KPHI Quest Drug Formulary 090121 - Kaiser Permanente

Kaiser Permanente Hawaii QUEST Integration Drug Formulary Effective October 1, 2021

Kaiser Permanente Hawaii uses a drug formulary to ensure that the most appropriate and effective prescription drugs are available to you. The formulary is a list of drugs that have been approved by our Pharmacy and Therapeutics (P&T) Committee. Committee members include pharmacists, physicians, nurses, and other allied health care professionals. Our drug formulary allows us to select drugs that are safe, effective, and a good value for you. We review our formulary regularly so that we can add new drugs and remove drugs that can be replaced by newer, more effective drugs. The formulary also helps us restrict drugs that can be toxic or otherwise dangerous if. Our drug formulary is considered a closed formulary, which means that drugs on the list are usually covered under the prescription drug benefit, if you have one. However, drugs on our formulary may not be automatically covered under your prescription benefit because these benefits vary depending on your plan. Please check with your Kaiser Permanente pharmacist when you have questions about whether a drug is on our formulary or if there are any restrictions or limitations to obtaining a drug.

NON-FORMULARY DRUGS Non-formulary drugs are those that are not included on our drug formulary. These include new drugs that haven’t been reviewed yet; drugs that our clinicians and pharmacists have decided to leave off the formulary, or a different strength or dosage of a formulary drug that we don’t stock in our Kaiser Permanente pharmacies. Even though non-formulary drugs are generally not covered under our prescription drug benefit options, your Kaiser Permanente doctor can request a non-formulary drug for you when formulary alternatives have failed and the non-formulary drug is medically necessary, provided the drug is not excluded under the prescription drug benefit. If the request is accepted, you may purchase your prescription at your usual supplemental charge. Non-formulary drugs are not usually stocked in our pharmacies, so it may take a little longer to have your prescription filled for one of these drugs. SHARE INFORMATION WITH YOUR DOCTOR If you’re taking multiple drugs–including prescription or over-the-counter drugs, herbs, natural supplements, and even nutraceuticals (foods or parts of a food that provide health benefits)–be sure to share this information with your physician or pharmacist. Because some drugs interact with others, we want to be sure that you get the maximum benefit and the least risk from everything you consume. Bring all your drugs to each physician appointment or call one of our pharmacies and make an appointment with a pharmacist to review everything you’re taking.

Kaiser Permanente Hawaii Drug Formulary

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USING THE KAISER PERMANENTE HAWAII FORMULARY Prescription drugs are listed in alphabetical order for easy reference. Generic drugs are listed in lower case. BRAND names are CAPITALIZED. This list is subject to change and drugs may be added or removed without notice. Tier definitions: Tier 1 covers Generic drugs on the published list Tier 2 covers Brand name drugs on the published list

Your Cost 2-Tier Plan $0 Tier 1 and 2

Please refer to your QUEST Integration Member Handbook for additional information. To find out the cost of your drugs, you may contact our QUEST Integration Call Center at 1-800-651-2237. There is no charge for covered drugs. If you choose to get drugs that are not covered, or if you get drugs from a pharmacy not owned or contracted by Kaiser Permanente, you will have to pay for them and Kaiser Permanente QUEST Integration might not cover those drugs. For a complete list of Kaiser Permanente and affiliate pharmacies, visit kp.org/locations. Abbreviations/Definitions used in list:

Abbreviation Definition PAH Pulmonary Arterial Hypertension

OVER THE COUNTER (OTC) DRUGS OTC drugs must be prescribed by your Kaiser Permanente doctor in order to be covered by QUEST Integration. Additional OTC drugs not published in this list may be covered, if deemed medically necessary by your Kaiser Permanente doctor. Please refer to your QUEST Integration Member Handbook for additional information.

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GENERIC COMMONBRAND 2-Tier Plan

Tier Your Cost

Abacavir 300mg Tablet ZIAGEN 1 $0

Abacavir/Dolutegravir/Lamivudine 600mg/50mg/300mg Tablet TRIUMEQ 2 $0

Abacavir/Lamivudine 600mg/300mg Tablet EPZICOM 1 $0

Abacavir/Lamivudine/Zidovudine 300mg/150mg/300mg Tablet TRIZIVIR 1 $0

Abatacept 125mg/ml Subcutaneous Solution ORENCIA 2 $0

Abiraterone Acetate 250mg Tablet ZYTIGA 1 $0

Abiraterone Acetate 500mg Tablet ZYTIGA 1 $0

Acalabrutinib 100mg Capsule CALQUENCE 2 $0

Acamprosate 333mg Delayed Release Enteric Coated Tablet CAMPRAL 1 $0

Acarbose 100mg Tablet PRECOSE 1 $0



Acebutolol 200mg Capsule SECTRAL 1 $0

Acetaminophen 100mg/ml Solution -- 1 $0

Acetaminophen 120mg Rectal Suppository -- 1 $0

Acetaminophen 160mg/5ml Suspension -- 1 $0

Acetaminophen 325mg Tablet -- 1 $0

Acetaminophen/Caffeine/Dihydrocodeine 320.5mg/30mg/16mg Capsule -- 1 $0

Acetaminophen/Codeine 120mg-12mg/5ml Solution TYLENOL WITH CODEINE 1 $0

Acetaminophen/Codeine 300mg/30mg Tablet TYLENOL WITH CODEINE NO. 3 1 $0

Acetaminophen/Codeine 300mg/60mg Tablet TYLENOL WITH CODEINE NO. 4 1 $0

Acetazolamide 125mg Tablet DIAMOX 1 $0

Acetazolamide 25mg/ml Suspension DIAMOX 1 $0

Acetazolamide 500mg Extended Release Capsule DIAMOX 1 $0

Acetic Acid 0.25% Irrigation Solution -- 1 $0

Acetic Acid 2% Otic Solution VOSOL 1 $0

Acetohydroxamic Acid 250mg Tablet LITHOSTAT 2 $0

Acetone Urine Test Strip KETOSTIX 2 $0

Acetylcysteine 20% Inhalation/Oral Solution MUCOMYST 1 $0

Acitretin 10mg Capsule SORIATANE 1 $0

Acitretin 17.5mg Capsule SORIATANE 1 $0

Acitretin 25mg Capsule SORIATANE 1 $0

Acyclovir 200mg Capsule ZOVIRAX 1 $0

Acyclovir 200mg/5ml Suspension ZOVIRAX 1 $0

Acyclovir 400mg Tablet ZOVIRAX 1 $0

Acyclovir 5% Topical Ointment ZOVIRAX 1 $0

Acyclovir 800mg Tablet ZOVIRAX 1 $0



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Tier Your Cost

Adalimumab 20mg/0.4ml Subcutaneous Injection Kit HUMIRA 2 $0

Adalimumab 40mg/0.8ml Subcutaneous Injection Kit HUMIRA 2 $0

Adalimumab Citrate-Free 10mg/0.1ml Subcutaneous Injection HUMIRA 2 $0



Adalimumab Citrate-Free 40mg/0.4ml Subcutaneous Pen Injector HUMIRA 2 $0

Adapalene 0.1% Topical Cream DIFFERIN 1 $0

Adapalene 0.1% Topical Gel DIFFERIN 1 $0

Adapalene 0.3% Topical Gel DIFFERIN 1 $0

Adapalene/Benzoyl Peroxide 0.1%/2.5% Topical Gel EPIDUO 1 $0

Adefovir 10mg Tablet HEPSERA 1 $0

Albendazole 200mg Tablet ALBENZA 1 $0

Albuterol 0.083% Inhalation Solution ACCUNEB 1 $0

Albuterol 0.5% Inhalation Solution ACCUNEB 1 $0

Albuterol 1.25mg/3ml Inhalation Solution ACCUNEB 1 $0

Albuterol 108mcg/Actuation Inhaler PROVENTIL 1 $0

Albuterol 108mcg/Actuation Inhaler VENTOLIN 1 $0

Albuterol 2mg Tablet -- 1 $0

Albuterol 2mg/5ml Syrup -- 1 $0

Albuterol 4mg Tablet -- 1 $0

Alcaftadine 0.25% Ophthalmic Solution LASTACAFT 2 $0

Alclometasone Dipropionate 0.05% Topical Ointment ACLOVATE 1 $0

Alcohol (Ethanol) 70% Lock -- 2 $0

Alendronate 10mg Tablet FOSAMAX 1 $0



Alfuzosin 10mg Extended Release Tablet UROXATRAL 1 $0

Alirocumab 150mg/ml Subcutaneous Solution PRALUENT 2 $0

Alirocumab 75mg/ml Subcutaneous Solution PRALUENT 2 $0

Aliskiren Fumarate 150mg Tablet TEKTURNA 1 $0

Alitretinoin 0.1% Topical Gel PANRETIN 2 $0

Allopurinol 100mg Tablet ZYLOPRIM 1 $0

Allopurinol 20mg/ml Suspension ZYLOPRIM 1 $0

Almotriptan 6.25mg Tablet AXERT 1 $0

Alosetron 0.5mg Tablet LOTRONEX 1 $0

Alprazolam 0.25mg Tablet XANAX 1 $0

Alprazolam 0.5mg Tablet XANAX 1 $0



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Tier Your Cost

Altretamine 50mg Capsule HEXALEN 2 $0

Aluminum Acetate/Acetic acid 10%/2% Otic Solution DOMEBORO 1 $0

Aluminum Chloride Hexahydrate 20% Topical Solution DRYSOL 1 $0

Aluminum Hydroxide/Magnesium Carbonate 95mg-358mg/15ml Suspension GAVISCON 1 $0

Alvimopan 12mg Capsule ENTEREG 2 $0

Amantadine 100mg Capsule SYMMETREL 1 $0

Amantadine 50mg/5ml Syrup SYMMETREL 1 $0

Ambrisentan 10mg Tablet LETAIRIS 1 $0

Ambrisentan 5mg Tablet LETAIRIS 1 $0

Amcinonide 0.1% Topical Cream -- 1 $0

Amcinonide 0.1% Topical Ointment -- 1 $0

Amiloride 5mg Tablet -- 1 $0

Aminocaproic Acid 500mg Tablet AMICAR 1 $0

Aminophylline 100mg Tablet -- 1 $0

Aminosalicylic Acid 4gm Granule PASER 1 $0

Amiodarone 200mg Tablet CORDARONE 1 $0

Amitriptyline 10mg Tablet ELAVIL 1 $0




Amitriptyline Bulk Powder -- 2 $0

Amlexanox 5% Oral Paste APHTHASOL 2 $0

Amlodipine 10mg Tablet NORVASC 1 $0

Amlodipine 2.5mg Tablet NORVASC 1 $0

Amlodipine 5mg Tablet NORVASC 1 $0

Amlodipine Besylate/Benazepril 10mg/20mg Capsule LOTREL 1 $0


Amlodipine Besylate/Benazepril 2.5mg/10mg Capsule LOTREL 1 $0




Amoxapine 100mg Tablet -- 1 $0

Amoxicillin 125mg Chewable Tablet -- 1 $0

Amoxicillin 250mg Capsule -- 1 $0

Amoxicillin 250mg Chewable Tablet -- 1 $0

Amoxicillin 400mg/5ml Suspension -- 1 $0

Amoxicillin 500mg Capsule -- 1 $0

Amoxicillin/Clavulanate 400mg-57mg/5ml Suspension AUGMENTIN 1 $0

Amoxicillin/Clavulanate 400mg/57mg Chewable Tablet AUGMENTIN 1 $0

Amoxicillin/Clavulanate 500mg/125mg Tablet AUGMENTIN 1 $0



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Tier Your Cost

Amoxicillin/Clavulanate 600mg-42.9mg/5ml Suspension AUGMENTIN 1 $0

Amoxicillin/Clavulanate 875mg/125mg Tablet AUGMENTIN 1 $0

Amphetamine/Dextroamphetamine 10mg Extended Release Capsule ADDERALL 1 $0

Amphetamine/Dextroamphetamine 10mg Tablet ADDERALL 1 $0










Ampicillin 125mg/5ml Oral Suspension AMPICILLIN 2 $0

Anagrelide 0.5mg Capsule AGRYLIN 1 $0

Anakinra 100mg/0.67ml Subcutaneous Injection KINERET 2 $0

Anastrozole 1mg Tablet ARIMIDEX 1 $0

Antipyrine/Benzocaine 5.4%/1.4% Otic Solution AURODEX 1 $0

Apomorphine 10mg Sublingual Film KYNMOBI 2 $0





Apraclonidine 0.5% Ophthalmic Solution IOPIDINE 1 $0

Apremilast 30mg Tablet OTEZLA 2 $0

Apremilast Starter Therapy Pack 10mg & 20mg & 30mg Tablets OTEZLA STARTER PACK 2 $0

Aprepitant 80mg Capsule EMEND 1 $0

Arformoterol Tartrate 15mcg/2ml Inhalation Solution BROVANA 1 $0

Aripiprazole 10mg Tablet ABILIFY 1 $0


Aripiprazole 1mg/ml Solution ABILIFY 1 $0






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Tier Your Cost


Armodafinil 50mg Tablet NUVIGIL 1 $0

Artemether/Lumefantrine 20mg/120mg Tablet COARTEM 2 $0

Artificial Tear 5mg Ophthalmic Insert LACRISERT 2 $0

Asenapine 5mg Sublingual Tablet SAPHRIS 1 $0

Aspirin 325mg Enteric Coated Tablet ECOTRIN 1 $0

Aspirin 325mg Tablet BUFFERIN 1 $0

Aspirin 81mg Chewable Tablet -- 1 $0

Aspirin 81mg Enteric Coated Tablet ECOTRIN LOW STRENGTH 1 $0

Aspirin Buffered (aluminum hydroxide, calcium carbonate, magnesium hydroxide) 325mg Tablet ASCRIPTIN 2 $0

Aspirin Buffered (calcium carbonate, magnesium carbonate, magnesium oxide) 325mg Tablet BUFFERIN 1 $0

Aspirin Buffered 81mg Tablet ASCRIPTIN 2 $0

Aspirin/Extended Release Dipyridamole 25mg/200mg Capsule AGGRENOX 1 $0

Atazanavir 150mg Capsule REYATAZ 1 $0



Atenolol 100mg Tablet ATENOLOL 1 $0

Atenolol 25mg Tablet TENORMIN 1 $0

Atenolol 2mg/ml Suspension TENORMIN 1 $0

Atenolol 50mg Tablet TENORMIN 1 $0

Atomoxetine 100mg Capsule STRATTERA 1 $0







Atorvastatin 10mg Tablet LIPITOR 1 $0




Atovaquone 750mg/5ml Suspension MEPRON 1 $0

Atovaquone/Proguanil 250mg/100mg Tablet MALARONE 1 $0

Atovaquone/Proguanil 62.5mg/25mg Tablet MALARONE 1 $0

Atropine 1% Ophthalmic Solution -- 1 $0

Axitinib 1mg Tablet INLYTA 2 $0

Axitinib 5mg Tablet INLYTA 2 $0

Azathioprine 50mg Tablet -- 1 $0



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Tier Your Cost

Azelaic Acid 15% Topical Gel FINACEA 1 $0

Azelaic Acid 20% Topical Cream AZELEX 2 $0

Azelastine 0.05% Ophthalmic Solution OPTIVAR 1 $0

Azelastine 137mcg/spray Nasal Solution ASTELIN 1 $0

Azelastine/Fluticasone 137mcg/50mcg Nasal Spray DYMISTA 1 $0

Azilsartan 40mg Tablet EDARBI 2 $0

Azithromycin 1% Ophthalmic Solution AZASITE 2 $0

Azithromycin 100mg/5ml Suspension ZITHROMAX 1 $0

Azithromycin 200mg/5ml Suspension ZITHROMAX 1 $0

Azithromycin 250mg Tablet ZITHROMAX 1 $0



Aztreonam 75mg Inhalation Solution CAYSTON 2 $0

Bacitracin 500unit/gm Ophthalmic Ointment -- 1 $0

Bacitracin Zinc 500units/gm Topical Ointment -- 1 $0

Bacitracin/Neomycin/Polymyxin B 400units/3.5mg/10,000units per gm Ophthalmic Ointment CORTISPORIN 2 $0

