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2019 MEDICAID DRUG FORMULARY
Effective January 1st, 2019
PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE
PRESCRIPTION DRUGS WE COVER.
Please refer to your “Member Handbook or other plan materials” to determine if your drug is covered.
This Drug Formulary does not guarantee coverage and is subject to change without notice. Members
must use participating pharmacies to fill their prescription drugs.
For the most recent information or other questions, please contact Neighborhood Member Services at
401-443-5992 (TTY 711). This formulary is for members enrolled in ACCESS or TRUST health plans
effective on January 1st, 2019.
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
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NHPRI Medicaid 2019 Effective: 4/1/19
Last Updated: March 2019
Drug Name Requirements/Limits
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS AMPHETAMINES
amphetamine-dextroamphetamine cap er 24hr 5
mg
amphetamine-dextroamphetamine cap er 24hr 10
mg
amphetamine-dextroamphetamine cap er 24hr 15
mg
amphetamine-dextroamphetamine cap er 24hr 20 mg
amphetamine-dextroamphetamine cap er 24hr 25 mg
amphetamine-dextroamphetamine cap er 24hr 30 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
dexedrine tab 5mg
ANOREXIANTS NON-AMPHETAMINE phendimetrazine tartrate tab 35 mg
phentermine hcl cap 15 mg
phentermine hcl cap 30 mg
phentermine hcl cap 37.5 mg
phentermine hcl tab 37.5 mg
QSYMIA CAP 3.75-23 PA
QSYMIA CAP 7.5-46MG PA
QSYMIA CAP 11.25-69 PA
QSYMIA CAP 15-92MG PA
ANTI-OBESITY AGENTS ALLI CAP 60MG OTC
BELVIQ TAB 10MG PA
BELVIQ XR TAB 20MG PA
CONTRAVE TAB 8-90MG PA
SAXENDA INJ 18MG/3ML PA
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS atomoxetine hcl cap 10 mg (base equiv) QL (1 cap / day)
atomoxetine hcl cap 18 mg (base equiv) QL (1 cap / day)
atomoxetine hcl cap 25 mg (base equiv) QL (1 cap / day)
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Drug Name Requirements/Limits
atomoxetine hcl cap 40 mg (base equiv) QL (1 cap / day)
atomoxetine hcl cap 60 mg (base equiv) QL (1 cap / day)
atomoxetine hcl cap 80 mg (base equiv) QL (1 cap / day)
atomoxetine hcl cap 100 mg (base equiv) QL (1 cap / day)
guanfacine hcl tab er 24hr 1 mg (base equiv)
guanfacine hcl tab er 24hr 2 mg (base equiv)
guanfacine hcl tab er 24hr 3 mg (base equiv)
guanfacine hcl tab er 24hr 4 mg (base equiv)
STIMULANTS - MISC. armodafinil tab 50 mg QL (1 tab / day)
armodafinil tab 150 mg QL (1 tab / day)
armodafinil tab 200 mg QL (1 tab / day)
armodafinil tab 250 mg QL (1 tab / day)
dexmethylphenidate hcl cap er 24 hr 5 mg QL (1 cap / day)
dexmethylphenidate hcl cap er 24 hr 10 mg QL (1 cap / day)
dexmethylphenidate hcl cap er 24 hr 15 mg QL (1 cap / day)
dexmethylphenidate hcl cap er 24 hr 20 mg QL (1 cap / day)
dexmethylphenidate hcl cap er 24 hr 25 mg QL (1 cap / day)
dexmethylphenidate hcl cap er 24 hr 30 mg QL (1 cap / day)
dexmethylphenidate hcl cap er 24 hr 35 mg QL (1 cap / day)
dexmethylphenidate hcl cap er 24 hr 40 mg QL (1 cap / day)
dexmethylphenidate hcl tab 2.5 mg
dexmethylphenidate hcl tab 5 mg
dexmethylphenidate hcl tab 10 mg
methylphenidate hcl cap er 10 mg (cd) QL (1 cap / day)
methylphenidate hcl cap er 20 mg (cd) QL (1 cap / day)
methylphenidate hcl cap er 30 mg (cd) QL (1 cap / day)
methylphenidate hcl cap er 40 mg (cd) QL (1 cap / day)
methylphenidate hcl cap er 50 mg (cd) QL (1 cap / day)
methylphenidate hcl cap er 60 mg (cd) QL (1 cap / day)
methylphenidate hcl tab 5 mg
methylphenidate hcl tab 10 mg
methylphenidate hcl tab 20 mg
methylphenidate hcl tab er 10 mg
methylphenidate hcl tab er 20 mg
modafinil tab 100 mg QL (2 tabs / day)
modafinil tab 200 mg QL (2 tabs / day)
ALTERNATIVE MEDICINES ALTERNATIVE MEDICINE - M'S
melatonin cap 5mg OTC
MELATONIN LIQ 1MG/4ML OTC
melatonin liquid 1 mg/ml OTC
melatonin sub 5mg OTC
melatonin tab 1 mg OTC
melatonin tab 3 mg OTC
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Drug Name Requirements/Limits
melatonin tab 5 mg OTC
melatonin tab 300 mcg OTC
ALTERNATIVE MEDICINE COMBINATIONS melatonin tr tab /vit-b6 OTC
melatonin/ tab vit b-6 OTC
AMINOGLYCOSIDES AMINOGLYCOSIDES
neomycin sulfate tab 500 mg
paromomycin sulfate cap 250 mg
tobramycin nebu soln 300 mg/5ml PA
ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES
HUMIRA INJ 10/0.1ML
HUMIRA INJ 10MG/0.2
HUMIRA INJ 20/0.2ML
HUMIRA INJ 40/0.4ML
HUMIRA KIT 20MG/0.4
HUMIRA KIT 40MG/0.8
HUMIRA PEDIA INJ CROHNS
HUMIRA PEN INJ 40/0.4ML
HUMIRA PEN INJ 40MG/0.8
HUMIRA PEN INJ CD/UC/HS
HUMIRA PEN INJ PS/UV
HUMIRA PEN KIT CD/UC/HS
HUMIRA PEN KIT PS/UV
ANTIRHEUMATIC - ENZYME INHIBITORS XELJANZ TAB 5MG QL (60 / 30 days), PA
XELJANZ TAB 10MG QL (60 / 30 days), PA
XELJANZ XR TAB 11MG QL (30 / 30 days), PA
INTERLEUKIN-6 RECEPTOR INHIBITORS KEVZARA INJ 150/1.14 QL (2 syringes / 28 days),
PA
KEVZARA INJ 200/1.14 QL (2 syringes / 28 days), PA
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) celecoxib cap 50 mg
celecoxib cap 100 mg
celecoxib cap 200 mg
celecoxib cap 400 mg QL (1 cap / day)
diclofenac potassium tab 50 mg
diclofenac sodium tab delayed release 50 mg
diclofenac sodium tab delayed release 75 mg
diclofenac sodium tab er 24hr 100 mg
etodolac cap 200 mg
etodolac tab 400 mg
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Drug Name Requirements/Limits
etodolac tab 500 mg
etodolac tab er 24hr 400 mg
etodolac tab er 24hr 500 mg
etodolac tab er 24hr 600 mg
flurbiprofen tab 50 mg
flurbiprofen tab 100 mg
ibuprofen dro 50/1.25 OTC
ibuprofen sus 100/5ml OTC
ibuprofen tab 200mg OTC
ibuprofen tab 400 mg
ibuprofen tab 600 mg
ibuprofen tab 800 mg
indomethacin cap 25 mg
indomethacin cap 50 mg
indomethacin cap er 75 mg
ketorolac tromethamine tab 10 mg QL (20 tabs / 30 days)
meloxicam tab 7.5 mg
meloxicam tab 15 mg
nabumetone tab 500 mg
nabumetone tab 750 mg
naproxen ec tab 375mg
naproxen ec tab 500mg
naproxen sod tab 220mg OTC
naproxen sodium tab 275 mg
naproxen sodium tab 550 mg
naproxen susp 125 mg/5ml
naproxen tab 250 mg
naproxen tab 375 mg
naproxen tab 500 mg
sulindac tab 150 mg
sulindac tab 200 mg
PYRIMIDINE SYNTHESIS INHIBITORS leflunomide tab 10 mg
leflunomide tab 20 mg
SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL INJ 25/0.5ML
ENBREL INJ 25MG
ENBREL INJ 50MG/ML
ENBREL MINI INJ 50MG/ML
ENBREL SRCLK INJ 50MG/ML
ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS
aspirin-acetaminophen-caffeine tab 250-250-65 mg
OTC
butalbital-acetaminophen tab 50-325 mg
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Drug Name Requirements/Limits
butalbital-acetaminophen-caffeine tab 50-325-40 mg
ANALGESICS OTHER acetaminophe chw 160mg OTC
acetaminophe tab 160mg OTC
acetaminophen elixir 160 mg/5ml OTC
acetaminophen liquid 160 mg/5ml OTC
acetaminophen soln 160 mg/5ml OTC
acetaminophen tab 325 mg OTC
acetaminophen tab er 650 mg OTC
acetaminophn sus 160/5ml OTC
acetaminophn tab 500mg OTC
pain/fever sup 120mg OTC
SALICYLATES ALKA-SELTZER TAB 500MG OTC
aspirin low chw 81mg OTC
aspirin tab 325mg OTC
aspirin tab 500 mg OTC
aspirin tab delayed release 81 mg OTC; Available for 90 day fill
aspirin tab delayed release 325 mg OTC
BAYER PLUS TAB 500MG OTC
eq aspirin tab 500mg ec OTC
ANALGESICS - OPIOID OPIOID AGONISTS
codeine sulfate tab 15 mg QL (42 tabs / 30 days), PA; Age Restriction
codeine sulfate tab 30 mg QL (42 tabs / 30 days), PA;
Age Restriction
codeine sulfate tab 60 mg QL (42 tabs / 30 days), PA;
Age Restriction
fentanyl td patch 72hr 12 mcg/hr QL (10 patches / 30 days),
PA
fentanyl td patch 72hr 25 mcg/hr QL (10 patches / 30 days),
PA
fentanyl td patch 72hr 50 mcg/hr PA
fentanyl td patch 72hr 75 mcg/hr PA
fentanyl td patch 72hr 100 mcg/hr PA
HYDROMORPHON SUP 3MG QL (120 / 30 days), PA
hydromorphone hcl liqd 1 mg/ml QL (600 ml / 30 days), PA
hydromorphone hcl tab 2 mg QL (180 tabs / 30 days), PA
hydromorphone hcl tab 4 mg QL (150 tabs / 30 days), PA
hydromorphone hcl tab 8 mg QL (60 tabs / 30 days), PA
meperidine hcl tab 50 mg QL (18 tabs / 30 days)
meperidine hcl tab 100 mg QL (18 tabs / 30 days)
methadone hcl soln 5 mg/5ml QL (450 ml / 30 days), PA
methadone hcl soln 10 mg/5ml QL (300 ml / 30 days), PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
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Drug Name Requirements/Limits
methadone hcl tab 5 mg QL (90 tabs / 30 days), PA
methadone hcl tab 10 mg QL (60 tabs / 30 days), PA
morphine sulfate oral soln 20 mg/5ml QL (675 ml / 30 days), PA
morphine sulfate oral soln 100 mg/5ml (20 mg/ml) QL (135 ml / 30 days), PA
morphine sulfate tab 15 mg QL (180 tabs / 30 days), PA
morphine sulfate tab 30 mg QL (90 tabs / 30 days), PA
morphine sulfate tab er 15 mg QL (90 tabs / 30 days), PA
morphine sulfate tab er 30 mg QL (90 tabs / 30 days), PA
morphine sulfate tab er 60 mg PA
morphine sulfate tab er 100 mg PA
morphine sulfate tab er 200 mg PA
oxycodone hcl cap 5 mg QL (180 caps / 30 days)
oxycodone hcl conc 100 mg/5ml (20 mg/ml) QL (90 ml / 30 days), PA
oxycodone hcl tab 5 mg QL (180 tabs / 30 days)
oxycodone hcl tab 10 mg QL (180 tabs / 30 days), PA
oxycodone hcl tab 15 mg QL (120 tabs / 30 days), PA
oxycodone hcl tab 20 mg QL (90 tabs / 30 days), PA
oxycodone hcl tab 30 mg QL (60 tabs / 30 days), PA
tramadol hcl tab 50 mg QL (180 tabs / 30 days)
tramadol hcl tab er 24hr 100 mg PA
tramadol hcl tab er 24hr 200 mg PA
tramadol hcl tab er 24hr 300 mg PA
tramadol hcl tab er 24hr biphasic release 100 mg PA
tramadol hcl tab er 24hr biphasic release 200 mg PA
tramadol hcl tab er 24hr biphasic release 300 mg PA
OPIOID COMBINATIONS acetaminophen w/ codeine soln 120-12 mg/5ml QL (2700 ml / 30 days), PA
acetaminophen w/ codeine tab 300-15 mg QL (400 tabs / 30 days)
acetaminophen w/ codeine tab 300-30 mg QL (360 tabs / 30 days)
acetaminophen w/ codeine tab 300-60 mg QL (180 tabs / 30 days)
butalbital-acetaminophen-caff w/ cod cap 50-325-
40-30 mg
hydrocodone-acetaminophen soln 7.5-325
mg/15ml
QL (2700 ml / 30 days)
hydrocodone-acetaminophen tab 5-325 mg QL (240 tabs / 30 days)
hydrocodone-acetaminophen tab 7.5-325 mg QL (180 tabs / 30 days)
hydrocodone-acetaminophen tab 10-325 mg QL (180 tabs / 30 days)
hydrocodone-ibuprofen tab 7.5-200 mg QL (50 tabs / 30 days)
oxycodone w/ acetaminophen tab 5-325 mg QL (360 tabs / 30 days)
oxycodone w/ acetaminophen tab 7.5-325 mg QL (240 tabs / 30 days)
oxycodone w/ acetaminophen tab 10-325 mg QL (180 tabs / 30 days), PA
oxycodone-aspirin tab 4.8355-325 mg QL (360 tabs / 30 days)
oxycodone-ibuprofen tab 5-400 mg QL (28 tabs / 30 days), PA
tramadol-acetaminophen tab 37.5-325 mg QL (40 tabs / 30 days)
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Drug Name Requirements/Limits
OPIOID PARTIAL AGONISTS buprenorphine hcl sl tab 2 mg (base equiv) QL (12 tabs / day), PA
buprenorphine hcl sl tab 8 mg (base equiv) QL (3 tabs / day), PA
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv)
QL (3 tabs / day)
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)
QL (3 tabs / day)
buprenorphine td patch weekly 5 mcg/hr QL (4 patches / 30 days), PA
buprenorphine td patch weekly 7.5 mcg/hr QL (4 patches / 30 days), PA
buprenorphine td patch weekly 10 mcg/hr QL (4 patches / 30 days), PA
buprenorphine td patch weekly 15 mcg/hr PA
buprenorphine td patch weekly 20 mcg/hr PA
butorphanol tartrate nasal soln 10 mg/ml QL (1.2 ml / day), PA
pentazocine w/ naloxone tab 50-0.5 mg QL (120 tabs / 30 days), PA
SUBOXONE MIS 2-0.5MG QL (3 films / day)
SUBOXONE MIS 4-1MG QL (3 films / day)
SUBOXONE MIS 8-2MG QL (3 films / day)
SUBOXONE MIS 12-3MG QL (3 films / day)
ANDROGENS-ANABOLIC ANABOLIC STEROIDS
oxandrolone tab 2.5 mg
ANDROGENS danazol cap 100 mg
danazol cap 200 mg
FIRST-TESTOS CRE MC 2%
FIRST-TESTOS OIN 2%
testosterone cypionate im inj in oil 100 mg/ml
testosterone cypionate im inj in oil 200 mg/ml
testosterone enanthate im inj in oil 200 mg/ml
testosterone td gel 12.5 mg/act (1%) QL (75 gm / fill), PA
testosterone td gel 50 mg/5gm (1%) QL (150 gm / fill), PA
ANORECTAL AGENTS INTRARECTAL STEROIDS
hydrocortisone enema 100 mg/60ml
UCERIS AER 2MG/ACT PA
RECTAL STEROIDS hydrocortisone rectal cream 2.5%
ANTACIDS ANTACID COMBINATIONS
antacid sus OTC
ANTACIDS - ALUMINUM SALTS ALUM HYDROX SUS 320/5ML OTC
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Drug Name Requirements/Limits
ANTACIDS - BICARBONATE sodium bicarbonate tab 650 mg OTC
ANTACIDS - CALCIUM SALTS CALCIUM CARB TAB 648MG OTC
calcium carbonate (antacid) chew tab 500 mg OTC
calcium carbonate (antacid) chew tab 750 mg OTC
calcium carbonate (antacid) susp 1250 mg/5ml OTC
stomach rlf chw 400mg OTC
ANTACIDS - MAGNESIUM SALTS magnesium oxide tab 250 mg OTC
magnesium oxide tab 400 mg OTC
ANTHELMINTICS ANTHELMINTICS
ivermectin tab 3 mg
pinworm med sus 144mg/ml OTC
ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC.
FIRST-METRON SUS 100MG/ML
METRONIDAZOL SUS 50MG/ML
metronidazole tab 250 mg
metronidazole tab 500 mg
trimethoprim tab 100 mg
XIFAXAN TAB 200MG PA
XIFAXAN TAB 550MG PA
ANTI-INFECTIVE MISC. - COMBINATIONS sulfamethoxazole-trimethoprim susp 200-40
mg/5ml
sulfamethoxazole-trimethoprim tab 400-80 mg
sulfamethoxazole-trimethoprim tab 800-160 mg
GLYCOPEPTIDES FIRST-VANC SOL 25MG/ML
FIRST-VANC SOL 50MG/ML
vancomycin hcl cap 125 mg (base equivalent)
vancomycin hcl cap 250 mg (base equivalent)
LEPROSTATICS dapsone tab 25 mg
dapsone tab 100 mg
LINCOSAMIDES clindamycin hcl cap 150 mg
clindamycin hcl cap 300 mg
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)
Age Restriction
OXAZOLIDINONES linezolid for susp 100 mg/5ml PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
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Drug Name Requirements/Limits
linezolid tab 600 mg PA
ANTIANGINAL AGENTS NITRATES
isosorbide mononitrate tab 10 mg
isosorbide mononitrate tab 20 mg
isosorbide mononitrate tab er 24hr 30 mg
isosorbide mononitrate tab er 24hr 60 mg
isosorbide mononitrate tab er 24hr 120 mg
nitroglycerin sl tab 0.3 mg
nitroglycerin sl tab 0.4 mg
nitroglycerin sl tab 0.6 mg
nitroglycerin td patch 24hr 0.1 mg/hr
nitroglycerin td patch 24hr 0.2 mg/hr
nitroglycerin td patch 24hr 0.4 mg/hr
nitroglycerin td patch 24hr 0.6 mg/hr
ANTIANXIETY AGENTS 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 syrup 10 mg/5ml
hydroxyzine hcl tab 10 mg
hydroxyzine hcl tab 25 mg
hydroxyzine hcl tab 50 mg
hydroxyzine pamoate cap 25 mg
hydroxyzine pamoate cap 50 mg
hydroxyzine pamoate cap 100 mg
BENZODIAZEPINES alprazolam tab 0.5 mg
alprazolam tab 0.25 mg
alprazolam tab 1 mg
alprazolam tab 2 mg
chlordiazepoxide hcl cap 5 mg
chlordiazepoxide hcl cap 10 mg
chlordiazepoxide hcl cap 25 mg
diazepam con 5mg/ml
diazepam oral soln 1 mg/ml
diazepam tab 2 mg
diazepam tab 5 mg
diazepam tab 10 mg
lorazepam tab 0.5 mg
lorazepam tab 1 mg
lorazepam tab 2 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
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Drug Name Requirements/Limits
oxazepam cap 10 mg
oxazepam cap 15 mg
oxazepam cap 30 mg
ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-B
mexiletine hcl cap 150 mg
ANTIARRHYTHMICS TYPE I-C flecainide acetate tab 50 mg
flecainide acetate tab 100 mg
flecainide acetate tab 150 mg
propafenone hcl tab 150 mg
ANTIARRHYTHMICS TYPE III amiodarone hcl tab 200 mg
ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTI-INFLAMMATORY AGENTS
cromolyn sodium soln nebu 20 mg/2ml
ANTIASTHMATIC - MONOCLONAL ANTIBODIES CINQAIR INJ PA
FASENRA INJ 30MG/ML PA
NUCALA INJ 100MG PA
XOLAIR INJ 75/0.5 PA
XOLAIR INJ 150MG/ML PA
XOLAIR SOL 150MG PA
BRONCHODILATORS - ANTICHOLINERGICS ipratropium bromide inhal soln 0.02%
SPIRIVA AER 1.25MCG
SPIRIVA CAP HANDIHLR ST
SPIRIVA SPR 2.5MCG
LEUKOTRIENE MODULATORS montelukast sodium chew tab 4 mg (base equiv)
montelukast sodium chew tab 5 mg (base equiv)
montelukast sodium oral granules packet 4 mg (base equiv)
ST; Age Restriction
montelukast sodium tab 10 mg (base equiv)
SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS DALIRESP TAB 500MCG PA
STEROID INHALANTS ASMANEX 7 AER 110MCG QL (1 inhaler / 30 days)
ASMANEX 14 AER 220MCG QL (1 inhaler / 30 days)
ASMANEX 30 AER 110MCG QL (1 inhaler / 30 days)
ASMANEX 30 AER 220MCG QL (1 inhaler / 30 days)
ASMANEX 60 AER 220MCG QL (1 inhaler / 30 days)
ASMANEX 120 AER 220MCG QL (1 inhaler / 30 days)
ASMANEX HFA AER 100 MCG
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
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Drug Name Requirements/Limits
ASMANEX HFA AER 200 MCG
budesonide inhalation susp 0.5 mg/2ml QL (60 ml / 30 days); Age Restriction
budesonide inhalation susp 0.25 mg/2ml QL (60 ml / 30 days); Age Restriction
budesonide inhalation susp 1 mg/2ml QL (60 ml / 30 days); Age Restriction
FLOVENT HFA AER 44MCG Age Restriction
PULMICORT INH 90MCG
PULMICORT INH 180MCG
QVAR AER 40MCG QL (34.8 gm / 30 days)
QVAR AER 80MCG
QVAR REDIHA AER 80MCG QL (21.2 gm / 30 days)
QVAR REDIHAL AER 40MCG QL (21.2 gm / 30 days)
SYMPATHOMIMETICS ADVAIR DISKU AER 100/50 ST
ADVAIR DISKU AER 250/50 ST
ADVAIR DISKU AER 500/50 ST
ADVAIR HFA AER 45/21 ST
ADVAIR HFA AER 115/21 ST
ADVAIR HFA AER 230/21 ST
albuterol sulfate soln nebu 0.5% (5 mg/ml)
albuterol sulfate soln nebu 0.63 mg/3ml (base equiv)
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv)
albuterol sulfate syrup 2 mg/5ml
albuterol sulfate tab 2 mg
albuterol sulfate tab er 12hr 4 mg
COMBIVENT AER 20-100
DULERA AER 100-5MCG ST
DULERA AER 200-5MCG ST
fluticasone-salmeterol aer powder ba 55-14 mcg/act
QL (1 inhaler / 30 days)
fluticasone-salmeterol aer powder ba 113-14 mcg/act
QL (1 inhaler / 30 days)
fluticasone-salmeterol aer powder ba 232-14 mcg/act
QL (1 inhaler / 30 days)
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
levalbuterol hcl soln nebu 0.31 mg/3ml (base
equiv)
QL (72 ml per fill)
levalbuterol hcl soln nebu 0.63 mg/3ml (base
equiv)
QL (72 ml per fill)
levalbuterol hcl soln nebu 1.25 mg/3ml (base
equiv)
QL (72 ml per fill)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
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Drug Name Requirements/Limits
levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv)
QL (15 gm / 30 days)
metaproterenol sulfate syrup 10 mg/5ml
SEREVENT DIS AER 50MCG
STIOLTO AER 2.5-2.5
STRIVERDI AER 2.5MCG
SYMBICORT AER 80-4.5 ST
SYMBICORT AER 160-4.5 ST
terbutaline sulfate tab 2.5 mg
terbutaline sulfate tab 5 mg
VENTOLIN HFA AER
XANTHINES theophylline tab er 12hr 100 mg
theophylline tab er 12hr 200 mg
theophylline tab er 12hr 300 mg
theophylline tab er 12hr 450 mg
theophylline tab er 24hr 400 mg
theophylline tab er 24hr 600 mg
ANTICOAGULANTS COUMARIN ANTICOAGULANTS
warfarin sodium tab 1 mg
warfarin sodium tab 2 mg
warfarin sodium tab 2.5 mg
warfarin sodium tab 3 mg
warfarin sodium tab 4 mg
warfarin sodium tab 5 mg
warfarin sodium tab 6 mg
warfarin sodium tab 7.5 mg
warfarin sodium tab 10 mg
DIRECT FACTOR XA INHIBITORS ELIQUIS TAB 2.5MG
ELIQUIS TAB 5MG
XARELTO STAR TAB 15/20MG
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
HEPARINS AND HEPARINOID-LIKE AGENTS enoxaparin sodium inj 30 mg/0.3ml QL (Max 10 days supply / 3
months)
enoxaparin sodium inj 40 mg/0.4ml QL (Max 10 days supply / 3 months)
enoxaparin sodium inj 60 mg/0.6ml QL (Max 10 days supply / 3 months)
enoxaparin sodium inj 80 mg/0.8ml QL (Max 10 days supply / 3 months)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
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Drug Name Requirements/Limits
enoxaparin sodium inj 100 mg/ml QL (Max 10 days supply / 3 months)
enoxaparin sodium inj 120 mg/0.8ml QL (Max 10 days supply / 3 months)
enoxaparin sodium inj 150 mg/ml QL (Max 10 days supply / 3 months)
heparin sodium (porcine) inj 5000 unit/ml
heparin sodium (porcine) inj 10000 unit/ml
THROMBIN INHIBITORS PRADAXA CAP 75MG
PRADAXA CAP 110MG
PRADAXA CAP 150MG
ANTICONVULSANTS ANTICONVULSANTS - BENZODIAZEPINES
clobazam suspension 2.5 mg/ml PA
clobazam tab 10 mg PA
clobazam tab 20 mg PA
clonazepam tab 0.5 mg
clonazepam tab 1 mg
clonazepam tab 2 mg
diazepam rectal gel delivery system 2.5 mg QL (2 kits / fill)
diazepam rectal gel delivery system 10 mg QL (2 kits / fill)
diazepam rectal gel delivery system 20 mg QL (2 kits / fill)
ANTICONVULSANTS - MISC. carbamazepine cap er 12hr 100 mg
carbamazepine cap er 12hr 200 mg
carbamazepine cap er 12hr 300 mg
carbamazepine chew tab 100 mg
carbamazepine susp 100 mg/5ml
carbamazepine tab 200 mg
carbamazepine tab er 12hr 100 mg
carbamazepine tab er 12hr 200 mg
carbamazepine tab er 12hr 400 mg
gabapentin cap 100 mg
gabapentin cap 300 mg
gabapentin cap 400 mg
gabapentin oral soln 250 mg/5ml
gabapentin tab 600 mg
gabapentin tab 800 mg
lamotrigine tab 25 mg
lamotrigine tab 100 mg
lamotrigine tab 150 mg
lamotrigine tab 200 mg
lamotrigine tab chewable dispersible 5 mg
lamotrigine tab chewable dispersible 25 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
14
Drug Name Requirements/Limits
lamotrigine tab er 24hr 25 mg
lamotrigine tab er 24hr 50 mg
lamotrigine tab er 24hr 100 mg
lamotrigine tab er 24hr 200 mg
lamotrigine tab er 24hr 250 mg
lamotrigine tab er 24hr 300 mg
levetiracetam oral soln 100 mg/ml
levetiracetam tab 250 mg
levetiracetam tab 500 mg
levetiracetam tab 750 mg
levetiracetam tab 1000 mg
levetiracetam tab er 24hr 500 mg
levetiracetam tab er 24hr 750 mg
LYRICA CAP 25MG QL (2 caps / day), PA
LYRICA CAP 50MG QL (2 caps / day), PA
LYRICA CAP 75MG QL (2 caps / day), PA
LYRICA CAP 100MG QL (2 caps / day), PA
LYRICA CAP 150MG QL (2 caps / day), PA
LYRICA CAP 200MG QL (2 caps / day), PA
LYRICA CAP 225MG QL (2 caps / day), PA
LYRICA CAP 300MG QL (2 caps / day), PA
LYRICA SOL 20MG/ML PA
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
oxcarbazepine tab 150 mg
oxcarbazepine tab 300 mg
oxcarbazepine tab 600 mg
primidone tab 50 mg
primidone tab 250 mg
topiramate sprinkle cap 15 mg
topiramate sprinkle cap 25 mg
topiramate tab 25 mg
topiramate tab 50 mg
topiramate tab 100 mg
topiramate tab 200 mg
VIMPAT SOL 10MG/ML PA
VIMPAT TAB 50MG PA
VIMPAT TAB 100MG PA
VIMPAT TAB 150MG PA
VIMPAT TAB 200MG PA
zonisamide cap 25 mg
zonisamide cap 50 mg
zonisamide cap 100 mg
HYDANTOINS phenytoin chew tab 50 mg Age Restriction
phenytoin sodium extended cap 100 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
15
Drug Name Requirements/Limits
phenytoin susp 125 mg/5ml
SUCCINIMIDES ethosuximide cap 250 mg
ethosuximide soln 250 mg/5ml
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 er 24 hr 250 mg
divalproex sodium tab er 24 hr 500 mg
valproate sodium oral soln 250 mg/5ml (base equiv)
valproic acid cap 250 mg
ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)
mirtazapine orally disintegrating tab 15 mg
mirtazapine orally disintegrating tab 30 mg
mirtazapine orally disintegrating tab 45 mg
mirtazapine tab 7.5 mg
mirtazapine tab 15 mg
mirtazapine tab 30 mg
mirtazapine tab 45 mg
ANTIDEPRESSANTS - MISC. bupropion hcl tab 75 mg
bupropion hcl tab 100 mg
bupropion hcl tab er 12hr 100 mg
bupropion hcl tab er 12hr 150 mg
bupropion hcl tab er 12hr 200 mg
bupropion hcl tab er 24hr 150 mg
bupropion hcl tab er 24hr 300 mg
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram hydrobromide oral soln 10 mg/5ml QL (600 ml / 30 days)
citalopram hydrobromide tab 10 mg (base equiv) QL (4 tabs / day)
citalopram hydrobromide tab 20 mg (base equiv) QL (2 tabs / day)
citalopram hydrobromide tab 40 mg (base equiv) QL (1 tab / day)
escitalopram oxalate tab 5 mg (base equiv)
escitalopram oxalate tab 10 mg (base equiv)
escitalopram oxalate tab 20 mg (base equiv)
fluoxetine hcl cap 10 mg
fluoxetine hcl cap 20 mg
fluoxetine hcl cap 40 mg
fluoxetine hcl solution 20 mg/5ml
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
fluvoxamine maleate tab 25 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
16
Drug Name Requirements/Limits
fluvoxamine maleate tab 50 mg
fluvoxamine maleate tab 100 mg
paroxetine hcl tab 10 mg
paroxetine hcl tab 20 mg
paroxetine hcl tab 30 mg
paroxetine hcl tab 40 mg
sertraline hcl oral concentrate for solution 20 mg/ml
sertraline hcl tab 25 mg
sertraline hcl tab 50 mg
sertraline hcl tab 100 mg
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
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) desvenlafaxine succinate tab er 24hr 25 mg (base
equiv) QL (1 tab / day)
desvenlafaxine succinate tab er 24hr 50 mg (base equiv)
QL (1 tab / day)
desvenlafaxine succinate tab er 24hr 100 mg (base equiv)
QL (1 tab / day)
duloxetine hcl cap 20 mg QL (2 caps / day)
duloxetine hcl cap 30 mg QL (2 caps / day)
duloxetine hcl cap 60 mg QL (2 caps / day)
venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)
venlafaxine hcl cap er 24hr 75 mg (base equivalent)
venlafaxine hcl cap er 24hr 150 mg (base equivalent)
venlafaxine hcl tab 25 mg
venlafaxine hcl tab 37.5 mg
venlafaxine hcl tab 50 mg
venlafaxine hcl tab 75 mg
venlafaxine hcl tab 100 mg
TRICYCLIC AGENTS amitriptyline hcl tab 10 mg
amitriptyline hcl tab 25 mg
amitriptyline hcl tab 50 mg
amitriptyline hcl tab 75 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
17
Drug Name Requirements/Limits
amitriptyline hcl tab 100 mg
amitriptyline hcl tab 150 mg
clomipramine hcl cap 25 mg QL (10 caps / day); Age Restriction
clomipramine hcl cap 50 mg QL (5 caps / day); Age
Restriction
clomipramine hcl cap 75 mg QL (3 caps / day); Age
Restriction
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
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
nortriptyline hcl cap 10 mg
nortriptyline hcl cap 25 mg
nortriptyline hcl cap 50 mg
nortriptyline hcl cap 75 mg
ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS
acarbose tab 25 mg
acarbose tab 50 mg
acarbose tab 100 mg
ANTIDIABETIC COMBINATIONS alogliptin-metformin hcl tab 12.5-500 mg PA
alogliptin-metformin hcl tab 12.5-1000 mg PA
alogliptin-pioglitazone tab 12.5-15 mg PA
alogliptin-pioglitazone tab 12.5-30 mg PA
alogliptin-pioglitazone tab 12.5-45 mg PA
alogliptin-pioglitazone tab 25-15 mg PA
alogliptin-pioglitazone tab 25-30 mg PA
alogliptin-pioglitazone tab 25-45 mg PA
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
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
18
Drug Name Requirements/Limits
glyburide-metformin tab 2.5-500 mg
glyburide-metformin tab 5-500 mg
INVOKAMET TAB 50-500MG PA
INVOKAMET TAB 50-1000 PA
INVOKAMET TAB 150-500 PA
INVOKAMET TAB 150-1000 PA
INVOKAMET XR TAB 50-500MG PA
INVOKAMET XR TAB 50-1000 PA
INVOKAMET XR TAB 150-500 PA
INVOKAMET XR TAB 150-1000 PA
JANUMET TAB 50-500MG PA
JANUMET TAB 50-1000 PA
JANUMET XR TAB 50-500MG PA
JANUMET XR TAB 50-1000 PA
JANUMET XR TAB 100-1000 PA
JENTADUETO TAB 2.5-500 PA
JENTADUETO TAB 2.5-850 PA
JENTADUETO TAB 2.5-1000 PA
JENTADUETO TAB XR PA
BIGUANIDES metformin hcl tab 500 mg
metformin hcl tab 850 mg
metformin hcl tab 1000 mg
metformin hcl tab er 24hr 500 mg
metformin hcl tab er 24hr 750 mg
DIABETIC OTHER BD GLUCOSE CHW 5GM OTC
GLUCAGEN INJ HYPOKIT QL (2 / 30 days)
GLUCAGON KIT 1MG
GLUCOSE BITS CHW 1GM OTC
GLUCOSE CHW 4GM OTC
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS alogliptin benzoate tab 6.25 mg (base equiv) PA
alogliptin benzoate tab 12.5 mg (base equiv) PA
alogliptin benzoate tab 25 mg (base equiv) PA
JANUVIA TAB 25MG PA
JANUVIA TAB 50MG PA
JANUVIA TAB 100MG PA
TRADJENTA TAB 5MG PA
INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) BYDUREON BC INJ 2/0.85ML ST
BYDUREON INJ 2MG ST
BYDUREON PEN INJ 2MG ST
BYETTA INJ 5MCG ST
BYETTA INJ 10MCG ST
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
19
Drug Name Requirements/Limits
TRULICITY INJ 0.75/0.5 ST
TRULICITY INJ 1.5/0.5 ST
VICTOZA INJ 18MG/3ML ST
INSULIN ADMELOG INJ 100U/ML
ADMELOG SOLO INJ 100U/ML
APIDRA INJ U-100
BASAGLAR KWIKPEN QL (30 ml / 30 days)
HUMALOG MIX INJ 50/50 QL (30 ml / fill)
HUMALOG MIX SUS 75/25 QL (30 ml / fill)
HUMULIN INJ 70/30 OTC, QL (30 ml / fill)
HUMULIN N INJ U-100 OTC, QL (30 ml / fill)
HUMULIN R INJ U-100 OTC, QL (30 ml / 30 days)
NOVOLIN70/30 INJ RELION OTC, QL (30 ml / fill)
NOVOLIN INJ 70/30 OTC, QL (30 ml / fill)
NOVOLIN N INJ RELION OTC, QL (30 ml / fill)
NOVOLIN N INJ U-100 OTC, QL (30 ml / fill)
NOVOLIN R INJ RELION OTC, QL (30 ml / 30 days)
NOVOLIN R INJ U-100 OTC, QL (30 ml / 30 days)
NOVOLOG MIX INJ 70/30
INSULIN SENSITIZING AGENTS pioglitazone hcl tab 15 mg (base equiv)
pioglitazone hcl tab 30 mg (base equiv)
pioglitazone hcl tab 45 mg (base equiv)
SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA TAB 5MG PA
FARXIGA TAB 10MG PA
INVOKANA TAB 100MG PA
INVOKANA TAB 300MG PA
JARDIANCE TAB 10MG PA
JARDIANCE TAB 25MG PA
SULFONYLUREAS glimepiride tab 1 mg
glimepiride tab 2 mg
glimepiride tab 4 mg
glipizide tab 5 mg
glipizide tab 10 mg
glipizide tab er 24hr 2.5 mg
glipizide tab er 24hr 5 mg
glipizide tab er 24hr 10 mg
glyburide micronized tab 1.5 mg
glyburide micronized tab 3 mg
glyburide micronized tab 6 mg
glyburide tab 1.25 mg
glyburide tab 2.5 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
20
Drug Name Requirements/Limits
glyburide tab 5 mg
ANTIDIARRHEAL/PROBIOTIC AGENTS ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC.
