000 mg
levetiracetam tab er 24hr 500 mg
levetiracetam tab er 24hr 750 mg
MYSOLINE TAB 50MG +
MYSOLINE TAB 250MG +
NEURONTIN CAP 100MG QL (1080 per month); +
NEURONTIN CAP 300MG QL (360 per month); +
NEURONTIN CAP 400MG QL (270 per month); +
NEURONTIN SOL 250/5ML QL (2100 mL per month); +
NEURONTIN TAB 600MG QL (180 per month); +
NEURONTIN TAB 800MG QL (120 per month); +
ONFI SUS 2.5MG/ML +
ONFI TAB 10MG +
ONFI TAB 20MG +
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
oxcarbazepine tab 150 mg
oxcarbazepine tab 300 mg
oxcarbazepine tab 600 mg
OXTELLAR XR TAB 150MG
OXTELLAR XR TAB 300MG
OXTELLAR XR TAB 600MG
PEGANONE TAB 250MG
phenobarbital elixir 20 mg/5ml
phenobarbital tab 15 mg
phenobarbital tab 16.2 mg
phenobarbital tab 30 mg
phenobarbital tab 32.4 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
34
Drug Name Requirements/Limits
phenobarbital tab 60 mg
phenobarbital tab 64.8 mg
phenobarbital tab 97.2 mg
phenobarbital tab 100 mg
PHENYTEK CAP 200MG +
PHENYTEK CAP 300MG +
phenytoin chew tab 50 mg
phenytoin sodium extended cap 100 mg
phenytoin sodium extended cap 200 mg
phenytoin sodium extended cap 300 mg
phenytoin susp 125 mg/5ml
pregabalin cap 25 mg QL (120 per month)
pregabalin cap 50 mg QL (120 per month)
pregabalin cap 75 mg QL (120 per month)
pregabalin cap 100 mg QL (120 per month)
pregabalin cap 150 mg QL (120 per month)
pregabalin cap 200 mg QL (90 per month)
pregabalin cap 225 mg QL (60 per month)
pregabalin cap 300 mg QL (60 per month)
pregabalin soln 20 mg/ml QL (900 mL per month)
primidone tab 50 mg
primidone tab 250 mg
SABRIL POW 500MG SP, PA; +
SABRIL TAB 500MG SP, PA; +
TEGRETOL SUS 100/5ML +
TEGRETOL TAB 200MG +
TEGRETOL-XR TAB 100MG +
TEGRETOL-XR TAB 200MG +
TEGRETOL-XR TAB 400MG +
tiagabine hcl tab 2 mg
tiagabine hcl tab 4 mg
tiagabine hcl tab 12 mg
tiagabine hcl tab 16 mg
TOPAMAX SPR CAP 15MG +
TOPAMAX SPR CAP 25MG +
TOPAMAX TAB 25MG +
TOPAMAX TAB 50MG +
TOPAMAX TAB 100MG +
TOPAMAX TAB 200MG +
topiramate cap er 24hr sprinkle 25 mg
topiramate cap er 24hr sprinkle 50 mg
topiramate cap er 24hr sprinkle 100 mg
topiramate cap er 24hr sprinkle 150 mg
topiramate cap er 24hr sprinkle 200 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
35
Drug Name Requirements/Limits
topiramate sprinkle cap 15 mg
topiramate sprinkle cap 25 mg
topiramate tab 25 mg
topiramate tab 50 mg
topiramate tab 100 mg
topiramate tab 200 mg
TRILEPTAL SUS 300MG/5M +
TRILEPTAL TAB 150MG +
TRILEPTAL TAB 300MG +
TRILEPTAL TAB 600MG +
TROKENDI XR CAP 25MG
TROKENDI XR CAP 50MG
TROKENDI XR CAP 100MG
TROKENDI XR CAP 200MG
valproate sodium oral soln 250 mg/5ml (base equiv)
valproic acid cap 250 mg
vigabatrin powd pack 500 mg SP, PA
vigabatrin tab 500 mg SP, PA
VIMPAT SOL 10MG/ML
VIMPAT TAB 50MG
VIMPAT TAB 100MG
VIMPAT TAB 150MG
VIMPAT TAB 200MG
ZARONTIN CAP 250MG +
ZARONTIN SOL 250/5ML +
ZONEGRAN CAP 25MG +
ZONEGRAN CAP 100MG +
zonisamide cap 25 mg
zonisamide cap 50 mg
zonisamide cap 100 mg
ANTIDEMENTIA donepezil hydrochloride orally disintegrating tab 5
mg
donepezil hydrochloride orally disintegrating tab 10
mg
donepezil hydrochloride tab 5 mg
donepezil hydrochloride tab 10 mg
donepezil hydrochloride tab 23 mg
galantamine hydrobromide cap er 24hr 8 mg
galantamine hydrobromide cap er 24hr 16 mg
galantamine hydrobromide cap er 24hr 24 mg
galantamine hydrobromide oral soln 4 mg/ml
galantamine hydrobromide tab 4 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
36
Drug Name Requirements/Limits
galantamine hydrobromide tab 8 mg
galantamine hydrobromide tab 12 mg
memantine hcl oral solution 2 mg/ml PA only applies to members
less than 30 years of age
memantine hcl tab 5 mg PA only applies to members
less than 30 years of age
memantine hcl tab 5 mg (28) & 10 mg (21)
titration pak
PA only applies to members
less than 30 years of age
memantine hcl tab 10 mg PA only applies to members
less than 30 years of age
rivastigmine tartrate cap 1.5 mg (base equivalent) PA
rivastigmine tartrate cap 3 mg (base equivalent) PA
rivastigmine tartrate cap 4.5 mg (base equivalent) PA
rivastigmine tartrate cap 6 mg (base equivalent) PA
rivastigmine td patch 24hr 4.6 mg/24hr PA
rivastigmine td patch 24hr 9.5 mg/24hr PA
rivastigmine td patch 24hr 13.3 mg/24hr PA
ANTIDEPRESSANTS, MISCELLANEOUS APLENZIN TAB 174MG
APLENZIN TAB 348MG
APLENZIN TAB 522MG
bupropion hcl tab 75 mg
bupropion hcl tab 100 mg
bupropion hcl tab er 12hr 100 mg
bupropion hcl tab er 12hr 150 mg
bupropion hcl tab er 12hr 200 mg
bupropion hcl tab er 24hr 150 mg
bupropion hcl tab er 24hr 300 mg
bupropion hcl tab er 24hr 450 mg
chlordiazepoxide-amitriptyline tab 5-12.5 mg
chlordiazepoxide-amitriptyline tab 10-25 mg
FORFIVO XL TAB 450MG +
maprotiline hcl tab 25 mg
maprotiline hcl tab 50 mg
maprotiline hcl tab 75 mg
mirtazapine orally disintegrating tab 15 mg
mirtazapine orally disintegrating tab 30 mg
mirtazapine orally disintegrating tab 45 mg
mirtazapine tab 7.5 mg
mirtazapine tab 15 mg
mirtazapine tab 30 mg
mirtazapine tab 45 mg
nefazodone hcl tab 50 mg
nefazodone hcl tab 100 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
37
Drug Name Requirements/Limits
nefazodone hcl tab 150 mg
nefazodone hcl tab 200 mg
nefazodone hcl tab 250 mg
REMERON SLTB TAB 15MG +
REMERON SLTB TAB 30MG +
REMERON SLTB TAB 45MG +
REMERON TAB 15MG +
REMERON TAB 30MG +
trazodone hcl tab 50 mg
trazodone hcl tab 100 mg
trazodone hcl tab 150 mg
trazodone hcl tab 300 mg
WELLBUTRIN TAB 100MG SR +
WELLBUTRIN TAB 150MG SR +
WELLBUTRIN TAB 200MG SR +
WELLBUTRIN TAB XL 150MG +
WELLBUTRIN TAB XL 300MG +
ANTIDEPRESSANTS, MONOAMINE OXIDASE INHIBITORS (MAOIs) EMSAM DIS 6MG/24HR
EMSAM DIS 9MG/24HR
EMSAM DIS 12MG/24H
MARPLAN TAB 10MG
NARDIL TAB 15MG +
PARNATE TAB 10MG +
phenelzine sulfate tab 15 mg
tranylcypromine sulfate tab 10 mg
ANTIDEPRESSANTS, SELECTIVE SEROTONIN REUPTAKE
INHIBITORS (SSRIs) CELEXA TAB 10MG +
CELEXA TAB 20MG +
CELEXA TAB 40MG +
citalopram hydrobromide oral soln 10 mg/5ml
citalopram hydrobromide tab 10 mg (base equiv)
citalopram hydrobromide tab 20 mg (base equiv)
citalopram hydrobromide tab 40 mg (base equiv)
escitalopram oxalate soln 5 mg/5ml (base equiv)
escitalopram oxalate tab 5 mg (base equiv)
escitalopram oxalate tab 10 mg (base equiv)
escitalopram oxalate tab 20 mg (base equiv)
fluoxetine hcl (pmdd) cap 10 mg
fluoxetine hcl (pmdd) cap 20 mg
fluoxetine hcl (pmdd) tab 10 mg
fluoxetine hcl (pmdd) tab 20 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
38
Drug Name Requirements/Limits
fluoxetine hcl cap 10 mg
fluoxetine hcl cap 20 mg
fluoxetine hcl cap 40 mg
fluoxetine hcl cap delayed release 90 mg
fluoxetine hcl solution 20 mg/5ml
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
fluoxetine hcl tab 60 mg
FLUOXETINE TAB 60MG +
LEXAPRO TAB 5MG +
LEXAPRO TAB 10MG +
LEXAPRO TAB 20MG +
paroxetine hcl tab 10 mg
paroxetine hcl tab 20 mg
paroxetine hcl tab 30 mg
paroxetine hcl tab 40 mg
paroxetine hcl tab er 24hr 12.5 mg
paroxetine hcl tab er 24hr 25 mg
paroxetine hcl tab er 24hr 37.5 mg
PAXIL CR TAB 12.5MG +
PAXIL CR TAB 25MG +
PAXIL CR TAB 37.5MG +
PAXIL SUS 10MG/5ML
PAXIL TAB 10MG +
PAXIL TAB 20MG +
PAXIL TAB 30MG +
PAXIL TAB 40MG +
PEXEVA TAB 10MG
PEXEVA TAB 20MG
PEXEVA TAB 30MG
PEXEVA TAB 40MG
PROZAC CAP 10MG +
PROZAC CAP 20MG +
PROZAC CAP 40MG +
SARAFEM TAB 10MG +
SARAFEM TAB 20MG +
sertraline hcl oral concentrate for solution 20
mg/ml
sertraline hcl tab 25 mg
sertraline hcl tab 50 mg
sertraline hcl tab 100 mg
TRINTELLIX TAB 5MG
TRINTELLIX TAB 10MG
TRINTELLIX TAB 20MG
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
39
Drug Name Requirements/Limits
VIIBRYD KIT STARTER
VIIBRYD TAB 10MG
VIIBRYD TAB 20MG
VIIBRYD TAB 40MG
ZOLOFT TAB 25MG +
ZOLOFT TAB 50MG +
ZOLOFT TAB 100MG +
ANTIDEPRESSANTS, SEROTONIN NOREPINEPHRINE REUPTAKE
INHIBITORS (SNRIs) CYMBALTA CAP 20MG +
CYMBALTA CAP 30MG +
CYMBALTA CAP 60MG +
DESVENLAFAX TAB 50MG ER
DESVENLAFAX TAB 100MG ER
desvenlafaxine succinate tab er 24hr 25 mg (base equiv)
desvenlafaxine succinate tab er 24hr 50 mg (base equiv)
desvenlafaxine succinate tab er 24hr 100 mg
(base equiv)
desvenlafaxine tab er 24hr 50 mg
desvenlafaxine tab er 24hr 100 mg
duloxetine hcl enteric coated pellets cap 20 mg
(base eq)
duloxetine hcl enteric coated pellets cap 30 mg
(base eq)
duloxetine hcl enteric coated pellets cap 40 mg
(base eq)
duloxetine hcl enteric coated pellets cap 60 mg
(base eq)
EFFEXOR XR CAP 37.5MG +
EFFEXOR XR CAP 75MG +
EFFEXOR XR CAP 150MG +
FETZIMA CAP 20MG
FETZIMA CAP 40MG
FETZIMA CAP 80MG
FETZIMA CAP 120MG
FETZIMA CAP TITRATIO
KHEDEZLA TAB 50MG ER +
KHEDEZLA TAB 100MG ER +
PRISTIQ TAB 25MG +
PRISTIQ TAB 50MG +
PRISTIQ TAB 100MG +
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
40
Drug Name Requirements/Limits
venlafaxine hcl cap er 24hr 37.5 mg (base
equivalent)
venlafaxine hcl cap er 24hr 75 mg (base
equivalent)
venlafaxine hcl cap er 24hr 150 mg (base
equivalent)
venlafaxine hcl tab 25 mg (base equivalent)
venlafaxine hcl tab 37.5 mg (base equivalent)
venlafaxine hcl tab 50 mg (base equivalent)
venlafaxine hcl tab 75 mg (base equivalent)
venlafaxine hcl tab 100 mg (base equivalent)
venlafaxine hcl tab er 24hr 37.5 mg (base
equivalent)
venlafaxine hcl tab er 24hr 75 mg (base
equivalent)
venlafaxine hcl tab er 24hr 150 mg (base
equivalent)
venlafaxine hcl tab er 24hr 225 mg (base
equivalent)
ANTIDEPRESSANTS, TRICYCLIC ANTIDEPRESSANTS (TCAs) amitriptyline hcl tab 10 mg
amitriptyline hcl tab 25 mg
amitriptyline hcl tab 50 mg
amitriptyline hcl tab 75 mg
amitriptyline hcl tab 100 mg
amitriptyline hcl tab 150 mg
amoxapine tab 25 mg
amoxapine tab 50 mg
amoxapine tab 100 mg
amoxapine tab 150 mg
desipramine hcl tab 10 mg
desipramine hcl tab 25 mg
desipramine hcl tab 50 mg
desipramine hcl tab 75 mg
desipramine hcl tab 100 mg
desipramine hcl tab 150 mg
doxepin hcl cap 10 mg
doxepin hcl cap 25 mg
doxepin hcl cap 50 mg
doxepin hcl cap 75 mg
doxepin hcl cap 100 mg
doxepin hcl cap 150 mg
doxepin hcl conc 10 mg/ml
imipramine hcl tab 10 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
41
Drug Name Requirements/Limits
imipramine hcl tab 25 mg
imipramine hcl tab 50 mg
imipramine pamoate cap 75 mg
imipramine pamoate cap 100 mg
imipramine pamoate cap 125 mg
imipramine pamoate cap 150 mg
NORPRAMIN TAB 10MG +
NORPRAMIN TAB 25MG +
nortriptyline hcl cap 10 mg
nortriptyline hcl cap 25 mg
nortriptyline hcl cap 50 mg
nortriptyline hcl cap 75 mg
nortriptyline hcl soln 10 mg/5ml
PAMELOR CAP 10MG +
PAMELOR CAP 25MG +
PAMELOR CAP 50MG +
PAMELOR CAP 75MG +
protriptyline hcl tab 5 mg
protriptyline hcl tab 10 mg
TOFRANIL TAB 10MG +
TOFRANIL TAB 25MG +
TOFRANIL TAB 50MG +
trimipramine maleate cap 25 mg
trimipramine maleate cap 50 mg
trimipramine maleate cap 100 mg
ANTIPARKINSONIAN AGENTS amantadine hcl cap 100 mg
amantadine hcl syrup 50 mg/5ml
amantadine hcl tab 100 mg
benztropine mesylate tab 0.5 mg
benztropine mesylate tab 1 mg
benztropine mesylate tab 2 mg
bromocriptine mesylate cap 5 mg (base
equivalent)
bromocriptine mesylate tab 2.5 mg (base
equivalent)
carbidopa & levodopa orally disintegrating tab 10-
100 mg
carbidopa & levodopa orally disintegrating tab 25-
100 mg
carbidopa & levodopa orally disintegrating tab 25-250 mg
carbidopa & levodopa tab 10-100 mg
carbidopa & levodopa tab 25-100 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
42
Drug Name Requirements/Limits
carbidopa & levodopa tab 25-250 mg
carbidopa & levodopa tab er 25-100 mg
carbidopa & levodopa tab er 50-200 mg
carbidopa-levodopa-entacapone tabs 12.5-50-200
mg
carbidopa-levodopa-entacapone tabs 18.75-75-200 mg
carbidopa-levodopa-entacapone tabs 25-100-200 mg
carbidopa-levodopa-entacapone tabs 31.25-125-
200 mg
carbidopa-levodopa-entacapone tabs 37.5-150-
200 mg
carbidopa-levodopa-entacapone tabs 50-200-200
mg
entacapone tab 200 mg
pramipexole dihydrochloride tab 0.5 mg
pramipexole dihydrochloride tab 0.25 mg
pramipexole dihydrochloride tab 0.75 mg
pramipexole dihydrochloride tab 0.125 mg
pramipexole dihydrochloride tab 1 mg
pramipexole dihydrochloride tab 1.5 mg
ropinirole hydrochloride tab 0.5 mg
ropinirole hydrochloride tab 0.25 mg
ropinirole hydrochloride tab 1 mg
ropinirole hydrochloride tab 2 mg
ropinirole hydrochloride tab 3 mg
ropinirole hydrochloride tab 4 mg
ropinirole hydrochloride tab 5 mg
selegiline hcl cap 5 mg
selegiline hcl tab 5 mg
trihexyphenidyl hcl elixir 0.4 mg/ml
trihexyphenidyl hcl tab 2 mg
trihexyphenidyl hcl tab 5 mg
ANTIPSYCHOTICS, ATYPICALS ABILIFY MAIN INJ 300MG
ABILIFY MAIN INJ 400MG
ABILIFY TAB 2MG +
ABILIFY TAB 5MG +
ABILIFY TAB 10MG +
ABILIFY TAB 15MG +
ABILIFY TAB 20MG +
ABILIFY TAB 30MG +
aripiprazole oral solution 1 mg/ml
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
43
Drug Name Requirements/Limits
aripiprazole orally disintegrating tab 10 mg
aripiprazole orally disintegrating tab 15 mg
aripiprazole tab 2 mg
aripiprazole tab 5 mg
aripiprazole tab 10 mg
aripiprazole tab 15 mg
aripiprazole tab 20 mg
aripiprazole tab 30 mg
ARISTADA INJ 441MG/1.
ARISTADA INJ 662MG/2
ARISTADA INJ 882MG/3
ARISTADA INJ 1064MG
ARISTADA INJ INITIO
clozapine orally disintegrating tab 12.5 mg
clozapine orally disintegrating tab 25 mg
clozapine orally disintegrating tab 100 mg
clozapine orally disintegrating tab 150 mg
clozapine orally disintegrating tab 200 mg
clozapine tab 25 mg
clozapine tab 50 mg
clozapine tab 100 mg
clozapine tab 200 mg
CLOZARIL TAB 25MG +
CLOZARIL TAB 100MG +
FANAPT PAK
FANAPT TAB 1MG
FANAPT TAB 2MG
FANAPT TAB 4MG
FANAPT TAB 6MG
FANAPT TAB 8MG
FANAPT TAB 10MG
FANAPT TAB 12MG
FAZACLO TAB 12.5 ODT +
FAZACLO TAB 25MG ODT +
FAZACLO TAB 100 ODT +
FAZACLO TAB 150 ODT +
FAZACLO TAB 200 ODT +
GEODON CAP 20MG +
GEODON CAP 40MG +
GEODON CAP 60MG +
GEODON CAP 80MG +
GEODON INJ 20MG
INVEGA SUST INJ 39/0.25
INVEGA SUST INJ 78/0.5ML
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
44
Drug Name Requirements/Limits
INVEGA SUST INJ 117/0.75
INVEGA SUST INJ 156MG/ML
INVEGA SUST INJ 234/1.5
INVEGA TAB 1.5MG +
INVEGA TAB 3MG +
INVEGA TAB 6MG +
INVEGA TAB 9MG +
INVEGA TRINZ INJ 273MG
INVEGA TRINZ INJ 410MG
INVEGA TRINZ INJ 546MG
INVEGA TRINZ INJ 819MG
LATUDA TAB 20MG
LATUDA TAB 40MG
LATUDA TAB 60MG
LATUDA TAB 80MG
LATUDA TAB 120MG
olanzapine for im inj 10 mg
olanzapine orally disintegrating tab 5 mg
olanzapine orally disintegrating tab 10 mg
olanzapine orally disintegrating tab 15 mg
olanzapine orally disintegrating tab 20 mg
olanzapine tab 2.5 mg
olanzapine tab 5 mg
olanzapine tab 7.5 mg
olanzapine tab 10 mg
olanzapine tab 15 mg
olanzapine tab 20 mg
olanzapine-fluoxetine hcl cap 3-25 mg
olanzapine-fluoxetine hcl cap 6-25 mg
olanzapine-fluoxetine hcl cap 6-50 mg
olanzapine-fluoxetine hcl cap 12-25 mg
olanzapine-fluoxetine hcl cap 12-50 mg
paliperidone tab er 24hr 1.5 mg
paliperidone tab er 24hr 3 mg
paliperidone tab er 24hr 6 mg
paliperidone tab er 24hr 9 mg
quetiapine fumarate tab 25 mg
quetiapine fumarate tab 50 mg
quetiapine fumarate tab 100 mg
quetiapine fumarate tab 200 mg
quetiapine fumarate tab 300 mg
quetiapine fumarate tab 400 mg
quetiapine fumarate tab er 24hr 50 mg
quetiapine fumarate tab er 24hr 150 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
45
Drug Name Requirements/Limits
quetiapine fumarate tab er 24hr 200 mg
quetiapine fumarate tab er 24hr 300 mg
quetiapine fumarate tab er 24hr 400 mg
REXULTI TAB 0.5MG
REXULTI TAB 0.25MG
REXULTI TAB 1MG
REXULTI TAB 2MG
REXULTI TAB 3MG
REXULTI TAB 4MG
RISPERDAL INJ 12.5MG
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
RISPERDAL INJ 50MG
RISPERDAL SOL 1MG/ML +
RISPERDAL TAB 0.5MG +
RISPERDAL TAB 0.25MG +
RISPERDAL TAB 1MG +
RISPERDAL TAB 2MG +
RISPERDAL TAB 3MG +
RISPERDAL TAB 4MG +
risperidone orally disintegrating tab 0.5 mg
risperidone orally disintegrating tab 0.25 mg
risperidone orally disintegrating tab 1 mg
risperidone orally disintegrating tab 2 mg
risperidone orally disintegrating tab 3 mg
risperidone orally disintegrating tab 4 mg
risperidone soln 1 mg/ml
risperidone tab 0.5 mg
risperidone tab 0.25 mg
risperidone tab 1 mg
risperidone tab 2 mg
risperidone tab 3 mg
risperidone tab 4 mg
SAPHRIS SUB 2.5MG
SAPHRIS SUB 5MG
SAPHRIS SUB 10MG
SEROQUEL TAB 25MG +
SEROQUEL TAB 50MG +
SEROQUEL TAB 100MG +
SEROQUEL TAB 200MG +
SEROQUEL TAB 300MG +
SEROQUEL TAB 400MG +
SEROQUEL XR TAB 50MG +
SEROQUEL XR TAB 150MG +
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
46
Drug Name Requirements/Limits
SEROQUEL XR TAB 200MG +
SEROQUEL XR TAB 300MG +
SEROQUEL XR TAB 400MG +
VERSACLOZ SUS 50MG/ML
VRAYLAR CAP 1.5-3MG
VRAYLAR CAP 1.5MG
VRAYLAR CAP 3MG
VRAYLAR CAP 4.5MG
VRAYLAR CAP 6MG
ziprasidone hcl cap 20 mg
ziprasidone hcl cap 40 mg
ziprasidone hcl cap 60 mg
ziprasidone hcl cap 80 mg
ZYPREXA INJ 10MG +
ZYPREXA RELP INJ 210MG
ZYPREXA RELP INJ 300MG
ZYPREXA RELP INJ 405MG
ZYPREXA TAB 2.5MG +
ZYPREXA TAB 5MG +
ZYPREXA TAB 7.5MG +
ZYPREXA TAB 10MG +
ZYPREXA TAB 15MG +
ZYPREXA TAB 20MG +
ZYPREXA ZYDI TAB 5MG +
ZYPREXA ZYDI TAB 10MG +
ZYPREXA ZYDI TAB 15MG +
ZYPREXA ZYDI TAB 20MG +
ANTIPSYCHOTICS, MISCELLANEOUS ADASUVE INH 10MG
CHLORPROMAZ INJ 25MG/ML
CHLORPROMAZ INJ 50MG/2ML
chlorpromazine hcl tab 10 mg
chlorpromazine hcl tab 25 mg
chlorpromazine hcl tab 50 mg
chlorpromazine hcl tab 100 mg
chlorpromazine hcl tab 200 mg
fluphenazine decanoate inj 25 mg/ml
fluphenazine hcl elixir 2.5 mg/5ml
fluphenazine hcl inj 2.5 mg/ml
fluphenazine hcl oral conc 5 mg/ml
fluphenazine hcl tab 1 mg
fluphenazine hcl tab 2.5 mg
fluphenazine hcl tab 5 mg
fluphenazine hcl tab 10 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
47
Drug Name Requirements/Limits
haloperidol decanoate im soln 50 mg/ml
haloperidol decanoate im soln 100 mg/ml
haloperidol lactate inj 5 mg/ml
haloperidol lactate oral conc 2 mg/ml
haloperidol tab 0.5 mg
haloperidol tab 1 mg
haloperidol tab 2 mg
haloperidol tab 5 mg
haloperidol tab 10 mg
haloperidol tab 20 mg
loxapine succinate cap 5 mg
loxapine succinate cap 10 mg
loxapine succinate cap 25 mg
loxapine succinate cap 50 mg
NUPLAZID CAP 34MG SP
NUPLAZID TAB 10MG SP
perphenazine tab 2 mg
perphenazine tab 4 mg
perphenazine tab 8 mg
perphenazine tab 16 mg
perphenazine-amitriptyline tab 2-10 mg
perphenazine-amitriptyline tab 2-25 mg
perphenazine-amitriptyline tab 4-10 mg
perphenazine-amitriptyline tab 4-25 mg
perphenazine-amitriptyline tab 4-50 mg
thioridazine hcl tab 10 mg
thioridazine hcl tab 25 mg
thioridazine hcl tab 50 mg
thioridazine hcl tab 100 mg
thiothixene cap 1 mg
thiothixene cap 2 mg
thiothixene cap 5 mg
thiothixene cap 10 mg
trifluoperazine hcl tab 1 mg (base equivalent)
trifluoperazine hcl tab 2 mg (base equivalent)
trifluoperazine hcl tab 5 mg (base equivalent)
trifluoperazine hcl tab 10 mg (base equivalent)
ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap er 24hr 5
mg
QL (360 per month)
amphetamine-dextroamphetamine cap er 24hr 10
mg
QL (180 per month)
amphetamine-dextroamphetamine cap er 24hr 15
mg
QL (120 per month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
48
Drug Name Requirements/Limits
amphetamine-dextroamphetamine cap er 24hr 20
mg
QL (90 per month)
amphetamine-dextroamphetamine cap er 24hr 25
mg
QL (60 per month)
amphetamine-dextroamphetamine cap er 24hr 30
mg
QL (60 per month)
amphetamine-dextroamphetamine tab 5 mg QL (360 per month)
amphetamine-dextroamphetamine tab 7.5 mg QL (240 per month)
amphetamine-dextroamphetamine tab 10 mg QL (180 per month)
amphetamine-dextroamphetamine tab 12.5 mg QL (135 per month)
amphetamine-dextroamphetamine tab 15 mg QL (120 per month)
amphetamine-dextroamphetamine tab 20 mg QL (90 per month)
amphetamine-dextroamphetamine tab 30 mg QL (60 per month)
atomoxetine hcl cap 10 mg (base equiv) QL (120 per month); ST (Must have recently been on
30 days of generic
immediate-release ADHD
drug, methylphenidate cap
cr (cd), amphetamine-
dextroamphetamine cap sr 24hr OR
dextroamphetamine sulfate
cap sr 24hr)
atomoxetine hcl cap 18 mg (base equiv) QL (120 per month); ST
(Must have recently been on
30 days of generic
immediate-release ADHD
drug, methylphenidate cap cr (cd), amphetamine-
dextroamphetamine cap sr
24hr OR
dextroamphetamine sulfate
cap sr 24hr)
atomoxetine hcl cap 25 mg (base equiv) QL (120 per month); ST
(Must have recently been on
30 days of generic immediate-release ADHD
drug, methylphenidate cap
cr (cd), amphetamine-
dextroamphetamine cap sr
24hr OR dextroamphetamine sulfate
cap sr 24hr)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
49
Drug Name Requirements/Limits
atomoxetine hcl cap 40 mg (base equiv) QL (60 per month); ST
(Must have recently been on
30 days of generic immediate-release ADHD
drug, methylphenidate cap
cr (cd), amphetamine-
dextroamphetamine cap sr
24hr OR dextroamphetamine sulfate
cap sr 24hr)
atomoxetine hcl cap 60 mg (base equiv) QL (30 per month); ST (Must have recently been on
30 days of generic
immediate-release ADHD
drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr
24hr OR
dextroamphetamine sulfate
cap sr 24hr)
atomoxetine hcl cap 80 mg (base equiv) QL (30 per month); ST
(Must have recently been on
30 days of generic
immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine-
dextroamphetamine cap sr
24hr OR
dextroamphetamine sulfate cap sr 24hr)
atomoxetine hcl cap 100 mg (base equiv) QL (30 per month); ST
(Must have recently been on 30 days of generic
immediate-release ADHD
drug, methylphenidate cap
cr (cd), amphetamine-
dextroamphetamine cap sr 24hr OR
dextroamphetamine sulfate
cap sr 24hr)
dexmethylphenidate hcl tab 2.5 mg QL (600 per month)
dexmethylphenidate hcl tab 5 mg QL (300 per month)
dexmethylphenidate hcl tab 10 mg QL (150 per month)
dextroamphetamine sulfate cap er 24hr 5 mg QL (360 per month)
dextroamphetamine sulfate cap er 24hr 10 mg QL (180 per month)
dextroamphetamine sulfate cap er 24hr 15 mg QL (120 per month)
dextroamphetamine sulfate tab 5 mg QL (360 per month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
50
Drug Name Requirements/Limits
dextroamphetamine sulfate tab 10 mg QL (180 per month)
metadate tab 20mg er QL (150 per month); ST
(Must have recently been on
30 days of generic
immediate-release ADHD
drug, methylphenidate cap cr (cd), amphetamine-
dextroamphetamine cap sr
24hr OR
dextroamphetamine sulfate
cap sr 24hr)
methylphenidate hcl cap er 10 mg (cd) QL (300 per month)
methylphenidate hcl cap er 20 mg (cd) QL (150 per month)
methylphenidate hcl cap er 24hr 20 mg (la) QL (150 per month); ST
(Must have recently been on
30 days of generic immediate-release ADHD
drug, methylphenidate cap
cr (cd), amphetamine-
dextroamphetamine cap sr
24hr OR dextroamphetamine sulfate
cap sr 24hr)
methylphenidate hcl cap er 24hr 30 mg (la) QL (90 per month); ST (Must have recently been on
30 days of generic
immediate-release ADHD
drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr
24hr OR
dextroamphetamine sulfate
cap sr 24hr)
methylphenidate hcl cap er 24hr 40 mg (la) QL (60 per month); ST
(Must have recently been on
30 days of generic
immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine-
dextroamphetamine cap sr
24hr OR
dextroamphetamine sulfate
cap sr 24hr)
methylphenidate hcl cap er 30 mg (cd) QL (90 per month)
methylphenidate hcl cap er 40 mg (cd) QL (60 per month)
methylphenidate hcl cap er 50 mg (cd) QL (60 per month)
methylphenidate hcl cap er 60 mg (cd) QL (30 per month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
51
Drug Name Requirements/Limits
methylphenidate hcl soln 5 mg/5ml QL (3000 mL per month)
methylphenidate hcl soln 10 mg/5ml QL (1500 mL per month)
methylphenidate hcl tab 5 mg QL (600 per month)
methylphenidate hcl tab 10 mg QL (300 per month)
methylphenidate hcl tab 20 mg QL (150 per month)
methylphenidate hcl tab er 10 mg QL (300 per month); ST
(Must have recently been on
30 days of generic
immediate-release ADHD
drug, methylphenidate cap cr (cd), amphetamine-
dextroamphetamine cap sr
24hr OR
dextroamphetamine sulfate
cap sr 24hr)
methylphenidate hcl tab er 20 mg QL (150 per month); ST
(Must have recently been on
30 days of generic immediate-release ADHD
drug, methylphenidate cap
cr (cd), amphetamine-
dextroamphetamine cap sr
24hr OR dextroamphetamine sulfate
cap sr 24hr)
methylphenidate hcl tab er 24hr 18 mg QL (180 per month); ST (Must have recently been on
30 days of generic
immediate-release ADHD
drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr
24hr OR
dextroamphetamine sulfate
cap sr 24hr)
methylphenidate hcl tab er 24hr 27 mg QL (120 per month); ST
(Must have recently been on
30 days of generic
immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine-
dextroamphetamine cap sr
24hr OR
dextroamphetamine sulfate cap sr 24hr)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
52
Drug Name Requirements/Limits
methylphenidate hcl tab er 24hr 36 mg QL (90 per month); ST
(Must have recently been on
30 days of generic immediate-release ADHD
drug, methylphenidate cap
cr (cd), amphetamine-
dextroamphetamine cap sr
24hr OR dextroamphetamine sulfate
cap sr 24hr)
methylphenidate hcl tab er 24hr 54 mg QL (60 per month); ST (Must have recently been on
30 days of generic
immediate-release ADHD
drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr
24hr OR
dextroamphetamine sulfate
cap sr 24hr)
methylphenidate hcl tab er osmotic release (osm)
18 mg
QL (180 per month); ST
(Must have recently been on
30 days of generic
immediate-release ADHD drug, methylphenidate cap
cr (cd), amphetamine-
dextroamphetamine cap sr
24hr OR
dextroamphetamine sulfate cap sr 24hr)
methylphenidate hcl tab er osmotic release (osm)
27 mg
QL (120 per month); ST
(Must have recently been on 30 days of generic
immediate-release ADHD
drug, methylphenidate cap
cr (cd), amphetamine-
dextroamphetamine cap sr 24hr OR
dextroamphetamine sulfate
cap sr 24hr)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
53
Drug Name Requirements/Limits
methylphenidate hcl tab er osmotic release (osm)
36 mg
QL (90 per month); ST
(Must have recently been on
30 days of generic immediate-release ADHD
drug, methylphenidate cap
cr (cd), amphetamine-
dextroamphetamine cap sr
24hr OR dextroamphetamine sulfate
cap sr 24hr)
methylphenidate hcl tab er osmotic release (osm) 54 mg
QL (60 per month); ST (Must have recently been on
30 days of generic
immediate-release ADHD
drug, methylphenidate cap
cr (cd), amphetamine- dextroamphetamine cap sr
24hr OR
dextroamphetamine sulfate
cap sr 24hr)
FIBROMYALGIA SAVELLA MIS TITR PAK PA
SAVELLA TAB 12.5MG PA
SAVELLA TAB 25MG PA
SAVELLA TAB 50MG PA
SAVELLA TAB 100MG PA
HUNTINGTON'S DISEASE AGENTS AUSTEDO TAB 6MG SP, PA
AUSTEDO TAB 9MG SP, PA
AUSTEDO TAB 12MG SP, PA
tetrabenazine tab 12.5 mg SP, PA
tetrabenazine tab 25 mg SP, PA
HYPNOTICS, BENZODIAZEPINES temazepam cap 7.5 mg OB7, QL (15 per month)
temazepam cap 15 mg OB7, QL (15 per month)
temazepam cap 22.5 mg OB7, QL (15 per month)
temazepam cap 30 mg OB7, QL (15 per month)
HYPNOTICS, NON-BENZODIAZEPINES diphenhydramine hcl (sleep) cap 50 mg OTC
diphenhydramine hcl (sleep) tab 25 mg OTC
diphenhydramine hcl (sleep) tab 50 mg OTC
doxylamine succinate (sleep) tab 25 mg OTC
zolpidem tartrate tab 5 mg QL (30 per month)
zolpidem tartrate tab 10 mg QL (30 per month)
zolpidem tartrate tab er 6.25 mg QL (30 per month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
54
Drug Name Requirements/Limits
zolpidem tartrate tab er 12.5 mg QL (30 per month)
MIGRAINE, ERGOTAMINE DERIVATIVES ergotamine w/ caffeine tab 1-100 mg
MIGRAINE, SELECTIVE SEROTONIN AGONISTS naratriptan hcl tab 1 mg (base equiv) QL (12 per month); ST
(Must have recently been on
9 days of sumatriptan)
naratriptan hcl tab 1 mg (base equiv) QL (12 per month); ST
(Must have recently been on
9 days supply of
sumatriptan)
naratriptan hcl tab 2.5 mg (base equiv) QL (12 per month); ST
(Must have recently been on
9 days of sumatriptan)
naratriptan hcl tab 2.5 mg (base equiv) QL (12 per month); ST
(Must have recently been on 9 days supply of
sumatriptan)
rizatriptan benzoate oral disintegrating tab 5 mg (base eq)
QL (18 per month); ST (Must have recently been on
9 days supply of
sumatriptan)
rizatriptan benzoate oral disintegrating tab 10 mg
(base eq)
QL (18 per month); ST
(Must have recently been on
9 days supply of
sumatriptan)
rizatriptan benzoate tab 5 mg (base equivalent) QL (18 per month); ST
(Must have recently been on
9 days supply of
sumatriptan)
rizatriptan benzoate tab 10 mg (base equivalent) QL (18 per month); ST
(Must have recently been on 9 days supply of
sumatriptan)
sumatriptan nasal spray 5 mg/act QL (24 per month)
sumatriptan nasal spray 20 mg/act QL (24 per month)
sumatriptan succinate inj 6 mg/0.5ml QL (6 per month)
sumatriptan succinate solution auto-injector 4
mg/0.5ml
QL (6 per month)
sumatriptan succinate solution auto-injector 6
mg/0.5ml
QL (6 per month)
sumatriptan succinate solution cartridge 4
mg/0.5ml
QL (6 per month)
sumatriptan succinate solution cartridge 6
mg/0.5ml
QL (6 per month)
sumatriptan succinate tab 25 mg QL (12 per month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
55
Drug Name Requirements/Limits
sumatriptan succinate tab 50 mg QL (12 per month)
sumatriptan succinate tab 100 mg QL (12 per month)
zolmitriptan orally disintegrating tab 2.5 mg QL (12 per month); ST
(Must have recently been on
9 days supply of sumatriptan)
zolmitriptan orally disintegrating tab 5 mg QL (12 per month); ST (Must have recently been on
9 days supply of
sumatriptan)
zolmitriptan tab 2.5 mg QL (12 per month); ST
(Must have recently been on
9 days supply of
sumatriptan)
zolmitriptan tab 5 mg QL (12 per month); ST
(Must have recently been on
9 days supply of
sumatriptan)
MISCELLANEOUS riluzole tab 50 mg
MOOD STABILIZERS EQUETRO CAP 100MG
EQUETRO CAP 200MG
EQUETRO CAP 300MG
lithium carbonate cap 150 mg
lithium carbonate cap 300 mg
lithium carbonate cap 600 mg
lithium carbonate tab 300 mg
lithium carbonate tab er 300 mg
lithium carbonate tab er 450 mg
LITHIUM SOL 8MEQ/5ML
LITHOBID TAB 300MG CR +
MULTIPLE SCLEROSIS AUBAGIO TAB 7MG SP, PA
AUBAGIO TAB 14MG SP, PA
AVONEX PEN KIT 30MCG SP
AVONEX PREFL KIT 30MCG SP
BETASERON INJ 0.3MG SP
COPAXONE INJ 40MG/ML SP; +
dalfampridine tab er 12hr 10 mg SP, PA
EXTAVIA INJ 0.3MG SP
GILENYA CAP 0.5MG SP, PA
glatiramer acetate soln prefilled syringe 20 mg/ml SP
glatiramer acetate soln prefilled syringe 40 mg/ml SP
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
56
Drug Name Requirements/Limits
REBIF INJ 22/0.5 SP
REBIF INJ 44/0.5 SP
REBIF REBIDO INJ 22/0.5 SP
REBIF REBIDO INJ 44/0.5 SP
REBIF REBIDO INJ TITRATN SP
REBIF TITRTN INJ PACK SP
TECFIDERA CAP 120MG SP, PA
TECFIDERA CAP 240MG SP, PA
TECFIDERA MIS STARTER SP, PA
MUSCULOSKELETAL THERAPY AGENTS baclofen tab 10 mg
baclofen tab 20 mg
carisoprodol tab 250 mg QL (120 per month)
carisoprodol tab 350 mg QL (120 per month)
chlorzoxazone tab 500 mg
cyclobenzaprine hcl tab 5 mg
cyclobenzaprine hcl tab 10 mg
dantrolene sodium cap 25 mg
dantrolene sodium cap 50 mg
dantrolene sodium cap 100 mg
methocarbamol tab 500 mg
methocarbamol tab 750 mg
orphenadrine citrate tab er 12hr 100 mg
tizanidine hcl tab 2 mg (base equivalent)
tizanidine hcl tab 4 mg (base equivalent)
MYASTHENIA GRAVIS pyridostigmine bromide oral soln 60 mg/5ml
pyridostigmine bromide tab 60 mg
pyridostigmine bromide tab er 180 mg
NARCOLEPSY armodafinil tab 50 mg PA
armodafinil tab 150 mg PA
armodafinil tab 200 mg PA
armodafinil tab 250 mg PA
modafinil tab 100 mg PA
modafinil tab 200 mg PA
PSYCHOTHERAPEUTIC-MISCELLANEOUS, ALCOHOL DETERRENTS acamprosate calcium tab delayed release 333 mg PA
disulfiram tab 250 mg
disulfiram tab 500 mg
PSYCHOTHERAPEUTIC-MISCELLANEOUS, OPIOID ANTAGONISTS naltrexone hcl tab 50 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
57
Drug Name Requirements/Limits
NARCAN SPR QL (2 cartons (4 nasal
sprays) per 180 days)
PSYCHOTHERAPEUTIC-MISCELLANEOUS, PARTIAL OPIOID
AGONIST/OPIOID ANTAGONIST COMBINATIONS buprenorphine hcl-naloxone hcl sl film 2-0.5 mg
(base equiv)
buprenorphine hcl-naloxone hcl sl film 4-1 mg
(base equiv)
buprenorphine hcl-naloxone hcl sl film 8-2 mg
(base equiv)
buprenorphine hcl-naloxone hcl sl film 12-3 mg
(base equiv)
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg
(base equiv)
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)
ZUBSOLV SUB 0.7-0.18
ZUBSOLV SUB 1.4-0.36
ZUBSOLV SUB 2.9-0.71
ZUBSOLV SUB 5.7-1.4
ZUBSOLV SUB 8.6-2.1
ZUBSOLV SUB 11.4-2.9
PSYCHOTHERAPEUTIC-MISCELLANEOUS, PARTIAL OPIOID
AGONISTS buprenorphine hcl sl tab 2 mg (base equiv)
buprenorphine hcl sl tab 8 mg (base equiv)
PSYCHOTHERAPEUTIC-MISCELLANEOUS, PSEUDOBULBAR AFFECT
AGENTS NUEDEXTA CAP 20-10MG PA
PSYCHOTHERAPEUTIC-MISCELLANEOUS, SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab er 12hr 150
mg
QL (Max 180 days per
year); AL (covered for ages 18 and over)
CHANTIX PAK 0.5& 1MG QL (Max 180 days per
year); AL (covered for ages 18 and over)
CHANTIX PAK 1MG QL (Max 180 days per year); AL (covered for ages
18 and over)
CHANTIX TAB 0.5MG QL (Max 180 days per year); AL (covered for ages
18 and over)
CHANTIX TAB 1MG QL (Max 180 days per year); AL (covered for ages
18 and over)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
58
Drug Name Requirements/Limits
nicotine polacrilex gum 2 mg OTC, QL (Max 180 days per
year); AL (covered for ages
18 and over)
nicotine polacrilex gum 4 mg OTC, QL (Max 180 days per
year); AL (covered for ages
18 and over)
nicotine td patch 24hr 7 mg/24hr OTC, QL (Max 180 days per
year); AL (covered for ages 18 and over)
nicotine td patch 24hr 14 mg/24hr OTC, QL (Max 180 days per
year); AL (covered for ages 18 and over)
nicotine td patch 24hr 21 mg/24hr OTC, QL (Max 180 days per year); AL (covered for ages
18 and over)
ENDOCRINE AND METABOLIC ANDROGENS
danazol cap 50 mg
danazol cap 100 mg
danazol cap 200 mg
testosterone td gel 10mg/act (2%) PA; Males only
testosterone td gel 25 mg/2.5gm (1%) PA
ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS acarbose tab 25 mg
acarbose tab 50 mg
acarbose tab 100 mg
ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS glipizide-metformin hcl tab 2.5-250 mg
glipizide-metformin hcl tab 2.5-500 mg
glipizide-metformin hcl tab 5-500 mg
glyburide-metformin tab 1.25-250 mg
glyburide-metformin tab 2.5-500 mg
glyburide-metformin tab 5-500 mg
ANTIDIABETICS, BIGUANIDES metformin hcl tab 500 mg
metformin hcl tab 850 mg
metformin hcl tab 1000 mg
metformin hcl tab er 24hr 500 mg
metformin hcl tab er 24hr 750 mg
ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)
INHIBITOR/BIGUANIDE COMBINATIONS JANUMET TAB 50-500MG ST (Must try metformin,
sulfonylurea, or insulin
sensitizer)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
59
Drug Name Requirements/Limits
JANUMET TAB 50-1000 ST (Must try metformin,
sulfonylurea, or insulin
sensitizer)
JANUMET XR TAB 50-500MG ST (Must try metformin,
sulfonylurea, or insulin
sensitizer)
JANUMET XR TAB 50-1000 ST (Must try metformin,
sulfonylurea, or insulin sensitizer)
JANUMET XR TAB 100-1000 ST (Must try metformin,
sulfonylurea, or insulin sensitizer)
ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TAB 25MG ST (Must try metformin,
sulfonylurea, or insulin sensitizer)
JANUVIA TAB 50MG ST (Must try metformin,
sulfonylurea, or insulin sensitizer)
JANUVIA TAB 100MG ST (Must try metformin,
sulfonylurea, or insulin sensitizer)
ANTIDIABETICS, INCRETIN MIMETIC AGENT/INSULIN
COMBINATIONS SOLIQUA INJ 100/33 ST (Must try metformin AND
long-acting insulin or
another mono incretin
mimetic agent)
ANTIDIABETICS, INCRETIN MIMETIC AGENTS OZEMPIC INJ 2/1.5ML ST (Must have been on 30
days of metformin)
TRULICITY INJ 0.75/0.5 ST (Must have been on 30 days of metformin)
TRULICITY INJ 1.5/0.5 ST (Must have been on 30 days of metformin)
VICTOZA INJ 18MG/3ML ST (Must have been on 30
days of metformin)
ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE
COMBINATIONS pioglitazone hcl-metformin hcl tab 15-500 mg
pioglitazone hcl-metformin hcl tab 15-850 mg
ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA
COMBINATIONS pioglitazone hcl-glimepiride tab 30-2 mg
pioglitazone hcl-glimepiride tab 30-4 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
60
Drug Name Requirements/Limits
ANTIDIABETICS, INSULIN SENSITIZERS pioglitazone hcl tab 15 mg (base equiv)
pioglitazone hcl tab 30 mg (base equiv)
