THE FORMULARY Capital BlueCross (Capital) has created the Formulary to give members access to quality, affordable medications and to provide physicians with a reference list of preferred medications for cost-effective prescribing. The Formulary represents the cornerstone of drug therapy quality assurance and cost containment efforts. The Capital Formulary was developed and is maintained by the Capital BlueCross Pharmacy and Therapeutics (P&T) Committee. This committee, composed of practicing physicians from various medical specialties, practicing pharmacists, and other health care providers, reviews medications in all therapeutic categories based on safety and effectiveness and designates the most effective agent(s) in each class. Formulary development and maintenance is a dynamic process. The P&T Committee will regularly review new and existing medications to ensure the Formulary remains responsive to the needs of our members and providers. A provider may request a reconsideration of tier status for a medication on the Capital Formulary by completing a Formulary Status Reconsiderations Form or by writing a letter indicating the significant advantages of the specific drug product and mailing it to the address below: Pharmacy Services Capital BlueCross P&T Committee P.O. Box 773735 Harrisburg, PA 17177-3735 The P&T Committee will review drug-specific requests and communicate the results of the review to the requesting provider. Patient-specific requests need to follow the Professional Provider dispute and appeal process.
HOW TO USE THE FORMULARY The Formulary lists the most commonly prescribed medications by therapeutic class. Medications listed in bold lower case print are generic medications, and medications listed in all UPPER CASE PRINT are brand-name medications. For each drug listed, it is indicated whether that drug falls in the Generic category, Brand Preferred category or Brand Non-Preferred category. These categories are defined as follows:
Generic Preferred (GP) and Generic Non-Preferred (GNP)*: Drugs that contain the same active ingredient(s) as their corresponding brand-name drug and have been approved by the U.S. Food and Drug Administration (FDA) for therapeutic equivalency to their brand-name product. (Not all strengths and formulations of generic drugs have the same tier status.)
Brand Preferred (BP): Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found to have therapeutic advantage or overall value over non-preferred brands, factoring safety, efficacy, and cost.
Brand Non-Preferred (BNP): Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found not to have significant therapeutic advantage or overall value over alternative generics, preferred brands or over-the-counter medications.
*Please note that all plans do not include separate cost shares for generic preferred and generic nonpreferred drugs. For plans that do not include separate cost shares, the generic cost share will be applied to both generic preferred and generic non-preferred drugs. Please also note that for specialty medications, the specialty generic cost share will apply to both generic preferred and generic non-preferred specialty medications when applicable. To help maximize the pharmacy benefit, preferred formulary alternatives, where applicable, are provided. Please note that the information provided is not intended to substitute for the physician's independent medical judgment based on the member's specific needs. The information contained in this document is current at the time of printing, is not all encompassing and is subject to change. The following Selectively Closed Formulary provides access to generic preferred, generic non-preferred, brand preferred and select brand non-preferred drugs. Under a selectively closed formulary, only select brand
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non-preferred drugs (non-formulary drugs) are covered unless approved via a Non-Formulary Consideration Process. The provider or member may initiate a request that coverage be granted when medically necessary. The Non-Formulary Consideration Process may require the trial and failure of two (2) formulary alternatives (if two are available) prior to approval of the non-formulary medication. Approvals will be member- and drugspecific. Each unique non-formulary drug exception must be reviewed and approved separately. As determined by the member’s benefit plan, the member may share more of the cost for brand-name drugs, especially those designated as non-preferred brands. Despite being listed in the formulary, please note that some drugs are excluded by benefit design and therefore are not covered (see Benefit Exclusions/Limitations below). Newly-released brand-name drugs are not covered until the P&T Committee reviews the medication’s safety and efficacy profile. Brand-name drugs that have an available generic equivalent, deemed suitable for substitution by the P&T Committee, are placed in the non-preferred brand category. The Formulary applies only to prescription medications dispensed in outpatient pharmacies. The Formulary does not apply to inpatient medications or to medications obtained from and/or administered by a physician or a home health agency. While Capital BlueCross strives to provide prompt notice of changes and updates, the Formulary, as well as the pharmacy clinical programs (such as prior authorization, quantity level limits, etc.), are subject to change. Please visit our website at www.capbluecross.com for current information. If preferred, contact our pharmacy benefit manager via phone at the number listed below. CVS/caremark™ 1-800-585-5794 (for provider and member inquires) On behalf of Capital BlueCross, CVS/caremark assists in the administration of our prescription drug program. CVS/caremark is an independent pharmacy benefit manager.
GENERIC DRUG SUBSTITUTION Generic drug substitution is encouraged if the FDA has determined the generic drug is bioequivalent to the brand-name product. The member's financial responsibility for a brand-name medication when a generic equivalent is available will vary as indicated below.
For members with mandatory generic substitution, if the physician indicates "Dispense As Written" (DAW) or a member requests a brand-name product when a generic is available, the member is responsible for the cost difference between the brand-name medication and its generic cost (ancillary charge) in addition to the member's applicable brand copayment/coinsurance, up to the original cost of the brand-name medication.
For members with restricted generic substitution, if a member requests a brand-name product when a generic is available, the member is responsible for the cost difference between the brand-name medication and its generic cost (ancillary charge) in addition to the member's applicable brand copayment/coinsurance, up to the original cost of the brand-name medication. If the physician indicates DAW, then the member pays the applicable copayment/coinsurance for the brand product and is not required to pay the ancillary charge.
Capital encourages generic substitution, when possible and appropriate, to help reduce the member's out-ofpocket expense, plus help contain the overall cost of the prescription drug benefit.
NON-PRESCRIPTION MEDICATION (OTC) POLICY* Select Over-The-Counter (OTC) products may be covered as determined by Capital BlueCross or if mandated by the Patient Protection and Affordable Care Act (PPACA). If a prescription drug has an available OTC equivalent, the prescription drug will not be covered. Physicians and pharmacists should guide and refer members to the OTC equivalent product, when appropriate. *As mandated by PPACA, select Over-The-Counter medications may be covered at $0 cost share for members
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with individual coverage or members of a non-grandfathered group health plan. Please consult your employer for questions relating to grandfathered status.
COMPOUND DRUG POLICY Prescribed compound drug products are considered Brand Non-Preferred (BNP) and require prior authorization.
BENEFIT EXCLUSIONS / LIMITATIONS* Depending on the member's pharmacy benefit plan, some medications listed may not be covered for individual members based on benefit design purchased by the member. Examples of contractual exclusions include, but are not limited to:
Appetite suppressants (weight loss) Infertility medications Drugs used for cosmetic purposes (wrinkles, hair loss, etc.) Erectile dysfunction medications Smoking cessation products Contraceptives Non self-administered injectable drugs Allergy serums Experimental and investigational (including off-label use) use Some types of vitamins (non-prenatal) Products with OTC equivalents
*As mandated by PPACA, select medications in these drug classes may be covered at $0 cost share for members with individual coverage or members of a non-grandfathered group health plan. Please consult your employer for questions relating to grandfathered status.
PRIOR AUTHORIZATION PROGRAM Pharmacy benefit plans include the prior authorization program. Prior authorization helps encourage appropriate and cost-effective use of certain drugs by allowing coverage only after clinical criteria are met. All clinical criteria are regularly reviewed and approved by the P&T Committee. Drugs requiring prior authorization are subject to change. Please always visit our website (www.capbluecross.com) for the most up-to-date information on drugs requiring prior authorization. Drugs requiring prior authorization are designated in the Formulary by “PAR” (Prior Authorization Required) after the drug name. These drugs require prior authorization before members can obtain them as a covered benefit. For some drugs, part of the criteria may be automated (Enhanced Prior Authorization or EPA) to encourage first-line agents before second-line agents are utilized. If automated criteria are not met, then prior authorization is required by the physician (or representative) or pharmacist by calling / faxing the request with supporting clinical information to the pharmacy benefit manager at: CVS/caremark Prior Authorization Department Telephone: 1-800-294-5979 Fax: 1-888-836-0730
QUANTITY LIMITATIONS Some drug products may be subject to quantity limitations based on FDA-recommended doses or adopted clinical guidelines. These drugs are designated in the Formulary by “QLL” (Quantity Level Limits) after the drug name. The purpose of these maximum quantity limits is to ensure the proper billing of products and encourage the use of therapeutically indicated drug regimens. Quantity limitations are subject to change. Please check your provider manual or the on-line formulary at our website (www.capbluecross.com) for the most up-to-date information on drugs that are part of this program. If a quantity of medication exceeding the limit is required, the physician (or representative) or pharmacist should call / fax the request with supporting clinical information to the pharmacy benefit manager at:
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CVS/caremark Prior Authorization Department Telephone: 1-800-294-5979 Fax: 1-888-836-0730
MAINTENANCE DRUGS Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or longterm. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease and diabetes.
INJECTABLE MEDICATION POLICY Self-administered pharmacy injectable medications are usually covered under the Capital BlueCross prescription drug benefit. Injectable medications that are not routinely self-administered are not covered under the prescription drug benefit, but may be covered under the member’s medical benefit. Procurement of select medical injectable medications may be available from ACRO Pharmaceuticals (by calling 1-800-906-7798 or faxing 1-877-381-3806), Capital BlueCross’ specialty medical injectable provider, which will assist with distribution and billing of these medications. On behalf of Capital BlueCross, ACRO Pharmaceutical Services LLC assists in the administration of physicianadministered specialty medications. ACRO Pharmaceutical Services is an independent company.
SPECIALTY MEDICATION PROVIDER: OUTPATIENT PRESCRIPTION DRUG BENEFIT Specialty oral medications and self-administered injectable medications are available through Accredo® under the Capital BlueCross outpatient prescription drug benefit. Members or providers can call 1-877-595-3707 or fax 1-888-773-7386 to receive more information on starting service. The following medications are available through Accredo. (This list is current as of the printing of this formulary but is subject to change.) On behalf of Capital BlueCross, Accredo Health Group, Inc. assists in the delivery of specialty medications directly to our Members. Accredo Health Group, Inc. is an independent company.
SPECIALTY DRUGS ACTIMMUNE ACTEMRA PAR ADCIRCA PAR ADEMPAS PAR ADVATE AFINITOR ALECENZA PAR ALPHANATE ALPHANINE SD AMPYRA PAR, QLL APOKYN ARANESP PAR ARCALYST AUBAGIO PAR AVONEX BEBULIN BEBULIN VH BENEFIX BERINERT BETASERON CAPECITABINE CAPRELSA
CARBAGLU CERDELGA PAR CHOLBAM PAR CHORIONIC GONADOTROPIN CIMZIA PAR COMETRIQ PAR COPAXONE COTELLIC PAR CYSTADANE CYSTAGON PAR CYSTARAN DOFETILIDE EGRIFTA PAR ELIGARD ENBREL PAR ERIVEDGE PAR ESBRIET PAR EXJADE PAR EXTAVIA EPA FEIBA NF FEIBA VH FERRIPROX PAR FIRAZYR
FIRMAGON FORTEO PAR FUZEON GILENYA PAR GILOTRIF PAR GLATOPA GLEEVEC HARVONI PAR HELIXATE FS HEMOFIL M HIZENTRA HUMATE-P HUMIRA PAR HYCAMTIN IBRANCE PAR ICLUSIG PAR IMATINIB IMBRUVICA PAR INCRELEX PAR INLYTA PAR INTRON A JAKAFI PAR JUXTAPID PAR
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KALYDECO PAR KINERET PAR KOATE-DVI KOGENATE FS KORLYM PAR KUVAN LENVIMA PAR LETAIRIS PAR LEUKINE LEUPROLIDE ACETATE LONSURF PAR LUPRON DEPOT LYNPARZA PAR MATULANE MEKINIST PAR MONOCLATE-P MONONINE MOZOBIL PAR MYALEPT PAR NEULASTA NEUPOGEN NEXAVAR NINLARO PAR NORDITROPIN PAR NOVAREL NOVOSEVEN RT OCTREOTIDE ODOMZO PAR OFEV PAR ORENCIA 125 mg/mL PAR ORFADIN ORKAMBI PAR
PEGASYS PEGINTRON EPA PEGINTRON REDIPEN EPA PRALUENT PAR PREGNYL PROCRIT PAR PROFILNINE SD PROMACTA PULMOZYME REBETOL solution RECOMBINATE REPATHA PAR REVATIO SUSP PAR REVLIMID RIBASPHERE RIBAVIRIN SABRIL SAMSCA SANDOSTATIN LAR SENSIPAR SEROSTIM PAR SIGNIFOR PAR SILDENAFIL PAR SIMPONI PAR SOMATULINE PAR SOMAVERT SOVALDI PAR SPRYCEL STIVARGA PAR STRENSIQ PAR SUTENT SYNAREL
TAFINLAR PAR TAGRISSO PAR TARCEVA PAR TARGRETIN TASIGNA TECFIDERA TEMOZOLOMIDE TETRABENAZINE PAR THALOMID TIKOSYN TOBRAMYCIN INHALATION SOLN TRACLEER PAR TYKERB VALCHLOR VENCLEXTA PAR VENTAVIS PAR VICTRELIS PAR VOTRIENT WILATE XALKORI XELJANZ PAR XENAZINE PAR XTANDI PAR XURIDEN PAR ZELBORAF ZOLINZA ZYDELIG PAR ZYKADIA PAR ZYTIGA PAR
LEGEND AL BNP
Age Limitations apply. Brand Non-Preferred: Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found not to have significant therapeutic advantage or overall value over alternative generics, preferred brands or over-thecounter medications.
BP
Brand Preferred: Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found to have therapeutic advantage or overall value over non-preferred brands, factoring safety, efficacy, and cost.
EPA
Enhanced Prior Authorization applies.
GP and GNP
Generic Preferred and Generic Non-Preferred: Drugs that contain the same active ingredient(s) as their corresponding brand-name drug and have been approved by the Food and Drug Administration (FDA) for therapeutic equivalency to their brand-name product.
M
Maintenance Drugs: An M located after the drug class name indicates the drugs in the class are generally considered maintenance drugs.
OTC
Over-The-Counter medication.
PAR
Prior Authorization Required.
PHC
Preventive Health Care: Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and are mandated by the Patient Protection and
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Affordable Care Act (PPACA) to have $0 cost share for members with individual coverage or members of a group health plan that is not "grandfathered" under PPACA. Please consult your employer for questions relating to grandfathered status. QLL
Quantity Level Limits apply.
SRx
Specialty Drug available from Accredo.
Lower case italicized letters
Generic; every strength or dosage form under the listed generic name may not apply.
UPPER CASE letters
Indicates brand medication; every strength or dosage form under the listed name may not apply.
NOTICE The information provided is intended to establish a guideline to help promote Formulary compliance, but it is in no way to be considered all encompassing. The Formulary is also in no way meant to interfere with the physician's independent medical judgment based on specific needs of the patient. The information contained herein is current at the time of printing and may be subject to change. Members should refer to their Certificate of Coverage for specific terms, conditions, exclusions and limitations relating to coverage. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2015. All rights reserved. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Capital BlueCross and CVS/caremark do not operate the websites/organizations listed below, nor are they responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by Capital BlueCross or CVS/caremark
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Effective 10/1/2016 Drug Name
Drug Tier Requirements/Limits
NATURAL PENICILLINS penicillin penicillin penicillin penicillin
v v v v
potassium potassium potassium potassium
tab 250 mg GP tab 500 mg GP for soln 125 mg/5ml GP for soln 250 mg/5ml GP
AMINOPENICILLINS amoxicillin (trihydrate) cap 250 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg amoxicillin (trihydrate) chew tab 125 mg amoxicillin (trihydrate) chew tab 250 mg amoxicillin (trihydrate) for susp 125 mg/5ml amoxicillin (trihydrate) for susp 200 mg/5ml amoxicillin (trihydrate) for susp 250 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml ampicillin cap 250 mg ampicillin cap 500 mg ampicillin for susp 125 mg/5ml ampicillin for susp 250 mg/5ml
GP GP GP GP GP GP GP GP GP GP GP GNP GNP GNP
PENICILLINASERESISTANT PENICILLINS dicloxacillin sodium cap 250 mg dicloxacillin sodium cap 500 mg
GNP GNP
PENICILLIN COMBINATIONS amoxicillin & k amoxicillin & k amoxicillin & k amoxicillin & k 28.5 mg amoxicillin & k 57 mg amoxicillin & k 28.5 mg/5ml amoxicillin & k 62.5 mg/5ml amoxicillin & k mg/5ml
clavulanate clavulanate clavulanate clavulanate
tab 250-125 mg GNP tab 500-125 mg GNP tab 875-125 mg GNP chew tab 200- GNP
clavulanate chew tab 400-
GNP
clavulanate for susp 200-
GNP
clavulanate for susp 250-
GNP
clavulanate for susp 400-57 GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
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Drug Name amoxicillin & k clavulanate for susp 60042.9 mg/5ml amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
Drug Tier Requirements/Limits GNP GNP
CEPHALOSPORINS 1ST GENERATION cefadroxil cap 500 mg cefadroxil tab 1 gm cefadroxil for susp 250 mg/5ml cefadroxil for susp 500 mg/5ml cephalexin cap 250 mg cephalexin cap 500 mg cephalexin cap 750 mg cephalexin tab 250 mg cephalexin tab 500 mg cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml
GNP GNP GNP GNP GP GP GNP GNP GNP GNP GNP
CEPHALOSPORINS 2ND GENERATION cefaclor cap 250 mg cefaclor cap 500 mg cefaclor for susp 125 mg/5ml cefaclor for susp 250 mg/5ml cefaclor for susp 375 mg/5ml CEFACLOR ER TAB 500MG cefprozil tab 250 mg cefprozil tab 500 mg cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml cefuroxime axetil tab 250 mg cefuroxime axetil tab 500 mg CEFTIN SUS 125/5ML
GNP GNP GNP GNP GNP BP GNP GNP GNP GNP GNP GNP BP
CEPHALOSPORINS 3RD GENERATION 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) SUPRAX CAP 400MG SUPRAX CHW 100MG SUPRAX CHW 200MG cefixime for susp 100 mg/5ml cefixime for susp 200 mg/5ml SUPRAX SUS 500/5ML
GNP GNP GNP GNP GNP BNP BNP BNP GNP GNP BNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
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Drug Name cefpodoxime proxetil tab 100 mg cefpodoxime proxetil tab 200 mg cefpodoxime proxetil for susp 50 mg/5ml cefpodoxime proxetil for susp 100 mg/5ml ceftibuten cap 400 mg CEDAX SUS 90MG/5ML ceftibuten for susp 180 mg/5ml
Drug Tier Requirements/Limits GNP GNP GNP GNP GNP BNP GNP
ERYTHROMYCINS erythromycin tab 250 mg GNP erythromycin tab 500 mg GNP ery-tab tab 250mg ec GNP ery-tab tab 333mg ec GNP ery-tab tab 500mg ec GNP erythromycin w/ delayed release particles GNP cap 250 mg erythrocin tab 250mg GNP e.e.s. 400 tab 400mg GNP
AZITHROMYCIN azithromycin azithromycin azithromycin azithromycin azithromycin azithromycin
tab 250 mg tab 500 mg tab 600 mg for susp 100 mg/5ml for susp 200 mg/5ml powd pack for susp 1 gm
GNP GNP GNP GNP GNP GNP
CLARITHROMYCIN clarithromycin clarithromycin clarithromycin clarithromycin clarithromycin
tab 250 mg tab 500 mg for susp 125 mg/5ml for susp 250 mg/5ml tab sr 24hr 500 mg
GNP GNP GNP GNP GNP
FIDAXOMICIN DIFICID TAB 200MG
BNP
TETRACYCLINES demeclocycline hcl tab 150 mg demeclocycline hcl tab 300 mg doxycycline monohydrate cap 50 mg doxycycline monohydrate cap 75 mg doxycycline monohydrate cap 100 mg doxycycline monohydrate cap 150 mg doxycycline monohydrate tab 50 mg doxycycline monohydrate tab 75 mg doxycycline monohydrate tab 100 mg doxycycline monohydrate tab 150 mg
GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
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Drug Name Drug Tier Requirements/Limits doxycycline monohydrate for susp 25 GNP mg/5ml doxycycline hyclate cap 50 mg GNP doxycycline hyclate cap 100 mg GNP doxycycline hyclate tab 20 mg GNP doxycycline hyclate tab 100 mg GNP doxycycline hyclate tab delayed release 75 GNP mg doxycycline hyclate tab delayed release GNP 100 mg doxycycline hyclate tab delayed release GNP 150 mg minocycline hcl cap 50 mg GNP minocycline hcl cap 75 mg GNP minocycline hcl cap 100 mg GNP minocycline hcl tab 50 mg GNP minocycline hcl tab 75 mg GNP minocycline hcl tab 100 mg GNP minocycline hcl tab sr 24hr 45 mg GNP minocycline hcl tab sr 24hr 90 mg GNP minocycline hcl tab sr 24hr 135 mg GNP tetracycline hcl cap 250 mg GNP tetracycline hcl cap 500 mg GNP
FLUOROQUINOLONES ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) ciprofloxacin hcl tab 100 mg (base equiv) ciprofloxacin hcl tab 250 mg (base equiv) ciprofloxacin hcl tab 500 mg (base equiv) ciprofloxacin hcl tab 750 mg (base equiv) levofloxacin tab 250 mg levofloxacin tab 500 mg levofloxacin tab 750 mg levofloxacin oral soln 25 mg/ml moxifloxacin hcl tab 400 mg (base equiv) ofloxacin tab 400 mg FACTIVE TAB 320MG
GNP GNP GNP GNP GP GP GNP GNP GNP GNP GNP GNP BNP
AMINOGLYCOSIDES neomycin sulfate tab 500 mg paromomycin sulfate cap 250 mg tobramycin nebu soln 300 mg/5ml
GP GNP GP
SRx
SULFONAMIDES PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
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Drug Name SULFADIAZINE TAB 500MG
Drug Tier Requirements/Limits BP
ANTIMYCOBACTERIAL AGENTS PASER GRA 4GM cycloserine cap 250 mg ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg TRECATOR TAB 250MG isoniazid tab 100 mg isoniazid tab 300 mg isoniazid syrup 50 mg/5ml pyrazinamide tab 500 mg rifabutin cap 150 mg rifampin cap 150 mg rifampin cap 300 mg PRIFTIN TAB 150MG
BP GNP GNP GNP BP GNP GP GNP GNP GNP GNP GNP BP
ANTI TB COMBINATIONS RIFAMATE CAP RIFATER TAB
BP BP
ANTIFUNGALS flucytosine cap 250 mg flucytosine cap 500 mg griseofulvin microsize tab 500 mg griseofulvin microsize susp 125 mg/5ml griseofulvin ultramicrosize tab 125 mg griseofulvin ultramicrosize tab 250 mg nystatin tab 500000 unit bio-statin pow terbinafine hcl tab 250 mg LAMISIL GRA 125MG LAMISIL GRA 187.5MG
GNP GNP GNP GNP GNP GNP GNP GNP GNP BNP BNP
IMIDAZOLERELATED ANTIFUNGALS ketoconazole tab 200 mg fluconazole tab 50 mg fluconazole tab 100 mg fluconazole tab 150 mg fluconazole tab 200 mg fluconazole for susp 10 mg/ml fluconazole for susp 40 mg/ml itraconazole cap 100 mg NOXAFIL TAB 100MG NOXAFIL SUS 40MG/ML voriconazole tab 50 mg voriconazole tab 200 mg
GP GP GNP GNP GNP GNP GNP GNP BNP BNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
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Drug Name
Drug Tier Requirements/Limits
ANTIRETROVIRALS SELZENTRY TAB 150MG BP SELZENTRY TAB 300MG BP FUZEON INJ 90MG BP ISENTRESS TAB 400MG BP ISENTRESS CHW 25MG BP ISENTRESS CHW 100MG BP ISENTRESS POW 100MG BP REYATAZ CAP 150MG BP REYATAZ CAP 200MG BP REYATAZ CAP 300MG BP REYATAZ POW 50MG BP PREZISTA TAB 75MG BP PREZISTA TAB 150MG BP PREZISTA TAB 600MG BP PREZISTA TAB 800MG BP PREZISTA SUS 100MG/ML BP LEXIVA TAB 700MG BP LEXIVA SUS 50MG/ML BP CRIXIVAN CAP 200MG BP CRIXIVAN CAP 400MG BP VIRACEPT TAB 250MG BP VIRACEPT TAB 625MG BP NORVIR CAP 100MG BP NORVIR TAB 100MG BP NORVIR SOL 80MG/ML BP INVIRASE CAP 200MG BP INVIRASE TAB 500MG BP APTIVUS CAP 250MG BP APTIVUS SOL BP abacavir sulfate tab 300 mg (base equiv) GNP ZIAGEN SOL 20MG/ML BP VIDEX SOL 2GM BP VIDEX SOL 4GM BP didanosine delayed release capsule 125 mg GNP didanosine delayed release capsule 200 mg GNP didanosine delayed release capsule 250 mg GNP didanosine delayed release capsule 400 mg GNP EMTRIVA CAP 200MG BP EMTRIVA SOL 10MG/ML BP lamivudine tab 150 mg GNP lamivudine tab 300 mg GNP lamivudine oral soln 10 mg/ml GNP stavudine cap 15 mg GNP
SRx
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
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Drug Name Drug Tier Requirements/Limits stavudine cap 20 mg GNP stavudine cap 30 mg GNP stavudine cap 40 mg GNP stavudine for oral soln 1 mg/ml GNP zidovudine cap 100 mg GNP zidovudine tab 300 mg GNP zidovudine syrup 10 mg/ml GNP VIREAD TAB 150MG BP VIREAD TAB 200MG BP VIREAD TAB 250MG BP VIREAD TAB 300MG BP VIREAD POW 40MG/GM BP RESCRIPTOR TAB 100 MG BP RESCRIPTOR TAB 200MG BP SUSTIVA CAP 50MG BP SUSTIVA CAP 200MG BP SUSTIVA TAB 600MG BP INTELENCE TAB 25MG BP INTELENCE TAB 100MG BP INTELENCE TAB 200MG BP nevirapine tab 200 mg GNP nevirapine susp 50 mg/5ml GNP nevirapine tab sr 24hr 100 mg GNP VIRAMUNE XR TAB 100MG BP nevirapine tab sr 24hr 400 mg GNP EDURANT TAB 25MG BP EPZICOM TAB 600-300 BP TRUVADA TAB 100-150 BP TRUVADA TAB 133-200 BP TRUVADA TAB 167-250 BP TRUVADA TAB 200-300 BP lamivudine-zidovudine tab 150-300 mg GNP KALETRA TAB 100-25MG BP KALETRA TAB 200-50MG BP KALETRA SOL BP TRIUMEQ TAB BNP abacavir sulfate-lamivudine-zidovudine tab GNP 300-150-300 mg ATRIPLA TAB BP ODEFSEY TAB BP COMPLERA TAB BP STRIBILD TAB BP
CMV AGENTS PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
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Drug Name valganciclovir hcl tab 450 mg (base equivalent) VALCYTE SOL 50MG/ML
Drug Tier Requirements/Limits GNP BP
HEPATITIS AGENTS adefovir dipivoxil tab 10 mg entecavir tab 0.5 mg entecavir tab 1 mg BARACLUDE SOL .05MG/ML lamivudine tab 100 mg (hbv) TYZEKA TAB 600MG VICTRELIS CAP 200MG PEGASYS INJ 180MCG/M PEGASYS INJ PROCLICK PEGASYS INJ PEG-INTRON KIT 50MCG RP PEG-INTRON KIT 80MCG PEG-INTRON KIT 120MCG PEG-INTRON KIT 150 RP ribavirin cap 200 mg ribavirin tab 200 mg ribasphere tab 400mg ribasphere tab 600mg REBETOL SOL 40MG/ML SOVALDI TAB 400MG HARVONI TAB 90-400MG
GNP GNP GNP BNP GNP BNP BNP BP BP BP BNP BNP BNP BNP GP GP GP GP BP BP BP
PAR; SRx SRx SRx SRx SRx, EPA SRx, EPA SRx, EPA SRx, EPA SRx SRx SRx SRx SRx PAR; SRx PAR; SRx
HERPES AGENTS acyclovir cap 200 mg acyclovir tab 400 mg acyclovir tab 800 mg acyclovir susp 200 mg/5ml valacyclovir hcl tab 500 mg valacyclovir hcl tab 1 gm famciclovir tab 125 mg famciclovir tab 250 mg famciclovir tab 500 mg
GNP GNP GNP GNP GNP GNP GNP GNP GNP
INFLUENZA AGENTS rimantadine hydrochloride tab 100 mg TAMIFLU CAP 30MG
GNP BP
TAMIFLU CAP 45MG
BP
QLL (20 caps per Rx; max of 2 prescriptions per year) QLL (10 caps per Rx; max of 2 prescriptions per year)
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
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Drug Name TAMIFLU CAP 75MG TAMIFLU SUS 6MG/ML RELENZA MIS DISKHALE
Drug Tier Requirements/Limits BP QLL (10 caps per Rx; max of 2 prescriptions per year) BP QLL (240 ml's per Rx; max of 2 prescriptions per year) BNP QLL (1 kit per prescription); Limit of 2 prescriptions per year
ANTIMALARIALS chloroquine phosphate tab 250 mg chloroquine phosphate tab 500 mg hydroxychloroquine sulfate tab 200 mg mefloquine hcl tab 250 mg PRIMAQUINE TAB 26.3MG DARAPRIM TAB 25MG quinine sulfate cap 324 mg
GNP GNP GNP GNP BNP BP GNP
ANTIMALARIAL COMBINATIONS COARTEM TAB 20-120MG BNP atovaquone-proguanil hcl tab 62.5-25 mg GNP atovaquone-proguanil hcl tab 250-100 mg GNP
ANTHELMINTICS ALBENZA TAB 200MG ivermectin tab 3 mg BILTRICIDE TAB 600MG
BP GNP BP
ANTIINFECTIVE AGENTS MISC. CAYSTON INH 75MG metronidazole cap 375 mg metronidazole tab 250 mg metronidazole tab 500 mg NEBUPENT INH 300MG XIFAXAN TAB 200MG XIFAXAN TAB 550MG tinidazole tab 250 mg tinidazole tab 500 mg trimethoprim tab 100 mg vancomycin hcl cap 125 mg vancomycin hcl cap 250 mg
BNP GNP GP GP BP BNP BNP GNP GNP GP GNP GNP
KETOLIDES KETEK TAB 300MG KETEK TAB 400MG
BNP BNP
LINCOSAMIDES clindamycin hcl cap 75 mg
GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
16
Drug Name clindamycin hcl cap 150 mg clindamycin hcl cap 300 mg clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)
Drug Tier Requirements/Limits GNP GNP GNP
OXAZOLIDINONES linezolid tab 600 mg linezolid for susp 100 mg/5ml ZYVOX SUS 100MG/5M SIVEXTRO TAB 200MG
GNP GNP BNP BP
LEPROSTATICS dapsone tab 25 mg dapsone tab 100 mg
GNP GNP
ANTIPROTOZOAL AGENTS atovaquone susp 750 mg/5ml ALINIA TAB 500MG ALINIA SUS 100/5ML
GNP BP BP
ANTIINFECTIVE MISC. COMBINATIONS sulfamethoxazole-trimethoprim tab 400-80 GP mg sulfamethoxazole-trimethoprim tab 800- GNP 160 mg sulfamethoxazole-trimethoprim susp 200- GNP 40 mg/5ml
IMMUNE SERUMS HIZENTRA HIZENTRA HIZENTRA HIZENTRA
INJ INJ INJ INJ
1GM/5ML 2GM/10ML 4GM/20ML 10/50ML
BNP BNP BNP BNP
SRx SRx SRx SRx
BP BP BP BP BP BP GNP GNP GNP GP GP GP GP GP
SRx SRx SRx SRx SRx
ALKYLATING AGENTS HEXALEN CAP 50MG MYLERAN TAB 2MG LEUKERAN TAB 2MG CYCLOPHOSPH CAP 25MG CYCLOPHOSPH CAP 50MG ALKERAN TAB 2MG lomustine cap 10 mg lomustine cap 40 mg lomustine cap 100 mg temozolomide cap 5 mg temozolomide cap 20 mg temozolomide cap 100 mg temozolomide cap 140 mg temozolomide cap 180 mg
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
17
Drug Name temozolomide cap 250 mg
Drug Tier Requirements/Limits GP SRx
ANTIMETABOLITES capecitabine tab 150 mg GP capecitabine tab 500 mg GP mercaptopurine tab 50 mg GNP methotrexate sodium tab 2.5 mg (base GNP equiv) TREXALL TAB 5MG BP TREXALL TAB 7.5MG BP TREXALL TAB 10MG BP TREXALL TAB 15MG BP methotrexate sodium inj 50 mg/2ml (25 GP mg/ml) methotrexate sodium inj pf 50 mg/2ml (25 GNP mg/ml) methotrexate sodium inj pf 100 mg/4ml GNP (25 mg/ml) methotrexate sodium inj pf 200 mg/8ml GP (25 mg/ml) methotrexate sodium inj pf 200 mg/8ml GNP (25 mg/ml) methotrexate sodium inj pf 250 mg/10ml GNP (25 mg/ml) methotrexate sodium inj pf 1000 mg/40ml GNP (25 mg/ml) TABLOID TAB 40MG BP
SRx SRx
ANTINEOPLASTIC HEDGEHOG PATHWAY INHIBITORS ODOMZO CAP 200MG ERIVEDGE CAP 150MG
BP BP
PAR; SRx PAR; SRx
ANTINEOPLASTIC HORMONAL AND RELATED AGENTS LYSODREN TAB 500MG bicalutamide tab 50 mg XTANDI CAP 40MG flutamide cap 125 mg NILANDRON TAB 150MG nilutamide tab 150 mg
BP GNP BP GNP BP GNP
PAR; SRx
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
18
Drug Name tamoxifen citrate tab 10 mg (base equivalent)
tamoxifen citrate tab 20 mg (base equivalent)
SOLTAMOX SOL 10MG/5ML FARESTON TAB 60MG anastrozole tab 1 mg exemestane tab 25 mg letrozole tab 2.5 mg EMCYT CAP 140MG megestrol acetate tab 20 mg megestrol acetate tab 40 mg megestrol acetate susp 40 mg/ml LUPRON DEPOT INJ 3.75MG leuprolide acetate inj kit 5 mg/ml LUPRON DEPOT INJ 7.5MG ELIGARD INJ 7.5MG LUPRON DEPOT INJ 11.25MG LUPRON DEPOT INJ 22.5MG ELIGARD INJ 22.5MG LUPRON DEPOT INJ 30MG ELIGARD INJ 30MG ELIGARD INJ 45MG LUPRON DEPOT INJ 45MG FIRMAGON INJ 80MG FIRMAGON INJ 120MG ZYTIGA TAB 250MG
Drug Tier Requirements/Limits GNP PAR; PHC, PAR is needed for coverage under PHC. Limited to women age 35 years and older with no previous history of breast cancer, ductal carcinoma in situ (CIS) or lobular carcinoma in situ. GNP PAR; PHC, PAR is needed for coverage under PHC. Limited to women age 35 years and older with no previous history of breast cancer, ductal carcinoma in situ (CIS) or lobular carcinoma in situ. BP BP GNP GNP GNP BP GP GNP GNP BP SRx GP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BNP SRx BNP SRx BP PAR; SRx
ANTINEOPLASTIC - BCL-2 INHIBITORS VENCLEXTA TAB 10MG
BP
PAR; SRx
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
19
Drug Name VENCLEXTA TAB 50MG VENCLEXTA TAB 100MG VENCLEXTA TAB START PK
Drug Tier Requirements/Limits BP PAR; SRx BP PAR; SRx BP PAR; SRx
MITOTIC INHIBITORS etoposide cap 50 mg
GNP
ANTINEOPLASTIC ENZYME INHIBITORS IBRANCE CAP 75MG IBRANCE CAP 100MG IBRANCE CAP 125MG ZOLINZA CAP 100MG TAFINLAR CAP 50MG TAFINLAR CAP 75MG ZELBORAF TAB 240MG AFINITOR TAB 2.5MG AFINITOR TAB 5MG AFINITOR TAB 7.5MG AFINITOR TAB 10MG AFINITOR DIS TAB 2MG AFINITOR DIS TAB 3MG AFINITOR DIS TAB 5MG STIVARGA TAB 40MG NEXAVAR TAB 200MG SUTENT CAP 12.5MG SUTENT CAP 25MG SUTENT CAP 37.5MG SUTENT CAP 50MG COTELLIC TAB 20MG MEKINIST TAB 0.5MG MEKINIST TAB 2MG GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG ALECENSA CAP 150MG INLYTA TAB 1MG INLYTA TAB 5MG COMETRIQ KIT 60MG COMETRIQ KIT 100MG COMETRIQ KIT 140MG ZYKADIA CAP 150MG XALKORI CAP 200MG XALKORI CAP 250MG SPRYCEL TAB 20MG SPRYCEL TAB 50MG SPRYCEL TAB 70MG
BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP
PAR; PAR; PAR; SRx PAR; PAR; SRx SRx SRx SRx SRx SRx SRx SRx PAR; SRx SRx SRx SRx SRx PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; SRx SRx SRx SRx SRx
SRx SRx SRx SRx SRx
SRx
SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
20
Drug Name SPRYCEL TAB 80MG SPRYCEL TAB 100MG SPRYCEL TAB 140MG TARCEVA TAB 25MG TARCEVA TAB 100MG TARCEVA TAB 150MG IMBRUVICA CAP 140MG GLEEVEC TAB 100MG imatinib mesylate tab 100 mg (base equivalent) GLEEVEC TAB 400MG imatinib mesylate tab 400 mg (base equivalent) TYKERB TAB 250MG LENVIMA CAP 8 MG LENVIMA CAP 10 MG LENVIMA CAP 20 MG LENVIMA CAP 14 MG LENVIMA CAP 18 MG LENVIMA CAP 24 MG TASIGNA CAP 150MG TASIGNA CAP 200MG TAGRISSO TAB 40MG TAGRISSO TAB 80MG VOTRIENT TAB 200MG ICLUSIG TAB 15MG ICLUSIG TAB 45MG CAPRELSA TAB 100MG CAPRELSA TAB 300MG LYNPARZA CAP 50MG NINLARO CAP 2.3MG NINLARO CAP 3MG NINLARO CAP 4MG JAKAFI TAB 5MG JAKAFI TAB 10MG JAKAFI TAB 15MG JAKAFI TAB 20MG JAKAFI TAB 25MG ZYDELIG TAB 100MG ZYDELIG TAB 150MG
Drug Tier Requirements/Limits BP SRx BP SRx BP SRx BP PAR; SRx BP PAR; SRx BP PAR; SRx BP PAR; SRx BP SRx GP SRx BP GP
SRx SRx
BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP
SRx PAR; PAR; PAR; PAR; PAR; PAR; SRx SRx PAR; PAR; SRx PAR; PAR; SRx SRx PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR;
BP BP
SRx SRx
SRx SRx SRx SRx SRx SRx
SRx SRx SRx SRx
SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx
TOPOISOMERASE I INHIBITORS HYCAMTIN CAP 0.25MG HYCAMTIN CAP 1MG
ANTINEOPLASTICS MISC. PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
21
Drug Name hydroxyurea cap 500 mg MATULANE CAP 50MG INTRON A INJ 18MU INTRON A INJ 25MU INTRON A INJ 10MU INTRON A INJ 18MU INTRON A INJ 50MU ACTIMMUNE INJ 2MU/0.5 tretinoin cap 10 mg bexarotene cap 75 mg
Drug Tier Requirements/Limits GNP BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx GNP GNP
CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS leucovorin calcium tab leucovorin calcium tab leucovorin calcium tab leucovorin calcium tab MESNEX TAB 400MG
5 mg 10 mg 15 mg 25 mg
GP GNP GNP GNP BP
ANTINEOPLASTIC COMBINATIONS LONSURF TAB 15-6.14 LONSURF TAB 20-8.19
BP BP
PAR; SRx PAR; SRx
GLUCOCORTICOSTEROIDS budesonide delayed release particles cap 3 mg cortisone acetate tab 25 mg dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1 mg dexamethasone tab 1.5 mg dexamethasone tab 2 mg dexamethasone tab 4 mg dexamethasone tab 6 mg dexamethasone elixir 0.5 mg/5ml DEXAMETHASON CON 1MG/ML dexamethasone soln 0.5 mg/5ml hydrocortisone tab 5 mg hydrocortisone tab 10 mg hydrocortisone tab 20 mg methylprednisolone tab 4 mg methylprednisolone tab 8 mg methylprednisolone tab 16 mg methylprednisolone tab 32 mg methylprednisolone tab therapy pack 4 mg (21) prednisolone syrup 15 mg/5ml (usp solution equivalent)
GNP GNP GP GP GP GP GNP GP GP GNP BP GNP GNP GNP GNP GNP GNP GNP GNP GNP GP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
22
Drug Name prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) prednisone tab 1 mg prednisone tab 2.5 mg prednisone tab 5 mg prednisone tab 10 mg prednisone tab 20 mg prednisone tab 50 mg PREDNISONE CON 5MG/ML prednisone oral soln 5 mg/5ml 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)
Drug Tier Requirements/Limits GP GNP GNP GNP GP GP GP GP GP BP GNP GP GP GNP GNP
MINERALOCORTICOIDS fludrocortisone acetate tab 0.1 mg
GNP
ANDROGENS danazol cap 50 mg danazol cap 100 mg danazol cap 200 mg ANDROXY TAB 10MG android cap 10mg METHITEST TAB 10MG AXIRON SOL 30MG/ACT testosterone td gel 25 mg/2.5gm (1%) ANDROGEL GEL 1%(50MG) testosterone td gel 50 mg/5gm (1%) testosterone td gel 12.5 mg/act (1%) ANDROGEL GEL 1.62% ANDROGEL GEL 1.62% ANDROGEL GEL 1.62% ANDRODERM DIS 2MG/24HR ANDRODERM DIS 4MG/24HR 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
GNP GNP GNP BP GNP BP BP GNP BP GNP GNP BP BP BP BP BP GNP GNP GNP
ANABOLIC STEROIDS PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
23
Drug Name oxandrolone tab 2.5 mg oxandrolone tab 10 mg ANADROL-50 TAB 50MG
Drug Tier Requirements/Limits GNP GNP BP
ESTROGENS PREMARIN TAB 0.3MG PREMARIN TAB 0.45MG PREMARIN TAB 0.625MG PREMARIN TAB 0.9MG PREMARIN TAB 1.25MG CENESTIN TAB 0.625MG CENESTIN TAB 0.9MG ENJUVIA TAB 0.3MG ENJUVIA TAB 0.45MG ENJUVIA TAB 0.625MG ENJUVIA TAB 0.9MG ENJUVIA TAB 1.25MG MENEST TAB 0.3MG MENEST TAB 0.625MG MENEST TAB 1.25MG MENEST TAB 2.5MG estradiol tab 0.5 mg estradiol tab 1 mg estradiol tab 2 mg estradiol td patch weekly 0.025 mg/24hr estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) estradiol td patch weekly 0.05 mg/24hr estradiol td patch weekly 0.06 mg/24hr estradiol td patch weekly 0.075 mg/24hr estradiol td patch weekly 0.1 mg/24hr DEPO-ESTRADI INJ 5MG/ML estradiol valerate im in oil 20 mg/ml estradiol valerate im in oil 40 mg/ml estropipate tab 0.75 mg estropipate tab 1.5 mg estropipate tab 3 mg
BP BP BP BP BP BNP BNP BNP BNP BNP BNP BNP BNP BNP BNP BNP GNP GNP GNP GNP GNP GNP GNP GNP GNP BP GNP GNP GP GNP GNP
ESTROGEN COMBINATIONS est estrogen tab mtest hs esterified estrogens & methyltestosterone tab 1.25-2.5 mg PREMPRO TAB 0.3-1.5 PREMPRO TAB 0.45-1.5 PREMPRO TAB .625-2.5 PREMPRO TAB 0.625-5
GNP GNP BP BP BP BP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
24
Drug Name Drug Tier Requirements/Limits PREMPHASE TAB BP mimvey lo tab 0.5-0.1 GNP estradiol & norethindrone acetate tab 1-0.5 GNP mg COMBIPATCH DIS .05/.14 BP COMBIPATCH DIS .05/.25 BP norethindrone acetate-ethinyl estradiol tab GNP 0.5 mg-2.5 mcg jinteli tab 1mg-5mcg GNP CLIMARA PRO DIS WEEKLY BP
PROGESTIN CONTRACEPTIVES - ORAL deblitane tab 0.35mg errin tab 0.35mg heather tab 0.35mg jencycla tab 0.35mg jolivette tab 0.35mg lyza tab 0.35mg nora-be tab 0.35mg norethindrone tab 0.35 mg
GNP GNP GNP GNP GNP GNP GNP GNP
PHC PHC PHC PHC PHC PHC PHC PHC
GNP
PHC
GNP
PHC
PROGESTIN CONTRACEPTIVES ORAL norlyroc tab 0.35mg
PROGESTIN CONTRACEPTIVES - ORAL sharobel tab 0.35mg
PROGESTIN CONTRACEPTIVES INJECTABLE medroxyprogesterone acetate im susp 150 GNP mg/ml DEPO-SQ PROV INJ 104 BP
PHC
EMERGENCY CONTRACEPTIVES aftera tab 1.5mg econtra ez tab 1.5mg fallback tab 1.5mg levonorgestrel tab 1.5 mg my way tab 1.5mg next choice tab 1.5mg opcicon tab 1.5mg plan b tab 1.5mg react tab 1.5mg take action tab 1.5mg ELLA TAB 30MG
GNP GNP GNP GNP GNP GNP GNP BNP GNP GNP BNP
PHC PHC PHC PHC PHC PHC PHC PHC; OTC PHC PHC PHC
COMBINATION CONTRACEPTIVES TRANSDERMAL xulane dis 150-35
GNP
PHC
COMBINATION CONTRACEPTIVES VAGINAL NUVARING MIS
BP
PHC
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
25
Drug Name
Drug Tier Requirements/Limits
COMBINATION CONTRACEPTIVES - ORAL apri tab cyred tab desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg emoquette tab enskyce tab juleber tab
GNP GNP GNP
PHC PHC PHC
GNP GNP GNP
PHC PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL reclipsen tab
COMBINATION CONTRACEPTIVES - ORAL solia tab drospirenone-ethinyl estradiol tab 3-0.02 mg
GNP GNP
PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL gianvi tab 3-0.02mg
COMBINATION CONTRACEPTIVES - ORAL loryna tab 3-0.02mg nikki tab 3-0.02mg vestura tab 3-0.02mg drospirenone-ethinyl estradiol tab 3-0.03 mg
GNP GNP GNP GNP
PHC PHC PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL ocella tab 3-0.03mg
COMBINATION CONTRACEPTIVES - ORAL syeda tab 3-0.03mg zarah tab 3-0.03mg kelnor tab 1/35
GNP GNP GNP
PHC PHC PHC
GNP GNP
PHC PHC
COMBINATION CONTRACEPTIVES ORAL zovia 1/35e tab zovia 1/50e tab
COMBINATION CONTRACEPTIVES - ORAL aubra tab 0.1-0.02 aviane tab delyla tab 0.1-0.02 falmina tab lessina tab
GNP GNP GNP GNP GNP
PHC PHC PHC PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg
COMBINATION CONTRACEPTIVES - ORAL lutera tab orsythia tab
GNP GNP
PHC PHC
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
26
Drug Name Drug Tier Requirements/Limits sronyx tab GNP PHC vienva tab 0.1-20 GNP PHC altavera tab GNP PHC chateal tab 0.15/30 GNP PHC kurvelo tab 0.15/30 GNP PHC levonorgestrel & ethinyl estradiol tab 0.15 GNP PHC mg-30 mcg levora-28 tab 0.15/30 GNP PHC marlissa tab 0.15/30 GNP PHC portia-28 tab GNP PHC balziva tab GNP PHC briellyn tab GNP PHC gildagia tab 0.4-35 GNP PHC philith tab 0.4-35 GNP PHC vyfemla tab 0.4-35 GNP PHC
COMBINATION CONTRACEPTIVES ORAL zenchent tab
GNP
PHC
COMBINATION CONTRACEPTIVES - ORAL necon tab 0.5/35 nortrel tab 0.5/35
GNP GNP
PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL wera tab 0.5/35
COMBINATION CONTRACEPTIVES - ORAL alyacen tab 1/35 cyclafem tab 1/35 dasetta tab 1/35 nortrel tab 1/35
GNP GNP GNP GNP
PHC PHC PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL pirmella tab 1/35
COMBINATION CONTRACEPTIVES - ORAL gildess tab 1/20 junel 1/20 tab
GNP GNP
PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL larin tab 1/20
COMBINATION CONTRACEPTIVES - ORAL microgestin tab 1/20 GNP norethindrone ace & ethinyl estradiol tab 1 GNP mg-20 mcg
PHC PHC
COMBINATION CONTRACEPTIVES ORAL gildess tab 1.5/30
GNP
PHC
COMBINATION CONTRACEPTIVES - ORAL junel 1.5/30 tab larin tab 1.5/30
GNP GNP
PHC PHC
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
27
Drug Name microgestin tab 1.5/30
Drug Tier Requirements/Limits GNP PHC
COMBINATION CONTRACEPTIVES ORAL necon tab 1/50-28
GNP
PHC
COMBINATION CONTRACEPTIVES - ORAL cryselle-28 tab 28 tabs elinest tab
GNP GNP
PHC PHC
GNP GNP
PHC PHC
COMBINATION CONTRACEPTIVES ORAL low-ogestrel tab ogestrel tab
COMBINATION CONTRACEPTIVES - ORAL estarylla tab 0.25-35 mono-linyah tab 0.25-35 mononessa tab
GNP GNP GNP
PHC PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
COMBINATION CONTRACEPTIVES - ORAL previfem tab sprintec 28 tab 28 day
GNP GNP
PHC PHC
BNP BNP BNP GNP
PHC PHC PHC PHC
COMBINATION CONTRACEPTIVES ORAL BEYAZ TAB SAFYRAL TAB FALESSA KIT wymzya fe chw 0.4mg-35
COMBINATION CONTRACEPTIVES - ORAL zenchent fe chw 0.4mg-35 kaitlib fe chw layolis fe chw
GNP GNP GNP
PHC PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg
COMBINATION CONTRACEPTIVES - ORAL blisovi fe tab 1/20 gildess fe tab 1/20 junel fe tab 1/20
GNP GNP GNP
PHC PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL larin fe tab 1/20
COMBINATION CONTRACEPTIVES - ORAL microgestin tab fe 1/20 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg tarina fe tab 1/20
GNP GNP
PHC PHC
GNP
PHC
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
28
Drug Name blisovi 24 tab fe 1/20 gildess 24 tab fe 1/20 junel fe 24 tab 1/20 larin 24 tab fe 1/20 lomedia 24 tab fe micrgstin 24 tab fe 1/20
Drug Tier Requirements/Limits GNP PHC GNP PHC GNP PHC GNP PHC GNP PHC GNP PHC
COMBINATION CONTRACEPTIVES ORAL norethindrone ace-ethinyl estradiol-fe tab GNP 1 mg-20 mcg (24)
PHC
COMBINATION CONTRACEPTIVES - ORAL blisovi fe tab 1.5/30 gildess fe tab 1.5/30 junel fe tab 1.5/30 larin fe tab 1.5/30
GNP GNP GNP GNP
PHC PHC PHC PHC
GNP BNP
PHC PHC
COMBINATION CONTRACEPTIVES ORAL microgestin tab fe1.5/30 MINASTRIN 24 CHW FE
COMBINATION CONTRACEPTIVES - ORAL azurette tab 28 day bekyree tab
GNP GNP
PHC PHC
desogest-eth estrad & eth estrad tab 0.15- GNP 0.02/0.01 mg(21/5)
PHC
COMBINATION CONTRACEPTIVES ORAL COMBINATION CONTRACEPTIVES - ORAL kariva tab 28 day kimidess tab pimtrea tab viorele tab
GNP GNP GNP GNP
PHC PHC PHC PHC
BP BNP
PHC PHC
COMBINATION CONTRACEPTIVES ORAL NECON TAB 10/11-28 LO LOESTRIN TAB
COMBINATION CONTRACEPTIVES - ORAL caziant pak cesia pak
GNP GNP
PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL velivet pak
COMBINATION CONTRACEPTIVES - ORAL enpresse-28 tab levonest tab levonorgestrel-eth estra tab 0.0530/0.075-40/0.125-30mg-mcg
GNP GNP GNP
PHC PHC PHC
COMBINATION CONTRACEPTIVES ORAL PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
29
Drug Name myzilra tab
Drug Tier Requirements/Limits GNP PHC
COMBINATION CONTRACEPTIVES - ORAL trivora-28 tab alyacen tab 7/7/7 cyclafem tab 7/7/7 dasetta tab 7/7/7 necon tab 7/7/7 nortrel tab 7/7/7
GNP GNP GNP GNP GNP GNP
PHC PHC PHC PHC PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL pirmella tab 7/7/7
COMBINATION CONTRACEPTIVES - ORAL aranelle tab
GNP
PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL leena tab
COMBINATION CONTRACEPTIVES - ORAL norgestimate-eth estrad tab 0.1825/0.215-25/0.25-25 mg-mcg
GNP
PHC
BNP
PHC
COMBINATION CONTRACEPTIVES ORAL ORTHO TRI- TAB CYCLN LO
COMBINATION CONTRACEPTIVES - ORAL tri-lo tab estaryll tri-lo- tab marzia
GNP GNP
PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL tri-lo- tab sprintec
COMBINATION CONTRACEPTIVES - ORAL trinessa lo tab norgestimate-eth estrad tab 0.1835/0.215-35/0.25-35 mg-mcg
GNP GNP
PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL tri-estaryll tab
COMBINATION CONTRACEPTIVES - ORAL tri-linyah tab tri-previfem tab tri-sprintec tab trinessa tab
GNP GNP GNP GNP
PHC PHC PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL tilia fe tab
COMBINATION CONTRACEPTIVES - ORAL tri-legest tab fe
GNP
PHC
BNP GNP
PHC PHC
COMBINATION CONTRACEPTIVES ORAL NATAZIA TAB amethia lo tab
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
30
Drug Name
Drug Tier Requirements/Limits
COMBINATION CONTRACEPTIVES - ORAL camrese lo tab GNP levonorg-eth est tab 0.1-0.02mg(84) & eth GNP est tab 0.01mg(7) introvale tab GNP jolessa tab GNP
PHC PHC PHC PHC
COMBINATION CONTRACEPTIVES ORAL levonorgestrel & ethinyl estradiol (91-day) GNP tab 0.15-0.03 mg
PHC
COMBINATION CONTRACEPTIVES - ORAL quasense tab setlakin tab amethia tab
GNP GNP GNP
PHC PHC PHC
GNP
PHC
COMBINATION CONTRACEPTIVES ORAL ashlyna tab
COMBINATION CONTRACEPTIVES - ORAL camrese tab daysee tab levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)
GNP GNP GNP
PHC PHC PHC
BNP GNP
PHC PHC
COMBINATION CONTRACEPTIVES ORAL QUARTETTE TAB amethyst tab 90-20mcg
COMBINATION CONTRACEPTIVES - ORAL levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg
GNP
PHC
PROGESTINS medroxyprogesterone acetate tab 2.5 mg medroxyprogesterone acetate tab 5 mg medroxyprogesterone acetate tab 10 mg norethindrone acetate tab 5 mg progesterone im in oil 50 mg/ml progesterone micronized cap 100 mg progesterone micronized cap 200 mg
GNP GNP GNP GNP GNP GNP GNP
INSULIN NOVOLOG INJ 100/ML NOVOLOG INJ FLEXPEN NOVOLOG INJ PENFILL LANTUS INJ 100/ML LANTUS INJ SOLOSTAR TOUJEO SOLO INJ 300IU/ML APIDRA INJ U-100 APIDRA INJ SOLOSTAR
BP BP BP BP BP BP BNP BNP
PAR PAR
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
31
Drug Name HUMALOG INJ 100/ML HUMALOG KWIK INJ 100/ML HUMALOG KWIK INJ 200/ML HUMALOG INJ 100/ML LEVEMIR INJ LEVEMIR INJ FLEXTOUC HUMULIN R INJ U-100 NOVOLIN R INJ U-100 HUMULIN R INJ U-500 HUMULIN N INJ U-100 NOVOLIN N INJ U-100 HUMULIN N INJ U-100KWP NOVOLOG MIX INJ 70/30 NOVOLOG MIX INJ FLEXPEN HUMALOG MIX SUS 75/25 HUMALOG MIX INJ 50/50 HUMALOG MIX INJ 75/25KWP HUMALOG MIX INJ 50/50KWP HUMULIN INJ 70/30 NOVOLIN70/30 INJ RELION HUMULIN INJ 70/30KWP
Drug Tier Requirements/Limits BNP PAR BNP PAR BNP PAR BNP PAR BP BP BNP PAR BP BP BNP PAR BP BNP PAR BP BP BNP PAR BNP PAR BNP PAR BNP PAR BNP PAR BP BNP PAR
ANTIDIABETIC AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG SYMLNPEN 120 INJ 1000MCG
BP BP
EPA EPA
INCRETIN MIMETIC AGENTS (GLP1 RECEPTOR AGONISTS) TRULICITY INJ 0.75/0.5 TRULICITY INJ 1.5/0.5 BYETTA INJ 5MCG BYETTA INJ 10MCG VICTOZA INJ 18MG/3ML
BP BP BNP BNP BP
PAR PAR
SULFONYLUREAS chlorpropamide tab 100 mg chlorpropamide tab 250 mg glimepiride tab 1 mg glimepiride tab 2 mg glimepiride tab 4 mg glipizide tab 5 mg glipizide tab 10 mg glipizide xl tab 2.5mg glipizide xl tab 5mg glipizide xl tab 10mg glyburide tab 1.25 mg glyburide tab 2.5 mg
GNP GNP GP GP GP GNP GP GNP GNP GNP GNP GP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
32
Drug Name glyburide tab 5 mg glyburide micronized tab 1.5 mg glyburide micronized tab 3 mg glyburide micronized tab 6 mg tolazamide tab 250 mg tolazamide tab 500 mg tolbutamide tab 500 mg
Drug Tier Requirements/Limits GNP GP GNP GNP GNP GNP GNP
BIGUANIDES metformin metformin metformin metformin metformin metformin metformin mg
hcl hcl hcl hcl hcl hcl hcl
tab tab tab tab tab tab tab
500 mg 850 mg 1000 mg sr 24hr 500 mg sr 24hr 750 mg sr 24hr osmotic 500 mg sr 24hr osmotic 1000
GNP GNP GP GP GNP GNP GNP
MEGLITINIDE ANALOGUES nateglinide nateglinide repaglinide repaglinide repaglinide
tab tab tab tab tab
60 mg 120 mg 0.5 mg 1 mg 2 mg
GNP GNP GNP GNP GNP
DIABETIC OTHER GLUCAGON KIT 1MG GLUCAGEN INJ HYPOKIT PROGLYCEM SUS 50MG/ML GLUCOSE BITS CHW 1GM DEX4 GLUCOSE CHW QK DISLV BD GLUCOSE CHW 5GM glutose 15 gel 40% KORLYM TAB 300MG TGT GLUCOSE CHW ORANGE
BP BP BNP BNP BNP BNP GNP BP BP
OTC OTC OTC OTC PAR; SRx OTC
ALPHAGLUCOSIDASE INHIBITORS acarbose tab 25 mg acarbose tab 50 mg acarbose tab 100 mg GLYSET TAB 25MG miglitol tab 25 mg GLYSET TAB 50MG miglitol tab 50 mg GLYSET TAB 100MG miglitol tab 100 mg
GNP GNP GNP BP GNP BP GNP BP GNP
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
33
Drug Name alogliptin benzoate tab 6.25 mg (base equiv)
Drug Tier Requirements/Limits GNP
DIPEPTIDYL PEPTIDASE4 (DPP4) INHIBITORS NESINA TAB 6.25MG
BNP
PAR
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS alogliptin benzoate tab 12.5 mg (base equiv)
GNP
DIPEPTIDYL PEPTIDASE4 (DPP4) INHIBITORS NESINA TAB 12.5MG
BNP
PAR
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS alogliptin benzoate tab 25 mg (base equiv) GNP
DIPEPTIDYL PEPTIDASE4 (DPP4) INHIBITORS NESINA TAB 25MG TRADJENTA TAB 5MG ONGLYZA TAB 2.5MG ONGLYZA TAB 5MG JANUVIA TAB 25MG JANUVIA TAB 50MG JANUVIA TAB 100MG
BNP BP BNP BNP BP BP BP
PAR PAR PAR
DOPAMINE RECEPTOR AGONISTS ANTIDIABETIC CYCLOSET TAB 0.8MG
BNP
INSULIN SENSITIZING AGENTS pioglitazone hcl tab 15 mg (base equiv) pioglitazone hcl tab 30 mg (base equiv) pioglitazone hcl tab 45 mg (base equiv) AVANDIA TAB 2MG AVANDIA TAB 4MG AVANDIA TAB 8MG
GNP GNP GNP BP BP BP
SODIUMGLUCOSE COTRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA TAB 5MG FARXIGA TAB 10MG JARDIANCE TAB 10MG JARDIANCE TAB 25MG
BP BP BP BP
ANTIDIABETIC COMBINATIONS alogliptin-metformin hcl tab 12.5-500 mg KAZANO 12.5- TAB 500MG alogliptin-metformin hcl tab 12.5-1000 mg KAZANO 12.5- TAB 1000MG JENTADUETO TAB 2.5-500 JENTADUETO TAB 2.5-850 JENTADUETO TAB 2.5-1000 JENTADUETO TAB XR JENTADUETO TAB XR
GNP BNP GNP BNP BP BP BP BP BP
PAR PAR
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
34
Drug Name KOMBIGLYZE TAB 2.5-1000 KOMBIGLYZE TAB 5-500MG KOMBIGLYZE TAB 5-1000MG JANUMET TAB 50-500MG JANUMET TAB 50-1000 JANUMET XR TAB 50-500MG JANUMET XR TAB 50-1000 JANUMET XR TAB 100-1000 alogliptin-pioglitazone tab 12.5-15 mg OSENI TAB 12.5-15 alogliptin-pioglitazone tab 12.5-30 mg OSENI TAB 12.5-30 alogliptin-pioglitazone tab 12.5-45 mg OSENI TAB 12.5-45 alogliptin-pioglitazone tab 25-15 mg OSENI TAB 25-15MG alogliptin-pioglitazone tab 25-30 mg OSENI TAB 25-30MG alogliptin-pioglitazone tab 25-45 mg OSENI TAB 25-45MG XIGDUO XR TAB 5-500MG XIGDUO XR TAB 5-1000MG XIGDUO XR TAB 10-500MG XIGDUO XR TAB 10-1000 SYNJARDY TAB 5-500MG SYNJARDY TAB 5-1000MG SYNJARDY TAB 12.5-500 SYNJARDY TAB glipizide-metformin hcl tab 2.5-250 mg glipizide-metformin hcl tab 2.5-500 mg glipizide-metformin hcl tab 5-500 mg glyburide-metformin tab 1.25-250 mg glyburide-metformin tab 2.5-500 mg glyburide-metformin tab 5-500 mg pioglitazone hcl-glimepiride tab 30-2 mg pioglitazone hcl-glimepiride tab 30-4 mg pioglitazone hcl-metformin hcl tab 15-500 mg pioglitazone hcl-metformin hcl tab 15-850 mg ACTOPLUS MET TAB XR ACTOPLUS MET TAB XR AVANDAMET TAB 2-1000MG
Drug Tier Requirements/Limits BNP PAR BNP PAR BNP PAR BP BP BP BP BP GNP BNP PAR GNP BNP PAR GNP BNP PAR GNP BNP PAR GNP BNP PAR GNP BNP PAR BP BP BP BP BP BP BP BP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP BP BP BP
THYROID HORMONES PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
35
Drug Name levoxyl tab 25mcg levoxyl tab 50mcg levoxyl tab 75mcg levoxyl tab 88mcg levoxyl tab 100mcg levothyroxine sodium tab 112 mcg levothyroxine sodium tab 125 mcg levoxyl tab 137mcg levothyroxine sodium tab 150 mcg unithroid tab 175mcg unithroid tab 200mcg unithroid tab 300mcg liothyronine sodium tab 5 mcg liothyronine sodium tab 25 mcg liothyronine sodium tab 50 mcg THYROLAR-1/4 TAB 15MG THYROLAR-1/2 TAB 30MG THYROLAR-1 TAB 60MG THYROLAR-2 TAB 120MG THYROLAR-3 TAB 180MG ARMOUR THYRO TAB 15MG NATURE-THROI TAB 16.25MG np thyroid tab 30mg NATURE-THROI TAB 32.5MG NATURE-THROI TAB 48.75MG np thyroid tab 60mg WP THYROID TAB 65MG NATURE-THROI TAB 81.25MG WESTHROID TAB 97.5MG NATURE-THROI TAB 113.75MG ARMOUR THYRO TAB 120MG WP THYROID TAB 130MG NATURE THROI TAB 162.5MG ARMOUR THYRO TAB 180MG WESTHROID TAB 195MG ARMOUR THYRO TAB 240MG NATURE-THROI TAB 260MG ARMOUR THYRO TAB 300MG NATURE-THROI TAB 325MG NATURE-THROI TAB 146.25MG THYROID POW
Drug Tier Requirements/Limits GP GNP GP GP GP GP GP GP GP GNP GNP GNP GNP GNP GNP BP BP BP BP BP BP BP GP BP BP GNP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP
ANTITHYROID AGENTS methimazole tab 5 mg methimazole tab 10 mg
GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
36
Drug Name propylthiouracil tab 50 mg
Drug Tier Requirements/Limits GNP
OXYTOCICS methylergonovine maleate tab 0.2 mg
GNP
BONE DENSITY REGULATORS alendronate sodium tab 5 mg GP alendronate sodium tab 10 mg GNP alendronate sodium tab 35 mg GP alendronate sodium tab 40 mg GNP alendronate sodium tab 70 mg GP alendronate sodium oral soln 70 mg/75ml GNP FOSAMAX + D TAB 70-2800 BP FOSAMAX + D TAB 70-5600
BP
etidronate disodium tab 200 mg etidronate disodium tab 400 mg ibandronate sodium tab 150 mg (base equivalent) risedronate sodium tab 5 mg risedronate sodium tab 30 mg risedronate sodium tab 35 mg risedronate sodium tab 150 mg calcitonin (salmon) nasal soln 200 unit/act FORTEO SOL 600/2.4
GNP GNP GNP GNP GNP GNP GNP GNP BP
QLL (4 tabs / 30 days) QLL (4 tabs / 28 days) QLL (4 tabs / 28 days); EPA QLL (4 tabs / 28 days); EPA
QLL (1 tabs / 28 days)
QLL (4 tabs / 30 days) QLL (1 tabs / 30 days) PAR; SRx
HORMONE RECEPTOR MODULATORS raloxifene hcl tab 60 mg
GNP
PAR; PHC, PAR is needed for coverage under PHC. Limited to women age 35 years and older with no previous history of breast cancer, ductal carcinoma in situ (CIS) or lobular carcinoma in situ.
