This document contains information about the drugs … · OptumRx SelectStandard 1 Effective July...

OptumRx Select Standard

1

Effective July 1, 2017

Please read: This document contains information about the drugs

covered under your pharmacy benefit plan.

For a complete list of covered drugs or if you have questions:

Call the toll-free member phone number

on the back of your ID card.

Visit your plan’s member website listed on your ID card.

• Locate a participating retail pharmacy by zip code.

• Look up possible lower-cost medication alternatives.

• Compare medication pricing and options.

2

Your Formulary

This Formulary includes medications from your plan’s complete pharmacy benefit

coverage list. A formulary identifies the drugs available for certain conditions and

organizes them into cost levels, also known as tiers. An important part of the

Formulary is giving you choices so you and your doctor can choose the best course of

treatment for you.

Go to your plan’s member website for complete and up-to-date drug

information

Since the Formulary may change, we encourage you to visit our website, your plan’s

member website, which should be listed on your ID card. This website is the best source

for up-to-date information about all of the medications your pharmacy benefit covers,

possible lower-cost options and cost comparisons.

3

Table of Contents

Go to your plan’s member website for complete and up-to-date drug information ............................................................ 2

What is a Formulary? ........................................................ 6

How do I use my Formulary?........................................... 6

What are tiers? .................................................................... 7

Why are some medications excluded from coverage?8

What if I don’t agree with a decision about an excluded medication? ........................................................ 8

Should I talk to my doctor about OTC medications? .. 8

What is the difference between brand-name and generic medications? ......................................................... 8

Is it a generic or brand-name drug? ............................... 8

What if my doctor writes a brand-name prescription? . 8

Are you taking a specialty medication? .......................... 9

How do I get updated information about my pharmacy benefit? .............................................................. 9

Analgesics ........................................................................... 10

Analgesics : Nonsteroidal Anti-inflammatory Drugs ............. 10

Analgesics : Opioid Analgesics, Long-acting ....................... 11

Analgesics : Opioid Analgesics, Short-acting ...................... 11

Anesthetics : Local Anesthetics ........................................... 12

Anti-Addiction/Substance Abuse Treatment Agents : Alcohol Deterrents/Anti-craving ........................................................ 13

Anti-Addiction/Substance Abuse Treatment Agents : Opioid Dependence Treatments ..................................................... 13

Anti-Addiction/Substance Abuse Treatment Agents : Opioid Reversal Agents .................................................................. 13

Anti-Addiction/Substance Abuse Treatment Agents : Smoking Cessation Agents .................................................. 13

Anti-infective Agents : Antibacterials ................................... 13

Anti-infective Agents : Antivirals .......................................... 13

Anti-inflammatory Agents : Nonsteroidal Anti-inflammatory Drugs ................................................................................... 13

Antibacterials : Aminoglycosides ......................................... 14

Antibacterials : Antibacterials, Other .................................... 14

Antibacterials : Beta-lactam, Cephalosporins ...................... 15

Antibacterials : Beta-lactam, Other ...................................... 16

Antibacterials : Beta-lactam, Penicillins ............................... 16

Antibacterials : Macrolides ................................................... 17

Antibacterials : Quinolones .................................................. 17

Antibacterials : Sulfonamides .............................................. 17

Antibacterials : Tetracyclines ............................................... 18

Anticonvulsants : Anticonvulsants, Other............................. 18

Anticonvulsants : Calcium Channel Modifying Agents ......... 18

Anticonvulsants : Gamma-aminobutyric Acid (GABA) Augmenting Agents ............................................................. 18

Anticonvulsants : Glutamate Reducing Agents .................... 19

Anticonvulsants : Sodium Channel Agents .......................... 19

Antidementia Agents : Antidementia Agents, Other ............. 20

Antidementia Agents : Cholinesterase Inhibitors ................. 20

Antidementia Agents : N-methyl-D-aspartate (NMDA)

Receptor Antagonist ............................................................ 20

Antidepressants : Antidepressants, Other ........................... 20

Antidepressants : Monoamine Oxidase Inhibitors ............... 20

Antidepressants : SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) ............................................................................ 21

Antidepressants : Tricyclics ................................................. 21

Antiemetics : Antiemetics, Other ......................................... 21

Antiemetics : Emetogenic Therapy Adjuncts ....................... 22

Antifungals .......................................................................... 22

Antigout Agents ................................................................... 23

Antihistamine Drugs : First Generation Antihistamines ....... 23

Antimigraine Agents : .......................................................... 23

Antimigraine Agents : Ergot Alkaloids ................................. 23

Antimigraine Agents : Serotonin (5-HT) 1b/1d Receptor Agonists .............................................................................. 23

Antimyasthenic Agents ........................................................ 24

Antimyasthenic Agents : Parasympathomimetics ................ 24

Antimycobacterials : Antimycobacterials, Other .................. 24

Antimycobacterials : Antituberculars ................................... 24

Antineoplastic Agents .......................................................... 24

Antineoplastics : .................................................................. 24

Antineoplastics : Alkylating Agents ...................................... 24

Antineoplastics : Antiandrogens .......................................... 24

Antineoplastics : Antiangiogenic Agents.............................. 25

Antineoplastics : Antiestrogens/Modifiers ............................ 25

Antineoplastics : Antimetabolites ......................................... 25

Antineoplastics .................................................................... 25

Antineoplastics : Antineoplastics, Other .............................. 25

Antineoplastics : Aromatase Inhibitors, 3rd Generation ...... 25

Antineoplastics : Enzyme Inhibitors ..................................... 25

Antineoplastics : Molecular Target Inhibitors ....................... 25

Antineoplastics : Monoclonal Antibodies ............................. 26

Antineoplastics : Retinoids .................................................. 26

Antiparasitics : Anthelmintics ............................................... 26

Antiparasitics : Antiprotozoals ............................................. 26

Antiparasitics : Pediculicides/Scabicides ............................. 26

Antiparkinson Agents : Anticholinergics .............................. 26

Antiparkinson Agents : Antiparkinson Agents, Other ........... 26

Antiparkinson Agents : Dopamine Agonists ........................ 26

Antiparkinson Agents : Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors ..................................................... 27

Antiparkinson Agents : Monoamine Oxidase B (MAO-B) Inhibitors .............................................................................. 27

Antipsychotics : 1st Generation/Typical .............................. 27

Antipsychotics : 2nd Generation/Atypical ............................ 27

Antipsychotics : Treatment-Resistant .................................. 27

Antispasticity Agents ........................................................... 27

Antitoxins, Immune Globulins, Toxoids, and Vaccines : Antitoxins and Immune Globulins ........................................ 28

Antivirals : ............................................................................ 28

Antivirals : Anti-cytomegalovirus (CMV) Agents .................. 28

Antivirals : Anti-hepatitis B (HBV) Agents ............................ 28

4

Antivirals : Anti-hepatitis C (HCV) Agents ............................ 28

Antivirals : Anti-HIV Agents, Integrase Inhibitors (INSTI) ..... 28

Antivirals : Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) ......................................... 28

Antivirals : Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) ............................. 28

Antivirals : Anti-HIV Agents, Other ....................................... 29

Antivirals : Anti-HIV Agents, Protease Inhibitors .................. 29

Antivirals : Anti-influenza Agents ......................................... 29

Antivirals : Antiherpetic Agents ............................................ 29

Anxiolytics : Anxiolytics, Other ............................................. 29

Anxiolytics : Benzodiazepines ............................................. 29

Autonomic Drugs : Anticholinergic Agents ........................... 30

Autonomic Drugs : Parasympathomimetic (Cholinergic) Agents ................................................................................. 30

Autonomic Drugs : Skeletal Muscle Relaxants .................... 30

Autonomic Drugs : Sympathomimetic (Adrenergic) Agents . 30

Bipolar Agents : Bipolar Agents, Other ................................ 30

Bipolar Agents : Mood Stabilizers ........................................ 30

Blood Formation,Coagulation & Thrombosis : Antianemia Drugs ................................................................................... 30

Blood Formation,Coagulation & Thrombosis : Antithrombotic Agents ................................................................................. 30

Blood Formation,Coagulation & Thrombosis : Hematopoietic Agents ................................................................................. 30

Blood Glucose Regulators : Antidiabetic Agents ................. 30

Blood Glucose Regulators : Glycemic Agents ..................... 31

Blood Glucose Regulators : Insulins .................................... 31

Blood Products/Modifiers/Volume Expanders : Anticoagulants ..................................................................... 32

Blood Products/Modifiers/Volume Expanders : Blood Formation Modifiers ............................................................. 32

Blood Products/Modifiers/Volume Expanders ...................... 32

Blood Products/Modifiers/Volume Expanders : Coagulants 32

Blood Products/Modifiers/Volume Expanders : Platelet Modifying Agents ................................................................. 33

Cardiovascular Agents : Alpha-adrenergic Agonists ............ 33

Cardiovascular Agents : Alpha-adrenergic Blocking Agents 33

Cardiovascular Agents : Angiotensin II Receptor Antagonists ............................................................................................. 33

Cardiovascular Agents : Angiotensin-converting Enzyme (ACE) Inhibitors ................................................................... 34

Cardiovascular Agents : Antiarrhythmics ............................. 34

Cardiovascular Agents : Beta-adrenergic Blocking Agents . 35

Cardiovascular Agents : Calcium Channel Blocking Agents 35

Cardiovascular Agents ......................................................... 36

Cardiovascular Agents : Cardiovascular Agents, Other ....... 36

Cardiovascular Agents : Diuretics, Carbonic Anhydrase Inhibitors .............................................................................. 36

Cardiovascular Agents : Diuretics, Loop .............................. 37

Cardiovascular Agents : Diuretics, Potassium-sparing ........ 37

Cardiovascular Agents : Diuretics, Thiazide ........................ 37

Cardiovascular Agents : Dyslipidemics, Fibric Acid Derivatives ........................................................................... 37

Cardiovascular Agents : Dyslipidemics, HMG CoA Reductase Inhibitors .............................................................................. 37

Cardiovascular Agents : Dyslipidemics, Other .................... 37

Cardiovascular Agents : Vasodilators, Direct-acting Arterial 38

Cardiovascular Agents : Vasodilators, Direct-acting Arterial/Venous .................................................................... 38

Cardiovascular Drugs : beta-Adrenergic Blocking Agents ... 38

Cardiovascular Drugs : Calcium-Channel Blocking Agents . 38

Cardiovascular Drugs : Cardiac Drugs ................................ 38

Cardiovascular Drugs : Vasodilating Agents ....................... 38

Central Nervous System Agents : Analgesics and Antipyretics .......................................................................... 38

Central Nervous System Agents : Anorexigenic Agents and Respiratory and CNS Stimulants ......................................... 39

Central Nervous System Agents : Anticonvulsants ............. 39

Central Nervous System Agents : Anxiolytics, Sedatives, and Hypnotics ............................................................................ 39

Central Nervous System Agents : Attention Deficit Hyperactivity Disorder Agents, Amphetamines ................... 39

Central Nervous System Agents : Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines ............ 39

Central Nervous System Agents ......................................... 39

Central Nervous System Agents : Central Nervous System Agents, Misc ........................................................................ 39

Central Nervous System Agents : Central Nervous System, Other ................................................................................... 39

Central Nervous System Agents : Fibromyalgia Agents ...... 40

Central Nervous System Agents : Multiple Sclerosis Agents ............................................................................................ 40

Central Nervous System Agents : Opiate Antagonists ........ 40

Dental and Oral Agents ....................................................... 40

Dermatological Agents ........................................................ 40

Devices ............................................................................... 43

Electrolytic, Caloric, and Water Balance : Replacement Preparations ........................................................................ 43

Electrolytic, Caloric, and Water Balance : Uricosuric Agents ............................................................................................ 43

Enzyme Replacement/Modifiers .......................................... 43

Eye, Ear, Nose & Throat Preparations : Anti-infectives ....... 44

Eye, Ear, Nose & Throat Preparations : Anti-inflammatory Agents ................................................................................. 44

Eye, Ear, Nose & Throat Preparations : EENT Drugs, Miscellaneous...................................................................... 44

Gastrointestinal Agents : Antispasmodics, Gastrointestinal 44

Gastrointestinal Agents ....................................................... 44

Gastrointestinal Agents : Gastrointestinal Agents, Other .... 44

Gastrointestinal Agents : Histamine2 (H2) Receptor Antagonists ......................................................................... 45

Gastrointestinal Agents : Irritable Bowel Syndrome Agents 45

Gastrointestinal Agents : Laxatives ..................................... 45

Gastrointestinal Agents : Protectants .................................. 45

Gastrointestinal Agents : Proton Pump Inhibitors ................ 45

Gastrointestinal Drugs : Antiemetics ................................... 46

Gastrointestinal Drugs : Digestants ..................................... 46

5

Gastrointestinal Drugs : GI Drugs, Miscellaneous ............... 46

Genitourinary Agents : Antispasmodics, Urinary ................. 46

Genitourinary Agents : Benign Prostatic Hypertrophy Agents ............................................................................................. 46

Genitourinary Agents : Genitourinary Agents, Other ........... 46

Genitourinary Agents : Phosphate Binders .......................... 46

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) : ............................................................................ 46

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) .............................................................................. 46

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) ............................................................................. 47

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) ................................................................... 47

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Anabolic Steroids ............................. 48

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Androgens ....................................... 48

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Estrogens ........................................ 48

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) ........................................................... 49

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Progesterone Agonists/Antagonists. 49

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Progestins........................................ 49

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Selective Estrogen Receptor Modifying Agents ................................................................. 49

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) .............................................................................. 49

Hormonal Agents, Suppressant (Adrenal) ........................... 49

Hormonal Agents, Suppressant (Parathyroid) ..................... 49

Hormonal Agents, Suppressant (Pituitary) ........................... 49

Hormonal Agents, Suppressant (Thyroid) : Antithyroid Agents ............................................................................................. 50

Hormones and Synthetic Substitutes : Adrenals .................. 50

Hormones and Synthetic Substitutes : Antidiabetic Agents . 50

Hormones and Synthetic Substitutes : Pituitary ................... 50

Immunological Agents : Immune Suppressants ................... 50

Immunological Agents : Immunizing Agents, Passive ......... 51

Immunological Agents : Immunomodulators ........................ 51

Immunological Agents : Vaccines ........................................ 51

Inflammatory Bowel Disease Agents : Aminosalicylates ..... 51

Inflammatory Bowel Disease Agents : Glucocorticoids ........ 51

Inflammatory Bowel Disease Agents : Sulfonamides .......... 51

Local Anesthetics ................................................................. 51

Metabolic Bone Disease Agents .......................................... 51

Miscellaneous Therapeutic Agents : .................................... 52

Miscellaneous Therapeutic Agents : Antidotes .................... 52

Miscellaneous Therapeutic Agents : Cariostatic Agents ...... 52

Miscellaneous Therapeutic Agents : Disease-modifying Antirheumatic Drugs ............................................................ 52

Miscellaneous Therapeutic Agents ...................................... 52

Miscellaneous Therapeutic Agents : Other Miscellaneous Therapeutic Agents ............................................................. 59

Multiple Classifications ........................................................ 59

Ophthalmic Agents : Ophthalmic Prostaglandin and Prostamide Analogs ............................................................ 60

Ophthalmic Agents : Ophthalmic Agents, Other .................. 60

Ophthalmic Agents : Ophthalmic Anti-allergy Agents .......... 60

Ophthalmic Agents : Ophthalmic Anti-inflammatories ......... 61

Ophthalmic Agents : Ophthalmic Antiglaucoma Agents ...... 61

Otic Agents .......................................................................... 61

Oxytocics ............................................................................. 61

Respiratory Tract Agents : Expectorants ............................. 62

Respiratory Tract/Pulmonary Agents : Anti-inflammatories, Inhaled Corticosteroids ........................................................ 62

Respiratory Tract/Pulmonary Agents : Antihistamines ........ 62

Respiratory Tract/Pulmonary Agents : Antileukotrienes ...... 62

Respiratory Tract/Pulmonary Agents : Bronchodilators, Anticholinergic ..................................................................... 63

Respiratory Tract/Pulmonary Agents : Bronchodilators, Sympathomimetic ................................................................ 63

Respiratory Tract/Pulmonary Agents : Cystic Fibrosis Agents ............................................................................................ 63

Respiratory Tract/Pulmonary Agents : Mast Cell Stabilizers 63

Respiratory Tract/Pulmonary Agents : Phosphodiesterase Inhibitors, Airways Disease ................................................. 63

Respiratory Tract/Pulmonary Agents : Pulmonary Antihypertensives ................................................................ 63

Respiratory Tract/Pulmonary Agents : Respiratory Tract Agents, Other ...................................................................... 64

Skeletal Muscle Relaxants .................................................. 64

Skin and Mucous Membrane Preparations : Anti-infectives 64

Skin and Mucous Membrane Preparations : Anti-inflammatory Agents ............................................................ 64

Skin and Mucous Membrane Preparations : Cell Stimulants and Proliferants ................................................................... 64

Skin and Mucous Membrane Preparations : Skin and Mucous Membrane Agents, Misc ...................................................... 64

Sleep Disorder Agents : GABA Receptor Modulators ......... 65

Sleep Disorder Agents : Sleep Disorders, Other ................. 65

Therapeutic Nutrients/Minerals/Electrolytes : ...................... 65

Therapeutic Nutrients/Minerals/Electrolytes : Electrolyte/Mineral Modifiers ............................................... 65

Therapeutic Nutrients/Minerals/Electrolytes : Electrolyte/Mineral Replacement ......................................... 65

Therapeutic Nutrients/Minerals/Electrolytes ........................ 66

Therapeutic Nutrients/Minerals/Electrolytes : Vitamins ....... 66

Vitamins : Multivitamin Preparations ................................... 67

Vitamins : Vitamin A ............................................................ 68

Vitamins : Vitamin B Complex ............................................. 68

Vitamins : Vitamin D ............................................................ 68

Index of Covered Drugs ...................................................... 69

Nondiscrimination Notice and Access to Communication Services ............................................................................ 101

Multi-language Interpreter Services .................................. 102

6

Your pharmacy benefit offers flexibility and choice in determining the right medication

for you. To help you get the most out of your pharmacy benefit, we’ve included some

of the most commonly asked questions about the Formulary.

What is a Formulary?

This document is a list of commonly prescribed medications preferred by your plan

sponsor for their safety, cost and effectiveness. Drugs are listed by common categories or

class. They are placed into cost levels known as tiers. It includes both brand and generic

prescription medications approved by the U.S. Food and Drug Administration (FDA).

Please note: Where differences are noted between this Formulary and your benefit

plan documents, the benefit plan documents will rule. It is not intended to be a

complete list of medications, and not all medications listed may be covered under your

plan. Please look at your benefit plan documents provided by your employer or plan

sponsor to see what medications are covered under your plan. You may also log on to

your plan’s member website or call the toll-free member phone number on your ID card

for more information.

How do I use my Formulary? When choosing a medication, you and your doctor should consult the Formulary. It will

help you and your doctor choose the most cost-effective prescription drugs. This guide

tells you if a medication is generic or brand, and if special rules apply. Bring this list

with you when you see your doctor. It is organized by medical conditions. Medications

are then listed alphabetically.

If your medication is not listed in this document, please visit your plan’s member website or call the toll-free member phone number on your ID card.

7

What are tiers?

Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost,

which is determined by your employer or plan sponsor. This is how much you will pay

when you fill a prescription. Tier 1 medications are your lowest-cost options. If your

medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available.

Discuss these options with your doctor.

Check your benefit plan documents to find out your specific pharmacy plan costs.

Please note: Some plans may have two or four tiers, while others may not have any. If

you have a high deductible plan, the tier cost levels will apply once you hit your

deductible. Refer to your enrollment and plan materials on your plan’s member

website, or call the toll-free member phone number on your ID card for more

information about your benefit plan.

When does the Formulary change?

• Medications may move to a lower tier at any time.

• Medications may move to a higher tier when its generic becomes available.

• Medications may move to a higher tier or be excluded from coverage

on January 1 or July 1 of each year.

When a medication changes tiers, you may have to pay a different amount

for that medication.

For the most up-to-date list, call customer service at the toll-free member

phone number on the back of your ID card.

$ Drug Tier Includes Helpful Tips

$

Tier 1 Lowest Cost

Lower-cost, commonly Use Tier 1 drugs for used generic drugs. the lowest out-of-

Some low-cost brands pocket costs.

may be included.

$$ Tier 2 Mid-range

Cost

Many common brand- Use Tier 2 drugs, instead name drugs, called of Tier 3, to help reduce

preferred brands. your out-of-pocket costs.

$$$

Tier 3 Highest Cost

Mostly higher-cost brand drugs, also

known as non-

preferred brands.

Many Tier 3 drugs have lower-cost options in Tier

1 or 2. Ask your doctor if

they could work for you.

8

Why are some medications excluded from coverage?

Medications may be excluded from coverage under your pharmacy benefit when it

works the same as or similar to another prescription medication or an over-the-counter

(OTC) medication. There may be other medication options available.

What if I don’t agree with a decision about an excluded medication?

You (or your authorized representative) and your doctor can ask for an initial coverage

decision by calling the toll-free member phone number on the back of your ID card.

Should I talk to my doctor about OTC medications?

An OTC medication may be the right treatment option for some conditions. Talk to

your doctor about available OTC options. Even though these medications may not

be covered under your pharmacy benefit, they may cost less than your out-of-pocket

expense for prescription medications.

What is the difference between brand-name and generic medications?

Generic medications contain the same active ingredients (what makes the medication

work) as brand-name medications, but they often cost less. Once the patent of a

brand-name medication ends, the FDA can approve a generic version with the same

active ingredients. These types of medications are known as generic medications.

Sometimes the same company that makes a brand-name medication also makes the

generic version.

Is it a generic or brand-name drug?

The drug list shows brand-name drugs in bold type (for example, Clobex)

and generic drugs in plain type (for example, clobetasol).

What if my doctor writes a brand-name prescription? The next time your doctor gives you a prescription for a brand-name medication,

ask if a generic equivalent or lower-cost option is available and if it might be right

for you. Generic medications are usually your lowest-cost option, but not always.

Visit your plan’s member website to make sure.

9

Are you taking a specialty medication?

Specialty medications treat rare or complex conditions and are typically higher cost

medications.

BriovaRx, the OptumRx specialty pharmacy, can provide most of your specialty medications along with helpful programs and services. Call BriovaRx and have your prescriptions delivered right to your home or office.

How do I get updated information about my pharmacy benefit?

Since the Formulary may change during your plan year, we encourage you to

visit your plan’s member website or call the toll-free member phone number

on your ID card for more current information.

When you register at our website and open an account, you can use the website’s

helpful tools and features to:

• Look up the price of drugs covered by your plan

• Find lower-cost options

• Refill and renew mail service prescriptions

• View your order status and claims history

• View your benefits in real time

More information

If you have additional questions please call customer service, 24 hours

a day, 7 days a week using the toll-free member phone number on

your ID card. Or visit your plan’s member website.

Bold type = Brand-name drug

[Plain type = Generic drug]

10

Drug Name Drug

Tier

Requirements

& Limits

Analgesics Bupap (Tablet) 3

Butalbital/Acetaminophen (300mg-

50mg Tablet, 50mg-325mg Tablet)

1

Gralise (Tablet) 3

Gralise Starter Pack 3

Ofirmev (Injection) 3

Prialt (Injection) 2

Vanatol LQ (Oral Solution) 3

Analgesics : Nonsteroidal Anti-inflammatory Drugs Anaprox DS (Tablet) 3

Arthrotec 50 (Tablet Delayed-

Release)

3

Arthrotec 75 (Tablet Delayed-

Release)

3

Butalbital/Acetaminophen/Caffeine

(325mg-50mg-40mg Tablet, 50mg-

300mg-40mg Capsule)

1

Butalbital/Aspirin/Caffeine

(Capsule)

1

Cambia (Packet) 3

CapXib Kit (Kit) 3

Celebrex (Capsule) 3

Celecoxib (Capsule) 1

Choline Magnesium Trisalicylate

(1000mg Tablet)

2

Choline Magnesium Trisalicylate

(500mg/5ml Liquid)

1

Daypro (Tablet) 3

Diclofenac Potassium (Tablet) 1

Diclofenac Sodium DR (Tablet

Delayed-Release)

1

Diclofenac Sodium ER (Tablet

Extended-Release 24 Hour)

1

Diclofenac Sodium/Misoprostol

(Tablet Delayed-Release)

1

Diflunisal (Tablet) 1

EC-Naprosyn (Tablet Delayed-

Release)

3

Esgic (Tablet) 3

Etodolac (200mg Capsule, 300mg

Capsule, 400mg Tablet, 500mg

Tablet)

1

Etodolac ER (Tablet Extended-

Release 24 Hour)

1

Feldene (Capsule) 3

Fenoprofen Calcium (200mg

Capsule, 400mg Capsule, 600mg

Tablet)

1

Fenortho (Capsule) 3

Fioricet (Capsule) 3

Fiorinal (Capsule) 3

Flanax Pain Relief Kit (Kit) 3

Flector (Patch) 3

Flurbiprofen (100mg Tablet, 50mg

Tablet)

1

Hydrocodone/Ibuprofen (Tablet) 1

Drug Name Drug

Tier

Requirements

& Limits

Ibudone (10mg-200mg Tablet) 3

Ibuprofen (100mg/5ml Suspension,

400mg Tablet, 600mg Tablet,

800mg Tablet)

1

Ibuprofen Comfort Pac (Kit) 3

IC 400 (Kit) 3

IC 800 (Kit) 3

Indocin (25mg/5ml Suspension) 3

Indocin (50mg Suppository) 2

Indomethacin (25mg Capsule, 50mg

Capsule)

1

Indomethacin ER (Capsule

Extended-Release)

1

Ketoprofen (Capsule Immediate-

Release)

1

Ketoprofen ER (Capsule Extended-

Release 24 Hour)

1

Ketorocaine-L (Injection) 3

Ketorocaine-LM (Injection) 3

Ketorolac Tromethamine (10mg

Tablet)

1

Lodine (Tablet) 3

Meclofenamate Sodium (100mg

Capsule, 50mg Capsule)

1

Mefenamic Acid (250mg Capsule) 1

Meloxicam (Tablet) 1

Meloxicam Comfort Pac (Kit) 3

Mobic (Tablet) 3

Nabumetone (Tablet) 1

Nalfon (Capsule) 3

Naprelan (Tablet Extended-

Release 24 Hour)

3

Naprosyn (125mg/5ml Suspension,

500mg Tablet)

3

Naproxen (125mg/5ml Suspension,


500mg Tablet)

1

Naproxen Comfort Pac (Kit) 3

Naproxen Sodium (275mg Tablet,

550mg Tablet)

1

Naproxen Sodium CR (Tablet


1

Naproxen Sodium ER (Tablet


1

Oxaprozin (Tablet) 1

Oxycodone/Ibuprofen (Tablet) 1

Piroxicam (10mg Capsule, 20mg

Capsule)

1

Ponstel (Capsule) 3

Reprexain (5mg-200mg Tablet) 3

Salsalate (500mg Tablet, 750mg

Tablet)

1

Sprix (Nasal Solution) 3

Sulindac (150mg Tablet, 200mg

Tablet)

1

Tolmetin Sodium (200mg Tablet,

600mg Tablet, 400mg Capsule)

1

Zorvolex (Capsule) 3



11

Drug Name Drug

Tier

Requirements

& Limits

Analgesics : Opioid Analgesics, Long-acting Belbuca (Film) 3

Bunavail (Film) 3

Buprenex (Injection) 3

Buprenorphine HCl (0.3mg/ml

Solution, 2mg Tablet Sublingual,

8mg Tablet Sublingual)

1

Buprenorphine HCl/Naloxone HCl

(Tablet Sublingual)

1

Butrans (Patch Weekly) 3

Dolophine (Tablet) 3

Duragesic (Patch 72 Hour) 3

Embeda (Capsule Extended-

Release)

2

Fentanyl (Patch 72 Hour) 1

Hydromorphone HCl ER (Tablet

Extended-Release 24 Hour Abuse-

Deterrent)

1

Infumorph 200 (Injection) 3

Infumorph 500 (Injection) 3

Levorphanol Tartrate (Tablet) 3

Methadone HCl (10mg Tablet, 5mg

Tablet, 10mg/5ml Oral Solution,

5mg/5ml Oral Solution, 10mg/ml

Concentrate, 40mg Tablet Soluble)

1

Methadone HCl (10mg/ml

Injection)

3

Methadose (10mg/ml

Concentrate)

3

Methadose Sugar-Free

(Concentrate)

3

Morphine Sulfate (10mg/0.7ml

Injection)

3

Morphine Sulfate (30mg

Suppository)

2

Morphine Sulfate ER (Capsule

Extended-Release 24 Hour, Tablet

Extended-Release)

1

MS Contin (Tablet Extended-

Release)

3

Nucynta ER (Tablet Extended-

Release 12 Hour)

3

Opana ER (Tablet Extended-

Release 12 Hour Abuse-Deterrent)

2

Oxycodone HCl ER (80mg Tablet

Extended-Release 12 Hour Abuse-

Deterrent)

2

Oxycodone HCl Tablet Extended-

Release 12 Hour Abuse-Deterrent

(10mg, 15mg, 20mg, 30mg, 40mg,

60mg)

3

OxyContin (Tablet Extended-


2

Oxymorphone HCl ER (Tablet


1

Suboxone (Film) 2

Tramadol HCl ER (100mg Tablet

Extended-Release 24 Hour, 200mg

Tablet Extended-Release 24 Hour,

1

Drug Name Drug

Tier

Requirements

& Limits

300mg Tablet Extended-Release 24

Hour, 150mg Capsule Extended-

Release 24 Hour)

Xartemis XR (Tablet Extended-

Release)

3

Xtampza ER (Capsule Extended-


3

Zohydro ER (Capsule Extended-


3

Analgesics : Opioid Analgesics, Short-acting Abstral (Tablet Sublingual) 3

Acetaminophen/Caffeine/Dihydroco

deine (Capsule)

1

Acetaminophen/Codeine

(120mg/5ml-12mg/5ml Oral

Solution, 300mg-15mg Tablet,

300mg-30mg Tablet, 300mg-60mg

Tablet)

1

Actiq (Lollipop) 3

Alfentanil (Injection) 1

Alfentanil HCl (Injection) 3

Aspirin-Caffeine-Dihydrocodeine

(Capsule)

1

Butalbital/Acetaminophen/Caffeine/

Codeine (Capsule)

1

Butalbital/Aspirin/Caffeine/Codeine

(Capsule)

1

Butorphanol Tartrate (10mg/ml

Nasal Solution, 1mg/ml Injection,

2mg/ml Injection)

1

Capital/Codeine (Suspension) 3

Codeine Sulfate (Tablet) 1

Demerol (100mg Tablet,

100mg/2ml Injection, 100mg/ml

Injection, 25mg/0.5ml Injection,

25mg/ml Injection, 50mg/ml


75mg/ml Injection)

3

Dilaudid (1mg/ml Liquid, 1mg/ml

Solution, 2mg/ml Solution,

4mg/ml Solution, 2mg Tablet, 4mg

Tablet, 8mg Tablet)

3

Fentanyl Citrate Oral Transmucosal

(Lollipop)

1

Fentanyl Citrate/NaCl (Injection) 3

Fentanyl Citrate/Sodium Chloride

(1mg/100ml-0.9% Injection,

2mg/100ml-0.9% Injection)

3

Fentora (Tablet) 3

Fioricet/Codeine (Capsule) 3

Fiorinal/Codeine #3 (Capsule) 3

Hycet (Oral Solution) 3

Hydrocodone

Bitartrate/Acetaminophen (300mg-

10mg Tablet, 300mg-5mg Tablet,

300mg-7.5mg Tablet, 325mg-2.5mg

Tablet, 325mg/15ml-10mg/15ml

Oral Solution, 325mg/15ml-

7.5mg/15ml Oral Solution)

1



12

Drug Name Drug

Tier

Requirements

& Limits

Hydrocodone/Acetaminophen

(Tablet)

1

Hydromorphone HCl (1mg/ml

Injection, 2mg/ml Injection, 4mg/ml

Injection, 500mg/50ml Injection,

1mg/ml Liquid, 2mg Tablet, 4mg

Tablet, 8mg Tablet)

1

Hydromorphone HCl/ Sodium

Chloride (Solution)

3

Hydromorphone HCl/Sodium

Chloride (10mg/50ml-0.9%

Injection, 15mg/30ml-0.9%

Injection)

1



Solution, 50mg/100ml-0.9%



Solution Prefilled Syringe)

3

Lazanda (Nasal Solution) 3

Lortab (300mg/15ml-10mg/15ml

Elixir)

3

Meperidine HCl (100mg Tablet,

50mg Tablet, 100mg/ml Injection,


Injection, 50mg/ml Injection,

50mg/5ml Oral Solution)

1

Meperidine HCl/Sodium Chloride



1

Morphine Sulfate (0.5mg/ml

Injection, 100mg/5ml Oral Solution,

10mg/5ml Oral Solution, 20mg/5ml

Oral Solution, 10mg/ml Injection,

1mg/ml Injection, 4mg/ml Injection,

8mg/ml Injection, 15mg Tablet,

30mg Tablet)

1

Morphine Sulfate (10mg/ml





Injection)

3

Morphine Sulfate/Sodium Chloride

(0.5mg/ml-0.9% Injection,


1

Morphine Sulfate/Sodium



Solution)

3

Nalbuphine HCl (Injection) 1

Norco (325mg-10mg Tablet,

325mg-7.5mg Tablet, 325mg-5mg

Tablet)

3

Nucynta (Tablet) 3

Opana (Tablet Immediate-

Release, 1mg/ml Injection)

3

Oxaydo (Tablet Abuse-Deterrent) 3

Oxycodone HCl (100mg/5ml

Concentrate, 10mg Tablet, 15mg

Tablet, 20mg Tablet, 30mg Tablet,

1

Drug Name Drug

Tier

Requirements

& Limits

5mg Tablet, 5mg Capsule, 5mg/5ml

Oral Solution)

Oxycodone/Acetaminophen (2.5mg-


325mg-5mg Tablet, 325mg-7.5mg

Tablet)

1

Oxycodone/Acetaminophen

(325mg/5ml-5mg/5ml Oral

Solution)

3

Oxycodone/Aspirin (Tablet) 1

Oxymorphone HCl (Tablet

Immediate-Release)

1

Pentazocine/Naloxone HCl (Tablet) 1

Percocet (Tablet) 3

Primlev (Tablet) 3

Roxicodone (Tablet) 3

Subsys (Liquid) 3

Synalgos-DC (Capsule) 3

Talwin (Injection) 3

Tramadol HCl (Tablet Immediate-

Release)

1

Tramadol HCl/Acetaminophen

(Tablet)

1

Trezix (Capsule) 3

Tylenol/Codeine #3 (Tablet) 3

Tylenol/Codeine #4 (Tablet) 3

Ultiva (Injection) 3

Ultracet (Tablet) 3

Ultram (Tablet) 3

Xodol (Tablet) 3

Zamicet (Oral Solution) 3

Anesthetics : Local Anesthetics Akten (Gel) 3

BD Pudendal/Local Block Tray

1% Lidocaine (Kit)

3

Bupivacaine HCl (Injection) 1

Bupivacaine HCl/Sodium

Chloride (0.1%-0.9% Injection,

0.125%-0.9% Injection, 0.2%-

0.9% Injection, 0.25%-0.9%

Injection)

3

Bupivacaine/Epinephrine (0.25%-

1:200000 Injection)

1

Carbocaine (Injection) 3

Durasafe Spinal/Epidural

Tray/1% Xylocaine/20gx36"close

Cath (Kit)

3

Durasafe Spinal/Epidural

Tray/1% Xylocaine/20gx36"open

Cath (Kit)

3

Dyural-40 (Injection) 3

Dyural-80 (Injection) 3

Dyural-LM (Injection) 3

Epifoam (Foam) 3

Ethyl Chloride (Aerosol) 3

Exparel (Suspension) 3

Gebauers Pain Ease (0-0 Aerosol) 3

IV Infusion CPI (Kit) 3



13

Drug Name Drug

Tier

Requirements

& Limits

Lidocaine (3% Cream, 5%

Ointment, 5% Patch)

1

Lidocaine HCl (0.5% Injection, 1%

Injection, 1.5% Injection, 2%

Injection, 4% Injection, 2% Gel, 4%

External Solution)

1

Lidocaine HCl (Gel) 1

Lidocaine HCl/Dextrose

(Injection)

3

Lidocaine Viscous (Solution) 1

Lidocaine/Epinephrine (Injection) 1

Lidocaine/Prilocaine (2.5%-2.5%

Cream, 2.5%-2.5% Kit)

1

Lidoderm (Patch) 3

Marcaine (Injection) 3

Marcaine/Epinephrine (0.25%-

1:200000 Injection)

3

Marlido-25 (Injection) 3

Monoject Bone Marrow Biopsy

Prepping Tray (Kit)

3

Monoject Bone Marrow Biopsy

Tray/Sternal-Iliac Needle 16g

(Kit)

3

Naropin (Injection) 3

Nesacaine (Injection) 3

Nesacaine-Mpf (Injection) 3

Pliaglis (Cream) 3

Pramosone (1%-1% Cream) 2

Pramosone (1%-1% Lotion,

2.5%-1% Lotion)

3

Readysharp-A (Injection) 3

Readysharp-K (Injection) 3

Readysharp-P40 (Injection) 3

Readysharp-P80 (Injection) 3

Ropivacaine (Injection) 1

Ropivacaine HCl (Injection) 1

Ropivacaine HCl/Sodium

Chloride (0.1%-0.9% Solution,

0.2%-0.9% Solution)

3

Sensorcaine-Mpf/Epinephrine

(Injection)

3

Synera (Patch) 3

Turkel Paracentesis Procedure

Tray/8french (Kit)

3

Vitrase (Injection) 3

Xerese (Cream) 3

Xylocaine (0.5% Injection, 1%

Injection, 2% Injection, 4%

External Solution)

3

Xylocaine-MPF (Injection) 3

Xylocaine-Mpf/Epinephrine

(Injection)

3

Xylocaine/Epinephrine (Injection) 3

Anti-Addiction/Substance Abuse Treatment Agents : Alcohol Deterrents/Anti-craving Acamprosate Calcium DR (Tablet

Delayed-Release)

1

Drug Name Drug

Tier

Requirements

& Limits

Antabuse (Tablet) 3

Disulfiram (Tablet) 1

Naltrexone HCl (Tablet) 1

Vivitrol (Injection) 3

Anti-Addiction/Substance Abuse Treatment Agents : Opioid Dependence Treatments Zubsolv (1.4mg-0.36mg Tablet

Sublingual, 11.4mg-2.9mg Tablet




Sublingual)

2

Anti-Addiction/Substance Abuse Treatment Agents : Opioid Reversal Agents Evzio (0.4mg/0.4ml Injection) 3

Naloxone HCl (Injection) 1

Narcan (Liquid) 2

Anti-Addiction/Substance Abuse Treatment Agents : Smoking Cessation Agents Bupropion HCl (Tablet) 1

Bupropion HCl XL (Tablet


1

Wellbutrin SR (Tablet Extended-

Release 12 Hour)

3

Wellbutrin XL (Tablet Extended-

Release 24 Hour)

3

Anti-infective Agents : Antibacterials Cefazolin Sodium/Dextrose

(2gm/50ml-5% Injection)

3

Cefazolin/Sodium Chloride

(3gm/100ml-0.9% Solution)

3

Ofloxacin (300mg Tablet) 1

Piperacillin/Tazobactam (12gm-

1.5gm Solution)

3

Vancomycin HCl + Syrspendsf

Ph4 (Suspension)

3

Vancomycin HCl/Dextrose (5%-

1.25gm/250ml Solution, 5%-

1.5gm/500ml Solution, 5%-

1.75gm/500ml Solution)

3


1.5gm/250ml Injection)

1

Vancomycin HCl/Sodium Chloride

(0.9%-1.5gm/500ml Injection)

1

Vancomycin HCl/Sodium

Chloride (0.9%-1.75gm/300ml

Solution, 0.9%-2.5gm/500ml

Solution, 0.9%-2gm/250ml

Solution, 0.9%-2gm/500ml

Solution)

3


Chloride (Solution)

3

Anti-infective Agents : Antivirals Selzentry (25mg Tablet, 75mg

Tablet)

2

Vemlidy (Tablet) 3

Anti-inflammatory Agents : Nonsteroidal Anti-



14

Drug Name Drug

Tier

Requirements

& Limits

inflammatory Drugs Diclofenac Sodium (3% Gel) 1

Dyloject (Injection) 3

Antibacterials : Aminoglycosides Amikacin Sulfate (1gm/4ml

Injection, 500mg/2ml Injection)

1

Gentamicin Sulfate (0.1% Cream,

0.1% Ointment, 0.3% Ophthalmic

Ointment, 0.3% Ophthalmic

Solution, 10mg/ml Injection,

40mg/ml Injection)

1

Gentamicin Sulfate/0.9% Sodium

Chloride (0.8mg/ml-0.9% Injection,

1.2mg/ml-0.9% Injection, 1mg/ml-

0.9% Injection)

1

Gentamicin Sulfate/0.9% Sodium

Chloride (0.9mg/ml Injection,

1.4mg/ml Injection, 2mg/ml-0.9%

Injection)

3

Isotonic Gentamicin (Injection) 1

Kitabis Pak (Nebulized Solution) 3

Neomycin Sulfate (Tablet) 1

Neomycin/Polymyxin/Gramicidin

(Ophthalmic Solution)

1

Neosporin (Ophthalmic Solution) 3

Paromomycin Sulfate (Capsule) 1

Pred-G (Suspension) 3

Pred-G S.O.P. (Ointment) 3

Prednisolone/Moxifloxacin


3

Streptomycin Sulfate (1gm

Injection)

3

TOBI (Nebulized Solution) 3

TOBI Podhaler (Capsule) 3

Tobradex (0.3%-0.1%

Ophthalmic Ointment, 0.3%-

0.1% Ophthalmic Suspension)

3

Tobradex ST (Ophthalmic

Suspension)

3

Tobramycin (300mg/5ml Nebulized

Solution)

1

Tobramycin (300mg/5ml

Nebulized Solution)

3

Tobramycin Sulfate (0.3%

Ophthalmic Solution, 1.2gm

Injection, 1.2gm/30ml Injection,

10mg/ml Injection, 80mg/2ml

Injection)

1

Tobramycin/Dexamethasone

(Ophthalmic Suspension)

1

Tobrex (0.3% Ophthalmic

Ointment, 0.3% Ophthalmic

Solution)

3

Zylet (Suspension) 3

Antibacterials : Antibacterials, Other Alcoh-Glove Contoured Wipe 3

Alcoh-Wipe 12" X 12" 3

Altabax (Ointment) 3

Drug Name Drug

Tier

Requirements

& Limits

Arzol Silver Nitrate App Licators 2

Bacitracin (50000unit Injection,

500unit/gm Ophthalmic Ointment)

1

Bacitracin/Polymyxin B

(Ophthalmic Ointment)

1

Bactroban (Cream) 3

Bactroban Nasal (Ointment) 3

Benzalkonium Chloride (0

External Solution, 50% External

Solution)

3

Betadine Ophthalmic Prep


3

Bucalsep (600mg/30ml-

30mg/30ml-45mg/30ml-

30mg/30ml External Solution,

600mg/30ml-30mg/30ml-

45mg/30ml-30mg/30ml Liquid)

3

Centany (Ointment) 2

Centany AT (Kit) 3

Chloramphenicol Sodium

Succinate (Injection)

3

Cleocin (100mg Suppository) 2

Cleocin (150mg Capsule, 300mg

Capsule, 75mg Capsule, 2%

Cream)

3

Cleocin in D5W (Injection) 3

Cleocin Pediatric Granules (Oral

Solution)

3

Cleocin Phosphate (150mg/ml


600mg/4ml Injection, 900mg/6ml

Injection, 9gm/60ml Injection)

3

Clindamycin HCl (Capsule

Immediate-Release)

1

Clindamycin Palmitate HCl (Oral

Solution)

1

Clindamycin Phosphate (2% Cream,



900mg/6ml Injection)

1

Clindamycin Phosphate in D5W

(Injection)

1

Clindesse (Cream) 3

Colistimethate Sodium (Injection) 1

Coly-Mycin M (Injection) 3

Cubicin (Injection) 3

Cubicin RF (Injection) 3

Dalvance (Injection) 3

Daptomycin (Solution) 1

First-Vancomycin 25 (Oral

Solution)

3

First-Vancomycin 50 (Oral

Solution)

3

Flagyl (250mg Tablet, 500mg

Tablet, 375mg Capsule)

3

Furadantin (Suspension) 3

Glutaraldehyde (External

Solution)

3

Hiprex (Tablet) 3



15

Drug Name Drug

Tier

Requirements

& Limits

Hydrogen Peroxide (30% Does

Not Apply Solution)

3

Impavido (Capsule) 3

Iodine Tincture (2% Tincture) 3

Lincocin (Injection) 3

Lincomycin HCl (Injection) 1

Linezolid (100mg/5ml Suspension,

600mg Tablet, 600mg/300ml

Injection)

1

Macrobid (Capsule) 3

Macrodantin (Capsule) 3

Maxitrol (0.1% Ointment, 0.1%

Suspension)

3

Methenamine Hippurate (Tablet) 1

Metro IV (Injection) 3

MetroCream (Cream) 3

MetroGel (Gel) 3

MetroGel-Vaginal (Gel) 3

MetroLotion (Lotion) 3

Metronidazole (0.75% Cream,

0.75% Gel, 1% Gel, 0.75% Lotion,


375mg Capsule)

1

Metronidazole in NaCl 0.79%

(Injection)

1

Metronidazole Vaginal (Gel) 1

Monurol (Packet) 3

Mupirocin (2% Cream, 2%

Ointment)

1

Neomycin/Bacitracin/Polymyxin

(Ointment)

1

Neomycin/Polymyxin/Bacitracin/Hy

drocortisone (Ointment)

1

Neomycin/Polymyxin/Dexamethaso

ne (0.1% Ophthalmic Suspension,

0.1%-3.5mg/gm-10000unit/gm

Ointment)

1

Neomycin/Polymyxin/Hydrocortiso

ne (1% Ophthalmic Suspension)

1

Nitrofurantoin (Suspension) 1

Nitrofurantoin Macrocrystals

(Capsule)

1

Nitrofurantoin Monohydrate (100mg

Capsule)

1

Noritate (Cream) 3

Orbactiv (Injection) 3

Polymyxin B Sulfate (500000unit

Injection)

1

Polymyxin B Sulfate/Trimethoprim

Sulfate (Ophthalmic Solution)

1

Polytrim (Ophthalmic Solution) 3

Primsol (Oral Solution) 3

Relagard (Gel) 3

Silvadene (Cream) 3

Silver Nitrate (0.5% External

Solution, 10% External Solution,

25% External Solution, 50%

External Solution)

2

Drug Name Drug

Tier

Requirements

& Limits

Silver Nitrate (10% Ointment) 3

Silver Sulfadiazine (Cream) 1

Sivextro (200mg Injection, 200mg

Tablet)

3

Sulfamylon (5% Packet, 85mg/gm

Cream)

3

Synercid (Injection) 3

Trimethoprim (100mg Tablet) 1

Trimethoprim Sulfate/Polymyxin B

Sulfate (Ophthalmic Solution)

1

Tygacil (Injection) 3

Vancocin HCl (Capsule) 3

Vancomycin (Injection) 1

Vancomycin HCl (0.9%-1gm/200ml

Injection, 1000mg Injection, 10gm

Injection, 5000mg Injection, 125mg


1

Vancomycin HCl in Dextrose

(Injection)

3


1gm/100ml Injection)

3


1gm/250ml Injection, 5%-


1


Chloride (0.9%-1.25gm/250ml

Injection, 0.9%-1.5gm/250ml

Injection, 0.9%-1gm/250ml

Solution)

3

Vancomycin HCl/Sodium Chloride

(0.9%-1.5gm/150ml Injection,

0.9%-1gm/150ml Injection, 0.9%-


1

Vibativ (Injection) 3

Xifaxan (Tablet) 3

Zyvox (100mg/5ml Suspension,

600mg Tablet, 600mg/300ml

Injection)

3

Antibacterials : Beta-lactam, Cephalosporins Avycaz (Injection) 3

Cedax (180mg/5ml Suspension,

400mg Capsule)

3

Cefaclor (125mg/5ml Suspension) 2

Cefaclor (Capsule Immediate-

Release, Oral Suspension)

1

Cefaclor ER (Tablet Extended-

Release 12 Hour)

1

Cefadroxil (1gm Tablet, 250mg/5ml

Suspension, 500mg/5ml Suspension,

500mg Capsule)

1

Cefazolin (Injection) 3

Cefazolin Sodium (100gm

Injection, 300gm Injection,

1gm/50ml Injection)

3

Cefazolin Sodium (10gm Injection,

1gm Injection, 20gm Injection,

500mg Injection)

1

Cefazolin Sodium/Dextrose (1gm-

4% Injection, 2gm-3% Injection)

3



16

Drug Name Drug

Tier

Requirements

& Limits

Cefazolin Sodium/Sodium Chloride

(Injection)

1

Cefazolin/D5W (Injection) 1

Cefazolin/Dextrose (Injection) 1

Cefazolin/Sodium Chloride

(2gm/100ml-0.9% Injection)

1

Cefdinir (125mg/5ml Suspension,

250mg/5ml Suspension, 300mg

Capsule)

1

Cefditoren Pivoxil (Tablet) 3

Cefepime (1gm Injection, 2gm

Injection)

1

Cefepime (1gm/50ml Injection,


3

Cefepime/Dextrose (Injection) 3

Cefixime (Suspension) 1

Cefotaxime Sodium (Injection) 1

Cefotetan/Dextrose (Injection) 3

Cefoxitin Sodium (10gm Injection,

1gm Injection, 2gm Injection)

1

Cefoxitin Sodium (1gm-4%

Injection, 2gm-2.2% Injection)

3

Cefpodoxime Proxetil (100mg

Tablet, 200mg Tablet, 100mg/5ml

Suspension, 50mg/5ml Suspension)

1

Cefprozil (125mg/5ml Suspension,


Tablet, 500mg Tablet)

1

Ceftazidime (Injection) 1

Ceftazidime/Dextrose (Injection) 3

Ceftibuten (180mg/5ml

Suspension, 400mg Capsule)

3

Ceftin (Suspension) 3

Ceftriaxone in Iso-Osmotic

Dextrose (Injection)

1

Ceftriaxone Sodium (100gm

Injection, 1gm Injection, 250mg

Injection, 500mg Injection, 10gm

Injection, 2gm Solution)

1

Ceftriaxone/Dextrose (Injection) 3

Cefuroxime Axetil (Tablet) 1

Cefuroxime Sodium (Injection) 1

Cephalexin (125mg/5ml


250mg Capsule, 500mg Capsule,

750mg Capsule, 250mg Tablet,

500mg Tablet)

1

Fortaz (Injection) 3

Keflex (Capsule) 3

Maxipime (Injection) 3

Spectracef (Tablet) 3

Suprax (100mg Tablet Chewable,

200mg Tablet Chewable,

100mg/5ml Suspension,

200mg/5ml Suspension,


Capsule)

3

Tazicef (1gm/50ml-4.4%

Injection)

3

Drug Name Drug

Tier

Requirements

& Limits

Teflaro (Injection) 3

Zerbaxa (Injection) 3

Zinacef (Injection) 3

Antibacterials : Beta-lactam, Other Azactam (Injection) 3

Azactam in Iso-Osmotic Dextrose

(Injection)

3

Aztreonam (Injection) 1

Cayston (Inhalation Solution) 3

Cefotan (Injection) 3

Cefotetan (1gm Injection, 2gm

Injection)

1

Cefotetan (Injection) 3

Doribax (Injection) 3

Doripenem (Injection) 3

Imipenem/Cilastatin (Injection) 1

Invanz (Injection) 3

Meropenem (Injection) 1

Meropenem/Sodium Chloride

(Injection)

1

Merrem (Injection) 3

Primaxin IV (Injection) 3

Antibacterials : Beta-lactam, Penicillins Amoxicillin (125mg Tablet

Chewable, 250mg Tablet Chewable,

125mg/5ml Suspension, 200mg/5ml





1

Amoxicillin/Clavulanate Potassium

(Tablet Chewable, Tablet

Immediate-Release, Oral

Suspension)

1

Amoxicillin/Clavulanate Potassium

ER (Tablet Extended-Release 12

Hour)

1

Ampicillin (125mg/5ml Suspension,



1

Ampicillin Sodium (10gm Injection,

1gm Injection, 250mg Injection,

2gm Injection, 500mg Injection)

1

Ampicillin Sodium (125mg

Injection, 1gm Injection)

3

Ampicillin-Sulbactam (10gm-5gm

Injection, 1gm-0.5gm Injection,

2gm-1gm Injection)

1

Augmentin (125mg/5ml-

31.25mg/5ml Suspension,

250mg/5ml-62.5mg/5ml

Suspension, 500mg-125mg Tablet,

875mg-125mg Tablet)

3

Augmentin ES-600 (Suspension) 3

Augmentin XR (Tablet Extended-

Release 12 Hour)

3

Bactocill in Dextrose (Injection) 3

Bicillin C-R (Injection) 3



17

Drug Name Drug

Tier

Requirements

& Limits

Bicillin L-A (Injection) 3

Dicloxacillin Sodium (Capsule) 1

Moxatag (Tablet Extended-

Release 24 Hour)

3

Nafcillin (Injection) 1

Nafcillin Sodium (10gm Injection,

1gm Injection, 2gm Injection)

1

Nafcillin Sodium (1gm Injection,

2gm Injection)

3

Oxacillin Sodium (Injection) 1

Penicillin G Potassium (Injection) 1

Penicillin G Potassium in Iso-

Osmotic Dextrose (Injection)

3

Penicillin G Procaine (Injection) 3

Penicillin G Sodium (Injection) 3

Penicillin V Potassium (125mg/5ml

Oral Solution, 250mg/5ml Oral

Solution, 250mg Tablet, 500mg

Tablet)

1

Pfizerpen-G (Injection) 3

Piperacillin/Tazobactam (2gm-

0.25gm Injection, 3gm-0.375gm

Injection, 4gm-0.5gm Injection,

36gm-4.5gm Solution)

1

Unasyn (Injection) 3

Unasyn Bulk Pack (Injection) 3

Zosyn (Injection) 3

Antibacterials : Macrolides Azasite (Ophthalmic Solution) 3

Azithromycin (100mg/5ml


1gm Packet, 250mg Tablet, 500mg

Tablet, 600mg Tablet, 500mg

Injection)

1

Biaxin (250mg Tablet, 500mg

Tablet, 250mg/5ml Suspension)

3

Clarithromycin (125mg/5ml


250mg Tablet, 500mg Tablet)

1

Clarithromycin ER (Tablet


1

Dificid (Tablet) 3

E.E.S. Granules (Suspension) 3

Ery-Tab (Tablet Delayed-Release) 3

EryPed 200 (Suspension) 3

EryPed 400 (Suspension) 3

Erythrocin Lactobionate

(Injection)

3

Erythrocin Stearate (Tablet) 3

Erythromycin (250mg Capsule

Delayed-Release, 5mg/gm

Ointment)

1

Erythromycin Base (Tablet) 1

Erythromycin Ethylsuccinate

(200mg/5ml Suspension, 400mg

Tablet)

1

PCE (Tablet Delayed-Release) 3

Zithromax (100mg/5ml 3

Drug Name Drug

Tier

Requirements

& Limits

Suspension, 200mg/5ml

Suspension, 250mg Tablet, 500mg


Injection)

Zithromax (1gm Packet) 2

Zithromax Tri-Pak (Tablet) 3

Zithromax Z-Pak (Tablet) 3

Zmax (Suspension) 3

Antibacterials : Quinolones Avelox (Tablet, Injection) 3

Avelox ABC Pack (Tablet) 3

Besivance (Suspension) 3

Cetraxal (Otic Solution) 3

Ciloxan (0.3% Ointment, 0.3%

Ophthalmic Solution)

3

Cipro (250mg Tablet, 500mg

Tablet, 500mg/5ml Suspension,

5gm/100ml Suspension)

3

Cipro I.V. in D5W (Injection) 3

Cipro XR (Tablet Extended-

Release 24 Hour)

3

Ciprofloxacin (0.2% Otic

Solution)

3

Ciprofloxacin (250mg/5ml

Suspension, 500mg/5ml

Suspension)

1

Ciprofloxacin ER (Tablet Extended-

Release 24 Hour)

1

Ciprofloxacin HCl (0.3%

Ophthalmic Solution, Tablet

Immediate-Release)

1

Ciprofloxacin I.V. in D5W

(Injection)

1

Factive (Tablet) 3

Floxin Otic (Otic Solution) 3

Gatifloxacin (Ophthalmic Solution) 1

Levaquin (Tablet) 3

Levofloxacin (0.5% Ophthalmic


Tablet, 750mg Tablet, 25mg/ml

Injection, 25mg/ml Oral Solution)

1

Levofloxacin in D5W (Injection) 1

Moxeza (Ophthalmic Solution) 2

Moxifloxacin HCl (400mg Tablet,


1

Ocuflox (Ophthalmic Solution) 3

Ofloxacin (0.3% Ophthalmic

Solution, 0.3% Otic Solution,

400mg Tablet)

1

Vigamox (Ophthalmic Solution) 2

Zymaxid (Ophthalmic Solution) 3

Antibacterials : Sulfonamides AVC (Cream) 3

Bactrim (Tablet) 3

Bactrim DS (Tablet) 3

Bleph-10 (Ophthalmic Solution) 3

Blephamide (Suspension) 3

Blephamide S.O.P. (Ointment) 3



18

Drug Name Drug

Tier

Requirements

& Limits

Sodium Sulfacetamide (Ophthalmic

Solution)

1

Sulfacetamide Sodium (10%

Ophthalmic Ointment)

2

Sulfacetamide Sodium (10%


1

Sulfacetamide Sodium/Prednisolone

Sodium Phosphate (Ophthalmic

Solution)

1

Sulfadiazine (500mg Tablet) 1

Sulfamethoxazole/Trimethoprim

(200mg/5ml-40mg/5ml Suspension,

400mg-80mg Tablet)

1

Sulfamethoxazole/Trimethoprim

(400mg/5ml-80mg/5ml Injection)

3

Sulfamethoxazole/Trimethoprim DS

(Tablet)

1

Antibacterials : Tetracyclines Acticlate (Tablet) 3

Adoxa (100mg Tablet, 50mg


Capsule)

3

Adoxa Pak 1/100 (Tablet) 3



Avidoxy DK (Kit) 3

Demeclocycline HCl (150mg


1

Doryx (Tablet Delayed-Release) 3

Doryx MPC (Tablet Delayed-

Release)

3

Doxycycline (25mg/5ml

Suspension)

1

Doxycycline Hyclate (100mg


Injection, 100mg Tablet, 20mg

Tablet)

1

Doxycycline Hyclate DR (Tablet

Delayed-Release)

1

Doxycycline Monohydrate (100mg




75mg Tablet)

1

Minocin (100mg Capsule, 50mg


Injection)

3

Minocycline HCl (100mg Capsule,


100mg Tablet, 50mg Tablet, 75mg

Tablet)

1

Minocycline HCl ER (Tablet


1

Monodox (Capsule) 3

Morgidox 1x100mg (0-100mg-Kit) 3

Morgidox 1x50mg Kit (Kit) 3

Morgidox 2x100mg (0-100mg-Kit) 3

Solodyn (Tablet Extended-Release

24 Hour)

3

Drug Name Drug

Tier

Requirements

& Limits

Targadox (Tablet) 3

Tetracycline HCl (Capsule) 1

Vibramycin (100mg Capsule,

25mg/5ml Suspension, 50mg/5ml

Syrup)

3

Anticonvulsants : Anticonvulsants, Other Aptiom (Tablet) 3

BRIVIACT (100mg Tablet, 10mg


75mg Tablet, 10mg/ml Oral

Solution, 50mg/5ml Injection)

3

Fycompa (0.5mg/ml Suspension,



8mg Tablet)

3

Keppra (1000mg Tablet, 250mg


Tablet, 100mg/ml Oral Solution,


3

Keppra XR (Tablet Extended-

Release 24 Hour)

3

Levetiracetam (1000mg/100ml-

750mg/100ml Injection,

1500mg/100ml-540mg/100ml

Injection, 500mg/100ml-


3

Levetiracetam (Tablet Immediate-

Release, Oral Solution, Injection)

1

Levetiracetam ER (Tablet Extended-

Release 24 Hour)

1

Magnesium Sulfate in D5W (5%-

10mg/ml Injection)

1


10mg/ml Injection)

3

Magnesium Sulfate/Dextrose (5%-

2gm/50ml Injection, 5%-

3gm/50ml Injection)

3

Magnesium Sulfate/Sodium

Chloride (2gm/50ml-0.9%

Injection, 40gm/L-0.9% Injection)

3

Potiga (Tablet) 3

Anticonvulsants : Calcium Channel Modifying Agents Celontin (Capsule) 3

Ethosuximide (250mg Capsule,


1

Lyrica (100mg Capsule, 150mg




Capsule)

