January 1, 2017
Arkansas Blue Cross and Blue Shield Metallic Formulary 2017 List of Covered Drugs
PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.
Members must use network pharmacies to fill their prescription drugs. Your benefits, drug list, pharmacy network, premium and/or copayments/coinsurance may sometimes change.
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
1
January 1, 2017
What is the Arkansas Blue Cross and Blue Shield Metallic Plans Drug List? A drug list is a list of covered drugs. Arkansas Blue Cross and Blue Shield Metallic Plans works with a team of health care providers to choose drugs that provide quality treatment. Arkansas Blue Cross and Blue Shield Metallic Plans cover drugs on our drug list, as long as:
The drug is medically necessary The prescription is filled at a Arkansas Blue Cross and Blue Shield Metallic Plans network pharmacy Other plan rules are followed
For more information on how to fill your prescriptions, please review your plan document or other plan materials.
Can the Drug List change? The drug list may change from time to time as described in the plan document or other plan materials. The enclosed drug list is the most current drug list covered by Arkansas Blue Cross and Blue Shield Metallic Plans. To get updated information about the drugs covered by Arkansas Blue Cross and Blue Shield Metallic Plans, please www.arkansasbluecross.com, or call Member Services at 1-800-863-5561.
How do I use the Drug List? There are two ways to find your drug on the drug list: 1. Medical Condition The drug list starts on page 5. The drugs on this drug list are grouped by the type of medical conditions they are used to treat. For example, drugs used to treat a heart condition are listed under “anticoagulants.”
If you know what your drug is used for, look for the category name in the list that starts on the next page. Then look under the category name for your drug
2. Alphabetical Listing If you are not sure what category to look under, look for your drug in the Index that starts on page 60. The Index is an alphabetical list of all the drugs in this document. Both brand-name drugs and generic drugs are in the Index.
Look in the Index and find your drug Next to your drug, see the page number where you can find coverage information Turn to the page listed in the Index and find the name of your drug in the first column of the list
For more information about your Arkansas Blue Cross and Blue Shield Metallic Plans prescription drug coverage, please look at your plan document and other plan materials. If you have questions
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
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January 1, 2017 about Arkansas Blue Cross and Blue Shield Metallic Plans, or this drug list please call Member Services at 1-800-863-5561or visit www.arkansasbluecross.com.
Arkansas Blue Cross and Blue Shield Metallic Plans’ Drug List The drug list set forth below gives information about the drugs covered by Arkansas Blue Cross and Blue Shield Metallic Plans. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LIPITOR). Generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the Requirements/Limits column tells you if Arkansas Blue Cross and Blue Shield Metallic Plans have any special requirements for coverage of your drug. These requirements and limits may include:
Prior Authorization: Arkansas Blue Cross and Blue Shield needs you (or your doctor) to get prior approval or authorization for certain drugs. This means that you need to get approval from Arkansas Blue Cross and Blue Shield before you fill your prescriptions. If you don’t get approval, Arkansas Blue Cross and Blue Shield may not cover the drug
Quantity Limits: For certain drugs, Arkansas Blue Cross and Blue Shield limits the amount of the drug that it will cover. For example, Arkansas Blue Cross and Blue Shield provides 28 caplets per 90 day prescription for Tamiflu. This may be in addition to a standard one-month or three-month supply
Step Therapy: Arkansas Blue Cross and Blue Shield needs you to try certain drugs as the first step to treat your medical condition before covering another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Arkansas Blue Cross and Blue Shield may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Arkansas Blue Cross and Blue Shield will then cover Drug B
Specialty Medications: Arkansas Blue Cross and Blue Shield requires that specialty medications be filled at a network specialty pharmacy.
What if my drug is not on the Drug List? If your drug is not on this drug list, call Member Services and make sure that your drug is not covered. If you learn that Arkansas Blue Cross and Blue Shield does not cover your drug, you have two choices:
Ask Member Services for a list of similar drugs that are covered by Arkansas Blue Cross and Blue Shield Metallic Plans. When you get the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Arkansas Blue Cross and Blue Shield
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
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January 1, 2017 Metallic Plans. Similar drugs that are preferred and covered by your plan’s formulary may be easier to obtain and lower cost to you than non-preferred drugs.
Ask Arkansas Blue Cross and Blue Shield to make an exception and cover your drug. Exception requests may include: o You can ask us to cover your drug, even if it is not on our drug list. o You can ask us to remove coverage restrictions or limits on your drug. For example, for certain drugs, Arkansas Blue Cross and Blue Shield limits the amount of the drug that we will cover. If your drug has this quantity limit, you can ask us to remove the limit and cover more.
Generally, Arkansas Blue Cross and Blue Shield will only approve your request for an exception if the preferred drugs included on the plan’s drug list are not as effective in treating your condition or cause you to have adverse medical effects. The table below tells you the copayment or coinsurance amount (i.e., the share of the drug’s cost that you will pay) for drugs in each tier. Drug Tier column instructions: Plans that provide different levels of cost sharing for drugs depending on their tier must include a column indicating the drug’s tier placement. Plans may choose from several methods to indicate the tier placement, including tier numbers from your plan benefit package (e.g., 0/1/2/3), standard tier names from your plan benefit package (e.g., ACA preventive/generic/preferred brand/other brand), copayment amounts (e.g.,$0/$10/$20/$35), or coinsurance percentages (e.g., 0%/10%/25%). The latter two methods are preferred because they are generally easier for members to understand. If one of the two former methods is used, plans must provide an explanation before the table explaining the copayment amount or coinsurance percentage associated with each tier number or tier name. Plans that have different copayment amounts or coinsurance percentages for retail and mail-service prescriptions may include both retail and mail service amounts within the same column or include separate columns for retail and mail service prescriptions.
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
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January 1, 2017 Drug Tier Requirements/Limits
Drug Name
ANALGESICS COX-2 INHIBITORS§ celecoxib celecoxib celecoxib celecoxib
cap cap cap cap
50 mg 100 mg 200 mg 400 mg
2 2 2 2
GOUT allopurinol sodium for inj 500 mg allopurinol tab 100 mg allopurinol tab 300 mg colchicine tab 0.6 mg colchicine w/ probenecid tab 0.5-500 mg probenecid tab 500 mg ULORIC TAB 40MG ULORIC TAB 80MG
2 2 2 2 2 2 4 4
ST; PA** ST; PA**
2 2
QL (720 mL / 25 days) QL (48 caps / 25 days)
2
QL (48 caps / 25 days)
2
QL (48 tabs / 25 days)
2
QL (48 caps / 25 days)
2
QL (48 tabs / 25 days)
2
QL (48 tabs per 25 days)
NON-OPIOID ANALGESICS§ alagesic lq sol butalbital-acetaminophen-caffeine cap 50-300-40 mg butalbital-acetaminophen-caffeine cap 50-325-40 mg butalbital-acetaminophen-caffeine tab 50-325-40 mg butalbital-aspirin-caffeine cap 50-325-40 mg butalbital-aspirin-caffeine tab 50-325-40 mg tencon tab 50-325mg
NSAIDS, COMBINATIONS§ diclofenac w/ misoprostol tab delayed release 50-0.2 mg diclofenac w/ misoprostol tab delayed release 75-0.2 mg
2 2
NSAIDS§ diclofenac diclofenac mg diclofenac mg diclofenac mg
potassium tab 50 mg sodium tab delayed release 25
2 2
sodium tab delayed release 50
2
sodium tab delayed release 75
2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
5
January 1, 2017 Drug Tier Requirements/Limits
Drug Name diclofenac sodium tab sr 24hr 100 mg etodolac cap 200 mg etodolac cap 300 mg etodolac tab 400 mg etodolac tab 500 mg etodolac tab sr 24hr 400 mg etodolac tab sr 24hr 500 mg etodolac tab sr 24hr 600 mg fenoprofen calcium cap 400 mg fenoprofen calcium tab 600 mg flurbiprofen tab 50 mg flurbiprofen tab 100 mg ibuprofen susp 100 mg/5ml ibuprofen tab 400 mg ibuprofen tab 600 mg ibuprofen tab 800 mg indomethacin cap 25 mg indomethacin cap 50 mg ketoprofen cap 50 mg ketoprofen cap 75 mg ketoprofen cap sr 24hr 200 mg ketorolac tromethamine im inj 60 mg/2ml (30 mg/ml) ketorolac tromethamine inj 15 mg/ml ketorolac tromethamine inj 30 mg/ml ketorolac tromethamine inj 60 mg/2ml (30 mg/ml) ketorolac tromethamine inj 300 mg/10ml (30 mg/ml) ketorolac tromethamine tab 10 mg meclofenamate sodium cap 50 mg meclofenamate sodium cap 100 mg mefenamic acid cap 250 mg meloxicam susp 7.5 mg/5ml meloxicam tab 7.5 mg meloxicam tab 15 mg nabumetone tab 500 mg nabumetone tab 750 mg naproxen dr tab 375mg naproxen dr tab 500mg naproxen sodium tab 275 mg
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
QL - Quantity Limits
QL (20 tabs / 25 days)
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
6
January 1, 2017 Drug Tier Requirements/Limits
Drug Name naproxen sodium tab 550 mg naproxen susp 125 mg/5ml naproxen tab 250 mg naproxen tab 375 mg naproxen tab 500 mg oxaprozin tab 600 mg piroxicam cap 10 mg piroxicam cap 20 mg sulindac tab 150 mg sulindac tab 200 mg tolmetin sodium cap 400 mg tolmetin sodium tab 200 mg tolmetin sodium tab 600 mg
2 2 2 2 2 2 2 2 2 2 2 2 2
OPIOID AGONIST/ANTAGONIST§ buprenorphine hcl-naloxone hcl sl tab 2-0.52 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 2 mg (base equiv) SUBOXONE MIS 2-0.5MG 3 SUBOXONE MIS 4-1MG
3
SUBOXONE MIS 8-2MG
3
SUBOXONE MIS 12-3MG
3
QL (90 tabs / 25 days), PA QL (90 tabs / 25 days), PA QL (90 units / 25 days), PA QL (90 units / 25 days), PA QL (90 units / 25 days), PA QL (60 films per 25 days), PA
OPIOID ANALGESICS§ acetaminophen w/ codeine soln 120-12 mg/5ml acetaminophen w/ codeine tab 300-15 mg acetaminophen w/ codeine tab 300-30 mg acetaminophen w/ codeine tab 300-60 mg astramorph inj 1mg/2ml astramorph inj 2mg/2ml butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg butorphanol tartrate inj 1 mg/ml butorphanol tartrate inj 2 mg/ml butorphanol tartrate nasal soln 10 mg/ml CAPITAL/COD SUS 120-12/5 CODEINE SULF SOL 30MG/5ML codeine sulfate tab 15 mg
PA - Prior Authorization (applies to pharmacy benefit only)
2
QL (2700 mL / 25 days)
2 2 2 2 2 2
QL (400 tabs / 25 days) QL (360 tabs / 25 days) QL (180 tabs / 25 days)
2 2 2 4 3 2
QL - Quantity Limits
QL (48 caps per 25 days)
QL QL QL QL
(2 bottles / 25 days) (2700 mL / 25 days) (210 mL / 25 days) (42 tabs / 25 days)
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
7
January 1, 2017 Drug Tier Requirements/Limits
Drug Name codeine sulfate tab 30 mg codeine sulfate tab 60 mg EMBEDA CAP 20-0.8MG EMBEDA CAP 30-1.2MG EMBEDA CAP 50-2MG EMBEDA CAP 60-2.4MG EMBEDA CAP 80-3.2MG EMBEDA CAP 100-4MG endocet tab 2.5-325 endocet tab 5-325mg endocet tab 7.5-325 endocet tab 10-325mg fentanyl citrate lozenge on a handle mcg fentanyl citrate lozenge on a handle mcg fentanyl citrate lozenge on a handle mcg fentanyl citrate lozenge on a handle mcg fentanyl citrate lozenge on a handle mcg fentanyl citrate lozenge on a handle mcg fentanyl td patch 72hr 12 mcg/hr
200
2 2 4 4 4 4 4 4 2 2 2 2 2
soln 7.5-325 2
QL (42 tabs / 25 days) QL (42 tabs / 25 days) QL (60 caps / 25 days) QL (60 caps / 25 days) QL (60 caps / 25 days) QL (30 caps / 25 days) QL (30 caps / 25 days) QL (30 caps / 25 days) QL (360 tabs / 25 days) QL (360 tabs / 25 days) QL (240 tabs / 25 days) QL (180 tabs / 25 days) QL (120 lozenges / 25 days), PA QL (120 lozenges / 25 days), PA QL (120 lozenges / 25 days), PA QL (120 lozenges / 25 days), PA QL (120 lozenges / 25 days), PA QL (120 lozenges / 25 days), PA QL (10 patches / 25 days) QL (10 patches / 25 days) QL (10 patches / 25 days) QL (10 patches / 25 days) QL (10 patches / 25 days) QL (2700 mL / 25 days)
400
2
600
2
800
2
1200
2
1600
2
soln 10-325
2
QL (2700 mL / 25 days)
tab 2.5-325
2
QL (360 tabs / 25 days)
tab 5-300 mg 2 tab 5-325 mg 2
QL (240 tabs / 25 days) QL (240 tabs / 25 days)
2
fentanyl td patch 72hr 25 mcg/hr
2
fentanyl td patch 72hr 50 mcg/hr
2
fentanyl td patch 72hr 75 mcg/hr
2
fentanyl td patch 72hr 100 mcg/hr
2
hydrocodone-acetaminophen mg/15ml hydrocodone-acetaminophen mg/15ml hydrocodone-acetaminophen mg hydrocodone-acetaminophen hydrocodone-acetaminophen
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
8
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
hydrocodone-acetaminophen tab 7.5-300 2 mg hydrocodone-acetaminophen tab 7.5-325 2 mg hydrocodone-acetaminophen tab 10-300 2 mg hydrocodone-acetaminophen tab 10-325 2 mg HYDROMORPHON SUP 3MG 4 hydromorphone hcl inj 1 mg/ml 2 hydromorphone hcl inj 2 mg/ml 2 hydromorphone hcl inj 4 mg/ml 2 hydromorphone hcl liqd 1 mg/ml 2 hydromorphone hcl preservative free (pf) 2 inj 10 mg/ml hydromorphone hcl tab 2 mg 2 hydromorphone hcl tab 4 mg 2 hydromorphone hcl tab 8 mg 2 hydromorphone hcl tab er 24hr deter 8 mg 2 hydromorphone hcl tab er 24hr deter 12 mg2 hydromorphone hcl tab er 24hr deter 16 mg2 hydromorphone hcl tab er 24hr deter 32 mg2 HYSINGLA ER TAB 20 MG HYSINGLA ER TAB 30 MG HYSINGLA ER TAB 40 MG HYSINGLA ER TAB 60 MG HYSINGLA ER TAB 80 MG HYSINGLA ER TAB 100 MG HYSINGLA ER TAB 120 MG levorphanol tartrate tab 2 mg lortab tab 10-325mg meperidine hcl inj 10 mg/ml meperidine hcl inj 25 mg/ml meperidine hcl inj 50 mg/ml meperidine hcl inj 100 mg/ml meperidine hcl oral soln 50 mg/5ml meperidine hcl tab 50 mg meperidine hcl tab 100 mg
PA - Prior Authorization (applies to pharmacy benefit only)
3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2
QL - Quantity Limits
QL (180 tabs / 25 days) QL (180 tabs / 25 days) QL (180 tabs / 25 days) QL (180 tabs / 25 days) QL (120 units / 25 days)
QL (600 mL / 25 days)
QL (180 tabs / 25 days) QL (150 tabs / 25 days) QL (60 tabs / 25 days) QL (30 tablets per 25 days) QL (30 tablets per 25 days) QL (30 tablets per 25 days) QL (30 tablets per 25 days) QL (60 tabs / 25 days) QL (60 tabs / 25 days) QL (60 tabs / 25 days) QL (60 tabs / 25 days) QL (30 tabs / 25 days) QL (30 tabs / 25 days) QL (30 tabs / 25 days) QL (120 tabs / 25 days) QL (180 tabs / 25 days)
QL (90 mL / 25 days) QL (18 tabs / 25 days) QL (18 tabs / 25 days)
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
9
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
methadone hcl conc 10 mg/ml 2 methadone hcl soln 5 mg/5ml 2 methadone hcl soln 10 mg/5ml 2 methadone hcl tab 5 mg 2 methadone hcl tab 10 mg 2 methadone hcl tab for oral susp 40 mg 2 METHADONE INJ 10MG/ML 4 methadose tab 40mg 2 MORPHINE SUL INJ 2MG/ML 4 MORPHINE SUL INJ 4MG/ML 4 MORPHINE SUL INJ 5MG/ML 4 MORPHINE SUL INJ 150/30ML 4 MORPHINE SUL SUP 30MG 3 morphine sulfate beads cap sr 24hr 30 mg 2 morphine sulfate beads cap sr 24hr 45 mg 2 morphine sulfate beads cap sr 24hr 60 mg 2 morphine sulfate beads cap sr 24hr 75 mg 2 morphine sulfate beads cap sr 24hr 90 mg 2 morphine sulfate beads cap sr 24hr 120 mg2 morphine sulfate cap sr 24hr 10 mg 2 morphine sulfate cap sr 24hr 20 mg 2 morphine sulfate cap sr 24hr 30 mg 2 morphine sulfate cap sr 24hr 50 mg 2 morphine sulfate cap sr 24hr 60 mg 2 morphine sulfate cap sr 24hr 80 mg 2 morphine sulfate cap sr 24hr 100 mg 2 morphine sulfate inj 8 mg/ml 2 morphine sulfate inj 10 mg/ml 2 morphine sulfate inj pf 1 mg/ml 2 morphine sulfate iv soln 1 mg/ml 2 morphine sulfate iv soln 25 mg/ml 2 morphine sulfate iv soln pf 4 mg/ml 2 morphine sulfate iv soln pf 8 mg/ml 2 morphine sulfate iv soln pf 10 mg/ml 2 morphine sulfate iv soln pf 15 mg/ml 2 morphine sulfate oral soln 10 mg/5ml 2 morphine sulfate oral soln 20 mg/5ml 2 morphine sulfate oral soln 100 mg/5ml (20 2 mg/ml) morphine sulfate suppos 5 mg 2 morphine sulfate suppos 10 mg 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
QL QL QL QL QL QL QL QL
(30mL / 25 days) (600 mL / 25 days) (300 mL / 25 days) (120 tabs / 25 days) (60 tabs / 25 days) (9 tabs / 25 days) (1 vial / 25 days) (9 tabs / 25 days)
QL QL QL QL QL QL QL QL QL QL QL QL QL QL
(90 (60 (60 (60 (30 (30 (30 (60 (60 (60 (60 (60 (60 (30
supp / 25 days) caps / 25 days) caps / 25 days) caps / 25 days) caps / 25 days) caps / 25 days) caps / 25 days) caps / 25 days) caps / 25 days) caps / 25 days) caps / 25 days) caps / 25 days) caps / 25 days) caps / 25 days)
QL (900 mL / 25 days) QL (675 mL / 25 days) QL (135 mL / 25 days) QL (180 supp / 25 days) QL (180 supp / 25 days)
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
10
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
morphine sulfate suppos 20 mg 2 morphine sulfate tab 15 mg 2 morphine sulfate tab 30 mg 2 morphine sulfate tab cr 15 mg 2 morphine sulfate tab cr 30 mg 2 morphine sulfate tab cr 60 mg 2 morphine sulfate tab cr 100 mg 2 morphine sulfate tab cr 200 mg 2 nalbuphine hcl inj 10 mg/ml 2 nalbuphine hcl inj 20 mg/ml 2 NUCYNTA ER TAB 50MG 3 NUCYNTA ER TAB 100MG 3 NUCYNTA ER TAB 150MG 3 NUCYNTA ER TAB 200MG 3 NUCYNTA ER TAB 250MG 3 NUCYNTA TAB 50MG 3 NUCYNTA TAB 75MG 3 NUCYNTA TAB 100MG 3 oxycodone hcl cap 5 mg 2 oxycodone hcl conc 100 mg/5ml (20 mg/ml)2 oxycodone hcl soln 5 mg/5ml 2 oxycodone hcl tab 5 mg 2 oxycodone hcl tab 10 mg 2 oxycodone hcl tab 15 mg 2 oxycodone hcl tab 20 mg 2 oxycodone hcl tab 30 mg 2 oxycodone hcl tab er 12hr deter 10 mg 2 oxycodone hcl tab er 12hr deter 15 mg 2 oxycodone hcl tab er 12hr deter 20 mg 2 oxycodone hcl tab er 12hr deter 30 mg 2 oxycodone hcl tab er 12hr deter 40 mg 2 oxycodone hcl tab er 12hr deter 60 mg 2 oxycodone hcl tab er 12hr deter 80 mg 2 oxycodone w/ acetaminophen soln 5-325 2 mg/5ml oxycodone w/ acetaminophen tab 2.5-325 2 mg oxycodone w/ acetaminophen tab 5-325 mg2 oxycodone w/ acetaminophen tab 7.5-325 2 mg oxycodone w/ acetaminophen tab 10-325 2 mg
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
QL QL QL QL QL QL QL QL
(120 supp / 25 days) (180 tabs / 25 days) (90 tabs / 25 days) (120 tabs / 25 days) (120 tabs / 25 days) (120 tabs / 25 days) (60 tabs / 25 days) (60 tabs / 25 days)
QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL
(120 tabs / 25 days) (120 tabs / 25 days) (60 tabs / 25 days) (60 tabs / 25 days) (60 tabs / 25 days) (120 tabs / 25 days) (90 tabs / 25 days) (60 tabs / 25 days) (180 caps / 25 days) (90 mL / 25 days) (900 mL / 25 days) (180 tabs / 25 days) (180 tabs / 25 days) (120 tabs / 25 days) (90 tabs / 25 days) (60 tabs / 25 days) (120 tabs / 25 days) (120 tabs / 25 days) (120 tabs / 25 days) (120 tabs / 25 days) (120 tabs / 25 days) (60 tabs / 25 days) (60 tabs / 25 days) (1800 mL / 25 days)
QL (360 tabs / 25 days) QL (360 tabs / 25 days) QL (240 tabs / 25 days) QL (180 tabs / 25 days)
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
11
January 1, 2017 Drug Tier Requirements/Limits
Drug Name oxycodone-aspirin tab 4.8355-325 mg oxycodone-ibuprofen tab 5-400 mg OXYCONTIN TAB 10MG CR OXYCONTIN TAB 15MG CR OXYCONTIN TAB 20MG CR OXYCONTIN TAB 30MG CR OXYCONTIN TAB 40MG CR OXYCONTIN TAB 60MG CR OXYCONTIN TAB 80MG CR oxymorphone hcl tab 5 mg oxymorphone hcl tab 10 mg oxymorphone hcl tab sr 12hr 5 mg oxymorphone hcl tab sr 12hr 7.5 mg oxymorphone hcl tab sr 12hr 10 mg oxymorphone hcl tab sr 12hr 15 mg oxymorphone hcl tab sr 12hr 20 mg oxymorphone hcl tab sr 12hr 30 mg oxymorphone hcl tab sr 12hr 40 mg PRIMLEV TAB 5-300MG PRIMLEV TAB 7.5-300 PRIMLEV TAB 10-300MG roxicet tab 5-325mg tramadol hcl tab 50 mg tramadol hcl tab sr 24hr 100 mg tramadol hcl tab sr 24hr 200 mg tramadol hcl tab sr 24hr 300 mg vicodin es tab 7.5-300 vicodin hp tab 10-300mg vicodin tab 5-300mg XARTEMIS XR TAB 7.5-325
2 2 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 4 4 4 2 2 2 2 2 2 2 2 4
xylon tab 10-200mg
2
QL (360 tabs / 25 days) QL (28 tabs / 25 days) QL (120 tabs / 25 days) QL (120 tabs / 25 days) QL (120 tabs / 25 days) QL (120 tabs / 25 days) QL (120 tabs / 25 days) QL (60 tabs / 25 days) QL (60 tabs / 25 days) QL (180 tabs / 25 days) QL (90 tabs / 25 days) QL (120 tabs / 25 days) QL (120 tabs / 25 days) QL (120 tabs / 25 days) QL (120 tabs / 25 days) QL (120 tabs / 25 days) QL (60 tabs / 25 days) QL (60 tabs / 25 days) QL (360 tabs / 25 days) QL (240 tabs / 25 days) QL (180 tabs / 25 days) QL (360 tabs / 25 days) QL (160 tabs / 25 days) QL (90 tabs / 25 days) QL (30 tabs / 25 days) QL (30 tabs / 25 days) QL (180 tabs / 25 days) QL (180 tabs / 25 days) QL (240 tabs / 25 days) QL (120 tabs per 25 days) QL (50 tabs / 25 days)
OPIOID PARTIAL AGONISTS§ buprenorphine hcl inj 0.3 mg/ml (base 2 equiv) buprenorphine hcl sl tab 2 mg (base equiv) 2 buprenorphine hcl sl tab 8 mg (base equiv) 2 BUTRANS DIS 5MCG/HR
PA - Prior Authorization (applies to pharmacy benefit only)
4
QL - Quantity Limits
QL (90 tablets per 25 days), PA QL (90 tablets per 25 days), PA QL (8 patches/25 days), PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
12
January 1, 2017 Drug Tier Requirements/Limits
Drug Name BUTRANS DIS 7.5/HR
4
BUTRANS DIS 10MCG/HR
4
BUTRANS DIS 15MCG/HR
4
BUTRANS DIS 20MCG/HR
4
QL PA QL PA QL PA QL PA
(8 patches/25 days), (8 patches/25 days), (4 patches/25 days), (4 patches/25 days),
SALICYLATES aspirin chew tab 81 mg
1
aspirin low tab 81mg ec
1
aspirin tab 81 mg
1
aspirin tab 325 mg
1
aspirin tab delayed release 325 mg
1
diflunisal tab 500 mg
2
QL (100 tabs / 30 days); OTC; $0 copay-age and gender restrictions apply QL (100 tabs / 30 days); OTC; $0 copay-age and gender restrictions apply QL (100 tabs / 30 days); OTC; $0 copay-age and gender restrictions apply QL (100 tabs / 30 days); OTC; $0 copay-age and gender restrictions apply QL (100 tabs / 30 days); OTC; $0 copay-age and gender restrictions apply
ANESTHETICS LOCAL ANESTHETICS LIDO/DEXTROS INJ 5-7.5% lidocaine hcl local inj 0.5% lidocaine hcl local inj 1% lidocaine hcl local inj 1.5% lidocaine hcl local inj 2% lidocaine hcl local preservative 0.5% lidocaine hcl local preservative 1% lidocaine hcl local preservative 2% lidocaine hcl local preservative 4%
4 2 2 2 2 free (pf) inj 2 free (pf) inj 2 free (pf) inj 2 free (pf) inj 2
ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
13
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
amikacin sulfate inj 1 gm/4ml (250 mg/ml) 2 amikacin sulfate inj 500 mg/2ml (250 2 mg/ml) chloramphenicol sodium succinate for iv inj 2 1 gm e.s.p. sus 200-600 2 GENTAM/NACL INJ 0.9MG/ML 4 GENTAM/NACL INJ 1.4MG/ML 4 gentamicin in saline inj 0.8 mg/ml 2 gentamicin in saline inj 1 mg/ml 2 gentamicin in saline inj 1.2 mg/ml 2 gentamicin in saline inj 1.6 mg/ml 2 gentamicin in saline inj 2 mg/ml 2 gentamicin sulfate inj 10 mg/ml 2 gentamicin sulfate inj 40 mg/ml 2 gentamicin sulfate iv soln 10 mg/ml 2 kanamycin sulfate inj 333 mg/ml 2 KETEK TAB 300MG 4 KETEK TAB 400MG 4 MONUROL PAK GRANULES 4 NEO-FRADIN SOL 125/5ML 4 neomycin sulfate tab 500 mg 2 paromomycin sulfate cap 250 mg 2 streptomycin sulfate for inj 1 gm 2 SULFADIAZINE TAB 500MG 4 tinidazole tab 250 mg 2 tinidazole tab 500 mg 2 TOBRA/NACL INJ 80/0.9 4 tobramycin nebu soln 300 mg/5ml 2 tobramycin sulfate for inj 1.2 gm 2 tobramycin sulfate inj 1.2 gm/30ml (40 2 mg/ml) (base equiv) tobramycin sulfate inj 2 gm/50ml (40 2 mg/ml) (base equiv) tobramycin sulfate inj 10 mg/ml (base 2 equivalent) tobramycin sulfate inj 80 mg/2ml (40 2 mg/ml) (base equiv) VIBATIV INJ 250MG 4 VIBATIV INJ 750MG 4
PA
ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 200MG
PA - Prior Authorization (applies to pharmacy benefit only)
3
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
14
January 1, 2017 Drug Tier Requirements/Limits
Drug Name ALINIA SUS 100/5ML ALINIA TAB 500MG atovaquone susp 750 mg/5ml AZACTAM/DEX INJ 1GM AZACTAM/DEX INJ 2GM aztreonam for inj 1 gm aztreonam for inj 2 gm BILTRICIDE TAB 600MG CAYSTON INH 75MG clindamycin hcl cap 75 mg clindamycin hcl cap 150 mg clindamycin hcl cap 300 mg clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) clindamycin phosphate inj 9 gm/60ml clindamycin phosphate inj 300 mg/2ml clindamycin phosphate inj 600 mg/4ml clindamycin phosphate inj 900 mg/6ml clindamycin phosphate iv soln 300 mg/2ml clindamycin phosphate iv soln 600 mg/4ml clindamycin phosphate iv soln 900 mg/6ml CUBICIN SOL 500MG dapsone tab 25 mg dapsone tab 100 mg DARAPRIM TAB 25MG DORIBAX INJ 250MG DORIBAX INJ 500MG EMVERM CHW 100MG FLAGYL ER TAB 750MG imipenem-cilastatin intravenous for soln 250 mg imipenem-cilastatin intravenous for soln 500 mg INVANZ INJ 1GM ivermectin tab 3 mg linezolid for susp 100 mg/5ml linezolid in sodium chloride iv soln 600 mg/300ml-0.9% linezolid iv soln 600 mg/300ml (2 mg/ml) linezolid tab 600 mg meropenem iv for soln 1 gm meropenem iv for soln 500 mg
PA - Prior Authorization (applies to pharmacy benefit only)
3 3 2 4 4 2 2 4 5 2 2 2 2
PA
2 2 2 2 2 2 2 4 2 2 4 4 4 4 4 2 2 4 2 2 2 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
15
January 1, 2017 Drug Tier Requirements/Limits
Drug Name methenamine hippurate tab 1 gm metronidazole cap 375 mg metronidazole in nacl 0.79% iv soln 500 mg/100ml metronidazole tab 250 mg metronidazole tab 500 mg NEBUPENT INH 300MG nitrofurantoin macrocrystalline cap 25 mg
2 2 2 2 2 4 2
nitrofurantoin macrocrystalline cap 50 mg 2
nitrofurantoin macrocrystalline cap 100 mg 2
nitrofurantoin monohydrate macrocrystalline cap 100 mg
2
nitrofurantoin susp 25 mg/5ml
2
PENTAM 300 INJ 300MG polymyxin b sulfate for inj 500000 unit
4 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
PA; High Risk Medications require PA for members age 65 and older; PA applies to greater than cumulative 90 days of therapy per year PA; High Risk Medications require PA for members age 65 and older; PA applies to greater than cumulative 90 days of therapy per year PA; High Risk Medications require PA for members age 65 and older; PA applies to greater than cumulative 90 days of therapy per year PA; High Risk Medications require PA for members age 65 and older; PA applies to greater than cumulative 90 days of therapy per year PA; High Risk Medications require PA for members age 65 and older; PA applies to greater than cumulative 90 days of therapy per year
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
16
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
PRIMSOL SOL 50MG/5ML 3 SIVEXTRO INJ 200MG 4 SIVEXTRO TAB 200MG 4 sulfamethoxazole-trimethoprim iv soln 2 400-80 mg/5ml sulfamethoxazole-trimethoprim susp 2 200-40 mg/5ml sulfamethoxazole-trimethoprim tab 400-80 2 mg sulfamethoxazole-trimethoprim tab 2 800-160 mg trimethoprim tab 100 mg 2 TYGACIL INJ 50MG 4 vancomycin hcl cap 125 mg 2 vancomycin hcl cap 250 mg 2 vancomycin hcl for inj 10 gm 2 vancomycin hcl for inj 500 mg 2 vancomycin hcl for inj 1000 mg 2 vancomycin hcl for inj 5000 mg 2 XIFAXAN TAB 200MG 3 XIFAXAN TAB 550MG 3
ST; PA** ST; PA**
PA
ANTIFUNGALS ABELCET INJ 5MG/ML 4 AMBISOME INJ 50MG 4 AMPHOTEC INJ 50MG 4 AMPHOTEC INJ 100MG 4 amphotericin b for inj 50 mg 2 BIO-STATIN CAP 500000 3 BIO-STATIN CAP 1000000 3 CANCIDAS INJ 50MG 4 CANCIDAS INJ 70MG 4 CRESEMBA CAP 186 MG 4 ERAXIS INJ 50MG 4 ERAXIS INJ 100MG 4 fluconazole for susp 10 mg/ml 2 fluconazole for susp 40 mg/ml 2 fluconazole in dextrose inj 200 mg/100ml 2 fluconazole in dextrose inj 400 mg/200ml 2 fluconazole in nacl 0.9% inj 200 mg/100ml 2 fluconazole in nacl 0.9% inj 400 mg/200ml 2 fluconazole tab 50 mg 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
17
January 1, 2017 Drug Tier Requirements/Limits
Drug Name fluconazole tab 100 mg fluconazole tab 150 mg fluconazole tab 200 mg FLUCONAZOLE/ INJ NACL 100 griseofulvin microsize susp 125 mg/5ml griseofulvin microsize tab 500 mg griseofulvin ultramicrosize tab 125 mg griseofulvin ultramicrosize tab 250 mg itraconazole cap 100 mg LAMISIL GRA 125MG LAMISIL GRA 187.5MG MYCAMINE INJ 50MG MYCAMINE INJ 100MG NOXAFIL SUS 40MG/ML NOXAFIL TAB 100MG nystatin oral powder nystatin tab 500000 unit SPORANOX SOL 10MG/ML terbinafine hcl tab 250 mg voriconazole for susp 40 mg/ml voriconazole tab 50 mg voriconazole tab 200 mg
2 2 2 4 2 2 2 2 2 4 4 4 4 3 3 2 2 3 2 2 2 2
PA PA PA
PA PA PA PA PA
ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg atovaquone-proguanil hcl tab 250-100 mg chloroquine phosphate tab 250 mg chloroquine phosphate tab 500 mg COARTEM TAB 20-120MG mefloquine hcl tab 250 mg PRIMAQUINE TAB 26.3MG quinine sulfate cap 324 mg quinine sulfate tab 260 mg
2 2 2 2 4 2 4 2 2
ANTIRETROVIRAL AGENTS abacavir sulfate tab 300 mg (base equiv) 2 APTIVUS CAP 250MG 3 APTIVUS SOL 3 CRIXIVAN CAP 200MG 3 CRIXIVAN CAP 400MG 3 didanosine delayed release capsule 125 mg 2 didanosine delayed release capsule 200 mg 2 didanosine delayed release capsule 250 mg 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
18
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
didanosine delayed release capsule 400 mg 2 EDURANT TAB 25MG 3 EMTRIVA CAP 200MG 3 EMTRIVA SOL 10MG/ML 3 FUZEON INJ 90MG 5 INTELENCE TAB 25MG 3 INTELENCE TAB 100MG 3 INTELENCE TAB 200MG 3 INVIRASE CAP 200MG 3 INVIRASE TAB 500MG 3 ISENTRESS CHW 25MG 3 ISENTRESS CHW 100MG 3 ISENTRESS POW 100MG 3 ISENTRESS TAB 400MG 3 lamivudine oral soln 10 mg/ml 2 lamivudine tab 150 mg 2 lamivudine tab 300 mg 2 LEXIVA SUS 50MG/ML 3 LEXIVA TAB 700MG 3 nevirapine susp 50 mg/5ml 2 nevirapine tab 200 mg 2 nevirapine tab sr 24hr 100 mg 2 nevirapine tab sr 24hr 400 mg 2 NORVIR CAP 100MG 3 NORVIR SOL 80MG/ML 3 NORVIR TAB 100MG 3 PREZISTA SUS 100MG/ML 3 PREZISTA TAB 75MG 3 PREZISTA TAB 150MG 3 PREZISTA TAB 400MG 3 PREZISTA TAB 600MG 3 PREZISTA TAB 800MG 3 RESCRIPTOR TAB 100 MG 4 RESCRIPTOR TAB 200MG 4 RETROVIR INJ 10MG/ML 3 REYATAZ CAP 100MG 3 REYATAZ CAP 150MG 3 REYATAZ CAP 200MG 3 REYATAZ CAP 300MG 3 REYATAZ POW 50MG 3 SELZENTRY TAB 150MG 3
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
19
January 1, 2017 Drug Tier Requirements/Limits
Drug Name SELZENTRY TAB 300MG stavudine cap 15 mg stavudine cap 20 mg stavudine cap 30 mg stavudine cap 40 mg stavudine for oral soln 1 mg/ml SUSTIVA CAP 50MG SUSTIVA CAP 200MG SUSTIVA TAB 600MG TIVICAY TAB 10MG TIVICAY TAB 25MG TIVICAY TAB 50MG TYBOST TAB 150MG VIDEX SOL 2GM VIDEX SOL 4GM VIRACEPT TAB 250MG VIRACEPT TAB 625MG VIREAD POW 40MG/GM VIREAD TAB 150MG VIREAD TAB 200MG VIREAD TAB 250MG VIREAD TAB 300MG VITEKTA TAB 85MG VITEKTA TAB 150MG ZIAGEN SOL 20MG/ML zidovudine cap 100 mg zidovudine syrup 10 mg/ml zidovudine tab 300 mg
3 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 2 2
ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine tab 2 300-150-300 mg ATRIPLA TAB 3 COMPLERA TAB 3 EPZICOM TAB 600-300 3 EVOTAZ TAB 300-150 3 GENVOYA TAB 3 KALETRA SOL 3 KALETRA TAB 100-25MG 3 KALETRA TAB 200-50MG 3 lamivudine-zidovudine tab 150-300 mg 2 PREZCOBIX TAB 800-150 3
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
20
January 1, 2017 Drug Tier Requirements/Limits
Drug Name STRIBILD TAB TRIUMEQ TAB TRUVADA TAB TRUVADA TAB TRUVADA TAB TRUVADA TAB
100-150 133-200 167-250 200-300
3 3 3 3 3 3
ANTITUBERCULAR AGENTS CAPASTAT SUL INJ 1GM cycloserine cap 250 mg ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg isoniazid inj 100 mg/ml isoniazid syrup 50 mg/5ml isoniazid tab 100 mg isoniazid tab 300 mg PASER GRA 4GM PRIFTIN TAB 150MG pyrazinamide tab 500 mg rifabutin cap 150 mg RIFAMATE CAP rifampin cap 150 mg rifampin cap 300 mg rifampin for inj 600 mg RIFATER TAB SIRTURO TAB 100MG TRECATOR TAB 250MG
3 2 2 2 2 2 2 2 4 3 2 2 3 2 2 2 3 4 3
ANTIVIRALS§ acyclovir cap 200 mg acyclovir sodium for inj 500 mg acyclovir sodium for inj 1000 mg acyclovir sodium iv soln 50 mg/ml acyclovir susp 200 mg/5ml acyclovir tab 400 mg acyclovir tab 800 mg adefovir dipivoxil tab 10 mg BARACLUDE SOL .05MG/ML cidofovir iv inj 75 mg/ml entecavir tab 0.5 mg entecavir tab 1 mg EPCLUSA TAB 400-100 EPIVIR HBV SOL 5MG/ML
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 2 2 2 3 2 2 2 5 3
QL - Quantity Limits
PA
PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
21
January 1, 2017 Drug Tier Requirements/Limits
Drug Name famciclovir tab 125 mg famciclovir tab 250 mg famciclovir tab 500 mg foscarnet sodium inj 24 mg/ml HARVONI TAB 90-400MG lamivudine tab 100 mg (hbv) OLYSIO CAP 150MG PEGASYS INJ PEGASYS INJ 180MCG/M PEGASYS INJ PROCLICK PEGASYS KIT REBETOL SOL 40MG/ML RELENZA MIS DISKHALE ribasphere cap 200mg ribasphere tab 200mg ribasphere tab 400mg ribasphere tab 600mg ribavirin cap 200 mg ribavirin tab 200 mg rimantadine hydrochloride tab 100 mg SOVALDI TAB 400MG TAMIFLU CAP 30MG TAMIFLU CAP 45MG TAMIFLU CAP 75MG TAMIFLU SUS 6MG/ML TECHNIVIE TAB TYZEKA TAB 600MG valacyclovir hcl tab 1 gm valacyclovir hcl tab 500 mg VALCYTE SOL 50MG/ML valganciclovir hcl tab 450 mg (base equivalent) VIRAZOLE INH 6GM
2 2 2 2 5 2 6 5 5 5 5 5 3 2 2 2 2 2 2 2 5 3 3 3 3 6 5 2 2 4 2
PA PA, ST PA PA PA PA PA QL (2 inhalers / 90 days) PA PA PA PA PA PA PA QL (28 caps / 90 days) QL (14 caps / 90 days) QL (14 caps / 90 days) QL (180 mL / 90 days) PA, ST PA
4
CEPHALOSPORINS CEDAX SUS 90MG/5ML cefaclor cap 250 mg cefaclor cap 500 mg CEFACLOR ER TAB 500MG cefaclor for susp 125 mg/5ml cefaclor for susp 250 mg/5ml cefaclor for susp 375 mg/5ml
PA - Prior Authorization (applies to pharmacy benefit only)
4 2 2 3 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
22
January 1, 2017 Drug Tier Requirements/Limits
Drug Name cefadroxil cap 500 mg cefadroxil for susp 250 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm CEFAZOL/DEX SOL 1GM CEFAZOL/DEX SOL 2GM CEFAZOLIN INJ 1GM/50ML cefazolin sodium for inj 1 gm cefazolin sodium for inj 10 gm cefazolin sodium for inj 20 gm cefazolin sodium for inj 500 mg cefazolin sodium for iv soln 1 gm CEFAZOLIN SOL cefdinir cap 300 mg cefdinir for susp 125 mg/5ml cefdinir for susp 250 mg/5ml cefditoren pivoxil tab 200 mg (base equivalent) cefditoren pivoxil tab 400 mg (base equivalent) cefepime hcl for inj 1 gm cefepime hcl for inj 2 gm CEFEPIME INJ 1GM CEFEPIME INJ 2GM CEFEPIME/DEX INJ 1GM cefixime for susp 100 mg/5ml cefixime for susp 200 mg/5ml cefotaxime sodium for inj 1 gm cefotaxime sodium for inj 2 gm cefotaxime sodium for inj 10 gm cefotaxime sodium for inj 500 mg CEFOTET/DEX INJ 1-3.58% CEFOTET/DEX INJ 2-2.08% cefotetan disodium for inj 1 gm cefotetan disodium for inj 2 gm cefotetan disodium for inj 10 gm CEFOXITIN INJ 1GM CEFOXITIN INJ 2GM cefoxitin sodium for inj 10 gm cefoxitin sodium for iv soln 1 gm cefoxitin sodium for iv soln 2 gm
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 4 4 4 2 2 2 2 2 4 2 2 2 2 2 2 2 4 4 4 2 2 2 2 2 2 4 4 2 2 2 4 4 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
23
January 1, 2017 Drug Tier Requirements/Limits
Drug Name cefpodoxime proxetil for susp 50 mg/5ml cefpodoxime proxetil for susp 100 mg/5ml cefpodoxime proxetil tab 100 mg cefpodoxime proxetil tab 200 mg cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml cefprozil tab 250 mg cefprozil tab 500 mg ceftazidime for inj 2 gm CEFTAZIDIME INJ 100GM CEFTAZIDIME/ SOL D5W 1GM CEFTAZIDIME/ SOL D5W 2GM ceftibuten cap 400 mg ceftibuten for susp 180 mg/5ml CEFTIN SUS 125/5ML CEFTIN SUS 250/5ML ceftriaxone sodium for inj 1 gm ceftriaxone sodium for inj 2 gm ceftriaxone sodium for inj 10 gm ceftriaxone sodium for inj 250 mg ceftriaxone sodium for inj 500 mg ceftriaxone sodium for iv soln 1 gm ceftriaxone sodium for iv soln 2 gm CEFUROX/DEXT INJ 1.5GM CEFUROX/DEXT INJ 750MG cefuroxime axetil tab 250 mg cefuroxime axetil tab 500 mg CEFUROXIME INJ 7.5GM CEFUROXIME INJ 75GM CEFUROXIME INJ 225GM cefuroxime sodium for inj 1.5 gm cefuroxime sodium for inj 7.5 gm cefuroxime sodium for inj 750 mg cefuroxime sodium for iv soln 1.5 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
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 2 2 2 2 4 4 4 2 2 3 3 2 2 2 2 2 2 2 4 4 2 2 4 4 4 2 2 2 2 2 2 2 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
24
January 1, 2017 Drug Tier Requirements/Limits
Drug Name CLAFORAN INJ 1GM CLAFORAN INJ 2GM FORTAZ INJ 1GM FORTAZ INJ 2GM FORTAZ INJ 500MG MAXIPIME INJ 1GM MAXIPIME INJ 2GM MEFOXIN INJ 1GM/50ML MEFOXIN INJ 2GM/50ML SUPRAX CAP 400MG SUPRAX CHW 100MG SUPRAX CHW 200MG SUPRAX SUS 500/5ML SUPRAX TAB 400MG tazicef inj 1gm tazicef inj 2gm tazicef inj 6gm TEFLARO INJ 400MG TEFLARO INJ 600MG ZINACEF INJ 750MG ZINACEF/H20 INJ 1.5GM PB
4 4 4 4 4 4 4 4 4 3 3 3 3 3 2 2 2 4 4 4 4
ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml azithromycin for susp 200 mg/5ml azithromycin iv for soln 500 mg 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 clarithromycin tab 250 mg clarithromycin tab 500 mg clarithromycin tab sr 24hr 500 mg DIFICID TAB 200MG e.e.s. 400 tab 400mg E.E.S. GRAN SUS 200/5ML ery-tab tab 250mg ec ery-tab tab 333mg ec ery-tab tab 500mg ec ERYPED SUS 200/5ML
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 2 2 2 2 2 2 2 3 2 3 2 2 2 3
QL - Quantity Limits
PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
25
January 1, 2017 Drug Tier Requirements/Limits
Drug Name ERYPED SUS 400/5ML ERYTHROCIN INJ 500MG ERYTHROCIN INJ 1000MG erythrocin tab 250mg erythromycin ethylsuccinate tab 400 mg erythromycin tab 250 mg erythromycin tab 500 mg erythromycin w/ delayed release particles cap 250 mg PCE TAB 333MG EC PCE TAB 500MG EC ZMAX SUS 2GM
3 4 4 2 2 2 2 2 4 4 4
FLUOROQUINOLONES AVELOX INJ 4 ciprofloxacin 200 mg/100ml in d5w 2 ciprofloxacin 400 mg/200ml in d5w 2 ciprofloxacin for oral susp 250 mg/5ml (5%)2 (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml 2 (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 mg (base equiv) 2 ciprofloxacin hcl tab 250 mg (base equiv) 2 ciprofloxacin hcl tab 500 mg (base equiv) 2 ciprofloxacin hcl tab 750 mg (base equiv) 2 ciprofloxacin iv soln 200 mg/20ml (1%) 2 ciprofloxacin iv soln 400 mg/40ml (1%) 2 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 2 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 2 1000 mg(base eq) FACTIVE TAB 320MG 4 levofloxacin in d5w iv soln 250 mg/50ml 2 levofloxacin in d5w iv soln 500 mg/100ml 2 levofloxacin in d5w iv soln 750 mg/150ml 2 levofloxacin iv soln 25 mg/ml 2 levofloxacin oral soln 25 mg/ml 2 levofloxacin tab 250 mg 2 levofloxacin tab 500 mg 2 levofloxacin tab 750 mg 2 moxifloxacin hcl tab 400 mg (base equiv) 2 ofloxacin tab 200 mg 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
26
January 1, 2017 Drug Tier Requirements/Limits
Drug Name ofloxacin tab 300 mg ofloxacin tab 400 mg
2 2
PENICILLINS amoxicillin & k clavulanate chew tab 2 200-28.5 mg amoxicillin & k clavulanate chew tab 400-572 mg amoxicillin & k clavulanate for susp 2 200-28.5 mg/5ml amoxicillin & k clavulanate for susp 2 250-62.5 mg/5ml amoxicillin & k clavulanate for susp 400-57 2 mg/5ml amoxicillin & k clavulanate for susp 2 600-42.9 mg/5ml amoxicillin & k clavulanate tab 250-125 mg 2 amoxicillin & k clavulanate tab 500-125 mg 2 amoxicillin & k clavulanate tab 875-125 mg 2 amoxicillin & k clavulanate tab sr 12hr 2 1000-62.5 mg amoxicillin (trihydrate) cap 250 mg 2 amoxicillin (trihydrate) cap 500 mg 2 amoxicillin (trihydrate) chew tab 125 mg 2 amoxicillin (trihydrate) chew tab 250 mg 2 amoxicillin (trihydrate) for susp 125 mg/5ml2 amoxicillin (trihydrate) for susp 200 mg/5ml2 amoxicillin (trihydrate) for susp 250 mg/5ml2 amoxicillin (trihydrate) for susp 400 mg/5ml2 amoxicillin (trihydrate) tab 500 mg 2 amoxicillin (trihydrate) tab 875 mg 2 ampicillin & sulbactam sodium for inj 1-0.5 2 gm ampicillin & sulbactam sodium for inj 2-1 gm2 ampicillin & sulbactam sodium for inj 10-5 2 gm ampicillin & sulbactam sodium for iv soln 2 1-0.5 gm ampicillin & sulbactam sodium for iv soln 2 2-1 gm ampicillin & sulbactam sodium for iv soln 2 10-5 gm ampicillin cap 250 mg 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
27
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
ampicillin cap 500 mg 2 ampicillin for susp 125 mg/5ml 2 ampicillin for susp 250 mg/5ml 2 ampicillin sodium for inj 1 gm 2 ampicillin sodium for inj 2 gm 2 ampicillin sodium for inj 10 gm 2 ampicillin sodium for inj 125 mg 2 ampicillin sodium for inj 250 mg 2 ampicillin sodium for inj 500 mg 2 ampicillin sodium for iv soln 1 gm 2 ampicillin sodium for iv soln 2 gm 2 ampicillin sodium for iv soln 10 gm 2 AUGMENTIN SUS 125/5ML 3 BACTOCILL INJ DEX 1GM 4 BACTOCILL INJ DEX 2GM 4 BICILLIN C-R INJ 900/300 4 BICILLIN C-R INJ 1200000 4 BICILLIN L-A INJ 600000 4 BICILLIN L-A INJ 1200000 4 BICILLIN L-A INJ 2400000 4 dicloxacillin sodium cap 250 mg 2 dicloxacillin sodium cap 500 mg 2 NAFCILLIN INJ 1GM/50ML 4 NAFCILLIN INJ 2GM/100 4 nafcillin sodium for inj 1 gm 2 nafcillin sodium for inj 2 gm 2 nafcillin sodium for inj 10 gm 2 nafcillin sodium for iv soln 1 gm 2 nafcillin sodium for iv soln 2 gm 2 oxacillin sodium for inj 1 gm 2 oxacillin sodium for inj 2 gm 2 oxacillin sodium for inj 10 gm 2 PEN G PROC INJ 600000 4 PENICILL GK/ INJ DEX 1MU 4 PENICILL GK/ INJ DEX 2MU 4 PENICILL GK/ INJ DEX 3MU 4 penicillin g potassium for inj 5000000 unit 2 penicillin g potassium for inj 20000000 unit 2 penicillin g sodium for inj 5000000 unit 2 penicillin v potassium for soln 125 mg/5ml 2 penicillin v potassium for soln 250 mg/5ml 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
28
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
penicillin v potassium tab 250 mg 2 penicillin v potassium tab 500 mg 2 pfizerpen-g inj 20mu 2 piperacillin sod-tazobactam na for inj 3.3752 gm (3-0.375 gm) piperacillin sod-tazobactam sod for inj 2.25 2 gm (2-0.25 gm) piperacillin sod-tazobactam sod for inj 4.5 2 gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj 40.5 2 gm (36-4.5 gm) ZOSYN SOL 2-0.25GM 4 ZOSYN SOL 3-0.375G 4 ZOSYN SOL 4-0.50GM 4
TETRACYCLINES avidoxy tab 100mg 2 demeclocycline hcl tab 150 mg 2 demeclocycline hcl tab 300 mg 2 doxy 100 inj 100mg 2 doxycycline hyclate cap 50 mg 2 doxycycline hyclate cap 100 mg 2 doxycycline hyclate for inj 100 mg 2 doxycycline hyclate tab 20 mg 2 doxycycline hyclate tab 100 mg 2 doxycycline hyclate tab delayed release 75 2 mg doxycycline hyclate tab delayed release 1002 mg doxycycline hyclate tab delayed release 1502 mg doxycycline monohydrate cap 50 mg 2 doxycycline monohydrate cap 75 mg 2 doxycycline monohydrate cap 100 mg 2 doxycycline monohydrate cap 150 mg 2 doxycycline monohydrate for susp 25 2 mg/5ml doxycycline monohydrate tab 50 mg 2 doxycycline monohydrate tab 75 mg 2 doxycycline monohydrate tab 150 mg 2 minocycline hcl cap 50 mg 2 minocycline hcl cap 75 mg 2 minocycline hcl cap 100 mg 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
29
January 1, 2017 Drug Tier Requirements/Limits
Drug Name minocycline hcl tab 50 mg minocycline hcl tab 75 mg minocycline hcl tab 100 mg minocycline hcl tab sr 24hr 45 mg minocycline hcl tab sr 24hr 90 mg minocycline hcl tab sr 24hr 135 mg morgidox cap 1x100mg tetracycline hcl cap 250 mg tetracycline hcl cap 500 mg VIBRAMYCIN SYP 50MG/5ML
2 2 2 2 2 2 2 2 2 4
ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN TAB 2MG BICNU INJ 100MG BUSULFEX INJ 6MG/ML CYCLOPHOSPH CAP 25MG CYCLOPHOSPH CAP 50MG cyclophosphamide for inj 1 gm cyclophosphamide for inj 2 gm cyclophosphamide for inj 500 mg cyclophosphamide tab 25 mg cyclophosphamide tab 50 mg dacarbazine for inj 100 mg dacarbazine for inj 200 mg EMCYT CAP 140MG GLEOSTINE CAP 5MG GLEOSTINE CAP 10MG GLEOSTINE CAP 40MG GLEOSTINE CAP 100MG GLIADEL WAF 7.7MG HEXALEN CAP 50MG ifosfamide for inj 1 gm ifosfamide iv inj 1 gm/20ml (50 mg/ml) ifosfamide iv inj 3 gm/60ml (50 mg/ml) LEUKERAN TAB 2MG melphalan hcl for inj 50 mg (base equiv) MYLERAN TAB 2MG TEMODAR INJ 100MG temozolomide cap 5 mg temozolomide cap 20 mg temozolomide cap 100 mg
PA - Prior Authorization (applies to pharmacy benefit only)
3 3 3 3 3 2 2 2 2 2 2 2 3 3 3 3 3 3 3 2 2 2 3 2 3 5 5 5 5
QL - Quantity Limits
PA PA PA PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
30
January 1, 2017 Drug Tier Requirements/Limits
Drug Name temozolomide cap 140 mg temozolomide cap 180 mg temozolomide cap 250 mg ZANOSAR INJ 1GM
5 5 5 3
PA PA PA
ANTHRACYCLINES adriamycin inj 10mg 2 ADRIAMYCIN INJ 20MG 3 daunorubicin hcl for inj 20 mg 2 daunorubicin hcl inj 5 mg/ml (base equiv) 2 DAUNOXOME INJ 2MG/ML 3 doxorubicin hcl for inj 10 mg 2 doxorubicin hcl for inj 50 mg 2 doxorubicin hcl inj 2 mg/ml 2 doxorubicin hcl liposomal inj (for iv infusion)2 2 mg/ml epirubicin hcl iv soln 50 mg/25ml (2 mg/ml)2 epirubicin hcl iv soln 200 mg/100ml (2 2 mg/ml) EPIRUBICIN INJ 50MG 3 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 2 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 2 idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 2 lipodox inj 2mg/ml 2
ANTIBIOTICS bleomycin sulfate for inj 15 unit bleomycin sulfate for inj 30 unit dactinomycin for inj 0.5 mg mitomycin for iv soln 5 mg mitomycin for iv soln 20 mg mitomycin for iv soln 40 mg
2 2 2 2 2 2
ANTIMETABOLITES adrucil inj 500/10ml ALIMTA INJ 100MG ALIMTA INJ 500MG ARRANON INJ 5MG/ML azacitidine for inj 100 mg capecitabine tab 150 mg capecitabine tab 500 mg cladribine iv soln 10 mg/10ml (1 mg/ml) CLOLAR INJ 1MG/ML cytarabine for inj 1 gm
PA - Prior Authorization (applies to pharmacy benefit only)
2 3 3 3 5 5 5 2 3 2
QL - Quantity Limits
PA PA PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
31
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
cytarabine for inj 100 mg 2 cytarabine for inj 500 mg 2 cytarabine inj 20 mg/ml 2 cytarabine inj pf 20 mg/ml 2 cytarabine inj pf 100 mg/ml 2 decitabine for inj 50 mg 5 DEPOCYT INJ 50MG/5ML 3 floxuridine for inj 0.5 gm 2 fludarabine phosphate for inj 50 mg 2 fludarabine phosphate inj 25 mg/ml 2 fluorouracil inj 1 gm/20ml (50 mg/ml) 2 fluorouracil inj 2.5 gm/50ml (50 mg/ml) 2 fluorouracil inj 5 gm/100ml (50 mg/ml) 2 fluorouracil inj 500 mg/10ml (50 mg/ml) 2 gemcitabine hcl for inj 1 gm 2 gemcitabine hcl for inj 2 gm 2 gemcitabine hcl for inj 200 mg 2 gemcitabine hcl inj 1 gm/26.3ml (38 2 mg/ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 2 mg/ml) (base equiv) gemcitabine hcl inj 200 mg/5.26ml (38 2 mg/ml) (base equiv) mercaptopurine tab 50 mg 2 methotrexate sodium for inj 1 gm 2 methotrexate sodium inj 50 mg/2ml (25 2 mg/ml) methotrexate sodium inj 250 mg/10ml (25 2 mg/ml) methotrexate sodium inj pf 50 mg/2ml (25 2 mg/ml) methotrexate sodium inj pf 100 mg/4ml (252 mg/ml) methotrexate sodium inj pf 200 mg/8ml (252 mg/ml) methotrexate sodium inj pf 250 mg/10ml 2 (25 mg/ml) methotrexate sodium inj pf 1000 mg/40ml 2 (25 mg/ml) NIPENT INJ 10MG 3 TABLOID TAB 40MG 3
PA
ANTIMITOTIC, TAXOIDS
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
32
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
ABRAXANE INJ 100MG 3 DOCEFREZ INJ 20MG 3 DOCEFREZ INJ 80MG 3 docetaxel for inj conc 20 mg/ml 2 docetaxel for inj conc 80 mg/4ml (20 2 mg/ml) DOCETAXEL INJ 20/0.5ML 3 DOCETAXEL INJ 20MG/2ML 3 DOCETAXEL INJ 80MG/2ML 3 DOCETAXEL INJ 80MG/8ML 3 DOCETAXEL INJ 140/7ML 3 DOCETAXEL INJ 160/8ML 3 DOCETAXEL INJ 160/16ML 3 DOCETAXEL INJ 200MG/20 3 DOCETAXEL INJ NON-ALCO 3 paclitaxel iv conc 30 mg/5ml (6 mg/ml) 2 paclitaxel iv conc 100 mg/16.7ml (6 mg/ml)2 paclitaxel iv conc 150 mg/25ml (6 mg/ml) 2 paclitaxel iv conc 300 mg/50ml (6 mg/ml) 2
ANTIMITOTIC, VINCA ALKALOIDS VINBLASTINE INJ 10MG vinblastine sulfate inj 1 mg/ml vincasar pfs inj 1mg/ml vincristine sulfate iv soln 1 mg/ml vinorelbine tartrate inj 10 mg/ml (base equiv) vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv)
3 2 2 2 2 2
BIOLOGIC RESPONSE MODIFIERS ARZERRA CON 100/5ML ARZERRA CON 1000/50 ERBITUX INJ 100MG ERBITUX INJ 200MG ERIVEDGE CAP 150MG FARYDAK CAP 10MG FARYDAK CAP 15MG FARYDAK CAP 20MG GAZYVA INJ 25MG/ML IBRANCE CAP 75MG IBRANCE CAP 100MG IBRANCE CAP 125MG
PA - Prior Authorization (applies to pharmacy benefit only)
5 5 5 5 5 5 5 5 5 5 5 5
QL - Quantity Limits
PA PA PA PA PA PA PA PA PA PA PA PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
33
January 1, 2017 Drug Tier Requirements/Limits
Drug Name KADCYLA INJ 100MG KADCYLA INJ 160MG KEYTRUDA INJ 100MG/4M KEYTRUDA SOL 50MG LYNPARZA CAP 50MG RITUXAN INJ 100MG RITUXAN INJ 500MG TORISEL SOL 25MG/ML YERVOY INJ 50MG YERVOY INJ 200MG ZALTRAP INJ 100/4ML ZALTRAP INJ 200/8ML ZOLINZA CAP 100MG
5 5 5 5 5 5 5 5 5 5 5 5 5
PA PA PA PA PA PA PA PA PA PA PA PA PA
HORMONAL ANTINEOPLASTIC AGENTS anastrozole tab 1 mg bicalutamide tab 50 mg DEPO-PROVERA INJ 400/ML ELIGARD INJ 7.5MG ELIGARD INJ 22.5MG ELIGARD INJ 30MG ELIGARD INJ 45MG exemestane tab 25 mg FARESTON TAB 60MG FASLODEX INJ 250MG FIRMAGON INJ 80MG FIRMAGON INJ 120MG flutamide cap 125 mg letrozole tab 2.5 mg leuprolide acetate inj kit 5 mg/ml LUPR DEP-PED INJ 7.5MG LUPR DEP-PED INJ 11.25MG LUPR DEP-PED INJ 15MG LUPR DEP-PED INJ 30MG LUPRON DEPOT INJ 3.75MG LUPRON DEPOT INJ 7.5MG LUPRON DEPOT INJ 11.25MG LUPRON DEPOT INJ 22.5MG LUPRON DEPOT INJ 30MG LUPRON DEPOT INJ 45MG LYSODREN TAB 500MG megestrol acetate susp 40 mg/ml
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 4 5 5 5 5 2 3 3 5 5 2 2 5 5 5 5 5 5 5 5 5 5 5 3 2
QL - Quantity Limits
PA PA PA PA
PA PA
PA PA PA PA PA PA PA PA PA PA PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
34
January 1, 2017 Drug Tier Requirements/Limits
Drug Name megestrol acetate susp 625 mg/5ml megestrol acetate tab 20 mg megestrol acetate tab 40 mg nilutamide tab 150 mg tamoxifen citrate tab 10 mg (base equivalent)
2 2 2 2 2
tamoxifen citrate tab 20 mg (base equivalent)
2
TRELSTAR INJ 11.25MG TRELSTAR MIX INJ 3.75MG TRELSTAR MIX INJ 22.5MG ZYTIGA TAB 250MG
5 5 5 5
$0 copay for women > 35 years for the primary prevention of breast cancer $0 copay for women > 35 years for the primary prevention of breast cancer PA PA PA PA
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA
5
PA
5 5 5 5 5
PA PA PA PA PA
KINASE INHIBITORS AFINITOR DIS TAB 2MG AFINITOR DIS TAB 3MG AFINITOR DIS TAB 5MG AFINITOR TAB 2.5MG AFINITOR TAB 5MG AFINITOR TAB 7.5MG AFINITOR TAB 10MG BOSULIF TAB 100MG BOSULIF TAB 500MG CAPRELSA TAB 100MG CAPRELSA TAB 300MG COMETRIQ KIT 60MG COMETRIQ KIT 100MG COMETRIQ KIT 140MG ICLUSIG TAB 15MG ICLUSIG TAB 45MG imatinib mesylate tab 100 mg (base equivalent) imatinib mesylate tab 400 mg (base equivalent) IMBRUVICA CAP 140MG INLYTA TAB 1MG INLYTA TAB 5MG JAKAFI TAB 5MG JAKAFI TAB 10MG
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
35
January 1, 2017 Drug Tier Requirements/Limits
Drug Name JAKAFI TAB 15MG JAKAFI TAB 20MG JAKAFI TAB 25MG LENVIMA CAP 8 MG LENVIMA CAP 10 MG LENVIMA CAP 14 MG LENVIMA CAP 18 MG LENVIMA CAP 20 MG LENVIMA CAP 24 MG MEKINIST TAB 0.5MG MEKINIST TAB 2MG NEXAVAR TAB 200MG SPRYCEL TAB 20MG SPRYCEL TAB 50MG SPRYCEL TAB 70MG SPRYCEL TAB 80MG SPRYCEL TAB 100MG SPRYCEL TAB 140MG STIVARGA TAB 40MG SUTENT CAP 12.5MG SUTENT CAP 25MG SUTENT CAP 37.5MG SUTENT CAP 50MG TAFINLAR CAP 50MG TAFINLAR CAP 75MG TARCEVA TAB 25MG TARCEVA TAB 100MG TARCEVA TAB 150MG TYKERB TAB 250MG VOTRIENT TAB 200MG XALKORI CAP 200MG XALKORI CAP 250MG ZELBORAF TAB 240MG ZYDELIG TAB 100MG ZYDELIG TAB 150MG ZYKADIA CAP 150MG
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA
5 3 3 3
PA
MISCELLANEOUS bexarotene cap 75 mg DROXIA CAP 200MG DROXIA CAP 300MG DROXIA CAP 400MG
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
36
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
hydroxyurea cap 500 mg 2 ifosfamide & mesna inj kit 1000-1000 mg 2 MATULANE CAP 50MG 3 mitoxantrone hcl inj conc 20 mg/10ml (2 5 mg/ml) mitoxantrone hcl inj conc 25 mg/12.5ml (2 5 mg/ml) mitoxantrone hcl inj conc 30 mg/15ml (2 5 mg/ml) ONCASPAR INJ 750/ML 5 PHOTOFRIN INJ 75MG 3 QUADRAMET INJ 3 SYNRIBO INJ 3.5MG 5 THERACYS INJ 3 TICE BCG INJ 3 tretinoin cap 10 mg 2 TRISENOX SOL 10MG/10M 3 UVADEX INJ 20MCG/ML 3