Baclofen 10mg Tablet LIORESAL 1 $0

Baclofen 5mg Tablet LIORESAL 1 $0

Baclofen 5mg/ml Suspension LIORESAL 1 $0

Balsalazide 750mg Capsule COLAZAL 1 $0

Becaplermin 0.01% Topical Gel REGRANEX 2 $0

Beclomethasone 40mcg/Actuation Inhaler QVAR 2 $0

Beclomethasone 80mcg/Actuation Inhaler QVAR 2 $0

Belladonna/Opium 16.2mg/30mg Suppository B&O 2 $0

Benazepril 10mg Tablet LOTENSIN 1 $0




Benralizumab 30mg/ml Subcutaneous Solution FASENRA 2 $0

Benzonatate 100mg Capsule TESSALON 1 $0

Benzoyl Peroxide 5%-Erythromycin 3% Topical Gel BENZAMYCIN 1 $0

Benztropine 0.5mg Tablet COGENTIN 1 $0

Benztropine 1mg Tablet COGENTIN 1 $0

Benztropine 2mg Tablet COGENTIN 1 $0

Benzyl Alcohol 5% Topical Lotion ULESFIA 2 $0

Bepotastine 1.5% Ophthalmic Solution BEPREVE 1 $0

Besifloxacin 0.6% Ophthalmic Suspension BESIVANCE 2 $0

Betamethasone Dipropionate 0.05% Augmented Topical Gel DIPROLENE AF 1 $0



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Tier Your Cost

Betamethasone Dipropionate 0.05% Lotion DIPROLENE 1 $0

Betamethasone Dipropionate 0.05% Topical Cream DIPROLENE 1 $0

Betamethasone Dipropionate 0.05% Topical Ointment DIPROLENE 1 $0

Betamethasone Valerate 0.1% Topical Lotion BETA-VAL 1 $0

Betaxolol 0.5% Ophthalmic Solution BETOPTIC 1 $0

Betaxolol 10mg Tablet KERLONE 1 $0

Bethanechol Chloride 25mg Tablet URECHOLINE 1 $0

Bexarotene 1% Topical Gel TARGRETIN 2 $0

Bexarotene 75mg Capsule TARGRETIN 1 $0

Bicalutamide 50mg Tablet CASODEX 1 $0

Bictegravir/Emtricitabine/Tenofovir 50mg/200mg/25mg Tablet BIKTARVY 2 $0

Bimatoprost 0.01% Ophthalmic Solution LUMIGAN 2 $0

Bisacodyl 10mg Rectal Suppository -- 1 $0

Bisacodyl Delayed Release (Enteric Coated) 5mg Tablet -- 1 $0

Bisacodyl Enema 10mg/30ml -- 2 $0

Bisacodyl Tablet & Polyethylene Glycol-3350/Potassium Chloride/Sodium Bicarbonate/Sodium C PEG-PREP KIT 1 $0

Bisoprolol Fumarate 10mg Tablet ZEBETA 1 $0

Bisoprolol Fumarate 5mg Tablet ZEBETA 1 $0

Bisoprolol/Hydrochlorothiazide 10mg/6.25mg Tablet ZIAC 1 $0

Bisoprolol/Hydrochlorothiazide 2.5mg/6.25mg Tablet ZIAC 1 $0

Bisoprolol/Hydrochlorothiazide 5mg/6.25mg Tablet ZIAC 1 $0

Boceprevir 200mg Capsule VICTRELIS 2 $0

Bosentan 125mg Tablet TRACLEER 1 $0

Bosentan 62.5mg Tablet TRACLEER 1 $0

Bosutinib 100mg Tablet BOSULIF 2 $0

Bosutinib 500mg Tablet BOSULIF 2 $0

Brimonidine Tartrate 0.2% Ophthalmic Solution ALPHAGAN 1 $0

Brimonidine Tartrate 0.33% Topical Gel MIRVASO 2 $0

Brimonidine/Timolol 0.2%/0.5% Ophthalmic Solution COMBIGAN 2 $0

Brinzolamide 1% Ophthalmic Suspension AZOPT 1 $0

Bromfenac 0.09% Ophthalmic Solution -- 1 $0

Bromocriptine 0.8mg Tablet CYCLOSET 2 $0

Bromocriptine 2.5mg Tablet PARLODEL 1 $0

Budesonide 0.25mg/2ml Inhalation Suspension PULMICORT 1 $0

Budesonide 0.5mg/2ml Inhalation Suspension PULMICORT 1 $0

Budesonide 3mg Enteric Coated Capsule ENTOCORT 1 $0

Budesonide 9mg Extended Release Tablet UCERIS 1 $0

Budesonide/Formoterol 160mcg-4.5mcg/inh Inhalation Inhaler SYMBICORT 1 $0



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Tier Your Cost

Budesonide/Formoterol 80mcg-4.5mcg/inh Inhalation Inhaler SYMBICORT 1 $0

Bumetanide 0.5mg Tablet BUMEX 1 $0

Buprenorphine 10mcg/hr Weekly Transdermal Patch BUTRANS 1 $0

Buprenorphine 150mcg Buccal Film BELBUCA 1 $0



Buprenorphine 2mg Sublingual Tablet -- 1 $0





Buprenorphine 7.5mcg/hr Weekly Transdermal Patch BUTRANS 1 $0



Buprenorphine 8mg Sublingual Tablet -- 1 $0


Buprenorphine/Naloxone 2mg/0.5mg Sublingual Film SUBOXONE 1 $0

Buprenorphine/Naloxone 2mg/0.5mg Sublingual Tablet SUBOXONE 1 $0

Buprenorphine/Naloxone 4mg/1mg Sublingual Film SUBOXONE 1 $0

Buprenorphine/Naloxone 8mg/2mg Sublingual Film SUBOXONE 1 $0

Buprenorphine/Naloxone 8mg/2mg Sublingual Tablet SUBOXONE 1 $0

Bupropion 100mg Sustained Release Tablet WELLBUTRIN 1 $0

Bupropion 100mg Tablet WELLBUTRIN 1 $0

Bupropion 150mg Extended Release Tablet WELLBUTRIN 1 $0

Bupropion 150mg Sustained Release Tablet WELLBUTRIN 1 $0

Bupropion 300mg Extended Release Tablet WELLBUTRIN 1 $0

Bupropion 75mg Tablet WELLBUTRIN 1 $0

Buspirone 10mg Tablet BUSPAR 1 $0



Butalbital/Acetaminophen/Caffeine 50mg/325mg/40mg Tablet ESGIC 1 $0

Butalbital/Aspirin/Caffeine 50mg/325mg/40mg Capsule FIORINAL 1 $0

Butamben/Tetracaine/Benzocaine 2%/2%/14% Topical Spray CETACAINE 1 $0

C1 Esterase Inhibitor (Human) 500unit Intravenous Solution CINRYZE 2 $0

Cabozantinib 1 x 80mg & 1 x 20mg Capsule Kit (100mg Daily Dose) COMETRIQ 2 $0



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Tier Your Cost

Cabozantinib 1 x 80mg & 3 x 20mg Capsule Kit (140mg Daily Dose) COMETRIQ 2 $0

Cabozantinib 3 x 20mg Capsule Kit (60mg Daily Dose) COMETRIQ 2 $0

Caffeine Citrate 20mg/ml Solution CAFCIT 1 $0

Calcipotriene 0.005% Topical Cream DOVONEX 1 $0

Calcipotriene 0.005% Topical Ointment DOVONEX 1 $0

Calcipotriene 0.005% Topical Solution DOVONEX 1 $0

Calcipotriene/Betamethasone 0.005%/0.064% Topical Ointment TACLONEX 1 $0

Calcitonin 200iu/ml Injection MIACALCIN 1 $0

Calcitonin 200unit/Actuation Nasal Spray MIACALCIN 1 $0

Calcitriol 0.25mcg Capsule ROCALTROL 1 $0

Calcitriol 0.5mcg Capsule ROCALTROL 1 $0

Calcitriol 3mcg/gm Topical Ointment VECTICAL 1 $0

Calcium 500mg Tablet -- 1 $0

Calcium Acetate 667mg Capsule PHOSLO 1 $0

Calcium Acetate 667mg Tablet ELIPHOS 1 $0

Canagliflozin 100mg Tablet INVOKANA 2 $0

Candesartan 4mg Tablet ATACAND 1 $0

Capecitabine 150mg Tablet XELODA 1 $0

Capecitabine 500mg Tablet XELODA 1 $0

Captopril 1mg/ml Suspension CAPOTEN 1 $0

Captopril 25mg Tablet CAPOTEN 1 $0

Captopril 50mg Tablet CAPOTEN 1 $0

Carbamazepine 100mg Chewable Tablet TEGRETOL 1 $0

Carbamazepine 100mg Extended Release Tablet TEGRETOL 1 $0

Carbamazepine 100mg/5ml Suspension TEGRETOL 1 $0


Carbamazepine 200mg Tablet TEGRETOL 1 $0

Carbamazepine 300mg Extended Release Capsule CARBATROL 1 $0


Carbidopa 25mg Tablet LODOSYN 1 $0

Carbidopa/Levodopa 10mg/100mg Tablet SINEMET 1 $0



Carbidopa/Levodopa 50mg/200mg Extended Release Tablet SINEMET 1 $0

Carbidopa/Levodopa/Entacapone 25/100/200mg Tablets STALEVO 1 $0

Carbidopa/Levodopa/Entacapone 37.5/150/200mg Tablets STALEVO 1 $0



12


Tier Your Cost

Carbidopa/Levodopa/Entacapone 50/200/200mg Tablets STALEVO 1 $0

Carbinoxamine 4mg/5ml Solution PALGIC 1 $0

Carisoprodol 350mg Tablet SOMA 1 $0

Carteolol 1% Ophthalmic Solution -- 1 $0

Carvedilol 0.1mg/ml Suspension COREG 1 $0

Carvedilol 1.67mg/ml Suspension COREG 1 $0

Carvedilol 12.5mg Tablet COREG 1 $0

Carvedilol 25mg Tablet COREG 1 $0



Cefaclor 250mg Capsule CECLOR 1 $0

Cefadroxil 500mg/5ml Oral Suspension -- 1 $0

Cefazolin 50mg/ml Ophthalmic Solution KEFZOL 1 $0

Cefdinir 125mg/5ml Suspension OMNICEF 1 $0

Cefditoren Pivoxil 200mg Tablet SPECTRACEF 2 $0

Cefixime 100mg/5ml Oral Suspension -- 1 $0

Cefpodoxime 100mg Tablet VANTIN 1 $0

Cefpodoxime 200mg Tablet VANTIN 1 $0

Cefprozil 250mg Tablet -- 1 $0

Ceftibuten 400mg Capsule -- 1 $0

Cefuroxime 125mg/5ml Oral Suspension CEFTIN 1 $0

Celecoxib 100mg Capsule CELEBREX 1 $0



Cephalexin 250mg Capsule KEFLEX 1 $0

Cephalexin 250mg/5ml Suspension KEFLEX 1 $0

Cephalexin 500mg Capsule KEFLEX 1 $0

Certolizumab 200mg/ml Injection Kit CIMZIA 2 $0

Cetirizine 1mg/ml Solution ZYRTEC 1 $0

Cevimeline 30mg Capsule EVOXAC 1 $0

Chlorambucil 2mg Tablet LEUKERAN 2 $0

Chlordiazepoxide 10mg Capsule LIBRIUM 1 $0



Chlordiazepoxide/Clidinium 5mg/2.5mg Capsule LIBRAX 1 $0

Chlorhexidine Gluconate 0.12% Mouth/Throat Solution PERIDEX 1 $0

Chloroquine Phosphate 250mg Tablet ARALEN 1 $0

Chloroquine Phosphate 500mg Tablet ARALEN 1 $0

Chlorothiazide 250mg Tablet -- 1 $0

Chlorpromazine 100mg Tablet THORAZINE 1 $0



13


Tier Your Cost




Chlorpropamide 250mg Tablet DIABINESE 1 $0

Chlorthalidone 25mg Tablet HYGROTON 1 $0

Chlorthalidone 50mg Tablet HYGROTON 1 $0

Chlorzoxazone 500mg Tablet -- 1 $0

Cholestyramine Light 4gm/dose Powder PREVALITE 1 $0

Ciclesonide 160mcg/Actuation Aerosol Inhaler ALVESCO 2 $0

Ciclesonide 80mcg/Actuation Aerosol Inhaler ALVESCO 2 $0

Ciclopirox 0.77% Topical Cream CICLODAN 1 $0

Ciclopirox 8% Topical Solution CICLODAN 1 $0

Cilostazol 100mg Tablet PLETAL 1 $0

Cilostazol 50mg Tablet PLETAL 1 $0

Cimetidine 300mg Tablet TAGAMET 1 $0

Cimetidine 300mg/5ml Solution TAGAMET 1 $0

Cinacalcet 30mg Tablet SENSIPAR 1 $0



Ciprofloxacin 0.3% Ophthalmic Solution CILOXAN 1 $0

Ciprofloxacin 250mg Tablet CIPRO 1 $0



Ciprofloxacin/Dexamethasone 0.3%/0.1% Otic Suspension CIPRODEX 1 $0

Ciprofloxacin/Hydrocortisone 0.2%/1% Otic Suspension CIPRO HC 2 $0

Citalopram 10mg Tablet CELEXA 1 $0



Citric Acid Bladder Mixture Irrigation RENACIDIN 2 $0

Clarithromycin 125mg/5ml Suspension BIAXIN 1 $0

Clarithromycin 250mg Tablet BIAXIN 1 $0

Clarithromycin 500mg Tablet BIAXIN 1 $0

Clemastine Fumarate 2.68mg Tablet TAVIST 1 $0

Clindamycin 150mg Capsule CLEOCIN 1 $0

Clindamycin 300mg Capsule CLEOCIN 1 $0

Clindamycin 75mg/5ml Solution CLEOCIN 1 $0

Clindamycin Phosphate 1% Topical Gel CLEOCIN-T 1 $0

Clindamycin Phosphate 1% Topical Solution CLEOCIN-T 1 $0

Clindamycin Phosphate 2% Vaginal Cream CLEOCIN 1 $0

Clindamycin/Benzoyl Peroxide 1%/5% Topical Gel BENZACLIN 1 $0



14


Tier Your Cost

Clindamycin/Benzoyl Peroxide 1.2%/5% Topical Gel DUAC 1 $0

Clindamycin/Tretinoin 1.2%/0.025% Topical Gel VELTIN 1 $0

Clobetasol 0.05% Topical Cream TEMOVATE 1 $0

Clobetasol 0.05% Topical Ointment TEMOVATE 1 $0

Clobetasol 0.05% Topical Solution TEMOVATE 1 $0

Clobetasol Propionate 0.05% Topical Gel -- 1 $0

Clobetasol Propionate 0.05% Topical Lotion -- 1 $0

Clocortolone 0.1% Topical Cream CLODERM 1 $0

Clomipramine 25mg Capsule ANAFRANIL 1 $0

Clonazepam 0.5mg Tablet KLONOPIN 1 $0

Clonazepam 2mg Tablet KLONOPIN 1 $0

Clonidine 0.1mg Tablet CATAPRES 1 $0

Clonidine 0.1mg/ml Suspension CATAPRES 1 $0

Clonidine 0.2mg Tablet CATAPRES 1 $0

Clopidogrel 300mg Tablet PLAVIX 1 $0

Clopidogrel 5mg/ml Suspension PLAVIX 1 $0

Clopidogrel 75mg Tablet PLAVIX 1 $0

Clorazepate 15mg Tablet TRANXENE 1 $0

Clorazepate 3.75mg Tablet TRANXENE 1 $0

Clorazepate 7.5mg Tablet TRANXENE 1 $0

Clotrimazole 1% Cream LOTRIMIN AF 1 $0

Clotrimazole 10mg Lozenge MYCELEX 1 $0

Clotrimazole/Betamethasone 1%/0.05% Topical Cream LOTRISONE 1 $0

Clozapine 100mg Tablet CLOZARIL 1 $0

Codeine 30mg Tablet -- 1 $0

Codeine 60mg Tablet -- 1 $0

Colchicine 0.6mg Capsule -- 1 $0

Colchicine 0.6mg Tablet -- 1 $0

Colchicine/Probenecid 0.5mg/500mg Tablet -- 1 $0

Colesevelam 625mg Tablet WELCHOL 1 $0

Colestipol 1gm Tablet COLESTID 1 $0

Collagenase 250unit/gm Topical Ointment SANTYL 2 $0

Condoms - Female FC2 2 $0

Contraceptive Sponge TODAY 2 $0

Copper Intrauterine Device (Clinic Administered only) PARAGARD 2 $0

Cortisone Acetate 25mg Tablet -- 1 $0

Crizotinib 200mg Capsule XALKORI 2 $0

Crizotinib 250mg Capsule XALKORI 2 $0

Cromolyn 20mg/2ml Inhalation Solution INTAL 1 $0

Cromolyn 4% Ophthalmic Solution OPTICROM 1 $0

Crotamiton 10% Topical Cream EURAX 2 $0



15


Tier Your Cost

Cyclobenzaprine 10mg Tablet FLEXERIL 1 $0

Cyclophosphamide 50mg Capsule CYTOXAN 1 $0

Cyclophosphamide 50mg Tablet CYTOXAN 1 $0

Cycloserine 250mg Capsule SEROMYCIN 1 $0

Cyclosporine 0.05% Ophthalmic Emulsion RESTASIS 2 $0

Cyclosporine 0.09% Ophthalmic Solution CEQUA 2 $0

Cyclosporine 100mg Capsule GENGRAF 1 $0

Cyclosporine 100mg/ml Solution NEORAL 1 $0

Cyclosporine 25mg Capsule GENGRAF 1 $0

Cyproheptadine 2mg/5ml Syrup PERIACTIN 1 $0

Cyproheptadine 4mg Tablet PERIACTIN 1 $0

Cysteamine 0.44% Ophthalmic Solution CYSTARAN 2 $0

Cysteamine 50mg Capsule CYSTAGON 2 $0

Dabigatran 150mg Capsule PRADAXA 2 $0

Dabigatran 75mg Capsule PRADAXA 2 $0

Dalfampridine 10mg Tablet AMPYRA 1 $0

Danazol 200mg Capsule DANOCRINE 1 $0

Dantrolene 25mg Capsule -- 1 $0

Dapagliflozin Propanediol 10mg Tablet FARXIGA 2 $0

Dapsone 100mg Tablet -- 1 $0

Darifenacin 7.5mg Tablet ENABLEX 1 $0

Darunavir 150mg Tablet PREZISTA 2 $0



Darunavir/Cobicistat/Emtricitabine/Tenofovir Alafenamide 800mg/150mg/200mg/1mg Tablet SYMTUZA 2 $0