2

Lyrica (20mg/ml Oral Solution) 3

Zarontin (250mg Capsule,


3

Zonegran (Capsule) 3

Zonisamide (Capsule) 1

Anticonvulsants : Gamma-aminobutyric Acid (GABA) Augmenting Agents



19

Drug Name Drug

Tier

Requirements

& Limits

Ativan (0.5mg Tablet, 1mg Tablet,

2mg Tablet)

3

Clonazepam (Tablet Immediate-

Release)

1

Clonazepam ODT (Tablet

Dispersible)

1

Clorazepate Dipotassium (Tablet) 1

Depacon (Injection) 3

Depakene (250mg Capsule,

250mg/5ml Syrup)

3

Depakote (Tablet Delayed-

Release)

3

Depakote ER (Tablet Extended-

Release 24 Hour)

3

Depakote Sprinkles (Capsule

Sprinkle Delayed-Release)

3

Diastat AcuDial (Gel) 2

Diastat Pediatric (Gel) 2

Diazepam (10mg Gel, 2.5mg Gel,

20mg Gel, 10mg Tablet, 2mg

Tablet, 5mg Tablet, 1mg/ml Oral

Solution, 5mg/ml Concentrate)

1

Diazepam (5mg/ml Injection) 3

Divalproex Sodium (Capsule

Sprinkle Delayed-Release)

1

Divalproex Sodium DR (Tablet

Delayed-Release)

1

Divalproex Sodium ER (Tablet


1

Gabitril (Tablet) 3

Gene-Xene Tab 15mg (Tablet) 1

Gene-Xene Tab 3.75mg (Tablet) 1

Gene-Xene Tab 7.5mg (Tablet) 1

Klonopin (Tablet) 3

Lorazepam (0.5mg Tablet, 1mg

Tablet, 2mg Tablet)

1

Mysoline (Tablet) 3

Onfi (10mg Tablet, 20mg Tablet,

2.5mg/ml Suspension)

3

Phenobarbital (100mg Tablet, 15mg

Tablet, 16.2mg Tablet, 30mg Tablet,

32.4mg Tablet, 60mg Tablet,

64.8mg Tablet, 97.2mg Tablet,

20mg/5ml Elixir, 20mg/5ml Oral

Solution)

1

Primidone (Tablet) 1

Sabril (500mg Packet, 500mg

Tablet)

3

Tiagabine HCl (Tablet) 1

Tranxene T (Tablet) 3

Valium (Tablet) 3

Valproate Sodium (100mg/ml

Injection)

1

Valproic Acid (250mg Capsule,

250mg/5ml Oral Solution,

250mg/5ml Syrup)

1

Anticonvulsants : Glutamate Reducing Agents Felbamate (400mg Tablet, 600mg 1

Drug Name Drug

Tier

Requirements

& Limits


Felbatol (400mg Tablet, 600mg


3

Lamictal (Tablet) 3

Lamictal Chewable Dispersible

(Tablet Chewable)

3

Lamictal ODT (Kit, 100mg Tablet

Dispersible, 200mg Tablet



Dispersible)

3

Lamictal Starter (Blue Kit) 3

Lamictal Starter (Green Kit) 3

Lamictal Starter (Orange Kit) 3

Lamictal XR (100mg Tablet



250mg Tablet Extended-Release

24 Hour, 25mg Tablet Extended-

Release 24 Hour, 300mg Tablet


Tablet Extended-Release 24 Hour)

3

Lamotrigine (Tablet Immediate-

Release, Tablet Chewable)

1

Lamotrigine ER (100mg Tablet




Hour, 300mg Tablet Extended-

Release 24 Hour, 50mg Tablet



1

Lamotrigine ODT (Tablet

Dispersible)

1

Lamotrigine Titration (Kit) 1

Qudexy XR (Capsule Extended-

Release 24 Hour Sprinkle)

3

Topamax (Tablet) 3

Topamax Sprinkle (Capsule

Sprinkle)

3

Topiramate (Tablet Immediate-

Release, Capsule Sprinkle

Immediate-Release)

1

Topiramate ER (Capsule

Extended-Release 24 Hour

Sprinkle)

3

Trokendi XR (Capsule Extended-

Release 24 Hour)

3

Anticonvulsants : Sodium Channel Agents Banzel (200mg Tablet, 400mg

Tablet, 40mg/ml Suspension)

3

Carbamazepine (100mg Tablet

Chewable, 100mg/5ml Suspension,

200mg Tablet)

1

Carbamazepine Extended-Release

12 Hour (Capsule, Tablet)

1

Carbatrol (Capsule Extended-

Release 12 Hour)

3

Cerebyx (Injection) 3



20

Drug Name Drug

Tier

Requirements

& Limits

Dilantin (Capsule) 3

Dilantin INFATABS (Tablet

Chewable)

3

Dilantin-125 (Suspension) 3

Equetro (Capsule Extended-

Release 12 Hour)

3

Fosphenytoin Sodium (Injection) 1

Oxcarbazepine (150mg Tablet,


60mg/ml Suspension)

1

Oxtellar XR (Tablet Extended-

Release 24 Hour)

3

Peganone (Tablet) 3

Phenytek (Capsule) 3

Phenytoin (125mg/5ml Suspension,

50mg Tablet Chewable)

1

Phenytoin Sodium (50mg/ml

Injection)

1

Phenytoin Sodium Extended

(Capsule)

1

Tegretol (100mg/5ml Suspension,

200mg Tablet)

3

Tegretol-XR (Tablet Extended-

Release 12 Hour)

3

Trileptal (150mg Tablet, 300mg


Suspension)

3

Vimpat (Tablet, Oral Solution,

Injection)

3

Vraylar (Capsule Therapy Pack,

1.5mg Capsule, 3mg Capsule,

4.5mg Capsule, 6mg Capsule)

3

Antidementia Agents : Antidementia Agents, Other Ergoloid Mesylates (Tablet) 1

Namzaric (10mg-21mg Capsule

Extended-Release 24 Hour, 10mg-

7mg Capsule Extended-Release 24

Hour)

2

Antidementia Agents : Cholinesterase Inhibitors Aricept (Tablet) 3

Donepezil HCl (10mg Tablet

Dispersible, 5mg Tablet Dispersible,


Tablet)

1

Exelon (Patch 24 Hour) 3

Galantamine HBr (12mg Tablet,

4mg Tablet, 8mg Tablet, 4mg/ml

Oral Solution)

1

Galantamine HBr ER (Capsule


1

Razadyne (Tablet) 3

Razadyne ER (Capsule Extended-

Release 24 Hour)

3

Rivastigmine Tartrate (Capsule

Immediate-Release)

1

Rivastigmine Transdermal System

(Patch 24 Hour)

1

Antidementia Agents : N-methyl-D-aspartate

Drug Name Drug

Tier

Requirements

& Limits

(NMDA) Receptor Antagonist Memantine HCl (10mg Tablet, 5mg

Tablet, 2mg/ml Oral Solution)

1

Memantine HCl Titration Pak

(Tablet)

1

Namenda (10mg Tablet, 5mg

Tablet, 10mg/5ml Oral Solution)

3

Namenda Titration Pak (Tablet) 3

Namenda XR (Capsule Extended-

Release 24 Hour)

2

Namenda XR Titration Pack

(Capsule Extended-Release 24

Hour)

2

Antidepressants : Antidepressants, Other Abilify (Tablet) 3

Aplenzin (Tablet Extended-

Release 24 Hour)

3

Aripiprazole (10mg Tablet, 15mg



Oral Solution)

1

Bupropion HCl ER (Tablet


1

Bupropion HCl SR (Tablet


1

Forfivo XL (Tablet Extended-

Release 24 Hour)

2

Maprotiline HCl (Tablet) 1

Mirtazapine (Tablet) 1

Mirtazapine ODT (Tablet

Dispersible)

1

Nefazodone HCl (Tablet) 1

Quetiapine Fumarate (Tablet) 1

Quetiapine Fumarate ER (Tablet


1

Remeron (Tablet) 3

Remeron Soltab (Tablet

Dispersible)

3

Seroquel (Tablet) 3

Seroquel XR (150mg Tablet



300mg Tablet Extended-Release

24 Hour, 50mg Tablet Extended-

Release 24 Hour)

2

Seroquel XR (400mg Tablet


3

Trazodone HCl (100mg Tablet,


Tablet)

1

Trintellix (Tablet) 3

Antidepressants : Monoamine Oxidase Inhibitors Emsam (Patch 24 Hour) 3

Marplan (Tablet) 3

Nardil (Tablet) 3

Parnate (Tablet) 3

Phenelzine Sulfate (Tablet) 1

Zelapar (Tablet Dispersible) 3



21

Drug Name Drug

Tier

Requirements

& Limits

Antidepressants : SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) Brisdelle (Capsule) 3

Celexa (Tablet) 3

Citalopram HBr (10mg Tablet,



1

Cymbalta (Capsule Delayed-

Release)

3

Desvenlafaxine ER (100mg Tablet




Hour)

1

Desvenlafaxine ER (100mg Tablet



3

Duloxetine HCl (20mg Capsule

Delayed-Release, 30mg Capsule


Delayed-Release)

1

Duloxetine HCl (40mg Capsule

Delayed-Release)

3

Effexor XR (Capsule Extended-

Release 24 Hour)

3

Escitalopram Oxalate (10mg Tablet,

20mg Tablet, 5mg Tablet, 5mg/5ml

Oral Solution)

1

Fetzima (Capsule Extended-

Release 24 Hour)

3

Fetzima Titration Pack (Capsule


Therapy Pack)

3

Fluoxetine (Capsule) 1

Fluoxetine DR (Capsule Delayed-

Release)

1

Fluoxetine HCl (10mg Tablet, 20mg

Tablet, 60mg Tablet, 20mg/5ml Oral

Solution, 40mg Capsule)

1

Fluvoxamine Maleate (Tablet) 1

Fluvoxamine Maleate ER (Capsule


1

Khedezla (Tablet Extended-

Release 24 Hour)

3

Lexapro (10mg Tablet, 20mg


Solution)

3

Paroxetine HCl (Tablet) 1

Paroxetine HCl ER (Tablet


1

Paxil (10mg Tablet, 20mg Tablet,


3

Paxil (10mg/5ml Suspension) 2

Paxil CR (Tablet Extended-

Release 24 Hour)

3

Pexeva (Tablet) 3

Pristiq (Tablet Extended-Release

24 Hour)

3

Drug Name Drug

Tier

Requirements

& Limits

Prozac (Capsule) 3

Prozac Weekly (Capsule Delayed-

Release)

3

Sarafem (Tablet) 3

Sertraline HCl (100mg Tablet, 25mg


Concentrate)

1

Venlafaxine HCl (Tablet Immediate-

Release)

1

Venlafaxine HCl Extended-Release

24 Hour (Capsule, Tablet)

1

Viibryd (Tablet) 3

Viibryd Starter Pack (Kit) 3

Zoloft (100mg Tablet, 25mg


Concentrate)

3

Antidepressants : Tricyclics Amitriptyline HCl (100mg Tablet,


Tablet, 50mg Tablet, 75mg Tablet)

1

Amoxapine (Tablet) 1

Anafranil (Capsule) 3

Chlordiazepoxide/Amitriptyline

(Tablet)

1

Clomipramine HCl (Capsule) 1

Desipramine HCl (100mg Tablet,



1

Doxepin HCl (100mg Capsule,


25mg Capsule, 50mg Capsule, 75mg

Capsule, 10mg/ml Concentrate)

1

Elavil (Tablet) 3

Imipramine HCl (10mg Tablet,


1

Imipramine Pamoate (Capsule) 1

Norpramin (Tablet) 3

Nortriptyline HCl (10mg Capsule,

25mg Capsule, 50mg Capsule, 75mg

Capsule, 10mg/5ml Oral Solution)

1

Pamelor (Capsule) 3

Perphenazine/Amitriptyline (10mg-


25mg-4mg Tablet)

1

Perphenazine/Amitriptyline

(10mg-4mg Tablet, 50mg-4mg

Tablet)

2

Protriptyline HCl (Tablet) 1

Surmontil (Capsule) 3

Tofranil (Tablet) 3

Trimipramine Maleate (100mg


Capsule)

1

Antiemetics : Antiemetics, Other Akynzeo (Capsule) 3

Chlorpromazine HCl (100mg



1



22

Drug Name Drug

Tier

Requirements

& Limits

Diclegis (Tablet Delayed-Release) 3

Dimenhydrinate (50mg/ml

Injection)

3

Diphenhydramine HCl (12.5mg/5ml

Elixir, 50mg/ml Injection)

1

Droperidol (2.5mg/ml Injection) 1

Hydroxyzine HCl (10mg Tablet,


10mg/5ml Syrup, 50mg/ml

Injection)

1

Hydroxyzine Pamoate (100mg


Capsule)

1

Metoclopramide HCl (10mg Tablet,

5mg Tablet, 5mg/5ml Oral Solution)

1

Metoclopramide ODT (10mg

Tablet Dispersible)

3

Metoclopramide ODT (5mg Tablet

Dispersible)

1

Perphenazine (Tablet) 1

Phenergan (50mg/ml Injection) 3

Prochlorperazine (Suppository) 1

Prochlorperazine Edisylate

(Injection)

1

Prochlorperazine Maleate (10mg

Tablet, 5mg Tablet)

1

Promethazine HCl (12.5mg

Suppository, 25mg Suppository,

50mg Suppository, 12.5mg Tablet,


Injection, 6.25mg/5ml Oral

Solution)

1

Promethazine HCl Plain (Syrup) 1

Reglan (Tablet) 3

Transderm-Scop (Patch 72 Hour) 3

Vistaril (Capsule) 3

Antiemetics : Emetogenic Therapy Adjuncts Aloxi (Injection) 2

Anzemet (Tablet) 3

Aprepitant (Capsule) 1

Cesamet (Capsule) 3

Dronabinol (Capsule) 1

Emend (Capsule, 40mg Capsule,


125mg Suspension, 150mg

Injection)

3

Granisetron HCl (0.1mg/ml


4mg/4ml Injection, 1mg Tablet)

1

Marinol (Capsule) 3

Meclizine HCl (12.5mg Tablet,

25mg Tablet)

1

Ondansetron HCl (24mg Tablet,

4mg Tablet, 8mg Tablet, 40mg/20ml



1

Ondansetron HCl/Sodium Chloride

(Injection)

1

Ondansetron ODT (Tablet 1

Drug Name Drug

Tier

Requirements

& Limits

Dispersible)

Sancuso (Patch) 3

Tigan (100mg/ml Injection, 300mg

Capsule)

3

Trimethobenzamide HCl (Capsule) 1

Varubi (Tablet) 3

Zofran (4mg Tablet, 8mg Tablet,


3

Zofran ODT (Tablet Dispersible) 3

Antifungals Abelcet (Injection) 3

Ala-Quin (Cream) 2

AmBisome (Injection) 3

Amphotericin B (50mg Injection) 3

Ancobon (Capsule) 3

Cancidas (Injection) 3

Ciclodan Cream Kit (Kit) 3

Ciclodan Solution Kit (Kit) 3

Ciclopirox (0.77% Gel, 0.77%

Suspension, 1% Shampoo)

1

Ciclopirox Nail Lacquer (External

Solution)

1

Ciclopirox Olamine (0.77% Cream) 1

Clotrimazole (1% Cream, 1%

External Solution, 10mg Lozenge,

10mg Troche)

1

Clotrimazole/Betamethasone

Dipropionate (0.05%-1% Cream,

1%-0.05% Lotion)

1

Cresemba (186mg Capsule, 372mg

Injection)

3

Diflucan (100mg Tablet, 150mg


Tablet, 10mg/ml Suspension,

40mg/ml Suspension)

3

Econazole Nitrate (1% Cream) 1

Ecoza (Foam) 3

Eraxis (Injection) 3

Ertaczo (Cream) 3

Exelderm (1% Cream, 1%

External Solution)

3

Exoderm (Lotion) 2

Extina (Foam) 3

First-Metronidazole 100

(Suspension)

3

First-Metronidazole 50

(Suspension)

3

Fluconazole (100mg Tablet, 150mg


10mg/ml Suspension, 40mg/ml

Suspension)

1

Fluconazole in Dextrose (Injection) 1

Fluconazole in NaCl

(100mg/50ml-0.9% Injection)

3

Fluconazole in NaCl



1

Flucytosine (Capsule) 1



23

Drug Name Drug

Tier

Requirements

& Limits

GRIS-PEG (Tablet) 3

Griseofulvin Microsize (125mg/5ml

Suspension, 500mg Tablet)

1

Griseofulvin Ultramicrosize (Tablet) 1

Gynazole-1 (Cream) 3

Halotin (Cream) 3

Itraconazole (Capsule) 1

Jublia (External Solution) 3

Kerr Triple Dye (Swab) 3

Kerydin (External Solution) 3

Ketoconazole (2% Cream, 2%

Foam, 2% Shampoo, 200mg Tablet)

1

Ketodan Kit (Kit) 3

Lamisil (Tablet) 3

Loprox (0.77% Cream, 0.77%

Suspension, 0.77%-0-Kit)

3

Loprox Shampoo 3

Lotrisone (Cream) 3

Luzu (Cream) 3

Mentax (Cream) 3

Mycamine (Injection) 3

Naftifine HCl (Cream) 1

Naftifine HCl (Cream) 1

Naftin (1% Gel, 2% Gel, 2%

Cream)

3

Natacyn (Suspension) 2

Nizoral (Shampoo) 3

Noxafil (100mg Tablet Delayed-

Release, 300mg/16.7ml Injection,

40mg/ml Suspension)

3

Nystatin (100000unit/gm Cream,

100000unit/gm Ointment,

100000unit/gm Powder,

100000unit/ml Suspension,

500000unit Tablet)

1

Nystatin/Triamcinolone

(100000unit/gm-0.1% Ointment,

100000unit/gm-1mg/gm Cream)

1

ONMEL (Tablet) 3

Oxiconazole Nitrate (Cream) 1

Oxistat (1% Cream, 1% Lotion) 3

Penlac Nail Lacquer (External

Solution)

3

Sporanox (100mg Capsule,

10mg/ml Oral Solution)

3

Sporanox Pulsepak (Capsule) 3

Terazol 7 (Cream) 3

Terbinafine HCl (Tablet) 1

Terconazole (0.4% Cream, 0.8%

Cream, 80mg Suppository)

1

Triple Dye (Liquid) 3

Vfend (200mg Tablet, 50mg

Tablet, 40mg/ml Suspension)

3

Vfend IV (Injection) 3

Voriconazole (200mg Injection,


40mg/ml Suspension)

1

Vusion (Ointment) 3

Drug Name Drug

Tier

Requirements

& Limits

Xolegel (Gel) 3

Xolegel Corepak (Kit) 3

Xolegel Duo/Head & Shoulders

(Kit)

3

Xolegel Duo/Xolex (Kit) 3

Antigout Agents Allopurinol (Tablet) 1

Allopurinol Sodium (Injection) 1

Aloprim (Injection) 3

Colchicine (0.6mg Capsule) 3

Colchicine (0.6mg Tablet) 2

Colcrys (Tablet) 2

Krystexxa (Injection) 3

Mitigare (Capsule) 3

Probenecid (Tablet) 1

Probenecid/Colchicine (Tablet) 1

Uloric (Tablet) 2

Zyloprim (Tablet) 3

Antihistamine Drugs : First Generation Antihistamines Dologesic (Tablet) 2

Antimigraine Agents : Treximet (60mg-10mg Tablet) 3

Antimigraine Agents : Ergot Alkaloids Cafergot (Tablet) 3

D.h.e. 45 (Injection) 3

Dihydroergotamine Mesylate

(1mg/ml Injection, 4mg/ml Nasal

Solution)

1

Ergomar (Tablet Sublingual) 3

Ergotamine Tartrate/Caffeine

(Tablet)

1

Migergot (Suppository) 3

Migranal (Nasal Solution) 3

Antimigraine Agents : Serotonin (5-HT) 1b/1d Receptor Agonists Almotriptan Malate (Tablet) 1

Amerge (Tablet) 3

Axert (Tablet) 3

Frova (Tablet) 3

Frovatriptan Succinate (Tablet) 1

Imitrex (100mg Tablet, 25mg

Tablet, 50mg Tablet, 20mg/act

Nasal Solution, 5mg/act Nasal

Solution, 6mg/0.5ml Injection)

3

Imitrex Statdose System

(Injection)

3

Maxalt (Tablet) 3

Maxalt-MLT (Tablet Dispersible) 3

Naratriptan HCl (Tablet) 1

Onzetra Xsail (Exhaler Powder) 3

Relpax (Tablet) 3

Rizatriptan Benzoate (Tablet) 1

Rizatriptan Benzoate ODT (Tablet

Dispersible)

1



24

Drug Name Drug

Tier

Requirements

& Limits

Sumatriptan (Nasal Solution) 1

Sumatriptan Succinate (100mg


4mg/0.5ml Injection, 6mg/0.5ml

Injection)

1

Sumavel DosePro (Injection) 3

Treximet (500mg-85mg Tablet) 3

Zembrace Symtouch (Injection) 3

Zolmitriptan (Tablet) 1

Zolmitriptan ODT (Tablet

Dispersible)

1

Zomig (2.5mg Nasal Solution, 5mg

Nasal Solution, 2.5mg Tablet, 5mg

Tablet)

3

Zomig ZMT (Tablet Dispersible) 3

Antimyasthenic Agents Enlon (Injection) 3

Antimyasthenic Agents : Parasympathomimetics Bloxiverz (Injection) 3

Guanidine HCl (Tablet) 1

Mestinon (60mg Tablet) 3

Mestinon (60mg/5ml Syrup) 2

Mestinon Timespan (Tablet

Extended-Release)

3

Neostigmine Methylsulfate

(10mg/10ml Injection, 5mg/10ml

Injection)

1

Neostigmine Methylsulfate



3

Pyridostigmine Bromide (Tablet) 1

Pyridostigmine Bromide ER (Tablet

Extended-Release)

1

Regonol (Injection) 3

Antimycobacterials : Antimycobacterials, Other Dapsone (Tablet) 1

Mycobutin (Capsule) 3

Rifabutin (Capsule) 1

Antimycobacterials : Antituberculars Capastat Sulfate (Injection) 3

Cycloserine (Capsule) 3

Ethambutol HCl (100mg Tablet,

400mg Tablet)

1

Isoniazid (100mg Tablet, 300mg

Tablet, 50mg/5ml Syrup)

1

Isoniazid (100mg/ml Injection) 3

Myambutol (Tablet) 3

Paser (Packet) 3

Priftin (Tablet) 3

Pyrazinamide (Tablet) 1

Rifadin (150mg Capsule, 300mg

Capsule, 600mg Injection)

3

Rifamate (Capsule) 3

Rifampin (150mg Capsule, 300mg

Capsule, 600mg Injection)

1

Rifater (Tablet) 3

Sirturo (Tablet) 3

Drug Name Drug

Tier

Requirements

& Limits

Trecator (Tablet) 3

Antineoplastic Agents Campath (Injection) 2

Imlygic (Suspension) 3

Lartruvo (190mg/19ml Solution,


3

Rubraca (Tablet) 3

Antineoplastics : Kisqali (Tablet) 3

Antineoplastics : Alkylating Agents Alkeran (2mg Tablet) 2

Alkeran (50mg Injection) 3

Bendeka (Injection) 3

BiCNU (Injection) 2

Busulfex (Injection) 2

Carboplatin (Injection) 1

Cisplatin (100mg/100ml Injection,


1

Cisplatin (200mg/200ml Injection) 3

Cyclophosphamide (1gm Injection,

2gm Injection, 500mg Injection)

1

Cyclophosphamide (25mg


3

Dacarbazine (100mg Injection) 3

Dacarbazine (200mg Injection) 1

Doxorubicin HCl (Injection) 1

Evomela (Injection) 3

Gleostine (Capsule) 3

Gliadel Wafer (Wafer) 3

Hexalen (Capsule) 2

Ifex (Injection) 3

Ifosfamide (1gm Injection,

1gm/20ml Injection, 3gm/60ml

Injection)

1

Ifosfamide (3gm Injection) 3

Leukeran (Tablet) 2

Matulane (Capsule) 2

Melphalan HCl (Injection) 1

Mitoxantrone HCl (Injection) 1

Mustargen (Injection) 2

Myleran (Tablet) 2

Temodar (100mg Capsule, 140mg



Capsule)

3

Temodar (100mg Injection) 2

Temozolomide (Capsule) 1

Thiotepa (Injection) 1

Treanda (Injection) 2

Yondelis (Injection) 3

Zanosar (Injection) 2

Antineoplastics : Antiandrogens Bicalutamide (Tablet) 1

Casodex (Tablet) 3

Flutamide (Capsule) 1

Nilandron (Tablet) 3



25

Drug Name Drug

Tier

Requirements

& Limits

Nilutamide (Tablet) 1

Xtandi (Capsule) 3

Antineoplastics : Antiangiogenic Agents Caprelsa (Tablet) 2

Pomalyst (Capsule) 3

Revlimid (Capsule) 3

Thalomid (Capsule) 2

Antineoplastics : Antiestrogens/Modifiers Emcyt (Capsule) 2

Fareston (Tablet) 2

Faslodex (Injection) 2

Soltamox (Oral Solution) 3

Tamoxifen Citrate (Tablet) 1

Antineoplastics : Antimetabolites Arranon (Injection) 2

Capecitabine (Tablet) 1

Cladribine (Injection) 1

Clolar (Injection) 2

Cytarabine Aqueous (Injection) 1

Droxia (Capsule) 3

Elitek (Injection) 3

Floxuridine (Injection) 1

Fluorouracil (1gm/20ml Injection,

2.5gm/50ml Injection, 500mg/10ml

Injection, 5gm/100ml Injection, 5%

Cream)

1

Folotyn (Injection) 2

Gemcitabine (Injection) 1

Gemzar (Injection) 3

Hydrea (Capsule) 3

Hydroxyurea (Capsule) 1

Lonsurf (Tablet) 3

Mercaptopurine (Tablet) 1

Nipent (Injection) 3

Purixan (Suspension) 3

Tabloid (Tablet) 2

Xeloda (Tablet) 3

Antineoplastics Xofigo (Injection) 2

Antineoplastics : Antineoplastics, Other Alferon N (Injection) 2

Beleodaq (Injection) 3

Cosmegen (Injection) 3

Cotellic (Tablet) 3

Dacogen (Injection) 3

Decitabine (Injection) 1

Docetaxel (160mg/16ml Injection,




Injection)

3

Docetaxel (20mg/ml Injection,

80mg/4ml Injection)

1

Docetaxel (Non-Alcohol Formula)

(Injection)

3

Farydak (Capsule) 3

Drug Name Drug

Tier

Requirements

& Limits

Ibrance (Capsule) 3

Intron A (Injection) 3

Jakafi (Tablet) 2

Leucovorin Calcium (10mg Tablet,


Tablet)

1

Levoleucovorin (175mg/17.5ml


1

Lynparza (Capsule) 3

Marqibo (Injection) 3

Mesna (Injection) 1

Mesnex (100mg/ml Injection) 3

Navelbine (Injection) 3

Ninlaro (Capsule) 3

Odomzo (Capsule) 3

Paclitaxel (100mg/16.7ml Injection,


Injection)

1

Paclitaxel (150mg/25ml Injection) 3

Portrazza (Injection) 3

Sylatron (Injection) 3

Taxotere (Injection) 3

Teniposide (Injection) 3

Venclexta (Tablet) 3

Venclexta Starting Pack (Tablet

Therapy Pack)

3

Vinblastine Sulfate (Injection) 3

Vinorelbine Tartrate (Injection) 1

Zolinza (Capsule) 2

Zytiga (Tablet) 3

Antineoplastics : Aromatase Inhibitors, 3rd Generation Anastrozole (Tablet) 1

Arimidex (Tablet) 3

Aromasin (Tablet) 3

Exemestane (Tablet) 1

Femara (Tablet) 3

Letrozole (Tablet) 1

Antineoplastics : Enzyme Inhibitors Etopophos (Injection) 3

Etoposide (100mg/5ml Injection,

1gm/50ml Injection, 500mg/25ml

Injection)

1

Etoposide (50mg Capsule) 2

Hycamtin (0.25mg Capsule, 1mg

Capsule, 4mg Solution)

3

Kyprolis (30mg Injection) 2

Topotecan HCl (Injection) 1

Zydelig (Tablet) 3

Antineoplastics : Molecular Target Inhibitors Afinitor (Tablet) 2

Afinitor Disperz (Tablet Soluble) 3

Alecensa (Capsule) 3

Bosulif (Tablet) 3

Cabometyx (Tablet) 3

Cometriq (Kit) 3



26

Drug Name Drug

Tier

Requirements

& Limits

Erivedge (Capsule) 2

Gilotrif (Tablet) 3

Gleevec (Tablet) 3

Iclusig (Tablet) 3

Imatinib Mesylate (Tablet) 1

Imbruvica (Capsule) 3

Inlyta (Tablet) 3

Iressa (Tablet) 3

Lenvima (Capsule Therapy Pack) 3

Mekinist (Tablet) 2

Nexavar (Tablet) 2

Sprycel (Tablet) 2

Stivarga (Tablet) 3

Sutent (Capsule) 3

Tafinlar (Capsule) 2

Tarceva (Tablet) 3

Tasigna (Capsule) 3

Tykerb (Tablet) 2

Votrient (Tablet) 3

Xalkori (Capsule) 2

Zelboraf (Tablet) 3

Zykadia (Capsule) 3

Antineoplastics : Monoclonal Antibodies Adcetris (Injection) 2

Arzerra (Injection) 2

Avastin (Injection) 2

Blincyto (Injection) 3

Cyramza (Injection) 3

Darzalex (Injection) 3

Empliciti (Injection) 3

Erbitux (Injection) 2

Gazyva (Injection) 3

Herceptin (Injection) 2

Keytruda (Injection) 3

Opdivo (Injection) 3

Perjeta (Injection) 2

Rituxan (Injection) 3

Sylvant (Injection) 3

Tagrisso (Tablet) 3

Tecentriq (Injection) 3

Unituxin (Injection) 3

Vectibix (Injection) 3

Yervoy (Injection) 2

Zevalin Y-90 (Injection) 3

Antineoplastics : Retinoids Bexarotene (Capsule) 1

Panretin (Gel) 3

Targretin (1% Gel, 75mg

Capsule)

3

Tretinoin (10mg Capsule) 1

Antiparasitics : Anthelmintics Albenza (Tablet) 3

Biltricide (Tablet) 2

Emverm (Tablet Chewable) 3

Ivermectin (Tablet) 1

Drug Name Drug

Tier

Requirements

& Limits

Stromectol (Tablet) 3

Antiparasitics : Antiprotozoals Alinia (100mg/5ml Suspension,

500mg Tablet)

2

Atovaquone (Suspension) 1

Atovaquone/Proguanil HCl (Tablet) 1

Chloroquine Phosphate (250mg


1

Coartem (Tablet) 3

DARAPRIM (Tablet) 2

Hydroxychloroquine Sulfate

(Tablet)

1

Malarone (Tablet) 3

Mefloquine HCl (Tablet) 1

Mepron (Suspension) 3

Nebupent (Inhalation Solution) 2

Neutrexin (Injection) 3

Pentam 300 (Injection) 3

Plaquenil (Tablet) 3

Primaquine Phosphate (Tablet) 1

Qualaquin (Capsule) 3

Quinine Sulfate (324mg Capsule) 1

Tindamax (Tablet) 3

Tinidazole (Tablet) 1

Antiparasitics : Pediculicides/Scabicides Elimite (Cream) 3

Eurax (10% Cream, 10% Lotion) 2

Lindane (Shampoo) 1

Malathion (Lotion) 1

Natroba (Suspension) 3

Ovide (Lotion) 3

Permethrin (Cream) 1

Sklice (Lotion) 3

Spinosad (Suspension) 3

Sulfurated Lime (External

Solution)

3

Ulesfia (Lotion) 3

Antiparkinson Agents : Anticholinergics Benztropine Mesylate (0.5mg


1mg/ml Injection)

1

Cogentin (Injection) 3

Trihexyphenidyl HCl (0.4mg/ml

Elixir, 2mg Tablet, 5mg Tablet)

1

Antiparkinson Agents : Antiparkinson Agents, Other Amantadine HCl (100mg Capsule,

100mg Tablet, 50mg/5ml Syrup)

1

Comtan (Tablet) 3

Entacapone (Tablet) 1

Tasmar (Tablet) 3

Tolcapone (Tablet) 1

Antiparkinson Agents : Dopamine Agonists Apokyn (Injection) 2

Mirapex (Tablet) 3

Mirapex ER (Tablet Extended-

Release 24 Hour)

3



27

Drug Name Drug

Tier

Requirements

& Limits

Neupro (Patch 24 Hour) 3

Pramipexole Dihydrochloride

(Tablet Immediate-Release)

1

Pramipexole Dihydrochloride ER

(Tablet Extended-Release 24 Hour)

1

Requip (Tablet) 3

Requip XL (Tablet Extended-

Release 24 Hour)

3

Ropinirole ER (Tablet Extended-

Release 24 Hour)

1

Ropinirole HCl (Tablet) 1

Antiparkinson Agents : Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors Carbidopa (Tablet) 1

Carbidopa/Levodopa (Tablet

Immediate-Release)

1

Carbidopa/Levodopa ER (Tablet

Extended-Release)

1

Carbidopa/Levodopa/Entacapone

(Tablet)

1

Duopa (Suspension) 3

Lodosyn (Tablet) 3

Sinemet (Tablet) 3

Sinemet CR (Tablet Extended-

Release)

3

Stalevo 100 (Tablet) 3






Antiparkinson Agents : Monoamine Oxidase B (MAO-B) Inhibitors Azilect (Tablet) 3

Eldepryl (Capsule) 3

Rasagiline Mesylate (Tablet) 1

Selegiline HCl (5mg Capsule, 5mg

Tablet)

1

Antipsychotics : 1st Generation/Typical Adasuve (Aerosol Powder) 3

Fluphenazine Decanoate (Injection) 1

Fluphenazine HCl (10mg Tablet,

1mg Tablet, 2.5mg Tablet, 5mg

Tablet)

1

Fluphenazine HCl (2.5mg/5ml

Elixir, 5mg/ml Concentrate)

2

Fluphenazine HCl (2.5mg/ml

Injection)

3

Haldol (Injection) 3

Haldol Decanoate 100 (Injection) 3

Haldol Decanoate 50 (Injection) 3

Haloperidol (0.5mg Tablet, 10mg



Concentrate)

1

Haloperidol Decanoate (Injection) 1

Haloperidol Lactate (Injection) 1

Drug Name Drug

Tier

Requirements

& Limits

Loxapine Succinate (Capsule) 1

Molindone HCl (Tablet) 1

Orap (Tablet) 3

Pimozide (Tablet) 1

Thioridazine HCl (Tablet) 1

Thiothixene (Capsule) 1

Trifluoperazine HCl (Tablet) 1

Antipsychotics : 2nd Generation/Atypical Aristada (Injection) 3

Fanapt (Tablet) 3

Fanapt Titration Pack (Tablet) 3

Geodon (20mg Capsule, 40mg


Capsule)

3

Invega (Tablet Extended-Release

24 Hour)

3

Invega Sustenna (Injection) 3

Invega Trinza (Injection) 3

Latuda (Tablet) 3

Nuplazid (Tablet) 3

Olanzapine (Tablet Immediate-

Release)

1

Olanzapine ODT (Tablet

Dispersible)

1

Paliperidone ER (Tablet Extended-

Release 24 Hour)

1

Rexulti (Tablet) 3

Risperdal (0.25mg Tablet, 0.5mg



Oral Solution)

3

Risperdal M-Tab (Tablet

Dispersible)

3

Risperidone (0.25mg Tablet, 0.5mg



Oral Solution)

1

Risperidone ODT (Tablet

Dispersible)

1

Saphris (10mg Tablet Sublingual) 2

Ziprasidone HCl (Capsule) 1

Zyprexa (10mg Tablet, 15mg

Tablet, 2.5mg Tablet, 20mg

Tablet, 5mg Tablet, 7.5mg Tablet)

3

Zyprexa Zydis (Tablet

Dispersible)

3

Antipsychotics : Treatment-Resistant Clozapine (Tablet Immediate-

Release)

1

Clozapine ODT (Tablet Dispersible) 1

Clozaril (Tablet) 3

Fazaclo (Tablet Dispersible) 3

Versacloz (Suspension) 3

Antispasticity Agents Baclofen (10mg Tablet, 20mg

Tablet)

1

Cyproheptadine HCl (2mg/5ml 1



28

Drug Name Drug

Tier

Requirements

& Limits

Syrup, 4mg Tablet)

Dantrium (Capsule) 3

Dantrolene Sodium (Capsule) 1

Gabapentin (100mg Capsule, 300mg

Capsule, 400mg Capsule,

250mg/5ml Oral Solution, 600mg


1

Gablofen (Injection) 3

Lioresal Intrathecal (Injection) 2

Neurontin (100mg Capsule,


250mg/5ml Oral Solution, 600mg


3

Tizanidine Comfort Pac 3

Tizanidine HCl (2mg Capsule, 4mg

Capsule, 6mg Capsule, 2mg Tablet,

4mg Tablet)

1

Zanaflex (2mg Capsule, 4mg


Tablet)

3

Antitoxins, Immune Globulins, Toxoids, and Vaccines : Antitoxins and Immune Globulins Cuvitru (8gm/40ml Injection) 3

Zinplava (Injection) 3

Antivirals : Rapivab (Injection) 3

Antivirals : Anti-cytomegalovirus (CMV) Agents Cidofovir (Injection) 1

Cytovene (Injection) 3

Ganciclovir (Injection) 1

Valcyte (450mg Tablet, 50mg/ml

Oral Solution)

3

Valganciclovir (Tablet) 1

Valganciclovir Hydrochlorde (Oral

Solution)

1

Zirgan (Gel) 3

Antivirals : Anti-hepatitis B (HBV) Agents Adefovir Dipivoxil (Tablet) 1

Baraclude (0.05mg/ml Oral

Solution, 0.5mg Tablet, 1mg

Tablet)

3

Entecavir (Tablet) 1

Epivir HBV (100mg Tablet) 3

Epivir HBV (5mg/ml Oral

Solution)

2

Hepsera (Tablet) 3

Lamivudine (100mg Tablet) 1

Antivirals : Anti-hepatitis C (HCV) Agents Copegus (Tablet) 3

Daklinza (Tablet) 3

Epclusa (Tablet) 2

Harvoni (Tablet) 2

Moderiba 3

Moderiba 1200 Dose Pack

(Tablet)

3

Moderiba 800 Dose Pack (Tablet) 3

Drug Name Drug

Tier

Requirements

& Limits

Olysio (Capsule) 3

Peg intron Redipen (Injection) 3

PegIntron (Injection) 3

Rebetol (200mg Capsule, 40mg/ml

Oral Solution)

3

Ribasphere Ribapak (Tablet) 3

Ribavirin (200mg Capsule, 200mg

Tablet)

1

Sovaldi (Tablet) 2

Technivie (Tablet) 3

Viekira Pak (Tablet Therapy

Pack)

3

Viekira XR (Tablet Extended-

Release 24 Hour)

3

Zepatier (Tablet) 2

Antivirals : Anti-HIV Agents, Integrase Inhibitors (INSTI) Atripla (Tablet) 2

Genvoya (Tablet) 2

Isentress (100mg Packet, 100mg

Tablet Chewable, 25mg Tablet

Chewable, 400mg Tablet)

2

Tivicay (Tablet) 2

Antivirals : Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) Complera (Tablet) 2

Edurant (Tablet) 2

Intelence (Tablet) 2

Nevirapine (200mg Tablet,

50mg/5ml Suspension)

1

Nevirapine ER (Tablet Extended-

Release 24 Hour)

1

Odefsey (Tablet) 2

Rescriptor (Tablet) 2

Stribild (Tablet) 2

Sustiva (200mg Capsule, 50mg

Capsule, 600mg Tablet)

2

Viramune (200mg Tablet) 3

Viramune (50mg/5ml Suspension) 2

Viramune XR (Tablet Extended-

Release 24 Hour)

3

Antivirals : Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) Abacavir (Tablet) 1

Abacavir

Sulfate/Lamivudine/Zidovudine

(Tablet)

1

Abacavir/Lamivudine (Tablet) 1

Combivir (Tablet) 3

Descovy (Tablet) 2

Didanosine (Capsule Delayed-

Release)

1

Emtriva (10mg/ml Oral Solution,

200mg Capsule)

2

Epivir (10mg/ml Oral Solution,


3



29

Drug Name Drug

Tier

Requirements

& Limits

Epzicom (Tablet) 3

Lamivudine (10mg/ml Oral


Tablet)

1

Lamivudine/Zidovudine (Tablet) 1

Retrovir (100mg Capsule,

50mg/5ml Syrup)

3

Retrovir IV Infusion (Solution) 2

Stavudine (Capsule) 1

Triumeq (Tablet) 2

Trizivir (Tablet) 3

Truvada (Tablet) 2

Videx EC (Capsule Delayed-

Release)

3

Videx Pediatric (Oral Solution) 2

Viread (150mg Tablet, 200mg


Tablet, 40mg/gm Powder)

2

Zerit (15mg Capsule, 20mg


Capsule)

3

Zerit (1mg/ml Oral Solution) 2

Ziagen (20mg/ml Oral Solution) 2

Ziagen (300mg Tablet) 3

Zidovudine (100mg Capsule, 300mg

Tablet, 50mg/5ml Syrup)

1

Antivirals : Anti-HIV Agents, Other Fuzeon (Injection) 2

Selzentry (150mg Tablet, 300mg

Tablet)

2

Tybost (Tablet) 2

Antivirals : Anti-HIV Agents, Protease Inhibitors Aptivus (100mg/ml Oral Solution,

250mg Capsule)

2

Crixivan (Capsule) 2

Evotaz (Tablet) 2

Invirase (200mg Capsule, 500mg

Tablet)

2

Kaletra (100mg-25mg Tablet,

200mg-50mg Tablet)

2

Kaletra (400mg-100mg/5ml Oral

Solution)

3

Lexiva (50mg/ml Suspension,

700mg Tablet)

2

Lopinavir/Ritonavir (Solution) 1

Norvir (100mg Capsule, 100mg

Tablet, 80mg/ml Oral Solution)

2

Prezcobix (Tablet) 2

Prezista (100mg/ml Suspension,



2

Reyataz (150mg Capsule, 200mg


Packet)

2

Viracept (Tablet) 2

Antivirals : Anti-influenza Agents Flumadine (Tablet) 3

Drug Name Drug

Tier

Requirements

& Limits

Oseltamivir Phosphate (Capsule) 1

Relenza Diskhaler (Aerosol

Powder)

3

Rimantadine HCl (Tablet) 1

Tamiflu (30mg Capsule, 45mg

Capsule, 75mg Capsule, 6mg/ml

Suspension)

3

Antivirals : Antiherpetic Agents Acyclovir (200mg Capsule,


Tablet, 800mg Tablet, 5%

Ointment)

1

Acyclovir Sodium (Injection) 1

Denavir (Cream) 3

Famciclovir (Tablet) 1

Sitavig (Tablet) 3

Trifluridine (Ophthalmic Solution) 1

Valacyclovir HCl (Tablet) 1

Valtrex (Tablet) 3

Viroptic (Ophthalmic Solution) 3

Zovirax (200mg Capsule,


Tablet, 5% Ointment, 800mg

Tablet)

3

Zovirax (5% Cream) 2

Anxiolytics : Anxiolytics, Other Buspirone HCl (Tablet) 1

Dexmedetomidine HCl (Injection) 1

Meprobamate (Tablet) 1

Precedex (Injection) 3

Anxiolytics : Benzodiazepines Alprazolam (Tablet Immediate-

Release)

1

Alprazolam ER (Tablet Extended-

Release 24 Hour)

1

Alprazolam Intensol (1mg/ml

Concentrate)

3

Alprazolam ODT (Tablet

Dispersible)

1

Ativan (2mg/ml Injection, 4mg/ml

Injection)

3

Chlordiazepoxide HCl (Capsule) 1

Doral (Tablet) 3

Estazolam (Tablet) 1

Flurazepam HCl (Capsule) 1

Halcion (Tablet) 3

Lorazepam (20mg/10ml Injection,


Concentrate)

1

Lorazepam/Dextrose (5%-


3

Oxazepam (Capsule) 1

Quazepam (Tablet) 1

Restoril (Capsule) 3

Temazepam (Capsule) 1

Triazolam (Tablet) 1

Xanax (Tablet) 3



30

Drug Name Drug

Tier

Requirements

& Limits

Xanax XR (Tablet Extended-

Release 24 Hour)

3

Autonomic Drugs : Anticholinergic Agents Atropine Sulfate (2mg/5ml


3

Bevespi Aerosphere (Aerosol) 3

Glycopyrrolate (0.4mg/2ml


3

Seebri Neohaler (Capsule) 3

Symax Duotab (Tablet Extended-

Release)

2

Autonomic Drugs : Parasympathomimetic (Cholinergic) Agents Neostigmine Methylsulfate

(3mg/3ml Solution Prefilled

Syringe)

3

Autonomic Drugs : Skeletal Muscle Relaxants Cisatracurium Besylate

(10mg/5ml Solution Prefilled

Syringe)

3

Mivacron (Injection) 3

Autonomic Drugs : Sympathomimetic (Adrenergic) Agents Ephedrine Sulfate (50mg/ml

Solution)

3

Norepinephrine

Bitartrate/Dextrose (5%-


3

Norepinephrine

Bitartrate/Sodium Chloride

(16mg/250ml-0.9% Solution,

16mg/500ml-0.9% Solution,


3

Norepinephrine/Dextrose

(Solution)

3

Norepinephrine/Sodium Chloride

(0.8mg/50ml-0.9% Solution

Prefilled Syringe)

3

Phenylephrine HCl/Dextrose (5%-

20mg/250ml Solution)

3

Phenylephrine HCl/Sodium

Chloride (0.4mg/10ml-0.9%

Injection, 100mcg/10ml-0.9%







Solution)

3



Solution)

1

Utibron Neohaler (Capsule) 3

Bipolar Agents : Bipolar Agents, Other Olanzapine/Fluoxetine (Capsule) 1

Symbyax (Capsule) 3

Bipolar Agents : Mood Stabilizers

Drug Name Drug

Tier

Requirements

& Limits

Lithium (Oral Solution) 1

Lithium Carbonate (150mg


3

Lithium Carbonate (300mg Capsule,

600mg Capsule, 300mg Tablet)

1

Lithium Carbonate ER (Tablet

Extended-Release)

1

Lithobid (Tablet Extended-

Release)

3

Blood Formation,Coagulation & Thrombosis : Antianemia Drugs Feriva 21/7 (Tablet) 3

Ferro-Plex Hematinic (Tablet) 3

Ferrotrin (Capsule) 3

Focalgin DSS (Tablet) 3

Folitab 500 (Tablet Extended-

Release)

2

Folivane-Plus (Capsule) 3

Fusion Plus (Capsule) 3

Hemocyte Plus (Capsule) 3

Hemocyte-F (Elixir) 3

ICAR-C Plus (Tablet) 3

Integra Plus (210mg-300mcg-7mg-

10mcg-62.5mg-1000mcg-20mg-

62.5mg-25mg-5mg-5mg Capsule)

3

Is 24/6 3

Niferex (Tablet) 3

Nufera (Tablet) 3

Protectiron (Tablet) 3

Renatabs with Iron 3

Triferic (272mg Packet) 3

Blood Formation,Coagulation & Thrombosis : Antithrombotic Agents Heparin Sodium/NaCl 0.45%

(100unit/ml-0.45% Injection)

3

Heparin Sodium/Sodium Chloride

(2000unit/500ml-0.9% Solution)

1

Yosprala (Tablet Delayed-

Release)

3

Blood Formation,Coagulation & Thrombosis : Hematopoietic Agents Mircera (150mcg/0.3ml Injection,

30mcg/0.3ml Injection)

3

Blood Glucose Regulators : Antidiabetic Agents Acarbose (Tablet) 1

Actoplus Met (Tablet) 3

Actos (Tablet) 3

Alogliptin (Tablet) 3

Alogliptin/Metformin HCl

(Tablet)

3

Alogliptin/Pioglitazone (Tablet) 3

Amaryl (Tablet) 3

Avandia (Tablet) 3

Bydureon Pen (Injection) 2

Bydureon Vial (Injection) 2

Byetta (Injection) 2



31

Drug Name Drug

Tier

Requirements

& Limits

Chlorpropamide (Tablet) 1

Cycloset (Tablet) 3

Duetact (Tablet) 3

Farxiga (Tablet) 3

Fortamet (Tablet Extended-

Release 24 Hour)

3

Glimepiride (Tablet) 1

Glipizide (Tablet Immediate-

Release)

1

Glipizide ER (Tablet Extended-

Release 24 Hour)

1

Glipizide/Metformin HCl (Tablet) 1

Glucophage (Tablet) 3

Glucophage XR (Tablet


3

Glucotrol (Tablet) 3

Glucotrol XL (Tablet Extended-

Release 24 Hour)

3

Glucovance (Tablet) 3

Glumetza (Tablet Extended-

Release 24 Hour)

3

Glyburide (1.25mg Tablet, 2.5mg

Tablet, 5mg Tablet)

1

Glyburide Micronized (Tablet) 1

Glyburide/Metformin HCl (Tablet) 1

Glynase (Tablet) 3

Glyset (Tablet) 3

Glyxambi (Tablet) 3

Invokamet (Tablet) 2

Invokamet XR (Tablet Extended-

Release 24 Hour)

2

Invokana (Tablet) 2

Janumet (Tablet) 2

Janumet XR (Tablet Extended-

Release 24 Hour)

2

Januvia (Tablet) 2

Jardiance (Tablet) 2

Jentadueto (Tablet) 2

Kazano (Tablet) 3

Kombiglyze XR (Tablet


3

Metformin HCl (Tablet Immediate-

Release)

1

Metformin HCl ER (Tablet


(Generic Fortamet, Generic

Glucophage XR)

1

Miglitol (Tablet) 1

Nateglinide (Tablet) 1

Nesina (Tablet) 3

Onglyza (Tablet) 3

Oseni (Tablet) 3

Pioglitazone HCl (Tablet) 1

Pioglitazone HCl/Glimepiride

(Tablet)

1

Pioglitazone HCl/Metformin HCl

(Tablet)

1

Drug Name Drug

Tier

Requirements

& Limits

Prandin (Tablet) 3

Precose (Tablet) 3

Repaglinide (Tablet) 1

Repaglinide/Metformin HCl

(Tablet)

1

Riomet (Oral Solution) 3

Starlix (Tablet) 3

SymlinPen 120 (Injection) 3

SymlinPen 60 (Injection) 3

Synjardy (Tablet), Synjardy XR

(Tablet)

2

Tanzeum (Injection) 3

Tolazamide (Tablet) 1

Tolbutamide (Tablet) 1

Tradjenta (Tablet) 2

Tranylcypromine Sulfate (Tablet) 1

Trulicity (Injection) 2

Victoza (Injection) 2

Welchol (3.75gm Packet, 625mg

Tablet)

2

Xigduo XR (Tablet Extended-

Release 24 Hour)

3

Blood Glucose Regulators : Glycemic Agents Dextrose 30% (Injection) 3

Dextrose 70% (70% Injection) 1

GlucaGen HypoKit (Injection) 2

Glucagon Emergency Kit

(Injection)

2

Proglycem (Suspension) 2

Blood Glucose Regulators : Insulins Afrezza (Powder) 3

Apidra (Injection) 3

Apidra SoloStar (Injection) 3

Basaglar KwikPen (Injection) 3

Humalog (Injection) 2

Humalog KwikPen (Injection) 2

Humalog Mix 50/50 (Injection) 2

Humalog Mix 50/50 KwikPen

(Injection)

2

Humalog Mix 75/25 (Injection) 2

Humalog Mix 75/25 KwikPen

(Injection)

2

Humulin 70/30 (Injection) 2

Humulin 70/30 KwikPen

(Injection)

2

Humulin N (Injection) 2

Humulin N KwikPen (Injection) 2

Humulin R (Injection) 2

Humulin R U-500 (Concentrated)

(Injection)

2

Lantus (Injection) 2

Lantus SoloStar (Injection) 2

Levemir (Injection) 2

Levemir FlexTouch (Injection) 2

Novolin 70/30 (Injection) 2

Novolin 70/30 Relion (Injection) 2



32

Drug Name Drug

Tier

Requirements

& Limits

Novolin N (Injection) 2

Novolin N Relion (Injection) 2

Novolin R (Injection) 2

Novolin R Relion (Injection) 2

NovoLog (Injection) 2

NovoLog FlexPen (Injection) 2

NovoLog Mix 70/30 (Injection) 2

NovoLog Mix 70/30 Prefilled

FlexPen (Injection)

2

NovoLog PenFill (Injection) 2

Toujeo SoloStar (Injection) 2

Tresiba FlexTouch (Injection) 3

Blood Products/Modifiers/Volume Expanders : Anticoagulants Activase (Injection) 3

Angiomax (Injection) 3

Argatroban (125mg/125ml-0.9%



3

Argatroban (250mg/2.5ml Injection) 1

Arixtra (Injection) 3

Bivalirudin (Injection) 1

Cathflo Activase (Injection) 3

Coumadin (Tablet) 3

Eliquis (Tablet) 3

Enoxaparin Sodium (100mg/ml


150mg/ml Injection, 30mg/0.3ml




1

Fondaparinux Sodium (Injection) 1

Fragmin (Injection) 3

Heparin Lock Flush (Injection) 1

Heparin Sodium (10000unit/10ml

Injection, 3000unit/3ml Injection,

5000unit/5ml Injection,

10000unit/ml Injection, 1000unit/ml

Injection, 20000unit/ml Injection,

5000unit/0.5ml Injection,

5000unit/ml Injection)

1

Heparin Sodium Lock Flush (Kit) 1

Heparin Sodium/D5W (5%-

100unit/ml Injection, 5%-

50unit/ml Injection)

3

Heparin Sodium/D5W (5%-

40unit/ml Injection, 5%-50unit/ml

Injection)

1

Heparin Sodium/NaCl 0.45%

(50unit/ml-0.45% Injection)

3

Heparin Sodium/NaCl 0.9%

(Injection)

1

Heparin Sodium/Sodium Ch Loride

(Injection)

1


(20unit/20ml-0.9% Injection,

25000unit/250ml-0.45% Injection,

30000unit/L-0.9% Injection,

1

Drug Name Drug

Tier

Requirements

& Limits

4000unit/L-0.9% Injection,

50unit/50ml-0.45% Injection)


0.9% (Injection)

3


0.9% Premix (Injection)

1

Iprivask (Injection) 3

Lovenox (100mg/ml Injection,

120mg/0.8ml Injection, 150mg/ml





3

Pradaxa (Capsule) 2

Savaysa (Tablet) 3

Tnkase (Injection) 3

Warfarin Sodium (Tablet) 1

Xarelto (Tablet) 2

Xarelto Starter Pack (Tablet

Therapy Pack)

2

Blood Products/Modifiers/Volume Expanders : Blood Formation Modifiers Agrylin (Capsule) 3

Anagrelide HCl (Capsule) 1

Aranesp Albumin Free (Injection) 2

Epogen (Injection) 3

Falessa (Tablet) 3

Granix (Injection) 2

Leukine (Injection) 3

Mircera (100mcg/0.3ml Injection,

200mcg/0.3ml Injection,

50mcg/0.3ml Injection,

75mcg/0.3ml Injection)

3

Mozobil (Injection) 2

Neulasta (Injection) 3

Neulasta Onpro Kit (Injection) 3

Neupogen (Injection) 2

Nplate (Injection) 2

Procrit (Injection) 2

Promacta (Tablet) 3

Zarxio (Injection) 2

Blood Products/Modifiers/Volume Expanders Hespan (Injection) 3

Hetastarch 6%/NaCl (Injection) 1

LMD 10% Dextrose 5%

(Injection)

3

LMD 10% Sodium Chloride 0.9%

(Injection)

3

Voluven (Injection) 3

Blood Products/Modifiers/Volume Expanders : Coagulants Advate (Injection) 2

Alphanate/Von Willebrand Factor

Complex/Human (250unit

Injection)

2

Alphanine SD (Injection) 2

Amicar (0.25gm/ml Oral Solution, 3



33

Drug Name Drug

Tier

Requirements

& Limits


Aminocaproic Acid (Injection) 3

Bebulin (Injection) 2

Benefix (Injection) 2

Brilinta (90mg Tablet) 2

Corifact (Injection) 2

Cyklokapron (Injection) 3

Evithrom (External Solution) 3

Feiba (Injection) 2

Gelfilm Op (Film) 3

Helixate FS (Injection) 3

Hemofil M (1700unit Injection) 2

Humate-P (Injection) 2

Injectafer (Injection) 3

Ixinity (Injection) 3

Koate (Solution) 2

Koate-Dvi (Injection) 2

Kogenate FS (Injection) 3

Kogenate FS Bio-Set (Injection) 3

Kovaltry (Injection) 3

Lysteda (Tablet) 3

Monoclate-P (Injection) 2

Mononine (Injection) 2

Novoeight (Injection) 3

Novoseven (Solution) 2

Novoseven RT (Injection) 2

Nuwiq (Injection) 3

Profilnine (Injection) 2

Protamine Sulfate (Injection) 3

Recombinate (Injection) 2

Recothrom (Solution) 3

Riastap (Injection) 2

Thrombin-JMI Diluent (External

Solution)

3

Thrombin-JMI Epistaxis (Kit) 3

Thrombin-JMI Syringe Spray Kit

(Kit)

3

Thrombin-JMI w/Dil Spray Pump

Actuator (Kit)

3

Thrombogen (10000unit Kit,

10000unit Solution, 1000unit

Solution)

3

Tranexamic Acid (1000mg/10ml

Injection, 650mg Tablet)

1

Xyntha (Injection) 3

Xyntha Solofuse (Injection) 3

Blood Products/Modifiers/Volume Expanders : Platelet Modifying Agents Aggrastat (0.9%-12.5mg/250ml

Injection, 0.9%-5mg/100ml

Injection)

3

Aggrenox (Capsule Extended-

Release 12 Hour)

3

Aspirin/Dipyridamole (Capsule


1

Brilinta (60mg Tablet) 2

Drug Name Drug

Tier

Requirements

& Limits

Cilostazol (Tablet) 1

Clopidogrel (Tablet) 1

Dipyridamole (25mg Tablet, 50mg


1

Effient (Tablet) 2

Eptifibatide (Injection) 1

Integrilin (Injection) 3

Plavix (Tablet) 3

Reopro (Injection) 3

Zontivity (Tablet) 3

Cardiovascular Agents : Alpha-adrenergic Agonists Catapres (Tablet) 3

Catapres-TTS-1 (Patch Weekly) 3



Clonidine HCl (0.1mg Tablet,


0.1mg/24hr Patch Weekly,

0.2mg/24hr Patch Weekly,

0.3mg/24hr Patch Weekly)

1

Clorpres (Tablet) 3

Guanfacine HCl (Tablet Immediate-

Release)

1

Methyldopa (Tablet) 1

Methyldopa/Hydrochlorothiazide

(Tablet)

1

Methyldopate HCl (Injection) 3

Midodrine HCl (Tablet) 1

Phenylephrine HCl (10mg/ml

Injection)

1

Phenylephrine HCl/Dextrose (5%-


3


Chloride (0.5mg/5ml-0.9%

Injection, 0.8mg/10ml-0.9%


Injection, 200mcg/5ml-0.9%


Injection)

3

Vazculep (Injection) 3

Cardiovascular Agents : Alpha-adrenergic Blocking Agents Cardura (Tablet) 3

Dibenzyline (Capsule) 3

Doxazosin (Tablet) 1

Doxazosin Mesylate (Tablet) 1

Minipress (Capsule) 3

Phenoxybenzamine HCl (Capsule) 1

Phentolamine Mesylate (Injection) 3

Prazosin HCl (1mg Capsule, 2mg


1

Terazosin HCl (Capsule) 1

Cardiovascular Agents : Angiotensin II Receptor Antagonists Amlodipine Besylate/Valsartan

(Tablet)

1

Amlodipine/Olmesartan Medoxomil 1



34

Drug Name Drug

Tier

Requirements

& Limits

(Tablet)

Amlodipine/Valsartan/Hydrochlorot

hiazide (Tablet)

1

Atacand (Tablet) 3

Atacand HCT (Tablet) 3

Avalide (Tablet) 3

Avapro (Tablet) 3

Azor (Tablet) 3

Benicar (Tablet) 3

Benicar HCT (Tablet) 3

Candesartan Cilexetil (Tablet) 1

Candesartan

Cilexetil/Hydrochlorothiazide

(Tablet)

1

Cozaar (Tablet) 3

Diovan (Tablet) 3

Diovan HCT (Tablet) 3

Edarbi (Tablet) 3

Edarbyclor (Tablet) 3

Entresto (Tablet) 3

Eprosartan Mesylate (Tablet) 1

Exforge (Tablet) 3

Exforge HCT (Tablet) 3

Hyzaar (Tablet) 3

Irbesartan (Tablet) 1

Irbesartan/Hydrochlorothiazide

(Tablet)

1

Losartan Potassium (Tablet) 1

Losartan

Potassium/Hydrochlorothiazide

(Tablet)