PA PA PA PA
PA
PLATINUM-BASED AGENTS carboplatin iv for inj 150 mg carboplatin iv soln 50 mg/5ml carboplatin iv soln 150 mg/15ml carboplatin iv soln 450 mg/45ml carboplatin iv soln 600 mg/60ml cisplatin inj 50 mg/50ml (1 mg/ml) cisplatin inj 100 mg/100ml (1 mg/ml) cisplatin inj 200 mg/200ml (1 mg/ml) ELOXATIN INJ 200MG oxaliplatin for iv inj 50 mg oxaliplatin for iv inj 100 mg oxaliplatin iv soln 50 mg/10ml oxaliplatin iv soln 100 mg/20ml
2 2 2 2 2 2 2 2 3 2 2 2 2
PROTECTIVE AGENTS amifostine crystalline for inj 500 mg dexrazoxane for inj 250 mg dexrazoxane for inj 500 mg KEPIVANCE INJ 6.25MG leucovorin calcium for inj 50 mg leucovorin calcium for inj 100 mg leucovorin calcium for inj 200 mg leucovorin calcium for inj 350 mg
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 3 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
37
January 1, 2017 Drug Tier Requirements/Limits
Drug Name leucovorin calcium for inj 500 mg leucovorin calcium tab 5 mg leucovorin calcium tab 10 mg leucovorin calcium tab 15 mg leucovorin calcium tab 25 mg mesna inj 100 mg/ml MESNEX TAB 400MG
2 2 2 2 2 2 3
TOPOISOMERASE INHIBITORS CAMPTOSAR INJ 300/15ML 3 ETOPOPHOS INJ 100MG 3 etoposide cap 50 mg 2 etoposide inj 100 mg/5ml (20 mg/ml) 2 HYCAMTIN CAP 0.25MG 5 HYCAMTIN CAP 1MG 5 irinotecan hcl inj 40 mg/2ml (20 mg/ml) 2 irinotecan hcl inj 100 mg/5ml (20 mg/ml) 2 irinotecan hcl inj 500 mg/25ml (20 mg/ml) 2 TENIPOSIDE INJ 50MG/5ML 3 toposar inj 20mg/ml 2 toposar inj 100/5ml 2 topotecan hcl for inj 4 mg 2 TOPOTECAN INJ 4MG/4ML 3
PA PA
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTIC, BCL-2 INHIBITORS VENCLEXTA VENCLEXTA VENCLEXTA VENCLEXTA
TAB TAB TAB TAB
10MG 50MG 100MG START PK
5 5 5 5
PA PA PA PA
CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap 2 2.5-10 mg amlodipine besylate-benazepril hcl cap 5-102 mg amlodipine besylate-benazepril hcl cap 5-202 mg amlodipine besylate-benazepril hcl cap 5-402 mg amlodipine besylate-benazepril hcl cap 2 10-20 mg
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
38
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
amlodipine besylate-benazepril hcl cap 2 10-40 mg benazepril & hydrochlorothiazide tab 5-6.252 mg benazepril & hydrochlorothiazide tab 2 10-12.5 mg benazepril & hydrochlorothiazide tab 2 20-12.5 mg benazepril & hydrochlorothiazide tab 20-25 2 mg captopril & hydrochlorothiazide tab 25-15 2 mg captopril & hydrochlorothiazide tab 25-25 2 mg captopril & hydrochlorothiazide tab 50-15 2 mg captopril & hydrochlorothiazide tab 50-25 2 mg enalapril maleate & hydrochlorothiazide tab2 5-12.5 mg enalapril maleate & hydrochlorothiazide tab2 10-25 mg fosinopril sodium & hydrochlorothiazide tab 2 10-12.5 mg fosinopril sodium & hydrochlorothiazide tab 2 20-12.5 mg lisinopril & hydrochlorothiazide tab 10-12.5 2 mg lisinopril & hydrochlorothiazide tab 20-12.5 2 mg lisinopril & hydrochlorothiazide tab 20-25 2 mg moexipril-hydrochlorothiazide tab 7.5-12.5 2 mg moexipril-hydrochlorothiazide tab 15-12.5 2 mg moexipril-hydrochlorothiazide tab 15-25 mg2 quinapril-hydrochlorothiazide tab 10-12.5 2 mg quinapril-hydrochlorothiazide tab 20-12.5 2 mg quinapril-hydrochlorothiazide tab 20-25 mg 2 trandolapril-verapamil hcl tab cr 1-240 mg 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
39
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
trandolapril-verapamil hcl tab cr 2-180 mg 2 trandolapril-verapamil hcl tab cr 2-240 mg 2 trandolapril-verapamil hcl tab cr 4-240 mg 2
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 moexipril hcl tab 7.5 mg moexipril hcl tab 15 mg perindopril erbumine tab 2 mg perindopril erbumine tab 4 mg perindopril erbumine tab 8 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 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
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
40
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 mg eplerenone tab 50 mg
2 2
ALPHA BLOCKERS doxazosin mesylate tab 1 doxazosin mesylate tab 2 doxazosin mesylate tab 4 doxazosin mesylate tab 8 prazosin hcl cap 1 mg prazosin hcl cap 2 mg prazosin hcl cap 5 mg terazosin hcl cap 1 mg terazosin hcl cap 2 mg terazosin hcl cap 5 mg terazosin hcl cap 10 mg
mg mg mg mg
2 2 2 2 2 2 2 2 2 2 2
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan tab 5-160 mg amlodipine besylate-valsartan tab 5-320 mg amlodipine besylate-valsartan tab 10-160 mg amlodipine besylate-valsartan tab 10-320 mg amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg candesartan cilexetil-hydrochlorothiazide tab 32-25 mg irbesartan-hydrochlorothiazide tab 150-12.5 mg
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 2 2 2 2 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
41
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
irbesartan-hydrochlorothiazide tab 2 300-12.5 mg losartan potassium & hydrochlorothiazide 2 tab 50-12.5 mg losartan potassium & hydrochlorothiazide 2 tab 100-12.5 mg losartan potassium & hydrochlorothiazide 2 tab 100-25 mg telmisartan-amlodipine tab 40-5 mg 2 telmisartan-amlodipine tab 40-10 mg 2 telmisartan-amlodipine tab 80-5 mg 2 telmisartan-amlodipine tab 80-10 mg 2 telmisartan-hydrochlorothiazide tab 2 40-12.5 mg telmisartan-hydrochlorothiazide tab 2 80-12.5 mg telmisartan-hydrochlorothiazide tab 80-25 2 mg valsartan-hydrochlorothiazide tab 80-12.5 2 mg valsartan-hydrochlorothiazide tab 160-12.5 2 mg valsartan-hydrochlorothiazide tab 160-25 2 mg valsartan-hydrochlorothiazide tab 320-12.5 2 mg valsartan-hydrochlorothiazide tab 320-25 2 mg
ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR TAB 5MG BENICAR TAB 20MG BENICAR TAB 40MG candesartan cilexetil tab candesartan cilexetil tab candesartan cilexetil tab candesartan cilexetil tab EDARBI TAB 40MG EDARBI TAB 80MG eprosartan mesylate tab irbesartan tab 75 mg irbesartan tab 150 mg irbesartan tab 300 mg
4 mg 8 mg 16 mg 32 mg
600 mg
PA - Prior Authorization (applies to pharmacy benefit only)
4 4 4 2 2 2 2 4 4 2 2 2 2
QL - Quantity Limits
ST; PA** ST; PA** ST; PA**
ST; PA** ST; PA**
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
42
January 1, 2017 Drug Tier Requirements/Limits
Drug Name losartan potassium tab 25 mg losartan potassium tab 50 mg losartan potassium tab 100 mg telmisartan tab 20 mg telmisartan tab 40 mg telmisartan tab 80 mg valsartan tab 40 mg valsartan tab 80 mg valsartan tab 160 mg valsartan tab 320 mg
2 2 2 2 2 2 2 2 2 2
ANTIARRHYTHMICS amiodarone hcl inj 150 mg/3ml (50 mg/ml)2 amiodarone hcl inj 450 mg/9ml (50 mg/ml)2 amiodarone hcl inj 900 mg/18ml (50 2 mg/ml) amiodarone hcl tab 200 mg 2 amiodarone hcl tab 400 mg 2 disopyramide phosphate cap 100 mg 2 disopyramide phosphate cap 150 mg 2 dofetilide cap 125 mcg (0.125 mg) 5 dofetilide cap 250 mcg (0.25 mg) 5 dofetilide cap 500 mcg (0.5 mg) 5 flecainide acetate tab 50 mg 2 flecainide acetate tab 100 mg 2 flecainide acetate tab 150 mg 2 lidocaine hcl iv inj 10 mg/ml 2 lidocaine hcl iv inj 20 mg/ml 2 lidocaine iv infusion in d5w inj 4 mg/ml 2 lidocaine iv infusion in d5w inj 8 mg/ml 2 mexiletine hcl cap 150 mg 2 mexiletine hcl cap 200 mg 2 mexiletine hcl cap 250 mg 2 MULTAQ TAB 400MG 4 NEXTERONE INJ 4 NORPACE CAP 100MG CR 3 NORPACE CAP 150MG CR 3 pacerone tab 100mg 2 pacerone tab 200mg 2 procainamide hcl inj 100 mg/ml 2 PROCAINAMIDE INJ 500MG/ML 4 propafenone hcl cap sr 12hr 225 mg 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
PA PA PA
PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
43
January 1, 2017 Drug Tier Requirements/Limits
Drug Name propafenone hcl cap sr 12hr 325 mg propafenone hcl cap sr 12hr 425 mg propafenone hcl tab 150 mg propafenone hcl tab 225 mg propafenone hcl tab 300 mg quinidine sulfate tab 200 mg quinidine sulfate tab 300 mg sorine tab 80mg sorine tab 120mg sorine tab 160mg sorine tab 240mg sotalol hcl (afib/afl) tab 80 mg sotalol hcl (afib/afl) tab 120 mg sotalol hcl (afib/afl) tab 160 mg SOTALOL HCL INJ 150/10ML sotalol hcl tab 80 mg sotalol hcl tab 120 mg sotalol hcl tab 160 mg sotalol hcl tab 240 mg
2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 2 2 2 2
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 prevalite pow 4gm WELCHOL PAK 3.75GM WELCHOL TAB 625MG
2 2 2 2 2 2 2 2 3 3
ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITOR ZETIA TAB 10MG
3
ANTILIPEMICS, FIBRATES choline fenofibrate cap dr 45 mg (fenofibric 2 acid equiv) choline fenofibrate cap dr 135 mg (fenofibric2 acid equiv) fenofibrate cap 50 mg 2 fenofibrate cap 150 mg 2 fenofibrate micronized cap 43 mg 2 fenofibrate micronized cap 67 mg 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
44
January 1, 2017 Drug Tier Requirements/Limits
Drug Name fenofibrate micronized cap 130 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 fenofibric acid tab 35 mg fenofibric acid tab 105 mg gemfibrozil tab 600 mg
2 2 2 2 2 2 2 2 2 2
ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS VYTORIN VYTORIN VYTORIN VYTORIN
TAB TAB TAB TAB
10-10MG 10-20MG 10-40MG 10-80MG
3 3 3 3
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium tab 10 mg (base equivalent) atorvastatin calcium tab 20 mg (base equivalent) atorvastatin calcium tab 40 mg (base equivalent) atorvastatin calcium tab 80 mg (base equivalent) fluvastatin sodium cap 20 mg fluvastatin sodium cap 40 mg LIVALO TAB 1MG LIVALO TAB 2MG LIVALO TAB 4MG lovastatin tab 10 mg lovastatin tab 20 mg lovastatin tab 40 mg pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg pravastatin sodium tab 40 mg pravastatin sodium tab 80 mg rosuvastatin calcium tab 5 mg rosuvastatin calcium tab 10 mg rosuvastatin calcium tab 20 mg rosuvastatin calcium tab 40 mg
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 2 4 4 4 2 2 2 2 2 2 2 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
45
January 1, 2017 Drug Tier Requirements/Limits
Drug Name simvastatin simvastatin simvastatin simvastatin simvastatin
tab tab tab tab tab
5 mg 10 mg 20 mg 40 mg 80 mg
2 2 2 2 2
ST
ANTILIPEMICS, MISCELLANEOUS niacin tab cr 500 mg (antihyperlipidemic) 2 niacin tab cr 750 mg (antihyperlipidemic) 2 niacin tab cr 1000 mg (antihyperlipidemic) 2
ANTILIPEMICS, OMEGA-3 FATTY ACIDS omega-3-acid ethyl esters cap 1 gm VASCEPA CAP 1GM
2 3
PA
6 6 5 5 5
PA, ST PA, ST PA PA PA
ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT INJ 75MG/ML PRALUENT INJ 150MG/ML REPATHA INJ 140MG/ML REPATHA PUSH INJ 420/3.5 REPATHA SURE INJ 140MG/ML
BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab 50-25 mg 2 atenolol & chlorthalidone tab 100-25 mg 2 bisoprolol & hydrochlorothiazide tab 2 2.5-6.25 mg bisoprolol & hydrochlorothiazide tab 5-6.25 2 mg bisoprolol & hydrochlorothiazide tab 2 10-6.25 mg metoprolol & hydrochlorothiazide tab 50-252 mg metoprolol & hydrochlorothiazide tab 2 100-25 mg metoprolol & hydrochlorothiazide tab 2 100-50 mg nadolol & bendroflumethiazide tab 40-5 mg 2 nadolol & bendroflumethiazide tab 80-5 mg 2 propranolol & hydrochlorothiazide tab 40-252 mg propranolol & hydrochlorothiazide tab 80-252 mg
BETA-BLOCKERS acebutolol hcl cap 200 mg
PA - Prior Authorization (applies to pharmacy benefit only)
2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
46
January 1, 2017 Drug Tier Requirements/Limits
Drug Name acebutolol hcl cap 400 mg atenolol tab 25 mg atenolol tab 50 mg atenolol tab 100 mg betaxolol hcl tab 10 mg betaxolol hcl tab 20 mg bisoprolol fumarate tab 5 mg bisoprolol fumarate tab 10 mg BYSTOLIC TAB 2.5MG BYSTOLIC TAB 5MG BYSTOLIC TAB 10MG BYSTOLIC TAB 20MG carvedilol tab 3.125 mg carvedilol tab 6.25 mg carvedilol tab 12.5 mg carvedilol tab 25 mg COREG CR CAP 10MG COREG CR CAP 20MG COREG CR CAP 40MG COREG CR CAP 80MG HEMANGEOL SOL 4.28/ML labetalol hcl iv soln 5 mg/ml labetalol hcl tab 100 mg labetalol hcl tab 200 mg labetalol hcl tab 300 mg LEVATOL TAB 20MG metoprolol succinate tab sr 24hr (tartrate equiv) metoprolol succinate tab sr 24hr (tartrate equiv) metoprolol succinate tab sr 24hr (tartrate equiv) metoprolol succinate tab sr 24hr (tartrate equiv) metoprolol tartrate inj 1 mg/ml 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
25 mg
2 2 2 2 2 2 2 2 4 4 4 4 2 2 2 2 4 4 4 4 4 2 2 2 2 4 2
50 mg
2
100 mg
2
200 mg
2
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
47
January 1, 2017 Drug Tier Requirements/Limits
Drug Name pindolol tab 10 mg propranolol hcl cap sr 24hr 60 mg propranolol hcl cap sr 24hr 80 mg propranolol hcl cap sr 24hr 120 mg propranolol hcl cap sr 24hr 160 mg propranolol hcl inj 1 mg/ml 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
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin tab 2.5-10 mg amlodipine besylate-atorvastatin tab 2.5-20 mg amlodipine besylate-atorvastatin tab 2.5-40 mg amlodipine besylate-atorvastatin tab 5-10 mg amlodipine besylate-atorvastatin tab 5-20 mg amlodipine besylate-atorvastatin tab 5-40 mg amlodipine besylate-atorvastatin tab 5-80 mg amlodipine besylate-atorvastatin tab 10-10 mg amlodipine besylate-atorvastatin tab 10-20 mg amlodipine besylate-atorvastatin tab 10-40 mg amlodipine besylate-atorvastatin tab 10-80 mg
calcium
2
calcium
2
calcium
2
calcium
2
calcium
2
calcium
2
calcium
2
calcium
2
calcium
2
calcium
2
calcium
2
CALCIUM CHANNEL BLOCKERS afeditab tab 30mg cr afeditab tab 60mg cr
PA - Prior Authorization (applies to pharmacy benefit only)
2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
48
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
amlodipine besylate tab 2.5 mg 2 amlodipine besylate tab 5 mg 2 amlodipine besylate tab 10 mg 2 CARDENE IV INJ 40/200ML 4 CARDENE IV SOL 20/200ML 4 CARDIZEM LA TAB 120MG 3 cartia xt cap 120/24hr 2 cartia xt cap 180/24hr 2 cartia xt cap 240/24hr 2 cartia xt cap 300/24hr 2 diltiazem hcl cap sr 12hr 60 mg 2 diltiazem hcl cap sr 12hr 90 mg 2 diltiazem hcl cap sr 12hr 120 mg 2 diltiazem hcl cap sr 24hr 120 mg 2 diltiazem hcl cap sr 24hr 180 mg 2 diltiazem hcl cap sr 24hr 240 mg 2 diltiazem hcl coated beads cap sr 24hr 120 2 mg diltiazem hcl coated beads cap sr 24hr 180 2 mg diltiazem hcl coated beads cap sr 24hr 240 2 mg diltiazem hcl coated beads cap sr 24hr 300 2 mg diltiazem hcl coated beads cap sr 24hr 360 2 mg diltiazem hcl extended release beads cap sr2 24hr 120 mg diltiazem hcl extended release beads cap sr2 24hr 180 mg diltiazem hcl extended release beads cap sr2 24hr 240 mg diltiazem hcl extended release beads cap sr2 24hr 300 mg diltiazem hcl extended release beads cap sr2 24hr 360 mg diltiazem hcl extended release beads cap sr2 24hr 420 mg diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) 2 diltiazem hcl iv soln 50 mg/10ml (5 mg/ml)2 diltiazem hcl iv soln 125 mg/25ml (5 mg/ml)2 diltiazem hcl tab 30 mg 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
49
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
diltiazem hcl tab 60 mg 2 diltiazem hcl tab 90 mg 2 diltiazem hcl tab 120 mg 2 DILTIAZEM INJ 100MG 4 felodipine tab sr 24hr 2.5 mg 2 felodipine tab sr 24hr 5 mg 2 felodipine tab sr 24hr 10 mg 2 isradipine cap 2.5 mg 2 isradipine cap 5 mg 2 matzim la tab 180mg/24 2 matzim la tab 240mg/24 2 matzim la tab 300mg/24 2 matzim la tab 360mg/24 2 matzim la tab 420mg/24 2 nicardipine hcl cap 20 mg 2 nicardipine hcl cap 30 mg 2 nicardipine hcl iv soln 2.5 mg/ml 2 nifedical xl tab 30mg 2 nifedical xl tab 60mg 2 nifedipine tab sr 24hr 30 mg 2 nifedipine tab sr 24hr 60 mg 2 nifedipine tab sr 24hr 90 mg 2 nifedipine tab sr 24hr osmotic release 30 mg2 nifedipine tab sr 24hr osmotic release 60 mg2 nifedipine tab sr 24hr osmotic release 90 mg2 nimodipine cap 30 mg 2 nisoldipine tab sr 24hr 8.5 mg 2 nisoldipine tab sr 24hr 17 mg 2 nisoldipine tab sr 24hr 20 mg 2 nisoldipine tab sr 24hr 25.5 mg 2 nisoldipine tab sr 24hr 30 mg 2 nisoldipine tab sr 24hr 34 mg 2 nisoldipine tab sr 24hr 40 mg 2 taztia xt cap 120mg/24 2 taztia xt cap 180mg/24 2 taztia xt cap 240mg/24 2 taztia xt cap 300mg/24 2 taztia xt cap 360mg/24 2 verapamil hcl cap sr 24hr 100 mg 2 verapamil hcl cap sr 24hr 120 mg 2 verapamil hcl cap sr 24hr 180 mg 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
50
January 1, 2017 Drug Tier Requirements/Limits
Drug Name verapamil verapamil verapamil verapamil verapamil verapamil verapamil verapamil verapamil verapamil verapamil
hcl hcl hcl hcl hcl hcl hcl hcl hcl hcl hcl
cap sr 24hr 200 mg cap sr 24hr 240 mg cap sr 24hr 300 mg cap sr 24hr 360 mg iv soln 2.5 mg/ml tab 40 mg tab 80 mg tab 120 mg tab cr 120 mg tab cr 180 mg tab cr 240 mg
2 2 2 2 2 2 2 2 2 2 2
DIGITALIS GLYCOSIDES digox tab 0.25mg digox tab 0.125mg digoxin inj 0.25 mg/ml digoxin oral soln 0.05 mg/ml digoxin tab 125 mcg (0.125 mg) digoxin tab 250 mcg (0.25 mg) LANOXIN PED INJ 0.1MG/ML LANOXIN TAB 0.0625MG LANOXIN TAB 0.1875MG
2 2 2 2 2 2 4 3 3
DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA TAB 150MG TEKTURNA TAB 300MG
4 4
ST; PA** ST; PA**
DIURETICS acetazolamide cap sr 12hr 500 mg acetazolamide sodium for inj 500 mg acetazolamide tab 125 mg acetazolamide tab 250 mg ALDACTAZIDE TAB 50/50 amiloride & hydrochlorothiazide tab 5-50 mg amiloride hcl tab 5 mg bumetanide inj 0.25 mg/ml bumetanide tab 0.5 mg bumetanide tab 1 mg bumetanide tab 2 mg chlorothiazide sodium for inj 500 mg chlorothiazide tab 250 mg chlorothiazide tab 500 mg chlorthalidone tab 25 mg
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 3 2 2 2 2 2 2 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
51
January 1, 2017 Drug Tier Requirements/Limits
Drug Name chlorthalidone tab 50 mg chlorthalidone tab 100 mg DIURIL SUS 250/5ML DYRENIUM CAP 50MG DYRENIUM CAP 100MG ethacrynate sodium for inj 50 mg ethacrynic acid tab 25 mg furosemide inj 10 mg/ml FUROSEMIDE ORAL SOLN 8 MG/ML furosemide oral soln 10 mg/ml furosemide tab 20 mg furosemide tab 40 mg furosemide tab 80 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 methazolamide tab 25 mg methazolamide tab 50 mg methyclothiazide tab 5 mg metolazone tab 2.5 mg metolazone tab 5 mg metolazone tab 10 mg spironolactone & hydrochlorothiazide tab 25-25 mg spironolactone tab 25 mg spironolactone tab 50 mg spironolactone tab 100 mg TORSEMIDE INJ 20MG/2ML TORSEMIDE INJ 50MG/5ML torsemide tab 5 mg torsemide tab 10 mg torsemide tab 20 mg torsemide tab 100 mg triamterene & hydrochlorothiazide cap 37.5-25 mg triamterene & hydrochlorothiazide cap 50-25 mg triamterene & hydrochlorothiazide tab 37.5-25 mg
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 4 4 4 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 4 2 2 2 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
52
January 1, 2017 Drug Tier Requirements/Limits
Drug Name triamterene & hydrochlorothiazide tab 75-50 mg
2
MISCELLANEOUS clonidine hcl tab 0.1 mg clonidine hcl tab 0.2 mg clonidine hcl tab 0.3 mg clonidine hcl td patch weekly 0.1 mg/24hr clonidine hcl td patch weekly 0.2 mg/24hr clonidine hcl td patch weekly 0.3 mg/24hr ENTRESTO TAB 24-26MG ENTRESTO TAB 49-51MG ENTRESTO TAB 97-103MG guanfacine hcl tab 1 mg guanfacine hcl tab 2 mg hydralazine hcl inj 20 mg/ml hydralazine hcl tab 10 mg hydralazine hcl tab 25 mg hydralazine hcl tab 50 mg hydralazine hcl tab 100 mg methyldopa tab 250 mg methyldopa tab 500 mg methyldopate hcl inj 250 mg/5ml midodrine hcl tab 2.5 mg midodrine hcl tab 5 mg midodrine hcl tab 10 mg minoxidil tab 2.5 mg minoxidil tab 10 mg phenoxybenzamine hcl cap 10 mg RANEXA TAB 500MG RANEXA TAB 1000MG reserpine tab 0.1 mg reserpine tab 0.25 mg
2 2 2 2 2 2 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 2 2
ST; PA** ST; PA**
NITRATES DILATRATE SR CAP 40MG isoditrate tab 40mg er ISORDIL TAB 40MG isosorbide dinitrate sl tab 2.5 mg isosorbide dinitrate tab 5 mg isosorbide dinitrate tab 10 mg isosorbide dinitrate tab 20 mg isosorbide dinitrate tab 30 mg
PA - Prior Authorization (applies to pharmacy benefit only)
4 2 3 2 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
53
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
isosorbide dinitrate tab cr 40 mg 2 isosorbide mononitrate tab 10 mg 2 isosorbide mononitrate tab 20 mg 2 isosorbide mononitrate tab sr 24hr 30 mg 2 isosorbide mononitrate tab sr 24hr 60 mg 2 isosorbide mononitrate tab sr 24hr 120 mg 2 minitran dis 0.1mg/hr 2 minitran dis 0.2mg/hr 2 minitran dis 0.4mg/hr 2 minitran dis 0.6mg/hr 2 NITRO-BID OIN 2% 4 NITRO-DUR DIS 0.3MG/HR 3 NITRO-DUR DIS 0.8MG/HR 3 nitro-time cap 9mg cr 2 NITROGLYCER INJ 5MG/ML 4 nitroglycerin iv soln 100 mcg/ml in d5w 2 nitroglycerin iv soln 200 mcg/ml in d5w 2 nitroglycerin iv soln 400 mcg/ml in d5w 2 nitroglycerin lingual aerosol 400 mcg/spray 2 nitroglycerin td patch 24hr 0.1 mg/hr 2 nitroglycerin td patch 24hr 0.2 mg/hr 2 nitroglycerin td patch 24hr 0.4 mg/hr 2 nitroglycerin td patch 24hr 0.6 mg/hr 2 nitroglycerin tl soln 0.4 mg/spray (400 2 mcg/spray) NITROSTAT SUB 0.3MG 3 NITROSTAT SUB 0.4MG 3 NITROSTAT SUB 0.6MG 3
PULMONARY ARTERIAL HYPERTENSION ADCIRCA TAB 20MG ADEMPAS TAB 0.5MG ADEMPAS TAB 1.5MG ADEMPAS TAB 1MG ADEMPAS TAB 2.5MG ADEMPAS TAB 2MG epoprostenol sodium for inj 0.5 mg epoprostenol sodium for inj 1.5 mg LETAIRIS TAB 5MG LETAIRIS TAB 10MG OPSUMIT TAB 10MG ORENITRAM TAB 0.25MG
PA - Prior Authorization (applies to pharmacy benefit only)
6 6 6 6 6 6 5 5 5 5 6 5
QL - Quantity Limits
PA, ST PA PA PA PA PA PA PA PA PA PA, ST PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
54
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
ORENITRAM TAB 0.125MG 5 ORENITRAM TAB 1MG 5 ORENITRAM TAB 2.5MG 5 REMODULIN INJ 1MG/ML 6 REMODULIN INJ 2.5MG/ML 6 REMODULIN INJ 5MG/ML 6 REMODULIN INJ 10MG/ML 6 sildenafil citrate iv soln 10 mg/12.5ml (base5 equivalent) sildenafil citrate tab 20 mg 5 TRACLEER TAB 62.5MG 5 TRACLEER TAB 125MG 5 TYVASO START SOL 0.6MG/ML 5 VENTAVIS SOL 10MCG/ML 5 VENTAVIS SOL 20MCG/ML 5
PA PA PA PA PA PA PA PA PA PA PA PA PA PA
CENTRAL NERVOUS SYSTEM ANTIANXIETY§ ALPRAZOLAM CON 1 MG/ML 3 alprazolam orally disintegrating tab 0.5 mg 2 alprazolam orally disintegrating tab 0.25 mg2 alprazolam orally disintegrating tab 1 mg 2 alprazolam orally disintegrating tab 2 mg 2 alprazolam tab 0.5 mg 2 alprazolam tab 0.25 mg 2 alprazolam tab 1 mg 2 alprazolam tab 2 mg 2 buspirone hcl tab 5 mg 2 buspirone hcl tab 7.5 mg 2 buspirone hcl tab 10 mg 2 buspirone hcl tab 15 mg 2 buspirone hcl tab 30 mg 2 fluvoxamine maleate cap sr 24hr 100 mg 2 fluvoxamine maleate cap sr 24hr 150 mg 2 fluvoxamine maleate tab 25 mg 2 fluvoxamine maleate tab 50 mg 2 fluvoxamine maleate tab 100 mg 2 hydroxyzine hcl syrup 10 mg/5ml 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
QL QL QL QL QL QL QL QL QL
(120 mL (90 tabs (90 tabs (90 tabs (60 tabs (90 tabs (90 tabs (90 tabs (60 tabs
/ / / / / / / / /
25 25 25 25 25 25 25 25 25
days) days) days) days) days) days) days) days) days)
PA; High Risk Medications require PA for members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
55
January 1, 2017 Drug Tier Requirements/Limits
Drug Name hydroxyzine hcl tab 10 mg
2
hydroxyzine hcl tab 25 mg
2
hydroxyzine hcl tab 50 mg
2
lorazepam conc 2 mg/ml lorazepam tab 0.5 mg lorazepam tab 1 mg lorazepam tab 2 mg meprobamate tab 200 mg meprobamate tab 400 mg oxazepam cap 10 mg oxazepam cap 15 mg oxazepam cap 30 mg
2 2 2 2 2 2 2 2 2
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older QL (150 mL / 25 days) QL (150 tabs / 25 days) QL (150 tabs / 25 days) QL (150 tabs / 25 days)
QL (120 caps / 25 days) QL (120 caps / 25 days) QL (120 caps / 25 days)
ANTICONVULSANTS§ APTIOM TAB 200MG APTIOM TAB 400MG APTIOM TAB 600MG APTIOM TAB 800MG BANZEL SUS 40MG/ML BANZEL TAB 200MG BANZEL TAB 400MG carbamazepine cap sr 12hr 100 mg carbamazepine cap sr 12hr 200 mg carbamazepine cap sr 12hr 300 mg carbamazepine chew tab 100 mg carbamazepine susp 100 mg/5ml carbamazepine tab 200 mg carbamazepine tab sr 12hr 100 mg carbamazepine tab sr 12hr 200 mg carbamazepine tab sr 12hr 400 mg CELONTIN CAP 300MG clonazepam tab 0.5 mg clonazepam tab 1 mg clonazepam tab 2 mg
PA - Prior Authorization (applies to pharmacy benefit only)
4 4 4 4 4 4 4 2 2 2 2 2 2 2 2 2 4 2 2 2
QL - Quantity Limits
PA PA PA PA PA PA PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
56
January 1, 2017 Drug Tier Requirements/Limits
Drug Name clorazepate dipotassium tab 3.75 mg clorazepate dipotassium tab 7.5 mg clorazepate dipotassium tab 15 mg diazepam con 5mg/ml diazepam inj 5 mg/ml diazepam oral soln 1 mg/ml diazepam tab 2 mg diazepam tab 5 mg diazepam tab 10 mg DILANTIN CAP 30MG 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 sr 24 hr 250 mg divalproex sodium tab sr 24 hr 500 mg epitol tab 200mg ethosuximide cap 250 mg ethosuximide soln 250 mg/5ml felbamate susp 600 mg/5ml felbamate tab 400 mg felbamate tab 600 mg fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) FYCOMPA TAB 2MG FYCOMPA TAB 4MG FYCOMPA TAB 6MG FYCOMPA TAB 8MG FYCOMPA TAB 10MG FYCOMPA TAB 12MG gabapentin cap 100 mg gabapentin cap 300 mg gabapentin cap 400 mg gabapentin oral soln 250 mg/5ml gabapentin tab 600 mg gabapentin tab 800 mg
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 2 2 2 2 4 2
QL QL QL QL
(120 (120 (120 (240
tabs / 25 days) tabs / 25 days) tabs / 25 days) mL / 25 days)
QL QL QL QL
(1200 mL (120 tabs (120 tabs (120 tabs
/ / / /
25 25 25 25
days) days) days) days)
2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 2 2 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
57
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
GABITRIL TAB 12MG 3 GABITRIL TAB 16MG 3 LAMICTAL CHW 2MG 3 LAMICTAL KIT START 35 4 LAMICTAL KIT START 49 4 LAMICTAL KIT START 98 4 LAMICTAL XR KIT 4 lamotrigine orally disintegrating tab 25 mg 2 lamotrigine orally disintegrating tab 50 mg 2 lamotrigine orally disintegrating tab 100 mg2 lamotrigine orally disintegrating tab 200 mg2 lamotrigine tab 25 mg 2 lamotrigine tab 100 mg 2 lamotrigine tab 150 mg 2 lamotrigine tab 200 mg 2 lamotrigine tab chewable dispersible 5 mg 2 lamotrigine tab chewable dispersible 25 mg 2 lamotrigine tab disp 25 (14) & 50 mg (14) &2 100 mg (7) kit lamotrigine tab disp 25 mg (21) & 50 mg (7)2 titration kit lamotrigine tab disp 50 mg (42) & 100 mg 2 (14) titration kit lamotrigine tab sr 24hr 25 mg 2 lamotrigine tab sr 24hr 50 mg 2 lamotrigine tab sr 24hr 100 mg 2 lamotrigine tab sr 24hr 200 mg 2 lamotrigine tab sr 24hr 250 mg 2 lamotrigine tab sr 24hr 300 mg 2 LEVETIRACETA INJ 5MG/ML 4 LEVETIRACETA INJ 10MG/ML 4 LEVETIRACETA INJ 15MG/ML 4 levetiracetam inj 500 mg/5ml (100 mg/ml) 2 levetiracetam oral soln 100 mg/ml 2 levetiracetam tab 250 mg 2 levetiracetam tab 500 mg 2 levetiracetam tab 750 mg 2 levetiracetam tab 1000 mg 2 levetiracetam tab sr 24hr 500 mg 2 levetiracetam tab sr 24hr 750 mg 2 LYRICA CAP 25MG 4
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST; PA**
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
58
January 1, 2017 Drug Tier Requirements/Limits
Drug Name LYRICA CAP 50MG LYRICA CAP 75MG LYRICA CAP 100MG LYRICA CAP 150MG LYRICA CAP 200MG LYRICA CAP 225MG LYRICA CAP 300MG LYRICA SOL 20MG/ML ONFI SUS 2.5MG/ML ONFI TAB 5MG 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 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 phenobarbital tab 60 mg phenobarbital tab 64.8 mg phenobarbital tab 97.2 mg phenobarbital tab 100 mg phenytoin chew tab 50 mg phenytoin sodium extended cap 100 mg phenytoin sodium extended cap 200 mg phenytoin sodium extended cap 300 mg phenytoin sodium inj 50 mg/ml phenytoin susp 125 mg/5ml POTIGA TAB 50MG POTIGA TAB 200MG POTIGA TAB 300MG POTIGA TAB 400MG primidone tab 50 mg primidone tab 250 mg SABRIL POW 500MG SABRIL TAB 500MG
PA - Prior Authorization (applies to pharmacy benefit only)
4 4 4 4 4 4 4 4 4 4 4 4 2 2 2 2 4 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 4 4 4 2 2 5 5
QL - Quantity Limits
ST; ST; ST; ST; ST; ST; ST; ST; PA PA PA PA
PA** PA** PA** PA** PA** PA** PA** PA**
PA PA PA PA
PA PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
59
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
STAVZOR CAP 125MG 4 STAVZOR CAP 250MG 4 STAVZOR CAP 500MG 4 tiagabine hcl tab 2 mg 2 tiagabine hcl tab 4 mg 2 topiramate sprinkle cap 15 mg 2 topiramate sprinkle cap 25 mg 2 topiramate tab 25 mg 2 topiramate tab 50 mg 2 topiramate tab 100 mg 2 topiramate tab 200 mg 2 valproate sodium inj 100 mg/ml 2 valproate sodium syrup 250 mg/5ml (base 2 equiv) valproic acid cap 250 mg 2 VIMPAT INJ 200MG/20 4 VIMPAT SOL 10MG/ML 4 VIMPAT TAB 50MG 4 VIMPAT TAB 100MG 4 VIMPAT TAB 150MG 4 VIMPAT TAB 200MG 4 zonisamide cap 25 mg 2 zonisamide cap 50 mg 2 zonisamide cap 100 mg 2
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 EXELON SOL 2MG/ML galantamine hydrobromide cap sr 24hr 8 mg galantamine hydrobromide cap sr 24hr 16 mg galantamine hydrobromide cap sr 24hr 24 mg galantamine hydrobromide oral soln 4 mg/ml galantamine hydrobromide tab 4 mg
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 3 2
PA
2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
60
January 1, 2017 Drug Tier Requirements/Limits
Drug Name galantamine hydrobromide tab 8 mg galantamine hydrobromide tab 12 mg memantine hcl oral solution 2 mg/ml
2 2 2
memantine hcl tab 5 mg
2
memantine hcl tab 5 mg (28) & 10 mg (21)2 titration pak memantine hcl tab 10 mg
2
NAMENDA XR CAP 7MG
3
NAMENDA XR CAP 14MG
3
NAMENDA XR CAP 21MG
3
NAMENDA XR CAP 28MG
3
NAMENDA XR CAP TITRATIO
3
rivastigmine rivastigmine rivastigmine rivastigmine rivastigmine rivastigmine rivastigmine
tartrate cap 1.5 mg tartrate cap 3 mg tartrate cap 4.5 mg tartrate cap 6 mg td patch 24hr 4.6 mg/24hr td patch 24hr 9.5 mg/24hr td patch 24hr 13.3 mg/24hr
2 2 2 2 2 2 2
PA; PA applies for members less than years of age PA; PA applies for members less than years of age PA; PA applies for members less than years of age PA; PA applies for members less than years of age PA; PA applies for members less than years of age PA; PA applies for members less than years of age PA; PA applies for members less than years of age PA; PA applies for members less than years of age PA; PA applies for members less than years of age PA PA PA PA PA PA PA
30 30 30 30 30 30 30 30 30
ANTIDEPRESSANTS§ amitriptyline hcl tab 10 mg
2
amitriptyline hcl tab 25 mg
2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
QL (150 tabs / 25 days); QL applies to members age 65 and older QL (60 tabs / 25 days); QL applies to members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
61
January 1, 2017 Drug Tier Requirements/Limits
Drug Name amitriptyline hcl tab 50 mg
2
amitriptyline hcl tab 75 mg
2
amitriptyline hcl tab 100 mg
2
amitriptyline hcl tab 150 mg
2
amoxapine tab 25 mg
2
amoxapine tab 50 mg
2
amoxapine tab 100 mg
2
amoxapine tab 150 mg
2
APLENZIN TAB 174MG APLENZIN TAB 348MG APLENZIN TAB 522MG bupropion hcl tab 75 mg bupropion hcl tab 100 mg bupropion hcl tab sr 12hr 100 mg bupropion hcl tab sr 12hr 150 mg bupropion hcl tab sr 12hr 200 mg bupropion hcl tab sr 24hr 150 mg bupropion hcl tab sr 24hr 300 mg 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) clomipramine hcl cap 25 mg
4 4 4 2 2 2 2 2 2 2 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL (30 tabs / 25 days); QL applies to members age 65 and older Members 65 and older subject to PA Members 65 and older subject to PA Members 65 and older subject to PA QL (90 tabs / 25 days); QL applies to members age 65 and older QL (90 tabs / 25 days); QL applies to members age 65 and older QL (90 tabs / 25 days); QL applies to members age 65 and older QL (60 tabs / 25 days); QL applies to members age 65 and older
2 2 2 2
QL - Quantity Limits
QL (150 caps / 25 days); QL applies to members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
62
January 1, 2017 Drug Tier Requirements/Limits
Drug Name clomipramine hcl cap 50 mg
2
clomipramine hcl cap 75 mg
2
desipramine hcl tab 10 mg
2
desipramine hcl tab 25 mg
2
desipramine hcl tab 50 mg
2
desipramine hcl tab 75 mg
2
desipramine hcl tab 100 mg
2
desipramine hcl tab 150 mg
2
desvenlafaxine tab sr 24hr 50 mg desvenlafaxine tab sr 24hr 100 mg doxepin hcl cap 10 mg
2 2 2
doxepin hcl cap 25 mg
2
doxepin hcl cap 50 mg
2
doxepin hcl cap 75 mg
2
doxepin hcl cap 100 mg
2
doxepin hcl cap 150 mg
2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
QL (150 caps / 25 days); QL applies to members age 65 and older QL (90 caps / 25 days); QL applies to members age 65 and older QL (90 tabs / 25 days); QL applies to members age 65 and older QL (90 tabs / 25 days); QL applies to members age 65 and older QL (90 tabs / 25 days); QL applies to members age 65 and older QL (60 tabs / 25 days); QL applies to members age 65 and older QL (30 tabs / 25 days); QL applies to members age 65 and older QL (30 tabs / 25 days); QL applies to members age 65 and older
QL (90 caps / 25 days); QL applies to members age 65 and older QL (90 caps / 25 days); QL applies to members age 65 and older QL (90 caps / 25 days); QL applies to members age 65 and older QL (60 caps / 25 days); QL applies to members age 65 and older QL (30 caps / 25 days); QL applies to members age 65 and older QL (30 caps / 25 days); QL applies to members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
63
January 1, 2017 Drug Tier Requirements/Limits
Drug Name doxepin hcl conc 10 mg/ml
2
duloxetine hcl cap 20 mg 2 duloxetine hcl cap 30 mg 2 duloxetine hcl cap 60 mg 2 EMSAM DIS 6MG/24HR 4 EMSAM DIS 9MG/24HR 4 EMSAM DIS 12MG/24H 4 escitalopram oxalate soln 5 mg/5ml (base 2 equiv) escitalopram oxalate tab 5 mg (base equiv)2 escitalopram oxalate tab 10 mg (base 2 equiv) escitalopram oxalate tab 20 mg (base 2 equiv) FETZIMA CAP 20MG 4 FETZIMA CAP 40MG 4 FETZIMA CAP 80MG 4 FETZIMA CAP 120MG 4 FETZIMA CAP TITRATIO 4 fluoxetine hcl cap 10 mg 2 fluoxetine hcl cap 20 mg 2 fluoxetine hcl cap 40 mg 2 fluoxetine hcl cap delayed release 90 mg 2 fluoxetine hcl solution 20 mg/5ml 2 fluoxetine hcl tab 10 mg 2 fluoxetine hcl tab 20 mg 2 FLUOXETINE TAB 60MG 4 imipramine hcl tab 10 mg 2 imipramine hcl tab 25 mg
2
imipramine hcl tab 50 mg
2
imipramine pamoate cap 75 mg
2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
QL (450 mL / 25 days); QL applies to members age 65 and older
QL (120 tabs / 25 days); QL applies to members age 65 and older QL (120 tabs / 25 days); QL applies to members age 65 and older QL (60 tabs / 25 days); QL applies to members age 65 and older QL (30 caps / 25 days); QL applies to members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
64
January 1, 2017 Drug Tier Requirements/Limits
Drug Name imipramine pamoate cap 100 mg
2
imipramine pamoate cap 125 mg
2
imipramine pamoate cap 150 mg
2
maprotiline hcl tab 25 mg 2 maprotiline hcl tab 50 mg 2 maprotiline hcl tab 75 mg 2 MARPLAN TAB 10MG 4 mirtazapine orally disintegrating tab 15 mg 2 mirtazapine orally disintegrating tab 30 mg 2 mirtazapine orally disintegrating tab 45 mg 2 mirtazapine tab 7.5 mg 2 mirtazapine tab 15 mg 2 mirtazapine tab 30 mg 2 mirtazapine tab 45 mg 2 nefazodone hcl tab 50 mg 2 nefazodone hcl tab 100 mg 2 nefazodone hcl tab 150 mg 2 nefazodone hcl tab 200 mg 2 nefazodone hcl tab 250 mg 2 nortriptyline hcl cap 10 mg 2 nortriptyline hcl cap 25 mg
2
nortriptyline hcl cap 50 mg
2
nortriptyline hcl cap 75 mg
2
nortriptyline hcl soln 10 mg/5ml
2
paroxetine paroxetine paroxetine paroxetine paroxetine
2 2 2 2 2
hcl hcl hcl hcl hcl
tab tab tab tab tab
10 mg 20 mg 30 mg 40 mg sr 24hr 12.5 mg
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
QL (30 caps / 25 days); QL applies to members age 65 and older Members 65 and older subject to PA Members 65 and older subject to PA
QL (150 caps / 25 days); QL applies to members age 65 and older QL (60 caps / 25 days); QL applies to members age 65 and older QL (30 caps / 25 days); QL applies to members age 65 and older Members 65 and older subject to PA QL (750 mL / 25 days); QL applies to members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
65
January 1, 2017 Drug Tier Requirements/Limits
Drug Name paroxetine hcl tab sr 24hr 25 mg paroxetine hcl tab sr 24hr 37.5 mg phenelzine sulfate tab 15 mg protriptyline hcl tab 5 mg
2 2 2 2
protriptyline hcl tab 10 mg
2
sertraline hcl oral conc 20 mg/ml sertraline hcl tab 25 mg sertraline hcl tab 50 mg sertraline hcl tab 100 mg tranylcypromine sulfate tab 10 mg trazodone hcl tab 50 mg trazodone hcl tab 100 mg trazodone hcl tab 150 mg trazodone hcl tab 300 mg trimipramine maleate cap 25 mg
2 2 2 2 2 2 2 2 2 2
trimipramine maleate cap 50 mg
2
trimipramine maleate cap 100 mg
2
venlafaxine equivalent) venlafaxine equivalent) venlafaxine equivalent) venlafaxine venlafaxine venlafaxine venlafaxine venlafaxine venlafaxine equivalent) venlafaxine equivalent)
QL (90 tabs / 25 days); QL applies to members age 65 and older QL (60 tabs / 25 days); QL applies to members age 65 and older
QL (60 caps / 25 days); QL applies to members age 65 and older QL (60 caps / 25 days); QL applies to members age 65 and older QL (30 caps / 25 days); QL applies to members age 65 and older
hcl cap sr 24hr 37.5 mg (base 2 hcl cap sr 24hr 75 mg (base
2
hcl cap sr 24hr 150 mg (base
2
hcl hcl hcl hcl hcl hcl
2 2 2 2 2 2
tab tab tab tab tab tab
25 mg 37.5 mg 50 mg 75 mg 100 mg sr 24hr 37.5 mg (base
hcl tab sr 24hr 75 mg (base
PA - Prior Authorization (applies to pharmacy benefit only)
2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
66
January 1, 2017 Drug Tier Requirements/Limits
Drug Name venlafaxine hcl tab sr 24hr 150 mg (base equivalent) venlafaxine hcl tab sr 24hr 225 mg (base equivalent) VIIBRYD KIT VIIBRYD KIT STARTER VIIBRYD TAB 10MG VIIBRYD TAB 20MG VIIBRYD TAB 40MG
2 2 4 4 4 4 4
ST; ST; ST; ST; ST;
PA** PA** PA** PA** PA**
ANTIPARKINSONIAN AGENTS amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml amantadine hcl tab 100 mg APOKYN INJ 10MG/ML AZILECT TAB 0.5MG AZILECT TAB 1MG benztropine mesylate inj 1 mg/ml benztropine mesylate tab 0.5 mg benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg bromocriptine mesylate cap 5 mg bromocriptine mesylate tab 2.5 mg 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 carbidopa & levodopa tab 25-250 mg carbidopa & levodopa tab cr 25-100 mg carbidopa & levodopa tab cr 50-200 mg carbidopa tab 25 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
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 5 3 3 2 2 2 2 2 2 2
PA
2 2 2 2 2 2 2 2 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
67
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
carbidopa-levodopa-entacapone tabs 2 37.5-150-200 mg carbidopa-levodopa-entacapone tabs 2 50-200-200 mg entacapone tab 200 mg 2 NEUPRO DIS 1MG/24HR 3 NEUPRO DIS 2MG/24HR 3 NEUPRO DIS 3MG/24HR 3 NEUPRO DIS 4MG/24HR 3 NEUPRO DIS 6MG/24HR 3 NEUPRO DIS 8MG/24HR 3 pramipexole dihydrochloride tab 0.5 mg 2 pramipexole dihydrochloride tab 0.25 mg 2 pramipexole dihydrochloride tab 0.75 mg 2 pramipexole dihydrochloride tab 0.125 mg 2 pramipexole dihydrochloride tab 1 mg 2 pramipexole dihydrochloride tab 1.5 mg 2 pramipexole dihydrochloride tab sr 24hr 2 0.75 mg pramipexole dihydrochloride tab sr 24hr 2 0.375 mg pramipexole dihydrochloride tab sr 24hr 1.52 mg pramipexole dihydrochloride tab sr 24hr 2 2.25 mg pramipexole dihydrochloride tab sr 24hr 3 2 mg pramipexole dihydrochloride tab sr 24hr 2 3.75 mg pramipexole dihydrochloride tab sr 24hr 4.52 mg ropinirole hydrochloride tab 0.5 mg 2 ropinirole hydrochloride tab 0.25 mg 2 ropinirole hydrochloride tab 1 mg 2 ropinirole hydrochloride tab 2 mg 2 ropinirole hydrochloride tab 3 mg 2 ropinirole hydrochloride tab 4 mg 2 ropinirole hydrochloride tab 5 mg 2 selegiline hcl cap 5 mg 2 selegiline hcl tab 5 mg 2 tolcapone tab 100 mg 2 trihexyphenidyl hcl elixir 0.4 mg/ml 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
68
January 1, 2017 Drug Tier Requirements/Limits
Drug Name trihexyphenidyl hcl tab 2 mg trihexyphenidyl hcl tab 5 mg ZELAPAR TAB 1.25MG
2 2 4
ANTIPSYCHOTICS aripiprazole oral solution 1 mg/ml 2 aripiprazole orally disintegrating tab 10 mg 2 aripiprazole orally disintegrating tab 15 mg 2 aripiprazole tab 2 mg 2 aripiprazole tab 5 mg 2 aripiprazole tab 10 mg 2 aripiprazole tab 15 mg 2 aripiprazole tab 20 mg 2 aripiprazole tab 30 mg 2 ARISTADA INJ 441MG/1. 3 ARISTADA INJ 662MG/2 3 ARISTADA INJ 882MG/3 3 CHLORPROMAZ INJ 25MG/ML 4 CHLORPROMAZ INJ 50MG/2ML 4 chlorpromazine hcl tab 10 mg 2 chlorpromazine hcl tab 25 mg 2 chlorpromazine hcl tab 50 mg 2 chlorpromazine hcl tab 100 mg 2 chlorpromazine hcl tab 200 mg 2 clozapine orally disintegrating tab 12.5 mg 2 clozapine orally disintegrating tab 25 mg 2 clozapine orally disintegrating tab 100 mg 2 clozapine orally disintegrating tab 150 mg 2 clozapine orally disintegrating tab 200 mg 2 clozapine tab 25 mg 2 clozapine tab 50 mg 2 clozapine tab 100 mg 2 clozapine tab 200 mg 2 ergoloid mesylates tab 1 mg 2 FANAPT PAK 4 FANAPT TAB 1MG 4 FANAPT TAB 2MG 4 FANAPT TAB 4MG 4 FANAPT TAB 6MG 4 FANAPT TAB 8MG 4 FANAPT TAB 10MG 4 FANAPT TAB 12MG 4
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST; ST; ST; ST; ST; ST; ST; ST;
PA** PA** PA** PA** PA** PA** PA** PA**
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
69
January 1, 2017 Drug Tier Requirements/Limits
Drug Name 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 GEODON INJ 20MG 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 LATUDA TAB 20MG LATUDA TAB 40MG LATUDA TAB 60MG LATUDA TAB 80MG LATUDA TAB 120MG loxapine succinate cap 5 mg loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 50 mg NUPLAZID TAB 17MG 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 paliperidone tab sr 24hr 1.5 mg
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 2 2 2 4 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 2 2 2 2 5 2 2 2 2 2 2 2 2 2 2 2 2
QL - Quantity Limits
ST; ST; ST; ST; ST;
PA** PA** PA** PA** PA**
PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
70
January 1, 2017 Drug Tier Requirements/Limits
Drug Name paliperidone tab sr 24hr 3 mg paliperidone tab sr 24hr 6 mg paliperidone tab sr 24hr 9 mg perphenazine tab 2 mg perphenazine tab 4 mg perphenazine tab 8 mg perphenazine tab 16 mg pimozide tab 1 mg pimozide tab 2 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 REXULTI TAB 0.5MG REXULTI TAB 0.25MG REXULTI TAB 1MG REXULTI TAB 2MG REXULTI TAB 3MG REXULTI TAB 4MG risperidone orally disintegrating tab risperidone orally disintegrating tab mg risperidone orally disintegrating tab risperidone orally disintegrating tab risperidone orally disintegrating tab risperidone orally disintegrating tab 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 XR TAB 50MG SEROQUEL XR TAB 150MG SEROQUEL XR TAB 200MG
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 4 4 4 4 4 0.5 mg 2 0.25 2 1 2 3 4
mg mg mg mg
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 2 2 2 2 2 2 4 4 4 3 3 3
QL - Quantity Limits
ST; ST; ST; ST; ST; ST;
PA** PA** PA** PA** PA** PA**
ST; ST; ST; ST; ST; ST;
PA** PA** PA** PA** PA** PA**
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
71
January 1, 2017 Drug Tier Requirements/Limits
Drug Name SEROQUEL XR TAB 300MG SEROQUEL XR TAB 400MG 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 trifluoperazine hcl tab 2 mg trifluoperazine hcl tab 5 mg trifluoperazine hcl tab 10 mg ziprasidone hcl cap 20 mg ziprasidone hcl cap 40 mg ziprasidone hcl cap 60 mg ziprasidone hcl cap 80 mg
3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
ST; PA** ST; PA**
ATTENTION DEFICIT HYPERACTIVITY DISORDER§ amphetamine-dextroamphetamine 24hr 5 mg amphetamine-dextroamphetamine 24hr 10 mg amphetamine-dextroamphetamine 24hr 15 mg amphetamine-dextroamphetamine 24hr 20 mg amphetamine-dextroamphetamine 24hr 25 mg amphetamine-dextroamphetamine 24hr 30 mg amphetamine-dextroamphetamine mg amphetamine-dextroamphetamine mg amphetamine-dextroamphetamine mg amphetamine-dextroamphetamine mg amphetamine-dextroamphetamine mg
cap sr
2
QL (90 caps / 25 days)
cap sr
2
QL (90 caps / 25 days)
cap sr
2
QL (30 caps / 25 days)
cap sr
2
QL (30 caps / 25 days)
cap sr
2
QL (30 caps / 25 days)
cap sr
2
QL (30 caps / 25 days)
tab 5
2
QL (90 tabs / 25 days)
tab 7.5 2
QL (90 tabs / 25 days)
tab 10 2
QL (90 tabs / 25 days)
tab 12.52
QL (90 tabs / 25 days)
tab 15 2
QL (60 tabs / 25 days)
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
72
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
amphetamine-dextroamphetamine tab 20 2 mg amphetamine-dextroamphetamine tab 30 2 mg dexmethylphenidate hcl cap sr 24 hr 5 mg 2 dexmethylphenidate hcl cap sr 24 hr 10 mg2 dexmethylphenidate hcl cap sr 24 hr 15 mg2 dexmethylphenidate hcl cap sr 24 hr 20 mg2 dexmethylphenidate hcl cap sr 24 hr 30 mg2 dexmethylphenidate hcl cap sr 24 hr 40 mg2 dexmethylphenidate hcl tab 2.5 mg 2 dexmethylphenidate hcl tab 5 mg 2 dexmethylphenidate hcl tab 10 mg 2 dextroamphetamine sulfate cap sr 24hr 5 2 mg dextroamphetamine sulfate cap sr 24hr 10 2 mg dextroamphetamine sulfate cap sr 24hr 15 2 mg dextroamphetamine sulfate oral solution 5 2 mg/5ml dextroamphetamine sulfate tab 5 mg 2 dextroamphetamine sulfate tab 10 mg 2 guanfacine hcl tab sr 24hr 1 mg (base 2 equiv) guanfacine hcl tab sr 24hr 2 mg (base 2 equiv) guanfacine hcl tab sr 24hr 3 mg (base 2 equiv) guanfacine hcl tab sr 24hr 4 mg (base 2 equiv) methamphetamine hcl tab 5 mg 2 methylphenidate hcl cap cr 10 mg (cd) 2 methylphenidate hcl cap cr 20 mg (cd) 2 methylphenidate hcl cap cr 30 mg (cd) 2 methylphenidate hcl cap cr 40 mg (cd) 2 methylphenidate hcl cap cr 50 mg (cd) 2 methylphenidate hcl cap cr 60 mg (cd) 2 methylphenidate hcl cap sr 24hr 20 mg (la)2 methylphenidate hcl cap sr 24hr 30 mg (la)2 methylphenidate hcl cap sr 24hr 40 mg (la)2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
QL (60 tabs / 25 days) QL (30 tabs / 25 days) QL QL QL QL QL QL QL QL QL QL
(60 caps / 25 days) (60 caps / 25 days) (60 caps / 25 days) (60 caps / 25 days) (30 caps / 25 days) (30 caps / 25 days) (120 tabs / 25 days) (120 tabs / 25 days) (60 tabs / 25 days) (120 caps / 25 days)
QL (120 caps / 25 days) QL (60 caps / 25 days) QL (1,200 mL / 25 days) QL (120 tabs / 25 days) QL (120 tabs / 25 days) ST; PA** ST; PA** ST; PA** ST; PA** QL QL QL QL QL QL QL QL QL QL
(150 tabs / 25 days) (60 caps / 25 days) (60 caps / 25 days) (60 caps / 25 days) (30 caps / 25 days) (30 caps / 25 days) (30 caps / 25 days) (60 caps / 25 days) (60 caps / 25 days) (30 caps / 25 days)
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
73
January 1, 2017 Drug Tier Requirements/Limits
Drug Name methylphenidate hcl chew tab 2.5 mg
2
methylphenidate hcl chew tab 5 mg
2
methylphenidate hcl chew tab 10 mg
2
methylphenidate hcl soln 5 mg/5ml methylphenidate hcl soln 10 mg/5ml methylphenidate hcl tab 5 mg methylphenidate hcl tab 10 mg methylphenidate hcl tab 20 mg methylphenidate hcl tab cr 10 mg methylphenidate hcl tab cr 20 mg methylphenidate hcl tab sa osm 18 mg methylphenidate hcl tab sa osm 27 mg methylphenidate hcl tab sa osm 36 mg methylphenidate hcl tab sa osm 54 mg methylphenidate hcl tab sr 24hr 18 mg methylphenidate hcl tab sr 24hr 27 mg methylphenidate hcl tab sr 24hr 36 mg methylphenidate hcl tab sr 24hr 54 mg STRATTERA CAP 10MG STRATTERA CAP 18MG STRATTERA CAP 25MG STRATTERA CAP 40MG STRATTERA CAP 60MG STRATTERA CAP 80MG STRATTERA CAP 100MG VYVANSE CAP 10MG VYVANSE CAP 20MG VYVANSE CAP 30MG VYVANSE CAP 40MG VYVANSE CAP 50MG VYVANSE CAP 60MG VYVANSE CAP 70MG zenzedi tab 2.5mg zenzedi tab 7.5mg zenzedi tab 15mg zenzedi tab 20mg zenzedi tab 30mg
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 2 2 2 2
QL (180 chew tabs / 25 days) QL (180 chew tabs / 25 days) QL (180 chew tabs / 25 days) QL (1800 mL / 25 days) QL (900 mL / 25 days) QL (180 tabs / 25 days) QL (180 tabs / 25 days) QL (90 tabs / 25 days) QL (90 tabs / 25 days) QL (90 tabs / 25 days) QL (60 tabs / 25 days) QL (60 tabs / 25 days) QL (60 tabs / 25 days) QL (30 tabs / 25 days) QL (60 tabs / 25 days) QL (60 tabs / 25 days) QL (60 tabs / 25 days) QL (30 tabs / 25 days)
QL QL QL QL QL
(120 tabs / 25 days) (120 tabs / 25 days) (60 tabs / 25 days) (60 tabs / 25 days) (30 tabs / 25 days)
HYPNOTICS§
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
74
January 1, 2017 Drug Tier Requirements/Limits
Drug Name BELSOMRA TAB 5MG BELSOMRA TAB 10MG BELSOMRA TAB 15MG BELSOMRA TAB 20MG eszopiclone tab 1 mg eszopiclone tab 2 mg eszopiclone tab 3 mg HETLIOZ CAP 20MG ROZEREM TAB 8MG temazepam cap 7.5 mg temazepam cap 15 mg temazepam cap 22.5 mg temazepam cap 30 mg zaleplon cap 5 mg zaleplon cap 10 mg zolpidem tartrate tab 5 mg zolpidem tartrate tab 10 mg zolpidem tartrate tab cr 6.25 mg zolpidem tartrate tab cr 12.5 mg
3 3 3 3 2 2 2 6 4 2 2 2 2 2 2 2 2 2 2
ST ST ST ST
almotriptan malate tab 6.25 mg almotriptan malate tab 12.5 mg CAFERGOT TAB 1-100MG dihydroergotamine mesylate inj 1 mg/ml dihydroergotamine mesylate nasal spray 4 mg/ml ERGOMAR SUB 2MG frovatriptan succinate tab 2.5 mg (base equivalent) naratriptan hcl tab 1 mg (base equiv) naratriptan hcl tab 2.5 mg (base equiv) RELPAX TAB 20MG
2 2 3 2 2
QL (12 tabs / 25 days) QL (12 tabs / 25 days)
4 2
ST QL (18 tabs / 25 days)
2 2 4
RELPAX TAB 40MG
4
QL (12 tabs QL (12 tabs QL (12 tabs ST; PA** QL (12 tabs ST; PA** QL (18 tabs
PA ST; PA**
MIGRAINE§
rizatriptan benzoate oral disintegrating tab 2 5 mg (base eq) rizatriptan benzoate oral disintegrating tab 2 10 mg (base eq) rizatriptan benzoate tab 5 mg (base 2 equivalent)
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
QL (8 kits / 25 days)
/ 25 days) / 25 days) / 25 days), / 25 days), / 25 days)
QL (18 tabs / 25 days) QL (18 tabs / 25 days)
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
75
January 1, 2017 Drug Tier Requirements/Limits
Drug Name rizatriptan benzoate tab 10 mg (base equivalent) sumatriptan nasal spray 5 mg/act sumatriptan nasal spray 20 mg/act sumatriptan succinate inj 4 mg/0.5ml
2
QL (18 tabs / 25 days)
2 2 2
QL (24 sprays / 25 days) QL (12 sprays / 25 days) QL (18 syringes / 25 days) QL (12 vials per 25 days) QL (18 syringes / 25 days) QL (12 units / 25 days)
sumatriptan succinate inj 6 mg/0.5ml 2 sumatriptan succinate solution auto-injector2 4 mg/0.5ml sumatriptan succinate solution auto-injector2 6 mg/0.5ml sumatriptan succinate solution cartridge 4 2 mg/0.5ml sumatriptan succinate solution cartridge 6 2 mg/0.5ml sumatriptan succinate solution prefilled 2 syringe 6 mg/0.5ml sumatriptan succinate tab 25 mg 2 sumatriptan succinate tab 50 mg 2 sumatriptan succinate tab 100 mg 2 zolmitriptan orally disintegrating tab 2.5 mg2 zolmitriptan orally disintegrating tab 5 mg 2 zolmitriptan tab 2.5 mg 2 zolmitriptan tab 5 mg 2 ZOMIG NASAL SPR 5MG 4 ZOMIG SPR 2.5MG 4
QL (18 syringes / 25 days) QL (12 units / 25 days) QL (12 units / 25 days) QL QL QL QL QL QL QL QL QL
(12 (12 (12 (12 (12 (12 (12 (12 (12
tabs / 25 days) tabs / 25 days) tabs / 25 days) tabs / 25 days) tabs / 25 days) tabs / 25 days) tabs / 25 days) sprays / 25 days) sprays / 25 days)
MISCELLANEOUS GRALISE STAR MIS 300/600 GRALISE TAB 300MG GRALISE TAB 600MG GUANIDINE TAB 125MG lithium carbonate cap 150 mg lithium carbonate cap 300 mg lithium carbonate cap 600 mg lithium carbonate tab 300 mg lithium carbonate tab cr 300 mg lithium carbonate tab cr 450 mg LITHIUM SOL 8MEQ/5ML MESTINON SYP 60MG/5ML NUEDEXTA CAP 20-10MG pyridostigmine bromide tab 60 mg pyridostigmine bromide tab cr 180 mg
PA - Prior Authorization (applies to pharmacy benefit only)
4 4 4 4 2 2 2 2 2 2 4 3 3 2 2
QL - Quantity Limits
ST; PA** ST; PA** ST; PA**
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
76
January 1, 2017 Drug Tier Requirements/Limits
Drug Name REGONOL INJ 5MG/ML riluzole tab 50 mg SAVELLA MIS TITR PAK SAVELLA TAB 12.5MG SAVELLA TAB 25MG SAVELLA TAB 50MG SAVELLA TAB 100MG tetrabenazine tab 12.5 mg tetrabenazine tab 25 mg
4 2 4 4 4 4 4 5 5
PA PA
MULTIPLE SCLEROSIS AGENTS AMPYRA TAB 10MG 6 AUBAGIO TAB 7MG 3 AUBAGIO TAB 14MG 3 BETASERON INJ 0.3MG 3 COPAXONE INJ 40MG/ML 3 GILENYA CAP 0.5MG 3 glatiramer acetate soln prefilled syringe 20 3 mg/ml PLEGRIDY INJ 6 PLEGRIDY INJ PEN 6 PLEGRIDY INJ STARTER 6 PLEGRIDY PEN INJ STARTER 6 REBIF INJ 22/0.5 3 REBIF INJ 44/0.5 3 REBIF REBIDO INJ 22/0.5 3 REBIF REBIDO INJ 44/0.5 3 REBIF REBIDO INJ TITRATN 3 REBIF TITRTN INJ PACK 3 TECFIDERA CAP 120MG 3 TECFIDERA CAP 240MG 3 TECFIDERA MIS STARTER 3 TYSABRI INJ 300/15ML 6
