Blue Cross Community Centennial Medicaid Drug List Formulary · 2019-11-18 · Blue Cross Community...

Blue Cross Community CentennialSM Drug ListJanuary 2019

NTENNIALCARE

This document contains information about the drugs we cover in this plan.Effective: October 1, 2019

Blue Cross Community CentennialSM Drug ListOctober 2019

Blue Cross Community Centennial

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What is the Blue Cross Community Centennial drug list?The drug list (sometimes called a “formulary”) is a list showing the drugs that can be covered by your Blue Cross Community Centennial health 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 rules of your Blue Cross Community

Centennial health plan

For more information on how to fill your medication orders, please review your Member Handbook. You may also contact Blue Cross and Blue Shield of New Mexico (BCBSNM) Member Services at 1-866-689-1523 (TTY/TDD 711).

What will I pay?In most cases you do not pay for covered drugs. Some members will have prescription copays depending on their category of eligibility.

Can the drug list change?Yes, it can change for various reasons such as a new, less expensive generic drug becomes available.

You will be told in writing when changes are made to the drug list.

How do I use the drug list?There are two ways to find your drug in the list beginning on page 1.

1. Category• The list of covered drugs that begins on page 1 gives you

information about the drugs covered by Blue Cross Community Centennial. If you have trouble finding your drug in the list, turn to the Index that begins at the back of this book.

– The first column of the chart has the name of the drug. Brand name drugs are capitalized (e.g., CIPRO) and generic drugs are listed in lower-case italics (e.g., ciprofloxacin).

– The information in the “Necessary actions, restrictions, or limits on use” column tells you if Blue Cross Community Centennial has any rules for covering your drug.

• 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 at the back of this book.• 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 and Drug Administration (FDA) as having the same active ingredient as the brand name drug, but often costs less.

Does the plan cover over-the-counter (OTC) drugs?Yes, Blue Cross Community Centennial covers certain OTC drugs with a valid medication order from your health care provider, and you may get those at no cost. Generic OTC drugs are to be prescribed and filled by your pharmacy when available. These OTC drugs must be filled at a pharmacy that participates in the Blue Cross Community Centennial network and for quantities up to a 30-day supply. Many of the OTC drugs found on the drug list have an age restriction depending on what type of coverage you have.

Are there any limits on my coverage?Some drugs are subject to age restrictions. These restrictions are based on Food and Drug Administration (FDA), manufacturer, or clinical guidelines. Age restrictions are used as a safety measure for members to use medications appropriately. You can find out if your drug has any other conditions or limits by looking at the drug list that begins on page 1. The date we last updated the list is shown on the front cover page.

Drug List

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Added conditions or limits on some covered drugs may include:

• Prior Authorization: You or your provider may need to get approval from Blue Cross and Blue Shield of New Mexico (BCBSNM) before you fill some of your medication orders. Medications that require prior authorization are identified in the drug list by a “PA” in the “Necessary actions, restrictions, or limits on use” column. If you do not get approval, Blue Cross Community Centennial may not cover (pay for) the drug.

– What if my drug requires a prior authorization?

ú Contact BCBSNM Member Services at 1-866-689-1523 (TTY/TDD 711) and ask how you or your provider can submit a prior authorization (exception) request.

ú You can also talk to your provider to decide if you should first try a different drug on our list before you request an exception.

• Quantity Limits: For certain drugs, Blue Cross Community Centennial limits the amount of a drug that will be covered for a period of time (e.g., no more than 60 tablets for 30 days). Medications that have quantity limits are identified in the drug list by a “QL” in the “Necessary actions, restrictions, or limits on use” column.

– What if my drug is not covered because it exceeds the quantity limit?

ú Contact BCBSNM Member Services at 1-866-689-1523 (TTY/TDD 711) and ask how you or your provider can submit a quantity limit exception request.

ú You can also talk to your provider to decide if you should first try a different drug on our list or different dose of your medication before you request an exception.

• Step Therapy: In some cases, Blue Cross Community Centennial 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. Medications that are subject to step therapy are identified in the drug list by an “ST” in the “Necessary actions, restrictions, or limits on use” column.

– What if my drug is not covered because I have not met the step therapy?

ú Contact BCBSNM Member Services at 1-866-689-1523 (TTY/TDD 711) and ask how you or your provider can submit a step therapy exception request.

ú You can also talk to your provider to decide if you should first try a different drug on our list that does not require step therapy.

• Morphine Equivalent (ME) Dosing: ME dosing is a tool used to help prevent members from taking too much pain medication (opioids). This tool allows BCBSNM to calculate the total daily dose of pain medications a member is taking no matter which opioid they are prescribed. The current daily ME limit in New Mexico is 90 mg per day. If you are taking a dose above ME90, you will need to get prior authorization (approval) from BCBSNM for Blue Cross Community Centennial to pay for the prescription(s). Medications that have morphine equivalents are identified in the drug list by an “ME” in the “Necessary actions, restrictions, or limits on use” column.

• Opioid Limits: All opioids are subject to a 90% refill threshold. This means 90% of the original fill must be used before a second fill can be paid. If you don’t chronically take opioids on a daily basis, you are considered opioid naive. Opioid naive members are limited to a seven-day supply of immediate release (IR) opioids for their first fill. Once you have a history of IR opioids, you can fill more than seven days. You must have a history of IR opioids before you can fill an extended release (ER) opioid. If you do not have a history of IR opioids, you will need to get prior authorization from BCBSNM to fill an ER opioid. You will also need to get a prior authorization from BCBSNM to take a benzodiazepine and an opioid at the same time.


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• Oral Oncology Split Fill Program: Oncology is the study of cancer. Oral oncology drugs are medications that are taken by mouth for the treatment of various types of cancer. These drugs are an important part of many treatment plans. These drugs can cause side effects which may lead to your doctor making changes to the dose or stopping the drug entirely. As you go through treatment, your doctor may make changes to the treatment plan until the best dose is established for you. This may take a few months.

The reason for the Oral Oncology Split Fill Program for members newly starting therapy is to:

– Prevent unnecessary prescriptions at inappropriate doses. – Minimize waste of these drugs. – Manage side effects.

For the first 2 to 3 months of your treatment, you will receive a 14- or 15-day supply of your prescription twice a month. Following the first 2 to 3 months of treatment and once the right dose has been established, you may start to receive a full 1-month supply for the rest of your therapy. In the drug list, any drug that is labeled “SF” (Split Fill) falls under the Oral Oncology Split Fill Program.

What if my drug is not on the drug list?Contact BCBSNM Member Services at 1-866-689-1523 (TTY/TDD 711) and ask if your drug is covered. If you learn that Blue Cross Community Centennial does not cover your drug, you have two options:• Talk to your provider to decide if you should first try a

different drug on our list before you request an exception.• If your provider feels a different drug would not be

appropriate, they can request a prior authorization. A prior authorization is a request asking Blue Cross Community Centennial to make an exception to cover your drug. Member Services can work with you and your provider to help you ask for an exception. The prescription drug coverage exception form is on MyPrime.com. Providers can submit this coverage exception request form by:

– Fax: 1-877-243-6930 – Phone: 1-800-285-9426 (TTY/TDD: 711) – Website: MyPrime.com or CoverMyMeds.com

Specialty Pharmacy (SP) DrugsSpecialty drugs are certain prescription medications used to treat complex, chronic conditions like cancer, rheumatoid arthritis and multiple sclerosis. Specialty drugs often require special handling (like refrigeration during shipping) and administration (such as injection or infusion). Specialty pharmacy drugs require prior authorization before a prescription may be filled. They can be filled for up to a 30-day supply. They must be filled by a specialty drug supplier that participates in the network for Blue Cross Community Centennial. AllianceRx Walgreens Prime is the preferred BCBSNM supplier of specialty drugs. Most specialty drugs fall under the pharmacy benefit and can be filled by AllianceRx Walgreens Prime. Specialty drugs under the pharmacy benefit that are unavailable from AllianceRx Walgreens Prime can be obtained from a limited distribution pharmacy provider. Limited distribution pharmacy providers are identified by pharmaceutical manufacturers as having the highest standards for clinical expertise, patient education, service, treatment monitoring and support. For more information about specialty drugs, contact Member Services at 1-866-689-1523 (TTY/TDD 711).

Which drug categories are not covered by the Plan drug list?The following drug categories are not covered by your Blue Cross Community Centennial health plan:• Anorexia, weight loss, or weight gain drugs• Bulk chemicals• Cosmetic enhancing drugs• Diagnostic agents• Drug Efficacy Study Implementation (DESI). These are drugs

that are not shown to be safe and effective.• Experimental and investigational drugs• Erectile dysfunction drugs prescribed to treat impotence• Fertility drugs• General anesthetic drugs• Opioid cough and cold products (excluded ages <18)• Over-the-counter products not otherwise included on the

plan’s drug list• Surgical supply/medical devices

Drug List

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Blue Cross Community Centennial members who have dual coverage under both Medicare and Medicaid will find that most of their medications will be covered by Medicare. However, a limited number of drugs will be covered under Blue Cross Community Centennial. Some examples of these drugs include: • Drugs used for the symptomatic relief of cough and colds• Prescription vitamins and minerals (e.g., folic acid)• Non-prescription (over-the-counter) drugs• Non-prescription smoking cessation products

For Medicare Part B-covered drugs, Blue Cross Community Centennial members who are enrolled in both Medicare and Medicaid may be able to have their coinsurance covered under their Medicaid benefit. However, some drugs are only covered under Medicare Part B if a member has a specific medical condition or received a specific medical treatment. In some cases, medical history information will need to be reviewed first in order to cover a member’s coinsurance. Members should call Member Services at 1-866-689-1523 (TTY/TDD 711) to have this coverage determination completed.

Continuous Glucose Monitors and Supplies BCBSNM has changed our process for providing continuous glucose monitors and supplies. A continuous glucose monitor is a device that tracks blood sugar levels throughout the day. If your current Durable Medical Equipment (DME) provider is no longer eligible to provide your device and supplies as a result of this change, you will need to get these products from a different provider in our network. BCBSNM can help you find a new provider. If you are impacted by this change, you should have received a letter that will help you with this new process. BCBSNM has informed the prescribers and DME providers of impacted members about this change. If you need help finding an in-network provider, call Member Services at 1-866-689-1523 (TTY: 711).

For more Information For more details about drug coverage from your Blue Cross Community Centennial health plan, please review your Member Handbook and other plan materials.

If you have any questions, please call BCBSNM Member Services at: 1-866-689-1523 (TTY/TDD 711). We are open 8:00 a.m. until 5:00 p.m. Mountain time, Monday through Friday.

Drug List Language AssistanceInterpreter ServicesWe can arrange for someone to help you speak with us in any language. There is no charge for these services. If your health care provider does not speak your language, we can arrange for a translator to help you. Please call Member Services at 1-866-689-1523 (TTY/TDD 711).

Hearing and Vision ProblemsFor our members with hearing problems, we offer TTY/TDD service at no charge. The line is open 24 hours a day/seven day a week at 711.

Other Languages and FormatsYou can get this document in Spanish, or speak with someone about this information in other languages at no charge. Call 1-866-689-1523 (TTY/TDD: 711). The call is toll-free. You can also call Member Services, toll-free, to request this information in other alternative formats such as Braille, large print and other forms. Call toll-free: 1-866-689-1523 (TTY/TDD: 711). We are open 8:00 a.m. until 5:00 p.m. Mountain time, Monday through Friday.


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To ask for auxiliary aids and services or materials in other formats and languages at no cost,

please call 1-866-689-1523 (TTY/TDD: 711).Blue Cross and Blue Shield of New Mexico complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of New Mexico does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Blue Cross and Blue Shield of New Mexico:

Provides free aids and services to people with disabilities to communicate effectively with us,such as:o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible electronic formats, other

formats) Provides free language services to people whose primary language is not English, such as:

o Qualified interpreterso Information written in other languages

If you need these services, contact Civil Rights Coordinator.

If you believe that Blue Cross and Blue Shield of New Mexico has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago, Illinois 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW

Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-710-6984 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-710-6984 (TTY: 711).

Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dę́ę́’, t’áá jiik’eh, éí ná hólǫ́, kojį’ hódíílnih 1-855-710-6984 (TTY: 711).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-710-6984 (TTY: 711).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-710-6984 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-710-6984 (TTY: 711)。

6984-710-855-1ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم ).711(رقم ھاتف الصم والبكم:

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

1-855-710-6984 (TTY: 711) 번으로 전화해 주십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-710-6984 (TTY: 711).

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-855-710-6984 （TTY: 711）まで、お電話にてご連絡ください。

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-710-6984 (ATS: 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-710-6984 (TTY: 711).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-710-6984 (телетайп: 711).

!यान द': य)द आप ,हदी बोलते ह4 तो आपके िलए मु:त म' भाषा सहायता सेवाएं उपलAध ह4। 1-855-710-6984 (TTY: 711) पर कॉल कर'।

ھجوت: رگا ھب نابز یسراف وگتفگ یم دینک، تالیھست ینابز ھب تروص ناگیار یارب امش مھارف یم دشاب. اب 1-855-710-6984 (TTY: 711) سامت دیریگب.

เรียน: ถLาคุณพูดภาษาไทยคุณสามารถใชLบริการช_วยเหลือทางภาษาไดLฟรี โทร 1-855-710-6984 (TTY: 711).

Drug List

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ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-710-6984 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-710-6984 (TTY: 711).

Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dę́ę́’, t’áá jiik’eh, éí ná hólǫ́, kojį’ hódíílnih 1-855-710-6984 (TTY: 711).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-710-6984 (TTY: 711).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-710-6984 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-710-6984 (TTY: 711)。

6984-710-855-1ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم ).711(رقم ھاتف الصم والبكم:

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

1-855-710-6984 (TTY: 711) 번으로 전화해 주십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-710-6984 (TTY: 711).

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-855-710-6984 （TTY: 711）まで、お電話にてご連絡ください。

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-710-6984 (ATS: 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-710-6984 (TTY: 711).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-710-6984 (телетайп: 711).

!यान द': य)द आप ,हदी बोलते ह4 तो आपके िलए मु:त म' भाषा सहायता सेवाएं उपलAध ह4। 1-855-710-6984 (TTY: 711) पर कॉल कर'।

ھجوت: رگا ھب نابز یسراف وگتفگ یم دینک، تالیھست ینابز ھب تروص ناگیار یارب امش مھارف یم دشاب. اب 1-855-710-6984 (TTY: 711) سامت دیریگب.

เรียน: ถLาคุณพูดภาษาไทยคุณสามารถใชLบริการช_วยเหลือทางภาษาไดLฟรี โทร 1-855-710-6984 (TTY: 711).

Below is a list of drugs that require prior authorization for a specific age group to ensure appropriate usea=generic drug covered

Drug Ages that Requre Prior AuthorizationAbilify (aripiprazole)a

2 mg tablet Less than 65 mg tablet Less than 610 mg tablet Less than 615 mg tablet Less than 620 mg tablet Less than 630 mg tablet Less than 6Abilify Discmelt (aripiprazole)a

15 mg orally disintegrating tablet Less than 610 mg orally disintegrating tablet Less than 6Clozaril (clozapine)a

25 mg tablet Less than 1850 mg tablet Less than 18100 mg tablet Less than 18200 mg tablet Less than 18Fluphenazinea

25 mg/mL decanoate injection Less than 12Geodon (ziprasidone)a

20 mg capsule Less than 1040 mg capsule Less than 1060 mg capsule Less than 1080 mg capsule Less than 10Haldol (haloperidol)a

0.5 mg tablet Less than 51 mg tablet Less than 52 mg tablet Less than 55 mg tablet Less than 510 mg tablet Less than 520 mg tablet Less than 52 mg/mL oral concentrate Less than 1850 mg/mL IM injection Less than 18100 mg/mL IM injection Less than 18Loxapinea

5 mg capsule Less than 1810 mg capsule Less than 1825 mg capsule Less than 1850 mg capsule Less than 18Perphenazinea

2 mg tablet Less than 124 mg tablet Less than 128 mg tablet Less than 1216 mg tablet Less than 12Prochlorperazinea

5 mg tablet Less than 210 mg tablet Less than 225 mg suppository Less than 2Risperdal (risperidone)a

1 mg/mL oral solution Less than 50.25 mg tablet Less than 50.5 mg tablet Less than 51 mg tablet Less than 52 mg tablet Less than 53 mg tablet Less than 54 mg tablet Less than 5Risperdal M-Tab (risperidone)a

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0.5 mg orally disintegrating tablet Less than 51 mg orally disintegrating tablet Less than 52 mg orally disintegrating tablet Less than 53 mg orally disintegrating tablet Less than 54 mg orally disintegrating tablet Less than 5Risperidone0.25 mg orally disintegrating tablet Less than 5Seroquel (quetiapine)a

25 mg tablet Less than 1050 mg tablet Less than 10100 mg tablet Less than 10200 mg tablet Less than 10300 mg tablet Less than 10400 mg tablet Less than 10Thioridazinea

10 mg tablet Less than 525 mg tablet Less than 550 mg tablet Less than 5100 mg tablet Less than 5Thiothixenea

1 mg capsule Less than 122 mg capsule Less than 125 mg capsule Less than 1210 mg capsule Less than 12Trifluoperazinea

1 mg tablet Less than 62 mg tablet Less than 65 mg tablet Less than 610 mg tablet Less than 6Zyprexa (olanzapine)a

2.5 mg tablet Less than 135 mg tablet Less than 137.5 mg tablet Less than 1310 mg tablet Less than 1315 mg tablet Less than 1320 mg tablet Less than 13Zyprexa Zydis (olanzapine)a

5 mg orally disintegrating tablet Less than 1310 mg orally disintegrating tablet Less than 1315 mg orally disintegrating tablet Less than 1320 mg orally disintegrating tablet Less than 13Molindone5mg tablets Less than 1210mg tablets Less than 1225mg tablets Less than 12Atralin™ (tretinoin)

0.05% gela 25 years old and olderAvita® (tretinoin)

0.025% creama 25 years old and older0.025% gela 25 years old and older

Benzamycin (benzoyl peroxide/erythromycin)5%/3% gela 25 years old and older

benzoyl peroxide6% foaming clothsa 25 years old and older

Cleocin T (clindamycin phosphate)1% gela 25 years old and older1% lotiona 25 years old and older1% solutiona 25 years old and older1% padsa 25 years old and olderClindacin - P (clindamycin phosphate)

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1% Pledets 25 years old and older1% Pads 25 years old and older

Differin® (adapalene)0.1% creama 25 years old and older

Duac (clindamycin phosphate/benzoyl peroxide)

1.2%/5% gela 25 years old and oldererythromycin

2% padsa 25 years old and older2% solutiona 25 years old and older

Finacea (azelaic acid)15% gel 25 years old and older

isotretinoin10 mg capsulea 25 years old and older20 mg capsulea 25 years old and older30 mg capsulea 25 years old and older40 mg capsulea 25 years old and older

Klaron (sulfacetamide sodium)10% lotiona 25 years old and older

Metrocream (metronidazole)0.75% creama 25 years old and older

Metrogel (metronidazole)0.75% gela 25 years old and older

Retin-A® (tretinoin)0.025% creama 25 years old and older0.05% creama 25 years old and older0.1% creama 25 years old and older0.01% gela 25 years old and older0.025% gela 25 years old and older

Tazorac® (tazarotene)0.05% cream 25 years old and older0.1% creama 25 years old and older0.05% gel 25 years old and older0.1% gel 25 years old and older

Strattera (atomoxetine)10mg capsules under 6 years old and over 18 years old18mg capsules under 6 years old and over 18 years old25mg capsules under 6 years old and over 18 years old40mg capsules under 6 years old and over 18 years old60mg capsules under 6 years old and over 18 years old80mg capsules under 6 years old and over 18 years old100mg capsules under 6 years old and over 18 years old

Adderall (amphetamine/dextroamphetamine)5 mg tableta under 6 years old and over 18 years old7.5 mg tableta under 6 years old and over 18 years old10 mg tableta under 6 years old and over 18 years old12.5 mg tableta under 6 years old and over 18 years old15 mg tableta under 6 years old and over 18 years old20 mg tableta under 6 years old and over 18 years old30 mg tableta under 6 years old and over 18 years oldAdderall XR (amphetamine/dextroamphetamine ER)

5 mg capsulea under 6 years old and over 18 years old10 mg capsulea under 6 years old and over 18 years old15 mg capsulea under 6 years old and over 18 years old20 mg capsulea under 6 years old and over 18 years old25 mg capsulea under 6 years old and over 18 years old30 mg capsulea under 6 years old and over 18 years oldConcerta (methylphenidate osmotic ER)a

18 mg tableta under 6 years old and over 18 years old27 mg tableta under 6 years old and over 18 years old36 mg tableta under 6 years old and over 18 years old

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54 mg tableta under 6 years old and over 18 years oldmethylphenidate ER18 mg tablet under 6 years old and over 18 years old27 mg tablet under 6 years old and over 18 years old36 mg tablet under 6 years old and over 18 years old54 mg tablet under 6 years old and over 18 years oldDexedrine (dextroamphetamine)5 mg tableta under 6 years old and over 18 years old10 mg tableta under 6 years old and over 18 years oldDexedrine Spansule (dextroamphetamine ER)5 mg capsulea under 6 years old and over 18 years old10 mg capsulea under 6 years old and over 18 years old15 mg capsulea under 6 years old and over 18 years oldFocalin (dexmethylphenidate)2.5 mg tableta under 6 years old and over 18 years old5 mg tableta under 6 years old and over 18 years old10 mg tableta under 6 years old and over 18 years oldFocalin XR (dexmethylphenidate ER)5 mg capsulea under 6 years old and over 18 years old10 mg capsulea under 6 years old and over 18 years old15 mg capsulea under 6 years old and over 18 years old20 mg capsulea under 6 years old and over 18 years old30 mg capsulea under 6 years old and over 18 years old40 mg capsulea under 6 years old and over 18 years oldMetadate ER (methylphenidate ER)20 mg tableta under 6 years old and over 18 years oldMetadate CD (methylphenidate ER)10 mg capsulea under 6 years old and over 18 years old20 mg capsulea under 6 years old and over 18 years old30 mg capsulea under 6 years old and over 18 years old40 mg capsulea under 6 years old and over 18 years old50 mg capsulea under 6 years old and over 18 years old60 mg capsulea under 6 years old and over 18 years oldMethylin (methylphenidate)5 mg/5 mL solutiona under 6 years old and over 18 years old10 mg/5 mL solutiona under 6 years old and over 18 years oldMethylin (methylphenidate)2.5 mg chewable tableta under 6 years old and over 18 years old5 mg chewable tableta under 6 years old and over 18 years old10 mg chewable tableta under 6 years old and over 18 years oldMethylphenidate ER10 mg tableta under 6 years old and over 18 years old20 mg tableta under 6 years old and over 18 years oldProcentra (dextroamphetamine)5 mg/5 mL oral solutiona under 6 years old and over 18 years old

5 mg tableta under 6 years old and over 18 years old10 mg tableta under 6 years old and over 18 years old20 mg tableta under 6 years old and over 18 years oldRitalin LA (methylphenidate ER)10 mg capsulea under 6 years old and over 18 years old20 mg capsulea under 6 years old and over 18 years old30 mg capsulea under 6 years old and over 18 years old40 mg capsulea under 6 years old and over 18 years oldZenzedi (dextroamphetamine)5 mg tableta under 6 years old and over 18 years old10 mg tableta under 6 years old and over 18 years oldFlovent Diskus® (fluticasone)50 mcg/actuation 5 years old and older100 mcg/actuation 5 years old and older

Ritalin (methylphenidate)

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250 mcg/actuation 5 years old and olderFlovent HFA® (fluticasone)44 mcg/actuation 5 years old and older110 mcg/actuation 5 years old and older220 mcg/actuation 5 years old and olderQvar® Redihaler (beclomethasone)40 mcg/actuation 12 years old and older80 mcg/actuation 12 years old and olderSymbicort® (budesonide and formoterol fumaratedihydrate)80 mcg – 4.5 mcg/actuation 12 years old and older160 mcg – 4.5 mcg/actuation 12 years old and olderAcetaminophen/codeine120mg-12mg/5mL solution Less than 18 years oldButalbital/acetaminophen/caffeine/codeine50mg/325mg/40mg/30mg capsule Less than 18 years oldCodeine sulfate30 mg tablet Less than 18 years old60 mg tablet Less than 18 years oldFiorinal w/Codeine (butalbital/aspirin/caffeine/codeine)

50mg/325mg/40mg/30mg capsule Less than 18 years oldTylenol w/Codeine (acetaminophen/codeine)

300mg/15mg tablet Less than 18 years old300mg/30mg tablet Less than 18 years old300mg/60mg tablet Less than 18 years oldUltracet (tramadol/acetaminophen)

37.5mg/325mg tablet Less than 18 years oldUltram (tramadol)

50 mg tablet Less than 18 years old

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1 = Generic Drugs AL = Age Limit ME90 = Morphine Equivalent ST = Step Therapy2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty90 = 90 days available at mailorder

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Tier Level Necessary actions, restrictions,or limits on use

ANTI-INFECTIVE AGENTSPENICILLINSAMOXICILLIN – amoxicillin (trihydrate) chew tab 125 mg 2AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 mg 2amoxicillin (trihydrate) cap 250 mg 1amoxicillin (trihydrate) cap 500 mg 1amoxicillin (trihydrate) for susp 125 mg/5ml 1amoxicillin (trihydrate) for susp 200 mg/5ml 1amoxicillin (trihydrate) for susp 250 mg/5ml 1amoxicillin (trihydrate) for susp 400 mg/5ml 1amoxicillin (trihydrate) tab 875 mg 1amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 1amoxicillin & k clavulanate for susp 250-62.5 mg/5ml

(Augmentin)1

amoxicillin & k clavulanate for susp 400-57 mg/5ml 1amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin

es-600)1

amoxicillin & k clavulanate tab 250-125 mg 1amoxicillin & k clavulanate tab 500-125 mg (Augmentin) 1amoxicillin & k clavulanate tab 875-125 mg (Augmentin) 1AMOXICILLIN/CLAVULANATE P – amoxicillin & k clavulanate

chew tab 200-28.5 mg2

AMOXICILLIN/CLAVULANATE P – amoxicillin & k clavulanatechew tab 400-57 mg

2

dicloxacillin sodium cap 250 mg 1dicloxacillin sodium cap 500 mg 1penicillin v potassium tab 250 mg 1penicillin v potassium tab 500 mg 1

CEPHALOSPORINScefaclor 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 1

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cefdinir for susp 125 mg/5ml 1cefdinir for susp 250 mg/5ml 1cefixime for susp 100 mg/5ml (Suprax) 1cefixime for susp 200 mg/5ml (Suprax) 1cefprozil for susp 125 mg/5ml 1cefprozil for susp 250 mg/5ml 1cefprozil tab 250 mg 1cefprozil tab 500 mg 1ceftriaxone sodium for inj 250 mg 1ceftriaxone sodium for inj 500 mg 1ceftriaxone sodium for inj 1 gm 1ceftriaxone sodium for inj 2 gm 1cefuroxime axetil tab 250 mg 1cefuroxime axetil tab 500 mg (Ceftin) 1cephalexin cap 250 mg (Keflex) 1cephalexin cap 500 mg (Keflex) 1cephalexin for susp 125 mg/5ml 1cephalexin for susp 250 mg/5ml 1

MACROLIDESAZITHROMYCIN – azithromycin powd pack for susp 1 gm 2azithromycin for susp 100 mg/5ml (Zithromax) 1azithromycin for susp 200 mg/5ml (Zithromax) 1azithromycin tab 250 mg (Zithromax) 1 QL (60 tablets/180 days)azithromycin tab 500 mg (Zithromax) 1 QL (60 tablets/180 days)azithromycin tab 600 mg (Zithromax) 1 QL (60 tablets/180 days)clarithromycin tab 250 mg (Biaxin) 1clarithromycin tab 500 mg (Biaxin) 1

TETRACYCLINESdemeclocycline hcl tab 150 mg 1demeclocycline hcl tab 300 mg 1doxycycline hyclate cap 50 mg 1doxycycline hyclate cap 100 mg (Vibramycin) 1doxycycline hyclate tab delayed release 50 mg (Doryx) 1 PAdoxycycline hyclate tab 20 mg 1doxycycline hyclate tab 100 mg 1

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doxycycline monohydrate cap 50 mg 1doxycycline monohydrate cap 100 mg (Monodox) 1doxycycline monohydrate for susp 25 mg/5ml (Vibramycin) 1doxycycline monohydrate tab 50 mg (Adoxa) 1doxycycline monohydrate tab 75 mg (Adoxa) 1doxycycline monohydrate tab 100 mg (Adoxa pak 1/100) 1minocycline hcl cap 50 mg (Minocin) 1minocycline hcl cap 75 mg (Minocin) 1minocycline hcl cap 100 mg (Minocin) 1

FLUOROQUINOLONESciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml)

(Cipro)1

ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) 1ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) 1ciprofloxacin hcl tab 750 mg (base equiv) 1levofloxacin oral soln 25 mg/ml 1levofloxacin tab 250 mg (Levaquin) 1levofloxacin tab 500 mg (Levaquin) 1levofloxacin tab 750 mg (Levaquin) 1

AMINOGLYCOSIDESneomycin sulfate tab 500 mg 1paromomycin sulfate cap 250 mg 1TOBRAMYCIN – tobramycin nebu soln 300 mg/5ml 2 PA, QL (56 units/56 days), SPtobramycin nebu soln 300 mg/5ml (Tobi) 2 PA, QL (56 units/56 days), SP

TUBERCULOSISethambutol hcl tab 100 mg (Myambutol) 1ethambutol hcl tab 400 mg (Myambutol) 1isoniazid tab 100 mg 1 90isoniazid tab 300 mg 1 90PRIFTIN – rifapentine tab 150 mg 2pyrazinamide tab 500 mg 1rifabutin cap 150 mg (Mycobutin) 1rifampin cap 150 mg (Rifadin) 1rifampin cap 300 mg (Rifadin) 1

FUNGAL INFECTIONS

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Name of Drug


fluconazole for susp 10 mg/ml (Diflucan) 1 QL (35 mls/30 days)fluconazole for susp 40 mg/ml (Diflucan) 1 QL (35 mls/30 days)fluconazole tab 50 mg (Diflucan) 1 QL (30 tablets/30 days)fluconazole tab 100 mg (Diflucan) 1 QL (30 tablets/30 days)fluconazole tab 150 mg (Diflucan) 1 QL (30 tablets/30 days)fluconazole tab 200 mg (Diflucan) 1 QL (30 tablets/30 days)flucytosine cap 250 mg (Ancobon) 1flucytosine cap 500 mg (Ancobon) 1griseofulvin microsize susp 125 mg/5ml 1griseofulvin microsize tab 500 mg 1griseofulvin ultramicrosize tab 125 mg (Gris-peg) 1griseofulvin ultramicrosize tab 250 mg (Gris-peg) 1itraconazole cap 100 mg (Sporanox) 1 QL (120 capsules/30 days)NOXAFIL – posaconazole susp 40 mg/ml 2 PAnystatin oral powder 1nystatin tab 500000 unit 1posaconazole tab delayed release 100 mg (Noxafil) 1 PAterbinafine hcl tab 250 mg (Lamisil) 1 QL (90 tablets/365 days)voriconazole for susp 40 mg/ml (Vfend) 1 PAvoriconazole tab 50 mg (Vfend) 1 PAvoriconazole tab 200 mg (Vfend) 1 PA

VIRAL INFECTIONSCytomegalovirusvalganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte) 1valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) 1

Hepatitisadefovir dipivoxil tab 10 mg (Hepsera) 1BARACLUDE – entecavir oral soln 0.05 mg/ml 2entecavir tab 0.5 mg (Baraclude) 1entecavir tab 1 mg (Baraclude) 1lamivudine tab 100 mg (hbv) (Epivir hbv) 1MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg 2 PA, SPribavirin cap 200 mg (Rebetol) 2 PA, SPribavirin tab 200 mg (Copegus) 2 PA, SP

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SOFOSBUVIR/VELPATASVIR – sofosbuvir-velpatasvir tab400-100 mg

2 PA, SP

Herpesacyclovir cap 200 mg (Zovirax) 1acyclovir susp 200 mg/5ml (Zovirax) 1acyclovir tab 400 mg (Zovirax) 1acyclovir tab 800 mg (Zovirax) 1famciclovir tab 125 mg (Famvir) 1valacyclovir hcl tab 500 mg (Valtrex) 1valacyclovir hcl tab 1 gm (Valtrex) 1

HIV/AIDSabacavir sulfate soln 20 mg/ml (base equiv) (Ziagen) 1 QL (960 mls/30 days)abacavir sulfate tab 300 mg (base equiv) (Ziagen) 1 QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg (Epzicom) 1 QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg

(Trizivir)1 QL (60 tablets/30 days)

APTIVUS – tipranavir cap 250 mg 2 QL (120 capsules/30 days)APTIVUS – tipranavir oral soln 100 mg/ml 2 QL (4 bottles/30 days)atazanavir sulfate cap 150 mg (base equiv) (Reyataz) 1 QL (30 capsules/30 days)atazanavir sulfate cap 200 mg (base equiv) (Reyataz) 1 QL (60 capsules/30 days)atazanavir sulfate cap 300 mg (base equiv) (Reyataz) 1 QL (30 capsules/30 days)ATRIPLA – efavirenz-emtricitabine-tenofovir df tab

600-200-300 mg2 QL (30 tablets/30 days)

BIKTARVY – bictegravir-emtricitabine-tenofovir af tab50-200-25 mg

2 QL (30 tablets/30 days)

CIMDUO – lamivudine-tenofovir disoproxil fumarate tab300-300 mg


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


CRIXIVAN – indinavir sulfate cap 200 mg 2 QL (270 capsules/30 days)CRIXIVAN – indinavir sulfate cap 400 mg 2 QL (180 capsules/30 days)DELSTRIGO – doravirine-lamivudine-tenofovir df tab


DESCOVY – emtricitabine-tenofovir alafenamide fumarate tab200-25 mg


didanosine delayed release capsule 200 mg (Videx ec) 1 QL (30 capsules/30 days)didanosine delayed release capsule 250 mg (Videx ec) 1 QL (30 capsules/30 days)didanosine delayed release capsule 400 mg (Videx ec) 1 QL (30 capsules/30 days)

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Name of Drug


DOVATO – dolutegravir sodium-lamivudine tab 50-300 mg (baseeq)


EDURANT – rilpivirine hcl tab 25 mg (base equivalent) 2 QL (30 tablets/30 days)efavirenz cap 50 mg (Sustiva) 1 QL (90 capsules/30 days)efavirenz cap 200 mg (Sustiva) 1 QL (60 capsules/30 days)efavirenz tab 600 mg (Sustiva) 1 QL (30 tablets/30 days)EMTRIVA – emtricitabine caps 200 mg 2 QL (30 capsules/30 days)EMTRIVA – emtricitabine soln 10 mg/ml 2 QL (720 mls/30 days)EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg (base

equiv)2 QL (30 tablets/30 days)

fosamprenavir calcium tab 700 mg (base equiv) (Lexiva) 1 QL (120 tablets/30 days)FUZEON – enfuvirtide for inj 90 mg 2 QL (1 kit/30 days)GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg2 QL (30 tablets/30 days)

INTELENCE – etravirine tab 25 mg 2 QL (120 tablets/30 days)INTELENCE – etravirine tab 100 mg 2 QL (60 tablets/30 days)INTELENCE – etravirine tab 200 mg 2 QL (60 tablets/30 days)INVIRASE – saquinavir mesylate tab 500 mg 2 QL (120 tablets/30 days)ISENTRESS – raltegravir potassium packet for susp 100 mg

(base equiv)2 QL (60 packets/30 days)

ISENTRESS – raltegravir potassium tab 400 mg (base equiv) 2 QL (60 tablets/30 days)ISENTRESS – raltegravir potassium chew tab 25 mg (base

equiv)2 QL (180 tablets/30 days)

ISENTRESS – raltegravir potassium chew tab 100 mg (baseequiv)


ISENTRESS HD – raltegravir potassium tab 600 mg (base equiv) 2 QL (60 tablets/30 days)JULUCA – dolutegravir sodium-rilpivirine hcl tab 50-25 mg (base

eq)2 QL (30 tablets/30 days)

KALETRA – lopinavir-ritonavir tab 100-25 mg 2 QL (180 tablets/30 days)KALETRA – lopinavir-ritonavir tab 200-50 mg 2 QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml (Epivir) 1 QL (4 bottles/30 days)lamivudine tab 150 mg (Epivir) 1 QL (30 tablets/30 days)lamivudine tab 300 mg (Epivir) 1 QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg (Combivir) 1 QL (60 tablets/30 days)LEXIVA – fosamprenavir calcium susp 50 mg/ml (base equiv) 2 QL (8 bottles/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) (Kaletra) 1 QL (480 mls/30 days)nevirapine susp 50 mg/5ml (Viramune) 1 QL (1200 mls/30 days)nevirapine tab er 24hr 100 mg (Viramune xr) 1 QL (90 tablets/30 days)

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nevirapine tab er 24hr 400 mg (Viramune xr) 1 QL (30 tablets/30 days)nevirapine tab 200 mg (Viramune) 1 QL (60 tablets/30 days)NORVIR – ritonavir oral soln 80 mg/ml 2 QL (2 bottles/30 days)ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab


PIFELTRO – doravirine tab 100 mg 2 QL (30 tablets/30 days)PREZCOBIX – darunavir-cobicistat tab 800-150 mg 2 QL (30 tablets/30 days)PREZISTA – darunavir ethanolate susp 100 mg/ml (base equiv) 2 QL (2 bottles/30 days)PREZISTA – darunavir ethanolate tab 75 mg (base equiv) 2 QL (300 tablets/30 days)PREZISTA – darunavir ethanolate tab 150 mg (base equiv) 2 QL (180 tablets/30 days)PREZISTA – darunavir ethanolate tab 600 mg (base equiv) 2 QL (60 tablets/30 days)PREZISTA – darunavir ethanolate tab 800 mg (base equiv) 2 QL (30 tablets/30 days)RESCRIPTOR – delavirdine mesylate tab 200 mg 2 QL (180 tablets/30 days)ritonavir tab 100 mg (Norvir) 1 QL (180 tablets/30 days)SELZENTRY – maraviroc tab 150 mg 2 QL (60 tablets/30 days)SELZENTRY – maraviroc tab 300 mg 2 QL (120 tablets/30 days)stavudine cap 15 mg (Zerit) 1 QL (60 capsules/30 days)stavudine cap 20 mg (Zerit) 1 QL (60 capsules/30 days)stavudine cap 30 mg (Zerit) 1 QL (60 capsules/30 days)stavudine cap 40 mg (Zerit) 1 QL (60 capsules/30 days)STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab

150-150-200-300 mg2 QL (30 tablets/30 days)

SUSTIVA – efavirenz tab 600 mg 2 QL (30 tablets/30 days)SUSTIVA – efavirenz cap 50 mg 2 QL (90 capsules/30 days)SUSTIVA – efavirenz cap 200 mg 2 QL (60 capsules/30 days)SYMFI – efavirenz-lamivudine-tenofovir df tab 600-300-300 mg 2 QL (30 tablets/30 days)SYMFI LO – efavirenz-lamivudine-tenofovir df tab


SYMTUZA – darunavir-cobic-emtricitab-tenofov af tab800-150-200-10 mg


tenofovir disoproxil fumarate tab 300 mg (Viread) 1 QL (30 tablets/30 days)TIVICAY – dolutegravir sodium tab 50 mg (base equiv) 2 QL (60 tablets/30 days)TRIUMEQ – abacavir-dolutegravir-lamivudine tab 600-50-300 mg 2 QL (30 tablets/30 days)TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab

100-150 mg2 QL (30 tablets/30 days)

TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab133-200 mg


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TYBOST – cobicistat tab 150 mg 2 QL (30 tablets/30 days)VIDEX – didanosine for soln 2 gm 2 QL (1200 mls/30 days)VIRACEPT – nelfinavir mesylate tab 250 mg 2 QL (270 tablets/30 days)VIRACEPT – nelfinavir mesylate tab 625 mg 2 QL (120 tablets/30 days)VIREAD – tenofovir disoproxil fumarate oral powder 40 mg/gm 2 QL (4 bottles/30 days)VIREAD – tenofovir disoproxil fumarate tab 150 mg 2 QL (30 tablets/30 days)VIREAD – tenofovir disoproxil fumarate tab 200 mg 2 QL (30 tablets/30 days)VIREAD – tenofovir disoproxil fumarate tab 250 mg 2 QL (30 tablets/30 days)VIREAD – tenofovir disoproxil fumarate tab 300 mg 2 QL (30 tablets/30 days)zidovudine cap 100 mg (Retrovir) 1 QL (180 capsules/30 days)zidovudine syrup 10 mg/ml (Retrovir) 1 QL (8 bottles/30 days)zidovudine tab 300 mg 1 QL (60 tablets/30 days)

Influenzaoseltamivir phosphate cap 30 mg (base equiv) (Tamiflu) 1 QL (20 capsules/120 days)oseltamivir phosphate cap 45 mg (base equiv) (Tamiflu) 1 QL (20 capsules/120 days)oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu) 1 QL (20 capsules/120 days)oseltamivir phosphate for susp 6 mg/ml (base equiv) (Tamiflu) 1 QL (360 mls/120 days)RELENZA DISKHALER – zanamivir aero powder breath

activated 5 mg/blister2 QL (40 blisters/120 days)

MALARIAatovaquone-proguanil hcl tab 62.5-25 mg (Malarone) 1 QL (30 tablets/90 days)atovaquone-proguanil hcl tab 250-100 mg (Malarone) 1 QL (30 tablets/90 days)chloroquine phosphate tab 500 mg (Aralen) 1DARAPRIM – pyrimethamine tab 25 mg 2 PA, QL (90 tablets/30 days)hydroxychloroquine sulfate tab 200 mg (Plaquenil) 1KRINTAFEL – tafenoquine succinate tab 150 mg (base

equivalent)2

MEFLOQUINE HCL – mefloquine hcl tab 250 mg 2primaquine phosphate tab 26.3 mg (15 mg base) (Primaquine

phosphate)1

WORM INFECTIONSalbendazole tab 200 mg (Albenza) 1BENZNIDAZOLE – benznidazole tab 12.5 mg 2

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BENZNIDAZOLE – benznidazole tab 100 mg 2ivermectin tab 3 mg (Stromectol) 1praziquantel tab 600 mg (Biltricide) 1

OTHER ANTI-INFECTIVESALINIA – nitazoxanide tab 500 mg 2 QL (6 tablets/30 days)CAYSTON – aztreonam lysine for inhal soln 75 mg (base

equivalent)2 PA, QL (84 boxes/56 days), SP

clindamycin hcl cap 75 mg (Cleocin) 1clindamycin hcl cap 150 mg (Cleocin) 1clindamycin hcl cap 300 mg (Cleocin) 1clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)

(Cleocin pediatric gr)1

dapsone tab 25 mg 1dapsone tab 100 mg 1linezolid for susp 100 mg/5ml (Zyvox) 1 PA, QL (600 mls/180 days)linezolid tab 600 mg (Zyvox) 1 PA, QL (56 tablets/180 days)metronidazole cap 375 mg (Flagyl) 1metronidazole tab 250 mg (Flagyl) 1metronidazole tab 500 mg (Flagyl) 1sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 1sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim) 1sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds) 1trimethoprim tab 100 mg 1vancomycin hcl cap 125 mg (base equivalent) (Vancocin hcl) 1vancomycin hcl cap 250 mg (base equivalent) (Vancocin hcl) 1XIFAXAN – rifaximin tab 550 mg 2 PA, QL (60 tablets/30 days)ZYVOX – linezolid for susp 100 mg/5ml 2 PA, QL (600 mls/180 days)

IMMUNIZING AGENTSADACEL – tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-

mcg/0.5ml2

AFLURIA QUADRIVALENT 2019-2020 – influenza virus vac splitquadrivalent susp pref syr 0.25 ml

2

AFLURIA QUADRIVALENT 2019-2020 – influenza virus vac splitquadrivalent susp pref syr 0.5ml

2

AFLURIA QUADRIVALENT 2019-2020 – influenza virus vaccinesplit quadrivalent im inj

2

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Name of Drug


BOOSTRIX – tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml

2

ENGERIX-B – hepatitis b vaccine (recombinant) susp10 mcg/0.5ml

2

ENGERIX-B – hepatitis b vaccine (recombinant) susp 20 mcg/ml 2ENGERIX-B – hepatitis b vaccine (recombinant) 10 mcg/0.5ml 2ENGERIX-B – hepatitis b vaccine (recombinant) 20 mcg/ml 2FLUAD 2019-2020 – influenza vac type a&b surface ant adj susp

pref syr 0.5 ml2

FLUARIX QUADRIVALENT 2019-2020 – influenza virus vac splitquadrivalent susp pref syr 0.5ml

2

FLUBLOK QUADRIVALENT 2019-2020 – influenza vac recombha quad pf soln pref syr 0.5 ml

2

FLUCELVAX QUADRIVALENT 2019-2020 – influenza vac tiss-cult subunt quad susp pref syr 0.5 ml

2

FLUCELVAX QUADRIVALENT 2019-2020 – influenza vac tissue-cultured subunit quadrivalent im susp

2

FLULAVAL QUADRIVALENT 2019-2020 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml

2

FLULAVAL QUADRIVALENT 2019-2020 – influenza virusvaccine split quadrivalent im inj

2

FLUZONE HIGH-DOSE PF 2019-2020 – influenza virus vac splithigh-dose pf susp pref syr 0.5ml

2

FLUZONE QUADRIVALENT 2019-2020 – influenza virus vacsplit quadrivalent susp pref syr 0.25 ml

2

FLUZONE QUADRIVALENT 2019-2020 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml

2

FLUZONE QUADRIVALENT 2019-2020 – influenza virus vaccinesplit quadrivalent im inj

2

FLUZONE QUADRIVALENT 2019-2020 – influenza virus vaccinesplit quadrivalent inj 0.5 ml

2

HEPLISAV-B – hepatitis b vaccine recomb adjuvanted pref syr20 mcg/0.5ml

2

HEPLISAV-B – hepatitis b vaccine recombinant adjuvanted20 mcg/0.5ml

2

IMOVAX RABIES (H.D.C.V.) – rabies virus vaccine, hdc inj 2PNEUMOVAX 23 – pneumococcal vaccine polyvalent inj

25 mcg/0.5ml2

PNEUMOVAX 23/1 DOSE – pneumococcal vaccine polyvalent inj25 mcg/0.5ml

2

PREVNAR 13 – pneumococcal 13-valent conjugate vaccine inj 2RABAVERT – rabies vaccine, pcec for inj 2

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RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp5 mcg/0.5ml

2

RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp10 mcg/ml

2

RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp40 mcg/ml

2

SHINGRIX – zoster vac recombinant adjuvanted for im inj50 mcg/0.5ml

2 QL (2 vaccines/1 lifetime)

SYNAGIS – palivizumab im soln 50 mg/0.5ml 2 PA, SPSYNAGIS – palivizumab im soln 100 mg/ml 2 PA, SPZOSTAVAX – zoster vaccine live for subcutaneous susp 19400

unit/0.65ml2 QL (1 vaccine/1 lifetime)

CANCER DRUGSabiraterone acetate tab 250 mg (Zytiga) 2 PA, QL (120 tablets/30

days), SF, SPACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml

(2000000 unit/0.5ml)2 PA, QL (12 vials/28 days), SP

AFINITOR – everolimus tab 2.5 mg 2 PA, QL (30 tablets/30days), SF, SP

AFINITOR – everolimus tab 5 mg 2 PA, QL (30 tablets/30days), SF, SP

AFINITOR – everolimus tab 7.5 mg 2 PA, QL (30 tablets/30days), SF, SP

AFINITOR – everolimus tab 10 mg 2 PA, QL (30 tablets/30days), SF, SP

AFINITOR DISPERZ – everolimus tab for oral susp 2 mg 2 PA, QL (60 tablets/30days), SF, SP