1

Micardis (Tablet) 3

Micardis HCT (Tablet) 3

Olmesartan Medoxomil (Tablet) 1

Olmesartan

Medoxomil/Amlodipine/Hydrochlor

othiazide (Tablet)

1

Olmesartan

Medoxomil/Hydrochlorothiazide

(Tablet)

1

Telmisartan (Tablet) 1

Telmisartan/Amlodipine (Tablet) 1

Telmisartan/Hydrochlorothiazide

(Tablet)

1

Tribenzor (Tablet) 3

Twynsta (Tablet) 3

Valsartan (Tablet) 1

Valsartan/Hydrochlorothiazide

(Tablet)

1

Cardiovascular Agents : Angiotensin-converting Enzyme (ACE) Inhibitors Accupril (Tablet) 3

Accuretic (Tablet) 3

Aceon (Tablet) 3

Altace (Capsule) 3

Amlodipine Besylate/Benazepril

HCl (Capsule)

1

Drug Name Drug

Tier

Requirements

& Limits

Benazepril HCl (Tablet) 1

Benazepril

HCl/Hydrochlorothiazide (Tablet)

1

Captopril (Tablet) 1

Captopril/Hydrochlorothiazide

(Tablet)

1

Enalapril Maleate (Tablet) 1

Enalapril

Maleate/Hydrochlorothiazide

(Tablet)

1

Enalaprilat (Injection) 1

Epaned (Oral Solution) 3

Fosinopril Sodium (Tablet) 1

Fosinopril

Sodium/Hydrochlorothiazide

(Tablet)

1

Lisinopril (Tablet) 1

Lisinopril/Hydrochlorothiazide

(Tablet)

1

Lotensin (Tablet) 3

Lotensin HCT (Tablet) 3

Lotrel (Capsule) 3

Mavik (Tablet) 3

Moexipril HCl (Tablet) 1

Moexipril/Hydrochlorothiazide

(Tablet)

1

Perindopril Erbumine (Tablet) 1

Prestalia (Tablet) 3

Prinivil (Tablet) 3

Quinapril HCl (Tablet) 1

Quinapril/Hydrochlorothiazide

(Tablet)

1

Ramipril (Capsule) 1

Tarka (Tablet Extended-Release) 3

Trandolapril (Tablet) 1

Trandolapril/Verapamil HCl ER

(Tablet Extended-Release)

1

Vaseretic (Tablet) 3

Vasotec (Tablet) 3

Zestoretic (Tablet) 3

Zestril (Tablet) 3

Cardiovascular Agents : Antiarrhythmics Adenocard (Injection) 3

Adenosine (12mg/4ml Injection,

6mg/2ml Injection)

1

Amiodarone HCl (100mg Tablet,


50mg/ml Injection)

1

Amiodarone HCl/Dextrose

(Injection)

1

Betapace (120mg Tablet, 160mg


3

Betapace AF (120mg Tablet,


3

Cardizem (Tablet) 3

Corvert (Injection) 3

Diltiazem HCl (Tablet Immediate- 1



35

Drug Name Drug

Tier

Requirements

& Limits

Release)

Diltiazem HCl ER (Capsule


1

Disopyramide Phosphate (Capsule) 1

Dofetilide (Capsule) 1

Flecainide Acetate (Tablet) 1

Ibutilide Fumarate (Injection) 1

Lidocaine HCl (10mg/ml

Injection)

3

Lidocaine HCl (20mg/ml Injection) 1

Lidocaine HCl in D5W (Injection) 1

Mexiletine HCl (Capsule) 1

Multaq (Tablet) 3

Nexterone (Injection) 3

Norpace (Capsule) 3

Norpace CR (Capsule Extended-

Release 12 Hour)

2

Procainamide HCl (100mg/ml

Injection, 500mg/ml Injection)

3

Propafenone HCl (Tablet) 1

Propafenone HCl ER (Capsule


1

Quinidine Gluconate (Injection) 3

Quinidine Gluconate CR (Tablet

Extended-Release)

1

Quinidine Gluconate ER (Tablet

Extended-Release)

1

Quinidine Sulfate (Tablet) 1

Rythmol SR (Capsule Extended-

Release 12 Hour)

3

Sotalol HCl (AF) (Tablet) 1

Sotalol HCl (Injection) 3

Sotalol HCl (Tablet) 1

Tiazac (Capsule Extended-Release

24 Hour)

3

Tikosyn (Capsule) 3

Cardiovascular Agents : Beta-adrenergic Blocking Agents Acebutolol HCl (200mg Capsule,

400mg Capsule)

1

Atenolol (100mg Tablet, 25mg


1

Atenolol/Chlorthalidone (Tablet) 1

Betaxolol HCl (10mg Tablet, 20mg

Tablet)

1

Bisoprolol Fumarate (Tablet) 1

Bisoprolol

Fumarate/Hydrochlorothiazide

(Tablet)

1

Brevibloc (Injection) 3

Bystolic (Tablet) 2

Carvedilol (Tablet) 1

Coreg (Tablet) 3

Coreg CR (Capsule Extended-

Release 24 Hour)

3

Corgard (Tablet) 3

Corzide (Tablet) 3

Drug Name Drug

Tier

Requirements

& Limits

DUTOPROL (Tablet Extended-

Release 24 Hour)

3

Esmolol HCl (Injection) 1

Hemangeol (Oral Solution) 3

Inderal LA (Capsule Extended-

Release 24 Hour)

3

Inderal XL (Capsule Extended-

Release 24 Hour)

3

Innopran XL (Capsule Extended-

Release 24 Hour)

3

Labetalol HCl (100mg Tablet,


5mg/ml Solution)

1

Lopressor (Tablet) 3

Lopressor HCT (Tablet) 3

Metoprolol Succinate ER (Tablet


1

Metoprolol Succinate

ER/Hydrochlorothiazide (Tablet


3

Metoprolol Tartrate (100mg Tablet,

25mg Tablet, 37.5mg Tablet, 50mg


Injection, 5mg/5ml Solution)

1

Metoprolol/Hydrochlorothiazide

(Tablet)

1

Nadolol (20mg Tablet, 40mg Tablet,

80mg Tablet)

1

Nadolol/Bendroflumethiazide

(Tablet)

1

Pindolol (Tablet) 1

Propranolol HCl (Tablet Immediate-

Release, 1mg/ml Injection, Oral

Solution)

1

Propranolol HCl (Tablet) 1

Propranolol HCl ER (Capsule


1

Propranolol/Hydrochlorothiazide

(Tablet)

1

Sotylize (Oral Solution) 3

Tenoretic 100 (Tablet) 3

Tenoretic 50 (Tablet) 3

Tenormin (Tablet) 3

Timolol Maleate (10mg Tablet,


1

Toprol XL (Tablet Extended-

Release 24 Hour)

3

Zebeta (Tablet) 3

Ziac (Tablet) 3

Cardiovascular Agents : Calcium Channel Blocking Agents Adalat CC (30mg Tablet




Hour)

3

Amlodipine Besylate (Tablet) 1

Amlodipine Besylate/Atorvastatin 1



36

Drug Name Drug

Tier

Requirements

& Limits

Calcium (Tablet)

Caduet (Tablet) 3

Calan (Tablet) 3

Calan SR (Tablet Extended-

Release)

3

Cardene IV (20mg/200ml-0.86%

Injection)

3

Cardizem CD (Capsule Extended-

Release 24 Hour)

3

Cardizem LA (Tablet Extended-

Release 24 Hour)

3

Cleviprex (Injection) 3

Diltiazem CD (Capsule Extended-

Release 24 Hour)

1

Diltiazem HCl CD (Capsule


1

Diltiazem HCl ER (Capsule

Extended-Release 24 Hour, Tablet


1

Felodipine ER (Tablet Extended-

Release 24 Hour)

1

Isradipine (Capsule) 1

Nicardipine HCl (2.5mg/ml

Injection, 20mg Capsule, 30mg

Capsule)

1

Nifedipine (10mg Capsule, 20mg

Capsule)

1

Nifedipine ER (Tablet Extended-

Release 24 Hour)

1

Nimodipine (Capsule) 1

Nisoldipine ER (Tablet Extended-

Release 24 Hour)

1

Norvasc (Tablet) 3

Nymalize (Oral Solution) 3

Procardia (Capsule) 3

Procardia XL (Tablet Extended-

Release 24 Hour)

3

Sular (Tablet Extended-Release

24 Hour)

3

Verapamil HCl (Tablet Immediate-

Release, 2.5mg/ml Injection)

1

Verapamil HCl Extended-Release

24 Hour (100mg Capsule, 120mg



Capsule, 120mg Tablet, 180mg


1

Verapamil HCl SR (Capsule


1

Verelan (Capsule Extended-

Release 24 Hour)

3

Verelan PM (Capsule Extended-

Release 24 Hour)

3

Cardiovascular Agents Levophed (Injection) 3

Norepinephrine Bitartrate (Injection) 1

Norepinephrine

Bitartrate/Dextrose (5%-

4mg/250ml Injection, 5%-

3

Drug Name Drug

Tier

Requirements

& Limits


4mg/250ml Solution)

Norepinephrine

Bitartrate/Sodium Chloride

(0.08mg/10ml-0.9% Injection)

3

Norepinephrine/Sodium Chloride

(0.16mg/10ml-0.9% Injection,

8mg/250ml-0.9% Solution)

3

Cardiovascular Agents : Cardiovascular Agents, Other Asclera (Injection) 3

Corlanor (Tablet) 3

Demser (Capsule) 3

Digoxin (0.05mg/ml Oral Solution,

0.25mg/ml Injection, 125mcg

Tablet, 250mcg Tablet)

1

Dobutamine HCl (Injection) 1

Dobutamine HCl/D5W (Injection) 1

Dopamine HCl (160mg/ml

Injection)

3

Dopamine HCl (40mg/ml Injection,

80mg/ml Injection)

1

Dopamine/D5W (Injection) 1

Ethamolin (Injection) 3

Lanoxin (0.25mg/ml Injection,

125mcg Tablet, 187.5mcg Tablet,

250mcg Tablet, 62.5mcg Tablet)

2

Lanoxin Pediatric (Injection) 3

Mannitol (Injection) 1

Milrinone in Dextrose (5%-



1

Milrinone Lactate (Injection) 1

Natrecor (Injection) 3

Northera (Capsule) 3

Osmitrol Viaflex (10% Injection,

5% Injection)

3

Pentoxifylline ER (Tablet Extended-

Release)

1

Praluent (Injection) 2

Ranexa (Tablet Extended-Release

12 Hour)

2

Repatha (Injection) 3

Repatha Pushtronex System

(Injection)

3

Repatha SureClick (Injection) 3

Sotradecol (Injection) 3

Tekturna (Tablet) 2

Varithena (Injection) 3

Vecamyl (Tablet) 3

Cardiovascular Agents : Diuretics, Carbonic Anhydrase Inhibitors Acetazolamide (Tablet Immediate-

Release)

1

Dorzolamide HCl (Ophthalmic

Solution)

1

Methazolamide (Tablet) 1



37

Drug Name Drug

Tier

Requirements

& Limits

Neptazane (Tablet) 3

Trusopt (Ophthalmic Solution) 3

Cardiovascular Agents : Diuretics, Loop Bumetanide (0.25mg/ml Injection,

0.5mg Tablet, 1mg Tablet, 2mg

Tablet)

1

Bumex (Tablet) 3

Demadex (Tablet) 3

Edecrin (Tablet) 3

Ethacrynate Sodium (Injection) 1

Ethacrynic Acid (Tablet) 1

Furosemide (10mg/ml Injection,

10mg/ml Oral Solution, 8mg/ml

Oral Solution, 20mg Tablet, 40mg


1

Lasix (Tablet) 3

Sodium Edecrin (Injection) 3

Torsemide (Tablet) 1

Cardiovascular Agents : Diuretics, Potassium-sparing Aldactazide (Tablet) 3

Aldactone (Tablet) 3

Amiloride HCl (5mg Tablet) 1

Amiloride/Hydrochlorothiazide

(Tablet)

1

Dyazide (Capsule) 3

Dyrenium (Capsule) 3

Eplerenone (Tablet) 1

Inspra (Tablet) 3

Maxzide (Tablet) 3

Spironolactone (100mg Tablet,


1

Spironolactone/Hydrochlorothiazide

(Tablet)

1

Triamterene/Hydrochlorothiazide

(25mg-37.5mg Tablet, 50mg-75mg

Tablet, 37.5mg-25mg Capsule,

50mg-25mg Capsule)

1

Cardiovascular Agents : Diuretics, Thiazide Chlorothiazide (Tablet) 1

Chlorothiazide Sodium (Injection) 1

Chlorthalidone (100mg Tablet) 2

Chlorthalidone (25mg Tablet, 50mg

Tablet)

1

Diuril (Suspension) 3

Hydrochlorothiazide (12.5mg

Capsule, 12.5mg Tablet, 25mg


1

Indapamide (Tablet) 1

Methyclothiazide (5mg Tablet) 1

Metolazone (Tablet) 1

Microzide (Capsule) 3

Sodium Diuril (Injection) 3

Tekturna HCT (Tablet) 2

Cardiovascular Agents : Dyslipidemics, Fibric Acid Derivatives Antara (Capsule) 3

Drug Name Drug

Tier

Requirements

& Limits

Fenofibrate (120mg Tablet, 145mg





1

Fenofibrate Micronized (Capsule) 1

Fenofibric Acid (Tablet) 1

Fenofibric Acid DR (Capsule

Delayed-Release)

1

Fenoglide (Tablet) 3

Fibricor (Tablet) 2

Gemfibrozil (600mg Tablet) 1

Lipofen (Capsule) 2

Lofibra (134mg Capsule, 200mg



3

Lopid (Tablet) 3

Tricor (Tablet) 3

Triglide (Tablet) 3

Trilipix (Capsule Delayed-

Release)

3

Cardiovascular Agents : Dyslipidemics, HMG CoA Reductase Inhibitors Altoprev (Tablet Extended-

Release 24 Hour)

3

Atorvastatin Calcium (Tablet) 1

Crestor (Tablet) 3

Fluvastatin (Capsule) 1

Fluvastatin Sodium ER (Tablet


1

Lescol XL (Tablet Extended-

Release 24 Hour)

3

Lipitor (Tablet) 3

Livalo (Tablet) 3

Lovastatin (Tablet) 1

Mevacor (Tablet) 3

Pravachol (Tablet) 3

Pravastatin Sodium (Tablet) 1

Rosuvastatin Calcium (Tablet) 1

Simvastatin (Tablet) 1

Zocor (Tablet) 3

Cardiovascular Agents : Dyslipidemics, Other Cholestyramine (Powder) 1

Cholestyramine Light (Powder) 1

Colestid (1gm Tablet, 5gm

Granules, 5gm Packet)

3

Colestid Flavored (5gm Granules,

5gm/7.5gm Packet)

3

Colestipol HCl (1gm Tablet, 5gm

Packet)

1

Ezetimibe (Tablet) 1

Juxtapid (Capsule) 3

Kynamro (Solution Prefilled

Syringe)

3

Lovaza (Capsule) 3

Niacin ER (Tablet Extended-

Release)

1



38

Drug Name Drug

Tier

Requirements

& Limits

Niacor (Tablet) 2

Niaspan (Tablet Extended-

Release)

3

Omega-3-Acid Ethyl Esters

(Capsule)

1

Questran (Packet) 3

Questran Light (Powder) 3

Vascepa (Capsule) 2

Vytorin (Tablet) 2

Zetia (Tablet) 3

Cardiovascular Agents : Vasodilators, Direct-acting Arterial Corlopam (Injection) 3

Hydralazine HCl (100mg Tablet,


Tablet, 20mg/ml Injection)

1

Minoxidil (Tablet) 1

Cardiovascular Agents : Vasodilators, Direct-acting Arterial/Venous BiDil (Tablet) 3

Dilatrate SR (Capsule Extended-

Release)

3

Isordil Titradose (Tablet) 3

Isosorbide Dinitrate (Tablet

Immediate-Release)

1

Isosorbide Dinitrate ER (Tablet

Extended-Release)

1

Isosorbide Mononitrate (Tablet

Immediate-Release)

1

Isosorbide Mononitrate ER (Tablet


1

Nitro-Bid (Ointment) 3

Nitro-Dur (Patch 24 Hour) 3

Nitroglycerin (0.3mg Tablet

Sublingual, 0.4mg Tablet

Sublingual, 0.6mg Tablet

Sublingual)

1

Nitroglycerin (5mg/ml Injection) 3

Nitroglycerin ER (2.5mg Capsule

Extended-Release, 6.5mg Capsule

Extended-Release, 9mg Capsule

Extended-Release)

1

Nitroglycerin in 5% Dextrose

(Injection)

1

Nitroglycerin in Dextrose 5% (5%-

100mcg/ml Injection)

1

Nitroglycerin in Dextrose 5%

(5%-100mcg/ml Injection, 5%-

200mcg/ml Injection, 5%-

400mcg/ml Injection)

3

Nitroglycerin Lingual

(0.4mg/sprayTranslingual Solution,

400mcg/spray Aerosol Solution)

1

Nitroglycerin Transdermal (Patch 24

Hour)

1

Nitrolingual Pumpspray

(Translingual Solution)

3

NitroMist (Aerosol Solution) 3

Drug Name Drug

Tier

Requirements

& Limits

Nitropress (Injection) 3

Nitrostat (Tablet Sublingual) 3

Rectiv (Ointment) 3

Sodium Nitroprusside (Injection) 1

Cardiovascular Drugs : beta-Adrenergic Blocking Agents Byvalson (Tablet) 3

Metoprolol Tartrate (5mg/5ml


3

Cardiovascular Drugs : Calcium-Channel Blocking Agents Cardene IV (40mg/200ml-0.83%

Injection)

3

Diltiazem HCl/Dextrose (5%-

100mg/100ml Solution, 5%-


3

Diltiazem HCl/Sodium Chloride

(125mg/125ml-0.9% Solution)

3

Nicardipine HCl/Sodium Chloride

(Solution)

3

Cardiovascular Drugs : Cardiac Drugs Adenosine (60mg/20ml Injection,

90mg/30ml Solution Prefilled

Syringe)

3

Cardiovascular Drugs : Vasodilating Agents Gonitro (Packet) 3

Central Nervous System Agents : Analgesics and Antipyretics Arymo ER (Tablet Extended-

Release Abuse-Deterrent)

3

Fentanyl Citrate/Sodium Chloride

(1.25mg/250ml-0.9% Injection,

2.5mg/250ml-0.9% Injection)

3


Chloride (10mg/25ml-0.9% Solution

Prefilled Syringe, 1mg/5ml-0.9%

Solution Prefilled Syringe,

3mg/30ml-0.9% Solution Prefilled

Syringe, 15mg/50ml-0.9% Injection)

1


Chloride (Prefilled Syringe,

Injection Solution)

3


Chloride (Solution Prefilled

Syringe)

3

Ilaris (150mg/ml Solution) 3

Meperidine HCl/Sodium Chloride


3

Morphine Sulfate/Dextrose

(Solution)

3

Morphine Sulfate/Sodium







3

Tivorbex (Capsule) 3



39

Drug Name Drug

Tier

Requirements

& Limits

Vivlodex (Capsule) 3

Zubsolv (0.7mg-0.18mg Tablet

Sublingual)

2

Central Nervous System Agents : Anorexigenic Agents and Respiratory and CNS Stimulants Vyvanse (10mg Tablet Chewable,

20mg Tablet Chewable, 30mg

Tablet Chewable, 40mg Tablet

Chewable, 50mg Tablet

Chewable, 60mg Tablet

Chewable)

2

Central Nervous System Agents : Anticonvulsants Lamictal XR (Kit) 3

Central Nervous System Agents : Anxiolytics, Sedatives, and Hypnotics Lorazepam/Sodium Chloride


3

Central Nervous System Agents : Attention Deficit Hyperactivity Disorder Agents, Amphetamines Adderall (Tablet) 3

Adderall XR (Capsule Extended-

Release 24 Hour)

3

Adzenys XR-ODT (Tablet

Extended-Release Dispersible)

3

Amphetamine/Dextroamphetamine

(1.875mg-1.875mg-1.875mg-

1.875mg Tablet, 10mg Tablet,



10mg Capsule ER, 15mg Capsule

ER, 20mg Capsule ER, 25mg

Capsule ER, 30mg Capsule ER,

5mg Capsule ER)

1

Desoxyn (Tablet) 3

Dexedrine (10mg Capsule


Capsule Extended-Release 24

Hour, 5mg Capsule Extended-

Release 24 Hour)

3

Dextroamphetamine Sulfate (10mg


Solution)

1

Dextroamphetamine Sulfate ER

(Capsule Extended-Release 24

Hour)

1

Evekeo (Tablet) 3

Methamphetamine HCl (Tablet) 1

ProCentra (Oral Solution) 3

Vyvanse (10mg Capsule, 20mg




2

Zenzedi (15mg Tablet, 2.5mg


7.5mg Tablet)

3

Central Nervous System Agents : Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines Clonidine HCl ER (Tablet 1

Drug Name Drug

Tier

Requirements

& Limits


Concerta (Tablet Extended-

Release)

3

Daytrana (Patch) 3

Dexmethylphenidate HCl (Tablet

Immediate-Release)

1

Dexmethylphenidate HCl Capsule

Extended-Release 24 Hour (10mg,

15mg, 20mg, 30mg, 40mg, 5mg,

25mg, 35mg)

1

Focalin (Tablet) 3

Focalin XR (Capsule Extended-

Release 24 Hour)

3

Guanfacine ER (Tablet Extended-

Release 24 Hour)

1

Intuniv (Tablet Extended-Release

24 Hour)

3

Kapvay (Tablet Extended-Release

12 Hour)

3

Metadate CD (Capsule Extended-

Release)

3

Methylin (10mg Tablet Chewable,

2.5mg Tablet Chewable, 5mg

Tablet Chewable, 10mg/5ml Oral

Solution, 5mg/5ml Oral Solution)

3

Methylphenidate HCl (Tablet

Immediate-Release, Tablet

Chewable, Oral Solution)

1

Methylphenidate HCl CD (Capsule

Extended-Release)

1

Methylphenidate HCl ER (Tablet,

Capsule)

1

Methylphenidate HCl SR (Tablet

Extended-Release)

1

Quillivant XR (Suspension) 3

Ritalin (Tablet) 3

Ritalin LA (Capsule Extended-

Release 24 Hour)

3

Strattera (Capsule) 2

Central Nervous System Agents Dopram (Injection) 3

Central Nervous System Agents : Central Nervous System Agents, Misc Addyi (Tablet) 3

Namzaric (10mg-Capsule


Therapy Pack)

2

Central Nervous System Agents : Central Nervous System, Other Cafcit (Injection) 3

Caffeine Citrate (20mg/ml Oral

Solution, 60mg/3ml Injection)

1

Flumazenil (Injection) 1

Hetlioz (Capsule) 3

Horizant (Tablet Extended-

Release)

3

Levacet (Tablet) 3



40

Drug Name Drug

Tier

Requirements

& Limits

Namzaric (10mg-14mg Capsule

Extended-Release 24 Hour, 10mg-

28mg Capsule Extended-Release

24 Hour)

2

Nuedexta (Capsule) 3

Rilutek (Tablet) 3

Riluzole (Tablet) 1

Tetrabenazine (Tablet) 1

Xenazine (Tablet) 3

Central Nervous System Agents : Fibromyalgia Agents Savella (Tablet) 3

Savella Titration Pack 3

Central Nervous System Agents : Multiple Sclerosis Agents Ampyra (Tablet Extended-Release

12 Hour)

2

Aubagio (Tablet) 3

Avonex (Injection) 2

Avonex Pen (Injection) 2

Betaseron (Injection) 2

Copaxone (Injection) 2

Extavia (Injection) 3

Gilenya (Capsule) 3

Glatopa (Injection) 1

Rebif (Injection) 3

Rebif Rebidose Titration Pack

(Injection)

3

Rebif Titration Pack (Injection) 3

Tecfidera (Capsule Delayed-

Release)

2

Tecfidera Starter Pack 2

Central Nervous System Agents : Opiate Antagonists Evzio (2mg/0.4ml Injection) 3

Dental and Oral Agents Aquoral (Solution) 3

Caphosol (Solution) 3

Cevimeline HCl (Capsule) 1

Chlorhexidine Gluconate (0.12%

Solution)

1

Chlorhexidine Gluconate (20%

Solution)

3

Evoxac (Capsule) 3

Gel-Kam Oral Care Rinse

(Concentrate)

3

Kepivance (Injection) 2

Neutrasal (Packet) 3

Numoisyn (0-0-0-0-0-0-0-0 Liquid,

0-0-0-0-0-0-0-0-0.3gm Lozenge)

3

Peridex (Solution) 3

Pilocarpine HCl (5mg Tablet, 7.5mg

Tablet)

1

Prevident 5000 Enamel Protect

(Paste)

2

Q-Care Q2 Oral

Cleansing/Suctioning System/Chg

3

Drug Name Drug

Tier

Requirements

& Limits

Oral Rinse (Kit)

Q-Care Q4 Oral

Cleansing/Suctioning System/Chg

Oral Rinse (Kit)

3

Salagen (Tablet) 3

Salivamax (Packet) 3

Salivate Rx (Packet) 3

Triamcinolone Acetonide (0.1%

Paste)

1

Triamcinolone in Orabase (Paste) 1

Dermatological Agents Absorica (10mg Capsule, 20mg


Capsule)

3

Acanya (Gel) 3

Acitretin (Capsule) 1

Aclovate (Cream) 3

Aczone (Gel) 3

Adapalene (0.1% Cream, 0.1% Gel,

0.3% Gel)

1

Adapalene (0.1% Lotion) 3

Adapalene Pump (Gel) 1

Ala Scalp (Lotion) 3

Alclometasone Dipropionate (0.05%

Cream, 0.05% Ointment)

1

Aldara (Cream) 3

Alevicyn Antipruritic SG (Liquid) 3

Amcinonide (0.1% Cream, 0.1%

Lotion, 0.1% Ointment)

1

Ammonium Lactate (12% Cream,

12% Lotion)

1

Analpram-HC (2.5%-1% Lotion) 3

Anusol-HC (Cream) 3

Artiss (External Solution) 3

Atopiclair (Cream) 3

Atralin (Gel) 3

Augmented Betamethasone

Dipropionate (0.05% Cream, 0.05%

Gel, 0.05% Lotion, 0.05%

Ointment)

1

Avenova (Solution) 3

Avenova/Neutrox (Solution) 3

Azelex (Cream) 3

Benzac AC Wash (Liquid) 3

BenzaClin (Gel) 3

BenzaClin with Pump (Gel) 3

Benzamycin (Gel) 3

Benzefoam (Foam) 3

Benzefoam Ultra (Foam) 3

Benziq (Gel) 3

Benziq LS (Gel) 3

Benziq Wash (Liquid) 3

Benzoin Compound Tincture (0

Tincture)

1

Benzoyl Peroxide (9.8% Foam) 1

Betamethasone Dipropionate

(0.05% Cream, 0.05% Lotion,

1



41

Drug Name Drug

Tier

Requirements

& Limits

0.05% Ointment)

Betamethasone Valerate (0.1%

Cream, 0.1% Lotion, 0.1%

Ointment, 0.12% Foam)

1

Calcipotriene (0.005% Cream,

0.005% External Solution, 0.005%

Ointment)

1

Calcipotriene/Betamethasone

Dipropionate (Ointment)

1

Calcitriol (3mcg/gm Ointment) 1

Capex (Shampoo) 3

Carac (Cream) 3

Cleocin-T (1% External Solution,

1% Gel, 1% Lotion, 1% Swab)

3

Clindacin ETZ (Kit) 3

Clindacin PAC (Kit) 3

Clindagel (Gel) 2

Clindamycin Phosphate (1%

External Solution, 1% Foam, 1%

Gel, 1% Lotion, 1% Swab)

1

Clindamycin Phosphate/Tretinoin

(Gel)

1

Clindamycin/Benzoyl Peroxide

(Gel)

1

Clobetasol Propionate (0.05%

Cream, 0.05% External Solution,

0.05% Foam, 0.05% Gel, 0.05%

Liquid, 0.05% Lotion, 0.05%

Ointment, 0.05% Shampoo)

1

Clobex (0.05% Liquid, 0.05%

Lotion, 0.05% Shampoo)

3

Clocortolone Pivalate (Cream) 3

Clodan Kit (Kit) 3

Cloderm (Cream) 3

Cloderm Pump (Cream) 3

Coal Tar (External Solution) 3

Condylox (0.5% External

Solution, 0.5% Gel)

3

Copasil (Gel) 3

Cordran (0.05% Cream, 0.05%

Lotion, 0.05% Ointment,

4mcg/SQCM Tape)

3

Cortisporin (0.5%-0.5% Cream,

1%-0.5% Ointment)

3

Cosentyx (Injection) 3

Cosentyx Sensoready Pen

(Injection)

3

DermacinRx Clorhexacin (Kit) 3

DermacinRx Surgical Pharmapak

(Kit)

3

Dermasorb HC (Kit) 3

Dermasorb TA (Kit) 3

Dermatop (0.1% Cream, 0.1%

Ointment)

3

DermaweRx Surgical Plus Pak

(Kit)

3

DermOtic (Oil) 3

Desonate (Gel) 3

Drug Name Drug

Tier

Requirements

& Limits

Desonide (0.05% Cream, 0.05%


1

DesOwen (0.05% Cream, 0.05%

Lotion)

3

Desoximetasone (0.05% Cream,

0.25% Cream, 0.05% Gel, 0.05%

Ointment, 0.25% Ointment)

1

Diclofenac Sodium (1% Gel, 1.5%

Transdermal Solution)

1

Differin (0.1% Cream, 0.1% Gel,

0.3% Gel, 0.1% Lotion)

3

Diflorasone Diacetate (0.05%


1

Diprolene (0.05% Lotion, 0.05%

Ointment)

3

Diprolene AF (Cream) 3

Dovonex (Cream) 3

Doxepin HCl (Cream) 1

Doxycycline (40mg Capsule

Delayed-Release)

1

Dritho-Creme HP (Cream) 2

Drysol (External Solution) 2

Duac (Gel) 3

Efudex (Cream) 3

Eletone (Cream) 3

Eletone Twinpack (Cream) 3

Elidel (Cream) 2

Elocon (0.1% Cream, 0.1%


3

Epiduo (Gel) 3

Epiduo Forte (Gel) 3

Episone Cre (Cream) 1

Erygel (Gel) 3

Erythromycin (2% External

Solution, 2% Gel, 2% Pad)

1

Erythromycin/Benzoyl Peroxide

(Gel)

1

Eucrisa (Ointment) 3

Evicel (Kit) 3

Evoclin (Foam) 3

Excilon AMD Antimicrobialdrain

Sponges 4"x4" 6 Ply

3

Fabior (Foam) 3

Finacea (15% Foam, 15% Gel) 3

Fluocinolone Acetonide (Cream,

External Solution, Oil, Ointment)

1

Fluocinolone Acetonide Ear Drops

(Oil)

1

Fluocinonide (Cream, Cream,

External Solution, Gel, Ointment)

1

Fluocinonide-E (Cream) 1

Fluoroplex (Cream) 3

Fluorouracil (External Solution,

External Solution)

1

Flurandrenolide (Cream, Lotion,

Ointment)

1

Fluticasone Propionate (Ointment,

Cream, Lotion)

1



42

Drug Name Drug

Tier

Requirements

& Limits

Halobetasol Propionate (0.05%


1

Halog (0.1% Cream, 0.1%

Ointment)

3

Hydrocortisone (1% Cream, 2.5%

Cream, 1% Ointment, 2.5%

Ointment, 2.5% Cream, 2.5%

Lotion)

1

Hydrocortisone Butyrate (0.1%

Cream, 0.1% External Solution,

0.1% Ointment)

1

Hydrocortisone in Absorbase

(Ointment)

1

Hydrocortisone Valerate (0.2%


1

Imiquimod (Cream) 1

Kenalog (Aerosol Solution) 3

Keralyt (6% Gel) 3

Klaron (Lotion) 3

Lac-Hydrin (12% Cream, 12%

Lotion)

3

Lactic Acid (10% Lotion) 1

Lactic Acid E (10%-3500unit/30gm

Cream)

1

Lactic Acid with Vitamin E (Cream) 1

Latrix XM (Emulsion) 3

Levulan Kerastick (External

Solution)

3

Lidocaine HCl-Hydrocortisone

Acetate with Aloe (0.55%-2.8%

Gel)

3

Lidocaine HCl/Hydrocortisone

Acetate (0.5%-3% Cream, 0.5%-3%

Kit, 1%-3% Kit, 2%-2% Kit, 2.5%-

3% Kit)

1

Locoid (0.1% Cream, 0.1%

External Solution, 0.1% Lotion,

0.1% Ointment)

3

Locoid Lipocream (Cream) 3

Luxiq (Foam) 3

MB Hydrogel (Kit) 3

Medrox-Rx (Ointment) 3

Methoxsalen (10mg Capsule) 1

Mirvaso (Gel) 2

Mometasone Furoate (0.1% External

Solution)

1

Neo-Synalar (Cream) 3

Neo-Synalar Kit (Kit) 3

Neosalus (0-0 Cream, 0-0 Lotion,

0-0-0 Foam)

3

Neosalus CP (Cream) 3

Neuac Kit (Kit) 3

Nivatopic Plus (Cream) 3

Nusrugepak Surgical

Prep/Carepak (Kit)

3

Nuvail (External Solution) 3

Olux (Foam) 3

Olux-E (Foam) 3

Drug Name Drug

Tier

Requirements

& Limits

Onexton (Gel) 3

Oracea (Capsule Delayed-Release) 3

Orafate (Paste) 3

Ovace Plus Wash (10% Liquid) 3

Oxsoralen Ultra (Capsule) 3

Pandel (Cream) 3

Picato (Gel) 3

Podofilox (External Solution) 1

PR Cream (Kit) 3

Prednicarbate (0.1% Cream, 0.1%

Ointment)

1

Presera (Foam) 3

Proctofoam HC (Foam) 2

Promiseb (Cream) 3

Promiseb Complete (Kit) 3

Prothelial (Paste) 3

Protopic (Ointment) 3

Pruclair (Cream) 3

PRUDOXIN (Cream) 3

Prumyx (Cream) 3

Pyrogallic Acid (Ointment) 3

Qutenza (Kit) 3

Recedo (Gel) 3

Recura (Cream) 3

Retin-A (0.01% Gel, 0.025% Gel,

0.025% Cream, 0.05% Cream,

0.1% Cream)

3

Retin-A Micro (Gel) 3

Retin-A Micro Pump (0.04% Gel,

0.1% Gel)

3

Retin-A Micro Pump (0.08% Gel) 2

Riax (Foam) 3

Salicylic Acid (6% Cream, 6% Gel,

6% Lotion)

1

Salicylic Acid Cream (Kit) 1

Salicylic Acid Lotion (Kit) 1

Salvax Duo Plus (Kit) 3

Santyl (Ointment) 3

Scalacort DK (Kit) 3

Sebuderm (Gel) 3

Selenium Sulfide (Lotion) 1

Sernivo (Emulsion) 3

Sodium Sulfacetamide/Sulfur (10%-

4% Pad)

1

Sodium Sulfacetamide/Sulfur

(10%-5% Lotion)

2

Sodium Sulfacetamide/Sulfur

Cleanser (9.8%-4.8% Liquid)

1

Solaraze (Gel) 3

Soolantra (Cream) 2

Soriatane (Capsule) 3

Sorilux (Foam) 3

Stelara (45mg/0.5ml Injection,

90mg/ml Injection)

2

Sulfacetamide Sodium (10% Lotion,

10% Suspension)

1

Sulfacetamide Sodium/Sulfur 1



43

Drug Name Drug

Tier

Requirements

& Limits

Sulfoam (Shampoo) 3

Synalar (0.01% External Solution,

0.025% Cream, 0.025%

Ointment)

3

Synalar TS (Kit) 3

Synerderm (Emulsion) 3

Taclonex (0.064%-0.005%

Ointment, 0.064%-0.005%

Suspension)

3

Tacrolimus (0.03% Ointment, 0.1%

Ointment)

1

Taltz (Injection) 3

Tazorac (0.05% Cream, 0.1%

Cream, 0.05% Gel, 0.1% Gel)

3

Telfa AMD Antimicrobial Island

Dressing 4"x5"

3

Telfa AMD Antimicrobial Island

Dressing4"x8"

3

Telfa AMD Antimicrobial Non-

Adherent Pad 3"x8"

3

Temovate (0.05% Cream, 0.05%

External Solution, 0.05% Gel,

0.05% Ointment)

3

Temovate E (Cream) 3

Tetrix (Cream) 3

Texacort (External Solution) 3

Tisseel (External Solution) 3

Tisseel VH (Kit) 3

Tolak (Cream) 3

Topicort (0.05% Cream) 2

Topicort (0.05% Gel, 0.05%

Ointment, 0.25% Ointment,

0.25% Cream, 0.25% Liquid)

3

Tretin-X (Cream) 2

Tretinoin (0.01% Gel, 0.05% Gel,

0.025% Cream, 0.05% Cream, 0.1%

Cream, 0.025% Gel)

1

Tretinoin Microsphere (Gel) 1

Tretinoin Microsphere Pump (Gel) 1

Triamcinolone Acetonide (0.025%

Cream, 0.1% Cream, 0.5% Cream,

0.025% Lotion, 0.1% Lotion,

0.025% Ointment, 0.1% Ointment,

0.5% Ointment, 0.147mg/gm

Aerosol Solution)

1

Trianex (Ointment) 3

Tridesilon (Cream) 3

Ultravate (0.05% Cream, 0.05%


3

Uramaxin (45% Gel) 3

Urea (40% Cream, 45% Lotion) 1

Urea Topical (Suspension) 1

Uvadex (Injection) 3

Valchlor (Gel) 3

Vanos (Cream) 3

Vectical (Ointment) 3

Veltin (Gel) 3

Verdeso (Foam) 3

Drug Name Drug

Tier

Requirements

& Limits

Veregen (Ointment) 3

Voltaren (Gel) 3

Westcort (Ointment) 3

Xeralux (Cream) 3

Zacare 4% Kit (Kit) 3

Zacare 8% Kit (Kit) 3

Ziana (Gel) 3

Zonalon (Cream) 3

Zyclara (Cream) 3

Zyclara Pump (Cream) 3

Devices Insulin Syringes, Needles 2

Tena Cls+ Md Brf 1

Vanishpoint Insulin

Syringe/1ml/29g X 5/16"

2

Electrolytic, Caloric, and Water Balance : Replacement Preparations Calcium Gluconate/Dextrose

(1gm/100ml-5% Injection,

2gm/100ml-5% Injection)

3

Calcium Gluconate/Sodium


Solution, 3gm/100ml-0.9%

Injection)

3

Klor-Con/25 (Packet) 2


1gm/50ml Solution, 5%-

2gm/100ml Solution)

3

Magnesium Sulfate/Dextrose (0-



4gm/100ml Solution)

3

Magnesium Sulfate/Lactated

Ringers

3

Magnesium Sulfate/Lactated

Ringers (100mg/500ml-

20gm/500ml-150mg/500ml-

3gm/500ml-1.55gm/500ml Solution)

1






Solution)

3



Solution)

1

Potassium Chloride (0 Granules) 2

Sodium Phosphate/Sodium

Chloride (0.9%-7.5MMOL/100ml

Solution)

3

Electrolytic, Caloric, and Water Balance : Uricosuric Agents Zurampic (Tablet) 3

Enzyme Replacement/Modifiers Adagen (Injection) 2

Aldurazyme (Injection) 2



44

Drug Name Drug

Tier

Requirements

& Limits

Buphenyl (3gm/tsp Powder,

500mg Tablet)

3

Cerdelga (Capsule) 3

Cerezyme (Injection) 2

Creon (Capsule Delayed-Release) 2

Cystadane (Powder) 3

Cystagon (Capsule) 3

Elaprase (Injection) 2

Elelyso (Injection) 3

Fabrazyme (Injection) 2

Kanuma (Injection) 3

Kuvan (100mg Packet, 500mg

Packet, 100mg Tablet Soluble)

2

Lumizyme (Injection) 2

Naglazyme (Injection) 2

Orfadin (10mg Capsule, 20mg


Capsule, 4mg/ml Suspension)

3

Pancreaze (24600unit-4200unit-

14200unit Capsule Delayed-

Release, 61500unit-10500unit-






Release)

3

Pertzye (Capsule Delayed-

Release)

3

RAVICTI (Liquid) 3

Sodium Phenylbutyrate (Powder) 1

Strensiq (Injection) 3

Sucraid (Oral Solution) 3

Vimizim (Injection) 3

Viokace (Tablet) 3

VPRIV (Injection) 3

Xiaflex (Injection) 2

Zavesca (Capsule) 3

Zenpep (Capsule Delayed-

Release)

2

Eye, Ear, Nose & Throat Preparations : Anti-infectives Cefuroxime Sodium/Sodium

Chloride (Solution)

3

Eye, Ear, Nose & Throat Preparations : Anti-inflammatory Agents Xiidra (Ophthalmic Solution) 2

Eye, Ear, Nose & Throat Preparations : EENT Drugs, Miscellaneous Lucentis (0.5mg/0.05ml Solution

Prefilled Syringe)

3

Gastrointestinal Agents : Antispasmodics, Gastrointestinal Atropen (Injection) 3

Atropine Sulfate (0.05mg/ml

Injection, 0.8mg/2ml Injection)

3

Drug Name Drug

Tier

Requirements

& Limits

Atropine Sulfate (0.1mg/ml

Injection, 0.4mg/ml Injection,

1mg/ml Injection, 1mg/2.5ml


1

Bentyl (10mg Capsule, 10mg/ml

Injection)

3

Chlordiazepoxide HCl/Clidinium

Bromide (5mg-2.5mg Capsule)

1

Cuvposa (Oral Solution) 3

Dicyclomine HCl (10mg Capsule,

10mg/5ml Oral Solution, 10mg/ml


1

Entyvio (Injection) 3

Glycopyrrolate (0.4mg/2ml


4mg/20ml Injection, 1mg Tablet,

2mg Tablet)

1

Hyoscyamine Sulfate (0.125mg

Tablet Dispersible)

1

Librax (Capsule) 3

Methscopolamine Bromide (Tablet) 1

Pamine (Tablet) 3

Pamine Forte (Tablet) 3

Pamine FQ (Kit) 3

Propantheline Bromide (15mg

Tablet)

1

Robinul (0.2mg/ml Injection, 1mg

Tablet)

3

Robinul Forte (Tablet) 3

Gastrointestinal Agents Trulance (Tablet) 3

Gastrointestinal Agents : Gastrointestinal Agents, Other Actigall (Capsule) 3

Calcium Disodium Versenate

(Injection)

3

Cascara Sagrada (1gm/ml Fluid

Extract)

3

Chenodal (Tablet) 3

Cholbam (Capsule) 3

Cromolyn Sodium (100mg/5ml

Concentrate)

1

Diphenoxylate/Atropine (2.5mg-

0.025mg Tablet, 2.5mg-

0.025mg/5ml Liquid)

1

Ed Cyte F (Tablet) 3

Entereg (Capsule) 3

Gastrocrom (Concentrate) 3

Lansoprazole/Amoxicillin/Clarithro

mycin (Therapy Pack)

1

Lomotil (Tablet) 3

Loperamide HCl (2mg Capsule) 1

Movantik (Tablet) 3

Mytesi (Tablet Delayed-Release) 3

NutreStore (Packet) 3

Ocaliva (Tablet) 3

Omeclamox-Pak (Therapy Pack) 2



45

Drug Name Drug

Tier

Requirements

& Limits

OsmoPrep (Tablet) 3

Paregoric (Tincture) 2

Prevpac (Therapy Pack) 3

Pylera (Capsule) 2

Relistor (12mg/0.6ml Injection,

8mg/0.4ml Injection)

2

Restora Rx (Capsule) 3

Rezyst IM (Tablet Chewable) 3

Sodium Bicarbonate (Powder) 3

Urso (Tablet) 3

Ursodiol (250mg Tablet, 500mg


1

VSL#3 DS (Packet) 3

Gastrointestinal Agents : Histamine2 (H2) Receptor Antagonists Cimetidine (200mg Tablet, 300mg


Tablet)

1

Cimetidine HCl (Oral Solution) 1

Famotidine (200mg/20ml Injection,


Injection, 20mg Tablet, 40mg


1

Famotidine Premixed (Injection) 3

Nizatidine (150mg Capsule, 300mg

Capsule, 15mg/ml Oral Solution)

1

Pepcid (20mg Tablet, 40mg


3

Ranitidine HCl (150mg Capsule,

300mg Capsule, 150mg Tablet,

300mg Tablet, 150mg/6ml Injection,

50mg/2ml Injection, 15mg/ml

Syrup, 75mg/5ml Syrup)

1

Zantac (150mg Tablet, 300mg

Tablet, 25mg/ml Injection,

50mg/2ml Solution)

3

Gastrointestinal Agents : Irritable Bowel Syndrome Agents Alosetron HCl (Tablet) 1

Amitiza (Capsule) 2

Gattex (Injection) 3

Linzess (145mcg Capsule, 290mcg

Capsule)

2

Lotronex (Tablet) 3

Viberzi (Tablet) 3

Gastrointestinal Agents : Laxatives CoLyte-Flavor Packs (Oral

Solution)

3

GoLYTELY (Oral Solution) 3

Kristalose (Packet) 3

Lactulose (Oral Solution) 1

Mineral Oil Heavy (0 Oil) 1

MoviPrep (Oral Solution) 3

NuLYTELY/Flavor Packs (Oral

Solution)

3

PCP 100 (Kit) 3

PEG 3350/Electrolytes (Oral 1

Drug Name Drug

Tier

Requirements

& Limits

Solution)

PEG-3350/Electrolytes (Oral

Solution)

1

PEG-3350/NaCl/Na

Bicarbonate/KCl (Oral Solution)

1

Polyethylene Glycol 3350 Powder 1

Prepopik (Packet) 3

Suprep Bowel Prep (Oral

Solution)

3

Gastrointestinal Agents : Protectants Carafate (1gm Tablet, 1gm/10ml

Suspension)

3

Cytotec (Tablet) 3

Misoprostol (Tablet) 1

Sucralfate (1gm Tablet) 1

Gastrointestinal Agents : Proton Pump Inhibitors Aciphex (Tablet Delayed-Release) 3

Aciphex Sprinkle (Capsule

Sprinkle)

3

Dexilant (Capsule Delayed-

Release)

2

Esomeprazole Magnesium (Capsule

Delayed-Release)

1

Esomeprazole Sodium (20mg

Injection)

3

Esomeprazole Sodium (40mg

Injection)

1

Esomeprazole Strontium (Capsule

Delayed-Release)

3

First-Lansoprazole (Suspension) 3

First-Omeprazole (Suspension) 3

Lansoprazole (Capsule Delayed-

Release)

1

Nexium (10mg Packet, 2.5mg

Packet, 20mg Packet, 40mg

Packet, 5mg Packet, 20mg

Capsule Delayed-Release, 40mg

Capsule Delayed-Release)

3

Nexium I.V. (Injection) 3

Omeprazole (10mg Capsule



Delayed-Release)

1

Omeprazole + Syrspend SF Alka

(Suspension)

3

Omeprazole/Sodium Bicarbonate

(20mg-1100mg Capsule, 40mg-

1100mg Capsule, 20mg-1680mg

Packet, 40mg-1680mg Packet)

1

Pantoprazole Sodium (20mg Tablet

Delayed-Release, 40mg Tablet

Delayed-Release, 40mg Injection)

1

Prevacid (Capsule Delayed-

Release)

3

Prevacid SoluTab (Tablet

Dispersible)

3

Prilosec (Packet) 3

Protonix (20mg Tablet Delayed-

Release, 40mg Tablet Delayed-

3



46

Drug Name Drug

Tier

Requirements

& Limits

Release, 40mg Injection, 40mg

Packet)

Rabeprazole Sodium (Tablet

Delayed-Release)

1

Zegerid (20mg-1100mg Capsule,

40mg-1100mg Capsule, 20mg-

1680mg Packet, 40mg-1680mg

Packet)

3

Gastrointestinal Drugs : Antiemetics Sustol (Injection) 3

Gastrointestinal Drugs : Digestants Pancreaze (10850unit-2600unit-


Release)

3

Gastrointestinal Drugs : GI Drugs, Miscellaneous Linzess (72mcg Capsule) 2

Relistor (150mg Tablet) 3

Genitourinary Agents : Antispasmodics, Urinary Darifenacin HBr ER (Tablet


1

Detrol (Tablet) 3

Detrol LA (Capsule Extended-

Release 24 Hour)

3

Ditropan XL (Tablet Extended-

Release 24 Hour)

3

Enablex (Tablet Extended-Release

24 Hour)

3

Flavoxate HCl (Tablet) 1

Gelnique (Gel) 3

Myrbetriq (Tablet Extended-

Release 24 Hour)

3

Oxybutynin Chloride (5mg Tablet,

5mg/5ml Syrup)

1

Oxybutynin Chloride ER (Tablet


1

Oxytrol (Patch Twice Weekly) 3

Tolterodine Tartrate (Tablet) 1

Tolterodine Tartrate ER (Capsule


1

Toviaz (Tablet Extended-Release

24 Hour)

3

Trospium Chloride (Tablet) 1

Trospium Chloride ER (Capsule


1

Vesicare (Tablet) 2

Genitourinary Agents : Benign Prostatic Hypertrophy Agents Alfuzosin HCl ER (Tablet


1

Avodart (Capsule) 3

Cardura XL (Tablet Extended-

Release 24 Hour)

3

Cialis (2.5mg Tablet, 5mg Tablet) 2

Dutasteride (Capsule) 1

Dutasteride/Tamsulosin HCl

(Capsule)

1

Finasteride (5mg Tablet) 1

Drug Name Drug

Tier

Requirements

& Limits

Flomax (Capsule) 3

Jalyn (Capsule) 3

Proscar (Tablet) 3

Rapaflo (Capsule) 2

Tamsulosin HCl (Capsule) 1

Uroxatral (Tablet Extended-

Release 24 Hour)

3

Genitourinary Agents : Genitourinary Agents, Other Bethanechol Chloride (Tablet) 1

Cialis (10mg Tablet, 20mg Tablet) 2

Cuprimine (Capsule) 3

Depen Titratabs (Tablet) 2

Elmiron (Capsule) 2

Levitra (Tablet) 3

Lithostat (Tablet) 3

Stendra (Tablet) 3

Thiola (Tablet) 3

Urecholine (Tablet) 3

Viagra (Tablet) 2

Genitourinary Agents : Phosphate Binders Auryxia (Tablet) 3

Calcium Acetate (667mg Capsule,

667mg Tablet)

1

Eliphos (Tablet) 3

Fosrenol (1000mg Packet, 750mg

Packet, 1000mg Tablet Chewable,

500mg Tablet Chewable, 750mg

Tablet Chewable)

3

Phoslyra (Oral Solution) 3

Renagel (Tablet) 3

Renvela (0.8gm Packet, 2.4gm

Packet, 800mg Tablet)

2

Velphoro (Tablet Chewable) 3

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) : Methylprednisolone Pf (Injection) 3

Triamcinolone Pf (Injection) 3

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Analpram-HC (1%-1% Cream) 3

Betamethasone Sodium

Phosphate/Betamethasone Acetate

(Injection)

1

Celestone-Soluspan (Injection) 3

Cortef (Tablet) 3

Cortenema (Enema) 3

Cortisone Acetate (25mg Tablet) 2

Depo-Medrol (Injection) 3

Dexamethasone (0.5mg Tablet,

0.75mg Tablet, 1.5mg Tablet, 1mg


6mg Tablet, 0.5mg/5ml Elixir,

0.5mg/5ml Oral Solution)

1

Dexamethasone Intensol (1mg/ml

Concentrate)

3

Dexamethasone Sodium Phosphate 1



47

Drug Name Drug

Tier

Requirements

& Limits


Solution)

Dexlido (Injection) 3

DexPak 10 Day (Tablet Therapy

Pack)

3


Pack)

3


Pack)

3

Doubledex (Injection) 3

Dyural-L (Injection) 3

Emflaza (18mg Tablet, 30mg


22.75mg/ml Suspension)

3

Fludrocortisone Acetate (0.1mg

Tablet)

1

Hydrocort Enema 100mg (Enema) 1

Hydrocortisone (10mg Tablet, 20mg

Tablet, 5mg Tablet)

1

Interarticular Joint Kit (Kit) 3

Kenalog-10 (Injection) 3

Kenalog-40 (Injection) 3

LT Injection Kit (Injection) 3

Marbeta-L (Injection) 3

Mardex-25 (Injection) 3

Medrol (16mg Tablet, 32mg


3

Medrol (2mg Tablet) 2

Methylprednisolone (16mg Tablet,


Tablet)

1

Methylprednisolone Acetate

(40mg/ml Injection, 80mg/ml

Injection)

1

Methylprednisolone/Lidocaine

(Injection)

3

Millipred (10mg/5ml Oral

Solution)

3

Millipred (5mg Tablet) 2

Millipred DP (Tablet Therapy

Pack)

3

Mometasone Furoate (0.1% Cream,

0.1% Ointment)

1

Orapred ODT (Tablet

Dispersible)

3

Pediapred (Oral Solution) 3

Prednisolone (15mg/5ml Oral

Solution, 15mg/5ml Syrup)

1

Prednisolone Sodium Phosphate

(10mg/5ml Solution, 20mg/5ml

Solution, 25mg/5ml Oral Solution,


1


ODT (Tablet Dispersible)

1

Prednisone (10mg Tablet, 1mg

Tablet, 2.5mg Tablet, 20mg Tablet,


1

Prednisone (5mg/5ml Oral

Solution)

2

Drug Name Drug

Tier

Requirements

& Limits

Prednisone Intensol (5mg/ml

Concentrate)

2

Triamcinolone (Injection) 1

Uceris (2mg/act Foam, 9mg Tablet


3

Veripred 20 (Oral Solution) 3

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Bravelle (Injection) 3

Chorionic Gonadotropin (Injection) 1

DDAVP (0.01% Nasal Solution,


4mcg/ml Injection)

3

Desmopressin Acetate (0.01% Nasal

Solution, 0.1mg/ml Nasal Solution,


4mcg/ml Injection)

1

Egrifta (Injection) 3

Follistim AQ (300unit/0.36ml

Injection, 600unit/0.72ml

Injection, 900unit/1.08ml

Injection, 75unit/0.5ml Injection)

3

Genotropin (12mg Injection, 5mg

Injection)

3

Genotropin Miniquick (Injection) 3

Gonal-F (Injection) 2

Gonal-F RFf (Injection) 2

Gonal-F RFf Rediject (Injection) 2

H.P. Acthar (Injection) 2

Humatrope (Injection) 3

Humatrope Combo Pack

(Injection)

3

Increlex (Injection) 2

Norditropin FlexPro (Injection) 2

Nutropin AQ (Injection) 2

Omnitrope (Injection) 3

Ovidrel (Injection) 3

Oxytocin (Injection) 1

Oxytocin/Sodium Chloride

(20unit/L-0.9% Injection)

3

Pitocin (Injection) 3

Saizen (Injection) 3

Serostim (Injection) 2

Stimate (Nasal Solution) 3

Vaprisol (Injection) 3

Vasopressin/Sodium Chloride

(0.9%-40unit/100ml Injection,

0.9%-50unit/50ml Injection)

3

Vasostrict (Injection) 3

Zomacton (Injection) 3

Zorbtive (Injection) 3

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) Alprostadil (Injection) 1

Korlym (Tablet) 3

Muse (Pellet) 3

Prostin VR Pediatric (Injection) 3



48

Drug Name Drug

Tier

Requirements

& Limits

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Anabolic Steroids Anadrol-50 (Tablet) 3

Oxandrin (Tablet) 3

Oxandrolone (Tablet) 1

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Androgens Androderm (Patch 24 Hour) 2

AndroGel (25mg/2.5gm Gel,

50mg/5gm Gel)

3

AndroGel (40.5mg/2.5gm Gel) 2

Android (Capsule) 3

Androxy (Tablet) 2

Axiron (Transdermal Solution) 3

Danazol (100mg Capsule, 200mg


1

Depo-Testosterone (Injection) 3

Fortesta (Gel) 3

Methyltestosterone (10mg Capsule) 1

Natesto (Gel) 3

Striant 3

Testim (Gel) 3

Testopel (Pellet) 3

Testosterone (100mg Pellet,

200mg Pellet, 87.5mg Pellet)

3

Testosterone (25mg/2.5gm Gel,

50mg/5gm Gel)

1

Testosterone Cypionate (Injection) 1

Testosterone Enanthate (Injection) 1

Testosterone Pump (Gel) 1

Testred (Capsule) 3

Vogelxo (Gel) 3

Vogelxo Pump (Gel) 3

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Estrogens Activella (Tablet) 3

Alora (Patch Twice Weekly) 3

Angeliq (Tablet) 3

Beyaz (Tablet) 3

Brevicon-28 (Tablet) 3

Climara (Patch Weekly) 3

Climara Pro (Patch Weekly) 2

Combipatch (Patch Twice

Weekly)

3

Cyclessa (Tablet) 3

Delestrogen (Injection) 3

Depo-Estradiol (Injection) 3

Desogen (Tablet) 3

Desogestrel/Ethinyl Estradiol

(Tablet)

1

Divigel (Gel) 3

Drospirenone/Ethinyl Estradiol 1

Drug Name Drug

Tier

Requirements

& Limits

(Tablet)

Drospirenone/Ethinyl

Estradiol/Levomefolate Calcium

(Tablet)

1

Elestrin (Gel) 3

Estrace (0.1mg/gm Cream, 0.5mg


3

Estradiol (0.025mg/24hr Patch

Weekly, 0.05mg/24hr Patch



Weekly, 37.5mcg/24hr Patch

Weekly, 0.1mg/24hr Patch Weekly,


Tablet)

1

Estradiol Valerate (Injection) 1

Estradiol/Norethindrone Acetate

(Tablet)

1

Estring (Ring) 3

Estrogel (Gel) 3

Estropipate (Tablet) 1

Estrostep Fe (Tablet) 3

Ethynodiol Diacetate/Ethinyl

Estradiol (Tablet)

1

Evamist (Transdermal Solution) 3

Femcon Fe (Tablet Chewable) 3

Femhrt Low Dose (Tablet) 3

Femring (Ring) 3

Generess Fe (Tablet Chewable) 3

Levonorgestrel and Ethinyl

Estradiol (Tablet)

1

Levonorgestrel/Ethinyl Estradiol

(Tablet)

1

Lo Loestrin Fe (Tablet) 3

Loestrin 1.5/30-21 (Tablet) 3

Loestrin 1/20-21 (Tablet) 3

Loestrin Fe 1.5/30 (Tablet) 3

Loestrin Fe 1/20 (Tablet) 3

LoSeasonique (Tablet) 3

Menest (Tablet) 2

Menostar (Patch Weekly) 3

Minastrin 24 Fe (Tablet

Chewable)

3

Minivelle (Patch Twice Weekly) 3

Mircette (Tablet) 3

Natazia (Tablet) 2

Necon 10/11-28 (Tablet) 2

Norethindrone Acetate/Ethinyl

Estradiol (Tablet)

1

Norethindrone Acetate/Ethinyl

Estradiol/Ferrous Fumarate (Tablet)

1

Norethindrone/Ethinyl

Estradiol/Ferrous Fumarate (Tablet

Chewable)

1

Norgestimate/Ethinyl Estradiol (0-

Tablet, 35mcg-0.25mg Tablet)

1

Norinyl 1+35 (Tablet) 3

Nuvaring 3



49

Drug Name Drug

Tier

Requirements

& Limits

Ortho Tri-Cyclen (Tablet) 3

Ortho Tri-Cyclen Lo (Tablet) 3

Ortho-Cyclen (Tablet) 3

Ortho-Novum 1/35 (Tablet) 3

Ortho-Novum 7/7/7 (Tablet) 3

Ovcon-35 (Tablet) 3

Prefest (Tablet) 3

Premarin (0.3mg Tablet, 0.45mg

Tablet, 0.625mg Tablet, 0.9mg

Tablet, 1.25mg Tablet,

0.625mg/gm Cream)

2

Premarin (25mg Injection) 3

Premphase (Tablet) 2

Prempro (Tablet) 2

Safyral (Tablet) 3

Seasonique (Tablet) 3

Tri-Norinyl 28 (Tablet) 3

Vagifem (Tablet) 3

Vivelle-Dot (Patch Twice Weekly) 3

Yasmin 28 (Tablet) 3

Yaz (Tablet) 3

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Taytulla (Capsule) 3

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Progesterone Agonists/Antagonists Ella (Tablet) 3

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Progestins Aygestin (Tablet) 3

Crinone (Gel) 3

Depo-Provera (Injection) 3

Endometrin (Insert) 3

Hydroxyprogesterone Caproate

(Injection)

1

Makena (Injection) 2

Medroxyprogesterone Acetate

(Tablet)

1

Megace ES (Suspension) 3

Megace Oral (Suspension) 3

Megestrol Acetate (20mg Tablet,

40mg Tablet, 40mg/ml Suspension,

40mg/ml Suspension, 625mg/5ml

Suspension)