PA PA PA PA PA PA PA PA, PA, PA, PA, PA PA PA PA PA PA PA PA PA PA
ST ST ST ST
MUSCULOSKELETAL THERAPY AGENTS baclofen tab 10 mg baclofen tab 20 mg BOTOX INJ 100UNIT BOTOX INJ 200UNIT carisoprodol tab 250 mg
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 5 5 2
QL - Quantity Limits
PA PA PA; High Risk Medications require PA for members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
77
January 1, 2017 Drug Tier Requirements/Limits
Drug Name carisoprodol tab 350 mg
2
chlorzoxazone tab 500 mg cyclobenzaprine hcl tab 5 mg
2 2
cyclobenzaprine hcl tab 7.5 mg
2
cyclobenzaprine hcl tab 10 mg
2
dantrolene sodium cap 25 mg dantrolene sodium cap 50 mg dantrolene sodium cap 100 mg metaxalone tab 400 mg
2 2 2 2
metaxalone tab 800 mg
2
methocarbamol tab 500 mg
2
methocarbamol tab 750 mg
2
orphenadrine citrate inj 30 mg/ml orphenadrine citrate tab sr 12hr 100 mg
2 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
78
January 1, 2017 Drug Tier Requirements/Limits
Drug Name orphenadrine w/ aspirin & caffeine tab 25-385-30 mg
2
PA; High Risk Medications require PA for members age 65 and older
tizanidine hcl cap 2 mg (base equivalent) tizanidine hcl cap 4 mg (base equivalent) tizanidine hcl cap 6 mg (base equivalent) tizanidine hcl tab 2 mg (base equivalent) tizanidine hcl tab 4 mg (base equivalent) XEOMIN INJ 50 UNIT XEOMIN INJ 100UNIT XEOMIN INJ 200UNIT
2 2 2 2 2 5 5 5
PA PA PA
2 2 2 2 2 2 3
PA PA PA PA PA PA PA
acamprosate calcium tab delayed release 333 mg buproban tab 150mg
2
PA
1
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg CHANTIX PAK 0.5& 1MG
1
CHANTIX PAK 1MG
1
CHANTIX TAB 0.5MG
1
CHANTIX TAB 1MG
1
$0 limited to cycles/year $0 limited to cycles/year $0 limited to cycles/year $0 limited to cycles/year $0 limited to cycles/year $0 limited to cycles/year
disulfiram tab 250 mg disulfiram tab 500 mg naloxone hcl inj 0.4 mg/ml naloxone hcl inj 1 mg/ml naltrexone hcl tab 50 mg NARCAN SPR
2 2 2 2 2 3
NARCOLEPSY/CATAPLEXY§ armodafinil tab 50 mg armodafinil tab 150 mg armodafinil tab 200 mg armodafinil tab 250 mg modafinil tab 100 mg modafinil tab 200 mg XYREM SOL 500MG/ML
PSYCHOTHERAPEUTIC-MISC
PA - Prior Authorization (applies to pharmacy benefit only)
1
QL - Quantity Limits
2 treatment 2 treatment 2 treatment 2 treatment 2 treatment 2 treatment
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
79
January 1, 2017 Drug Tier Requirements/Limits
Drug Name nicotine polacrilex gum 2 mg
1
nicotine polacrilex gum 4 mg
1
nicotine polacrilex lozenge 2 mg
1
nicotine polacrilex lozenge 4 mg
1
nicotine td patch 24hr 7 mg/24hr
1
nicotine td patch 24hr 14 mg/24hr
1
nicotine td patch 24hr 21 mg/24hr
1
NICOTROL INH
1
NICOTROL NS SPR 10MG/ML
1
sm nicotine dis 7mg/24hr
1
sm nicotine dis 14mg/24h
1
sm nicotine dis 21mg
1
thrive gum 4mg mint
1
VIVITROL INJ 380MG
5
OTC; $0 limited to 2 treatment cycles/year OTC; $0 limited to 2 treatment cycles/year OTC; $0 limited to 2 treatment cycles/year OTC; $0 limited to 2 treatment cycles/year OTC; $0 limited to 2 treatment cycles/year OTC; $0 limited to 2 treatment cycles/year OTC; $0 limited to 2 treatment cycles/year QL (max 168 days per year); $0 limited to 2 treatment cycles/year QL (max 168 days per year); $0 limited to 2 treatment cycles/year OTC; $0 limited to 2 treatment cycles/year OTC; $0 limited to 2 treatment cycles/year OTC; $0 limited to 2 treatment cycles/year OTC; $0 limited to 2 treatment cycles/year PA
4 4 2 2 2 2
PA PA PA PA PA PA
2
PA
2
PA
2
PA
ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 TAB 50MG ANDROXY TAB 10MG methyltestosterone cap 10 mg oxandrolone tab 2.5 mg oxandrolone tab 10 mg testosterone cypionate im inj in oil 100 mg/ml testosterone cypionate im inj in oil 200 mg/ml testosterone enanthate im inj in oil 200 mg/ml testosterone td gel 10mg/act (2%)
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
80
January 1, 2017 Drug Tier Requirements/Limits
Drug Name testosterone td gel 25 mg/2.5gm (1%)
2
PA
ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS acarbose tab 25 mg acarbose tab 50 mg acarbose tab 100 mg miglitol tab 25 mg miglitol tab 50 mg miglitol tab 100 mg
2 2 2 2 2 2
ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG SYMLNPEN 120 INJ 1000MCG
4 4
PA PA
ANTIDIABETICS, BIGUANIDE metformin metformin metformin metformin metformin metformin metformin
hcl hcl hcl hcl hcl hcl hcl
tab tab tab tab tab tab tab
500 mg 2 850 mg 2 1000 mg 2 sr 24hr 500 mg 2 sr 24hr 750 mg 2 sr 24hr osmotic 500 mg 2 sr 24hr osmotic 1000 mg2
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
2 2 2 2
glyburide-metformin tab 2.5-500 mg
2
glyburide-metformin tab 5-500 mg
2
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS alogliptin benzoate tab 6.25 mg (base 2 equiv) alogliptin benzoate tab 12.5 mg (base 2 equiv) alogliptin benzoate tab 25 mg (base equiv) 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
PA PA PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
81
January 1, 2017 Drug Tier Requirements/Limits
Drug Name JANUVIA TAB 25MG JANUVIA TAB 50MG JANUVIA TAB 100MG ONGLYZA TAB 2.5MG ONGLYZA TAB 5MG TRADJENTA TAB 5MG
3 3 3 4 4 3
ST ST
ANTIDIABETICS, DOPAMINE RECEPTOR AGONISTS CYCLOSET TAB 0.8MG
4
ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS JANUMET TAB 50-500MG JANUMET TAB 50-1000 JANUMET XR TAB 50-500MG JANUMET XR TAB 50-1000 JANUMET XR TAB 100-1000 JENTADUETO TAB 2.5-500 JENTADUETO TAB 2.5-850 JENTADUETO TAB 2.5-1000
3 3 3 3 3 3 3 3
ANTIDIABETICS, INCRETIN MIMETIC AGENTS BYDUREON INJ 2MG BYDUREON PEN INJ 2MG TANZEUM INJ 30MG TANZEUM INJ 50MG TRULICITY INJ 0.75/0.5 TRULICITY INJ 1.5/0.5 VICTOZA INJ 18MG/3ML
4 4 4 4 3 3 3
ANTIDIABETICS, INSULIN APIDRA INJ SOLOSTAR APIDRA INJ U-100 BASAGLAR INJ
3 3 3
HUMALOG INJ 100/ML HUMALOG KWIK INJ 100/ML HUMALOG KWIK INJ 200/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 HUMULIN INJ 70/30KWP HUMULIN N INJ U-100 HUMULIN N INJ U-100KWP
4 4 4 4 4 4 4 4 4 4 4
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
Expected Availability 12/15/16
OTC OTC OTC OTC
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
82
January 1, 2017 Drug Tier Requirements/Limits
Drug Name HUMULIN R INJ U-100 HUMULIN R INJ U-500 LEVEMIR INJ LEVEMIR INJ FLEXTOUC NOVOLIN INJ 70/30 NOVOLIN N INJ U-100 NOVOLIN R INJ U-100 NOVOLOG INJ 100/ML NOVOLOG INJ FLEXPEN NOVOLOG INJ PENFILL NOVOLOG MIX INJ 70/30 NOVOLOG MIX INJ FLEXPEN TRESIBA FLEX INJ 100UNIT TRESIBA FLEX INJ 200UNIT
4 3 3 3 3 3 3 3 3 3 3 3 3 3
OTC
OTC;RELION not covered OTC;RELION not covered OTC;RELION not covered
ANTIDIABETICS, INSULIN SENSITIZER pioglitazone hcl tab 15 mg (base equiv) pioglitazone hcl tab 30 mg (base equiv) pioglitazone hcl tab 45 mg (base equiv)
2 2 2
ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION pioglitazone hcl-metformin hcl tab 15-500 2 mg pioglitazone hcl-metformin hcl tab 15-850 2 mg
ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBINATION pioglitazone hcl-glimepiride tab 30-2 mg pioglitazone hcl-glimepiride tab 30-4 mg
2 2
ANTIDIABETICS, MEGLITINIDE nateglinide nateglinide repaglinide repaglinide repaglinide
tab tab tab tab tab
60 mg 120 mg 0.5 mg 1 mg 2 mg
2 2 2 2 2
ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATION repaglinide-metformin hcl tab 1-500 mg repaglinide-metformin hcl tab 2-500 mg
2 2
ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO INVOKAMET TAB 50-500MG INVOKAMET TAB 50-1000
PA - Prior Authorization (applies to pharmacy benefit only)
4 4
QL - Quantity Limits
ST ST
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
83
January 1, 2017 Drug Tier Requirements/Limits
Drug Name INVOKAMET TAB 150-500 INVOKAMET TAB 150-1000 XIGDUO XR TAB 5-500MG XIGDUO XR TAB 5-1000MG XIGDUO XR TAB 10-500MG XIGDUO XR TAB 10-1000
4 4 3 3 3 3
ST ST
ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER2(SGLT2) INHIB FARXIGA TAB 5MG FARXIGA TAB 10MG INVOKANA TAB 100MG INVOKANA TAB 300MG JARDIANCE TAB 10MG JARDIANCE TAB 25MG
3 3 4 4 3 3
ST ST
ANTIDIABETICS, SULFONYLUREA glimepiride tab 1 mg glimepiride tab 2 mg glimepiride tab 4 mg glipizide tab 5 mg glipizide tab 10 mg glipizide tab sr 24hr 2.5 mg glipizide tab sr 24hr 5 mg glipizide tab sr 24hr 10 mg glyburide micronized tab 1.5 mg
2 2 2 2 2 2 2 2 2
glyburide micronized tab 3 mg
2
glyburide micronized tab 6 mg
2
glyburide tab 1.25 mg
2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
84
January 1, 2017 Drug Tier Requirements/Limits
Drug Name glyburide tab 2.5 mg
2
glyburide tab 5 mg
2
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
BISPHOSPHONATES alendronate sodium oral soln 70 mg/75ml 2 alendronate sodium tab 5 mg 2 alendronate sodium tab 10 mg 2 alendronate sodium tab 35 mg 2 alendronate sodium tab 40 mg 2 alendronate sodium tab 70 mg 2 FOSAMAX + D TAB 70-2800 4 FOSAMAX + D TAB 70-5600 4 ibandronate sodium iv soln 3 mg/3ml (base2 equivalent) ibandronate sodium tab 150 mg (base 2 equivalent) pamidronate disodium for inj 30 mg 2 pamidronate disodium for inj 90 mg 2 pamidronate disodium iv soln 3 mg/ml 2 pamidronate disodium iv soln 9 mg/ml 2 PAMIDRONATE INJ 6MG/ML 4 risedronate sodium tab 5 mg 2 risedronate sodium tab 30 mg 2 risedronate sodium tab 35 mg 2 risedronate sodium tab 150 mg 2 risedronate sodium tab delayed release 35 2 mg zoledronic acid inj conc for iv infusion 4 5 mg/5ml zoledronic acid iv soln 5 mg/100ml 5 ZOLEDRONIC INJ 4MG/100 5 ZOMETA INJ 4MG/100 5
ST; PA** ST; PA**
PA PA PA PA
CALCIUM RECEPTOR AGONISTS SENSIPAR TAB 30MG SENSIPAR TAB 60MG SENSIPAR TAB 90MG
5 5 5
PA PA PA
CHELATING AGENTS
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
85
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
CHEMET CAP 100MG 4 DEPEN TITRA TAB 250MG 4 EXJADE TAB 125MG 6 EXJADE TAB 250MG 6 EXJADE TAB 500MG 6 FERRIPROX TAB 500MG 5 JADENU TAB 90MG 6 JADENU TAB 180MG 6 JADENU TAB 360MG 6 kionex sus 15gm/60 2 sodium polystyrene sulfonate oral susp 15 2 gm/60ml sodium polystyrene sulfonate rectal susp 302 gm/120ml SYPRINE CAP 250MG 4 VISTOGARD PAK 10GM 3
PA PA PA PA PA PA PA
CONTRACEPTIVES altavera tab alyacen tab 1/35 alyacen tab 7/7/7 amethia tab amethyst tab 90-20mcg apri tab aranelle tab ashlyna tab aviane tab azurette tab 28 day BEYAZ TAB camila tab 0.35mg caziant pak cesia pak chateal tab 0.15/30 cryselle-28 tab 28 tabs cyclafem tab 1/35 cyclafem tab 7/7/7 dasetta tab 1/35 dasetta tab 7/7/7 delyla tab 0.1-0.02 DEPO-SQ PROV INJ 104 drospirenone-ethinyl estradiol tab 3-0.03 mg
PA - Prior Authorization (applies to pharmacy benefit only)
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
QL - Quantity Limits
QL (4 inj / 300 days)
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
86
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
elinest tab 1 ELLA TAB 30MG 1 emoquette tab 1 enpresse-28 tab 1 errin tab 0.35mg 1 falmina tab 1 gianvi tab 3-0.02mg 1 gildess fe tab 1.5/30 1 gildess fe tab 1/20 1 gildess tab 1.5/30 1 gildess tab 1/20 1 heather tab 0.35mg 1 IMPLANON IMP 68MG 1 introvale tab 1 jolessa tab 1 jolivette tab 0.35mg 1 junel 1.5/30 tab 1 junel 1/20 tab 1 junel fe tab 1.5/30 1 junel fe tab 1/20 1 kariva tab 28 day 1 kelnor tab 1/35 1 kurvelo tab 0.15/30 1 larin tab 1.5/30 1 leena tab 1 lessina tab 1 levonest tab 1 levonorg-eth est tab 0.1-0.02mg(84) & eth 1 est tab 0.01mg(7) levonorgestrel & ethinyl estradiol (91-day) 1 tab 0.15-0.03 mg levonorgestrel & ethinyl estradiol tab 0.15 1 mg-30 mcg levonorgestrel tab 0.75 mg 1 levonorgestrel tab 1.5 mg 1 levora-28 tab 0.15/30 1 LILETTA IUD 52MG 1 LO LOESTRIN TAB 1 lomedia 24 tab fe 1 loryna tab 3-0.02mg 1 low-ogestrel tab 1
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
QL (1 / 300 days)
QL (1 / 300 days)
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
87
January 1, 2017 Drug Tier Requirements/Limits
Drug Name lutera tab marlissa tab 0.15/30 medroxyprogesterone acetate im susp 150 mg/ml MINASTRIN 24 CHW FE MIRENA IUD SYSTEM mono-linyah tab 0.25-35 mononessa tab myzilra tab NATAZIA TAB necon tab 0.5/35 necon tab 1/35 necon tab 1/50-28 necon tab 7/7/7 NECON TAB 10/11-28 NEXPLANON IMP 68MG nikki tab 3-0.02mg nora-be tab 0.35mg norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg norethindrone tab 0.35 mg norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg nortrel tab 0.5/35 nortrel tab 1/35 nortrel tab 7/7/7 NUVARING MIS ocella tab 3-0.03mg ogestrel tab orsythia tab PARAGARD IUD T380A pirmella tab 1/35 portia-28 tab previfem tab QUARTETTE TAB quasense tab reclipsen tab SAFYRAL TAB
PA - Prior Authorization (applies to pharmacy benefit only)
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
QL (4 inj / 300 days)
QL (1 / 300 days)
QL (1 / 300 days)
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
QL - Quantity Limits
QL (13 / 300 days)
QL (1 unit / 300 days)
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
88
January 1, 2017 Drug Tier Requirements/Limits
Drug Name SKYLA IUD 13.5MG solia tab sprintec 28 tab 28 day sronyx tab syeda tab 3-0.03mg tilia fe tab tri-linyah tab tri-previfem tab tri-sprintec tab trinessa tab trivora-28 tab velivet pak vestura tab 3-0.02mg viorele tab wera tab 0.5/35 xulane dis 150-35 zarah tab 3-0.03mg zenchent fe chw 0.4mg-35 zenchent tab zovia 1/35e tab zovia 1/50e tab
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
QL (1 / 300 days)
ENDOMETRIOSIS danazol cap 50 mg danazol cap 100 mg danazol cap 200 mg SYNAREL SOL 2MG/ML
2 2 2 3
ENZYME REPLACEMENTS ADAGEN INJ 250/ML ALDURAZYME INJ 2.9MG/5M BUPHENYL TAB 500MG CARBAGLU TAB 200MG CERDELGA CAP 84MG CEREZYME INJ 400UNIT CYSTADANE POW CYSTAGON CAP 50MG CYSTAGON CAP 150MG ELAPRASE INJ 6MG/3ML ELELYSO INJ 200UNIT FABRAZYME INJ 5MG FABRAZYME INJ 35MG KUVAN POW 100MG
PA - Prior Authorization (applies to pharmacy benefit only)
5 5 5 5 6 5 5 5 5 5 5 5 5 5
QL - Quantity Limits
PA PA PA PA PA PA PA PA PA PA PA PA PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
89
January 1, 2017 Drug Tier Requirements/Limits
Drug Name KUVAN POW 500MG KUVAN TAB 100MG MYALEPT INJ 11.3MG MYOZYME INJ 50MG NAGLAZYME INJ 1MG/ML ORFADIN CAP 2MG ORFADIN CAP 5MG ORFADIN CAP 10MG ORFADIN CAP 20MG ORFADIN SUS 4MG/ML sodium phenylbutyrate oral powder 3 gm/teaspoonful VPRIV INJ 400UNIT ZAVESCA CAP 100MG
5 5 5 5 5 5 5 5 5 5 2
PA PA PA PA PA PA PA PA PA PA PA
5 5
PA PA
CENESTIN TAB 0.3MG
4
CENESTIN TAB 0.9MG
4
CENESTIN TAB 0.45MG
4
CENESTIN TAB 0.625MG
4
CENESTIN TAB 1.25MG
4
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
CLIMARA PRO DIS WEEKLY DEPO-ESTRADI INJ 5MG/ML DIVIGEL GEL 0.5MG
3 4 4
ESTROGENS
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
PA; High Risk Medications require PA for members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
90
January 1, 2017 Drug Tier Requirements/Limits
Drug Name DIVIGEL GEL 0.25MG
4
DIVIGEL GEL 1MG/GM
4
DUAVEE TAB 0.45-20 ELESTRIN GEL 0.06%
3 4
ENJUVIA TAB 0.3MG
4
ENJUVIA TAB 0.9MG
4
ENJUVIA TAB 0.45MG
4
ENJUVIA TAB 0.625MG
4
ENJUVIA TAB 1.25MG
4
ESTRACE VAG CRE 0.1MG/GM 3 estradiol & norethindrone acetate tab 2 0.5-0.1 mg estradiol & norethindrone acetate tab 1-0.5 2 mg estradiol tab 0.5 mg 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
PA; High Risk Medications require PA for members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
91
January 1, 2017 Drug Tier Requirements/Limits
Drug Name estradiol tab 1 mg
2
estradiol tab 2 mg
2
estradiol td patch twice weekly 0.1 mg/24hr2
estradiol td patch twice weekly 0.05 mg/24hr
2
estradiol td patch twice weekly 0.025 mg/24hr
2
estradiol td patch twice weekly 0.075 mg/24hr
2
estradiol td patch twice weekly 0.0375 mg/24hr
2
estradiol td patch weekly 0.1 mg/24hr
2
estradiol td patch weekly 0.05 mg/24hr
2
estradiol td patch weekly 0.06 mg/24hr
2
estradiol td patch weekly 0.025 mg/24hr
2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
92
January 1, 2017 Drug Tier Requirements/Limits
Drug Name estradiol td patch weekly 0.075 mg/24hr
2
estradiol td patch weekly 0.0375 mg/24hr 2 (37.5 mcg/24hr) estradiol valerate im in oil 10 mg/ml estradiol valerate im in oil 20 mg/ml estradiol valerate im in oil 40 mg/ml ESTRING MIS 2MG ESTROGEL GEL
2 2 2 4 4
estropipate tab 0.75 mg
2
estropipate tab 1.5 mg
2
estropipate tab 3 mg
2
EVAMIST SPR 1.53MG
4
FEMRING MIS 0.1MG/24 FEMRING MIS 0.05/24H jinteli tab 1mg-5mcg MENEST TAB 0.3MG
4 4 2 4
MENEST TAB 0.625MG
4
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
93
January 1, 2017 Drug Tier Requirements/Limits
Drug Name MENEST TAB 1.25MG
4
MENEST TAB 2.5MG
4
MENOSTAR DIS 14MCG
4
mimvey lo tab 0.5-0.1 2 mimvey tab 1-0.5mg 2 norethindrone acetate-ethinyl estradiol tab 2 0.5 mg-2.5 mcg ortho-est tab 0.625 2
ortho-est tab 1.25
2
PREMARIN INJ 25MG PREMARIN TAB 0.3MG
4 4
PREMARIN TAB 0.9MG
4
PREMARIN TAB 0.45MG
4
PREMARIN TAB 0.625MG
4
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
94
January 1, 2017 Drug Tier Requirements/Limits
Drug Name PREMARIN TAB 1.25MG
4
PREMARIN VAG CRE 0.625MG VAGIFEM TAB 10MCG
4 4
PA; High Risk Medications require PA for members age 65 and older
GLUCOCORTICOIDS a-hydrocort inj 100mg 2 a-methapred inj 40mg 2 a-methapred inj 125mg 2 cortisone acetate tab 25 mg 2 DEPO-MEDROL INJ 20MG/ML 4 DEXAMETHASON CON 1MG/ML 3 dexamethasone elixir 0.5 mg/5ml 2 dexamethasone sod phosphate preservative2 free inj 10 mg/ml dexamethasone sodium phosphate inj 4 2 mg/ml dexamethasone sodium phosphate inj 10 2 mg/ml dexamethasone sodium phosphate inj 20 2 mg/5ml dexamethasone sodium phosphate inj 100 2 mg/10ml dexamethasone sodium phosphate inj 120 2 mg/30ml dexamethasone soln 0.5 mg/5ml 2 dexamethasone tab 0.5 mg 2 dexamethasone tab 0.75 mg 2 dexamethasone tab 1 mg 2 dexamethasone tab 1.5 mg 2 dexamethasone tab 2 mg 2 dexamethasone tab 4 mg 2 dexamethasone tab 6 mg 2 DEXPAK PAK 6 DAY 4 DEXPAK PAK 10 DAY 4 DEXPAK PAK 13 DAY 4 fludrocortisone acetate tab 0.1 mg 2 hydrocortisone tab 5 mg 2 hydrocortisone tab 10 mg 2 hydrocortisone tab 20 mg 2 MEDROL TAB 2MG 3
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
95
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
methylprednisolone acetate inj susp 40 2 mg/ml methylprednisolone acetate inj susp 80 2 mg/ml methylprednisolone sodium succinate for inj2 40 mg methylprednisolone sodium succinate for inj2 125 mg methylprednisolone sodium succinate for inj2 500 mg methylprednisolone sodium succinate for inj2 1000 mg methylprednisolone tab 4 mg 2 methylprednisolone tab 8 mg 2 methylprednisolone tab 16 mg 2 methylprednisolone tab 32 mg 2 methylprednisolone tab therapy pack 4 mg 2 (21) MILLIPRED DP PAK 5MG 4 MILLIPRED SOL 10MG/5ML 4 MILLIPRED TAB 5MG 4 prednisolone sod phos orally disintegr tab 2 10 mg (base eq) prednisolone sod phos orally disintegr tab 2 15 mg (base eq) prednisolone sod phos orally disintegr tab 2 30 mg (base eq) prednisolone sod phosph oral soln 6.7 2 mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 15 2 mg/5ml (base equiv) prednisolone sodium phosphate oral soln 252 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp solution2 equivalent) PREDNISONE CON 5MG/ML 3 prednisone oral soln 5 mg/5ml 2 prednisone tab 1 mg 2 prednisone tab 2.5 mg 2 prednisone tab 5 mg 2 prednisone tab 10 mg 2 prednisone tab 20 mg 2 prednisone tab 50 mg 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
96
January 1, 2017 Drug Tier Requirements/Limits
Drug Name 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) SOLU-CORTEF INJ 100MG SOLU-CORTEF INJ 250MG SOLU-CORTEF INJ 500MG SOLU-CORTEF INJ 1000MG SOLU-MEDROL INJ 2GM VERIPRED 20 SOL 20MG/5ML
2 2 2 2 4 4 4 4 4 4
GLUCOSE ELEVATING AGENTS GLUCAGON KIT 1MG PROGLYCEM SUS 50MG/ML
3 4
HUMAN GROWTH HORMONES GENOTROPIN INJ 0.2MG GENOTROPIN INJ 0.4MG GENOTROPIN INJ 0.6MG GENOTROPIN INJ 0.8MG GENOTROPIN INJ 1.2MG GENOTROPIN INJ 1.4MG GENOTROPIN INJ 1.6MG GENOTROPIN INJ 1.8MG GENOTROPIN INJ 1MG GENOTROPIN INJ 2MG GENOTROPIN INJ 5MG GENOTROPIN INJ 12MG HUMATROPE INJ 5MG HUMATROPE INJ 6MG HUMATROPE INJ 12MG HUMATROPE INJ 24MG NORDITROPIN INJ 5/1.5ML NORDITROPIN INJ 10/1.5ML NORDITROPIN INJ 15/1.5ML NORDITROPIN INJ 30/3ML NUTROPIN AQ INJ 10MG/2ML NUTROPIN AQ INJ 20MG/2ML NUTROPIN AQ INJ NUSPIN 5 NUTROPIN INJ 10MG OMNITROPE INJ 5.8MG OMNITROPE INJ 5/1.5ML OMNITROPE INJ 10/1.5ML
PA - Prior Authorization (applies to pharmacy benefit only)
6 6 6 6 6 6 6 6 6 6 6 6 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6
QL - Quantity Limits
PA, PA, PA, PA, PA, PA, PA, PA, PA, PA, PA, PA, PA PA PA PA PA PA PA PA PA, PA, PA, PA, PA, PA, PA,
ST ST ST ST ST ST ST ST ST ST ST ST
ST ST ST ST ST ST ST
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
97
January 1, 2017 Drug Tier Requirements/Limits
Drug Name SAIZEN INJ 5MG SAIZEN INJ 8.8MG SEROSTIM INJ 4MG SEROSTIM INJ 5MG SEROSTIM INJ 6MG ZORBTIVE INJ 8.8MG
6 6 5 5 5 5
PA, ST PA, ST PA PA PA PA
cabergoline tab 0.5 mg calcitonin (salmon) nasal soln 200 unit/act chorionic gonadotropin for inj 10000 unit FORTEO SOL 600/2.4 INCRELEX INJ 40MG/4ML MIACALCIN INJ 200/ML octreotide acetate inj 50 mcg/ml (0.05 mg/ml) octreotide acetate inj 100 mcg/ml (0.1 mg/ml) octreotide acetate inj 200 mcg/ml (0.2 mg/ml) octreotide acetate inj 500 mcg/ml (0.5 mg/ml) octreotide acetate inj 1000 mcg/ml (1 mg/ml) OSPHENA TAB 60MG PROLIA SOL 60MG/ML raloxifene hcl tab 60 mg
2 2 5 5 5 4 5
PA PA PA
5
PA
5
PA
5
PA
5
PA
SAMSCA TAB 15MG SAMSCA TAB 30MG SANDOSTATIN KIT LAR 10MG SANDOSTATIN KIT LAR 20MG SANDOSTATIN KIT LAR 30MG SIGNIFOR INJ 0.3MG/ML SIGNIFOR INJ 0.6MG/ML SIGNIFOR INJ 0.9MG/ML SOMATULINE INJ 60/0.2ML SOMATULINE INJ 90/0.3ML SOMATULINE INJ 120/.5ML SOMAVERT INJ 10MG SOMAVERT INJ 15MG
5 5 5 5 5 6 6 6 5 5 5 5 5
MISCELLANEOUS
PA - Prior Authorization (applies to pharmacy benefit only)
3 5 2
QL - Quantity Limits
PA
PA $0 copay for women > 35 years for the primary prevention of breast cancer PA PA PA PA PA PA PA PA PA PA PA PA PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
98
January 1, 2017 Drug Tier Requirements/Limits
Drug Name SOMAVERT INJ 20MG SOMAVERT INJ 25MG SOMAVERT INJ 30MG XGEVA INJ
5 5 5 5
PA PA PA PA
PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) cap 6672 mg (169 mg ca) calcium acetate (phosphate binder) tab 6672 mg FOSRENOL CHW 500MG 4 FOSRENOL CHW 750MG 4 FOSRENOL CHW 1000MG 4 FOSRENOL POW 750MG 4 FOSRENOL POW 1000MG 4 PHOSLYRA SOL 3 RENVELA PAK 0.8GM 3 RENVELA PAK 2.4GM 3 RENVELA TAB 800MG 3 VELPHORO CHW 500MG 4
PROGESTINS CRINONE GEL 4% VAG CRINONE GEL 8% VAG LUPANETA KIT 3.75-5 LUPANETA KIT 11.25-5 medroxyprogesterone acetate tab 2.5 mg medroxyprogesterone acetate tab 5 mg medroxyprogesterone acetate tab 10 mg norethindrone acetate tab 5 mg progesterone micronized cap 100 mg progesterone micronized cap 200 mg
3 3 6 6 2 2 2 2 2 2
PA PA
THYROID AGENTS levothyroxine levothyroxine levothyroxine levothyroxine levothyroxine levothyroxine levothyroxine levothyroxine levothyroxine levothyroxine
sodium sodium sodium sodium sodium sodium sodium sodium sodium sodium
tab tab tab tab tab tab tab tab tab tab
25 mcg 50 mcg 75 mcg 88 mcg 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 2 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
99
January 1, 2017 Drug Tier Requirements/Limits
Drug Name levothyroxine sodium tab 200 mcg levothyroxine sodium tab 300 mcg levoxyl tab 25mcg levoxyl tab 50mcg levoxyl tab 75mcg levoxyl tab 88mcg levoxyl tab 100mcg levoxyl tab 112mcg levoxyl tab 125mcg levoxyl tab 137mcg levoxyl tab 150mcg levoxyl tab 175mcg levoxyl tab 200mcg liothyronine sodium iv soln 10 mcg/ml liothyronine sodium tab 5 mcg liothyronine sodium tab 25 mcg liothyronine sodium tab 50 mcg methimazole tab 5 mg methimazole tab 10 mg propylthiouracil tab 50 mg 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 THYROLAR-1 TAB 60MG THYROLAR-1/2 TAB 30MG THYROLAR-1/4 TAB 15MG THYROLAR-2 TAB 120MG THYROLAR-3 TAB 180MG unithroid tab 25mcg unithroid tab 50mcg unithroid tab 75mcg unithroid tab 88mcg
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
100
January 1, 2017 Drug Tier Requirements/Limits
Drug Name unithroid unithroid unithroid unithroid unithroid
tab tab tab tab tab
100mcg 112mcg 125mcg 200mcg 300mcg
2 2 2 2 2
VASOPRESSINS desmopressin acetate desmopressin acetate (refrigerated) desmopressin acetate 0.01% desmopressin acetate 0.01% (refrigerated) desmopressin acetate desmopressin acetate
inj 4 mcg/ml nasal soln 0.01%
2 2
nasal spray soln
2
nasal spray soln
2
tab 0.1 mg tab 0.2 mg
2 2
GASTROINTESTINAL ANTICHOLINERGICS§ ATROPEN INJ 0.5MG ATROPEN INJ 0.25MG ATROPEN INJ 1MG ATROPEN INJ 2MG atropine sulfate inj 0.1 mg/ml atropine sulfate inj 0.05 mg/ml atropine sulfate inj 1 mg/ml CANTIL TAB 25MG CUVPOSA SOL 1MG/5ML dicyclomine hcl cap 10 mg dicyclomine hcl inj 10 mg/ml dicyclomine hcl oral soln 10 mg/5ml dicyclomine hcl tab 20 mg ed-spaz tab 0.125mg glycopyrrolate inj 0.2 mg/ml glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) glycopyrrolate tab 1 mg glycopyrrolate tab 2 mg hyomax-sl sub 0.125mg hyoscyamine sulfate tab 0.125 mg hyoscyamine sulfate tab disp 0.125 mg hyoscyamine sulfate tab sl 0.125 mg
PA - Prior Authorization (applies to pharmacy benefit only)
4 4 4 4 2 2 2 4 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
101
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
hyoscyamine sulfate tab sr 12hr 0.375 mg 2 methscopolamine bromide tab 2.5 mg 2 methscopolamine bromide tab 5 mg 2 nulev tab 0.125mg 2 oscimin sr tab 0.375mg 2 oscimin sub 0.125mg 2 oscimin tab 0.125mg 2 symax fastab tab 0.125mg 2 symax-sl sub 0.125mg 2
ANTIEMETICS§ AKYNZEO CAP
4
ALOXI INJ 0.25MG/5 4 ANTIVERT TAB 50MG 3 ANZEMET TAB 50MG 4 ANZEMET TAB 100MG 4 CESAMET CAP 1MG 4 compro sup 25mg 2 dimenhydrinate tab 50 mg 2 dronabinol cap 2.5 mg 2 dronabinol cap 5 mg 2 dronabinol cap 10 mg 2 EMEND CAP 40MG 4 EMEND CAP 80MG 4 EMEND CAP 125MG 4 EMEND PAK 80 & 125 4 EMEND SUS 125MG 4 granisetron hcl inj 0.1 mg/ml 2 granisetron hcl inj 1 mg/ml 2 granisetron hcl inj 4 mg/4ml (1 mg/ml) 2 granisetron hcl tab 1 mg 2 meclizine hcl tab 12.5 mg 2 meclizine hcl tab 25 mg 2 metoclopramide hcl inj 5 mg/ml 2 metoclopramide hcl orally disintegrating tab2 5 mg metoclopramide hcl soln 5 mg/5ml (10 2 mg/10ml) metoclopramide hcl tab 5 mg 2 metoclopramide hcl tab 10 mg 2 ondansetron hcl inj 4 mg/2ml (2 mg/ml) 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
QL (2 capsules per 21 days) QL (10 mL / 21 days) QL (6 tablets / 21 days) QL (6 tablets / 21 days) QL (18 caps / 25 days)
QL (60 caps / 25 days) QL (60 caps / 25 days) QL (60 caps / 25 days) QL (3 caps / 180 days) QL (4 capsules / 21 days) QL (2 capsules / 21 days) QL (2 packs / 21 days) QL (6 kits / 25 days) QL (2 mL / 21 days) QL (2 mL / 21 days) QL (2 mL / 21 days) QL (12 tablets / 21 days)
QL (20 mL / 21 days)
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
102
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
ondansetron hcl inj 40 mg/20ml (2 mg/ml) 2 ondansetron hcl oral soln 4 mg/5ml 2 ondansetron hcl tab 4 mg 2 ondansetron hcl tab 8 mg 2 ondansetron hcl tab 24 mg 2 ondansetron orally disintegrating tab 4 mg 2 ondansetron orally disintegrating tab 8 mg 2 phenadoz sup 25mg 2 prochlorperazine edisylate inj 5 mg/ml 2 prochlorperazine maleate tab 5 mg (base 2 equivalent) prochlorperazine maleate tab 10 mg (base 2 equivalent) prochlorperazine suppos 25 mg 2 promethazine hcl inj 25 mg/ml 2 promethazine hcl inj 50 mg/ml 2 promethazine hcl suppos 12.5 mg 2 promethazine hcl suppos 25 mg 2 promethazine hcl syrup 6.25 mg/5ml 2
promethazine hcl tab 12.5 mg
2
promethazine hcl tab 25 mg
2
promethazine hcl tab 50 mg
2
promethegan sup 12.5mg promethegan sup 25mg promethegan sup 50mg SANCUSO DIS 3.1MG TRANSDERM-SC DIS 1MG trimethobenzamide hcl cap 300 mg
2 2 2 4 4 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
QL QL QL QL QL QL QL
(20 mL / 21 days) (200 mL / 21 days) (18 tablets / 21 days) (18 tablets / 21 days) (2 tablets / 21 days) (18 tablets / 21 days) (18 tablets / 21 days)
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
QL (2 patches / 21 days) PA; High Risk Medications require PA for members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
103
January 1, 2017 Drug Tier Requirements/Limits
Drug Name trimethobenzamide hcl inj 100 mg/ml
2
univert tab 32mg VARUBI TAB 90MG ZUPLENZ MIS 4MG ZUPLENZ MIS 8MG
2 3 4 4
PA; High Risk Medications require PA for members age 65 and older QL (2 packs per 21 days) QL (18 films / 21 days) QL (18 films / 21 days)
H2-RECEPTOR ANTAGONISTS cimetidine hcl soln 300 mg/5ml 2 cimetidine tab 200 mg 2 cimetidine tab 300 mg 2 cimetidine tab 400 mg 2 cimetidine tab 800 mg 2 famotidine for susp 40 mg/5ml 2 famotidine in nacl 0.9% iv soln 20 mg/50ml2 famotidine inj 20 mg/2ml 2 famotidine inj 40 mg/4ml 2 famotidine inj 200 mg/20ml 2 famotidine inj 500 mg/50ml 2 famotidine tab 20 mg 2 famotidine tab 40 mg 2 nizatidine cap 150 mg 2 nizatidine cap 300 mg 2 nizatidine oral soln 15 mg/ml 2 ranitidine hcl cap 150 mg 2 ranitidine hcl cap 300 mg 2 ranitidine hcl inj 50 mg/2ml (25 mg/ml) 2 ranitidine hcl inj 150 mg/6ml (25 mg/ml) 2 ranitidine hcl inj 1000 mg/40ml (25 mg/ml)2 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 2 ranitidine hcl tab 150 mg 2 ranitidine hcl tab 300 mg 2 ZANTAC INJ 50/50ML 4 ZANTAC TAB 25MG EF 4
INFLAMMATORY BOWEL DISEASE APRISO CAP 0.375GM 3 balsalazide disodium cap 750 mg 2 budesonide delayed release particles cap 3 2 mg CANASA SUP 1000MG 3
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
104
January 1, 2017 Drug Tier Requirements/Limits
Drug Name colocort ene 100mg DIPENTUM CAP 250MG mesalamine enema 4 gm mesalamine rectal enema 4 gm & cleanser wipe kit sulfasalazine tab 500 mg sulfasalazine tab delayed release 500 mg
2 4 2 2 2 2
IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl tab 0.5 mg (base equiv) alosetron hcl tab 1 mg (base equiv) LINZESS CAP 145MCG LINZESS CAP 290MCG
2 2 3 3
PA PA
LAXATIVES AMITIZA CAP 8MCG AMITIZA CAP 24MCG COLYTE/FLAVR SOL PACKS enulose sol 10gm/15 gavilyte-c sol gavilyte-g sol gavilyte-h kit
3 3 3 2 2 2 1
gavilyte-n sol flav pk generlac sol 10gm/15 GOLYTELY SOL KRISTALOSE PAK 10GM KRISTALOSE PAK 20GM lactulose solution 10 gm/15ml MOVIPREP SOL
2 2 3 4 4 2 3
OSMOPREP TAB 1.5GM 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 polyethylene glycol 3350 oral powder PREPOPIK PAK
4 2
SUPREP BOWEL SOL PREP
4
PA - Prior Authorization (applies to pharmacy benefit only)
$0 copay for members age 50 through 74
$0 copay for members age 50 through 74
2 2 2 2 1
QL - Quantity Limits
$0 copay for members age 50 through 74 $0 copay for members age 50 through 74
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
105
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
MISCELLANEOUS CARAFATE SUS 1GM/10ML 4 cromolyn sodium oral conc 100 mg/5ml 2 diphenoxylate w/ atropine liq 2.5-0.025 2 mg/5ml diphenoxylate w/ atropine tab 2.5-0.025 mg2 loperamide hcl cap 2 mg 2 misoprostol tab 100 mcg 2 misoprostol tab 200 mcg 2 MOTOFEN TAB 4 MOVANTIK TAB 12.5MG 3 MOVANTIK TAB 25MG 3 SUCRAID SOL 8500/ML 4 sucralfate tab 1 gm 2 ursodiol cap 300 mg 2 ursodiol tab 250 mg 2 ursodiol tab 500 mg 2
PANCREATIC ENZYMES CREON CAP 3000UNIT CREON CAP 6000UNIT CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 36000UNT VIOKACE TAB VIOKACE TAB 20880 ZENPEP CAP 3000UNIT ZENPEP CAP 5000UNIT ZENPEP CAP 10000UNT ZENPEP CAP 15000UNT ZENPEP CAP 20000UNT ZENPEP CAP 25000UNT ZENPEP CAP 40000UNT
3 3 3 3 3 3 3 3 3 3 3 3 3 3
PROTON PUMP INHIBITORS§ DEXILANT CAP 30MG DR DEXILANT CAP 60MG DR esomeprazole magnesium cap delayed release 20 mg (base eq) esomeprazole magnesium cap delayed release 40 mg (base eq) esomeprazole sodium for intravenous soln 20 mg (base equiv)
PA - Prior Authorization (applies to pharmacy benefit only)
4 4 2
ST; PA** ST; PA**
2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
106
January 1, 2017 Drug Tier Requirements/Limits
Drug Name esomeprazole sodium for intravenous soln 40 mg (base equiv) lansoprazole cap delayed release 15 mg lansoprazole cap delayed release 30 mg omeprazole cap delayed release 10 mg omeprazole cap delayed release 20 mg omeprazole cap delayed release 40 mg pantoprazole sodium ec tab 20 mg (base equiv) pantoprazole sodium ec tab 40 mg (base equiv) rabeprazole sodium ec tab 20 mg
2 2 2 2 2 2 2 2 2
GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl tab sr 24hr 10 mg CARDURA XL TAB 4MG CARDURA XL TAB 8MG CIALIS TAB 2.5MG
2 3 3 3
CIALIS TAB 5MG
3
dutasteride cap 0.5 mg 2 dutasteride-tamsulosin hcl cap 0.5-0.4 mg 2 finasteride tab 5 mg 2 RAPAFLO CAP 4MG 3 RAPAFLO CAP 8MG 3 tamsulosin hcl cap 0.4 mg 2
ST; PA** ST; PA** QL (30 tabs / 25 days), PA QL (30 tabs / 25 days), PA
ST; PA** ST; PA**
CONTRACEPTIVES CONCEPTROL GEL 4% ENCARE SUP 100MG GYNOL II GEL 3% SHUR-SEAL GEL 2% TODAY SPONGE MIS VCF VAGINAL AER CONTRACP VCF VAGINAL MIS CONTRACP
1 1 1 1 1 1 1
OTC OTC OTC OTC OTC OTC OTC
MISCELLANEOUS bethanechol chloride tab bethanechol chloride tab bethanechol chloride tab bethanechol chloride tab ELMIRON CAP 100MG
5 mg 10 mg 25 mg 50 mg
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 4
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
107
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
flavoxate hcl tab 100 mg 2 phenazopyridine hcl tab 100 mg 2 potassium citrate tab cr 5 meq (540 mg) 2 potassium citrate tab cr 10 meq (1080 mg) 2 potassium citrate tab cr 15 meq (1620 mg) 2
URINARY ANTISPASMODICS darifenacin hydrobromide tab sr 24hr 7.5 2 mg (base equiv) darifenacin hydrobromide tab sr 24hr 15 mg2 (base equiv) GELNIQUE GEL 10% 4 MYRBETRIQ TAB 25MG 4 MYRBETRIQ TAB 50MG 4 oxybutynin chloride syrup 5 mg/5ml 2 oxybutynin chloride tab 5 mg 2 oxybutynin chloride tab sr 24hr 5 mg 2 oxybutynin chloride tab sr 24hr 10 mg 2 oxybutynin chloride tab sr 24hr 15 mg 2 OXYTROL DIS 3.9MG/24 4 tolterodine tartrate cap sr 24hr 2 mg 2 tolterodine tartrate cap sr 24hr 4 mg 2 tolterodine tartrate tab 1 mg 2 tolterodine tartrate tab 2 mg 2 TOVIAZ TAB 4MG 3 TOVIAZ TAB 8MG 3 trospium chloride cap sr 24hr 60 mg 2 trospium chloride tab 20 mg 2 VESICARE TAB 5MG 4 VESICARE TAB 10MG 4
ST; PA** ST; PA** ST; PA**
ST; PA**
ST; PA** ST; PA**
VAGINAL ANTI-INFECTIVES CLEOCIN SUP 100MG 3 clindamycin phosphate vaginal cream 2% 2 GYNAZOLE-1 CRE 2% 4 metronidazole vaginal gel 0.75% 2 miconazole 3 kit combo pk 2 miconazole 3 sup 200mg 2 terconazole vaginal cream 0.4% 2 terconazole vaginal suppos 80 mg 2 vandazole gel 0.75% 2 zazole cre 0.4% 2 zazole cre 0.8% 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
108
January 1, 2017 Drug Tier Requirements/Limits
Drug Name zazole sup 80mg
2
HEMATOLOGIC ANTICOAGULANTS ARGATROBAN INJ 125/125 4 argatroban inj 250 mg/2.5ml (concentrate 2 for iv infusion) ARGATROBAN INJ 250/250 4 COUMADIN INJ 5 MG 4 ELIQUIS TAB 2.5MG 3 ELIQUIS TAB 5MG 3 enoxaparin sodium inj 30 mg/0.3ml 2 enoxaparin sodium inj 40 mg/0.4ml 2 enoxaparin sodium inj 60 mg/0.6ml 2 enoxaparin sodium inj 80 mg/0.8ml 2 enoxaparin sodium inj 100 mg/ml 2 enoxaparin sodium inj 120 mg/0.8ml 2 enoxaparin sodium inj 150 mg/ml 2 enoxaparin sodium inj 300 mg/3ml 2 fondaparinux sodium subcutaneous inj 2.5 2 mg/0.5ml fondaparinux sodium subcutaneous inj 5 2 mg/0.4ml fondaparinux sodium subcutaneous inj 7.5 2 mg/0.6ml fondaparinux sodium subcutaneous inj 10 2 mg/0.8ml FRAGMIN INJ 2500/0.2 4 FRAGMIN INJ 5000/0.2 4 FRAGMIN INJ 7500/0.3 4 FRAGMIN INJ 10000/ML 4 FRAGMIN INJ 12500UNT 4 FRAGMIN INJ 15000UNT 4 FRAGMIN INJ 18000UNT 4 FRAGMIN INJ 25000/ML 4 FRAGMIN INJ 95000UNT 4 heparin sodium (porcine) inj 1000 unit/ml 2 heparin sodium (porcine) inj 5000 unit/ml 2 heparin sodium (porcine) inj 10000 unit/ml 2 heparin sodium (porcine) inj 20000 unit/ml 2 heparin sodium (porcine) pf inj 5000 2 unit/0.5ml
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
109
January 1, 2017 Drug Tier Requirements/Limits
Drug Name jantoven tab 1mg jantoven tab 2.5mg jantoven tab 2mg jantoven tab 3mg jantoven tab 4mg jantoven tab 5mg jantoven tab 6mg jantoven tab 7.5mg jantoven tab 10mg PRADAXA CAP 75MG PRADAXA CAP 110MG PRADAXA CAP 150MG 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 10MG XARELTO TAB 15MG XARELTO TAB 20MG
2 2 2 2 2 2 2 2 2 4 4 4 2 2 2 2 2 2 2 2 2 3 3 3 3
HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 10MCG ARANESP INJ 25MCG ARANESP INJ 40MCG ARANESP INJ 60MCG ARANESP INJ 100MCG ARANESP INJ 150MCG ARANESP INJ 200MCG ARANESP INJ 300MCG ARANESP INJ 500MCG LEUKINE INJ 250MCG LEUKINE INJ 500 MCG MIRCERA INJ 50MCG MIRCERA INJ 75MCG MIRCERA INJ 100MCG MIRCERA INJ 200MCG
PA - Prior Authorization (applies to pharmacy benefit only)
5 5 5 5 5 5 5 5 5 5 5 6 6 6 6
QL - Quantity Limits
PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
110
January 1, 2017 Drug Tier Requirements/Limits
Drug Name MOZOBIL INJ NEULASTA INJ 6MG/0.6M NEULASTA KIT 6MG/0.6M PROCRIT INJ 2000/ML PROCRIT INJ 3000/ML PROCRIT INJ 4000/ML PROCRIT INJ 10000/ML PROCRIT INJ 20000/ML PROCRIT INJ 40000/ML PROMACTA TAB 12.5MG PROMACTA TAB 25MG PROMACTA TAB 50MG PROMACTA TAB 75MG ZARXIO INJ 300/0.5 ZARXIO INJ 480/0.8
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA
anagrelide hcl cap 0.5 mg 2 anagrelide hcl cap 1 mg 2 cilostazol tab 50 mg 2 cilostazol tab 100 mg 2 FIRAZYR INJ 30MG/3ML 5 pentoxifylline tab cr 400 mg 2 tranexamic acid iv soln 1000 mg/10ml (1002 mg/ml) tranexamic acid tab 650 mg 2
PA
MISCELLANEOUS
PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole cap sr 12hr 25-200 mg2 BRILINTA TAB 60MG 3 BRILINTA TAB 90MG 3 clopidogrel bisulfate tab 75 mg (base equiv)2 clopidogrel bisulfate tab 300 mg (base 2 equiv) dipyridamole tab 25 mg 2
dipyridamole tab 50 mg
PA - Prior Authorization (applies to pharmacy benefit only)
2
QL - Quantity Limits
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
111
January 1, 2017 Drug Tier Requirements/Limits
Drug Name dipyridamole tab 75 mg
2
EFFIENT TAB 5MG EFFIENT TAB 10MG ZONTIVITY TAB 2.08MG
3 3 3
PA; High Risk Medications require PA for members age 65 and older
IMMUNOLOGIC AGENTS BIOLOGIC DISEASE-MODIFYING AGENTS ACTEMRA INJ 80MG/4ML ACTEMRA INJ 162/0.9 ACTEMRA INJ 200/10ML ACTEMRA INJ 400/20ML CIMZIA KIT CIMZIA KIT STARTER CIMZIA PREFL KIT 200MG/ML ENBREL INJ 25/0.5ML ENBREL INJ 25MG ENBREL INJ 50MG/ML ENBREL SRCLK INJ 50MG/ML HUMIRA INJ 10MG/0.2 HUMIRA KIT 20MG/0.4 HUMIRA KIT 40MG/0.8 HUMIRA PEN INJ CROHNS KINERET INJ ORENCIA CLCK INJ 125MG/ML ORENCIA INJ 125MG/ML ORENCIA INJ 250MG REMICADE INJ 100MG SIMPONI ARIA SOL 50MG/4ML SIMPONI INJ 50/0.5ML SIMPONI INJ 100MG/ML STELARA INJ 45MG/0.5 STELARA INJ 90MG/ML XELJANZ TAB 5MG
6 6 6 6 6 6 6 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6
PA, PA, PA, PA, PA, PA, PA, PA PA PA PA PA PA PA PA PA, PA, PA, PA, PA, PA, PA, PA, PA, PA, PA,
ST ST ST ST ST ST ST
ST ST ST ST ST ST ST ST ST ST ST
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) hydroxychloroquine sulfate tab 200 mg leflunomide tab 10 mg leflunomide tab 20 mg methotrexate sodium tab 2.5 mg (base equiv)
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
112
January 1, 2017 Drug Tier Requirements/Limits
Drug Name OTEZLA TAB 10/20/30 OTEZLA TAB 30MG RHEUMATREX TAB 2.5MG TREXALL TAB 5MG TREXALL TAB 7.5MG TREXALL TAB 10MG TREXALL TAB 15MG
6 6 4 4 4 4 4
PA, ST PA, ST
5 5 5 5 5 5 5 5
PA PA PA PA PA PA PA PA
5
PA
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA
IMMUNOGLOBULIN CARIMUNE NF INJ 3GM CARIMUNE NF INJ 6GM CARIMUNE NF INJ 12GM HYQVIA INJ 2.5-200 HYQVIA INJ 5-400 HYQVIA INJ 10-800 HYQVIA INJ 20-1600 HYQVIA INJ 30-2400
IMMUNOGLOBULINS GAMASTAN S/D INJ
IMMUNOMODULATORS ACTIMMUNE INJ 2MU/0.5 ALFERON N INJ 5MU/ML ARCALYST INJ 220MG INTRON A INJ 10MU INTRON A INJ 18MU INTRON A INJ 25MU INTRON A INJ 50MU POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP 3MG POMALYST CAP 4MG REVLIMID CAP 2.5MG REVLIMID CAP 5MG REVLIMID CAP 10MG REVLIMID CAP 15MG REVLIMID CAP 20MG REVLIMID CAP 25MG THALOMID CAP 50MG THALOMID CAP 100MG THALOMID CAP 150MG THALOMID CAP 200MG
IMMUNOSUPPRESSANTS
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
113
January 1, 2017 Drug Tier Requirements/Limits
Drug Name ATGAM INJ 250MG AZASAN TAB 75 MG AZASAN TAB 100MG azathioprine tab 50 mg BENLYSTA INJ 120MG BENLYSTA INJ 400MG CELLCEPT IV INJ 500MG cyclosporine cap 25 mg cyclosporine cap 100 mg cyclosporine iv soln 50 mg/ml cyclosporine modified cap 25 mg cyclosporine modified cap 50 mg cyclosporine modified cap 100 mg cyclosporine modified oral soln 100 mg/ml gengraf cap 25mg gengraf cap 100mg gengraf sol 100mg/ml 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) NULOJIX INJ 250MG PROGRAF INJ 5MG/ML RAPAMUNE SOL 1MG/ML SANDIMMUNE SOL 100MG/ML SIMULECT INJ 10MG SIMULECT INJ 20MG sirolimus tab 0.5 mg sirolimus tab 1 mg sirolimus tab 2 mg tacrolimus cap 0.5 mg tacrolimus cap 1 mg tacrolimus cap 5 mg THYMOGLOBULN INJ 25MG ZORTRESS TAB 0.5MG ZORTRESS TAB 0.25MG ZORTRESS TAB 0.75MG
PA - Prior Authorization (applies to pharmacy benefit only)
4 4 4 2 5 5 4 2 2 2 2 2 2 2 2 2 2 2 2
PA PA
2 2 2 4 4 3 4 4 4 2 2 2 2 2 2 4 3 3 3
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
114
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
VACCINES ACTHIB INJ
1
ADACEL INJ AFLURIA INJ 2016-17 AFLURIA INJ PF 16-17 BEXSERO INJ BOOSTRIX INJ CERVARIX INJ COMVAX INJ
1 1 1 1 1 1 1
DAPTACEL INJ
1
DIP/TET PED INJ 25-5LFU
1
ENGERIX-B INJ 10/0.5ML ENGERIX-B INJ 20MCG/ML EZ FLU SHOT KIT 2016-17 FLUAD INJ 2016-17 FLUBLOK SOL 2016-17 FLUCLVX QUAD INJ 2016-17 FLULAVAL QUA INJ 2016-17 FLUVIRIN INJ 2016-17 FLUVIRIN PF INJ 2016-17 FLUZONE HD INJ PF 16-17 FLUZONE QUAD INJ 2016-17 GARDASIL 9 INJ GARDASIL INJ HAVRIX INJ 720UNIT HAVRIX INJ 1440UNIT HIBERIX SOL 10MCG
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
INFANRIX INJ
1
IPOL INJ INACTIVE
1
KINRIX INJ
1
M-M-R II INJ MENACTRA INJ MENHIBRIX INJ
1 1 1
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
$0 copay for members age 18 and younger
$0 copay for members age 18 and younger $0 copay for members age 18 and younger $0 copay for members age 18 and younger
$0 copay for members age 18 and younger $0 copay for members age 18 and younger $0 copay for members age 18 and younger $0 copay for members age 18 and younger
$0 copay for members age 18 and younger
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
115
January 1, 2017 Drug Tier Requirements/Limits
Drug Name MENOMUNE INJ A/C/Y/W MENVEO INJ PEDIARIX INJ 0.5ML
1 1 1
PEDVAX HIB INJ
1
PENTACEL INJ
1
PNEUMOVAX 23 INJ 25/0.5 PREVNAR 13 INJ PROQUAD INJ
1 1 1
RECOMBIVA HB INJ 5MCG/0.5 RECOMBIVA HB INJ 10MCG/ML RECOMBIVA-HB INJ 40MCG/ML ROTARIX SUS
1 1 1 1
ROTATEQ SOL
1
TENIVAC INJ 5-2LF
1
TET/DIP TOX INJ 2-2 LF
1
TRIPEDIA SUS P/F
1
TRUMENBA INJ TWINRIX INJ
1 1
VAQTA INJ 25/0.5ML VAQTA INJ 50UNT/ML VARIVAX INJ ZOSTAVAX INJ
1 1 1 1
$0 copay for members age 18 and younger $0 copay for members age 18 and younger $0 copay for members age 18 and younger
$0 copay for members age 18 and younger
$0 copay for members age 18 and younger $0 copay for members age 18 and younger $0 copay for members age 19 and older $0 copay for members age 19 and older $0 copay for members age 18 and younger $0 copay for members age 19 and older
$0 copay for members age 19 and older
MEDICAL DEVICES CONTRACEPTIVES CAYA DPR FC2 FEMALE MIS CONDOM FEMCAP MIS 22MM FEMCAP MIS 26MM FEMCAP MIS 30MM OMNIFLEX DPR ORTHO COIL DPR KIT 50
PA - Prior Authorization (applies to pharmacy benefit only)
1 1 1 1 1 1 1
QL - Quantity Limits
QL (1 OTC QL (1 QL (1 QL (1 QL (1 QL (1
/ 300 days) / / / / /
300 300 300 300 300
days) days) days) days) days)
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
116
January 1, 2017 Drug Tier Requirements/Limits
Drug Name ORTHO COIL DPR KIT 100 ORTHO COIL DPR KIT 105 ORTHO FLAT DPR KIT 55 ORTHO FLAT DPR KIT 60 ORTHO FLAT DPR KIT 65 ORTHO FLAT DPR KIT 70 ORTHO FLAT DPR KIT 75 ORTHO FLAT DPR KIT 80 ORTHO FLAT DPR KIT 85 ORTHO FLAT DPR KIT 90 ORTHO FLAT DPR KIT 95 ORTHO FLEX DPR 65MM ORTHO FLEX DPR 70MM ORTHO FLEX DPR 75MM ORTHO FLEX DPR 80MM PRENTIF MIS 22MM PRENTIF MIS 25MM PRENTIF MIS 28MM PRENTIF MIS 31MM PRENTIF MIS FITTING WIDE-SEAL DPR KIT 60 WIDE-SEAL DPR KIT 65 WIDE-SEAL DPR KIT 70 WIDE-SEAL DPR KIT 75 WIDE-SEAL DPR KIT 80 WIDE-SEAL DPR KIT 85 WIDE-SEAL DPR KIT 90 WIDE-SEAL DPR KIT 95
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL
(1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1
/ / / / / / / / / / / / / / / / / / / / / / / / / / / /
300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300
days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days)
DIABETIC SUPPLIES ALCOHOL PREP WIPES AND SWABS 3 BLOOD GLUCOSE CALIBRATION SOLUTION 3 CONTAINER MIS CLOSER 3 INSULIN PEN NEEDLES/SYRINGES 3 LANCETS 3 LANCING DEVICE 3 ONETOUCH BLOOD GLUCOSE TEST KITS 3 ONETOUCH BLOOD GLUCOSE TEST STRIPS 3 URINE TEST STRIPS 3
OTC OTC OTC OTC OTC OTC OTC OTC OTC
MISCELLANEOUS ADULT RESPIRATORY MASK ADULT RESPIRATORY MASK
PA - Prior Authorization (applies to pharmacy benefit only)
3 3
QL - Quantity Limits
OTC
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
117
January 1, 2017 Drug Tier Requirements/Limits
Drug Name HUMATROPEN MIS FOR 6MG HUMATROPEN MIS FOR 12MG HUMATROPEN MIS FOR 24MG PEDIATRIC RESPIRATORY MASK
3 3 3 3
OTC
NUTRITIONAL/ SUPPLEMENTS ELECTROLYTES k-effervesce tab 25meq ef
2
NUTRITIONAL/SUPPLEMENTS ELECTROLYTES AMMONIUM CHL INJ 5MEQ/ML fluor-a-day dro 0.125mg
4 1
FLUORABON DRO
1
fluoritab chw 0.5mg f
1
fluoritab chw 0.25mg f
1
fluoritab chw 2.2mg flura-drops dro 0.25mg f
2 1
flura-drops dro 0.125mg
1
klor-con 8 tab 8meq er klor-con 10 tab 10meq er KLOR-CON M15 TAB 15MEQ ER klor-con m20 tab 20meq er ludent chw 0.5mg f
2 2 3 2 1
ludent chw 0.25mg f
1
ludent chw 1mg f LURIDE CHW 0.5MG F
2 1
LURIDE CHW 0.25MG F
1
LURIDE DRO 0.5MG/ML
1
$0 applies under $0 applies under $0 applies under $0 applies under
for ages 5 and for ages 5 and for ages 5 and for ages 5 and
$0 applies for ages 5 and under $0 applies for ages 5 and under
$0 applies for ages 5 and under $0 applies for ages 5 and under $0 applies for ages 5 and under $0 applies for ages 5 and under $0 applies for ages 5 and under
magnesium sulfate 1% in d5w 2 magnesium sulfate inj 50% 2 magnesium sulfate iv soln 2 gm/50ml (40 2 mg/ml)
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
118
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
magnesium sulfate iv soln 4 gm/50ml (80 2 mg/ml) magnesium sulfate iv soln 4 gm/100ml (40 2 mg/ml) magnesium sulfate iv soln 20 gm/500ml (402 mg/ml) magnesium sulfate iv soln 40 gm/1000ml 2 (40 mg/ml) MG SO4/D5W INJ 20MG/ML 4 nafrinse chw 1mg f 2 potassium chloride cap cr 8 meq 2 potassium chloride cap cr 10 meq 2 potassium chloride microencapsulated crys 2 cr tab 10 meq potassium chloride microencapsulated crys 2 cr tab 20 meq potassium chloride oral soln 10% (20 2 meq/15ml) potassium chloride oral soln 20% (40 2 meq/15ml) potassium chloride tab cr 8 meq (600 mg) 2 potassium chloride tab cr 10 meq 2 potassium chloride tab cr 20 meq (1500 mg)2 sodium chloride flush iv soln 0.9% 2 sodium chloride inj 2.5 meq/ml (14.6%) 2 sodium fluoride chew tab 0.5 mg f (from 1.11 mg naf) sodium fluoride chew tab 0.25 mg f (from 1 0.55 mg naf) sodium fluoride chew tab 1 mg f (from 2.2 2 mg naf) sodium fluoride soln 0.5 mg/ml f (from 1.1 1 mg/ml naf) sodium fluoride tab 0.5 mg f (from 1.1 mg 1 naf) sodium fluoride tab 1 mg f (from 2.2 mg 2 naf)
$0 applies for ages 5 and under $0 applies for ages 5 and under
$0 applies for ages 5 and under $0 applies for ages 5 and under
IV REPLACEMENT SOLUTIONS ISOLYTE-S INJ kcl 20 meq/l (0.15%) in nacl 0.9% inj kcl 20 meq/l (0.15%) in nacl 0.45% inj kcl 40 meq/l (0.3%) in nacl 0.9% inj
PA - Prior Authorization (applies to pharmacy benefit only)
4 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
119
January 1, 2017 Drug Tier Requirements/Limits
Drug Name NORMOSOL -R INJ PLASMA-LYTE INJ -148 PLASMA-LYTE INJ -A potassium chloride inj 2 meq/ml potassium chloride inj 10 meq/50ml potassium chloride inj 10 meq/100ml potassium chloride inj 20 meq/50ml potassium chloride inj 20 meq/100ml potassium chloride inj 40 meq/100ml sodium chloride inj 0.9% sodium chloride inj 0.45% sodium chloride inj 3% sodium chloride inj 5% sodium chloride iv soln 0.9%
4 4 4 2 2 2 2 2 2 2 2 2 2 2
VITAMINS BABY SUPER DRO DAILY D3
1
bio-d-mulsio liq 400unit
1
calcitriol cap 0.5 mcg calcitriol cap 0.25 mcg calcitriol inj 1 mcg/ml calcitriol oral soln 1 mcg/ml child vit d chw 400unit
2 2 2 2 1
cholecalciferol cap 400 unit
1
CITRANATAL CAP HARMONY CITRANATAL MIS 90 DHA CITRANATAL MIS B-CALM CITRANATAL PAK ASSURE CITRANATAL PAK DHA CITRANATAL TAB RX cyanocobalamin inj 1000 mcg/ml D-VI-SOL LIQ 400UNIT
3 3 3 3 3 3 2 1
DDROPS BOOST LIQ 600/.028
1
decara cap 50000unt doxercalciferol cap 0.5 mcg doxercalciferol cap 1 mcg doxercalciferol cap 2.5 mcg
2 2 2 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
OTC;$0 applies for ages 65 and older OTC; $0 applies for ages 65 and older
OTC; $0 applies for ages 65 and older OTC; $0 applies for ages 65 and older
OTC; $0 applies for ages 65 and older OTC; $0 applies for ages 65 and older OTC
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
120
January 1, 2017 Drug Tier Requirements/Limits
Drug Name doxercalciferol inj 4 mcg/2ml (2 mcg/ml) elite-ob tab ergocalciferol cap 50000 unit folbic tab folic acid tab 1 mg folic acid tab 400 mcg
2 2 2 2 2 1
folic acid tab 800 mcg
1
MEPHYTON TAB 5MG multi-vit/fe dro /fl 0.25 multi-vit/fl dro 0.5mg/ml multi-vit/fl dro 0.25mg multi-vit/fl dro /fe 0.25 multivit/fl chw 0.5mg multivit/fl chw 0.25mg multivit/fl chw 1mg mvc-fluoride chw 0.5mg mvc-fluoride chw 1mg paricalcitol cap 1 mcg paricalcitol cap 2 mcg paricalcitol cap 4 mcg paricalcitol iv soln 2 mcg/ml paricalcitol iv soln 5 mcg/ml pedia d-vite dro 400unit
3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1
prenatabs rx tab QUFLORA PED CHW 0.5MG QUFLORA PED CHW 0.25MG QUFLORA PED CHW 1MG quflora ped dro 0.5mg/ml quflora ped dro 0.25mg sm vitamin d tab 400unit
2 4 4 4 2 2 1
tri-vit/fe dro /fl 0.25 tri-vit/fl dro 0.5mg tri-vit/fl dro 0.25mg tri-vit/fluo dro 0.25mg
2 2 2 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
QL (100 tabs / 30 days); OTC; $0 copay for women ages 55 and under QL (100 tabs / 30 days); OTC; $0 copay for women ages 55 and under
OTC; $0 applies for ages 65 and older
OTC; $0 applies for ages 65 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
121
January 1, 2017 Drug Tier Requirements/Limits
Drug Name tri-vita/fl dro 0.25mg vit a/c/d/fl dro 0.25mg VITAMIN D2 TAB 400UNIT
2 2 1
VITAMIN D3 LIQ 1000UNIT
1
VITAMIN D3 LIQ 1200UNIT
1
OTC; $0 applies for ages 65 and older OTC; $0 applies for ages 65 and older OTC; $0 applies for ages 65 and older
OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-polymyxin-neomycin-hc ophth oint 1% BLEPHAMIDE OIN S.O.P. BLEPHAMIDE SUS OP neomycin-polymyxin-dexamethasone ophth oint 0.1% neomycin-polymyxin-dexamethasone ophth susp 0.1% neomycin-polymyxin-hc ophth susp poly-dex oin 0.1% op sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% TOBRADEX OIN 0.3-0.1% tobramycin-dexamethasone ophth susp 0.3-0.1%
2 3 3 2 2 2 2 2 3 2
ANTI-INFECTIVES AZASITE SOL 1% bacitracin ophth oint 500 unit/gm bacitracin-polymyxin b ophth oint BESIVANCE SUS 0.6% CILOXAN OIN 0.3% OP ciprofloxacin hcl ophth soln 0.3% erythromycin ophth oint 5 mg/gm gatifloxacin ophth soln 0.5% gentak oin 0.3% op gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% ilotycin oin op levofloxacin ophth soln 0.5% MOXEZA SOL 0.5% NATACYN SUS 5% OP
PA - Prior Authorization (applies to pharmacy benefit only)
4 2 2 4 3 2 2 2 2 2 2 2 2 4 3
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
122
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
neomycin-polymy-gramicid op sol 2 1.75-10000-0.025mg-unt-mg/ml ofloxacin ophth soln 0.3% 2 polycin oin op 2 polymyxin b-trimethoprim ophth soln 100002 unit/ml-0.1% romycin oin op 2 sulfacetamide sodium ophth oint 10% 2 sulfacetamide sodium ophth soln 10% 2 tobramycin ophth soln 0.3% 2 TOBREX OIN 0.3% OP 3 trifluridine ophth soln 1% 2 VIGAMOX DRO 0.5% 3 ZIRGAN GEL 0.15% 4