ALECENSA – alectinib hcl cap 150 mg (base equivalent) 2 PA, QL (240 capsules/30days), SF, SP

ALKERAN – melphalan tab 2 mg 2 SPanastrozole tab 1 mg (Arimidex) 1 90BALVERSA – erdafitinib tab 3 mg 2 PA, QL (84 tablets/28

days), SF, SPBALVERSA – erdafitinib tab 4 mg 2 PA, QL (56 tablets/28

days), SF, SP

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BALVERSA – erdafitinib tab 5 mg 2 PA, QL (28 tablets/28days), SF, SP

bexarotene cap 75 mg (Targretin) 2 PA, SF, SPbicalutamide tab 50 mg (Casodex) 2 SPBOSULIF – bosutinib tab 100 mg 2 PA, QL (120 tablets/30

days), SF, SPBOSULIF – bosutinib tab 500 mg 2 PA, QL (30 tablets/30

days), SF, SPBRAFTOVI – encorafenib cap 75 mg 2 PA, QL (180

capsules/30 days), SPCABOMETYX – cabozantinib s-malate tab 20 mg (base

equivalent)2 PA, QL (30 tablets/30

days), SF, SPCABOMETYX – cabozantinib s-malate tab 40 mg (base


days), SF, SPCABOMETYX – cabozantinib s-malate tab 60 mg (base


days), SF, SPCALQUENCE – acalabrutinib cap 100 mg 2 PA, QL (60 capsules/30 days), SPcapecitabine tab 150 mg (Xeloda) 2 PA, SPcapecitabine tab 500 mg (Xeloda) 2 PA, SPCAPRELSA – vandetanib tab 100 mg 2 PA, QL (60 tablets/30 days), SPCAPRELSA – vandetanib tab 300 mg 2 PA, QL (30 tablets/30 days), SPCOMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 mg dose)

kit2 PA, QL (1 carton/28 days), SF, SP

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg(100 dose) kit

2 PA, QL (1 carton/28 days), SF, SP

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg(140 dose) kit

2 PA, QL (1 carton/28 days), SF, SP

COPIKTRA – duvelisib cap 15 mg 2 PA, QL (56 capsules/28days), SF, SP

COPIKTRA – duvelisib cap 25 mg 2 PA, QL (56 capsules/28days), SF, SP

COTELLIC – cobimetinib fumarate tab 20 mg (base equivalent) 2 PA, QL (63 tablets/28 days), SPcyclophosphamide cap 25 mg (Cyclophosphamide) 1cyclophosphamide cap 50 mg (Cyclophosphamide) 1DAURISMO – glasdegib maleate tab 25 mg (base equivalent) 2 PA, QL (60 tablets/30

days), SF, SPDAURISMO – glasdegib maleate tab 100 mg (base equivalent) 2 PA, QL (30 tablets/30

days), SF, SP

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ELIGARD – leuprolide acetate for subcutaneous inj kit 7.5 mg 2 SPELIGARD – leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg2 SP

ELIGARD – leuprolide acetate (4 month) for subcutaneous inj kit30 mg

2 SP

ELIGARD – leuprolide acetate (6 month) for subcutaneous inj kit45 mg

2 SP

ERIVEDGE – vismodegib cap 150 mg 2 PA, QL (30 capsules/30 days), SPERLEADA – apalutamide tab 60 mg 2 PA, QL (120 tablets/30 days), SPerlotinib hcl tab 25 mg (base equivalent) (Tarceva) 2 PA, QL (60 tablets/30

days), SF, SPerlotinib hcl tab 100 mg (base equivalent) (Tarceva) 2 PA, QL (30 tablets/30

days), SF, SPerlotinib hcl tab 150 mg (base equivalent) (Tarceva) 2 PA, QL (30 tablets/30

days), SF, SPETOPOSIDE – etoposide cap 50 mg 2 SPexemestane tab 25 mg (Aromasin) 1 90flutamide cap 125 mg 1GILOTRIF – afatinib dimaleate tab 20 mg (base equivalent) 2 PA, QL (30 tablets/30 days), SPGILOTRIF – afatinib dimaleate tab 30 mg (base equivalent) 2 PA, QL (30 tablets/30 days), SPGILOTRIF – afatinib dimaleate tab 40 mg (base equivalent) 2 PA, QL (30 tablets/30 days), SPHYCAMTIN – topotecan hcl cap 0.25 mg (base equiv) 2 PA, SPHYCAMTIN – topotecan hcl cap 1 mg (base equiv) 2 PA, SPhydroxyurea cap 500 mg (Hydrea) 1IBRANCE – palbociclib cap 75 mg 2 PA, QL (21 capsules/28 days), SPIBRANCE – palbociclib cap 100 mg 2 PA, QL (21 capsules/28 days), SPIBRANCE – palbociclib cap 125 mg 2 PA, QL (21 capsules/28 days), SPICLUSIG – ponatinib hcl tab 15 mg (base equiv) 2 PA, QL (60 tablets/30

days), SF, SPICLUSIG – ponatinib hcl tab 45 mg (base equiv) 2 PA, QL (30 tablets/30

days), SF, SPimatinib mesylate tab 100 mg (base equivalent) (Gleevec) 2 PA, QL (90 tablets/30

days), SF, SPimatinib mesylate tab 400 mg (base equivalent) (Gleevec) 2 PA, QL (60 tablets/30

days), SF, SPINLYTA – axitinib tab 1 mg 2 PA, QL (180 tablets/30

days), SF, SP

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INLYTA – axitinib tab 5 mg 2 PA, QL (120 tablets/30days), SF, SP

JAKAFI – ruxolitinib phosphate tab 5 mg (base equivalent) 2 PA, QL (60 tablets/30days), SF, SP





KISQALI – ribociclib succinate tab pack 200 mg daily dose 2 PA, QL (63 tablets/28 days), SPKISQALI – ribociclib succinate tab pack 400 mg daily dose

(200 mg tab)2 PA, QL (63 tablets/28 days), SP

KISQALI – ribociclib succinate tab pack 600 mg daily dose(200 mg tab)

2 PA, QL (63 tablets/28 days), SP

KISQALI FEMARA 200 DOSE – ribociclib 200 mg dose (200 mgtab) & letrozole 2.5 mg tbpk






LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapy pack10 mg (10 mg daily dose)

2 PA, QL (30 capsules/30days), SF, SP

LENVIMA 12MG DAILY DOSE – lenvatinib cap therapy pack 4(3) mg (12 mg daily dose)


LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy pack 10& 4 mg (14 mg daily dose)


LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapy pack 10& 4 (2) mg (18 mg daily dose)


LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapy pack 10(2) mg (20 mg daily dose)


LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapy pack 10(2) & 4 mg (24 mg daily dose)


LENVIMA 4 MG DAILY DOSE – lenvatinib cap therapy pack4 mg (4 mg daily dose)


LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapy pack 4(2) mg (8 mg daily dose)


letrozole tab 2.5 mg (Femara) 1 90

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LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg 2LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg 2leucovorin calcium tab 5 mg 1leucovorin calcium tab 25 mg 1LEUKERAN – chlorambucil tab 2 mg 2 SPLONSURF – trifluridine-tipiracil tab 15-6.14 mg 2 PA, QL (100 tablets/28 days), SPLONSURF – trifluridine-tipiracil tab 20-8.19 mg 2 PA, QL (80 tablets/28 days), SPLORBRENA – lorlatinib tab 25 mg 2 PA, QL (90 tablets/30

days), SF, SPLORBRENA – lorlatinib tab 100 mg 2 PA, QL (30 tablets/30

days), SF, SPLUPRON DEPOT (1-MONTH) – leuprolide acetate for inj kit

3.75 mg2 PA, SP

LUPRON DEPOT (1-MONTH) – leuprolide acetate for inj kit7.5 mg

2 PA, SP

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3 month) forinj kit 11.25 mg

2 PA, SP

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3 month) forinj kit 22.5 mg

2 PA, SP

LUPRON DEPOT (4-MONTH) – leuprolide acetate (4 month) forinj kit 30 mg

2 PA, SP

LUPRON DEPOT (6-MONTH) – leuprolide acetate (6 month) forinj kit 45 mg

2 PA, SP

LYNPARZA – olaparib tab 100 mg 2 PA, QL (120 tablets/30days), SF, SP

LYNPARZA – olaparib tab 150 mg 2 PA, QL (120 tablets/30days), SF, SP

LYSODREN – mitotane tab 500 mg 2 PA, SPMATULANE – procarbazine hcl cap 50 mg 2 PA, SPmegestrol acetate susp 40 mg/ml (Megace oral) 1megestrol acetate tab 20 mg 1megestrol acetate tab 40 mg 1MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg (base

equivalent)2 PA, QL (90 tablets/30 days), SP

MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (baseequivalent)


MEKTOVI – binimetinib tab 15 mg 2 PA, QL (180 tablets/30 days), SPmercaptopurine tab 50 mg 1methotrexate sodium tab 2.5 mg (base equiv) 1

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MYLERAN – busulfan tab 2 mg 2 SPNERLYNX – neratinib maleate tab 40 mg (base equivalent) 2 PA, QL (180 tablets/30

days), SF, SPNEXAVAR – sorafenib tosylate tab 200 mg (base equivalent) 2 PA, QL (120 tablets/30

days), SF, SPNINLARO – ixazomib citrate cap 3 mg (base equivalent) 2 PA, QL (3 capsules/28 days), SPNINLARO – ixazomib citrate cap 4 mg (base equivalent) 2 PA, QL (3 capsules/28 days), SPNINLARO member friendly text – ixazomib citrate cap 2.3 mg

(base equivalent)2 PA, QL (3 capsules/28 days), SP

POMALYST – pomalidomide cap 1 mg 2 PA, QL (21 capsules/30 days), SPPOMALYST – pomalidomide cap 2 mg 2 PA, QL (21 capsules/30 days), SPPOMALYST – pomalidomide cap 3 mg 2 PA, QL (21 capsules/30 days), SPPOMALYST – pomalidomide cap 4 mg 2 PA, QL (21 capsules/30 days), SPPURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml) 2 PA, SPRUBRACA – rucaparib camsylate tab 200 mg (base equivalent) 2 PA, QL (120 tablets/30

days), SF, SPRUBRACA – rucaparib camsylate tab 250 mg (base equivalent) 2 PA, QL (120 tablets/30

days), SF, SPRUBRACA – rucaparib camsylate tab 300 mg (base equivalent) 2 PA, QL (120 tablets/30

days), SF, SPSPRYCEL – dasatinib tab 20 mg 2 PA, QL (90 tablets/30






days), SF, SPSTIVARGA – regorafenib tab 40 mg 2 PA, QL (90 tablets/30 days), SPSUTENT – sunitinib malate cap 12.5 mg (base equivalent) 2 PA, QL (90 capsules/30

days), SF, SPSUTENT – sunitinib malate cap 25 mg (base equivalent) 2 PA, QL (30 capsules/30

days), SF, SP

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SUTENT – sunitinib malate cap 37.5 mg (base equivalent) 2 PA, QL (30 capsules/30days), SF, SP

SUTENT – sunitinib malate cap 50 mg (base equivalent) 2 PA, QL (30 capsules/30days), SF, SP

SYLATRON – peginterferon alfa-2b for inj kit 200 mcg 2 PA, SPSYLATRON – peginterferon alfa-2b for inj kit 300 mcg 2 PA, SPSYLATRON – peginterferon alfa-2b for inj kit 600 mcg 2 PA, SPTABLOID – thioguanine tab 40 mg 2 SPTAFINLAR – dabrafenib mesylate cap 50 mg (base equivalent) 2 PA, QL (120

capsules/30 days), SPTAFINLAR – dabrafenib mesylate cap 75 mg (base equivalent) 2 PA, QL (120

capsules/30 days), SPTALZENNA – talazoparib tosylate cap 0.25 mg (base equivalent) 2 PA, QL (90 capsules/30

days), SF, SPTALZENNA – talazoparib tosylate cap 1 mg (base equivalent) 2 PA, QL (30 capsules/30

days), SF, SPtamoxifen citrate tab 10 mg (base equivalent) 1tamoxifen citrate tab 20 mg (base equivalent) 1TARGRETIN – bexarotene cap 75 mg 2 PA, SF, SPTASIGNA – nilotinib hcl cap 50 mg (base equivalent) 2 PA, QL (120 capsules/30

days), SF, SPTASIGNA – nilotinib hcl cap 150 mg (base equivalent) 2 PA, QL (120 capsules/30

days), SF, SPTASIGNA – nilotinib hcl cap 200 mg (base equivalent) 2 PA, QL (120 capsules/30

days), SF, SPtemozolomide cap 5 mg (Temodar) 2 PA, SPtemozolomide cap 20 mg (Temodar) 2 PA, SPtemozolomide cap 100 mg (Temodar) 2 PA, SPtemozolomide cap 140 mg (Temodar) 2 PA, SPtemozolomide cap 180 mg (Temodar) 2 PA, SPtemozolomide cap 250 mg (Temodar) 2 PA, SPTIBSOVO – ivosidenib tab 250 mg 2 PA, QL (60 tablets/30 days), SPtoremifene citrate tab 60 mg (base equivalent) (Fareston) 1 SPtretinoin cap 10 mg 2 PA, SPTYKERB – lapatinib ditosylate tab 250 mg (base equiv) 2 PA, QL (180 tablets/30 days), SPVENCLEXTA – venetoclax tab 10 mg 2 PA, QL (60 tablets/30 days), SPVENCLEXTA – venetoclax tab 50 mg 2 PA, QL (30 tablets/30 days), SP

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VENCLEXTA – venetoclax tab 100 mg 2 PA, QL (180 tablets/30 days), SPVENCLEXTA STARTING PACK – venetoclax tab therapy starter

pack 10 & 50 & 100 mg2 PA, QL (1 pack/180 days), SP

VERZENIO – abemaciclib tab 50 mg 2 PA, QL (60 tablets/30 days), SPVERZENIO – abemaciclib tab 100 mg 2 PA, QL (60 tablets/30 days), SPVERZENIO – abemaciclib tab 150 mg 2 PA, QL (60 tablets/30 days), SPVERZENIO – abemaciclib tab 200 mg 2 PA, QL (60 tablets/30 days), SPVITRAKVI – larotrectinib sulfate oral soln 20 mg/ml (base

equivalent)2 PA, QL (300 mls/30 days), SF, SP

VITRAKVI – larotrectinib sulfate cap 25 mg (base equivalent) 2 PA, QL (180 capsules/30days), SF, SP

VITRAKVI – larotrectinib sulfate cap 100 mg (base equivalent) 2 PA, QL (60 capsules/30days), SF, SP

VIZIMPRO – dacomitinib tab 15 mg 2 PA, QL (30 tablets/30days), SF, SP



VOTRIENT – pazopanib hcl tab 200 mg (base equiv) 2 PA, QL (120 tablets/30days), SF, SP

XALKORI – crizotinib cap 200 mg 2 PA, QL (60 capsules/30days), SF, SP

XALKORI – crizotinib cap 250 mg 2 PA, QL (60 capsules/30days), SF, SP

XOSPATA – gilteritinib fumarate tablet 40 mg (base equivalent) 2 PA, QL (90 tablets/30 days), SPXTANDI – enzalutamide cap 40 mg 2 PA, QL (120 capsules/30

days), SF, SPYONSA – abiraterone acetate tab 125 mg 2 PA, QL (120 tablets/30

days), SF, SPZELBORAF – vemurafenib tab 240 mg 2 PA, QL (240 tablets/30 days), SPZOLINZA – vorinostat cap 100 mg 2 PA, QL (120 capsules/30

days), SF, SPZYKADIA – ceritinib cap 150 mg 2 PA, QL (90 capsules/30

days), SF, SPZYKADIA – ceritinib tab 150 mg 2 PA, QL (90 tablets/30

days), SF, SP

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ZYTIGA – abiraterone acetate tab 500 mg 2 PA, QL (60 tablets/30days), SF, SP

HORMONES, DIABETES AND RELATED DRUGSCORTICOSTEROIDSbudesonide delayed release particles cap 3 mg (Entocort ec) 1CORTISONE ACETATE – cortisone acetate tab 25 mg 2DEXAMETHASONE – dexamethasone soln 0.5 mg/5ml 2dexamethasone elixir 0.5 mg/5ml 1dexamethasone tab 0.5 mg 1dexamethasone tab 0.75 mg 1dexamethasone tab 1.5 mg 1dexamethasone tab 4 mg 1dexamethasone tab 6 mg 1fludrocortisone acetate tab 0.1 mg 1 90hydrocortisone tab 5 mg (Cortef) 1hydrocortisone tab 10 mg (Cortef) 1hydrocortisone tab 20 mg (Cortef) 1methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak) 1methylprednisolone tab 4 mg (Medrol) 1methylprednisolone tab 8 mg (Medrol) 1methylprednisolone tab 16 mg (Medrol) 1methylprednisolone tab 32 mg (Medrol) 1PREDNISOLONE – prednisolone syrup 15 mg/5ml (usp solution

equivalent)2

prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)(Pediapred)

1

prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) 1PREDNISONE – prednisone tab 50 mg 2PREDNISONE – prednisone oral soln 5 mg/5ml 2prednisone tab therapy pack 5 mg (21) 1prednisone tab therapy pack 5 mg (48) 1prednisone tab therapy pack 10 mg (21) 1prednisone tab therapy pack 10 mg (48) 1prednisone tab 1 mg 1prednisone tab 2.5 mg 1prednisone tab 5 mg 1

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prednisone tab 10 mg 1prednisone tab 20 mg 1SOLU-CORTEF – hydrocortisone sodium succinate pf for inj

100 mg2

SOLU-CORTEF – hydrocortisone sodium succinate pf for inj250 mg

2


2


2

MALE HORMONESdanazol cap 50 mg 1danazol cap 100 mg 1danazol cap 200 mg 1testosterone td gel 25 mg/2.5gm (1%) (Androgel) 1 PA, QL (60 packets/30 days)testosterone td gel 50 mg/5gm (1%) (Androgel) 1 PA, QL (60 packets/30 days)testosterone td gel 12.5 mg/act (1%) (Androgel pump) 1 PA, QL (4 pump bottles/30 days)

ESTROGENSCOMBIPATCH – estradiol-norethindrone ace td pttw

0.05-0.14 mg/day2 90

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

2 90

estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella) 1 90estradiol & norethindrone acetate tab 1-0.5 mg (Activella) 1 90estradiol tab 0.5 mg (Estrace) 1 90estradiol tab 1 mg (Estrace) 1 90estradiol tab 2 mg (Estrace) 1 90estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot) 1 QL (8 patches/28 days), 90estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot) 1 QL (8 patches/28 days), 90estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot) 1 QL (8 patches/28 days), 90estradiol td patch twice weekly 0.075 mg/24hr (Vivelle-dot) 1 QL (8 patches/28 days), 90estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-dot) 1 QL (8 patches/28 days), 90estradiol td patch weekly 0.025 mg/24hr (Climara) 1 QL (4 patches/28 days), 90estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)

(Climara)1 QL (4 patches/28 days), 90

estradiol td patch weekly 0.05 mg/24hr (Climara) 1 QL (4 patches/28 days), 90estradiol td patch weekly 0.06 mg/24hr (Climara) 1 QL (4 patches/28 days), 90

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estradiol td patch weekly 0.075 mg/24hr (Climara) 1 QL (4 patches/28 days), 90estradiol td patch weekly 0.1 mg/24hr (Climara) 1 QL (4 patches/28 days), 90ESTROGEL – estradiol gel 0.06% (0.75 mg/1.25 gm metered-

dose pump)2 90

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg(Femhrt low dose)

1 90

norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg 1 90

PROGESTINSmedroxyprogesterone acetate tab 2.5 mg (Provera) 1 90medroxyprogesterone acetate tab 5 mg (Provera) 1 90medroxyprogesterone acetate tab 10 mg (Provera) 1 90megestrol acetate susp 625 mg/5ml (Megace es) 1 90norethindrone acetate tab 5 mg (Aygestin) 1 90progesterone micronized cap 100 mg (Prometrium) 1 90progesterone micronized cap 200 mg (Prometrium) 1 90

BIRTH CONTROLELLA – ulipristal acetate tab 30 mg 2 QL (3 tablets/365 days)KYLEENA – levonorgestrel releasing iud 17.5 mcg/day (19.5 mg

total)2

LILETTA – levonorgestrel releasing iud 19.5 mcg/day (52 mgtotal)

2

MIRENA – levonorgestrel releasing iud 20 mcg/day (52 mg total) 2NEXPLANON – etonogestrel subdermal implant 68 mg 2NUVARING – etonogestrel-ethinyl estradiol va ring

0.120-0.015 mg/24hr2 QL (1 ring/21 days), 90

PARAGARD INTRAUTERINE COP – copper iud 2 90SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5 mg total) 2 90XULANE – norelgestromin-ethinyl estradiol td ptwk

150-35 mcg/24hr2 QL (3 patches/21 days), 90

ENDOMETRIOSISLUPANETA PACK – leuprolide (1 mon) inj 3.75 mg &

norethindrone tab 5 mg kit2 PA, SP

LUPANETA PACK – leuprolide (3 mon) inj 11.25 mg &norethindrone tab 5 mg kit

2 PA, SP

LUPRON DEPOT-PED (1-MONTH – leuprolide acetate for injpediatric kit 7.5 mg

2 PA, SP


2 PA, SP

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LUPRON DEPOT-PED (1-MONTH – leuprolide acetate for injpediatric kit 15 mg

2 PA, SP

LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3month) for inj pediatric kit 11.25 mg

2 PA, SP

LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3month) for inj pediatric kit 30 mg

2 PA, SP

SYNAREL – nafarelin acetate nasal soln 2 mg/ml (200 mcg/act)(base eq)

2

DIABETESacarbose tab 25 mg (Precose) 1 QL (180 tablets/30 days), 90acarbose tab 50 mg (Precose) 1 QL (180 tablets/30 days), 90acarbose tab 100 mg (Precose) 1 QL (90 tablets/30 days), 90ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (base equiv) 2 QL (30 tablets/30 days), ST, 90ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (base equiv) 2 QL (30 tablets/30 days), ST, 90ALOGLIPTIN – alogliptin benzoate tab 25 mg (base equiv) 2 QL (30 tablets/30 days), ST, 90ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab

12.5-500 mg2 QL (60 tablets/30 days), ST, 90

ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab12.5-1000 mg

2 QL (60 tablets/30 days), ST, 90

ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab12.5-15 mg






ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab25-15 mg






glimepiride tab 1 mg (Amaryl) 1 QL (60 tablets/30 days), 90glimepiride tab 2 mg (Amaryl) 1 QL (60 tablets/30 days), 90glimepiride tab 4 mg (Amaryl) 1 QL (60 tablets/30 days), 90glipizide tab er 24hr 2.5 mg (Glucotrol xl) 1 QL (60 tablets/30 days), 90glipizide tab er 24hr 5 mg (Glucotrol xl) 1 QL (90 tablets/30 days), 90glipizide tab er 24hr 10 mg (Glucotrol xl) 1 QL (60 tablets/30 days), 90glipizide tab 5 mg (Glucotrol) 1 QL (120 tablets/30 days), 90glipizide tab 10 mg (Glucotrol) 1 QL (120 tablets/30 days), 90glipizide-metformin hcl tab 2.5-250 mg 1 QL (120 tablets/30 days), 90

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glipizide-metformin hcl tab 2.5-500 mg 1 QL (120 tablets/30 days), 90glipizide-metformin hcl tab 5-500 mg 1 QL (120 tablets/30 days), 90GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj kit 1 mg 2 QL (6 pens/365 days)glyburide tab 1.25 mg 1 QL (60 tablets/30 days), 90glyburide tab 2.5 mg 1 QL (60 tablets/30 days), 90glyburide tab 5 mg 1 QL (120 tablets/30 days), 90glyburide-metformin tab 1.25-250 mg (Glucovance) 1 QL (120 tablets/30 days), 90glyburide-metformin tab 2.5-500 mg (Glucovance) 1 QL (120 tablets/30 days), 90glyburide-metformin tab 5-500 mg (Glucovance) 1 QL (120 tablets/30 days), 90KORLYM – mifepristone tab 300 mg 2 PA, QL (120 tablets/30 days), SPmetformin hcl tab er 24hr 500 mg (Glucophage xr) 1 QL (120 tablets/30 days), 90metformin hcl tab er 24hr 750 mg (Glucophage xr) 1 QL (60 tablets/30 days), 90metformin hcl tab 500 mg (Glucophage) 1 QL (120 tablets/30 days), 90metformin hcl tab 850 mg (Glucophage) 1 QL (90 tablets/30 days), 90metformin hcl tab 1000 mg (Glucophage) 1 QL (60 tablets/30 days), 90nateglinide tab 60 mg (Starlix) 1 QL (120 tablets/30 days), 90nateglinide tab 120 mg (Starlix) 1 QL (90 tablets/30 days), 90pioglitazone hcl tab 15 mg (base equiv) (Actos) 1 QL (30 tablets/30 days), 90pioglitazone hcl tab 30 mg (base equiv) (Actos) 1 QL (30 tablets/30 days), 90pioglitazone hcl tab 45 mg (base equiv) (Actos) 1 QL (30 tablets/30 days), 90STEGLATRO – ertugliflozin l-pyroglutamic acid tab 5 mg (base

equiv)2 QL (60 tablets/30 days), ST

STEGLATRO – ertugliflozin l-pyroglutamic acid tab 15 mg (baseequiv)

2 QL (30 tablets/30 days), ST

TRULICITY – dulaglutide soln pen-injector 0.75 mg/0.5ml 2 PA, QL (4 pens/28 days)TRULICITY – dulaglutide soln pen-injector 1.5 mg/0.5ml 2 PA, QL (4 pens/28 days)VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 2 PA, QL (3 pens/30 days)

DIABETES - INSULINSRapid-Acting InsulinsADMELOG – insulin lispro inj 100 unit/ml 2 QL (45 mls/30 days), 90ADMELOG SOLOSTAR – insulin lispro soln pen-injector 100

unit/ml2 QL (45 mls/30 days), 90

Short-Acting InsulinsHUMULIN R – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90NOVOLIN R – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90NOVOLIN R RELION – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90

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RELION R – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90

Intermediate-Acting InsulinsHUMALOG MIX 50/50 – insulin lispro protamine & lispro inj 100

unit/ml (50-50)2 QL (45 mls/30 days), 90

HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot & lispro suspen-inj 100 unit/ml (50-50)

2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

HUMULIN N – insulin nph (human) (isophane) inj 100 unit/ml 2 QL (45 mls/30 days), 90HUMULIN N KWIKPEN – insulin nph (human) (isophane) susp

pen-injector 100 unit/ml2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

HUMULIN 70/30 KWIKPEN – insulin nph & regular susp pen-inj100 unit/ml (70-30)

2 QL (45 mls/30 days), 90

NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml 2 QL (45 mls/30 days), 90NOVOLIN N RELION – insulin nph (human) (isophane) inj 100


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

2 QL (45 mls/30 days), 90

NOVOLIN 70/30 FLEXPEN – insulin nph & regular susp pen-inj100 unit/ml (70-30)

2 QL (45 mls/30 days), 90

NOVOLIN 70/30 FLEXPEN REL – insulin nph & regular susppen-inj 100 unit/ml (70-30)

2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

NOVOLOG MIX 70/30 – insulin aspart prot & aspart (human) inj100 unit/ml (70-30)

2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

Basal InsulinsBASAGLAR KWIKPEN – insulin glargine soln pen-injector 100


THYROID REGULATIONlevothyroxine sodium tab 25 mcg (Synthroid) 1 90levothyroxine sodium tab 50 mcg (Synthroid) 1 90levothyroxine sodium tab 75 mcg (Synthroid) 1 90levothyroxine sodium tab 88 mcg (Synthroid) 1 90levothyroxine sodium tab 100 mcg (Synthroid) 1 90

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levothyroxine sodium tab 112 mcg (Synthroid) 1 90levothyroxine sodium tab 125 mcg (Synthroid) 1 90levothyroxine sodium tab 137 mcg (Synthroid) 1 90levothyroxine sodium tab 150 mcg (Synthroid) 1 90levothyroxine sodium tab 175 mcg (Synthroid) 1 90levothyroxine sodium tab 200 mcg (Synthroid) 1 90levothyroxine sodium tab 300 mcg (Synthroid) 1 90liothyronine sodium tab 5 mcg (Cytomel) 1 90liothyronine sodium tab 25 mcg (Cytomel) 1 90liothyronine sodium tab 50 mcg (Cytomel) 1 90methimazole tab 5 mg (Tapazole) 1 90methimazole tab 10 mg (Tapazole) 1 90propylthiouracil tab 50 mg 1 90thyroid tab 30 mg (1/2 grain) (Armour thyroid) 1 90thyroid tab 60 mg (1 grain) (Armour thyroid) 1 90thyroid tab 90 mg (1 1/2 grain) (Armour thyroid) 1 90

GROWTH HORMONEINCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml) 2 PA, SPOMNITROPE – somatropin for inj 5.8 mg 2 PA, SPSEROSTIM – somatropin (non-refrigerated) for subcutaneous inj

4 mg2 PA, SP

SEROSTIM – somatropin (non-refrigerated) for subcutaneous inj5 mg

2 PA, SP

SEROSTIM – somatropin (non-refrigerated) for subcutaneous inj6 mg

2 PA, SP

ZORBTIVE – somatropin (non-refrigerated) for subcutaneous inj8.8 mg

2 PA, SP

OTHER HORMONES AND RELATED DRUGSACTHAR – corticotropin inj gel 80 unit/ml 2 PA, SPALENDRONATE SODIUM – alendronate sodium tab 5 mg 2 QL (30 tablets/30 days), 90ALENDRONATE SODIUM – alendronate sodium tab 40 mg 2 QL (30 tablets/30 days)alendronate sodium tab 10 mg 1 QL (30 tablets/30 days), 90alendronate sodium tab 35 mg 1 QL (4 tablets/28 days), 90alendronate sodium tab 70 mg (Fosamax) 1 QL (4 tablets/28 days), 90BUPHENYL – sodium phenylbutyrate tab 500 mg 2 PA, SPcabergoline tab 0.5 mg 1

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calcitonin (salmon) nasal soln 200 unit/act (Miacalcin) 1 90calcitriol cap 0.25 mcg (Rocaltrol) 1 90calcitriol cap 0.5 mcg (Rocaltrol) 1 90calcitriol oral soln 1 mcg/ml (Rocaltrol) 1 90CARBAGLU – carglumic acid tab 200 mg 2 PA, SPcinacalcet hcl tab 30 mg (base equiv) 1 PA, 90cinacalcet hcl tab 60 mg (base equiv) 1 PA, 90cinacalcet hcl tab 90 mg (base equiv) 1 PA, 90CYSTADANE – betaine powder for oral solution 2 PA, QL (180 grams/30 days), 90desmopressin acetate nasal spray soln 0.01% (Ddavp) 1desmopressin acetate nasal spray soln 0.01% (refrigerated) 1desmopressin acetate tab 0.1 mg (Ddavp) 1 90desmopressin acetate tab 0.2 mg (Ddavp) 1 90ETIDRONATE DISODIUM – etidronate disodium tab 200 mg 2ibandronate sodium tab 150 mg (base equivalent) (Boniva) 1 QL (1 tablet/30 days), 90KUVAN – sapropterin dihydrochloride soluble tab 100 mg 2 PA, SPKUVAN – sapropterin dihydrochloride powder packet 100 mg 2 PA, SPKUVAN – sapropterin dihydrochloride powder packet 500 mg 2 PA, SPlevocarnitine oral soln 1 gm/10ml (10%) (Carnitor) 1 90levocarnitine tab 330 mg (Carnitor) 1 90LUPRON DEPOT-PED (1-MONTH – leuprolide acetate for inj

pediatric kit 7.5 mg2 PA, SP


2 PA, SP

LUPRON DEPOT-PED (1-MONTH – leuprolide acetate for injpediatric kit 15 mg

2 PA, SP

methylergonovine maleate tab 0.2 mg 1NITYR – nitisinone tab 2 mg 2 PA, SPNITYR – nitisinone tab 5 mg 2 PA, SPNITYR – nitisinone tab 10 mg 2 PA, SPraloxifene hcl tab 60 mg (Evista) 1 90RAVICTI – glycerol phenylbutyrate liquid 1.1 gm/ml 2 PA, SPrisedronate sodium tab delayed release 35 mg (Atelvia) 1 QL (4 tablets/28 days), 90SAMSCA – tolvaptan tab 15 mg 2 PA, QL (30 tablets/365 days), SPSAMSCA – tolvaptan tab 30 mg 2 PA, QL (60 tablets/365 days), SPSIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (base equiv) 2 PA, QL (60 mls/30 days), SP

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SIGNIFOR – pasireotide diaspartate inj 0.6 mg/ml (base equiv) 2 PA, QL (60 mls/30 days), SPSIGNIFOR – pasireotide diaspartate inj 0.9 mg/ml (base equiv) 2 PA, QL (60 mls/30 days), SPSOMAVERT – pegvisomant for inj 10 mg (as protein) 2 PA, QL (30 vials/30 days), SPSOMAVERT – pegvisomant for inj 15 mg (as protein) 2 PA, QL (30 vials/30 days), SPSOMAVERT – pegvisomant for inj 20 mg (as protein) 2 PA, QL (30 vials/30 days), SPSOMAVERT – pegvisomant for inj 25 mg (as protein) 2 PA, QL (30 vials/30 days), SPSOMAVERT – pegvisomant for inj 30 mg (as protein) 2 PA, QL (30 vials/30 days), SPSTIMATE – desmopressin acetate nasal soln 1.5 mg/ml 2STRENSIQ – asfotase alfa subcutaneous inj 18 mg/0.45ml 2 PA, SPSTRENSIQ – asfotase alfa subcutaneous inj 28 mg/0.7ml 2 PA, SPSTRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml 2 PA, SPSTRENSIQ – asfotase alfa subcutaneous inj 80 mg/0.8ml 2 PA, SPTYMLOS – abaloparatide subcutaneous soln pen-injector

3120 mcg/1.56ml2 PA, QL (1 pen/30 days), SP

XURIDEN – uridine triacetate oral granules packet 2 gm 2 SP

HEART AND CIRCULATORY DRUGSANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIbenazepril & hydrochlorothiazide tab 5-6.25 mg 1 90benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) 1 90benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct) 1 90benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct) 1 90benazepril hcl tab 5 mg 1 90benazepril hcl tab 10 mg (Lotensin) 1 90benazepril hcl tab 20 mg (Lotensin) 1 90benazepril hcl tab 40 mg (Lotensin) 1 90captopril tab 12.5 mg 1 90captopril tab 25 mg 1 90captopril tab 50 mg 1 90captopril tab 100 mg 1 90CAPTOPRIL/HYDROCHLOROTHIA – captopril &

hydrochlorothiazide tab 25-15 mg2 90

CAPTOPRIL/HYDROCHLOROTHIA – captopril &hydrochlorothiazide tab 25-25 mg

2 90


2 90


2 90

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enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1 90enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic) 1 90enalapril maleate tab 2.5 mg (Vasotec) 1 90enalapril maleate tab 5 mg (Vasotec) 1 90enalapril maleate tab 10 mg (Vasotec) 1 90enalapril maleate tab 20 mg (Vasotec) 1 90fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg 1 90fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg 1 90fosinopril sodium tab 10 mg 1 90fosinopril sodium tab 20 mg 1 90fosinopril sodium tab 40 mg 1 90lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic) 1 90lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) 1 90lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic) 1 90lisinopril tab 2.5 mg (Zestril) 1 90lisinopril tab 5 mg (Prinivil) 1 90lisinopril tab 10 mg (Prinivil) 1 90lisinopril tab 20 mg (Prinivil) 1 90lisinopril tab 30 mg (Zestril) 1 90lisinopril tab 40 mg (Zestril) 1 90moexipril hcl tab 7.5 mg 1 90moexipril hcl tab 15 mg 1 90perindopril erbumine tab 2 mg 1 90perindopril erbumine tab 4 mg (Aceon) 1 90perindopril erbumine tab 8 mg (Aceon) 1 90quinapril hcl tab 5 mg (Accupril) 1 90quinapril hcl tab 10 mg (Accupril) 1 90quinapril hcl tab 20 mg (Accupril) 1 90quinapril hcl tab 40 mg (Accupril) 1 90quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic) 1 90quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic) 1 90quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic) 1 90ramipril cap 1.25 mg (Altace) 1 90ramipril cap 2.5 mg (Altace) 1 90ramipril cap 5 mg (Altace) 1 90

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ramipril cap 10 mg (Altace) 1 90trandolapril tab 1 mg (Mavik) 1 90trandolapril tab 2 mg (Mavik) 1 90trandolapril tab 4 mg 1 90

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONSirbesartan tab 75 mg (Avapro) 1 QL (30 tablets/30 days), 90irbesartan tab 150 mg (Avapro) 1 QL (30 tablets/30 days), 90irbesartan tab 300 mg (Avapro) 1 QL (30 tablets/30 days), 90irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide) 1 QL (30 tablets/30 days), 90irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide) 1 QL (30 tablets/30 days), 90losartan potassium & hydrochlorothiazide tab 50-12.5 mg

(Hyzaar)1 QL (30 tablets/30 days), 90

losartan potassium & hydrochlorothiazide tab 100-12.5 mg(Hyzaar)

1 QL (30 tablets/30 days), 90

losartan potassium & hydrochlorothiazide tab 100-25 mg(Hyzaar)


losartan potassium tab 25 mg (Cozaar) 1 QL (60 tablets/30 days), 90losartan potassium tab 50 mg (Cozaar) 1 QL (60 tablets/30 days), 90losartan potassium tab 100 mg (Cozaar) 1 QL (30 tablets/30 days), 90olmesartan medoxomil tab 5 mg (Benicar) 1 QL (60 tablets/30 days), 90olmesartan medoxomil tab 20 mg (Benicar) 1 QL (30 tablets/30 days), 90olmesartan medoxomil tab 40 mg (Benicar) 1 QL (30 tablets/30 days), 90olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg

(Benicar hct)1 QL (30 tablets/30 days), 90

olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg(Benicar hct)


olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg(Benicar hct)


valsartan tab 40 mg (Diovan) 1 QL (60 tablets/30 days), 90valsartan tab 80 mg (Diovan) 1 QL (60 tablets/30 days), 90valsartan tab 160 mg (Diovan) 1 QL (60 tablets/30 days), 90valsartan tab 320 mg (Diovan) 1 QL (30 tablets/30 days), 90valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct) 1 QL (30 tablets/30 days), 90valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct) 1 QL (30 tablets/30 days), 90valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct) 1 QL (30 tablets/30 days), 90valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan hct) 1 QL (30 tablets/30 days), 90valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct) 1 QL (30 tablets/30 days), 90

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BETA BLOCKERS AND COMBINATIONSacebutolol hcl cap 200 mg (Sectral) 1 90acebutolol hcl cap 400 mg (Sectral) 1 90atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) 1 90atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100) 1 90atenolol tab 25 mg (Tenormin) 1 90atenolol tab 50 mg (Tenormin) 1 90atenolol tab 100 mg (Tenormin) 1 90betaxolol hcl tab 10 mg (Kerlone) 1 90betaxolol hcl tab 20 mg (Kerlone) 1 90bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac) 1 90bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac) 1 90bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac) 1 90bisoprolol fumarate tab 5 mg (Zebeta) 1 90bisoprolol fumarate tab 10 mg (Zebeta) 1 90carvedilol tab 3.125 mg (Coreg) 1 90carvedilol tab 6.25 mg (Coreg) 1 90carvedilol tab 12.5 mg (Coreg) 1 90carvedilol tab 25 mg (Coreg) 1 90labetalol hcl tab 100 mg 1 90labetalol hcl tab 200 mg 1 90labetalol hcl tab 300 mg 1 90metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct) 1 90metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct) 1 90metoprolol succinate tab er 24hr 25 mg (tartrate equiv) (Toprol xl) 1 90metoprolol succinate tab er 24hr 50 mg (tartrate equiv) (Toprol xl) 1 90metoprolol succinate tab er 24hr 100 mg (tartrate equiv) (Toprol

xl)1 90

metoprolol succinate tab er 24hr 200 mg (tartrate equiv) (Toprolxl)

1 90

metoprolol tartrate tab 25 mg 1 90metoprolol tartrate tab 50 mg (Lopressor) 1 90metoprolol tartrate tab 100 mg (Lopressor) 1 90METOPROLOL/HYDROCHLOROTHI – metoprolol &


nadolol tab 20 mg (Corgard) 1 90

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nadolol tab 40 mg (Corgard) 1 90nadolol tab 80 mg (Corgard) 1 90pindolol tab 5 mg 1 90PROPRANOLOL HCL – propranolol hcl oral soln 20 mg/5ml 2 90PROPRANOLOL HCL – propranolol hcl oral soln 40 mg/5ml 2 90propranolol hcl cap er 24hr 60 mg (Inderal la) 1 90propranolol hcl cap er 24hr 80 mg (Inderal la) 1 90propranolol hcl cap er 24hr 120 mg (Inderal la) 1 90propranolol hcl cap er 24hr 160 mg (Inderal la) 1 90propranolol hcl tab 10 mg 1 90propranolol hcl tab 20 mg 1 90propranolol hcl tab 40 mg 1 90propranolol hcl tab 60 mg 1 90propranolol hcl tab 80 mg 1 90PROPRANOLOL/HYDROCHLOROTH – propranolol &


PROPRANOLOL/HYDROCHLOROTH – propranolol &hydrochlorothiazide tab 80-25 mg

2 90

CALCIUM CHANNEL BLOCKERS AND COMBINATIONSamlodipine besylate tab 2.5 mg (base equivalent) (Norvasc) 1 90amlodipine besylate tab 5 mg (base equivalent) (Norvasc) 1 90amlodipine besylate tab 10 mg (base equivalent) (Norvasc) 1 90amlodipine besylate-benazepril hcl cap 2.5-10 mg 1 90amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel) 1 90amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel) 1 90amlodipine besylate-benazepril hcl cap 5-40 mg 1 90amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel) 1 90amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel) 1 90DILT-XR – diltiazem hcl cap er 24hr 120 mg 2 90diltiazem hcl cap er 12hr 60 mg 1 90diltiazem hcl cap er 12hr 90 mg 1 90diltiazem hcl cap er 12hr 120 mg 1 90diltiazem hcl cap er 24hr 180 mg 1 90diltiazem hcl cap er 24hr 240 mg 1 90diltiazem hcl coated beads cap er 24hr 120 mg (Cardizem cd) 1 90diltiazem hcl coated beads cap er 24hr 180 mg (Cardizem cd) 1 90

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diltiazem hcl coated beads cap er 24hr 240 mg (Cardizem cd) 1 90diltiazem hcl coated beads cap er 24hr 300 mg 1 90diltiazem hcl extended release beads cap er 24hr 120 mg

(Tiazac)1 90

diltiazem hcl extended release beads cap er 24hr 180 mg(Tiazac)

1 90


1 90


1 90


1 90


1 90

diltiazem hcl tab 30 mg (Cardizem) 1 90diltiazem hcl tab 60 mg (Cardizem) 1 90diltiazem hcl tab 90 mg 1 90diltiazem hcl tab 120 mg (Cardizem) 1 90ENTRESTO – sacubitril-valsartan tab 24-26 mg 2 PA, QL (60 tablets/30 days), 90ENTRESTO – sacubitril-valsartan tab 49-51 mg 2 PA, QL (60 tablets/30 days), 90ENTRESTO – sacubitril-valsartan tab 97-103 mg 2 PA, QL (60 tablets/30 days), 90felodipine tab er 24hr 2.5 mg 1 90felodipine tab er 24hr 5 mg 1 90felodipine tab er 24hr 10 mg 1 90isradipine cap 2.5 mg 1 90isradipine cap 5 mg 1 90nicardipine hcl cap 20 mg 1 90nifedipine cap 10 mg (Procardia) 1 90nifedipine cap 20 mg 1 90nifedipine tab er 24hr 30 mg (Adalat cc) 1 90nifedipine tab er 24hr 60 mg (Adalat cc) 1 90nifedipine tab er 24hr 90 mg (Adalat cc) 1 90nifedipine tab er 24hr osmotic release 30 mg (Procardia xl) 1 90nifedipine tab er 24hr osmotic release 60 mg (Procardia xl) 1 90nifedipine tab er 24hr osmotic release 90 mg (Procardia xl) 1 90nimodipine cap 30 mg 1 90trandolapril-verapamil hcl tab er 2-180 mg (Tarka) 1 90

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trandolapril-verapamil hcl tab er 2-240 mg (Tarka) 1 90trandolapril-verapamil hcl tab er 4-240 mg (Tarka) 1 90TRANDOLAPRIL/VERAPAMIL HC – trandolapril-verapamil hcl

tab er 1-240 mg2 90

verapamil hcl cap er 24hr 120 mg (Verelan) 1 90verapamil hcl cap er 24hr 180 mg (Verelan) 1 90verapamil hcl cap er 24hr 200 mg (Verelan pm) 1 90verapamil hcl cap er 24hr 240 mg (Verelan) 1 90VERAPAMIL HCL ER – verapamil hcl cap er 24hr 100 mg 2 90VERAPAMIL HCL ER – verapamil hcl cap er 24hr 300 mg 2 90VERAPAMIL HCL SR – verapamil hcl cap er 24hr 360 mg 2 90verapamil hcl tab er 120 mg (Calan sr) 1 90verapamil hcl tab er 180 mg (Calan sr) 1 90verapamil hcl tab er 240 mg (Calan sr) 1 90verapamil hcl tab 40 mg 1 90verapamil hcl tab 80 mg (Calan) 1 90verapamil hcl tab 120 mg (Calan) 1 90

CHEST PAINisosorbide mononitrate tab er 24hr 30 mg 1 90isosorbide mononitrate tab er 24hr 60 mg 1 90isosorbide mononitrate tab er 24hr 120 mg 1 90isosorbide mononitrate tab 10 mg 1 90isosorbide mononitrate tab 20 mg 1 90NITRO-TIME – nitroglycerin cap er 6.5 mg 2 90NITRO-TIME – nitroglycerin cap er 9 mg 2 90nitroglycerin cap er 2.5 mg 1 90nitroglycerin sl tab 0.3 mg (Nitrostat) 1nitroglycerin sl tab 0.4 mg (Nitrostat) 1nitroglycerin sl tab 0.6 mg (Nitrostat) 1nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) 1 90nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) 1 90nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) 1 90nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur) 1 90

CHOLESTEROL LOWERINGatorvastatin calcium tab 10 mg (base equivalent) (Lipitor) 1 QL (30 tablets/30 days), 90