1

Norethindrone (Tablet) 1

Norethindrone Acetate (5mg Tablet) 1

Ortho Micronor (Tablet) 3

Progesterone (100mg Capsule,

200mg Capsule, 50mg/ml Injection)

1

Prometrium (Capsule) 3

Provera (Tablet) 3

Drug Name Drug

Tier

Requirements

& Limits

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Selective Estrogen Receptor Modifying Agents Clomiphene Citrate (50mg Tablet) 1

Evista (Tablet) 3

Osphena (Tablet) 3

Raloxifene HCl (Tablet) 1

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Armour Thyroid (Tablet) 3

Cytomel (Tablet) 3

Levothyroxine Sodium (100mcg

Injection, 200mcg Injection,

500mcg Injection)

3

Levothyroxine Sodium (100mcg

Tablet, 112mcg Tablet, 125mcg






1

Liothyronine Sodium (10mcg/ml

Injection, 25mcg Tablet, 50mcg


1

Nature-Throid (Tablet) 3

Nature-Throid Nt-2.5 (Tablet) 3

Synthroid (Tablet) 3

Thyrolar (Tablet) 3

Tirosint (Capsule) 3

Triostat (Injection) 3

Westhroid (Tablet) 3

WP Thyroid (Tablet) 3

Hormonal Agents, Suppressant (Adrenal) Lysodren (Tablet) 2

Hormonal Agents, Suppressant (Parathyroid) Sensipar (Tablet) 3

Hormonal Agents, Suppressant (Pituitary) Bromocriptine Mesylate (2.5mg


1

Cabergoline (Tablet) 1

Cetrotide (Injection) 2

Eligard (Injection) 3

Firmagon (Injection) 3

Ganirelix Acetate (Injection) 3

Leuprolide Acetate (Injection) 1

Lupaneta Pack (Kit) 3

Lupron Depot (11.25mg Injection,

3.75mg Injection)

3

Lupron Depot (22.5mg Injection,

30mg Injection, 45mg Injection,

7.5mg Injection)

2

Lupron Depot-PED (11.25mg

Injection)

3

Lupron Depot-PED (15mg

Injection, 30mg Injection, 7.5mg

2



50

Drug Name Drug

Tier

Requirements

& Limits

Injection)

Menopur (Injection) 3

Octreotide Acetate (Injection) 1

Parlodel (2.5mg Tablet, 5mg

Capsule)

3

Sandostatin (Injection) 3

Sandostatin LAR Depot

(Injection)

3

Signifor (Injection) 3

Signifor LAR (Injection) 3

Somatuline Depot (Injection) 3

Somavert (Injection) 3

Supprelin LA (Injection) 2

Synarel (Nasal Solution) 2

Trelstar (Injection) 3

Trelstar Mixject (11.25mg

Suspension, 3.75mg Suspension,

22.5mg Injection)

3

Vantas (Injection) 3

Zoladex (10.8mg Injection) 3

Zoladex (3.6mg Injection) 2

Hormonal Agents, Suppressant (Thyroid) : Antithyroid Agents Methimazole (10mg Tablet, 5mg

Tablet)

1

Propylthiouracil (Tablet) 1

Tapazole (Tablet) 3

Hormones and Synthetic Substitutes : Adrenals Dexamethasone Sodium Phosphate

(10mg/ml Injection)

1

Dexamethasone Sodium

Phosphate/Sodium Chloride

(Solution)

3

Dmt Suik (Kit) 3

Prednisone (10mg Tablet Therapy

Pack, 5mg Tablet Therapy Pack)

1

Zonacort 11 Day (Tablet Therapy

Pack)

3

Zonacort 7 Day (Tablet Therapy

Pack)

3

Hormones and Synthetic Substitutes : Antidiabetic Agents Actoplus Met XR (Tablet


3

Adlyxin (Injection) 3

Adlyxin Starter Pack (Injection) 3

Jentadueto XR (Tablet Extended-

Release 24 Hour)

2

Soliqua 100/33 (Injection) 3

Xultophy (Solution Pen injector) 3

Hormones and Synthetic Substitutes : Pituitary Vasopressin/Sodium Chloride

(0.9%-60unit/100ml Solution)

3

Immunological Agents : Immune Suppressants Astagraf XL (Capsule Extended-

Release 24 Hour)

3

Drug Name Drug

Tier

Requirements

& Limits

Azasan (Tablet) 3

Azathioprine (100mg Injection,

50mg Tablet)

1

Benlysta (Injection) 3

Cellcept (200mg/ml Suspension,

250mg Capsule, 500mg Tablet)

3

Cellcept Intravenous (Injection) 3

Cimzia (Injection) 2

Cimzia Starter Kit (Injection) 2

Cyclosporine (100mg Capsule,


1

Cyclosporine Modified (100mg



1

Enbrel (25mg Injection) 3

Envarsus XR (Tablet Extended-

Release 24 Hour)

3

Humira (20mg/0.4ml Injection,

40mg/0.8ml Injection)

2

Humira Pediatric Crohns Disease

Starter Pack (Injection)

2

Humira Pen (Injection) 2

Humira Pen Crohns Disease

Starter Pack (Injection)

2

Humira Pen-Psoriasis Starter

(Injection)

2

Imuran (Tablet) 3

Methotrexate (2.5mg Tablet) 1

Methotrexate Sodium (Injection) 1

Mycophenolate Mofetil (200mg/ml

Suspension, 250mg Capsule, 500mg


1

Mycophenolic Acid DR (Tablet

Delayed-Release)

1

Myfortic (Tablet Delayed-Release) 3

Neoral (100mg Capsule, 25mg


3

Nulojix (Injection) 3

Orencia (125mg/ml Injection,

250mg Injection)

3

Orencia Clickject (Injection) 3

Otrexup (Injection) 3

Prograf (0.5mg Capsule, 1mg

Capsule, 5mg Capsule, 5mg/ml

Injection)

3

Rapamune (0.5mg Tablet, 1mg

Tablet, 2mg Tablet, 1mg/ml Oral

Solution)

3

Rasuvo (Injection) 2

Remicade (Injection) 2

Sandimmune (100mg Capsule,


3

Sandimmune (100mg/ml Oral

Solution)

2

Simponi (Injection) 2

Simponi Aria (Injection) 2

Sirolimus (Tablet) 1

Tacrolimus (0.5mg Capsule, 1mg 1



51

Drug Name Drug

Tier

Requirements

& Limits


Torisel (Injection) 2

Trexall (Tablet) 3

Zortress (Tablet) 3

Immunological Agents : Immunizing Agents, Passive Atgam (Injection) 2

BIVIGAM (Injection) 2

Carimune Nanofiltered (Injection) 2

Cuvitru (1gm/5ml Injection,


Injection)

3

Cytogam (Injection) 2

Flebogamma DIF (Injection) 2

Gamastan S/D (Injection) 2

Gammagard Liquid (Injection) 2

Gammagard S/D IGA Less Than

1 mcg/ml (Injection)

2

Gammaked (Injection) 2

Gammaplex (Injection) 2

Gamunex-C (Injection) 2

Hizentra (Injection) 2

Hyperrab S/D (Injection) 2

Hyperrho S/D (Injection) 2

Hyperrho S/D Mini-Dose

(Injection)

2

Imogam Rabies-HT (Injection) 2

Micrhogam Ultra-Filtered Plus

(Injection)

2

Octagam (Injection) 2

Privigen (Injection) 2

Rhogam Ultra-Filtered Plus

(Injection)

2

Rhophylac (Injection) 2

Thymoglobulin (Injection) 3

WinRho SDF (Injection) 2

Immunological Agents : Immunomodulators Actemra (162mg/0.9ml Injection,

200mg/10ml Injection,


Injection)

3

Actimmune (Injection) 2

Arava (Tablet) 3

Arcalyst (Injection) 3

Hylira (0.1% Lotion, 0.2% Gel) 3

Ilaris (180mg Injection) 2

Leflunomide (Tablet) 1

Lemtrada (Injection) 3

Otezla (Tablet Therapy Pack,

30mg Tablet)

3

Provenge (Injection) 2

Ridaura (Capsule) 3

Simulect (Injection) 3

Sodium Hyaluronate (Gel) 1

Stelara (130mg/26ml Injection) 2

Synagis (Injection) 2

Xeljanz (Tablet) 3

Drug Name Drug

Tier

Requirements

& Limits

Xeljanz XR (Tablet Extended-

Release 24 Hour)

3

Immunological Agents : Vaccines Hyqvia (Injection) 3

Theracys (Injection) 2

Inflammatory Bowel Disease Agents : Aminosalicylates Apriso (Capsule Extended-Release

24 Hour)

2

Asacol HD (Tablet Delayed-

Release)

3

Balsalazide Disodium (Capsule) 1

Canasa (Suppository) 2

Colazal (Capsule) 3

Delzicol (Capsule Delayed-

Release)

3

Dipentum (Capsule) 3

Lialda (Tablet Delayed-Release) 2

Mesalamine (4gm Enema, 4gm Kit) 1

Mesalamine DR (Tablet Delayed-

Release)

3

Pentasa (Capsule Extended-

Release)

3

Rowasa (Kit) 3

sfRowasa (Enema) 2

Inflammatory Bowel Disease Agents : Glucocorticoids Budesonide (3mg Capsule Delayed-

Release)

1

Cortifoam (Foam) 3

Entocort EC (Capsule Delayed-

Release)

3

Inflammatory Bowel Disease Agents : Sulfonamides Azulfidine (Tablet) 3

Azulfidine EN-Tabs (Tablet

Delayed-Release)

3

Sulfasalazine (500mg Tablet, 500mg

Tablet Delayed-Release)

1

Local Anesthetics Articadent Dental (Injection) 3

Bupivacaine/Epinephrine (0.5%-

1:200000 Injection)

1

Lidocaine HCl (Solution Prefilled

Syringe)

3

Marcaine/Epinephrine (0.5%-

1:200000 Injection)

3

Metabolic Bone Disease Agents Actonel (Tablet) 3

Alendronate Sodium (10mg Tablet,



1

Alendronate Sodium (70mg/75ml

Oral Solution)

2

Atelvia (Tablet Delayed-Release) 3

Binosto (Tablet Effervescent) 3

Boniva (150mg Tablet, 3mg/3ml 3



52

Drug Name Drug

Tier

Requirements

& Limits

Injection)

Calcitonin-Salmon (Nasal Solution) 1

Calcitriol (0.25mcg Capsule, 0.5mcg

Capsule, 1mcg/ml Injection,

1mcg/ml Oral Solution)

1

Doxercalciferol (0.5mcg Capsule,

1mcg Capsule, 2.5mcg Capsule,

4mcg/2ml Injection)

1

Etidronate Disodium (Tablet) 1

Forteo (Injection) 2

Fosamax (Tablet) 3

Fosamax Plus D (Tablet) 3

Hectorol (0.5mcg Capsule, 1mcg

Capsule, 2.5mcg Capsule,

2mcg/ml Injection, 4mcg/2ml

Injection)

3

Ibandronate Sodium (150mg Tablet,

3mg/3ml Injection)

1

Miacalcin (200unit/act Nasal

Solution, 200unit/ml Injection)

3

Pamidronate Disodium (30mg


90mg Injection, 90mg/10ml

Injection)

1

Pamidronate Disodium (6mg/ml

Injection)

3

Paricalcitol (1mcg Capsule, 2mcg

Capsule, 4mcg Capsule, 2mcg/ml

Injection, 5mcg/ml Injection)

1

Prolia (Injection) 2

Reclast (Injection) 3

Risedronate Sodium (Tablet) 1

Risedronate Sodium DR (Tablet

Delayed-Release)

1

Rocaltrol (0.25mcg Capsule,

0.5mcg Capsule, 1mcg/ml Oral

Solution)

3

Xgeva (Injection) 2

Zemplar (1mcg Capsule, 2mcg

Capsule, 2mcg/ml Injection,

5mcg/ml Injection)

3

Zoledronic Acid (4mg/100ml

Injection)

3

Zoledronic Acid (4mg/5ml


1

Zometa (Injection) 3

Miscellaneous Therapeutic Agents : Aggrastat (3.75mg/15ml Injection) 3

Amphadase (Injection) 3

Cyanokit (Injection) 3

Ryanodex (Injection) 3

Thyrogen (Injection) 2

Xermelo (Tablet) 3

Miscellaneous Therapeutic Agents : Antidotes Levoleucovorin (175mg Solution) 3

Miscellaneous Therapeutic Agents : Cariostatic Agents

Drug Name Drug

Tier

Requirements

& Limits

Florical (364mg-8.3mg Capsule,

364mg-8.3mg Tablet)

2

Floriva (Liquid) 2

Fluor-A-Day (Tablet Chewable) 2

Fluorabon (Oral Solution) 2

Flura-Drops (Oral Solution) 2

Monocal (Tablet) 2

Nafrinse Daily/Neutral (Solution) 3

Nafrinse Weekly (Solution) 3

Miscellaneous Therapeutic Agents : Disease-modifying Antirheumatic Drugs Inflectra (Injection) 3

Miscellaneous Therapeutic Agents 1st Choice Lancets Thin 2

1st Tier Unifine Pentips

29gx12mm

2

1st Tier Unifine Pentips 31gx6mm 2

1st Tier Unifine Pentips 31gx8mm 2

3ml Glass Syringe Kit/1ml Na

Hep/Swab/Prep/Cap/Ndl

St/Label/Drap (Kit)

3

5ml Glass Syringe Kit/1ml Na

Hep/Swab/Prep/Cap/Ndl

St/Label/Drap (Kit)

3

Accu-Chek Aviva 2

Accu-Chek Aviva Connect (Kit) 2

Accu-Chek Aviva Plus (Kit, Strip) 2

Accu-Chek Compact Plus (Strip) 2

Accu-Chek Compact Plus Care

Kit (Kit)

2

Accu-Chek Compact Test Drum

(Strip)

2

Accu-Chek Fastclix Lancet Device

Kit (Kit)

2

Accu-Chek Fastclix Lancets 2

Accu-Chek Guide (Kit, Strip) 2

Accu-Chek Multiclix Lancet

Device Kit (Kit)

2

Accu-Chek Multiclix Lancets 2

Accu-Chek Nano Smartview (Kit) 2

Accu-Chek Safe-T-Pro Lancets 2

Accu-Chek Safe-T-Pro Pluslancets 2

Accu-Chek Smartview Strips

(Strip)

2

Accu-Chek Soft Touch Lancets 2

Accu-Chek Softclix Lancet Device

Kit (Kit)

2

Accu-Chek Softclix Lancets 2

Accutrend Glucose (Strip) 2

Active 1st Blood Lancets 30g/Easy

Twist Cap

2

Advocate Insulin Pen Needles 2

Advocate Lancets 2

Advocate Lancets 30g 2

Advocate Safety Lancets 26g 2

AeroChamber Mini Aerosol

Chamber (Device)

2



53

Drug Name Drug

Tier

Requirements

& Limits

AeroChamber MV 2

AeroChamber Plus Flow Vu 2

AeroChamber Plus Flow-Vu 2

AeroChamber Plus Flow-

Vu/Large Mask

2


Vu/Mask

2


Vu/Medium Mask

2


Vu/Small Mask

2

AeroChamber Z-Stat

Plus/Medium Mask

2

AeroChamber/FlowSignal 2

Aerovent Plus Holding

Chamber/Collapsible (Device)

2

AF Lancets Super Thin 2

Agamatrix Ultra-Thin Lancets

33g

2

Amino PM Rms (Capsule) 3

Ammonul (Injection) 3

Antizol (Injection) 3

App Slim RMS (Capsule) 3

Arial Chamber (Device) 2

Arnica Flower (Tincture) 3

Assure Haemolance Plus High

Flow 18g

2

Assure Haemolance Plus Low

Flow 25g

2

Assure Haemolance Plus Micro

Flow 28g

2

Assure Haemolance Plus Normal

Flow 21g

2

Assure Haemolance Plus Pediatric

Blade

2

Assure Lance Lancets 2

Assure Lance Lancets 21g 2

Assure Lance Plus Safety Lancets

25g

2

Assure Lance Plus Safety Lancets

30g

2

Assure Lancets 2

Astamed Myo (Capsule) 3

At Last Lancets 2

Aurora Lancet Super Thin 30g 2

Aurora Lancet Thin 23g 2

Aurora Pen Needles 29gx12mm 2

Aurora Pen Needles 31g X 6mm 2

Aurora Pen Needles 31g X 8mm 2

Autolet Platforms 2

Availnex (Tablet Chewable) 3

Bacteriostatic Water for

Injection/Benzyl Alcohol

(Injection)

3

Bayer Microlet Lancets 2

BD 3ml LL Syringe/Prefill Lith

Hep/Tip Cap/Ndl Stop/Safetycone

(Kit)

3

Drug Name Drug

Tier

Requirements

& Limits

BD Autoshield 29g X 3/16" 2

BD Autoshield 29g X 5/16" 2

BD Autoshield Duo 30g X 3/16" 2

Bd insul Syr Mis Lo Dose 2

BD Lancet Ultrafine 30g 2

BD Lancet Ultrafine 33g 2

BD Microtainer Lancets 2

Benzoin Tincture (0 Tincture) 3

Betalido (Injection) 3

Boric Acid (0 Granules) 3

BreatheRite 2

BreatheRite Collapsible Spacer

w/ Neonate Mask

2

BreatheRite Rigid Spacer w/Mask 2

BreatheRite w/Large Mask 2

BreatheRite w/Medium Mask 2

BreatheRite w/Small Mask 2

Bridion (200mg/2ml Injection,


3

Bullseye Safety Lancets 2

Cardiovid Plus (Capsule) 3

Careone Lancet Thin 2

Careone Lancet Ultra Thin 2

Caretouch Pen Needles 31 G X 6

Mm

2

Caretouch Pen Needles 31gx 5mm 2



Caretouch Twist Lancets 30g 2

Carnitor (1gm/10ml Oral


330mg Tablet)

3

Carnitor SF (Oral Solution) 3

Citrus Bergamot (Powder) 3

Cleanlet Lancets 28g 2

Clever Chek Lancets Ultrathin 2

Clever Chek Lancets Ultrathin

30g

2

Clever Choice Anti-Static Valved

Holding Chamber/Adult Large

(Device)

2


Holding Chamber/Medium

(Device)

2


Holding Chamber/Small (Device)

2

Clever Choice Comfort EZ Insulin

Pen Needles 31gx8mm

2

Clever Choice Comfort EZ Pen

Needles 29gx12mm

2


Needles 31gx5mm

2


Needles 31gx6mm

2


Needles 32gx4mm

2


Needles 32gx8mm

2



54

Drug Name Drug

Tier

Requirements

& Limits


Needles 33gx4mm

2


Needles 33gx5mm

2


Needles 33gx6mm

2


Needles 33gx8mm

2

Coaguchek Lancets 2

Comfort Lancets 2

Compact Space Chamber/Anti-

Static (Device)

2


Static/Large Mask (Device)

2


Static/Medium Mask (Device)

2


Static/Small Mask (Device)

2

Deferoxamine Mesylate (Injection) 1

Delivery Fee ( ) 1

Deplin 15 (Capsule) 3

Deplin 7.5 (Capsule) 3

Desferal (Injection) 3

Dexcom G4 Plat Ped 3

Dexcom G4 Platinum 3

Dexcom G5 Kit

(Receiver/Transmit)

3

Dexlido-M (Injection) 3

Diastar Easy Test II Lancets 30g 2

Diastar Easy Test Lancets30g 2

Diastix (Strip) 2

Digifab (Injection) 3

DrCaps Size 0 Clear (Capsule) 3



Drihep Arterial Line Sampling

Syr/3ml Ll/5ml Waste Syr/2-Cap

(Kit)

3

DriHep Plus 3ml LL Prefilled

Syringe/Tip Cap/Ndl

Stop/Safetycone (Kit)

3

Droplet Lancets Ultra Thin 30g 2

Drug Mart On-The-Go Lancets

Gentle 30g

2

Drug Mart Unilet Lancets Ultra

Thin 28g

2

Duodote (Injection) 3

E-Z Ject Lancets 2

E-Z Ject Lancets 21g 2

E-Z Ject Lancets Color 2

E-Z Ject Lancets Super Thin 30g 2

E-Z Ject Lancets Thin 26g 2

E-Z Spacer (Device) 2

E-Z Spacer the Body Guards Pack

(Device)

2

E-Zject Lancets Micro-Thin 33g 2

Easivent 2

Drug Name Drug

Tier

Requirements

& Limits

Easivent/Mask-Large 2

Easivent/Mask-Medium 2

Easivent/Mask-Small 2

Easy Touch Insulin Syringe/U-

100/1ml/31g X 5/16"

2

Easy Touch Lancets 26g/Pressure

Activated

2


Activated

2


Activated

2


Activated

2

Easy Touch Lancets 33g/Twist 2

Easy Touch Pen Needles 29gx1/2" 2

Easy Touch Pen Needles 31gx1/4" 2

Easy Touch Pen Needles

31gx5/16"

2

Easy Touch Pen Needles

32gx5/32"

2

Easy Touch Pen Needles/31g X

3/16"

2

Easy Touch Safety

Lancets21g/Pressure Activated

2

Easy Touch Safety

Lancets23g/Pressure Activated

2

Easytest II Lancets 2

Easytest Lancets 2

Elfolate (Tablet) 3

Eligen B12 (Tablet) 3

Embrace Lancets Ultra Thin 30g 2

Enteragam (Packet) 3

Erecaid Classic (Kit) 3

Erecaid Esteem (Kit) 3

Eros-CTD (Device) 3

Euflexxa (Injection) 2

Excel Comfort Point Insulin Pen

Needles 31g X 4mm

2

Exel Comfort Point Insulin Pen

Needles 29g X 12mm

2

Exel Comfort Point Insulin Pen

Needles 31g X 8mm

2

Exel Comfort Point Insulin

Syringe/0.3ml/29g X 1/2"

2

Exel Comfort Point Insulin


2

EZ Smart Blood Glucose Lancets 2

EZ-Lets Lancets 21g 2


EZ-Lets Lancets 26g Super-Soft 2

EZ-Lets Lancets 28g Ultra-Soft 2


Ferriprox (100mg/ml Oral

Solution, 500mg Tablet)

3

Fifty50 Pen Needles 31g X3/16"

(5mm)

2

Fifty50 Pen Needles 31g X5/16"

(8mm)

2



55

Drug Name Drug

Tier

Requirements

& Limits

Fifty50 Pen Needles 31gx5mm 2

Fifty50 Pen Needles/31gx8mm 2

Fifty50 Pen Needles/32gx4mm 2

Fifty50 Safety Seal Lancets 30g 2

Fifty50 Unilet Lancets 33g 2

Fine 30 2

Fingerstix Lancets 2

Flavor Blend (Suspension) 3

Flexichamber (Device) 2

Flexichamber Child Mask/Large 2

Flexichamber Child Mask/Small 2

Fomepizole (Injection) 1

Fora Lancets 2

FreeStyle Unistick II Lancets 2

G5/G4 Kit Sensor 3

Galaxtra (Powder) 3

Gel-One (Prefilled Syringe) 3

Gelsyn-3 (Injection) 3

Gentle-Let GP Lancets 2

Gentle-Let Lancets General

Purpose Style/Medium Point

2

Gentle-Let Platforms 2.4mm 2

Genvisc 850 (Solution Prefilled

Syringe)

3

GlucoCom Lancets 28g 2



Glucosource Lancets 2

Glycolic Acid 70% High Purity 3

Glycophos (Injection) 3

Gmate Lancets 30g 2

H-E-B in Control Pen Needles

31gx6mm

2

H-E-B in Control Pen Needles

31gx8mm

2

H-E-B Incontrol Pen Needles

29gx12mm

2

Haemolance 2

Haemolance Low Flow Lancets 2

Haemolance Plus 2

Haemolance Plus High Flow 2

Haemolance Plus Low Flow 2

Haemolance Plus Max Flow 2

Haemolance Plus Pediatric Flow 2

HSA Sterile Diluent (Injection) 3

Hy-Vee Lancets 2

Hyalgan (Injection) 3

Hylenex (Injection) 3

Hymovis (Injection) 3

In Touch Sterile Lancets 30g 2

InspiraChamber/Anti-Static

Valved/Mouthpiece (Device)

2

InspiraChamber/Large (Device) 2

InspiraChamber/Soother

Mask/InspiraMask/Medium

(Device)

2

Drug Name Drug

Tier

Requirements

& Limits

InspiraChamber/Soother

Mask/InspiraMask/Small (Device)

2

Inspirease Bags 2

Inspirease Drug Delivery System 2

Inspirease Mouthpiece 2

Inspirease Reservoir Bags 2

Insulin Syringe/0.5ml/27g X 1/2" 2

Insulin Syringe/U-100/1ml/28g X

1/2"

2

Insulin Syringes, Needles 2

Insulin Syringes/0.5ml/27gx1/2" 2

Insulin Syringes/1ml/30gx1/2" 2

Insupen Sensitive 32gx8mm 2

Insupen Ultrafin 29gx12mm 2




Intralipid (30gm/100ml Injection) 3

Kalbitor (Injection) 3

L-Methylfolate (Tablet) 1

L-Methylfolate Calcium (Tablet) 3

Lancet Transporter Case 2

Lancets 2

Lancets 26g Twist Top 2

Lancets 28g 2

Lancets 31g Twist Top 2

Lancets Thin 2

Lancets Ultra Fine 2

Lancets Ultra Thin 2

Leader Unifine Pentips

Plus/Short/31gx5/16"

2

Leader Unifine

Pentips/Mini/31gx3/16"

2

Leader Unifine

Pentips/Nano/32gx5/32"

2

Lecithin (0 Granules) 3

Levocarnitine (1gm/10ml Oral


330mg Tablet)

1

Liberty Medical Lancets 30g 2

Lifescan Unistik 2 Deep

Penetration

2

Lifescan Unistik II Lancets 2

Limbrel (Capsule) 3

Limbrel250 (Capsule) 3

Limbrel500 (Capsule) 3

Liquihep BD 3ml Prefil

Syr/Swab/Gauze/Cap/Ndl

Stop/Lbl/Ndls (Kit)

3

Liquihep II BD 3ml LL

Syringe/Ll/Swab/Gz/Cap/Ndl

St/Safetycone (Kit)

3

LiteAire (Device) 2

LiteTouch Lancets Micro Thin

33g

2

LiteTouch Pen Needles

29gx12.7mm

2



56

Drug Name Drug

Tier

Requirements

& Limits

LiteTouch Pen Needles 31gx8mm

Short

2

Live Better Lancet Super Thin

30g

2

Live Better Lancet Ultra Thin 28g 2

Lozibase S 3

Marbeta-25 (Injection) 3

Mask Vortex/Baby Whirl

Duckling

2

Mask Vortex/Child/Frog 2

Mask Vortex/Spinner the Duck 2

Mask Vortex/Toddler/Lady Bug 2

Medisense Thin Lancets 2

Medlance Plus Extra Lancets 21g 2

Medlance Plus Lancets 2

Medlance Plus Lite Lancets 25g 2

Medlance Plus Special Lancets

0.8mm

2

Medlance Plus SuperLite 30g 2

Medlance Plus SuperLite

30g/Comfort Max

2

Medlance Plus Universal Lancets

21g

2

Medlance/Extra 2

Medlance/Lite 2

Medlance/Universal 2

Meijer Lancets Universal 30g 2

Meijer Super Thin Lancets 2

Metastron (Injection) 3

Methylergonovine Maleate

(Injection)

1

Microchamber 2

Microlet Lancets 2

Microspacer 2

Microtainer Safety Flow

Lancet/Sterile/Single-Use

2

Mitosol (Kit) 3

Monoject Insulin Syringe/1ml 2

Monoject Insulin

Syringe/Softpack/1ml/27g X 1/2"

2

Monoject Insulin

Syringe/Softpack/U-100/0.5ml/28g

X 1/2"

2

Monoject Ultra Comfort Insulin


2

Monojector End Caps 2

Monolet Lancets 2

Monolet Opd Lancets 2

Monolettor Safety Lancets 2

Monovisc (Injection) 3

Myalept (Injection) 3

MyGlucoHealth MGH Softlance

Lancets 30g

2

Myobloc (Injection) 3

N-Acetyl-L-Cysteine (Capsule) 1

Natpara (Injection) 3

Neoke Alcar (Powder) 3

Drug Name Drug

Tier

Requirements

& Limits

Neoke MCT70 (Powder) 3

Neoke RA Lipoic (Powder) 3

Nexavir (Injection) 3

Nicomide (Tablet) 3

Nithiodote (Injection) 3

Nova Safety Lancets 23g 2

Nova Safety Lancets 28g 2

Nova Sureflex Lancets 2

Novofine Pen Needles 3

Novotwist 3

On Call Lancets 2

On Call Plus Lancets 2

Onetouch Club Lancets Fine Point 2

Onetouch Combo Pack 2

Onetouch Delica Lancets Extra

Fine 33g

2

Onetouch Delica Lancets Fine 30g 2

Onetouch Suresoft Lancing

Device/21g

2

Onetouch Ultra 2 (Kit) 2

Onetouch Ultra Blue (Strip) 2

Onetouch Ultra Mini (Kit) 2

Onetouch Ultralink System (Hex)

(Kit)

2

Onetouch Ultrasoft Lancets 2

Onetouch Verio (Kit) 2

Onetouch Verio Flex Bloodglucose

Monitoring System (Kit)

2

Onetouch Verio Iq Blood Glucose

Monitoring System (Kit)

2

Onetouch Verio Sync

Bloodglucose Monitoring System

(Kit)

2

Onetouch Verio Test Strips (Strip) 2

OptiChamber Advantage 2

OptiChamber Advantage/Large

Mask

2

OptiChamber Advantage/Medium

Face Mask

2

OptiChamber Advantage/Small

Face Mask

2

OptiChamber Diamond 2

OptiChamber Diamond/Large

Face Mask (Device)

2

OptiChamber Diamond/Medium

Face Mask

2

OptiChamber Diamond/Small

Face Mask

2

OptiChamber Face Mask/Small 2

Optihaler MDI Drug Delivery

System (Device)

2

Ora-Blend (0-0-0-0-0-0

Suspension)

3

Ora-Blend SF (0-0-0-0-0

Suspension)

3

Ora-Plus (0-0-0-0 Liquid) 3

ORA-Sweet (5%-4%-54% Syrup) 3



57

Drug Name Drug

Tier

Requirements

& Limits

ORA-Sweet SF (9%-10% Syrup) 3

Oral Mix Flavored Suspending

Vehicle (Liquid)

3

Oral Mix SF (Liquid) 3

Oral Suspend (Liquid) 3

Oral Syrup Flavored Vehicle

(Liquid)

3

Oral Syrup SF (Liquid) 3

Orthovisc (Injection) 3

Panda Mask Large 2

Panda Mask Medium 2

Panda Mask Small 2

PC Unifine Pentips 29g X 1/2" 2

PC Unifine Pentips 31g X 6mm

Ultra Short

2

Pediatric Panda Mask 2

Pen Needles 29gx1/2" 2

Pen Needles 30gx5/16" 2

Pen Needles 30gx5mm 2

Pen Needles 30gx8mm 2

Pen Needles 31gx6mm (1/4") 2

Penlet II Replacement Caps-Deep 2

Pentetate Calcium Trisodium

(Combination Solution)

3

Pentetate Zinc Trisodium

(Combination Solution)

3

Pentips 29gx12mm 2

Pentips 31gx5mm 2

Pentips 31gx6mm 2

Pentips 31gx8mm 2

Pentips 32gx4mm 2

Perfect Lancets 30g 2

Perfect Pressure Activated Safety

Lancets 28g

2

Ph 12 Sterile Diluent Forflolan

(Injection)

3

Pharmacist Choice Ultra Thin

Lancets

2


Lancets 28g

2


Lancets 30g

2


Lancets 31g

2


Lancets 33g

2

Pharmacy Couniter Lancets 2

Pocket Chamber (Device) 2

Pocket Spacer (Device) 2

Pralidoxime Chloride (Injection) 3

Precision Thin Lancets 2

Precision Ultra Lancet 2

Preset 1ml LS Syr/Prefilllyophil

Lith Hep/Tip Cap/Safetycone

(Kit)

3

Preset 3ml Ll Syr/Prefilllyoph

Lith Hep/Cap/Prep/Gz/Sftycone

3

Drug Name Drug

Tier

Requirements

& Limits

(Kit)

Prodigy Safety Lancets 2

Prodigy Twist Top Lancets 2

Propylene Glycol (0 External

Solution)

3

Protopam Chloride (Injection) 3

Provayblue (Injection) 3

PSS Select GP Lancets 2

PSS Select Platforms 2

PSS Select Safety Lancets 2

Purified Water (0 Liquid) 3

PX Lancets Ultra Thin 2

QC Lancets Super Thin 2

QC Lancets Ultra Thin 2

Quadramet (Solution) 3

Quinzyme (Tablet Dispersible) 3

Radiogardase (Capsule) 3

Relion Lancets Micro-Thin33g 2

Relion Lancets Standard 21g 2

Relion Lancets Thin 26g 2

Relion Lancets Ultra-Thin30g 2

Relion Pen Needles 29gx12mm 2




Relion Thin Lancets 2

Relion Ultra Thin Lancets 2

Relion Ultra Thin Plus Lancets

32g

2

Rightest GD-L500 Alternate Site

Adapter

2

Rightest GL300 Lancets 2

RiteFlo (Device) 2

Saccharin Sodium (0 Granules, 0

Powder)

3

Safe-T-Lance Low Flow 25g 2

Safe-T-Lance Normal Flow 21g 2

Safe-T-Lance Plus Safety Lancet

High Flow

2


Low Flow

2


Normal Flow

2

Safety Lancets 2

Safety Lancets 21g 2

Safety Lancets 28g 2

Safety Let Lancets 2

Safety Seal Lancets 28g 2

Safety Seal Lancets 30g 2

Shopko Unifine Pentips Pen

Needles/Mini/31gx5mm

2

Single-Let 2

Smart Sense Color Lancets

Universal 33g

2

Smart Sense Standard Lancets

Universal 21g

2

Smart Sense Super Thin Lancets 2



58

Drug Name Drug

Tier

Requirements

& Limits

Universal 30g

Smart Sense Thin Lancets

Universal 26g

2

Smartest Lancets 28g 2

Smoflipid (Injection) 3

Sodium Nitrite (Injection) 3

Sodium Phenylacetate/Sodium

Benzoate (Injection)

1

Sodium Phosphate/Sodium

Chloride (0.9%-15MMOL/250ml

Injection)

3

Sodium Thiosulfate (25%

Injection)

3

Solus V2 Pressure Activated

Safety Lancets 28g

2

Solus V2 Twist Lancets 30g 2

Sterilance PA 2

Sterilance Tl 2

Sterile Diluent for Epoprostenol

Sodium (Injection)

1

Sterile Diluent for Remodoulin

(Solution)

3

Supartz (Injection) 3

Supartz Fx (Injection) 3

Sure-Fine Pen Needles 29gx1/2"

12.7mm

2


5mm

2


8mm

2

Sure-Lance Lancets 26g 2

Sure-Lance Thin Lancets 28g 2

Sure-Touch Lancets Universal 2

Surelite Lancets 2

Suspension Vehicle (Suspension) 3

Synvisc (Injection) 2

Synvisc One (Injection) 2

Techlite Ast Lancets 2

TechLite Lancets 2

Techlite Lancets 30g 2

Techlite Pen Needles/31g X 5mm 2

Techlite Pen Needles/32g X 8mm 2

Thinlets GP Lancets 2

Thinlets Lancet 2

Travel Lancets Advanced 28g 2

TruePlus Lancets 26g 2




Trueplus Lancets 33g Micro Thin 2

Ulticare Insulin Safety


2

Ulticare Insulin Safety


2

Ulticare Insulin Syringe/0.3ml/29g

X 1/2"

2

Ulticare Insulin Syringe/0.5ml/28g 2

Drug Name Drug

Tier

Requirements

& Limits

X 1/2"

Ulticare Insulin Syringe/U-

100/0.3ml/30g X 1/2"

2


100/0.3ml/31g X 5/16"

2


100/0.5ml/31g X 5/16"

2

Ulticare Micro Pen Needles/32g X

4mm

2

Ulticare Pen Needles/29g X

12.7mm

2

Ulticare Thin Lancets 30g 2

Ulticare U-100 Insulin

Syringes/0.3ml/31g X1/4"

2


Syringes/0.5ml/31g X 1/4"

2


Syringes/1ml/31g X 1/4"

2

Ultiguard Insulin Syringe/U-

100/0.5ml/30g X 5/16"

2

Ultilet Classic Lancets 2

Ultilet Insulin

Syringe/Short/1ml/31g X 5/16"

2

Ultilet Lancets 2

Ultilet Lancets 33g 2

Ultilet Pen Needle 32gx4mm/Short 2

Ultilet Safety Lancets 23g 2

Ultilet Short Pen Needles

31gx5/16"

2

Ultilet Short Pen

Needles31gx3/16"

2

Ultra-Thin II Auto Lancet 2

Ultra-Thin II Lancets 28g 2

Ultra-Thin II Lancets 30g 2

Ultra-Thin II Pen Needles

29gx1/2"

2

Ultra-Thin II Safety Autolancets

26g

2

Ultralance 2

Unifine Pentips 32gx4mm 2

Unilet ComforTouch Lancet 2

Unilet Excelite 2

Unilet Excelite II 2

Unilet G.P. Lancet 2

Unilet G.P. SuperLite Lancet 2

Unilet GP 28 Ultra Thin 2

Unilet Lancet 2

Unilet Lancets Micro-Thin33g 2

Unilet Lancets Super-Thin30g 2

Unilet SuperLite Lancet 2

Unistik 1 2

Unistik 2 2

Unistik 2 Comfort 2

Unistik 2 Extra 2

Unistik 2 Neonatal 2

Unistik 2 Normal 2

Unistik 2 Super 2



59

Drug Name Drug

Tier

Requirements

& Limits

Unistik 3 2

Unistik 3 Comfort 2

Unistik 3 Extra 2

Unistik 3 Extra Single Use Safety

Lancets/21g

2

Unistik 3 Gentle 2

Unistik 3 Neonatal 2

Unistik 3 Normal 2

Unistik CZT Comfort 2

Unistik CZT Normal 2

Unistik Safety Lancets 28g 2

Unistik Safety Lancets 30g 2

Unistik Touch Safety Lancets 21g 2




Universal 1 Lancets Thin 26g 2

Universal 1 Lancets Ultra Thin

30g

2

Universal 1 Lancets/33g/Micro-

Thin

2

Valumark Lancet Ultra Thin 28g 2

Vanishpoint Insulin


2

Vanishpoint Insulin


2

Vida Mia Unifine Pentips

32gx4mm

2

Vida Mia Unifine Pentips Original

29gx12mm

2

Vida Mia Unipfine Pentipsshort

31gx8mm

2

Vistogard (Packet) 3

Vitalet Pro Lancets 2

Vitalet Pro Plus Lancets 2

Voraxaze (Injection) 3

Vortex Valved Holding Chamber

(Device)

2

W&F Lancets 26g 2

W&F Lancets Colored 21g 2

Walgreens Lancets 2

Walgreens Thin Lancets 2

Walgreens Ultra Thin Lancets 2

WatchHaler (Device) 2

Xeomin (100unit Injection, 50unit

Injection)

3

Xuriden (Packet) 3

Miscellaneous Therapeutic Agents : Other Miscellaneous Therapeutic Agents Exondys 51 (Injection) 3

Multiple Classifications Abilify Maintena (Injection) 3

Abraxane (Injection) 2

Acetazolamide Sodium (Solution) 1

Alimta (Injection) 2

Amifostine (Injection) 1

Drug Name Drug

Tier

Requirements

& Limits

Aripiprazole ODT (Tablet

Dispersible)

1

Azacitidine (Injection) 1

Berinert (Injection) 2

Bethkis (Nebulized Solution) 2

Bleomycin Sulfate (Injection) 1

Caldolor (Injection) 3

Camptosar (Injection) 3

Chlorpromazine HCl (25mg/ml


3

Cinryze (Injection) 2

Daunorubicin HCl (Injection) 1

DermacinRx Therazole Pak

(Therapy Pack)

3

Dexamethasone Sodium Phosphate

(4mg/ml Solution)

1

Dexrazoxane (Injection) 1

Dextrose 10% (Injection) 1





Dextrose 50% (50% Injection) 1

Diazepam (10mg/2ml Injection) 3

Diltiazem HCl (100mg Injection) 3

Diltiazem HCl (125mg/25ml



1

Diltiazem HCl/Dextrose (5%-


1

Diltiazem HCl/Sodium Chloride

(100mg/100ml-0.9% Injection)

1

Docetaxel (20mg/0.5ml Injection,

80mg/2ml Injection)

1

Doxil (Injection) 3

Duavee (Tablet) 2

Dysport (Injection) 3

Ellence (Injection) 3

Enbrel (25mg/0.5ml Injection,

50mg/ml Injection)

3

Enbrel SureClick (Injection) 3

Epirubicin HCl (Injection) 1

Erwinaze (Injection) 3

Ethyol (Injection) 3

Firazyr (Injection) 2

Fludarabine Phosphate (Injection) 1

Foscavir (Injection) 3

Fusilev (Injection) 3

Geodon (20mg Injection) 3

Halaven (Injection) 2

Humira (10mg/0.2ml Injection) 2

Hydroxyzine HCl (25mg/ml

Injection)

3

Ibuprofen Lysine (Injection) 1

Idamycin PFS (Injection) 3

Idarubicin HCl (Injection) 1

Indomethacin (1mg Solution) 1



60

Drug Name Drug

Tier

Requirements

& Limits

Intron A w/Diluent (Injection) 3

Ipratropium Bromide/Albuterol

Sulfate (Inhalation Solution)

1

Irinotecan (40mg/2ml Injection) 1

Irinotecan (500mg/25ml Injection) 3

Irinotecan HCl (Injection) 1

Istodax (Injection) 2

Istodax (Overfill) (Injection) 2

Ixempra Kit (Injection) 2

Jevtana (Injection) 2

Kadcyla (Injection) 3

Ketorolac Tromethamine (15mg/ml


30mg/ml Injection)

1

Kineret (Injection) 3

Kyprolis (60mg Injection) 2

Leucovorin Calcium (100mg

Injection, 200mg Injection, 350mg

Injection, 50mg Injection)

1

Leucovorin Calcium (500mg

Injection)

3

Levoleucovorin (50mg Injection) 1

Mesnex (400mg Tablet) 3

Methylprednisolone Sodium

Succinate (Injection)

1

Metoclopramide HCl (5mg/ml

Injection)

1

Mitomycin (Injection) 1

Neoprofen (Injection) 3

Nucala (Injection) 3

Olanzapine (10mg Injection) 1

Oncaspar (Injection) 2

Onivyde (Injection) 3

Oxaliplatin (IV Solution

100mg/20ml)

1

Oxytocin/Dextrose (5%-10unit/L

Injection, 5%-20unit/L Injection)

3

Oxytocin/Lactated Ringers

(0.1gm/500ml-30unit/500ml-

0.15gm/500ml-3gm/500ml-

1.55gm/500ml Injection)

3

Pegasys (Injection) 2

Pegasys ProClick (Injection) 2

Phenergan (25mg/ml Injection) 3

Photofrin (Injection) 3

Plegridy (Injection) 3

Plegridy Starter Pack (Injection) 3

Proleukin (Injection) 2

Promethazine HCl (25mg/ml

Injection)

1

Pulmozyme (Inhalation Solution) 2

Rebif Rebidose (Injection) 3

Risperdal Consta (Injection) 3

Saphris (2.5mg Tablet Sublingual,

5mg Tablet Sublingual)

2

Soliris (Injection) 2

Solu-Cortef (Injection) 3

Drug Name Drug

Tier

Requirements

& Limits

Solu-Medrol (Injection) 3

Synribo (Injection) 3

Tice BCG (Injection) 2

Triamcinolone Acetonide Pf

(Injection)

3

Trisenox (Injection) 2

Tysabri (Injection) 3

Velcade (Injection) 2

Vidaza (Injection) 3

Vincristine Sulfate (Injection) 1

Xeomin (200unit Injection) 3

Zaltrap (Injection) 2

Zinbryta (Injection) 3

Zinecard (Injection) 3

Zyprexa (10mg Injection) 3

Zyprexa Relprevv (Injection) 3

Ophthalmic Agents : Ophthalmic Prostaglandin and Prostamide Analogs Bimatoprost (Ophthalmic Solution) 1

Latanoprost (Ophthalmic Solution) 1

Lumigan (Ophthalmic Solution) 2

Rescula (Ophthalmic Solution) 3

Travatan Z (Ophthalmic Solution) 2

Xalatan (Ophthalmic Solution) 3

Zioptan (Ophthalmic Solution) 3

Ophthalmic Agents : Ophthalmic Agents, Other Atropine Sulfate (1% Ointment) 2

Atropine Sulfate (1% Ophthalmic

Solution)

1

Cyclogyl (Ophthalmic Solution) 3

Cyclomydril (Ophthalmic

Solution)

3

Cyclopentolate HCl (Ophthalmic

Solution)

1

Cyclopentolate HCl (Ophthalmic

Solution)

1

Cystaran (Ophthalmic Solution) 3

Lacrisert (Insert) 3

Lucentis (0.3mg/0.05ml Injection,

0.5mg/0.05ml Injection)

2

Phenylephrine HCl (10%

Ophthalmic Solution, 2.5%


1

Procysbi (Capsule Delayed-

Release)

3

Proparacaine HCl (Ophthalmic

Solution)

1

Restasis (Emulsion) 2

Restasis Multidose (Emulsion) 2

Tetracaine HCl (0.5% Ophthalmic

Solution)

1

Visudyne (Injection) 3

Ophthalmic Agents : Ophthalmic Anti-allergy Agents Alocril (Ophthalmic Solution) 3

Alomide (Ophthalmic Solution) 3

Azelastine HCl (0.05% Ophthalmic 1



61

Drug Name Drug

Tier

Requirements

& Limits

Solution)

Bepreve (Ophthalmic Solution) 3

Cromolyn Sodium (4% Ophthalmic

Solution)

1

Elestat (Ophthalmic Solution) 3

Emadine (Ophthalmic Solution) 3

Epinastine HCl (Ophthalmic

Solution)

1

Lastacaft (Ophthalmic Solution) 3

Olopatadine HCl (0.1% Ophthalmic

Solution)

1

Pataday (Ophthalmic Solution) 2

Patanol (Ophthalmic Solution) 3

Pazeo (Ophthalmic Solution) 2

Ophthalmic Agents : Ophthalmic Anti-inflammatories Acular (Ophthalmic Solution) 3

Acular LS (Ophthalmic Solution) 3

Acuvail (Ophthalmic Solution) 3

Alrex (Suspension) 3

Bromfenac (Ophthalmic Solution) 1

Bromsite (Ophthalmic Solution) 3

Dexamethasone Sodium Phosphate

(0.1% Ophthalmic Solution)

1

Diclofenac Sodium (0.1%


1

Durezol (Emulsion) 3

Flarex (Suspension) 3

Fluorometholone (Ophthalmic

Suspension)

1

Flurbiprofen Sodium (Ophthalmic

Solution)

1

FML (Ointment) 2

FML Forte (Suspension) 2

FML Liquifilm (Suspension) 3

Ilevro (Suspension) 3

Ketorolac Tromethamine (0.4%



1

Lotemax (0.5% Gel, 0.5%

Ointment, 0.5% Suspension)

3

Maxidex (Suspension) 3

Nevanac (Suspension) 3

Ocufen (Ophthalmic Solution) 3

Omnipred (Suspension) 3

Pred Forte (Suspension) 3

Pred Mild (Suspension) 2

Prednisolone Acetate (Suspension) 1


(1% Ophthalmic Solution)

1

Prolensa (Ophthalmic Solution) 3

Ophthalmic Agents : Ophthalmic Antiglaucoma Agents Acetazolamide ER (Capsule


1

Alphagan P (Ophthalmic 2

Drug Name Drug

Tier

Requirements

& Limits

Solution)

Apraclonidine (Ophthalmic

Solution)

1

Azopt (Suspension) 2

Betagan (Ophthalmic Solution) 3

Betaxolol HCl (0.5% Ophthalmic

Solution)

1

Betimol (Ophthalmic Solution) 3

Betoptic-S (Suspension) 2

Brimonidine Tartrate (Ophthalmic

Solution)

1

Carteolol HCl (Ophthalmic

Solution)

1

Combigan (Ophthalmic Solution) 2

Cosopt (Ophthalmic Solution) 3

Cosopt PF (Ophthalmic Solution) 3

Diamox (Capsule Extended-

Release 12 Hour)

3

Dorzolamide HCl/Timolol Maleate


1

Iopidine (Ophthalmic Solution) 3

Isopto Carpine (Ophthalmic

Solution)

3

Istalol (Ophthalmic Solution) 3

Keveyis (Tablet) 3

Levobunolol HCl (Ophthalmic

Solution)

1

Metipranolol (Ophthalmic Solution) 1

Phospholine Iodide (Ophthalmic

Solution)

2

Pilocarpine HCl (1% Ophthalmic

Solution, 2% Ophthalmic Solution,

4% Ophthalmic Solution)

1

Simbrinza (Suspension) 2

Timolol Maleate (0.25%



1

Timolol Maleate Ophthalmic Gel

Forming (Solution)

1

Timoptic (Ophthalmic Solution) 3

Timoptic Ocudose (Ophthalmic

Solution)

2

Timoptic-XE (Gel Form Solution) 3

Otic Agents Acetic Acid (Otic Solution) 1

Acetic Acid/Aluminum Acetate

(Otic Solution)

1

Cipro HC (Suspension) 3

Ciprodex (Otic Suspension) 2

Coly-Mycin S (Suspension) 3

Hydrocortisone/Acetic Acid (Otic

Solution)

1

Neomycin/Polymyxin/Hydrocortiso

ne (1% Otic Solution, 1% Otic

Suspension)

1

Pramotic (Liquid) 2

Oxytocics



62

Drug Name Drug

Tier

Requirements

& Limits

Oxytocin/Dextrose (5%-40unit/L

Solution)

3

Oxytocin/Dextrose/Lactated

Ringers (Solution)

3

Oxytocin/Lactated Ringers 3


(20unit/L-0.45% Solution,

30unit/L-0.9% Solution, 60unit/L-

0.9% Solution)

3


(30unit/500ml-0.9% Solution)

1

Respiratory Tract Agents : Expectorants Mucinex Maximum Strength

(1200mg Tablet Extended-Release

12 Hour)

2

Respiratory Tract/Pulmonary Agents : Anti-inflammatories, Inhaled Corticosteroids Advair Diskus (Aerosol Powder) 2

Advair HFA (Aerosol) 2

Aerospan (Aerosol Solution) 3

Alvesco (Aerosol Solution) 3

Arnuity Ellipta (Aerosol Powder) 2

Asmanex HFA (Aerosol) 3

Asmanex Twisthaler 120 Metered

Doses (Aerosol Powder)

3



3



3



3



3

Beconase AQ (Suspension) 3

Breo Ellipta (Aerosol Powder) 2

Budesonide (0.25mg/2ml

Suspension, 0.5mg/2ml Suspension,

1mg/2ml Suspension, 32mcg/act

Suspension)

1

Dulera (Aerosol) 3

Flovent Diskus (Aerosol Powder) 2

Flovent HFA (Aerosol) 2

Flunisolide (Nasal Solution) 1

Fluticasone Propionate (50mcg/act

Suspension)

1

Mometasone Furoate (50mcg/act

Suspension)

1

Nasonex (Suspension) 2

Omnaris (Suspension) 3

Pulmicort (Suspension) 3

Pulmicort Flexhaler (Aerosol

Powder)

2

Qnasl (Aerosol Solution) 3

Qnasl Childrens (Aerosol

Solution)

3

QVAR (Aerosol Solution) 2

Rhinocort Aqua (Suspension) 3

Drug Name Drug

Tier

Requirements

& Limits

Symbicort (Aerosol) 2

Triamcinolone Acetonide

(55mcg/act Aerosol)

1

Zetonna (Aerosol Solution) 3

Respiratory Tract/Pulmonary Agents : Antihistamines Astepro (Nasal Solution) 3

Azelastine HCl (0.1% Nasal

Solution, 0.15% Nasal Solution)

1

Bromphen/Pseudoephedrine

HCl/Dextromethorphan HBr (Syrup)

1

Brompheniramine Tannate

(Tablet Chewable)

3

Carbinoxamine Maleate (4mg

Tablet, 4mg/5ml Oral Solution)

1

Cetirizine HCl (1mg/ml Syrup) 1

Clarinex (0.5mg/ml Syrup, 5mg

Tablet)

3

Clemastine Fumarate (2.68mg

Tablet)

2

Desloratadine (Tablet) 1

Desloratadine ODT (Tablet

Dispersible)

1

Dymista (Suspension) 2

Hydrocodone

Bitartrate/Chlorpheniramine

Maleate/PSE (Oral Solution)

1

Hydrocodone

Polistirex/Chlorpheniramine

Polistirex (Suspension Extended-

Release)

1

Karbinal ER (Suspension

Extended-Release)

3

Levocetirizine Dihydrochloride

(2.5mg/5ml Oral Solution, 5mg

Tablet)

1

Olopatadine HCl (0.6% Nasal

Solution)

1

Patanase (Nasal Solution) 3

Promethazine/Phenylephrine

(Syrup)

1

Tussionex Pennkinetic Extended-

Release (Suspension Extended-

Release)

3

Xyzal (2.5mg/5ml Oral Solution,

5mg Tablet)

3

Zutripro (Oral Solution) 3

Respiratory Tract/Pulmonary Agents : Antileukotrienes Accolate (Tablet) 3

Montelukast Sodium (10mg Tablet,

4mg Packet, 4mg Tablet Chewable,


1

Singulair (10mg Tablet, 4mg

Packet, 4mg Tablet Chewable,


3

Zafirlukast (Tablet) 1

Zyflo (Tablet) 3



63

Drug Name Drug

Tier

Requirements

& Limits

Zyflo CR (Tablet Extended-

Release 12 Hour)

3

Respiratory Tract/Pulmonary Agents : Bronchodilators, Anticholinergic Anoro Ellipta (Aerosol Powder) 2

Atrovent HFA (Aerosol Solution) 3

Combivent Respimat (Aerosol

Solution)

2

Incruse Ellipta (Aerosol Powder) 2

Ipratropium Bromide (0.02%

Inhalation Solution, 0.03% Nasal

Solution, 0.06% Nasal Solution)

1

Spiriva HandiHaler (Capsule) 2

Spiriva Respimat (Aerosol

Solution)

2

Tudorza Pressair (Aerosol

Powder)

3

Respiratory Tract/Pulmonary Agents : Bronchodilators, Sympathomimetic Adrenaclick (Injection) 3

Adrenalin (0.1% Nasal Solution,

1mg/ml Injection, 30mg/30ml

Injection)

3

Albuterol Sulfate (Nebulized

Solution, Tablet, Syrup)

1

Albuterol Sulfate ER (Tablet


1

Arcapta Neohaler (Capsule) 3

Auvi-Q (Solution Auto injector) 3

Brovana (Nebulized Solution) 3

Ephedrine Sulfate (250mg/5ml

Injection)

3

Ephedrine Sulfate/Sodium


Injection, 10mg/ml-0.9%



Injection)

3

Epinephrine (0.15mg/0.15ml

Solution Auto injector,

0.3mg/0.3ml Solution Auto

injector) (authorized generic Epi-

Pen made by Mylan)

3

Epinephrine (0.15mg/0.3ml

Injection, 0.3mg/0.3ml Injection)

2

Epinephrine HCl (1mg/ml

Injection)

3

EpiPen (Injection) 3

Isuprel (Injection) 3

Levalbuterol (Nebulized Solution) 1

Levalbuterol Tartrate HFA

(Aerosol)

3

Metaproterenol Sulfate (10mg


Syrup)

1

Perforomist (Nebulized Solution) 3

ProAir HFA (Aerosol Solution) 2

ProAir RespiClick (Aerosol 2

Drug Name Drug

Tier

Requirements

& Limits

Powder)

Proventil HFA (Aerosol Solution) 3

Serevent Diskus (Aerosol Powder) 2

Striverdi Respimat (Aerosol

Solution)

3

Terbutaline Sulfate (1mg/ml

Injection, 2.5mg Tablet, 5mg

Tablet)

1

Ventolin HFA (Aerosol Solution) 2

Vospire ER (Tablet Extended-

Release 12 Hour)

3

Xopenex (Nebulized Solution) 3

Xopenex Concentrate (Nebulized

Solution)

3

Xopenex HFA (Aerosol) 3

Respiratory Tract/Pulmonary Agents : Cystic Fibrosis Agents Kalydeco (150mg Tablet, 50mg

Packet, 75mg Packet)

3

Orkambi (Tablet) 3

Respiratory Tract/Pulmonary Agents : Mast Cell Stabilizers Cromolyn Sodium (20mg/2ml

Nebulized Solution)

1

Respiratory Tract/Pulmonary Agents : Phosphodiesterase Inhibitors, Airways Disease Aminophylline (Injection) 1

Daliresp (Tablet) 3

Elixophyllin (Elixir) 2

Theo-24 (Capsule Extended-

Release 24 Hour)

3

Theophylline (Oral Solution) 1

Theophylline CR (Tablet Extended-

Release 12 Hour)

1

Theophylline ER (Tablet Extended-

Release 12 Hour, Tablet Extended-

Release 24 Hou)

1

Theophylline/D5W (Injection) 3

Respiratory Tract/Pulmonary Agents : Pulmonary Antihypertensives Adcirca (Tablet) 3

Adempas (Tablet) 2

Epoprostenol Sodium (Injection) 1

Flolan (Injection) 3

Letairis (Tablet) 2

Opsumit (Tablet) 2

Orenitram (Tablet Extended-

Release)

3

Remodulin (Injection) 2

Revatio (10mg/12.5ml Injection,

10mg/ml Suspension, 20mg

Tablet)

3

Sildenafil (10mg/12.5ml Injection,

20mg Tablet)

1

Tracleer (Tablet) 2

Tyvaso (Inhalation Solution) 3



64

Drug Name Drug

Tier

Requirements

& Limits

Tyvaso Refill (Inhalation

Solution)

3

Tyvaso Starter (Inhalation

Solution)

3

Uptravi (Tablet) 3

Veletri (Injection) 2

Ventavis (Inhalation Solution) 3

Respiratory Tract/Pulmonary Agents : Respiratory Tract Agents, Other Acetadote (Injection) 3

Acetylcysteine (10% Inhalation

Solution, 20% Inhalation Solution,

200mg/ml Injection)

1

Aralast NP (Injection) 3

Benzonatate (Capsule) 1

Cetylev (Tablet Effervescent) 3

Cinqair (Injection) 3

Curosurf (Suspension) 3

Esbriet (Capsule) 3

Exactuss (Liquid) 3

Giltuss (Liquid) 3

Glassia (Injection) 3

Hydrocodone

Bitartrate/Homatropine

Methylbromide (1.5mg-5mg Tablet,

1.5mg/5ml-5mg/5ml Syrup)

1

Hyper-Sal (Nebulized Solution) 3

Hypersal (Nebulized Solution) 3

Infasurf (Suspension) 3

Iodine Strong (5%-10% Oral

Solution)

3

Lugols (Solution) 3

Nebusal (6% Nebulized Solution) 3

Ofev (Capsule) 3

Prolastin-C (Injection) 3

Promethazine-DM (Syrup) 1

Promethazine/Codeine (Syrup) 1

Promethazine/Phenylephrine/Codein

e (Syrup)

1

Rezira (Oral Solution) 3

Ribavirin (6gm Solution) 1

Sodium Chloride (Nebulized

Solution)

1

SSKI (Oral Solution) 2

Stiolto Respimat (Aerosol

Solution)

2

Survanta Intratracheal

(Suspension)

3

Tessalon Perles (Capsule) 3

Tyzine Pediatric Nasal Drops

(Nasal Solution)

3

Virazole (Inhalation Solution) 3

Xolair (Injection) 2

Zemaira (Injection) 3

Skeletal Muscle Relaxants Anectine (Injection) 3

Atracurium Besylate (Injection) 1

Drug Name Drug

Tier

Requirements

& Limits

Carisoprodol (250mg Tablet, 350mg

Tablet)

1

Carisoprodol/Aspirin (Tablet) 1

Carisoprodol/Aspirin/Codeine

(Tablet)

1

Chlorzoxazone (Tablet) 1

Cisatracurium Besylate (Injection) 1

Cyclobenzaprine HCl (10mg Tablet,

5mg Tablet, 7.5mg Tablet)

1

Dantrium IV (Injection) 3

Fexmid (Tablet) 3

Lorzone (Tablet) 3

Metaxalone (Tablet) 1

Methocarbamol (Injection, Tablet) 1

Nimbex (Injection) 3

Orphenadrine Citrate (30mg/ml

Injection)

1

Orphenadrine Citrate ER (Tablet


1

Pancuronium Bromide (Injection) 1

Parafon Forte DSC (Tablet) 3

Quelicin (Injection) 3

Robaxin (Injection, 500mg Tablet) 3

Robaxin-750 (Tablet) 3

Rocuronium Bromide (100mg/10ml


1

Rocuronium Bromide (50mg/5ml

Injection)