ANTI-INFLAMMATORIES ALREX SUS 0.2% 4 bromfenac sodium ophth soln 0.09% (base 2 equiv) (once-daily) bromfenac sodium ophth soln 0.09% (base 2 equivalent) dexamethasone sodium phosphate ophth 2 soln 0.1% diclofenac sodium ophth soln 0.1% 2 DUREZOL EMU 0.05% 4 FLAREX SUS 0.1% OP 4 fluorometholone ophth susp 0.1% 2 flurbiprofen sodium ophth soln 0.03% 2 FML FORTE SUS 0.25% OP 4 FML OIN 0.1% OP 4 ketorolac tromethamine ophth soln 0.4% 2 ketorolac tromethamine ophth soln 0.5% 2 LOTEMAX GEL 0.5% 4 LOTEMAX OIN 0.5% 4 LOTEMAX SUS 0.5% 4 MAXIDEX SUS 0.1% OP 4 NEVANAC SUS 0.1% 4 PRED MILD SUS 0.12% OP 3 PRED SOD PHO SOL 1% OP 3 prednisolone acetate ophth susp 1% 2 VEXOL SUS 1% OP 4
ANTIALLERGICS
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
123
January 1, 2017 Drug Tier Requirements/Limits
Drug Name ALOCRIL SOL 2% ALOMIDE SOL 0.1% OP azelastine hcl ophth soln 0.05% BEPREVE DRO 1.5% cromolyn sodium ophth soln 4% EMADINE SOL 0.05% OP epinastine hcl ophth soln 0.05% LASTACAFT SOL 0.25% olopatadine hcl ophth soln 0.1% (base equivalent) PATADAY SOL 0.2%
4 4 2 4 2 4 2 4 2 4
ANTIGLAUCOMA ALPHAGAN P SOL 0.1% 4 apraclonidine hcl ophth soln 0.5% (base 2 equivalent) AZOPT SUS 1% OP 4 betaxolol hcl ophth soln 0.5% 2 BETIMOL SOL 0.5% 4 BETIMOL SOL 0.25% 4 BETOPTIC-S SUS 0.25% OP 3 bimatoprost ophth soln 0.03% 2 brimonidine tartrate ophth soln 0.2% 2 brimonidine tartrate ophth soln 0.15% 2 carteolol hcl ophth soln 1% 2 COMBIGAN SOL 0.2/0.5% 3 dorzolamide hcl ophth soln 2% 2 dorzolamide hcl-timolol maleate ophth soln 2 22.3-6.8 mg/ml IOPIDINE SOL 1% OP 4 ISTALOL SOL 0.5% OP 4 latanoprost ophth soln 0.005% 2 levobunolol hcl ophth soln 0.5% 2 levobunolol hcl ophth soln 0.25% 2 LUMIGAN SOL 0.01% 4 metipranolol ophth soln 0.3% 2 PHOSPHOLINE SOL 0.125%OP 4 PILOPINE HS GEL 4% OP 4 SIMBRINZA SUS 1-0.2% 3 timolol maleate ophth gel forming soln 0.5%2 timolol maleate ophth gel forming soln 2 0.25%
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST; PA**
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
124
January 1, 2017 Drug Tier Requirements/Limits
Drug Name timolol maleate ophth soln 0.5% timolol maleate ophth soln 0.25% TIMOPTIC OCU SOL 0.5% OP TIMOPTIC OCU SOL 0.25% OP TRAVATAN Z DRO 0.004% ZIOPTAN DRO 0.0015%
2 2 3 3 4 4
ST; PA** ST; PA**
MISCELLANEOUS atropine sulfate ophth soln 1% CYSTARAN SOL 0.44% LACRISERT MIS 5MG OP naphazoline hcl ophth soln 0.1% parcaine sol 0.5% op phenylephrine hcl ophth soln 2.5% phenylephrine hcl ophth soln 10% proparacaine hcl ophth soln 0.5% RESTASIS EMU 0.05% tropicamide ophth soln 0.5% tropicamide ophth soln 1%
2 6 4 2 2 2 2 2 4 2 2
PA
OTHER IRRIGATION SOLUTIONS physiolyte sol physiosol sol irrigat tis-u-sol sol
2 2 2
RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS epinephrine hcl soln prefilled syringe 0.1 mg/ml epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) EPIPEN 2-PAK INJ 0.3MG EPIPEN-JR INJ 2-PAK
2 2 2 3 3
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS§ ANORO ELLIPT AER 62.5-25 BEVESPI AER COMBIVENT AER 20-100 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
3 3 3 2
QL (1 package / 25 days) QL (1 package / 25 days) QL (2 inhalers / 25 days) QL (6 boxes / 25 days)
ANTICHOLINERGICS§
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
125
January 1, 2017 Drug Tier Requirements/Limits
Drug Name INCRUSE ELPT INH 62.5MCG
3
ipratropium bromide inhal soln 0.02% 2 ipratropium bromide nasal soln 0.03% (21 2 mcg/spray) ipratropium bromide nasal soln 0.06% (42 2 mcg/spray) SPIRIVA AER 1.25MCG 3 SPIRIVA CAP HANDIHLR 3 SPIRIVA SPR RESPIMAT 3 TUDORZA PRES AER 400/ACT 4
QL (1 package per 25 days) QL (5 boxes / 25 days)
QL (1 packages per 25 days)
ANTIHISTAMINE COMBINATIONS DYMISTA SPR 137-50
3
QL (1 package / 25 days)
arbinoxa sol 4mg/5ml azelastine hcl nasal spray 0.1% (137 mcg/spray) azelastine hcl nasal spray 0.15% (205.5 mcg/spray) brompheniramine tannate chew tab 12 mg carbinoxamine maleate soln 4 mg/5ml carbinoxamine maleate tab 4 mg CLARINEX SYP 0.5MG/ML clemastine fumarate syrup 0.67 mg/5ml (0.5 mg/5ml base eq)
2 2
QL (2 bottles / 25 days)
2
QL (2 bottles / 25 days)
clemastine fumarate tab 2.68 mg
2
ANTIHISTAMINES§
2 2 2 4 2
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
cyproheptadine hcl syrup 2 mg/5ml 2 cyproheptadine hcl tab 4 mg 2 desloratadine tab 5 mg 2 desloratadine tab orally disintegrating 2.5 2 mg desloratadine tab orally disintegrating 5 mg2 dexchlorpheniramine maleate syrup 2 2 mg/5ml diphenhydramine hcl cap 25 mg 2 diphenhydramine hcl cap 50 mg 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
126
January 1, 2017 Drug Tier Requirements/Limits
Drug Name diphenhydramine hcl elixir 12.5 mg/5ml diphenhydramine hcl inj 50 mg/ml fexofenadine hcl tab 60 mg fexofenadine hcl tab 180 mg fexofenadine sus 30mg/5ml hydroxyzine hcl im soln 25 mg/ml
2 2 2 2 2 2
hydroxyzine hcl im soln 50 mg/ml
2
hydroxyzine pamoate cap 25 mg
2
hydroxyzine pamoate cap 50 mg
2
hydroxyzine pamoate cap 100 mg
2
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg olopatadine hcl nasal soln 0.6%
2 2 2
PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older
QL (1 container / 25 days)
BETA AGONISTS§ albuterol sulfate albuterol sulfate albuterol sulfate (base equiv) albuterol sulfate mg/3ml) albuterol sulfate (base equiv) albuterol sulfate albuterol sulfate albuterol sulfate albuterol sulfate
soln nebu 0.5% (5 mg/ml)2 soln nebu 0.5% (5 mg/ml)2 soln nebu 0.63 mg/3ml 2
QL (3 boxes / 25 days) QL (4 boxes / 25 days) QL (5 boxes / 25 days)
soln nebu 0.083% (2.5
2
QL (5 boxes / 25 days)
soln nebu 1.25 mg/3ml
2
QL (5 boxes / 25 days)
syrup 2 mg/5ml tab 2 mg tab 4 mg tab sr 12hr 4 mg
2 2 2 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
127
January 1, 2017 Drug Tier Requirements/Limits
Drug Name albuterol sulfate tab sr 12hr 8 mg ARCAPTA CAP 75MCG BROVANA NEB 15MCG levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) metaproterenol sulfate syrup 10 mg/5ml metaproterenol sulfate tab 10 mg metaproterenol sulfate tab 20 mg PERFOROMIST NEB 20MCG PROAIR HFA AER PROAIR RESPI AER
2 4 4 2
QL (30 caps / 25 days) QL (2 boxes / 25 days) QL (300 mL / 25 days)
2
QL (300 mL / 25 days)
2
QL (300 mL / 25 days)
2
QL (90 mL / 25 days)
SEREVENT DIS AER 50MCG STRIVERDI AER 2.5MCG
4 3
terbutaline sulfate inj 1 mg/ml terbutaline sulfate tab 2.5 mg terbutaline sulfate tab 5 mg XOPENEX HFA AER
2 2 2 4
2 2 2 3 3 3
QL (2 QL (2 QL (2 days) QL (1 QL (1 days)
boxes / 25 days) inhalers / 25 days) packages / 25 inhaler / 25 days) package per 25
QL (2 inhalers per 25 days), ST; PA**
COLD/COUGH ALLFEN CDX LIQ 3 benzonatate cap 100 mg 2 benzonatate cap 200 mg 2 cheratussin syp 100-10/5 2 FLOWTUSS SOL 2.5-200 4 hydrocodone w/ homatropine syrup 5-1.5 2 mg/5ml hydrocodone w/ homatropine tab 5-1.5 mg 2 hydromet syp 5-1.5/5 2 NORTUSS-EX LIQ 200-20/5 3 OBREDON SOL 2.5-200 4 prometh vc syp plain 2 prometh vc/ syp codeine 2 promethazine w/ codeine syrup 6.25-10 2 mg/5ml
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
OTC
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
128
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
promethazine-dm syrup 6.25-15 mg/5ml 2 pseudoephed-bromphen-dm syrup 30-2-10 2 mg/5ml tgq 50pse/3 syp brm/30dm 2 tussigon tab 5-1.5mg 2 TUZISTRA XR SUS 4
LEUKOTRIENE MODIFIERS ZYFLO CR TAB 600MG
4
LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium chew tab 4 mg (base 2 equiv) montelukast sodium chew tab 5 mg (base 2 equiv) montelukast sodium oral granules packet 4 2 mg (base equiv) montelukast sodium tab 10 mg (base equiv)2 zafirlukast tab 10 mg 2 zafirlukast tab 20 mg 2
MAST CELL STABILIZERS§ cromolyn sodium soln nebu 20 mg/2ml
2
QL (2 boxes / 25 days)
MISCELLANEOUS acetylcysteine inhal soln 10% acetylcysteine inhal soln 20% ARALAST NP INJ 400MG ARALAST NP INJ 500MG ARALAST NP INJ 800MG ARALAST NP INJ 1000MG DALIRESP TAB 500MCG epinephrine hcl inj 1 mg/ml GLASSIA INJ KALYDECO PAK 50MG KALYDECO PAK 75MG KALYDECO TAB 150MG ORKAMBI TAB 200-125 PROLASTIN-C INJ 1000MG sodium chloride soln nebu 0.9% sodium chloride soln nebu 3% sodium chloride soln nebu 7% sodium chloride soln nebu 10% TYZINE PED DRO 0.05% TYZINE SOL 0.1%
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 5 5 5 5 4 2 5 5 5 5 5 5 2 2 2 2 4 4
QL - Quantity Limits
PA PA PA PA PA PA PA PA PA PA PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
129
January 1, 2017 Drug Tier Requirements/Limits
Drug Name ZEMAIRA INJ 1000MG
5
PA
2
QL (2 days) QL (3 days) QL (1 days) QL (1 days) QL (1 days)
containers / 25
QL (2 QL (2 days) QL (1 days) QL (1 days) QL (1 days) QL (2 QL (3 QL (1
inhalers / 25 days) inhalers per 25
NASAL STEROIDS§ budesonide nasal susp 32 mcg/act
flunisolide nasal soln 25 mcg/act (0.025%) 2 fluticasone propionate nasal susp 50 mcg/act OMNARIS SPR
2
triamcinolone acetonide nasal aerosol suspension 55 mcg/act
2
4
containers / 25 container / 25 package per 25 container / 25
STEROID INHALANTS§ ASMANEX 30 AER 110MCG ASMANEX 60 AER 220MCG
3 3
ASMANEX 120 AER 220MCG
3
ASMANEX HFA AER 100 MCG
3
ASMANEX HFA AER 200 MCG
3
budesonide inhalation susp 0.5 mg/2ml budesonide inhalation susp 0.25 mg/2ml budesonide inhalation susp 1 mg/2ml QVAR AER 40MCG QVAR AER 80MCG
2 2 2 3 3
inhaler per 25 inhaler per 25 inhaler per 25 boxes / 25 days) boxes / 25 days) box / 25 days)
STEROID/BETA-AGONIST COMBINATIONS§ ADVAIR DISKU AER 100/50 ADVAIR DISKU AER 250/50 ADVAIR DISKU AER 500/50 ADVAIR HFA AER 45/21 ADVAIR HFA AER 115/21 ADVAIR HFA AER 230/21 BREO ELLIPTA INH 100-25 BREO ELLIPTA INH 200-25
3 3 3 3 3 3 3 3
QL (1 package / 25 days) QL (1 package / 25 days)
XANTHINES aminophylline inj 25 mg/ml ELIXOPHYLLIN ELX 80/15ML LUFYLLIN TAB 200MG LUFYLLIN TAB 400MG
PA - Prior Authorization (applies to pharmacy benefit only)
2 4 4 4
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
130
January 1, 2017 Drug Tier Requirements/Limits
Drug Name THEO-24 CAP 100MG CR THEO-24 CAP 200MG CR THEO-24 CAP 300MG CR THEO-24 CAP 400MG ER theochron tab 100mg cr theochron tab 200mg cr theochron tab 300mg cr theophylline soln 80 mg/15ml theophylline tab sr 12hr 450 mg theophylline tab sr 24hr 400 mg theophylline tab sr 24hr 600 mg
4 4 4 4 2 2 2 2 2 2 2
TOPICAL DERMATOLOGY, ACNE ACANYA GEL 1.2-2.5% adapalene cream 0.1%
4 2
adapalene gel 0.1%
2
adapalene gel 0.3%
2
adapalene lotion 0.1%
2
amnesteem cap 10mg amnesteem cap 20mg amnesteem cap 40mg avita cre 0.025%
2 2 2 2
avita gel 0.025%
2
AZELEX CRE 20% BENZAMYCIN GEL PAK benzepro aer 5.3% BENZIQ GEL 5.25% BENZIQ LS GEL 2.75% benziq wash liq 5.25% benzoyl per liq 10% wash
4 3 2 3 3 2 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST; PA** PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA PA PA PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older ST; PA**
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
131
January 1, 2017 Drug Tier Requirements/Limits
Drug Name benzoyl peroxide-erythromycin gel 5-3% bp wash liq 2.5% bp wash liq 7% claravis cap 10mg claravis cap 20mg claravis cap 30mg claravis cap 40mg clearplex x gel 10% clindamax gel 1% clindamax lot 10mg/ml clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% clindamycin phosphate foam 1% clindamycin phosphate gel 1% clindamycin phosphate lotion 1% clindamycin phosphate soln 1% clindamycin phosphate swab 1% clindamycin phosphate-benzoyl peroxide gel 1-5% EPIDUO FORTE GEL 0.3-2.5% EPIDUO GEL 0.1-2.5% ery pad 2% erythromycin gel 2% erythromycin pads 2% erythromycin soln 2% myorisan cap 10mg myorisan cap 20mg myorisan cap 40mg oscion clnsr lot 6% sulfacetamide sodium lotion 10% (acne) TRETIN-X CRE 0.075%
2 2 2 2 2 2 2 2 2 2 2
TRETIN-X CRE 0.0375%
4
tretinoin cream 0.1%
2
tretinoin cream 0.05%
2
PA - Prior Authorization (applies to pharmacy benefit only)
PA PA PA PA
2 2 2 2 2 2 4 4 2 2 2 2 2 2 2 2 2 4
QL - Quantity Limits
PA PA PA
PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
132
January 1, 2017 Drug Tier Requirements/Limits
Drug Name tretinoin cream 0.025%
2
tretinoin gel 0.01%
2
tretinoin gel 0.05%
2
tretinoin gel 0.025%
2
tretinoin microsphere gel 0.1%
2
tretinoin microsphere gel 0.04%
2
ZIANA GEL
4
PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older
DERMATOLOGY, ACTINIC KERATOSIS FLUOROPLEX CRE 1% fluorouracil cream 0.5% fluorouracil cream 5% fluorouracil soln 2% fluorouracil soln 5% imiquimod cream 5% PICATO GEL 0.05% PICATO GEL 0.015% ZYCLARA CRE 3.75% ZYCLARA PUMP CRE 2.5%
4 2 2 2 2 2 4 4 4 4
DERMATOLOGY, ANTIBIOTICS ALTABAX OIN 1% BACTROBAN OIN NASAL 2% CORTISPORIN CRE 0.5% CORTISPORIN OIN 1% gentamicin sulfate cream 0.1% gentamicin sulfate oint 0.1% IV PREP WIPE PAD mupirocin oint 2% NEO-SYNALAR CRE
PA - Prior Authorization (applies to pharmacy benefit only)
4 4 4 4 2 2 3 2 4
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
133
January 1, 2017 Drug Tier Requirements/Limits
Drug Name PHISOHEX LIQ 3% silver sulfadiazine cream 1% ssd cre 1% SULFAMYLON CRE 85MG/GM
4 2 2 4
DERMATOLOGY, ANTIFUNGALS ciclopirox gel 0.77% 2 ciclopirox olamine cream 0.77% (base 2 equiv) ciclopirox olamine susp 0.77% (base equiv)2 ciclopirox shampoo 1% 2 ciclopirox solution 8% 2 clotrimazole cream 1% 2 CLOTRIMAZOLE CRY 4 clotrimazole soln 1% 2 clotrimazole w/ betamethasone cream 2 1-0.05% clotrimazole w/ betamethasone lotion 2 1-0.05% econazole nitrate cream 1% 2 ERTACZO CRE 2% 4 EXELDERM CRE 1% 4 EXELDERM SOL 1% 4 JUBLIA SOL 10% 4 KERYDIN SOL 5% 4 ketoconazole cream 2% 2 ketodan aer 2% 2 LUZU CRE 1% 4 MENTAX CRE 1% 4 naftifine hcl cream 1% 2 naftifine hcl cream 2% 2 NAFTIN GEL 1% 4 NAFTIN GEL 2% 4 nyamyc pow 100000 2 nystatin cream 100000 unit/gm 2 nystatin oint 100000 unit/gm 2 nystatin topical powder 2 nystatin-triamcinolone cream 100000-0.1 2 unit/gm-% nystatin-triamcinolone oint 100000-0.1 2 unit/gm-% nystop pow 100000 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST ST PA PA
PA
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
134
January 1, 2017 Drug Tier Requirements/Limits
Drug Name oxiconazole nitrate cream 1% OXISTAT LOT 1% XOLEGEL GEL 2%
2 4 4
DERMATOLOGY, ANTIPRURITIC doxepin hcl cream 5% procto-pak cre 1% proctosol hc cre 2.5% proctozone cre -hc 2.5%
2 2 2 2
DERMATOLOGY, ANTIPSORIATICS acitretin cap 10 mg acitretin cap 17.5 mg acitretin cap 25 mg calcipotriene cream 0.005% calcipotriene oint 0.005% calcipotriene soln 0.005% (50 mcg/ml) calcitrene oin 0.005% calcitriol oint 3 mcg/gm COSENTYX INJ 150MG/ML COSENTYX PEN INJ 150MG/ML methoxsalen rapid cap 10 mg 8-MOP CAP 10MG TAZORAC CRE 0.1% TAZORAC CRE 0.05% TAZORAC GEL 0.1% TAZORAC GEL 0.05%
2 2 2 2 2 2 2 2 6 6 2 4 3 3 3 3
PA, ST PA, ST
PA PA PA PA
DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 2% selenium sulfide lotion 2.5%
2 2
DERMATOLOGY, CORTICOSTEROIDS ala cort cre 1% alclometasone dipropionate cream 0.05% alclometasone dipropionate oint 0.05% alphatrex gel 0.05% amcinonide cream 0.1% amcinonide lotion 0.1% AMCINONIDE OIN 0.1% apexicon oin 0.05% betamethasone dipropionate augmented cream 0.05% betamethasone dipropionate augmented lotion 0.05%
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 2 3 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
135
January 1, 2017 Drug Tier Requirements/Limits
Drug Name betamethasone dipropionate augmented oint 0.05% betamethasone dipropionate cream 0.05% betamethasone dipropionate lotion 0.05% betamethasone dipropionate oint 0.05% betamethasone valerate aerosol foam 0.12% betamethasone valerate cream 0.1% betamethasone valerate lotion 0.1% betamethasone valerate oint 0.1% calcipotriene-betamethasone dipropionate oint 0.005-0.064% CAPEX SHA 0.01% clobetasol propionate cream 0.05% clobetasol propionate foam 0.05% clobetasol propionate gel 0.05% clobetasol propionate lotion 0.05% clobetasol propionate oint 0.05% clobetasol propionate shampoo 0.05% clobetasol propionate soln 0.05% clobetasol propionate spray 0.05% clocortolone pivalate cream 0.1% CORDRAN 24X3 TAP 4MCG/CM CORDRAN LOT 0.05% CORDRAN OIN 0.05% DESONATE GEL 0.05% desonide cream 0.05% desonide lotion 0.05% desonide oint 0.05% DESOWEN OINT KIT 0.05% desoximetasone cream 0.05% desoximetasone cream 0.25% desoximetasone gel 0.05% desoximetasone oint 0.05% desoximetasone oint 0.25% diflorasone diacetate cream 0.05% diflorasone diacetate oint 0.05% fluocin acet oil 0.01% sc fluocin acet oil body fluocinolone acetonide cream 0.01% fluocinolone acetonide cream 0.025%
PA - Prior Authorization (applies to pharmacy benefit only)
2 2 2 2 2 2 2 2 2 4 2 2 2 2 2 2 2 2 2 4 4 4 4 2 2 2 4 2 2 2 2 2 2 2 2 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
136
January 1, 2017 Drug Tier Requirements/Limits
Drug Name
fluocinolone acetonide oint 0.025% 2 fluocinolone acetonide soln 0.01% 2 fluocinonide cream 0.1% 2 fluocinonide cream 0.05% 2 fluocinonide gel 0.05% 2 fluocinonide oint 0.05% 2 fluocinonide soln 0.05% 2 flurandrenolide cream 0.05% 2 fluticasone propionate cream 0.05% 2 fluticasone propionate lotion 0.05% 2 fluticasone propionate oint 0.005% 2 halobetasol propionate cream 0.05% 2 halobetasol propionate oint 0.05% 2 HALOG CRE 0.1% 4 HALOG OIN 0.1% 4 hydrocortisone butyrate cream 0.1% 2 hydrocortisone butyrate hydrophilic lipo 2 base cream 0.1% hydrocortisone butyrate oint 0.1% 2 hydrocortisone butyrate soln 0.1% 2 hydrocortisone cream 1% 2 hydrocortisone cream 2.5% 2 hydrocortisone lotion 2.5% 2 hydrocortisone oint 1% 2 hydrocortisone oint 2.5% 2 hydrocortisone valerate cream 0.2% 2 hydrocortisone valerate oint 0.2% 2 lokara lot 0.05% 2 mometasone furoate cream 0.1% 2 mometasone furoate oint 0.1% 2 mometasone furoate solution 0.1% (lotion) 2 PEDIADERM HC KIT 4 PEDIADERM TA KIT 4 prednicarbate cream 0.1% 2 prednicarbate oint 0.1% 2 scalacort lot 2% 2 TACLONEX SUS 4 TEXACORT SOL 2.5% 4 triamcinolone acetonide aerosol soln 0.147 2 mg/gm triamcinolone acetonide cream 0.1% 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
137
January 1, 2017 Drug Tier Requirements/Limits
Drug Name triamcinolone acetonide triamcinolone acetonide triamcinolone acetonide triamcinolone acetonide triamcinolone acetonide triamcinolone acetonide triamcinolone acetonide TRIANEX OIN 0.05% triderm cre 0.1% VERDESO AER 0.05%
cream 0.5% cream 0.025% lotion 0.1% lotion 0.025% oint 0.1% oint 0.5% oint 0.025%
2 2 2 2 2 2 2 4 2 4
DERMATOLOGY, LOCAL ANESTHETICS lidocaine hcl gel 2% lidocaine hcl soln 4% lidocaine oint 5% lidocaine patch 5% lidocaine-prilocaine cream 2.5-2.5% lidocaine-prilocaine cream kit 2.5-2.5% pramox gel 1% SYNERA DIS 70-70MG
2 2 2 2 2 2 2 4
QL (30gm / 25 days) QL (50mL / 25 days) QL (50gm / 25 days) QL (30gm / 25 days)
QL (2 patches / 25 days)
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE§ acyclovir oint 5% 2 CONDYLOX GEL 0.5% 4 DENAVIR CRE 1% 4 diclofenac sodium gel 1% 2 ELIDEL CRE 1% 3 laclotion lot 12% 2 lactic acid (ammonium lactate) cream 12% 2 lactic acid (ammonium lactate) lotion 10% 2 lactic acid (ammonium lactate) lotion 12% 2 PANRETIN GEL 0.1% 4 podofilox soln 0.5% 2 RECTIV OIN 0.4% 4 tacrolimus oint 0.1% 2 tacrolimus oint 0.03% 2 TARGRETIN GEL 1% 5 VEREGEN OIN 15% 4
ST; PA**
ST; PA** ST; PA** PA
DERMATOLOGY, ROSACEA FINACEA GEL 15% metronidazole cream 0.75% metronidazole gel 0.75% metronidazole gel 1%
PA - Prior Authorization (applies to pharmacy benefit only)
3 2 2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
138
January 1, 2017 Drug Tier Requirements/Limits
Drug Name metronidazole lotion 0.75% MIRVASO GEL 0.33% rosadan cre 0.75%
2 4 2
DERMATOLOGY, SCABICIDES AND PEDICULIDES acticin cre 5% EURAX CRE 10% EURAX LOT 10% lindane lotion 1% lindane shampoo 1% malathion lotion 0.5% permethrin cream 5% SKLICE LOT 0.5% spinosad susp 0.9% ULESFIA LOT 5%
2 4 4 2 2 2 2 4 2 4
DERMATOLOGY, WOUND CARE AGENTS REGRANEX GEL 0.01% SANTYL OIN 250/GM sodium chloride irrigation soln 0.9%
4 4 2
MOUTH/THROAT/DENTAL AGENTS cevimeline hcl cap 30 mg chlorhexidine gluconate soln 0.12% clotrimazole troche 10 mg lidocaine hcl laryngotracheal soln 4% lidocaine hcl viscous soln 2% nystatin susp 100000 unit/ml oralone pst 0.1% ORAVIG TAB 50MG periogard sol 0.12% pilocarpine hcl tab 5 mg pilocarpine hcl tab 7.5 mg triamcinolone acetonide dental paste 0.1%
2 2 2 2 2 2 2 4 2 2 2 2
OTIC acetic acid 2% in aluminum acetate otic soln2 acetic acid otic soln 2% 2 CIPRO HC SUS OTIC 4 CIPRODEX SUS 0.3-0.1% 3 CORTISPORIN SUS -TC OTIC 4 fluocinolone acetonide (otic) oil 0.01% 2 hydrocortisone w/ acetic acid otic soln 1-2%2 neomycin-polymyxin-hc otic soln 1% 2
PA - Prior Authorization (applies to pharmacy benefit only)
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
139
January 1, 2017 Drug Tier Requirements/Limits
Drug Name neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ofloxacin otic soln 0.3%
PA - Prior Authorization (applies to pharmacy benefit only)
2 2
QL - Quantity Limits
ST - Step Therapy
(Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications)
140
Index 8 8-MOP CAP 10MG ........................... 135 A abacavir sulfate tab 300 mg (base equiv) ......................................................18 abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg .........................20 ABELCET INJ 5MG/ML ........................17 ABRAXANE INJ 100MG .......................33 acamprosate calcium tab delayed release 333 mg ...........................................79 ACANYA GEL 1.2-2.5% .................... 131 acarbose tab 100 mg.........................81 acarbose tab 25 mg ..........................81 acarbose tab 50 mg ..........................81 acebutolol hcl cap 200 mg .................46 acebutolol hcl cap 400 mg .................47 acetaminophen w/ codeine soln 120-12 mg/5ml ............................................ 7 acetaminophen w/ codeine tab 300-15 mg ....................................................... 7 acetaminophen w/ codeine tab 300-30 mg ....................................................... 7 acetaminophen w/ codeine tab 300-60 mg ....................................................... 7 acetazolamide cap sr 12hr 500 mg ......51 acetazolamide sodium for inj 500 mg ..51 acetazolamide tab 125 mg .................51 acetazolamide tab 250 mg .................51 acetic acid 2% in aluminum acetate otic soln............................................... 139 acetic acid otic soln 2% ................... 139 acetylcysteine inhal soln 10% ........... 129 acetylcysteine inhal soln 20% ........... 129 acitretin cap 10 mg ......................... 135 acitretin cap 17.5 mg ...................... 135 acitretin cap 25 mg ......................... 135 ACTEMRA INJ 162/0.9 ..................... 112 ACTEMRA INJ 200/10ML .................. 112 ACTEMRA INJ 400/20ML .................. 112 ACTEMRA INJ 80MG/4ML ................. 112 ACTHIB INJ .................................... 115 acticin cre 5% ................................ 139 ACTIMMUNE INJ 2MU/0.5................. 113 acyclovir cap 200 mg ........................21
January 1, 2017
acyclovir oint 5% ........................... 138 acyclovir sodium for inj 1000 mg ....... 21 acyclovir sodium for inj 500 mg ......... 21 acyclovir sodium iv soln 50 mg/ml...... 21 acyclovir susp 200 mg/5ml ................ 21 acyclovir tab 400 mg ........................ 21 acyclovir tab 800 mg ........................ 21 ADACEL INJ ................................... 115 ADAGEN INJ 250/ML ......................... 89 adapalene cream 0.1% ................... 131 adapalene gel 0.1% ........................ 131 adapalene gel 0.3% ........................ 131 adapalene lotion 0.1% .................... 131 ADCIRCA TAB 20MG ......................... 54 adefovir dipivoxil tab 10 mg .............. 21 ADEMPAS TAB 0.5MG ....................... 54 ADEMPAS TAB 1.5MG ....................... 54 ADEMPAS TAB 1MG .......................... 54 ADEMPAS TAB 2.5MG ....................... 54 ADEMPAS TAB 2MG .......................... 54 adriamycin inj 10mg ......................... 31 ADRIAMYCIN INJ 20MG ..................... 31 adrucil inj 500/10ml ......................... 31 ADULT RESPIRATORY MASK ............ 117 ADVAIR DISKU AER 100/50 ............. 130 ADVAIR DISKU AER 250/50 ............. 130 ADVAIR DISKU AER 500/50 ............. 130 ADVAIR HFA AER 115/21 ................ 130 ADVAIR HFA AER 230/21 ................ 130 ADVAIR HFA AER 45/21 .................. 130 afeditab tab 30mg cr ........................ 48 afeditab tab 60mg cr ........................ 48 AFINITOR DIS TAB 2MG .................... 35 AFINITOR DIS TAB 3MG .................... 35 AFINITOR DIS TAB 5MG .................... 35 AFINITOR TAB 10MG ........................ 35 AFINITOR TAB 2.5MG ....................... 35 AFINITOR TAB 5MG .......................... 35 AFINITOR TAB 7.5MG ....................... 35 AFLURIA INJ 2016-17 ..................... 115 AFLURIA INJ PF 16-17 .................... 115 a-hydrocort inj 100mg ...................... 95 AKYNZEO CAP................................ 102 ala cort cre 1% .............................. 135 alagesic lq sol .................................... 5 141
January 1, 2017
ALBENZA TAB 200MG ........................14 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) ........................................ 127 albuterol sulfate soln nebu 0.5% (5 mg/ml) .......................................... 127 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) ................................... 127 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) ................................... 127 albuterol sulfate syrup 2 mg/5ml ...... 127 albuterol sulfate tab 2 mg ................ 127 albuterol sulfate tab 4 mg ................ 127 albuterol sulfate tab sr 12hr 4 mg ..... 127 albuterol sulfate tab sr 12hr 8 mg ..... 128 alclometasone dipropionate cream 0.05% .................................................... 135 alclometasone dipropionate oint 0.05% .................................................... 135 ALCOHOL PREP WIPES AND SWABS .. 117 ALDACTAZIDE TAB 50/50 ..................51 ALDURAZYME INJ 2.9MG/5M ..............89 alendronate sodium oral soln 70 mg/75ml ......................................................85 alendronate sodium tab 10 mg ...........85 alendronate sodium tab 35 mg ...........85 alendronate sodium tab 40 mg ...........85 alendronate sodium tab 5 mg .............85 alendronate sodium tab 70 mg ...........85 ALFERON N INJ 5MU/ML .................. 113 alfuzosin hcl tab sr 24hr 10 mg......... 107 ALIMTA INJ 100MG ...........................31 ALIMTA INJ 500MG ...........................31 ALINIA SUS 100/5ML ........................15 ALINIA TAB 500MG ...........................15 ALKERAN TAB 2MG ...........................30 ALLFEN CDX LIQ ............................. 128 allopurinol sodium for inj 500 mg ......... 5 allopurinol tab 100 mg........................ 5 allopurinol tab 300 mg........................ 5 almotriptan malate tab 12.5 mg .........75 almotriptan malate tab 6.25 mg .........75 ALOCRIL SOL 2% ............................ 124 alogliptin benzoate tab 12.5 mg (base equiv) .............................................81 alogliptin benzoate tab 25 mg (base equiv) .............................................81 alogliptin benzoate tab 6.25 mg (base
equiv) ............................................. 81 ALOMIDE SOL 0.1% OP................... 124 alosetron hcl tab 0.5 mg (base equiv) 105 alosetron hcl tab 1 mg (base equiv) . 105 ALOXI INJ 0.25MG/5....................... 102 ALPHAGAN P SOL 0.1%................... 124 alphatrex gel 0.05% ....................... 135 ALPRAZOLAM CON 1 MG/ML .............. 55 alprazolam orally disintegrating tab 0.25 mg ................................................. 55 alprazolam orally disintegrating tab 0.5 mg ................................................. 55 alprazolam orally disintegrating tab 1 mg ...................................................... 55 alprazolam orally disintegrating tab 2 mg ...................................................... 55 alprazolam tab 0.25 mg .................... 55 alprazolam tab 0.5 mg ...................... 55 alprazolam tab 1 mg ......................... 55 alprazolam tab 2 mg ......................... 55 ALREX SUS 0.2% ........................... 123 ALTABAX OIN 1% ........................... 133 altavera tab ..................................... 86 alyacen tab 1/35 .............................. 86 alyacen tab 7/7/7 ............................. 86 amantadine hcl cap 100 mg ............... 67 amantadine hcl syrup 50 mg/5ml ....... 67 amantadine hcl tab 100 mg ............... 67 AMBISOME INJ 50MG........................ 17 amcinonide cream 0.1% ................. 135 amcinonide lotion 0.1% .................. 135 AMCINONIDE OIN 0.1% .................. 135 a-methapred inj 125mg .................... 95 a-methapred inj 40mg ...................... 95 amethia tab ..................................... 86 amethyst tab 90-20mcg .................... 86 amifostine crystalline for inj 500 mg ... 37 amikacin sulfate inj 1 gm/4ml (250 mg/ml) ........................................... 14 amikacin sulfate inj 500 mg/2ml (250 mg/ml) ........................................... 14 amiloride & hydrochlorothiazide tab 5-50 mg ................................................. 51 amiloride hcl tab 5 mg ...................... 51 aminophylline inj 25 mg/ml ............. 130 amiodarone hcl inj 150 mg/3ml (50 mg/ml) ........................................... 43 142
January 1, 2017
amiodarone hcl inj 450 mg/9ml (50 mg/ml) ............................................43 amiodarone hcl inj 900 mg/18ml (50 mg/ml) ............................................43 amiodarone hcl tab 200 mg................43 amiodarone hcl tab 400 mg................43 AMITIZA CAP 24MCG ....................... 105 AMITIZA CAP 8MCG ........................ 105 amitriptyline hcl tab 10 mg ................61 amitriptyline hcl tab 100 mg ..............62 amitriptyline hcl tab 150 mg ..............62 amitriptyline hcl tab 25 mg ................61 amitriptyline hcl tab 50 mg ................62 amitriptyline hcl tab 75 mg ................62 amlodipine besylate tab 10 mg ...........49 amlodipine besylate tab 2.5 mg ..........49 amlodipine besylate tab 5 mg .............49 amlodipine besylate-atorvastatin calcium tab 10-10 mg ...................................48 amlodipine besylate-atorvastatin calcium tab 10-20 mg ...................................48 amlodipine besylate-atorvastatin calcium tab 10-40 mg ...................................48 amlodipine besylate-atorvastatin calcium tab 10-80 mg ...................................48 amlodipine besylate-atorvastatin calcium tab 2.5-10 mg ..................................48 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg ..................................48 amlodipine besylate-atorvastatin calcium tab 2.5-40 mg ..................................48 amlodipine besylate-atorvastatin calcium tab 5-10 mg .....................................48 amlodipine besylate-atorvastatin calcium tab 5-20 mg .....................................48 amlodipine besylate-atorvastatin calcium tab 5-40 mg .....................................48 amlodipine besylate-atorvastatin calcium tab 5-80 mg .....................................48 amlodipine besylate-benazepril hcl cap 10-20 mg ........................................38 amlodipine besylate-benazepril hcl cap 10-40 mg ........................................39 amlodipine besylate-benazepril hcl cap 2.5-10 mg .......................................38 amlodipine besylate-benazepril hcl cap 5-10 mg ..........................................38
amlodipine besylate-benazepril hcl cap 5-20 mg.......................................... 38 amlodipine besylate-benazepril hcl cap 5-40 mg.......................................... 38 amlodipine besylate-valsartan tab 10-160 mg ................................................. 41 amlodipine besylate-valsartan tab 10-320 mg ................................................. 41 amlodipine besylate-valsartan tab 5-160 mg ................................................. 41 amlodipine besylate-valsartan tab 5-320 mg ................................................. 41 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg ......................... 41 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg ............................ 41 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg ............................ 41 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg ........................... 41 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg.............................. 41 AMMONIUM CHL INJ 5MEQ/ML ......... 118 amnesteem cap 10mg .................... 131 amnesteem cap 20mg .................... 131 amnesteem cap 40mg .................... 131 amoxapine tab 100 mg ..................... 62 amoxapine tab 150 mg ..................... 62 amoxapine tab 25 mg ....................... 62 amoxapine tab 50 mg ....................... 62 amoxicillin & k clavulanate chew tab 200-28.5 mg ................................... 27 amoxicillin & k clavulanate chew tab 400-57 mg ...................................... 27 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml ............................. 27 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml ............................. 27 amoxicillin & k clavulanate for susp 400-57 mg/5ml................................ 27 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml ............................. 27 amoxicillin & k clavulanate tab 250-125 mg ................................................. 27 amoxicillin & k clavulanate tab 500-125 mg ................................................. 27 amoxicillin & k clavulanate tab 875-125 143
January 1, 2017
mg ..................................................27 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg ..................................27 amoxicillin (trihydrate) cap 250 mg .....27 amoxicillin (trihydrate) cap 500 mg .....27 amoxicillin (trihydrate) chew tab 125 mg ......................................................27 amoxicillin (trihydrate) chew tab 250 mg ......................................................27 amoxicillin (trihydrate) for susp 125 mg/5ml ...........................................27 amoxicillin (trihydrate) for susp 200 mg/5ml ...........................................27 amoxicillin (trihydrate) for susp 250 mg/5ml ...........................................27 amoxicillin (trihydrate) for susp 400 mg/5ml ...........................................27 amoxicillin (trihydrate) tab 500 mg .....27 amoxicillin (trihydrate) tab 875 mg .....27 amphetamine-dextroamphetamine cap sr 24hr 10 mg ......................................72 amphetamine-dextroamphetamine cap sr 24hr 15 mg ......................................72 amphetamine-dextroamphetamine cap sr 24hr 20 mg ......................................72 amphetamine-dextroamphetamine cap sr 24hr 25 mg ......................................72 amphetamine-dextroamphetamine cap sr 24hr 30 mg ......................................72 amphetamine-dextroamphetamine cap sr 24hr 5 mg........................................72 amphetamine-dextroamphetamine tab 10 mg ..................................................72 amphetamine-dextroamphetamine tab 12.5 mg ..........................................72 amphetamine-dextroamphetamine tab 15 mg ..................................................72 amphetamine-dextroamphetamine tab 20 mg ..................................................73 amphetamine-dextroamphetamine tab 30 mg ..................................................73 amphetamine-dextroamphetamine tab 5 mg ..................................................72 amphetamine-dextroamphetamine tab 7.5 mg ............................................72 AMPHOTEC INJ 100MG ......................17 AMPHOTEC INJ 50MG ........................17
amphotericin b for inj 50 mg ............. 17 ampicillin & sulbactam sodium for inj 1-0.5 gm......................................... 27 ampicillin & sulbactam sodium for inj 10-5 gm ................................................. 27 ampicillin & sulbactam sodium for inj 2-1 gm ................................................. 27 ampicillin & sulbactam sodium for iv soln 1-0.5 gm......................................... 27 ampicillin & sulbactam sodium for iv soln 10-5 gm.......................................... 27 ampicillin & sulbactam sodium for iv soln 2-1 gm ........................................... 27 ampicillin cap 250 mg ....................... 27 ampicillin cap 500 mg ....................... 28 ampicillin for susp 125 mg/5ml .......... 28 ampicillin for susp 250 mg/5ml .......... 28 ampicillin sodium for inj 1 gm ............ 28 ampicillin sodium for inj 10 gm .......... 28 ampicillin sodium for inj 125 mg ........ 28 ampicillin sodium for inj 2 gm ............ 28 ampicillin sodium for inj 250 mg ........ 28 ampicillin sodium for inj 500 mg ........ 28 ampicillin sodium for iv soln 1 gm ...... 28 ampicillin sodium for iv soln 10 gm ..... 28 ampicillin sodium for iv soln 2 gm ...... 28 AMPYRA TAB 10MG........................... 77 ANADROL-50 TAB 50MG.................... 80 anagrelide hcl cap 0.5 mg ............... 111 anagrelide hcl cap 1 mg .................. 111 anastrozole tab 1 mg ........................ 34 ANDROXY TAB 10MG ........................ 80 ANORO ELLIPT AER 62.5-25 ............ 125 ANTIVERT TAB 50MG ...................... 102 ANZEMET TAB 100MG ..................... 102 ANZEMET TAB 50MG ....................... 102 apexicon oin 0.05% ........................ 135 APIDRA INJ SOLOSTAR ..................... 82 APIDRA INJ U-100 ............................ 82 APLENZIN TAB 174MG ...................... 62 APLENZIN TAB 348MG ...................... 62 APLENZIN TAB 522MG ...................... 62 APOKYN INJ 10MG/ML ...................... 67 apraclonidine hcl ophth soln 0.5% (base equivalent) .................................... 124 apri tab ........................................... 86 APRISO CAP 0.375GM ..................... 104 144
January 1, 2017
APTIOM TAB 200MG ..........................56 APTIOM TAB 400MG ..........................56 APTIOM TAB 600MG ..........................56 APTIOM TAB 800MG ..........................56 APTIVUS CAP 250MG .........................18 APTIVUS SOL ...................................18 ARALAST NP INJ 1000MG ................. 129 ARALAST NP INJ 400MG .................. 129 ARALAST NP INJ 500MG .................. 129 ARALAST NP INJ 800MG .................. 129 aranelle tab ......................................86 ARANESP INJ 100MCG ..................... 110 ARANESP INJ 10MCG ....................... 110 ARANESP INJ 150MCG ..................... 110 ARANESP INJ 200MCG ..................... 110 ARANESP INJ 25MCG ....................... 110 ARANESP INJ 300MCG ..................... 110 ARANESP INJ 40MCG ....................... 110 ARANESP INJ 500MCG ..................... 110 ARANESP INJ 60MCG ....................... 110 arbinoxa sol 4mg/5ml...................... 126 ARCALYST INJ 220MG ..................... 113 ARCAPTA CAP 75MCG ...................... 128 ARGATROBAN INJ 125/125 .............. 109 argatroban inj 250 mg/2.5ml (concentrate for iv infusion) ............. 109 ARGATROBAN INJ 250/250 .............. 109 aripiprazole oral solution 1 mg/ml .......69 aripiprazole orally disintegrating tab 10 mg ..................................................69 aripiprazole orally disintegrating tab 15 mg ..................................................69 aripiprazole tab 10 mg.......................69 aripiprazole tab 15 mg.......................69 aripiprazole tab 2 mg ........................69 aripiprazole tab 20 mg.......................69 aripiprazole tab 30 mg.......................69 aripiprazole tab 5 mg ........................69 ARISTADA INJ 441MG/1. ...................69 ARISTADA INJ 662MG/2 ....................69 ARISTADA INJ 882MG/3 ....................69 armodafinil tab 150 mg .....................79 armodafinil tab 200 mg .....................79 armodafinil tab 250 mg .....................79 armodafinil tab 50 mg .......................79 ARRANON INJ 5MG/ML ......................31 ARZERRA CON 100/5ML.....................33
ARZERRA CON 1000/50 .................... 33 ashlyna tab ..................................... 86 ASMANEX 120 AER 220MCG ............ 130 ASMANEX 30 AER 110MCG .............. 130 ASMANEX 60 AER 220MCG .............. 130 ASMANEX HFA AER 100 MCG ........... 130 ASMANEX HFA AER 200 MCG ........... 130 aspirin chew tab 81 mg ..................... 13 aspirin low tab 81mg ec .................... 13 aspirin tab 325 mg ........................... 13 aspirin tab 81 mg ............................. 13 aspirin tab delayed release 325 mg .... 13 aspirin-dipyridamole cap sr 12hr 25-200 mg ............................................... 111 astramorph inj 1mg/2ml ..................... 7 astramorph inj 2mg/2ml ..................... 7 atenolol & chlorthalidone tab 100-25 mg ...................................................... 46 atenolol & chlorthalidone tab 50-25 mg ...................................................... 46 atenolol tab 100 mg ......................... 47 atenolol tab 25 mg ........................... 47 atenolol tab 50 mg ........................... 47 ATGAM INJ 250MG ......................... 114 atorvastatin calcium tab 10 mg (base equivalent) ...................................... 45 atorvastatin calcium tab 20 mg (base equivalent) ...................................... 45 atorvastatin calcium tab 40 mg (base equivalent) ...................................... 45 atorvastatin calcium tab 80 mg (base equivalent) ...................................... 45 atovaquone susp 750 mg/5ml ............ 15 atovaquone-proguanil hcl tab 250-100 mg ...................................................... 18 atovaquone-proguanil hcl tab 62.5-25 mg ...................................................... 18 ATRIPLA TAB ................................... 20 ATROPEN INJ 0.25MG ..................... 101 ATROPEN INJ 0.5MG ....................... 101 ATROPEN INJ 1MG.......................... 101 ATROPEN INJ 2MG.......................... 101 atropine sulfate inj 0.05 mg/ml ........ 101 atropine sulfate inj 0.1 mg/ml.......... 101 atropine sulfate inj 1 mg/ml ............ 101 atropine sulfate ophth soln 1% ........ 125 AUBAGIO TAB 14MG ......................... 77 145
January 1, 2017
AUBAGIO TAB 7MG ...........................77 AUGMENTIN SUS 125/5ML .................28 AVELOX INJ......................................26 aviane tab........................................86 avidoxy tab 100mg ...........................29 avita cre 0.025% ............................ 131 avita gel 0.025% ............................ 131 azacitidine for inj 100 mg ..................31 AZACTAM/DEX INJ 1GM .....................15 AZACTAM/DEX INJ 2GM .....................15 AZASAN TAB 100MG ....................... 114 AZASAN TAB 75 MG ........................ 114 AZASITE SOL 1% ............................ 122 azathioprine tab 50 mg .................... 114 azelastine hcl nasal spray 0.1% (137 mcg/spray) .................................... 126 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) .................................... 126 azelastine hcl ophth soln 0.05% ....... 124 AZELEX CRE 20% ........................... 131 AZILECT TAB 0.5MG ..........................67 AZILECT TAB 1MG.............................67 azithromycin for susp 100 mg/5ml ......25 azithromycin for susp 200 mg/5ml ......25 azithromycin iv for soln 500 mg ..........25 azithromycin powd pack for susp 1 gm 25 azithromycin tab 250 mg ...................25 azithromycin tab 500 mg ...................25 azithromycin tab 600 mg ...................25 AZOPT SUS 1% OP ......................... 124 aztreonam for inj 1 gm ......................15 aztreonam for inj 2 gm ......................15 azurette tab 28 day ...........................86 B BABY SUPER DRO DAILY D3 ............. 120 bacitracin ophth oint 500 unit/gm ..... 122 bacitracin-polymyxin b ophth oint ..... 122 bacitracin-polymyxin-neomycin-hc ophth oint 1% ......................................... 122 baclofen tab 10 mg ...........................77 baclofen tab 20 mg ...........................77 BACTOCILL INJ DEX 1GM ...................28 BACTOCILL INJ DEX 2GM ...................28 BACTROBAN OIN NASAL 2% ............ 133 balsalazide disodium cap 750 mg ...... 104 BANZEL SUS 40MG/ML ......................56 BANZEL TAB 200MG ..........................56
BANZEL TAB 400MG ......................... 56 BARACLUDE SOL .05MG/ML ............... 21 BASAGLAR INJ ................................. 82 BELSOMRA TAB 10MG....................... 75 BELSOMRA TAB 15MG....................... 75 BELSOMRA TAB 20MG....................... 75 BELSOMRA TAB 5MG ........................ 75 benazepril & hydrochlorothiazide tab 10-12.5 mg ..................................... 39 benazepril & hydrochlorothiazide tab 20-12.5 mg ..................................... 39 benazepril & hydrochlorothiazide tab 20-25 mg ........................................ 39 benazepril & hydrochlorothiazide tab 5-6.25 mg ....................................... 39 benazepril hcl tab 10 mg ................... 40 benazepril hcl tab 20 mg ................... 40 benazepril hcl tab 40 mg ................... 40 benazepril hcl tab 5 mg ..................... 40 BENICAR TAB 20MG ......................... 42 BENICAR TAB 40MG ......................... 42 BENICAR TAB 5MG ........................... 42 BENLYSTA INJ 120MG ..................... 114 BENLYSTA INJ 400MG ..................... 114 BENZAMYCIN GEL PAK .................... 131 benzepro aer 5.3% ......................... 131 BENZIQ GEL 5.25% ........................ 131 BENZIQ LS GEL 2.75% ................... 131 benziq wash liq 5.25% .................... 131 benzonatate cap 100 mg ................. 128 benzonatate cap 200 mg ................. 128 benzoyl per liq 10% wash ............... 131 benzoyl peroxide-erythromycin gel 5-3% .................................................... 132 benztropine mesylate inj 1 mg/ml ...... 67 benztropine mesylate tab 0.5 mg ....... 67 benztropine mesylate tab 1 mg .......... 67 benztropine mesylate tab 2 mg .......... 67 BEPREVE DRO 1.5% ....................... 124 BESIVANCE SUS 0.6% .................... 122 betamethasone dipropionate augmented cream 0.05%................................. 135 betamethasone dipropionate augmented lotion 0.05% ................................. 135 betamethasone dipropionate augmented oint 0.05% .................................... 136 betamethasone dipropionate cream 146
January 1, 2017
0.05% ........................................... 136 betamethasone dipropionate lotion 0.05% .................................................... 136 betamethasone dipropionate oint 0.05% .................................................... 136 betamethasone valerate aerosol foam 0.12% ........................................... 136 betamethasone valerate cream 0.1% 136 betamethasone valerate lotion 0.1% . 136 betamethasone valerate oint 0.1%.... 136 BETASERON INJ 0.3MG......................77 betaxolol hcl ophth soln 0.5% .......... 124 betaxolol hcl tab 10 mg .....................47 betaxolol hcl tab 20 mg .....................47 bethanechol chloride tab 10 mg ........ 107 bethanechol chloride tab 25 mg ........ 107 bethanechol chloride tab 5 mg .......... 107 bethanechol chloride tab 50 mg ........ 107 BETIMOL SOL 0.25% ....................... 124 BETIMOL SOL 0.5% ........................ 124 BETOPTIC-S SUS 0.25% OP ............. 124 BEVESPI AER.................................. 125 bexarotene cap 75 mg .......................36 BEXSERO INJ ................................. 115 BEYAZ TAB.......................................86 bicalutamide tab 50 mg .....................34 BICILLIN C-R INJ 1200000 .................28 BICILLIN C-R INJ 900/300 .................28 BICILLIN L-A INJ 1200000 .................28 BICILLIN L-A INJ 2400000 .................28 BICILLIN L-A INJ 600000 ...................28 BICNU INJ 100MG .............................30 BILTRICIDE TAB 600MG ....................15 bimatoprost ophth soln 0.03% ......... 124 bio-d-mulsio liq 400unit ................... 120 BIO-STATIN CAP 1000000 .................17 BIO-STATIN CAP 500000 ...................17 bisoprolol & hydrochlorothiazide tab 10-6.25 mg ......................................46 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg .....................................46 bisoprolol & hydrochlorothiazide tab 5-6.25 mg .......................................46 bisoprolol fumarate tab 10 mg ............47 bisoprolol fumarate tab 5 mg .............47 bleomycin sulfate for inj 15 unit ..........31 bleomycin sulfate for inj 30 unit ..........31
BLEPHAMIDE OIN S.O.P. ................. 122 BLEPHAMIDE SUS OP ...................... 122 BLOOD GLUCOSE CALIBRATION SOLUTION ..................................... 117 BOOSTRIX INJ ............................... 115 BOSULIF TAB 100MG ........................ 35 BOSULIF TAB 500MG ........................ 35 BOTOX INJ 100UNIT ......................... 77 BOTOX INJ 200UNIT ......................... 77 bp wash liq 2.5% ........................... 132 bp wash liq 7% .............................. 132 BREO ELLIPTA INH 100-25 .............. 130 BREO ELLIPTA INH 200-25 .............. 130 BRILINTA TAB 60MG ....................... 111 BRILINTA TAB 90MG ....................... 111 brimonidine tartrate ophth soln 0.15% .................................................... 124 brimonidine tartrate ophth soln 0.2% 124 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) ................ 123 bromfenac sodium ophth soln 0.09% (base equivalent) ........................... 123 bromocriptine mesylate cap 5 mg....... 67 bromocriptine mesylate tab 2.5 mg .... 67 brompheniramine tannate chew tab 12 mg ............................................... 126 BROVANA NEB 15MCG .................... 128 budesonide delayed release particles cap 3 mg ............................................ 104 budesonide inhalation susp 0.25 mg/2ml .................................................... 130 budesonide inhalation susp 0.5 mg/2ml .................................................... 130 budesonide inhalation susp 1 mg/2ml 130 budesonide nasal susp 32 mcg/act ... 130 bumetanide inj 0.25 mg/ml ............... 51 bumetanide tab 0.5 mg ..................... 51 bumetanide tab 1 mg ....................... 51 bumetanide tab 2 mg ....................... 51 BUPHENYL TAB 500MG ..................... 89 buprenorphine hcl inj 0.3 mg/ml (base equiv) ............................................. 12 buprenorphine hcl sl tab 2 mg (base equiv) ............................................. 12 buprenorphine hcl sl tab 8 mg (base equiv) ............................................. 12 buprenorphine hcl-naloxone hcl sl tab 147
January 1, 2017
2-0.5 mg (base equiv) ........................ 7 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) ................................ 7 buproban tab 150mg .........................79 bupropion hcl (smoking deterrent) tab sr 12hr 150 mg ....................................79 bupropion hcl tab 100 mg ..................62 bupropion hcl tab 75 mg ....................62 bupropion hcl tab sr 12hr 100 mg .......62 bupropion hcl tab sr 12hr 150 mg .......62 bupropion hcl tab sr 12hr 200 mg .......62 bupropion hcl tab sr 24hr 150 mg .......62 bupropion hcl tab sr 24hr 300 mg .......62 buspirone hcl tab 10 mg ....................55 buspirone hcl tab 15 mg ....................55 buspirone hcl tab 30 mg ....................55 buspirone hcl tab 5 mg ......................55 buspirone hcl tab 7.5 mg ...................55 BUSULFEX INJ 6MG/ML ......................30 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg .............................. 7 butalbital-acetaminophen-caffeine cap 50-300-40 mg ................................... 5 butalbital-acetaminophen-caffeine cap 50-325-40 mg ................................... 5 butalbital-acetaminophen-caffeine tab 50-325-40 mg ................................... 5 butalbital-aspirin-caffeine cap 50-325-40 mg ................................................... 5 butalbital-aspirin-caffeine tab 50-325-40 mg ................................................... 5 butorphanol tartrate inj 1 mg/ml ......... 7 butorphanol tartrate inj 2 mg/ml ......... 7 butorphanol tartrate nasal soln 10 mg/ml ....................................................... 7 BUTRANS DIS 10MCG/HR ..................13 BUTRANS DIS 15MCG/HR ..................13 BUTRANS DIS 20MCG/HR ..................13 BUTRANS DIS 5MCG/HR ....................12 BUTRANS DIS 7.5/HR ........................13 BYDUREON INJ 2MG ..........................82 BYDUREON PEN INJ 2MG ...................82 BYSTOLIC TAB 10MG .........................47 BYSTOLIC TAB 2.5MG ........................47 BYSTOLIC TAB 20MG .........................47 BYSTOLIC TAB 5MG ..........................47