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atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) 1 QL (30 tablets/30 days), 90atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) 1 QL (30 tablets/30 days), 90atorvastatin calcium tab 80 mg (base equivalent) (Lipitor) 1 QL (30 tablets/30 days), 90cholestyramine light powder packets 4 gm 1 90cholestyramine light powder 4 gm/dose (Questran light) 1 90cholestyramine powder packets 4 gm (Questran) 1 90cholestyramine powder 4 gm/dose (Questran) 1 90choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix) 1 QL (60 capsules/30 days), 90colestipol hcl granule packets 5 gm (Colestid flavored) 1 90colestipol hcl granules 5 gm (Colestid flavored) 1 90colestipol hcl tab 1 gm (Colestid) 1 90fenofibrate micronized cap 43 mg 1 QL (60 capsules/30 days), 90fenofibrate micronized cap 67 mg (Lofibra) 1 QL (30 capsules/30 days), 90fenofibrate micronized cap 134 mg (Lofibra) 1 QL (30 capsules/30 days), 90fenofibrate micronized cap 200 mg (Lofibra) 1 QL (30 capsules/30 days), 90fenofibrate tab 48 mg (Tricor) 1 QL (60 tablets/30 days), 90fenofibrate tab 54 mg (Lofibra) 1 QL (60 tablets/30 days), 90fenofibrate tab 145 mg (Tricor) 1 QL (30 tablets/30 days), 90fenofibrate tab 160 mg (Lofibra) 1 QL (30 tablets/30 days), 90fluvastatin sodium tab er 24 hr 80 mg (base equivalent) (Lescol

xl)1 QL (30 tablets/30 days), 90

gemfibrozil tab 600 mg (Lopid) 1 QL (60 tablets/30 days), 90JUXTAPID – lomitapide mesylate cap 5 mg (base equiv) 2 PA, QL (30 capsules/30 days), SPJUXTAPID – lomitapide mesylate cap 10 mg (base equiv) 2 PA, QL (30 capsules/30 days), SPJUXTAPID – lomitapide mesylate cap 20 mg (base equiv) 2 PA, QL (30 capsules/30 days), SPJUXTAPID – lomitapide mesylate cap 30 mg (base equiv) 2 PA, QL (30 capsules/30 days), SPJUXTAPID – lomitapide mesylate cap 40 mg (base equiv) 2 PA, QL (30 capsules/30 days), SPJUXTAPID – lomitapide mesylate cap 60 mg (base equiv) 2 PA, QL (30 capsules/30 days), SPlovastatin tab 10 mg 1 QL (60 tablets/30 days), 90lovastatin tab 20 mg 1 QL (60 tablets/30 days), 90lovastatin tab 40 mg (Mevacor) 1 QL (60 tablets/30 days), 90pravastatin sodium tab 10 mg 1 QL (45 tablets/30 days), 90pravastatin sodium tab 20 mg (Pravachol) 1 QL (45 tablets/30 days), 90pravastatin sodium tab 40 mg (Pravachol) 1 QL (45 tablets/30 days), 90pravastatin sodium tab 80 mg (Pravachol) 1 QL (30 tablets/30 days), 90

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REPATHA – evolocumab subcutaneous soln prefilled syringe140 mg/ml

2 PA, QL (2 syringes/28 days), SP

REPATHA PUSHTRONEX SYSTEM – evolocumabsubcutaneous soln cartridge/infusor 420 mg/3.5ml

2 PA, QL (1 syringe/30 days), SP

REPATHA SURECLICK – evolocumab subcutaneous soln auto-injector 140 mg/ml


rosuvastatin calcium tab 5 mg (Crestor) 1 QL (30 tablets/30 days), 90rosuvastatin calcium tab 10 mg (Crestor) 1 QL (30 tablets/30 days), 90rosuvastatin calcium tab 20 mg (Crestor) 1 QL (30 tablets/30 days), 90rosuvastatin calcium tab 40 mg (Crestor) 1 QL (30 tablets/30 days), 90simvastatin tab 5 mg (Zocor) 1 QL (30 tablets/30 days), 90simvastatin tab 10 mg (Zocor) 1 QL (30 tablets/30 days), 90simvastatin tab 20 mg (Zocor) 1 QL (30 tablets/30 days), 90simvastatin tab 40 mg (Zocor) 1 QL (30 tablets/30 days), 90simvastatin tab 80 mg (Zocor) 1 QL (30 tablets/30 days), 90

FLUID RETENTIONacetazolamide cap er 12hr 500 mg (Diamox) 1 90acetazolamide tab 250 mg 1 90amiloride & hydrochlorothiazide tab 5-50 mg 1 90amiloride hcl tab 5 mg 1 90bumetanide tab 0.5 mg (Bumex) 1 90bumetanide tab 1 mg (Bumex) 1 90bumetanide tab 2 mg (Bumex) 1 90CHLOROTHIAZIDE – chlorothiazide tab 250 mg 2 90CHLOROTHIAZIDE – chlorothiazide tab 500 mg 2 90chlorthalidone tab 25 mg 1 90furosemide oral soln 10 mg/ml 1 90furosemide tab 20 mg (Lasix) 1 90furosemide tab 40 mg (Lasix) 1 90furosemide tab 80 mg (Lasix) 1 90hydrochlorothiazide cap 12.5 mg (Microzide) 1 90hydrochlorothiazide tab 12.5 mg 1 90hydrochlorothiazide tab 25 mg 1 90hydrochlorothiazide tab 50 mg 1 90indapamide tab 1.25 mg 1 90indapamide tab 2.5 mg 1 90

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metolazone tab 2.5 mg 1 90metolazone tab 5 mg 1 90metolazone tab 10 mg 1 90spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide) 1 90spironolactone tab 25 mg (Aldactone) 1 90spironolactone tab 50 mg (Aldactone) 1 90spironolactone tab 100 mg (Aldactone) 1 90torsemide tab 5 mg 1 90torsemide tab 10 mg (Demadex) 1 90torsemide tab 20 mg (Demadex) 1 90torsemide tab 100 mg 1 90triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide) 1 90triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25) 1 90triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) 1 90

HEART RHYTHMamiodarone hcl tab 200 mg (Cordarone) 1 90disopyramide phosphate cap 100 mg (Norpace) 1 90disopyramide phosphate cap 150 mg (Norpace) 1 90dofetilide cap 125 mcg (0.125 mg) (Tikosyn) 1dofetilide cap 250 mcg (0.25 mg) (Tikosyn) 1dofetilide cap 500 mcg (0.5 mg) (Tikosyn) 1flecainide acetate tab 50 mg 1 90flecainide acetate tab 100 mg 1 90flecainide acetate tab 150 mg 1 90propafenone hcl tab 150 mg 1 90propafenone hcl tab 225 mg (Rythmol) 1 90propafenone hcl tab 300 mg 1 90quinidine gluconate tab er 324 mg 1 90QUINIDINE SULFATE – quinidine sulfate tab 200 mg 2 90QUINIDINE SULFATE – quinidine sulfate tab 300 mg 2 90sotalol hcl (afib/afl) tab 80 mg (Betapace af) 1 90sotalol hcl (afib/afl) tab 120 mg (Betapace af) 1 90sotalol hcl (afib/afl) tab 160 mg (Betapace af) 1 90sotalol hcl tab 80 mg (Betapace) 1 90sotalol hcl tab 120 mg (Betapace) 1 90

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sotalol hcl tab 160 mg (Betapace) 1 90sotalol hcl tab 240 mg 1 90

OTHER HEART RELATED DRUGSADEMPAS – riociguat tab 0.5 mg 2 PA, QL (90 tablets/30 days), SPADEMPAS – riociguat tab 1 mg 2 PA, QL (90 tablets/30 days), SPADEMPAS – riociguat tab 1.5 mg 2 PA, QL (90 tablets/30 days), SPADEMPAS – riociguat tab 2 mg 2 PA, QL (90 tablets/30 days), SPADEMPAS – riociguat tab 2.5 mg 2 PA, QL (90 tablets/30 days), SPambrisentan tab 5 mg (Letairis) 2 PA, QL (30 tablets/30 days), SPambrisentan tab 10 mg (Letairis) 2 PA, QL (30 tablets/30 days), SPbosentan tab 62.5 mg (Tracleer) 2 PA, QL (60 tablets/30 days), SPbosentan tab 125 mg (Tracleer) 2 PA, QL (60 tablets/30 days), SPclonidine hcl tab 0.1 mg (Catapres) 1 90clonidine hcl tab 0.2 mg (Catapres) 1 90clonidine hcl tab 0.3 mg (Catapres) 1 90clonidine td patch weekly 0.1 mg/24hr (Catapres-tts-1) 1clonidine td patch weekly 0.2 mg/24hr (Catapres-tts-2) 1clonidine td patch weekly 0.3 mg/24hr (Catapres-tts-3) 1DIGOXIN – digoxin oral soln 0.05 mg/ml 2 90digoxin tab 125 mcg (0.125 mg) (Lanoxin) 1 90digoxin tab 250 mcg (0.25 mg) (Lanoxin) 1 90doxazosin mesylate tab 1 mg (Cardura) 1 QL (30 tablets/30 days), 90doxazosin mesylate tab 2 mg (Cardura) 1 QL (30 tablets/30 days), 90doxazosin mesylate tab 4 mg (Cardura) 1 QL (30 tablets/30 days), 90doxazosin mesylate tab 8 mg (Cardura) 1 QL (60 tablets/30 days), 90guanfacine hcl tab 1 mg (Tenex) 1 90guanfacine hcl tab 2 mg (Tenex) 1 90hydralazine hcl tab 10 mg 1 90hydralazine hcl tab 25 mg 1 90hydralazine hcl tab 50 mg 1 90hydralazine hcl tab 100 mg 1 90methyldopa tab 250 mg 1 90methyldopa tab 500 mg 1 90midodrine hcl tab 2.5 mg 1midodrine hcl tab 5 mg 1

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midodrine hcl tab 10 mg 1minoxidil tab 2.5 mg 1 90minoxidil tab 10 mg 1 90phenoxybenzamine hcl cap 10 mg (Dibenzyline) 1prazosin hcl cap 1 mg (Minipress) 1 90prazosin hcl cap 2 mg (Minipress) 1 90prazosin hcl cap 5 mg (Minipress) 1 90sildenafil citrate for suspension 10 mg/ml (Revatio) 2 PA, QL (2 bottles/30 days), SPsildenafil citrate tab 20 mg (Revatio) 1 PA, QL (90 tablets/30 days), SPtadalafil tab 20 mg (pah) (Adcirca) 2 PA, QL (60 tablets/30 days), SPterazosin hcl cap 1 mg (base equivalent) 1 QL (30 capsules/30 days), 90terazosin hcl cap 2 mg (base equivalent) 1 QL (30 capsules/30 days), 90terazosin hcl cap 5 mg (base equivalent) 1 QL (30 capsules/30 days), 90terazosin hcl cap 10 mg (base equivalent) 1 QL (60 capsules/30 days), 90TRACLEER – bosentan tab for oral susp 32 mg 2 PA, QL (120 tablets/30 days), SPTYVASO – treprostinil inhalation solution 0.6 mg/ml 2 PA, QL (81.2 mls/28 days), SPTYVASO REFILL – treprostinil inhalation solution 0.6 mg/ml 2 PA, QL (81.2 mls/28 days), SPTYVASO STARTER – treprostinil inhalation solution 0.6 mg/ml 2 PA, QL (1 kit/180 days), SPUPTRAVI – selexipag tab therapy pack 200 mcg (140) &

800 mcg (60)2 PA, QL (200

tablets/180 days), SPUPTRAVI – selexipag tab 200 mcg 2 PA, QL (60 tablets/30 days), SPUPTRAVI – selexipag tab 200 mcg 2UPTRAVI – selexipag tab 400 mcg 2 PA, QL (60 tablets/30 days), SPUPTRAVI – selexipag tab 600 mcg 2 PA, QL (60 tablets/30 days), SPUPTRAVI – selexipag tab 800 mcg 2 PA, QL (60 tablets/30 days), SPUPTRAVI – selexipag tab 1000 mcg 2 PA, QL (60 tablets/30 days), SPUPTRAVI – selexipag tab 1200 mcg 2 PA, QL (60 tablets/30 days), SPUPTRAVI – selexipag tab 1400 mcg 2 PA, QL (60 tablets/30 days), SPUPTRAVI – selexipag tab 1600 mcg 2 PA, QL (60 tablets/30 days), SP

ANAPHYLAXISepinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)

(Epipen-jr 2-pak)1 QL (4 pens/1 prescription)

epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) (Epipen2-pak)

1 QL (4 pens/1 prescription)

RESPIRATORY AGENTSANTIHISTAMINES

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carbinoxamine maleate soln 4 mg/5ml 1carbinoxamine maleate tab 4 mg 1cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) 1cyproheptadine hcl syrup 2 mg/5ml 1cyproheptadine hcl tab 4 mg 1desloratadine tab 5 mg (Clarinex) 1diphenhydramine hcl cap 50 mg 1levocetirizine dihydrochloride tab 5 mg (Xyzal) 1promethazine hcl suppos 12.5 mg 1promethazine hcl suppos 25 mg 1promethazine hcl syrup 6.25 mg/5ml 1promethazine hcl tab 12.5 mg 1promethazine hcl tab 25 mg 1promethazine hcl tab 50 mg 1

NASAL PRODUCTSazelastine hcl nasal spray 0.1% (137 mcg/spray) 1 QL (2 bottles/30 days)FLUNISOLIDE – flunisolide nasal soln 25 mcg/act (0.025%) 2 QL (3 bottles/30 days)fluticasone propionate nasal susp 50 mcg/act 1 QL (1 bottle/30 days)ipratropium bromide nasal soln 0.03% (21 mcg/spray) 1 QL (2 bottles/30 days), 90ipratropium bromide nasal soln 0.06% (42 mcg/spray) 1 QL (3 bottles/30 days), 90triamcinolone acetonide nasal aerosol suspension 55 mcg/act 1 QL (1 bottle/30 days)

COUGH/COLD/ALLERGYacetylcysteine inhal soln 10% 1acetylcysteine inhal soln 20% 1HYDROCODONE BITARTRATE/CH – pseudoeph-chlorphen w/

hydrocodone soln 60-4-5 mg/5ml2 ME90

promethazine w/ codeine syrup 6.25-10 mg/5ml 1 ME90sodium chloride soln nebu 0.9% 1sodium chloride soln nebu 3% 1sodium chloride soln nebu 7% (Hyper-sal) 1sodium chloride soln nebu 10% 1

ASTHMA/COPDALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr 4 mg 2 90ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr 8 mg 2 90

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ALBUTEROL SULFATE HFA – albuterol sulfate inhal aero108 mcg/act (90mcg base equiv)

2 QL (3 inhalers/30 days)

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 1 QL (125 containers/30 days)albuterol sulfate soln nebu 0.5% (5 mg/ml) 1 QL (60 mls/30 days)albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) 1 QL (125 containers/30 days)albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) 1 QL (125 containers/30 days)albuterol sulfate syrup 2 mg/5ml 1albuterol sulfate tab 2 mg 1albuterol sulfate tab 4 mg 1ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath

activ 50 mcg/act2 QL (30 blisters/30 days)

ARNUITY ELLIPTA – fluticasone furoate aerosol powder breathactiv 100 mcg/act

2 QL (30 blisters/30 days), 90

ARNUITY ELLIPTA – fluticasone furoate aerosol powder breathactiv 200 mcg/act


ATROVENT HFA – ipratropium bromide hfa inhal aerosol17 mcg/act

2 QL (2 inhalers/30 days), 90

BEVESPI AEROSPHERE – glycopyrrolate-formoterol fumarateaerosol 9-4.8 mcg/act

2 QL (1 inhaler/30 days), 90

budesonide inhalation susp 0.25 mg/2ml (Pulmicort) 1 QL (2 packages/30 days), 90budesonide inhalation susp 0.5 mg/2ml (Pulmicort) 1 QL (2 packages/30 days), 90budesonide inhalation susp 1 mg/2ml (Pulmicort) 1 QL (60 mls/30 days), 90COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol

soln 20-100 mcg/act2 QL (2 inhalers/30 days), 90

dyphylline-guaifenesin liqd 100-100 mg/5ml 1FLOVENT DISKUS – fluticasone propionate aer pow ba 50 mcg/

blister2 AL, QL (1 inhaler/30 days), 90

FLOVENT DISKUS – fluticasone propionate aer pow ba100 mcg/blister

2 AL, QL (1 inhaler/30 days), 90

FLOVENT DISKUS – fluticasone propionate aer pow ba250 mcg/blister

2 AL, QL (4 inhalers/30 days), 90

FLOVENT HFA – fluticasone propionate hfa inhal aero 44 mcg/act (50/valve)


FLOVENT HFA – fluticasone propionate hfa inhal aer 110 mcg/act (125/valve)


FLOVENT HFA – fluticasone propionate hfa inhal aer 220 mcg/act (250/valve)

2 AL, QL (2 inhalers/30 days), 90

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aerpowder ba 55-14 mcg/act




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INCRUSE ELLIPTA – umeclidinium br aero powd breath act62.5 mcg/inh (base eq)


ipratropium bromide inhal soln 0.02% 1 QL (125 cartridges/30 days), 90ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml 1 QL (180 containers/30 days), 90montelukast sodium chew tab 4 mg (base equiv) (Singulair) 1 QL (30 tablets/30 days), 90montelukast sodium chew tab 5 mg (base equiv) (Singulair) 1 QL (30 tablets/30 days), 90montelukast sodium oral granules packet 4 mg (base equiv)

(Singulair)1 QL (30 packets/30 days), 90

montelukast sodium tab 10 mg (base equiv) (Singulair) 1 QL (30 tablets/30 days), 90QVAR REDIHALER – beclomethasone diprop hfa breath act inh

aer 40 mcg/act2 AL, QL (1 inhaler/30 days)

QVAR REDIHALER – beclomethasone diprop hfa breath act inhaer 80 mcg/act

2 AL, QL (2 inhalers/30 days)

STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln2.5 mcg/act (base equiv)


SYMBICORT – budesonide-formoterol fumarate dihyd aerosol80-4.5 mcg/act


SYMBICORT – budesonide-formoterol fumarate dihyd aerosol160-4.5 mcg/act


terbutaline sulfate tab 2.5 mg 1 90terbutaline sulfate tab 5 mg 1 90THEOCHRON – theophylline tab er 12hr 100 mg 2 90THEOCHRON – theophylline tab er 12hr 200 mg 2 90THEOPHYLLINE ER – theophylline tab er 12hr 450 mg 2 90theophylline soln 80 mg/15ml 1 90theophylline tab er 12hr 300 mg 1 90theophylline tab er 24hr 400 mg 1 90theophylline tab er 24hr 600 mg 1 90

OTHER RESPIRATORY DRUGSESBRIET – pirfenidone cap 267 mg 2 PA, QL (180

capsules/30 days), SPKALYDECO – ivacaftor tab 150 mg 2 PA, QL (60 tablets/30 days), SPKALYDECO – ivacaftor packet 25 mg 2 PA, QL (60 packets/30 days), SPKALYDECO – ivacaftor packet 50 mg 2 PA, QL (60 packets/30 days), SPKALYDECO – ivacaftor packet 75 mg 2 PA, QL (60 packets/30 days), SPOFEV – nintedanib esylate cap 100 mg (base equivalent) 2 PA, QL (60 capsules/30 days), SP

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OFEV – nintedanib esylate cap 150 mg (base equivalent) 2 PA, QL (60 capsules/30 days), SPORKAMBI – lumacaftor-ivacaftor tab 100-125 mg 2 PA, QL (120 tablets/30 days), SPORKAMBI – lumacaftor-ivacaftor tab 200-125 mg 2 PA, QL (120 tablets/30 days), SPORKAMBI – lumacaftor-ivacaftor granules packet 100-125 mg 2 PA, QL (60 packets/30 days), SPORKAMBI – lumacaftor-ivacaftor granules packet 150-188 mg 2 PA, QL (60 packets/30 days), SPPULMOZYME – dornase alfa inhal soln 1 mg/ml 2 PA, SPSYMDEKO – tezacaftor-ivacaftor 50-75 mg & ivacaftor 75 mg tab

tbpk2 PA, QL (60 tablets/30 days), SP

SYMDEKO – tezacaftor-ivacaftor 100-150 mg & ivacaftor 150 mgtab tbpk


GASTROINTESTINAL DRUGSLAXATIVESbisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit 1lactulose solution 10 gm/15ml 1 90peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor

pack)1

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely) 1peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte-

flavor packs)1

ANTIDIARRHEALSdiphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil) 1loperamide hcl cap 2 mg 1

ULCER/GERDCIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml 2 90dicyclomine hcl cap 10 mg (Bentyl) 1dicyclomine hcl oral soln 10 mg/5ml 1dicyclomine hcl tab 20 mg (Bentyl) 1famotidine for susp 40 mg/5ml (Pepcid) 1 90famotidine tab 20 mg (Pepcid) 1 90famotidine tab 40 mg (Pepcid) 1 90glycopyrrolate tab 1 mg (Robinul) 1glycopyrrolate tab 2 mg (Robinul forte) 1hyoscyamine sulfate elixir 0.125 mg/5ml 1 90hyoscyamine sulfate sl tab 0.125 mg (Levsin/sl) 1 90hyoscyamine sulfate soln 0.125 mg/ml 1 90hyoscyamine sulfate tab disint 0.125 mg (Anaspaz) 1 90

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hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid) 1 90hyoscyamine sulfate tab 0.125 mg (Levsin) 1 90lansoprazole cap delayed release 15 mg (Prevacid) 1 QL (120 days supply/365 days)lansoprazole cap delayed release 30 mg (Prevacid) 1 QL (120 days supply/365 days)methscopolamine bromide tab 2.5 mg (Pamine) 1misoprostol tab 100 mcg (Cytotec) 1 90misoprostol tab 200 mcg (Cytotec) 1 90nizatidine cap 150 mg 1 90nizatidine cap 300 mg 1 90omeprazole cap delayed release 10 mg (Prilosec) 1 QL (120 days supply/365 days)omeprazole cap delayed release 20 mg (Prilosec) 1 QL (120 days supply/365 days)omeprazole cap delayed release 40 mg (Prilosec) 1 QL (120 days supply/365 days)pantoprazole sodium ec tab 20 mg (base equiv) (Protonix) 1 QL (120 days supply/365 days)pantoprazole sodium ec tab 40 mg (base equiv) (Protonix) 1 QL (120 days supply/365 days)rabeprazole sodium ec tab 20 mg (Aciphex) 1 QL (120 days supply/365 days)ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1 90ranitidine hcl tab 150 mg (Zantac) 1 90ranitidine hcl tab 300 mg (Zantac) 1 90sucralfate tab 1 gm (Carafate) 1 90

NAUSEA AND VOMITINGaprepitant capsule 40 mg (Emend) 1 QL (2 capsules/30 days)aprepitant capsule 80 mg (Emend) 1 QL (6 capsules/30 days)aprepitant capsule 125 mg (Emend) 1 QL (3 capsules/30 days)meclizine hcl tab 12.5 mg 1meclizine hcl tab 25 mg 1ondansetron hcl oral soln 4 mg/5ml (Zofran) 1 QL (300 mls/30 days)ondansetron hcl tab 4 mg (Zofran) 1 QL (30 tablets/30 days)ondansetron hcl tab 8 mg (Zofran) 1 QL (30 tablets/30 days)ondansetron hcl tab 24 mg 1 QL (1 tablet/30 days)ondansetron orally disintegrating tab 4 mg (Zofran odt) 1 QL (30 tablets/30 days)ondansetron orally disintegrating tab 8 mg (Zofran odt) 1 QL (30 tablets/30 days)trimethobenzamide hcl cap 300 mg (Tigan) 1

DIGESTIVE ENZYMESCREON – pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000

unit2

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CREON – pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000unit

2

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

2


2


2

SUCRAID – sacrosidase soln 8500 unit/ml 2 PA, QL (1 box/28 days), SP

OTHER GASTROINTESTINAL DRUGSalosetron hcl tab 0.5 mg (base equiv) (Lotronex) 1 PA, QL (60 tablets/30 days)alosetron hcl tab 1 mg (base equiv) (Lotronex) 1 PA, QL (60 tablets/30 days)balsalazide disodium cap 750 mg (Colazal) 1calcium acetate (phosphate binder) cap 667 mg (169 mg ca)

(Phoslo)1

calcium acetate (phosphate binder) tab 667 mg (Eliphos) 1CHENODAL – chenodiol tab 250 mg 2 PA, SPCHOLBAM – cholic acid cap 50 mg 2 SPCHOLBAM – cholic acid cap 250 mg 2 SPCIMZIA – certolizumab pegol inj kit 2 x 200 mg/ml 2 PA, QL (2 kits/28 days), SPCIMZIA STARTER KIT – certolizumab pegol inj kit 6 x 200 mg/ml 2 PA, QL (1 kit/180 days), SPGATTEX – teduglutide (rdna) for inj kit 5 mg 2 PA, SPlactulose (encephalopathy) solution 10 gm/15ml 1 90lanthanum carbonate chew tab 500 mg (elemental) (Fosrenol) 1lanthanum carbonate chew tab 750 mg (elemental) (Fosrenol) 1lanthanum carbonate chew tab 1000 mg (elemental) (Fosrenol) 1mesalamine enema 4 gm 1mesalamine suppos 1000 mg (Canasa) 1mesalamine tab delayed release 800 mg (Asacol hd) 1metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv) 1metoclopramide hcl tab 5 mg (base equivalent) (Reglan) 1metoclopramide hcl tab 10 mg (base equivalent) (Reglan) 1 90sevelamer carbonate packet 0.8 gm (Renvela) 1sevelamer carbonate packet 2.4 gm (Renvela) 1sevelamer carbonate tab 800 mg (Renvela) 1sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs) 1sulfasalazine tab 500 mg (Azulfidine) 1

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ursodiol cap 300 mg (Actigall) 1 90ursodiol tab 250 mg (Urso 250) 1 90ursodiol tab 500 mg (Urso forte) 1 90

GENITOURINARY DRUGSURINARY TRACT INFECTIONSnitrofurantoin macrocrystalline cap 25 mg (Macrodantin) 1nitrofurantoin macrocrystalline cap 50 mg (Macrodantin) 1nitrofurantoin macrocrystalline cap 100 mg (Macrodantin) 1nitrofurantoin monohydrate macrocrystalline cap 100 mg

(Macrobid)1

URINARY TRACT SPASMSbethanechol chloride tab 5 mg (Urecholine) 1bethanechol chloride tab 10 mg (Urecholine) 1bethanechol chloride tab 25 mg (Urecholine) 1bethanechol chloride tab 50 mg (Urecholine) 1darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv)

(Enablex)1 QL (30 tablets/30 days)

darifenacin hydrobromide tab er 24hr 15 mg (base equiv)(Enablex)


oxybutynin chloride syrup 5 mg/5ml 1 QL (600 mls/30 days)oxybutynin chloride tab er 24hr 5 mg (Ditropan xl) 1 QL (30 tablets/30 days)oxybutynin chloride tab er 24hr 10 mg (Ditropan xl) 1 QL (60 tablets/30 days)oxybutynin chloride tab er 24hr 15 mg (Ditropan xl) 1 QL (60 tablets/30 days)oxybutynin chloride tab 5 mg 1 QL (120 tablets/30 days)tolterodine tartrate tab 2 mg (Detrol) 1 QL (60 tablets/30 days)trospium chloride cap er 24hr 60 mg 1 QL (30 capsules/30 days)trospium chloride tab 20 mg 1 QL (60 tablets/30 days)

VAGINAL PRODUCTSclindamycin phosphate vaginal cream 2% (Cleocin) 1estradiol vaginal cream 0.1 mg/gm (Estrace) 1estradiol vaginal tab 10 mcg (Vagifem) 1metronidazole vaginal gel 0.75% (Metrogel-vaginal) 1TERCONAZOLE – terconazole vaginal cream 0.8% 2terconazole vaginal cream 0.4% (Terazol 7) 1terconazole vaginal suppos 80 mg 1

OTHER GENITOURINARY DRUGS

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alfuzosin hcl tab er 24hr 10 mg (Uroxatral) 1 QL (30 tablets/30 days)CYSTAGON – cysteamine bitartrate cap 50 mg 2 PA, SPCYSTAGON – cysteamine bitartrate cap 150 mg 2 PA, SPdutasteride cap 0.5 mg (Avodart) 1 QL (30 capsules/30 days)dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn) 1 QL (30 capsules/30 days)finasteride tab 5 mg (Proscar) 1 QL (30 tablets/30 days)phenazopyridine hcl tab 100 mg (Pyridium) 1phenazopyridine hcl tab 200 mg (Pyridium) 1pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml 1potassium citrate & citric acid powder pack 3300-1002 mg 1potassium citrate & citric acid soln 1100-334 mg/5ml 1potassium citrate tab er 5 meq (540 mg) (Urocit-k 5) 1potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10) 1potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15) 1sodium chloride irrigation soln 0.9% 1sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution

modi)1

tamsulosin hcl cap 0.4 mg (Flomax) 1 QL (60 capsules/30 days)

CENTRAL NERVOUS SYSTEM DRUGSANXIETYALPRAZOLAM INTENSOL – alprazolam conc 1 mg/ml 2 QL (180 mls/30 days)alprazolam tab er 24hr 0.5 mg (Xanax xr) 1 QL (30 tablets/30 days)alprazolam tab er 24hr 1 mg (Xanax xr) 1 QL (30 tablets/30 days)alprazolam tab er 24hr 2 mg (Xanax xr) 1 QL (90 tablets/30 days)alprazolam tab er 24hr 3 mg (Xanax xr) 1 QL (60 tablets/30 days)alprazolam tab 0.25 mg (Xanax) 1 QL (120 tablets/30 days)alprazolam tab 0.5 mg (Xanax) 1 QL (120 tablets/30 days)alprazolam tab 1 mg (Xanax) 1 QL (120 tablets/30 days)alprazolam tab 2 mg (Xanax) 1 QL (90 tablets/30 days)buspirone hcl tab 5 mg 1buspirone hcl tab 10 mg 1buspirone hcl tab 15 mg 1buspirone hcl tab 30 mg 1chlordiazepoxide hcl cap 5 mg 1 QL (120 capsules/30 days)chlordiazepoxide hcl cap 10 mg 1 QL (120 capsules/30 days)

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chlordiazepoxide hcl cap 25 mg 1 QL (120 capsules/30 days)clorazepate dipotassium tab 3.75 mg 1 QL (90 tablets/30 days)clorazepate dipotassium tab 7.5 mg (Tranxene t) 1 QL (90 tablets/30 days)clorazepate dipotassium tab 15 mg 1 QL (120 tablets/30 days)DIAZEPAM – diazepam oral soln 1 mg/ml 2 QL (1200 mls/30 days)diazepam conc 5 mg/ml 1 QL (240 mls/30 days)diazepam tab 2 mg (Valium) 1 QL (120 tablets/30 days)diazepam tab 5 mg (Valium) 1 QL (120 tablets/30 days)diazepam tab 10 mg (Valium) 1 QL (120 tablets/30 days)hydroxyzine hcl syrup 10 mg/5ml 1hydroxyzine hcl tab 10 mg 1hydroxyzine hcl tab 25 mg 1hydroxyzine hcl tab 50 mg 1hydroxyzine pamoate cap 25 mg (Vistaril) 1hydroxyzine pamoate cap 50 mg (Vistaril) 1lorazepam conc 2 mg/ml 1 QL (150 mls/30 days)lorazepam tab 0.5 mg (Ativan) 1 QL (90 tablets/30 days)lorazepam tab 1 mg (Ativan) 1 QL (90 tablets/30 days)lorazepam tab 2 mg (Ativan) 1 QL (150 tablets/30 days)

DEPRESSIONamitriptyline hcl tab 10 mg 1amitriptyline hcl tab 25 mg (Elavil) 1amitriptyline hcl tab 50 mg 1amitriptyline hcl tab 75 mg 1amitriptyline hcl tab 100 mg 1amitriptyline hcl tab 150 mg 1APLENZIN – bupropion hbr tab er 24hr 174 mg 2 PA, QL (30 tablets/30 days)APLENZIN – bupropion hbr tab er 24hr 348 mg 2 PA, QL (30 tablets/30 days)APLENZIN – bupropion hbr tab er 24hr 522 mg 2 PA, QL (30 tablets/30 days)bupropion hcl tab er 12hr 100 mg (Wellbutrin sr) 1 QL (60 tablets/30 days)bupropion hcl tab er 12hr 150 mg (Wellbutrin sr) 1 QL (60 tablets/30 days)bupropion hcl tab er 12hr 200 mg (Wellbutrin sr) 1 QL (60 tablets/30 days)bupropion hcl tab er 24hr 150 mg (Wellbutrin xl) 1 QL (30 tablets/30 days)bupropion hcl tab er 24hr 300 mg (Wellbutrin xl) 1 QL (30 tablets/30 days)bupropion hcl tab 75 mg 1 QL (60 tablets/30 days)

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bupropion hcl tab 100 mg 1 QL (120 tablets/30 days)BUPROPION HYDROCHLORIDE E – bupropion hcl tab er 24hr

450 mg2 PA, QL (30 tablets/30 days)

citalopram hydrobromide oral soln 10 mg/5ml 1 QL (600 mls/30 days)citalopram hydrobromide tab 10 mg (base equiv) (Celexa) 1 QL (30 tablets/30 days)citalopram hydrobromide tab 20 mg (base equiv) (Celexa) 1 QL (30 tablets/30 days)citalopram hydrobromide tab 40 mg (base equiv) (Celexa) 1 QL (30 tablets/30 days)desipramine hcl tab 10 mg (Norpramin) 1desipramine hcl tab 25 mg (Norpramin) 1desipramine hcl tab 50 mg 1desipramine hcl tab 75 mg 1desipramine hcl tab 100 mg 1desipramine hcl tab 150 mg 1DOXEPIN HCL – doxepin hcl cap 150 mg 2doxepin hcl cap 10 mg 1doxepin hcl cap 25 mg 1doxepin hcl cap 50 mg 1doxepin hcl cap 75 mg 1doxepin hcl cap 100 mg 1doxepin hcl conc 10 mg/ml 1duloxetine hcl enteric coated pellets cap 20 mg (base eq)

(Cymbalta)1 QL (60 capsules/30 days)

duloxetine hcl enteric coated pellets cap 30 mg (base eq)(Cymbalta)

1 QL (90 capsules/30 days)

duloxetine hcl enteric coated pellets cap 60 mg (base eq)(Cymbalta)

1 QL (60 capsules/30 days)

EMSAM – selegiline td patch 24hr 6 mg/24hr 2 PAEMSAM – selegiline td patch 24hr 9 mg/24hr 2 PAEMSAM – selegiline td patch 24hr 12 mg/24hr 2 PAescitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro) 1 QL (600 mls/30 days)escitalopram oxalate tab 5 mg (base equiv) (Lexapro) 1 QL (30 tablets/30 days)escitalopram oxalate tab 10 mg (base equiv) (Lexapro) 1 QL (30 tablets/30 days)escitalopram oxalate tab 20 mg (base equiv) (Lexapro) 1 QL (30 tablets/30 days)FETZIMA – levomilnacipran hcl cap er 24hr 20 mg (base

equivalent)2 PA, QL (30 capsules/30 days)

FETZIMA – levomilnacipran hcl cap er 24hr 40 mg (baseequivalent)

2 PA, QL (30 capsules/30 days)

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FETZIMA TITRATION PACK – levomilnacipran hcl cap er 24hr20 & 40 mg therapy pack


fluoxetine hcl cap 10 mg (Prozac) 1 QL (30 capsules/30 days)fluoxetine hcl cap 20 mg (Prozac) 1 QL (120 capsules/30 days)fluoxetine hcl cap 40 mg (Prozac) 1 QL (60 capsules/30 days)fluoxetine hcl solution 20 mg/5ml 1 QL (600 mls/30 days)fluoxetine hcl tab 10 mg 1 QL (30 tablets/30 days)fluoxetine hcl tab 20 mg 1 QL (120 tablets/30 days)fluvoxamine maleate tab 25 mg 1 QL (30 tablets/30 days)fluvoxamine maleate tab 50 mg 1 QL (30 tablets/30 days)fluvoxamine maleate tab 100 mg 1 QL (90 tablets/30 days)FORFIVO XL – bupropion hcl tab er 24hr 450 mg 2 PA, QL (30 tablets/30 days)imipramine hcl tab 10 mg (Tofranil) 1imipramine hcl tab 25 mg (Tofranil) 1imipramine hcl tab 50 mg (Tofranil) 1MAPROTILINE HCL – maprotiline hcl tab 25 mg 2 PA, QL (90 tablets/30 days)MAPROTILINE HCL – maprotiline hcl tab 50 mg 2 PA, QL (90 tablets/30 days)MAPROTILINE HCL – maprotiline hcl tab 75 mg 2 PA, QL (90 tablets/30 days)MARPLAN – isocarboxazid tab 10 mg 2 PAmirtazapine tab 15 mg (Remeron) 1 QL (30 tablets/30 days)mirtazapine tab 30 mg (Remeron) 1 QL (30 tablets/30 days)mirtazapine tab 45 mg (Remeron) 1 QL (30 tablets/30 days)nortriptyline hcl cap 10 mg (Pamelor) 1nortriptyline hcl cap 25 mg (Pamelor) 1nortriptyline hcl cap 50 mg (Pamelor) 1nortriptyline hcl cap 75 mg (Pamelor) 1paroxetine hcl tab 10 mg (Paxil) 1 QL (30 tablets/30 days)paroxetine hcl tab 20 mg (Paxil) 1 QL (30 tablets/30 days)paroxetine hcl tab 30 mg (Paxil) 1 QL (60 tablets/30 days)paroxetine hcl tab 40 mg (Paxil) 1 QL (30 tablets/30 days)PAXIL – paroxetine hcl oral susp 10 mg/5ml (base equiv) 2 PA, QL (900 mls/30 days)PEXEVA – paroxetine mesylate tab 10 mg (base equiv) 2 PA, QL (30 tablets/30 days)

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PEXEVA – paroxetine mesylate tab 20 mg (base equiv) 2 PA, QL (30 tablets/30 days)PEXEVA – paroxetine mesylate tab 30 mg (base equiv) 2 PA, QL (60 tablets/30 days)PEXEVA – paroxetine mesylate tab 40 mg (base equiv) 2 PA, QL (30 tablets/30 days)sertraline hcl oral concentrate for solution 20 mg/ml (Zoloft) 1 QL (300 mls/30 days)sertraline hcl tab 25 mg (Zoloft) 1 QL (30 tablets/30 days)sertraline hcl tab 50 mg (Zoloft) 1 QL (30 tablets/30 days)sertraline hcl tab 100 mg (Zoloft) 1 QL (60 tablets/30 days)trazodone hcl tab 50 mg 1trazodone hcl tab 100 mg 1trazodone hcl tab 150 mg 1venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) (Effexor

xr)1 QL (30 capsules/30 days)

venlafaxine hcl cap er 24hr 75 mg (base equivalent) (Effexor xr) 1 QL (90 capsules/30 days)venlafaxine hcl cap er 24hr 150 mg (base equivalent) (Effexor xr) 1 QL (30 capsules/30 days)venlafaxine hcl tab 25 mg (base equivalent) 1 QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg (base equivalent) 1 QL (90 tablets/30 days)venlafaxine hcl tab 50 mg (base equivalent) 1 QL (90 tablets/30 days)venlafaxine hcl tab 75 mg (base equivalent) 1 QL (90 tablets/30 days)venlafaxine hcl tab 100 mg (base equivalent) 1 QL (90 tablets/30 days)VIIBRYD – vilazodone hcl tab 10 mg 2 PA, QL (30 tablets/30 days)VIIBRYD – vilazodone hcl tab 20 mg 2 PA, QL (30 tablets/30 days)VIIBRYD – vilazodone hcl tab 40 mg 2 PA, QL (30 tablets/30 days)VIIBRYD STARTER PACK – vilazodone hcl tab starter kit 10 (7)

& 20 (23) mg2 PA, QL (30 tablets/180 days)

PSYCHOTIC AND BIPOLAR DISORDERSABILIFY MAINTENA – aripiprazole im for er susp prefilled

syringe 300 mg2 PA, QL (1 syringe/28 days)

ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 400 mg

2 PA, QL (1 syringe/28 days)

ABILIFY MAINTENA – aripiprazole im for extended release susp300 mg


ABILIFY MAINTENA – aripiprazole im for extended release susp400 mg


ADASUVE – loxapine aerosol powder breath activated 10 mg 2 PAaripiprazole oral solution 1 mg/ml 1 PA, QL (150 mls/30 days)aripiprazole orally disintegrating tab 10 mg 1 AL, QL (30 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 1 AL, QL (30 tablets/30 days)

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aripiprazole tab 2 mg (Abilify) 1 AL, QL (30 tablets/30 days)aripiprazole tab 5 mg (Abilify) 1 AL, QL (30 tablets/30 days)aripiprazole tab 10 mg (Abilify) 1 AL, QL (30 tablets/30 days)aripiprazole tab 15 mg (Abilify) 1 AL, QL (30 tablets/30 days)aripiprazole tab 20 mg (Abilify) 1 AL, QL (30 tablets/30 days)aripiprazole tab 30 mg (Abilify) 1 AL, QL (30 tablets/30 days)ARISTADA – aripiprazole lauroxil im er susp prefilled syr

441 mg/1.6ml2 PA, QL (1 syringe/28 days)

ARISTADA – aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml






ARISTADA INITIO – aripiprazole lauroxil im er susp prefilled syr675 mg/2.4ml

2 PA, QL (1 kit/180 days)

CHLORPROMAZINE HCL – chlorpromazine hcl inj 50 mg/2ml 2 PAchlorpromazine hcl tab 10 mg 1 PAchlorpromazine hcl tab 25 mg 1 PAchlorpromazine hcl tab 50 mg 1 PAchlorpromazine hcl tab 100 mg 1 PAchlorpromazine hcl tab 200 mg 1 PACLOZAPINE ODT – clozapine orally disintegrating tab 150 mg 2 PA, QL (60 tablets/30 days)CLOZAPINE ODT – clozapine orally disintegrating tab 200 mg 2 PA, QL (120 tablets/30 days)clozapine orally disintegrating tab 12.5 mg (Fazaclo) 1 PA, QL (60 tablets/30 days)clozapine orally disintegrating tab 25 mg (Fazaclo) 1 PA, QL (60 tablets/30 days)clozapine orally disintegrating tab 100 mg (Fazaclo) 1 PA, QL (60 tablets/30 days)clozapine tab 25 mg (Clozaril) 1 AL, QL (90 tablets/30 days)clozapine tab 50 mg 1 AL, QL (90 tablets/30 days)clozapine tab 100 mg (Clozaril) 1 AL, QL (270 tablets/30 days)clozapine tab 200 mg 1 AL, QL (120 tablets/30 days)EQUETRO – carbamazepine (antipsychotic) cap er 12hr 100 mg 2 PAEQUETRO – carbamazepine (antipsychotic) cap er 12hr 200 mg 2 PAEQUETRO – carbamazepine (antipsychotic) cap er 12hr 300 mg 2 PAFANAPT – iloperidone tab 1 mg 2 PA, QL (60 tablets/30 days)FANAPT – iloperidone tab 2 mg 2 PA, QL (60 tablets/30 days)FANAPT – iloperidone tab 4 mg 2 PA, QL (60 tablets/30 days)

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FANAPT – iloperidone tab 6 mg 2 PA, QL (60 tablets/30 days)FANAPT – iloperidone tab 8 mg 2 PA, QL (60 tablets/30 days)FANAPT – iloperidone tab 10 mg 2 PA, QL (60 tablets/30 days)FANAPT – iloperidone tab 12 mg 2 PA, QL (60 tablets/30 days)FANAPT TITRATION PACK – iloperidone tab 1 mg & 2 mg &

4 mg & 6 mg titration pak2 PA, QL (8 tablets/180 days)

FAZACLO – clozapine orally disintegrating tab 150 mg 2 PA, QL (60 tablets/30 days)FAZACLO – clozapine orally disintegrating tab 200 mg 2 PA, QL (120 tablets/30 days)fluphenazine decanoate inj 25 mg/ml 1 ALFLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 mg/5ml 2 PAFLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml 2 PAFLUPHENAZINE HCL – fluphenazine hcl inj 2.5 mg/ml 2 PAFLUPHENAZINE HCL – fluphenazine hcl tab 1 mg 2FLUPHENAZINE HCL – fluphenazine hcl tab 2.5 mg 2FLUPHENAZINE HCL – fluphenazine hcl tab 5 mg 2FLUPHENAZINE HCL – fluphenazine hcl tab 10 mg 2GEODON – ziprasidone mesylate for inj 20 mg (base equivalent) 2 PA, QL (60 vials/30 days)haloperidol decanoate im soln 50 mg/ml (Haldol decanoate 50) 1 ALhaloperidol decanoate im soln 100 mg/ml (Haldol decanoate 100) 1 ALhaloperidol lactate oral conc 2 mg/ml 1 ALhaloperidol tab 0.5 mg 1 ALhaloperidol tab 1 mg 1 ALhaloperidol tab 2 mg 1 ALhaloperidol tab 5 mg 1 ALhaloperidol tab 10 mg 1 ALhaloperidol tab 20 mg 1 ALINVEGA – paliperidone tab er 24hr 1.5 mg 2 PA, QL (30 tablets/30 days)INVEGA – paliperidone tab er 24hr 3 mg 2 PA, QL (30 tablets/30 days)INVEGA – paliperidone tab er 24hr 6 mg 2 PA, QL (60 tablets/30 days)INVEGA – paliperidone tab er 24hr 9 mg 2 PA, QL (30 tablets/30 days)INVEGA SUSTENNA – paliperidone palmitate er susp pref syr

39 mg/0.25ml2 PA, QL (1 kit/28 days), 90

INVEGA SUSTENNA – paliperidone palmitate er susp pref syr78 mg/0.5ml

2 PA, QL (1 kit/28 days), 90


2 PA, QL (1 kit/28 days), 90

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INVEGA SUSTENNA – paliperidone palmitate er susp pref syr156 mg/ml

2 PA, QL (1 kit/28 days), 90


2 PA, QL (1 kit/28 days), 90

INVEGA TRINZA – paliperidone palmitate er susp pref syr273 mg/0.875ml

2 PA, QL (1 syringe/90 days), 90







LATUDA – lurasidone hcl tab 20 mg 2 PA, QL (30 tablets/30 days)LATUDA – lurasidone hcl tab 40 mg 2 PA, QL (30 tablets/30 days)LATUDA – lurasidone hcl tab 60 mg 2 PA, QL (30 tablets/30 days)LATUDA – lurasidone hcl tab 80 mg 2 PA, QL (60 tablets/30 days)LATUDA – lurasidone hcl tab 120 mg 2 PA, QL (30 tablets/30 days)LITHIUM – lithium oral solution 8 meq/5ml 2 PAlithium carbonate cap 150 mg (Lithium carbonate) 1lithium carbonate cap 300 mg 1lithium carbonate cap 600 mg (Lithium carbonate) 1lithium carbonate tab er 300 mg (Lithobid) 1lithium carbonate tab er 450 mg 1lithium carbonate tab 300 mg 1loxapine succinate cap 5 mg 1 ALloxapine succinate cap 10 mg 1 ALloxapine succinate cap 25 mg 1 ALloxapine succinate cap 50 mg 1 ALMOLINDONE HYDROCHLORIDE – molindone hcl tab 5 mg 2 ALMOLINDONE HYDROCHLORIDE – molindone hcl tab 10 mg 2 ALMOLINDONE HYDROCHLORIDE – molindone hcl tab 25 mg 2 ALolanzapine orally disintegrating tab 5 mg (Zyprexa zydis) 1 AL, QL (30 tablets/30 days)olanzapine orally disintegrating tab 10 mg (Zyprexa zydis) 1 AL, QL (30 tablets/30 days)olanzapine orally disintegrating tab 15 mg (Zyprexa zydis) 1 AL, QL (30 tablets/30 days)olanzapine orally disintegrating tab 20 mg (Zyprexa zydis) 1 AL, QL (30 tablets/30 days)olanzapine tab 2.5 mg (Zyprexa) 1 AL, QL (30 tablets/30 days)olanzapine tab 5 mg (Zyprexa) 1 AL, QL (30 tablets/30 days)