3

Skelaxin (Tablet) 3

Soma (Tablet) 3

Succinylcholine Chloride

(100mg/5ml Injection,


3

Vecuronium Bromide (10mg

Injection, 20mg Injection)

1

Vecuronium Bromide/Sodium

Chloride (Injection)

3

Skin and Mucous Membrane Preparations : Anti-infectives Rosadan Kit (Kit) 3

Skin and Mucous Membrane Preparations : Anti-inflammatory Agents Synalar Cream Kit (Kit) 3

Ultravate X (Kit) 3

Skin and Mucous Membrane Preparations : Cell Stimulants and Proliferants Retinoic Acid (Powder) 2

Retinoic Acid-All Trans (Powder) 2

Tretinoin (Powder) 2

Skin and Mucous Membrane Preparations : Skin and Mucous Membrane Agents, Misc Absorica (25mg Capsule, 35mg

Capsule)

3

Rhofade (Cream) 3

Scarlet Red Dressing 3



65

Drug Name Drug

Tier

Requirements

& Limits

Sleep Disorder Agents : GABA Receptor Modulators Ambien (Tablet) 3

Ambien CR (Tablet Extended-

Release)

3

Edluar (Tablet Sublingual) 3

Eszopiclone (Tablet) 1

Intermezzo (Tablet Sublingual) 3

Lunesta (Tablet) 3

Sonata (Capsule) 3

Zaleplon (Capsule) 1

Zolpidem Tartrate (Tablet

Sublingual, Tablet)

1

Zolpidem Tartrate ER (Tablet

Extended-Release)

1

Zolpimist (Oral Solution) 3

Sleep Disorder Agents : Sleep Disorders, Other Armodafinil (Tablet) 1

Belsomra (Tablet) 3

Butisol Sodium (Tablet) 3

Modafinil (Tablet) 1

Nembutal Sodium (Injection) 3

Nuvigil (Tablet) 3

Provigil (Tablet) 3

Rozerem (Tablet) 3

Seconal Sodium (Capsule) 3

Silenor (Tablet) 3

Tryptophan (500mg Capsule) 3

Xyrem (Oral Solution) 3

Therapeutic Nutrients/Minerals/Electrolytes : Feraheme (Injection) 3

Kabiven (Injection) 3

Therapeutic Nutrients/Minerals/Electrolytes : Electrolyte/Mineral Modifiers Carbaglu (Tablet) 2

Chemet (Capsule) 3

Exjade (Tablet Soluble) 3

Jadenu (Tablet) 3

Kayexalate (Powder) 3

Samsca (Tablet) 2

Sodium Acetate (2meq/ml Injection) 1

Sodium Bicarbonate (7.5%

Injection)

1

Sodium Lactate (Injection) 3

Sodium Polystyrene Sulfonate

(Powder, Suspension)

1

Syprine (Capsule) 3

Veltassa (Packet) 3

Zinc Trace Metal (Injection) 3

Therapeutic Nutrients/Minerals/Electrolytes : Electrolyte/Mineral Replacement Aminosyn (Injection) 3

Aminosyn 7%/Electrolytes

(Injection)

3

Aminosyn II (Injection) 3

Aminosyn M (Injection) 3

Drug Name Drug

Tier

Requirements

& Limits

Aminosyn-HBC (Injection) 3

Aminosyn-PF (Injection) 3

Aminosyn-RF (Injection) 3

Axona (Packet) 3

Calcifol (Wafer) 3

Calcium Chloride (10% Injection) 1

Calcium Gluconate/Sodium


Injection, 2gm/100ml-0.9%

Injection, 2gm/50ml-0.9%

Injection)

3

Camino Pro Bettermilk/Glytactin

(Packet)

3

Camino Pro Complete/Glytactin

(Bar)

3

Camino Pro Swirl (Packet) 3

Chromium Chloride (Injection) 1

Clinimix/Dextrose (Injection) 3

Copper Trace Metal (Injection) 3

Corvite 150 (Tablet) 3

Cytra-3 (Syrup) 2

Effervescent Potassium/Chloride

(Tablet Effervescent)

1

Ferrlecit (Injection) 3

Fluoride (0.5mg Tablet Chewable) 1

Folivane-F (Capsule) 3

Fosteum Plus (Capsule) 3

Fovex (Capsule) 3

FreAmine HBC 6.9% (Injection) 3

FreAmine III (Injection) 3

Gabadone (Capsule) 3

Galzin (Capsule) 3

Glytactin Bettermilk 15 (Packet) 3

Glytactin Bettermilk De-Lite

(Packet)

3

Glytactin Build 10pe (Packet) 3

Glytactin Complete 10pe (Bar) 3

Glytactin Restore 5 (Packet) 3

Glytactin Restore Lite 10PE

(Packet)

3

Hematron-Af (Tablet) 3

HepatAmine (Injection) 3

Hextend (Injection) 3

Hypertensa (Capsule) 3

Infed (Injection) 3

Integra F (40mg-62.5mg-

1000mcg-3mg-62.5mg Capsule)

3

K-Tab (10meq Tablet Extended-

Release)

3

K-Tab (20meq Tablet Extended-

Release, 8meq Tablet Extended-

Release)

2

Klor-Con M15 (Tablet Extended-

Release)

3

Lipichol 540 (Capsule) 3

Lister-V (Capsule) 3

Lozi-Flur (Lozenge) 2



66

Drug Name Drug

Tier

Requirements

& Limits

Lukaid GLA (Emulsion) 3

Luride (Oral Solution) 3

Macutek (Tablet Dispersible) 3

Magnesium Chloride (200mg/ml

Injection)

1

Magnesium Sulfate (20gm/500ml

Injection, 2gm/50ml Injection,

40gm/1000ml Injection,


Injection)

3

Manganese Trace Metal

(Injection)

3

Micro-K (Capsule Extended-

Release)

3

Multigen (Tablet) 3

Multigen Folic (Tablet) 3

Multigen Plus (Tablet) 3

Nafrinse Daily/Acidulated

(Solution)

3

Nephramine (Injection) 3

Neurepa (Capsule) 3

Nicaprin (Tablet) 3

Normal Saline Flush (Solution) 1

Percura (Capsule) 3

Perikabiven (Injection) 3

Potassium Acetate (2meq/ml

Injection)

1

Potassium Acetate (2meq/ml

Injection, 4meq/ml Injection)

3

Potassium Chloride (10meq/50ml

Injection)

3

Potassium Chloride CR (Tablet

Extended-Release)

1

Potassium Chloride ER (10meq

Capsule Extended-Release, 8meq

Capsule Extended-Release, 10meq

Tablet Extended-Release, 20meq

Tablet Extended-Release, 8meq

Tablet Extended-Release)

1

Potassium Chloride SR (Tablet

Extended-Release)

1

Potassium Citrate ER (Tablet

Extended-Release)

1

Premasol (Injection) 3

Prismasol (Injection) 3

Procalamine (Injection) 3

Proferrin-Forte (Tablet) 3

Prosol (Injection) 3

Proteolin (Tablet) 3

Pulmona (Capsule) 3

Saline Flush (Injection) 1

Saline/Phenol (Injection) 3

Sentra AM (Capsule) 3

Sentra PM (Capsule) 3

Shohls Solution Modified (Oral

Solution)

3

Sodium Chloride (2.5meq/ml

Injection, 3% Injection, 5%

1

Drug Name Drug

Tier

Requirements

& Limits

Injection)

Sodium Chloride 0.45% (Injection) 1

Sodium Chloride Bacteriostatic

(0.9% Injection)

1

Sodium Chloride

Bacteriostatic/Benzyl Alcohol

(Injection)

3

Sodium Chloride Flush (Injection) 1

Sodium Ferric Gluconate

Complex/Sucrose (Injection)

1

Sodium Fluoride (0.25mg Tablet

Chewable, 1.1mg Tablet Chewable,

1mg Tablet Chewable, 0.5mg/ml

Solution, 1mg Tablet)

1

Sodium Fluoride (0.5mg Tablet) 2

Sodium Phosphate (3MMOLE/ml

Injection)

1

Sulfzix (500mcg-0-0-Capsule) 3

Theramine (Capsule) 3

Theramine Plus (Packet) 3

Travasol (Injection) 3

Trepadone (Capsule) 3

Trophamine (Injection) 3

Tylactin Restore 5PE (Packet) 3

Urocit-K (Tablet Extended-

Release)

3

Vasculera (Tablet) 3

Venofer (Injection) 3

Visbiome (Packet) 3

Therapeutic Nutrients/Minerals/Electrolytes Krisgel 100 (Gel) 3

Plo Gel - Mediflo Kit (Kit) 3

Sodium Citrate (Injection) 3

Sulfzix (500mcg/0.25gm-0-0-0

Powder)

3

Therapeutic Nutrients/Minerals/Electrolytes : Vitamins Aquasol A Parenteral (Injection) 3

Atabex Prenatal (Tablet

Chewable)

2

B-6 Folic Acid (Capsule) 3

Cerefolin Nac (Tablet) 3

Cod Liver Oil (0 Oil) 3

Corvite (Tablet) 3

Cyanocobalamin (1000mcg/ml

Injection)

1

Floriva Plus (Oral Solution) 2

Folbee Plus Cz (Tablet) 2

Folbic RF (Tablet) 3

Folcaps Omega 3 (Capsule) 2

Folgard Rx (Tablet) 3

Folic Acid (1mg Tablet) 1

Folic Acid (5mg/ml Injection) 3

Folic Acid/Vitamin B-6/Vitamin B-

12 (Tablet)

1

Foltanx (Tablet) 3

Foltanx RF (Capsule) 3



67

Drug Name Drug

Tier

Requirements

& Limits

Foltx (Tablet) 3

Fortavit (Capsule) 3

Fosteum (Capsule) 3

Healthy Mama Be Well Rounded

(Therapy Pack)

2

Hydroxocobalamin (Injection) 3

Infuvite (Injection) 3

Infuvite Pediatric (Injection) 3

L-Methyl-B6-B12 (Tablet) 3

L-Methylfolate Ca/P-5-P/Me-Cbl

(Capsule)

1

Lmthf/Pyridoxine

HCl/Cyanocobalamin (Tablet)

1

M.V.I. Adult (Injection) 3

M.V.I.-12 without Vitamin K

(Injection)

3

Mephyton (Tablet) 2

Metafolbic Plus (Tablet) 3

Metafolbic Plus RF (Tablet) 3

Metanx (Capsule) 3

Methionine/Inositol/Choline/Cyan

ocobalamin (Injection)

3

Mission Prenatal (Tablet) 2

NascoBAL (Nasal Solution) 3

Nephro-Vite Rx (Tablet) 3

Nephrocaps (Capsule) 3

Niacin (Powder) 3

Nicadan (Tablet) 3

Nicadan Zx (Tablet) 3

Nicazel (Tablet) 3

Nicazel Forte (Tablet) 3

Niva-Plus (Tablet) 2

Nutricap (Tablet) 3

O-Cal Fa (Tablet) 2

OB Complete (Tablet) 2

Obtrex (Tablet) 2

One A Day Womens

Prenatal/DHA

2

One A Day Womens Prenatal1

(Capsule)

2

One-A-Day Womens Prenatal 2

Phytonadione (Injection) 1

PKU Easy Microtabs (Tablet

Delayed-Release)

3

Prenatal Vitamin (Tablet) 2

Prenatal Vitamins (120mg-

4000unit-200mg-400unit-8mcg-

28mg-800mcg-20mg-2.6mg-1.7mg-

1.8mg-30unit-25mg Tablet)

2

Protect Plus (Capsule) 3

Pyridoxine HCl (100mg/ml

Injection)

1

Req 49+ (Tablet) 3

Right Step Prenatal (Tablet) 2

Siderol (Tablet) 3

Theranatal Core Nutrition

(Tablet)

2

Drug Name Drug

Tier

Requirements

& Limits

Thiamine HCl (100mg/ml Injection) 1

Triveen-Duo DHA 3

Vascazen (Capsule) 3

Vayacog (Capsule) 3

Vayarin (Capsule) 3

Vayarol (Capsule) 3

Vinate Care (Tablet Chewable) 2

Vitamin C 222mg (Injection) 1

Vitamin D (50000unit Capsule) 1

Vitamin K1 (10mg/ml Injection) 3

Vitamin K1 (1mg/0.5ml Injection) 1

Vitaroca Plus (Tablet) 3

Wheat Germ (Oil) 3

Your Life Multi Prenatal

(Capsule)

2

Zatean-PN DHA (Capsule) 3

Vitamins : Multivitamin Preparations Adrenal C Formula (Tablet) 3

Atabex EC (Tablet Delayed-

Release)

2

Bal-Care DHA 2

Citranatal B-Calm 2

Citranatal Rx (Tablet) 2

Clinical Nutrients Prenatal

Formula (Tablet)

2

Concept DHA (Capsule) 2

Concept Ob (Capsule) 2

Duet DHA 400 2

Duet DHA Balanced 2

Enbrace HR (Capsule) 2

Escavite (Tablet Chewable) 2

Escavite D (Tablet Chewable) 2

Focalgin 90 DHA 3

Focalgin Ca 3

Folgard Os (Tablet) 3

Folivane-Ob (Capsule) 2

M.V.I. Pediatric (Injection) 3

Marnatal-F (Capsule) 2

Mteryti (Tablet Therapy Pack) 2

Mteryti Folic 5 (Tablet Therapy

Pack)

2

MyKidz Iron Fl (Suspension) 2

Mynatal (Capsule) 2

Natachew (Tablet Chewable) 2

Natalvit (Tablet) 2

Natelle One (Capsule) 2

Neevo DHA (Capsule) 2

Nestabs (Tablet) 2

Nestabs DHA 2

Newgen (Tablet) 2

Nexa Plus (Capsule) 3

Nutrivit (Liquid) 3

O-Cal Prenatal (Tablet) 2

OB Complete Gold (Capsule) 3

OB Complete One (Capsule) 2

OB Complete Petite (Capsule) 2



68

Drug Name Drug

Tier

Requirements

& Limits

OB Complete Premier (Tablet) 2

OB Complete/DHA (Capsule) 2

Obstetrix DHA 2

Obstetrix One (Capsule) 3

Obtrex DHA 2

Poly-Vi-Flor (Tablet

Chewable,Suspension)

2

Poly-Vi-Flor Fs (Strip) 2

Poly-Vi-Flor/Iron (Tablet

Chewable, Suspension)

2

PreferaOB (Tablet) 2

Prenata (Tablet Chewable) 2

Prenate AM (Tablet) 2

Prenate Elite (Tablet) 2

Prenate Essential (Capsule) 2

Prenate Star (Tablet) 2

Primacare (Capsule) 2

Provida OB (Capsule) 2

Quflora Fe (Tablet Chewable) 3

R-Natal OB (Capsule) 3

Renatabs (Tablet) 3

Select-OB (Tablet Chewable) 2

Strovite Forte (Syrup) 3

Supervite (Liquid) 3

Support-500 (Capsule) 3

Synagex (Capsule) 3

Synatek (Capsule) 3

Taron-BC 2

Taron-C DHA (Capsule) 2

Tl G-Fol Os (Tablet) 3

Tri-Vi-Flor (Suspension) 2

Tricare Prenatal (Tablet

Chewable)

2

Tricare Prenatal Compleat 2

Tricare Prenatal DHA One

(Capsule)

2

Udamin Sp (Tablet) 3

Vinate DHA RF (Capsule) 2

Vita-Pren (Tablet) 2

Vitafol Gummies (Tablet

Chewable)

2

Vitafol-Nano (Tablet) 2

Vitamedmd One Rx/Quatrefolic

(Capsule)

3

Vitamedmd Redichew Rx (Tablet

Chewable)

2

Vitapearl (Capsule Extended-

Release)

2

Viva DHA (Capsule) 2

Zatean-PN Plus (Capsule) 2

Vitamins : Vitamin A Vitamin A (Capsule) 2

Vitamins : Vitamin B Complex Abaneu-Sl (Tablet Sublingual) 3

Cardiotek-Rx (Tablet) 3

Cenfol (Tablet) 3

Drug Name Drug

Tier

Requirements

& Limits

Cerefolin (Tablet) 3

Cyfolex (Capsule) 3

Elfolate Plus (Tablet) 3

Metafolbic (Tablet) 3

Podiapn (Capsule) 3

Pre-Folic (Tablet) 3

Vitamins : Vitamin D Rayaldee (Capsule Extended-

Release)

3

69

Index of Covered Drugs

1

1st Choice Lancets Thin ............................... 52 1st Tier Unifine Pentips 29gx12mm ........... 52 1st Tier Unifine Pentips 31gx6mm ............. 52 1st Tier Unifine Pentips 31gx8mm ............. 52

3

3ml Glass Syringe Kit/1ml Na Hep/Swab/Prep/Cap/Ndl St/Label/Drap (Kit) ......................................................... 52

5

5ml Glass Syringe Kit/1ml Na Hep/Swab/Prep/Cap/Ndl St/Label/Drap (Kit) ......................................................... 52

A

Abacavir (Tablet) ......................................... 28 Abacavir Sulfate/Lamivudine/Zidovudine

(Tablet) ................................................... 28 Abacavir/Lamivudine (Tablet) ..................... 28 Abaneu-Sl (Tablet Sublingual) .................... 68 Abelcet (Injection) ...................................... 22 Abilify (Tablet) ............................................ 20 Abilify Maintena (Injection)........................ 59 Abraxane (Injection) ................................... 59 Absorica (10mg Capsule, 20mg Capsule,

30mg Capsule, 40mg Capsule) ............... 40 Absorica (25mg Capsule, 35mg Capsule) .... 64 Abstral (Tablet Sublingual) ......................... 11 Acamprosate Calcium DR (Tablet Delayed-

Release) .................................................. 13 Acanya (Gel) ................................................ 40 Acarbose (Tablet) ........................................ 30 Accolate (Tablet) ......................................... 62 Accu-Chek Aviva .......................................... 52 Accu-Chek Aviva Connect (Kit) ................... 52 Accu-Chek Aviva Plus (Kit, Strip) ................ 52 Accu-Chek Compact Plus (Strip) ................. 52 Accu-Chek Compact Plus Care Kit (Kit) ....... 52 Accu-Chek Compact Test Drum (Strip) ....... 52 Accu-Chek Fastclix Lancet Device Kit (Kit) .. 52 Accu-Chek Fastclix Lancets ......................... 52 Accu-Chek Guide (Kit, Strip) ....................... 52 Accu-Chek Multiclix Lancet Device Kit (Kit) 52 Accu-Chek Multiclix Lancets ....................... 52 Accu-Chek Nano Smartview (Kit)................ 52 Accu-Chek Safe-T-Pro Lancets .................... 52 Accu-Chek Safe-T-Pro Pluslancets .............. 52 Accu-Chek Smartview Strips (Strip) ............ 52 Accu-Chek Soft Touch Lancets .................... 52 Accu-Chek Softclix Lancet Device Kit (Kit) .. 52 Accu-Chek Softclix Lancets ......................... 52 Accupril (Tablet) .......................................... 34 Accuretic (Tablet) ........................................ 34

Accutrend Glucose (Strip) .......................... 52 Acebutolol HCl (200mg Capsule, 400mg

Capsule) .................................................. 35 Aceon (Tablet) ............................................ 34 Acetadote (Injection) ................................. 64 Acetaminophen/Caffeine/Dihydrocodeine

(Capsule) ................................................ 11 Acetaminophen/Codeine (120mg/5ml-

12mg/5ml Oral Solution, 300mg-15mg Tablet, 300mg-30mg Tablet, 300mg-60mg Tablet) .................................................... 11

Acetazolamide (Tablet Immediate-Release) 36 Acetazolamide ER (Capsule Extended-Release

12 Hour) ................................................. 61 Acetazolamide Sodium (Solution) ............... 59 Acetic Acid (Otic Solution) ........................... 61 Acetic Acid/Aluminum Acetate (Otic Solution)

............................................................... 61 Acetylcysteine (10% Inhalation Solution, 20%

Inhalation Solution, 200mg/ml Injection) ............................................................... 64

Aciphex (Tablet Delayed-Release) ............. 45 Aciphex Sprinkle (Capsule Sprinkle) .......... 45 Acitretin (Capsule) ...................................... 40 Aclovate (Cream) ........................................ 40 Actemra (162mg/0.9ml Injection,

200mg/10ml Injection, 400mg/20ml Injection, 80mg/4ml Injection).............. 51

Acticlate (Tablet) ........................................ 18 Actigall (Capsule) ........................................ 44 Actimmune (Injection) ............................... 51 Actiq (Lollipop) ........................................... 11 Activase (Injection) ..................................... 32 Active 1st Blood Lancets 30g/Easy Twist Cap

............................................................... 52 Activella (Tablet) ........................................ 48 Actonel (Tablet) .......................................... 51 Actoplus Met (Tablet) ................................ 30 Actoplus Met XR (Tablet Extended-Release

24 Hour) ................................................. 50 Actos (Tablet) ............................................. 30 Acular (Ophthalmic Solution) ..................... 61 Acular LS (Ophthalmic Solution) ................ 61 Acuvail (Ophthalmic Solution) ................... 61 Acyclovir (200mg Capsule, 200mg/5ml

Suspension, 400mg Tablet, 800mg Tablet, 5% Ointment) ......................................... 29

Acyclovir Sodium (Injection) ....................... 29 Aczone (Gel) ............................................... 40 Adagen (Injection) ...................................... 43 Adalat CC (30mg Tablet Extended-Release 24

Hour, 60mg Tablet Extended-Release 24 Hour, 90mg Tablet Extended-Release 24 Hour) ...................................................... 35

Adapalene (0.1% Cream, 0.1% Gel, 0.3% Gel) ............................................................... 40

Adapalene (0.1% Lotion) ............................ 40 Adapalene Pump (Gel) ................................ 40

Adasuve (Aerosol Powder) ......................... 27 Adcetris (Injection) ..................................... 26 Adcirca (Tablet) ........................................... 63 Adderall (Tablet) ......................................... 39 Adderall XR (Capsule Extended-Release 24

Hour) ...................................................... 39 Addyi (Tablet).............................................. 39 Adefovir Dipivoxil (Tablet) ........................... 28 Adempas (Tablet) ........................................ 63 Adenocard (Injection) ................................. 34 Adenosine (12mg/4ml Injection, 6mg/2ml

Injection) ................................................. 34 Adenosine (60mg/20ml Injection,

90mg/30ml Solution Prefilled Syringe) . 38 Adlyxin (Injection) ....................................... 50 Adlyxin Starter Pack (Injection) .................. 50 Adoxa (100mg Tablet, 50mg Tablet, 75mg

Tablet, 150mg Capsule) .......................... 18 Adoxa Pak 1/100 (Tablet) ........................... 18 Adoxa Pak 1/150 (Tablet) ........................... 18 Adoxa Pak 2/100 (Tablet) ........................... 18 Adrenaclick (Injection) ................................ 63 Adrenal C Formula (Tablet) ......................... 67 Adrenalin (0.1% Nasal Solution, 1mg/ml

Injection, 30mg/30ml Injection) ............ 63 Advair Diskus (Aerosol Powder) ................. 62 Advair HFA (Aerosol) .................................. 62 Advate (Injection) ....................................... 32 Advocate Insulin Pen Needles .................... 52 Advocate Lancets ........................................ 52 Advocate Lancets 30g ................................. 52 Advocate Safety Lancets 26g ...................... 52 Adzenys XR-ODT (Tablet Extended-Release

Dispersible) ............................................ 39 AeroChamber Mini Aerosol Chamber

(Device) .................................................. 52 AeroChamber MV ....................................... 53 AeroChamber Plus Flow Vu ........................ 53 AeroChamber Plus Flow-Vu ........................ 53 AeroChamber Plus Flow-Vu/Large Mask.... 53 AeroChamber Plus Flow-Vu/Mask ............. 53 AeroChamber Plus Flow-Vu/Medium Mask

................................................................ 53 AeroChamber Plus Flow-Vu/Small Mask ... 53 AeroChamber Z-Stat Plus/Medium Mask .. 53 AeroChamber/FlowSignal ........................... 53 Aerospan (Aerosol Solution)....................... 62 Aerovent Plus Holding Chamber/Collapsible

(Device) .................................................. 53 AF Lancets Super Thin ................................. 53 Afinitor (Tablet) .......................................... 25 Afinitor Disperz (Tablet Soluble) ................ 25 Afrezza (Powder)......................................... 31 Agamatrix Ultra-Thin Lancets 33g .............. 53 Aggrastat (0.9%-12.5mg/250ml Injection,

0.9%-5mg/100ml Injection) ................... 33 Aggrastat (3.75mg/15ml Injection) ............ 52 Aggrenox (Capsule Extended-Release 12

70

Hour) ...................................................... 33 Agrylin (Capsule) ......................................... 32 Akten (Gel) .................................................. 12 Akynzeo (Capsule)....................................... 21 Ala Scalp (Lotion) ........................................ 40 Ala-Quin (Cream) ........................................ 22 Albenza (Tablet) .......................................... 26 Albuterol Sulfate (Nebulized Solution, Tablet,

Syrup) ..................................................... 63 Albuterol Sulfate ER (Tablet Extended-

Release 12 Hour) .................................... 63 Alclometasone Dipropionate (0.05% Cream,

0.05% Ointment) .................................... 40 Alcoh-Glove Contoured Wipe ..................... 14 Alcoh-Wipe 12" X 12" ................................. 14 Aldactazide (Tablet) .................................... 37 Aldactone (Tablet) ...................................... 37 Aldara (Cream) ............................................ 40 Aldurazyme (Injection) ............................... 43 Alecensa (Capsule) ...................................... 25 Alendronate Sodium (10mg Tablet, 35mg

Tablet, 40mg Tablet, 5mg Tablet, 70mg Tablet)..................................................... 51

Alendronate Sodium (70mg/75ml Oral Solution) ................................................. 51

Alevicyn Antipruritic SG (Liquid) ................ 40 Alfentanil (Injection) .................................... 11 Alfentanil HCl (Injection) ............................ 11 Alferon N (Injection) ................................... 25 Alfuzosin HCl ER (Tablet Extended-Release 24

Hour) ....................................................... 46 Alimta (Injection) ........................................ 59 Alinia (100mg/5ml Suspension, 500mg

Tablet) .................................................... 26 Alkeran (2mg Tablet) .................................. 24 Alkeran (50mg Injection) ............................ 24 Allopurinol (Tablet) ...................................... 23 Allopurinol Sodium (Injection) ..................... 23 Almotriptan Malate (Tablet) ........................ 23 Alocril (Ophthalmic Solution) ..................... 60 Alogliptin (Tablet) ....................................... 30 Alogliptin/Metformin HCl (Tablet) ............. 30 Alogliptin/Pioglitazone (Tablet) ................. 30 Alomide (Ophthalmic Solution) .................. 60 Aloprim (Injection) ...................................... 23 Alora (Patch Twice Weekly) ........................ 48 Alosetron HCl (Tablet) ................................. 45 Aloxi (Injection) ........................................... 22 Alphagan P (Ophthalmic Solution) ............. 61 Alphanate/Von Willebrand Factor

Complex/Human (250unit Injection) ..... 32 Alphanine SD (Injection) ............................. 32 Alprazolam (Tablet Immediate-Release) ..... 29 Alprazolam ER (Tablet Extended-Release 24

Hour) ....................................................... 29 Alprazolam Intensol (1mg/ml Concentrate)

................................................................ 29 Alprazolam ODT (Tablet Dispersible) ........... 29 Alprostadil (Injection) .................................. 47 Alrex (Suspension) ...................................... 61 Altabax (Ointment) ..................................... 14

Altace (Capsule) .......................................... 34 Altoprev (Tablet Extended-Release 24 Hour)

............................................................... 37 Alvesco (Aerosol Solution) ......................... 62 Amantadine HCl (100mg Capsule, 100mg

Tablet, 50mg/5ml Syrup)........................ 26 Amaryl (Tablet) ........................................... 30 Ambien (Tablet) .......................................... 65 Ambien CR (Tablet Extended-Release) ...... 65 AmBisome (Injection) ................................. 22 Amcinonide (0.1% Cream, 0.1% Lotion, 0.1%

Ointment) ............................................... 40 Amerge (Tablet) .......................................... 23 Amicar (0.25gm/ml Oral Solution, 1000mg

Tablet, 500mg Tablet)............................ 32 Amifostine (Injection) ................................. 59 Amikacin Sulfate (1gm/4ml Injection,

500mg/2ml Injection) ............................. 14 Amiloride HCl (5mg Tablet) ......................... 37 Amiloride/Hydrochlorothiazide (Tablet) ..... 37 Amino PM Rms (Capsule) ........................... 53 Aminocaproic Acid (Injection) .................... 33 Aminophylline (Injection) ............................ 63 Aminosyn (Injection) .................................. 65 Aminosyn 7%/Electrolytes (Injection) ....... 65 Aminosyn II (Injection) ............................... 65 Aminosyn M (Injection) .............................. 65 Aminosyn-HBC (Injection) .......................... 65 Aminosyn-PF (Injection) ............................. 65 Aminosyn-RF (Injection) ............................. 65 Amiodarone HCl (100mg Tablet, 200mg

Tablet, 400mg Tablet, 50mg/ml Injection) ............................................................... 34

Amiodarone HCl/Dextrose (Injection) ......... 34 Amitiza (Capsule) ........................................ 45 Amitriptyline HCl (100mg Tablet, 10mg

Tablet, 150mg Tablet, 25mg Tablet, 50mg Tablet, 75mg Tablet) .............................. 21

Amlodipine Besylate (Tablet) ...................... 35 Amlodipine Besylate/Atorvastatin Calcium

(Tablet) ................................................... 35 Amlodipine Besylate/Benazepril HCl (Capsule)

............................................................... 34 Amlodipine Besylate/Valsartan (Tablet) ..... 33 Amlodipine/Olmesartan Medoxomil (Tablet)

............................................................... 33 Amlodipine/Valsartan/Hydrochlorothiazide

(Tablet) ................................................... 34 Ammonium Lactate (12% Cream, 12% Lotion)

............................................................... 40 Ammonul (Injection) .................................. 53 Amoxapine (Tablet) ..................................... 21 Amoxicillin (125mg Tablet Chewable, 250mg

Tablet Chewable, 125mg/5ml Suspension, 200mg/5ml Suspension, 250mg/5ml Suspension, 400mg/5ml Suspension, 250mg Capsule, 500mg Capsule, 500mg Tablet, 875mg Tablet) ............................ 16

Amoxicillin/Clavulanate Potassium (Tablet Chewable, Tablet Immediate-Release, Oral Suspension) ............................................ 16

Amoxicillin/Clavulanate Potassium ER (Tablet Extended-Release 12 Hour) .................... 16

Amphadase (Injection)................................ 52 Amphetamine/Dextroamphetamine

(1.875mg-1.875mg-1.875mg-1.875mg Tablet, 10mg Tablet, 12.5mg Tablet, 15mg Tablet, 20mg Tablet, 30mg Tablet, 5mg Tablet, 10mg Capsule ER, 15mg Capsule ER, 20mg Capsule ER, 25mg Capsule ER, 30mg Capsule ER, 5mg Capsule ER) ........ 39

Amphotericin B (50mg Injection) ............... 22 Ampicillin (125mg/5ml Suspension,

250mg/5ml Suspension, 250mg Capsule, 500mg Capsule) ...................................... 16

Ampicillin Sodium (10gm Injection, 1gm Injection, 250mg Injection, 2gm Injection, 500mg Injection) ..................................... 16

Ampicillin Sodium (125mg Injection, 1gm Injection) ................................................ 16

Ampicillin-Sulbactam (10gm-5gm Injection, 1gm-0.5gm Injection, 2gm-1gm Injection) ................................................................ 16

Ampyra (Tablet Extended-Release 12 Hour) ................................................................ 40

Anadrol-50 (Tablet) ..................................... 48 Anafranil (Capsule) ..................................... 21 Anagrelide HCl (Capsule) ............................. 32 Analpram-HC (1%-1% Cream) ..................... 46 Analpram-HC (2.5%-1% Lotion) .................. 40 Anaprox DS (Tablet) .................................... 10 Anastrozole (Tablet) .................................... 25 Ancobon (Capsule) ...................................... 22 Androderm (Patch 24 Hour) ....................... 48 AndroGel (25mg/2.5gm Gel, 50mg/5gm Gel)

................................................................ 48 AndroGel (40.5mg/2.5gm Gel) ................... 48 Android (Capsule) ....................................... 48 Androxy (Tablet) ......................................... 48 Anectine (Injection) .................................... 64 Angeliq (Tablet) ........................................... 48 Angiomax (Injection) .................................. 32 Anoro Ellipta (Aerosol Powder) .................. 63 Antabuse (Tablet) ....................................... 13 Antara (Capsule) ......................................... 37 Antizol (Injection) ....................................... 53 Anusol-HC (Cream) ...................................... 40 Anzemet (Tablet) ........................................ 22 Apidra (Injection) ........................................ 31 Apidra SoloStar (Injection) ......................... 31 Aplenzin (Tablet Extended-Release 24 Hour)

................................................................ 20 Apokyn (Injection) ...................................... 26 App Slim RMS (Capsule) .............................. 53 Apraclonidine (Ophthalmic Solution) .......... 61 Aprepitant (Capsule).................................... 22 Apriso (Capsule Extended-Release 24 Hour)

................................................................ 51 Aptiom (Tablet) ........................................... 18 Aptivus (100mg/ml Oral Solution, 250mg

Capsule) .................................................. 29 Aquasol A Parenteral (Injection) ................ 66

71

Aquoral (Solution)....................................... 40 Aralast NP (Injection) .................................. 64 Aranesp Albumin Free (Injection) .............. 32 Arava (Tablet) ............................................. 51 Arcalyst (Injection) ...................................... 51 Arcapta Neohaler (Capsule) ........................ 63 Argatroban (125mg/125ml-0.9% Injection,

250mg/250ml-0.9% Injection, 50mg/50ml Injection) ................................................ 32

Argatroban (250mg/2.5ml Injection) ........... 32 Arial Chamber (Device) ............................... 53 Aricept (Tablet) ........................................... 20 Arimidex (Tablet) ........................................ 25 Aripiprazole (10mg Tablet, 15mg Tablet,

20mg Tablet, 2mg Tablet, 30mg Tablet, 5mg Tablet, 1mg/ml Oral Solution) ........ 20

Aripiprazole ODT (Tablet Dispersible) ......... 59 Aristada (Injection) ..................................... 27 Arixtra (Injection) ........................................ 32 Armodafinil (Tablet) .................................... 65 Armour Thyroid (Tablet) ............................. 49 Arnica Flower (Tincture) ............................. 53 Arnuity Ellipta (Aerosol Powder) ................ 62 Aromasin (Tablet) ....................................... 25 Arranon (Injection) ..................................... 25 Arthrotec 50 (Tablet Delayed-Release) ...... 10 Arthrotec 75 (Tablet Delayed-Release) ...... 10 Articadent Dental (Injection) ...................... 51 Artiss (External Solution) ............................ 40 Arymo ER (Tablet Extended-Release Abuse-

Deterrent) .............................................. 38 Arzerra (Injection) ....................................... 26 Arzol Silver Nitrate App Licators ................. 14 Asacol HD (Tablet Delayed-Release) .......... 51 Asclera (Injection) ....................................... 36 Asmanex HFA (Aerosol) .............................. 62 Asmanex Twisthaler 120 Metered Doses

(Aerosol Powder) ................................... 62 Asmanex Twisthaler 14 Metered Doses




(Aerosol Powder) ................................... 62 Aspirin/Dipyridamole (Capsule Extended-

Release 12 Hour) .................................... 33 Aspirin-Caffeine-Dihydrocodeine (Capsule) 11 Assure Haemolance Plus High Flow 18g ..... 53 Assure Haemolance Plus Low Flow 25g ..... 53 Assure Haemolance Plus Micro Flow 28g ... 53 Assure Haemolance Plus Normal Flow 21g 53 Assure Haemolance Plus Pediatric Blade ... 53 Assure Lance Lancets .................................. 53 Assure Lance Lancets 21g ........................... 53 Assure Lance Plus Safety Lancets 25g ........ 53 Assure Lance Plus Safety Lancets 30g ........ 53 Assure Lancets ............................................ 53 Astagraf XL (Capsule Extended-Release 24

Hour) ...................................................... 50

Astamed Myo (Capsule) ............................. 53 Astepro (Nasal Solution) ............................ 62 At Last Lancets ............................................ 53 Atabex EC (Tablet Delayed-Release) .......... 67 Atabex Prenatal (Tablet Chewable) ........... 66 Atacand (Tablet) ......................................... 34 Atacand HCT (Tablet) ................................. 34 Atelvia (Tablet Delayed-Release) ............... 51 Atenolol (100mg Tablet, 25mg Tablet, 50mg

Tablet) .................................................... 35 Atenolol/Chlorthalidone (Tablet) ................ 35 Atgam (Injection) ........................................ 51 Ativan (0.5mg Tablet, 1mg Tablet, 2mg

Tablet) .................................................... 19 Ativan (2mg/ml Injection, 4mg/ml Injection)

............................................................... 29 Atopiclair (Cream) ...................................... 40 Atorvastatin Calcium (Tablet) ..................... 37 Atovaquone (Suspension) ........................... 26 Atovaquone/Proguanil HCl (Tablet) ............ 26 Atracurium Besylate (Injection) .................. 64 Atralin (Gel) ................................................ 40 Atripla (Tablet) ........................................... 28 Atropen (Injection) ..................................... 44 Atropine Sulfate (0.05mg/ml Injection,

0.8mg/2ml Injection) ............................. 44 Atropine Sulfate (0.1mg/ml Injection,

0.4mg/ml Injection, 1mg/ml Injection, 1mg/2.5ml Solution Prefilled Syringe) ... 44

Atropine Sulfate (1% Ointment) ................ 60 Atropine Sulfate (1% Ophthalmic Solution) 60 Atropine Sulfate (2mg/5ml Solution Prefilled

Syringe) .................................................. 30 Atrovent HFA (Aerosol Solution) ............... 63 Aubagio (Tablet) ......................................... 40 Augmented Betamethasone Dipropionate

(0.05% Cream, 0.05% Gel, 0.05% Lotion, 0.05% Ointment) .................................... 40

Augmentin (125mg/5ml-31.25mg/5ml Suspension, 250mg/5ml-62.5mg/5ml Suspension, 500mg-125mg Tablet, 875mg-125mg Tablet) ........................... 16

Augmentin ES-600 (Suspension) ................ 16 Augmentin XR (Tablet Extended-Release 12

Hour) ...................................................... 16 Aurora Lancet Super Thin 30g .................... 53 Aurora Lancet Thin 23g .............................. 53 Aurora Pen Needles 29gx12mm................. 53 Aurora Pen Needles 31g X 6mm ................ 53 Aurora Pen Needles 31g X 8mm ................ 53 Auryxia (Tablet) .......................................... 46 Autolet Platforms ....................................... 53 Auvi-Q (Solution Auto injector) ................. 63 Availnex (Tablet Chewable) ....................... 53 Avalide (Tablet) .......................................... 34 Avandia (Tablet) ......................................... 30 Avapro (Tablet) ........................................... 34 Avastin (Injection) ...................................... 26 AVC (Cream) ............................................... 17 Avelox (Tablet, Injection) ........................... 17 Avelox ABC Pack (Tablet) ........................... 17

Avenova (Solution) ..................................... 40 Avenova/Neutrox (Solution) ...................... 40 Avidoxy DK (Kit) .......................................... 18 Avodart (Capsule) ....................................... 46 Avonex (Injection) ....................................... 40 Avonex Pen (Injection)................................ 40 Avycaz (Injection) ........................................ 15 Axert (Tablet) .............................................. 23 Axiron (Transdermal Solution) ................... 48 Axona (Packet) ............................................ 65 Aygestin (Tablet) ......................................... 49 Azacitidine (Injection) .................................. 59 Azactam (Injection) ..................................... 16 Azactam in Iso-Osmotic Dextrose (Injection)

................................................................ 16 Azasan (Tablet) ........................................... 50 Azasite (Ophthalmic Solution) .................... 17 Azathioprine (100mg Injection, 50mg Tablet)

................................................................ 50 Azelastine HCl (0.05% Ophthalmic Solution)60 Azelastine HCl (0.1% Nasal Solution, 0.15%

Nasal Solution) ........................................ 62 Azelex (Cream) ............................................ 40 Azilect (Tablet) ............................................ 27 Azithromycin (100mg/5ml Suspension,

200mg/5ml Suspension, 1gm Packet, 250mg Tablet, 500mg Tablet, 600mg Tablet, 500mg Injection) ......................... 17

Azopt (Suspension) ..................................... 61 Azor (Tablet) ............................................... 34 Aztreonam (Injection) .................................. 16 Azulfidine (Tablet)....................................... 51 Azulfidine EN-Tabs (Tablet Delayed-Release)

................................................................ 51

B

B-6 Folic Acid (Capsule) ............................... 66 Bacitracin (50000unit Injection, 500unit/gm

Ophthalmic Ointment) ............................ 14 Bacitracin/Polymyxin B (Ophthalmic

Ointment) ............................................... 14 Baclofen (10mg Tablet, 20mg Tablet) .......... 27 Bacteriostatic Water for Injection/Benzyl

Alcohol (Injection) .................................. 53 Bactocill in Dextrose (Injection) ................. 16 Bactrim (Tablet) .......................................... 17 Bactrim DS (Tablet) ..................................... 17 Bactroban (Cream) ...................................... 14 Bactroban Nasal (Ointment) ....................... 14 Bal-Care DHA ............................................... 67 Balsalazide Disodium (Capsule) ................... 51 Banzel (200mg Tablet, 400mg Tablet,

40mg/ml Suspension) ............................ 19 Baraclude (0.05mg/ml Oral Solution, 0.5mg

Tablet, 1mg Tablet) ................................ 28 Basaglar KwikPen (Injection) ...................... 31 Bayer Microlet Lancets ............................... 53 BD 3ml LL Syringe/Prefill Lith Hep/Tip

Cap/Ndl Stop/Safetycone (Kit) .............. 53 BD Autoshield 29g X 3/16" ......................... 53

72

BD Autoshield 29g X 5/16" ......................... 53 BD Autoshield Duo 30g X 3/16".................. 53 Bd insul Syr Mis Lo Dose ............................. 53 BD Lancet Ultrafine 30g .............................. 53 BD Lancet Ultrafine 33g .............................. 53 BD Microtainer Lancets .............................. 53 BD Pudendal/Local Block Tray 1% Lidocaine

(Kit) ......................................................... 12 Bebulin (Injection) ...................................... 33 Beconase AQ (Suspension) ......................... 62 Belbuca (Film) ............................................. 11 Beleodaq (Injection) ................................... 25 Belsomra (Tablet)........................................ 65 Benazepril HCl (Tablet) ................................ 34 Benazepril HCl/Hydrochlorothiazide (Tablet)

................................................................ 34 Bendeka (Injection) ..................................... 24 Benefix (Injection)....................................... 33 Benicar (Tablet) ........................................... 34 Benicar HCT (Tablet) ................................... 34 Benlysta (Injection) ..................................... 50 Bentyl (10mg Capsule, 10mg/ml Injection) 44 Benzac AC Wash (Liquid) ............................ 40 BenzaClin (Gel) ............................................ 40 BenzaClin with Pump (Gel) ......................... 40 Benzalkonium Chloride (0 External Solution,

50% External Solution) ........................... 14 Benzamycin (Gel) ........................................ 40 Benzefoam (Foam) ...................................... 40 Benzefoam Ultra (Foam) ............................. 40 Benziq (Gel) ................................................. 40 Benziq LS (Gel) ............................................ 40 Benziq Wash (Liquid) .................................. 40 Benzoin Compound Tincture (0 Tincture).... 40 Benzoin Tincture (0 Tincture) ..................... 53 Benzonatate (Capsule) ................................ 64 Benzoyl Peroxide (9.8% Foam) .................... 40 Benztropine Mesylate (0.5mg Tablet, 1mg

Tablet, 2mg Tablet, 1mg/ml Injection) ... 26 Bepreve (Ophthalmic Solution) .................. 61 Berinert (Injection) ..................................... 59 Besivance (Suspension) .............................. 17 Betadine Ophthalmic Prep (Ophthalmic

Solution) ................................................. 14 Betagan (Ophthalmic Solution) .................. 61 Betalido (Injection) ..................................... 53 Betamethasone Dipropionate (0.05% Cream,

0.05% Lotion, 0.05% Ointment) .............. 40 Betamethasone Sodium

Phosphate/Betamethasone Acetate (Injection) ............................................... 46

Betamethasone Valerate (0.1% Cream, 0.1% Lotion, 0.1% Ointment, 0.12% Foam) ..... 41

Betapace (120mg Tablet, 160mg Tablet, 80mg Tablet) .......................................... 34

Betapace AF (120mg Tablet, 160mg Tablet, 80mg Tablet) .......................................... 34

Betaseron (Injection) .................................. 40 Betaxolol HCl (0.5% Ophthalmic Solution) .. 61 Betaxolol HCl (10mg Tablet, 20mg Tablet) .. 35 Bethanechol Chloride (Tablet) ..................... 46

Bethkis (Nebulized Solution) ...................... 59 Betimol (Ophthalmic Solution) .................. 61 Betoptic-S (Suspension) ............................. 61 Bevespi Aerosphere (Aerosol).................... 30 Bexarotene (Capsule) .................................. 26 Beyaz (Tablet) ............................................. 48 Biaxin (250mg Tablet, 500mg Tablet,

250mg/5ml Suspension) ........................ 17 Bicalutamide (Tablet) .................................. 24 Bicillin C-R (Injection) ................................. 16 Bicillin L-A (Injection) ................................. 17 BiCNU (Injection) ........................................ 24 BiDil (Tablet) ............................................... 38 Biltricide (Tablet) ........................................ 26 Bimatoprost (Ophthalmic Solution) ............ 60 Binosto (Tablet Effervescent) ..................... 51 Bisoprolol Fumarate (Tablet) ...................... 35 Bisoprolol Fumarate/Hydrochlorothiazide

(Tablet) ................................................... 35 Bivalirudin (Injection) .................................. 32 BIVIGAM (Injection) ................................... 51 Bleomycin Sulfate (Injection) ...................... 59 Bleph-10 (Ophthalmic Solution) ................ 17 Blephamide (Suspension) ........................... 17 Blephamide S.O.P. (Ointment) ................... 17 Blincyto (Injection) ..................................... 26 Bloxiverz (Injection) ................................... 24 Boniva (150mg Tablet, 3mg/3ml Injection) 51 Boric Acid (0 Granules) ............................... 53 Bosulif (Tablet) ........................................... 25 Bravelle (Injection) ..................................... 47 BreatheRite ................................................. 53 BreatheRite Collapsible Spacer w/ Neonate

Mask ...................................................... 53 BreatheRite Rigid Spacer w/Mask ............. 53 BreatheRite w/Large Mask ........................ 53 BreatheRite w/Medium Mask ................... 53 BreatheRite w/Small Mask ........................ 53 Breo Ellipta (Aerosol Powder) .................... 62 Brevibloc (Injection) ................................... 35 Brevicon-28 (Tablet) ................................... 48 Bridion (200mg/2ml Injection, 500mg/5ml

Injection) ................................................ 53 Brilinta (60mg Tablet)................................. 33 Brilinta (90mg Tablet)................................. 33 Brimonidine Tartrate (Ophthalmic Solution)

............................................................... 61 Brisdelle (Capsule) ...................................... 21 BRIVIACT (100mg Tablet, 10mg Tablet, 25mg

Tablet, 50mg Tablet, 75mg Tablet, 10mg/ml Oral Solution, 50mg/5ml Injection) ................................................ 18

Bromfenac (Ophthalmic Solution) .............. 61 Bromocriptine Mesylate (2.5mg Tablet, 5mg

Capsule) .................................................. 49 Bromphen/Pseudoephedrine

HCl/Dextromethorphan HBr (Syrup) ...... 62 Brompheniramine Tannate (Tablet

Chewable) .............................................. 62 Bromsite (Ophthalmic Solution) ................ 61 Brovana (Nebulized Solution) .................... 63

Bucalsep (600mg/30ml-30mg/30ml-45mg/30ml-30mg/30ml External Solution, 600mg/30ml-30mg/30ml-45mg/30ml-30mg/30ml Liquid) ............. 14

Budesonide (0.25mg/2ml Suspension, 0.5mg/2ml Suspension, 1mg/2ml Suspension, 32mcg/act Suspension) ...... 62

Budesonide (3mg Capsule Delayed-Release) ................................................................ 51

Bullseye Safety Lancets ............................... 53 Bumetanide (0.25mg/ml Injection, 0.5mg

Tablet, 1mg Tablet, 2mg Tablet) ............. 37 Bumex (Tablet) ............................................ 37 Bunavail (Film) ............................................ 11 Bupap (Tablet) ............................................. 10 Buphenyl (3gm/tsp Powder, 500mg Tablet)

................................................................ 44 Bupivacaine HCl (Injection) .......................... 12 Bupivacaine HCl/Sodium Chloride (0.1%-

0.9% Injection, 0.125%-0.9% Injection, 0.2%-0.9% Injection, 0.25%-0.9% Injection) ................................................ 12

Bupivacaine/Epinephrine (0.25%-1 200000 Injection) .................................... 12

Bupivacaine/Epinephrine (0.5%-1 200000 Injection) .................................... 51

Buprenex (Injection) ................................... 11 Buprenorphine HCl (0.3mg/ml Solution, 2mg

Tablet Sublingual, 8mg Tablet Sublingual) ................................................................ 11

Buprenorphine HCl/Naloxone HCl (Tablet Sublingual) .............................................. 11

Bupropion HCl (Tablet) ................................ 13 Bupropion HCl ER (Tablet Extended-Release

12 Hour) .................................................. 20 Bupropion HCl SR (Tablet Extended-Release

12 Hour) .................................................. 20 Bupropion HCl XL (Tablet Extended-Release

24 Hour) .................................................. 13 Buspirone HCl (Tablet) ................................. 29 Busulfex (Injection) ..................................... 24 Butalbital/Acetaminophen (300mg-50mg

Tablet, 50mg-325mg Tablet) .................. 10 Butalbital/Acetaminophen/Caffeine (325mg-

50mg-40mg Tablet, 50mg-300mg-40mg Capsule) .................................................. 10

Butalbital/Acetaminophen/Caffeine/Codeine (Capsule) ................................................. 11

Butalbital/Aspirin/Caffeine (Capsule) .......... 10 Butalbital/Aspirin/Caffeine/Codeine (Capsule)

................................................................ 11 Butisol Sodium (Tablet) .............................. 65 Butorphanol Tartrate (10mg/ml Nasal

Solution, 1mg/ml Injection, 2mg/ml Injection) ................................................. 11

Butrans (Patch Weekly) .............................. 11 Bydureon Pen (Injection) ............................ 30 Bydureon Vial (Injection) ............................ 30 Byetta (Injection) ........................................ 30 Bystolic (Tablet) .......................................... 35 Byvalson (Tablet) ........................................ 38

73

C

Cabergoline (Tablet) .................................... 49 Cabometyx (Tablet) .................................... 25 Caduet (Tablet) ........................................... 36 Cafcit (Injection) .......................................... 39 Cafergot (Tablet) ......................................... 23 Caffeine Citrate (20mg/ml Oral Solution,

60mg/3ml Injection) ............................... 39 Calan (Tablet) .............................................. 36 Calan SR (Tablet Extended-Release) ........... 36 Calcifol (Wafer) ........................................... 65 Calcipotriene (0.005% Cream, 0.005%

External Solution, 0.005% Ointment) ..... 41 Calcipotriene/Betamethasone Dipropionate

(Ointment) .............................................. 41 Calcitonin-Salmon (Nasal Solution) ............. 52 Calcitriol (0.25mcg Capsule, 0.5mcg Capsule,

1mcg/ml Injection, 1mcg/ml Oral Solution) ................................................................ 52

Calcitriol (3mcg/gm Ointment) .................... 41 Calcium Acetate (667mg Capsule, 667mg

Tablet)..................................................... 46 Calcium Chloride (10% Injection)................. 65 Calcium Disodium Versenate (Injection) .... 44 Calcium Gluconate/Dextrose (1gm/100ml-

5% Injection, 2gm/100ml-5% Injection) 43 Calcium Gluconate/Sodium Chloride

(1gm/100ml-0.9% Injection, 2gm/100ml-0.9% Injection, 2gm/50ml-0.9% Injection) ................................................................ 65

Calcium Gluconate/Sodium Chloride (1gm/50ml-0.9% Solution, 3gm/100ml-0.9% Injection) ....................................... 43

Caldolor (Injection) ..................................... 59 Cambia (Packet) .......................................... 10 Camino Pro Bettermilk/Glytactin (Packet) . 65 Camino Pro Complete/Glytactin (Bar)........ 65 Camino Pro Swirl (Packet) .......................... 65 Campath (Injection) .................................... 24 Camptosar (Injection) ................................. 59 Canasa (Suppository) .................................. 51 Cancidas (Injection) .................................... 22 Candesartan Cilexetil (Tablet) ..................... 34 Candesartan Cilexetil/Hydrochlorothiazide

(Tablet) ................................................... 34 Capastat Sulfate (Injection) ........................ 24 Capecitabine (Tablet) .................................. 25 Capex (Shampoo) ........................................ 41 Caphosol (Solution) ..................................... 40 Capital/Codeine (Suspension) .................... 11 Caprelsa (Tablet) ......................................... 25 Captopril (Tablet)......................................... 34 Captopril/Hydrochlorothiazide (Tablet) ...... 34 CapXib Kit (Kit) ............................................ 10 Carac (Cream) .............................................. 41 Carafate (1gm Tablet, 1gm/10ml

Suspension) ............................................ 45 Carbaglu (Tablet) ........................................ 65 Carbamazepine (100mg Tablet Chewable,

100mg/5ml Suspension, 200mg Tablet) . 19

Carbamazepine Extended-Release 12 Hour (Capsule, Tablet).................................... 19

Carbatrol (Capsule Extended-Release 12 Hour) ...................................................... 19

Carbidopa (Tablet) ...................................... 27 Carbidopa/Levodopa (Tablet Immediate-

Release) .................................................. 27 Carbidopa/Levodopa ER (Tablet Extended-

Release) .................................................. 27 Carbidopa/Levodopa/Entacapone (Tablet) . 27 Carbinoxamine Maleate (4mg Tablet,

4mg/5ml Oral Solution) .......................... 62 Carbocaine (Injection) ................................ 12 Carboplatin (Injection) ................................ 24 Cardene IV (20mg/200ml-0.86% Injection) 36 Cardene IV (40mg/200ml-0.83% Injection) 38 Cardiotek-Rx (Tablet) ................................. 68 Cardiovid Plus (Capsule) ............................. 53 Cardizem (Tablet) ....................................... 34 Cardizem CD (Capsule Extended-Release 24

Hour) ...................................................... 36 Cardizem LA (Tablet Extended-Release 24

Hour) ...................................................... 36 Cardura (Tablet) ......................................... 33 Cardura XL (Tablet Extended-Release 24

Hour) ...................................................... 46 Careone Lancet Thin ................................... 53 Careone Lancet Ultra Thin .......................... 53 Caretouch Pen Needles 31 G X 6 Mm ........ 53 Caretouch Pen Needles 31gx 5mm ............ 53 Caretouch Pen Needles 31gx 8mm ............ 53 Caretouch Pen Needles 32gx 4mm ............ 53 Caretouch Twist Lancets 30g ...................... 53 Carimune Nanofiltered (Injection) ............. 51 Carisoprodol (250mg Tablet, 350mg Tablet)64 Carisoprodol/Aspirin (Tablet) ...................... 64 Carisoprodol/Aspirin/Codeine (Tablet) ....... 64 Carnitor (1gm/10ml Oral Solution,

200mg/ml Injection, 330mg Tablet) ...... 53 Carnitor SF (Oral Solution) ......................... 53 Carteolol HCl (Ophthalmic Solution) ........... 61 Carvedilol (Tablet) ....................................... 35 Cascara Sagrada (1gm/ml Fluid Extract) .... 44 Casodex (Tablet) ......................................... 24 Catapres (Tablet) ........................................ 33 Catapres-TTS-1 (Patch Weekly) .................. 33 Catapres-TTS-2 (Patch Weekly) .................. 33 Catapres-TTS-3 (Patch Weekly) .................. 33 Cathflo Activase (Injection) ........................ 32 Cayston (Inhalation Solution) .................... 16 Cedax (180mg/5ml Suspension, 400mg

Capsule) ................................................. 15 Cefaclor (125mg/5ml Suspension) ............. 15 Cefaclor (Capsule Immediate-Release, Oral

Suspension) ............................................ 15 Cefaclor ER (Tablet Extended-Release 12

Hour) ...................................................... 15 Cefadroxil (1gm Tablet, 250mg/5ml

Suspension, 500mg/5ml Suspension, 500mg Capsule) ...................................... 15

Cefazolin (Injection) ................................... 15

Cefazolin Sodium (100gm Injection, 300gm Injection, 1gm/50ml Injection) .............. 15

Cefazolin Sodium (10gm Injection, 1gm Injection, 20gm Injection, 500mg Injection) ................................................................ 15

Cefazolin Sodium/Dextrose (1gm-4% Injection, 2gm-3% Injection) .................. 15

Cefazolin Sodium/Dextrose (2gm/50ml-5% Injection) ................................................ 13

Cefazolin Sodium/Sodium Chloride (Injection) ................................................................ 16

Cefazolin/D5W (Injection) ........................... 16 Cefazolin/Dextrose (Injection) ..................... 16 Cefazolin/Sodium Chloride (2gm/100ml-0.9%

Injection) ................................................. 16 Cefazolin/Sodium Chloride (3gm/100ml-

0.9% Solution) ........................................ 13 Cefdinir (125mg/5ml Suspension, 250mg/5ml

Suspension, 300mg Capsule) .................. 16 Cefditoren Pivoxil (Tablet) .......................... 16 Cefepime (1gm Injection, 2gm Injection) .... 16 Cefepime (1gm/50ml Injection, 2gm/100ml

Injection) ................................................ 16 Cefepime/Dextrose (Injection) ................... 16 Cefixime (Suspension) ................................. 16 Cefotan (Injection) ...................................... 16 Cefotaxime Sodium (Injection) .................... 16 Cefotetan (1gm Injection, 2gm Injection) .... 16 Cefotetan (Injection) ................................... 16 Cefotetan/Dextrose (Injection) .................. 16 Cefoxitin Sodium (10gm Injection, 1gm

Injection, 2gm Injection) ......................... 16 Cefoxitin Sodium (1gm-4% Injection, 2gm-

2.2% Injection) ....................................... 16 Cefpodoxime Proxetil (100mg Tablet, 200mg

Tablet, 100mg/5ml Suspension, 50mg/5ml Suspension) ............................................ 16

Cefprozil (125mg/5ml Suspension, 250mg/5ml Suspension, 250mg Tablet, 500mg Tablet) ......................................... 16

Ceftazidime (Injection) ................................ 16 Ceftazidime/Dextrose (Injection) ............... 16 Ceftibuten (180mg/5ml Suspension, 400mg

Capsule) .................................................. 16 Ceftin (Suspension) ..................................... 16 Ceftriaxone in Iso-Osmotic Dextrose

(Injection) ............................................... 16 Ceftriaxone Sodium (100gm Injection, 1gm

Injection, 250mg Injection, 500mg Injection, 10gm Injection, 2gm Solution) 16

Ceftriaxone/Dextrose (Injection) ............... 16 Cefuroxime Axetil (Tablet) ........................... 16 Cefuroxime Sodium (Injection) .................... 16 Cefuroxime Sodium/Sodium Chloride

(Solution) ................................................ 44 Celebrex (Capsule) ...................................... 10 Celecoxib (Capsule) ..................................... 10 Celestone-Soluspan (Injection) ................... 46 Celexa (Tablet) ............................................ 21 Cellcept (200mg/ml Suspension, 250mg

Capsule, 500mg Tablet) .......................... 50

74

Cellcept Intravenous (Injection) ................. 50 Celontin (Capsule) ....................................... 18 Cenfol (Tablet) ............................................ 68 Centany (Ointment) .................................... 14 Centany AT (Kit) .......................................... 14 Cephalexin (125mg/5ml Suspension,

250mg/5ml Suspension, 250mg Capsule, 500mg Capsule, 750mg Capsule, 250mg Tablet, 500mg Tablet) ............................. 16

Cerdelga (Capsule) ...................................... 44 Cerebyx (Injection) ...................................... 19 Cerefolin (Tablet) ........................................ 68 Cerefolin Nac (Tablet) ................................. 66 Cerezyme (Injection) ................................... 44 Cesamet (Capsule) ...................................... 22 Cetirizine HCl (1mg/ml Syrup) ..................... 62 Cetraxal (Otic Solution)............................... 17 Cetrotide (Injection) ................................... 49 Cetylev (Tablet Effervescent)...................... 64 Cevimeline HCl (Capsule) ............................. 40 Chemet (Capsule) ........................................ 65 Chenodal (Tablet) ....................................... 44 Chloramphenicol Sodium Succinate

(Injection) ............................................... 14 Chlordiazepoxide HCl (Capsule) ................... 29 Chlordiazepoxide HCl/Clidinium Bromide

