2015 Drug List - BCBSIL

2015 Drug List This document contains information

about the drugs we cover in this plan

Blue Cross Community Integrated Care Plan (ICP)SM

ILICPRX15 Approved 02132015 227605.0115

Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an Independent Licensee of the Blue Cross and Blue Shield Association.

Drug List

i

What is the Blue Cross Community ICP Plan (the “Plan”) drug list?The drug list (sometimes called a formulary) is a list showing the drugs that can be covered by the Plan. The drugs listed will be covered as long as you:

• have a medical need for them• fill the medication orders at an in-network pharmacy• follow the other Plan rules

For more information on how to fill your medication orders, please review your Member Handbook.

What will I pay?You do not pay for covered drugs.

Can the drug list change?Yes, it can change, but we won’t stop or reduce coverage of a drug during the 2015 plan year even if the drug has been removed from the list. Coverage may change if:

• a new, less expensive generic drug becomes available • new information about a drug shows it to be unsafe or less

effective

You will be told in writing when the drug list does change.

How do I use the drug list? 1. Category

• The drugs are listed in categories, or groups, based on the type of medical conditions they treat. (For example, drugs used to treat a heart condition are listed under Heart and Circulatory Drugs).

• If you know what your drug is used for, look for the group in the drug list.

• Then, look under that group for your drug.

2. Alphabetical Listing

• Look for your drug in the Index. • Next to your drug, you will see the page number where

you can find coverage information.

What are generic drugs?A generic drug is approved by the Food & Drug Administration (FDA) as having the same active ingredient as the brand name drug, but often costs less. The Plan covers both brand name drugs and generic drugs.

Blue Cross Community Integrated Care Plan (ICP)

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Are there any limits on my coverage?Added conditions or limits on some covered drugs may include:

• Prior Authorization: You or your doctor may need to get approval before you fill your medication orders. If you do not get approval, the Plan may not cover the drug.

• Quantity Limits: For certain drugs, the Plan limits the amount that will be covered.

• Step Therapy: In some cases, the Plan requires you to first try certain drugs before another drug can be covered. For example, if Drug A and Drug B both treat your medical condition, the Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the Plan will then cover Drug B.

You can find out if your drug has any added conditions or limits by looking at the list that begins on page 1.

Does the plan pay for over-the-counter (OTC) drugs?Yes, the Plan pays for certain OTC drugs with a valid medication order from your doctor, and you may get those at no cost.

What if my drug is not on the drug list?Contact Member Services and ask if your drug is covered. If you learn that the Plan does not cover your drug, you have two options:

• Talk to your doctor to decide if you should first try a different drug on our list before you request an exception.

• Ask Member Services about making an exception to cover your drug. Send in a statement from your doctor backing your request. We must decide within 10 days of getting your doctor’s statement.

We usually only approve requests for exceptions if the other drugs included on our list or the added use limits would make your treatment less effective and/or would be harmful to your health.

You or your doctor can ask for an expedited (fast) decision if you both believe that your health could be harmed by waiting up to 10 days for a decision. If we agree to expedite, we must give you a decision within 24 hours (one day) after we get the statement from your doctor.

Which drug categories are not covered by the Plan drug list?The following drug categories are not covered by your plan:

• Anorexia, weight loss, or weight gain drugs

• Bulk chemicals

• Cosmetic enhancing drugs

• Diagnostic agents

• Drug Efficacy Study Implementation (DESI) that are classified as ineffective

• Experimental and investigational drugs

• Erectile dysfunction drugs prescribed to treat impotence

• Fertility drugs

• General anesthetic drugs

• Over-the-counter products not otherwise included on the Plan’s drug list

• Surgical supply/medical devices

Drug List

iii

For more Information For more details about your Plan’s drug coverage, please review your Member Handbook and other Plan materials.

If you still have questions or want more recent information, please call Member Services at 1-888-657-1211 TTY 711. We are open between 8 a.m. to 8 p.m. local time, seven days a week from October 1st to February 14th. From February 15th to September 30th we are open 8 a.m. to 8 p.m local time, Monday through Friday. Alternate technologies (for example, voicemail) will be used on the weekends and holidays, or visit www.bcbsilcommunityicp.com.

Language AssistanceInterpreter Services We can arrange for someone to help you speak with us in any language. These services are free. If your doctor does not speak your language, we can arrange for a translator to help you. Please call Member Services at the number above.

Hearing and Vision ProblemsFor our members with hearing and vision problems, we offer TTY/TDD service free of charge. The line is open 24/7 at 711.

Other Languages and Formats: You can get a copy of this booklet and your Member Handbook in Spanish by going to our website at: www.bcbsilcommunityicp.com. We also offer our materials in other languages, large format, audio and Braille through Member Services.

Blue Cross Community ICP Plan Over-the-Counter (OTC) Drug ListThe Plan covers a large selection of OTC products. These products are listed below and they require a medication order from your doctor. Generic products are to be prescribed and given out when available. These products are to be filled at a Plan network pharmacy and for quantities up to a 30-day supply.

OTC Drug List

Analgesic* Acetaminophen (generic)

Antacids*Calcium carbonate (generic); Aluminum/magnesium hydroxide (generic)

Antibiotics*Bacitracin (generic); Clotrimazole (generic); Miconazole (generic); Neomycin/Bacitracin/Polymyxin (generic); Tioconazole, Tolnaftate (generic)

Anti-Diarrheal* Loperamide (generic); Pink bismuth (generic)

Anti-Emetic* Meclizine (generic)

Anti-Flatulent* Simethicone (generic)

Anti-Histamine*Chlorpheniramine (generic); Clemastine (generic); Diphenhydramine (generic); Cetirizine (generic); Fexofenadine (generic); Loratadine (generic)

Anti-Tussive* Guaifenesin with DM (generic)

Combination Cough & Cold*

Brompheniramine & phenylephrine, Chlorpheniramine & phenylephrine, Diphenhydramine & phenylephrine, Guaifenesin with PE (generic); Guaifenesin with CF (generic)

Blue Cross Community Integrated Care Plan (ICP)

iv

Diluents* Sodium chloride (generic)

DME Products* Diabetes testing supplies, Peak flow meters, Spacers

Ear Preparations* Carbamide peroxide (generic)

Electrolytes* Electrolyte solution (generic)

Expectorant* Guaifenesin (generic)

Fertility Prevention* Condom, Levonorgestrel (emergency OC), Nonoxynol-9

H2-Receptor Antagonists* Famotidine (generic); Ranitidine (generic)

Laxatives*Bisacodyl (generic); Docusate sodium (generic); Magnesium citrate (generic); Polyethylene Glycol 3350, Psyllium (generic); Sennosides (generic)

Nasal Decongestant* Phenylephrine (generic); Saline nasal spray (generic)

NSAIDs* Aspirin (generic); Ibuprofen (generic); Naproxen (generic)

Ophthalmic Preparations*Artificial Tears (generic); Ketotifen (generic); Naphazoline with pheniramine (generic)

Pediculicides* Permethrin (generic)

Poison Ivy* Calamine (generic); Hydrocortisone (generic)

Protectants* Zinc oxide (generic)

Proton Pump Inhibitors (PPI)* Lansoprazole (generic); Omeprazole (generic)

Smoking Deterrents* Nicotine gum (generic); Nicotine patch (generic)

Vitamins and Minerals*

Calcium carbonate with vitamin D (generic); Calcium citrate with vitamin D (generic); Ferrous gluconate (generic); Ferrous sulfate (generic); Folic acid (generic); Multi-vitamins (generic); Multi-vitamins with iron (generic); Nicotinic acid (generic); Pediatric multi-vitamins (generic); Prenatal multi-vitamins (generic); Vitamin C (generic); Vitamin D (generic);

* Generic products are to be prescribed and given out when available.

2015

1 = Generic Drugs PA = Prior Authorization2 = Brand Drugs QL = Quantity Limits3 = Over the Counter Drugs SP = Specialty

ST = Step Therapy

1

Name of Drug

What thedrug willcost you(tier level)

Necessaryactions,restrictions,or limits onuse

ANTI-INFECTIVE DRUGS

PENICILLINSAMOXICILLIN – amoxicillin

(trihydrate) chew tab125 mg

$0 (2)

AMOXICILLIN – amoxicillin(trihydrate) chew tab250 mg

$0 (2)

amoxicillin (trihydrate) cap250 mg

$0 (1)

amoxicillin (trihydrate) cap500 mg

$0 (1)

amoxicillin (trihydrate) forsusp 125 mg/5ml

$0 (1)


$0 (1)


$0 (1)


$0 (1)

amoxicillin (trihydrate) tab500 mg

$0 (1)

amoxicillin (trihydrate) tab875 mg

$0 (1)

amoxicillin & k clavulanatechew tab 200-28.5 mg

$0 (1)

amoxicillin & k clavulanatechew tab 400-57 mg

$0 (1)

amoxicillin & k clavulanate forsusp 200-28.5 mg/5ml

$0 (1)

amoxicillin & k clavulanatefor susp 250-62.5 mg/5ml(Augmentin)

$0 (1)

amoxicillin & k clavulanate forsusp 400-57 mg/5ml

$0 (1)

Name of Drug



amoxicillin & k clavulanatefor susp 600-42.9 mg/5ml(Augmentin es-600)

$0 (1)

amoxicillin & k clavulanatetab sr 12hr 1000-62.5 mg(Augmentin xr)

$0 (1)

amoxicillin & k clavulanate tab250-125 mg

$0 (1)

amoxicillin & k clavulanate tab500-125 mg (Augmentin)

$0 (1)

amoxicillin & k clavulanate tab875-125 mg (Augmentin)

$0 (1)

ampicillin cap 250 mg $0 (1)

ampicillin cap 500 mg $0 (1)

dicloxacillin sodium cap250 mg

$0 (1)

dicloxacillin sodium cap500 mg

$0 (1)

penicillin v potassium for soln125 mg/5ml

$0 (1)

penicillin v potassium for soln250 mg/5ml

$0 (1)

penicillin v potassium tab250 mg

$0 (1)

penicillin v potassium tab500 mg

$0 (1)

CEPHALOSPORINScefaclor cap 250 mg $0 (1)

cefaclor cap 500 mg $0 (1)

cefadroxil cap 500 mg $0 (1)

cefadroxil for susp250 mg/5ml

$0 (1)

cefadroxil for susp500 mg/5ml

$0 (1)

cefadroxil tab 1 gm $0 (1)

2015


ST = Step Therapy

2

Name of Drug



cefdinir cap 300 mg $0 (1)

cefdinir for susp 125 mg/5ml $0 (1)

cefdinir for susp 250 mg/5ml $0 (1)

cefpodoxime proxetil for susp100 mg/5ml

$0 (1)

cefpodoxime proxetil for susp50 mg/5ml

$0 (1)

cefpodoxime proxetil tab100 mg

$0 (1)

cefpodoxime proxetil tab200 mg

$0 (1)

cefprozil for susp 125 mg/5ml $0 (1)

cefprozil for susp 250 mg/5ml $0 (1)

cefprozil tab 250 mg $0 (1)

cefprozil tab 500 mg $0 (1)

ceftriaxone sodium for inj1 gm (Rocephin)

$0 (1)

ceftriaxone sodium for inj2 gm

$0 (1)

ceftriaxone sodium for inj250 mg

$0 (1)

ceftriaxone sodium for inj500 mg (Rocephin)

$0 (1)

cefuroxime axetil for susp125 mg/5ml (Ceftin)

$0 (1)

cefuroxime axetil tab 250 mg(Ceftin)

$0 (1)

cefuroxime axetil tab 500 mg(Ceftin)

$0 (1)

cephalexin cap 250 mg(Keflex)

$0 (1)

cephalexin cap 500 mg(Keflex)

$0 (1)

cephalexin for susp125 mg/5ml

$0 (1)

Name of Drug



cephalexin for susp250 mg/5ml

$0 (1)

SUPRAX – cefixime cap400 mg

$0 (2)

SUPRAX – cefixime chew tab100 mg

$0 (2)

SUPRAX – cefixime chew tab200 mg

$0 (2)

SUPRAX – cefixime for susp100 mg/5ml

$0 (2)


$0 (2)


$0 (2)

MACROLIDESAZITHROMYCIN –

azithromycin powd pack forsusp 1 gm

$0 (2)

azithromycin for susp100 mg/5ml (Zithromax)

$0 (1)

azithromycin for susp200 mg/5ml (Zithromax)

$0 (1)

azithromycin tab 250 mg(Zithromax)

$0 (1) QL


$0 (1) QL


$0 (1) QL

clarithromycin for susp125 mg/5ml

$0 (1)

clarithromycin for susp250 mg/5ml (Biaxin)

$0 (1)

clarithromycin tab sr 24hr500 mg (Biaxin xl pac)

$0 (1) QL

clarithromycin tab 250 mg(Biaxin)

$0 (1)

2015


ST = Step Therapy

3

Name of Drug



clarithromycin tab 500 mg(Biaxin)

$0 (1)

E.E.S. 400 – erythromycinethylsuccinate tab 400 mg

$0 (2)

ERY-TAB – erythromycin tabdelayed release 250 mg

$0 (2)


$0 (2)


$0 (2)

ERYTHROMYCINETHYLSUCCINA –erythromycin ethylsuccinatetab 400 mg

$0 (2)

erythromycin w/ delayedrelease particles cap250 mg

$0 (1)

TETRACYCLINESdemeclocycline hcl tab

150 mg$0 (1)

demeclocycline hcl tab300 mg

$0 (1)

doxycycline hyclate cap100 mg (Vibramycin)

$0 (1)

doxycycline hyclate cap50 mg

$0 (1)

doxycycline hyclate tab100 mg

$0 (1)

doxycycline hyclate tab 20 mg $0 (1)

doxycycline monohydrate cap100 mg (Monodox)

$0 (1)

doxycycline monohydrate cap150 mg (Adoxa)

$0 (1)

doxycycline monohydrate cap50 mg

$0 (1)

Name of Drug



doxycycline monohydrate cap75 mg (Monodox)

$0 (1)

doxycycline monohydrate tab100 mg (Adoxa pak 1/100)

$0 (1)

doxycycline monohydrate tab150 mg (Adoxa pak 1/150)

$0 (1)

doxycycline monohydrate tab50 mg (Adoxa)

$0 (1)

doxycycline monohydrate tab75 mg (Adoxa)

$0 (1)

minocycline hcl cap 100 mg(Minocin)

$0 (1)


$0 (1)


$0 (1)

minocycline hcl tab 100 mg $0 (1)



TETRACYCLINE HCL –tetracycline hcl cap 250 mg

$0 (2)

TETRACYCLINE HCL –tetracycline hcl cap 500 mg

$0 (2)

FLUOROQUINOLONESciprofloxacin for oral

susp 250 mg/5ml (5%)(5 gm/100ml) (Cipro)

$0 (1)

ciprofloxacin for oral susp500 mg/5ml (10%)(10 gm/100ml) (Cipro)

$0 (1)

ciprofloxacin hcl tab 100 mg(base equiv)

$0 (1)

ciprofloxacin hcl tab 250 mg(base equiv) (Cipro)

$0 (1)

ciprofloxacin hcl tab 500 mg(base equiv) (Cipro)

$0 (1)

2015


ST = Step Therapy

4

Name of Drug



ciprofloxacin hcl tab 750 mg(base equiv)

$0 (1)

ciprofloxacin-ciprofloxacin hcltab sr 24hr 1000 mg(baseeq) (Cipro xr)

$0 (1)

ciprofloxacin-ciprofloxacin hcltab sr 24hr 500 mg (baseeq) (Cipro xr)

$0 (1)

levofloxacin oral soln 25 mg/ml (Levaquin)

$0 (1)

levofloxacin tab 250 mg(Levaquin)

$0 (1)


$0 (1)


$0 (1)

OFLOXACIN – ofloxacin tab400 mg

$0 (2)

AMINOGLYCOSIDESneomycin sulfate tab 500 mg $0 (1)

paromomycin sulfate cap250 mg

$0 (1)

tobramycin nebu soln300 mg/5ml (Tobi)

$0 (1) QL, SP

TUBERCULOSISethambutol hcl tab 100 mg

(Myambutol)$0 (1)

ethambutol hcl tab 400 mg(Myambutol)

$0 (1)

isoniazid tab 100 mg $0 (1)

isoniazid tab 300 mg $0 (1)

MYCOBUTIN – rifabutin cap150 mg

$0 (2)

PRIFTIN – rifapentine tab150 mg

$0 (2)

pyrazinamide tab 500 mg $0 (1)

Name of Drug



rifabutin cap 150 mg(Mycobutin)

$0 (1)

rifampin cap 150 mg (Rifadin) $0 (1)

rifampin cap 300 mg (Rifadin) $0 (1)

FUNGAL INFECTIONSfluconazole for susp 10 mg/ml

(Diflucan)$0 (1)

fluconazole for susp 40 mg/ml(Diflucan)

$0 (1)

fluconazole tab 100 mg(Diflucan)

$0 (1)


$0 (1)


$0 (1)


$0 (1)

flucytosine cap 250 mg(Ancobon)

$0 (1)

flucytosine cap 500 mg(Ancobon)

$0 (1)

griseofulvin microsize susp125 mg/5ml

$0 (1)

griseofulvin microsize tab500 mg (Grifulvin v)

$0 (1)

itraconazole cap 100 mg(Sporanox)

$0 (1)

NOXAFIL – posaconazole tabdelayed release 100 mg

$0 (2) PA

NOXAFIL – posaconazolesusp 40 mg/ml

$0 (2) PA

nystatin tab 500000 unit $0 (1)

SPORANOX – itraconazoleoral soln 10 mg/ml

$0 (2) PA

terbinafine hcl tab 250 mg(Lamisil)

$0 (1)

2015


ST = Step Therapy

5

Name of Drug



voriconazole for susp 40 mg/ml (Vfend)

$0 (1)

voriconazole tab 200 mg(Vfend)

$0 (1)

voriconazole tab 50 mg(Vfend)

$0 (1)

VIRAL INFECTIONS

CytomegalovirusVALCYTE – valganciclovir hcl

tab 450 mg$0 (2)

VALCYTE – valganciclovirhcl for soln 50 mg/ml (baseequiv)

$0 (2)

valganciclovir hcl tab 450 mg(Valcyte)

$0 (1)

Hepatitisadefovir dipivoxil tab 10 mg

(Hepsera)$0 (1)

BARACLUDE – entecavir tab0.5 mg

$0 (2)

BARACLUDE – entecavir tab1 mg

$0 (2)

BARACLUDE – entecavir oralsoln 0.05 mg/ml

$0 (2)

entecavir tab 0.5 mg(Baraclude)

$0 (1)

entecavir tab 1 mg(Baraclude)

$0 (1)

EPIVIR HBV – lamivudineoral soln 5 mg/ml

$0 (2) QL

lamivudine tab 100 mg (Epivirhbv)

$0 (1) QL

OLYSIO – simeprevirsodium cap 150 mg (baseequivalent)

$0 (2) PA, SP

Name of Drug



PEG-INTRON – peginterferonalfa-2b for inj kit50 mcg/0.5ml

$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP

PEG-INTRON REDIPEN –peginterferon alfa-2b for injkit 50 mcg/0.5ml

$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP

PEG-INTRON REDIPEN PAK4 – peginterferon alfa-2b forinj kit 50 mcg/0.5ml

$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP

2015


ST = Step Therapy

6

Name of Drug



PEGASYS – peginterferonalfa-2a inj 180 mcg/ml

$0 (2) PA, SP

PEGASYS – peginterferonalfa-2a inj 180 mcg/0.5ml

$0 (2) PA, SP

PEGASYS – peginterferonalfa-2a inj kit 180 mcg/0.5ml

$0 (2) PA, SP

PEGASYS PROCLICK –peginterferon alfa-2a inj135 mcg/0.5ml

$0 (2) PA, SP

PEGASYS PROCLICK –peginterferon alfa-2a inj180 mcg/0.5ml

$0 (2) PA, SP

PEGINTRON – peginterferonalfa-2b for inj kit50 mcg/0.5ml

$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP

ribavirin cap 200 mg(Rebetol)

$0 (1) SP

ribavirin tab 200 mg(Copegus)

$0 (1) SP

SOVALDI – sofosbuvir tab400 mg

$0 (2) PA, SP

Herpesacyclovir cap 200 mg

(Zovirax)$0 (1)

acyclovir susp 200 mg/5ml(Zovirax)

$0 (1)

acyclovir tab 400 mg(Zovirax)

$0 (1)

Name of Drug



acyclovir tab 800 mg(Zovirax)

$0 (1)

famciclovir tab 125 mg(Famvir)

$0 (1)


$0 (1)


$0 (1)

valacyclovir hcl tab 1 gm(Valtrex)

$0 (1)

valacyclovir hcl tab 500 mg(Valtrex)

$0 (1)

HIV/AIDSabacavir sulfate tab 300 mg

(base equiv) (Ziagen)$0 (1) QL

abacavir sulfate-lamivudine-zidovudine tab300-150-300 mg (Trizivir)

$0 (1) QL

APTIVUS – tipranavir cap250 mg

$0 (2) QL

APTIVUS – tipranavir oralsoln 100 mg/ml

$0 (2) QL

ATRIPLA – efavirenz-emtricitabine-tenofovir dftab 600-200-300 mg

$0 (2) QL

COMPLERA – emtricitabine-rilpivirine-tenofovir df tab200-25-300 mg

$0 (2) QL

CRIXIVAN – indinavir sulfatecap 200 mg

$0 (2) QL

CRIXIVAN – indinavir sulfatecap 400 mg

$0 (2) QL

didanosine delayed releasecapsule 125 mg (Videx ec)

$0 (1) QL


$0 (1) QL

2015


ST = Step Therapy

7

Name of Drug




$0 (1) QL


$0 (1) QL

EDURANT – rilpivirine hcl tab25 mg (base equivalent)

$0 (2) QL

EMTRIVA – emtricitabinecaps 200 mg

$0 (2) QL

EMTRIVA – emtricitabine soln10 mg/ml

$0 (2) QL

EPIVIR – lamivudine oral soln10 mg/ml

$0 (2) QL

EPZICOM – abacavir sulfate-lamivudine tab 600-300 mg

$0 (2) QL

FUZEON – enfuvirtide for inj90 mg

$0 (2) QL, SP

INTELENCE – etravirine tab25 mg

$0 (2) QL


$0 (2) QL


$0 (2) QL

INVIRASE – saquinavirmesylate cap 200 mg

$0 (2) QL

INVIRASE – saquinavirmesylate tab 500 mg

$0 (2) QL

ISENTRESS – raltegravirpotassium tab 400 mg(base equiv)

$0 (2) QL

ISENTRESS – raltegravirpotassium chew tab 25 mg(base equiv)

$0 (2) QL

ISENTRESS – raltegravirpotassium chew tab 100 mg(base equiv)

$0 (2) QL

Name of Drug



ISENTRESS – raltegravirpotassium packet for susp100 mg (base equiv)

$0 (2) QL

KALETRA – lopinavir-ritonavirtab 100-25 mg

$0 (2) QL

KALETRA – lopinavir-ritonavirtab 200-50 mg

$0 (2) QL

KALETRA – lopinavir-ritonavirsoln 400-100 mg/5ml(80-20 mg/ml)

$0 (2) QL

lamivudine tab 150 mg(Epivir)

$0 (1) QL

lamivudine tab 300 mg(Epivir)

$0 (1) QL

lamivudine-zidovudine tab150-300 mg (Combivir)

$0 (1) QL

LEXIVA – fosamprenavircalcium tab 700 mg (baseequiv)

$0 (2) QL

LEXIVA – fosamprenavircalcium susp 50 mg/ml(base equiv)

$0 (2) QL

nevirapine tab sr 24hr 400 mg(Viramune xr)

$0 (1) QL

nevirapine tab 200 mg(Viramune)

$0 (1) QL

NORVIR – ritonavir cap100 mg

$0 (2) QL

NORVIR – ritonavir tab100 mg

$0 (2) QL

NORVIR – ritonavir oral soln80 mg/ml

$0 (2) QL

PREZISTA – darunavirethanolate tab 75 mg (baseequiv)

$0 (2) QL

2015


ST = Step Therapy

8

Name of Drug



PREZISTA – darunavirethanolate tab 150 mg(base equiv)

$0 (2) QL


$0 (2) QL


$0 (2) QL

PREZISTA – darunavirethanolate susp 100 mg/ml(base equiv)

$0 (2) QL

RESCRIPTOR – delavirdinemesylate tab 100 mg

$0 (2) QL

RESCRIPTOR – delavirdinemesylate tab 200 mg

$0 (2) QL

REYATAZ – atazanavirsulfate cap 150 mg (baseequiv)

$0 (2) QL


$0 (2) QL


$0 (2) QL

SELZENTRY – maraviroc tab150 mg

$0 (2) QL

SELZENTRY – maraviroc tab300 mg

$0 (2) QL

stavudine cap 15 mg (Zerit) $0 (1) QL




stavudine for oral soln 1 mg/ml (Zerit)

$0 (1) QL

Name of Drug



STRIBILD – elvitegrav-cobicis-emtricitab-tenofovtab 150-150-200-300 mg

$0 (2) QL

SUSTIVA – efavirenz cap50 mg

$0 (2) QL

SUSTIVA – efavirenz cap200 mg

$0 (2) QL

SUSTIVA – efavirenz tab600 mg

$0 (2) QL

TIVICAY – dolutegravirsodium tab 50 mg (baseequiv)

$0 (2) QL

TRUVADA – emtricitabine-tenofovir disoproxilfumarate tab 200-300 mg

$0 (2) QL

VIDEX – didanosine for soln2 gm

$0 (2) QL

VIDEX – didanosine for soln4 gm

$0 (2) QL

VIRACEPT – nelfinavirmesylate tab 250 mg

$0 (2) QL

VIRACEPT – nelfinavirmesylate tab 625 mg

$0 (2) QL

VIRAMUNE – nevirapinesusp 50 mg/5ml

$0 (2) QL

VIRAMUNE XR – nevirapinetab sr 24hr 100 mg

$0 (2) QL

VIRAMUNE XR – nevirapinetab sr 24hr 400 mg

$0 (2) QL

VIREAD – tenofovir disoproxilfumarate tab 150 mg

$0 (2) QL


$0 (2) QL


$0 (2) QL


$0 (2) QL

2015


ST = Step Therapy

9

Name of Drug



VIREAD – tenofovir disoproxilfumarate oral powder40 mg/gm

$0 (2) QL

ZIAGEN – abacavir sulfatesoln 20 mg/ml (base equiv)

$0 (2) QL

zidovudine cap 100 mg(Retrovir)

$0 (1) QL

zidovudine syrup 10 mg/ml(Retrovir)

$0 (1) QL

zidovudine tab 300 mg $0 (1) QL

InfluenzaRELENZA DISKHALER –

zanamivir aero powderbreath activated 5 mg/blister

$0 (2) QL

TAMIFLU – oseltamivirphosphate cap 30 mg (baseequiv)

$0 (2) QL


$0 (2) QL


$0 (2) QL

TAMIFLU – oseltamivirphosphate for susp 6 mg/ml(base equiv)

$0 (2) QL

MALARIAatovaquone-proguanil hcl tab

250-100 mg (Malarone)$0 (1)

atovaquone-proguanil hcl tab62.5-25 mg (Malarone)

$0 (1)

chloroquine phosphate tab250 mg

$0 (1)

chloroquine phosphate tab500 mg (Aralen)

$0 (1)

Name of Drug



DARAPRIM – pyrimethaminetab 25 mg

$0 (2)

hydroxychloroquine sulfatetab 200 mg (Plaquenil)

$0 (1)

mefloquine hcl tab 250 mg $0 (1)

PRIMAQUINE PHOSPHATE– primaquine phosphate tab26.3 mg

$0 (2)

WORM INFECTIONSALBENZA – albendazole tab

200 mg$0 (2)

BILTRICIDE – praziquanteltab 600 mg

$0 (2)

ivermectin tab 3 mg(Stromectol)

$0 (1)

STROMECTOL – ivermectintab 3 mg

$0 (2)

OTHER ANTI-INFECTIVESclindamycin hcl cap 150 mg

(Cleocin)$0 (1)

clindamycin hcl cap 300 mg(Cleocin)

$0 (1)

clindamycin hcl cap 75 mg(Cleocin)

$0 (1)

clindamycin palmitate hclfor soln 75 mg/5ml (baseequiv) (Cleocin pediatric gr)

$0 (1)

DAPSONE – dapsone tab25 mg

$0 (2)

DAPSONE – dapsone tab100 mg

$0 (2)

metronidazole tab 250 mg(Flagyl)

$0 (1)

metronidazole tab 500 mg(Flagyl)

$0 (1)

2015


ST = Step Therapy

10

Name of Drug



sulfamethoxazole-trimethoprim susp200-40 mg/5ml

$0 (1)

sulfamethoxazole-trimethoprim tab 400-80 mg(Bactrim)

$0 (1)

sulfamethoxazole-trimethoprim tab800-160 mg (Bactrim ds)

$0 (1)

trimethoprim tab 100 mg $0 (1)

vancomycin hcl cap 125 mg(Vancocin hcl)

$0 (1)

vancomycin hcl cap 250 mg(Vancocin hcl)

$0 (1)

XIFAXAN – rifaximin tab550 mg

$0 (2) QL

ZYVOX – linezolid tab600 mg

$0 (2) QL

ZYVOX – linezolid for susp100 mg/5ml

$0 (2) QL

IMMUNIZING AGENTSSYNAGIS – palivizumab im

soln 50 mg/0.5ml$0 (2) PA, SP

SYNAGIS – palivizumab imsoln 100 mg/ml

$0 (2) PA, SP

CANCER DRUGSAFINITOR – everolimus tab

2.5 mg$0 (2) PA, QL, SP

AFINITOR – everolimus tab5 mg

$0 (2) PA, QL, SP

AFINITOR – everolimus tab7.5 mg

$0 (2) PA, QL, SP

AFINITOR – everolimus tab10 mg

$0 (2) PA, QL, SP

Name of Drug



AFINITOR DISPERZ –everolimus tab for oral susp2 mg

$0 (2) PA, QL, SP


$0 (2) PA, QL, SP


$0 (2) PA, QL, SP

ALKERAN – melphalan tab2 mg

$0 (2)

anastrozole tab 1 mg(Arimidex)

$0 (1)

bicalutamide tab 50 mg(Casodex)

$0 (1)

capecitabine tab 150 mg(Xeloda)

$0 (1) PA, SP

capecitabine tab 500 mg(Xeloda)

$0 (1) PA, SP

CEENU – lomustine cap10 mg

$0 (2)


$0 (2)


$0 (2)

CYCLOPHOSPHAMIDE– cyclophosphamide tab25 mg

$0 (2)

CYCLOPHOSPHAMIDE– cyclophosphamide tab50 mg

$0 (2)

exemestane tab 25 mg(Aromasin)

$0 (1)

flutamide cap 125 mg $0 (1)

GLEEVEC – imatinibmesylate tab 100 mg (baseequivalent)

$0 (2) PA, QL, SP

2015


ST = Step Therapy

11

Name of Drug



GLEEVEC – imatinibmesylate tab 400 mg (baseequivalent)

$0 (2) PA, QL, SP

hydroxyurea cap 500 mg(Hydrea)

$0 (1)

letrozole tab 2.5 mg (Femara) $0 (1)

LEUCOVORIN CALCIUM– leucovorin calcium tab10 mg

$0 (2)

LEUCOVORIN CALCIUM– leucovorin calcium tab15 mg

$0 (2)

leucovorin calcium tab 25 mg $0 (1)

leucovorin calcium tab 5 mg $0 (1)

LEUKERAN – chlorambuciltab 2 mg

$0 (2)

megestrol acetate susp40 mg/ml (Megace oral)

$0 (1)

megestrol acetate tab 20 mg $0 (1)

megestrol acetate tab 40 mg $0 (1)

MEKINIST – trametinibdimethyl sulfoxide tab0.5 mg (base equivalent)

$0 (2) PA, QL, SP

MEKINIST – trametinibdimethyl sulfoxide tab 2 mg(base equivalent)

$0 (2) PA, QL, SP

mercaptopurine tab 50 mg(Purinethol)

$0 (1)

methotrexate sodium tab2.5 mg (base equiv)

$0 (1)

MYLERAN – busulfan tab2 mg

$0 (2)

NEXAVAR – sorafenibtosylate tab 200 mg (baseequivalent)

$0 (2) QL, SP

Name of Drug



SPRYCEL – dasatinib tab20 mg

$0 (2) PA, QL, SP


$0 (2) PA, QL, SP


$0 (2) PA, QL, SP


$0 (2) PA, QL, SP


$0 (2) PA, QL, SP


$0 (2) PA, QL, SP

STIVARGA – regorafenib tab40 mg

$0 (2) PA, QL, SP

SUTENT – sunitinib malatecap 12.5 mg (baseequivalent)

$0 (2) QL, SP

SUTENT – sunitinibmalate cap 25 mg (baseequivalent)

$0 (2) QL, SP

SUTENT – sunitinib malatecap 37.5 mg (baseequivalent)

$0 (2) QL, SP

SUTENT – sunitinibmalate cap 50 mg (baseequivalent)

$0 (2) QL, SP

tamoxifen citrate tab 10 mg(base equivalent)

$0 (1)

tamoxifen citrate tab 20 mg(base equivalent)

$0 (1)

TARCEVA – erlotinib hcl tab25 mg (base equivalent)

$0 (2) QL, SP


$0 (2) QL, SP


$0 (2) QL, SP

2015


ST = Step Therapy

12

Name of Drug



TASIGNA – nilotinib hcl cap150 mg (base equivalent)

$0 (2) PA, QL, SP

TASIGNA – nilotinib hcl cap200 mg (base equivalent)

$0 (2) PA, QL, SP

temozolomide cap 100 mg(Temodar)

$0 (1) SP


$0 (1) SP


$0 (1) SP


$0 (1) SP


$0 (1) SP


$0 (1) SP

tretinoin cap 10 mg $0 (1) PA, SP

VOTRIENT – pazopanib hcltab 200 mg (base equiv)

$0 (2) PA, QL, SP

XALKORI – crizotinib cap200 mg

$0 (2) PA, QL, SP

XALKORI – crizotinib cap250 mg

$0 (2) PA, QL, SP

ZELBORAF – vemurafenibtab 240 mg (baseequivalent)

$0 (2) PA, QL, SP

ZYTIGA – abiraterone acetatetab 250 mg

$0 (2) PA, QL, SP

HORMONES, DIABETES AND RELATED DRUGS

CORTICOSTEROIDSbudesonide cap sr 24hr 3 mg

(Entocort ec)$0 (1)

CORTISONE ACETATE –cortisone acetate tab 25 mg

$0 (2)

Name of Drug



DEXAMETHASONE –dexamethasone soln0.5 mg/5ml

$0 (2)

dexamethasone elixir0.5 mg/5ml

$0 (1)

dexamethasone tab 0.5 mg $0 (1)



dexamethasone tab 4 mg $0 (1)

dexamethasone tab 6 mg $0 (1)

fludrocortisone acetate tab0.1 mg

$0 (1)

hydrocortisone tab 10 mg(Cortef)

$0 (1)


$0 (1)


$0 (1)

methylprednisolone tab16 mg (Medrol)

$0 (1)

methylprednisolone tab32 mg (Medrol)

$0 (1)

methylprednisolone tab 4 mg(Medrol)

$0 (1)

methylprednisolone tab4 mg dose pack (Medroldosepak)

$0 (1)

methylprednisolone tab 8 mg(Medrol)

$0 (1)

prednisolone sod phosph oralsoln 6.7 mg/5ml (5 mg/5mlbase) (Pediapred)

$0 (1)

prednisolone sod phosphateoral soln 15 mg/5ml (baseequiv)

$0 (1)

2015


ST = Step Therapy

13

Name of Drug



prednisolone syrup15 mg/5ml (usp solutionequivalent) (Prelone)

$0 (1)

PREDNISONE – prednisonetab 50 mg

$0 (2)

PREDNISONE – prednisoneoral soln 5 mg/5ml

$0 (2)

PREDNISONE – prednisonetab 5 mg dose pack

$0 (2)

PREDNISONE – prednisonetab 10 mg dose pack

$0 (2)

prednisone tab 1 mg $0 (1)


prednisone tab 2.5 mg $0 (1)



MALE HORMONESANDRODERM – testosterone

td patch 24hr 2 mg/24hr$0 (2) QL

ANDRODERM – testosteronetd patch 24hr 4 mg/24hr

$0 (2) QL

danazol cap 100 mg $0 (1)



testosterone cypionate iminj in oil 100 mg/ml (Depo-testosterone)

$0 (1) QL

testosterone cypionate iminj in oil 200 mg/ml (Depo-testosterone)

$0 (1) QL

testosterone enanthate im injin oil 200 mg/ml

$0 (1) QL

ESTROGENS

Name of Drug



COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.14 mg/day

$0 (2)

COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.25 mg/day

$0 (2)

DIVIGEL – estradiol td gel0.25 mg/0.25gm (0.1%)

$0 (2)

DIVIGEL – estradiol td gel0.5 mg/0.5gm (0.1%)

$0 (2)

DIVIGEL – estradiol td gel1 mg/gm (0.1%)

$0 (2)

ENJUVIA – estrogens,conjugated synthetic b tab0.3 mg

$0 (2)


$0 (2)


$0 (2)


$0 (2)


$0 (2)

estradiol & norethindroneacetate tab 0.5-0.1 mg(Activella)

$0 (1)

estradiol & norethindroneacetate tab 1-0.5 mg(Activella)

$0 (1)

estradiol tab 0.5 mg (Estrace) $0 (1)

estradiol tab 1 mg (Estrace) $0 (1)

estradiol tab 2 mg (Estrace) $0 (1)

2015


ST = Step Therapy

14

Name of Drug



estradiol td patch weekly0.025 mg/24hr (Climara)

$0 (1) QL

estradiol td patch weekly0.0375 mg/24hr(37.5 mcg/24hr) (Climara)

$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL

ESTROPIPATE – estropipatetab 3 mg

$0 (2)

estropipate tab 0.75 mg $0 (1)

estropipate tab 1.5 mg $0 (1)

JINTELI – norethindroneacetate-ethinyl estradiol tab1 mg-5 mcg

$0 (2)

PREMPRO – conjugatedestrogen-medroxyprogestacetate tab 0.3-1.5 mg

$0 (2)

PREMPRO – conjugatedestrogen-medroxyprogestacetate tab 0.45-1.5 mg

$0 (2)

PREMPRO – conjugatedestrogen-medroxyprogestacetate tab 0.625-5 mg

$0 (2)

VIVELLE-DOT – estradioltd patch biweekly0.025 mg/24hr

$0 (2) QL


$0 (2) QL

Name of Drug




$0 (2) QL


$0 (2) QL

VIVELLE-DOT – estradiol tdpatch biweekly 0.1 mg/24hr

$0 (2) QL

PROGESTINSmedroxyprogesterone acetate

tab 10 mg (Provera)$0 (1)

medroxyprogesterone acetatetab 2.5 mg (Provera)

$0 (1)

medroxyprogesterone acetatetab 5 mg (Provera)

$0 (1)

norethindrone acetate tab5 mg (Aygestin)

$0 (1)

progesterone micronized cap100 mg (Prometrium)

$0 (1)

progesterone micronized cap200 mg (Prometrium)

$0 (1)

BIRTH CONTROLAMETHYST – levonorgestrel-

ethinyl estradiol(continuous) tab 90-20 mcg

$0 (2) QL

BEYAZ – drospirenone-ethinyl estrad-levomefolatetab 3-0.02-0.451 mg

$0 (2) QL

BREVICON-28 –norethindrone & ethinylestradiol tab 0.5 mg-35 mcg

$0 (2) QL

CONDOMS – various $0 (3)

CYCLESSA – desogest-ethin est tab0.1-0.025/0.125-0.025/0.15-0.025mg-mg

$0 (2) QL

2015


ST = Step Therapy

15

Name of Drug



DEPO-PROVERACONTRACEPTIV –medroxyprogesteroneacetate im susp 150 mg/ml

$0 (2)

DEPO-SUBQ PROVERA 104– medroxyprogesteroneacetate subcutaneous susp104 mg/0.65ml

$0 (2)

DESOGEN – desogestrel& ethinyl estradiol tab0.15 mg-30 mcg

$0 (2) QL

DIAPHRAGMS – various $0 (2) QL

ELLA – ulipristal acetate tab30 mg

$0 (2) QL

ESTROSTEP FE –norethindrone ac-ethinyl estrad-fe tab1-20/1-30/1-35 mg-mcg

$0 (2) QL

FALESSA – levonorgest-ethestrad tab 0.1 mg-20 mcg &fa tab 1 mg kit

$0 (2) QL

FEMCON FE – norethindrone& ethinyl estradiol-fe chewtab 0.4 mg-35 mcg

$0 (2) QL

GENERESS FE –norethindrone & ethinylestradiol-fe chew tab0.8 mg-25 mcg

$0 (2) QL

IMPLANON – etonogestrelsubdermal implant 68 mg

$0 (2)

levonorgestrel tab 0.75 mg(Plan b)