pioglitazone hcl tab 45 mg (base equiv)
ANTIDIABETICS, INSULINS APIDRA INJ SOLOSTAR
APIDRA INJ U-100
BASAGLAR INJ 100UNIT
FIASP FLEX INJ TOUCH
FIASP INJ 100/ML
HUMALOG INJ 100/ML
HUMALOG JR INJ 100/ML
HUMALOG KWIK INJ 100/ML
HUMALOG MIX INJ 50/50
HUMALOG MIX INJ 50/50KWP
HUMALOG MIX INJ 75/25KWP
HUMALOG MIX SUS 75/25
HUMULIN INJ 70/30 OTC
HUMULIN INJ 70/30KWP OTC
HUMULIN N INJ U-100 OTC
HUMULIN N INJ U-100KWP OTC
HUMULIN R INJ U-100 OTC
HUMULIN R INJ U-500
NOVOLIN70/30 INJ RELION OTC
NOVOLIN INJ 70/30 OTC
NOVOLIN INJ FLEXPEN OTC
NOVOLIN N INJ RELION OTC
NOVOLIN N INJ U-100 OTC
NOVOLIN R INJ RELION OTC
NOVOLIN R INJ U-100 OTC
NOVOLOG INJ 100/ML
NOVOLOG INJ FLEXPEN
NOVOLOG INJ PENFILL
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ FLEXPEN
ANTIDIABETICS, MEGLITINIDES nateglinide tab 60 mg
nateglinide tab 120 mg
repaglinide tab 0.5 mg
repaglinide tab 1 mg
repaglinide tab 2 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
61
Drug Name Requirements/Limits
ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)
INHIBITOR/BIGUANIDE COMBINATIONS INVOKAMET TAB 50-500MG ST (Must try metformin,
sulfonylurea, or insulin
sensitizer)
INVOKAMET TAB 50-1000 ST (Must try metformin,
sulfonylurea, or insulin
sensitizer)
INVOKAMET TAB 150-500 ST (Must try metformin,
sulfonylurea, or insulin
sensitizer)
INVOKAMET TAB 150-1000 ST (Must try metformin,
sulfonylurea, or insulin
sensitizer)
INVOKAMET XR TAB 50-500MG ST (Must try metformin,
sulfonylurea, or insulin
sensitizer)
INVOKAMET XR TAB 50-1000 ST (Must try metformin,
sulfonylurea, or insulin
sensitizer)
INVOKAMET XR TAB 150-500 ST (Must try metformin,
sulfonylurea, or insulin
sensitizer)
INVOKAMET XR TAB 150-1000 ST (Must try metformin,
sulfonylurea, or insulin sensitizer)
ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)
INHIBITORS INVOKANA TAB 100MG ST (Must try metformin,
sulfonylurea, or insulin
sensitizer)
INVOKANA TAB 300MG ST (Must try metformin, sulfonylurea, or insulin
sensitizer)
ANTIDIABETICS, SULFONYLUREAS glimepiride tab 1 mg
glimepiride tab 2 mg
glimepiride tab 4 mg
glipizide tab 5 mg
glipizide tab 10 mg
glipizide tab er 24hr 2.5 mg
glipizide tab er 24hr 5 mg
glipizide tab er 24hr 10 mg
glyburide micronized tab 1.5 mg
glyburide micronized tab 3 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
62
Drug Name Requirements/Limits
glyburide micronized tab 6 mg
glyburide tab 1.25 mg
glyburide tab 2.5 mg
glyburide tab 5 mg
ANTIDIABETICS, SUPPLIES ALCOHOL SWAB PAD OTC, QL (400 per month)
BD INSULIN SYRINGE 0.3/30G OTC
BD INSULIN SYRINGE 0.3/31G OTC
BD INSULIN SYRINGE 0.5/30G OTC
BD INSULIN SYRINGE 0.5/31G OTC
BD INSULIN SYRINGE 1ML/30G OTC
BD INSULIN SYRINGE 1ML/31G OTC
BD PEN NEEDL MIS 29GX12.7 OTC
BD PEN NEEDL MIS 31GX5MM OTC
BD PEN NEEDL MIS 31GX8MM OTC
BD PEN NEEDL MIS 32GX4MM OTC
BD PEN NEEDL MIS 32GX6MM OTC
BD U-500 MIS 31GX6MM OTC
FREESTYLE TES OTC
FREESTYLE TES INSULINX OTC
FREESTYLE TES LITE OTC
KETO-DIASTIX TES OTC, QL (100 per month)
LANCETS MIS OTC
PRECISION TES XTRA OTC
CALCIUM RECEPTOR ANTAGONISTS SENSIPAR TAB 30MG SP, PA
SENSIPAR TAB 60MG SP, PA
SENSIPAR TAB 90MG SP, PA
CALCIUM REGULATORS, BISPHOSPHONATES alendronate sodium tab 5 mg
alendronate sodium tab 10 mg
alendronate sodium tab 35 mg
alendronate sodium tab 40 mg
alendronate sodium tab 70 mg
CALCIUM REGULATORS, CALCITONINS calcitonin (salmon) nasal soln 200 unit/act
CALCIUM REGULATORS, PARATHYROID HORMONES FORTEO SOL 600/2.4 SP, PA
CARNITINE DEFICIENCY AGENTS levocarnitine oral soln 1 gm/10ml (10%)
levocarnitine tab 330 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
63
Drug Name Requirements/Limits
CONTRACEPTIVES, BIPHASIC desogest-eth estrad & eth estrad tab 0.15-
0.02/0.01 mg(21/5) Females only
CONTRACEPTIVES, EMERGENCY CONTRACEPTION ELLA TAB 30MG QL (2 per year); Females
only
levonorgestrel tab 1.5 mg OTC, QL (2 per year);
Females only
CONTRACEPTIVES, INJECTABLE medroxyprogesterone acetate im susp 150 mg/ml QL (1 mL per 3 months);
Females only
medroxyprogesterone acetate im susp prefilled syr
150 mg/ml
QL (1 mL per 3 months);
Females only
CONTRACEPTIVES, MISCELLANEOUS CONDOMS MIS OTC, QL (24 per month);
Males only
DIAPHRAGM QL (1 per year)
ENCARE SUP 100MG OTC
GYNOL II GEL 3% OTC
nonoxynol-9 gel 4% OTC
SHUR-SEAL GEL 2% OTC
VCF VAGINAL AER CONTRACP OTC
VCF VAGINAL MIS CONTRACP OTC
CONTRACEPTIVES, MONOPHASIC, 20 mcg Estrogen drospirenone-ethinyl estradiol tab 3-0.02 mg Females only
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg
Females only
norethindrone ace & ethinyl estradiol tab 1 mg-20
mcg
Females only
norethindrone ace & ethinyl estradiol-fe tab 1 mg-
20 mcg
Females only
CONTRACEPTIVES, MONOPHASIC, 30 mcg Estrogen desogestrel & ethinyl estradiol tab 0.15 mg-30
mcg
Females only
drospirenone-ethinyl estradiol tab 3-0.03 mg Females only
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg
Females only
norethindrone ace & ethinyl estradiol tab 1.5 mg-
30 mcg
Females only
norethindrone ace & ethinyl estradiol-fe tab 1.5
mg-30 mcg
Females only
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg Females only
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
64
Drug Name Requirements/Limits
CONTRACEPTIVES, MONOPHASIC, 35 mcg Estrogen ethynodiol diacetate & ethinyl estradiol tab 1 mg-
35 mcg Females only
norethindrone & ethinyl estradiol tab 0.4 mg-35
mcg
Females only
norethindrone & ethinyl estradiol tab 0.5 mg-35
mcg
Females only
norethindrone & ethinyl estradiol tab 1 mg-35 mcg Females only
norgestimate & ethinyl estradiol tab 0.25 mg-35
mcg
Females only
CONTRACEPTIVES, MONOPHASIC, 50 mcg Estrogen ethynodiol diacetate & ethinyl estradiol tab 1 mg-
50 mcg
Females only
norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg Females only
CONTRACEPTIVES, PROGESTIN ONLY norethindrone tab 0.35 mg Females only
CONTRACEPTIVES, TRANSDERMAL norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr
Females only
CONTRACEPTIVES, TRIPHASIC desogest-ethin est tab 0.1-0.025/0.125-
0.025/0.15-0.025mg-mg
Females only
levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg
Females only
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-
35 mg-mcg
Females only
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-
35 mg-mcg
Females only
norgestimate-eth estrad tab 0.18-25/0.215-
25/0.25-25 mg-mcg
Females only
norgestimate-eth estrad tab 0.18-35/0.215-
35/0.25-35 mg-mcg
Females only
CONTRACEPTIVES, VAGINAL NUVARING MIS Females only
ENDOMETRIOSIS danazol cap 50 mg
danazol cap 100 mg
danazol cap 200 mg
SYNAREL SOL 2MG/ML
ESTROGEN/PROGESTIN, ORAL estradiol & norethindrone acetate tab 0.5-0.1 mg Females only
estradiol & norethindrone acetate tab 1-0.5 mg Females only
norethindrone acetate-ethinyl estradiol tab 0.5
mg-2.5 mcg
Females only
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
65
Drug Name Requirements/Limits
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg
Females only
ESTROGEN/PROGESTIN, TRANSDERMAL COMBIPATCH DIS Females only
ESTROGENS, ORAL estradiol tab 0.5 mg Females only
estradiol tab 1 mg Females only
estradiol tab 2 mg Females only
ESTROGENS, TRANSDERMAL estradiol td patch weekly 0.1 mg/24hr Females only
estradiol td patch weekly 0.05 mg/24hr Females only
estradiol td patch weekly 0.06 mg/24hr Females only
estradiol td patch weekly 0.025 mg/24hr Females only
estradiol td patch weekly 0.075 mg/24hr Females only
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr)
Females only
ESTROGENS, VAGINAL estradiol vaginal tab 10 mcg
PREMARIN VAG CRE 0.625MG
GAUCHER DISEASE CERDELGA CAP 84MG SP, PA
GLUCOCORTICOIDS dexamethasone elixir 0.5 mg/5ml
dexamethasone soln 0.5 mg/5ml
dexamethasone tab 0.5 mg
dexamethasone tab 0.75 mg
dexamethasone tab 1 mg
dexamethasone tab 1.5 mg
dexamethasone tab 2 mg
dexamethasone tab 4 mg
dexamethasone tab 6 mg
hydrocortisone tab 5 mg
hydrocortisone tab 10 mg
hydrocortisone tab 20 mg
MEDROL TAB 2MG
methylprednisolone tab 4 mg
methylprednisolone tab 8 mg
methylprednisolone tab 16 mg
methylprednisolone tab 32 mg
methylprednisolone tab therapy pack 4 mg (21)
prednisolone sod phos orally disintegr tab 10 mg (base eq)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
66
Drug Name Requirements/Limits
prednisolone sod phos orally disintegr tab 15 mg
(base eq)
prednisolone sod phos orally disintegr tab 30 mg
(base eq)
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base)
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv)
prednisolone syrup 15 mg/5ml (usp solution
equivalent)
prednisone oral soln 5 mg/5ml
prednisone tab 1 mg
prednisone tab 2.5 mg
prednisone tab 5 mg
prednisone tab 10 mg
prednisone tab 20 mg
prednisone tab 50 mg
prednisone tab therapy pack 5 mg (21)
prednisone tab therapy pack 5 mg (48)
prednisone tab therapy pack 10 mg (21)
prednisone tab therapy pack 10 mg (48)
GLUCOSE ELEVATING AGENTS GLUCAGEN INJ HYPOKIT QL (2 inj per month)
GLUCAGON KIT 1MG QL (2 inj per month)
HEREDITARY TYROSINEMIA TYPE 1 AGENTS NITYR TAB 2MG SP, PA
NITYR TAB 5MG SP, PA
NITYR TAB 10MG SP, PA
HUMAN GROWTH HORMONES GENOTROPIN INJ 0.2MG SP, PA
GENOTROPIN INJ 0.4MG SP, PA
GENOTROPIN INJ 0.6MG SP, PA
GENOTROPIN INJ 0.8MG SP, PA
GENOTROPIN INJ 1.2MG SP, PA
GENOTROPIN INJ 1.4MG SP, PA
GENOTROPIN INJ 1.6MG SP, PA
GENOTROPIN INJ 1.8MG SP, PA
GENOTROPIN INJ 1MG SP, PA
GENOTROPIN INJ 2MG SP, PA
GENOTROPIN INJ 5MG SP, PA
GENOTROPIN INJ 12MG SP, PA
HUMATROPE INJ 5MG SP, PA
HUMATROPE INJ 6MG SP, PA
HUMATROPE INJ 12MG SP, PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
67
Drug Name Requirements/Limits
HUMATROPE INJ 24MG SP, PA
NORDITROPIN INJ 5/1.5ML SP, PA
NORDITROPIN INJ 10/1.5ML SP, PA
NORDITROPIN INJ 15/1.5ML SP, PA
NORDITROPIN INJ 30/3ML SP, PA
NUTROPIN AQ INJ 10MG/2ML SP, PA
NUTROPIN AQ INJ 20MG/2ML SP, PA
NUTROPIN AQ INJ NUSPIN 5 SP, PA
OMNITROPE INJ 5.8MG SP, PA
OMNITROPE INJ 5/1.5ML SP, PA
OMNITROPE INJ 10/1.5ML SP, PA
SAIZEN INJ 5MG SP, PA
SAIZEN INJ 8.8MG SP, PA
SAIZENPREP INJ 8.8MG SP, PA
SEROSTIM INJ 4MG SP, PA
SEROSTIM INJ 5MG SP, PA
SEROSTIM INJ 6MG SP, PA
ZOMACTON INJ 5MG SP, PA
ZOMACTON INJ 10MG SP, PA
ZORBTIVE INJ 8.8MG SP, PA
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol cap 0.5 mcg
calcitriol cap 0.25 mcg
calcitriol oral soln 1 mcg/ml
doxercalciferol cap 0.5 mcg
doxercalciferol cap 1 mcg
doxercalciferol cap 2.5 mcg
paricalcitol cap 1 mcg
paricalcitol cap 2 mcg
paricalcitol cap 4 mcg
MINERALOCORTICOIDS fludrocortisone acetate tab 0.1 mg
MISCELLANEOUS cabergoline tab 0.5 mg
CYSTAGON CAP 50MG SP, PA
CYSTAGON CAP 150MG SP, PA
PHENYLKETONURIA TREATMENT AGENTS KUVAN POW 100MG SP, PA
KUVAN TAB 100MG SP, PA
PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) cap 667 mg
(169 mg ca)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
68
Drug Name Requirements/Limits
sevelamer carbonate packet 0.8 gm ST (Must try calcium acetate
(generic PHOSLO))
sevelamer carbonate packet 2.4 gm ST (Must try calcium acetate
(generic PHOSLO))
sevelamer carbonate tab 800 mg ST (Must try calcium acetate
(generic PHOSLO))
POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate oral susp 15
gm/60ml
sodium polystyrene sulfonate rectal susp 30 gm/120ml
PROGESTINS, ORAL medroxyprogesterone acetate tab 2.5 mg
medroxyprogesterone acetate tab 5 mg
medroxyprogesterone acetate tab 10 mg
megestrol acetate susp 40 mg/ml
norethindrone acetate tab 5 mg
progesterone micronized cap 100 mg
progesterone micronized cap 200 mg
PROGESTINS, VAGINAL CRINONE GEL 4% VAG PA
CRINONE GEL 8% VAG PA
SELECTIVE ESTROGEN RECEPTOR MODULATORS OSPHENA TAB 60MG PA
raloxifene hcl tab 60 mg
THYROID AGENTS, ANTITHYROID AGENTS methimazole tab 5 mg
methimazole tab 10 mg
propylthiouracil tab 50 mg
SSKI SOL 1GM/ML
THYROID AGENTS, THYROID SUPPLEMENTS CYTOMEL TAB 5MCG +
CYTOMEL TAB 25MCG +
CYTOMEL TAB 50MCG +
levothyroxine sodium tab 25 mcg
levothyroxine sodium tab 50 mcg
levothyroxine sodium tab 75 mcg
levothyroxine sodium tab 88 mcg
levothyroxine sodium tab 100 mcg
levothyroxine sodium tab 112 mcg
levothyroxine sodium tab 125 mcg
levothyroxine sodium tab 137 mcg
levothyroxine sodium tab 150 mcg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
69
Drug Name Requirements/Limits
levothyroxine sodium tab 175 mcg
levothyroxine sodium tab 200 mcg
levothyroxine sodium tab 300 mcg
liothyronine sodium tab 5 mcg
liothyronine sodium tab 25 mcg
liothyronine sodium tab 50 mcg
SYNTHROID TAB 25MCG +
SYNTHROID TAB 50MCG +
SYNTHROID TAB 75MCG +
SYNTHROID TAB 88MCG +
SYNTHROID TAB 100MCG +
SYNTHROID TAB 112MCG +
SYNTHROID TAB 125MCG +
SYNTHROID TAB 137MCG +
SYNTHROID TAB 150MCG +
SYNTHROID TAB 175MCG +
SYNTHROID TAB 200MCG +
SYNTHROID TAB 300MCG +
UREA CYCLE DISORDERS sodium phenylbutyrate oral powder 3
gm/teaspoonful
SP, PA
sodium phenylbutyrate tab 500 mg SP, PA
VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA TAB 15MG SP, PA
SAMSCA TAB 30MG SP, PA
VASOPRESSINS DDAVP SOL 0.01% PA
desmopressin acetate nasal spray soln 0.01% PA
desmopressin acetate nasal spray soln 0.01% (refrigerated)
PA
desmopressin acetate tab 0.1 mg PA
desmopressin acetate tab 0.2 mg PA
GASTROINTESTINAL ANTACIDS
alum & mag hydroxide-simethicone chew tab 200-200-25 mg
OTC
alum & mag hydroxide-simethicone susp 200-200-20 mg/5ml
OTC
alum & mag hydroxide-simethicone susp 400-400-
40 mg/5ml
OTC
aluminum hydroxide-magnesium carbonate chew
tab 160-105 mg
OTC
aluminum hydroxide-magnesium carbonate susp
95-358 mg/15ml
OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
70
Drug Name Requirements/Limits
aluminum hydroxide-magnesium carbonate susp
508-475 mg/10ml
OTC
aluminum hydroxide-magnesium trisilicate chew
tab 80-20 mg
OTC
ANTACID CHW 1177MG OTC
CALCIUM CARB TAB 648MG OTC
calcium carbonate (antacid) chew tab 400 mg OTC
calcium carbonate (antacid) chew tab 420 mg OTC
calcium carbonate (antacid) chew tab 500 mg OTC
calcium carbonate (antacid) chew tab 750 mg OTC
calcium carbonate (antacid) chew tab 1000 mg OTC
calcium carbonate (antacid) susp 1250 mg/5ml OTC
calcium carbonate-mag hydroxide chew tab 550-
110 mg
OTC
calcium carbonate-mag hydroxide susp 400-135
mg/5ml
OTC
MAALOX CHW 600MG OTC
TUMS CHW DEL CHW 1177MG OTC
ANTIDIARRHEALS bismuth subsalicylate chew tab 262 mg OTC
bismuth subsalicylate susp 262 mg/15ml OTC
bismuth subsalicylate susp 525 mg/15ml OTC
bismuth subsalicylate tab 262 mg OTC
diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml
diphenoxylate w/ atropine tab 2.5-0.025 mg
loperamide hcl cap 2 mg
loperamide hcl cap 2 mg OTC
loperamide hcl liq 1 mg/5ml (0.2 mg/ml) OTC
loperamide hcl tab 2 mg OTC
ANTIEMETICS aprepitant capsule 40 mg QL (6 caps per 6 months),
PA
aprepitant capsule 80 mg QL (16 caps per 21 days), PA
aprepitant capsule 125 mg QL (4 caps per 21 days), PA
aprepitant capsule therapy pack 80 & 125 mg QL (4 packs per 21 days)
dronabinol cap 2.5 mg QL (60 per month)
dronabinol cap 5 mg QL (60 per month)
dronabinol cap 10 mg QL (60 per month)
fosaprepitant dimeglumine for iv infusion 150 mg
(base eq)
QL (12 kits per 21 days), PA
granisetron hcl tab 1 mg QL (6 per 15 days)
meclizine hcl chew tab 25 mg OTC
meclizine hcl tab 12.5 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
71
Drug Name Requirements/Limits
meclizine hcl tab 12.5 mg OTC
meclizine hcl tab 25 mg
meclizine hcl tab 25 mg OTC
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)
(base equiv)
metoclopramide hcl tab 5 mg (base equivalent)
metoclopramide hcl tab 10 mg (base equivalent)
ondansetron hcl oral soln 4 mg/5ml QL (100 mL per 15 days)
ondansetron hcl tab 4 mg QL (12 per 15 days)
ondansetron hcl tab 8 mg QL (12 per 15 days)
ondansetron hcl tab 24 mg QL (1 per 15 days)
ondansetron orally disintegrating tab 4 mg QL (12 per 15 days)
ondansetron orally disintegrating tab 8 mg QL (12 per 15 days)
prochlorperazine maleate tab 5 mg (base
equivalent)
prochlorperazine maleate tab 10 mg (base
equivalent)
prochlorperazine suppos 25 mg
promethazine hcl suppos 12.5 mg
promethazine hcl suppos 25 mg
promethazine hcl suppos 50 mg
promethazine hcl syrup 6.25 mg/5ml
promethazine hcl tab 12.5 mg
promethazine hcl tab 25 mg
promethazine hcl tab 50 mg
trimethobenzamide hcl cap 300 mg
ANTISPASMODICS chlordiazepoxide hcl-clidinium bromide cap 5-2.5
mg
dicyclomine hcl cap 10 mg
dicyclomine hcl oral soln 10 mg/5ml
dicyclomine hcl tab 20 mg
glycopyrrolate tab 1 mg
glycopyrrolate tab 2 mg
CHOLELITHOLYTICS ursodiol cap 300 mg
ursodiol tab 250 mg
ursodiol tab 500 mg
H2-RECEPTOR ANTAGONISTS cimetidine hcl soln 300 mg/5ml
cimetidine tab 200 mg
cimetidine tab 200 mg OTC
cimetidine tab 300 mg
cimetidine tab 400 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
72
Drug Name Requirements/Limits
cimetidine tab 800 mg
famotidine for susp 40 mg/5ml
famotidine tab 10 mg OTC
famotidine tab 20 mg
famotidine tab 20 mg OTC
famotidine tab 40 mg
nizatidine cap 150 mg
nizatidine cap 300 mg
nizatidine oral soln 15 mg/ml
ranitidine hcl cap 150 mg
ranitidine hcl cap 300 mg
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)
ranitidine hcl tab 75 mg OTC
ranitidine hcl tab 150 mg
ranitidine hcl tab 150 mg OTC
ranitidine hcl tab 300 mg
INFLAMMATORY BOWEL DISEASE, ORAL AGENTS APRISO CAP 0.375GM ST (Must have recently been
on 30 days of sulfasalazine)
balsalazide disodium cap 750 mg
budesonide delayed release particles cap 3 mg
sulfasalazine tab 500 mg
sulfasalazine tab delayed release 500 mg
INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS hydrocortisone enema 100 mg/60ml
mesalamine enema 4 gm
mesalamine rectal enema 4 gm & cleanser wipe kit
IRRITABLE BOWEL SYNDROME WITH CONSTIPATION/CHRONIC
IDIOPATHIC CONSTIPATION LINZESS CAP 72MCG
LINZESS CAP 145MCG
LINZESS CAP 290MCG
TRULANCE TAB 3MG
LAXATIVES/STOOL SOFTENERS bisacodyl suppos 10 mg OTC
bisacodyl tab delayed release 5 mg OTC
docusate calcium cap 240 mg OTC
docusate sodium cap 50 mg OTC
docusate sodium cap 100 mg OTC
docusate sodium cap 250 mg OTC
docusate sodium liquid 150 mg/15ml OTC
docusate sodium syrup 60 mg/15ml OTC
docusate sodium tab 100 mg OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
73
Drug Name Requirements/Limits
lactulose solution 10 gm/15ml
PEDIA-LAX LIQ 50MG OTC
peg 3350-kcl-na bicarb-nacl-na sulfate for soln
236 gm
peg 3350-kcl-na bicarb-nacl-na sulfate for soln
240 gm
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
polyethylene glycol 3350 oral packet OTC
polyethylene glycol 3350 oral powder OTC
sennosides chew tab 15 mg OTC
sennosides syrup 8.8 mg/5ml OTC
sennosides tab 8.6 mg OTC
sennosides tab 15 mg OTC
sennosides tab 17.2 mg OTC
sennosides tab 25 mg OTC
sennosides-docusate sodium tab 8.6-50 mg OTC
MISCELLANEOUS CUVPOSA SOL 1MG/5ML AL (covered for ages 3-16)
GAS-X CHILD MIS 40MG OTC
lactulose (encephalopathy) solution 10 gm/15ml
simethicone cap 125 mg OTC
simethicone cap 180 mg OTC
simethicone chew tab 80 mg OTC
simethicone chew tab 125 mg OTC
simethicone liquid 40 mg/0.6ml OTC
simethicone susp 40 mg/0.6ml OTC
sucralfate tab 1 gm
OPIOID-INDUCED CONSTIPATION MOVANTIK TAB 12.5MG
MOVANTIK TAB 25MG
PANCREATIC ENZYMES CREON CAP 3000UNIT
CREON CAP 6000UNIT
CREON CAP 12000UNT
CREON CAP 24000UNT
CREON CAP 36000UNT
VIOKACE TAB 10440
VIOKACE TAB 20880
ZENPEP CAP 3000UNIT
ZENPEP CAP 5000UNIT
ZENPEP CAP 10000UNT
ZENPEP CAP 15000UNT
ZENPEP CAP 20000UNT
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
74
Drug Name Requirements/Limits
ZENPEP CAP 25000
ZENPEP CAP 25000UNT
ZENPEP CAP 40000
ZENPEP CAP 40000UNT
PROSTAGLANDINS misoprostol tab 100 mcg
misoprostol tab 200 mcg
PROTON PUMP INHIBITORS esomeprazole magnesium cap delayed release 20
mg (base eq)
QL (30 per month)
lansoprazole cap delayed release 15 mg OTC, QL (30 per month)
NEXIUM 24HR TAB 20MG OTC, QL (30 per month)
NEXIUM GRA 2.5MG DR QL (30 per month); AL
(Covered for ages less than
1 only)
NEXIUM GRA 5MG DR QL (30 per month); AL
(Covered for ages less than
1 only)
NEXIUM GRA 10MG DR QL (30 per month); AL
(Covered for ages less than
1 only)
omeprazole cap delayed release 10 mg QL (30 per month)
omeprazole cap delayed release 20 mg QL (30 per month)
omeprazole cap delayed release 40 mg QL (30 per month)
omeprazole delayed release tab 20 mg OTC
omeprazole magnesium cap dr 20.6 mg (20 mg
base equiv)
OTC, QL (30 per month)
omeprazole tab 20mg OTC
omeprazole-sodium bicarbonate cap 20-1100 mg QL (30 per month)
pantoprazole sodium ec tab 20 mg (base equiv) QL (30 per month)
pantoprazole sodium ec tab 40 mg (base equiv) QL (30 per month)
PRILOSEC OTC TAB 20MG OTC
SALIVA STIMULANTS pilocarpine hcl tab 5 mg
pilocarpine hcl tab 7.5 mg
STEROIDS, RECTAL hydrocortisone rectal cream 1%
hydrocortisone rectal cream 2.5%
GENITOURINARY BENIGN PROSTATIC HYPERPLASIA
alfuzosin hcl tab er 24hr 10 mg
finasteride tab 5 mg
tamsulosin hcl cap 0.4 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
75
Drug Name Requirements/Limits
MISCELLANEOUS acetic acid vaginal solution OTC
bethanechol chloride tab 5 mg
bethanechol chloride tab 10 mg
bethanechol chloride tab 25 mg
bethanechol chloride tab 50 mg
ELMIRON CAP 100MG
K-PHOS TAB
K-PHOS TAB NO 2
phenazopyridine hcl tab 100 mg
phenazopyridine hcl tab 200 mg
potassium citrate & citric acid powder pack 3300-
1002 mg
potassium citrate & citric acid soln 1100-334 mg/5ml
potassium citrate tab er 5 meq (540 mg)
potassium citrate tab er 10 meq (1080 mg)
potassium citrate tab er 15 meq (1620 mg)
URINARY ANTISPASMODICS oxybutynin chloride syrup 5 mg/5ml
oxybutynin chloride tab 5 mg
oxybutynin chloride tab er 24hr 5 mg
oxybutynin chloride tab er 24hr 10 mg
oxybutynin chloride tab er 24hr 15 mg
tolterodine tartrate tab 1 mg
tolterodine tartrate tab 2 mg
trospium chloride cap er 24hr 60 mg
trospium chloride tab 20 mg
VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal cream 2%
clotrimazole vaginal cream 1% OTC
clotrimazole vaginal cream 2% OTC
metronidazole vaginal gel 0.75%
miconazole nitrate vaginal app 200 mg & 2%
cream 9 gm kit
OTC
miconazole nitrate vaginal cream 2% OTC
miconazole nitrate vaginal cream 4% (200
mg/5gm)
OTC
miconazole nitrate vaginal supp 200 mg & 2%
cream 9 gm kit
OTC
miconazole nitrate vaginal supp 1200 mg & 2% cream kit
OTC
miconazole nitrate vaginal suppos 100 mg OTC
miconazole nitrate vaginal suppos 200 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
76
Drug Name Requirements/Limits
MONISTAT 3 KIT COMBO PK OTC
MONISTAT 7 KIT COMPLETE OTC
terconazole vaginal cream 0.4%
terconazole vaginal cream 0.8%
terconazole vaginal suppos 80 mg
HEMATOLOGIC ANTICOAGULANTS, ORAL
COUMADIN TAB 1MG +
COUMADIN TAB 2.5MG +
COUMADIN TAB 2MG +
COUMADIN TAB 3MG +
COUMADIN TAB 4MG +
COUMADIN TAB 5MG +
COUMADIN TAB 6MG +
COUMADIN TAB 7.5MG +
COUMADIN TAB 10MG +
ELIQUIS TAB 2.5MG
ELIQUIS TAB 5MG
warfarin sodium tab 1 mg
warfarin sodium tab 2 mg
warfarin sodium tab 2.5 mg
warfarin sodium tab 3 mg
warfarin sodium tab 4 mg
warfarin sodium tab 5 mg
warfarin sodium tab 6 mg
warfarin sodium tab 7.5 mg
warfarin sodium tab 10 mg
XARELTO STAR TAB 15/20MG
XARELTO TAB 2.5MG
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
HEMOSTATICS, SYSTEMIC aminocaproic acid oral soln 0.25 gm/ml
aminocaproic acid tab 500 mg
aminocaproic acid tab 1000 mg
MISCELLANEOUS CHEMET CAP 100MG
cilostazol tab 50 mg
cilostazol tab 100 mg
ENDARI POW 5GM SP, PA
pentoxifylline tab er 400 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
77
Drug Name Requirements/Limits
PLATELET AGGREGATION INHIBITORS aspirin chew tab 81 mg OTC
aspirin tab 325 mg OTC
aspirin tab 500 mg OTC
aspirin tab delayed release 81 mg OTC
aspirin tab delayed release 325 mg OTC
aspirin tab delayed release 500 mg OTC
BRILINTA TAB 60MG
BRILINTA TAB 90MG
clopidogrel bisulfate tab 75 mg (base equiv)
clopidogrel bisulfate tab 300 mg (base equiv)
dipyridamole tab 25 mg
dipyridamole tab 50 mg
dipyridamole tab 75 mg
prasugrel hcl tab 5 mg (base equiv)
prasugrel hcl tab 10 mg (base equiv)
ZONTIVITY TAB 2.08MG
PLATELET SYNTHESIS INHIBITOR anagrelide hcl cap 0.5 mg
anagrelide hcl cap 1 mg
THROMBOCYTOPENIA AGENTS MULPLETA TAB 3MG SP, PA
PROMACTA TAB 12.5MG SP, PA
PROMACTA TAB 25MG SP, PA
PROMACTA TAB 50MG SP, PA
PROMACTA TAB 75MG SP, PA
IMMUNOLOGIC AGENTS AUTOIMMUNE AGENTS
ENBREL INJ 25/0.5ML SP, PA
ENBREL INJ 25MG SP, PA
ENBREL INJ 50MG/ML SP, PA
ENBREL MINI INJ 50MG/ML SP, PA
ENBREL SRCLK INJ 50MG/ML SP, PA
HUMIRA INJ 10/0.1ML SP, PA
HUMIRA INJ 10MG/0.2 SP, PA
HUMIRA INJ 20/0.2ML SP, PA
HUMIRA INJ 40/0.4ML SP, PA
HUMIRA KIT 20MG/0.4 SP, PA
HUMIRA KIT 40MG/0.8 SP, PA
HUMIRA PEDIA INJ CROHNS SP, PA
HUMIRA PEN INJ 40/0.4ML SP, PA
HUMIRA PEN INJ 40MG/0.8 SP, PA
HUMIRA PEN INJ CD/UC/HS SP, PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
78
Drug Name Requirements/Limits
HUMIRA PEN INJ PS/UV SP, PA
HUMIRA PEN KIT CD/UC/HS SP, PA
HUMIRA PEN KIT PS/UV SP, PA
XELJANZ TAB 5MG SP, PA
XELJANZ TAB 10MG SP, PA
XELJANZ XR TAB 11MG SP, PA
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine sulfate tab 200 mg
leflunomide tab 10 mg
leflunomide tab 20 mg
IMMUNOMODULATORS, INTERFERONS PEGASYS INJ SP, PA
PEGASYS INJ 180MCG/M SP, PA
PEGASYS INJ PROCLICK SP, PA
PEGINTRON KIT 50MCG SP, PA
IMMUNOSUPPRESSANTS, ANTIMETABOLITES AZASAN TAB 75 MG +
AZASAN TAB 100MG
azathioprine tab 50 mg
CELLCEPT CAP 250MG +
CELLCEPT SUS 200MG/ML +
CELLCEPT TAB 500MG +
IMURAN TAB 50MG +
mycophenolate mofetil cap 250 mg
mycophenolate mofetil for oral susp 200 mg/ml
mycophenolate mofetil tab 500 mg
mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)
mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)
MYFORTIC TAB 180MG +
MYFORTIC TAB 360MG +
IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS ASTAGRAF XL CAP 0.5MG
ASTAGRAF XL CAP 1MG
ASTAGRAF XL CAP 5MG
cyclosporine cap 25 mg
cyclosporine cap 100 mg
cyclosporine modified cap 25 mg
cyclosporine modified cap 50 mg
cyclosporine modified cap 100 mg
cyclosporine modified oral soln 100 mg/ml
ENVARSUS XR TAB 0.75MG
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
79
Drug Name Requirements/Limits
ENVARSUS XR TAB 1MG
ENVARSUS XR TAB 4MG
gengraf cap 25mg
gengraf cap 100mg
gengraf sol 100mg/ml
NEORAL CAP 25MG +
NEORAL CAP 100MG +
NEORAL SOL 100MG/ML +
PROGRAF CAP 0.5MG +
PROGRAF CAP 1MG +
PROGRAF CAP 5MG +
SANDIMMUNE CAP 25MG +
SANDIMMUNE CAP 100MG +
SANDIMMUNE SOL 100MG/ML
tacrolimus cap 0.5 mg
tacrolimus cap 1 mg
tacrolimus cap 5 mg
IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE RAPAMUNE SOL 1MG/ML +
RAPAMUNE TAB 0.5MG +
RAPAMUNE TAB 1MG +
RAPAMUNE TAB 2MG +
sirolimus oral soln 1 mg/ml
sirolimus tab 0.5 mg
sirolimus tab 1 mg
sirolimus tab 2 mg
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG
VACCINES ADACEL INJ AL (covered for ages 19 and
over)
BOOSTRIX INJ AL (covered for ages 19 and
over)
DAPTACEL INJ AL (covered for ages 19 and
over)
DIP/TET PED INJ 25-5LFU AL (covered for ages 19 and
over)
ENGERIX-B INJ 10/0.5ML QL (3 vaccines per lifetime);
AL (covered for ages 19 and
over)
ENGERIX-B INJ 20MCG/ML QL (3 vaccines per lifetime);
AL (covered for ages 19 and
over)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
80
Drug Name Requirements/Limits
GARDASIL 9 INJ QL (3 vaccines per lifetime);
AL (covered for ages 19-26)
HAVRIX INJ 720UNIT QL (2 vaccines per lifetime);
AL (covered for ages 19 and
over)
HAVRIX INJ 1440UNIT QL (2 vaccines per lifetime);
AL (covered for ages 19 and
over)
INFANRIX INJ AL (covered for ages 19 and
over)
M-M-R II INJ AL (covered for ages 19 and
over)
MENACTRA INJ AL (covered for ages 19 and
over)
MENVEO INJ AL (covered for ages 19 and
over)
PNEUMOVAX 23 INJ 25/0.5 AL (covered for ages 19 and
over)
RECOMBIVA HB INJ 5MCG/0.5 QL (3 vaccines per lifetime); AL (covered for ages 19 and
over)
RECOMBIVA HB INJ 10MCG/ML QL (3 vaccines per lifetime);
AL (covered for ages 19 and
over)
RECOMBIVA-HB INJ 40MCG/ML QL (3 vaccines per lifetime);
AL (covered for ages 19 and
over)
TDVAX INJ 2-2 LF AL (covered for ages 19 and
over)
TENIVAC INJ 5-2LF AL (covered for ages 19 and
over)
TWINRIX INJ QL (3 vaccines per lifetime); AL (covered for ages 19 and
over)
VAQTA INJ 25/0.5ML QL (2 vaccines per lifetime); AL (covered for ages 19 and
over)
VAQTA INJ 50UNT/ML QL (2 vaccines per lifetime);
AL (covered for ages 19 and
over)
VARIVAX INJ AL (covered for ages 19 and
over)
ZOSTAVAX INJ AL (covered for ages 60 and over)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
81
Drug Name Requirements/Limits
MISCELLANEOUS DIAGNOSTIC AGENTS
CHEMSTRIP 2 TES GP OTC, QL (100 per month)
CHEMSTRIP 5 TES OB OTC, QL (100 per month)
CHEMSTRIP 7 TES OTC, QL (100 per month)
CHEMSTRIP 9 TES STRIPS OTC, QL (100 per month)
CHEMSTRIP 10 TES MD OTC, QL (100 per month)
CHEMSTRIP TES -10 SG OTC, QL (100 per month)
COMBISTIX TES OTC, QL (100 per month)
HEMA-COMBIST TES OTC, QL (100 per month)
LABSTIX TES OTC, QL (100 per month)
MULTISTIX 5 TES OTC, QL (100 per month)
MULTISTIX 7 TES OTC, QL (100 per month)
MULTISTIX 8 TES SG OTC, QL (100 per month)
MULTISTIX 9 TES OTC, QL (100 per month)
MULTISTIX 9 TES SG OTC, QL (100 per month)
MULTISTIX 10 TES SG OTC, QL (100 per month)
MULTISTIX TES OTC, QL (100 per month)
URISTIX 4 TES OTC, QL (100 per month)
URISTIX TES OTC, QL (100 per month)
MEDICAL SUPPLIES bandages: adhesive; elastic; gauze OTC
NUTRITIONAL / SUPPLEMENTS ELECTROLYTES, MISCELLANEOUS
oral electrolyte solution OTC
ELECTROLYTES, POTASSIUM potassium bicarbonate effer tab 25 meq
potassium chloride cap er 8 meq
potassium chloride cap er 10 meq
potassium chloride microencapsulated crys er tab 10 meq
potassium chloride microencapsulated crys er tab 20 meq
potassium chloride oral soln 10% (20 meq/15ml)
potassium chloride oral soln 20% (40 meq/15ml)
potassium chloride tab er 8 meq (600 mg)
potassium chloride tab er 10 meq
potassium chloride tab er 20 meq (1500 mg)
VITAMINS AND MINERALS, CALCIUM SUPPLEMENTS calcium carbonate chew tab 1250 mg (500 mg
elemental ca)
OTC
calcium carbonate tab 600 mg OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
82
Drug Name Requirements/Limits
calcium carbonate tab 1250 mg (500 mg
elemental ca)
OTC
calcium carbonate tab 1500 mg (600 mg
elemental ca)
OTC
calcium carbonate-cholecalciferol cap 600 mg-500
unit
OTC
calcium carbonate-cholecalciferol chew tab 500
mg-400 unit
OTC
calcium carbonate-cholecalciferol chew tab 500
mg-600 unit
OTC
calcium carbonate-cholecalciferol tab 250 mg-125 unit
OTC
calcium carbonate-cholecalciferol tab 500 mg-125 unit
OTC
calcium carbonate-cholecalciferol tab 500 mg-200
unit
OTC
calcium carbonate-cholecalciferol tab 500 mg-400
unit
OTC
calcium carbonate-cholecalciferol tab 600 mg-200
unit
OTC
calcium carbonate-cholecalciferol tab 600 mg-400
unit
OTC
calcium carbonate-cholecalciferol tab 600 mg-800
unit
OTC
calcium carbonate-vitamin d cap 600 mg-200 unit OTC
calcium carbonate-vitamin d chew tab 600 mg-400
unit
OTC
calcium carbonate-vitamin d tab 250 mg-125 unit OTC
calcium carbonate-vitamin d tab 500 mg-125 unit OTC
calcium carbonate-vitamin d tab 500 mg-200 unit OTC
calcium carbonate-vitamin d tab 500 mg-400 unit OTC
calcium carbonate-vitamin d tab 600 mg-125 unit OTC
calcium carbonate-vitamin d tab 600 mg-200 unit OTC
calcium carbonate-vitamin d tab 600 mg-400 unit OTC
calcium citrate tab 950 mg (200 mg elemental ca) OTC
calcium citrate-vitamin d tab 200 mg-250 unit
(elemental ca)
OTC
calcium citrate-vitamin d tab 250 mg-200 unit
(elemental ca)
OTC
calcium citrate-vitamin d tab 315 mg-200 unit
(elemental ca)
OTC
calcium citrate-vitamin d tab 315 mg-250 unit
(elemental ca)
OTC
calcium tab 500 mg OTC
calcium tab 600 mg OTC
calcium w/ magnesium tab 250-125 mg OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
83
Drug Name Requirements/Limits
calcium w/ magnesium tab 333-167 mg OTC
calcium w/ magnesium tab 500-250 mg OTC
calcium w/ vitamin d & k chew tab 500 mg-100
unit-40 mcg
OTC
calcium w/ vitamin d & k chew tab 500 mg-200
unit-40 mcg
OTC
calcium w/ vitamin d tab 600 mg-200 unit OTC
calcium-mag-vit c-vit d cap 185 mg-28 mg-2.5 mg-200 unit
OTC
calcium-magnesium-zinc tab 333-133-5 mg OTC
calcium-magnesium-zinc tab 333-133-8.3 mg OTC
oyster shell calcium tab 500 mg OTC
VITAMINS AND MINERALS, FOLIC ACID/COMBINATIONS folic acid tab 1 mg
folic acid tab 1 mg OTC
folic acid tab 400 mcg OTC
folic acid tab 800 mcg OTC
folic acid-vitamin b6-vitamin b12 tab 0.8-10-0.115
mg
OTC
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5
mg
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg
folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg
VITAMINS AND MINERALS, IRON/COMBINATIONS fe bisglyc-vit c-vit b12-folic acid cap 28-60-0.008-
0.4 mg OTC
fe fum-iron polysacch complex-fa-b cmplx-c-zn-
mn-cu cap
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-
0.5-240 mg
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-
0.01-1 mg
ferrous fumarate tab 324 mg (106 mg elemental
fe)
OTC
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab
106-1 mg
ferrous fumarate-folic acid tab 324-1 mg
ferrous gluconate tab 240 mg (27 mg elemental
fe)
OTC
ferrous gluconate tab 324 mg (37.5 mg elemental
iron)
OTC
ferrous sulfate dried tab 200 mg (65 mg elemental
fe)
OTC
ferrous sulfate dried tab er 45 mg (fe equivalent) OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
84
Drug Name Requirements/Limits
ferrous sulfate dried tab er 160 mg (50 mg fe
equivalent)
OTC
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml
elemental fe)
OTC
ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe)
OTC
ferrous sulfate tab 27 mg (elemental fe) OTC
ferrous sulfate tab 134 mg (27 mg elemental fe) OTC
ferrous sulfate tab 325 mg (65 mg elemental fe) OTC
ferrous sulfate tab ec 325 mg (65 mg fe
equivalent)
OTC
ferrous sulfate tab er 47.5 mg (elemental fe) OTC
ferrous sulfate tab er 50 mg (elemental fe) OTC
ferrous sulfate tab er 142 mg (45 mg fe
equivalent)
OTC
iron combination cap
iron combination cap OTC
iron polysacch complex-vit b12-fa cap 150-0.025-1
mg
iron polysacch complex-vit b12-fa cap 150-0.025-1
mg
OTC
iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-
1 mg
iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-
1 mg
OTC
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-
1.25 mg
iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg
OTC
iron-vitamin c tab 100-250 mg OTC
polysaccharide iron complex cap 150 mg (iron
equivalent)
OTC
VITAMINS AND MINERALS, MISCELLANEOUS b-complex vitamin cap OTC
b-complex vitamin sublingual liquid OTC
b-complex vitamin tab OTC
b-complex vitamin tab er OTC
b-complex w/ c & calcium tab OTC
b-complex w/ c & e + zn tab OTC
b-complex w/ c & folic acid cap 1 mg
b-complex w/ c & folic acid tab
b-complex w/ c & folic acid tab OTC
b-complex w/ c & folic acid tab 0.8 mg OTC
b-complex w/ c & folic acid tab 1 mg
b-complex w/ c & folic acid tab 1 mg OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
85
Drug Name Requirements/Limits
b-complex w/ c & folic acid tab 5 mg
b-complex w/ c cap OTC
b-complex w/ c tab OTC
b-complex w/ c tab er OTC
b-complex w/ c-biotin-minerals & folic acid tab 5
mg
b-complex w/ folic acid cap OTC
b-complex w/ folic acid tab OTC
b-complex w/ folic acid tab er OTC
b-complex w/ iron tab OTC
b-complex w/ minerals liq OTC
b-complex w/biotin & folic acid tab OTC
b-complex w/biotin & folic acid tab er OTC
bioflavonoid products tab OTC
bioflavonoid products tab er OTC
brewers yeast tab OTC
calcium ascorbate tab 500 mg OTC
calcium pantothenate tab 500 mg OTC
cholecalciferol cap 1.25 mg (50000 unit) OTC
cholecalciferol cap 10 mcg (400 unit) OTC
cholecalciferol cap 25 mcg (1000 unit) OTC
cholecalciferol cap 50 mcg (2000 unit) OTC
cholecalciferol cap 125 mcg (5000 unit) OTC
cholecalciferol cap 250 mcg (10000 unit) OTC
cholecalciferol chew tab 10 mcg (400 unit) OTC
cholecalciferol chew tab 25 mcg (1000 unit) OTC
cholecalciferol chew tab 50 mcg (2000 unit) OTC
cholecalciferol chew tab 125 mcg (5000 unit) OTC
cholecalciferol drops 10 mcg/0.03ml (400 unit/0.03ml)
OTC
cholecalciferol drops 50 mcg/0.03ml (2000
unit/0.03ml)
OTC
cholecalciferol drops 125 mcg/ml (5000 unit/ml) OTC
cholecalciferol oral liquid 10 mcg/ml (400 unit/ml) OTC
cholecalciferol tab 1.25 mg (50000 unit) OTC
cholecalciferol tab 10 mcg (400 unit) OTC
cholecalciferol tab 25 mcg (1000 unit) OTC
cholecalciferol tab 50 mcg (2000 unit) OTC
cholecalciferol tab 125 mcg (5000 unit) OTC
cod liver oil cap OTC