bismuth subsalicylate chew tab 262 mg OTC
ANTIPERISTALTIC AGENTS diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml
diphenoxylate w/ atropine tab 2.5-0.025 mg
loperamide hcl cap 2 mg
loperamide hcl liq 1 mg/5ml (0.2 mg/ml) OTC
loperamide hcl tab 2 mg OTC
ANTIDOTES AND SPECIFIC ANTAGONISTS ANTIDOTES AND SPECIFIC ANTAGONISTS
IPECAC SYP OTC
OPIOID ANTAGONISTS naloxone hcl inj 0.4 mg/ml
naloxone hcl soln cartridge 0.4 mg/ml
naloxone hcl soln prefilled syringe 2 mg/2ml
naltrexone hcl tab 50 mg
NARCAN SPR QL (1 kit / fill)
VIVITROL INJ 380MG PA
ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS
granisetron hcl tab 1 mg ST
ondansetron hcl oral soln 4 mg/5ml QL (50 ml / 30 days)
ondansetron hcl tab 4 mg
ondansetron hcl tab 8 mg
ondansetron hcl tab 24 mg QL (6 tabs / 30 days, max 2 fills every 30 days)
ondansetron orally disintegrating tab 4 mg
ondansetron orally disintegrating tab 8 mg
ANTIEMETICS - ANTICHOLINERGIC dimenhydrinate tab 50 mg OTC
meclizine hcl chew tab 25 mg OTC
meclizine hcl tab 12.5 mg
meclizine hcl tab 25 mg
trimethobenzamide hcl cap 300 mg
ANTIEMETICS - MISCELLANEOUS DICLEGIS TAB 10-10MG QL (4 per day), PA
dronabinol cap 2.5 mg PA
dronabinol cap 5 mg PA
dronabinol cap 10 mg PA
SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS aprepitant capsule 40 mg PA
aprepitant capsule 80 mg PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
21
Drug Name Requirements/Limits
aprepitant capsule 125 mg PA
aprepitant capsule therapy pack 80 & 125 mg PA
EMEND SOL 150MG PA
EMEND SUS 125MG PA
ANTIFUNGALS ANTIFUNGALS
griseofulvin microsize susp 125 mg/5ml
nystatin tab 500000 unit
terbinafine hcl tab 250 mg
IMIDAZOLE-RELATED ANTIFUNGALS CRESEMBA CAP 186 MG PA
CRESEMBA INJ 372MG PA
fluconazole for susp 10 mg/ml
fluconazole for susp 40 mg/ml
fluconazole tab 50 mg
fluconazole tab 100 mg
fluconazole tab 150 mg
fluconazole tab 200 mg
itraconazole cap 100 mg PA
ANTIHISTAMINES ANTIHISTAMINES - ALKYLAMINES
aller-chlor syp 2mg/5ml OTC
chlorpheniramine maleate tab 4 mg OTC
chlorpheniramine maleate tab er 12 mg OTC
ANTIHISTAMINES - ETHANOLAMINES diphenhydram cap 50mg OTC
diphenhydramine hcl cap 25 mg OTC
diphenhydramine hcl elixir 12.5 mg/5ml
diphenhydramine hcl liquid 12.5 mg/5ml OTC
diphenhydramine hcl tab 25 mg OTC
ANTIHISTAMINES - NON-SEDATING ALLEGRA ALRG TAB 30MG OTC, ST
cetirizine sol 1mg/ml OTC
cetirizine tab 5mg OTC
cetirizine tab 10mg OTC; Available for 90 day fill
desloratadine tab 5 mg
fexofenadine sus 30mg/5ml OTC
fexofenadine tab 180mg OTC
levocetirizine dihydrochloride tab 5 mg
loratadine sol 5mg/5ml OTC
loratadine tab 10 mg OTC; Available for 90 day fill
ANTIHISTAMINES - PHENOTHIAZINES promethazine hcl suppos 12.5 mg
promethazine hcl suppos 25 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
22
Drug Name Requirements/Limits
promethazine hcl syrup 6.25 mg/5ml
promethazine hcl tab 12.5 mg
promethazine hcl tab 25 mg
promethazine hcl tab 50 mg
ANTIHISTAMINES - PIPERIDINES cyproheptadine hcl syrup 2 mg/5ml
cyproheptadine hcl tab 4 mg
ANTIHYPERLIPIDEMICS BILE ACID SEQUESTRANTS
cholestyramine light powder 4 gm/dose
cholestyramine light powder packets 4 gm
cholestyramine powder 4 gm/dose
cholestyramine powder packets 4 gm
colesevelam hcl tab 625 mg
colestipol hcl granule packets 5 gm
colestipol hcl granules 5 gm
colestipol hcl tab 1 gm
FIBRIC ACID DERIVATIVES fenofibrate micronized cap 67 mg
fenofibrate micronized cap 134 mg
fenofibrate micronized cap 200 mg
fenofibrate tab 54 mg
fenofibrate tab 145 mg
gemfibrozil tab 600 mg
HMG COA REDUCTASE INHIBITORS atorvastatin calcium tab 10 mg (base equivalent)
atorvastatin calcium tab 20 mg (base equivalent)
atorvastatin calcium tab 40 mg (base equivalent)
atorvastatin calcium tab 80 mg (base equivalent)
lovastatin tab 10 mg
lovastatin tab 20 mg
lovastatin tab 40 mg
pravastatin sodium tab 10 mg
pravastatin sodium tab 20 mg
pravastatin sodium tab 40 mg
pravastatin sodium tab 80 mg
rosuvastatin calcium tab 5 mg
rosuvastatin calcium tab 10 mg
rosuvastatin calcium tab 20 mg
rosuvastatin calcium tab 40 mg
simvastatin tab 5 mg Available for 90 day fill
simvastatin tab 10 mg Available for 90 day fill
simvastatin tab 20 mg Available for 90 day fill
simvastatin tab 40 mg Available for 90 day fill
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
23
Drug Name Requirements/Limits
INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg
NICOTINIC ACID DERIVATIVES niacin tab er 1000 mg (antihyperlipidemic)
PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS REPATHA INJ 140MG/ML PA
REPATHA PUSH INJ 420/3.5 PA
REPATHA SURE INJ 140MG/ML PA
ANTIHYPERTENSIVES ACE INHIBITORS
benazepril hcl tab 5 mg Available for 90 day fill
benazepril hcl tab 10 mg Available for 90 day fill
benazepril hcl tab 20 mg Available for 90 day fill
benazepril hcl tab 40 mg Available for 90 day fill
enalapril maleate tab 2.5 mg Available for 90 day fill
enalapril maleate tab 5 mg Available for 90 day fill
enalapril maleate tab 10 mg Available for 90 day fill
enalapril maleate tab 20 mg Available for 90 day fill
fosinopril sodium tab 10 mg
fosinopril sodium tab 20 mg
fosinopril sodium tab 40 mg
lisinopril tab 2.5 mg Available for 90 day fill
lisinopril tab 5 mg Available for 90 day fill
lisinopril tab 10 mg Available for 90 day fill
lisinopril tab 20 mg Available for 90 day fill
lisinopril tab 30 mg Available for 90 day fill
lisinopril tab 40 mg Available for 90 day fill
moexipril hcl tab 7.5 mg
moexipril hcl tab 15 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
ANGIOTENSIN II RECEPTOR ANTAGONISTS irbesartan tab 75 mg
irbesartan tab 150 mg
irbesartan tab 300 mg
losartan potassium tab 25 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
24
Drug Name Requirements/Limits
losartan potassium tab 50 mg
losartan potassium tab 100 mg
olmesartan medoxomil tab 5 mg
olmesartan medoxomil tab 20 mg
olmesartan medoxomil tab 40 mg
telmisartan tab 20 mg
telmisartan tab 40 mg
telmisartan tab 80 mg
valsartan tab 40 mg
valsartan tab 80 mg
valsartan tab 160 mg
valsartan tab 320 mg
ANTIADRENERGIC ANTIHYPERTENSIVES clonidine hcl tab 0.1 mg
clonidine hcl tab 0.2 mg
clonidine hcl tab 0.3 mg
doxazosin mesylate tab 1 mg
doxazosin mesylate tab 2 mg
doxazosin mesylate tab 4 mg
doxazosin mesylate tab 8 mg
guanfacine hcl tab 1 mg
guanfacine hcl tab 2 mg
methyldopa tab 250 mg
methyldopa tab 500 mg
prazosin hcl cap 1 mg
prazosin hcl cap 2 mg
prazosin hcl cap 5 mg
terazosin hcl cap 1 mg (base equivalent)
terazosin hcl cap 2 mg (base equivalent)
terazosin hcl cap 5 mg (base equivalent)
terazosin hcl cap 10 mg (base equivalent)
ANTIHYPERTENSIVE COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-10 mg
amlodipine besylate-benazepril hcl cap 5-10 mg
amlodipine besylate-benazepril hcl cap 5-20 mg
amlodipine besylate-benazepril hcl cap 5-40 mg
amlodipine besylate-benazepril hcl cap 10-20 mg
amlodipine besylate-benazepril hcl cap 10-40 mg
amlodipine besylate-olmesartan medoxomil tab 5-
20 mg
amlodipine besylate-olmesartan medoxomil tab 5-
40 mg
amlodipine besylate-olmesartan medoxomil tab 10-20 mg
amlodipine besylate-olmesartan medoxomil tab 10-40 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
25
Drug Name Requirements/Limits
amlodipine besylate-valsartan tab 5-160 mg
amlodipine besylate-valsartan tab 5-320 mg
amlodipine besylate-valsartan tab 10-160 mg
amlodipine besylate-valsartan tab 10-320 mg
atenolol & chlorthalidone tab 50-25 mg
atenolol & chlorthalidone tab 100-25 mg
benazepril & hydrochlorothiazide tab 10-12.5 mg
benazepril & hydrochlorothiazide tab 20-12.5 mg
benazepril & hydrochlorothiazide tab 20-25 mg
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg
enalapril maleate & hydrochlorothiazide tab 10-25 mg
fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg
fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg
irbesartan-hydrochlorothiazide tab 150-12.5 mg
irbesartan-hydrochlorothiazide tab 300-12.5 mg
lisinopril & hydrochlorothiazide tab 10-12.5 mg Available for 90 day fill
lisinopril & hydrochlorothiazide tab 20-12.5 mg Available for 90 day fill
lisinopril & hydrochlorothiazide tab 20-25 mg Available for 90 day fill
losartan potassium & hydrochlorothiazide tab 50-12.5 mg
losartan potassium & hydrochlorothiazide tab 100-12.5 mg
losartan potassium & hydrochlorothiazide tab 100-25 mg
moexipril-hydrochlorothiazide tab 7.5-12.5 mg
moexipril-hydrochlorothiazide tab 15-12.5 mg
moexipril-hydrochlorothiazide tab 15-25 mg
olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg
olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg
olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg
olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg
olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg
olmesartan-amlodipine-hydrochlorothiazide tab
40-5-25 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
26
Drug Name Requirements/Limits
olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg
olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg
propranolol & hydrochlorothiazide tab 40-25 mg
propranolol & hydrochlorothiazide tab 80-25 mg
quinapril-hydrochlorothiazide tab 10-12.5 mg
quinapril-hydrochlorothiazide tab 20-12.5 mg
quinapril-hydrochlorothiazide tab 20-25 mg
valsartan-hydrochlorothiazide tab 80-12.5 mg
valsartan-hydrochlorothiazide tab 160-12.5 mg
valsartan-hydrochlorothiazide tab 160-25 mg
valsartan-hydrochlorothiazide tab 320-12.5 mg
valsartan-hydrochlorothiazide tab 320-25 mg
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
ANTIMALARIALS ANTIMALARIALS
hydroxychloroquine sulfate tab 200 mg
ANTIMYASTHENIC/CHOLINERGIC AGENTS ANTIMYASTHENIC/CHOLINERGIC AGENTS
pyridostigmine bromide tab 60 mg
ANTIMYCOBACTERIAL AGENTS ANTIMYCOBACTERIAL AGENTS
ethambutol hcl tab 400 mg
isoniazid syrup 50 mg/5ml
isoniazid tab 100 mg
isoniazid tab 300 mg
pyrazinamide tab 500 mg
rifampin cap 150 mg
rifampin cap 300 mg
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALKYLATING AGENTS
LEUKERAN TAB 2MG
temozolomide cap 5 mg
temozolomide cap 20 mg
temozolomide cap 100 mg
temozolomide cap 140 mg
temozolomide cap 180 mg
temozolomide cap 250 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
27
Drug Name Requirements/Limits
ANTIMETABOLITES capecitabine tab 150 mg
capecitabine tab 500 mg
mercaptopurine tab 50 mg
methotrexate sodium inj 50 mg/2ml (25 mg/ml)
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)
methotrexate sodium tab 2.5 mg (base equiv)
TABLOID TAB 40MG
ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS anastrozole tab 1 mg
bicalutamide tab 50 mg
exemestane tab 25 mg
flutamide cap 125 mg
letrozole tab 2.5 mg
LUPRON DEPOT INJ 3.75MG PA
LUPRON DEPOT INJ 7.5MG PA
LUPRON DEPOT INJ 11.25MG PA
LUPRON DEPOT INJ 22.5MG PA
LUPRON DEPOT INJ 30MG PA
LUPRON DEPOT INJ 45MG PA
megestrol acetate susp 40 mg/ml
megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
tamoxifen citrate tab 10 mg (base equivalent)
tamoxifen citrate tab 20 mg (base equivalent)
XTANDI CAP 40MG PA
ANTINEOPLASTIC COMBINATIONS KISQALI 200 PAK FEMARA PA
KISQALI 400 PAK FEMARA PA
KISQALI 600 PAK FEMARA PA
ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR TAB 2.5MG
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
AFINITOR TAB 10MG
IBRANCE CAP 75MG QL (21 caps / 28 days), PA
IBRANCE CAP 100MG QL (21 caps / 28 days), PA
IBRANCE CAP 125MG QL (21 caps / 28 days), PA
imatinib mesylate tab 100 mg (base equivalent)
imatinib mesylate tab 400 mg (base equivalent)
NERLYNX TAB 40MG QL (180 / 30 days), PA
NEXAVAR TAB 200MG PA
SPRYCEL TAB 50MG PA
STIVARGA TAB 40MG
SUTENT CAP 12.5MG
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
28
Drug Name Requirements/Limits
SUTENT CAP 25MG
SUTENT CAP 50MG
TARCEVA TAB 25MG
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TYKERB TAB 250MG
VERZENIO TAB 50MG QL (56 / 28 days), PA
VERZENIO TAB 100MG QL (56 / 28 days), PA
VERZENIO TAB 150MG QL (56 / 28 days), PA
VERZENIO TAB 200MG QL (56 / 28 days), PA
VOTRIENT TAB 200MG PA
ANTINEOPLASTICS MISC. hydroxyurea cap 500 mg
INTRON A INJ 10MU PA
INTRON A INJ 18MU PA
INTRON A INJ 25MU PA
INTRON A INJ 50MU PA
MATULANE CAP 50MG
tretinoin cap 10 mg
CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS leucovorin calcium tab 5 mg
leucovorin calcium tab 25 mg
mesna inj 100 mg/ml
MESNEX TAB 400MG
MITOTIC INHIBITORS etoposide cap 50 mg
TOPOISOMERASE I INHIBITORS HYCAMTIN CAP 0.25MG
HYCAMTIN CAP 1MG
ANTIPARKINSON AND RELATED THERAPY AGENTS ANTIPARKINSON ANTICHOLINERGICS
benztropine mesylate tab 0.5 mg
benztropine mesylate tab 1 mg
benztropine mesylate tab 2 mg
trihexyphenidyl hcl elixir 0.4 mg/ml
trihexyphenidyl hcl tab 2 mg
trihexyphenidyl hcl tab 5 mg
ANTIPARKINSON DOPAMINERGICS amantadine hcl cap 100 mg
amantadine hcl syrup 50 mg/5ml
amantadine hcl tab 100 mg
bromocriptine mesylate cap 5 mg (base equivalent)
bromocriptine mesylate tab 2.5 mg (base equivalent)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
29
Drug Name Requirements/Limits
carbidopa & levodopa tab 10-100 mg
carbidopa & levodopa tab 25-100 mg
carbidopa & levodopa tab 25-250 mg
carbidopa & levodopa tab er 25-100 mg
pramipexole dihydrochloride tab 0.5 mg
pramipexole dihydrochloride tab 0.25 mg
pramipexole dihydrochloride tab 0.75 mg
pramipexole dihydrochloride tab 0.125 mg
pramipexole dihydrochloride tab 1 mg
pramipexole dihydrochloride tab 1.5 mg
ropinirole hydrochloride tab 0.5 mg
ropinirole hydrochloride tab 0.25 mg
ropinirole hydrochloride tab 1 mg
ropinirole hydrochloride tab 2 mg
ropinirole hydrochloride tab 3 mg
ropinirole hydrochloride tab 4 mg
ropinirole hydrochloride tab 5 mg
ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS selegiline hcl tab 5 mg
ANTIPSYCHOTICS/ANTIMANIC AGENTS ANTIMANIC AGENTS
lithium carbonate cap 150 mg
lithium carbonate cap 300 mg
lithium carbonate cap 600 mg
lithium carbonate tab 300 mg
lithium carbonate tab er 300 mg
lithium carbonate tab er 450 mg
LITHIUM SOL 8MEQ/5ML
ANTIPSYCHOTICS - MISC. NUPLAZID TAB 17MG PA
ziprasidone hcl cap 20 mg
ziprasidone hcl cap 40 mg
ziprasidone hcl cap 60 mg
ziprasidone hcl cap 80 mg
BENZISOXAZOLES INVEGA SUST INJ 39/0.25 PA
INVEGA SUST INJ 78/0.5ML PA
INVEGA SUST INJ 117/0.75 PA
INVEGA SUST INJ 156MG/ML PA
INVEGA SUST INJ 234/1.5 PA
INVEGA TRINZ INJ 273MG PA
INVEGA TRINZ INJ 410MG PA
INVEGA TRINZ INJ 546MG PA
INVEGA TRINZ INJ 819MG PA
paliperidone tab er 24hr 1.5 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
30
Drug Name Requirements/Limits
paliperidone tab er 24hr 3 mg
paliperidone tab er 24hr 6 mg
paliperidone tab er 24hr 9 mg
RISPERDAL INJ 12.5MG PA
RISPERDAL INJ 25MG PA
RISPERDAL INJ 37.5MG PA
RISPERDAL INJ 50MG PA
risperidone soln 1 mg/ml
risperidone tab 0.5 mg
risperidone tab 0.25 mg
risperidone tab 1 mg
risperidone tab 2 mg
risperidone tab 3 mg
risperidone tab 4 mg
BUTYROPHENONES haloperidol decanoate im soln 50 mg/ml
haloperidol decanoate im soln 100 mg/ml
haloperidol lactate oral conc 2 mg/ml
haloperidol tab 0.5 mg
haloperidol tab 1 mg
haloperidol tab 2 mg
haloperidol tab 5 mg
haloperidol tab 10 mg
haloperidol tab 20 mg
DIBENZAPINES clozapine tab 25 mg
clozapine tab 50 mg
clozapine tab 100 mg
clozapine tab 200 mg
loxapine succinate cap 5 mg
loxapine succinate cap 10 mg
loxapine succinate cap 25 mg
loxapine succinate cap 50 mg
olanzapine for im inj 10 mg
olanzapine orally disintegrating tab 5 mg
olanzapine orally disintegrating tab 10 mg
olanzapine orally disintegrating tab 15 mg
olanzapine orally disintegrating tab 20 mg
olanzapine tab 2.5 mg
olanzapine tab 5 mg
olanzapine tab 7.5 mg
olanzapine tab 10 mg
olanzapine tab 15 mg
olanzapine tab 20 mg
quetiapine fumarate tab 25 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
31
Drug Name Requirements/Limits
quetiapine fumarate tab 50 mg
quetiapine fumarate tab 100 mg
quetiapine fumarate tab 200 mg
quetiapine fumarate tab 300 mg
quetiapine fumarate tab 400 mg
quetiapine fumarate tab er 24hr 50 mg
quetiapine fumarate tab er 24hr 150 mg
quetiapine fumarate tab er 24hr 200 mg
quetiapine fumarate tab er 24hr 300 mg
quetiapine fumarate tab er 24hr 400 mg
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 decanoate inj 25 mg/ml
perphenazine tab 2 mg
perphenazine tab 4 mg
perphenazine tab 8 mg
perphenazine tab 16 mg
prochlorperazine maleate tab 5 mg (base equivalent)
prochlorperazine maleate tab 10 mg (base equivalent)
prochlorperazine suppos 25 mg QL (12 / fill)
thioridazine hcl tab 25 mg
thioridazine hcl tab 50 mg
thioridazine hcl tab 100 mg
trifluoperazine hcl tab 1 mg (base equivalent)
trifluoperazine hcl tab 2 mg (base equivalent)
trifluoperazine hcl tab 5 mg (base equivalent)
trifluoperazine hcl tab 10 mg (base equivalent)
QUINOLINONE DERIVATIVES aripiprazole tab 2 mg
aripiprazole tab 5 mg
aripiprazole tab 10 mg
aripiprazole tab 15 mg
aripiprazole tab 20 mg
aripiprazole tab 30 mg
THIOXANTHENES thiothixene cap 5 mg
thiothixene cap 10 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
32
Drug Name Requirements/Limits
ANTISEPTICS & DISINFECTANTS IODINE ANTISEPTICS
NUPREP 5% SOL POV-IODI OTC
povidone-iod sol 7.5% OTC
povidone-iodine oint 10% OTC
povidone-iodine soln 10% OTC
ANTIVIRALS ANTIRETROVIRALS
abacavir sulfate soln 20 mg/ml (base equiv)
abacavir sulfate tab 300 mg (base equiv)
abacavir sulfate-lamivudine tab 600-300 mg
abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg
APTIVUS CAP 250MG
APTIVUS SOL
atazanavir sulfate cap 150 mg (base equiv)
atazanavir sulfate cap 200 mg (base equiv)
atazanavir sulfate cap 300 mg (base equiv)
ATRIPLA TAB
BIKTARVY TAB
COMPLERA TAB
CRIXIVAN CAP 200MG
CRIXIVAN CAP 400MG
DESCOVY TAB 200/25
didanosine delayed release capsule 200 mg
didanosine delayed release capsule 250 mg
didanosine delayed release capsule 400 mg
EDURANT TAB 25MG
efavirenz cap 50 mg
efavirenz cap 200 mg
efavirenz tab 600 mg
EMTRIVA CAP 200MG
EMTRIVA SOL 10MG/ML
EVOTAZ TAB 300-150
fosamprenavir calcium tab 700 mg (base equiv)
FUZEON INJ 90MG
GENVOYA TAB
INTELENCE TAB 25MG
INTELENCE TAB 100MG
INTELENCE TAB 200MG
INVIRASE CAP 200MG
INVIRASE TAB 500MG
ISENTRESS CHW 25MG
ISENTRESS CHW 100MG
ISENTRESS TAB 400MG
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
33
Drug Name Requirements/Limits
JULUCA TAB 50-25MG
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
lamivudine oral soln 10 mg/ml
lamivudine tab 150 mg
lamivudine tab 300 mg
lamivudine-zidovudine tab 150-300 mg
LEXIVA SUS 50MG/ML
lopinavir-ritonavir soln 400-100 mg/5ml (80-20
mg/ml)
nevirapine susp 50 mg/5ml
nevirapine tab 200 mg
nevirapine tab er 24hr 400 mg
NORVIR SOL 80MG/ML
ODEFSEY TAB
PREZCOBIX TAB 800-150
PREZISTA SUS 100MG/ML
PREZISTA TAB 75MG
PREZISTA TAB 150MG
PREZISTA TAB 600MG
PREZISTA TAB 800MG
RESCRIPTOR TAB 100 MG
RESCRIPTOR TAB 200MG
ritonavir tab 100 mg
SELZENTRY TAB 25MG
SELZENTRY TAB 75MG
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
stavudine cap 15 mg
stavudine cap 20 mg
stavudine cap 30 mg
stavudine cap 40 mg
STRIBILD TAB
tenofovir disoproxil fumarate tab 300 mg
TIVICAY TAB 50MG
TRIUMEQ TAB
TRUVADA TAB
TRUVADA TAB 100-150
TRUVADA TAB 133-200
TRUVADA TAB 167-250
VIDEX EC CAP 125MG
VIDEX SOL 4GM
VIRACEPT TAB 250MG
VIRACEPT TAB 625MG
zidovudine cap 100 mg
zidovudine syrup 10 mg/ml
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
34
Drug Name Requirements/Limits
zidovudine tab 300 mg
CMV AGENTS valganciclovir hcl for soln 50 mg/ml (base equiv) Age Restriction
valganciclovir hcl tab 450 mg (base equivalent)
HEPATITIS AGENTS adefovir dipivoxil tab 10 mg
entecavir tab 0.5 mg
entecavir tab 1 mg
lamivudine tab 100 mg (hbv)
MAVYRET TAB 100-40MG PA
ribavirin cap 200 mg PA
ribavirin tab 200 mg PA
VOSEVI TAB PA
HERPES AGENTS acyclovir cap 200 mg
acyclovir susp 200 mg/5ml
acyclovir tab 400 mg
acyclovir tab 800 mg
famciclovir tab 125 mg
famciclovir tab 250 mg
famciclovir tab 500 mg
valacyclovir hcl tab 1 gm
valacyclovir hcl tab 500 mg
INFLUENZA AGENTS oseltamivir phosphate cap 30 mg (base equiv)
oseltamivir phosphate cap 45 mg (base equiv)
oseltamivir phosphate cap 75 mg (base equiv)
oseltamivir phosphate for susp 6 mg/ml (base
equiv)
RELENZA MIS DISKHALE QL (1 inhaler / 90 days)
rimantadine hydrochloride tab 100 mg
BETA BLOCKERS ALPHA-BETA 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
BETA BLOCKERS CARDIO-SELECTIVE acebutolol hcl cap 200 mg
acebutolol hcl cap 400 mg
atenolol tab 25 mg Available for 90 day fill
atenolol tab 50 mg Available for 90 day fill
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
35
Drug Name Requirements/Limits
atenolol tab 100 mg Available for 90 day fill
bisoprolol fumarate tab 5 mg
bisoprolol fumarate tab 10 mg
FIRST - METO SOL 10MG/ML
metoprolol succinate tab er 24hr 25 mg (tartrate equiv)
metoprolol succinate tab er 24hr 50 mg (tartrate equiv)
metoprolol succinate tab er 24hr 100 mg (tartrate equiv)
metoprolol succinate tab er 24hr 200 mg (tartrate equiv)
metoprolol tartrate tab 25 mg
metoprolol tartrate tab 50 mg
metoprolol tartrate tab 100 mg
BETA BLOCKERS NON-SELECTIVE nadolol tab 20 mg
nadolol tab 40 mg
nadolol tab 80 mg
propranolol hcl cap er 24hr 60 mg
propranolol hcl cap er 24hr 80 mg
propranolol hcl cap er 24hr 120 mg
propranolol hcl cap er 24hr 160 mg
propranolol hcl oral soln 20 mg/5ml
propranolol hcl oral soln 40 mg/5ml
propranolol hcl tab 10 mg
propranolol hcl tab 20 mg
propranolol hcl tab 40 mg
propranolol hcl tab 60 mg
propranolol hcl tab 80 mg
sotalol hcl tab 80 mg
sotalol hcl tab 120 mg
sotalol hcl tab 160 mg
CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS
amlodipine besylate tab 2.5 mg (base equivalent) Available for 90 day fill
amlodipine besylate tab 5 mg (base equivalent) Available for 90 day fill
amlodipine besylate tab 10 mg (base equivalent) Available for 90 day fill
diltiazem hcl cap er 24hr 120 mg
diltiazem hcl cap er 24hr 180 mg
diltiazem hcl cap er 24hr 240 mg
diltiazem hcl coated beads cap er 24hr 120 mg
diltiazem hcl coated beads cap er 24hr 180 mg
diltiazem hcl coated beads cap er 24hr 240 mg
diltiazem hcl coated beads cap er 24hr 300 mg
diltiazem hcl coated beads cap er 24hr 360 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
36
Drug Name Requirements/Limits
diltiazem hcl coated beads tab er 24hr 360 mg
diltiazem hcl extended release beads cap er 24hr 120 mg
diltiazem hcl extended release beads cap er 24hr 240 mg
diltiazem hcl extended release beads cap er 24hr 300 mg
diltiazem hcl extended release beads cap er 24hr 360 mg
diltiazem hcl extended release beads cap er 24hr 420 mg
diltiazem hcl tab 30 mg
diltiazem hcl tab 60 mg
diltiazem hcl tab 90 mg
diltiazem hcl tab 120 mg
felodipine tab er 24hr 2.5 mg
felodipine tab er 24hr 5 mg
felodipine tab er 24hr 10 mg
nifedipine cap 10 mg
nifedipine cap 20 mg
nifedipine tab er 24hr 30 mg
nifedipine tab er 24hr 60 mg
nifedipine tab er 24hr 90 mg
nifedipine tab er 24hr osmotic release 30 mg
nifedipine tab er 24hr osmotic release 60 mg
nifedipine tab er 24hr osmotic release 90 mg
nimodipine cap 30 mg
verapamil hcl cap er 24hr 120 mg
verapamil hcl cap er 24hr 180 mg
verapamil hcl cap er 24hr 200 mg
verapamil hcl cap er 24hr 240 mg
verapamil hcl cap er 24hr 300 mg
verapamil hcl cap er 24hr 360 mg
verapamil hcl tab 40 mg
verapamil hcl tab 80 mg
verapamil hcl tab 120 mg
verapamil hcl tab er 120 mg
verapamil hcl tab er 180 mg
verapamil hcl tab er 240 mg
CARDIOTONICS CARDIAC GLYCOSIDES
digoxin oral soln 0.05 mg/ml
digoxin tab 125 mcg (0.125 mg)
digoxin tab 250 mcg (0.25 mg)
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Drug Name Requirements/Limits
CARDIOVASCULAR AGENTS - MISC. CARDIOVASCULAR AGENTS MISC. - COMBINATIONS
ENTRESTO TAB 24-26MG PA
ENTRESTO TAB 49-51MG PA
ENTRESTO TAB 97-103MG PA
PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR
ANTAGONISTS LETAIRIS TAB 5MG PA
LETAIRIS TAB 10MG PA
PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS sildenafil citrate tab 20 mg PA
tadalafil tab 20 mg (pah) PA
CEPHALOSPORINS CEPHALOSPORINS - 1ST GENERATION
cefadroxil cap 500 mg
cefadroxil for susp 250 mg/5ml
cefadroxil for susp 500 mg/5ml
cefadroxil tab 1 gm
cephalexin cap 250 mg
cephalexin cap 500 mg
cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
CEPHALOSPORINS - 2ND GENERATION cefprozil for susp 125 mg/5ml
cefprozil for susp 250 mg/5ml
cefprozil tab 250 mg
cefprozil tab 500 mg
cefuroxime axetil tab 250 mg
cefuroxime axetil tab 500 mg
CEPHALOSPORINS - 3RD GENERATION cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
CHEMICALS BULK CHEMICALS - M'S
MECLOFENOXAT POW HCL
LIQUIDS GLYCERIN LIQ OTC
CONTRACEPTIVES COMBINATION CONTRACEPTIVES - ORAL
aranelle tab
cryselle-28 tab
desogest-eth estrad & eth estrad tab 0.15-
0.02/0.01 mg(21/5)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
38
Drug Name Requirements/Limits
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
drospirenone-ethinyl estradiol tab 3-0.03 mg
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg
ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg
levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg
levonorgestrel-eth estra tab 0.05-30/0.075-
40/0.125-30mg-mcg
microgestin tab 1.5/30
microgestin tab 1/20
necon tab 1/50-28
NECON TAB 10/11-28
norethindrone ace & ethinyl estradiol tab 1 mg-20
mcg
norethindrone ace & ethinyl estradiol-fe tab 1 mg-
20 mcg
norgestimate & ethinyl estradiol tab 0.25 mg-35
mcg
norgestimate-eth estrad tab 0.18-25/0.215-
25/0.25-25 mg-mcg
norgestimate-eth estrad tab 0.18-35/0.215-
35/0.25-35 mg-mcg
nortrel tab 1/35
ogestrel tab
velivet pak
COMBINATION CONTRACEPTIVES - TRANSDERMAL xulane dis 150-35 QL (3 / 28 days)
COMBINATION CONTRACEPTIVES - VAGINAL NUVARING MIS
EMERGENCY CONTRACEPTIVES ELLA TAB 30MG
levonorgestrel tab 1.5 mg OTC
PROGESTIN CONTRACEPTIVES - INJECTABLE medroxyprogesterone acetate im susp 150 mg/ml
medroxyprogesterone acetate im susp prefilled syr 150 mg/ml
QL (1 syringe / 90 days)
PROGESTIN CONTRACEPTIVES - ORAL norethindrone tab 0.35 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
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Drug Name Requirements/Limits
CORTICOSTEROIDS GLUCOCORTICOSTEROIDS
budesonide delayed release particles cap 3 mg
budesonide tab er 24hr 9 mg PA
DEXAMETHASON CON 1MG/ML
dexamethasone elixir 0.5 mg/5ml
dexamethasone sodium phosphate inj 4 mg/ml
dexamethasone soln 0.5 mg/5ml
dexamethasone tab 0.5 mg
dexamethasone tab 0.75 mg
dexamethasone tab 1 mg
dexamethasone tab 1.5 mg
dexamethasone tab 2 mg
dexamethasone tab 4 mg
dexamethasone tab 6 mg
hydrocortisone tab 5 mg
hydrocortisone tab 10 mg
hydrocortisone tab 20 mg
methylprednisolone tab 4 mg
methylprednisolone tab 8 mg
methylprednisolone tab 16 mg
methylprednisolone tab 32 mg
methylprednisolone tab therapy pack 4 mg (21)
prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)
prednisolone syrup 15 mg/5ml (usp solution equivalent)
PREDNISONE CON 5MG/ML
prednisone oral soln 5 mg/5ml
prednisone tab 1 mg
prednisone tab 2.5 mg
prednisone tab 5 mg
prednisone tab 10 mg
prednisone tab 20 mg
prednisone tab 50 mg
prednisone tab therapy pack 5 mg (21)
prednisone tab therapy pack 10 mg (21)
MINERALOCORTICOIDS fludrocortisone acetate tab 0.1 mg
COUGH/COLD/ALLERGY ANTITUSSIVES
benzonatate cap 100 mg
benzonatate cap 200 mg
COUGH/COLD/ALLERGY COMBINATIONS cetirizine-pseudoephedrine tab er 12hr 5-120 mg OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
40
Drug Name Requirements/Limits
cold/allergy elx OTC
cold/allergy tab pe OTC
dextromethorphan-guaifenesin syrup 10-100 mg/5ml
OTC
DOUBLE-TUSSN LIQ DM OTC
intense coug liq reliever OTC
LOHIST-D LIQ OTC
loratadine & pseudoephedrine tab er 24hr 10-240 mg
OTC
loratadine-d tab 5-120mg OTC
mucus rel dm liq 5-100/5 OTC
prometh vc syp 6.25-5/5
promethazine w/ codeine syrup 6.25-10 mg/5ml Age Restriction
promethazine-dm syrup 6.25-15 mg/5ml
promethazine-phenylephrine-codeine syrup 6.25-
5-10 mg/5ml
Age Restriction
pseudoephed-bromphen-dm syrup 30-2-10
mg/5ml
sinus congst tab /pain dt OTC
tussin dm liq OTC
tussin dm liq max OTC
ZYNCOF SYP 20-400/5 OTC
EXPECTORANTS guaifenesin liquid 100 mg/5ml OTC
guaifenesin tab 200 mg OTC
MISC. RESPIRATORY INHALANTS sodium chloride soln nebu 0.9%
sodium chloride soln nebu 3%
sodium chloride soln nebu 7%
MUCOLYTICS acetylcysteine inhal soln 10%
acetylcysteine inhal soln 20%
DERMATOLOGICALS ACNE PRODUCTS
ABSORICA CAP 10MG PA
ABSORICA CAP 20MG PA
ABSORICA CAP 30MG PA
ABSORICA CAP 40MG PA
ACNE MEDICAT LOT 5% OTC
ACNE MEDICAT LOT 10% OTC
adapalene gel 0.1%
amnesteem cap 10mg PA
amnesteem cap 20mg PA
amnesteem cap 40mg PA
benzoyl peroxide-erythromycin gel 5-3% QL (23.3 gm / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
41
Drug Name Requirements/Limits
bp gel gel 5% OTC, QL (1 fill / 30 days)
bp gel gel 10% OTC, QL (1 fill / 30 days)
bp wash liq 5% OTC, QL (240 gm / fill)
claravis cap 10mg PA
claravis cap 20mg PA
claravis cap 30mg PA
claravis cap 40mg PA
clindamycin phosph-benzoyl peroxide (refrig) gel
1.2 (1)-5%
QL (45 gm / 30 days)
clindamycin phosphate gel 1% QL (30 gm / 30 days)
clindamycin phosphate lotion 1% QL (60 ml / 30 days)
clindamycin phosphate soln 1% QL (30 ml / 30 days)
clindamycin phosphate swab 1% QL (60 / 30 days)
erythromycin gel 2% QL (30 gm / 30 days)
erythromycin soln 2% QL (60 ml / 30 days)
isotretinoin cap 10 mg PA
isotretinoin cap 20 mg PA
isotretinoin cap 30 mg PA
isotretinoin cap 40 mg PA
myorisan cap 10mg PA
myorisan cap 20mg PA
myorisan cap 30mg PA
myorisan cap 40mg PA
panoxyl wash liq 4% OTC, QL (170.1 gm / 30 days)
tretinoin cream 0.1% QL (20 gm / 30 days); Age Restriction
tretinoin cream 0.05% QL (20 gm / 30 days); Age Restriction
tretinoin cream 0.025% QL (20 gm / 30 days); Age Restriction
tretinoin gel 0.01% QL (15 gm / 30 days); Age Restriction
tretinoin gel 0.025% QL (15 gm / 30 days); Age Restriction
zenatane cap 10mg PA
zenatane cap 20mg PA
zenatane cap 30mg PA
zenatane cap 40mg PA
ANTI-INFLAMMATORY AGENTS - TOPICAL diclofenac sodium gel 1% QL (100 gm / 30 days)
ANTIBIOTICS - TOPICAL bacitracin oint 500 unit/gm OTC
bacitracin zinc oint 500 unit/gm OTC