GP GP GP GNP
SRx SRx SRx
FERTILITY REGULATORS chorionic gonadotropin for inj 10000 unit novarel inj 10000unt pregnyl inj 10000unt clomiphene citrate tab 50 mg
LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS LUPR DEP-PED INJ 7.5MG LUPR DEP-PED INJ 11.25MG LUPR DEP-PED INJ 15MG
BP BP BP
SRx SRx SRx
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
37
Drug Name LUPR DEP-PED INJ 11.25MG LUPR DEP-PED INJ 30MG SYNAREL SOL 2MG/ML
Drug Tier Requirements/Limits BP SRx BP SRx BP SRx
GROWTH HORMONES NORDITROPIN INJ 5/1.5ML NORDITROPIN INJ 10/1.5ML NORDITROPIN INJ 15/1.5ML NORDITROPIN INJ 30/3ML SEROSTIM INJ 4MG SEROSTIM INJ 5MG SEROSTIM INJ 6MG
BP BP BP BP BP BP BP
PAR; PAR; PAR; PAR; PAR; PAR; PAR;
SRx SRx SRx SRx SRx SRx SRx
GROWTH HORMONE RELEASING HORMONES (GHRH) EGRIFTA SOL 1MG EGRIFTA SOL 2MG
BP BP
PAR; SRx PAR; SRx
INSULINLIKE GROWTH FACTORS (SOMATOMEDINS) INCRELEX INJ 40MG/4ML
BP
PAR; SRx
BP BP BP GP
PAR; SRx PAR; SRx PAR; SRx SRx
GP
SRx
GP
SRx
GP
SRx
GP
SRx
BP BP BP BP BP BP
SRx SRx SRx PAR; SRx PAR; SRx PAR; SRx
SOMATOSTATIC AGENTS SOMATULINE INJ 60/0.2ML SOMATULINE INJ 90/0.3ML SOMATULINE INJ 120/.5ML 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) 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
GROWTH HORMONE RECEPTOR ANTAGONISTS SOMAVERT SOMAVERT SOMAVERT SOMAVERT SOMAVERT
INJ INJ INJ INJ INJ
10MG 15MG 20MG 25MG 30MG
BP BP BP BP BP
SRx SRx SRx SRx SRx
POSTERIOR PITUITARY HORMONES PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
38
Drug Name desmopressin acetate tab 0.1 mg desmopressin acetate tab 0.2 mg STIMATE SOL 1.5MG/ML desmopressin acetate inj 4 mcg/ml desmopressin acetate nasal soln 0.01% (refrigerated) desmopressin acetate nasal spray soln 0.01% (refrigerated)
Drug Tier Requirements/Limits GNP GNP BP GNP GNP GNP
PROLACTIN INHIBITORS cabergoline tab 0.5 mg
GNP
VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA TAB 15MG SAMSCA TAB 30MG
BNP BNP
SRx SRx
METABOLIC MODIFIERS levocarnitine tab 330 mg levocarnitine oral soln 1 gm/10ml (10%) XURIDEN POW 2GM ORFADIN CAP 2MG ORFADIN CAP 5MG ORFADIN CAP 10MG ORFADIN CAP 20MG ORFADIN SUS 4MG/ML CYSTADANE POW calcitriol cap 0.25 mcg calcitriol cap 0.5 mcg calcitriol oral soln 1 mcg/ml doxercalciferol cap 0.5 mcg doxercalciferol cap 1 mcg doxercalciferol cap 2.5 mcg paricalcitol cap 1 mcg paricalcitol cap 2 mcg paricalcitol cap 4 mcg SENSIPAR TAB 30MG SENSIPAR TAB 60MG SENSIPAR TAB 90MG STRENSIQ INJ 18/0.45 STRENSIQ INJ 28/0.7ML STRENSIQ INJ 40MG/ML STRENSIQ INJ 80/0.8ML MYALEPT INJ 11.3MG BUPHENYL TAB 500MG sodium phenylbutyrate oral powder 3 gm/teaspoonful CARBAGLU TAB 200MG
GNP GNP BP BP BP BP BP BP BNP GNP GNP GNP GNP GNP GNP GNP GNP GNP BP BP BP BP BP BP BP BP BNP GNP BNP
PAR; SRx SRx SRx SRx SRx SRx SRx
SRx SRx SRx PAR; PAR; PAR; PAR; PAR;
SRx SRx SRx SRx SRx
SRx
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
39
Drug Name KUVAN POW 100MG KUVAN POW 500MG KUVAN TAB 100MG
Drug Tier Requirements/Limits BP SRx BP SRx BP SRx
CARDIAC GLYCOSIDES digoxin tab 125 mcg (0.125 mg) digoxin tab 250 mcg (0.25 mg) digoxin oral soln 0.05 mg/ml
GNP GNP GNP
NITRATES DILATRATE SR CAP 40MG BP isosorbide dinitrate tab 5 mg GNP isosorbide dinitrate tab 10 mg GNP isosorbide dinitrate tab 20 mg GNP isosorbide dinitrate tab 30 mg GNP ISORDIL TAB 40MG BP isoditrate tab 40mg er GNP isosorbide mononitrate tab 10 mg GP isosorbide mononitrate tab 20 mg GP isosorbide mononitrate tab sr 24hr 30 mg GP isosorbide mononitrate tab sr 24hr 60 mg GNP isosorbide mononitrate tab sr 24hr 120 mg GNP nitroglycerin cap cr 2.5 mg GNP nitroglycerin cap cr 6.5 mg GNP nitroglycerin cap cr 9 mg GNP NITROSTAT SUB 0.3MG BP NITROSTAT SUB 0.4MG BP NITROSTAT SUB 0.6MG BNP nitroglycerin tl soln 0.4 mg/spray (400 GNP mcg/spray) nitroglycerin lingual aerosol 400 mcg/spray GNP NITRO-BID OIN 2% BP nitroglycerin td patch 24hr 0.1 mg/hr GNP nitroglycerin td patch 24hr 0.2 mg/hr GNP NITRO-DUR DIS 0.3MG/HR BNP nitroglycerin td patch 24hr 0.4 mg/hr GNP nitroglycerin td patch 24hr 0.6 mg/hr GNP NITRO-DUR DIS 0.8MG/HR BP
ANTIANGINALSOTHER RANEXA TAB 500MG RANEXA TAB 1000MG
BP BP
PAR PAR
BETA BLOCKERS NONSELECTIVE nadolol tab 20 mg nadolol tab 40 mg nadolol tab 80 mg
GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
40
Drug Name LEVATOL TAB 20MG pindolol tab 5 mg pindolol tab 10 mg 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 propranolol hcl oral soln 20 mg/5ml propranolol hcl oral soln 40 mg/5ml 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 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 timolol maleate tab 5 mg timolol maleate tab 10 mg timolol maleate tab 20 mg
Drug Tier Requirements/Limits BNP GNP GNP GP GP GP GNP GP GP GNP GNP GNP GNP GNP GP GNP GP GNP GNP GNP GNP GNP GNP GNP
BETA BLOCKERS CARDIOSELECTIVE acebutolol hcl cap 200 mg 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 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 tab 25 mg metoprolol tartrate tab 50 mg
25 mg
GNP GNP GNP GP GNP GNP GNP GNP GNP GP
50 mg
GNP
100 mg
GNP
200 mg
GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
41
Drug Name metoprolol tartrate tab 100 mg BYSTOLIC TAB 2.5MG BYSTOLIC TAB 5MG BYSTOLIC TAB 10MG BYSTOLIC TAB 20MG
Drug Tier Requirements/Limits GNP BP BP BP BP
ALPHABETA BLOCKERS carvedilol tab 3.125 mg carvedilol tab 6.25 mg carvedilol tab 12.5 mg carvedilol tab 25 mg labetalol hcl tab 100 mg labetalol hcl tab 200 mg labetalol hcl tab 300 mg
GNP GP GP GNP GNP GNP GNP
CALCIUM CHANNEL BLOCKERS amlodipine besylate tab 2.5 mg amlodipine besylate tab 5 mg amlodipine besylate tab 10 mg diltiazem hcl tab 30 mg diltiazem hcl tab 60 mg diltiazem hcl tab 90 mg diltiazem hcl tab 120 mg diltiazem hcl cap sr 12hr 60 mg diltiazem hcl cap sr 12hr 90 mg diltiazem hcl cap sr 12hr 120 mg diltiazem hcl cap sr 24hr 120 mg diltiazem hcl cap sr 24hr 180 mg diltiazem hcl cap sr 24hr 240 mg diltiazem hcl extended release beads cap sr 24hr 120 mg diltiazem hcl extended release beads cap sr 24hr 180 mg diltiazem hcl extended release beads cap sr 24hr 240 mg diltiazem hcl extended release beads cap sr 24hr 300 mg taztia xt cap 360mg/24 diltiazem hcl extended release beads cap sr 24hr 420 mg diltiazem hcl coated beads cap sr 24hr 120 mg diltiazem hcl coated beads cap sr 24hr 180 mg diltiazem hcl coated beads cap sr 24hr 240 mg
GNP GNP GP GNP GP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
42
Drug Name diltiazem hcl coated beads cap sr 24hr 300 mg diltiazem hcl coated beads cap sr 24hr 360 mg diltiazem hcl coated beads tab sr 24hr 180 mg diltiazem hcl coated beads tab sr 24hr 240 mg diltiazem hcl coated beads tab sr 24hr 300 mg diltiazem hcl coated beads tab sr 24hr 360 mg diltiazem hcl coated beads tab sr 24hr 420 mg felodipine tab sr 24hr 2.5 mg felodipine tab sr 24hr 5 mg felodipine tab sr 24hr 10 mg isradipine cap 2.5 mg isradipine cap 5 mg nicardipine hcl cap 20 mg nicardipine hcl cap 30 mg nifedipine cap 10 mg nifedipine cap 20 mg afeditab tab 30mg cr nifedipine tab sr 24hr 60 mg nifedipine tab sr 24hr 90 mg nifedipine tab sr 24hr osmotic release 30 mg nifedipine tab sr 24hr osmotic release 60 mg nifedipine tab sr 24hr osmotic release 90 mg nimodipine cap 30 mg nisoldipine tab sr 24hr 8.5 mg nisoldipine tab sr 24hr 17 mg nisoldipine tab sr 24hr 20 mg nisoldipine tab sr 24hr 25.5 mg nisoldipine tab sr 24hr 30 mg nisoldipine tab sr 24hr 34 mg nisoldipine tab sr 24hr 40 mg verapamil hcl tab 40 mg verapamil hcl tab 80 mg verapamil hcl tab 120 mg verapamil hcl tab cr 120 mg verapamil hcl tab cr 180 mg
Drug Tier Requirements/Limits GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GP GNP GP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
43
Drug Name verapamil hcl verapamil hcl verapamil hcl verapamil hcl verapamil hcl verapamil hcl verapamil hcl verapamil hcl
tab cr 240 mg cap sr 24hr 100 cap sr 24hr 120 cap sr 24hr 180 cap sr 24hr 200 cap sr 24hr 240 cap sr 24hr 300 cap sr 24hr 360
mg mg mg mg mg mg mg
Drug Tier Requirements/Limits GNP GNP GNP GNP GNP GNP GNP GNP
ANTIARRHYTHMICS TYPE IA disopyramide phosphate cap 150 mg NORPACE CAP 100MG CR NORPACE CAP 150MG CR quinidine gluconate tab cr 324 mg quinidine sulfate tab 200 mg quinidine sulfate tab 300 mg quinidine sulfate tab cr 300 mg
GNP BP BP GNP GNP GNP GNP
ANTIARRHYTHMICS TYPE IB mexiletine hcl cap 150 mg mexiletine hcl cap 200 mg mexiletine hcl cap 250 mg
GNP GNP GNP
ANTIARRHYTHMICS TYPE IC flecainide acetate tab 50 mg flecainide acetate tab 100 mg flecainide acetate tab 150 mg propafenone hcl tab 150 mg propafenone hcl tab 225 mg propafenone hcl tab 300 mg propafenone hcl cap sr 12hr 225 mg propafenone hcl cap sr 12hr 325 mg propafenone hcl cap sr 12hr 425 mg
GNP GNP GNP GNP GNP GNP GNP GNP GNP
ANTIARRHYTHMICS TYPE III amiodarone hcl tab 100 mg amiodarone hcl tab 200 mg amiodarone hcl tab 400 mg dofetilide cap 125 mcg (0.125 mg) TIKOSYN CAP 125MCG dofetilide cap 250 mcg (0.25 mg) TIKOSYN CAP 250MCG dofetilide cap 500 mcg (0.5 mg) TIKOSYN CAP 500MCG MULTAQ TAB 400MG
GNP GP GNP GP BP GP BP GP BP BNP
SRx SRx SRx SRx SRx SRx
ACE INHIBITORS benazepril hcl tab 5 mg
GP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
44
Drug Name 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
Drug Tier Requirements/Limits GNP GNP GP GNP GNP GNP GNP GNP GP GP GNP GP GP GP GNP GP GNP GP GNP GP GNP GNP GNP GNP GNP GP GP GP GP GNP GP GNP GP GNP GNP GNP
ANGIOTENSIN II RECEPTOR ANTAGONISTS EDARBI TAB 40MG EDARBI TAB 80MG candesartan cilexetil candesartan cilexetil candesartan cilexetil candesartan cilexetil eprosartan mesylate
tab tab tab tab tab
4 mg 8 mg 16 mg 32 mg 600 mg
BNP BNP GNP GNP GNP GNP GNP
PAR PAR
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
45
Drug Name irbesartan tab 75 mg irbesartan tab 150 mg irbesartan tab 300 mg losartan potassium tab 25 mg losartan potassium tab 50 mg losartan potassium tab 100 mg BENICAR TAB 5MG BENICAR TAB 20MG BENICAR TAB 40MG 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
Drug Tier Requirements/Limits GNP GNP GNP GNP GNP GNP BP BP BP GNP GNP GNP GNP GNP GNP GNP
DIRECT RENIN INHIBITORS TEKTURNA TAB 150MG TEKTURNA TAB 300MG
BP BP
ANTIADRENERGIC ANTIHYPERTENSIVES clonidine hcl tab 0.1 mg GP clonidine hcl tab 0.2 mg GP clonidine hcl tab 0.3 mg GNP clonidine hcl td patch weekly 0.1 mg/24hr GNP clonidine hcl td patch weekly 0.2 mg/24hr GNP clonidine hcl td patch weekly 0.3 mg/24hr GNP guanfacine hcl tab 1 mg GNP guanfacine hcl tab 2 mg GNP methyldopa tab 250 mg GP methyldopa tab 500 mg GNP doxazosin mesylate tab 1 mg GNP doxazosin mesylate tab 2 mg GNP doxazosin mesylate tab 4 mg GNP doxazosin mesylate tab 8 mg GNP prazosin hcl cap 1 mg GNP prazosin hcl cap 2 mg GNP prazosin hcl cap 5 mg GNP terazosin hcl cap 1 mg GP terazosin hcl cap 2 mg GP terazosin hcl cap 5 mg GP terazosin hcl cap 10 mg GP reserpine tab 0.1 mg GNP reserpine tab 0.25 mg GNP PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
46
Drug Name
Drug Tier Requirements/Limits
SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) eplerenone tab 25 mg eplerenone tab 50 mg
GNP GNP
AGENTS FOR PHEOCHROMOCYTOMA phenoxybenzamine hcl cap 10 mg DEMSER CAP 250MG
GNP BP
VASODILATORS hydralazine hcl tab 10 mg hydralazine hcl tab 25 mg hydralazine hcl tab 50 mg hydralazine hcl tab 100 mg minoxidil tab 2.5 mg minoxidil tab 10 mg
GP GNP GNP GNP GNP GNP
ANTIHYPERTENSIVE COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-GNP 10 mg amlodipine besylate-benazepril hcl cap 5- GNP 10 mg amlodipine besylate-benazepril hcl cap 5- GNP 20 mg amlodipine besylate-benazepril hcl cap 5- GNP 40 mg amlodipine besylate-benazepril hcl cap 10- GNP 20 mg amlodipine besylate-benazepril hcl cap 10- GNP 40 mg benazepril & hydrochlorothiazide tab 5GNP 6.25 mg benazepril & hydrochlorothiazide tab 10- GNP 12.5 mg benazepril & hydrochlorothiazide tab 20- GNP 12.5 mg benazepril & hydrochlorothiazide tab 20-25 GNP mg captopril & hydrochlorothiazide tab 25-15 GNP mg captopril & hydrochlorothiazide tab 25-25 GNP mg captopril & hydrochlorothiazide tab 50-15 GNP mg captopril & hydrochlorothiazide tab 50-25 GNP mg enalapril maleate & hydrochlorothiazide tabGP 5-12.5 mg
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
47
Drug Name Drug Tier Requirements/Limits enalapril maleate & hydrochlorothiazide tabGNP 10-25 mg fosinopril sodium & hydrochlorothiazide tab GNP 10-12.5 mg fosinopril sodium & hydrochlorothiazide tab GNP 20-12.5 mg lisinopril & hydrochlorothiazide tab 10-12.5 GNP mg lisinopril & hydrochlorothiazide tab 20-12.5 GP mg lisinopril & hydrochlorothiazide tab 20-25 GP mg moexipril-hydrochlorothiazide tab 7.5-12.5 GNP mg moexipril-hydrochlorothiazide tab 15-12.5 GNP mg moexipril-hydrochlorothiazide tab 15-25 GNP mg quinapril-hydrochlorothiazide tab 10-12.5 GNP mg quinapril-hydrochlorothiazide tab 20-12.5 GNP mg quinapril-hydrochlorothiazide tab 20-25 mg GNP atenolol & chlorthalidone tab 50-25 mg GNP atenolol & chlorthalidone tab 100-25 mg GNP bisoprolol & hydrochlorothiazide tab 2.5- GNP 6.25 mg bisoprolol & hydrochlorothiazide tab 5-6.25 GNP mg bisoprolol & hydrochlorothiazide tab 10GNP 6.25 mg metoprolol & hydrochlorothiazide tab 50- GNP 25 mg metoprolol & hydrochlorothiazide tab 100- GNP 25 mg metoprolol & hydrochlorothiazide tab 100- GNP 50 mg DUTOPROL TAB 25-12.5 BP DUTOPROL TAB 50-12.5 BP DUTOPROL TAB 100-12.5 BP nadolol & bendroflumethiazide tab 40-5 mg GNP nadolol & bendroflumethiazide tab 80-5 mg GNP propranolol & hydrochlorothiazide tab 40- GNP 25 mg propranolol & hydrochlorothiazide tab 80- GNP 25 mg PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
48
Drug Name Drug Tier Requirements/Limits AZOR TAB 5-20MG BP AZOR TAB 5-40MG BP AZOR TAB 10-20MG BP AZOR TAB 10-40MG BP amlodipine besylate-valsartan tab 5-160 GNP mg amlodipine besylate-valsartan tab 5-320 GNP mg amlodipine besylate-valsartan tab 10-160 GNP mg amlodipine besylate-valsartan tab 10-320 GNP mg candesartan cilexetil-hydrochlorothiazide GNP tab 16-12.5 mg candesartan cilexetil-hydrochlorothiazide GNP tab 32-12.5 mg candesartan cilexetil-hydrochlorothiazide GNP tab 32-25 mg irbesartan-hydrochlorothiazide tab 150GNP 12.5 mg irbesartan-hydrochlorothiazide tab 300GNP 12.5 mg losartan potassium & hydrochlorothiazide GNP tab 50-12.5 mg losartan potassium & hydrochlorothiazide GNP tab 100-12.5 mg losartan potassium & hydrochlorothiazide GNP tab 100-25 mg BENICAR HCT TAB 20-12.5 BP BENICAR HCT TAB 40-12.5 BP BENICAR HCT TAB 40-25MG BP telmisartan-hydrochlorothiazide tab 40GNP 12.5 mg telmisartan-hydrochlorothiazide tab 80GNP 12.5 mg telmisartan-hydrochlorothiazide tab 80-25 GNP mg valsartan-hydrochlorothiazide tab 80-12.5 GNP mg valsartan-hydrochlorothiazide tab 160-12.5 GNP mg valsartan-hydrochlorothiazide tab 160-25 GNP mg valsartan-hydrochlorothiazide tab 320-12.5 GNP mg
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
49
Drug Name Drug Tier Requirements/Limits valsartan-hydrochlorothiazide tab 320-25 GNP mg amlodipine-valsartan-hydrochlorothiazide GNP tab 5-160-12.5 mg amlodipine-valsartan-hydrochlorothiazide GNP tab 5-160-25 mg amlodipine-valsartan-hydrochlorothiazide GNP tab 10-160-12.5 mg amlodipine-valsartan-hydrochlorothiazide GNP tab 10-160-25 mg amlodipine-valsartan-hydrochlorothiazide GNP tab 10-320-25 mg TRIBENZOR20- TAB 5-12.5MG BP TRIBENZOR40- TAB 5-12.5MG BP TRIBENZOR40- TAB 5-25MG BP TRIBENZOR40- TAB 10-12.5 BP TRIBENZOR40- TAB 10-25MG BP clorpres tab 0.1-15mg GNP clorpres tab 0.2-15mg GNP clorpres tab 0.3-15mg GNP methyldopa & hydrochlorothiazide tab 250- GNP 15 mg methyldopa & hydrochlorothiazide tab 250- GNP 25 mg TEKTURNA HCT TAB 150-12.5 BP TEKTURNA HCT TAB 150-25MG BP TEKTURNA HCT TAB 300-12.5 BP TEKTURNA HCT TAB 300-25MG BP
CARBONIC ANHYDRASE INHIBITORS acetazolamide tab 125 mg acetazolamide tab 250 mg acetazolamide cap sr 12hr 500 mg methazolamide tab 25 mg methazolamide tab 50 mg
GNP GNP GNP GNP GNP
LOOP DIURETICS bumetanide tab 0.5 mg bumetanide tab 1 mg bumetanide tab 2 mg EDECRIN TAB 25MG ethacrynic acid tab 25 mg furosemide tab 20 mg furosemide tab 40 mg furosemide tab 80 mg FUROSEMIDE SOL 8MG/ML
GNP GNP GNP BNP GNP GP GP GNP BP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
50
Drug Name furosemide oral soln 10 mg/ml torsemide tab 5 mg torsemide tab 10 mg torsemide tab 20 mg torsemide tab 100 mg
Drug Tier Requirements/Limits GP GP GP GNP GNP
POTASSIUM SPARING DIURETICS amiloride hcl tab 5 mg spironolactone tab 25 mg spironolactone tab 50 mg spironolactone tab 100 mg DYRENIUM CAP 50MG DYRENIUM CAP 100MG
GNP GP GNP GNP BNP BNP
THIAZIDES AND THIAZIDELIKE DIURETICS chlorothiazide tab 250 mg chlorothiazide tab 500 mg chlorthalidone tab 25 mg chlorthalidone tab 50 mg chlorthalidone tab 100 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 methyclothiazide tab 5 mg metolazone tab 2.5 mg metolazone tab 5 mg metolazone tab 10 mg
GP GP GNP GNP GNP GNP GNP GP GP GP GP GNP GNP GNP GP
DIURETIC COMBINATIONS amiloride & hydrochlorothiazide tab 5-50 mg spironolactone & hydrochlorothiazide tab 25-25 mg ALDACTAZIDE TAB 50/50 triamterene & hydrochlorothiazide cap 37.5-25 mg triamterene & hydrochlorothiazide cap 5025 mg triamterene & hydrochlorothiazide tab 37.5-25 mg triamterene & hydrochlorothiazide tab 7550 mg
GP GNP BP GNP GNP GNP GP
VASOPRESSORS midodrine hcl tab 2.5 mg
GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
51
Drug Name midodrine hcl tab 5 mg midodrine hcl tab 10 mg
Drug Tier Requirements/Limits GNP GNP
ANAPHYLAXIS THERAPY AGENTS EPIPEN-JR INJ 2-PAK epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) EPIPEN 2-PAK INJ 0.3MG
BP GNP BP
BILE ACID SEQUESTRANTS cholestyramine powder 4 gm/dose cholestyramine powder packets 4 gm cholestyramine light powder 4 gm/dose cholestyramine light powder packets 4 gm WELCHOL TAB 625MG WELCHOL PAK 3.75GM colestipol tab 1gm colestipol hcl granules 5 gm colestipol hcl granule packets 5 gm
GNP GNP GNP GNP BP BP GNP GNP GNP
FIBRIC ACID DERIVATIVES fenofibric acid tab 35 mg fenofibric acid tab 105 mg fenofibrate tab 48 mg fenofibrate tab 54 mg fenofibrate tab 145 mg fenofibrate tab 160 mg fenofibrate micronized cap fenofibrate micronized cap fenofibrate micronized cap fenofibrate micronized cap fenofibrate micronized cap gemfibrozil tab 600 mg
43 mg 67 mg 130 mg 134 mg 200 mg
GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ZETIA TAB 10MG
BP
PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS PRALUENT INJ 75MG/ML PRALUENT INJ 150MG/ML PRALUENT INJ 75MG/ML PRALUENT INJ 150MG/ML REPATHA SURE INJ 140MG/ML REPATHA PUSH INJ 420/3.5 REPATHA INJ 140MG/ML
BP BP BP BP BP BP BP
PAR; PAR; PAR; PAR; PAR; PAR; PAR;
SRx SRx SRx SRx SRx SRx SRx
GNP
QLL (30 tabs / 30 days)
HMG COA REDUCTASE INHIBITORS atorvastatin calcium tab 10 mg (base equivalent)
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
52
Drug Name 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 lovastatin tab 10 mg lovastatin tab 20 mg lovastatin tab 40 mg LIVALO TAB 1MG
Drug Tier Requirements/Limits GNP QLL (30 tabs / 30 days) GNP
QLL (30 tabs / 30 days)
GNP
QLL (30 tabs / 30 days)
GNP GNP GP GP GNP BNP
LIVALO TAB 2MG
BNP
LIVALO TAB 4MG
BNP
CRESTOR TAB 5MG rosuvastatin calcium tab 5 mg CRESTOR TAB 10MG rosuvastatin calcium tab 10 mg CRESTOR TAB 20MG rosuvastatin calcium tab 20 mg CRESTOR TAB 40MG rosuvastatin calcium tab 40 mg pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg pravastatin sodium tab 40 mg pravastatin sodium tab 80 mg simvastatin tab 5 mg simvastatin tab 10 mg simvastatin tab 20 mg simvastatin tab 40 mg simvastatin tab 80 mg
BP GNP BP GNP BP GNP BP GNP GNP GNP GNP GNP GP GP GNP GP GNP
SIMCOR SIMCOR SIMCOR SIMCOR SIMCOR
BP BP BP BP BP
TAB TAB TAB TAB TAB
500-20MG 500-40MG 750-20MG 1000-20 1000-40
QLL (30 QLL (30 QLL (60 QLL (30 PAR QLL (30 PAR QLL (30 PAR QLL (30 QLL (30 QLL (30 QLL (30 QLL (30 QLL (30 QLL (30 QLL (30 QLL (30 QLL (30 QLL (30 QLL (30 QLL (30 QLL (30 QLL (30 QLL (30 QLL (30 EPA QLL (60 QLL (60 QLL (60 QLL (60 QLL (60
tabs tabs tabs tabs
/ / / /
30 30 30 30
days) days) days) days),
tabs / 30 days), tabs / 30 days), tabs tabs tabs tabs tabs tabs tabs tabs tabs tabs tabs tabs tabs tabs tabs tabs tabs
/ / / / / / / / / / / / / / / / /
ea ea ea ea ea
30 30 30 30 30
/ / / / /
30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30
days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days);
days) days) days) days) days)
NICOTINIC ACID DERIVATIVES niacin tab cr 500 mg (antihyperlipidemic) GNP niacin tab cr 750 mg (antihyperlipidemic) GNP niacin tab cr 1000 mg (antihyperlipidemic) GNP PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
53
Drug Name
Drug Tier Requirements/Limits
MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP) INHIBITORS JUXTAPID JUXTAPID JUXTAPID JUXTAPID JUXTAPID JUXTAPID
CAP CAP CAP CAP CAP CAP
5MG 10MG 20MG 30MG 40MG 60MG
BP BP BP BP BP BP
PAR; PAR; PAR; PAR; PAR; PAR;
SRx SRx SRx SRx SRx SRx
ANTIHYPERLIPIDEMICS MISC. omega-3-acid ethyl esters cap 1 gm
GNP
ANTIHYPERLIPIDEMICS COMBINATIONS VYTORIN VYTORIN VYTORIN VYTORIN
TAB TAB TAB TAB
10-10MG 10-20MG 10-40MG 10-80MG
BP BP BP BP
QLL QLL QLL QLL EPA
(30 (30 (30 (30
tabs tabs tabs tabs
/ / / /
30 30 30 30
days) days) days) days);
PERIPHERAL VASODILATORS isoxsuprine hcl tab 10 mg isoxsuprine hcl tab 20 mg
GNP GNP
PULMONARY HYPERTENSION SOL GUANYLATE CYCLASE STIMULATOR ADEMPAS ADEMPAS ADEMPAS ADEMPAS ADEMPAS
TAB TAB TAB TAB TAB
0.5MG 1MG 1.5MG 2MG 2.5MG
BP BP BP BP BP
PAR; PAR; PAR; PAR; PAR;
SRx SRx SRx SRx SRx
PULMONARY HYPERTENSION PHOSPHODIESTERASE INHIBITORS sildenafil citrate tab 20 mg REVATIO SUS 10MG/ML ADCIRCA TAB 20MG
GP BP BP
PAR; SRx PAR; SRx PAR; SRx
PULMONARY HYPERTENSION ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS TAB 5MG LETAIRIS TAB 10MG TRACLEER TAB 62.5MG TRACLEER TAB 125MG
BNP BNP BNP BNP
PAR; PAR; PAR; PAR;
SRx SRx SRx SRx
BNP BNP
PAR; SRx PAR; SRx
PROSTAGLANDIN VASODILATORS VENTAVIS SOL 10MCG/ML VENTAVIS SOL 20MCG/ML
CARDIOVASCULAR AGENTS MISC. - COMBINATIONS ENTRESTO TAB 24-26MG ENTRESTO TAB 49-51MG ENTRESTO TAB 97-103MG
BP BP BP
PAR PAR PAR
CARDIOVASCULAR AGENTS MISC. COMBINATIONS amlodipine besylate-atorvastatin calcium tab 2.5-10 mg
GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
54
Drug Name 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
Drug Tier Requirements/Limits GNP
calcium
GNP
calcium
GNP
calcium
GNP
calcium
GNP
calcium
GNP
calcium
GNP
calcium
GNP
calcium
GNP
calcium
GNP
ANTIHISTAMINES ETHANOLAMINES carbinoxamine maleate tab 4 mg carbinoxamine maleate soln 4 mg/5ml clemastine fumarate tab 2.68 mg clemastine fumarate syrup 0.67 mg/5ml (0.5 mg/5ml base eq)
GNP GNP GNP GNP
ANTIHISTAMINES PHENOTHIAZINES promethazine hcl tab 12.5 mg promethazine hcl tab 25 mg promethazine hcl tab 50 mg promethazine hcl syrup 6.25 mg/5ml promethazine hcl suppos 12.5 mg promethazine hcl suppos 25 mg promethegan sup 50mg
GP GP GP GP GNP GNP GNP
ANTIHISTAMINES PIPERIDINES cyproheptadine hcl tab 4 mg cyproheptadine hcl syrup 2 mg/5ml
GNP GNP
ANTIHISTAMINES NONSEDATING desloratadine tab 5 mg desloratadine tab orally disintegrating 2.5 mg desloratadine tab orally disintegrating 5 mg levocetirizine dihydrochloride tab 5 mg
GNP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
55
Drug Name levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml)
Drug Tier Requirements/Limits GNP
SYMPATHOMIMETIC DECONGESTANTS TYZINE PED DRO 0.05% TYZINE SOL 0.1%
BNP BNP
NASAL STEROIDS QNASL CHILD SPR 40MCG BNP QNASL AER 80MCG BNP BECONASE AQ SUS 0.042% BNP budesonide nasal susp 32 mcg/act GNP OMNARIS SPR BNP flunisolide nasal soln 25 mcg/act (0.025%) GNP mometasone furoate nasal susp 50 GNP mcg/act NASONEX SPR 50MCG/AC BNP
PAR PAR PAR PAR
PAR
NASAL ANTIINFECTIVES BACTROBAN OIN NASAL 2%
BP
NASAL ANTICHOLINERGICS ipratropium bromide nasal soln 0.03% (21 GNP mcg/spray) ipratropium bromide nasal soln 0.06% (42 GNP mcg/spray)
NASAL ANTIALLERGY azelastine hcl nasal spray 0.1% (137 mcg/spray) olopatadine hcl nasal soln 0.6%
GNP GNP
ANTITUSSIVES hydrocodone w/ homatropine tab 5-1.5 mg GNP hydrocodone w/ homatropine syrup 5-1.5 GNP mg/5ml benzonatate cap 100 mg GNP benzonatate cap 200 mg GNP
MUCOLYTICS acetylcysteine inhal soln 10% acetylcysteine inhal soln 20%
GNP GNP
MISC. RESPIRATORY INHALANTS sodium chloride soln nebu 0.9% sodium chloride soln nebu 3% pulmosal neb 7% sodium chloride soln nebu 10%
GNP GNP GNP GNP
COUGH/COLD/ALLERGY COMBINATIONS prometh vc syp plain
GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
56
Drug Name promethazine w/ codeine syrup 6.25-10 mg/5ml hydrocod polst-chlorphen polst er susp 108 mg/5ml prometh vc/ syp codeine promethazine-dm syrup 6.25-15 mg/5ml
Drug Tier Requirements/Limits GP GNP GNP GP
BRONCHODILATORS ANTICHOLINERGICS TUDORZA PRES AER 400/ACT ipratropium bromide inhal soln 0.02% ATROVENT HFA AER 17MCG SPIRIVA CAP HANDIHLR SPIRIVA AER 1.25MCG SPIRIVA SPR 2.5MCG
BNP GNP BP BP BP BP
PAR
ANTIINFLAMMATORY AGENTS cromolyn sodium soln nebu 20 mg/2ml
GNP
SYMPATHOMIMETICS albuterol sulfate tab 2 mg GNP albuterol sulfate tab 4 mg GNP albuterol sulfate syrup 2 mg/5ml GP albuterol sulfate soln nebu 0.083% (2.5 GNP mg/3ml) albuterol sulfate soln nebu 0.5% (5 mg/ml)GNP albuterol sulfate soln nebu 0.63 mg/3ml GNP (base equiv) albuterol sulfate soln nebu 1.25 mg/3ml GNP (base equiv) VENTOLIN HFA AER BP albuterol sulfate tab sr 12hr 4 mg GNP albuterol sulfate tab sr 12hr 8 mg GNP PROAIR RESPI AER BP BROVANA NEB 15MCG BNP FORADIL CAP AEROLIZE BP ARCAPTA CAP 75MCG BNP levalbuterol hcl soln nebu 0.31 mg/3ml GNP (base equiv) levalbuterol hcl soln nebu 0.63 mg/3ml GNP (base equiv) levalbuterol hcl soln nebu 1.25 mg/3ml GNP (base equiv) levalbuterol hcl soln nebu conc 1.25 GNP mg/0.5ml (base equiv) metaproterenol sulfate tab 10 mg GNP metaproterenol sulfate tab 20 mg GNP metaproterenol sulfate syrup 10 mg/5ml GNP PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
57
Drug Name Drug Tier Requirements/Limits SEREVENT DIS AER 50MCG BP terbutaline sulfate tab 2.5 mg GNP terbutaline sulfate tab 5 mg GNP ipratropium-albuterol nebu soln 0.5-2.5(3) GNP mg/3ml COMBIVENT AER 20-100 BP SYMBICORT AER 80-4.5 BNP QLL (1 inhaler per 30 days), PAR SYMBICORT AER 160-4.5 BNP QLL (1 inhaler per 30 days), PAR ADVAIR HFA AER 45/21 BP QLL (1 inhaler per 30 days) ADVAIR HFA AER 115/21 BP QLL (1 inhaler per 30 days) ADVAIR HFA AER 230/21 BP QLL (1 inhaler per 30 days) ADVAIR DISKU AER 100/50 BP QLL (1 inhaler per 30 days) ADVAIR DISKU AER 250/50 BP QLL (1 inhaler per 30 days) ADVAIR DISKU AER 500/50 BP QLL (1 inhaler per 30 days) BREO ELLIPTA INH 100-25 BP QLL (1 inhaler per 30 days) BREO ELLIPTA INH 200-25 BP QLL (1 inhaler per 30 days) DULERA AER 100-5MCG BP QLL (1 inhaler per 30 days) DULERA AER 200-5MCG BP QLL (1 inhaler per 30 days) ANORO ELLIPT AER 62.5-25 BP
XANTHINES LUFYLLIN TAB 400MG ELIXOPHYLLIN ELX 80/15ML theophylline soln 80 mg/15ml THEO-24 CAP 100MG CR THEO-24 CAP 200MG CR THEO-24 CAP 300MG CR THEO-24 CAP 400MG ER theophylline tab sr 12hr 100 mg theophylline tab sr 12hr 200 mg theophylline tab sr 12hr 300 mg theophylline tab sr 12hr 450 mg theophylline tab sr 24hr 400 mg theophylline tab sr 24hr 600 mg
BNP BP GNP BP BP BP BP GP GNP GNP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
58
Drug Name
Drug Tier Requirements/Limits
STEROID INHALANTS QVAR AER 40MCG
BNP
QVAR AER 80MCG
BNP
budesonide inhalation susp 0.25 mg/2ml budesonide inhalation susp 0.5 mg/2ml ALVESCO AER 80MCG
GNP GNP BNP
ALVESCO AER 160MCG
BNP
FLOVENT DISK AER 50MCG
BP
FLOVENT DISK AER 100MCG
BP
FLOVENT DISK AER 250MCG
BP
FLOVENT HFA AER 44MCG
BP
FLOVENT HFA AER 110MCG
BP
FLOVENT HFA AER 220MCG
BP
ASMANEX HFA AER 100 MCG
BP
ASMANEX HFA AER 200 MCG
BP
ASMANEX 30 AER 110MCG
BP
ASMANEX 30 AER 220MCG
BP
QLL (1 inhaler per 30 days) QLL (1 inhaler per 30 days)
QLL (2 days) QLL (2 days) QLL (1 days) QLL (1 days) QLL (1 days) QLL (1 days) QLL (1 days) QLL (1 days) QLL (1 days) QLL (1 days) QLL (1 days) QLL (1 days)
inhalers / 30 inhalers / 30 inhaler per 30 inhaler per 30 inhaler per 30 inhaler per 30 inhaler per 30 inhaler per 30 inhaler per 30 inhaler per 30 inhaler per 30 inhaler per 30
SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS DALIRESP TAB 500MCG
BNP
LEUKOTRIENE MODULATORS ZYFLO TAB 600MG BNP ZYFLO CR TAB 600MG BNP montelukast sodium tab 10 mg (base GNP equiv) montelukast sodium chew tab 4 mg (base GNP equiv) montelukast sodium chew tab 5 mg (base GNP equiv) montelukast sodium oral granules packet 4 GNP mg (base equiv) zafirlukast tab 10 mg GNP PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
59
Drug Name zafirlukast tab 20 mg
Drug Tier Requirements/Limits GNP
ASTHMA AND BRONCHODILATOR AGENT COMBINATIONS difil-g fort liq 100-100
GNP
CYSTIC FIBROSIS AGENTS KALYDECO TAB 150MG KALYDECO PAK 50MG KALYDECO PAK 75MG PULMOZYME SOL 1MG/ML ORKAMBI TAB 200-125
BP BP BP BP BP
PAR; PAR; PAR; SRx PAR;
SRx SRx SRx
BP BP BP
PAR; SRx PAR; SRx PAR; SRx
SRx
PULMONARY FIBROSIS AGENTS ESBRIET CAP 267MG OFEV CAP 100MG OFEV CAP 150MG
SALINE LAXATIVES OSMOPREP TAB 1.5GM
BNP
LAXATIVES MISCELLANEOUS lactulose solution 10 gm/15ml
GNP
LAXATIVE COMBINATIONS PREPOPIK PAK SUPREP BOWEL SOL PREP peg 3350-kcl-sod bicarb-nacl for soln 420 gm bisacodyl tab & peg 3350-kcl-sod bicarbnacl for soln kit peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm MOVIPREP SOL
BNP BNP GNP
PHC PHC
GNP
PHC
GP GNP BNP
PHC
ANTIPERISTALTIC AGENTS diphenoxylate w/ atropine tab 2.5-0.025 mg diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml MOTOFEN TAB opium tincture 1% (10 mg/ml) (morphine equiv) paregoric tincture 2 mg/5ml
GNP GNP BNP GNP GNP
ANTISPASMODICS hyoscyamine sulfate tab 0.125 mg symax-sl sub 0.125mg hyoscyamine sulfate elixir 0.125 mg/5ml hyoscyamine sulfate soln 0.125 mg/ml
GNP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
60
Drug Name Drug Tier Requirements/Limits symax fastab tab 0.125mg GNP symax-sr tab 0.375mg GNP glycopyrrolate tab 1 mg GNP glycopyrrolate tab 2 mg GNP CANTIL TAB 25MG BNP methscopolamine bromide tab 2.5 mg GNP methscopolamine bromide tab 5 mg GNP propantheline bromide tab 15 mg GNP dicyclomine hcl cap 10 mg GNP dicyclomine hcl tab 20 mg GNP dicyclomine hcl oral soln 10 mg/5ml GNP BELLA/OPIUM SUP 16.2-30 BP BELLA/OPIUM SUP 16.2-60 BP chlordiazepoxide hcl-clidinium bromide cap GNP 5-2.5 mg GASTRINEX NF CAP BNP
H2 ANTAGONISTS cimetidine tab 300 mg GP cimetidine tab 400 mg GNP cimetidine tab 800 mg GNP cimetidine hcl soln 300 mg/5ml GNP ranitidine hcl cap 300 mg GNP ranitidine hcl tab 300 mg GNP ranitidine hcl syrup 15 mg/ml (75 mg/5ml) GNP famotidine tab 40 mg GNP famotidine for susp 40 mg/5ml GNP nizatidine cap 150 mg GNP nizatidine cap 300 mg GNP nizatidine oral soln 15 mg/ml GNP
ULCER DRUGS PROSTAGLANDINS misoprostol tab 100 mcg misoprostol tab 200 mcg
GNP GNP
PROTON PUMP INHIBITORS DEXILANT CAP 30MG DR DEXILANT CAP 60MG DR NEXIUM GRA 2.5MG DR NEXIUM GRA 5MG DR NEXIUM GRA 10MG DR NEXIUM GRA 20MG DR NEXIUM GRA 40MG DR esomeprazole magnesium cap delayed release 40 mg (base eq) NEXIUM CAP 40MG
BP BP BNP BNP BNP BNP BNP GNP
QLL (30 ea / 30 days) QLL (30 ea / 30 days)
BNP
QLL (30 ea / 30 days); EPA
QLL (30 ea / 30 days)
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
61
Drug Name 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 PRILOSEC POW 2.5MG PRILOSEC POW 10MG pantoprazole sodium ec tab 20 mg (base equiv) pantoprazole sodium ec tab 40 mg (base equiv) rabeprazole sodium ec tab 20 mg
Drug Tier Requirements/Limits GNP QLL (30 ea / 30 days) GNP QLL (30 ea / 30 days) GNP QLL (30 ea / 30 days) GNP GNP QLL (30 ea / 30 days) BP BP GNP QLL (30 ea / 30 days) GNP
QLL (30 ea / 30 days)
GNP
QLL (30 ea / 30 days)
MISC. ANTIULCER sucralfate tab 1 gm CARAFATE SUS 1GM/10ML
GNP BP
ULCER THERAPY COMBINATIONS omeprazole-sodium bicarbonate cap 401100 mg
GNP
QLL (30 caps / 30 days)
ANTIEMETICS ANTICHOLINERGIC meclizine hcl tab 12.5 mg meclizine hcl tab 25 mg vertin-32 tab TRANSDERM-SC DIS 1MG trimethobenzamide hcl cap 300 mg
GNP GNP GNP BNP GNP
5HT3 RECEPTOR ANTAGONISTS ANZEMET TAB 50MG
BNP
ANZEMET TAB 100MG
BNP
granisetron hcl tab 1 mg
GNP
ondansetron orally disintegrating tab 4 mg GNP ondansetron orally disintegrating tab 8 mg GNP ondansetron hcl tab 4 mg
GNP
ondansetron hcl tab 8 mg
GNP
ondansetron hcl tab 24 mg
GNP
ondansetron hcl oral soln 4 mg/5ml
GNP
QLL (5 tabs per prescription) QLL (5 tabs per prescription) QLL (8 tabs per prescription) QLL (24 tabs per prescription) QLL (24 tabs per prescription) QLL (24 tabs per prescription) QLL (24 tabs per prescription) QLL (8 tabs per prescription) QLL (250 ml's per prescription)
SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
62
Drug Name EMEND CAP 40MG EMEND CAP 80MG EMEND CAP 125MG EMEND PAK 80 & 125
Drug Tier Requirements/Limits BP QLL (8 caps per prescription) BP QLL (8 caps per prescription) BP QLL (4 caps per prescription) BP QLL (4 packs per prescription)
ANTIEMETICS MISCELLANEOUS dronabinol cap 2.5 mg dronabinol cap 5 mg dronabinol cap 10 mg CESAMET CAP 1MG
GNP GNP GNP BNP
QLL (6 caps per prescription)
DIGESTIVE ENZYMES CREON CAP 3000UNIT pancrelipase (lip-prot-amyl) dr cap 500017000-27000 unit CREON CAP 6000UNIT CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 36000UNT SUCRAID SOL 8500/ML
BP GNP BP BP BP BP BP
GALLSTONE SOLUBILIZING AGENTS ursodiol cap 300 mg ursodiol tab 250 mg ursodiol tab 500 mg
GNP GNP GNP
GASTROINTESTINAL ANTIALLERGY AGENTS cromolyn sodium oral conc 100 mg/5ml
GNP
GASTROINTESTINAL STIMULANTS metoclopramide hcl tab 5 mg metoclopramide hcl tab 10 mg metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)
GP GP GP
INTESTINAL ACIDIFIERS enulose sol 10gm/15
GNP
GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS AMITIZA CAP 8MCG AMITIZA CAP 24MCG
BNP BNP
PAR PAR
INFLAMMATORY BOWEL AGENTS balsalazide disodium cap 750 mg PENTASA CAP 250MG CR PENTASA CAP 500MG CR
GNP BP BP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
63
Drug Name ASACOL HD TAB 800MG mesalamine tab delayed release 800 mg LIALDA TAB 1.2GM mesalamine enema 4 gm CANASA SUP 1000MG DELZICOL CAP 400MG mesalamine rectal enema 4 gm & cleanser wipe kit DIPENTUM CAP 250MG sulfasalazine tab 500 mg sulfasalazin tab 500mg dr CIMZIA PREFL KIT 200MG/ML CIMZIA KIT STARTER
Drug Tier Requirements/Limits BP GNP BP GNP BP BP GNP BNP GNP GNP BNP BNP
PAR; SRx PAR; SRx
IRRITABLE BOWEL SYNDROME (IBS) AGENTS alosetron hcl tab 0.5 mg (base equiv)
GNP
alosetron hcl tab 1 mg (base equiv)
GNP
LINZESS CAP 145MCG LINZESS CAP 290MCG
BP BP
To prescribe Alosetron Hydrochloride Tablets, the prescriber must be enrolled in the Alosetron REMS Program. To prescribe Alosetron Hydrochloride Tablets, the prescriber must be enrolled in the Alosetron REMS Program.