Dasatinib 100mg Tablet SPRYCEL 2 $0






Deferasirox 250mg Soluble Tablet EXJADE 1 $0

Deferasirox 500mg Soluble Tablet EXJADE 1 $0

Deferiprone 500mg Tablet FERRIPROX 1 $0

Delavirdine 200mg Tablet RESCRIPTOR 2 $0

Demeclocycline 150mg Tablet DECLOMYCIN 1 $0

Denosumab 120mg/1.7ml Injection XGEVA 2 $0

Desipramine 10mg Tablet NORPRAMIN 1 $0





16


Tier Your Cost

Desloratadine 5mg Tablet CLARINEX 1 $0

Desmopressin Acetate 0.01% Nasal Solution DDAVP 1 $0

Desogestrel/Ethinyl Estradiol 0.15mg/30mcg Tablet EMOQUETTE 1 $0

Desonide 0.05% Topical Cream DESOWEN 1 $0

Desoximetasone 0.05% Topical Gel TOPICORT 1 $0

Desoximetasone 0.25% Topical Cream -- 1 $0

Desvenlafaxine Succinate 100mg Extended Release Tablet PRISTIQ 1 $0



Dexamethasone 0.1% Ophthalmic Solution DECADRON 1 $0

Dexamethasone 0.5mg Tablet DECADRON 1 $0

Dexamethasone 0.5mg/5ml Solution DECADRON 1 $0



Dexamethasone 4mg Tablet DECADRON 1 $0

Dexlansoprazole 30mg Delayed Release Capsule DEXILANT 2 $0

Dexmethylphenidate 10mg Extended Release Capsule FOCALIN XR 1 $0


Dexmethylphenidate 2.5mg Tablet FOCALIN 1 $0







Dextroamphetamine 10mg Sustained Release Capsule DEXEDRINE 1 $0



Dextroamphetamine 5mg Tablet DEXEDRINE 1 $0

Dextromethorphan/Quinidine 20mg/10mg Capsule NUEDEXTA 2 $0

Diaphragm Flex-Spring 60mm -- 2 $0








Diazepam 10mg Rectal Gel DIASTAT 1 $0

Diazepam 10mg Tablet VALIUM 1 $0



17


Tier Your Cost

Diazepam 1mg/ml Solution VALIUM 1 $0

Diazepam 2.5mg Rectal Gel DIASTAT 1 $0

Diazepam 20mg Rectal Gel DIASTAT 1 $0



Diazepam Bulk Powder -- 2 $0

Diazoxide 50mg/ml Suspension PROGLYCEM 1 $0

Diclofenac 0.1% Ophthalmic Solution VOLTAREN 1 $0

Diclofenac 1% Transdermal Gel VOLTAREN 1 $0

Diclofenac 50mg Enteric Coated Tablet VOLTAREN 1 $0

Diclofenac 75mg Enteric Coated Tablet VOLTAREN 1 $0

Dicloxacillin 250mg Capsule -- 1 $0

Dicloxacillin 500mg Capsule -- 1 $0

Dicyclomine 10mg Capsule BENTYL 1 $0

Dicyclomine 10mg/5ml Solution BENTYL 1 $0

Dicyclomine 20mg Tablet BENTYL 1 $0

Didanosine 400mg Delayed Release Capsule VIDEX 1 $0

Diethylpropion 25mg Tablet TENUATE 1 $0

Diethylpropion 75mg Extended ReleaseTablet TENUATE 1 $0

Difenoxin/Atropine 1mg/0.025mg Tablet MOTOFEN 2 $0

Diflorasone 0.05% Topical Ointment APEXICON 1 $0

Diflunisal 500mg Tablet DOLOBID 1 $0

Difluprednate 0.05% Ophthalmic Emulsion DUREZOL 2 $0

Digoxin 0.05mg/ml Solution LANOXIN 1 $0

Digoxin 0.125mg Tablet LANOXIN 1 $0

Digoxin 0.25mg Tablet LANOXIN 1 $0

Digoxin Micronized Bulk Powder -- 2 $0

Dihydroergotamine 1mg/ml Injection D.H.E. 1 $0

Diltiazem 120mg Extended Release 24hr Capsule DILT-XR 1 $0

Diltiazem 120mg Tablet CARDIZEM 1 $0

Diltiazem 12mg/ml Suspension CARDIZEM 1 $0


Diltiazem 180mg Extended Release 24hr Capsule CARDIZEM CD 1 $0





Dimethyl Fumarate 120mg Capsule TECFIDERA 1 $0

Dimethyl Fumarate 240mg Capsule TECFIDERA 1 $0

Diphenhydramine 12.5mg/5ml Solution -- 1 $0



18


Tier Your Cost

Diphenhydramine/Lidocaine/Aluminum Hydroxide/Magnesium Hydroxide/Simethicone Mouthwash MAGIC MOUTHWASH 1 $0

Diphenoxylate/Atropine 2.5mg-0.025mg/5ml Liquid LOMOTIL 1 $0

Diphenoxylate/Atropine 2.5mg/0.025mg Tablet LOMOTIL 1 $0

Dipyridamole 25mg Tablet PERSANTINE 1 $0

Dipyridamole 75mg Tablet PERSANTINE 1 $0

Disopyramide Phosphate 100mg Capsule NORPACE 1 $0

Disopyramide Phosphate 100mg Controlled Release Capsule NORPACE 2 $0

Disopyramide Phosphate 150mg Capsule NORPACE 1 $0

Disopyramide Phosphate 150mg Controlled Release Capsule NORPACE 1 $0

Disulfiram 250mg Tablet ANTABUSE 1 $0

Divalproex 125mg Delayed Release Tablet DEPAKOTE 1 $0

Divalproex 125mg Sprinkle Capsule DEPAKOTE 1 $0


Divalproex 250mg Extended Release Tablet DEPAKOTE 1 $0


Divalproex 500mg Extended Release Tablet DEPAKOTE 1 $0

Docusate Sodium 100mg Capsule -- 1 $0

Dofetilide 125mcg Capsule TIKOSYN 1 $0



Dolasetron 50mg Tablet ANZEMET 2 $0

Dolutegravir 10mg Tablet TIVICAY 2 $0



Dolutegravir 5mg Tablet For Oral Suspension TIVICAY PD 2 $0

Dolutegravir/Lamivudine 50mg/300mg Tablet DOVATO 2 $0

Dolutegravir/Rilpivirine 50mg/25mg Tablet JULUCA 2 $0

Donepezil 10mg Tablet ARICEPT 1 $0

Donepezil 5mg Tablet ARICEPT 1 $0

Dornase 1mg/ml Inhalation Solution PULMOZYME 2 $0

Dorzolamide 2% Ophthalmic Solution TRUSOPT 1 $0

Dorzolamide/Timolol 2%/0.5% Ophthalmic Solution COSOPT 1 $0

Doxazosin 1mg Tablet CARDURA 1 $0




Doxepin 10mg Capsule SINEQUAN 1 $0



19


Tier Your Cost


Doxepin 5% Topical Cream PRUDOXIN 1 $0


Doxercalciferol 0.5mcg Capsule HECTOROL 1 $0

Doxycycline 100mg Tablet ADOXA 1 $0

Doxycycline 20mg Tablet -- 1 $0

Doxycycline 25mg/5ml Suspension VIBRAMYCIN 1 $0

Doxycycline 50mg Tablet ADOXA 1 $0

Dronabinol 10mg Capsule MARINOL 1 $0

Dronedarone 400mg Tablet MULTAQ 2 $0

Drospirenone/Ethinyl Estradiol 3mg/0.02mg Tablet NIKKI 1 $0

Drospirenone/Ethinyl Estradiol 3mg/0.03mg Tablet DROSPIRENONE-EE 1 $0

Duloxetine 20mg Delayed Release Capsule CYMBALTA 1 $0



Dupilumab 300mg/2ml Subcutaneous Pen-Injector DUPIXENT 2 $0

Dupilumab 300mg/2ml Subcutaneous Solution Syringe DUPIXENT 2 $0

Dutasteride 0.5mg Capsule AVODART 1 $0

Dyphylline 200mg Tablet LUFYLLIN 2 $0

Echothiophate Iodide 0.125% Ophthalmic Solution PHOSPHOLINE 2 $0

Econazole 1% Topical Cream SPECTAZOLE 1 $0

Efavirenz 200mg Capsule SUSTIVA 1 $0

Efavirenz 600mg Tablet SUSTIVA 1 $0

Efavirenz/Emtricitabine/Tenofovir 600mg/200mg/300mg Tablet ATRIPLA 1 $0

Efavirenz/Lamivudine/Tenofovir 600mg/300mg/300mg Tablet SYMFI 1 $0

Eletriptan 20mg Tablet RELPAX 1 $0

Eletriptan 40mg Tablet RELPAX 1 $0

Elexacaftor/Tezacaftor/Ivacaftor 100mg/50mg/75mg & Ivacaftor 150mg Tablet Therapy Pack TRIKAFTA 2 $0

Eltrombopag 12.5mg Tablet PROMACTA 2 $0

Eltrombopag 25mg Tablet PROMACTA 2 $0



Elvitegravir/Cobicistat/Emtricitabine/Tenofovir 150mg/150mg/200mg/10mg Tablet GENVOYA 2 $0

Elvitegravir/Cobicistat/Emtricitabine/Tenofovir 150mg/150mg/200mg/300mg Tablet STRIBILD 2 $0