$0 (1) QL

levonorgestrel tab 1.5 mg(Plan b one-step)

$0 (1) QL

levonorgestrel tab 1.5 mg(Plan b one-step)

$0 (3) QL

Name of Drug



LO LOESTRIN FE – norethin-eth estradiol-fe tab1 mg-10 mcg (24)/10 mcg(2)

$0 (2) QL

LOESTRIN FE 1.5/30 –norethindrone ace &ethinyl estradiol-fe tab1.5 mg-30 mcg

$0 (2) QL

LOESTRIN FE 1/20 –norethindrone ace &ethinyl estradiol-fe tab1 mg-20 mcg

$0 (2) QL

LOESTRIN 1.5/30-21 –norethindrone ace & ethinylestradiol tab 1.5 mg-30 mcg

$0 (2) QL

LOESTRIN 1/20-21 –norethindrone ace & ethinylestradiol tab 1 mg-20 mcg

$0 (2) QL

LOSEASONIQUE – levonorg-eth est tab 0.1-0.02mg(84)& eth est tab 0.01mg(7)

$0 (2) QL

medroxyprogesterone acetateim susp 150 mg/ml (Depo-provera contrac)

$0 (1)

MINASTRIN 24 FE –norethindrone ace-ethestradiol-fe chew tab1 mg-20 mcg (24)

$0 (2) QL

MIRCETTE – desogest-ethestrad & eth estrad tab0.15-0.02/0.01 mg(21/5)

$0 (2) QL

MIRENA – levonorgestrelreleasing iud 20 mcg/24hr(52 mg total)

$0 (2)

MODICON – norethindrone& ethinyl estradiol tab0.5 mg-35 mcg

$0 (2) QL

2015


ST = Step Therapy

16

Name of Drug



NATAZIA – estradiolvalerate-dienogest tab3 mg /2-2 mg/2-3 mg/1 mg

$0 (2) QL

NECON 1/50-28 –norethindrone & mestranoltab 1 mg-50 mcg

$0 (2) QL

NECON 10/11-28 –norethindrone-eth estradioltab 0.5-35/1-35 mg-mcg(10/11)

$0 (2) QL

NEXPLANON – etonogestrelsubdermal implant 68 mg

$0 (2)

NOR-QD – norethindrone tab0.35 mg

$0 (2) QL

norelgestromin-ethinylestradiol td ptwk150-35 mcg/24hr (Orthoevra)

$0 (1) QL

NORINYL 1+35 –norethindrone & ethinylestradiol tab 1 mg-35 mcg

$0 (2) QL

NORINYL 1+50 –norethindrone & mestranoltab 1 mg-50 mcg

$0 (2) QL

NUVARING – etonogestrel-ethinyl estradiol va ring0.120-0.015 mg/24hr

$0 (2) QL

OGESTREL – norgestrel& ethinyl estradiol tab0.5 mg-50 mcg

$0 (2) QL

oral contraceptives –all generics

$0 (1) QL

ORTHO EVRA –norelgestromin-ethinylestradiol td ptwk150-35 mcg/24hr

$0 (2) QL

Name of Drug



ORTHO MICRONOR –norethindrone tab 0.35 mg

$0 (2) QL

ORTHO TRI-CYCLEN –norgestimate-eth estrad tab0.18-35/0.215-35/0.25-35 mg-mcg

$0 (2) QL

ORTHO TRI-CYCLEN LO –norgestimate-eth estrad tab0.18-25/0.215-25/0.25-25 mg-mcg

$0 (2) QL

ORTHO-CEPT – desogestrel& ethinyl estradiol tab0.15 mg-30 mcg

$0 (2) QL

ORTHO-CYCLEN– norgestimate &ethinyl estradiol tab0.25 mg-35 mcg

$0 (2) QL

ORTHO-NOVUM 1/35 –norethindrone & ethinylestradiol tab 1 mg-35 mcg

$0 (2) QL

ORTHO-NOVUM 7/7/7 –norethindrone-eth estradioltab 0.5-35/0.75-35/1-35 mg-mcg

$0 (2) QL

OVCON-35 – norethindrone& ethinyl estradiol tab0.4 mg-35 mcg

$0 (2) QL

PARAGARD INTRAUTERINECOP – copper iud

$0 (2)

PLAN B – levonorgestrel tab0.75 mg

$0 (2) QL

PLAN B ONE-STEP –levonorgestrel tab 1.5 mg

$0 (2) QL

PLAN B ONE-STEP –levonorgestrel tab 1.5 mg

$0 (3) QL

QUARTETTE –levonor-eth est tab

$0 (2) QL

2015


ST = Step Therapy

17

Name of Drug



0.15-0.02/0.025/0.03 mg&eth est 0.01 mg

SAFYRAL – drospirenone-ethinyl estrad-levomefolatetab 3-0.03-0.451 mg

$0 (2) QL

SEASONIQUE – levonorg-ethest tab 0.15-0.03mg(84) &eth est tab 0.01mg(7)

$0 (2) QL

SKYLA – levonorgestrelreleasing iud 13.5 mg

$0 (2)

TRI-NORINYL 28 –norethindrone-eth estradioltab 0.5-35/1-35/0.5-35 mg-mcg

$0 (2) QL

YASMIN 28 – drospirenone-ethinyl estradiol tab3-0.03 mg

$0 (2) QL

YAZ – drospirenone-ethinylestradiol tab 3-0.02 mg

$0 (2) QL

ZOVIA 1/50E – ethynodioldiacetate & ethinyl estradioltab 1 mg-50 mcg

$0 (2) QL

DIABETESacarbose tab 100 mg

(Precose)$0 (1)

acarbose tab 25 mg(Precose)

$0 (1)

acarbose tab 50 mg(Precose)

$0 (1)

glimepiride tab 1 mg (Amaryl) $0 (1)



glipizide tab sr 24hr 10 mg(Glucotrol xl)

$0 (1)

glipizide tab sr 24hr 2.5 mg(Glucotrol xl)

$0 (1)

Name of Drug



glipizide tab sr 24hr 5 mg(Glucotrol xl)

$0 (1)

glipizide tab 10 mg (Glucotrol) $0 (1)

glipizide tab 5 mg (Glucotrol) $0 (1)

glipizide-metformin hcl tab2.5-250 mg

$0 (1)

glipizide-metformin hcl tab2.5-500 mg

$0 (1)

glipizide-metformin hcl tab5-500 mg

$0 (1)

GLUCAGON EMERGENCYKIT – glucagon (rdna) for injkit 1 mg

$0 (2)

glyburide micronized tab1.5 mg (Glynase)

$0 (1)

glyburide micronized tab 3 mg(Glynase)

$0 (1)

glyburide micronized tab 6 mg(Glynase)

$0 (1)

glyburide tab 1.25 mg $0 (1)

glyburide tab 2.5 mg $0 (1)

glyburide tab 5 mg $0 (1)

glyburide-metformin tab1.25-250 mg (Glucovance)

$0 (1)

glyburide-metformin tab2.5-500 mg (Glucovance)

$0 (1)

glyburide-metformin tab5-500 mg (Glucovance)

$0 (1)

JANUMET – sitagliptin-metformin hcl tab50-500 mg

$0 (2) QL

JANUMET – sitagliptin-metformin hcl tab50-1000 mg

$0 (2) QL

2015


ST = Step Therapy

18

Name of Drug



JANUMET XR – sitagliptin-metformin hcl tab sr 24hr50-500 mg

$0 (2) QL


$0 (2) QL


$0 (2) QL

JANUVIA – sitagliptinphosphate tab 25 mg (baseequiv)

$0 (2) QL

JANUVIA – sitagliptinphosphate tab 50 mg (baseequiv)

$0 (2) QL

JANUVIA – sitagliptinphosphate tab 100 mg(base equiv)

$0 (2) QL

metformin hcl tab sr 24hr500 mg (Glucophage xr)

$0 (1)

metformin hcl tab sr 24hr750 mg (Glucophage xr)

$0 (1)

metformin hcl tab 1000 mg(Glucophage)

$0 (1)


$0 (1)


$0 (1)

nateglinide tab 120 mg(Starlix)

$0 (1)

nateglinide tab 60 mg (Starlix) $0 (1)

pioglitazone hcl tab 15 mg(base equiv) (Actos)

$0 (1)


$0 (1)


$0 (1)

Name of Drug



pioglitazone hcl-metformin hcltab 15-500 mg (Actoplusmet)

$0 (1)

pioglitazone hcl-metformin hcltab 15-850 mg (Actoplusmet)

$0 (1)

repaglinide tab 0.5 mg(Prandin)

$0 (1)

repaglinide tab 1 mg(Prandin)

$0 (1)

repaglinide tab 2 mg(Prandin)

$0 (1)

VICTOZA – liraglutide solnpen-injector 18 mg/3ml(6 mg/ml)

$0 (2) QL

DIABETES - INSULINS

Rapid-Acting InsulinsHUMALOG – insulin lispro

(human) soln cartridge 100unit/ml

$0 (2) QL

HUMALOG – insulin lispro(human) inj 100 unit/ml

$0 (2) QL

HUMALOG KWIKPEN –insulin lispro (human) solnpen-injector 100 unit/ml

$0 (2) QL

NOVOLOG – insulin aspart inj100 unit/ml

$0 (2) QL

NOVOLOG FLEXPEN –insulin aspart soln pen-injector 100 unit/ml

$0 (2) QL

NOVOLOG PENFILL – insulinaspart soln cartridge 100unit/ml

$0 (2) QL

NOVOLOG PENFILL – insulinaspart inj 100 unit/ml

$0 (2) QL

Short-Acting Insulins

2015


ST = Step Therapy

19

Name of Drug



HUMULIN R – insulin regular(human) inj 100 unit/ml

$0 (2) QL

HUMULIN R U-500(CONCENTR – insulinregular (human) inj 500 unit/ml

$0 (2) QL

NOVOLIN R – insulin regular(human) inj 100 unit/ml

$0 (2) QL

NOVOLIN R RELION –insulin regular (human) inj100 unit/ml

$0 (2) QL

Intermediate-Acting InsulinsHUMALOG MIX 50/50 –

insulin lispro prot & lispro(human) inj 100 unit/ml(50-50)

$0 (2) QL

HUMALOG MIX 50/50KWIKPEN – insulin lisproprot & lispro sus pen-inj 100unit/ml (50-50)

$0 (2) QL

HUMALOG MIX 75/25 –insulin lispro prot & lispro(human) inj 100 unit/ml(75-25)

$0 (2) QL

HUMALOG MIX 75/25KWIKPEN – insulin lisproprot & lispro sus pen-inj 100unit/ml (75-25)

$0 (2) QL

HUMULIN N – insulinisophane (human) inj 100unit/ml

$0 (2) QL

HUMULIN N KWIKPEN –insulin isophane (human)susp pen-injector 100 unit/ml

$0 (2) QL

HUMULIN N U-100 PEN –insulin isophane (human)

$0 (2) QL

Name of Drug



susp pen-injector 100 unit/ml

HUMULIN 70/30 – insulinisophane & regular (human)inj 100 unit/ml (70-30)

$0 (2) QL

HUMULIN 70/30 KWIKPEN –insulin isophane & regularsusp pen-inj 100 unit/ml(70-30)

$0 (2) QL

HUMULIN 70/30 PEN –insulin isophane & regularsusp pen-inj 100 unit/ml(70-30)

$0 (2) QL

NOVOLIN N – insulinisophane (human) inj 100unit/ml

$0 (2) QL

NOVOLIN N RELION –insulin isophane (human) inj100 unit/ml

$0 (2) QL

NOVOLIN 70/30 – insulinisophane & regular (human)inj 100 unit/ml (70-30)

$0 (2) QL

NOVOLIN 70/30 RELION –insulin isophane & regular(human) inj 100 unit/ml(70-30)

$0 (2) QL

NOVOLOG MIX 70/30 –insulin aspart prot & aspart(human) inj 100 unit/ml(70-30)

$0 (2) QL

NOVOLOG MIX 70/30PREFILL – insulin aspartprot & aspart sus pen-inj100 unit/ml (70-30)

$0 (2) QL

Basal InsulinsLANTUS – insulin glargine inj

100 unit/ml$0 (2) QL

2015


ST = Step Therapy

20

Name of Drug



LANTUS SOLOSTAR –insulin glargine soln pen-injector 100 unit/ml

$0 (2) QL

LEVEMIR – insulin detemir inj100 unit/ml

$0 (2) QL

LEVEMIR FLEXPEN – insulindetemir soln pen-injector100 unit/ml

$0 (2) QL

LEVEMIR FLEXTOUCH –insulin detemir soln pen-injector 100 unit/ml

$0 (2) QL

THYROID REGULATIONlevothyroxine sodium tab

100 mcg (Synthroid)$0 (1)

levothyroxine sodium tab112 mcg (Synthroid)

$0 (1)


$0 (1)


$0 (1)


$0 (1)


$0 (1)


$0 (1)


$0 (1)


$0 (1)


$0 (1)


$0 (1)


$0 (1)

Name of Drug



liothyronine sodium tab25 mcg (Cytomel)

$0 (1)

liothyronine sodium tab 5 mcg(Cytomel)

$0 (1)

liothyronine sodium tab50 mcg (Cytomel)

$0 (1)

methimazole tab 10 mg(Tapazole)

$0 (1)

methimazole tab 5 mg(Tapazole)

$0 (1)

propylthiouracil tab 50 mg $0 (1)

GROWTH HORMONEOMNITROPE – somatropin

inj 5 mg/1.5ml$0 (2) PA, SP

OMNITROPE – somatropininj 10 mg/1.5ml

$0 (2) PA, SP

OMNITROPE – somatropinfor inj 5.8 mg

$0 (2) PA, SP

OTHER HORMONES AND RELATED DRUGSALENDRONATE SODIUM

– alendronate sodium tab40 mg

$0 (2) QL

alendronate sodium tab10 mg

$0 (1) QL

alendronate sodium tab35 mg

$0 (1) QL

alendronate sodium tab 5 mg $0 (1) QL

alendronate sodium tab70 mg (Fosamax)

$0 (1) QL

cabergoline tab 0.5 mg $0 (1)

calcitonin (salmon) nasal soln200 unit/act (Miacalcin)

$0 (1)

calcitriol cap 0.25 mcg(Rocaltrol)

$0 (1)

calcitriol cap 0.5 mcg(Rocaltrol)

$0 (1)

2015


ST = Step Therapy

21

Name of Drug



calcitriol oral soln 1 mcg/ml(Rocaltrol)

$0 (1)

desmopressin acetate nasalsoln 0.01% (refrigerated)(Ddavp)

$0 (1)

desmopressin acetate nasalspray soln 0.01% (Ddavp)

$0 (1)

desmopressin acetatenasal spray soln 0.01%(refrigerated)

$0 (1)

desmopressin acetate tab0.1 mg (Ddavp)

$0 (1)

desmopressin acetate tab0.2 mg (Ddavp)

$0 (1)

ETIDRONATE DISODIUM– etidronate disodium tab400 mg

$0 (2)

EVISTA – raloxifene hcl tab60 mg

$0 (2)

FORTEO – teriparatide(recombinant) inj600 mcg/2.4ml

$0 (2) PA, QL, SP

FORTICAL – calcitonin(salmon) nasal soln 200unit/act

$0 (2)

ibandronate sodium tab150 mg (base equivalent)(Boniva)

$0 (1) QL

levocarnitine oral soln1 gm/10ml (10%) (Carnitor)

$0 (1)

levocarnitine tab 330 mg(Carnitor)

$0 (1)

methylergonovine maleatetab 0.2 mg

$0 (1)

MIFEPREX – mifepristone tab200 mg

$0 (2)

Name of Drug



octreotide acetate inj100 mcg/ml (0.1 mg/ml)(Sandostatin)

$0 (1) SP

octreotide acetate inj1000 mcg/ml (1 mg/ml)(Sandostatin)

$0 (1) SP


$0 (1) SP


$0 (1) SP


$0 (1) SP

paricalcitol cap 1 mcg(Zemplar)

$0 (1)


$0 (1)


$0 (1)

raloxifene hcl tab 60 mg(Evista)

$0 (1)

risedronate sodium tab150 mg (Actonel)

$0 (1) QL

SENSIPAR – cinacalcet hcltab 30 mg (base equiv)

$0 (2)


$0 (2)


$0 (2)

STIMATE – desmopressinacetate nasal soln 1.5 mg/ml

$0 (2)

SYNAREL – nafarelin acetatenasal soln 2 mg/ml

$0 (2)

HEART AND CIRCULATORY DRUGS

2015


ST = Step Therapy

22

Name of Drug



ANGIOTENSIN CONVERTING ENZYME (ACE)INHIBITORS AND COMBINATIONSbenazepril &

hydrochlorothiazide tab10-12.5 mg (Lotensin hct)

$0 (1)

benazepril &hydrochlorothiazide tab20-12.5 mg (Lotensin hct)

$0 (1)

benazepril &hydrochlorothiazide tab20-25 mg (Lotensin hct)

$0 (1)

benazepril &hydrochlorothiazide tab5-6.25 mg

$0 (1)

benazepril hcl tab 10 mg(Lotensin)

$0 (1)


$0 (1)


$0 (1)

benazepril hcl tab 5 mg $0 (1)

captopril tab 100 mg $0 (1)

captopril tab 12.5 mg $0 (1)



CAPTOPRIL/HYDROCHLOROTHIA– captopril &hydrochlorothiazide tab25-15 mg

$0 (2)


$0 (2)

Name of Drug




$0 (2)


$0 (2)

enalapril maleate &hydrochlorothiazide tab10-25 mg (Vaseretic)

$0 (1)

enalapril maleate &hydrochlorothiazide tab5-12.5 mg

$0 (1)

enalapril maleate tab 10 mg(Vasotec)

$0 (1)

enalapril maleate tab 2.5 mg(Vasotec)

$0 (1)


$0 (1)


$0 (1)

fosinopril sodium &hydrochlorothiazide tab10-12.5 mg

$0 (1)

fosinopril sodium &hydrochlorothiazide tab20-12.5 mg

$0 (1)

fosinopril sodium tab 10 mg $0 (1)



lisinopril &hydrochlorothiazide tab10-12.5 mg (Zestoretic)

$0 (1)

2015


ST = Step Therapy

23

Name of Drug



lisinopril &hydrochlorothiazide tab20-12.5 mg (Zestoretic)

$0 (1)

lisinopril &hydrochlorothiazide tab20-25 mg (Zestoretic)

$0 (1)

lisinopril tab 10 mg (Prinivil) $0 (1)

lisinopril tab 2.5 mg (Zestril) $0 (1)


lisinopril tab 30 mg (Zestril) $0 (1)

lisinopril tab 40 mg (Zestril) $0 (1)


moexipril hcl tab 15 mg(Univasc)

$0 (1)

moexipril hcl tab 7.5 mg(Univasc)

$0 (1)

moexipril-hydrochlorothiazidetab 15-12.5 mg (Uniretic)

$0 (1)

moexipril-hydrochlorothiazidetab 15-25 mg

$0 (1)

moexipril-hydrochlorothiazidetab 7.5-12.5 mg

$0 (1)

perindopril erbumine tab 2 mg $0 (1)

perindopril erbumine tab 4 mg(Aceon)

$0 (1)

perindopril erbumine tab 8 mg(Aceon)

$0 (1)

quinapril hcl tab 10 mg(Accupril)

$0 (1)


$0 (1)


$0 (1)


$0 (1)

Name of Drug



quinapril-hydrochlorothiazidetab 10-12.5 mg (Accuretic)

$0 (1)

quinapril-hydrochlorothiazidetab 20-12.5 mg (Accuretic)

$0 (1)

quinapril-hydrochlorothiazidetab 20-25 mg (Accuretic)

$0 (1)

ramipril cap 1.25 mg (Altace) $0 (1)

ramipril cap 10 mg (Altace) $0 (1)

ramipril cap 2.5 mg (Altace) $0 (1)

ramipril cap 5 mg (Altace) $0 (1)

trandolapril tab 1 mg (Mavik) $0 (1)



ANGIOTENSIN II RECEPTOR ANTAGONISTS(ARBS) AND COMBINATIONSirbesartan tab 150 mg

(Avapro)$0 (1)

irbesartan tab 300 mg(Avapro)

$0 (1)

irbesartan tab 75 mg (Avapro) $0 (1)

irbesartan-hydrochlorothiazide tab150-12.5 mg (Avalide)

$0 (1)

irbesartan-hydrochlorothiazide tab300-12.5 mg (Avalide)

$0 (1)

losartan potassium &hydrochlorothiazide tab100-12.5 mg (Hyzaar)

$0 (1)

losartan potassium &hydrochlorothiazide tab100-25 mg (Hyzaar)

$0 (1)

losartan potassium &hydrochlorothiazide tab50-12.5 mg (Hyzaar)

$0 (1)

2015


ST = Step Therapy

24

Name of Drug



losartan potassium tab100 mg (Cozaar)

$0 (1)

losartan potassium tab 25 mg(Cozaar)

$0 (1)

losartan potassium tab 50 mg(Cozaar)

$0 (1)

MICARDIS – telmisartan tab20 mg

$0 (2)


$0 (2)


$0 (2)

MICARDIS HCT– telmisartan-hydrochlorothiazide tab40-12.5 mg

$0 (2)

MICARDIS HCT– telmisartan-hydrochlorothiazide tab80-12.5 mg

$0 (2)

MICARDIS HCT– telmisartan-hydrochlorothiazide tab80-25 mg

$0 (2)

valsartan tab 160 mg(Diovan)

$0 (1)

valsartan tab 320 mg(Diovan)

$0 (1)

valsartan tab 40 mg (Diovan) $0 (1)

valsartan tab 80 mg (Diovan) $0 (1)

valsartan-hydrochlorothiazidetab 160-12.5 mg (Diovanhct)

$0 (1)

valsartan-hydrochlorothiazidetab 160-25 mg (Diovan hct)

$0 (1)

Name of Drug



valsartan-hydrochlorothiazidetab 320-12.5 mg (Diovanhct)

$0 (1)

valsartan-hydrochlorothiazidetab 320-25 mg (Diovan hct)

$0 (1)

valsartan-hydrochlorothiazidetab 80-12.5 mg (Diovan hct)

$0 (1)

BETA BLOCKERS AND COMBINATIONSacebutolol hcl cap 200 mg

(Sectral)$0 (1)

acebutolol hcl cap 400 mg(Sectral)

$0 (1)

atenolol & chlorthalidone tab100-25 mg (Tenoretic 100)

$0 (1)

atenolol & chlorthalidone tab50-25 mg (Tenoretic 50)

$0 (1)

atenolol tab 100 mg(Tenormin)

$0 (1)


$0 (1)


$0 (1)

bisoprolol &hydrochlorothiazide tab10-6.25 mg (Ziac)

$0 (1)

bisoprolol &hydrochlorothiazide tab2.5-6.25 mg (Ziac)

$0 (1)

bisoprolol &hydrochlorothiazide tab5-6.25 mg (Ziac)

$0 (1)

bisoprolol fumarate tab 10 mg(Zebeta)

$0 (1)

bisoprolol fumarate tab 5 mg(Zebeta)

$0 (1)

carvedilol tab 12.5 mg(Coreg)

$0 (1)

2015


ST = Step Therapy

25

Name of Drug



carvedilol tab 25 mg (Coreg) $0 (1)


$0 (1)


$0 (1)

labetalol hcl tab 100 mg(Trandate)

$0 (1)


$0 (1)


$0 (1)

metoprolol succinate tab sr24hr 100 mg (Toprol xl)

$0 (1)


$0 (1)


$0 (1)


$0 (1)

metoprolol tartrate tab100 mg (Lopressor)

$0 (1)

metoprolol tartrate tab 25 mg $0 (1)

metoprolol tartrate tab 50 mg(Lopressor)

$0 (1)

nadolol tab 20 mg (Corgard) $0 (1)



pindolol tab 10 mg $0 (1)

pindolol tab 5 mg $0 (1)

propranolol hcl cap sr 24hr120 mg (Inderal la)

$0 (1)


$0 (1)


$0 (1)

Name of Drug




$0 (1)

propranolol hcl tab 10 mg $0 (1)





PROPRANOLOL/HYDROCHLOROTH– propranolol &hydrochlorothiazide tab40-25 mg

$0 (2)

CALCIUM CHANNEL BLOCKERS ANDCOMBINATIONSamlodipine besylate tab

10 mg (Norvasc)$0 (1)

amlodipine besylate tab2.5 mg (Norvasc)

$0 (1)

amlodipine besylate tab 5 mg(Norvasc)

$0 (1)

amlodipine besylate-benazepril hcl cap10-20 mg (Lotrel)

$0 (1)

amlodipine besylate-benazepril hcl cap10-40 mg (Lotrel)

$0 (1)

amlodipine besylate-benazepril hcl cap2.5-10 mg (Lotrel)

$0 (1)

amlodipine besylate-benazepril hcl cap 5-10 mg(Lotrel)

$0 (1)


$0 (1)

2015


ST = Step Therapy

26

Name of Drug




$0 (1)

amlodipine besylate-valsartantab 10-160 mg (Exforge)

$0 (1)


$0 (1)


$0 (1)


$0 (1)

diltiazem hcl cap sr 24hr120 mg

$0 (1)


$0 (1)


$0 (1)

diltiazem hcl coated beadscap sr 24hr 120 mg(Cardizem cd)

$0 (1)


$0 (1)


$0 (1)


$0 (1)


$0 (1)

diltiazem hcl extendedrelease beads cap sr 24hr120 mg (Tiazac)

$0 (1)

Name of Drug




$0 (1)


$0 (1)


$0 (1)


$0 (1)


$0 (1)

diltiazem hcl tab 120 mg(Cardizem)

$0 (1)


$0 (1)


$0 (1)

diltiazem hcl tab 90 mg $0 (1)

felodipine tab sr 24hr 10 mg $0 (1)

felodipine tab sr 24hr 2.5 mg $0 (1)

felodipine tab sr 24hr 5 mg $0 (1)

nifedipine tab sr 24hr osmotic30 mg (Procardia xl)

$0 (1)


$0 (1)


$0 (1)

nifedipine tab sr 24hr 30 mg(Adalat cc)

$0 (1)


$0 (1)

2015


ST = Step Therapy

27

Name of Drug




$0 (1)

VERAPAMIL HCL –verapamil hcl tab 40 mg

$0 (2)

verapamil hcl cap sr 24hr120 mg (Verelan)

$0 (1)


$0 (1)


$0 (1)


$0 (1)

verapamil hcl tab cr 120 mg(Calan sr)

$0 (1)


$0 (1)


$0 (1)

verapamil hcl tab 120 mg(Calan)

$0 (1)

verapamil hcl tab 80 mg(Calan)

$0 (1)

CHEST PAINISOSORBIDE DINITRATE

– isosorbide dinitrate tab30 mg

$0 (2)

isosorbide dinitrate tab 10 mg $0 (1)

isosorbide dinitrate tab 20 mg $0 (1)

isosorbide dinitrate tab 5 mg(Isordil titradose)

$0 (1)

isosorbide mononitrate tab sr24hr 120 mg (Imdur)

$0 (1)


$0 (1)


$0 (1)

Name of Drug



isosorbide mononitrate tab10 mg

$0 (1)

isosorbide mononitrate tab20 mg

$0 (1)

nitroglycerin td patch 24hr0.1 mg/hr (Nitro-dur)

$0 (1)


$0 (1)


$0 (1)


$0 (1)

NITROSTAT – nitroglycerin sltab 0.3 mg

$0 (2)


$0 (2)


$0 (2)

RANEXA – ranolazine tab sr12hr 500 mg

$0 (2)

RANEXA – ranolazine tab sr12hr 1000 mg

$0 (2)

CHOLESTEROL LOWERINGatorvastatin calcium tab

10 mg (base equivalent)(Lipitor)

$0 (1)

atorvastatin calcium tab20 mg (base equivalent)(Lipitor)

$0 (1)


$0 (1)


$0 (1)

cholestyramine light powderpackets 4 gm

$0 (1)

2015


ST = Step Therapy

28

Name of Drug



cholestyramine light powder4 gm/dose (Questran light)

$0 (1)

cholestyramine powderpackets 4 gm (Questran)

$0 (1)

cholestyramine powder 4 gm/dose (Questran)

$0 (1)

choline fenofibrate cap dr135 mg (fenofibric acidequiv) (Trilipix)

$0 (1)

choline fenofibrate cap dr45 mg (fenofibric acidequiv) (Trilipix)

$0 (1)

colestipol hcl granule packets5 gm (Colestid flavored)

$0 (1)

colestipol hcl granules 5 gm(Colestid flavored)

$0 (1)

colestipol hcl tab 1 gm(Colestid)

$0 (1)

CRESTOR – rosuvastatincalcium tab 40 mg

$0 (2)

fenofibrate micronized cap134 mg (Lofibra)

$0 (1)


$0 (1)


$0 (1)

fenofibrate tab 145 mg(Tricor)

$0 (1)

fenofibrate tab 160 mg(Lofibra)

$0 (1)

fenofibrate tab 48 mg (Tricor) $0 (1)

fenofibrate tab 54 mg(Lofibra)

$0 (1)

gemfibrozil tab 600 mg(Lopid)

$0 (1)

lovastatin tab 10 mg $0 (1)

Name of Drug



lovastatin tab 20 mg(Mevacor)

$0 (1)

lovastatin tab 40 mg(Mevacor)

$0 (1)

niacin tab cr 1000 mg(antihyperlipidemic)(Niaspan)

$0 (1)


$0 (1)


$0 (1)

pravastatin sodium tab 10 mg $0 (1)

pravastatin sodium tab 20 mg(Pravachol)

$0 (1)


$0 (1)


$0 (1)

simvastatin tab 10 mg (Zocor) $0 (1)





WELCHOL – colesevelam hcltab 625 mg

$0 (2)

WELCHOL – colesevelam hclpacket for susp 3.75 gm

$0 (2)

FLUID RETENTIONACETAZOLAMIDE –

acetazolamide tab 125 mg$0 (2)

acetazolamide cap sr 12hr500 mg (Diamox)

$0 (1)

acetazolamide tab 250 mg $0 (1)

2015


ST = Step Therapy

29

Name of Drug



amiloride &hydrochlorothiazide tab5-50 mg

$0 (1)

amiloride hcl tab 5 mg $0 (1)

bumetanide tab 0.5 mg $0 (1)

bumetanide tab 1 mg $0 (1)

bumetanide tab 2 mg $0 (1)

CHLOROTHIAZIDE –chlorothiazide tab 250 mg

$0 (2)

chlorothiazide tab 500 mg $0 (1)

CHLORTHALIDONE –chlorthalidone tab 25 mg

$0 (2)

CHLORTHALIDONE –chlorthalidone tab 50 mg

$0 (2)

furosemide oral soln 10 mg/ml

$0 (1)

furosemide tab 20 mg (Lasix) $0 (1)



hydrochlorothiazide cap12.5 mg (Microzide)

$0 (1)

hydrochlorothiazide tab25 mg

$0 (1)

hydrochlorothiazide tab50 mg

$0 (1)

indapamide tab 1.25 mg $0 (1)

indapamide tab 2.5 mg $0 (1)

methazolamide tab 25 mg(Neptazane)

$0 (1)

methazolamide tab 50 mg(Neptazane)

$0 (1)

metolazone tab 10 mg $0 (1)

metolazone tab 2.5 mg(Zaroxolyn)

$0 (1)

Name of Drug



metolazone tab 5 mg(Zaroxolyn)

$0 (1)

spironolactone &hydrochlorothiazide tab25-25 mg (Aldactazide)

$0 (1)

spironolactone tab 100 mg(Aldactone)

$0 (1)


$0 (1)


$0 (1)

torsemide tab 10 mg(Demadex)

$0 (1)


$0 (1)


$0 (1)


$0 (1)

triamterene &hydrochlorothiazide cap37.5-25 mg (Dyazide)

$0 (1)

triamterene &hydrochlorothiazide tab37.5-25 mg (Maxzide-25)

$0 (1)

triamterene &hydrochlorothiazide tab75-50 mg (Maxzide)

$0 (1)

TRIAMTERENE/HYDROCHLOROTH– triamterene &hydrochlorothiazide cap50-25 mg

$0 (2)

HEART RHYTHMamiodarone hcl tab 100 mg $0 (1)

amiodarone hcl tab 200 mg(Cordarone)

$0 (1)

2015


ST = Step Therapy

30

Name of Drug



amiodarone hcl tab 400 mg $0 (1)

disopyramide phosphate cap100 mg (Norpace)

$0 (1)

disopyramide phosphate cap150 mg (Norpace)

$0 (1)

flecainide acetate tab 100 mg $0 (1)



mexiletine hcl cap 150 mg $0 (1)



MULTAQ – dronedaronehcl tab 400 mg (baseequivalent)

$0 (2)

propafenone hcl cap sr 12hr225 mg (Rythmol sr)

$0 (1)


$0 (1)


$0 (1)

propafenone hcl tab 150 mg(Rythmol)

$0 (1)

propafenone hcl tab 225 mg(Rythmol)

$0 (1)

propafenone hcl tab 300 mg $0 (1)

quinidine gluconate tab cr324 mg

$0 (1)

QUINIDINE SULFATE –quinidine sulfate tab 200 mg

$0 (2)

quinidine sulfate tab 300 mg $0 (1)

sotalol hcl (afib/afl) tab120 mg (Betapace af)

$0 (1)

sotalol hcl (afib/afl) tab160 mg (Betapace af)

$0 (1)

Name of Drug



sotalol hcl (afib/afl) tab 80 mg(Betapace af)

$0 (1)

sotalol hcl tab 120 mg(Betapace)

$0 (1)


$0 (1)

sotalol hcl tab 240 mg $0 (1)


$0 (1)

OTHER HEART RELATED DRUGSADCIRCA – tadalafil tab

20 mg (pah)$0 (2) PA, QL, SP

amlodipine besylate-atorvastatin calcium tab10-10 mg (Caduet)

$0 (1)


$0 (1)


$0 (1)


$0 (1)

amlodipine besylate-atorvastatin calcium tab2.5-10 mg (Caduet)

$0 (1)


$0 (1)


$0 (1)


$0 (1)

2015


ST = Step Therapy

31

Name of Drug




$0 (1)


$0 (1)


$0 (1)

clonidine hcl tab 0.1 mg(Catapres)

$0 (1)


$0 (1)


$0 (1)

clonidine hcl td patch weekly0.1 mg/24hr (Catapres-tts-1)

$0 (1)


$0 (1)


$0 (1)

DIGOXIN – digoxin oral soln0.05 mg/ml

$0 (2)

digoxin tab 125 mcg(0.125 mg) (Lanoxin)

$0 (1)

digoxin tab 250 mcg(0.25 mg) (Lanoxin)

$0 (1)

doxazosin mesylate tab 1 mg(Cardura)

$0 (1)


$0 (1)


$0 (1)

Name of Drug




$0 (1)

eplerenone tab 25 mg(Inspra)

$0 (1)

eplerenone tab 50 mg(Inspra)

$0 (1)

guanfacine hcl tab 1 mg(Tenex)

$0 (1)

guanfacine hcl tab 2 mg(Tenex)

$0 (1)

hydralazine hcl tab 10 mg $0 (1)




methyldopa tab 250 mg $0 (1)

methyldopa tab 500 mg $0 (1)

midodrine hcl tab 10 mg $0 (1)

midodrine hcl tab 2.5 mg $0 (1)

midodrine hcl tab 5 mg $0 (1)

minoxidil tab 10 mg $0 (1)

minoxidil tab 2.5 mg $0 (1)

OPSUMIT – macitentan tab10 mg

$0 (2) PA, QL, SP

prazosin hcl cap 1 mg(Minipress)

$0 (1)


$0 (1)


$0 (1)

sildenafil citrate tab 20 mg(Revatio)

$0 (1) QL, SP

terazosin hcl cap 1 mg $0 (1)



2015


ST = Step Therapy

32

Name of Drug




TRACLEER – bosentan tab62.5 mg

$0 (2) PA, QL, SP

TRACLEER – bosentan tab125 mg

$0 (2) PA, QL, SP

BEE STING KITSEPIPEN 2-PAK – epinephrine

solution auto-injector0.3 mg/0.3ml (1:1000)

$0 (2)

EPIPEN-JR 2-PAK –epinephrine solution auto-injector 0.15 mg/0.3ml(1:2000)

$0 (2)

RESPIRATORY AGENTS

ANTIHISTAMINEScetirizine hcl chew tab 10 mg $0 (3)

cetirizine hcl chew tab 5 mg $0 (3)

cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)

$0 (1)

cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)

$0 (3)

cetirizine hcl syrup 1 mg/ml(5 mg/5ml)

$0 (3)

cetirizine hcl tab 10 mg $0 (3)

cetirizine hcl tab 5 mg $0 (3)

chlorpheniramine maleate tab4 mg

$0 (3)

clemastine fumarate tab1.34 mg (1 mg base equiv)

$0 (3)

cyproheptadine hcl syrup2 mg/5ml

$0 (1)

cyproheptadine hcl tab 4 mg $0 (1)

diphenhydramine hcl cap25 mg

$0 (3)

Name of Drug



diphenhydramine hcl cap50 mg

$0 (3)

diphenhydramine hcl chewtab 12.5 mg

$0 (3)

diphenhydramine hcl liquid12.5 mg/5ml

$0 (3)

diphenhydramine hcl tab25 mg

$0 (3)

fexofenadine hcl susp30 mg/5ml (6 mg/ml)

$0 (3)

fexofenadine hcl tab 180 mg $0 (3)

fexofenadine hcl tab 60 mg $0 (3)

loratadine syrup 5 mg/5ml $0 (3)

loratadine tab 10 mg $0 (3)

promethazine hcl suppos12.5 mg

$0 (1)

promethazine hcl suppos25 mg

$0 (1)

promethazine hcl suppos50 mg

$0 (1)

promethazine hcl syrup6.25 mg/5ml

$0 (1)

promethazine hcl tab 12.5 mg $0 (1)

promethazine hcl tab 25 mg $0 (1)

promethazine hcl tab 50 mg $0 (1)

NASAL PRODUCTSASTEPRO – azelastine

hcl nasal spray 0.15%(205.5 mcg/spray)

$0 (2) QL

azelastine hcl nasal spray0.15% (205.5 mcg/spray)(Astepro)

$0 (1) QL

azelastine hcl nasal spray137 mcg/spray (1 mg/ml)

$0 (1) QL

2015


ST = Step Therapy

33

Name of Drug



flunisolide nasal soln 0.025%(Flunisolide)

$0 (1) QL

fluticasone propionate nasalsusp 50 mcg/act (Flonase)

$0 (1) QL

ipratropium bromide nasalsoln 0.03% (21 mcg/spray)(Atrovent)

$0 (1) QL

ipratropium bromide nasalsoln 0.06% (42 mcg/spray)(Atrovent)

$0 (1) QL

NASONEX – mometasonefuroate nasal susp 50 mcg/act

$0 (2) QL

phenylephrine hcl tab 10 mg $0 (3)

saline nasal spray 0.65% $0 (3)

SUDAFED PE CHILDRENSNASA – phenylephrine hclsoln 2.5 mg/5ml

$0 (3)

triamcinolone acetonide nasalaerosol suspension 55 mcg/act (Nasacort aq)

$0 (1) QL

COUGH/COLD/ALLERGYacetylcysteine inhal soln 10% $0 (1)

acetylcysteine inhal soln 20% $0 (1)

BROHIST D –brompheniramine &phenylephrine tab 4-10 mg

$0 (3)

brompheniramine &phenylephrine elixir1-2.5 mg/5ml

$0 (3)

brompheniramine &phenylephrine liqd4-10 mg/5ml

$0 (3)

brompheniramine &phenylephrine susp6-10 mg/5ml

$0 (3)

Name of Drug



chlorpheniramine &phenylephrine liquid1-2 mg/ml

$0 (3)

chlorpheniramine &phenylephrine liquid1-3.5 mg/ml

$0 (3)

chlorpheniramine &phenylephrine liquid4-10 mg/5ml

$0 (3)

chlorpheniramine &phenylephrine tab 4-10 mg

$0 (3)

DALLERGY –chlorpheniramine &phenylephrine liquid1-2.5 mg/ml

$0 (3)

dextromethorphan-guaifenesin liquid10-100 mg/5ml

$0 (3)

DIMETAPP COLD& ALLERGY –brompheniramine &phenylephrine chew tab1-2.5 mg

$0 (3)

diphenhydramine-phenylephrine liq6.25-2.5 mg/5ml

$0 (3)

diphenhydramine-phenylephrine soln12.5-5 mg/5ml

$0 (3)

ED CHLORPED D –chlorpheniramine &phenylephrine liquid2-5 mg/ml

$0 (3)

guaifenesin liquid 100 mg/5ml $0 (3)

guaifenesin-codeine soln100-10 mg/5ml

$0 (3)

2015


ST = Step Therapy

34

Name of Drug



phenylephrine w/ dm-gg liqd5-10-200 mg/5ml

$0 (3)

phenylephrine-brompheniramine-dm elixir2.5-1-5 mg/5ml

$0 (3)

phenylephrine-guaifenesintab 10-400 mg

$0 (3)