PERIPHERAL OPIOID RECEPTOR ANTAGONISTS RELISTOR INJ 8/0.4ML RELISTOR INJ 12/0.6ML MOVANTIK TAB 12.5MG MOVANTIK TAB 25MG
BNP BNP BP BP
BILE ACID SYNTHESIS DISORDER AGENTS CHOLBAM CAP 50MG CHOLBAM CAP 250MG
BP BP
PAR; SRx PAR; SRx
PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) cap 667 mg (169 mg ca) calcium acetate (phosphate binder) tab 667 mg FOSRENOL CHW 500MG FOSRENOL CHW 750MG FOSRENOL CHW 1000MG FOSRENOL POW 750MG FOSRENOL POW 1000MG
GNP GNP BNP BNP BNP BNP BNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
64
Drug Name RENVELA TAB 800MG RENVELA PAK 0.8GM RENVELA PAK 2.4GM RENAGEL TAB 400MG RENAGEL TAB 800MG
Drug Tier Requirements/Limits BNP BP BP BP BP
URINARY ANTIINFECTIVES MONUROL PAK GRANULES BNP methenamine mandelate tab 0.5 gm GNP methenamine mandelate tab 1 gm GNP methenamine hippurate tab 1 gm GNP nitrofurantoin susp 25 mg/5ml GNP nitrofurantoin macrocrystalline cap 50 mg GNP nitrofurantoin macrocrystalline cap 100 mg GNP nitrofurantoin monohydrate GNP macrocrystalline cap 100 mg
URINARY ANTIINFECTIVE COMBINATIONS uryl tab hyophen tab uticap cap urin d/s tab
GNP GNP GNP GP
URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC) darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv)
GNP
URINARY ANTISPASMODIC ANTIMUSCARINICS (ANTICHOLINERGIC) ENABLEX TAB 7.5MG
BNP
PAR
URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC) darifenacin hydrobromide tab sr 24hr 15 mg (base equiv)
GNP
URINARY ANTISPASMODIC ANTIMUSCARINICS (ANTICHOLINERGIC) ENABLEX TAB 15MG TOVIAZ TAB 4MG TOVIAZ TAB 8MG GELNIQUE GEL 3% oxybutynin chloride tab 5 mg oxybutynin chloride syrup 5 mg/5ml GELNIQUE GEL 10% oxybutynin chloride tab sr 24hr 5 mg oxybutynin chloride tab sr 24hr 10 mg oxybutynin chloride tab sr 24hr 15 mg VESICARE TAB 5MG VESICARE TAB 10MG
BNP BNP BNP BP GNP GP BP GNP GNP GNP BP BP
PAR PAR PAR
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
65
Drug Name tolterodine tartrate tab 1 mg tolterodine tartrate tab 2 mg tolterodine tartrate cap sr 24hr 2 mg tolterodine tartrate cap sr 24hr 4 mg trospium chloride tab 20 mg trospium chloride cap sr 24hr 60 mg
Drug Tier Requirements/Limits GNP GNP GNP GNP GNP GNP
URINARY ANTISPASMODICS BETA3 ADRENERGIC AGONISTS MYRBETRIQ TAB 25MG MYRBETRIQ TAB 50MG
BNP BNP
PAR PAR
URINARY ANTISPASMODICS CHOLINERGIC AGONISTS bethanechol bethanechol bethanechol bethanechol
chloride chloride chloride chloride
tab tab tab tab
5 mg 10 mg 25 mg 50 mg
GNP GNP GNP GNP
URINARY ANTISPASMODICS DIRECT MUSCLE RELAXANTS flavoxate hcl tab 100 mg
GNP
VAGINAL ANTIINFECTIVES clindamycin phosphate vaginal cream 2% GNP metronidazole vaginal gel 0.75% GNP AVC CRE 15% BP GYNAZOLE-1 CRE 2% BNP zazole cre 0.4% GNP zazole cre 0.8% GNP zazole sup 80mg GNP
SPERMICIDES VCF VAGINAL AER CONTRACP SHUR-SEAL GEL 2% GYNOL II GEL 3% vcf vaginal gel contrace ENCARE SUP 100MG TODAY SPONGE MIS VCF VAGINAL MIS CONTRACP
BNP BNP BNP GNP BNP BNP BNP
PHC, PHC, PHC, PHC, PHC, PHC, PHC,
OTC OTC OTC OTC OTC OTC OTC
VAGINAL ESTROGENS VAGIFEM TAB 10MCG ESTRACE VAG CRE 0.1MG/GM ESTRING MIS 2MG PREMARIN VAG CRE 0.625MG
BP BP BP BP
VAGINAL PROGESTINS PROGESTERONE PROGESTERONE PROGESTERONE PROGESTERONE PROGESTERONE
SUP SUP SUP SUP SUP
VGS VGS VGS VGS VGS
25 50 100 200 400
BP BP BP BP BP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
66
Drug Name
Drug Tier Requirements/Limits
MISCELLANEOUS VAGINAL PRODUCTS relagard gel
GNP
ALKALINIZERS potassium citrate potassium citrate potassium citrate virtrate-2 sol ORACIT SOL virtrate-k sol potassium citrate 3300-1002 mg cytra-3 syp virtrate-3 sol
tab cr 5 meq (540 mg) GNP tab cr 10 meq (1080 mg) GNP tab cr 15 meq (1620 mg) GNP GNP BP GNP & citric acid powder pack GNP GNP GNP
URINARY ANALGESICS phenazopyridine hcl tab 100 mg phenazopyridine hcl tab 200 mg
GP GNP
CYSTINOSIS AGENTS CYSTAGON CAP 50MG CYSTAGON CAP 150MG
BP BP
PAR; SRx PAR; SRx
INTERSTITIAL CYSTITIS AGENTS ELMIRON CAP 100MG
BP
GENITOURINARY IRRIGANTS acetic acid irrigation soln 0.25% glycine irrigation soln 1.5% sodium chloride irrigation soln 0.9% neomycin-polymyxin b gu irrigation soln
GNP GNP GNP GNP
PROSTATIC HYPERTROPHY AGENTS AVODART CAP 0.5MG BP dutasteride cap 0.5 mg GNP finasteride tab 5 mg GNP alfuzosin hcl tab sr 24hr 10 mg GNP RAPAFLO CAP 4MG BNP RAPAFLO CAP 8MG BNP tamsulosin hcl cap 0.4 mg GNP dutasteride-tamsulosin hcl cap 0.5-0.4 mg GNP JALYN CAP BP
BENZODIAZEPINES alprazolam tab 0.25 mg alprazolam tab 0.5 mg alprazolam tab 1 mg alprazolam tab 2 mg ALPRAZOLAM CON 1 MG/ML
GP GP GP GNP BP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
67
Drug Name Drug Tier Requirements/Limits alprazolam orally disintegrating tab 0.25 GNP mg alprazolam orally disintegrating tab 0.5 mg GNP alprazolam orally disintegrating tab 1 mg GNP alprazolam orally disintegrating tab 2 mg GNP alprazolam tab sr 24hr 0.5 mg GNP alprazolam tab sr 24hr 1 mg GNP alprazolam tab sr 24hr 2 mg GNP alprazolam tab sr 24hr 3 mg GNP chlordiazepoxide hcl cap 5 mg GP chlordiazepoxide hcl cap 10 mg GP chlordiazepoxide hcl cap 25 mg GP clorazepate dipotassium tab 3.75 mg GNP clorazepate dipotassium tab 7.5 mg GNP clorazepate dipotassium tab 15 mg GNP diazepam tab 2 mg GP diazepam tab 5 mg GP diazepam tab 10 mg GP diazepam con 5mg/ml GNP diazepam oral soln 1 mg/ml GP lorazepam tab 0.5 mg GNP lorazepam tab 1 mg GP lorazepam tab 2 mg GNP lorazepam conc 2 mg/ml GNP oxazepam cap 10 mg GNP oxazepam cap 15 mg GNP oxazepam cap 30 mg GNP
ANTIANXIETY AGENTS MISC. buspirone hcl tab 5 mg buspirone hcl tab 7.5 mg buspirone hcl tab 10 mg buspirone hcl tab 15 mg buspirone hcl tab 30 mg hydroxyzine hcl tab 10 mg hydroxyzine hcl tab 25 mg hydroxyzine hcl tab 50 mg hydroxyzine hcl syrup 10 mg/5ml hydroxyzine pamoate cap 25 mg hydroxyzine pamoate cap 50 mg hydroxyzine pamoate cap 100 mg meprobamate tab 200 mg meprobamate tab 400 mg
GP GNP GP GP GNP GNP GNP GNP GP GNP GP GNP GNP GNP
ALPHA2 RECEPTOR ANTAGONISTS (TETRACYCLICS) mirtazapine tab 7.5 mg
GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
68
Drug Name mirtazapine mirtazapine mirtazapine mirtazapine mirtazapine mirtazapine
Drug Tier Requirements/Limits tab 15 mg GP tab 30 mg GNP tab 45 mg GNP orally disintegrating tab 15 mg GNP orally disintegrating tab 30 mg GNP orally disintegrating tab 45 mg GNP
MONOAMINE OXIDASE INHIBITORS (MAOIS) MARPLAN TAB 10MG phenelzine sulfate tab 15 mg EMSAM DIS 6MG/24HR EMSAM DIS 9MG/24HR EMSAM DIS 12MG/24H tranylcypromine sulfate tab 10 mg
BP GNP BNP BNP BNP GNP
PAR PAR PAR
SEROTONIN MODULATORS nefazodone hcl tab 50 mg nefazodone hcl tab 100 mg nefazodone hcl tab 150 mg nefazodone hcl tab 200 mg nefazodone hcl tab 250 mg trazodone hcl tab 50 mg trazodone hcl tab 100 mg trazodone hcl tab 150 mg trazodone hcl tab 300 mg VIIBRYD TAB 10MG VIIBRYD TAB 20MG VIIBRYD TAB 40MG VIIBRYD KIT
GNP GNP GNP GNP GNP GP GP GP GNP BNP BNP BNP BNP
PAR PAR PAR PAR
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram hydrobromide tab 10 mg (base equiv) citalopram hydrobromide tab 20 mg (base equiv) citalopram hydrobromide tab 40 mg (base equiv) citalopram hydrobromide oral soln 10 mg/5ml escitalopram oxalate tab 5 mg (base equiv) escitalopram oxalate tab 10 mg (base equiv) escitalopram oxalate tab 20 mg (base equiv) escitalopram oxalate soln 5 mg/5ml (base equiv)
GNP
QLL (30 tabs / 30 days)
GNP
QLL (60 tabs / 30 days)
GNP
QLL (30 tabs / 30 days)
GNP GNP
QLL (30 tabs / 30 days)
GNP
QLL (30 tabs / 30 days)
GNP
QLL (30 tabs / 30 days)
GNP
QLL (720 ml's / 30 days)
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
69
Drug Name fluoxetine hcl cap 10 mg fluoxetine hcl cap 20 mg fluoxetine hcl cap 40 mg fluoxetine hcl tab 10 mg fluoxetine hcl tab 20 mg FLUOXETINE TAB 60MG fluoxetine hcl solution 20 mg/5ml fluoxetine hcl cap delayed release 90 mg fluvoxamine maleate tab 25 mg fluvoxamine maleate tab 50 mg fluvoxamine maleate tab 100 mg fluvoxamine maleate cap sr 24hr 100 mg fluvoxamine maleate cap sr 24hr 150 mg paroxetine hcl tab 10 mg paroxetine hcl tab 20 mg paroxetine hcl tab 30 mg paroxetine hcl tab 40 mg PAXIL SUS 10MG/5ML paroxetine hcl tab sr 24hr 12.5 mg paroxetine hcl tab sr 24hr 25 mg paroxetine hcl tab sr 24hr 37.5 mg sertraline hcl tab 25 mg sertraline hcl tab 50 mg sertraline hcl tab 100 mg sertraline hcl oral conc 20 mg/ml
Drug Tier Requirements/Limits GP QLL (90 caps / 30 days) GNP QLL (90 caps / 30 days) GNP GP QLL (90 tabs / 30 days) GNP QLL (90 tabs / 30 days) BNP PAR GNP GNP QLL (4 ea / 30 days) GNP GNP GNP GNP GNP GP QLL (60 tabs / 30 days) GP QLL (60 tabs / 30 days) GNP QLL (60 tabs / 30 days) GP QLL (30 tabs / 30 days) BNP PAR GNP QLL (30 ea / 30 days) GNP QLL (30 ea / 30 days) GNP GP GP GP GNP
SEROTONINNOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) PRISTIQ TAB 25MG
BNP
PRISTIQ TAB 50MG
BNP
PRISTIQ TAB 100MG
BNP
QLL (30 ea / 30 days), PAR QLL (30 ea / 30 days), PAR QLL (30 ea / 30 days), PAR
duloxetine hcl enteric coated pellets cap 20 GNP mg duloxetine hcl enteric coated pellets cap 30 GNP mg duloxetine hcl enteric coated pellets cap 60 GNP mg venlafaxine hcl tab 25 mg GNP venlafaxine hcl tab 37.5 mg GNP venlafaxine hcl tab 50 mg GNP venlafaxine hcl tab 75 mg GNP venlafaxine hcl tab 100 mg GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
70
Drug Name venlafaxine hcl equivalent) venlafaxine hcl equivalent) venlafaxine hcl equivalent) venlafaxine hcl equivalent) venlafaxine hcl equivalent) venlafaxine hcl equivalent) venlafaxine hcl equivalent)
Drug Tier Requirements/Limits cap sr 24hr 37.5 mg (base GNP QLL (90 ea / 30 days) cap sr 24hr 75 mg (base
GNP
QLL (90 ea / 30 days)
cap sr 24hr 150 mg (base
GNP
QLL (60 ea / 30 days)
tab sr 24hr 37.5 mg (base GNP
QLL (90 ea / 30 days)
tab sr 24hr 75 mg (base
GNP
QLL (90 ea / 30 days)
tab sr 24hr 150 mg (base
GNP
QLL (60 ea / 30 days)
tab sr 24hr 225 mg (base
GNP
QLL (30 ea / 30 days)
TRICYCLIC AGENTS amitriptyline hcl tab 10 mg amitriptyline hcl tab 25 mg amitriptyline hcl tab 50 mg amitriptyline hcl tab 75 mg amitriptyline hcl tab 100 mg amitriptyline hcl tab 150 mg amoxapine tab 25 mg amoxapine tab 50 mg amoxapine tab 100 mg amoxapine tab 150 mg clomipramine hcl cap 25 mg clomipramine hcl cap 50 mg clomipramine hcl cap 75 mg desipramine hcl tab 10 mg desipramine hcl tab 25 mg desipramine hcl tab 50 mg desipramine hcl tab 75 mg desipramine hcl tab 100 mg desipramine hcl tab 150 mg doxepin hcl cap 10 mg doxepin hcl cap 25 mg doxepin hcl cap 50 mg doxepin hcl cap 75 mg doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl conc 10 mg/ml imipramine hcl tab 10 mg imipramine hcl tab 25 mg imipramine hcl tab 50 mg
GP GP GP GP GNP GP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GP GNP GNP GNP GNP GNP GP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
71
Drug Name imipramine pamoate cap 75 mg imipramine pamoate cap 100 mg imipramine pamoate cap 125 mg imipramine pamoate cap 150 mg nortriptyline hcl cap 10 mg nortriptyline hcl cap 25 mg nortriptyline hcl cap 50 mg nortriptyline hcl cap 75 mg nortriptyline hcl soln 10 mg/5ml protriptyline hcl tab 5 mg protriptyline hcl tab 10 mg SURMONTIL CAP 25MG trimipramine maleate cap 25 mg SURMONTIL CAP 50MG trimipramine maleate cap 50 mg SURMONTIL CAP 100MG trimipramine maleate cap 100 mg
Drug Tier Requirements/Limits GNP GNP GNP GNP GNP GP GNP GP GNP GNP GNP BNP GNP BNP GNP BNP GNP
ANTIDEPRESSANTS MISC. maprotiline hcl tab 25 mg maprotiline hcl tab 50 mg maprotiline hcl tab 75 mg bupropion hcl tab 75 mg bupropion hcl tab 100 mg bupropion hcl tab sr 12hr 100 bupropion hcl tab sr 12hr 150 bupropion hcl tab sr 12hr 200 bupropion hcl tab sr 24hr 150 bupropion hcl tab sr 24hr 300
mg mg mg mg mg
GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
BENZISOXAZOLES FANAPT FANAPT FANAPT FANAPT FANAPT FANAPT FANAPT FANAPT INVEGA
TAB TAB TAB TAB TAB TAB TAB PAK TAB
1MG 2MG 4MG 6MG 8MG 10MG 12MG 1.5MG
BNP BNP BNP BNP BNP BNP BNP BNP BNP
paliperidone tab sr 24hr 1.5 mg INVEGA TAB 3MG
GNP BNP
paliperidone tab sr 24hr 3 mg
GNP
PAR PAR PAR PAR PAR PAR PAR PAR QLL (60 PAR QLL (60 QLL (60 PAR QLL (60
ea / 30 days), ea / 30 days) ea / 30 days), ea / 30 days)
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
72
Drug Name INVEGA TAB 6MG paliperidone tab sr 24hr 6 mg INVEGA TAB 9MG
Drug Tier Requirements/Limits BNP QLL (60 ea / 30 days), PAR GNP QLL (60 ea / 30 days) BNP QLL (60 ea / 30 days), PAR GNP QLL (60 ea / 30 days) GNP GNP GP GNP GNP GNP GNP GNP
paliperidone tab sr 24hr 9 mg risperidone tab 0.25 mg risperidone tab 0.5 mg risperidone tab 1 mg risperidone tab 2 mg risperidone tab 3 mg risperidone tab 4 mg risperidone soln 1 mg/ml risperidone orally disintegrating tab 0.25 mg risperidone orally disintegrating tab 0.5 mg GNP risperidone tab 1mg odt GNP risperidone tab 2mg odt GNP risperidone tab 3mg odt GNP risperidone tab 4mg odt GNP
BUTYROPHENONES haloperidol haloperidol haloperidol haloperidol haloperidol haloperidol haloperidol haloperidol haloperidol
tab 0.5 mg tab 1 mg tab 2 mg tab 5 mg tab 10 mg tab 20 mg lactate oral conc 2 mg/ml decanoate im soln 50 mg/ml decanoate im soln 100 mg/ml
GNP GNP GNP GNP GNP GNP GP GNP GNP
DIBENZAPINES clozapine tab 25 mg clozapine tab 50 mg clozapine tab 100 mg clozapine tab 200 mg clozapine orally disintegrating tab 12.5 mg clozapine orally disintegrating tab 25 mg clozapine orally disintegrating tab 100 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
GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
73
Drug Name SEROQUEL XR TAB 50MG SEROQUEL XR TAB 150MG SEROQUEL XR TAB 200MG SEROQUEL XR TAB 300MG SEROQUEL XR TAB 400MG loxapine succinate cap 5 mg loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 50 mg SAPHRIS SUB 2.5MG SAPHRIS SUB 5MG SAPHRIS SUB 10MG olanzapine tab 2.5 mg olanzapine tab 5 mg olanzapine tab 7.5 mg olanzapine tab 10 mg olanzapine tab 15 mg olanzapine tab 20 mg olanzapine orally disintegrating olanzapine orally disintegrating olanzapine orally disintegrating olanzapine orally disintegrating
Drug Tier Requirements/Limits BNP QLL (60 ea / 30 days), PAR BNP QLL (60 ea / 30 days), PAR BNP QLL (60 ea / 30 days), PAR BNP QLL (60 ea / 30 days), PAR BNP QLL (60 ea / 30 days), PAR GNP GNP GNP GNP BNP PAR BNP PAR BNP PAR GNP QLL (30 tabs / 30 days) GNP QLL (30 tabs / 30 days) GNP QLL (30 tabs / 30 days) GNP QLL (30 tabs / 30 days) GNP QLL (30 tabs / 30 days) GNP QLL (30 tabs / 30 days) tab 5 mg GNP QLL (30 ea / 30 days) tab 10 mg GNP QLL (30 ea / 30 days) tab 15 mg GNP QLL (30 ea / 30 days) tab 20 mg GNP QLL (30 ea / 30 days)
PHENOTHIAZINES chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 25 mg chlorpromazine hcl tab 50 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 200 mg fluphenazine hcl tab 1 mg fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg fluphenazine hcl tab 10 mg fluphenazine hcl elixir 2.5 mg/5ml fluphenazine hcl oral conc 5 mg/ml perphenazine tab 2 mg perphenazine tab 4 mg perphenazine tab 8 mg perphenazine tab 16 mg compazine sup 25mg
GNP GNP GNP GNP GNP GP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
74
Drug Name prochlorperazine maleate tab 5 mg (base equivalent) prochlorperazine maleate tab 10 mg (base equivalent) thioridazine hcl tab 10 mg thioridazine hcl tab 25 mg thioridazine hcl tab 50 mg thioridazine hcl tab 100 mg trifluoperazine hcl tab 1 mg trifluoperazine hcl tab 2 mg trifluoperazine hcl tab 5 mg trifluoperazine hcl tab 10 mg
Drug Tier Requirements/Limits GNP GNP GNP GNP GP GNP GNP GNP GNP GNP
QUINOLINONE DERIVATIVES aripiprazole aripiprazole aripiprazole aripiprazole aripiprazole aripiprazole aripiprazole
tab 2 mg tab 5 mg tab 10 mg tab 15 mg tab 20 mg tab 30 mg oral solution 1 mg/ml
GNP GNP GNP GNP GNP GNP GNP
THIOXANTHENES thiothixene thiothixene thiothixene thiothixene
cap cap cap cap
1 mg 2 mg 5 mg 10 mg
GNP GP GNP GNP
ANTIPSYCHOTICS MISC. LATUDA LATUDA LATUDA LATUDA
TAB TAB TAB TAB
20MG 40MG 80MG 120MG
BNP BNP BNP BNP
PAR PAR PAR PAR
BP
PAR
ANTIPSYCHOTICS - MISC. NUPLAZID TAB 17MG
ANTIPSYCHOTICS MISC. ziprasidone ziprasidone ziprasidone ziprasidone
hcl hcl hcl hcl
cap cap cap cap
20 40 60 80
mg mg mg mg
GNP GNP GNP GNP
ANTIMANIC AGENTS LITHIUM SOL 8MEQ/5ML lithium carbonate cap 150 mg lithium carbonate cap 300 mg lithium carbonate cap 600 mg lithium carbonate tab 300 mg
BP GP GP GP GP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
75
Drug Name lithium carbonate tab cr 300 mg lithium carbonate tab cr 450 mg
Drug Tier Requirements/Limits GNP GNP
BARBITURATE HYPNOTICS phenobarbital phenobarbital phenobarbital phenobarbital phenobarbital phenobarbital phenobarbital phenobarbital phenobarbital
tab 15 mg tab 16.2 mg tab 30 mg tab 32.4 mg tab 60 mg tab 64.8 mg tab 97.2 mg tab 100 mg elixir 20 mg/5ml
GNP GNP GP GNP GP GNP GNP GNP GNP
NONBARBITURATE HYPNOTICS estazolam tab 1 mg estazolam tab 2 mg flurazepam hcl cap 15 mg flurazepam hcl cap 30 mg midazolam hcl syrup 2 mg/ml (base equivalent) temazepam cap 7.5 mg temazepam cap 15 mg temazepam cap 22.5 mg temazepam cap 30 mg triazolam tab 0.125 mg triazolam tab 0.25 mg eszopiclone tab 1 mg eszopiclone tab 2 mg eszopiclone tab 3 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
GNP GNP GNP GP GNP GNP GP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
QLL QLL QLL QLL QLL QLL QLL QLL QLL
(30 (30 (30 (30 (30 (30 (30 (30 (30
tabs / 30 days) tabs / 30 days) tabs / 30 days) caps / 30 days) caps / 30 days) tabs / 30 days) tabs / 30 days) tabs / 30 days) tabs / 30 days)
SELECTIVE MELATONIN RECEPTOR AGONISTS ROZEREM TAB 8MG
BP
AMPHETAMINES zenzedi tab 2.5mg dextroamphetamine sulfate tab 5 mg zenzedi tab 7.5mg dextroamphetamine sulfate tab 10 mg dextroamphetamine sulfate oral solution 5 mg/5ml
GNP GNP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
76
Drug Name dextroamphetamine sulfate cap sr 24hr 5 mg dextroamphetamine sulfate cap sr 24hr 10 mg dextroamphetamine sulfate cap sr 24hr 15 mg VYVANSE CAP 10MG VYVANSE CAP 20MG VYVANSE CAP 30MG VYVANSE CAP 40MG VYVANSE CAP 50MG VYVANSE CAP 60MG VYVANSE CAP 70MG methamphetamine hcl tab 5 mg amphetamine-dextroamphetamine tab 5 mg amphetamine-dextroamphetamine tab 7.5 mg amphetamine-dextroamphetamine tab 10 mg amphetamine-dextroamphetamine tab 12.5 mg amphetamine-dextroamphetamine tab 15 mg amphetamine-dextroamphetamine tab 20 mg amphetamine-dextroamphetamine tab 30 mg amphetamine-dextroamphetamine cap sr 24hr 5 mg amphetamine-dextroamphetamine cap sr 24hr 10 mg amphetamine-dextroamphetamine cap sr 24hr 15 mg amphetamine-dextroamphetamine cap sr 24hr 20 mg amphetamine-dextroamphetamine cap sr 24hr 25 mg amphetamine-dextroamphetamine cap sr 24hr 30 mg
Drug Tier Requirements/Limits GNP GNP GNP BP BP BP BP BP BP BP GNP GNP
PAR
GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
ANALEPTICS caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)
GNP
ATTENTIONDEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
77
Drug Name guanfacine hcl tab sr 24hr equiv) guanfacine hcl tab sr 24hr equiv) guanfacine hcl tab sr 24hr equiv) guanfacine hcl tab sr 24hr equiv) STRATTERA CAP 10MG STRATTERA CAP 18MG STRATTERA CAP 25MG STRATTERA CAP 40MG STRATTERA CAP 60MG STRATTERA CAP 80MG STRATTERA CAP 100MG
1 mg (base
Drug Tier Requirements/Limits GNP
2 mg (base
GNP
3 mg (base
GNP
4 mg (base
GNP BNP BNP BNP BNP BNP BNP BNP
STIMULANTS MISC. armodafinil tab 50 mg NUVIGIL TAB 50MG armodafinil tab 150 mg NUVIGIL TAB 150MG armodafinil tab 200 mg NUVIGIL TAB 200MG armodafinil tab 250 mg NUVIGIL TAB 250MG dexmethylphenidate hcl tab 2.5 mg dexmethylphenidate hcl tab 5 mg dexmethylphenidate hcl tab 10 mg methylphenidate hcl cap cr 10 mg (cd) methylphenidate hcl cap cr 20 mg (cd) methylphenidate hcl cap cr 30 mg (cd) methylphenidate hcl cap cr 40 mg (cd) methylphenidate hcl cap cr 50 mg (cd) methylphenidate hcl cap cr 60 mg (cd) 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 27 mg methylphenidate hcl tab sa osm 36 mg methylphenidate hcl tab sa osm 54 mg methylphenidate hcl soln 5 mg/5ml methylphenidate hcl soln 10 mg/5ml
GNP BNP GNP BNP GNP BNP GNP BNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
PAR PAR PAR PAR PAR PAR PAR PAR
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
78
Drug Name methylphenidate hcl cap sr 24hr 20 mg (la) methylphenidate hcl cap sr 24hr 30 mg (la) methylphenidate hcl cap sr 24hr 40 mg (la) methylphenidate hcl tab sr 24hr 18 mg modafinil tab 100 mg modafinil tab 200 mg
Drug Tier Requirements/Limits GNP GNP GNP GNP GNP GNP
PAR PAR
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. ergoloid mesylates tab 1 mg ORAP TAB 1MG pimozide tab 1 mg ORAP TAB 2MG pimozide tab 2 mg
GNP BP GNP BP GNP
ANTIDEMENTIA AGENTS donepezil hydrochloride tab 5 mg donepezil hydrochloride tab 10 mg donepezil hydrochloride tab 23 mg donepezil hydrochloride orally disintegrating tab 5 mg donepezil hydrochloride orally disintegrating tab 10 mg galantamine hydrobromide tab 4 mg galantamine hydrobromide tab 8 mg galantamine hydrobromide tab 12 mg galantamine hydrobromide oral soln 4 mg/ml galantamine hydrobromide cap sr 24hr 8 mg galantamine hydrobromide cap sr 24hr 16 mg galantamine hydrobromide cap sr 24hr 24 mg rivastigmine tartrate cap 1.5 mg rivastigmine tartrate cap 3 mg rivastigmine tartrate cap 4.5 mg rivastigmine tartrate cap 6 mg memantine hcl tab 5 mg memantine hcl tab 10 mg memantine hcl tab 5 mg (28) & 10 mg (21) titration pak memantine hcl oral solution 2 mg/ml NAMENDA SOL 10MG/5ML NAMENDA XR CAP 7MG
GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP BP BP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
79
Drug Name NAMENDA XR NAMENDA XR NAMENDA XR NAMENDA XR
CAP CAP CAP CAP
14MG 21MG 28MG TITRATIO
Drug Tier Requirements/Limits BP BP BP BP
SMOKING DETERRENTS buproban tab 150mg NICOTROL NS SPR 10MG/ML NICOTROL INH nicotine td patch 24hr 7 mg/24hr
GNP BP BP GNP
nicotine td dis 14mg/24h
GNP
nicotine td patch 24hr 21 mg/24hr
GNP
nicotine pol gum 2mg
GNP
nicotine pol gum 4mg
GNP
nicotine polacrilex lozenge 2 mg
GNP
nicotine pol loz 4mg mint
GNP
CHANTIX TAB 0.5MG CHANTIX TAB 1MG CHANTIX PAK 0.5& 1MG
BP BP BP
QLL (180 QLL (180 QLL (180 QLL (180 OTC QLL (180 OTC QLL (180 OTC QLL (180 OTC QLL (180 OTC QLL (180 OTC QLL (180 OTC QLL (180 QLL (180 QLL (180
days); days); days); days);
PHC PHC PHC PHC,
days); PHC, days); PHC, days); PHC, days); PHC, days); PHC, days); PHC, days); PHC days); PHC days); PHC
PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS fluoxetine hcl (pmdd) cap 10 mg fluoxetine hcl (pmdd) cap 20 mg
GNP GNP
MOVEMENT DISORDER DRUG THERAPY tetrabenazine tab 12.5 mg tetrabenazine tab 25 mg
GP GP
PAR; SRx PAR; SRx
GP BP BP BP BP
SRx SRx SRx SRx SRx
BP
SRx
BNP BNP BNP
SRx, EPA PAR; SRx PAR; SRx
MULTIPLE SCLEROSIS AGENTS glatopa inj 20mg/ml COPAXONE INJ 40MG/ML AVONEX KIT 30MCG AVONEX PEN KIT 30MCG AVONEX PREFL KIT 30MCG
Central Nervous System Agents BETASERON INJ 0.3MG
MULTIPLE SCLEROSIS AGENTS EXTAVIA INJ 0.3MG AUBAGIO TAB 7MG AUBAGIO TAB 14MG
Central Nervous System Agents PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
80
Drug Name TECFIDERA MIS STARTER TECFIDERA CAP 120MG TECFIDERA CAP 240MG
Drug Tier Requirements/Limits BP SRx BP SRx BP SRx
MULTIPLE SCLEROSIS AGENTS AMPYRA TAB 10MG
BP
GILENYA CAP 0.5MG
BP
QLL (2 ea / 30 days), PAR; SRx PAR; SRx
BNP
PAR
BP BP BP BP BP
EPA EPA EPA EPA EPA
ANTICATAPLECTIC AGENTS XYREM SOL 500MG/ML
FIBROMYALGIA AGENTS SAVELLA SAVELLA SAVELLA SAVELLA SAVELLA
TAB TAB TAB TAB MIS
12.5MG 25MG 50MG 100MG TITR PAK
RESTLESS LEG SYNDROME (RLS) AGENTS HORIZANT TAB 600MG
BNP
PSEUDOBULBAR AFFECT (PBA) AGENTS NUEDEXTA CAP 20-10MG
BNP
AGENTS FOR CHEMICAL DEPENDENCY acamprosate calcium tab delayed release 333 mg disulfiram tab 250 mg disulfiram tab 500 mg
GNP GNP GNP
COMBINATION PSYCHOTHERAPEUTICS chlordiazepoxide-amitriptyline tab 5-12.5 mg chlordiazepoxide-amitriptyline tab 10-25 mg perphenazine-amitriptyline tab 2-10 mg perphenazine-amitriptyline tab 2-25 mg perphenazine-amitriptyline tab 4-10 mg perphenazine-amitriptyline tab 4-25 mg perphenazine-amitriptyline tab 4-50 mg olanzapine-fluoxetine hcl cap 3-25 mg olanzapine-fluoxetine hcl cap 6-25 mg olanzapine-fluoxetine hcl cap 6-50 mg olanzapine-fluoxetine hcl cap 12-25 mg olanzapine-fluoxetine hcl cap 12-50 mg
GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
SALICYLATES
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
81
Drug Name ASPIRIN TAB 81MG
Drug Tier Requirements/Limits BP PHC, OTC; Limited to one dose per day (d325 mg) for men ages 45 to 79 and women ages 55 to 79. PAR required for preeclampsia. bayer asa tab 325mg GNP PHC, OTC; Limited to one dose per day (d325 mg) for men ages 45 to 79 and women ages 55 to 79. ST JOSEPH CHW 75MG ADU BNP PHC, OTC; Limited to one dose per day (d325 mg) for men ages 45 to 79 and women ages 55 to 79. aspirin low chw 81mg GNP PHC, OTC; Limited to one dose per day (d325 mg) for men ages 45 to 79 and women ages 55 to 79. PAR required for preeclampsia. aspirin tab delayed release 81 mg GNP PHC, OTC; Limited to one dose per day (d325 mg) for men ages 45 to 79 and women ages 55 to 79. PAR required for preeclampsia. aspirin tab delayed release 325 mg GNP PHC, OTC; Limited to one dose per day (d325 mg) for men ages 45 to 79 and women ages 55 to 79. diflunisal tab 500 mg GNP salsalate tab 500 mg GNP salsalate tab 750 mg GNP choline & magnesium salicylates tab 1000 GNP mg choline & magnesium salicylates liq 500 GNP mg/5ml
ANALGESIC COMBINATIONS ed-flex cap butalbital-acetaminophen tab 50-325 mg EQUAGESIC TAB 200-325 esgic cap
GNP GNP BP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
82
Drug Name Drug Tier Requirements/Limits butalbital-acetaminophen-caffeine tab 50- GNP 325-40 mg butalbital-aspirin-caffeine cap 50-325-40 GNP mg
OPIOID AGONISTS codeine sulfate tab 15 mg codeine sulfate tab 30 mg codeine sulfate tab 60 mg fentanyl td patch 72hr 12 mcg/hr
GP GNP GNP GNP
fentanyl td patch 72hr 25 mcg/hr
GNP
fentanyl td patch 72hr 50 mcg/hr
GNP
fentanyl td patch 72hr 75 mcg/hr
GNP
fentanyl td patch 72hr 100 mcg/hr
GNP
fentanyl citrate lozenge on a handle 200 GNP mcg fentanyl citrate lozenge on a handle 400 GNP mcg fentanyl citrate lozenge on a handle 600 GNP mcg fentanyl citrate lozenge on a handle 800 GNP mcg fentanyl citrate lozenge on a handle 1200 GNP mcg fentanyl citrate lozenge on a handle 1600 GNP mcg hydromorphone hcl tab 2 mg GNP hydromorphone hcl tab 4 mg GNP hydromorphone hcl tab 8 mg GNP hydromorphone hcl liqd 1 mg/ml GNP HYDROMORPHON SUP 3MG BP hydromorphone hcl tab er 24hr deter 8 mg GNP hydromorphone hcl tab er 24hr deter 12 GNP mg hydromorphone hcl tab er 24hr deter 16 GNP mg hydromorphone hcl tab er 24hr deter 32 GNP mg levorphanol tartrate tab 2 mg GNP meperidine hcl tab 50 mg GP meperidine hcl tab 100 mg GNP
QLL (15 patches per days) QLL (15 patches per days) QLL (15 patches per days) QLL (15 patches per days) QLL (15 patches per days) QLL (120 lpop / 30 days); EPA QLL (120 lpop / 30 days); EPA QLL (120 lpop / 30 days); EPA QLL (120 lpop / 30 days); EPA QLL (120 lpop / 30 days); EPA QLL (120 lpop / 30 days); EPA
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
30 30 30 30 30
83
Drug Name Drug Tier Requirements/Limits meperidine hcl oral soln 50 mg/5ml GNP methadone hcl tab 5 mg GNP methadone hcl tab 10 mg GNP methadone hcl conc 10 mg/ml GNP methadone hcl soln 5 mg/5ml GNP methadone hcl soln 10 mg/5ml GNP methadone hcl tab for oral susp 40 mg GNP METHADOSE TAB 40MG BNP morphine sulfate tab 15 mg GNP morphine sulfate tab 30 mg GNP morphine sulfate tab cr 15 mg GNP QLL (90 ea / 30 days) morphine sulfate tab cr 30 mg GNP QLL (90 ea / 30 days) morphine sulfate tab cr 60 mg GNP QLL (90 ea / 30 days) morphine sulfate tab cr 100 mg GNP QLL (90 ea / 30 days) morphine sulfate tab cr 200 mg GNP QLL (90 ea / 30 days) morphine sulfate oral soln 10 mg/5ml GNP morphine sulfate oral soln 20 mg/5ml GP morphine sulfate oral soln 100 mg/5ml (20 GNP mg/ml) morphine sulfate suppos 5 mg GNP morphine sulfate suppos 10 mg GNP morphine sulfate suppos 20 mg GNP MORPHINE SUL SUP 30MG BP morphine sulfate cap sr 24hr 10 mg GNP QLL (60 ea / 30 days) morphine sulfate cap sr 24hr 20 mg GNP QLL (60 ea / 30 days) morphine sulfate cap sr 24hr 30 mg GNP QLL (60 ea / 30 days) morphine sulfate cap sr 24hr 50 mg GNP QLL (60 ea / 30 days) morphine sulfate cap sr 24hr 60 mg GNP QLL (60 ea / 30 days) morphine sulfate cap sr 24hr 80 mg GNP QLL (60 ea / 30 days) morphine sulfate cap sr 24hr 100 mg GNP QLL (60 ea / 30 days) KADIAN CAP 200MG ER BP QLL (60 ea / 30 days) oxycodone hcl cap 5 mg GNP oxycodone hcl tab 5 mg GNP oxycodone hcl tab 10 mg GNP oxycodone hcl tab 15 mg GNP oxycodone hcl tab 20 mg GNP oxycodone hcl tab 30 mg GNP oxycodone hcl conc 100 mg/5ml (20 GNP mg/ml) oxycodone hcl soln 5 mg/5ml GNP OXYCONTIN TAB 10MG CR BNP QLL (90 tabs / 30 days) OXYCONTIN TAB 15MG CR BNP QLL (90 tabs / 30 days) OXYCONTIN TAB 20MG CR BNP QLL (90 tabs / 30 days) OXYCONTIN TAB 30MG CR BNP QLL (90 tabs / 30 days) PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
84
Drug Name 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 oxymorphone hcl tab sr 12hr oxymorphone hcl tab sr 12hr oxymorphone hcl tab sr 12hr oxymorphone hcl tab sr 12hr oxymorphone hcl tab sr 12hr oxymorphone hcl tab sr 12hr NUCYNTA TAB 50MG
5 mg 7.5 mg 10 mg 15 mg 20 mg 30 mg 40 mg
NUCYNTA TAB 75MG NUCYNTA TAB 100MG NUCYNTA ER TAB 50MG NUCYNTA ER TAB 100MG NUCYNTA ER TAB 150MG NUCYNTA ER TAB 200MG NUCYNTA ER TAB 250MG tramadol hcl tab 50 mg tramadol tramadol tramadol tramadol 100 mg tramadol 200 mg tramadol 300 mg
hcl hcl hcl hcl
tab tab tab tab
sr sr sr sr
24hr 24hr 24hr 24hr
100 mg 200 mg 300 mg biphasic release
Drug Tier Requirements/Limits BNP QLL (90 tabs / 30 days) BNP QLL (90 tabs / 30 days) BNP QLL (90 tabs / 30 days) GNP GNP GNP QLL (90 ea / 30 days) GNP QLL (90 ea / 30 days) GNP QLL (90 ea / 30 days) GNP QLL (90 ea / 30 days) GNP QLL (90 ea / 30 days) GNP QLL (90 ea / 30 days) GNP QLL (90 ea / 30 days) BNP QLL (360 tabs / 30 days) BNP QLL (240 tabs / 30 days) BNP QLL (180 tabs / 30 days) BNP QLL (60 ea / 30 days) BNP QLL (60 ea / 30 days) BNP QLL (60 ea / 30 days) BNP QLL (60 ea / 30 days) BNP QLL (60 ea / 30 days) GP QLL (240 tabs / 30 days) GNP QLL (90 ea / 30 days) GNP QLL (30 ea / 30 days) GNP QLL (30 ea / 30 days) GNP QLL (90 ea / 30 days)
hcl tab sr 24hr biphasic release
GNP
QLL (30 ea / 30 days)
hcl tab sr 24hr biphasic release
GNP
QLL (30 ea / 30 days)
OPIOID PARTIAL AGONISTS BUTRANS DIS 5MCG/HR BNP BUTRANS DIS 10MCG/HR BNP BUTRANS DIS 20MCG/HR BNP buprenorphine hcl sl tab 2 mg (base equiv) GNP buprenorphine hcl sl tab 8 mg (base equiv) GNP SUBOXONE MIS 2-0.5MG BP SUBOXONE MIS 4-1MG BP SUBOXONE MIS 8-2MG BP SUBOXONE MIS 12-3MG BP
QLL (4 ea / 28 days) QLL (4 ea / 28 days) QLL (4 ea / 28 days)
QLL (90 films / 30 days) QLL (90 films / 30 days) QLL (90 films / 30 days) QLL (60 films / 30 days)
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
85
Drug Name butorphanol tartrate nasal soln 10 mg/ml pentazocine w/ naloxone tab 50-0.5 mg
Drug Tier Requirements/Limits GNP QLL (4 spray pumps of 2.5ml's per prescription) GNP
OPIOID COMBINATIONS oxycodone w/ acetaminophen tab 2.5-325 mg oxycodone w/ acetaminophen tab 5-325 mg oxycodone w/ acetaminophen tab 7.5-325 mg oxycodone w/ acetaminophen tab 10-325 mg ROXICET SOL 5-325/5 ROXICET SOL 5-325/5 oxycodone-aspirin tab 4.8355-325 mg
GNP
oxycodone-ibuprofen tab 5-400 mg
GNP
GNP GNP GNP GNP BP GNP
acetaminophen w/ codeine tab 300-15 mg GP acetaminophen w/ codeine tab 300-30 mg GP acetaminophen w/ codeine tab 300-60 mg GNP acetaminophen w/ codeine soln 120-12 mg/5ml butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg ascomp/cod cap 30mg aspirin-caffeine-dihydrocodeine cap 356.430-16 mg hydrocodone-acetaminophen tab 2.5-325 mg lortab tab 10-325mg
tabs / 30
QLL (360 days) QLL (120 days) QLL (420 days) QLL (360 days) QLL (180 days)
tabs / 30
tabs / 30 tabs / 30 tabs / 30
tabs / 30 tabs / 30 tabs / 30 tabs / 30
GP GNP GNP GNP GNP GNP
hydrocodone-acetaminophen tab 5-300 mg GNP hydrocodone-acetaminophen tab 7.5-300 GNP mg hydrocodone-acetaminophen tab 5-325 mg GNP lortab tab 7.5-325
QLL (360 days) QLL (360 days) QLL (360 days) QLL (360 days)
GNP
QLL (360 tabs / 30 days) QLL (360 tabs / 30 days)
QLL (360 tabs / 30 days) QLL (360 tabs / 30 days)
vicodin hp tab 10-300mg GNP hydrocodone-acetaminophen soln 7.5-325 GNP mg/15ml
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
86
Drug Name hydrocodone-ibuprofen tab 2.5-200 mg
Drug Tier Requirements/Limits GNP QLL (150 tabs / 30 days) ibudone tab 5-200mg GNP QLL (150 tabs / 30 days) hydrocodone-ibuprofen tab 7.5-200 mg GNP QLL (150 tabs / 30 days) ibudone tab 10-200mg GNP QLL (150 tabs / 30 days) tramadol-acetaminophen tab 37.5-325 mg GNP QLL (240 tabs / 30 days)