C cabergoline tab 0.5 mg ..................... 98 CAFERGOT TAB 1-100MG .................. 75 calcipotriene cream 0.005% ............ 135 calcipotriene oint 0.005% ................ 135 calcipotriene soln 0.005% (50 mcg/ml) .................................................... 135 calcipotriene-betamethasone dipropionate oint 0.005-0.064% ...... 136 calcitonin (salmon) nasal soln 200 unit/act ...................................................... 98 calcitrene oin 0.005% ..................... 135 calcitriol cap 0.25 mcg .................... 120 calcitriol cap 0.5 mcg ...................... 120 calcitriol inj 1 mcg/ml ..................... 120 calcitriol oint 3 mcg/gm .................. 135 calcitriol oral soln 1 mcg/ml ............. 120 calcium acetate (phosphate binder) cap 667 mg (169 mg ca)......................... 99 calcium acetate (phosphate binder) tab 667 mg ........................................... 99 camila tab 0.35mg ........................... 86 CAMPTOSAR INJ 300/15ML ................ 38 CANASA SUP 1000MG ..................... 104 CANCIDAS INJ 50MG ........................ 17 CANCIDAS INJ 70MG ........................ 17 candesartan cilexetil tab 16 mg.......... 42 candesartan cilexetil tab 32 mg.......... 42 candesartan cilexetil tab 4 mg ........... 42 candesartan cilexetil tab 8 mg ........... 42 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg................................ 41 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg................................ 41 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg .................................. 41 CANTIL TAB 25MG .......................... 101 CAPASTAT SUL INJ 1GM .................... 21 capecitabine tab 150 mg ................... 31 capecitabine tab 500 mg ................... 31 CAPEX SHA 0.01% ......................... 136 CAPITAL/COD SUS 120-12/5 ............... 7 CAPRELSA TAB 100MG ...................... 35 CAPRELSA TAB 300MG ...................... 35 captopril & hydrochlorothiazide tab 25-15 mg ................................................. 39 captopril & hydrochlorothiazide tab 25-25 148
January 1, 2017
mg ..................................................39 captopril & hydrochlorothiazide tab 50-15 mg ..................................................39 captopril & hydrochlorothiazide tab 50-25 mg ..................................................39 captopril tab 100 mg .........................40 captopril tab 12.5 mg ........................40 captopril tab 25 mg ...........................40 captopril tab 50 mg ...........................40 CARAFATE SUS 1GM/10ML ............... 106 CARBAGLU TAB 200MG ......................89 carbamazepine cap sr 12hr 100 mg.....56 carbamazepine cap sr 12hr 200 mg.....56 carbamazepine cap sr 12hr 300 mg.....56 carbamazepine chew tab 100 mg ........56 carbamazepine susp 100 mg/5ml........56 carbamazepine tab 200 mg ................56 carbamazepine tab sr 12hr 100 mg .....56 carbamazepine tab sr 12hr 200 mg .....56 carbamazepine tab sr 12hr 400 mg .....56 carbidopa & levodopa orally disintegrating tab 10-100 mg .................................67 carbidopa & levodopa orally disintegrating tab 25-100 mg .................................67 carbidopa & levodopa orally disintegrating tab 25-250 mg .................................67 carbidopa & levodopa tab 10-100 mg ..67 carbidopa & levodopa tab 25-100 mg ..67 carbidopa & levodopa tab 25-250 mg ..67 carbidopa & levodopa tab cr 25-100 mg ......................................................67 carbidopa & levodopa tab cr 50-200 mg ......................................................67 carbidopa tab 25 mg .........................67 carbidopa-levodopa-entacapone tabs 12.5-50-200 mg ...............................67 carbidopa-levodopa-entacapone tabs 18.75-75-200 mg .............................67 carbidopa-levodopa-entacapone tabs 25-100-200 mg ................................67 carbidopa-levodopa-entacapone tabs 31.25-125-200 mg............................67 carbidopa-levodopa-entacapone tabs 37.5-150-200 mg .............................68 carbidopa-levodopa-entacapone tabs 50-200-200 mg ................................68 carbinoxamine maleate soln 4 mg/5ml
.................................................... 126 carbinoxamine maleate tab 4 mg ..... 126 carboplatin iv for inj 150 mg .............. 37 carboplatin iv soln 150 mg/15ml ........ 37 carboplatin iv soln 450 mg/45ml ........ 37 carboplatin iv soln 50 mg/5ml ............ 37 carboplatin iv soln 600 mg/60ml ........ 37 CARDENE IV INJ 40/200ML................ 49 CARDENE IV SOL 20/200ML .............. 49 CARDIZEM LA TAB 120MG ................. 49 CARDURA XL TAB 4MG .................... 107 CARDURA XL TAB 8MG .................... 107 CARIMUNE NF INJ 12GM ................. 113 CARIMUNE NF INJ 3GM ................... 113 CARIMUNE NF INJ 6GM ................... 113 carisoprodol tab 250 mg ................... 77 carisoprodol tab 350 mg ................... 78 carteolol hcl ophth soln 1% ............. 124 cartia xt cap 120/24hr ...................... 49 cartia xt cap 180/24hr ...................... 49 cartia xt cap 240/24hr ...................... 49 cartia xt cap 300/24hr ...................... 49 carvedilol tab 12.5 mg ...................... 47 carvedilol tab 25 mg ......................... 47 carvedilol tab 3.125 mg .................... 47 carvedilol tab 6.25 mg ...................... 47 CAYA DPR ..................................... 116 CAYSTON INH 75MG ......................... 15 caziant pak ...................................... 86 CEDAX SUS 90MG/5ML ..................... 22 cefaclor cap 250 mg ......................... 22 cefaclor cap 500 mg ......................... 22 CEFACLOR ER TAB 500MG ................. 22 cefaclor for susp 125 mg/5ml ............ 22 cefaclor for susp 250 mg/5ml ............ 22 cefaclor for susp 375 mg/5ml ............ 22 cefadroxil cap 500 mg....................... 23 cefadroxil for susp 250 mg/5ml .......... 23 cefadroxil for susp 500 mg/5ml .......... 23 cefadroxil tab 1 gm .......................... 23 CEFAZOL/DEX SOL 1GM .................... 23 CEFAZOL/DEX SOL 2GM .................... 23 CEFAZOLIN INJ 1GM/50ML ................ 23 cefazolin sodium for inj 1 gm ............. 23 cefazolin sodium for inj 10 gm ........... 23 cefazolin sodium for inj 20 gm ........... 23 cefazolin sodium for inj 500 mg ......... 23 149
January 1, 2017
cefazolin sodium for iv soln 1 gm ........23 CEFAZOLIN SOL ...............................23 cefdinir cap 300 mg ..........................23 cefdinir for susp 125 mg/5ml..............23 cefdinir for susp 250 mg/5ml..............23 cefditoren pivoxil tab 200 mg (base equivalent) ......................................23 cefditoren pivoxil tab 400 mg (base equivalent) ......................................23 cefepime hcl for inj 1 gm ...................23 cefepime hcl for inj 2 gm ...................23 CEFEPIME INJ 1GM ...........................23 CEFEPIME INJ 2GM ...........................23 CEFEPIME/DEX INJ 1GM ....................23 cefixime for susp 100 mg/5ml ............23 cefixime for susp 200 mg/5ml ............23 cefotaxime sodium for inj 1 gm ..........23 cefotaxime sodium for inj 10 gm .........23 cefotaxime sodium for inj 2 gm ..........23 cefotaxime sodium for inj 500 mg .......23 CEFOTET/DEX INJ 1-3.58% ................23 CEFOTET/DEX INJ 2-2.08% ................23 cefotetan disodium for inj 1 gm ..........23 cefotetan disodium for inj 10 gm ........23 cefotetan disodium for inj 2 gm ..........23 CEFOXITIN INJ 1GM ..........................23 CEFOXITIN INJ 2GM ..........................23 cefoxitin sodium for inj 10 gm ............23 cefoxitin sodium for iv soln 1 gm ........23 cefoxitin sodium for iv soln 2 gm ........23 cefpodoxime proxetil for susp 100 mg/5ml ......................................................24 cefpodoxime proxetil for susp 50 mg/5ml ......................................................24 cefpodoxime proxetil tab 100 mg ........24 cefpodoxime proxetil tab 200 mg ........24 cefprozil for susp 125 mg/5ml ............24 cefprozil for susp 250 mg/5ml ............24 cefprozil tab 250 mg .........................24 cefprozil tab 500 mg .........................24 ceftazidime for inj 2 gm .....................24 CEFTAZIDIME INJ 100GM...................24 CEFTAZIDIME/ SOL D5W 1GM ............24 CEFTAZIDIME/ SOL D5W 2GM ............24 ceftibuten cap 400 mg .......................24 ceftibuten for susp 180 mg/5ml ..........24 CEFTIN SUS 125/5ML ........................24
CEFTIN SUS 250/5ML ....................... 24 ceftriaxone sodium for inj 1 gm ......... 24 ceftriaxone sodium for inj 10 gm ........ 24 ceftriaxone sodium for inj 2 gm ......... 24 ceftriaxone sodium for inj 250 mg ...... 24 ceftriaxone sodium for inj 500 mg ...... 24 ceftriaxone sodium for iv soln 1 gm .... 24 ceftriaxone sodium for iv soln 2 gm .... 24 CEFUROX/DEXT INJ 1.5GM ................ 24 CEFUROX/DEXT INJ 750MG ............... 24 cefuroxime axetil tab 250 mg ............ 24 cefuroxime axetil tab 500 mg ............ 24 CEFUROXIME INJ 225GM ................... 24 CEFUROXIME INJ 7.5GM ................... 24 CEFUROXIME INJ 75GM .................... 24 cefuroxime sodium for inj 1.5 gm ....... 24 cefuroxime sodium for inj 7.5 gm ....... 24 cefuroxime sodium for inj 750 mg ...... 24 cefuroxime sodium for iv soln 1.5 gm . 24 celecoxib cap 100 mg ......................... 5 celecoxib cap 200 mg ......................... 5 celecoxib cap 400 mg ......................... 5 celecoxib cap 50 mg ........................... 5 CELLCEPT IV INJ 500MG ................. 114 CELONTIN CAP 300MG ...................... 56 CENESTIN TAB 0.3MG ....................... 90 CENESTIN TAB 0.45MG ..................... 90 CENESTIN TAB 0.625MG ................... 90 CENESTIN TAB 0.9MG ....................... 90 CENESTIN TAB 1.25MG ..................... 90 cephalexin cap 250 mg ..................... 24 cephalexin cap 500 mg ..................... 24 cephalexin cap 750 mg ..................... 24 cephalexin for susp 125 mg/5ml ........ 24 cephalexin for susp 250 mg/5ml ........ 24 cephalexin tab 250 mg...................... 24 cephalexin tab 500 mg...................... 24 CERDELGA CAP 84MG ....................... 89 CEREZYME INJ 400UNIT .................... 89 CERVARIX INJ ................................ 115 CESAMET CAP 1MG ........................ 102 cesia pak......................................... 86 cevimeline hcl cap 30 mg ................ 139 CHANTIX PAK 0.5& 1MG ................... 79 CHANTIX PAK 1MG ........................... 79 CHANTIX TAB 0.5MG ........................ 79 CHANTIX TAB 1MG ........................... 79 150
January 1, 2017
chateal tab 0.15/30...........................86 CHEMET CAP 100MG .........................86 cheratussin syp 100-10/5 ................ 128 child vit d chw 400unit .................... 120 chloramphenicol sodium succinate for iv inj 1 gm...........................................14 chlorhexidine gluconate soln 0.12% .. 139 chloroquine phosphate tab 250 mg .....18 chloroquine phosphate tab 500 mg .....18 chlorothiazide sodium for inj 500 mg ...51 chlorothiazide tab 250 mg ..................51 chlorothiazide tab 500 mg ..................51 CHLORPROMAZ INJ 25MG/ML .............69 CHLORPROMAZ INJ 50MG/2ML ...........69 chlorpromazine hcl tab 10 mg ............69 chlorpromazine hcl tab 100 mg ...........69 chlorpromazine hcl tab 200 mg ...........69 chlorpromazine hcl tab 25 mg ............69 chlorpromazine hcl tab 50 mg ............69 chlorthalidone tab 100 mg .................52 chlorthalidone tab 25 mg ...................51 chlorthalidone tab 50 mg ...................52 chlorzoxazone tab 500 mg .................78 cholecalciferol cap 400 unit .............. 120 cholestyramine light powder 4 gm/dose ......................................................44 cholestyramine light powder packets 4 gm ......................................................44 cholestyramine powder 4 gm/dose ......44 cholestyramine powder packets 4 gm ..44 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) ........................44 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) ........................44 chorionic gonadotropin for inj 10000 unit ......................................................98 CIALIS TAB 2.5MG .......................... 107 CIALIS TAB 5MG ............................. 107 ciclopirox gel 0.77% ........................ 134 ciclopirox olamine cream 0.77% (base equiv) ........................................... 134 ciclopirox olamine susp 0.77% (base equiv) ........................................... 134 ciclopirox shampoo 1% .................... 134 ciclopirox solution 8% ..................... 134 cidofovir iv inj 75 mg/ml ....................21 cilostazol tab 100 mg ...................... 111
cilostazol tab 50 mg ....................... 111 CILOXAN OIN 0.3% OP ................... 122 cimetidine hcl soln 300 mg/5ml ....... 104 cimetidine tab 200 mg .................... 104 cimetidine tab 300 mg .................... 104 cimetidine tab 400 mg .................... 104 cimetidine tab 800 mg .................... 104 CIMZIA KIT ................................... 112 CIMZIA KIT STARTER ..................... 112 CIMZIA PREFL KIT 200MG/ML .......... 112 CIPRO HC SUS OTIC ....................... 139 CIPRODEX SUS 0.3-0.1% ................ 139 ciprofloxacin 200 mg/100ml in d5w .... 26 ciprofloxacin 400 mg/200ml in d5w .... 26 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml).......................... 26 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) ...................... 26 ciprofloxacin hcl ophth soln 0.3% ..... 122 ciprofloxacin hcl tab 100 mg (base equiv) ...................................................... 26 ciprofloxacin hcl tab 250 mg (base equiv) ...................................................... 26 ciprofloxacin hcl tab 500 mg (base equiv) ...................................................... 26 ciprofloxacin hcl tab 750 mg (base equiv) ...................................................... 26 ciprofloxacin iv soln 200 mg/20ml (1%) ...................................................... 26 ciprofloxacin iv soln 400 mg/40ml (1%) ...................................................... 26 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) ............................ 26 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) ............................ 26 cisplatin inj 100 mg/100ml (1 mg/ml) . 37 cisplatin inj 200 mg/200ml (1 mg/ml) . 37 cisplatin inj 50 mg/50ml (1 mg/ml) .... 37 citalopram hydrobromide oral soln 10 mg/5ml ........................................... 62 citalopram hydrobromide tab 10 mg (base equiv) ............................................. 62 citalopram hydrobromide tab 20 mg (base equiv) ............................................. 62 citalopram hydrobromide tab 40 mg (base equiv) ............................................. 62 CITRANATAL CAP HARMONY ............ 120 151
January 1, 2017
CITRANATAL MIS 90 DHA ................ 120 CITRANATAL MIS B-CALM ................ 120 CITRANATAL PAK ASSURE................ 120 CITRANATAL PAK DHA ..................... 120 CITRANATAL TAB RX ....................... 120 cladribine iv soln 10 mg/10ml (1 mg/ml) ......................................................31 CLAFORAN INJ 1GM ..........................25 CLAFORAN INJ 2GM ..........................25 claravis cap 10mg ........................... 132 claravis cap 20mg ........................... 132 claravis cap 30mg ........................... 132 claravis cap 40mg ........................... 132 CLARINEX SYP 0.5MG/ML................. 126 clarithromycin for susp 125 mg/5ml ....25 clarithromycin for susp 250 mg/5ml ....25 clarithromycin tab 250 mg .................25 clarithromycin tab 500 mg .................25 clarithromycin tab sr 24hr 500 mg ......25 clearplex x gel 10% ........................ 132 clemastine fumarate syrup 0.67 mg/5ml (0.5 mg/5ml base eq) ..................... 126 clemastine fumarate tab 2.68 mg ..... 126 CLEOCIN SUP 100MG ...................... 108 CLIMARA PRO DIS WEEKLY ................90 clindamax gel 1% ........................... 132 clindamax lot 10mg/ml .................... 132 clindamycin hcl cap 150 mg ...............15 clindamycin hcl cap 300 mg ...............15 clindamycin hcl cap 75 mg .................15 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) .........................15 clindamycin phosphate foam 1% ...... 132 clindamycin phosphate gel 1% ......... 132 clindamycin phosphate inj 300 mg/2ml 15 clindamycin phosphate inj 600 mg/4ml 15 clindamycin phosphate inj 9 gm/60ml .15 clindamycin phosphate inj 900 mg/6ml 15 clindamycin phosphate iv soln 300 mg/2ml ...........................................15 clindamycin phosphate iv soln 600 mg/4ml ...........................................15 clindamycin phosphate iv soln 900 mg/6ml ...........................................15 clindamycin phosphate lotion 1% ...... 132 clindamycin phosphate soln 1% ........ 132 clindamycin phosphate swab 1% ...... 132
clindamycin phosphate vaginal cream 2% .................................................... 108 clindamycin phosphate-benzoyl peroxide gel 1-5% ....................................... 132 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5%.................... 132 clobetasol propionate cream 0.05% .. 136 clobetasol propionate foam 0.05% ... 136 clobetasol propionate gel 0.05% ...... 136 clobetasol propionate lotion 0.05% ... 136 clobetasol propionate oint 0.05% ..... 136 clobetasol propionate shampoo 0.05% .................................................... 136 clobetasol propionate soln 0.05% ..... 136 clobetasol propionate spray 0.05% ... 136 clocortolone pivalate cream 0.1%..... 136 CLOLAR INJ 1MG/ML......................... 31 clomipramine hcl cap 25 mg .............. 62 clomipramine hcl cap 50 mg .............. 63 clomipramine hcl cap 75 mg .............. 63 clonazepam tab 0.5 mg ..................... 56 clonazepam tab 1 mg ....................... 56 clonazepam tab 2 mg ....................... 56 clonidine hcl tab 0.1 mg .................... 53 clonidine hcl tab 0.2 mg .................... 53 clonidine hcl tab 0.3 mg .................... 53 clonidine hcl td patch weekly 0.1 mg/24hr ...................................................... 53 clonidine hcl td patch weekly 0.2 mg/24hr ...................................................... 53 clonidine hcl td patch weekly 0.3 mg/24hr ...................................................... 53 clopidogrel bisulfate tab 300 mg (base equiv) ........................................... 111 clopidogrel bisulfate tab 75 mg (base equiv) ........................................... 111 clorazepate dipotassium tab 15 mg .... 57 clorazepate dipotassium tab 3.75 mg .. 57 clorazepate dipotassium tab 7.5 mg ... 57 clotrimazole cream 1% ................... 134 CLOTRIMAZOLE CRY ....................... 134 clotrimazole soln 1% ...................... 134 clotrimazole troche 10 mg ............... 139 clotrimazole w/ betamethasone cream 1-0.05% ....................................... 134 clotrimazole w/ betamethasone lotion 1-0.05% ....................................... 134 152
January 1, 2017
clozapine orally disintegrating tab 100 mg ......................................................69 clozapine orally disintegrating tab 12.5 mg ..................................................69 clozapine orally disintegrating tab 150 mg ......................................................69 clozapine orally disintegrating tab 200 mg ......................................................69 clozapine orally disintegrating tab 25 mg ......................................................69 clozapine tab 100 mg ........................69 clozapine tab 200 mg ........................69 clozapine tab 25 mg ..........................69 clozapine tab 50 mg ..........................69 COARTEM TAB 20-120MG ..................18 CODEINE SULF SOL 30MG/5ML............ 7 codeine sulfate tab 15 mg ................... 7 codeine sulfate tab 30 mg ................... 8 codeine sulfate tab 60 mg ................... 8 colchicine tab 0.6 mg ......................... 5 colchicine w/ probenecid tab 0.5-500 mg ....................................................... 5 colestipol hcl granule packets 5 gm .....44 colestipol hcl granules 5 gm ...............44 colestipol hcl tab 1 gm .......................44 colocort ene 100mg ........................ 105 COLYTE/FLAVR SOL PACKS .............. 105 COMBIGAN SOL 0.2/0.5% ................ 124 COMBIVENT AER 20-100.................. 125 COMETRIQ KIT 100MG ......................35 COMETRIQ KIT 140MG ......................35 COMETRIQ KIT 60MG ........................35 COMPLERA TAB ................................20 compro sup 25mg ........................... 102 COMVAX INJ................................... 115 CONCEPTROL GEL 4% ..................... 107 CONDYLOX GEL 0.5%...................... 138 CONTAINER MIS CLOSER ................. 117 COPAXONE INJ 40MG/ML ...................77 CORDRAN 24X3 TAP 4MCG/CM ......... 136 CORDRAN LOT 0.05% ..................... 136 CORDRAN OIN 0.05% ..................... 136 COREG CR CAP 10MG ........................47 COREG CR CAP 20MG ........................47 COREG CR CAP 40MG ........................47 COREG CR CAP 80MG ........................47 cortisone acetate tab 25 mg ...............95
CORTISPORIN CRE 0.5%................. 133 CORTISPORIN OIN 1% ................... 133 CORTISPORIN SUS -TC OTIC ........... 139 COSENTYX INJ 150MG/ML ............... 135 COSENTYX PEN INJ 150MG/ML ........ 135 COUMADIN INJ 5 MG ...................... 109 CREON CAP 12000UNT.................... 106 CREON CAP 24000UNT.................... 106 CREON CAP 3000UNIT .................... 106 CREON CAP 36000UNT.................... 106 CREON CAP 6000UNIT .................... 106 CRESEMBA CAP 186 MG .................... 17 CRINONE GEL 4% VAG ..................... 99 CRINONE GEL 8% VAG ..................... 99 CRIXIVAN CAP 200MG ...................... 18 CRIXIVAN CAP 400MG ...................... 18 cromolyn sodium ophth soln 4% ...... 124 cromolyn sodium oral conc 100 mg/5ml .................................................... 106 cromolyn sodium soln nebu 20 mg/2ml .................................................... 129 cryselle-28 tab 28 tabs ..................... 86 CUBICIN SOL 500MG ........................ 15 CUVPOSA SOL 1MG/5ML ................. 101 cyanocobalamin inj 1000 mcg/ml ..... 120 cyclafem tab 1/35 ............................ 86 cyclafem tab 7/7/7 ........................... 86 cyclobenzaprine hcl tab 10 mg ........... 78 cyclobenzaprine hcl tab 5 mg ............. 78 cyclobenzaprine hcl tab 7.5 mg .......... 78 CYCLOPHOSPH CAP 25MG ................. 30 CYCLOPHOSPH CAP 50MG ................. 30 cyclophosphamide for inj 1 gm .......... 30 cyclophosphamide for inj 2 gm .......... 30 cyclophosphamide for inj 500 mg ....... 30 cyclophosphamide tab 25 mg............. 30 cyclophosphamide tab 50 mg............. 30 cycloserine cap 250 mg..................... 21 CYCLOSET TAB 0.8MG ...................... 82 cyclosporine cap 100 mg ................. 114 cyclosporine cap 25 mg ................... 114 cyclosporine iv soln 50 mg/ml .......... 114 cyclosporine modified cap 100 mg .... 114 cyclosporine modified cap 25 mg ...... 114 cyclosporine modified cap 50 mg ...... 114 cyclosporine modified oral soln 100 mg/ml .................................................... 114 153
January 1, 2017
cyproheptadine hcl syrup 2 mg/5ml .. 126 cyproheptadine hcl tab 4 mg ............ 126 CYSTADANE POW..............................89 CYSTAGON CAP 150MG .....................89 CYSTAGON CAP 50MG .......................89 CYSTARAN SOL 0.44% .................... 125 cytarabine for inj 1 gm ......................31 cytarabine for inj 100 mg ...................32 cytarabine for inj 500 mg ...................32 cytarabine inj 20 mg/ml ....................32 cytarabine inj pf 100 mg/ml ...............32 cytarabine inj pf 20 mg/ml .................32 D dacarbazine for inj 100 mg ................30 dacarbazine for inj 200 mg ................30 dactinomycin for inj 0.5 mg................31 DALIRESP TAB 500MCG ................... 129 danazol cap 100 mg ..........................89 danazol cap 200 mg ..........................89 danazol cap 50 mg ............................89 dantrolene sodium cap 100 mg ...........78 dantrolene sodium cap 25 mg ............78 dantrolene sodium cap 50 mg ............78 dapsone tab 100 mg .........................15 dapsone tab 25 mg ...........................15 DAPTACEL INJ ................................ 115 DARAPRIM TAB 25MG ........................15 darifenacin hydrobromide tab sr 24hr 15 mg (base equiv) ............................. 108 darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv) ............................. 108 dasetta tab 1/35 ...............................86 dasetta tab 7/7/7..............................86 daunorubicin hcl for inj 20 mg ............31 daunorubicin hcl inj 5 mg/ml (base equiv) ......................................................31 DAUNOXOME INJ 2MG/ML ..................31 DDROPS BOOST LIQ 600/.028 .......... 120 decara cap 50000unt ....................... 120 decitabine for inj 50 mg .....................32 delyla tab 0.1-0.02 ...........................86 demeclocycline hcl tab 150 mg ...........29 demeclocycline hcl tab 300 mg ...........29 DENAVIR CRE 1% ........................... 138 DEPEN TITRA TAB 250MG ..................86 DEPOCYT INJ 50MG/5ML ....................32 DEPO-ESTRADI INJ 5MG/ML ...............90
DEPO-MEDROL INJ 20MG/ML ............. 95 DEPO-PROVERA INJ 400/ML .............. 34 DEPO-SQ PROV INJ 104 .................... 86 desipramine hcl tab 10 mg ................ 63 desipramine hcl tab 100 mg .............. 63 desipramine hcl tab 150 mg .............. 63 desipramine hcl tab 25 mg ................ 63 desipramine hcl tab 50 mg ................ 63 desipramine hcl tab 75 mg ................ 63 desloratadine tab 5 mg ................... 126 desloratadine tab orally disintegrating 2.5 mg ............................................... 126 desloratadine tab orally disintegrating 5 mg ............................................... 126 desmopressin acetate inj 4 mcg/ml .. 101 desmopressin acetate nasal soln 0.01% (refrigerated)................................. 101 desmopressin acetate nasal spray soln 0.01% .......................................... 101 desmopressin acetate nasal spray soln 0.01% (refrigerated) ...................... 101 desmopressin acetate tab 0.1 mg ..... 101 desmopressin acetate tab 0.2 mg ..... 101 DESONATE GEL 0.05% ................... 136 desonide cream 0.05% ................... 136 desonide lotion 0.05% .................... 136 desonide oint 0.05%....................... 136 DESOWEN OINT KIT 0.05% ............. 136 desoximetasone cream 0.05% ......... 136 desoximetasone cream 0.25% ......... 136 desoximetasone gel 0.05%.............. 136 desoximetasone oint 0.05% ............ 136 desoximetasone oint 0.25% ............ 136 desvenlafaxine tab sr 24hr 100 mg..... 63 desvenlafaxine tab sr 24hr 50 mg ...... 63 DEXAMETHASON CON 1MG/ML .......... 95 dexamethasone elixir 0.5 mg/5ml ...... 95 dexamethasone sod phosphate preservative free inj 10 mg/ml ........... 95 dexamethasone sodium phosphate inj 10 mg/ml ............................................ 95 dexamethasone sodium phosphate inj 100 mg/10ml ......................................... 95 dexamethasone sodium phosphate inj 120 mg/30ml ......................................... 95 dexamethasone sodium phosphate inj 20 mg/5ml ........................................... 95 154
January 1, 2017
dexamethasone sodium phosphate inj 4 mg/ml .............................................95 dexamethasone sodium phosphate ophth soln 0.1% ...................................... 123 dexamethasone soln 0.5 mg/5ml ........95 dexamethasone tab 0.5 mg ................95 dexamethasone tab 0.75 mg ..............95 dexamethasone tab 1 mg ..................95 dexamethasone tab 1.5 mg ................95 dexamethasone tab 2 mg ..................95 dexamethasone tab 4 mg ..................95 dexamethasone tab 6 mg ..................95 dexchlorpheniramine maleate syrup 2 mg/5ml ......................................... 126 DEXILANT CAP 30MG DR ................. 106 DEXILANT CAP 60MG DR ................. 106 dexmethylphenidate hcl cap sr 24 hr 10 mg ..................................................73 dexmethylphenidate hcl cap sr 24 hr 15 mg ..................................................73 dexmethylphenidate hcl cap sr 24 hr 20 mg ..................................................73 dexmethylphenidate hcl cap sr 24 hr 30 mg ..................................................73 dexmethylphenidate hcl cap sr 24 hr 40 mg ..................................................73 dexmethylphenidate hcl cap sr 24 hr 5 mg ......................................................73 dexmethylphenidate hcl tab 10 mg .....73 dexmethylphenidate hcl tab 2.5 mg ....73 dexmethylphenidate hcl tab 5 mg .......73 DEXPAK PAK 10 DAY .........................95 DEXPAK PAK 13 DAY .........................95 DEXPAK PAK 6 DAY ...........................95 dexrazoxane for inj 250 mg ...............37 dexrazoxane for inj 500 mg ...............37 dextroamphetamine sulfate cap sr 24hr 10 mg .............................................73 dextroamphetamine sulfate cap sr 24hr 15 mg .............................................73 dextroamphetamine sulfate cap sr 24hr 5 mg ..................................................73 dextroamphetamine sulfate oral solution 5 mg/5ml.........................................73 dextroamphetamine sulfate tab 10 mg 73 dextroamphetamine sulfate tab 5 mg ..73 diazepam con 5mg/ml .......................57
diazepam inj 5 mg/ml ....................... 57 diazepam oral soln 1 mg/ml .............. 57 diazepam tab 10 mg ......................... 57 diazepam tab 2 mg........................... 57 diazepam tab 5 mg........................... 57 diclofenac potassium tab 50 mg ........... 5 diclofenac sodium gel 1% ................ 138 diclofenac sodium ophth soln 0.1% .. 123 diclofenac sodium tab delayed release 25 mg ................................................... 5 diclofenac sodium tab delayed release 50 mg ................................................... 5 diclofenac sodium tab delayed release 75 mg ................................................... 5 diclofenac sodium tab sr 24hr 100 mg .. 6 diclofenac w/ misoprostol tab delayed release 50-0.2 mg .............................. 5 diclofenac w/ misoprostol tab delayed release 75-0.2 mg .............................. 5 dicloxacillin sodium cap 250 mg ......... 28 dicloxacillin sodium cap 500 mg ......... 28 dicyclomine hcl cap 10 mg .............. 101 dicyclomine hcl inj 10 mg/ml ........... 101 dicyclomine hcl oral soln 10 mg/5ml . 101 dicyclomine hcl tab 20 mg ............... 101 didanosine delayed release capsule 125 mg ................................................. 18 didanosine delayed release capsule 200 mg ................................................. 18 didanosine delayed release capsule 250 mg ................................................. 18 didanosine delayed release capsule 400 mg ................................................. 19 DIFICID TAB 200MG ......................... 25 diflorasone diacetate cream 0.05%... 136 diflorasone diacetate oint 0.05% ...... 136 diflunisal tab 500 mg ........................ 13 digox tab 0.125mg ........................... 51 digox tab 0.25mg ............................. 51 digoxin inj 0.25 mg/ml...................... 51 digoxin oral soln 0.05 mg/ml ............. 51 digoxin tab 125 mcg (0.125 mg) ........ 51 digoxin tab 250 mcg (0.25 mg) .......... 51 dihydroergotamine mesylate inj 1 mg/ml ...................................................... 75 dihydroergotamine mesylate nasal spray 4 mg/ml .......................................... 75 155
January 1, 2017
DILANTIN CAP 30MG .........................57 DILATRATE SR CAP 40MG ..................53 diltiazem hcl cap sr 12hr 120 mg ........49 diltiazem hcl cap sr 12hr 60 mg ..........49 diltiazem hcl cap sr 12hr 90 mg ..........49 diltiazem hcl cap sr 24hr 120 mg ........49 diltiazem hcl cap sr 24hr 180 mg ........49 diltiazem hcl cap sr 24hr 240 mg ........49 diltiazem hcl coated beads cap sr 24hr 120 mg ..................................................49 diltiazem hcl coated beads cap sr 24hr 180 mg ..................................................49 diltiazem hcl coated beads cap sr 24hr 240 mg ..................................................49 diltiazem hcl coated beads cap sr 24hr 300 mg ..................................................49 diltiazem hcl coated beads cap sr 24hr 360 mg ..................................................49 diltiazem hcl extended release beads cap sr 24hr 120 mg ................................49 diltiazem hcl extended release beads cap sr 24hr 180 mg ................................49 diltiazem hcl extended release beads cap sr 24hr 240 mg ................................49 diltiazem hcl extended release beads cap sr 24hr 300 mg ................................49 diltiazem hcl extended release beads cap sr 24hr 360 mg ................................49 diltiazem hcl extended release beads cap sr 24hr 420 mg ................................49 diltiazem hcl iv soln 125 mg/25ml (5 mg/ml) ............................................49 diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) ......................................................49 diltiazem hcl iv soln 50 mg/10ml (5 mg/ml) ............................................49 diltiazem hcl tab 120 mg ...................50 diltiazem hcl tab 30 mg .....................49 diltiazem hcl tab 60 mg .....................50 diltiazem hcl tab 90 mg .....................50 DILTIAZEM INJ 100MG ......................50 dimenhydrinate tab 50 mg ............... 102 DIP/TET PED INJ 25-5LFU ................ 115 DIPENTUM CAP 250MG .................... 105 diphenhydramine hcl cap 25 mg ....... 126 diphenhydramine hcl cap 50 mg ....... 126 diphenhydramine hcl elixir 12.5 mg/5ml
.................................................... 127 diphenhydramine hcl inj 50 mg/ml ... 127 diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml ......................................... 106 diphenoxylate w/ atropine tab 2.5-0.025 mg ............................................... 106 dipyridamole tab 25 mg .................. 111 dipyridamole tab 50 mg .................. 111 dipyridamole tab 75 mg .................. 112 disopyramide phosphate cap 100 mg .. 43 disopyramide phosphate cap 150 mg .. 43 disulfiram tab 250 mg ....................... 79 disulfiram tab 500 mg ....................... 79 DIURIL SUS 250/5ML........................ 52 divalproex sodium cap delayed release sprinkle 125 mg ............................... 57 divalproex sodium tab delayed release 125 mg ........................................... 57 divalproex sodium tab delayed release 250 mg ........................................... 57 divalproex sodium tab delayed release 500 mg ........................................... 57 divalproex sodium tab sr 24 hr 250 mg57 divalproex sodium tab sr 24 hr 500 mg57 DIVIGEL GEL 0.25MG ....................... 91 DIVIGEL GEL 0.5MG ......................... 90 DIVIGEL GEL 1MG/GM ...................... 91 DOCEFREZ INJ 20MG ........................ 33 DOCEFREZ INJ 80MG ........................ 33 docetaxel for inj conc 20 mg/ml ......... 33 docetaxel for inj conc 80 mg/4ml (20 mg/ml) ........................................... 33 DOCETAXEL INJ 140/7ML .................. 33 DOCETAXEL INJ 160/16ML ................ 33 DOCETAXEL INJ 160/8ML .................. 33 DOCETAXEL INJ 20/0.5ML ................. 33 DOCETAXEL INJ 200MG/20 ................ 33 DOCETAXEL INJ 20MG/2ML ............... 33 DOCETAXEL INJ 80MG/2ML ............... 33 DOCETAXEL INJ 80MG/8ML ............... 33 DOCETAXEL INJ NON-ALCO ............... 33 dofetilide cap 125 mcg (0.125 mg) ..... 43 dofetilide cap 250 mcg (0.25 mg)....... 43 dofetilide cap 500 mcg (0.5 mg) ........ 43 donepezil hydrochloride orally disintegrating tab 10 mg ................... 60 donepezil hydrochloride orally 156
January 1, 2017
disintegrating tab 5 mg .....................60 donepezil hydrochloride tab 10 mg ......60 donepezil hydrochloride tab 23 mg ......60 donepezil hydrochloride tab 5 mg .......60 DORIBAX INJ 250MG .........................15 DORIBAX INJ 500MG .........................15 dorzolamide hcl ophth soln 2% ......... 124 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml ....................... 124 doxazosin mesylate tab 1 mg .............41 doxazosin mesylate tab 2 mg .............41 doxazosin mesylate tab 4 mg .............41 doxazosin mesylate tab 8 mg .............41 doxepin hcl cap 10 mg.......................63 doxepin hcl cap 100 mg .....................63 doxepin hcl cap 150 mg .....................63 doxepin hcl cap 25 mg.......................63 doxepin hcl cap 50 mg.......................63 doxepin hcl cap 75 mg.......................63 doxepin hcl conc 10 mg/ml ................64 doxepin hcl cream 5% ..................... 135 doxercalciferol cap 0.5 mcg .............. 120 doxercalciferol cap 1 mcg................. 120 doxercalciferol cap 2.5 mcg .............. 120 doxercalciferol inj 4 mcg/2ml (2 mcg/ml) .................................................... 121 doxorubicin hcl for inj 10 mg ..............31 doxorubicin hcl for inj 50 mg ..............31 doxorubicin hcl inj 2 mg/ml ................31 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml .............................31 doxy 100 inj 100mg ..........................29 doxycycline hyclate cap 100 mg .........29 doxycycline hyclate cap 50 mg ...........29 doxycycline hyclate for inj 100 mg ......29 doxycycline hyclate tab 100 mg ..........29 doxycycline hyclate tab 20 mg ............29 doxycycline hyclate tab delayed release 100 mg ...........................................29 doxycycline hyclate tab delayed release 150 mg ...........................................29 doxycycline hyclate tab delayed release 75 mg .............................................29 doxycycline monohydrate cap 100 mg .29 doxycycline monohydrate cap 150 mg .29 doxycycline monohydrate cap 50 mg ...29 doxycycline monohydrate cap 75 mg ...29
doxycycline monohydrate for susp 25 mg/5ml ........................................... 29 doxycycline monohydrate tab 150 mg . 29 doxycycline monohydrate tab 50 mg .. 29 doxycycline monohydrate tab 75 mg .. 29 dronabinol cap 10 mg ..................... 102 dronabinol cap 2.5 mg .................... 102 dronabinol cap 5 mg ....................... 102 drospirenone-ethinyl estradiol tab 3-0.03 mg ................................................. 86 DROXIA CAP 200MG ......................... 36 DROXIA CAP 300MG ......................... 36 DROXIA CAP 400MG ......................... 36 DUAVEE TAB 0.45-20 ....................... 91 duloxetine hcl cap 20 mg .................. 64 duloxetine hcl cap 30 mg .................. 64 duloxetine hcl cap 60 mg .................. 64 DUREZOL EMU 0.05% ..................... 123 dutasteride cap 0.5 mg ................... 107 dutasteride-tamsulosin hcl cap 0.5-0.4 mg ............................................... 107 D-VI-SOL LIQ 400UNIT ................... 120 DYMISTA SPR 137-50 ..................... 126 DYRENIUM CAP 100MG ..................... 52 DYRENIUM CAP 50MG ....................... 52 E e.e.s. 400 tab 400mg ....................... 25 E.E.S. GRAN SUS 200/5ML ................ 25 e.s.p. sus 200-600 ........................... 14 econazole nitrate cream 1% ............ 134 EDARBI TAB 40MG ........................... 42 EDARBI TAB 80MG ........................... 42 ed-spaz tab 0.125mg ...................... 101 EDURANT TAB 25MG ........................ 19 EFFIENT TAB 10MG ........................ 112 EFFIENT TAB 5MG .......................... 112 ELAPRASE INJ 6MG/3ML ................... 89 ELELYSO INJ 200UNIT ...................... 89 ELESTRIN GEL 0.06% ....................... 91 ELIDEL CRE 1% ............................. 138 ELIGARD INJ 22.5MG ........................ 34 ELIGARD INJ 30MG .......................... 34 ELIGARD INJ 45MG .......................... 34 ELIGARD INJ 7.5MG ......................... 34 elinest tab ....................................... 87 ELIQUIS TAB 2.5MG ....................... 109 ELIQUIS TAB 5MG .......................... 109 157
January 1, 2017
elite-ob tab .................................... 121 ELIXOPHYLLIN ELX 80/15ML ............ 130 ELLA TAB 30MG ................................87 ELMIRON CAP 100MG ...................... 107 ELOXATIN INJ 200MG ........................37 EMADINE SOL 0.05% OP ................. 124 EMBEDA CAP 100-4MG ....................... 8 EMBEDA CAP 20-0.8MG ...................... 8 EMBEDA CAP 30-1.2MG ...................... 8 EMBEDA CAP 50-2MG ......................... 8 EMBEDA CAP 60-2.4MG ...................... 8 EMBEDA CAP 80-3.2MG ...................... 8 EMCYT CAP 140MG ...........................30 EMEND CAP 125MG ......................... 102 EMEND CAP 40MG ........................... 102 EMEND CAP 80MG ........................... 102 EMEND PAK 80 & 125 ...................... 102 EMEND SUS 125MG......................... 102 emoquette tab ..................................87 EMSAM DIS 12MG/24H ......................64 EMSAM DIS 6MG/24HR ......................64 EMSAM DIS 9MG/24HR ......................64 EMTRIVA CAP 200MG ........................19 EMTRIVA SOL 10MG/ML .....................19 EMVERM CHW 100MG ........................15 enalapril maleate & hydrochlorothiazide tab 10-25 mg ...................................39 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg ..................................39 enalapril maleate tab 10 mg ...............40 enalapril maleate tab 2.5 mg ..............40 enalapril maleate tab 20 mg ...............40 enalapril maleate tab 5 mg ................40 ENBREL INJ 25/0.5ML...................... 112 ENBREL INJ 25MG ........................... 112 ENBREL INJ 50MG/ML...................... 112 ENBREL SRCLK INJ 50MG/ML ........... 112 ENCARE SUP 100MG ....................... 107 endocet tab 10-325mg ....................... 8 endocet tab 2.5-325 ........................... 8 endocet tab 5-325mg ......................... 8 endocet tab 7.5-325 ........................... 8 ENGERIX-B INJ 10/0.5ML................. 115 ENGERIX-B INJ 20MCG/ML ............... 115 ENJUVIA TAB 0.3MG..........................91 ENJUVIA TAB 0.45MG ........................91 ENJUVIA TAB 0.625MG ......................91
ENJUVIA TAB 0.9MG ......................... 91 ENJUVIA TAB 1.25MG ....................... 91 enoxaparin sodium inj 100 mg/ml .... 109 enoxaparin sodium inj 120 mg/0.8ml 109 enoxaparin sodium inj 150 mg/ml .... 109 enoxaparin sodium inj 30 mg/0.3ml . 109 enoxaparin sodium inj 300 mg/3ml .. 109 enoxaparin sodium inj 40 mg/0.4ml . 109 enoxaparin sodium inj 60 mg/0.6ml . 109 enoxaparin sodium inj 80 mg/0.8ml . 109 enpresse-28 tab ............................... 87 entacapone tab 200 mg .................... 68 entecavir tab 0.5 mg ........................ 21 entecavir tab 1 mg ........................... 21 ENTRESTO TAB 24-26MG .................. 53 ENTRESTO TAB 49-51MG .................. 53 ENTRESTO TAB 97-103MG ................ 53 enulose sol 10gm/15 ...................... 105 EPCLUSA TAB 400-100 ..................... 21 EPIDUO FORTE GEL 0.3-2.5% .......... 132 EPIDUO GEL 0.1-2.5% .................... 132 epinastine hcl ophth soln 0.05% ...... 124 epinephrine hcl inj 1 mg/ml ............. 129 epinephrine hcl soln prefilled syringe 0.1 mg/ml .......................................... 125 epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) ...................... 125 epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) ........................ 125 EPIPEN 2-PAK INJ 0.3MG ................ 125 EPIPEN-JR INJ 2-PAK ...................... 125 epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) ........................................... 31 epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) ........................................... 31 EPIRUBICIN INJ 50MG ...................... 31 epitol tab 200mg .............................. 57 EPIVIR HBV SOL 5MG/ML .................. 21 eplerenone tab 25 mg ....................... 41 eplerenone tab 50 mg ....................... 41 epoprostenol sodium for inj 0.5 mg .... 54 epoprostenol sodium for inj 1.5 mg .... 54 eprosartan mesylate tab 600 mg ........ 42 EPZICOM TAB 600-300 ..................... 20 ERAXIS INJ 100MG ........................... 17 ERAXIS INJ 50MG ............................ 17 ERBITUX INJ 100MG ......................... 33 158
January 1, 2017
ERBITUX INJ 200MG..........................33 ergocalciferol cap 50000 unit ............ 121 ergoloid mesylates tab 1 mg ..............69 ERGOMAR SUB 2MG ..........................75 ERIVEDGE CAP 150MG ......................33 errin tab 0.35mg ..............................87 ERTACZO CRE 2%........................... 134 ery pad 2% .................................... 132 ERYPED SUS 200/5ML .......................25 ERYPED SUS 400/5ML .......................26 ery-tab tab 250mg ec ........................25 ery-tab tab 333mg ec ........................25 ery-tab tab 500mg ec ........................25 ERYTHROCIN INJ 1000MG ..................26 ERYTHROCIN INJ 500MG ...................26 erythrocin tab 250mg ........................26 erythromycin ethylsuccinate tab 400 mg ......................................................26 erythromycin gel 2% ....................... 132 erythromycin ophth oint 5 mg/gm..... 122 erythromycin pads 2% .................... 132 erythromycin soln 2% ..................... 132 erythromycin tab 250 mg...................26 erythromycin tab 500 mg...................26 erythromycin w/ delayed release particles cap 250 mg ......................................26 escitalopram oxalate soln 5 mg/5ml (base equiv) .............................................64 escitalopram oxalate tab 10 mg (base equiv) .............................................64 escitalopram oxalate tab 20 mg (base equiv) .............................................64 escitalopram oxalate tab 5 mg (base equiv) .............................................64 esomeprazole magnesium cap delayed release 20 mg (base eq) .................. 106 esomeprazole magnesium cap delayed release 40 mg (base eq) .................. 106 esomeprazole sodium for intravenous soln 20 mg (base equiv) ......................... 106 esomeprazole sodium for intravenous soln 40 mg (base equiv) ......................... 107 ESTRACE VAG CRE 0.1MG/GM ............91 estradiol & norethindrone acetate tab 0.5-0.1 mg ......................................91 estradiol & norethindrone acetate tab 1-0.5 mg .........................................91
estradiol tab 0.5 mg ......................... 91 estradiol tab 1 mg ............................ 92 estradiol tab 2 mg ............................ 92 estradiol td patch twice weekly 0.025 mg/24hr ......................................... 92 estradiol td patch twice weekly 0.0375 mg/24hr ......................................... 92 estradiol td patch twice weekly 0.05 mg/24hr ......................................... 92 estradiol td patch twice weekly 0.075 mg/24hr ......................................... 92 estradiol td patch twice weekly 0.1 mg/24hr ......................................... 92 estradiol td patch weekly 0.025 mg/24hr ...................................................... 92 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) .............................. 93 estradiol td patch weekly 0.05 mg/24hr ...................................................... 92 estradiol td patch weekly 0.06 mg/24hr ...................................................... 92 estradiol td patch weekly 0.075 mg/24hr ...................................................... 93 estradiol td patch weekly 0.1 mg/24hr 92 estradiol valerate im in oil 10 mg/ml .. 93 estradiol valerate im in oil 20 mg/ml .. 93 estradiol valerate im in oil 40 mg/ml .. 93 ESTRING MIS 2MG ........................... 93 ESTROGEL GEL ................................ 93 estropipate tab 0.75 mg .................... 93 estropipate tab 1.5 mg ..................... 93 estropipate tab 3 mg ........................ 93 eszopiclone tab 1 mg ........................ 75 eszopiclone tab 2 mg ........................ 75 eszopiclone tab 3 mg ........................ 75 ethacrynate sodium for inj 50 mg ....... 52 ethacrynic acid tab 25 mg ................. 52 ethambutol hcl tab 100 mg................ 21 ethambutol hcl tab 400 mg................ 21 ethosuximide cap 250 mg ................. 57 ethosuximide soln 250 mg/5ml .......... 57 etodolac cap 200 mg .......................... 6 etodolac cap 300 mg .......................... 6 etodolac tab 400 mg ........................... 6 etodolac tab 500 mg ........................... 6 etodolac tab sr 24hr 400 mg ................ 6 etodolac tab sr 24hr 500 mg ................ 6 159
January 1, 2017
etodolac tab sr 24hr 600 mg ............... 6 ETOPOPHOS INJ 100MG.....................38 etoposide cap 50 mg .........................38 etoposide inj 100 mg/5ml (20 mg/ml) .38 EURAX CRE 10%............................. 139 EURAX LOT 10% ............................. 139 EVAMIST SPR 1.53MG .......................93 EVOTAZ TAB 300-150........................20 EXELDERM CRE 1% ......................... 134 EXELDERM SOL 1% ......................... 134 EXELON SOL 2MG/ML ........................60 exemestane tab 25 mg ......................34 EXJADE TAB 125MG ..........................86 EXJADE TAB 250MG ..........................86 EXJADE TAB 500MG ..........................86 EZ FLU SHOT KIT 2016-17 ............... 115 F FABRAZYME INJ 35MG .......................89 FABRAZYME INJ 5MG.........................89 FACTIVE TAB 320MG .........................26 falmina tab ......................................87 famciclovir tab 125 mg ......................22 famciclovir tab 250 mg ......................22 famciclovir tab 500 mg ......................22 famotidine for susp 40 mg/5ml ......... 104 famotidine in nacl 0.9% iv soln 20 mg/50ml ....................................... 104 famotidine inj 20 mg/2ml................. 104 famotidine inj 200 mg/20ml ............. 104 famotidine inj 40 mg/4ml................. 104 famotidine inj 500 mg/50ml ............. 104 famotidine tab 20 mg ...................... 104 famotidine tab 40 mg ...................... 104 FANAPT PAK .....................................69 FANAPT TAB 10MG ............................69 FANAPT TAB 12MG ............................69 FANAPT TAB 1MG ..............................69 FANAPT TAB 2MG ..............................69 FANAPT TAB 4MG ..............................69 FANAPT TAB 6MG ..............................69 FANAPT TAB 8MG ..............................69 FARESTON TAB 60MG ........................34 FARXIGA TAB 10MG ..........................84 FARXIGA TAB 5MG ............................84 FARYDAK CAP 10MG ..........................33 FARYDAK CAP 15MG ..........................33 FARYDAK CAP 20MG ..........................33