bacitracin-polymyxin b oint OTC
gentamicin sulfate cream 0.1%
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
42
Drug Name Requirements/Limits
gentamicin sulfate oint 0.1%
mupirocin oint 2%
neomycin-bacitracin-polymyxin oint OTC
triple antib oin plus OTC
ANTIFUNGALS - TOPICAL antifungal cre 1% OTC
athlete foot cre 1% OTC
ciclodan cre 0.77% QL (30 gm / fill)
ciclodan sol 8%
clotrimazole cream 1%
clotrimazole soln 1%
clotrimazole w/ betamethasone cream 1-0.05% Age Restriction
clotrimazole w/ betamethasone lotion 1-0.05% Age Restriction
ketoconazole cream 2%
ketoconazole shampoo 2%
miconazole cre 2% OTC
nystatin cream 100000 unit/gm
nystatin oint 100000 unit/gm
nystatin topical powder 100000 unit/gm QL (60 gm / fill)
ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL fluorouracil cream 5%
fluorouracil soln 2%
fluorouracil soln 5%
ANTIPSORIATICS acitretin cap 10 mg PA
acitretin cap 17.5 mg PA
acitretin cap 25 mg PA
calcipotriene oint 0.005% QL (60 gm per fill)
calcipotriene soln 0.005% (50 mcg/ml) QL (60 ml per fill)
STELARA INJ 45MG/0.5 PA
STELARA INJ 90MG/ML PA
ANTISEBORRHEIC PRODUCTS selenium sulfide lotion 2.5%
ANTIVIRALS - TOPICAL acyclovir oint 5% QL (5 gm / fill)
BURN PRODUCTS silver sulfadiazine cream 1%
CORTICOSTEROIDS - TOPICAL betamethasone dipropionate augmented cream
0.05%
betamethasone dipropionate augmented gel
0.05%
betamethasone dipropionate augmented lotion
0.05%
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
43
Drug Name Requirements/Limits
betamethasone dipropionate augmented oint 0.05%
betamethasone dipropionate cream 0.05%
betamethasone dipropionate lotion 0.05%
betamethasone valerate cream 0.1% (base
equivalent)
betamethasone valerate lotion 0.1% (base
equivalent)
betamethasone valerate oint 0.1% (base
equivalent)
clobetasol e cre 0.05%
clobetasol propionate cream 0.05%
clobetasol propionate oint 0.05%
clobetasol propionate soln 0.05%
desonide cream 0.05% QL (15 gm per fill)
desonide oint 0.05% QL (15 gm per fill)
fluocinolone acetonide cream 0.01%
fluocinolone acetonide cream 0.025%
fluocinolone acetonide oint 0.025%
fluocinolone acetonide soln 0.01%
fluocinonide cream 0.05%
fluocinonide emulsified base cream 0.05%
fluocinonide gel 0.05%
fluocinonide oint 0.05%
fluocinonide soln 0.05%
fluticasone propionate cream 0.05%
fluticasone propionate oint 0.005%
hydrocortisone cream 0.5% OTC
hydrocortisone cream 1%
hydrocortisone cream 2.5%
hydrocortisone lotion 1% OTC
hydrocortisone oint 0.5% OTC
hydrocortisone oint 1%
hydrocortisone oint 2.5%
mometasone furoate oint 0.1%
triamcinolone acetonide cream 0.1%
triamcinolone acetonide cream 0.5%
triamcinolone acetonide cream 0.025%
triamcinolone acetonide lotion 0.1%
triamcinolone acetonide lotion 0.025%
triamcinolone acetonide oint 0.1%
triamcinolone acetonide oint 0.5%
triamcinolone acetonide oint 0.025%
ECZEMA AGENTS DUPIXENT INJ 300/2ML PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
44
Drug Name Requirements/Limits
EMOLLIENTS AQUAPHOR OIN OTC
geri-hydrola lot 5% OTC
lactic acid (ammonium lactate) cream 12% OTC
lactic acid (ammonium lactate) lotion 12% OTC
soothng bath pow treatmnt OTC
THERAPEUTIC CRE MOISTUR OTC
ENZYMES - TOPICAL SANTYL OIN 250/GM QL (30 gm per fill, max 2
fills / 30 days), PA
IMMUNOMODULATING AGENTS - TOPICAL imiquimod cream 5% QL (12 per fill, max 4 fills /
year)
IMMUNOSUPPRESSIVE AGENTS - TOPICAL tacrolimus oint 0.1% QL (May fill 3-30gram tubes
per year); Age Restriction
tacrolimus oint 0.03% QL (May fill 3-30gram tubes per year)
KERATOLYTIC/ANTIMITOTIC AGENTS podofilox soln 0.5%
wart remover gel 17% OTC
wart remover liq 17% OTC
wart remover sol 17% OTC
LINIMENTS arthricream cre 10% OTC
icy hot cre ex st OTC
pain relieve cre rub OTC
LOCAL ANESTHETICS - TOPICAL anti-itch lot sens 1% OTC
ARTH PAIN CRE 0.075% OTC
capsaicin cream 0.1% OTC
capsaicin cream 0.025% OTC
CAPZASIN-P CRE 0.035% OTC
lidocaine hcl gel 2%
lidocaine hcl soln 4%
lidocaine patch 5% QL (60 / 30 days)
ZOSTRIX NAT CRE 0.033% OTC
MISC. TOPICAL ALUMINUM SOL ACETATE OTC
CALAMINE LOT OTC
CALAMINE LOT 8-8% OTC
dermacerin cre OTC
DRYSOL SOL 20%
hemorrhoidal pad hygiene OTC
MOISTURE GUA CRE OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
45
Drug Name Requirements/Limits
RISAMINE OIN OTC
ZINC OXIDE PST 25% OTC
ROSACEA AGENTS metronidazole cream 0.75%
metronidazole gel 0.75%
SCABICIDES & PEDICULICIDES complete kit lice OTC
lice killing sha OTC
lice treatmt lot 1% OTC
lice trtmnt liq 1% OTC
malathion lotion 0.5% ST
permethrin cream 5%
spinosad susp 0.9% ST
DIAGNOSTIC PRODUCTS DIAGNOSTIC PRODUCTS, MISC.
URINE TEST STRIPS OTC
DIAGNOSTIC TESTS ACCU-CHEK BLOOD GLUCOSE TEST STRIPS OTC, QL (50 test strips / 50
days)
ALBUSTIX TES OTC
GLUCOSE URINE TEST STRIPS OTC
KETONE TEST TES OTC, QL (100 strips / 30 days)
KETONE URINE TEST STRIPS OTC, QL (100 strips / 30 days)
MULTISTIX TES OTC
DIGESTIVE AIDS DIGESTIVE ENZYMES
CREON CAP 3000UNIT
CREON CAP 6000UNIT
CREON CAP 12000UNT
CREON CAP 24000UNT
CREON CAP 36000UNT
lactase enz tab 3000unit OTC
DIURETICS CARBONIC ANHYDRASE INHIBITORS
acetazolamide cap er 12hr 500 mg
acetazolamide tab 125 mg
acetazolamide tab 250 mg
IURETIC COMBINATIONS amiloride & hydrochlorothiazide tab 5-50 mg
spironolactone & hydrochlorothiazide tab 25-25 mg
triamterene & hydrochlorothiazide cap 37.5-25 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
46
Drug Name Requirements/Limits
triamterene & hydrochlorothiazide tab 37.5-25 mg
triamterene & hydrochlorothiazide tab 75-50 mg
LOOP DIURETICS bumetanide tab 0.5 mg
bumetanide tab 1 mg
bumetanide tab 2 mg
furosemide oral soln 10 mg/ml
furosemide tab 20 mg Available for 90 day fill
furosemide tab 40 mg
furosemide tab 80 mg
torsemide tab 5 mg
torsemide tab 10 mg
torsemide tab 20 mg
torsemide tab 100 mg
POTASSIUM SPARING DIURETICS amiloride hcl tab 5 mg
spironolactone tab 25 mg
spironolactone tab 50 mg
spironolactone tab 100 mg
THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorothiazide tab 250 mg
chlorothiazide tab 500 mg
chlorthalidone tab 25 mg Available for 90 day fill
chlorthalidone tab 50 mg Available for 90 day fill
hydrochlorothiazide cap 12.5 mg
hydrochlorothiazide tab 12.5 mg
hydrochlorothiazide tab 25 mg Available for 90 day fill
hydrochlorothiazide tab 50 mg Available for 90 day fill
indapamide tab 1.25 mg
indapamide tab 2.5 mg
metolazone tab 2.5 mg
metolazone tab 5 mg
metolazone tab 10 mg
ENDOCRINE AND METABOLIC AGENTS - MISC. BONE DENSITY REGULATORS
alendronate sodium tab 10 mg
alendronate sodium tab 35 mg
alendronate sodium tab 70 mg
ibandronate sodium tab 150 mg (base equivalent)
PROLIA SOL 60MG/ML PA
CORTICOTROPIN H.P. ACTHAR INJ 80UNIT
GROWTH HORMONES NUTROPIN AQ INJ 10MG/2ML PA
NUTROPIN AQ INJ 20MG/2ML PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
47
Drug Name Requirements/Limits
NUTROPIN AQ INJ NUSPIN 5 PA
HORMONE RECEPTOR MODULATORS raloxifene hcl tab 60 mg
LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS LUPR DEP-PED INJ 3M 30MG PA
LUPR DEP-PED INJ 7.5MG PA
LUPR DEP-PED INJ 11.25MG PA
LUPR DEP-PED INJ 15MG PA
METABOLIC MODIFIERS calcitriol cap 0.5 mcg
calcitriol cap 0.25 mcg
calcitriol oral soln 1 mcg/ml
KANUMA INJ 20/10ML PA
KUVAN POW 100MG PA
KUVAN POW 500MG PA
KUVAN TAB 100MG PA
levocarnitine oral soln 1 gm/10ml (10%)
levocarnitine tab 330 mg
STRENSIQ INJ 18/0.45 PA
STRENSIQ INJ 80/0.8ML PA
POSTERIOR PITUITARY HORMONES DDAVP SOL 0.01%
desmopressin acetate nasal spray soln 0.01%
desmopressin acetate tab 0.1 mg
desmopressin acetate tab 0.2 mg
PROLACTIN INHIBITORS cabergoline tab 0.5 mg
SOMATOSTATIC AGENTS 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)
ESTROGENS ESTROGEN COMBINATIONS
estradiol & norethindrone acetate tab 1-0.5 mg
PREMPHASE TAB
PREMPRO TAB 0.3-1.5
PREMPRO TAB 0.45-1.5
PREMPRO TAB 0.625-5
PREMPRO TAB .625-2.5
ESTROGENS estradiol tab 0.5 mg
estradiol tab 1 mg
estradiol tab 2 mg
estradiol td patch weekly 0.1 mg/24hr
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
48
Drug Name Requirements/Limits
estradiol td patch weekly 0.05 mg/24hr
estradiol td patch weekly 0.06 mg/24hr
estradiol td patch weekly 0.025 mg/24hr
estradiol td patch weekly 0.075 mg/24hr
estropipate tab 0.75 mg
estropipate tab 1.5 mg
estropipate tab 3 mg
PREMARIN TAB 0.3MG
PREMARIN TAB 0.9MG
PREMARIN TAB 0.45MG
PREMARIN TAB 0.625MG
PREMARIN TAB 1.25MG
FLUOROQUINOLONES FLUOROQUINOLONES
ciprofloxacin hcl tab 100 mg (base equiv)
ciprofloxacin hcl tab 250 mg (base equiv)
ciprofloxacin hcl tab 500 mg (base equiv)
ciprofloxacin hcl tab 750 mg (base equiv)
levofloxacin oral soln 25 mg/ml
levofloxacin tab 250 mg
levofloxacin tab 500 mg
levofloxacin tab 750 mg
moxifloxacin hcl tab 400 mg (base equiv)
GASTROINTESTINAL AGENTS - MISC. ANTIFLATULENTS
simethicone chew tab 80 mg OTC
simethicone susp 40 mg/0.6ml OTC
GALLSTONE SOLUBILIZING AGENTS ursodiol cap 300 mg
ursodiol tab 250 mg
ursodiol tab 500 mg
GASTROINTESTINAL STIMULANTS metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)
(base equiv)
metoclopramide hcl tab 5 mg (base equivalent)
metoclopramide hcl tab 10 mg (base equivalent)
INFLAMMATORY BOWEL AGENTS APRISO CAP 0.375GM
balsalazide disodium cap 750 mg
ENTYVIO INJ 300MG PA
INFLECTRA INJ 100MG
mesalamine enema 4 gm
PENTASA CAP 250MG CR
PENTASA CAP 500MG CR
RENFLEXIS INJ 100MG
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
49
Drug Name Requirements/Limits
sulfasalazine tab delayed release 500 mg
sulfazine tab 500mg
INTESTINAL ACIDIFIERS lactulose (encephalopathy) solution 10 gm/15ml
IRRITABLE BOWEL SYNDROME (IBS) AGENTS LINZESS CAP 72MCG PA
LINZESS CAP 145MCG PA
LINZESS CAP 290MCG PA
PERIPHERAL OPIOID RECEPTOR ANTAGONISTS MOVANTIK TAB 12.5MG PA
MOVANTIK TAB 25MG PA
RELISTOR INJ 8/0.4ML PA
RELISTOR INJ 12/0.6ML PA
RELISTOR TAB 150MG PA
PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) cap 667 mg
(169 mg ca)
lanthanum carbonate chew tab 500 mg (elemental)
ST
lanthanum carbonate chew tab 750 mg (elemental)
ST
lanthanum carbonate chew tab 1000 mg (elemental)
ST
RENAGEL TAB 400MG ST
sevelamer carbonate packet 0.8 gm ST
sevelamer carbonate packet 2.4 gm ST
sevelamer carbonate tab 800 mg ST
GENITOURINARY AGENTS - MISCELLANEOUS ALKALINIZERS
potassium citrate & citric acid soln 1100-334 mg/5ml
potassium citrate tab er 5 meq (540 mg)
potassium citrate tab er 10 meq (1080 mg)
sodium citrate & citric acid soln 500-334 mg/5ml
PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl tab er 24hr 10 mg
dutasteride cap 0.5 mg
finasteride tab 5 mg
tamsulosin hcl cap 0.4 mg
GOUT AGENTS GOUT AGENT COMBINATIONS
colchicine w/ probenecid tab 0.5-500 mg
GOUT AGENTS allopurinol tab 100 mg
allopurinol tab 300 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
50
Drug Name Requirements/Limits
colchicine tab 0.6 mg
KRYSTEXXA INJ 8MG/ML PA
URICOSURICS probenecid tab 500 mg
HEMATOLOGICAL AGENTS - MISC. BRADYKININ B2 RECEPTOR ANTAGONISTS
FIRAZYR INJ 30MG/3ML QL (9ml per fill per 23 days)
HEMATORHEOLOGIC AGENTS pentoxifylline tab er 400 mg
PLATELET AGGREGATION INHIBITORS cilostazol tab 50 mg
cilostazol tab 100 mg
clopidogrel bisulfate tab 75 mg (base equiv)
dipyridamole tab 25 mg
dipyridamole tab 50 mg
dipyridamole tab 75 mg
HEMATOPOIETIC AGENTS AGENTS FOR SICKLE CELL ANEMIA
DROXIA CAP 200MG
DROXIA CAP 300MG
DROXIA CAP 400MG
COBALAMINS vitamin b-12 injection
vitamin b-12 tab 100mcg OTC
vitamin b-12 tab 250mcg OTC
vitamin b-12 tab 500mcg OTC
vitamin b-12 tab 1000mcg OTC
FOLIC ACID/FOLATES folic acid tab 1 mg Available for 90 day fill
folic acid tab 400 mcg OTC
folic acid tab 800mcg OTC
HEMATOPOIETIC GROWTH FACTORS EPOGEN INJ 2000/ML
EPOGEN INJ 3000/ML
EPOGEN INJ 4000/ML
EPOGEN INJ 10000/ML
EPOGEN INJ 20000/ML
GRANIX INJ 300/0.5
GRANIX INJ 300/1ML
GRANIX INJ 480/0.8
GRANIX INJ 480/1.6
NEULASTA INJ 6MG/0.6M PA
NEUPOGEN INJ 300/0.5
NEUPOGEN INJ 300MCG
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
51
Drug Name Requirements/Limits
NEUPOGEN INJ 480/0.8
NEUPOGEN INJ 480MCG
ZARXIO INJ 300/0.5
ZARXIO INJ 480/0.8
HEMATOPOIETIC MIXTURES folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5
mg
IRON ferrous gluconate tab 240 mg (27 mg elemental
fe) OTC
FERROUS SUL LIQ 220/5ML OTC
FERROUS SULF SYP 300/5ML OTC
FERROUS SULF TAB 324MG EC OTC
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe)
OTC
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe)
OTC
ferrous sulfate tab ec 325 mg (65 mg fe equivalent)
OTC; Available for 90 day fill
HEMOSTATICS HEMOSTATICS - SYSTEMIC
tranexamic acid tab 650 mg QL (1 fill / 30 days)
HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS ANTIHISTAMINE HYPNOTICS
sleep aid tab 25mg OTC
BARBITURATE HYPNOTICS phenobarbital elixir 20 mg/5ml
phenobarbital tab 15 mg
phenobarbital tab 16.2 mg
phenobarbital tab 30 mg
phenobarbital tab 32.4 mg
phenobarbital tab 60 mg
phenobarbital tab 64.8 mg
phenobarbital tab 97.2 mg
phenobarbital tab 100 mg
NON-BARBITURATE HYPNOTICS estazolam tab 1 mg
estazolam tab 2 mg
eszopiclone tab 1 mg
eszopiclone tab 2 mg
eszopiclone tab 3 mg
flurazepam hcl cap 15 mg
flurazepam hcl cap 30 mg
temazepam cap 15 mg
temazepam cap 30 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
52
Drug Name Requirements/Limits
zaleplon cap 5 mg
zaleplon cap 10 mg
zolpidem tartrate tab 5 mg
zolpidem tartrate tab 10 mg
zolpidem tartrate tab er 6.25 mg QL (1 tab / day)
zolpidem tartrate tab er 12.5 mg QL (1 tab / day)
SELECTIVE MELATONIN RECEPTOR AGONISTS HETLIOZ CAP 20MG PA
LAXATIVES BULK LAXATIVES
calcium polycarbophil tab 625 mg OTC
fiber oral powder OTC
fiber tab 500mg OTC
nat fiber pow 28.3% OTC
nat fiber pow 48.57% OTC
naturl fiber pow 58.6% OTC
LAXATIVE COMBINATIONS peg 3350-kcl-na bicarb-nacl-na sulfate for soln
240 gm
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
LAXATIVES - MISCELLANEOUS glycerin suppos 2 gm OTC
glycerin suppos 80.7% OTC
lactulose solution 10 gm/15ml
LUBRICANT LAXATIVES mineral oil OTC
SALINE LAXATIVES mag citrate sol OTC
milk of magn sus OTC
STIMULANT LAXATIVES bisacodyl suppos 10 mg OTC
bisacodyl tab 5mg ec OTC
sennosides syrup 8.8 mg/5ml OTC
sennosides tab 8.6 mg OTC
SURFACTANT LAXATIVES docusate calcium cap 240 mg OTC
docusate sodium cap 250 mg OTC
docusate sodium liquid 150 mg/15ml OTC
PEDIA-LAX LIQ 50MG OTC
MACROLIDES AZITHROMYCIN
azithromycin for susp 100 mg/5ml
azithromycin for susp 200 mg/5ml
azithromycin powd pack for susp 1 gm
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
53
Drug Name Requirements/Limits
azithromycin tab 250 mg
azithromycin tab 500 mg
azithromycin tab 600 mg
CLARITHROMYCIN clarithromycin for susp 125 mg/5ml
clarithromycin for susp 250 mg/5ml
clarithromycin tab 250 mg
clarithromycin tab 500 mg
MEDICAL DEVICES AND SUPPLIES CONTRACEPTIVES
CONDOMS OTC
DIABETIC SUPPLIES ACCU-CHEK BLOOD GLUCOSE TEST KITS OTC
ACCU-CHEK LIQ GUIDE OTC
BLOOD GLUCOSE CALIBRATION SOLUTION OTC
LANCETS OTC
URINE GLUCOSE MONITORING SUPPLIES OTC
INFANT CARE PRODUCTS AVEENO BABY KIT BATHTIME OTC
MISC. DEVICES ALCOHOL PAD OTC
PARENTERAL THERAPY SUPPLIES INSULIN PEN NEEDLES/SYRINGES OTC
RESPIRATORY THERAPY SUPPLIES ADULT RESPIRATORY MASK Age Restriction
DISPOSABLE MIS MTHPIECE OTC
POCKET PEAK MIS METER OTC
MIGRAINE PRODUCTS SEROTONIN AGONISTS
naratriptan hcl tab 1 mg (base equiv) QL (6 tabs / 30 days)
naratriptan hcl tab 2.5 mg (base equiv) QL (6 tabs / 30 days)
rizatriptan benzoate oral disintegrating tab 5 mg (base eq)
QL (9 tabs / 30 days)
rizatriptan benzoate oral disintegrating tab 10 mg (base eq)
QL (9 tabs / 30 days)
rizatriptan benzoate tab 5 mg (base equivalent) QL (9 tabs / 30 days)
rizatriptan benzoate tab 10 mg (base equivalent) QL (9 tabs / 30 days)
sumatriptan nasal spray 5 mg/act QL (6 / 30 days)
sumatriptan nasal spray 20 mg/act QL (6 / 30 days)
sumatriptan succinate inj 6 mg/0.5ml QL (2.5 ml / 30 days)
sumatriptan succinate solution auto-injector 4
mg/0.5ml
QL (3 ml / 30 days)
sumatriptan succinate solution auto-injector 6
mg/0.5ml
QL (3 ml / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
54
Drug Name Requirements/Limits
sumatriptan succinate solution cartridge 4 mg/0.5ml
QL (3 ml / 30 days)
sumatriptan succinate solution cartridge 6 mg/0.5ml
QL (3 ml / 30 days)
sumatriptan succinate tab 25 mg QL (9 tabs / fill, max 2 fills every 30 days)
sumatriptan succinate tab 50 mg QL (9 tabs / fill, max 2 fills every 30 days)
sumatriptan succinate tab 100 mg QL (9 tabs / fill, max 2 fills every 30 days)
MINERALS & ELECTROLYTES CALCIUM
CA CITRATE TAB 250MG OTC
CA GLUCONATE TAB 50MG OTC
CA LACTATE TAB 100MG OTC
calc cit+d3 tab 200-250 OTC
calcium OTC
calcium + d tab 600mg OTC
calcium carbonate tab 1250 mg (500 mg
elemental ca)
OTC
calcium carbonate tab 1500 mg (600 mg
elemental ca)
OTC
calcium carbonate-vitamin d cap 600 mg-200 unit OTC
calcium carbonate-vitamin d tab 600 mg-200 unit OTC; Available for 90 day fill
CALCIUM CHW 500MG OTC
CALCIUM CIT TAB 1040MG OTC
CALCIUM CITR TAB 200MG OTC
calcium citrate tab 950 mg (200 mg elemental ca) OTC
calcium citrate-vitamin d tab 315 mg-250 unit (elemental ca)
OTC
CALCIUM GLUC TAB 500MG OTC
CALCIUM LACT TAB 648MG OTC
CALCIUM LACT TAB 750MG OTC
CALCIUM TAB 333MG OTC
calcium+d tab 600-800 OTC
calcium/d chw 500-400 OTC
CHEWABLE CHW CALCIUM OTC
oyster shell calcium tab 500 mg OTC
ELECTROLYTE MIXTURES EQUALYTE SOL OTC
FLUORIDE sodium fluoride chew tab 0.5 mg f (from 1.1 mg
naf)
sodium fluoride chew tab 0.25 mg f (from 0.55 mg
naf)
sodium fluoride chew tab 1 mg f (from 2.2 mg naf) Available for 90 day fill
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
55
Drug Name Requirements/Limits
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
MAGNESIUM MAG64 TAB 64MG OTC
magnesium oxide tab 400 mg (240 mg elemental
mg)
OTC
magnesium oxide tab 400 mg (241.3 mg elemental mg)
OTC
magnesium tab 250mg OTC
POTASSIUM klor-con pow 20meq
potassium chloride microencapsulated crys er tab 10 meq
potassium chloride microencapsulated crys er tab 20 meq
potassium chloride oral soln 10% (20 meq/15ml)
potassium chloride oral soln 20% (40 meq/15ml)
potassium chloride tab er 8 meq (600 mg)
potassium chloride tab er 10 meq
TRACE MINERALS SELENIUM TAB 200MCG OTC
ZINC zinc gluconate tab 30 mg OTC
zinc gluconate tab 50 mg (elemental zn) OTC
zinc sulfate cap 220 mg (50 mg elemental zn) OTC
MISCELLANEOUS THERAPEUTIC CLASSES IMMUNOSUPPRESSIVE AGENTS
azathioprine tab 50 mg
cyclosporine cap 25 mg
cyclosporine modified cap 25 mg
cyclosporine modified cap 50 mg
cyclosporine modified cap 100 mg
cyclosporine modified oral soln 100 mg/ml Age Restriction
mycophenolate mofetil cap 250 mg
mycophenolate mofetil for oral susp 200 mg/ml Age Restriction
mycophenolate mofetil tab 500 mg
mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)
RAPAMUNE SOL 1MG/ML Age Restriction
sirolimus tab 0.5 mg
sirolimus tab 1 mg
sirolimus tab 2 mg
tacrolimus cap 0.5 mg
tacrolimus cap 1 mg
tacrolimus cap 5 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
56
Drug Name Requirements/Limits
POTASSIUM REMOVING AGENTS VELTASSA POW 8.4GM PA
VELTASSA POW 16.8GM PA
VELTASSA POW 25.2GM PA
SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS BENLYSTA INJ 120MG PA
BENLYSTA INJ 200MG/ML PA
BENLYSTA INJ 400MG PA
MOUTH/THROAT/DENTAL AGENTS ANESTHETICS TOPICAL ORAL
baby teethng gel 7.5% OTC
cvs sore loz throat OTC
FIRST-MOUTHW SUS BLM
lidocaine hcl viscous soln 2%
ultra throat loz cherry OTC
zilactin gel baby 10% OTC
ANTI-INFECTIVES - THROAT clotrimazole troche 10 mg
nystatin susp 100000 unit/ml
ANTISEPTICS - MOUTH/THROAT chlorhexidine gluconate soln 0.12%
DENTAL PRODUCTS act fluoride sol 0.05% OTC
act total sol dry mout OTC
denta 5000 cre plus
fluoridex gel 1.1%
mouth rinse sol OTC
prevident sol 0.2%
STEROIDS - MOUTH/THROAT triamcinolone acetonide dental paste 0.1%
THROAT PRODUCTS - MISC. pilocarpine hcl tab 5 mg
MULTIVITAMINS B-COMPLEX VITAMINS
b-complex vitamin cap OTC
b-complex vitamin tab OTC
B-COMPLEX W/ C b complex tab plus c OTC
B-COMPLEX W/ FOLIC ACID B-COMPLEX TAB C/FA/BIO OTC
NEPHROCAPS TAB QT
MULTIPLE VITAMINS W/ IRON daily multi tab vit/iron OTC; Available for 90 day fill
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
57
Drug Name Requirements/Limits
MULTIPLE VITAMINS W/ MINERALS MULTIVITAMIN CHW ADULT OTC
MULTIVITAMINS multi-vitamn tab OTC; Available for 90 day fill
PED MULTI VITAMINS W/FL & FE tri-vit/fe dro /fl 0.25
PED MULTIPLE VITAMINS W/ MINERALS vitamax ped dro
PED MV W/ FLUORIDE tri-vit/fl dro 0.25mg
PED MV W/ IRON pediatric multiple vitamins w/ iron chew tab 15 mg OTC; Available for 90 day fill
polyvitamin dro /iron OTC; Available for 90 day fill
PEDIATRIC MULTIPLE VITAMINS childrens chw multivit OTC; Available for 90 day fill
polyvitamin dro OTC
PEDIATRIC VITAMINS bprotected sol tri-vite OTC
TRI-VITAMIN DRO OTC
PRENATAL VITAMINS ACTIVE OB CAP
ATABEX CHW PRENATAL OTC; Available for 90 day fill
ATABEX EC TAB
BAL-CARE MIS DHA
BE WELL PAK ROUNDED OTC
BRAINSTRONG MIS PRENATAL OTC
CADEAU DHA CAP OTC
CENTRUM SPEC PAK PRENATAL OTC
CITRANATAL CAP HARMONY
CITRANATAL CAP MEDLEY
CITRANATAL MIS
CITRANATAL MIS B-CALM
CITRANATAL PAK ASSURE
CITRANATAL TAB BLOOM
CITRANATAL TAB RX
COMPLETE NAT PAK DHA
CONCEPT DHA CAP
CVS PRENATAL CHW GUMMY OTC; Available for 90 day fill
DUET DHA 400 MIS 25-1-400
DUET DHA MIS BALANCED
elite-ob tab
ENBRACE HR CAP
EZFE FORTE CAP OTC
FOLCAL DHA CAP
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
58
Drug Name Requirements/Limits
FOLCAPS CAP OMEGA 3
FOLET DHA PAK
FOLET ONE CAP 38-1-225
FOLIVANE-OB CAP
HEMENATAL OB MIS + DHA
HEMENATAL OB TAB 28-6-1MG
KOSHR PRENAT TAB 30-1MG
MACNATAL CN CAP DHA
MARNATAL-F CAP
MTERYTI TAB OTC
MTERYTI TAB FOLIC 5 OTC
MYNATE 90 TAB PLUS
NATACHEW CHW
NATALVIT TAB 75-1MG
NATELLE ONE CAP
NESTABS ABC MIS
NESTABS DHA PAK
NESTABS ONE CAP
NESTABS TAB
NUTRIENTS TAB PRENATAL OTC; Available for 90 day fill
O-CAL TAB PRENATAL
OB COMPLETE CAP GOLD
OB COMPLETE CAP ONE
OB COMPLETE CAP PETITE
OB COMPLETE TAB PREMIER
OB COMPLETE/ CAP DHA
OBSTETRIX PAK DHA
OBTREX TAB OTC; Available for 90 day fill
ONE A DAY CAP PRENATAL OTC
ONE A DAY MIS PRENATAL OTC
PERRY PRENAT CAP OTC
PNV OB+DHA PAK
PNV-OMEGA CAP
PR NATAL 400 PAK
PR NATAL 400 PAK EC
PR NATAL 430 PAK
PR NATAL 430 PAK EC
PRENA 1 TRUE MIS
PRENATA CHW 29-1MG
prenatal 19 chw tab
PRENATAL 19 TAB 29-1MG
PRENATAL CAP FORMULA OTC
PRENATAL CAP OMEGA-3 OTC
PRENATAL DHA PAK 27-1-250
PRENATAL DHA PAK MULTI OTC
PRENATAL FRM TAB A-FREE OTC; Available for 90 day fill
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
59
Drug Name Requirements/Limits
PRENATAL MIS COMPLEAT
PRENATAL MUL CAP +DHA OTC
PRENATAL MUL CAP DHA OTC
PRENATAL MV MIS + DHA OTC
PRENATAL PLS MIS MV + DHA
PRENATAL TAB Available for 90 day fill
PRENATAL TAB OTC; Available for 90 day fill
PRENATAL TAB 27-1MG Available for 90 day fill
PRENATAL TAB 28-0.8MG OTC; Available for 90 day fill
PRENATAL TAB COMPLETE OTC; Available for 90 day fill
PRENATAL TAB FORMULA OTC; Available for 90 day fill
PRENATAL+DHA MIS OTC
PRENATAL+FE TAB 29-1MG
PRENATAL-U CAP 106.5-1
PRENATE CAP ENHANCE
PRENATE CAP PIXIE
PRENATE CAP RESTORE
PRENATE DHA CAP
PRENATE MINI CAP
PRENATE TAB ELITE
PRENATL MULT CAP + DHA OTC
PRETAB TAB 29-1MG
PRIMACARE CAP
PROVIDA DHA CAP
PROVIDA OB CAP
PUREFE OB CAP PLUS
SELECT-OB CHW
SELECT-OB+ PAK DHA
STUART ONE CAP OTC
TARON-BC MIS
TARON-PREX CAP
THERANATAL CAP ONE OTC
THERANATAL MIS COMPLETE OTC
THERANATAL PAK OVAVITE OTC
TL FOLATE TAB
TL-CARE DHA CAP 27-1-500
TL-SELECT CAP
TRICARE CHW PRENATAL
TRINATAL GT TAB
TRINATAL RX TAB 1
trinate tab
TRISTART DHA CAP
TRISTART ONE CAP 35-1-215
VINATE DHA CAP 27-1.13
VINATE II TAB
VINATE M TAB
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
60
Drug Name Requirements/Limits
VIRT-PN TAB
VITAFOL CAP ULTRA
VITAFOL CHW GUMMIES
VITAFOL FE+ CAP
VITAFOL-NANO TAB
VITAFOL-OB PAK +DHA
VITAFOL-ONE CAP
VITAMEDMD CAP ONE RX
VITAPEARL CAP
VIVA DHA CAP
VP-PNV-DHA CAP
MUSCULOSKELETAL THERAPY AGENTS CENTRAL MUSCLE RELAXANTS
baclofen tab 10 mg
baclofen tab 20 mg
chlorzoxazone tab 500 mg
cyclobenzaprine hcl tab 5 mg
FIRST-BACLOF SUS 1
FIRST-BACLOF SUS 5 KIT
methocarbamol tab 500 mg
methocarbamol tab 750 mg
tizanidine hcl tab 2 mg (base equivalent)
tizanidine hcl tab 4 mg (base equivalent)
DIRECT MUSCLE RELAXANTS dantrolene sodium cap 25 mg
NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL ANTIALLERGY
azelastine hcl nasal spray 0.1% (137 mcg/spray)
cromolyn sodium nasal aerosol soln 5.2 mg/act (4%)
OTC
NASAL ANTICHOLINERGICS ipratropium bromide nasal soln 0.03% (21
mcg/spray)
ipratropium bromide nasal soln 0.06% (42
mcg/spray)
NASAL STEROIDS fluticasone propionate nasal susp 50 mcg/act
triamcinolone acetonide nasal aerosol suspension
55 mcg/act
SYMPATHOMIMETIC DECONGESTANTS AFRIN CHILD SPR 0.25% OTC
decongestant sol 1% OTC
LITTLE NOSES DRO 0.125% OTC
pseudoephedrine hcl tab 30 mg OTC
pseudoephedrine hcl tab 60 mg OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
61
Drug Name Requirements/Limits
sinus nasal spr 0.05% OTC
NEUROMUSCULAR AGENTS ALS AGENTS
riluzole tab 50 mg
NEUROMUSCULAR BLOCKING AGENT - NEUROTOXINS BOTOX INJ 100UNIT PA
BOTOX INJ 200UNIT PA
NUTRIENTS MISC. NUTRITIONAL SUBSTANCES
alp high3 cap 600mg OTC
fish oil cap 435mg OTC
fish oil cap 645mg OTC
fish oil cap 1000mg OTC
omega 3 500 cap 500mg OTC
omega essent liq basic OTC
omega-3 fatty acids cap 300 mg OTC
omega-3 fatty acids cap 600 mg OTC
omega-3 fatty acids cap 1000 mg OTC
omega-3 fatty acids cap 1200 mg OTC
omega-3 fatty acids cap delayed release 1200 mg OTC
PROTEINS levocarnitine (dietary) oral soln 1 gm/10ml OTC
levocarnitine tab 500 mg OTC
OPHTHALMIC AGENTS ARTIFICIAL TEARS AND LUBRICANTS
artifi tears oin op OTC
artifi tears sol 1.4% op OTC
carboxymethylcellulose sodium ophth soln 0.5% OTC
lubricnt eye dro 0.4-0.3% OTC
BETA-BLOCKERS - OPHTHALMIC dorzolamide hcl-timolol maleate ophth soln 22.3-
6.8 mg/ml
levobunolol hcl ophth soln 0.5%
timolol maleate ophth gel forming soln 0.5%
timolol maleate ophth gel forming soln 0.25%
timolol maleate ophth soln 0.5%
timolol maleate ophth soln 0.25%
CYCLOPLEGIC MYDRIATICS ATROPINE SUL OIN 1% OP
atropine sulfate ophth soln 1%
cyclopentolate hcl ophth soln 1%
tropicamide ophth soln 1%
MIOTICS pilocarpine hcl ophth soln 1%
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
62
Drug Name Requirements/Limits
pilocarpine hcl ophth soln 4%
OPHTHALMIC ADRENERGIC AGENTS brimonidine tartrate ophth soln 0.2%
OPHTHALMIC ANTI-INFECTIVES bacitracin-polymyxin b ophth oint
ciprofloxacin hcl ophth soln 0.3%
erythromycin ophth oint 5 mg/gm
gentamicin sulfate ophth oint 0.3%
gentamicin sulfate ophth soln 0.3%
neo-polycin oin op
neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml
ofloxacin ophth soln 0.3%
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%
sulfacetamide sodium ophth soln 10%
tobramycin ophth soln 0.3%
trifluridine ophth soln 1%
OPHTHALMIC IMMUNOMODULATORS RESTASIS EMU 0.05% QL (30 vials / fill), PA
OPHTHALMIC STEROIDS dexamethasone sodium phosphate ophth soln
0.1%
fluorometholone ophth susp 0.1%
neomycin-polymyxin-dexamethasone ophth oint
0.1%
neomycin-polymyxin-dexamethasone ophth susp 0.1%
PRED SOD PHO SOL 1% OP
prednisolone acetate ophth susp 1% QL (5 ml / fill)
sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%
OPHTHALMICS - MISC. azelastine hcl ophth soln 0.05%
claritin eye dro 0.025%op OTC
cromolyn sodium ophth soln 4%
diclofenac sodium ophth soln 0.1%
dorzolamide hcl ophth soln 2%
flurbiprofen sodium ophth soln 0.03%
ketorolac tromethamine ophth soln 0.4% QL (5 ml per fill)
ketorolac tromethamine ophth soln 0.5% QL (5 ml / fill)
olopatadine hcl ophth soln 0.1% (base equivalent) QL (5 ml per fill)
sodium chloride hypertonic ophth soln 5% OTC
PROSTAGLANDINS - OPHTHALMIC latanoprost ophth soln 0.005% QL (2.5 ml / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
63
Drug Name Requirements/Limits
OTIC AGENTS OTIC AGENTS - MISCELLANEOUS
acetic acid 2% in aluminum acetate otic soln
acetic acid otic soln 2%
ear drops dro 6.5% OTC
OTIC ANTI-INFECTIVES ofloxacin otic soln 0.3%
OTIC COMBINATIONS neomycin-polymyxin-hc otic soln 1%
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%
OTIC STEROIDS fluocinolone acetonide (otic) oil 0.01%
PASSIVE IMMUNIZING AND TREATMENT AGENTS MONOCLONAL ANTIBODIES
SYNAGIS INJ 50MG PA
SYNAGIS INJ 100MG/ML PA
PENICILLINS AMINOPENICILLINS
amoxicillin (trihydrate) cap 250 mg
amoxicillin (trihydrate) cap 500 mg
amoxicillin (trihydrate) chew tab 125 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
amoxicillin (trihydrate) tab 875 mg
ampicillin cap 250 mg
ampicillin cap 500 mg
ampicillin for susp 125 mg/5ml
ampicillin for susp 250 mg/5ml
NATURAL PENICILLINS penicillin v potassium for soln 125 mg/5ml
penicillin v potassium for soln 250 mg/5ml
penicillin v potassium tab 250 mg
penicillin v potassium tab 500 mg
PENICILLIN COMBINATIONS amoxicillin & k clavulanate chew tab 200-28.5 mg
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml
amoxicillin & k clavulanate for susp 400-57
mg/5ml
amoxicillin & k clavulanate for susp 600-42.9
mg/5ml
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
64
Drug Name Requirements/Limits
amoxicillin & k clavulanate tab 500-125 mg
amoxicillin & k clavulanate tab 875-125 mg
PENICILLINASE-RESISTANT PENICILLINS dicloxacillin sodium cap 250 mg
dicloxacillin sodium cap 500 mg
PHARMACEUTICAL ADJUVANTS INTERNAL VEHICLE INGREDIENTS/AGENTS
food thicknr pow instant OTC
RESOURCE POW THICKENU OTC
SIMPLYTHICK GEL OTC
THICK-IT POW ORIGINAL OTC
THICKENUP POW CLEAR OTC
SEMI SOLID VEHICLES PETROLATUM OIN WHITE OTC
white petrolatum gel OTC
white petrolatum topical gel OTC
PROGESTINS PROGESTINS
hydroxyprogesterone caproate im in oil 250 mg/ml PA
medroxyprogesterone acetate tab 2.5 mg
medroxyprogesterone acetate tab 5 mg
medroxyprogesterone acetate tab 10 mg
norethindrone acetate tab 5 mg
progesterone micronized cap 100 mg
progesterone micronized cap 200 mg
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. AGENTS FOR CHEMICAL DEPENDENCY
acamprosate calcium tab delayed release 333 mg