NONSTEROIDAL ANTIINFLAMMATORY AGENTS (NSAIDS) ZORVOLEX CAP 18MG ZORVOLEX CAP 35MG diclofenac potassium tab 50 mg diclofenac sodium tab delayed release 25 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab 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 tab 600 mg flurbiprofen tab 50 mg flurbiprofen tab 100 mg ibuprofen tab 400 mg ibuprofen tab 600 mg ibuprofen tab 800 mg indomethacin cap 25 mg indomethacin cap 50 mg indomethacin cap cr 75 mg ketoprofen cap 50 mg ketoprofen cap 75 mg ketoprofen cap sr 24hr 200 mg ketorolac tromethamine tab 10 mg ketorolac tromethamine im inj 60 mg/2ml (30 mg/ml) meclofenamate sodium cap 50 mg meclofenamate sodium cap 100 mg
BP BP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GP GP GP GNP GNP GNP GNP GNP GNP GNP GP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
87
Drug Name mefenamic acid cap 250 mg meloxicam tab 7.5 mg meloxicam tab 15 mg meloxicam susp 7.5 mg/5ml nabumetone tab 500 mg nabumetone tab 750 mg naproxen tab 250 mg naproxen tab 375 mg naproxen tab 500 mg naproxen dr tab 375mg naproxen dr tab 500mg naproxen susp 125 mg/5ml naproxen sodium tab 275 mg naproxen sodium tab 550 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 celecoxib cap 50 mg celecoxib cap 100 mg celecoxib cap 200 mg celecoxib cap 400 mg diclofenac w/ misoprostol tab delayed release 50-0.2 mg diclofenac w/ misoprostol tab delayed release 75-0.2 mg
Drug Tier Requirements/Limits GNP GP GNP GNP GNP GNP GP GP GNP GP GNP GNP GP GNP GNP GNP GNP GP GNP GNP GNP GNP GNP EPA GNP EPA GNP EPA GNP EPA GNP GNP
GOLD COMPOUNDS RIDAURA CAP 3MG
BP
INTERLEUKIN1 RECEPTOR ANTAGONIST (IL1RA) KINERET INJ
BNP
PAR; SRx
ANTITNFALPHA MONOCLONAL ANTIBODIES HUMIRA PEN INJ PSORIASI HUMIRA KIT 20MG/0.4 HUMIRA KIT 40MG/0.8 SIMPONI INJ 50/0.5ML SIMPONI INJ 100MG/ML SIMPONI INJ 50/0.5ML SIMPONI INJ 100MG/ML
BP BP BP BNP BNP BNP BNP
PAR; PAR; PAR; PAR; PAR; PAR; PAR;
SRx SRx SRx SRx SRx SRx SRx
PYRIMIDINE SYNTHESIS INHIBITORS PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
88
Drug Name leflunomide tab 10 mg leflunomide tab 20 mg
Drug Tier Requirements/Limits GNP GNP
SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL ENBREL ENBREL ENBREL
INJ 25MG SRCLK INJ 50MG/ML INJ 25/0.5ML INJ 50MG/ML
BP BP BP BP
PAR; PAR; PAR; PAR;
SRx SRx SRx SRx
SELECTIVE COSTIMULATION MODULATORS ORENCIA INJ 125MG/ML
BNP
PAR; SRx
BP
SRx
BNP
PAR; SRx
BNP
PAR; SRx
INTERLEUKIN1 BLOCKERS ARCALYST INJ 220MG
INTERLEUKIN6 RECEPTOR INHIBITORS ACTEMRA INJ 162/0.9
ANTIRHEUMATIC ENZYME INHIBITORS XELJANZ TAB 5MG
ANTIRHEUMATIC - ENZYME INHIBITORS XELJANZ XR TAB 11MG
BNP
PAR; SRx
MIGRAINE PRODUCTS ERGOMAR SUB 2MG BNP dihydroergotamine mesylate inj 1 mg/ml GNP dihydroergotamine mesylate nasal spray 4 GNP mg/ml
QLL (1 kit (8 ampules)per prescription)
SEROTONIN AGONISTS almotriptan malate tab 6.25 mg
GNP
almotriptan malate tab 12.5 mg
GNP
RELPAX TAB 20MG
BNP
RELPAX TAB 40MG
BNP
FROVA TAB 2.5MG
BNP
frovatriptan succinate tab 2.5 mg (base equivalent) naratriptan hcl tab 1 mg (base equiv)
GNP
naratriptan hcl tab 2.5 mg (base equiv)
GNP
rizatriptan benzoate tab 5 mg (base equivalent) rizatriptan benzoate tab 10 mg (base equivalent)
GNP
GNP
GNP
QLL (18 tabs per prescription) QLL (8 tabs per prescription) QLL (12 tabs per prescription); EPA QLL (6 tabs per prescription); EPA QLL (9 tabs per prescription); EPA QLL (9 tabs per prescription) QLL (20 tabs per prescription) QLL (9 tabs per prescription) QLL (24 tabs per prescription) QLL (12 tabs per prescription)
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
89
Drug Name Drug Tier Requirements/Limits rizatriptan benzoate oral disintegrating tab GNP QLL (24 tabs per 5 mg (base eq) prescription) rizatriptan benzoate oral disintegrating tab GNP QLL (12 tabs per 10 mg (base eq) prescription) sumatriptan nasal spray 5 mg/act GNP QLL (32 nasal sprays per prescription) sumatriptan nasal spray 20 mg/act GNP QLL (8 nasal sprays per prescription) sumatriptan succinate tab 25 mg GNP QLL (36 tabs per prescription) sumatriptan succinate tab 50 mg GNP QLL (18 tabs per prescription) sumatriptan succinate tab 100 mg GNP QLL (9 tabs per prescription) sumatriptan succinate inj 4 mg/0.5ml GNP QLL (4 kits per prescription) sumatriptan succinate inj 6 mg/0.5ml GNP QLL (4 kits per prescription) sumatriptan succinate solution autoGNP QLL (4 kits per injector 4 mg/0.5ml prescription) sumatriptan succinate solution autoGNP QLL (4 kits per injector 6 mg/0.5ml prescription) sumatriptan succinate solution cartridge 4 GNP QLL (4 kits per mg/0.5ml prescription) sumatriptan succinate solution cartridge 6 GNP QLL (4 kits per mg/0.5ml prescription) sumatriptan succinate solution prefilled GNP QLL (4 kits per syringe 6 mg/0.5ml prescription) zolmitriptan tab 2.5 mg GNP QLL (18 tabs per prescription) zolmitriptan tab 5 mg GNP QLL (9 tabs per prescription) ZOMIG SPR 2.5MG BNP QLL (8 sprays per prescription); EPA zolmitriptan orally disintegrating tab 2.5 GNP QLL (18 tabs per mg prescription) zolmitriptan orally disintegrating tab 5 mg GNP QLL (9 tabs per prescription)
MIGRAINE COMBINATIONS isometheptene-dichloral-acetaminophen cap 65-100-325 mg migergot sup 2/100
GNP GNP
GOUT AGENTS allopurinol tab 100 mg allopurinol tab 300 mg colchicine cap 0.6 mg
GP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
90
Drug Name colchicine tab 0.6 mg ULORIC TAB 40MG ULORIC TAB 80MG
Drug Tier Requirements/Limits GNP BNP EPA BNP EPA
URICOSURICS probenecid tab 500 mg
GNP
GOUT AGENT COMBINATIONS colchicine w/ probenecid tab 0.5-500 mg
GNP
VOLATILE ANESTHETICS terrell sol sojourn sol
GNP GNP
ANTICONVULSANTS BENZODIAZEPINES clonazepam tab 0.5 mg clonazepam tab 1 mg clonazepam tab 2 mg clonazepam orally disintegrating tab 0.125 mg clonazepam orally disintegrating tab 0.25 mg clonazepam orally disintegrating tab 0.5 mg clonazepam orally disintegrating tab 1 mg clonazepam orally disintegrating tab 2 mg diazepam rectal gel delivery system 2.5 mg diazepam rectal gel delivery system 10 mg diazepam rectal gel delivery system 20 mg
GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
CARBAMATES felbamate tab 400 mg felbamate tab 600 mg felbamate susp 600 mg/5ml
GNP GNP GNP
GABA MODULATORS tiagabine hcl tab 2 mg tiagabine hcl tab 4 mg GABITRIL TAB 12MG GABITRIL TAB 16MG SABRIL TAB 500MG SABRIL POW 500MG
GNP GNP BP BP BNP BNP
SRx SRx
HYDANTOINS PEGANONE TAB 250MG phenytoin chew tab 50 mg phenytoin susp 125 mg/5ml DILANTIN CAP 30MG phenytoin sodium extended cap 100 mg
BP GNP GNP BP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
91
Drug Name
Drug Tier Requirements/Limits
SUCCINIMIDES ethosuximide cap 250 mg ethosuximide soln 250 mg/5ml CELONTIN CAP 300MG
GNP GNP BP
VALPROIC ACID 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 divalproex sodium cap delayed release sprinkle 125 mg valproate sodium syrup 250 mg/5ml (base equiv) valproic acid cap 250 mg
GNP GNP GNP GNP GNP GNP GNP GNP
ANTICONVULSANTS MISC. carbamazepine carbamazepine carbamazepine carbamazepine carbamazepine carbamazepine
tab 200 mg chew tab 100 mg susp 100 mg/5ml cap sr 12hr 100 mg cap sr 12hr 200 mg cap sr 12hr 300 mg
GP GP GNP GNP GNP GNP
ANTICONVULSANTS - MISC. carbamazepine tab sr 12hr 100 mg
GNP
ANTICONVULSANTS MISC. TEGRETOL-XR TAB 100MG carbamazepine tab sr 12hr 200 mg carbamazepine tab sr 12hr 400 mg POTIGA TAB 50MG POTIGA TAB 200MG POTIGA TAB 300MG POTIGA TAB 400MG gabapentin cap 100 mg gabapentin cap 300 mg gabapentin cap 400 mg gabapentin tab 600 mg gabapentin tab 800 mg gabapentin oral soln 250 mg/5ml VIMPAT TAB 50MG VIMPAT TAB 100MG VIMPAT TAB 150MG
BP GNP GNP BNP BNP BNP BNP GP GNP GNP GNP GNP GNP BNP BNP BNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
92
Drug Name Drug Tier Requirements/Limits VIMPAT TAB 200MG BNP VIMPAT SOL 10MG/ML BNP lamotrigine tab 25 mg GP lamotrigine tab 100 mg GP lamotrigine tab 150 mg GP lamotrigine tab 200 mg GP lamotrigine tab chewable dispersible 5 mg GNP lamotrigine tab chewable dispersible 25 mg GNP lamotrigine tab sr 24hr 25 mg GNP lamotrigine tab sr 24hr 50 mg GNP lamotrigine tab sr 24hr 100 mg GNP lamotrigine tab sr 24hr 200 mg GNP lamotrigine tab sr 24hr 250 mg GNP lamotrigine tab sr 24hr 300 mg GNP levetiracetam tab 250 mg GNP levetiracetam tab 500 mg GNP levetiracetam tab 750 mg GNP levetiracetam tab 1000 mg GNP levetiracetam oral soln 100 mg/ml GNP levetiracetam tab sr 24hr 500 mg GNP levetiracetam tab sr 24hr 750 mg GNP oxcarbazepine tab 150 mg GNP oxcarbazepine tab 300 mg GNP oxcarbazepine tab 600 mg GNP oxcarbazepine susp 300 mg/5ml (60 GNP mg/ml) LYRICA CAP 25MG BP EPA LYRICA CAP 50MG BP EPA LYRICA CAP 75MG BP EPA LYRICA CAP 100MG BP EPA LYRICA CAP 150MG BP EPA LYRICA CAP 200MG BP EPA LYRICA CAP 225MG BP EPA LYRICA CAP 300MG BP EPA LYRICA SOL 20MG/ML BP EPA primidone tab 50 mg GNP primidone tab 250 mg GNP BANZEL TAB 200MG BNP BANZEL TAB 400MG BNP BANZEL SUS 40MG/ML BNP topiramate tab 25 mg GP topiramate tab 50 mg GNP topiramate tab 100 mg GNP topiramate tab 200 mg GNP PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
93
Drug Name topiramate sprinkle cap 15 mg topiramate sprinkle cap 25 mg zonisamide cap 25 mg zonisamide cap 50 mg zonisamide cap 100 mg
Drug Tier Requirements/Limits GNP GNP GNP GNP GNP
ANTIPARKINSON ANTICHOLINERGICS benztropine mesylate tab 0.5 mg benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg trihexyphenidyl hcl tab 2 mg trihexyphenidyl hcl tab 5 mg trihexyphenidyl hcl elixir 0.4 mg/ml
GP GP GP GP GP GNP
ANTIPARKINSON COMT INHIBITORS tolcapone tab 100 mg entacapone tab 200 mg
GNP GNP
ANTIPARKINSON DOPAMINERGICS amantadine hcl cap 100 mg amantadine hcl tab 100 mg amantadine hcl syrup 50 mg/5ml bromocriptine mesylate cap 5 mg bromocriptine mesylate tab 2.5 mg APOKYN INJ 10MG/ML pramipexole dihydrochloride tab 0.125 mg pramipexole dihydrochloride tab 0.25 mg pramipexole dihydrochloride tab 0.5 mg pramipexole dihydrochloride tab 0.75 mg pramipexole dihydrochloride tab 1 mg pramipexole dihydrochloride tab 1.5 mg ropinirole hydrochloride tab 0.25 mg ropinirole hydrochloride tab 0.5 mg ropinirole hydrochloride tab 1 mg ropinirole hydrochloride tab 2 mg ropinirole hydrochloride tab 3 mg ropinirole hydrochloride tab 4 mg ropinirole hydrochloride tab 5 mg ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent)
GNP GNP GNP GNP GNP BP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
SRx
GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
94
Drug Name Drug Tier Requirements/Limits ropinirole hydrochloride tab sr 24hr 12 mg GNP (base equivalent) NEUPRO DIS 1MG/24HR BP EPA NEUPRO DIS 2MG/24HR BP EPA NEUPRO DIS 3MG/24HR BP EPA NEUPRO DIS 4MG/24HR BP EPA NEUPRO DIS 6MG/24HR BP EPA NEUPRO DIS 8MG/24HR BP EPA carbidopa & levodopa tab 10-100 mg GNP carbidopa & levodopa tab 25-100 mg GNP carbidopa & levodopa tab 25-250 mg GNP carbidopa & levodopa tab cr 25-100 mg GNP carbidopa & levodopa tab cr 50-200 mg GNP carbidopa & levodopa orally disintegrating GNP tab 10-100 mg carbidopa & levodopa orally disintegrating GNP tab 25-100 mg carbidopa & levodopa orally disintegrating GNP tab 25-250 mg carbidopa-levodopa-entacapone tabs 12.5- GNP 50-200 mg carbidopa-levodopa-entacapone tabs GNP 18.75-75-200 mg carbidopa-levodopa-entacapone tabs 25- GNP 100-200 mg carbidopa-levodopa-entacapone tabs GNP 31.25-125-200 mg carbidopa-levodopa-entacapone tabs 37.5- GNP 150-200 mg carbidopa-levodopa-entacapone tabs 50- GNP 200-200 mg
ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS AZILECT TAB 0.5MG AZILECT TAB 1MG selegiline hcl cap 5 mg selegiline hcl tab 5 mg
BNP BNP GNP GNP
ANTIPARKINSON ADJUVANTS carbidopa tab 25 mg
GNP
ALS AGENTS riluzole tab 50 mg
GNP
CENTRAL MUSCLE RELAXANTS baclofen tab 10 mg baclofen tab 20 mg carisoprodol tab 250 mg
GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
95
Drug Name carisoprodol tab 350 mg chlorzoxazone tab 500 mg cyclobenzaprine hcl tab 5 mg cyclobenzaprine hcl tab 7.5 mg cyclobenzaprine hcl tab 10 mg metaxalone tab 800 mg methocarbamol tab 500 mg methocarbamol tab 750 mg orphenadrine citrate tab sr 12hr 100 mg 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)
Drug Tier Requirements/Limits GNP GNP GP GNP GP GNP GNP GP GNP GNP GNP GNP GNP GNP
DIRECT MUSCLE RELAXANTS dantrolene sodium cap 25 mg dantrolene sodium cap 50 mg dantrolene sodium cap 100 mg
GNP GNP GNP
MUSCLE RELAXANT COMBINATIONS carisoprodol w/ aspirin tab 200-325 mg GNP carisoprodol w/ aspirin & codeine tab 200- GNP 325-16 mg orphenadrine w/ aspirin & caffeine tab 25- GNP 385-30 mg
ANTIMYASTHENIC/CHOLINERGIC AGENTS GUANIDINE TAB 125MG pyridostigmine bromide tab 60 mg pyridostigmine bromide tab cr 180 mg MESTINON SYP 60MG/5ML
BP GNP GNP BP
WATER SOLUBLE VITAMINS POTABA CAP 500MG POTABA TAB 500MG potassium aminobenzoate packet 2 gm
BP BP GNP
OIL SOLUBLE VITAMINS ergocalciferol cap 50000 unit vitamin d3 cap 400unit
GNP GNP
d 400 tab 400unit
GNP
MEPHYTON TAB 5MG
BP
PHC, OTC, AL, Limited to 400 IU caps, tabs for members age 65 years and older. PHC, OTC, AL, Limited to 400 IU caps, tabs for members age 65 years and older.
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
96
Drug Name
Drug Tier Requirements/Limits
BCOMPLEX W/ FOLIC ACID reno cap b-plex tab nephronex tab 1mg folbee plus tab virt-vite tab plus
GNP GNP GP GNP GNP
PED MV W/ FLUORIDE tri-vita/fl dro 0.25mg tri-vit/fluo dro 0.5mg multivit/fl chw 0.25mg multivit/fl chw 0.5mg multivit/fl chw 1mg multi-vit/fl dro 0.25mg multi-vit/fl dro 0.5mg/ml
PED MULTI VITAMINS W/FL tri-vit/fe dro /fl 0.25
GNP GNP GP GNP GNP GP GP
FE GNP
PRENATAL VITAMINS bp folinatal tab plus b triadvance tab prenatal 19 tab
GNP GP GNP
FLUORIDE sodium fluoride tab 0.5 mg f (from 1.1 mg GNP naf)
sodium fluoride tab 1 mg f (from 2.2 mg GNP naf) sodium fluoride chew tab 0.25 mg f (from GNP 0.55 mg naf)
fluoritab chw 0.5mg f
GNP
QLL (60 tabs / 30 days); PHC, AL, Limited to children through age 18. Overthecounter products are excluded even with a prescription.
QLL (1 ea / 30 days); PHC, AL, Limited to children through age 18. Overthecounter products are excluded even with a prescription. QLL (2 ea / 30 days); PHC, AL, Limited to children through age 18. Overthecounter products are excluded even with a prescription.
sodium fluoride chew tab 1 mg f (from 2.2 GNP mg naf)
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
97
Drug Name fluoritab dro 0.125mg
Drug Tier Requirements/Limits GNP QLL (30 ml's per prescription); PHC, AL, Limited to children through age 18. Overthecounter products are excluded even with a prescription. flura-drops dro 0.25mg f GNP QLL (24 ml's per prescription); PHC, AL, Limited to children through age 18. Overthecounter products are excluded even with a prescription. FLUORABON DRO BP QLL (60 ml's per prescription); PHC, AL, Limited to children through age 18. Overthecounter products are excluded even with a prescription. sodium fluoride soln 0.5 mg/ml f (from 1.1 GNP QLL (50 ml's per mg/ml naf) prescription); PHC, AL, Limited to children through age 18. Overthecounter products are excluded even with a prescription. LOZI-FLUR LOZ 1MG F BP
IODINE PRODUCTS iodine solution strong 5% (lugol's)
GNP
PHOSPHATE phospha 250 tab neutral
GNP
POTASSIUM k-effervesce tab 25meq ef potassium chloride cap cr 8 meq potassium chloride cap cr 10 meq potassium chloride tab cr 8 meq (600 mg) potassium chloride tab cr 10 meq k-sol sol 10% potassium chloride oral soln 10% (20 meq/15ml) k-sol sol 20% potassium chloride oral soln 20% (40 meq/15ml) potassium chloride powder packet 20 meq
GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
98
Drug Name potassium chloride microencapsulated crys cr tab 10 meq KLOR-CON M15 TAB 15MEQ ER potassium chloride microencapsulated crys cr tab 20 meq pot bicarbonate & chloride effer tab 25 meq EFFER-K TAB 10MEQ EFFER-K TAB 20MEQ
Drug Tier Requirements/Limits GNP BP GNP GNP BP BP
PROTEINS acetylcysteine cap 600 mg
GNP
DIETARY MANAGEMENT PRODUCTS virt-vite tab forte
GNP
COBALAMINS cyanocobalamin inj 1000 mcg/ml NASCOBAL SPR 500MCG
GP BP
FOLIC ACID/FOLATES FA-8 CAP 800MCG
BNP
folic acid tab 400 mcg
GNP
folic acid tab 800 mcg
GNP
folic acid tab 1 mg
GP
QLL (30 caps / 30 days); OTC, AL, Limited to women through age 55. QLL (30 tabs / 30 days); PHC, OTC, AL, Limited to women through age 55. QLL (30 tabs / 30 days); PHC, OTC, AL, Limited to women through age 55.
IRON wee care sus 15/1.25
GNP
MYKIDZ IRON SUS 15/1.5ML
GNP
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe)
GNP
QLL (118 ml's per prescription); PHC, OTC, AL, Limited to children through age one. QLL (118 ml's per prescription); PHC, OTC, AL, Limited to children through age one. QLL (120 ml's per 30 days); PHC, OTC, AL, Limited to children through age one.
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
99
Drug Name FERROUS SULF SYP 300/5ML
fer-iron dro 15mg/ml
Drug Tier Requirements/Limits BNP QLL (90 ml's / 30 days); OTC, AL, Limited to children through age one. GNP QLL (50 ml's per prescription); PHC, OTC, AL, Limited to children through age one.
HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 25MCG ARANESP INJ 40MCG ARANESP INJ 60MCG ARANESP INJ 100MCG ARANESP INJ 200MCG ARANESP INJ 300MCG 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 PROCRIT INJ 2000/ML PROCRIT INJ 3000/ML PROCRIT INJ 4000/ML PROCRIT INJ 10000/ML PROCRIT INJ 20000/ML PROCRIT INJ 40000/ML NEUPOGEN INJ 300MCG NEUPOGEN INJ 480MCG NEUPOGEN INJ 300/0.5 NEUPOGEN INJ 480/0.8 NEULASTA INJ 6MG/0.6M NEULASTA KIT 6MG/0.6M LEUKINE INJ 250MCG PROMACTA TAB 12.5MG PROMACTA TAB 25MG PROMACTA TAB 50MG PROMACTA TAB 75MG
BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP
PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; PAR; SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx
SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx
BP
PAR; SRx
STEM CELL MOBILIZERS MOZOBIL INJ
AGENTS FOR GAUCHER DISEASE PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
100
Drug Name CERDELGA CAP 84MG ZAVESCA CAP 100MG
Drug Tier Requirements/Limits BP PAR; SRx BP
AGENTS FOR SICKLE CELL ANEMIA DROXIA CAP 200MG DROXIA CAP 300MG DROXIA CAP 400MG
BP BP BP
HEMATOPOIETIC MIXTURES folic acid-vitamin b6-vitamin b12 tab 2.2- GP 25-0.5 mg tl gard rx tab GNP folbee tab GNP polysacchari cap iron GP fe c plus tab GNP HEMATOGEN FA CAP BP ferrogels fo cap forte GNP ferocon cap GNP tl-hem 150 tab GNP CENTRATEX CAP BP hemocyte-f tab GP
HEPARINS AND HEPARINOIDLIKE AGENTS heparin sodium (porcine) inj 1000 unit/ml GNP HEPARIN SOD INJ 2000/ML BP HEPARIN SOD INJ 2500/ML BP heparin sodium (porcine) inj 5000 unit/ml GNP heparin sodium (porcine) pf inj 5000 GNP unit/0.5ml heparin sodium (porcine) inj 10000 unit/ml GNP heparin sodium (porcine) inj 20000 unit/ml GNP heparin sodium (porcine) 2 unit/ml in GNP sodium chloride 0.9% HEP SOD/NACL INJ 25000UNT BP HEP SOD/NACL INJ 25000UNT BP heparin sodium (porcine) 40 unit/ml in GNP d5w heparin sodium (porcine) 50 unit/ml in GNP d5w heparin sodium (porcine) 100 unit/ml in GNP d5w heparin sodium (porcine) lock flush iv soln GNP 1 unit/ml heparin sodium (porcine) lock flush iv soln GNP 2 unit/ml heparin sodium (porcine) lock flush iv soln GP 10 unit/ml PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
101
Drug Name Drug Tier Requirements/Limits heparin lock inj 100/ml GNP heparin sod lock flush & nacl lock flush 10 GNP unt/ml-0.9% kit heparin sod lock flush & nacl lock flush 100 GNP unt/ml-0.9% kit FRAGMIN INJ 10000/ML BP FRAGMIN INJ 2500/0.2 BP FRAGMIN INJ 5000/0.2 BP FRAGMIN INJ 7500/0.3 BP FRAGMIN INJ 12500UNT BP FRAGMIN INJ 15000UNT BP FRAGMIN INJ 18000UNT BP enoxaparin sodium inj 30 mg/0.3ml GNP enoxaparin sodium inj 40 mg/0.4ml GNP enoxaparin sodium inj 60 mg/0.6ml GNP enoxaparin sodium inj 80 mg/0.8ml GNP enoxaparin sodium inj 100 mg/ml GNP enoxaparin sodium inj 120 mg/0.8ml GNP enoxaparin sodium inj 150 mg/ml GNP fondaparinux sodium subcutaneous inj 2.5 GNP mg/0.5ml fondaparinux sodium subcutaneous inj 5 GNP mg/0.4ml fondaparinux sodium subcutaneous inj 7.5 GNP mg/0.6ml fondaparinux sodium subcutaneous inj 10 GNP mg/0.8ml
COUMARIN ANTICOAGULANTS warfarin warfarin warfarin warfarin warfarin warfarin warfarin warfarin warfarin
sodium sodium sodium sodium sodium sodium sodium sodium sodium
tab tab tab tab tab tab tab tab tab
1 mg 2 mg 2.5 mg 3 mg 4 mg 5 mg 6 mg 7.5 mg 10 mg
GP GP GP GP GP GP GP GP GP
THROMBIN INHIBITORS PRADAXA CAP 75MG PRADAXA CAP 110MG PRADAXA CAP 150MG
BNP BNP BNP
Blood Products/Modifiers/ Volume Expanders ELIQUIS TAB 2.5MG ELIQUIS TAB 5MG
BP BP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
102
Drug Name
Drug Tier Requirements/Limits
DIRECT FACTOR XA INHIBITORS XARELTO TAB 10MG XARELTO TAB 15MG XARELTO TAB 20MG
BP BP BP
HEMOSTATICS SYSTEMIC AMICAR TAB 500MG AMICAR TAB 1000MG AMICAR SYP 25% AMICAR SOL 0.25/ML tranexamic acid tab 650 mg
BP BP BP BP GNP
ANTIHEMOPHILIC PRODUCTS HEMOFIL M INJ 220-400 KOATE-DVI INJ 250UNIT HEMOFIL M INJ 401-800 HEMOFIL M INJ 500UNIT KOATE-DVI INJ 1000UNIT HEMOFIL M INJ 1700UNIT MONOCLATE-P INJ 250UNIT MONOCLATE-P INJ 500UNIT MONOCLATE-P INJ 1000UNIT MONOCLATE-P INJ 1500UNIT RECOMBINATE INJ 220-400 RECOMBINATE INJ 401-800 RECOMBINATE INJ 801-1240 RECOMBINATE INJ RECOMBINATE INJ HELIXATE FS INJ 250UNIT HELIXATE FS INJ 500UNIT HELIXATE FS INJ 1000UNIT HELIXATE FS INJ 2000UNIT KOGENATE FS INJ 3000/BS ADVATE INJ 250UNIT ADVATE INJ 500UNIT ADVATE INJ 1000UNIT ADVATE INJ 1500UNIT ADVATE INJ 2000UNIT ADVATE INJ 3000UNIT ADVATE INJ 4000UNIT HUMATE-P SOL 250-600 WILATE INJ HUMATE-P SOL 500-1200 WILATE INJ HUMATE-P SOL 2400UNIT
BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP BP
SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
103
Drug Name ALPHANATE INJ VWF/HUM ALPHANATE INJ VWF/HUM ALPHANATE INJ VWF/HUM ALPHANATE INJ VWF/HUM ALPHANATE INJ VWF/HUM WILATE INJ WILATE INJ FEIBA INJ NOVOSEVEN RT INJ 1MG NOVOSEVEN RT INJ 2MG NOVOSEVEN RT INJ 5MG NOVOSEVEN RT INJ 8MG MONONINE INJ 250UNIT ALPHANINE SD INJ 500UNIT MONONINE INJ 1000UNIT ALPHANINE SD INJ 1500UNIT BENEFIX INJ 250UNIT BENEFIX INJ 500UNIT BENEFIX INJ 1000UNIT BENEFIX INJ 2000UNIT BENEFIX INJ 3000UNIT PROFILNINE INJ 500UNIT PROFILNINE INJ 1000UNIT PROFILNINE INJ 1500UNIT BEBULIN INJ 200-1200
Drug Tier Requirements/Limits BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx BP SRx
PLATELET AGGREGATION INHIBITORS dipyridamole tab 25 mg dipyridamole tab 50 mg dipyridamole tab 75 mg cilostazol tab 50 mg cilostazol tab 100 mg anagrelide hcl cap 0.5 mg anagrelide hcl cap 1 mg clopidogrel bisulfate tab 75 mg (base equiv) clopidogrel bisulfate tab 300 mg (base equiv) EFFIENT TAB 5MG EFFIENT TAB 10MG ticlopidine hcl tab 250 mg BRILINTA TAB 90MG aspirin-dipyridamole cap sr 12hr 25-200 mg
GNP GNP GNP GNP GNP GNP GNP GNP GNP BP BP GNP BNP GNP
HEMATORHEOLOGIC AGENTS PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
104
Drug Name pentoxifylline tab cr 400 mg
Drug Tier Requirements/Limits GNP
COMPLEMENT INHIBITORS BERINERT INJ 500UNIT
BP
SRx
BRADYKININ B2 RECEPTOR ANTAGONISTS FIRAZYR INJ 30MG/3ML
BP
SRx
OPHTHALMIC ANTIINFECTIVES bacitracin ophth oint 500 unit/gm BESIVANCE SUS 0.6% ciprofloxacin hcl ophth soln 0.3% CILOXAN OIN 0.3% OP erythromycin ophth oint 5 mg/gm gatifloxacin ophth soln 0.5% gentamicin sulfate ophth soln 0.3% gentak oin 0.3% op levofloxacin ophth soln 0.5% ofloxacin ophth soln 0.3% tobramycin ophth soln 0.3% sulfacetamide sodium ophth soln 10% sulfacetamide sodium ophth oint 10% ZIRGAN GEL 0.15% trifluridine ophth soln 1% NATACYN SUS 5% OP bacitracin-polymyxin b ophth oint polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% neomycin-bacitrac zn-polymyx 5(3.5)mg400unt-10000unt op oin neomycin-polymy-gramicid op sol 1.7510000-0.025mg-unt-mg/ml
GNP BNP GP BP GP GNP GP GNP GNP GP GP GNP GNP BNP GNP BNP GNP GNP GNP GNP
ARTIFICIAL TEARS AND LUBRICANTS LACRISERT MIS 5MG OP
BP
BETABLOCKERS OPHTHALMIC BETOPTIC-S SUS 0.25% OP betaxolol hcl ophth soln 0.5% carteolol hcl ophth soln 1% metipranolol ophth soln 0.3% levobunolol hcl ophth soln 0.25% levobunolol hcl ophth soln 0.5% timolol maleate ophth soln 0.25% timolol maleate ophth soln 0.5% timolol maleate ophth gel forming soln 0.25% timolol maleate ophth gel forming soln 0.5%
BP GNP GNP GNP GNP GNP GNP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
105
Drug Name Drug Tier Requirements/Limits COMBIGAN SOL 0.2/0.5% BNP dorzolamide hcl-timolol maleate ophth soln GNP 22.3-6.8 mg/ml
OPHTHALMIC STEROIDS dexamethasone sodium phosphate ophth soln 0.1% DUREZOL EMU 0.05% fluorometholone ophth susp 0.1% FML OIN 0.1% OP ALREX SUS 0.2% LOTEMAX SUS 0.5% LOTEMAX GEL 0.5% LOTEMAX OIN 0.5% PRED MILD SUS 0.12% OP prednisolone acetate ophth susp 1% PRED SOD PHO SOL 1% OP VEXOL SUS 1% OP PRED-G SUS OP PRED-G S.O.P OIN OP BLEPHAMIDE SUS OP sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% BLEPHAMIDE OIN S.O.P. tobramycin-dexamethasone ophth susp 0.3-0.1% TOBRADEX OIN 0.3-0.1% neomycin-polymyxin-dexamethasone ophth susp 0.1% neomycin-polymyxin-dexamethasone ophth oint 0.1% neomycin-polymyxin-hc ophth susp bacitracin-polymyxin-neomycin-hc ophth oint 1%
GNP BNP GNP BP BP BP BP BP BP GNP BP BNP BP BP BP GNP BP GNP BP GNP GNP GNP GNP
PROSTAGLANDINS OPHTHALMIC LUMIGAN SOL 0.01% latanoprost ophth soln 0.005% ZIOPTAN DRO 0.0015% TRAVATAN Z DRO 0.004%
BP GNP BNP BP
CYCLOPLEGIC MYDRIATICS atropine sulfate ophth soln 1% cyclopentolate hcl ophth soln 1% cyclopentolate hcl ophth soln 2% homatropaire sol 5% op tropicamide ophth soln 0.5%
GNP GNP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
106
Drug Name tropicamide ophth soln 1%
Drug Tier Requirements/Limits GNP
OPHTHALMIC DECONGESTANTS naphazoline hcl ophth soln 0.1% altafrin sol 2.5% op altafrin sol 10% op
GP GNP GNP
MIOTICS pilocarpine hcl ophth soln 1% pilocarpine hcl ophth soln 2% pilocarpine hcl ophth soln 4% PHOSPHOLINE SOL 0.125%OP
GNP GNP GNP BP
OPHTHALMIC ADRENERGIC AGENTS apraclonidine hcl ophth soln 0.5% (base equivalent) ALPHAGAN P SOL 0.1% brimonidine tartrate ophth soln 0.15% brimonidine tartrate ophth soln 0.2%
GNP BP GNP GP
OPHTHALMIC IMMUNOMODULATORS RESTASIS EMU 0.05%
BNP
OPHTHALMIC LOCAL ANESTHETICS proparacaine hcl ophth soln 0.5% tetracaine hcl ophth soln 0.5%
GNP GP
OPHTHALMICS MISC. LASTACAFT SOL 0.25% BNP azelastine hcl ophth soln 0.05% GNP BEPREVE DRO 1.5% BNP cromolyn sodium ophth soln 4% GP EMADINE SOL 0.05% OP BP epinastine hcl ophth soln 0.05% GNP ALOMIDE SOL 0.1% OP BNP ALOCRIL SOL 2% BNP olopatadine hcl ophth soln 0.1% (base GNP equivalent) PATANOL SOL 0.1% OP BNP PATADAY SOL 0.2% BNP AZOPT SUS 1% OP BP dorzolamide hcl ophth soln 2% GNP bromfenac sodium ophth soln 0.09% (base GNP equivalent) bromfenac sodium ophth soln 0.09% (base GNP equiv) (once-daily) diclofenac sodium ophth soln 0.1% GNP flurbiprofen sodium ophth soln 0.03% GNP ketorolac tromethamine ophth soln 0.4% GNP PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
107
Drug Name ketorolac tromethamine ophth soln 0.5% NEVANAC SUS 0.1% CYSTARAN SOL 0.44% flucaine sol 0.25-0.5
Drug Tier Requirements/Limits GNP BNP BP SRx GNP
OTIC ANTIINFECTIVES ciprofloxacin hcl otic soln 0.2% (base equivalent) ofloxacin otic soln 0.3%
GNP GNP
OTIC ANALGESICS PINNACAINE DRO 20% OTIC
BP
OTIC STEROIDS fluocinolone acetonide (otic) oil 0.01% acetasol hc sol otic
GNP GNP
OTIC AGENTS MISCELLANEOUS acetic acid otic soln 2% acetic acid 2% in aluminum acetate otic soln
GNP GNP
OTIC COMBINATIONS CIPRODEX SUS 0.3-0.1% CIPRO HC SUS OTIC neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% neomycin-polymyxin-hc otic soln 1% CORTISPORIN SUS -TC OTIC antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%) antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%) oticin dro 1-0.1% PRAMOTIC DRO 1-0.1% otic care dro cyotic dro
BP BNP GNP GNP BNP GP GNP GNP BNP GNP GP
ANTIINFECTIVES THROAT nystatin susp 100000 unit/ml clotrimazole troche 10 mg ORAVIG TAB 50MG
GNP GNP BNP
ANTISEPTICS MOUTH/THROAT periogard sol 0.12% DEBACTEROL SOL 30-50%
GP BP
STEROIDS MOUTH/THROAT triamcinolone acetonide dental paste 0.1% GNP
ANESTHETICS TOPICAL ORAL lidocaine hcl laryngotracheal soln 4%
GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
108
Drug Name lidocaine hcl viscous soln 2%
Drug Tier Requirements/Limits GP
DENTAL PRODUCTS cavirinse sol 0.2% denta 5000 cre plus 2pk neutragard gel 1.1% clinpro 5000 pst 1.1% periomed con 0.63% fluoridex dd pst sensitiv
GP GP GP GNP GNP GP
THROAT PRODUCTS MISC. cevimeline hcl cap 30 mg pilocarpine hcl tab 5 mg pilocarpine hcl tab 7.5 mg
GNP GNP GNP
RECTAL STEROIDS procto-pak cre 1% proctozone cre -hc 2.5% grx hicort sup 25mg hydrocortisone acetate suppos 30 mg
GNP GNP GNP GNP
INTRARECTAL STEROIDS hydrocortisone enema 100 mg/60ml CORTIFOAM AER 90MG
GNP BP
VASODILATING AGENTS RECTIV OIN 0.4%
BNP
RECTAL COMBINATIONS lidocaine-hydrocortisone acetate rectal GNP cream 3-0.5% lidocaine-hydrocortisone acetate rectal GNP cream kit 3-0.5% lidocaine-hydrocortisone acetate rectal GNP cream kit 3-1% lidocaine-hydrocortisone acetate rectal gel GNP kit 3-2.5% pramcort cre 1-1% GNP hydrocortisone acetate w/ pramoxine rectalGNP cream 2.5-1% PROCTOFOAM AER HC 1% BP ANALPRAM E KIT BNP hc-pramoxine emol cream 2.5-1% & GNP pramoxine wipe 1% kit
ACNE PRODUCTS adapalene cream 0.1% adapalene gel 0.1% adapalene gel 0.3% pr benzoyl liq 7% wash
GNP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
109
Drug Name benzoyl peroxide foam 5.3% bpo cloths mis 6% zenatane cap 10mg zenatane cap 20mg zenatane cap 30mg zenatane cap 40mg tretinoin cream 0.025% tretinoin cream 0.05% tretinoin cream 0.1% tretinoin gel 0.01% tretinoin gel 0.025% tretinoin microsphere gel 0.04% tretinoin microsphere gel 0.1% clindamycin phosphate soln 1% clindamycin phosphate foam 1% clindamycin phosphate gel 1% clindamycin phosphate lotion 1% clindamycin phosphate swab 1% erythromycin soln 2% erythromycin gel 2% erythromycin pads 2% sulfacetamide sodium lotion 10% (acne) EPIDUO GEL 0.1-2.5% benzoyl peroxide-erythromycin gel 5-3% clindamycin phosphate-benzoyl peroxide gel 1-5% clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% clindamycin phosphate-tretinoin gel 1.20.025% ZIANA GEL
Drug Tier Requirements/Limits GNP GNP GNP GNP GNP GNP GNP PAR; AL, *PAR required for members age 25 and older. GNP PAR; AL, *PAR required for members age 25 and older. GNP PAR; AL, *PAR required for members age 25 and older. GNP PAR; AL, *PAR required for members age 25 and older. GNP PAR; AL, *PAR required for members age 25 and older. GNP PAR; AL, *PAR required for members age 25 and older. GNP PAR; AL, *PAR required for members age 25 and older. GNP GNP GNP GNP GNP GNP GNP GNP GNP BNP GNP GNP GNP GNP BNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
110
Drug Name zencia liq 9-4% sulfacetamide sodium w/ sulfur wash 94.5% cerisa wash emu 10-1% sulfacetamide sodium w/ sulfur emulsion 10-5% sulfacetamide sodium w/ sulfur susp 8-4% sss cre 10%-5% sulfacetamide sodium w/ sulfur foam 105% sulfacetamide sodium w/ sulfur lotion 105% sulfacetamide sodium w/ sulfur cleansing pad 10-4% rosula pad 10-5% bp cleansing emu 10-4% sulfacetamide sodium-sulfur in urea gel 10-5%
Drug Tier Requirements/Limits GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
ROSACEA AGENTS FINACEA AER 15% FINACEA GEL 15% SOOLANTRA CRE 1% metronidazole cream 0.75% NORITATE CRE 1% metronidazole gel 0.75% metronidazole gel 1% metronidazole lotion 0.75%
BP BP BP GNP BP GNP GNP GNP
ANTIBIOTICS TOPICAL gentamicin sulfate cream 0.1% gentamicin sulfate oint 0.1% mupirocin oint 2% ALTABAX OIN 1% CORTISPORIN CRE 0.5% CORTISPORIN OIN 1%
GNP GNP GNP BNP BNP BNP
ANTIFUNGALS TOPICAL ciclopirox ciclopirox ciclopirox ciclopirox ciclopirox equiv) ciclopirox equiv)
solution 8% gel 0.77% shampoo 1% kit 8% olamine susp 0.77% (base
GNP GNP GNP GNP GNP
olamine cream 0.77% (base
GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
111
Drug Name ciclopirox solution 8% & vitamin e 5% topical kit naftifine hcl cream 1% naftifine hcl cream 2% NAFTIN CRE 2% NAFTIN GEL 1% nystop pow 100000 nystatin cream 100000 unit/gm nystatin oint 100000 unit/gm econazole nitrate cream 1% ketoconazole cream 2% ketoconazole foam 2% ketoconazole shampoo 2% oxiconazole nitrate cream 1% OXISTAT CRE 1% OXISTAT LOT 1% ERTACZO CRE 2% EXELDERM SOL 1% EXELDERM CRE 1% clotrimazole w/ betamethasone cream 10.05% clotrimazole w/ betamethasone lotion 10.05% iodoquinol-hc cream 1% nystatin-triamcinolone cream 100000-0.1 unit/gm-% nystatin-triamcinolone oint 100000-0.1 unit/gm-% exoderm lot 25-1%
Drug Tier Requirements/Limits GNP GNP GNP BNP BNP GNP GNP GNP GNP GNP GNP GNP GNP BNP BNP BNP BNP BNP GNP GNP GNP GNP GNP GNP
ANTI-INFLAMMATORY AGENTS - TOPICAL diclofenac sodium gel 1%
GNP
ANTIINFLAMMATORY AGENTS TOPICAL VOLTAREN GEL 1%
BP
ANTIPRURITICS TOPICAL prudoxin cre 5%
GNP
ANTIPSORIATICS DRITHO-CREME CRE HP 1% calcipotriene soln 0.005% (50 mcg/ml) calcipotriene cream 0.005% calcipotriene oint 0.005% calcitriol oint 3 mcg/gm TAZORAC CRE 0.05%
BP GNP GNP GNP GNP BP
PAR; AL, *PAR required for members age 25 and older.