(5mg-2.5mg Capsule) .............................. 44 Chlordiazepoxide/Amitriptyline (Tablet) ..... 21 Chlorhexidine Gluconate (0.12% Solution) .. 40 Chlorhexidine Gluconate (20% Solution) ... 40 Chloroquine Phosphate (250mg Tablet,

500mg Tablet) ......................................... 26 Chlorothiazide (Tablet) ................................ 37 Chlorothiazide Sodium (Injection) ............... 37 Chlorpromazine HCl (100mg Tablet, 10mg

Tablet, 200mg Tablet, 25mg Tablet, 50mg Tablet)..................................................... 21

Chlorpromazine HCl (25mg/ml Injection, 50mg/2ml Injection) .............................. 59

Chlorpropamide (Tablet) ............................. 31 Chlorthalidone (100mg Tablet)................... 37 Chlorthalidone (25mg Tablet, 50mg Tablet) 37 Chlorzoxazone (Tablet) ................................ 64 Cholbam (Capsule) ...................................... 44 Cholestyramine (Powder) ............................ 37 Cholestyramine Light (Powder) ................... 37 Choline Magnesium Trisalicylate (1000mg

Tablet) .................................................... 10 Choline Magnesium Trisalicylate (500mg/5ml

Liquid) ..................................................... 10 Chorionic Gonadotropin (Injection) ............. 47 Chromium Chloride (Injection) .................... 65 Cialis (10mg Tablet, 20mg Tablet) .............. 46 Cialis (2.5mg Tablet, 5mg Tablet) ............... 46 Ciclodan Cream Kit (Kit) .............................. 22 Ciclodan Solution Kit (Kit) ........................... 22 Ciclopirox (0.77% Gel, 0.77% Suspension, 1%

Shampoo) ............................................... 22 Ciclopirox Nail Lacquer (External Solution) . 22 Ciclopirox Olamine (0.77% Cream) .............. 22 Cidofovir (Injection) ..................................... 28

Cilostazol (Tablet) ....................................... 33 Ciloxan (0.3% Ointment, 0.3% Ophthalmic

Solution) ................................................ 17 Cimetidine (200mg Tablet, 300mg Tablet,

400mg Tablet, 800mg Tablet) ................ 45 Cimetidine HCl (Oral Solution) .................... 45 Cimzia (Injection) ........................................ 50 Cimzia Starter Kit (Injection) ...................... 50 Cinqair (Injection) ....................................... 64 Cinryze (Injection) ...................................... 59 Cipro (250mg Tablet, 500mg Tablet,

500mg/5ml Suspension, 5gm/100ml Suspension)............................................ 17

Cipro HC (Suspension) ................................ 61 Cipro I.V. in D5W (Injection) ...................... 17 Cipro XR (Tablet Extended-Release 24 Hour)

............................................................... 17 Ciprodex (Otic Suspension) ........................ 61 Ciprofloxacin (0.2% Otic Solution) ............. 17 Ciprofloxacin (250mg/5ml Suspension,

500mg/5ml Suspension) ........................ 17 Ciprofloxacin ER (Tablet Extended-Release 24

Hour) ...................................................... 17 Ciprofloxacin HCl (0.3% Ophthalmic Solution,

Tablet Immediate-Release) .................... 17 Ciprofloxacin I.V. in D5W (Injection) ........... 17 Cisatracurium Besylate (10mg/5ml Solution

Prefilled Syringe) ................................... 30 Cisatracurium Besylate (Injection) .............. 64 Cisplatin (100mg/100ml Injection,

50mg/50ml Injection) ............................. 24 Cisplatin (200mg/200ml Injection) ............ 24 Citalopram HBr (10mg Tablet, 20mg Tablet,

40mg Tablet, 10mg/5ml Oral Solution) .. 21 Citranatal B-Calm ....................................... 67 Citranatal Rx (Tablet) ................................. 67 Citrus Bergamot (Powder) .......................... 53 Cladribine (Injection) ................................... 25 Clarinex (0.5mg/ml Syrup, 5mg Tablet) ..... 62 Clarithromycin (125mg/5ml Suspension,

250mg/5ml Suspension, 250mg Tablet, 500mg Tablet) ........................................ 17

Clarithromycin ER (Tablet Extended-Release 24 Hour) ................................................. 17

Cleanlet Lancets 28g ................................... 53 Clemastine Fumarate (2.68mg Tablet)....... 62 Cleocin (100mg Suppository) ..................... 14 Cleocin (150mg Capsule, 300mg Capsule,

75mg Capsule, 2% Cream) ..................... 14 Cleocin in D5W (Injection) .......................... 14 Cleocin Pediatric Granules (Oral Solution) 14 Cleocin Phosphate (150mg/ml Injection,

300mg/2ml Injection, 600mg/4ml Injection, 900mg/6ml Injection, 9gm/60ml Injection) .............................. 14

Cleocin-T (1% External Solution, 1% Gel, 1% Lotion, 1% Swab) ................................... 41

Clever Chek Lancets Ultrathin .................... 53 Clever Chek Lancets Ultrathin 30g ............. 53 Clever Choice Anti-Static Valved Holding

Chamber/Adult Large (Device) .............. 53

Clever Choice Anti-Static Valved Holding Chamber/Medium (Device) ................... 53

Clever Choice Anti-Static Valved Holding Chamber/Small (Device) ........................ 53

Clever Choice Comfort EZ Insulin Pen Needles 31gx8mm .................................. 53

Clever Choice Comfort EZ Pen Needles 29gx12mm .............................................. 53

Clever Choice Comfort EZ Pen Needles 31gx5mm ................................................ 53








Cleviprex (Injection) .................................... 36 Climara (Patch Weekly) .............................. 48 Climara Pro (Patch Weekly) ........................ 48 Clindacin ETZ (Kit) ....................................... 41 Clindacin PAC (Kit) ...................................... 41 Clindagel (Gel) ............................................. 41 Clindamycin HCl (Capsule Immediate-Release)

................................................................ 14 Clindamycin Palmitate HCl (Oral Solution) .. 14 Clindamycin Phosphate (1% External Solution,

1% Foam, 1% Gel, 1% Lotion, 1% Swab) . 41 Clindamycin Phosphate (2% Cream,

300mg/2ml Injection, 600mg/4ml Injection, 9000mg/60ml Injection, 900mg/6ml Injection) ............................. 14

Clindamycin Phosphate in D5W (Injection) . 14 Clindamycin Phosphate/Tretinoin (Gel) ...... 41 Clindamycin/Benzoyl Peroxide (Gel) ........... 41 Clindesse (Cream) ....................................... 14 Clinical Nutrients Prenatal Formula (Tablet)

................................................................ 67 Clinimix/Dextrose (Injection) ..................... 65 Clobetasol Propionate (0.05% Cream, 0.05%

External Solution, 0.05% Foam, 0.05% Gel, 0.05% Liquid, 0.05% Lotion, 0.05% Ointment, 0.05% Shampoo) ................... 41

Clobex (0.05% Liquid, 0.05% Lotion, 0.05% Shampoo) ............................................... 41

Clocortolone Pivalate (Cream) .................... 41 Clodan Kit (Kit) ............................................ 41 Cloderm (Cream) ......................................... 41 Cloderm Pump (Cream) .............................. 41 Clolar (Injection) ......................................... 25 Clomiphene Citrate (50mg Tablet) .............. 49 Clomipramine HCl (Capsule) ........................ 21 Clonazepam (Tablet Immediate-Release) .... 19 Clonazepam ODT (Tablet Dispersible) ......... 19

75

Clonidine HCl (0.1mg Tablet, 0.2mg Tablet, 0.3mg Tablet, 0.1mg/24hr Patch Weekly, 0.2mg/24hr Patch Weekly, 0.3mg/24hr Patch Weekly) ......................................... 33

Clonidine HCl ER (Tablet Extended-Release 12 Hour) ....................................................... 39

Clopidogrel (Tablet) ..................................... 33 Clorazepate Dipotassium (Tablet) ............... 19 Clorpres (Tablet) ......................................... 33 Clotrimazole (1% Cream, 1% External

Solution, 10mg Lozenge, 10mg Troche).. 22 Clotrimazole/Betamethasone Dipropionate

(0.05%-1% Cream, 1%-0.05% Lotion) ..... 22 Clozapine (Tablet Immediate-Release) ........ 27 Clozapine ODT (Tablet Dispersible) ............. 27 Clozaril (Tablet) ........................................... 27 Coaguchek Lancets ...................................... 54 Coal Tar (External Solution) ........................ 41 Coartem (Tablet) ......................................... 26 Cod Liver Oil (0 Oil) ..................................... 66 Codeine Sulfate (Tablet) .............................. 11 Cogentin (Injection) .................................... 26 Colazal (Capsule) ......................................... 51 Colchicine (0.6mg Capsule) ......................... 23 Colchicine (0.6mg Tablet) ............................ 23 Colcrys (Tablet) ........................................... 23 Colestid (1gm Tablet, 5gm Granules, 5gm

Packet) .................................................... 37 Colestid Flavored (5gm Granules,

5gm/7.5gm Packet) ................................ 37 Colestipol HCl (1gm Tablet, 5gm Packet) ..... 37 Colistimethate Sodium (Injection) ............... 14 Coly-Mycin M (Injection) ............................ 14 Coly-Mycin S (Suspension) .......................... 61 CoLyte-Flavor Packs (Oral Solution) ........... 45 Combigan (Ophthalmic Solution) ............... 61 Combipatch (Patch Twice Weekly) ............. 48 Combivent Respimat (Aerosol Solution) .... 63 Combivir (Tablet) ........................................ 28 Cometriq (Kit).............................................. 25 Comfort Lancets .......................................... 54 Compact Space Chamber/Anti-Static

(Device) .................................................. 54 Compact Space Chamber/Anti-Static/Large

Mask (Device) ......................................... 54 Compact Space Chamber/Anti-

Static/Medium Mask (Device) ............... 54 Compact Space Chamber/Anti-Static/Small

Mask (Device) ......................................... 54 Complera (Tablet) ....................................... 28 Comtan (Tablet) .......................................... 26 Concept DHA (Capsule) ............................... 67 Concept Ob (Capsule) ................................. 67 Concerta (Tablet Extended-Release) .......... 39 Condylox (0.5% External Solution, 0.5% Gel)

................................................................ 41 Copasil (Gel) ................................................ 41 Copaxone (Injection) ................................... 40 Copegus (Tablet) ......................................... 28 Copper Trace Metal (Injection) ................... 65 Cordran (0.05% Cream, 0.05% Lotion, 0.05%

Ointment, 4mcg/SQCM Tape) ............... 41 Coreg (Tablet) ............................................. 35 Coreg CR (Capsule Extended-Release 24

Hour) ...................................................... 35 Corgard (Tablet).......................................... 35 Corifact (Injection) ...................................... 33 Corlanor (Tablet) ........................................ 36 Corlopam (Injection) .................................. 38 Cortef (Tablet) ............................................ 46 Cortenema (Enema) ................................... 46 Cortifoam (Foam) ....................................... 51 Cortisone Acetate (25mg Tablet) ............... 46 Cortisporin (0.5%-0.5% Cream, 1%-0.5%

Ointment) .............................................. 41 Corvert (Injection) ...................................... 34 Corvite (Tablet) ........................................... 66 Corvite 150 (Tablet) .................................... 65 Corzide (Tablet) .......................................... 35 Cosentyx (Injection) ................................... 41 Cosentyx Sensoready Pen (Injection) ........ 41 Cosmegen (Injection) ................................. 25 Cosopt (Ophthalmic Solution) .................... 61 Cosopt PF (Ophthalmic Solution) ............... 61 Cotellic (Tablet) .......................................... 25 Coumadin (Tablet) ...................................... 32 Cozaar (Tablet) ........................................... 34 Creon (Capsule Delayed-Release) .............. 44 Cresemba (186mg Capsule, 372mg Injection)

............................................................... 22 Crestor (Tablet)........................................... 37 Crinone (Gel)............................................... 49 Crixivan (Capsule) ....................................... 29 Cromolyn Sodium (100mg/5ml Concentrate)

............................................................... 44 Cromolyn Sodium (20mg/2ml Nebulized

Solution) ................................................. 63 Cromolyn Sodium (4% Ophthalmic Solution)

............................................................... 61 Cubicin (Injection) ...................................... 14 Cubicin RF (Injection) ................................. 14 Cuprimine (Capsule) ................................... 46 Curosurf (Suspension) ................................ 64 Cuvitru (1gm/5ml Injection, 2gm/10ml

Injection, 4gm/20ml Injection).............. 51 Cuvitru (8gm/40ml Injection) ..................... 28 Cuvposa (Oral Solution) ............................. 44 Cyanocobalamin (1000mcg/ml Injection) ... 66 Cyanokit (Injection) .................................... 52 Cyclessa (Tablet) ......................................... 48 Cyclobenzaprine HCl (10mg Tablet, 5mg

Tablet, 7.5mg Tablet) ............................. 64 Cyclogyl (Ophthalmic Solution) .................. 60 Cyclomydril (Ophthalmic Solution) ............ 60 Cyclopentolate HCl (Ophthalmic Solution).. 60 Cyclophosphamide (1gm Injection, 2gm

Injection, 500mg Injection) .................... 24 Cyclophosphamide (25mg Capsule, 50mg

Capsule) ................................................. 24 Cycloserine (Capsule) ................................. 24 Cycloset (Tablet) ......................................... 31 Cyclosporine (100mg Capsule, 25mg Capsule,

50mg/ml Injection) ................................. 50 Cyclosporine Modified (100mg Capsule, 25mg

Capsule, 50mg Capsule, 100mg/ml Oral Solution) ................................................. 50

Cyfolex (Capsule) ........................................ 68 Cyklokapron (Injection) .............................. 33 Cymbalta (Capsule Delayed-Release) ......... 21 Cyproheptadine HCl (2mg/5ml Syrup, 4mg

Tablet) ..................................................... 27 Cyramza (Injection) ..................................... 26 Cystadane (Powder) .................................... 44 Cystagon (Capsule) ...................................... 44 Cystaran (Ophthalmic Solution) ................. 60 Cytarabine Aqueous (Injection) ................... 25 Cytogam (Injection) .................................... 51 Cytomel (Tablet) ......................................... 49 Cytotec (Tablet)........................................... 45 Cytovene (Injection).................................... 28 Cytra-3 (Syrup) ............................................ 65

D

D.h.e. 45 (Injection) .................................... 23 Dacarbazine (100mg Injection) ................... 24 Dacarbazine (200mg Injection) .................... 24 Dacogen (Injection) ..................................... 25 Daklinza (Tablet) ......................................... 28 Daliresp (Tablet).......................................... 63 Dalvance (Injection) .................................... 14 Danazol (100mg Capsule, 200mg Capsule,

50mg Capsule) ........................................ 48 Dantrium (Capsule) ..................................... 28 Dantrium IV (Injection) ............................... 64 Dantrolene Sodium (Capsule) ...................... 28 Dapsone (Tablet) ......................................... 24 Daptomycin (Solution) ................................. 14 DARAPRIM (Tablet) ..................................... 26 Darifenacin HBr ER (Tablet Extended-Release

24 Hour) .................................................. 46 Darzalex (Injection) ..................................... 26 Daunorubicin HCl (Injection) ....................... 59 Daypro (Tablet) ........................................... 10 Daytrana (Patch) ......................................... 39 DDAVP (0.01% Nasal Solution, 0.1mg Tablet,

0.2mg Tablet, 4mcg/ml Injection) ......... 47 Decitabine (Injection) .................................. 25 Deferoxamine Mesylate (Injection) ............. 54 Delestrogen (Injection) ............................... 48 Delivery Fee ( ) ............................................. 54 Delzicol (Capsule Delayed-Release) ............ 51 Demadex (Tablet) ....................................... 37 Demeclocycline HCl (150mg Tablet, 300mg

Tablet) ..................................................... 18 Demerol (100mg Tablet, 100mg/2ml

Injection, 100mg/ml Injection, 25mg/0.5ml Injection, 25mg/ml Injection, 50mg/ml Injection, 75mg/1.5ml Injection, 75mg/ml Injection) ................................ 11

Demser (Capsule) ........................................ 36 Denavir (Cream) .......................................... 29 Depacon (Injection) .................................... 19

76

Depakene (250mg Capsule, 250mg/5ml Syrup) ..................................................... 19

Depakote (Tablet Delayed-Release) ........... 19 Depakote ER (Tablet Extended-Release 24

Hour) ...................................................... 19 Depakote Sprinkles (Capsule Sprinkle

Delayed-Release) ................................... 19 Depen Titratabs (Tablet) ............................. 46 Deplin 15 (Capsule) ..................................... 54 Deplin 7.5 (Capsule) .................................... 54 Depo-Estradiol (Injection) ........................... 48 Depo-Medrol (Injection) ............................. 46 Depo-Provera (Injection) ............................ 49 Depo-Testosterone (Injection) ................... 48 DermacinRx Clorhexacin (Kit) ..................... 41 DermacinRx Surgical Pharmapak (Kit) ........ 41 DermacinRx Therazole Pak (Therapy Pack) 59 Dermasorb HC (Kit) ..................................... 41 Dermasorb TA (Kit) ..................................... 41 Dermatop (0.1% Cream, 0.1% Ointment) ... 41 DermaweRx Surgical Plus Pak (Kit) ............. 41 DermOtic (Oil) ............................................. 41 Descovy (Tablet) ......................................... 28 Desferal (Injection) ..................................... 54 Desipramine HCl (100mg Tablet, 10mg Tablet,

150mg Tablet, 25mg Tablet, 50mg Tablet, 75mg Tablet) ........................................... 21

Desloratadine (Tablet) ................................. 62 Desloratadine ODT (Tablet Dispersible) ...... 62 Desmopressin Acetate (0.01% Nasal Solution,

0.1mg/ml Nasal Solution, 0.1mg Tablet, 0.2mg Tablet, 4mcg/ml Injection)........... 47

Desogen (Tablet) ......................................... 48 Desogestrel/Ethinyl Estradiol (Tablet) ......... 48 Desonate (Gel) ............................................ 41 Desonide (0.05% Cream, 0.05% Lotion, 0.05%

Ointment) ............................................... 41 DesOwen (0.05% Cream, 0.05% Lotion) ..... 41 Desoximetasone (0.05% Cream, 0.25%

Cream, 0.05% Gel, 0.05% Ointment, 0.25% Ointment) ............................................... 41

Desoxyn (Tablet) ......................................... 39 Desvenlafaxine ER (100mg Tablet Extended-

Release 24 Hour, 25mg Tablet Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Hour) .................................... 21

Desvenlafaxine ER (100mg Tablet Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Hour) .................................... 21

Detrol (Tablet) ............................................. 46 Detrol LA (Capsule Extended-Release 24

Hour) ...................................................... 46 Dexamethasone (0.5mg Tablet, 0.75mg

Tablet, 1.5mg Tablet, 1mg Tablet, 2mg Tablet, 4mg Tablet, 6mg Tablet, 0.5mg/5ml Elixir, 0.5mg/5ml Oral Solution) ................................................................ 46

Dexamethasone Intensol (1mg/ml Concentrate) .......................................... 46

Dexamethasone Sodium Phosphate (0.1% Ophthalmic Solution) .............................. 61

Dexamethasone Sodium Phosphate (10mg/ml Injection) ............................... 50

Dexamethasone Sodium Phosphate (120mg/30ml Injection, 20mg/5ml Solution) ................................................. 46

Dexamethasone Sodium Phosphate (4mg/ml Solution) ................................................. 59

Dexamethasone Sodium Phosphate/Sodium Chloride (Solution)................................. 50

Dexcom G4 Plat Ped ................................... 54 Dexcom G4 Platinum .................................. 54 Dexcom G5 Kit (Receiver/Transmit) .......... 54 Dexedrine (10mg Capsule Extended-Release

24 Hour, 15mg Capsule Extended-Release 24 Hour, 5mg Capsule Extended-Release 24 Hour) ................................................. 39

Dexilant (Capsule Delayed-Release) .......... 45 Dexlido (Injection) ...................................... 47 Dexlido-M (Injection) ................................. 54 Dexmedetomidine HCl (Injection) ............... 29 Dexmethylphenidate HCl (Tablet Immediate-

Release) .................................................. 39 Dexmethylphenidate HCl Capsule Extended-

Release 24 Hour (10mg, 15mg, 20mg, 30mg, 40mg, 5mg, 25mg, 35mg)............ 39

DexPak 10 Day (Tablet Therapy Pack) ....... 47 DexPak 13 Day (Tablet Therapy Pack) ....... 47 DexPak 6 Day (Tablet Therapy Pack) ......... 47 Dexrazoxane (Injection) .............................. 59 Dextroamphetamine Sulfate (10mg Tablet,

5mg Tablet, 5mg/5ml Oral Solution) ...... 39 Dextroamphetamine Sulfate ER (Capsule

Extended-Release 24 Hour) .................... 39 Dextrose 10% (Injection) ............................. 59 Dextrose 20% (Injection) ............................ 59 Dextrose 25% (Injection) ............................ 59 Dextrose 30% (Injection) ............................ 31 Dextrose 40% (Injection) ............................ 59 Dextrose 5% (Injection) ............................... 59 Dextrose 50% (50% Injection) ..................... 59 Dextrose 70% (70% Injection) ..................... 31 Diamox (Capsule Extended-Release 12 Hour)

............................................................... 61 Diastar Easy Test II Lancets 30g ................. 54 Diastar Easy Test Lancets30g ..................... 54 Diastat AcuDial (Gel) .................................. 19 Diastat Pediatric (Gel) ................................ 19 Diastix (Strip) .............................................. 54 Diazepam (10mg Gel, 2.5mg Gel, 20mg Gel,

10mg Tablet, 2mg Tablet, 5mg Tablet, 1mg/ml Oral Solution, 5mg/ml Concentrate) .......................................... 19

Diazepam (10mg/2ml Injection) ................ 59 Diazepam (5mg/ml Injection) .................... 19 Dibenzyline (Capsule) ................................. 33 Diclegis (Tablet Delayed-Release) .............. 22 Diclofenac Potassium (Tablet)..................... 10 Diclofenac Sodium (0.1% Ophthalmic

Solution) ................................................. 61 Diclofenac Sodium (1% Gel, 1.5%

Transdermal Solution) ............................ 41

Diclofenac Sodium (3% Gel)......................... 14 Diclofenac Sodium DR (Tablet Delayed-

Release) .................................................. 10 Diclofenac Sodium ER (Tablet Extended-

Release 24 Hour) .................................... 10 Diclofenac Sodium/Misoprostol (Tablet

Delayed-Release) .................................... 10 Dicloxacillin Sodium (Capsule) ..................... 17 Dicyclomine HCl (10mg Capsule, 10mg/5ml

Oral Solution, 10mg/ml Injection, 20mg Tablet) ..................................................... 44

Didanosine (Capsule Delayed-Release) ....... 28 Differin (0.1% Cream, 0.1% Gel, 0.3% Gel,

0.1% Lotion) ........................................... 41 Dificid (Tablet) ............................................. 17 Diflorasone Diacetate (0.05% Cream, 0.05%

Ointment) ............................................... 41 Diflucan (100mg Tablet, 150mg Tablet,

200mg Tablet, 50mg Tablet, 10mg/ml Suspension, 40mg/ml Suspension) ........ 22

Diflunisal (Tablet) ........................................ 10 Digifab (Injection) ....................................... 54 Digoxin (0.05mg/ml Oral Solution, 0.25mg/ml

Injection, 125mcg Tablet, 250mcg Tablet) ................................................................ 36

Dihydroergotamine Mesylate (1mg/ml Injection, 4mg/ml Nasal Solution) .......... 23

Dilantin (Capsule) ........................................ 20 Dilantin INFATABS (Tablet Chewable) ........ 20 Dilantin-125 (Suspension) ........................... 20 Dilatrate SR (Capsule Extended-Release) ... 38 Dilaudid (1mg/ml Liquid, 1mg/ml Solution,

2mg/ml Solution, 4mg/ml Solution, 2mg Tablet, 4mg Tablet, 8mg Tablet) ............ 11

Diltiazem CD (Capsule Extended-Release 24 Hour) ....................................................... 36

Diltiazem HCl (100mg Injection) ................. 59 Diltiazem HCl (125mg/25ml Injection,

25mg/5ml Injection, 50mg/10ml Injection) ................................................................ 59

Diltiazem HCl (Tablet Immediate-Release) .. 34 Diltiazem HCl CD (Capsule Extended-Release

24 Hour) .................................................. 36 Diltiazem HCl ER (Capsule Extended-Release

24 Hour) .................................................. 35 Diltiazem HCl ER (Capsule Extended-Release

24 Hour, Tablet Extended-Release 24 Hour) ....................................................... 36

Diltiazem HCl/Dextrose (5%-100mg/100ml Solution, 5%-250mg/250ml Solution) ... 38

Diltiazem HCl/Dextrose (5%-125mg/125ml Injection) ................................................. 59

Diltiazem HCl/Sodium Chloride (100mg/100ml-0.9% Injection) ............... 59

Diltiazem HCl/Sodium Chloride (125mg/125ml-0.9% Solution) ............... 38

Dimenhydrinate (50mg/ml Injection) ........ 22 Diovan (Tablet) ........................................... 34 Diovan HCT (Tablet) .................................... 34 Dipentum (Capsule) .................................... 51 Diphenhydramine HCl (12.5mg/5ml Elixir,

77

50mg/ml Injection) ................................. 22 Diphenoxylate/Atropine (2.5mg-0.025mg

Tablet, 2.5mg-0.025mg/5ml Liquid) ....... 44 Diprolene (0.05% Lotion, 0.05% Ointment) 41 Diprolene AF (Cream) ................................. 41 Dipyridamole (25mg Tablet, 50mg Tablet,

75mg Tablet) ........................................... 33 Disopyramide Phosphate (Capsule) ............. 35 Disulfiram (Tablet) ....................................... 13 Ditropan XL (Tablet Extended-Release 24

Hour) ...................................................... 46 Diuril (Suspension) ...................................... 37 Divalproex Sodium (Capsule Sprinkle Delayed-

Release) .................................................. 19 Divalproex Sodium DR (Tablet Delayed-

Release) .................................................. 19 Divalproex Sodium ER (Tablet Extended-

Release 24 Hour) .................................... 19 Divigel (Gel) ................................................. 48 Dmt Suik (Kit) .............................................. 50 Dobutamine HCl (Injection) ......................... 36 Dobutamine HCl/D5W (Injection)................ 36 Docetaxel (160mg/16ml Injection,

160mg/8ml Injection, 20mg/2ml Injection, 20mg/ml Injection, 80mg/4ml Injection, 80mg/8ml Injection) .............. 25

Docetaxel (20mg/0.5ml Injection, 80mg/2ml Injection) ................................................. 59

Docetaxel (20mg/ml Injection, 80mg/4ml Injection) ................................................. 25

Docetaxel (Non-Alcohol Formula) (Injection) ................................................................ 25

Dofetilide (Capsule) ..................................... 35 Dologesic (Tablet) ....................................... 23 Dolophine (Tablet) ...................................... 11 Donepezil HCl (10mg Tablet Dispersible, 5mg

Tablet Dispersible, 10mg Tablet, 23mg Tablet, 5mg Tablet) ................................. 20

Dopamine HCl (160mg/ml Injection) .......... 36 Dopamine HCl (40mg/ml Injection, 80mg/ml

Injection) ................................................. 36 Dopamine/D5W (Injection) ......................... 36 Dopram (Injection) ...................................... 39 Doral (Tablet) .............................................. 29 Doribax (Injection) ...................................... 16 Doripenem (Injection) ................................ 16 Doryx (Tablet Delayed-Release) ................. 18 Doryx MPC (Tablet Delayed-Release) ........ 18 Dorzolamide HCl (Ophthalmic Solution) ...... 36 Dorzolamide HCl/Timolol Maleate

(Ophthalmic Solution) ............................. 61 Doubledex (Injection) ................................. 47 Dovonex (Cream) ........................................ 41 Doxazosin (Tablet) ....................................... 33 Doxazosin Mesylate (Tablet) ....................... 33 Doxepin HCl (100mg Capsule, 10mg Capsule,

150mg Capsule, 25mg Capsule, 50mg Capsule, 75mg Capsule, 10mg/ml Concentrate) ........................................... 21

Doxepin HCl (Cream) ................................... 41 Doxercalciferol (0.5mcg Capsule, 1mcg

Capsule, 2.5mcg Capsule, 4mcg/2ml Injection) ................................................ 52

Doxil (Injection) .......................................... 59 Doxorubicin HCl (Injection) ......................... 24 Doxycycline (25mg/5ml Suspension) .......... 18 Doxycycline (40mg Capsule Delayed-Release)

............................................................... 41 Doxycycline Hyclate (100mg Capsule, 50mg

Capsule, 100mg Injection, 100mg Tablet, 20mg Tablet) .......................................... 18

Doxycycline Hyclate DR (Tablet Delayed-Release) .................................................. 18

Doxycycline Monohydrate (100mg Capsule, 150mg Capsule, 50mg Capsule, 75mg Capsule, 100mg Tablet, 150mg Tablet, 50mg Tablet, 75mg Tablet) .................... 18

DrCaps Size 0 Clear (Capsule) ..................... 54 DrCaps Size 00 Clear (Capsule) ................... 54 DrCaps Size 1 Clear (Capsule) ..................... 54 Drihep Arterial Line Sampling Syr/3ml Ll/5ml

Waste Syr/2-Cap (Kit) ............................ 54 DriHep Plus 3ml LL Prefilled Syringe/Tip

Cap/Ndl Stop/Safetycone (Kit) .............. 54 Dritho-Creme HP (Cream) .......................... 41 Dronabinol (Capsule) .................................. 22 Droperidol (2.5mg/ml Injection) ................. 22 Droplet Lancets Ultra Thin 30g................... 54 Drospirenone/Ethinyl Estradiol (Tablet) ..... 48 Drospirenone/Ethinyl Estradiol/Levomefolate

Calcium (Tablet) ..................................... 48 Droxia (Capsule) ......................................... 25 Drug Mart On-The-Go Lancets Gentle 30g . 54 Drug Mart Unilet Lancets Ultra Thin 28g ... 54 Drysol (External Solution) .......................... 41 Duac (Gel) ................................................... 41 Duavee (Tablet) .......................................... 59 Duet DHA 400 ............................................. 67 Duet DHA Balanced .................................... 67 Duetact (Tablet).......................................... 31 Dulera (Aerosol) ......................................... 62 Duloxetine HCl (20mg Capsule Delayed-

Release, 30mg Capsule Delayed-Release, 60mg Capsule Delayed-Release) ............ 21

Duloxetine HCl (40mg Capsule Delayed-Release) ................................................. 21

Duodote (Injection) .................................... 54 Duopa (Suspension) ................................... 27 Duragesic (Patch 72 Hour) .......................... 11 Durasafe Spinal/Epidural Tray/1%

Xylocaine/20gx36"close Cath (Kit) ........ 12 Durasafe Spinal/Epidural Tray/1%

Xylocaine/20gx36"open Cath (Kit) ........ 12 Durezol (Emulsion) ..................................... 61 Dutasteride (Capsule) ................................. 46 Dutasteride/Tamsulosin HCl (Capsule) ....... 46 DUTOPROL (Tablet Extended-Release 24

Hour) ...................................................... 35 Dyazide (Capsule) ....................................... 37 Dyloject (Injection) ..................................... 14 Dymista (Suspension) ................................. 62 Dyrenium (Capsule) .................................... 37

Dysport (Injection) ...................................... 59 Dyural-40 (Injection) ................................... 12 Dyural-80 (Injection) ................................... 12 Dyural-L (Injection) ..................................... 47 Dyural-LM (Injection) .................................. 12

E

E.E.S. Granules (Suspension) ...................... 17 Easivent ....................................................... 54 Easivent/Mask-Large .................................. 54 Easivent/Mask-Medium ............................. 54 Easivent/Mask-Small .................................. 54 Easy Touch Insulin Syringe/U-100/1ml/31g X

5/16" ...................................................... 54 Easy Touch Lancets 26g/Pressure Activated

................................................................ 54 Easy Touch Lancets 28g/Pressure Activated



................................................................ 54 Easy Touch Lancets 33g/Twist .................... 54 Easy Touch Pen Needles 29gx1/2" ............. 54 Easy Touch Pen Needles 31gx1/4" ............. 54 Easy Touch Pen Needles 31gx5/16" ........... 54 Easy Touch Pen Needles 32gx5/32" ........... 54 Easy Touch Pen Needles/31g X 3/16" ........ 54 Easy Touch Safety Lancets21g/Pressure

Activated ................................................ 54 Easy Touch Safety Lancets23g/Pressure

Activated ................................................ 54 Easytest II Lancets ....................................... 54 Easytest Lancets .......................................... 54 EC-Naprosyn (Tablet Delayed-Release) ...... 10 Econazole Nitrate (1% Cream) ..................... 22 Ecoza (Foam) ............................................... 22 Ed Cyte F (Tablet) ........................................ 44 Edarbi (Tablet)............................................. 34 Edarbyclor (Tablet) ..................................... 34 Edecrin (Tablet) ........................................... 37 Edluar (Tablet Sublingual)........................... 65 Edurant (Tablet) .......................................... 28 Effervescent Potassium/Chloride (Tablet

Effervescent) ........................................... 65 Effexor XR (Capsule Extended-Release 24

Hour) ...................................................... 21 Effient (Tablet) ............................................ 33 Efudex (Cream) ........................................... 41 Egrifta (Injection) ........................................ 47 Elaprase (Injection) ..................................... 44 Elavil (Tablet) .............................................. 21 Eldepryl (Capsule) ....................................... 27 Elelyso (Injection)........................................ 44 Elestat (Ophthalmic Solution) .................... 61 Elestrin (Gel)................................................ 48 Eletone (Cream) .......................................... 41 Eletone Twinpack (Cream) .......................... 41 Elfolate (Tablet) .......................................... 54 Elfolate Plus (Tablet) ................................... 68

78

Elidel (Cream) .............................................. 41 Eligard (Injection) ........................................ 49 Eligen B12 (Tablet) ...................................... 54 Elimite (Cream) ........................................... 26 Eliphos (Tablet) ........................................... 46 Eliquis (Tablet) ............................................ 32 Elitek (Injection) .......................................... 25 Elixophyllin (Elixir) ...................................... 63 Ella (Tablet) ................................................. 49 Ellence (Injection) ....................................... 59 Elmiron (Capsule) ........................................ 46 Elocon (0.1% Cream, 0.1% Lotion, 0.1%

Ointment) ............................................... 41 Emadine (Ophthalmic Solution) ................. 61 Embeda (Capsule Extended-Release) ......... 11 Embrace Lancets Ultra Thin 30g ................. 54 Emcyt (Capsule) .......................................... 25 Emend (Capsule, 40mg Capsule, 125mg

Capsule, 80mg Capsule, 125mg Suspension, 150mg Injection) ................ 22

Emflaza (18mg Tablet, 30mg Tablet, 36mg Tablet, 6mg Tablet, 22.75mg/ml Suspension) ............................................ 47

Empliciti (Injection) ..................................... 26 Emsam (Patch 24 Hour) .............................. 20 Emtriva (10mg/ml Oral Solution, 200mg

Capsule) .................................................. 28 Emverm (Tablet Chewable) ........................ 26 Enablex (Tablet Extended-Release 24 Hour)

................................................................ 46 Enalapril Maleate (Tablet) ........................... 34 Enalapril Maleate/Hydrochlorothiazide

(Tablet) ................................................... 34 Enalaprilat (Injection) .................................. 34 Enbrace HR (Capsule) .................................. 67 Enbrel (25mg Injection) .............................. 50 Enbrel (25mg/0.5ml Injection, 50mg/ml

Injection) ................................................ 59 Enbrel SureClick (Injection)......................... 59 Endometrin (Insert) .................................... 49 Enlon (Injection) .......................................... 24 Enoxaparin Sodium (100mg/ml Injection,

120mg/0.8ml Injection, 150mg/ml Injection, 30mg/0.3ml Injection, 40mg/0.4ml Injection, 60mg/0.6ml Injection, 80mg/0.8ml Injection, 300mg/3ml Injection) ............................. 32

Entacapone (Tablet) .................................... 26 Entecavir (Tablet) ........................................ 28 Enteragam (Packet)..................................... 54 Entereg (Capsule) ........................................ 44 Entocort EC (Capsule Delayed-Release) ..... 51 Entresto (Tablet) ......................................... 34 Entyvio (Injection) ....................................... 44 Envarsus XR (Tablet Extended-Release 24

Hour) ...................................................... 50 Epaned (Oral Solution)................................ 34 Epclusa (Tablet) ........................................... 28 Ephedrine Sulfate (250mg/5ml Injection) .. 63 Ephedrine Sulfate (50mg/ml Solution) ....... 30 Ephedrine Sulfate/Sodium Chloride

(100mg/10ml-0.9% Injection, 10mg/ml-0.9% Injection, 25mg/5ml-0.9% Injection, 50mg/5ml-0.9% Injection) ..................... 63

Epiduo (Gel) ................................................ 41 Epiduo Forte (Gel) ...................................... 41 Epifoam (Foam) .......................................... 12 Epinastine HCl (Ophthalmic Solution) ......... 61 Epinephrine (0.15mg/0.15ml Solution Auto

injector, 0.3mg/0.3ml Solution Auto injector) (authorized generic Epi-Pen made by Mylan) ..................................... 63

Epinephrine (0.15mg/0.3ml Injection, 0.3mg/0.3ml Injection) .......................... 63

Epinephrine HCl (1mg/ml Injection) .......... 63 EpiPen (Injection) ....................................... 63 Epirubicin HCl (Injection) ............................ 59 Episone Cre (Cream) ............................... 41 Epivir (10mg/ml Oral Solution, 150mg

Tablet, 300mg Tablet)............................ 28 Epivir HBV (100mg Tablet) ......................... 28 Epivir HBV (5mg/ml Oral Solution) ............ 28 Eplerenone (Tablet) .................................... 37 Epogen (Injection) ...................................... 32 Epoprostenol Sodium (Injection) ................ 63 Eprosartan Mesylate (Tablet) ...................... 34 Eptifibatide (Injection) ................................ 33 Epzicom (Tablet) ......................................... 29 Equetro (Capsule Extended-Release 12 Hour)

............................................................... 20 Eraxis (Injection) ......................................... 22 Erbitux (Injection) ....................................... 26 Erecaid Classic (Kit) ..................................... 54 Erecaid Esteem (Kit) ................................... 54 Ergoloid Mesylates (Tablet) ........................ 20 Ergomar (Tablet Sublingual) ....................... 23 Ergotamine Tartrate/Caffeine (Tablet) ....... 23 Erivedge (Capsule) ...................................... 26 Eros-CTD (Device) ....................................... 54 Ertaczo (Cream) .......................................... 22 Erwinaze (Injection).................................... 59 Erygel (Gel) ................................................. 41 EryPed 200 (Suspension) ............................ 17 EryPed 400 (Suspension) ............................ 17 Ery-Tab (Tablet Delayed-Release) .............. 17 Erythrocin Lactobionate (Injection) ........... 17 Erythrocin Stearate (Tablet) ....................... 17 Erythromycin (2% External Solution, 2% Gel,

2% Pad) .................................................. 41 Erythromycin (250mg Capsule Delayed-

Release, 5mg/gm Ointment) .................. 17 Erythromycin Base (Tablet) ......................... 17 Erythromycin Ethylsuccinate (200mg/5ml

Suspension, 400mg Tablet) .................... 17 Erythromycin/Benzoyl Peroxide (Gel) ......... 41 Esbriet (Capsule) ......................................... 64 Escavite (Tablet Chewable) ........................ 67 Escavite D (Tablet Chewable) ..................... 67 Escitalopram Oxalate (10mg Tablet, 20mg

Tablet, 5mg Tablet, 5mg/5ml Oral Solution) ................................................. 21

Esgic (Tablet) .............................................. 10

Esmolol HCl (Injection) ................................ 35 Esomeprazole Magnesium (Capsule Delayed-

Release) .................................................. 45 Esomeprazole Sodium (20mg Injection) ..... 45 Esomeprazole Sodium (40mg Injection) ...... 45 Esomeprazole Strontium (Capsule Delayed-

Release) .................................................. 45 Estazolam (Tablet) ....................................... 29 Estrace (0.1mg/gm Cream, 0.5mg Tablet,

1mg Tablet, 2mg Tablet) ........................ 48 Estradiol (0.025mg/24hr Patch Weekly,

0.05mg/24hr Patch Weekly, 0.06mg/24hr Patch Weekly, 0.075mg/24hr Patch Weekly, 37.5mcg/24hr Patch Weekly, 0.1mg/24hr Patch Weekly, 0.5mg Tablet, 1mg Tablet, 2mg Tablet) ......................... 48

Estradiol Valerate (Injection) ....................... 48 Estradiol/Norethindrone Acetate (Tablet)... 48 Estring (Ring) ............................................... 48 Estrogel (Gel) ............................................... 48 Estropipate (Tablet) ..................................... 48 Estrostep Fe (Tablet) ................................... 48 Eszopiclone (Tablet)..................................... 65 Ethacrynate Sodium (Injection) ................... 37 Ethacrynic Acid (Tablet) ............................... 37 Ethambutol HCl (100mg Tablet, 400mg

Tablet) ..................................................... 24 Ethamolin (Injection) .................................. 36 Ethosuximide (250mg Capsule, 250mg/5ml

Oral Solution) .......................................... 18 Ethyl Chloride (Aerosol) .............................. 12 Ethynodiol Diacetate/Ethinyl Estradiol

(Tablet) ................................................... 48 Ethyol (Injection) ......................................... 59 Etidronate Disodium (Tablet) ...................... 52 Etodolac (200mg Capsule, 300mg Capsule,

400mg Tablet, 500mg Tablet) ................. 10 Etodolac ER (Tablet Extended-Release 24

Hour) ....................................................... 10 Etopophos (Injection) ................................. 25 Etoposide (100mg/5ml Injection, 1gm/50ml

Injection, 500mg/25ml Injection) ........... 25 Etoposide (50mg Capsule) .......................... 25 Eucrisa (Ointment) ...................................... 41 Euflexxa (Injection) ..................................... 54 Eurax (10% Cream, 10% Lotion) .................. 26 Evamist (Transdermal Solution) ................. 48 Evekeo (Tablet) ........................................... 39 Evicel (Kit) ................................................... 41 Evista (Tablet) ............................................. 49 Evithrom (External Solution) ...................... 33 Evoclin (Foam) ............................................. 41 Evomela (Injection) ..................................... 24 Evotaz (Tablet) ............................................ 29 Evoxac (Capsule) ......................................... 40 Evzio (0.4mg/0.4ml Injection)..................... 13 Evzio (2mg/0.4ml Injection) ........................ 40 Exactuss (Liquid) ......................................... 64 Excel Comfort Point Insulin Pen Needles 31g

X 4mm .................................................... 54 Excilon AMD Antimicrobialdrain Sponges

79

4"x4" 6 Ply .............................................. 41 Exel Comfort Point Insulin Pen Needles 29g X

12mm ..................................................... 54 Exel Comfort Point Insulin Pen Needles 31g X

8mm ....................................................... 54 Exel Comfort Point Insulin

Syringe/0.3ml/29g X 1/2" ...................... 54 Exel Comfort Point Insulin

Syringe/0.3ml/30g X 5/16" .................... 54 Exelderm (1% Cream, 1% External Solution)

................................................................ 22 Exelon (Patch 24 Hour) ............................... 20 Exemestane (Tablet) .................................... 25 Exforge (Tablet) ........................................... 34 Exforge HCT (Tablet) ................................... 34 Exjade (Tablet Soluble) ............................... 65 Exoderm (Lotion) ........................................ 22 Exondys 51 (Injection) ................................ 59 Exparel (Suspension)................................... 12 Extavia (Injection) ....................................... 40 Extina (Foam) .............................................. 22 E-Z Ject Lancets ........................................... 54 E-Z Ject Lancets 21g .................................... 54 E-Z Ject Lancets Color .................................. 54 E-Z Ject Lancets Super Thin 30g .................. 54 E-Z Ject Lancets Thin 26g ............................ 54 EZ Smart Blood Glucose Lancets ................. 54 E-Z Spacer (Device) ..................................... 54 E-Z Spacer the Body Guards Pack (Device) . 54 Ezetimibe (Tablet) ....................................... 37 E-Zject Lancets Micro-Thin 33g ................... 54 EZ-Lets Lancets 21g ..................................... 54 EZ-Lets Lancets 23g ..................................... 54 EZ-Lets Lancets 26g Super-Soft ................... 54 EZ-Lets Lancets 28g Ultra-Soft .................... 54 EZ-Lets Lancets 30g ..................................... 54

F

Fabior (Foam) .............................................. 41 Fabrazyme (Injection) ................................. 44 Factive (Tablet) ........................................... 17 Falessa (Tablet) ........................................... 32 Famciclovir (Tablet) ..................................... 29 Famotidine (200mg/20ml Injection,

20mg/2ml Injection, 40mg/4ml Injection, 20mg Tablet, 40mg Tablet, 40mg/5ml Suspension) ............................................ 45

Famotidine Premixed (Injection) ................ 45 Fanapt (Tablet) ............................................ 27 Fanapt Titration Pack (Tablet) .................... 27 Fareston (Tablet) ......................................... 25 Farxiga (Tablet) ........................................... 31 Farydak (Capsule) ....................................... 25 Faslodex (Injection)..................................... 25 Fazaclo (Tablet Dispersible) ........................ 27 Feiba (Injection) .......................................... 33 Felbamate (400mg Tablet, 600mg Tablet,

600mg/5ml Suspension) ......................... 19 Felbatol (400mg Tablet, 600mg Tablet,

600mg/5ml Suspension) ........................ 19

Feldene (Capsule) ....................................... 10 Felodipine ER (Tablet Extended-Release 24

Hour) ...................................................... 36 Femara (Tablet) .......................................... 25 Femcon Fe (Tablet Chewable) .................... 48 Femhrt Low Dose (Tablet) .......................... 48 Femring (Ring) ............................................ 48 Fenofibrate (120mg Tablet, 145mg Tablet,

160mg Tablet, 40mg Tablet, 48mg Tablet, 54mg Tablet, 130mg Capsule, 150mg Capsule, 43mg Capsule, 50mg Capsule) . 37

Fenofibrate Micronized (Capsule) ............... 37 Fenofibric Acid (Tablet) ............................... 37 Fenofibric Acid DR (Capsule Delayed-Release)

............................................................... 37 Fenoglide (Tablet)....................................... 37 Fenoprofen Calcium (200mg Capsule, 400mg

Capsule, 600mg Tablet) .......................... 10 Fenortho (Capsule) ..................................... 10 Fentanyl (Patch 72 Hour) ............................ 11 Fentanyl Citrate Oral Transmucosal (Lollipop)

............................................................... 11 Fentanyl Citrate/NaCl (Injection) ............... 11 Fentanyl Citrate/Sodium Chloride

(1.25mg/250ml-0.9% Injection, 2.5mg/250ml-0.9% Injection) ................ 38

Fentanyl Citrate/Sodium Chloride (1mg/100ml-0.9% Injection, 2mg/100ml-0.9% Injection) ....................................... 11

Fentora (Tablet) .......................................... 11 Feraheme (Injection) .................................. 65 Feriva 21/7 (Tablet) .................................... 30 Ferriprox (100mg/ml Oral Solution, 500mg

Tablet) .................................................... 54 Ferrlecit (Injection) ..................................... 65 Ferro-Plex Hematinic (Tablet) .................... 30 Ferrotrin (Capsule) ..................................... 30 Fetzima (Capsule Extended-Release 24 Hour)

............................................................... 21 Fetzima Titration Pack (Capsule Extended-

Release 24 Hour Therapy Pack) ............. 21 Fexmid (Tablet)........................................... 64 Fibricor (Tablet) .......................................... 37 Fifty50 Pen Needles 31g X3/16" (5mm) ..... 54 Fifty50 Pen Needles 31g X5/16" (8mm) ..... 54 Fifty50 Pen Needles 31gx5mm ................... 55 Fifty50 Pen Needles/31gx8mm .................. 55 Fifty50 Pen Needles/32gx4mm .................. 55 Fifty50 Safety Seal Lancets 30g .................. 55 Fifty50 Unilet Lancets 33g .......................... 55 Finacea (15% Foam, 15% Gel) .................... 41 Finasteride (5mg Tablet) ............................. 46 Fine 30 ........................................................ 55 Fingerstix Lancets ....................................... 55 Fioricet (Capsule) ........................................ 10 Fioricet/Codeine (Capsule) ......................... 11 Fiorinal (Capsule) ........................................ 10 Fiorinal/Codeine #3 (Capsule) .................... 11 Firazyr (Injection) ....................................... 59 Firmagon (Injection) ................................... 49 First-Lansoprazole (Suspension) ................ 45

First-Metronidazole 100 (Suspension) ....... 22 First-Metronidazole 50 (Suspension) ......... 22 First-Omeprazole (Suspension) .................. 45 First-Vancomycin 25 (Oral Solution) ........... 14 First-Vancomycin 50 (Oral Solution) ........... 14 Flagyl (250mg Tablet, 500mg Tablet, 375mg

Capsule) .................................................. 14 Flanax Pain Relief Kit (Kit)........................... 10 Flarex (Suspension) ..................................... 61 Flavor Blend (Suspension) .......................... 55 Flavoxate HCl (Tablet) .................................. 46 Flebogamma DIF (Injection) ....................... 51 Flecainide Acetate (Tablet) .......................... 35 Flector (Patch) ............................................. 10 Flexichamber (Device) ................................ 55 Flexichamber Child Mask/Large ................. 55 Flexichamber Child Mask/Small ................. 55 Flolan (Injection) ......................................... 63 Flomax (Capsule) ......................................... 46 Florical (364mg-8.3mg Capsule, 364mg-

8.3mg Tablet) ......................................... 52 Floriva (Liquid) ............................................ 52 Floriva Plus (Oral Solution) ......................... 66 Flovent Diskus (Aerosol Powder) ............... 62 Flovent HFA (Aerosol) ................................. 62 Floxin Otic (Otic Solution) ........................... 17 Floxuridine (Injection) ................................. 25 Fluconazole (100mg Tablet, 150mg Tablet,

200mg Tablet, 50mg Tablet, 10mg/ml Suspension, 40mg/ml Suspension) ......... 22

Fluconazole in Dextrose (Injection) ............. 22 Fluconazole in NaCl (100mg/50ml-0.9%

Injection) ................................................ 22 Fluconazole in NaCl (200mg/100ml-0.9%

Injection, 400mg/200ml-0.9% Injection) 22 Flucytosine (Capsule) ................................... 22 Fludarabine Phosphate (Injection) .............. 59 Fludrocortisone Acetate (0.1mg Tablet) ...... 47 Flumadine (Tablet) ...................................... 29 Flumazenil (Injection) .................................. 39 Flunisolide (Nasal Solution) ......................... 62 Fluocinolone Acetonide (Cream, External

Solution, Oil, Ointment) .......................... 41 Fluocinolone Acetonide Ear Drops (Oil) ....... 41 Fluocinonide (Cream, Cream, External

Solution, Gel, Ointment) ......................... 41 Fluocinonide-E (Cream) ............................... 41 Fluorabon (Oral Solution) ........................... 52 Fluor-A-Day (Tablet Chewable) .................. 52 Fluoride (0.5mg Tablet Chewable)............... 65 Fluorometholone (Ophthalmic Suspension) 61 Fluoroplex (Cream) ..................................... 41 Fluorouracil (1gm/20ml Injection,

2.5gm/50ml Injection, 500mg/10ml Injection, 5gm/100ml Injection, 5% Cream) ................................................................ 25

Fluorouracil (External Solution, External Solution) ................................................. 41

Fluoxetine (Capsule) .................................... 21 Fluoxetine DR (Capsule Delayed-Release) ... 21 Fluoxetine HCl (10mg Tablet, 20mg Tablet,

80

60mg Tablet, 20mg/5ml Oral Solution, 40mg Capsule) ........................................ 21

Fluphenazine Decanoate (Injection) ............ 27 Fluphenazine HCl (10mg Tablet, 1mg Tablet,

2.5mg Tablet, 5mg Tablet) ...................... 27 Fluphenazine HCl (2.5mg/5ml Elixir, 5mg/ml

Concentrate) .......................................... 27 Fluphenazine HCl (2.5mg/ml Injection) ...... 27 Flura-Drops (Oral Solution) ......................... 52 Flurandrenolide (Cream, Lotion, Ointment) 41 Flurazepam HCl (Capsule) ............................ 29 Flurbiprofen (100mg Tablet, 50mg Tablet).. 10 Flurbiprofen Sodium (Ophthalmic Solution) 61 Flutamide (Capsule) ..................................... 24 Fluticasone Propionate (50mcg/act

Suspension) ............................................ 62 Fluticasone Propionate (Ointment, Cream,

Lotion) .................................................... 41 Fluvastatin (Capsule) ................................... 37 Fluvastatin Sodium ER (Tablet Extended-

Release 24 Hour) .................................... 37 Fluvoxamine Maleate (Tablet) ..................... 21 Fluvoxamine Maleate ER (Capsule Extended-

Release 24 Hour) .................................... 21 FML (Ointment)........................................... 61 FML Forte (Suspension) .............................. 61 FML Liquifilm (Suspension) ......................... 61 Focalgin 90 DHA .......................................... 67 Focalgin Ca .................................................. 67 Focalgin DSS (Tablet) .................................. 30 Focalin (Tablet) ........................................... 39 Focalin XR (Capsule Extended-Release 24

Hour) ...................................................... 39 Folbee Plus Cz (Tablet) ................................ 66 Folbic RF (Tablet) ........................................ 66 Folcaps Omega 3 (Capsule) ......................... 66 Folgard Os (Tablet)...................................... 67 Folgard Rx (Tablet) ...................................... 66 Folic Acid (1mg Tablet) ................................ 66 Folic Acid (5mg/ml Injection) ..................... 66 Folic Acid/Vitamin B-6/Vitamin B-12 (Tablet)

................................................................ 66 Folitab 500 (Tablet Extended-Release)....... 30 Folivane-F (Capsule) .................................... 65 Folivane-Ob (Capsule) ................................. 67 Folivane-Plus (Capsule) ............................... 30 Follistim AQ (300unit/0.36ml Injection,

600unit/0.72ml Injection, 900unit/1.08ml Injection, 75unit/0.5ml Injection) ......... 47

Folotyn (Injection) ...................................... 25 Foltanx (Tablet) ........................................... 66 Foltanx RF (Capsule) ................................... 66 Foltx (Tablet) ............................................... 67 Fomepizole (Injection) ................................. 55 Fondaparinux Sodium (Injection) ................ 32 Fora Lancets ................................................ 55 Forfivo XL (Tablet Extended-Release 24

Hour) ...................................................... 20 Fortamet (Tablet Extended-Release 24 Hour)

................................................................ 31 Fortavit (Capsule) ........................................ 67

Fortaz (Injection) ........................................ 16 Forteo (Injection) ........................................ 52 Fortesta (Gel) .............................................. 48 Fosamax (Tablet) ........................................ 52 Fosamax Plus D (Tablet) ............................. 52 Foscavir (Injection) ..................................... 59 Fosinopril Sodium (Tablet) .......................... 34 Fosinopril Sodium/Hydrochlorothiazide

(Tablet) ................................................... 34 Fosphenytoin Sodium (Injection) ................ 20 Fosrenol (1000mg Packet, 750mg Packet,

1000mg Tablet Chewable, 500mg Tablet Chewable, 750mg Tablet Chewable) ..... 46

Fosteum (Capsule) ...................................... 67 Fosteum Plus (Capsule) .............................. 65 Fovex (Capsule) .......................................... 65 Fragmin (Injection) ..................................... 32 FreAmine HBC 6.9% (Injection) .................. 65 FreAmine III (Injection) .............................. 65 FreeStyle Unistick II Lancets ....................... 55 Frova (Tablet) ............................................. 23 Frovatriptan Succinate (Tablet) ................... 23 Furadantin (Suspension) ............................ 14 Furosemide (10mg/ml Injection, 10mg/ml

Oral Solution, 8mg/ml Oral Solution, 20mg Tablet, 40mg Tablet, 80mg Tablet) ........ 37

Fusilev (Injection) ....................................... 59 Fusion Plus (Capsule) .................................. 30 Fuzeon (Injection) ....................................... 29 Fycompa (0.5mg/ml Suspension, 10mg

Tablet, 12mg Tablet, 2mg Tablet, 4mg Tablet, 6mg Tablet, 8mg Tablet) ........... 18

G

G5/G4 Kit Sensor ........................................ 55 Gabadone (Capsule) ................................... 65 Gabapentin (100mg Capsule, 300mg Capsule,

400mg Capsule, 250mg/5ml Oral Solution, 600mg Tablet, 800mg Tablet) ................ 28

Gabitril (Tablet) .......................................... 19 Gablofen (Injection) ................................... 28 Galantamine HBr (12mg Tablet, 4mg Tablet,

8mg Tablet, 4mg/ml Oral Solution) ........ 20 Galantamine HBr ER (Capsule Extended-

Release 24 Hour) .................................... 20 Galaxtra (Powder) ...................................... 55 Galzin (Capsule) .......................................... 65 Gamastan S/D (Injection) ........................... 51 Gammagard Liquid (Injection) ................... 51 Gammagard S/D IGA Less Than 1 mcg/ml

(Injection) .............................................. 51 Gammaked (Injection) ................................ 51 Gammaplex (Injection) ............................... 51 Gamunex-C (Injection) ............................... 51 Ganciclovir (Injection) ................................. 28 Ganirelix Acetate (Injection) ...................... 49 Gastrocrom (Concentrate) ......................... 44 Gatifloxacin (Ophthalmic Solution) ............. 17 Gattex (Injection) ....................................... 45 Gazyva (Injection) ....................................... 26

Gebauers Pain Ease (0-0 Aerosol) ............... 12 Gelfilm Op (Film) ......................................... 33 Gel-Kam Oral Care Rinse (Concentrate) ..... 40 Gelnique (Gel) ............................................. 46 Gel-One (Prefilled Syringe) ......................... 55 Gelsyn-3 (Injection) ..................................... 55 Gemcitabine (Injection) ............................... 25 Gemfibrozil (600mg Tablet) ......................... 37 Gemzar (Injection) ...................................... 25 Generess Fe (Tablet Chewable) .................. 48 Gene-Xene Tab 15mg (Tablet) ..................... 19 Gene-Xene Tab 3.75mg (Tablet) .................. 19 Gene-Xene Tab 7.5mg (Tablet) .................... 19 Genotropin (12mg Injection, 5mg Injection)

................................................................ 47 Genotropin Miniquick (Injection) ............... 47 Gentamicin Sulfate (0.1% Cream, 0.1%

Ointment, 0.3% Ophthalmic Ointment, 0.3% Ophthalmic Solution, 10mg/ml Injection, 40mg/ml Injection) ................. 14

Gentamicin Sulfate/0.9% Sodium Chloride (0.8mg/ml-0.9% Injection, 1.2mg/ml-0.9% Injection, 1mg/ml-0.9% Injection) .......... 14

Gentamicin Sulfate/0.9% Sodium Chloride (0.9mg/ml Injection, 1.4mg/ml Injection, 2mg/ml-0.9% Injection) ......................... 14

Gentle-Let GP Lancets ................................. 55 Gentle-Let Lancets General Purpose

Style/Medium Point ............................... 55 Gentle-Let Platforms 2.4mm ...................... 55 Genvisc 850 (Solution Prefilled Syringe) .... 55 Genvoya (Tablet) ......................................... 28 Geodon (20mg Capsule, 40mg Capsule, 60mg

Capsule, 80mg Capsule) ......................... 27 Geodon (20mg Injection) ............................ 59 Gilenya (Capsule) ........................................ 40 Gilotrif (Tablet) ........................................... 26 Giltuss (Liquid) ............................................ 64 Glassia (Injection) ....................................... 64 Glatopa (Injection) ....................................... 40 Gleevec (Tablet) .......................................... 26 Gleostine (Capsule) ..................................... 24 Gliadel Wafer (Wafer) ................................. 24 Glimepiride (Tablet) ..................................... 31 Glipizide (Tablet Immediate-Release) .......... 31 Glipizide ER (Tablet Extended-Release 24

Hour) ....................................................... 31 Glipizide/Metformin HCl (Tablet) ................ 31 GlucaGen HypoKit (Injection) ..................... 31 Glucagon Emergency Kit (Injection) ........... 31 GlucoCom Lancets 28g ................................ 55 GlucoCom Lancets 30g ................................ 55 GlucoCom Lancets 33g ................................ 55 Glucophage (Tablet) .................................... 31 Glucophage XR (Tablet Extended-Release 24

Hour) ...................................................... 31 Glucosource Lancets ................................... 55 Glucotrol (Tablet) ........................................ 31 Glucotrol XL (Tablet Extended-Release 24

Hour) ...................................................... 31 Glucovance (Tablet) .................................... 31

81

Glumetza (Tablet Extended-Release 24 Hour) ................................................................ 31

Glutaraldehyde (External Solution) ............ 14 Glyburide (1.25mg Tablet, 2.5mg Tablet, 5mg

Tablet)..................................................... 31 Glyburide Micronized (Tablet) ..................... 31 Glyburide/Metformin HCl (Tablet) .............. 31 Glycolic Acid 70% High Purity ..................... 55 Glycophos (Injection) .................................. 55 Glycopyrrolate (0.4mg/2ml Injection,