cyanocobalamin inj 1000 mcg/ml
ergocalciferol cap 1.25 mg (50000 unit)
ergocalciferol soln 200 mcg/ml (8000 unit/ml) OTC
iron w/ vitamin liq OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
86
Drug Name Requirements/Limits
iron w/ vitamin tab OTC
multiple vitamin cap OTC; AL (covered for ages
20 and under)
multiple vitamin tab OTC; AL (covered for ages 20 and under)
multiple vitamins w/ calcium tab OTC; AL (covered for ages 20 and under)
multiple vitamins w/ iron tab OTC; AL (covered for ages
20 and under)
multiple vitamins w/ minerals & fa tab 1.25 mg AL (covered for ages 20 and
under)
multiple vitamins w/ minerals cap AL (covered for ages 20 and
under)
multiple vitamins w/ minerals cap OTC; AL (covered for ages
20 and under)
multiple vitamins w/ minerals chew tab OTC; AL (covered for ages
20 and under)
multiple vitamins w/ minerals effer tab OTC; AL (covered for ages
20 and under)
multiple vitamins w/ minerals liquid OTC; AL (covered for ages 20 and under)
multiple vitamins w/ minerals tab AL (covered for ages 20 and under)
multiple vitamins w/ minerals tab OTC; AL (covered for ages
20 and under)
multiple vitamins w/ minerals tab er OTC; AL (covered for ages
20 and under)
NASCOBAL SPR 500MCG
niacin cap er 250 mg OTC
niacin cap er 500 mg OTC
niacin tab 50 mg OTC
niacin tab 100 mg OTC
niacin tab 250 mg OTC
niacin tab 500 mg OTC
niacin tab er 250 mg OTC
niacin tab er 500 mg OTC
niacin tab er 750 mg OTC
niacin w/ inositol cap 400-100 mg OTC
niacinamide tab 100 mg OTC
niacinamide tab 500 mg OTC
omega-3 fatty acids - oral liquid OTC
omega-3 fatty acids cap 300 mg OTC
omega-3 fatty acids cap 435 mg OTC
omega-3 fatty acids cap 500 mg OTC
omega-3 fatty acids cap 1000 mg OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
87
Drug Name Requirements/Limits
omega-3 fatty acids cap 1200 mg OTC
omega-3 fatty acids chew tab 113.5 mg OTC
pantothenic acid tab 500 mg OTC
pediatric multiple vitamin liq OTC; AL (covered for ages
20 and under)
pediatric multiple vitamin w/ c & fa chew tab OTC; AL (covered for ages 20 and under)
pediatric multiple vitamin w/ c soln 35 mg/ml OTC; AL (covered for ages 20 and under)
pediatric multiple vitamin w/ extra c & fa chew tab OTC; AL (covered for ages
20 and under)
pediatric multiple vitamin w/ minerals & c chew
tab
OTC; AL (covered for ages
20 and under)
pediatric multiple vitamin w/ minerals & c drops 45
mg/ml
AL (covered for ages 20 and
under)
pediatric multiple vitamin w/ minerals & c drops 45
mg/ml
OTC; AL (covered for ages
20 and under)
pediatric multiple vitamins w/ fl-fe drops 0.25-6
mg/ml
AL (covered for ages 20 and
under)
pediatric multiple vitamins w/ fl-fe drops 0.25-10
mg/ml
AL (covered for ages 20 and
under)
pediatric multiple vitamins w/ fluoride chew tab
0.5 mg
AL (covered for ages 20 and
under)
pediatric multiple vitamins w/ fluoride chew tab 0.25 mg
AL (covered for ages 20 and under)
pediatric multiple vitamins w/ fluoride chew tab 1
mg
AL (covered for ages 20 and
under)
pediatric multiple vitamins w/ fluoride soln 0.5
mg/ml
AL (covered for ages 20 and
under)
pediatric multiple vitamins w/ fluoride soln 0.25
mg/ml
AL (covered for ages 20 and
under)
pediatric multiple vitamins w/ iron chew tab 15 mg OTC; AL (covered for ages
20 and under)
pediatric multiple vitamins w/ iron drops 10 mg/ml OTC; AL (covered for ages
20 and under)
pediatric vitamins acd w/ fluoride soln 0.5 mg/ml AL (covered for ages 20 and
under)
pediatric vitamins acd w/ fluoride soln 0.25 mg/ml AL (covered for ages 20 and
under)
pediatric vitamins adc drops 1500 unit-400 unit-35 mg/ml
OTC; AL (covered for ages 20 and under)
phytonadione tab 5 mg
pyridoxine hcl tab 25 mg OTC
pyridoxine hcl tab 50 mg OTC
pyridoxine hcl tab 100 mg OTC
pyridoxine hcl tab 250 mg OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
88
Drug Name Requirements/Limits
pyridoxine hcl tab 500 mg OTC
pyridoxine hcl tab er 200 mg OTC
riboflavin tab 25 mg OTC
riboflavin tab 50 mg OTC
riboflavin tab 100 mg OTC
sodium fluoride chew tab 0.5 mg f (from 1.1 mg
naf)
sodium fluoride chew tab 0.25 mg f (from 0.55 mg
naf)
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml
naf)
sodium fluoride soln 0.25 mg/drop f (from 0.55
mg/drop naf)
sodium fluoride soln 0.125 mg/drop f (0.275
mg/drop naf)
sodium fluoride tab 0.5 mg f (from 1.1 mg naf)
sodium fluoride tab 1 mg f (from 2.2 mg naf)
thiamine hcl tab 50 mg OTC
thiamine hcl tab 100 mg OTC
thiamine hcl tab 250 mg OTC
thiamine mononitrate tab 100 mg OTC
vitamin e cap 400 unit OTC
vitamin mixture cap OTC
vitamin mixture tab OTC
vitamins a & d cap OTC
vitamins a & d tab OTC
vitamins a & d w/ c chew tab OTC
vitamins c & e cap OTC
vitamins w/ lipotropics cap OTC
vitamins w/ lipotropics tab OTC
vitamins w/ lipotropics tab er OTC
VITAMINS AND MINERALS, PRENATAL VITAMINS CITRANATAL CAP HARMONY
CITRANATAL CAP MEDLEY
CITRANATAL MIS
CITRANATAL MIS 90 DHA
CITRANATAL MIS B-CALM
CITRANATAL PAK ASSURE
CITRANATAL PAK DHA
CITRANATAL TAB BLOOM
CITRANATAL TAB RX
PRENAISSANCE CAP PLUS
prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
89
Drug Name Requirements/Limits
prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg
prenatal vit w/ fe fumarate-fa chew tab 29-1 mg
prenatal vit w/ iron carbonyl-fa tab 29-1 mg
RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS
epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)
QL (8 per year)
epinephrine solution auto-injector 0.15 mg/0.15ml
(1:1000)
QL (8 per year)
EPIPEN 2-PAK INJ 0.3MG QL (8 per year)
EPIPEN-JR INJ 0.15MG QL (8 per year)
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, LONG ACTING STIOLTO AER 2.5-2.5 QL (1 inhaler per month)
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, SHORT
ACTING COMBIVENT AER 20-100 QL (2 inhalers per month)
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml QL (540 mL per month)
ANTICHOLINERGICS INCRUSE ELPT INH 62.5MCG QL (1 inhaler per month)
ipratropium bromide inhal soln 0.02% QL (313 mL per month)
ANTIHISTAMINE/DECONGESTANT COMBINATIONS brompheniramine & pseudoephedrine elixir 1-15
mg/5ml
OTC
cetirizine-pseudoephedrine tab er 12hr 5-120 mg OTC
fexofenadine-pseudoephedrine tab er 12hr 60-120
mg
OTC
fexofenadine-pseudoephedrine tab er 24hr 180-
240 mg
OTC
loratadine & pseudoephedrine tab er 12hr 5-120
mg
OTC
loratadine & pseudoephedrine tab er 24hr 10-240
mg
OTC
promethazine & phenylephrine syrup 6.25-5
mg/5ml
ANTIHISTAMINES, LOW SEDATING cetirizine hcl cap 10 mg OTC
cetirizine hcl chew tab 5 mg OTC; AL (covered for ages
less than 12 years of age)
cetirizine hcl chew tab 10 mg OTC; AL (covered for ages
less than 12 years of age)
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) OTC
cetirizine hcl tab 5 mg OTC
cetirizine hcl tab 10 mg OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
90
Drug Name Requirements/Limits
ZYRTEC ALLGY TAB 10MG OTC
ZYRTEC CHILD TAB 10MG OTC
ANTIHISTAMINES, NONSEDATING ALLEGRA ALRG TAB 30MG OTC
CLARITIN RDT TAB 5MG OTC
fexofenadine hcl susp 30 mg/5ml (6 mg/ml) OTC
fexofenadine hcl tab 60 mg OTC
fexofenadine hcl tab 180 mg OTC
loratadine cap 10 mg OTC
loratadine chew tab 5 mg OTC
loratadine rapidly-disintegrating tab 10 mg OTC
loratadine syrup 5 mg/5ml OTC
loratadine tab 10 mg OTC
ANTIHISTAMINES, SEDATING chlorpheniramine maleate syrup 2 mg/5ml OTC
chlorpheniramine maleate tab 4 mg OTC
chlorpheniramine maleate tab er 12 mg OTC
clemastine fumarate tab 1.34 mg (1 mg base
equiv)
OTC
clemastine fumarate tab 2.68 mg
cyproheptadine hcl syrup 2 mg/5ml
cyproheptadine hcl tab 4 mg
diphenhydramine hcl cap 25 mg OTC
diphenhydramine hcl cap 50 mg OTC
diphenhydramine hcl chew tab 12.5 mg OTC
diphenhydramine hcl elixir 12.5 mg/5ml
diphenhydramine hcl elixir 12.5 mg/5ml OTC
diphenhydramine hcl liquid 12.5 mg/5ml OTC
diphenhydramine hcl syrup 12.5 mg/5ml OTC
diphenhydramine hcl tab 25 mg OTC
diphenhydramine hcl tab disint 12.5 mg OTC
hydroxyzine hcl syrup 10 mg/5ml
hydroxyzine hcl tab 10 mg
hydroxyzine hcl tab 25 mg
hydroxyzine hcl tab 50 mg
hydroxyzine pamoate cap 25 mg
hydroxyzine pamoate cap 50 mg
hydroxyzine pamoate cap 100 mg
VISTARIL CAP 25MG +
VISTARIL CAP 50MG +
ANTITUSSIVE COMBINATIONS, NON-OPIOID dextromethorphan-guaifenesin liquid 5-100
mg/5ml
OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
91
Drug Name Requirements/Limits
dextromethorphan-guaifenesin liquid 10-100
mg/5ml
OTC
dextromethorphan-guaifenesin liquid 10-200
mg/5ml
OTC
dextromethorphan-guaifenesin liquid 20-300
mg/5ml
OTC
dextromethorphan-guaifenesin liquid 30-200
mg/5ml
OTC
dextromethorphan-guaifenesin syrup 10-100
mg/5ml
OTC
dextromethorphan-guaifenesin tab er 12hr 30-600 mg
OTC
dextromethorphan-guaifenesin tab er 12hr 60-1200 mg
OTC
MUCINEX CGH GRA 5-100MG OTC
MUCINEX DM TAB 30-600ER OTC
promethazine-dm syrup 6.25-15 mg/5ml
pseudoephed-bromphen-dm syrup 30-2-10
mg/5ml
pseudoephed-bromphen-dm syrup 30-2-10
mg/5ml
OTC
pseudoephedrine w/ dm-gg liquid 30-10-100
mg/5ml
OTC
ANTITUSSIVE COMBINATIONS, OPIOID guaifenesin-codeine soln 100-6.3 mg/5ml OTC
guaifenesin-codeine soln 100-10 mg/5ml OTC
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml
hydrocodone w/ homatropine tab 5-1.5 mg
promethazine w/ codeine syrup 6.25-10 mg/5ml
promethazine-phenylephrine-codeine syrup 6.25-
5-10 mg/5ml
pseudoephedrine w/ cod-gg soln 30-10-100
mg/5ml
OTC
ANTITUSSIVES benzonatate cap 100 mg
benzonatate cap 200 mg
BETA AGONISTS, INHALANTS, Long Acting: Hand-held Active
Inhalation STRIVERDI AER 2.5MCG QL (1 inhaler per month)
BETA AGONISTS, INHALANTS, Short Acting albuterol sulfate inhal aero 108 mcg/act (90mcg
base equiv)
QL (18g - 2 inhalers per
month)
albuterol sulfate soln nebu 0.5% (5 mg/ml)
albuterol sulfate soln nebu 0.63 mg/3ml (base equiv)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
92
Drug Name Requirements/Limits
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv)
PROAIR RESPI AER QL (2 inhalers per month)
VENTOLIN HFA AER QL (18g - 2 inhalers per
month)
VENTOLIN HFA AER QL (3.7g - 6 inhalers per
month)
VENTOLIN HFA AER QL (8g - 4 inhalers per
month)
BETA AGONISTS, ORAL AGENTS albuterol sulfate syrup 2 mg/5ml
albuterol sulfate tab 2 mg
albuterol sulfate tab 4 mg
albuterol sulfate tab er 12hr 4 mg
albuterol sulfate tab er 12hr 8 mg
terbutaline sulfate tab 2.5 mg
terbutaline sulfate tab 5 mg
CYSTIC FIBROSIS BETHKIS NEB 300/4ML SP, PA
KALYDECO PAK 25MG SP, PA
KALYDECO PAK 50MG SP, PA
KALYDECO PAK 75MG SP, PA
KALYDECO TAB 150MG SP, PA
ORKAMBI GRA 100-125 SP, PA
ORKAMBI GRA 150-188 SP, PA
ORKAMBI TAB 100-125 SP, PA
ORKAMBI TAB 200-125 SP, PA
PULMOZYME SOL 1MG/ML SP, PA
SYMDEKO TAB 50-75MG SP, PA
SYMDEKO TAB 100-150 SP, PA
tobramycin nebu soln 300 mg/5ml SP, PA
DECONGESTANT/EXPECTORANT COMBINATIONS pseudoephedrine-guaifenesin tab er 12hr 60-600
mg OTC
pseudoephedrine-guaifenesin tab er 12hr 120-1200 mg
OTC
DECONGESTANTS pseudoephedrine hcl liq 15 mg/5ml OTC
pseudoephedrine hcl tab 30 mg OTC
pseudoephedrine hcl tab 60 mg OTC
pseudoephedrine hcl tab er 12hr 120 mg OTC, QL (60 per month)
SUDAFED 24HR TAB 240MG OTC, QL (30 per month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
93
Drug Name Requirements/Limits
EXPECTORANTS guaifenesin liquid 100 mg/5ml OTC
guaifenesin syrup 100 mg/5ml OTC
guaifenesin tab 200 mg OTC
guaifenesin tab 400 mg OTC
guaifenesin tab er 12hr 600 mg OTC
guaifenesin tab er 12hr 1200 mg OTC
MUCINEX/KIDS GRA 100MG OTC
YODEFAN-NF LIQ 200-5ML OTC
LEUKOTRIENE MODULATORS montelukast sodium chew tab 4 mg (base equiv)
montelukast sodium chew tab 5 mg (base equiv)
montelukast sodium oral granules packet 4 mg (base equiv)
montelukast sodium tab 10 mg (base equiv)
MAST CELL STABILIZERS cromolyn sodium nasal aerosol soln 5.2 mg/act
(4%)
OTC
cromolyn sodium soln nebu 20 mg/2ml QL (240 mL per month)
MEDICAL SUPPLIES AERCHMBR PLS MIS LRG MASK QL (2 per year)
AERCHMBR PLS MIS MED MASK QL (2 per year)
AERCHMBR PLS MIS SM MASK QL (2 per year)
AERCHMBR Z- MIS STAT PLS QL (2 per year)
AEROCHAMBER MIS CHAMBER QL (2 per year)
AEROCHAMBER MIS FLOSIGNA QL (2 per year)
AEROCHAMBER MIS MV QL (2 per year)
AEROCHAMBER MIS PLUS QL (2 per year)
MASK VORTEX/ MIS BABY DUC OTC, QL (2 per year)
MASK VORTEX/ MIS DUCK OTC, QL (2 per year)
MASK VORTEX/ MIS FROG OTC, QL (2 per year)
MASK VORTEX/ MIS LADY BUG OTC, QL (2 per year)
NEBULIZER MIS OTC
PEDIATRIC SM MIS MASK OTC
VAPORIZER OTC
VORTEX VALVE MIS CHAMBER QL (2 per year)
VORTEX/MASK MIS CHILDS QL (2 per year)
VORTEX/MASK MIS TODDLER QL (2 per year)
MISCELLANEOUS AYR NASAL DRO 0.65% OTC
CVS NASAL SPR MIST OTC
ipratropium bromide nasal soln 0.03% (21
mcg/spray)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
94
Drug Name Requirements/Limits
ipratropium bromide nasal soln 0.06% (42
mcg/spray)
RHINARIS SPR 0.2% OTC
saline nasal spray 0.65% OTC
SIMPLY SALIN AER 0.9% OTC
sodium chloride aero soln 0.9% OTC
sodium chloride soln nebu 0.9%
sodium chloride soln nebu 3%
sodium chloride soln nebu 7%
sodium chloride soln nebu 10%
NASAL ANTIHISTAMINES azelastine hcl nasal spray 0.1% (137 mcg/spray) QL (2 bottles per month)
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
QL (2 bottles per month)
NASAL STEROIDS budesonide nasal susp 32 mcg/act OTC, QL (1 bottle per
month)
flunisolide nasal soln 25 mcg/act (0.025%) QL (2 bottles per month)
fluticasone propionate nasal susp 50 mcg/act QL (1 bottle per month)
fluticasone propionate nasal susp 50 mcg/act OTC, QL (1 bottle per
month)
triamcinolone acetonide nasal aerosol suspension
55 mcg/act
OTC, QL (1 bottle per
month)
PULMONARY FIBROSIS AGENTS OFEV CAP 100MG SP, PA
OFEV CAP 150MG SP, PA
SEVERE ASTHMA AGENTS XOLAIR INJ 75/0.5 SP, PA
XOLAIR INJ 150MG/ML SP, PA
XOLAIR SOL 150MG SP, PA
STEROID INHALANTS ARNUITY ELPT INH 50MCG QL (1 inhaler per month)
ARNUITY ELPT INH 100MCG QL (1 inhaler per month)
ARNUITY ELPT INH 200MCG QL (1 inhaler per month)
budesonide inhalation susp 0.5 mg/2ml QL (120 mL per month)
budesonide inhalation susp 0.25 mg/2ml QL (120 mL per month)
budesonide inhalation susp 1 mg/2ml QL (60 mL per month)
FLOVENT DISK AER 50MCG QL (3 inhalers per month)
FLOVENT DISK AER 100MCG QL (4 inhalers per month)
FLOVENT DISK AER 250MCG QL (3 inhalers per month)
FLOVENT HFA AER 44MCG QL (2 inhalers per month)
FLOVENT HFA AER 110MCG QL (2 inhalers per month)
FLOVENT HFA AER 220MCG QL (2 inhalers per month)
QVAR REDIHA AER 80MCG QL (2 inhalers per month)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
95
Drug Name Requirements/Limits
QVAR REDIHAL AER 40MCG QL (2 inhalers per month)
STEROID/BETA AGONIST COMBINATIONS ADVAIR HFA AER 45/21 QL (1 inhaler per month)
ADVAIR HFA AER 115/21 QL (1 inhaler per month)
ADVAIR HFA AER 230/21 QL (1 inhaler per month)
DULERA AER 100-5MCG QL (1 inhaler per month)
DULERA AER 200-5MCG QL (1 inhaler per month)
fluticasone-salmeterol aer powder ba 100-50
mcg/dose
QL (1 inhaler per month)
fluticasone-salmeterol aer powder ba 250-50
mcg/dose
QL (1 inhaler per month)
fluticasone-salmeterol aer powder ba 500-50
mcg/dose
QL (1 inhaler per month)
XANTHINES ELIXOPHYLLIN ELX 80/15ML
THEO-24 CAP 100MG CR
THEO-24 CAP 200MG CR
THEO-24 CAP 300MG CR
THEO-24 CAP 400MG ER
theophylline soln 80 mg/15ml
theophylline tab er 12hr 100 mg
theophylline tab er 12hr 200 mg
theophylline tab er 12hr 300 mg
theophylline tab er 12hr 450 mg
theophylline tab er 24hr 400 mg
theophylline tab er 24hr 600 mg
TOPICAL DERMATOLOGY, ACNE, Oral
claravis cap 10mg PA
claravis cap 20mg PA
claravis cap 30mg PA
claravis cap 40mg PA
myorisan cap 10mg PA
myorisan cap 20mg PA
myorisan cap 30mg PA
myorisan cap 40mg PA
zenatane cap 10mg PA
zenatane cap 20mg PA
zenatane cap 30mg PA
zenatane cap 40mg PA
DERMATOLOGY, ACNE, Topical BENZOYL PER GEL 2.5% OTC
benzoyl peroxide cream 2.5% OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
96
Drug Name Requirements/Limits
benzoyl peroxide cream 10% OTC
benzoyl peroxide gel 5% OTC
benzoyl peroxide gel 10% OTC
benzoyl peroxide liq 2.5%
benzoyl peroxide liq 4% OTC
benzoyl peroxide liq 5% OTC
benzoyl peroxide liq 5.25%
benzoyl peroxide liq 5.25% OTC
benzoyl peroxide liq 6% OTC
benzoyl peroxide liq 7%
benzoyl peroxide liq 10% OTC
benzoyl peroxide-erythromycin gel 5-3%
clindamycin phosphate gel 1%
clindamycin phosphate lotion 1%
clindamycin phosphate soln 1%
erythromycin gel 2%
erythromycin soln 2%
sulfacetamide sodium lotion 10% (acne)
tretinoin cream 0.1% ST (Members 35 years and older must have recently
been on 30 days of a topical
formulary alternative)
tretinoin cream 0.05% ST (Members 35 years and
older must have recently
been on 30 days of a topical
formulary alternative)
tretinoin cream 0.025% ST (Members 35 years and
older must have recently
been on 30 days of a topical
formulary alternative)
tretinoin gel 0.01% ST (Members 35 years and
older must have recently been on 30 days of a topical
formulary alternative)
tretinoin gel 0.025% ST (Members 35 years and older must have recently
been on 30 days of a topical
formulary alternative)
DERMATOLOGY, ACTINIC KERATOSIS fluorouracil cream 5%
TOLAK CRE 4%
DERMATOLOGY, ANTIBIOTICS bacitracin oint 500 unit/gm OTC
bacitracin zinc oint 500 unit/gm OTC
bacitracin-polymyxin b oint OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
97
Drug Name Requirements/Limits
gentamicin sulfate cream 0.1%
gentamicin sulfate oint 0.1%
mupirocin oint 2%
neomycin-bacitracin-polymyxin oint OTC
silver sulfadiazine cream 1%
DERMATOLOGY, ANTIFUNGALS ciclopirox gel 0.77%
ciclopirox olamine cream 0.77% (base equiv)
ciclopirox olamine susp 0.77% (base equiv)
ciclopirox shampoo 1%
clotrimazole cream 1%
clotrimazole cream 1% OTC
clotrimazole soln 1%
clotrimazole soln 1% OTC
ketoconazole cream 2%
ketoconazole shampoo 2%
miconazole nitrate cream 2% OTC
miconazole nitrate ointment 2% OTC
miconazole nitrate powder 2% OTC
nystatin cream 100000 unit/gm
nystatin oint 100000 unit/gm
nystatin topical powder 100000 unit/gm
tolnaftate aerosol pow 1% OTC
tolnaftate cream 1% OTC
tolnaftate soln 1% OTC
DERMATOLOGY, ANTIPSORIATICS, Topical calcipotriene oint 0.005% QL (120 gm per month); ST
(Must have recently been on 30 days of generic topical
steroid)
calcipotriene soln 0.005% (50 mcg/ml) QL (120 mL per month); ST (Must have recently been on
30 days of generic topical
steroid)
DERMATOLOGY, ANTISEBORRHEICS selenium sulfide lotion 1% OTC
selenium sulfide lotion 2.5%
DERMATOLOGY, ANTISEPTICS/DISINFECTANTS IV PREP WIPE PAD OTC
MICROCLENS PAD WIPES OTC
povidone-iodine oint 10% OTC
povidone-iodine soln 7.5% OTC
povidone-iodine soln 10% OTC
UNI-SOLVE PAD WIPES OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
98
Drug Name Requirements/Limits
DERMATOLOGY, ATOPIC DERMATITIS, Topical tacrolimus oint 0.1% ST (Must have recently been
on a generic steroid); AL
(Must be 16 years of age
and older)
tacrolimus oint 0.03% ST (Must have recently been
on a generic steroid); AL
(Must be 2 years of age and
older)
DERMATOLOGY, CORTICOSTEROID COMBINATIONS hydrocortisone-aloe vera cream 1% OTC
DERMATOLOGY, CORTICOSTEROIDS, High Potency betamethasone dipropionate augmented cream
0.05%
QL (120 grams per month)
betamethasone dipropionate augmented lotion
0.05%
QL (120 mL per month)
betamethasone dipropionate cream 0.05% QL (120 grams per month)
betamethasone dipropionate lotion 0.05% QL (120 mL per month)
betamethasone dipropionate oint 0.05% QL (120 grams per month)
desoximetasone cream 0.25% QL (120 grams per month)
desoximetasone gel 0.05% QL (120 grams per month)
desoximetasone oint 0.25% QL (120 grams per month)
fluocinonide cream 0.05% QL (120 grams per month)
fluocinonide gel 0.05% QL (120 grams per month)
fluocinonide oint 0.05% QL (120 grams per month)
fluocinonide soln 0.05%
triamcinolone acetonide cream 0.5% QL (120 grams per month)
triamcinolone acetonide oint 0.5% QL (120 grams per month)
DERMATOLOGY, CORTICOSTEROIDS, Low Potency alclometasone dipropionate cream 0.05% QL (120 grams per month)
alclometasone dipropionate oint 0.05% QL (120 grams per month)
desonide cream 0.05% QL (120 grams per month)
desonide lotion 0.05% QL (120 mL per month)
desonide oint 0.05% QL (120 grams per month)
fluocinolone acetonide soln 0.01%
hydrocortisone acetate cream 1% OTC
hydrocortisone cream 0.5% OTC
hydrocortisone cream 1%
hydrocortisone cream 1% OTC
hydrocortisone cream 2.5% QL (120 grams per month)
hydrocortisone gel 1% OTC
hydrocortisone lotion 1% OTC
hydrocortisone lotion 2.5% QL (120 mL per month)
hydrocortisone oint 0.5% OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
99
Drug Name Requirements/Limits
hydrocortisone oint 1%
hydrocortisone oint 1% OTC
hydrocortisone oint 2.5% QL (120 grams per month)
hydrocortisone soln 1% OTC
DERMATOLOGY, CORTICOSTEROIDS, Medium Potency betamethasone valerate cream 0.1% (base
equivalent)
QL (120 grams per month)
betamethasone valerate lotion 0.1% (base
equivalent)
QL (120 mL per month)
betamethasone valerate oint 0.1% (base
equivalent)
desoximetasone cream 0.05% QL (120 grams per month)
fluocinolone acetonide cream 0.025% QL (120 grams per month)
fluocinolone acetonide oint 0.025% QL (120 grams per month)
fluticasone propionate cream 0.05% QL (120 grams per month)
fluticasone propionate oint 0.005% QL (120 grams per month)
hydrocortisone butyrate cream 0.1% QL (120 grams per month)
hydrocortisone butyrate oint 0.1% QL (120 grams per month)
hydrocortisone butyrate soln 0.1%
hydrocortisone valerate cream 0.2% QL (120 grams per month)
hydrocortisone valerate oint 0.2% QL (120 grams per month)
mometasone furoate cream 0.1% QL (120 grams per month)
mometasone furoate oint 0.1% QL (120 grams per month)
mometasone furoate solution 0.1% (lotion)
triamcinolone acetonide cream 0.1% QL (120 grams per month)
triamcinolone acetonide cream 0.025% QL (120 grams per month)
triamcinolone acetonide lotion 0.1% QL (120 mL per month)
triamcinolone acetonide lotion 0.025% QL (120 mL per month)
triamcinolone acetonide oint 0.1% QL (120 grams per month)
triamcinolone acetonide oint 0.025% QL (120 grams per month)
DERMATOLOGY, CORTICOSTEROIDS, Very High Potency betamethasone dipropionate augmented gel
0.05%
QL (120 grams per month)
betamethasone dipropionate augmented oint
0.05%
QL (120 grams per month)
clobetasol propionate cream 0.05% QL (120 grams per month)
clobetasol propionate foam 0.05%
clobetasol propionate gel 0.05% QL (120 grams per month)
clobetasol propionate oint 0.05% QL (120 grams per month)
clobetasol propionate soln 0.05%
halobetasol propionate cream 0.05% QL (120 grams per month)
halobetasol propionate oint 0.05% QL (120 grams per month)
DERMATOLOGY, EMOLLIENTS lactic acid (ammonium lactate) cream 12%
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
100
Drug Name Requirements/Limits
lactic acid (ammonium lactate) cream 12% OTC
lactic acid (ammonium lactate) lotion 12%
lactic acid (ammonium lactate) lotion 12% OTC
DERMATOLOGY, INSECT REPELLENTS CUTTER BACKW AER 25% OTC, QL (2 per 30 days);
Females aged 14-45 years
old only
NATRAPEL 12H SPR 20% OTC, QL (2 per 30 days);
Females aged 14-45 years
old only
OFF DEEP WDS AER 25% OTC, QL (2 per 30 days);
Females aged 14-45 years
old only
REPEL SPORTS AER 25% OTC, QL (2 per 30 days);
Females aged 14-45 years
old only
SAWYER REPEL SPR 20% OTC, QL (2 per 30 days);
Females aged 14-45 years
old only
DERMATOLOGY, LOCAL ANALGESICS ARTH PAIN CRE 0.075% OTC, QL (120 grams per
month)
capsaicin cream 0.1% OTC, QL (120 grams per month)
capsaicin cream 0.025% OTC, QL (120 grams per month)
CAPSAICIN LIQ 0.15% OTC, QL (30 grams per
month)
CAPZASIN GEL RELIEF OTC, QL (42.5 grams per
month)
CAPZASIN LIQ 0.15% OTC, QL (30 grams per
month)
CAPZASIN-P CRE 0.035% OTC, QL (120 grams per
month)
CASTIVA LOT OTC, QL (120 grams per
month)
lidocaine hcl soln 4%
lidocaine patch 4% OTC, QL (30 patches per
month)
lidocaine patch 5% PA
ZOSTRIX NAT CRE 0.033% OTC, QL (120 grams per
month)
DERMATOLOGY, LOCAL ANESTHETICS lidocaine-prilocaine cream 2.5-2.5% QL (30 grams per month)
lidocaine-prilocaine cream kit 2.5-2.5%
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
101
Drug Name Requirements/Limits
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CALAMINE LOT OTC
CALAMINE LOT 8-8% OTC
docosanol cream 10% OTC
imiquimod cream 5%
podofilox soln 0.5%
SM CALAMINE LOT OTC
DERMATOLOGY, ROSACEA metronidazole cream 0.75%
metronidazole gel 0.75%
metronidazole gel 1% ST (Must have recently been on 60 days of metronidazole
0.075%)
metronidazole lotion 0.75%
DERMATOLOGY, SCABICIDES AND PEDICULICIDES malathion lotion 0.5% ST (Must have recently been
on 14 days of permethrin)
NIX CREM RIN LIQ 1% OTC
permethrin aerosol 0.5% OTC
permethrin cream 5%
permethrin creme rinse 1% OTC
permethrin lotion 1% OTC
RID AER OTC
spinosad susp 0.9% ST (Must have recently been
on 14 days of permethrin)
MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS chlorhexidine gluconate soln 0.12%
lidocaine hcl viscous soln 2%
sodium fluoride cream 1.1%
sodium fluoride gel 1.1% (0.5% f)
sodium fluoride paste 1.1%
sodium fluoride rinse 0.2%
triamcinolone acetonide dental paste 0.1%
OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY
COMBINATIONS bacitracin-polymyxin-neomycin-hc ophth oint 1%
neomycin-polymyxin-dexamethasone ophth oint
0.1%
neomycin-polymyxin-dexamethasone ophth susp
0.1%
neomycin-polymyxin-hc ophth susp
sulfacetamide sodium-prednisolone ophth soln 10-
0.23(0.25)%
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
102
Drug Name Requirements/Limits
OPHTHALMIC, ANTI-INFECTIVES bacitracin ophth oint 500 unit/gm
bacitracin-polymyxin b ophth oint
ciprofloxacin hcl ophth soln 0.3% (base equivalent)
erythromycin ophth oint 5 mg/gm
gentamicin sulfate ophth oint 0.3%
gentamicin sulfate ophth soln 0.3%
levofloxacin ophth soln 0.5%
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin
neomycin-polymy-gramicid op sol 1.75-10000-
0.025mg-unt-mg/ml
ofloxacin ophth soln 0.3%
polymyxin b-trimethoprim ophth soln 10000
unit/ml-0.1%
sulfacetamide sodium ophth soln 10%
tobramycin ophth soln 0.3%
OPHTHALMIC, ANTI-INFLAMMATORY, Nonsteroidal diclofenac sodium ophth soln 0.1%
ketorolac tromethamine ophth soln 0.4%
ketorolac tromethamine ophth soln 0.5%
OPHTHALMIC, ANTI-INFLAMMATORY, Steroidal dexamethasone sodium phosphate ophth soln
0.1%
fluorometholone ophth susp 0.1%
LOTEMAX GEL 0.5%
PRED SOD PHO SOL 1% OP
prednisolone acetate ophth susp 1%
OPHTHALMIC, ANTIALLERGICS azelastine hcl ophth soln 0.05%
cromolyn sodium ophth soln 4%
ketotifen fumarate ophth soln 0.025% (base
equiv)
OTC
OPHTHALMIC, ANTIFUNGALS NATACYN SUS 5% OP
OPHTHALMIC, ANTIVIRALS trifluridine ophth soln 1%
OPHTHALMIC, ARTIFICIAL TEARS/LUBRICANTS artificial tear ophth ointment OTC
artificial tear ophth solution OTC
carboxymethylcellulose sodium (pf) ophth gel 1% OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
103
Drug Name Requirements/Limits
carboxymethylcellulose sodium (pf) ophth soln
0.5%
OTC
carboxymethylcellulose sodium ophth gel 1% OTC
carboxymethylcellulose sodium ophth soln 0.5% OTC
carboxymethylcellulose sodium ophth soln 0.25% OTC
carboxymethylcellulose-glycerin ophth soln 0.5-0.9%
OTC
dextran 70-hypromellose (pf) ophth soln 0.1-0.3% OTC
dextran 70-hypromellose ophth soln 0.1-0.3% OTC
GENTEAL GEL 0.3% OTC
GENTEAL MILD DRO 0.2% OTC
glycerin-hypromellose-peg 400 ophth soln 0.2-0.2-1%
OTC
HYPOTEARS SOL 1-1% OTC
hypromellose ophth soln 0.3% OTC
hypromellose ophth soln 0.4% OTC
LUBRICNT GEL DRO 0.25-0.3 OTC
polyethylene glycol-propylene glycol ophth soln 0.4-0.3%
OTC
polyethylene glycol-propylene glycol pf op soln
0.4-0.3%
OTC
polyvinyl alcohol ophth soln 1.4% OTC
polyvinyl alcohol-povidone (pf) ophth soln 1.4-
0.6%
OTC
polyvinyl alcohol-povidone ophth soln 5-6 mg/ml
(0.5-0.6%)
OTC
propylene glycol ophth soln 0.6% OTC
propylene glycol-glycerin ophth soln 1-0.3% OTC
REFRESH OPTI DRO 0.5-0.9% OTC
REFRESH SOL OPTIVE OTC
SYSTANE GEL 0.3% OTC
THERATEARS SOL 0.25% PF OTC
white petrolatum-mineral oil ophth ointment OTC
OPHTHALMIC, BETA-BLOCKERS, Nonselective levobunolol hcl ophth soln 0.5%
timolol maleate ophth gel forming soln 0.5%
timolol maleate ophth gel forming soln 0.25%
timolol maleate ophth soln 0.5%
timolol maleate ophth soln 0.25%
OPHTHALMIC, BETA-BLOCKERS, Selective betaxolol hcl ophth soln 0.5%
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit
104
Drug Name Requirements/Limits
OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER
COMBINATIONS dorzolamide hcl-timolol maleate ophth soln 22.3-
6.8 mg/ml
OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS dorzolamide hcl ophth soln 2%
OPHTHALMIC, DRY EYE DISEASE XIIDRA DRO 5%
OPHTHALMIC, MYDRIATICS ATROPINE SUL SOL 1% OP
CYCLOMYDRIL SOL OP
OPHTHALMIC, PROSTAGLANDINS latanoprost ophth soln 0.005%
OPHTHALMIC, SYMPATHOMIMETICS brimonidine tartrate ophth soln 0.2%
brimonidine tartrate ophth soln 0.15%
OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CIPRODEX SUS 0.3-0.1%
neomycin-polymyxin-hc otic soln 1%
neomycin-polymyxin-hc otic susp 3.5 mg/ml-
10000 unit/ml-1%
OTIC, ANTI-INFECTIVES acetic acid otic soln 2%
ofloxacin otic soln 0.3%
105
Index A abacavir sulfate soln 20 mg/ml (base
equiv) ............................................. 11 abacavir sulfate tab 300 mg (base equiv)
..................................................... 11
abacavir sulfate-lamivudine tab 600-300 mg ................................................. 10
abacavir sulfate-lamivudine-zidovudine
tab 300-150-300 mg ........................ 10 ABILIFY MAIN INJ 300MG .................. 42
ABILIFY MAIN INJ 400MG .................. 42
ABILIFY TAB 10MG ........................... 42
ABILIFY TAB 15MG ........................... 42 ABILIFY TAB 20MG ........................... 42
ABILIFY TAB 2MG ............................. 42
ABILIFY TAB 30MG ........................... 42 ABILIFY TAB 5MG ............................. 42
abiraterone acetate tab 250 mg ......... 15 acamprosate calcium tab delayed release 333 mg ........................................... 56
acarbose tab 100 mg ........................ 58
acarbose tab 25 mg .......................... 58 acarbose tab 50 mg .......................... 58
acetaminophen cap 500 mg ................ 3 acetaminophen chew tab 160 mg ........ 3 acetaminophen chew tab 80 mg .......... 3
acetaminophen disintegrating tab 160 mg .................................................. 3
acetaminophen disintegrating tab 80 mg
...................................................... 3
acetaminophen elixir 160 mg/5ml ........ 3 acetaminophen liquid 160 mg/5ml ....... 3
acetaminophen liquid 167 mg/5ml ....... 3
acetaminophen soln 160 mg/5ml ......... 3 acetaminophen suppos 120 mg ........... 3
acetaminophen suppos 325 mg ........... 3
acetaminophen suppos 650 mg ........... 3 acetaminophen susp 160 mg/5ml ........ 3
acetaminophen susp 80 mg/0.8ml ....... 3
acetaminophen tab 325 mg ................ 3 acetaminophen tab 500 mg ................ 3
acetaminophen tab er 650 mg ............. 3
acetaminophen w/ codeine soln 120-12 mg/5ml ............................................ 5
acetaminophen w/ codeine tab 300-15
mg .................................................. 5
acetaminophen w/ codeine tab 300-30
mg .................................................. 5
acetaminophen w/ codeine tab 300-60
mg .................................................. 5 acetazolamide cap er 12hr 500 mg .... 25
acetazolamide tab 125 mg ................ 25
acetazolamide tab 250 mg ................ 25 acetic acid otic soln 2% ................... 104
acetic acid vaginal solution ............... 75
acyclovir cap 200 mg ....................... 14 acyclovir susp 200 mg/5ml ............... 14
acyclovir tab 400 mg ........................ 14
acyclovir tab 800 mg ........................ 14
ADACEL INJ .................................... 79 ADASUVE INH 10MG ........................ 46
adefovir dipivoxil tab 10 mg .............. 13
ADVAIR HFA AER 115/21 .................. 95 ADVAIR HFA AER 230/21 .................. 95
ADVAIR HFA AER 45/21 .................... 95 AERCHMBR PLS MIS LRG MASK ......... 93 AERCHMBR PLS MIS MED MASK ......... 93
AERCHMBR PLS MIS SM MASK ........... 93
AERCHMBR Z- MIS STAT PLS ............ 93 AEROCHAMBER MIS CHAMBER .......... 93
AEROCHAMBER MIS FLOSIGNA .......... 93 AEROCHAMBER MIS MV .................... 93 AEROCHAMBER MIS PLUS ................. 93
AFINITOR TAB 10MG ........................ 16 AFINITOR TAB 2.5MG ....................... 16
AFINITOR TAB 5MG ......................... 16
AFINITOR TAB 7.5MG ....................... 16
albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) ......................... 91
albuterol sulfate soln nebu 0.083% (2.5
mg/3ml)......................................... 92 albuterol sulfate soln nebu 0.5% (5
mg/ml) .......................................... 91
albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) ................................... 91
albuterol sulfate soln nebu 1.25 mg/3ml
(base equiv) ................................... 92 albuterol sulfate syrup 2 mg/5ml ....... 92
albuterol sulfate tab 2 mg ................. 92
albuterol sulfate tab 4 mg ................. 92 albuterol sulfate tab er 12hr 4 mg ...... 92
albuterol sulfate tab er 12hr 8 mg ...... 92
alclometasone dipropionate cream 0.05%
..................................................... 98
106
alclometasone dipropionate oint 0.05%
..................................................... 98 ALCOHOL SWAB PAD ........................ 62
ALDACTAZIDE TAB 50/50 .................. 25
ALECENSA CAP 150MG ...................... 16
alendronate sodium tab 10 mg ........... 62
alendronate sodium tab 35 mg ........... 62
alendronate sodium tab 40 mg ........... 62
alendronate sodium tab 5 mg ............. 62
alendronate sodium tab 70 mg ........... 62
alfuzosin hcl tab er 24hr 10 mg .......... 74
ALLEGRA ALRG TAB 30MG ................. 90 allopurinol tab 100 mg ....................... 3
allopurinol tab 300 mg ....................... 3
ALPRAZOLAM CON 1 MG/ML .............. 28 alprazolam orally disintegrating tab 0.25
mg ................................................. 28
alprazolam orally disintegrating tab 0.5 mg ................................................. 28
alprazolam orally disintegrating tab 1 mg ..................................................... 28
alprazolam orally disintegrating tab 2 mg
..................................................... 28
alprazolam tab 0.25 mg .................... 28 alprazolam tab 0.5 mg ...................... 28
alprazolam tab 1 mg ......................... 28 alprazolam tab 2 mg ......................... 28
alprazolam tab er 24hr 0.5 mg ........... 28 alprazolam tab er 24hr 1 mg .............. 28
alprazolam tab er 24hr 2 mg .............. 28 alprazolam tab er 24hr 3 mg .............. 28 alum & mag hydroxide-simethicone chew
tab 200-200-25 mg .......................... 69 alum & mag hydroxide-simethicone susp
200-200-20 mg/5ml ......................... 69
alum & mag hydroxide-simethicone susp 400-400-40 mg/5ml ......................... 69
aluminum hydroxide-magnesium
carbonate chew tab 160-105 mg ........ 69
aluminum hydroxide-magnesium
carbonate susp 508-475 mg/10ml ...... 70
aluminum hydroxide-magnesium carbonate susp 95-358 mg/15ml ........ 69
aluminum hydroxide-magnesium
trisilicate chew tab 80-20 mg ............. 70
amantadine hcl cap 100 mg ............... 41 amantadine hcl syrup 50 mg/5ml ....... 41
amantadine hcl tab 100 mg ............... 41
ambrisentan tab 10 mg .................... 27
ambrisentan tab 5 mg ...................... 27 amiloride & hydrochlorothiazide tab 5-50
mg ................................................ 25
amiloride hcl tab 5 mg ..................... 26
aminocaproic acid oral soln 0.25 gm/ml
..................................................... 76
aminocaproic acid tab 1000 mg ......... 76
aminocaproic acid tab 500 mg ........... 76
amiodarone hcl tab 100 mg .............. 21
amiodarone hcl tab 200 mg .............. 21
amiodarone hcl tab 400 mg .............. 21 amitriptyline hcl tab 10 mg ............... 40
amitriptyline hcl tab 100 mg ............. 40
amitriptyline hcl tab 150 mg ............. 40 amitriptyline hcl tab 25 mg ............... 40
amitriptyline hcl tab 50 mg ............... 40