disulfiram tab 250 mg
disulfiram tab 500 mg
ANTI-CATAPLECTIC AGENTS XYREM SOL 500MG/ML PA
ANTIDEMENTIA AGENTS donepezil hydrochloride orally disintegrating tab 5
mg
donepezil hydrochloride orally disintegrating tab 10
mg
donepezil hydrochloride tab 5 mg
donepezil hydrochloride tab 10 mg
donepezil hydrochloride tab 23 mg
galantamine hydrobromide cap er 24hr 8 mg
galantamine hydrobromide cap er 24hr 16 mg
galantamine hydrobromide cap er 24hr 24 mg
galantamine hydrobromide tab 8 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
65
Drug Name Requirements/Limits
memantine hcl tab 5 mg
memantine hcl tab 10 mg
rivastigmine tartrate cap 1.5 mg (base equivalent)
rivastigmine tartrate cap 3 mg (base equivalent)
rivastigmine tartrate cap 4.5 mg (base equivalent)
rivastigmine tartrate cap 6 mg (base equivalent)
MOVEMENT DISORDER DRUG THERAPY tetrabenazine tab 12.5 mg QL (8 tabs / day), PA
tetrabenazine tab 25 mg QL (4 tabs / day), PA
MULTIPLE SCLEROSIS AGENTS AUBAGIO TAB 7MG
AUBAGIO TAB 14MG
AVONEX KIT 30MCG
AVONEX PEN KIT 30MCG
AVONEX PREFL KIT 30MCG
dalfampridine tab er 12hr 10 mg QL (2 tabs / day)
EXTAVIA INJ 0.3MG
GILENYA CAP 0.5MG
glatiramer acetate soln prefilled syringe 20 mg/ml
glatiramer acetate soln prefilled syringe 40 mg/ml
glatopa inj 40mg/ml
TECFIDERA CAP 120MG
TECFIDERA CAP 240MG
TECFIDERA MIS STARTER
PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS fluoxetine hcl (pmdd) cap 10 mg
fluoxetine hcl (pmdd) cap 20 mg
fluoxetine hcl (pmdd) tab 10 mg
PSEUDOBULBAR AFFECT (PBA) AGENTS NUEDEXTA CAP 20-10MG PA
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. pimozide tab 1 mg
pimozide tab 2 mg
SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab er 12hr 150
mg
CHANTIX PAK 0.5& 1MG ST
CHANTIX TAB 0.5MG ST
CHANTIX TAB 1MG ST
nicotine loz 4mg mint OTC
nicotine loz mini 2mg OTC
nicotine polacrilex gum 2 mg OTC
nicotine polacrilex gum 4 mg OTC
nicotine td patch 24hr 7 mg/24hr OTC
nicotine td patch 24hr 14 mg/24hr OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
66
Drug Name Requirements/Limits
nicotine td patch 24hr 21 mg/24hr OTC
NICOTROL INH PA
NICOTROL NS SPR 10MG/ML PA
RESPIRATORY AGENTS - MISC. CYSTIC FIBROSIS AGENTS
KALYDECO PAK 50MG PA
KALYDECO PAK 75MG PA
KALYDECO TAB 150MG PA
ORKAMBI TAB 100-125 PA
ORKAMBI TAB 200-125 PA
PULMOZYME SOL 1MG/ML
SULFONAMIDES SULFONAMIDES
SULFADIAZINE TAB 500MG
TETRACYCLINES TETRACYCLINES
doxycycline hyclate cap 100 mg
doxycycline hyclate tab 20 mg
doxycycline hyclate tab 100 mg
doxycycline monohydrate cap 50 mg
doxycycline monohydrate cap 100 mg
doxycycline monohydrate tab 50 mg
doxycycline monohydrate tab 100 mg
minocycline hcl cap 50 mg
minocycline hcl cap 75 mg
minocycline hcl cap 100 mg
minocycline hcl tab 75 mg
THYROID AGENTS ANTITHYROID AGENTS
methimazole tab 5 mg
methimazole tab 10 mg
propylthiouracil tab 50 mg
THYROID HORMONES levothyroxine sodium tab 25 mcg
levothyroxine sodium tab 50 mcg
levothyroxine sodium tab 75 mcg
levothyroxine sodium tab 88 mcg
levothyroxine sodium tab 100 mcg
levothyroxine sodium tab 112 mcg
levothyroxine sodium tab 125 mcg
levothyroxine sodium tab 137 mcg
levothyroxine sodium tab 150 mcg
levothyroxine sodium tab 175 mcg
levothyroxine sodium tab 200 mcg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
67
Drug Name Requirements/Limits
levothyroxine sodium tab 300 mcg
liothyronine sodium tab 5 mcg
liothyronine sodium tab 25 mcg
liothyronine sodium tab 50 mcg
np thyroid tab 15mg
np thyroid tab 30mg
np thyroid tab 60mg
np thyroid tab 120mg
ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS ANTISPASMODICS
dicyclomine hcl cap 10 mg
dicyclomine hcl oral soln 10 mg/5ml
dicyclomine hcl tab 20 mg
glycopyrrolate tab 1 mg
glycopyrrolate tab 2 mg
hyoscyamine sulfate elixir 0.125 mg/5ml
hyoscyamine sulfate sl tab 0.125 mg
hyoscyamine sulfate soln 0.125 mg/ml
hyoscyamine sulfate tab 0.125 mg
methscopolamine bromide tab 5 mg
propantheline bromide tab 15 mg
H-2 ANTAGONISTS cimetidine tab 200mg OTC
cimetidine tab 300 mg
cimetidine tab 400 mg
cimetidine tab 800 mg
famotidine tab 10 mg OTC
famotidine tab 40 mg
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)
ranitidine hcl tab 75 mg OTC
ranitidine hcl tab 150 mg
ranitidine hcl tab 300 mg
MISC. ANTI-ULCER sucralfate tab 1 gm
PROTON PUMP INHIBITORS esomeprazole magnesium cap delayed release 20
mg (base eq)
QL (1 cap / day)
esomeprazole magnesium cap delayed release 40 mg (base eq)
lansoprazole cap delayed release 15 mg
lansoprazole cap delayed release 30 mg
OMEPRAZOLE + SUS SYRSPEND
omeprazole cap delayed release 10 mg
omeprazole cap delayed release 20 mg OTC
omeprazole cap delayed release 40 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
68
Drug Name Requirements/Limits
pantoprazole sodium ec tab 20 mg (base equiv)
pantoprazole sodium ec tab 40 mg (base equiv)
rabeprazole sodium ec tab 20 mg
ULCER DRUGS - PROSTAGLANDINS misoprostol tab 100 mcg
misoprostol tab 200 mcg
URINARY ANTI-INFECTIVES URINARY ANTI-INFECTIVES
methenamine hippurate tab 1 gm
nitrofurantoin macrocrystalline cap 50 mg
nitrofurantoin macrocrystalline cap 100 mg
nitrofurantoin monohydrate macrocrystalline cap 100 mg
nitrofurantoin susp 25 mg/5ml
URINARY ANTISPASMODICS URINARY ANTISPASMODIC - ANTIMUSCARINICS
(ANTICHOLINERGIC) oxybutynin chloride syrup 5 mg/5ml
oxybutynin chloride tab 5 mg
oxybutynin chloride tab er 24hr 5 mg
oxybutynin chloride tab er 24hr 10 mg
oxybutynin chloride tab er 24hr 15 mg
tolterodine tartrate cap er 24hr 2 mg QL (1 cap / day)
tolterodine tartrate cap er 24hr 4 mg QL (1 cap / day)
tolterodine tartrate tab 1 mg QL (2 tabs / day)
tolterodine tartrate tab 2 mg QL (2 tabs / day)
trospium chloride tab 20 mg QL (60 tabs / 30 days), ST
URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS bethanechol chloride tab 10 mg
bethanechol chloride tab 25 mg
VACCINES VIRAL VACCINES
AFLURIA INJ 2018-19
AFLURIA INJ PF 18-19
AFLURIA QUAD INJ 2018-19
AFLURIA QUAD INJ PF 18-19
FLUAD INJ 2018-19
FLUARIX QUAD INJ 2018-19
FLUBLOK QUAD INJ 2018-19
FLUCELVAX INJ 2015-16
FLUCLVX QUAD INJ 2018-19
FLULAVAL QUA INJ 2018-19
FLUMIST QUAD SUS 2018-19
FLUZONE HD INJ PF 18-19
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
69
Drug Name Requirements/Limits
FLUZONE QUAD INJ 2018-19
SHINGRIX INJ 50MCG QL (2 injections per lifetime); Age Restriction
VAGINAL PRODUCTS SPERMICIDES
ENCARE SUP 100MG OTC
GYNOL II GEL 3% OTC
SHUR-SEAL GEL 2% OTC
TODAY SPONGE MIS OTC
vcf vaginal gel contrace OTC
VCF VAGINAL MIS CONTRACP OTC
VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal cream 2%
clotrimazole vaginal cream 1% OTC
metronidazole vaginal gel 0.75%
miconazole 3 kit combo pk OTC
miconazole nitrate vaginal cream 2% OTC
miconazole nitrate vaginal suppos 100 mg OTC
terconazole vaginal cream 0.4% QL (45 gm / 30 days)
terconazole vaginal cream 0.8% ST
terconazole vaginal suppos 80 mg ST
VAGINAL ESTROGENS estradiol vaginal cream 0.1 mg/gm ST
estradiol vaginal tab 10 mcg
VASOPRESSORS ANAPHYLAXIS THERAPY AGENTS
epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)
QL (2 pens / 30 days)
epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)
QL (2 pens / 30 days)
epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000)
QL (2 pens / 30 days)
EPIPEN 2-PAK INJ 0.3MG QL (2 pens / 30 days)
EPIPEN-JR INJ 0.15MG QL (2 pens / 30 days)
VASOPRESSORS midodrine hcl tab 2.5 mg
midodrine hcl tab 5 mg
midodrine hcl tab 10 mg
VITAMINS OIL SOLUBLE VITAMINS
VIT A FISH CAP 7500UNIT OTC
vitamin a cap 8000 unit OTC
vitamin a cap 10000 unit OTC
VITAMIN A CAP 25000UNT OTC
vitamin d3 cap 400unit OTC; Available for 90 day fill
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
70
Drug Name Requirements/Limits
vitamin d3 cap 2000unit OTC
vitamin d3 cap 5000unit OTC
vitamin d3 cap 10000 OTC
vitamin d3 cap 50000unt OTC
vitamin d3 chw 400unit OTC
vitamin d3 chw 1000unit OTC
vitamin d3 chw 2000unit OTC
vitamin d3 chw 5000unit OTC
vitamin d3 dro 400unit OTC
vitamin d3 sol 8000/ml OTC
vitamin d3 tab 1000unit OTC
vitamin d3 tab 2000unit OTC
vitamin d3 tab 5000unit OTC
vitamin d3 tab 50000unt OTC
vitamin d cap 50000unt
vitamin d tab 400unit OTC; Available for 90 day fill
vitamin d-3 cap 1000unit OTC
vitamin e cap 100 unit OTC
vitamin e cap 200 unit OTC
vitamin e cap 400 unit OTC
vitamin e cap 600 unit OTC
vitamin e cap 1000 unit OTC
WATER SOLUBLE VITAMINS biotin cap 5 mg OTC
biotin tab 5 mg OTC
LIQUID C 500 LIQ 500/15ML OTC
niacin cap er 500 mg OTC
niacin tab 100 mg OTC
niacin tab 250 mg OTC
niacin tab 500 mg OTC
niacin tab er 500 mg OTC
vitamin b6 tab 100mg OTC
vitamin b-1 tab 50mg OTC
vitamin b-1 tab 100mg OTC
vitamin b-1 tab 100mg OTC; Available for 90 day fill
vitamin b-1 tab 250mg OTC
vitamin b-2 tab 25mg OTC
vitamin b-2 tab 100mg OTC
vitamin b-6 tab 25mg OTC
vitamin b-6 tab 50mg OTC
vitamin b-6 tab 200mg cr OTC
vitamin b-6 tab 250mg OTC
vitamin c chw 250mg OTC
vitamin c chw 500mg OTC
vitamin c liq 500/5ml OTC
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter
71
Drug Name Requirements/Limits
VITAMIN C SYP 500/5ML OTC
vitamin c tab 250mg OTC
vitamin c tab 1000mg OTC
72
Index
A abacavir sulfate soln 20 mg/ml (base equiv) ............................................. 32
abacavir sulfate tab 300 mg (base equiv) ...................................................... 32
abacavir sulfate-lamivudine tab 600-300 mg .................................................. 32
abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg ......................... 32
ABSORICA CAP 10MG ........................ 40
ABSORICA CAP 20MG ........................ 40 ABSORICA CAP 30MG ........................ 40
ABSORICA CAP 40MG ........................ 40 acamprosate calcium tab delayed release
333 mg ........................................... 64 acarbose tab 100 mg ......................... 17
acarbose tab 25 mg .......................... 17 acarbose tab 50 mg .......................... 17
ACCU-CHEK BLOOD GLUCOSE TEST KITS ...................................................... 53
ACCU-CHEK BLOOD GLUCOSE TEST STRIPS ............................................ 45
ACCU-CHEK LIQ GUIDE ..................... 53 acebutolol hcl cap 200 mg ................. 34
acebutolol hcl cap 400 mg ................. 34
acetaminophe chw 160mg .................. 5 acetaminophe tab 160mg ................... 5
acetaminophen elixir 160 mg/5ml ........ 5 acetaminophen liquid 160 mg/5ml ....... 5
acetaminophen soln 160 mg/5ml ......... 5 acetaminophen tab 325 mg ................. 5
acetaminophen tab er 650 mg ............. 5 acetaminophen w/ codeine soln 120-12
mg/5ml ............................................ 6 acetaminophen w/ codeine tab 300-15
mg ................................................... 6 acetaminophen w/ codeine tab 300-30
mg ................................................... 6 acetaminophen w/ codeine tab 300-60
mg ................................................... 6
acetaminophn sus 160/5ml ................. 5 acetaminophn tab 500mg ................... 5
acetazolamide cap er 12hr 500 mg ..... 45 acetazolamide tab 125 mg ................. 45
acetazolamide tab 250 mg ................. 45 acetic acid 2% in aluminum acetate otic
soln ................................................ 63
acetic acid otic soln 2% ..................... 63 acetylcysteine inhal soln 10% ............ 40
acetylcysteine inhal soln 20% ............ 40 acitretin cap 10 mg .......................... 42
acitretin cap 17.5 mg ........................ 42 acitretin cap 25 mg .......................... 42
ACNE MEDICAT LOT 10% .................. 40 ACNE MEDICAT LOT 5% .................... 40
act fluoride sol 0.05% ....................... 56
act total sol dry mout ....................... 56 ACTIVE OB CAP ................................ 57
acyclovir cap 200 mg ........................ 34 acyclovir oint 5% ............................. 42
acyclovir susp 200 mg/5ml ................ 34 acyclovir tab 400 mg ........................ 34
acyclovir tab 800 mg ........................ 34 adapalene gel 0.1% .......................... 40
adefovir dipivoxil tab 10 mg .............. 34 ADMELOG INJ 100U/ML ..................... 19
ADMELOG SOLO INJ 100U/ML ............ 19 ADULT RESPIRATORY MASK .............. 53
ADVAIR DISKU AER 100/50 ............... 11 ADVAIR DISKU AER 250/50 ............... 11
ADVAIR DISKU AER 500/50 ............... 11
ADVAIR HFA AER 115/21 .................. 11 ADVAIR HFA AER 230/21 .................. 11
ADVAIR HFA AER 45/21 .................... 11 AFINITOR TAB 10MG ........................ 27
AFINITOR TAB 2.5MG ....................... 27 AFINITOR TAB 5MG .......................... 27
AFINITOR TAB 7.5MG ....................... 27 AFLURIA INJ 2018-19 ....................... 68
AFLURIA INJ PF 18-19 ...................... 68 AFLURIA QUAD INJ 2018-19 .............. 68
AFLURIA QUAD INJ PF 18-19 ............. 68 AFRIN CHILD SPR 0.25% .................. 60
ALBUSTIX TES ................................. 45 albuterol sulfate soln nebu 0.083% (2.5
mg/3ml) ......................................... 11
albuterol sulfate soln nebu 0.5% (5 mg/ml) ........................................... 11
albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) .................................... 11
albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) .................................... 11
73
albuterol sulfate syrup 2 mg/5ml ........ 11
albuterol sulfate tab 2 mg .................. 11 albuterol sulfate tab er 12hr 4 mg ....... 11
ALCOHOL PAD .................................. 53 alendronate sodium tab 10 mg ........... 46
alendronate sodium tab 35 mg ........... 46 alendronate sodium tab 70 mg ........... 46
alfuzosin hcl tab er 24hr 10 mg .......... 49 ALKA-SELTZER TAB 500MG ................. 5
ALLEGRA ALRG TAB 30MG ................. 21 aller-chlor syp 2mg/5ml ..................... 21
ALLI CAP 60MG.................................. 1 allopurinol tab 100 mg....................... 49
allopurinol tab 300 mg....................... 49 alogliptin benzoate tab 12.5 mg (base
equiv) ............................................. 18
alogliptin benzoate tab 25 mg (base equiv) ............................................. 18
alogliptin benzoate tab 6.25 mg (base equiv) ............................................. 18
alogliptin-metformin hcl tab 12.5-1000 mg .................................................. 17
alogliptin-metformin hcl tab 12.5-500 mg ...................................................... 17
alogliptin-pioglitazone tab 12.5-15 mg. 17 alogliptin-pioglitazone tab 12.5-30 mg. 17
alogliptin-pioglitazone tab 12.5-45 mg. 17 alogliptin-pioglitazone tab 25-15 mg ... 17
alogliptin-pioglitazone tab 25-30 mg ... 17 alogliptin-pioglitazone tab 25-45 mg ... 17
alp high3 cap 600mg ......................... 61
alprazolam tab 0.25 mg ...................... 9 alprazolam tab 0.5 mg........................ 9
alprazolam tab 1 mg .......................... 9 alprazolam tab 2 mg .......................... 9
ALUM HYDROX SUS 320/5ML .............. 7 ALUMINUM SOL ACETATE .................. 44
amantadine hcl cap 100 mg ............... 28 amantadine hcl syrup 50 mg/5ml ........ 28
amantadine hcl tab 100 mg ................ 28 amiloride & hydrochlorothiazide tab 5-50
mg .................................................. 45 amiloride hcl tab 5 mg ....................... 46
amiodarone hcl tab 200 mg ................ 10 amitriptyline hcl tab 10 mg ................ 16
amitriptyline hcl tab 100 mg .............. 17
amitriptyline hcl tab 150 mg .............. 17 amitriptyline hcl tab 25 mg ................ 16
amitriptyline hcl tab 50 mg ................ 16
amitriptyline hcl tab 75 mg ................ 16 amlodipine besylate tab 10 mg (base
equivalent) ...................................... 35 amlodipine besylate tab 2.5 mg (base
equivalent) ...................................... 35 amlodipine besylate tab 5 mg (base
equivalent) ...................................... 35 amlodipine besylate-benazepril hcl cap
10-20 mg ........................................ 24 amlodipine besylate-benazepril hcl cap
10-40 mg ........................................ 24 amlodipine besylate-benazepril hcl cap
2.5-10 mg ....................................... 24 amlodipine besylate-benazepril hcl cap 5-
10 mg ............................................. 24
amlodipine besylate-benazepril hcl cap 5-20 mg ............................................. 24
amlodipine besylate-benazepril hcl cap 5-40 mg ............................................. 24
amlodipine besylate-olmesartan medoxomil tab 10-20 mg .................. 24
amlodipine besylate-olmesartan medoxomil tab 10-40 mg .................. 24
amlodipine besylate-olmesartan medoxomil tab 5-20 mg .................... 24
amlodipine besylate-olmesartan medoxomil tab 5-40 mg .................... 24
amlodipine besylate-valsartan tab 10-160 mg ........................................... 25
amlodipine besylate-valsartan tab 10-
320 mg ........................................... 25 amlodipine besylate-valsartan tab 5-160
mg ................................................. 25 amlodipine besylate-valsartan tab 5-320
mg ................................................. 25 amnesteem cap 10mg ...................... 40
amnesteem cap 20mg ...................... 40 amnesteem cap 40mg ...................... 40
amoxicillin & k clavulanate chew tab 200-28.5 mg .......................................... 63
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml ................................... 63
amoxicillin & k clavulanate for susp 400-57 mg/5ml ...................................... 63
amoxicillin & k clavulanate for susp 600-
42.9 mg/5ml ................................... 63 amoxicillin & k clavulanate tab 500-125
74
mg .................................................. 63
amoxicillin & k clavulanate tab 875-125 mg .................................................. 64
amoxicillin (trihydrate) cap 250 mg ..... 63 amoxicillin (trihydrate) cap 500 mg ..... 63
amoxicillin (trihydrate) chew tab 125 mg ...................................................... 63
amoxicillin (trihydrate) for susp 125 mg/5ml ........................................... 63
amoxicillin (trihydrate) for susp 200 mg/5ml ........................................... 63
amoxicillin (trihydrate) for susp 250 mg/5ml ........................................... 63
amoxicillin (trihydrate) for susp 400 mg/5ml ........................................... 63
amoxicillin (trihydrate) tab 875 mg ..... 63
amphetamine-dextroamphetamine cap er 24hr 10 mg ....................................... 1
amphetamine-dextroamphetamine cap er 24hr 15 mg ....................................... 1
amphetamine-dextroamphetamine cap er 24hr 20 mg ....................................... 1
amphetamine-dextroamphetamine cap er 24hr 25 mg ....................................... 1
amphetamine-dextroamphetamine cap er 24hr 30 mg ....................................... 1
amphetamine-dextroamphetamine cap er 24hr 5 mg ......................................... 1
amphetamine-dextroamphetamine tab 10 mg .............................................. 1
amphetamine-dextroamphetamine tab
12.5 mg ........................................... 1 amphetamine-dextroamphetamine tab
15 mg .............................................. 1 amphetamine-dextroamphetamine tab
20 mg .............................................. 1 amphetamine-dextroamphetamine tab
30 mg .............................................. 1 amphetamine-dextroamphetamine tab 5
mg ................................................... 1 amphetamine-dextroamphetamine tab
7.5 mg ............................................. 1 ampicillin cap 250 mg ........................ 63
ampicillin cap 500 mg ........................ 63 ampicillin for susp 125 mg/5ml ........... 63
ampicillin for susp 250 mg/5ml ........... 63
anastrozole tab 1 mg ........................ 27 antacid sus ....................................... 7
antifungal cre 1% ............................. 42
anti-itch lot sens 1% ........................ 44 APIDRA INJ U-100 ............................ 19
aprepitant capsule 125 mg ................ 21 aprepitant capsule 40 mg .................. 20
aprepitant capsule 80 mg .................. 20 aprepitant capsule therapy pack 80 &
125 mg ........................................... 21 APRISO CAP 0.375GM ....................... 48
APTIVUS CAP 250MG ........................ 32 APTIVUS SOL ................................... 32
AQUAPHOR OIN ............................... 44 aranelle tab ..................................... 37
aripiprazole tab 10 mg ...................... 31 aripiprazole tab 15 mg ...................... 31
aripiprazole tab 2 mg ........................ 31
aripiprazole tab 20 mg ...................... 31 aripiprazole tab 30 mg ...................... 31
aripiprazole tab 5 mg ........................ 31 armodafinil tab 150 mg ....................... 2
armodafinil tab 200 mg ....................... 2 armodafinil tab 250 mg ....................... 2
armodafinil tab 50 mg ........................ 2 ARTH PAIN CRE 0.075% ................... 44
arthricream cre 10% ........................ 44 artifi tears oin op ............................. 61
artifi tears sol 1.4% op ..................... 61 ASMANEX 120 AER 220MCG .............. 10
ASMANEX 14 AER 220MCG ................ 10 ASMANEX 30 AER 110MCG ................ 10
ASMANEX 30 AER 220MCG ................ 10
ASMANEX 60 AER 220MCG ................ 10 ASMANEX 7 AER 110MCG .................. 10
ASMANEX HFA AER 100 MCG ............. 10 ASMANEX HFA AER 200 MCG ............. 11
aspirin low chw 81mg ......................... 5 aspirin tab 325mg .............................. 5
aspirin tab 500 mg ............................. 5 aspirin tab delayed release 325 mg ...... 5
aspirin tab delayed release 81 mg ........ 5 aspirin-acetaminophen-caffeine tab 250-
250-65 mg ........................................ 4 ATABEX CHW PRENATAL ................... 57
ATABEX EC TAB ............................... 57 atazanavir sulfate cap 150 mg (base
equiv) ............................................. 32
atazanavir sulfate cap 200 mg (base equiv) ............................................. 32
75
atazanavir sulfate cap 300 mg (base
equiv) ............................................. 32 atenolol & chlorthalidone tab 100-25 mg
...................................................... 25 atenolol & chlorthalidone tab 50-25 mg
...................................................... 25 atenolol tab 100 mg .......................... 35
atenolol tab 25 mg ............................ 34 atenolol tab 50 mg ............................ 34
athlete foot cre 1% ........................... 42 atomoxetine hcl cap 10 mg (base equiv)
....................................................... 1 atomoxetine hcl cap 100 mg (base
equiv) .............................................. 2 atomoxetine hcl cap 18 mg (base equiv)
....................................................... 1
atomoxetine hcl cap 25 mg (base equiv) ....................................................... 1
atomoxetine hcl cap 40 mg (base equiv) ....................................................... 2
atomoxetine hcl cap 60 mg (base equiv) ....................................................... 2
atomoxetine hcl cap 80 mg (base equiv) ....................................................... 2
atorvastatin calcium tab 10 mg (base equivalent) ...................................... 22
atorvastatin calcium tab 20 mg (base equivalent) ...................................... 22
atorvastatin calcium tab 40 mg (base equivalent) ...................................... 22
atorvastatin calcium tab 80 mg (base
equivalent) ...................................... 22 ATRIPLA TAB .................................... 32
ATROPINE SUL OIN 1% OP ................ 61 atropine sulfate ophth soln 1% ........... 61
AUBAGIO TAB 14MG ......................... 65 AUBAGIO TAB 7MG ........................... 65
AVEENO BABY KIT BATHTIME ............. 53 AVONEX KIT 30MCG .......................... 65
AVONEX PEN KIT 30MCG ................... 65 AVONEX PREFL KIT 30MCG ................ 65
azathioprine tab 50 mg ...................... 55 azelastine hcl nasal spray 0.1% (137
mcg/spray) ...................................... 60 azelastine hcl ophth soln 0.05% ......... 62
azithromycin for susp 100 mg/5ml ...... 52
azithromycin for susp 200 mg/5ml ...... 52 azithromycin powd pack for susp 1 gm 52
azithromycin tab 250 mg .................. 53
azithromycin tab 500 mg .................. 53 azithromycin tab 600 mg .................. 53
B b complex tab plus c ......................... 56
baby teethng gel 7.5% ..................... 56 bacitracin oint 500 unit/gm ............... 41
bacitracin zinc oint 500 unit/gm ......... 41 bacitracin-polymyxin b oint ............... 41
bacitracin-polymyxin b ophth oint ...... 62 baclofen tab 10 mg .......................... 60
baclofen tab 20 mg .......................... 60 BAL-CARE MIS DHA .......................... 57
balsalazide disodium cap 750 mg ....... 48 BASAGLAR KWIKPEN ........................ 19
BAYER PLUS TAB 500MG ..................... 5
B-COMPLEX TAB C/FA/BIO ................ 56 b-complex vitamin cap ...................... 56
b-complex vitamin tab ...................... 56 BD GLUCOSE CHW 5GM .................... 18
BE WELL PAK ROUNDED .................... 57 BELVIQ TAB 10MG .............................. 1
BELVIQ XR TAB 20MG ......................... 1 benazepril & hydrochlorothiazide tab 10-
12.5 mg .......................................... 25 benazepril & hydrochlorothiazide tab 20-
12.5 mg .......................................... 25 benazepril & hydrochlorothiazide tab 20-
25 mg ............................................. 25 benazepril hcl tab 10 mg ................... 23
benazepril hcl tab 20 mg ................... 23
benazepril hcl tab 40 mg ................... 23 benazepril hcl tab 5 mg ..................... 23
BENLYSTA INJ 120MG ....................... 56 BENLYSTA INJ 200MG/ML .................. 56
BENLYSTA INJ 400MG ....................... 56 benzonatate cap 100 mg ................... 39
benzonatate cap 200 mg ................... 39 benzoyl peroxide-erythromycin gel 5-3%
...................................................... 40 benztropine mesylate tab 0.5 mg ....... 28
benztropine mesylate tab 1 mg .......... 28 benztropine mesylate tab 2 mg .......... 28
betamethasone dipropionate augmented cream 0.05% ................................... 42
betamethasone dipropionate augmented
gel 0.05% ....................................... 42 betamethasone dipropionate augmented
76
lotion 0.05% .................................... 42
betamethasone dipropionate augmented oint 0.05% ....................................... 43
betamethasone dipropionate cream 0.05% ............................................. 43
betamethasone dipropionate lotion 0.05% ............................................. 43
betamethasone valerate cream 0.1% (base equivalent) .............................. 43
betamethasone valerate lotion 0.1% (base equivalent) .............................. 43
betamethasone valerate oint 0.1% (base equivalent) ...................................... 43
bethanechol chloride tab 10 mg .......... 68 bethanechol chloride tab 25 mg .......... 68
bicalutamide tab 50 mg ..................... 27
BIKTARVY TAB .................................. 32 biotin cap 5 mg ................................ 70
biotin tab 5 mg ................................. 70 bisacodyl suppos 10 mg ..................... 52
bisacodyl tab 5mg ec ......................... 52 bismuth subsalicylate chew tab 262 mg
...................................................... 20 bisoprolol & hydrochlorothiazide tab 10-
6.25 mg .......................................... 25 bisoprolol & hydrochlorothiazide tab 2.5-
6.25 mg .......................................... 25 bisoprolol & hydrochlorothiazide tab 5-
6.25 mg .......................................... 25 bisoprolol fumarate tab 10 mg ............ 35
bisoprolol fumarate tab 5 mg ............. 35
BLOOD GLUCOSE CALIBRATION SOLUTION ....................................... 53
BOTOX INJ 100UNIT.......................... 61 BOTOX INJ 200UNIT.......................... 61
bp gel gel 10% ................................. 41 bp gel gel 5% ................................... 41
bp wash liq 5% ................................. 41 bprotected sol tri-vite ........................ 57
BRAINSTRONG MIS PRENATAL ........... 57 brimonidine tartrate ophth soln 0.2% .. 62
bromocriptine mesylate cap 5 mg (base equivalent) ...................................... 28
bromocriptine mesylate tab 2.5 mg (base equivalent) ...................................... 28
budesonide delayed release particles cap
3 mg ............................................... 39 budesonide inhalation susp 0.25 mg/2ml
...................................................... 11
budesonide inhalation susp 0.5 mg/2ml...................................................... 11
budesonide inhalation susp 1 mg/2ml . 11 budesonide tab er 24hr 9 mg ............. 39
bumetanide tab 0.5 mg ..................... 46 bumetanide tab 1 mg ....................... 46
bumetanide tab 2 mg ....................... 46 buprenorphine hcl sl tab 2 mg (base
equiv) ............................................... 7 buprenorphine hcl sl tab 8 mg (base
equiv) ............................................... 7 buprenorphine hcl-naloxone hcl sl tab 2-
0.5 mg (base equiv) ........................... 7 buprenorphine hcl-naloxone hcl sl tab 8-
2 mg (base equiv) .............................. 7
buprenorphine td patch weekly 10 mcg/hr ............................................. 7
buprenorphine td patch weekly 15 mcg/hr ............................................. 7