RELHIST – bromphen tan-phenyleph tan chew tab6-15 mg

$0 (3)

RU-HIST D –brompheniramine &phenylephrine tab 4-10 mg

$0 (3)

SUDAFED PE DAY & NIGHT– diphenhyd-phenyleph tab25-10 mg & phenyleph tab10 mg pak

$0 (3)

TRIAMINIC COLD& ALLERGY –chlorpheniramine &phenylephrine syrup1-2.5 mg/5ml

$0 (3)

TRIAMINIC COLD/COUGHNIGH – diphenhydramine-phenylephrine oral strip12.5-5 mg

$0 (3)

TRIAMINIC NIGHT TIMECOLD – diphenhydramine-phenylephrine syrup6.25-2.5 mg/5ml

$0 (3)

ASTHMA/COPDADVAIR DISKUS –

fluticasone-salmeterol aerpowder ba 100-50 mcg/dose

$0 (2) QL

ADVAIR DISKUS –fluticasone-salmeterol aer

$0 (2) QL

Name of Drug



powder ba 250-50 mcg/dose

ADVAIR DISKUS –fluticasone-salmeterol aerpowder ba 500-50 mcg/dose

$0 (2) QL

ADVAIR HFA – fluticasone-salmeterol inhal aerosol45-21 mcg/act

$0 (2) QL


$0 (2) QL


$0 (2) QL

albuterol sulfate soln nebu0.083% (2.5 mg/3ml)

$0 (1) QL

albuterol sulfate soln nebu0.5% (5 mg/ml)

$0 (1) QL

albuterol sulfate soln nebu0.63 mg/3ml (base equiv)

$0 (1) QL

albuterol sulfate soln nebu1.25 mg/3ml (base equiv)

$0 (1) QL

albuterol sulfate syrup2 mg/5ml

$0 (1)

albuterol sulfate tab 2 mg $0 (1)

albuterol sulfate tab 4 mg $0 (1)

ASMANEX TWISTHALER120 ME – mometasonefuroate inhal powd220 mcg/inh (breathactivated)

$0 (2) QL

ASMANEX TWISTHALER 14MET – mometasone furoateinhal powd 220 mcg/inh(breath activated)

$0 (2) QL

2015


ST = Step Therapy

35

Name of Drug



ASMANEX TWISTHALER 30ME – mometasone furoateinhal powd 220 mcg/inh(breath activated)

$0 (2) QL


$0 (2) QL


$0 (2) QL

ASMANEX TWISTHALER7 METE – mometasonefuroate inhal powd110 mcg/inh (breathactivated)

$0 (2) QL

ATROVENT HFA –ipratropium bromide hfainhal aerosol 17 mcg/act

$0 (2) QL

budesonide inhalation susp0.25 mg/2ml (Pulmicort)

$0 (1) QL

budesonide inhalation susp0.5 mg/2ml (Pulmicort)

$0 (1) QL

COMBIVENT RESPIMAT –ipratropium-albuterol inhalaerosol soln 20-100 mcg/act

$0 (2) QL

cromolyn sodium soln nebu20 mg/2ml

$0 (1) QL

DULERA – mometasonefuroate-formoterol fumarateaerosol 100-5 mcg/act

$0 (2) QL

DULERA – mometasonefuroate-formoterol fumarateaerosol 200-5 mcg/act

$0 (2) QL

Name of Drug



FLOVENT DISKUS –fluticasone propionate aerpow ba 50 mcg/blister

$0 (2) QL


$0 (2) QL


$0 (2) QL

FLOVENT HFA – fluticasonepropionate hfa inhal aero44 mcg/act (50/valve)

$0 (2) QL

FLOVENT HFA – fluticasonepropionate hfa inhal aer110 mcg/act (125/valve)

$0 (2) QL

FLOVENT HFA – fluticasonepropionate hfa inhal aer220 mcg/act (250/valve)

$0 (2) QL

FORADIL AEROLIZER –formoterol fumarate inhalcap 12 mcg

$0 (2) QL

ipratropium bromide inhalsoln 0.02%

$0 (1) QL

ipratropium-albuterol nebusoln 0.5-2.5(3) mg/3ml

$0 (1) QL

levalbuterol hcl soln nebu0.31 mg/3ml (base equiv)(Xopenex)

$0 (1) QL


$0 (1) QL


$0 (1) QL

montelukast sodium chewtab 4 mg (base equiv)(Singulair)

$0 (1)

2015


ST = Step Therapy

36

Name of Drug



montelukast sodium chewtab 5 mg (base equiv)(Singulair)

$0 (1)

montelukast sodiumoral granules packet 4 mg(base equiv) (Singulair)

$0 (1)

montelukast sodium tab10 mg (base equiv)(Singulair)

$0 (1)

PROAIR HFA – albuterolsulfate inhal aero 108 mcg/act (90mcg base equiv)

$0 (2) QL

QVAR – beclomethasonedipropionate inhal aero soln40 mcg/act

$0 (2) QL

QVAR – beclomethasonedipropionate inhal aero soln80 mcg/act

$0 (2) QL

SPIRIVA HANDIHALER– tiotropium bromidemonohydrate inhal cap18 mcg (base equiv)

$0 (2) QL

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 80-4.5 mcg/act

$0 (2) QL

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 160-4.5 mcg/act

$0 (2) QL

terbutaline sulfate tab 2.5 mg $0 (1)

terbutaline sulfate tab 5 mg $0 (1)

theophylline tab sr 12hr100 mg

$0 (1)


$0 (1)


$0 (1)

Name of Drug




$0 (1)


$0 (1)


$0 (1)

VENTOLIN HFA – albuterolsulfate inhal aero 108 mcg/act (90mcg base equiv)

$0 (2) QL

zafirlukast tab 10 mg(Accolate)

$0 (1)

zafirlukast tab 20 mg(Accolate)

$0 (1)

OTHER RESPIRATORY DRUGSKALYDECO – ivacaftor tab

150 mg$0 (2) PA, SP

GASTROINTESTINAL DRUGS

LAXATIVESbisacodyl tab delayed release

5 mg$0 (3)

docusate sodium cap 100 mg $0 (3)

docusate sodium liquid150 mg/15ml

$0 (3)

FLEET LIQUID GLYCERINSUP – glycerin enema adult5.6 gm/average delivereddose

$0 (3)

glycerin suppos 1 gm $0 (3)

glycerin suppos 2 gm $0 (3)

glycerin suppos 80.7% $0 (3)

KONSYL – psyllium powder60.3%

$0 (3)

KONSYL – psyllium powder71.67%

$0 (3)

2015


ST = Step Therapy

37

Name of Drug



KONSYL-D – psylliumpowder 52.3%

$0 (3)

lactulose solution 10 gm/15ml $0 (1)

magnesium citrate soln $0 (3)

METAMUCIL MULTIHEALTHFIB – psyllium powder55.46%

$0 (3)

METAMUCIL MULTIHEALTHFIB – psyllium powder 63%

$0 (3)

METAMUCIL SMOOTHTEXTURE – psylliumpowder 63%

$0 (3)

PEDIA-LAX – glycerin liquidsuppos 2.8 gm (2.7 ml)

$0 (3)

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm(Golytely)

$0 (1)

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm(Colyte-flavor packs)

$0 (1)

peg 3350-kcl-sod bicarb-naclfor soln 420 gm (Nulytely/flavor pack)

$0 (1)

polyethylene glycol 3350 oralpacket

$0 (3)

polyethylene glycol 3350 oralpowder

$0 (3)

psyllium powder 28.3% $0 (3)


psyllium powder 30% $0 (3)






Name of Drug



SB NATURAL FIBERLAXATIVE – psylliumpowder 49%

$0 (3)

sennosides tab 8.6 mg $0 (3)

ANTIDIARRHEALSbismuth subsalicylate susp

262 mg/15ml$0 (3)

diphenoxylate w/ atropine tab2.5-0.025 mg (Lomotil)

$0 (1)

loperamide hcl cap 2 mg $0 (1)

loperamide hcl liq 1 mg/5ml(0.2 mg/ml)

$0 (3)

loperamide hcl tab 2 mg $0 (3)

ANTACIDSalum & mag hydroxide-

simethicone susp200-200-20 mg/5ml

$0 (3)

alum & mag hydroxide-simethicone susp400-400-40 mg/5ml

$0 (3)

calcium carbonate (antacid)chew tab 1000 mg

$0 (3)


$0 (3)


$0 (3)

magnesium oxide tab 400 mg $0 (3)

ULCER/GERDAXID AR – nizatidine tab

75 mg$0 (3)

cimetidine hcl soln300 mg/5ml

$0 (1)

cimetidine tab 300 mg $0 (1)



2015


ST = Step Therapy

38

Name of Drug



DICYCLOMINE HCL –dicyclomine hcl oral soln10 mg/5ml

$0 (2)

dicyclomine hcl cap 10 mg(Bentyl)

$0 (1)

dicyclomine hcl tab 20 mg(Bentyl)

$0 (1)

famotidine tab 10 mg $0 (3)

famotidine tab 20 mg (Pepcid) $0 (1)



glycopyrrolate tab 1 mg(Robinul)

$0 (1)

glycopyrrolate tab 2 mg(Robinul forte)

$0 (1)

GNP OMEPRAZOLE –omeprazole delayedrelease tab 20 mg

$0 (3)

HM OMEPRAZOLE –omeprazole delayedrelease tab 20 mg

$0 (3)

hyoscyamine sulfate elixir0.125 mg/5ml

$0 (1)

hyoscyamine sulfate soln0.125 mg/ml

$0 (1)

hyoscyamine sulfate tab sl0.125 mg (Levsin/sl)

$0 (1)

hyoscyamine sulfate tab sr12hr 0.375 mg (Levbid)

$0 (1)

hyoscyamine sulfate tab0.125 mg (Levsin)

$0 (1)

lansoprazole cap delayedrelease 15 mg (Prevacid)

$0 (1) QL


$0 (3) QL

Name of Drug




$0 (1) QL

methscopolamine bromidetab 2.5 mg (Pamine)

$0 (1)

methscopolamine bromidetab 5 mg (Pamine forte)

$0 (1)

misoprostol tab 100 mcg(Cytotec)

$0 (1)

misoprostol tab 200 mcg(Cytotec)

$0 (1)

OMEPRAZOLE – omeprazoledelayed release tab 20 mg

$0 (3)

omeprazole cap delayedrelease 10 mg (Prilosec)

$0 (1) QL


$0 (1) QL


$0 (1) QL

pantoprazole sodium ectab 20 mg (base equiv)(Protonix)

$0 (1) QL

pantoprazole sodium ectab 40 mg (base equiv)(Protonix)

$0 (1) QL

PEPCID – famotidine tab20 mg

$0 (3)

PREVACID – lansoprazolecap delayed release 15 mg

$0 (3)

ranitidine hcl cap 150 mg $0 (1)

ranitidine hcl cap 300 mg $0 (1)

ranitidine hcl syrup 15 mg/ml(75 mg/5ml)

$0 (1)

ranitidine hcl tab 150 mg(Zantac)

$0 (1)


$0 (3)

2015


ST = Step Therapy

39

Name of Drug




$0 (1)

ranitidine hcl tab 75 mg $0 (3)

SB OMEPRAZOLE –omeprazole delayedrelease tab 20 mg

$0 (3)

SM OMEPRAZOLE –omeprazole delayedrelease tab 20 mg

$0 (3)

sucralfate tab 1 gm (Carafate) $0 (1)

ZANTAC – ranitidine hcl tab150 mg

$0 (3)

NAUSEA AND VOMITINGEMEND – aprepitant capsule

40 mg$0 (2) QL

EMEND – aprepitant capsule80 mg

$0 (2) QL

EMEND – aprepitant capsule125 mg

$0 (2) QL

EMEND – aprepitant capsuletherapy pack 80 & 125 mg

$0 (2) QL

fructose-dextrose-phosphoricacid oral soln

$0 (3)

granisetron hcl tab 1 mg $0 (1) QL

meclizine hcl tab 12.5 mg $0 (1)

meclizine hcl tab 12.5 mg $0 (3)

meclizine hcl tab 25 mg $0 (1)

meclizine hcl tab 25 mg $0 (3)

ondansetron hcl oral soln4 mg/5ml (Zofran)

$0 (1) QL

ondansetron hcl tab 24 mg $0 (1) QL

ondansetron hcl tab 4 mg(Zofran)

$0 (1) QL

ondansetron hcl tab 8 mg(Zofran)

$0 (1) QL

Name of Drug



ondansetron orallydisintegrating tab 4 mg(Zofran odt)

$0 (1) QL

ondansetron orallydisintegrating tab 8 mg(Zofran odt)

$0 (1) QL

prochlorperazine maleate tab10 mg (Compazine)

$0 (1)

prochlorperazine maleate tab5 mg (Compazine)

$0 (1)

prochlorperazine suppos25 mg

$0 (1)

trimethobenzamide hcl cap300 mg (Tigan)

$0 (1)

DIGESTIVE ENZYMESCREON – pancrelipase

(lip-prot-amyl) dr cap3000-9500-15000 unit

$0 (2)

CREON – pancrelipase(lip-prot-amyl) dr cap6000-19000-30000 unit

$0 (2)


$0 (2)


$0 (2)


$0 (2)

ZENPEP – pancrelipase(lip-prot-amyl) dr cap3000-10000-16000 unit

$0 (2)


$0 (2)

2015


ST = Step Therapy

40

Name of Drug




$0 (2)


$0 (2)


$0 (2)


$0 (2)


$0 (2)

OTHER GASTROINTESTINAL DRUGSASACOL HD – mesalamine

tab delayed release 800 mg$0 (2)

balsalazide disodium cap750 mg (Colazal)

$0 (1)

calcium acetate (phosphatebinder) cap 667 mg(169 mg ca) (Phoslo)

$0 (1)

calcium acetate (phosphatebinder) tab 667 mg(Eliphos)

$0 (1)

CANASA – mesalaminesuppos 1000 mg

$0 (2)

DELZICOL – mesalamine capdr 400 mg

$0 (2)

lactulose (encephalopathy)solution 10 gm/15ml

$0 (1)

mesalamine enema 4 gm $0 (1)

metoclopramide hcl soln5 mg/5ml (10 mg/10ml)

$0 (1)

metoclopramide hcl tab10 mg (Reglan)

$0 (1)

Name of Drug



metoclopramide hcl tab 5 mg(Reglan)

$0 (1)

PENTASA – mesalamine capcr 250 mg

$0 (2)

PENTASA – mesalamine capcr 500 mg

$0 (2)

RENAGEL – sevelamer hcltab 400 mg

$0 (2)

RENAGEL – sevelamer hcltab 800 mg

$0 (2)

simethicone chew tab 80 mg $0 (3)

simethicone susp40 mg/0.6ml

$0 (3)

sulfasalazine tab delayedrelease 500 mg (Azulfidineen-tabs)

$0 (1)

sulfasalazine tab 500 mg(Azulfidine)

$0 (1)

ursodiol cap 300 mg (Actigall) $0 (1)

ursodiol tab 250 mg (Urso250)

$0 (1)

ursodiol tab 500 mg (Ursoforte)

$0 (1)

GENITOURINARY DRUGS

URINARY TRACT INFECTIONSnitrofurantoin macrocrystalline

cap 100 mg (Macrodantin)$0 (1)

nitrofurantoin macrocrystallinecap 50 mg (Macrodantin)

$0 (1)

nitrofurantoin monohydratemacrocrystalline cap100 mg (Macrobid)

$0 (1)

nitrofurantoin susp 25 mg/5ml(Furadantin)

$0 (1)

URINARY TRACT SPASMS

2015


ST = Step Therapy

41

Name of Drug



oxybutynin chloride syrup5 mg/5ml

$0 (1)

oxybutynin chloride tab sr24hr 10 mg (Ditropan xl)

$0 (1)


$0 (1)


$0 (1)

oxybutynin chloride tab 5 mg $0 (1)

tolterodine tartrate cap sr24hr 2 mg (Detrol la)

$0 (1)

tolterodine tartrate cap sr24hr 4 mg (Detrol la)

$0 (1)

tolterodine tartrate tab 1 mg(Detrol)

$0 (1)

tolterodine tartrate tab 2 mg(Detrol)

$0 (1)

VAGINAL PRODUCTSclindamycin phosphate

vaginal cream 2% (Cleocin)$0 (1)

clotrimazole vaginal cream2%

$0 (3)

metronidazole vaginal gel0.75% (Metrogel-vaginal)

$0 (1)

miconazole nitrate vaginalcream 2%

$0 (3)

NONOXYNOL-9 – various $0 (3)

terconazole vaginal cream0.4% (Terazol 7)

$0 (1)

terconazole vaginal cream0.8% (Terazol 3)

$0 (1)

terconazole vaginal suppos80 mg

$0 (1)

tioconazole vaginal oint 6.5% $0 (3)

VAGIFEM – estradiol vaginaltab 10 mcg

$0 (2)

Name of Drug



OTHER GENITOURINARY DRUGSalfuzosin hcl tab sr 24hr

10 mg (Uroxatral)$0 (1)

AVODART – dutasteride cap0.5 mg

$0 (2)

CYSTAGON – cysteaminebitartrate cap 50 mg

$0 (2) SP

CYSTAGON – cysteaminebitartrate cap 150 mg

$0 (2) SP

finasteride tab 5 mg (Proscar) $0 (1)

pot & sod citrates w/ cit acsoln 550-500-334 mg/5ml

$0 (1)

potassium citrate & citric acidpowder pack 3300-1002 mg

$0 (1)

potassium citrate & citric acidsoln 1100-334 mg/5ml

$0 (1)

potassium citrate tab cr 10meq (1080 mg) (Urocit-k10)

$0 (1)

potassium citrate tab cr 5meq (540 mg) (Urocit-k 5)

$0 (1)

sodium citrate & citric acidsoln 500-334 mg/5ml(Shohls solution modi)

$0 (1)

tamsulosin hcl cap 0.4 mg(Flomax)

$0 (1)

CENTRAL NERVOUS SYSTEM DRUGS

ANXIETYalprazolam tab sr 24hr 0.5 mg

(Xanax xr)$0 (1)

alprazolam tab sr 24hr 1 mg(Xanax xr)

$0 (1)


$0 (1)


$0 (1)

2015


ST = Step Therapy

42

Name of Drug



alprazolam tab 0.25 mg(Xanax)

$0 (1)

alprazolam tab 0.5 mg(Xanax)

$0 (1)

alprazolam tab 1 mg (Xanax) $0 (1)

alprazolam tab 2 mg (Xanax) $0 (1)

buspirone hcl tab 10 mg $0 (1)




diazepam tab 10 mg (Valium) $0 (1)



HYDROXYZINE HCL –hydroxyzine hcl im soln25 mg/ml

$0 (2)

hydroxyzine hcl syrup10 mg/5ml

$0 (1)

hydroxyzine hcl tab 10 mg $0 (1)



HYDROXYZINE PAMOATE– hydroxyzine pamoate cap100 mg

$0 (2)

hydroxyzine pamoate cap25 mg (Vistaril)

$0 (1)

hydroxyzine pamoate cap50 mg (Vistaril)

$0 (1)

lorazepam conc 2 mg/ml(Lorazepam intensol)

$0 (1)

lorazepam tab 0.5 mg(Ativan)

$0 (1)

lorazepam tab 1 mg (Ativan) $0 (1)

lorazepam tab 2 mg (Ativan) $0 (1)

Name of Drug



DEPRESSIONamitriptyline hcl tab 10 mg $0 (1)

amitriptyline hcl tab 100 mg $0 (1)





bupropion hcl tab sr 12hr100 mg (Wellbutrin sr)

$0 (1)


$0 (1)


$0 (1)

bupropion hcl tab sr 24hr150 mg (Wellbutrin xl)

$0 (1)

bupropion hcl tab sr 24hr300 mg (Wellbutrin xl)

$0 (1)

bupropion hcl tab 100 mg(Wellbutrin)

$0 (1)

bupropion hcl tab 75 mg(Wellbutrin)

$0 (1)

citalopram hydrobromide oralsoln 10 mg/5ml

$0 (1)

citalopram hydrobromidetab 10 mg (base equiv)(Celexa)

$0 (1)


$0 (1)


$0 (1)

clomipramine hcl cap 25 mg(Anafranil)

$0 (1)


$0 (1)

2015


ST = Step Therapy

43

Name of Drug




$0 (1)

desipramine hcl tab 10 mg(Norpramin)

$0 (1)


$0 (1)


$0 (1)


$0 (1)


$0 (1)


$0 (1)

DOXEPIN HCL – doxepin hclcap 75 mg

$0 (2)

doxepin hcl cap 10 mg $0 (1)




doxepin hcl conc 10 mg/ml $0 (1)

duloxetine hcl entericcoated pellets cap 20 mg(Cymbalta)

$0 (1) QL


$0 (1) QL


$0 (1) QL

escitalopram oxalate soln5 mg/5ml (base equiv)(Lexapro)

$0 (1)

escitalopram oxalate tab10 mg (base equiv)(Lexapro)

$0 (1)

Name of Drug



escitalopram oxalate tab20 mg (base equiv)(Lexapro)

$0 (1)

escitalopram oxalate tab 5 mg(base equiv) (Lexapro)

$0 (1)

fluoxetine hcl cap 10 mg(Prozac)

$0 (1)


$0 (1)


$0 (1)

fluoxetine hcl solution20 mg/5ml

$0 (1)

fluoxetine hcl tab 10 mg $0 (1)

fluoxetine hcl tab 20 mg $0 (1)

fluvoxamine maleate tab100 mg

$0 (1)


$0 (1)


$0 (1)

imipramine hcl tab 10 mg(Tofranil)

$0 (1)


$0 (1)


$0 (1)

mirtazapine tab 15 mg(Remeron)

$0 (1)


$0 (1)


$0 (1)

mirtazapine tab 7.5 mg $0 (1)

2015


ST = Step Therapy

44

Name of Drug



NORTRIPTYLINE HCL– nortriptyline hcl soln10 mg/5ml

$0 (2)

nortriptyline hcl cap 10 mg(Pamelor)

$0 (1)


$0 (1)


$0 (1)


$0 (1)

paroxetine hcl tab sr 24hr12.5 mg (Paxil cr)

$0 (1)

paroxetine hcl tab sr 24hr25 mg (Paxil cr)

$0 (1)

paroxetine hcl tab sr 24hr37.5 mg (Paxil cr)

$0 (1)

paroxetine hcl tab 10 mg(Paxil)

$0 (1)


$0 (1)


$0 (1)


$0 (1)

phenelzine sulfate tab 15 mg(Nardil)

$0 (1)

sertraline hcl oral conc 20 mg/ml (Zoloft)

$0 (1)

sertraline hcl tab 100 mg(Zoloft)

$0 (1)


$0 (1)


$0 (1)

tranylcypromine sulfate tab10 mg (Parnate)

$0 (1)

Name of Drug



trazodone hcl tab 100 mg $0 (1)




venlafaxine hcl cap sr 24hr150 mg (base equivalent)(Effexor xr)

$0 (1)

venlafaxine hcl cap sr 24hr37.5 mg (base equivalent)(Effexor xr)

$0 (1)

venlafaxine hcl cap sr 24hr75 mg (base equivalent)(Effexor xr)

$0 (1)

venlafaxine hcl tab sr 24hr150 mg (base equivalent)(Venlafaxine hcl er)

$0 (1)

venlafaxine hcl tab sr 24hr37.5 mg (base equivalent)(Venlafaxine hcl er)

$0 (1)

venlafaxine hcl tab sr 24hr75 mg (base equivalent)(Venlafaxine hcl er)

$0 (1)

venlafaxine hcl tab 100 mg $0 (1)


venlafaxine hcl tab 37.5 mg $0 (1)



PSYCHOTIC AND BIPOLAR DISORDERSchlorpromazine hcl tab 10 mg $0 (1)

chlorpromazine hcl tab100 mg

$0 (1)

chlorpromazine hcl tab200 mg

$0 (1)

chlorpromazine hcl tab 25 mg $0 (1)

chlorpromazine hcl tab 50 mg $0 (1)

2015


ST = Step Therapy

45

Name of Drug



clozapine tab 100 mg(Clozaril)

$0 (1) QL

clozapine tab 200 mg $0 (1) QL

clozapine tab 25 mg (Clozaril) $0 (1) QL

clozapine tab 50 mg $0 (1) QL

fluphenazine decanoate inj25 mg/ml

$0 (1)

FLUPHENAZINE HCL –fluphenazine hcl elixir2.5 mg/5ml

$0 (2)

FLUPHENAZINE HCL –fluphenazine hcl oral conc5 mg/ml

$0 (2)

fluphenazine hcl tab 1 mg $0 (1)


fluphenazine hcl tab 2.5 mg $0 (1)


haloperidol decanoate imsoln 100 mg/ml (Haldoldecanoate 100)

$0 (1)

haloperidol decanoate im soln50 mg/ml (Haldol decanoate50)

$0 (1)

haloperidol lactate oral conc2 mg/ml

$0 (1)

haloperidol tab 0.5 mg $0 (1)

haloperidol tab 1 mg $0 (1)





LITHIUM – lithium oralsolution 8 meq/5ml

$0 (2)

lithium carbonate cap 150 mg(Lithium carbonate)

$0 (1)

Name of Drug



lithium carbonate cap 300 mg $0 (1)

lithium carbonate cap 600 mg(Lithium carbonate)

$0 (1)

lithium carbonate tab cr300 mg (Lithobid)

$0 (1)

lithium carbonate tab cr450 mg

$0 (1)

lithium carbonate tab 300 mg $0 (1)

loxapine succinate cap 10 mg $0 (1)




olanzapine orallydisintegrating tab 10 mg(Zyprexa zydis)

$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL

olanzapine tab 10 mg(Zyprexa)

$0 (1) QL


$0 (1) QL

olanzapine tab 2.5 mg(Zyprexa)

$0 (1) QL


$0 (1) QL


$0 (1) QL

olanzapine tab 7.5 mg(Zyprexa)

$0 (1) QL

2015


ST = Step Therapy

46

Name of Drug



perphenazine tab 16 mg $0 (1)




quetiapine fumarate tab100 mg (Seroquel)

$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL

risperidone orallydisintegrating tab 0.25 mg

$0 (1) QL

risperidone orallydisintegrating tab 0.5 mg(Risperdal m-tab)

$0 (1) QL

risperidone orallydisintegrating tab 1 mg(Risperdal m-tab)

$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL

risperidone soln 1 mg/ml(Risperdal)

$0 (1) QL

Name of Drug



risperidone tab 0.25 mg(Risperdal)

$0 (1) QL

risperidone tab 0.5 mg(Risperdal)

$0 (1) QL

risperidone tab 1 mg(Risperdal)

$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL

thiothixene cap 1 mg $0 (1)




trifluoperazine hcl tab 1 mg $0 (1)




ziprasidone hcl cap 20 mg(Geodon)

$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL

SLEEP AIDSestazolam tab 1 mg $0 (1)

estazolam tab 2 mg $0 (1)

PHENOBARBITAL –phenobarbital tab 15 mg

$0 (2)


$0 (2)

2015


ST = Step Therapy

47

Name of Drug




$0 (2)


$0 (2)

phenobarbital elixir 20 mg/5ml $0 (1)

phenobarbital tab 16.2 mg $0 (1)

phenobarbital tab 32.4 mg $0 (1)

temazepam cap 15 mg(Restoril)

$0 (1)

temazepam cap 22.5 mg(Restoril)

$0 (1)

temazepam cap 30 mg(Restoril)

$0 (1)

temazepam cap 7.5 mg(Restoril)

$0 (1)

zaleplon cap 10 mg (Sonata) $0 (1) QL

zaleplon cap 5 mg (Sonata) $0 (1) QL

zolpidem tartrate tab cr12.5 mg (Ambien cr)

$0 (1) QL

zolpidem tartrate tab cr6.25 mg (Ambien cr)

$0 (1) QL

zolpidem tartrate tab 10 mg(Ambien)

$0 (1) QL

zolpidem tartrate tab 5 mg(Ambien)

$0 (1) QL

HYPERACTIVITY/NARCOLEPSYamphetamine-

dextroamphetamine cap sr24hr 10 mg (Adderall xr)

$0 (1) QL

amphetamine-dextroamphetamine cap sr24hr 15 mg (Adderall xr)

$0 (1) QL


$0 (1) QL

Name of Drug




$0 (1) QL


$0 (1) QL


$0 (1) QL

amphetamine-dextroamphetamine tab10 mg (Adderall)

$0 (1) QL

amphetamine-dextroamphetamine tab12.5 mg (Adderall)

$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL

amphetamine-dextroamphetamine tab7.5 mg (Adderall)

$0 (1) QL

caffeine citrate oral soln60 mg/3ml (10 mg/ml baseequiv) (Cafcit)

$0 (1)

dextroamphetamine sulfatecap sr 24hr 10 mg(Dexedrine)

$0 (1) QL

2015


ST = Step Therapy

48

Name of Drug



dextroamphetamine sulfatecap sr 24hr 15 mg(Dexedrine)

$0 (1) QL

dextroamphetaminesulfate cap sr 24hr 5 mg(Dexedrine)

$0 (1) QL

dextroamphetamine sulfatetab 5 mg

$0 (1) QL

INTUNIV – guanfacine hcl tabsr 24hr 1 mg (base equiv)

$0 (2) QL


$0 (2) QL


$0 (2) QL


$0 (2) QL

METHYLPHENIDATE HCLER – methylphenidate hcltab cr 10 mg

$0 (2) QL

METHYLPHENIDATE HCLER – methylphenidate hcltab sa osm 18 mg

$0 (2) QL


$0 (2) QL


$0 (2) QL


$0 (2) QL

methylphenidate hcl tab cr20 mg (Ritalin sr)

$0 (1) QL

methylphenidate hcl tab10 mg (Ritalin)

$0 (1) QL

methylphenidate hcl tab20 mg (Ritalin)

$0 (1) QL

Name of Drug



methylphenidate hcl tab 5 mg(Ritalin)

$0 (1) QL

modafinil tab 100 mg(Provigil)

$0 (1)

modafinil tab 200 mg(Provigil)

$0 (1)

STRATTERA – atomoxetinehcl cap 10 mg (base equiv)

$0 (2) QL


$0 (2) QL


$0 (2) QL


$0 (2) QL


$0 (2) QL


$0 (2) QL

STRATTERA – atomoxetinehcl cap 100 mg (baseequiv)

$0 (2) QL

VYVANSE –lisdexamfetaminedimesylate cap 20 mg

$0 (2) QL


$0 (2) QL


$0 (2) QL


$0 (2) QL


$0 (2) QL

2015


ST = Step Therapy

49

Name of Drug




$0 (2) QL

MULTIPLE SCLEROSISBETASERON – interferon

beta-1b for inj kit 0.3 mg$0 (2) QL, SP

COPAXONE – glatirameracetate soln prefilledsyringe 40 mg/ml

$0 (2) QL, SP

COPAXONE – glatirameracetate inj kit 20 mg/ml

$0 (2) QL, SP

REBIF – interferon beta-1ainj 22 mcg/0.5ml (12mu/ml)(44 mcg/ml)

$0 (2) QL, SP

REBIF – interferon beta-1ainj 44 mcg/0.5ml (24mu/ml)(88 mcg/ml)

$0 (2) QL, SP

REBIF REBIDOSE –interferon beta-1a inj22 mcg/0.5ml (12mu/ml)(44 mcg/ml)

$0 (2) QL, SP

REBIF REBIDOSE –interferon beta-1a inj44 mcg/0.5ml (24mu/ml)(88 mcg/ml)

$0 (2) QL, SP

REBIF REBIDOSETITRATION – interferonbeta-1a inj 6 x8.8 mcg/0.2ml & 6 x22 mcg/0.5ml

$0 (2) QL, SP

REBIF TITRATION PACK– interferon beta-1a inj6 x 8.8 mcg/0.2ml & 6 x22 mcg/0.5ml

$0 (2) QL, SP

TECFIDERA – dimethylfumarate capsule delayedrelease 120 mg

$0 (2) QL, SP

Name of Drug



TECFIDERA – dimethylfumarate capsule delayedrelease 240 mg

$0 (2) QL, SP

TECFIDERA STARTERPACK – dimethyl fumaratecapsule dr starter pack120 mg & 240 mg

$0 (2) QL, SP

OTHER CENTRAL NERVOUS SYSTEM DRUGSacamprosate calcium tab

delayed release 333 mg(Campral)

$0 (1)

bupropion hcl (smokingdeterrent) tab sr 12hr150 mg (Zyban)

$0 (1)

CHANTIX – vareniclinetartrate tab 0.5 mg (baseequiv)

$0 (2)

CHANTIX – vareniclinetartrate tab 1 mg (baseequiv)

$0 (2)

CHANTIX CONTINUINGMONTH – vareniclinetartrate tab 1 mg (baseequiv)

$0 (2)

CHANTIX STARTINGMONTH PA – vareniclinetartrate tab 0.5 mg x 11 &tab 1 mg x 42 pack

$0 (2)

disulfiram tab 250 mg(Antabuse)

$0 (1)

disulfiram tab 500 mg(Antabuse)

$0 (1)

donepezil hydrochloride orallydisintegrating tab 10 mg(Aricept odt)

$0 (1)

donepezil hydrochloride orallydisintegrating tab 5 mg

$0 (1)

2015


ST = Step Therapy

50

Name of Drug



donepezil hydrochloride tab10 mg (Aricept)

$0 (1)

donepezil hydrochloride tab5 mg (Aricept)

$0 (1)

galantamine hydrobromidecap sr 24hr 16 mg(Razadyne er)

$0 (1)


$0 (1)


$0 (1)

galantamine hydrobromideoral soln 4 mg/ml(Razadyne)

$0 (1)

galantamine hydrobromidetab 12 mg (Razadyne)

$0 (1)


$0 (1)


$0 (1)

naltrexone hcl tab 50 mg(Revia)

$0 (1)

nicotine polacrilex gum 2 mg $0 (3)

nicotine polacrilex gum 4 mg $0 (3)

nicotine td patch 24hr14 mg/24hr

$0 (3)


$0 (3)


$0 (3)

NUEDEXTA –dextromethorphan hbr-quinidine sulfate cap20-10 mg

$0 (2)

Name of Drug



rivastigmine tartrate cap1.5 mg (Exelon)

$0 (1)

rivastigmine tartrate cap 3 mg(Exelon)

$0 (1)

rivastigmine tartrate cap4.5 mg (Exelon)

$0 (1)

rivastigmine tartrate cap 6 mg(Exelon)

$0 (1)

PAIN RELIEF DRUGS

NON-NARCOTIC DRUGSacetaminophen cap 500 mg $0 (3)

acetaminophen chew tab160 mg

$0 (3)

acetaminophen chew tab80 mg

$0 (3)

acetaminophen dispersibletab 80 mg

$0 (3)

acetaminophen elixir160 mg/5ml

$0 (3)

acetaminophen liquid160 mg/5ml

$0 (3)

acetaminophen soln 100 mg/ml

$0 (3)

acetaminophen soln160 mg/5ml

$0 (3)

acetaminophen suppos120 mg

$0 (3)

acetaminophen susp160 mg/5ml

$0 (3)

acetaminophen susp80 mg/0.8ml

$0 (3)

acetaminophen tab 325 mg $0 (3)

acetaminophen tab 500 mg $0 (3)

aspirin chew tab 81 mg $0 (3)

2015


ST = Step Therapy

51

Name of Drug



aspirin tab delayed release325 mg

$0 (3)

aspirin tab delayed release81 mg

$0 (3)

aspirin tab 325 mg $0 (3)

butalbital-acetaminophen tab50-325 mg

$0 (1)

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

$0 (1)

butalbital-acetaminophen-caffeine tab 50-325-40 mg(Esgic)

$0 (1)

butalbital-aspirin-caffeine cap50-325-40 mg (Fiorinal)

$0 (1)

salsalate tab 500 mg $0 (1)

salsalate tab 750 mg $0 (1)

NARCOTIC DRUGSacetaminophen w/ codeine

soln 120-12 mg/5ml$0 (1)

acetaminophen w/ codeinetab 300-15 mg (Tylenol/codeine)

$0 (1)

acetaminophen w/ codeinetab 300-30 mg (Tylenol/codeine #3)

$0 (1)

acetaminophen w/ codeinetab 300-60 mg (Tylenol/codeine #4)

$0 (1)

buprenorphine hcl sl tab 2 mg(base equiv)

$0 (1) PA, QL

buprenorphine hcl sl tab 8 mg(base equiv)

$0 (1) PA, QL

buprenorphine hcl-naloxonehcl sl tab 2-0.5 mg (baseequiv)

$0 (1) PA, QL

Name of Drug



buprenorphine hcl-naloxonehcl sl tab 8-2 mg (baseequiv)

$0 (1) PA, QL

butalbital-aspirin-caff w/ codeine cap50-325-40-30 mg (Fiorinal/codeine #3)

$0 (1)

codeine sulfate tab 30 mg $0 (1)

codeine sulfate tab 60 mg $0 (1)

fentanyl citrate lollipop1200 mcg (Actiq)

$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL

fentanyl td patch 72hr100 mcg/hr (Duragesic)

$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL

hydrocodone-acetaminophensoln 7.5-325 mg/15ml(Hycet)

$0 (1)

hydrocodone-acetaminophentab 10-325 mg (Norco)

$0 (1)

2015


ST = Step Therapy

52

Name of Drug



hydrocodone-acetaminophentab 5-325 mg (Norco)

$0 (1)

hydrocodone-acetaminophentab 7.5-325 mg (Norco)

$0 (1)

hydrocodone-ibuprofen tab10-200 mg (Ibudone)

$0 (1)

hydrocodone-ibuprofen tab5-200 mg (Reprexain)

$0 (1)

hydrocodone-ibuprofen tab7.5-200 mg (Vicoprofen)

$0 (1)

hydromorphone hcl liqd 1 mg/ml (Dilaudid)

$0 (1)

hydromorphone hcl tab 2 mg(Dilaudid)

$0 (1)


$0 (1)


$0 (1)

methadone hcl conc 10 mg/ml(Methadose)

$0 (1)

methadone hcl soln10 mg/5ml (Methadone hcl)

$0 (1)

methadone hcl soln 5 mg/5ml(Methadone hcl)

$0 (1)

methadone hcl tab for oralsusp 40 mg

$0 (1)

methadone hcl tab 10 mg(Dolophine)

$0 (1)

methadone hcl tab 5 mg(Dolophine hcl)

$0 (1)

MORPHINE SULFATE –morphine sulfate tab 15 mg

$0 (2)

MORPHINE SULFATE –morphine sulfate tab 30 mg

$0 (2)

MORPHINE SULFATE –morphine sulfate suppos5 mg

$0 (2)

Name of Drug




$0 (2)


$0 (2)


$0 (2)

morphine sulfate(concentrate) oral soln20 mg/ml

$0 (1)

morphine sulfate beads capsr 24hr 120 mg (Avinza)

$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL

morphine sulfate oral soln10 mg/5ml

$0 (1)

morphine sulfate oral soln20 mg/5ml

$0 (1)

morphine sulfate tab cr100 mg (Ms contin)

$0 (1) QL

morphine sulfate tab cr 15 mg(Ms contin)

$0 (1) QL

morphine sulfate tab cr200 mg (Ms contin)

$0 (1) QL


$0 (1) QL

2015


ST = Step Therapy

53

Name of Drug




$0 (1) QL

OXYCODONE HCL –oxycodone hcl conc100 mg/5ml (20 mg/ml)

$0 (2)

oxycodone hcl cap 5 mg $0 (1)

oxycodone hcl conc100 mg/5ml (20 mg/ml)(Oxycodone hcl)

$0 (1)

oxycodone hcl soln 5 mg/5ml(Oxycodone hcl)

$0 (1)

oxycodone hcl tab 10 mg $0 (1)

oxycodone hcl tab 15 mg(Roxicodone)

$0 (1)

oxycodone hcl tab 20 mg $0 (1)


$0 (1)


$0 (1)

oxycodone w/ acetaminophentab 10-325 mg (Percocet)

$0 (1)

oxycodone w/ acetaminophentab 5-325 mg (Percocet)

$0 (1)

oxycodone w/ acetaminophentab 7.5-325 mg (Percocet)

$0 (1)

oxycodone-aspirin tab4.8355-325 mg (Percodan)

$0 (1)

SUBOXONE – buprenorphinehcl-naloxone hcl sl film2-0.5 mg (base equiv)

$0 (2) PA, QL

SUBOXONE – buprenorphinehcl-naloxone hcl sl film4-1 mg (base equiv)

$0 (2) PA, QL


$0 (2) PA, QL

Name of Drug




$0 (2) PA, QL

tramadol hcl tab sr 24hr100 mg (Ultram er)

$0 (1) QL


$0 (1) QL


$0 (1) QL

tramadol hcl tab 50 mg(Ultram)

$0 (1) QL

tramadol-acetaminophen tab37.5-325 mg (Ultracet)

$0 (1)