1mg/5ml Injection, 4mg/20ml Injection, 1mg Tablet, 2mg Tablet) ......................... 44

Glycopyrrolate (0.4mg/2ml Solution Prefilled Syringe) .................................................. 30

Glynase (Tablet) .......................................... 31 Glyset (Tablet) ............................................. 31 Glytactin Bettermilk 15 (Packet) ................ 65 Glytactin Bettermilk De-Lite (Packet) ......... 65 Glytactin Build 10pe (Packet) ..................... 65 Glytactin Complete 10pe (Bar) ................... 65 Glytactin Restore 5 (Packet) ....................... 65 Glytactin Restore Lite 10PE (Packet) .......... 65 Glyxambi (Tablet)........................................ 31 Gmate Lancets 30g ...................................... 55 GoLYTELY (Oral Solution) ............................ 45 Gonal-F (Injection) ...................................... 47 Gonal-F RFf (Injection) ................................ 47 Gonal-F RFf Rediject (Injection) .................. 47 Gonitro (Packet) .......................................... 38 Gralise (Tablet) ............................................ 10 Gralise Starter Pack..................................... 10 Granisetron HCl (0.1mg/ml Injection, 1mg/ml

Injection, 4mg/4ml Injection, 1mg Tablet) ................................................................ 22

Granix (Injection) ........................................ 32 Griseofulvin Microsize (125mg/5ml

Suspension, 500mg Tablet) ..................... 23 Griseofulvin Ultramicrosize (Tablet) ............ 23 GRIS-PEG (Tablet)........................................ 23 Guanfacine ER (Tablet Extended-Release 24

Hour) ....................................................... 39 Guanfacine HCl (Tablet Immediate-Release)

................................................................ 33 Guanidine HCl (Tablet) ................................ 24 Gynazole-1 (Cream) .................................... 23

H

H.P. Acthar (Injection) ................................ 47 Haemolance ................................................ 55 Haemolance Low Flow Lancets ................... 55 Haemolance Plus......................................... 55 Haemolance Plus High Flow ....................... 55 Haemolance Plus Low Flow ........................ 55 Haemolance Plus Max Flow ........................ 55 Haemolance Plus Pediatric Flow ................ 55 Halaven (Injection)...................................... 59 Halcion (Tablet) ........................................... 29 Haldol (Injection) ........................................ 27 Haldol Decanoate 100 (Injection) ............... 27 Haldol Decanoate 50 (Injection) ................. 27

Halobetasol Propionate (0.05% Cream, 0.05% Ointment) ............................................... 42

Halog (0.1% Cream, 0.1% Ointment) ......... 42 Haloperidol (0.5mg Tablet, 10mg Tablet, 1mg

Tablet, 20mg Tablet, 2mg Tablet, 5mg Tablet, 2mg/ml Concentrate) ................. 27

Haloperidol Decanoate (Injection) .............. 27 Haloperidol Lactate (Injection).................... 27 Halotin (Cream) .......................................... 23 Harvoni (Tablet).......................................... 28 Healthy Mama Be Well Rounded (Therapy

Pack) ...................................................... 67 H-E-B in Control Pen Needles 31gx6mm .... 55 H-E-B in Control Pen Needles 31gx8mm .... 55 H-E-B Incontrol Pen Needles 29gx12mm ... 55 Hectorol (0.5mcg Capsule, 1mcg Capsule,

2.5mcg Capsule, 2mcg/ml Injection, 4mcg/2ml Injection) .............................. 52

Helixate FS (Injection) ................................ 33 Hemangeol (Oral Solution) ......................... 35 Hematron-Af (Tablet) ................................. 65 Hemocyte Plus (Capsule) ............................ 30 Hemocyte-F (Elixir) ..................................... 30 Hemofil M (1700unit Injection) .................. 33 Heparin Lock Flush (Injection) ..................... 32 Heparin Sodium (10000unit/10ml Injection,

3000unit/3ml Injection, 5000unit/5ml Injection, 10000unit/ml Injection, 1000unit/ml Injection, 20000unit/ml Injection, 5000unit/0.5ml Injection, 5000unit/ml Injection) ........................... 32

Heparin Sodium Lock Flush (Kit) ................. 32 Heparin Sodium/D5W (5%-100unit/ml

Injection, 5%-50unit/ml Injection) ........ 32 Heparin Sodium/D5W (5%-40unit/ml

Injection, 5%-50unit/ml Injection) ......... 32 Heparin Sodium/NaCl 0.45% (100unit/ml-

0.45% Injection) ..................................... 30 Heparin Sodium/NaCl 0.45% (50unit/ml-

0.45% Injection) ..................................... 32 Heparin Sodium/NaCl 0.9% (Injection) ....... 32 Heparin Sodium/Sodium Ch Loride (Injection)

............................................................... 32 Heparin Sodium/Sodium Chloride

(2000unit/500ml-0.9% Solution) ............ 30 Heparin Sodium/Sodium Chloride

(20unit/20ml-0.9% Injection, 25000unit/250ml-0.45% Injection, 30000unit/L-0.9% Injection, 4000unit/L-0.9% Injection, 50unit/50ml-0.45% Injection) ................................................ 32

Heparin Sodium/Sodium Chloride 0.9% (Injection) .............................................. 32

Heparin Sodium/Sodium Chloride 0.9% Premix (Injection) ................................... 32

HepatAmine (Injection) .............................. 65 Hepsera (Tablet) ......................................... 28 Herceptin (Injection) .................................. 26 Hespan (Injection) ...................................... 32 Hetastarch 6%/NaCl (Injection) ................... 32 Hetlioz (Capsule)......................................... 39

Hexalen (Capsule) ....................................... 24 Hextend (Injection) ..................................... 65 Hiprex (Tablet) ............................................ 14 Hizentra (Injection) ..................................... 51 Horizant (Tablet Extended-Release) ........... 39 HSA Sterile Diluent (Injection) .................... 55 Humalog (Injection) .................................... 31 Humalog KwikPen (Injection) ..................... 31 Humalog Mix 50/50 (Injection) .................. 31 Humalog Mix 50/50 KwikPen (Injection) ... 31 Humalog Mix 75/25 (Injection) .................. 31 Humalog Mix 75/25 KwikPen (Injection) ... 31 Humate-P (Injection)................................... 33 Humatrope (Injection) ................................ 47 Humatrope Combo Pack (Injection) ........... 47 Humira (10mg/0.2ml Injection) .................. 59 Humira (20mg/0.4ml Injection, 40mg/0.8ml

Injection) ................................................ 50 Humira Pediatric Crohns Disease Starter

Pack (Injection) ...................................... 50 Humira Pen (Injection) ................................ 50 Humira Pen Crohns Disease Starter Pack

(Injection) ............................................... 50 Humira Pen-Psoriasis Starter (Injection) .... 50 Humulin 70/30 (Injection) .......................... 31 Humulin 70/30 KwikPen (Injection) ........... 31 Humulin N (Injection) ................................. 31 Humulin N KwikPen (Injection) .................. 31 Humulin R (Injection) .................................. 31 Humulin R U-500 (Concentrated) (Injection)

................................................................ 31 Hyalgan (Injection) ...................................... 55 Hycamtin (0.25mg Capsule, 1mg Capsule,

4mg Solution) ......................................... 25 Hycet (Oral Solution) .................................. 11 Hydralazine HCl (100mg Tablet, 10mg Tablet,

25mg Tablet, 50mg Tablet, 20mg/ml Injection) ................................................. 38

Hydrea (Capsule) ......................................... 25 Hydrochlorothiazide (12.5mg Capsule,

12.5mg Tablet, 25mg Tablet, 50mg Tablet) ................................................................ 37

Hydrocodone Bitartrate/Acetaminophen (300mg-10mg Tablet, 300mg-5mg Tablet, 300mg-7.5mg Tablet, 325mg-2.5mg Tablet, 325mg/15ml-10mg/15ml Oral Solution, 325mg/15ml-7.5mg/15ml Oral Solution) ................................................. 11

Hydrocodone Bitartrate/Chlorpheniramine Maleate/PSE (Oral Solution) ................... 62

Hydrocodone Bitartrate/Homatropine Methylbromide (1.5mg-5mg Tablet, 1.5mg/5ml-5mg/5ml Syrup) ................... 64

Hydrocodone Polistirex/Chlorpheniramine Polistirex (Suspension Extended-Release) ................................................................ 62

Hydrocodone/Acetaminophen (Tablet)....... 12 Hydrocodone/Ibuprofen (Tablet) ................ 10 Hydrocort Enema 100mg (Enema) .............. 47 Hydrocortisone (1% Cream, 2.5% Cream, 1%

Ointment, 2.5% Ointment, 2.5% Cream,

82

2.5% Lotion) ............................................ 42 Hydrocortisone (10mg Tablet, 20mg Tablet,

5mg Tablet) ............................................. 47 Hydrocortisone Butyrate (0.1% Cream, 0.1%

External Solution, 0.1% Ointment) ......... 42 Hydrocortisone in Absorbase (Ointment).... 42 Hydrocortisone Valerate (0.2% Cream, 0.2%

Ointment) ............................................... 42 Hydrocortisone/Acetic Acid (Otic Solution) . 61 Hydrogen Peroxide (30% Does Not Apply

Solution) ................................................. 15 Hydromorphone HCl (1mg/ml Injection,

2mg/ml Injection, 4mg/ml Injection, 500mg/50ml Injection, 1mg/ml Liquid, 2mg Tablet, 4mg Tablet, 8mg Tablet) ..... 12

Hydromorphone HCl ER (Tablet Extended-Release 24 Hour Abuse-Deterrent) ......... 11

Hydromorphone HCl/ Sodium Chloride (Solution) ................................................ 12

Hydromorphone HCl/Sodium Chloride (10mg/25ml-0.9% Solution Prefilled Syringe, 1mg/5ml-0.9% Solution Prefilled Syringe, 3mg/30ml-0.9% Solution Prefilled Syringe, 15mg/50ml-0.9% Injection) ...... 38

Hydromorphone HCl/Sodium Chloride (10mg/50ml-0.9% Injection, 15mg/30ml-0.9% Injection) ........................................ 12

Hydromorphone HCl/Sodium Chloride (10mg/50ml-0.9% Solution, 50mg/100ml-0.9% Solution, 40mg/100ml-0.9% Injection, 5mg/25ml-0.9% Solution Prefilled Syringe) .................................... 12

Hydromorphone HCl/Sodium Chloride (Prefilled Syringe, Injection Solution) .... 38

Hydromorphone HCl/Sodium Chloride (Solution Prefilled Syringe) .................... 38

Hydroxocobalamin (Injection) .................... 67 Hydroxychloroquine Sulfate (Tablet) ........... 26 Hydroxyprogesterone Caproate (Injection) . 49 Hydroxyurea (Capsule) ................................ 25 Hydroxyzine HCl (10mg Tablet, 25mg Tablet,

50mg Tablet, 10mg/5ml Syrup, 50mg/ml Injection) ................................................. 22

Hydroxyzine HCl (25mg/ml Injection) ........ 59 Hydroxyzine Pamoate (100mg Capsule, 25mg

Capsule, 50mg Capsule) .......................... 22 Hylenex (Injection) ...................................... 55 Hylira (0.1% Lotion, 0.2% Gel) .................... 51 Hymovis (Injection) ..................................... 55 Hyoscyamine Sulfate (0.125mg Tablet

Dispersible) ............................................. 44 Hyperrab S/D (Injection) ............................. 51 Hyperrho S/D (Injection) ............................ 51 Hyperrho S/D Mini-Dose (Injection) ........... 51 Hypersal (Nebulized Solution) .................... 64 Hyper-Sal (Nebulized Solution) .................. 64 Hypertensa (Capsule) .................................. 65 Hyqvia (Injection) ........................................ 51 Hy-Vee Lancets............................................ 55 Hyzaar (Tablet) ............................................ 34

I

Ibandronate Sodium (150mg Tablet, 3mg/3ml Injection) ................................................ 52

Ibrance (Capsule) ........................................ 25 Ibudone (10mg-200mg Tablet)................... 10 Ibuprofen (100mg/5ml Suspension, 400mg

Tablet, 600mg Tablet, 800mg Tablet) .... 10 Ibuprofen Comfort Pac (Kit) ....................... 10 Ibuprofen Lysine (Injection) ........................ 59 Ibutilide Fumarate (Injection) ..................... 35 IC 400 (Kit) .................................................. 10 IC 800 (Kit) .................................................. 10 ICAR-C Plus (Tablet) .................................... 30 Iclusig (Tablet) ............................................ 26 Idamycin PFS (Injection) ............................. 59 Idarubicin HCl (Injection) ............................ 59 Ifex (Injection) ............................................ 24 Ifosfamide (1gm Injection, 1gm/20ml

Injection, 3gm/60ml Injection) ............... 24 Ifosfamide (3gm Injection) ......................... 24 Ilaris (150mg/ml Solution) ......................... 38 Ilaris (180mg Injection)............................... 51 Ilevro (Suspension) ..................................... 61 Imatinib Mesylate (Tablet) .......................... 26 Imbruvica (Capsule) .................................... 26 Imipenem/Cilastatin (Injection) .................. 16 Imipramine HCl (10mg Tablet, 25mg Tablet,

50mg Tablet) .......................................... 21 Imipramine Pamoate (Capsule) ................... 21 Imiquimod (Cream) ..................................... 42 Imitrex (100mg Tablet, 25mg Tablet, 50mg

Tablet, 20mg/act Nasal Solution, 5mg/act Nasal Solution, 6mg/0.5ml Injection) ... 23

Imitrex Statdose System (Injection) ........... 23 Imlygic (Suspension) ................................... 24 Imogam Rabies-HT (Injection) .................... 51 Impavido (Capsule) ..................................... 15 Imuran (Tablet) ........................................... 50 In Touch Sterile Lancets 30g ....................... 55 Increlex (Injection) ..................................... 47 Incruse Ellipta (Aerosol Powder) ................ 63 Indapamide (Tablet) .................................... 37 Inderal LA (Capsule Extended-Release 24

Hour) ...................................................... 35 Inderal XL (Capsule Extended-Release 24

Hour) ...................................................... 35 Indocin (25mg/5ml Suspension) ................ 10 Indocin (50mg Suppository) ....................... 10 Indomethacin (1mg Solution) ..................... 59 Indomethacin (25mg Capsule, 50mg Capsule)

............................................................... 10 Indomethacin ER (Capsule Extended-Release)

............................................................... 10 Infasurf (Suspension).................................. 64 Infed (Injection) .......................................... 65 Inflectra (Injection) ..................................... 52 Infumorph 200 (Injection) .......................... 11 Infumorph 500 (Injection) .......................... 11 Infuvite (Injection) ...................................... 67 Infuvite Pediatric (Injection) ...................... 67

Injectafer (Injection) ................................... 33 Inlyta (Tablet) .............................................. 26 Innopran XL (Capsule Extended-Release 24

Hour) ...................................................... 35 InspiraChamber/Anti-Static

Valved/Mouthpiece (Device) ................. 55 InspiraChamber/Large (Device) .................. 55 InspiraChamber/Soother

Mask/InspiraMask/Medium (Device) ... 55 InspiraChamber/Soother

Mask/InspiraMask/Small (Device) ........ 55 Inspirease Bags ........................................... 55 Inspirease Drug Delivery System ................ 55 Inspirease Mouthpiece ............................... 55 Inspirease Reservoir Bags ........................... 55 Inspra (Tablet) ............................................. 37 Insulin Syringe/0.5ml/27g X 1/2" ............... 55 Insulin Syringe/U-100/1ml/28g X 1/2" ...... 55 Insulin Syringes, Needles ...................... 43, 55 Insulin Syringes/0.5ml/27gx1/2" ............... 55 Insulin Syringes/1ml/30gx1/2"................... 55 Insupen Sensitive 32gx8mm ....................... 55 Insupen Ultrafin 29gx12mm ....................... 55 Insupen Ultrafin 30gx8mm ......................... 55 Insupen Ultrafin 31gx6mm ......................... 55 Insupen Ultrafin 31gx8mm ......................... 55 Integra F (40mg-62.5mg-1000mcg-3mg-

62.5mg Capsule) ..................................... 65 Integra Plus (210mg-300mcg-7mg-10mcg-

62.5mg-1000mcg-20mg-62.5mg-25mg-5mg-5mg Capsule).................................. 30

Integrilin (Injection) .................................... 33 Intelence (Tablet) ........................................ 28 Interarticular Joint Kit (Kit) ......................... 47 Intermezzo (Tablet Sublingual) ................... 65 Intralipid (30gm/100ml Injection) .............. 55 Intron A (Injection) ..................................... 25 Intron A w/Diluent (Injection) .................... 60 Intuniv (Tablet Extended-Release 24 Hour)39 Invanz (Injection) ........................................ 16 Invega (Tablet Extended-Release 24 Hour) 27 Invega Sustenna (Injection) ........................ 27 Invega Trinza (Injection) ............................. 27 Invirase (200mg Capsule, 500mg Tablet) ... 29 Invokamet (Tablet) ..................................... 31 Invokamet XR (Tablet Extended-Release 24

Hour) ...................................................... 31 Invokana (Tablet) ........................................ 31 Iodine Strong (5%-10% Oral Solution) ........ 64 Iodine Tincture (2% Tincture) ..................... 15 Iopidine (Ophthalmic Solution) .................. 61 Ipratropium Bromide (0.02% Inhalation

Solution, 0.03% Nasal Solution, 0.06% Nasal Solution) ........................................ 63

Ipratropium Bromide/Albuterol Sulfate (Inhalation Solution) ............................... 60

Iprivask (Injection) ...................................... 32 Irbesartan (Tablet) ....................................... 34 Irbesartan/Hydrochlorothiazide (Tablet) ..... 34 Iressa (Tablet) ............................................. 26 Irinotecan (40mg/2ml Injection).................. 60

83

Irinotecan (500mg/25ml Injection) ............ 60 Irinotecan HCl (Injection) ............................. 60 Is 24/6 ......................................................... 30 Isentress (100mg Packet, 100mg Tablet

Chewable, 25mg Tablet Chewable, 400mg Tablet) .................................................... 28

Isoniazid (100mg Tablet, 300mg Tablet, 50mg/5ml Syrup) .................................... 24

Isoniazid (100mg/ml Injection) ................... 24 Isopto Carpine (Ophthalmic Solution) ........ 61 Isordil Titradose (Tablet) ............................ 38 Isosorbide Dinitrate (Tablet Immediate-

Release) .................................................. 38 Isosorbide Dinitrate ER (Tablet Extended-

Release) .................................................. 38 Isosorbide Mononitrate (Tablet Immediate-

Release) .................................................. 38 Isosorbide Mononitrate ER (Tablet Extended-

Release 24 Hour) .................................... 38 Isotonic Gentamicin (Injection) ................... 14 Isradipine (Capsule) ..................................... 36 Istalol (Ophthalmic Solution) ...................... 61 Istodax (Injection) ....................................... 60 Istodax (Overfill) (Injection) ....................... 60 Isuprel (Injection) ........................................ 63 Itraconazole (Capsule) ................................. 23 IV Infusion CPI (Kit) ..................................... 12 Ivermectin (Tablet) ...................................... 26 Ixempra Kit (Injection) ................................ 60 Ixinity (Injection) ......................................... 33

J

Jadenu (Tablet) ........................................... 65 Jakafi (Tablet) .............................................. 25 Jalyn (Capsule) ............................................ 46 Janumet (Tablet) ......................................... 31 Janumet XR (Tablet Extended-Release 24

Hour) ...................................................... 31 Januvia (Tablet) ........................................... 31 Jardiance (Tablet) ....................................... 31 Jentadueto (Tablet) .................................... 31 Jentadueto XR (Tablet Extended-Release 24

Hour) ...................................................... 50 Jevtana (Injection) ...................................... 60 Jublia (External Solution) ............................ 23 Juxtapid (Capsule) ....................................... 37

K

Kabiven (Injection) ...................................... 65 Kadcyla (Injection) ...................................... 60 Kalbitor (Injection) ...................................... 55 Kaletra (100mg-25mg Tablet, 200mg-50mg

Tablet) .................................................... 29 Kaletra (400mg-100mg/5ml Oral Solution) 29 Kalydeco (150mg Tablet, 50mg Packet, 75mg

Packet) .................................................... 63 Kanuma (Injection) ..................................... 44 Kapvay (Tablet Extended-Release 12 Hour)

................................................................ 39

Karbinal ER (Suspension Extended-Release) ............................................................... 62

Kayexalate (Powder) .................................. 65 Kazano (Tablet) ........................................... 31 Keflex (Capsule) .......................................... 16 Kenalog (Aerosol Solution)......................... 42 Kenalog-10 (Injection) ................................ 47 Kenalog-40 (Injection) ................................ 47 Kepivance (Injection) .................................. 40 Keppra (1000mg Tablet, 250mg Tablet,

500mg Tablet, 750mg Tablet, 100mg/ml Oral Solution, 500mg/5ml Injection) .... 18

Keppra XR (Tablet Extended-Release 24 Hour) ...................................................... 18

Keralyt (6% Gel) .......................................... 42 Kerr Triple Dye (Swab) ............................... 23 Kerydin (External Solution) ........................ 23 Ketoconazole (2% Cream, 2% Foam, 2%

Shampoo, 200mg Tablet) ....................... 23 Ketodan Kit (Kit) ......................................... 23 Ketoprofen (Capsule Immediate-Release) .. 10 Ketoprofen ER (Capsule Extended-Release 24

Hour) ...................................................... 10 Ketorocaine-L (Injection) ............................ 10 Ketorocaine-LM (Injection) ........................ 10 Ketorolac Tromethamine (0.4% Ophthalmic

Solution, 0.5% Ophthalmic Solution) ..... 61 Ketorolac Tromethamine (10mg Tablet) ..... 10 Ketorolac Tromethamine (15mg/ml Injection,

30mg/ml Injection, 30mg/ml Injection) . 60 Keveyis (Tablet) .......................................... 61 Keytruda (Injection) ................................... 26 Khedezla (Tablet Extended-Release 24 Hour)

............................................................... 21 Kineret (Injection) ...................................... 60 Kisqali (Tablet) ............................................ 24 Kitabis Pak (Nebulized Solution) ................ 14 Klaron (Lotion) ............................................ 42 Klonopin (Tablet) ........................................ 19 Klor-Con M15 (Tablet Extended-Release) .. 65 Klor-Con/25 (Packet) .................................. 43 Koate (Solution) .......................................... 33 Koate-Dvi (Injection) .................................. 33 Kogenate FS (Injection) .............................. 33 Kogenate FS Bio-Set (Injection) .................. 33 Kombiglyze XR (Tablet Extended-Release 24

Hour) ...................................................... 31 Korlym (Tablet) ........................................... 47 Kovaltry (Injection) ..................................... 33 Krisgel 100 (Gel).......................................... 66 Kristalose (Packet) ...................................... 45 Krystexxa (Injection) .................................. 23 K-Tab (10meq Tablet Extended-Release) ... 65 K-Tab (20meq Tablet Extended-Release,

8meq Tablet Extended-Release) ........... 65 Kuvan (100mg Packet, 500mg Packet, 100mg

Tablet Soluble) ....................................... 44 Kynamro (Solution Prefilled Syringe) ......... 37 Kyprolis (30mg Injection) ........................... 25 Kyprolis (60mg Injection) ........................... 60

L

Labetalol HCl (100mg Tablet, 200mg Tablet, 300mg Tablet, 5mg/ml Solution) ............ 35

Lac-Hydrin (12% Cream, 12% Lotion) ......... 42 Lacrisert (Insert) .......................................... 60 Lactic Acid (10% Lotion) ............................... 42 Lactic Acid E (10%-3500unit/30gm Cream) . 42 Lactic Acid with Vitamin E (Cream) .............. 42 Lactulose (Oral Solution) ............................. 45 Lamictal (Tablet) ......................................... 19 Lamictal Chewable Dispersible (Tablet

Chewable) .............................................. 19 Lamictal ODT (Kit, 100mg Tablet Dispersible,

200mg Tablet Dispersible, 25mg Tablet Dispersible, 50mg Tablet Dispersible) ... 19

Lamictal Starter (Blue Kit) ........................... 19 Lamictal Starter (Green Kit) ........................ 19 Lamictal Starter (Orange Kit) ...................... 19 Lamictal XR (100mg Tablet Extended-

Release 24 Hour, 200mg Tablet Extended-Release 24 Hour, 250mg Tablet Extended-Release 24 Hour, 25mg Tablet Extended-Release 24 Hour, 300mg Tablet Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Hour) .................................... 19

Lamictal XR (Kit) .......................................... 39 Lamisil (Tablet) ............................................ 23 Lamivudine (100mg Tablet) ......................... 28 Lamivudine (10mg/ml Oral Solution, 150mg

Tablet, 300mg Tablet) ............................. 29 Lamivudine/Zidovudine (Tablet).................. 29 Lamotrigine (Tablet Immediate-Release,

Tablet Chewable) .................................... 19 Lamotrigine ER (100mg Tablet Extended-

Release 24 Hour, 200mg Tablet Extended-Release 24 Hour, 25mg Tablet Extended-Release 24 Hour, 300mg Tablet Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Hour, 250mg Tablet Extended-Release 24 Hour) .................................... 19

Lamotrigine ODT (Tablet Dispersible) .......... 19 Lamotrigine Titration (Kit) ........................... 19 Lancet Transporter Case ............................. 55 Lancets ........................................................ 55 Lancets 26g Twist Top ................................. 55 Lancets 28g .................................................. 55 Lancets 31g Twist Top ................................. 55 Lancets Thin ................................................ 55 Lancets Ultra Fine ....................................... 55 Lancets Ultra Thin ....................................... 55 Lanoxin (0.25mg/ml Injection, 125mcg

Tablet, 187.5mcg Tablet, 250mcg Tablet, 62.5mcg Tablet) ...................................... 36

Lanoxin Pediatric (Injection) ....................... 36 Lansoprazole (Capsule Delayed-Release) .... 45 Lansoprazole/Amoxicillin/Clarithromycin

(Therapy Pack) ........................................ 44 Lantus (Injection) ........................................ 31 Lantus SoloStar (Injection) .......................... 31 Lartruvo (190mg/19ml Solution,

84

500mg/50ml Injection) .......................... 24 Lasix (Tablet) ............................................... 37 Lastacaft (Ophthalmic Solution) ................. 61 Latanoprost (Ophthalmic Solution) ............. 60 Latrix XM (Emulsion) ................................... 42 Latuda (Tablet) ............................................ 27 Lazanda (Nasal Solution) ............................ 12 Leader Unifine Pentips

Plus/Short/31gx5/16" ............................ 55 Leader Unifine Pentips/Mini/31gx3/16" ... 55 Leader Unifine Pentips/Nano/32gx5/32" .. 55 Lecithin (0 Granules) ................................... 55 Leflunomide (Tablet) ................................... 51 Lemtrada (Injection) ................................... 51 Lenvima (Capsule Therapy Pack) ................ 26 Lescol XL (Tablet Extended-Release 24 Hour)

................................................................ 37 Letairis (Tablet) ........................................... 63 Letrozole (Tablet) ........................................ 25 Leucovorin Calcium (100mg Injection, 200mg

Injection, 350mg Injection, 50mg Injection) ................................................................ 60

Leucovorin Calcium (10mg Tablet, 15mg Tablet, 25mg Tablet, 5mg Tablet) ........... 25

Leucovorin Calcium (500mg Injection) ....... 60 Leukeran (Tablet) ........................................ 24 Leukine (Injection) ...................................... 32 Leuprolide Acetate (Injection) ..................... 49 Levacet (Tablet) .......................................... 39 Levalbuterol (Nebulized Solution) ............... 63 Levalbuterol Tartrate HFA (Aerosol) .......... 63 Levaquin (Tablet) ........................................ 17 Levemir (Injection) ...................................... 31 Levemir FlexTouch (Injection) .................... 31 Levetiracetam (1000mg/100ml-

750mg/100ml Injection, 1500mg/100ml-540mg/100ml Injection, 500mg/100ml-820mg/100ml Injection) ........................ 18

Levetiracetam (Tablet Immediate-Release, Oral Solution, Injection) .......................... 18

Levetiracetam ER (Tablet Extended-Release 24 Hour) .................................................. 18

Levitra (Tablet) ............................................ 46 Levobunolol HCl (Ophthalmic Solution) ...... 61 Levocarnitine (1gm/10ml Oral Solution,

200mg/ml Injection, 330mg Tablet) ....... 55 Levocetirizine Dihydrochloride (2.5mg/5ml

Oral Solution, 5mg Tablet) ...................... 62 Levofloxacin (0.5% Ophthalmic Solution,

250mg Tablet, 500mg Tablet, 750mg Tablet, 25mg/ml Injection, 25mg/ml Oral Solution) ................................................. 17

Levofloxacin in D5W (Injection) ................... 17 Levoleucovorin (175mg Solution) ............... 52 Levoleucovorin (175mg/17.5ml Injection,

250mg/25ml Injection) ........................... 25 Levoleucovorin (50mg Injection) ................. 60 Levonorgestrel and Ethinyl Estradiol (Tablet)

................................................................ 48 Levonorgestrel/Ethinyl Estradiol (Tablet) .... 48 Levophed (Injection) ................................... 36

Levorphanol Tartrate (Tablet) .................... 11 Levothyroxine Sodium (100mcg Injection,

200mcg Injection, 500mcg Injection) .... 49 Levothyroxine Sodium (100mcg Tablet,

112mcg Tablet, 125mcg Tablet, 137mcg Tablet, 150mcg Tablet, 175mcg Tablet, 200mcg Tablet, 25mcg Tablet, 300mcg Tablet, 50mcg Tablet, 75mcg Tablet, 88mcg Tablet) ........................................ 49

Levulan Kerastick (External Solution) ........ 42 Lexapro (10mg Tablet, 20mg Tablet, 5mg

Tablet, 5mg/5ml Oral Solution) ............ 21 Lexiva (50mg/ml Suspension, 700mg Tablet)

............................................................... 29 Lialda (Tablet Delayed-Release) ................. 51 Liberty Medical Lancets 30g ....................... 55 Librax (Capsule) .......................................... 44 Lidocaine (3% Cream, 5% Ointment, 5%

Patch) ..................................................... 13 Lidocaine HCl (0.5% Injection, 1% Injection,

1.5% Injection, 2% Injection, 4% Injection, 2% Gel, 4% External Solution) ................ 13

Lidocaine HCl (10mg/ml Injection)............. 35 Lidocaine HCl (20mg/ml Injection) .............. 35 Lidocaine HCl (Gel) ...................................... 13 Lidocaine HCl (Solution Prefilled Syringe).. 51 Lidocaine HCl in D5W (Injection)................. 35 Lidocaine HCl/Dextrose (Injection) ............ 13 Lidocaine HCl/Hydrocortisone Acetate (0.5%-

3% Cream, 0.5%-3% Kit, 1%-3% Kit, 2%-2% Kit, 2.5%-3% Kit) ..................................... 42

Lidocaine HCl-Hydrocortisone Acetate with Aloe (0.55%-2.8% Gel) ........................... 42

Lidocaine Viscous (Solution) ....................... 13 Lidocaine/Epinephrine (Injection) ............... 13 Lidocaine/Prilocaine (2.5%-2.5% Cream,

2.5%-2.5% Kit) ........................................ 13 Lidoderm (Patch) ........................................ 13 Lifescan Unistik 2 Deep Penetration .......... 55 Lifescan Unistik II Lancets .......................... 55 Limbrel (Capsule) ........................................ 55 Limbrel250 (Capsule) .................................. 55 Limbrel500 (Capsule) .................................. 55 Lincocin (Injection) ..................................... 15 Lincomycin HCl (Injection) .......................... 15 Lindane (Shampoo) ..................................... 26 Linezolid (100mg/5ml Suspension, 600mg

Tablet, 600mg/300ml Injection) ............. 15 Linzess (145mcg Capsule, 290mcg Capsule)45 Linzess (72mcg Capsule) ............................. 46 Lioresal Intrathecal (Injection) ................... 28 Liothyronine Sodium (10mcg/ml Injection,

25mcg Tablet, 50mcg Tablet, 5mcg Tablet) ............................................................... 49

Lipichol 540 (Capsule)................................. 65 Lipitor (Tablet) ............................................ 37 Lipofen (Capsule) ........................................ 37 Liquihep BD 3ml Prefil

Syr/Swab/Gauze/Cap/Ndl Stop/Lbl/Ndls (Kit) ........................................................ 55

Liquihep II BD 3ml LL

Syringe/Ll/Swab/Gz/Cap/Ndl St/Safetycone (Kit) ................................. 55

Lisinopril (Tablet) ......................................... 34 Lisinopril/Hydrochlorothiazide (Tablet) ....... 34 Lister-V (Capsule) ........................................ 65 LiteAire (Device) .......................................... 55 LiteTouch Lancets Micro Thin 33g .............. 55 LiteTouch Pen Needles 29gx12.7mm ......... 55 LiteTouch Pen Needles 31gx8mm Short ..... 56 Lithium (Oral Solution) ................................ 30 Lithium Carbonate (150mg Capsule, 600mg

Capsule) .................................................. 30 Lithium Carbonate (300mg Capsule, 600mg

Capsule, 300mg Tablet) .......................... 30 Lithium Carbonate ER (Tablet Extended-

Release) .................................................. 30 Lithobid (Tablet Extended-Release) ........... 30 Lithostat (Tablet) ........................................ 46 Livalo (Tablet) ............................................. 37 Live Better Lancet Super Thin 30g .............. 56 Live Better Lancet Ultra Thin 28g ............... 56 LMD 10% Dextrose 5% (Injection) .............. 32 LMD 10% Sodium Chloride 0.9% (Injection)

................................................................ 32 L-Methyl-B6-B12 (Tablet) ........................... 67 L-Methylfolate (Tablet) ................................ 55 L-Methylfolate Ca/P-5-P/Me-Cbl (Capsule) . 67 L-Methylfolate Calcium (Tablet) ................. 55 Lmthf/Pyridoxine HCl/Cyanocobalamin

(Tablet) ................................................... 67 Lo Loestrin Fe (Tablet) ................................ 48 Locoid (0.1% Cream, 0.1% External Solution,

0.1% Lotion, 0.1% Ointment) ................. 42 Locoid Lipocream (Cream) .......................... 42 Lodine (Tablet) ............................................ 10 Lodosyn (Tablet) ......................................... 27 Loestrin 1.5/30-21 (Tablet) ......................... 48 Loestrin 1/20-21 (Tablet) ............................ 48 Loestrin Fe 1.5/30 (Tablet) ......................... 48 Loestrin Fe 1/20 (Tablet) ............................ 48 Lofibra (134mg Capsule, 200mg Capsule,

67mg Capsule, 160mg Tablet, 54mg Tablet) .................................................... 37

Lomotil (Tablet)........................................... 44 Lonsurf (Tablet) ........................................... 25 Loperamide HCl (2mg Capsule) ................... 44 Lopid (Tablet) .............................................. 37 Lopinavir/Ritonavir (Solution) ..................... 29 Lopressor (Tablet) ....................................... 35 Lopressor HCT (Tablet) ................................ 35 Loprox (0.77% Cream, 0.77% Suspension,

0.77%-0-Kit) ............................................ 23 Loprox Shampoo ......................................... 23 Lorazepam (0.5mg Tablet, 1mg Tablet, 2mg

Tablet) ..................................................... 19 Lorazepam (20mg/10ml Injection, 4mg/ml

Injection, 2mg/ml Concentrate) ............. 29 Lorazepam/Dextrose (5%-100mg/100ml

Injection) ................................................ 29 Lorazepam/Sodium Chloride (100mg/100ml-

0.9% Solution) ........................................ 39

85

Lortab (300mg/15ml-10mg/15ml Elixir) ..... 12 Lorzone (Tablet) .......................................... 64 Losartan Potassium (Tablet) ........................ 34 Losartan Potassium/Hydrochlorothiazide

(Tablet) ................................................... 34 LoSeasonique (Tablet) ................................ 48 Lotemax (0.5% Gel, 0.5% Ointment, 0.5%

Suspension) ............................................ 61 Lotensin (Tablet) ......................................... 34 Lotensin HCT (Tablet) .................................. 34 Lotrel (Capsule) ........................................... 34 Lotrisone (Cream) ....................................... 23 Lotronex (Tablet) ........................................ 45 Lovastatin (Tablet) ....................................... 37 Lovaza (Capsule) ......................................... 37 Lovenox (100mg/ml Injection, 120mg/0.8ml

Injection, 150mg/ml Injection, 30mg/0.3ml Injection, 40mg/0.4ml Injection, 60mg/0.6ml Injection, 80mg/0.8ml Injection, 300mg/3ml Injection) ................................................ 32

Loxapine Succinate (Capsule) ...................... 27 Lozibase S .................................................... 56 Lozi-Flur (Lozenge) ...................................... 65 LT Injection Kit (Injection) ........................... 47 Lucentis (0.3mg/0.05ml Injection,

0.5mg/0.05ml Injection) ........................ 60 Lucentis (0.5mg/0.05ml Solution Prefilled

Syringe) .................................................. 44 Lugols (Solution) ......................................... 64 Lukaid GLA (Emulsion) ................................ 66 Lumigan (Ophthalmic Solution) .................. 60 Lumizyme (Injection) .................................. 44 Lunesta (Tablet) .......................................... 65 Lupaneta Pack (Kit) ..................................... 49 Lupron Depot (11.25mg Injection, 3.75mg

Injection) ................................................ 49 Lupron Depot (22.5mg Injection, 30mg

Injection, 45mg Injection, 7.5mg Injection) ................................................ 49

Lupron Depot-PED (11.25mg Injection) ...... 49 Lupron Depot-PED (15mg Injection, 30mg

Injection, 7.5mg Injection) ..................... 49 Luride (Oral Solution) ................................. 66 Luxiq (Foam) ............................................... 42 Luzu (Cream) ............................................... 23 Lynparza (Capsule) ...................................... 25 Lyrica (100mg Capsule, 150mg Capsule,

200mg Capsule, 225mg Capsule, 25mg Capsule, 300mg Capsule, 50mg Capsule, 75mg Capsule) ........................................ 18

Lyrica (20mg/ml Oral Solution) .................. 18 Lysodren (Tablet) ........................................ 49 Lysteda (Tablet) .......................................... 33

M

M.V.I. Adult (Injection) ............................... 67 M.V.I. Pediatric (Injection) ......................... 67 M.V.I.-12 without Vitamin K (Injection) ..... 67 Macrobid (Capsule) ..................................... 15

Macrodantin (Capsule) ............................... 15 Macutek (Tablet Dispersible) ..................... 66 Magnesium Chloride (200mg/ml Injection) 66 Magnesium Sulfate (20gm/500ml Injection,

2gm/50ml Injection, 40gm/1000ml Injection, 4gm/100ml Injection, 4gm/50ml Injection) .............................. 66

Magnesium Sulfate in D5W (5%-10mg/ml Injection) ................................................ 18

Magnesium Sulfate in D5W (5%-1gm/50ml Solution, 5%-2gm/100ml Solution) ....... 43

Magnesium Sulfate/Dextrose (0-10gm/250ml Solution, 5%-40gm/500ml Solution, 5%-4gm/100ml Solution) ....... 43

Magnesium Sulfate/Dextrose (5%-2gm/50ml Injection, 5%-3gm/50ml Injection) ....... 18

Magnesium Sulfate/Lactated Ringers ........ 43 Magnesium Sulfate/Lactated Ringers

(100mg/500ml-20gm/500ml-150mg/500ml-3gm/500ml-1.55gm/500ml Solution) ................................................. 43

Magnesium Sulfate/Sodium Chloride (10gm/100ml-0.9% Solution, 1gm/50ml-0.9% Solution, 6gm/150ml-0.9% Solution, 6gm/50ml-0.9% Solution) ..................... 43

Magnesium Sulfate/Sodium Chloride (2gm/50ml-0.9% Injection, 40gm/L-0.9% Injection) ................................................ 18

Magnesium Sulfate/Sodium Chloride (4gm/100ml-0.9% Solution) ................... 43

Makena (Injection) ..................................... 49 Malarone (Tablet)....................................... 26 Malathion (Lotion) ...................................... 26 Manganese Trace Metal (Injection) ........... 66 Mannitol (Injection) .................................... 36 Maprotiline HCl (Tablet).............................. 20 Marbeta-25 (Injection) ............................... 56 Marbeta-L (Injection) ................................. 47 Marcaine (Injection) ................................... 13 Marcaine/Epinephrine (0.25%-1

200000 Injection) ................................... 13 Marcaine/Epinephrine (0.5%-1

200000 Injection) ................................... 51 Mardex-25 (Injection) ................................ 47 Marinol (Capsule) ....................................... 22 Marlido-25 (Injection) ................................ 13 Marnatal-F (Capsule) .................................. 67 Marplan (Tablet)......................................... 20 Marqibo (Injection) .................................... 25 Mask Vortex/Baby Whirl Duckling ............. 56 Mask Vortex/Child/Frog ............................ 56 Mask Vortex/Spinner the Duck .................. 56 Mask Vortex/Toddler/Lady Bug ................. 56 Matulane (Capsule) .................................... 24 Mavik (Tablet) ............................................ 34 Maxalt (Tablet) ........................................... 23 Maxalt-MLT (Tablet Dispersible) ................ 23 Maxidex (Suspension) ................................ 61 Maxipime (Injection) .................................. 16 Maxitrol (0.1% Ointment, 0.1% Suspension)

............................................................... 15

Maxzide (Tablet) ......................................... 37 MB Hydrogel (Kit) ....................................... 42 Meclizine HCl (12.5mg Tablet, 25mg Tablet)

................................................................ 22 Meclofenamate Sodium (100mg Capsule,

50mg Capsule) ........................................ 10 Medisense Thin Lancets .............................. 56 Medlance Plus Extra Lancets 21g ............... 56 Medlance Plus Lancets ................................ 56 Medlance Plus Lite Lancets 25g .................. 56 Medlance Plus Special Lancets 0.8mm ....... 56 Medlance Plus SuperLite 30g ..................... 56 Medlance Plus SuperLite 30g/Comfort Max

................................................................ 56 Medlance Plus Universal Lancets 21g ........ 56 Medlance/Extra .......................................... 56 Medlance/Lite ............................................. 56 Medlance/Universal ................................... 56 Medrol (16mg Tablet, 32mg Tablet, 4mg

Tablet, 8mg Tablet) ................................ 47 Medrol (2mg Tablet) ................................... 47 Medrox-Rx (Ointment) ............................... 42 Medroxyprogesterone Acetate (Tablet) ...... 49 Mefenamic Acid (250mg Capsule) ............... 10 Mefloquine HCl (Tablet) .............................. 26 Megace ES (Suspension) ............................. 49 Megace Oral (Suspension) .......................... 49 Megestrol Acetate (20mg Tablet, 40mg

Tablet, 40mg/ml Suspension, 40mg/ml Suspension, 625mg/5ml Suspension) ..... 49

Meijer Lancets Universal 30g ...................... 56 Meijer Super Thin Lancets .......................... 56 Mekinist (Tablet) ......................................... 26 Meloxicam (Tablet) ...................................... 10 Meloxicam Comfort Pac (Kit) ...................... 10 Melphalan HCl (Injection) ............................ 24 Memantine HCl (10mg Tablet, 5mg Tablet,

2mg/ml Oral Solution) ............................ 20 Memantine HCl Titration Pak (Tablet) ......... 20 Menest (Tablet) .......................................... 48 Menopur (Injection) .................................... 50 Menostar (Patch Weekly) ........................... 48 Mentax (Cream) .......................................... 23 Meperidine HCl (100mg Tablet, 50mg Tablet,

100mg/ml Injection, 10mg/ml Injection, 25mg/ml Injection, 50mg/ml Injection, 50mg/5ml Oral Solution) ........................ 12

Meperidine HCl/Sodium Chloride (1000mg/100ml-0.9% Injection, 500mg/50ml-0.9% Injection) .................. 12

Meperidine HCl/Sodium Chloride (300mg/30ml-0.9% Solution) ................. 38

Mephyton (Tablet) ...................................... 67 Meprobamate (Tablet) ................................ 29 Mepron (Suspension) .................................. 26 Mercaptopurine (Tablet) ............................. 25 Meropenem (Injection) ............................... 16 Meropenem/Sodium Chloride (Injection) ... 16 Merrem (Injection) ..................................... 16 Mesalamine (4gm Enema, 4gm Kit) ............. 51 Mesalamine DR (Tablet Delayed-Release) ... 51

86

Mesna (Injection) ........................................ 25 Mesnex (100mg/ml Injection) .................... 25 Mesnex (400mg Tablet) .............................. 60 Mestinon (60mg Tablet) ............................. 24 Mestinon (60mg/5ml Syrup) ...................... 24 Mestinon Timespan (Tablet Extended-

Release) .................................................. 24 Metadate CD (Capsule Extended-Release) . 39 Metafolbic (Tablet) ..................................... 68 Metafolbic Plus (Tablet) ............................. 67 Metafolbic Plus RF (Tablet)......................... 67 Metanx (Capsule) ........................................ 67 Metaproterenol Sulfate (10mg Tablet, 20mg

Tablet, 10mg/5ml Syrup) ........................ 63 Metastron (Injection).................................. 56 Metaxalone (Tablet) .................................... 64 Metformin HCl (Tablet Immediate-Release) 31 Metformin HCl ER (Tablet Extended-Release

24 Hour) (Generic Fortamet, Generic Glucophage XR) ...................................... 31

Methadone HCl (10mg Tablet, 5mg Tablet, 10mg/5ml Oral Solution, 5mg/5ml Oral Solution, 10mg/ml Concentrate, 40mg Tablet Soluble) ........................................ 11

Methadone HCl (10mg/ml Injection) ......... 11 Methadose (10mg/ml Concentrate) ........... 11 Methadose Sugar-Free (Concentrate) ........ 11 Methamphetamine HCl (Tablet) .................. 39 Methazolamide (Tablet) .............................. 36 Methenamine Hippurate (Tablet) ............... 15 Methimazole (10mg Tablet, 5mg Tablet) .... 50 Methionine/Inositol/Choline/Cyanocobalam

in (Injection) ........................................... 67 Methocarbamol (Injection, Tablet) ............. 64 Methotrexate (2.5mg Tablet) ...................... 50 Methotrexate Sodium (Injection) ................ 50 Methoxsalen (10mg Capsule) ...................... 42 Methscopolamine Bromide (Tablet) ............ 44 Methyclothiazide (5mg Tablet) ................... 37 Methyldopa (Tablet) .................................... 33 Methyldopa/Hydrochlorothiazide (Tablet).. 33 Methyldopate HCl (Injection) ..................... 33 Methylergonovine Maleate (Injection)........ 56 Methylin (10mg Tablet Chewable, 2.5mg

Tablet Chewable, 5mg Tablet Chewable, 10mg/5ml Oral Solution, 5mg/5ml Oral Solution) ................................................. 39

Methylphenidate HCl (Tablet Immediate-Release, Tablet Chewable, Oral Solution) ................................................................ 39

Methylphenidate HCl CD (Capsule Extended-Release) .................................................. 39

Methylphenidate HCl ER (Tablet, Capsule) .. 39 Methylphenidate HCl SR (Tablet Extended-

Release) .................................................. 39 Methylprednisolone (16mg Tablet, 32mg

Tablet, 4mg Tablet, 8mg Tablet) ............. 47 Methylprednisolone Acetate (40mg/ml

Injection, 80mg/ml Injection) ................. 47 Methylprednisolone Pf (Injection) ............. 46 Methylprednisolone Sodium Succinate

(Injection) ............................................... 60 Methylprednisolone/Lidocaine (Injection) 47 Methyltestosterone (10mg Capsule) .......... 48 Metipranolol (Ophthalmic Solution) ........... 61 Metoclopramide HCl (10mg Tablet, 5mg

Tablet, 5mg/5ml Oral Solution) .............. 22 Metoclopramide HCl (5mg/ml Injection) .... 60 Metoclopramide ODT (10mg Tablet

Dispersible) ............................................ 22 Metoclopramide ODT (5mg Tablet

Dispersible) ............................................ 22 Metolazone (Tablet) .................................... 37 Metoprolol Succinate ER (Tablet Extended-

Release 24 Hour) .................................... 35 Metoprolol Succinate

ER/Hydrochlorothiazide (Tablet Extended-Release 24 Hour) ................... 35

Metoprolol Tartrate (100mg Tablet, 25mg Tablet, 37.5mg Tablet, 50mg Tablet, 75mg Tablet, 5mg/5ml Injection, 5mg/5ml Solution) ................................................. 35

Metoprolol Tartrate (5mg/5ml Solution Prefilled Syringe) ................................... 38

Metoprolol/Hydrochlorothiazide (Tablet) .. 35 Metro IV (Injection) .................................... 15 MetroCream (Cream) ................................. 15 MetroGel (Gel)............................................ 15 MetroGel-Vaginal (Gel) .............................. 15 MetroLotion (Lotion) .................................. 15 Metronidazole (0.75% Cream, 0.75% Gel, 1%

Gel, 0.75% Lotion, 250mg Tablet, 500mg Tablet, 375mg Capsule) .......................... 15

Metronidazole in NaCl 0.79% (Injection) .... 15 Metronidazole Vaginal (Gel) ....................... 15 Mevacor (Tablet) ........................................ 37 Mexiletine HCl (Capsule) ............................. 35 Miacalcin (200unit/act Nasal Solution,

200unit/ml Injection) ............................ 52 Micardis (Tablet) ........................................ 34 Micardis HCT (Tablet) ................................. 34 Micrhogam Ultra-Filtered Plus (Injection) . 51 Microchamber ............................................ 56 Micro-K (Capsule Extended-Release) ......... 66 Microlet Lancets ......................................... 56 Microspacer ................................................ 56 Microtainer Safety Flow

Lancet/Sterile/Single-Use ..................... 56 Microzide (Capsule) .................................... 37 Midodrine HCl (Tablet) ................................ 33 Migergot (Suppository) .............................. 23 Miglitol (Tablet)........................................... 31 Migranal (Nasal Solution)........................... 23 Millipred (10mg/5ml Oral Solution) .......... 47 Millipred (5mg Tablet)................................ 47 Millipred DP (Tablet Therapy Pack) ........... 47 Milrinone in Dextrose (5%-20mg/100ml

Injection, 5%-40mg/200ml Solution) ..... 36 Milrinone Lactate (Injection) ....................... 36 Minastrin 24 Fe (Tablet Chewable) ............ 48 Mineral Oil Heavy (0 Oil) ............................. 45 Minipress (Capsule) .................................... 33

Minivelle (Patch Twice Weekly) ................. 48 Minocin (100mg Capsule, 50mg Capsule,

75mg Capsule, 100mg Injection)............ 18 Minocycline HCl (100mg Capsule, 50mg

Capsule, 75mg Capsule, 100mg Tablet, 50mg Tablet, 75mg Tablet) ..................... 18

Minocycline HCl ER (Tablet Extended-Release 24 Hour) .................................................. 18

Minoxidil (Tablet) ........................................ 38 Mirapex (Tablet) ......................................... 26 Mirapex ER (Tablet Extended-Release 24

Hour) ...................................................... 26 Mircera (100mcg/0.3ml Injection,

200mcg/0.3ml Injection, 50mcg/0.3ml Injection, 75mcg/0.3ml Injection) ......... 32

Mircera (150mcg/0.3ml Injection, 30mcg/0.3ml Injection) .......................... 30

Mircette (Tablet) ......................................... 48 Mirtazapine (Tablet) .................................... 20 Mirtazapine ODT (Tablet Dispersible).......... 20 Mirvaso (Gel)............................................... 42 Misoprostol (Tablet) .................................... 45 Mission Prenatal (Tablet) ........................... 67 Mitigare (Capsule) ....................................... 23 Mitomycin (Injection) .................................. 60 Mitosol (Kit) ................................................ 56 Mitoxantrone HCl (Injection) ....................... 24 Mivacron (Injection) ................................... 30 Mobic (Tablet) ............................................. 10 Modafinil (Tablet) ........................................ 65 Moderiba ..................................................... 28 Moderiba 1200 Dose Pack (Tablet) ............ 28 Moderiba 800 Dose Pack (Tablet) .............. 28 Moexipril HCl (Tablet) .................................. 34 Moexipril/Hydrochlorothiazide (Tablet) ...... 34 Molindone HCl (Tablet) ............................... 27 Mometasone Furoate (0.1% Cream, 0.1%

Ointment) ............................................... 47 Mometasone Furoate (0.1% External

Solution) ................................................. 42 Mometasone Furoate (50mcg/act

Suspension) ............................................ 62 Monocal (Tablet) ......................................... 52 Monoclate-P (Injection) .............................. 33 Monodox (Capsule) ..................................... 18 Monoject Bone Marrow Biopsy Prepping

Tray (Kit) ................................................. 13 Monoject Bone Marrow Biopsy

Tray/Sternal-Iliac Needle 16g (Kit) ........ 13 Monoject Insulin Syringe/1ml .................... 56 Monoject Insulin Syringe/Softpack/1ml/27g

X 1/2" ..................................................... 56 Monoject Insulin Syringe/Softpack/U-

100/0.5ml/28g X 1/2" ............................ 56 Monoject Ultra Comfort Insulin

Syringe/1ml/30g X 5/16" ....................... 56 Monojector End Caps .................................. 56 Monolet Lancets ......................................... 56 Monolet Opd Lancets.................................. 56 Monolettor Safety Lancets ......................... 56 Mononine (Injection) .................................. 33

87

Monovisc (Injection) ................................... 56 Montelukast Sodium (10mg Tablet, 4mg

Packet, 4mg Tablet Chewable, 5mg Tablet Chewable) ............................................... 62

Monurol (Packet) ........................................ 15 Morgidox 1x100mg (0-100mg-Kit) .............. 18 Morgidox 1x50mg Kit (Kit) .......................... 18 Morgidox 2x100mg (0-100mg-Kit) .............. 18 Morphine Sulfate (0.5mg/ml Injection,

100mg/5ml Oral Solution, 10mg/5ml Oral Solution, 20mg/5ml Oral Solution, 10mg/ml Injection, 1mg/ml Injection, 4mg/ml Injection, 8mg/ml Injection, 15mg Tablet, 30mg Tablet) ............................... 12

Morphine Sulfate (10mg/0.7ml Injection) . 11 Morphine Sulfate (10mg/ml Injection,

150mg/30ml Injection, 15mg/ml Injection, 2mg/ml Injection, 4mg/ml Injection, 8mg/ml Injection, 5mg/ml Injection) ................................................ 12

Morphine Sulfate (30mg Suppository) ....... 11 Morphine Sulfate ER (Capsule Extended-

Release 24 Hour, Tablet Extended-Release) .................................................. 11

Morphine Sulfate/Dextrose (Solution) ...... 38 Morphine Sulfate/Sodium Chloride

(0.5mg/ml-0.9% Injection, 50mg/50ml-0.9% Injection) ........................................ 12

Morphine Sulfate/Sodium Chloride (150mg/150ml-0.9% Solution, 250mg/50ml-0.9% Solution, 500mg/100ml-0.9% Solution, 500mg/250ml-0.9% Solution, 275mg/55ml-0.9% Solution Prefilled Syringe) .................................................. 38

Morphine Sulfate/Sodium Chloride (50mg/50ml-0.9% Injection, 50mg/50ml-0.9% Solution) ........................................ 12

Movantik (Tablet) ....................................... 44 MoviPrep (Oral Solution) ............................ 45 Moxatag (Tablet Extended-Release 24 Hour)

................................................................ 17 Moxeza (Ophthalmic Solution) ................... 17 Moxifloxacin HCl (400mg Tablet,

400mg/250ml Injection) ......................... 17 Mozobil (Injection) ...................................... 32 MS Contin (Tablet Extended-Release) ........ 11 Mteryti (Tablet Therapy Pack) .................... 67 Mteryti Folic 5 (Tablet Therapy Pack) ........ 67 Mucinex Maximum Strength (1200mg Tablet

Extended-Release 12 Hour) ................... 62 Multaq (Tablet) ........................................... 35 Multigen (Tablet) ........................................ 66 Multigen Folic (Tablet) ................................ 66 Multigen Plus (Tablet) ................................ 66 Mupirocin (2% Cream, 2% Ointment) .......... 15 Muse (Pellet) ............................................... 47 Mustargen (Injection) ................................. 24 Myalept (Injection) ..................................... 56 Myambutol (Tablet) .................................... 24 Mycamine (Injection) .................................. 23

Mycobutin (Capsule) .................................. 24 Mycophenolate Mofetil (200mg/ml

Suspension, 250mg Capsule, 500mg Injection, 500mg Tablet) ........................ 50

Mycophenolic Acid DR (Tablet Delayed-Release) .................................................. 50

Myfortic (Tablet Delayed-Release) ............ 50 MyGlucoHealth MGH Softlance Lancets 30g

............................................................... 56 MyKidz Iron Fl (Suspension) ...................... 67 Myleran (Tablet) ......................................... 24 Mynatal (Capsule) ...................................... 67 Myobloc (Injection) .................................... 56 Myrbetriq (Tablet Extended-Release 24

Hour) ...................................................... 46 Mysoline (Tablet) ....................................... 19 Mytesi (Tablet Delayed-Release) ............... 44

N

Nabumetone (Tablet) .................................. 10 N-Acetyl-L-Cysteine (Capsule) ..................... 56 Nadolol (20mg Tablet, 40mg Tablet, 80mg

Tablet) .................................................... 35 Nadolol/Bendroflumethiazide (Tablet) ....... 35 Nafcillin (Injection) ...................................... 17 Nafcillin Sodium (10gm Injection, 1gm

Injection, 2gm Injection) ........................ 17 Nafcillin Sodium (1gm Injection, 2gm

Injection) ................................................ 17 Nafrinse Daily/Acidulated (Solution) ......... 66 Nafrinse Daily/Neutral (Solution) .............. 52 Nafrinse Weekly (Solution) ........................ 52 Naftifine HCl (Cream) .................................. 23 Naftin (1% Gel, 2% Gel, 2% Cream) ............ 23 Naglazyme (Injection) ................................ 44 Nalbuphine HCl (Injection) .......................... 12 Nalfon (Capsule) ......................................... 10 Naloxone HCl (Injection) ............................. 13 Naltrexone HCl (Tablet) ............................... 13 Namenda (10mg Tablet, 5mg Tablet,

10mg/5ml Oral Solution) ....................... 20 Namenda Titration Pak (Tablet) ................. 20 Namenda XR (Capsule Extended-Release 24

Hour) ...................................................... 20 Namenda XR Titration Pack (Capsule

Extended-Release 24 Hour) ................... 20 Namzaric (10mg-14mg Capsule Extended-

Release 24 Hour, 10mg-28mg Capsule Extended-Release 24 Hour) ................... 40

Namzaric (10mg-21mg Capsule Extended-Release 24 Hour, 10mg-7mg Capsule Extended-Release 24 Hour) ................... 20

Namzaric (10mg-Capsule Extended-Release 24 Hour Therapy Pack) .......................... 39

Naprelan (Tablet Extended-Release 24 Hour) ............................................................... 10

Naprosyn (125mg/5ml Suspension, 500mg Tablet) .................................................... 10

Naproxen (125mg/5ml Suspension, 250mg Tablet, 375mg Tablet, 500mg Tablet) .... 10

Naproxen Comfort Pac (Kit) ........................ 10 Naproxen Sodium (275mg Tablet, 550mg

Tablet) ..................................................... 10 Naproxen Sodium CR (Tablet Extended-

Release 24 Hour) .................................... 10 Naproxen Sodium ER (Tablet Extended-

Release 24 Hour) .................................... 10 Naratriptan HCl (Tablet) .............................. 23 Narcan (Liquid) ............................................ 13 Nardil (Tablet) ............................................. 20 Naropin (Injection) ...................................... 13 NascoBAL (Nasal Solution) .......................... 67 Nasonex (Suspension) ................................. 62 Natachew (Tablet Chewable) ..................... 67 Natacyn (Suspension) ................................. 23 Natalvit (Tablet) .......................................... 67 Natazia (Tablet) ........................................... 48 Nateglinide (Tablet) ..................................... 31 Natelle One (Capsule) ................................. 67 Natesto (Gel) ............................................... 48 Natpara (Injection) ...................................... 56 Natrecor (Injection) .................................... 36 Natroba (Suspension) ................................. 26 Nature-Throid (Tablet) ................................ 49 Nature-Throid Nt-2.5 (Tablet)..................... 49 Navelbine (Injection) .................................. 25 Nebupent (Inhalation Solution) .................. 26 Nebusal (6% Nebulized Solution) ............... 64 Necon 10/11-28 (Tablet) ............................. 48 Neevo DHA (Capsule) .................................. 67 Nefazodone HCl (Tablet).............................. 20 Nembutal Sodium (Injection) ..................... 65 Neoke Alcar (Powder) ................................. 56 Neoke MCT70 (Powder) .............................. 56 Neoke RA Lipoic (Powder) .......................... 56 Neomycin Sulfate (Tablet) ........................... 14 Neomycin/Bacitracin/Polymyxin (Ointment)

................................................................ 15 Neomycin/Polymyxin/Bacitracin/Hydrocortis

one (Ointment) ....................................... 15 Neomycin/Polymyxin/Dexamethasone (0.1%