buprenorphine td patch weekly 20 mcg/hr ............................................. 7
buprenorphine td patch weekly 5 mcg/hr........................................................ 7
buprenorphine td patch weekly 7.5 mcg/hr ............................................. 7
bupropion hcl (smoking deterrent) tab er 12hr 150 mg ................................... 65
bupropion hcl tab 100 mg ................. 15 bupropion hcl tab 75 mg ................... 15
bupropion hcl tab er 12hr 100 mg ...... 15
bupropion hcl tab er 12hr 150 mg ...... 15 bupropion hcl tab er 12hr 200 mg ...... 15
bupropion hcl tab er 24hr 150 mg ...... 15 bupropion hcl tab er 24hr 300 mg ...... 15
buspirone hcl tab 10 mg ..................... 9 buspirone hcl tab 15 mg ..................... 9
buspirone hcl tab 30 mg ..................... 9 buspirone hcl tab 5 mg ....................... 9
buspirone hcl tab 7.5 mg .................... 9 butalbital-acetaminophen tab 50-325 mg
........................................................ 4 butalbital-acetaminophen-caff w/ cod cap
50-325-40-30 mg .............................. 6 butalbital-acetaminophen-caffeine tab
50-325-40 mg ................................... 5
butorphanol tartrate nasal soln 10 mg/ml........................................................ 7
77
BYDUREON BC INJ 2/0.85ML .............. 18
BYDUREON INJ 2MG .......................... 18 BYDUREON PEN INJ 2MG ................... 18
BYETTA INJ 10MCG ........................... 18 BYETTA INJ 5MCG ............................. 18
C CA CITRATE TAB 250MG .................... 54
CA GLUCONATE TAB 50MG ................. 54 CA LACTATE TAB 100MG .................... 54
cabergoline tab 0.5 mg ...................... 47 CADEAU DHA CAP ............................. 57
CALAMINE LOT ................................. 44 CALAMINE LOT 8-8% ........................ 44
calc cit+d3 tab 200-250 .................... 54 calcipotriene oint 0.005% .................. 42
calcipotriene soln 0.005% (50 mcg/ml)
...................................................... 42 calcitriol cap 0.25 mcg ....................... 47
calcitriol cap 0.5 mcg ........................ 47 calcitriol oral soln 1 mcg/ml ............... 47
calcium ............................................ 54 calcium + d tab 600mg...................... 54
calcium acetate (phosphate binder) cap 667 mg (169 mg ca) ......................... 49
CALCIUM CARB TAB 648MG ................ 8 calcium carbonate (antacid) chew tab
500 mg ............................................ 8 calcium carbonate (antacid) chew tab
750 mg ............................................ 8 calcium carbonate (antacid) susp 1250
mg/5ml ............................................ 8
calcium carbonate tab 1250 mg (500 mg elemental ca) ................................... 54
calcium carbonate tab 1500 mg (600 mg elemental ca) ................................... 54
calcium carbonate-vitamin d cap 600 mg-200 unit ..................................... 54
calcium carbonate-vitamin d tab 600 mg-200 unit ........................................... 54
CALCIUM CHW 500MG ....................... 54 CALCIUM CIT TAB 1040MG ................ 54
CALCIUM CITR TAB 200MG ................ 54 calcium citrate tab 950 mg (200 mg
elemental ca) ................................... 54 calcium citrate-vitamin d tab 315 mg-
250 unit (elemental ca) ..................... 54
CALCIUM GLUC TAB 500MG ............... 54 CALCIUM LACT TAB 648MG ................ 54
CALCIUM LACT TAB 750MG ............... 54
calcium polycarbophil tab 625 mg ...... 52 CALCIUM TAB 333MG ....................... 54
calcium/d chw 500-400 ..................... 54 calcium+d tab 600-800 ..................... 54
capecitabine tab 150 mg ................... 27 capecitabine tab 500 mg ................... 27
capsaicin cream 0.025% ................... 44 capsaicin cream 0.1% ....................... 44
CAPZASIN-P CRE 0.035% ................. 44 carbamazepine cap er 12hr 100 mg .... 13
carbamazepine cap er 12hr 200 mg .... 13 carbamazepine cap er 12hr 300 mg .... 13
carbamazepine chew tab 100 mg ....... 13 carbamazepine susp 100 mg/5ml ....... 13
carbamazepine tab 200 mg ............... 13
carbamazepine tab er 12hr 100 mg .... 13 carbamazepine tab er 12hr 200 mg .... 13
carbamazepine tab er 12hr 400 mg .... 13 carbidopa & levodopa tab 10-100 mg . 29
carbidopa & levodopa tab 25-100 mg . 29 carbidopa & levodopa tab 25-250 mg . 29
carbidopa & levodopa tab er 25-100 mg...................................................... 29
carboxymethylcellulose sodium ophth soln 0.5% ....................................... 61
carvedilol tab 12.5 mg ...................... 34 carvedilol tab 25 mg ......................... 34
carvedilol tab 3.125 mg .................... 34 carvedilol tab 6.25 mg ...................... 34
cefadroxil cap 500 mg....................... 37
cefadroxil for susp 250 mg/5ml .......... 37 cefadroxil for susp 500 mg/5ml .......... 37
cefadroxil tab 1 gm .......................... 37 cefdinir cap 300 mg .......................... 37
cefdinir for susp 125 mg/5ml ............. 37 cefdinir for susp 250 mg/5ml ............. 37
cefprozil for susp 125 mg/5ml ........... 37 cefprozil for susp 250 mg/5ml ........... 37
cefprozil tab 250 mg ......................... 37 cefprozil tab 500 mg ......................... 37
cefuroxime axetil tab 250 mg ............ 37 cefuroxime axetil tab 500 mg ............ 37
celecoxib cap 100 mg ......................... 3 celecoxib cap 200 mg ......................... 3
celecoxib cap 400 mg ......................... 3
celecoxib cap 50 mg ........................... 3 CENTRUM SPEC PAK PRENATAL .......... 57
78
cephalexin cap 250 mg ...................... 37
cephalexin cap 500 mg ...................... 37 cephalexin for susp 125 mg/5ml ......... 37
cephalexin for susp 250 mg/5ml ......... 37 cetirizine sol 1mg/ml ......................... 21
cetirizine tab 10mg ........................... 21 cetirizine tab 5mg ............................. 21
cetirizine-pseudoephedrine tab er 12hr 5-120 mg ........................................ 39
CHANTIX PAK 0.5& 1MG .................... 65 CHANTIX TAB 0.5MG ......................... 65
CHANTIX TAB 1MG ............................ 65 CHEWABLE CHW CALCIUM ................. 54
childrens chw multivit ........................ 57 chlordiazepoxide hcl cap 10 mg ........... 9
chlordiazepoxide hcl cap 25 mg ........... 9
chlordiazepoxide hcl cap 5 mg ............. 9 chlorhexidine gluconate soln 0.12% .... 56
chlorothiazide tab 250 mg .................. 46 chlorothiazide tab 500 mg .................. 46
chlorpheniramine maleate tab 4 mg .... 21 chlorpheniramine maleate tab er 12 mg
...................................................... 21 chlorpromazine hcl tab 10 mg ............ 31
chlorpromazine hcl tab 100 mg ........... 31 chlorpromazine hcl tab 200 mg ........... 31
chlorpromazine hcl tab 25 mg ............ 31 chlorpromazine hcl tab 50 mg ............ 31
chlorthalidone tab 25 mg ................... 46 chlorthalidone tab 50 mg ................... 46
chlorzoxazone tab 500 mg ................. 60
cholestyramine light powder 4 gm/dose ...................................................... 22
cholestyramine light powder packets 4 gm .................................................. 22
cholestyramine powder 4 gm/dose ...... 22 cholestyramine powder packets 4 gm .. 22
ciclodan cre 0.77% ........................... 42 ciclodan sol 8% ................................ 42
cilostazol tab 100 mg ........................ 50 cilostazol tab 50 mg .......................... 50
cimetidine tab 200mg ........................ 67 cimetidine tab 300 mg ....................... 67
cimetidine tab 400 mg ....................... 67 cimetidine tab 800 mg ....................... 67
CINQAIR INJ .................................... 10
ciprofloxacin hcl ophth soln 0.3% ........ 62 ciprofloxacin hcl tab 100 mg (base equiv)
...................................................... 48
ciprofloxacin hcl tab 250 mg (base equiv)...................................................... 48
ciprofloxacin hcl tab 500 mg (base equiv)...................................................... 48
ciprofloxacin hcl tab 750 mg (base equiv)...................................................... 48
citalopram hydrobromide oral soln 10 mg/5ml ........................................... 15
citalopram hydrobromide tab 10 mg (base equiv) .................................... 15
citalopram hydrobromide tab 20 mg (base equiv) .................................... 15
citalopram hydrobromide tab 40 mg (base equiv) .................................... 15
CITRANATAL CAP HARMONY .............. 57
CITRANATAL CAP MEDLEY ................. 57 CITRANATAL MIS ............................. 57
CITRANATAL MIS B-CALM ................. 57 CITRANATAL PAK ASSURE ................. 57
CITRANATAL TAB BLOOM .................. 57 CITRANATAL TAB RX ........................ 57
claravis cap 10mg ............................ 41 claravis cap 20mg ............................ 41
claravis cap 30mg ............................ 41 claravis cap 40mg ............................ 41
clarithromycin for susp 125 mg/5ml ... 53 clarithromycin for susp 250 mg/5ml ... 53
clarithromycin tab 250 mg ................ 53 clarithromycin tab 500 mg ................ 53
claritin eye dro 0.025%op ................. 62
clindamycin hcl cap 150 mg ................. 8 clindamycin hcl cap 300 mg ................. 8
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) .......................... 8
clindamycin phosphate gel 1% ........... 41 clindamycin phosphate lotion 1% ....... 41
clindamycin phosphate soln 1% ......... 41 clindamycin phosphate swab 1% ........ 41
clindamycin phosphate vaginal cream 2%...................................................... 69
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% ...................... 41
clobazam suspension 2.5 mg/ml ........ 13 clobazam tab 10 mg ......................... 13
clobazam tab 20 mg ......................... 13
clobetasol e cre 0.05% ..................... 43 clobetasol propionate cream 0.05% .... 43
79
clobetasol propionate oint 0.05% ........ 43
clobetasol propionate soln 0.05% ....... 43 clomipramine hcl cap 25 mg ............... 17
clomipramine hcl cap 50 mg ............... 17 clomipramine hcl cap 75 mg ............... 17
clonazepam tab 0.5 mg ..................... 13 clonazepam tab 1 mg ........................ 13
clonazepam tab 2 mg ........................ 13 clonidine hcl tab 0.1 mg..................... 24
clonidine hcl tab 0.2 mg..................... 24 clonidine hcl tab 0.3 mg..................... 24
clopidogrel bisulfate tab 75 mg (base equiv) ............................................. 50
clotrimazole cream 1% ...................... 42 clotrimazole soln 1% ......................... 42
clotrimazole troche 10 mg .................. 56
clotrimazole vaginal cream 1% ........... 69 clotrimazole w/ betamethasone cream 1-
0.05% ............................................. 42 clotrimazole w/ betamethasone lotion 1-
0.05% ............................................. 42 clozapine tab 100 mg ........................ 30
clozapine tab 200 mg ........................ 30 clozapine tab 25 mg .......................... 30
clozapine tab 50 mg .......................... 30 codeine sulfate tab 15 mg ................... 5
codeine sulfate tab 30 mg ................... 5 codeine sulfate tab 60 mg ................... 5
colchicine tab 0.6 mg ........................ 50 colchicine w/ probenecid tab 0.5-500 mg
...................................................... 49
cold/allergy elx ................................. 40 cold/allergy tab pe ............................ 40
colesevelam hcl tab 625 mg ............... 22 colestipol hcl granule packets 5 gm ..... 22
colestipol hcl granules 5 gm ............... 22 colestipol hcl tab 1 gm ....................... 22
COMBIVENT AER 20-100 .................... 11 COMPLERA TAB ................................ 32
complete kit lice ............................... 45 COMPLETE NAT PAK DHA ................... 57
CONCEPT DHA CAP ........................... 57 CONDOMS ....................................... 53
CONTRAVE TAB 8-90MG ..................... 1 CREON CAP 12000UNT ...................... 45
CREON CAP 24000UNT ...................... 45
CREON CAP 3000UNIT ....................... 45 CREON CAP 36000UNT ...................... 45
CREON CAP 6000UNIT ...................... 45
CRESEMBA CAP 186 MG .................... 21 CRESEMBA INJ 372MG ...................... 21
CRIXIVAN CAP 200MG ...................... 32 CRIXIVAN CAP 400MG ...................... 32
cromolyn sodium nasal aerosol soln 5.2 mg/act (4%) ................................... 60
cromolyn sodium ophth soln 4% ........ 62 cromolyn sodium soln nebu 20 mg/2ml
...................................................... 10 cryselle-28 tab ................................. 37
CVS PRENATAL CHW GUMMY ............. 57 cvs sore loz throat ............................ 56
cyclobenzaprine hcl tab 5 mg ............. 60 cyclopentolate hcl ophth soln 1% ....... 61
cyclosporine cap 25 mg ..................... 55
cyclosporine modified cap 100 mg ...... 55 cyclosporine modified cap 25 mg ........ 55
cyclosporine modified cap 50 mg ........ 55 cyclosporine modified oral soln 100
mg/ml ............................................ 55 cyproheptadine hcl syrup 2 mg/5ml .... 22
cyproheptadine hcl tab 4 mg ............. 22 D daily multi tab vit/iron ...................... 56 dalfampridine tab er 12hr 10 mg ........ 65
DALIRESP TAB 500MCG .................... 10 danazol cap 100 mg ........................... 7
danazol cap 200 mg ........................... 7 dantrolene sodium cap 25 mg ............ 60
dapsone tab 100 mg ........................... 8
dapsone tab 25 mg ............................ 8 DDAVP SOL 0.01% ........................... 47
decongestant sol 1% ........................ 60 denta 5000 cre plus .......................... 56
dermacerin cre ................................ 44 DESCOVY TAB 200/25 ...................... 32
desipramine hcl tab 10 mg ................ 17 desipramine hcl tab 100 mg .............. 17
desipramine hcl tab 25 mg ................ 17 desipramine hcl tab 50 mg ................ 17
desipramine hcl tab 75 mg ................ 17 desloratadine tab 5 mg ..................... 21
desmopressin acetate nasal spray soln 0.01% ............................................ 47
desmopressin acetate tab 0.1 mg ....... 47
desmopressin acetate tab 0.2 mg ....... 47 desogest-eth estrad & eth estrad tab
80
0.15-0.02/0.01 mg(21/5) .................. 37
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg ...................................... 38
desonide cream 0.05% ...................... 43 desonide oint 0.05% ......................... 43
desvenlafaxine succinate tab er 24hr 100 mg (base equiv) ............................... 16
desvenlafaxine succinate tab er 24hr 25 mg (base equiv) ............................... 16
desvenlafaxine succinate tab er 24hr 50 mg (base equiv) ............................... 16
DEXAMETHASON CON 1MG/ML ........... 39 dexamethasone elixir 0.5 mg/5ml ....... 39
dexamethasone sodium phosphate inj 4 mg/ml ............................................. 39
dexamethasone sodium phosphate ophth
soln 0.1% ........................................ 62 dexamethasone soln 0.5 mg/5ml ........ 39
dexamethasone tab 0.5 mg ................ 39 dexamethasone tab 0.75 mg .............. 39
dexamethasone tab 1 mg .................. 39 dexamethasone tab 1.5 mg ................ 39
dexamethasone tab 2 mg .................. 39 dexamethasone tab 4 mg .................. 39
dexamethasone tab 6 mg .................. 39 dexedrine tab 5mg ............................. 1
dexmethylphenidate hcl cap er 24 hr 10 mg ................................................... 2
dexmethylphenidate hcl cap er 24 hr 15 mg ................................................... 2
dexmethylphenidate hcl cap er 24 hr 20
mg ................................................... 2 dexmethylphenidate hcl cap er 24 hr 25
mg ................................................... 2 dexmethylphenidate hcl cap er 24 hr 30
mg ................................................... 2 dexmethylphenidate hcl cap er 24 hr 35
mg ................................................... 2 dexmethylphenidate hcl cap er 24 hr 40
mg ................................................... 2 dexmethylphenidate hcl cap er 24 hr 5
mg ................................................... 2 dexmethylphenidate hcl tab 10 mg ...... 2
dexmethylphenidate hcl tab 2.5 mg ..... 2 dexmethylphenidate hcl tab 5 mg ........ 2
dextromethorphan-guaifenesin syrup 10-
100 mg/5ml ..................................... 40 diazepam con 5mg/ml ........................ 9
diazepam oral soln 1 mg/ml ................ 9
diazepam rectal gel delivery system 10 mg ................................................. 13
diazepam rectal gel delivery system 2.5 mg ................................................. 13
diazepam rectal gel delivery system 20 mg ................................................. 13
diazepam tab 10 mg ........................... 9 diazepam tab 2 mg............................. 9
diazepam tab 5 mg............................. 9 DICLEGIS TAB 10-10MG ................... 20
diclofenac potassium tab 50 mg ........... 3 diclofenac sodium gel 1% .................. 41
diclofenac sodium ophth soln 0.1% .... 62 diclofenac sodium tab delayed release 50
mg ................................................... 3
diclofenac sodium tab delayed release 75 mg ................................................... 3
diclofenac sodium tab er 24hr 100 mg .. 3 dicloxacillin sodium cap 250 mg ......... 64
dicloxacillin sodium cap 500 mg ......... 64 dicyclomine hcl cap 10 mg ................ 67
dicyclomine hcl oral soln 10 mg/5ml ... 67 dicyclomine hcl tab 20 mg ................. 67
didanosine delayed release capsule 200 mg ................................................. 32
didanosine delayed release capsule 250 mg ................................................. 32
didanosine delayed release capsule 400 mg ................................................. 32
digoxin oral soln 0.05 mg/ml ............. 36
digoxin tab 125 mcg (0.125 mg) ........ 36 digoxin tab 250 mcg (0.25 mg) .......... 36
diltiazem hcl cap er 24hr 120 mg ....... 35 diltiazem hcl cap er 24hr 180 mg ....... 35
diltiazem hcl cap er 24hr 240 mg ....... 35 diltiazem hcl coated beads cap er 24hr
120 mg ........................................... 35 diltiazem hcl coated beads cap er 24hr
180 mg ........................................... 35 diltiazem hcl coated beads cap er 24hr
240 mg ........................................... 35 diltiazem hcl coated beads cap er 24hr
300 mg ........................................... 35 diltiazem hcl coated beads cap er 24hr
360 mg ........................................... 35
diltiazem hcl coated beads tab er 24hr 360 mg ........................................... 36
81
diltiazem hcl extended release beads cap
er 24hr 120 mg ................................ 36 diltiazem hcl extended release beads cap
er 24hr 240 mg ................................ 36 diltiazem hcl extended release beads cap
er 24hr 300 mg ................................ 36 diltiazem hcl extended release beads cap
er 24hr 360 mg ................................ 36 diltiazem hcl extended release beads cap
er 24hr 420 mg ................................ 36 diltiazem hcl tab 120 mg ................... 36
diltiazem hcl tab 30 mg ..................... 36 diltiazem hcl tab 60 mg ..................... 36
diltiazem hcl tab 90 mg ..................... 36 dimenhydrinate tab 50 mg ................. 20
diphenhydram cap 50mg ................... 21
diphenhydramine hcl cap 25 mg ......... 21 diphenhydramine hcl elixir 12.5 mg/5ml
...................................................... 21 diphenhydramine hcl liquid 12.5 mg/5ml
...................................................... 21 diphenhydramine hcl tab 25 mg .......... 21
diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml ........................................... 20
diphenoxylate w/ atropine tab 2.5-0.025 mg .................................................. 20
dipyridamole tab 25 mg ..................... 50 dipyridamole tab 50 mg ..................... 50
dipyridamole tab 75 mg ..................... 50 DISPOSABLE MIS MTHPIECE .............. 53
disulfiram tab 250 mg ....................... 64
disulfiram tab 500 mg ....................... 64 divalproex sodium tab delayed release
125 mg ........................................... 15 divalproex sodium tab delayed release
250 mg ........................................... 15 divalproex sodium tab delayed release
500 mg ........................................... 15 divalproex sodium tab er 24 hr 250 mg
...................................................... 15 divalproex sodium tab er 24 hr 500 mg
...................................................... 15 docusate calcium cap 240 mg ............. 52
docusate sodium cap 250 mg ............. 52 docusate sodium liquid 150 mg/15ml .. 52
donepezil hydrochloride orally
disintegrating tab 10 mg .................... 64 donepezil hydrochloride orally
disintegrating tab 5 mg ..................... 64
donepezil hydrochloride tab 10 mg ..... 64 donepezil hydrochloride tab 23 mg ..... 64
donepezil hydrochloride tab 5 mg ....... 64 dorzolamide hcl ophth soln 2% .......... 62
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml ......................... 61
DOUBLE-TUSSN LIQ DM .................... 40 doxazosin mesylate tab 1 mg ............ 24
doxazosin mesylate tab 2 mg ............ 24 doxazosin mesylate tab 4 mg ............ 24
doxazosin mesylate tab 8 mg ............ 24 doxepin hcl cap 10 mg ...................... 17
doxepin hcl cap 100 mg .................... 17 doxepin hcl cap 150 mg .................... 17
doxepin hcl cap 25 mg ...................... 17
doxepin hcl cap 50 mg ...................... 17 doxepin hcl cap 75 mg ...................... 17
doxepin hcl conc 10 mg/ml ................ 17 doxycycline hyclate cap 100 mg ......... 66
doxycycline hyclate tab 100 mg ......... 66 doxycycline hyclate tab 20 mg ........... 66
doxycycline monohydrate cap 100 mg 66 doxycycline monohydrate cap 50 mg .. 66
doxycycline monohydrate tab 100 mg . 66 doxycycline monohydrate tab 50 mg .. 66
dronabinol cap 10 mg ....................... 20 dronabinol cap 2.5 mg ...................... 20
dronabinol cap 5 mg ......................... 20 drospirenone-ethinyl estradiol tab 3-0.03
mg ................................................. 38
DROXIA CAP 200MG ......................... 50 DROXIA CAP 300MG ......................... 50
DROXIA CAP 400MG ......................... 50 DRYSOL SOL 20% ............................ 44
DUET DHA 400 MIS 25-1-400 ............ 57 DUET DHA MIS BALANCED ................ 57
DULERA AER 100-5MCG .................... 11 DULERA AER 200-5MCG .................... 11
duloxetine hcl cap 20 mg .................. 16 duloxetine hcl cap 30 mg .................. 16
duloxetine hcl cap 60 mg .................. 16 DUPIXENT INJ 300/2ML .................... 43
dutasteride cap 0.5 mg ..................... 49 E ear drops dro 6.5% .......................... 63
EDURANT TAB 25MG ........................ 32 efavirenz cap 200 mg ....................... 32
82
efavirenz cap 50 mg .......................... 32
efavirenz tab 600 mg ........................ 32 ELIQUIS TAB 2.5MG .......................... 12
ELIQUIS TAB 5MG ............................. 12 elite-ob tab ...................................... 57
ELLA TAB 30MG ................................ 38 EMEND SOL 150MG ........................... 21
EMEND SUS 125MG ........................... 21 EMTRIVA CAP 200MG ........................ 32
EMTRIVA SOL 10MG/ML ..................... 32 enalapril maleate & hydrochlorothiazide
tab 10-25 mg ................................... 25 enalapril maleate & hydrochlorothiazide
tab 5-12.5 mg .................................. 25 enalapril maleate tab 10 mg ............... 23
enalapril maleate tab 2.5 mg .............. 23
enalapril maleate tab 20 mg ............... 23 enalapril maleate tab 5 mg ................ 23
ENBRACE HR CAP ............................. 57 ENBREL INJ 25/0.5ML......................... 4
ENBREL INJ 25MG .............................. 4 ENBREL INJ 50MG/ML ......................... 4
ENBREL MINI INJ 50MG/ML ................. 4 ENBREL SRCLK INJ 50MG/ML .............. 4
ENCARE SUP 100MG ......................... 69 enoxaparin sodium inj 100 mg/ml ....... 13
enoxaparin sodium inj 120 mg/0.8ml .. 13 enoxaparin sodium inj 150 mg/ml ....... 13
enoxaparin sodium inj 30 mg/0.3ml .... 12 enoxaparin sodium inj 40 mg/0.4ml .... 12
enoxaparin sodium inj 60 mg/0.6ml .... 12
enoxaparin sodium inj 80 mg/0.8ml .... 12 entecavir tab 0.5 mg ......................... 34
entecavir tab 1 mg ............................ 34 ENTRESTO TAB 24-26MG ................... 37
ENTRESTO TAB 49-51MG ................... 37 ENTRESTO TAB 97-103MG ................. 37
ENTYVIO INJ 300MG ......................... 48 epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000) ......................... 69 epinephrine solution auto-injector 0.15
mg/0.3ml (1:2000) ........................... 69 epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000) ........................... 69 EPIPEN 2-PAK INJ 0.3MG ................... 69
EPIPEN-JR INJ 0.15MG ...................... 69
EPOGEN INJ 10000/ML ...................... 50 EPOGEN INJ 2000/ML ........................ 50
EPOGEN INJ 20000/ML ..................... 50
EPOGEN INJ 3000/ML ....................... 50 EPOGEN INJ 4000/ML ....................... 50
eq aspirin tab 500mg ec ...................... 5 EQUALYTE SOL ................................ 54
erythromycin gel 2% ........................ 41 erythromycin ophth oint 5 mg/gm ...... 62
erythromycin soln 2% ....................... 41 escitalopram oxalate tab 10 mg (base
equiv) ............................................. 15 escitalopram oxalate tab 20 mg (base
equiv) ............................................. 15 escitalopram oxalate tab 5 mg (base
equiv) ............................................. 15 esomeprazole magnesium cap delayed
release 20 mg (base eq) ................... 67
esomeprazole magnesium cap delayed release 40 mg (base eq) ................... 67
estazolam tab 1 mg .......................... 51 estazolam tab 2 mg .......................... 51
estradiol & norethindrone acetate tab 1-0.5 mg ............................................ 47
estradiol tab 0.5 mg ......................... 47 estradiol tab 1 mg ............................ 47
estradiol tab 2 mg ............................ 47 estradiol td patch weekly 0.025 mg/24hr
...................................................... 48 estradiol td patch weekly 0.05 mg/24hr
...................................................... 48 estradiol td patch weekly 0.06 mg/24hr
...................................................... 48
estradiol td patch weekly 0.075 mg/24hr...................................................... 48
estradiol td patch weekly 0.1 mg/24hr 47 estradiol vaginal cream 0.1 mg/gm .... 69
estradiol vaginal tab 10 mcg .............. 69 estropipate tab 0.75 mg .................... 48
estropipate tab 1.5 mg ..................... 48 estropipate tab 3 mg ........................ 48
eszopiclone tab 1 mg ........................ 51 eszopiclone tab 2 mg ........................ 51
eszopiclone tab 3 mg ........................ 51 ethambutol hcl tab 400 mg................ 26
ethosuximide cap 250 mg ................. 15 ethosuximide soln 250 mg/5ml .......... 15
ethynodiol diacetate & ethinyl estradiol
tab 1 mg-35 mcg ............................. 38 ethynodiol diacetate & ethinyl estradiol
83
tab 1 mg-50 mcg .............................. 38
etodolac cap 200 mg .......................... 3 etodolac tab 400 mg .......................... 3
etodolac tab 500 mg .......................... 4 etodolac tab er 24hr 400 mg ............... 4
etodolac tab er 24hr 500 mg ............... 4 etodolac tab er 24hr 600 mg ............... 4
etoposide cap 50 mg ......................... 28 EVOTAZ TAB 300-150........................ 32
exemestane tab 25 mg ...................... 27 EXTAVIA INJ 0.3MG .......................... 65
ezetimibe tab 10 mg ......................... 23 EZFE FORTE CAP............................... 57
F famciclovir tab 125 mg ...................... 34
famciclovir tab 250 mg ...................... 34
famciclovir tab 500 mg ...................... 34 famotidine tab 10 mg ........................ 67
famotidine tab 40 mg ........................ 67 FARXIGA TAB 10MG .......................... 19
FARXIGA TAB 5MG ............................ 19 FASENRA INJ 30MG/ML ..................... 10
felodipine tab er 24hr 10 mg .............. 36 felodipine tab er 24hr 2.5 mg ............. 36
felodipine tab er 24hr 5 mg ................ 36 fenofibrate micronized cap 134 mg ..... 22
fenofibrate micronized cap 200 mg ..... 22 fenofibrate micronized cap 67 mg ....... 22
fenofibrate tab 145 mg ...................... 22 fenofibrate tab 54 mg ........................ 22
fentanyl td patch 72hr 100 mcg/hr ....... 5
fentanyl td patch 72hr 12 mcg/hr ........ 5 fentanyl td patch 72hr 25 mcg/hr ........ 5
fentanyl td patch 72hr 50 mcg/hr ........ 5 fentanyl td patch 72hr 75 mcg/hr ........ 5
ferrous gluconate tab 240 mg (27 mg elemental fe) .................................... 51
FERROUS SUL LIQ 220/5ML ............... 51 FERROUS SULF SYP 300/5ML ............. 51
FERROUS SULF TAB 324MG EC ........... 51 ferrous sulfate elixir 220 mg/5ml (44
mg/5ml elemental fe) ........................ 51 ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe) .................................... 51 ferrous sulfate tab ec 325 mg (65 mg fe