RHEUMATOID AND OSTEOARTHRITISCELEBREX – celecoxib cap

50 mg$0 (2) QL, ST

CELEBREX – celecoxib cap100 mg

$0 (2) QL, ST


$0 (2) QL, ST


$0 (2) QL, ST

diclofenac potassium tab50 mg (Cataflam)

$0 (1)

diclofenac sodium tabdelayed release 25 mg

$0 (1)


$0 (1)


$0 (1)

diclofenac sodium tab sr 24hr100 mg (Voltaren-xr)

$0 (1)

ENBREL – etanerceptsubcutaneous soln prefilledsyringe 25 mg/0.5ml

$0 (2) QL, SP, ST

2015


ST = Step Therapy

54

Name of Drug



ENBREL – etanerceptsubcutaneous soln prefilledsyringe 50 mg/ml

$0 (2) QL, SP, ST

ENBREL – etanercept forsubcutaneous inj kit 25 mg

$0 (2) QL, SP, ST

ENBREL SURECLICK –etanercept subcutaneoussolution auto-injector50 mg/ml

$0 (2) QL, SP, ST

etodolac cap 200 mg $0 (1)

etodolac cap 300 mg $0 (1)

etodolac tab sr 24hr 400 mg $0 (1)



etodolac tab 400 mg $0 (1)

etodolac tab 500 mg $0 (1)

flurbiprofen tab 100 mg $0 (1)

flurbiprofen tab 50 mg $0 (1)

HUMIRA – adalimumabprefilled syringe kit10 mg/0.2ml

$0 (2) QL, SP, ST

HUMIRA – adalimumab inj kit20 mg/0.4ml

$0 (2) QL, SP, ST

HUMIRA – adalimumab inj kit40 mg/0.8ml (50 mg/ml)

$0 (2) QL, SP, ST

HUMIRA PEDIATRICCROHNS D – adalimumabinj kit 40 mg/0.8ml (50 mg/ml)

$0 (2) QL, SP, ST

HUMIRA PEN – adalimumabinj kit 40 mg/0.8ml (50 mg/ml)

$0 (2) QL, SP, ST

HUMIRA PEN-CROHNSDISEASE – adalimumab injkit 40 mg/0.8ml (50 mg/ml)

$0 (2) QL, SP, ST

Name of Drug



HUMIRA PEN-PSORIASISSTAR – adalimumab inj kit40 mg/0.8ml (50 mg/ml)

$0 (2) QL, SP, ST

ibuprofen cap 200 mg $0 (3)

ibuprofen susp 100 mg/5ml $0 (1)

ibuprofen susp 100 mg/5ml $0 (3)

ibuprofen tab 200 mg $0 (3)




indomethacin cap 25 mg $0 (1)

indomethacin cap 50 mg $0 (1)

ketoprofen cap 50 mg $0 (1)

ketoprofen cap 75 mg $0 (1)

leflunomide tab 10 mg(Arava)

$0 (1)

leflunomide tab 20 mg(Arava)

$0 (1)

meloxicam tab 15 mg (Mobic) $0 (1)

meloxicam tab 7.5 mg(Mobic)

$0 (1)

nabumetone tab 500 mg $0 (1)

nabumetone tab 750 mg $0 (1)

naproxen sodium tab 220 mg $0 (3)

naproxen sodium tab 275 mg(Anaprox)

$0 (1)

naproxen sodium tab 550 mg(Anaprox ds)

$0 (1)

naproxen susp 125 mg/5ml(Naprosyn)

$0 (1)

naproxen tab ec 375 mg (Ec-naprosyn)

$0 (1)

naproxen tab ec 500 mg (Ec-naprosyn)

$0 (1)

2015


ST = Step Therapy

55

Name of Drug



naproxen tab 250 mg(Naprosyn)

$0 (1)


$0 (1)


$0 (1)

oxaprozin tab 600 mg(Daypro)

$0 (1)

piroxicam cap 10 mg(Feldene)

$0 (1)

piroxicam cap 20 mg(Feldene)

$0 (1)

sulindac tab 150 mg $0 (1)

sulindac tab 200 mg $0 (1)

MIGRAINE HEADACHESIMITREX – sumatriptan nasal

spray 5 mg/act$0 (2) QL

IMITREX – sumatriptan nasalspray 20 mg/act

$0 (2) QL

naratriptan hcl tab 1 mg (baseequiv) (Amerge)

$0 (1) QL

naratriptan hcl tab 2.5 mg(base equiv) (Amerge)

$0 (1) QL

rizatriptan benzoate orallydisintegrating tab 10 mg(Maxalt-mlt)

$0 (1) QL

rizatriptan benzoate orallydisintegrating tab 5 mg(Maxalt-mlt)

$0 (1) QL

rizatriptan benzoate tab10 mg (Maxalt)

$0 (1) QL

rizatriptan benzoate tab 5 mg(Maxalt)

$0 (1) QL

SUMATRIPTAN SUCCINATE– sumatriptan succinate

$0 (2) QL

Name of Drug



solution prefilled syringe6 mg/0.5ml

SUMATRIPTAN SUCCINATE– sumatriptan succinate inj4 mg/0.5ml

$0 (2) QL

sumatriptan succinate inj6 mg/0.5ml (Imitrex)

$0 (1) QL

sumatriptan succinatesolution auto-injector4 mg/0.5ml (Imitrexstatdose sys)

$0 (1) QL

sumatriptan succinatesolution auto-injector6 mg/0.5ml (Imitrexstatdose sys)

$0 (1) QL

sumatriptan succinatesolution cartridge4 mg/0.5ml (Imitrexstatdose ref)

$0 (1) QL

sumatriptan succinatesolution cartridge6 mg/0.5ml (Imitrexstatdose ref)

$0 (1) QL

sumatriptan succinate tab100 mg (Imitrex)

$0 (1) QL


$0 (1) QL


$0 (1) QL

GOUTallopurinol tab 100 mg

(Zyloprim)$0 (1)

allopurinol tab 300 mg(Zyloprim)

$0 (1)

colchicine w/ probenecid tab0.5-500 mg

$0 (1)

probenecid tab 500 mg $0 (1)

2015


ST = Step Therapy

56

Name of Drug



NEUROMUSCULAR DRUGS

SEIZUREScarbamazepine cap sr 12hr

100 mg (Carbatrol)$0 (1)

carbamazepine cap sr 12hr200 mg (Carbatrol)

$0 (1)

carbamazepine cap sr 12hr300 mg (Carbatrol)

$0 (1)

carbamazepine chew tab100 mg

$0 (1)

carbamazepine susp100 mg/5ml (Tegretol)

$0 (1)

carbamazepine tab sr 12hr200 mg (Tegretol-xr)

$0 (1)

carbamazepine tab sr 12hr400 mg (Tegretol-xr)

$0 (1)

carbamazepine tab 200 mg(Tegretol)

$0 (1)

clonazepam tab 0.5 mg(Klonopin)

$0 (1)

clonazepam tab 1 mg(Klonopin)

$0 (1)

clonazepam tab 2 mg(Klonopin)

$0 (1)

DILANTIN – phenytoinsodium extended cap30 mg

$0 (2)

divalproex sodium capsprinkle 125 mg (Depakotesprinkles)

$0 (1)

divalproex sodium tabdelayed release 125 mg(Depakote)

$0 (1)


$0 (1)

Name of Drug




$0 (1)

divalproex sodium tab sr 24hr 250 mg (Depakote er)

$0 (1)

divalproex sodium tab sr 24hr 500 mg (Depakote er)

$0 (1)

ethosuximide cap 250 mg(Zarontin)

$0 (1)

ethosuximide soln250 mg/5ml (Zarontin)

$0 (1)

gabapentin cap 100 mg(Neurontin)

$0 (1)


$0 (1)


$0 (1)

gabapentin oral soln250 mg/5ml (Neurontin)

$0 (1)

gabapentin tab 600 mg(Neurontin)

$0 (1)

gabapentin tab 800 mg(Neurontin)

$0 (1)

lamotrigine tab chewabledispersible 25 mg (Lamictalchewable di)

$0 (1)

lamotrigine tab chewabledispersible 5 mg (Lamictalchewable di)

$0 (1)

lamotrigine tab 100 mg(Lamictal)

$0 (1)


$0 (1)


$0 (1)


$0 (1)

2015


ST = Step Therapy

57

Name of Drug



levetiracetam oral soln100 mg/ml (Keppra)

$0 (1)

levetiracetam tab 1000 mg(Keppra)

$0 (1)


$0 (1)


$0 (1)


$0 (1)

LYRICA – pregabalin cap25 mg

$0 (2)


$0 (2)


$0 (2)


$0 (2)


$0 (2)


$0 (2)


$0 (2)


$0 (2)

oxcarbazepine susp300 mg/5ml (60 mg/ml)(Trileptal)

$0 (1)

oxcarbazepine tab 150 mg(Trileptal)

$0 (1)


$0 (1)


$0 (1)

phenytoin chew tab 50 mg(Dilantin infatabs)

$0 (1)

Name of Drug



phenytoin sodium extendedcap 100 mg (Dilantin)

$0 (1)

phenytoin sodium extendedcap 200 mg (Phenytek)

$0 (1)

phenytoin sodium extendedcap 300 mg (Phenytek)

$0 (1)

phenytoin susp 125 mg/5ml(Dilantin)

$0 (1)

primidone tab 250 mg(Mysoline)

$0 (1)

primidone tab 50 mg(Mysoline)

$0 (1)

TEGRETOL-XR –carbamazepine tab sr 12hr100 mg

$0 (2)

topiramate sprinkle cap15 mg (Topamax sprinkle)

$0 (1)

topiramate sprinkle cap25 mg (Topamax sprinkle)

$0 (1)

topiramate tab 100 mg(Topamax)

$0 (1)


$0 (1)


$0 (1)


$0 (1)

valproate sodium syrup250 mg/5ml (base equiv)(Depakene)

$0 (1)

valproic acid cap 250 mg(Depakene)

$0 (1)

zonisamide cap 100 mg(Zonegran)

$0 (1)

zonisamide cap 25 mg(Zonegran)

$0 (1)

zonisamide cap 50 mg $0 (1)

2015


ST = Step Therapy

58

Name of Drug



PARKINSON'S DISEASEamantadine hcl cap 100 mg $0 (1)

amantadine hcl syrup50 mg/5ml

$0 (1)

AZILECT – rasagilinemesylate tab 0.5 mg (baseequiv)

$0 (2)

AZILECT – rasagilinemesylate tab 1 mg (baseequiv)

$0 (2)

benztropine mesylate tab0.5 mg

$0 (1)

benztropine mesylate tab1 mg

$0 (1)

benztropine mesylate tab2 mg

$0 (1)

bromocriptine mesylate cap5 mg (Parlodel)

$0 (1)

bromocriptine mesylate tab2.5 mg

$0 (1)

carbidopa & levodopaorally disintegrating tab10-100 mg

$0 (1)


$0 (1)


$0 (1)

carbidopa & levodopa tab cr25-100 mg (Sinemet cr)

$0 (1)

carbidopa & levodopa tab cr50-200 mg (Sinemet cr)

$0 (1)

carbidopa & levodopa tab10-100 mg (Sinemet)

$0 (1)


$0 (1)

Name of Drug




$0 (1)

entacapone tab 200 mg(Comtan)

$0 (1)

pramipexole dihydrochloridetab 0.125 mg (Mirapex)

$0 (1)


$0 (1)


$0 (1)


$0 (1)

pramipexole dihydrochloridetab 1 mg (Mirapex)

$0 (1)


$0 (1)

ropinirole hydrochloride tab0.25 mg (Requip)

$0 (1)

ropinirole hydrochloride tab0.5 mg (Requip)

$0 (1)

ropinirole hydrochloride tab1 mg (Requip)

$0 (1)


$0 (1)


$0 (1)


$0 (1)


$0 (1)

selegiline hcl cap 5 mg(Eldepryl)

$0 (1)

selegiline hcl tab 5 mg $0 (1)

trihexyphenidyl hcl elixir0.4 mg/ml

$0 (1)

trihexyphenidyl hcl tab 2 mg $0 (1)

2015


ST = Step Therapy

59

Name of Drug



trihexyphenidyl hcl tab 5 mg $0 (1)

MUSCLE RELAXANTSbaclofen tab 10 mg $0 (1)

baclofen tab 20 mg $0 (1)

chlorzoxazone tab 500 mg(Parafon forte dsc)

$0 (1)

cyclobenzaprine hcl tab10 mg

$0 (1)

cyclobenzaprine hcl tab 5 mg $0 (1)

DANTROLENE SODIUM– dantrolene sodium cap100 mg

$0 (2)

dantrolene sodium cap 25 mg(Dantrium)

$0 (1)

dantrolene sodium cap 50 mg(Dantrium)

$0 (1)

metaxalone tab 800 mg(Skelaxin)

$0 (1)

methocarbamol tab 500 mg(Robaxin)

$0 (1)

methocarbamol tab 750 mg(Robaxin-750)

$0 (1)

orphenadrine citrate tab sr12hr 100 mg

$0 (1)

orphenadrine w/ aspirin &caffeine tab 25-385-30 mg

$0 (1)

tizanidine hcl tab 2 mg $0 (1) QL

tizanidine hcl tab 4 mg(Zanaflex)

$0 (1) QL

OTHER NEUROMUSCULAR DRUGSMESTINON – pyridostigmine

bromide syrup 60 mg/5ml$0 (2)

MESTINON TIMESPAN –pyridostigmine bromide tabcr 180 mg

$0 (2)

Name of Drug



pyridostigmine bromide tab60 mg (Mestinon)

$0 (1)

riluzole tab 50 mg (Rilutek) $0 (1)

SUPPLEMENTS

VITAMINSascorbic acid tab 500 mg $0 (3)

cholecalciferol cap 1000 unit $0 (3)





cholecalciferol chew tab 1000unit

$0 (3)

cholecalciferol chew tab 400unit

$0 (3)

cholecalciferol oral liquid 400unit/ml

$0 (3)

cholecalciferol tab 1000 unit $0 (3)




DECARA – cholecalciferolcap 25000 unit

$0 (3)

DIALYVITE VITAMIN D3MAX – cholecalciferol tab50000 unit

$0 (3)

ergocalciferol cap 50000 unit(Drisdol)

$0 (1)

MEPHYTON – phytonadionetab 5 mg

$0 (2)

niacin cap cr 250 mg $0 (3)

niacin cap cr 500 mg $0 (3)

niacin tab cr 250 mg $0 (3)


2015


ST = Step Therapy

60

Name of Drug




niacin tab 100 mg $0 (3)



NIACIN TR – niacin tab cr1000 mg

$0 (3)

thiamine hcl tab 100 mg $0 (3)



VITAMIN D – cholecalciferolcap 400 unit

$0 (3)

MULTIVITAMINSmultiple vitamin tab $0 (3)

multiple vitamins w/ iron tab $0 (3)

pediatric multiple vitamin w/ c& fa chew tab

$0 (3)

pediatric multiple vitamin w/ csoln 35 mg/ml

$0 (3)

pediatric multiple vitamins w/fl-fe drops 0.25-10 mg/ml

$0 (1)

pediatric multiple vitamins w/fluoride chew tab 0.25 mg

$0 (1)

pediatric multiple vitamins w/fluoride chew tab 0.5 mg

$0 (1)

pediatric multiple vitamins w/fluoride chew tab 1 mg

$0 (1)

pediatric multiple vitamins w/fluoride soln 0.25 mg/ml

$0 (1)

pediatric multiple vitamins w/fluoride soln 0.5 mg/ml

$0 (1)

pediatric vitamins acd w/fluoride soln 0.25 mg/ml

$0 (1)

pediatric vitamins acd w/fluoride soln 0.5 mg/ml

$0 (1)

Name of Drug



pediatric vitamins adc drops1500 unit-400 unit-35 mg/ml

$0 (3)

PRENATALMULTIVITAMINS/FOLICACID

$0 (2)

TRI-VI-SOL – pediatricvitamins adc drops 750unit-400 unit-35 mg/ml

$0 (3)

TRI-VIT/FLUORIDE/IRON– pediatric vitaminsacd fluoride & fe drops0.25-10 mg/ml

$0 (2)

MINERALS AND ELECTROLYTEScalcium carbonate tab

1250 mg (500 mg elementalca)

$0 (3)

calcium carbonate-cholecalciferol tab600 mg-400 unit

$0 (3)

calcium carbonate-vitamin dtab 250 mg-125 unit

$0 (3)


$0 (3)


$0 (3)


$0 (3)

calcium citrate tab 950 mg(200 mg elemental ca)

$0 (3)

calcium citrate-vitamin d tab315 mg-200 unit (elementalca)

$0 (3)

calcium w/ vitamin d tab600 mg-200 unit

$0 (3)

K-PHOS – potassiumphosphate monobasic tab500 mg

$0 (2)

2015


ST = Step Therapy

61

Name of Drug



oral electrolyte solution $0 (3)

pot bicarbonate & chlorideeffer tab 25 meq

$0 (1)

pot phos monobasic w/sodphos di & monobas tab155-852-130mg (K-phosneutral)

$0 (1)

potassium chloride cap cr 10meq (Micro-k)

$0 (1)

potassium chloride cap cr 8meq (Micro-k)

$0 (1)

potassium chloridemicroencapsulated crys crtab 10 meq

$0 (1)

potassium chloridemicroencapsulated crys crtab 20 meq

$0 (1)

potassium chloride oral liq10% (20 meq/15ml)

$0 (1)

potassium chloride powderpacket 20 meq

$0 (1)

potassium chloride tab cr 10meq (K-tab)

$0 (1)

potassium chloride tab cr 8meq (600 mg)

$0 (1)

SODIUM FLUORIDE –sodium fluoride tab 1 mg f(from 2.2 mg naf)

$0 (2)

sodium fluoride chew tab0.25 mg f (from 0.55 mgnaf) (Luride)

$0 (1)

sodium fluoride chew tab0.5 mg f (from 1.1 mg naf)(Luride)

$0 (1)

sodium fluoride chew tab1 mg f (from 2.2 mg naf)(Luride)

$0 (1)

Name of Drug



sodium fluoride soln0.125 mg/drop f (0.275 mg/drop naf)

$0 (1)

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)(Luride)

$0 (1)

OTHER SUPPLEMENTSDIALYVITE OMEGA-3

CONCENT – omega-3 fattyacids cap 600 mg

$0 (3)

docosahexaenoic acid cap200 mg

$0 (3)

MINICAPS OMEGA-3 –omega-3 fatty acids cap350 mg

$0 (3)

OMEGA POWER – omega-3fatty acids cap 1050 mg

$0 (3)

OMEGA-3 – omega-3 fattyacids cap 1400 mg

$0 (3)

omega-3 fatty acids capdelayed release 1000 mg

$0 (3)

omega-3 fatty acids capdelayed release 1200 mg

$0 (3)

omega-3 fatty acids cap1000 mg

$0 (3)


$0 (3)


$0 (3)


$0 (3)

OMEGA-3 IQ – omega-3 fattyacids chew tab 240 mg

$0 (3)

OMEGA-3 2100 – omega-3fatty acids cap 1050 mg

$0 (3)

2015


ST = Step Therapy

62

Name of Drug



PRO NUTRIENTS OMEGA 3– omega-3 fatty acids capdelayed release 332.5 mg

$0 (3)

SYSTANE VITAMINOMEGA-3 H – omega-3fatty acids cap delayedrelease 500 mg

$0 (3)

BLOOD MODIFYING DRUGSAGGRENOX – aspirin-

dipyridamole cap sr 12hr25-200 mg

$0 (2)

ALPROLIX – coagulationfactor ix (recomb) (rfixfc) forinj 500 unit

$0 (2) SP


$0 (2) SP


$0 (2) SP


$0 (2) SP

anagrelide hcl cap 0.5 mg(Agrylin)

$0 (1)

anagrelide hcl cap 1 mg $0 (1)

ARANESP ALBUMINFREE – darbepoetin alfa-polysorbate 80 soln inj25 mcg/ml

$0 (2) PA, SP

ARANESP ALBUMINFREE – darbepoetin alfa-polysorbate 80 soln inj25 mcg/0.42ml

$0 (2) PA, SP

ARANESP ALBUMINFREE – darbepoetin alfa-

$0 (2) PA, SP

Name of Drug



polysorbate 80 soln inj40 mcg/ml


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP

2015


ST = Step Therapy

63

Name of Drug




$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP

cilostazol tab 100 mg (Pletal) $0 (1)

cilostazol tab 50 mg (Pletal) $0 (1)

clopidogrel bisulfate tab75 mg (base equiv) (Plavix)

$0 (1)

cyanocobalamin inj1000 mcg/ml

$0 (1)

cyanocobalamin tab cr1000 mcg

$0 (3)

cyanocobalamin tab cr2000 mcg

$0 (3)

cyanocobalamin tab sl1000 mcg

$0 (3)


$0 (3)


$0 (3)

cyanocobalamin tab 100 mcg $0 (3)

cyanocobalamin tab1000 mcg

$0 (3)



dipyridamole tab 25 mg(Persantine)

$0 (1)

Name of Drug




$0 (1)


$0 (1)

enoxaparin sodium inj100 mg/ml (Lovenox)

$0 (1) QL

enoxaparin sodium inj120 mg/0.8ml (Lovenox)

$0 (1) QL

enoxaparin sodium inj150 mg/ml (Lovenox)

$0 (1) QL


$0 (1) QL

enoxaparin sodium inj300 mg/3ml (Lovenox)

$0 (1) QL


$0 (1) QL


$0 (1) QL


$0 (1) QL

EPOGEN – epoetin alfa inj2000 unit/ml

$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP

ferrous sulfate tab ec 325 mg(65 mg fe equivalent)

$0 (3)

ferrous sulfate tab 325 mg(65 mg elemental fe)

$0 (3)

folic acid tab 1 mg $0 (1)

folic acid tab 400 mcg $0 (3)

2015


ST = Step Therapy

64

Name of Drug



folic acid tab 800 mcg $0 (3)

NEUPOGEN – filgrastim inj300 mcg/ml

$0 (2) SP

NEUPOGEN – filgrastim inj480 mcg/1.6ml (300 mcg/ml)

$0 (2) SP


$0 (2) SP


$0 (2) SP

pentoxifylline tab cr 400 mg $0 (1)

PROCRIT – epoetin alfa inj2000 unit/ml

$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP


$0 (2) PA, SP

TRETTEN – coagulationfactor xiii a-subunit for inj2000-3125 unit

$0 (2) SP

warfarin sodium tab 1 mg(Coumadin)

$0 (1)


$0 (1)


$0 (1)

warfarin sodium tab 2.5 mg(Coumadin)

$0 (1)

Name of Drug




$0 (1)


$0 (1)


$0 (1)


$0 (1)

warfarin sodium tab 7.5 mg(Coumadin)

$0 (1)

XARELTO – rivaroxaban tab10 mg

$0 (2) QL


$0 (2) QL


$0 (2) QL

XARELTO STARTER PACK– rivaroxaban tab startertherapy pack 15 mg &20 mg

$0 (2) QL

TOPICAL DRUGS

EYE

Anti-infectivesBACITRACIN – bacitracin

ophth oint 500 unit/gm$0 (2)

bacitracin-polymyxin b ophthoint

$0 (1)

ciprofloxacin hcl ophth soln0.3% (Ciloxan)

$0 (1)

erythromycin ophth oint 5 mg/gm

$0 (1)

gentamicin sulfate ophth oint0.3%

$0 (1)

gentamicin sulfate ophth soln0.3% (Garamycin)

$0 (1)

2015


ST = Step Therapy

65

Name of Drug



NATACYN – natamycin ophthsusp 5%

$0 (2)

neomycin-bacitraczn-polymyx5(3.5)mg-400unt-10000untop oin

$0 (1)

neomycin-polymy-gramicid opsol 1.75-10000-0.025mg-unt-mg/ml (Neosporin)

$0 (1)

ofloxacin ophth soln 0.3%(Ocuflox)

$0 (1)

polymyxin b-trimethoprimophth soln 10000 unit/ml-0.1% (Polytrim)

$0 (1)

sulfacetamide sodium ophthsoln 10% (Bleph-10)

$0 (1)

tobramycin ophth soln 0.3%(Tobrex)

$0 (1)

trifluridine ophth soln 1%(Viroptic)

$0 (1)

Steroids and Combination Productsbacitracin-polymyxin-

neomycin-hc ophth oint 1%$0 (1)

dexamethasone sodiumphosphate ophth soln 0.1%

$0 (1)

fluorometholone ophth susp0.1% (Fml liquifilm)

$0 (1)

LOTEMAX – loteprednoletabonate ophth susp 0.5%

$0 (2)

neomycin-polymyxin-dexamethasone ophth oint0.1% (Maxitrol)

$0 (1)

neomycin-polymyxin-dexamethasone ophth susp0.1% (Maxitrol)

$0 (1)

prednisolone acetate ophthsusp 1% (Pred forte)

$0 (1)

Name of Drug



PREDNISOLONE SODIUMPHOSP – prednisolonesodium phosphate ophthsoln 1%

$0 (2)

sulfacetamide sodium-prednisolone ophth soln10-0.23(0.25)%

$0 (1)

TOBRADEX – tobramycin-dexamethasone ophth oint0.3-0.1%

$0 (2)

tobramycin-dexamethasoneophth susp 0.3-0.1%(Tobradex)

$0 (1)

ZYLET – loteprednoletabonate-tobramycin ophthsusp 0.5-0.3%

$0 (2)

GlaucomaALPHAGAN P – brimonidine

tartrate ophth soln 0.1%$0 (2)

AZOPT – brinzolamide ophthsusp 1%

$0 (2)

brimonidine tartrate ophthsoln 0.15% (Alphagan p)

$0 (1)

brimonidine tartrate ophthsoln 0.2%

$0 (1)

carteolol hcl ophth soln 1% $0 (1)

dorzolamide hcl ophth soln2% (Trusopt)

$0 (1)

dorzolamide hcl-timololmaleate ophth soln22.3-6.8 mg/ml (Cosopt)

$0 (1)

latanoprost ophth soln0.005% (Xalatan)

$0 (1) QL

levobunolol hcl ophth soln0.5% (Betagan)

$0 (1)

2015


ST = Step Therapy

66

Name of Drug



METIPRANOLOL –metipranolol ophth soln0.3%

$0 (2)

pilocarpine hcl ophth soln 1%(Isopto carpine)

$0 (1)


$0 (1)


$0 (1)

timolol maleate ophth gelforming soln 0.25%(Timoptic-xe)

$0 (1)

timolol maleate ophth gelforming soln 0.5%(Timoptic-xe)

$0 (1)

timolol maleate ophth soln0.25% (Timoptic)

$0 (1)

timolol maleate ophth soln0.5% (Timoptic)

$0 (1)

Other Eye Productsartificial tear ophth solution $0 (3)

ATROPINE SULFATE –atropine sulfate ophth oint1%

$0 (2)

atropine sulfate ophth soln1% (Isopto atropine)

$0 (1)

azelastine hcl ophth soln0.05% (Optivar)

$0 (1)

cromolyn sodium ophth soln4%

$0 (1)

cyclopentolate hcl ophth soln1% (Cyclogyl)

$0 (1)

diclofenac sodium ophth soln0.1%

$0 (1)

flurbiprofen sodium ophthsoln 0.03% (Ocufen)

$0 (1)

Name of Drug



homatropine hbr ophth soln5% (Isopto homatropine)

$0 (1)

ketorolac tromethamine ophthsoln 0.4% (Acular ls)

$0 (1)

ketorolac tromethamine ophthsoln 0.5% (Acular)

$0 (1)

ketotifen fumarate ophth soln0.025% (base equiv)

$0 (3)

NAPHAZOLINE HCL –naphazoline hcl ophth soln0.1%

$0 (2)

naphazoline w/ pheniramineophth soln 0.025-0.3%

$0 (3)

PATADAY – olopatadine hclophth soln 0.2%

$0 (2)

tetrahydroz-dextran-peg-povidone ophth soln0.05-0.1-1-1%

$0 (3)

tropicamide ophth soln 0.5% $0 (1)

tropicamide ophth soln 1%(Mydriacyl)

$0 (1)

EARacetic acid otic soln 2% $0 (1)

antipyrine-benzocaineotic soln 54-14 mg/ml(5.4-1.4%)

$0 (1)

ANTIPYRINE/BENZOCAINE– antipyrine-benzocaineotic soln 55-14 mg/ml(5.5-1.4%)

$0 (2)

carbamide peroxide 6.5% oticsoln

$0 (3)

CIPRODEX – ciprofloxacin-dexamethasone otic susp0.3-0.1%

$0 (2)

2015


ST = Step Therapy

67

Name of Drug



hydrocortisone w/ acetic acidotic soln 1-2% (Vosol hc)

$0 (1)

neomycin-polymyxin-hc oticsoln 1% (Cortisporin)

$0 (1)

neomycin-polymyxin-hc oticsusp 3.5 mg/ml-10000 unit/ml-1%

$0 (1)

ofloxacin otic soln 0.3% $0 (1)

MOUTH AND THROAT (local)cevimeline hcl cap 30 mg

(Evoxac)$0 (1)

chlorhexidine gluconate soln0.12% (Peridex)

$0 (1)

clotrimazole troche 10 mg $0 (1)

lidocaine hcl laryngotrachealsoln 4% (Lta 360 kit)

$0 (1)

lidocaine hcl viscous soln 2% $0 (1)

nystatin susp 100000 unit/ml $0 (1)

pilocarpine hcl tab 5 mg(Salagen)

$0 (1)

pilocarpine hcl tab 7.5 mg(Salagen)

$0 (1)

sodium fluoride cream 1.1%(Prevident 5000 plus)

$0 (1)

sodium fluoride gel 1.1%(0.5% f) (Prevident fluoride)

$0 (1)

triamcinolone acetonidedental paste 0.1%

$0 (1)

ANORECTAL AGENTSCORTIFOAM –

hydrocortisone acetaterectal foam 90 mg/dose

$0 (2)

hydrocortisone enema100 mg/60ml (Cortenema)

$0 (1)

hydrocortisone rectal cream2.5% (Anusol-hc)

$0 (1)

Name of Drug



SKIN CONDITIONS/PRODUCTS

Acneadapalene cream 0.1%

(Differin)$0 (1) QL

adapalene gel 0.1% (Differin) $0 (1) QL

adapalene gel 0.3% (Differin) $0 (1) QL

benzoyl peroxide-erythromycin gel 5-3%(Benzamycin)

$0 (1)

CLARAVIS – isotretinoin cap30 mg

$0 (2)

clindamycin phosph-benzoylperoxide (refrig) gel 1.2(1)-5% (Duac)

$0 (1)

clindamycin phosphate gel1% (Cleocin-t)

$0 (1)

clindamycin phosphate lotion1% (Cleocin-t)

$0 (1)

clindamycin phosphate soln1% (Cleocin-t)

$0 (1)

clindamycin phosphate swab1% (Cleocin-t)

$0 (1)

clindamycin phosphate-benzoyl peroxide gel 1-5%(Benzaclin)

$0 (1)

DIFFERIN – adapalene gel0.3%

$0 (2) QL

DIFFERIN – adapalene lotion0.1%

$0 (2) QL

erythromycin gel 2% (Erygel) $0 (1)

erythromycin pads 2% $0 (1)

erythromycin soln 2% $0 (1)

FINACEA – azelaic acid gel15%

$0 (2)

isotretinoin cap 10 mg $0 (1)

2015


ST = Step Therapy

68

Name of Drug





metronidazole cream 0.75%(Metrocream)

$0 (1)

metronidazole gel 0.75% $0 (1)

metronidazole gel 1%(Metrogel)

$0 (1)

metronidazole lotion 0.75%(Metrolotion)

$0 (1)

sulfacetamide sodium lotion10% (acne) (Klaron)

$0 (1)

sulfacetamide sodium w/sulfur cream 10-5%

$0 (1)

sulfacetamide sodium w/sulfur emulsion 10-5%

$0 (1)

sulfacetamide sodium w/sulfur lotion 10-5%

$0 (1)

TAZORAC – tazarotenecream 0.05%

$0 (2)

TAZORAC – tazarotenecream 0.1%

$0 (2)

TAZORAC – tazarotene gel0.05%

$0 (2)

TAZORAC – tazarotene gel0.1%

$0 (2)

tretinoin cream 0.025%(Retin-a)

$0 (1) QL

tretinoin cream 0.05% (Retin-a)

$0 (1) QL

tretinoin cream 0.1% (Retin-a) $0 (1) QL

tretinoin gel 0.01% (Retin-a) $0 (1) QL

tretinoin gel 0.025% (Retin-a) $0 (1) QL

tretinoin microsphere gel0.04% (Retin-a micro)

$0 (1) QL

tretinoin microsphere gel0.1% (Retin-a micro)

$0 (1) QL

Name of Drug



Anti-infectivesbacitracin oint 500 unit/gm $0 (3)

bacitracin-polymyxin b oint $0 (3)

CENTANY – mupirocin oint2%

$0 (2)

ciclopirox gel 0.77% $0 (1)

ciclopirox olamine cream0.77% (base equiv)

$0 (1)

ciclopirox olamine susp0.77% (base equiv)

$0 (1)

ciclopirox shampoo 1%(Loprox shampoo)

$0 (1)

ciclopirox solution 8% (PenlacNail Lacquer)

$0 (1)

CICLOPIROX TOPICALSOLUTI – ciclopiroxsolution 8% & vitamin e 5%topical kit

$0 (2)

econazole nitrate cream 1% $0 (1)

GENTAMICIN SULFATE– gentamicin sulfate cream0.1%

$0 (2)

GENTAMICIN SULFATE– gentamicin sulfate oint0.1%

$0 (2)

ketoconazole cream 2% $0 (1)

ketoconazole shampoo 2%(Nizoral)

$0 (1)

miconazole nitrate aerosolpow 2%

$0 (3)

miconazole nitrate cream 2% $0 (3)

mupirocin calcium cream 2%(Bactroban)

$0 (1)

mupirocin oint 2%(Bactroban)

$0 (1)

2015


ST = Step Therapy

69

Name of Drug



neomycin-bacitracin-polymyxin oint

$0 (3)

nystatin cream 100000 unit/gm

$0 (1)

nystatin oint 100000 unit/gm $0 (1)

nystatin topical powder $0 (1)

silver sulfadiazine cream 1%(Silvadene)

$0 (1)

tolnaftate aerosol 1% $0 (3)

ZOVIRAX – acyclovir cream5%

$0 (2)

Corticosteroidsalclometasone dipropionate

cream 0.05% (Aclovate)$0 (1)

alclometasone dipropionateoint 0.05%

$0 (1)

betamethasone dipropionateaugmented cream 0.05%(Diprolene af)

$0 (1)

betamethasone dipropionateaugmented gel 0.05%

$0 (1)

betamethasone dipropionateaugmented lotion 0.05%(Diprolene)

$0 (1)

betamethasone dipropionateaugmented oint 0.05%(Diprolene)

$0 (1)

betamethasone dipropionatecream 0.05%

$0 (1)

betamethasone dipropionatelotion 0.05%

$0 (1)

betamethasone dipropionateoint 0.05%

$0 (1)

betamethasone valeratecream 0.1%

$0 (1)

Name of Drug



betamethasone valeratelotion 0.1%

$0 (1)

betamethasone valerate oint0.1%

$0 (1)

clobetasol propionate cream0.05% (Temovate)

$0 (1)

clobetasol propionateemollient base cream0.05% (Temovate e)

$0 (1)

clobetasol propionate foam0.05% (Olux)

$0 (1)

clobetasol propionate gel0.05% (Temovate)

$0 (1)

clobetasol propionate oint0.05% (Temovate)

$0 (1)

clobetasol propionate soln0.05% (Temovate)

$0 (1)

desonide cream 0.05%(Desowen)

$0 (1)

desonide lotion 0.05%(Desowen)

$0 (1)

desonide oint 0.05%(Desowen)

$0 (1)

DESOXIMETASONE –desoximetasone cream0.05%

$0 (2)

desoximetasone cream0.25% (Topicort)

$0 (1)

desoximetasone gel 0.05%(Topicort)

$0 (1)

desoximetasone oint 0.25%(Topicort)

$0 (1)

diflorasone diacetate oint0.05%

$0 (1)

EPIFOAM – pramoxine-hcaerosol foam 1-1%

$0 (2)

2015


ST = Step Therapy

70

Name of Drug



fluocinolone acetonide cream0.01%

$0 (1)

fluocinolone acetonide cream0.025% (Synalar)

$0 (1)

fluocinolone acetonide oil0.01% (body oil) (Derma-smoothe/fs bod)

$0 (1)

fluocinolone acetonide oil0.01% (scalp oil) (Derma-smoothe/fs sca)

$0 (1)

fluocinolone acetonide oint0.025% (Synalar)

$0 (1)

fluocinolone acetonide soln0.01% (Synalar)

$0 (1)

fluocinonide cream 0.05% $0 (1)

fluocinonide emulsified basecream 0.05%

$0 (1)

fluocinonide gel 0.05% $0 (1)

fluocinonide oint 0.05% $0 (1)

fluocinonide soln 0.05% $0 (1)

fluticasone propionate cream0.05% (Cutivate)

$0 (1)

fluticasone propionate oint0.005% (Cutivate)

$0 (1)

halobetasol propionate cream0.05% (Ultravate)

$0 (1)

halobetasol propionate oint0.05% (Ultravate)

$0 (1)

hydrocortisone cream 0.5% $0 (3)

hydrocortisone cream 1% $0 (3)

hydrocortisone cream 2.5% $0 (1)

hydrocortisone lotion 2.5% $0 (1)

hydrocortisone oint 0.5% $0 (3)

hydrocortisone oint 1% $0 (3)

hydrocortisone oint 2.5% $0 (1)

Name of Drug



hydrocortisone valeratecream 0.2%

$0 (1)

hydrocortisone valerate oint0.2% (Westcort)

$0 (1)

mometasone furoate cream0.1% (Elocon)

$0 (1)

mometasone furoate oint0.1% (Elocon)

$0 (1)

mometasone furoate solution0.1% (lotion) (Elocon)

$0 (1)

nystatin-triamcinolone cream100000-0.1 unit/gm-%

$0 (1)

nystatin-triamcinolone oint100000-0.1 unit/gm-%

$0 (1)

triamcinolone acetonidecream 0.025%

$0 (1)


$0 (1)


$0 (1)

triamcinolone acetonide lotion0.025%

$0 (1)

triamcinolone acetonide lotion0.1%

$0 (1)

triamcinolone acetonide oint0.025%

$0 (1)

triamcinolone acetonide oint0.1%

$0 (1)

Other Skin Productsacitretin cap 10 mg

(Soriatane)$0 (1)

acitretin cap 17.5 mg(Soriatane)

$0 (1)

acitretin cap 25 mg(Soriatane)

$0 (1)

2015


ST = Step Therapy

71

Name of Drug



aluminum chloride soln 20%(Drysol)

$0 (1)

CALAMINE – calamine lotion $0 (3)

calcipotriene cream 0.005%(Dovonex)

$0 (1)

calcipotriene oint 0.005% $0 (1)

calcipotriene soln 0.005%(50 mcg/ml)

$0 (1)

CEM-UREA – urea soln 45% $0 (2)

diclofenac sodium (actinickeratoses) gel 3%(Solaraze)

$0 (1)

ELIDEL – pimecrolimuscream 1%

$0 (2)

fluorouracil cream 5%(Efudex)

$0 (1)

fluorouracil soln 2% $0 (1)

fluorouracil soln 5% $0 (1)

imiquimod cream 5% (Aldara) $0 (1) QL

lactic acid (ammoniumlactate) lotion 12% (Lac-hydrin)

$0 (3)

lidocaine hcl gel 2% $0 (1)

lidocaine hcl soln 4%(Xylocaine)

$0 (1)

lidocaine oint 5% $0 (1)

lidocaine patch 5%(Lidoderm)

$0 (1)

lidocaine-prilocaine cream2.5-2.5% (Emla)

$0 (1)

lindane lotion 1% $0 (1)

lindane shampoo 1% $0 (1)

malathion lotion 0.5% (Ovide) $0 (1)

permethrin cream 5%(Elimite)

$0 (1)

Name of Drug



permethrin creme rinse 1% $0 (3)

permethrin lotion 1% $0 (3)

podofilox soln 0.5%(Condylox)

$0 (1)

PROTOPIC – tacrolimus oint0.03%

$0 (2)

PROTOPIC – tacrolimus oint0.1%

$0 (2)

QC CALAMINE – calaminelotion

$0 (3)

selenium sulfide lotion 2.5% $0 (1)

SM CALAMINE – calaminelotion

$0 (3)

VALCHLOR –mechlorethamine hcl gel0.016% (base equivalent)

$0 (2) SP

vitamins a & d oint $0 (3)

zinc oxide oint 10% $0 (3)



ZYCLARA – imiquimod cream3.75%

$0 (2) QL

ZYCLARA PUMP –imiquimod cream 2.5%

$0 (2) QL

ZYCLARA PUMP –imiquimod cream 3.75%

$0 (2) QL

MISCELLANEOUS CATEGORIES (includes suppliesand devices)

DIABETIC SUPPLIESALCOHOL PREP PADS,

SWABS – various$0 (3)