FASLODEX INJ 250MG ...................... 34 FC2 FEMALE MIS CONDOM .............. 116 felbamate susp 600 mg/5ml .............. 57 felbamate tab 400 mg ...................... 57 felbamate tab 600 mg ...................... 57 felodipine tab sr 24hr 10 mg .............. 50 felodipine tab sr 24hr 2.5 mg ............. 50 felodipine tab sr 24hr 5 mg ............... 50 FEMCAP MIS 22MM ......................... 116 FEMCAP MIS 26MM ......................... 116 FEMCAP MIS 30MM ......................... 116 FEMRING MIS 0.05/24H .................... 93 FEMRING MIS 0.1MG/24 ................... 93 fenofibrate cap 150 mg ..................... 44 fenofibrate cap 50 mg ....................... 44 fenofibrate micronized cap 130 mg ..... 45 fenofibrate micronized cap 134 mg ..... 45 fenofibrate micronized cap 200 mg ..... 45 fenofibrate micronized cap 43 mg....... 44 fenofibrate micronized cap 67 mg....... 44 fenofibrate tab 145 mg ..................... 45 fenofibrate tab 160 mg ..................... 45 fenofibrate tab 48 mg ....................... 45 fenofibrate tab 54 mg ....................... 45 fenofibric acid tab 105 mg ................. 45 fenofibric acid tab 35 mg ................... 45 fenoprofen calcium cap 400 mg ........... 6 fenoprofen calcium tab 600 mg ............ 6 fentanyl citrate lozenge on a handle 1200 mcg .................................................. 8 fentanyl citrate lozenge on a handle 1600 mcg .................................................. 8 fentanyl citrate lozenge on a handle 200 mcg .................................................. 8 fentanyl citrate lozenge on a handle 400 mcg .................................................. 8 fentanyl citrate lozenge on a handle 600 mcg .................................................. 8 fentanyl citrate lozenge on a handle 800 mcg .................................................. 8 fentanyl td patch 72hr 100 mcg/hr ....... 8 fentanyl td patch 72hr 12 mcg/hr ......... 8 fentanyl td patch 72hr 25 mcg/hr ......... 8 fentanyl td patch 72hr 50 mcg/hr ......... 8 fentanyl td patch 72hr 75 mcg/hr ......... 8 FERRIPROX TAB 500MG .................... 86 FETZIMA CAP 120MG ........................ 64 160
January 1, 2017
FETZIMA CAP 20MG ..........................64 FETZIMA CAP 40MG ..........................64 FETZIMA CAP 80MG ..........................64 FETZIMA CAP TITRATIO .....................64 fexofenadine hcl tab 180 mg ............ 127 fexofenadine hcl tab 60 mg .............. 127 fexofenadine sus 30mg/5ml ............. 127 FINACEA GEL 15% .......................... 138 finasteride tab 5 mg ........................ 107 FIRAZYR INJ 30MG/3ML ................... 111 FIRMAGON INJ 120MG.......................34 FIRMAGON INJ 80MG ........................34 FLAGYL ER TAB 750MG ......................15 FLAREX SUS 0.1% OP ..................... 123 flavoxate hcl tab 100 mg ................. 108 flecainide acetate tab 100 mg .............43 flecainide acetate tab 150 mg .............43 flecainide acetate tab 50 mg ..............43 FLOWTUSS SOL 2.5-200 .................. 128 floxuridine for inj 0.5 gm ...................32 FLUAD INJ 2016-17 ......................... 115 FLUBLOK SOL 2016-17 .................... 115 FLUCLVX QUAD INJ 2016-17 ............ 115 fluconazole for susp 10 mg/ml ............17 fluconazole for susp 40 mg/ml ............17 fluconazole in dextrose inj 200 mg/100ml ......................................................17 fluconazole in dextrose inj 400 mg/200ml ......................................................17 fluconazole in nacl 0.9% inj 200 mg/100ml ........................................17 fluconazole in nacl 0.9% inj 400 mg/200ml ........................................17 fluconazole tab 100 mg .....................18 fluconazole tab 150 mg .....................18 fluconazole tab 200 mg .....................18 fluconazole tab 50 mg .......................17 FLUCONAZOLE/ INJ NACL 100 ............18 fludarabine phosphate for inj 50 mg ....32 fludarabine phosphate inj 25 mg/ml ....32 fludrocortisone acetate tab 0.1 mg ......95 FLULAVAL QUA INJ 2016-17 ............. 115 flunisolide nasal soln 25 mcg/act (0.025%)....................................... 130 fluocin acet oil 0.01% sc .................. 136 fluocin acet oil body ........................ 136 fluocinolone acetonide (otic) oil 0.01%
.................................................... 139 fluocinolone acetonide cream 0.01% 136 fluocinolone acetonide cream 0.025% 136 fluocinolone acetonide oint 0.025% .. 137 fluocinolone acetonide soln 0.01% ... 137 fluocinonide cream 0.05% ............... 137 fluocinonide cream 0.1% ................. 137 fluocinonide gel 0.05% ................... 137 fluocinonide oint 0.05% .................. 137 fluocinonide soln 0.05% .................. 137 FLUORABON DRO ........................... 118 fluor-a-day dro 0.125mg ................. 118 fluoritab chw 0.25mg f .................... 118 fluoritab chw 0.5mg f...................... 118 fluoritab chw 2.2mg ....................... 118 fluorometholone ophth susp 0.1% .... 123 FLUOROPLEX CRE 1% ..................... 133 fluorouracil cream 0.5% .................. 133 fluorouracil cream 5% .................... 133 fluorouracil inj 1 gm/20ml (50 mg/ml) 32 fluorouracil inj 2.5 gm/50ml (50 mg/ml) ...................................................... 32 fluorouracil inj 5 gm/100ml (50 mg/ml) ...................................................... 32 fluorouracil inj 500 mg/10ml (50 mg/ml) ...................................................... 32 fluorouracil soln 2%........................ 133 fluorouracil soln 5%........................ 133 fluoxetine hcl cap 10 mg ................... 64 fluoxetine hcl cap 20 mg ................... 64 fluoxetine hcl cap 40 mg ................... 64 fluoxetine hcl cap delayed release 90 mg ...................................................... 64 fluoxetine hcl solution 20 mg/5ml ...... 64 fluoxetine hcl tab 10 mg ................... 64 fluoxetine hcl tab 20 mg ................... 64 FLUOXETINE TAB 60MG .................... 64 fluphenazine decanoate inj 25 mg/ml . 70 fluphenazine hcl elixir 2.5 mg/5ml ...... 70 fluphenazine hcl inj 2.5 mg/ml ........... 70 fluphenazine hcl oral conc 5 mg/ml .... 70 fluphenazine hcl tab 1 mg ................. 70 fluphenazine hcl tab 10 mg ............... 70 fluphenazine hcl tab 2.5 mg .............. 70 fluphenazine hcl tab 5 mg ................. 70 flura-drops dro 0.125mg ................. 118 flura-drops dro 0.25mg f ................. 118 161
January 1, 2017
flurandrenolide cream 0.05% ........... 137 flurbiprofen sodium ophth soln 0.03% .................................................... 123 flurbiprofen tab 100 mg ...................... 6 flurbiprofen tab 50 mg ........................ 6 flutamide cap 125 mg........................34 fluticasone propionate cream 0.05% . 137 fluticasone propionate lotion 0.05% .. 137 fluticasone propionate nasal susp 50 mcg/act ......................................... 130 fluticasone propionate oint 0.005% ... 137 fluvastatin sodium cap 20 mg .............45 fluvastatin sodium cap 40 mg .............45 FLUVIRIN INJ 2016-17 .................... 115 FLUVIRIN PF INJ 2016-17 ................ 115 fluvoxamine maleate cap sr 24hr 100 mg ......................................................55 fluvoxamine maleate cap sr 24hr 150 mg ......................................................55 fluvoxamine maleate tab 100 mg ........55 fluvoxamine maleate tab 25 mg ..........55 fluvoxamine maleate tab 50 mg ..........55 FLUZONE HD INJ PF 16-17 ............... 115 FLUZONE QUAD INJ 2016-17............ 115 FML FORTE SUS 0.25% OP ............... 123 FML OIN 0.1% OP ........................... 123 folbic tab ....................................... 121 folic acid tab 1 mg .......................... 121 folic acid tab 400 mcg ..................... 121 folic acid tab 800 mcg ..................... 121 fondaparinux sodium subcutaneous inj 10 mg/0.8ml ...................................... 109 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml ................................. 109 fondaparinux sodium subcutaneous inj 5 mg/0.4ml ...................................... 109 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml ................................. 109 FORTAZ INJ 1GM ..............................25 FORTAZ INJ 2GM ..............................25 FORTAZ INJ 500MG ...........................25 FORTEO SOL 600/2.4 ........................98 FOSAMAX + D TAB 70-2800 ...............85 FOSAMAX + D TAB 70-5600 ...............85 foscarnet sodium inj 24 mg/ml ...........22 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg ................................39
fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg................................ 39 fosinopril sodium tab 10 mg .............. 40 fosinopril sodium tab 20 mg .............. 40 fosinopril sodium tab 40 mg .............. 40 fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) ............................. 57 fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) ............................. 57 FOSRENOL CHW 1000MG .................. 99 FOSRENOL CHW 500MG .................... 99 FOSRENOL CHW 750MG .................... 99 FOSRENOL POW 1000MG .................. 99 FOSRENOL POW 750MG .................... 99 FRAGMIN INJ 10000/ML .................. 109 FRAGMIN INJ 12500UNT ................. 109 FRAGMIN INJ 15000UNT ................. 109 FRAGMIN INJ 18000UNT ................. 109 FRAGMIN INJ 2500/0.2 ................... 109 FRAGMIN INJ 25000/ML .................. 109 FRAGMIN INJ 5000/0.2 ................... 109 FRAGMIN INJ 7500/0.3 ................... 109 FRAGMIN INJ 95000UNT ................. 109 frovatriptan succinate tab 2.5 mg (base equivalent) ...................................... 75 furosemide inj 10 mg/ml ................... 52 furosemide oral soln 10 mg/ml .......... 52 FUROSEMIDE ORAL SOLN 8 MG/ML .... 52 furosemide tab 20 mg....................... 52 furosemide tab 40 mg....................... 52 furosemide tab 80 mg....................... 52 FUZEON INJ 90MG ........................... 19 FYCOMPA TAB 10MG ......................... 57 FYCOMPA TAB 12MG ......................... 57 FYCOMPA TAB 2MG .......................... 57 FYCOMPA TAB 4MG .......................... 57 FYCOMPA TAB 6MG .......................... 57 FYCOMPA TAB 8MG .......................... 57 G gabapentin cap 100 mg .................... 57 gabapentin cap 300 mg .................... 57 gabapentin cap 400 mg .................... 57 gabapentin oral soln 250 mg/5ml ....... 57 gabapentin tab 600 mg ..................... 57 gabapentin tab 800 mg ..................... 57 GABITRIL TAB 12MG......................... 58 GABITRIL TAB 16MG......................... 58 162
January 1, 2017
galantamine hydrobromide cap sr 24hr 16 mg ..................................................60 galantamine hydrobromide cap sr 24hr 24 mg ..................................................60 galantamine hydrobromide cap sr 24hr 8 mg ..................................................60 galantamine hydrobromide oral soln 4 mg/ml .............................................60 galantamine hydrobromide tab 12 mg .61 galantamine hydrobromide tab 4 mg ...60 galantamine hydrobromide tab 8 mg ...61 GAMASTAN S/D INJ......................... 113 GARDASIL 9 INJ ............................. 115 GARDASIL INJ ................................ 115 gatifloxacin ophth soln 0.5% ............ 122 gavilyte-c sol .................................. 105 gavilyte-g sol ................................. 105 gavilyte-h kit .................................. 105 gavilyte-n sol flav pk ....................... 105 GAZYVA INJ 25MG/ML .......................33 GELNIQUE GEL 10%........................ 108 gemcitabine hcl for inj 1 gm ...............32 gemcitabine hcl for inj 2 gm ...............32 gemcitabine hcl for inj 200 mg ...........32 gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) (base equiv) .........................32 gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) (base equiv) .........................32 gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) (base equiv) .........................32 gemfibrozil tab 600 mg ......................45 generlac sol 10gm/15 ...................... 105 gengraf cap 100mg ......................... 114 gengraf cap 25mg ........................... 114 gengraf sol 100mg/ml ..................... 114 GENOTROPIN INJ 0.2MG ....................97 GENOTROPIN INJ 0.4MG ....................97 GENOTROPIN INJ 0.6MG ....................97 GENOTROPIN INJ 0.8MG ....................97 GENOTROPIN INJ 1.2MG ....................97 GENOTROPIN INJ 1.4MG ....................97 GENOTROPIN INJ 1.6MG ....................97 GENOTROPIN INJ 1.8MG ....................97 GENOTROPIN INJ 12MG .....................97 GENOTROPIN INJ 1MG.......................97 GENOTROPIN INJ 2MG.......................97 GENOTROPIN INJ 5MG.......................97
gentak oin 0.3% op ........................ 122 GENTAM/NACL INJ 0.9MG/ML ............ 14 GENTAM/NACL INJ 1.4MG/ML ............ 14 gentamicin in saline inj 0.8 mg/ml...... 14 gentamicin in saline inj 1 mg/ml ........ 14 gentamicin in saline inj 1.2 mg/ml...... 14 gentamicin in saline inj 1.6 mg/ml...... 14 gentamicin in saline inj 2 mg/ml ........ 14 gentamicin sulfate cream 0.1% ........ 133 gentamicin sulfate inj 10 mg/ml ......... 14 gentamicin sulfate inj 40 mg/ml ......... 14 gentamicin sulfate iv soln 10 mg/ml ... 14 gentamicin sulfate oint 0.1% ........... 133 gentamicin sulfate ophth oint 0.3% .. 122 gentamicin sulfate ophth soln 0.3% .. 122 GENVOYA TAB ................................. 20 GEODON INJ 20MG........................... 70 gianvi tab 3-0.02mg ......................... 87 gildess fe tab 1.5/30......................... 87 gildess fe tab 1/20 ........................... 87 gildess tab 1.5/30 ............................ 87 gildess tab 1/20 ............................... 87 GILENYA CAP 0.5MG ......................... 77 GLASSIA INJ.................................. 129 glatiramer acetate soln prefilled syringe 20 mg/ml ........................................ 77 GLEOSTINE CAP 100MG .................... 30 GLEOSTINE CAP 10MG ...................... 30 GLEOSTINE CAP 40MG ...................... 30 GLEOSTINE CAP 5MG........................ 30 GLIADEL WAF 7.7MG ........................ 30 glimepiride tab 1 mg ........................ 84 glimepiride tab 2 mg ........................ 84 glimepiride tab 4 mg ........................ 84 glipizide tab 10 mg ........................... 84 glipizide tab 5 mg............................. 84 glipizide tab sr 24hr 10 mg ................ 84 glipizide tab sr 24hr 2.5 mg ............... 84 glipizide tab sr 24hr 5 mg ................. 84 glipizide-metformin hcl tab 2.5-250 mg ...................................................... 81 glipizide-metformin hcl tab 2.5-500 mg ...................................................... 81 glipizide-metformin hcl tab 5-500 mg . 81 GLUCAGON KIT 1MG ........................ 97 glyburide micronized tab 1.5 mg ........ 84 glyburide micronized tab 3 mg ........... 84 163
January 1, 2017
glyburide micronized tab 6 mg ...........84 glyburide tab 1.25 mg .......................84 glyburide tab 2.5 mg .........................85 glyburide tab 5 mg ............................85 glyburide-metformin tab 1.25-250 mg .81 glyburide-metformin tab 2.5-500 mg ..81 glyburide-metformin tab 5-500 mg .....81 glycopyrrolate inj 0.2 mg/ml ............ 101 glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) .......................................... 101 glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) .................................................... 101 glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) .................................................... 101 glycopyrrolate tab 1 mg ................... 101 glycopyrrolate tab 2 mg ................... 101 GOLYTELY SOL ............................... 105 GRALISE STAR MIS 300/600 ..............76 GRALISE TAB 300MG.........................76 GRALISE TAB 600MG.........................76 granisetron hcl inj 0.1 mg/ml ........... 102 granisetron hcl inj 1 mg/ml .............. 102 granisetron hcl inj 4 mg/4ml (1 mg/ml) .................................................... 102 granisetron hcl tab 1 mg .................. 102 griseofulvin microsize susp 125 mg/5ml ......................................................18 griseofulvin microsize tab 500 mg .......18 griseofulvin ultramicrosize tab 125 mg 18 griseofulvin ultramicrosize tab 250 mg 18 guanfacine hcl tab 1 mg ....................53 guanfacine hcl tab 2 mg ....................53 guanfacine hcl tab sr 24hr 1 mg (base equiv) .............................................73 guanfacine hcl tab sr 24hr 2 mg (base equiv) .............................................73 guanfacine hcl tab sr 24hr 3 mg (base equiv) .............................................73 guanfacine hcl tab sr 24hr 4 mg (base equiv) .............................................73 GUANIDINE TAB 125MG ....................76 GYNAZOLE-1 CRE 2%...................... 108 GYNOL II GEL 3% ........................... 107 H halobetasol propionate cream 0.05% 137 halobetasol propionate oint 0.05% .... 137 HALOG CRE 0.1% ........................... 137
HALOG OIN 0.1% ........................... 137 haloperidol decanoate im soln 100 mg/ml ...................................................... 70 haloperidol decanoate im soln 50 mg/ml ...................................................... 70 haloperidol lactate inj 5 mg/ml .......... 70 haloperidol lactate oral conc 2 mg/ml . 70 haloperidol tab 0.5 mg ...................... 70 haloperidol tab 1 mg......................... 70 haloperidol tab 10 mg ....................... 70 haloperidol tab 2 mg......................... 70 haloperidol tab 20 mg ....................... 70 haloperidol tab 5 mg......................... 70 HARVONI TAB 90-400MG .................. 22 HAVRIX INJ 1440UNIT .................... 115 HAVRIX INJ 720UNIT ...................... 115 heather tab 0.35mg.......................... 87 HEMANGEOL SOL 4.28/ML ................. 47 heparin sodium (porcine) inj 1000 unit/ml .................................................... 109 heparin sodium (porcine) inj 10000 unit/ml ......................................... 109 heparin sodium (porcine) inj 20000 unit/ml ......................................... 109 heparin sodium (porcine) inj 5000 unit/ml .................................................... 109 heparin sodium (porcine) pf inj 5000 unit/0.5ml ..................................... 109 HETLIOZ CAP 20MG .......................... 75 HEXALEN CAP 50MG ......................... 30 HIBERIX SOL 10MCG ...................... 115 HUMALOG INJ 100/ML ...................... 82 HUMALOG KWIK INJ 100/ML .............. 82 HUMALOG KWIK INJ 200/ML .............. 82 HUMALOG MIX INJ 50/50 .................. 82 HUMALOG MIX INJ 50/50KWP ............ 82 HUMALOG MIX INJ 75/25KWP ............ 82 HUMALOG MIX SUS 75/25 ................. 82 HUMATROPE INJ 12MG ..................... 97 HUMATROPE INJ 24MG ..................... 97 HUMATROPE INJ 5MG ....................... 97 HUMATROPE INJ 6MG ....................... 97 HUMATROPEN MIS FOR 12MG .......... 118 HUMATROPEN MIS FOR 24MG .......... 118 HUMATROPEN MIS FOR 6MG............ 118 HUMIRA INJ 10MG/0.2 .................... 112 HUMIRA KIT 20MG/0.4 ................... 112 164
January 1, 2017
HUMIRA KIT 40MG/0.8 .................... 112 HUMIRA PEN INJ CROHNS ................ 112 HUMULIN INJ 70/30 ..........................82 HUMULIN INJ 70/30KWP ....................82 HUMULIN N INJ U-100 .......................82 HUMULIN N INJ U-100KWP ................82 HUMULIN R INJ U-100 .......................83 HUMULIN R INJ U-500 .......................83 HYCAMTIN CAP 0.25MG .....................38 HYCAMTIN CAP 1MG..........................38 hydralazine hcl inj 20 mg/ml ..............53 hydralazine hcl tab 10 mg ..................53 hydralazine hcl tab 100 mg ................53 hydralazine hcl tab 25 mg ..................53 hydralazine hcl tab 50 mg ..................53 hydrochlorothiazide cap 12.5 mg ........52 hydrochlorothiazide tab 12.5 mg .........52 hydrochlorothiazide tab 25 mg ...........52 hydrochlorothiazide tab 50 mg ...........52 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml ......................................... 128 hydrocodone w/ homatropine tab 5-1.5 mg ................................................ 128 hydrocodone-acetaminophen soln 10-325 mg/15ml .......................................... 8 hydrocodone-acetaminophen soln 7.5-325 mg/15ml .............................. 8 hydrocodone-acetaminophen tab 10-300 mg ................................................... 9 hydrocodone-acetaminophen tab 10-325 mg ................................................... 9 hydrocodone-acetaminophen tab 2.5-325 mg ................................................... 8 hydrocodone-acetaminophen tab 5-300 mg ................................................... 8 hydrocodone-acetaminophen tab 5-325 mg ................................................... 8 hydrocodone-acetaminophen tab 7.5-300 mg ................................................... 9 hydrocodone-acetaminophen tab 7.5-325 mg ................................................... 9 hydrocortisone butyrate cream 0.1%. 137 hydrocortisone butyrate hydrophilic lipo base cream 0.1%............................ 137 hydrocortisone butyrate oint 0.1% .... 137 hydrocortisone butyrate soln 0.1%.... 137 hydrocortisone cream 1% ................ 137
hydrocortisone cream 2.5% ............. 137 hydrocortisone lotion 2.5%.............. 137 hydrocortisone oint 1% ................... 137 hydrocortisone oint 2.5% ................ 137 hydrocortisone tab 10 mg ................. 95 hydrocortisone tab 20 mg ................. 95 hydrocortisone tab 5 mg ................... 95 hydrocortisone valerate cream 0.2% 137 hydrocortisone valerate oint 0.2% .... 137 hydrocortisone w/ acetic acid otic soln 1-2% ............................................ 139 hydromet syp 5-1.5/5 ..................... 128 HYDROMORPHON SUP 3MG ................. 9 hydromorphone hcl inj 1 mg/ml ........... 9 hydromorphone hcl inj 2 mg/ml ........... 9 hydromorphone hcl inj 4 mg/ml ........... 9 hydromorphone hcl liqd 1 mg/ml .......... 9 hydromorphone hcl preservative free (pf) inj 10 mg/ml ..................................... 9 hydromorphone hcl tab 2 mg ............... 9 hydromorphone hcl tab 4 mg ............... 9 hydromorphone hcl tab 8 mg ............... 9 hydromorphone hcl tab er 24hr deter 12 mg ................................................... 9 hydromorphone hcl tab er 24hr deter 16 mg ................................................... 9 hydromorphone hcl tab er 24hr deter 32 mg ................................................... 9 hydromorphone hcl tab er 24hr deter 8 mg ................................................... 9 hydroxychloroquine sulfate tab 200 mg .................................................... 112 hydroxyurea cap 500 mg .................. 37 hydroxyzine hcl im soln 25 mg/ml .... 127 hydroxyzine hcl im soln 50 mg/ml .... 127 hydroxyzine hcl syrup 10 mg/5ml....... 55 hydroxyzine hcl tab 10 mg ................ 56 hydroxyzine hcl tab 25 mg ................ 56 hydroxyzine hcl tab 50 mg ................ 56 hydroxyzine pamoate cap 100 mg .... 127 hydroxyzine pamoate cap 25 mg ...... 127 hydroxyzine pamoate cap 50 mg ...... 127 hyomax-sl sub 0.125mg.................. 101 hyoscyamine sulfate tab 0.125 mg ... 101 hyoscyamine sulfate tab disp 0.125 mg .................................................... 101 hyoscyamine sulfate tab sl 0.125 mg 101 165
January 1, 2017
hyoscyamine sulfate tab sr 12hr 0.375 mg .................................................... 102 HYQVIA INJ 10-800 ......................... 113 HYQVIA INJ 2.5-200 ........................ 113 HYQVIA INJ 20-1600 ....................... 113 HYQVIA INJ 30-2400 ....................... 113 HYQVIA INJ 5-400 .......................... 113 HYSINGLA ER TAB 100 MG .................. 9 HYSINGLA ER TAB 120 MG .................. 9 HYSINGLA ER TAB 20 MG.................... 9 HYSINGLA ER TAB 30 MG.................... 9 HYSINGLA ER TAB 40 MG.................... 9 HYSINGLA ER TAB 60 MG.................... 9 HYSINGLA ER TAB 80 MG.................... 9 I ibandronate sodium iv soln 3 mg/3ml (base equivalent) ..............................85 ibandronate sodium tab 150 mg (base equivalent) ......................................85 IBRANCE CAP 100MG ........................33 IBRANCE CAP 125MG ........................33 IBRANCE CAP 75MG ..........................33 ibuprofen susp 100 mg/5ml ................ 6 ibuprofen tab 400 mg ......................... 6 ibuprofen tab 600 mg ......................... 6 ibuprofen tab 800 mg ......................... 6 ICLUSIG TAB 15MG ...........................35 ICLUSIG TAB 45MG ...........................35 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) ......................................................31 idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) ......................................................31 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) ......................................................31 ifosfamide & mesna inj kit 1000-1000 mg ......................................................37 ifosfamide for inj 1 gm ......................30 ifosfamide iv inj 1 gm/20ml (50 mg/ml) ......................................................30 ifosfamide iv inj 3 gm/60ml (50 mg/ml) ......................................................30 ilotycin oin op ................................. 122 imatinib mesylate tab 100 mg (base equivalent) ......................................35 imatinib mesylate tab 400 mg (base equivalent) ......................................35 IMBRUVICA CAP 140MG .....................35
imipenem-cilastatin intravenous for soln 250 mg ........................................... 15 imipenem-cilastatin intravenous for soln 500 mg ........................................... 15 imipramine hcl tab 10 mg ................. 64 imipramine hcl tab 25 mg ................. 64 imipramine hcl tab 50 mg ................. 64 imipramine pamoate cap 100 mg ....... 65 imipramine pamoate cap 125 mg ....... 65 imipramine pamoate cap 150 mg ....... 65 imipramine pamoate cap 75 mg ......... 64 imiquimod cream 5%...................... 133 IMPLANON IMP 68MG ....................... 87 INCRELEX INJ 40MG/4ML .................. 98 INCRUSE ELPT INH 62.5MCG ........... 126 indapamide tab 1.25 mg ................... 52 indapamide tab 2.5 mg ..................... 52 indomethacin cap 25 mg ..................... 6 indomethacin cap 50 mg ..................... 6 INFANRIX INJ ................................ 115 INLYTA TAB 1MG .............................. 35 INLYTA TAB 5MG .............................. 35 INSULIN PEN NEEDLES/SYRINGES ... 117 INTELENCE TAB 100MG .................... 19 INTELENCE TAB 200MG .................... 19 INTELENCE TAB 25MG ...................... 19 INTRON A INJ 10MU ....................... 113 INTRON A INJ 18MU ....................... 113 INTRON A INJ 25MU ....................... 113 INTRON A INJ 50MU ....................... 113 introvale tab .................................... 87 INVANZ INJ 1GM .............................. 15 INVIRASE CAP 200MG ...................... 19 INVIRASE TAB 500MG ...................... 19 INVOKAMET TAB 150-1000 ............... 84 INVOKAMET TAB 150-500 ................. 84 INVOKAMET TAB 50-1000 ................. 83 INVOKAMET TAB 50-500MG .............. 83 INVOKANA TAB 100MG ..................... 84 INVOKANA TAB 300MG ..................... 84 IOPIDINE SOL 1% OP ..................... 124 IPOL INJ INACTIVE ......................... 115 ipratropium bromide inhal soln 0.02% .................................................... 126 ipratropium bromide nasal soln 0.03% (21 mcg/spray) ................................... 126 ipratropium bromide nasal soln 0.06% (42 166
January 1, 2017
mcg/spray) .................................... 126 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml .......................... 125 irbesartan tab 150 mg .......................42 irbesartan tab 300 mg .......................42 irbesartan tab 75 mg .........................42 irbesartan-hydrochlorothiazide tab 150-12.5 mg ....................................41 irbesartan-hydrochlorothiazide tab 300-12.5 mg ....................................42 irinotecan hcl inj 100 mg/5ml (20 mg/ml) ......................................................38 irinotecan hcl inj 40 mg/2ml (20 mg/ml) ......................................................38 irinotecan hcl inj 500 mg/25ml (20 mg/ml) ............................................38 ISENTRESS CHW 100MG....................19 ISENTRESS CHW 25MG .....................19 ISENTRESS POW 100MG ....................19 ISENTRESS TAB 400MG .....................19 isoditrate tab 40mg er .......................53 ISOLYTE-S INJ................................ 119 isoniazid inj 100 mg/ml .....................21 isoniazid syrup 50 mg/5ml .................21 isoniazid tab 100 mg .........................21 isoniazid tab 300 mg .........................21 ISORDIL TAB 40MG ...........................53 isosorbide dinitrate sl tab 2.5 mg ........53 isosorbide dinitrate tab 10 mg ............53 isosorbide dinitrate tab 20 mg ............53 isosorbide dinitrate tab 30 mg ............53 isosorbide dinitrate tab 5 mg ..............53 isosorbide dinitrate tab cr 40 mg ........54 isosorbide mononitrate tab 10 mg .......54 isosorbide mononitrate tab 20 mg .......54 isosorbide mononitrate tab sr 24hr 120 mg ..................................................54 isosorbide mononitrate tab sr 24hr 30 mg ......................................................54 isosorbide mononitrate tab sr 24hr 60 mg ......................................................54 isradipine cap 2.5 mg ........................50 isradipine cap 5 mg ...........................50 ISTALOL SOL 0.5% OP .................... 124 itraconazole cap 100 mg ....................18 IV PREP WIPE PAD .......................... 133 ivermectin tab 3 mg ..........................15
J JADENU TAB 180MG ......................... 86 JADENU TAB 360MG ......................... 86 JADENU TAB 90MG ........................... 86 JAKAFI TAB 10MG ............................ 35 JAKAFI TAB 15MG ............................ 36 JAKAFI TAB 20MG ............................ 36 JAKAFI TAB 25MG ............................ 36 JAKAFI TAB 5MG .............................. 35 jantoven tab 10mg ......................... 110 jantoven tab 1mg ........................... 110 jantoven tab 2.5mg ........................ 110 jantoven tab 2mg ........................... 110 jantoven tab 3mg ........................... 110 jantoven tab 4mg ........................... 110 jantoven tab 5mg ........................... 110 jantoven tab 6mg ........................... 110 jantoven tab 7.5mg ........................ 110 JANUMET TAB 50-1000 ..................... 82 JANUMET TAB 50-500MG .................. 82 JANUMET XR TAB 100-1000............... 82 JANUMET XR TAB 50-1000 ................ 82 JANUMET XR TAB 50-500MG.............. 82 JANUVIA TAB 100MG ........................ 82 JANUVIA TAB 25MG .......................... 82 JANUVIA TAB 50MG .......................... 82 JARDIANCE TAB 10MG ...................... 84 JARDIANCE TAB 25MG ...................... 84 JENTADUETO TAB 2.5-1000 ............... 82 JENTADUETO TAB 2.5-500 ................ 82 JENTADUETO TAB 2.5-850 ................ 82 jinteli tab 1mg-5mcg ........................ 93 jolessa tab ...................................... 87 jolivette tab 0.35mg ......................... 87 JUBLIA SOL 10%............................ 134 junel 1.5/30 tab ............................... 87 junel 1/20 tab .................................. 87 junel fe tab 1.5/30 ........................... 87 junel fe tab 1/20 .............................. 87 K KADCYLA INJ 100MG ........................ 34 KADCYLA INJ 160MG ........................ 34 KALETRA SOL .................................. 20 KALETRA TAB 100-25MG ................... 20 KALETRA TAB 200-50MG ................... 20 KALYDECO PAK 50MG ..................... 129 KALYDECO PAK 75MG ..................... 129 167
January 1, 2017
KALYDECO TAB 150MG .................... 129 kanamycin sulfate inj 333 mg/ml ........14 kariva tab 28 day ..............................87 kcl 20 meq/l (0.15%) in nacl 0.45% inj .................................................... 119 kcl 20 meq/l (0.15%) in nacl 0.9% inj .................................................... 119 kcl 40 meq/l (0.3%) in nacl 0.9% inj . 119 k-effervesce tab 25meq ef ............... 118 kelnor tab 1/35 ................................87 KEPIVANCE INJ 6.25MG .....................37 KERYDIN SOL 5% ........................... 134 KETEK TAB 300MG ............................14 KETEK TAB 400MG ............................14 ketoconazole cream 2% ................... 134 ketoconazole shampoo 2% ............... 135 ketodan aer 2% .............................. 134 ketoprofen cap 50 mg ........................ 6 ketoprofen cap 75 mg ........................ 6 ketoprofen cap sr 24hr 200 mg............ 6 ketorolac tromethamine im inj 60 mg/2ml (30 mg/ml) ....................................... 6 ketorolac tromethamine inj 15 mg/ml ... 6 ketorolac tromethamine inj 30 mg/ml ... 6 ketorolac tromethamine inj 300 mg/10ml (30 mg/ml) ....................................... 6 ketorolac tromethamine inj 60 mg/2ml (30 mg/ml) ....................................... 6 ketorolac tromethamine ophth soln 0.4% .................................................... 123 ketorolac tromethamine ophth soln 0.5% .................................................... 123 ketorolac tromethamine tab 10 mg ...... 6 KEYTRUDA INJ 100MG/4M .................34 KEYTRUDA SOL 50MG .......................34 KINERET INJ .................................. 112 KINRIX INJ..................................... 115 kionex sus 15gm/60 ..........................86 klor-con 10 tab 10meq er ................ 118 klor-con 8 tab 8meq er .................... 118 KLOR-CON M15 TAB 15MEQ ER ........ 118 klor-con m20 tab 20meq er .............. 118 KRISTALOSE PAK 10GM ................... 105 KRISTALOSE PAK 20GM ................... 105 kurvelo tab 0.15/30 ..........................87 KUVAN POW 100MG ..........................89 KUVAN POW 500MG ..........................90
KUVAN TAB 100MG .......................... 90 L labetalol hcl iv soln 5 mg/ml .............. 47 labetalol hcl tab 100 mg .................... 47 labetalol hcl tab 200 mg .................... 47 labetalol hcl tab 300 mg .................... 47 laclotion lot 12% ............................ 138 LACRISERT MIS 5MG OP ................. 125 lactic acid (ammonium lactate) cream 12% ............................................. 138 lactic acid (ammonium lactate) lotion 10% .................................................... 138 lactic acid (ammonium lactate) lotion 12% .................................................... 138 lactulose solution 10 gm/15ml ......... 105 LAMICTAL CHW 2MG ........................ 58 LAMICTAL KIT START 35 ................... 58 LAMICTAL KIT START 49 ................... 58 LAMICTAL KIT START 98 ................... 58 LAMICTAL XR KIT ............................. 58 LAMISIL GRA 125MG ........................ 18 LAMISIL GRA 187.5MG ..................... 18 lamivudine oral soln 10 mg/ml ........... 19 lamivudine tab 100 mg (hbv)............. 22 lamivudine tab 150 mg ..................... 19 lamivudine tab 300 mg ..................... 19 lamivudine-zidovudine tab 150-300 mg ...................................................... 20 lamotrigine orally disintegrating tab 100 mg ................................................. 58 lamotrigine orally disintegrating tab 200 mg ................................................. 58 lamotrigine orally disintegrating tab 25 mg ................................................. 58 lamotrigine orally disintegrating tab 50 mg ................................................. 58 lamotrigine tab 100 mg ..................... 58 lamotrigine tab 150 mg ..................... 58 lamotrigine tab 200 mg ..................... 58 lamotrigine tab 25 mg ...................... 58 lamotrigine tab chewable dispersible 25 mg ................................................. 58 lamotrigine tab chewable dispersible 5 mg ...................................................... 58 lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit .............................. 58 lamotrigine tab disp 25 mg (21) & 50 mg 168
January 1, 2017
(7) titration kit .................................58 lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit ................................58 lamotrigine tab sr 24hr 100 mg ..........58 lamotrigine tab sr 24hr 200 mg ..........58 lamotrigine tab sr 24hr 25 mg ............58 lamotrigine tab sr 24hr 250 mg ..........58 lamotrigine tab sr 24hr 300 mg ..........58 lamotrigine tab sr 24hr 50 mg ............58 LANCETS ....................................... 117 LANCING DEVICE ............................ 117 LANOXIN PED INJ 0.1MG/ML ..............51 LANOXIN TAB 0.0625MG....................51 LANOXIN TAB 0.1875MG....................51 lansoprazole cap delayed release 15 mg .................................................... 107 lansoprazole cap delayed release 30 mg .................................................... 107 larin tab 1.5/30 ................................87 LASTACAFT SOL 0.25% ................... 124 latanoprost ophth soln 0.005% ......... 124 LATUDA TAB 120MG ..........................70 LATUDA TAB 20MG ...........................70 LATUDA TAB 40MG ...........................70 LATUDA TAB 60MG ...........................70 LATUDA TAB 80MG ...........................70 leena tab .........................................87 leflunomide tab 10 mg ..................... 112 leflunomide tab 20 mg ..................... 112 LENVIMA CAP 10 MG .........................36 LENVIMA CAP 14 MG .........................36 LENVIMA CAP 18 MG .........................36 LENVIMA CAP 20 MG .........................36 LENVIMA CAP 24 MG .........................36 LENVIMA CAP 8 MG ...........................36 lessina tab .......................................87 LETAIRIS TAB 10MG ..........................54 LETAIRIS TAB 5MG ...........................54 letrozole tab 2.5 mg ..........................34 leucovorin calcium for inj 100 mg .......37 leucovorin calcium for inj 200 mg .......37 leucovorin calcium for inj 350 mg .......37 leucovorin calcium for inj 50 mg .........37 leucovorin calcium for inj 500 mg .......38 leucovorin calcium tab 10 mg .............38 leucovorin calcium tab 15 mg .............38 leucovorin calcium tab 25 mg .............38
leucovorin calcium tab 5 mg .............. 38 LEUKERAN TAB 2MG ......................... 30 LEUKINE INJ 250MCG ..................... 110 LEUKINE INJ 500 MCG .................... 110 leuprolide acetate inj kit 5 mg/ml ....... 34 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) .................................. 128 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) .................................. 128 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) .................................. 128 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) ................... 128 LEVATOL TAB 20MG ......................... 47 LEVEMIR INJ .................................... 83 LEVEMIR INJ FLEXTOUC .................... 83 LEVETIRACETA INJ 10MG/ML ............. 58 LEVETIRACETA INJ 15MG/ML ............. 58 LEVETIRACETA INJ 5MG/ML ............... 58 levetiracetam inj 500 mg/5ml (100 mg/ml) ........................................... 58 levetiracetam oral soln 100 mg/ml ..... 58 levetiracetam tab 1000 mg ................ 58 levetiracetam tab 250 mg ................. 58 levetiracetam tab 500 mg ................. 58 levetiracetam tab 750 mg ................. 58 levetiracetam tab sr 24hr 500 mg ...... 58 levetiracetam tab sr 24hr 750 mg ...... 58 levobunolol hcl ophth soln 0.25% ..... 124 levobunolol hcl ophth soln 0.5%....... 124 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) ...................... 127 levocetirizine dihydrochloride tab 5 mg .................................................... 127 levofloxacin in d5w iv soln 250 mg/50ml ...................................................... 26 levofloxacin in d5w iv soln 500 mg/100ml ...................................................... 26 levofloxacin in d5w iv soln 750 mg/150ml ...................................................... 26 levofloxacin iv soln 25 mg/ml ............ 26 levofloxacin ophth soln 0.5% ........... 122 levofloxacin oral soln 25 mg/ml.......... 26 levofloxacin tab 250 mg .................... 26 levofloxacin tab 500 mg .................... 26 levofloxacin tab 750 mg .................... 26 levonest tab .................................... 87 169
January 1, 2017
levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg ................87 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg ......................................87 levonorgestrel tab 0.75 mg ................87 levonorgestrel tab 1.5 mg ..................87 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) .......................87 levora-28 tab 0.15/30 .......................87 levorphanol tartrate tab 2 mg .............. 9 levothyroxine sodium tab 100 mcg ......99 levothyroxine sodium tab 112 mcg ......99 levothyroxine sodium tab 125 mcg ......99 levothyroxine sodium tab 137 mcg ......99 levothyroxine sodium tab 150 mcg ......99 levothyroxine sodium tab 175 mcg ......99 levothyroxine sodium tab 200 mcg .... 100 levothyroxine sodium tab 25 mcg .......99 levothyroxine sodium tab 300 mcg .... 100 levothyroxine sodium tab 50 mcg .......99 levothyroxine sodium tab 75 mcg .......99 levothyroxine sodium tab 88 mcg .......99 levoxyl tab 100mcg ......................... 100 levoxyl tab 112mcg ......................... 100 levoxyl tab 125mcg ......................... 100 levoxyl tab 137mcg ......................... 100 levoxyl tab 150mcg ......................... 100 levoxyl tab 175mcg ......................... 100 levoxyl tab 200mcg ......................... 100 levoxyl tab 25mcg........................... 100 levoxyl tab 50mcg........................... 100 levoxyl tab 75mcg........................... 100 levoxyl tab 88mcg........................... 100 LEXIVA SUS 50MG/ML .......................19 LEXIVA TAB 700MG ...........................19 LIDO/DEXTROS INJ 5-7.5% ...............13 lidocaine hcl gel 2% ........................ 138 lidocaine hcl iv inj 10 mg/ml...............43 lidocaine hcl iv inj 20 mg/ml...............43 lidocaine hcl laryngotracheal soln 4% 139 lidocaine hcl local inj 0.5% .................13 lidocaine hcl local inj 1%....................13 lidocaine hcl local inj 1.5% .................13 lidocaine hcl local inj 2%....................13 lidocaine hcl local preservative free (pf) inj 0.5% ...............................................13 lidocaine hcl local preservative free (pf) inj
1% ................................................. 13 lidocaine hcl local preservative free (pf) inj 2% ................................................. 13 lidocaine hcl local preservative free (pf) inj 4% ................................................. 13 lidocaine hcl soln 4% ...................... 138 lidocaine hcl viscous soln 2% ........... 139 lidocaine iv infusion in d5w inj 4 mg/ml ...................................................... 43 lidocaine iv infusion in d5w inj 8 mg/ml ...................................................... 43 lidocaine oint 5% ........................... 138 lidocaine patch 5% ......................... 138 lidocaine-prilocaine cream 2.5-2.5% . 138 lidocaine-prilocaine cream kit 2.5-2.5% .................................................... 138 LILETTA IUD 52MG ........................... 87 lindane lotion 1% ........................... 139 lindane shampoo 1% ...................... 139 linezolid for susp 100 mg/5ml ............ 15 linezolid in sodium chloride iv soln 600 mg/300ml-0.9% .............................. 15 linezolid iv soln 600 mg/300ml (2 mg/ml) ...................................................... 15 linezolid tab 600 mg ......................... 15 LINZESS CAP 145MCG .................... 105 LINZESS CAP 290MCG .................... 105 liothyronine sodium iv soln 10 mcg/ml .................................................... 100 liothyronine sodium tab 25 mcg ....... 100 liothyronine sodium tab 5 mcg ......... 100 liothyronine sodium tab 50 mcg ....... 100 lipodox inj 2mg/ml ........................... 31 lisinopril & hydrochlorothiazide tab 10-12.5 mg ..................................... 39 lisinopril & hydrochlorothiazide tab 20-12.5 mg ..................................... 39 lisinopril & hydrochlorothiazide tab 20-25 mg ................................................. 39 lisinopril tab 10 mg........................... 40 lisinopril tab 2.5 mg ......................... 40 lisinopril tab 20 mg........................... 40 lisinopril tab 30 mg........................... 40 lisinopril tab 40 mg........................... 40 lisinopril tab 5 mg ............................ 40 lithium carbonate cap 150 mg............ 76 lithium carbonate cap 300 mg............ 76 170
January 1, 2017
lithium carbonate cap 600 mg ............76 lithium carbonate tab 300 mg.............76 lithium carbonate tab cr 300 mg .........76 lithium carbonate tab cr 450 mg .........76 LITHIUM SOL 8MEQ/5ML....................76 LIVALO TAB 1MG ..............................45 LIVALO TAB 2MG ..............................45 LIVALO TAB 4MG ..............................45 LO LOESTRIN TAB .............................87 lokara lot 0.05% ............................. 137 lomedia 24 tab fe ..............................87 loperamide hcl cap 2 mg .................. 106 lorazepam conc 2 mg/ml ...................56 lorazepam tab 0.5 mg .......................56 lorazepam tab 1 mg ..........................56 lorazepam tab 2 mg ..........................56 lortab tab 10-325mg .......................... 9 loryna tab 3-0.02mg .........................87 losartan potassium & hydrochlorothiazide tab 100-12.5 mg ..............................42 losartan potassium & hydrochlorothiazide tab 100-25 mg .................................42 losartan potassium & hydrochlorothiazide tab 50-12.5 mg ................................42 losartan potassium tab 100 mg ..........43 losartan potassium tab 25 mg ............43 losartan potassium tab 50 mg ............43 LOTEMAX GEL 0.5% ........................ 123 LOTEMAX OIN 0.5% ........................ 123 LOTEMAX SUS 0.5%........................ 123 lovastatin tab 10 mg .........................45 lovastatin tab 20 mg .........................45 lovastatin tab 40 mg .........................45 low-ogestrel tab................................87 loxapine succinate cap 10 mg .............70 loxapine succinate cap 25 mg .............70 loxapine succinate cap 5 mg...............70 loxapine succinate cap 50 mg .............70 ludent chw 0.25mg f ....................... 118 ludent chw 0.5mg f ......................... 118 ludent chw 1mg f ............................ 118 LUFYLLIN TAB 200MG ...................... 130 LUFYLLIN TAB 400MG ...................... 130 LUMIGAN SOL 0.01% ...................... 124 LUPANETA KIT 11.25-5 ......................99 LUPANETA KIT 3.75-5 .......................99 LUPR DEP-PED INJ 11.25MG...............34
LUPR DEP-PED INJ 15MG .................. 34 LUPR DEP-PED INJ 30MG .................. 34 LUPR DEP-PED INJ 7.5MG ................. 34 LUPRON DEPOT INJ 11.25MG............. 34 LUPRON DEPOT INJ 22.5MG .............. 34 LUPRON DEPOT INJ 3.75MG .............. 34 LUPRON DEPOT INJ 30MG ................. 34 LUPRON DEPOT INJ 45MG ................. 34 LUPRON DEPOT INJ 7.5MG ................ 34 LURIDE CHW 0.25MG F ................... 118 LURIDE CHW 0.5MG F ..................... 118 LURIDE DRO 0.5MG/ML................... 118 lutera tab ........................................ 88 LUZU CRE 1% ................................ 134 LYNPARZA CAP 50MG ....................... 34 LYRICA CAP 100MG .......................... 59 LYRICA CAP 150MG .......................... 59 LYRICA CAP 200MG .......................... 59 LYRICA CAP 225MG .......................... 59 LYRICA CAP 25MG ............................ 58 LYRICA CAP 300MG .......................... 59 LYRICA CAP 50MG ............................ 59 LYRICA CAP 75MG ............................ 59 LYRICA SOL 20MG/ML ....................... 59 LYSODREN TAB 500MG ..................... 34 M magnesium sulfate 1% in d5w ......... 118 magnesium sulfate inj 50% ............. 118 magnesium sulfate iv soln 2 gm/50ml (40 mg/ml) ......................................... 118 magnesium sulfate iv soln 20 gm/500ml (40 mg/ml) ................................... 119 magnesium sulfate iv soln 4 gm/100ml (40 mg/ml) ................................... 119 magnesium sulfate iv soln 4 gm/50ml (80 mg/ml) ......................................... 119 magnesium sulfate iv soln 40 gm/1000ml (40 mg/ml) ................................... 119 malathion lotion 0.5% .................... 139 maprotiline hcl tab 25 mg ................. 65 maprotiline hcl tab 50 mg ................. 65 maprotiline hcl tab 75 mg ................. 65 marlissa tab 0.15/30 ........................ 88 MARPLAN TAB 10MG ......................... 65 MATULANE CAP 50MG ....................... 37 matzim la tab 180mg/24 ................... 50 matzim la tab 240mg/24 ................... 50 171
January 1, 2017
matzim la tab 300mg/24 ...................50 matzim la tab 360mg/24 ...................50 matzim la tab 420mg/24 ...................50 MAXIDEX SUS 0.1% OP ................... 123 MAXIPIME INJ 1GM ...........................25 MAXIPIME INJ 2GM ...........................25 meclizine hcl tab 12.5 mg ................ 102 meclizine hcl tab 25 mg ................... 102 meclofenamate sodium cap 100 mg ..... 6 meclofenamate sodium cap 50 mg ....... 6 MEDROL TAB 2MG.............................95 medroxyprogesterone acetate im susp 150 mg/ml .......................................88 medroxyprogesterone acetate tab 10 mg ......................................................99 medroxyprogesterone acetate tab 2.5 mg ......................................................99 medroxyprogesterone acetate tab 5 mg ......................................................99 mefenamic acid cap 250 mg ................ 6 mefloquine hcl tab 250 mg .................18 MEFOXIN INJ 1GM/50ML ....................25 MEFOXIN INJ 2GM/50ML ....................25 megestrol acetate susp 40 mg/ml .......34 megestrol acetate susp 625 mg/5ml ...35 megestrol acetate tab 20 mg ..............35 megestrol acetate tab 40 mg ..............35 MEKINIST TAB 0.5MG ........................36 MEKINIST TAB 2MG ..........................36 meloxicam susp 7.5 mg/5ml ............... 6 meloxicam tab 15 mg ......................... 6 meloxicam tab 7.5 mg ........................ 6 melphalan hcl for inj 50 mg (base equiv) ......................................................30 memantine hcl oral solution 2 mg/ml ..61 memantine hcl tab 10 mg ..................61 memantine hcl tab 5 mg ....................61 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak ..............................61 MENACTRA INJ ............................... 115 MENEST TAB 0.3MG ..........................93 MENEST TAB 0.625MG .......................93 MENEST TAB 1.25MG ........................94 MENEST TAB 2.5MG ..........................94 MENHIBRIX INJ .............................. 115 MENOMUNE INJ A/C/Y/W ................. 116 MENOSTAR DIS 14MCG .....................94