Emedastine 0.05% Ophthalmic Solution EMADINE 2 $0

Empagliflozin 10mg Tablet JARDIANCE 2 $0



20


Tier Your Cost

Empagliflozin 25mg Tablet JARDIANCE 2 $0

Emtricitabine 10mg/ml Solution EMTRIVA 2 $0

Emtricitabine 200mg Capsule EMTRIVA 1 $0

Emtricitabine/Rilpivirine/Tenofovir 200mg/25mg/25mg Tablet ODEFSEY 2 $0

Emtricitabine/Rilpivirine/Tenofovir 200mg/25mg/300mg Tablet COMPLERA 2 $0

Emtricitabine/Tenofovir 200mg/25mg Tablet DESCOVY 2 $0

Emtricitabine/Tenofovir 200mg/300mg Tablet TRUVADA 1 $0

Enalapril 2.5mg Tablet VASOTEC 1 $0

Enalapril 20mg Tablet VASOTEC 1 $0

Enalapril Maleate 1mg/ml Oral Solution EPANED 2 $0

Enoxaparin 100mg/ml Injection LOVENOX 1 $0

Enoxaparin 120mg/0.8ml Injection LOVENOX 1 $0

Enoxaparin 150mg/ml Injection LOVENOX 1 $0

Enoxaparin 300mg/3ml Injection LOVENOX 1 $0





Entacapone 200mg Tablet COMTAN 1 $0

Entecavir 0.05mg/ml Solution BARACLUDE 2 $0

Entecavir 0.5mg Tablet BARACLUDE 1 $0

Entecavir 1mg Tablet BARACLUDE 1 $0

Entrectinib 100mg Capsule ROZLYTREK 2 $0

Entrectinib 200mg Capsule ROZLYTREK 2 $0

Enzalutamide 40mg Capsule XTANDI 2 $0

Enzalutamide 40mg Tablet XTANDI 2 $0

Enzalutamide 80mg Tablet XTANDI 2 $0

Epinastine 0.05% Ophthalmic Solution ELESTAT 1 $0

Epinephrine 0.1% Nasal Solution ADRENALIN 1 $0

Epinephrine 0.15mg/0.15ml Injection EPIPEN-JR 1 $0

Epinephrine 0.3mg/0.3ml Injection EPIPEN 1 $0

Eplerenone 25mg Tablet INSPRA 1 $0

Epoetin 10,000unit/ml Injection PROCRIT 2 $0



Eprosartan 600mg Tablet TEVETAN 1 $0

Ergocalciferol 50,000unit Capsule -- 1 $0

Ergoloid Mesylates 1mg Tablet HYDERGINE 1 $0

Ergotamine Tartrate 2mg Sublingual Tablet ERGOMAR 1 $0



21


Tier Your Cost

Ergotamine/Caffeine 2mg/100mg Rectal Suppository MIGERGOT 1 $0

Erlotinib 100mg Tablet TARCEVA 2 $0



Erythromycin 2% Topical Solution T-STAT 1 $0

Erythromycin 200mg/5ml Suspension ERYPED 1 $0

Erythromycin 250mg Enteric Coated Tablet ERY-TAB 1 $0

Erythromycin 333mg Enteric Coated Tablet ERY-TAB 1 $0

Erythromycin 400mg Tablet E.E.S. 1 $0

Erythromycin 400mg/5ml Suspension ERYPED 1 $0

Erythromycin 5mg/gm Ophthalmic Ointment ILOTYCIN 1 $0

Escitalopram 10mg Tablet LEXAPRO 1 $0



Esomeprazole 20mg Capsule NEXIUM 1 $0

Esterified Estrogens 0.3mg Tablet MENEST 1 $0

Esterified Estrogens/Methyltestosterone 0.625mg/1.25mg Tablet EEMT HS 1 $0

Esterified Estrogens/Methyltestosterone 1.2mg/2.5mg Tablet EEMT DS 1 $0

Estradiol 0.05mg/24hr Twice Weekly Transdermal Patch DOTTI 1 $0

Estradiol 0.05mg/24hr Weekly Transdermal Patch CLIMARA 1 $0

Estradiol 0.1mg/24hr Twice Weekly Transdermal Patch DOTTI 1 $0

Estradiol 0.1mg/24hr Weekly Transdermal Patch CLIMARA 1 $0

Estradiol 0.5mg Tablet ESTRACE 1 $0

Estradiol 10mcg Vaginal Tablet VAGIFEM 1 $0

Estradiol 1mg Tablet ESTRACE 1 $0

Estradiol 2mg Tablet ESTRACE 1 $0

Estradiol 2mg Vaginal Ring ESTRING 2 $0

Estradiol Vaginal Cream 0.1mg/gm ESTRACE 1 $0

Estramustine Phosphate 140mg Capsule EMCYT 2 $0

Estrogens, Conjugated (Synthetic A) 0.3mg Tablet CENESTIN 2 $0

Estrogens, Conjugated 0.3mg Tablet PREMARIN 2 $0

Estrogens, Conjugated 0.625mg/gm Vaginal Cream PREMARIN 2 $0

Estropipate 0.75mg Tablet OGEN 1 $0

Estropipate 1.5mg Tablet OGEN 1 $0

Estropipate 3mg Tablet OGEN 1 $0

Eszopiclone 1mg Tablet LUNESTA 1 $0

Etanercept 25mg/0.5ml Injection ENBREL 2 $0

Etanercept 50mg/ml Injection ENBREL 2 $0

Ethacrynic Acid 25mg Tablet EDECRIN 1 $0



22


Tier Your Cost

Ethambutol 400mg Tablet MYAMBUTOL 1 $0

Ethinyl Estradiol/Ethynodiol Diacetate 0.035mg/1mg Tablet ZOVIA 1 $0

Ethionamide 250mg Tablet TRECATOR 2 $0

Ethosuximide 250mg Capsule ZARONTIN 1 $0

Ethosuximide 250mg/5ml Solution -- 1 $0

Ethotoin 250mg Tablet PEGANONE 2 $0

Etidronate 200mg Tablet DIDRONEL 1 $0

Etodolac 200mg Capsule LODINE 1 $0

Etodolac 300mg Capsule LODINE 1 $0

Etodolac 400mg Tablet LODINE 1 $0

Etodolac 500mg Tablet LODINE 1 $0

Etonogestrel Subdermal 68mg Implant (Clinic Administered only) NEXPLANON 2 $0

Etonogestrel/Ethinyl Estradiol 0.120/0.015mcg Vaginal Ring NUVARING 1 $0

Etoposide 50mg Capsule VEPESID 1 $0

Etravirine 100mg Tablet INTELENCE 1 $0

Etravirine 200mg Tablet INTELENCE 1 $0

Everolimus 0.5mg Tablet ZORTRESS 1 $0

Everolimus 0.75mg Tablet ZORTRESS 1 $0

Everolimus 10mg Tablet AFINITOR 2 $0

Everolimus 2.5mg Tablet AFINITOR 1 $0

Everolimus 5mg Tablet AFINITOR 1 $0

Everolimus 7.5mg Tablet AFINITOR 1 $0

Evolocumab 140mg/ml Subcutaneous Injection REPATHA 2 $0

Evolocumab 420mg/3.5ml Subcutaneous Injection REPATHA 2 $0

Exemestane 25mg Tablet AROMASIN 1 $0

Exenatide 2mg Injection BYDUREON 2 $0

Exenatide 5mcg/0.02ml Injection BYETTA 2 $0

Ezetimibe 10mg Tablet ZETIA 1 $0

Ezogabine 200mg Tablet POTIGA 2 $0

Famciclovir 500mg Tablet FAMVIR 1 $0

Famotidine 40mg/5ml Oral Suspension -- 1 $0

Febuxostat 40mg Tablet ULORIC 1 $0

Febuxostat 80mg Tablet ULORIC 1 $0

Felbamate 400mg Tablet FELBATOL 1 $0

Felbamate 600mg Tablet FELBATOL 1 $0

Felbamate 600mg/5ml Suspension FELBATOL 1 $0

Felodipine 10mg Extended Release Tablet PLENDIL 1 $0

Felodipine 2.5mg Extended Release Tablet PLENDIL 1 $0



23


Tier Your Cost

Felodipine 5mg Extended Release Tablet PLENDIL 1 $0

Fenofibrate 160mg Tablet LOFIBRA 1 $0

Fenofibrate 54mg Tablet LOFIBRA 1 $0

Fenoprofen 600mg Tablet -- 1 $0

Fentanyl 100mcg/hr 72-hour Transdermal Patch DURAGESIC 1 $0





Ferrous Sulfate 15mg/ml Drop FER-IN-SOL 1 $0

Ferrous Sulfate 200mg Tablet -- 1 $0

Fesoterodine Fumarate 4mg Tablet TOVIAZ 2 $0

Fidaxomicin 200mg Tablet DIFICID 2 $0

Filgrastim 300mcg/0.5ml Injection NEUPOGEN 2 $0

Filgrastim 480mcg/0.8ml Solution Prefilled Syringe NEUPOGEN 2 $0

Filgrastim-aafi 300mcg/0.5ml Injection NIVESTYM 2 $0

Filgrastim-aafi 480mcg/0.8ml Injection NIVESTYM 2 $0

Filgrastim-sndz 300mcg/0.5ml Solution Prefilled Syringe ZARXIO 2 $0

Filgrastim-sndz 480mcg/0.8ml Solution Prefilled Syringe ZARXIO 2 $0

Finasteride 5mg Tablet PROSCAR 1 $0

Fingolimod 0.5mg Capsule GILENYA 2 $0

Flavoxate 100mg Tablet -- 1 $0

Flecainide Acetate 100mg Tablet TAMBOCOR 1 $0

Flecainide Acetate 20mg/ml Suspension TAMBOCOR 1 $0

Fluconazole 100mg Tablet DIFLUCAN 1 $0



Flucytosine 250mg Capsule ANCOBON 1 $0

Flucytosine 500mg Capsule ANCOBON 1 $0

Fludrocortisone Acetate 0.1mg Tablet FLORINEF 1 $0

Fluocinolone Acetonide 0.01% Otic Drop DERMOTIC 1 $0

Fluocinolone Acetonide 0.01% Topical Cream SYNALAR 1 $0

Fluocinolone Acetonide 0.01% Topical Oil DERMA-SMOOTHE/FS 1 $0

Fluocinolone Acetonide 0.01% Topical Solution SYNALAR 1 $0

Fluocinonide 0.05% Topical Cream LIDEX 1 $0

Fluocinonide 0.05% Topical Gel LIDEX 1 $0

Fluocinonide 0.05% Topical Ointment LIDEX 1 $0

Fluocinonide 0.05% Topical Solution LIDEX 1 $0

Fluorometholone 0.1% Ophthalmic Ointment FML 2 $0

Fluorometholone 0.1% Ophthalmic Suspension FML 1 $0

Fluorouracil 0.5% Topical Cream CARAC 1 $0



24


Tier Your Cost

Fluorouracil 1% Aqueous Topical Cream FLUOROPLEX 2 $0

Fluorouracil 2% Topical Solution EFUDEX 1 $0

Fluorouracil 5% Topical Cream EFUDEX 1 $0

Fluorouracil/Diclofenac Sodium 5%/1% Topical Cream FLUORAC 2 $0

Fluoxetine 10mg Capsule PROZAC 1 $0


Fluoxetine 20mg/5ml Solution PROZAC 1 $0


Fluoxymesterone 10mg Tablet ANDROXY 1 $0

Fluphenazine 2.5mg Tablet PROLIXIN 1 $0

Flurandrenolide 4mcg/sqcm Topical Tape CORDRAN 2 $0

Flurbiprofen 0.03% Ophthalmic Solution OCUFEN 1 $0

Flurbiprofen 50mg Tablet -- 1 $0

Flutamide 125mg Capsule EULEXIN 1 $0

Fluticasone 0.005% Topical Ointment CUTIVATE 1 $0

Fluticasone 50mcg/Actuation Nasal Spray FLONASE 1 $0

Fluticasone Furoate/Vilanterol Aerosol Inhalation 100mcg/25mcg BREO ELLIPTA 2 $0

Fluticasone/Salmeterol 100mcg/50mcg Powder Inhalation ADVAIR DISKUS 1 $0

Fluticasone/Salmeterol 115mcg/21mcg Aerosol Inhalation ADVAIR HFA 2 $0





Fluticasone/Umeclidinium/Vilanterol 100mcg/62.5mcg/25mcg Inhaler TRELEGY ELLIPTA 2 $0

Fluvastatin 20mg Capsule LESCOL 1 $0

Fluvoxamine 25mg Tablet LUVOX 1 $0

Folic Acid 1mg Tablet -- 1 $0

Folic Acid 1mg/ml Solution -- 1 $0

Folic Acid 400mcg Tablet -- 1 $0

Folic Acid 800mcg Tablet -- 1 $0

Formoterol Fumarate 20mcg/2ml Inhaler PERFOROMIST 1 $0

Fosamprenavir 50mg/ml Suspension LEXIVA 2 $0

Fosamprenavir 700mg Tablet LEXIVA 1 $0

Fosfomycin Tromethamine Powder 3gm MONUROL 2 $0



25


Tier Your Cost

Fosinopril 20mg Tablet MONOPRIL 1 $0

Fostamatinib 100mg Tablet TAVALISSE 2 $0

Fostamatinib 150mg Tablet TAVALISSE 2 $0

Fremanezumab-vfrm 225mg/1.5ml Subcutaneous Solution AJOVY 2 $0

Frovatriptan Succinate 2.5mg Tablet FROVA 1 $0

Furosemide 10mg/ml Solution LASIX 1 $0

Furosemide 20mg Tablet LASIX 1 $0

Furosemide 40mg Tablet LASIX 1 $0

Gabapentin 100mg Capsule NEURONTIN 1 $0



Gabapentin 600mg Tablet NEURONTIN 1 $0

Gabapentin 800mg Tablet NEURONTIN 1 $0

Gabapentin Enacarbil 600mg Tablet HORIZANT 2 $0

Galantamine 12mg Tablet RAZADYNE 1 $0

Galantamine 16mg Extended Release Capsule RAZADYNE 1 $0





Galcanezumab-gnlm 120mg/ml Subcutaneous Solution EMGALITY 2 $0

Ganciclovir 0.15% Ophthalmic Gel ZIRGAN 2 $0

Ganirelix Acetate 250mcg/0.5ml Subcutaneous Injection -- 1 $0

Gatifloxacin 0.5% Ophthalmic Solution ZYMAXID 1 $0

Gefitinib 250mg Tablet IRESSA 2 $0

Gemfibrozil 600mg Tablet LOPID 1 $0

Gemifloxacin 320mg Tablet FACTIVE 2 $0

Gentamicin 0.1% Topical Cream GARAMYCIN 1 $0

Gentamicin 0.1% Topical Ointment GARAMYCIN 1 $0

Gentamicin 0.3% Nasal Solution -- 1 $0

Gentamicin 0.3% Ophthalmic Ointment GENTAK 1 $0

Gentamicin 0.85mg/ml Irrigation Solution -- 1 $0

Gentamicin 13.6mg/ml Ophthalmic Solution GARAMYCIN 1 $0

Gentamicin/Prednisolone 0.3%/1% Ophthalmic Suspension PRED-G 2 $0

Glatiramer Acetate 20mg/ml Injection COPAXONE 1 $0

Glatiramer Acetate 40mg/ml Injection COPAXONE 1 $0

Glimepiride 1mg Tablet AMARYL 1 $0





26


Tier Your Cost

Glipizide 10mg Extended Release Tablet GLUCOTROL 1 $0

Glipizide 10mg Tablet GLUCOTROL 1 $0

Glipizide 2.5mg Extended Release Tablet GLUCOTROL 1 $0

Glipizide 5mg Extended Release Tablet GLUCOTROL 1 $0

Glipizide 5mg Tablet GLUCOTROL 1 $0

Glipizide/Metformin 2.5mg/250mg Tablet METAGLIP 1 $0

Glipizide/Metformin 2.5mg/500mg Tablet METAGLIP 1 $0

Glipizide/Metformin 5mg/500mg Tablet METAGLIP 1 $0

Glucagon 1mg Injection -- 1 $0

Glutamine (Sickle Cell) 5gm Powder Pack ENDARI 2 $0

Glyburide 2.5mg Tablet DIABETA 1 $0

Glyburide 5mg Tablet DIABETA 1 $0

Glyburide/Metformin 5mg/500mg Tablet GLUCOVANCE 1 $0

Glycerol Phenylbutyrate 1.1gm/ml Liquid RAVICTI 2 $0

Glycopyrrolate 1mg Tablet ROBINUL 1 $0

Glycopyrrolate 25mcg/ml Inhalation Solution (Refill) LONHALA MAGNAIR 2 $0

Glycopyrrolate 25mcg/ml Inhalation Solution (Starter Kit) LONHALA MAGNAIR 2 $0

Golimumab 50mg/0.5ml Injection SIMPONI 2 $0

Granisetron 1mg Tablet KYTRIL 1 $0

Griseofulvin 250mg Ultramicrosize Tablet GRIS-PEG 1 $0

Guaifenesin/Codeine 100mg-10mg/5ml Syrup CHERATUSSIN 1 $0

Guanfacine 1mg Sustained Release Tablet INTUNIV 1 $0

Guanfacine 1mg Tablet TENEX 1 $0


Guanfacine 2mg Tablet TENEX 1 $0



Guanidine 125mg Tablet -- 2 $0

Guselkumab 100mg/ml Injection Solution TREMFYA 2 $0

Halcinonide 0.1% Topical Ointment HALOG 2 $0

Halobetasol 0.05% Topical Ointment ULTRAVATE 1 $0

Haloperidol 0.5mg Tablet HALDOL 1 $0

Haloperidol 2mg Tablet HALDOL 1 $0

Haloperidol 2mg/ml Liquid HALDOL 1 $0

Haloperidol 5mg Tablet HALDOL 1 $0

Heparin 10000units/ml Injection -- 1 $0



Hexachlorophene 3% Topical Liquid PHISOHEX 2 $0

Hydralazine 10mg Tablet APRESOLINE 1 $0

Hydralazine 1mg/ml Solution APRESOLINE 1 $0



27


Tier Your Cost



Hydrochlorothiazide 10mg/ml Suspension -- 1 $0

Hydrochlorothiazide 12.5mg Tablet -- 1 $0

Hydrochlorothiazide 25mg Tablet -- 1 $0

Hydrochlorothiazide 50mg Tablet -- 1 $0

Hydrocodone/Acetaminophen 10mg/325mg Tablet VICODIN 1 $0

Hydrocodone/Acetaminophen 5mg/325mg Tablet VICODIN 1 $0

Hydrocodone/Acetaminophen 7.5mg-325mg/15ml Solution HYCET 1 $0

Hydrocodone/Acetaminophen 7.5mg/325mg Tablet VICODIN 1 $0

Hydrocodone/Chlorpheniramine 10mg-8mg/5ml Liquid TUSSIONEX 1 $0

Hydrocodone/Homatropine 5mg-1.5mg/5ml Syrup HYDROMET 1 $0

Hydrocortisone 1 % Cream -- 1 $0

Hydrocortisone 100mg/60ml Rectal Enema COLOCORT 1 $0

Hydrocortisone 10mg Tablet -- 1 $0

Hydrocortisone 2.5% Rectal Cream ANUSOL-HC 1 $0

Hydrocortisone 2.5% Topical Cream HYTONE 1 $0

Hydrocortisone 2.5% Topical Lotion HYTONE 1 $0

Hydrocortisone 2.5% Topical Ointment HYTONE 1 $0

Hydrocortisone 20mg Tablet CORTEF 1 $0

Hydrocortisone 2mg/ml Suspension CORTEF 1 $0

Hydrocortisone 5mg Tablet CORTEF 1 $0

Hydrocortisone Acetate 25mg Rectal Suppository ANUCORT 1 $0

Hydrocortisone Acetate/Pramoxine 1%/1% Rectal Foam PROCTOFOAM-HC 1 $0

Hydrocortisone Acetate/Pramoxine 2.5%/1% Rectal Cream ANALPRAM-HC 1 $0

Hydrocortisone Butyrate 0.1% Topical Cream LOCOID 1 $0

Hydrocortisone Butyrate 0.1% Topical Ointment LOCOID 1 $0

Hydrocortisone Butyrate 0.1% Topical Solution LOCOID 1 $0

Hydrocortisone Valerate 0.2% Topical Cream WESTCORT 1 $0

Hydrocortisone Valerate 0.2% Topical Ointment WESTCORT 1 $0

Hydrocortisone/Acetic Acid/Propylene Glycol 1%/2%/3% Otic Solution ACETASOL HC 1 $0