BAYER Blood GlucoseMonitoring System –BREEZE 2, CONTOUR,

$0 (3)

2015


ST = Step Therapy

72

Name of Drug



COUNTOUR NEXT/EZ/LINK/USB

Blood Glucose MonitoringSystem – various

$0 (3)

CALIBRATION LIQUID –ACCU-CHEK ACTIVE,AVIVA, COMFORTCURVE, COMPACT,INSTANT, SMARTVIEW;ACCUTREND

$0 (2)

CALIBRATION LIQUID– BAYER BREEZE 2,CONTOUR

$0 (2)

CHEMSTRIP-K, UGK $0 (2)

INSULIN PEN NEEDLES –VARIOUS

$0 (2) QL

INSULIN SYRINGES –VARIOUS

$0 (2) QL

LANCETS – VARIOUS $0 (2)

ROCHE Blood GlucoseMonitoring System –ACCU-CHEK AVIVAPLUS/COMPACT/NANOSMARTVIEW

$0 (3)

TEST STRIPS – BAYERASCENSIA AUTODISC,BREEZE 2, CONTOUR,CONTOUR NEXT

$0 (2) QL

TEST STRIPS – ROCHEACCU-CHEK ACTIVE,AVIVA, AVIVA PLUS,COMFORT CURVE,COMPACT, SMARTVIEW

$0 (2) QL

TEST STRIPS – ROCHEACCUTREND

$0 (2) QL

RESPIRATORY INHALER-ASSIST DEVICES

Name of Drug



PEAK FLOW METER –various

$0 (3)

RESPIRATORY THERAPYSUPPLIES – various

$0 (3)

SPACER/AEROSOL-HOLDING CHAMBERS –VARIOUS

$0 (2)

SPACER/AEROSOL-HOLDING CHAMBERS –various

$0 (3)

MISCELLANEOUS DRUGSazathioprine tab 50 mg

(Imuran)$0 (1)

CELLCEPT – mycophenolatemofetil for oral susp200 mg/ml

$0 (2)

CHEMET – succimer cap100 mg

$0 (2)

CUPRIMINE – penicillaminecap 250 mg

$0 (2) SP

cyclosporine cap 100 mg(Sandimmune)

$0 (1)

cyclosporine cap 25 mg(Sandimmune)

$0 (1)

CYCLOSPORINE MODIFIED– cyclosporine modified cap50 mg

$0 (2)

cyclosporine modified cap100 mg (Neoral)

$0 (1)

cyclosporine modified cap25 mg (Neoral)

$0 (1)

cyclosporine modified oralsoln 100 mg/ml (Neoral)

$0 (1)

mycophenolate mofetil cap250 mg (Cellcept)

$0 (1)

2015


ST = Step Therapy

73

Name of Drug



mycophenolate mofetilfor oral susp 200 mg/ml(Cellcept)

$0 (1)

mycophenolate mofetil tab500 mg (Cellcept)

$0 (1)

mycophenolate sodium tab dr180 mg (mycophenolic acidequiv) (Myfortic)

$0 (1)

mycophenolate sodium tab dr360 mg (mycophenolic acidequiv) (Myfortic)

$0 (1)

naloxone hcl inj 0.4 mg/ml $0 (1)

REVLIMID – lenalidomidecaps 2.5 mg

$0 (2) PA, QL, SP

REVLIMID – lenalidomide cap5 mg

$0 (2) PA, QL, SP


$0 (2) PA, QL, SP


$0 (2) PA, QL, SP


$0 (2) PA, QL, SP


$0 (2) PA, QL, SP

sirolimus tab 0.5 mg(Rapamune)

$0 (1)

sirolimus tab 1 mg(Rapamune)

$0 (1)

sirolimus tab 2 mg(Rapamune)

$0 (1)

sodium polystyrene sulfonateoral susp 15 gm/60ml (Sps)

$0 (1)

sodium polystyrene sulfonatepowder (Kayexalate)

$0 (1)

tacrolimus cap 0.5 mg(Prograf)

$0 (1)

Name of Drug



tacrolimus cap 1 mg (Prograf) $0 (1)

tacrolimus cap 5 mg (Prograf) $0 (1)

THALOMID – thalidomide cap50 mg

$0 (2) PA, QL, SP


$0 (2) PA, QL, SP


$0 (2) PA, QL, SP

ZORTRESS – everolimus tab0.25 mg

$0 (2)


$0 (2)


$0 (2)

2015

74

INDEX

A

abacavir sulfate-lamivudine-zidovudine tab300-150-300 mg (Trizivir).......................................... 6

abacavir sulfate tab 300 mg (base equiv)(Ziagen)........................................................................ 6

acamprosate calcium tab delayed release 333 mg(Campral)................................................................... 49

acarbose tab 100 mg (Precose)................................ 17acarbose tab 25 mg (Precose).................................. 17acarbose tab 50 mg (Precose).................................. 17acebutolol hcl cap 200 mg (Sectral)..........................24acebutolol hcl cap 400 mg (Sectral)..........................24acetaminophen cap 500 mg.......................................50acetaminophen chew tab 160 mg............................. 50acetaminophen chew tab 80 mg................................50acetaminophen dispersible tab 80 mg...................... 50acetaminophen elixir 160 mg/5ml..............................50acetaminophen liquid 160 mg/5ml.............................50acetaminophen soln 100 mg/ml.................................50acetaminophen soln 160 mg/5ml...............................50acetaminophen suppos 120 mg................................ 50acetaminophen susp 160 mg/5ml............................. 50acetaminophen susp 80 mg/0.8ml............................ 50acetaminophen tab 325 mg........................................50acetaminophen tab 500 mg........................................50acetaminophen w/ codeine soln 120-12

mg/5ml........................................................................51acetaminophen w/ codeine tab 300-15 mg (Tylenol/

codeine)......................................................................51acetaminophen w/ codeine tab 300-30 mg (Tylenol/

codeine #3)................................................................51acetaminophen w/ codeine tab 300-60 mg (Tylenol/

codeine #4)................................................................51ACETAZOLAMIDE – acetazolamide tab 125

mg............................................................................... 28acetazolamide cap sr 12hr 500 mg

(Diamox).....................................................................28acetazolamide tab 250 mg......................................... 28acetic acid otic soln 2%..............................................66acetylcysteine inhal soln 10%....................................33acetylcysteine inhal soln 20%....................................33acitretin cap 10 mg (Soriatane)................................. 70acitretin cap 17.5 mg (Soriatane).............................. 70acitretin cap 25 mg (Soriatane)................................. 70acyclovir cap 200 mg (Zovirax)....................................6acyclovir susp 200 mg/5ml (Zovirax)...........................6acyclovir tab 400 mg (Zovirax).....................................6acyclovir tab 800 mg (Zovirax).....................................6adapalene cream 0.1% (Differin)...............................67

adapalene gel 0.1% (Differin).................................... 67adapalene gel 0.3% (Differin).................................... 67ADCIRCA – tadalafil tab 20 mg (pah).......................30adefovir dipivoxil tab 10 mg (Hepsera)....................... 5ADVAIR DISKUS – fluticasone-salmeterol aer

powder ba 100-50 mcg/dose.................................. 34ADVAIR DISKUS – fluticasone-salmeterol aer

powder ba 250-50 mcg/dose.................................. 34ADVAIR DISKUS – fluticasone-salmeterol aer

powder ba 500-50 mcg/dose.................................. 34ADVAIR HFA – fluticasone-salmeterol inhal aerosol

115-21 mcg/act......................................................... 34ADVAIR HFA – fluticasone-salmeterol inhal aerosol

230-21 mcg/act......................................................... 34ADVAIR HFA – fluticasone-salmeterol inhal aerosol

45-21 mcg/act........................................................... 34AFINITOR DISPERZ – everolimus tab for oral susp

2 mg............................................................................10AFINITOR DISPERZ – everolimus tab for oral susp

3 mg............................................................................10AFINITOR DISPERZ – everolimus tab for oral susp

5 mg............................................................................10AFINITOR – everolimus tab 10 mg...........................10AFINITOR – everolimus tab 2.5 mg..........................10AFINITOR – everolimus tab 5 mg............................. 10AFINITOR – everolimus tab 7.5 mg..........................10AGGRENOX – aspirin-dipyridamole cap sr 12hr

25-200 mg................................................................. 62ALBENZA – albendazole tab 200 mg......................... 9albuterol sulfate soln nebu 0.083% (2.5

mg/3ml)...................................................................... 34albuterol sulfate soln nebu 0.5% (5 mg/

ml)............................................................................... 34albuterol sulfate soln nebu 0.63 mg/3ml (base

equiv)..........................................................................34albuterol sulfate soln nebu 1.25 mg/3ml (base

equiv)..........................................................................34albuterol sulfate syrup 2 mg/5ml................................34albuterol sulfate tab 2 mg...........................................34albuterol sulfate tab 4 mg...........................................34alclometasone dipropionate cream 0.05%

(Aclovate)...................................................................69alclometasone dipropionate oint

0.05%..........................................................................69ALCOHOL PREP PADS, SWABS –

various........................................................................71ALENDRONATE SODIUM – alendronate sodium tab

40 mg......................................................................... 20alendronate sodium tab 10 mg.................................. 20alendronate sodium tab 35 mg.................................. 20alendronate sodium tab 5 mg.................................... 20

2015

75

alendronate sodium tab 70 mg(Fosamax)..................................................................20

alfuzosin hcl tab sr 24hr 10 mg(Uroxatral).................................................................. 41

ALKERAN – melphalan tab 2 mg..............................10allopurinol tab 100 mg (Zyloprim)..............................55allopurinol tab 300 mg (Zyloprim)..............................55ALPHAGAN P – brimonidine tartrate ophth soln

0.1%............................................................................65alprazolam tab 0.25 mg (Xanax)............................... 42alprazolam tab 0.5 mg (Xanax)................................. 42alprazolam tab 1 mg (Xanax).....................................42alprazolam tab 2 mg (Xanax).....................................42alprazolam tab sr 24hr 0.5 mg (Xanax

xr)................................................................................ 41alprazolam tab sr 24hr 1 mg (Xanax



xr)................................................................................ 41ALPROLIX – coagulation factor ix (recomb) (rfixfc)

for inj 1000 unit.........................................................62ALPROLIX – coagulation factor ix (recomb) (rfixfc)



for inj 500 unit...........................................................62alum & mag hydroxide-simethicone susp 200-200-20

mg/5ml........................................................................37alum & mag hydroxide-simethicone susp 400-400-40

mg/5ml........................................................................37aluminum chloride soln 20% (Drysol)....................... 71amantadine hcl cap 100 mg.......................................58amantadine hcl syrup 50 mg/5ml.............................. 58AMETHYST – levonorgestrel-ethinyl estradiol

(continuous) tab 90-20 mcg.................................... 14amiloride & hydrochlorothiazide tab 5-50

mg............................................................................... 29amiloride hcl tab 5 mg................................................ 29amiodarone hcl tab 100 mg....................................... 29amiodarone hcl tab 200 mg

(Cordarone)............................................................... 29amiodarone hcl tab 400 mg....................................... 30amitriptyline hcl tab 100 mg....................................... 42amitriptyline hcl tab 10 mg......................................... 42amitriptyline hcl tab 150 mg....................................... 42amitriptyline hcl tab 25 mg......................................... 42amitriptyline hcl tab 50 mg......................................... 42amitriptyline hcl tab 75 mg......................................... 42

amlodipine besylate-atorvastatin calcium tab 10-10mg (Caduet).............................................................. 30




amlodipine besylate-atorvastatin calcium tab 2.5-10mg (Caduet).............................................................. 30







amlodipine besylate-benazepril hcl cap 10-20 mg(Lotrel)........................................................................ 25


amlodipine besylate-benazepril hcl cap 2.5-10 mg(Lotrel)........................................................................ 25




amlodipine besylate tab 10 mg(Norvasc)....................................................................25

amlodipine besylate tab 2.5 mg(Norvasc)....................................................................25

amlodipine besylate tab 5 mg(Norvasc)....................................................................25

amlodipine besylate-valsartan tab 10-160 mg(Exforge).................................................................... 26




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

mg/5ml..........................................................................1

2015

76

amoxicillin (trihydrate) for susp 200mg/5ml..........................................................................1



amoxicillin (trihydrate) tab 500 mg.............................. 1amoxicillin (trihydrate) tab 875 mg.............................. 1amoxicillin & k clavulanate chew tab 200-28.5

mg................................................................................. 1amoxicillin & k clavulanate chew tab 400-57

mg................................................................................. 1amoxicillin & k clavulanate for susp 200-28.5

mg/5ml..........................................................................1amoxicillin & k clavulanate for susp 250-62.5 mg/5ml

(Augmentin)................................................................. 1amoxicillin & k clavulanate for susp 400-57

mg/5ml..........................................................................1amoxicillin & k clavulanate for susp 600-42.9 mg/5ml

(Augmentin es-600)....................................................1amoxicillin & k clavulanate tab 250-125

mg................................................................................. 1amoxicillin & k clavulanate tab 500-125 mg

(Augmentin)................................................................. 1amoxicillin & k clavulanate tab 875-125 mg

(Augmentin)................................................................. 1amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg

(Augmentin xr).............................................................1AMOXICILLIN – amoxicillin (trihydrate) chew tab 125

mg................................................................................. 1AMOXICILLIN – amoxicillin (trihydrate) chew tab 250

mg................................................................................. 1amphetamine-dextroamphetamine cap sr 24hr 10

mg (Adderall xr)........................................................ 47amphetamine-dextroamphetamine cap sr 24hr 15




mg (Adderall xr)........................................................ 47amphetamine-dextroamphetamine cap sr 24hr 5 mg

(Adderall xr)...............................................................47amphetamine-dextroamphetamine tab 10 mg

(Adderall)....................................................................47amphetamine-dextroamphetamine tab 12.5 mg

(Adderall)....................................................................47amphetamine-dextroamphetamine tab 15 mg

(Adderall)....................................................................47amphetamine-dextroamphetamine tab 20 mg

(Adderall)....................................................................47

amphetamine-dextroamphetamine tab 30 mg(Adderall)....................................................................47

amphetamine-dextroamphetamine tab 5 mg(Adderall)....................................................................47

amphetamine-dextroamphetamine tab 7.5 mg(Adderall)....................................................................47

ampicillin cap 250 mg................................................... 1ampicillin cap 500 mg................................................... 1anagrelide hcl cap 0.5 mg (Agrylin)...........................62anagrelide hcl cap 1 mg............................................. 62anastrozole tab 1 mg (Arimidex)................................10ANDRODERM – testosterone td patch 24hr 2

mg/24hr...................................................................... 13ANDRODERM – testosterone td patch 24hr 4

mg/24hr...................................................................... 13ANTIPYRINE/BENZOCAINE – antipyrine-

benzocaine otic soln 55-14 mg/ml(5.5-1.4%).................................................................. 66

antipyrine-benzocaine otic soln 54-14 mg/ml(5.4-1.4%).................................................................. 66

APTIVUS – tipranavir cap 250 mg.............................. 6APTIVUS – tipranavir oral soln 100 mg/

ml...................................................................................6ARANESP ALBUMIN FREE – darbepoetin

alfa-polysorbate 80 soln inj 100mcg/0.5ml.................................................................. 62

ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 100 mcg/ml........................62

ARANESP ALBUMIN FREE – darbepoetinalfa-polysorbate 80 soln inj 150mcg/0.3ml.................................................................. 62

ARANESP ALBUMIN FREE – darbepoetinalfa-polysorbate 80 soln inj 150mcg/0.75ml................................................................ 62



ARANESP ALBUMIN FREE – darbepoetinalfa-polysorbate 80 soln inj 25mcg/0.42ml................................................................ 62

ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 25 mcg/ml..........................62



ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 40 mcg/0.4ml.....................62

2015

77



ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 60 mcg/0.3ml.....................62


artificial tear ophth solution ....................................... 66ASACOL HD – mesalamine tab delayed release 800

mg............................................................................... 40ascorbic acid tab 500 mg........................................... 59ASMANEX TWISTHALER 120 ME – mometasone

furoate inhal powd 220 mcg/inh (breathactivated)....................................................................34

ASMANEX TWISTHALER 14 MET – mometasonefuroate inhal powd 220 mcg/inh (breathactivated)....................................................................34

ASMANEX TWISTHALER 30 ME – mometasonefuroate inhal powd 220 mcg/inh (breathactivated)....................................................................35



ASMANEX TWISTHALER 7 METE – mometasonefuroate inhal powd 110 mcg/inh (breathactivated)....................................................................35

aspirin chew tab 81 mg.............................................. 50aspirin tab 325 mg.......................................................51aspirin tab delayed release 325 mg.......................... 51aspirin tab delayed release 81 mg............................ 51ASTEPRO – azelastine hcl nasal spray 0.15%

(205.5 mcg/spray).....................................................32atenolol & chlorthalidone tab 100-25 mg (Tenoretic

100).............................................................................24atenolol & chlorthalidone tab 50-25 mg (Tenoretic

50)...............................................................................24atenolol tab 100 mg (Tenormin)................................ 24atenolol tab 25 mg (Tenormin)...................................24atenolol tab 50 mg (Tenormin)...................................24atorvastatin calcium tab 10 mg (base equivalent)

(Lipitor)....................................................................... 27atorvastatin calcium tab 20 mg (base equivalent)



(Lipitor)....................................................................... 27

atovaquone-proguanil hcl tab 250-100 mg(Malarone)....................................................................9

atovaquone-proguanil hcl tab 62.5-25 mg(Malarone)....................................................................9

ATRIPLA – efavirenz-emtricitabine-tenofovir df tab600-200-300 mg..........................................................6

ATROPINE SULFATE – atropine sulfate ophth oint1%...............................................................................66

atropine sulfate ophth soln 1% (Isoptoatropine)..................................................................... 66

ATROVENT HFA – ipratropium bromide hfa inhalaerosol 17 mcg/act...................................................35

AVODART – dutasteride cap 0.5 mg........................ 41AXID AR – nizatidine tab 75 mg................................37azathioprine tab 50 mg (Imuran)............................... 72azelastine hcl nasal spray 0.15% (205.5 mcg/spray)

(Astepro).................................................................... 32azelastine hcl nasal spray 137 mcg/spray (1 mg/

ml)............................................................................... 32azelastine hcl ophth soln 0.05%

(Optivar)..................................................................... 66AZILECT – rasagiline mesylate tab 0.5 mg (base

equiv)..........................................................................58AZILECT – rasagiline mesylate tab 1 mg (base

equiv)..........................................................................58AZITHROMYCIN – azithromycin powd pack for susp

1 gm..............................................................................2azithromycin for susp 100 mg/5ml

(Zithromax)...................................................................2azithromycin for susp 200 mg/5ml

(Zithromax)...................................................................2azithromycin tab 250 mg (Zithromax)..........................2azithromycin tab 500 mg (Zithromax)..........................2azithromycin tab 600 mg (Zithromax)..........................2AZOPT – brinzolamide ophth susp 1%.....................65

B

BACITRACIN – bacitracin ophth oint 500 unit/gm............................................................................... 64

bacitracin oint 500 unit/gm......................................... 68bacitracin-polymyxin b oint ........................................68bacitracin-polymyxin b ophth oint.............................. 64bacitracin-polymyxin-neomycin-hc ophth oint

1%...............................................................................65baclofen tab 10 mg......................................................59baclofen tab 20 mg......................................................59balsalazide disodium cap 750 mg

(Colazal).....................................................................40BARACLUDE – entecavir oral soln 0.05 mg/

ml...................................................................................5BARACLUDE – entecavir tab 0.5 mg..........................5BARACLUDE – entecavir tab 1 mg.............................5

2015

78

BAYER Blood Glucose Monitoring System –BREEZE 2, CONTOUR, COUNTOUR NEXT/EZ/LINK/USB...................................................................71

benazepril & hydrochlorothiazide tab 10-12.5 mg(Lotensin hct)............................................................ 22

benazepril & hydrochlorothiazide tab 20-12.5 mg(Lotensin hct)............................................................ 22

benazepril & hydrochlorothiazide tab 20-25 mg(Lotensin hct)............................................................ 22

benazepril & hydrochlorothiazide tab 5-6.25mg............................................................................... 22

benazepril hcl tab 10 mg (Lotensin)..........................22benazepril hcl tab 20 mg (Lotensin)..........................22benazepril hcl tab 40 mg (Lotensin)..........................22benazepril hcl tab 5 mg.............................................. 22benzoyl peroxide-erythromycin gel 5-3%

(Benzamycin).............................................................67benztropine mesylate tab 0.5 mg.............................. 58benztropine mesylate tab 1 mg................................. 58benztropine mesylate tab 2 mg................................. 58betamethasone dipropionate augmented cream

0.05% (Diprolene af)................................................69betamethasone dipropionate augmented gel

0.05%..........................................................................69betamethasone dipropionate augmented lotion

0.05% (Diprolene).....................................................69betamethasone dipropionate augmented oint 0.05%

(Diprolene)................................................................. 69betamethasone dipropionate cream

0.05%..........................................................................69betamethasone dipropionate lotion

0.05%..........................................................................69betamethasone dipropionate oint

0.05%..........................................................................69betamethasone valerate cream 0.1%....................... 69betamethasone valerate lotion 0.1%.........................69betamethasone valerate oint 0.1%............................69BETASERON – interferon beta-1b for inj kit 0.3

mg............................................................................... 49BEYAZ – drospirenone-ethinyl estrad-levomefolate

tab 3-0.02-0.451 mg.................................................14bicalutamide tab 50 mg (Casodex)........................... 10BILTRICIDE – praziquantel tab 600 mg..................... 9bisacodyl tab delayed release 5 mg..........................36bismuth subsalicylate susp 262

mg/15ml......................................................................37bisoprolol & hydrochlorothiazide tab 10-6.25 mg

(Ziac)...........................................................................24bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg

(Ziac)...........................................................................24bisoprolol & hydrochlorothiazide tab 5-6.25 mg

(Ziac)...........................................................................24

bisoprolol fumarate tab 10 mg(Zebeta)......................................................................24

bisoprolol fumarate tab 5 mg (Zebeta)......................24Blood Glucose Monitoring System –

various........................................................................72BREVICON-28 – norethindrone & ethinyl estradiol

tab 0.5 mg-35 mcg...................................................14brimonidine tartrate ophth soln 0.15% (Alphagan

p)................................................................................. 65brimonidine tartrate ophth soln 0.2%........................ 65BROHIST D – brompheniramine & phenylephrine

tab 4-10 mg...............................................................33bromocriptine mesylate cap 5 mg

(Parlodel)....................................................................58bromocriptine mesylate tab 2.5 mg........................... 58brompheniramine & phenylephrine elixir 1-2.5

mg/5ml........................................................................33brompheniramine & phenylephrine liqd 4-10

mg/5ml........................................................................33brompheniramine & phenylephrine susp 6-10

mg/5ml........................................................................33budesonide cap sr 24hr 3 mg (Entocort

ec)............................................................................... 12budesonide inhalation susp 0.25 mg/2ml

(Pulmicort)..................................................................35budesonide inhalation susp 0.5 mg/2ml

(Pulmicort)..................................................................35bumetanide tab 0.5 mg...............................................29bumetanide tab 1 mg.................................................. 29bumetanide tab 2 mg.................................................. 29buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg

(base equiv)...............................................................51buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base

equiv)..........................................................................51buprenorphine hcl sl tab 2 mg (base

equiv)..........................................................................51buprenorphine hcl sl tab 8 mg (base

equiv)..........................................................................51bupropion hcl (smoking deterrent) tab sr 12hr 150

mg (Zyban)................................................................ 49bupropion hcl tab 100 mg (Wellbutrin)......................42bupropion hcl tab 75 mg (Wellbutrin)........................ 42bupropion hcl tab sr 12hr 100 mg (Wellbutrin

sr)................................................................................ 42bupropion hcl tab sr 12hr 150 mg (Wellbutrin



xl).................................................................................42bupropion hcl tab sr 24hr 300 mg (Wellbutrin

xl).................................................................................42

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79

buspirone hcl tab 10 mg.............................................42buspirone hcl tab 15 mg.............................................42buspirone hcl tab 30 mg.............................................42buspirone hcl tab 5 mg............................................... 42butalbital-acetaminophen-caffeine cap 50-325-40

mg............................................................................... 51butalbital-acetaminophen-caffeine tab 50-325-40 mg

(Esgic)........................................................................ 51butalbital-acetaminophen tab 50-325

mg............................................................................... 51butalbital-aspirin-caffeine cap 50-325-40 mg

(Fiorinal)..................................................................... 51butalbital-aspirin-caff w/ codeine cap 50-325-40-30

mg (Fiorinal/codeine #3)..........................................51

C

cabergoline tab 0.5 mg............................................... 20caffeine citrate oral soln 60 mg/3ml (10 mg/ml base

equiv) (Cafcit)............................................................47CALAMINE – calamine lotion.....................................71calcipotriene cream 0.005%

(Dovonex).................................................................. 71calcipotriene oint 0.005%........................................... 71calcipotriene soln 0.005% (50 mcg/ml).....................71calcitonin (salmon) nasal soln 200 unit/act

(Miacalcin)..................................................................20calcitriol cap 0.25 mcg (Rocaltrol)............................. 20calcitriol cap 0.5 mcg (Rocaltrol)............................... 20calcitriol oral soln 1 mcg/ml (Rocaltrol)..................... 21calcium acetate (phosphate binder) cap 667 mg (169

mg ca) (Phoslo)........................................................ 40calcium acetate (phosphate binder) tab 667 mg

(Eliphos)..................................................................... 40calcium carbonate (antacid) chew tab 1000

mg............................................................................... 37calcium carbonate (antacid) chew tab 500

mg............................................................................... 37calcium carbonate (antacid) chew tab 750

mg............................................................................... 37calcium carbonate-cholecalciferol tab 600 mg-400

unit.............................................................................. 60calcium carbonate tab 1250 mg (500 mg elemental

ca)............................................................................... 60calcium carbonate-vitamin d tab 250 mg-125

unit.............................................................................. 60calcium carbonate-vitamin d tab 500 mg-200



unit.............................................................................. 60calcium citrate tab 950 mg (200 mg elemental

ca)............................................................................... 60

calcium citrate-vitamin d tab 315 mg-200 unit(elemental ca)........................................................... 60

calcium w/ vitamin d tab 600 mg-200unit.............................................................................. 60

CALIBRATION LIQUID – ACCU-CHEK ACTIVE,AVIVA, COMFORT CURVE, COMPACT,INSTANT, SMARTVIEW;ACCUTREND............................................................72

CALIBRATION LIQUID – BAYER BREEZE 2,CONTOUR.................................................................72

CANASA – mesalamine suppos 1000mg............................................................................... 40

capecitabine tab 150 mg (Xeloda).............................10capecitabine tab 500 mg (Xeloda).............................10CAPTOPRIL/HYDROCHLOROTHIA – captopril &

hydrochlorothiazide tab 25-15 mg..........................22CAPTOPRIL/HYDROCHLOROTHIA – captopril &



hydrochlorothiazide tab 50-25 mg..........................22captopril tab 100 mg................................................... 22captopril tab 12.5 mg.................................................. 22captopril tab 25 mg......................................................22captopril tab 50 mg......................................................22carbamazepine cap sr 12hr 100 mg

(Carbatrol)..................................................................56carbamazepine cap sr 12hr 200 mg

(Carbatrol)..................................................................56carbamazepine cap sr 12hr 300 mg

(Carbatrol)..................................................................56carbamazepine chew tab 100 mg............................. 56carbamazepine susp 100 mg/5ml

(Tegretol)....................................................................56carbamazepine tab 200 mg (Tegretol)......................56carbamazepine tab sr 12hr 200 mg (Tegretol-

xr)................................................................................ 56carbamazepine tab sr 12hr 400 mg (Tegretol-

xr)................................................................................ 56carbamide peroxide 6.5% otic soln........................... 66carbidopa & levodopa orally disintegrating tab

10-100 mg................................................................. 58carbidopa & levodopa orally disintegrating tab

25-100 mg................................................................. 58carbidopa & levodopa orally disintegrating tab

25-250 mg................................................................. 58carbidopa & levodopa tab 10-100 mg

(Sinemet)....................................................................58carbidopa & levodopa tab 25-100 mg

(Sinemet)....................................................................58

2015

80

carbidopa & levodopa tab 25-250 mg(Sinemet)....................................................................58

carbidopa & levodopa tab cr 25-100 mg (Sinemetcr)................................................................................ 58

carbidopa & levodopa tab cr 50-200 mg (Sinemetcr)................................................................................ 58

carteolol hcl ophth soln 1%........................................ 65carvedilol tab 12.5 mg (Coreg).................................. 24carvedilol tab 25 mg (Coreg)......................................25carvedilol tab 3.125 mg (Coreg)................................ 25carvedilol tab 6.25 mg (Coreg).................................. 25CEENU – lomustine cap 100 mg...............................10CEENU – lomustine cap 10 mg.................................10CEENU – lomustine cap 40 mg.................................10cefaclor cap 250 mg......................................................1cefaclor cap 500 mg......................................................1cefadroxil cap 500 mg...................................................1cefadroxil for susp 250 mg/5ml....................................1cefadroxil for susp 500 mg/5ml....................................1cefadroxil tab 1 gm........................................................1cefdinir cap 300 mg.......................................................2cefdinir for susp 125 mg/5ml........................................2cefdinir for susp 250 mg/5ml........................................2cefpodoxime proxetil for susp 100

mg/5ml..........................................................................2cefpodoxime proxetil for susp 50

mg/5ml..........................................................................2cefpodoxime proxetil tab 100 mg.................................2cefpodoxime proxetil tab 200 mg.................................2cefprozil for susp 125 mg/5ml......................................2cefprozil for susp 250 mg/5ml......................................2cefprozil tab 250 mg......................................................2cefprozil tab 500 mg......................................................2ceftriaxone sodium for inj 1 gm

(Rocephin)....................................................................2ceftriaxone sodium for inj 250 mg............................... 2ceftriaxone sodium for inj 2 gm....................................2ceftriaxone sodium for inj 500 mg

(Rocephin)....................................................................2cefuroxime axetil for susp 125 mg/5ml

(Ceftin)..........................................................................2cefuroxime axetil tab 250 mg (Ceftin)......................... 2cefuroxime axetil tab 500 mg (Ceftin)......................... 2CELEBREX – celecoxib cap 100 mg........................ 53CELEBREX – celecoxib cap 200 mg........................ 53CELEBREX – celecoxib cap 400 mg........................ 53CELEBREX – celecoxib cap 50 mg.......................... 53CELLCEPT – mycophenolate mofetil for oral susp

200 mg/ml..................................................................72CEM-UREA – urea soln 45%.....................................71CENTANY – mupirocin oint 2%.................................68cephalexin cap 250 mg (Keflex).................................. 2

cephalexin cap 500 mg (Keflex).................................. 2cephalexin for susp 125 mg/5ml..................................2cephalexin for susp 250 mg/5ml..................................2cetirizine hcl chew tab 10 mg.....................................32cetirizine hcl chew tab 5 mg.......................................32cetirizine hcl oral soln 1 mg/ml (5

mg/5ml)...................................................................... 32cetirizine hcl oral soln 1 mg/ml (5

mg/5ml)...................................................................... 32cetirizine hcl syrup 1 mg/ml (5 mg/5ml).................... 32cetirizine hcl tab 10 mg...............................................32cetirizine hcl tab 5 mg.................................................32cevimeline hcl cap 30 mg (Evoxac)...........................67CHANTIX CONTINUING MONTH – varenicline

tartrate tab 1 mg (base equiv)................................ 49CHANTIX STARTING MONTH PA – varenicline

tartrate tab 0.5 mg x 11 & tab 1 mg x 42pack............................................................................ 49

CHANTIX – varenicline tartrate tab 0.5 mg (baseequiv)..........................................................................49

CHANTIX – varenicline tartrate tab 1 mg (baseequiv)..........................................................................49

CHEMET – succimer cap 100 mg.............................72CHEMSTRIP-K, UGK..................................................72chlorhexidine gluconate soln 0.12%

(Peridex).....................................................................67chloroquine phosphate tab 250 mg.............................9chloroquine phosphate tab 500 mg

(Aralen).........................................................................9CHLOROTHIAZIDE – chlorothiazide tab 250

mg............................................................................... 29chlorothiazide tab 500 mg.......................................... 29chlorpheniramine & phenylephrine liquid 1-2 mg/

ml.................................................................................33chlorpheniramine & phenylephrine liquid 1-3.5 mg/

ml.................................................................................33chlorpheniramine & phenylephrine liquid 4-10

mg/5ml........................................................................33chlorpheniramine & phenylephrine tab 4-10

mg............................................................................... 33chlorpheniramine maleate tab 4 mg..........................32chlorpromazine hcl tab 100 mg................................. 44chlorpromazine hcl tab 10 mg....................................44chlorpromazine hcl tab 200 mg................................. 44chlorpromazine hcl tab 25 mg....................................44chlorpromazine hcl tab 50 mg....................................44CHLORTHALIDONE – chlorthalidone tab 25

mg............................................................................... 29CHLORTHALIDONE – chlorthalidone tab 50

mg............................................................................... 29chlorzoxazone tab 500 mg (Parafon forte

dsc)............................................................................. 59

2015

81

cholecalciferol cap 10000 unit................................... 59cholecalciferol cap 1000 unit......................................59cholecalciferol cap 2000 unit......................................59cholecalciferol cap 50000 unit................................... 59cholecalciferol cap 5000 unit......................................59cholecalciferol chew tab 1000 unit............................ 59cholecalciferol chew tab 400 unit.............................. 59cholecalciferol oral liquid 400 unit/ml........................ 59cholecalciferol tab 1000 unit...................................... 59cholecalciferol tab 2000 unit...................................... 59cholecalciferol tab 400 unit.........................................59cholecalciferol tab 5000 unit...................................... 59cholestyramine light powder 4 gm/dose (Questran

light)............................................................................ 28cholestyramine light powder packets 4

gm............................................................................... 27cholestyramine powder 4 gm/dose

(Questran)..................................................................28cholestyramine powder packets 4 gm

(Questran)..................................................................28choline fenofibrate cap dr 135 mg (fenofibric acid

equiv) (Trilipix).......................................................... 28choline fenofibrate cap dr 45 mg (fenofibric acid

equiv) (Trilipix).......................................................... 28ciclopirox gel 0.77%.................................................... 68ciclopirox olamine cream 0.77% (base

equiv)..........................................................................68ciclopirox olamine susp 0.77% (base

equiv)..........................................................................68ciclopirox shampoo 1% (Loprox

shampoo)................................................................... 68ciclopirox solution 8% (Penlac Nail

Lacquer)..................................................................... 68CICLOPIROX TOPICAL SOLUTI – ciclopirox

solution 8% & vitamin e 5% topicalkit.................................................................................68

cilostazol tab 100 mg (Pletal).....................................63cilostazol tab 50 mg (Pletal).......................................63cimetidine hcl soln 300 mg/5ml................................. 37cimetidine tab 300 mg.................................................37cimetidine tab 400 mg.................................................37cimetidine tab 800 mg.................................................37CIPRODEX – ciprofloxacin-dexamethasone otic

susp 0.3-0.1%........................................................... 66ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000

mg(base eq) (Cipro xr)...............................................4ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg

(base eq) (Cipro xr)....................................................4ciprofloxacin for oral susp 250 mg/5ml (5%) (5

gm/100ml) (Cipro).......................................................3ciprofloxacin for oral susp 500 mg/5ml (10%) (10

gm/100ml) (Cipro).......................................................3

ciprofloxacin hcl ophth soln 0.3%(Ciloxan).....................................................................64

ciprofloxacin hcl tab 100 mg (baseequiv)............................................................................ 3

ciprofloxacin hcl tab 250 mg (base equiv)(Cipro)...........................................................................3

ciprofloxacin hcl tab 500 mg (base equiv)(Cipro)...........................................................................3

ciprofloxacin hcl tab 750 mg (baseequiv)............................................................................ 4

citalopram hydrobromide oral soln 10mg/5ml........................................................................42

citalopram hydrobromide tab 10 mg (base equiv)(Celexa)......................................................................42



CLARAVIS – isotretinoin cap 30 mg......................... 67clarithromycin for susp 125 mg/5ml.............................2clarithromycin for susp 250 mg/5ml

(Biaxin)..........................................................................2clarithromycin tab 250 mg (Biaxin).............................. 2clarithromycin tab 500 mg (Biaxin).............................. 3clarithromycin tab sr 24hr 500 mg (Biaxin xl

pac)............................................................................... 2clemastine fumarate tab 1.34 mg (1 mg base

equiv)..........................................................................32clindamycin hcl cap 150 mg (Cleocin)........................ 9clindamycin hcl cap 300 mg (Cleocin)........................ 9clindamycin hcl cap 75 mg (Cleocin)...........................9clindamycin palmitate hcl for soln 75 mg/5ml (base

equiv) (Cleocin pediatric gr)...................................... 9clindamycin phosphate-benzoyl peroxide gel 1-5%

(Benzaclin).................................................................67clindamycin phosphate gel 1% (Cleocin-

t).................................................................................. 67clindamycin phosphate lotion 1% (Cleocin-

t).................................................................................. 67clindamycin phosphate soln 1% (Cleocin-

t).................................................................................. 67clindamycin phosphate swab 1% (Cleocin-

t).................................................................................. 67clindamycin phosphate vaginal cream 2%

(Cleocin).....................................................................41clindamycin phosph-benzoyl peroxide (refrig) gel 1.2

(1)-5% (Duac)............................................................67clobetasol propionate cream 0.05%

(Temovate).................................................................69clobetasol propionate emollient base cream 0.05%

(Temovate e).............................................................69

2015

82

clobetasol propionate foam 0.05%(Olux)..........................................................................69

clobetasol propionate gel 0.05%(Temovate).................................................................69

clobetasol propionate oint 0.05%(Temovate).................................................................69

clobetasol propionate soln 0.05%(Temovate).................................................................69

clomipramine hcl cap 25 mg(Anafranil).................................................................. 42



clonazepam tab 0.5 mg (Klonopin)........................... 56clonazepam tab 1 mg (Klonopin)...............................56clonazepam tab 2 mg (Klonopin)...............................56clonidine hcl tab 0.1 mg (Catapres).......................... 31clonidine hcl tab 0.2 mg (Catapres).......................... 31clonidine hcl tab 0.3 mg (Catapres).......................... 31clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-

tts-1)............................................................................31clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-

tts-2)............................................................................31clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-

tts-3)............................................................................31clopidogrel bisulfate tab 75 mg (base equiv)

(Plavix)........................................................................63clotrimazole troche 10 mg.......................................... 67clotrimazole vaginal cream 2%..................................41clozapine tab 100 mg (Clozaril)................................. 45clozapine tab 200 mg..................................................45clozapine tab 25 mg (Clozaril)................................... 45clozapine tab 50 mg....................................................45codeine sulfate tab 30 mg..........................................51codeine sulfate tab 60 mg..........................................51colchicine w/ probenecid tab 0.5-500

mg............................................................................... 55colestipol hcl granule packets 5 gm (Colestid

flavored)..................................................................... 28colestipol hcl granules 5 gm (Colestid

flavored)..................................................................... 28colestipol hcl tab 1 gm (Colestid).............................. 28COMBIPATCH – estradiol-norethindrone ace td pttw

0.05-0.14 mg/day......................................................13COMBIPATCH – estradiol-norethindrone ace td pttw

0.05-0.25 mg/day......................................................13COMBIVENT RESPIMAT – ipratropium-albuterol

inhal aerosol soln 20-100 mcg/act......................... 35COMPLERA – emtricitabine-rilpivirine-tenofovir df

tab 200-25-300 mg.....................................................6CONDOMS – various..................................................14

COPAXONE – glatiramer acetate inj kit 20 mg/ml.................................................................................49

COPAXONE – glatiramer acetate soln prefilledsyringe 40 mg/ml...................................................... 49

CORTIFOAM – hydrocortisone acetate rectal foam90 mg/dose................................................................67

CORTISONE ACETATE – cortisone acetate tab 25mg............................................................................... 12

CREON – pancrelipase (lip-prot-amyl) dr cap12000-38000-60000 unit......................................... 39

CREON – pancrelipase (lip-prot-amyl) dr cap24000-76000-120000 unit....................................... 39

CREON – pancrelipase (lip-prot-amyl) dr cap3000-9500-15000 unit..............................................39

CREON – pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit..................................... 39

CREON – pancrelipase (lip-prot-amyl) dr cap6000-19000-30000 unit............................................39

CRESTOR – rosuvastatin calcium tab 40mg............................................................................... 28

CRIXIVAN – indinavir sulfate cap 200mg................................................................................. 6