equivalent) ...................................... 51
fexofenadine sus 30mg/5ml ............... 21 fexofenadine tab 180mg .................... 21
fiber oral powder .............................. 52
fiber tab 500mg ............................... 52 finasteride tab 5 mg ......................... 49
FIRAZYR INJ 30MG/3ML .................... 50 FIRST - METO SOL 10MG/ML ............. 35
FIRST-BACLOF SUS 1 ....................... 60 FIRST-BACLOF SUS 5 KIT .................. 60
FIRST-METRON SUS 100MG/ML ........... 8 FIRST-MOUTHW SUS BLM ................. 56
FIRST-TESTOS CRE MC 2% ................. 7 FIRST-TESTOS OIN 2% ....................... 7
FIRST-VANC SOL 25MG/ML ................. 8 FIRST-VANC SOL 50MG/ML ................. 8
fish oil cap 1000mg .......................... 61 fish oil cap 435mg ............................ 61
fish oil cap 645mg ............................ 61
flecainide acetate tab 100 mg ............ 10 flecainide acetate tab 150 mg ............ 10
flecainide acetate tab 50 mg .............. 10 FLOVENT HFA AER 44MCG ................. 11
FLUAD INJ 2018-19 .......................... 68 FLUARIX QUAD INJ 2018-19 .............. 68
FLUBLOK QUAD INJ 2018-19 ............. 68 FLUCELVAX INJ 2015-16 ................... 68
FLUCLVX QUAD INJ 2018-19 ............. 68 fluconazole for susp 10 mg/ml ........... 21
fluconazole for susp 40 mg/ml ........... 21 fluconazole tab 100 mg ..................... 21
fluconazole tab 150 mg ..................... 21 fluconazole tab 200 mg ..................... 21
fluconazole tab 50 mg....................... 21
fludrocortisone acetate tab 0.1 mg ..... 39 FLULAVAL QUA INJ 2018-19 .............. 68
FLUMIST QUAD SUS 2018-19 ............ 68 fluocinolone acetonide (otic) oil 0.01% 63
fluocinolone acetonide cream 0.01% .. 43 fluocinolone acetonide cream 0.025% . 43
fluocinolone acetonide oint 0.025% .... 43 fluocinolone acetonide soln 0.01% ..... 43
fluocinonide cream 0.05% ................. 43 fluocinonide emulsified base cream
0.05% ............................................ 43 fluocinonide gel 0.05% ..................... 43
fluocinonide oint 0.05% .................... 43 fluocinonide soln 0.05% .................... 43
fluoridex gel 1.1% ............................ 56
fluorometholone ophth susp 0.1% ...... 62 fluorouracil cream 5% ...................... 42
84
fluorouracil soln 2% .......................... 42
fluorouracil soln 5% .......................... 42 fluoxetine hcl (pmdd) cap 10 mg ........ 65
fluoxetine hcl (pmdd) cap 20 mg ........ 65 fluoxetine hcl (pmdd) tab 10 mg ......... 65
fluoxetine hcl cap 10 mg .................... 15 fluoxetine hcl cap 20 mg .................... 15
fluoxetine hcl cap 40 mg .................... 15 fluoxetine hcl solution 20 mg/5ml ....... 15
fluoxetine hcl tab 10 mg .................... 15 fluoxetine hcl tab 20 mg .................... 15
fluphenazine decanoate inj 25 mg/ml .. 31 flurazepam hcl cap 15 mg .................. 51
flurazepam hcl cap 30 mg .................. 51 flurbiprofen sodium ophth soln 0.03% . 62
flurbiprofen tab 100 mg ...................... 4
flurbiprofen tab 50 mg ........................ 4 flutamide cap 125 mg ........................ 27
fluticasone propionate cream 0.05% ... 43 fluticasone propionate nasal susp 50
mcg/act ........................................... 60 fluticasone propionate oint 0.005% ..... 43
fluticasone-salmeterol aer powder ba 113-14 mcg/act ................................ 11
fluticasone-salmeterol aer powder ba 232-14 mcg/act ................................ 11
fluticasone-salmeterol aer powder ba 55-14 mcg/act ...................................... 11
fluvoxamine maleate tab 100 mg ........ 16 fluvoxamine maleate tab 25 mg .......... 15
fluvoxamine maleate tab 50 mg .......... 16
FLUZONE HD INJ PF 18-19 ................. 68 FLUZONE QUAD INJ 2018-19.............. 68
FOLCAL DHA CAP .............................. 57 FOLCAPS CAP OMEGA 3 ..................... 58
FOLET DHA PAK ................................ 58 FOLET ONE CAP 38-1-225 .................. 58
folic acid tab 1 mg ............................ 50 folic acid tab 400 mcg ....................... 50
folic acid tab 800mcg ........................ 50 folic acid-vitamin b6-vitamin b12 tab
2.2-25-0.5 mg .................................. 51 FOLIVANE-OB CAP ............................ 58
food thicknr pow instant .................... 64 fosamprenavir calcium tab 700 mg (base
equiv) ............................................. 32
fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg ................................ 25
fosinopril sodium & hydrochlorothiazide
tab 20-12.5 mg ................................ 25 fosinopril sodium tab 10 mg .............. 23
fosinopril sodium tab 20 mg .............. 23 fosinopril sodium tab 40 mg .............. 23
furosemide oral soln 10 mg/ml .......... 46 furosemide tab 20 mg ....................... 46
furosemide tab 40 mg ....................... 46 furosemide tab 80 mg ....................... 46
FUZEON INJ 90MG ........................... 32 G gabapentin cap 100 mg .................... 13 gabapentin cap 300 mg .................... 13
gabapentin cap 400 mg .................... 13 gabapentin oral soln 250 mg/5ml ....... 13
gabapentin tab 600 mg ..................... 13
gabapentin tab 800 mg ..................... 13 galantamine hydrobromide cap er 24hr
16 mg ............................................. 64 galantamine hydrobromide cap er 24hr
24 mg ............................................. 64 galantamine hydrobromide cap er 24hr 8
mg ................................................. 64 galantamine hydrobromide tab 8 mg .. 64
gemfibrozil tab 600 mg ..................... 22 gentamicin sulfate cream 0.1% .......... 41
gentamicin sulfate oint 0.1% ............. 42 gentamicin sulfate ophth oint 0.3% .... 62
gentamicin sulfate ophth soln 0.3% .... 62 GENVOYA TAB ................................. 32
geri-hydrola lot 5% .......................... 44
GILENYA CAP 0.5MG ......................... 65 glatiramer acetate soln prefilled syringe
20 mg/ml ........................................ 65 glatiramer acetate soln prefilled syringe
40 mg/ml ........................................ 65 glatopa inj 40mg/ml ......................... 65
glimepiride tab 1 mg ........................ 19 glimepiride tab 2 mg ........................ 19
glimepiride tab 4 mg ........................ 19 glipizide tab 10 mg ........................... 19
glipizide tab 5 mg ............................. 19 glipizide tab er 24hr 10 mg................ 19
glipizide tab er 24hr 2.5 mg............... 19 glipizide tab er 24hr 5 mg ................. 19
glipizide-metformin hcl tab 2.5-250 mg
...................................................... 17 glipizide-metformin hcl tab 2.5-500 mg
85
...................................................... 17
glipizide-metformin hcl tab 5-500 mg .. 17 GLUCAGEN INJ HYPOKIT .................... 18
GLUCAGON KIT 1MG ......................... 18 GLUCOSE BITS CHW 1GM .................. 18
GLUCOSE CHW 4GM .......................... 18 GLUCOSE URINE TEST STRIPS ........... 45
glyburide micronized tab 1.5 mg ......... 19 glyburide micronized tab 3 mg ........... 19
glyburide micronized tab 6 mg ........... 19 glyburide tab 1.25 mg ....................... 19
glyburide tab 2.5 mg ......................... 19 glyburide tab 5 mg ............................ 20
glyburide-metformin tab 1.25-250 mg . 17 glyburide-metformin tab 2.5-500 mg .. 18
glyburide-metformin tab 5-500 mg ..... 18
GLYCERIN LIQ .................................. 37 glycerin suppos 2 gm ........................ 52
glycerin suppos 80.7% ...................... 52 glycopyrrolate tab 1 mg ..................... 67
glycopyrrolate tab 2 mg ..................... 67 granisetron hcl tab 1 mg .................... 20
GRANIX INJ 300/0.5 ......................... 50 GRANIX INJ 300/1ML ........................ 50
GRANIX INJ 480/0.8 ......................... 50 GRANIX INJ 480/1.6 ......................... 50
griseofulvin microsize susp 125 mg/5ml ...................................................... 21
guaifenesin liquid 100 mg/5ml ............ 40 guaifenesin tab 200 mg ..................... 40
guanfacine hcl tab 1 mg .................... 24
guanfacine hcl tab 2 mg .................... 24 guanfacine hcl tab er 24hr 1 mg (base
equiv) .............................................. 2 guanfacine hcl tab er 24hr 2 mg (base
equiv) .............................................. 2 guanfacine hcl tab er 24hr 3 mg (base
equiv) .............................................. 2 guanfacine hcl tab er 24hr 4 mg (base
equiv) .............................................. 2 GYNOL II GEL 3% ............................. 69
H H.P. ACTHAR INJ 80UNIT ................... 46
haloperidol decanoate im soln 100 mg/ml ...................................................... 30
haloperidol decanoate im soln 50 mg/ml
...................................................... 30 haloperidol lactate oral conc 2 mg/ml .. 30
haloperidol tab 0.5 mg ...................... 30
haloperidol tab 1 mg......................... 30 haloperidol tab 10 mg ....................... 30
haloperidol tab 2 mg......................... 30 haloperidol tab 20 mg ....................... 30
haloperidol tab 5 mg......................... 30 HEMENATAL OB MIS + DHA ............... 58
HEMENATAL OB TAB 28-6-1MG .......... 58 hemorrhoidal pad hygiene ................. 44
heparin sodium (porcine) inj 10000 unit/ml ........................................... 13
heparin sodium (porcine) inj 5000 unit/ml ........................................... 13
HETLIOZ CAP 20MG .......................... 52 HUMALOG MIX INJ 50/50 .................. 19
HUMALOG MIX SUS 75/25 ................. 19
HUMIRA INJ 10/0.1ML ........................ 3 HUMIRA INJ 10MG/0.2 ........................ 3
HUMIRA INJ 20/0.2ML ........................ 3 HUMIRA INJ 40/0.4ML ........................ 3
HUMIRA KIT 20MG/0.4 ....................... 3 HUMIRA KIT 40MG/0.8 ....................... 3
HUMIRA PEDIA INJ CROHNS ................ 3 HUMIRA PEN INJ 40/0.4ML .................. 3
HUMIRA PEN INJ 40MG/0.8 ................. 3 HUMIRA PEN INJ CD/UC/HS ................. 3
HUMIRA PEN INJ PS/UV ...................... 3 HUMIRA PEN KIT CD/UC/HS ................ 3
HUMIRA PEN KIT PS/UV ...................... 3 HUMULIN INJ 70/30 ......................... 19
HUMULIN N INJ U-100 ...................... 19
HUMULIN R INJ U-100 ...................... 19 HYCAMTIN CAP 0.25MG .................... 28
HYCAMTIN CAP 1MG ......................... 28 hydralazine hcl tab 10 mg ................. 26
hydralazine hcl tab 100 mg ............... 26 hydralazine hcl tab 25 mg ................. 26
hydralazine hcl tab 50 mg ................. 26 hydrochlorothiazide cap 12.5 mg ........ 46
hydrochlorothiazide tab 12.5 mg ........ 46 hydrochlorothiazide tab 25 mg ........... 46
hydrochlorothiazide tab 50 mg ........... 46 hydrocodone-acetaminophen soln 7.5-
325 mg/15ml ..................................... 6 hydrocodone-acetaminophen tab 10-325
mg ................................................... 6
hydrocodone-acetaminophen tab 5-325 mg ................................................... 6
86
hydrocodone-acetaminophen tab 7.5-325
mg ................................................... 6 hydrocodone-ibuprofen tab 7.5-200 mg 6
hydrocortisone cream 0.5% ............... 43 hydrocortisone cream 1% .................. 43
hydrocortisone cream 2.5% ............... 43 hydrocortisone enema 100 mg/60ml .... 7
hydrocortisone lotion 1% ................... 43 hydrocortisone oint 0.5% ................... 43
hydrocortisone oint 1% ..................... 43 hydrocortisone oint 2.5% ................... 43
hydrocortisone rectal cream 2.5%........ 7 hydrocortisone tab 10 mg .................. 39
hydrocortisone tab 20 mg .................. 39 hydrocortisone tab 5 mg .................... 39
HYDROMORPHON SUP 3MG ................. 5
hydromorphone hcl liqd 1 mg/ml ......... 5 hydromorphone hcl tab 2 mg .............. 5
hydromorphone hcl tab 4 mg .............. 5 hydromorphone hcl tab 8 mg .............. 5
hydroxychloroquine sulfate tab 200 mg ...................................................... 26
hydroxyprogesterone caproate im in oil 250 mg/ml ....................................... 64
hydroxyurea cap 500 mg ................... 28 hydroxyzine hcl syrup 10 mg/5ml ........ 9
hydroxyzine hcl tab 10 mg .................. 9 hydroxyzine hcl tab 25 mg .................. 9
hydroxyzine hcl tab 50 mg .................. 9 hydroxyzine pamoate cap 100 mg ........ 9
hydroxyzine pamoate cap 25 mg ......... 9
hydroxyzine pamoate cap 50 mg ......... 9 hyoscyamine sulfate elixir 0.125 mg/5ml
...................................................... 67 hyoscyamine sulfate sl tab 0.125 mg ... 67
hyoscyamine sulfate soln 0.125 mg/ml 67 hyoscyamine sulfate tab 0.125 mg ...... 67
I ibandronate sodium tab 150 mg (base
equivalent) ...................................... 46 IBRANCE CAP 100MG ........................ 27
IBRANCE CAP 125MG ........................ 27 IBRANCE CAP 75MG .......................... 27
ibuprofen dro 50/1.25 ........................ 4 ibuprofen sus 100/5ml ........................ 4
ibuprofen tab 200mg .......................... 4
ibuprofen tab 400 mg ......................... 4 ibuprofen tab 600 mg ......................... 4
ibuprofen tab 800 mg ......................... 4
icy hot cre ex st ............................... 44 imatinib mesylate tab 100 mg (base
equivalent) ...................................... 27 imatinib mesylate tab 400 mg (base
equivalent) ...................................... 27 imipramine hcl tab 10 mg ................. 17
imipramine hcl tab 25 mg ................. 17 imipramine hcl tab 50 mg ................. 17
imiquimod cream 5% ........................ 44 indapamide tab 1.25 mg ................... 46
indapamide tab 2.5 mg ..................... 46 indomethacin cap 25 mg ..................... 4
indomethacin cap 50 mg ..................... 4 indomethacin cap er 75 mg ................. 4
INFLECTRA INJ 100MG ...................... 48
INSULIN PEN NEEDLES/SYRINGES ..... 53 INTELENCE TAB 100MG .................... 32
INTELENCE TAB 200MG .................... 32 INTELENCE TAB 25MG ...................... 32
intense coug liq reliever .................... 40 INTRON A INJ 10MU ......................... 28
INTRON A INJ 18MU ......................... 28 INTRON A INJ 25MU ......................... 28
INTRON A INJ 50MU ......................... 28 INVEGA SUST INJ 117/0.75 ............... 29
INVEGA SUST INJ 156MG/ML ............. 29 INVEGA SUST INJ 234/1.5 ................ 29
INVEGA SUST INJ 39/0.25 ................ 29 INVEGA SUST INJ 78/0.5ML .............. 29
INVEGA TRINZ INJ 273MG................. 29
INVEGA TRINZ INJ 410MG................. 29 INVEGA TRINZ INJ 546MG................. 29
INVEGA TRINZ INJ 819MG................. 29 INVIRASE CAP 200MG ...................... 32
INVIRASE TAB 500MG ...................... 32 INVOKAMET TAB 150-1000 ............... 18
INVOKAMET TAB 150-500 ................. 18 INVOKAMET TAB 50-1000 ................. 18
INVOKAMET TAB 50-500MG .............. 18 INVOKAMET XR TAB 150-1000 ........... 18
INVOKAMET XR TAB 150-500 ............ 18 INVOKAMET XR TAB 50-1000 ............ 18
INVOKAMET XR TAB 50-500MG .......... 18 INVOKANA TAB 100MG ..................... 19
INVOKANA TAB 300MG ..................... 19
IPECAC SYP ..................................... 20 ipratropium bromide inhal soln 0.02% 10
87
ipratropium bromide nasal soln 0.03%
(21 mcg/spray) ................................ 60 ipratropium bromide nasal soln 0.06%
(42 mcg/spray) ................................ 60 ipratropium-albuterol nebu soln 0.5-
2.5(3) mg/3ml ................................. 11 irbesartan tab 150 mg ....................... 23
irbesartan tab 300 mg ....................... 23 irbesartan tab 75 mg ......................... 23
irbesartan-hydrochlorothiazide tab 150-12.5 mg .......................................... 25
irbesartan-hydrochlorothiazide tab 300-12.5 mg .......................................... 25
ISENTRESS CHW 100MG .................... 32 ISENTRESS CHW 25MG ..................... 32
ISENTRESS TAB 400MG ..................... 32
isoniazid syrup 50 mg/5ml ................. 26 isoniazid tab 100 mg ......................... 26
isoniazid tab 300 mg ......................... 26 isosorbide mononitrate tab 10 mg ........ 9
isosorbide mononitrate tab 20 mg ........ 9 isosorbide mononitrate tab er 24hr 120
mg ................................................... 9 isosorbide mononitrate tab er 24hr 30
mg ................................................... 9 isosorbide mononitrate tab er 24hr 60
mg ................................................... 9 isotretinoin cap 10 mg ....................... 41
isotretinoin cap 20 mg ....................... 41 isotretinoin cap 30 mg ....................... 41
isotretinoin cap 40 mg ....................... 41
itraconazole cap 100 mg .................... 21 ivermectin tab 3 mg ........................... 8
J JANUMET TAB 50-1000 ...................... 18
JANUMET TAB 50-500MG ................... 18 JANUMET XR TAB 100-1000 ............... 18
JANUMET XR TAB 50-1000 ................. 18 JANUMET XR TAB 50-500MG .............. 18
JANUVIA TAB 100MG ......................... 18 JANUVIA TAB 25MG .......................... 18
JANUVIA TAB 50MG .......................... 18 JARDIANCE TAB 10MG ....................... 19
JARDIANCE TAB 25MG ....................... 19 JENTADUETO TAB 2.5-1000 ............... 18
JENTADUETO TAB 2.5-500 ................. 18
JENTADUETO TAB 2.5-850 ................. 18 JENTADUETO TAB XR ........................ 18
JULUCA TAB 50-25MG....................... 33
K KALETRA TAB 100-25MG ................... 33
KALETRA TAB 200-50MG ................... 33 KALYDECO PAK 50MG ....................... 66
KALYDECO PAK 75MG ....................... 66 KALYDECO TAB 150MG ..................... 66
KANUMA INJ 20/10ML ....................... 47 ketoconazole cream 2% .................... 42
ketoconazole shampoo 2% ................ 42 KETONE TEST TES ............................ 45
KETONE URINE TEST STRIPS ............. 45 ketorolac tromethamine ophth soln 0.4%
...................................................... 62 ketorolac tromethamine ophth soln 0.5%
...................................................... 62
ketorolac tromethamine tab 10 mg ....... 4 KEVZARA INJ 150/1.14 ....................... 3
KEVZARA INJ 200/1.14 ....................... 3 KISQALI 200 PAK FEMARA ................. 27
KISQALI 400 PAK FEMARA ................. 27 KISQALI 600 PAK FEMARA ................. 27
klor-con pow 20meq ......................... 55 KOSHR PRENAT TAB 30-1MG ............. 58
KRYSTEXXA INJ 8MG/ML ................... 50 KUVAN POW 100MG ......................... 47
KUVAN POW 500MG ......................... 47 KUVAN TAB 100MG .......................... 47
L labetalol hcl tab 100 mg .................... 34
labetalol hcl tab 200 mg .................... 34
labetalol hcl tab 300 mg .................... 34 lactase enz tab 3000unit ................... 45
lactic acid (ammonium lactate) cream 12% ............................................... 44
lactic acid (ammonium lactate) lotion 12% ............................................... 44
lactulose (encephalopathy) solution 10 gm/15ml ......................................... 49
lactulose solution 10 gm/15ml ........... 52 lamivudine oral soln 10 mg/ml ........... 33
lamivudine tab 100 mg (hbv) ............. 34 lamivudine tab 150 mg ..................... 33
lamivudine tab 300 mg ..................... 33 lamivudine-zidovudine tab 150-300 mg
...................................................... 33
lamotrigine tab 100 mg ..................... 13 lamotrigine tab 150 mg ..................... 13
88
lamotrigine tab 200 mg ..................... 13
lamotrigine tab 25 mg ....................... 13 lamotrigine tab chewable dispersible 25
mg .................................................. 13 lamotrigine tab chewable dispersible 5
mg .................................................. 13 lamotrigine tab er 24hr 100 mg .......... 14
lamotrigine tab er 24hr 200 mg .......... 14 lamotrigine tab er 24hr 25 mg ............ 14
lamotrigine tab er 24hr 250 mg .......... 14 lamotrigine tab er 24hr 300 mg .......... 14
lamotrigine tab er 24hr 50 mg ............ 14 LANCETS ......................................... 53
lansoprazole cap delayed release 15 mg ...................................................... 67
lansoprazole cap delayed release 30 mg
...................................................... 67 lanthanum carbonate chew tab 1000 mg
(elemental) ...................................... 49 lanthanum carbonate chew tab 500 mg
(elemental) ...................................... 49 lanthanum carbonate chew tab 750 mg
(elemental) ...................................... 49 latanoprost ophth soln 0.005% ........... 62
leflunomide tab 10 mg ........................ 4 leflunomide tab 20 mg ........................ 4
LETAIRIS TAB 10MG .......................... 37 LETAIRIS TAB 5MG ........................... 37
letrozole tab 2.5 mg .......................... 27 leucovorin calcium tab 25 mg ............. 28
leucovorin calcium tab 5 mg ............... 28
LEUKERAN TAB 2MG.......................... 26 levalbuterol hcl soln nebu 0.31 mg/3ml
(base equiv) ..................................... 11 levalbuterol hcl soln nebu 0.63 mg/3ml
(base equiv) ..................................... 11 levalbuterol hcl soln nebu 1.25 mg/3ml
(base equiv) ..................................... 11 levalbuterol tartrate inhal aerosol 45
mcg/act (base equiv) ........................ 12 levetiracetam oral soln 100 mg/ml ...... 14
levetiracetam tab 1000 mg ................ 14 levetiracetam tab 250 mg .................. 14
levetiracetam tab 500 mg .................. 14 levetiracetam tab 750 mg .................. 14
levetiracetam tab er 24hr 500 mg ....... 14
levetiracetam tab er 24hr 750 mg ....... 14 levobunolol hcl ophth soln 0.5% ......... 61
levocarnitine (dietary) oral soln 1
gm/10ml ......................................... 61 levocarnitine oral soln 1 gm/10ml (10%)
...................................................... 47 levocarnitine tab 330 mg ................... 47
levocarnitine tab 500 mg ................... 61 levocetirizine dihydrochloride tab 5 mg 21
levofloxacin oral soln 25 mg/ml.......... 48 levofloxacin tab 250 mg .................... 48
levofloxacin tab 500 mg .................... 48 levofloxacin tab 750 mg .................... 48
levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg ..................... 38
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg ..................................... 38
levonorgestrel & ethinyl estradiol tab
0.15 mg-30 mcg .............................. 38 levonorgestrel tab 1.5 mg ................. 38
levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg .......... 38
levothyroxine sodium tab 100 mcg ..... 66 levothyroxine sodium tab 112 mcg ..... 66
levothyroxine sodium tab 125 mcg ..... 66 levothyroxine sodium tab 137 mcg ..... 66
levothyroxine sodium tab 150 mcg ..... 66 levothyroxine sodium tab 175 mcg ..... 66
levothyroxine sodium tab 200 mcg ..... 66 levothyroxine sodium tab 25 mcg ....... 66
levothyroxine sodium tab 300 mcg ..... 66 levothyroxine sodium tab 50 mcg ....... 66
levothyroxine sodium tab 75 mcg ....... 66
levothyroxine sodium tab 88 mcg ....... 66 LEXIVA SUS 50MG/ML ...................... 33
lice killing sha .................................. 45 lice treatmt lot 1% ........................... 45
lice trtmnt liq 1% ............................. 45 lidocaine hcl gel 2% ......................... 44
lidocaine hcl soln 4% ........................ 44 lidocaine hcl viscous soln 2% ............. 56
lidocaine patch 5% ........................... 44 linezolid for susp 100 mg/5ml .............. 8
linezolid tab 600 mg ........................... 9 LINZESS CAP 145MCG ...................... 49
LINZESS CAP 290MCG ...................... 49 LINZESS CAP 72MCG ........................ 49
liothyronine sodium tab 25 mcg ......... 67
liothyronine sodium tab 5 mcg ........... 67 liothyronine sodium tab 50 mcg ......... 67
89
LIQUID C 500 LIQ 500/15ML .............. 70
lisinopril & hydrochlorothiazide tab 10-12.5 mg .......................................... 25
lisinopril & hydrochlorothiazide tab 20-12.5 mg .......................................... 25
lisinopril & hydrochlorothiazide tab 20-25 mg .................................................. 25
lisinopril tab 10 mg ........................... 23 lisinopril tab 2.5 mg .......................... 23
lisinopril tab 20 mg ........................... 23 lisinopril tab 30 mg ........................... 23
lisinopril tab 40 mg ........................... 23 lisinopril tab 5 mg ............................. 23
lithium carbonate cap 150 mg ............ 29 lithium carbonate cap 300 mg ............ 29
lithium carbonate cap 600 mg ............ 29
lithium carbonate tab 300 mg ............. 29 lithium carbonate tab er 300 mg ......... 29
lithium carbonate tab er 450 mg ......... 29 LITHIUM SOL 8MEQ/5ML .................... 29
LITTLE NOSES DRO 0.125% ............... 60 LOHIST-D LIQ .................................. 40
loperamide hcl cap 2 mg .................... 20 loperamide hcl liq 1 mg/5ml (0.2 mg/ml)
...................................................... 20 loperamide hcl tab 2 mg .................... 20
lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) ................................. 33
loratadine & pseudoephedrine tab er 24hr 10-240 mg ............................... 40
loratadine sol 5mg/5ml ...................... 21
loratadine tab 10 mg ......................... 21 loratadine-d tab 5-120mg .................. 40
lorazepam tab 0.5 mg ........................ 9 lorazepam tab 1 mg ........................... 9
lorazepam tab 2 mg ........................... 9 losartan potassium & hydrochlorothiazide
tab 100-12.5 mg .............................. 25 losartan potassium & hydrochlorothiazide
tab 100-25 mg ................................. 25 losartan potassium & hydrochlorothiazide
tab 50-12.5 mg ................................ 25 losartan potassium tab 100 mg .......... 24
losartan potassium tab 25 mg ............ 23 losartan potassium tab 50 mg ............ 24
lovastatin tab 10 mg ......................... 22
lovastatin tab 20 mg ......................... 22 lovastatin tab 40 mg ......................... 22
loxapine succinate cap 10 mg ............ 30
loxapine succinate cap 25 mg ............ 30 loxapine succinate cap 5 mg .............. 30
loxapine succinate cap 50 mg ............ 30 lubricnt eye dro 0.4-0.3% ................. 61
LUPR DEP-PED INJ 11.25MG .............. 47 LUPR DEP-PED INJ 15MG .................. 47
LUPR DEP-PED INJ 3M 30MG ............. 47 LUPR DEP-PED INJ 7.5MG ................. 47
LUPRON DEPOT INJ 11.25MG ............. 27 LUPRON DEPOT INJ 22.5MG .............. 27
LUPRON DEPOT INJ 3.75MG .............. 27 LUPRON DEPOT INJ 30MG ................. 27
LUPRON DEPOT INJ 45MG ................. 27 LUPRON DEPOT INJ 7.5MG ................ 27
LYRICA CAP 100MG .......................... 14
LYRICA CAP 150MG .......................... 14 LYRICA CAP 200MG .......................... 14
LYRICA CAP 225MG .......................... 14 LYRICA CAP 25MG ............................ 14
LYRICA CAP 300MG .......................... 14 LYRICA CAP 50MG ............................ 14
LYRICA CAP 75MG ............................ 14 LYRICA SOL 20MG/ML ....................... 14
M MACNATAL CN CAP DHA .................... 58
mag citrate sol ................................. 52 MAG64 TAB 64MG ............................ 55
magnesium oxide tab 250 mg .............. 8 magnesium oxide tab 400 mg .............. 8
magnesium oxide tab 400 mg (240 mg
elemental mg) ................................. 55 magnesium oxide tab 400 mg (241.3 mg
elemental mg) ................................. 55 magnesium tab 250mg ..................... 55
malathion lotion 0.5% ...................... 45 MARNATAL-F CAP ............................. 58
MATULANE CAP 50MG ....................... 28 MAVYRET TAB 100-40MG .................. 34
meclizine hcl chew tab 25 mg ............ 20 meclizine hcl tab 12.5 mg ................. 20
meclizine hcl tab 25 mg .................... 20 MECLOFENOXAT POW HCL ................ 37
medroxyprogesterone acetate im susp 150 mg/ml ...................................... 38
medroxyprogesterone acetate im susp
prefilled syr 150 mg/ml ..................... 38 medroxyprogesterone acetate tab 10 mg
90
...................................................... 64
medroxyprogesterone acetate tab 2.5 mg .................................................. 64
medroxyprogesterone acetate tab 5 mg ...................................................... 64
megestrol acetate susp 40 mg/ml ....... 27 megestrol acetate tab 20 mg .............. 27
megestrol acetate tab 40 mg .............. 27 melatonin cap 5mg ............................ 2
MELATONIN LIQ 1MG/4ML .................. 2 melatonin liquid 1 mg/ml .................... 2
melatonin sub 5mg ............................ 2 melatonin tab 1 mg ............................ 2
melatonin tab 3 mg ............................ 2 melatonin tab 300 mcg ....................... 3
melatonin tab 5 mg ............................ 3
melatonin tr tab /vit-b6 ...................... 3 melatonin/ tab vit b-6 ........................ 3
meloxicam tab 15 mg ......................... 4 meloxicam tab 7.5 mg ........................ 4
memantine hcl tab 10 mg .................. 65 memantine hcl tab 5 mg .................... 64