amitriptyline hcl tab 75 mg ............... 40 amlodipine besylate tab 10 mg (base
equivalent) ..................................... 24 amlodipine besylate tab 2.5 mg (base
equivalent) ..................................... 24
amlodipine besylate tab 5 mg (base
equivalent) ..................................... 24 amlodipine besylate-benazepril hcl cap
10-20 mg ....................................... 18 amlodipine besylate-benazepril hcl cap
10-40 mg ....................................... 18 amlodipine besylate-benazepril hcl cap
2.5-10 mg ...................................... 18 amlodipine besylate-benazepril hcl cap 5-10 mg ............................................ 18
amlodipine besylate-benazepril hcl cap 5-20 mg ............................................ 18
amlodipine besylate-benazepril hcl cap 5-
40 mg ............................................ 18 amoxapine tab 100 mg ..................... 40
amoxapine tab 150 mg ..................... 40
amoxapine tab 25 mg ...................... 40
amoxapine tab 50 mg ...................... 40
amoxicillin & k clavulanate chew tab 200-
28.5 mg ........................................... 8 amoxicillin & k clavulanate chew tab 400-
57 mg .............................................. 8
amoxicillin & k clavulanate for susp 200-
28.5 mg/5ml ..................................... 8 amoxicillin & k clavulanate for susp 250-
62.5 mg/5ml ..................................... 8
107
amoxicillin & k clavulanate for susp 400-
57 mg/5ml ....................................... 8 amoxicillin & k clavulanate for susp 600-
42.9 mg/5ml .................................... 8
amoxicillin & k clavulanate tab 250-125
mg .................................................. 8
amoxicillin & k clavulanate tab 500-125
mg .................................................. 8
amoxicillin & k clavulanate tab 875-125
mg .................................................. 8
amoxicillin (trihydrate) cap 250 mg ..... 8
amoxicillin (trihydrate) cap 500 mg ..... 8 amoxicillin (trihydrate) chew tab 125 mg
...................................................... 8
amoxicillin (trihydrate) chew tab 250 mg ...................................................... 8
amoxicillin (trihydrate) for susp 125
mg/5ml ............................................ 8 amoxicillin (trihydrate) for susp 200
mg/5ml ............................................ 8 amoxicillin (trihydrate) for susp 250
mg/5ml ............................................ 8
amoxicillin (trihydrate) for susp 400
mg/5ml ............................................ 8 amoxicillin (trihydrate) tab 500 mg ...... 9
amoxicillin (trihydrate) tab 875 mg ...... 9 amphetamine-dextroamphetamine cap er
24hr 10 mg ..................................... 47 amphetamine-dextroamphetamine cap er
24hr 15 mg ..................................... 47 amphetamine-dextroamphetamine cap er 24hr 20 mg ..................................... 48
amphetamine-dextroamphetamine cap er 24hr 25 mg ..................................... 48
amphetamine-dextroamphetamine cap er
24hr 30 mg ..................................... 48 amphetamine-dextroamphetamine cap er
24hr 5 mg ....................................... 47
amphetamine-dextroamphetamine tab
10 mg ............................................ 48
amphetamine-dextroamphetamine tab
12.5 mg .......................................... 48 amphetamine-dextroamphetamine tab
15 mg ............................................ 48
amphetamine-dextroamphetamine tab
20 mg ............................................ 48 amphetamine-dextroamphetamine tab
30 mg ............................................ 48
amphetamine-dextroamphetamine tab 5
mg ................................................ 48 amphetamine-dextroamphetamine tab
7.5 mg ........................................... 48
ampicillin cap 500 mg ........................ 9
ANAFRANIL CAP 25MG ..................... 29
ANAFRANIL CAP 50MG ..................... 29
ANAFRANIL CAP 75MG ..................... 29
anagrelide hcl cap 0.5 mg ................. 77
anagrelide hcl cap 1 mg ................... 77
anastrozole tab 1 mg ....................... 16
ANTACID CHW 1177MG .................... 70 APIDRA INJ SOLOSTAR ..................... 60
APIDRA INJ U-100 ........................... 60
APLENZIN TAB 174MG ...................... 36 APLENZIN TAB 348MG ...................... 36
APLENZIN TAB 522MG ...................... 36
aprepitant capsule 125 mg ................ 70 aprepitant capsule 40 mg ................. 70
aprepitant capsule 80 mg ................. 70 aprepitant capsule therapy pack 80 &
125 mg .......................................... 70
APRISO CAP 0.375GM ...................... 72
APTIOM TAB 200MG ......................... 30 APTIOM TAB 400MG ......................... 30
APTIOM TAB 600MG ......................... 30 APTIOM TAB 800MG ......................... 30
APTIVUS CAP 250MG ....................... 12 APTIVUS SOL .................................. 12
aripiprazole oral solution 1 mg/ml ...... 42 aripiprazole orally disintegrating tab 10 mg ................................................ 43
aripiprazole orally disintegrating tab 15 mg ................................................ 43
aripiprazole tab 10 mg ..................... 43
aripiprazole tab 15 mg ..................... 43 aripiprazole tab 2 mg ....................... 43
aripiprazole tab 20 mg ..................... 43
aripiprazole tab 30 mg ..................... 43
aripiprazole tab 5 mg ....................... 43
ARISTADA INJ 1064MG .................... 43
ARISTADA INJ 441MG/1. .................. 43 ARISTADA INJ 662MG/2 ................... 43
ARISTADA INJ 882MG/3 ................... 43
ARISTADA INJ INITIO ...................... 43
armodafinil tab 150 mg .................... 56 armodafinil tab 200 mg .................... 56
armodafinil tab 250 mg .................... 56
108
armodafinil tab 50 mg ....................... 56
ARNUITY ELPT INH 100MCG ............... 94 ARNUITY ELPT INH 200MCG ............... 94
ARNUITY ELPT INH 50MCG ................ 94
ARTH PAIN CRE 0.075% .................. 100
artificial tear ophth ointment ............ 102
artificial tear ophth solution ............. 102
aspirin chew tab 81 mg ..................... 77
aspirin tab 325 mg ........................... 77
aspirin tab 500 mg ........................... 77
aspirin tab delayed release 325 mg ..... 77
aspirin tab delayed release 500 mg ..... 77 aspirin tab delayed release 81 mg ...... 77
ASTAGRAF XL CAP 0.5MG .................. 78
ASTAGRAF XL CAP 1MG ..................... 78 ASTAGRAF XL CAP 5MG ..................... 78
atazanavir sulfate cap 150 mg (base
equiv) ............................................. 12 atazanavir sulfate cap 200 mg (base
equiv) ............................................. 12 atazanavir sulfate cap 300 mg (base
equiv) ............................................. 12
atenolol & chlorthalidone tab 100-25 mg
..................................................... 23 atenolol & chlorthalidone tab 50-25 mg
..................................................... 23 atenolol tab 100 mg ......................... 23
atenolol tab 25 mg ........................... 23 atenolol tab 50 mg ........................... 23
ATIVAN INJ 2MG/ML ......................... 28 ATIVAN INJ 4MG/ML ......................... 28 ATIVAN TAB 0.5MG .......................... 28
ATIVAN TAB 1MG ............................. 28 ATIVAN TAB 2MG ............................. 28
atomoxetine hcl cap 10 mg (base equiv)
..................................................... 48 atomoxetine hcl cap 100 mg (base
equiv) ............................................. 49
atomoxetine hcl cap 18 mg (base equiv)
..................................................... 48
atomoxetine hcl cap 25 mg (base equiv)
..................................................... 48 atomoxetine hcl cap 40 mg (base equiv)
..................................................... 49
atomoxetine hcl cap 60 mg (base equiv)
..................................................... 49 atomoxetine hcl cap 80 mg (base equiv)
..................................................... 49
atorvastatin calcium tab 10 mg (base
equivalent) ..................................... 22 atorvastatin calcium tab 20 mg (base
equivalent) ..................................... 22
atorvastatin calcium tab 40 mg (base
equivalent) ..................................... 22
atorvastatin calcium tab 80 mg (base
equivalent) ..................................... 22
atovaquone susp 750 mg/5ml ........... 14
atovaquone-proguanil hcl tab 250-100
mg ................................................ 10
atovaquone-proguanil hcl tab 62.5-25 mg ................................................ 10
ATRIPLA TAB .................................. 10
ATROPINE SUL SOL 1% OP .............. 104 AUBAGIO TAB 14MG ........................ 55
AUBAGIO TAB 7MG .......................... 55
AUGMENTIN SUS 125/5ML .................. 9 AUSTEDO TAB 12MG ........................ 53
AUSTEDO TAB 6MG .......................... 53 AUSTEDO TAB 9MG .......................... 53
AVONEX PEN KIT 30MCG .................. 55
AVONEX PREFL KIT 30MCG ............... 55
AYR NASAL DRO 0.65% .................... 93 AZASAN TAB 100MG ........................ 78
AZASAN TAB 75 MG ......................... 78 azathioprine tab 50 mg .................... 78
azelastine hcl nasal spray 0.1% (137 mcg/spray) ..................................... 94
azelastine hcl nasal spray 0.15% (205.5 mcg/spray) ..................................... 94 azelastine hcl ophth soln 0.05% ....... 102
azithromycin for susp 100 mg/5ml ....... 7 azithromycin for susp 200 mg/5ml ....... 7
azithromycin powd pack for susp 1 gm . 7
azithromycin tab 250 mg .................... 7 azithromycin tab 500 mg .................... 7
azithromycin tab 600 mg .................... 7
B bacitracin oint 500 unit/gm ............... 96
bacitracin ophth oint 500 unit/gm ..... 102
bacitracin zinc oint 500 unit/gm ......... 96 bacitracin-polymyxin b oint ............... 96
bacitracin-polymyxin b ophth oint ..... 102
bacitracin-polymyxin-neomycin-hc ophth
oint 1% ......................................... 101 baclofen tab 10 mg .......................... 56
baclofen tab 20 mg .......................... 56
109
balsalazide disodium cap 750 mg ........ 72
bandages: adhesive; elastic; gauze .... 81 BANZEL SUS 40MG/ML ...................... 30
BANZEL TAB 200MG ......................... 30
BANZEL TAB 400MG ......................... 30
BARACLUDE SOL .............................. 13
BASAGLAR INJ 100UNIT .................... 60
b-complex vitamin cap ...................... 84
b-complex vitamin sublingual liquid .... 84
b-complex vitamin tab ...................... 84
b-complex vitamin tab er................... 84
b-complex w/ c & calcium tab ............ 84 b-complex w/ c & e + zn tab .............. 84
b-complex w/ c & folic acid cap 1 mg .. 84
b-complex w/ c & folic acid tab ........... 84 b-complex w/ c & folic acid tab 0.8 mg 84
b-complex w/ c & folic acid tab 1 mg ... 84
b-complex w/ c & folic acid tab 5 mg ... 85 b-complex w/ c cap .......................... 85
b-complex w/ c tab ........................... 85 b-complex w/ c tab er ....................... 85
b-complex w/ c-biotin-minerals & folic
acid tab 5 mg .................................. 85
b-complex w/ folic acid cap ................ 85 b-complex w/ folic acid tab ................ 85
b-complex w/ folic acid tab er ............ 85 b-complex w/ iron tab ....................... 85
b-complex w/ minerals liq.................. 85 b-complex w/biotin & folic acid tab ..... 85
b-complex w/biotin & folic acid tab er .. 85 BD INSULIN SYRINGE 0.3/30G ........... 62 BD INSULIN SYRINGE 0.3/31G ........... 62
BD INSULIN SYRINGE 0.5/30G ........... 62 BD INSULIN SYRINGE 0.5/31G ........... 62
BD INSULIN SYRINGE 1ML/30G .......... 62
BD INSULIN SYRINGE 1ML/31G .......... 62 BD PEN NEEDL MIS 29GX12.7 ............ 62
BD PEN NEEDL MIS 31GX5MM ............ 62
BD PEN NEEDL MIS 31GX8MM ............ 62
BD PEN NEEDL MIS 32GX4MM ............ 62
BD PEN NEEDL MIS 32GX6MM ............ 62
BD U-500 MIS 31GX6MM ................... 62 benazepril & hydrochlorothiazide tab 10-
12.5 mg .......................................... 18
benazepril & hydrochlorothiazide tab 20-
12.5 mg .......................................... 18 benazepril & hydrochlorothiazide tab 20-
25 mg ............................................ 18
benazepril & hydrochlorothiazide tab 5-
6.25 mg ......................................... 18 benazepril hcl tab 10 mg .................. 19
benazepril hcl tab 20 mg .................. 19
benazepril hcl tab 40 mg .................. 19
benazepril hcl tab 5 mg .................... 19
benzonatate cap 100 mg .................. 91
benzonatate cap 200 mg .................. 91
BENZOYL PER GEL 2.5% ................... 95
benzoyl peroxide cream 10% ............ 96
benzoyl peroxide cream 2.5% ........... 95
benzoyl peroxide gel 10% ................. 96 benzoyl peroxide gel 5% .................. 96
benzoyl peroxide liq 10% .................. 96
benzoyl peroxide liq 2.5% ................. 96 benzoyl peroxide liq 4% ................... 96
benzoyl peroxide liq 5% ................... 96
benzoyl peroxide liq 5.25% ............... 96 benzoyl peroxide liq 6% ................... 96
benzoyl peroxide liq 7% ................... 96 benzoyl peroxide-erythromycin gel 5-3%
..................................................... 96
benztropine mesylate tab 0.5 mg ....... 41
benztropine mesylate tab 1 mg ......... 41 benztropine mesylate tab 2 mg ......... 41
betamethasone dipropionate augmented cream 0.05% .................................. 98
betamethasone dipropionate augmented gel 0.05% ...................................... 99
betamethasone dipropionate augmented lotion 0.05% ................................... 98 betamethasone dipropionate augmented
oint 0.05% ..................................... 99 betamethasone dipropionate cream
0.05% ........................................... 98
betamethasone dipropionate lotion 0.05% ........................................... 98
betamethasone dipropionate oint 0.05%
..................................................... 98
betamethasone valerate cream 0.1%
(base equivalent) ............................ 99
betamethasone valerate lotion 0.1% (base equivalent) ............................ 99
betamethasone valerate oint 0.1% (base
equivalent) ..................................... 99
BETAPACE AF TAB 120MG ................. 21 BETAPACE AF TAB 160MG ................. 21
BETAPACE AF TAB 80MG .................. 21
110
BETAPACE TAB 120MG ...................... 21
BETAPACE TAB 160MG ...................... 21 BETAPACE TAB 80MG ........................ 21
BETASERON INJ 0.3MG ..................... 55
betaxolol hcl ophth soln 0.5% .......... 103
bethanechol chloride tab 10 mg .......... 75
bethanechol chloride tab 25 mg .......... 75
bethanechol chloride tab 5 mg ........... 75
bethanechol chloride tab 50 mg .......... 75
BETHKIS NEB 300/4ML ..................... 92
bexarotene cap 75 mg ...................... 18
bicalutamide tab 50 mg ..................... 15 BIKTARVY TAB ................................. 10
bioflavonoid products tab .................. 85
bioflavonoid products tab er ............... 85 bisacodyl suppos 10 mg .................... 72
bisacodyl tab delayed release 5 mg ..... 72
bismuth subsalicylate chew tab 262 mg ..................................................... 70
bismuth subsalicylate susp 262 mg/15ml ..................................................... 70
bismuth subsalicylate susp 525 mg/15ml
..................................................... 70
bismuth subsalicylate tab 262 mg ....... 70 bisoprolol & hydrochlorothiazide tab 10-
6.25 mg .......................................... 23 bisoprolol & hydrochlorothiazide tab 2.5-
6.25 mg .......................................... 23 bisoprolol & hydrochlorothiazide tab 5-
6.25 mg .......................................... 23 bisoprolol fumarate tab 10 mg ........... 23 bisoprolol fumarate tab 5 mg ............. 23
BOOSTRIX INJ ................................. 79 bosentan tab 125 mg ........................ 27
bosentan tab 62.5 mg ....................... 27
brewers yeast tab ............................. 85 BRILINTA TAB 60MG ......................... 77
BRILINTA TAB 90MG ......................... 77
brimonidine tartrate ophth soln 0.15%
................................................... 104
brimonidine tartrate ophth soln 0.2% 104
BRIVIACT SOL 10MG/ML ................... 30 BRIVIACT TAB 100MG ....................... 30
BRIVIACT TAB 10MG ......................... 30
BRIVIACT TAB 25MG ......................... 30
BRIVIACT TAB 50MG ......................... 30 BRIVIACT TAB 75MG ......................... 30
bromocriptine mesylate cap 5 mg (base
equivalent) ..................................... 41
bromocriptine mesylate tab 2.5 mg (base equivalent) ..................................... 41
brompheniramine & pseudoephedrine
elixir 1-15 mg/5ml ........................... 89
budesonide delayed release particles cap
3 mg ............................................. 72
budesonide inhalation susp 0.25 mg/2ml
..................................................... 94
budesonide inhalation susp 0.5 mg/2ml
..................................................... 94
budesonide inhalation susp 1 mg/2ml . 94 budesonide nasal susp 32 mcg/act ..... 94
bumetanide tab 0.5 mg .................... 26
bumetanide tab 1 mg ....................... 26 bumetanide tab 2 mg ....................... 26
buprenorphine hcl sl tab 2 mg (base
equiv) ............................................ 57 buprenorphine hcl sl tab 8 mg (base
equiv) ............................................ 57 buprenorphine hcl-naloxone hcl sl film
12-3 mg (base equiv) ...................... 57
buprenorphine hcl-naloxone hcl sl film 2-
0.5 mg (base equiv) ........................ 57 buprenorphine hcl-naloxone hcl sl film 4-
1 mg (base equiv) ........................... 57 buprenorphine hcl-naloxone hcl sl film 8-
2 mg (base equiv) ........................... 57 buprenorphine hcl-naloxone hcl sl tab 2-
0.5 mg (base equiv) ........................ 57 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) ........................... 57
bupropion hcl (smoking deterrent) tab er 12hr 150 mg ................................... 57
bupropion hcl tab 100 mg ................. 36
bupropion hcl tab 75 mg ................... 36 bupropion hcl tab er 12hr 100 mg ...... 36
bupropion hcl tab er 12hr 150 mg ...... 36
bupropion hcl tab er 12hr 200 mg ...... 36
bupropion hcl tab er 24hr 150 mg ...... 36
bupropion hcl tab er 24hr 300 mg ...... 36
bupropion hcl tab er 24hr 450 mg ...... 36 buspirone hcl tab 10 mg ................... 30
buspirone hcl tab 15 mg ................... 30
buspirone hcl tab 30 mg ................... 30
buspirone hcl tab 5 mg ..................... 30 buspirone hcl tab 7.5 mg .................. 30
butalbital-acetaminophen-caffeine cap
111
50-325-40 mg .................................. 4
butalbital-acetaminophen-caffeine tab 50-325-40 mg .................................. 4
butalbital-aspirin-caffeine cap 50-325-40
mg .................................................. 4
C cabergoline tab 0.5 mg ..................... 67
CABOMETYX TAB 20MG ..................... 16
CABOMETYX TAB 40MG ..................... 16
CABOMETYX TAB 60MG ..................... 16
CALAMINE LOT ............................... 101
CALAMINE LOT 8-8% ...................... 101 calcipotriene oint 0.005% .................. 97
calcipotriene soln 0.005% (50 mcg/ml)
..................................................... 97 calcitonin (salmon) nasal soln 200
unit/act ........................................... 62
calcitriol cap 0.25 mcg ...................... 67 calcitriol cap 0.5 mcg ........................ 67
calcitriol oral soln 1 mcg/ml ............... 67 calcium acetate (phosphate binder) cap
667 mg (169 mg ca) ......................... 67
calcium ascorbate tab 500 mg ............ 85
CALCIUM CARB TAB 648MG ............... 70 calcium carbonate (antacid) chew tab
1000 mg ......................................... 70 calcium carbonate (antacid) chew tab
400 mg ........................................... 70 calcium carbonate (antacid) chew tab
420 mg ........................................... 70 calcium carbonate (antacid) chew tab 500 mg ........................................... 70
calcium carbonate (antacid) chew tab 750 mg ........................................... 70
calcium carbonate (antacid) susp 1250
mg/5ml ........................................... 70 calcium carbonate chew tab 1250 mg
(500 mg elemental ca) ...................... 81
calcium carbonate tab 1250 mg (500 mg
elemental ca) .................................. 82
calcium carbonate tab 1500 mg (600 mg
elemental ca) .................................. 82 calcium carbonate tab 600 mg ........... 81
calcium carbonate-cholecalciferol cap
600 mg-500 unit .............................. 82
calcium carbonate-cholecalciferol chew tab 500 mg-400 unit ......................... 82
calcium carbonate-cholecalciferol chew
tab 500 mg-600 unit ........................ 82
calcium carbonate-cholecalciferol tab 250 mg-125 unit ................................... 82
calcium carbonate-cholecalciferol tab 500
mg-125 unit ................................... 82
calcium carbonate-cholecalciferol tab 500
mg-200 unit ................................... 82
calcium carbonate-cholecalciferol tab 500
mg-400 unit ................................... 82
calcium carbonate-cholecalciferol tab 600
mg-200 unit ................................... 82
calcium carbonate-cholecalciferol tab 600 mg-400 unit ................................... 82
calcium carbonate-cholecalciferol tab 600
mg-800 unit ................................... 82 calcium carbonate-mag hydroxide chew
tab 550-110 mg .............................. 70
calcium carbonate-mag hydroxide susp 400-135 mg/5ml ............................. 70
calcium carbonate-vitamin d cap 600 mg-200 unit ................................... 82
calcium carbonate-vitamin d chew tab
600 mg-400 unit ............................. 82
calcium carbonate-vitamin d tab 250 mg-125 unit ......................................... 82
calcium carbonate-vitamin d tab 500 mg-125 unit ......................................... 82
calcium carbonate-vitamin d tab 500 mg-200 unit ......................................... 82
calcium carbonate-vitamin d tab 500 mg-400 unit ......................................... 82 calcium carbonate-vitamin d tab 600 mg-
125 unit ......................................... 82 calcium carbonate-vitamin d tab 600 mg-
200 unit ......................................... 82
calcium carbonate-vitamin d tab 600 mg-400 unit ......................................... 82
calcium citrate tab 950 mg (200 mg
elemental ca) .................................. 82
calcium citrate-vitamin d tab 200 mg-
250 unit (elemental ca) .................... 82
calcium citrate-vitamin d tab 250 mg-200 unit (elemental ca) .................... 82
calcium citrate-vitamin d tab 315 mg-
200 unit (elemental ca) .................... 82
calcium citrate-vitamin d tab 315 mg-250 unit (elemental ca) .................... 82
calcium pantothenate tab 500 mg ...... 85
112
calcium tab 500 mg .......................... 82
calcium tab 600 mg .......................... 82 calcium w/ magnesium tab 250-125 mg
..................................................... 82
calcium w/ magnesium tab 333-167 mg
..................................................... 83
calcium w/ magnesium tab 500-250 mg
..................................................... 83
calcium w/ vitamin d & k chew tab 500
mg-100 unit-40 mcg ......................... 83
calcium w/ vitamin d & k chew tab 500
mg-200 unit-40 mcg ......................... 83 calcium w/ vitamin d tab 600 mg-200
unit ................................................ 83
calcium-magnesium-zinc tab 333-133-5 mg ................................................. 83
calcium-magnesium-zinc tab 333-133-
8.3 mg ........................................... 83 calcium-mag-vit c-vit d cap 185 mg-28
mg-2.5 mg-200 unit ......................... 83 CALQUENCE CAP 100MG ................... 16
capecitabine tab 150 mg ................... 15
capecitabine tab 500 mg ................... 15
CAPRELSA TAB 100MG ...................... 16 CAPRELSA TAB 300MG ...................... 16
capsaicin cream 0.025% ................. 100 capsaicin cream 0.1% ..................... 100
CAPSAICIN LIQ 0.15% .................... 100 captopril & hydrochlorothiazide tab 25-15
mg ................................................. 18 captopril & hydrochlorothiazide tab 25-25 mg ................................................. 19
captopril & hydrochlorothiazide tab 50-15 mg ................................................. 19
captopril & hydrochlorothiazide tab 50-25
mg ................................................. 19 captopril tab 100 mg ........................ 19
captopril tab 12.5 mg ....................... 19
captopril tab 25 mg .......................... 19
captopril tab 50 mg .......................... 19
CAPZASIN GEL RELIEF .................... 100
CAPZASIN LIQ 0.15% ..................... 100 CAPZASIN-P CRE 0.035% ................ 100
carbamazepine cap er 12hr 100 mg .... 30
carbamazepine cap er 12hr 200 mg .... 30
carbamazepine cap er 12hr 300 mg .... 30 carbamazepine chew tab 100 mg ........ 30
carbamazepine susp 100 mg/5ml ....... 30
carbamazepine tab 200 mg ............... 30
carbamazepine tab er 12hr 100 mg .... 30 carbamazepine tab er 12hr 200 mg .... 30
carbamazepine tab er 12hr 400 mg .... 30
CARBATROL CAP 100MG ................... 30
CARBATROL CAP 200MG ................... 30
CARBATROL CAP 300MG ................... 30
carbidopa & levodopa orally
disintegrating tab 10-100 mg ............ 41
carbidopa & levodopa orally
disintegrating tab 25-100 mg ............ 41
carbidopa & levodopa orally disintegrating tab 25-250 mg ............ 41
carbidopa & levodopa tab 10-100 mg . 41
carbidopa & levodopa tab 25-100 mg . 41 carbidopa & levodopa tab 25-250 mg . 42
carbidopa & levodopa tab er 25-100 mg
..................................................... 42 carbidopa & levodopa tab er 50-200 mg
..................................................... 42 carbidopa-levodopa-entacapone tabs
12.5-50-200 mg .............................. 42
carbidopa-levodopa-entacapone tabs
18.75-75-200 mg ............................ 42 carbidopa-levodopa-entacapone tabs 25-
100-200 mg ................................... 42 carbidopa-levodopa-entacapone tabs
31.25-125-200 mg .......................... 42 carbidopa-levodopa-entacapone tabs
37.5-150-200 mg ............................ 42 carbidopa-levodopa-entacapone tabs 50-200-200 mg ................................... 42
carboxymethylcellulose sodium (pf) ophth gel 1% ................................. 102
carboxymethylcellulose sodium (pf)
ophth soln 0.5% ............................. 103 carboxymethylcellulose sodium ophth gel
1% ............................................... 103
carboxymethylcellulose sodium ophth
soln 0.25% .................................... 103
carboxymethylcellulose sodium ophth
soln 0.5% ...................................... 103 carboxymethylcellulose-glycerin ophth
soln 0.5-0.9% ................................ 103
carisoprodol tab 250 mg ................... 56
carisoprodol tab 350 mg ................... 56 carvedilol tab 12.5 mg ..................... 23
carvedilol tab 25 mg ........................ 23
113
carvedilol tab 3.125 mg ..................... 23
carvedilol tab 6.25 mg ...................... 23 CASTIVA LOT ................................. 100
cefadroxil cap 500 mg ........................ 7
cefadroxil for susp 250 mg/5ml ........... 7
cefadroxil for susp 500 mg/5ml ........... 7
cefadroxil tab 1 gm ............................ 7
cefdinir cap 300 mg ........................... 7
cefdinir for susp 125 mg/5ml .............. 7
cefdinir for susp 250 mg/5ml .............. 7
cefprozil for susp 125 mg/5ml ............. 7
cefprozil for susp 250 mg/5ml ............. 7 cefprozil tab 250 mg .......................... 7
cefprozil tab 500 mg .......................... 7
cefuroxime axetil tab 250 mg .............. 7 cefuroxime axetil tab 500 mg .............. 7
celecoxib cap 100 mg ........................ 3
celecoxib cap 200 mg ........................ 3 celecoxib cap 400 mg ........................ 3
celecoxib cap 50 mg .......................... 3 CELEXA TAB 10MG ........................... 37
CELEXA TAB 20MG ........................... 37
CELEXA TAB 40MG ........................... 37
CELLCEPT CAP 250MG ....................... 78 CELLCEPT SUS 200MG/ML ................. 78
CELLCEPT TAB 500MG ....................... 78 CELONTIN CAP 300MG ...................... 30
cephalexin cap 250 mg ...................... 7 cephalexin cap 500 mg ...................... 7
cephalexin cap 750 mg ...................... 7 cephalexin for susp 125 mg/5ml .......... 7 cephalexin for susp 250 mg/5ml .......... 7
cephalexin tab 250 mg ....................... 7 cephalexin tab 500 mg ....................... 7
CERDELGA CAP 84MG ....................... 65
cetirizine hcl cap 10 mg ..................... 89 cetirizine hcl chew tab 10 mg ............. 89
cetirizine hcl chew tab 5 mg ............... 89
cetirizine hcl oral soln 1 mg/ml (5
mg/5ml) ......................................... 89
cetirizine hcl tab 10 mg ..................... 89
cetirizine hcl tab 5 mg ....................... 89 cetirizine-pseudoephedrine tab er 12hr
5-120 mg ........................................ 89
CHANTIX PAK 0.5& 1MG .................... 57
CHANTIX PAK 1MG ........................... 57 CHANTIX TAB 0.5MG ........................ 57
CHANTIX TAB 1MG ........................... 57
CHEMET CAP 100MG ........................ 76
CHEMSTRIP 10 TES MD .................... 81 CHEMSTRIP 2 TES GP ....................... 81
CHEMSTRIP 5 TES OB ...................... 81
CHEMSTRIP 7 TES ........................... 81
CHEMSTRIP 9 TES STRIPS ................ 81
CHEMSTRIP TES -10 SG ................... 81
chlordiazepoxide hcl cap 10 mg ......... 28
chlordiazepoxide hcl cap 25 mg ......... 28
chlordiazepoxide hcl cap 5 mg ........... 28
chlordiazepoxide hcl-clidinium bromide
cap 5-2.5 mg .................................. 71 chlordiazepoxide-amitriptyline tab 10-25
mg ................................................ 36
chlordiazepoxide-amitriptyline tab 5-12.5 mg ................................................ 36
chlorhexidine gluconate soln 0.12% .. 101
chloroquine phosphate tab 250 mg .... 10 chloroquine phosphate tab 500 mg .... 10
chlorpheniramine maleate syrup 2 mg/5ml .......................................... 90
chlorpheniramine maleate tab 4 mg ... 90
chlorpheniramine maleate tab er 12 mg
..................................................... 90 CHLORPROMAZ INJ 25MG/ML ............ 46
CHLORPROMAZ INJ 50MG/2ML .......... 46 chlorpromazine hcl tab 10 mg ........... 46
chlorpromazine hcl tab 100 mg .......... 46 chlorpromazine hcl tab 200 mg .......... 46
chlorpromazine hcl tab 25 mg ........... 46 chlorpromazine hcl tab 50 mg ........... 46 chlorthalidone tab 25 mg .................. 26
chlorthalidone tab 50 mg .................. 26 chlorzoxazone tab 500 mg ................ 56
cholecalciferol cap 1.25 mg (50000 unit)
..................................................... 85 cholecalciferol cap 10 mcg (400 unit) . 85
cholecalciferol cap 125 mcg (5000 unit)
..................................................... 85
cholecalciferol cap 25 mcg (1000 unit) 85
cholecalciferol cap 250 mcg (10000 unit)
..................................................... 85 cholecalciferol cap 50 mcg (2000 unit) 85
cholecalciferol chew tab 10 mcg (400
unit) .............................................. 85
cholecalciferol chew tab 125 mcg (5000 unit) .............................................. 85
cholecalciferol chew tab 25 mcg (1000
114
unit) ............................................... 85
cholecalciferol chew tab 50 mcg (2000 unit) ............................................... 85
cholecalciferol drops 10 mcg/0.03ml
(400 unit/0.03ml) ............................ 85
cholecalciferol drops 125 mcg/ml (5000
unit/ml) .......................................... 85
cholecalciferol drops 50 mcg/0.03ml
(2000 unit/0.03ml) ........................... 85
cholecalciferol oral liquid 10 mcg/ml (400
unit/ml) .......................................... 85
cholecalciferol tab 1.25 mg (50000 unit) ..................................................... 85
cholecalciferol tab 10 mcg (400 unit) .. 85
cholecalciferol tab 125 mcg (5000 unit) ..................................................... 85
cholecalciferol tab 25 mcg (1000 unit) . 85
cholecalciferol tab 50 mcg (2000 unit) . 85 cholestyramine light powder 4 gm/dose
..................................................... 22 cholestyramine light powder packets 4
gm ................................................. 22
cholestyramine powder 4 gm/dose ...... 22
cholestyramine powder packets 4 gm .. 22 ciclopirox gel 0.77% ......................... 97
ciclopirox olamine cream 0.77% (base equiv) ............................................. 97
ciclopirox olamine susp 0.77% (base equiv) ............................................. 97
ciclopirox shampoo 1% ..................... 97 cilostazol tab 100 mg ........................ 76 cilostazol tab 50 mg .......................... 76
CIMDUO TAB 300-300 ....................... 10 cimetidine hcl soln 300 mg/5ml .......... 71
cimetidine tab 200 mg ...................... 71
cimetidine tab 300 mg ...................... 71 cimetidine tab 400 mg ...................... 71
cimetidine tab 800 mg ...................... 72
CIPRODEX SUS 0.3-0.1% ................ 104
ciprofloxacin hcl ophth soln 0.3% (base
equivalent) .................................... 102
ciprofloxacin hcl tab 100 mg (base equiv) ...................................................... 8
ciprofloxacin hcl tab 250 mg (base equiv)
...................................................... 8
ciprofloxacin hcl tab 500 mg (base equiv) ...................................................... 8
ciprofloxacin hcl tab 750 mg (base equiv)
....................................................... 8
citalopram hydrobromide oral soln 10 mg/5ml .......................................... 37
citalopram hydrobromide tab 10 mg
(base equiv) ................................... 37
citalopram hydrobromide tab 20 mg
(base equiv) ................................... 37
citalopram hydrobromide tab 40 mg
(base equiv) ................................... 37
CITRANATAL CAP HARMONY .............. 88
CITRANATAL CAP MEDLEY ................. 88
CITRANATAL MIS ............................. 88 CITRANATAL MIS 90 DHA ................. 88
CITRANATAL MIS B-CALM ................. 88
CITRANATAL PAK ASSURE ................ 88 CITRANATAL PAK DHA ...................... 88
CITRANATAL TAB BLOOM .................. 88
CITRANATAL TAB RX ........................ 88 claravis cap 10mg ............................ 95
claravis cap 20mg ............................ 95 claravis cap 30mg ............................ 95
claravis cap 40mg ............................ 95
clarithromycin for susp 125 mg/5ml ..... 7
clarithromycin for susp 250 mg/5ml ..... 7 clarithromycin tab 250 mg .................. 8
clarithromycin tab 500 mg .................. 8 clarithromycin tab er 24hr 500 mg ....... 8
CLARITIN RDT TAB 5MG ................... 90 clemastine fumarate tab 1.34 mg (1 mg
base equiv) .................................... 90 clemastine fumarate tab 2.68 mg ...... 90 clindamycin hcl cap 150 mg .............. 14
clindamycin hcl cap 300 mg .............. 14 clindamycin palmitate hcl for soln 75
mg/5ml (base equiv) ....................... 14
clindamycin phosphate gel 1% .......... 96 clindamycin phosphate lotion 1% ....... 96