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olanzapine tab 7.5 mg (Zyprexa) 1 AL, QL (30 tablets/30 days)olanzapine tab 10 mg (Zyprexa) 1 AL, QL (30 tablets/30 days)olanzapine tab 15 mg (Zyprexa) 1 AL, QL (30 tablets/30 days)olanzapine tab 20 mg (Zyprexa) 1 AL, QL (30 tablets/30 days)paliperidone tab er 24hr 1.5 mg (Invega) 1 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 3 mg (Invega) 1 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 6 mg (Invega) 1 PA, QL (60 tablets/30 days)paliperidone tab er 24hr 9 mg (Invega) 1 PA, QL (30 tablets/30 days)perphenazine tab 2 mg 1 ALperphenazine tab 4 mg 1 ALperphenazine tab 8 mg 1 ALperphenazine tab 16 mg 1 ALprochlorperazine maleate tab 5 mg (base equivalent) 1 ALprochlorperazine maleate tab 10 mg (base equivalent) 1 ALprochlorperazine suppos 25 mg 1 ALquetiapine fumarate tab er 24hr 50 mg (Seroquel xr) 1 PA, QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 150 mg (Seroquel xr) 1 PA, QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 200 mg (Seroquel xr) 1 PA, QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 300 mg (Seroquel xr) 1 PA, QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 400 mg (Seroquel xr) 1 PA, QL (60 tablets/30 days)quetiapine fumarate tab 25 mg (Seroquel) 1 AL, QL (90 tablets/30 days)quetiapine fumarate tab 50 mg (Seroquel) 1 AL, QL (90 tablets/30 days)quetiapine fumarate tab 100 mg (Seroquel) 1 AL, QL (90 tablets/30 days)quetiapine fumarate tab 200 mg (Seroquel) 1 AL, QL (90 tablets/30 days)quetiapine fumarate tab 300 mg (Seroquel) 1 AL, QL (60 tablets/30 days)quetiapine fumarate tab 400 mg (Seroquel) 1 AL, QL (60 tablets/30 days)REXULTI – brexpiprazole tab 0.25 mg 2 PA, QL (30 tablets/30 days)REXULTI – brexpiprazole tab 0.5 mg 2 PA, QL (30 tablets/30 days)REXULTI – brexpiprazole tab 1 mg 2 PA, QL (30 tablets/30 days)REXULTI – brexpiprazole tab 2 mg 2 PA, QL (30 tablets/30 days)REXULTI – brexpiprazole tab 3 mg 2 PA, QL (30 tablets/30 days)REXULTI – brexpiprazole tab 4 mg 2 PA, QL (30 tablets/30 days)RISPERDAL CONSTA – risperidone microspheres for inj

12.5 mg2 PA, QL (2 vials/28 days)

RISPERDAL CONSTA – risperidone microspheres for inj 25 mg 2 PA, QL (2 vials/28 days)

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RISPERDAL CONSTA – risperidone microspheres for inj37.5 mg

2 PA, QL (2 vials/28 days)

RISPERDAL CONSTA – risperidone microspheres for inj 50 mg 2 PA, QL (2 vials/28 days)RISPERIDONE ODT – risperidone orally disintegrating tab

0.25 mg2 AL, QL (60 tablets/30 days)

risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab) 1 AL, QL (60 tablets/30 days)risperidone orally disintegrating tab 1 mg (Risperdal m-tab) 1 AL, QL (60 tablets/30 days)risperidone orally disintegrating tab 2 mg (Risperdal m-tab) 1 AL, QL (60 tablets/30 days)risperidone orally disintegrating tab 3 mg (Risperdal m-tab) 1 AL, QL (60 tablets/30 days)risperidone orally disintegrating tab 4 mg (Risperdal m-tab) 1 AL, QL (120 tablets/30 days)risperidone soln 1 mg/ml (Risperdal) 1 AL, QL (480 mls/30 days)risperidone tab 0.25 mg (Risperdal) 1 AL, QL (120 tablets/30 days)risperidone tab 0.5 mg (Risperdal) 1 AL, QL (120 tablets/30 days)risperidone tab 1 mg (Risperdal) 1 AL, QL (120 tablets/30 days)risperidone tab 2 mg (Risperdal) 1 AL, QL (120 tablets/30 days)risperidone tab 3 mg (Risperdal) 1 AL, QL (60 tablets/30 days)risperidone tab 4 mg (Risperdal) 1 AL, QL (120 tablets/30 days)SAPHRIS – asenapine maleate sl tab 2.5 mg (base equiv) 2 PA, QL (60 tablets/30 days)SAPHRIS – asenapine maleate sl tab 5 mg (base equiv) 2 PA, QL (60 tablets/30 days)SAPHRIS – asenapine maleate sl tab 10 mg (base equiv) 2 PA, QL (60 tablets/30 days)thioridazine hcl tab 10 mg 1 ALthioridazine hcl tab 25 mg 1 ALthioridazine hcl tab 50 mg 1 ALthioridazine hcl tab 100 mg 1 ALthiothixene cap 1 mg 1 ALthiothixene cap 2 mg 1 ALthiothixene cap 5 mg 1 ALthiothixene cap 10 mg 1 ALtrifluoperazine hcl tab 1 mg (base equivalent) 1 ALtrifluoperazine hcl tab 2 mg (base equivalent) 1 ALtrifluoperazine hcl tab 5 mg (base equivalent) 1 ALtrifluoperazine hcl tab 10 mg (base equivalent) 1 ALVERSACLOZ – clozapine susp 50 mg/ml 2 PA, QL (540 mls/30 days)ziprasidone hcl cap 20 mg (Geodon) 1 AL, QL (60 capsules/30 days)ziprasidone hcl cap 40 mg (Geodon) 1 AL, QL (60 capsules/30 days)ziprasidone hcl cap 60 mg (Geodon) 1 AL, QL (60 capsules/30 days)

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ziprasidone hcl cap 80 mg (Geodon) 1 AL, QL (60 capsules/30 days)ZYPREXA RELPREVV – olanzapine pamoate for extended rel im

susp 210 mg (base eq)2 PA, QL (2 vials/28 days)

ZYPREXA RELPREVV – olanzapine pamoate for extended rel imsusp 300 mg (base eq)

2 PA, QL (2 vials/28 days)

ZYPREXA RELPREVV – olanzapine pamoate for extended rel imsusp 405 mg (base eq)

2 PA, QL (1 vial/28 days)

SLEEP AIDSestazolam tab 1 mg 1 QL (30 tablets/30 days)estazolam tab 2 mg 1 QL (30 tablets/30 days)eszopiclone tab 1 mg (Lunesta) 1 QL (30 tablets/30 days)eszopiclone tab 2 mg (Lunesta) 1 QL (30 tablets/30 days)eszopiclone tab 3 mg (Lunesta) 1 QL (30 tablets/30 days)phenobarbital elixir 20 mg/5ml 1phenobarbital tab 15 mg 1phenobarbital tab 16.2 mg 1phenobarbital tab 30 mg 1phenobarbital tab 32.4 mg 1phenobarbital tab 60 mg 1phenobarbital tab 64.8 mg 1phenobarbital tab 97.2 mg 1phenobarbital tab 100 mg 1QUAZEPAM – quazepam tab 15 mg 2 QL (30 tablets/30 days)temazepam cap 15 mg (Restoril) 1 QL (30 capsules/30 days)temazepam cap 30 mg (Restoril) 1 QL (30 capsules/30 days)zaleplon cap 5 mg (Sonata) 1 QL (30 capsules/30 days)zaleplon cap 10 mg (Sonata) 1 QL (30 capsules/30 days)zolpidem tartrate tab 5 mg (Ambien) 1 QL (30 tablets/30 days)zolpidem tartrate tab 10 mg (Ambien) 1 QL (30 tablets/30 days)

HYPERACTIVITY/NARCOLEPSYamphetamine-dextroamphetamine cap er 24hr 5 mg (Adderall xr) 1 AL, QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 10 mg (Adderall

xr)1 AL, QL (30 capsules/30 days)

amphetamine-dextroamphetamine cap er 24hr 15 mg (Adderallxr)

1 AL, QL (30 capsules/30 days)



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amphetamine-dextroamphetamine tab 5 mg (Adderall) 1 AL, QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 7.5 mg (Adderall) 1 AL, QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 10 mg (Adderall) 1 AL, QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 12.5 mg (Adderall) 1 AL, QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 15 mg (Adderall) 1 AL, QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 20 mg (Adderall) 1 AL, QL (90 tablets/30 days)amphetamine-dextroamphetamine tab 30 mg (Adderall) 1 AL, QL (60 tablets/30 days)armodafinil tab 50 mg (Nuvigil) 1 PA, QL (30 tablets/30 days)armodafinil tab 150 mg (Nuvigil) 1 PA, QL (30 tablets/30 days)armodafinil tab 200 mg (Nuvigil) 1 PA, QL (30 tablets/30 days)armodafinil tab 250 mg (Nuvigil) 1 PA, QL (30 tablets/30 days)atomoxetine hcl cap 10 mg (base equiv) (Strattera) 1 AL, QL (60 capsules/30 days)atomoxetine hcl cap 18 mg (base equiv) (Strattera) 1 AL, QL (60 capsules/30 days)atomoxetine hcl cap 25 mg (base equiv) (Strattera) 1 AL, QL (60 capsules/30 days)atomoxetine hcl cap 40 mg (base equiv) (Strattera) 1 AL, QL (60 capsules/30 days)atomoxetine hcl cap 60 mg (base equiv) (Strattera) 1 AL, QL (30 capsules/30 days)atomoxetine hcl cap 80 mg (base equiv) (Strattera) 1 AL, QL (30 capsules/30 days)atomoxetine hcl cap 100 mg (base equiv) (Strattera) 1 AL, QL (30 capsules/30 days)caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) 1clonidine hcl tab er 12hr 0.1 mg (Kapvay) 1 QL (120 tablets/30 days)dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin xr) 1 AL, QL (30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin xr) 1 AL, QL (30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 15 mg (Focalin xr) 1 AL, QL (30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 20 mg (Focalin xr) 1 AL, QL (30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 30 mg (Focalin xr) 1 AL, QL (30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 40 mg (Focalin xr) 1 AL, QL (30 capsules/30 days)dexmethylphenidate hcl tab 2.5 mg (Focalin) 1 AL, QL (60 tablets/30 days)dexmethylphenidate hcl tab 5 mg (Focalin) 1 AL, QL (60 tablets/30 days)dexmethylphenidate hcl tab 10 mg (Focalin) 1 AL, QL (60 tablets/30 days)dextroamphetamine sulfate cap er 24hr 5 mg (Dexedrine) 1 AL, QL (90 capsules/30 days)dextroamphetamine sulfate cap er 24hr 10 mg (Dexedrine) 1 AL, QL (120 capsules/30 days)dextroamphetamine sulfate cap er 24hr 15 mg (Dexedrine) 1 AL, QL (120 capsules/30 days)

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dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra) 1 AL, QL (1800 mls/30 days)dextroamphetamine sulfate tab 5 mg 1 AL, QL (90 tablets/30 days)dextroamphetamine sulfate tab 10 mg 1 AL, QL (180 tablets/30 days)guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days)guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days)guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days)guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days)methylphenidate hcl cap er 10 mg (cd) 1 AL, QL (30 capsules/30 days)methylphenidate hcl cap er 20 mg (cd) 1 AL, QL (30 capsules/30 days)methylphenidate hcl cap er 30 mg (cd) 1 AL, QL (30 capsules/30 days)methylphenidate hcl cap er 40 mg (cd) 1 AL, QL (30 capsules/30 days)methylphenidate hcl cap er 50 mg (cd) 1 AL, QL (30 capsules/30 days)methylphenidate hcl cap er 60 mg (cd) 1 AL, QL (30 capsules/30 days)methylphenidate hcl cap er 24hr 10 mg (la) (Ritalin la) 1 AL, QL (30 capsules/30 days)methylphenidate hcl cap er 24hr 20 mg (la) (Ritalin la) 1 AL, QL (30 capsules/30 days)methylphenidate hcl cap er 24hr 30 mg (la) (Ritalin la) 1 AL, QL (60 capsules/30 days)methylphenidate hcl cap er 24hr 40 mg (la) (Ritalin la) 1 AL, QL (30 capsules/30 days)methylphenidate hcl chew tab 2.5 mg 1 AL, QL (90 tablets/30 days)methylphenidate hcl chew tab 5 mg 1 AL, QL (90 tablets/30 days)methylphenidate hcl chew tab 10 mg 1 AL, QL (180 tablets/30 days)methylphenidate hcl soln 5 mg/5ml (Methylin) 1 AL, QL (450 mls/30 days)methylphenidate hcl soln 10 mg/5ml (Methylin) 1 AL, QL (900 mls/30 days)methylphenidate hcl tab er 10 mg 1 AL, QL (90 tablets/30 days)methylphenidate hcl tab er 20 mg 1 AL, QL (90 tablets/30 days)methylphenidate hcl tab 5 mg (Ritalin) 1 AL, QL (90 tablets/30 days)methylphenidate hcl tab 10 mg (Ritalin) 1 AL, QL (90 tablets/30 days)methylphenidate hcl tab 20 mg (Ritalin) 1 AL, QL (90 tablets/30 days)METHYLPHENIDATE HYDROCHLO – methylphenidate hcl tab

er 24hr 18 mg2 AL, QL (30 tablets/30 days)

METHYLPHENIDATE HYDROCHLO – methylphenidate hcl taber 24hr 27 mg

2 AL, QL (30 tablets/30 days)





modafinil tab 100 mg (Provigil) 1 PA, QL (30 tablets/30 days)

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modafinil tab 200 mg (Provigil) 1 PA, QL (30 tablets/30 days)

MULTIPLE SCLEROSISAUBAGIO – teriflunomide tab 7 mg 2 PA, QL (30 tablets/30 days), SPAUBAGIO – teriflunomide tab 14 mg 2 PA, QL (30 tablets/30 days), SPAVONEX – interferon beta-1a im prefilled syringe kit

30 mcg/0.5ml2 PA, QL (1 kit/28 days), SP

AVONEX PEN – interferon beta-1a im auto-injector kit30 mcg/0.5ml

2 PA, QL (1 kit/28 days), SP

EXTAVIA – interferon beta-1b for inj kit 0.3 mg 2 PA, QL (14 vials/28 days), SPglatiramer acetate soln prefilled syringe 40 mg/ml (Copaxone) 2 PA, QL (12 syringes/28 days), SP

OTHER CENTRAL NERVOUS SYSTEM DRUGSacamprosate calcium tab delayed release 333 mg 1bupropion hcl (smoking deterrent) tab er 12hr 150 mg (Zyban) 1 QL (180 days/365 days)CHANTIX – varenicline tartrate tab 0.5 mg (base equiv) 2 QL (180 days/365 days)CHANTIX – varenicline tartrate tab 1 mg (base equiv) 2 QL (180 days/365 days)CHANTIX CONTINUING MONTH – varenicline tartrate tab 1 mg

(base equiv)2 QL (180 days/365 days)

CHANTIX STARTING MONTH PA – varenicline tartrate tab0.5 mg x 11 & tab 1 mg x 42 pack

2 QL (180 days/365 days)

CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide-amitriptyline tab 5-12.5 mg


CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide-amitriptyline tab 10-25 mg


disulfiram tab 250 mg (Antabuse) 1disulfiram tab 500 mg (Antabuse) 1donepezil hydrochloride orally disintegrating tab 5 mg 1 QL (30 tablets/30 days)donepezil hydrochloride orally disintegrating tab 10 mg 1 QL (30 tablets/30 days)donepezil hydrochloride tab 5 mg (Aricept) 1 QL (30 tablets/30 days)donepezil hydrochloride tab 10 mg (Aricept) 1 QL (30 tablets/30 days)GALANTAMINE HYDROBROMIDE – galantamine hydrobromide

oral soln 4 mg/ml2 QL (200 mls/30 days)

galantamine hydrobromide cap er 24hr 8 mg (Razadyne er) 1 QL (30 capsules/30 days)galantamine hydrobromide cap er 24hr 16 mg (Razadyne er) 1 QL (30 capsules/30 days)galantamine hydrobromide cap er 24hr 24 mg (Razadyne er) 1 QL (30 capsules/30 days)galantamine hydrobromide tab 4 mg (Razadyne) 1 QL (60 tablets/30 days)galantamine hydrobromide tab 8 mg (Razadyne) 1 QL (60 tablets/30 days)galantamine hydrobromide tab 12 mg (Razadyne) 1 QL (60 tablets/30 days), 90

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memantine hcl oral solution 2 mg/ml (Namenda) 1 QL (360 mls/30 days), 90memantine hcl tab 5 mg (Namenda) 1 QL (60 tablets/30 days)memantine hcl tab 10 mg (Namenda) 1 QL (60 tablets/30 days)NICOTROL INHALER – nicotine inhaler system 10 mg (4 mg

delivered)2 QL (180 days/365 days)

NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray) 2 QL (180 days/365 days)PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline

tab 2-10 mg2 PA

PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptylinetab 2-25 mg

2 PA


2 PA


2 PA


2 PA

PIMOZIDE – pimozide tab 1 mg 2PIMOZIDE – pimozide tab 2 mg 2rivastigmine tartrate cap 4.5 mg (base equivalent) 1 QL (60 capsules/30 days)

PAIN RELIEF DRUGSNON-NARCOTIC DRUGSbutalbital-acetaminophen tab 50-325 mg 1 QL (180 tablets/30 days)butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet) 1 QL (180 capsules/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic) 1 QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal) 1 QL (180 capsules/30 days)

NARCOTIC DRUGSacetaminophen w/ codeine soln 120-12 mg/5ml 1 AL, ME90, QL (2700 mls/30 days)acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine) 1 AL, ME90, QL (360

tablets/30 days)acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3) 1 AL, ME90, QL (360

tablets/30 days)acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4) 1 AL, ME90, QL (180

tablets/30 days)ACETAMINOPHEN/CAFFEINE/DI – acetaminophen-caffeine-

dihydrocodeine cap 320.5-30-16 mg2 ME90, QL (300 capsules/30 days)

buprenorphine hcl sl tab 2 mg (base equiv) 1 QL (90 tablets/30 days)buprenorphine hcl sl tab 8 mg (base equiv) 1 QL (90 tablets/30 days)

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buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv)(Suboxone)

1 QL (90 films/30 days)

buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv)(Suboxone)






buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) 1 QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) 1 QL (90 tablets/30 days)butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg 1 AL, ME90, QL (180

capsules/30 days)butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/

codeine #3)1 AL, ME90, QL (180

capsules/30 days)butorphanol tartrate nasal soln 10 mg/ml 1 ME90, QL (2 bottles/30 days)codeine sulfate tab 30 mg (Codeine sulfate) 1 AL, ME90, QL (180

tablets/30 days)fentanyl td patch 72hr 12 mcg/hr (Duragesic) 1 ME90, PA, QL (15

patches/30 days)fentanyl td patch 72hr 25 mcg/hr (Duragesic) 1 ME90, PA, QL (15




patches/30 days)hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet) 1 ME90, QL (3600 mls/30 days)hydrocodone-acetaminophen tab 10-325 mg (Norco) 1 ME90, QL (180 tablets/30 days)hydrocodone-acetaminophen tab 7.5-300 mg (Xodol) 1 ME90, QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-325 mg (Norco) 1 ME90, QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-325 mg (Norco) 1 ME90, QL (180 tablets/30 days)hydrocodone-acetaminophen tab 10-300 mg (Xodol) 1 ME90, QL (180 tablets/30 days)hydrocodone-ibuprofen tab 5-200 mg (Reprexain) 1 ME90, QL (150 tablets/30 days)hydrocodone-ibuprofen tab 7.5-200 mg 1 ME90, QL (150 tablets/30 days)hydromorphone hcl liqd 1 mg/ml (Dilaudid) 1 ME90, QL (1440 mls/30 days)hydromorphone hcl tab 2 mg (Dilaudid) 1 ME90, QL (180 tablets/30 days)hydromorphone hcl tab 4 mg (Dilaudid) 1 ME90, QL (180 tablets/30 days)

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hydromorphone hcl tab 8 mg (Dilaudid) 1 ME90, QL (180 tablets/30 days)methadone hcl conc 10 mg/ml (Methadose) 1 ME90, QL (90 mls/30 days)methadone hcl soln 5 mg/5ml (Methadone hcl) 1 ME90, QL (900 mls/30 days)methadone hcl soln 10 mg/5ml (Methadone hcl) 1 ME90, QL (450 mls/30 days)methadone hcl tab for oral susp 40 mg 1 ME90, QL (90 tablets/30 days)methadone hcl tab 5 mg (Dolophine) 1 ME90, QL (90 tablets/30 days)methadone hcl tab 10 mg (Dolophine) 1 ME90, QL (90 tablets/30 days)MORPHINE SULFATE – morphine sulfate suppos 5 mg 2 ME90MORPHINE SULFATE – morphine sulfate suppos 10 mg 2 ME90MORPHINE SULFATE – morphine sulfate suppos 20 mg 2 ME90MORPHINE SULFATE – morphine sulfate suppos 30 mg 2 ME90morphine sulfate cap er 24hr 100 mg (Kadian) 1 ME90, PA, QL (60

capsules/30 days)MORPHINE SULFATE ER – morphine sulfate beads cap er 24hr

60 mg2 ME90, PA, QL (30


75 mg2 ME90, PA, QL (30


120 mg2 ME90, PA, QL (30

capsules/30 days)morphine sulfate oral soln 10 mg/5ml 1 ME90, QL (2700 mls/30 days)morphine sulfate oral soln 20 mg/5ml 1 ME90, QL (1350 mls/30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 1 ME90, QL (270 mls/30 days)morphine sulfate tab er 15 mg (Ms contin) 1 ME90, PA, QL (90

tablets/30 days)morphine sulfate tab er 30 mg (Ms contin) 1 ME90, PA, QL (90




tablets/30 days)morphine sulfate tab 15 mg (Morphine sulfate) 1 ME90, QL (240 tablets/30 days)morphine sulfate tab 30 mg (Morphine sulfate) 1 ME90, QL (180 tablets/30 days)oxycodone hcl conc 100 mg/5ml (20 mg/ml) 1 ME90, QL (270 mls/30 days)oxycodone hcl soln 5 mg/5ml 1 ME90, QL (5400 mls/30 days)oxycodone hcl tab 5 mg (Roxicodone) 1 ME90, QL (360 tablets/30 days)

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oxycodone hcl tab 10 mg 1 ME90, QL (180 tablets/30 days)oxycodone hcl tab 15 mg (Roxicodone) 1 ME90, QL (180 tablets/30 days)oxycodone hcl tab 20 mg 1 ME90, QL (180 tablets/30 days)oxycodone hcl tab 30 mg (Roxicodone) 1 ME90, QL (180 tablets/30 days)oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet) 1 ME90, QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 5-325 mg (Percocet) 1 ME90, QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet) 1 ME90, QL (240 tablets/30 days)oxycodone w/ acetaminophen tab 10-325 mg (Percocet) 1 ME90, QL (180 tablets/30 days)OXYCODONE/ASPIRIN – oxycodone-aspirin tab 4.8355-325 mg 2 ME90, QL (360 tablets/30 days)OXYCODONE/IBUPROFEN – oxycodone-ibuprofen tab

5-400 mg2 ME90, QL (120 tablets/30 days)

oxymorphone hcl tab 5 mg (Opana) 1 ME90, QL (180 tablets/30 days)oxymorphone hcl tab 10 mg (Opana) 1 ME90, QL (180 tablets/30 days)OXYMORPHONE HYDROCHLORIDE – oxymorphone hcl tab er

12hr 5 mg2 ME90, PA, QL (60

tablets/30 days)OXYMORPHONE HYDROCHLORIDE – oxymorphone hcl tab er

12hr 7.5 mg2 ME90, PA, QL (60


12hr 10 mg2 ME90, PA, QL (60


12hr 15 mg2 ME90, PA, QL (60


12hr 20 mg2 ME90, PA, QL (60


12hr 30 mg2 ME90, PA, QL (60


12hr 40 mg2 ME90, PA, QL (60

tablets/30 days)SUBOXONE – buprenorphine hcl-naloxone hcl sl film 2-0.5 mg

(base equiv)2 QL (90 films/30 days)

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 mg(base equiv)






tramadol hcl tab 50 mg (Ultram) 1 AL, ME90, QL (240tablets/30 days)

tramadol-acetaminophen tab 37.5-325 mg (Ultracet) 1 AL, ME90, QL (240tablets/30 days)

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RHEUMATOID AND OSTEOARTHRITISARCALYST – rilonacept for inj 220 mg 2 PA, QL (4 vials/28 days), SPcelecoxib cap 50 mg (Celebrex) 1 QL (60 capsules/30 days)celecoxib cap 100 mg (Celebrex) 1 QL (60 capsules/30 days)celecoxib cap 200 mg (Celebrex) 1 QL (60 capsules/30 days)celecoxib cap 400 mg (Celebrex) 1 QL (30 capsules/30 days)diclofenac potassium tab 50 mg 1 QL (120 tablets/30 days)diclofenac sodium tab delayed release 50 mg 1 QL (120 tablets/30 days)diclofenac sodium tab delayed release 75 mg 1 QL (60 tablets/30 days)diclofenac sodium tab er 24hr 100 mg 1 QL (60 tablets/30 days)ENBREL – etanercept for subcutaneous inj 25 mg 2 PA, QL (8 vials/28 days), SPENBREL – etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml2 PA, QL (4 syringes/28 days), SP

ENBREL – etanercept subcutaneous soln prefilled syringe50 mg/ml


ENBREL MINI – etanercept subcutaneous solution cartridge50 mg/ml

2 PA, QL (4 cartridges/28 days), SP

ENBREL SURECLICK – etanercept subcutaneous solution auto-injector 50 mg/ml


flurbiprofen tab 50 mg 1 QL (180 tablets/30 days)flurbiprofen tab 100 mg 1 QL (90 tablets/30 days)HUMIRA – adalimumab prefilled syringe kit 10 mg/0.1ml 2 PA, QL (2 syringes/28 days), SPHUMIRA – adalimumab prefilled syringe kit 10 mg/0.2ml 2 PA, QL (2 syringes/28 days), SPHUMIRA – adalimumab prefilled syringe kit 20 mg/0.2ml 2 PA, QL (2 syringes/28 days), SPHUMIRA – adalimumab prefilled syringe kit 20 mg/0.4ml 2 PA, QL (2 syringes/28 days), SPHUMIRA – adalimumab prefilled syringe kit 40 mg/0.8ml 2 PA, QL (2 syringes/28 days), SPHUMIRA – adalimumab prefilled syringe kit 40 mg/0.4ml 2 PA, QL (2 syringes/28 days), SPHUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringe

kit 40 mg/0.8ml2 PA, QL (3 syringes/180 days), SP

HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringekit 40 mg/0.8ml

2

HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringekit 80 mg/0.8ml


HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringekit 80 mg/0.8ml & 40 mg/0.4ml


HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.8ml 2 PA, QL (2 pens/28 days), SPHUMIRA PEN – adalimumab pen-injector kit 40 mg/0.4ml 2 PA, QL (2 pens/28 days), SP

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HUMIRA PEN-CD/UC/HS START – adalimumab pen-injector kit40 mg/0.8ml

2 PA, QL (6 pens/180 days), SP

HUMIRA PEN-CD/UC/HS START – adalimumab pen-injector kit80 mg/0.8ml


HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit40 mg/0.8ml


HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit80 mg/0.8ml & 40 mg/0.4ml


ibuprofen susp 100 mg/5ml 1 QL (1000 mls/30 days)ibuprofen tab 400 mg 1 QL (120 tablets/30 days)ibuprofen tab 600 mg 1 QL (150 tablets/30 days)ibuprofen tab 800 mg 1 QL (120 tablets/30 days)indomethacin cap er 75 mg 1 QL (60 capsules/30 days)indomethacin cap 25 mg 1 QL (90 capsules/30 days)indomethacin cap 50 mg 1 QL (60 capsules/30 days)ketorolac tromethamine tab 10 mg 1 QL (20 tablets/30 days)KINERET – anakinra subcutaneous soln prefilled syringe

100 mg/0.67ml2 PA, QL (28 syringes/28 days), SP

leflunomide tab 10 mg (Arava) 1leflunomide tab 20 mg (Arava) 1meloxicam tab 7.5 mg (Mobic) 1 QL (60 tablets/30 days)meloxicam tab 15 mg (Mobic) 1 QL (30 tablets/30 days)nabumetone tab 500 mg 1 QL (120 tablets/30 days)nabumetone tab 750 mg 1 QL (60 tablets/30 days)naproxen sodium tab er 24hr 375 mg (base equiv) (Naprelan) 1 QL (120 tablets/30 days)naproxen sodium tab 275 mg 1 QL (150 tablets/30 days)naproxen sodium tab 550 mg (Anaprox ds) 1 QL (90 tablets/30 days)naproxen susp 125 mg/5ml (Naprosyn) 1 PA, QL (1800 mls/30 days)naproxen tab ec 375 mg (Ec-naprosyn) 1 QL (120 tablets/30 days)naproxen tab ec 500 mg (Ec-naprosyn) 1 QL (90 tablets/30 days)naproxen tab 250 mg 1 QL (150 tablets/30 days)naproxen tab 375 mg 1 QL (120 tablets/30 days)naproxen tab 500 mg (Naprosyn) 1 QL (90 tablets/30 days)OLUMIANT – baricitinib tab 2 mg 2 PA, QL (30 tablets/30 days), SPORENCIA – abatacept subcutaneous soln prefilled syringe

125 mg/ml2 PA, QL (4 syringes/28 days), SP

ORENCIA CLICKJECT – abatacept subcutaneous soln auto-injector 125 mg/ml


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OTEZLA – apremilast tab starter therapy pack 10 mg & 20 mg &30 mg


OTEZLA – apremilast tab 30 mg 2 PA, QL (60 tablets/30 days), SPpiroxicam cap 10 mg (Feldene) 1 QL (60 capsules/30 days)piroxicam cap 20 mg (Feldene) 1 QL (30 capsules/30 days)SIMPONI – golimumab subcutaneous soln auto-injector

50 mg/0.5ml2 PA, QL (1 syringe/28 days), SP

SIMPONI – golimumab subcutaneous soln auto-injector 100 mg/ml


SIMPONI – golimumab subcutaneous soln prefilled syringe50 mg/0.5ml


SIMPONI – golimumab subcutaneous soln prefilled syringe100 mg/ml


sulindac tab 150 mg 1 QL (60 tablets/30 days)sulindac tab 200 mg 1 QL (60 tablets/30 days)XELJANZ – tofacitinib citrate tab 5 mg (base equivalent) 2 PA, QL (60 tablets/30 days), SPXELJANZ – tofacitinib citrate tab 10 mg (base equivalent) 2 PA, QL (60 tablets/30 days), SPXELJANZ XR – tofacitinib citrate tab er 24hr 11 mg (base

equivalent)2 PA, QL (30 tablets/30 days), SP

MIGRAINE HEADACHESalmotriptan malate tab 6.25 mg (Axert) 1 QL (18 tablets/30 days)almotriptan malate tab 12.5 mg (Axert) 1 QL (18 tablets/30 days)frovatriptan succinate tab 2.5 mg (base equivalent) (Frova) 1 QL (18 tablets/30 days)IMITREX – sumatriptan nasal spray 5 mg/act 2 QL (12 units/30 days)IMITREX – sumatriptan nasal spray 20 mg/act 2 QL (12 units/30 days)rizatriptan benzoate oral disintegrating tab 5 mg (base eq)

(Maxalt-mlt)1 QL (18 tablets/30 days)

rizatriptan benzoate oral disintegrating tab 10 mg (base eq)(Maxalt-mlt)


rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt) 1 QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt) 1 QL (18 tablets/30 days)sumatriptan nasal spray 5 mg/act (Imitrex) 1 QL (12 units/30 days)sumatriptan nasal spray 20 mg/act (Imitrex) 1 QL (12 units/30 days)SUMATRIPTAN SUCCINATE – sumatriptan succinate solution

prefilled syringe 6 mg/0.5ml2 QL (12 doses/30 days)

sumatriptan succinate inj 6 mg/0.5ml (Imitrex) 1 QL (12 vials/30 days)sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex

statdose sys)1 QL (12 doses/30 days)

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sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrexstatdose sys)

1 QL (12 doses/30 days)

sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrexstatdose ref)

1 QL (12 doses/30 days)

sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrexstatdose ref)

1 QL (6 packages/30 days)

sumatriptan succinate tab 25 mg (Imitrex) 1 QL (18 tablets/30 days)sumatriptan succinate tab 50 mg (Imitrex) 1 QL (18 tablets/30 days)sumatriptan succinate tab 100 mg (Imitrex) 1 QL (18 tablets/30 days)

GOUTallopurinol tab 100 mg (Zyloprim) 1allopurinol tab 300 mg (Zyloprim) 1COLCHICINE – colchicine cap 0.6 mg 2colchicine w/ probenecid tab 0.5-500 mg 1MITIGARE – colchicine cap 0.6 mg 2probenecid tab 500 mg 1

NEUROMUSCULAR DRUGSSEIZURESAPTIOM – eslicarbazepine acetate tab 200 mg 2APTIOM – eslicarbazepine acetate tab 400 mg 2APTIOM – eslicarbazepine acetate tab 600 mg 2APTIOM – eslicarbazepine acetate tab 800 mg 2carbamazepine cap er 12hr 100 mg (Carbatrol) 1carbamazepine cap er 12hr 200 mg (Carbatrol) 1carbamazepine cap er 12hr 300 mg (Carbatrol) 1carbamazepine chew tab 100 mg 1carbamazepine susp 100 mg/5ml (Tegretol) 1carbamazepine tab er 12hr 100 mg (Tegretol-xr) 1carbamazepine tab er 12hr 200 mg (Tegretol-xr) 1carbamazepine tab er 12hr 400 mg (Tegretol-xr) 1carbamazepine tab 200 mg (Tegretol) 1clonazepam orally disintegrating tab 0.125 mg 1 QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg 1 QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg 1 QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg 1 QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg 1 QL (60 tablets/30 days)

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clonazepam tab 0.5 mg (Klonopin) 1 QL (90 tablets/30 days)clonazepam tab 1 mg (Klonopin) 1 QL (90 tablets/30 days)clonazepam tab 2 mg (Klonopin) 1 QL (60 tablets/30 days)DILANTIN – phenytoin sodium extended cap 30 mg 2divalproex sodium cap delayed release sprinkle 125 mg

(Depakote sprinkles)1

divalproex sodium tab delayed release 125 mg (Depakote) 1divalproex sodium tab delayed release 250 mg (Depakote) 1divalproex sodium tab delayed release 500 mg (Depakote) 1divalproex sodium tab er 24 hr 250 mg (Depakote er) 1divalproex sodium tab er 24 hr 500 mg (Depakote er) 1ethosuximide cap 250 mg (Zarontin) 1ethosuximide soln 250 mg/5ml (Zarontin) 1felbamate susp 600 mg/5ml (Felbatol) 1felbamate tab 400 mg (Felbatol) 1felbamate tab 600 mg (Felbatol) 1gabapentin cap 100 mg (Neurontin) 1 QL (720 capsules/30 days)gabapentin cap 300 mg (Neurontin) 1 QL (240 capsules/30 days)gabapentin cap 400 mg (Neurontin) 1 QL (180 capsules/30 days)gabapentin oral soln 250 mg/5ml (Neurontin) 1 QL (1500 mls/30 days)gabapentin tab 600 mg (Neurontin) 1 QL (120 tablets/30 days)gabapentin tab 800 mg (Neurontin) 1 QL (90 tablets/30 days)LAMICTAL XR – lamotrigine tab er 24hr 25 mg (21) & 50 mg (7)

titration kit2 PA

LAMICTAL XR – lamotrigine tab er 24hr 25 (14) & 50 mg (14) &100 mg(7) kit

2 PA

LAMICTAL XR – lamotrigine tab er 24hr 50 (14) & 100 mg(14) &200 mg(7) kit

2 PA

lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di) 1lamotrigine tab chewable dispersible 25 mg (Lamictal chewable

di)1

lamotrigine tab er 24hr 25 mg (Lamictal xr) 1lamotrigine tab er 24hr 50 mg (Lamictal xr) 1lamotrigine tab er 24hr 100 mg (Lamictal xr) 1lamotrigine tab er 24hr 200 mg (Lamictal xr) 1lamotrigine tab er 24hr 250 mg (Lamictal xr) 1lamotrigine tab er 24hr 300 mg (Lamictal xr) 1

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lamotrigine tab 25 mg (Lamictal) 1lamotrigine tab 100 mg (Lamictal) 1lamotrigine tab 150 mg (Lamictal) 1lamotrigine tab 200 mg (Lamictal) 1lamotrigine tab 25 mg (35) starter kit (Lamictal starter/tak) 1 PAlamotrigine tab 25 mg (42) & 100 mg (7) starter kit (Lamictal

starter/not)1 PA

lamotrigine tab 25 mg (84) & 100 mg (14) starter kit (Lamictalstarter/tak)

1 PA

levetiracetam oral soln 100 mg/ml (Keppra) 1levetiracetam tab er 24hr 500 mg (Keppra xr) 1levetiracetam tab er 24hr 750 mg (Keppra xr) 1levetiracetam tab 250 mg (Keppra) 1levetiracetam tab 500 mg (Keppra) 1levetiracetam tab 750 mg (Keppra) 1levetiracetam tab 1000 mg (Keppra) 1oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal) 1oxcarbazepine tab 150 mg (Trileptal) 1oxcarbazepine tab 300 mg (Trileptal) 1oxcarbazepine tab 600 mg (Trileptal) 1OXTELLAR XR – oxcarbazepine tab er 24hr 150 mg 2 PAOXTELLAR XR – oxcarbazepine tab er 24hr 300 mg 2 PAOXTELLAR XR – oxcarbazepine tab er 24hr 600 mg 2 PAphenytoin chew tab 50 mg (Dilantin infatabs) 1phenytoin sodium extended cap 100 mg (Dilantin) 1phenytoin sodium extended cap 200 mg (Phenytek) 1phenytoin sodium extended cap 300 mg (Phenytek) 1phenytoin susp 125 mg/5ml (Dilantin-125) 1primidone tab 50 mg (Mysoline) 1primidone tab 250 mg (Mysoline) 1tiagabine hcl tab 2 mg (Gabitril) 1tiagabine hcl tab 4 mg (Gabitril) 1topiramate sprinkle cap 15 mg (Topamax sprinkle) 1topiramate sprinkle cap 25 mg (Topamax sprinkle) 1topiramate tab 25 mg (Topamax) 1topiramate tab 50 mg (Topamax) 1

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topiramate tab 100 mg (Topamax) 1 90topiramate tab 200 mg (Topamax) 1valproic acid cap 250 mg (Depakene) 1vigabatrin powd pack 500 mg (Sabril) 2 PA, QL (180 packets/30 days), SPvigabatrin tab 500 mg (Sabril) 2 PA, QL (180 tablets/30 days), SPzonisamide cap 25 mg (Zonegran) 1zonisamide cap 50 mg 1zonisamide cap 100 mg (Zonegran) 1

PARKINSON'S DISEASEamantadine hcl cap 100 mg 1amantadine hcl syrup 50 mg/5ml 1benztropine mesylate tab 0.5 mg 1benztropine mesylate tab 1 mg 1benztropine mesylate tab 2 mg 1bromocriptine mesylate cap 5 mg (base equivalent) 1bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel) 1carbidopa & levodopa orally disintegrating tab 10-100 mg 1carbidopa & levodopa orally disintegrating tab 25-100 mg 1carbidopa & levodopa orally disintegrating tab 25-250 mg 1carbidopa & levodopa tab er 25-100 mg (Sinemet cr) 1carbidopa & levodopa tab er 50-200 mg (Sinemet cr) 1carbidopa & levodopa tab 10-100 mg (Sinemet) 1carbidopa & levodopa tab 25-100 mg (Sinemet) 1carbidopa & levodopa tab 25-250 mg (Sinemet) 1carbidopa tab 25 mg (Lodosyn) 1entacapone tab 200 mg (Comtan) 1pramipexole dihydrochloride tab er 24hr 2.25 mg (Mirapex er) 1pramipexole dihydrochloride tab 0.125 mg (Mirapex) 1pramipexole dihydrochloride tab 0.25 mg (Mirapex) 1pramipexole dihydrochloride tab 0.5 mg (Mirapex) 1pramipexole dihydrochloride tab 0.75 mg (Mirapex) 1pramipexole dihydrochloride tab 1 mg (Mirapex) 1pramipexole dihydrochloride tab 1.5 mg (Mirapex) 1ropinirole hydrochloride tab 0.25 mg (Requip) 1ropinirole hydrochloride tab 0.5 mg (Requip) 1

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ropinirole hydrochloride tab 1 mg (Requip) 1ropinirole hydrochloride tab 2 mg (Requip) 1ropinirole hydrochloride tab 3 mg (Requip) 1ropinirole hydrochloride tab 4 mg (Requip) 1ropinirole hydrochloride tab 5 mg (Requip) 1SELEGILINE HCL – selegiline hcl tab 5 mg 2selegiline hcl cap 5 mg (Eldepryl) 1tolcapone tab 100 mg (Tasmar) 1trihexyphenidyl hcl elixir 0.4 mg/ml 1trihexyphenidyl hcl tab 2 mg 1trihexyphenidyl hcl tab 5 mg 1

MUSCLE RELAXANTSbaclofen tab 10 mg 1baclofen tab 20 mg 1carisoprodol tab 250 mg (Soma) 1CHLORZOXAZONE – chlorzoxazone tab 500 mg 2cyclobenzaprine hcl tab 5 mg 1cyclobenzaprine hcl tab 10 mg 1dantrolene sodium cap 25 mg (Dantrium) 1dantrolene sodium cap 50 mg (Dantrium) 1dantrolene sodium cap 100 mg 1methocarbamol tab 500 mg (Robaxin) 1methocarbamol tab 750 mg (Robaxin-750) 1orphenadrine citrate tab er 12hr 100 mg 1tizanidine hcl tab 2 mg (base equivalent) 1 QL (180 tablets/30 days)tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) 1 QL (180 tablets/30 days)

OTHER NEUROMUSCULAR DRUGSpyridostigmine bromide tab 60 mg (Mestinon) 1riluzole tab 50 mg (Rilutek) 1

SUPPLEMENTSVITAMINScholecalciferol cap 5000 unit 1ergocalciferol cap 50000 unit 1phytonadione tab 5 mg (Mephyton) 1

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MULTIVITAMINSb-complex w/ c & folic acid cap 1 mg (Nephrocaps) 1b-complex w/ c & folic acid tab 1b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx) 1b-complex w/ c & folic acid tab 5 mg 1CLASSIC PRENATAL – prenatal vit w/ fe fumarate-fa tab

28-0.8 mg2

CORVITA – multiple vitamins w/ minerals & fa tab 1.25 mg 2CVS PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 2EQL PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab

28-0.8 mg2

FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals & folic acidtab 5 mg

2

GNP PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2GOODSENSE PRENATAL VITAMI – prenatal vit w/ fe fumarate-

fa tab 28-0.8 mg2

HM PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2KP PRENATAL MULTIVITAMINS – prenatal vit w/ fe fumarate-fa

tab 28-0.8 mg2

M-NATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2M-VIT – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2MULTI PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 2multiple vitamins w/ minerals cap 1multiple vitamins w/ minerals tab (Strovite forte) 1NIVA-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2O-CAL FA – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2pediatric multiple vitamin w/ minerals & c drops 45 mg/ml 1pediatric vitamins acd w/ fluoride soln 0.25 mg/ml 1PNV FOLIC ACID + IRON MUL – prenatal vit w/ fe fumarate-fa

tab 27-1 mg2

PNV PRENATAL PLUS MULTIVI – prenatal vit w/ fe fumarate-fatab 27-1 mg

2

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab0.25 mg

2

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab0.5 mg

2

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab1 mg

2

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PRE-NATAL FORMULA – prenatal multivitamins & minerals w/iron & fa tab 0.8 mg

2

PRENATAL – prenatal multivitamins & minerals w/iron & fa tab0.8 mg

2

PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 2PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2PRENATAL AND IRON – prenatal multivitamins & minerals w/

iron & fa tab 0.8 mg2

PRENATAL FORTE – prenatal multivitamins & minerals w/iron &fa tab 0.8 mg

2

PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa tab27-0.8 mg

2

PRENATAL MULTI +DHA – prenatal vit w/ fe fum-fa-omega 3 cap27-0.8-228 mg

2

PRENATAL MULTIVITAMIN – prenatal vit w/ fe fumarate-fa tab28-0.8 mg

2

PRENATAL ONE DAILY – prenatal vit w/ fe fumarate-fa tab27-0.8 mg

2

prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 1PRENATAL VITAMIN – prenatal vit w/ fe fumarate-fa tab

27-0.8 mg2

PRENATAL VITAMIN & MINERA – prenatal vit w/ fe fumarate-fatab 28-0.8 mg

2

PRENATAL VITAMIN/IRON – prenatal vit w/ fe fumarate-fa tab28-0.8 mg

2

PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab28-0.8 mg

2

PRENATAL VITAMINS PLUS LO – prenatal vit w/ fe fumarate-fatab 27-1 mg

2

PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 2PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 2PREPLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2PX PRENATAL MULTIVITAMINS – prenatal vit w/ fe fumarate-fa

tab 28-0.8 mg2

QC PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2RA PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2RA PRENATAL FORMULA/FOLIC – prenatal vit w/ fe fumarate-fa

tab 28-0.8 mg2

RIGHT STEP PRENATAL – prenatal vit w/ fe fumarate-fa tab27-0.8 mg

2

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SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 2SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 2SM PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab

28-0.8 mg2

speciality vitamin product tab 1TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1 mg 2VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg 2VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1 mg 2VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2

MINERALS AND ELECTROLYTESEFFERVESCENT POTASSIUM/CH – pot bicarbonate & chloride

effer tab 25 meq2

K-PHOS – potassium phosphate monobasic tab 500 mg 2pot phos monobasic w/sod phos di & monobas tab

155-852-130mg (K-phos neutral)1

potassium bicarbonate effer tab 25 meq 1potassium chloride cap er 8 meq (Micro-k) 1potassium chloride cap er 10 meq (Micro-k) 1POTASSIUM CHLORIDE ER – potassium chloride tab er 8 meq

(600 mg)2

potassium chloride microencapsulated crys er tab 10 meq 1potassium chloride microencapsulated crys er tab 20 meq 1potassium chloride oral soln 10% (20 meq/15ml) 1potassium chloride oral soln 20% (40 meq/15ml) 1potassium chloride tab er 8 meq (600 mg) 1potassium chloride tab er 10 meq (K-tab) 1SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from 1.1 mg

naf)2

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

2

sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride) 1sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride) 1sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride) 1sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) 1sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride) 1

OTHER SUPPLEMENTS

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acetylcysteine cap 600 mg 1amino acids cap 1folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2 mg 1

BLOOD MODIFYING DRUGSBLOOD MODIFYING DRUGSanagrelide hcl cap 0.5 mg (Agrylin) 1anagrelide hcl cap 1 mg 1ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled

syringe 10 mcg/0.4ml2 PA, SP

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilledsyringe 25 mcg/0.42ml

2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilledsyringe 500 mcg/ml

2 PA, SP

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25 mcg/ml

2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP

BRILINTA – ticagrelor tab 60 mg 2 PA, QL (60 tablets/30 days)BRILINTA – ticagrelor tab 90 mg 2 PA, QL (60 tablets/30 days)cilostazol tab 50 mg 1cilostazol tab 100 mg 1

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clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) 1clopidogrel bisulfate tab 300 mg (base equiv) (Plavix) 1cyanocobalamin inj 1000 mcg/ml 1dipyridamole tab 25 mg 1 90dipyridamole tab 50 mg 1dipyridamole tab 75 mg 1DROXIA – hydroxyurea cap 200 mg 2DROXIA – hydroxyurea cap 300 mg 2DROXIA – hydroxyurea cap 400 mg 2ELIQUIS – apixaban tab 2.5 mg 2 PA, QL (60 tablets/30 days)ELIQUIS – apixaban tab 5 mg 2 PA, QL (74 tablets/30 days)ELIQUIS STARTER PACK – apixaban tab 5 mg 2 PA, QL (74 tablets/180 days)enoxaparin sodium inj 30 mg/0.3ml (Lovenox) 1 QL (30 syringes/365 days)enoxaparin sodium inj 40 mg/0.4ml (Lovenox) 1 QL (30 syringes/365 days)enoxaparin sodium inj 60 mg/0.6ml (Lovenox) 1 QL (30 syringes/365 days)enoxaparin sodium inj 80 mg/0.8ml (Lovenox) 1 QL (30 syringes/365 days)enoxaparin sodium inj 100 mg/ml (Lovenox) 1 QL (30 syringes/365 days)enoxaparin sodium inj 120 mg/0.8ml (Lovenox) 1 QL (30 syringes/365 days)enoxaparin sodium inj 150 mg/ml (Lovenox) 1 QL (30 syringes/365 days)fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap

(Tandem plus)1

fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg 1fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg 1ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg 1ferrous fumarate-folic acid tab 324-1 mg 1folic acid tab 1 mg 1folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg 1folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx) 1folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg 1FULPHILA – pegfilgrastim-jmdb soln prefilled syringe 6 mg/0.6ml 2 PA, SPHAEGARDA – c1 esterase inhibitor (human) for subcutaneous inj

2000 unit2 PA, QL (16 vials/28 days), SP

HAEGARDA – c1 esterase inhibitor (human) for subcutaneous inj3000 unit

2 PA, QL (8 vials/28 days), SP

icatibant acetate inj 30 mg/3ml (base equivalent) (Firazyr) 2 PA, QL (6 syringes/30 days), SPiron combination cap 1

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iron polysacch complex-vit b12-fa cap 150-0.025-1 mg 1iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg

(Hematron-af)1

iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite150)

1

miglustat cap 100 mg (Zavesca) 2 PA, QL (90 capsules/30 days), SPNIVESTYM – filgrastim-aafi soln prefilled syringe 300 mcg/0.5ml 2 PA, SPNIVESTYM – filgrastim-aafi soln prefilled syringe 480 mcg/0.8ml 2 PA, SPNIVESTYM – filgrastim-aafi inj 300 mcg/ml 2 PA, SPNIVESTYM – filgrastim-aafi inj 480 mcg/1.6ml (300 mcg/ml) 2 PA, SPpentoxifylline tab er 400 mg 1PROMACTA – eltrombopag olamine powder pack for susp

12.5 mg (base eq)2 PA, QL (30 packets/30 days), SP

PROMACTA – eltrombopag olamine tab 12.5 mg (base equiv) 2 PA, QL (30 tablets/30 days), SPPROMACTA – eltrombopag olamine tab 25 mg (base equiv) 2 PA, QL (30 tablets/30 days), SPPROMACTA – eltrombopag olamine tab 50 mg (base equiv) 2 PA, QL (60 tablets/30 days), SPPROMACTA – eltrombopag olamine tab 75 mg (base equiv) 2 PA, QL (60 tablets/30 days), SPRETACRIT – epoetin alfa-epbx inj 2000 unit/ml 2 PA, SPRETACRIT – epoetin alfa-epbx inj 3000 unit/ml 2 PA, SPRETACRIT – epoetin alfa-epbx inj 4000 unit/ml 2 PA, SPRETACRIT – epoetin alfa-epbx inj 10000 unit/ml 2 PA, SPRETACRIT – epoetin alfa-epbx inj 40000 unit/ml 2 PA, SPtranexamic acid tab 650 mg (Lysteda) 1warfarin sodium tab 1 mg (Coumadin) 1warfarin sodium tab 2 mg (Coumadin) 1warfarin sodium tab 2.5 mg (Coumadin) 1warfarin sodium tab 3 mg (Coumadin) 1warfarin sodium tab 4 mg (Coumadin) 1warfarin sodium tab 5 mg (Coumadin) 1warfarin sodium tab 6 mg (Coumadin) 1warfarin sodium tab 7.5 mg (Coumadin) 1warfarin sodium tab 10 mg (Coumadin) 1XARELTO – rivaroxaban tab 2.5 mg 2 QL (60 tablets/30 days)XARELTO – rivaroxaban tab 10 mg 2 PA, QL (35 tablets/365 days)XARELTO – rivaroxaban tab 15 mg 2 PA, QL (60 tablets/30 days)XARELTO – rivaroxaban tab 20 mg 2 PA, QL (30 tablets/30 days)

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XARELTO STARTER PACK – rivaroxaban tab starter therapypack 15 mg & 20 mg

2 PA, QL (51 tablets/30 days)

TOPICAL PRODUCTSEYEAnti-infectivesBACITRACIN – bacitracin ophth oint 500 unit/gm 2bacitracin-polymyxin b ophth oint 1ciprofloxacin hcl ophth soln 0.3% (base equivalent) (Ciloxan) 1erythromycin ophth oint 5 mg/gm 1gentamicin sulfate ophth soln 0.3% 1moxifloxacin hcl ophth soln 0.5% (base equiv) (Vigamox) 1NATACYN – natamycin ophth susp 5% 2neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 1NEOMYCIN/POLYMYXIN/GRAMIC – neomycin-polymy-gramicid

op sol 1.75-10000-0.025mg-unt-mg/ml2

ofloxacin ophth soln 0.3% (Ocuflox) 1polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%

(Polytrim)1

sulfacetamide sodium ophth soln 10% (Bleph-10) 1tobramycin ophth soln 0.3% (Tobrex) 1TRIFLURIDINE – trifluridine ophth soln 1% 2

Steroids and Combination Productsbacitracin-polymyxin-neomycin-hc ophth oint 1% 1DEXAMETHASONE SODIUM PHOS – dexamethasone sodium

phosphate ophth soln 0.1%2

fluorometholone ophth susp 0.1% (Fml liquifilm) 1neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol) 1neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol) 1PREDNISOLONE ACETATE – prednisolone acetate ophth susp

1%2

PREDNISOLONE SODIUM PHOSP – prednisolone sodiumphosphate ophth soln 1%

2

SULFACETAMIDE SODIUM/PRED – sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%

2

Glaucomaapraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine) 1betaxolol hcl ophth soln 0.5% 1

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brimonidine tartrate ophth soln 0.2% 1CARTEOLOL HCL – carteolol hcl ophth soln 1% 2dorzolamide hcl ophth soln 2% (Trusopt) 1dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml

(Cosopt)1

latanoprost ophth soln 0.005% (Xalatan) 1 QL (1 bottle/30 days)levobunolol hcl ophth soln 0.5% (Betagan) 1pilocarpine hcl ophth soln 1% (Isopto carpine) 1pilocarpine hcl ophth soln 2% (Isopto carpine) 1pilocarpine hcl ophth soln 4% (Isopto carpine) 1timolol maleate ophth soln 0.25% (Timoptic) 1timolol maleate ophth soln 0.5% (Timoptic) 1

Other Eye ProductsATROPINE SULFATE – atropine sulfate ophth oint 1% 2ATROPINE SULFATE – atropine sulfate ophth soln 1% 2azelastine hcl ophth soln 0.05% 1cromolyn sodium ophth soln 4% 1cyclopentolate hcl ophth soln 0.5% (Cyclogyl) 1cyclopentolate hcl ophth soln 1% (Cyclogyl) 1cyclopentolate hcl ophth soln 2% (Cyclogyl) 1diclofenac sodium ophth soln 0.1% 1epinastine hcl ophth soln 0.05% (Elestat) 1FLURBIPROFEN SODIUM – flurbiprofen sodium ophth soln

0.03%2

homatropine hbr ophth soln 5% 1ISOPTO ATROPINE – atropine sulfate ophth soln 1% 2ketorolac tromethamine ophth soln 0.4% (Acular ls) 1ketorolac tromethamine ophth soln 0.5% (Acular) 1olopatadine hcl ophth soln 0.1% (base equivalent) (Patanol) 1phenylephrine hcl ophth soln 2.5% 1proparacaine hcl ophth soln 0.5% (Alcaine) 1tetracaine hcl ophth soln 0.5% 1

EARacetic acid otic soln 2% 1hydrocortisone w/ acetic acid otic soln 1-2% 1

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neomycin-polymyxin-hc otic soln 1% 1neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% 1ofloxacin otic soln 0.3% (Floxin otic) 1

MOUTH AND THROAT (LOCAL)chlorhexidine gluconate soln 0.12% (Peridex) 1clotrimazole troche 10 mg 1lidocaine hcl viscous soln 2% 1nystatin susp 100000 unit/ml 1pilocarpine hcl tab 5 mg (Salagen) 1pilocarpine hcl tab 7.5 mg (Salagen) 1PREVIDENT FLUORIDE – sodium fluoride gel 1.1% (0.5% f) 2PREVIDENT RINSE – sodium fluoride rinse 0.2% 2PREVIDENT 5000 DRY MOUTH – sodium fluoride gel 1.1%

(0.5% f)2

sodium fluoride cream 1.1% (Prevident 5000 plus) 1sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) 1sodium fluoride paste 1.1% (Prevident 5000 boost) 1sodium fluoride rinse 0.2% 1sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000

sensi)1

stannous fluoride gel 0.4% 1triamcinolone acetonide dental paste 0.1% 1

ANORECTAL AGENTShydrocortisone enema 100 mg/60ml (Cortenema) 1hydrocortisone rectal cream 1% (Proctocort) 1hydrocortisone rectal cream 2.5% (Anusol-hc) 1

SKIN CONDITIONS/PRODUCTSAcneadapalene cream 0.1% (Differin) 1 ALazelaic acid gel 15% (Finacea) 1 ALbenzoyl peroxide cloth 6% 1 ALbenzoyl peroxide-erythromycin gel 5-3% (Benzamycin) 1 ALCLINDACIN ETZ PLEDGETS – clindamycin phosphate swab 1% 2 ALCLINDACIN-P – clindamycin phosphate swab 1% 2 ALclindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5%

(Duac)1 AL

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Name of Drug


CLINDAMYCIN PHOSPHATE – clindamycin phosphate swab 1% 2 ALclindamycin phosphate gel 1% (Cleocin-t) 1 ALclindamycin phosphate lotion 1% (Cleocin-t) 1 ALclindamycin phosphate soln 1% (Cleocin-t) 1 ALerythromycin pads 2% 1 ALerythromycin soln 2% 1 ALisotretinoin cap 10 mg 1 ALisotretinoin cap 20 mg 1 ALisotretinoin cap 30 mg 1 ALisotretinoin cap 40 mg 1 ALmetronidazole cream 0.75% (Metrocream) 1 ALmetronidazole gel 0.75% 1 ALsulfacetamide sodium lotion 10% (acne) (Klaron) 1 ALtazarotene cream 0.1% (Tazorac) 1 ALTAZORAC – tazarotene cream 0.05% 2 ALTAZORAC – tazarotene gel 0.05% 2 ALTAZORAC – tazarotene gel 0.1% 2 ALtretinoin cream 0.025% (Retin-a) 1 ALtretinoin cream 0.05% (Retin-a) 1 ALtretinoin cream 0.1% (Retin-a) 1 ALtretinoin gel 0.01% (Retin-a) 1 ALtretinoin gel 0.025% (Retin-a) 1 ALtretinoin gel 0.05% (Atralin) 1 AL

Anti-infectivesacyclovir oint 5% (Zovirax) 1ciclopirox olamine cream 0.77% (base equiv) (Loprox) 1ciclopirox olamine susp 0.77% (base equiv) 1ciclopirox solution 8% (Penlac Nail Lacquer) 1 PA, QL (6.6 mls/30 days)clotrimazole cream 1% 1clotrimazole soln 1% 1clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone) 1diclofenac sodium gel 1% (Voltaren) 1 QL (200 grams/30 days)gentamicin sulfate oint 0.1% 1ketoconazole cream 2% 1ketoconazole shampoo 2% (Nizoral) 1

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Name of Drug


mupirocin oint 2% 1naftifine hcl cream 2% (Naftin) 1nystatin cream 100000 unit/gm 1nystatin oint 100000 unit/gm 1oxiconazole nitrate cream 1% (Oxistat) 1salicylic acid cream 6% 1salicylic acid cream 6% & cleanser liqd kit (Salex cream) 1salicylic acid film forming liquid 27.5% (Virasal) 1salicylic acid foam 6% (Salvax) 1salicylic acid gel 6% (Keralyt) 1SALICYLIC ACID LOTION – salicylic acid lotion 6% & cleanser

liqd kit2

salicylic acid lotion 6% 1salicylic acid shampoo 6% (Salex) 1silver sulfadiazine cream 1% (Silvadene) 1

Corticosteroidsalclometasone dipropionate cream 0.05% (Aclovate) 1alclometasone dipropionate oint 0.05% 1AUGMENTED BETAMETHASONE D – betamethasone

dipropionate augmented gel 0.05%2 QL (180 grams/90 days)

betamethasone dipropionate augmented cream 0.05%(Diprolene af)

1 QL (180 grams/90 days)

betamethasone dipropionate augmented lotion 0.05% (Diprolene) 1 QL (180 mls/90 days)betamethasone dipropionate augmented oint 0.05% (Diprolene) 1 QL (180 grams/90 days)betamethasone dipropionate cream 0.05% 1 QL (180 grams/90 days)betamethasone dipropionate lotion 0.05% 1 QL (180 mls/90 days)betamethasone dipropionate oint 0.05% 1 QL (180 grams/90 days)betamethasone valerate cream 0.1% (base equivalent) 1betamethasone valerate lotion 0.1% (base equivalent) 1betamethasone valerate oint 0.1% (base equivalent) 1clobetasol propionate emollient base cream 0.05% (Temovate e) 1clobetasol propionate soln 0.05% (Temovate) 1 QL (180 mls/90 days)desonide cream 0.05% (Desowen) 1desonide oint 0.05% 1desoximetasone cream 0.25% (Topicort) 1 QL (180 grams/90 days)desoximetasone gel 0.05% (Topicort) 1 QL (180 grams/90 days)

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Name of Drug


fluocinolone acetonide cream 0.01% 1fluocinolone acetonide cream 0.025% (Synalar) 1fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs

sca)1

fluocinolone acetonide oint 0.025% (Synalar) 1fluocinolone acetonide soln 0.01% (Synalar) 1fluocinonide cream 0.05% 1 QL (180 grams/90 days)fluocinonide emulsified base cream 0.05% 1 QL (180 grams/90 days)fluocinonide gel 0.05% 1 QL (180 grams/90 days)fluocinonide oint 0.05% 1 QL (180 grams/90 days)fluocinonide soln 0.05% 1 QL (180 mls/90 days)flurandrenolide cream 0.05% (Cordran) 1fluticasone propionate cream 0.05% (Cutivate) 1fluticasone propionate oint 0.005% 1halobetasol propionate cream 0.05% (Ultravate) 1 QL (180 grams/90 days)halobetasol propionate oint 0.05% (Ultravate) 1 QL (180 grams/90 days)hydrocortisone butyrate oint 0.1% (Locoid) 1hydrocortisone butyrate soln 0.1% (Locoid) 1hydrocortisone cream 1% 1hydrocortisone cream 2.5% 1hydrocortisone lotion 2.5% 1hydrocortisone oint 1% 1hydrocortisone oint 2.5% 1hydrocortisone valerate cream 0.2% 1hydrocortisone valerate oint 0.2% (Westcort) 1mometasone furoate cream 0.1% (Elocon) 1mometasone furoate oint 0.1% (Elocon) 1 QL (180 grams/90 days)mometasone furoate solution 0.1% (lotion) (Elocon) 1PREDNICARBATE – prednicarbate cream 0.1% 2PREDNICARBATE – prednicarbate oint 0.1% 2triamcinolone acetonide aerosol soln 0.147 mg/gm (Kenalog) 1triamcinolone acetonide cream 0.025% 1triamcinolone acetonide cream 0.1% 1triamcinolone acetonide cream 0.5% 1 QL (180 grams/90 days)triamcinolone acetonide lotion 0.025% 1

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Name of Drug


triamcinolone acetonide lotion 0.1% 1triamcinolone acetonide oint 0.025% 1triamcinolone acetonide oint 0.1% 1

Other Skin Productsacitretin cap 10 mg (Soriatane) 1acitretin cap 17.5 mg (Soriatane) 1acitretin cap 25 mg (Soriatane) 1calcipotriene cream 0.005% (Dovonex) 1calcipotriene oint 0.005% 1calcipotriene soln 0.005% (50 mcg/ml) 1CEM-UREA – urea soln 45% 2CERAMAX – dermatological products misc - cream 2COSENTYX – secukinumab subcutaneous soln prefilled syringe

150 mg/ml2 PA, QL (2 syringes/28 days), SP

COSENTYX – secukinumab subcutaneous soln prefilled syringe150 mg/ml

2

COSENTYX SENSOREADY PEN – secukinumab subcutaneoussoln auto-injector 150 mg/ml


COSENTYX SENSOREADY PEN – secukinumab subcutaneoussoln auto-injector 150 mg/ml

2

CUTTER BACKWOODS – diethyltoluamide (deet) aerosol 2CUTTER SKINSATIONS – diethyltoluamide (deet) liquid 2fluorouracil cream 5% (Efudex) 1 QL (240 grams/180 days)imiquimod cream 5% (Aldara) 1 QL (48 packets/180 days)lidocaine hcl gel 2% 1 QL (120 grams/30 days)lidocaine hcl soln 4% (Xylocaine) 1 QL (120 grams/30 days)lidocaine hcl urethral/mucosal gel 2% 1 QL (120 grams/30 days)lidocaine patch 5% (Lidoderm) 1 PA, QL (90 patches/30 days)lidocaine-prilocaine cream 2.5-2.5% 1 QL (30 grams/60 days)malathion lotion 0.5% (Ovide) 1methoxsalen rapid cap 10 mg (Oxsoralen ultra) 1NATRAPEL 12-HOUR TICK & I – picaridin aerosol 2OFF ACTIVE – diethyltoluamide (deet) aerosol 2OFF DEEP WOODS – diethyltoluamide (deet) aerosol 2OFF DEEP WOODS DRY – diethyltoluamide (deet) aerosol 2OFF SMOOTH & DRY – diethyltoluamide (deet) aerosol 2

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Name of Drug


permethrin cream 5% (Elimite) 1podofilox soln 0.5% (Condylox) 1REPEL SPORTSMEN – diethyltoluamide (deet) aerosol 2REPEL SPORTSMEN MAX – diethyltoluamide (deet) aerosol 2SAWYER PREMIUM INSECT REP – picaridin liquid 2selenium sulfide lotion 2.5% 1selenium sulfide shampoo 2.25% 1STELARA – ustekinumab soln prefilled syringe 45 mg/0.5ml 2 PA, QL (1 syringe/84 days), SPSTELARA – ustekinumab soln prefilled syringe 90 mg/ml 2 PA, QL (1 syringe/56 days), SPtacrolimus oint 0.03% (Protopic) 1 QL (60 days supply/120 days), STtacrolimus oint 0.1% (Protopic) 1 QL (60 days supply/120 days), ST

MISCELLANEOUS CATEGORIESDIABETIC SUPPLIESKETOSTIX – acetone (urine) test strip 2ONETOUCH ULTRA BLUE – glucose blood test strip 2 QL (153 strips/30 days), STONETOUCH ULTRA CONTROL – blood glucose calibration -

liquid2

ONETOUCH ULTRA MINI – blood glucose monitoring kit w/device

2 QL (2 systems/365 days)

ONETOUCH ULTRA 2 – blood glucose monitoring kit w/ device 2 QL (2 systems/365 days)ONETOUCH VERIO – blood glucose monitoring kit w/ device 2 QL (2 systems/365 days)ONETOUCH VERIO CONTROL SO – blood glucose calibration -

liquid - high2

ONETOUCH VERIO FLEX BLOOD – blood glucose monitoringkit w/ device


ONETOUCH VERIO IQ BLOOD G – blood glucose monitoring kitw/ device


ONETOUCH VERIO MID CONTRO – blood glucose calibration -liquid

2

ONETOUCH VERIO TEST STRIP – glucose blood test strip 2 QL (153 strips/30 days), STINSULIN SYRINGES - TECHLITE AND TRUEPLUS 2 QL (200 syringes/30 days)INUSLIN PEN NEEDLES - TECHLITE AND TRUEPLUS 2 QL (200 insulin pen

needles/30 days)ONETOUCH DELICA LANCETS E – lancets 2 QL (200 units/30 days)ONETOUCH DELICA LANCETS F – lancets 2 QL (200 units/30 days)ONETOUCH DELICA LANCING D – lancet devices 2ONETOUCH DELICA PLUS LANC – lancet devices 2

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Name of Drug


ONETOUCH SURESOFT LANCING – lancets misc. 2ONETOUCH ULTRASOFT LANCET – lancets 2 QL (200 units/30 days)

RESPIRATORY INHALER-ASSIST DEVICESAEROCHAMBER 2BREATHERITE 2

MISCELLANEOUS DRUGSazathioprine tab 50 mg (Imuran) 1CHEMET – succimer cap 100 mg 2cyclosporine cap 25 mg (Sandimmune) 1cyclosporine cap 100 mg (Sandimmune) 1CYCLOSPORINE MODIFIED – cyclosporine modified cap 50 mg 2cyclosporine modified cap 25 mg (Neoral) 1cyclosporine modified cap 100 mg (Neoral) 1cyclosporine modified oral soln 100 mg/ml (Neoral) 1deferasirox tab for oral susp 125 mg (Exjade) 2 PA, QL (30 tablets/30 days), SPdeferasirox tab for oral susp 250 mg (Exjade) 2 PA, QL (30 tablets/30 days), SPdeferasirox tab for oral susp 500 mg (Exjade) 2 PA, QL (90 tablets/30 days), SPDEPEN TITRATABS – penicillamine tab 250 mg 2 PA, SPFERRIPROX – deferiprone oral soln 100 mg/ml 2 PA, QL (2700 mls/30 days), SPFERRIPROX – deferiprone tab 500 mg 2 PA, QL (540 tablets/30 days), SPFERRIPROX – deferiprone tab 1000 mg 2 PA, QL (270 tablets/30 days)irrigation solution, physiological 1lactated ringer's for irrigation 1mycophenolate mofetil cap 250 mg (Cellcept) 1mycophenolate mofetil for oral susp 200 mg/ml (Cellcept) 1mycophenolate mofetil tab 500 mg (Cellcept) 1mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)

(Myfortic)1

mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)(Myfortic)

1

naltrexone hcl tab 50 mg 1NARCAN – naloxone hcl nasal spray 4 mg/0.1ml 2penicillamine cap 250 mg (Cuprimine) 2 PA, SPREVLIMID – lenalidomide caps 2.5 mg 2 PA, QL (30 capsules/30 days), SPREVLIMID – lenalidomide cap 5 mg 2 PA, QL (30 capsules/30 days), SP

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Name of Drug


REVLIMID – lenalidomide cap 10 mg 2 PA, QL (30 capsules/30 days), SPREVLIMID – lenalidomide cap 15 mg 2 PA, QL (21 capsules/28 days), SPREVLIMID – lenalidomide cap 20 mg 2 PA, QL (21 capsules/28 days), SPREVLIMID – lenalidomide cap 25 mg 2 PA, QL (21 capsules/28 days), SPringer's solution for irrigation 1sirolimus tab 0.5 mg (Rapamune) 1sirolimus tab 1 mg (Rapamune) 1sirolimus tab 2 mg (Rapamune) 1sodium polystyrene sulfonate oral susp 15 gm/60ml 1sodium polystyrene sulfonate powder (Kayexalate) 1sodium polystyrene sulfonate rectal susp 30 gm/120ml 1tacrolimus cap 0.5 mg (Prograf) 1tacrolimus cap 1 mg (Prograf) 1tacrolimus cap 5 mg (Prograf) 1THALOMID – thalidomide cap 50 mg 2 PA, QL (30 capsules/30 days), SPTHALOMID – thalidomide cap 100 mg 2 PA, QL (30 capsules/30 days), SPTHALOMID – thalidomide cap 150 mg 2 PA, QL (60 capsules/30 days), SPTHALOMID – thalidomide cap 200 mg 2 PA, QL (60 capsules/30 days), SPtrientine hcl cap 250 mg (Syprine) 2 PA, QL (240

capsules/30 days), SPVIVITROL – naltrexone for im extended release susp 380 mg 2 QL (1 vial/28 days), SPwater for irrigation, sterile irrigation soln 1ZORTRESS – everolimus tab 0.25 mg 2ZORTRESS – everolimus tab 0.5 mg 2ZORTRESS – everolimus tab 0.75 mg 2ZORTRESS – everolimus tab 1 mg 2

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INDEX

Aabacavir sulfate-lamivudine tab 600-300 mg(Epzicom).......................................................................... 10

abacavir sulfate-lamivudine-zidovudine tab 300-150-300mg (Trizivir)....................................................................... 10

abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen)...... 10abacavir sulfate tab 300 mg (base equiv) (Ziagen)...........10ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 300 mg.................................................................55

ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 400 mg.................................................................55

ABILIFY MAINTENA – aripiprazole im for extendedrelease susp 300 mg........................................................55

ABILIFY MAINTENA – aripiprazole im for extendedrelease susp 400 mg........................................................55

abiraterone acetate tab 250 mg (Zytiga)...........................16acamprosate calcium tab delayed release 333 mg...........64acarbose tab 25 mg (Precose)..........................................27acarbose tab 50 mg (Precose)..........................................27acarbose tab 100 mg (Precose)........................................27acebutolol hcl cap 200 mg (Sectral)..................................35acebutolol hcl cap 400 mg (Sectral)..................................35ACETAMINOPHEN/CAFFEINE/DI – acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg................. 65

acetaminophen w/ codeine soln 120-12 mg/5ml...............65acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine).............................................................................65

acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3)....................................................................... 65

acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4)....................................................................... 65

acetazolamide cap er 12hr 500 mg (Diamox)................... 40acetazolamide tab 250 mg................................................ 40acetic acid otic soln 2%..................................................... 84acetylcysteine cap 600 mg................................................ 80acetylcysteine inhal soln 10%............................................44acetylcysteine inhal soln 20%............................................44acitretin cap 10 mg (Soriatane)......................................... 89acitretin cap 17.5 mg (Soriatane)...................................... 89acitretin cap 25 mg (Soriatane)......................................... 89ACTHAR – corticotropin inj gel 80 unit/ml.........................30ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml(2000000 unit/0.5ml).........................................................16

acyclovir cap 200 mg (Zovirax)......................................... 10acyclovir oint 5% (Zovirax)................................................ 86acyclovir susp 200 mg/5ml (Zovirax).................................10acyclovir tab 400 mg (Zovirax).......................................... 10acyclovir tab 800 mg (Zovirax).......................................... 10ADACEL – tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml..........................................................................14

adapalene cream 0.1% (Differin).......................................85ADASUVE – loxapine aerosol powder breath activated 10mg......................................................................................55

adefovir dipivoxil tab 10 mg (Hepsera)................................9ADEMPAS – riociguat tab 0.5 mg..................................... 42ADEMPAS – riociguat tab 1 mg........................................ 42ADEMPAS – riociguat tab 1.5 mg..................................... 42ADEMPAS – riociguat tab 2 mg........................................ 42ADEMPAS – riociguat tab 2.5 mg..................................... 42ADMELOG – insulin lispro inj 100 unit/ml......................... 28ADMELOG SOLOSTAR – insulin lispro soln pen-injector100 unit/ml........................................................................ 28

AEROCHAMBER................................................................91AFINITOR DISPERZ – everolimus tab for oral susp 2mg......................................................................................16

AFINITOR DISPERZ – everolimus tab for oral susp 3mg......................................................................................16

AFINITOR DISPERZ – everolimus tab for oral susp 5mg......................................................................................16

AFINITOR – everolimus tab 2.5 mg.................................. 16AFINITOR – everolimus tab 5 mg..................................... 16AFINITOR – everolimus tab 7.5 mg.................................. 16AFINITOR – everolimus tab 10 mg................................... 16AFLURIA QUADRIVALENT 2019-2020 – influenza virusvaccine split quadrivalent im inj.......................................14

AFLURIA QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.25 ml.................... 14

AFLURIA QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.5ml....................... 14

albendazole tab 200 mg (Albenza)....................................13ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr4 mg.................................................................................. 44

ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr8 mg.................................................................................. 44

ALBUTEROL SULFATE HFA – albuterol sulfate inhal aero108 mcg/act (90mcg base equiv).................................... 45

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..............45albuterol sulfate soln nebu 0.5% (5 mg/ml).......................45albuterol sulfate soln nebu 0.63 mg/3ml (base equiv).......45albuterol sulfate soln nebu 1.25 mg/3ml (base equiv).......45albuterol sulfate syrup 2 mg/5ml....................................... 45albuterol sulfate tab 2 mg..................................................45albuterol sulfate tab 4 mg..................................................45alclometasone dipropionate cream 0.05% (Aclovate).......87alclometasone dipropionate oint 0.05%............................ 87ALECENSA – alectinib hcl cap 150 mg (baseequivalent).........................................................................16

ALENDRONATE SODIUM – alendronate sodium tab 5mg......................................................................................30

ALENDRONATE SODIUM – alendronate sodium tab 40mg......................................................................................30

alendronate sodium tab 10 mg..........................................30alendronate sodium tab 35 mg..........................................30alendronate sodium tab 70 mg (Fosamax)....................... 30alfuzosin hcl tab er 24hr 10 mg (Uroxatral).......................51ALINIA – nitazoxanide tab 500 mg....................................14ALKERAN – melphalan tab 2 mg......................................16allopurinol tab 100 mg (Zyloprim)......................................72allopurinol tab 300 mg (Zyloprim)......................................72

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almotriptan malate tab 6.25 mg (Axert).............................71almotriptan malate tab 12.5 mg (Axert).............................71ALOGLIPTIN/METFORMIN HCL – alogliptin-metforminhcl tab 12.5-500 mg......................................................... 27

ALOGLIPTIN/METFORMIN HCL – alogliptin-metforminhcl tab 12.5-1000 mg....................................................... 27

ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazonetab 12.5-15 mg................................................................. 27



ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazonetab 25-15 mg.................................................................... 27



ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (baseequiv).................................................................................27

ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (baseequiv).................................................................................27

ALOGLIPTIN – alogliptin benzoate tab 25 mg (baseequiv).................................................................................27

alosetron hcl tab 0.5 mg (base equiv) (Lotronex)............. 49alosetron hcl tab 1 mg (base equiv) (Lotronex)................ 49ALPRAZOLAM INTENSOL – alprazolam conc 1 mg/ml.......................................................................................51

alprazolam tab er 24hr 0.5 mg (Xanax xr)........................ 51alprazolam tab er 24hr 1 mg (Xanax xr)........................... 51alprazolam tab er 24hr 2 mg (Xanax xr)........................... 51alprazolam tab er 24hr 3 mg (Xanax xr)........................... 51alprazolam tab 0.25 mg (Xanax)....................................... 51alprazolam tab 0.5 mg (Xanax)......................................... 51alprazolam tab 1 mg (Xanax)............................................ 51alprazolam tab 2 mg (Xanax)............................................ 51amantadine hcl cap 100 mg.............................................. 75amantadine hcl syrup 50 mg/5ml...................................... 75ambrisentan tab 5 mg (Letairis).........................................42ambrisentan tab 10 mg (Letairis).......................................42amiloride & hydrochlorothiazide tab 5-50 mg....................40amiloride hcl tab 5 mg....................................................... 40amino acids cap................................................................. 80amiodarone hcl tab 200 mg (Cordarone).......................... 41amitriptyline hcl tab 10 mg.................................................52amitriptyline hcl tab 50 mg.................................................52amitriptyline hcl tab 75 mg.................................................52amitriptyline hcl tab 100 mg...............................................52amitriptyline hcl tab 150 mg...............................................52amitriptyline hcl tab 25 mg (Elavil).................................... 52amlodipine besylate-benazepril hcl cap 2.5-10 mg...........36amlodipine besylate-benazepril hcl cap 5-40 mg..............36amlodipine besylate-benazepril hcl cap 5-10 mg(Lotrel)............................................................................... 36

amlodipine besylate-benazepril hcl cap 5-20 mg(Lotrel)............................................................................... 36



amlodipine besylate tab 2.5 mg (base equivalent)(Norvasc)...........................................................................36

amlodipine besylate tab 5 mg (base equivalent)(Norvasc)...........................................................................36

amlodipine besylate tab 10 mg (base equivalent)(Norvasc)...........................................................................36

AMOXICILLIN/CLAVULANATE P – amoxicillin & kclavulanate chew tab 200-28.5 mg....................................6

AMOXICILLIN/CLAVULANATE P – amoxicillin & kclavulanate chew tab 400-57 mg.......................................6

amoxicillin & k clavulanate for susp 200-28.5 mg/5ml........ 6amoxicillin & k clavulanate for susp 400-57 mg/5ml........... 6amoxicillin & k clavulanate for susp 250-62.5 mg/5ml(Augmentin).........................................................................6

amoxicillin & k clavulanate for susp 600-42.9 mg/5ml(Augmentin es-600)............................................................ 6

amoxicillin & k clavulanate tab 250-125 mg........................6amoxicillin & k clavulanate tab 500-125 mg(Augmentin).........................................................................6

amoxicillin & k clavulanate tab 875-125 mg(Augmentin).........................................................................6

AMOXICILLIN – amoxicillin (trihydrate) chew tab 125mg........................................................................................6

AMOXICILLIN – amoxicillin (trihydrate) chew tab 250mg........................................................................................6

amoxicillin (trihydrate) cap 250 mg......................................6amoxicillin (trihydrate) cap 500 mg......................................6amoxicillin (trihydrate) for susp 125 mg/5ml........................6amoxicillin (trihydrate) for susp 200 mg/5ml........................6amoxicillin (trihydrate) for susp 250 mg/5ml........................6amoxicillin (trihydrate) for susp 400 mg/5ml........................6amoxicillin (trihydrate) tab 875 mg...................................... 6amphetamine-dextroamphetamine cap er 24hr 5 mg(Adderall xr)...................................................................... 61

amphetamine-dextroamphetamine cap er 24hr 10 mg(Adderall xr)...................................................................... 61





amphetamine-dextroamphetamine tab 5 mg(Adderall)...........................................................................62

amphetamine-dextroamphetamine tab 7.5 mg(Adderall)...........................................................................62


amphetamine-dextroamphetamine tab 12.5 mg(Adderall)...........................................................................62

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anagrelide hcl cap 1 mg.................................................... 80anagrelide hcl cap 0.5 mg (Agrylin)...................................80anastrozole tab 1 mg (Arimidex)....................................... 16APLENZIN – bupropion hbr tab er 24hr 174 mg...............52APLENZIN – bupropion hbr tab er 24hr 348 mg...............52APLENZIN – bupropion hbr tab er 24hr 522 mg...............52apraclonidine hcl ophth soln 0.5% (base equivalent)(Iopidine)........................................................................... 83

aprepitant capsule 40 mg (Emend)................................... 48aprepitant capsule 80 mg (Emend)................................... 48aprepitant capsule 125 mg (Emend)................................. 48APTIOM – eslicarbazepine acetate tab 200 mg................72APTIOM – eslicarbazepine acetate tab 400 mg................72APTIOM – eslicarbazepine acetate tab 600 mg................72APTIOM – eslicarbazepine acetate tab 800 mg................72APTIVUS – tipranavir cap 250 mg.................................... 10APTIVUS – tipranavir oral soln 100 mg/ml....................... 10ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25mcg/ml...............................................................................80

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40mcg/ml...............................................................................80

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60mcg/ml...............................................................................80

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj100 mcg/ml....................................................................... 80



ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 10 mcg/0.4ml......................................... 80

ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 25 mcg/0.42ml.......................................80







ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 500 mcg/ml............................................ 80

ARCALYST – rilonacept for inj 220 mg.............................69aripiprazole orally disintegrating tab 10 mg.......................55aripiprazole orally disintegrating tab 15 mg.......................55

aripiprazole oral solution 1 mg/ml......................................55aripiprazole tab 2 mg (Abilify)............................................56aripiprazole tab 5 mg (Abilify)............................................56aripiprazole tab 10 mg (Abilify)..........................................56aripiprazole tab 15 mg (Abilify)..........................................56aripiprazole tab 20 mg (Abilify)..........................................56aripiprazole tab 30 mg (Abilify)..........................................56ARISTADA – aripiprazole lauroxil im er susp prefilled syr441 mg/1.6ml....................................................................56

ARISTADA – aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml....................................................................56

ARISTADA – aripiprazole lauroxil im er susp prefilled syr882 mg/3.2ml....................................................................56

ARISTADA – aripiprazole lauroxil im er susp prefilled syr1064 mg/3.9ml..................................................................56

ARISTADA INITIO – aripiprazole lauroxil im er suspprefilled syr 675 mg/2.4ml................................................56

armodafinil tab 50 mg (Nuvigil)..........................................62armodafinil tab 150 mg (Nuvigil)........................................62armodafinil tab 200 mg (Nuvigil)........................................62armodafinil tab 250 mg (Nuvigil)........................................62ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 50 mcg/act....................................................45

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 100 mcg/act..................................................45

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 200 mcg/act..................................................45

atazanavir sulfate cap 150 mg (base equiv) (Reyataz).....10atazanavir sulfate cap 200 mg (base equiv) (Reyataz).....10atazanavir sulfate cap 300 mg (base equiv) (Reyataz).....10atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)......35atenolol & chlorthalidone tab 100-25 mg (Tenoretic100)................................................................................... 35

atenolol tab 25 mg (Tenormin).......................................... 35atenolol tab 50 mg (Tenormin).......................................... 35atenolol tab 100 mg (Tenormin)........................................ 35atomoxetine hcl cap 10 mg (base equiv) (Strattera)......... 62atomoxetine hcl cap 18 mg (base equiv) (Strattera)......... 62atomoxetine hcl cap 25 mg (base equiv) (Strattera)......... 62atomoxetine hcl cap 40 mg (base equiv) (Strattera)......... 62atomoxetine hcl cap 60 mg (base equiv) (Strattera)......... 62atomoxetine hcl cap 80 mg (base equiv) (Strattera)......... 62atomoxetine hcl cap 100 mg (base equiv) (Strattera)....... 62atorvastatin calcium tab 10 mg (base equivalent)(Lipitor).............................................................................. 38

atorvastatin calcium tab 20 mg (base equivalent)(Lipitor).............................................................................. 39



atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)...... 13atovaquone-proguanil hcl tab 250-100 mg (Malarone)..... 13ATRIPLA – efavirenz-emtricitabine-tenofovir df tab600-200-300 mg............................................................... 10

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ATROPINE SULFATE – atropine sulfate ophth oint1%..................................................................................... 84

ATROPINE SULFATE – atropine sulfate ophth soln1%..................................................................................... 84

ATROVENT HFA – ipratropium bromide hfa inhal aerosol17 mcg/act........................................................................ 45

AUBAGIO – teriflunomide tab 7 mg.................................. 64AUBAGIO – teriflunomide tab 14 mg................................ 64AUGMENTED BETAMETHASONE D – betamethasonedipropionate augmented gel 0.05%.................................87

AVONEX – interferon beta-1a im prefilled syringe kit 30mcg/0.5ml..........................................................................64

AVONEX PEN – interferon beta-1a im auto-injector kit 30mcg/0.5ml..........................................................................64

azathioprine tab 50 mg (Imuran)....................................... 91azelaic acid gel 15% (Finacea)......................................... 85azelastine hcl nasal spray 0.1% (137 mcg/spray).............44azelastine hcl ophth soln 0.05%........................................84AZITHROMYCIN – azithromycin powd pack for susp 1gm........................................................................................7

azithromycin for susp 100 mg/5ml (Zithromax)...................7azithromycin for susp 200 mg/5ml (Zithromax)...................7azithromycin tab 250 mg (Zithromax)..................................7azithromycin tab 500 mg (Zithromax)..................................7azithromycin tab 600 mg (Zithromax)..................................7

BBACITRACIN – bacitracin ophth oint 500 unit/gm............ 83bacitracin-polymyxin b ophth oint...................................... 83bacitracin-polymyxin-neomycin-hc ophth oint 1%............. 83baclofen tab 10 mg............................................................ 76baclofen tab 20 mg............................................................ 76balsalazide disodium cap 750 mg (Colazal)......................49BALVERSA – erdafitinib tab 3 mg.....................................16BALVERSA – erdafitinib tab 4 mg.....................................16BALVERSA – erdafitinib tab 5 mg.....................................17BARACLUDE – entecavir oral soln 0.05 mg/ml.................. 9BASAGLAR KWIKPEN – insulin glargine soln pen-injector100 unit/ml........................................................................ 29

b-complex w/ c & folic acid cap 1 mg (Nephrocaps)......... 77b-complex w/ c & folic acid tab..........................................77b-complex w/ c & folic acid tab 5 mg................................ 77b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx).......77benazepril & hydrochlorothiazide tab 5-6.25 mg...............32benazepril & hydrochlorothiazide tab 10-12.5 mg(Lotensin hct)....................................................................32

benazepril & hydrochlorothiazide tab 20-12.5 mg(Lotensin hct)....................................................................32

benazepril & hydrochlorothiazide tab 20-25 mg (Lotensinhct).....................................................................................32

benazepril hcl tab 5 mg..................................................... 32benazepril hcl tab 10 mg (Lotensin)..................................32benazepril hcl tab 20 mg (Lotensin)..................................32benazepril hcl tab 40 mg (Lotensin)..................................32BENZNIDAZOLE – benznidazole tab 12.5 mg................. 13BENZNIDAZOLE – benznidazole tab 100 mg.................. 14

benzoyl peroxide cloth 6%.................................................85benzoyl peroxide-erythromycin gel 5-3%(Benzamycin).................................................................... 85

benztropine mesylate tab 0.5 mg...................................... 75benztropine mesylate tab 1 mg......................................... 75benztropine mesylate tab 2 mg......................................... 75betamethasone dipropionate augmented cream 0.05%(Diprolene af)....................................................................87

betamethasone dipropionate augmented lotion 0.05%(Diprolene)........................................................................ 87

betamethasone dipropionate augmented oint 0.05%(Diprolene)........................................................................ 87

betamethasone dipropionate cream 0.05%.......................87betamethasone dipropionate lotion 0.05%........................87betamethasone dipropionate oint 0.05%...........................87betamethasone valerate cream 0.1% (baseequivalent).........................................................................87

betamethasone valerate lotion 0.1% (baseequivalent).........................................................................87

betamethasone valerate oint 0.1% (base equivalent).......87betaxolol hcl ophth soln 0.5%............................................83betaxolol hcl tab 10 mg (Kerlone)..................................... 35betaxolol hcl tab 20 mg (Kerlone)..................................... 35bethanechol chloride tab 5 mg (Urecholine)..................... 50bethanechol chloride tab 10 mg (Urecholine)................... 50bethanechol chloride tab 25 mg (Urecholine)................... 50bethanechol chloride tab 50 mg (Urecholine)................... 50BEVESPI AEROSPHERE – glycopyrrolate-formoterolfumarate aerosol 9-4.8 mcg/act.......................................45

bexarotene cap 75 mg (Targretin)..................................... 17bicalutamide tab 50 mg (Casodex)....................................17BIKTARVY – bictegravir-emtricitabine-tenofovir af tab50-200-25 mg................................................................... 10

bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for solnkit....................................................................................... 47

bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg(Ziac)................................................................................. 35

bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)......35bisoprolol & hydrochlorothiazide tab 10-6.25 mg(Ziac)................................................................................. 35

bisoprolol fumarate tab 5 mg (Zebeta)..............................35bisoprolol fumarate tab 10 mg (Zebeta)............................35BOOSTRIX – tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml.......................................................................15

bosentan tab 62.5 mg (Tracleer)....................................... 42bosentan tab 125 mg (Tracleer)........................................ 42BOSULIF – bosutinib tab 100 mg..................................... 17BOSULIF – bosutinib tab 500 mg..................................... 17BRAFTOVI – encorafenib cap 75 mg................................17BREATHERITE...................................................................91BRILINTA – ticagrelor tab 60 mg...................................... 80BRILINTA – ticagrelor tab 90 mg...................................... 80brimonidine tartrate ophth soln 0.2%.................................84bromocriptine mesylate cap 5 mg (base equivalent).........75bromocriptine mesylate tab 2.5 mg (base equivalent)(Parlodel)...........................................................................75

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budesonide delayed release particles cap 3 mg (Entocortec)......................................................................................24

budesonide inhalation susp 0.25 mg/2ml (Pulmicort)....... 45budesonide inhalation susp 0.5 mg/2ml (Pulmicort)......... 45budesonide inhalation susp 1 mg/2ml (Pulmicort)............ 45bumetanide tab 0.5 mg (Bumex).......................................40bumetanide tab 1 mg (Bumex)..........................................40bumetanide tab 2 mg (Bumex)..........................................40BUPHENYL – sodium phenylbutyrate tab 500 mg............30buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (baseequiv) (Suboxone)............................................................ 66

buprenorphine hcl-naloxone hcl sl film 4-1 mg (baseequiv) (Suboxone)............................................................ 66



buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (baseequiv).................................................................................66

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (baseequiv).................................................................................66

buprenorphine hcl sl tab 2 mg (base equiv)......................65buprenorphine hcl sl tab 8 mg (base equiv)......................65bupropion hcl (smoking deterrent) tab er 12hr 150 mg(Zyban).............................................................................. 64

bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)..............52bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)..............52bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)..............52bupropion hcl tab er 24hr 150 mg (Wellbutrin xl).............. 52bupropion hcl tab er 24hr 300 mg (Wellbutrin xl).............. 52bupropion hcl tab 75 mg....................................................52bupropion hcl tab 100 mg..................................................53BUPROPION HYDROCHLORIDE E – bupropion hcl taber 24hr 450 mg.................................................................53

buspirone hcl tab 5 mg...................................................... 51buspirone hcl tab 10 mg....................................................51buspirone hcl tab 15 mg....................................................51buspirone hcl tab 30 mg....................................................51butalbital-acetaminophen-caffeine cap 50-300-40 mg(Fioricet)............................................................................ 65

butalbital-acetaminophen-caffeine tab 50-325-40 mg(Esgic)............................................................................... 65

butalbital-acetaminophen-caff w/ cod cap 50-325-40-30mg......................................................................................66

butalbital-acetaminophen tab 50-325 mg..........................65butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal).....65butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg(Fiorinal/codeine #3).........................................................66

butorphanol tartrate nasal soln 10 mg/ml..........................66

Ccabergoline tab 0.5 mg...................................................... 30CABOMETYX – cabozantinib s-malate tab 20 mg (baseequivalent).........................................................................17

CABOMETYX – cabozantinib s-malate tab 40 mg (baseequivalent).........................................................................17

CABOMETYX – cabozantinib s-malate tab 60 mg (baseequivalent).........................................................................17

caffeine citrate oral soln 60 mg/3ml (10 mg/ml baseequiv).................................................................................62

calcipotriene cream 0.005% (Dovonex)............................ 89calcipotriene oint 0.005%...................................................89calcipotriene soln 0.005% (50 mcg/ml)............................. 89calcitonin (salmon) nasal soln 200 unit/act (Miacalcin).....31calcitriol cap 0.25 mcg (Rocaltrol)..................................... 31calcitriol cap 0.5 mcg (Rocaltrol)....................................... 31calcitriol oral soln 1 mcg/ml (Rocaltrol)............................. 31calcium acetate (phosphate binder) cap 667 mg (169 mgca) (Phoslo)...................................................................... 49

calcium acetate (phosphate binder) tab 667 mg(Eliphos)............................................................................ 49

CALQUENCE – acalabrutinib cap 100 mg........................17capecitabine tab 150 mg (Xeloda).....................................17capecitabine tab 500 mg (Xeloda).....................................17CAPRELSA – vandetanib tab 100 mg.............................. 17CAPRELSA – vandetanib tab 300 mg.............................. 17CAPTOPRIL/HYDROCHLOROTHIA – captopril &hydrochlorothiazide tab 25-15 mg................................... 32