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
112
Drug Name TAZORAC CRE 0.1% TAZORAC GEL 0.05% TAZORAC GEL 0.1% acitretin cap 10 mg acitretin cap 17.5 mg acitretin cap 25 mg 8-MOP CAP 10MG methoxsalen rapid cap 10 mg
Drug Tier Requirements/Limits BP PAR; AL, *PAR required for members age 25 and older. BP PAR; AL, *PAR required for members age 25 and older. BP PAR; AL, *PAR required for members age 25 and older. GNP GNP GNP BP GNP
ANTISEBORRHEIC PRODUCTS selenium sulfide lotion 2.5% sulfacetamide sodium liquid 10% selenium sulfide-pyrithione zinc in urea shampoo 2.25%
GP GNP GNP
ANTIVIRALS TOPICAL acyclovir oint 5% DENAVIR CRE 1%
GNP BNP
ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS TOPICAL VALCHLOR GEL 0.016% fluorouracil soln 2% fluorouracil soln 5% fluorouracil cream 5% PANRETIN GEL 0.1% TARGRETIN GEL 1% PICATO GEL 0.015% PICATO GEL 0.05%
BP GNP GNP GNP BNP BP BNP BNP
SRx
SRx
BURN PRODUCTS SULFAMYLON CRE 85MG/GM silver sulfadiazine cream 1%
BNP GNP
CAUTERIZING AGENTS SILVER NITRA SOL 0.5% SILVER NITRA SOL 10% SILVER NITRA SOL 25% SILVER NITRA SOL 50% SILVER NITRA OIN 10% arzol silver mis nitr app
BP BP BP BP BP GNP
TAR PRODUCTS coal tar soln 20%
GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
113
Drug Name
Drug Tier Requirements/Limits
CORTICOSTEROIDS TOPICAL alclometasone dipropionate cream 0.05% alclometasone dipropionate oint 0.05% amcinonide cream 0.1% amcinonide lotion 0.1% AMCINONIDE OIN 0.1% betamethasone dipropionate cream 0.05% betamethasone dipropionate lotion 0.05% betamethasone dipropionate oint 0.05% betamethasone dipropionate augmented cream 0.05% betamethasone dipropionate augmented gel 0.05% betamethasone dipropionate augmented lotion 0.05% betamethasone dipropionate augmented oint 0.05% betamethasone valerate cream 0.1% betamethasone valerate aerosol foam 0.12% betamethasone valerate lotion 0.1% betamethasone valerate oint 0.1% clobetasol propionate soln 0.05% 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 e cre 0.05% clocortolone pivalate cream 0.1% desonide cream 0.05% DESONATE GEL 0.05% desonide lotion 0.05% desonide oint 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 body fluocin acet oil 0.01% sc
GNP GNP GNP GNP BP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP BNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
114
Drug Name Drug Tier Requirements/Limits fluocinolone acetonide soln 0.01% GNP fluocinolone acetonide cream 0.01% GNP fluocinolone acetonide cream 0.025% GNP fluocinolone acetonide oint 0.025% GNP CAPEX SHA 0.01% BP fluocinonide soln 0.05% GNP fluocinonide cream 0.05% GNP fluocinonide gel 0.05% GNP fluocinonide oint 0.05% GNP fluocinonide emulsified base cream 0.05% GNP CORDRAN LOT 0.05% BNP CORDRAN 80X3 TAP 4MCG/CM BNP fluticasone propionate cream 0.05% GNP fluticasone propionate lotion 0.05% GNP fluticasone propionate oint 0.005% GNP HALOG CRE 0.1% BNP HALOG OIN 0.1% BNP halobetasol propionate cream 0.05% GNP halobetasol propionate oint 0.05% GNP hydrocortisone cream 2.5% GP scalacort lot 2% GNP hydrocortisone lotion 2.5% GNP hydrocortisone oint 2.5% GP hydrocortisone valerate cream 0.2% GNP hydrocortisone valerate oint 0.2% GNP hydrocortisone butyrate soln 0.1% GNP hydrocortisone butyrate cream 0.1% GNP hydrocortisone butyrate oint 0.1% GNP mometasone furoate solution 0.1% (lotion) GNP mometasone furoate cream 0.1% GNP mometasone furoate oint 0.1% GNP prednicarbate cream 0.1% GNP prednicarbate oint 0.1% GNP triamcinolone acetonide cream 0.025% GP triamcinolone acetonide cream 0.1% GP triamcinolone acetonide cream 0.5% GNP triamcinolone acetonide lotion 0.025% GNP triamcinolone acetonide lotion 0.1% GNP triamcinolone acetonide oint 0.025% GP TRIANEX OIN 0.05% BP triamcinolone acetonide oint 0.1% GP triamcinolone acetonide oint 0.5% GNP pramoxine-hc cream 1-2.5% GNP EPIFOAM AER 1% BP PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
115
Drug Name Drug Tier Requirements/Limits PRAMOSONE LOT 1% BP PRAMOSONE LOT 2.5% BP PRAMOSONE OIN 1% BP TACLONEX SUS BNP calcipotriene-betamethasone dipropionate GNP oint 0.005-0.064% cortalo gel 2% GNP
EMOLLIENTS hygel gel 0.2% GNP lactic acid (ammonium lactate) cream 12% GNP lactic acid (ammonium lactate) lotion 10% GNP lactic acid w/ vitamin e cream 10%-3500 GNP unit/30gm
EMOLLIENT/KERATOLYTIC AGENTS urea suspension 40% urea cream 39% u-kera e cre 40% urea cream 45% remeven cre 50% umecta mouss aer 40% carb-o-philc gel 40% urea nail gel 45% rea lo 40 lot 40% urea lotion 45% urea hydrati aer 35% latrix sus 50% urea in zinc undecylenate-lactic acid vehicle emulsion 50%
GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP GNP
ENZYMES TOPICAL SANTYL OIN 250/GM tbc aer
BNP GNP
KERATOLYTIC/ANTIMITOTIC AGENTS podofilox soln 0.5% CONDYLOX GEL 0.5% salicylic ac liq 27.5% salicylic acid cream 6% salicylic acid foam 6% salicylic acid gel 6% salicylic acid lotion 6% salicylic acid shampoo 6% salicylic acid cream 6% & cleanser liqd kit salicylic acid lotion 6% & cleanser liqd kit salicylic acid in ammonium lactate vehicle foam 6%
GNP BP GNP GNP GNP GNP GNP GNP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
116
Drug Name
Drug Tier Requirements/Limits
AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTS VEREGEN OIN 15%
BNP
IMMUNOMODULATING AGENTS TOPICAL imiquimod cream 5%
GNP
IMMUNOSUPPRESSIVE AGENTS TOPICAL ELIDEL CRE 1% tacrolimus oint 0.03% tacrolimus oint 0.1%
BP GNP GNP
LOCAL ANESTHETICS TOPICAL cocaine hcl soln 4% cocaine hcl soln 10% lidocaine oint 5% lidocaine patch 5% lidocaine hcl soln 4% lidocaine hcl cream 3% lidocaine hcl gel 2% lidocaine hcl lotion 3% ethyl chloride aerosol spray SYNERA DIS 70-70MG lidocaine-prilocaine cream 2.5-2.5% lidocaine-prilocaine cream kit 2.5-2.5%
SCABICIDES
GNP GNP GNP GNP GNP GNP GP GNP GNP BNP GNP GNP
PEDICULICIDES
ULESFIA LOT 5% EURAX CRE 10% EURAX LOT 10% SKLICE LOT 0.5% lindane lotion 1% lindane shampoo 1% malathion lotion 0.5% permethrin cream 5% spinosad susp 0.9%
BNP BP BP BNP GNP GNP GNP GNP GNP
WOUND CARE PRODUCTS REGRANEX GEL 0.01%
ANTISEPTICS
BP
PAR
DISINFECTANTS
formadon sol forma-ray sol 20%
GNP GNP
CHLORINE ANTISEPTICS benzalkonium chloride soln 50%
GNP
ANTIDOTES AND SPECIFIC ANTAGONISTS VISTOGARD PAK 10GM
BP
ANTIDOTES CHELATING AGENTS EXJADE TAB 125MG
BP
PAR; SRx
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
117
Drug Name EXJADE TAB 250MG EXJADE TAB 500MG FERRIPROX TAB 500MG FERRIPROX SOL 100MG/ML CHEMET CAP 100MG
Drug Tier Requirements/Limits BP PAR; SRx BP PAR; SRx BNP PAR; SRx BNP PAR; SRx BP
OPIOID ANTAGONISTS NARCAN SPR naloxone hcl inj 1 mg/ml EVZIO INJ naltrexone hcl tab 50 mg
BP GNP BP GNP
DIAGNOSTIC TESTS ACETEST TAB TABLETS KETOSTIX TES STRIP CHEMSTRIP TES STRIPS ACCUTREND TES GLUCOSE ONETOUCH TES VERIO DIASTIX TES STRIPS PTS PANELS TES KETONE KETO-DIASTIX TES
BNP BNP BNP BNP BP BP BNP BP
OTC OTC OTC PAR; OTC OTC OTC OTC OTC
DIAGNOSTIC DRUGS isosulfan blue subcutaneous soln 1%
GNP
LIQUIDS CHLORHEXIDIN SOL GLUCONAT
BP
DIABETIC SUPPLIES ULTIMA KIT MONITOR ONETOUCH KIT ULT MINI TRUE METRIX KIT METER
BNP BP BNP
PAR; OTC OTC PAR; OTC
BP
OTC
BNP BNP BNP BP BP BP BP
OTC OTC OTC OTC
BNP BNP BNP BNP BNP
PHC, OTC PHC PHC PHC PHC
DIAGNOSTIC TESTS VERIO FLEX KIT ONETOUCH
DIABETIC SUPPLIES CGMS SYSTEM MIS GOLD G4 PLATINUM KIT RCV/SHAR CGMS MIS SOFTWARE RELION LANCE MIS THIN 26G LANCING DEVI MIS ONETOUCH MIS LANC DEV ACCU-CHEK KIT MLTICLIX
CONTRACEPTIVES FC FEMALE MIS CONDOM FEMCAP MIS 22MM PRENTIF MIS 25MM FEMCAP MIS 26MM PRENTIF MIS 28MM
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
118
Drug Name FEMCAP MIS 30MM PRENTIF MIS 31MM PRENTIF MIS FITTING OMNIFLEX DPR CAYA DPR ORTHO COIL DPR KIT 50 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 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
Drug Tier Requirements/Limits BNP PHC BNP PHC BNP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC BP PHC
CHELATING AGENTS SYPRINE CAP 250MG CUPRIMINE CAP 250MG DEPEN TITRA TAB 250MG
BNP BP BP
IMMUNOMODULATORS THALOMID CAP 50MG THALOMID CAP 100MG THALOMID CAP 150MG THALOMID CAP 200MG REVLIMID CAP 2.5MG REVLIMID CAP 5MG REVLIMID CAP 10MG REVLIMID CAP 15MG REVLIMID CAP 20MG REVLIMID CAP 25MG
BP BP BP BP BP BP BP BP BP BP
SRx SRx SRx SRx SRx SRx SRx SRx SRx SRx
IMMUNOSUPPRESSIVE AGENTS cyclosporine cap 25 mg cyclosporine cap 100 mg
GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
119
Drug Name gengraf cap 25mg cyclosporine modified cap 50 mg cyclosporine modified cap 100 mg cyclosporine modified oral soln 100 mg/ml mycophenolate mofetil cap 250 mg mycophenolate mofetil tab 500 mg mycophenolate mofetil for oral susp 200 mg/ml mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) ZORTRESS TAB 0.25MG ZORTRESS TAB 0.5MG ZORTRESS TAB 0.75MG sirolimus tab 0.5 mg sirolimus tab 1 mg sirolimus tab 2 mg RAPAMUNE SOL 1MG/ML tacrolimus cap 0.5 mg tacrolimus cap 1 mg tacrolimus cap 5 mg azathioprine tab 50 mg
Drug Tier Requirements/Limits GNP GNP GNP GNP GNP GNP GNP GNP GNP BP BP BP GNP GNP GNP BP GNP GNP GNP GNP
POTASSIUM REMOVING RESINS sodium polystyrene sulfonate oral susp 15 GNP gm/60ml sodium polystyrene sulfonate rectal susp GNP 30 gm/120ml sodium polystyrene sulfonate powder GNP
IRRIGATION SOLUTIONS physiosol sol irrigat water for irrigation, sterile irrigation soln lactated ringer's for irrigation ringer's solution for irrigation
GNP GNP GNP GNP
PAR - Prior Authorization Required QLL - Quantity Level Limit EPA - Enhanced Prior Auth AL - Age Limit OTC - Over-The-Counter PHC - Preventative Health Care
120
Index 8-MOP CAP 10MG ........................... 113 abacavir sulfate tab 300 mg (base equiv) ......................................................13 abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg .........................14 acamprosate calcium tab delayed release 333 mg ...........................................81 acarbose tab 100 mg.........................33 acarbose tab 25 mg ..........................33 acarbose tab 50 mg ..........................33 ACCU-CHEK KIT MLTICLIX ............... 118 ACCUTREND TES GLUCOSE .............. 118 acebutolol hcl cap 200 mg .................41 acebutolol hcl cap 400 mg .................41 acetaminophen w/ codeine soln 120-12 mg/5ml ...........................................86 acetaminophen w/ codeine tab 300-15 mg ..................................................86 acetaminophen w/ codeine tab 300-30 mg ..................................................86 acetaminophen w/ codeine tab 300-60 mg ..................................................86 acetasol hc sol otic .......................... 108 acetazolamide cap sr 12hr 500 mg ......50 acetazolamide tab 125 mg .................50 acetazolamide tab 250 mg .................50 ACETEST TAB TABLETS .................... 118 acetic acid 2% in aluminum acetate otic soln............................................... 108 acetic acid irrigation soln 0.25% .........67 acetic acid otic soln 2% ................... 108 acetylcysteine cap 600 mg .................99 acetylcysteine inhal soln 10% .............56 acetylcysteine inhal soln 20% .............56 acitretin cap 10 mg ......................... 113 acitretin cap 17.5 mg ...................... 113 acitretin cap 25 mg ......................... 113 ACTEMRA INJ 162/0.9 .......................89 ACTIMMUNE ...................................... 6 ACTIMMUNE INJ 2MU/0.5...................22 ACTOPLUS MET TAB XR .....................35 acyclovir cap 200 mg ........................15 acyclovir oint 5% ............................ 113 acyclovir susp 200 mg/5ml ................15 acyclovir tab 400 mg .........................15
acyclovir tab 800 mg ........................ 15 adapalene cream 0.1% ................... 109 adapalene gel 0.1% ........................ 109 adapalene gel 0.3% ........................ 109 ADCIRCA TAB 20MG ......................... 54 adefovir dipivoxil tab 10 mg .............. 15 ADEMPAS TAB 0.5MG ....................... 54 ADEMPAS TAB 1.5MG ....................... 54 ADEMPAS TAB 1MG .......................... 54 ADEMPAS TAB 2.5MG ....................... 54 ADEMPAS TAB 2MG .......................... 54 ADVAIR DISKU AER 100/50 ............... 58 ADVAIR DISKU AER 250/50 ............... 58 ADVAIR DISKU AER 500/50 ............... 58 ADVAIR HFA AER 115/21 .................. 58 ADVAIR HFA AER 230/21 .................. 58 ADVAIR HFA AER 45/21 .................... 58 ADVATE INJ 1000UNIT .................... 103 ADVATE INJ 1500UNIT .................... 103 ADVATE INJ 2000UNIT .................... 103 ADVATE INJ 250UNIT ..................... 103 ADVATE INJ 3000UNIT .................... 103 ADVATE INJ 4000UNIT .................... 103 ADVATE INJ 500UNIT ..................... 103 afeditab tab 30mg cr ........................ 43 AFINITOR DIS TAB 2MG .................... 20 AFINITOR DIS TAB 3MG .................... 20 AFINITOR DIS TAB 5MG .................... 20 AFINITOR TAB 10MG ........................ 20 AFINITOR TAB 2.5MG ....................... 20 AFINITOR TAB 5MG .......................... 20 AFINITOR TAB 7.5MG ....................... 20 aftera tab 1.5mg .............................. 25 ALBENZA TAB 200MG ....................... 16 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) ......................................... 57 albuterol sulfate soln nebu 0.5% (5 mg/ml) ........................................... 57 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) .................................... 57 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) .................................... 57 albuterol sulfate syrup 2 mg/5ml ....... 57 albuterol sulfate tab 2 mg ................. 57 albuterol sulfate tab 4 mg ................. 57 121
albuterol sulfate tab sr 12hr 4 mg .......57 albuterol sulfate tab sr 12hr 8 mg .......57 alclometasone dipropionate cream 0.05% .................................................... 114 alclometasone dipropionate oint 0.05% .................................................... 114 ALDACTAZIDE TAB 50/50 ..................51 ALECENSA CAP 150MG ......................20 alendronate sodium oral soln 70 mg/75ml .........................................37 alendronate sodium tab 10 mg ...........37 alendronate sodium tab 35 mg ...........37 alendronate sodium tab 40 mg ...........37 alendronate sodium tab 5 mg .............37 alendronate sodium tab 70 mg ...........37 alfuzosin hcl tab sr 24hr 10 mg...........67 ALINIA SUS 100/5ML ........................17 ALINIA TAB 500MG ...........................17 ALKERAN TAB 2MG ...........................17 allopurinol tab 100 mg.......................90 allopurinol tab 300 mg.......................90 almotriptan malate tab 12.5 mg .........89 almotriptan malate tab 6.25 mg .........89 ALOCRIL SOL 2% ............................ 107 alogliptin benzoate tab 12.5 mg (base equiv) .............................................34 alogliptin benzoate tab 25 mg (base equiv) .............................................34 alogliptin benzoate tab 6.25 mg (base equiv) .............................................34 alogliptin-metformin hcl tab 12.5-1000 mg ..................................................34 alogliptin-metformin hcl tab 12.5-500 mg ......................................................34 alogliptin-pioglitazone tab 12.5-15 mg.35 alogliptin-pioglitazone tab 12.5-30 mg.35 alogliptin-pioglitazone tab 12.5-45 mg.35 alogliptin-pioglitazone tab 25-15 mg ...35 alogliptin-pioglitazone tab 25-30 mg ...35 alogliptin-pioglitazone tab 25-45 mg ...35 ALOMIDE SOL 0.1% OP ................... 107 alosetron hcl tab 0.5 mg (base equiv) .64 alosetron hcl tab 1 mg (base equiv) ....64 ALPHAGAN P SOL 0.1% ................... 107 ALPHANATE INJ VWF/HUM ............... 104 ALPHANINE SD INJ 1500UNIT .......... 104 ALPHANINE SD INJ 500UNIT ............ 104
ALPRAZOLAM CON 1 MG/ML .............. 67 alprazolam orally disintegrating tab 0.25 mg ................................................. 68 alprazolam orally disintegrating tab 0.5 mg ................................................. 68 alprazolam orally disintegrating tab 1 mg ...................................................... 68 alprazolam orally disintegrating tab 2 mg ...................................................... 68 alprazolam tab 0.25 mg .................... 67 alprazolam tab 0.5 mg ...................... 67 alprazolam tab 1 mg ......................... 67 alprazolam tab 2 mg ......................... 67 alprazolam tab sr 24hr 0.5 mg ........... 68 alprazolam tab sr 24hr 1 mg.............. 68 alprazolam tab sr 24hr 2 mg.............. 68 alprazolam tab sr 24hr 3 mg.............. 68 ALREX SUS 0.2% ........................... 106 ALTABAX OIN 1% ........................... 111 altafrin sol 10% op ......................... 107 altafrin sol 2.5% op ........................ 107 altavera tab ..................................... 27 ALVESCO AER 160MCG ..................... 59 ALVESCO AER 80MCG ....................... 59 alyacen tab 1/35 .............................. 27 alyacen tab 7/7/7 ............................. 30 amantadine hcl cap 100 mg ............... 94 amantadine hcl syrup 50 mg/5ml ....... 94 amantadine hcl tab 100 mg ............... 94 amcinonide cream 0.1% ................. 114 amcinonide lotion 0.1% .................. 114 AMCINONIDE OIN 0.1% .................. 114 amethia lo tab ................................. 30 amethia tab ..................................... 31 amethyst tab 90-20mcg .................... 31 AMICAR SOL 0.25/ML ..................... 103 AMICAR SYP 25%........................... 103 AMICAR TAB 1000MG ..................... 103 AMICAR TAB 500MG ....................... 103 amiloride & hydrochlorothiazide tab 5-50 mg ................................................. 51 amiloride hcl tab 5 mg ...................... 51 amiodarone hcl tab 100 mg ............... 44 amiodarone hcl tab 200 mg ............... 44 amiodarone hcl tab 400 mg ............... 44 AMITIZA CAP 24MCG ........................ 63 AMITIZA CAP 8MCG .......................... 63 122
amitriptyline hcl tab 10 mg ................71 amitriptyline hcl tab 100 mg ..............71 amitriptyline hcl tab 150 mg ..............71 amitriptyline hcl tab 25 mg ................71 amitriptyline hcl tab 50 mg ................71 amitriptyline hcl tab 75 mg ................71 amlodipine besylate tab 10 mg ...........42 amlodipine besylate tab 2.5 mg ..........42 amlodipine besylate tab 5 mg .............42 amlodipine besylate-atorvastatin calcium tab 10-10 mg ...................................55 amlodipine besylate-atorvastatin calcium tab 10-20 mg ...................................55 amlodipine besylate-atorvastatin calcium tab 10-40 mg ...................................55 amlodipine besylate-atorvastatin calcium tab 10-80 mg ...................................55 amlodipine besylate-atorvastatin calcium tab 2.5-10 mg ..................................54 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg ..................................55 amlodipine besylate-atorvastatin calcium tab 2.5-40 mg ..................................55 amlodipine besylate-atorvastatin calcium tab 5-10 mg .....................................55 amlodipine besylate-atorvastatin calcium tab 5-20 mg .....................................55 amlodipine besylate-atorvastatin calcium tab 5-40 mg .....................................55 amlodipine besylate-atorvastatin calcium tab 5-80 mg .....................................55 amlodipine besylate-benazepril hcl cap 10-20 mg ........................................47 amlodipine besylate-benazepril hcl cap 10-40 mg ........................................47 amlodipine besylate-benazepril hcl cap 2.5-10 mg .......................................47 amlodipine besylate-benazepril hcl cap 510 mg .............................................47 amlodipine besylate-benazepril hcl cap 520 mg .............................................47 amlodipine besylate-benazepril hcl cap 540 mg .............................................47 amlodipine besylate-valsartan tab 10160 mg ...........................................49 amlodipine besylate-valsartan tab 10320 mg ...........................................49
amlodipine besylate-valsartan tab 5-160 mg ................................................. 49 amlodipine besylate-valsartan tab 5-320 mg ................................................. 49 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg ......................... 50 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg ............................ 50 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg ............................ 50 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg ........................... 50 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg.............................. 50 amoxapine tab 100 mg ..................... 71 amoxapine tab 150 mg ..................... 71 amoxapine tab 25 mg ....................... 71 amoxapine tab 50 mg ....................... 71 amoxicillin & k clavulanate chew tab 20028.5 mg ............................................ 8 amoxicillin & k clavulanate chew tab 40057 mg............................................... 8 amoxicillin & k clavulanate for susp 20028.5 mg/5ml ..................................... 8 amoxicillin & k clavulanate for susp 25062.5 mg/5ml ..................................... 8 amoxicillin & k clavulanate for susp 40057 mg/5ml ........................................ 8 amoxicillin & k clavulanate for susp 60042.9 mg/5ml ..................................... 9 amoxicillin & k clavulanate tab 250-125 mg ................................................... 8 amoxicillin & k clavulanate tab 500-125 mg ................................................... 8 amoxicillin & k clavulanate tab 875-125 mg ................................................... 8 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg ................................... 9 amoxicillin (trihydrate) cap 250 mg ...... 8 amoxicillin (trihydrate) cap 500 mg ...... 8 amoxicillin (trihydrate) chew tab 125 mg ........................................................ 8 amoxicillin (trihydrate) chew tab 250 mg ........................................................ 8 amoxicillin (trihydrate) for susp 125 mg/5ml ............................................. 8 amoxicillin (trihydrate) for susp 200 123
mg/5ml ............................................ 8 amoxicillin (trihydrate) for susp 250 mg/5ml ............................................ 8 amoxicillin (trihydrate) for susp 400 mg/5ml ............................................ 8 amoxicillin (trihydrate) tab 500 mg ...... 8 amoxicillin (trihydrate) tab 875 mg ...... 8 amphetamine-dextroamphetamine cap sr 24hr 10 mg ......................................77 amphetamine-dextroamphetamine cap sr 24hr 15 mg ......................................77 amphetamine-dextroamphetamine cap sr 24hr 20 mg ......................................77 amphetamine-dextroamphetamine cap sr 24hr 25 mg ......................................77 amphetamine-dextroamphetamine cap sr 24hr 30 mg ......................................77 amphetamine-dextroamphetamine cap sr 24hr 5 mg........................................77 amphetamine-dextroamphetamine tab 10 mg .............................................77 amphetamine-dextroamphetamine tab 12.5 mg ..........................................77 amphetamine-dextroamphetamine tab 15 mg .............................................77 amphetamine-dextroamphetamine tab 20 mg .............................................77 amphetamine-dextroamphetamine tab 30 mg .............................................77 amphetamine-dextroamphetamine tab 5 mg ..................................................77 amphetamine-dextroamphetamine tab 7.5 mg ............................................77 ampicillin cap 250 mg......................... 8 ampicillin cap 500 mg......................... 8 ampicillin for susp 125 mg/5ml ............ 8 ampicillin for susp 250 mg/5ml ............ 8 AMPYRA TAB 10MG ...........................81 ANADROL-50 TAB 50MG ....................24 anagrelide hcl cap 0.5 mg ................ 104 anagrelide hcl cap 1 mg ................... 104 ANALPRAM E KIT ............................ 109 anastrozole tab 1 mg ........................19 ANDRODERM DIS 2MG/24HR..............23 ANDRODERM DIS 4MG/24HR..............23 ANDROGEL GEL 1%(50MG) ................23 ANDROGEL GEL 1.62% ......................23
android cap 10mg ............................ 23 ANDROXY TAB 10MG ........................ 23 ANORO ELLIPT AER 62.5-25 .............. 58 antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%).......................... 108 antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%).......................... 108 ANZEMET TAB 100MG ....................... 62 ANZEMET TAB 50MG ......................... 62 APIDRA INJ SOLOSTAR ..................... 31 APIDRA INJ U-100 ............................ 31 APOKYN INJ 10MG/ML ...................... 94 apraclonidine hcl ophth soln 0.5% (base equivalent) .................................... 107 apri tab ........................................... 26 APTIVUS CAP 250MG ........................ 13 APTIVUS SOL ................................... 13 aranelle tab ..................................... 30 ARANESP INJ 100MCG .................... 100 ARANESP INJ 10MCG ...................... 100 ARANESP INJ 150MCG .................... 100 ARANESP INJ 200MCG .................... 100 ARANESP INJ 25MCG ...................... 100 ARANESP INJ 300MCG .................... 100 ARANESP INJ 40MCG ...................... 100 ARANESP INJ 500MCG .................... 100 ARANESP INJ 60MCG ...................... 100 ARCALYST INJ 220MG ....................... 89 ARCAPTA CAP 75MCG ....................... 57 aripiprazole oral solution 1 mg/ml ...... 75 aripiprazole tab 10 mg ...................... 75 aripiprazole tab 15 mg ...................... 75 aripiprazole tab 2 mg ........................ 75 aripiprazole tab 20 mg ...................... 75 aripiprazole tab 30 mg ...................... 75 aripiprazole tab 5 mg ........................ 75 armodafinil tab 150 mg ..................... 78 armodafinil tab 200 mg ..................... 78 armodafinil tab 250 mg ..................... 78 armodafinil tab 50 mg ...................... 78 ARMOUR THYRO TAB 120MG ............. 36 ARMOUR THYRO TAB 15MG ............... 36 ARMOUR THYRO TAB 180MG ............. 36 ARMOUR THYRO TAB 240MG ............. 36 ARMOUR THYRO TAB 300MG ............. 36 arzol silver mis nitr app................... 113 ASACOL HD TAB 800MG .................... 64 124
ascomp/cod cap 30mg .......................86 ashlyna tab ......................................31 ASMANEX 30 AER 110MCG .................59 ASMANEX 30 AER 220MCG .................59 ASMANEX HFA AER 100 MCG..............59 ASMANEX HFA AER 200 MCG..............59 aspirin low chw 81mg ........................82 ASPIRIN TAB 81MG ...........................82 aspirin tab delayed release 325 mg .....82 aspirin tab delayed release 81 mg .......82 aspirin-caffeine-dihydrocodeine cap 356.4-30-16 mg ...............................86 aspirin-dipyridamole cap sr 12hr 25-200 mg ................................................ 104 atenolol & chlorthalidone tab 100-25 mg ......................................................48 atenolol & chlorthalidone tab 50-25 mg ......................................................48 atenolol tab 100 mg ..........................41 atenolol tab 25 mg ............................41 atenolol tab 50 mg ............................41 atorvastatin calcium tab 10 mg (base equivalent) ......................................52 atorvastatin calcium tab 20 mg (base equivalent) ......................................53 atorvastatin calcium tab 40 mg (base equivalent) ......................................53 atorvastatin calcium tab 80 mg (base equivalent) ......................................53 atovaquone susp 750 mg/5ml ............17 atovaquone-proguanil hcl tab 250-100 mg ..................................................16 atovaquone-proguanil hcl tab 62.5-25 mg ..................................................16 ATRIPLA TAB ....................................14 atropine sulfate ophth soln 1% ......... 106 ATROVENT HFA AER 17MCG ...............57 AUBAGIO TAB 14MG .........................80 AUBAGIO TAB 7MG ...........................80 aubra tab 0.1-0.02 ............................26 AVANDAMET TAB 2-1000MG...............35 AVANDIA TAB 2MG ...........................34 AVANDIA TAB 4MG ...........................34 AVANDIA TAB 8MG ...........................34 AVC CRE 15% ..................................66 aviane tab........................................26 AVODART CAP 0.5MG ........................67
AVONEX KIT 30MCG ......................... 80 AVONEX PEN KIT 30MCG ................... 80 AVONEX PREFL KIT 30MCG................ 80 AXIRON SOL 30MG/ACT .................... 23 azathioprine tab 50 mg ................... 120 azelastine hcl nasal spray 0.1% (137 mcg/spray) ..................................... 56 azelastine hcl ophth soln 0.05% ....... 107 AZILECT TAB 0.5MG ......................... 95 AZILECT TAB 1MG ............................ 95 azithromycin for susp 100 mg/5ml ..... 10 azithromycin for susp 200 mg/5ml ..... 10 azithromycin powd pack for susp 1 gm 10 azithromycin tab 250 mg .................. 10 azithromycin tab 500 mg .................. 10 azithromycin tab 600 mg .................. 10 AZOPT SUS 1% OP ......................... 107 AZOR TAB 10-20MG ......................... 49 AZOR TAB 10-40MG ......................... 49 AZOR TAB 5-20MG ........................... 49 AZOR TAB 5-40MG ........................... 49 azurette tab 28 day .......................... 29 bacitracin ophth oint 500 unit/gm .... 105 bacitracin-polymyxin b ophth oint .... 105 bacitracin-polymyxin-neomycin-hc ophth oint 1% ........................................ 106 baclofen tab 10 mg .......................... 95 baclofen tab 20 mg .......................... 95 BACTROBAN OIN NASAL 2% .............. 56 balsalazide disodium cap 750 mg ....... 63 balziva tab ...................................... 27 BANZEL SUS 40MG/ML ..................... 93 BANZEL TAB 200MG ......................... 93 BANZEL TAB 400MG ......................... 93 BARACLUDE SOL .05MG/ML ............... 15 bayer asa tab 325mg ........................ 82 BD GLUCOSE CHW 5GM .................... 33 BEBULIN INJ 200-1200 ................... 104 BECONASE AQ SUS 0.042% .............. 56 bekyree tab ..................................... 29 BELLA/OPIUM SUP 16.2-30................ 61 BELLA/OPIUM SUP 16.2-60................ 61 benazepril & hydrochlorothiazide tab 1012.5 mg .......................................... 47 benazepril & hydrochlorothiazide tab 2012.5 mg .......................................... 47 benazepril & hydrochlorothiazide tab 20125
25 mg .............................................47 benazepril & hydrochlorothiazide tab 56.25 mg ..........................................47 benazepril hcl tab 10 mg ...................45 benazepril hcl tab 20 mg ...................45 benazepril hcl tab 40 mg ...................45 benazepril hcl tab 5 mg .....................44 BENEFIX INJ 1000UNIT ................... 104 BENEFIX INJ 2000UNIT ................... 104 BENEFIX INJ 250UNIT ..................... 104 BENEFIX INJ 3000UNIT ................... 104 BENEFIX INJ 500UNIT ..................... 104 BENICAR HCT TAB 20-12.5 ................49 BENICAR HCT TAB 40-12.5 ................49 BENICAR HCT TAB 40-25MG ..............49 BENICAR TAB 20MG ..........................46 BENICAR TAB 40MG ..........................46 BENICAR TAB 5MG ............................46 benzalkonium chloride soln 50% ....... 117 benzonatate cap 100 mg ...................56 benzonatate cap 200 mg ...................56 benzoyl peroxide foam 5.3% ............ 110 benzoyl peroxide-erythromycin gel 5-3% .................................................... 110 benztropine mesylate tab 0.5 mg ........94 benztropine mesylate tab 1 mg ..........94 benztropine mesylate tab 2 mg ..........94 BEPREVE DRO 1.5% ........................ 107 BERINERT INJ 500UNIT ................... 105 BESIVANCE SUS 0.6%..................... 105 betamethasone dipropionate augmented cream 0.05% ................................. 114 betamethasone dipropionate augmented gel 0.05% ...................................... 114 betamethasone dipropionate augmented lotion 0.05% .................................. 114 betamethasone dipropionate augmented oint 0.05% ..................................... 114 betamethasone dipropionate cream 0.05% ........................................... 114 betamethasone dipropionate lotion 0.05% ........................................... 114 betamethasone dipropionate oint 0.05% .................................................... 114 betamethasone valerate aerosol foam 0.12% ........................................... 114 betamethasone valerate cream 0.1% 114
betamethasone valerate lotion 0.1% 114 betamethasone valerate oint 0.1% ... 114 BETASERON INJ 0.3MG ..................... 80 betaxolol hcl ophth soln 0.5% .......... 105 betaxolol hcl tab 10 mg .................... 41 betaxolol hcl tab 20 mg .................... 41 bethanechol chloride tab 10 mg ......... 66 bethanechol chloride tab 25 mg ......... 66 bethanechol chloride tab 5 mg ........... 66 bethanechol chloride tab 50 mg ......... 66 BETOPTIC-S SUS 0.25% OP ............ 105 bexarotene cap 75 mg ...................... 22 BEYAZ TAB ...................................... 28 bicalutamide tab 50 mg .................... 18 BILTRICIDE TAB 600MG .................... 16 bio-statin pow .................................. 12 bisacodyl tab & peg 3350-kcl-sod bicarbnacl for soln kit ................................ 60 bisoprolol & hydrochlorothiazide tab 106.25 mg .......................................... 48 bisoprolol & hydrochlorothiazide tab 2.56.25 mg .......................................... 48 bisoprolol & hydrochlorothiazide tab 56.25 mg .......................................... 48 bisoprolol fumarate tab 10 mg ........... 41 bisoprolol fumarate tab 5 mg ............. 41 BLEPHAMIDE OIN S.O.P. ................. 106 BLEPHAMIDE SUS OP ...................... 106 blisovi 24 tab fe 1/20 ........................ 29 blisovi fe tab 1.5/30 ......................... 29 blisovi fe tab 1/20 ............................ 28 bp cleansing emu 10-4% ................ 111 bp folinatal tab plus b ....................... 97 b-plex tab ....................................... 97 bpo cloths mis 6% .......................... 110 BREO ELLIPTA INH 100-25 ................ 58 BREO ELLIPTA INH 200-25 ................ 58 briellyn tab ...................................... 27 BRILINTA TAB 90MG ....................... 104 brimonidine tartrate ophth soln 0.15% .................................................... 107 brimonidine tartrate ophth soln 0.2% 107 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) ................ 107 bromfenac sodium ophth soln 0.09% (base equivalent) ........................... 107 bromocriptine mesylate cap 5 mg....... 94 126
bromocriptine mesylate tab 2.5 mg .....94 BROVANA NEB 15MCG .......................57 budesonide delayed release particles cap 3 mg ...............................................22 budesonide inhalation susp 0.25 mg/2ml ......................................................59 budesonide inhalation susp 0.5 mg/2ml ......................................................59 budesonide nasal susp 32 mcg/act ......56 bumetanide tab 0.5 mg .....................50 bumetanide tab 1 mg ........................50 bumetanide tab 2 mg ........................50 BUPHENYL TAB 500MG ......................39 buprenorphine hcl sl tab 2 mg (base equiv) .............................................85 buprenorphine hcl sl tab 8 mg (base equiv) .............................................85 buproban tab 150mg .........................80 bupropion hcl tab 100 mg ..................72 bupropion hcl tab 75 mg ....................72 bupropion hcl tab sr 12hr 100 mg .......72 bupropion hcl tab sr 12hr 150 mg .......72 bupropion hcl tab sr 12hr 200 mg .......72 bupropion hcl tab sr 24hr 150 mg .......72 bupropion hcl tab sr 24hr 300 mg .......72 buspirone hcl tab 10 mg ....................68 buspirone hcl tab 15 mg ....................68 buspirone hcl tab 30 mg ....................68 buspirone hcl tab 5 mg ......................68 buspirone hcl tab 7.5 mg ...................68 butalbital-acetaminophen tab 50-325 mg ......................................................82 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg .............................86 butalbital-acetaminophen-caffeine tab 50-325-40 mg ..................................83 butalbital-aspirin-caffeine cap 50-325-40 mg ..................................................83 butorphanol tartrate nasal soln 10 mg/ml ......................................................86 BUTRANS DIS 10MCG/HR ..................85 BUTRANS DIS 20MCG/HR ..................85 BUTRANS DIS 5MCG/HR ....................85 BYETTA INJ 10MCG ...........................32 BYETTA INJ 5MCG .............................32 BYSTOLIC TAB 10MG .........................42 BYSTOLIC TAB 2.5MG ........................42
BYSTOLIC TAB 20MG ........................ 42 BYSTOLIC TAB 5MG .......................... 42 cabergoline tab 0.5 mg ..................... 39 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) ........................... 77 calcipotriene cream 0.005% ............ 112 calcipotriene oint 0.005% ................ 112 calcipotriene soln 0.005% (50 mcg/ml) .................................................... 112 calcipotriene-betamethasone dipropionate oint 0.005-0.064% ...... 116 calcitonin (salmon) nasal soln 200 unit/act ........................................... 37 calcitriol cap 0.25 mcg ...................... 39 calcitriol cap 0.5 mcg ........................ 39 calcitriol oint 3 mcg/gm .................. 112 calcitriol oral soln 1 mcg/ml ............... 39 calcium acetate (phosphate binder) cap 667 mg (169 mg ca)......................... 64 calcium acetate (phosphate binder) tab 667 mg ........................................... 64 camrese lo tab ................................. 31 camrese tab .................................... 31 CANASA SUP 1000MG ....................... 64 candesartan cilexetil tab 16 mg.......... 45 candesartan cilexetil tab 32 mg.......... 45 candesartan cilexetil tab 4 mg ........... 45 candesartan cilexetil tab 8 mg ........... 45 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg................................ 49 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg................................ 49 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg .................................. 49 CANTIL TAB 25MG ............................ 61 capecitabine tab 150 mg ................... 18 capecitabine tab 500 mg ................... 18 CAPEX SHA 0.01% ......................... 115 CAPRELSA TAB 100MG ...................... 21 CAPRELSA TAB 300MG ...................... 21 captopril & hydrochlorothiazide tab 25-15 mg ................................................. 47 captopril & hydrochlorothiazide tab 25-25 mg ................................................. 47 captopril & hydrochlorothiazide tab 50-15 mg ................................................. 47 captopril & hydrochlorothiazide tab 50-25 127
mg ..................................................47 captopril tab 100 mg .........................45 captopril tab 12.5 mg ........................45 captopril tab 25 mg ...........................45 captopril tab 50 mg ...........................45 CARAFATE SUS 1GM/10ML .................62 CARBAGLU TAB 200MG ......................39 carbamazepine cap sr 12hr 100 mg.....92 carbamazepine cap sr 12hr 200 mg.....92 carbamazepine cap sr 12hr 300 mg.....92 carbamazepine chew tab 100 mg ........92 carbamazepine susp 100 mg/5ml........92 carbamazepine tab 200 mg ................92 carbamazepine tab sr 12hr 100 mg .....92 carbamazepine tab sr 12hr 200 mg .....92 carbamazepine tab sr 12hr 400 mg .....92 carbidopa & levodopa orally disintegrating tab 10-100 mg .............95 carbidopa & levodopa orally disintegrating tab 25-100 mg .............95 carbidopa & levodopa orally disintegrating tab 25-250 mg .............95 carbidopa & levodopa tab 10-100 mg ..95 carbidopa & levodopa tab 25-100 mg ..95 carbidopa & levodopa tab 25-250 mg ..95 carbidopa & levodopa tab cr 25-100 mg ......................................................95 carbidopa & levodopa tab cr 50-200 mg ......................................................95 carbidopa tab 25 mg .........................95 carbidopa-levodopa-entacapone tabs 12.5-50-200 mg ...............................95 carbidopa-levodopa-entacapone tabs 18.75-75-200 mg .............................95 carbidopa-levodopa-entacapone tabs 25100-200 mg .....................................95 carbidopa-levodopa-entacapone tabs 31.25-125-200 mg............................95 carbidopa-levodopa-entacapone tabs 37.5-150-200 mg .............................95 carbidopa-levodopa-entacapone tabs 50200-200 mg .....................................95 carbinoxamine maleate soln 4 mg/5ml 55 carbinoxamine maleate tab 4 mg ........55 carb-o-philc gel 40% ....................... 116 carisoprodol tab 250 mg ....................95 carisoprodol tab 350 mg ....................96
carisoprodol w/ aspirin & codeine tab 200-325-16 mg ............................... 96 carisoprodol w/ aspirin tab 200-325 mg ...................................................... 96 carteolol hcl ophth soln 1% ............. 105 carvedilol tab 12.5 mg ...................... 42 carvedilol tab 25 mg ......................... 42 carvedilol tab 3.125 mg .................... 42 carvedilol tab 6.25 mg ...................... 42 cavirinse sol 0.2% .......................... 109 CAYA DPR ..................................... 119 CAYSTON INH 75MG ......................... 16 caziant pak ...................................... 29 CEDAX SUS 90MG/5ML ..................... 10 cefaclor cap 250 mg ........................... 9 cefaclor cap 500 mg ........................... 9 CEFACLOR ER TAB 500MG ................... 9 cefaclor for susp 125 mg/5ml .............. 9 cefaclor for susp 250 mg/5ml .............. 9 cefaclor for susp 375 mg/5ml .............. 9 cefadroxil cap 500 mg......................... 9 cefadroxil for susp 250 mg/5ml ............ 9 cefadroxil for susp 500 mg/5ml ............ 9 cefadroxil tab 1 gm ............................ 9 cefdinir cap 300 mg ............................ 9 cefdinir for susp 125 mg/5ml ............... 9 cefdinir for susp 250 mg/5ml ............... 9 cefditoren pivoxil tab 200 mg (base equivalent) ........................................ 9 cefditoren pivoxil tab 400 mg (base equivalent) ........................................ 9 cefixime for susp 100 mg/5ml.............. 9 cefixime for susp 200 mg/5ml.............. 9 cefpodoxime proxetil for susp 100 mg/5ml ........................................... 10 cefpodoxime proxetil for susp 50 mg/5ml ...................................................... 10 cefpodoxime proxetil tab 100 mg ....... 10 cefpodoxime proxetil tab 200 mg ....... 10 cefprozil for susp 125 mg/5ml ............. 9 cefprozil for susp 250 mg/5ml ............. 9 cefprozil tab 250 mg ........................... 9 cefprozil tab 500 mg ........................... 9 ceftibuten cap 400 mg ...................... 10 ceftibuten for susp 180 mg/5ml ......... 10 CEFTIN SUS 125/5ML ......................... 9 cefuroxime axetil tab 250 mg .............. 9 128
cefuroxime axetil tab 500 mg .............. 9 celecoxib cap 100 mg ........................88 celecoxib cap 200 mg ........................88 celecoxib cap 400 mg ........................88 celecoxib cap 50 mg ..........................88 CELONTIN CAP 300MG ......................92 CENESTIN TAB 0.625MG ....................24 CENESTIN TAB 0.9MG .......................24 CENTRATEX CAP ............................. 101 cephalexin cap 250 mg ....................... 9 cephalexin cap 500 mg ....................... 9 cephalexin cap 750 mg ....................... 9 cephalexin for susp 125 mg/5ml .......... 9 cephalexin for susp 250 mg/5ml .......... 9 cephalexin tab 250 mg ....................... 9 cephalexin tab 500 mg ....................... 9 CERDELGA CAP 84MG ...................... 101 cerisa wash emu 10-1% .................. 111 CESAMET CAP 1MG ...........................63 cesia pak .........................................29 cevimeline hcl cap 30 mg ................. 109 CGMS MIS SOFTWARE ..................... 118 CGMS SYSTEM MIS GOLD ................ 118 CHANTIX PAK 0.5& 1MG ....................80 CHANTIX TAB 0.5MG .........................80 CHANTIX TAB 1MG ............................80 chateal tab 0.15/30...........................27 CHEMET CAP 100MG ....................... 118 CHEMSTRIP TES STRIPS .................. 118 chlordiazepoxide hcl cap 10 mg ..........68 chlordiazepoxide hcl cap 25 mg ..........68 chlordiazepoxide hcl cap 5 mg ............68 chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg ...................................61 chlordiazepoxide-amitriptyline tab 10-25 mg ..................................................81 chlordiazepoxide-amitriptyline tab 5-12.5 mg ..................................................81 CHLORHEXIDIN SOL GLUCONAT ....... 118 chloroquine phosphate tab 250 mg .....16 chloroquine phosphate tab 500 mg .....16 chlorothiazide tab 250 mg ..................51 chlorothiazide tab 500 mg ..................51 chlorpromazine hcl tab 10 mg ............74 chlorpromazine hcl tab 100 mg ...........74 chlorpromazine hcl tab 200 mg ...........74 chlorpromazine hcl tab 25 mg ............74
chlorpromazine hcl tab 50 mg ............ 74 chlorpropamide tab 100 mg ............... 32 chlorpropamide tab 250 mg ............... 32 chlorthalidone tab 100 mg ................. 51 chlorthalidone tab 25 mg .................. 51 chlorthalidone tab 50 mg .................. 51 chlorzoxazone tab 500 mg................. 96 CHOLBAM CAP 250MG ...................... 64 CHOLBAM CAP 50MG ........................ 64 cholestyramine light powder 4 gm/dose ...................................................... 52 cholestyramine light powder packets 4 gm ................................................. 52 cholestyramine powder 4 gm/dose ..... 52 cholestyramine powder packets 4 gm . 52 choline & magnesium salicylates liq 500 mg/5ml ........................................... 82 choline & magnesium salicylates tab 1000 mg ......................................... 82 chorionic gonadotropin for inj 10000 unit ...................................................... 37 ciclopirox gel 0.77% ....................... 111 ciclopirox kit 8% ............................ 111 ciclopirox olamine cream 0.77% (base equiv) ........................................... 111 ciclopirox olamine susp 0.77% (base equiv) ........................................... 111 ciclopirox shampoo 1% ................... 111 ciclopirox solution 8% ..................... 111 ciclopirox solution 8% & vitamin e 5% topical kit ...................................... 112 cilostazol tab 100 mg ...................... 104 cilostazol tab 50 mg ....................... 104 CILOXAN OIN 0.3% OP ................... 105 cimetidine hcl soln 300 mg/5ml ......... 61 cimetidine tab 300 mg ...................... 61 cimetidine tab 400 mg ...................... 61 cimetidine tab 800 mg ...................... 61 CIMZIA KIT STARTER ....................... 64 CIMZIA PREFL KIT 200MG/ML ............ 64 CIPRO HC SUS OTIC ....................... 108 CIPRODEX SUS 0.3-0.1% ................ 108 ciprofloxacin hcl ophth soln 0.3% ..... 105 ciprofloxacin hcl otic soln 0.2% (base equivalent) .................................... 108 ciprofloxacin hcl tab 100 mg (base equiv) ...................................................... 11 129
ciprofloxacin hcl tab 250 mg (base equiv) ......................................................11 ciprofloxacin hcl tab 500 mg (base equiv) ......................................................11 ciprofloxacin hcl tab 750 mg (base equiv) ......................................................11 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) ............................11 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) .............................11 citalopram hydrobromide oral soln 10 mg/5ml ...........................................69 citalopram hydrobromide tab 10 mg (base equiv) .....................................69 citalopram hydrobromide tab 20 mg (base equiv) .....................................69 citalopram hydrobromide tab 40 mg (base equiv) .....................................69 clarithromycin for susp 125 mg/5ml ....10 clarithromycin for susp 250 mg/5ml ....10 clarithromycin tab 250 mg .................10 clarithromycin tab 500 mg .................10 clarithromycin tab sr 24hr 500 mg ......10 clemastine fumarate syrup 0.67 mg/5ml (0.5 mg/5ml base eq) .......................55 clemastine fumarate tab 2.68 mg .......55 CLIMARA PRO DIS WEEKLY ................25 clindamycin hcl cap 150 mg ...............17 clindamycin hcl cap 300 mg ...............17 clindamycin hcl cap 75 mg .................16 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) .........................17 clindamycin phosphate foam 1% ...... 110 clindamycin phosphate gel 1% ......... 110 clindamycin phosphate lotion 1% ...... 110 clindamycin phosphate soln 1% ........ 110 clindamycin phosphate swab 1% ...... 110 clindamycin phosphate vaginal cream 2% ......................................................66 clindamycin phosphate-benzoyl peroxide gel 1-5% ....................................... 110 clindamycin phosphate-tretinoin gel 1.20.025% ......................................... 110 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% .................... 110 clinpro 5000 pst 1.1% ..................... 109 clobetasol e cre 0.05% .................... 114
clobetasol propionate cream 0.05% .. 114 clobetasol propionate foam 0.05% ... 114 clobetasol propionate gel 0.05% ...... 114 clobetasol propionate lotion 0.05% ... 114 clobetasol propionate oint 0.05% ..... 114 clobetasol propionate shampoo 0.05% .................................................... 114 clobetasol propionate soln 0.05% ..... 114 clocortolone pivalate cream 0.1%..... 114 clomiphene citrate tab 50 mg ............ 37 clomipramine hcl cap 25 mg .............. 71 clomipramine hcl cap 50 mg .............. 71 clomipramine hcl cap 75 mg .............. 71 clonazepam orally disintegrating tab 0.125 mg ........................................ 91 clonazepam orally disintegrating tab 0.25 mg ................................................. 91 clonazepam orally disintegrating tab 0.5 mg ................................................. 91 clonazepam orally disintegrating tab 1 mg ................................................. 91 clonazepam orally disintegrating tab 2 mg ................................................. 91 clonazepam tab 0.5 mg ..................... 91 clonazepam tab 1 mg ....................... 91 clonazepam tab 2 mg ....................... 91 clonidine hcl tab 0.1 mg .................... 46 clonidine hcl tab 0.2 mg .................... 46 clonidine hcl tab 0.3 mg .................... 46 clonidine hcl td patch weekly 0.1 mg/24hr ......................................... 46 clonidine hcl td patch weekly 0.2 mg/24hr ......................................... 46 clonidine hcl td patch weekly 0.3 mg/24hr ......................................... 46 clopidogrel bisulfate tab 300 mg (base equiv) ........................................... 104 clopidogrel bisulfate tab 75 mg (base equiv) ........................................... 104 clorazepate dipotassium tab 15 mg .... 68 clorazepate dipotassium tab 3.75 mg .. 68 clorazepate dipotassium tab 7.5 mg ... 68 clorpres tab 0.1-15mg ...................... 50 clorpres tab 0.2-15mg ...................... 50 clorpres tab 0.3-15mg ...................... 50 clotrimazole troche 10 mg ............... 108 clotrimazole w/ betamethasone cream 1130
0.05% ........................................... 112 clotrimazole w/ betamethasone lotion 10.05% ........................................... 112 clozapine orally disintegrating tab 100 mg ..................................................73 clozapine orally disintegrating tab 12.5 mg ..................................................73 clozapine orally disintegrating tab 25 mg ......................................................73 clozapine tab 100 mg ........................73 clozapine tab 200 mg ........................73 clozapine tab 25 mg ..........................73 clozapine tab 50 mg ..........................73 coal tar soln 20%............................ 113 COARTEM TAB 20-120MG ..................16 cocaine hcl soln 10% ....................... 117 cocaine hcl soln 4% ........................ 117 codeine sulfate tab 15 mg ..................83 codeine sulfate tab 30 mg ..................83 codeine sulfate tab 60 mg ..................83 colchicine cap 0.6 mg ........................90 colchicine tab 0.6 mg ........................91 colchicine w/ probenecid tab 0.5-500 mg ......................................................91 colestipol hcl granule packets 5 gm .....52 colestipol hcl granules 5 gm ...............52 colestipol tab 1gm.............................52 COMBIGAN SOL 0.2/0.5% ................ 106 COMBIPATCH DIS .05/.14 ..................25 COMBIPATCH DIS .05/.25 ..................25 COMBIVENT AER 20-100....................58 COMETRIQ KIT 100MG ......................20 COMETRIQ KIT 140MG ......................20 COMETRIQ KIT 60MG ........................20 compazine sup 25mg ........................74 COMPLERA TAB ................................14 CONDYLOX GEL 0.5%...................... 116 COPAXONE INJ 40MG/ML ...................80 CORDRAN 80X3 TAP 4MCG/CM ......... 115 CORDRAN LOT 0.05% ..................... 115 cortalo gel 2% ................................ 116 CORTIFOAM AER 90MG .................... 109 cortisone acetate tab 25 mg ...............22 CORTISPORIN CRE 0.5% ................. 111 CORTISPORIN OIN 1% .................... 111 CORTISPORIN SUS -TC OTIC ............ 108 COTELLIC TAB 20MG .........................20