Hydromorphone 2mg Tablet DILAUDID 1 $0

Hydromorphone 8mg Extended ReleaseTablet EXALGO 1 $0

Hydroxychloroquine 200mg Tablet PLAQUENIL 1 $0

Hydroxyurea 500mg Capsule HYDREA 1 $0

Hydroxyzine 10mg Tablet ATARAX 1 $0

Hydroxyzine 10mg/5ml Syrup ATARAX 1 $0




28


Tier Your Cost


Hydroxyzine Pamoate 100mg Capsule VISTARIL 1 $0



Ibandronate 150mg Tablet BONIVA 1 $0

Ibrutinib 140mg Capsule IMBRUVICA 2 $0

Ibuprofen 100mg/5ml Suspension -- 1 $0

Ibuprofen 400mg Tablet MOTRIN 1 $0



Icatibant Acetate 30mg/3ml Subcutaneous Injection FIRAZYR 1 $0

Icosapent 1gm Capsule VASCEPA 1 $0

Idelalisib 100mg Tablet ZYDELIG 2 $0

Idelalisib 150mg Tablet ZYDELIG 2 $0

Iloperidone 1mg Tablet FANAPT 2 $0

Iloprost 10mcg/ml Inhalation Solution VENTAVIS 2 $0

Imatinib 100mg Tablet GLEEVEC 2 $0

Imatinib 400mg Tablet GLEEVEC 2 $0

Imipramine 25mg Tablet TOFRANIL 1 $0

Imipramine 50mg Tablet TOFRANIL 1 $0

Imiquimod 5% Topical Cream ALDARA 1 $0

Indacaterol 75mcg Inhalation Capsule ARCAPTA 2 $0

Indapamide 1.25mg Tablet LOZOL 1 $0

Indinavir 400mg Capsule CRIXIVAN 2 $0

Indomethacin 25mg Capsule INDOCIN 1 $0

Indomethacin 50mg Capsule INDOCIN 1 $0

Indomethacin 50mg Rectal Suppository INDOCIN 1 $0

Ingenol 0.015% Topical Gel PICATO 2 $0

Insulin Aspart 100unit/ml Injection NOVOLOG 1 $0

Insulin Aspart 70/30 100unit/ml Injection NOVOLOG 1 $0

Insulin Detemir 100unit/ml Injection LEVEMIR 2 $0

Insulin Glargine 100unit/ml Injection LANTUS 2 $0

Insulin Glulisine 100unit/ml Injection APIDRA 2 $0

Insulin Infusion Disposable Pump Refill Pod OMNIPOD DASH 2 $0

Insulin Infusion Disposable Pump Starter Kit OMNIPOD DASH 2 $0

Insulin Isophane 100unit/ml Injection HUMULIN N 1 $0

Insulin Isophane/Insulin Regular 70/30 100unit/ml Injection HUMULIN 70/30 1 $0

Insulin Lispro 100unit/ml Injection HUMALOG 2 $0

Insulin Lispro 75/25 100unit/ml Injection HUMALOG 2 $0

Insulin Regular 100unit/ml Injection HUMULIN R 1 $0



29


Tier Your Cost

Insulin Regular 500unit/ml Injection HUMULIN R 2 $0

Interferon Alfa-2b 10mu/ml Injection INTRON-A 2 $0

Interferon Alfa-2b 18mu Injection INTRON-A 2 $0

Interferon Alfa-2b 50mu Injection INTRON-A 2 $0

Interferon Alfa-2b 6000000u/ml Injection INTRON-A 2 $0

Interferon Beta-1a 22mcg/0.5ml Injection REBIF 2 $0

Interferon Beta-1a 30mcg/0.5ml Intramuscular Injection Kit AVONEX 2 $0

Interferon Beta-1a 44mcg/0.5ml Injection REBIF 2 $0

Interferon Beta-1b 0.3mg Injection BETASERON 1 $0

Interferon Beta-1b 0.3mg Injection EXTAVIA 1 $0

Interferon Gamma-1b 2000000unit/0.5ml Injection ACTIMMUNE 2 $0

Iodoquinol/Hydrocortisone 1%/1% Topical Cream DERMAZENE 1 $0

Ipratropium 0.02% Inhalation Solution ATROVENT 1 $0

Ipratropium 0.03% Nasal Solution ATROVENT 1 $0

Ipratropium 17mcg/Actuation Inhaler ATROVENT 2 $0

Ipratropium/Albuterol 0.5mg-2.5mg/3ml Inhalation Solution DUONEB 1 $0

Ipratropium/Albuterol 20mcg/100mcg/Actuation Inhaler COMBIVENT 2 $0

Irbesartan 150mg Tablet AVAPRO 1 $0



Isavuconazonium 186mg Capsule CRESEMBA 2 $0

Isocarboxazid 10mg Tablet MARPLAN 2 $0

Isoniazid 100mg Tablet -- 1 $0

Isoniazid 300mg Tablet -- 1 $0

Isoniazid 50mg/5ml Syrup -- 1 $0

Isoniazid/Rifampin 150mg/300mg Capsule RIFAMATE 1 $0

Isosorbide Dinitrate 10mg Tablet ISORDIL 1 $0

Isosorbide Dinitrate 20mg Tablet ISORDIL 1 $0

Isosorbide Monohydrate 10mg Tablet -- 1 $0

Isosorbide Mononitrate 120mg Extended Release Tablet IMDUR 1 $0



Isotretinoin 10mg Capsule CLARAVIS 1 $0



Isradipine 5mg Capsule DYNACIRC 1 $0

Itraconazole 100mg Capsule SPORANOX 1 $0

Itraconazole 10mg/ml Solution SPORANOX 1 $0

Ivacaftor 150mg Tablet KALYDECO 2 $0



30


Tier Your Cost

Ivermectin 3mg Tablet STROMECTOL 1 $0

Ixazomib Citrate 2.3mg Capsule NINLARO 2 $0

Ixazomib Citrate 3mg Capsule NINLARO 2 $0

Ixazomib Citrate 4mg Capsule NINLARO 2 $0

Ketoconazole 2% Shampoo NIZORAL 1 $0

Ketoconazole 2% Topical Cream NIZORAL 1 $0

Ketoconazole 200mg Tablet NIZORAL 1 $0

Ketoconazole 20mg/ml Suspension NIZORAL 1 $0

Ketoprofen 50mg Capsule -- 1 $0

Ketorolac 10mg Tablet -- 1 $0

Ketorolac Tromethamine 0.4% Ophthalmic Solution ACULAR LS 1 $0

Ketotifen Fumarate 0.025% Ophthalmic Solution ZADITOR 1 $0

Labetalol 10mg/ml Suspension TRANDATE 1 $0

Labetalol 200mg Tablet TRANDATE 1 $0

Labetalol 300mg Tablet TRANDATE 1 $0

Labetalol 40mg/ml Suspension TRANDATE 1 $0

Lacosamide 100mg Tablet VIMPAT 2 $0




Lactic Acid/Ammonium Hydroxide 12% Topical Cream LAC-HYDRIN 1 $0

Lactulose 10gm/15ml Solution ENULOSE 1 $0

Lamivudine 150mg Tablet EPIVIR 1 $0

Lamivudine 300mg Tablet EPIVIR 1 $0

Lamivudine/Tenofovir Disoproxil 300mg/300mg Tablet CIMDUO 1 $0

Lamivudine/Zidovudine 150mg/300mg Tablet COMBIVIR 1 $0

Lamotrigine 100mg Tablet LAMICTAL 1 $0



Lamotrigine 25mg Chewable Tablet LAMICTAL 1 $0


Lamotrigine 5mg Chewable Tablet LAMICTAL 1 $0

Lansoprazole 30mg Capsule PREVACID 1 $0

Lanthanum Carbonate 1000mg Chewable Tablet FOSRENOL 1 $0



Lapatinib 250mg Tablet TYKERB 2 $0

Latanoprost 0.005% Ophthalmic Solution XALATAN 1 $0

Ledipasvir/Sofosbuvir 90mg/400mg Tablet HARVONI 1 $0

Leflunomide 20mg Tablet ARAVA 1 $0

Lenalidomide 10mg Capsule REVLIMID 2 $0



31


Tier Your Cost


Lenalidomide 2.5mg Capsule REVLIMID 2 $0



Lenvatinib 1 x 10mg & 1 x 4mg Capsule Therapy Pack (14mg Daily Dose) LENVIMA 2 $0


Lenvatinib 1 x 10mg Capsule Therapy Pack (10mg Daily Dose) LENVIMA 2 $0






Letermovir 240mg Tablet PREVYMIS 2 $0

Letermovir 480mg Tablet PREVYMIS 2 $0

Letrozole 2.5mg Tablet FEMARA 1 $0

Leucovorin 5mg Tablet -- 1 $0

Levalbuterol 1.25mg/3ml Inhalation XOPENEX 1 $0

Levetiracetam 1000mg Tablet KEPPRA 1 $0

Levetiracetam 100mg/ml Solution KEPPRA 1 $0




Levobunolol 0.5% Ophthalmic Solution BETAGAN 1 $0

Levocarnitine 1gm/10ml Solution CARNITOR 1 $0

Levocetirizine 2.5mg/5ml Solution XYZA 1 $0

Levofloxacin 0.5% Ophthalmic Solution -- 1 $0

Levofloxacin 250mg Tablet LEVAQUIN 1 $0

Levofloxacin 25mg/ml Solution LEVAQUIN 1 $0



Levonorgestrel 1.5mg Tablet PLAN-B 1 $0

Levonorgestrel Releasing Intrauterine Device 20mcg/day (Clinic Administered only) MIRENA 2 $0



32


Tier Your Cost

Levonorgestrel/Ethinyl Estradiol 0.05-0.03/0.075-0.04/0.125-0.03mg/mg Tablet TRIVORA 1 $0

Levonorgestrel/Ethinyl Estradiol 0.10mg/0.02mg Tablet LUTERA 1 $0

Levonorgestrel/Ethinyl Estradiol 0.15mg/30mg Tablet PORTIA 1 $0

Levorphanol Tartrate 2mg Tablet LEVO-DROMORAN 1 $0

Levothyroxine 100mcg Tablet SYNTHROID 1 $0












Lidocaine 2% Topical Gel XYLOCAINE 1 $0

Lidocaine 4% Topical Solution XYLOCAINE 1 $0

Lidocaine 5% Transdermal Patch LIDODERM 1 $0

Lidocaine/Aluminum Hydroxide/Magnesium Hydroxide/Simethicone 3:1 Suspension GI COCKTAIL 1 $0

Lidocaine/Prilocaine 2.5%/2.5% Topical Cream EMLA 1 $0

Lidocaine/Prilocaine 2.5%/2.5% Topical Kit EMLA 1 $0

Lidocaine/Tetracaine 70mg/70mg Transdermal Patch SYNERA 2 $0

Linaclotide 145mcg Capsule LINZESS 2 $0

Linaclotide 290mcg Capsule LINZESS 2 $0

Linagliptin 5mg Tablet TRADJENTA 2 $0

Lindane 1% Topical Shampoo KWELL 1 $0

Linezolid 100mg/5ml Suspension ZYVOX 1 $0

Linezolid 600mg Tablet ZYVOX 1 $0

Liothyronine 25mcg Tablet CYTOMEL 1 $0

Liotrix 120mg Tablet THYROLAR-2 2 $0

Liraglutide 18mg/3ml Subcutaneous Solution VICTOZA 2 $0

Lisdexamfetamine 20mg Capsule VYVANSE 2 $0

Lisinopril 10mg Tablet PRINIVIL 1 $0

Lisinopril 2.5mg Tablet PRINIVIL 1 $0







33


Tier Your Cost

Lisinopril/Hydrochlorothiazide 10mg/12.5mg Tablet PRINIZIDE 1 $0

Lisinopril/Hydrochlorothiazide 20mg/12.5mg Tablet PRINIZIDE 1 $0

Lisinopril/Hydrochlorothiazide 20mg/25mg Tablet PRINIZIDE 1 $0

Lithium Carbonate 300mg Capsule LITHOBID 1 $0

Lithium Carbonate 300mg Extended ReleaseTablet ESKALITH-CR 1 $0

Lithium Carbonate 450mg Extended ReleaseTablet ESKALITH-CR 1 $0

Lithium Citrate 8meq/5ml Solution LITHOBID 2 $0

Lodoxamide 0.1% Ophthalmic Solution ALOMIDE 2 $0

Lofexidine 0.18mg Tablet LUCEMYRA 2 $0

Lomitapide 10mg Capsule JUXTAPID 2 $0



Lomustine 10mg Capsule GLEOSTINE 2 $0

Lopinavir/Ritonavir 200mg/50mg Tablet KALETRA 1 $0

Lopinavir/Ritonavir 80mg-20mg/ml Solution KALETRA 1 $0

Loratadine 10mg Tablet CLARITIN 1 $0

Loratadine 5mg/5ml Syrup CLARITIN 1 $0

Lorazepam 0.5mg Tablet ATIVAN 1 $0

Lorazepam 1mg Tablet ATIVAN 1 $0

Lorazepam 2mg Tablet ATIVAN 1 $0

Lorazepam 2mg/ml Concentrate Solution ATIVAN 1 $0

Lorlatinib 100mg Tablet LORBRENA 2 $0

Lorlatinib 25mg Tablet LORBRENA 2 $0

Losartan 100mg Tablet COZAAR 1 $0

Losartan 2.5mg/ml Suspension COZAAR 1 $0



Losartan/Hydrochlorothiazide 100mg/12.5mg Tablet HYZAAR 1 $0

Losartan/Hydrochlorothiazide 100mg/25mg Tablet HYZAAR 1 $0

Losartan/Hydrochlorothiazide 50mg/12.5mg Tablet HYZAAR 1 $0

Loteprednol 0.5% Ophthalmic Gel LOTEMAX 1 $0

Lovastatin 10mg Tablet MEVACOR 1 $0



Loxapine Succinate 10mg Capsule LOXITANE 1 $0

Lubiprostone 24mcg Capsule AMITIZA 1 $0

Lubiprostone 8mcg Capsule AMITIZA 1 $0

Lurasidone 120mg Tablet LATUDA 2 $0






34


Tier Your Cost


Mafenide 5% Topical Solution SULFAMYLON 1 $0

Magnesium Citrate 1.745gm/30ml Solution CITRATE OF MAGNESIA 1 $0

Malathion 0.5% Topical Lotion OVIDE 1 $0

Maprotiline 50mg Tablet LUDIOMIL 1 $0

Maraviroc 150mg Tablet SELZENTRY 2 $0

Maraviroc 300mg Tablet SELZENTRY 2 $0

Mecasermin 40mg/4ml Subcutaneous Solution INCRELEX 2 $0

Meclofenamate 50mg Capsule MECLOMEN 1 $0

Medroxyprogesterone 10mg Tablet PROVERA 1 $0

Medroxyprogesterone 2.5mg Tablet PROVERA 1 $0

Medroxyprogesterone 5mg Tablet PROVERA 1 $0

Medroxyprogesterone Acetate Suspension 150mg Injection (Clinic Administered only) -- 1 $0