CAPTOPRIL/HYDROCHLOROTHIA – captopril &hydrochlorothiazide tab 25-25 mg................................... 32



captopril tab 12.5 mg......................................................... 32captopril tab 25 mg............................................................ 32captopril tab 50 mg............................................................ 32captopril tab 100 mg.......................................................... 32CARBAGLU – carglumic acid tab 200 mg........................ 31carbamazepine cap er 12hr 100 mg (Carbatrol)............... 72carbamazepine cap er 12hr 200 mg (Carbatrol)............... 72carbamazepine cap er 12hr 300 mg (Carbatrol)............... 72carbamazepine chew tab 100 mg..................................... 72carbamazepine susp 100 mg/5ml (Tegretol).....................72carbamazepine tab er 12hr 100 mg (Tegretol-xr)..............72carbamazepine tab er 12hr 200 mg (Tegretol-xr)..............72carbamazepine tab er 12hr 400 mg (Tegretol-xr)..............72carbamazepine tab 200 mg (Tegretol).............................. 72carbidopa & levodopa orally disintegrating tab 10-100mg......................................................................................75

carbidopa & levodopa orally disintegrating tab 25-100mg......................................................................................75

carbidopa & levodopa orally disintegrating tab 25-250mg......................................................................................75

carbidopa & levodopa tab er 25-100 mg (Sinemet cr)...... 75carbidopa & levodopa tab er 50-200 mg (Sinemet cr)...... 75carbidopa & levodopa tab 10-100 mg (Sinemet)...............75carbidopa & levodopa tab 25-100 mg (Sinemet)...............75carbidopa & levodopa tab 25-250 mg (Sinemet)...............75carbidopa tab 25 mg (Lodosyn).........................................75carbinoxamine maleate soln 4 mg/5ml..............................44carbinoxamine maleate tab 4 mg...................................... 44

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carisoprodol tab 250 mg (Soma).......................................76CARTEOLOL HCL – carteolol hcl ophth soln 1%............. 84carvedilol tab 3.125 mg (Coreg)........................................35carvedilol tab 6.25 mg (Coreg)..........................................35carvedilol tab 12.5 mg (Coreg)..........................................35carvedilol tab 25 mg (Coreg).............................................35CAYSTON – aztreonam lysine for inhal soln 75 mg (baseequivalent).........................................................................14

cefaclor cap 250 mg............................................................ 6cefaclor cap 500 mg............................................................ 6cefadroxil cap 500 mg..........................................................6cefadroxil for susp 250 mg/5ml........................................... 6cefadroxil for susp 500 mg/5ml........................................... 6cefadroxil tab 1 gm.............................................................. 6cefdinir cap 300 mg............................................................. 6cefdinir for susp 125 mg/5ml............................................... 7cefdinir for susp 250 mg/5ml............................................... 7cefixime for susp 100 mg/5ml (Suprax)...............................7cefixime for susp 200 mg/5ml (Suprax)...............................7cefprozil for susp 125 mg/5ml............................................. 7cefprozil for susp 250 mg/5ml............................................. 7cefprozil tab 250 mg............................................................ 7cefprozil tab 500 mg............................................................ 7ceftriaxone sodium for inj 1 gm........................................... 7ceftriaxone sodium for inj 2 gm........................................... 7ceftriaxone sodium for inj 250 mg....................................... 7ceftriaxone sodium for inj 500 mg....................................... 7cefuroxime axetil tab 250 mg.............................................. 7cefuroxime axetil tab 500 mg (Ceftin)................................. 7celecoxib cap 50 mg (Celebrex)........................................69celecoxib cap 100 mg (Celebrex)......................................69celecoxib cap 200 mg (Celebrex)......................................69celecoxib cap 400 mg (Celebrex)......................................69CEM-UREA – urea soln 45%............................................ 89cephalexin cap 250 mg (Keflex)..........................................7cephalexin cap 500 mg (Keflex)..........................................7cephalexin for susp 125 mg/5ml..........................................7cephalexin for susp 250 mg/5ml..........................................7CERAMAX – dermatological products misc - cream.........89cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)........................44CHANTIX CONTINUING MONTH – varenicline tartratetab 1 mg (base equiv)......................................................64

CHANTIX STARTING MONTH PA – varenicline tartratetab 0.5 mg x 11 & tab 1 mg x 42 pack............................ 64

CHANTIX – varenicline tartrate tab 0.5 mg (baseequiv).................................................................................64

CHANTIX – varenicline tartrate tab 1 mg (base equiv)..... 64CHEMET – succimer cap 100 mg.....................................91CHENODAL – chenodiol tab 250 mg................................49CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide-amitriptyline tab 5-12.5 mg.............................................. 64

CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide-amitriptyline tab 10-25 mg............................................... 64

chlordiazepoxide hcl cap 5 mg..........................................51chlordiazepoxide hcl cap 10 mg........................................51chlordiazepoxide hcl cap 25 mg........................................52

chlorhexidine gluconate soln 0.12% (Peridex).................. 85chloroquine phosphate tab 500 mg (Aralen).....................13CHLOROTHIAZIDE – chlorothiazide tab 250 mg............. 40CHLOROTHIAZIDE – chlorothiazide tab 500 mg............. 40CHLORPROMAZINE HCL – chlorpromazine hcl inj 50mg/2ml...............................................................................56

chlorpromazine hcl tab 10 mg........................................... 56chlorpromazine hcl tab 25 mg........................................... 56chlorpromazine hcl tab 50 mg........................................... 56chlorpromazine hcl tab 100 mg......................................... 56chlorpromazine hcl tab 200 mg......................................... 56chlorthalidone tab 25 mg................................................... 40CHLORZOXAZONE – chlorzoxazone tab 500 mg............76CHOLBAM – cholic acid cap 50 mg..................................49CHOLBAM – cholic acid cap 250 mg................................49cholecalciferol cap 5000 unit............................................. 76cholestyramine light powder 4 gm/dose (Questranlight)...................................................................................39

cholestyramine light powder packets 4 gm....................... 39cholestyramine powder 4 gm/dose (Questran)................. 39cholestyramine powder packets 4 gm (Questran).............39choline fenofibrate cap dr 45 mg (fenofibric acid equiv)(Trilipix)..............................................................................39

ciclopirox olamine cream 0.77% (base equiv)(Loprox).............................................................................86

ciclopirox olamine susp 0.77% (base equiv).....................86ciclopirox solution 8% (Penlac Nail Lacquer)....................86cilostazol tab 50 mg...........................................................80cilostazol tab 100 mg.........................................................80CIMDUO – lamivudine-tenofovir disoproxil fumarate tab300-300 mg.......................................................................10

CIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml........47CIMZIA – certolizumab pegol inj kit 2 x 200 mg/ml...........49CIMZIA STARTER KIT – certolizumab pegol inj kit 6 x 200mg/ml.................................................................................49

cinacalcet hcl tab 30 mg (base equiv)...............................31cinacalcet hcl tab 60 mg (base equiv)...............................31cinacalcet hcl tab 90 mg (base equiv)...............................31ciprofloxacin for oral susp 500 mg/5ml (10%) (10gm/100ml) (Cipro)...............................................................8

ciprofloxacin hcl ophth soln 0.3% (base equivalent)(Ciloxan)............................................................................83

ciprofloxacin hcl tab 750 mg (base equiv)...........................8ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)...............8ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)...............8citalopram hydrobromide oral soln 10 mg/5ml.................. 53citalopram hydrobromide tab 10 mg (base equiv)(Celexa).............................................................................53

citalopram hydrobromide tab 20 mg (base equiv)(Celexa).............................................................................53

citalopram hydrobromide tab 40 mg (base equiv)(Celexa).............................................................................53

clarithromycin tab 250 mg (Biaxin)......................................7clarithromycin tab 500 mg (Biaxin)......................................7CLASSIC PRENATAL – prenatal vit w/ fe fumarate-fa tab28-0.8 mg..........................................................................77

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CLINDACIN ETZ PLEDGETS – clindamycin phosphateswab 1%........................................................................... 85

CLINDACIN-P – clindamycin phosphate swab 1%...........85clindamycin hcl cap 75 mg (Cleocin).................................14clindamycin hcl cap 150 mg (Cleocin)...............................14clindamycin hcl cap 300 mg (Cleocin)...............................14clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)(Cleocin pediatric gr)........................................................ 14

CLINDAMYCIN PHOSPHATE – clindamycin phosphateswab 1%........................................................................... 86

clindamycin phosphate gel 1% (Cleocin-t)........................ 86clindamycin phosphate lotion 1% (Cleocin-t).................... 86clindamycin phosphate soln 1% (Cleocin-t)...................... 86clindamycin phosphate vaginal cream 2% (Cleocin).........50clindamycin phosph-benzoyl peroxide (refrig) gel 1.2(1)-5% (Duac)................................................................... 85

clobetasol propionate emollient base cream 0.05%(Temovate e).....................................................................87

clobetasol propionate soln 0.05% (Temovate).................. 87clonazepam orally disintegrating tab 0.125 mg.................72clonazepam orally disintegrating tab 0.25 mg...................72clonazepam orally disintegrating tab 0.5 mg.....................72clonazepam orally disintegrating tab 1 mg........................72clonazepam orally disintegrating tab 2 mg........................72clonazepam tab 0.5 mg (Klonopin)....................................73clonazepam tab 1 mg (Klonopin).......................................73clonazepam tab 2 mg (Klonopin).......................................73clonidine hcl tab er 12hr 0.1 mg (Kapvay)........................ 62clonidine hcl tab 0.1 mg (Catapres).................................. 42clonidine hcl tab 0.2 mg (Catapres).................................. 42clonidine hcl tab 0.3 mg (Catapres).................................. 42clonidine td patch weekly 0.1 mg/24hr (Catapres-tts-1).................................................................................. 42

clonidine td patch weekly 0.2 mg/24hr (Catapres-tts-2).................................................................................. 42

clonidine td patch weekly 0.3 mg/24hr (Catapres-tts-3).................................................................................. 42

clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)........81clopidogrel bisulfate tab 300 mg (base equiv) (Plavix)......81clorazepate dipotassium tab 3.75 mg................................52clorazepate dipotassium tab 15 mg...................................52clorazepate dipotassium tab 7.5 mg (Tranxene t)............. 52clotrimazole cream 1%.......................................................86clotrimazole soln 1%.......................................................... 86clotrimazole troche 10 mg................................................. 85clotrimazole w/ betamethasone cream 1-0.05%(Lotrisone)......................................................................... 86

CLOZAPINE ODT – clozapine orally disintegrating tab150 mg..............................................................................56

CLOZAPINE ODT – clozapine orally disintegrating tab200 mg..............................................................................56

clozapine orally disintegrating tab 12.5 mg (Fazaclo).......56clozapine orally disintegrating tab 25 mg (Fazaclo)..........56clozapine orally disintegrating tab 100 mg (Fazaclo)........56clozapine tab 50 mg...........................................................56clozapine tab 200 mg.........................................................56

clozapine tab 25 mg (Clozaril)...........................................56clozapine tab 100 mg (Clozaril).........................................56codeine sulfate tab 30 mg (Codeine sulfate).................... 66COLCHICINE – colchicine cap 0.6 mg............................. 72colchicine w/ probenecid tab 0.5-500 mg..........................72colestipol hcl granule packets 5 gm (Colestidflavored)............................................................................ 39

colestipol hcl granules 5 gm (Colestid flavored)................39colestipol hcl tab 1 gm (Colestid)...................................... 39COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.14 mg/day..............................................................25

COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.25 mg/day..............................................................25

COMBIVENT RESPIMAT – ipratropium-albuterol inhalaerosol soln 20-100 mcg/act............................................45

COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60mg dose) kit......................................................................17

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20mg (100 dose) kit............................................................. 17

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20mg (140 dose) kit............................................................. 17

COMPLERA – emtricitabine-rilpivirine-tenofovir df tab200-25-300 mg................................................................. 10

COPIKTRA – duvelisib cap 15 mg....................................17COPIKTRA – duvelisib cap 25 mg....................................17CORTISONE ACETATE – cortisone acetate tab 25mg......................................................................................24

CORVITA – multiple vitamins w/ minerals & fa tab 1.25mg......................................................................................77

COSENTYX – secukinumab subcutaneous soln prefilledsyringe 150 mg/ml............................................................89

COSENTYX SENSOREADY PEN – secukinumabsubcutaneous soln auto-injector 150 mg/ml....................89

COTELLIC – cobimetinib fumarate tab 20 mg (baseequivalent).........................................................................17

CREON – pancrelipase (lip-prot-amyl) dr cap3000-9500-15000 unit...................................................... 48

CREON – pancrelipase (lip-prot-amyl) dr cap6000-19000-30000 unit.................................................... 49

CREON – pancrelipase (lip-prot-amyl) dr cap12000-38000-60000 unit.................................................. 49

CREON – pancrelipase (lip-prot-amyl) dr cap24000-76000-120000 unit................................................ 49

CREON – pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit.............................................. 49

CRIXIVAN – indinavir sulfate cap 200 mg.........................10CRIXIVAN – indinavir sulfate cap 400 mg.........................10cromolyn sodium ophth soln 4%....................................... 84CUTTER BACKWOODS – diethyltoluamide (deet)aerosol...............................................................................89

CUTTER SKINSATIONS – diethyltoluamide (deet)liquid.................................................................................. 89

CVS PRENATAL – prenatal vit w/ fe fumarate-fa tab27-0.8 mg..........................................................................77

cyanocobalamin inj 1000 mcg/ml...................................... 81cyclobenzaprine hcl tab 5 mg............................................76

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cyclobenzaprine hcl tab 10 mg..........................................76cyclopentolate hcl ophth soln 0.5% (Cyclogyl)..................84cyclopentolate hcl ophth soln 1% (Cyclogyl).....................84cyclopentolate hcl ophth soln 2% (Cyclogyl).....................84cyclophosphamide cap 25 mg (Cyclophosphamide).........17cyclophosphamide cap 50 mg (Cyclophosphamide).........17cyclosporine cap 25 mg (Sandimmune)............................91cyclosporine cap 100 mg (Sandimmune)..........................91cyclosporine modified cap 25 mg (Neoral)........................91cyclosporine modified cap 100 mg (Neoral)......................91CYCLOSPORINE MODIFIED – cyclosporine modified cap50 mg................................................................................ 91

cyclosporine modified oral soln 100 mg/ml (Neoral)......... 91cyproheptadine hcl syrup 2 mg/5ml...................................44cyproheptadine hcl tab 4 mg............................................. 44CYSTADANE – betaine powder for oral solution.............. 31CYSTAGON – cysteamine bitartrate cap 50 mg............... 51CYSTAGON – cysteamine bitartrate cap 150 mg............. 51

Ddanazol cap 50 mg............................................................ 25danazol cap 100 mg.......................................................... 25danazol cap 200 mg.......................................................... 25dantrolene sodium cap 100 mg.........................................76dantrolene sodium cap 25 mg (Dantrium).........................76dantrolene sodium cap 50 mg (Dantrium).........................76dapsone tab 25 mg............................................................14dapsone tab 100 mg..........................................................14DARAPRIM – pyrimethamine tab 25 mg...........................13darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv)(Enablex)...........................................................................50

darifenacin hydrobromide tab er 24hr 15 mg (base equiv)(Enablex)...........................................................................50

DAURISMO – glasdegib maleate tab 25 mg (baseequivalent).........................................................................17

DAURISMO – glasdegib maleate tab 100 mg (baseequivalent).........................................................................17

deferasirox tab for oral susp 125 mg (Exjade).................. 91deferasirox tab for oral susp 250 mg (Exjade).................. 91deferasirox tab for oral susp 500 mg (Exjade).................. 91DELSTRIGO – doravirine-lamivudine-tenofovir df tab100-300-300 mg............................................................... 10

demeclocycline hcl tab 150 mg........................................... 7demeclocycline hcl tab 300 mg........................................... 7DEPEN TITRATABS – penicillamine tab 250 mg..............91DESCOVY – emtricitabine-tenofovir alafenamide fumaratetab 200-25 mg.................................................................. 10

desipramine hcl tab 50 mg................................................ 53desipramine hcl tab 75 mg................................................ 53desipramine hcl tab 100 mg.............................................. 53desipramine hcl tab 150 mg.............................................. 53desipramine hcl tab 10 mg (Norpramin)............................53desipramine hcl tab 25 mg (Norpramin)............................53desloratadine tab 5 mg (Clarinex)..................................... 44desmopressin acetate nasal spray soln 0.01%(Ddavp)..............................................................................31

desmopressin acetate nasal spray soln 0.01%(refrigerated)..................................................................... 31

desmopressin acetate tab 0.1 mg (Ddavp)....................... 31desmopressin acetate tab 0.2 mg (Ddavp)....................... 31desonide cream 0.05% (Desowen)................................... 87desonide oint 0.05%.......................................................... 87desoximetasone cream 0.25% (Topicort)..........................87desoximetasone gel 0.05% (Topicort)............................... 87DEXAMETHASONE – dexamethasone soln 0.5mg/5ml...............................................................................24

dexamethasone elixir 0.5 mg/5ml......................................24DEXAMETHASONE SODIUM PHOS – dexamethasonesodium phosphate ophth soln 0.1%................................ 83

dexamethasone tab 0.5 mg............................................... 24dexamethasone tab 0.75 mg.............................................24dexamethasone tab 1.5 mg............................................... 24dexamethasone tab 4 mg.................................................. 24dexamethasone tab 6 mg.................................................. 24dexmethylphenidate hcl cap er 24 hr 5 mg (Focalinxr)...................................................................................... 62

dexmethylphenidate hcl cap er 24 hr 10 mg (Focalinxr)...................................................................................... 62





dexmethylphenidate hcl tab 2.5 mg (Focalin)................... 62dexmethylphenidate hcl tab 5 mg (Focalin)...................... 62dexmethylphenidate hcl tab 10 mg (Focalin).................... 62dextroamphetamine sulfate cap er 24hr 5 mg(Dexedrine)....................................................................... 62

dextroamphetamine sulfate cap er 24hr 10 mg(Dexedrine)....................................................................... 62

dextroamphetamine sulfate cap er 24hr 15 mg(Dexedrine)....................................................................... 62

dextroamphetamine sulfate oral solution 5 mg/5ml(Procentra)........................................................................ 63

dextroamphetamine sulfate tab 5 mg................................63dextroamphetamine sulfate tab 10 mg..............................63diazepam conc 5 mg/ml.....................................................52DIAZEPAM – diazepam oral soln 1 mg/ml........................52diazepam tab 2 mg (Valium)..............................................52diazepam tab 5 mg (Valium)..............................................52diazepam tab 10 mg (Valium)............................................52diclofenac potassium tab 50 mg........................................69diclofenac sodium gel 1% (Voltaren).................................86diclofenac sodium ophth soln 0.1%...................................84diclofenac sodium tab delayed release 50 mg..................69diclofenac sodium tab delayed release 75 mg..................69diclofenac sodium tab er 24hr 100 mg..............................69dicloxacillin sodium cap 250 mg..........................................6dicloxacillin sodium cap 500 mg..........................................6

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dicyclomine hcl cap 10 mg (Bentyl)...................................47dicyclomine hcl oral soln 10 mg/5ml................................. 47dicyclomine hcl tab 20 mg (Bentyl)................................... 47didanosine delayed release capsule 200 mg (Videxec)......................................................................................10

didanosine delayed release capsule 250 mg (Videxec)......................................................................................10

didanosine delayed release capsule 400 mg (Videxec)......................................................................................10

DIGOXIN – digoxin oral soln 0.05 mg/ml.......................... 42digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................... 42digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................... 42DILANTIN – phenytoin sodium extended cap 30 mg........73diltiazem hcl cap er 12hr 60 mg........................................36diltiazem hcl cap er 12hr 90 mg........................................36diltiazem hcl cap er 12hr 120 mg......................................36diltiazem hcl cap er 24hr 180 mg......................................36diltiazem hcl cap er 24hr 240 mg......................................36diltiazem hcl coated beads cap er 24hr 300 mg............... 37diltiazem hcl coated beads cap er 24hr 120 mg (Cardizemcd)......................................................................................36

diltiazem hcl coated beads cap er 24hr 180 mg (Cardizemcd)......................................................................................36

diltiazem hcl coated beads cap er 24hr 240 mg (Cardizemcd)......................................................................................37

diltiazem hcl extended release beads cap er 24hr 120 mg(Tiazac)............................................................................. 37






diltiazem hcl tab 90 mg......................................................37diltiazem hcl tab 30 mg (Cardizem)...................................37diltiazem hcl tab 60 mg (Cardizem)...................................37diltiazem hcl tab 120 mg (Cardizem).................................37DILT-XR – diltiazem hcl cap er 24hr 120 mg.................... 36diphenhydramine hcl cap 50 mg....................................... 44diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)...... 47dipyridamole tab 25 mg..................................................... 81dipyridamole tab 50 mg..................................................... 81dipyridamole tab 75 mg..................................................... 81disopyramide phosphate cap 100 mg (Norpace).............. 41disopyramide phosphate cap 150 mg (Norpace).............. 41disulfiram tab 250 mg (Antabuse)..................................... 64disulfiram tab 500 mg (Antabuse)..................................... 64divalproex sodium cap delayed release sprinkle 125 mg(Depakote sprinkles).........................................................73

divalproex sodium tab delayed release 125 mg(Depakote)........................................................................ 73



divalproex sodium tab er 24 hr 250 mg (Depakote er)......73divalproex sodium tab er 24 hr 500 mg (Depakote er)......73dofetilide cap 125 mcg (0.125 mg) (Tikosyn)....................41dofetilide cap 250 mcg (0.25 mg) (Tikosyn)......................41dofetilide cap 500 mcg (0.5 mg) (Tikosyn)........................41donepezil hydrochloride orally disintegrating tab 5 mg..... 64donepezil hydrochloride orally disintegrating tab 10mg......................................................................................64

donepezil hydrochloride tab 5 mg (Aricept).......................64donepezil hydrochloride tab 10 mg (Aricept).....................64dorzolamide hcl ophth soln 2% (Trusopt)..........................84dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt)....................................................................... 84

DOVATO – dolutegravir sodium-lamivudine tab 50-300 mg(base eq)...........................................................................11

doxazosin mesylate tab 1 mg (Cardura)........................... 42doxazosin mesylate tab 2 mg (Cardura)........................... 42doxazosin mesylate tab 4 mg (Cardura)........................... 42doxazosin mesylate tab 8 mg (Cardura)........................... 42doxepin hcl cap 10 mg...................................................... 53doxepin hcl cap 25 mg...................................................... 53doxepin hcl cap 50 mg...................................................... 53doxepin hcl cap 75 mg...................................................... 53doxepin hcl cap 100 mg.................................................... 53doxepin hcl conc 10 mg/ml................................................53DOXEPIN HCL – doxepin hcl cap 150 mg........................53doxycycline hyclate cap 50 mg............................................7doxycycline hyclate cap 100 mg (Vibramycin).................... 7doxycycline hyclate tab delayed release 50 mg (Doryx).....7doxycycline hyclate tab 20 mg............................................ 7doxycycline hyclate tab 100 mg.......................................... 7doxycycline monohydrate cap 50 mg..................................8doxycycline monohydrate cap 100 mg (Monodox)..............8doxycycline monohydrate for susp 25 mg/5ml(Vibramycin)........................................................................ 8

doxycycline monohydrate tab 50 mg (Adoxa).....................8doxycycline monohydrate tab 75 mg (Adoxa).....................8doxycycline monohydrate tab 100 mg (Adoxa pak1/100).................................................................................. 8

DROXIA – hydroxyurea cap 200 mg.................................81DROXIA – hydroxyurea cap 300 mg.................................81DROXIA – hydroxyurea cap 400 mg.................................81duloxetine hcl enteric coated pellets cap 20 mg (base eq)(Cymbalta).........................................................................53

duloxetine hcl enteric coated pellets cap 30 mg (base eq)(Cymbalta).........................................................................53

duloxetine hcl enteric coated pellets cap 60 mg (base eq)(Cymbalta).........................................................................53

dutasteride cap 0.5 mg (Avodart)...................................... 51dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)............51dyphylline-guaifenesin liqd 100-100 mg/5ml..................... 45

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EEDURANT – rilpivirine hcl tab 25 mg (baseequivalent).........................................................................11

efavirenz cap 50 mg (Sustiva)...........................................11efavirenz cap 200 mg (Sustiva).........................................11efavirenz tab 600 mg (Sustiva)..........................................11EFFERVESCENT POTASSIUM/CH – pot bicarbonate &chloride effer tab 25 meq.................................................79

ELIGARD – leuprolide acetate for subcutaneous inj kit 7.5mg......................................................................................18

ELIGARD – leuprolide acetate (3 month) forsubcutaneous inj kit 22.5mg............................................ 18

ELIGARD – leuprolide acetate (4 month) forsubcutaneous inj kit 30 mg.............................................. 18

ELIGARD – leuprolide acetate (6 month) forsubcutaneous inj kit 45 mg.............................................. 18

ELIQUIS – apixaban tab 2.5 mg....................................... 81ELIQUIS – apixaban tab 5 mg.......................................... 81ELIQUIS STARTER PACK – apixaban tab 5 mg.............. 81ELLA – ulipristal acetate tab 30 mg.................................. 26EMSAM – selegiline td patch 24hr 6 mg/24hr...................53EMSAM – selegiline td patch 24hr 9 mg/24hr...................53EMSAM – selegiline td patch 24hr 12 mg/24hr.................53EMTRIVA – emtricitabine caps 200 mg............................ 11EMTRIVA – emtricitabine soln 10 mg/ml...........................11enalapril maleate & hydrochlorothiazide tab 5-12.5mg......................................................................................33

enalapril maleate & hydrochlorothiazide tab 10-25 mg(Vaseretic)......................................................................... 33

enalapril maleate tab 2.5 mg (Vasotec).............................33enalapril maleate tab 5 mg (Vasotec)............................... 33enalapril maleate tab 10 mg (Vasotec)............................. 33enalapril maleate tab 20 mg (Vasotec)............................. 33ENBREL – etanercept for subcutaneous inj 25 mg...........69ENBREL – etanercept subcutaneous soln prefilled syringe25 mg/0.5ml...................................................................... 69

ENBREL – etanercept subcutaneous soln prefilled syringe50 mg/ml........................................................................... 69

ENBREL MINI – etanercept subcutaneous solutioncartridge 50 mg/ml............................................................69

ENBREL SURECLICK – etanercept subcutaneoussolution auto-injector 50 mg/ml........................................69

ENGERIX-B – hepatitis b vaccine (recombinant) 10mcg/0.5ml..........................................................................15

ENGERIX-B – hepatitis b vaccine (recombinant) 20 mcg/ml.......................................................................................15

ENGERIX-B – hepatitis b vaccine (recombinant) susp 10mcg/0.5ml..........................................................................15

ENGERIX-B – hepatitis b vaccine (recombinant) susp 20mcg/ml...............................................................................15

enoxaparin sodium inj 30 mg/0.3ml (Lovenox)................. 81enoxaparin sodium inj 40 mg/0.4ml (Lovenox)................. 81enoxaparin sodium inj 60 mg/0.6ml (Lovenox)................. 81enoxaparin sodium inj 80 mg/0.8ml (Lovenox)................. 81enoxaparin sodium inj 100 mg/ml (Lovenox).................... 81

enoxaparin sodium inj 120 mg/0.8ml (Lovenox)............... 81enoxaparin sodium inj 150 mg/ml (Lovenox).................... 81entacapone tab 200 mg (Comtan).....................................75entecavir tab 0.5 mg (Baraclude)........................................ 9entecavir tab 1 mg (Baraclude)........................................... 9ENTRESTO – sacubitril-valsartan tab 24-26 mg.............. 37ENTRESTO – sacubitril-valsartan tab 49-51 mg.............. 37ENTRESTO – sacubitril-valsartan tab 97-103 mg............ 37epinastine hcl ophth soln 0.05% (Elestat).........................84epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)(Epipen-jr 2-pak)...............................................................43

epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)(Epipen 2-pak).................................................................. 43

EQL PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...............................................................77

EQUETRO – carbamazepine (antipsychotic) cap er 12hr100 mg..............................................................................56



ergocalciferol cap 50000 unit.............................................76ERIVEDGE – vismodegib cap 150 mg..............................18ERLEADA – apalutamide tab 60 mg.................................18erlotinib hcl tab 25 mg (base equivalent) (Tarceva).......... 18erlotinib hcl tab 100 mg (base equivalent) (Tarceva)........ 18erlotinib hcl tab 150 mg (base equivalent) (Tarceva)........ 18erythromycin ophth oint 5 mg/gm......................................83erythromycin pads 2%....................................................... 86erythromycin soln 2%.........................................................86ESBRIET – pirfenidone cap 267 mg................................. 46escitalopram oxalate soln 5 mg/5ml (base equiv)(Lexapro)...........................................................................53

escitalopram oxalate tab 5 mg (base equiv) (Lexapro).....53escitalopram oxalate tab 10 mg (base equiv)(Lexapro)...........................................................................53

escitalopram oxalate tab 20 mg (base equiv)(Lexapro)...........................................................................53

estazolam tab 1 mg........................................................... 61estazolam tab 2 mg........................................................... 61estradiol & norethindrone acetate tab 0.5-0.1 mg(Activella)...........................................................................25

estradiol & norethindrone acetate tab 1-0.5 mg(Activella)...........................................................................25

estradiol tab 0.5 mg (Estrace)........................................... 25estradiol tab 1 mg (Estrace).............................................. 25estradiol tab 2 mg (Estrace).............................................. 25estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot).................................................................................... 25

estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot).................................................................................... 25



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estradiol td patch weekly 0.025 mg/24hr (Climara)...........25estradiol td patch weekly 0.05 mg/24hr (Climara).............25estradiol td patch weekly 0.06 mg/24hr (Climara).............25estradiol td patch weekly 0.075 mg/24hr (Climara)...........26estradiol td patch weekly 0.1 mg/24hr (Climara)...............26estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)(Climara)............................................................................25

estradiol vaginal cream 0.1 mg/gm (Estrace)....................50estradiol vaginal tab 10 mcg (Vagifem).............................50ESTROGEL – estradiol gel 0.06% (0.75 mg/1.25 gmmetered-dose pump)........................................................ 26

eszopiclone tab 1 mg (Lunesta)........................................ 61eszopiclone tab 2 mg (Lunesta)........................................ 61eszopiclone tab 3 mg (Lunesta)........................................ 61ethambutol hcl tab 100 mg (Myambutol).............................8ethambutol hcl tab 400 mg (Myambutol).............................8ethosuximide cap 250 mg (Zarontin).................................73ethosuximide soln 250 mg/5ml (Zarontin)......................... 73ETIDRONATE DISODIUM – etidronate disodium tab 200mg......................................................................................31

ETOPOSIDE – etoposide cap 50 mg................................18EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg(base equiv)...................................................................... 11

exemestane tab 25 mg (Aromasin)................................... 18EXTAVIA – interferon beta-1b for inj kit 0.3 mg.................64

Ffamciclovir tab 125 mg (Famvir)........................................10famotidine for susp 40 mg/5ml (Pepcid)............................47famotidine tab 20 mg (Pepcid).......................................... 47famotidine tab 40 mg (Pepcid).......................................... 47FANAPT – iloperidone tab 1 mg........................................56FANAPT – iloperidone tab 2 mg........................................56FANAPT – iloperidone tab 4 mg........................................56FANAPT – iloperidone tab 6 mg........................................57FANAPT – iloperidone tab 8 mg........................................57FANAPT – iloperidone tab 10 mg......................................57FANAPT – iloperidone tab 12 mg......................................57FANAPT TITRATION PACK – iloperidone tab 1 mg & 2mg & 4 mg & 6 mg titration pak...................................... 57

FAZACLO – clozapine orally disintegrating tab 150mg......................................................................................57

FAZACLO – clozapine orally disintegrating tab 200mg......................................................................................57

fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1mg......................................................................................81

fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240mg......................................................................................81

fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap(Tandem plus)...................................................................81

felbamate susp 600 mg/5ml (Felbatol)..............................73felbamate tab 400 mg (Felbatol)....................................... 73felbamate tab 600 mg (Felbatol)....................................... 73felodipine tab er 24hr 2.5 mg............................................ 37

felodipine tab er 24hr 5 mg............................................... 37felodipine tab er 24hr 10 mg............................................. 37fenofibrate micronized cap 43 mg..................................... 39fenofibrate micronized cap 67 mg (Lofibra).......................39fenofibrate micronized cap 134 mg (Lofibra).....................39fenofibrate micronized cap 200 mg (Lofibra).....................39fenofibrate tab 54 mg (Lofibra)..........................................39fenofibrate tab 160 mg (Lofibra)........................................39fenofibrate tab 48 mg (Tricor)............................................ 39fenofibrate tab 145 mg (Tricor).......................................... 39fentanyl td patch 72hr 12 mcg/hr (Duragesic)...................66fentanyl td patch 72hr 25 mcg/hr (Duragesic)...................66fentanyl td patch 72hr 50 mcg/hr (Duragesic)...................66fentanyl td patch 72hr 75 mcg/hr (Duragesic)...................66fentanyl td patch 72hr 100 mcg/hr (Duragesic).................66FERRIPROX – deferiprone oral soln 100 mg/ml...............91FERRIPROX – deferiprone tab 500 mg............................91FERRIPROX – deferiprone tab 1000 mg..........................91ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1mg......................................................................................81

ferrous fumarate-folic acid tab 324-1 mg.......................... 81FETZIMA – levomilnacipran hcl cap er 24hr 20 mg (baseequivalent).........................................................................53

FETZIMA – levomilnacipran hcl cap er 24hr 40 mg (baseequivalent).........................................................................53



FETZIMA TITRATION PACK – levomilnacipran hcl cap er24hr 20 & 40 mg therapy pack........................................54

finasteride tab 5 mg (Proscar)...........................................51flecainide acetate tab 50 mg............................................. 41flecainide acetate tab 100 mg........................................... 41flecainide acetate tab 150 mg........................................... 41FLOVENT DISKUS – fluticasone propionate aer pow ba50 mcg/blister................................................................... 45

FLOVENT DISKUS – fluticasone propionate aer pow ba100 mcg/blister................................................................. 45

FLOVENT DISKUS – fluticasone propionate aer pow ba250 mcg/blister................................................................. 45

FLOVENT HFA – fluticasone propionate hfa inhal aer 110mcg/act (125/valve).......................................................... 45

FLOVENT HFA – fluticasone propionate hfa inhal aer 220mcg/act (250/valve).......................................................... 45

FLOVENT HFA – fluticasone propionate hfa inhal aero 44mcg/act (50/valve)............................................................ 45

FLUAD 2019-2020 – influenza vac type a&b surface antadj susp pref syr 0.5 ml................................................... 15

FLUARIX QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.5ml....................... 15

FLUBLOK QUADRIVALENT 2019-2020 – influenza vacrecomb ha quad pf soln pref syr 0.5 ml...........................15

FLUCELVAX QUADRIVALENT 2019-2020 – influenza vactiss-cult subunt quad susp pref syr 0.5 ml.......................15

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FLUCELVAX QUADRIVALENT 2019-2020 – influenza vactissue-cultured subunit quadrivalent im susp.................. 15

fluconazole for susp 10 mg/ml (Diflucan)............................9fluconazole for susp 40 mg/ml (Diflucan)............................9fluconazole tab 50 mg (Diflucan).........................................9fluconazole tab 100 mg (Diflucan).......................................9fluconazole tab 150 mg (Diflucan).......................................9fluconazole tab 200 mg (Diflucan).......................................9flucytosine cap 250 mg (Ancobon)......................................9flucytosine cap 500 mg (Ancobon)......................................9fludrocortisone acetate tab 0.1 mg....................................24FLULAVAL QUADRIVALENT 2019-2020 – influenza virusvaccine split quadrivalent im inj.......................................15

FLULAVAL QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.5ml....................... 15

FLUNISOLIDE – flunisolide nasal soln 25 mcg/act(0.025%)............................................................................44

fluocinolone acetonide cream 0.01%................................ 88fluocinolone acetonide cream 0.025% (Synalar)...............88fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs sca)................................................................ 88

fluocinolone acetonide oint 0.025% (Synalar)...................88fluocinolone acetonide soln 0.01% (Synalar).................... 88fluocinonide cream 0.05%................................................. 88fluocinonide emulsified base cream 0.05%.......................88fluocinonide gel 0.05%.......................................................88fluocinonide oint 0.05%......................................................88fluocinonide soln 0.05%.....................................................88fluorometholone ophth susp 0.1% (Fml liquifilm).............. 83fluorouracil cream 5% (Efudex)......................................... 89fluoxetine hcl cap 10 mg (Prozac).....................................54fluoxetine hcl cap 20 mg (Prozac).....................................54fluoxetine hcl cap 40 mg (Prozac).....................................54fluoxetine hcl solution 20 mg/5ml...................................... 54fluoxetine hcl tab 10 mg.................................................... 54fluoxetine hcl tab 20 mg.................................................... 54fluphenazine decanoate inj 25 mg/ml................................57FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5mg/5ml...............................................................................57

FLUPHENAZINE HCL – fluphenazine hcl inj 2.5 mg/ml.......................................................................................57

FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml.......................................................................................57

FLUPHENAZINE HCL – fluphenazine hcl tab 1 mg..........57FLUPHENAZINE HCL – fluphenazine hcl tab 2.5 mg.......57FLUPHENAZINE HCL – fluphenazine hcl tab 5 mg..........57FLUPHENAZINE HCL – fluphenazine hcl tab 10 mg........57flurandrenolide cream 0.05% (Cordran)............................ 88FLURBIPROFEN SODIUM – flurbiprofen sodium ophthsoln 0.03%........................................................................ 84

flurbiprofen tab 50 mg........................................................69flurbiprofen tab 100 mg......................................................69flutamide cap 125 mg........................................................ 18FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 55-14 mcg/act........................ 45

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 113-14 mcg/act...................... 45

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 232-14 mcg/act...................... 46

fluticasone propionate cream 0.05% (Cutivate)................ 88fluticasone propionate nasal susp 50 mcg/act.................. 44fluticasone propionate oint 0.005%................................... 88fluvastatin sodium tab er 24 hr 80 mg (base equivalent)(Lescol xl)..........................................................................39

fluvoxamine maleate tab 25 mg........................................ 54fluvoxamine maleate tab 50 mg........................................ 54fluvoxamine maleate tab 100 mg...................................... 54FLUZONE HIGH-DOSE PF 2019-2020 – influenza virusvac split high-dose pf susp pref syr 0.5ml....................... 15

FLUZONE QUADRIVALENT 2019-2020 – influenza virusvaccine split quadrivalent im inj.......................................15

FLUZONE QUADRIVALENT 2019-2020 – influenza virusvaccine split quadrivalent inj 0.5 ml.................................15

FLUZONE QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.25 ml.................... 15

FLUZONE QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.5ml....................... 15

FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals &folic acid tab 5 mg............................................................77

folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2 mg.....80folic acid tab 1 mg............................................................. 81folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg..........81folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg.............81folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgardrx)...................................................................................... 81

FORFIVO XL – bupropion hcl tab er 24hr 450 mg............54fosamprenavir calcium tab 700 mg (base equiv)(Lexiva)..............................................................................11

fosinopril sodium & hydrochlorothiazide tab 10-12.5mg......................................................................................33

fosinopril sodium & hydrochlorothiazide tab 20-12.5mg......................................................................................33

fosinopril sodium tab 10 mg.............................................. 33fosinopril sodium tab 20 mg.............................................. 33fosinopril sodium tab 40 mg.............................................. 33frovatriptan succinate tab 2.5 mg (base equivalent)(Frova)...............................................................................71

FULPHILA – pegfilgrastim-jmdb soln prefilled syringe 6mg/0.6ml............................................................................81

furosemide oral soln 10 mg/ml.......................................... 40furosemide tab 20 mg (Lasix)............................................40furosemide tab 40 mg (Lasix)............................................40furosemide tab 80 mg (Lasix)............................................40FUZEON – enfuvirtide for inj 90 mg..................................11

Ggabapentin cap 100 mg (Neurontin)..................................73gabapentin cap 300 mg (Neurontin)..................................73gabapentin cap 400 mg (Neurontin)..................................73gabapentin oral soln 250 mg/5ml (Neurontin)...................73gabapentin tab 600 mg (Neurontin)...................................73

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gabapentin tab 800 mg (Neurontin)...................................73galantamine hydrobromide cap er 24hr 8 mg (Razadyneer)...................................................................................... 64

galantamine hydrobromide cap er 24hr 16 mg (Razadyneer)...................................................................................... 64

galantamine hydrobromide cap er 24hr 24 mg (Razadyneer)...................................................................................... 64

GALANTAMINE HYDROBROMIDE – galantaminehydrobromide oral soln 4 mg/ml...................................... 64

galantamine hydrobromide tab 4 mg (Razadyne).............64galantamine hydrobromide tab 8 mg (Razadyne).............64galantamine hydrobromide tab 12 mg (Razadyne)...........64GATTEX – teduglutide (rdna) for inj kit 5 mg.................... 49gemfibrozil tab 600 mg (Lopid)..........................................39gentamicin sulfate oint 0.1%..............................................86gentamicin sulfate ophth soln 0.3%...................................83GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab150-150-200-10 mg..........................................................11

GEODON – ziprasidone mesylate for inj 20 mg (baseequivalent).........................................................................57

GILOTRIF – afatinib dimaleate tab 20 mg (baseequivalent).........................................................................18



glatiramer acetate soln prefilled syringe 40 mg/ml(Copaxone)....................................................................... 64

glimepiride tab 1 mg (Amaryl)........................................... 27glimepiride tab 2 mg (Amaryl)........................................... 27glimepiride tab 4 mg (Amaryl)........................................... 27glipizide-metformin hcl tab 2.5-250 mg............................. 27glipizide-metformin hcl tab 2.5-500 mg............................. 28glipizide-metformin hcl tab 5-500 mg................................ 28glipizide tab er 24hr 2.5 mg (Glucotrol xl)......................... 27glipizide tab er 24hr 5 mg (Glucotrol xl)............................ 27glipizide tab er 24hr 10 mg (Glucotrol xl).......................... 27glipizide tab 5 mg (Glucotrol).............................................27glipizide tab 10 mg (Glucotrol)...........................................27GLUCAGON EMERGENCY KIT – glucagon (rdna) for injkit 1 mg.............................................................................28

glyburide-metformin tab 1.25-250 mg (Glucovance).........28glyburide-metformin tab 2.5-500 mg (Glucovance)...........28glyburide-metformin tab 5-500 mg (Glucovance)..............28glyburide tab 1.25 mg........................................................ 28glyburide tab 2.5 mg.......................................................... 28glyburide tab 5 mg............................................................. 28glycopyrrolate tab 1 mg (Robinul)..................................... 47glycopyrrolate tab 2 mg (Robinul forte).............................47GNP PRENATAL – prenatal vit w/ fe fumarate-fa tab28-0.8 mg..........................................................................77

GOODSENSE PRENATAL VITAMI – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 77

griseofulvin microsize susp 125 mg/5ml..............................9griseofulvin microsize tab 500 mg.......................................9griseofulvin ultramicrosize tab 125 mg (Gris-peg)...............9

griseofulvin ultramicrosize tab 250 mg (Gris-peg)...............9guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv).....63guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv).....63guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv).....63guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv).....63guanfacine hcl tab 1 mg (Tenex).......................................42guanfacine hcl tab 2 mg (Tenex).......................................42

HHAEGARDA – c1 esterase inhibitor (human) forsubcutaneous inj 2000 unit.............................................. 81

HAEGARDA – c1 esterase inhibitor (human) forsubcutaneous inj 3000 unit.............................................. 81

halobetasol propionate cream 0.05% (Ultravate)..............88halobetasol propionate oint 0.05% (Ultravate).................. 88haloperidol decanoate im soln 50 mg/ml (Haldoldecanoate 50)...................................................................57

haloperidol decanoate im soln 100 mg/ml (Haldoldecanoate 100).................................................................57

haloperidol lactate oral conc 2 mg/ml................................57haloperidol tab 0.5 mg....................................................... 57haloperidol tab 1 mg.......................................................... 57haloperidol tab 2 mg.......................................................... 57haloperidol tab 5 mg.......................................................... 57haloperidol tab 10 mg........................................................ 57haloperidol tab 20 mg........................................................ 57HEPLISAV-B – hepatitis b vaccine recomb adjuvantedpref syr 20 mcg/0.5ml...................................................... 15

HEPLISAV-B – hepatitis b vaccine recombinantadjuvanted 20 mcg/0.5ml.................................................15

HM PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................77

homatropine hbr ophth soln 5%........................................ 84HUMALOG MIX 75/25 – insulin lispro prot & lispro inj 100unit/ml (75-25)...................................................................29

HUMALOG MIX 50/50 – insulin lispro protamine & lisproinj 100 unit/ml (50-50)...................................................... 29

HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot &lispro sus pen-inj 100 unit/ml (50-50).............................. 29

HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot &lispro sus pen-inj 100 unit/ml (75-25).............................. 29

HUMIRA – adalimumab prefilled syringe kit 10mg/0.1ml............................................................................69






HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 40 mg/0.8ml....................................................69

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HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 80 mg/0.8ml....................................................69

HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 80 mg/0.8ml & 40 mg/0.4ml........................... 69

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.8ml............................................................................69

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.4ml............................................................................69

HUMIRA PEN-CD/UC/HS START – adalimumab pen-injector kit 40 mg/0.8ml....................................................70

HUMIRA PEN-CD/UC/HS START – adalimumab pen-injector kit 80 mg/0.8ml....................................................70

HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit 40 mg/0.8ml....................................................70

HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit 80 mg/0.8ml & 40 mg/0.4ml........................... 70

HUMULIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30)...................................................... 29

HUMULIN 70/30 KWIKPEN – insulin nph & regular susppen-inj 100 unit/ml (70-30)...............................................29

HUMULIN N – insulin nph (human) (isophane) inj 100unit/ml................................................................................29

HUMULIN N KWIKPEN – insulin nph (human) (isophane)susp pen-injector 100 unit/ml...........................................29

HUMULIN R – insulin regular (human) inj 100 unit/ml...... 28HYCAMTIN – topotecan hcl cap 0.25 mg (baseequiv).................................................................................18

HYCAMTIN – topotecan hcl cap 1 mg (base equiv)......... 18hydralazine hcl tab 10 mg................................................. 42hydralazine hcl tab 25 mg................................................. 42hydralazine hcl tab 50 mg................................................. 42hydralazine hcl tab 100 mg............................................... 42hydrochlorothiazide cap 12.5 mg (Microzide)................... 40hydrochlorothiazide tab 12.5 mg....................................... 40hydrochlorothiazide tab 25 mg.......................................... 40hydrochlorothiazide tab 50 mg.......................................... 40hydrocodone-acetaminophen soln 7.5-325 mg/15ml(Hycet)...............................................................................66

hydrocodone-acetaminophen tab 7.5-325 mg (Norco)..... 66hydrocodone-acetaminophen tab 5-325 mg (Norco)........ 66hydrocodone-acetaminophen tab 10-325 mg (Norco)...... 66hydrocodone-acetaminophen tab 7.5-300 mg (Xodol)......66hydrocodone-acetaminophen tab 10-300 mg (Xodol).......66HYDROCODONE BITARTRATE/CH – pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml.............. 44

hydrocodone-ibuprofen tab 7.5-200 mg............................ 66hydrocodone-ibuprofen tab 5-200 mg (Reprexain)........... 66hydrocortisone butyrate oint 0.1% (Locoid).......................88hydrocortisone butyrate soln 0.1% (Locoid)......................88hydrocortisone cream 1%.................................................. 88hydrocortisone cream 2.5%............................................... 88hydrocortisone enema 100 mg/60ml (Cortenema)............85hydrocortisone lotion 2.5%................................................ 88hydrocortisone oint 1%...................................................... 88hydrocortisone oint 2.5%................................................... 88hydrocortisone rectal cream 2.5% (Anusol-hc)................. 85

hydrocortisone rectal cream 1% (Proctocort)....................85hydrocortisone tab 5 mg (Cortef).......................................24hydrocortisone tab 10 mg (Cortef).....................................24hydrocortisone tab 20 mg (Cortef).....................................24hydrocortisone valerate cream 0.2%.................................88hydrocortisone valerate oint 0.2% (Westcort)................... 88hydrocortisone w/ acetic acid otic soln 1-2%.................... 84hydromorphone hcl liqd 1 mg/ml (Dilaudid).......................66hydromorphone hcl tab 2 mg (Dilaudid)............................66hydromorphone hcl tab 4 mg (Dilaudid)............................66hydromorphone hcl tab 8 mg (Dilaudid)............................67hydroxychloroquine sulfate tab 200 mg (Plaquenil).......... 13hydroxyurea cap 500 mg (Hydrea)....................................18hydroxyzine hcl syrup 10 mg/5ml......................................52hydroxyzine hcl tab 10 mg.................................................52hydroxyzine hcl tab 25 mg.................................................52hydroxyzine hcl tab 50 mg.................................................52hydroxyzine pamoate cap 25 mg (Vistaril)........................ 52hydroxyzine pamoate cap 50 mg (Vistaril)........................ 52hyoscyamine sulfate elixir 0.125 mg/5ml.......................... 47hyoscyamine sulfate sl tab 0.125 mg (Levsin/sl)...............47hyoscyamine sulfate soln 0.125 mg/ml............................. 47hyoscyamine sulfate tab disint 0.125 mg (Anaspaz).........47hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid)......... 48hyoscyamine sulfate tab 0.125 mg (Levsin)......................48