CREON CAP 12000UNT...................... 63 CREON CAP 24000UNT...................... 63 CREON CAP 3000UNIT ...................... 63 CREON CAP 36000UNT...................... 63 CREON CAP 6000UNIT ...................... 63 CRESTOR TAB 10MG ......................... 53 CRESTOR TAB 20MG ......................... 53 CRESTOR TAB 40MG ......................... 53 CRESTOR TAB 5MG .......................... 53 CRIXIVAN CAP 200MG ...................... 13 CRIXIVAN CAP 400MG ...................... 13 cromolyn sodium ophth soln 4% ...... 107 cromolyn sodium oral conc 100 mg/5ml ...................................................... 63 cromolyn sodium soln nebu 20 mg/2ml ...................................................... 57 cryselle-28 tab 28 tabs ..................... 28 CUPRIMINE CAP 250MG .................. 119 cyanocobalamin inj 1000 mcg/ml ....... 99 cyclafem tab 1/35 ............................ 27 cyclafem tab 7/7/7 ........................... 30 cyclobenzaprine hcl tab 10 mg ........... 96 cyclobenzaprine hcl tab 5 mg ............. 96 cyclobenzaprine hcl tab 7.5 mg .......... 96 cyclopentolate hcl ophth soln 1% ..... 106 cyclopentolate hcl ophth soln 2% ..... 106 CYCLOPHOSPH CAP 25MG ................. 17 CYCLOPHOSPH CAP 50MG ................. 17 cycloserine cap 250 mg..................... 12 CYCLOSET TAB 0.8MG ...................... 34 cyclosporine cap 100 mg ................. 119 cyclosporine cap 25 mg ................... 119 cyclosporine modified cap 100 mg .... 120 cyclosporine modified cap 50 mg ...... 120 cyclosporine modified oral soln 100 mg/ml .......................................... 120 cyotic dro ...................................... 108 cyproheptadine hcl syrup 2 mg/5ml .... 55 cyproheptadine hcl tab 4 mg ............. 55 cyred tab ........................................ 26 CYSTADANE POW ............................. 39 CYSTAGON CAP 150MG ..................... 67 CYSTAGON CAP 50MG ...................... 67 CYSTARAN SOL 0.44%.................... 108 cytra-3 syp ...................................... 67 d 400 tab 400unit ............................ 96 DALIRESP TAB 500MCG .................... 59 131
danazol cap 100 mg ..........................23 danazol cap 200 mg ..........................23 danazol cap 50 mg ............................23 dantrolene sodium cap 100 mg ...........96 dantrolene sodium cap 25 mg ............96 dantrolene sodium cap 50 mg ............96 dapsone tab 100 mg .........................17 dapsone tab 25 mg ...........................17 DARAPRIM TAB 25MG ........................16 darifenacin hydrobromide tab sr 24hr 15 mg (base equiv) ...............................65 darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv) ...............................65 dasetta tab 1/35 ...............................27 dasetta tab 7/7/7..............................30 daysee tab .......................................31 DEBACTEROL SOL 30-50%............... 108 deblitane tab 0.35mg ........................25 delyla tab 0.1-0.02 ...........................26 DELZICOL CAP 400MG .......................64 demeclocycline hcl tab 150 mg ...........10 demeclocycline hcl tab 300 mg ...........10 DEMSER CAP 250MG .........................47 DENAVIR CRE 1% ........................... 113 denta 5000 cre plus 2pk .................. 109 DEPEN TITRA TAB 250MG ................ 119 DEPO-ESTRADI INJ 5MG/ML ...............24 DEPO-SQ PROV INJ 104 .....................25 desipramine hcl tab 10 mg .................71 desipramine hcl tab 100 mg ...............71 desipramine hcl tab 150 mg ...............71 desipramine hcl tab 25 mg .................71 desipramine hcl tab 50 mg .................71 desipramine hcl tab 75 mg .................71 desloratadine tab 5 mg ......................55 desloratadine tab orally disintegrating 2.5 mg ............................................55 desloratadine tab orally disintegrating 5 mg ..................................................55 desmopressin acetate inj 4 mcg/ml .....39 desmopressin acetate nasal soln 0.01% (refrigerated) ...................................39 desmopressin acetate nasal spray soln 0.01% (refrigerated) .........................39 desmopressin acetate tab 0.1 mg .......39 desmopressin acetate tab 0.2 mg .......39 desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5).................. 29 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg ..................................... 26 DESONATE GEL 0.05% ................... 114 desonide cream 0.05% ................... 114 desonide lotion 0.05% .................... 114 desonide oint 0.05%....................... 114 desoximetasone cream 0.05% ......... 114 desoximetasone cream 0.25% ......... 114 desoximetasone gel 0.05%.............. 114 desoximetasone oint 0.05% ............ 114 desoximetasone oint 0.25% ............ 114 DEX4 GLUCOSE CHW QK DISLV ......... 33 DEXAMETHASON CON 1MG/ML .......... 22 dexamethasone elixir 0.5 mg/5ml ...... 22 dexamethasone sodium phosphate ophth soln 0.1% ..................................... 106 dexamethasone soln 0.5 mg/5ml ....... 22 dexamethasone tab 0.5 mg ............... 22 dexamethasone tab 0.75 mg ............. 22 dexamethasone tab 1 mg .................. 22 dexamethasone tab 1.5 mg ............... 22 dexamethasone tab 2 mg .................. 22 dexamethasone tab 4 mg .................. 22 dexamethasone tab 6 mg .................. 22 DEXILANT CAP 30MG DR ................... 61 DEXILANT CAP 60MG DR ................... 61 dexmethylphenidate hcl tab 10 mg ..... 78 dexmethylphenidate hcl tab 2.5 mg .... 78 dexmethylphenidate hcl tab 5 mg ...... 78 dextroamphetamine sulfate cap sr 24hr 10 mg............................................. 77 dextroamphetamine sulfate cap sr 24hr 15 mg............................................. 77 dextroamphetamine sulfate cap sr 24hr 5 mg ................................................. 77 dextroamphetamine sulfate oral solution 5 mg/5ml ........................................ 76 dextroamphetamine sulfate tab 10 mg 76 dextroamphetamine sulfate tab 5 mg . 76 DIASTIX TES STRIPS ...................... 118 diazepam con 5mg/ml ...................... 68 diazepam oral soln 1 mg/ml .............. 68 diazepam rectal gel delivery system 10 mg ................................................. 91 diazepam rectal gel delivery system 2.5 mg ................................................. 91 132
diazepam rectal gel delivery system 20 mg ..................................................91 diazepam tab 10 mg .........................68 diazepam tab 2 mg ...........................68 diazepam tab 5 mg ...........................68 diclofenac potassium tab 50 mg ..........87 diclofenac sodium gel 1% ................ 112 diclofenac sodium ophth soln 0.1% ... 107 diclofenac sodium tab delayed release 25 mg ..................................................87 diclofenac sodium tab delayed release 50 mg ..................................................87 diclofenac sodium tab delayed release 75 mg ..................................................87 diclofenac sodium tab sr 24hr 100 mg .87 diclofenac w/ misoprostol tab delayed release 50-0.2 mg ............................88 diclofenac w/ misoprostol tab delayed release 75-0.2 mg ............................88 dicloxacillin sodium cap 250 mg ........... 8 dicloxacillin sodium cap 500 mg ........... 8 dicyclomine hcl cap 10 mg .................61 dicyclomine hcl oral soln 10 mg/5ml ....61 dicyclomine hcl tab 20 mg .................61 didanosine delayed release capsule 125 mg ..................................................13 didanosine delayed release capsule 200 mg ..................................................13 didanosine delayed release capsule 250 mg ..................................................13 didanosine delayed release capsule 400 mg ..................................................13 DIFICID TAB 200MG ..........................10 difil-g fort liq 100-100 .......................60 diflorasone diacetate cream 0.05% ... 114 diflorasone diacetate oint 0.05%....... 114 diflunisal tab 500 mg .........................82 digoxin oral soln 0.05 mg/ml ..............40 digoxin tab 125 mcg (0.125 mg).........40 digoxin tab 250 mcg (0.25 mg) ..........40 dihydroergotamine mesylate inj 1 mg/ml ......................................................89 dihydroergotamine mesylate nasal spray 4 mg/ml ..........................................89 DILANTIN CAP 30MG .........................91 DILATRATE SR CAP 40MG ..................40 diltiazem hcl cap sr 12hr 120 mg ........42
diltiazem hcl cap sr 12hr 60 mg ......... 42 diltiazem hcl cap sr 12hr 90 mg ......... 42 diltiazem hcl cap sr 24hr 120 mg ....... 42 diltiazem hcl cap sr 24hr 180 mg ....... 42 diltiazem hcl cap sr 24hr 240 mg ....... 42 diltiazem hcl coated beads cap sr 24hr 120 mg ........................................... 42 diltiazem hcl coated beads cap sr 24hr 180 mg ........................................... 42 diltiazem hcl coated beads cap sr 24hr 240 mg ........................................... 42 diltiazem hcl coated beads cap sr 24hr 300 mg ........................................... 43 diltiazem hcl coated beads cap sr 24hr 360 mg ........................................... 43 diltiazem hcl coated beads tab sr 24hr 180 mg ........................................... 43 diltiazem hcl coated beads tab sr 24hr 240 mg ........................................... 43 diltiazem hcl coated beads tab sr 24hr 300 mg ........................................... 43 diltiazem hcl coated beads tab sr 24hr 360 mg ........................................... 43 diltiazem hcl coated beads tab sr 24hr 420 mg ........................................... 43 diltiazem hcl extended release beads cap sr 24hr 120 mg ................................ 42 diltiazem hcl extended release beads cap sr 24hr 180 mg ................................ 42 diltiazem hcl extended release beads cap sr 24hr 240 mg ................................ 42 diltiazem hcl extended release beads cap sr 24hr 300 mg ................................ 42 diltiazem hcl extended release beads cap sr 24hr 420 mg ................................ 42 diltiazem hcl tab 120 mg ................... 42 diltiazem hcl tab 30 mg ..................... 42 diltiazem hcl tab 60 mg ..................... 42 diltiazem hcl tab 90 mg ..................... 42 DIPENTUM CAP 250MG ..................... 64 diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml ........................................... 60 diphenoxylate w/ atropine tab 2.5-0.025 mg ................................................. 60 dipyridamole tab 25 mg .................. 104 dipyridamole tab 50 mg .................. 104 dipyridamole tab 75 mg .................. 104 133
disopyramide phosphate cap 150 mg ..44 disulfiram tab 250 mg .......................81 disulfiram tab 500 mg .......................81 divalproex sodium cap delayed release sprinkle 125 mg................................92 divalproex sodium tab delayed release 125 mg ...........................................92 divalproex sodium tab delayed release 250 mg ...........................................92 divalproex sodium tab delayed release 500 mg ...........................................92 divalproex sodium tab sr 24 hr 250 mg92 divalproex sodium tab sr 24 hr 500 mg92 dofetilide cap 125 mcg (0.125 mg) .....44 dofetilide cap 250 mcg (0.25 mg) .......44 dofetilide cap 500 mcg (0.5 mg) .........44 donepezil hydrochloride orally disintegrating tab 10 mg ....................79 donepezil hydrochloride orally disintegrating tab 5 mg .....................79 donepezil hydrochloride tab 10 mg ......79 donepezil hydrochloride tab 23 mg ......79 donepezil hydrochloride tab 5 mg .......79 dorzolamide hcl ophth soln 2% ......... 107 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml ....................... 106 doxazosin mesylate tab 1 mg .............46 doxazosin mesylate tab 2 mg .............46 doxazosin mesylate tab 4 mg .............46 doxazosin mesylate tab 8 mg .............46 doxepin hcl cap 10 mg.......................71 doxepin hcl cap 100 mg .....................71 doxepin hcl cap 150 mg .....................71 doxepin hcl cap 25 mg.......................71 doxepin hcl cap 50 mg.......................71 doxepin hcl cap 75 mg.......................71 doxepin hcl conc 10 mg/ml ................71 doxercalciferol cap 0.5 mcg ................39 doxercalciferol cap 1 mcg...................39 doxercalciferol cap 2.5 mcg ................39 doxycycline hyclate cap 100 mg .........11 doxycycline hyclate cap 50 mg ...........11 doxycycline hyclate tab 100 mg ..........11 doxycycline hyclate tab 20 mg ............11 doxycycline hyclate tab delayed release 100 mg ...........................................11 doxycycline hyclate tab delayed release
150 mg ........................................... 11 doxycycline hyclate tab delayed release 75 mg............................................. 11 doxycycline monohydrate cap 100 mg 10 doxycycline monohydrate cap 150 mg 10 doxycycline monohydrate cap 50 mg .. 10 doxycycline monohydrate cap 75 mg .. 10 doxycycline monohydrate for susp 25 mg/5ml ........................................... 11 doxycycline monohydrate tab 100 mg . 10 doxycycline monohydrate tab 150 mg . 10 doxycycline monohydrate tab 50 mg .. 10 doxycycline monohydrate tab 75 mg .. 10 DRITHO-CREME CRE HP 1% ............ 112 dronabinol cap 10 mg ....................... 63 dronabinol cap 2.5 mg ...................... 63 dronabinol cap 5 mg ......................... 63 drospirenone-ethinyl estradiol tab 3-0.02 mg ................................................. 26 drospirenone-ethinyl estradiol tab 3-0.03 mg ................................................. 26 DROXIA CAP 200MG ....................... 101 DROXIA CAP 300MG ....................... 101 DROXIA CAP 400MG ....................... 101 DULERA AER 100-5MCG .................... 58 DULERA AER 200-5MCG .................... 58 duloxetine hcl enteric coated pellets cap 20 mg............................................. 70 duloxetine hcl enteric coated pellets cap 30 mg............................................. 70 duloxetine hcl enteric coated pellets cap 60 mg............................................. 70 DUREZOL EMU 0.05% ..................... 106 dutasteride cap 0.5 mg ..................... 67 dutasteride-tamsulosin hcl cap 0.5-0.4 mg ................................................. 67 DUTOPROL TAB 100-12.5 .................. 48 DUTOPROL TAB 25-12.5.................... 48 DUTOPROL TAB 50-12.5.................... 48 DYRENIUM CAP 100MG ..................... 51 DYRENIUM CAP 50MG ....................... 51 e.e.s. 400 tab 400mg ....................... 10 econazole nitrate cream 1% ............ 112 econtra ez tab 1.5mg........................ 25 EDARBI TAB 40MG ........................... 45 EDARBI TAB 80MG ........................... 45 EDECRIN TAB 25MG ......................... 50 134
ed-flex cap .......................................82 EDURANT TAB 25MG .........................14 EFFER-K TAB 10MEQ .........................99 EFFER-K TAB 20MEQ .........................99 EFFIENT TAB 10MG ......................... 104 EFFIENT TAB 5MG ........................... 104 EGRIFTA SOL 1MG ............................38 EGRIFTA SOL 2MG ............................38 ELIDEL CRE 1% .............................. 117 ELIGARD INJ 22.5MG ........................19 ELIGARD INJ 30MG ...........................19 ELIGARD INJ 45MG ...........................19 ELIGARD INJ 7.5MG ..........................19 elinest tab ........................................28 ELIQUIS TAB 2.5MG ........................ 102 ELIQUIS TAB 5MG ........................... 102 ELIXOPHYLLIN ELX 80/15ML ..............58 ELLA TAB 30MG ................................25 ELMIRON CAP 100MG ........................67 EMADINE SOL 0.05% OP ................. 107 EMCYT CAP 140MG ...........................19 EMEND CAP 125MG ...........................63 EMEND CAP 40MG .............................63 EMEND CAP 80MG .............................63 EMEND PAK 80 & 125 ........................63 emoquette tab ..................................26 EMSAM DIS 12MG/24H ......................69 EMSAM DIS 6MG/24HR ......................69 EMSAM DIS 9MG/24HR ......................69 EMTRIVA CAP 200MG ........................13 EMTRIVA SOL 10MG/ML .....................13 ENABLEX TAB 15MG ..........................65 ENABLEX TAB 7.5MG .........................65 enalapril maleate & hydrochlorothiazide tab 10-25 mg ...................................48 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg ..................................47 enalapril maleate tab 10 mg ...............45 enalapril maleate tab 2.5 mg ..............45 enalapril maleate tab 20 mg ...............45 enalapril maleate tab 5 mg ................45 ENBREL INJ 25/0.5ML........................89 ENBREL INJ 25MG .............................89 ENBREL INJ 50MG/ML........................89 ENBREL SRCLK INJ 50MG/ML .............89 ENCARE SUP 100MG .........................66 ENJUVIA TAB 0.3MG..........................24
ENJUVIA TAB 0.45MG ....................... 24 ENJUVIA TAB 0.625MG ..................... 24 ENJUVIA TAB 0.9MG ......................... 24 ENJUVIA TAB 1.25MG ....................... 24 enoxaparin sodium inj 100 mg/ml .... 102 enoxaparin sodium inj 120 mg/0.8ml 102 enoxaparin sodium inj 150 mg/ml .... 102 enoxaparin sodium inj 30 mg/0.3ml . 102 enoxaparin sodium inj 40 mg/0.4ml . 102 enoxaparin sodium inj 60 mg/0.6ml . 102 enoxaparin sodium inj 80 mg/0.8ml . 102 enpresse-28 tab ............................... 29 enskyce tab ..................................... 26 entacapone tab 200 mg .................... 94 entecavir tab 0.5 mg ........................ 15 entecavir tab 1 mg ........................... 15 ENTRESTO TAB 24-26MG .................. 54 ENTRESTO TAB 49-51MG .................. 54 ENTRESTO TAB 97-103MG ................ 54 enulose sol 10gm/15 ........................ 63 EPIDUO GEL 0.1-2.5% .................... 110 EPIFOAM AER 1% ........................... 115 epinastine hcl ophth soln 0.05% ...... 107 epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) ........................ 52 EPIPEN 2-PAK INJ 0.3MG .................. 52 EPIPEN-JR INJ 2-PAK ........................ 52 eplerenone tab 25 mg ....................... 47 eplerenone tab 50 mg ....................... 47 eprosartan mesylate tab 600 mg ........ 45 EPZICOM TAB 600-300 ..................... 14 EQUAGESIC TAB 200-325 ................. 82 ergocalciferol cap 50000 unit ............. 96 ergoloid mesylates tab 1 mg .............. 79 ERGOMAR SUB 2MG ......................... 89 ERIVEDGE CAP 150MG ...................... 18 errin tab 0.35mg .............................. 25 ERTACZO CRE 2% .......................... 112 ery-tab tab 250mg ec ....................... 10 ery-tab tab 333mg ec ....................... 10 ery-tab tab 500mg ec ....................... 10 erythrocin tab 250mg ....................... 10 erythromycin gel 2% ...................... 110 erythromycin ophth oint 5 mg/gm .... 105 erythromycin pads 2% .................... 110 erythromycin soln 2% ..................... 110 erythromycin tab 250 mg .................. 10 135
erythromycin tab 500 mg...................10 erythromycin w/ delayed release particles cap 250 mg .........................10 ESBRIET CAP 267MG .........................60 escitalopram oxalate soln 5 mg/5ml (base equiv) .....................................69 escitalopram oxalate tab 10 mg (base equiv) .............................................69 escitalopram oxalate tab 20 mg (base equiv) .............................................69 escitalopram oxalate tab 5 mg (base equiv) .............................................69 esgic cap .........................................82 esomeprazole magnesium cap delayed release 40 mg (base eq) ....................61 est estrogen tab mtest hs ..................24 estarylla tab 0.25-35 .........................28 estazolam tab 1 mg ..........................76 estazolam tab 2 mg ..........................76 esterified estrogens & methyltestosterone tab 1.25-2.5 mg ...24 ESTRACE VAG CRE 0.1MG/GM ............66 estradiol & norethindrone acetate tab 10.5 mg ............................................25 estradiol tab 0.5 mg ..........................24 estradiol tab 1 mg .............................24 estradiol tab 2 mg .............................24 estradiol td patch weekly 0.025 mg/24hr ......................................................24 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) ..................24 estradiol td patch weekly 0.05 mg/24hr ......................................................24 estradiol td patch weekly 0.06 mg/24hr ......................................................24 estradiol td patch weekly 0.075 mg/24hr ......................................................24 estradiol td patch weekly 0.1 mg/24hr 24 estradiol valerate im in oil 20 mg/ml ...24 estradiol valerate im in oil 40 mg/ml ...24 ESTRING MIS 2MG ............................66 estropipate tab 0.75 mg ....................24 estropipate tab 1.5 mg ......................24 estropipate tab 3 mg .........................24 eszopiclone tab 1 mg.........................76 eszopiclone tab 2 mg.........................76 eszopiclone tab 3 mg.........................76
ethacrynic acid tab 25 mg ................. 50 ethambutol hcl tab 100 mg................ 12 ethambutol hcl tab 400 mg................ 12 ethosuximide cap 250 mg ................. 92 ethosuximide soln 250 mg/5ml .......... 92 ethyl chloride aerosol spray ............. 117 etidronate disodium tab 200 mg......... 37 etidronate disodium tab 400 mg......... 37 etodolac cap 200 mg ........................ 87 etodolac cap 300 mg ........................ 87 etodolac tab 400 mg ......................... 87 etodolac tab 500 mg ......................... 87 etodolac tab sr 24hr 400 mg .............. 87 etodolac tab sr 24hr 500 mg.............. 87 etodolac tab sr 24hr 600 mg .............. 87 etoposide cap 50 mg ........................ 20 EURAX CRE 10% ............................ 117 EURAX LOT 10% ............................ 117 EVZIO INJ ..................................... 118 EXELDERM CRE 1% ........................ 112 EXELDERM SOL 1% ........................ 112 exemestane tab 25 mg ..................... 19 EXJADE TAB 125MG........................ 117 EXJADE TAB 250MG........................ 118 EXJADE TAB 500MG........................ 118 exoderm lot 25-1% ........................ 112 EXTAVIA INJ 0.3MG .......................... 80 FA-8 CAP 800MCG ............................ 99 FACTIVE TAB 320MG ........................ 11 FALESSA KIT ................................... 28 fallback tab 1.5mg ........................... 25 falmina tab ...................................... 26 famciclovir tab 125 mg ..................... 15 famciclovir tab 250 mg ..................... 15 famciclovir tab 500 mg ..................... 15 famotidine for susp 40 mg/5ml .......... 61 famotidine tab 40 mg ....................... 61 FANAPT PAK .................................... 72 FANAPT TAB 10MG ........................... 72 FANAPT TAB 12MG ........................... 72 FANAPT TAB 1MG ............................. 72 FANAPT TAB 2MG ............................. 72 FANAPT TAB 4MG ............................. 72 FANAPT TAB 6MG ............................. 72 FANAPT TAB 8MG ............................. 72 FARESTON TAB 60MG ....................... 19 FARXIGA TAB 10MG ......................... 34 136
FARXIGA TAB 5MG ............................34 FC FEMALE MIS CONDOM................. 118 fe c plus tab ................................... 101 FEIBA INJ ...................................... 104 felbamate susp 600 mg/5ml ...............91 felbamate tab 400 mg .......................91 felbamate tab 600 mg .......................91 felodipine tab sr 24hr 10 mg ..............43 felodipine tab sr 24hr 2.5 mg .............43 felodipine tab sr 24hr 5 mg ................43 FEMCAP MIS 22MM ......................... 118 FEMCAP MIS 26MM ......................... 118 FEMCAP MIS 30MM ......................... 119 fenofibrate micronized cap 130 mg .....52 fenofibrate micronized cap 134 mg .....52 fenofibrate micronized cap 200 mg .....52 fenofibrate micronized cap 43 mg .......52 fenofibrate micronized cap 67 mg .......52 fenofibrate tab 145 mg ......................52 fenofibrate tab 160 mg ......................52 fenofibrate tab 48 mg ........................52 fenofibrate tab 54 mg ........................52 fenofibric acid tab 105 mg .................52 fenofibric acid tab 35 mg ...................52 fenoprofen calcium tab 600 mg ..........87 fentanyl citrate lozenge on a handle 1200 mcg ................................................83 fentanyl citrate lozenge on a handle 1600 mcg ................................................83 fentanyl citrate lozenge on a handle 200 mcg ................................................83 fentanyl citrate lozenge on a handle 400 mcg ................................................83 fentanyl citrate lozenge on a handle 600 mcg ................................................83 fentanyl citrate lozenge on a handle 800 mcg ................................................83 fentanyl td patch 72hr 100 mcg/hr ......83 fentanyl td patch 72hr 12 mcg/hr .......83 fentanyl td patch 72hr 25 mcg/hr .......83 fentanyl td patch 72hr 50 mcg/hr .......83 fentanyl td patch 72hr 75 mcg/hr .......83 fer-iron dro 15mg/ml ...................... 100 ferocon cap .................................... 101 FERRIPROX SOL 100MG/ML .............. 118 FERRIPROX TAB 500MG ................... 118 ferrogels fo cap forte ....................... 101
FERROUS SULF SYP 300/5ML ........... 100 ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ....................... 99 FINACEA AER 15% ......................... 111 FINACEA GEL 15% ......................... 111 finasteride tab 5 mg ......................... 67 FIRAZYR INJ 30MG/3ML .................. 105 FIRMAGON INJ 120MG ...................... 19 FIRMAGON INJ 80MG ........................ 19 flavoxate hcl tab 100 mg ................... 66 flecainide acetate tab 100 mg ............ 44 flecainide acetate tab 150 mg ............ 44 flecainide acetate tab 50 mg .............. 44 FLOVENT DISK AER 100MCG ............. 59 FLOVENT DISK AER 250MCG ............. 59 FLOVENT DISK AER 50MCG ............... 59 FLOVENT HFA AER 110MCG ............... 59 FLOVENT HFA AER 220MCG ............... 59 FLOVENT HFA AER 44MCG ................. 59 flucaine sol 0.25-0.5 ....................... 108 fluconazole for susp 10 mg/ml ........... 12 fluconazole for susp 40 mg/ml ........... 12 fluconazole tab 100 mg ..................... 12 fluconazole tab 150 mg ..................... 12 fluconazole tab 200 mg ..................... 12 fluconazole tab 50 mg....................... 12 flucytosine cap 250 mg ..................... 12 flucytosine cap 500 mg ..................... 12 fludrocortisone acetate tab 0.1 mg ..... 23 flunisolide nasal soln 25 mcg/act (0.025%) ........................................ 56 fluocin acet oil 0.01% sc ................. 114 fluocin acet oil body ........................ 114 fluocinolone acetonide (otic) oil 0.01% .................................................... 108 fluocinolone acetonide cream 0.01% 115 fluocinolone acetonide cream 0.025% 115 fluocinolone acetonide oint 0.025% .. 115 fluocinolone acetonide soln 0.01% ... 115 fluocinonide cream 0.05% ............... 115 fluocinonide emulsified base cream 0.05% .......................................... 115 fluocinonide gel 0.05% ................... 115 fluocinonide oint 0.05% .................. 115 fluocinonide soln 0.05% .................. 115 FLUORABON DRO ............................. 98 fluoridex dd pst sensitiv .................. 109 137
fluoritab chw 0.5mg f ........................97 fluoritab dro 0.125mg........................98 fluorometholone ophth susp 0.1%..... 106 fluorouracil cream 5% ..................... 113 fluorouracil soln 2% ........................ 113 fluorouracil soln 5% ........................ 113 fluoxetine hcl (pmdd) cap 10 mg ........80 fluoxetine hcl (pmdd) cap 20 mg ........80 fluoxetine hcl cap 10 mg ....................70 fluoxetine hcl cap 20 mg ....................70 fluoxetine hcl cap 40 mg ....................70 fluoxetine hcl cap delayed release 90 mg ......................................................70 fluoxetine hcl solution 20 mg/5ml .......70 fluoxetine hcl tab 10 mg ....................70 fluoxetine hcl tab 20 mg ....................70 FLUOXETINE TAB 60MG .....................70 fluphenazine hcl elixir 2.5 mg/5ml ......74 fluphenazine hcl oral conc 5 mg/ml .....74 fluphenazine hcl tab 1 mg ..................74 fluphenazine hcl tab 10 mg ................74 fluphenazine hcl tab 2.5 mg ...............74 fluphenazine hcl tab 5 mg ..................74 flura-drops dro 0.25mg f....................98 flurazepam hcl cap 15 mg ..................76 flurazepam hcl cap 30 mg ..................76 flurbiprofen sodium ophth soln 0.03% .................................................... 107 flurbiprofen tab 100 mg .....................87 flurbiprofen tab 50 mg .......................87 flutamide cap 125 mg........................18 fluticasone propionate cream 0.05% . 115 fluticasone propionate lotion 0.05% .. 115 fluticasone propionate oint 0.005% ... 115 fluvastatin sodium cap 20 mg .............53 fluvastatin sodium cap 40 mg .............53 fluvoxamine maleate cap sr 24hr 100 mg ......................................................70 fluvoxamine maleate cap sr 24hr 150 mg ......................................................70 fluvoxamine maleate tab 100 mg ........70 fluvoxamine maleate tab 25 mg ..........70 fluvoxamine maleate tab 50 mg ..........70 FML OIN 0.1% OP ........................... 106 folbee plus tab ..................................97 folbee tab ...................................... 101 folic acid tab 1 mg ............................99
folic acid tab 400 mcg ....................... 99 folic acid tab 800 mcg ....................... 99 folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg ............................... 101 fondaparinux sodium subcutaneous inj 10 mg/0.8ml ................................. 102 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml ................................ 102 fondaparinux sodium subcutaneous inj 5 mg/0.4ml ...................................... 102 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml ................................ 102 FORADIL CAP AEROLIZE ................... 57 formadon sol ................................. 117 forma-ray sol 20% ......................... 117 FORTEO SOL 600/2.4 ....................... 37 FOSAMAX + D TAB 70-2800 .............. 37 FOSAMAX + D TAB 70-5600 .............. 37 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg................................ 48 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg................................ 48 fosinopril sodium tab 10 mg .............. 45 fosinopril sodium tab 20 mg .............. 45 fosinopril sodium tab 40 mg .............. 45 FOSRENOL CHW 1000MG .................. 64 FOSRENOL CHW 500MG .................... 64 FOSRENOL CHW 750MG .................... 64 FOSRENOL POW 1000MG .................. 64 FOSRENOL POW 750MG .................... 64 FRAGMIN INJ 10000/ML .................. 102 FRAGMIN INJ 12500UNT ................. 102 FRAGMIN INJ 15000UNT ................. 102 FRAGMIN INJ 18000UNT ................. 102 FRAGMIN INJ 2500/0.2 ................... 102 FRAGMIN INJ 5000/0.2 ................... 102 FRAGMIN INJ 7500/0.3 ................... 102 FROVA TAB 2.5MG ........................... 89 frovatriptan succinate tab 2.5 mg (base equivalent) ...................................... 89 furosemide oral soln 10 mg/ml .......... 51 FUROSEMIDE SOL 8MG/ML ................ 50 furosemide tab 20 mg....................... 50 furosemide tab 40 mg....................... 50 furosemide tab 80 mg....................... 50 FUZEON INJ 90MG ........................... 13 G4 PLATINUM KIT RCV/SHAR ........... 118 138
gabapentin cap 100 mg .....................92 gabapentin cap 300 mg .....................92 gabapentin cap 400 mg .....................92 gabapentin oral soln 250 mg/5ml........92 gabapentin tab 600 mg .....................92 gabapentin tab 800 mg .....................92 GABITRIL TAB 12MG .........................91 GABITRIL TAB 16MG .........................91 galantamine hydrobromide cap sr 24hr 16 mg .............................................79 galantamine hydrobromide cap sr 24hr 24 mg .............................................79 galantamine hydrobromide cap sr 24hr 8 mg ..................................................79 galantamine hydrobromide oral soln 4 mg/ml .............................................79 galantamine hydrobromide tab 12 mg .79 galantamine hydrobromide tab 4 mg ...79 galantamine hydrobromide tab 8 mg ...79 GASTRINEX NF CAP...........................61 gatifloxacin ophth soln 0.5% ............ 105 GELNIQUE GEL 10%..........................65 GELNIQUE GEL 3% ...........................65 gemfibrozil tab 600 mg ......................52 gengraf cap 25mg ........................... 120 gentak oin 0.3% op......................... 105 gentamicin sulfate cream 0.1% ........ 111 gentamicin sulfate oint 0.1% ............ 111 gentamicin sulfate ophth soln 0.3% .. 105 gianvi tab 3-0.02mg ..........................26 gildagia tab 0.4-35 ............................27 gildess 24 tab fe 1/20........................29 gildess fe tab 1.5/30 .........................29 gildess fe tab 1/20 ............................28 gildess tab 1.5/30 .............................27 gildess tab 1/20 ................................27 GILENYA CAP 0.5MG .........................81 GILOTRIF TAB 20MG .........................20 GILOTRIF TAB 30MG .........................20 GILOTRIF TAB 40MG .........................20 glatopa inj 20mg/ml ..........................80 GLEEVEC TAB 100MG ........................21 GLEEVEC TAB 400MG ........................21 glimepiride tab 1 mg .........................32 glimepiride tab 2 mg .........................32 glimepiride tab 4 mg .........................32 glipizide tab 10 mg ...........................32
glipizide tab 5 mg............................. 32 glipizide xl tab 10mg ........................ 32 glipizide xl tab 2.5mg ....................... 32 glipizide xl tab 5mg .......................... 32 glipizide-metformin hcl tab 2.5-250 mg ...................................................... 35 glipizide-metformin hcl tab 2.5-500 mg ...................................................... 35 glipizide-metformin hcl tab 5-500 mg . 35 GLUCAGEN INJ HYPOKIT ................... 33 GLUCAGON KIT 1MG ........................ 33 GLUCOSE BITS CHW 1GM ................. 33 glutose 15 gel 40% .......................... 33 glyburide micronized tab 1.5 mg ........ 33 glyburide micronized tab 3 mg ........... 33 glyburide micronized tab 6 mg ........... 33 glyburide tab 1.25 mg ...................... 32 glyburide tab 2.5 mg ........................ 32 glyburide tab 5 mg ........................... 33 glyburide-metformin tab 1.25-250 mg 35 glyburide-metformin tab 2.5-500 mg .. 35 glyburide-metformin tab 5-500 mg ..... 35 glycine irrigation soln 1.5% ............... 67 glycopyrrolate tab 1 mg .................... 61 glycopyrrolate tab 2 mg .................... 61 GLYSET TAB 100MG ......................... 33 GLYSET TAB 25MG ........................... 33 GLYSET TAB 50MG ........................... 33 granisetron hcl tab 1 mg ................... 62 griseofulvin microsize susp 125 mg/5ml ...................................................... 12 griseofulvin microsize tab 500 mg ...... 12 griseofulvin ultramicrosize tab 125 mg 12 griseofulvin ultramicrosize tab 250 mg 12 grx hicort sup 25mg ....................... 109 guanfacine hcl tab 1 mg .................... 46 guanfacine hcl tab 2 mg .................... 46 guanfacine hcl tab sr 24hr 1 mg (base equiv) ............................................. 78 guanfacine hcl tab sr 24hr 2 mg (base equiv) ............................................. 78 guanfacine hcl tab sr 24hr 3 mg (base equiv) ............................................. 78 guanfacine hcl tab sr 24hr 4 mg (base equiv) ............................................. 78 GUANIDINE TAB 125MG .................... 96 GYNAZOLE-1 CRE 2% ....................... 66 139
GYNOL II GEL 3% .............................66 halobetasol propionate cream 0.05% 115 halobetasol propionate oint 0.05% .... 115 HALOG CRE 0.1% ........................... 115 HALOG OIN 0.1% ........................... 115 haloperidol decanoate im soln 100 mg/ml ......................................................73 haloperidol decanoate im soln 50 mg/ml ......................................................73 haloperidol lactate oral conc 2 mg/ml ..73 haloperidol tab 0.5 mg ......................73 haloperidol tab 1 mg .........................73 haloperidol tab 10 mg .......................73 haloperidol tab 2 mg .........................73 haloperidol tab 20 mg .......................73 haloperidol tab 5 mg .........................73 HARVONI TAB 90-400MG ...................15 hc-pramoxine emol cream 2.5-1% & pramoxine wipe 1% kit .................... 109 heather tab 0.35mg ..........................25 HELIXATE FS INJ 1000UNIT ............. 103 HELIXATE FS INJ 2000UNIT ............. 103 HELIXATE FS INJ 250UNIT ............... 103 HELIXATE FS INJ 500UNIT ............... 103 HEMATOGEN FA CAP ....................... 101 hemocyte-f tab ............................... 101 HEMOFIL M INJ 1700UNIT ................ 103 HEMOFIL M INJ 220-400 .................. 103 HEMOFIL M INJ 401-800 .................. 103 HEMOFIL M INJ 500UNIT ................. 103 HEP SOD/NACL INJ 25000UNT .......... 101 heparin lock inj 100/ml .................... 102 HEPARIN SOD INJ 2000/ML .............. 101 HEPARIN SOD INJ 2500/ML .............. 101 heparin sod lock flush & nacl lock flush 10 unt/ml-0.9% kit ......................... 102 heparin sod lock flush & nacl lock flush 100 unt/ml-0.9% kit ....................... 102 heparin sodium (porcine) 100 unit/ml in d5w .............................................. 101 heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9% ...................... 101 heparin sodium (porcine) 40 unit/ml in d5w .............................................. 101 heparin sodium (porcine) 50 unit/ml in d5w .............................................. 101 heparin sodium (porcine) inj 1000
unit/ml ......................................... 101 heparin sodium (porcine) inj 10000 unit/ml ......................................... 101 heparin sodium (porcine) inj 20000 unit/ml ......................................... 101 heparin sodium (porcine) inj 5000 unit/ml ......................................... 101 heparin sodium (porcine) lock flush iv soln 1 unit/ml ................................ 101 heparin sodium (porcine) lock flush iv soln 10 unit/ml .............................. 101 heparin sodium (porcine) lock flush iv soln 2 unit/ml ................................ 101 heparin sodium (porcine) pf inj 5000 unit/0.5ml ..................................... 101 HEXALEN CAP 50MG ......................... 17 HIZENTRA INJ 10/50ML .................... 17 HIZENTRA INJ 1GM/5ML ................... 17 HIZENTRA INJ 2GM/10ML .................. 17 HIZENTRA INJ 4GM/20ML.................. 17 homatropaire sol 5% op .................. 106 HORIZANT TAB 600MG ..................... 81 HUMALOG INJ 100/ML ...................... 32 HUMALOG KWIK INJ 100/ML .............. 32 HUMALOG KWIK INJ 200/ML .............. 32 HUMALOG MIX INJ 50/50 .................. 32 HUMALOG MIX INJ 50/50KWP ............ 32 HUMALOG MIX INJ 75/25KWP ............ 32 HUMALOG MIX SUS 75/25 ................. 32 HUMATE-P SOL 2400UNIT ............... 103 HUMATE-P SOL 250-600 ................. 103 HUMATE-P SOL 500-1200................ 103 HUMIRA KIT 20MG/0.4 ..................... 88 HUMIRA KIT 40MG/0.8 ..................... 88 HUMIRA PEN INJ PSORIASI ............... 88 HUMULIN INJ 70/30 ......................... 32 HUMULIN INJ 70/30KWP ................... 32 HUMULIN N INJ U-100 ...................... 32 HUMULIN N INJ U-100KWP ................ 32 HUMULIN R INJ U-100 ...................... 32 HUMULIN R INJ U-500 ...................... 32 HYCAMTIN CAP 0.25MG .................... 21 HYCAMTIN CAP 1MG ......................... 21 hydralazine hcl tab 10 mg ................. 47 hydralazine hcl tab 100 mg ............... 47 hydralazine hcl tab 25 mg ................. 47 hydralazine hcl tab 50 mg ................. 47 140
hydrochlorothiazide cap 12.5 mg ........51 hydrochlorothiazide tab 12.5 mg .........51 hydrochlorothiazide tab 25 mg ...........51 hydrochlorothiazide tab 50 mg ...........51 hydrocod polst-chlorphen polst er susp 10-8 mg/5ml ....................................57 hydrocodone w/ homatropine syrup 51.5 mg/5ml ......................................56 hydrocodone w/ homatropine tab 5-1.5 mg ..................................................56 hydrocodone-acetaminophen soln 7.5325 mg/15ml ...................................86 hydrocodone-acetaminophen tab 2.5-325 mg ..................................................86 hydrocodone-acetaminophen tab 5-300 mg ..................................................86 hydrocodone-acetaminophen tab 5-325 mg ..................................................86 hydrocodone-acetaminophen tab 7.5-300 mg ..................................................86 hydrocodone-ibuprofen tab 2.5-200 mg ......................................................87 hydrocodone-ibuprofen tab 7.5-200 mg ......................................................87 hydrocortisone acetate suppos 30 mg 109 hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% ....................... 109 hydrocortisone butyrate cream 0.1%. 115 hydrocortisone butyrate oint 0.1% .... 115 hydrocortisone butyrate soln 0.1%.... 115 hydrocortisone cream 2.5% ............. 115 hydrocortisone enema 100 mg/60ml . 109 hydrocortisone lotion 2.5% .............. 115 hydrocortisone oint 2.5% ................. 115 hydrocortisone tab 10 mg ..................22 hydrocortisone tab 20 mg ..................22 hydrocortisone tab 5 mg ....................22 hydrocortisone valerate cream 0.2% . 115 hydrocortisone valerate oint 0.2% .... 115 HYDROMORPHON SUP 3MG ................83 hydromorphone hcl liqd 1 mg/ml ........83 hydromorphone hcl tab 2 mg .............83 hydromorphone hcl tab 4 mg .............83 hydromorphone hcl tab 8 mg .............83 hydromorphone hcl tab er 24hr deter 12 mg ..................................................83 hydromorphone hcl tab er 24hr deter 16
mg ................................................. 83 hydromorphone hcl tab er 24hr deter 32 mg ................................................. 83 hydromorphone hcl tab er 24hr deter 8 mg ................................................. 83 hydroxychloroquine sulfate tab 200 mg ...................................................... 16 hydroxyurea cap 500 mg .................. 22 hydroxyzine hcl syrup 10 mg/5ml....... 68 hydroxyzine hcl tab 10 mg ................ 68 hydroxyzine hcl tab 25 mg ................ 68 hydroxyzine hcl tab 50 mg ................ 68 hydroxyzine pamoate cap 100 mg ...... 68 hydroxyzine pamoate cap 25 mg ........ 68 hydroxyzine pamoate cap 50 mg ........ 68 hygel gel 0.2% .............................. 116 hyophen tab .................................... 65 hyoscyamine sulfate elixir 0.125 mg/5ml ...................................................... 60 hyoscyamine sulfate soln 0.125 mg/ml 60 hyoscyamine sulfate tab 0.125 mg ..... 60 ibandronate sodium tab 150 mg (base equivalent) ...................................... 37 IBRANCE CAP 100MG ........................ 20 IBRANCE CAP 125MG ........................ 20 IBRANCE CAP 75MG ......................... 20 ibudone tab 10-200mg ..................... 87 ibudone tab 5-200mg ....................... 87 ibuprofen tab 400 mg ....................... 87 ibuprofen tab 600 mg ....................... 87 ibuprofen tab 800 mg ....................... 87 ICLUSIG TAB 15MG .......................... 21 ICLUSIG TAB 45MG .......................... 21 imatinib mesylate tab 100 mg (base equivalent) ...................................... 21 imatinib mesylate tab 400 mg (base equivalent) ...................................... 21 IMBRUVICA CAP 140MG .................... 21 imipramine hcl tab 10 mg ................. 71 imipramine hcl tab 25 mg ................. 71 imipramine hcl tab 50 mg ................. 71 imipramine pamoate cap 100 mg ....... 72 imipramine pamoate cap 125 mg ....... 72 imipramine pamoate cap 150 mg ....... 72 imipramine pamoate cap 75 mg ......... 72 imiquimod cream 5%...................... 117 INCRELEX INJ 40MG/4ML .................. 38 141
indapamide tab 1.25 mg ....................51 indapamide tab 2.5 mg ......................51 indomethacin cap 25 mg ....................87 indomethacin cap 50 mg ....................87 indomethacin cap cr 75 mg ................87 INLYTA TAB 1MG ..............................20 INLYTA TAB 5MG ..............................20 INTELENCE TAB 100MG .....................14 INTELENCE TAB 200MG .....................14 INTELENCE TAB 25MG .......................14 INTRON A INJ 10MU ..........................22 INTRON A INJ 18MU ..........................22 INTRON A INJ 25MU ..........................22 INTRON A INJ 50MU ..........................22 introvale tab ....................................31 INVEGA TAB 1.5MG ...........................72 INVEGA TAB 3MG .............................72 INVEGA TAB 6MG .............................73 INVEGA TAB 9MG .............................73 INVIRASE CAP 200MG .......................13 INVIRASE TAB 500MG .......................13 iodine solution strong 5% (lugol's) ......98 iodoquinol-hc cream 1% .................. 112 ipratropium bromide inhal soln 0.02% .57 ipratropium bromide nasal soln 0.03% (21 mcg/spray) ................................56 ipratropium bromide nasal soln 0.06% (42 mcg/spray) ................................56 ipratropium-albuterol nebu soln 0.52.5(3) mg/3ml .................................58 irbesartan tab 150 mg .......................46 irbesartan tab 300 mg .......................46 irbesartan tab 75 mg .........................46 irbesartan-hydrochlorothiazide tab 15012.5 mg ..........................................49 irbesartan-hydrochlorothiazide tab 30012.5 mg ..........................................49 ISENTRESS CHW 100MG....................13 ISENTRESS CHW 25MG .....................13 ISENTRESS POW 100MG ....................13 ISENTRESS TAB 400MG .....................13 isoditrate tab 40mg er .......................40 isometheptene-dichloral-acetaminophen cap 65-100-325 mg ..........................90 isoniazid syrup 50 mg/5ml .................12 isoniazid tab 100 mg .........................12 isoniazid tab 300 mg .........................12
ISORDIL TAB 40MG .......................... 40 isosorbide dinitrate tab 10 mg ........... 40 isosorbide dinitrate tab 20 mg ........... 40 isosorbide dinitrate tab 30 mg ........... 40 isosorbide dinitrate tab 5 mg ............. 40 isosorbide mononitrate tab 10 mg ...... 40 isosorbide mononitrate tab 20 mg ...... 40 isosorbide mononitrate tab sr 24hr 120 mg ................................................. 40 isosorbide mononitrate tab sr 24hr 30 mg ................................................. 40 isosorbide mononitrate tab sr 24hr 60 mg ................................................. 40 isosulfan blue subcutaneous soln 1% 118 isoxsuprine hcl tab 10 mg ................. 54 isoxsuprine hcl tab 20 mg ................. 54 isradipine cap 2.5 mg ....................... 43 isradipine cap 5 mg .......................... 43 itraconazole cap 100 mg ................... 12 ivermectin tab 3 mg ......................... 16 JAKAFI TAB 10MG ............................ 21 JAKAFI TAB 15MG ............................ 21 JAKAFI TAB 20MG ............................ 21 JAKAFI TAB 25MG ............................ 21 JAKAFI TAB 5MG .............................. 21 JALYN CAP....................................... 67 JANUMET TAB 50-1000 ..................... 35 JANUMET TAB 50-500MG .................. 35 JANUMET XR TAB 100-1000............... 35 JANUMET XR TAB 50-1000 ................ 35 JANUMET XR TAB 50-500MG.............. 35 JANUVIA TAB 100MG ........................ 34 JANUVIA TAB 25MG .......................... 34 JANUVIA TAB 50MG .......................... 34 JARDIANCE TAB 10MG ...................... 34 JARDIANCE TAB 25MG ...................... 34 jencycla tab 0.35mg ......................... 25 JENTADUETO TAB 2.5-1000 ............... 34 JENTADUETO TAB 2.5-500 ................ 34 JENTADUETO TAB 2.5-850 ................ 34 JENTADUETO TAB XR ........................ 34 jinteli tab 1mg-5mcg ........................ 25 jolessa tab ...................................... 31 jolivette tab 0.35mg ......................... 25 juleber tab ...................................... 26 junel 1.5/30 tab ............................... 27 junel 1/20 tab .................................. 27 142
junel fe 24 tab 1/20 ..........................29 junel fe tab 1.5/30 ............................29 junel fe tab 1/20 ...............................28 JUXTAPID CAP 10MG .........................54 JUXTAPID CAP 20MG .........................54 JUXTAPID CAP 30MG .........................54 JUXTAPID CAP 40MG .........................54 JUXTAPID CAP 5MG ...........................54 JUXTAPID CAP 60MG .........................54 KADIAN CAP 200MG ER .....................84 kaitlib fe chw ....................................28 KALETRA SOL ...................................14 KALETRA TAB 100-25MG ...................14 KALETRA TAB 200-50MG ...................14 KALYDECO PAK 50MG ........................60 KALYDECO PAK 75MG ........................60 KALYDECO TAB 150MG ......................60 kariva tab 28 day ..............................29 KAZANO 12.5- TAB 1000MG ...............34 KAZANO 12.5- TAB 500MG ................34 k-effervesce tab 25meq ef .................98 kelnor tab 1/35 ................................26 KETEK TAB 300MG ............................16 KETEK TAB 400MG ............................16 ketoconazole cream 2% ................... 112 ketoconazole foam 2% .................... 112 ketoconazole shampoo 2% ............... 112 ketoconazole tab 200 mg ...................12 KETO-DIASTIX TES ......................... 118 ketoprofen cap 50 mg .......................87 ketoprofen cap 75 mg .......................87 ketoprofen cap sr 24hr 200 mg...........87 ketorolac tromethamine im inj 60 mg/2ml (30 mg/ml) ..........................87 ketorolac tromethamine ophth soln 0.4% .................................................... 107 ketorolac tromethamine ophth soln 0.5% .................................................... 108 ketorolac tromethamine tab 10 mg .....87 KETOSTIX TES STRIP ...................... 118 kimidess tab .....................................29 KINERET INJ ....................................88 KLOR-CON M15 TAB 15MEQ ER ..........99 KOATE-DVI INJ 1000UNIT ................ 103 KOATE-DVI INJ 250UNIT ................. 103 KOGENATE FS INJ 3000/BS .............. 103 KOMBIGLYZE TAB 2.5-1000 ...............35
KOMBIGLYZE TAB 5-1000MG ............. 35 KOMBIGLYZE TAB 5-500MG ............... 35 KORLYM TAB 300MG ......................... 33 k-sol sol 10% .................................. 98 k-sol sol 20% .................................. 98 kurvelo tab 0.15/30 .......................... 27 KUVAN POW 100MG ......................... 40 KUVAN POW 500MG ......................... 40 KUVAN TAB 100MG .......................... 40 labetalol hcl tab 100 mg .................... 42 labetalol hcl tab 200 mg .................... 42 labetalol hcl tab 300 mg .................... 42 LACRISERT MIS 5MG OP ................. 105 lactated ringer's for irrigation ........... 120 lactic acid (ammonium lactate) cream 12% ............................................. 116 lactic acid (ammonium lactate) lotion 10% ............................................. 116 lactic acid w/ vitamin e cream 10%-3500 unit/30gm ..................................... 116 lactulose solution 10 gm/15ml ........... 60 LAMISIL GRA 125MG ........................ 12 LAMISIL GRA 187.5MG ..................... 12 lamivudine oral soln 10 mg/ml ........... 13 lamivudine tab 100 mg (hbv)............. 15 lamivudine tab 150 mg ..................... 13 lamivudine tab 300 mg ..................... 13 lamivudine-zidovudine tab 150-300 mg ...................................................... 14 lamotrigine tab 100 mg ..................... 93 lamotrigine tab 150 mg ..................... 93 lamotrigine tab 200 mg ..................... 93 lamotrigine tab 25 mg ...................... 93 lamotrigine tab chewable dispersible 25 mg ................................................. 93 lamotrigine tab chewable dispersible 5 mg ................................................. 93 lamotrigine tab sr 24hr 100 mg.......... 93 lamotrigine tab sr 24hr 200 mg.......... 93 lamotrigine tab sr 24hr 25 mg ........... 93 lamotrigine tab sr 24hr 250 mg.......... 93 lamotrigine tab sr 24hr 300 mg.......... 93 lamotrigine tab sr 24hr 50 mg ........... 93 LANCING DEVI MIS ........................ 118 lansoprazole cap delayed release 15 mg ...................................................... 62 lansoprazole cap delayed release 30 mg 143