Mefenamic Acid 250mg Capsule PONSTEL 1 $0

Mefloquine 250mg Tablet LARIAM 1 $0

Megestrol Acetate 40mg Tablet MEGACE 1 $0

Megestrol Acetate 40mg/ml Suspension MEGACE 1 $0

Meloxicam 15mg Tablet MOBIC 1 $0

Meloxicam 7.5mg Tablet MOBIC 1 $0

Melphalan 2mg Tablet ALKERAN 1 $0

Memantine 10mg Tablet NAMENDA 1 $0

Memantine 5mg Tablet NAMENDA 1 $0

Memantine Titration Pack Tablet NAMENDA 1 $0

Mepenzolate Bromide 25mg Tablet CANTIL 2 $0

Meprobamate 200mg Tablet EQUANIL 1 $0

Mercaptopurine 50mg Tablet PURINETHOL 1 $0

Mesalamine 1.2gm Enteric Coated Tablet LIALDA 1 $0

Mesalamine 4gm Rectal Enema ROWASA 1 $0

Metaproterenol 10mg Tablet METAPREL 1 $0

Metaxalone 800mg Tablet SKELAXIN 1 $0

Metformin 1000mg Tablet GLUCOPHAGE 1 $0

Metformin 500mg Sustained Release Tablet GLUCOPHAGE XR 1 $0


Metformin 750mg Sustained Release Tablet GLUCOPHAGE XR 1 $0


Methadone 10mg Tablet DOLOPHINE 1 $0

Methadone 5mg Tablet DOLOPHINE 1 $0

Methamphetamine 5mg Tablet DESOXYN 1 $0

Methazolamide 50mg Tablet NEPTAZANE 1 $0

Methenamine Hippurate 1gm Tablet HIPREX 1 $0



35


Tier Your Cost

Methimazole 10mg Tablet TAPAZOLE 1 $0

Methimazole 5mg Tablet TAPAZOLE 1 $0

Methocarbamol 500mg Tablet ROBAXIN 1 $0

Methocarbamol 750mg Tablet ROBAXIN 1 $0

Methotrexate 2.5mg Tablet RHEUMATREX 1 $0

Methotrexate Preservative-Free 10mg/0.2ml Subcutaneous Solution RASUVO 2 $0

Methotrexate Preservative-Free 12.5mg/0.25ml Subcutaneous Solution RASUVO 2 $0









Methoxsalen 1% Topical Lotion OXSORALEN 2 $0

Methscopolamine 2.5mg Tablet PAMINE 1 $0

Methsuximide 300mg Capsule CELONTIN 2 $0

Methyclothiazide 5mg Tablet ENDURON 1 $0

Methyldopa 250mg Tablet ALDOMET 1 $0

Methyldopa 500mg Tablet ALDOMET 1 $0

Methylergonovine 0.2mg Tablet METHERGINE 1 $0

Methylnaltrexone 12mg/0.6ml Subcutaneous Kit RELISTOR 2 $0

Methylphenidate 10mg Controlled Delivery Capsule METADATE 1 $0

Methylphenidate 10mg Tablet RITALIN 1 $0

Methylphenidate 18mg Extended Release Tablet CONCERTA 1 $0


Methylphenidate 20mg Extended Release Tablet METADATE 1 $0







36


Tier Your Cost



Methylphenidate 5mg Tablet RITALIN 1 $0


Methylprednisolone 16mg Tablet MEDROL 1 $0

Methylprednisolone 4mg Tablet MEDROL 1 $0

Methyltestosterone 10mg Tablet METHITEST 1 $0

Metipranolol 0.3% Ophthalmic Solution OPTIPRANOLOL 1 $0

Metoclopramide 10mg Tablet REGLAN 1 $0

Metoclopramide 5mg/5ml Solution REGLAN 1 $0

Metolazone 2.5mg Tablet ZAROXOLYN 1 $0

Metolazone 5mg Tablet ZAROXOLYN 1 $0

Metoprolol Succinate 100mg Extended Release Tablet TOPROL 1 $0




Metoprolol Tartrate 100mg Tablet LOPRESSOR 1 $0

Metoprolol Tartrate 10mg/ml Suspension LOPRESSOR 1 $0



Metronidazole 0.75% Topical Cream METROCREAM 1 $0

Metronidazole 0.75% Topical Gel METROGEL 1 $0

Metronidazole 250mg Tablet FLAGYL 1 $0

Metronidazole 500mg Tablet FLAGYL 1 $0

Metronidazole 50mg/ml Suspension FLAGYL 1 $0

Mexiletine 150mg Capsule MEXITIL 1 $0

Midazolam 2mg/ml Syrup VERSED 1 $0

Midodrine 10mg Tablet PROAMATINE 1 $0

Midodrine 2.5mg Tablet PROAMATINE 1 $0

Midodrine 5mg Tablet PROAMATINE 1 $0

Mifepristone 200mg Tablet -- 2 $0

Mifepristone 300mg Tablet KORLYM 2 $0

Migalastat 123mg Capsule GALAFOLD 2 $0

Miglitol 25mg Tablet GLYSET 1 $0

Miglustat 100mg Capsule ZAVESCA 1 $0

Milnacipran 12.5mg Tablet SAVELLA 2 $0

Minocycline 50mg Capsule MINOCIN 1 $0

Minoxidil 10mg Tablet -- 1 $0

Minoxidil 2.5mg Tablet -- 1 $0

Mipomersen 200mg/ml Subcutaneous Solution KYNAMRO 2 $0

Mirabegron 25mg Sustained Release Tablet MYRBETRIQ SR 2 $0



37


Tier Your Cost

Mirabegron 50mg Sustained Release Tablet MYRBETRIQ SR 2 $0

Mirtazapine 15mg Tablet REMERON 1 $0

Mirtazapine 30mg Tablet REMERON 1 $0

Misoprostol 100mcg Tablet CYTOTEC 1 $0

Misoprostol 200mcg Tablet CYTOTEC 1 $0

Mitotane 500mg Tablet LYSODREN 2 $0

Modafinil 100mg Tablet PROVIGIL 1 $0

Modafinil 200mg Tablet PROVIGIL 1 $0

Moexipril 7.5mg Tablet UNIVASC 1 $0

Mometasone 0.1% Topical Cream ELOCON 1 $0

Mometasone 0.1% Topical Ointment ELOCON 1 $0

Mometasone 110mcg/inh Inhalation ASMANEX TWISTHALER 2 $0

Mometasone 200mcg/Actuation Inhalation Suspension ASMANEX HFA 2 $0

Mometasone 220mcg/inh Inhalation ASMANEX TWISTHALER 2 $0

Mometasone/Formoterol 100mcg-5mcg/inh Inhalation Inhaler DULERA 2 $0

Mometasone/Formoterol 200mcg-5mcg/inh Inhalation Inhaler DULERA 2 $0

Montelukast 10mg Tablet SINGULAIR 1 $0

Montelukast 4mg Chewable Tablet SINGULAIR 1 $0

Montelukast 5mg Chewable Tablet SINGULAIR 1 $0

Morphine 100mg Extended Release Tablet ORAMORPH 1 $0

Morphine 10mg Rectal Suppository RMS 1 $0

Morphine 10mg/5ml Solution ROXANOL 1 $0


Morphine 15mg Tablet -- 1 $0

Morphine 20mg/ml Solution ROXANOL 1 $0

Morphine 30mg Extended ReleaseTablet ORAMORPH 1 $0

Morphine 30mg Tablet -- 1 $0


Morphine Sulfate Powder -- 2 $0

Morphine/Naltrexone 30mg/1.2mg Capsule EMBEDA 2 $0

Moxifloxacin 0.5% Ophthalmic Solution VIGAMOX 1 $0

Moxifloxacin 400mg Tablet AVELOX 1 $0

Multivitamin/Fluoride 0.25mg Chewable Tablets POLY-VI-FLOR 1 $0

Multivitamin/Fluoride 0.25mg/ml Drops Solution POLY-VI-FLOR 1 $0

Multivitamin/Fluoride 0.5mg Chewable Tablets POLY-VI-FLOR 1 $0

Multivitamin/Fluoride 0.5mg/ml Drops Solution POLY-VI-FLOR 1 $0

Multivitamin/Fluoride 1mg Chewable Tablets POLY-VI-FLOR 1 $0

Multivitamin/Iron/Fluoride 0.25mg-10mg/ml Drops Solution POLY-VI-FLOR WITH IRON 1 $0



38


Tier Your Cost

Mupirocin 2% Nasal Ointment BACTROBAN 2 $0

Mupirocin 2% Topical Ointment BACTROBAN 1 $0

Mycophenolate 250mg Capsule CELLCEPT 1 $0

Mycophenolate 500mg Tablet CELLCEPT 1 $0

Nabilone 1mg Capsule CESAMET 2 $0

Nabumetone 500mg Tablet RELAFEN 1 $0

Nabumetone 750mg Tablet RELAFEN 1 $0

Nadolol 40mg Tablet CORGARD 1 $0

Nadolol 80mg Tablet CORGARD 1 $0

Nafarelin Acetate 2mg/ml Nasal Solution SYNAREL 2 $0

Naftifine 1% Topical Cream NAFTIN 1 $0

Naloxone 4mg/0.1ml Nasal Spray NARCAN 2 $0

Naltrexone 50mg Tablet REVIA 1 $0

Naphazoline 0.1% Ophthalmic Solution AK-CON 1 $0

Naproxen 250mg Tablet NAPROSYN 1 $0

Naproxen 275mg Tablet ANAPROX 1 $0

Naproxen 500mg Tablet NAPROSYN 1 $0

Naratriptan 1mg Tablet AMERGE 1 $0

Naratriptan 2.5mg Tablet AMERGE 1 $0

Natamycin 5% Ophthalmic Suspension NATACYN 2 $0

Nateglinide 60mg Tablet STARLIX 1 $0

Nebivolol 10mg Tablet BYSTOLIC 1 $0

Nebulizer Supply, Adult Aerosol Mask -- 2 $0

Nebulizer Supply, Baby Conversion Kit -- 2 $0

Nebulizer Supply, Bubbles The Fish II Pediatric Aerosol Mask -- 2 $0

Nebulizer Supply, Replacement Air Filters -- 2 $0

Nebulizer, Vios LC Plus -- 2 $0

Nebulizer, Vios LC Sprint -- 2 $0

Nebulizer, Vios LC Sprint Deluxe -- 2 $0

Nedocromil 2% Ophthalmic Solution ALOCRIL 2 $0

Nefazodone 100mg Tablet SERZONE 1 $0





Nelfinavir 250mg Tablet VIRACEPT 2 $0

Nelfinavir 625mg Tablet VIRACEPT 2 $0

Neomycin 500mg Tablet -- 1 $0

Neomycin/Bacitracin/Polymyxin B Ophthalmic Ointment NEO-POLYCIN 1 $0



39


Tier Your Cost

Neomycin/Colistin/Hydrocortisone/Thonzonium Otic Suspension CORTISPORIN-TC 2 $0

Neomycin/Fluocinolone 0.35%/0.025% Topical Cream NEO-SYNALAR 1 $0

Neomycin/Polymyxin B/Dexamethasone Ophthalmic Ointment MAXITROL 1 $0

Neomycin/Polymyxin B/Dexamethasone Ophthalmic Suspension POLY-DEX 1 $0

Neomycin/Polymyxin B/Gramicidin Ophthalmic Solution NEOSPORIN 1 $0

Neomycin/Polymyxin B/Hydrocortisone 0.5% Topical Cream CORTISPORIN 2 $0

Neomycin/Polymyxin B/Hydrocortisone Otic Suspension CORTOMYCIN 1 $0

Nepafenac 0.1% Ophthalmic Suspension NEVANAC 2 $0

Netupitant/Palonosetron 300mg/0.5mg Capsule AKYNZEO 2 $0

Nevirapine 200mg Tablet VIRAMUNE 1 $0

Nevirapine 400mg Extended Release Tablet VIRAMUNE 1 $0

Niacin 500mg Extended Release Tablet SLO-NIACIN 1 $0

Niacin 750mg Extended Release Tablet SLO-NIACIN 1 $0

Nicardipine 20mg Capsule -- 1 $0

Nicotine 10mg Inhalation Inhaler NICOTROL 2 $0

Nicotine 14mg/24hr Transdermal Patch HABITROL 1 $0


Nicotine 2mg Dental Gum NICORETTE 1 $0

Nicotine 4mg Dental Gum NICORETTE 1 $0


Nifedipine 10mg Capsule PROCARDIA 1 $0

Nifedipine 30mg Extended Release Tablet ADALAT 1 $0



Nilotinib 150mg Capsule TASIGNA 2 $0

Nilotinib 200mg Capsule TASIGNA 2 $0

Nilutamide 150mg Tablet NILANDRON 1 $0

Nimodipine 30mg Capsule NIMOTOP 1 $0

Nimodipine 60mg/20ml Solution NYMALIZE 2 $0

Nisoldipine 8.5mg Extended Release Tablet SULAR 1 $0

Nitazoxanide 500mg Tablet ALINIA 1 $0

Nitisinone 10mg Capsule ORFADIN 1 $0



Nitrofurantoin 100mg Capsule MACROBID 1 $0

Nitrofurantoin 25mg Capsule MACRODANTIN 2 $0

Nitrofurantoin 25mg/5ml Suspension FURADANTIN 2 $0



40


Tier Your Cost

Nitrofurantoin 50mg Capsule MACRODANTIN 1 $0

Nitroglycerin 0.1mg/hr Transdermal Patch NITRO-DUR 1 $0


Nitroglycerin 0.3% Topical Ointment NITROBID 1 $0

Nitroglycerin 0.3mg Sublingual Tablet NITROSTAT 1 $0


Nitroglycerin 0.4% Rectal Ointment RECTIV 2 $0




Nitroglycerin 2.5mg Extended Release Capsule NITRO-TIME 1 $0

Nizatidine 150mg Capsule AXID 1 $0

Nonoxynol-9 12.5% Vaginal Foam VCF 2 $0

Nonoxynol-9 2% Vaginal Gel SHUR-SEAL 2 $0

Nonoxynol-9 28% Vaginal Film VCF 2 $0

Nonoxynol-9 4% Vaginal Gel CONCEPTROL 1 $0

Norelgestromin/Ethinyl Estradiol 150mcg/35mcg Weekly Transdermal Patch XULANE 1 $0

Norethindrone 0.35mg Tablet NORA-BE 1 $0

Norethindrone Acetate 5mg Tablet AYGESTIN 1 $0

Norethindrone/Ethinyl Estradiol 0.5-35/1-35/0.5-35mg/mcg Tablet ARANELLE 1 $0

Norethindrone/Ethinyl Estradiol 0.5-35/1-35/0.5-35mg/mcg Tablet LEENA 1 $0

Norethindrone/Ethinyl Estradiol 0.5mg/35mcg Tablet NECON 1 $0

Norethindrone/Ethinyl Estradiol 1mg/35mcg Tablet NORTREL 1 $0

Norethindrone/Ethinyl Estradiol/Ferrous Fumarate 1mg/20mcg/75mg Tablet MICROGESTIN FE 1 $0

Norethindrone/Ethinyl Estradiol/Ferrous Fumarate 1mg/20mcg/75mg Tablet JUNEL FE 1 $0

Norfloxacin 400mg Tablet NOROXIN 2 $0

Norgestimate/Ethinyl Estradiol 0.18-0.035/0.215-0.035/0.25-0.035mg/mg Tablet TRI-SPRINTEC 1 $0