CRIXIVAN – indinavir sulfate cap 400mg................................................................................. 6

cromolyn sodium ophth soln 4%................................66cromolyn sodium soln nebu 20 mg/2ml.................... 35CUPRIMINE – penicillamine cap 250

mg............................................................................... 72cyanocobalamin inj 1000 mcg/ml.............................. 63cyanocobalamin tab 1000 mcg..................................63cyanocobalamin tab 100 mcg.................................... 63cyanocobalamin tab 250 mcg.................................... 63cyanocobalamin tab 500 mcg.................................... 63cyanocobalamin tab cr 1000 mcg..............................63cyanocobalamin tab cr 2000 mcg..............................63cyanocobalamin tab sl 1000 mcg.............................. 63cyanocobalamin tab sl 2500 mcg.............................. 63cyanocobalamin tab sl 5000 mcg.............................. 63CYCLESSA – desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg............................................................................... 14

cyclobenzaprine hcl tab 10 mg.................................. 59cyclobenzaprine hcl tab 5 mg.................................... 59cyclopentolate hcl ophth soln 1%

(Cyclogyl)................................................................... 66CYCLOPHOSPHAMIDE – cyclophosphamide tab 25

mg............................................................................... 10CYCLOPHOSPHAMIDE – cyclophosphamide tab 50

mg............................................................................... 10cyclosporine cap 100 mg

(Sandimmune)...........................................................72

2015

83

cyclosporine cap 25 mg(Sandimmune)...........................................................72

cyclosporine modified cap 100 mg(Neoral)...................................................................... 72

cyclosporine modified cap 25 mg(Neoral)...................................................................... 72

CYCLOSPORINE MODIFIED – cyclosporinemodified cap 50 mg..................................................72

cyclosporine modified oral soln 100 mg/ml(Neoral)...................................................................... 72

cyproheptadine hcl syrup 2 mg/5ml.......................... 32cyproheptadine hcl tab 4 mg......................................32CYSTAGON – cysteamine bitartrate cap 150

mg............................................................................... 41CYSTAGON – cysteamine bitartrate cap 50

mg............................................................................... 41

D

DALLERGY – chlorpheniramine & phenylephrineliquid 1-2.5 mg/ml.....................................................33

danazol cap 100 mg....................................................13danazol cap 200 mg....................................................13danazol cap 50 mg......................................................13dantrolene sodium cap 25 mg

(Dantrium).................................................................. 59dantrolene sodium cap 50 mg

(Dantrium).................................................................. 59DANTROLENE SODIUM – dantrolene sodium cap

100 mg....................................................................... 59DAPSONE – dapsone tab 100 mg..............................9DAPSONE – dapsone tab 25 mg................................ 9DARAPRIM – pyrimethamine tab 25 mg.................... 9DECARA – cholecalciferol cap 25000

unit.............................................................................. 59DELZICOL – mesalamine cap dr 400

mg............................................................................... 40demeclocycline hcl tab 150 mg....................................3demeclocycline hcl tab 300 mg....................................3DEPO-PROVERA CONTRACEPTIV –

medroxyprogesterone acetate im susp 150 mg/ml.................................................................................15

DEPO-SUBQ PROVERA 104 –medroxyprogesterone acetate subcutaneous susp104 mg/0.65ml.......................................................... 15

desipramine hcl tab 100 mg(Norpramin)................................................................43






desmopressin acetate nasal soln 0.01%(refrigerated) (Ddavp).............................................. 21

desmopressin acetate nasal spray soln 0.01%(Ddavp).......................................................................21

desmopressin acetate nasal spray soln 0.01%(refrigerated)..............................................................21

desmopressin acetate tab 0.1 mg(Ddavp).......................................................................21

desmopressin acetate tab 0.2 mg(Ddavp).......................................................................21

DESOGEN – desogestrel & ethinyl estradiol tab 0.15mg-30 mcg.................................................................15

desonide cream 0.05% (Desowen)........................... 69desonide lotion 0.05% (Desowen).............................69desonide oint 0.05% (Desowen)................................69desoximetasone cream 0.25%

(Topicort)....................................................................69DESOXIMETASONE – desoximetasone cream

0.05%..........................................................................69desoximetasone gel 0.05% (Topicort)...................... 69desoximetasone oint 0.25% (Topicort)..................... 69DEXAMETHASONE – dexamethasone soln 0.5

mg/5ml........................................................................12dexamethasone elixir 0.5 mg/5ml..............................12dexamethasone sodium phosphate ophth soln

0.1%............................................................................65dexamethasone tab 0.5 mg........................................12dexamethasone tab 0.75 mg..................................... 12dexamethasone tab 1.5 mg........................................12dexamethasone tab 4 mg...........................................12dexamethasone tab 6 mg...........................................12dextroamphetamine sulfate cap sr 24hr 10 mg

(Dexedrine)................................................................ 47dextroamphetamine sulfate cap sr 24hr 15 mg

(Dexedrine)................................................................ 48dextroamphetamine sulfate cap sr 24hr 5 mg

(Dexedrine)................................................................ 48dextroamphetamine sulfate tab 5 mg........................48dextromethorphan-guaifenesin liquid 10-100

mg/5ml........................................................................33DIALYVITE OMEGA-3 CONCENT – omega-3 fatty

acids cap 600 mg.....................................................61DIALYVITE VITAMIN D3 MAX – cholecalciferol tab

50000 unit..................................................................59DIAPHRAGMS – various............................................15diazepam tab 10 mg (Valium)....................................42diazepam tab 2 mg (Valium)......................................42diazepam tab 5 mg (Valium)......................................42

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diclofenac potassium tab 50 mg(Cataflam).................................................................. 53

diclofenac sodium (actinic keratoses) gel 3%(Solaraze).................................................................. 71

diclofenac sodium ophth soln 0.1%...........................66diclofenac sodium tab delayed release 25

mg............................................................................... 53diclofenac sodium tab delayed release 50

mg............................................................................... 53diclofenac sodium tab delayed release 75

mg............................................................................... 53diclofenac sodium tab sr 24hr 100 mg (Voltaren-

xr)................................................................................ 53dicloxacillin sodium cap 250 mg.................................. 1dicloxacillin sodium cap 500 mg.................................. 1dicyclomine hcl cap 10 mg (Bentyl)...........................38DICYCLOMINE HCL – dicyclomine hcl oral soln 10

mg/5ml........................................................................38dicyclomine hcl tab 20 mg (Bentyl)........................... 38didanosine delayed release capsule 125 mg (Videx

ec)................................................................................. 6didanosine delayed release capsule 200 mg (Videx



ec)................................................................................. 7DIFFERIN – adapalene gel 0.3%.............................. 67DIFFERIN – adapalene lotion 0.1%..........................67diflorasone diacetate oint 0.05%............................... 69DIGOXIN – digoxin oral soln 0.05 mg/

ml.................................................................................31digoxin tab 125 mcg (0.125 mg)

(Lanoxin).................................................................... 31digoxin tab 250 mcg (0.25 mg)

(Lanoxin).................................................................... 31DILANTIN – phenytoin sodium extended cap 30

mg............................................................................... 56diltiazem hcl cap sr 24hr 120 mg...............................26diltiazem hcl cap sr 24hr 180 mg...............................26diltiazem hcl cap sr 24hr 240 mg...............................26diltiazem hcl coated beads cap sr 24hr 120 mg

(Cardizem cd)............................................................26diltiazem hcl coated beads cap sr 24hr 180 mg




(Cardizem cd)............................................................26

diltiazem hcl extended release beads cap sr 24hr120 mg (Tiazac)........................................................26






diltiazem hcl tab 120 mg (Cardizem)........................ 26diltiazem hcl tab 30 mg (Cardizem)...........................26diltiazem hcl tab 60 mg (Cardizem)...........................26diltiazem hcl tab 90 mg...............................................26DIMETAPP COLD & ALLERGY – brompheniramine

& phenylephrine chew tab 1-2.5 mg...................... 33diphenhydramine hcl cap 25 mg................................32diphenhydramine hcl cap 50 mg................................32diphenhydramine hcl chew tab 12.5

mg............................................................................... 32diphenhydramine hcl liquid 12.5

mg/5ml........................................................................32diphenhydramine hcl tab 25 mg................................ 32diphenhydramine-phenylephrine liq 6.25-2.5

mg/5ml........................................................................33diphenhydramine-phenylephrine soln 12.5-5

mg/5ml........................................................................33diphenoxylate w/ atropine tab 2.5-0.025 mg

(Lomotil)..................................................................... 37dipyridamole tab 25 mg (Persantine)........................ 63dipyridamole tab 50 mg (Persantine)........................ 63dipyridamole tab 75 mg (Persantine)........................ 63disopyramide phosphate cap 100 mg

(Norpace)................................................................... 30disopyramide phosphate cap 150 mg

(Norpace)................................................................... 30disulfiram tab 250 mg (Antabuse)............................. 49disulfiram tab 500 mg (Antabuse)............................. 49divalproex sodium cap sprinkle 125 mg (Depakote

sprinkles)....................................................................56divalproex sodium tab delayed release 125 mg

(Depakote)................................................................. 56divalproex sodium tab delayed release 250 mg

(Depakote)................................................................. 56divalproex sodium tab delayed release 500 mg

(Depakote)................................................................. 56divalproex sodium tab sr 24 hr 250 mg (Depakote

er)................................................................................56divalproex sodium tab sr 24 hr 500 mg (Depakote

er)................................................................................56

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DIVIGEL – estradiol td gel 0.25 mg/0.25gm(0.1%)......................................................................... 13

DIVIGEL – estradiol td gel 0.5 mg/0.5gm(0.1%)......................................................................... 13

DIVIGEL – estradiol td gel 1 mg/gm(0.1%)......................................................................... 13

docosahexaenoic acid cap 200 mg...........................61docusate sodium cap 100 mg....................................36docusate sodium liquid 150 mg/15ml........................36donepezil hydrochloride orally disintegrating tab 10

mg (Aricept odt)........................................................49donepezil hydrochloride orally disintegrating tab 5

mg............................................................................... 49donepezil hydrochloride tab 10 mg

(Aricept)......................................................................50donepezil hydrochloride tab 5 mg

(Aricept)......................................................................50dorzolamide hcl ophth soln 2%

(Trusopt).....................................................................65dorzolamide hcl-timolol maleate ophth soln 22.3-6.8

mg/ml (Cosopt)......................................................... 65doxazosin mesylate tab 1 mg

(Cardura)....................................................................31doxazosin mesylate tab 2 mg



(Cardura)....................................................................31doxepin hcl cap 100 mg............................................. 43doxepin hcl cap 10 mg................................................43doxepin hcl cap 25 mg................................................43doxepin hcl cap 50 mg................................................43doxepin hcl conc 10 mg/ml........................................ 43DOXEPIN HCL – doxepin hcl cap 75

mg............................................................................... 43doxycycline hyclate cap 100 mg

(Vibramycin).................................................................3doxycycline hyclate cap 50 mg....................................3doxycycline hyclate tab 100 mg...................................3doxycycline hyclate tab 20 mg.....................................3doxycycline monohydrate cap 100 mg

(Monodox).................................................................... 3doxycycline monohydrate cap 150 mg

(Adoxa)......................................................................... 3doxycycline monohydrate cap 50 mg..........................3doxycycline monohydrate cap 75 mg

(Monodox).................................................................... 3doxycycline monohydrate tab 100 mg (Adoxa pak

1/100)............................................................................3doxycycline monohydrate tab 150 mg (Adoxa pak

1/150)............................................................................3

doxycycline monohydrate tab 50 mg(Adoxa)......................................................................... 3

doxycycline monohydrate tab 75 mg(Adoxa)......................................................................... 3

DULERA – mometasone furoate-formoterol fumarateaerosol 100-5 mcg/act............................................. 35

DULERA – mometasone furoate-formoterol fumarateaerosol 200-5 mcg/act............................................. 35

duloxetine hcl enteric coated pellets cap 20 mg(Cymbalta)................................................................. 43



E

E.E.S. 400 – erythromycin ethylsuccinate tab 400mg................................................................................. 3

econazole nitrate cream 1%...................................... 68ED CHLORPED D – chlorpheniramine &

phenylephrine liquid 2-5 mg/ml...............................33EDURANT – rilpivirine hcl tab 25 mg (base

equivalent)....................................................................7ELIDEL – pimecrolimus cream 1%........................... 71ELLA – ulipristal acetate tab 30 mg.......................... 15EMEND – aprepitant capsule 125 mg.......................39EMEND – aprepitant capsule 40 mg.........................39EMEND – aprepitant capsule 80 mg.........................39EMEND – aprepitant capsule therapy pack 80 & 125

mg............................................................................... 39EMTRIVA – emtricitabine caps 200 mg......................7EMTRIVA – emtricitabine soln 10 mg/ml.................... 7enalapril maleate & hydrochlorothiazide tab 10-25

mg (Vaseretic)...........................................................22enalapril maleate & hydrochlorothiazide tab 5-12.5

mg............................................................................... 22enalapril maleate tab 10 mg (Vasotec)..................... 22enalapril maleate tab 2.5 mg (Vasotec)....................22enalapril maleate tab 20 mg (Vasotec)..................... 22enalapril maleate tab 5 mg (Vasotec)....................... 22ENBREL – etanercept for subcutaneous inj kit 25

mg............................................................................... 54ENBREL – etanercept subcutaneous soln prefilled

syringe 25 mg/0.5ml.................................................53ENBREL – etanercept subcutaneous soln prefilled

syringe 50 mg/ml...................................................... 54ENBREL SURECLICK – etanercept subcutaneous

solution auto-injector 50 mg/ml...............................54ENJUVIA – estrogens, conjugated synthetic b tab

0.3 mg........................................................................ 13ENJUVIA – estrogens, conjugated synthetic b tab

0.45 mg...................................................................... 13

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86

ENJUVIA – estrogens, conjugated synthetic b tab0.625 mg....................................................................13

ENJUVIA – estrogens, conjugated synthetic b tab0.9 mg........................................................................ 13

ENJUVIA – estrogens, conjugated synthetic b tab1.25 mg...................................................................... 13

enoxaparin sodium inj 100 mg/ml(Lovenox)................................................................... 63

enoxaparin sodium inj 120 mg/0.8ml(Lovenox)................................................................... 63

enoxaparin sodium inj 150 mg/ml(Lovenox)................................................................... 63

enoxaparin sodium inj 300 mg/3ml(Lovenox)................................................................... 63





entacapone tab 200 mg (Comtan).............................58entecavir tab 0.5 mg (Baraclude)................................ 5entecavir tab 1 mg (Baraclude)....................................5EPIFOAM – pramoxine-hc aerosol foam

1-1%............................................................................69EPIPEN 2-PAK – epinephrine solution auto-injector

0.3 mg/0.3ml (1:1000)..............................................32EPIPEN-JR 2-PAK – epinephrine solution auto-

injector 0.15 mg/0.3ml (1:2000)..............................32EPIVIR HBV – lamivudine oral soln 5 mg/

ml...................................................................................5EPIVIR – lamivudine oral soln 10 mg/ml.................... 7eplerenone tab 25 mg (Inspra).................................. 31eplerenone tab 50 mg (Inspra).................................. 31EPOGEN – epoetin alfa inj 10000 unit/

ml.................................................................................63EPOGEN – epoetin alfa inj 20000 unit/




ml.................................................................................63EPZICOM – abacavir sulfate-lamivudine tab 600-300

mg................................................................................. 7ergocalciferol cap 50000 unit (Drisdol)..................... 59ERY-TAB – erythromycin tab delayed release 250

mg................................................................................. 3

ERY-TAB – erythromycin tab delayed release 333mg................................................................................. 3

ERY-TAB – erythromycin tab delayed release 500mg................................................................................. 3

ERYTHROMYCIN ETHYLSUCCINA – erythromycinethylsuccinate tab 400 mg........................................ 3

erythromycin gel 2% (Erygel).....................................67erythromycin ophth oint 5 mg/gm.............................. 64erythromycin pads 2%................................................ 67erythromycin soln 2%..................................................67erythromycin w/ delayed release particles cap 250

mg................................................................................. 3escitalopram oxalate soln 5 mg/5ml (base equiv)

(Lexapro)....................................................................43escitalopram oxalate tab 10 mg (base equiv)



(Lexapro)....................................................................43estazolam tab 1 mg.....................................................46estazolam tab 2 mg.....................................................46estradiol & norethindrone acetate tab 0.5-0.1 mg

(Activella)................................................................... 13estradiol & norethindrone acetate tab 1-0.5 mg

(Activella)................................................................... 13estradiol tab 0.5 mg (Estrace)....................................13estradiol tab 1 mg (Estrace).......................................13estradiol tab 2 mg (Estrace).......................................13estradiol td patch weekly 0.025 mg/24hr

(Climara).................................................................... 14estradiol td patch weekly 0.0375 mg/24hr (37.5

mcg/24hr) (Climara)................................................. 14estradiol td patch weekly 0.05 mg/24hr

(Climara).................................................................... 14estradiol td patch weekly 0.06 mg/24hr



(Climara).................................................................... 14ESTROPIPATE – estropipate tab 3

mg............................................................................... 14estropipate tab 0.75 mg..............................................14estropipate tab 1.5 mg................................................14ESTROSTEP FE – norethindrone ac-ethinyl estrad-

fe tab 1-20/1-30/1-35 mg-mcg................................ 15ethambutol hcl tab 100 mg (Myambutol).................... 4ethambutol hcl tab 400 mg (Myambutol).................... 4ethosuximide cap 250 mg (Zarontin)........................ 56ethosuximide soln 250 mg/5ml

(Zarontin)....................................................................56

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87

ETIDRONATE DISODIUM – etidronate disodium tab400 mg....................................................................... 21

etodolac cap 200 mg...................................................54etodolac cap 300 mg...................................................54etodolac tab 400 mg................................................... 54etodolac tab 500 mg................................................... 54etodolac tab sr 24hr 400 mg......................................54etodolac tab sr 24hr 500 mg......................................54etodolac tab sr 24hr 600 mg......................................54EVISTA – raloxifene hcl tab 60 mg........................... 21exemestane tab 25 mg (Aromasin)........................... 10

F

FALESSA – levonorgest-eth estrad tab 0.1 mg-20mcg & fa tab 1 mg kit.............................................. 15

famciclovir tab 125 mg (Famvir).................................. 6famciclovir tab 250 mg (Famvir).................................. 6famciclovir tab 500 mg (Famvir).................................. 6famotidine tab 10 mg.................................................. 38famotidine tab 20 mg (Pepcid)...................................38famotidine tab 20 mg (Pepcid)...................................38famotidine tab 40 mg (Pepcid)...................................38felodipine tab sr 24hr 10 mg...................................... 26felodipine tab sr 24hr 2.5 mg..................................... 26felodipine tab sr 24hr 5 mg........................................ 26FEMCON FE – norethindrone & ethinyl estradiol-fe

chew tab 0.4 mg-35 mcg.........................................15fenofibrate micronized cap 134 mg

(Lofibra)......................................................................28fenofibrate micronized cap 200 mg

(Lofibra)......................................................................28fenofibrate micronized cap 67 mg

(Lofibra)......................................................................28fenofibrate tab 145 mg (Tricor).................................. 28fenofibrate tab 160 mg (Lofibra)................................ 28fenofibrate tab 48 mg (Tricor).................................... 28fenofibrate tab 54 mg (Lofibra).................................. 28fentanyl citrate lollipop 1200 mcg

(Actiq)......................................................................... 51fentanyl citrate lollipop 1600 mcg

(Actiq)......................................................................... 51fentanyl citrate lollipop 200 mcg (Actiq)....................51fentanyl citrate lollipop 400 mcg (Actiq)....................51fentanyl citrate lollipop 600 mcg (Actiq)....................51fentanyl citrate lollipop 800 mcg (Actiq)....................51fentanyl td patch 72hr 100 mcg/hr

(Duragesic)................................................................ 51fentanyl td patch 72hr 12 mcg/hr



(Duragesic)................................................................ 51

fentanyl td patch 72hr 75 mcg/hr(Duragesic)................................................................ 51

ferrous sulfate tab 325 mg (65 mg elementalfe)................................................................................ 63

ferrous sulfate tab ec 325 mg (65 mg feequivalent)................................................................. 63

fexofenadine hcl susp 30 mg/5ml (6 mg/ml)............................................................................... 32

fexofenadine hcl tab 180 mg......................................32fexofenadine hcl tab 60 mg........................................32FINACEA – azelaic acid gel 15%..............................67finasteride tab 5 mg (Proscar)................................... 41flecainide acetate tab 100 mg....................................30flecainide acetate tab 150 mg....................................30flecainide acetate tab 50 mg......................................30FLEET LIQUID GLYCERIN SUP – glycerin enema

adult 5.6 gm/average delivered dose.....................36FLOVENT DISKUS – fluticasone propionate aer pow

ba 100 mcg/blister....................................................35FLOVENT DISKUS – fluticasone propionate aer pow

ba 250 mcg/blister....................................................35FLOVENT DISKUS – fluticasone propionate aer pow

ba 50 mcg/blister...................................................... 35FLOVENT HFA – fluticasone propionate hfa inhal

aer 110 mcg/act (125/valve)................................... 35FLOVENT HFA – fluticasone propionate hfa inhal

aer 220 mcg/act (250/valve)................................... 35FLOVENT HFA – fluticasone propionate hfa inhal

aero 44 mcg/act (50/valve)..................................... 35fluconazole for susp 10 mg/ml

(Diflucan)......................................................................4fluconazole for susp 40 mg/ml

(Diflucan)......................................................................4fluconazole tab 100 mg (Diflucan)...............................4fluconazole tab 150 mg (Diflucan)...............................4fluconazole tab 200 mg (Diflucan)...............................4fluconazole tab 50 mg (Diflucan).................................4flucytosine cap 250 mg (Ancobon).............................. 4flucytosine cap 500 mg (Ancobon).............................. 4fludrocortisone acetate tab 0.1 mg............................12flunisolide nasal soln 0.025%

(Flunisolide)............................................................... 33fluocinolone acetonide cream 0.01%........................ 70fluocinolone acetonide cream 0.025%

(Synalar).....................................................................70fluocinolone acetonide oil 0.01% (body oil) (Derma-

smoothe/fs bod)........................................................ 70fluocinolone acetonide oil 0.01% (scalp oil) (Derma-

smoothe/fs sca).........................................................70fluocinolone acetonide oint 0.025%

(Synalar).....................................................................70

2015

88

fluocinolone acetonide soln 0.01%(Synalar).....................................................................70

fluocinonide cream 0.05%.......................................... 70fluocinonide emulsified base cream

0.05%..........................................................................70fluocinonide gel 0.05%................................................70fluocinonide oint 0.05%...............................................70fluocinonide soln 0.05%..............................................70fluorometholone ophth susp 0.1% (Fml

liquifilm)...................................................................... 65fluorouracil cream 5% (Efudex)................................. 71fluorouracil soln 2%.....................................................71fluorouracil soln 5%.....................................................71fluoxetine hcl cap 10 mg (Prozac).............................43fluoxetine hcl cap 20 mg (Prozac).............................43fluoxetine hcl cap 40 mg (Prozac).............................43fluoxetine hcl solution 20 mg/5ml.............................. 43fluoxetine hcl tab 10 mg............................................. 43fluoxetine hcl tab 20 mg............................................. 43fluphenazine decanoate inj 25 mg/ml....................... 45FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5

mg/5ml........................................................................45FLUPHENAZINE HCL – fluphenazine hcl oral conc 5

mg/ml..........................................................................45fluphenazine hcl tab 10 mg........................................ 45fluphenazine hcl tab 1 mg.......................................... 45fluphenazine hcl tab 2.5 mg.......................................45fluphenazine hcl tab 5 mg.......................................... 45flurbiprofen sodium ophth soln 0.03%

(Ocufen)..................................................................... 66flurbiprofen tab 100 mg...............................................54flurbiprofen tab 50 mg.................................................54flutamide cap 125 mg................................................. 10fluticasone propionate cream 0.05%

(Cutivate)....................................................................70fluticasone propionate nasal susp 50 mcg/act

(Flonase).................................................................... 33fluticasone propionate oint 0.005%

(Cutivate)....................................................................70fluvoxamine maleate tab 100 mg.............................. 43fluvoxamine maleate tab 25 mg.................................43fluvoxamine maleate tab 50 mg.................................43folic acid tab 1 mg.......................................................63folic acid tab 400 mcg.................................................63folic acid tab 800 mcg.................................................64FORADIL AEROLIZER – formoterol fumarate inhal

cap 12 mcg................................................................35FORTEO – teriparatide (recombinant) inj 600

mcg/2.4ml.................................................................. 21FORTICAL – calcitonin (salmon) nasal soln 200 unit/

act............................................................................... 21

fosinopril sodium & hydrochlorothiazide tab 10-12.5mg............................................................................... 22

fosinopril sodium & hydrochlorothiazide tab 20-12.5mg............................................................................... 22

fosinopril sodium tab 10 mg.......................................22fosinopril sodium tab 20 mg.......................................22fosinopril sodium tab 40 mg.......................................22fructose-dextrose-phosphoric acid oral soln

.....................................................................................39furosemide oral soln 10 mg/ml...................................29furosemide tab 20 mg (Lasix).................................... 29furosemide tab 40 mg (Lasix).................................... 29furosemide tab 80 mg (Lasix).................................... 29FUZEON – enfuvirtide for inj 90 mg............................7

G

gabapentin cap 100 mg (Neurontin)..........................56gabapentin cap 300 mg (Neurontin)..........................56gabapentin cap 400 mg (Neurontin)..........................56gabapentin oral soln 250 mg/5ml

(Neurontin).................................................................56gabapentin tab 600 mg (Neurontin).......................... 56gabapentin tab 800 mg (Neurontin).......................... 56galantamine hydrobromide cap sr 24hr 16 mg

(Razadyne er)........................................................... 50galantamine hydrobromide cap sr 24hr 24 mg

(Razadyne er)........................................................... 50galantamine hydrobromide cap sr 24hr 8 mg

(Razadyne er)........................................................... 50galantamine hydrobromide oral soln 4 mg/ml

(Razadyne)................................................................ 50galantamine hydrobromide tab 12 mg



(Razadyne)................................................................ 50gemfibrozil tab 600 mg (Lopid).................................. 28GENERESS FE – norethindrone & ethinyl estradiol-

fe chew tab 0.8 mg-25 mcg.................................... 15GENTAMICIN SULFATE – gentamicin sulfate cream

0.1%............................................................................68GENTAMICIN SULFATE – gentamicin sulfate oint

0.1%............................................................................68gentamicin sulfate ophth oint 0.3%........................... 64gentamicin sulfate ophth soln 0.3%

(Garamycin)...............................................................64GLEEVEC – imatinib mesylate tab 100 mg (base

equivalent)................................................................. 10GLEEVEC – imatinib mesylate tab 400 mg (base

equivalent)................................................................. 11glimepiride tab 1 mg (Amaryl)....................................17glimepiride tab 2 mg (Amaryl)....................................17

2015

89

glimepiride tab 4 mg (Amaryl)....................................17glipizide-metformin hcl tab 2.5-250 mg.....................17glipizide-metformin hcl tab 2.5-500 mg.....................17glipizide-metformin hcl tab 5-500 mg........................ 17glipizide tab 10 mg (Glucotrol)...................................17glipizide tab 5 mg (Glucotrol)..................................... 17glipizide tab sr 24hr 10 mg (Glucotrol

xl).................................................................................17glipizide tab sr 24hr 2.5 mg (Glucotrol

xl).................................................................................17glipizide tab sr 24hr 5 mg (Glucotrol xl).................... 17GLUCAGON EMERGENCY KIT – glucagon (rdna)

for inj kit 1 mg...........................................................17glyburide-metformin tab 1.25-250 mg

(Glucovance)............................................................. 17glyburide-metformin tab 2.5-500 mg

(Glucovance)............................................................. 17glyburide-metformin tab 5-500 mg

(Glucovance)............................................................. 17glyburide micronized tab 1.5 mg

(Glynase)....................................................................17glyburide micronized tab 3 mg

(Glynase)....................................................................17glyburide micronized tab 6 mg

(Glynase)....................................................................17glyburide tab 1.25 mg................................................. 17glyburide tab 2.5 mg................................................... 17glyburide tab 5 mg.......................................................17glycerin suppos 1 gm..................................................36glycerin suppos 2 gm..................................................36glycerin suppos 80.7%................................................36glycopyrrolate tab 1 mg (Robinul)............................. 38glycopyrrolate tab 2 mg (Robinul forte).....................38GNP OMEPRAZOLE – omeprazole delayed release

tab 20 mg.................................................................. 38granisetron hcl tab 1 mg.............................................39griseofulvin microsize susp 125 mg/5ml..................... 4griseofulvin microsize tab 500 mg (Grifulvin

v)....................................................................................4guaifenesin-codeine soln 100-10

mg/5ml........................................................................33guaifenesin liquid 100 mg/5ml................................... 33guanfacine hcl tab 1 mg (Tenex)...............................31guanfacine hcl tab 2 mg (Tenex)...............................31

H

halobetasol propionate cream 0.05%(Ultravate).................................................................. 70

halobetasol propionate oint 0.05%(Ultravate).................................................................. 70

haloperidol decanoate im soln 100 mg/ml (Haldoldecanoate 100).........................................................45

haloperidol decanoate im soln 50 mg/ml (Haldoldecanoate 50)........................................................... 45

haloperidol lactate oral conc 2 mg/ml....................... 45haloperidol tab 0.5 mg................................................ 45haloperidol tab 10 mg................................................. 45haloperidol tab 1 mg................................................... 45haloperidol tab 20 mg................................................. 45haloperidol tab 2 mg................................................... 45haloperidol tab 5 mg................................................... 45HM OMEPRAZOLE – omeprazole delayed release

tab 20 mg.................................................................. 38homatropine hbr ophth soln 5% (Isopto

homatropine)............................................................. 66HUMALOG – insulin lispro (human) inj 100 unit/

ml.................................................................................18HUMALOG – insulin lispro (human) soln cartridge

100 unit/ml................................................................. 18HUMALOG KWIKPEN – insulin lispro (human) soln

pen-injector 100 unit/ml........................................... 18HUMALOG MIX 50/50 – insulin lispro prot & lispro

(human) inj 100 unit/ml (50-50).............................. 19HUMALOG MIX 50/50 KWIKPEN – insulin

lispro prot & lispro sus pen-inj 100 unit/ml(50-50)........................................................................19

HUMALOG MIX 75/25 – insulin lispro prot & lispro(human) inj 100 unit/ml (75-25).............................. 19

HUMALOG MIX 75/25 KWIKPEN – insulinlispro prot & lispro sus pen-inj 100 unit/ml(75-25)........................................................................19

HUMIRA – adalimumab inj kit 20mg/0.4ml.................................................................... 54

HUMIRA – adalimumab inj kit 40 mg/0.8ml (50 mg/ml)............................................................................... 54

HUMIRA – adalimumab prefilled syringe kit 10mg/0.2ml.................................................................... 54

HUMIRA PEDIATRIC CROHNS D – adalimumab injkit 40 mg/0.8ml (50 mg/ml)..................................... 54

HUMIRA PEN – adalimumab inj kit 40 mg/0.8ml (50mg/ml).........................................................................54

HUMIRA PEN-CROHNS DISEASE – adalimumab injkit 40 mg/0.8ml (50 mg/ml)..................................... 54

HUMIRA PEN-PSORIASIS STAR – adalimumab injkit 40 mg/0.8ml (50 mg/ml)..................................... 54

HUMULIN 70/30 – insulin isophane & regular(human) inj 100 unit/ml (70-30).............................. 19

HUMULIN 70/30 KWIKPEN – insulin isophane& regular susp pen-inj 100 unit/ml(70-30)........................................................................19

HUMULIN 70/30 PEN – insulin isophane & regularsusp pen-inj 100 unit/ml (70-30).............................19

HUMULIN N – insulin isophane (human) inj 100 unit/ml.................................................................................19

2015

90

HUMULIN N KWIKPEN – insulin isophane (human)susp pen-injector 100 unit/ml..................................19

HUMULIN N U-100 PEN – insulin isophane (human)susp pen-injector 100 unit/ml..................................19

HUMULIN R – insulin regular (human) inj 100 unit/ml.................................................................................19

HUMULIN R U-500 (CONCENTR – insulin regular(human) inj 500 unit/ml............................................19

hydralazine hcl tab 100 mg........................................ 31hydralazine hcl tab 10 mg.......................................... 31hydralazine hcl tab 25 mg.......................................... 31hydralazine hcl tab 50 mg.......................................... 31hydrochlorothiazide cap 12.5 mg

(Microzide)................................................................. 29hydrochlorothiazide tab 25 mg...................................29hydrochlorothiazide tab 50 mg...................................29hydrocodone-acetaminophen soln 7.5-325 mg/15ml

(Hycet)........................................................................51hydrocodone-acetaminophen tab 10-325 mg

(Norco)........................................................................51hydrocodone-acetaminophen tab 5-325 mg

(Norco)........................................................................52hydrocodone-acetaminophen tab 7.5-325 mg

(Norco)........................................................................52hydrocodone-ibuprofen tab 10-200 mg

(Ibudone)....................................................................52hydrocodone-ibuprofen tab 5-200 mg

(Reprexain)................................................................ 52hydrocodone-ibuprofen tab 7.5-200 mg

(Vicoprofen)............................................................... 52hydrocortisone cream 0.5%........................................70hydrocortisone cream 1%...........................................70hydrocortisone cream 2.5%........................................70hydrocortisone enema 100 mg/60ml

(Cortenema)...............................................................67hydrocortisone lotion 2.5%.........................................70hydrocortisone oint 0.5%............................................ 70hydrocortisone oint 1%............................................... 70hydrocortisone oint 2.5%............................................ 70hydrocortisone rectal cream 2.5% (Anusol-

hc)............................................................................... 67hydrocortisone tab 10 mg (Cortef).............................12hydrocortisone tab 20 mg (Cortef).............................12hydrocortisone tab 5 mg (Cortef)...............................12hydrocortisone valerate cream 0.2%.........................70hydrocortisone valerate oint 0.2%

(Westcort).................................................................. 70hydrocortisone w/ acetic acid otic soln 1-2% (Vosol

hc)............................................................................... 67hydromorphone hcl liqd 1 mg/ml

(Dilaudid)....................................................................52

hydromorphone hcl tab 2 mg(Dilaudid)....................................................................52



hydroxychloroquine sulfate tab 200 mg(Plaquenil).................................................................... 9

hydroxyurea cap 500 mg (Hydrea)............................11HYDROXYZINE HCL – hydroxyzine hcl im soln 25

mg/ml..........................................................................42hydroxyzine hcl syrup 10 mg/5ml.............................. 42hydroxyzine hcl tab 10 mg......................................... 42hydroxyzine hcl tab 25 mg......................................... 42hydroxyzine hcl tab 50 mg......................................... 42hydroxyzine pamoate cap 25 mg

(Vistaril)...................................................................... 42hydroxyzine pamoate cap 50 mg

(Vistaril)...................................................................... 42HYDROXYZINE PAMOATE – hydroxyzine pamoate

cap 100 mg............................................................... 42hyoscyamine sulfate elixir 0.125

mg/5ml........................................................................38hyoscyamine sulfate soln 0.125 mg/ml.....................38hyoscyamine sulfate tab 0.125 mg

(Levsin).......................................................................38hyoscyamine sulfate tab sl 0.125 mg (Levsin/

sl).................................................................................38hyoscyamine sulfate tab sr 12hr 0.375 mg

(Levbid)...................................................................... 38

I

ibandronate sodium tab 150 mg (base equivalent)(Boniva)......................................................................21

ibuprofen cap 200 mg.................................................54ibuprofen susp 100 mg/5ml........................................54ibuprofen susp 100 mg/5ml........................................54ibuprofen tab 200 mg..................................................54ibuprofen tab 400 mg..................................................54ibuprofen tab 600 mg..................................................54ibuprofen tab 800 mg..................................................54imipramine hcl tab 10 mg (Tofranil)...........................43imipramine hcl tab 25 mg (Tofranil)...........................43imipramine hcl tab 50 mg (Tofranil)...........................43imiquimod cream 5% (Aldara)................................... 71IMITREX – sumatriptan nasal spray 20 mg/

act............................................................................... 55IMITREX – sumatriptan nasal spray 5 mg/

act............................................................................... 55IMPLANON – etonogestrel subdermal implant 68

mg............................................................................... 15indapamide tab 1.25 mg.............................................29indapamide tab 2.5 mg............................................... 29

2015

91

indomethacin cap 25 mg............................................ 54indomethacin cap 50 mg............................................ 54INSULIN PEN NEEDLES – VARIOUS..................... 72INSULIN SYRINGES – VARIOUS............................ 72INTELENCE – etravirine tab 100 mg.......................... 7INTELENCE – etravirine tab 200 mg.......................... 7INTELENCE – etravirine tab 25 mg............................ 7INTUNIV – guanfacine hcl tab sr 24hr 1 mg (base

equiv)..........................................................................48INTUNIV – guanfacine hcl tab sr 24hr 2 mg (base



equiv)..........................................................................48INVIRASE – saquinavir mesylate cap 200

mg................................................................................. 7INVIRASE – saquinavir mesylate tab 500

mg................................................................................. 7ipratropium-albuterol nebu soln 0.5-2.5(3)

mg/3ml........................................................................35ipratropium bromide inhal soln 0.02%.......................35ipratropium bromide nasal soln 0.03% (21 mcg/

spray) (Atrovent).......................................................33ipratropium bromide nasal soln 0.06% (42 mcg/

spray) (Atrovent).......................................................33irbesartan-hydrochlorothiazide tab 150-12.5 mg

(Avalide)..................................................................... 23irbesartan-hydrochlorothiazide tab 300-12.5 mg

(Avalide)..................................................................... 23irbesartan tab 150 mg (Avapro).................................23irbesartan tab 300 mg (Avapro).................................23irbesartan tab 75 mg (Avapro)...................................23ISENTRESS – raltegravir potassium chew tab 100

mg (base equiv)..........................................................7ISENTRESS – raltegravir potassium chew tab 25 mg

(base equiv).................................................................7ISENTRESS – raltegravir potassium packet for susp

100 mg (base equiv).................................................. 7ISENTRESS – raltegravir potassium tab 400 mg

(base equiv).................................................................7isoniazid tab 100 mg..................................................... 4isoniazid tab 300 mg..................................................... 4ISOSORBIDE DINITRATE – isosorbide dinitrate tab

30 mg......................................................................... 27isosorbide dinitrate tab 10 mg....................................27isosorbide dinitrate tab 20 mg....................................27isosorbide dinitrate tab 5 mg (Isordil

titradose).................................................................... 27isosorbide mononitrate tab 10 mg.............................27isosorbide mononitrate tab 20 mg.............................27

isosorbide mononitrate tab sr 24hr 120 mg(Imdur)........................................................................27



isotretinoin cap 10 mg.................................................67isotretinoin cap 20 mg.................................................68isotretinoin cap 40 mg.................................................68itraconazole cap 100 mg (Sporanox).......................... 4ivermectin tab 3 mg (Stromectol).................................9

J

JANUMET – sitagliptin-metformin hcl tab 50-1000mg............................................................................... 17

JANUMET – sitagliptin-metformin hcl tab 50-500mg............................................................................... 17

JANUMET XR – sitagliptin-metformin hcl tab sr 24hr100-1000 mg............................................................. 18

JANUMET XR – sitagliptin-metformin hcl tab sr 24hr50-1000 mg............................................................... 18

JANUMET XR – sitagliptin-metformin hcl tab sr 24hr50-500 mg................................................................. 18

JANUVIA – sitagliptin phosphate tab 100 mg (baseequiv)..........................................................................18



JINTELI – norethindrone acetate-ethinyl estradiol tab1 mg-5 mcg............................................................... 14

K

KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml(80-20 mg/ml)..............................................................7

KALETRA – lopinavir-ritonavir tab 100-25mg................................................................................. 7

KALETRA – lopinavir-ritonavir tab 200-50mg................................................................................. 7

KALYDECO – ivacaftor tab 150 mg..........................36ketoconazole cream 2%............................................. 68ketoconazole shampoo 2% (Nizoral)........................ 68ketoprofen cap 50 mg.................................................54ketoprofen cap 75 mg.................................................54ketorolac tromethamine ophth soln 0.4% (Acular

ls).................................................................................66ketorolac tromethamine ophth soln 0.5%

(Acular).......................................................................66ketotifen fumarate ophth soln 0.025% (base

equiv)..........................................................................66KONSYL-D – psyllium powder 52.3%.......................37KONSYL – psyllium powder 60.3%...........................36KONSYL – psyllium powder 71.67%........................ 36

2015

92

K-PHOS – potassium phosphate monobasic tab 500mg............................................................................... 60

L

labetalol hcl tab 100 mg (Trandate).......................... 25labetalol hcl tab 200 mg (Trandate).......................... 25labetalol hcl tab 300 mg (Trandate).......................... 25lactic acid (ammonium lactate) lotion 12% (Lac-

hydrin).........................................................................71lactulose (encephalopathy) solution 10

gm/15ml......................................................................40lactulose solution 10 gm/15ml................................... 37lamivudine tab 100 mg (Epivir hbv).............................5lamivudine tab 150 mg (Epivir).................................... 7lamivudine tab 300 mg (Epivir).................................... 7lamivudine-zidovudine tab 150-300 mg