......................................................62 LANTUS INJ 100/ML ..........................31 LANTUS INJ SOLOSTAR .....................31 larin 24 tab fe 1/20 ...........................29 larin fe tab 1.5/30 .............................29 larin fe tab 1/20 ...............................28 larin tab 1.5/30 ................................27 larin tab 1/20 ...................................27 LASTACAFT SOL 0.25% ................... 107 latanoprost ophth soln 0.005% ......... 106 latrix sus 50% ................................ 116 LATUDA TAB 120MG ..........................75 LATUDA TAB 20MG ...........................75 LATUDA TAB 40MG ...........................75 LATUDA TAB 80MG ...........................75 layolis fe chw ...................................28 leena tab .........................................30 leflunomide tab 10 mg .......................89 leflunomide tab 20 mg .......................89 LENVIMA CAP 10 MG .........................21 LENVIMA CAP 14 MG .........................21 LENVIMA CAP 18 MG .........................21 LENVIMA CAP 20 MG .........................21 LENVIMA CAP 24 MG .........................21 LENVIMA CAP 8 MG ...........................21 lessina tab .......................................26 LETAIRIS TAB 10MG ..........................54 LETAIRIS TAB 5MG ...........................54 letrozole tab 2.5 mg ..........................19 leucovorin calcium tab 10 mg .............22 leucovorin calcium tab 15 mg .............22 leucovorin calcium tab 25 mg .............22 leucovorin calcium tab 5 mg ...............22 LEUKERAN TAB 2MG..........................17 LEUKINE INJ 250MCG ...................... 100 leuprolide acetate inj kit 5 mg/ml .......19 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) .....................................57 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) .....................................57 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) .....................................57 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) ......................57 LEVATOL TAB 20MG ..........................41 LEVEMIR INJ ....................................32 LEVEMIR INJ FLEXTOUC .....................32
levetiracetam oral soln 100 mg/ml ..... 93 levetiracetam tab 1000 mg ................ 93 levetiracetam tab 250 mg ................. 93 levetiracetam tab 500 mg ................. 93 levetiracetam tab 750 mg ................. 93 levetiracetam tab sr 24hr 500 mg ...... 93 levetiracetam tab sr 24hr 750 mg ...... 93 levobunolol hcl ophth soln 0.25% ..... 105 levobunolol hcl ophth soln 0.5%....... 105 levocarnitine oral soln 1 gm/10ml (10%) ...................................................... 39 levocarnitine tab 330 mg................... 39 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) ........................ 56 levocetirizine dihydrochloride tab 5 mg 55 levofloxacin ophth soln 0.5% ........... 105 levofloxacin oral soln 25 mg/ml.......... 11 levofloxacin tab 250 mg .................... 11 levofloxacin tab 500 mg .................... 11 levofloxacin tab 750 mg .................... 11 levonest tab .................................... 29 levonorgestrel & ethinyl estradiol (91day) tab 0.15-0.03 mg ..................... 31 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg ..................................... 26 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg .............................. 27 levonorgestrel tab 1.5 mg ................. 25 levonorgestrel-eth estra tab 0.0530/0.075-40/0.125-30mg-mcg .......... 29 levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg .............. 31 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) ...................... 31 levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) ...................... 31 levora-28 tab 0.15/30....................... 27 levorphanol tartrate tab 2 mg ............ 83 levothyroxine sodium tab 112 mcg ..... 36 levothyroxine sodium tab 125 mcg ..... 36 levothyroxine sodium tab 150 mcg ..... 36 levoxyl tab 100mcg .......................... 36 levoxyl tab 137mcg .......................... 36 levoxyl tab 25mcg ............................ 36 levoxyl tab 50mcg ............................ 36 levoxyl tab 75mcg ............................ 36 levoxyl tab 88mcg ............................ 36 144
LEXIVA SUS 50MG/ML .......................13 LEXIVA TAB 700MG ...........................13 LIALDA TAB 1.2GM ...........................64 lidocaine hcl cream 3% .................... 117 lidocaine hcl gel 2% ........................ 117 lidocaine hcl laryngotracheal soln 4% 108 lidocaine hcl lotion 3%..................... 117 lidocaine hcl soln 4% ....................... 117 lidocaine hcl viscous soln 2% ........... 109 lidocaine oint 5% ............................ 117 lidocaine patch 5%.......................... 117 lidocaine-hydrocortisone acetate rectal cream 3-0.5% ................................ 109 lidocaine-hydrocortisone acetate rectal cream kit 3-0.5%............................ 109 lidocaine-hydrocortisone acetate rectal cream kit 3-1% .............................. 109 lidocaine-hydrocortisone acetate rectal gel kit 3-2.5% ................................ 109 lidocaine-prilocaine cream 2.5-2.5% . 117 lidocaine-prilocaine cream kit 2.5-2.5% .................................................... 117 lindane lotion 1% ............................ 117 lindane shampoo 1% ....................... 117 linezolid for susp 100 mg/5ml ............17 linezolid tab 600 mg ..........................17 LINZESS CAP 145MCG .......................64 LINZESS CAP 290MCG .......................64 liothyronine sodium tab 25 mcg ..........36 liothyronine sodium tab 5 mcg............36 liothyronine sodium tab 50 mcg ..........36 lisinopril & hydrochlorothiazide tab 1012.5 mg ..........................................48 lisinopril & hydrochlorothiazide tab 2012.5 mg ..........................................48 lisinopril & hydrochlorothiazide tab 20-25 mg ..................................................48 lisinopril tab 10 mg ...........................45 lisinopril tab 2.5 mg ..........................45 lisinopril tab 20 mg ...........................45 lisinopril tab 30 mg ...........................45 lisinopril tab 40 mg ...........................45 lisinopril tab 5 mg .............................45 lithium carbonate cap 150 mg ............75 lithium carbonate cap 300 mg ............75 lithium carbonate cap 600 mg ............75 lithium carbonate tab 300 mg.............75
lithium carbonate tab cr 300 mg ........ 76 lithium carbonate tab cr 450 mg ........ 76 LITHIUM SOL 8MEQ/5ML ................... 75 LIVALO TAB 1MG.............................. 53 LIVALO TAB 2MG.............................. 53 LIVALO TAB 4MG.............................. 53 LO LOESTRIN TAB ............................ 29 lomedia 24 tab fe ............................. 29 lomustine cap 10 mg ........................ 17 lomustine cap 100 mg ...................... 17 lomustine cap 40 mg ........................ 17 LONSURF TAB 15-6.14 ...................... 22 LONSURF TAB 20-8.19 ...................... 22 lorazepam conc 2 mg/ml ................... 68 lorazepam tab 0.5 mg ....................... 68 lorazepam tab 1 mg ......................... 68 lorazepam tab 2 mg ......................... 68 lortab tab 10-325mg ........................ 86 lortab tab 7.5-325 ............................ 86 loryna tab 3-0.02mg ......................... 26 losartan potassium & hydrochlorothiazide tab 100-12.5 mg .............................. 49 losartan potassium & hydrochlorothiazide tab 100-25 mg................................. 49 losartan potassium & hydrochlorothiazide tab 50-12.5 mg................................ 49 losartan potassium tab 100 mg .......... 46 losartan potassium tab 25 mg ............ 46 losartan potassium tab 50 mg ............ 46 LOTEMAX GEL 0.5% ....................... 106 LOTEMAX OIN 0.5% ....................... 106 LOTEMAX SUS 0.5% ....................... 106 lovastatin tab 10 mg......................... 53 lovastatin tab 20 mg......................... 53 lovastatin tab 40 mg......................... 53 low-ogestrel tab ............................... 28 loxapine succinate cap 10 mg ............ 74 loxapine succinate cap 25 mg ............ 74 loxapine succinate cap 5 mg .............. 74 loxapine succinate cap 50 mg ............ 74 LOZI-FLUR LOZ 1MG F ...................... 98 LUFYLLIN TAB 400MG ....................... 58 LUMIGAN SOL 0.01% ..................... 106 LUPR DEP-PED INJ 11.25MG ......... 37, 38 LUPR DEP-PED INJ 15MG .................. 37 LUPR DEP-PED INJ 30MG .................. 38 LUPR DEP-PED INJ 7.5MG ................. 37 145
LUPRON DEPOT INJ 11.25MG .............19 LUPRON DEPOT INJ 22.5MG ...............19 LUPRON DEPOT INJ 3.75MG ...............19 LUPRON DEPOT INJ 30MG ..................19 LUPRON DEPOT INJ 45MG ..................19 LUPRON DEPOT INJ 7.5MG .................19 lutera tab .........................................26 LYNPARZA CAP 50MG ........................21 LYRICA CAP 100MG ...........................93 LYRICA CAP 150MG ...........................93 LYRICA CAP 200MG ...........................93 LYRICA CAP 225MG ...........................93 LYRICA CAP 25MG ............................93 LYRICA CAP 300MG ...........................93 LYRICA CAP 50MG ............................93 LYRICA CAP 75MG ............................93 LYRICA SOL 20MG/ML .......................93 LYSODREN TAB 500MG ......................18 lyza tab 0.35mg ...............................25 malathion lotion 0.5% ..................... 117 maprotiline hcl tab 25 mg ..................72 maprotiline hcl tab 50 mg ..................72 maprotiline hcl tab 75 mg ..................72 marlissa tab 0.15/30 .........................27 MARPLAN TAB 10MG .........................69 MATULANE CAP 50MG .......................22 meclizine hcl tab 12.5 mg ..................62 meclizine hcl tab 25 mg .....................62 meclofenamate sodium cap 100 mg ....87 meclofenamate sodium cap 50 mg ......87 medroxyprogesterone acetate im susp 150 mg/ml .......................................25 medroxyprogesterone acetate tab 10 mg ......................................................31 medroxyprogesterone acetate tab 2.5 mg ..................................................31 medroxyprogesterone acetate tab 5 mg ......................................................31 mefenamic acid cap 250 mg ...............88 mefloquine hcl tab 250 mg .................16 megestrol acetate susp 40 mg/ml .......19 megestrol acetate tab 20 mg ..............19 megestrol acetate tab 40 mg ..............19 MEKINIST TAB 0.5MG ........................20 MEKINIST TAB 2MG ..........................20 meloxicam susp 7.5 mg/5ml ..............88 meloxicam tab 15 mg ........................88
meloxicam tab 7.5 mg ...................... 88 memantine hcl oral solution 2 mg/ml .. 79 memantine hcl tab 10 mg ................. 79 memantine hcl tab 5 mg ................... 79 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak ............................. 79 MENEST TAB 0.3MG ......................... 24 MENEST TAB 0.625MG ...................... 24 MENEST TAB 1.25MG ........................ 24 MENEST TAB 2.5MG ......................... 24 meperidine hcl oral soln 50 mg/5ml .... 84 meperidine hcl tab 100 mg ................ 83 meperidine hcl tab 50 mg .................. 83 MEPHYTON TAB 5MG ........................ 96 meprobamate tab 200 mg ................. 68 meprobamate tab 400 mg ................. 68 mercaptopurine tab 50 mg ................ 18 mesalamine enema 4 gm .................. 64 mesalamine rectal enema 4 gm & cleanser wipe kit .............................. 64 mesalamine tab delayed release 800 mg ...................................................... 64 MESNEX TAB 400MG......................... 22 MESTINON SYP 60MG/5ML ................ 96 metaproterenol sulfate syrup 10 mg/5ml ...................................................... 57 metaproterenol sulfate tab 10 mg ...... 57 metaproterenol sulfate tab 20 mg ...... 57 metaxalone tab 800 mg .................... 96 metformin hcl tab 1000 mg ............... 33 metformin hcl tab 500 mg ................. 33 metformin hcl tab 850 mg ................. 33 metformin hcl tab sr 24hr 500 mg ...... 33 metformin hcl tab sr 24hr 750 mg ...... 33 metformin hcl tab sr 24hr osmotic 1000 mg ................................................. 33 metformin hcl tab sr 24hr osmotic 500 mg ................................................. 33 methadone hcl conc 10 mg/ml ........... 84 methadone hcl soln 10 mg/5ml .......... 84 methadone hcl soln 5 mg/5ml ............ 84 methadone hcl tab 10 mg ................. 84 methadone hcl tab 5 mg ................... 84 methadone hcl tab for oral susp 40 mg 84 METHADOSE TAB 40MG .................... 84 methamphetamine hcl tab 5 mg ......... 77 methazolamide tab 25 mg ................. 50 146
methazolamide tab 50 mg .................50 methenamine hippurate tab 1 gm .......65 methenamine mandelate tab 0.5 gm ...65 methenamine mandelate tab 1 gm ......65 methimazole tab 10 mg .....................36 methimazole tab 5 mg .......................36 METHITEST TAB 10MG.......................23 methocarbamol tab 500 mg ...............96 methocarbamol tab 750 mg ...............96 methotrexate sodium inj 50 mg/2ml (25 mg/ml) ............................................18 methotrexate sodium inj pf 100 mg/4ml (25 mg/ml) ......................................18 methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) ........................18 methotrexate sodium inj pf 200 mg/8ml (25 mg/ml) ......................................18 methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) ......................................18 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) ......................................18 methotrexate sodium tab 2.5 mg (base equiv) .............................................18 methoxsalen rapid cap 10 mg........... 113 methscopolamine bromide tab 2.5 mg .61 methscopolamine bromide tab 5 mg ....61 methyclothiazide tab 5 mg .................51 methyldopa & hydrochlorothiazide tab 250-15 mg .......................................50 methyldopa & hydrochlorothiazide tab 250-25 mg .......................................50 methyldopa tab 250 mg .....................46 methyldopa tab 500 mg .....................46 methylergonovine maleate tab 0.2 mg 37 methylphenidate hcl cap cr 10 mg (cd) 78 methylphenidate hcl cap cr 20 mg (cd) 78 methylphenidate hcl cap cr 30 mg (cd) 78 methylphenidate hcl cap cr 40 mg (cd) 78 methylphenidate hcl cap cr 50 mg (cd) 78 methylphenidate hcl cap cr 60 mg (cd) 78 methylphenidate hcl cap sr 24hr 20 mg (la) .................................................79 methylphenidate hcl cap sr 24hr 30 mg (la) .................................................79 methylphenidate hcl cap sr 24hr 40 mg (la) .................................................79 methylphenidate hcl soln 10 mg/5ml ...78
methylphenidate hcl soln 5 mg/5ml .... 78 methylphenidate hcl tab 10 mg .......... 78 methylphenidate hcl tab 20 mg .......... 78 methylphenidate hcl tab 5 mg............ 78 methylphenidate hcl tab cr 10 mg ...... 78 methylphenidate hcl tab cr 20 mg ...... 78 methylphenidate hcl tab sa osm 27 mg 78 methylphenidate hcl tab sa osm 36 mg78 methylphenidate hcl tab sa osm 54 mg 78 methylphenidate hcl tab sr 24hr 18 mg ...................................................... 79 methylprednisolone tab 16 mg ........... 22 methylprednisolone tab 32 mg ........... 22 methylprednisolone tab 4 mg ............ 22 methylprednisolone tab 8 mg ............ 22 methylprednisolone tab therapy pack 4 mg (21) .......................................... 22 metipranolol ophth soln 0.3% .......... 105 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)........................................ 63 metoclopramide hcl tab 10 mg ........... 63 metoclopramide hcl tab 5 mg ............ 63 metolazone tab 10 mg ...................... 51 metolazone tab 2.5 mg ..................... 51 metolazone tab 5 mg ........................ 51 metoprolol & hydrochlorothiazide tab 100-25 mg ...................................... 48 metoprolol & hydrochlorothiazide tab 100-50 mg ...................................... 48 metoprolol & hydrochlorothiazide tab 5025 mg............................................. 48 metoprolol succinate tab sr 24hr 100 mg (tartrate equiv) ................................ 41 metoprolol succinate tab sr 24hr 200 mg (tartrate equiv) ................................ 41 metoprolol succinate tab sr 24hr 25 mg (tartrate equiv) ................................ 41 metoprolol succinate tab sr 24hr 50 mg (tartrate equiv) ................................ 41 metoprolol tartrate tab 100 mg .......... 42 metoprolol tartrate tab 25 mg............ 41 metoprolol tartrate tab 50 mg............ 41 metronidazole cap 375 mg ................ 16 metronidazole cream 0.75% ............ 111 metronidazole gel 0.75% ................ 111 metronidazole gel 1% ..................... 111 metronidazole lotion 0.75% ............. 111 147
metronidazole tab 250 mg .................16 metronidazole tab 500 mg .................16 metronidazole vaginal gel 0.75% ........66 mexiletine hcl cap 150 mg .................44 mexiletine hcl cap 200 mg .................44 mexiletine hcl cap 250 mg .................44 micrgstin 24 tab fe 1/20 ....................29 microgestin tab 1.5/30 ......................28 microgestin tab 1/20 .........................27 microgestin tab fe 1/20 .....................28 microgestin tab fe1.5/30....................29 midazolam hcl syrup 2 mg/ml (base equivalent) ......................................76 midodrine hcl tab 10 mg ....................52 midodrine hcl tab 2.5 mg ...................51 midodrine hcl tab 5 mg ......................52 migergot sup 2/100 ..........................90 miglitol tab 100 mg ...........................33 miglitol tab 25 mg.............................33 miglitol tab 50 mg.............................33 mimvey lo tab 0.5-0.1 .......................25 MINASTRIN 24 CHW FE .....................29 minocycline hcl cap 100 mg ...............11 minocycline hcl cap 50 mg .................11 minocycline hcl cap 75 mg .................11 minocycline hcl tab 100 mg ................11 minocycline hcl tab 50 mg .................11 minocycline hcl tab 75 mg .................11 minocycline hcl tab sr 24hr 135 mg .....11 minocycline hcl tab sr 24hr 45 mg ......11 minocycline hcl tab sr 24hr 90 mg ......11 minoxidil tab 10 mg ..........................47 minoxidil tab 2.5 mg .........................47 mirtazapine orally disintegrating tab 15 mg ..................................................69 mirtazapine orally disintegrating tab 30 mg ..................................................69 mirtazapine orally disintegrating tab 45 mg ..................................................69 mirtazapine tab 15 mg ......................69 mirtazapine tab 30 mg ......................69 mirtazapine tab 45 mg ......................69 mirtazapine tab 7.5 mg .....................68 misoprostol tab 100 mcg ...................61 misoprostol tab 200 mcg ...................61 modafinil tab 100 mg ........................79 modafinil tab 200 mg ........................79
moexipril hcl tab 15 mg .................... 45 moexipril hcl tab 7.5 mg ................... 45 moexipril-hydrochlorothiazide tab 1512.5 mg .......................................... 48 moexipril-hydrochlorothiazide tab 15-25 mg ................................................. 48 moexipril-hydrochlorothiazide tab 7.512.5 mg .......................................... 48 mometasone furoate cream 0.1% .... 115 mometasone furoate nasal susp 50 mcg/act .......................................... 56 mometasone furoate oint 0.1% ........ 115 mometasone furoate solution 0.1% (lotion) ......................................... 115 MONOCLATE-P INJ 1000UNIT .......... 103 MONOCLATE-P INJ 1500UNIT .......... 103 MONOCLATE-P INJ 250UNIT ............ 103 MONOCLATE-P INJ 500UNIT ............ 103 mono-linyah tab 0.25-35................... 28 mononessa tab ................................ 28 MONONINE INJ 1000UNIT ............... 104 MONONINE INJ 250UNIT ................. 104 montelukast sodium chew tab 4 mg (base equiv) .................................... 59 montelukast sodium chew tab 5 mg (base equiv) .................................... 59 montelukast sodium oral granules packet 4 mg (base equiv) ............................ 59 montelukast sodium tab 10 mg (base equiv) ............................................. 59 MONUROL PAK GRANULES ................ 65 MORPHINE SUL SUP 30MG ................ 84 morphine sulfate cap sr 24hr 10 mg ... 84 morphine sulfate cap sr 24hr 100 mg . 84 morphine sulfate cap sr 24hr 20 mg ... 84 morphine sulfate cap sr 24hr 30 mg ... 84 morphine sulfate cap sr 24hr 50 mg ... 84 morphine sulfate cap sr 24hr 60 mg ... 84 morphine sulfate cap sr 24hr 80 mg ... 84 morphine sulfate oral soln 10 mg/5ml . 84 morphine sulfate oral soln 100 mg/5ml (20 mg/ml) ..................................... 84 morphine sulfate oral soln 20 mg/5ml . 84 morphine sulfate suppos 10 mg ......... 84 morphine sulfate suppos 20 mg ......... 84 morphine sulfate suppos 5 mg ........... 84 morphine sulfate tab 15 mg............... 84 148
morphine sulfate tab 30 mg ...............84 morphine sulfate tab cr 100 mg ..........84 morphine sulfate tab cr 15 mg ............84 morphine sulfate tab cr 200 mg ..........84 morphine sulfate tab cr 30 mg ............84 morphine sulfate tab cr 60 mg ............84 MOTOFEN TAB ..................................60 MOVANTIK TAB 12.5MG .....................64 MOVANTIK TAB 25MG .......................64 MOVIPREP SOL .................................60 moxifloxacin hcl tab 400 mg (base equiv) ......................................................11 MOZOBIL INJ ................................. 100 MULTAQ TAB 400MG .........................44 multivit/fl chw 0.25mg ......................97 multivit/fl chw 0.5mg ........................97 multivit/fl chw 1mg ...........................97 multi-vit/fl dro 0.25mg ......................97 multi-vit/fl dro 0.5mg/ml ...................97 mupirocin oint 2% .......................... 111 my way tab 1.5mg ............................25 MYALEPT INJ 11.3MG ........................39 mycophenolate mofetil cap 250 mg ... 120 mycophenolate mofetil for oral susp 200 mg/ml ........................................... 120 mycophenolate mofetil tab 500 mg ... 120 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)................ 120 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)................ 120 MYKIDZ IRON SUS 15/1.5ML ..............99 MYLERAN TAB 2MG ...........................17 MYRBETRIQ TAB 25MG ......................66 MYRBETRIQ TAB 50MG ......................66 myzilra tab.......................................30 nabumetone tab 500 mg....................88 nabumetone tab 750 mg....................88 nadolol & bendroflumethiazide tab 40-5 mg ..................................................48 nadolol & bendroflumethiazide tab 80-5 mg ..................................................48 nadolol tab 20 mg .............................40 nadolol tab 40 mg .............................40 nadolol tab 80 mg .............................40 naftifine hcl cream 1% .................... 112 naftifine hcl cream 2% .................... 112 NAFTIN CRE 2% ............................. 112
NAFTIN GEL 1% ............................. 112 naloxone hcl inj 1 mg/ml ................. 118 naltrexone hcl tab 50 mg ................ 118 NAMENDA SOL 10MG/5ML ................. 79 NAMENDA XR CAP 14MG ................... 80 NAMENDA XR CAP 21MG ................... 80 NAMENDA XR CAP 28MG ................... 80 NAMENDA XR CAP 7MG ..................... 79 NAMENDA XR CAP TITRATIO.............. 80 naphazoline hcl ophth soln 0.1% ...... 107 naproxen dr tab 375mg .................... 88 naproxen dr tab 500mg .................... 88 naproxen sodium tab 275 mg ............ 88 naproxen sodium tab 550 mg ............ 88 naproxen susp 125 mg/5ml ............... 88 naproxen tab 250 mg ....................... 88 naproxen tab 375 mg ....................... 88 naproxen tab 500 mg ....................... 88 naratriptan hcl tab 1 mg (base equiv) . 89 naratriptan hcl tab 2.5 mg (base equiv) ...................................................... 89 NARCAN SPR ................................. 118 NASCOBAL SPR 500MCG ................... 99 NASONEX SPR 50MCG/AC ................. 56 NATACYN SUS 5% OP ..................... 105 NATAZIA TAB .................................. 30 nateglinide tab 120 mg ..................... 33 nateglinide tab 60 mg ....................... 33 NATURE THROI TAB 162.5MG ............ 36 NATURE-THROI TAB 113.75MG .......... 36 NATURE-THROI TAB 146.25MG .......... 36 NATURE-THROI TAB 16.25MG ............ 36 NATURE-THROI TAB 260MG .............. 36 NATURE-THROI TAB 32.5MG ............. 36 NATURE-THROI TAB 325MG .............. 36 NATURE-THROI TAB 48.75MG ............ 36 NATURE-THROI TAB 81.25MG ............ 36 NEBUPENT INH 300MG ..................... 16 necon tab 0.5/35 ............................. 27 necon tab 1/50-28 ........................... 28 NECON TAB 10/11-28 ....................... 29 necon tab 7/7/7 ............................... 30 nefazodone hcl tab 100 mg ............... 69 nefazodone hcl tab 150 mg ............... 69 nefazodone hcl tab 200 mg ............... 69 nefazodone hcl tab 250 mg ............... 69 nefazodone hcl tab 50 mg ................. 69 149
neomycin sulfate tab 500 mg .............11 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin ... 105 neomycin-polymy-gramicid op sol 1.7510000-0.025mg-unt-mg/ml ............. 105 neomycin-polymyxin b gu irrigation soln ......................................................67 neomycin-polymyxin-dexamethasone ophth oint 0.1% ............................. 106 neomycin-polymyxin-dexamethasone ophth susp 0.1% ............................ 106 neomycin-polymyxin-hc ophth susp .. 106 neomycin-polymyxin-hc otic soln 1% 108 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ................ 108 nephronex tab 1mg ...........................97 NESINA TAB 12.5MG .........................34 NESINA TAB 25MG ............................34 NESINA TAB 6.25MG .........................34 NEULASTA INJ 6MG/0.6M ................ 100 NEULASTA KIT 6MG/0.6M ................ 100 NEUPOGEN INJ 300/0.5 ................... 100 NEUPOGEN INJ 300MCG .................. 100 NEUPOGEN INJ 480/0.8 ................... 100 NEUPOGEN INJ 480MCG .................. 100 NEUPRO DIS 1MG/24HR ....................95 NEUPRO DIS 2MG/24HR ....................95 NEUPRO DIS 3MG/24HR ....................95 NEUPRO DIS 4MG/24HR ....................95 NEUPRO DIS 6MG/24HR ....................95 NEUPRO DIS 8MG/24HR ....................95 neutragard gel 1.1% ....................... 109 NEVANAC SUS 0.1% ....................... 108 nevirapine susp 50 mg/5ml ................14 nevirapine tab 200 mg ......................14 nevirapine tab sr 24hr 100 mg ...........14 nevirapine tab sr 24hr 400 mg ...........14 NEXAVAR TAB 200MG........................20 NEXIUM CAP 40MG ...........................61 NEXIUM GRA 10MG DR ......................61 NEXIUM GRA 2.5MG DR .....................61 NEXIUM GRA 20MG DR ......................61 NEXIUM GRA 40MG DR ......................61 NEXIUM GRA 5MG DR ........................61 next choice tab 1.5mg .......................25 niacin tab cr 1000 mg (antihyperlipidemic) ..........................53
niacin tab cr 500 mg (antihyperlipidemic) ...................................................... 53 niacin tab cr 750 mg (antihyperlipidemic) ...................................................... 53 nicardipine hcl cap 20 mg .................. 43 nicardipine hcl cap 30 mg .................. 43 nicotine pol gum 2mg ....................... 80 nicotine pol gum 4mg ....................... 80 nicotine pol loz 4mg mint .................. 80 nicotine polacrilex lozenge 2 mg ........ 80 nicotine td dis 14mg/24h .................. 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 nifedipine cap 10 mg ........................ 43 nifedipine cap 20 mg ........................ 43 nifedipine tab sr 24hr 60 mg.............. 43 nifedipine tab sr 24hr 90 mg.............. 43 nifedipine tab sr 24hr osmotic release 30 mg ................................................. 43 nifedipine tab sr 24hr osmotic release 60 mg ................................................. 43 nifedipine tab sr 24hr osmotic release 90 mg ................................................. 43 nikki tab 3-0.02mg ........................... 26 NILANDRON TAB 150MG ................... 18 nilutamide tab 150 mg ...................... 18 nimodipine cap 30 mg ...................... 43 NINLARO CAP 2.3MG ........................ 21 NINLARO CAP 3MG ........................... 21 NINLARO CAP 4MG ........................... 21 nisoldipine tab sr 24hr 17 mg ............ 43 nisoldipine tab sr 24hr 20 mg ............ 43 nisoldipine tab sr 24hr 25.5 mg ......... 43 nisoldipine tab sr 24hr 30 mg ............ 43 nisoldipine tab sr 24hr 34 mg ............ 43 nisoldipine tab sr 24hr 40 mg ............ 43 nisoldipine tab sr 24hr 8.5 mg ........... 43 NITRO-BID OIN 2% .......................... 40 NITRO-DUR DIS 0.3MG/HR ................ 40 NITRO-DUR DIS 0.8MG/HR ................ 40 nitrofurantoin macrocrystalline cap 100 mg ................................................. 65 nitrofurantoin macrocrystalline cap 50 mg ................................................. 65 nitrofurantoin monohydrate 150
macrocrystalline cap 100 mg ..............65 nitrofurantoin susp 25 mg/5ml ...........65 nitroglycerin cap cr 2.5 mg ................40 nitroglycerin cap cr 6.5 mg ................40 nitroglycerin cap cr 9 mg ...................40 nitroglycerin lingual aerosol 400 mcg/spray .......................................40 nitroglycerin td patch 24hr 0.1 mg/hr ..40 nitroglycerin td patch 24hr 0.2 mg/hr ..40 nitroglycerin td patch 24hr 0.4 mg/hr ..40 nitroglycerin td patch 24hr 0.6 mg/hr ..40 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) ......................................40 NITROSTAT SUB 0.3MG .....................40 NITROSTAT SUB 0.4MG .....................40 NITROSTAT SUB 0.6MG .....................40 nizatidine cap 150 mg .......................61 nizatidine cap 300 mg .......................61 nizatidine oral soln 15 mg/ml .............61 nora-be tab 0.35mg ..........................25 NORDITROPIN INJ 10/1.5ML ..............38 NORDITROPIN INJ 15/1.5ML ..............38 NORDITROPIN INJ 30/3ML .................38 NORDITROPIN INJ 5/1.5ML ................38 norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg ...........................28 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg ...................................27 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg ..............................28 norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) .......................29 norethindrone acetate tab 5 mg ..........31 norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg ..........................25 norethindrone tab 0.35 mg ................25 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg ......................................28 norgestimate-eth estrad tab 0.1825/0.215-25/0.25-25 mg-mcg ............30 norgestimate-eth estrad tab 0.1835/0.215-35/0.25-35 mg-mcg ............30 NORITATE CRE 1% ......................... 111 norlyroc tab 0.35mg ..........................25 NORPACE CAP 100MG CR ...................44 NORPACE CAP 150MG CR ...................44 nortrel tab 0.5/35 .............................27
nortrel tab 1/35 ............................... 27 nortrel tab 7/7/7 .............................. 30 nortriptyline hcl cap 10 mg ................ 72 nortriptyline hcl cap 25 mg ................ 72 nortriptyline hcl cap 50 mg ................ 72 nortriptyline hcl cap 75 mg ................ 72 nortriptyline hcl soln 10 mg/5ml ........ 72 NORVIR CAP 100MG ......................... 13 NORVIR SOL 80MG/ML...................... 13 NORVIR TAB 100MG ......................... 13 novarel inj 10000unt ........................ 37 NOVOLIN N INJ U-100 ...................... 32 NOVOLIN R INJ U-100 ...................... 32 NOVOLIN70/30 INJ RELION ............... 32 NOVOLOG INJ 100/ML ...................... 31 NOVOLOG INJ FLEXPEN..................... 31 NOVOLOG INJ PENFILL ..................... 31 NOVOLOG MIX INJ 70/30 .................. 32 NOVOLOG MIX INJ FLEXPEN .............. 32 NOVOSEVEN RT INJ 1MG ................ 104 NOVOSEVEN RT INJ 2MG ................ 104 NOVOSEVEN RT INJ 5MG ................ 104 NOVOSEVEN RT INJ 8MG ................ 104 NOXAFIL SUS 40MG/ML .................... 12 NOXAFIL TAB 100MG ........................ 12 np thyroid tab 30mg ......................... 36 np thyroid tab 60mg ......................... 36 NUCYNTA ER TAB 100MG .................. 85 NUCYNTA ER TAB 150MG .................. 85 NUCYNTA ER TAB 200MG .................. 85 NUCYNTA ER TAB 250MG .................. 85 NUCYNTA ER TAB 50MG .................... 85 NUCYNTA TAB 100MG ....................... 85 NUCYNTA TAB 50MG......................... 85 NUCYNTA TAB 75MG......................... 85 NUEDEXTA CAP 20-10MG .................. 81 NUPLAZID TAB 17MG ........................ 75 NUVARING MIS ................................ 25 NUVIGIL TAB 150MG ........................ 78 NUVIGIL TAB 200MG ........................ 78 NUVIGIL TAB 250MG ........................ 78 NUVIGIL TAB 50MG .......................... 78 nystatin cream 100000 unit/gm ....... 112 nystatin oint 100000 unit/gm .......... 112 nystatin susp 100000 unit/ml .......... 108 nystatin tab 500000 unit ................... 12 nystatin-triamcinolone cream 100000151
0.1 unit/gm-% ............................... 112 nystatin-triamcinolone oint 100000-0.1 unit/gm-% ..................................... 112 nystop pow 100000......................... 112 ocella tab 3-0.03mg ..........................26 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) ............................................38 octreotide acetate inj 1000 mcg/ml (1 mg/ml) ............................................38 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) ............................................38 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) ............................................38 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) ............................................38 ODEFSEY TAB ...................................14 ODOMZO CAP 200MG ........................18 OFEV CAP 100MG .............................60 OFEV CAP 150MG .............................60 ofloxacin ophth soln 0.3% ................ 105 ofloxacin otic soln 0.3% ................... 108 ofloxacin tab 400 mg .........................11 ogestrel tab .....................................28 olanzapine orally disintegrating tab 10 mg ..................................................74 olanzapine orally disintegrating tab 15 mg ..................................................74 olanzapine orally disintegrating tab 20 mg ..................................................74 olanzapine orally disintegrating tab 5 mg ......................................................74 olanzapine tab 10 mg ........................74 olanzapine tab 15 mg ........................74 olanzapine tab 2.5 mg .......................74 olanzapine tab 20 mg ........................74 olanzapine tab 5 mg ..........................74 olanzapine tab 7.5 mg .......................74 olanzapine-fluoxetine hcl cap 12-25 mg ......................................................81 olanzapine-fluoxetine hcl cap 12-50 mg ......................................................81 olanzapine-fluoxetine hcl cap 3-25 mg.81 olanzapine-fluoxetine hcl cap 6-25 mg.81 olanzapine-fluoxetine hcl cap 6-50 mg.81 olopatadine hcl nasal soln 0.6% ..........56 olopatadine hcl ophth soln 0.1% (base equivalent) .................................... 107
omega-3-acid ethyl esters cap 1 gm ... 54 omeprazole cap delayed release 10 mg62 omeprazole cap delayed release 20 mg62 omeprazole cap delayed release 40 mg62 omeprazole-sodium bicarbonate cap 401100 mg ......................................... 62 OMNARIS SPR.................................. 56 OMNIFLEX DPR .............................. 119 ondansetron hcl oral soln 4 mg/5ml .... 62 ondansetron hcl tab 24 mg ................ 62 ondansetron hcl tab 4 mg.................. 62 ondansetron hcl tab 8 mg.................. 62 ondansetron orally disintegrating tab 4 mg ................................................. 62 ondansetron orally disintegrating tab 8 mg ................................................. 62 ONETOUCH KIT ULT MINI ................ 118 ONETOUCH MIS LANC DEV .............. 118 ONETOUCH TES VERIO ................... 118 ONGLYZA TAB 2.5MG........................ 34 ONGLYZA TAB 5MG .......................... 34 opcicon tab 1.5mg ............................ 25 opium tincture 1% (10 mg/ml) (morphine equiv) ............................. 60 ORACIT SOL .................................... 67 ORAP TAB 1MG ................................ 79 ORAP TAB 2MG ................................ 79 ORAVIG TAB 50MG ......................... 108 ORENCIA INJ 125MG/ML ................... 89 ORFADIN CAP 10MG ......................... 39 ORFADIN CAP 20MG ......................... 39 ORFADIN CAP 2MG ........................... 39 ORFADIN CAP 5MG ........................... 39 ORFADIN SUS 4MG/ML ..................... 39 ORKAMBI TAB 200-125 ..................... 60 orphenadrine citrate tab sr 12hr 100 mg ...................................................... 96 orphenadrine w/ aspirin & caffeine tab 25-385-30 mg ................................. 96 orsythia tab ..................................... 26 ORTHO COIL DPR KIT 100 ............... 119 ORTHO COIL DPR KIT 105 ............... 119 ORTHO COIL DPR KIT 50................. 119 ORTHO FLAT DPR KIT 55 ................. 119 ORTHO FLAT DPR KIT 60 ................. 119 ORTHO FLAT DPR KIT 65 ................. 119 ORTHO FLAT DPR KIT 70 ................. 119 152
ORTHO FLAT DPR KIT 75 ................. 119 ORTHO FLAT DPR KIT 80 ................. 119 ORTHO FLAT DPR KIT 85 ................. 119 ORTHO FLAT DPR KIT 90 ................. 119 ORTHO FLAT DPR KIT 95 ................. 119 ORTHO TRI- TAB CYCLN LO ................30 OSENI TAB 12.5-15...........................35 OSENI TAB 12.5-30...........................35 OSENI TAB 12.5-45...........................35 OSENI TAB 25-15MG .........................35 OSENI TAB 25-30MG .........................35 OSENI TAB 25-45MG .........................35 OSMOPREP TAB 1.5GM ......................60 otic care dro ................................... 108 oticin dro 1-0.1%............................ 108 oxandrolone tab 10 mg ......................24 oxandrolone tab 2.5 mg.....................24 oxaprozin tab 600 mg .......................88 oxazepam cap 10 mg ........................68 oxazepam cap 15 mg ........................68 oxazepam cap 30 mg ........................68 oxcarbazepine susp 300 mg/5ml (60 mg/ml) ............................................93 oxcarbazepine tab 150 mg .................93 oxcarbazepine tab 300 mg .................93 oxcarbazepine tab 600 mg .................93 oxiconazole nitrate cream 1% .......... 112 OXISTAT CRE 1% ........................... 112 OXISTAT LOT 1%............................ 112 oxybutynin chloride syrup 5 mg/5ml ...65 oxybutynin chloride tab 5 mg .............65 oxybutynin chloride tab sr 24hr 10 mg 65 oxybutynin chloride tab sr 24hr 15 mg 65 oxybutynin chloride tab sr 24hr 5 mg ..65 oxycodone hcl cap 5 mg ....................84 oxycodone hcl conc 100 mg/5ml (20 mg/ml) ............................................84 oxycodone hcl soln 5 mg/5ml .............84 oxycodone hcl tab 10 mg ...................84 oxycodone hcl tab 15 mg ...................84 oxycodone hcl tab 20 mg ...................84 oxycodone hcl tab 30 mg ...................84 oxycodone hcl tab 5 mg .....................84 oxycodone w/ acetaminophen tab 10-325 mg ..................................................86 oxycodone w/ acetaminophen tab 2.5325 mg ...........................................86
oxycodone w/ acetaminophen tab 5-325 mg ................................................. 86 oxycodone w/ acetaminophen tab 7.5325 mg ........................................... 86 oxycodone-aspirin tab 4.8355-325 mg 86 oxycodone-ibuprofen tab 5-400 mg .... 86 OXYCONTIN TAB 10MG CR ................ 84 OXYCONTIN TAB 15MG CR ................ 84 OXYCONTIN TAB 20MG CR ................ 84 OXYCONTIN TAB 30MG CR ................ 84 OXYCONTIN TAB 40MG CR ................ 85 OXYCONTIN TAB 60MG CR ................ 85 OXYCONTIN TAB 80MG CR ................ 85 oxymorphone hcl tab 10 mg .............. 85 oxymorphone hcl tab 5 mg ................ 85 oxymorphone hcl tab sr 12hr 10 mg ... 85 oxymorphone hcl tab sr 12hr 15 mg ... 85 oxymorphone hcl tab sr 12hr 20 mg ... 85 oxymorphone hcl tab sr 12hr 30 mg ... 85 oxymorphone hcl tab sr 12hr 40 mg ... 85 oxymorphone hcl tab sr 12hr 5 mg ..... 85 oxymorphone hcl tab sr 12hr 7.5 mg .. 85 paliperidone tab sr 24hr 1.5 mg ......... 72 paliperidone tab sr 24hr 3 mg ............ 72 paliperidone tab sr 24hr 6 mg ............ 73 paliperidone tab sr 24hr 9 mg ............ 73 pancrelipase (lip-prot-amyl) dr cap 500017000-27000 unit ............................ 63 PANRETIN GEL 0.1% ...................... 113 pantoprazole sodium ec tab 20 mg (base equiv) ............................................. 62 pantoprazole sodium ec tab 40 mg (base equiv) ............................................. 62 paregoric tincture 2 mg/5ml .............. 60 paricalcitol cap 1 mcg ....................... 39 paricalcitol cap 2 mcg ....................... 39 paricalcitol cap 4 mcg ....................... 39 paromomycin sulfate cap 250 mg ....... 11 paroxetine hcl tab 10 mg .................. 70 paroxetine hcl tab 20 mg .................. 70 paroxetine hcl tab 30 mg .................. 70 paroxetine hcl tab 40 mg .................. 70 paroxetine hcl tab sr 24hr 12.5 mg..... 70 paroxetine hcl tab sr 24hr 25 mg ....... 70 paroxetine hcl tab sr 24hr 37.5 mg..... 70 PASER GRA 4GM .............................. 12 PATADAY SOL 0.2% ....................... 107 153
PATANOL SOL 0.1% OP ................... 107 PAXIL SUS 10MG/5ML .......................70 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm ................................60 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm ................................60 peg 3350-kcl-sod bicarb-nacl for soln 420 gm ...........................................60 PEGANONE TAB 250MG .....................91 PEGASYS INJ ....................................15 PEGASYS INJ 180MCG/M ...................15 PEGASYS INJ PROCLICK ....................15 PEG-INTRON KIT 120MCG ..................15 PEG-INTRON KIT 150 RP....................15 PEG-INTRON KIT 50MCG RP ...............15 PEG-INTRON KIT 80MCG ...................15 penicillin v potassium for soln 125 mg/5ml ............................................ 8 penicillin v potassium for soln 250 mg/5ml ............................................ 8 penicillin v potassium tab 250 mg ........ 8 penicillin v potassium tab 500 mg ........ 8 PENTASA CAP 250MG CR ...................63 PENTASA CAP 500MG CR ...................63 pentazocine w/ naloxone tab 50-0.5 mg ......................................................86 pentoxifylline tab cr 400 mg ............. 105 perindopril erbumine tab 2 mg ...........45 perindopril erbumine tab 4 mg ...........45 perindopril erbumine tab 8 mg ...........45 periogard sol 0.12% ........................ 108 periomed con 0.63% ....................... 109 permethrin cream 5% ..................... 117 perphenazine tab 16 mg ....................74 perphenazine tab 2 mg ......................74 perphenazine tab 4 mg ......................74 perphenazine tab 8 mg ......................74 perphenazine-amitriptyline tab 2-10 mg ......................................................81 perphenazine-amitriptyline tab 2-25 mg ......................................................81 perphenazine-amitriptyline tab 4-10 mg ......................................................81 perphenazine-amitriptyline tab 4-25 mg ......................................................81 perphenazine-amitriptyline tab 4-50 mg ......................................................81
phenazopyridine hcl tab 100 mg ........ 67 phenazopyridine hcl tab 200 mg ........ 67 phenelzine sulfate tab 15 mg ............. 69 phenobarbital elixir 20 mg/5ml .......... 76 phenobarbital tab 100 mg ................. 76 phenobarbital tab 15 mg ................... 76 phenobarbital tab 16.2 mg ................ 76 phenobarbital tab 30 mg ................... 76 phenobarbital tab 32.4 mg ................ 76 phenobarbital tab 60 mg ................... 76 phenobarbital tab 64.8 mg ................ 76 phenobarbital tab 97.2 mg ................ 76 phenoxybenzamine hcl cap 10 mg ...... 47 phenytoin chew tab 50 mg ................ 91 phenytoin sodium extended cap 100 mg ...................................................... 91 phenytoin susp 125 mg/5ml .............. 91 philith tab 0.4-35 ............................. 27 phospha 250 tab neutral ................... 98 PHOSPHOLINE SOL 0.125%OP ......... 107 physiosol sol irrigat ........................ 120 PICATO GEL 0.015% ...................... 113 PICATO GEL 0.05% ........................ 113 pilocarpine hcl ophth soln 1% .......... 107 pilocarpine hcl ophth soln 2% .......... 107 pilocarpine hcl ophth soln 4% .......... 107 pilocarpine hcl tab 5 mg .................. 109 pilocarpine hcl tab 7.5 mg ............... 109 pimozide tab 1 mg ........................... 79 pimozide tab 2 mg ........................... 79 pimtrea tab ..................................... 29 pindolol tab 10 mg ........................... 41 pindolol tab 5 mg ............................. 41 PINNACAINE DRO 20% OTIC ........... 108 pioglitazone hcl tab 15 mg (base equiv) ...................................................... 34 pioglitazone hcl tab 30 mg (base equiv) ...................................................... 34 pioglitazone hcl tab 45 mg (base equiv) ...................................................... 34 pioglitazone hcl-glimepiride tab 30-2 mg ...................................................... 35 pioglitazone hcl-glimepiride tab 30-4 mg ...................................................... 35 pioglitazone hcl-metformin hcl tab 15500 mg ........................................... 35 pioglitazone hcl-metformin hcl tab 15154
850 mg ...........................................35 pirmella tab 1/35 ..............................27 pirmella tab 7/7/7 .............................30 piroxicam cap 10 mg .........................88 piroxicam cap 20 mg .........................88 plan b tab 1.5mg ..............................25 podofilox soln 0.5% ........................ 116 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% ....................... 105 polysacchari cap iron ....................... 101 portia-28 tab ....................................27 pot bicarbonate & chloride effer tab 25 meq ................................................99 POTABA CAP 500MG ..........................96 POTABA TAB 500MG ..........................96 potassium aminobenzoate packet 2 gm ......................................................96 potassium chloride cap cr 10 meq .......98 potassium chloride cap cr 8 meq .........98 potassium chloride microencapsulated crys cr tab 10 meq ............................99 potassium chloride microencapsulated crys cr tab 20 meq ............................99 potassium chloride oral soln 10% (20 meq/15ml) .......................................98 potassium chloride oral soln 20% (40 meq/15ml) .......................................98 potassium chloride powder packet 20 meq ................................................98 potassium chloride tab cr 10 meq .......98 potassium chloride tab cr 8 meq (600 mg) ................................................98 potassium citrate & citric acid powder pack 3300-1002 mg ..........................67 potassium citrate tab cr 10 meq (1080 mg) ................................................67 potassium citrate tab cr 15 meq (1620 mg) ................................................67 potassium citrate tab cr 5 meq (540 mg) ......................................................67 POTIGA TAB 200MG ..........................92 POTIGA TAB 300MG ..........................92 POTIGA TAB 400MG ..........................92 POTIGA TAB 50MG ............................92 pr benzoyl liq 7% wash.................... 109 PRADAXA CAP 110MG ...................... 102 PRADAXA CAP 150MG ...................... 102
PRADAXA CAP 75MG ....................... 102 PRALUENT INJ 150MG/ML ................. 52 PRALUENT INJ 75MG/ML ................... 52 pramcort cre 1-1% ......................... 109 pramipexole dihydrochloride tab 0.125 mg ................................................. 94 pramipexole dihydrochloride tab 0.25 mg ...................................................... 94 pramipexole dihydrochloride tab 0.5 mg ...................................................... 94 pramipexole dihydrochloride tab 0.75 mg ...................................................... 94 pramipexole dihydrochloride tab 1 mg 94 pramipexole dihydrochloride tab 1.5 mg ...................................................... 94 PRAMOSONE LOT 1% ..................... 116 PRAMOSONE LOT 2.5% ................... 116 PRAMOSONE OIN 1% ..................... 116 PRAMOTIC DRO 1-0.1% .................. 108 pramoxine-hc cream 1-2.5% ........... 115 pravastatin sodium tab 10 mg ........... 53 pravastatin sodium tab 20 mg ........... 53 pravastatin sodium tab 40 mg ........... 53 pravastatin sodium tab 80 mg ........... 53 prazosin hcl cap 1 mg ....................... 46 prazosin hcl cap 2 mg ....................... 46 prazosin hcl cap 5 mg ....................... 46 PRED MILD SUS 0.12% OP .............. 106 PRED SOD PHO SOL 1% OP ............. 106 PRED-G S.O.P OIN OP ..................... 106 PRED-G SUS OP ............................. 106 prednicarbate cream 0.1% .............. 115 prednicarbate oint 0.1% ................. 115 prednisolone acetate ophth susp 1% 106 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) .................. 23 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) ........................ 23 prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) ........................ 23 prednisolone syrup 15 mg/5ml (usp solution equivalent) .......................... 22 PREDNISONE CON 5MG/ML ............... 23 prednisone oral soln 5 mg/5ml ........... 23 prednisone tab 1 mg......................... 23 prednisone tab 10 mg ....................... 23 prednisone tab 2.5 mg ...................... 23 155
prednisone tab 20 mg .......................23 prednisone tab 5 mg .........................23 prednisone tab 50 mg .......................23 prednisone tab therapy pack 10 mg (21) ......................................................23 prednisone tab therapy pack 10 mg (48) ......................................................23 prednisone tab therapy pack 5 mg (21) ......................................................23 prednisone tab therapy pack 5 mg (48) ......................................................23 pregnyl inj 10000unt .........................37 PREMARIN TAB 0.3MG .......................24 PREMARIN TAB 0.45MG .....................24 PREMARIN TAB 0.625MG ...................24 PREMARIN TAB 0.9MG .......................24 PREMARIN TAB 1.25MG .....................24 PREMARIN VAG CRE 0.625MG ............66 PREMPHASE TAB ...............................25 PREMPRO TAB .625-2.5 .....................24 PREMPRO TAB 0.3-1.5 .......................24 PREMPRO TAB 0.45-1.5 .....................24 PREMPRO TAB 0.625-5 ......................24 prenatal 19 tab .................................97 PRENTIF MIS 25MM ......................... 118 PRENTIF MIS 28MM ......................... 118 PRENTIF MIS 31MM ......................... 119 PRENTIF MIS FITTING ..................... 119 PREPOPIK PAK ..................................60 previfem tab ....................................28 PREZISTA SUS 100MG/ML..................13 PREZISTA TAB 150MG .......................13 PREZISTA TAB 600MG .......................13 PREZISTA TAB 75MG .........................13 PREZISTA TAB 800MG .......................13 PRIFTIN TAB 150MG ..........................12 PRILOSEC POW 10MG .......................62 PRILOSEC POW 2.5MG ......................62 PRIMAQUINE TAB 26.3MG ..................16 primidone tab 250 mg .......................93 primidone tab 50 mg .........................93 PRISTIQ TAB 100MG .........................70 PRISTIQ TAB 25MG ...........................70 PRISTIQ TAB 50MG ...........................70 PROAIR RESPI AER ...........................57 probenecid tab 500 mg ......................91 prochlorperazine maleate tab 10 mg
(base equivalent) ............................. 75 prochlorperazine maleate tab 5 mg (base equivalent) ...................................... 75 PROCRIT INJ 10000/ML................... 100 PROCRIT INJ 2000/ML .................... 100 PROCRIT INJ 20000/ML................... 100 PROCRIT INJ 3000/ML .................... 100 PROCRIT INJ 4000/ML .................... 100 PROCRIT INJ 40000/ML................... 100 PROCTOFOAM AER HC 1%............... 109 procto-pak cre 1% ......................... 109 proctozone cre -hc 2.5% ................. 109 PROFILNINE INJ 1000UNIT .............. 104 PROFILNINE INJ 1500UNIT .............. 104 PROFILNINE INJ 500UNIT................ 104 progesterone im in oil 50 mg/ml ........ 31 progesterone micronized cap 100 mg . 31 progesterone micronized cap 200 mg . 31 PROGESTERONE SUP VGS 100 ........... 66 PROGESTERONE SUP VGS 200 ........... 66 PROGESTERONE SUP VGS 25 ............ 66 PROGESTERONE SUP VGS 400 ........... 66 PROGESTERONE SUP VGS 50 ............ 66 PROGLYCEM SUS 50MG/ML ............... 33 PROMACTA TAB 12.5MG .................. 100 PROMACTA TAB 25MG .................... 100 PROMACTA TAB 50MG .................... 100 PROMACTA TAB 75MG .................... 100 prometh vc syp plain ........................ 56 prometh vc/ syp codeine ................... 57 promethazine hcl suppos 12.5 mg ...... 55 promethazine hcl suppos 25 mg ......... 55 promethazine hcl syrup 6.25 mg/5ml.. 55 promethazine hcl tab 12.5 mg ........... 55 promethazine hcl tab 25 mg .............. 55 promethazine hcl tab 50 mg .............. 55 promethazine w/ codeine syrup 6.25-10 mg/5ml ........................................... 57 promethazine-dm syrup 6.25-15 mg/5ml ...................................................... 57 promethegan sup 50mg .................... 55 propafenone hcl cap sr 12hr 225 mg... 44 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 .............. 44 156