MENTAX CRE 1% ........................... 134 MENVEO INJ .................................. 116 meperidine hcl inj 10 mg/ml ................ 9 meperidine hcl inj 100 mg/ml .............. 9 meperidine hcl inj 25 mg/ml ................ 9 meperidine hcl inj 50 mg/ml ................ 9 meperidine hcl oral soln 50 mg/5ml ...... 9 meperidine hcl tab 100 mg .................. 9 meperidine hcl tab 50 mg.................... 9 MEPHYTON TAB 5MG ...................... 121 meprobamate tab 200 mg ................. 56 meprobamate tab 400 mg ................. 56 mercaptopurine tab 50 mg ................ 32 meropenem iv for soln 1 gm .............. 15 meropenem iv for soln 500 mg .......... 15 mesalamine enema 4 gm ................ 105 mesalamine rectal enema 4 gm & cleanser wipe kit ......................................... 105 mesna inj 100 mg/ml ....................... 38 MESNEX TAB 400MG......................... 38 MESTINON SYP 60MG/5ML ................ 76 metaproterenol sulfate syrup 10 mg/5ml .................................................... 128 metaproterenol sulfate tab 10 mg .... 128 metaproterenol sulfate tab 20 mg .... 128 metaxalone tab 400 mg .................... 78 metaxalone tab 800 mg .................... 78 metformin hcl tab 1000 mg ............... 81 metformin hcl tab 500 mg ................. 81 metformin hcl tab 850 mg ................. 81 metformin hcl tab sr 24hr 500 mg ...... 81 metformin hcl tab sr 24hr 750 mg ...... 81 metformin hcl tab sr 24hr osmotic 1000 mg ................................................. 81 metformin hcl tab sr 24hr osmotic 500 mg ...................................................... 81 methadone hcl conc 10 mg/ml ........... 10 methadone hcl soln 10 mg/5ml .......... 10 methadone hcl soln 5 mg/5ml ............ 10 methadone hcl tab 10 mg ................. 10 methadone hcl tab 5 mg ................... 10 methadone hcl tab for oral susp 40 mg 10 METHADONE INJ 10MG/ML ................ 10 methadose tab 40mg ........................ 10 methamphetamine hcl tab 5 mg ......... 73 methazolamide tab 25 mg ................. 52 methazolamide tab 50 mg ................. 52 172
January 1, 2017
methenamine hippurate tab 1 gm .......16 methimazole tab 10 mg ................... 100 methimazole tab 5 mg ..................... 100 methocarbamol tab 500 mg ...............78 methocarbamol tab 750 mg ...............78 methotrexate sodium for inj 1 gm .......32 methotrexate sodium inj 250 mg/10ml (25 mg/ml) ......................................32 methotrexate sodium inj 50 mg/2ml (25 mg/ml) ............................................32 methotrexate sodium inj pf 100 mg/4ml (25 mg/ml) ......................................32 methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) ........................32 methotrexate sodium inj pf 200 mg/8ml (25 mg/ml) ......................................32 methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) ......................................32 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) ......................................32 methotrexate sodium tab 2.5 mg (base equiv) ........................................... 112 methoxsalen rapid cap 10 mg........... 135 methscopolamine bromide tab 2.5 mg .................................................... 102 methscopolamine bromide tab 5 mg .. 102 methyclothiazide tab 5 mg .................52 methyldopa tab 250 mg .....................53 methyldopa tab 500 mg .....................53 methyldopate hcl inj 250 mg/5ml .......53 methylphenidate hcl cap cr 10 mg (cd) 73 methylphenidate hcl cap cr 20 mg (cd) 73 methylphenidate hcl cap cr 30 mg (cd) 73 methylphenidate hcl cap cr 40 mg (cd) 73 methylphenidate hcl cap cr 50 mg (cd) 73 methylphenidate hcl cap cr 60 mg (cd) 73 methylphenidate hcl cap sr 24hr 20 mg (la) .................................................73 methylphenidate hcl cap sr 24hr 30 mg (la) .................................................73 methylphenidate hcl cap sr 24hr 40 mg (la) .................................................73 methylphenidate hcl chew tab 10 mg ..74 methylphenidate hcl chew tab 2.5 mg .74 methylphenidate hcl chew tab 5 mg ....74 methylphenidate hcl soln 10 mg/5ml ...74 methylphenidate hcl soln 5 mg/5ml.....74
methylphenidate hcl tab 10 mg .......... 74 methylphenidate hcl tab 20 mg .......... 74 methylphenidate hcl tab 5 mg............ 74 methylphenidate hcl tab cr 10 mg ...... 74 methylphenidate hcl tab cr 20 mg ...... 74 methylphenidate hcl tab sa osm 18 mg74 methylphenidate hcl tab sa osm 27 mg 74 methylphenidate hcl tab sa osm 36 mg 74 methylphenidate hcl tab sa osm 54 mg 74 methylphenidate hcl tab sr 24hr 18 mg ...................................................... 74 methylphenidate hcl tab sr 24hr 27 mg ...................................................... 74 methylphenidate hcl tab sr 24hr 36 mg ...................................................... 74 methylphenidate hcl tab sr 24hr 54 mg ...................................................... 74 methylprednisolone acetate inj susp 40 mg/ml ............................................ 96 methylprednisolone acetate inj susp 80 mg/ml ............................................ 96 methylprednisolone sodium succinate for inj 1000 mg ..................................... 96 methylprednisolone sodium succinate for inj 125 mg ...................................... 96 methylprednisolone sodium succinate for inj 40 mg ........................................ 96 methylprednisolone sodium succinate for inj 500 mg ...................................... 96 methylprednisolone tab 16 mg ........... 96 methylprednisolone tab 32 mg ........... 96 methylprednisolone tab 4 mg ............ 96 methylprednisolone tab 8 mg ............ 96 methylprednisolone tab therapy pack 4 mg (21) .......................................... 96 methyltestosterone cap 10 mg ........... 80 metipranolol ophth soln 0.3% .......... 124 metoclopramide hcl inj 5 mg/ml ....... 102 metoclopramide hcl orally disintegrating tab 5 mg ....................................... 102 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)...................................... 102 metoclopramide hcl tab 10 mg ......... 102 metoclopramide hcl tab 5 mg .......... 102 metolazone tab 10 mg ...................... 52 metolazone tab 2.5 mg ..................... 52 metolazone tab 5 mg ........................ 52 173
January 1, 2017
metoprolol & hydrochlorothiazide tab 100-25 mg .......................................46 metoprolol & hydrochlorothiazide tab 100-50 mg .......................................46 metoprolol & hydrochlorothiazide tab 50-25 mg ........................................46 metoprolol succinate tab sr 24hr 100 mg (tartrate equiv) ................................47 metoprolol succinate tab sr 24hr 200 mg (tartrate equiv) ................................47 metoprolol succinate tab sr 24hr 25 mg (tartrate equiv) ................................47 metoprolol succinate tab sr 24hr 50 mg (tartrate equiv) ................................47 metoprolol tartrate inj 1 mg/ml ..........47 metoprolol tartrate tab 100 mg ..........47 metoprolol tartrate tab 25 mg ............47 metoprolol tartrate tab 50 mg ............47 metronidazole cap 375 mg .................16 metronidazole cream 0.75% ............ 138 metronidazole gel 0.75% ................. 138 metronidazole gel 1%...................... 138 metronidazole in nacl 0.79% iv soln 500 mg/100ml ........................................16 metronidazole lotion 0.75% ............. 139 metronidazole tab 250 mg .................16 metronidazole tab 500 mg .................16 metronidazole vaginal gel 0.75% ...... 108 mexiletine hcl cap 150 mg .................43 mexiletine hcl cap 200 mg .................43 mexiletine hcl cap 250 mg .................43 MG SO4/D5W INJ 20MG/ML ............. 119 MIACALCIN INJ 200/ML .....................98 miconazole 3 kit combo pk ............... 108 miconazole 3 sup 200mg ................. 108 midodrine hcl tab 10 mg ....................53 midodrine hcl tab 2.5 mg ...................53 midodrine hcl tab 5 mg ......................53 miglitol tab 100 mg ...........................81 miglitol tab 25 mg.............................81 miglitol tab 50 mg.............................81 MILLIPRED DP PAK 5MG ....................96 MILLIPRED SOL 10MG/5ML ................96 MILLIPRED TAB 5MG .........................96 mimvey lo tab 0.5-0.1 .......................94 mimvey tab 1-0.5mg .........................94 MINASTRIN 24 CHW FE .....................88
minitran dis 0.1mg/hr ....................... 54 minitran dis 0.2mg/hr ....................... 54 minitran dis 0.4mg/hr ....................... 54 minitran dis 0.6mg/hr ....................... 54 minocycline hcl cap 100 mg ............... 29 minocycline hcl cap 50 mg ................ 29 minocycline hcl cap 75 mg ................ 29 minocycline hcl tab 100 mg ............... 30 minocycline hcl tab 50 mg ................. 30 minocycline hcl tab 75 mg ................. 30 minocycline hcl tab sr 24hr 135 mg .... 30 minocycline hcl tab sr 24hr 45 mg ...... 30 minocycline hcl tab sr 24hr 90 mg ...... 30 minoxidil tab 10 mg.......................... 53 minoxidil tab 2.5 mg......................... 53 MIRCERA INJ 100MCG .................... 110 MIRCERA INJ 200MCG .................... 110 MIRCERA INJ 50MCG ...................... 110 MIRCERA INJ 75MCG ...................... 110 MIRENA IUD SYSTEM ........................ 88 mirtazapine orally disintegrating tab 15 mg ................................................. 65 mirtazapine orally disintegrating tab 30 mg ................................................. 65 mirtazapine orally disintegrating tab 45 mg ................................................. 65 mirtazapine tab 15 mg ...................... 65 mirtazapine tab 30 mg ...................... 65 mirtazapine tab 45 mg ...................... 65 mirtazapine tab 7.5 mg ..................... 65 MIRVASO GEL 0.33% ..................... 139 misoprostol tab 100 mcg ................. 106 misoprostol tab 200 mcg ................. 106 mitomycin for iv soln 20 mg .............. 31 mitomycin for iv soln 40 mg .............. 31 mitomycin for iv soln 5 mg ................ 31 mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) ........................................... 37 mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) ....................................... 37 mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) ........................................... 37 M-M-R II INJ.................................. 115 modafinil tab 100 mg........................ 79 modafinil tab 200 mg........................ 79 moexipril hcl tab 15 mg .................... 40 moexipril hcl tab 7.5 mg ................... 40 174
January 1, 2017
moexipril-hydrochlorothiazide tab 15-12.5 mg ......................................39 moexipril-hydrochlorothiazide tab 15-25 mg ..................................................39 moexipril-hydrochlorothiazide tab 7.5-12.5 mg .....................................39 mometasone furoate cream 0.1% ..... 137 mometasone furoate oint 0.1% ........ 137 mometasone furoate solution 0.1% (lotion) .......................................... 137 mono-linyah tab 0.25-35 ...................88 mononessa tab .................................88 montelukast sodium chew tab 4 mg (base equiv) ........................................... 129 montelukast sodium chew tab 5 mg (base equiv) ........................................... 129 montelukast sodium oral granules packet 4 mg (base equiv) .......................... 129 montelukast sodium tab 10 mg (base equiv) ........................................... 129 MONUROL PAK GRANULES .................14 morgidox cap 1x100mg .....................30 MORPHINE SUL INJ 150/30ML ............10 MORPHINE SUL INJ 2MG/ML ...............10 MORPHINE SUL INJ 4MG/ML ...............10 MORPHINE SUL INJ 5MG/ML ...............10 MORPHINE SUL SUP 30MG .................10 morphine sulfate beads cap sr 24hr 120 mg ..................................................10 morphine sulfate beads cap sr 24hr 30 mg ......................................................10 morphine sulfate beads cap sr 24hr 45 mg ......................................................10 morphine sulfate beads cap sr 24hr 60 mg ......................................................10 morphine sulfate beads cap sr 24hr 75 mg ......................................................10 morphine sulfate beads cap sr 24hr 90 mg ......................................................10 morphine sulfate cap sr 24hr 10 mg ....10 morphine sulfate cap sr 24hr 100 mg ..10 morphine sulfate cap sr 24hr 20 mg ....10 morphine sulfate cap sr 24hr 30 mg ....10 morphine sulfate cap sr 24hr 50 mg ....10 morphine sulfate cap sr 24hr 60 mg ....10 morphine sulfate cap sr 24hr 80 mg ....10 morphine sulfate inj 10 mg/ml............10
morphine sulfate inj 8 mg/ml ............. 10 morphine sulfate inj pf 1 mg/ml ......... 10 morphine sulfate iv soln 1 mg/ml ....... 10 morphine sulfate iv soln 25 mg/ml ..... 10 morphine sulfate iv soln pf 10 mg/ml .. 10 morphine sulfate iv soln pf 15 mg/ml .. 10 morphine sulfate iv soln pf 4 mg/ml ... 10 morphine sulfate iv soln pf 8 mg/ml ... 10 morphine sulfate oral soln 10 mg/5ml . 10 morphine sulfate oral soln 100 mg/5ml (20 mg/ml) ..................................... 10 morphine sulfate oral soln 20 mg/5ml . 10 morphine sulfate suppos 10 mg ......... 10 morphine sulfate suppos 20 mg ......... 11 morphine sulfate suppos 5 mg ........... 10 morphine sulfate tab 15 mg............... 11 morphine sulfate tab 30 mg............... 11 morphine sulfate tab cr 100 mg ......... 11 morphine sulfate tab cr 15 mg ........... 11 morphine sulfate tab cr 200 mg ......... 11 morphine sulfate tab cr 30 mg ........... 11 morphine sulfate tab cr 60 mg ........... 11 MOTOFEN TAB ............................... 106 MOVANTIK TAB 12.5MG .................. 106 MOVANTIK TAB 25MG ..................... 106 MOVIPREP SOL .............................. 105 MOXEZA SOL 0.5% ........................ 122 moxifloxacin hcl tab 400 mg (base equiv) ...................................................... 26 MOZOBIL INJ ................................. 111 MULTAQ TAB 400MG......................... 43 multi-vit/fe dro /fl 0.25 ................... 121 multivit/fl chw 0.25mg .................... 121 multivit/fl chw 0.5mg...................... 121 multivit/fl chw 1mg ........................ 121 multi-vit/fl dro /fe 0.25 ................... 121 multi-vit/fl dro 0.25mg ................... 121 multi-vit/fl dro 0.5mg/ml ................ 121 mupirocin oint 2% .......................... 133 mvc-fluoride chw 0.5mg.................. 121 mvc-fluoride chw 1mg .................... 121 MYALEPT INJ 11.3MG ........................ 90 MYCAMINE INJ 100MG ...................... 18 MYCAMINE INJ 50MG ........................ 18 mycophenolate mofetil cap 250 mg .. 114 mycophenolate mofetil for oral susp 200 mg/ml .......................................... 114 175
January 1, 2017
mycophenolate mofetil tab 500 mg ... 114 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)................ 114 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)................ 114 MYLERAN TAB 2MG ...........................30 myorisan cap 10mg......................... 132 myorisan cap 20mg......................... 132 myorisan cap 40mg......................... 132 MYOZYME INJ 50MG ..........................90 MYRBETRIQ TAB 25MG .................... 108 MYRBETRIQ TAB 50MG .................... 108 myzilra tab.......................................88 N nabumetone tab 500 mg..................... 6 nabumetone tab 750 mg..................... 6 nadolol & bendroflumethiazide tab 40-5 mg ..................................................46 nadolol & bendroflumethiazide tab 80-5 mg ..................................................46 nadolol tab 20 mg .............................47 nadolol tab 40 mg .............................47 nadolol tab 80 mg .............................47 NAFCILLIN INJ 1GM/50ML ..................28 NAFCILLIN INJ 2GM/100 ....................28 nafcillin sodium for inj 1 gm ...............28 nafcillin sodium for inj 10 gm .............28 nafcillin sodium for inj 2 gm ...............28 nafcillin sodium for iv soln 1 gm .........28 nafcillin sodium for iv soln 2 gm .........28 nafrinse chw 1mg f ......................... 119 naftifine hcl cream 1% .................... 134 naftifine hcl cream 2% .................... 134 NAFTIN GEL 1% ............................. 134 NAFTIN GEL 2% ............................. 134 NAGLAZYME INJ 1MG/ML ...................90 nalbuphine hcl inj 10 mg/ml ...............11 nalbuphine hcl inj 20 mg/ml ...............11 naloxone hcl inj 0.4 mg/ml.................79 naloxone hcl inj 1 mg/ml ...................79 naltrexone hcl tab 50 mg ...................79 NAMENDA XR CAP 14MG ....................61 NAMENDA XR CAP 21MG ....................61 NAMENDA XR CAP 28MG ....................61 NAMENDA XR CAP 7MG .....................61 NAMENDA XR CAP TITRATIO ..............61 naphazoline hcl ophth soln 0.1% ...... 125
naproxen dr tab 375mg ...................... 6 naproxen dr tab 500mg ...................... 6 naproxen sodium tab 275 mg .............. 6 naproxen sodium tab 550 mg .............. 7 naproxen susp 125 mg/5ml ................. 7 naproxen tab 250 mg ......................... 7 naproxen tab 375 mg ......................... 7 naproxen tab 500 mg ......................... 7 naratriptan hcl tab 1 mg (base equiv) . 75 naratriptan hcl tab 2.5 mg (base equiv) ...................................................... 75 NARCAN SPR ................................... 79 NATACYN SUS 5% OP ..................... 122 NATAZIA TAB .................................. 88 nateglinide tab 120 mg ..................... 83 nateglinide tab 60 mg ....................... 83 NEBUPENT INH 300MG ..................... 16 necon tab 0.5/35 ............................. 88 necon tab 1/35 ................................ 88 necon tab 1/50-28 ........................... 88 NECON TAB 10/11-28 ....................... 88 necon tab 7/7/7 ............................... 88 nefazodone hcl tab 100 mg ............... 65 nefazodone hcl tab 150 mg ............... 65 nefazodone hcl tab 200 mg ............... 65 nefazodone hcl tab 250 mg ............... 65 nefazodone hcl tab 50 mg ................. 65 NEO-FRADIN SOL 125/5ML ................ 14 neomycin sulfate tab 500 mg ............. 14 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml ..... 123 neomycin-polymyxin-dexamethasone ophth oint 0.1% ............................. 122 neomycin-polymyxin-dexamethasone ophth susp 0.1% ............................ 122 neomycin-polymyxin-hc ophth susp .. 122 neomycin-polymyxin-hc otic soln 1% 139 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ............... 140 NEO-SYNALAR CRE ......................... 133 NEULASTA INJ 6MG/0.6M ................ 111 NEULASTA KIT 6MG/0.6M................ 111 NEUPRO DIS 1MG/24HR .................... 68 NEUPRO DIS 2MG/24HR .................... 68 NEUPRO DIS 3MG/24HR .................... 68 NEUPRO DIS 4MG/24HR .................... 68 NEUPRO DIS 6MG/24HR .................... 68 176
January 1, 2017
NEUPRO DIS 8MG/24HR ....................68 NEVANAC SUS 0.1% ....................... 123 nevirapine susp 50 mg/5ml ................19 nevirapine tab 200 mg ......................19 nevirapine tab sr 24hr 100 mg ...........19 nevirapine tab sr 24hr 400 mg ...........19 NEXAVAR TAB 200MG........................36 NEXPLANON IMP 68MG ......................88 NEXTERONE INJ................................43 niacin tab cr 1000 mg (antihyperlipidemic) ..........................46 niacin tab cr 500 mg (antihyperlipidemic) ......................................................46 niacin tab cr 750 mg (antihyperlipidemic) ......................................................46 nicardipine hcl cap 20 mg ..................50 nicardipine hcl cap 30 mg ..................50 nicardipine hcl iv soln 2.5 mg/ml ........50 nicotine polacrilex gum 2 mg ..............80 nicotine polacrilex gum 4 mg ..............80 nicotine polacrilex lozenge 2 mg .........80 nicotine polacrilex lozenge 4 mg .........80 nicotine td patch 24hr 14 mg/24hr ......80 nicotine td patch 24hr 21 mg/24hr ......80 nicotine td patch 24hr 7 mg/24hr .......80 NICOTROL INH .................................80 NICOTROL NS SPR 10MG/ML ..............80 nifedical xl tab 30mg .........................50 nifedical xl tab 60mg .........................50 nifedipine tab sr 24hr 30 mg ..............50 nifedipine tab sr 24hr 60 mg ..............50 nifedipine tab sr 24hr 90 mg ..............50 nifedipine tab sr 24hr osmotic release 30 mg ..................................................50 nifedipine tab sr 24hr osmotic release 60 mg ..................................................50 nifedipine tab sr 24hr osmotic release 90 mg ..................................................50 nikki tab 3-0.02mg ...........................88 nilutamide tab 150 mg ......................35 nimodipine cap 30 mg .......................50 NIPENT INJ 10MG .............................32 nisoldipine tab sr 24hr 17 mg .............50 nisoldipine tab sr 24hr 20 mg .............50 nisoldipine tab sr 24hr 25.5 mg ..........50 nisoldipine tab sr 24hr 30 mg .............50 nisoldipine tab sr 24hr 34 mg .............50
nisoldipine tab sr 24hr 40 mg ............ 50 nisoldipine tab sr 24hr 8.5 mg ........... 50 NITRO-BID OIN 2% .......................... 54 NITRO-DUR DIS 0.3MG/HR ................ 54 NITRO-DUR DIS 0.8MG/HR ................ 54 nitrofurantoin macrocrystalline cap 100 mg ................................................. 16 nitrofurantoin macrocrystalline cap 25 mg ...................................................... 16 nitrofurantoin macrocrystalline cap 50 mg ...................................................... 16 nitrofurantoin monohydrate macrocrystalline cap 100 mg ............. 16 nitrofurantoin susp 25 mg/5ml ........... 16 NITROGLYCER INJ 5MG/ML................ 54 nitroglycerin iv soln 100 mcg/ml in d5w ...................................................... 54 nitroglycerin iv soln 200 mcg/ml in d5w ...................................................... 54 nitroglycerin iv soln 400 mcg/ml in d5w ...................................................... 54 nitroglycerin lingual aerosol 400 mcg/spray ....................................... 54 nitroglycerin td patch 24hr 0.1 mg/hr . 54 nitroglycerin td patch 24hr 0.2 mg/hr . 54 nitroglycerin td patch 24hr 0.4 mg/hr . 54 nitroglycerin td patch 24hr 0.6 mg/hr . 54 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) ..................................... 54 NITROSTAT SUB 0.3MG .................... 54 NITROSTAT SUB 0.4MG .................... 54 NITROSTAT SUB 0.6MG .................... 54 nitro-time cap 9mg cr ....................... 54 nizatidine cap 150 mg ..................... 104 nizatidine cap 300 mg ..................... 104 nizatidine oral soln 15 mg/ml........... 104 nora-be tab 0.35mg ......................... 88 NORDITROPIN INJ 10/1.5ML.............. 97 NORDITROPIN INJ 15/1.5ML.............. 97 NORDITROPIN INJ 30/3ML ................ 97 NORDITROPIN INJ 5/1.5ML ............... 97 norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg .......................... 88 norethindrone acetate tab 5 mg ......... 99 norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg ......................... 94 norethindrone tab 0.35 mg ................ 88 177
January 1, 2017
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg ......................................88 norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg ....88 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg ....88 NORMOSOL -R INJ .......................... 120 NORPACE CAP 100MG CR ...................43 NORPACE CAP 150MG CR ...................43 nortrel tab 0.5/35 .............................88 nortrel tab 1/35 ................................88 nortrel tab 7/7/7 ...............................88 nortriptyline hcl cap 10 mg ................65 nortriptyline hcl cap 25 mg ................65 nortriptyline hcl cap 50 mg ................65 nortriptyline hcl cap 75 mg ................65 nortriptyline hcl soln 10 mg/5ml .........65 NORTUSS-EX LIQ 200-20/5.............. 128 NORVIR CAP 100MG ..........................19 NORVIR SOL 80MG/ML ......................19 NORVIR TAB 100MG ..........................19 NOVOLIN INJ 70/30 ..........................83 NOVOLIN N INJ U-100 .......................83 NOVOLIN R INJ U-100 .......................83 NOVOLOG INJ 100/ML .......................83 NOVOLOG INJ FLEXPEN .....................83 NOVOLOG INJ PENFILL ......................83 NOVOLOG MIX INJ 70/30 ...................83 NOVOLOG MIX INJ FLEXPEN ...............83 NOXAFIL SUS 40MG/ML .....................18 NOXAFIL TAB 100MG.........................18 NUCYNTA ER TAB 100MG ...................11 NUCYNTA ER TAB 150MG ...................11 NUCYNTA ER TAB 200MG ...................11 NUCYNTA ER TAB 250MG ...................11 NUCYNTA ER TAB 50MG.....................11 NUCYNTA TAB 100MG .......................11 NUCYNTA TAB 50MG .........................11 NUCYNTA TAB 75MG .........................11 NUEDEXTA CAP 20-10MG ...................76 nulev tab 0.125mg .......................... 102 NULOJIX INJ 250MG ........................ 114 NUPLAZID TAB 17MG ........................70 NUTROPIN AQ INJ 10MG/2ML .............97 NUTROPIN AQ INJ 20MG/2ML .............97 NUTROPIN AQ INJ NUSPIN 5 ..............97 NUTROPIN INJ 10MG .........................97
NUVARING MIS ................................ 88 nyamyc pow 100000 ...................... 134 nystatin cream 100000 unit/gm ....... 134 nystatin oint 100000 unit/gm .......... 134 nystatin oral powder ......................... 18 nystatin susp 100000 unit/ml .......... 139 nystatin tab 500000 unit ................... 18 nystatin topical powder ................... 134 nystatin-triamcinolone cream 100000-0.1 unit/gm-% .................................... 134 nystatin-triamcinolone oint 100000-0.1 unit/gm-% .................................... 134 nystop pow 100000 ........................ 134 O OBREDON SOL 2.5-200 ................... 128 ocella tab 3-0.03mg ......................... 88 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) ........................................... 98 octreotide acetate inj 1000 mcg/ml (1 mg/ml) ........................................... 98 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) ........................................... 98 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) ........................................... 98 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) ........................................... 98 ofloxacin ophth soln 0.3% ............... 123 ofloxacin otic soln 0.3% .................. 140 ofloxacin tab 200 mg ........................ 26 ofloxacin tab 300 mg ........................ 27 ofloxacin tab 400 mg ........................ 27 ogestrel tab ..................................... 88 olanzapine for im inj 10 mg ............... 70 olanzapine orally disintegrating tab 10 mg ...................................................... 70 olanzapine orally disintegrating tab 15 mg ...................................................... 70 olanzapine orally disintegrating tab 20 mg ...................................................... 70 olanzapine orally disintegrating tab 5 mg ...................................................... 70 olanzapine tab 10 mg ....................... 70 olanzapine tab 15 mg ....................... 70 olanzapine tab 2.5 mg ...................... 70 olanzapine tab 20 mg ....................... 70 olanzapine tab 5 mg ......................... 70 olanzapine tab 7.5 mg ...................... 70 178
January 1, 2017
olopatadine hcl nasal soln 0.6% ........ 127 olopatadine hcl ophth soln 0.1% (base equivalent) .................................... 124 OLYSIO CAP 150MG ..........................22 omega-3-acid ethyl esters cap 1 gm....46 omeprazole cap delayed release 10 mg .................................................... 107 omeprazole cap delayed release 20 mg .................................................... 107 omeprazole cap delayed release 40 mg .................................................... 107 OMNARIS SPR ................................ 130 OMNIFLEX DPR ............................... 116 OMNITROPE INJ 10/1.5ML .................97 OMNITROPE INJ 5.8MG ......................97 OMNITROPE INJ 5/1.5ML ...................97 ONCASPAR INJ 750/ML ......................37 ondansetron hcl inj 4 mg/2ml (2 mg/ml) .................................................... 102 ondansetron hcl inj 40 mg/20ml (2 mg/ml) .......................................... 103 ondansetron hcl oral soln 4 mg/5ml .. 103 ondansetron hcl tab 24 mg .............. 103 ondansetron hcl tab 4 mg ................ 103 ondansetron hcl tab 8 mg ................ 103 ondansetron orally disintegrating tab 4 mg ................................................ 103 ondansetron orally disintegrating tab 8 mg ................................................ 103 ONETOUCH BLOOD GLUCOSE TEST KITS .................................................... 117 ONETOUCH BLOOD GLUCOSE TEST STRIPS .......................................... 117 ONFI SUS 2.5MG/ML .........................59 ONFI TAB 10MG ................................59 ONFI TAB 20MG ................................59 ONFI TAB 5MG .................................59 ONGLYZA TAB 2.5MG ........................82 ONGLYZA TAB 5MG ...........................82 OPSUMIT TAB 10MG ..........................54 oralone pst 0.1% ............................ 139 ORAVIG TAB 50MG ......................... 139 ORENCIA CLCK INJ 125MG/ML ......... 112 ORENCIA INJ 125MG/ML .................. 112 ORENCIA INJ 250MG ....................... 112 ORENITRAM TAB 0.125MG .................55 ORENITRAM TAB 0.25MG ...................54
ORENITRAM TAB 1MG ....................... 55 ORENITRAM TAB 2.5MG .................... 55 ORFADIN CAP 10MG ......................... 90 ORFADIN CAP 20MG ......................... 90 ORFADIN CAP 2MG ........................... 90 ORFADIN CAP 5MG ........................... 90 ORFADIN SUS 4MG/ML ..................... 90 ORKAMBI TAB 200-125 ................... 129 orphenadrine citrate inj 30 mg/ml ...... 78 orphenadrine citrate tab sr 12hr 100 mg ...................................................... 78 orphenadrine w/ aspirin & caffeine tab 25-385-30 mg ................................. 79 orsythia tab ..................................... 88 ORTHO COIL DPR KIT 100 ............... 117 ORTHO COIL DPR KIT 105 ............... 117 ORTHO COIL DPR KIT 50................. 116 ORTHO FLAT DPR KIT 55 ................. 117 ORTHO FLAT DPR KIT 60 ................. 117 ORTHO FLAT DPR KIT 65 ................. 117 ORTHO FLAT DPR KIT 70 ................. 117 ORTHO FLAT DPR KIT 75 ................. 117 ORTHO FLAT DPR KIT 80 ................. 117 ORTHO FLAT DPR KIT 85 ................. 117 ORTHO FLAT DPR KIT 90 ................. 117 ORTHO FLAT DPR KIT 95 ................. 117 ORTHO FLEX DPR 65MM .................. 117 ORTHO FLEX DPR 70MM .................. 117 ORTHO FLEX DPR 75MM .................. 117 ORTHO FLEX DPR 80MM .................. 117 ortho-est tab 0.625 .......................... 94 ortho-est tab 1.25 ............................ 94 oscimin sr tab 0.375mg .................. 102 oscimin sub 0.125mg...................... 102 oscimin tab 0.125mg ...................... 102 oscion clnsr lot 6% ......................... 132 OSMOPREP TAB 1.5GM ................... 105 OSPHENA TAB 60MG ........................ 98 OTEZLA TAB 10/20/30 .................... 113 OTEZLA TAB 30MG ......................... 113 oxacillin sodium for inj 1 gm .............. 28 oxacillin sodium for inj 10 gm ............ 28 oxacillin sodium for inj 2 gm .............. 28 oxaliplatin for iv inj 100 mg ............... 37 oxaliplatin for iv inj 50 mg ................. 37 oxaliplatin iv soln 100 mg/20ml ......... 37 oxaliplatin iv soln 50 mg/10ml ........... 37 179
January 1, 2017
oxandrolone tab 10 mg ......................80 oxandrolone tab 2.5 mg.....................80 oxaprozin tab 600 mg ........................ 7 oxazepam cap 10 mg ........................56 oxazepam cap 15 mg ........................56 oxazepam cap 30 mg ........................56 oxcarbazepine susp 300 mg/5ml (60 mg/ml) ............................................59 oxcarbazepine tab 150 mg .................59 oxcarbazepine tab 300 mg .................59 oxcarbazepine tab 600 mg .................59 oxiconazole nitrate cream 1% .......... 135 OXISTAT LOT 1%............................ 135 oxybutynin chloride syrup 5 mg/5ml . 108 oxybutynin chloride tab 5 mg ........... 108 oxybutynin chloride tab sr 24hr 10 mg .................................................... 108 oxybutynin chloride tab sr 24hr 15 mg .................................................... 108 oxybutynin chloride tab sr 24hr 5 mg 108 oxycodone hcl cap 5 mg ....................11 oxycodone hcl conc 100 mg/5ml (20 mg/ml) ............................................11 oxycodone hcl soln 5 mg/5ml .............11 oxycodone hcl tab 10 mg ...................11 oxycodone hcl tab 15 mg ...................11 oxycodone hcl tab 20 mg ...................11 oxycodone hcl tab 30 mg ...................11 oxycodone hcl tab 5 mg .....................11 oxycodone hcl tab er 12hr deter 10 mg ......................................................11 oxycodone hcl tab er 12hr deter 15 mg ......................................................11 oxycodone hcl tab er 12hr deter 20 mg ......................................................11 oxycodone hcl tab er 12hr deter 30 mg ......................................................11 oxycodone hcl tab er 12hr deter 40 mg ......................................................11 oxycodone hcl tab er 12hr deter 60 mg ......................................................11 oxycodone hcl tab er 12hr deter 80 mg ......................................................11 oxycodone w/ acetaminophen soln 5-325 mg/5ml ...........................................11 oxycodone w/ acetaminophen tab 10-325 mg ..................................................11
oxycodone w/ acetaminophen tab 2.5-325 mg ................................................. 11 oxycodone w/ acetaminophen tab 5-325 mg ................................................. 11 oxycodone w/ acetaminophen tab 7.5-325 mg ................................................. 11 oxycodone-aspirin tab 4.8355-325 mg 12 oxycodone-ibuprofen tab 5-400 mg .... 12 OXYCONTIN TAB 10MG CR ................ 12 OXYCONTIN TAB 15MG CR ................ 12 OXYCONTIN TAB 20MG CR ................ 12 OXYCONTIN TAB 30MG CR ................ 12 OXYCONTIN TAB 40MG CR ................ 12 OXYCONTIN TAB 60MG CR ................ 12 OXYCONTIN TAB 80MG CR ................ 12 oxymorphone hcl tab 10 mg .............. 12 oxymorphone hcl tab 5 mg ................ 12 oxymorphone hcl tab sr 12hr 10 mg ... 12 oxymorphone hcl tab sr 12hr 15 mg ... 12 oxymorphone hcl tab sr 12hr 20 mg ... 12 oxymorphone hcl tab sr 12hr 30 mg ... 12 oxymorphone hcl tab sr 12hr 40 mg ... 12 oxymorphone hcl tab sr 12hr 5 mg ..... 12 oxymorphone hcl tab sr 12hr 7.5 mg .. 12 OXYTROL DIS 3.9MG/24 ................. 108 P pacerone tab 100mg......................... 43 pacerone tab 200mg......................... 43 paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) ........................................... 33 paclitaxel iv conc 150 mg/25ml (6 mg/ml) ...................................................... 33 paclitaxel iv conc 30 mg/5ml (6 mg/ml) ...................................................... 33 paclitaxel iv conc 300 mg/50ml (6 mg/ml) ...................................................... 33 paliperidone tab sr 24hr 1.5 mg ......... 70 paliperidone tab sr 24hr 3 mg ............ 71 paliperidone tab sr 24hr 6 mg ............ 71 paliperidone tab sr 24hr 9 mg ............ 71 pamidronate disodium for inj 30 mg ... 85 pamidronate disodium for inj 90 mg ... 85 pamidronate disodium iv soln 3 mg/ml 85 pamidronate disodium iv soln 9 mg/ml 85 PAMIDRONATE INJ 6MG/ML ............... 85 PANRETIN GEL 0.1% ...................... 138 pantoprazole sodium ec tab 20 mg (base 180
January 1, 2017
equiv) ........................................... 107 pantoprazole sodium ec tab 40 mg (base equiv) ........................................... 107 PARAGARD IUD T380A ......................88 parcaine sol 0.5% op....................... 125 paricalcitol cap 1 mcg ...................... 121 paricalcitol cap 2 mcg ...................... 121 paricalcitol cap 4 mcg ...................... 121 paricalcitol iv soln 2 mcg/ml ............. 121 paricalcitol iv soln 5 mcg/ml ............. 121 paromomycin sulfate cap 250 mg .......14 paroxetine hcl tab 10 mg ...................65 paroxetine hcl tab 20 mg ...................65 paroxetine hcl tab 30 mg ...................65 paroxetine hcl tab 40 mg ...................65 paroxetine hcl tab sr 24hr 12.5 mg .....65 paroxetine hcl tab sr 24hr 25 mg ........66 paroxetine hcl tab sr 24hr 37.5 mg .....66 PASER GRA 4GM ...............................21 PATADAY SOL 0.2% ........................ 124 PCE TAB 333MG EC ...........................26 PCE TAB 500MG EC ...........................26 pedia d-vite dro 400unit .................. 121 PEDIADERM HC KIT ......................... 137 PEDIADERM TA KIT ......................... 137 PEDIARIX INJ 0.5ML ........................ 116 PEDIATRIC RESPIRATORY MASK ....... 118 PEDVAX HIB INJ ............................. 116 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm ................................... 105 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm ................................... 105 peg 3350-kcl-sod bicarb-nacl for soln 420 gm ................................................ 105 PEGANONE TAB 250MG .....................59 PEGASYS INJ ....................................22 PEGASYS INJ 180MCG/M ...................22 PEGASYS INJ PROCLICK ....................22 PEGASYS KIT ...................................22 PEN G PROC INJ 600000 ....................28 PENICILL GK/ INJ DEX 1MU ................28 PENICILL GK/ INJ DEX 2MU ................28 PENICILL GK/ INJ DEX 3MU ................28 penicillin g potassium for inj 20000000 unit .................................................28 penicillin g potassium for inj 5000000 unit ......................................................28
penicillin g sodium for inj 5000000 unit ...................................................... 28 penicillin v potassium for soln 125 mg/5ml ...................................................... 28 penicillin v potassium for soln 250 mg/5ml ...................................................... 28 penicillin v potassium tab 250 mg ...... 29 penicillin v potassium tab 500 mg ...... 29 PENTACEL INJ ................................ 116 PENTAM 300 INJ 300MG.................... 16 pentoxifylline tab cr 400 mg ............ 111 PERFOROMIST NEB 20MCG ............. 128 perindopril erbumine tab 2 mg ........... 40 perindopril erbumine tab 4 mg ........... 40 perindopril erbumine tab 8 mg ........... 40 periogard sol 0.12% ....................... 139 permethrin cream 5% ..................... 139 perphenazine tab 16 mg ................... 71 perphenazine tab 2 mg ..................... 71 perphenazine tab 4 mg ..................... 71 perphenazine tab 8 mg ..................... 71 pfizerpen-g inj 20mu ........................ 29 phenadoz sup 25mg ....................... 103 phenazopyridine hcl tab 100 mg ...... 108 phenelzine sulfate tab 15 mg ............. 66 phenobarbital elixir 20 mg/5ml .......... 59 phenobarbital tab 100 mg ................. 59 phenobarbital tab 15 mg ................... 59 phenobarbital tab 16.2 mg ................ 59 phenobarbital tab 30 mg ................... 59 phenobarbital tab 32.4 mg ................ 59 phenobarbital tab 60 mg ................... 59 phenobarbital tab 64.8 mg ................ 59 phenobarbital tab 97.2 mg ................ 59 phenoxybenzamine hcl cap 10 mg ...... 53 phenylephrine hcl ophth soln 10% .... 125 phenylephrine hcl ophth soln 2.5% ... 125 phenytoin chew tab 50 mg ................ 59 phenytoin sodium extended cap 100 mg ...................................................... 59 phenytoin sodium extended cap 200 mg ...................................................... 59 phenytoin sodium extended cap 300 mg ...................................................... 59 phenytoin sodium inj 50 mg/ml ......... 59 phenytoin susp 125 mg/5ml .............. 59 PHISOHEX LIQ 3% ......................... 134 181
January 1, 2017
PHOSLYRA SOL .................................99 PHOSPHOLINE SOL 0.125%OP ......... 124 PHOTOFRIN INJ 75MG .......................37 physiolyte sol ................................. 125 physiosol sol irrigat ......................... 125 PICATO GEL 0.015% ....................... 133 PICATO GEL 0.05% ......................... 133 pilocarpine hcl tab 5 mg .................. 139 pilocarpine hcl tab 7.5 mg ................ 139 PILOPINE HS GEL 4% OP ................. 124 pimozide tab 1 mg ............................71 pimozide tab 2 mg ............................71 pindolol tab 10 mg ............................48 pindolol tab 5 mg ..............................47 pioglitazone hcl tab 15 mg (base equiv) ......................................................83 pioglitazone hcl tab 30 mg (base equiv) ......................................................83 pioglitazone hcl tab 45 mg (base equiv) ......................................................83 pioglitazone hcl-glimepiride tab 30-2 mg ......................................................83 pioglitazone hcl-glimepiride tab 30-4 mg ......................................................83 pioglitazone hcl-metformin hcl tab 15-500 mg ..................................................83 pioglitazone hcl-metformin hcl tab 15-850 mg ..................................................83 piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) .....................29 piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) ........................29 piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) .................................29 piperacillin sod-tazobactam sod for inj 40.5 gm (36-4.5 gm) ........................29 pirmella tab 1/35 ..............................88 piroxicam cap 10 mg .......................... 7 piroxicam cap 20 mg .......................... 7 PLASMA-LYTE INJ -148 .................... 120 PLASMA-LYTE INJ -A ....................... 120 PLEGRIDY INJ ...................................77 PLEGRIDY INJ PEN ............................77 PLEGRIDY INJ STARTER .....................77 PLEGRIDY PEN INJ STARTER ..............77 PNEUMOVAX 23 INJ 25/0.5 .............. 116 podofilox soln 0.5% ........................ 138
polycin oin op ................................ 123 poly-dex oin 0.1% op ..................... 122 polyethylene glycol 3350 oral packet 105 polyethylene glycol 3350 oral powder 105 polymyxin b sulfate for inj 500000 unit 16 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% ....................... 123 POMALYST CAP 1MG ....................... 113 POMALYST CAP 2MG ....................... 113 POMALYST CAP 3MG ....................... 113 POMALYST CAP 4MG ....................... 113 portia-28 tab ................................... 88 potassium chloride cap cr 10 meq .... 119 potassium chloride cap cr 8 meq ...... 119 potassium chloride inj 10 meq/100ml 120 potassium chloride inj 10 meq/50ml . 120 potassium chloride inj 2 meq/ml ...... 120 potassium chloride inj 20 meq/100ml 120 potassium chloride inj 20 meq/50ml . 120 potassium chloride inj 40 meq/100ml 120 potassium chloride microencapsulated crys cr tab 10 meq ......................... 119 potassium chloride microencapsulated crys cr tab 20 meq ......................... 119 potassium chloride oral soln 10% (20 meq/15ml) .................................... 119 potassium chloride oral soln 20% (40 meq/15ml) .................................... 119 potassium chloride tab cr 10 meq ..... 119 potassium chloride tab cr 20 meq (1500 mg) .............................................. 119 potassium chloride tab cr 8 meq (600 mg) .................................................... 119 potassium citrate tab cr 10 meq (1080 mg) .............................................. 108 potassium citrate tab cr 15 meq (1620 mg) .............................................. 108 potassium citrate tab cr 5 meq (540 mg) .................................................... 108 POTIGA TAB 200MG ......................... 59 POTIGA TAB 300MG ......................... 59 POTIGA TAB 400MG ......................... 59 POTIGA TAB 50MG ........................... 59 PRADAXA CAP 110MG ..................... 110 PRADAXA CAP 150MG ..................... 110 PRADAXA CAP 75MG ....................... 110 PRALUENT INJ 150MG/ML ................. 46 182
January 1, 2017
PRALUENT INJ 75MG/ML ....................46 pramipexole dihydrochloride tab 0.125 mg ..................................................68 pramipexole dihydrochloride tab 0.25 mg ......................................................68 pramipexole dihydrochloride tab 0.5 mg ......................................................68 pramipexole dihydrochloride tab 0.75 mg ......................................................68 pramipexole dihydrochloride tab 1 mg .68 pramipexole dihydrochloride tab 1.5 mg ......................................................68 pramipexole dihydrochloride tab sr 24hr 0.375 mg .........................................68 pramipexole dihydrochloride tab sr 24hr 0.75 mg ..........................................68 pramipexole dihydrochloride tab sr 24hr 1.5 mg ............................................68 pramipexole dihydrochloride tab sr 24hr 2.25 mg ..........................................68 pramipexole dihydrochloride tab sr 24hr 3 mg ..................................................68 pramipexole dihydrochloride tab sr 24hr 3.75 mg ..........................................68 pramipexole dihydrochloride tab sr 24hr 4.5 mg ............................................68 pramox gel 1% ............................... 138 pravastatin sodium tab 10 mg ............45 pravastatin sodium tab 20 mg ............45 pravastatin sodium tab 40 mg ............45 pravastatin sodium tab 80 mg ............45 prazosin hcl cap 1 mg........................41 prazosin hcl cap 2 mg........................41 prazosin hcl cap 5 mg........................41 PRED MILD SUS 0.12% OP............... 123 PRED SOD PHO SOL 1% OP ............. 123 prednicarbate cream 0.1% ............... 137 prednicarbate oint 0.1% .................. 137 prednisolone acetate ophth susp 1% . 123 prednisolone sod phos orally disintegr tab 10 mg (base eq) ...............................96 prednisolone sod phos orally disintegr tab 15 mg (base eq) ...............................96 prednisolone sod phos orally disintegr tab 30 mg (base eq) ...............................96 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) ...................96
prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) ........................ 96 prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) ........................ 96 prednisolone syrup 15 mg/5ml (usp solution equivalent) .......................... 96 PREDNISONE CON 5MG/ML ............... 96 prednisone oral soln 5 mg/5ml ........... 96 prednisone tab 1 mg......................... 96 prednisone tab 10 mg ....................... 96 prednisone tab 2.5 mg ...................... 96 prednisone tab 20 mg ....................... 96 prednisone tab 5 mg......................... 96 prednisone tab 50 mg ....................... 96 prednisone tab therapy pack 10 mg (21) ...................................................... 97 prednisone tab therapy pack 10 mg (48) ...................................................... 97 prednisone tab therapy pack 5 mg (21) ...................................................... 97 prednisone tab therapy pack 5 mg (48) ...................................................... 97 PREMARIN INJ 25MG ........................ 94 PREMARIN TAB 0.3MG ...................... 94 PREMARIN TAB 0.45MG .................... 94 PREMARIN TAB 0.625MG ................... 94 PREMARIN TAB 0.9MG ...................... 94 PREMARIN TAB 1.25MG .................... 95 PREMARIN VAG CRE 0.625MG ............ 95 prenatabs rx tab ............................ 121 PRENTIF MIS 22MM ........................ 117 PRENTIF MIS 25MM ........................ 117 PRENTIF MIS 28MM ........................ 117 PRENTIF MIS 31MM ........................ 117 PRENTIF MIS FITTING ..................... 117 PREPOPIK PAK ............................... 105 prevalite pow 4gm............................ 44 previfem tab .................................... 88 PREVNAR 13 INJ ............................ 116 PREZCOBIX TAB 800-150 .................. 20 PREZISTA SUS 100MG/ML ................. 19 PREZISTA TAB 150MG ...................... 19 PREZISTA TAB 400MG ...................... 19 PREZISTA TAB 600MG ...................... 19 PREZISTA TAB 75MG ........................ 19 PREZISTA TAB 800MG ...................... 19 PRIFTIN TAB 150MG ......................... 21 183
January 1, 2017
PRIMAQUINE TAB 26.3MG ..................18 primidone tab 250 mg .......................59 primidone tab 50 mg .........................59 PRIMLEV TAB 10-300MG ....................12 PRIMLEV TAB 5-300MG......................12 PRIMLEV TAB 7.5-300 .......................12 PRIMSOL SOL 50MG/5ML ...................17 PROAIR HFA AER ............................ 128 PROAIR RESPI AER ......................... 128 probenecid tab 500 mg ....................... 5 procainamide hcl inj 100 mg/ml ..........43 PROCAINAMIDE INJ 500MG/ML ...........43 prochlorperazine edisylate inj 5 mg/ml .................................................... 103 prochlorperazine maleate tab 10 mg (base equivalent) .................................... 103 prochlorperazine maleate tab 5 mg (base equivalent) .................................... 103 prochlorperazine suppos 25 mg ........ 103 PROCRIT INJ 10000/ML ................... 111 PROCRIT INJ 2000/ML ..................... 111 PROCRIT INJ 20000/ML ................... 111 PROCRIT INJ 3000/ML ..................... 111 PROCRIT INJ 4000/ML ..................... 111 PROCRIT INJ 40000/ML ................... 111 procto-pak cre 1% .......................... 135 proctosol hc cre 2.5% ..................... 135 proctozone cre -hc 2.5%.................. 135 progesterone micronized cap 100 mg ..99 progesterone micronized cap 200 mg ..99 PROGLYCEM SUS 50MG/ML ................97 PROGRAF INJ 5MG/ML ..................... 114 PROLASTIN-C INJ 1000MG ............... 129 PROLIA SOL 60MG/ML .......................98 PROMACTA TAB 12.5MG .................. 111 PROMACTA TAB 25MG ..................... 111 PROMACTA TAB 50MG ..................... 111 PROMACTA TAB 75MG ..................... 111 prometh vc syp plain ....................... 128 prometh vc/ syp codeine.................. 128 promethazine hcl inj 25 mg/ml ......... 103 promethazine hcl inj 50 mg/ml ......... 103 promethazine hcl suppos 12.5 mg ..... 103 promethazine hcl suppos 25 mg ....... 103 promethazine hcl syrup 6.25 mg/5ml 103 promethazine hcl tab 12.5 mg .......... 103 promethazine hcl tab 25 mg ............. 103