(Combivir).....................................................................7lamotrigine tab 100 mg (Lamictal).............................56lamotrigine tab 150 mg (Lamictal).............................56lamotrigine tab 200 mg (Lamictal).............................56lamotrigine tab 25 mg (Lamictal)............................... 56lamotrigine tab chewable dispersible 25 mg

(Lamictal chewable di).............................................56lamotrigine tab chewable dispersible 5 mg (Lamictal

chewable di).............................................................. 56LANCETS – VARIOUS............................................... 72lansoprazole cap delayed release 15 mg

(Prevacid)...................................................................38lansoprazole cap delayed release 15 mg

(Prevacid)...................................................................38lansoprazole cap delayed release 30 mg

(Prevacid)...................................................................38LANTUS – insulin glargine inj 100 unit/

ml.................................................................................19LANTUS SOLOSTAR – insulin glargine soln pen-

injector 100 unit/ml................................................... 20latanoprost ophth soln 0.005%

(Xalatan).....................................................................65leflunomide tab 10 mg (Arava)...................................54leflunomide tab 20 mg (Arava)...................................54letrozole tab 2.5 mg (Femara)................................... 11LEUCOVORIN CALCIUM – leucovorin calcium tab

10 mg......................................................................... 11LEUCOVORIN CALCIUM – leucovorin calcium tab

15 mg......................................................................... 11leucovorin calcium tab 25 mg.................................... 11leucovorin calcium tab 5 mg...................................... 11LEUKERAN – chlorambucil tab 2 mg....................... 11levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)

(Xopenex).................................................................. 35levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)

(Xopenex).................................................................. 35

levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)(Xopenex).................................................................. 35

LEVEMIR FLEXPEN – insulin detemir soln pen-injector 100 unit/ml................................................... 20

LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector 100 unit/ml................................................... 20

LEVEMIR – insulin detemir inj 100 unit/ml.................................................................................20

levetiracetam oral soln 100 mg/ml(Keppra)..................................................................... 57

levetiracetam tab 1000 mg (Keppra).........................57levetiracetam tab 250 mg (Keppra)...........................57levetiracetam tab 500 mg (Keppra)...........................57levetiracetam tab 750 mg (Keppra)...........................57levobunolol hcl ophth soln 0.5%

(Betagan)................................................................... 65levocarnitine oral soln 1 gm/10ml (10%)

(Carnitor).................................................................... 21levocarnitine tab 330 mg (Carnitor)...........................21levofloxacin oral soln 25 mg/ml

(Levaquin).................................................................... 4levofloxacin tab 250 mg (Levaquin).............................4levofloxacin tab 500 mg (Levaquin).............................4levofloxacin tab 750 mg (Levaquin).............................4levonorgestrel tab 0.75 mg (Plan b)..........................15levonorgestrel tab 1.5 mg (Plan b one-

step)............................................................................15levonorgestrel tab 1.5 mg (Plan b one-

step)............................................................................15levothyroxine sodium tab 100 mcg

(Synthroid)................................................................. 20levothyroxine sodium tab 112 mcg










(Synthroid)................................................................. 20

2015

93

levothyroxine sodium tab 88 mcg(Synthroid)................................................................. 20

LEXIVA – fosamprenavir calcium susp 50 mg/ml(base equiv).................................................................7

LEXIVA – fosamprenavir calcium tab 700 mg (baseequiv)............................................................................ 7

lidocaine hcl gel 2%.................................................... 71lidocaine hcl laryngotracheal soln 4% (Lta 360

kit)............................................................................... 67lidocaine hcl soln 4% (Xylocaine)..............................71lidocaine hcl viscous soln 2%.................................... 67lidocaine oint 5%......................................................... 71lidocaine patch 5% (Lidoderm).................................. 71lidocaine-prilocaine cream 2.5-2.5%

(Emla)......................................................................... 71lindane lotion 1%......................................................... 71lindane shampoo 1%...................................................71liothyronine sodium tab 25 mcg

(Cytomel)....................................................................20liothyronine sodium tab 50 mcg

(Cytomel)....................................................................20liothyronine sodium tab 5 mcg

(Cytomel)....................................................................20lisinopril & hydrochlorothiazide tab 10-12.5 mg

(Zestoretic).................................................................22lisinopril & hydrochlorothiazide tab 20-12.5 mg

(Zestoretic).................................................................23lisinopril & hydrochlorothiazide tab 20-25 mg

(Zestoretic).................................................................23lisinopril tab 10 mg (Prinivil).......................................23lisinopril tab 2.5 mg (Zestril).......................................23lisinopril tab 20 mg (Prinivil).......................................23lisinopril tab 30 mg (Zestril)........................................23lisinopril tab 40 mg (Zestril)........................................23lisinopril tab 5 mg (Prinivil)......................................... 23lithium carbonate cap 150 mg (Lithium

carbonate)..................................................................45lithium carbonate cap 300 mg....................................45lithium carbonate cap 600 mg (Lithium

carbonate)..................................................................45lithium carbonate tab 300 mg.................................... 45lithium carbonate tab cr 300 mg

(Lithobid).................................................................... 45lithium carbonate tab cr 450 mg................................ 45LITHIUM – lithium oral solution 8

meq/5ml......................................................................45LOESTRIN 1/20-21 – norethindrone ace & ethinyl

estradiol tab 1 mg-20 mcg...................................... 15LOESTRIN 1.5/30-21 – norethindrone ace & ethinyl

estradiol tab 1.5 mg-30 mcg................................... 15LOESTRIN FE 1/20 – norethindrone ace & ethinyl

estradiol-fe tab 1 mg-20 mcg..................................15

LOESTRIN FE 1.5/30 – norethindrone ace & ethinylestradiol-fe tab 1.5 mg-30 mcg...............................15

LO LOESTRIN FE – norethin-eth estradiol-fe tab 1mg-10 mcg (24)/10 mcg (2).................................... 15

loperamide hcl cap 2 mg............................................ 37loperamide hcl liq 1 mg/5ml (0.2 mg/

ml)............................................................................... 37loperamide hcl tab 2 mg.............................................37loratadine syrup 5 mg/5ml..........................................32loratadine tab 10 mg................................................... 32lorazepam conc 2 mg/ml (Lorazepam

intensol)......................................................................42lorazepam tab 0.5 mg (Ativan)...................................42lorazepam tab 1 mg (Ativan)......................................42lorazepam tab 2 mg (Ativan)......................................42losartan potassium & hydrochlorothiazide tab

100-12.5 mg (Hyzaar)..............................................23losartan potassium & hydrochlorothiazide tab 100-25

mg (Hyzaar)...............................................................23losartan potassium & hydrochlorothiazide tab

50-12.5 mg (Hyzaar)................................................23losartan potassium tab 100 mg

(Cozaar)..................................................................... 24losartan potassium tab 25 mg

(Cozaar)..................................................................... 24losartan potassium tab 50 mg

(Cozaar)..................................................................... 24LOSEASONIQUE – levonorg-eth est

tab 0.1-0.02mg(84) & eth est tab0.01mg(7)...................................................................15

LOTEMAX – loteprednol etabonate ophth susp0.5%............................................................................65

lovastatin tab 10 mg....................................................28lovastatin tab 20 mg (Mevacor)................................. 28lovastatin tab 40 mg (Mevacor)................................. 28loxapine succinate cap 10 mg................................... 45loxapine succinate cap 25 mg................................... 45loxapine succinate cap 50 mg................................... 45loxapine succinate cap 5 mg..................................... 45LYRICA – pregabalin cap 100 mg.............................57LYRICA – pregabalin cap 150 mg.............................57LYRICA – pregabalin cap 200 mg.............................57LYRICA – pregabalin cap 225 mg.............................57LYRICA – pregabalin cap 25 mg...............................57LYRICA – pregabalin cap 300 mg.............................57LYRICA – pregabalin cap 50 mg...............................57LYRICA – pregabalin cap 75 mg...............................57

M

magnesium citrate soln...............................................37magnesium oxide tab 400 mg....................................37malathion lotion 0.5% (Ovide)....................................71meclizine hcl tab 12.5 mg...........................................39

2015

94

meclizine hcl tab 12.5 mg...........................................39meclizine hcl tab 25 mg..............................................39meclizine hcl tab 25 mg..............................................39medroxyprogesterone acetate im susp 150 mg/ml

(Depo-provera contrac)............................................15medroxyprogesterone acetate tab 10 mg

(Provera).................................................................... 14medroxyprogesterone acetate tab 2.5 mg

(Provera).................................................................... 14medroxyprogesterone acetate tab 5 mg

(Provera).................................................................... 14mefloquine hcl tab 250 mg........................................... 9megestrol acetate susp 40 mg/ml (Megace

oral).............................................................................11megestrol acetate tab 20 mg..................................... 11megestrol acetate tab 40 mg..................................... 11MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg

(base equivalent)...................................................... 11MEKINIST – trametinib dimethyl sulfoxide tab 2 mg

(base equivalent)...................................................... 11meloxicam tab 15 mg (Mobic)....................................54meloxicam tab 7.5 mg (Mobic)...................................54MEPHYTON – phytonadione tab 5 mg.....................59mercaptopurine tab 50 mg (Purinethol).................... 11mesalamine enema 4 gm...........................................40MESTINON – pyridostigmine bromide syrup 60

mg/5ml........................................................................59MESTINON TIMESPAN – pyridostigmine bromide

tab cr 180 mg............................................................59METAMUCIL MULTIHEALTH FIB – psyllium powder

55.46%....................................................................... 37METAMUCIL MULTIHEALTH FIB – psyllium powder

63%.............................................................................37METAMUCIL SMOOTH TEXTURE – psyllium

powder 63%.............................................................. 37metaxalone tab 800 mg (Skelaxin)............................59metformin hcl tab 1000 mg

(Glucophage).............................................................18metformin hcl tab 500 mg

(Glucophage).............................................................18metformin hcl tab 850 mg

(Glucophage).............................................................18metformin hcl tab sr 24hr 500 mg (Glucophage

xr)................................................................................ 18metformin hcl tab sr 24hr 750 mg (Glucophage

xr)................................................................................ 18methadone hcl conc 10 mg/ml

(Methadose)...............................................................52methadone hcl soln 10 mg/5ml (Methadone

hcl).............................................................................. 52methadone hcl soln 5 mg/5ml (Methadone

hcl).............................................................................. 52

methadone hcl tab 10 mg (Dolophine)......................52methadone hcl tab 5 mg (Dolophine

hcl).............................................................................. 52methadone hcl tab for oral susp 40 mg.................... 52methazolamide tab 25 mg

(Neptazane)...............................................................29methazolamide tab 50 mg

(Neptazane)...............................................................29methimazole tab 10 mg (Tapazole)...........................20methimazole tab 5 mg (Tapazole).............................20methocarbamol tab 500 mg (Robaxin)......................59methocarbamol tab 750 mg

(Robaxin-750)............................................................59methotrexate sodium tab 2.5 mg (base

equiv)..........................................................................11methscopolamine bromide tab 2.5 mg

(Pamine).....................................................................38methscopolamine bromide tab 5 mg (Pamine

forte)............................................................................38methyldopa tab 250 mg..............................................31methyldopa tab 500 mg..............................................31methylergonovine maleate tab 0.2 mg......................21METHYLPHENIDATE HCL ER – methylphenidate

hcl tab cr 10 mg....................................................... 48METHYLPHENIDATE HCL ER – methylphenidate

hcl tab sa osm 18 mg.............................................. 48METHYLPHENIDATE HCL ER – methylphenidate



hcl tab sa osm 54 mg.............................................. 48methylphenidate hcl tab 10 mg

(Ritalin)....................................................................... 48methylphenidate hcl tab 20 mg

(Ritalin)....................................................................... 48methylphenidate hcl tab 5 mg (Ritalin)......................48methylphenidate hcl tab cr 20 mg (Ritalin

sr)................................................................................ 48methylprednisolone tab 16 mg

(Medrol)......................................................................12methylprednisolone tab 32 mg

(Medrol)......................................................................12methylprednisolone tab 4 mg (Medrol)..................... 12methylprednisolone tab 4 mg dose pack (Medrol

dosepak).................................................................... 12methylprednisolone tab 8 mg (Medrol)..................... 12METIPRANOLOL – metipranolol ophth soln

0.3%............................................................................66metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).................................................................... 40

2015

95

metoclopramide hcl tab 10 mg(Reglan)......................................................................40

metoclopramide hcl tab 5 mg (Reglan).....................40metolazone tab 10 mg................................................ 29metolazone tab 2.5 mg (Zaroxolyn).......................... 29metolazone tab 5 mg (Zaroxolyn)..............................29metoprolol succinate tab sr 24hr 100 mg (Toprol

xl).................................................................................25metoprolol succinate tab sr 24hr 200 mg (Toprol



xl).................................................................................25metoprolol tartrate tab 100 mg

(Lopressor).................................................................25metoprolol tartrate tab 25 mg.....................................25metoprolol tartrate tab 50 mg

(Lopressor).................................................................25metronidazole cream 0.75%

(Metrocream).............................................................68metronidazole gel 0.75%............................................ 68metronidazole gel 1% (Metrogel)...............................68metronidazole lotion 0.75%

(Metrolotion)...............................................................68metronidazole tab 250 mg (Flagyl)..............................9metronidazole tab 500 mg (Flagyl)..............................9metronidazole vaginal gel 0.75% (Metrogel-

vaginal).......................................................................41mexiletine hcl cap 150 mg..........................................30mexiletine hcl cap 200 mg..........................................30mexiletine hcl cap 250 mg..........................................30MICARDIS HCT – telmisartan-hydrochlorothiazide

tab 40-12.5 mg..........................................................24MICARDIS HCT – telmisartan-hydrochlorothiazide

tab 80-12.5 mg..........................................................24MICARDIS HCT – telmisartan-hydrochlorothiazide

tab 80-25 mg.............................................................24MICARDIS – telmisartan tab 20 mg..........................24MICARDIS – telmisartan tab 40 mg..........................24MICARDIS – telmisartan tab 80 mg..........................24miconazole nitrate aerosol pow 2%.......................... 68miconazole nitrate cream 2%.....................................68miconazole nitrate vaginal cream 2%....................... 41midodrine hcl tab 10 mg.............................................31midodrine hcl tab 2.5 mg............................................31midodrine hcl tab 5 mg............................................... 31MIFEPREX – mifepristone tab 200 mg.....................21MINASTRIN 24 FE – norethindrone ace-

eth estradiol-fe chew tab 1 mg-20 mcg(24)..............................................................................15

MINICAPS OMEGA-3 – omega-3 fatty acids cap 350mg............................................................................... 61

minocycline hcl cap 100 mg (Minocin)........................ 3minocycline hcl cap 50 mg (Minocin).......................... 3minocycline hcl cap 75 mg (Minocin).......................... 3minocycline hcl tab 100 mg..........................................3minocycline hcl tab 50 mg............................................3minocycline hcl tab 75 mg............................................3minoxidil tab 10 mg..................................................... 31minoxidil tab 2.5 mg.................................................... 31MIRCETTE – desogest-eth estrad & eth estrad tab

0.15-0.02/0.01 mg(21/5).......................................... 15MIRENA – levonorgestrel releasing iud 20 mcg/24hr

(52 mg total)..............................................................15mirtazapine tab 15 mg (Remeron).............................43mirtazapine tab 30 mg (Remeron).............................43mirtazapine tab 45 mg (Remeron).............................43mirtazapine tab 7.5 mg............................................... 43misoprostol tab 100 mcg (Cytotec)........................... 38misoprostol tab 200 mcg (Cytotec)........................... 38modafinil tab 100 mg (Provigil).................................. 48modafinil tab 200 mg (Provigil).................................. 48MODICON – norethindrone & ethinyl estradiol tab

0.5 mg-35 mcg..........................................................15moexipril hcl tab 15 mg (Univasc)............................. 23moexipril hcl tab 7.5 mg (Univasc)............................ 23moexipril-hydrochlorothiazide tab 15-12.5 mg

(Uniretic).....................................................................23moexipril-hydrochlorothiazide tab 15-25

mg............................................................................... 23moexipril-hydrochlorothiazide tab 7.5-12.5

mg............................................................................... 23mometasone furoate cream 0.1%

(Elocon)......................................................................70mometasone furoate oint 0.1%

(Elocon)......................................................................70mometasone furoate solution 0.1% (lotion)

(Elocon)......................................................................70montelukast sodium chew tab 4 mg (base equiv)

(Singulair)...................................................................35montelukast sodium chew tab 5 mg (base equiv)

(Singulair)...................................................................36montelukast sodium oral granules packet 4 mg (base

equiv) (Singulair).......................................................36montelukast sodium tab 10 mg (base equiv)

(Singulair)...................................................................36morphine sulfate (concentrate) oral soln 20 mg/

ml.................................................................................52morphine sulfate beads cap sr 24hr 120 mg

(Avinza)...................................................................... 52morphine sulfate beads cap sr 24hr 30 mg

(Avinza)...................................................................... 52

2015

96

morphine sulfate beads cap sr 24hr 45 mg(Avinza)...................................................................... 52




MORPHINE SULFATE – morphine sulfate suppos10 mg......................................................................... 52



MORPHINE SULFATE – morphine sulfate suppos 5mg............................................................................... 52

MORPHINE SULFATE – morphine sulfate tab 15mg............................................................................... 52

MORPHINE SULFATE – morphine sulfate tab 30mg............................................................................... 52

morphine sulfate oral soln 10 mg/5ml.......................52morphine sulfate oral soln 20 mg/5ml.......................52morphine sulfate tab cr 100 mg (Ms

contin).........................................................................52morphine sulfate tab cr 15 mg (Ms




contin).........................................................................53MULTAQ – dronedarone hcl tab 400 mg (base

equivalent)................................................................. 30multiple vitamins w/ iron tab ......................................60multiple vitamin tab .................................................... 60mupirocin calcium cream 2%

(Bactroban)................................................................ 68mupirocin oint 2% (Bactroban).................................. 68MYCOBUTIN – rifabutin cap 150 mg..........................4mycophenolate mofetil cap 250 mg

(Cellcept)....................................................................72mycophenolate mofetil for oral susp 200 mg/ml

(Cellcept)....................................................................73mycophenolate mofetil tab 500 mg

(Cellcept)....................................................................73mycophenolate sodium tab dr 180 mg (mycophenolic

acid equiv) (Myfortic)................................................73mycophenolate sodium tab dr 360 mg (mycophenolic

acid equiv) (Myfortic)................................................73MYLERAN – busulfan tab 2 mg................................ 11

N

nabumetone tab 500 mg............................................ 54nabumetone tab 750 mg............................................ 54nadolol tab 20 mg (Corgard)......................................25nadolol tab 40 mg (Corgard)......................................25nadolol tab 80 mg (Corgard)......................................25naloxone hcl inj 0.4 mg/ml..........................................73naltrexone hcl tab 50 mg (Revia).............................. 50NAPHAZOLINE HCL – naphazoline hcl ophth soln

0.1%............................................................................66naphazoline w/ pheniramine ophth soln

0.025-0.3%.................................................................66naproxen sodium tab 220 mg.................................... 54naproxen sodium tab 275 mg

(Anaprox)................................................................... 54naproxen sodium tab 550 mg (Anaprox

ds)............................................................................... 54naproxen susp 125 mg/5ml

(Naprosyn)................................................................. 54naproxen tab 250 mg (Naprosyn)..............................55naproxen tab 375 mg (Naprosyn)..............................55naproxen tab 500 mg (Naprosyn)..............................55naproxen tab ec 375 mg (Ec-

naprosyn)................................................................... 54naproxen tab ec 500 mg (Ec-

naprosyn)................................................................... 54naratriptan hcl tab 1 mg (base equiv)

(Amerge).................................................................... 55naratriptan hcl tab 2.5 mg (base equiv)

(Amerge).................................................................... 55NASONEX – mometasone furoate nasal susp 50

mcg/act.......................................................................33NATACYN – natamycin ophth susp

5%...............................................................................65NATAZIA – estradiol valerate-dienogest tab 3

mg /2-2 mg/2-3 mg/1 mg.........................................16nateglinide tab 120 mg (Starlix).................................18nateglinide tab 60 mg (Starlix)...................................18NECON 1/50-28 – norethindrone & mestranol tab 1

mg-50 mcg.................................................................16NECON 10/11-28 – norethindrone-eth estradiol tab

0.5-35/1-35 mg-mcg (10/11)................................... 16neomycin-bacitracin-polymyxin oint ......................... 69neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin..........................65neomycin-polymy-gramicid op sol

1.75-10000-0.025mg-unt-mg/ml(Neosporin)................................................................ 65

neomycin-polymyxin-dexamethasone ophth oint0.1% (Maxitrol)..........................................................65

neomycin-polymyxin-dexamethasone ophth susp0.1% (Maxitrol)..........................................................65

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97

neomycin-polymyxin-hc otic soln 1%(Cortisporin)...............................................................67

neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000unit/ml-1%.................................................................. 67

neomycin sulfate tab 500 mg.......................................4NEUPOGEN – filgrastim inj 300 mcg/0.5ml (600

mcg/ml).......................................................................64NEUPOGEN – filgrastim inj 300 mcg/

ml.................................................................................64NEUPOGEN – filgrastim inj 480 mcg/0.8ml (600

mcg/ml).......................................................................64NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300

mcg/ml).......................................................................64nevirapine tab 200 mg (Viramune).............................. 7nevirapine tab sr 24hr 400 mg (Viramune

xr).................................................................................. 7NEXAVAR – sorafenib tosylate tab 200 mg (base

equivalent)................................................................. 11NEXPLANON – etonogestrel subdermal implant 68

mg............................................................................... 16niacin cap cr 250 mg.................................................. 59niacin cap cr 500 mg.................................................. 59niacin tab 100 mg........................................................60niacin tab 500 mg........................................................60niacin tab 50 mg.......................................................... 60niacin tab cr 1000 mg (antihyperlipidemic)

(Niaspan)....................................................................28niacin tab cr 250 mg................................................... 59niacin tab cr 500 mg................................................... 59niacin tab cr 500 mg (antihyperlipidemic)

(Niaspan)....................................................................28niacin tab cr 750 mg................................................... 60niacin tab cr 750 mg (antihyperlipidemic)

(Niaspan)....................................................................28NIACIN TR – niacin tab cr 1000 mg..........................60nicotine polacrilex gum 2 mg..................................... 50nicotine polacrilex gum 4 mg..................................... 50nicotine td patch 24hr 14 mg/24hr.............................50nicotine td patch 24hr 21 mg/24hr.............................50nicotine td patch 24hr 7 mg/24hr...............................50nifedipine tab sr 24hr 30 mg (Adalat

cc)............................................................................... 26nifedipine tab sr 24hr 60 mg (Adalat

cc)............................................................................... 26nifedipine tab sr 24hr 90 mg (Adalat

cc)............................................................................... 27nifedipine tab sr 24hr osmotic 30 mg (Procardia

xl).................................................................................26nifedipine tab sr 24hr osmotic 60 mg (Procardia

xl).................................................................................26nifedipine tab sr 24hr osmotic 90 mg (Procardia

xl).................................................................................26

nitrofurantoin macrocrystalline cap 100 mg(Macrodantin)............................................................ 40

nitrofurantoin macrocrystalline cap 50 mg(Macrodantin)............................................................ 40

nitrofurantoin monohydrate macrocrystalline cap 100mg (Macrobid)...........................................................40

nitrofurantoin susp 25 mg/5ml(Furadantin)............................................................... 40

nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)..............................................................................27




NITROSTAT – nitroglycerin sl tab 0.3mg............................................................................... 27



NONOXYNOL-9 – various..........................................41norelgestromin-ethinyl estradiol td ptwk 150-35

mcg/24hr (Ortho evra)............................................. 16norethindrone acetate tab 5 mg

(Aygestin)...................................................................14NORINYL 1+35 – norethindrone & ethinyl estradiol

tab 1 mg-35 mcg...................................................... 16NORINYL 1+50 – norethindrone & mestranol tab 1

mg-50 mcg.................................................................16NOR-QD – norethindrone tab 0.35 mg..................... 16nortriptyline hcl cap 10 mg (Pamelor)....................... 44nortriptyline hcl cap 25 mg (Pamelor)....................... 44nortriptyline hcl cap 50 mg (Pamelor)....................... 44nortriptyline hcl cap 75 mg (Pamelor)....................... 44NORTRIPTYLINE HCL – nortriptyline hcl soln 10

mg/5ml........................................................................44NORVIR – ritonavir cap 100 mg..................................7NORVIR – ritonavir oral soln 80 mg/ml.......................7NORVIR – ritonavir tab 100 mg...................................7NOVOLIN 70/30 – insulin isophane & regular

(human) inj 100 unit/ml (70-30).............................. 19NOVOLIN 70/30 RELION – insulin isophane

& regular (human) inj 100 unit/ml(70-30)........................................................................19

NOVOLIN N – insulin isophane (human) inj 100 unit/ml.................................................................................19

NOVOLIN N RELION – insulin isophane (human) inj100 unit/ml................................................................. 19

NOVOLIN R – insulin regular (human) inj 100 unit/ml.................................................................................19

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98

NOVOLIN R RELION – insulin regular (human) inj100 unit/ml................................................................. 19

NOVOLOG FLEXPEN – insulin aspart soln pen-injector 100 unit/ml................................................... 18

NOVOLOG – insulin aspart inj 100 unit/ml.................................................................................18

NOVOLOG MIX 70/30 – insulin aspart prot & aspart(human) inj 100 unit/ml (70-30).............................. 19

NOVOLOG MIX 70/30 PREFILL – insulinaspart prot & aspart sus pen-inj 100 unit/ml(70-30)........................................................................19

NOVOLOG PENFILL – insulin aspart inj 100 unit/ml.................................................................................18

NOVOLOG PENFILL – insulin aspart soln cartridge100 unit/ml................................................................. 18

NOXAFIL – posaconazole susp 40 mg/ml...................................................................................4

NOXAFIL – posaconazole tab delayed release 100mg................................................................................. 4

NUEDEXTA – dextromethorphan hbr-quinidinesulfate cap 20-10 mg............................................... 50

NUVARING – etonogestrel-ethinyl estradiol va ring0.120-0.015 mg/24hr................................................16

nystatin cream 100000 unit/gm..................................69nystatin oint 100000 unit/gm...................................... 69nystatin susp 100000 unit/ml..................................... 67nystatin tab 500000 unit................................................4nystatin topical powder ..............................................69nystatin-triamcinolone cream 100000-0.1 unit/gm-

%................................................................................. 70nystatin-triamcinolone oint 100000-0.1 unit/gm-

%................................................................................. 70

O

octreotide acetate inj 1000 mcg/ml (1 mg/ml)(Sandostatin)............................................................. 21

octreotide acetate inj 100 mcg/ml (0.1 mg/ml)(Sandostatin)............................................................. 21




OFLOXACIN – ofloxacin tab 400 mg.......................... 4ofloxacin ophth soln 0.3% (Ocuflox)..........................65ofloxacin otic soln 0.3%..............................................67OGESTREL – norgestrel & ethinyl estradiol tab 0.5

mg-50 mcg.................................................................16olanzapine orally disintegrating tab 10 mg (Zyprexa

zydis).......................................................................... 45olanzapine orally disintegrating tab 15 mg (Zyprexa

zydis).......................................................................... 45

olanzapine orally disintegrating tab 20 mg (Zyprexazydis).......................................................................... 45

olanzapine orally disintegrating tab 5 mg (Zyprexazydis).......................................................................... 45

olanzapine tab 10 mg (Zyprexa)................................45olanzapine tab 15 mg (Zyprexa)................................45olanzapine tab 2.5 mg (Zyprexa)...............................45olanzapine tab 20 mg (Zyprexa)................................45olanzapine tab 5 mg (Zyprexa)..................................45olanzapine tab 7.5 mg (Zyprexa)...............................45OLYSIO – simeprevir sodium cap 150 mg (base

equivalent)....................................................................5OMEGA-3 2100 – omega-3 fatty acids cap 1050

mg............................................................................... 61omega-3 fatty acids cap 1000 mg ............................61omega-3 fatty acids cap 1200 mg ............................61omega-3 fatty acids cap 435 mg .............................. 61omega-3 fatty acids cap 500 mg .............................. 61omega-3 fatty acids cap delayed release 1000 mg

.....................................................................................61omega-3 fatty acids cap delayed release 1200 mg

.....................................................................................61OMEGA-3 IQ – omega-3 fatty acids chew tab 240

mg............................................................................... 61OMEGA-3 – omega-3 fatty acids cap 1400

mg............................................................................... 61OMEGA POWER – omega-3 fatty acids cap 1050

mg............................................................................... 61omeprazole cap delayed release 10 mg

(Prilosec).................................................................... 38omeprazole cap delayed release 20 mg

(Prilosec).................................................................... 38omeprazole cap delayed release 40 mg

(Prilosec).................................................................... 38OMEPRAZOLE – omeprazole delayed release tab

20 mg......................................................................... 38OMNITROPE – somatropin for inj 5.8

mg............................................................................... 20OMNITROPE – somatropin inj 10

mg/1.5ml.................................................................... 20OMNITROPE – somatropin inj 5

mg/1.5ml.................................................................... 20ondansetron hcl oral soln 4 mg/5ml

(Zofran).......................................................................39ondansetron hcl tab 24 mg........................................ 39ondansetron hcl tab 4 mg (Zofran)............................39ondansetron hcl tab 8 mg (Zofran)............................39ondansetron orally disintegrating tab 4 mg (Zofran

odt)..............................................................................39ondansetron orally disintegrating tab 8 mg (Zofran

odt)..............................................................................39OPSUMIT – macitentan tab 10 mg........................... 31

2015

99

oral contraceptives – all generics.............................. 16oral electrolyte solution ..............................................61orphenadrine citrate tab sr 12hr 100

mg............................................................................... 59orphenadrine w/ aspirin & caffeine tab 25-385-30

mg............................................................................... 59ORTHO-CEPT – desogestrel & ethinyl estradiol tab

0.15 mg-30 mcg........................................................16ORTHO-CYCLEN – norgestimate & ethinyl estradiol

tab 0.25 mg-35 mcg.................................................16ORTHO EVRA – norelgestromin-ethinyl estradiol td

ptwk 150-35 mcg/24hr............................................. 16ORTHO MICRONOR – norethindrone tab 0.35

mg............................................................................... 16ORTHO-NOVUM 1/35 – norethindrone & ethinyl

estradiol tab 1 mg-35 mcg...................................... 16ORTHO-NOVUM 7/7/7 – norethindrone-eth estradiol

tab 0.5-35/0.75-35/1-35 mg-mcg............................16ORTHO TRI-CYCLEN LO – norgestimate-

eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg............................................................................. 16

ORTHO TRI-CYCLEN – norgestimate-eth estrad tab0.18-35/0.215-35/0.25-35 mg-mcg.........................16

OVCON-35 – norethindrone & ethinyl estradiol tab0.4 mg-35 mcg..........................................................16

oxaprozin tab 600 mg (Daypro).................................55oxcarbazepine susp 300 mg/5ml (60 mg/ml)

(Trileptal).................................................................... 57oxcarbazepine tab 150 mg (Trileptal)....................... 57oxcarbazepine tab 300 mg (Trileptal)....................... 57oxcarbazepine tab 600 mg (Trileptal)....................... 57oxybutynin chloride syrup 5 mg/5ml..........................41oxybutynin chloride tab 5 mg..................................... 41oxybutynin chloride tab sr 24hr 10 mg (Ditropan

xl).................................................................................41oxybutynin chloride tab sr 24hr 15 mg (Ditropan

xl).................................................................................41oxybutynin chloride tab sr 24hr 5 mg (Ditropan

xl).................................................................................41oxycodone-aspirin tab 4.8355-325 mg

(Percodan)................................................................. 53oxycodone hcl cap 5 mg.............................................53oxycodone hcl conc 100 mg/5ml (20 mg/ml)

(Oxycodone hcl)........................................................53OXYCODONE HCL – oxycodone hcl conc 100

mg/5ml (20 mg/ml)................................................... 53oxycodone hcl soln 5 mg/5ml (Oxycodone

hcl).............................................................................. 53oxycodone hcl tab 10 mg........................................... 53oxycodone hcl tab 15 mg

(Roxicodone)............................................................. 53oxycodone hcl tab 20 mg........................................... 53

oxycodone hcl tab 30 mg(Roxicodone)............................................................. 53

oxycodone hcl tab 5 mg (Roxicodone)..................... 53oxycodone w/ acetaminophen tab 10-325 mg

(Percocet).................................................................. 53oxycodone w/ acetaminophen tab 5-325 mg

(Percocet).................................................................. 53oxycodone w/ acetaminophen tab 7.5-325 mg

(Percocet).................................................................. 53

P

pantoprazole sodium ec tab 20 mg (base equiv)(Protonix)....................................................................38

pantoprazole sodium ec tab 40 mg (base equiv)(Protonix)....................................................................38

PARAGARD INTRAUTERINE COP – copperiud............................................................................... 16

paricalcitol cap 1 mcg (Zemplar)............................... 21paricalcitol cap 2 mcg (Zemplar)............................... 21paricalcitol cap 4 mcg (Zemplar)............................... 21paromomycin sulfate cap 250 mg................................4paroxetine hcl tab 10 mg (Paxil)................................44paroxetine hcl tab 20 mg (Paxil)................................44paroxetine hcl tab 30 mg (Paxil)................................44paroxetine hcl tab 40 mg (Paxil)................................44paroxetine hcl tab sr 24hr 12.5 mg (Paxil

cr)................................................................................ 44paroxetine hcl tab sr 24hr 25 mg (Paxil

cr)................................................................................ 44paroxetine hcl tab sr 24hr 37.5 mg (Paxil

cr)................................................................................ 44PATADAY – olopatadine hcl ophth soln

0.2%............................................................................66PEAK FLOW METER – various................................ 72PEDIA-LAX – glycerin liquid suppos 2.8 gm (2.7

ml)............................................................................... 37pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/

ml ...............................................................................60pediatric multiple vitamins w/ fluoride chew tab 0.25

mg ..............................................................................60pediatric multiple vitamins w/ fluoride chew tab 0.5

mg ..............................................................................60pediatric multiple vitamins w/ fluoride chew tab 1 mg

.....................................................................................60pediatric multiple vitamins w/ fluoride soln 0.25 mg/

ml ...............................................................................60pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml

.....................................................................................60pediatric multiple vitamin w/ c & fa chew

tab............................................................................... 60pediatric multiple vitamin w/ c soln 35 mg/ml

.....................................................................................60

2015

100

pediatric vitamins acd w/ fluoride soln 0.25 mg/ml.....................................................................................60

pediatric vitamins acd w/ fluoride soln 0.5 mg/ml.....................................................................................60

pediatric vitamins adc drops 1500 unit-400 unit-35mg/ml ........................................................................ 60

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236gm (Golytely).............................................................37

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240gm (Colyte-flavor packs)..........................................37

peg 3350-kcl-sod bicarb-nacl for soln 420 gm(Nulytely/flavor pack)................................................37

PEGASYS – peginterferon alfa-2a inj 180mcg/0.5ml.....................................................................6

PEGASYS – peginterferon alfa-2a inj 180 mcg/ml...................................................................................6

PEGASYS – peginterferon alfa-2a inj kit 180mcg/0.5ml.....................................................................6

PEGASYS PROCLICK – peginterferon alfa-2a inj135 mcg/0.5ml.............................................................6

PEGASYS PROCLICK – peginterferon alfa-2a inj180 mcg/0.5ml.............................................................6

PEGINTRON – peginterferon alfa-2b for inj kit 120mcg/0.5ml.....................................................................6

PEG-INTRON – peginterferon alfa-2b for inj kit 120mcg/0.5ml.....................................................................5







PEG-INTRON REDIPEN PAK 4 – peginterferonalfa-2b for inj kit 120 mcg/0.5ml................................5

PEG-INTRON REDIPEN PAK 4 – peginterferonalfa-2b for inj kit 150 mcg/0.5ml................................5

PEG-INTRON REDIPEN PAK 4 – peginterferonalfa-2b for inj kit 50 mcg/0.5ml..................................5

PEG-INTRON REDIPEN PAK 4 – peginterferonalfa-2b for inj kit 80 mcg/0.5ml..................................5

PEG-INTRON REDIPEN – peginterferon alfa-2b forinj kit 120 mcg/0.5ml.................................................. 5

PEG-INTRON REDIPEN – peginterferon alfa-2b forinj kit 150 mcg/0.5ml.................................................. 5

PEG-INTRON REDIPEN – peginterferon alfa-2b forinj kit 50 mcg/0.5ml.................................................... 5

PEG-INTRON REDIPEN – peginterferon alfa-2b forinj kit 80 mcg/0.5ml.................................................... 5

penicillin v potassium for soln 125mg/5ml..........................................................................1

penicillin v potassium for soln 250mg/5ml..........................................................................1

penicillin v potassium tab 250 mg............................... 1penicillin v potassium tab 500 mg............................... 1PENTASA – mesalamine cap cr 250

mg............................................................................... 40PENTASA – mesalamine cap cr 500

mg............................................................................... 40pentoxifylline tab cr 400 mg....................................... 64PEPCID – famotidine tab 20 mg............................... 38perindopril erbumine tab 2 mg...................................23perindopril erbumine tab 4 mg (Aceon).................... 23perindopril erbumine tab 8 mg (Aceon).................... 23permethrin cream 5% (Elimite).................................. 71permethrin creme rinse 1%........................................71permethrin lotion 1%................................................... 71perphenazine tab 16 mg.............................................46perphenazine tab 2 mg...............................................46perphenazine tab 4 mg...............................................46perphenazine tab 8 mg...............................................46phenelzine sulfate tab 15 mg (Nardil)....................... 44phenobarbital elixir 20 mg/5ml...................................47PHENOBARBITAL – phenobarbital tab 100

mg............................................................................... 47PHENOBARBITAL – phenobarbital tab 15



mg............................................................................... 47phenobarbital tab 16.2 mg......................................... 47phenobarbital tab 32.4 mg......................................... 47phenylephrine-brompheniramine-dm elixir 2.5-1-5

mg/5ml........................................................................34phenylephrine-guaifenesin tab 10-400

mg............................................................................... 34phenylephrine hcl tab 10 mg......................................33phenylephrine w/ dm-gg liqd 5-10-200

mg/5ml........................................................................34phenytoin chew tab 50 mg (Dilantin

infatabs)......................................................................57phenytoin sodium extended cap 100 mg

(Dilantin).....................................................................57phenytoin sodium extended cap 200 mg

(Phenytek)..................................................................57phenytoin sodium extended cap 300 mg

(Phenytek)..................................................................57phenytoin susp 125 mg/5ml (Dilantin).......................57

2015

101

pilocarpine hcl ophth soln 1% (Isoptocarpine)...................................................................... 66



pilocarpine hcl tab 5 mg (Salagen)............................67pilocarpine hcl tab 7.5 mg (Salagen)........................ 67pindolol tab 10 mg.......................................................25pindolol tab 5 mg.........................................................25pioglitazone hcl-metformin hcl tab 15-500 mg

(Actoplus met)...........................................................18pioglitazone hcl-metformin hcl tab 15-850 mg

(Actoplus met)...........................................................18pioglitazone hcl tab 15 mg (base equiv)

(Actos)........................................................................ 18pioglitazone hcl tab 30 mg (base equiv)

(Actos)........................................................................ 18pioglitazone hcl tab 45 mg (base equiv)

(Actos)........................................................................ 18piroxicam cap 10 mg (Feldene)................................. 55piroxicam cap 20 mg (Feldene)................................. 55PLAN B – levonorgestrel tab 0.75 mg.......................16PLAN B ONE-STEP – levonorgestrel tab 1.5

mg............................................................................... 16PLAN B ONE-STEP – levonorgestrel tab 1.5

mg............................................................................... 16podofilox soln 0.5% (Condylox)................................. 71polyethylene glycol 3350 oral packet........................ 37polyethylene glycol 3350 oral powder.......................37polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1% (Polytrim)....................................................65pot & sod citrates w/ cit ac soln 550-500-334

mg/5ml........................................................................41potassium chloride cap cr 10 meq (Micro-

k)................................................................................. 61potassium chloride cap cr 8 meq (Micro-

k)................................................................................. 61potassium chloride microencapsulated crys cr tab 10

meq............................................................................. 61potassium chloride microencapsulated crys cr tab 20

meq............................................................................. 61potassium chloride oral liq 10% (20

meq/15ml).................................................................. 61potassium chloride powder packet 20

meq............................................................................. 61potassium chloride tab cr 10 meq (K-

tab)..............................................................................61potassium chloride tab cr 8 meq (600

mg)..............................................................................61potassium citrate & citric acid powder pack

3300-1002 mg...........................................................41

potassium citrate & citric acid soln 1100-334mg/5ml........................................................................41

potassium citrate tab cr 10 meq (1080 mg) (Urocit-k10)...............................................................................41

potassium citrate tab cr 5 meq (540 mg) (Urocit-k5)................................................................................. 41

pot bicarbonate & chloride effer tab 25meq............................................................................. 61

pot phos monobasic w/sod phos di & monobas tab155-852-130mg (K-phos neutral)........................... 61

pramipexole dihydrochloride tab 0.125 mg(Mirapex).................................................................... 58





pramipexole dihydrochloride tab 1 mg(Mirapex).................................................................... 58

pravastatin sodium tab 10 mg....................................28pravastatin sodium tab 20 mg