meperidine hcl tab 100 mg ................. 5 meperidine hcl tab 50 mg ................... 5
mercaptopurine tab 50 mg ................. 27 mesalamine enema 4 gm ................... 48
mesna inj 100 mg/ml ........................ 28 MESNEX TAB 400MG ......................... 28
metaproterenol sulfate syrup 10 mg/5ml ...................................................... 12
metformin hcl tab 1000 mg ................ 18
metformin hcl tab 500 mg .................. 18 metformin hcl tab 850 mg .................. 18
metformin hcl tab er 24hr 500 mg ...... 18 metformin hcl tab er 24hr 750 mg ...... 18
methadone hcl soln 10 mg/5ml ........... 5 methadone hcl soln 5 mg/5ml ............. 5
methadone hcl tab 10 mg ................... 6 methadone hcl tab 5 mg ..................... 6
methenamine hippurate tab 1 gm ....... 68 methimazole tab 10 mg ..................... 66
methimazole tab 5 mg ....................... 66 methocarbamol tab 500 mg ............... 60
methocarbamol tab 750 mg ............... 60 methotrexate sodium inj 50 mg/2ml (25
mg/ml) ............................................ 27
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) ...................................... 27
methotrexate sodium tab 2.5 mg (base
equiv) ............................................. 27 methscopolamine bromide tab 5 mg ... 67
methyldopa tab 250 mg .................... 24 methyldopa tab 500 mg .................... 24
methylphenidate hcl cap er 10 mg (cd) . 2 methylphenidate hcl cap er 20 mg (cd) . 2
methylphenidate hcl cap er 30 mg (cd) . 2 methylphenidate hcl cap er 40 mg (cd) . 2
methylphenidate hcl cap er 50 mg (cd) . 2 methylphenidate hcl cap er 60 mg (cd) . 2
methylphenidate hcl tab 10 mg ............ 2 methylphenidate hcl tab 20 mg ............ 2
methylphenidate hcl tab 5 mg .............. 2 methylphenidate hcl tab er 10 mg ........ 2
methylphenidate hcl tab er 20 mg ........ 2
methylprednisolone tab 16 mg ........... 39 methylprednisolone tab 32 mg ........... 39
methylprednisolone tab 4 mg ............ 39 methylprednisolone tab 8 mg ............ 39
methylprednisolone tab therapy pack 4 mg (21) .......................................... 39
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv) ..................... 48
metoclopramide hcl tab 10 mg (base equivalent) ...................................... 48
metoclopramide hcl tab 5 mg (base equivalent) ...................................... 48
metolazone tab 10 mg ...................... 46 metolazone tab 2.5 mg ..................... 46
metolazone tab 5 mg ........................ 46
metoprolol succinate tab er 24hr 100 mg (tartrate equiv) ................................ 35
metoprolol succinate tab er 24hr 200 mg (tartrate equiv) ................................ 35
metoprolol succinate tab er 24hr 25 mg (tartrate equiv) ................................ 35
metoprolol succinate tab er 24hr 50 mg (tartrate equiv) ................................ 35
metoprolol tartrate tab 100 mg .......... 35 metoprolol tartrate tab 25 mg ............ 35
metoprolol tartrate tab 50 mg ............ 35 METRONIDAZOL SUS 50MG/ML ............ 8
metronidazole cream 0.75% .............. 45 metronidazole gel 0.75% .................. 45
metronidazole tab 250 mg ................... 8
metronidazole tab 500 mg ................... 8 metronidazole vaginal gel 0.75% ....... 69
91
mexiletine hcl cap 150 mg ................. 10
miconazole 3 kit combo pk ................. 69 miconazole cre 2% ............................ 42
miconazole nitrate vaginal cream 2% .. 69 miconazole nitrate vaginal suppos 100
mg .................................................. 69 microgestin tab 1.5/30 ...................... 38
microgestin tab 1/20 ......................... 38 midodrine hcl tab 10 mg .................... 69
midodrine hcl tab 2.5 mg ................... 69 midodrine hcl tab 5 mg ...................... 69
milk of magn sus .............................. 52 mineral oil ....................................... 52
minocycline hcl cap 100 mg ............... 66 minocycline hcl cap 50 mg ................. 66
minocycline hcl cap 75 mg ................. 66
minocycline hcl tab 75 mg ................. 66 minoxidil tab 10 mg .......................... 26
minoxidil tab 2.5 mg ......................... 26 mirtazapine orally disintegrating tab 15
mg .................................................. 15 mirtazapine orally disintegrating tab 30
mg .................................................. 15 mirtazapine orally disintegrating tab 45
mg .................................................. 15 mirtazapine tab 15 mg ...................... 15
mirtazapine tab 30 mg ...................... 15 mirtazapine tab 45 mg ...................... 15
mirtazapine tab 7.5 mg ..................... 15 misoprostol tab 100 mcg ................... 68
misoprostol tab 200 mcg ................... 68
modafinil tab 100 mg ......................... 2 modafinil tab 200 mg ......................... 2
moexipril hcl tab 15 mg ..................... 23 moexipril hcl tab 7.5 mg .................... 23
moexipril-hydrochlorothiazide tab 15-12.5 mg .......................................... 25
moexipril-hydrochlorothiazide tab 15-25 mg .................................................. 25
moexipril-hydrochlorothiazide tab 7.5-12.5 mg .......................................... 25
MOISTURE GUA CRE ......................... 44 mometasone furoate oint 0.1% .......... 43
montelukast sodium chew tab 4 mg (base equiv) ..................................... 10
montelukast sodium chew tab 5 mg
(base equiv) ..................................... 10 montelukast sodium oral granules packet
4 mg (base equiv) ............................ 10
montelukast sodium tab 10 mg (base equiv) ............................................. 10
morphine sulfate oral soln 100 mg/5ml (20 mg/ml) ....................................... 6
morphine sulfate oral soln 20 mg/5ml ... 6 morphine sulfate tab 15 mg ................. 6
morphine sulfate tab 30 mg ................. 6 morphine sulfate tab er 100 mg ........... 6
morphine sulfate tab er 15 mg ............. 6 morphine sulfate tab er 200 mg ........... 6
morphine sulfate tab er 30 mg ............. 6 morphine sulfate tab er 60 mg ............. 6
mouth rinse sol ................................ 56 MOVANTIK TAB 12.5MG .................... 49
MOVANTIK TAB 25MG ....................... 49
moxifloxacin hcl tab 400 mg (base equiv)...................................................... 48
MTERYTI TAB ................................... 58 MTERYTI TAB FOLIC 5....................... 58
mucus rel dm liq 5-100/5 .................. 40 MULTISTIX TES ................................ 45
MULTIVITAMIN CHW ADULT .............. 57 multi-vitamn tab .............................. 57
mupirocin oint 2% ............................ 42 mycophenolate mofetil cap 250 mg .... 55
mycophenolate mofetil for oral susp 200 mg/ml ............................................ 55
mycophenolate mofetil tab 500 mg..... 55 mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv) ................. 55
MYNATE 90 TAB PLUS ....................... 58 myorisan cap 10mg .......................... 41
myorisan cap 20mg .......................... 41 myorisan cap 30mg .......................... 41
myorisan cap 40mg .......................... 41 N nabumetone tab 500 mg ..................... 4 nabumetone tab 750 mg ..................... 4
nadolol tab 20 mg ............................ 35 nadolol tab 40 mg ............................ 35
nadolol tab 80 mg ............................ 35 naloxone hcl inj 0.4 mg/ml ................ 20
naloxone hcl soln cartridge 0.4 mg/ml 20 naloxone hcl soln prefilled syringe 2
mg/2ml ........................................... 20
naltrexone hcl tab 50 mg .................. 20 naproxen ec tab 375mg ...................... 4
92
naproxen ec tab 500mg ...................... 4
naproxen sod tab 220mg .................... 4 naproxen sodium tab 275 mg .............. 4
naproxen sodium tab 550 mg .............. 4 naproxen susp 125 mg/5ml ................. 4
naproxen tab 250 mg ......................... 4 naproxen tab 375 mg ......................... 4
naproxen tab 500 mg ......................... 4 naratriptan hcl tab 1 mg (base equiv).. 53
naratriptan hcl tab 2.5 mg (base equiv) ...................................................... 53
NARCAN SPR .................................... 20 nat fiber pow 28.3% ......................... 52
nat fiber pow 48.57% ........................ 52 NATACHEW CHW .............................. 58
NATALVIT TAB 75-1MG ...................... 58
NATELLE ONE CAP ............................ 58 naturl fiber pow 58.6% ...................... 52
necon tab 1/50-28 ............................ 38 NECON TAB 10/11-28 ........................ 38
nefazodone hcl tab 100 mg ................ 16 nefazodone hcl tab 150 mg ................ 16
nefazodone hcl tab 200 mg ................ 16 nefazodone hcl tab 250 mg ................ 16
nefazodone hcl tab 50 mg .................. 16 neomycin sulfate tab 500 mg .............. 3
neomycin-bacitracin-polymyxin oint .... 42 neomycin-polymy-gramicid op sol 1.75-
10000-0.025mg-unt-mg/ml ............... 62 neomycin-polymyxin-dexamethasone
ophth oint 0.1% ............................... 62
neomycin-polymyxin-dexamethasone ophth susp 0.1% .............................. 62
neomycin-polymyxin-hc otic soln 1% .. 63 neomycin-polymyxin-hc otic susp 3.5
mg/ml-10000 unit/ml-1% .................. 63 neo-polycin oin op ............................ 62
NEPHROCAPS TAB QT ........................ 56 NERLYNX TAB 40MG .......................... 27
NESTABS ABC MIS ............................ 58 NESTABS DHA PAK ........................... 58
NESTABS ONE CAP ............................ 58 NESTABS TAB ................................... 58
NEULASTA INJ 6MG/0.6M .................. 50 NEUPOGEN INJ 300/0.5 ..................... 50
NEUPOGEN INJ 300MCG .................... 50
NEUPOGEN INJ 480/0.8 ..................... 51 NEUPOGEN INJ 480MCG .................... 51
nevirapine susp 50 mg/5ml ............... 33
nevirapine tab 200 mg ...................... 33 nevirapine tab er 24hr 400 mg........... 33
NEXAVAR TAB 200MG ....................... 27 niacin cap er 500 mg ........................ 70
niacin tab 100 mg ............................ 70 niacin tab 250 mg ............................ 70
niacin tab 500 mg ............................ 70 niacin tab er 1000 mg
(antihyperlipidemic) ......................... 23 niacin tab er 500 mg ........................ 70
nicotine loz 4mg mint ....................... 65 nicotine loz mini 2mg ........................ 65
nicotine polacrilex gum 2 mg ............. 65 nicotine polacrilex gum 4 mg ............. 65
nicotine td patch 24hr 14 mg/24hr ..... 65
nicotine td patch 24hr 21 mg/24hr ..... 65 nicotine td patch 24hr 7 mg/24hr ....... 65
NICOTROL INH ................................ 66 NICOTROL NS SPR 10MG/ML ............. 66
nifedipine cap 10 mg ........................ 36 nifedipine cap 20 mg ........................ 36
nifedipine tab er 24hr 30 mg ............. 36 nifedipine tab er 24hr 60 mg ............. 36
nifedipine tab er 24hr 90 mg ............. 36 nifedipine tab er 24hr osmotic release 30
mg ................................................. 36 nifedipine tab er 24hr osmotic release 60
mg ................................................. 36 nifedipine tab er 24hr osmotic release 90
mg ................................................. 36
nimodipine cap 30 mg ...................... 36 nitrofurantoin macrocrystalline cap 100
mg ................................................. 68 nitrofurantoin macrocrystalline cap 50
mg ................................................. 68 nitrofurantoin monohydrate
macrocrystalline cap 100 mg ............. 68 nitrofurantoin susp 25 mg/5ml ........... 68
nitroglycerin sl tab 0.3 mg................... 9 nitroglycerin sl tab 0.4 mg................... 9
nitroglycerin sl tab 0.6 mg................... 9 nitroglycerin td patch 24hr 0.1 mg/hr ... 9
nitroglycerin td patch 24hr 0.2 mg/hr ... 9 nitroglycerin td patch 24hr 0.4 mg/hr ... 9
nitroglycerin td patch 24hr 0.6 mg/hr ... 9
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg ................................... 38
93
norethindrone ace & ethinyl estradiol-fe
tab 1 mg-20 mcg .............................. 38 norethindrone acetate tab 5 mg .......... 64
norethindrone tab 0.35 mg ................ 38 norgestimate & ethinyl estradiol tab 0.25
mg-35 mcg ...................................... 38 norgestimate-eth estrad tab 0.18-
25/0.215-25/0.25-25 mg-mcg ............ 38 norgestimate-eth estrad tab 0.18-
35/0.215-35/0.25-35 mg-mcg ............ 38 nortrel tab 1/35 ................................ 38
nortriptyline hcl cap 10 mg ................ 17 nortriptyline hcl cap 25 mg ................ 17
nortriptyline hcl cap 50 mg ................ 17 nortriptyline hcl cap 75 mg ................ 17
NORVIR SOL 80MG/ML ...................... 33
NOVOLIN INJ 70/30 .......................... 19 NOVOLIN N INJ RELION ..................... 19
NOVOLIN N INJ U-100 ....................... 19 NOVOLIN R INJ RELION ..................... 19
NOVOLIN R INJ U-100 ....................... 19 NOVOLIN70/30 INJ RELION ................ 19
NOVOLOG MIX INJ 70/30 ................... 19 np thyroid tab 120mg ........................ 67
np thyroid tab 15mg ......................... 67 np thyroid tab 30mg ......................... 67
np thyroid tab 60mg ......................... 67 NUCALA INJ 100MG ........................... 10
NUEDEXTA CAP 20-10MG ................... 65 NUPLAZID TAB 17MG ........................ 29
NUPREP 5% SOL POV-IODI ................ 32
NUTRIENTS TAB PRENATAL ................ 58 NUTROPIN AQ INJ 10MG/2ML ............. 46
NUTROPIN AQ INJ 20MG/2ML ............. 46 NUTROPIN AQ INJ NUSPIN 5 .............. 47
NUVARING MIS ................................. 38 nystatin cream 100000 unit/gm .......... 42
nystatin oint 100000 unit/gm ............. 42 nystatin susp 100000 unit/ml ............. 56
nystatin tab 500000 unit .................... 21 nystatin topical powder 100000 unit/gm
...................................................... 42 O OB COMPLETE CAP GOLD ................... 58 OB COMPLETE CAP ONE ..................... 58
OB COMPLETE CAP PETITE ................. 58
OB COMPLETE TAB PREMIER .............. 58 OB COMPLETE/ CAP DHA ................... 58
OBSTETRIX PAK DHA ........................ 58
OBTREX TAB .................................... 58 O-CAL TAB PRENATAL ....................... 58
octreotide acetate inj 100 mcg/ml (0.1 mg/ml) ........................................... 47
octreotide acetate inj 200 mcg/ml (0.2 mg/ml) ........................................... 47
octreotide acetate inj 50 mcg/ml (0.05 mg/ml) ........................................... 47
ODEFSEY TAB .................................. 33 ofloxacin ophth soln 0.3% ................. 62
ofloxacin otic soln 0.3% .................... 63 ogestrel tab ..................................... 38
olanzapine for im inj 10 mg ............... 30 olanzapine orally disintegrating tab 10
mg ................................................. 30
olanzapine orally disintegrating tab 15 mg ................................................. 30
olanzapine orally disintegrating tab 20 mg ................................................. 30
olanzapine orally disintegrating tab 5 mg...................................................... 30
olanzapine tab 10 mg ....................... 30 olanzapine tab 15 mg ....................... 30
olanzapine tab 2.5 mg ...................... 30 olanzapine tab 20 mg ....................... 30
olanzapine tab 5 mg ......................... 30 olanzapine tab 7.5 mg ...................... 30
olmesartan medoxomil tab 20 mg ...... 24 olmesartan medoxomil tab 40 mg ...... 24
olmesartan medoxomil tab 5 mg ........ 24
olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg ... 25
olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg ... 25
olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg ...... 25
olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg 25
olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg
...................................................... 26 olmesartan-amlodipine-
hydrochlorothiazide tab 40-10-25 mg . 26 olmesartan-amlodipine-
hydrochlorothiazide tab 40-5-12.5 mg 25
olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg ... 25
94
olopatadine hcl ophth soln 0.1% (base
equivalent) ...................................... 62 omega 3 500 cap 500mg ................... 61
omega essent liq basic ...................... 61 omega-3 fatty acids cap 1000 mg ....... 61
omega-3 fatty acids cap 1200 mg ....... 61 omega-3 fatty acids cap 300 mg ......... 61
omega-3 fatty acids cap 600 mg ......... 61 omega-3 fatty acids cap delayed release
1200 mg .......................................... 61 OMEPRAZOLE + SUS SYRSPEND ......... 67
omeprazole cap delayed release 10 mg67 omeprazole cap delayed release 20 mg67
omeprazole cap delayed release 40 mg67 ondansetron hcl oral soln 4 mg/5ml .... 20
ondansetron hcl tab 24 mg ................ 20
ondansetron hcl tab 4 mg .................. 20 ondansetron hcl tab 8 mg .................. 20
ondansetron orally disintegrating tab 4 mg .................................................. 20
ondansetron orally disintegrating tab 8 mg .................................................. 20
ONE A DAY CAP PRENATAL ................. 58 ONE A DAY MIS PRENATAL ................. 58
ORKAMBI TAB 100-125 ..................... 66 ORKAMBI TAB 200-125 ..................... 66
oseltamivir phosphate cap 30 mg (base equiv) ............................................. 34
oseltamivir phosphate cap 45 mg (base equiv) ............................................. 34
oseltamivir phosphate cap 75 mg (base
equiv) ............................................. 34 oseltamivir phosphate for susp 6 mg/ml
(base equiv) ..................................... 34 oxandrolone tab 2.5 mg ...................... 7
oxazepam cap 10 mg ........................ 10 oxazepam cap 15 mg ........................ 10
oxazepam cap 30 mg ........................ 10 oxcarbazepine susp 300 mg/5ml (60
mg/ml) ............................................ 14 oxcarbazepine tab 150 mg ................. 14
oxcarbazepine tab 300 mg ................. 14 oxcarbazepine tab 600 mg ................. 14
oxybutynin chloride syrup 5 mg/5ml ... 68 oxybutynin chloride tab 5 mg ............. 68
oxybutynin chloride tab er 24hr 10 mg 68
oxybutynin chloride tab er 24hr 15 mg 68 oxybutynin chloride tab er 24hr 5 mg .. 68
oxycodone hcl cap 5 mg ...................... 6
oxycodone hcl conc 100 mg/5ml (20 mg/ml) ............................................. 6
oxycodone hcl tab 10 mg .................... 6 oxycodone hcl tab 15 mg .................... 6
oxycodone hcl tab 20 mg .................... 6 oxycodone hcl tab 30 mg .................... 6
oxycodone hcl tab 5 mg ...................... 6 oxycodone w/ acetaminophen tab 10-325
mg ................................................... 6 oxycodone w/ acetaminophen tab 5-325
mg ................................................... 6 oxycodone w/ acetaminophen tab 7.5-
325 mg ............................................. 6 oxycodone-aspirin tab 4.8355-325 mg .. 6
oxycodone-ibuprofen tab 5-400 mg ...... 6
oyster shell calcium tab 500 mg ......... 54 P pain relieve cre rub .......................... 44 pain/fever sup 120mg ......................... 5
paliperidone tab er 24hr 1.5 mg ......... 29 paliperidone tab er 24hr 3 mg............ 30
paliperidone tab er 24hr 6 mg............ 30 paliperidone tab er 24hr 9 mg............ 30
panoxyl wash liq 4%......................... 41 pantoprazole sodium ec tab 20 mg (base
equiv) ............................................. 67 pantoprazole sodium ec tab 40 mg (base
equiv) ............................................. 68 paromomycin sulfate cap 250 mg ......... 3
paroxetine hcl tab 10 mg .................. 16
paroxetine hcl tab 20 mg .................. 16 paroxetine hcl tab 30 mg .................. 16
paroxetine hcl tab 40 mg .................. 16 PEDIA-LAX LIQ 50MG ....................... 52
pediatric multiple vitamins w/ iron chew tab 15 mg ....................................... 57
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm ............................... 52
peg 3350-kcl-sod bicarb-nacl for soln 420 gm ........................................... 52
penicillin v potassium for soln 125 mg/5ml ........................................... 63
penicillin v potassium for soln 250 mg/5ml ........................................... 63
penicillin v potassium tab 250 mg ...... 63
penicillin v potassium tab 500 mg ...... 63 PENTASA CAP 250MG CR .................. 48
95
PENTASA CAP 500MG CR ................... 48
pentazocine w/ naloxone tab 50-0.5 mg 7 pentoxifylline tab er 400 mg ............... 50
permethrin cream 5% ....................... 45 perphenazine tab 16 mg .................... 31
perphenazine tab 2 mg ...................... 31 perphenazine tab 4 mg ...................... 31
perphenazine tab 8 mg ...................... 31 PERRY PRENAT CAP ........................... 58
PETROLATUM OIN WHITE................... 64 phendimetrazine tartrate tab 35 mg ..... 1
phenobarbital elixir 20 mg/5ml ........... 51 phenobarbital tab 100 mg .................. 51
phenobarbital tab 15 mg .................... 51 phenobarbital tab 16.2 mg ................. 51
phenobarbital tab 30 mg .................... 51
phenobarbital tab 32.4 mg ................. 51 phenobarbital tab 60 mg .................... 51
phenobarbital tab 64.8 mg ................. 51 phenobarbital tab 97.2 mg ................. 51
phentermine hcl cap 15 mg ................. 1 phentermine hcl cap 30 mg ................. 1
phentermine hcl cap 37.5 mg .............. 1 phentermine hcl tab 37.5 mg .............. 1
phenytoin chew tab 50 mg ................. 14 phenytoin sodium extended cap 100 mg
...................................................... 14 phenytoin susp 125 mg/5ml ............... 15
pilocarpine hcl ophth soln 1% ............. 61 pilocarpine hcl ophth soln 4% ............. 62
pilocarpine hcl tab 5 mg .................... 56
pimozide tab 1 mg ............................ 65 pimozide tab 2 mg ............................ 65
pinworm med sus 144mg/ml ............... 8 pioglitazone hcl tab 15 mg (base equiv)
...................................................... 19 pioglitazone hcl tab 30 mg (base equiv)
...................................................... 19 pioglitazone hcl tab 45 mg (base equiv)
...................................................... 19 PNV OB+DHA PAK ............................. 58
PNV-OMEGA CAP .............................. 58 POCKET PEAK MIS METER .................. 53
podofilox soln 0.5% .......................... 44 polymyxin b-trimethoprim ophth soln
10000 unit/ml-0.1% ......................... 62
polyvitamin dro ................................ 57 polyvitamin dro /iron ......................... 57
potassium chloride microencapsulated
crys er tab 10 meq ........................... 55 potassium chloride microencapsulated
crys er tab 20 meq ........................... 55 potassium chloride oral soln 10% (20
meq/15ml) ...................................... 55 potassium chloride oral soln 20% (40
meq/15ml) ...................................... 55 potassium chloride tab er 10 meq ...... 55
potassium chloride tab er 8 meq (600 mg) ................................................ 55
potassium citrate & citric acid soln 1100-334 mg/5ml .................................... 49
potassium citrate tab er 10 meq (1080 mg) ................................................ 49
potassium citrate tab er 5 meq (540 mg)
...................................................... 49 povidone-iod sol 7.5% ...................... 32
povidone-iodine oint 10% ................. 32 povidone-iodine soln 10% ................. 32
PR NATAL 400 PAK ........................... 58 PR NATAL 400 PAK EC ...................... 58
PR NATAL 430 PAK ........................... 58 PR NATAL 430 PAK EC ...................... 58
PRADAXA CAP 110MG ....................... 13 PRADAXA CAP 150MG ....................... 13
PRADAXA CAP 75MG ......................... 13 pramipexole dihydrochloride tab 0.125
mg ................................................. 29 pramipexole dihydrochloride tab 0.25 mg
...................................................... 29
pramipexole dihydrochloride tab 0.5 mg...................................................... 29
pramipexole dihydrochloride tab 0.75 mg...................................................... 29
pramipexole dihydrochloride tab 1 mg 29 pramipexole dihydrochloride tab 1.5 mg
...................................................... 29 pravastatin sodium tab 10 mg ........... 22
pravastatin sodium tab 20 mg ........... 22 pravastatin sodium tab 40 mg ........... 22
pravastatin sodium tab 80 mg ........... 22 prazosin hcl cap 1 mg ....................... 24
prazosin hcl cap 2 mg ....................... 24 prazosin hcl cap 5 mg ....................... 24
PRED SOD PHO SOL 1% OP ............... 62
prednisolone acetate ophth susp 1% .. 62 prednisolone sod phosphate oral soln 15
96
mg/5ml (base equiv) ......................... 39
prednisolone syrup 15 mg/5ml (usp solution equivalent)........................... 39
PREDNISONE CON 5MG/ML ................ 39 prednisone oral soln 5 mg/5ml ........... 39
prednisone tab 1 mg ......................... 39 prednisone tab 10 mg ....................... 39
prednisone tab 2.5 mg ...................... 39 prednisone tab 20 mg ....................... 39
prednisone tab 5 mg ......................... 39 prednisone tab 50 mg ....................... 39
prednisone tab therapy pack 10 mg (21) ...................................................... 39
prednisone tab therapy pack 5 mg (21) ...................................................... 39
PREMARIN TAB 0.3MG ....................... 48
PREMARIN TAB 0.45MG ..................... 48 PREMARIN TAB 0.625MG ................... 48
PREMARIN TAB 0.9MG ....................... 48 PREMARIN TAB 1.25MG ..................... 48
PREMPHASE TAB ............................... 47 PREMPRO TAB .625-2.5 ..................... 47
PREMPRO TAB 0.3-1.5 ....................... 47 PREMPRO TAB 0.45-1.5 ..................... 47
PREMPRO TAB 0.625-5 ...................... 47 PRENA 1 TRUE MIS ........................... 58
PRENATA CHW 29-1MG ..................... 58 prenatal 19 chw tab .......................... 58
PRENATAL 19 TAB 29-1MG ................. 58 PRENATAL CAP FORMULA ................... 58
PRENATAL CAP OMEGA-3 ................... 58
PRENATAL DHA PAK 27-1-250 ............ 58 PRENATAL DHA PAK MULTI ................ 58
PRENATAL FRM TAB A-FREE ............... 58 PRENATAL MIS COMPLEAT ................. 59
PRENATAL MUL CAP +DHA ................. 59 PRENATAL MUL CAP DHA ................... 59
PRENATAL MV MIS + DHA .................. 59 PRENATAL PLS MIS MV + DHA ............ 59
PRENATAL TAB ................................. 59 PRENATAL TAB 27-1MG ..................... 59
PRENATAL TAB 28-0.8MG .................. 59 PRENATAL TAB COMPLETE ................. 59
PRENATAL TAB FORMULA ................... 59 PRENATAL+DHA MIS ......................... 59
PRENATAL+FE TAB 29-1MG ................ 59
PRENATAL-U CAP 106.5-1 .................. 59 PRENATE CAP ENHANCE .................... 59
PRENATE CAP PIXIE .......................... 59
PRENATE CAP RESTORE .................... 59 PRENATE DHA CAP ........................... 59
PRENATE MINI CAP .......................... 59 PRENATE TAB ELITE ......................... 59
PRENATL MULT CAP + DHA ............... 59 PRETAB TAB 29-1MG ........................ 59
prevident sol 0.2% ........................... 56 PREZCOBIX TAB 800-150 .................. 33
PREZISTA SUS 100MG/ML ................. 33 PREZISTA TAB 150MG ...................... 33
PREZISTA TAB 600MG ...................... 33 PREZISTA TAB 75MG ........................ 33
PREZISTA TAB 800MG ...................... 33 PRIMACARE CAP .............................. 59
primidone tab 250 mg ...................... 14
primidone tab 50 mg ........................ 14 probenecid tab 500 mg ..................... 50
prochlorperazine maleate tab 10 mg (base equivalent) ............................. 31
prochlorperazine maleate tab 5 mg (base equivalent) ...................................... 31
prochlorperazine suppos 25 mg.......... 31 progesterone micronized cap 100 mg . 64
progesterone micronized cap 200 mg . 64 PROLIA SOL 60MG/ML ...................... 46
prometh vc syp 6.25-5/5 .................. 40 promethazine hcl suppos 12.5 mg ...... 21
promethazine hcl suppos 25 mg ......... 21 promethazine hcl syrup 6.25 mg/5ml.. 22
promethazine hcl tab 12.5 mg ........... 22
promethazine hcl tab 25 mg .............. 22 promethazine hcl tab 50 mg .............. 22
promethazine w/ codeine syrup 6.25-10 mg/5ml ........................................... 40
promethazine-dm syrup 6.25-15 mg/5ml...................................................... 40
promethazine-phenylephrine-codeine syrup 6.25-5-10 mg/5ml ................... 40
propafenone hcl tab 150 mg .............. 10 propantheline bromide tab 15 mg ...... 67
propranolol & hydrochlorothiazide tab 40-25 mg ........................................ 26
propranolol & hydrochlorothiazide tab 80-25 mg ........................................ 26
propranolol hcl cap er 24hr 120 mg .... 35
propranolol hcl cap er 24hr 160 mg .... 35 propranolol hcl cap er 24hr 60 mg ...... 35
97
propranolol hcl cap er 24hr 80 mg ...... 35
propranolol hcl oral soln 20 mg/5ml .... 35 propranolol hcl oral soln 40 mg/5ml .... 35