Norgestimate/Ethinyl Estradiol 0.25mg/0.035mg Tablet SPRINTEC 1 $0

Nortriptyline 10mg Capsule AVENTYL 1 $0




Nystatin 100000units/gm Topical Powder NYSTOP 1 $0

Nystatin 500000unit Tablet BIO-STATIN 1 $0



41


Tier Your Cost

Nystatin/Triamcinolone 100000units/0.1% Topical Cream -- 1 $0

Nystatin/Triamcinolone 100000units/0.1% Topical Ointment -- 1 $0

Ofloxacin 0.3% Ophthalmic Solution OCUFLOX 1 $0

Ofloxacin 0.3% Otic Solution -- 1 $0

Ofloxacin 300mg Tablet -- 1 $0

Olanzapine 10mg Tablet ZYPREXA 1 $0


Olanzapine 2.5mg Tablet ZYPREXA 1 $0



Olanzapine 7.5mg Tablet ZYPREXA 1 $0

Olmesartan 5mg Tablet BENICAR 1 $0

Olodaterol Inhalation Solution 2.5mcg/Actuation STRIVERDI RESPIMAT 2 $0

Olopatadine 0.1% Ophthalmic Solution PATANOL 1 $0

Olopatadine 0.6% Nasal Solution PATANASE 1 $0

Olsalazine 250mg Capsule DIPENTUM 2 $0

Omacetaxine 3.5mg Subcutaneous Solution SYNRIBO 2 $0

Omega-3-Acid 1gm Capsule LOVAZA 1 $0

Omeprazole 10mg Capsule PRILOSEC 1 $0

Omeprazole 20mg Delayed Release Tablet PRILOSEC 1 $0

Omeprazole 2mg/ml Solution PRILOSEC 1 $0

Omeprazole Magnesium Delayed Release 2.5mg Powder Packet PRILOSEC 2 $0

Omeprazole/Sodium Bicarbonate 20mg Powder ZEGERID 1 $0

Omeprazole/Sodium Bicarbonate 40mg Powder ZEGERID 1 $0

Ondansetron 4mg Disintegrating Tablet ZOFRAN 1 $0

Ondansetron 4mg Tablet ZOFRAN 1 $0

Ondansetron 4mg/5ml Solution ZOFRAN 1 $0

Ondansetron 8mg Disintegrating Tablet ZOFRAN 1 $0

Ondansetron 8mg Tablet ZOFRAN 1 $0

Oprelvekin 5mg Subcutaneous Solution NEUMEGA 2 $0

Oral Electrolyte Solution (various flavors) PEDIALYTE 1 $0

Orphenadrine Citrate 100mg Extended Release Tablet NORFLEX 1 $0

Oseltamivir 30mg Capsule TAMIFLU 1 $0

Oseltamivir Phosphate 6mg/ml Suspension TAMIFLU 1 $0

Oseltamivir Phosphate 75mg Capsule TAMIFLU 1 $0

Oxandrolone 2.5mg Tablet OXANDRIN 1 $0

Oxaprozin 600mg Tablet DAYPRO 1 $0

Oxazepam 10mg Capsule SERAX 1 $0



42


Tier Your Cost



Oxcarbazepine 150mg Tablet TRILEPTAL 1 $0


Oxcarbazepine 300mg/5ml Suspension TRILEPTIL 1 $0


Oxiconazole 1% Topical Cream OXISTAT 1 $0

Oxybutynin Chloride 10mg Extended Release Tablet DITROPAN XL 1 $0



Oxybutynin Chloride 5mg Tablet DITROPAN 1 $0

Oxybutynin Chloride 5mg/5ml Syrup DITROPAN 1 $0

Oxycodone 10mg Extended Release Tablet OXYCONTIN 1 $0

Oxycodone 5mg Tablet ROXICODONE 1 $0

Oxycodone 5mg/5ml Solution ROXICODONE 1 $0

Oxycodone/Acetaminophen 2.5mg/325mg Tablet -- 1 $0

Oxycodone/Acetaminophen 5mg/325mg Tablet PERCOCET 1 $0

Oxycodone/Aspirin 4.8355mg/325mg Tablet ENDODAN 1 $0

Oxycodone/Ibuprofen 5mg/400mg Tablet -- 1 $0

Oxymetholone 50mg Tablet ANADROL 2 $0

Oxymorphone 10mg Extended Release Tablet OPANA ER 1 $0



Palbociclib 100mg Tablet IBRANCE 2 $0



Pancrelipase Enteric Coated 10,000/32,000units Capsule ZENPEP 2 $0



Pantoprazole 40mg Enteric Coated Tablet PROTONIX 1 $0

Paricalcitol 1mcg Capsule -- 1 $0

Paroxetine 10mg Tablet PAXIL 1 $0




Pasireotide 0.3mg/ml Subcutaneous Solution SIGNIFOR 2 $0



Pazopanib 200mg Tablet VOTRIENT 2 $0

Pediatric Multiple Vitamin 35mg/ml Solution -- 1 $0



43


Tier Your Cost

Pediatric Multiple Vitamin/Iron/Zinc 30mg/200mg/3mg Chewable Tablet -- 2 $0

Pediatric Vitamins A/D/C 1500units-400units-35mg/ml Solution -- 1 $0

Pegfilgrastim 6mg/0.6ml Subcutaneous Solution NEULASTA 2 $0

Peginterferon Alfa-2a 180mcg/0.5ml Subcutaneous Solution PEGASYS 2 $0

Peginterferon Alfa-2a 180mcg/ml Subcutaneous Solution PEGASYS 2 $0

Peginterferon Alfa-2b 120mcg/0.5ml Subcutaneous Kit PEG-INTRON 2 $0


Peginterferon Alfa-2b 296mcg Subcutaneous Kit SYLATRON 2 $0





Pegvaliase-pqpz 10mg/0.5ml Subcutaneous Injection PALYNZIQ 2 $0

Pegvaliase-pqpz 2.5mg/0.5ml Subcutaneous Injection PALYNZIQ 2 $0

Pegvaliase-pqpz 20mg/1ml Subcutaneous Injection PALYNZIQ 2 $0

Pegvisomant 10mg Subcutaneous Solution SOMAVERT 2 $0



Penbutolol 20mg Tablet LEVATOL 2 $0

Penciclovir 1% Topical Cream DENAVIR 2 $0

Penicillamine 250mg Capsule -- 1 $0

Penicillamine 250mg Tablet DEPEN 1 $0

Penicillin V Potassium 125mg/5ml Solution PEN VK 1 $0

Penicillin V Potassium 250mg Tablet PEN VK 1 $0

Penicillin V Potassium 250mg/5ml Solution PEN VK 1 $0

Penicillin V Potassium 500mg Tablet PEN VK 1 $0

Pentafluoropropane/Tetrafluoroethane 95%/5% Topical Spray GEBAUERS 2 $0

Pentamidine 300mg Inhalation Mist NEBUPENT 1 $0

Pentosan 100mg Capsule ELMIRON 2 $0

Pentoxifylline 400mg Extended Release Tablet TRENTAL 1 $0

Perindopril 2mg Tablet ACEON 1 $0

Permethrin 1% Topical Liquid -- 1 $0

Permethrin 5% Topical Cream ELIMITE 1 $0

Perphenazine 2mg Tablet TRILAFON 1 $0

Perphenazine 4mg Tablet TRILAFON 1 $0

Phenazopyridine 100mg Tablet -- 1 $0

Phenelzine 15mg Tablet NARDIL 1 $0



44


Tier Your Cost

Phenobarbital 16.2mg Tablet -- 1 $0

Phenobarbital 20mg/5ml Elixir -- 1 $0




Phenoxybenzamine 10mg Capsule DIBENZYLINE 1 $0

Phentermine 15mg Capsule FASTIN 1 $0

Phentermine 30mg Capsule FASTIN 1 $0

Phentermine 8mg Tablet LOMAIRA 1 $0

Phenylepherine/Promethazine/Codeine Syrup PHENERGAN VC WITH CODEINE 1 $0

Phenylephrine 10% Ophthalmic Solution NEO-SYNEPHRINE 1 $0

Phenylephrine 2.5% Ophthalmic Solution NEO-SYNEPHRINE 1 $0

Phenytoin 100mg Capsule DILANTIN 1 $0

Phenytoin 125mg/5ml Suspension DILANTIN 1 $0

Phenytoin 30mg Capsule DILANTIN 1 $0

Phenytoin 50mg ChewableTablet DILANTIN 1 $0

Phytonadione 5mg Tablet MEPHYTON 1 $0

Pilocarpine 1% Ophthalmic Solution ISOPTO-CARPINE 1 $0



Pilocarpine 5mg Tablet SALAGEN 1 $0

Pimecrolimus 1% Topical Cream ELIDEL 1 $0

Pimozide 1mg Tablet ORAP 1 $0

Pindolol 5mg Tablet VISKEN 1 $0

Pioglitazone 15mg Tablet ACTOS 1 $0



Pirfenidone 801mg Tablet ESBRIET 2 $0

Piroxicam 10mg Capsule FELDENE 1 $0

Piroxicam 20mg Capsule FELDENE 1 $0

Pitavastatin 1mg Tablet LIVALO 2 $0

Podofilox 0.5% Topical Solution CONDYLOX 1 $0

Polyethylene Glycol 3350 Powder For Solution GLYCOLAX 1 $0

Polyethylene Glycol-3350/Potassium Chloride/Sodium Bicarbonate/Sodium Chloride/Sodium Asco MOVIPREP 1 $0

Polyethylene Glycol-3350/Potassium Chloride/Sodium Bicarbonate/Sodium Chloride/Sodium Sulf COLYTE 2 $0

Polyethylene Glycol-3350/Potassium Chloride/Sodium Bicarbonate/Sodium Chloride/Sodium Sulf -- 1 $0

Polyethylene Glycol-3350/Potassium Chloride/Sodium Bicarbonate/Sodium Chloride/Sodium Sulf GAVILYTE-C 1 $0



45


Tier Your Cost

Polyethylene Glycol-3350/Potassium Chloride/Sodium Bicarbonate/Sodium Chloride/Sodium Sulf GOLYTELY 2 $0

Polyethylene Glycol-3350/Sodium Bicarbonate/Sodium Chloride Powder For Solution 420gm -- 1 $0

Polymyxin B/Trimethoprim Ophthalmic Solution POLYTRIM 1 $0

Pomalidomide 1mg Capsule POMALYST 2 $0




Posaconazole 100mg Delayed Release Tablet NOXAFIL 1 $0

Posaconazole 40mg/ml Suspension NOXAFIL 2 $0

Potassium Aminobenzoate 500mg Capsule POTABA 1 $0

Potassium Bicarbonate 25meq Effervescent Tablet KLOR-CON/EF 1 $0

Potassium Chloride 10% Liquid -- 1 $0

Potassium Chloride 10meq Controlled Release Tablet K-TAB 1 $0

Potassium Chloride 20meq Microencapsulated Extended Release Tablet KLOR-CON M 1 $0

Potassium Chloride 20meq Powder KLOR-CON 1 $0

Potassium Citrate 1080mg Tablet UROCIT-K 1 $0

Potassium Citrate 540mg Tablet UROCIT-K 1 $0

Potassium Iodide 1gm/ml Solution SSKI 2 $0

Potassium/Citric Acid Solution CYTRA-K 1 $0

Povidone/Iodine 5% Ophthalmic Solution BETADINE 2 $0

Pramipexole 0.125mg Tablet MIRAPEX 1 $0



Pramipexole 1mg Tablet MIRAPEX 1 $0

Pramlintide Acetate 1500mcg/1.5ml Subcutaneous Solution SYMLINPEN 2 $0

Pramlintide Acetate 2700mcg/2.7ml Subcutaneous Solution SYMLINPEN 2 $0

Pramoxine/Hydrocortisone 1% Topical Lotion PRAMOSONE 1 $0

Pramoxine/Hydrocortisone 2.5% Topical Lotion PRAMOSONE 1 $0

Prasugrel 10mg Tablet EFFIENT 1 $0

Prasugrel 5mg Tablet EFFIENT 1 $0

Pravastatin 10mg Tablet PRAVACHOL 1 $0




Praziquantel 600mg Tablet BILTRICIDE 1 $0

Prazosin 1mg Capsule MINIPRESS 1 $0



46


Tier Your Cost



Prednicarbate 0.1% Topical Ointment -- 1 $0

Prednisolone 15mg/5ml Solution ORAPRED 1 $0

Prednisolone 6.7mg/5ml Liquid ORAPRED 1 $0

Prednisolone Acetate 0.12% Ophthalmic Suspension PRED-MILD 2 $0

Prednisolone Acetate 1% Ophthalmic Suspension PRED 1 $0

Prednisone 10mg Tablet -- 1 $0




Prednisone 5mg Dose Pack Tablet -- 1 $0


Prednisone 5mg/5ml Solution -- 1 $0

Pregabalin 100mg Capsule LYRICA 1 $0








Prenatal Vitamin Tablet -- 2 $0

Primaquine Phosphate 26.3mg Tablet -- 1 $0

Primidone 250mg Tablet MYSOLINE 1 $0

Primidone 50mg Tablet MYSOLINE 1 $0

Probenecid 500mg Tablet BENEMID 1 $0

Procarbazine 50mg Capsule MATULANE 2 $0

Prochlorperazine 10mg Tablet COMPAZINE 1 $0

Prochlorperazine 25mg Rectal Suppository COMPRO 1 $0

Prochlorperazine 5mg Tablet COMPAZINE 1 $0

Progesterone 100mg Vaginal Suppository ENDOMETRIN 2 $0

Progesterone 8% Vaginal Gel CRINONE 1 $0

Progesterone Micronized 100mg Capsule PROMETRIUM 1 $0

Progesterone Micronized 200mg Capsule PROMETRIUM 1 $0

Promethazine 12.5mg Tablet PHENERGAN 1 $0

Promethazine 25mg Rectal Suppository PROMETHEGAN 1 $0

Promethazine 25mg Tablet PHENERGAN 1 $0

Promethazine 6.25mg/5ml Syrup PHENERGAN 1 $0

Promethazine/Codeine 6.25mg-10mg/5ml Syrup PHENERGAN-FORTIS 1 $0

Promethazine/Phenylephrine Syrup PHENERGAN VC 1 $0



47


Tier Your Cost

Propafenone 150mg Tablet RYTHMOL 1 $0

Propranolol 10mg Tablet INDERAL 1 $0


Propranolol 20mg/5ml Solution INDERAL 1 $0



Propylthiouracil 50mg Tablet PTU 1 $0

Protriptyline 10mg Tablet VIVACTIL 1 $0

Pyrantel Pamoate 144mg/ml Suspension -- 1 $0

Pyrazinamide 500mg Tablet -- 1 $0

Pyridostigmine 60mg Tablet MESTINON 1 $0

Pyridostigmine Timespan 180mg Tablet MESTINON 1 $0

Pyrimethamine 25mg Tablet DARAPRIM 1 $0

Quetiapine Fumarate 100mg Tablet SEROQUEL 1 $0





Quetiapine Fumarate 50mg Extended Release Tablet SEROQUEL XR 1 $0


Quinapril 5mg Tablet ACCUPRIL 1 $0

Quinidine 300mg Extended Release Tablet QUINIDEX 2 $0

Quinidine Gluconate 324mg Controlled Release Tablet QUINAGLUTE 1 $0

Quinine 324mg Capsule QUALAQUIN 1 $0

Rabeprazole 20mg Enteric Coated Tablet ACIPHEX 1 $0

Raloxifene 60mg Tablet EVISTA 1 $0

Raltegravir 25mg Chewable Tablet ISENTRESS 2 $0

Raltegravir 400mg Tablet ISENTRESS 2 $0

Raltegravir Potassium 600mg Tablet ISENTRESS HD 2 $0

Ramelteon 8mg Tablet ROZEREM 1 $0

Ramipril 1.25mg Capsule ALTACE 1 $0

Ranitidine 15mg/ml Syrup ZANTAC 1 $0

Ranolazine 500mg Tablet RANEXA 1 $0

Rasagiline 0.5mg Tablet AZILECT 1 $0

Regorafenib 40mg Tablet STIVARGA 2 $0

Repaglinide 1mg Tablet PRANDIN 1 $0

Ribavirin 200mg Capsule REBETOL 1 $0

Rifabutin 150mg Capsule MYCOBUTIN 1 $0

Rifampin 10mg/ml Suspension RIFADIN 1 $0

Rifampin 300mg Capsule RIDADIN 1 $0

Rifampin 50mg/ml Suspension RIFADIN 1 $0



48


Tier Your Cost

Rifapentine 150mg Tablet PRIFTIN 2 $0

Rifaximin 200mg Tablet XIFAXAN 2 $0

Rifaximin 550mg Tablet XIFAXAN 2 $0

Rilonacept 220mg Subcutaneous Solution ARCALYST 2 $0

Rilpivirine 25mg Tablet EDURANT 2 $0

Riluzole 50mg Tablet RILUTEK 1 $0

Rimantadine 100mg Tablet FLUMADINE 1 $0

Rimexolone 1% Ophthalmic Suspension VEXOL 2 $0

Risankizumab-rzaa 75mg/0.83ml Injection Solution SKYRIZI 2 $0

Risedronate 35mg Tablet ACTONEL 1 $0

Risedronate 5mg Tablet ACTONEL 1 $0

Risperidone 0.25mg Tablet RISPERDAL 1 $0

Risperidone 0.5mg Tablet RISPERDAL 1 $0

Risperidone 1mg Tablet RISPERDAL 1 $0

Risperidone 1mg/ml Solution RISPERDAL 1 $0




Ritonavir 100mg Tablet NORVIR 1 $0

Ritonavir 80mg/ml Solution NORVIR 2 $0

Rivaroxaban 10mg Tablet XARELTO 2 $0



Rivastigmine Tartrate 3mg Capsule EXELON 1 $0

Rizatriptan 10mg Disintegrating Tablet MAXALT-MLT 1 $0

Rizatriptan 10mg Tablet MAXALT 1 $0

Rizatriptan 5mg Disintegrating Tablet MAXALT-MLT 1 $0

Rizatriptan 5mg Tablet MAXALT 1 $0

Roflumilast 500mcg Tablet DALIRESP 2 $0

Ropinirole 0.25mg Tablet REQUIP 1 $0

Ropinirole 0.5mg Tablet REQUIP 1 $0

Ropinirole 1mg Tablet REQUIP 1 $0

Ropinirole 2mg Tablet REQUIP 1 $0

Rosiglitazone 2mg Tablet AVANDIA 2 $0

Rosuvastatin 10mg Tablet CRESTOR 1 $0




Rufinamide 200mg Tablet BANZEL 1 $0

Ruxolitinib Phosphate 10mg Tablet JAKAFI 2 $0




49


Tier Your Cost




Sacubitril/Valsartan 24mg/26mg Tablet ENTRESTO 2 $0



Saline 0.65% Nasal Spray OCEAN 1 $0

Salsalate 750mg Tablet DISALCID 1 $0

Saquinavir 200mg Capsule INVIRASE 2 $0

Saquinavir 500mg Tablet INVIRASE 2 $0

Saxagliptin 2.5mg Tablet ONGLYZA 2 $0

Scopolamine 1.5mg 72-hour Transdermal Patch TRANSDERM-SCOP 1 $0

Secukinumab 150mg/ml Subcutaneous Solution COSENTYX 2 $0

Selegiline 5mg Capsule ELDEPRYL 1 $0

Selegiline 6mg/24hr Transdermal Patch EMSAM 2 $0

Selenium 2.5% Topical Shampoo SELSUN 1 $0

Sertaconazole 2% Topical Cream ERTACZO 2 $0

Sertraline 100mg Tablet ZOLOFT 1 $0



Sevelamer Carbonate 2.4gm Powder RENVELA 1 $0

Sevelamer Carbonate 800mg Tablet RENVELA 1 $0

Sildenafil Citrate 2.5mg/ml Suspension (for PAH only) REVATIO 1 $0

Sildenafil Citrate 20mg Tablet (for PAH only) REVATIO 1 $0

Silodosin 4mg Capsule RAPAFLO 1 $0

Silver Nitrate/Potassium Topical Applicators ARZOL 1 $0

Silver Sulfadiazine 1% Topical Cream THERMAZENE 1 $0

Simvastatin 10mg Tablet ZOCOR 1 $0





Sinecatechins 15% Topical Ointment VEREGEN 2 $0

Sirolimus 1mg Tablet RAPAMUNE 1 $0

Sirolimus 1mg/ml Solution RAPAMUNE 1 $0

Sirolimus 2mg Tablet RAPAMUNE 1 $0

Sitagliptin 25mg Tablet JANUVIA 2 $0

Sodium Bicarbonate 650mg Tablet -- 1 $0

Sodium Chloride 0.9% Bladder Irrigation Solution -- 1 $0

Sodium Citrate/Citric Acid 334mg/5ml Solution -- 1 $0

Sodium Fluoride 0.275 (0.125 F) mg/drop Solution FLUOR-A-DAY 1 $0



50


Tier Your Cost

Sodium Fluoride 0.275 (0.125 F) mg/drop Solution FLUORITAB 1 $0

Sodium Fluoride 0.55 (0.25 F) mg Chewable Tablet -- 1 $0

Sodium Fluoride 0.55 (0.25 F) mg/0.6ml Solution FLUORABON 2 $0

Sodium Fluoride 0.55 (0.25 F) mg/drop Solution FLURA-DROPS 2 $0

Sodium Fluoride 1.1 (0.5 F) mg Chewable Tablet -- 1 $0

Sodium Fluoride 1.1 (0.5 F) mg/ml Solution -- 1 $0

Sodium Fluoride 2.2 (1 F) mg Chewable Tablet FLUORABON 1 $0

Sodium Fluoride 2.2 (1 F) mg Lozenge LOZI-FLUR 1 $0

Sodium Oxybate 500mg/ml Solution XYREM 2 $0

Sodium Phenylbutyrate 3gm/tsp Powder BUPHENYL 1 $0

Sodium Phenylbutyrate 500mg Tablet BUPHENYL 1 $0

Sodium Phosphate Monobasic Monohydrate 1.102gm/0.398gm Tablet OSMOPREP 2 $0

Sodium Phosphates Solution -- 1 $0

Sodium Picosulfate/Magnesium Oxide/Anhydrous Citric Acid 10mg/3.5gm/12gm Solution CLENPIQ 2 $0

Sodium Picosulfate/Magnesium Oxide/Citric Acid 10mg/3.5gm/12gm Powder PREPOPIK 2 $0

Sodium Polystyrene Sulfate 15gm/60ml Suspension KAYEXALATE 1 $0

Sodium Sulfate-Potassium Sulfate-Magnesium Sulfate Solution SUPREP BOWEL PREP 2 $0