clindamycin phosphate soln 1% ......... 96
clindamycin phosphate vaginal cream 2%
..................................................... 75
clobazam suspension 2.5 mg/ml ........ 30
clobazam tab 10 mg ........................ 30 clobazam tab 20 mg ........................ 31
clobetasol propionate cream 0.05% ... 99
clobetasol propionate foam 0.05% ..... 99
clobetasol propionate gel 0.05% ........ 99 clobetasol propionate oint 0.05% ....... 99
clobetasol propionate soln 0.05% ...... 99
115
clomipramine hcl cap 25 mg .............. 30
clomipramine hcl cap 50 mg .............. 30 clomipramine hcl cap 75 mg .............. 30
clonazepam orally disintegrating tab
0.125 mg ........................................ 29
clonazepam orally disintegrating tab 0.25
mg ................................................. 28
clonazepam orally disintegrating tab 0.5
mg ................................................. 28
clonazepam orally disintegrating tab 1
mg ................................................. 29
clonazepam orally disintegrating tab 2 mg ................................................. 29
clonazepam tab 0.5 mg ..................... 29
clonazepam tab 1 mg ........................ 29 clonazepam tab 2 mg ........................ 29
clonidine hcl tab 0.1 mg .................... 20
clonidine hcl tab 0.2 mg .................... 20 clonidine hcl tab 0.3 mg .................... 20
clonidine td patch weekly 0.1 mg/24hr 20 clonidine td patch weekly 0.2 mg/24hr 20
clonidine td patch weekly 0.3 mg/24hr 20
clopidogrel bisulfate tab 300 mg (base
equiv) ............................................. 77 clopidogrel bisulfate tab 75 mg (base
equiv) ............................................. 77 clorazepate dipotassium tab 15 mg ..... 29
clorazepate dipotassium tab 3.75 mg .. 29 clorazepate dipotassium tab 7.5 mg .... 29
clotrimazole cream 1% ..................... 97 clotrimazole soln 1% ........................ 97 clotrimazole troche 10 mg .................. 9
clotrimazole vaginal cream 1% ........... 75 clotrimazole vaginal cream 2% ........... 75
clozapine orally disintegrating tab 100
mg ................................................. 43 clozapine orally disintegrating tab 12.5
mg ................................................. 43
clozapine orally disintegrating tab 150
mg ................................................. 43
clozapine orally disintegrating tab 200
mg ................................................. 43 clozapine orally disintegrating tab 25 mg
..................................................... 43
clozapine tab 100 mg ........................ 43
clozapine tab 200 mg ........................ 43 clozapine tab 25 mg ......................... 43
clozapine tab 50 mg ......................... 43
CLOZARIL TAB 100MG ...................... 43
CLOZARIL TAB 25MG ....................... 43 cod liver oil cap ............................... 85
colchicine tab 0.6 mg ......................... 3
colestipol hcl granule packets 5 gm .... 22
colestipol hcl granules 5 gm .............. 22
colestipol hcl tab 1 gm ..................... 22
COMBIPATCH DIS ............................ 65
COMBISTIX TES .............................. 81
COMBIVENT AER 20-100 .................. 89
COMBIVIR TAB 150-300 ................... 10
COMETRIQ KIT 100MG ..................... 16 COMETRIQ KIT 140MG ..................... 16
COMETRIQ KIT 60MG ....................... 16
COMPLERA TAB ............................... 10 CONDOMS MIS ................................ 63
COPAXONE INJ 40MG/ML .................. 55
CORLANOR TAB 5MG........................ 26 CORLANOR TAB 7.5MG ..................... 26
COUMADIN TAB 10MG ...................... 76 COUMADIN TAB 1MG ....................... 76
COUMADIN TAB 2.5MG ..................... 76
COUMADIN TAB 2MG ....................... 76
COUMADIN TAB 3MG ....................... 76 COUMADIN TAB 4MG ....................... 76
COUMADIN TAB 5MG ....................... 76 COUMADIN TAB 6MG ....................... 76
COUMADIN TAB 7.5MG ..................... 76 CREON CAP 12000UNT ..................... 73
CREON CAP 24000UNT ..................... 73 CREON CAP 3000UNIT ...................... 73 CREON CAP 36000UNT ..................... 73
CREON CAP 6000UNIT ...................... 73 CRINONE GEL 4% VAG ..................... 68
CRINONE GEL 8% VAG ..................... 68
CRIXIVAN CAP 200MG ...................... 12 CRIXIVAN CAP 400MG ...................... 12
cromolyn sodium nasal aerosol soln 5.2
mg/act (4%) ................................... 93
cromolyn sodium ophth soln 4% ....... 102
cromolyn sodium soln nebu 20 mg/2ml
..................................................... 93 CUTTER BACKW AER 25% ............... 100
CUVPOSA SOL 1MG/5ML ................... 73
CVS NASAL SPR MIST ...................... 93
cyanocobalamin inj 1000 mcg/ml ....... 85 cyclobenzaprine hcl tab 10 mg .......... 56
cyclobenzaprine hcl tab 5 mg ............ 56
116
CYCLOMYDRIL SOL OP .................... 104
cyclophosphamide cap 25 mg............. 15 cyclophosphamide cap 50 mg............. 15
cyclosporine cap 100 mg ................... 78
cyclosporine cap 25 mg ..................... 78
cyclosporine modified cap 100 mg ...... 78
cyclosporine modified cap 25 mg ........ 78
cyclosporine modified cap 50 mg ........ 78
cyclosporine modified oral soln 100
mg/ml ............................................ 78
CYMBALTA CAP 20MG ....................... 39
CYMBALTA CAP 30MG ....................... 39 CYMBALTA CAP 60MG ....................... 39
cyproheptadine hcl syrup 2 mg/5ml .... 90
cyproheptadine hcl tab 4 mg .............. 90 CYSTAGON CAP 150MG ..................... 67
CYSTAGON CAP 50MG ....................... 67
CYTOMEL TAB 25MCG ....................... 68 CYTOMEL TAB 50MCG ....................... 68
CYTOMEL TAB 5MCG ......................... 68 D dalfampridine tab er 12hr 10 mg ........ 55
danazol cap 100 mg ................... 58, 64
danazol cap 200 mg ................... 58, 64 danazol cap 50 mg ..................... 58, 64
dantrolene sodium cap 100 mg .......... 56 dantrolene sodium cap 25 mg ............ 56
dantrolene sodium cap 50 mg ............ 56 dapsone tab 100 mg ......................... 14
dapsone tab 25 mg ........................... 14 DAPTACEL INJ .................................. 79 DARAPRIM TAB 25MG ....................... 14
DDAVP SOL 0.01% ........................... 69 demeclocycline hcl tab 150 mg ............ 9
demeclocycline hcl tab 300 mg ............ 9
DEPAKENE CAP 250MG ..................... 31 DEPAKOTE ER TAB 250MG ................. 31
DEPAKOTE ER TAB 500MG ................. 31
DEPAKOTE SPR CAP 125MG ............... 31
DEPAKOTE TAB 125MG DR ................ 31
DEPAKOTE TAB 250MG DR ................ 31
DEPAKOTE TAB 500MG DR ................ 31 DESCOVY TAB 200/25 ....................... 10
desipramine hcl tab 10 mg ................ 40
desipramine hcl tab 100 mg ............... 40
desipramine hcl tab 150 mg ............... 40 desipramine hcl tab 25 mg ................ 40
desipramine hcl tab 50 mg ................ 40
desipramine hcl tab 75 mg ................ 40
desmopressin acetate nasal spray soln 0.01% ........................................... 69
desmopressin acetate nasal spray soln
0.01% (refrigerated) ........................ 69
desmopressin acetate tab 0.1 mg ...... 69
desmopressin acetate tab 0.2 mg ...... 69
desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5) ................. 63
desogest-ethin est tab 0.1-0.025/0.125-
0.025/0.15-0.025mg-mg .................. 64
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg ..................................... 63
desonide cream 0.05% ..................... 98
desonide lotion 0.05% ...................... 98 desonide oint 0.05% ........................ 98
desoximetasone cream 0.05% ........... 99
desoximetasone cream 0.25% ........... 98 desoximetasone gel 0.05% ............... 98
desoximetasone oint 0.25% .............. 98 DESVENLAFAX TAB 100MG ER ........... 39
DESVENLAFAX TAB 50MG ER ............. 39
desvenlafaxine succinate tab er 24hr 100
mg (base equiv) .............................. 39 desvenlafaxine succinate tab er 24hr 25
mg (base equiv) .............................. 39 desvenlafaxine succinate tab er 24hr 50
mg (base equiv) .............................. 39 desvenlafaxine tab er 24hr 100 mg .... 39
desvenlafaxine tab er 24hr 50 mg ...... 39 dexamethasone elixir 0.5 mg/5ml ...... 65 dexamethasone sodium phosphate ophth
soln 0.1% ...................................... 102 dexamethasone soln 0.5 mg/5ml ....... 65
dexamethasone tab 0.5 mg ............... 65
dexamethasone tab 0.75 mg ............. 65 dexamethasone tab 1 mg ................. 65
dexamethasone tab 1.5 mg ............... 65
dexamethasone tab 2 mg ................. 65
dexamethasone tab 4 mg ................. 65
dexamethasone tab 6 mg ................. 65
dexmethylphenidate hcl tab 10 mg .... 49 dexmethylphenidate hcl tab 2.5 mg ... 49
dexmethylphenidate hcl tab 5 mg ...... 49
dextran 70-hypromellose (pf) ophth soln
0.1-0.3% ...................................... 103 dextran 70-hypromellose ophth soln 0.1-
0.3% ............................................ 103
117
dextroamphetamine sulfate cap er 24hr
10 mg ............................................ 49 dextroamphetamine sulfate cap er 24hr
15 mg ............................................ 49
dextroamphetamine sulfate cap er 24hr 5
mg ................................................. 49
dextroamphetamine sulfate tab 10 mg 50
dextroamphetamine sulfate tab 5 mg .. 49
dextromethorphan-guaifenesin liquid 10-
100 mg/5ml .................................... 91
dextromethorphan-guaifenesin liquid 10-
200 mg/5ml .................................... 91 dextromethorphan-guaifenesin liquid 20-
300 mg/5ml .................................... 91
dextromethorphan-guaifenesin liquid 30-200 mg/5ml .................................... 91
dextromethorphan-guaifenesin liquid 5-
100 mg/5ml .................................... 90 dextromethorphan-guaifenesin syrup 10-
100 mg/5ml .................................... 91 dextromethorphan-guaifenesin tab er
12hr 30-600 mg ............................... 91
dextromethorphan-guaifenesin tab er
12hr 60-1200 mg ............................. 91 DIAPHRAGM .................................... 63
DIASTAT ACDL GEL 12.5-20 .............. 31 DIASTAT ACDL GEL 5-10MG .............. 31
DIASTAT PED GEL 2.5M GEL .............. 31 diazepam conc 5 mg/ml .................... 29
DIAZEPAM INJ 10MG/2ML .................. 29 diazepam inj 5 mg/ml ....................... 29 diazepam oral soln 1 mg/ml ............... 29
diazepam rectal gel delivery system 10 mg ................................................. 31
diazepam rectal gel delivery system 2.5
mg ................................................. 31 diazepam rectal gel delivery system 20
mg ................................................. 31
diazepam tab 10 mg ......................... 29
diazepam tab 2 mg ........................... 29
diazepam tab 5 mg ........................... 29
diclofenac potassium tab 50 mg .......... 4 diclofenac sodium gel 1% ................... 5
diclofenac sodium ophth soln 0.1% ... 102
diclofenac sodium tab delayed release 25
mg .................................................. 4 diclofenac sodium tab delayed release 50
mg .................................................. 4
diclofenac sodium tab delayed release 75
mg .................................................. 4 diclofenac sodium tab er 24hr 100 mg .. 4
dicloxacillin sodium cap 250 mg ........... 9
dicloxacillin sodium cap 500 mg ........... 9
dicyclomine hcl cap 10 mg ................ 71
dicyclomine hcl oral soln 10 mg/5ml ... 71
dicyclomine hcl tab 20 mg ................ 71
didanosine delayed release capsule 200
mg ................................................ 11
didanosine delayed release capsule 250
mg ................................................ 11 didanosine delayed release capsule 400
mg ................................................ 11
diflunisal tab 500 mg ......................... 4 digoxin oral soln 0.05 mg/ml ............. 25
digoxin tab 125 mcg (0.125 mg)........ 25
digoxin tab 250 mcg (0.25 mg) ......... 25 DILANTIN CAP 100MG ...................... 31
DILANTIN CAP 30MG ........................ 31 DILANTIN CHW 50MG ...................... 31
DILANTIN-125 SUS 125/5ML ............. 31
diltiazem hcl cap er 12hr 120 mg ....... 24
diltiazem hcl cap er 12hr 60 mg ......... 24 diltiazem hcl cap er 12hr 90 mg ......... 24
diltiazem hcl cap er 24hr 120 mg ....... 24 diltiazem hcl cap er 24hr 180 mg ....... 24
diltiazem hcl cap er 24hr 240 mg ....... 24 diltiazem hcl coated beads cap er 24hr
120 mg .......................................... 24 diltiazem hcl coated beads cap er 24hr 180 mg .......................................... 25
diltiazem hcl coated beads cap er 24hr 240 mg .......................................... 25
diltiazem hcl coated beads cap er 24hr
300 mg .......................................... 25 diltiazem hcl coated beads cap er 24hr
360 mg .......................................... 25
diltiazem hcl coated beads tab er 24hr
180 mg .......................................... 25
diltiazem hcl coated beads tab er 24hr
240 mg .......................................... 25 diltiazem hcl coated beads tab er 24hr
300 mg .......................................... 25
diltiazem hcl coated beads tab er 24hr
360 mg .......................................... 25 diltiazem hcl coated beads tab er 24hr
420 mg .......................................... 25
118
diltiazem hcl extended release beads cap
er 24hr 120 mg ................................ 25 diltiazem hcl extended release beads cap
er 24hr 180 mg ................................ 25
diltiazem hcl extended release beads cap
er 24hr 240 mg ................................ 25
diltiazem hcl extended release beads cap
er 24hr 300 mg ................................ 25
diltiazem hcl extended release beads cap
er 24hr 360 mg ................................ 25
diltiazem hcl extended release beads cap
er 24hr 420 mg ................................ 25 diltiazem hcl tab 120 mg ................... 25
diltiazem hcl tab 30 mg ..................... 25
diltiazem hcl tab 60 mg ..................... 25 diltiazem hcl tab 90 mg ..................... 25
DIP/TET PED INJ 25-5LFU .................. 79
diphenhydramine hcl (sleep) cap 50 mg ..................................................... 53
diphenhydramine hcl (sleep) tab 25 mg ..................................................... 53
diphenhydramine hcl (sleep) tab 50 mg
..................................................... 53
diphenhydramine hcl cap 25 mg ......... 90 diphenhydramine hcl cap 50 mg ......... 90
diphenhydramine hcl chew tab 12.5 mg ..................................................... 90
diphenhydramine hcl elixir 12.5 mg/5ml ..................................................... 90
diphenhydramine hcl liquid 12.5 mg/5ml ..................................................... 90 diphenhydramine hcl syrup 12.5 mg/5ml
..................................................... 90 diphenhydramine hcl tab 25 mg ......... 90
diphenhydramine hcl tab disint 12.5 mg
..................................................... 90 diphenoxylate w/ atropine liq 2.5-0.025
mg/5ml ........................................... 70
diphenoxylate w/ atropine tab 2.5-0.025
mg ................................................. 70
dipyridamole tab 25 mg .................... 77
dipyridamole tab 50 mg .................... 77 dipyridamole tab 75 mg .................... 77
disopyramide phosphate cap 100 mg .. 21
disopyramide phosphate cap 150 mg .. 21
disulfiram tab 250 mg ....................... 56 disulfiram tab 500 mg ....................... 56
divalproex sodium cap delayed release
sprinkle 125 mg .............................. 31
divalproex sodium tab delayed release 125 mg .......................................... 31
divalproex sodium tab delayed release
250 mg .......................................... 31
divalproex sodium tab delayed release
500 mg .......................................... 31
divalproex sodium tab er 24 hr 250 mg
..................................................... 31
divalproex sodium tab er 24 hr 500 mg
..................................................... 31
docosanol cream 10% ..................... 101 docusate calcium cap 240 mg ............ 72
docusate sodium cap 100 mg ............ 72
docusate sodium cap 250 mg ............ 72 docusate sodium cap 50 mg .............. 72
docusate sodium liquid 150 mg/15ml . 72
docusate sodium syrup 60 mg/15ml ... 72 docusate sodium tab 100 mg ............ 72
dofetilide cap 125 mcg (0.125 mg) .... 21 dofetilide cap 250 mcg (0.25 mg) ...... 21
dofetilide cap 500 mcg (0.5 mg) ........ 21
donepezil hydrochloride orally
disintegrating tab 10 mg .................. 35 donepezil hydrochloride orally
disintegrating tab 5 mg .................... 35 donepezil hydrochloride tab 10 mg ..... 35
donepezil hydrochloride tab 23 mg ..... 35 donepezil hydrochloride tab 5 mg ...... 35
dorzolamide hcl ophth soln 2% ......... 104 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml ....................... 104
doxazosin mesylate tab 1 mg ............ 20 doxazosin mesylate tab 2 mg ............ 20
doxazosin mesylate tab 4 mg ............ 20
doxazosin mesylate tab 8 mg ............ 20 doxepin hcl cap 10 mg ..................... 40
doxepin hcl cap 100 mg .................... 40
doxepin hcl cap 150 mg .................... 40
doxepin hcl cap 25 mg ..................... 40
doxepin hcl cap 50 mg ..................... 40
doxepin hcl cap 75 mg ..................... 40 doxepin hcl conc 10 mg/ml ............... 40
doxercalciferol cap 0.5 mcg ............... 67
doxercalciferol cap 1 mcg ................. 67
doxercalciferol cap 2.5 mcg ............... 67 doxycycline hyclate cap 100 mg .......... 9
doxycycline hyclate cap 50 mg ............ 9
119
doxycycline hyclate tab 100 mg ........... 9
doxycycline hyclate tab 20 mg ............ 9 doxycycline monohydrate for susp 25
mg/5ml ............................................ 9
doxylamine succinate (sleep) tab 25 mg
..................................................... 53
dronabinol cap 10 mg ....................... 70
dronabinol cap 2.5 mg ...................... 70
dronabinol cap 5 mg ......................... 70
drospirenone-ethinyl estradiol tab 3-0.02
mg ................................................. 63
drospirenone-ethinyl estradiol tab 3-0.03 mg ................................................. 63
DULERA AER 100-5MCG .................... 95
DULERA AER 200-5MCG .................... 95 duloxetine hcl enteric coated pellets cap
20 mg (base eq) .............................. 39
duloxetine hcl enteric coated pellets cap 30 mg (base eq) .............................. 39
duloxetine hcl enteric coated pellets cap 40 mg (base eq) .............................. 39
duloxetine hcl enteric coated pellets cap
60 mg (base eq) .............................. 39
E EDURANT TAB 25MG ......................... 11
efavirenz cap 200 mg ....................... 11 efavirenz cap 50 mg ......................... 11
efavirenz tab 600 mg ........................ 11 EFFEXOR XR CAP 150MG ................... 39
EFFEXOR XR CAP 37.5MG .................. 39 EFFEXOR XR CAP 75MG ..................... 39 ELIQUIS TAB 2.5MG ......................... 76
ELIQUIS TAB 5MG ............................ 76 ELIXOPHYLLIN ELX 80/15ML .............. 95
ELLA TAB 30MG ............................... 63
ELMIRON CAP 100MG ....................... 75 EMSAM DIS 12MG/24H ..................... 37
EMSAM DIS 6MG/24HR ..................... 37
EMSAM DIS 9MG/24HR ..................... 37
EMTRIVA CAP 200MG ........................ 11
EMTRIVA SOL 10MG/ML .................... 11
EMVERM CHW 100MG ....................... 14 enalapril maleate & hydrochlorothiazide
tab 10-25 mg .................................. 19
enalapril maleate & hydrochlorothiazide
tab 5-12.5 mg ................................. 19 enalapril maleate tab 10 mg .............. 19
enalapril maleate tab 2.5 mg ............. 19
enalapril maleate tab 20 mg .............. 19
enalapril maleate tab 5 mg ............... 19 ENBREL INJ 25/0.5ML ...................... 77
ENBREL INJ 25MG ........................... 77
ENBREL INJ 50MG/ML ...................... 77
ENBREL MINI INJ 50MG/ML ............... 77
ENBREL SRCLK INJ 50MG/ML ............ 77
ENCARE SUP 100MG ........................ 63
ENDARI POW 5GM ........................... 76
ENGERIX-B INJ 10/0.5ML ................. 79
ENGERIX-B INJ 20MCG/ML ................ 79
entacapone tab 200 mg .................... 42 entecavir tab 0.5 mg ........................ 13
entecavir tab 1 mg .......................... 13
ENTRESTO TAB 24-26MG .................. 26 ENTRESTO TAB 49-51MG .................. 26
ENTRESTO TAB 97-103MG ................ 26
ENVARSUS XR TAB 0.75MG ............... 78 ENVARSUS XR TAB 1MG ................... 79
ENVARSUS XR TAB 4MG ................... 79 epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000) ........................ 89
epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000) .......................... 89 EPIPEN 2-PAK INJ 0.3MG .................. 89
EPIPEN-JR INJ 0.15MG ..................... 89 epitol tab 200mg ............................. 31
EPIVIR SOL 10MG/ML ....................... 12 EPIVIR TAB 150MG .......................... 12
EPIVIR TAB 300MG .......................... 12 eplerenone tab 25 mg ...................... 20 eplerenone tab 50 mg ...................... 20
EPZICOM TAB 600-300 ..................... 10 EQUETRO CAP 100MG ...................... 55
EQUETRO CAP 200MG ...................... 55
EQUETRO CAP 300MG ...................... 55 ergocalciferol cap 1.25 mg (50000 unit)
..................................................... 85
ergocalciferol soln 200 mcg/ml (8000
unit/ml) ......................................... 85
ergotamine w/ caffeine tab 1-100 mg . 54
ERIVEDGE CAP 150MG ..................... 18 erlotinib hcl tab 100 mg (base
equivalent) ..................................... 16
erlotinib hcl tab 150 mg (base
equivalent) ..................................... 16 erlotinib hcl tab 25 mg (base equivalent)
..................................................... 16
120
erythromycin ethylsuccinate for susp 200
mg/5ml ............................................ 8 erythromycin ethylsuccinate tab 400 mg
...................................................... 8
erythromycin gel 2% ........................ 96
erythromycin ophth oint 5 mg/gm .... 102
erythromycin soln 2% ....................... 96
erythromycin stearate tab 250 mg ....... 8
erythromycin tab 250 mg ................... 8
erythromycin tab 500 mg ................... 8
erythromycin tab delayed release 250
mg .................................................. 8 erythromycin tab delayed release 333
mg .................................................. 8
erythromycin tab delayed release 500 mg .................................................. 8
erythromycin w/ delayed release
particles cap 250 mg ......................... 8 escitalopram oxalate soln 5 mg/5ml
(base equiv) .................................... 37 escitalopram oxalate tab 10 mg (base
equiv) ............................................. 37
escitalopram oxalate tab 20 mg (base
equiv) ............................................. 37 escitalopram oxalate tab 5 mg (base
equiv) ............................................. 37 esomeprazole magnesium cap delayed
release 20 mg (base eq) ................... 74 estradiol & norethindrone acetate tab
0.5-0.1 mg ...................................... 64 estradiol & norethindrone acetate tab 1-0.5 mg ........................................... 64
estradiol tab 0.5 mg ......................... 65 estradiol tab 1 mg ............................ 65
estradiol tab 2 mg ............................ 65
estradiol td patch weekly 0.025 mg/24hr ..................................................... 65
estradiol td patch weekly 0.0375
mg/24hr (37.5 mcg/24hr) ................. 65
estradiol td patch weekly 0.05 mg/24hr
..................................................... 65
estradiol td patch weekly 0.06 mg/24hr ..................................................... 65
estradiol td patch weekly 0.075 mg/24hr
..................................................... 65
estradiol td patch weekly 0.1 mg/24hr 65 estradiol vaginal tab 10 mcg .............. 65
ethambutol hcl tab 100 mg ................ 13
ethambutol hcl tab 400 mg ............... 13
ethosuximide cap 250 mg ................. 31 ethosuximide soln 250 mg/5ml .......... 31
ethynodiol diacetate & ethinyl estradiol
tab 1 mg-35 mcg ............................. 64
ethynodiol diacetate & ethinyl estradiol
tab 1 mg-50 mcg ............................. 64
etodolac cap 200 mg .......................... 4
etodolac cap 300 mg .......................... 4
etodolac tab 400 mg .......................... 4
etodolac tab 500 mg .......................... 4
etodolac tab er 24hr 400 mg ............... 4 etodolac tab er 24hr 500 mg ............... 4
etodolac tab er 24hr 600 mg ............... 4
etoposide cap 50 mg ........................ 18 EVOTAZ TAB 300-150 ...................... 10
exemestane tab 25 mg ..................... 16
EXTAVIA INJ 0.3MG ......................... 55 ezetimibe tab 10 mg ........................ 22
F famciclovir tab 125 mg ..................... 14
famciclovir tab 250 mg ..................... 14
famciclovir tab 500 mg ..................... 14
famotidine for susp 40 mg/5ml .......... 72 famotidine tab 10 mg ....................... 72
famotidine tab 20 mg ....................... 72 famotidine tab 40 mg ....................... 72
FANAPT PAK ................................... 43 FANAPT TAB 10MG ........................... 43
FANAPT TAB 12MG ........................... 43 FANAPT TAB 1MG ............................ 43 FANAPT TAB 2MG ............................ 43
FANAPT TAB 4MG ............................ 43 FANAPT TAB 6MG ............................ 43
FANAPT TAB 8MG ............................ 43
FANATREX SUS 25MG/ML ................. 31 FARYDAK CAP 10MG ........................ 18
FARYDAK CAP 15MG ........................ 18
FARYDAK CAP 20MG ........................ 18
FAZACLO TAB 100 ODT .................... 43
FAZACLO TAB 12.5 ODT ................... 43
FAZACLO TAB 150 ODT .................... 43 FAZACLO TAB 200 ODT .................... 43
FAZACLO TAB 25MG ODT .................. 43
fe bisglyc-vit c-vit b12-folic acid cap 28-
60-0.008-0.4 mg ............................. 83 fe fumarate w/ b12-vit c-fa-ifc cap 110-
0.015-75-0.5-240 mg ...................... 83
121
fe fumarate-vit c-vit b12-fa cap 460 (151
fe)-60-0.01-1 mg ............................. 83 fe fum-iron polysacch complex-fa-b
cmplx-c-zn-mn-cu cap ...................... 83
felbamate susp 600 mg/5ml .............. 31
felbamate tab 400 mg ....................... 31
felbamate tab 600 mg ....................... 31
FELBATOL SUS 600/5ML .................... 31
FELBATOL TAB 400MG ...................... 31
FELBATOL TAB 600MG ...................... 31
felodipine tab er 24hr 10 mg .............. 24
felodipine tab er 24hr 2.5 mg ............. 24 felodipine tab er 24hr 5 mg ............... 24
fenofibrate micronized cap 134 mg ..... 22
fenofibrate micronized cap 200 mg ..... 22 fenofibrate micronized cap 67 mg ....... 22
fenofibrate tab 145 mg ..................... 22
fenofibrate tab 160 mg ..................... 22 fenofibrate tab 48 mg ....................... 22
fenofibrate tab 54 mg ....................... 22 fentanyl td patch 72hr 100 mcg/hr ...... 5
fentanyl td patch 72hr 12 mcg/hr ........ 5
fentanyl td patch 72hr 25 mcg/hr ........ 5
fentanyl td patch 72hr 50 mcg/hr ........ 5 fentanyl td patch 72hr 75 mcg/hr ........ 5
ferrous fumarate tab 324 mg (106 mg elemental fe) ................................... 83
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg ......................... 83
ferrous fumarate-folic acid tab 324-1 mg ..................................................... 83 ferrous gluconate tab 240 mg (27 mg
elemental fe) ................................... 83 ferrous gluconate tab 324 mg (37.5 mg
elemental iron) ................................ 83
ferrous sulfate dried tab 200 mg (65 mg elemental fe) ................................... 83
ferrous sulfate dried tab er 160 mg (50
mg fe equivalent) ............................. 84
ferrous sulfate dried tab er 45 mg (fe
equivalent) ...................................... 83
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ....................... 84
ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe) ................................... 84
ferrous sulfate tab 134 mg (27 mg elemental fe) ................................... 84
ferrous sulfate tab 27 mg (elemental fe)
..................................................... 84
ferrous sulfate tab 325 mg (65 mg elemental fe) .................................. 84
ferrous sulfate tab ec 325 mg (65 mg fe
equivalent) ..................................... 84
ferrous sulfate tab er 142 mg (45 mg fe
equivalent) ..................................... 84
ferrous sulfate tab er 47.5 mg (elemental
fe) ................................................. 84
ferrous sulfate tab er 50 mg (elemental
fe) ................................................. 84
FETZIMA CAP 120MG ....................... 39 FETZIMA CAP 20MG ......................... 39
FETZIMA CAP 40MG ......................... 39
FETZIMA CAP 80MG ......................... 39 FETZIMA CAP TITRATIO .................... 39
FEVERALL INF SUP 80MG .................... 4
FEVERALL SUP 325MG ........................ 4 fexofenadine hcl susp 30 mg/5ml (6
mg/ml) .......................................... 90 fexofenadine hcl tab 180 mg ............. 90
fexofenadine hcl tab 60 mg ............... 90
fexofenadine-pseudoephedrine tab er
12hr 60-120 mg .............................. 89 fexofenadine-pseudoephedrine tab er
24hr 180-240 mg ............................ 89 FIASP FLEX INJ TOUCH ..................... 60
FIASP INJ 100/ML ............................ 60 finasteride tab 5 mg ......................... 74
flecainide acetate tab 100 mg ........... 21 flecainide acetate tab 150 mg ........... 21 flecainide acetate tab 50 mg ............. 21
FLOVENT DISK AER 100MCG ............. 94 FLOVENT DISK AER 250MCG ............. 94
FLOVENT DISK AER 50MCG ............... 94
FLOVENT HFA AER 110MCG .............. 94 FLOVENT HFA AER 220MCG .............. 94
FLOVENT HFA AER 44MCG ................ 94
fluconazole for susp 10 mg/ml ............. 9
fluconazole for susp 40 mg/ml ............. 9
fluconazole tab 100 mg ...................... 9
fluconazole tab 150 mg ...................... 9 fluconazole tab 200 mg ...................... 9
fluconazole tab 50 mg ........................ 9
fludrocortisone acetate tab 0.1 mg ..... 67
flunisolide nasal soln 25 mcg/act (0.025%) ....................................... 94
fluocinolone acetonide cream 0.025% 99
122
fluocinolone acetonide oint 0.025% ..... 99
fluocinolone acetonide soln 0.01% ...... 98 fluocinonide cream 0.05% ................. 98
fluocinonide gel 0.05% ...................... 98
fluocinonide oint 0.05% .................... 98
fluocinonide soln 0.05% .................... 98
fluorometholone ophth susp 0.1% .... 102
fluorouracil cream 5% ....................... 96
fluoxetine hcl (pmdd) cap 10 mg ........ 37
fluoxetine hcl (pmdd) cap 20 mg ........ 37
fluoxetine hcl (pmdd) tab 10 mg ........ 37
fluoxetine hcl (pmdd) tab 20 mg ........ 37 fluoxetine hcl cap 10 mg ................... 38
fluoxetine hcl cap 20 mg ................... 38
fluoxetine hcl cap 40 mg ................... 38 fluoxetine hcl cap delayed release 90 mg
..................................................... 38
fluoxetine hcl solution 20 mg/5ml ....... 38 fluoxetine hcl tab 10 mg .................... 38
fluoxetine hcl tab 20 mg .................... 38 fluoxetine hcl tab 60 mg .................... 38
FLUOXETINE TAB 60MG..................... 38
fluphenazine decanoate inj 25 mg/ml .. 46
fluphenazine hcl elixir 2.5 mg/5ml ...... 46 fluphenazine hcl inj 2.5 mg/ml ........... 46
fluphenazine hcl oral conc 5 mg/ml ..... 46 fluphenazine hcl tab 1 mg .................. 46
fluphenazine hcl tab 10 mg ................ 46 fluphenazine hcl tab 2.5 mg ............... 46
fluphenazine hcl tab 5 mg .................. 46 flurbiprofen tab 100 mg ..................... 4 flurbiprofen tab 50 mg ....................... 4
flutamide cap 125 mg ....................... 15 fluticasone propionate cream 0.05% ... 99
fluticasone propionate nasal susp 50
mcg/act .......................................... 94 fluticasone propionate oint 0.005% ..... 99
fluticasone-salmeterol aer powder ba
100-50 mcg/dose ............................. 95
fluticasone-salmeterol aer powder ba
250-50 mcg/dose ............................. 95
fluticasone-salmeterol aer powder ba 500-50 mcg/dose ............................. 95
fluvoxamine maleate cap er 24hr 100 mg
..................................................... 30
fluvoxamine maleate cap er 24hr 150 mg ..................................................... 30
fluvoxamine maleate tab 100 mg ........ 30
fluvoxamine maleate tab 25 mg ......... 30
fluvoxamine maleate tab 50 mg ......... 30 folic acid tab 1 mg ........................... 83
folic acid tab 400 mcg ...................... 83
folic acid tab 800 mcg ...................... 83
folic acid-vitamin b6-vitamin b12 tab
0.8-10-0.115 mg ............................. 83
folic acid-vitamin b6-vitamin b12 tab
2.2-25-0.5 mg ................................ 83
folic acid-vitamin b6-vitamin b12 tab
2.2-25-1 mg ................................... 83
folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg ................................... 83
FORFIVO XL TAB 450MG ................... 36
FORTEO SOL 600/2.4 ....................... 62 fosamprenavir calcium tab 700 mg (base
equiv) ............................................ 12
fosaprepitant dimeglumine for iv infusion 150 mg (base eq) ............................ 70
fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg ............................... 19
fosinopril sodium & hydrochlorothiazide
tab 20-12.5 mg ............................... 19
fosinopril sodium tab 10 mg .............. 19 fosinopril sodium tab 20 mg .............. 19
fosinopril sodium tab 40 mg .............. 19 FREESTYLE TES ............................... 62
FREESTYLE TES INSULINX ................ 62 FREESTYLE TES LITE ........................ 62
furosemide oral soln 10 mg/ml .......... 26 furosemide tab 20 mg ...................... 26 furosemide tab 40 mg ...................... 26
furosemide tab 80 mg ...................... 26 FUZEON INJ 90MG ........................... 11
FYCOMPA SUS 0.5MG/ML .................. 31
FYCOMPA TAB 10MG ........................ 31 FYCOMPA TAB 12MG ........................ 31
FYCOMPA TAB 2MG .......................... 31
FYCOMPA TAB 4MG .......................... 31
FYCOMPA TAB 6MG .......................... 31
FYCOMPA TAB 8MG .......................... 31
G gabapentin cap 100 mg .................... 31
gabapentin cap 300 mg .................... 31
gabapentin cap 400 mg .................... 32
gabapentin oral soln 250 mg/5ml ....... 32 gabapentin tab 600 mg .................... 32
gabapentin tab 800 mg .................... 32
123
GABITRIL TAB 12MG ......................... 32
GABITRIL TAB 16MG ......................... 32 GABITRIL TAB 2MG .......................... 32
GABITRIL TAB 4MG .......................... 32
galantamine hydrobromide cap er 24hr
16 mg ............................................ 35
galantamine hydrobromide cap er 24hr
24 mg ............................................ 35
galantamine hydrobromide cap er 24hr 8
mg ................................................. 35
galantamine hydrobromide oral soln 4
mg/ml ............................................ 35 galantamine hydrobromide tab 12 mg . 36