propranolol hcl tab 10 mg .................. 35 propranolol hcl tab 20 mg .................. 35
propranolol hcl tab 40 mg .................. 35 propranolol hcl tab 60 mg .................. 35
propranolol hcl tab 80 mg .................. 35 propylthiouracil tab 50 mg ................. 66
PROVIDA DHA CAP ............................ 59 PROVIDA OB CAP .............................. 59
pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml ....................................... 40
pseudoephedrine hcl tab 30 mg .......... 60 pseudoephedrine hcl tab 60 mg .......... 60
PULMICORT INH 180MCG ................... 11
PULMICORT INH 90MCG .................... 11 PULMOZYME SOL 1MG/ML .................. 66
PUREFE OB CAP PLUS ........................ 59 pyrazinamide tab 500 mg .................. 26
pyridostigmine bromide tab 60 mg ...... 26 Q QSYMIA CAP 11.25-69 ........................ 1 QSYMIA CAP 15-92MG ........................ 1
QSYMIA CAP 3.75-23 ......................... 1 QSYMIA CAP 7.5-46MG ....................... 1
quetiapine fumarate tab 100 mg ......... 31 quetiapine fumarate tab 200 mg ......... 31
quetiapine fumarate tab 25 mg ........... 30 quetiapine fumarate tab 300 mg ......... 31
quetiapine fumarate tab 400 mg ......... 31
quetiapine fumarate tab 50 mg ........... 31 quetiapine fumarate tab er 24hr 150 mg
...................................................... 31 quetiapine fumarate tab er 24hr 200 mg
...................................................... 31 quetiapine fumarate tab er 24hr 300 mg
...................................................... 31 quetiapine fumarate tab er 24hr 400 mg
...................................................... 31 quetiapine fumarate tab er 24hr 50 mg
...................................................... 31 quinapril hcl tab 10 mg ...................... 23
quinapril hcl tab 20 mg ...................... 23 quinapril hcl tab 40 mg ...................... 23
quinapril hcl tab 5 mg........................ 23
quinapril-hydrochlorothiazide tab 10-12.5 mg .................................................. 26
quinapril-hydrochlorothiazide tab 20-12.5
mg ................................................. 26 quinapril-hydrochlorothiazide tab 20-25
mg ................................................. 26 QVAR AER 40MCG ............................ 11
QVAR AER 80MCG ............................ 11 QVAR REDIHA AER 80MCG ................ 11
QVAR REDIHAL AER 40MCG ............... 11 R rabeprazole sodium ec tab 20 mg ....... 68 raloxifene hcl tab 60 mg ................... 47
ramipril cap 1.25 mg ........................ 23 ramipril cap 10 mg ........................... 23
ramipril cap 2.5 mg .......................... 23 ramipril cap 5 mg ............................. 23
ranitidine hcl syrup 15 mg/ml (75
mg/5ml) ......................................... 67 ranitidine hcl tab 150 mg .................. 67
ranitidine hcl tab 300 mg .................. 67 ranitidine hcl tab 75 mg .................... 67
RAPAMUNE SOL 1MG/ML ................... 55 RELENZA MIS DISKHALE ................... 34
RELISTOR INJ 12/0.6ML .................... 49 RELISTOR INJ 8/0.4ML ..................... 49
RELISTOR TAB 150MG ...................... 49 RENAGEL TAB 400MG ....................... 49
RENFLEXIS INJ 100MG ...................... 48 REPATHA INJ 140MG/ML ................... 23
REPATHA PUSH INJ 420/3.5 .............. 23 REPATHA SURE INJ 140MG/ML ........... 23
RESCRIPTOR TAB 100 MG ................. 33
RESCRIPTOR TAB 200MG .................. 33 RESOURCE POW THICKENU ............... 64
RESTASIS EMU 0.05% ...................... 62 ribavirin cap 200 mg ......................... 34
ribavirin tab 200 mg ......................... 34 rifampin cap 150 mg ........................ 26
rifampin cap 300 mg ........................ 26 riluzole tab 50 mg ............................ 61
rimantadine hydrochloride tab 100 mg 34 RISAMINE OIN ................................. 45
RISPERDAL INJ 12.5MG .................... 30 RISPERDAL INJ 25MG ....................... 30
RISPERDAL INJ 37.5MG .................... 30 RISPERDAL INJ 50MG ....................... 30
risperidone soln 1 mg/ml .................. 30
risperidone tab 0.25 mg .................... 30 risperidone tab 0.5 mg ...................... 30
98
risperidone tab 1 mg ......................... 30
risperidone tab 2 mg ......................... 30 risperidone tab 3 mg ......................... 30
risperidone tab 4 mg ......................... 30 ritonavir tab 100 mg ......................... 33
rivastigmine tartrate cap 1.5 mg (base equivalent) ...................................... 65
rivastigmine tartrate cap 3 mg (base equivalent) ...................................... 65
rivastigmine tartrate cap 4.5 mg (base equivalent) ...................................... 65
rivastigmine tartrate cap 6 mg (base equivalent) ...................................... 65
rizatriptan benzoate oral disintegrating tab 10 mg (base eq) ......................... 53
rizatriptan benzoate oral disintegrating
tab 5 mg (base eq) ........................... 53 rizatriptan benzoate tab 10 mg (base
equivalent) ...................................... 53 rizatriptan benzoate tab 5 mg (base
equivalent) ...................................... 53 ropinirole hydrochloride tab 0.25 mg ... 29
ropinirole hydrochloride tab 0.5 mg ..... 29 ropinirole hydrochloride tab 1 mg ....... 29
ropinirole hydrochloride tab 2 mg ....... 29 ropinirole hydrochloride tab 3 mg ....... 29
ropinirole hydrochloride tab 4 mg ....... 29 ropinirole hydrochloride tab 5 mg ....... 29
rosuvastatin calcium tab 10 mg .......... 22 rosuvastatin calcium tab 20 mg .......... 22
rosuvastatin calcium tab 40 mg .......... 22
rosuvastatin calcium tab 5 mg ............ 22 S SANTYL OIN 250/GM ......................... 44 SAXENDA INJ 18MG/3ML .................... 1
SELECT-OB CHW .............................. 59 SELECT-OB+ PAK DHA ...................... 59
selegiline hcl tab 5 mg ....................... 29 selenium sulfide lotion 2.5% .............. 42
SELENIUM TAB 200MCG .................... 55 SELZENTRY TAB 150MG ..................... 33
SELZENTRY TAB 25MG ...................... 33 SELZENTRY TAB 300MG ..................... 33
SELZENTRY TAB 75MG ...................... 33 sennosides syrup 8.8 mg/5ml ............. 52
sennosides tab 8.6 mg ...................... 52
SEREVENT DIS AER 50MCG ................ 12 sertraline hcl oral concentrate for
solution 20 mg/ml ............................ 16
sertraline hcl tab 100 mg .................. 16 sertraline hcl tab 25 mg .................... 16
sertraline hcl tab 50 mg .................... 16 sevelamer carbonate packet 0.8 gm ... 49
sevelamer carbonate packet 2.4 gm ... 49 sevelamer carbonate tab 800 mg ....... 49
SHINGRIX INJ 50MCG ....................... 69 SHUR-SEAL GEL 2% ......................... 69
sildenafil citrate tab 20 mg ................ 37 silver sulfadiazine cream 1% ............. 42
simethicone chew tab 80 mg ............. 48 simethicone susp 40 mg/0.6ml .......... 48
SIMPLYTHICK GEL ............................ 64 simvastatin tab 10 mg ...................... 22
simvastatin tab 20 mg ...................... 22
simvastatin tab 40 mg ...................... 22 simvastatin tab 5 mg ........................ 22
sinus congst tab /pain dt ................... 40 sinus nasal spr 0.05% ...................... 61
sirolimus tab 0.5 mg ......................... 55 sirolimus tab 1 mg ........................... 55
sirolimus tab 2 mg ........................... 55 sleep aid tab 25mg ........................... 51
sodium bicarbonate tab 650 mg ........... 8 sodium chloride hypertonic ophth soln
5% ................................................. 62 sodium chloride soln nebu 0.9% ........ 40
sodium chloride soln nebu 3% ........... 40 sodium chloride soln nebu 7% ........... 40
sodium citrate & citric acid soln 500-334
mg/5ml ........................................... 49 sodium fluoride chew tab 0.25 mg f
(from 0.55 mg naf) .......................... 54 sodium fluoride chew tab 0.5 mg f (from
1.1 mg naf) ..................................... 54 sodium fluoride chew tab 1 mg f (from
2.2 mg naf) ..................................... 54 sodium fluoride soln 0.5 mg/ml f (from
1.1 mg/ml naf) ................................ 55 soothng bath pow treatmnt ............... 44
sotalol hcl tab 120 mg ...................... 35 sotalol hcl tab 160 mg ...................... 35
sotalol hcl tab 80 mg ........................ 35 spinosad susp 0.9% ......................... 45
SPIRIVA AER 1.25MCG ...................... 10
SPIRIVA CAP HANDIHLR ................... 10 SPIRIVA SPR 2.5MCG ....................... 10
99
spironolactone & hydrochlorothiazide tab
25-25 mg ........................................ 45 spironolactone tab 100 mg ................. 46
spironolactone tab 25 mg .................. 46 spironolactone tab 50 mg .................. 46
SPRYCEL TAB 50MG .......................... 27 stavudine cap 15 mg ......................... 33
stavudine cap 20 mg ......................... 33 stavudine cap 30 mg ......................... 33
stavudine cap 40 mg ......................... 33 STELARA INJ 45MG/0.5 ..................... 42
STELARA INJ 90MG/ML ...................... 42 STIOLTO AER 2.5-2.5 ........................ 12
STIVARGA TAB 40MG ........................ 27 stomach rlf chw 400mg ...................... 8
STRENSIQ INJ 18/0.45 ...................... 47
STRENSIQ INJ 80/0.8ML .................... 47 STRIBILD TAB .................................. 33
STRIVERDI AER 2.5MCG .................... 12 STUART ONE CAP.............................. 59
SUBOXONE MIS 12-3MG ..................... 7 SUBOXONE MIS 2-0.5MG .................... 7
SUBOXONE MIS 4-1MG ....................... 7 SUBOXONE MIS 8-2MG ....................... 7
sucralfate tab 1 gm ........................... 67 sulfacetamide sodium ophth soln 10% . 62
sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% ................ 62
SULFADIAZINE TAB 500MG ................ 66 sulfamethoxazole-trimethoprim susp
200-40 mg/5ml ................................. 8
sulfamethoxazole-trimethoprim tab 400-80 mg .............................................. 8
sulfamethoxazole-trimethoprim tab 800-160 mg ............................................ 8
sulfasalazine tab delayed release 500 mg ...................................................... 49
sulfazine tab 500mg .......................... 49 sulindac tab 150 mg ........................... 4
sulindac tab 200 mg ........................... 4 sumatriptan nasal spray 20 mg/act ..... 53
sumatriptan nasal spray 5 mg/act ....... 53 sumatriptan succinate inj 6 mg/0.5ml . 53
sumatriptan succinate solution auto-injector 4 mg/0.5ml .......................... 53
sumatriptan succinate solution auto-
injector 6 mg/0.5ml .......................... 53 sumatriptan succinate solution cartridge
4 mg/0.5ml ..................................... 54
sumatriptan succinate solution cartridge 6 mg/0.5ml ..................................... 54
sumatriptan succinate tab 100 mg ..... 54 sumatriptan succinate tab 25 mg ....... 54
sumatriptan succinate tab 50 mg ....... 54 SUTENT CAP 12.5MG ........................ 27
SUTENT CAP 25MG ........................... 28 SUTENT CAP 50MG ........................... 28
SYMBICORT AER 160-4.5 .................. 12 SYMBICORT AER 80-4.5 .................... 12
SYNAGIS INJ 100MG/ML ................... 63 SYNAGIS INJ 50MG .......................... 63
T TABLOID TAB 40MG ......................... 27
tacrolimus cap 0.5 mg ...................... 55
tacrolimus cap 1 mg ......................... 55 tacrolimus cap 5 mg ......................... 55
tacrolimus oint 0.03% ...................... 44 tacrolimus oint 0.1% ........................ 44
tadalafil tab 20 mg (pah) .................. 37 tamoxifen citrate tab 10 mg (base
equivalent) ...................................... 27 tamoxifen citrate tab 20 mg (base
equivalent) ...................................... 27 tamsulosin hcl cap 0.4 mg ................. 49
TARCEVA TAB 100MG ....................... 28 TARCEVA TAB 150MG ....................... 28
TARCEVA TAB 25MG ......................... 28 TARON-BC MIS ................................ 59
TARON-PREX CAP ............................. 59
TECFIDERA CAP 120MG .................... 65 TECFIDERA CAP 240MG .................... 65
TECFIDERA MIS STARTER ................. 65 telmisartan tab 20 mg ...................... 24
telmisartan tab 40 mg ...................... 24 telmisartan tab 80 mg ...................... 24
temazepam cap 15 mg ..................... 51 temazepam cap 30 mg ..................... 51
temozolomide cap 100 mg ................ 26 temozolomide cap 140 mg ................ 26
temozolomide cap 180 mg ................ 26 temozolomide cap 20 mg .................. 26
temozolomide cap 250 mg ................ 26 temozolomide cap 5 mg .................... 26
tenofovir disoproxil fumarate tab 300 mg
...................................................... 33 terazosin hcl cap 1 mg (base equivalent)
100
...................................................... 24
terazosin hcl cap 10 mg (base equivalent) ...................................... 24
terazosin hcl cap 2 mg (base equivalent) ...................................................... 24
terazosin hcl cap 5 mg (base equivalent) ...................................................... 24
terbinafine hcl tab 250 mg ................. 21 terbutaline sulfate tab 2.5 mg ............ 12
terbutaline sulfate tab 5 mg ............... 12 terconazole vaginal cream 0.4% ......... 69
terconazole vaginal cream 0.8% ......... 69 terconazole vaginal suppos 80 mg ...... 69
testosterone cypionate im inj in oil 100 mg/ml .............................................. 7
testosterone cypionate im inj in oil 200
mg/ml .............................................. 7 testosterone enanthate im inj in oil 200
mg/ml .............................................. 7 testosterone td gel 12.5 mg/act (1%) .. 7
testosterone td gel 50 mg/5gm (1%) ... 7 tetrabenazine tab 12.5 mg ................. 65
tetrabenazine tab 25 mg .................... 65 theophylline tab er 12hr 100 mg ......... 12
theophylline tab er 12hr 200 mg ......... 12 theophylline tab er 12hr 300 mg ......... 12
theophylline tab er 12hr 450 mg ......... 12 theophylline tab er 24hr 400 mg ......... 12
theophylline tab er 24hr 600 mg ......... 12 THERANATAL CAP ONE ...................... 59
THERANATAL MIS COMPLETE ............. 59
THERANATAL PAK OVAVITE ................ 59 THERAPEUTIC CRE MOISTUR .............. 44
THICKENUP POW CLEAR .................... 64 THICK-IT POW ORIGINAL................... 64
thioridazine hcl tab 100 mg ................ 31 thioridazine hcl tab 25 mg .................. 31
thioridazine hcl tab 50 mg .................. 31 thiothixene cap 10 mg ....................... 31
thiothixene cap 5 mg ......................... 31 timolol maleate ophth gel forming soln
0.25% ............................................. 61 timolol maleate ophth gel forming soln
0.5% ............................................... 61 timolol maleate ophth soln 0.25% ....... 61
timolol maleate ophth soln 0.5% ........ 61
TIVICAY TAB 50MG ........................... 33 tizanidine hcl tab 2 mg (base equivalent)
...................................................... 60
tizanidine hcl tab 4 mg (base equivalent)...................................................... 60
TL FOLATE TAB ................................ 59 TL-CARE DHA CAP 27-1-500 .............. 59
TL-SELECT CAP ................................ 59 tobramycin nebu soln 300 mg/5ml ....... 3
tobramycin ophth soln 0.3% .............. 62 TODAY SPONGE MIS ......................... 69
tolterodine tartrate cap er 24hr 2 mg .. 68 tolterodine tartrate cap er 24hr 4 mg .. 68
tolterodine tartrate tab 1 mg ............. 68 tolterodine tartrate tab 2 mg ............. 68
topiramate sprinkle cap 15 mg ........... 14 topiramate sprinkle cap 25 mg ........... 14
topiramate tab 100 mg ..................... 14
topiramate tab 200 mg ..................... 14 topiramate tab 25 mg ....................... 14
topiramate tab 50 mg ....................... 14 torsemide tab 10 mg ........................ 46
torsemide tab 100 mg ...................... 46 torsemide tab 20 mg ........................ 46
torsemide tab 5 mg .......................... 46 TRADJENTA TAB 5MG ....................... 18
tramadol hcl tab 50 mg ....................... 6 tramadol hcl tab er 24hr 100 mg .......... 6
tramadol hcl tab er 24hr 200 mg .......... 6 tramadol hcl tab er 24hr 300 mg .......... 6
tramadol hcl tab er 24hr biphasic release 100 mg ............................................. 6
tramadol hcl tab er 24hr biphasic release
200 mg ............................................. 6 tramadol hcl tab er 24hr biphasic release
300 mg ............................................. 6 tramadol-acetaminophen tab 37.5-325
mg ................................................... 6 trandolapril tab 1 mg ........................ 23
trandolapril tab 2 mg ........................ 23 trandolapril tab 4 mg ........................ 23
tranexamic acid tab 650 mg .............. 51 trazodone hcl tab 100 mg ................. 16
trazodone hcl tab 150 mg ................. 16 trazodone hcl tab 50 mg ................... 16
tretinoin cap 10 mg .......................... 28 tretinoin cream 0.025% .................... 41
tretinoin cream 0.05% ...................... 41
tretinoin cream 0.1% ........................ 41 tretinoin gel 0.01% .......................... 41
101
tretinoin gel 0.025% ......................... 41
triamcinolone acetonide cream 0.025% ...................................................... 43
triamcinolone acetonide cream 0.1% ... 43 triamcinolone acetonide cream 0.5% ... 43
triamcinolone acetonide dental paste 0.1% ............................................... 56
triamcinolone acetonide lotion 0.025% 43 triamcinolone acetonide lotion 0.1% .... 43
triamcinolone acetonide nasal aerosol suspension 55 mcg/act ...................... 60
triamcinolone acetonide oint 0.025%... 43 triamcinolone acetonide oint 0.1% ...... 43
triamcinolone acetonide oint 0.5% ...... 43 triamterene & hydrochlorothiazide cap
37.5-25 mg ...................................... 45
triamterene & hydrochlorothiazide tab 37.5-25 mg ...................................... 46
triamterene & hydrochlorothiazide tab 75-50 mg ........................................ 46
TRICARE CHW PRENATAL ................... 59 trifluoperazine hcl tab 1 mg (base
equivalent) ...................................... 31 trifluoperazine hcl tab 10 mg (base
equivalent) ...................................... 31 trifluoperazine hcl tab 2 mg (base
equivalent) ...................................... 31 trifluoperazine hcl tab 5 mg (base
equivalent) ...................................... 31 trifluridine ophth soln 1% .................. 62
trihexyphenidyl hcl elixir 0.4 mg/ml .... 28
trihexyphenidyl hcl tab 2 mg .............. 28 trihexyphenidyl hcl tab 5 mg .............. 28
trimethobenzamide hcl cap 300 mg ..... 20 trimethoprim tab 100 mg .................... 8
TRINATAL GT TAB ............................. 59 TRINATAL RX TAB 1 .......................... 59
trinate tab ....................................... 59 triple antib oin plus ........................... 42
TRISTART DHA CAP ........................... 59 TRISTART ONE CAP 35-1-215 ............. 59
TRIUMEQ TAB ................................... 33 tri-vit/fe dro /fl 0.25 .......................... 57
tri-vit/fl dro 0.25mg .......................... 57 TRI-VITAMIN DRO ............................. 57
tropicamide ophth soln 1% ................ 61
trospium chloride tab 20 mg .............. 68 TRULICITY INJ 0.75/0.5 ..................... 19
TRULICITY INJ 1.5/0.5 ...................... 19
TRUVADA TAB.................................. 33 TRUVADA TAB 100-150 ..................... 33
TRUVADA TAB 133-200 ..................... 33 TRUVADA TAB 167-250 ..................... 33
tussin dm liq .................................... 40 tussin dm liq max ............................. 40
TYKERB TAB 250MG ......................... 28 U UCERIS AER 2MG/ACT ........................ 7 ultra throat loz cherry ....................... 56
URINE GLUCOSE MONITORING SUPPLIES...................................................... 53
URINE TEST STRIPS ......................... 45 ursodiol cap 300 mg ......................... 48
ursodiol tab 250 mg ......................... 48
ursodiol tab 500 mg ......................... 48 V valacyclovir hcl tab 1 gm ................... 34 valacyclovir hcl tab 500 mg ............... 34
valganciclovir hcl for soln 50 mg/ml (base equiv) .................................... 34
valganciclovir hcl tab 450 mg (base equivalent) ...................................... 34
valproate sodium oral soln 250 mg/5ml (base equiv) .................................... 15
valproic acid cap 250 mg ................... 15 valsartan tab 160 mg ....................... 24
valsartan tab 320 mg ....................... 24 valsartan tab 40 mg ......................... 24
valsartan tab 80 mg ......................... 24
valsartan-hydrochlorothiazide tab 160-12.5 mg .......................................... 26
valsartan-hydrochlorothiazide tab 160-25 mg ................................................. 26
valsartan-hydrochlorothiazide tab 320-12.5 mg .......................................... 26
valsartan-hydrochlorothiazide tab 320-25 mg ................................................. 26
valsartan-hydrochlorothiazide tab 80-12.5 mg .......................................... 26
vancomycin hcl cap 125 mg (base equivalent) ........................................ 8
vancomycin hcl cap 250 mg (base equivalent) ........................................ 8
vcf vaginal gel contrace .................... 69
VCF VAGINAL MIS CONTRACP ............ 69 velivet pak ...................................... 38
102
VELTASSA POW 16.8GM .................... 56
VELTASSA POW 25.2GM .................... 56 VELTASSA POW 8.4GM ...................... 56
venlafaxine hcl cap er 24hr 150 mg (base equivalent) .............................. 16
venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) .............................. 16
venlafaxine hcl cap er 24hr 75 mg (base equivalent) ...................................... 16
venlafaxine hcl tab 100 mg ................ 16 venlafaxine hcl tab 25 mg .................. 16
venlafaxine hcl tab 37.5 mg ............... 16 venlafaxine hcl tab 50 mg .................. 16
venlafaxine hcl tab 75 mg .................. 16 VENTOLIN HFA AER ........................... 12
verapamil hcl cap er 24hr 120 mg ....... 36
verapamil hcl cap er 24hr 180 mg ....... 36 verapamil hcl cap er 24hr 200 mg ....... 36
verapamil hcl cap er 24hr 240 mg ....... 36 verapamil hcl cap er 24hr 300 mg ....... 36
verapamil hcl cap er 24hr 360 mg ....... 36 verapamil hcl tab 120 mg .................. 36
verapamil hcl tab 40 mg .................... 36 verapamil hcl tab 80 mg .................... 36
verapamil hcl tab er 120 mg .............. 36 verapamil hcl tab er 180 mg .............. 36
verapamil hcl tab er 240 mg .............. 36 VERZENIO TAB 100MG ...................... 28
VERZENIO TAB 150MG ...................... 28 VERZENIO TAB 200MG ...................... 28
VERZENIO TAB 50MG ........................ 28
VICTOZA INJ 18MG/3ML .................... 19 VIDEX EC CAP 125MG ....................... 33
VIDEX SOL 4GM ............................... 33 VIMPAT SOL 10MG/ML ....................... 14
VIMPAT TAB 100MG .......................... 14 VIMPAT TAB 150MG .......................... 14
VIMPAT TAB 200MG .......................... 14 VIMPAT TAB 50MG ............................ 14
VINATE DHA CAP 27-1.13 .................. 59 VINATE II TAB .................................. 59
VINATE M TAB .................................. 59 VIRACEPT TAB 250MG ....................... 33
VIRACEPT TAB 625MG ....................... 33 VIRT-PN TAB .................................... 60
VIT A FISH CAP 7500UNIT ................. 69
VITAFOL CAP ULTRA .......................... 60 VITAFOL CHW GUMMIES .................... 60
VITAFOL FE+ CAP ............................ 60
VITAFOL-NANO TAB.......................... 60 VITAFOL-OB PAK +DHA .................... 60
VITAFOL-ONE CAP ............................ 60 vitamax ped dro ............................... 57
VITAMEDMD CAP ONE RX .................. 60 vitamin a cap 10000 unit................... 69
VITAMIN A CAP 25000UNT ................ 69 vitamin a cap 8000 unit .................... 69
vitamin b-1 tab 100mg ..................... 70 vitamin b-1 tab 250mg ..................... 70
vitamin b-1 tab 50mg ....................... 70 vitamin b-12 injection ....................... 50
vitamin b-12 tab 1000mcg ................ 50 vitamin b-12 tab 100mcg .................. 50
vitamin b-12 tab 250mcg .................. 50
vitamin b-12 tab 500mcg .................. 50 vitamin b-2 tab 100mg ..................... 70
vitamin b-2 tab 25mg ....................... 70 vitamin b6 tab 100mg ...................... 70
vitamin b-6 tab 200mg cr .................. 70 vitamin b-6 tab 250mg ..................... 70
vitamin b-6 tab 25mg ....................... 70 vitamin b-6 tab 50mg ....................... 70
vitamin c chw 250mg ........................ 70 vitamin c chw 500mg ........................ 70
vitamin c liq 500/5ml ........................ 70 VITAMIN C SYP 500/5ML ................... 70
vitamin c tab 1000mg ....................... 71 vitamin c tab 250mg ......................... 71
vitamin d cap 50000unt .................... 70
vitamin d tab 400unit ....................... 70 vitamin d3 cap 10000 ....................... 70
vitamin d-3 cap 1000unit .................. 70 vitamin d3 cap 2000unit ................... 69
vitamin d3 cap 400unit ..................... 69 vitamin d3 cap 50000unt .................. 70
vitamin d3 cap 5000unit ................... 70 vitamin d3 chw 1000unit ................... 70
vitamin d3 chw 2000unit ................... 70 vitamin d3 chw 400unit ..................... 70
vitamin d3 chw 5000unit ................... 70 vitamin d3 dro 400unit ..................... 70
vitamin d3 sol 8000/ml ..................... 70 vitamin d3 tab 1000unit .................... 70
vitamin d3 tab 2000unit .................... 70
vitamin d3 tab 50000unt ................... 70 vitamin d3 tab 5000unit .................... 70
103
vitamin e cap 100 unit ....................... 70
vitamin e cap 1000 unit ..................... 70 vitamin e cap 200 unit ....................... 70
vitamin e cap 400 unit ....................... 70 vitamin e cap 600 unit ....................... 70
VITAPEARL CAP ................................ 60 VIVA DHA CAP .................................. 60
VIVITROL INJ 380MG ........................ 20 VOSEVI TAB ..................................... 34
VOTRIENT TAB 200MG ...................... 28 VP-PNV-DHA CAP .............................. 60
W warfarin sodium tab 1 mg .................. 12
warfarin sodium tab 10 mg ................ 12 warfarin sodium tab 2 mg .................. 12
warfarin sodium tab 2.5 mg ............... 12
warfarin sodium tab 3 mg .................. 12 warfarin sodium tab 4 mg .................. 12
warfarin sodium tab 5 mg .................. 12 warfarin sodium tab 6 mg .................. 12
warfarin sodium tab 7.5 mg ............... 12 wart remover gel 17% ....................... 44
wart remover liq 17% ........................ 44 wart remover sol 17% ....................... 44
white petrolatum gel ......................... 64 white petrolatum topical gel ............... 64
X XARELTO STAR TAB 15/20MG ............. 12
XARELTO TAB 10MG .......................... 12 XARELTO TAB 15MG .......................... 12
XARELTO TAB 20MG .......................... 12
XELJANZ TAB 10MG ........................... 3 XELJANZ TAB 5MG ............................. 3
XELJANZ XR TAB 11MG....................... 3 XIFAXAN TAB 200MG ......................... 8
XIFAXAN TAB 550MG ......................... 8 XOLAIR INJ 150MG/ML ...................... 10
XOLAIR INJ 75/0.5 ........................... 10
XOLAIR SOL 150MG ......................... 10 XTANDI CAP 40MG ........................... 27
xulane dis 150-35 ............................ 38 XYREM SOL 500MG/ML ..................... 64
Z zaleplon cap 10 mg .......................... 52
zaleplon cap 5 mg ............................ 52 ZARXIO INJ 300/0.5 ......................... 51
ZARXIO INJ 480/0.8 ......................... 51 zenatane cap 10mg .......................... 41
zenatane cap 20mg .......................... 41 zenatane cap 30mg .......................... 41
zenatane cap 40mg .......................... 41 zidovudine cap 100 mg ..................... 33
zidovudine syrup 10 mg/ml ............... 33
zidovudine tab 300 mg ..................... 34 zilactin gel baby 10% ....................... 56
zinc gluconate tab 30 mg .................. 55 zinc gluconate tab 50 mg (elemental zn)
...................................................... 55 ZINC OXIDE PST 25%....................... 45
zinc sulfate cap 220 mg (50 mg elemental zn) .................................. 55
ziprasidone hcl cap 20 mg ................. 29 ziprasidone hcl cap 40 mg ................. 29
ziprasidone hcl cap 60 mg ................. 29 ziprasidone hcl cap 80 mg ................. 29
zolpidem tartrate tab 10 mg .............. 52 zolpidem tartrate tab 5 mg ................ 52
zolpidem tartrate tab er 12.5 mg ....... 52
zolpidem tartrate tab er 6.25 mg ....... 52 zonisamide cap 100 mg .................... 14
zonisamide cap 25 mg ...................... 14 zonisamide cap 50 mg ...................... 14
ZOSTRIX NAT CRE 0.033%................ 44 ZYNCOF SYP 20-400/5 ...................... 40