Iibandronate sodium tab 150 mg (base equivalent)(Boniva).............................................................................31

IBRANCE – palbociclib cap 75 mg....................................18IBRANCE – palbociclib cap 100 mg..................................18IBRANCE – palbociclib cap 125 mg..................................18ibuprofen susp 100 mg/5ml............................................... 70ibuprofen tab 400 mg.........................................................70ibuprofen tab 600 mg.........................................................70ibuprofen tab 800 mg.........................................................70icatibant acetate inj 30 mg/3ml (base equivalent)(Firazyr).............................................................................81

ICLUSIG – ponatinib hcl tab 15 mg (base equiv)..............18ICLUSIG – ponatinib hcl tab 45 mg (base equiv)..............18imatinib mesylate tab 100 mg (base equivalent)(Gleevec)...........................................................................18

imatinib mesylate tab 400 mg (base equivalent)(Gleevec)...........................................................................18

imipramine hcl tab 10 mg (Tofranil)...................................54imipramine hcl tab 25 mg (Tofranil)...................................54imipramine hcl tab 50 mg (Tofranil)...................................54imiquimod cream 5% (Aldara)........................................... 89IMITREX – sumatriptan nasal spray 5 mg/act...................71IMITREX – sumatriptan nasal spray 20 mg/act.................71IMOVAX RABIES (H.D.C.V.) – rabies virus vaccine, hdcinj....................................................................................... 15

INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)........30INCRUSE ELLIPTA – umeclidinium br aero powd breathact 62.5 mcg/inh (base eq).............................................. 46

indapamide tab 1.25 mg.................................................... 40

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indapamide tab 2.5 mg...................................................... 40indomethacin cap er 75 mg...............................................70indomethacin cap 25 mg................................................... 70indomethacin cap 50 mg................................................... 70INLYTA – axitinib tab 1 mg................................................18INLYTA – axitinib tab 5 mg................................................19INTELENCE – etravirine tab 25 mg.................................. 11INTELENCE – etravirine tab 100 mg................................ 11INTELENCE – etravirine tab 200 mg................................ 11INVEGA – paliperidone tab er 24hr 1.5 mg...................... 57INVEGA – paliperidone tab er 24hr 3 mg......................... 57INVEGA – paliperidone tab er 24hr 6 mg......................... 57INVEGA – paliperidone tab er 24hr 9 mg......................... 57INVEGA SUSTENNA – paliperidone palmitate er susppref syr 39 mg/0.25ml...................................................... 57

INVEGA SUSTENNA – paliperidone palmitate er susppref syr 78 mg/0.5ml........................................................ 57

INVEGA SUSTENNA – paliperidone palmitate er susppref syr 117 mg/0.75ml.................................................... 57

INVEGA SUSTENNA – paliperidone palmitate er susppref syr 156 mg/ml........................................................... 58

INVEGA SUSTENNA – paliperidone palmitate er susppref syr 234 mg/1.5ml...................................................... 58

INVEGA TRINZA – paliperidone palmitate er susp pref syr273 mg/0.875ml................................................................58


INVEGA TRINZA – paliperidone palmitate er susp pref syr546 mg/1.75ml..................................................................58


INVIRASE – saquinavir mesylate tab 500 mg...................11ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml........... 46ipratropium bromide inhal soln 0.02%...............................46ipratropium bromide nasal soln 0.03% (21 mcg/spray).....44ipratropium bromide nasal soln 0.06% (42 mcg/spray).....44irbesartan-hydrochlorothiazide tab 150-12.5 mg(Avalide)............................................................................ 34

irbesartan-hydrochlorothiazide tab 300-12.5 mg(Avalide)............................................................................ 34

irbesartan tab 75 mg (Avapro)...........................................34irbesartan tab 150 mg (Avapro).........................................34irbesartan tab 300 mg (Avapro).........................................34iron combination cap..........................................................81iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg(Hematron-af)....................................................................82

iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg(Corvite 150)..................................................................... 82

iron polysacch complex-vit b12-fa cap 150-0.025-1mg......................................................................................82

irrigation solution, physiological.........................................91ISENTRESS HD – raltegravir potassium tab 600 mg(base equiv)...................................................................... 11

ISENTRESS – raltegravir potassium chew tab 25 mg(base equiv)...................................................................... 11

ISENTRESS – raltegravir potassium chew tab 100 mg(base equiv)...................................................................... 11

ISENTRESS – raltegravir potassium packet for susp 100mg (base equiv)................................................................11

ISENTRESS – raltegravir potassium tab 400 mg (baseequiv).................................................................................11

isoniazid tab 100 mg............................................................8isoniazid tab 300 mg............................................................8ISOPTO ATROPINE – atropine sulfate ophth soln 1%..... 84isosorbide mononitrate tab er 24hr 30 mg........................ 38isosorbide mononitrate tab er 24hr 60 mg........................ 38isosorbide mononitrate tab er 24hr 120 mg...................... 38isosorbide mononitrate tab 10 mg.....................................38isosorbide mononitrate tab 20 mg.....................................38isotretinoin cap 10 mg........................................................86isotretinoin cap 20 mg........................................................86isotretinoin cap 30 mg........................................................86isotretinoin cap 40 mg........................................................86isradipine cap 2.5 mg.........................................................37isradipine cap 5 mg............................................................37itraconazole cap 100 mg (Sporanox).................................. 9ivermectin tab 3 mg (Stromectol)...................................... 14

JJAKAFI – ruxolitinib phosphate tab 5 mg (baseequivalent).........................................................................19

JAKAFI – ruxolitinib phosphate tab 10 mg (baseequivalent).........................................................................19




JULUCA – dolutegravir sodium-rilpivirine hcl tab 50-25 mg(base eq)...........................................................................11

JUXTAPID – lomitapide mesylate cap 5 mg (baseequiv).................................................................................39






KKALETRA – lopinavir-ritonavir tab 100-25 mg.................. 11KALETRA – lopinavir-ritonavir tab 200-50 mg.................. 11KALYDECO – ivacaftor packet 25 mg...............................46KALYDECO – ivacaftor packet 50 mg...............................46KALYDECO – ivacaftor packet 75 mg...............................46KALYDECO – ivacaftor tab 150 mg.................................. 46

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ketoconazole cream 2%.....................................................86ketoconazole shampoo 2% (Nizoral).................................86ketorolac tromethamine ophth soln 0.5% (Acular)............ 84ketorolac tromethamine ophth soln 0.4% (Acular ls).........84ketorolac tromethamine tab 10 mg....................................70KETOSTIX – acetone (urine) test strip..............................90KINERET – anakinra subcutaneous soln prefilled syringe100 mg/0.67ml..................................................................70

KISQALI FEMARA 200 DOSE – ribociclib 200 mg dose(200 mg tab) & letrozole 2.5 mg tbpk..............................19



KISQALI – ribociclib succinate tab pack 200 mg dailydose...................................................................................19

KISQALI – ribociclib succinate tab pack 400 mg dailydose (200 mg tab)............................................................19

KISQALI – ribociclib succinate tab pack 600 mg dailydose (200 mg tab)............................................................19

KORLYM – mifepristone tab 300 mg.................................28K-PHOS – potassium phosphate monobasic tab 500mg......................................................................................79

KP PRENATAL MULTIVITAMINS – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 77

KRINTAFEL – tafenoquine succinate tab 150 mg (baseequivalent).........................................................................13

KUVAN – sapropterin dihydrochloride powder packet 100mg......................................................................................31

KUVAN – sapropterin dihydrochloride powder packet 500mg......................................................................................31

KUVAN – sapropterin dihydrochloride soluble tab 100mg......................................................................................31

KYLEENA – levonorgestrel releasing iud 17.5 mcg/day(19.5 mg total).................................................................. 26

Llabetalol hcl tab 100 mg.................................................... 35labetalol hcl tab 200 mg.................................................... 35labetalol hcl tab 300 mg.................................................... 35lactated ringer's for irrigation............................................. 91lactulose (encephalopathy) solution 10 gm/15ml.............. 49lactulose solution 10 gm/15ml........................................... 47LAMICTAL XR – lamotrigine tab er 24hr 25 (14) & 50 mg(14) & 100 mg(7) kit.........................................................73

LAMICTAL XR – lamotrigine tab er 24hr 50 (14) & 100mg(14) & 200 mg(7) kit....................................................73

LAMICTAL XR – lamotrigine tab er 24hr 25 mg (21) & 50mg (7) titration kit............................................................. 73

lamivudine oral soln 10 mg/ml (Epivir).............................. 11lamivudine tab 150 mg (Epivir)..........................................11lamivudine tab 300 mg (Epivir)..........................................11lamivudine tab 100 mg (hbv) (Epivir hbv)........................... 9lamivudine-zidovudine tab 150-300 mg (Combivir)...........11lamotrigine tab chewable dispersible 5 mg (Lamictalchewable di)......................................................................73

lamotrigine tab chewable dispersible 25 mg (Lamictalchewable di)......................................................................73

lamotrigine tab er 24hr 25 mg (Lamictal xr)...................... 73lamotrigine tab er 24hr 50 mg (Lamictal xr)...................... 73lamotrigine tab er 24hr 100 mg (Lamictal xr).................... 73lamotrigine tab er 24hr 200 mg (Lamictal xr).................... 73lamotrigine tab er 24hr 250 mg (Lamictal xr).................... 73lamotrigine tab er 24hr 300 mg (Lamictal xr).................... 73lamotrigine tab 25 mg (42) & 100 mg (7) starter kit(Lamictal starter/not).........................................................74

lamotrigine tab 25 mg (84) & 100 mg (14) starter kit(Lamictal starter/tak).........................................................74

lamotrigine tab 25 mg (Lamictal).......................................74lamotrigine tab 100 mg (Lamictal).....................................74lamotrigine tab 150 mg (Lamictal).....................................74lamotrigine tab 200 mg (Lamictal).....................................74lamotrigine tab 25 mg (35) starter kit (Lamictal starter/tak).....................................................................................74

lansoprazole cap delayed release 15 mg (Prevacid)........ 48lansoprazole cap delayed release 30 mg (Prevacid)........ 48lanthanum carbonate chew tab 500 mg (elemental)(Fosrenol)..........................................................................49

lanthanum carbonate chew tab 750 mg (elemental)(Fosrenol)..........................................................................49

lanthanum carbonate chew tab 1000 mg (elemental)(Fosrenol)..........................................................................49

latanoprost ophth soln 0.005% (Xalatan).......................... 84LATUDA – lurasidone hcl tab 20 mg.................................58LATUDA – lurasidone hcl tab 40 mg.................................58LATUDA – lurasidone hcl tab 60 mg.................................58LATUDA – lurasidone hcl tab 80 mg.................................58LATUDA – lurasidone hcl tab 120 mg...............................58leflunomide tab 10 mg (Arava).......................................... 70leflunomide tab 20 mg (Arava).......................................... 70LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 mg (14 mg daily dose)................................ 19

LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 (2) mg (18 mg daily dose)...........................19

LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapypack 10 (2) & 4 mg (24 mg daily dose)...........................19

LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapypack 10 mg (10 mg daily dose).......................................19

LENVIMA 12MG DAILY DOSE – lenvatinib cap therapypack 4 (3) mg (12 mg daily dose)................................... 19

LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapypack 10 (2) mg (20 mg daily dose)................................. 19

LENVIMA 4 MG DAILY DOSE – lenvatinib cap therapypack 4 mg (4 mg daily dose)...........................................19

LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapypack 4 (2) mg (8 mg daily dose)..................................... 19

letrozole tab 2.5 mg (Femara)...........................................19LEUCOVORIN CALCIUM – leucovorin calcium tab 10mg......................................................................................20

LEUCOVORIN CALCIUM – leucovorin calcium tab 15mg......................................................................................20

leucovorin calcium tab 5 mg..............................................20

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leucovorin calcium tab 25 mg............................................20LEUKERAN – chlorambucil tab 2 mg................................20levetiracetam oral soln 100 mg/ml (Keppra)..................... 74levetiracetam tab er 24hr 500 mg (Keppra xr).................. 74levetiracetam tab er 24hr 750 mg (Keppra xr).................. 74levetiracetam tab 250 mg (Keppra)...................................74levetiracetam tab 500 mg (Keppra)...................................74levetiracetam tab 750 mg (Keppra)...................................74levetiracetam tab 1000 mg (Keppra).................................74levobunolol hcl ophth soln 0.5% (Betagan).......................84levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...........31levocarnitine tab 330 mg (Carnitor)...................................31levocetirizine dihydrochloride tab 5 mg (Xyzal).................44levofloxacin oral soln 25 mg/ml........................................... 8levofloxacin tab 250 mg (Levaquin).....................................8levofloxacin tab 500 mg (Levaquin).....................................8levofloxacin tab 750 mg (Levaquin).....................................8levothyroxine sodium tab 25 mcg (Synthroid)...................29levothyroxine sodium tab 50 mcg (Synthroid)...................29levothyroxine sodium tab 75 mcg (Synthroid)...................29levothyroxine sodium tab 88 mcg (Synthroid)...................29levothyroxine sodium tab 100 mcg (Synthroid).................29levothyroxine sodium tab 112 mcg (Synthroid)................. 30levothyroxine sodium tab 125 mcg (Synthroid).................30levothyroxine sodium tab 137 mcg (Synthroid).................30levothyroxine sodium tab 150 mcg (Synthroid).................30levothyroxine sodium tab 175 mcg (Synthroid).................30levothyroxine sodium tab 200 mcg (Synthroid).................30levothyroxine sodium tab 300 mcg (Synthroid).................30LEXIVA – fosamprenavir calcium susp 50 mg/ml (baseequiv).................................................................................11

lidocaine hcl gel 2%...........................................................89lidocaine hcl soln 4% (Xylocaine)......................................89lidocaine hcl urethral/mucosal gel 2%...............................89lidocaine hcl viscous soln 2%............................................85lidocaine patch 5% (Lidoderm)..........................................89lidocaine-prilocaine cream 2.5-2.5%................................. 89LILETTA – levonorgestrel releasing iud 19.5 mcg/day (52mg total)............................................................................26

linezolid for susp 100 mg/5ml (Zyvox)...............................14linezolid tab 600 mg (Zyvox)............................................. 14liothyronine sodium tab 5 mcg (Cytomel)..........................30liothyronine sodium tab 25 mcg (Cytomel)........................30liothyronine sodium tab 50 mcg (Cytomel)........................30lisinopril & hydrochlorothiazide tab 10-12.5 mg(Zestoretic)........................................................................ 33

lisinopril & hydrochlorothiazide tab 20-12.5 mg(Zestoretic)........................................................................ 33

lisinopril & hydrochlorothiazide tab 20-25 mg(Zestoretic)........................................................................ 33

lisinopril tab 5 mg (Prinivil)................................................ 33lisinopril tab 10 mg (Prinivil).............................................. 33lisinopril tab 20 mg (Prinivil).............................................. 33lisinopril tab 2.5 mg (Zestril).............................................. 33lisinopril tab 30 mg (Zestril)............................................... 33lisinopril tab 40 mg (Zestril)............................................... 33

lithium carbonate cap 300 mg........................................... 58lithium carbonate cap 150 mg (Lithium carbonate)...........58lithium carbonate cap 600 mg (Lithium carbonate)...........58lithium carbonate tab er 450 mg........................................58lithium carbonate tab er 300 mg (Lithobid)....................... 58lithium carbonate tab 300 mg............................................58LITHIUM – lithium oral solution 8 meq/5ml....................... 58LONSURF – trifluridine-tipiracil tab 15-6.14 mg................20LONSURF – trifluridine-tipiracil tab 20-8.19 mg................20loperamide hcl cap 2 mg................................................... 47lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)(Kaletra).............................................................................11

lorazepam conc 2 mg/ml................................................... 52lorazepam tab 0.5 mg (Ativan).......................................... 52lorazepam tab 1 mg (Ativan)............................................. 52lorazepam tab 2 mg (Ativan)............................................. 52LORBRENA – lorlatinib tab 25 mg....................................20LORBRENA – lorlatinib tab 100 mg..................................20losartan potassium & hydrochlorothiazide tab 50-12.5 mg(Hyzaar).............................................................................34

losartan potassium & hydrochlorothiazide tab 100-12.5mg (Hyzaar)...................................................................... 34

losartan potassium & hydrochlorothiazide tab 100-25 mg(Hyzaar).............................................................................34

losartan potassium tab 25 mg (Cozaar)............................34losartan potassium tab 50 mg (Cozaar)............................34losartan potassium tab 100 mg (Cozaar)..........................34lovastatin tab 10 mg...........................................................39lovastatin tab 20 mg...........................................................39lovastatin tab 40 mg (Mevacor).........................................39loxapine succinate cap 5 mg.............................................58loxapine succinate cap 10 mg...........................................58loxapine succinate cap 25 mg...........................................58loxapine succinate cap 50 mg...........................................58LUPANETA PACK – leuprolide (1 mon) inj 3.75 mg &norethindrone tab 5 mg kit...............................................26

LUPANETA PACK – leuprolide (3 mon) inj 11.25 mg &norethindrone tab 5 mg kit...............................................26

LUPRON DEPOT (1-MONTH) – leuprolide acetate for injkit 3.75 mg........................................................................20

LUPRON DEPOT (1-MONTH) – leuprolide acetate for injkit 7.5 mg..........................................................................20

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3month) for inj kit 11.25 mg............................................... 20

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3month) for inj kit 22.5 mg.................................................20

LUPRON DEPOT (4-MONTH) – leuprolide acetate (4month) for inj kit 30 mg....................................................20

LUPRON DEPOT (6-MONTH) – leuprolide acetate (6month) for inj kit 45 mg....................................................20

LUPRON DEPOT-PED (1-MONTH – leuprolide acetatefor inj pediatric kit 7.5 mg........................................... 26,31

LUPRON DEPOT-PED (1-MONTH – leuprolide acetatefor inj pediatric kit 11.25 mg........................................26,31

LUPRON DEPOT-PED (1-MONTH – leuprolide acetatefor inj pediatric kit 15 mg............................................ 27,31

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LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3month) for inj pediatric kit 11.25 mg................................ 27

LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3month) for inj pediatric kit 30 mg..................................... 27

LYNPARZA – olaparib tab 100 mg....................................20LYNPARZA – olaparib tab 150 mg....................................20LYSODREN – mitotane tab 500 mg..................................20

Mmalathion lotion 0.5% (Ovide)........................................... 89MAPROTILINE HCL – maprotiline hcl tab 25 mg............. 54MAPROTILINE HCL – maprotiline hcl tab 50 mg............. 54MAPROTILINE HCL – maprotiline hcl tab 75 mg............. 54MARPLAN – isocarboxazid tab 10 mg..............................54MATULANE – procarbazine hcl cap 50 mg.......................20MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg......... 9meclizine hcl tab 12.5 mg..................................................48meclizine hcl tab 25 mg.....................................................48medroxyprogesterone acetate tab 2.5 mg (Provera)........ 26medroxyprogesterone acetate tab 5 mg (Provera)........... 26medroxyprogesterone acetate tab 10 mg (Provera)......... 26MEFLOQUINE HCL – mefloquine hcl tab 250 mg............13megestrol acetate susp 625 mg/5ml (Megace es)............ 26megestrol acetate susp 40 mg/ml (Megace oral)..............20megestrol acetate tab 20 mg.............................................20megestrol acetate tab 40 mg.............................................20MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg(base equivalent).............................................................. 20

MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (baseequivalent).........................................................................20

MEKTOVI – binimetinib tab 15 mg....................................20meloxicam tab 7.5 mg (Mobic).......................................... 70meloxicam tab 15 mg (Mobic)........................................... 70memantine hcl oral solution 2 mg/ml (Namenda)..............65memantine hcl tab 5 mg (Namenda).................................65memantine hcl tab 10 mg (Namenda)...............................65mercaptopurine tab 50 mg.................................................20mesalamine enema 4 gm.................................................. 49mesalamine suppos 1000 mg (Canasa)........................... 49mesalamine tab delayed release 800 mg (Asacol hd)...... 49metformin hcl tab er 24hr 500 mg (Glucophage xr).......... 28metformin hcl tab er 24hr 750 mg (Glucophage xr).......... 28metformin hcl tab 500 mg (Glucophage)...........................28metformin hcl tab 850 mg (Glucophage)...........................28metformin hcl tab 1000 mg (Glucophage).........................28methadone hcl conc 10 mg/ml (Methadose).....................67methadone hcl soln 5 mg/5ml (Methadone hcl)................ 67methadone hcl soln 10 mg/5ml (Methadone hcl).............. 67methadone hcl tab for oral susp 40 mg............................ 67methadone hcl tab 5 mg (Dolophine)................................67methadone hcl tab 10 mg (Dolophine)..............................67methimazole tab 5 mg (Tapazole)..................................... 30methimazole tab 10 mg (Tapazole)................................... 30methocarbamol tab 750 mg (Robaxin-750).......................76methocarbamol tab 500 mg (Robaxin)..............................76methotrexate sodium tab 2.5 mg (base equiv)..................20

methoxsalen rapid cap 10 mg (Oxsoralen ultra)............... 89methscopolamine bromide tab 2.5 mg (Pamine).............. 48methyldopa tab 250 mg..................................................... 42methyldopa tab 500 mg..................................................... 42methylergonovine maleate tab 0.2 mg.............................. 31methylphenidate hcl cap er 24hr 10 mg (la) (Ritalinla).......................................................................................63

methylphenidate hcl cap er 24hr 20 mg (la) (Ritalinla).......................................................................................63



methylphenidate hcl cap er 10 mg (cd).............................63methylphenidate hcl cap er 20 mg (cd).............................63methylphenidate hcl cap er 30 mg (cd).............................63methylphenidate hcl cap er 40 mg (cd).............................63methylphenidate hcl cap er 50 mg (cd).............................63methylphenidate hcl cap er 60 mg (cd).............................63methylphenidate hcl chew tab 2.5 mg...............................63methylphenidate hcl chew tab 5 mg..................................63methylphenidate hcl chew tab 10 mg................................63methylphenidate hcl soln 5 mg/5ml (Methylin)..................63methylphenidate hcl soln 10 mg/5ml (Methylin)................63methylphenidate hcl tab er 10 mg.....................................63methylphenidate hcl tab er 20 mg.....................................63methylphenidate hcl tab 5 mg (Ritalin)..............................63methylphenidate hcl tab 10 mg (Ritalin)............................63methylphenidate hcl tab 20 mg (Ritalin)............................63METHYLPHENIDATE HYDROCHLO – methylphenidatehcl tab er 24hr 18 mg...................................................... 63

METHYLPHENIDATE HYDROCHLO – methylphenidatehcl tab er 24hr 27 mg...................................................... 63



methylprednisolone tab 4 mg (Medrol)..............................24methylprednisolone tab 8 mg (Medrol)..............................24methylprednisolone tab 16 mg (Medrol)............................24methylprednisolone tab 32 mg (Medrol)............................24methylprednisolone tab therapy pack 4 mg (21) (Medroldosepak)............................................................................24

metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (baseequiv).................................................................................49

metoclopramide hcl tab 5 mg (base equivalent)(Reglan).............................................................................49

metoclopramide hcl tab 10 mg (base equivalent)(Reglan).............................................................................49

metolazone tab 2.5 mg...................................................... 41metolazone tab 5 mg......................................................... 41metolazone tab 10 mg....................................................... 41METOPROLOL/HYDROCHLOROTHI – metoprolol &hydrochlorothiazide tab 100-50 mg................................. 35

metoprolol & hydrochlorothiazide tab 50-25 mg(Lopressor hct)..................................................................35

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metoprolol & hydrochlorothiazide tab 100-25 mg(Lopressor hct)..................................................................35

metoprolol succinate tab er 24hr 25 mg (tartrate equiv)(Toprol xl).......................................................................... 35




metoprolol tartrate tab 25 mg............................................ 35metoprolol tartrate tab 50 mg (Lopressor).........................35metoprolol tartrate tab 100 mg (Lopressor).......................35metronidazole cap 375 mg (Flagyl)...................................14metronidazole cream 0.75% (Metrocream).......................86metronidazole gel 0.75%................................................... 86metronidazole tab 250 mg (Flagyl)....................................14metronidazole tab 500 mg (Flagyl)....................................14metronidazole vaginal gel 0.75% (Metrogel-vaginal)........ 50midodrine hcl tab 2.5 mg...................................................42midodrine hcl tab 5 mg...................................................... 42midodrine hcl tab 10 mg....................................................43miglustat cap 100 mg (Zavesca)....................................... 82minocycline hcl cap 50 mg (Minocin).................................. 8minocycline hcl cap 75 mg (Minocin).................................. 8minocycline hcl cap 100 mg (Minocin)................................ 8minoxidil tab 2.5 mg...........................................................43minoxidil tab 10 mg............................................................43MIRENA – levonorgestrel releasing iud 20 mcg/day (52mg total)............................................................................26

mirtazapine tab 15 mg (Remeron).....................................54mirtazapine tab 30 mg (Remeron).....................................54mirtazapine tab 45 mg (Remeron).....................................54misoprostol tab 100 mcg (Cytotec)....................................48misoprostol tab 200 mcg (Cytotec)....................................48MITIGARE – colchicine cap 0.6 mg.................................. 72M-NATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................77

modafinil tab 100 mg (Provigil)..........................................63modafinil tab 200 mg (Provigil)..........................................64moexipril hcl tab 7.5 mg.................................................... 33moexipril hcl tab 15 mg..................................................... 33MOLINDONE HYDROCHLORIDE – molindone hcl tab 5mg......................................................................................58

MOLINDONE HYDROCHLORIDE – molindone hcl tab 10mg......................................................................................58

MOLINDONE HYDROCHLORIDE – molindone hcl tab 25mg......................................................................................58

mometasone furoate cream 0.1% (Elocon).......................88mometasone furoate oint 0.1% (Elocon)...........................88mometasone furoate solution 0.1% (lotion) (Elocon)........ 88montelukast sodium chew tab 4 mg (base equiv)(Singulair)..........................................................................46

montelukast sodium chew tab 5 mg (base equiv)(Singulair)..........................................................................46

montelukast sodium oral granules packet 4 mg (baseequiv) (Singulair).............................................................. 46

montelukast sodium tab 10 mg (base equiv)(Singulair)..........................................................................46

morphine sulfate cap er 24hr 100 mg (Kadian).................67MORPHINE SULFATE ER – morphine sulfate beads caper 24hr 60 mg...................................................................67

MORPHINE SULFATE ER – morphine sulfate beads caper 24hr 75 mg...................................................................67

MORPHINE SULFATE ER – morphine sulfate beads caper 24hr 120 mg.................................................................67

MORPHINE SULFATE – morphine sulfate suppos 5mg......................................................................................67




morphine sulfate oral soln 10 mg/5ml............................... 67morphine sulfate oral soln 20 mg/5ml............................... 67morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...........67morphine sulfate tab er 15 mg (Ms contin)....................... 67morphine sulfate tab er 30 mg (Ms contin)....................... 67morphine sulfate tab er 60 mg (Ms contin)....................... 67morphine sulfate tab er 100 mg (Ms contin)..................... 67morphine sulfate tab er 200 mg (Ms contin)..................... 67morphine sulfate tab 15 mg (Morphine sulfate).................67morphine sulfate tab 30 mg (Morphine sulfate).................67moxifloxacin hcl ophth soln 0.5% (base equiv)(Vigamox)..........................................................................83

multiple vitamins w/ minerals cap......................................77multiple vitamins w/ minerals tab (Strovite forte)...............77MULTI PRENATAL – prenatal vit w/ fe fumarate-fa tab27-0.8 mg..........................................................................77

mupirocin oint 2%...............................................................87M-VIT – prenatal vit w/ fe fumarate-fa tab 27-1 mg.......... 77mycophenolate mofetil cap 250 mg (Cellcept)..................91mycophenolate mofetil for oral susp 200 mg/ml(Cellcept)...........................................................................91

mycophenolate mofetil tab 500 mg (Cellcept)...................91mycophenolate sodium tab dr 180 mg (mycophenolic acidequiv) (Myfortic)................................................................91

mycophenolate sodium tab dr 360 mg (mycophenolic acidequiv) (Myfortic)................................................................91

MYLERAN – busulfan tab 2 mg........................................ 21

Nnabumetone tab 500 mg....................................................70nabumetone tab 750 mg....................................................70nadolol tab 20 mg (Corgard)............................................. 35nadolol tab 40 mg (Corgard)............................................. 36nadolol tab 80 mg (Corgard)............................................. 36naftifine hcl cream 2% (Naftin).......................................... 87naltrexone hcl tab 50 mg...................................................91

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naproxen sodium tab er 24hr 375 mg (base equiv)(Naprelan)......................................................................... 70

naproxen sodium tab 275 mg............................................70naproxen sodium tab 550 mg (Anaprox ds)......................70naproxen susp 125 mg/5ml (Naprosyn)............................ 70naproxen tab ec 375 mg (Ec-naprosyn)............................70naproxen tab ec 500 mg (Ec-naprosyn)............................70naproxen tab 250 mg.........................................................70naproxen tab 375 mg.........................................................70naproxen tab 500 mg (Naprosyn)......................................70NARCAN – naloxone hcl nasal spray 4 mg/0.1ml.............91NATACYN – natamycin ophth susp 5%............................ 83nateglinide tab 60 mg (Starlix)...........................................28nateglinide tab 120 mg (Starlix).........................................28NATRAPEL 12-HOUR TICK & I – picaridin aerosol..........89NEOMYCIN/POLYMYXIN/GRAMIC – neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml.............83

neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000untop oin................................................................................ 83

neomycin-polymyxin-dexamethasone ophth oint 0.1%(Maxitrol)........................................................................... 83

neomycin-polymyxin-dexamethasone ophth susp 0.1%(Maxitrol)........................................................................... 83

neomycin-polymyxin-hc otic soln 1%................................ 85neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%................................................................................ 85

neomycin sulfate tab 500 mg.............................................. 8NERLYNX – neratinib maleate tab 40 mg (baseequivalent).........................................................................21

nevirapine susp 50 mg/5ml (Viramune).............................11nevirapine tab er 24hr 100 mg (Viramune xr)................... 11nevirapine tab er 24hr 400 mg (Viramune xr)................... 12nevirapine tab 200 mg (Viramune)....................................12NEXAVAR – sorafenib tosylate tab 200 mg (baseequivalent).........................................................................21

NEXPLANON – etonogestrel subdermal implant 68mg......................................................................................26

nicardipine hcl cap 20 mg..................................................37NICOTROL INHALER – nicotine inhaler system 10 mg (4mg delivered)....................................................................65

NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray)................................................................................ 65

nifedipine cap 20 mg..........................................................37nifedipine cap 10 mg (Procardia)...................................... 37nifedipine tab er 24hr 30 mg (Adalat cc)...........................37nifedipine tab er 24hr 60 mg (Adalat cc)...........................37nifedipine tab er 24hr 90 mg (Adalat cc)...........................37nifedipine tab er 24hr osmotic release 30 mg (Procardiaxl).......................................................................................37

nifedipine tab er 24hr osmotic release 60 mg (Procardiaxl).......................................................................................37

nifedipine tab er 24hr osmotic release 90 mg (Procardiaxl).......................................................................................37

nimodipine cap 30 mg........................................................37NINLARO – ixazomib citrate cap 3 mg (baseequivalent).........................................................................21

NINLARO – ixazomib citrate cap 4 mg (baseequivalent).........................................................................21

NINLARO – ixazomib citrate cap 2.3 mg (baseequivalent).........................................................................21

nitrofurantoin macrocrystalline cap 25 mg(Macrodantin)....................................................................50



nitrofurantoin monohydrate macrocrystalline cap 100 mg(Macrobid)......................................................................... 50

nitroglycerin cap er 2.5 mg................................................38nitroglycerin sl tab 0.3 mg (Nitrostat)................................ 38nitroglycerin sl tab 0.4 mg (Nitrostat)................................ 38nitroglycerin sl tab 0.6 mg (Nitrostat)................................ 38nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)............... 38nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)............... 38nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)............... 38nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)............... 38NITRO-TIME – nitroglycerin cap er 6.5 mg.......................38NITRO-TIME – nitroglycerin cap er 9 mg..........................38NITYR – nitisinone tab 2 mg............................................. 31NITYR – nitisinone tab 5 mg............................................. 31NITYR – nitisinone tab 10 mg........................................... 31NIVA-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................77

NIVESTYM – filgrastim-aafi inj 300 mcg/ml...................... 82NIVESTYM – filgrastim-aafi inj 480 mcg/1.6ml (300 mcg/ml)......................................................................................82

NIVESTYM – filgrastim-aafi soln prefilled syringe 300mcg/0.5ml..........................................................................82

NIVESTYM – filgrastim-aafi soln prefilled syringe 480mcg/0.8ml..........................................................................82

nizatidine cap 150 mg........................................................48nizatidine cap 300 mg........................................................48norethindrone acetate-ethinyl estradiol tab 1 mg-5mcg....................................................................................26

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5mcg (Femhrt low dose).................................................... 26

norethindrone acetate tab 5 mg (Aygestin).......................26nortriptyline hcl cap 10 mg (Pamelor)............................... 54nortriptyline hcl cap 25 mg (Pamelor)............................... 54nortriptyline hcl cap 50 mg (Pamelor)............................... 54nortriptyline hcl cap 75 mg (Pamelor)............................... 54NORVIR – ritonavir oral soln 80 mg/ml.............................12NOVOLIN 70/30 FLEXPEN – insulin nph & regular susppen-inj 100 unit/ml (70-30)...............................................29

NOVOLIN 70/30 FLEXPEN REL – insulin nph & regularsusp pen-inj 100 unit/ml (70-30)......................................29

NOVOLIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30)...................................................... 29

NOVOLIN 70/30 RELION – insulin nph isophane &regular human inj 100 unit/ml (70-30)............................. 29

NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml.......................................................................................29

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NOVOLIN N RELION – insulin nph (human) (isophane) inj100 unit/ml........................................................................ 29

NOVOLIN R – insulin regular (human) inj 100 unit/ml...... 28NOVOLIN R RELION – insulin regular (human) inj 100unit/ml................................................................................28

NOVOLOG MIX 70/30 – insulin aspart prot & aspart(human) inj 100 unit/ml (70-30)....................................... 29

NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &aspart sus pen-inj 100 unit/ml (70-30).............................29

NOXAFIL – posaconazole susp 40 mg/ml.......................... 9NUVARING – etonogestrel-ethinyl estradiol va ring0.120-0.015 mg/24hr........................................................ 26

nystatin cream 100000 unit/gm......................................... 87nystatin oint 100000 unit/gm..............................................87nystatin oral powder.............................................................9nystatin susp 100000 unit/ml.............................................85nystatin tab 500000 unit...................................................... 9

OO-CAL FA – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................77

ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab200-25-25 mg................................................................... 12

OFEV – nintedanib esylate cap 100 mg (baseequivalent).........................................................................46

OFEV – nintedanib esylate cap 150 mg (baseequivalent).........................................................................47

OFF ACTIVE – diethyltoluamide (deet) aerosol................89OFF DEEP WOODS – diethyltoluamide (deet)aerosol...............................................................................89

OFF DEEP WOODS DRY – diethyltoluamide (deet)aerosol...............................................................................89

OFF SMOOTH & DRY – diethyltoluamide (deet)aerosol...............................................................................89

ofloxacin ophth soln 0.3% (Ocuflox)..................................83ofloxacin otic soln 0.3% (Floxin otic).................................85olanzapine orally disintegrating tab 5 mg (Zyprexazydis)................................................................................. 58

olanzapine orally disintegrating tab 10 mg (Zyprexazydis)................................................................................. 58



olanzapine tab 2.5 mg (Zyprexa).......................................58olanzapine tab 5 mg (Zyprexa)..........................................58olanzapine tab 7.5 mg (Zyprexa).......................................59olanzapine tab 10 mg (Zyprexa)........................................59olanzapine tab 15 mg (Zyprexa)........................................59olanzapine tab 20 mg (Zyprexa)........................................59olmesartan medoxomil-hydrochlorothiazide tab 20-12.5mg (Benicar hct)...............................................................34

olmesartan medoxomil-hydrochlorothiazide tab 40-12.5mg (Benicar hct)...............................................................34

olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg(Benicar hct)..................................................................... 34

olmesartan medoxomil tab 5 mg (Benicar)....................... 34olmesartan medoxomil tab 20 mg (Benicar)..................... 34olmesartan medoxomil tab 40 mg (Benicar)..................... 34olopatadine hcl ophth soln 0.1% (base equivalent)(Patanol)............................................................................84

OLUMIANT – baricitinib tab 2 mg..................................... 70omeprazole cap delayed release 10 mg (Prilosec)...........48omeprazole cap delayed release 20 mg (Prilosec)...........48omeprazole cap delayed release 40 mg (Prilosec)...........48OMNITROPE – somatropin for inj 5.8 mg.........................30ondansetron hcl oral soln 4 mg/5ml (Zofran).................... 48ondansetron hcl tab 24 mg................................................48ondansetron hcl tab 4 mg (Zofran)....................................48ondansetron hcl tab 8 mg (Zofran)....................................48ondansetron orally disintegrating tab 4 mg (Zofranodt).................................................................................... 48

ondansetron orally disintegrating tab 8 mg (Zofranodt).................................................................................... 48

ONETOUCH DELICA LANCETS E – lancets................... 90ONETOUCH DELICA LANCETS F – lancets................... 90ONETOUCH DELICA LANCING D – lancet devices........ 90ONETOUCH DELICA PLUS LANC – lancet devices........90ONETOUCH SURESOFT LANCING – lancets misc........ 91ONETOUCH ULTRA 2 – blood glucose monitoring kit w/device................................................................................ 90

ONETOUCH ULTRA BLUE – glucose blood test strip......90ONETOUCH ULTRA CONTROL – blood glucosecalibration - liquid............................................................. 90

ONETOUCH ULTRA MINI – blood glucose monitoring kitw/ device...........................................................................90

ONETOUCH ULTRASOFT LANCET – lancets................. 91ONETOUCH VERIO – blood glucose monitoring kit w/device................................................................................ 90

ONETOUCH VERIO CONTROL SO – blood glucosecalibration - liquid - high...................................................90

ONETOUCH VERIO FLEX BLOOD – blood glucosemonitoring kit w/ device....................................................90

ONETOUCH VERIO IQ BLOOD G – blood glucosemonitoring kit w/ device....................................................90

ONETOUCH VERIO MID CONTRO – blood glucosecalibration - liquid............................................................. 90

ONETOUCH VERIO TEST STRIP – glucose blood teststrip....................................................................................90

ORENCIA – abatacept subcutaneous soln prefilledsyringe 125 mg/ml............................................................70

ORENCIA CLICKJECT – abatacept subcutaneous solnauto-injector 125 mg/ml....................................................70

ORKAMBI – lumacaftor-ivacaftor granules packet 100-125mg......................................................................................47

ORKAMBI – lumacaftor-ivacaftor granules packet 150-188mg......................................................................................47

ORKAMBI – lumacaftor-ivacaftor tab 100-125 mg............47ORKAMBI – lumacaftor-ivacaftor tab 200-125 mg............47orphenadrine citrate tab er 12hr 100 mg...........................76oseltamivir phosphate cap 30 mg (base equiv)(Tamiflu).............................................................................13

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oseltamivir phosphate cap 45 mg (base equiv)(Tamiflu).............................................................................13

oseltamivir phosphate cap 75 mg (base equiv)(Tamiflu).............................................................................13

oseltamivir phosphate for susp 6 mg/ml (base equiv)(Tamiflu).............................................................................13

OTEZLA – apremilast tab 30 mg.......................................71OTEZLA – apremilast tab starter therapy pack 10 mg & 20mg & 30 mg......................................................................71

oxcarbazepine susp 300 mg/5ml (60 mg/ml)(Trileptal)........................................................................... 74

oxcarbazepine tab 150 mg (Trileptal)................................74oxcarbazepine tab 300 mg (Trileptal)................................74oxcarbazepine tab 600 mg (Trileptal)................................74oxiconazole nitrate cream 1% (Oxistat).............................87OXTELLAR XR – oxcarbazepine tab er 24hr 150 mg.......74OXTELLAR XR – oxcarbazepine tab er 24hr 300 mg.......74OXTELLAR XR – oxcarbazepine tab er 24hr 600 mg.......74oxybutynin chloride syrup 5 mg/5ml..................................50oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)........... 50oxybutynin chloride tab er 24hr 10 mg (Ditropan xl)......... 50oxybutynin chloride tab er 24hr 15 mg (Ditropan xl)......... 50oxybutynin chloride tab 5 mg.............................................50OXYCODONE/ASPIRIN – oxycodone-aspirin tab4.8355-325 mg..................................................................68

OXYCODONE/IBUPROFEN – oxycodone-ibuprofen tab5-400 mg...........................................................................68

oxycodone hcl conc 100 mg/5ml (20 mg/ml).................... 67oxycodone hcl soln 5 mg/5ml............................................67oxycodone hcl tab 10 mg.................................................. 68oxycodone hcl tab 20 mg.................................................. 68oxycodone hcl tab 5 mg (Roxicodone)..............................67oxycodone hcl tab 15 mg (Roxicodone)............................68oxycodone hcl tab 30 mg (Roxicodone)............................68oxycodone w/ acetaminophen tab 2.5-325 mg(Percocet)..........................................................................68

oxycodone w/ acetaminophen tab 5-325 mg(Percocet)..........................................................................68

oxycodone w/ acetaminophen tab 7.5-325 mg(Percocet)..........................................................................68

oxycodone w/ acetaminophen tab 10-325 mg(Percocet)..........................................................................68

oxymorphone hcl tab 5 mg (Opana)..................................68oxymorphone hcl tab 10 mg (Opana)................................68OXYMORPHONE HYDROCHLORIDE – oxymorphone hcltab er 12hr 5 mg.............................................................. 68

OXYMORPHONE HYDROCHLORIDE – oxymorphone hcltab er 12hr 7.5 mg........................................................... 68

OXYMORPHONE HYDROCHLORIDE – oxymorphone hcltab er 12hr 10 mg............................................................ 68





Ppaliperidone tab er 24hr 1.5 mg (Invega)..........................59paliperidone tab er 24hr 3 mg (Invega).............................59paliperidone tab er 24hr 6 mg (Invega).............................59paliperidone tab er 24hr 9 mg (Invega).............................59pantoprazole sodium ec tab 20 mg (base equiv)(Protonix)...........................................................................48

pantoprazole sodium ec tab 40 mg (base equiv)(Protonix)...........................................................................48

PARAGARD INTRAUTERINE COP – copper iud............. 26paromomycin sulfate cap 250 mg....................................... 8paroxetine hcl tab 10 mg (Paxil)........................................54paroxetine hcl tab 20 mg (Paxil)........................................54paroxetine hcl tab 30 mg (Paxil)........................................54paroxetine hcl tab 40 mg (Paxil)........................................54PAXIL – paroxetine hcl oral susp 10 mg/5ml (baseequiv).................................................................................54

pediatric multiple vitamin w/ minerals & c drops 45 mg/ml.......................................................................................77

pediatric vitamins acd w/ fluoride soln 0.25 mg/ml............77peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm(Colyte-flavor packs).........................................................47

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm(Golytely)...........................................................................47

peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack)....................................................................... 47

penicillamine cap 250 mg (Cuprimine)..............................91penicillin v potassium tab 250 mg....................................... 6penicillin v potassium tab 500 mg....................................... 6pentoxifylline tab er 400 mg.............................................. 82perindopril erbumine tab 2 mg...........................................33perindopril erbumine tab 4 mg (Aceon).............................33perindopril erbumine tab 8 mg (Aceon).............................33permethrin cream 5% (Elimite)..........................................90PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline tab 2-10 mg................................................. 65

PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline tab 2-25 mg................................................. 65




perphenazine tab 2 mg......................................................59perphenazine tab 4 mg......................................................59perphenazine tab 8 mg......................................................59perphenazine tab 16 mg....................................................59PEXEVA – paroxetine mesylate tab 10 mg (baseequiv).................................................................................54

PEXEVA – paroxetine mesylate tab 20 mg (baseequiv).................................................................................55

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phenazopyridine hcl tab 100 mg (Pyridium)......................51phenazopyridine hcl tab 200 mg (Pyridium)......................51phenobarbital elixir 20 mg/5ml...........................................61phenobarbital tab 15 mg....................................................61phenobarbital tab 16.2 mg.................................................61phenobarbital tab 30 mg....................................................61phenobarbital tab 32.4 mg.................................................61phenobarbital tab 60 mg....................................................61phenobarbital tab 64.8 mg.................................................61phenobarbital tab 97.2 mg.................................................61phenobarbital tab 100 mg..................................................61phenoxybenzamine hcl cap 10 mg (Dibenzyline)..............43phenylephrine hcl ophth soln 2.5%................................... 84phenytoin chew tab 50 mg (Dilantin infatabs)................... 74phenytoin sodium extended cap 100 mg (Dilantin)...........74phenytoin sodium extended cap 200 mg (Phenytek)........74phenytoin sodium extended cap 300 mg (Phenytek)........74phenytoin susp 125 mg/5ml (Dilantin-125)........................74phytonadione tab 5 mg (Mephyton)...................................76PIFELTRO – doravirine tab 100 mg.................................. 12pilocarpine hcl ophth soln 1% (Isopto carpine)................. 84pilocarpine hcl ophth soln 2% (Isopto carpine)................. 84pilocarpine hcl ophth soln 4% (Isopto carpine)................. 84pilocarpine hcl tab 5 mg (Salagen)....................................85pilocarpine hcl tab 7.5 mg (Salagen).................................85PIMOZIDE – pimozide tab 1 mg....................................... 65PIMOZIDE – pimozide tab 2 mg....................................... 65pindolol tab 5 mg............................................................... 36pioglitazone hcl tab 15 mg (base equiv) (Actos)............... 28pioglitazone hcl tab 30 mg (base equiv) (Actos)............... 28pioglitazone hcl tab 45 mg (base equiv) (Actos)............... 28piroxicam cap 10 mg (Feldene).........................................71piroxicam cap 20 mg (Feldene).........................................71PNEUMOVAX 23/1 DOSE – pneumococcal vaccinepolyvalent inj 25 mcg/0.5ml............................................. 15

PNEUMOVAX 23 – pneumococcal vaccine polyvalent inj25 mcg/0.5ml.................................................................... 15

PNV FOLIC ACID + IRON MUL – prenatal vit w/ fefumarate-fa tab 27-1 mg.................................................. 77

PNV PRENATAL PLUS MULTIVI – prenatal vit w/ fefumarate-fa tab 27-1 mg.................................................. 77

podofilox soln 0.5% (Condylox).........................................90polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%(Polytrim)...........................................................................83