Sofosbuvir 400mg Tablet SOVALDI 2 $0

Sofosbuvir/Velpatasvir 400mg/100mg Tablet EPCLUSA 1 $0

Sofosbuvir/Velpatasvir/Voxilaprevir 400mg/100mg/100mg Tablet VOSEVI 2 $0

Solifenacin Succinate 10mg Tablet VESICARE 1 $0

Solifenacin Succinate 5mg Tablet VESICARE 1 $0

Somatropin 10mg/1.5ml Subcutaneous Solution OMNITROPE 2 $0

Somatropin 12mg Injection Solution HUMATROPE 2 $0

Somatropin 12mg Subcutaneous Solution GENOTROPIN 2 $0

Somatropin 15mg/1.5ml Subcutaneous Solution NORDITROPIN 2 $0

Somatropin 24mg Injection Solution HUMATROPE 2 $0


Somatropin 30mg/3ml Subcutaneous Solution NORDITROPIN 2 $0

Somatropin 5mg Subcutaneous Injection SAIZEN 2 $0


Somatropin 5mg/1.5ml Subcutaneous Solution OMNITROPE 2 $0

Somatropin 5mg/2ml Subcutaneous Solution NUTROPIN 2 $0

Somatropin 6mg Subcutaneous Solution SEROSTIM 2 $0

Somatropin 8.8mg Injection Solution SAIZEN 2 $0

Somatropin 8.8mg Subcutaneous Solution ZORBTIVE 2 $0



51


Tier Your Cost

Sorafenib 200mg Tablet NEXAVAR 2 $0

Sotalol 160mg Tablet BETAPACE 1 $0

Sotalol 80mg Tablet BETAPACE 1 $0

Spinosad 0.9% Topical Suspension NATROBA 1 $0

Spironolactone 100mg Tablet ALDACTONE 1 $0



Spironolactone/Hydrochlorothiazide 25mg/25mg Tablet ALDACTAZIDE 1 $0

Spironolactone/Hydrochlorothiazide 5mg-5mg/ml Suspension ALDACTAZIDE 1 $0

Stavudine 20mg Capsule ZERIT 1 $0



Sterile Water for Irrigation Solution -- 1 $0

Succimer 100mg Capsule CHEMET 2 $0

Sucralfate 100mg/ml Suspension CARAFATE 1 $0

Sucralfate 1gm Tablet -- 1 $0

Sulconazole 1% Topical Cream EXELDERM 1 $0

Sulfacetamide 10% Ophthalmic Solution BLEPHAMIDE 1 $0

Sulfacetamide Sodium/Prednisolone Ophthalmic Ointment BLEPHAMIDE-S.O.P. 1 $0

Sulfacetamide Sodium/Prednisolone Ophthalmic Solution SULFACET 1 $0

Sulfadiazine 500mg Tablet -- 1 $0

Sulfamethoxazole/Trimethoprim 200mg-40mg/5ml Suspension BACTRIM 1 $0

Sulfamethoxazole/Trimethoprim 400mg/80mg Tablet BACTRIM 1 $0

Sulfamethoxazole/Trimethoprim 800mg/160mg Tablet BACTIM-DS 1 $0

Sulfasalazine 500mg Delayed Release Enteric Coated Tablet AZULFIDINE 1 $0

Sulindac 150mg Tablet CLINORIL 1 $0

Sulindac 200mg Tablet CLINORIL 1 $0

Sumatriptan 20mg/Actuation Nasal Spray IMITREX 1 $0

Sumatriptan 5mg/Actuation Nasal Spray IMITREX 1 $0

Sumatriptan Succinate 100mg Tablet IMITREX 1 $0



Sumatriptan Succinate 6mg/0.5ml Subcutaneous Solution IMITREX 1 $0

Sunitinib 12.5mg Capsule SUTENT 1 $0

Sunitinib 25mg Capsule SUTENT 1 $0



52


Tier Your Cost

Sunitinib 50mg Capsule SUTENT 1 $0

Tacrolimus 0.03% Topical Ointment PROTOPIC 1 $0

Tacrolimus 0.1% Topical Ointment PROTOPIC 1 $0

Tacrolimus 0.5mg Capsule PROGRAF 1 $0

Tacrolimus 0.5mg/ml Suspension PROGRAF 1 $0

Tacrolimus 1mg Capsule PROGRAF 1 $0

Tacrolimus 5mg Capsule PROGRAF 1 $0

Tafenoquine Succinate 100mg Tablet ARAKODA 2 $0

Tafenoquine Succinate 150mg Tablet KRINTAFEL 2 $0

Tafluprost 0.015mg/ml Ophthalmic Solution ZIOPTAN 2 $0

Tamoxifen Citrate 10mg Tablet NOLVADEX 1 $0

Tamoxifen Citrate 10mg/5ml Solution SOLTAMOX 2 $0

Tamoxifen Citrate 20mg Tablet NOLVADEX 1 $0

Tamsulosin 0.4mg Capsule FLOMAX 1 $0

Tapentadol 50mg Extended Release Tablet NUCYNTA 2 $0

Tapentadol 75mg Tablet NUCYNTA 2 $0

Tazarotene 0.05% Topical Cream TAZORAC 2 $0

Tazarotene 0.05% Topical Gel TAZORAC 2 $0

Tazarotene 0.1% Topical Cream TAZORAC 1 $0

Tazarotene 0.1% Topical Gel TAZORAC 2 $0

Tedizolid 200mg Tablet SIVEXTRO 2 $0

Teduglutide 5mg Subcutaneous Kit GATTEX 2 $0

Telaprevir 375mg Tablet INCIVEK 2 $0

Telithromycin 300mg Tablet KETEK 2 $0

Telmisartan 20mg Tablet MICARDIS 1 $0

Temazepam 15mg Capsule RESTORIL 1 $0

Temazepam 30mg Capsule RESTORIL 1 $0

Temozolomide 100mg Capsule TEMODAR 1 $0




Tenofovir 150mg Tablet VIREAD 2 $0




Tenofovir 40mg/gm Powder VIREAD 2 $0

Terazosin 10mg Capsule HYTRIN 1 $0




Terbinafine 250mg Tablet LAMISIL 1 $0



53


Tier Your Cost

Terbutaline 5mg Tablet BRETHINE 1 $0

Terconazole 0.4% Vaginal Cream TERAZOL 1 $0

Terconazole 80mg Vaginal Suppository TERAZOL 1 $0

Teriflunomide 14mg Tablet AUBAGIO 2 $0

Teriflunomide 7mg Tablet AUBAGIO 2 $0

Teriparatide 600mcg/2.4ml Subcutaneous Solution FORTEO 2 $0

Tesamorelin Acetate 2mg Subcutaneous Solution EGRIFTA 2 $0

Testosterone Transdermal Gel 12.5mg/Actuation (1%) TESTIM 1 $0

Testosterone Transdermal Gel 20.25mg/Actuation (1.62%) TESTIM 1 $0

Tetrabenazine 12.5mg Tablet XENAZINE 1 $0

Tetrabenazine 25mg Tablet XENAZINE 1 $0

Tetracycline 250mg Capsule -- 1 $0

Tezacaftor/Ivacaftor 100mg/150mg & Ivacaftor 150mg Tablet Pack SYMDEKO 2 $0

Thalidomide 100mg Capsule THALOMID 2 $0




Theophylline 100mg Controlled Release Tablet THEO-DUR 1 $0

Theophylline 200mg Controlled Release Tablet THEO-DUR 1 $0

Theophylline 300mg Extended Release Tablet THEO-DUR 1 $0

Theophylline 450mg Extended Release Tablet THEO-DUR 1 $0

Thioguanine 40mg Tablet TABLOID 2 $0

Thioridazine 100mg Tablet MELLARIL 1 $0




Thiothixene 5mg Capsule NAVANE 1 $0

Thyroid 120mg Tablet ARMOUR THYROID 1 $0






Tiagabine 2mg Tablet GABITRIL 1 $0

Ticagrelor 60mg Tablet BRILINTA 2 $0

Ticagrelor 90mg Tablet BRILINTA 2 $0

Ticlopidine 250mg Tablet TICLID 1 $0

Timolol 0.25% Ophthalmic Solution TIMOPTIC 1 $0

Timolol 0.5% Ophthalmic Solution TIMOPTIC 1 $0



54


Tier Your Cost

Timolol 10mg Tablet BLOCADREN 1 $0

Timothy Grass Pollen Allergen Extract 2800BAU Sublingual Tablet GRASTEK 2 $0

Tinidazole 250mg Tablet -- 1 $0

Tinidazole 500mg Tablet TINDAMAX 1 $0

Tiotropium Bromide/Olodaterol 2.5mcg/2.5mcg/inhalation Aerosol Solution STIOLTO RESPIMAT 2 $0

Tiotropium Inhalation Aerosol 2.5mcg/Actuation SPIRIVA RESPIMAT 2 $0

Tipranavir 100mg/ml Solution APTIVUS 2 $0

Tipranavir 250mg Capsule APTIVUS 2 $0

Tizanidine 2mg Tablet ZANAFLEX 1 $0

Tizanidine 4mg Tablet ZANAFLEX 1 $0

Tobramycin 0.3% Ophthalmic Ointment TOBREX 2 $0

Tobramycin 13.6mg/ml Ophthalmic Solution TOBREX 1 $0

Tobramycin 300mg/5ml Inhalation Mist TOBI 1 $0

Tobramycin/Dexamethasone 0.3%/0.1% Ophthalmic Ointment TOBRADEX 2 $0

Tofacitinib 10mg Tablet XELJANZ 2 $0

Tofacitinib 5mg Tablet XELJANZ 2 $0

Tolazamide 250mg Tablet -- 1 $0

Tolbutamide 500mg Tablet -- 1 $0

Tolcapone 100mg Tablet TASMAR 1 $0

Tolmetin 200mg Tablet TOLECTIN 1 $0

Tolterodine 1mg Tablet DETROL 1 $0

Tolvaptan 15mg Tablet SAMSCA 1 $0

Topiramate 100mg Tablet TOPAMAX 1 $0

Topiramate 15mg Sprinkle Capsule TOPAMAX 1 $0


Topiramate 25mg Sprinkle Capsule TOPAMAX 1 $0



Toremifene Citrate 60mg Tablet FARESTON 1 $0

Torsemide 100mg Tablet -- 1 $0



Torsemide 5mg Tablet DEMADEX 1 $0

Tramadol 100mg Extended Release Tablet ULTRAM 1 $0

Tramadol 50mg Tablet ULTRAM 1 $0

Trandolapril 1mg Tablet MAVIK 1 $0

Tranexamic Acid 650mg Tablet LYSTEDA 1 $0

Tranylcypromine 10mg Tablet PARNATE 1 $0



55


Tier Your Cost

Travoprost 0.004% Ophthalmic Solution TRAVATAN 1 $0

Trazodone 100mg Tablet DESYREL 1 $0

Trazodone 50mg Tablet DESYREL 1 $0

Tretinoin 0.01% Topical Gel RETIN-A 1 $0

Tretinoin 0.025% Topical Cream RETIN-A 1 $0





Tretinoin 10mg Capsule VESANOID 1 $0

Triamcinolone Acetonide 0.025% Topical Cream KENALOG 1 $0

Triamcinolone Acetonide 0.025% Topical Ointment KENALOG 1 $0

Triamcinolone Acetonide 0.1% Dental Paste KENALOG 1 $0



Triamcinolone Acetonide 0.5% Topical Ointment -- 1 $0

Triamcinolone Acetonide 55mcg/actuation Nasal Aerosol Suspension NASACORT 1 $0

Triamcinolone Acetonide Topical Spray KENALOG 1 $0

Triamcinolone Acetonide/LCD 0.1%/10% Topical Ointment KENALOG 1 $0

Triamterene 50mg Capsule DYRENIUM 1 $0

Triamterene/Hydrochlorothiazide 37.5mg/25mg Tablet MAXZIDE-25 1 $0

Triamterene/Hydrochlorothiazide 75mg/50mg Tablet MAXZIDE 1 $0

Triazolam 0.125mg Tablet HALCION 1 $0

Triazolam 0.25mg Tablet HALCION 1 $0

Trientine 250mg Capsule SYPRINE 1 $0

Trifluoperazine 10mg Tablet STELAZINE 1 $0



Trifluridine 1% Ophthalmic Solution VIROPTIC 1 $0

Trihexyphenidyl 0.4mg/ml Elixir -- 2 $0

Trihexyphenidyl 2mg Tablet ARTANE 1 $0

Trimethobenzamide 300mg Capsule TIGAN 1 $0

Trimethoprim 100mg Tablet -- 1 $0

Trimipramine 100mg Capsule SURMONTIL 1 $0

Trivitamin/Fluoride 0.25mg/ml Drops Solution TRI-VI-FLOR 1 $0

Trospium Chloride 20mg Tablet SANCTURA 1 $0

Trospium Chloride 60mg Extended Release Capsule SANCTURA XR 1 $0

Tucatinib 150mg Tablet TUKYSA 2 $0

Tucatinib 50mg Tablet TUKYSA 2 $0



56


Tier Your Cost

Ulipristal Acetate 30mg Tablet ELLA 2 $0

Urea 40% Topical Cream CARMOL 1 $0

Ursodiol 250mg Tablet URSO 1 $0

Ursodiol 300mg Capsule ACTIGALL 1 $0

Ursodiol 500mg Tablet URSO 1 $0

Ursodiol 60mg/ml Suspension ACTIGALL 1 $0

Ustekinumab 45mg/0.5ml Subcutaneous Solution STELARA 2 $0

Ustekinumab 90mg/ml Subcutaneous Solution STELARA 2 $0

Valacyclovir 1gm Tablet -- 1 $0

Valacyclovir 500mg Tablet VALTREX 1 $0

Valganciclovir 450mg Tablet VALCYTE 1 $0

Valganciclovir 50mg/ml Solution VALCYTE 1 $0

Valproate 250mg/5ml Solution DEPAKENE 1 $0

Valproic Acid 250mg Capsule DEPAKENE 1 $0

Valsartan 40mg Tablet DIOVAN 1 $0

Vancomycin 125mg Capsule VANCOCIN 1 $0

Vancomycin 250mg Capsule VANCOCIN 1 $0

Vancomycin 25mg/ml Ophthalmic Solution -- 1 $0

Vancomycin 25mg/ml Oral Solution FIRVANQ 2 $0

Vancomycin 25mg/ml Oral Solution (compounded by pharmacy) -- 2 $0

Vancomycin 50mg/ml Ophthalmic Solution -- 1 $0

Varenicline Tartrate 0.5mg Tablet CHANTIX 1 $0

Varenicline Tartrate 1mg Tablet CHANTIX 1 $0

Varenicline Tartrate Tablet CHANTIX STARTER MONTH PACK 2 $0

Vemurafenib 240mg Tablet ZELBORAF 2 $0

Venlafaxine 100mg Tablet EFFEXOR 1 $0

Venlafaxine 150mg Extended Release Capsule EFFEXOR 1 $0


Venlafaxine 37.5mg Extended Release Capsule EFFEXOR 1 $0

Venlafaxine 37.5mg Tablet EFFEXOR 1 $0

Venlafaxine 75mg Extended Release Capsule EFFEXOR 1 $0


Verapamil 120mg Tablet CALAN 1 $0

Verapamil 240mg Sustained Release Tablet CALAN-SR 1 $0

Verapamil 50mg/ml Suspension CALAN 1 $0

Verapamil 80mg Tablet CALAN 1 $0

Vigabatrin 500mg Powder SABRIL 1 $0

Vigabatrin 500mg Tablet SABRIL 1 $0

Vilazodone 10mg Tablet VIIBRYD 2 $0

Vismodegib 150mg Capsule ERIVEDGE 2 $0



57


Tier Your Cost

Voriconazole 200mg Tablet VFEND 1 $0

Voriconazole 40mg/ml Suspension VFEND 1 $0

Voriconazole 50mg Tablet VFEND 1 $0

Vorinostat 100mg Capsule ZOLINZA 2 $0

Warfarin 10mg Tablet COUMADIN 1 $0


Warfarin 2.5mg Tablet COUMADIN 1 $0






Warfarin 7.5mg Tablet COUMADIN 1 $0

Zafirlukast 10mg Tablet ACCOLATE 1 $0

Zaleplon 10mg Capsule SONATA 1 $0

Zaleplon 5mg Capsule SONATA 1 $0

Zanamivir 5mg/blister Inhalation Inhaler RELENZA 2 $0

Zanubrutinib 80mg Capsule BRUKINSA 2 $0

Zidovudine 100mg Capsule RETROVIR 1 $0

Zidovudine 300mg Tablet RETROVIR 1 $0

Zileuton 600mg Controlled Release Tablet ZYFLO 1 $0

Ziprasidone 20mg Capsule GEODON 1 $0




Zolmitriptan 2.5mg Disintegrating Tablet ZOMIG 1 $0

Zolpidem Tartrate 10mg Tablet AMBIEN 1 $0

Zolpidem Tartrate 5mg Tablet AMBIEN 1 $0

Zonisamide 100mg Capsule ZONEGRAN 1 $0




KPHI Quest Drug Formulary 090121 - Kaiser Permanente

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Transcript of KPHI Quest Drug Formulary 090121 - Kaiser Permanente