promethazine hcl tab 50 mg ............ 103 promethazine w/ codeine syrup 6.25-10 mg/5ml ......................................... 128 promethazine-dm syrup 6.25-15 mg/5ml .................................................... 129 promethegan sup 12.5mg ............... 103 promethegan sup 25mg .................. 103 promethegan sup 50mg .................. 103 propafenone hcl cap sr 12hr 225 mg... 43 propafenone hcl cap sr 12hr 325 mg... 44 propafenone hcl cap sr 12hr 425 mg... 44 propafenone hcl tab 150 mg .............. 44 propafenone hcl tab 225 mg .............. 44 propafenone hcl tab 300 mg .............. 44 proparacaine hcl ophth soln 0.5% .... 125 propranolol & hydrochlorothiazide tab 40-25 mg ........................................ 46 propranolol & hydrochlorothiazide tab 80-25 mg ........................................ 46 propranolol hcl cap sr 24hr 120 mg .... 48 propranolol hcl cap sr 24hr 160 mg .... 48 propranolol hcl cap sr 24hr 60 mg ...... 48 propranolol hcl cap sr 24hr 80 mg ...... 48 propranolol hcl inj 1 mg/ml ............... 48 propranolol hcl oral soln 20 mg/5ml ... 48 propranolol hcl oral soln 40 mg/5ml ... 48 propranolol hcl tab 10 mg ................. 48 propranolol hcl tab 20 mg ................. 48 propranolol hcl tab 40 mg ................. 48 propranolol hcl tab 60 mg ................. 48 propranolol hcl tab 80 mg ................. 48 propylthiouracil tab 50 mg............... 100 PROQUAD INJ ................................ 116 protriptyline hcl tab 10 mg ................ 66 protriptyline hcl tab 5 mg .................. 66 pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml ............................ 129 pyrazinamide tab 500 mg .................. 21 pyridostigmine bromide tab 60 mg ..... 76 pyridostigmine bromide tab cr 180 mg 76 Q QUADRAMET INJ .............................. 37 QUARTETTE TAB .............................. 88 quasense tab ................................... 88 quetiapine fumarate tab 100 mg ........ 71 quetiapine fumarate tab 200 mg ........ 71 quetiapine fumarate tab 25 mg .......... 71 184
January 1, 2017
quetiapine fumarate tab 300 mg .........71 quetiapine fumarate tab 400 mg .........71 quetiapine fumarate tab 50 mg...........71 QUFLORA PED CHW 0.25MG ............. 121 QUFLORA PED CHW 0.5MG .............. 121 QUFLORA PED CHW 1MG ................. 121 quflora ped dro 0.25mg ................... 121 quflora ped dro 0.5mg/ml ................ 121 quinapril hcl tab 10 mg ......................40 quinapril hcl tab 20 mg ......................40 quinapril hcl tab 40 mg ......................40 quinapril hcl tab 5 mg........................40 quinapril-hydrochlorothiazide tab 10-12.5 mg ..................................................39 quinapril-hydrochlorothiazide tab 20-12.5 mg ..................................................39 quinapril-hydrochlorothiazide tab 20-25 mg ..................................................39 quinidine sulfate tab 200 mg ..............44 quinidine sulfate tab 300 mg ..............44 quinine sulfate cap 324 mg ................18 quinine sulfate tab 260 mg.................18 QVAR AER 40MCG ........................... 130 QVAR AER 80MCG ........................... 130 R rabeprazole sodium ec tab 20 mg ..... 107 raloxifene hcl tab 60 mg ....................98 ramipril cap 1.25 mg .........................40 ramipril cap 10 mg ............................40 ramipril cap 2.5 mg ...........................40 ramipril cap 5 mg .............................40 RANEXA TAB 1000MG ........................53 RANEXA TAB 500MG .........................53 ranitidine hcl cap 150 mg ................. 104 ranitidine hcl cap 300 mg ................. 104 ranitidine hcl inj 1000 mg/40ml (25 mg/ml) .......................................... 104 ranitidine hcl inj 150 mg/6ml (25 mg/ml) .................................................... 104 ranitidine hcl inj 50 mg/2ml (25 mg/ml) .................................................... 104 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ........................................ 104 ranitidine hcl tab 150 mg ................. 104 ranitidine hcl tab 300 mg ................. 104 RAPAFLO CAP 4MG .......................... 107 RAPAFLO CAP 8MG .......................... 107
RAPAMUNE SOL 1MG/ML ................. 114 REBETOL SOL 40MG/ML .................... 22 REBIF INJ 22/0.5 ............................. 77 REBIF INJ 44/0.5 ............................. 77 REBIF REBIDO INJ 22/0.5 ................. 77 REBIF REBIDO INJ 44/0.5 ................. 77 REBIF REBIDO INJ TITRATN .............. 77 REBIF TITRTN INJ PACK .................... 77 reclipsen tab .................................... 88 RECOMBIVA HB INJ 10MCG/ML ........ 116 RECOMBIVA HB INJ 5MCG/0.5 ......... 116 RECOMBIVA-HB INJ 40MCG/ML ........ 116 RECTIV OIN 0.4% .......................... 138 REGONOL INJ 5MG/ML ...................... 77 REGRANEX GEL 0.01% ................... 139 RELENZA MIS DISKHALE ................... 22 RELPAX TAB 20MG ........................... 75 RELPAX TAB 40MG ........................... 75 REMICADE INJ 100MG .................... 112 REMODULIN INJ 10MG/ML ................. 55 REMODULIN INJ 1MG/ML .................. 55 REMODULIN INJ 2.5MG/ML ................ 55 REMODULIN INJ 5MG/ML .................. 55 RENVELA PAK 0.8GM ........................ 99 RENVELA PAK 2.4GM ........................ 99 RENVELA TAB 800MG ....................... 99 repaglinide tab 0.5 mg ...................... 83 repaglinide tab 1 mg......................... 83 repaglinide tab 2 mg......................... 83 repaglinide-metformin hcl tab 1-500 mg ...................................................... 83 repaglinide-metformin hcl tab 2-500 mg ...................................................... 83 REPATHA INJ 140MG/ML ................... 46 REPATHA PUSH INJ 420/3.5 .............. 46 REPATHA SURE INJ 140MG/ML........... 46 RESCRIPTOR TAB 100 MG ................. 19 RESCRIPTOR TAB 200MG .................. 19 reserpine tab 0.1 mg ........................ 53 reserpine tab 0.25 mg ...................... 53 RESTASIS EMU 0.05% .................... 125 RETROVIR INJ 10MG/ML ................... 19 REVLIMID CAP 10MG ...................... 113 REVLIMID CAP 15MG ...................... 113 REVLIMID CAP 2.5MG ..................... 113 REVLIMID CAP 20MG ...................... 113 REVLIMID CAP 25MG ...................... 113 185
January 1, 2017
REVLIMID CAP 5MG ........................ 113 REXULTI TAB 0.25MG ........................71 REXULTI TAB 0.5MG ..........................71 REXULTI TAB 1MG ............................71 REXULTI TAB 2MG ............................71 REXULTI TAB 3MG ............................71 REXULTI TAB 4MG ............................71 REYATAZ CAP 100MG ........................19 REYATAZ CAP 150MG ........................19 REYATAZ CAP 200MG ........................19 REYATAZ CAP 300MG ........................19 REYATAZ POW 50MG .........................19 RHEUMATREX TAB 2.5MG ................ 113 ribasphere cap 200mg .......................22 ribasphere tab 200mg .......................22 ribasphere tab 400mg .......................22 ribasphere tab 600mg .......................22 ribavirin cap 200 mg .........................22 ribavirin tab 200 mg..........................22 rifabutin cap 150 mg .........................21 RIFAMATE CAP .................................21 rifampin cap 150 mg .........................21 rifampin cap 300 mg .........................21 rifampin for inj 600 mg ......................21 RIFATER TAB ....................................21 riluzole tab 50 mg .............................77 rimantadine hydrochloride tab 100 mg 22 risedronate sodium tab 150 mg ..........85 risedronate sodium tab 30 mg ............85 risedronate sodium tab 35 mg ............85 risedronate sodium tab 5 mg ..............85 risedronate sodium tab delayed release 35 mg ..................................................85 risperidone orally disintegrating tab 0.25 mg ..................................................71 risperidone orally disintegrating tab 0.5 mg ..................................................71 risperidone orally disintegrating tab 1 mg ......................................................71 risperidone orally disintegrating tab 2 mg ......................................................71 risperidone orally disintegrating tab 3 mg ......................................................71 risperidone orally disintegrating tab 4 mg ......................................................71 risperidone soln 1 mg/ml ...................71 risperidone tab 0.25 mg ....................71
risperidone tab 0.5 mg...................... 71 risperidone tab 1 mg ........................ 71 risperidone tab 2 mg ........................ 71 risperidone tab 3 mg ........................ 71 risperidone tab 4 mg ........................ 71 RITUXAN INJ 100MG......................... 34 RITUXAN INJ 500MG......................... 34 rivastigmine tartrate cap 1.5 mg ........ 61 rivastigmine tartrate cap 3 mg ........... 61 rivastigmine tartrate cap 4.5 mg ........ 61 rivastigmine tartrate cap 6 mg ........... 61 rivastigmine td patch 24hr 13.3 mg/24hr ...................................................... 61 rivastigmine td patch 24hr 4.6 mg/24hr ...................................................... 61 rivastigmine td patch 24hr 9.5 mg/24hr ...................................................... 61 rizatriptan benzoate oral disintegrating tab 10 mg (base eq) ......................... 75 rizatriptan benzoate oral disintegrating tab 5 mg (base eq)........................... 75 rizatriptan benzoate tab 10 mg (base equivalent) ...................................... 76 rizatriptan benzoate tab 5 mg (base equivalent) ...................................... 75 romycin oin op ............................... 123 ropinirole hydrochloride tab 0.25 mg .. 68 ropinirole hydrochloride tab 0.5 mg .... 68 ropinirole hydrochloride tab 1 mg ....... 68 ropinirole hydrochloride tab 2 mg ....... 68 ropinirole hydrochloride tab 3 mg ....... 68 ropinirole hydrochloride tab 4 mg ....... 68 ropinirole hydrochloride tab 5 mg ....... 68 rosadan cre 0.75% ......................... 139 rosuvastatin calcium tab 10 mg ......... 45 rosuvastatin calcium tab 20 mg ......... 45 rosuvastatin calcium tab 40 mg ......... 45 rosuvastatin calcium tab 5 mg ........... 45 ROTARIX SUS ................................ 116 ROTATEQ SOL................................ 116 roxicet tab 5-325mg ......................... 12 ROZEREM TAB 8MG .......................... 75 S SABRIL POW 500MG ......................... 59 SABRIL TAB 500MG .......................... 59 SAFYRAL TAB................................... 88 SAIZEN INJ 5MG .............................. 98 186
January 1, 2017
SAIZEN INJ 8.8MG ............................98 SAMSCA TAB 15MG ...........................98 SAMSCA TAB 30MG ...........................98 SANCUSO DIS 3.1MG ...................... 103 SANDIMMUNE SOL 100MG/ML .......... 114 SANDOSTATIN KIT LAR 10MG ............98 SANDOSTATIN KIT LAR 20MG ............98 SANDOSTATIN KIT LAR 30MG ............98 SANTYL OIN 250/GM ....................... 139 SAPHRIS SUB 10MG ..........................71 SAPHRIS SUB 2.5MG .........................71 SAPHRIS SUB 5MG............................71 SAVELLA MIS TITR PAK .....................77 SAVELLA TAB 100MG ........................77 SAVELLA TAB 12.5MG .......................77 SAVELLA TAB 25MG ..........................77 SAVELLA TAB 50MG ..........................77 scalacort lot 2%.............................. 137 selegiline hcl cap 5 mg ......................68 selegiline hcl tab 5 mg .......................68 selenium sulfide lotion 2.5% ............ 135 SELZENTRY TAB 150MG .....................19 SELZENTRY TAB 300MG .....................20 SENSIPAR TAB 30MG ........................85 SENSIPAR TAB 60MG ........................85 SENSIPAR TAB 90MG ........................85 SEREVENT DIS AER 50MCG .............. 128 SEROQUEL XR TAB 150MG .................71 SEROQUEL XR TAB 200MG .................71 SEROQUEL XR TAB 300MG .................72 SEROQUEL XR TAB 400MG .................72 SEROQUEL XR TAB 50MG...................71 SEROSTIM INJ 4MG...........................98 SEROSTIM INJ 5MG...........................98 SEROSTIM INJ 6MG...........................98 sertraline hcl oral conc 20 mg/ml ........66 sertraline hcl tab 100 mg ...................66 sertraline hcl tab 25 mg .....................66 sertraline hcl tab 50 mg .....................66 SHUR-SEAL GEL 2% ........................ 107 SIGNIFOR INJ 0.3MG/ML ...................98 SIGNIFOR INJ 0.6MG/ML ...................98 SIGNIFOR INJ 0.9MG/ML ...................98 sildenafil citrate iv soln 10 mg/12.5ml (base equivalent) ..............................55 sildenafil citrate tab 20 mg .................55 silver sulfadiazine cream 1% ............ 134
SIMBRINZA SUS 1-0.2% ................. 124 SIMPONI ARIA SOL 50MG/4ML ......... 112 SIMPONI INJ 100MG/ML .................. 112 SIMPONI INJ 50/0.5ML ................... 112 SIMULECT INJ 10MG ....................... 114 SIMULECT INJ 20MG ....................... 114 simvastatin tab 10 mg ...................... 46 simvastatin tab 20 mg ...................... 46 simvastatin tab 40 mg ...................... 46 simvastatin tab 5 mg ........................ 46 simvastatin tab 80 mg ...................... 46 sirolimus tab 0.5 mg ....................... 114 sirolimus tab 1 mg ......................... 114 sirolimus tab 2 mg ......................... 114 SIRTURO TAB 100MG ....................... 21 SIVEXTRO INJ 200MG ....................... 17 SIVEXTRO TAB 200MG ...................... 17 SKLICE LOT 0.5% .......................... 139 SKYLA IUD 13.5MG .......................... 89 sm nicotine dis 14mg/24h ................. 80 sm nicotine dis 21mg ........................ 80 sm nicotine dis 7mg/24hr .................. 80 sm vitamin d tab 400unit ................ 121 sodium chloride flush iv soln 0.9% ... 119 sodium chloride inj 0.45% ............... 120 sodium chloride inj 0.9%................. 120 sodium chloride inj 2.5 meq/ml (14.6%) .................................................... 119 sodium chloride inj 3% ................... 120 sodium chloride inj 5% ................... 120 sodium chloride irrigation soln 0.9% . 139 sodium chloride iv soln 0.9% ........... 120 sodium chloride soln nebu 0.9% ...... 129 sodium chloride soln nebu 10% ....... 129 sodium chloride soln nebu 3% ......... 129 sodium chloride soln nebu 7% ......... 129 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) ................................. 119 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) ................................... 119 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) ........................................ 119 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) .................................... 119 sodium fluoride tab 0.5 mg f (from 1.1 mg naf) .............................................. 119 sodium fluoride tab 1 mg f (from 2.2 mg 187
January 1, 2017
naf)............................................... 119 sodium phenylbutyrate oral powder 3 gm/teaspoonful ................................90 sodium polystyrene sulfonate oral susp 15 gm/60ml .........................................86 sodium polystyrene sulfonate rectal susp 30 gm/120ml ...................................86 solia tab ..........................................89 SOLU-CORTEF INJ 1000MG ................97 SOLU-CORTEF INJ 100MG ..................97 SOLU-CORTEF INJ 250MG ..................97 SOLU-CORTEF INJ 500MG ..................97 SOLU-MEDROL INJ 2GM .....................97 SOMATULINE INJ 120/.5ML ................98 SOMATULINE INJ 60/0.2ML ................98 SOMATULINE INJ 90/0.3ML ................98 SOMAVERT INJ 10MG ........................98 SOMAVERT INJ 15MG ........................98 SOMAVERT INJ 20MG ........................99 SOMAVERT INJ 25MG ........................99 SOMAVERT INJ 30MG ........................99 sorine tab 120mg..............................44 sorine tab 160mg..............................44 sorine tab 240mg..............................44 sorine tab 80mg ...............................44 sotalol hcl (afib/afl) tab 120 mg ..........44 sotalol hcl (afib/afl) tab 160 mg ..........44 sotalol hcl (afib/afl) tab 80 mg ...........44 SOTALOL HCL INJ 150/10ML ..............44 sotalol hcl tab 120 mg .......................44 sotalol hcl tab 160 mg .......................44 sotalol hcl tab 240 mg .......................44 sotalol hcl tab 80 mg .........................44 SOVALDI TAB 400MG ........................22 spinosad susp 0.9% ........................ 139 SPIRIVA AER 1.25MCG .................... 126 SPIRIVA CAP HANDIHLR .................. 126 SPIRIVA SPR RESPIMAT ................... 126 spironolactone & hydrochlorothiazide tab 25-25 mg ........................................52 spironolactone tab 100 mg .................52 spironolactone tab 25 mg ..................52 spironolactone tab 50 mg ..................52 SPORANOX SOL 10MG/ML ..................18 sprintec 28 tab 28 day .......................89 SPRYCEL TAB 100MG ........................36 SPRYCEL TAB 140MG ........................36
SPRYCEL TAB 20MG.......................... 36 SPRYCEL TAB 50MG.......................... 36 SPRYCEL TAB 70MG.......................... 36 SPRYCEL TAB 80MG.......................... 36 sronyx tab ....................................... 89 ssd cre 1% .................................... 134 stavudine cap 15 mg ........................ 20 stavudine cap 20 mg ........................ 20 stavudine cap 30 mg ........................ 20 stavudine cap 40 mg ........................ 20 stavudine for oral soln 1 mg/ml ......... 20 STAVZOR CAP 125MG ....................... 60 STAVZOR CAP 250MG ....................... 60 STAVZOR CAP 500MG ....................... 60 STELARA INJ 45MG/0.5 ................... 112 STELARA INJ 90MG/ML ................... 112 STIVARGA TAB 40MG ....................... 36 STRATTERA CAP 100MG .................... 74 STRATTERA CAP 10MG ...................... 74 STRATTERA CAP 18MG ...................... 74 STRATTERA CAP 25MG ...................... 74 STRATTERA CAP 40MG ...................... 74 STRATTERA CAP 60MG ...................... 74 STRATTERA CAP 80MG ...................... 74 streptomycin sulfate for inj 1 gm........ 14 STRIBILD TAB.................................. 21 STRIVERDI AER 2.5MCG ................. 128 SUBOXONE MIS 12-3MG ..................... 7 SUBOXONE MIS 2-0.5MG .................... 7 SUBOXONE MIS 4-1MG ....................... 7 SUBOXONE MIS 8-2MG ....................... 7 SUCRAID SOL 8500/ML ................... 106 sucralfate tab 1 gm ........................ 106 sulfacetamide sodium lotion 10% (acne) .................................................... 132 sulfacetamide sodium ophth oint 10% .................................................... 123 sulfacetamide sodium ophth soln 10% .................................................... 123 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% ...................... 122 SULFADIAZINE TAB 500MG ............... 14 sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml................................ 17 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml................................ 17 sulfamethoxazole-trimethoprim tab 188
January 1, 2017
400-80 mg .......................................17 sulfamethoxazole-trimethoprim tab 800-160 mg .....................................17 SULFAMYLON CRE 85MG/GM ............ 134 sulfasalazine tab 500 mg ................. 105 sulfasalazine tab delayed release 500 mg .................................................... 105 sulindac tab 150 mg ........................... 7 sulindac tab 200 mg ........................... 7 sumatriptan nasal spray 20 mg/act .....76 sumatriptan nasal spray 5 mg/act .......76 sumatriptan succinate inj 4 mg/0.5ml .76 sumatriptan succinate inj 6 mg/0.5ml .76 sumatriptan succinate solution auto-injector 4 mg/0.5ml ...................76 sumatriptan succinate solution auto-injector 6 mg/0.5ml ...................76 sumatriptan succinate solution cartridge 4 mg/0.5ml ........................................76 sumatriptan succinate solution cartridge 6 mg/0.5ml ........................................76 sumatriptan succinate solution prefilled syringe 6 mg/0.5ml ...........................76 sumatriptan succinate tab 100 mg ......76 sumatriptan succinate tab 25 mg ........76 sumatriptan succinate tab 50 mg ........76 SUPRAX CAP 400MG ..........................25 SUPRAX CHW 100MG ........................25 SUPRAX CHW 200MG ........................25 SUPRAX SUS 500/5ML .......................25 SUPRAX TAB 400MG ..........................25 SUPREP BOWEL SOL PREP ............... 105 SUSTIVA CAP 200MG ........................20 SUSTIVA CAP 50MG ..........................20 SUSTIVA TAB 600MG ........................20 SUTENT CAP 12.5MG .........................36 SUTENT CAP 25MG ...........................36 SUTENT CAP 37.5MG .........................36 SUTENT CAP 50MG ...........................36 syeda tab 3-0.03mg ..........................89 symax fastab tab 0.125mg............... 102 symax-sl sub 0.125mg .................... 102 SYMLINPEN 60 INJ 1000MCG .............81 SYMLNPEN 120 INJ 1000MCG .............81 SYNAREL SOL 2MG/ML ......................89 SYNERA DIS 70-70MG ..................... 138 SYNRIBO INJ 3.5MG ..........................37
SYNTHROID TAB 100MCG ............... 100 SYNTHROID TAB 112MCG ............... 100 SYNTHROID TAB 125MCG ............... 100 SYNTHROID TAB 137MCG ............... 100 SYNTHROID TAB 150MCG ............... 100 SYNTHROID TAB 175MCG ............... 100 SYNTHROID TAB 200MCG ............... 100 SYNTHROID TAB 25MCG ................. 100 SYNTHROID TAB 300MCG ............... 100 SYNTHROID TAB 50MCG ................. 100 SYNTHROID TAB 75MCG ................. 100 SYNTHROID TAB 88MCG ................. 100 SYPRINE CAP 250MG ........................ 86 T TABLOID TAB 40MG ......................... 32 TACLONEX SUS .............................. 137 tacrolimus cap 0.5 mg .................... 114 tacrolimus cap 1 mg ....................... 114 tacrolimus cap 5 mg ....................... 114 tacrolimus oint 0.03% .................... 138 tacrolimus oint 0.1% ...................... 138 TAFINLAR CAP 50MG ........................ 36 TAFINLAR CAP 75MG ........................ 36 TAMIFLU CAP 30MG .......................... 22 TAMIFLU CAP 45MG .......................... 22 TAMIFLU CAP 75MG .......................... 22 TAMIFLU SUS 6MG/ML ...................... 22 tamoxifen citrate tab 10 mg (base equivalent) ...................................... 35 tamoxifen citrate tab 20 mg (base equivalent) ...................................... 35 tamsulosin hcl cap 0.4 mg ............... 107 TANZEUM INJ 30MG ......................... 82 TANZEUM INJ 50MG ......................... 82 TARCEVA TAB 100MG ....................... 36 TARCEVA TAB 150MG ....................... 36 TARCEVA TAB 25MG ......................... 36 TARGRETIN GEL 1% ....................... 138 tazicef inj 1gm ................................. 25 tazicef inj 2gm ................................. 25 tazicef inj 6gm ................................. 25 TAZORAC CRE 0.05% ..................... 135 TAZORAC CRE 0.1% ....................... 135 TAZORAC GEL 0.05% ..................... 135 TAZORAC GEL 0.1% ....................... 135 taztia xt cap 120mg/24 ..................... 50 taztia xt cap 180mg/24 ..................... 50 189
January 1, 2017
taztia xt cap 240mg/24 .....................50 taztia xt cap 300mg/24 .....................50 taztia xt cap 360mg/24 .....................50 TECFIDERA CAP 120MG .....................77 TECFIDERA CAP 240MG .....................77 TECFIDERA MIS STARTER ..................77 TECHNIVIE TAB ................................22 TEFLARO INJ 400MG .........................25 TEFLARO INJ 600MG .........................25 TEKTURNA TAB 150MG ......................51 TEKTURNA TAB 300MG ......................51 telmisartan tab 20 mg .......................43 telmisartan tab 40 mg .......................43 telmisartan tab 80 mg .......................43 telmisartan-amlodipine tab 40-10 mg ..42 telmisartan-amlodipine tab 40-5 mg ...42 telmisartan-amlodipine tab 80-10 mg ..42 telmisartan-amlodipine tab 80-5 mg ...42 telmisartan-hydrochlorothiazide tab 40-12.5 mg ......................................42 telmisartan-hydrochlorothiazide tab 80-12.5 mg ......................................42 telmisartan-hydrochlorothiazide tab 80-25 mg ........................................42 temazepam cap 15 mg ......................75 temazepam cap 22.5 mg ...................75 temazepam cap 30 mg ......................75 temazepam cap 7.5 mg .....................75 TEMODAR INJ 100MG ........................30 temozolomide cap 100 mg .................30 temozolomide cap 140 mg .................31 temozolomide cap 180 mg .................31 temozolomide cap 20 mg ...................30 temozolomide cap 250 mg .................31 temozolomide cap 5 mg .....................30 tencon tab 50-325mg ......................... 5 TENIPOSIDE INJ 50MG/5ML ...............38 TENIVAC INJ 5-2LF ......................... 116 terazosin hcl cap 1 mg.......................41 terazosin hcl cap 10 mg .....................41 terazosin hcl cap 2 mg.......................41 terazosin hcl cap 5 mg.......................41 terbinafine hcl tab 250 mg .................18 terbutaline sulfate inj 1 mg/ml ......... 128 terbutaline sulfate tab 2.5 mg .......... 128 terbutaline sulfate tab 5 mg ............. 128 terconazole vaginal cream 0.4% ....... 108
terconazole vaginal suppos 80 mg .... 108 testosterone cypionate im inj in oil 100 mg/ml ............................................ 80 testosterone cypionate im inj in oil 200 mg/ml ............................................ 80 testosterone enanthate im inj in oil 200 mg/ml ............................................ 80 testosterone td gel 10mg/act (2%) .... 80 testosterone td gel 25 mg/2.5gm (1%)81 TET/DIP TOX INJ 2-2 LF .................. 116 tetrabenazine tab 12.5 mg ................ 77 tetrabenazine tab 25 mg ................... 77 tetracycline hcl cap 250 mg ............... 30 tetracycline hcl cap 500 mg ............... 30 TEXACORT SOL 2.5% ..................... 137 tgq 50pse/3 syp brm/30dm ............. 129 THALOMID CAP 100MG ................... 113 THALOMID CAP 150MG ................... 113 THALOMID CAP 200MG ................... 113 THALOMID CAP 50MG ..................... 113 THEO-24 CAP 100MG CR ................. 131 THEO-24 CAP 200MG CR ................. 131 THEO-24 CAP 300MG CR ................. 131 THEO-24 CAP 400MG ER ................. 131 theochron tab 100mg cr .................. 131 theochron tab 200mg cr .................. 131 theochron tab 300mg cr .................. 131 theophylline soln 80 mg/15ml .......... 131 theophylline tab sr 12hr 450 mg ...... 131 theophylline tab sr 24hr 400 mg ...... 131 theophylline tab sr 24hr 600 mg ...... 131 THERACYS INJ ................................. 37 thioridazine hcl tab 10 mg ................. 72 thioridazine hcl tab 100 mg ............... 72 thioridazine hcl tab 25 mg ................. 72 thioridazine hcl tab 50 mg ................. 72 thiothixene cap 1 mg ........................ 72 thiothixene cap 10 mg ...................... 72 thiothixene cap 2 mg ........................ 72 thiothixene cap 5 mg ........................ 72 thrive gum 4mg mint ........................ 80 THYMOGLOBULN INJ 25MG.............. 114 THYROLAR-1 TAB 60MG .................. 100 THYROLAR-1/2 TAB 30MG ............... 100 THYROLAR-1/4 TAB 15MG ............... 100 THYROLAR-2 TAB 120MG ................ 100 THYROLAR-3 TAB 180MG ................ 100 190
January 1, 2017
tiagabine hcl tab 2 mg .......................60 tiagabine hcl tab 4 mg .......................60 TICE BCG INJ ...................................37 tilia fe tab ........................................89 timolol maleate ophth gel forming soln 0.25% ........................................... 124 timolol maleate ophth gel forming soln 0.5% ............................................. 124 timolol maleate ophth soln 0.25% ..... 125 timolol maleate ophth soln 0.5% ...... 125 timolol maleate tab 10 mg .................48 timolol maleate tab 20 mg .................48 timolol maleate tab 5 mg ...................48 TIMOPTIC OCU SOL 0.25% OP ......... 125 TIMOPTIC OCU SOL 0.5% OP ........... 125 tinidazole tab 250 mg ........................14 tinidazole tab 500 mg ........................14 tis-u-sol sol .................................... 125 TIVICAY TAB 10MG ...........................20 TIVICAY TAB 25MG ...........................20 TIVICAY TAB 50MG ...........................20 tizanidine hcl cap 2 mg (base equivalent) ......................................................79 tizanidine hcl cap 4 mg (base equivalent) ......................................................79 tizanidine hcl cap 6 mg (base equivalent) ......................................................79 tizanidine hcl tab 2 mg (base equivalent) ......................................................79 tizanidine hcl tab 4 mg (base equivalent) ......................................................79 TOBRA/NACL INJ 80/0.9 ....................14 TOBRADEX OIN 0.3-0.1% ................ 122 tobramycin nebu soln 300 mg/5ml ......14 tobramycin ophth soln 0.3% ............ 123 tobramycin sulfate for inj 1.2 gm ........14 tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) (base equiv) .........................14 tobramycin sulfate inj 10 mg/ml (base equivalent) ......................................14 tobramycin sulfate inj 2 gm/50ml (40 mg/ml) (base equiv) .........................14 tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv) .........................14 tobramycin-dexamethasone ophth susp 0.3-0.1% ....................................... 122 TOBREX OIN 0.3% OP ..................... 123
TODAY SPONGE MIS ....................... 107 tolcapone tab 100 mg ....................... 68 tolmetin sodium cap 400 mg ............... 7 tolmetin sodium tab 200 mg ................ 7 tolmetin sodium tab 600 mg ................ 7 tolterodine tartrate cap sr 24hr 2 mg 108 tolterodine tartrate cap sr 24hr 4 mg 108 tolterodine tartrate tab 1 mg ........... 108 tolterodine tartrate tab 2 mg ........... 108 topiramate sprinkle cap 15 mg ........... 60 topiramate sprinkle cap 25 mg ........... 60 topiramate tab 100 mg ..................... 60 topiramate tab 200 mg ..................... 60 topiramate tab 25 mg ....................... 60 topiramate tab 50 mg ....................... 60 toposar inj 100/5ml .......................... 38 toposar inj 20mg/ml ......................... 38 topotecan hcl for inj 4 mg ................. 38 TOPOTECAN INJ 4MG/4ML ................. 38 TORISEL SOL 25MG/ML..................... 34 TORSEMIDE INJ 20MG/2ML ............... 52 TORSEMIDE INJ 50MG/5ML ............... 52 torsemide tab 10 mg ........................ 52 torsemide tab 100 mg ...................... 52 torsemide tab 20 mg ........................ 52 torsemide tab 5 mg .......................... 52 TOVIAZ TAB 4MG ........................... 108 TOVIAZ TAB 8MG ........................... 108 TRACLEER TAB 125MG ...................... 55 TRACLEER TAB 62.5MG ..................... 55 TRADJENTA TAB 5MG ....................... 82 tramadol hcl tab 50 mg ..................... 12 tramadol hcl tab sr 24hr 100 mg ........ 12 tramadol hcl tab sr 24hr 200 mg ........ 12 tramadol hcl tab sr 24hr 300 mg ........ 12 trandolapril tab 1 mg ........................ 40 trandolapril tab 2 mg ........................ 40 trandolapril tab 4 mg ........................ 40 trandolapril-verapamil hcl tab cr 1-240 mg ................................................. 39 trandolapril-verapamil hcl tab cr 2-180 mg ................................................. 40 trandolapril-verapamil hcl tab cr 2-240 mg ................................................. 40 trandolapril-verapamil hcl tab cr 4-240 mg ................................................. 40 tranexamic acid iv soln 1000 mg/10ml 191
January 1, 2017
(100 mg/ml) .................................. 111 tranexamic acid tab 650 mg ............. 111 TRANSDERM-SC DIS 1MG ................ 103 tranylcypromine sulfate tab 10 mg ......66 TRAVATAN Z DRO 0.004% ............... 125 trazodone hcl tab 100 mg ..................66 trazodone hcl tab 150 mg ..................66 trazodone hcl tab 300 mg ..................66 trazodone hcl tab 50 mg ....................66 TRECATOR TAB 250MG ......................21 TRELSTAR INJ 11.25MG .....................35 TRELSTAR MIX INJ 22.5MG ................35 TRELSTAR MIX INJ 3.75MG ................35 TRESIBA FLEX INJ 100UNIT ...............83 TRESIBA FLEX INJ 200UNIT ...............83 tretinoin cap 10 mg ...........................37 tretinoin cream 0.025% ................... 133 tretinoin cream 0.05%..................... 132 tretinoin cream 0.1% ...................... 132 tretinoin gel 0.01% ......................... 133 tretinoin gel 0.025% ....................... 133 tretinoin gel 0.05% ......................... 133 tretinoin microsphere gel 0.04% ....... 133 tretinoin microsphere gel 0.1% ......... 133 TRETIN-X CRE 0.0375% .................. 132 TRETIN-X CRE 0.075% .................... 132 TREXALL TAB 10MG ........................ 113 TREXALL TAB 15MG ........................ 113 TREXALL TAB 5MG .......................... 113 TREXALL TAB 7.5MG ....................... 113 triamcinolone acetonide aerosol soln 0.147 mg/gm ................................. 137 triamcinolone acetonide cream 0.025% .................................................... 138 triamcinolone acetonide cream 0.1% . 137 triamcinolone acetonide cream 0.5% . 138 triamcinolone acetonide dental paste 0.1% ............................................. 139 triamcinolone acetonide lotion 0.025% .................................................... 138 triamcinolone acetonide lotion 0.1% .. 138 triamcinolone acetonide nasal aerosol suspension 55 mcg/act .................... 130 triamcinolone acetonide oint 0.025%. 138 triamcinolone acetonide oint 0.1% .... 138 triamcinolone acetonide oint 0.5% .... 138 triamterene & hydrochlorothiazide cap
37.5-25 mg ..................................... 52 triamterene & hydrochlorothiazide cap 50-25 mg ........................................ 52 triamterene & hydrochlorothiazide tab 37.5-25 mg ..................................... 52 triamterene & hydrochlorothiazide tab 75-50 mg ........................................ 53 TRIANEX OIN 0.05% ...................... 138 triderm cre 0.1% ........................... 138 trifluoperazine hcl tab 1 mg ............... 72 trifluoperazine hcl tab 10 mg ............. 72 trifluoperazine hcl tab 2 mg ............... 72 trifluoperazine hcl tab 5 mg ............... 72 trifluridine ophth soln 1% ................ 123 trihexyphenidyl hcl elixir 0.4 mg/ml .... 68 trihexyphenidyl hcl tab 2 mg ............. 69 trihexyphenidyl hcl tab 5 mg ............. 69 tri-linyah tab ................................... 89 trimethobenzamide hcl cap 300 mg .. 103 trimethobenzamide hcl inj 100 mg/ml104 trimethoprim tab 100 mg .................. 17 trimipramine maleate cap 100 mg ...... 66 trimipramine maleate cap 25 mg ........ 66 trimipramine maleate cap 50 mg ........ 66 trinessa tab ..................................... 89 TRIPEDIA SUS P/F .......................... 116 tri-previfem tab ............................... 89 TRISENOX SOL 10MG/10M ................ 37 tri-sprintec tab ................................. 89 TRIUMEQ TAB .................................. 21 tri-vit/fe dro /fl 0.25 ....................... 121 tri-vit/fl dro 0.25mg ....................... 121 tri-vit/fl dro 0.5mg ......................... 121 tri-vit/fluo dro 0.25mg .................... 121 tri-vita/fl dro 0.25mg ...................... 122 trivora-28 tab .................................. 89 tropicamide ophth soln 0.5% ........... 125 tropicamide ophth soln 1% .............. 125 trospium chloride cap sr 24hr 60 mg 108 trospium chloride tab 20 mg ............ 108 TRULICITY INJ 0.75/0.5 .................... 82 TRULICITY INJ 1.5/0.5 ...................... 82 TRUMENBA INJ .............................. 116 TRUVADA TAB 100-150 ..................... 21 TRUVADA TAB 133-200 ..................... 21 TRUVADA TAB 167-250 ..................... 21 TRUVADA TAB 200-300 ..................... 21 192
January 1, 2017
TUDORZA PRES AER 400/ACT .......... 126 tussigon tab 5-1.5mg ...................... 129 TUZISTRA XR SUS .......................... 129 TWINRIX INJ .................................. 116 TYBOST TAB 150MG ..........................20 TYGACIL INJ 50MG............................17 TYKERB TAB 250MG ..........................36 TYSABRI INJ 300/15ML......................77 TYVASO START SOL 0.6MG/ML ...........55 TYZEKA TAB 600MG ..........................22 TYZINE PED DRO 0.05% .................. 129 TYZINE SOL 0.1% ........................... 129 U ULESFIA LOT 5% ............................ 139 ULORIC TAB 40MG ............................. 5 ULORIC TAB 80MG ............................. 5 unithroid tab 100mcg ...................... 101 unithroid tab 112mcg ...................... 101 unithroid tab 125mcg ...................... 101 unithroid tab 200mcg ...................... 101 unithroid tab 25mcg ........................ 100 unithroid tab 300mcg ...................... 101 unithroid tab 50mcg ........................ 100 unithroid tab 75mcg ........................ 100 unithroid tab 88mcg ........................ 100 univert tab 32mg ............................ 104 URINE TEST STRIPS ........................ 117 ursodiol cap 300 mg ........................ 106 ursodiol tab 250 mg ........................ 106 ursodiol tab 500 mg ........................ 106 UVADEX INJ 20MCG/ML .....................37 V VAGIFEM TAB 10MCG ........................95 valacyclovir hcl tab 1 gm ...................22 valacyclovir hcl tab 500 mg ................22 VALCYTE SOL 50MG/ML .....................22 valganciclovir hcl tab 450 mg (base equivalent) ......................................22 valproate sodium inj 100 mg/ml .........60 valproate sodium syrup 250 mg/5ml (base equiv) .....................................60 valproic acid cap 250 mg ...................60 valsartan tab 160 mg ........................43 valsartan tab 320 mg ........................43 valsartan tab 40 mg ..........................43 valsartan tab 80 mg ..........................43 valsartan-hydrochlorothiazide tab
160-12.5 mg ................................... 42 valsartan-hydrochlorothiazide tab 160-25 mg ................................................. 42 valsartan-hydrochlorothiazide tab 320-12.5 mg ................................... 42 valsartan-hydrochlorothiazide tab 320-25 mg ................................................. 42 valsartan-hydrochlorothiazide tab 80-12.5 mg ..................................... 42 vancomycin hcl cap 125 mg............... 17 vancomycin hcl cap 250 mg............... 17 vancomycin hcl for inj 10 gm ............. 17 vancomycin hcl for inj 1000 mg ......... 17 vancomycin hcl for inj 500 mg ........... 17 vancomycin hcl for inj 5000 mg ......... 17 vandazole gel 0.75% ...................... 108 VAQTA INJ 25/0.5ML ...................... 116 VAQTA INJ 50UNT/ML ..................... 116 VARIVAX INJ ................................. 116 VARUBI TAB 90MG ......................... 104 VASCEPA CAP 1GM ........................... 46 VCF VAGINAL AER CONTRACP.......... 107 VCF VAGINAL MIS CONTRACP .......... 107 velivet pak ...................................... 89 VELPHORO CHW 500MG .................... 99 VENCLEXTA TAB 100MG .................... 38 VENCLEXTA TAB 10MG...................... 38 VENCLEXTA TAB 50MG...................... 38 VENCLEXTA TAB START PK ................ 38 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) ...................................... 66 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) ...................................... 66 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) ...................................... 66 venlafaxine hcl tab 100 mg ............... 66 venlafaxine hcl tab 25 mg ................. 66 venlafaxine hcl tab 37.5 mg .............. 66 venlafaxine hcl tab 50 mg ................. 66 venlafaxine hcl tab 75 mg ................. 66 venlafaxine hcl tab sr 24hr 150 mg (base equivalent) ...................................... 67 venlafaxine hcl tab sr 24hr 225 mg (base equivalent) ...................................... 67 venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) ...................................... 66 venlafaxine hcl tab sr 24hr 75 mg (base 193
January 1, 2017
equivalent) ......................................66 VENTAVIS SOL 10MCG/ML .................55 VENTAVIS SOL 20MCG/ML .................55 verapamil hcl cap sr 24hr 100 mg .......50 verapamil hcl cap sr 24hr 120 mg .......50 verapamil hcl cap sr 24hr 180 mg .......50 verapamil hcl cap sr 24hr 200 mg .......51 verapamil hcl cap sr 24hr 240 mg .......51 verapamil hcl cap sr 24hr 300 mg .......51 verapamil hcl cap sr 24hr 360 mg .......51 verapamil hcl iv soln 2.5 mg/ml ..........51 verapamil hcl tab 120 mg ..................51 verapamil hcl tab 40 mg ....................51 verapamil hcl tab 80 mg ....................51 verapamil hcl tab cr 120 mg ...............51 verapamil hcl tab cr 180 mg ...............51 verapamil hcl tab cr 240 mg ...............51 VERDESO AER 0.05% ...................... 138 VEREGEN OIN 15% ......................... 138 VERIPRED 20 SOL 20MG/5ML .............97 VESICARE TAB 10MG ...................... 108 VESICARE TAB 5MG ........................ 108 vestura tab 3-0.02mg........................89 VEXOL SUS 1% OP.......................... 123 VIBATIV INJ 250MG ..........................14 VIBATIV INJ 750MG ..........................14 VIBRAMYCIN SYP 50MG/5ML ..............30 vicodin es tab 7.5-300 .......................12 vicodin hp tab 10-300mg ...................12 vicodin tab 5-300mg .........................12 VICTOZA INJ 18MG/3ML ....................82 VIDEX SOL 2GM ...............................20 VIDEX SOL 4GM ...............................20 VIGAMOX DRO 0.5% ....................... 123 VIIBRYD KIT ....................................67 VIIBRYD KIT STARTER .......................67 VIIBRYD TAB 10MG ...........................67 VIIBRYD TAB 20MG ...........................67 VIIBRYD TAB 40MG ...........................67 VIMPAT INJ 200MG/20 ......................60 VIMPAT SOL 10MG/ML .......................60 VIMPAT TAB 100MG ..........................60 VIMPAT TAB 150MG ..........................60 VIMPAT TAB 200MG ..........................60 VIMPAT TAB 50MG ............................60 VINBLASTINE INJ 10MG .....................33 vinblastine sulfate inj 1 mg/ml ...........33
vincasar pfs inj 1mg/ml .................... 33 vincristine sulfate iv soln 1 mg/ml ...... 33 vinorelbine tartrate inj 10 mg/ml (base equiv) ............................................. 33 vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv)......................... 33 VIOKACE TAB ................................ 106 VIOKACE TAB 20880 ...................... 106 viorele tab ....................................... 89 VIRACEPT TAB 250MG ...................... 20 VIRACEPT TAB 625MG ...................... 20 VIRAZOLE INH 6GM .......................... 22 VIREAD POW 40MG/GM .................... 20 VIREAD TAB 150MG ......................... 20 VIREAD TAB 200MG ......................... 20 VIREAD TAB 250MG ......................... 20 VIREAD TAB 300MG ......................... 20 VISTOGARD PAK 10GM ..................... 86 vit a/c/d/fl dro 0.25mg ................... 122 VITAMIN D2 TAB 400UNIT ............... 122 VITAMIN D3 LIQ 1000UNIT ............. 122 VITAMIN D3 LIQ 1200UNIT ............. 122 VITEKTA TAB 150MG ........................ 20 VITEKTA TAB 85MG .......................... 20 VIVITROL INJ 380MG ........................ 80 voriconazole for susp 40 mg/ml ......... 18 voriconazole tab 200 mg ................... 18 voriconazole tab 50 mg ..................... 18 VOTRIENT TAB 200MG ...................... 36 VPRIV INJ 400UNIT .......................... 90 VYTORIN TAB 10-10MG..................... 45 VYTORIN TAB 10-20MG..................... 45 VYTORIN TAB 10-40MG..................... 45 VYTORIN TAB 10-80MG..................... 45 VYVANSE CAP 10MG ......................... 74 VYVANSE CAP 20MG ......................... 74 VYVANSE CAP 30MG ......................... 74 VYVANSE CAP 40MG ......................... 74 VYVANSE CAP 50MG ......................... 74 VYVANSE CAP 60MG ......................... 74 VYVANSE CAP 70MG ......................... 74 W warfarin sodium tab 1 mg ............... 110 warfarin sodium tab 10 mg .............. 110 warfarin sodium tab 2 mg ............... 110 warfarin sodium tab 2.5 mg ............. 110 warfarin sodium tab 3 mg ............... 110 194
January 1, 2017
warfarin sodium tab 4 mg ................ 110 warfarin sodium tab 5 mg ................ 110 warfarin sodium tab 6 mg ................ 110 warfarin sodium tab 7.5 mg ............. 110 WELCHOL PAK 3.75GM ......................44 WELCHOL TAB 625MG .......................44 wera tab 0.5/35 ................................89 WIDE-SEAL DPR KIT 60 ................... 117 WIDE-SEAL DPR KIT 65 ................... 117 WIDE-SEAL DPR KIT 70 ................... 117 WIDE-SEAL DPR KIT 75 ................... 117 WIDE-SEAL DPR KIT 80 ................... 117 WIDE-SEAL DPR KIT 85 ................... 117 WIDE-SEAL DPR KIT 90 ................... 117 WIDE-SEAL DPR KIT 95 ................... 117 X XALKORI CAP 200MG ........................36 XALKORI CAP 250MG ........................36 XARELTO STAR TAB 15/20MG........... 110 XARELTO TAB 10MG ........................ 110 XARELTO TAB 15MG ........................ 110 XARELTO TAB 20MG ........................ 110 XARTEMIS XR TAB 7.5-325 ................12 XELJANZ TAB 5MG .......................... 112 XEOMIN INJ 100UNIT ........................79 XEOMIN INJ 200UNIT ........................79 XEOMIN INJ 50 UNIT .........................79 XGEVA INJ .......................................99 XIFAXAN TAB 200MG ........................17 XIFAXAN TAB 550MG ........................17 XIGDUO XR TAB 10-1000 ..................84 XIGDUO XR TAB 10-500MG ................84 XIGDUO XR TAB 5-1000MG ................84 XIGDUO XR TAB 5-500MG .................84 XOLEGEL GEL 2% ........................... 135 XOPENEX HFA AER .......................... 128 xulane dis 150-35 .............................89 xylon tab 10-200mg ..........................12 XYREM SOL 500MG/ML ......................79 Y YERVOY INJ 200MG ...........................34 YERVOY INJ 50MG ............................34 Z zafirlukast tab 10 mg ...................... 129 zafirlukast tab 20 mg ...................... 129 zaleplon cap 10 mg ...........................75 zaleplon cap 5 mg .............................75
ZALTRAP INJ 100/4ML ...................... 34 ZALTRAP INJ 200/8ML ...................... 34 ZANOSAR INJ 1GM ........................... 31 ZANTAC INJ 50/50ML ..................... 104 ZANTAC TAB 25MG EF .................... 104 zarah tab 3-0.03mg.......................... 89 ZARXIO INJ 300/0.5 ....................... 111 ZARXIO INJ 480/0.8 ....................... 111 ZAVESCA CAP 100MG ....................... 90 zazole cre 0.4% ............................. 108 zazole cre 0.8% ............................. 108 zazole sup 80mg ............................ 109 ZELAPAR TAB 1.25MG ....................... 69 ZELBORAF TAB 240MG...................... 36 ZEMAIRA INJ 1000MG ..................... 130 zenchent fe chw 0.4mg-35 ................ 89 zenchent tab ................................... 89 ZENPEP CAP 10000UNT................... 106 ZENPEP CAP 15000UNT................... 106 ZENPEP CAP 20000UNT................... 106 ZENPEP CAP 25000UNT................... 106 ZENPEP CAP 3000UNIT ................... 106 ZENPEP CAP 40000UNT................... 106 ZENPEP CAP 5000UNIT ................... 106 zenzedi tab 15mg ............................. 74 zenzedi tab 2.5mg ............................ 74 zenzedi tab 20mg ............................. 74 zenzedi tab 30mg ............................. 74 zenzedi tab 7.5mg ............................ 74 ZETIA TAB 10MG.............................. 44 ZIAGEN SOL 20MG/ML ...................... 20 ZIANA GEL .................................... 133 zidovudine cap 100 mg ..................... 20 zidovudine syrup 10 mg/ml ............... 20 zidovudine tab 300 mg ..................... 20 ZINACEF INJ 750MG ......................... 25 ZINACEF/H20 INJ 1.5GM PB .............. 25 ZIOPTAN DRO 0.0015% .................. 125 ziprasidone hcl cap 20 mg ................. 72 ziprasidone hcl cap 40 mg ................. 72 ziprasidone hcl cap 60 mg ................. 72 ziprasidone hcl cap 80 mg ................. 72 ZIRGAN GEL 0.15% ........................ 123 ZMAX SUS 2GM ............................... 26 zoledronic acid inj conc for iv infusion 4 mg/5ml ........................................... 85 zoledronic acid iv soln 5 mg/100ml ..... 85 195
January 1, 2017
ZOLEDRONIC INJ 4MG/100 ................85 ZOLINZA CAP 100MG ........................34 zolmitriptan orally disintegrating tab 2.5 mg ..................................................76 zolmitriptan orally disintegrating tab 5 mg ......................................................76 zolmitriptan tab 2.5 mg .....................76 zolmitriptan tab 5 mg ........................76 zolpidem tartrate tab 10 mg ...............75 zolpidem tartrate tab 5 mg ................75 zolpidem tartrate tab cr 12.5 mg ........75 zolpidem tartrate tab cr 6.25 mg ........75 ZOMETA INJ 4MG/100 .......................85 ZOMIG NASAL SPR 5MG ....................76 ZOMIG SPR 2.5MG ............................76 zonisamide cap 100 mg .....................60 zonisamide cap 25 mg .......................60 zonisamide cap 50 mg .......................60 ZONTIVITY TAB 2.08MG .................. 112
ZORBTIVE INJ 8.8MG........................ 98 ZORTRESS TAB 0.25MG .................. 114 ZORTRESS TAB 0.5MG .................... 114 ZORTRESS TAB 0.75MG .................. 114 ZOSTAVAX INJ ............................... 116 ZOSYN SOL 2-0.25GM ...................... 29 ZOSYN SOL 3-0.375G ....................... 29 ZOSYN SOL 4-0.50GM ...................... 29 zovia 1/35e tab ................................ 89 zovia 1/50e tab ................................ 89 ZUPLENZ MIS 4MG ......................... 104 ZUPLENZ MIS 8MG ......................... 104 ZYCLARA CRE 3.75% ...................... 133 ZYCLARA PUMP CRE 2.5% ............... 133 ZYDELIG TAB 100MG ........................ 36 ZYDELIG TAB 150MG ........................ 36 ZYFLO CR TAB 600MG .................... 129 ZYKADIA CAP 150MG ........................ 36 ZYTIGA TAB 250MG .......................... 35
196
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