propantheline bromide tab 15 mg .......61 proparacaine hcl ophth soln 0.5% ..... 107 propranolol & hydrochlorothiazide tab 40-25 mg ........................................48 propranolol & hydrochlorothiazide tab 80-25 mg ........................................48 propranolol hcl cap sr 24hr 120 mg .....41 propranolol hcl cap sr 24hr 160 mg .....41 propranolol hcl cap sr 24hr 60 mg .......41 propranolol hcl cap sr 24hr 80 mg .......41 propranolol hcl oral soln 20 mg/5ml ....41 propranolol hcl oral soln 40 mg/5ml ....41 propranolol hcl tab 10 mg ..................41 propranolol hcl tab 20 mg ..................41 propranolol hcl tab 40 mg ..................41 propranolol hcl tab 60 mg ..................41 propranolol hcl tab 80 mg ..................41 propylthiouracil tab 50 mg .................37 protriptyline hcl tab 10 mg .................72 protriptyline hcl tab 5 mg...................72 prudoxin cre 5% ............................. 112 PTS PANELS TES KETONE ................ 118 pulmosal neb 7% ..............................56 PULMOZYME SOL 1MG/ML ..................60 pyrazinamide tab 500 mg ..................12 pyridostigmine bromide tab 60 mg ......96 pyridostigmine bromide tab cr 180 mg 96 QNASL AER 80MCG ...........................56 QNASL CHILD SPR 40MCG .................56 QUARTETTE TAB ...............................31 quasense tab ....................................31 quetiapine fumarate tab 100 mg .........73 quetiapine fumarate tab 200 mg .........73 quetiapine fumarate tab 25 mg...........73 quetiapine fumarate tab 300 mg .........73 quetiapine fumarate tab 400 mg .........73 quetiapine fumarate tab 50 mg...........73 quinapril hcl tab 10 mg ......................45 quinapril hcl tab 20 mg ......................45 quinapril hcl tab 40 mg ......................45 quinapril hcl tab 5 mg........................45 quinapril-hydrochlorothiazide tab 10-12.5 mg ..................................................48 quinapril-hydrochlorothiazide tab 20-12.5 mg ..................................................48 quinapril-hydrochlorothiazide tab 20-25 mg ..................................................48
quinidine gluconate tab cr 324 mg...... 44 quinidine sulfate tab 200 mg ............. 44 quinidine sulfate tab 300 mg ............. 44 quinidine sulfate tab cr 300 mg .......... 44 quinine sulfate cap 324 mg ............... 16 QVAR AER 40MCG ............................ 59 QVAR AER 80MCG ............................ 59 rabeprazole sodium ec tab 20 mg ....... 62 raloxifene hcl tab 60 mg ................... 37 ramipril cap 1.25 mg ........................ 45 ramipril cap 10 mg ........................... 45 ramipril cap 2.5 mg .......................... 45 ramipril cap 5 mg ............................. 45 RANEXA TAB 1000MG ....................... 40 RANEXA TAB 500MG ......................... 40 ranitidine hcl cap 300 mg .................. 61 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ......................................... 61 ranitidine hcl tab 300 mg .................. 61 RAPAFLO CAP 4MG ........................... 67 RAPAFLO CAP 8MG ........................... 67 RAPAMUNE SOL 1MG/ML ................. 120 rea lo 40 lot 40% ........................... 116 react tab 1.5mg ............................... 25 REBETOL SOL 40MG/ML .................... 15 reclipsen tab .................................... 26 RECOMBINATE INJ ......................... 103 RECOMBINATE INJ 220-400............. 103 RECOMBINATE INJ 401-800............. 103 RECOMBINATE INJ 801-1240 ........... 103 RECTIV OIN 0.4% .......................... 109 REGRANEX GEL 0.01% ................... 117 relagard gel ..................................... 67 RELENZA MIS DISKHALE ................... 16 RELION LANCE MIS THIN 26G.......... 118 RELISTOR INJ 12/0.6ML .................... 64 RELISTOR INJ 8/0.4ML ..................... 64 RELPAX TAB 20MG ........................... 89 RELPAX TAB 40MG ........................... 89 remeven cre 50% .......................... 116 RENAGEL TAB 400MG ....................... 65 RENAGEL TAB 800MG ....................... 65 reno cap ......................................... 97 RENVELA PAK 0.8GM ........................ 65 RENVELA PAK 2.4GM ........................ 65 RENVELA TAB 800MG ....................... 65 repaglinide tab 0.5 mg ...................... 33 157
repaglinide tab 1 mg .........................33 repaglinide tab 2 mg .........................33 REPATHA INJ 140MG/ML ....................52 REPATHA PUSH INJ 420/3.5 ...............52 REPATHA SURE INJ 140MG/ML ...........52 RESCRIPTOR TAB 100 MG ..................14 RESCRIPTOR TAB 200MG ...................14 reserpine tab 0.1 mg .........................46 reserpine tab 0.25 mg .......................46 RESTASIS EMU 0.05% ..................... 107 REVATIO SUS 10MG/ML .....................54 REVLIMID CAP 10MG ....................... 119 REVLIMID CAP 15MG ....................... 119 REVLIMID CAP 2.5MG ...................... 119 REVLIMID CAP 20MG ....................... 119 REVLIMID CAP 25MG ....................... 119 REVLIMID CAP 5MG ........................ 119 REYATAZ CAP 150MG ........................13 REYATAZ CAP 200MG ........................13 REYATAZ CAP 300MG ........................13 REYATAZ POW 50MG .........................13 ribasphere tab 400mg .......................15 ribasphere tab 600mg .......................15 ribavirin cap 200 mg .........................15 ribavirin tab 200 mg..........................15 RIDAURA CAP 3MG ...........................88 rifabutin cap 150 mg .........................12 RIFAMATE CAP .................................12 rifampin cap 150 mg .........................12 rifampin cap 300 mg .........................12 RIFATER TAB ....................................12 riluzole tab 50 mg .............................95 rimantadine hydrochloride tab 100 mg 15 ringer's solution for irrigation ........... 120 risedronate sodium tab 150 mg ..........37 risedronate sodium tab 30 mg ............37 risedronate sodium tab 35 mg ............37 risedronate sodium tab 5 mg ..............37 risperidone orally disintegrating tab 0.25 mg ..................................................73 risperidone orally disintegrating tab 0.5 mg ..................................................73 risperidone soln 1 mg/ml ...................73 risperidone tab 0.25 mg ....................73 risperidone tab 0.5 mg ......................73 risperidone tab 1 mg .........................73 risperidone tab 1mg odt ....................73
risperidone tab 2 mg ........................ 73 risperidone tab 2mg odt .................... 73 risperidone tab 3 mg ........................ 73 risperidone tab 3mg odt .................... 73 risperidone tab 4 mg ........................ 73 risperidone tab 4mg odt .................... 73 rivastigmine tartrate cap 1.5 mg ........ 79 rivastigmine tartrate cap 3 mg ........... 79 rivastigmine tartrate cap 4.5 mg ........ 79 rivastigmine tartrate cap 6 mg ........... 79 rizatriptan benzoate oral disintegrating tab 10 mg (base eq) ......................... 90 rizatriptan benzoate oral disintegrating tab 5 mg (base eq)........................... 90 rizatriptan benzoate tab 10 mg (base equivalent) ...................................... 89 rizatriptan benzoate tab 5 mg (base equivalent) ...................................... 89 ropinirole hydrochloride tab 0.25 mg .. 94 ropinirole hydrochloride tab 0.5 mg .... 94 ropinirole hydrochloride tab 1 mg ....... 94 ropinirole hydrochloride tab 2 mg ....... 94 ropinirole hydrochloride tab 3 mg ....... 94 ropinirole hydrochloride tab 4 mg ....... 94 ropinirole hydrochloride tab 5 mg ....... 94 ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) ........................ 95 ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) ............................. 94 ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) ............................. 94 ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) ............................. 94 ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) ............................. 94 rosula pad 10-5% .......................... 111 rosuvastatin calcium tab 10 mg ......... 53 rosuvastatin calcium tab 20 mg ......... 53 rosuvastatin calcium tab 40 mg ......... 53 rosuvastatin calcium tab 5 mg ........... 53 ROXICET SOL 5-325/5 ...................... 86 ROZEREM TAB 8MG .......................... 76 SABRIL POW 500MG ......................... 91 SABRIL TAB 500MG .......................... 91 SAFYRAL TAB................................... 28 salicylic ac liq 27.5% ...................... 116 salicylic acid cream 6% ................... 116 158
salicylic acid cream 6% & cleanser liqd kit ................................................. 116 salicylic acid foam 6% ..................... 116 salicylic acid gel 6% ........................ 116 salicylic acid in ammonium lactate vehicle foam 6% ............................. 116 salicylic acid lotion 6% .................... 116 salicylic acid lotion 6% & cleanser liqd kit .................................................... 116 salicylic acid shampoo 6% ............... 116 salsalate tab 500 mg .........................82 salsalate tab 750 mg .........................82 SAMSCA TAB 15MG ...........................39 SAMSCA TAB 30MG ...........................39 SANDOSTATIN KIT LAR 10MG ............38 SANDOSTATIN KIT LAR 20MG ............38 SANDOSTATIN KIT LAR 30MG ............38 SANTYL OIN 250/GM ....................... 116 SAPHRIS SUB 10MG ..........................74 SAPHRIS SUB 2.5MG .........................74 SAPHRIS SUB 5MG............................74 SAVELLA MIS TITR PAK .....................81 SAVELLA TAB 100MG ........................81 SAVELLA TAB 12.5MG .......................81 SAVELLA TAB 25MG ..........................81 SAVELLA TAB 50MG ..........................81 scalacort lot 2%.............................. 115 selegiline hcl cap 5 mg ......................95 selegiline hcl tab 5 mg .......................95 selenium sulfide lotion 2.5% ............ 113 selenium sulfide-pyrithione zinc in urea shampoo 2.25% ............................. 113 SELZENTRY TAB 150MG .....................13 SELZENTRY TAB 300MG .....................13 SENSIPAR TAB 30MG ........................39 SENSIPAR TAB 60MG ........................39 SENSIPAR TAB 90MG ........................39 SEREVENT DIS AER 50MCG ................58 SEROQUEL XR TAB 150MG .................74 SEROQUEL XR TAB 200MG .................74 SEROQUEL XR TAB 300MG .................74 SEROQUEL XR TAB 400MG .................74 SEROQUEL XR TAB 50MG...................74 SEROSTIM INJ 4MG...........................38 SEROSTIM INJ 5MG...........................38 SEROSTIM INJ 6MG...........................38 sertraline hcl oral conc 20 mg/ml ........70
sertraline hcl tab 100 mg .................. 70 sertraline hcl tab 25 mg .................... 70 sertraline hcl tab 50 mg .................... 70 setlakin tab ..................................... 31 sharobel tab 0.35mg ........................ 25 SHUR-SEAL GEL 2% ......................... 66 SIGNIFOR INJ 0.3MG/ML ................... 38 SIGNIFOR INJ 0.6MG/ML ................... 38 SIGNIFOR INJ 0.9MG/ML ................... 38 sildenafil citrate tab 20 mg ................ 54 SILVER NITRA OIN 10% .................. 113 SILVER NITRA SOL 0.5% ................ 113 SILVER NITRA SOL 10% ................. 113 SILVER NITRA SOL 25% ................. 113 SILVER NITRA SOL 50% ................. 113 silver sulfadiazine cream 1% ........... 113 SIMCOR TAB 1000-20 ....................... 53 SIMCOR TAB 1000-40 ....................... 53 SIMCOR TAB 500-20MG .................... 53 SIMCOR TAB 500-40MG .................... 53 SIMCOR TAB 750-20MG .................... 53 SIMPONI INJ 100MG/ML .................... 88 SIMPONI INJ 50/0.5ML ..................... 88 simvastatin tab 10 mg ...................... 53 simvastatin tab 20 mg ...................... 53 simvastatin tab 40 mg ...................... 53 simvastatin tab 5 mg ........................ 53 simvastatin tab 80 mg ...................... 53 sirolimus tab 0.5 mg ....................... 120 sirolimus tab 1 mg ......................... 120 sirolimus tab 2 mg ......................... 120 SIVEXTRO TAB 200MG ...................... 17 SKLICE LOT 0.5% .......................... 117 sodium chloride irrigation soln 0.9% ... 67 sodium chloride soln nebu 0.9% ........ 56 sodium chloride soln nebu 10% ......... 56 sodium chloride soln nebu 3% ........... 56 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) .......................... 97 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) ..................................... 97 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) ................................ 98 sodium fluoride tab 0.5 mg f (from 1.1 mg naf) .......................................... 97 sodium fluoride tab 1 mg f (from 2.2 mg naf) ................................................ 97 159
sodium phenylbutyrate oral powder 3 gm/teaspoonful ................................39 sodium polystyrene sulfonate oral susp 15 gm/60ml ................................... 120 sodium polystyrene sulfonate powder 120 sodium polystyrene sulfonate rectal susp 30 gm/120ml ................................. 120 sojourn sol .......................................91 solia tab ..........................................26 SOLTAMOX SOL 10MG/5ML ................19 SOMATULINE INJ 120/.5ML ................38 SOMATULINE INJ 60/0.2ML ................38 SOMATULINE INJ 90/0.3ML ................38 SOMAVERT INJ 10MG ........................38 SOMAVERT INJ 15MG ........................38 SOMAVERT INJ 20MG ........................38 SOMAVERT INJ 25MG ........................38 SOMAVERT INJ 30MG ........................38 SOOLANTRA CRE 1% ...................... 111 sorine tab 120mg..............................41 sorine tab 160mg..............................41 sorine tab 240mg..............................41 sorine tab 80mg ...............................41 sotalol hcl (afib/afl) tab 120 mg ..........41 sotalol hcl (afib/afl) tab 160 mg ..........41 sotalol hcl (afib/afl) tab 80 mg ...........41 SOVALDI TAB 400MG ........................15 spinosad susp 0.9% ........................ 117 SPIRIVA AER 1.25MCG ......................57 SPIRIVA CAP HANDIHLR ....................57 SPIRIVA SPR 2.5MCG ........................57 spironolactone & hydrochlorothiazide tab 25-25 mg ........................................51 spironolactone tab 100 mg .................51 spironolactone tab 25 mg ..................51 spironolactone tab 50 mg ..................51 sprintec 28 tab 28 day .......................28 SPRYCEL TAB 100MG ........................21 SPRYCEL TAB 140MG ........................21 SPRYCEL TAB 20MG ..........................20 SPRYCEL TAB 50MG ..........................20 SPRYCEL TAB 70MG ..........................20 SPRYCEL TAB 80MG ..........................21 sronyx tab .......................................27 sss cre 10%-5% ............................. 111 ST JOSEPH CHW 75MG ADU ...............82 stavudine cap 15 mg .........................13
stavudine cap 20 mg ........................ 14 stavudine cap 30 mg ........................ 14 stavudine cap 40 mg ........................ 14 stavudine for oral soln 1 mg/ml ......... 14 STIMATE SOL 1.5MG/ML ................... 39 STIVARGA TAB 40MG ....................... 20 STRATTERA CAP 100MG .................... 78 STRATTERA CAP 10MG ...................... 78 STRATTERA CAP 18MG ...................... 78 STRATTERA CAP 25MG ...................... 78 STRATTERA CAP 40MG...................... 78 STRATTERA CAP 60MG ...................... 78 STRATTERA CAP 80MG ...................... 78 STRENSIQ INJ 18/0.45 ..................... 39 STRENSIQ INJ 28/0.7ML ................... 39 STRENSIQ INJ 40MG/ML ................... 39 STRENSIQ INJ 80/0.8ML ................... 39 STRIBILD TAB.................................. 14 SUBOXONE MIS 12-3MG ................... 85 SUBOXONE MIS 2-0.5MG .................. 85 SUBOXONE MIS 4-1MG ..................... 85 SUBOXONE MIS 8-2MG ..................... 85 SUCRAID SOL 8500/ML ..................... 63 sucralfate tab 1 gm .......................... 62 sulfacetamide sodium liquid 10% ..... 113 sulfacetamide sodium lotion 10% (acne) .................................................... 110 sulfacetamide sodium ophth oint 10% .................................................... 105 sulfacetamide sodium ophth soln 10% .................................................... 105 sulfacetamide sodium w/ sulfur cleansing pad 10-4% .................................... 111 sulfacetamide sodium w/ sulfur emulsion 10-5% .......................................... 111 sulfacetamide sodium w/ sulfur foam 105% ............................................... 111 sulfacetamide sodium w/ sulfur lotion 105% ............................................... 111 sulfacetamide sodium w/ sulfur susp 84% ............................................... 111 sulfacetamide sodium w/ sulfur wash 94.5% ............................................ 111 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% ............. 106 sulfacetamide sodium-sulfur in urea gel 10-5% .......................................... 111 160
SULFADIAZINE TAB 500MG ................12 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml ................................17 sulfamethoxazole-trimethoprim tab 40080 mg .............................................17 sulfamethoxazole-trimethoprim tab 800160 mg ...........................................17 SULFAMYLON CRE 85MG/GM ............ 113 sulfasalazin tab 500mg dr ..................64 sulfasalazine tab 500 mg ...................64 sulindac tab 150 mg ..........................88 sulindac tab 200 mg ..........................88 sumatriptan nasal spray 20 mg/act .....90 sumatriptan nasal spray 5 mg/act .......90 sumatriptan succinate inj 4 mg/0.5ml .90 sumatriptan succinate inj 6 mg/0.5ml .90 sumatriptan succinate solution autoinjector 4 mg/0.5ml ..........................90 sumatriptan succinate solution autoinjector 6 mg/0.5ml ..........................90 sumatriptan succinate solution cartridge 4 mg/0.5ml ......................................90 sumatriptan succinate solution cartridge 6 mg/0.5ml ......................................90 sumatriptan succinate solution prefilled syringe 6 mg/0.5ml ...........................90 sumatriptan succinate tab 100 mg ......90 sumatriptan succinate tab 25 mg ........90 sumatriptan succinate tab 50 mg ........90 SUPRAX CAP 400MG ........................... 9 SUPRAX CHW 100MG ......................... 9 SUPRAX CHW 200MG ......................... 9 SUPRAX SUS 500/5ML ........................ 9 SUPREP BOWEL SOL PREP .................60 SURMONTIL CAP 100MG ....................72 SURMONTIL CAP 25MG ......................72 SURMONTIL CAP 50MG ......................72 SUSTIVA CAP 200MG ........................14 SUSTIVA CAP 50MG ..........................14 SUSTIVA TAB 600MG ........................14 SUTENT CAP 12.5MG .........................20 SUTENT CAP 25MG ...........................20 SUTENT CAP 37.5MG .........................20 SUTENT CAP 50MG ...........................20 syeda tab 3-0.03mg ..........................26 symax fastab tab 0.125mg.................61 symax-sl sub 0.125mg ......................60
symax-sr tab 0.375mg...................... 61 SYMBICORT AER 160-4.5 .................. 58 SYMBICORT AER 80-4.5 .................... 58 SYMLINPEN 60 INJ 1000MCG ............. 32 SYMLNPEN 120 INJ 1000MCG ............ 32 SYNAREL SOL 2MG/ML ...................... 38 SYNERA DIS 70-70MG .................... 117 SYNJARDY TAB ................................ 35 SYNJARDY TAB 12.5-500................... 35 SYNJARDY TAB 5-1000MG ................. 35 SYNJARDY TAB 5-500MG................... 35 SYPRINE CAP 250MG ...................... 119 TABLOID TAB 40MG ......................... 18 TACLONEX SUS .............................. 116 tacrolimus cap 0.5 mg .................... 120 tacrolimus cap 1 mg ....................... 120 tacrolimus cap 5 mg ....................... 120 tacrolimus oint 0.03% .................... 117 tacrolimus oint 0.1% ...................... 117 TAFINLAR CAP 50MG ........................ 20 TAFINLAR CAP 75MG ........................ 20 TAGRISSO TAB 40MG ....................... 21 TAGRISSO TAB 80MG ....................... 21 take action tab 1.5mg ....................... 25 TAMIFLU CAP 30MG .......................... 15 TAMIFLU CAP 45MG .......................... 15 TAMIFLU CAP 75MG .......................... 16 TAMIFLU SUS 6MG/ML ...................... 16 tamoxifen citrate tab 10 mg (base equivalent) ...................................... 19 tamoxifen citrate tab 20 mg (base equivalent) ...................................... 19 tamsulosin hcl cap 0.4 mg ................. 67 TARCEVA TAB 100MG ....................... 21 TARCEVA TAB 150MG ....................... 21 TARCEVA TAB 25MG ......................... 21 TARGRETIN GEL 1% ....................... 113 tarina fe tab 1/20 ............................. 28 TASIGNA CAP 150MG ....................... 21 TASIGNA CAP 200MG ....................... 21 TAZORAC CRE 0.05% ..................... 112 TAZORAC CRE 0.1% ....................... 113 TAZORAC GEL 0.05% ..................... 113 TAZORAC GEL 0.1% ....................... 113 taztia xt cap 360mg/24 ..................... 42 tbc aer .......................................... 116 TECFIDERA CAP 120MG .................... 81 161
TECFIDERA CAP 240MG .....................81 TECFIDERA MIS STARTER ..................81 TEGRETOL-XR TAB 100MG .................92 TEKTURNA HCT TAB 150-12.5 ............50 TEKTURNA HCT TAB 150-25MG ..........50 TEKTURNA HCT TAB 300-12.5 ............50 TEKTURNA HCT TAB 300-25MG ..........50 TEKTURNA TAB 150MG ......................46 TEKTURNA TAB 300MG ......................46 telmisartan tab 20 mg .......................46 telmisartan tab 40 mg .......................46 telmisartan tab 80 mg .......................46 telmisartan-hydrochlorothiazide tab 4012.5 mg ..........................................49 telmisartan-hydrochlorothiazide tab 8012.5 mg ..........................................49 telmisartan-hydrochlorothiazide tab 8025 mg .............................................49 temazepam cap 15 mg ......................76 temazepam cap 22.5 mg ...................76 temazepam cap 30 mg ......................76 temazepam cap 7.5 mg .....................76 temozolomide cap 100 mg .................17 temozolomide cap 140 mg .................17 temozolomide cap 180 mg .................17 temozolomide cap 20 mg ...................17 temozolomide cap 250 mg .................18 temozolomide cap 5 mg .....................17 terazosin hcl cap 1 mg.......................46 terazosin hcl cap 10 mg .....................46 terazosin hcl cap 2 mg.......................46 terazosin hcl cap 5 mg.......................46 terbinafine hcl tab 250 mg .................12 terbutaline sulfate tab 2.5 mg ............58 terbutaline sulfate tab 5 mg ...............58 terrell sol .........................................91 testosterone cypionate im inj in oil 100 mg/ml .............................................23 testosterone cypionate im inj in oil 200 mg/ml .............................................23 testosterone enanthate im inj in oil 200 mg/ml .............................................23 testosterone td gel 12.5 mg/act (1%) .23 testosterone td gel 25 mg/2.5gm (1%)23 testosterone td gel 50 mg/5gm (1%) ..23 tetrabenazine tab 12.5 mg .................80 tetrabenazine tab 25 mg ....................80
tetracaine hcl ophth soln 0.5% ........ 107 tetracycline hcl cap 250 mg ............... 11 tetracycline hcl cap 500 mg ............... 11 TGT GLUCOSE CHW ORANGE ............. 33 THALOMID CAP 100MG ................... 119 THALOMID CAP 150MG ................... 119 THALOMID CAP 200MG ................... 119 THALOMID CAP 50MG ..................... 119 THEO-24 CAP 100MG CR ................... 58 THEO-24 CAP 200MG CR ................... 58 THEO-24 CAP 300MG CR ................... 58 THEO-24 CAP 400MG ER ................... 58 theophylline soln 80 mg/15ml ............ 58 theophylline tab sr 12hr 100 mg ........ 58 theophylline tab sr 12hr 200 mg ........ 58 theophylline tab sr 12hr 300 mg ........ 58 theophylline tab sr 12hr 450 mg ........ 58 theophylline tab sr 24hr 400 mg ........ 58 theophylline tab sr 24hr 600 mg ........ 58 thioridazine hcl tab 10 mg ................. 75 thioridazine hcl tab 100 mg ............... 75 thioridazine hcl tab 25 mg ................. 75 thioridazine hcl tab 50 mg ................. 75 thiothixene cap 1 mg ........................ 75 thiothixene cap 10 mg ...................... 75 thiothixene cap 2 mg ........................ 75 thiothixene cap 5 mg ........................ 75 THYROID POW ................................. 36 THYROLAR-1 TAB 60MG .................... 36 THYROLAR-1/2 TAB 30MG ................. 36 THYROLAR-1/4 TAB 15MG ................. 36 THYROLAR-2 TAB 120MG .................. 36 THYROLAR-3 TAB 180MG .................. 36 tiagabine hcl tab 2 mg ...................... 91 tiagabine hcl tab 4 mg ...................... 91 ticlopidine hcl tab 250 mg ............... 104 TIKOSYN CAP 125MCG ...................... 44 TIKOSYN CAP 250MCG ...................... 44 TIKOSYN CAP 500MCG ...................... 44 tilia fe tab ....................................... 30 timolol maleate ophth gel forming soln 0.25% .......................................... 105 timolol maleate ophth gel forming soln 0.5% ............................................ 105 timolol maleate ophth soln 0.25% .... 105 timolol maleate ophth soln 0.5% ...... 105 timolol maleate tab 10 mg ................ 41 162
timolol maleate tab 20 mg .................41 timolol maleate tab 5 mg ...................41 tinidazole tab 250 mg ........................16 tinidazole tab 500 mg ........................16 tizanidine hcl cap 2 mg (base equivalent) ......................................................96 tizanidine hcl cap 4 mg (base equivalent) ......................................................96 tizanidine hcl cap 6 mg (base equivalent) ......................................................96 tizanidine hcl tab 2 mg (base equivalent) ......................................................96 tizanidine hcl tab 4 mg (base equivalent) ......................................................96 tl gard rx tab .................................. 101 tl-hem 150 tab ............................... 101 TOBRADEX OIN 0.3-0.1% ................ 106 tobramycin nebu soln 300 mg/5ml ......11 tobramycin ophth soln 0.3% ............ 105 tobramycin-dexamethasone ophth susp 0.3-0.1% ....................................... 106 TODAY SPONGE MIS .........................66 tolazamide tab 250 mg ......................33 tolazamide tab 500 mg ......................33 tolbutamide tab 500 mg ....................33 tolcapone tab 100 mg........................94 tolmetin sodium cap 400 mg ..............88 tolmetin sodium tab 200 mg ..............88 tolmetin sodium tab 600 mg ..............88 tolterodine tartrate cap sr 24hr 2 mg ..66 tolterodine tartrate cap sr 24hr 4 mg ..66 tolterodine tartrate tab 1 mg ..............66 tolterodine tartrate tab 2 mg ..............66 topiramate sprinkle cap 15 mg ...........94 topiramate sprinkle cap 25 mg ...........94 topiramate tab 100 mg ......................93 topiramate tab 200 mg ......................93 topiramate tab 25 mg........................93 topiramate tab 50 mg........................93 torsemide tab 10 mg .........................51 torsemide tab 100 mg .......................51 torsemide tab 20 mg .........................51 torsemide tab 5 mg ...........................51 TOUJEO SOLO INJ 300IU/ML ..............31 TOVIAZ TAB 4MG ..............................65 TOVIAZ TAB 8MG ..............................65 TRACLEER TAB 125MG ......................54
TRACLEER TAB 62.5MG ..................... 54 TRADJENTA TAB 5MG ....................... 34 tramadol hcl tab 50 mg ..................... 85 tramadol hcl tab sr 24hr 100 mg ........ 85 tramadol hcl tab sr 24hr 200 mg ........ 85 tramadol hcl tab sr 24hr 300 mg ........ 85 tramadol hcl tab sr 24hr biphasic release 100 mg ........................................... 85 tramadol hcl tab sr 24hr biphasic release 200 mg ........................................... 85 tramadol hcl tab sr 24hr biphasic release 300 mg ........................................... 85 tramadol-acetaminophen tab 37.5-325 mg ................................................. 87 trandolapril tab 1 mg ........................ 45 trandolapril tab 2 mg ........................ 45 trandolapril tab 4 mg ........................ 45 tranexamic acid tab 650 mg ............ 103 TRANSDERM-SC DIS 1MG ................. 62 tranylcypromine sulfate tab 10 mg ..... 69 TRAVATAN Z DRO 0.004% .............. 106 trazodone hcl tab 100 mg ................. 69 trazodone hcl tab 150 mg ................. 69 trazodone hcl tab 300 mg ................. 69 trazodone hcl tab 50 mg ................... 69 TRECATOR TAB 250MG ..................... 12 tretinoin cap 10 mg .......................... 22 tretinoin cream 0.025% .................. 110 tretinoin cream 0.05% .................... 110 tretinoin cream 0.1% ...................... 110 tretinoin gel 0.01% ........................ 110 tretinoin gel 0.025% ....................... 110 tretinoin microsphere gel 0.04% ...... 110 tretinoin microsphere gel 0.1% ........ 110 TREXALL TAB 10MG .......................... 18 TREXALL TAB 15MG .......................... 18 TREXALL TAB 5MG ........................... 18 TREXALL TAB 7.5MG ......................... 18 triadvance tab ................................. 97 triamcinolone acetonide cream 0.025% .................................................... 115 triamcinolone acetonide cream 0.1% 115 triamcinolone acetonide cream 0.5% 115 triamcinolone acetonide dental paste 0.1% ............................................ 108 triamcinolone acetonide lotion 0.025% .................................................... 115 163
triamcinolone acetonide lotion 0.1% .. 115 triamcinolone acetonide oint 0.025%. 115 triamcinolone acetonide oint 0.1% .... 115 triamcinolone acetonide oint 0.5% .... 115 triamterene & hydrochlorothiazide cap 37.5-25 mg ......................................51 triamterene & hydrochlorothiazide cap 50-25 mg ........................................51 triamterene & hydrochlorothiazide tab 37.5-25 mg ......................................51 triamterene & hydrochlorothiazide tab 75-50 mg ........................................51 TRIANEX OIN 0.05% ....................... 115 triazolam tab 0.125 mg .....................76 triazolam tab 0.25 mg .......................76 TRIBENZOR20- TAB 5-12.5MG............50 TRIBENZOR40- TAB 10-12.5 ..............50 TRIBENZOR40- TAB 10-25MG.............50 TRIBENZOR40- TAB 5-12.5MG............50 TRIBENZOR40- TAB 5-25MG ..............50 tri-estaryll tab ..................................30 trifluoperazine hcl tab 1 mg................75 trifluoperazine hcl tab 10 mg ..............75 trifluoperazine hcl tab 2 mg................75 trifluoperazine hcl tab 5 mg................75 trifluridine ophth soln 1% ................ 105 trihexyphenidyl hcl elixir 0.4 mg/ml ....94 trihexyphenidyl hcl tab 2 mg ..............94 trihexyphenidyl hcl tab 5 mg ..............94 tri-legest tab fe ................................30 tri-linyah tab ....................................30 tri-lo tab estaryll ...............................30 tri-lo- tab marzia ..............................30 tri-lo- tab sprintec .............................30 trimethobenzamide hcl cap 300 mg .....62 trimethoprim tab 100 mg ...................16 trimipramine maleate cap 100 mg.......72 trimipramine maleate cap 25 mg ........72 trimipramine maleate cap 50 mg ........72 trinessa lo tab ..................................30 trinessa tab ......................................30 tri-previfem tab ................................30 tri-sprintec tab .................................30 TRIUMEQ TAB...................................14 tri-vit/fe dro /fl 0.25 ..........................97 tri-vit/fluo dro 0.5mg ........................97 tri-vita/fl dro 0.25mg ........................97
trivora-28 tab .................................. 30 tropicamide ophth soln 0.5% ........... 106 tropicamide ophth soln 1% .............. 107 trospium chloride cap sr 24hr 60 mg .. 66 trospium chloride tab 20 mg .............. 66 TRUE METRIX KIT METER ................ 118 TRULICITY INJ 0.75/0.5 .................... 32 TRULICITY INJ 1.5/0.5 ...................... 32 TRUVADA TAB 100-150 ..................... 14 TRUVADA TAB 133-200 ..................... 14 TRUVADA TAB 167-250 ..................... 14 TRUVADA TAB 200-300 ..................... 14 TUDORZA PRES AER 400/ACT ............ 57 TYKERB TAB 250MG ......................... 21 TYZEKA TAB 600MG ......................... 15 TYZINE PED DRO 0.05% ................... 56 TYZINE SOL 0.1% ............................ 56 u-kera e cre 40% ........................... 116 ULESFIA LOT 5% ........................... 117 ULORIC TAB 40MG ........................... 91 ULORIC TAB 80MG ........................... 91 ULTIMA KIT MONITOR .................... 118 umecta mouss aer 40% .................. 116 unithroid tab 175mcg ....................... 36 unithroid tab 200mcg ....................... 36 unithroid tab 300mcg ....................... 36 urea cream 39% ............................ 116 urea cream 45% ............................ 116 urea hydrati aer 35% ..................... 116 urea in zinc undecylenate-lactic acid vehicle emulsion 50% ..................... 116 urea lotion 45% ............................. 116 urea nail gel 45% ........................... 116 urea suspension 40% ..................... 116 urin d/s tab ..................................... 65 ursodiol cap 300 mg ......................... 63 ursodiol tab 250 mg ......................... 63 ursodiol tab 500 mg ......................... 63 uryl tab ........................................... 65 uticap cap ....................................... 65 VAGIFEM TAB 10MCG ....................... 66 valacyclovir hcl tab 1 gm ................... 15 valacyclovir hcl tab 500 mg ............... 15 VALCHLOR GEL 0.016% .................. 113 VALCYTE SOL 50MG/ML .................... 15 valganciclovir hcl tab 450 mg (base equivalent) ...................................... 15 164
valproate sodium syrup 250 mg/5ml (base equiv) .....................................92 valproic acid cap 250 mg ...................92 valsartan tab 160 mg ........................46 valsartan tab 320 mg ........................46 valsartan tab 40 mg ..........................46 valsartan tab 80 mg ..........................46 valsartan-hydrochlorothiazide tab 16012.5 mg ..........................................49 valsartan-hydrochlorothiazide tab 160-25 mg ..................................................49 valsartan-hydrochlorothiazide tab 32012.5 mg ..........................................49 valsartan-hydrochlorothiazide tab 320-25 mg ..................................................50 valsartan-hydrochlorothiazide tab 8012.5 mg ..........................................49 vancomycin hcl cap 125 mg ...............16 vancomycin hcl cap 250 mg ...............16 VCF VAGINAL AER CONTRACP ............66 vcf vaginal gel contrace .....................66 VCF VAGINAL MIS CONTRACP ............66 velivet pak .......................................29 VENCLEXTA TAB 100MG ....................20 VENCLEXTA TAB 10MG ......................19 VENCLEXTA TAB 50MG ......................20 VENCLEXTA TAB START PK ................20 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) ......................................71 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) ..............................71 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) ......................................71 venlafaxine hcl tab 100 mg ................70 venlafaxine hcl tab 25 mg ..................70 venlafaxine hcl tab 37.5 mg ...............70 venlafaxine hcl tab 50 mg ..................70 venlafaxine hcl tab 75 mg ..................70 venlafaxine hcl tab sr 24hr 150 mg (base equivalent) ......................................71 venlafaxine hcl tab sr 24hr 225 mg (base equivalent) ......................................71 venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) ..............................71 venlafaxine hcl tab sr 24hr 75 mg (base equivalent) ......................................71 VENTAVIS SOL 10MCG/ML .................54
VENTAVIS SOL 20MCG/ML ................ 54 VENTOLIN HFA AER .......................... 57 verapamil hcl cap sr 24hr 100 mg ...... 44 verapamil hcl cap sr 24hr 120 mg ...... 44 verapamil hcl cap sr 24hr 180 mg ...... 44 verapamil hcl cap sr 24hr 200 mg ...... 44 verapamil hcl cap sr 24hr 240 mg ...... 44 verapamil hcl cap sr 24hr 300 mg ...... 44 verapamil hcl cap sr 24hr 360 mg ...... 44 verapamil hcl tab 120 mg .................. 43 verapamil hcl tab 40 mg ................... 43 verapamil hcl tab 80 mg ................... 43 verapamil hcl tab cr 120 mg .............. 43 verapamil hcl tab cr 180 mg .............. 43 verapamil hcl tab cr 240 mg .............. 44 VEREGEN OIN 15% ........................ 117 VERIO FLEX KIT ONETOUCH ............ 118 vertin-32 tab ................................... 62 VESICARE TAB 10MG ........................ 65 VESICARE TAB 5MG.......................... 65 vestura tab 3-0.02mg ....................... 26 VEXOL SUS 1% OP ......................... 106 vicodin hp tab 10-300mg .................. 86 VICTOZA INJ 18MG/3ML ................... 32 VICTRELIS CAP 200MG ..................... 15 VIDEX SOL 2GM ............................... 13 VIDEX SOL 4GM ............................... 13 vienva tab 0.1-20 ............................. 27 VIIBRYD KIT .................................... 69 VIIBRYD TAB 10MG .......................... 69 VIIBRYD TAB 20MG .......................... 69 VIIBRYD TAB 40MG .......................... 69 VIMPAT SOL 10MG/ML ...................... 93 VIMPAT TAB 100MG.......................... 92 VIMPAT TAB 150MG.......................... 92 VIMPAT TAB 200MG.......................... 93 VIMPAT TAB 50MG ........................... 92 viorele tab ....................................... 29 VIRACEPT TAB 250MG ...................... 13 VIRACEPT TAB 625MG ...................... 13 VIRAMUNE XR TAB 100MG ................ 14 VIREAD POW 40MG/GM .................... 14 VIREAD TAB 150MG ......................... 14 VIREAD TAB 200MG ......................... 14 VIREAD TAB 250MG ......................... 14 VIREAD TAB 300MG ......................... 14 virtrate-2 sol ................................... 67 165
virtrate-3 sol ....................................67 virtrate-k sol ....................................67 virt-vite tab forte ..............................99 virt-vite tab plus ...............................97 VISTOGARD PAK 10GM .................... 117 vitamin d3 cap 400unit ......................96 VOLTAREN GEL 1% ......................... 112 voriconazole tab 200 mg ....................12 voriconazole tab 50 mg .....................12 VOTRIENT TAB 200MG ......................21 vyfemla tab 0.4-35 ...........................27 VYTORIN TAB 10-10MG .....................54 VYTORIN TAB 10-20MG .....................54 VYTORIN TAB 10-40MG .....................54 VYTORIN TAB 10-80MG .....................54 VYVANSE CAP 10MG..........................77 VYVANSE CAP 20MG..........................77 VYVANSE CAP 30MG..........................77 VYVANSE CAP 40MG..........................77 VYVANSE CAP 50MG..........................77 VYVANSE CAP 60MG..........................77 VYVANSE CAP 70MG..........................77 warfarin sodium tab 1 mg ................ 102 warfarin sodium tab 10 mg .............. 102 warfarin sodium tab 2 mg ................ 102 warfarin sodium tab 2.5 mg ............. 102 warfarin sodium tab 3 mg ................ 102 warfarin sodium tab 4 mg ................ 102 warfarin sodium tab 5 mg ................ 102 warfarin sodium tab 6 mg ................ 102 warfarin sodium tab 7.5 mg ............. 102 water for irrigation, sterile irrigation soln .................................................... 120 wee care sus 15/1.25 ........................99 WELCHOL PAK 3.75GM ......................52 WELCHOL TAB 625MG .......................52 wera tab 0.5/35 ................................27 WESTHROID TAB 195MG ...................36 WESTHROID TAB 97.5MG ..................36 WIDE-SEAL DPR KIT 60 ................... 119 WIDE-SEAL DPR KIT 65 ................... 119 WIDE-SEAL DPR KIT 70 ................... 119 WIDE-SEAL DPR KIT 75 ................... 119 WIDE-SEAL DPR KIT 80 ................... 119 WIDE-SEAL DPR KIT 85 ................... 119 WIDE-SEAL DPR KIT 90 ................... 119 WIDE-SEAL DPR KIT 95 ................... 119
WILATE INJ ............................ 103, 104 WP THYROID TAB 130MG .................. 36 WP THYROID TAB 65MG .................... 36 wymzya fe chw 0.4mg-35 ................. 28 XALKORI CAP 200MG ........................ 20 XALKORI CAP 250MG ........................ 20 XARELTO TAB 10MG ....................... 103 XARELTO TAB 15MG ....................... 103 XARELTO TAB 20MG ....................... 103 XELJANZ TAB 5MG ........................... 89 XELJANZ XR TAB 11MG ..................... 89 XIFAXAN TAB 200MG ........................ 16 XIFAXAN TAB 550MG ........................ 16 XIGDUO XR TAB 10-1000 .................. 35 XIGDUO XR TAB 10-500MG ............... 35 XIGDUO XR TAB 5-1000MG ............... 35 XIGDUO XR TAB 5-500MG ................. 35 XTANDI CAP 40MG ........................... 18 xulane dis 150-35 ............................ 25 XURIDEN POW 2GM .......................... 39 XYREM SOL 500MG/ML ..................... 81 zafirlukast tab 10 mg ........................ 59 zafirlukast tab 20 mg ........................ 60 zaleplon cap 10 mg .......................... 76 zaleplon cap 5 mg ............................ 76 zarah tab 3-0.03mg.......................... 26 ZAVESCA CAP 100MG ..................... 101 zazole cre 0.4% ............................... 66 zazole cre 0.8% ............................... 66 zazole sup 80mg .............................. 66 ZELBORAF TAB 240MG...................... 20 zenatane cap 10mg ........................ 110 zenatane cap 20mg ........................ 110 zenatane cap 30mg ........................ 110 zenatane cap 40mg ........................ 110 zenchent fe chw 0.4mg-35 ................ 28 zenchent tab ................................... 27 zencia liq 9-4% .............................. 111 zenzedi tab 2.5mg ............................ 76 zenzedi tab 7.5mg ............................ 76 ZETIA TAB 10MG.............................. 52 ZIAGEN SOL 20MG/ML ...................... 13 ZIANA GEL .................................... 110 zidovudine cap 100 mg ..................... 14 zidovudine syrup 10 mg/ml ............... 14 zidovudine tab 300 mg ..................... 14 ZIOPTAN DRO 0.0015% .................. 106 166
ziprasidone hcl cap 20 mg ..................75 ziprasidone hcl cap 40 mg ..................75 ziprasidone hcl cap 60 mg ..................75 ziprasidone hcl cap 80 mg ..................75 ZIRGAN GEL 0.15% ........................ 105 ZOLINZA CAP 100MG ........................20 zolmitriptan orally disintegrating tab 2.5 mg ..................................................90 zolmitriptan orally disintegrating tab 5 mg ..................................................90 zolmitriptan tab 2.5 mg .....................90 zolmitriptan tab 5 mg ........................90 zolpidem tartrate tab 10 mg ...............76 zolpidem tartrate tab 5 mg ................76 zolpidem tartrate tab cr 12.5 mg ........76 zolpidem tartrate tab cr 6.25 mg ........76 ZOMIG SPR 2.5MG ............................90
zonisamide cap 100 mg .................... 94 zonisamide cap 25 mg ...................... 94 zonisamide cap 50 mg ...................... 94 ZORTRESS TAB 0.25MG .................. 120 ZORTRESS TAB 0.5MG .................... 120 ZORTRESS TAB 0.75MG .................. 120 ZORVOLEX CAP 18MG ....................... 87 ZORVOLEX CAP 35MG ....................... 87 zovia 1/35e tab ................................ 26 zovia 1/50e tab ................................ 26 ZYDELIG TAB 100MG ........................ 21 ZYDELIG TAB 150MG ........................ 21 ZYFLO CR TAB 600MG ...................... 59 ZYFLO TAB 600MG ........................... 59 ZYKADIA CAP 150MG ........................ 20 ZYTIGA TAB 250MG .......................... 19 ZYVOX SUS 100MG/5M ..................... 17
167
Nondiscrimination and Foreign Language Assistance Notice At Capital BlueCross and our family of companies, our customers and the community we serve are at the heart of everything we do. We know health insurance is complicated, and we’re here to make it simple so you can focus on living healthy. Capital BlueCross and its family of companies comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. Capital BlueCross does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Capital BlueCross provides free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters or written information in other formats (large print, audio, accessible electronic format, other formats). Capital BlueCross provides free language service to people whose primary language is not English, such as: qualified interpreters, and information written in other languages. If you need these services, contact our Civil Rights Coordinator. If you believe that Capital BlueCross has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age disability, or sex, you can file a grievance with our Civil Rights Coordinator at Capital BlueCross, P.O. Box 779880, Harrisburg, PA 17177-9880, call 800.417.7842 (TTY: 711), fax, 855.990.9001 or email at
[email protected] . You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW., Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. This notice may have important information about your application or coverage through your health plan. Look for key dates in this notice; you may need to take action by certain deadlines to keep your health coverage or help with costs. If you, or someone you’re helping, has questions or needs assistance or information about your health plan or this notice, you have the right to get help in your language at no cost. To talk to an interpreter, call 800.962.2242 (TTY: 711). Spanish Este aviso puede contener información importante acerca de su solicitud o cobertura a través de su plan de salud. Ponga atención a la fechas importantes en este aviso; es posible que tenga que actuar antes de ciertas fechas límite para mantener su cobertura de salud o con ayuda del costo. Si usted, o alguien a quien usted ayuda, tiene preguntas o necesita asistencia o información acerca de su plan de salud o este aviso, tiene el derecho de obtener ayuda en su idioma sin costo alguno. Para hablar con un intérprete, llame al 800.962.2242 (TTY: 711). Chinese 本通知可能包含有关您的健康计划申请或涵盖范围的重要信息。请注意本通知中的重要日期；您可能需 要在具体的截止期限前采取行动维护您的健康涵盖范围或缴纳费用。如果您自己或者您提供帮助的某个 人对您的健康计划或本通知有任何疑问或者需要获得帮助或信息，您有权免费获得以您的语言提供的帮 助。欲与翻译员通话，请拨打电话 800.962.2242（聋哑人电话 TTY：711)。
C-572 (09/12/16)
Vietnamese Thông báo này có thể chứa những thông tin quan trọng về đơn xin của quý khách hoặc phạm vi bảo hiểm trong chương trình bảo hiểm sức khỏe của quý khách hàng. Hãy xem những ngày quan trọng trong thông báo này; quý khách có thể cần xử lý trước khi đến hạn cuối để duy trì bảo hiểm sức khỏe hoặc để giảm chi phí. Nếu quý khách hàng, hoặc người nào đó đang trợ giúp cho quý khách hàng, có câu hỏi hay cần trợ giúp hay thông tin về chương trình bảo hiểm sức khỏe của quý khách, quý khách có quyền yêu cầu được trợ giúp bằng ngôn ngữ của quý khách mà không phát sinh chi phí nào. Để kết nối với thông dịch viên, hãy gọi 800.962.2242 (TTY: 711). Russian Данное уведомление может содержать важную информацию по вашей заявке и медицинской страховке. Просмотрите ключевые даты в этом уведомлении – может понадобиться придерживаться некоторых сроков для сохранения медицинской страховки или же внести плату. Если у вас или помогающего вам есть вопросы, а также нужна помощь или информация по медицинской страховке или по данному уведомлению, позвоните на бесплатный телефон. Для соединения с переводчиком, звоните 800.962.2242 (TTY: 711). Pennsylvanian Dutch Die notice hot vielleicht wichtige information iwwer dei bitt oder coverage darrich dei gesundheitsplans. Guck for die certain days in daere notice; du brauchscht vielleicht ebbes duh bis certain deadlines fa dei gesundheits versicherings bhalde odder fa mit die koschde zu helfe. Wann du, odder ebber ess du am helfe bischt, froge hot odder hilf braucht odder information iwwer dei gesundheits plan odder iwwer die notice, hoscht du die recht fa hilf griege in dei sprooch es nichts koschtet. Fa schwetze mit me dolmetscher, ruf 800.962.2242 (TTY: 711). Korean 이 안내문에는 귀하의 건강보험을 통한 신청 또는 보장에 관한 중요한 정보가 포함될 수 있습니다. 이 안내문의 주요 날짜를 확인해 주십시오! 건강보험을 유지하거나 비용 지원을 위해 특정 마감일까지 관련 조처를 해야 할 수도 있습니다. 귀하 또는 귀하가 부양하는 사람이 귀하의 건강보험이나 이 안내문에 관하여 문의 사항이 있거나 도움말 또는 정보가 필요할 때는, 무료로 귀하의 언어를 통하여 도움을 받을 권리가 있습니다. 통역사에게 문의하려면 800.962.2242 (TTY: 711)으로 전화해 주십시오.
Italian Questo avviso potrebbe avere importanti informazioni circa la vostra applicazioni o copertura attraverso il vostro programma di salute. Cercate les principali date in questo avviso; pottrebe essere necessario applicare missuri ritoccando alcune scadenze per mantenere le vostre programma di salute o per contribuire con i costi. Se voi, o qualcuno voi state aiutando, ha quesiti o necessita di assistenza o informazione circa il vostro programma di salute o questo avviso, voi avvere può le diritto per ottenere aiuto in la vostra lingua gratuitamente. Per parlare con un interprete, chiamate 800.962.2242 (TTY: 711). Arabic اﺑﺣث ﻋن اﻟﺗوارﯾﺦ اﻟرﺋﯾﺳﯾﺔ ﻓﻲ ھذا اﻹﺷﻌﺎر؛ رﺑﻣﺎ ﺗﺣﺗﺎج إﻟﻰ اﺗﺧﺎذ إﺟراء ﻣن ﺧﻼل ﺣول طﻠﺑك أو.ﺣول اﻟﺗﻐطﯾﺔ ﻣن ﺧﻼل ﺧطﺗك اﻟﺻﺣﯾﺔ أو ﻛﻧت ﺗﺳﺎﻋد، إذا ﻛﻧت ﺗﺣﺗﺎج إﻟﻰ ﻣﺳﺎﻋدة.ﺑﻌض اﻟﻣواﻋﯾد اﻟﻧﮭﺎﺋﯾﺔ ﻟﻠﺣﻔﺎظ ﻋﻠﻰ اﻟﺗﻐطﯾﺔ اﻟﺻﺣﯾﺔ اﻟﺧﺎﺻﺔ ﺑك أو اﻟﻣﺳﺎﻋدة ﻓﻲ ﺳداد اﻟﺗﻛﺎﻟﯾف ﻓﻠدﯾك، أو ﻛﺎن ﻟدﯾك أﺳﺋﻠﺔ أو ﺑﺣﺎﺟﺔ إﻟﻰ اﻟﻣﺳﺎﻋدة أو ﺑﺣﺎﺟﺔ ﻟﻠﺣﺻول ﻋﻠﻰ ﻣﻌﻠوﻣﺎت ﺣول ﺧطﺗك اﻟﺻﺣﯾﺔ أو ﺣول ھذا اﻹﺷﻌﺎر،ﺷﺧﺻً ﺎ أﺧر اﺗﺻل ﻋﻠﻰ اﻟرﻗم، ﻟﻠﺗﺣدث إﻟﻰ ﻣﺗرﺟم ﻓوري.اﻟﺣق ﻓﻲ اﻟﺣﺻول ﻋﻠﻰ اﻟﻣﺳﺎﻋدة ﺑﻠﻐﺗك اﻷم ﻣﺟﺎ ًﻧﺎ800.962.2242 .(711 :)اﻟﮭﺎﺗف اﻟﻧﺻﻲ French Le présent avis peut avoir information importante concernant votre application ou la couverture à travers de votre plan sanitaire. Regarde pour clef dates dans cet avis ; vous pourries devoir prendre des mesures à certaines dates pour maintenir votre plan sanitaire ou de l’aidé à payer les coûts. Si vous, ou quelqu’un vous les aidez avoir des questions ou il a besoin d’aide ou information concernant votre plan sanitaire ou cet avis, vous avez le droit à obtenir de l’aide dans votre langue à titre gratuit. Pour parler à un interprète, appel 800.962.2242 (TTY: 711).
C-572 (09/12/16)
German Diese Mitteilung enthält eventuell wichtige Informationen bezüglich Ihres Antrages auf oder Ihres Schutzes durch Ihre Krankenversicherung. Suchen Sie nach Schlüsseldaten in diesem Dokument. Eventuell müssen Sie innerhalb von gewissen Fristen handeln um Ihren Versicherungsschutz zu behalten oder Hilfe mit Kosten zu erhalten. Fall Sie oder jemand, dem/der Sie helfen, Fragen hat oder Hilfe benötigt bezüglich dieser Mitteilung oder der Krankenversicherung, haben Sie Anspruch auf kostenlose Hilfe in Ihrer Sprache. Um mit einem Dolmetscher zu sprechen, rufen Sie an unter 800.962.2242 (TTY [Schreibtelefon]: 711). Gujarati આ નો ટસ માં તમાર અર
અથવા તમાર આરો ય યોજના મારફતે કવરજ િવશે મહ વની
છે . આ નો ટસ માં મહ વ ની તાર ખો ુ ચો સ અ ક
ુ તો દ
ુ ઓ; તમારા આરો ય કવરજ ને
ણકાર હોઈ શક
ળવવા માટ અથવા ખચ બચાવવા માટ
ુ ી તમને પગલાં લેવા પડ શક છે . જો તમે, અથવા ધ
ની તમે મદદ કર ર ા છો, તેમણે
કોઈ સવાલ હોય અથવા સહાય ક તમાર આરો ય યોજના અથવા આ નો ટસ િવશે મા હતી જોઇએ, તો તમને તમાર ભાષા માં કોઇ પણ ખચ વગર મદદ મેળવવા
ું અિધકાર છે . ુ ભાિષયા સાથે વાત કરવા માટ,
800.962.2242 (TTY : 711) ફોન કરો. Polish To powiadomienie może zawierać ważne informacje na temat Pana/Pani wniosku lub zakresu ubezpieczenia w posiadanym planie. Zalecamy zapoznać się z kluczowymi terminami w tym powiadomieniu; może istnieć konieczność podjęcia działania przed upłynięciem pewnych terminów, aby utrzymać ubezpieczenie zdrowotne lub uzyskać pomoc w kosztach. Jeżeli Pan/Pani lub ktoś, komu Pan/Pani pomaga, ma pytania bądź potrzebuje pomocy lub informacji w sprawie planu ubezpieczenia zdrowotnego albo tego powiadomienia, przysługuje Panu/Pani prawo do nieodpłatnego uzyskania pomocy w ojczystym języku. Aby porozmawiać z tłumaczem ustnym, prosimy zadzwonić pod numer 800.962.2242 (TTY: 711). French Creole Avi sila a ka genyen enfòmasyon ki enpòtan konsènan aplikasyon w lan oubyen asirans ou atravè plan lasante w la. Chèch e dat enpòtan yo ki nan avi sila a; ou ka gen pou w fè sèten bagay anvan kèk dat limit pou w sa kenbe asirans ou a oubyen pou yo ede w ak kèk depans. Si oumenm, oubyen yon lòt moun w ap ede, genyen kesyon oubyen bezwen èd oswa plis enf òmasyon sou plan lasante w oswa sou avi sila a, ou genyen dwa pou w resevwa asistans nan lang ou pale a san li pa kout e w anyen ditou. Pou w pale ak yon entèprèt, rele 800.962.2242 (TTY: 711). Cambodian–Mon-Khmer រជូ នដំណឹងេនះ ច នពត៌ នសំ ន់អំពីកមវធី រ ប់រងរបស់អក មរយៈគេ ងសុខ ពរប ស់អក។កេមល លបរេចទសំ ន់ៗេ កង រជូ នដំណឹងេនះក ចេធចំ ត់ រេ យ លបរេចទ ក់ ក់េដម ីរក រ ប់រងសុខ ពជួ យ មួ យនឹង រចំ យ។សិន អកនរ ក់ែដលអកកំពុងជួ យនសំណួរ តវ រជំនួយពត៌ នអំពីគេ ងសុខ ពរបស់អក រជូ នដំណឹងេនះក នសិទិេដម ីទទួ លជំនួ យ របស់អកេ យមិនគិតៃថ។ េដម ីនិ យេ ន់អកបកែ ប ល់ ត់ សូ មេ េ ន់េលខ 800.962.2242 (TTY: 711)។ Portuguese Este aviso pode ter informações importantes sobre a sua aplicação ou cobertura de plano de saúde. Olhe para as datas importantes neste aviso; pode ser necessário tomar medidas em determinados prazos para manter a sua cobertura de saúde ou ajudar com os custos. Se você, ou alguém que você está ajudando, tem dúvidas ou precisa de assistência ou informação sobre seu plano de saúde ou este aviso, você tem o direito de obter ajuda na sua língua sem nenhum custo. Para falar com um intérprete, ligue para 800.962.2242 (TTY: 711).
C-572 (09/12/16)
Pharmacy Services Capital BlueCross P&T Committee P.O. Box 773735 Harrisburg, PA 17177-3735