galantamine hydrobromide tab 4 mg ... 35
galantamine hydrobromide tab 8 mg ... 36 GARDASIL 9 INJ ............................... 80
GAS-X CHILD MIS 40MG ................... 73
gemfibrozil tab 600 mg ..................... 22 gengraf cap 100mg .......................... 79
gengraf cap 25mg ............................ 79 gengraf sol 100mg/ml ....................... 79
GENOTROPIN INJ 0.2MG ................... 66
GENOTROPIN INJ 0.4MG ................... 66
GENOTROPIN INJ 0.6MG ................... 66 GENOTROPIN INJ 0.8MG ................... 66
GENOTROPIN INJ 1.2MG ................... 66 GENOTROPIN INJ 1.4MG ................... 66
GENOTROPIN INJ 1.6MG ................... 66 GENOTROPIN INJ 1.8MG ................... 66
GENOTROPIN INJ 12MG .................... 66 GENOTROPIN INJ 1MG ...................... 66 GENOTROPIN INJ 2MG ...................... 66
GENOTROPIN INJ 5MG ...................... 66 gentamicin sulfate cream 0.1% .......... 97
gentamicin sulfate oint 0.1% ............. 97
gentamicin sulfate ophth oint 0.3%... 102 gentamicin sulfate ophth soln 0.3% .. 102
GENTEAL GEL 0.3% ........................ 103
GENTEAL MILD DRO 0.2% ............... 103
GENVOYA TAB ................................. 10
GEODON CAP 20MG .......................... 43
GEODON CAP 40MG .......................... 43 GEODON CAP 60MG .......................... 43
GEODON CAP 80MG .......................... 43
GEODON INJ 20MG ........................... 43
GILENYA CAP 0.5MG ......................... 55 GILOTRIF TAB 20MG ......................... 16
GILOTRIF TAB 30MG ......................... 16
GILOTRIF TAB 40MG ........................ 16
glatiramer acetate soln prefilled syringe 20 mg/ml ....................................... 55
glatiramer acetate soln prefilled syringe
40 mg/ml ....................................... 55
GLEOSTINE CAP 100MG ................... 15
GLEOSTINE CAP 10MG ..................... 15
GLEOSTINE CAP 40MG ..................... 15
glimepiride tab 1 mg ........................ 61
glimepiride tab 2 mg ........................ 61
glimepiride tab 4 mg ........................ 61
glipizide tab 10 mg .......................... 61 glipizide tab 5 mg ............................ 61
glipizide tab er 24hr 10 mg ............... 61
glipizide tab er 24hr 2.5 mg .............. 61 glipizide tab er 24hr 5 mg ................. 61
glipizide-metformin hcl tab 2.5-250 mg
..................................................... 58 glipizide-metformin hcl tab 2.5-500 mg
..................................................... 58 glipizide-metformin hcl tab 5-500 mg . 58
GLUCAGEN INJ HYPOKIT................... 66
GLUCAGON KIT 1MG ........................ 66
glyburide micronized tab 1.5 mg ........ 61 glyburide micronized tab 3 mg .......... 61
glyburide micronized tab 6 mg .......... 62 glyburide tab 1.25 mg ...................... 62
glyburide tab 2.5 mg ........................ 62 glyburide tab 5 mg .......................... 62
glyburide-metformin tab 1.25-250 mg 58 glyburide-metformin tab 2.5-500 mg .. 58 glyburide-metformin tab 5-500 mg .... 58
glycerin-hypromellose-peg 400 ophth soln 0.2-0.2-1% ............................. 103
glycopyrrolate tab 1 mg.................... 71
glycopyrrolate tab 2 mg.................... 71 granisetron hcl tab 1 mg................... 70
griseofulvin microsize susp 125 mg/5ml 9
griseofulvin ultramicrosize tab 125 mg . 9
griseofulvin ultramicrosize tab 250 mg . 9
guaifenesin liquid 100 mg/5ml ........... 93
guaifenesin syrup 100 mg/5ml .......... 93 guaifenesin tab 200 mg .................... 93
guaifenesin tab 400 mg .................... 93
guaifenesin tab er 12hr 1200 mg ....... 93
guaifenesin tab er 12hr 600 mg ......... 93 guaifenesin-codeine soln 100-10 mg/5ml
..................................................... 91
124
guaifenesin-codeine soln 100-6.3
mg/5ml ........................................... 91 guanfacine hcl tab 1 mg .................... 20
guanfacine hcl tab 2 mg .................... 20
GYNOL II GEL 3% ............................ 63
H halobetasol propionate cream 0.05% .. 99
halobetasol propionate oint 0.05% ...... 99
haloperidol decanoate im soln 100 mg/ml
..................................................... 47
haloperidol decanoate im soln 50 mg/ml
..................................................... 47 haloperidol lactate inj 5 mg/ml ........... 47
haloperidol lactate oral conc 2 mg/ml .. 47
haloperidol tab 0.5 mg ...................... 47 haloperidol tab 1 mg ......................... 47
haloperidol tab 10 mg ....................... 47
haloperidol tab 2 mg ......................... 47 haloperidol tab 20 mg ....................... 47
haloperidol tab 5 mg ......................... 47 HAVRIX INJ 1440UNIT ...................... 80
HAVRIX INJ 720UNIT ........................ 80
HEMA-COMBIST TES ......................... 81
HUMALOG INJ 100/ML ....................... 60 HUMALOG JR INJ 100/ML .................. 60
HUMALOG KWIK INJ 100/ML .............. 60 HUMALOG MIX INJ 50/50 .................. 60
HUMALOG MIX INJ 50/50KWP ............ 60 HUMALOG MIX INJ 75/25KWP ............ 60
HUMALOG MIX SUS 75/25 ................. 60 HUMATROPE INJ 12MG ...................... 66 HUMATROPE INJ 24MG ...................... 67
HUMATROPE INJ 5MG ....................... 66 HUMATROPE INJ 6MG ....................... 66
HUMIRA INJ 10/0.1ML ....................... 77
HUMIRA INJ 10MG/0.2 ...................... 77 HUMIRA INJ 20/0.2ML ....................... 77
HUMIRA INJ 40/0.4ML ....................... 77
HUMIRA KIT 20MG/0.4 ...................... 77
HUMIRA KIT 40MG/0.8 ...................... 77
HUMIRA PEDIA INJ CROHNS .............. 77
HUMIRA PEN INJ 40/0.4ML ................ 77 HUMIRA PEN INJ 40MG/0.8 ................ 77
HUMIRA PEN INJ CD/UC/HS ............... 77
HUMIRA PEN INJ PS/UV ..................... 78
HUMIRA PEN KIT CD/UC/HS ............... 78 HUMIRA PEN KIT PS/UV .................... 78
HUMULIN INJ 70/30 .......................... 60
HUMULIN INJ 70/30KWP ................... 60
HUMULIN N INJ U-100 ...................... 60 HUMULIN N INJ U-100KWP ............... 60
HUMULIN R INJ U-100 ...................... 60
HUMULIN R INJ U-500 ...................... 60
hydralazine hcl tab 10 mg ................. 26
hydralazine hcl tab 100 mg ............... 26
hydralazine hcl tab 25 mg ................. 26
hydralazine hcl tab 50 mg ................. 26
hydrochlorothiazide cap 12.5 mg ....... 26
hydrochlorothiazide tab 12.5 mg ........ 26
hydrochlorothiazide tab 25 mg .......... 26 hydrochlorothiazide tab 50 mg .......... 26
hydrocodone w/ homatropine syrup 5-
1.5 mg/5ml .................................... 91 hydrocodone w/ homatropine tab 5-1.5
mg ................................................ 91
hydrocodone-acetaminophen soln 7.5-325 mg/15ml .................................... 5
hydrocodone-acetaminophen tab 10-325 mg .................................................. 5
hydrocodone-acetaminophen tab 5-325
mg .................................................. 5
hydrocodone-acetaminophen tab 7.5-325 mg .................................................. 5
hydrocortisone acetate cream 1% ...... 98 hydrocortisone butyrate cream 0.1% .. 99
hydrocortisone butyrate oint 0.1% ..... 99 hydrocortisone butyrate soln 0.1% ..... 99
hydrocortisone cream 0.5% .............. 98 hydrocortisone cream 1% ................. 98 hydrocortisone cream 2.5% .............. 98
hydrocortisone enema 100 mg/60ml .. 72 hydrocortisone gel 1% ..................... 98
hydrocortisone lotion 1% .................. 98
hydrocortisone lotion 2.5% ............... 98 hydrocortisone oint 0.5% ................. 98
hydrocortisone oint 1% .................... 99
hydrocortisone oint 2.5% ................. 99
hydrocortisone rectal cream 1% ........ 74
hydrocortisone rectal cream 2.5% ...... 74
hydrocortisone soln 1% .................... 99 hydrocortisone tab 10 mg ................. 65
hydrocortisone tab 20 mg ................. 65
hydrocortisone tab 5 mg ................... 65
hydrocortisone valerate cream 0.2% .. 99 hydrocortisone valerate oint 0.2% ..... 99
hydrocortisone-aloe vera cream 1% ... 98
125
hydromorphone hcl tab 2 mg .............. 5
hydromorphone hcl tab 4 mg .............. 5 hydromorphone hcl tab 8 mg .............. 5
hydroxychloroquine sulfate tab 200 mg
..................................................... 78
hydroxyurea cap 500 mg ................... 18
hydroxyzine hcl syrup 10 mg/5ml ....... 90
hydroxyzine hcl tab 10 mg ................. 90
hydroxyzine hcl tab 25 mg ................. 90
hydroxyzine hcl tab 50 mg ................. 90
hydroxyzine pamoate cap 100 mg ...... 90
hydroxyzine pamoate cap 25 mg ........ 90 hydroxyzine pamoate cap 50 mg ........ 90
HYPOTEARS SOL 1-1%.................... 103
hypromellose ophth soln 0.3% ......... 103 hypromellose ophth soln 0.4% ......... 103
I IBRANCE CAP 100MG ........................ 16 IBRANCE CAP 125MG ........................ 16
IBRANCE CAP 75MG.......................... 16 ibuprofen cap 200 mg ........................ 4
ibuprofen chew tab 100 mg ................ 4
ibuprofen susp 100 mg/5ml ................ 4
ibuprofen susp 40 mg/ml .................... 4 ibuprofen tab 100 mg ........................ 4
ibuprofen tab 200 mg ........................ 4 ibuprofen tab 400 mg ........................ 4
ibuprofen tab 600 mg ........................ 4 ibuprofen tab 800 mg ........................ 4
IDHIFA TAB 100MG .......................... 18 IDHIFA TAB 50MG ............................ 18 imatinib mesylate tab 100 mg (base
equivalent) ...................................... 17 imatinib mesylate tab 400 mg (base
equivalent) ...................................... 17
IMBRUVICA CAP 140MG .................... 16 IMBRUVICA CAP 70MG ...................... 16
IMBRUVICA TAB 140MG .................... 16
IMBRUVICA TAB 280MG .................... 16
IMBRUVICA TAB 420MG .................... 17
IMBRUVICA TAB 560MG .................... 17
imipramine hcl tab 10 mg .................. 40 imipramine hcl tab 25 mg .................. 41
imipramine hcl tab 50 mg .................. 41
imipramine pamoate cap 100 mg ........ 41
imipramine pamoate cap 125 mg ........ 41 imipramine pamoate cap 150 mg ........ 41
imipramine pamoate cap 75 mg ......... 41
imiquimod cream 5% ...................... 101
IMURAN TAB 50MG .......................... 78 INCRUSE ELPT INH 62.5MCG ............. 89
indapamide tab 1.25 mg ................... 26
indapamide tab 2.5 mg .................... 26
INFANRIX INJ ................................. 80
INLYTA TAB 1MG ............................. 17
INLYTA TAB 5MG ............................. 17
INTELENCE TAB 100MG .................... 11
INTELENCE TAB 200MG .................... 11
INTELENCE TAB 25MG ...................... 11
INVEGA SUST INJ 117/0.75 .............. 44 INVEGA SUST INJ 156MG/ML ............ 44
INVEGA SUST INJ 234/1.5 ................ 44
INVEGA SUST INJ 39/0.25 ................ 43 INVEGA SUST INJ 78/0.5ML .............. 43
INVEGA TAB 1.5MG ......................... 44
INVEGA TAB 3MG ............................ 44 INVEGA TAB 6MG ............................ 44
INVEGA TAB 9MG ............................ 44 INVEGA TRINZ INJ 273MG ................ 44
INVEGA TRINZ INJ 410MG ................ 44
INVEGA TRINZ INJ 546MG ................ 44
INVEGA TRINZ INJ 819MG ................ 44 INVIRASE TAB 500MG ...................... 12
INVOKAMET TAB 150-1000 ............... 61 INVOKAMET TAB 150-500 ................. 61
INVOKAMET TAB 50-1000 ................. 61 INVOKAMET TAB 50-500MG .............. 61
INVOKAMET XR TAB 150-1000 .......... 61 INVOKAMET XR TAB 150-500 ............ 61 INVOKAMET XR TAB 50-1000 ............ 61
INVOKAMET XR TAB 50-500MG ......... 61 INVOKANA TAB 100MG ..................... 61
INVOKANA TAB 300MG ..................... 61
ipratropium bromide inhal soln 0.02% 89 ipratropium bromide nasal soln 0.03%
(21 mcg/spray) ............................... 93
ipratropium bromide nasal soln 0.06%
(42 mcg/spray) ............................... 94
ipratropium-albuterol nebu soln 0.5-
2.5(3) mg/3ml ................................ 89 irbesartan tab 150 mg ...................... 21
irbesartan tab 300 mg ...................... 21
irbesartan tab 75 mg ....................... 21
irbesartan-hydrochlorothiazide tab 150-12.5 mg ......................................... 20
irbesartan-hydrochlorothiazide tab 300-
126
12.5 mg .......................................... 20
iron combination cap ........................ 84 iron polysacch complex-vit b12-fa cap
150-0.025-1 mg ............................... 84
iron w/ vitamin liq ............................ 85
iron w/ vitamin tab ........................... 86
iron-docusate-b12-folic acid-c-e-cu-biotin
tab 150-1 mg .................................. 84
iron-folic acid-vit c-vit b6-vit b12-zinc
tab 150-1.25 mg .............................. 84
iron-vit c-vit b12-folic acid tab 100-250-
0.025-1 mg ..................................... 84 iron-vitamin c tab 100-250 mg ........... 84
ISENTRESS CHW 100MG ................... 11
ISENTRESS CHW 25MG ..................... 11 ISENTRESS HD TAB 600MG ............... 11
ISENTRESS POW 100MG ................... 11
ISENTRESS TAB 400MG .................... 11 isoniazid syrup 50 mg/5ml ................. 13
isoniazid tab 100 mg......................... 13 isoniazid tab 300 mg......................... 13
ISORDIL TAB 40MG .......................... 26
isosorbide dinitrate tab 10 mg ............ 26
isosorbide dinitrate tab 20 mg ............ 27 isosorbide dinitrate tab 30 mg ............ 27
isosorbide dinitrate tab 5 mg ............. 26 isosorbide dinitrate tab er 40 mg ........ 27
isosorbide mononitrate tab 10 mg ...... 27 isosorbide mononitrate tab 20 mg ...... 27
isosorbide mononitrate tab er 24hr 120 mg ................................................. 27 isosorbide mononitrate tab er 24hr 30
mg ................................................. 27 isosorbide mononitrate tab er 24hr 60
mg ................................................. 27
itraconazole cap 100 mg .................... 9 IV PREP WIPE PAD ............................ 97
ivermectin tab 3 mg ......................... 14
J JAKAFI TAB 10MG ............................ 17
JAKAFI TAB 15MG ............................ 17
JAKAFI TAB 20MG ............................ 17 JAKAFI TAB 25MG ............................ 17
JAKAFI TAB 5MG .............................. 17
JANUMET TAB 50-1000 ..................... 59
JANUMET TAB 50-500MG ................... 58 JANUMET XR TAB 100-1000 ............... 59
JANUMET XR TAB 50-1000 ................. 59
JANUMET XR TAB 50-500MG ............. 59
JANUVIA TAB 100MG ....................... 59 JANUVIA TAB 25MG ......................... 59
JANUVIA TAB 50MG ......................... 59
K KALETRA SOL .................................. 12
KALETRA TAB 100-25MG .................. 12
KALETRA TAB 200-50MG .................. 12
KALYDECO PAK 25MG ...................... 92
KALYDECO PAK 50MG ...................... 92
KALYDECO PAK 75MG ...................... 92
KALYDECO TAB 150MG ..................... 92 KEPPRA SOL 100MG/ML .................... 32
KEPPRA TAB 1000MG ....................... 32
KEPPRA TAB 250MG ......................... 32 KEPPRA TAB 500MG ......................... 32
KEPPRA TAB 750MG ......................... 32
KEPPRA XR TAB 500MG .................... 32 KEPPRA XR TAB 750MG .................... 32
ketoconazole cream 2% ................... 97 ketoconazole shampoo 2% ............... 97
KETO-DIASTIX TES .......................... 62
ketorolac tromethamine ophth soln 0.4%
.................................................... 102 ketorolac tromethamine ophth soln 0.5%
.................................................... 102 ketorolac tromethamine tab 10 mg ...... 4
ketotifen fumarate ophth soln 0.025% (base equiv) .................................. 102
KHEDEZLA TAB 100MG ER ................ 39 KHEDEZLA TAB 50MG ER .................. 39 KLONOPIN TAB 0.5MG ...................... 29
KLONOPIN TAB 1MG ........................ 29 KLONOPIN TAB 2MG ........................ 29
K-PHOS TAB ................................... 75
K-PHOS TAB NO 2 ........................... 75 KUVAN POW 100MG ......................... 67
KUVAN TAB 100MG .......................... 67
L labetalol hcl tab 100 mg ................... 23
labetalol hcl tab 200 mg ................... 23
labetalol hcl tab 300 mg ................... 23 LABSTIX TES .................................. 81
lactic acid (ammonium lactate) cream
12% ....................................... 99, 100
lactic acid (ammonium lactate) lotion 12% ............................................. 100
lactulose (encephalopathy) solution 10
127
gm/15ml ......................................... 73
lactulose solution 10 gm/15ml ........... 73 LAMICTAL CHW 25MG ....................... 32
LAMICTAL CHW 5MG ......................... 32
LAMICTAL KIT START 35 ................... 32
LAMICTAL KIT START 49 ................... 32
LAMICTAL KIT START 98 ................... 32
LAMICTAL ODT KIT ........................... 32
LAMICTAL ODT TAB 100MG ............... 32
LAMICTAL ODT TAB 200MG ............... 32
LAMICTAL ODT TAB 25MG ................. 32
LAMICTAL ODT TAB 50MG ................. 32 LAMICTAL TAB 100MG ...................... 32
LAMICTAL TAB 150MG ...................... 32
LAMICTAL TAB 200MG ...................... 32 LAMICTAL TAB 25MG ........................ 32
LAMICTAL XR KIT ............................. 32
LAMICTAL XR TAB 100MG .................. 32 LAMICTAL XR TAB 200MG .................. 32
LAMICTAL XR TAB 250MG .................. 32 LAMICTAL XR TAB 25MG ................... 32
LAMICTAL XR TAB 300MG .................. 32
LAMICTAL XR TAB 50MG ................... 32
lamivudine oral soln 10 mg/ml ........... 12 lamivudine tab 100 mg (hbv) ............. 13
lamivudine tab 150 mg ..................... 12 lamivudine tab 300 mg ..................... 12
lamivudine-zidovudine tab 150-300 mg ..................................................... 10
lamotrigine orally disintegrating tab 100 mg ................................................. 32 lamotrigine orally disintegrating tab 200
mg ................................................. 32 lamotrigine orally disintegrating tab 25
mg ................................................. 32
lamotrigine orally disintegrating tab 50 mg ................................................. 32
lamotrigine tab 100 mg ..................... 33
lamotrigine tab 150 mg ..................... 33
lamotrigine tab 200 mg ..................... 33
lamotrigine tab 25 mg ....................... 32
lamotrigine tab 25 mg (35) starter kit . 32 lamotrigine tab 25 mg (42) & 100 mg (7)
starter kit ........................................ 32
lamotrigine tab 25 mg (84) & 100 mg
(14) starter kit ................................. 33 lamotrigine tab chewable dispersible 25
mg ................................................. 33
lamotrigine tab chewable dispersible 5
mg ................................................ 33 lamotrigine tab er 24hr 100 mg ......... 33
lamotrigine tab er 24hr 200 mg ......... 33
lamotrigine tab er 24hr 25 mg ........... 33
lamotrigine tab er 24hr 250 mg ......... 33
lamotrigine tab er 24hr 300 mg ......... 33
lamotrigine tab er 24hr 50 mg ........... 33
LANCETS MIS .................................. 62
LANOXIN TAB 0.0625MG .................. 25
lansoprazole cap delayed release 15 mg
..................................................... 74 latanoprost ophth soln 0.005% ......... 104
LATUDA TAB 120MG ........................ 44
LATUDA TAB 20MG .......................... 44 LATUDA TAB 40MG .......................... 44
LATUDA TAB 60MG .......................... 44
LATUDA TAB 80MG .......................... 44 leflunomide tab 10 mg ..................... 78
leflunomide tab 20 mg ..................... 78 LENVIMA CAP 10 MG ........................ 17
LENVIMA CAP 12MG ......................... 17
LENVIMA CAP 14 MG ........................ 17
LENVIMA CAP 18 MG ........................ 17 LENVIMA CAP 20 MG ........................ 17
LENVIMA CAP 24 MG ........................ 17 LENVIMA CAP 4MG .......................... 17
LENVIMA CAP 8 MG.......................... 17 letrozole tab 2.5 mg ......................... 16
leucovorin calcium tab 10 mg ............ 18 leucovorin calcium tab 15 mg ............ 18 leucovorin calcium tab 25 mg ............ 18
leucovorin calcium tab 5 mg .............. 18 LEUKERAN TAB 2MG ........................ 15
levetiracetam oral soln 100 mg/ml ..... 33
levetiracetam tab 1000 mg ............... 33 levetiracetam tab 250 mg ................. 33
levetiracetam tab 500 mg ................. 33
levetiracetam tab 750 mg ................. 33
levetiracetam tab er 24hr 500 mg ...... 33
levetiracetam tab er 24hr 750 mg ...... 33
levobunolol hcl ophth soln 0.5% ....... 103 levocarnitine oral soln 1 gm/10ml (10%)
..................................................... 62
levocarnitine tab 330 mg .................. 62
levofloxacin ophth soln 0.5% ........... 102 levofloxacin oral soln 25 mg/ml ........... 8
levofloxacin tab 250 mg ..................... 8
128
levofloxacin tab 500 mg ..................... 8
levofloxacin tab 750 mg ..................... 8 levonorgestrel & ethinyl estradiol tab 0.1
mg-20 mcg ..................................... 63
levonorgestrel & ethinyl estradiol tab
0.15 mg-30 mcg .............................. 63
levonorgestrel tab 1.5 mg ................. 63
levonorgestrel-eth estra tab 0.05-
30/0.075-40/0.125-30mg-mcg ........... 64
levothyroxine sodium tab 100 mcg ..... 68
levothyroxine sodium tab 112 mcg ..... 68
levothyroxine sodium tab 125 mcg ..... 68 levothyroxine sodium tab 137 mcg ..... 68
levothyroxine sodium tab 150 mcg ..... 68
levothyroxine sodium tab 175 mcg ..... 69 levothyroxine sodium tab 200 mcg ..... 69
levothyroxine sodium tab 25 mcg ....... 68
levothyroxine sodium tab 300 mcg ..... 69 levothyroxine sodium tab 50 mcg ....... 68
levothyroxine sodium tab 75 mcg ....... 68 levothyroxine sodium tab 88 mcg ....... 68
LEXAPRO TAB 10MG ......................... 38
LEXAPRO TAB 20MG ......................... 38
LEXAPRO TAB 5MG ........................... 38 LEXIVA SUS 50MG/ML ....................... 13
LEXIVA TAB 700MG .......................... 13 lidocaine hcl soln 4% ...................... 100
lidocaine hcl viscous soln 2% ........... 101 lidocaine patch 4% ......................... 100
lidocaine patch 5% ......................... 100 lidocaine-prilocaine cream 2.5-2.5% . 100 lidocaine-prilocaine cream kit 2.5-2.5%
................................................... 100 linezolid for susp 100 mg/5ml ............ 14
linezolid tab 600 mg ......................... 14
LINZESS CAP 145MCG ...................... 72 LINZESS CAP 290MCG ...................... 72
LINZESS CAP 72MCG ........................ 72
liothyronine sodium tab 25 mcg ......... 69
liothyronine sodium tab 5 mcg ........... 69
liothyronine sodium tab 50 mcg ......... 69
lisinopril & hydrochlorothiazide tab 10-12.5 mg .......................................... 19
lisinopril & hydrochlorothiazide tab 20-
12.5 mg .......................................... 19
lisinopril & hydrochlorothiazide tab 20-25 mg ................................................. 19
lisinopril tab 10 mg ........................... 19
lisinopril tab 2.5 mg ......................... 19
lisinopril tab 20 mg .......................... 19 lisinopril tab 30 mg .......................... 19
lisinopril tab 40 mg .......................... 19
lisinopril tab 5 mg ............................ 19
lithium carbonate cap 150 mg ........... 55
lithium carbonate cap 300 mg ........... 55
lithium carbonate cap 600 mg ........... 55
lithium carbonate tab 300 mg ........... 55
lithium carbonate tab er 300 mg ........ 55
lithium carbonate tab er 450 mg ........ 55
LITHIUM SOL 8MEQ/5ML .................. 55 LITHOBID TAB 300MG CR ................. 55
loperamide hcl cap 2 mg ................... 70
loperamide hcl liq 1 mg/5ml (0.2 mg/ml) ..................................................... 70
loperamide hcl tab 2 mg ................... 70
lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) ................................ 13
loratadine & pseudoephedrine tab er 12hr 5-120 mg ................................ 89
loratadine & pseudoephedrine tab er
24hr 10-240 mg .............................. 89
loratadine cap 10 mg ....................... 90 loratadine chew tab 5 mg ................. 90
loratadine rapidly-disintegrating tab 10 mg ................................................ 90
loratadine syrup 5 mg/5ml ................ 90 loratadine tab 10 mg ........................ 90
lorazepam conc 2 mg/ml .................. 29 lorazepam inj 2 mg/ml ..................... 29 lorazepam inj 4 mg/ml ..................... 29
lorazepam tab 0.5 mg ...................... 29 lorazepam tab 1 mg ......................... 29
lorazepam tab 2 mg ......................... 29
LORBRENA TAB 100MG .................... 17 LORBRENA TAB 25MG ...................... 17
losartan potassium & hydrochlorothiazide
tab 100-12.5 mg ............................. 20
losartan potassium & hydrochlorothiazide
tab 100-25 mg ................................ 21
losartan potassium & hydrochlorothiazide tab 50-12.5 mg ............................... 20
losartan potassium tab 100 mg ......... 21
losartan potassium tab 25 mg ........... 21
losartan potassium tab 50 mg ........... 21 LOTEMAX GEL 0.5% ........................ 102
lovastatin tab 10 mg ........................ 22
129
lovastatin tab 20 mg ......................... 22
lovastatin tab 40 mg ......................... 23 loxapine succinate cap 10 mg ............ 47
loxapine succinate cap 25 mg ............ 47
loxapine succinate cap 5 mg .............. 47
loxapine succinate cap 50 mg ............ 47
LUBRICNT GEL DRO 0.25-0.3 ........... 103
LYNPARZA TAB 100MG ...................... 18
LYNPARZA TAB 150MG ...................... 18
LYSODREN TAB 500MG ..................... 18
M MAALOX CHW 600MG ....................... 70 malathion lotion 0.5% ..................... 101
maprotiline hcl tab 25 mg .................. 36
maprotiline hcl tab 50 mg .................. 36 maprotiline hcl tab 75 mg .................. 36
MARPLAN TAB 10MG ......................... 37
MASK VORTEX/ MIS BABY DUC .......... 93 MASK VORTEX/ MIS DUCK ................. 93
MASK VORTEX/ MIS FROG ................. 93 MASK VORTEX/ MIS LADY BUG .......... 93
MATULANE CAP 50MG ....................... 18
MAVYRET TAB 100-40MG .................. 14
meclizine hcl chew tab 25 mg ............ 70 meclizine hcl tab 12.5 mg ............ 70, 71
meclizine hcl tab 25 mg .................... 71 MEDROL TAB 2MG ............................ 65
medroxyprogesterone acetate im susp 150 mg/ml ...................................... 63
medroxyprogesterone acetate im susp prefilled syr 150 mg/ml ..................... 63 medroxyprogesterone acetate tab 10 mg
..................................................... 68 medroxyprogesterone acetate tab 2.5
mg ................................................. 68
medroxyprogesterone acetate tab 5 mg ..................................................... 68
mefloquine hcl tab 250 mg ................ 10
megestrol acetate susp 40 mg/ml ....... 68
megestrol acetate tab 20 mg ............. 16
megestrol acetate tab 40 mg ............. 16
MEKINIST TAB 0.5MG ....................... 17 MEKINIST TAB 2MG .......................... 17
meloxicam tab 15 mg ........................ 4
meloxicam tab 7.5 mg ....................... 4
melphalan tab 2 mg .......................... 15 memantine hcl oral solution 2 mg/ml .. 36
memantine hcl tab 10 mg .................. 36
memantine hcl tab 5 mg ................... 36
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak ............................. 36
MENACTRA INJ ................................ 80
MENVEO INJ ................................... 80
meprobamate tab 200 mg ................ 30
meprobamate tab 400 mg ................ 30
mercaptopurine tab 50 mg ................ 15
mesalamine enema 4 gm .................. 72
mesalamine rectal enema 4 gm &
cleanser wipe kit ............................. 72
metadate tab 20mg er ..................... 50 metformin hcl tab 1000 mg ............... 58
metformin hcl tab 500 mg ................ 58
metformin hcl tab 850 mg ................ 58 metformin hcl tab er 24hr 500 mg ..... 58
metformin hcl tab er 24hr 750 mg ..... 58
methadone hcl tab 10 mg ................... 5 methadone hcl tab 5 mg ..................... 5
methazolamide tab 25 mg ................ 25 methazolamide tab 50 mg ................ 25
methimazole tab 10 mg .................... 68
methimazole tab 5 mg ..................... 68
methocarbamol tab 500 mg .............. 56 methocarbamol tab 750 mg .............. 56
methotrexate sodium tab 2.5 mg (base equiv) ............................................ 15
methyldopa tab 250 mg ................... 20 methyldopa tab 500 mg ................... 20
methylphenidate hcl cap er 10 mg (cd) 50 methylphenidate hcl cap er 20 mg (cd) 50 methylphenidate hcl cap er 24hr 20 mg
(la) ................................................ 50 methylphenidate hcl cap er 24hr 30 mg
(la) ................................................ 50
methylphenidate hcl cap er 24hr 40 mg (la) ................................................ 50
methylphenidate hcl cap er 30 mg (cd) 50
methylphenidate hcl cap er 40 mg (cd) 50
methylphenidate hcl cap er 50 mg (cd) 50
methylphenidate hcl cap er 60 mg (cd) 50
methylphenidate hcl soln 10 mg/5ml .. 51 methylphenidate hcl soln 5 mg/5ml .... 51
methylphenidate hcl tab 10 mg ......... 51
methylphenidate hcl tab 20 mg ......... 51
methylphenidate hcl tab 5 mg ........... 51 methylphenidate hcl tab er 10 mg ...... 51
methylphenidate hcl tab er 20 mg ...... 51
130
methylphenidate hcl tab er 24hr 18 mg
..................................................... 51 methylphenidate hcl tab er 24hr 27 mg
..................................................... 51
methylphenidate hcl tab er 24hr 36 mg
..................................................... 52
methylphenidate hcl tab er 24hr 54 mg
..................................................... 52
methylphenidate hcl tab er osmotic
release (osm) 18 mg ........................ 52
methylphenidate hcl tab er osmotic
release (osm) 27 mg ........................ 52 methylphenidate hcl tab er osmotic
release (osm) 36 mg ........................ 53
methylphenidate hcl tab er osmotic release (osm) 54 mg ........................ 53
methylprednisolone tab 16 mg ........... 65
methylprednisolone tab 32 mg ........... 65 methylprednisolone tab 4 mg ............. 65
methylprednisolone tab 8 mg ............. 65 methylprednisolone tab therapy pack 4
mg (21) .......................................... 65
metoclopramide hcl soln 5 mg/5ml (10
mg/10ml) (base equiv) ..................... 71 metoclopramide hcl tab 10 mg (base
equivalent) ...................................... 71 metoclopramide hcl tab 5 mg (base
equivalent) ...................................... 71 metolazone tab 10 mg ...................... 26
metolazone tab 2.5 mg ..................... 26 metolazone tab 5 mg ........................ 26 metoprolol & hydrochlorothiazide tab
100-25 mg ...................................... 23 metoprolol & hydrochlorothiazide tab
100-50 mg ...................................... 23
metoprolol & hydrochlorothiazide tab 50-25 mg ............................................ 23
metoprolol succinate tab er 24hr 100 mg
(tartrate equiv) ................................ 23
metoprolol succinate tab er 24hr 200 mg
(tartrate equiv) ................................ 23
metoprolol succinate tab er 24hr 25 mg (tartrate equiv) ................................ 23
metoprolol succinate tab er 24hr 50 mg
(tartrate equiv) ................................ 23
metoprolol tartrate tab 100 mg .......... 24 metoprolol tartrate tab 25 mg ............ 24
metoprolol tartrate tab 50 mg ............ 24
metronidazole cap 375 mg ................ 14
metronidazole cream 0.75% ............ 101 metronidazole gel 0.75% ................. 101
metronidazole gel 1% ..................... 101
metronidazole lotion 0.75% ............. 101
metronidazole tab 250 mg ................ 15
metronidazole tab 500 mg ................ 15
metronidazole vaginal gel 0.75% ....... 75
miconazole nitrate cream 2% ............ 97
miconazole nitrate ointment 2% ........ 97
miconazole nitrate powder 2% .......... 97
miconazole nitrate vaginal app 200 mg & 2% cream 9 gm kit .......................... 75
miconazole nitrate vaginal cream 2% . 75
miconazole nitrate vaginal cream 4% (200 mg/5gm) ................................ 75
miconazole nitrate vaginal supp 1200 mg
& 2% cream kit ............................... 75 miconazole nitrate vaginal supp 200 mg
& 2% cream 9 gm kit ....................... 75 miconazole nitrate vaginal suppos 100
mg ................................................ 75
miconazole nitrate vaginal suppos 200
mg ................................................ 75 MICROCLENS PAD WIPES ................. 97
midodrine hcl tab 10 mg ................... 28 midodrine hcl tab 2.5 mg .................. 28
midodrine hcl tab 5 mg .................... 28 minocycline hcl cap 100 mg ................ 9
minocycline hcl cap 50 mg .................. 9 minocycline hcl cap 75 mg .................. 9 mirtazapine orally disintegrating tab 15
mg ................................................ 36 mirtazapine orally disintegrating tab 30
mg ................................................ 36
mirtazapine orally disintegrating tab 45 mg ................................................ 36
mirtazapine tab 15 mg ..................... 36
mirtazapine tab 30 mg ..................... 36
mirtazapine tab 45 mg ..................... 36
mirtazapine tab 7.5 mg .................... 36
misoprostol tab 100 mcg .................. 74 misoprostol tab 200 mcg .................. 74
M-M-R II INJ ................................... 80
modafinil tab 100 mg ....................... 56
modafinil tab 200 mg ....................... 56 mometasone furoate cream 0.1% ...... 99
mometasone furoate oint 0.1% ......... 99
131
mometasone furoate solution 0.1%
(lotion) ........................................... 99 MONISTAT 3 KIT COMBO PK .............. 76
MONISTAT 7 KIT COMPLETE .............. 76
montelukast sodium chew tab 4 mg
(base equiv) .................................... 93
montelukast sodium chew tab 5 mg
(base equiv) .................................... 93
montelukast sodium oral granules packet
4 mg (base equiv) ............................ 93
montelukast sodium tab 10 mg (base
equiv) ............................................. 93 morphine sulfate oral soln 10 mg/5ml .. 5
morphine sulfate oral soln 100 mg/5ml
(20 mg/ml) ...................................... 6 morphine sulfate oral soln 20 mg/5ml .. 6
morphine sulfate tab 15 mg ................ 6
morphine sulfate tab 30 mg ................ 6 morphine sulfate tab er 100 mg .......... 6
morphine sulfate tab er 15 mg ............ 6 morphine sulfate tab er 200 mg .......... 6
morphine sulfate tab er 30 mg ............ 6
morphine sulfate tab er 60 mg ............ 6
MOVANTIK TAB 12.5MG .................... 73 MOVANTIK TAB 25MG ....................... 73
MUCINEX CGH GRA 5-100MG ............. 91 MUCINEX DM TAB 30-600ER .............. 91
MUCINEX/KIDS GRA 100MG .............. 93 MULPLETA TAB 3MG ......................... 77
MULTAQ TAB 400MG ......................... 21 multiple vitamin cap ......................... 86 multiple vitamin tab .......................... 86
multiple vitamins w/ calcium tab ........ 86 multiple vitamins w/ iron tab ............. 86
multiple vitamins w/ minerals & fa tab
1.25 mg .......................................... 86 multiple vitamins w/ minerals cap ....... 86
multiple vitamins w/ minerals chew tab
..................................................... 86
multiple vitamins w/ minerals effer tab 86
multiple vitamins w/ minerals liquid .... 86