(Pravachol).................................................................28pravastatin sodium tab 40 mg

(Pravachol).................................................................28pravastatin sodium tab 80 mg

(Pravachol).................................................................28prazosin hcl cap 1 mg (Minipress)............................ 31prazosin hcl cap 2 mg (Minipress)............................ 31prazosin hcl cap 5 mg (Minipress)............................ 31prednisolone acetate ophth susp 1% (Pred

forte)............................................................................65PREDNISOLONE SODIUM PHOSP – prednisolone

sodium phosphate ophth soln 1%.......................... 65prednisolone sod phosphate oral soln 15 mg/5ml

(base equiv)...............................................................12prednisolone sod phosph oral soln 6.7 mg/5ml (5

mg/5ml base) (Pediapred).......................................12prednisolone syrup 15 mg/5ml (usp solution

equivalent) (Prelone)................................................13PREDNISONE – prednisone oral soln 5

mg/5ml........................................................................13PREDNISONE – prednisone tab 10 mg dose

pack............................................................................ 13PREDNISONE – prednisone tab 50

mg............................................................................... 13PREDNISONE – prednisone tab 5 mg dose

pack............................................................................ 13prednisone tab 10 mg.................................................13prednisone tab 1 mg................................................... 13

2015

102

prednisone tab 2.5 mg................................................13prednisone tab 20 mg.................................................13prednisone tab 5 mg................................................... 13PREMPRO – conjugated estrogen-medroxyprogest

acetate tab 0.3-1.5 mg.............................................14PREMPRO – conjugated estrogen-medroxyprogest

acetate tab 0.45-1.5 mg.......................................... 14PREMPRO – conjugated estrogen-medroxyprogest

acetate tab 0.625-5 mg........................................... 14PRENATAL MULTIVITAMINS/FOLIC

ACID........................................................................... 60PREVACID – lansoprazole cap delayed release 15

mg............................................................................... 38PREZISTA – darunavir ethanolate susp 100 mg/ml

(base equiv).................................................................8PREZISTA – darunavir ethanolate tab 150 mg (base

equiv)............................................................................ 8PREZISTA – darunavir ethanolate tab 600 mg (base



equiv)............................................................................ 8PRIFTIN – rifapentine tab 150 mg...............................4PRIMAQUINE PHOSPHATE – primaquine

phosphate tab 26.3 mg..............................................9primidone tab 250 mg (Mysoline).............................. 57primidone tab 50 mg (Mysoline)................................ 57PROAIR HFA – albuterol sulfate inhal aero 108 mcg/

act (90mcg base equiv)........................................... 36probenecid tab 500 mg...............................................55prochlorperazine maleate tab 10 mg

(Compazine).............................................................. 39prochlorperazine maleate tab 5 mg

(Compazine).............................................................. 39prochlorperazine suppos 25 mg................................ 39PROCRIT – epoetin alfa inj 10000 unit/

ml.................................................................................64PROCRIT – epoetin alfa inj 20000 unit/





ml.................................................................................64progesterone micronized cap 100 mg

(Prometrium)..............................................................14progesterone micronized cap 200 mg

(Prometrium)..............................................................14

promethazine hcl suppos 12.5 mg............................ 32promethazine hcl suppos 25 mg................................32promethazine hcl suppos 50 mg................................32promethazine hcl syrup 6.25 mg/5ml........................ 32promethazine hcl tab 12.5 mg................................... 32promethazine hcl tab 25 mg.......................................32promethazine hcl tab 50 mg.......................................32PRO NUTRIENTS OMEGA 3 – omega-3 fatty acids

cap delayed release 332.5 mg............................... 62propafenone hcl cap sr 12hr 225 mg (Rythmol

sr)................................................................................ 30propafenone hcl cap sr 12hr 325 mg (Rythmol

sr)................................................................................ 30propafenone hcl cap sr 12hr 425 mg (Rythmol

sr)................................................................................ 30propafenone hcl tab 150 mg (Rythmol).................... 30propafenone hcl tab 225 mg (Rythmol).................... 30propafenone hcl tab 300 mg...................................... 30PROPRANOLOL/HYDROCHLOROTH – propranolol

& hydrochlorothiazide tab 40-25 mg...................... 25propranolol hcl cap sr 24hr 120 mg (Inderal

la)................................................................................ 25propranolol hcl cap sr 24hr 160 mg (Inderal



la)................................................................................ 25propranolol hcl tab 10 mg...........................................25propranolol hcl tab 20 mg...........................................25propranolol hcl tab 40 mg...........................................25propranolol hcl tab 60 mg...........................................25propranolol hcl tab 80 mg...........................................25propylthiouracil tab 50 mg.......................................... 20PROTOPIC – tacrolimus oint 0.03%.........................71PROTOPIC – tacrolimus oint 0.1%........................... 71psyllium powder 28.3%...............................................37psyllium powder 30.9%...............................................37psyllium powder 30%.................................................. 37psyllium powder 33%.................................................. 37psyllium powder 48.57%.............................................37psyllium powder 58.6%...............................................37psyllium powder 68%.................................................. 37psyllium powder 95%.................................................. 37pyrazinamide tab 500 mg............................................. 4pyridostigmine bromide tab 60 mg

(Mestinon).................................................................. 59

Q

QC CALAMINE – calamine lotion..............................71QUARTETTE – levonor-eth est tab

0.15-0.02/0.025/0.03 mg &eth est 0.01mg............................................................................... 16

2015

103

quetiapine fumarate tab 100 mg(Seroquel).................................................................. 46






quinapril hcl tab 10 mg (Accupril)..............................23quinapril hcl tab 20 mg (Accupril)..............................23quinapril hcl tab 40 mg (Accupril)..............................23quinapril hcl tab 5 mg (Accupril)................................ 23quinapril-hydrochlorothiazide tab 10-12.5 mg

(Accuretic)..................................................................23quinapril-hydrochlorothiazide tab 20-12.5 mg

(Accuretic)..................................................................23quinapril-hydrochlorothiazide tab 20-25 mg

(Accuretic)..................................................................23quinidine gluconate tab cr 324 mg............................ 30QUINIDINE SULFATE – quinidine sulfate tab 200

mg............................................................................... 30quinidine sulfate tab 300 mg......................................30QVAR – beclomethasone dipropionate inhal aero

soln 40 mcg/act........................................................ 36QVAR – beclomethasone dipropionate inhal aero

soln 80 mcg/act........................................................ 36

R

raloxifene hcl tab 60 mg (Evista)...............................21ramipril cap 1.25 mg (Altace).....................................23ramipril cap 10 mg (Altace)........................................ 23ramipril cap 2.5 mg (Altace).......................................23ramipril cap 5 mg (Altace).......................................... 23RANEXA – ranolazine tab sr 12hr 1000

mg............................................................................... 27RANEXA – ranolazine tab sr 12hr 500

mg............................................................................... 27ranitidine hcl cap 150 mg........................................... 38ranitidine hcl cap 300 mg........................................... 38ranitidine hcl syrup 15 mg/ml (75

mg/5ml)...................................................................... 38ranitidine hcl tab 150 mg (Zantac).............................38ranitidine hcl tab 150 mg (Zantac).............................38ranitidine hcl tab 300 mg (Zantac).............................39ranitidine hcl tab 75 mg.............................................. 39REBIF – interferon beta-1a inj 22 mcg/0.5ml (12mu/

ml) (44 mcg/ml).........................................................49REBIF – interferon beta-1a inj 44 mcg/0.5ml (24mu/

ml) (88 mcg/ml).........................................................49

REBIF REBIDOSE – interferon beta-1a inj 22mcg/0.5ml (12mu/ml) (44 mcg/ml)......................... 49

REBIF REBIDOSE – interferon beta-1a inj 44mcg/0.5ml (24mu/ml) (88 mcg/ml)......................... 49

REBIF REBIDOSE TITRATION – interferonbeta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22mcg/0.5ml.................................................................. 49

REBIF TITRATION PACK – interferon beta-1a inj 6 x8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml.........................49

RELENZA DISKHALER – zanamivir aero powderbreath activated 5 mg/blister.....................................9

RELHIST – bromphen tan-phenyleph tan chew tab6-15 mg......................................................................34

RENAGEL – sevelamer hcl tab 400mg............................................................................... 40

RENAGEL – sevelamer hcl tab 800mg............................................................................... 40

repaglinide tab 0.5 mg (Prandin)............................... 18repaglinide tab 1 mg (Prandin).................................. 18repaglinide tab 2 mg (Prandin).................................. 18RESCRIPTOR – delavirdine mesylate tab 100

mg................................................................................. 8RESCRIPTOR – delavirdine mesylate tab 200

mg................................................................................. 8RESPIRATORY THERAPY SUPPLIES –

various........................................................................72REVLIMID – lenalidomide cap 10 mg.......................73REVLIMID – lenalidomide cap 15 mg.......................73REVLIMID – lenalidomide cap 20 mg.......................73REVLIMID – lenalidomide cap 25 mg.......................73REVLIMID – lenalidomide cap 5 mg......................... 73REVLIMID – lenalidomide caps 2.5 mg....................73REYATAZ – atazanavir sulfate cap 150 mg (base

equiv)............................................................................ 8REYATAZ – atazanavir sulfate cap 200 mg (base

equiv)............................................................................ 8REYATAZ – atazanavir sulfate cap 300 mg (base

equiv)............................................................................ 8ribavirin cap 200 mg (Rebetol).....................................6ribavirin tab 200 mg (Copegus)................................... 6rifabutin cap 150 mg (Mycobutin)................................ 4rifampin cap 150 mg (Rifadin)......................................4rifampin cap 300 mg (Rifadin)......................................4riluzole tab 50 mg (Rilutek)........................................ 59risedronate sodium tab 150 mg

(Actonel).....................................................................21risperidone orally disintegrating tab 0.25

mg............................................................................... 46risperidone orally disintegrating tab 0.5 mg

(Risperdal m-tab)......................................................46risperidone orally disintegrating tab 1 mg (Risperdal

m-tab)......................................................................... 46

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risperidone orally disintegrating tab 2 mg (Risperdalm-tab)......................................................................... 46



risperidone soln 1 mg/ml (Risperdal)........................ 46risperidone tab 0.25 mg (Risperdal)..........................46risperidone tab 0.5 mg (Risperdal)............................46risperidone tab 1 mg (Risperdal)............................... 46risperidone tab 2 mg (Risperdal)............................... 46risperidone tab 3 mg (Risperdal)............................... 46risperidone tab 4 mg (Risperdal)............................... 46rivastigmine tartrate cap 1.5 mg

(Exelon)......................................................................50rivastigmine tartrate cap 3 mg (Exelon).................... 50rivastigmine tartrate cap 4.5 mg

(Exelon)......................................................................50rivastigmine tartrate cap 6 mg (Exelon).................... 50rizatriptan benzoate orally disintegrating tab 10 mg

(Maxalt-mlt)................................................................55rizatriptan benzoate orally disintegrating tab 5 mg

(Maxalt-mlt)................................................................55rizatriptan benzoate tab 10 mg

(Maxalt)...................................................................... 55rizatriptan benzoate tab 5 mg (Maxalt)..................... 55ROCHE Blood Glucose Monitoring System –

ACCU-CHEK AVIVA PLUS/COMPACT/NANOSMARTVIEW.............................................................72

ropinirole hydrochloride tab 0.25 mg(Requip)......................................................................58

ropinirole hydrochloride tab 0.5 mg(Requip)......................................................................58

ropinirole hydrochloride tab 1 mg(Requip)......................................................................58





RU-HIST D – brompheniramine & phenylephrine tab4-10 mg......................................................................34

S

SAFYRAL – drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg......................... 17

saline nasal spray 0.65%........................................... 33salsalate tab 500 mg...................................................51salsalate tab 750 mg...................................................51

SB NATURAL FIBER LAXATIVE – psyllium powder49%.............................................................................37

SB OMEPRAZOLE – omeprazole delayed releasetab 20 mg.................................................................. 39

SEASONIQUE – levonorg-eth est tab0.15-0.03mg(84) & eth est tab0.01mg(7)...................................................................17

selegiline hcl cap 5 mg (Eldepryl)..............................58selegiline hcl tab 5 mg................................................58selenium sulfide lotion 2.5%...................................... 71SELZENTRY – maraviroc tab 150 mg........................ 8SELZENTRY – maraviroc tab 300 mg........................ 8sennosides tab 8.6 mg................................................37SENSIPAR – cinacalcet hcl tab 30 mg (base

equiv)..........................................................................21SENSIPAR – cinacalcet hcl tab 60 mg (base

equiv)..........................................................................21SENSIPAR – cinacalcet hcl tab 90 mg (base

equiv)..........................................................................21sertraline hcl oral conc 20 mg/ml

(Zoloft)........................................................................ 44sertraline hcl tab 100 mg (Zoloft)...............................44sertraline hcl tab 25 mg (Zoloft).................................44sertraline hcl tab 50 mg (Zoloft).................................44sildenafil citrate tab 20 mg (Revatio).........................31silver sulfadiazine cream 1%

(Silvadene).................................................................69simethicone chew tab 80 mg..................................... 40simethicone susp 40 mg/0.6ml.................................. 40simvastatin tab 10 mg (Zocor)................................... 28simvastatin tab 20 mg (Zocor)................................... 28simvastatin tab 40 mg (Zocor)................................... 28simvastatin tab 5 mg (Zocor)..................................... 28simvastatin tab 80 mg (Zocor)................................... 28sirolimus tab 0.5 mg (Rapamune)............................. 73sirolimus tab 1 mg (Rapamune)................................ 73sirolimus tab 2 mg (Rapamune)................................ 73SKYLA – levonorgestrel releasing iud 13.5

mg............................................................................... 17SM CALAMINE – calamine lotion..............................71SM OMEPRAZOLE – omeprazole delayed release

tab 20 mg.................................................................. 39sodium citrate & citric acid soln 500-334 mg/5ml

(Shohls solution modi)............................................. 41sodium fluoride chew tab 0.25 mg f (from 0.55 mg

naf) (Luride)...............................................................61sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)

(Luride)....................................................................... 61sodium fluoride chew tab 1 mg f (from 2.2 mg naf)

(Luride)....................................................................... 61sodium fluoride cream 1.1% (Prevident 5000

plus)............................................................................ 67

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105

sodium fluoride gel 1.1% (0.5% f) (Previdentfluoride)...................................................................... 67

SODIUM FLUORIDE – sodium fluoride tab 1 mg f(from 2.2 mg naf)......................................................61

sodium fluoride soln 0.125 mg/drop f (0.275 mg/dropnaf)..............................................................................61

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)(Luride)....................................................................... 61

sodium polystyrene sulfonate oral susp 15 gm/60ml(Sps)........................................................................... 73

sodium polystyrene sulfonate powder(Kayexalate)...............................................................73

sotalol hcl (afib/afl) tab 120 mg (Betapaceaf)................................................................................ 30



sotalol hcl tab 120 mg (Betapace).............................30sotalol hcl tab 160 mg (Betapace).............................30sotalol hcl tab 240 mg.................................................30sotalol hcl tab 80 mg (Betapace)...............................30SOVALDI – sofosbuvir tab 400 mg............................. 6SPACER/AEROSOL-HOLDING CHAMBERS –

various........................................................................72SPACER/AEROSOL-HOLDING CHAMBERS –

VARIOUS...................................................................72SPIRIVA HANDIHALER – tiotropium bromide

monohydrate inhal cap 18 mcg (baseequiv)..........................................................................36

spironolactone & hydrochlorothiazide tab 25-25 mg(Aldactazide)..............................................................29

spironolactone tab 100 mg (Aldactone)....................29spironolactone tab 25 mg (Aldactone)...................... 29spironolactone tab 50 mg (Aldactone)...................... 29SPORANOX – itraconazole oral soln 10 mg/

ml...................................................................................4SPRYCEL – dasatinib tab 100 mg............................ 11SPRYCEL – dasatinib tab 140 mg............................ 11SPRYCEL – dasatinib tab 20 mg.............................. 11SPRYCEL – dasatinib tab 50 mg.............................. 11SPRYCEL – dasatinib tab 70 mg.............................. 11SPRYCEL – dasatinib tab 80 mg.............................. 11stavudine cap 15 mg (Zerit)......................................... 8stavudine cap 20 mg (Zerit)......................................... 8stavudine cap 30 mg (Zerit)......................................... 8stavudine cap 40 mg (Zerit)......................................... 8stavudine for oral soln 1 mg/ml (Zerit)........................ 8STIMATE – desmopressin acetate nasal soln 1.5

mg/ml..........................................................................21STIVARGA – regorafenib tab 40 mg.........................11

STRATTERA – atomoxetine hcl cap 100 mg (baseequiv)..........................................................................48







STRIBILD – elvitegrav-cobicis-emtricitab-tenofov tab150-150-200-300 mg..................................................8

STROMECTOL – ivermectin tab 3 mg........................9SUBOXONE – buprenorphine hcl-naloxone hcl sl

film 12-3 mg (base equiv)....................................... 53SUBOXONE – buprenorphine hcl-naloxone hcl sl

film 2-0.5 mg (base equiv)...................................... 53SUBOXONE – buprenorphine hcl-naloxone hcl sl

film 4-1 mg (base equiv)..........................................53SUBOXONE – buprenorphine hcl-naloxone hcl sl

film 8-2 mg (base equiv)..........................................53sucralfate tab 1 gm (Carafate)...................................39SUDAFED PE CHILDRENS NASA – phenylephrine

hcl soln 2.5 mg/5ml..................................................33SUDAFED PE DAY & NIGHT – diphenhyd-

phenyleph tab 25-10 mg & phenyleph tab 10 mgpak.............................................................................. 34

sulfacetamide sodium lotion 10% (acne)(Klaron).......................................................................68

sulfacetamide sodium ophth soln 10%(Bleph-10).................................................................. 65

sulfacetamide sodium-prednisolone ophth soln10-0.23(0.25)%......................................................... 65

sulfacetamide sodium w/ sulfur cream10-5%......................................................................... 68

sulfacetamide sodium w/ sulfur emulsion10-5%......................................................................... 68

sulfacetamide sodium w/ sulfur lotion10-5%......................................................................... 68

sulfamethoxazole-trimethoprim susp 200-40mg/5ml........................................................................10

sulfamethoxazole-trimethoprim tab 400-80 mg(Bactrim).....................................................................10

sulfamethoxazole-trimethoprim tab 800-160 mg(Bactrim ds)............................................................... 10

sulfasalazine tab 500 mg (Azulfidine)....................... 40sulfasalazine tab delayed release 500 mg (Azulfidine

en-tabs)...................................................................... 40

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106

sulindac tab 150 mg....................................................55sulindac tab 200 mg....................................................55sumatriptan succinate inj 6 mg/0.5ml

(Imitrex)...................................................................... 55sumatriptan succinate solution auto-injector 4

mg/0.5ml (Imitrex statdose sys)..............................55sumatriptan succinate solution auto-injector 6

mg/0.5ml (Imitrex statdose sys)..............................55sumatriptan succinate solution cartridge 4 mg/0.5ml

(Imitrex statdose ref)................................................55sumatriptan succinate solution cartridge 6 mg/0.5ml

(Imitrex statdose ref)................................................55SUMATRIPTAN SUCCINATE – sumatriptan

succinate inj 4 mg/0.5ml..........................................55SUMATRIPTAN SUCCINATE – sumatriptan

succinate solution prefilled syringe 6mg/0.5ml.................................................................... 55

sumatriptan succinate tab 100 mg(Imitrex)...................................................................... 55



SUPRAX – cefixime cap 400 mg.................................2SUPRAX – cefixime chew tab 100 mg........................2SUPRAX – cefixime chew tab 200 mg........................2SUPRAX – cefixime for susp 100

mg/5ml..........................................................................2SUPRAX – cefixime for susp 200

mg/5ml..........................................................................2SUPRAX – cefixime for susp 500

mg/5ml..........................................................................2SUSTIVA – efavirenz cap 200 mg...............................8SUSTIVA – efavirenz cap 50 mg.................................8SUSTIVA – efavirenz tab 600 mg............................... 8SUTENT – sunitinib malate cap 12.5 mg (base

equivalent)................................................................. 11SUTENT – sunitinib malate cap 25 mg (base

equivalent)................................................................. 11SUTENT – sunitinib malate cap 37.5 mg (base

equivalent)................................................................. 11SUTENT – sunitinib malate cap 50 mg (base

equivalent)................................................................. 11SYMBICORT – budesonide-formoterol fumarate

dihyd aerosol 160-4.5 mcg/act............................... 36SYMBICORT – budesonide-formoterol fumarate

dihyd aerosol 80-4.5 mcg/act..................................36SYNAGIS – palivizumab im soln 100 mg/

ml.................................................................................10SYNAGIS – palivizumab im soln 50

mg/0.5ml.................................................................... 10

SYNAREL – nafarelin acetate nasal soln 2 mg/ml.................................................................................21

SYSTANE VITAMIN OMEGA-3 H – omega-3 fattyacids cap delayed release 500 mg.........................62

T

tacrolimus cap 0.5 mg (Prograf)................................ 73tacrolimus cap 1 mg (Prograf)................................... 73tacrolimus cap 5 mg (Prograf)................................... 73TAMIFLU – oseltamivir phosphate cap 30 mg (base

equiv)............................................................................ 9TAMIFLU – oseltamivir phosphate cap 45 mg (base

equiv)............................................................................ 9TAMIFLU – oseltamivir phosphate cap 75 mg (base

equiv)............................................................................ 9TAMIFLU – oseltamivir phosphate for susp 6 mg/ml

(base equiv).................................................................9tamoxifen citrate tab 10 mg (base

equivalent)................................................................. 11tamoxifen citrate tab 20 mg (base

equivalent)................................................................. 11tamsulosin hcl cap 0.4 mg (Flomax)......................... 41TARCEVA – erlotinib hcl tab 100 mg (base

equivalent)................................................................. 11TARCEVA – erlotinib hcl tab 150 mg (base

equivalent)................................................................. 11TARCEVA – erlotinib hcl tab 25 mg (base

equivalent)................................................................. 11TASIGNA – nilotinib hcl cap 150 mg (base

equivalent)................................................................. 12TASIGNA – nilotinib hcl cap 200 mg (base

equivalent)................................................................. 12TAZORAC – tazarotene cream 0.05%......................68TAZORAC – tazarotene cream 0.1%........................68TAZORAC – tazarotene gel 0.05%........................... 68TAZORAC – tazarotene gel 0.1%............................. 68TECFIDERA – dimethyl fumarate capsule delayed

release 120 mg.........................................................49TECFIDERA – dimethyl fumarate capsule delayed

release 240 mg.........................................................49TECFIDERA STARTER PACK – dimethyl fumarate

capsule dr starter pack 120 mg & 240mg............................................................................... 49

TEGRETOL-XR – carbamazepine tab sr 12hr 100mg............................................................................... 57

temazepam cap 15 mg (Restoril).............................. 47temazepam cap 22.5 mg (Restoril)........................... 47temazepam cap 30 mg (Restoril).............................. 47temazepam cap 7.5 mg (Restoril)............................. 47temozolomide cap 100 mg (Temodar)......................12temozolomide cap 140 mg (Temodar)......................12temozolomide cap 180 mg (Temodar)......................12temozolomide cap 20 mg (Temodar)........................ 12

2015

107

temozolomide cap 250 mg (Temodar)......................12temozolomide cap 5 mg (Temodar).......................... 12terazosin hcl cap 10 mg............................................. 31terazosin hcl cap 1 mg................................................31terazosin hcl cap 2 mg................................................31terazosin hcl cap 5 mg................................................32terbinafine hcl tab 250 mg (Lamisil)............................ 4terbutaline sulfate tab 2.5 mg.................................... 36terbutaline sulfate tab 5 mg........................................36terconazole vaginal cream 0.4% (Terazol

7)................................................................................. 41terconazole vaginal cream 0.8% (Terazol

3)................................................................................. 41terconazole vaginal suppos 80 mg............................41testosterone cypionate im inj in oil 100 mg/ml (Depo-

testosterone)..............................................................13testosterone cypionate im inj in oil 200 mg/ml (Depo-

testosterone)..............................................................13testosterone enanthate im inj in oil 200 mg/

ml.................................................................................13TEST STRIPS – BAYER ASCENSIA

AUTODISC, BREEZE 2, CONTOUR, CONTOURNEXT.......................................................................... 72

TEST STRIPS – ROCHE ACCU-CHEK ACTIVE,AVIVA, AVIVA PLUS, COMFORT CURVE,COMPACT, SMARTVIEW.......................................72

TEST STRIPS – ROCHEACCUTREND............................................................72

TETRACYCLINE HCL – tetracycline hcl cap 250mg................................................................................. 3

TETRACYCLINE HCL – tetracycline hcl cap 500mg................................................................................. 3

tetrahydroz-dextran-peg-povidone ophth soln0.05-0.1-1-1%............................................................66

THALOMID – thalidomide cap 100 mg..................... 73THALOMID – thalidomide cap 150 mg..................... 73THALOMID – thalidomide cap 50 mg....................... 73theophylline tab sr 12hr 100 mg................................ 36theophylline tab sr 12hr 200 mg................................ 36theophylline tab sr 12hr 300 mg................................ 36theophylline tab sr 12hr 450 mg................................ 36theophylline tab sr 24hr 400 mg................................ 36theophylline tab sr 24hr 600 mg................................ 36thiamine hcl tab 100 mg............................................. 60thiamine hcl tab 250 mg............................................. 60thiamine hcl tab 50 mg............................................... 60thiothixene cap 10 mg.................................................46thiothixene cap 1 mg...................................................46thiothixene cap 2 mg...................................................46thiothixene cap 5 mg...................................................46timolol maleate ophth gel forming soln 0.25%

(Timoptic-xe)..............................................................66

timolol maleate ophth gel forming soln 0.5%(Timoptic-xe)..............................................................66

timolol maleate ophth soln 0.25%(Timoptic)................................................................... 66

timolol maleate ophth soln 0.5%(Timoptic)................................................................... 66

tioconazole vaginal oint 6.5%.................................... 41TIVICAY – dolutegravir sodium tab 50 mg (base

equiv)............................................................................ 8tizanidine hcl tab 2 mg................................................59tizanidine hcl tab 4 mg (Zanaflex)............................. 59TOBRADEX – tobramycin-dexamethasone ophth

oint 0.3-0.1%............................................................. 65tobramycin-dexamethasone ophth susp 0.3-0.1%

(Tobradex)................................................................. 65tobramycin nebu soln 300 mg/5ml

(Tobi).............................................................................4tobramycin ophth soln 0.3% (Tobrex).......................65tolnaftate aerosol 1%.................................................. 69tolterodine tartrate cap sr 24hr 2 mg (Detrol

la)................................................................................ 41tolterodine tartrate cap sr 24hr 4 mg (Detrol

la)................................................................................ 41tolterodine tartrate tab 1 mg (Detrol).........................41tolterodine tartrate tab 2 mg (Detrol).........................41topiramate sprinkle cap 15 mg (Topamax

sprinkle)......................................................................57topiramate sprinkle cap 25 mg (Topamax

sprinkle)......................................................................57topiramate tab 100 mg (Topamax)............................57topiramate tab 200 mg (Topamax)............................57topiramate tab 25 mg (Topamax).............................. 57topiramate tab 50 mg (Topamax).............................. 57torsemide tab 100 mg (Demadex).............................29torsemide tab 10 mg (Demadex)...............................29torsemide tab 20 mg (Demadex)...............................29torsemide tab 5 mg (Demadex)................................. 29TRACLEER – bosentan tab 125 mg......................... 32TRACLEER – bosentan tab 62.5 mg........................ 32tramadol-acetaminophen tab 37.5-325 mg

(Ultracet).................................................................... 53tramadol hcl tab 50 mg (Ultram)................................53tramadol hcl tab sr 24hr 100 mg (Ultram

er)................................................................................53tramadol hcl tab sr 24hr 200 mg (Ultram

er)................................................................................53tramadol hcl tab sr 24hr 300 mg (Ultram

er)................................................................................53trandolapril tab 1 mg (Mavik)..................................... 23trandolapril tab 2 mg (Mavik)..................................... 23trandolapril tab 4 mg (Mavik)..................................... 23

2015

108

tranylcypromine sulfate tab 10 mg(Parnate).................................................................... 44

trazodone hcl tab 100 mg...........................................44trazodone hcl tab 150 mg...........................................44trazodone hcl tab 300 mg...........................................44trazodone hcl tab 50 mg.............................................44tretinoin cap 10 mg......................................................12tretinoin cream 0.025% (Retin-a)...............................68tretinoin cream 0.05% (Retin-a).................................68tretinoin cream 0.1% (Retin-a)...................................68tretinoin gel 0.01% (Retin-a)...................................... 68tretinoin gel 0.025% (Retin-a).................................... 68tretinoin microsphere gel 0.04% (Retin-a

micro)..........................................................................68tretinoin microsphere gel 0.1% (Retin-a

micro)..........................................................................68TRETTEN – coagulation factor xiii a-subunit for inj

2000-3125 unit.......................................................... 64triamcinolone acetonide cream

0.025%....................................................................... 70triamcinolone acetonide cream 0.1%........................70triamcinolone acetonide cream 0.5%........................70triamcinolone acetonide dental paste

0.1%............................................................................67triamcinolone acetonide lotion 0.025%..................... 70triamcinolone acetonide lotion 0.1%......................... 70triamcinolone acetonide nasal aerosol suspension

55 mcg/act (Nasacort aq)........................................33triamcinolone acetonide oint 0.025%........................ 70triamcinolone acetonide oint 0.1%............................ 70TRIAMINIC COLD/COUGH NIGH –

diphenhydramine-phenylephrine oral strip 12.5-5mg............................................................................... 34

TRIAMINIC COLD & ALLERGY – chlorpheniramine& phenylephrine syrup 1-2.5 mg/5ml..................... 34

TRIAMINIC NIGHT TIME COLD –diphenhydramine-phenylephrine syrup 6.25-2.5mg/5ml........................................................................34

TRIAMTERENE/HYDROCHLOROTH – triamterene& hydrochlorothiazide cap 50-25 mg..................... 29

triamterene & hydrochlorothiazide cap 37.5-25 mg(Dyazide)....................................................................29

triamterene & hydrochlorothiazide tab 37.5-25 mg(Maxzide-25)..............................................................29

triamterene & hydrochlorothiazide tab 75-50 mg(Maxzide)................................................................... 29

trifluoperazine hcl tab 10 mg......................................46trifluoperazine hcl tab 1 mg........................................46trifluoperazine hcl tab 2 mg........................................46trifluoperazine hcl tab 5 mg........................................46trifluridine ophth soln 1% (Viroptic)........................... 65trihexyphenidyl hcl elixir 0.4 mg/ml........................... 58

trihexyphenidyl hcl tab 2 mg...................................... 58trihexyphenidyl hcl tab 5 mg...................................... 59trimethobenzamide hcl cap 300 mg

(Tigan)........................................................................ 39trimethoprim tab 100 mg.............................................10TRI-NORINYL 28 – norethindrone-eth estradiol tab

0.5-35/1-35/0.5-35 mg-mcg.....................................17TRI-VI-SOL – pediatric vitamins adc drops 750

unit-400 unit-35 mg/ml.............................................60TRI-VIT/FLUORIDE/IRON – pediatric vitamins acd

fluoride & fe drops 0.25-10 mg/ml..........................60tropicamide ophth soln 0.5%......................................66tropicamide ophth soln 1% (Mydriacyl).....................66TRUVADA – emtricitabine-tenofovir disoproxil

fumarate tab 200-300 mg..........................................8

U

ursodiol cap 300 mg (Actigall)................................... 40ursodiol tab 250 mg (Urso 250).................................40ursodiol tab 500 mg (Urso forte)................................40

V

VAGIFEM – estradiol vaginal tab 10mcg............................................................................. 41

valacyclovir hcl tab 1 gm (Valtrex)...............................6valacyclovir hcl tab 500 mg (Valtrex).......................... 6VALCHLOR – mechlorethamine hcl gel 0.016%

(base equivalent)...................................................... 71VALCYTE – valganciclovir hcl for soln 50 mg/ml

(base equiv).................................................................5VALCYTE – valganciclovir hcl tab 450

mg................................................................................. 5valganciclovir hcl tab 450 mg (Valcyte).......................5valproate sodium syrup 250 mg/5ml (base equiv)

(Depakene)................................................................ 57valproic acid cap 250 mg (Depakene)...................... 57valsartan-hydrochlorothiazide tab 160-12.5 mg

(Diovan hct)............................................................... 24valsartan-hydrochlorothiazide tab 160-25 mg

(Diovan hct)............................................................... 24valsartan-hydrochlorothiazide tab 320-12.5 mg

(Diovan hct)............................................................... 24valsartan-hydrochlorothiazide tab 320-25 mg

(Diovan hct)............................................................... 24valsartan-hydrochlorothiazide tab 80-12.5 mg

(Diovan hct)............................................................... 24valsartan tab 160 mg (Diovan)...................................24valsartan tab 320 mg (Diovan)...................................24valsartan tab 40 mg (Diovan).....................................24valsartan tab 80 mg (Diovan).....................................24vancomycin hcl cap 125 mg (Vancocin

hcl).............................................................................. 10

2015

109

vancomycin hcl cap 250 mg (Vancocinhcl).............................................................................. 10

venlafaxine hcl cap sr 24hr 150 mg (base equivalent)(Effexor xr).................................................................44

venlafaxine hcl cap sr 24hr 37.5 mg (baseequivalent) (Effexor xr)............................................ 44

venlafaxine hcl cap sr 24hr 75 mg (base equivalent)(Effexor xr).................................................................44

venlafaxine hcl tab 100 mg........................................ 44venlafaxine hcl tab 25 mg.......................................... 44venlafaxine hcl tab 37.5 mg....................................... 44venlafaxine hcl tab 50 mg.......................................... 44venlafaxine hcl tab 75 mg.......................................... 44venlafaxine hcl tab sr 24hr 150 mg (base equivalent)

(Venlafaxine hcl er).................................................. 44venlafaxine hcl tab sr 24hr 37.5 mg (base

equivalent) (Venlafaxine hcl er)..............................44venlafaxine hcl tab sr 24hr 75 mg (base equivalent)

(Venlafaxine hcl er).................................................. 44VENTOLIN HFA – albuterol sulfate inhal aero 108

mcg/act (90mcg base equiv)...................................36verapamil hcl cap sr 24hr 120 mg

(Verelan).................................................................... 27verapamil hcl cap sr 24hr 180 mg



(Verelan).................................................................... 27verapamil hcl tab 120 mg (Calan)............................. 27verapamil hcl tab 80 mg (Calan)............................... 27verapamil hcl tab cr 120 mg (Calan sr).....................27verapamil hcl tab cr 180 mg (Calan sr).....................27verapamil hcl tab cr 240 mg (Calan sr).....................27VERAPAMIL HCL – verapamil hcl tab 40

mg............................................................................... 27VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6

mg/ml).........................................................................18VIDEX – didanosine for soln 2 gm.............................. 8VIDEX – didanosine for soln 4 gm.............................. 8VIRACEPT – nelfinavir mesylate tab 250

mg................................................................................. 8VIRACEPT – nelfinavir mesylate tab 625

mg................................................................................. 8VIRAMUNE – nevirapine susp 50

mg/5ml..........................................................................8VIRAMUNE XR – nevirapine tab sr 24hr 100

mg................................................................................. 8VIRAMUNE XR – nevirapine tab sr 24hr 400

mg................................................................................. 8VIREAD – tenofovir disoproxil fumarate oral powder

40 mg/gm.....................................................................9

VIREAD – tenofovir disoproxil fumarate tab 150mg................................................................................. 8




VITAMIN D – cholecalciferol cap 400unit.............................................................................. 60

vitamins a & d oint.......................................................71VIVELLE-DOT – estradiol td patch biweekly 0.025

mg/24hr...................................................................... 14VIVELLE-DOT – estradiol td patch biweekly 0.0375




mg/24hr...................................................................... 14voriconazole for susp 40 mg/ml (Vfend)..................... 5voriconazole tab 200 mg (Vfend).................................5voriconazole tab 50 mg (Vfend)...................................5VOTRIENT – pazopanib hcl tab 200 mg (base

equiv)..........................................................................12VYVANSE – lisdexamfetamine dimesylate cap 20

mg............................................................................... 48VYVANSE – lisdexamfetamine dimesylate cap 30





mg............................................................................... 49

W

warfarin sodium tab 10 mg(Coumadin)................................................................ 64

warfarin sodium tab 1 mg (Coumadin)......................64warfarin sodium tab 2.5 mg

(Coumadin)................................................................ 64warfarin sodium tab 2 mg (Coumadin)......................64warfarin sodium tab 3 mg (Coumadin)......................64warfarin sodium tab 4 mg (Coumadin)......................64warfarin sodium tab 5 mg (Coumadin)......................64warfarin sodium tab 6 mg (Coumadin)......................64warfarin sodium tab 7.5 mg

(Coumadin)................................................................ 64

2015

110

WELCHOL – colesevelam hcl packet for susp 3.75gm............................................................................... 28

WELCHOL – colesevelam hcl tab 625mg............................................................................... 28

X

XALKORI – crizotinib cap 200 mg.............................12XALKORI – crizotinib cap 250 mg.............................12XARELTO – rivaroxaban tab 10 mg..........................64XARELTO – rivaroxaban tab 15 mg..........................64XARELTO – rivaroxaban tab 20 mg..........................64XARELTO STARTER PACK – rivaroxaban tab

starter therapy pack 15 mg & 20 mg......................64XIFAXAN – rifaximin tab 550 mg...............................10

Y

YASMIN 28 – drospirenone-ethinyl estradiol tab3-0.03 mg...................................................................17

YAZ – drospirenone-ethinyl estradiol tab 3-0.02mg............................................................................... 17

Z

zafirlukast tab 10 mg (Accolate)................................ 36zafirlukast tab 20 mg (Accolate)................................ 36zaleplon cap 10 mg (Sonata).....................................47zaleplon cap 5 mg (Sonata).......................................47ZANTAC – ranitidine hcl tab 150 mg........................ 39ZELBORAF – vemurafenib tab 240 mg (base

equivalent)................................................................. 12ZENPEP – pancrelipase (lip-prot-amyl) dr cap

10000-34000-55000 unit......................................... 40ZENPEP – pancrelipase (lip-prot-amyl) dr cap

15000-51000-82000 unit......................................... 40ZENPEP – pancrelipase (lip-prot-amyl) dr cap

20000-68000-109000 unit....................................... 40ZENPEP – pancrelipase (lip-prot-amyl) dr cap

25000-85000-136000 unit....................................... 40ZENPEP – pancrelipase (lip-prot-amyl) dr cap

3000-10000-16000 unit............................................39ZENPEP – pancrelipase (lip-prot-amyl) dr cap

40000-136000-218000 unit..................................... 40ZENPEP – pancrelipase (lip-prot-amyl) dr cap

5000-17000-27000 unit............................................39ZIAGEN – abacavir sulfate soln 20 mg/ml (base

equiv)............................................................................ 9zidovudine cap 100 mg (Retrovir)................................9zidovudine syrup 10 mg/ml (Retrovir)......................... 9zidovudine tab 300 mg..................................................9zinc oxide oint 10%..................................................... 71zinc oxide oint 20%..................................................... 71zinc oxide oint 40%..................................................... 71ziprasidone hcl cap 20 mg (Geodon)........................ 46ziprasidone hcl cap 40 mg (Geodon)........................ 46

ziprasidone hcl cap 60 mg (Geodon)........................ 46ziprasidone hcl cap 80 mg (Geodon)........................ 46zolpidem tartrate tab 10 mg (Ambien).......................47zolpidem tartrate tab 5 mg (Ambien).........................47zolpidem tartrate tab cr 12.5 mg (Ambien

cr)................................................................................ 47zolpidem tartrate tab cr 6.25 mg (Ambien

cr)................................................................................ 47zonisamide cap 100 mg (Zonegran)......................... 57zonisamide cap 25 mg (Zonegran)........................... 57zonisamide cap 50 mg................................................57ZORTRESS – everolimus tab 0.25 mg.....................73ZORTRESS – everolimus tab 0.5 mg.......................73ZORTRESS – everolimus tab 0.75 mg.....................73ZOVIA 1/50E – ethynodiol diacetate & ethinyl

estradiol tab 1 mg-50 mcg...................................... 17ZOVIRAX – acyclovir cream 5%................................69ZYCLARA – imiquimod cream 3.75%.......................71ZYCLARA PUMP – imiquimod cream

2.5%............................................................................71ZYCLARA PUMP – imiquimod cream

3.75%..........................................................................71ZYLET – loteprednol etabonate-tobramycin ophth

susp 0.5-0.3%........................................................... 65ZYTIGA – abiraterone acetate tab 250

mg............................................................................... 12ZYVOX – linezolid for susp 100

mg/5ml........................................................................10ZYVOX – linezolid tab 600 mg.................................. 10

2015 Drug List - BCBSIL

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