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasicchew tab 0.25 mg.............................................................77

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasicchew tab 0.5 mg...............................................................77

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasicchew tab 1 mg..................................................................77

POMALYST – pomalidomide cap 1 mg.............................21POMALYST – pomalidomide cap 2 mg.............................21

POMALYST – pomalidomide cap 3 mg.............................21POMALYST – pomalidomide cap 4 mg.............................21posaconazole tab delayed release 100 mg (Noxafil).......... 9pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml.......51potassium bicarbonate effer tab 25 meq...........................79potassium chloride cap er 8 meq (Micro-k).......................79potassium chloride cap er 10 meq (Micro-k).....................79POTASSIUM CHLORIDE ER – potassium chloride tab er8 meq (600 mg)................................................................79

potassium chloride microencapsulated crys er tab 10meq....................................................................................79

potassium chloride microencapsulated crys er tab 20meq....................................................................................79

potassium chloride oral soln 10% (20 meq/15ml)............. 79potassium chloride oral soln 20% (40 meq/15ml)............. 79potassium chloride tab er 10 meq (K-tab).........................79potassium chloride tab er 8 meq (600 mg)....................... 79potassium citrate & citric acid powder pack 3300-1002mg......................................................................................51

potassium citrate & citric acid soln 1100-334 mg/5ml....... 51potassium citrate tab er 5 meq (540 mg) (Urocit-k 5)........51potassium citrate tab er 10 meq (1080 mg) (Urocit-k10)..................................................................................... 51

potassium citrate tab er 15 meq (1620 mg) (Urocit-k15)..................................................................................... 51

pot phos monobasic w/sod phos di & monobas tab155-852-130mg (K-phos neutral).....................................79

pramipexole dihydrochloride tab er 24hr 2.25 mg (Mirapexer)...................................................................................... 75

pramipexole dihydrochloride tab 0.125 mg (Mirapex).......75pramipexole dihydrochloride tab 0.25 mg (Mirapex).........75pramipexole dihydrochloride tab 0.5 mg (Mirapex)...........75pramipexole dihydrochloride tab 0.75 mg (Mirapex).........75pramipexole dihydrochloride tab 1 mg (Mirapex)..............75pramipexole dihydrochloride tab 1.5 mg (Mirapex)...........75pravastatin sodium tab 10 mg........................................... 39pravastatin sodium tab 20 mg (Pravachol)........................39pravastatin sodium tab 40 mg (Pravachol)........................39pravastatin sodium tab 80 mg (Pravachol)........................39praziquantel tab 600 mg (Biltricide)...................................14prazosin hcl cap 1 mg (Minipress).................................... 43prazosin hcl cap 2 mg (Minipress).................................... 43prazosin hcl cap 5 mg (Minipress).................................... 43PREDNICARBATE – prednicarbate cream 0.1%..............88PREDNICARBATE – prednicarbate oint 0.1%..................88PREDNISOLONE ACETATE – prednisolone acetateophth susp 1%..................................................................83

PREDNISOLONE – prednisolone syrup 15 mg/5ml (uspsolution equivalent)...........................................................24

PREDNISOLONE SODIUM PHOSP – prednisolonesodium phosphate ophth soln 1%................................... 83

prednisolone sod phosphate oral soln 15 mg/5ml (baseequiv).................................................................................24

prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5mlbase) (Pediapred).............................................................24

PREDNISONE – prednisone oral soln 5 mg/5ml.............. 24

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PREDNISONE – prednisone tab 50 mg............................24prednisone tab 1 mg..........................................................24prednisone tab 2.5 mg.......................................................24prednisone tab 5 mg..........................................................24prednisone tab 10 mg........................................................25prednisone tab 20 mg........................................................25prednisone tab therapy pack 5 mg (21)............................ 24prednisone tab therapy pack 5 mg (48)............................ 24prednisone tab therapy pack 10 mg (21).......................... 24prednisone tab therapy pack 10 mg (48).......................... 24PRENATAL AND IRON – prenatal multivitamins &minerals w/iron & fa tab 0.8 mg.......................................78

PRE-NATAL FORMULA – prenatal multivitamins &minerals w/iron & fa tab 0.8 mg.......................................78

PRENATAL FORTE – prenatal multivitamins & mineralsw/iron & fa tab 0.8 mg..................................................... 78

PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fatab 27-0.8 mg................................................................... 78

PRENATAL MULTI +DHA – prenatal vit w/ fe fum-fa-omega 3 cap 27-0.8-228 mg........................................... 78

PRENATAL MULTIVITAMIN – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...............................................................78

PRENATAL ONE DAILY – prenatal vit w/ fe fumarate-fatab 27-0.8 mg................................................................... 78

PRENATAL – prenatal multivitamins & minerals w/iron &fa tab 0.8 mg.................................................................... 78

PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab29-1 mg.............................................................................78

PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab29-1 mg.............................................................................78

PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8mg......................................................................................78

PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................78

PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................78

PRENATAL VITAMIN/IRON – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...............................................................78

PRENATAL VITAMIN & MINERA – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 78

PRENATAL VITAMIN – prenatal vit w/ fe fumarate-fa tab27-0.8 mg..........................................................................78

PRENATAL VITAMINS PLUS LO – prenatal vit w/ fefumarate-fa tab 27-1 mg.................................................. 78

PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab28-0.8 mg..........................................................................78

prenatal vit w/ fe fumarate-fa tab 28-0.8 mg..................... 78PREPLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................78

PREVIDENT 5000 DRY MOUTH – sodium fluoride gel1.1% (0.5% f)....................................................................85

PREVIDENT FLUORIDE – sodium fluoride gel 1.1%(0.5% f)............................................................................. 85

PREVIDENT RINSE – sodium fluoride rinse 0.2%........... 85PREVNAR 13 – pneumococcal 13-valent conjugatevaccine inj......................................................................... 15

PREZCOBIX – darunavir-cobicistat tab 800-150 mg........12PREZISTA – darunavir ethanolate susp 100 mg/ml (baseequiv).................................................................................12

PREZISTA – darunavir ethanolate tab 75 mg (baseequiv).................................................................................12




PRIFTIN – rifapentine tab 150 mg...................................... 8primaquine phosphate tab 26.3 mg (15 mg base)(Primaquine phosphate)................................................... 13

primidone tab 50 mg (Mysoline)........................................74primidone tab 250 mg (Mysoline)......................................74probenecid tab 500 mg......................................................72prochlorperazine maleate tab 5 mg (base equivalent)......59prochlorperazine maleate tab 10 mg (baseequivalent).........................................................................59

prochlorperazine suppos 25 mg........................................ 59progesterone micronized cap 100 mg (Prometrium).........26progesterone micronized cap 200 mg (Prometrium).........26PROMACTA – eltrombopag olamine powder pack forsusp 12.5 mg (base eq)...................................................82

PROMACTA – eltrombopag olamine tab 12.5 mg (baseequiv).................................................................................82

PROMACTA – eltrombopag olamine tab 25 mg (baseequiv).................................................................................82



promethazine hcl suppos 12.5 mg.................................... 44promethazine hcl suppos 25 mg....................................... 44promethazine hcl syrup 6.25 mg/5ml................................ 44promethazine hcl tab 12.5 mg...........................................44promethazine hcl tab 25 mg..............................................44promethazine hcl tab 50 mg..............................................44promethazine w/ codeine syrup 6.25-10 mg/5ml.............. 44propafenone hcl tab 150 mg..............................................41propafenone hcl tab 300 mg..............................................41propafenone hcl tab 225 mg (Rythmol).............................41proparacaine hcl ophth soln 0.5% (Alcaine)......................84PROPRANOLOL/HYDROCHLOROTH – propranolol &hydrochlorothiazide tab 40-25 mg................................... 36

PROPRANOLOL/HYDROCHLOROTH – propranolol &hydrochlorothiazide tab 80-25 mg................................... 36

propranolol hcl cap er 24hr 60 mg (Inderal la)..................36propranolol hcl cap er 24hr 80 mg (Inderal la)..................36propranolol hcl cap er 24hr 120 mg (Inderal la)................36propranolol hcl cap er 24hr 160 mg (Inderal la)................36PROPRANOLOL HCL – propranolol hcl oral soln 20mg/5ml...............................................................................36

PROPRANOLOL HCL – propranolol hcl oral soln 40mg/5ml...............................................................................36

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propranolol hcl tab 10 mg..................................................36propranolol hcl tab 20 mg..................................................36propranolol hcl tab 40 mg..................................................36propranolol hcl tab 60 mg..................................................36propranolol hcl tab 80 mg..................................................36propylthiouracil tab 50 mg................................................. 30PULMOZYME – dornase alfa inhal soln 1 mg/ml..............47PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml)......................................................................................21

PX PRENATAL MULTIVITAMINS – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 78

pyrazinamide tab 500 mg.................................................... 8pyridostigmine bromide tab 60 mg (Mestinon)..................76

QQC PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................78

QUAZEPAM – quazepam tab 15 mg................................ 61quetiapine fumarate tab er 24hr 50 mg (Seroquel xr)....... 59quetiapine fumarate tab er 24hr 150 mg (Seroquel xr)..... 59quetiapine fumarate tab er 24hr 200 mg (Seroquel xr)..... 59quetiapine fumarate tab er 24hr 300 mg (Seroquel xr)..... 59quetiapine fumarate tab er 24hr 400 mg (Seroquel xr)..... 59quetiapine fumarate tab 25 mg (Seroquel)........................59quetiapine fumarate tab 50 mg (Seroquel)........................59quetiapine fumarate tab 100 mg (Seroquel)......................59quetiapine fumarate tab 200 mg (Seroquel)......................59quetiapine fumarate tab 300 mg (Seroquel)......................59quetiapine fumarate tab 400 mg (Seroquel)......................59quinapril hcl tab 5 mg (Accupril)........................................33quinapril hcl tab 10 mg (Accupril)......................................33quinapril hcl tab 20 mg (Accupril)......................................33quinapril hcl tab 40 mg (Accupril)......................................33quinapril-hydrochlorothiazide tab 10-12.5 mg(Accuretic)......................................................................... 33

quinapril-hydrochlorothiazide tab 20-12.5 mg(Accuretic)......................................................................... 33

quinapril-hydrochlorothiazide tab 20-25 mg(Accuretic)......................................................................... 33

quinidine gluconate tab er 324 mg....................................41QUINIDINE SULFATE – quinidine sulfate tab 200 mg......41QUINIDINE SULFATE – quinidine sulfate tab 300 mg......41QVAR REDIHALER – beclomethasone diprop hfa breathact inh aer 40 mcg/act..................................................... 46

QVAR REDIHALER – beclomethasone diprop hfa breathact inh aer 80 mcg/act..................................................... 46

RRABAVERT – rabies vaccine, pcec for inj.........................15rabeprazole sodium ec tab 20 mg (Aciphex).................... 48raloxifene hcl tab 60 mg (Evista).......................................31ramipril cap 1.25 mg (Altace)............................................ 33ramipril cap 2.5 mg (Altace).............................................. 33ramipril cap 5 mg (Altace)................................................. 33ramipril cap 10 mg (Altace)............................................... 34ranitidine hcl syrup 15 mg/ml (75 mg/5ml)........................ 48

ranitidine hcl tab 150 mg (Zantac).....................................48ranitidine hcl tab 300 mg (Zantac).....................................48RA PRENATAL FORMULA/FOLIC – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 78

RA PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................78

RAVICTI – glycerol phenylbutyrate liquid 1.1 gm/ml......... 31RECOMBIVAX HB – hepatitis b vaccine (recombinant)susp 5 mcg/0.5ml............................................................. 16

RECOMBIVAX HB – hepatitis b vaccine (recombinant)susp 10 mcg/ml................................................................ 16

RECOMBIVAX HB – hepatitis b vaccine (recombinant)susp 40 mcg/ml................................................................ 16

RELENZA DISKHALER – zanamivir aero powder breathactivated 5 mg/blister....................................................... 13

RELION R – insulin regular (human) inj 100 unit/ml......... 29REPATHA – evolocumab subcutaneous soln prefilledsyringe 140 mg/ml............................................................40

REPATHA PUSHTRONEX SYSTEM – evolocumabsubcutaneous soln cartridge/infusor 420 mg/3.5ml.........40

REPATHA SURECLICK – evolocumab subcutaneous solnauto-injector 140 mg/ml....................................................40

REPEL SPORTSMEN – diethyltoluamide (deet)aerosol...............................................................................90

REPEL SPORTSMEN MAX – diethyltoluamide (deet)aerosol...............................................................................90

RESCRIPTOR – delavirdine mesylate tab 200 mg...........12RETACRIT – epoetin alfa-epbx inj 2000 unit/ml................82RETACRIT – epoetin alfa-epbx inj 3000 unit/ml................82RETACRIT – epoetin alfa-epbx inj 4000 unit/ml................82RETACRIT – epoetin alfa-epbx inj 10000 unit/ml..............82RETACRIT – epoetin alfa-epbx inj 40000 unit/ml..............82REVLIMID – lenalidomide cap 5 mg................................. 91REVLIMID – lenalidomide cap 10 mg............................... 92REVLIMID – lenalidomide cap 15 mg............................... 92REVLIMID – lenalidomide cap 20 mg............................... 92REVLIMID – lenalidomide cap 25 mg............................... 92REVLIMID – lenalidomide caps 2.5 mg............................ 91REXULTI – brexpiprazole tab 0.25 mg..............................59REXULTI – brexpiprazole tab 0.5 mg................................59REXULTI – brexpiprazole tab 1 mg...................................59REXULTI – brexpiprazole tab 2 mg...................................59REXULTI – brexpiprazole tab 3 mg...................................59REXULTI – brexpiprazole tab 4 mg...................................59ribavirin cap 200 mg (Rebetol)............................................ 9ribavirin tab 200 mg (Copegus)...........................................9rifabutin cap 150 mg (Mycobutin)........................................8rifampin cap 150 mg (Rifadin)............................................. 8rifampin cap 300 mg (Rifadin)............................................. 8RIGHT STEP PRENATAL – prenatal vit w/ fe fumarate-fatab 27-0.8 mg................................................................... 78

riluzole tab 50 mg (Rilutek)................................................76ringer's solution for irrigation..............................................92risedronate sodium tab delayed release 35 mg(Atelvia)............................................................................. 31

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RISPERDAL CONSTA – risperidone microspheres for inj12.5 mg.............................................................................59

RISPERDAL CONSTA – risperidone microspheres for inj25 mg................................................................................ 59

RISPERDAL CONSTA – risperidone microspheres for inj37.5 mg.............................................................................60

RISPERDAL CONSTA – risperidone microspheres for inj50 mg................................................................................ 60

RISPERIDONE ODT – risperidone orally disintegratingtab 0.25 mg...................................................................... 60

risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab).................................................................................... 60

risperidone orally disintegrating tab 1 mg (Risperdal m-tab).................................................................................... 60




risperidone soln 1 mg/ml (Risperdal).................................60risperidone tab 0.25 mg (Risperdal)..................................60risperidone tab 0.5 mg (Risperdal)....................................60risperidone tab 1 mg (Risperdal).......................................60risperidone tab 2 mg (Risperdal).......................................60risperidone tab 3 mg (Risperdal).......................................60risperidone tab 4 mg (Risperdal).......................................60ritonavir tab 100 mg (Norvir)..............................................12rivastigmine tartrate cap 4.5 mg (base equivalent)........... 65rizatriptan benzoate oral disintegrating tab 5 mg (base eq)(Maxalt-mlt)....................................................................... 71

rizatriptan benzoate oral disintegrating tab 10 mg (baseeq) (Maxalt-mlt).................................................................71

rizatriptan benzoate tab 5 mg (base equivalent)(Maxalt)............................................................................. 71

rizatriptan benzoate tab 10 mg (base equivalent)(Maxalt)............................................................................. 71

ropinirole hydrochloride tab 0.25 mg (Requip)..................75ropinirole hydrochloride tab 0.5 mg (Requip)....................75ropinirole hydrochloride tab 1 mg (Requip).......................76ropinirole hydrochloride tab 2 mg (Requip).......................76ropinirole hydrochloride tab 3 mg (Requip).......................76ropinirole hydrochloride tab 4 mg (Requip).......................76ropinirole hydrochloride tab 5 mg (Requip).......................76rosuvastatin calcium tab 5 mg (Crestor)........................... 40rosuvastatin calcium tab 10 mg (Crestor)......................... 40rosuvastatin calcium tab 20 mg (Crestor)......................... 40rosuvastatin calcium tab 40 mg (Crestor)......................... 40RUBRACA – rucaparib camsylate tab 200 mg (baseequivalent).........................................................................21

RUBRACA – rucaparib camsylate tab 250 mg (baseequivalent).........................................................................21

RUBRACA – rucaparib camsylate tab 300 mg (baseequivalent).........................................................................21

Ssalicylic acid cream 6%..................................................... 87salicylic acid cream 6% & cleanser liqd kit (Salexcream)............................................................................... 87

salicylic acid film forming liquid 27.5% (Virasal)................87salicylic acid foam 6% (Salvax).........................................87salicylic acid gel 6% (Keralyt)............................................87salicylic acid lotion 6%.......................................................87SALICYLIC ACID LOTION – salicylic acid lotion 6% &cleanser liqd kit.................................................................87

salicylic acid shampoo 6% (Salex)....................................87SAMSCA – tolvaptan tab 15 mg....................................... 31SAMSCA – tolvaptan tab 30 mg....................................... 31SAPHRIS – asenapine maleate sl tab 2.5 mg (baseequiv).................................................................................60

SAPHRIS – asenapine maleate sl tab 5 mg (baseequiv).................................................................................60

SAPHRIS – asenapine maleate sl tab 10 mg (baseequiv).................................................................................60

SAWYER PREMIUM INSECT REP – picaridin liquid....... 90selegiline hcl cap 5 mg (Eldepryl)..................................... 76SELEGILINE HCL – selegiline hcl tab 5 mg..................... 76selenium sulfide lotion 2.5%.............................................. 90selenium sulfide shampoo 2.25%......................................90SELZENTRY – maraviroc tab 150 mg.............................. 12SELZENTRY – maraviroc tab 300 mg.............................. 12SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1mg......................................................................................79

SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab29-1 mg.............................................................................79

SEROSTIM – somatropin (non-refrigerated) forsubcutaneous inj 4 mg.....................................................30



sertraline hcl oral concentrate for solution 20 mg/ml(Zoloft)............................................................................... 55

sertraline hcl tab 25 mg (Zoloft)........................................ 55sertraline hcl tab 50 mg (Zoloft)........................................ 55sertraline hcl tab 100 mg (Zoloft)...................................... 55sevelamer carbonate packet 0.8 gm (Renvela)................ 49sevelamer carbonate packet 2.4 gm (Renvela)................ 49sevelamer carbonate tab 800 mg (Renvela).....................49SHINGRIX – zoster vac recombinant adjuvanted for im inj50 mcg/0.5ml.................................................................... 16

SIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (baseequiv).................................................................................31



sildenafil citrate for suspension 10 mg/ml (Revatio)..........43sildenafil citrate tab 20 mg (Revatio).................................43silver sulfadiazine cream 1% (Silvadene)......................... 87

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SIMPONI – golimumab subcutaneous soln auto-injector50 mg/0.5ml...................................................................... 71

SIMPONI – golimumab subcutaneous soln auto-injector100 mg/ml......................................................................... 71

SIMPONI – golimumab subcutaneous soln prefilledsyringe 50 mg/0.5ml.........................................................71

SIMPONI – golimumab subcutaneous soln prefilledsyringe 100 mg/ml............................................................71

simvastatin tab 5 mg (Zocor).............................................40simvastatin tab 10 mg (Zocor)...........................................40simvastatin tab 20 mg (Zocor)...........................................40simvastatin tab 40 mg (Zocor)...........................................40simvastatin tab 80 mg (Zocor)...........................................40sirolimus tab 0.5 mg (Rapamune)..................................... 92sirolimus tab 1 mg (Rapamune)........................................ 92sirolimus tab 2 mg (Rapamune)........................................ 92SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5mg total)............................................................................26

SM PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fatab 28-0.8 mg................................................................... 79

sodium chloride irrigation soln 0.9%..................................51sodium chloride soln nebu 0.9%....................................... 44sodium chloride soln nebu 3%.......................................... 44sodium chloride soln nebu 10%........................................ 44sodium chloride soln nebu 7% (Hyper-sal)....................... 44sodium citrate & citric acid soln 500-334 mg/5ml (Shohlssolution modi)................................................................... 51

sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)(Luride).............................................................................. 79

sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)(Luride).............................................................................. 79

sodium fluoride chew tab 1 mg f (from 2.2 mg naf)(Luride).............................................................................. 79

sodium fluoride cream 1.1% (Prevident 5000 plus).......... 85sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)......85sodium fluoride paste 1.1% (Prevident 5000 boost)......... 85sodium fluoride-potassium nitrate paste 1.1-5% (Prevident5000 sensi)....................................................................... 85

sodium fluoride rinse 0.2%................................................ 85SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from1.1 mg naf)....................................................................... 79

SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from2.2 mg naf)....................................................................... 79

sodium fluoride soln 0.125 mg/drop f (0.275 mg/dropnaf).................................................................................... 79

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)(Luride).............................................................................. 79

sodium polystyrene sulfonate oral susp 15 gm/60ml........ 92sodium polystyrene sulfonate powder (Kayexalate)..........92sodium polystyrene sulfonate rectal susp 30gm/120ml...........................................................................92

SOFOSBUVIR/VELPATASVIR – sofosbuvir-velpatasvirtab 400-100 mg................................................................ 10

SOLU-CORTEF – hydrocortisone sodium succinate pf forinj 100 mg.........................................................................25



SOLU-CORTEF – hydrocortisone sodium succinate pf forinj 1000 mg.......................................................................25

SOMAVERT – pegvisomant for inj 10 mg (as protein)......32SOMAVERT – pegvisomant for inj 15 mg (as protein)......32SOMAVERT – pegvisomant for inj 20 mg (as protein)......32SOMAVERT – pegvisomant for inj 25 mg (as protein)......32SOMAVERT – pegvisomant for inj 30 mg (as protein)......32sotalol hcl (afib/afl) tab 80 mg (Betapace af).................... 41sotalol hcl (afib/afl) tab 120 mg (Betapace af).................. 41sotalol hcl (afib/afl) tab 160 mg (Betapace af).................. 41sotalol hcl tab 240 mg....................................................... 42sotalol hcl tab 80 mg (Betapace).......................................41sotalol hcl tab 120 mg (Betapace).....................................41sotalol hcl tab 160 mg (Betapace).....................................42speciality vitamin product tab............................................ 79spironolactone & hydrochlorothiazide tab 25-25 mg(Aldactazide)..................................................................... 41

spironolactone tab 25 mg (Aldactone)...............................41spironolactone tab 50 mg (Aldactone)...............................41spironolactone tab 100 mg (Aldactone)............................ 41SPRYCEL – dasatinib tab 20 mg...................................... 21SPRYCEL – dasatinib tab 50 mg...................................... 21SPRYCEL – dasatinib tab 70 mg...................................... 21SPRYCEL – dasatinib tab 80 mg...................................... 21SPRYCEL – dasatinib tab 100 mg.................................... 21SPRYCEL – dasatinib tab 140 mg.................................... 21stannous fluoride gel 0.4%................................................ 85stavudine cap 15 mg (Zerit)...............................................12stavudine cap 20 mg (Zerit)...............................................12stavudine cap 30 mg (Zerit)...............................................12stavudine cap 40 mg (Zerit)...............................................12STEGLATRO – ertugliflozin l-pyroglutamic acid tab 5 mg(base equiv)...................................................................... 28

STEGLATRO – ertugliflozin l-pyroglutamic acid tab 15 mg(base equiv)...................................................................... 28

STELARA – ustekinumab soln prefilled syringe 45mg/0.5ml............................................................................90

STELARA – ustekinumab soln prefilled syringe 90 mg/ml.......................................................................................90

STIMATE – desmopressin acetate nasal soln 1.5 mg/ml.......................................................................................32

STIVARGA – regorafenib tab 40 mg................................. 21STRENSIQ – asfotase alfa subcutaneous inj 18mg/0.45ml......................................................................... 32

STRENSIQ – asfotase alfa subcutaneous inj 28mg/0.7ml............................................................................32

STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml.......................................................................................32

STRENSIQ – asfotase alfa subcutaneous inj 80mg/0.8ml............................................................................32

STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab150-150-200-300 mg........................................................12

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STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln2.5 mcg/act (base equiv)................................................. 46

SUBOXONE – buprenorphine hcl-naloxone hcl sl film2-0.5 mg (base equiv)......................................................68

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1mg (base equiv)................................................................68

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2mg (base equiv)................................................................68

SUBOXONE – buprenorphine hcl-naloxone hcl sl film12-3 mg (base equiv).......................................................68

SUCRAID – sacrosidase soln 8500 unit/ml.......................49sucralfate tab 1 gm (Carafate)...........................................48SULFACETAMIDE SODIUM/PRED – sulfacetamidesodium-prednisolone ophth soln 10-0.23(0.25)%............83

sulfacetamide sodium lotion 10% (acne) (Klaron).............86sulfacetamide sodium ophth soln 10% (Bleph-10)............83sulfamethoxazole-trimethoprim susp 200-40 mg/5ml....... 14sulfamethoxazole-trimethoprim tab 400-80 mg(Bactrim)............................................................................14

sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrimds)......................................................................................14

sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)...................................................................................49

sulfasalazine tab 500 mg (Azulfidine)................................49sulindac tab 150 mg...........................................................71sulindac tab 200 mg...........................................................71sumatriptan nasal spray 5 mg/act (Imitrex).......................71sumatriptan nasal spray 20 mg/act (Imitrex).....................71sumatriptan succinate inj 6 mg/0.5ml (Imitrex)..................71sumatriptan succinate solution auto-injector 4 mg/0.5ml(Imitrex statdose sys)....................................................... 71

sumatriptan succinate solution auto-injector 6 mg/0.5ml(Imitrex statdose sys)....................................................... 72

sumatriptan succinate solution cartridge 4 mg/0.5ml(Imitrex statdose ref)........................................................ 72

sumatriptan succinate solution cartridge 6 mg/0.5ml(Imitrex statdose ref)........................................................ 72

SUMATRIPTAN SUCCINATE – sumatriptan succinatesolution prefilled syringe 6 mg/0.5ml............................... 71

sumatriptan succinate tab 25 mg (Imitrex)........................72sumatriptan succinate tab 50 mg (Imitrex)........................72sumatriptan succinate tab 100 mg (Imitrex)......................72SUSTIVA – efavirenz cap 50 mg.......................................12SUSTIVA – efavirenz cap 200 mg.....................................12SUSTIVA – efavirenz tab 600 mg..................................... 12SUTENT – sunitinib malate cap 12.5 mg (baseequivalent).........................................................................21

SUTENT – sunitinib malate cap 25 mg (baseequivalent).........................................................................21

SUTENT – sunitinib malate cap 37.5 mg (baseequivalent).........................................................................22

SUTENT – sunitinib malate cap 50 mg (baseequivalent).........................................................................22

SYLATRON – peginterferon alfa-2b for inj kit 200 mcg.....22SYLATRON – peginterferon alfa-2b for inj kit 300 mcg.....22SYLATRON – peginterferon alfa-2b for inj kit 600 mcg.....22

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 80-4.5 mcg/act.....................................................46

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 160-4.5 mcg/act...................................................46

SYMDEKO – tezacaftor-ivacaftor 50-75 mg & ivacaftor 75mg tab tbpk.......................................................................47

SYMDEKO – tezacaftor-ivacaftor 100-150 mg & ivacaftor150 mg tab tbpk............................................................... 47

SYMFI – efavirenz-lamivudine-tenofovir df tab600-300-300 mg............................................................... 12

SYMFI LO – efavirenz-lamivudine-tenofovir df tab400-300-300 mg............................................................... 12

SYMTUZA – darunavir-cobic-emtricitab-tenofov af tab800-150-200-10 mg..........................................................12

SYNAGIS – palivizumab im soln 50 mg/0.5ml..................16SYNAGIS – palivizumab im soln 100 mg/ml.....................16SYNAREL – nafarelin acetate nasal soln 2 mg/ml (200mcg/act) (base eq)........................................................... 27

TTABLOID – thioguanine tab 40 mg................................... 22tacrolimus cap 0.5 mg (Prograf)........................................92tacrolimus cap 1 mg (Prograf)...........................................92tacrolimus cap 5 mg (Prograf)...........................................92tacrolimus oint 0.03% (Protopic)........................................90tacrolimus oint 0.1% (Protopic)..........................................90tadalafil tab 20 mg (pah) (Adcirca)....................................43TAFINLAR – dabrafenib mesylate cap 50 mg (baseequivalent).........................................................................22

TAFINLAR – dabrafenib mesylate cap 75 mg (baseequivalent).........................................................................22

TALZENNA – talazoparib tosylate cap 0.25 mg (baseequivalent).........................................................................22

TALZENNA – talazoparib tosylate cap 1 mg (baseequivalent).........................................................................22

tamoxifen citrate tab 10 mg (base equivalent).................. 22tamoxifen citrate tab 20 mg (base equivalent).................. 22tamsulosin hcl cap 0.4 mg (Flomax)................................. 51TARGRETIN – bexarotene cap 75 mg..............................22TASIGNA – nilotinib hcl cap 50 mg (base equivalent)...... 22TASIGNA – nilotinib hcl cap 150 mg (baseequivalent).........................................................................22

TASIGNA – nilotinib hcl cap 200 mg (baseequivalent).........................................................................22

tazarotene cream 0.1% (Tazorac)..................................... 86TAZORAC – tazarotene cream 0.05%.............................. 86TAZORAC – tazarotene gel 0.05%................................... 86TAZORAC – tazarotene gel 0.1%..................................... 86TECHLITE PEN NEEDLES 29G....................................... 90temazepam cap 15 mg (Restoril)...................................... 61temazepam cap 30 mg (Restoril)...................................... 61temozolomide cap 5 mg (Temodar)...................................22temozolomide cap 20 mg (Temodar).................................22temozolomide cap 100 mg (Temodar)...............................22temozolomide cap 140 mg (Temodar)...............................22temozolomide cap 180 mg (Temodar)...............................22

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temozolomide cap 250 mg (Temodar)...............................22tenofovir disoproxil fumarate tab 300 mg (Viread)............ 12terazosin hcl cap 1 mg (base equivalent)......................... 43terazosin hcl cap 2 mg (base equivalent)......................... 43terazosin hcl cap 5 mg (base equivalent)......................... 43terazosin hcl cap 10 mg (base equivalent)....................... 43terbinafine hcl tab 250 mg (Lamisil).................................... 9terbutaline sulfate tab 2.5 mg............................................46terbutaline sulfate tab 5 mg...............................................46TERCONAZOLE – terconazole vaginal cream 0.8%........50terconazole vaginal cream 0.4% (Terazol 7).....................50terconazole vaginal suppos 80 mg....................................50testosterone td gel 12.5 mg/act (1%) (Androgelpump)................................................................................ 25

testosterone td gel 25 mg/2.5gm (1%) (Androgel)............ 25testosterone td gel 50 mg/5gm (1%) (Androgel)............... 25tetracaine hcl ophth soln 0.5%.......................................... 84THALOMID – thalidomide cap 50 mg............................... 92THALOMID – thalidomide cap 100 mg............................. 92THALOMID – thalidomide cap 150 mg............................. 92THALOMID – thalidomide cap 200 mg............................. 92THEOCHRON – theophylline tab er 12hr 100 mg............ 46THEOCHRON – theophylline tab er 12hr 200 mg............ 46THEOPHYLLINE ER – theophylline tab er 12hr 450mg......................................................................................46

theophylline soln 80 mg/15ml............................................46theophylline tab er 12hr 300 mg........................................46theophylline tab er 24hr 400 mg........................................46theophylline tab er 24hr 600 mg........................................46thioridazine hcl tab 10 mg................................................. 60thioridazine hcl tab 25 mg................................................. 60thioridazine hcl tab 50 mg................................................. 60thioridazine hcl tab 100 mg............................................... 60thiothixene cap 1 mg..........................................................60thiothixene cap 2 mg..........................................................60thiothixene cap 5 mg..........................................................60thiothixene cap 10 mg........................................................60thyroid tab 30 mg (1/2 grain) (Armour thyroid)..................30thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)...............30thyroid tab 60 mg (1 grain) (Armour thyroid).....................30tiagabine hcl tab 2 mg (Gabitril)........................................ 74tiagabine hcl tab 4 mg (Gabitril)........................................ 74TIBSOVO – ivosidenib tab 250 mg................................... 22timolol maleate ophth soln 0.25% (Timoptic).................... 84timolol maleate ophth soln 0.5% (Timoptic)...................... 84TIVICAY – dolutegravir sodium tab 50 mg (baseequiv).................................................................................12

tizanidine hcl tab 2 mg (base equivalent)..........................76tizanidine hcl tab 4 mg (base equivalent) (Zanaflex).........76tobramycin nebu soln 300 mg/5ml (Tobi)............................ 8tobramycin ophth soln 0.3% (Tobrex)................................83TOBRAMYCIN – tobramycin nebu soln 300 mg/5ml.......... 8tolcapone tab 100 mg (Tasmar)........................................ 76tolterodine tartrate tab 2 mg (Detrol).................................50topiramate sprinkle cap 15 mg (Topamax sprinkle).......... 74topiramate sprinkle cap 25 mg (Topamax sprinkle).......... 74

topiramate tab 25 mg (Topamax)...................................... 74topiramate tab 50 mg (Topamax)...................................... 74topiramate tab 100 mg (Topamax).................................... 75topiramate tab 200 mg (Topamax).................................... 75toremifene citrate tab 60 mg (base equivalent)(Fareston)..........................................................................22

torsemide tab 5 mg............................................................41torsemide tab 100 mg........................................................41torsemide tab 10 mg (Demadex).......................................41torsemide tab 20 mg (Demadex).......................................41TRACLEER – bosentan tab for oral susp 32 mg.............. 43tramadol-acetaminophen tab 37.5-325 mg (Ultracet)....... 68tramadol hcl tab 50 mg (Ultram)........................................68TRANDOLAPRIL/VERAPAMIL HC – trandolapril-verapamil hcl tab er 1-240 mg.........................................38

trandolapril tab 4 mg..........................................................34trandolapril tab 1 mg (Mavik).............................................34trandolapril tab 2 mg (Mavik).............................................34trandolapril-verapamil hcl tab er 2-180 mg (Tarka)........... 37trandolapril-verapamil hcl tab er 2-240 mg (Tarka)........... 38trandolapril-verapamil hcl tab er 4-240 mg (Tarka)........... 38tranexamic acid tab 650 mg (Lysteda).............................. 82trazodone hcl tab 50 mg....................................................55trazodone hcl tab 100 mg..................................................55trazodone hcl tab 150 mg..................................................55tretinoin cap 10 mg............................................................ 22tretinoin cream 0.025% (Retin-a).......................................86tretinoin cream 0.05% (Retin-a).........................................86tretinoin cream 0.1% (Retin-a)...........................................86tretinoin gel 0.05% (Atralin)............................................... 86tretinoin gel 0.01% (Retin-a)..............................................86tretinoin gel 0.025% (Retin-a)............................................86triamcinolone acetonide aerosol soln 0.147 mg/gm(Kenalog)...........................................................................88

triamcinolone acetonide cream 0.025%............................ 88triamcinolone acetonide cream 0.1%................................ 88triamcinolone acetonide cream 0.5%................................ 88triamcinolone acetonide dental paste 0.1%...................... 85triamcinolone acetonide lotion 0.025%..............................88triamcinolone acetonide lotion 0.1%..................................89triamcinolone acetonide nasal aerosol suspension 55mcg/act..............................................................................44

triamcinolone acetonide oint 0.025%................................ 89triamcinolone acetonide oint 0.1%.....................................89triamterene & hydrochlorothiazide cap 37.5-25 mg(Dyazide)...........................................................................41

triamterene & hydrochlorothiazide tab 37.5-25 mg(Maxzide-25)..................................................................... 41

triamterene & hydrochlorothiazide tab 75-50 mg(Maxzide)...........................................................................41

TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1 mg.....79trientine hcl cap 250 mg (Syprine).................................... 92trifluoperazine hcl tab 1 mg (base equivalent).................. 60trifluoperazine hcl tab 2 mg (base equivalent).................. 60trifluoperazine hcl tab 5 mg (base equivalent).................. 60trifluoperazine hcl tab 10 mg (base equivalent)................ 60

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TRIFLURIDINE – trifluridine ophth soln 1%......................83trihexyphenidyl hcl elixir 0.4 mg/ml....................................76trihexyphenidyl hcl tab 2 mg..............................................76trihexyphenidyl hcl tab 5 mg..............................................76trimethobenzamide hcl cap 300 mg (Tigan)......................48trimethoprim tab 100 mg....................................................14TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1mg......................................................................................79

TRIUMEQ – abacavir-dolutegravir-lamivudine tab600-50-300 mg................................................................. 12

trospium chloride cap er 24hr 60 mg................................ 50trospium chloride tab 20 mg..............................................50TRUEPLUS INSULIN SYRINGE/...................................... 90TRULICITY – dulaglutide soln pen-injector 0.75mg/0.5ml............................................................................28

TRULICITY – dulaglutide soln pen-injector 1.5mg/0.5ml............................................................................28

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 100-150 mg................................................................ 12




TYBOST – cobicistat tab 150 mg......................................13TYKERB – lapatinib ditosylate tab 250 mg (baseequiv).................................................................................22

TYMLOS – abaloparatide subcutaneous soln pen-injector3120 mcg/1.56ml.............................................................. 32

TYVASO REFILL – treprostinil inhalation solution 0.6 mg/ml.......................................................................................43

TYVASO STARTER – treprostinil inhalation solution 0.6mg/ml.................................................................................43

TYVASO – treprostinil inhalation solution 0.6 mg/ml.........43

UUPTRAVI – selexipag tab 200 mcg...................................43UPTRAVI – selexipag tab 400 mcg...................................43UPTRAVI – selexipag tab 600 mcg...................................43UPTRAVI – selexipag tab 800 mcg...................................43UPTRAVI – selexipag tab 1000 mcg.................................43UPTRAVI – selexipag tab 1200 mcg.................................43UPTRAVI – selexipag tab 1400 mcg.................................43UPTRAVI – selexipag tab 1600 mcg.................................43UPTRAVI – selexipag tab therapy pack 200 mcg (140) &800 mcg (60).................................................................... 43

ursodiol cap 300 mg (Actigall)...........................................50ursodiol tab 250 mg (Urso 250).........................................50ursodiol tab 500 mg (Urso forte)....................................... 50

Vvalacyclovir hcl tab 1 gm (Valtrex).....................................10valacyclovir hcl tab 500 mg (Valtrex).................................10valganciclovir hcl for soln 50 mg/ml (base equiv)(Valcyte).............................................................................. 9

valganciclovir hcl tab 450 mg (base equivalent)(Valcyte).............................................................................. 9

valproic acid cap 250 mg (Depakene)...............................75valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovanhct).....................................................................................34

valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovanhct).....................................................................................34

valsartan-hydrochlorothiazide tab 160-25 mg (Diovanhct).....................................................................................34

valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovanhct).....................................................................................34

valsartan-hydrochlorothiazide tab 320-25 mg (Diovanhct).....................................................................................34

valsartan tab 40 mg (Diovan)............................................ 34valsartan tab 80 mg (Diovan)............................................ 34valsartan tab 160 mg (Diovan).......................................... 34valsartan tab 320 mg (Diovan).......................................... 34vancomycin hcl cap 125 mg (base equivalent) (Vancocinhcl).....................................................................................14

vancomycin hcl cap 250 mg (base equivalent) (Vancocinhcl).....................................................................................14

VENCLEXTA STARTING PACK – venetoclax tab therapystarter pack 10 & 50 & 100 mg....................................... 23

VENCLEXTA – venetoclax tab 10 mg...............................22VENCLEXTA – venetoclax tab 50 mg...............................22VENCLEXTA – venetoclax tab 100 mg.............................23venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)(Effexor xr)........................................................................ 55

venlafaxine hcl cap er 24hr 75 mg (base equivalent)(Effexor xr)........................................................................ 55

venlafaxine hcl cap er 24hr 150 mg (base equivalent)(Effexor xr)........................................................................ 55

venlafaxine hcl tab 25 mg (base equivalent).....................55venlafaxine hcl tab 37.5 mg (base equivalent)..................55venlafaxine hcl tab 50 mg (base equivalent).....................55venlafaxine hcl tab 75 mg (base equivalent).....................55venlafaxine hcl tab 100 mg (base equivalent)...................55verapamil hcl cap er 24hr 120 mg (Verelan).....................38verapamil hcl cap er 24hr 180 mg (Verelan).....................38verapamil hcl cap er 24hr 240 mg (Verelan).....................38verapamil hcl cap er 24hr 200 mg (Verelan pm)...............38VERAPAMIL HCL ER – verapamil hcl cap er 24hr 100mg......................................................................................38

VERAPAMIL HCL ER – verapamil hcl cap er 24hr 300mg......................................................................................38

VERAPAMIL HCL SR – verapamil hcl cap er 24hr 360mg......................................................................................38

verapamil hcl tab er 120 mg (Calan sr).............................38verapamil hcl tab er 180 mg (Calan sr).............................38verapamil hcl tab er 240 mg (Calan sr).............................38verapamil hcl tab 40 mg.................................................... 38verapamil hcl tab 80 mg (Calan)....................................... 38verapamil hcl tab 120 mg (Calan)..................................... 38VERSACLOZ – clozapine susp 50 mg/ml.........................60VERZENIO – abemaciclib tab 50 mg................................23VERZENIO – abemaciclib tab 100 mg..............................23

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VERZENIO – abemaciclib tab 150 mg..............................23VERZENIO – abemaciclib tab 200 mg..............................23VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml)......................................................................................28

VIDEX – didanosine for soln 2 gm....................................13vigabatrin powd pack 500 mg (Sabril)...............................75vigabatrin tab 500 mg (Sabril)........................................... 75VIIBRYD STARTER PACK – vilazodone hcl tab starter kit10 (7) & 20 (23) mg......................................................... 55

VIIBRYD – vilazodone hcl tab 10 mg................................55VIIBRYD – vilazodone hcl tab 20 mg................................55VIIBRYD – vilazodone hcl tab 40 mg................................55VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1mg......................................................................................79

VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1mg......................................................................................79

VIRACEPT – nelfinavir mesylate tab 250 mg................... 13VIRACEPT – nelfinavir mesylate tab 625 mg................... 13VIREAD – tenofovir disoproxil fumarate oral powder 40mg/gm............................................................................... 13

VIREAD – tenofovir disoproxil fumarate tab 150 mg.........13VIREAD – tenofovir disoproxil fumarate tab 200 mg.........13VIREAD – tenofovir disoproxil fumarate tab 250 mg.........13VIREAD – tenofovir disoproxil fumarate tab 300 mg.........13VITRAKVI – larotrectinib sulfate cap 25 mg (baseequivalent).........................................................................23

VITRAKVI – larotrectinib sulfate cap 100 mg (baseequivalent).........................................................................23

VITRAKVI – larotrectinib sulfate oral soln 20 mg/ml (baseequivalent).........................................................................23

VIVITROL – naltrexone for im extended release susp 380mg......................................................................................92

VIZIMPRO – dacomitinib tab 15 mg..................................23VIZIMPRO – dacomitinib tab 30 mg..................................23VIZIMPRO – dacomitinib tab 45 mg..................................23VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................79

voriconazole for susp 40 mg/ml (Vfend)..............................9voriconazole tab 50 mg (Vfend).......................................... 9voriconazole tab 200 mg (Vfend)........................................ 9VOTRIENT – pazopanib hcl tab 200 mg (base equiv)......23

Wwarfarin sodium tab 1 mg (Coumadin)..............................82warfarin sodium tab 2 mg (Coumadin)..............................82warfarin sodium tab 2.5 mg (Coumadin)...........................82warfarin sodium tab 3 mg (Coumadin)..............................82warfarin sodium tab 4 mg (Coumadin)..............................82warfarin sodium tab 5 mg (Coumadin)..............................82warfarin sodium tab 6 mg (Coumadin)..............................82warfarin sodium tab 7.5 mg (Coumadin)...........................82warfarin sodium tab 10 mg (Coumadin)............................82water for irrigation, sterile irrigation soln........................... 92

XXALKORI – crizotinib cap 200 mg.....................................23

XALKORI – crizotinib cap 250 mg.....................................23XARELTO – rivaroxaban tab 2.5 mg.................................82XARELTO – rivaroxaban tab 10 mg..................................82XARELTO – rivaroxaban tab 15 mg..................................82XARELTO – rivaroxaban tab 20 mg..................................82XARELTO STARTER PACK – rivaroxaban tab startertherapy pack 15 mg & 20 mg.......................................... 83

XELJANZ – tofacitinib citrate tab 5 mg (baseequivalent).........................................................................71

XELJANZ – tofacitinib citrate tab 10 mg (baseequivalent).........................................................................71

XELJANZ XR – tofacitinib citrate tab er 24hr 11 mg (baseequivalent).........................................................................71

XIFAXAN – rifaximin tab 550 mg.......................................14XOSPATA – gilteritinib fumarate tablet 40 mg (baseequivalent).........................................................................23

XTANDI – enzalutamide cap 40 mg.................................. 23XULANE – norelgestromin-ethinyl estradiol td ptwk150-35 mcg/24hr.............................................................. 26

XURIDEN – uridine triacetate oral granules packet 2gm......................................................................................32

YYONSA – abiraterone acetate tab 125 mg....................... 23

Zzaleplon cap 5 mg (Sonata).............................................. 61zaleplon cap 10 mg (Sonata)............................................ 61ZELBORAF – vemurafenib tab 240 mg............................ 23zidovudine cap 100 mg (Retrovir)..................................... 13zidovudine syrup 10 mg/ml (Retrovir)................................13zidovudine tab 300 mg...................................................... 13ziprasidone hcl cap 20 mg (Geodon)................................ 60ziprasidone hcl cap 40 mg (Geodon)................................ 60ziprasidone hcl cap 60 mg (Geodon)................................ 60ziprasidone hcl cap 80 mg (Geodon)................................ 61ZOLINZA – vorinostat cap 100 mg....................................23zolpidem tartrate tab 5 mg (Ambien).................................61zolpidem tartrate tab 10 mg (Ambien)...............................61zonisamide cap 50 mg.......................................................75zonisamide cap 25 mg (Zonegran)....................................75zonisamide cap 100 mg (Zonegran)..................................75ZORBTIVE – somatropin (non-refrigerated) forsubcutaneous inj 8.8 mg..................................................30

ZORTRESS – everolimus tab 0.25 mg............................. 92ZORTRESS – everolimus tab 0.5 mg............................... 92ZORTRESS – everolimus tab 0.75 mg............................. 92ZORTRESS – everolimus tab 1 mg.................................. 92ZOSTAVAX – zoster vaccine live for subcutaneous susp19400 unit/0.65ml............................................................. 16

ZYKADIA – ceritinib cap 150 mg.......................................23ZYKADIA – ceritinib tab 150 mg....................................... 23ZYPREXA RELPREVV – olanzapine pamoate forextended rel im susp 210 mg (base eq)..........................61

ZYPREXA RELPREVV – olanzapine pamoate forextended rel im susp 300 mg (base eq)..........................61

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ZYPREXA RELPREVV – olanzapine pamoate forextended rel im susp 405 mg (base eq)..........................61

ZYTIGA – abiraterone acetate tab 500 mg....................... 24ZYVOX – linezolid for susp 100 mg/5ml........................... 14

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Such services are funded in part with the State of New Mexico.

Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 479328.1019

Blue Cross Community Centennial Medicaid Drug List Formulary · 2019-11-18 · Blue Cross Community...

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Transcript of Blue Cross Community Centennial Medicaid Drug List Formulary · 2019-11-18 · Blue Cross Community...