multiple vitamins w/ minerals tab ....... 86 multiple vitamins w/ minerals tab er ... 86
MULTISTIX 10 TES SG ...................... 81
MULTISTIX 5 TES ............................. 81
MULTISTIX 7 TES ............................. 81 MULTISTIX 8 TES SG ........................ 81
MULTISTIX 9 TES ............................. 81
MULTISTIX 9 TES SG ....................... 81
MULTISTIX TES ............................... 81 mupirocin oint 2% ........................... 97
mycophenolate mofetil cap 250 mg .... 78
mycophenolate mofetil for oral susp 200
mg/ml ........................................... 78
mycophenolate mofetil tab 500 mg .... 78
mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv) ................ 78
mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv) ................ 78
MYFORTIC TAB 180MG ..................... 78 MYFORTIC TAB 360MG ..................... 78
MYLERAN TAB 2MG .......................... 15
myorisan cap 10mg ......................... 95 myorisan cap 20mg ......................... 95
myorisan cap 30mg ......................... 95
myorisan cap 40mg ......................... 95 MYSOLINE TAB 250MG ..................... 33
MYSOLINE TAB 50MG ....................... 33 N nabumetone tab 500 mg .................... 4
nabumetone tab 750 mg .................... 4
nadolol tab 20 mg ........................... 24 nadolol tab 40 mg ........................... 24
nadolol tab 80 mg ........................... 24 naltrexone hcl tab 50 mg .................. 56
naproxen sodium cap 220 mg ............. 4 naproxen sodium tab 220 mg .............. 4
naproxen sodium tab 275 mg .............. 4 naproxen sodium tab 550 mg .............. 4 naproxen susp 125 mg/5ml ................ 4
naproxen tab 250 mg ......................... 4 naproxen tab 375 mg ......................... 5
naproxen tab 500 mg ......................... 5
naproxen tab ec 375 mg ..................... 5 naproxen tab ec 500 mg ..................... 5
naratriptan hcl tab 1 mg (base equiv) . 54
naratriptan hcl tab 2.5 mg (base equiv)
..................................................... 54
NARCAN SPR .................................. 57
NARDIL TAB 15MG ........................... 37 NASCOBAL SPR 500MCG .................. 86
NATACYN SUS 5% OP ..................... 102
nateglinide tab 120 mg .................... 60
nateglinide tab 60 mg ...................... 60 NATRAPEL 12H SPR 20% ................. 100
NEBULIZER MIS .............................. 93
132
nefazodone hcl tab 100 mg ................ 36
nefazodone hcl tab 150 mg ................ 37 nefazodone hcl tab 200 mg ................ 37
nefazodone hcl tab 250 mg ................ 37
nefazodone hcl tab 50 mg ................. 36
neomycin sulfate tab 500 mg .............. 7
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin ... 102
neomycin-bacitracin-polymyxin oint .... 97
neomycin-polymy-gramicid op sol 1.75-
10000-0.025mg-unt-mg/ml ............. 102
neomycin-polymyxin-dexamethasone ophth oint 0.1% ............................. 101
neomycin-polymyxin-dexamethasone
ophth susp 0.1% ............................ 101 neomycin-polymyxin-hc ophth susp .. 101
neomycin-polymyxin-hc otic soln 1% 104
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ............... 104
NEORAL CAP 100MG ......................... 79 NEORAL CAP 25MG ........................... 79
NEORAL SOL 100MG/ML .................... 79
NEURONTIN CAP 100MG ................... 33
NEURONTIN CAP 300MG ................... 33 NEURONTIN CAP 400MG ................... 33
NEURONTIN SOL 250/5ML ................. 33 NEURONTIN TAB 600MG ................... 33
NEURONTIN TAB 800MG ................... 33 nevirapine susp 50 mg/5ml ............... 11
nevirapine tab 200 mg ...................... 11 nevirapine tab er 24hr 100 mg ........... 11 nevirapine tab er 24hr 400 mg ........... 11
NEXAVAR TAB 200MG ....................... 17 NEXIUM 24HR TAB 20MG .................. 74
NEXIUM GRA 10MG DR ..................... 74
NEXIUM GRA 2.5MG DR .................... 74 NEXIUM GRA 5MG DR ....................... 74
niacin cap er 250 mg ........................ 86
niacin cap er 500 mg ........................ 86
niacin tab 100 mg ............................ 86
niacin tab 250 mg ............................ 86
niacin tab 50 mg .............................. 86 niacin tab 500 mg ............................ 86
niacin tab er 1000 mg
(antihyperlipidemic) .......................... 23
niacin tab er 250 mg ......................... 86 niacin tab er 500 mg ......................... 86
niacin tab er 500 mg (antihyperlipidemic)
..................................................... 23
niacin tab er 750 mg ........................ 86 niacin tab er 750 mg (antihyperlipidemic)
..................................................... 23
niacin w/ inositol cap 400-100 mg ...... 86
niacinamide tab 100 mg ................... 86
niacinamide tab 500 mg ................... 86
nicotine polacrilex gum 2 mg ............. 58
nicotine polacrilex gum 4 mg ............. 58
nicotine td patch 24hr 14 mg/24hr ..... 58
nicotine td patch 24hr 21 mg/24hr ..... 58
nicotine td patch 24hr 7 mg/24hr ...... 58 nifedipine tab er 24hr 30 mg ............. 24
nifedipine tab er 24hr 60 mg ............. 24
nifedipine tab er 24hr 90 mg ............. 24 nifedipine tab er 24hr osmotic release 30
mg ................................................ 24
nifedipine tab er 24hr osmotic release 60 mg ................................................ 24
nifedipine tab er 24hr osmotic release 90 mg ................................................ 24
NITRO-BID OIN 2% ......................... 27
NITRO-DUR DIS 0.3MG/HR ............... 27
NITRO-DUR DIS 0.8MG/HR ............... 27 nitrofurantoin macrocrystalline cap 100
mg ................................................ 15 nitrofurantoin macrocrystalline cap 25
mg ................................................ 15 nitrofurantoin macrocrystalline cap 50
mg ................................................ 15 nitrofurantoin monohydrate macrocrystalline cap 100 mg ............. 15
nitrofurantoin susp 25 mg/5ml .......... 15 nitroglycerin cap er 2.5 mg ............... 27
nitroglycerin cap er 6.5 mg ............... 27
nitroglycerin cap er 9 mg .................. 27 nitroglycerin sl tab 0.3 mg ................ 27
nitroglycerin sl tab 0.4 mg ................ 27
nitroglycerin sl tab 0.6 mg ................ 27
nitroglycerin td patch 24hr 0.1 mg/hr . 27
nitroglycerin td patch 24hr 0.2 mg/hr . 27
nitroglycerin td patch 24hr 0.4 mg/hr . 27 nitroglycerin td patch 24hr 0.6 mg/hr . 27
NITYR TAB 10MG ............................. 66
NITYR TAB 2MG............................... 66
NITYR TAB 5MG............................... 66 NIX CREM RIN LIQ 1% .................... 101
nizatidine cap 150 mg ...................... 72
133
nizatidine cap 300 mg ....................... 72
nizatidine oral soln 15 mg/ml ............. 72 nonoxynol-9 gel 4% ......................... 63
NORDITROPIN INJ 10/1.5ML .............. 67
NORDITROPIN INJ 15/1.5ML .............. 67
NORDITROPIN INJ 30/3ML ................. 67
NORDITROPIN INJ 5/1.5ML ................ 67
norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr ............................. 64
norethindrone & ethinyl estradiol tab 0.4
mg-35 mcg ..................................... 64
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg ..................................... 64
norethindrone & ethinyl estradiol tab 1
mg-35 mcg ..................................... 64 norethindrone ace & ethinyl estradiol tab
1 mg-20 mcg ................................... 63
norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg ................................ 63
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg ............................. 63
norethindrone ace & ethinyl estradiol-fe
tab 1.5 mg-30 mcg ........................... 63
norethindrone acetate tab 5 mg ......... 68 norethindrone acetate-ethinyl estradiol
tab 0.5 mg-2.5 mcg .......................... 64 norethindrone acetate-ethinyl estradiol
tab 1 mg-5 mcg ............................... 65 norethindrone tab 0.35 mg ................ 64
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg .................. 64 norethindrone-eth estradiol tab 0.5-
35/1-35/0.5-35 mg-mcg ................... 64 norgestimate & ethinyl estradiol tab 0.25
mg-35 mcg ..................................... 64
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg ........... 64
norgestimate-eth estrad tab 0.18-
35/0.215-35/0.25-35 mg-mcg ........... 64
norgestrel & ethinyl estradiol tab 0.3 mg-
30 mcg ........................................... 63
norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg ........................................... 64
NORPACE CAP 100MG ....................... 21
NORPACE CAP 100MG CR .................. 21
NORPACE CAP 150MG ....................... 21 NORPACE CAP 150MG CR .................. 21
NORPRAMIN TAB 10MG ..................... 41
NORPRAMIN TAB 25MG .................... 41
nortriptyline hcl cap 10 mg ............... 41 nortriptyline hcl cap 25 mg ............... 41
nortriptyline hcl cap 50 mg ............... 41
nortriptyline hcl cap 75 mg ............... 41
nortriptyline hcl soln 10 mg/5ml ........ 41
NORVIR POW 100MG ....................... 13
NORVIR SOL 80MG/ML ..................... 13
NORVIR TAB 100MG ........................ 13
NOVOLIN INJ 70/30 ......................... 60
NOVOLIN INJ FLEXPEN ..................... 60
NOVOLIN N INJ RELION .................... 60 NOVOLIN N INJ U-100 ...................... 60
NOVOLIN R INJ RELION .................... 60
NOVOLIN R INJ U-100 ...................... 60 NOVOLIN70/30 INJ RELION .............. 60
NOVOLOG INJ 100/ML ...................... 60
NOVOLOG INJ FLEXPEN .................... 60 NOVOLOG INJ PENFILL ..................... 60
NOVOLOG MIX INJ 70/30 .................. 60 NOVOLOG MIX INJ FLEXPEN .............. 60
NUEDEXTA CAP 20-10MG ................. 57
NUPLAZID CAP 34MG ....................... 47
NUPLAZID TAB 10MG ....................... 47 NUTROPIN AQ INJ 10MG/2ML ............ 67
NUTROPIN AQ INJ 20MG/2ML ............ 67 NUTROPIN AQ INJ NUSPIN 5 ............. 67
NUVARING MIS ............................... 64 nystatin cream 100000 unit/gm ......... 97
nystatin oint 100000 unit/gm ............ 97 nystatin oral powder .......................... 9 nystatin susp 100000 unit/ml .............. 9
nystatin tab 500000 unit .................. 10 nystatin topical powder 100000 unit/gm
..................................................... 97
O ODEFSEY TAB ................................. 10
OFEV CAP 100MG ............................ 94
OFEV CAP 150MG ............................ 94
OFF DEEP WDS AER 25%................. 100
ofloxacin ophth soln 0.3% ............... 102
ofloxacin otic soln 0.3% .................. 104 olanzapine for im inj 10 mg ............... 44
olanzapine orally disintegrating tab 10
mg ................................................ 44
olanzapine orally disintegrating tab 15 mg ................................................ 44
olanzapine orally disintegrating tab 20
134
mg ................................................. 44
olanzapine orally disintegrating tab 5 mg ..................................................... 44
olanzapine tab 10 mg ....................... 44
olanzapine tab 15 mg ....................... 44
olanzapine tab 2.5 mg ...................... 44
olanzapine tab 20 mg ....................... 44
olanzapine tab 5 mg ......................... 44
olanzapine tab 7.5 mg ...................... 44
olanzapine-fluoxetine hcl cap 12-25 mg
..................................................... 44
olanzapine-fluoxetine hcl cap 12-50 mg ..................................................... 44
olanzapine-fluoxetine hcl cap 3-25 mg 44
olanzapine-fluoxetine hcl cap 6-25 mg 44 olanzapine-fluoxetine hcl cap 6-50 mg 44
omega-3 fatty acids - oral liquid ......... 86
omega-3 fatty acids cap 1000 mg ....... 86 omega-3 fatty acids cap 1200 mg ....... 87
omega-3 fatty acids cap 300 mg ........ 86 omega-3 fatty acids cap 435 mg ........ 86
omega-3 fatty acids cap 500 mg ........ 86
omega-3 fatty acids chew tab 113.5 mg
..................................................... 87 omeprazole cap delayed release 10 mg74
omeprazole cap delayed release 20 mg74 omeprazole cap delayed release 40 mg74
omeprazole delayed release tab 20 mg 74 omeprazole magnesium cap dr 20.6 mg
(20 mg base equiv) .......................... 74 omeprazole tab 20mg ....................... 74 omeprazole-sodium bicarbonate cap 20-
1100 mg ......................................... 74 OMNITROPE INJ 10/1.5ML ................. 67
OMNITROPE INJ 5.8MG ..................... 67
OMNITROPE INJ 5/1.5ML ................... 67 ondansetron hcl oral soln 4 mg/5ml .... 71
ondansetron hcl tab 24 mg ................ 71
ondansetron hcl tab 4 mg .................. 71
ondansetron hcl tab 8 mg .................. 71
ondansetron orally disintegrating tab 4
mg ................................................. 71 ondansetron orally disintegrating tab 8
mg ................................................. 71
ONFI SUS 2.5MG/ML ......................... 33
ONFI TAB 10MG ............................... 33 ONFI TAB 20MG ............................... 33
OPSUMIT TAB 10MG ......................... 27
oral electrolyte solution .................... 81
ORENITRAM TAB 0.125MG ................ 28 ORENITRAM TAB 0.25MG .................. 28
ORENITRAM TAB 1MG ...................... 28
ORENITRAM TAB 2.5MG ................... 28
ORENITRAM TAB 5MG ...................... 28
ORKAMBI GRA 100-125 .................... 92
ORKAMBI GRA 150-188 .................... 92
ORKAMBI TAB 100-125 .................... 92
ORKAMBI TAB 200-125 .................... 92
orphenadrine citrate tab er 12hr 100 mg
..................................................... 56 oseltamivir phosphate cap 30 mg (base
equiv) ............................................ 14
oseltamivir phosphate cap 45 mg (base equiv) ............................................ 14
oseltamivir phosphate cap 75 mg (base
equiv) ............................................ 14 oseltamivir phosphate for susp 6 mg/ml
(base equiv) ................................... 14 OSPHENA TAB 60MG ........................ 68
oxaprozin tab 600 mg ........................ 5
oxazepam cap 10 mg ....................... 29
oxazepam cap 15 mg ....................... 29 oxazepam cap 30 mg ....................... 29
oxcarbazepine susp 300 mg/5ml (60 mg/ml) .......................................... 33
oxcarbazepine tab 150 mg ................ 33 oxcarbazepine tab 300 mg ................ 33
oxcarbazepine tab 600 mg ................ 33 OXTELLAR XR TAB 150MG ................ 33 OXTELLAR XR TAB 300MG ................ 33
OXTELLAR XR TAB 600MG ................ 33 oxybutynin chloride syrup 5 mg/5ml .. 75
oxybutynin chloride tab 5 mg ............ 75
oxybutynin chloride tab er 24hr 10 mg 75 oxybutynin chloride tab er 24hr 15 mg 75
oxybutynin chloride tab er 24hr 5 mg . 75
oxycodone hcl cap 5 mg ..................... 6
oxycodone hcl conc 100 mg/5ml (20
mg/ml) ............................................ 6
oxycodone hcl soln 5 mg/5ml .............. 6 oxycodone hcl tab 10 mg .................... 6
oxycodone hcl tab 15 mg .................... 6
oxycodone hcl tab 20 mg .................... 6
oxycodone hcl tab 30 mg .................... 6 oxycodone hcl tab 5 mg ..................... 6
oxycodone w/ acetaminophen tab 10-325
135
mg .................................................. 6
oxycodone w/ acetaminophen tab 2.5-325 mg ............................................ 6
oxycodone w/ acetaminophen tab 5-325
mg .................................................. 6
oxycodone w/ acetaminophen tab 7.5-
325 mg ............................................ 6
oxycodone-aspirin tab 4.8355-325 mg . 6
oyster shell calcium tab 500 mg ......... 83
OZEMPIC INJ 2/1.5ML ....................... 59
P paliperidone tab er 24hr 1.5 mg ......... 44 paliperidone tab er 24hr 3 mg ............ 44
paliperidone tab er 24hr 6 mg ............ 44
paliperidone tab er 24hr 9 mg ............ 44 PAMELOR CAP 10MG ......................... 41
PAMELOR CAP 25MG ......................... 41
PAMELOR CAP 50MG ......................... 41 PAMELOR CAP 75MG ......................... 41
pantoprazole sodium ec tab 20 mg (base equiv) ............................................. 74
pantoprazole sodium ec tab 40 mg (base
equiv) ............................................. 74
pantothenic acid tab 500 mg .............. 87 paricalcitol cap 1 mcg ....................... 67
paricalcitol cap 2 mcg ....................... 67 paricalcitol cap 4 mcg ....................... 67
PARNATE TAB 10MG ......................... 37 paroxetine hcl tab 10 mg ................... 38
paroxetine hcl tab 20 mg ................... 38 paroxetine hcl tab 30 mg ................... 38 paroxetine hcl tab 40 mg ................... 38
paroxetine hcl tab er 24hr 12.5 mg ..... 38 paroxetine hcl tab er 24hr 25 mg........ 38
paroxetine hcl tab er 24hr 37.5 mg ..... 38
PAXIL CR TAB 12.5MG ...................... 38 PAXIL CR TAB 25MG ......................... 38
PAXIL CR TAB 37.5MG ...................... 38
PAXIL SUS 10MG/5ML ....................... 38
PAXIL TAB 10MG .............................. 38
PAXIL TAB 20MG .............................. 38
PAXIL TAB 30MG .............................. 38 PAXIL TAB 40MG .............................. 38
PEDIA-LAX LIQ 50MG ........................ 73
pediatric multiple vitamin liq .............. 87
pediatric multiple vitamin w/ c & fa chew tab ................................................. 87
pediatric multiple vitamin w/ c soln 35
mg/ml ........................................... 87
pediatric multiple vitamin w/ extra c & fa chew tab ........................................ 87
pediatric multiple vitamin w/ minerals &
c chew tab ...................................... 87
pediatric multiple vitamin w/ minerals &
c drops 45 mg/ml ............................ 87
pediatric multiple vitamins w/ fl-fe drops
0.25-10 mg/ml ................................ 87
pediatric multiple vitamins w/ fl-fe drops
0.25-6 mg/ml ................................. 87
pediatric multiple vitamins w/ fluoride chew tab 0.25 mg ............................ 87
pediatric multiple vitamins w/ fluoride
chew tab 0.5 mg ............................. 87 pediatric multiple vitamins w/ fluoride
chew tab 1 mg ................................ 87
pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml .............................. 87
pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml................................ 87
pediatric multiple vitamins w/ iron chew
tab 15 mg ...................................... 87
pediatric multiple vitamins w/ iron drops 10 mg/ml ....................................... 87
PEDIATRIC SM MIS MASK ................. 93 pediatric vitamins acd w/ fluoride soln
0.25 mg/ml .................................... 87 pediatric vitamins acd w/ fluoride soln
0.5 mg/ml ...................................... 87 pediatric vitamins adc drops 1500 unit-400 unit-35 mg/ml .......................... 87
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm ............................... 73
peg 3350-kcl-na bicarb-nacl-na sulfate
for soln 240 gm ............................... 73 peg 3350-kcl-sod bicarb-nacl for soln
420 gm .......................................... 73
PEGANONE TAB 250MG .................... 33
PEGASYS INJ .................................. 78
PEGASYS INJ 180MCG/M .................. 78
PEGASYS INJ PROCLICK ................... 78 PEGINTRON KIT 50MCG .................... 78
penicillin v potassium for soln 125
mg/5ml ............................................ 9
penicillin v potassium for soln 250 mg/5ml ............................................ 9
penicillin v potassium tab 250 mg ........ 9
136
penicillin v potassium tab 500 mg ........ 9
pentoxifylline tab er 400 mg .............. 76 permethrin aerosol 0.5% ................. 101
permethrin cream 5% ..................... 101
permethrin creme rinse 1% ............. 101
permethrin lotion 1% ...................... 101
perphenazine tab 16 mg .................... 47
perphenazine tab 2 mg ..................... 47
perphenazine tab 4 mg ..................... 47
perphenazine tab 8 mg ..................... 47
perphenazine-amitriptyline tab 2-10 mg
..................................................... 47 perphenazine-amitriptyline tab 2-25 mg
..................................................... 47
perphenazine-amitriptyline tab 4-10 mg ..................................................... 47
perphenazine-amitriptyline tab 4-25 mg
..................................................... 47 perphenazine-amitriptyline tab 4-50 mg
..................................................... 47 PEXEVA TAB 10MG ........................... 38
PEXEVA TAB 20MG ........................... 38
PEXEVA TAB 30MG ........................... 38
PEXEVA TAB 40MG ........................... 38 phenazopyridine hcl tab 100 mg ......... 75
phenazopyridine hcl tab 200 mg ......... 75 phenelzine sulfate tab 15 mg ............. 37
phenobarbital elixir 20 mg/5ml ........... 33 phenobarbital tab 100 mg ................. 34
phenobarbital tab 15 mg ................... 33 phenobarbital tab 16.2 mg ................ 33 phenobarbital tab 30 mg ................... 33
phenobarbital tab 32.4 mg ................ 33 phenobarbital tab 60 mg ................... 34
phenobarbital tab 64.8 mg ................ 34
phenobarbital tab 97.2 mg ................ 34 PHENYTEK CAP 200MG ...................... 34
PHENYTEK CAP 300MG ...................... 34
phenytoin chew tab 50 mg ................ 34
phenytoin sodium extended cap 100 mg
..................................................... 34
phenytoin sodium extended cap 200 mg ..................................................... 34
phenytoin sodium extended cap 300 mg
..................................................... 34
phenytoin susp 125 mg/5ml .............. 34 phytonadione tab 5 mg ..................... 87
pilocarpine hcl tab 5 mg .................... 74
pilocarpine hcl tab 7.5 mg ................. 74
pindolol tab 10 mg ........................... 24 pindolol tab 5 mg ............................ 24
PINWORM TAB MEDICINE ................. 15
pioglitazone hcl tab 15 mg (base equiv)
..................................................... 60
pioglitazone hcl tab 30 mg (base equiv)
..................................................... 60
pioglitazone hcl tab 45 mg (base equiv)
..................................................... 60
pioglitazone hcl-glimepiride tab 30-2 mg
..................................................... 59 pioglitazone hcl-glimepiride tab 30-4 mg
..................................................... 59
pioglitazone hcl-metformin hcl tab 15-500 mg .......................................... 59
pioglitazone hcl-metformin hcl tab 15-
850 mg .......................................... 59 PNEUMOVAX 23 INJ 25/0.5 ............... 80
podofilox soln 0.5% ........................ 101 polyethylene glycol 3350 oral packet .. 73
polyethylene glycol 3350 oral powder . 73
polyethylene glycol-propylene glycol
ophth soln 0.4-0.3% ....................... 103 polyethylene glycol-propylene glycol pf
op soln 0.4-0.3% ........................... 103 polymyxin b-trimethoprim ophth soln
10000 unit/ml-0.1% ....................... 102 polysaccharide iron complex cap 150 mg
(iron equivalent) ............................. 84 polyvinyl alcohol ophth soln 1.4% ..... 103 polyvinyl alcohol-povidone (pf) ophth
soln 1.4-0.6% ................................ 103 polyvinyl alcohol-povidone ophth soln 5-
6 mg/ml (0.5-0.6%) ....................... 103
potassium bicarbonate effer tab 25 meq ..................................................... 81
potassium chloride cap er 10 meq ...... 81
potassium chloride cap er 8 meq ....... 81
potassium chloride microencapsulated
crys er tab 10 meq .......................... 81
potassium chloride microencapsulated crys er tab 20 meq .......................... 81
potassium chloride oral soln 10% (20
meq/15ml) ..................................... 81
potassium chloride oral soln 20% (40 meq/15ml) ..................................... 81
potassium chloride tab er 10 meq ...... 81
137
potassium chloride tab er 20 meq (1500
mg) ................................................ 81 potassium chloride tab er 8 meq (600
mg) ................................................ 81
potassium citrate & citric acid powder
pack 3300-1002 mg ......................... 75
potassium citrate & citric acid soln 1100-
334 mg/5ml .................................... 75
potassium citrate tab er 10 meq (1080
mg) ................................................ 75
potassium citrate tab er 15 meq (1620
mg) ................................................ 75 potassium citrate tab er 5 meq (540 mg)
..................................................... 75
povidone-iodine oint 10% .................. 97 povidone-iodine soln 10% ................. 97
povidone-iodine soln 7.5% ................ 97
pramipexole dihydrochloride tab 0.125 mg ................................................. 42
pramipexole dihydrochloride tab 0.25 mg ..................................................... 42
pramipexole dihydrochloride tab 0.5 mg
..................................................... 42
pramipexole dihydrochloride tab 0.75 mg ..................................................... 42
pramipexole dihydrochloride tab 1 mg . 42 pramipexole dihydrochloride tab 1.5 mg
..................................................... 42 prasugrel hcl tab 10 mg (base equiv) .. 77
prasugrel hcl tab 5 mg (base equiv) .... 77 pravastatin sodium tab 10 mg ............ 23 pravastatin sodium tab 20 mg ............ 23
pravastatin sodium tab 40 mg ............ 23 pravastatin sodium tab 80 mg ............ 23
prazosin hcl cap 1 mg ....................... 20
prazosin hcl cap 2 mg ....................... 20 prazosin hcl cap 5 mg ....................... 20
PRECISION TES XTRA ....................... 62
PRED SOD PHO SOL 1% OP ............. 102
prednisolone acetate ophth susp 1% . 102
prednisolone sod phos orally disintegr
tab 10 mg (base eq) ......................... 65 prednisolone sod phos orally disintegr
tab 15 mg (base eq) ......................... 66
prednisolone sod phos orally disintegr
tab 30 mg (base eq) ......................... 66 prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base) .................. 66
prednisolone sod phosphate oral soln 15
mg/5ml (base equiv) ....................... 66 prednisolone syrup 15 mg/5ml (usp
solution equivalent) ......................... 66
prednisone oral soln 5 mg/5ml .......... 66
prednisone tab 1 mg ........................ 66
prednisone tab 10 mg ...................... 66
prednisone tab 2.5 mg ..................... 66
prednisone tab 20 mg ...................... 66
prednisone tab 5 mg ........................ 66
prednisone tab 50 mg ...................... 66
prednisone tab therapy pack 10 mg (21) ..................................................... 66
prednisone tab therapy pack 10 mg (48)
..................................................... 66 prednisone tab therapy pack 5 mg (21)
..................................................... 66
prednisone tab therapy pack 5 mg (48) ..................................................... 66
pregabalin cap 100 mg ..................... 34 pregabalin cap 150 mg ..................... 34
pregabalin cap 200 mg ..................... 34
pregabalin cap 225 mg ..................... 34
pregabalin cap 25 mg ....................... 34 pregabalin cap 300 mg ..................... 34
pregabalin cap 50 mg ....................... 34 pregabalin cap 75 mg ....................... 34
pregabalin soln 20 mg/ml ................. 34 PREMARIN VAG CRE 0.625MG ........... 65
PRENAISSANCE CAP PLUS ................ 88 prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg ......................................... 88
prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg ......................................... 89
prenatal vit w/ fe fumarate-fa chew tab
29-1 mg ......................................... 89 prenatal vit w/ iron carbonyl-fa tab 29-1
mg ................................................ 89
PREZCOBIX TAB 800-150 ................. 10
PREZISTA SUS 100MG/ML ................ 13
PREZISTA TAB 150MG ...................... 13
PREZISTA TAB 600MG ...................... 13 PREZISTA TAB 75MG ....................... 13
PREZISTA TAB 800MG ...................... 13
PRILOSEC OTC TAB 20MG ................. 74
primidone tab 250 mg ...................... 34 primidone tab 50 mg ........................ 34
PRISTIQ TAB 100MG ........................ 39
138
PRISTIQ TAB 25MG .......................... 39
PRISTIQ TAB 50MG .......................... 39 PROAIR RESPI AER ........................... 92
probenecid tab 500 mg ...................... 3
prochlorperazine maleate tab 10 mg
(base equivalent) ............................. 71
prochlorperazine maleate tab 5 mg (base
equivalent) ...................................... 71
prochlorperazine suppos 25 mg .......... 71
progesterone micronized cap 100 mg .. 68
progesterone micronized cap 200 mg .. 68
PROGRAF CAP 0.5MG ........................ 79 PROGRAF CAP 1MG ........................... 79
PROGRAF CAP 5MG ........................... 79
PROMACTA TAB 12.5MG .................... 77 PROMACTA TAB 25MG ....................... 77
PROMACTA TAB 50MG ....................... 77
PROMACTA TAB 75MG ....................... 77 promethazine & phenylephrine syrup
6.25-5 mg/5ml ................................ 89 promethazine hcl suppos 12.5 mg ...... 71
promethazine hcl suppos 25 mg ......... 71
promethazine hcl suppos 50 mg ......... 71
promethazine hcl syrup 6.25 mg/5ml .. 71 promethazine hcl tab 12.5 mg ............ 71
promethazine hcl tab 25 mg .............. 71 promethazine hcl tab 50 mg .............. 71
promethazine w/ codeine syrup 6.25-10 mg/5ml ........................................... 91
promethazine-dm syrup 6.25-15 mg/5ml ..................................................... 91 promethazine-phenylephrine-codeine
syrup 6.25-5-10 mg/5ml ................... 91 propafenone hcl cap er 12hr 225 mg ... 21
propafenone hcl cap er 12hr 325 mg ... 21
propafenone hcl cap er 12hr 425 mg ... 21 propafenone hcl tab 150 mg .............. 22
propafenone hcl tab 225 mg .............. 22
propafenone hcl tab 300 mg .............. 22
propranolol hcl cap er 24hr 120 mg .... 24
propranolol hcl cap er 24hr 160 mg .... 24
propranolol hcl cap er 24hr 60 mg ...... 24 propranolol hcl cap er 24hr 80 mg ...... 24
propranolol hcl oral soln 20 mg/5ml .... 24
propranolol hcl oral soln 40 mg/5ml .... 24
propranolol hcl tab 10 mg .................. 24 propranolol hcl tab 20 mg .................. 24
propranolol hcl tab 40 mg .................. 24
propranolol hcl tab 60 mg ................. 24
propranolol hcl tab 80 mg ................. 24 propylene glycol ophth soln 0.6% ..... 103
propylene glycol-glycerin ophth soln 1-
0.3% ............................................ 103
propylthiouracil tab 50 mg ................ 68
protriptyline hcl tab 10 mg ................ 41
protriptyline hcl tab 5 mg ................. 41
PROZAC CAP 10MG .......................... 38
PROZAC CAP 20MG .......................... 38
PROZAC CAP 40MG .......................... 38
pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml ..................................... 91
pseudoephedrine hcl liq 15 mg/5ml .... 92
pseudoephedrine hcl tab 30 mg ......... 92 pseudoephedrine hcl tab 60 mg ......... 92
pseudoephedrine hcl tab er 12hr 120 mg
..................................................... 92 pseudoephedrine w/ cod-gg soln 30-10-
100 mg/5ml .................................... 91 pseudoephedrine w/ dm-gg liquid 30-10-
100 mg/5ml .................................... 91
pseudoephedrine-guaifenesin tab er 12hr
120-1200 mg .................................. 92 pseudoephedrine-guaifenesin tab er 12hr
60-600 mg ..................................... 92 PULMOZYME SOL 1MG/ML ................. 92
pyrantel pamoate susp 144 mg/ml (50 mg/ml base equiv) .......................... 15
pyrazinamide tab 500 mg ................. 13 pyridostigmine bromide oral soln 60 mg/5ml .......................................... 56
pyridostigmine bromide tab 60 mg ..... 56 pyridostigmine bromide tab er 180 mg 56
pyridoxine hcl tab 100 mg ................ 87
pyridoxine hcl tab 25 mg .................. 87 pyridoxine hcl tab 250 mg ................ 87
pyridoxine hcl tab 50 mg .................. 87
pyridoxine hcl tab 500 mg ................ 88
pyridoxine hcl tab er 200 mg ............. 88
Q quetiapine fumarate tab 100 mg ........ 44 quetiapine fumarate tab 200 mg ........ 44
quetiapine fumarate tab 25 mg ......... 44
quetiapine fumarate tab 300 mg ........ 44
quetiapine fumarate tab 400 mg ........ 44 quetiapine fumarate tab 50 mg ......... 44
quetiapine fumarate tab er 24hr 150 mg
139
..................................................... 44
quetiapine fumarate tab er 24hr 200 mg ..................................................... 45
quetiapine fumarate tab er 24hr 300 mg
..................................................... 45
quetiapine fumarate tab er 24hr 400 mg
..................................................... 45
quetiapine fumarate tab er 24hr 50 mg
..................................................... 44
quinapril hcl tab 10 mg ..................... 19
quinapril hcl tab 20 mg ..................... 19
quinapril hcl tab 40 mg ..................... 19 quinapril hcl tab 5 mg ....................... 19
quinapril-hydrochlorothiazide tab 10-12.5
mg ................................................. 19 quinapril-hydrochlorothiazide tab 20-12.5
mg ................................................. 19
quinapril-hydrochlorothiazide tab 20-25 mg ................................................. 19
QVAR REDIHA AER 80MCG ................ 94 QVAR REDIHAL AER 40MCG ............... 95
R raloxifene hcl tab 60 mg .................... 68
ramipril cap 1.25 mg ........................ 19 ramipril cap 10 mg ........................... 20
ramipril cap 2.5 mg .......................... 20 ramipril cap 5 mg ............................. 20
ranitidine hcl cap 150 mg .................. 72 ranitidine hcl cap 300 mg .................. 72
ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ......................................... 72 ranitidine hcl tab 150 mg ................... 72
ranitidine hcl tab 300 mg ................... 72 ranitidine hcl tab 75 mg .................... 72
RAPAMUNE SOL 1MG/ML ................... 79
RAPAMUNE TAB 0.5MG ...................... 79 RAPAMUNE TAB 1MG ........................ 79
RAPAMUNE TAB 2MG ........................ 79
REBIF INJ 22/0.5 ............................. 56
REBIF INJ 44/0.5 ............................. 56
REBIF REBIDO INJ 22/0.5 .................. 56
REBIF REBIDO INJ 44/0.5 .................. 56 REBIF REBIDO INJ TITRATN ............... 56
REBIF TITRTN INJ PACK .................... 56
RECOMBIVA HB INJ 10MCG/ML .......... 80
RECOMBIVA HB INJ 5MCG/0.5 ........... 80 RECOMBIVA-HB INJ 40MCG/ML .......... 80
REFRESH OPTI DRO 0.5-0.9% .......... 103
REFRESH SOL OPTIVE ..................... 103
REMERON SLTB TAB 15MG ................ 37 REMERON SLTB TAB 30MG ................ 37
REMERON SLTB TAB 45MG ................ 37
REMERON TAB 15MG ....................... 37
REMERON TAB 30MG ....................... 37
repaglinide tab 0.5 mg ..................... 60
repaglinide tab 1 mg ........................ 60
repaglinide tab 2 mg ........................ 60
REPEL SPORTS AER 25% ................. 100
RESCRIPTOR TAB 200MG .................. 11
RETROVIR CAP 100MG ..................... 12 RETROVIR SYP 50MG/5ML ................ 12
REVLIMID CAP 10MG ....................... 16
REVLIMID CAP 15MG ....................... 16 REVLIMID CAP 2.5MG ...................... 16
REVLIMID CAP 20MG ....................... 16
REVLIMID CAP 25MG ....................... 16 REVLIMID CAP 5MG ......................... 16
REXULTI TAB 0.25MG ....................... 45 REXULTI TAB 0.5MG ........................ 45
REXULTI TAB 1MG ........................... 45
REXULTI TAB 2MG ........................... 45
REXULTI TAB 3MG ........................... 45 REXULTI TAB 4MG ........................... 45
REYATAZ CAP 150MG ....................... 13 REYATAZ CAP 200MG ....................... 13
REYATAZ CAP 300MG ....................... 13 REYATAZ POW 50MG ........................ 13
RHINARIS SPR 0.2% ........................ 94 RIBAPAK PAK 1200/DAY ................... 14 RIBAPAK PAK 800/DAY ..................... 14
RIBAPAK TAB 1000/DAY ................... 14 RIBAPAK TAB 600/DAY ..................... 14
ribasphere cap 200mg ...................... 14
ribasphere tab 200mg ...................... 14 RIBASPHERE TAB 400MG .................. 14
ribasphere tab 600mg ...................... 14
ribavirin cap 200 mg ........................ 14
ribavirin tab 200 mg ........................ 14
riboflavin tab 100 mg ....................... 88
riboflavin tab 25 mg ......................... 88 riboflavin tab 50 mg ......................... 88
RID AER ........................................ 101
rifabutin cap 150 mg ........................ 15
rifampin cap 150 mg ........................ 13 rifampin cap 300 mg ........................ 13
riluzole tab 50 mg ........................... 55
140
RISPERDAL INJ 12.5MG ..................... 45
RISPERDAL INJ 25MG ....................... 45 RISPERDAL INJ 37.5MG ..................... 45
RISPERDAL INJ 50MG ....................... 45
RISPERDAL SOL 1MG/ML ................... 45
RISPERDAL TAB 0.25MG .................... 45
RISPERDAL TAB 0.5MG ..................... 45
RISPERDAL TAB 1MG ........................ 45
RISPERDAL TAB 2MG ........................ 45
RISPERDAL TAB 3MG ........................ 45
RISPERDAL TAB 4MG ........................ 45
risperidone orally disintegrating tab 0.25 mg ................................................. 45
risperidone orally disintegrating tab 0.5
mg ................................................. 45 risperidone orally disintegrating tab 1 mg
..................................................... 45
risperidone orally disintegrating tab 2 mg ..................................................... 45
risperidone orally disintegrating tab 3 mg ..................................................... 45
risperidone orally disintegrating tab 4 mg
..................................................... 45
risperidone soln 1 mg/ml ................... 45 risperidone tab 0.25 mg .................... 45
risperidone tab 0.5 mg ...................... 45 risperidone tab 1 mg ......................... 45
risperidone tab 2 mg ......................... 45 risperidone tab 3 mg ......................... 45
risperidone tab 4 mg ......................... 45 ritonavir tab 100 mg ......................... 13 rivastigmine tartrate cap 1.5 mg (base
equivalent) ...................................... 36 rivastigmine tartrate cap 3 mg (base
equivalent) ...................................... 36
rivastigmine tartrate cap 4.5 mg (base equivalent) ...................................... 36
rivastigmine tartrate cap 6 mg (base
equivalent) ...................................... 36
rivastigmine td patch 24hr 13.3 mg/24hr
..................................................... 36
rivastigmine td patch 24hr 4.6 mg/24hr ..................................................... 36
rivastigmine td patch 24hr 9.5 mg/24hr
..................................................... 36
rizatriptan benzoate oral disintegrating tab 10 mg (base eq) ......................... 54
rizatriptan benzoate oral disintegrating
tab 5 mg (base eq) .......................... 54
rizatriptan benzoate tab 10 mg (base equivalent) ..................................... 54
rizatriptan benzoate tab 5 mg (base
equivalent) ..................................... 54
ropinirole hydrochloride tab 0.25 mg .. 42
ropinirole hydrochloride tab 0.5 mg .... 42
ropinirole hydrochloride tab 1 mg ...... 42
ropinirole hydrochloride tab 2 mg ...... 42
ropinirole hydrochloride tab 3 mg ...... 42
ropinirole hydrochloride tab 4 mg ...... 42
ropinirole hydrochloride tab 5 mg ...... 42 RUBRACA TAB 200MG ...................... 18
RUBRACA TAB 250MG ...................... 18
RUBRACA TAB 300MG ...................... 18 RYDAPT CAP 25MG .......................... 17
RYTHMOL SR CAP 225MG ................. 22
RYTHMOL SR CAP 325MG ................. 22 RYTHMOL SR CAP 425MG ................. 22
S SABRIL POW 500MG ........................ 34
SABRIL TAB 500MG ......................... 34
SAIZEN INJ 5MG ............................. 67
SAIZEN INJ 8.8MG ........................... 67 SAIZENPREP INJ 8.8MG .................... 67
saline nasal spray 0.65% .................. 94 SAMSCA TAB 15MG .......................... 69
SAMSCA TAB 30MG .......................... 69 SANDIMMUNE CAP 100MG ................ 79
SANDIMMUNE CAP 25MG .................. 79 SANDIMMUNE SOL 100MG/ML ........... 79 SAPHRIS SUB 10MG ......................... 45
SAPHRIS SUB 2.5MG ........................ 45 SAPHRIS SUB 5MG .......................... 45
SARAFEM TAB 10MG ........................ 38
SARAFEM TAB 20MG ........................ 38 SAVELLA MIS TITR PAK .................... 53
SAVELLA TAB 100MG ....................... 53
SAVELLA TAB 12.5MG ...................... 53
SAVELLA TAB 25MG ......................... 53
SAVELLA TAB 50MG ......................... 53
SAWYER REPEL SPR 20% ................ 100 selegiline hcl cap 5 mg ..................... 42
selegiline hcl tab 5 mg ..................... 42
selenium sulfide lotion 1% ................ 97
selenium sulfide lotion 2.5% ............. 97 SELZENTRY SOL 20MG/ML ................ 10
SELZENTRY TAB 150MG ................... 11
141
SELZENTRY TAB 25MG ...................... 10
SELZENTRY TAB 300MG .................... 11 SELZENTRY TAB 75MG ...................... 11
sennosides chew tab 15 mg ............... 73
sennosides syrup 8.8 mg/5ml ............ 73
sennosides tab 15 mg ....................... 73
sennosides tab 17.2 mg .................... 73
sennosides tab 25 mg ....................... 73
sennosides tab 8.6 mg ...................... 73
sennosides-docusate sodium tab 8.6-50
mg ................................................. 73
SENSIPAR TAB 30MG ........................ 62 SENSIPAR TAB 60MG ........................ 62
SENSIPAR TAB 90MG ........................ 62
SEROQUEL TAB 100MG ..................... 45 SEROQUEL TAB 200MG ..................... 45
SEROQUEL TAB 25MG ....................... 45
SEROQUEL TAB 300MG ..................... 45 SEROQUEL TAB 400MG ..................... 45
SEROQUEL TAB 50MG ....................... 45 SEROQUEL XR TAB 150MG ................ 45
SEROQUEL XR TAB 200MG ................ 46
SEROQUEL XR TAB 300MG ................ 46
SEROQUEL XR TAB 400MG ................ 46 SEROQUEL XR TAB 50MG .................. 45
SEROSTIM INJ 4MG .......................... 67 SEROSTIM INJ 5MG .......................... 67
SEROSTIM INJ 6MG .......................... 67 sertraline hcl oral concentrate for
solution 20 mg/ml ............................ 38 sertraline hcl tab 100 mg................... 38 sertraline hcl tab 25 mg .................... 38
sertraline hcl tab 50 mg .................... 38 sevelamer carbonate packet 0.8 gm .... 68
sevelamer carbonate packet 2.4 gm .... 68
sevelamer carbonate tab 800 mg ........ 68 SHUR-SEAL GEL 2% ......................... 63
sildenafil citrate for suspension 10 mg/ml
..................................................... 27
sildenafil citrate tab 20 mg ................ 27
silver sulfadiazine cream 1% .............. 97
simethicone cap 125 mg .................... 73 simethicone cap 180 mg .................... 73
simethicone chew tab 125 mg ............ 73
simethicone chew tab 80 mg .............. 73
simethicone liquid 40 mg/0.6ml ......... 73 simethicone susp 40 mg/0.6ml ........... 73
SIMPLY SALIN AER 0.9% ................... 94
simvastatin tab 10 mg ...................... 23
simvastatin tab 20 mg ...................... 23 simvastatin tab 40 mg ...................... 23
simvastatin tab 5 mg ....................... 23
simvastatin tab 80 mg ...................... 23
sirolimus oral soln 1 mg/ml ............... 79
sirolimus tab 0.5 mg ........................ 79
sirolimus tab 1 mg ........................... 79
sirolimus tab 2 mg ........................... 79
SM CALAMINE LOT .......................... 101
sodium chloride aero soln 0.9% ......... 94
sodium chloride soln nebu 0.9% ........ 94 sodium chloride soln nebu 10% ......... 94
sodium chloride soln nebu 3% ........... 94
sodium chloride soln nebu 7% ........... 94 sodium fluoride chew tab 0.25 mg f
(from 0.55 mg naf) .......................... 88
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) .................................... 88
sodium fluoride chew tab 1 mg f (from 2.2 mg naf) .................................... 88
sodium fluoride cream 1.1% ............ 101
sodium fluoride gel 1.1% (0.5% f) .... 101
sodium fluoride paste 1.1% ............. 101 sodium fluoride rinse 0.2% .............. 101
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) ........................ 88
sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf) .................. 88
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) ............................... 88 sodium fluoride tab 0.5 mg f (from 1.1
mg naf) .......................................... 88 sodium fluoride tab 1 mg f (from 2.2 mg
naf) ............................................... 88
sodium phenylbutyrate oral powder 3 gm/teaspoonful ............................... 69
sodium phenylbutyrate tab 500 mg .... 69
sodium polystyrene sulfonate oral susp
15 gm/60ml .................................... 68
sodium polystyrene sulfonate rectal susp
30 gm/120ml .................................. 68 SOLIQUA INJ 100/33 ....................... 59
sotalol hcl (afib/afl) tab 120 mg ......... 22
sotalol hcl (afib/afl) tab 160 mg ......... 22
sotalol hcl (afib/afl) tab 80 mg .......... 22 sotalol hcl tab 120 mg ...................... 22
sotalol hcl tab 160 mg ...................... 22
142
sotalol hcl tab 240 mg....................... 22
sotalol hcl tab 80 mg ........................ 22 spinosad susp 0.9% ........................ 101
spironolactone & hydrochlorothiazide tab
25-25 mg ........................................ 25
spironolactone tab 100 mg ................ 20
spironolactone tab 25 mg .................. 20
spironolactone tab 50 mg .................. 20
SSKI SOL 1GM/ML ............................ 68
stavudine cap 15 mg ........................ 12
stavudine cap 20 mg ........................ 12
stavudine cap 30 mg ........................ 12 stavudine cap 40 mg ........................ 12
STIOLTO AER 2.5-2.5 ....................... 89
STIVARGA TAB 40MG ........................ 17 STRIBILD TAB .................................. 10
STRIVERDI AER 2.5MCG .................... 91
sucralfate tab 1 gm .......................... 73 SUDAFED 24HR TAB 240MG ............... 92
sulfacetamide sodium lotion 10% (acne) ..................................................... 96
sulfacetamide sodium ophth soln 10%
................................................... 102
sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% ............. 101
SULFADIAZINE TAB 500MG ................ 9 sulfamethoxazole-trimethoprim susp
200-40 mg/5ml ................................. 9 sulfamethoxazole-trimethoprim tab 400-
80 mg ............................................. 9 sulfamethoxazole-trimethoprim tab 800-160 mg ............................................ 9
sulfasalazine tab 500 mg ................... 72 sulfasalazine tab delayed release 500 mg
..................................................... 72
sulindac tab 150 mg .......................... 5 sulindac tab 200 mg .......................... 5
sumatriptan nasal spray 20 mg/act ..... 54
sumatriptan nasal spray 5 mg/act ....... 54
sumatriptan succinate inj 6 mg/0.5ml . 54
sumatriptan succinate solution auto-
injector 4 mg/0.5ml .......................... 54 sumatriptan succinate solution auto-
injector 6 mg/0.5ml .......................... 54
sumatriptan succinate solution cartridge
4 mg/0.5ml ..................................... 54 sumatriptan succinate solution cartridge
6 mg/0.5ml ..................................... 54
sumatriptan succinate tab 100 mg ..... 55
sumatriptan succinate tab 25 mg ....... 54 sumatriptan succinate tab 50 mg ....... 55
SUSTIVA CAP 200MG ....................... 11
SUSTIVA CAP 50MG ......................... 11
SUSTIVA TAB 600MG ....................... 11
SUTENT CAP 12.5MG ....................... 17
SUTENT CAP 25MG .......................... 17
SUTENT CAP 37.5MG ....................... 17
SUTENT CAP 50MG .......................... 17
SYMDEKO TAB 100-150 .................... 92
SYMDEKO TAB 50-75MG ................... 92 SYMFI LO TAB ................................. 10
SYMFI TAB ...................................... 10
SYMTUZA TAB ................................. 10 SYNAREL SOL 2MG/ML ..................... 64
SYNTHROID TAB 100MCG ................. 69
SYNTHROID TAB 112MCG ................. 69 SYNTHROID TAB 125MCG ................. 69
SYNTHROID TAB 137MCG ................. 69 SYNTHROID TAB 150MCG ................. 69
SYNTHROID TAB 175MCG ................. 69
SYNTHROID TAB 200MCG ................. 69
SYNTHROID TAB 25MCG ................... 69 SYNTHROID TAB 300MCG ................. 69
SYNTHROID TAB 50MCG ................... 69 SYNTHROID TAB 75MCG ................... 69
SYNTHROID TAB 88MCG ................... 69 SYSTANE GEL 0.3% ........................ 103
T tacrolimus cap 0.5 mg ...................... 79 tacrolimus cap 1 mg ........................ 79
tacrolimus cap 5 mg ........................ 79 tacrolimus oint 0.03% ...................... 98
tacrolimus oint 0.1% ........................ 98
TAFINLAR CAP 50MG ........................ 17 TAFINLAR CAP 75MG ........................ 17
tamoxifen citrate tab 10 mg (base
equivalent) ..................................... 15
tamoxifen citrate tab 20 mg (base
equivalent) ..................................... 15
tamsulosin hcl cap 0.4 mg ................ 74 TDVAX INJ 2-2 LF ............................ 80
TECFIDERA CAP 120MG .................... 56
TECFIDERA CAP 240MG .................... 56
TECFIDERA MIS STARTER ................. 56 TEGRETOL SUS 100/5ML .................. 34
TEGRETOL TAB 200MG ..................... 34
143
TEGRETOL-XR TAB 100MG ................. 34
TEGRETOL-XR TAB 200MG ................. 34 TEGRETOL-XR TAB 400MG ................. 34
temazepam cap 15 mg ...................... 53
temazepam cap 22.5 mg ................... 53
temazepam cap 30 mg ...................... 53
temazepam cap 7.5 mg ..................... 53
temozolomide cap 100 mg ................. 15
temozolomide cap 140 mg ................. 15
temozolomide cap 180 mg ................. 15
temozolomide cap 20 mg .................. 15
temozolomide cap 250 mg ................. 15 temozolomide cap 5 mg .................... 15
TENIVAC INJ 5-2LF ........................... 80
tenofovir disoproxil fumarate tab 300 mg ..................................................... 12
terazosin hcl cap 1 mg (base equivalent)
..................................................... 20 terazosin hcl cap 10 mg (base
equivalent) ...................................... 20 terazosin hcl cap 2 mg (base equivalent)
..................................................... 20
terazosin hcl cap 5 mg (base equivalent)
..................................................... 20 terbinafine hcl tab 250 mg ................. 10
terbutaline sulfate tab 2.5 mg ............ 92 terbutaline sulfate tab 5 mg ............... 92
terconazole vaginal cream 0.4% ......... 76 terconazole vaginal cream 0.8% ......... 76
terconazole vaginal suppos 80 mg ...... 76 testosterone td gel 10mg/act (2%) ..... 58 testosterone td gel 25 mg/2.5gm (1%)58
tetrabenazine tab 12.5 mg ................ 53 tetrabenazine tab 25 mg ................... 53
tetracycline hcl cap 250 mg ................ 9
tetracycline hcl cap 500 mg ................ 9 THEO-24 CAP 100MG CR ................... 95
THEO-24 CAP 200MG CR ................... 95
THEO-24 CAP 300MG CR ................... 95
THEO-24 CAP 400MG ER ................... 95
theophylline soln 80 mg/15ml ............ 95
theophylline tab er 12hr 100 mg ........ 95 theophylline tab er 12hr 200 mg ........ 95
theophylline tab er 12hr 300 mg ........ 95
theophylline tab er 12hr 450 mg ........ 95
theophylline tab er 24hr 400 mg ........ 95 theophylline tab er 24hr 600 mg ........ 95
THERATEARS SOL 0.25% PF ............ 103
thiamine hcl tab 100 mg ................... 88
thiamine hcl tab 250 mg ................... 88 thiamine hcl tab 50 mg .................... 88
thiamine mononitrate tab 100 mg ...... 88
thioridazine hcl tab 10 mg ................ 47
thioridazine hcl tab 100 mg ............... 47
thioridazine hcl tab 25 mg ................ 47
thioridazine hcl tab 50 mg ................ 47
thiothixene cap 1 mg ....................... 47
thiothixene cap 10 mg ...................... 47
thiothixene cap 2 mg ....................... 47
thiothixene cap 5 mg ....................... 47 tiagabine hcl tab 12 mg .................... 34
tiagabine hcl tab 16 mg .................... 34
tiagabine hcl tab 2 mg ...................... 34 tiagabine hcl tab 4 mg ...................... 34
TIKOSYN CAP 125MCG ..................... 22
TIKOSYN CAP 250MCG ..................... 22 TIKOSYN CAP 500MCG ..................... 22
timolol maleate ophth gel forming soln 0.25% .......................................... 103
timolol maleate ophth gel forming soln
0.5% ............................................ 103
timolol maleate ophth soln 0.25% ..... 103 timolol maleate ophth soln 0.5% ...... 103
timolol maleate tab 10 mg ................ 24 timolol maleate tab 20 mg ................ 24
timolol maleate tab 5 mg .................. 24 TIVICAY TAB 10MG .......................... 11
TIVICAY TAB 25MG .......................... 11 TIVICAY TAB 50MG .......................... 11 tizanidine hcl tab 2 mg (base equivalent)
..................................................... 56 tizanidine hcl tab 4 mg (base equivalent)
..................................................... 56
tobramycin nebu soln 300 mg/5ml ..... 92 tobramycin ophth soln 0.3% ............ 102
TOFRANIL TAB 10MG ....................... 41
TOFRANIL TAB 25MG ....................... 41
TOFRANIL TAB 50MG ....................... 41
TOLAK CRE 4% ............................... 96
tolnaftate aerosol pow 1% ................ 97 tolnaftate cream 1% ........................ 97
tolnaftate soln 1% ........................... 97
tolterodine tartrate tab 1 mg ............. 75
tolterodine tartrate tab 2 mg ............. 75 TOPAMAX SPR CAP 15MG ................. 34
TOPAMAX SPR CAP 25MG ................. 34
144
TOPAMAX TAB 100MG ....................... 34
TOPAMAX TAB 200MG ....................... 34 TOPAMAX TAB 25MG ......................... 34
TOPAMAX TAB 50MG ......................... 34
topiramate cap er 24hr sprinkle 100 mg
..................................................... 34
topiramate cap er 24hr sprinkle 150 mg
..................................................... 34
topiramate cap er 24hr sprinkle 200 mg
..................................................... 34
topiramate cap er 24hr sprinkle 25 mg 34
topiramate cap er 24hr sprinkle 50 mg 34 topiramate sprinkle cap 15 mg ........... 35
topiramate sprinkle cap 25 mg ........... 35
topiramate tab 100 mg ..................... 35 topiramate tab 200 mg ..................... 35
topiramate tab 25 mg ....................... 35
topiramate tab 50 mg ....................... 35 toremifene citrate tab 60 mg (base
equivalent) ...................................... 16 torsemide tab 10 mg ........................ 26
torsemide tab 100 mg ....................... 26
torsemide tab 20 mg ........................ 26
torsemide tab 5 mg .......................... 26 TRACLEER TAB 32MG ........................ 27
tramadol hcl tab 50 mg ...................... 6 tramadol hcl tab er 24hr 100 mg ......... 6
tramadol hcl tab er 24hr 200 mg ......... 7 tramadol hcl tab er 24hr 300 mg ......... 7
tramadol hcl tab er 24hr biphasic release 300 mg ............................................ 7 tramadol-acetaminophen tab 37.5-325
mg .................................................. 7 trandolapril tab 1 mg ........................ 20
trandolapril tab 2 mg ........................ 20
trandolapril tab 4 mg ........................ 20 TRANXENE T TAB 7.5MG ................... 29
tranylcypromine sulfate tab 10 mg ...... 37
trazodone hcl tab 100 mg .................. 37
trazodone hcl tab 150 mg .................. 37
trazodone hcl tab 300 mg .................. 37
trazodone hcl tab 50 mg .................... 37 tretinoin cap 10 mg .......................... 18
tretinoin cream 0.025% .................... 96
tretinoin cream 0.05% ...................... 96
tretinoin cream 0.1% ........................ 96 tretinoin gel 0.01%........................... 96
tretinoin gel 0.025% ......................... 96
triamcinolone acetonide cream 0.025%
..................................................... 99 triamcinolone acetonide cream 0.1% .. 99
triamcinolone acetonide cream 0.5% .. 98
triamcinolone acetonide dental paste
0.1% ............................................ 101
triamcinolone acetonide lotion 0.025% 99
triamcinolone acetonide lotion 0.1% ... 99
triamcinolone acetonide nasal aerosol
suspension 55 mcg/act ..................... 94
triamcinolone acetonide oint 0.025% .. 99
triamcinolone acetonide oint 0.1% ..... 99 triamcinolone acetonide oint 0.5% ..... 98
triamterene & hydrochlorothiazide cap
37.5-25 mg .................................... 25 triamterene & hydrochlorothiazide tab
37.5-25 mg .................................... 26
triamterene & hydrochlorothiazide tab 75-50 mg ....................................... 26
trifluoperazine hcl tab 1 mg (base equivalent) ..................................... 47
trifluoperazine hcl tab 10 mg (base
equivalent) ..................................... 47
trifluoperazine hcl tab 2 mg (base equivalent) ..................................... 47
trifluoperazine hcl tab 5 mg (base equivalent) ..................................... 47
trifluridine ophth soln 1% ................ 102 trihexyphenidyl hcl elixir 0.4 mg/ml ... 42
trihexyphenidyl hcl tab 2 mg ............. 42 trihexyphenidyl hcl tab 5 mg ............. 42 TRILEPTAL SUS 300MG/5M ............... 35
TRILEPTAL TAB 150MG ..................... 35 TRILEPTAL TAB 300MG ..................... 35
TRILEPTAL TAB 600MG ..................... 35
trimethobenzamide hcl cap 300 mg .... 71 trimethoprim tab 100 mg .................. 15
trimipramine maleate cap 100 mg ...... 41
trimipramine maleate cap 25 mg ....... 41
trimipramine maleate cap 50 mg ....... 41
TRINTELLIX TAB 10MG ..................... 38
TRINTELLIX TAB 20MG ..................... 38 TRINTELLIX TAB 5MG ....................... 38
TRIUMEQ TAB ................................. 10
TRIZIVIR TAB ................................. 10
TROKENDI XR CAP 100MG ................ 35 TROKENDI XR CAP 200MG ................ 35
TROKENDI XR CAP 25MG .................. 35
145
TROKENDI XR CAP 50MG ................... 35
trospium chloride cap er 24hr 60 mg ... 75 trospium chloride tab 20 mg .............. 75
TRULANCE TAB 3MG ......................... 72
TRULICITY INJ 0.75/0.5 .................... 59
TRULICITY INJ 1.5/0.5 ...................... 59
TRUVADA TAB 100-150 ..................... 10
TRUVADA TAB 133-200 ..................... 10
TRUVADA TAB 167-250 ..................... 10
TRUVADA TAB 200-300 ..................... 10
TUMS CHW DEL CHW 1177MG ........... 70
TWINRIX INJ ................................... 80 TYBOST TAB 150MG ......................... 10
TYKERB TAB 250MG ......................... 17
TYVASO REFIL SOL 0.6MG/ML ............ 28 TYVASO SOL 0.6MG/ML ..................... 28
TYVASO START SOL 0.6MG/ML ........... 28
U UNI-SOLVE PAD WIPES ..................... 97
UPTRAVI TAB 1000MCG .................... 28 UPTRAVI TAB 1200MCG .................... 28
UPTRAVI TAB 1400MCG .................... 28
UPTRAVI TAB 1600MCG .................... 28
UPTRAVI TAB 200/800 ...................... 27 UPTRAVI TAB 200MCG ...................... 27
UPTRAVI TAB 400MCG ...................... 27 UPTRAVI TAB 600MCG ...................... 27
UPTRAVI TAB 800MCG ...................... 27 URISTIX 4 TES ................................. 81
URISTIX TES ................................... 81 ursodiol cap 300 mg ......................... 71 ursodiol tab 250 mg .......................... 71
ursodiol tab 500 mg .......................... 71 V valacyclovir hcl tab 1 gm ................... 14
valacyclovir hcl tab 500 mg ............... 14 valganciclovir hcl for soln 50 mg/ml
(base equiv) .................................... 13
valganciclovir hcl tab 450 mg (base
equivalent) ...................................... 13
VALIUM TAB 10MG ........................... 29
VALIUM TAB 2MG ............................. 29 VALIUM TAB 5MG ............................. 29
valproate sodium oral soln 250 mg/5ml
(base equiv) .................................... 35
valproic acid cap 250 mg ................... 35 valsartan tab 160 mg ........................ 21
valsartan tab 320 mg ........................ 21
valsartan tab 40 mg ......................... 21
valsartan tab 80 mg ......................... 21 valsartan-hydrochlorothiazide tab 160-
12.5 mg ......................................... 21
valsartan-hydrochlorothiazide tab 160-25
mg ................................................ 21
valsartan-hydrochlorothiazide tab 320-
12.5 mg ......................................... 21
valsartan-hydrochlorothiazide tab 320-25
mg ................................................ 21
valsartan-hydrochlorothiazide tab 80-
12.5 mg ......................................... 21 vancomycin hcl cap 125 mg (base
equivalent) ..................................... 15
vancomycin hcl cap 250 mg (base equivalent) ..................................... 15
VAPORIZER .................................... 93
VAQTA INJ 25/0.5ML ........................ 80 VAQTA INJ 50UNT/ML ...................... 80
VARIVAX INJ ................................... 80 VCF VAGINAL AER CONTRACP ........... 63
VCF VAGINAL MIS CONTRACP ........... 63
VENCLEXTA TAB 100MG ................... 18
VENCLEXTA TAB 10MG ..................... 18 VENCLEXTA TAB 50MG ..................... 18
VENCLEXTA TAB START PK ............... 18 venlafaxine hcl cap er 24hr 150 mg
(base equivalent) ............................ 40 venlafaxine hcl cap er 24hr 37.5 mg
(base equivalent) ............................ 40 venlafaxine hcl cap er 24hr 75 mg (base equivalent) ..................................... 40
venlafaxine hcl tab 100 mg (base equivalent) ..................................... 40
venlafaxine hcl tab 25 mg (base
equivalent) ..................................... 40 venlafaxine hcl tab 37.5 mg (base
equivalent) ..................................... 40
venlafaxine hcl tab 50 mg (base
equivalent) ..................................... 40
venlafaxine hcl tab 75 mg (base
equivalent) ..................................... 40 venlafaxine hcl tab er 24hr 150 mg (base
equivalent) ..................................... 40
venlafaxine hcl tab er 24hr 225 mg (base
equivalent) ..................................... 40 venlafaxine hcl tab er 24hr 37.5 mg
(base equivalent) ............................ 40
146
venlafaxine hcl tab er 24hr 75 mg (base
equivalent) ...................................... 40 VENTOLIN HFA AER .......................... 92
verapamil hcl tab er 120 mg .............. 25
verapamil hcl tab er 180 mg .............. 25
verapamil hcl tab er 240 mg .............. 25
VERSACLOZ SUS 50MG/ML ................ 46
VICTOZA INJ 18MG/3ML .................... 59
VIDEX EC CAP 125MG ....................... 12
VIDEX EC CAP 200MG ....................... 12
VIDEX EC CAP 250MG ....................... 12
VIDEX EC CAP 400MG ....................... 12 VIDEX SOL 2GM ............................... 12
vigabatrin powd pack 500 mg ............ 35
vigabatrin tab 500 mg ....................... 35 VIIBRYD KIT STARTER ...................... 39
VIIBRYD TAB 10MG .......................... 39
VIIBRYD TAB 20MG .......................... 39 VIIBRYD TAB 40MG .......................... 39
VIMPAT SOL 10MG/ML ...................... 35 VIMPAT TAB 100MG .......................... 35
VIMPAT TAB 150MG .......................... 35
VIMPAT TAB 200MG .......................... 35
VIMPAT TAB 50MG ........................... 35 VIOKACE TAB 10440 ......................... 73
VIOKACE TAB 20880 ......................... 73 VIRACEPT TAB 250MG ...................... 13
VIRACEPT TAB 625MG ...................... 13 VIRAMUNE SUS 50MG/5ML ................ 11
VIRAMUNE TAB 200MG ..................... 11 VIRAMUNE XR TAB 400MG ................. 11 VIREAD POW 40MG/GM ..................... 12
VIREAD TAB 150MG .......................... 12 VIREAD TAB 200MG .......................... 12
VIREAD TAB 250MG .......................... 12
VIREAD TAB 300MG .......................... 12 VISTARIL CAP 25MG ......................... 90
VISTARIL CAP 50MG ......................... 90
VISTOGARD PAK 10GM ..................... 18
vitamin e cap 400 unit ...................... 88
vitamin mixture cap .......................... 88
vitamin mixture tab .......................... 88 vitamins a & d cap ............................ 88
vitamins a & d tab ............................ 88
vitamins a & d w/ c chew tab ............. 88
vitamins c & e cap ............................ 88 vitamins w/ lipotropics cap ................ 88
vitamins w/ lipotropics tab ................. 88
vitamins w/ lipotropics tab er ............ 88
VITRAKVI CAP 100MG ...................... 17 VITRAKVI CAP 25MG ........................ 17
VITRAKVI SOL 20MG/ML ................... 17
voriconazole for susp 40 mg/ml ......... 10
voriconazole tab 200 mg .................. 10
voriconazole tab 50 mg .................... 10
VORTEX VALVE MIS CHAMBER ........... 93
VORTEX/MASK MIS CHILDS .............. 93
VORTEX/MASK MIS TODDLER ............ 93
VOTRIENT TAB 200MG ..................... 17
VRAYLAR CAP 1.5-3MG ..................... 46 VRAYLAR CAP 1.5MG ........................ 46
VRAYLAR CAP 3MG .......................... 46
VRAYLAR CAP 4.5MG ........................ 46 VRAYLAR CAP 6MG .......................... 46
W warfarin sodium tab 1 mg ................. 76 warfarin sodium tab 10 mg ............... 76
warfarin sodium tab 2 mg ................. 76 warfarin sodium tab 2.5 mg .............. 76
warfarin sodium tab 3 mg ................. 76
warfarin sodium tab 4 mg ................. 76
warfarin sodium tab 5 mg ................. 76 warfarin sodium tab 6 mg ................. 76
warfarin sodium tab 7.5 mg .............. 76 WELLBUTRIN TAB 100MG SR ............. 37
WELLBUTRIN TAB 150MG SR ............. 37 WELLBUTRIN TAB 200MG SR ............. 37
WELLBUTRIN TAB XL 150MG ............. 37 WELLBUTRIN TAB XL 300MG ............. 37 white petrolatum-mineral oil ophth
ointment ....................................... 103 X XANAX TAB 0.25MG ......................... 29
XANAX TAB 0.5MG ........................... 29 XANAX TAB 1MG ............................. 29
XANAX TAB 2MG ............................. 29
XANAX XR TAB 0.5MG ...................... 29
XANAX XR TAB 1MG ......................... 29
XANAX XR TAB 2MG ......................... 29
XANAX XR TAB 3MG ......................... 29 XARELTO STAR TAB 15/20MG ........... 76
XARELTO TAB 10MG ........................ 76
XARELTO TAB 15MG ........................ 76
XARELTO TAB 2.5MG ....................... 76 XARELTO TAB 20MG ........................ 76
XELJANZ TAB 10MG ......................... 78
147
XELJANZ TAB 5MG ............................ 78
XELJANZ XR TAB 11MG ..................... 78 XIIDRA DRO 5% ............................ 104
XOLAIR INJ 150MG/ML ...................... 94
XOLAIR INJ 75/0.5 ........................... 94
XOLAIR SOL 150MG .......................... 94
Y YODEFAN-NF LIQ 200-5ML ................ 93
Z ZARONTIN CAP 250MG ...................... 35
ZARONTIN SOL 250/5ML ................... 35
ZEJULA CAP 100MG .......................... 18 ZELBORAF TAB 240MG ...................... 17
zenatane cap 10mg .......................... 95
zenatane cap 20mg .......................... 95 zenatane cap 30mg .......................... 95
zenatane cap 40mg .......................... 95
ZENPEP CAP 10000UNT ..................... 73 ZENPEP CAP 15000UNT ..................... 73
ZENPEP CAP 20000UNT ..................... 73 ZENPEP CAP 25000 ........................... 74
ZENPEP CAP 25000UNT ..................... 74
ZENPEP CAP 3000UNIT ..................... 73
ZENPEP CAP 40000 ........................... 74 ZENPEP CAP 40000UNT ..................... 74
ZENPEP CAP 5000UNIT ..................... 73 ZIAGEN SOL 20MG/ML ...................... 12
ZIAGEN TAB 300MG ......................... 12 zidovudine cap 100 mg ..................... 12
zidovudine syrup 10 mg/ml ............... 12 zidovudine tab 300 mg ...................... 12 ziprasidone hcl cap 20 mg ................. 46
ziprasidone hcl cap 40 mg ................. 46 ziprasidone hcl cap 60 mg ................. 46
ziprasidone hcl cap 80 mg ................. 46
ZOLINZA CAP 100MG ........................ 18 zolmitriptan orally disintegrating tab 2.5
mg ................................................. 55
zolmitriptan orally disintegrating tab 5
mg ................................................. 55
zolmitriptan tab 2.5 mg ..................... 55
zolmitriptan tab 5 mg ....................... 55 ZOLOFT TAB 100MG ......................... 39
ZOLOFT TAB 25MG ........................... 39
ZOLOFT TAB 50MG ........................... 39
zolpidem tartrate tab 10 mg .............. 53
zolpidem tartrate tab 5 mg ............... 53 zolpidem tartrate tab er 12.5 mg ....... 54
zolpidem tartrate tab er 6.25 mg ....... 53
ZOMACTON INJ 10MG ...................... 67
ZOMACTON INJ 5MG ........................ 67
ZONEGRAN CAP 100MG .................... 35
ZONEGRAN CAP 25MG ..................... 35
zonisamide cap 100 mg .................... 35
zonisamide cap 25 mg ...................... 35
zonisamide cap 50 mg ...................... 35
ZONTIVITY TAB 2.08MG ................... 77 ZORBTIVE INJ 8.8MG ....................... 67
ZORTRESS TAB 0.25MG ................... 79
ZORTRESS TAB 0.5MG ..................... 79 ZORTRESS TAB 0.75MG ................... 79
ZOSTAVAX INJ ................................ 80
ZOSTRIX NAT CRE 0.033% .............. 100 ZUBSOLV SUB 0.7-0.18 .................... 57
ZUBSOLV SUB 1.4-0.36 .................... 57 ZUBSOLV SUB 11.4-2.9 .................... 57
ZUBSOLV SUB 2.9-0.71 .................... 57
ZUBSOLV SUB 5.7-1.4 ..................... 57
ZUBSOLV SUB 8.6-2.1 ..................... 57 ZYDELIG TAB 100MG ....................... 17
ZYDELIG TAB 150MG ....................... 17 ZYKADIA CAP 150MG ....................... 17
ZYKADIA TAB 150MG ....................... 17 ZYPREXA INJ 10MG .......................... 46
ZYPREXA RELP INJ 210MG ................ 46 ZYPREXA RELP INJ 300MG ................ 46 ZYPREXA RELP INJ 405MG ................ 46
ZYPREXA TAB 10MG ......................... 46 ZYPREXA TAB 15MG ......................... 46
ZYPREXA TAB 2.5MG ........................ 46
ZYPREXA TAB 20MG ......................... 46 ZYPREXA TAB 5MG .......................... 46
ZYPREXA TAB 7.5MG ........................ 46
ZYPREXA ZYDI TAB 10MG ................. 46
ZYPREXA ZYDI TAB 15MG ................. 46
ZYPREXA ZYDI TAB 20MG ................. 46
ZYPREXA ZYDI TAB 5MG ................... 46 ZYRTEC ALLGY TAB 10MG ................. 90
ZYRTEC CHILD TAB 10MG ................. 90
Top Related