Ophthalmic Suspension, 0.1%-3.5mg/gm-10000unit/gm Ointment) ....................... 15

Neomycin/Polymyxin/Gramicidin (Ophthalmic Solution) ............................. 14

Neomycin/Polymyxin/Hydrocortisone (1% Ophthalmic Suspension) ......................... 15

Neomycin/Polymyxin/Hydrocortisone (1% Otic Solution, 1% Otic Suspension) ......... 61

Neoprofen (Injection) ................................. 60 Neoral (100mg Capsule, 25mg Capsule,

100mg/ml Oral Solution) ....................... 50 Neosalus (0-0 Cream, 0-0 Lotion, 0-0-0

Foam)...................................................... 42 Neosalus CP (Cream) ................................... 42 Neosporin (Ophthalmic Solution) ............... 14 Neostigmine Methylsulfate (10mg/10ml

Injection, 5mg/10ml Injection) ............... 24 Neostigmine Methylsulfate (10mg/10ml

Injection, 5mg/10ml Injection, 5mg/5ml Injection) ................................................ 24

88

Neostigmine Methylsulfate (3mg/3ml Solution Prefilled Syringe) ..................... 30

Neo-Synalar (Cream) ................................... 42 Neo-Synalar Kit (Kit) ................................... 42 Nephramine (Injection) .............................. 66 Nephrocaps (Capsule) ................................. 67 Nephro-Vite Rx (Tablet) .............................. 67 Neptazane (Tablet) ..................................... 37 Nesacaine (Injection) .................................. 13 Nesacaine-Mpf (Injection) .......................... 13 Nesina (Tablet) ............................................ 31 Nestabs (Tablet) .......................................... 67 Nestabs DHA ............................................... 67 Neuac Kit (Kit) ............................................. 42 Neulasta (Injection) .................................... 32 Neulasta Onpro Kit (Injection) .................... 32 Neupogen (Injection) .................................. 32 Neupro (Patch 24 Hour) .............................. 27 Neurepa (Capsule) ...................................... 66 Neurontin (100mg Capsule, 300mg Capsule,

400mg Capsule, 250mg/5ml Oral Solution, 600mg Tablet, 800mg Tablet) 28

Neutrasal (Packet) ...................................... 40 Neutrexin (Injection)................................... 26 Nevanac (Suspension) ................................. 61 Nevirapine (200mg Tablet, 50mg/5ml

Suspension) ............................................ 28 Nevirapine ER (Tablet Extended-Release 24

Hour) ....................................................... 28 Newgen (Tablet) ......................................... 67 Nexa Plus (Capsule) .................................... 67 Nexavar (Tablet) ......................................... 26 Nexavir (Injection) ...................................... 56 Nexium (10mg Packet, 2.5mg Packet, 20mg

Packet, 40mg Packet, 5mg Packet, 20mg Capsule Delayed-Release, 40mg Capsule Delayed-Release) ................................... 45

Nexium I.V. (Injection) ................................ 45 Nexterone (Injection) ................................. 35 Niacin (Powder) .......................................... 67 Niacin ER (Tablet Extended-Release) ........... 37 Niacor (Tablet) ............................................ 38 Niaspan (Tablet Extended-Release) ........... 38 Nicadan (Tablet) .......................................... 67 Nicadan Zx (Tablet) ..................................... 67 Nicaprin (Tablet) ......................................... 66 Nicardipine HCl (2.5mg/ml Injection, 20mg

Capsule, 30mg Capsule) .......................... 36 Nicardipine HCl/Sodium Chloride (Solution)

................................................................ 38 Nicazel (Tablet) ........................................... 67 Nicazel Forte (Tablet) .................................. 67 Nicomide (Tablet) ....................................... 56 Nifedipine (10mg Capsule, 20mg Capsule) .. 36 Nifedipine ER (Tablet Extended-Release 24

Hour) ....................................................... 36 Niferex (Tablet) ........................................... 30 Nilandron (Tablet) ....................................... 24 Nilutamide (Tablet)...................................... 25 Nimbex (Injection) ...................................... 64 Nimodipine (Capsule) .................................. 36

Ninlaro (Capsule) ........................................ 25 Nipent (Injection) ....................................... 25 Nisoldipine ER (Tablet Extended-Release 24

Hour) ...................................................... 36 Nithiodote (Injection) ................................. 56 Nitro-Bid (Ointment) .................................. 38 Nitro-Dur (Patch 24 Hour) .......................... 38 Nitrofurantoin (Suspension) ....................... 15 Nitrofurantoin Macrocrystals (Capsule) ...... 15 Nitrofurantoin Monohydrate (100mg

Capsule) .................................................. 15 Nitroglycerin (0.3mg Tablet Sublingual, 0.4mg

Tablet Sublingual, 0.6mg Tablet Sublingual).............................................. 38

Nitroglycerin (5mg/ml Injection) ............... 38 Nitroglycerin ER (2.5mg Capsule Extended-

Release, 6.5mg Capsule Extended-Release, 9mg Capsule Extended-Release) ............ 38

Nitroglycerin in 5% Dextrose (Injection) ..... 38 Nitroglycerin in Dextrose 5% (5%-100mcg/ml

Injection) ................................................ 38 Nitroglycerin in Dextrose 5% (5%-100mcg/ml

Injection, 5%-200mcg/ml Injection, 5%-400mcg/ml Injection) ............................ 38

Nitroglycerin Lingual (0.4mg/sprayTranslingual Solution, 400mcg/spray Aerosol Solution) ............ 38

Nitroglycerin Transdermal (Patch 24 Hour) 38 Nitrolingual Pumpspray (Translingual

Solution) ................................................ 38 NitroMist (Aerosol Solution) ...................... 38 Nitropress (Injection) ................................. 38 Nitrostat (Tablet Sublingual) ...................... 38 Niva-Plus (Tablet) ....................................... 67 Nivatopic Plus (Cream) ............................... 42 Nizatidine (150mg Capsule, 300mg Capsule,

15mg/ml Oral Solution) .......................... 45 Nizoral (Shampoo) ...................................... 23 Norco (325mg-10mg Tablet, 325mg-7.5mg

Tablet, 325mg-5mg Tablet) ................... 12 Norditropin FlexPro (Injection) .................. 47 Norepinephrine Bitartrate (Injection) ......... 36 Norepinephrine Bitartrate/Dextrose (5%-

4mg/250ml Injection, 5%-4mg/500ml Injection, 5%-4mg/250ml Solution) ...... 36

Norepinephrine Bitartrate/Dextrose (5%-8mg/250ml Injection) ............................ 30

Norepinephrine Bitartrate/Sodium Chloride (0.08mg/10ml-0.9% Injection) .............. 36

Norepinephrine Bitartrate/Sodium Chloride (16mg/250ml-0.9% Solution, 16mg/500ml-0.9% Solution, 4mg/250ml-0.9% Injection) ....................................... 30

Norepinephrine/Dextrose (Solution) ......... 30 Norepinephrine/Sodium Chloride

(0.16mg/10ml-0.9% Injection, 8mg/250ml-0.9% Solution) ................... 36

Norepinephrine/Sodium Chloride (0.8mg/50ml-0.9% Solution Prefilled Syringe) .................................................. 30

Norethindrone (Tablet) ............................... 49

Norethindrone Acetate (5mg Tablet) .......... 49 Norethindrone Acetate/Ethinyl Estradiol

(Tablet) ................................................... 48 Norethindrone Acetate/Ethinyl

Estradiol/Ferrous Fumarate (Tablet) ...... 48 Norethindrone/Ethinyl Estradiol/Ferrous

Fumarate (Tablet Chewable) .................. 48 Norgestimate/Ethinyl Estradiol (0-Tablet,

35mcg-0.25mg Tablet) ............................ 48 Norinyl 1+35 (Tablet) .................................. 48 Noritate (Cream) ......................................... 15 Normal Saline Flush (Solution) .................... 66 Norpace (Capsule) ....................................... 35 Norpace CR (Capsule Extended-Release 12

Hour) ...................................................... 35 Norpramin (Tablet) ..................................... 21 Northera (Capsule) ...................................... 36 Nortriptyline HCl (10mg Capsule, 25mg

Capsule, 50mg Capsule, 75mg Capsule, 10mg/5ml Oral Solution) ........................ 21

Norvasc (Tablet) .......................................... 36 Norvir (100mg Capsule, 100mg Tablet,

80mg/ml Oral Solution) ......................... 29 Nova Safety Lancets 23g ............................. 56 Nova Safety Lancets 28g ............................. 56 Nova Sureflex Lancets ................................. 56 Novoeight (Injection) .................................. 33 Novofine Pen Needles ................................ 56 Novolin 70/30 (Injection) ............................ 31 Novolin 70/30 Relion (Injection) ................ 31 Novolin N (Injection) ................................... 32 Novolin N Relion (Injection) ....................... 32 Novolin R (Injection) ................................... 32 Novolin R Relion (Injection) ........................ 32 NovoLog (Injection) ..................................... 32 NovoLog FlexPen (Injection) ....................... 32 NovoLog Mix 70/30 (Injection) ................... 32 NovoLog Mix 70/30 Prefilled FlexPen

(Injection) ............................................... 32 NovoLog PenFill (Injection) ......................... 32 Novoseven (Solution) ................................. 33 Novoseven RT (Injection) ............................ 33 Novotwist .................................................... 56 Noxafil (100mg Tablet Delayed-Release,

300mg/16.7ml Injection, 40mg/ml Suspension) ............................................ 23

Nplate (Injection) ........................................ 32 Nucala (Injection) ........................................ 60 Nucynta (Tablet) ......................................... 12 Nucynta ER (Tablet Extended-Release 12

Hour) ...................................................... 11 Nuedexta (Capsule) ..................................... 40 Nufera (Tablet) ............................................ 30 Nulojix (Injection) ....................................... 50 NuLYTELY/Flavor Packs (Oral Solution) ...... 45 Numoisyn (0-0-0-0-0-0-0-0 Liquid, 0-0-0-0-0-

0-0-0-0.3gm Lozenge) ............................. 40 Nuplazid (Tablet) ......................................... 27 Nusrugepak Surgical Prep/Carepak (Kit) .... 42 NutreStore (Packet) .................................... 44 Nutricap (Tablet) ......................................... 67

89

Nutrivit (Liquid) ........................................... 67 Nutropin AQ (Injection) .............................. 47 Nuvail (External Solution) ........................... 42 Nuvaring ...................................................... 48 Nuvigil (Tablet) ............................................ 65 Nuwiq (Injection) ........................................ 33 Nymalize (Oral Solution) ............................. 36 Nystatin (100000unit/gm Cream,

100000unit/gm Ointment, 100000unit/gm Powder, 100000unit/ml Suspension, 500000unit Tablet) ................................. 23

Nystatin/Triamcinolone (100000unit/gm-0.1% Ointment, 100000unit/gm-1mg/gm Cream) .................................................... 23

O

OB Complete (Tablet) ................................. 67 OB Complete Gold (Capsule) ...................... 67 OB Complete One (Capsule) ....................... 67 OB Complete Petite (Capsule) .................... 67 OB Complete Premier (Tablet) ................... 68 OB Complete/DHA (Capsule) ...................... 68 Obstetrix DHA ............................................. 68 Obstetrix One (Capsule).............................. 68 Obtrex (Tablet) ............................................ 67 Obtrex DHA ................................................. 68 O-Cal Fa (Tablet) ......................................... 67 O-Cal Prenatal (Tablet) ............................... 67 Ocaliva (Tablet) ........................................... 44 Octagam (Injection) .................................... 51 Octreotide Acetate (Injection) ..................... 50 Ocufen (Ophthalmic Solution) .................... 61 Ocuflox (Ophthalmic Solution) ................... 17 Odefsey (Tablet) ......................................... 28 Odomzo (Capsule) ....................................... 25 Ofev (Capsule) ............................................. 64 Ofirmev (Injection)...................................... 10 Ofloxacin (0.3% Ophthalmic Solution, 0.3%

Otic Solution, 400mg Tablet) .................. 17 Ofloxacin (300mg Tablet) ............................ 13 Olanzapine (10mg Injection) ....................... 60 Olanzapine (Tablet Immediate-Release) ..... 27 Olanzapine ODT (Tablet Dispersible) ........... 27 Olanzapine/Fluoxetine (Capsule) ................ 30 Olmesartan Medoxomil (Tablet) ................. 34 Olmesartan

Medoxomil/Amlodipine/Hydrochlorothiazide (Tablet) .............................................. 34

Olmesartan Medoxomil/Hydrochlorothiazide (Tablet) ................................................... 34

Olopatadine HCl (0.1% Ophthalmic Solution) ................................................................ 61

Olopatadine HCl (0.6% Nasal Solution)........ 62 Olux (Foam) ................................................. 42 Olux-E (Foam) ............................................. 42 Olysio (Capsule) .......................................... 28 Omeclamox-Pak (Therapy Pack) ................. 44 Omega-3-Acid Ethyl Esters (Capsule) .......... 38 Omeprazole (10mg Capsule Delayed-Release,

20mg Capsule Delayed-Release, 40mg

Capsule Delayed-Release) ...................... 45 Omeprazole + Syrspend SF Alka (Suspension)

............................................................... 45 Omeprazole/Sodium Bicarbonate (20mg-

1100mg Capsule, 40mg-1100mg Capsule, 20mg-1680mg Packet, 40mg-1680mg Packet) ................................................... 45

Omnaris (Suspension) ................................ 62 Omnipred (Suspension) .............................. 61 Omnitrope (Injection) ................................ 47 On Call Lancets ........................................... 56 On Call Plus Lancets .................................... 56 Oncaspar (Injection) ................................... 60 Ondansetron HCl (24mg Tablet, 4mg Tablet,

8mg Tablet, 40mg/20ml Injection, 4mg/2ml Injection, 4mg/5ml Oral Solution) ................................................. 22

Ondansetron HCl/Sodium Chloride (Injection) ............................................................... 22

Ondansetron ODT (Tablet Dispersible) ....... 22 One A Day Womens Prenatal/DHA ............ 67 One A Day Womens Prenatal1 (Capsule)... 67 One-A-Day Womens Prenatal .................... 67 Onetouch Club Lancets Fine Point ............. 56 Onetouch Combo Pack ............................... 56 Onetouch Delica Lancets Extra Fine 33g .... 56 Onetouch Delica Lancets Fine 30g ............. 56 Onetouch Suresoft Lancing Device/21g ..... 56 Onetouch Ultra 2 (Kit) ................................ 56 Onetouch Ultra Blue (Strip) ........................ 56 Onetouch Ultra Mini (Kit) ........................... 56 Onetouch Ultralink System (Hex) (Kit) ....... 56 Onetouch Ultrasoft Lancets ....................... 56 Onetouch Verio (Kit) .................................. 56 Onetouch Verio Flex Bloodglucose

Monitoring System (Kit) ........................ 56 Onetouch Verio Iq Blood Glucose Monitoring

System (Kit) ............................................ 56 Onetouch Verio Sync Bloodglucose

Monitoring System (Kit) ........................ 56 Onetouch Verio Test Strips (Strip) ............. 56 Onexton (Gel) ............................................. 42 Onfi (10mg Tablet, 20mg Tablet, 2.5mg/ml

Suspension)............................................ 19 Onglyza (Tablet) ......................................... 31 Onivyde (Injection) ..................................... 60 ONMEL (Tablet) .......................................... 23 Onzetra Xsail (Exhaler Powder) ................. 23 Opana (Tablet Immediate-Release, 1mg/ml

Injection) ................................................ 12 Opana ER (Tablet Extended-Release 12 Hour

Abuse-Deterrent) ................................... 11 Opdivo (Injection)....................................... 26 Opsumit (Tablet) ........................................ 63 OptiChamber Advantage ............................ 56 OptiChamber Advantage/Large Mask ....... 56 OptiChamber Advantage/Medium Face

Mask ...................................................... 56 OptiChamber Advantage/Small Face Mask 56 OptiChamber Diamond .............................. 56 OptiChamber Diamond/Large Face Mask

(Device) .................................................. 56 OptiChamber Diamond/Medium Face Mask

................................................................ 56 OptiChamber Diamond/Small Face Mask .. 56 OptiChamber Face Mask/Small .................. 56 Optihaler MDI Drug Delivery System

(Device) .................................................. 56 Ora-Blend (0-0-0-0-0-0 Suspension) ........... 56 Ora-Blend SF (0-0-0-0-0 Suspension) .......... 56 Oracea (Capsule Delayed-Release) ............. 42 Orafate (Paste) ............................................ 42 Oral Mix Flavored Suspending Vehicle

(Liquid) ................................................... 57 Oral Mix SF (Liquid) ..................................... 57 Oral Suspend (Liquid) .................................. 57 Oral Syrup Flavored Vehicle (Liquid) .......... 57 Oral Syrup SF (Liquid).................................. 57 Orap (Tablet) ............................................... 27 Ora-Plus (0-0-0-0 Liquid) ............................. 56 Orapred ODT (Tablet Dispersible) .............. 47 ORA-Sweet (5%-4%-54% Syrup) ................. 56 ORA-Sweet SF (9%-10% Syrup) ................... 57 Orbactiv (Injection) ..................................... 15 Orencia (125mg/ml Injection, 250mg

Injection) ................................................ 50 Orencia Clickject (Injection) ........................ 50 Orenitram (Tablet Extended-Release) ........ 63 Orfadin (10mg Capsule, 20mg Capsule, 2mg

Capsule, 5mg Capsule, 4mg/ml Suspension) ............................................ 44

Orkambi (Tablet) ......................................... 63 Orphenadrine Citrate (30mg/ml Injection) .. 64 Orphenadrine Citrate ER (Tablet Extended-

Release 12 Hour) .................................... 64 Ortho Micronor (Tablet) ............................. 49 Ortho Tri-Cyclen (Tablet) ............................ 49 Ortho Tri-Cyclen Lo (Tablet)........................ 49 Ortho-Cyclen (Tablet) ................................. 49 Ortho-Novum 1/35 (Tablet) ........................ 49 Ortho-Novum 7/7/7 (Tablet) ...................... 49 Orthovisc (Injection) ................................... 57 Oseltamivir Phosphate (Capsule)................. 29 Oseni (Tablet) .............................................. 31 Osmitrol Viaflex (10% Injection, 5%

Injection) ................................................ 36 OsmoPrep (Tablet) ...................................... 45 Osphena (Tablet) ........................................ 49 Otezla (Tablet Therapy Pack, 30mg Tablet) 51 Otrexup (Injection) ..................................... 50 Ovace Plus Wash (10% Liquid) .................... 42 Ovcon-35 (Tablet) ....................................... 49 Ovide (Lotion) ............................................. 26 Ovidrel (Injection) ....................................... 47 Oxacillin Sodium (Injection) ......................... 17 Oxaliplatin (IV Solution 100mg/20ml) ......... 60 Oxandrin (Tablet) ........................................ 48 Oxandrolone (Tablet) .................................. 48 Oxaprozin (Tablet) ....................................... 10 Oxaydo (Tablet Abuse-Deterrent) .............. 12 Oxazepam (Capsule) .................................... 29 Oxcarbazepine (150mg Tablet, 300mg Tablet,

90

600mg Tablet, 60mg/ml Suspension) ..... 20 Oxiconazole Nitrate (Cream) ....................... 23 Oxistat (1% Cream, 1% Lotion) ................... 23 Oxsoralen Ultra (Capsule) ........................... 42 Oxtellar XR (Tablet Extended-Release 24

Hour) ...................................................... 20 Oxybutynin Chloride (5mg Tablet, 5mg/5ml

Syrup) ..................................................... 46 Oxybutynin Chloride ER (Tablet Extended-

Release 24 Hour) .................................... 46 Oxycodone HCl (100mg/5ml Concentrate,

10mg Tablet, 15mg Tablet, 20mg Tablet, 30mg Tablet, 5mg Tablet, 5mg Capsule, 5mg/5ml Oral Solution) .......................... 12

Oxycodone HCl ER (80mg Tablet Extended-Release 12 Hour Abuse-Deterrent) ........ 11

Oxycodone HCl Tablet Extended-Release 12 Hour Abuse-Deterrent (10mg, 15mg, 20mg, 30mg, 40mg, 60mg) ..................... 11

Oxycodone/Acetaminophen (2.5mg-325mg Tablet, 325mg-10mg Tablet, 325mg-5mg Tablet, 325mg-7.5mg Tablet) ................. 12

Oxycodone/Acetaminophen (325mg/5ml-5mg/5ml Oral Solution) ......................... 12

Oxycodone/Aspirin (Tablet)......................... 12 Oxycodone/Ibuprofen (Tablet) .................... 10 OxyContin (Tablet Extended-Release 12

Hour Abuse-Deterrent) .......................... 11 Oxymorphone HCl (Tablet Immediate-

Release) .................................................. 12 Oxymorphone HCl ER (Tablet Extended-

Release 12 Hour) .................................... 11 Oxytocin (Injection) ..................................... 47 Oxytocin/Dextrose (5%-10unit/L Injection,

5%-20unit/L Injection) ........................... 60 Oxytocin/Dextrose (5%-40unit/L Solution) 62 Oxytocin/Dextrose/Lactated Ringers

(Solution) ................................................ 62 Oxytocin/Lactated Ringers ......................... 62 Oxytocin/Lactated Ringers (0.1gm/500ml-

30unit/500ml-0.15gm/500ml-3gm/500ml-1.55gm/500ml Injection) ... 60

Oxytocin/Sodium Chloride (20unit/L-0.45% Solution, 30unit/L-0.9% Solution, 60unit/L-0.9% Solution) ......................... 62

Oxytocin/Sodium Chloride (20unit/L-0.9% Injection) ................................................ 47

Oxytocin/Sodium Chloride (30unit/500ml-0.9% Solution) ......................................... 62

Oxytrol (Patch Twice Weekly) .................... 46

P

Paclitaxel (100mg/16.7ml Injection, 300mg/50ml Injection, 30mg/5ml Injection) ................................................. 25

Paclitaxel (150mg/25ml Injection) ............. 25 Paliperidone ER (Tablet Extended-Release 24

Hour) ....................................................... 27 Pamelor (Capsule) ....................................... 21 Pamidronate Disodium (30mg Injection,

30mg/10ml Injection, 90mg Injection, 90mg/10ml Injection) ............................. 52

Pamidronate Disodium (6mg/ml Injection) 52 Pamine (Tablet) .......................................... 44 Pamine Forte (Tablet)................................. 44 Pamine FQ (Kit) ........................................... 44 Pancreaze (10850unit-2600unit-6200unit

Capsule Delayed-Release) ..................... 46 Pancreaze (24600unit-4200unit-14200unit

Capsule Delayed-Release, 61500unit-10500unit-35500unit Capsule Delayed-Release, 83900unit-21000unit-54700unit Capsule Delayed-Release, 98400unit-16800unit-56800unit Capsule Delayed-Release) ................................................. 44

Pancuronium Bromide (Injection) ............... 64 Panda Mask Large ...................................... 57 Panda Mask Medium ................................. 57 Panda Mask Small ...................................... 57 Pandel (Cream) ........................................... 42 Panretin (Gel) ............................................. 26 Pantoprazole Sodium (20mg Tablet Delayed-

Release, 40mg Tablet Delayed-Release, 40mg Injection) ...................................... 45

Parafon Forte DSC (Tablet) ......................... 64 Paregoric (Tincture) .................................... 45 Paricalcitol (1mcg Capsule, 2mcg Capsule,

4mcg Capsule, 2mcg/ml Injection, 5mcg/ml Injection) ................................. 52

Parlodel (2.5mg Tablet, 5mg Capsule) ....... 50 Parnate (Tablet) .......................................... 20 Paromomycin Sulfate (Capsule) .................. 14 Paroxetine HCl (Tablet) ............................... 21 Paroxetine HCl ER (Tablet Extended-Release

24 Hour) ................................................. 21 Paser (Packet) ............................................. 24 Pataday (Ophthalmic Solution) .................. 61 Patanase (Nasal Solution) .......................... 62 Patanol (Ophthalmic Solution)................... 61 Paxil (10mg Tablet, 20mg Tablet, 30mg

Tablet, 40mg Tablet).............................. 21 Paxil (10mg/5ml Suspension) ..................... 21 Paxil CR (Tablet Extended-Release 24 Hour)

............................................................... 21 Pazeo (Ophthalmic Solution) ..................... 61 PC Unifine Pentips 29g X 1/2" .................... 57 PC Unifine Pentips 31g X 6mm Ultra Short 57 PCE (Tablet Delayed-Release) .................... 17 PCP 100 (Kit) ............................................... 45 Pediapred (Oral Solution)........................... 47 Pediatric Panda Mask ................................. 57 PEG 3350/Electrolytes (Oral Solution) ........ 45 Peg intron Redipen (Injection) ................... 28 PEG-3350/Electrolytes (Oral Solution) ........ 45 PEG-3350/NaCl/Na Bicarbonate/KCl (Oral

Solution) ................................................. 45 Peganone (Tablet) ...................................... 20 Pegasys (Injection) ..................................... 60 Pegasys ProClick (Injection) ....................... 60 PegIntron (Injection) .................................. 28 Pen Needles 29gx1/2" ................................ 57

Pen Needles 30gx5/16" .............................. 57 Pen Needles 30gx5mm ............................... 57 Pen Needles 30gx8mm ............................... 57 Pen Needles 31gx6mm (1/4") ..................... 57 Penicillin G Potassium (Injection) ................ 17 Penicillin G Potassium in Iso-Osmotic

Dextrose (Injection) ............................... 17 Penicillin G Procaine (Injection).................. 17 Penicillin G Sodium (Injection) ................... 17 Penicillin V Potassium (125mg/5ml Oral

Solution, 250mg/5ml Oral Solution, 250mg Tablet, 500mg Tablet) ............................. 17

Penlac Nail Lacquer (External Solution) ..... 23 Penlet II Replacement Caps-Deep .............. 57 Pentam 300 (Injection) ............................... 26 Pentasa (Capsule Extended-Release) ......... 51 Pentazocine/Naloxone HCl (Tablet) ............. 12 Pentetate Calcium Trisodium (Combination

Solution) ................................................. 57 Pentetate Zinc Trisodium (Combination

Solution) ................................................. 57 Pentips 29gx12mm ..................................... 57 Pentips 31gx5mm ....................................... 57 Pentips 31gx6mm ....................................... 57 Pentips 31gx8mm ....................................... 57 Pentips 32gx4mm ....................................... 57 Pentoxifylline ER (Tablet Extended-Release)

................................................................ 36 Pepcid (20mg Tablet, 40mg Tablet,

40mg/5ml Suspension) .......................... 45 Percocet (Tablet) ......................................... 12 Percura (Capsule) ........................................ 66 Perfect Lancets 30g ..................................... 57 Perfect Pressure Activated Safety Lancets

28g .......................................................... 57 Perforomist (Nebulized Solution) ............... 63 Peridex (Solution) ....................................... 40 Perikabiven (Injection) ................................ 66 Perindopril Erbumine (Tablet) ..................... 34 Perjeta (Injection) ....................................... 26 Permethrin (Cream) ..................................... 26 Perphenazine (Tablet) ................................. 22 Perphenazine/Amitriptyline (10mg-2mg

Tablet, 25mg-2mg Tablet, 25mg-4mg Tablet) ..................................................... 21

Perphenazine/Amitriptyline (10mg-4mg Tablet, 50mg-4mg Tablet) ...................... 21

Pertzye (Capsule Delayed-Release) ............ 44 Pexeva (Tablet) ........................................... 21 Pfizerpen-G (Injection) ................................ 17 Ph 12 Sterile Diluent Forflolan (Injection) .. 57 Pharmacist Choice Ultra Thin Lancets ........ 57 Pharmacist Choice Ultra Thin Lancets 28g . 57 Pharmacist Choice Ultra Thin Lancets 30g . 57 Pharmacist Choice Ultra Thin Lancets 31g . 57 Pharmacist Choice Ultra Thin Lancets 33g . 57 Pharmacy Couniter Lancets ........................ 57 Phenelzine Sulfate (Tablet) .......................... 20 Phenergan (25mg/ml Injection) ................. 60 Phenergan (50mg/ml Injection) ................. 22 Phenobarbital (100mg Tablet, 15mg Tablet,

91

16.2mg Tablet, 30mg Tablet, 32.4mg Tablet, 60mg Tablet, 64.8mg Tablet, 97.2mg Tablet, 20mg/5ml Elixir, 20mg/5ml Oral Solution) .......................................... 19

Phenoxybenzamine HCl (Capsule) ............... 33 Phentolamine Mesylate (Injection) ............ 33 Phenylephrine HCl (10% Ophthalmic Solution,

2.5% Ophthalmic Solution) ..................... 60 Phenylephrine HCl (10mg/ml Injection) ...... 33 Phenylephrine HCl/Dextrose (5%-

20mg/250ml Solution) ........................... 30 Phenylephrine HCl/Dextrose (5%-

50mg/500ml Injection) .......................... 33 Phenylephrine HCl/Sodium Chloride

(0.4mg/10ml-0.9% Injection, 100mcg/10ml-0.9% Injection, 1mg/10ml-0.9% Injection, 20mg/50ml-0.9% Injection, 25mg/250ml-0.9% Solution, 40mg/250ml-0.9% Solution, 80mg/250ml-0.9% Solution, 80mg/500ml-0.9% Solution) ................................................. 30

Phenylephrine HCl/Sodium Chloride (0.5mg/5ml-0.9% Injection, 0.8mg/10ml-0.9% Injection, 10mg/250ml-0.9% Injection, 200mcg/5ml-0.9% Injection, 5mg/50ml-0.9% Injection) ..................... 33

Phenylephrine HCl/Sodium Chloride (50mg/250ml-0.9% Solution) .................. 30

Phenytek (Capsule) ..................................... 20 Phenytoin (125mg/5ml Suspension, 50mg

Tablet Chewable) .................................... 20 Phenytoin Sodium (50mg/ml Injection) ...... 20 Phenytoin Sodium Extended (Capsule) ....... 20 Phoslyra (Oral Solution) .............................. 46 Phospholine Iodide (Ophthalmic Solution) 61 Photofrin (Injection) ................................... 60 Phytonadione (Injection) ............................. 67 Picato (Gel) .................................................. 42 Pilocarpine HCl (1% Ophthalmic Solution, 2%

Ophthalmic Solution, 4% Ophthalmic Solution) ................................................. 61

Pilocarpine HCl (5mg Tablet, 7.5mg Tablet) 40 Pimozide (Tablet) ......................................... 27 Pindolol (Tablet) .......................................... 35 Pioglitazone HCl (Tablet) ............................. 31 Pioglitazone HCl/Glimepiride (Tablet) ......... 31 Pioglitazone HCl/Metformin HCl (Tablet) .... 31 Piperacillin/Tazobactam (12gm-1.5gm

Solution) ................................................. 13 Piperacillin/Tazobactam (2gm-0.25gm

Injection, 3gm-0.375gm Injection, 4gm-0.5gm Injection, 36gm-4.5gm Solution) . 17

Piroxicam (10mg Capsule, 20mg Capsule) ... 10 Pitocin (Injection) ........................................ 47 PKU Easy Microtabs (Tablet Delayed-

Release) .................................................. 67 Plaquenil (Tablet) ........................................ 26 Plavix (Tablet) ............................................. 33 Plegridy (Injection) ...................................... 60 Plegridy Starter Pack (Injection) ................. 60 Pliaglis (Cream) ........................................... 13

Plo Gel - Mediflo Kit (Kit)............................ 66 Pocket Chamber (Device) ........................... 57 Pocket Spacer (Device) ............................... 57 Podiapn (Capsule)....................................... 68 Podofilox (External Solution) ...................... 42 Polyethylene Glycol 3350 Powder .............. 45 Polymyxin B Sulfate (500000unit Injection) 15 Polymyxin B Sulfate/Trimethoprim Sulfate

(Ophthalmic Solution) ............................ 15 Polytrim (Ophthalmic Solution) ................. 15 Poly-Vi-Flor (Tablet Chewable,Suspension) 68 Poly-Vi-Flor Fs (Strip) .................................. 68 Poly-Vi-Flor/Iron (Tablet Chewable,

Suspension)............................................ 68 Pomalyst (Capsule) ..................................... 25 Ponstel (Capsule) ........................................ 10 Portrazza (Injection) ................................... 25 Potassium Acetate (2meq/ml Injection) ..... 66 Potassium Acetate (2meq/ml Injection,

4meq/ml Injection) ................................ 66 Potassium Chloride (0 Granules) ................ 43 Potassium Chloride (10meq/50ml Injection)

............................................................... 66 Potassium Chloride CR (Tablet Extended-

Release) .................................................. 66 Potassium Chloride ER (10meq Capsule

Extended-Release, 8meq Capsule Extended-Release, 10meq Tablet Extended-Release, 20meq Tablet Extended-Release, 8meq Tablet Extended-Release) .................................................. 66

Potassium Chloride SR (Tablet Extended-Release) .................................................. 66

Potassium Citrate ER (Tablet Extended-Release) .................................................. 66

Potiga (Tablet) ............................................ 18 PR Cream (Kit) ............................................ 42 Pradaxa (Capsule) ....................................... 32 Pralidoxime Chloride (Injection) ................ 57 Praluent (Injection) .................................... 36 Pramipexole Dihydrochloride (Tablet

Immediate-Release) ............................... 27 Pramipexole Dihydrochloride ER (Tablet

Extended-Release 24 Hour) .................... 27 Pramosone (1%-1% Cream) ........................ 13 Pramosone (1%-1% Lotion, 2.5%-1% Lotion)

............................................................... 13 Pramotic (Liquid) ........................................ 61 Prandin (Tablet) .......................................... 31 Pravachol (Tablet) ...................................... 37 Pravastatin Sodium (Tablet) ........................ 37 Prazosin HCl (1mg Capsule, 2mg Capsule, 5mg

Capsule) .................................................. 33 Precedex (Injection) ................................... 29 Precision Thin Lancets ................................ 57 Precision Ultra Lancet ................................ 57 Precose (Tablet) .......................................... 31 Pred Forte (Suspension) ............................. 61 Pred Mild (Suspension) .............................. 61 Pred-G (Suspension) ................................... 14 Pred-G S.O.P. (Ointment) ........................... 14

Prednicarbate (0.1% Cream, 0.1% Ointment) ................................................................ 42

Prednisolone (15mg/5ml Oral Solution, 15mg/5ml Syrup) .................................... 47

Prednisolone Acetate (Suspension) ............. 61 Prednisolone Sodium Phosphate (1%

Ophthalmic Solution) .............................. 61 Prednisolone Sodium Phosphate (10mg/5ml

Solution, 20mg/5ml Solution, 25mg/5ml Oral Solution, 5mg/5ml Oral Solution) ... 47

Prednisolone Sodium Phosphate ODT (Tablet Dispersible) ............................................. 47

Prednisolone/Moxifloxacin (Ophthalmic Solution) ................................................. 14

Prednisone (10mg Tablet Therapy Pack, 5mg Tablet Therapy Pack) .............................. 50

Prednisone (10mg Tablet, 1mg Tablet, 2.5mg Tablet, 20mg Tablet, 50mg Tablet, 5mg Tablet) ..................................................... 47

Prednisone (5mg/5ml Oral Solution) ......... 47 Prednisone Intensol (5mg/ml Concentrate)

................................................................ 47 PreferaOB (Tablet) ...................................... 68 Prefest (Tablet) ........................................... 49 Pre-Folic (Tablet) ......................................... 68 Premarin (0.3mg Tablet, 0.45mg Tablet,

0.625mg Tablet, 0.9mg Tablet, 1.25mg Tablet, 0.625mg/gm Cream) .................. 49

Premarin (25mg Injection) .......................... 49 Premasol (Injection) .................................... 66 Premphase (Tablet)..................................... 49 Prempro (Tablet) ......................................... 49 Prenata (Tablet Chewable) ......................... 68 Prenatal Vitamin (Tablet) ........................... 67 Prenatal Vitamins (120mg-4000unit-200mg-

400unit-8mcg-28mg-800mcg-20mg-2.6mg-1.7mg-1.8mg-30unit-25mg Tablet) ................................................................ 67

Prenate AM (Tablet) ................................... 68 Prenate Elite (Tablet) .................................. 68 Prenate Essential (Capsule) ........................ 68 Prenate Star (Tablet) ................................... 68 Prepopik (Packet) ........................................ 45 Presera (Foam) ............................................ 42 Preset 1ml LS Syr/Prefilllyophil Lith Hep/Tip

Cap/Safetycone (Kit) .............................. 57 Preset 3ml Ll Syr/Prefilllyoph Lith

Hep/Cap/Prep/Gz/Sftycone (Kit)........... 57 Prestalia (Tablet) ......................................... 34 Prevacid (Capsule Delayed-Release) .......... 45 Prevacid SoluTab (Tablet Dispersible) ........ 45 Prevident 5000 Enamel Protect (Paste) ...... 40 Prevpac (Therapy Pack) .............................. 45 Prezcobix (Tablet) ....................................... 29 Prezista (100mg/ml Suspension, 150mg

Tablet, 600mg Tablet, 75mg Tablet, 800mg Tablet) ........................................ 29

Prialt (Injection) .......................................... 10 Priftin (Tablet) ............................................. 24 Prilosec (Packet) .......................................... 45 Primacare (Capsule) .................................... 68

92

Primaquine Phosphate (Tablet) ................... 26 Primaxin IV (Injection) ................................ 16 Primidone (Tablet) ....................................... 19 Primlev (Tablet) .......................................... 12 Primsol (Oral Solution) ............................... 15 Prinivil (Tablet) ............................................ 34 Prismasol (Injection) ................................... 66 Pristiq (Tablet Extended-Release 24 Hour) 21 Privigen (Injection) ...................................... 51 ProAir HFA (Aerosol Solution) .................... 63 ProAir RespiClick (Aerosol Powder) ........... 63 Probenecid (Tablet) ..................................... 23 Probenecid/Colchicine (Tablet) ................... 23 Procainamide HCl (100mg/ml Injection,

500mg/ml Injection) .............................. 35 Procalamine (Injection) .............................. 66 Procardia (Capsule) ..................................... 36 Procardia XL (Tablet Extended-Release 24

Hour) ...................................................... 36 ProCentra (Oral Solution) ........................... 39 Prochlorperazine (Suppository) ................... 22 Prochlorperazine Edisylate (Injection) ......... 22 Prochlorperazine Maleate (10mg Tablet, 5mg

Tablet)..................................................... 22 Procrit (Injection) ........................................ 32 Proctofoam HC (Foam) ............................... 42 Procysbi (Capsule Delayed-Release)........... 60 Prodigy Safety Lancets ................................ 57 Prodigy Twist Top Lancets .......................... 57 Proferrin-Forte (Tablet) .............................. 66 Profilnine (Injection) ................................... 33 Progesterone (100mg Capsule, 200mg

Capsule, 50mg/ml Injection) ................... 49 Proglycem (Suspension).............................. 31 Prograf (0.5mg Capsule, 1mg Capsule, 5mg

Capsule, 5mg/ml Injection) .................... 50 Prolastin-C (Injection) ................................. 64 Prolensa (Ophthalmic Solution) ................. 61 Proleukin (Injection) ................................... 60 Prolia (Injection) ......................................... 52 Promacta (Tablet) ....................................... 32 Promethazine HCl (12.5mg Suppository,

25mg Suppository, 50mg Suppository, 12.5mg Tablet, 25mg Tablet, 50mg Tablet, 50mg/ml Injection, 6.25mg/5ml Oral Solution) ................................................. 22

Promethazine HCl (25mg/ml Injection) ....... 60 Promethazine HCl Plain (Syrup) ................... 22 Promethazine/Codeine (Syrup) ................... 64 Promethazine/Phenylephrine (Syrup) ......... 62 Promethazine/Phenylephrine/Codeine

(Syrup) .................................................... 64 Promethazine-DM (Syrup) ........................... 64 Prometrium (Capsule) ................................. 49 Promiseb (Cream) ....................................... 42 Promiseb Complete (Kit)............................. 42 Propafenone HCl (Tablet) ............................ 35 Propafenone HCl ER (Capsule Extended-

Release 12 Hour) .................................... 35 Propantheline Bromide (15mg Tablet) ........ 44 Proparacaine HCl (Ophthalmic Solution) ..... 60

Propranolol HCl (Tablet Immediate-Release, 1mg/ml Injection, Oral Solution) ............ 35

Propranolol HCl (Tablet).............................. 35 Propranolol HCl ER (Capsule Extended-

Release 24 Hour) .................................... 35 Propranolol/Hydrochlorothiazide (Tablet) .. 35 Propylene Glycol (0 External Solution) ...... 57 Propylthiouracil (Tablet) ............................. 50 Proscar (Tablet) .......................................... 46 Prosol (Injection) ........................................ 66 Prostin VR Pediatric (Injection) .................. 47 Protamine Sulfate (Injection) ..................... 33 Protect Plus (Capsule) ................................ 67 Protectiron (Tablet) .................................... 30 Proteolin (Tablet) ....................................... 66 Prothelial (Paste) ........................................ 42 Protonix (20mg Tablet Delayed-Release,

40mg Tablet Delayed-Release, 40mg Injection, 40mg Packet) ......................... 45

Protopam Chloride (Injection) ................... 57 Protopic (Ointment) ................................... 42 Protriptyline HCl (Tablet) ............................ 21 Provayblue (Injection) ................................ 57 Provenge (Injection) ................................... 51 Proventil HFA (Aerosol Solution) ............... 63 Provera (Tablet) .......................................... 49 Provida OB (Capsule) .................................. 68 Provigil (Tablet) .......................................... 65 Prozac (Capsule) ......................................... 21 Prozac Weekly (Capsule Delayed-Release) 21 Pruclair (Cream) .......................................... 42 PRUDOXIN (Cream) .................................... 42 Prumyx (Cream) .......................................... 42 PSS Select GP Lancets ................................. 57 PSS Select Platforms ................................... 57 PSS Select Safety Lancets ........................... 57 Pulmicort (Suspension) .............................. 62 Pulmicort Flexhaler (Aerosol Powder) ....... 62 Pulmona (Capsule) ..................................... 66 Pulmozyme (Inhalation Solution) .............. 60 Purified Water (0 Liquid) ............................ 57 Purixan (Suspension) .................................. 25 PX Lancets Ultra Thin ................................. 57 Pylera (Capsule) .......................................... 45 Pyrazinamide (Tablet) ................................. 24 Pyridostigmine Bromide (Tablet) ................ 24 Pyridostigmine Bromide ER (Tablet Extended-

Release) .................................................. 24 Pyridoxine HCl (100mg/ml Injection) .......... 67 Pyrogallic Acid (Ointment) ......................... 42

Q

QC Lancets Super Thin ................................ 57 QC Lancets Ultra Thin ................................. 57 Q-Care Q2 Oral Cleansing/Suctioning

System/Chg Oral Rinse (Kit) .................. 40 Q-Care Q4 Oral Cleansing/Suctioning

System/Chg Oral Rinse (Kit) .................. 40 Qnasl (Aerosol Solution) ............................ 62 Qnasl Childrens (Aerosol Solution) ............ 62

Quadramet (Solution) ................................. 57 Qualaquin (Capsule).................................... 26 Quazepam (Tablet) ...................................... 29 Qudexy XR (Capsule Extended-Release 24

Hour Sprinkle) ........................................ 19 Quelicin (Injection) ..................................... 64 Questran (Packet) ....................................... 38 Questran Light (Powder)............................. 38 Quetiapine Fumarate (Tablet) ..................... 20 Quetiapine Fumarate ER (Tablet Extended-

Release 24 Hour) .................................... 20 Quflora Fe (Tablet Chewable) ..................... 68 Quillivant XR (Suspension) ......................... 39 Quinapril HCl (Tablet) .................................. 34 Quinapril/Hydrochlorothiazide (Tablet) ...... 34 Quinidine Gluconate (Injection) ................. 35 Quinidine Gluconate CR (Tablet Extended-

Release) .................................................. 35 Quinidine Gluconate ER (Tablet Extended-

Release) .................................................. 35 Quinidine Sulfate (Tablet) ............................ 35 Quinine Sulfate (324mg Capsule) ................ 26 Quinzyme (Tablet Dispersible) ................... 57 Qutenza (Kit) ............................................... 42 QVAR (Aerosol Solution) ............................. 62

R

Rabeprazole Sodium (Tablet Delayed-Release) .................................................. 46

Radiogardase (Capsule) .............................. 57 Raloxifene HCl (Tablet) ................................ 49 Ramipril (Capsule) ....................................... 34 Ranexa (Tablet Extended-Release 12 Hour)

................................................................ 36 Ranitidine HCl (150mg Capsule, 300mg

Capsule, 150mg Tablet, 300mg Tablet, 150mg/6ml Injection, 50mg/2ml Injection, 15mg/ml Syrup, 75mg/5ml Syrup).......... 45

Rapaflo (Capsule) ........................................ 46 Rapamune (0.5mg Tablet, 1mg Tablet, 2mg

Tablet, 1mg/ml Oral Solution) ............... 50 Rapivab (Injection) ...................................... 28 Rasagiline Mesylate (Tablet) ........................ 27 Rasuvo (Injection) ....................................... 50 RAVICTI (Liquid) .......................................... 44 Rayaldee (Capsule Extended-Release) ....... 68 Razadyne (Tablet) ....................................... 20 Razadyne ER (Capsule Extended-Release 24

Hour) ...................................................... 20 Readysharp-A (Injection) ............................ 13 Readysharp-K (Injection) ............................ 13 Readysharp-P40 (Injection) ........................ 13 Readysharp-P80 (Injection) ........................ 13 Rebetol (200mg Capsule, 40mg/ml Oral

Solution) ................................................. 28 Rebif (Injection) .......................................... 40 Rebif Rebidose (Injection) .......................... 60 Rebif Rebidose Titration Pack (Injection) ... 40 Rebif Titration Pack (Injection) ................... 40 Recedo (Gel) ................................................ 42

93

Reclast (Injection) ....................................... 52 Recombinate (Injection) ............................. 33 Recothrom (Solution) ................................. 33 Rectiv (Ointment) ....................................... 38 Recura (Cream) ........................................... 42 Reglan (Tablet) ............................................ 22 Regonol (Injection) ..................................... 24 Relagard (Gel) ............................................. 15 Relenza Diskhaler (Aerosol Powder) .......... 29 Relion Lancets Micro-Thin33g .................... 57 Relion Lancets Standard 21g ...................... 57 Relion Lancets Thin 26g .............................. 57 Relion Lancets Ultra-Thin30g ...................... 57 Relion Pen Needles 29gx12mm .................. 57 Relion Pen Needles 31gx6mm .................... 57 Relion Pen Needles 31gx8mm .................... 57 Relion Pen Needles 32gx4mm .................... 57 Relion Thin Lancets ..................................... 57 Relion Ultra Thin Lancets ............................ 57 Relion Ultra Thin Plus Lancets 32g ............. 57 Relistor (12mg/0.6ml Injection, 8mg/0.4ml

Injection) ................................................ 45 Relistor (150mg Tablet) .............................. 46 Relpax (Tablet) ............................................ 23 Remeron (Tablet) ........................................ 20 Remeron Soltab (Tablet Dispersible).......... 20 Remicade (Injection) ................................... 50 Remodulin (Injection) ................................. 63 Renagel (Tablet) .......................................... 46 Renatabs (Tablet) ........................................ 68 Renatabs with Iron ..................................... 30 Renvela (0.8gm Packet, 2.4gm Packet,

800mg Tablet) ........................................ 46 Reopro (Injection) ....................................... 33 Repaglinide (Tablet)..................................... 31 Repaglinide/Metformin HCl (Tablet) ........... 31 Repatha (Injection) ..................................... 36 Repatha Pushtronex System (Injection) ..... 36 Repatha SureClick (Injection) ..................... 36 Reprexain (5mg-200mg Tablet) .................. 10 Req 49+ (Tablet) .......................................... 67 Requip (Tablet) ........................................... 27 Requip XL (Tablet Extended-Release 24

Hour) ...................................................... 27 Rescriptor (Tablet) ...................................... 28 Rescula (Ophthalmic Solution) ................... 60 Restasis (Emulsion) ..................................... 60 Restasis Multidose (Emulsion) ................... 60 Restora Rx (Capsule) ................................... 45 Restoril (Capsule) ........................................ 29 Retin-A (0.01% Gel, 0.025% Gel, 0.025%

Cream, 0.05% Cream, 0.1% Cream) ....... 42 Retin-A Micro (Gel) ..................................... 42 Retin-A Micro Pump (0.04% Gel, 0.1% Gel) 42 Retin-A Micro Pump (0.08% Gel) ................ 42 Retinoic Acid (Powder) ............................... 64 Retinoic Acid-All Trans (Powder) ................ 64 Retrovir (100mg Capsule, 50mg/5ml Syrup)

................................................................ 29 Retrovir IV Infusion (Solution) .................... 29 Revatio (10mg/12.5ml Injection, 10mg/ml

Suspension, 20mg Tablet) ..................... 63 Revlimid (Capsule) ...................................... 25 Rexulti (Tablet) ........................................... 27 Reyataz (150mg Capsule, 200mg Capsule,

300mg Capsule, 50mg Packet) .............. 29 Rezira (Oral Solution) ................................. 64 Rezyst IM (Tablet Chewable) ..................... 45 Rhinocort Aqua (Suspension) ..................... 62 Rhofade (Cream) ........................................ 64 Rhogam Ultra-Filtered Plus (Injection) ...... 51 Rhophylac (Injection) ................................. 51 Riastap (Injection) ...................................... 33 Riax (Foam) ................................................. 42 Ribasphere Ribapak (Tablet) ...................... 28 Ribavirin (200mg Capsule, 200mg Tablet) .. 28 Ribavirin (6gm Solution) .............................. 64 Ridaura (Capsule) ....................................... 51 Rifabutin (Capsule) ...................................... 24 Rifadin (150mg Capsule, 300mg Capsule,

600mg Injection) .................................... 24 Rifamate (Capsule) ..................................... 24 Rifampin (150mg Capsule, 300mg Capsule,

600mg Injection) .................................... 24 Rifater (Tablet) ........................................... 24 Right Step Prenatal (Tablet) ....................... 67 Rightest GD-L500 Alternate Site Adapter .. 57 Rightest GL300 Lancets .............................. 57 Rilutek (Tablet) ........................................... 40 Riluzole (Tablet) .......................................... 40 Rimantadine HCl (Tablet) ............................ 29 Riomet (Oral Solution) ............................... 31 Risedronate Sodium (Tablet) ...................... 52 Risedronate Sodium DR (Tablet Delayed-

Release) .................................................. 52 Risperdal (0.25mg Tablet, 0.5mg Tablet, 1mg

Tablet, 2mg Tablet, 3mg Tablet, 4mg Tablet, 1mg/ml Oral Solution) .............. 27

Risperdal Consta (Injection) ....................... 60 Risperdal M-Tab (Tablet Dispersible)......... 27 Risperidone (0.25mg Tablet, 0.5mg Tablet,

1mg Tablet, 2mg Tablet, 3mg Tablet, 4mg Tablet, 1mg/ml Oral Solution) ................ 27

Risperidone ODT (Tablet Dispersible) ......... 27 Ritalin (Tablet) ............................................ 39 Ritalin LA (Capsule Extended-Release 24

Hour) ...................................................... 39 RiteFlo (Device) .......................................... 57 Rituxan (Injection) ...................................... 26 Rivastigmine Tartrate (Capsule Immediate-

Release) .................................................. 20 Rivastigmine Transdermal System (Patch 24

Hour) ...................................................... 20 Rizatriptan Benzoate (Tablet) ..................... 23 Rizatriptan Benzoate ODT (Tablet Dispersible)

............................................................... 23 R-Natal OB (Capsule) .................................. 68 Robaxin (Injection, 500mg Tablet) ............. 64 Robaxin-750 (Tablet) .................................. 64 Robinul (0.2mg/ml Injection, 1mg Tablet) . 44 Robinul Forte (Tablet) ................................ 44 Rocaltrol (0.25mcg Capsule, 0.5mcg Capsule,

1mcg/ml Oral Solution) .......................... 52 Rocuronium Bromide (100mg/10ml Injection,

50mg/5ml Injection) ............................... 64 Rocuronium Bromide (50mg/5ml Injection)

................................................................ 64 Ropinirole ER (Tablet Extended-Release 24

Hour) ....................................................... 27 Ropinirole HCl (Tablet) ................................ 27 Ropivacaine (Injection) ................................ 13 Ropivacaine HCl (Injection) .......................... 13 Ropivacaine HCl/Sodium Chloride (0.1%-

0.9% Solution, 0.2%-0.9% Solution) ....... 13 Rosadan Kit (Kit) ......................................... 64 Rosuvastatin Calcium (Tablet) ..................... 37 Rowasa (Kit) ................................................ 51 Roxicodone (Tablet) .................................... 12 Rozerem (Tablet) ........................................ 65 Rubraca (Tablet) .......................................... 24 Ryanodex (Injection) ................................... 52 Rythmol SR (Capsule Extended-Release 12

Hour) ...................................................... 35

S

Sabril (500mg Packet, 500mg Tablet) ......... 19 Saccharin Sodium (0 Granules, 0 Powder) . 57 Safe-T-Lance Low Flow 25g ......................... 57 Safe-T-Lance Normal Flow 21g ................... 57 Safe-T-Lance Plus Safety Lancet High Flow 57 Safe-T-Lance Plus Safety Lancet Low Flow . 57 Safe-T-Lance Plus Safety Lancet Normal Flow

................................................................ 57 Safety Lancets ............................................. 57 Safety Lancets 21g ...................................... 57 Safety Lancets 28g ...................................... 57 Safety Let Lancets ....................................... 57 Safety Seal Lancets 28g ............................... 57 Safety Seal Lancets 30g ............................... 57 Safyral (Tablet) ............................................ 49 Saizen (Injection) ........................................ 47 Salagen (Tablet) .......................................... 40 Salicylic Acid (6% Cream, 6% Gel, 6% Lotion)

................................................................ 42 Salicylic Acid Cream (Kit) ............................. 42 Salicylic Acid Lotion (Kit) .............................. 42 Saline Flush (Injection)................................. 66 Saline/Phenol (Injection) ............................ 66 Salivamax (Packet) ...................................... 40 Salivate Rx (Packet)..................................... 40 Salsalate (500mg Tablet, 750mg Tablet) ..... 10 Salvax Duo Plus (Kit) ................................... 42 Samsca (Tablet) ........................................... 65 Sancuso (Patch) ........................................... 22 Sandimmune (100mg Capsule, 25mg

Capsule, 50mg/ml Injection) .................. 50 Sandimmune (100mg/ml Oral Solution) .... 50 Sandostatin (Injection) ............................... 50 Sandostatin LAR Depot (Injection) ............. 50 Santyl (Ointment) ....................................... 42 Saphris (10mg Tablet Sublingual) ............... 27 Saphris (2.5mg Tablet Sublingual, 5mg

94

Tablet Sublingual) .................................. 60 Sarafem (Tablet) ......................................... 21 Savaysa (Tablet) .......................................... 32 Savella (Tablet) ........................................... 40 Savella Titration Pack ................................. 40 Scalacort DK (Kit) ........................................ 42 Scarlet Red Dressing ................................... 64 Seasonique (Tablet) .................................... 49 Sebuderm (Gel) ........................................... 42 Seconal Sodium (Capsule)........................... 65 Seebri Neohaler (Capsule) .......................... 30 Select-OB (Tablet Chewable) ...................... 68 Selegiline HCl (5mg Capsule, 5mg Tablet) ... 27 Selenium Sulfide (Lotion)............................. 42 Selzentry (150mg Tablet, 300mg Tablet) .... 29 Selzentry (25mg Tablet, 75mg Tablet) ........ 13 Sensipar (Tablet) ......................................... 49 Sensorcaine-Mpf/Epinephrine (Injection) .. 13 Sentra AM (Capsule) ................................... 66 Sentra PM (Capsule) ................................... 66 Serevent Diskus (Aerosol Powder) ............. 63 Sernivo (Emulsion) ...................................... 42 Seroquel (Tablet) ........................................ 20 Seroquel XR (150mg Tablet Extended-

Release 24 Hour, 200mg Tablet Extended-Release 24 Hour, 300mg Tablet Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Hour) .................................... 20

Seroquel XR (400mg Tablet Extended-Release 24 Hour) .................................... 20

Serostim (Injection) .................................... 47 Sertraline HCl (100mg Tablet, 25mg Tablet,

50mg Tablet, 20mg/ml Concentrate) ..... 21 sfRowasa (Enema)....................................... 51 Shohls Solution Modified (Oral Solution) ... 66 Shopko Unifine Pentips Pen

Needles/Mini/31gx5mm ........................ 57 Siderol (Tablet) ........................................... 67 Signifor (Injection) ...................................... 50 Signifor LAR (Injection) ............................... 50 Sildenafil (10mg/12.5ml Injection, 20mg

Tablet)..................................................... 63 Silenor (Tablet) ........................................... 65 Silvadene (Cream) ....................................... 15 Silver Nitrate (0.5% External Solution, 10%

External Solution, 25% External Solution, 50% External Solution) ........................... 15

Silver Nitrate (10% Ointment) .................... 15 Silver Sulfadiazine (Cream) .......................... 15 Simbrinza (Suspension)............................... 61 Simponi (Injection)...................................... 50 Simponi Aria (Injection) .............................. 50 Simulect (Injection) ..................................... 51 Simvastatin (Tablet) ..................................... 37 Sinemet (Tablet) ......................................... 27 Sinemet CR (Tablet Extended-Release) ...... 27 Single-Let ..................................................... 57 Singulair (10mg Tablet, 4mg Packet, 4mg

Tablet Chewable, 5mg Tablet Chewable) ................................................................ 62

Sirolimus (Tablet)......................................... 50

Sirturo (Tablet) ........................................... 24 Sitavig (Tablet) ............................................ 29 Sivextro (200mg Injection, 200mg Tablet) . 15 Skelaxin (Tablet) ......................................... 64 Sklice (Lotion) ............................................. 26 Smart Sense Color Lancets Universal 33g .. 57 Smart Sense Standard Lancets Universal 21g

............................................................... 57 Smart Sense Super Thin Lancets Universal

30g ......................................................... 57 Smart Sense Thin Lancets Universal 26g .... 58 Smartest Lancets 28g ................................. 58 Smoflipid (Injection) ................................... 58 Sodium Acetate (2meq/ml Injection) .......... 65 Sodium Bicarbonate (7.5% Injection) .......... 65 Sodium Bicarbonate (Powder) ................... 45 Sodium Chloride (2.5meq/ml Injection, 3%

Injection, 5% Injection) .......................... 66 Sodium Chloride (Nebulized Solution) ........ 64 Sodium Chloride 0.45% (Injection) .............. 66 Sodium Chloride Bacteriostatic (0.9%

Injection) ................................................ 66 Sodium Chloride Bacteriostatic/Benzyl

Alcohol (Injection) ................................. 66 Sodium Chloride Flush (Injection) ............... 66 Sodium Citrate (Injection) .......................... 66 Sodium Diuril (Injection) ............................ 37 Sodium Edecrin (Injection) ......................... 37 Sodium Ferric Gluconate Complex/Sucrose

(Injection) ............................................... 66 Sodium Fluoride (0.25mg Tablet Chewable,

1.1mg Tablet Chewable, 1mg Tablet Chewable, 0.5mg/ml Solution, 1mg Tablet) ............................................................... 66

Sodium Fluoride (0.5mg Tablet) ................. 66 Sodium Hyaluronate (Gel) ........................... 51 Sodium Lactate (Injection) ......................... 65 Sodium Nitrite (Injection) .......................... 58 Sodium Nitroprusside (Injection) ................ 38 Sodium Phenylacetate/Sodium Benzoate

(Injection) ............................................... 58 Sodium Phenylbutyrate (Powder) ............... 44 Sodium Phosphate (3MMOLE/ml Injection) 66 Sodium Phosphate/Sodium Chloride (0.9%-

15MMOL/250ml Injection) .................... 58 Sodium Phosphate/Sodium Chloride (0.9%-

7.5MMOL/100ml Solution) ................... 43 Sodium Polystyrene Sulfonate (Powder,

Suspension) ............................................ 65 Sodium Sulfacetamide (Ophthalmic Solution)

............................................................... 18 Sodium Sulfacetamide/Sulfur (10%-4% Pad)

............................................................... 42 Sodium Sulfacetamide/Sulfur (10%-5%

Lotion) .................................................... 42 Sodium Sulfacetamide/Sulfur Cleanser (9.8%-

4.8% Liquid) ............................................ 42 Sodium Thiosulfate (25% Injection) ........... 58 Solaraze (Gel).............................................. 42 Soliqua 100/33 (Injection) .......................... 50 Soliris (Injection)......................................... 60

Solodyn (Tablet Extended-Release 24 Hour) ................................................................ 18

Soltamox (Oral Solution) ............................ 25 Solu-Cortef (Injection) ................................ 60 Solu-Medrol (Injection) ............................... 60 Solus V2 Pressure Activated Safety Lancets

28g .......................................................... 58 Solus V2 Twist Lancets 30g ......................... 58 Soma (Tablet) .............................................. 64 Somatuline Depot (Injection) ..................... 50 Somavert (Injection) ................................... 50 Sonata (Capsule) ......................................... 65 Soolantra (Cream) ....................................... 42 Soriatane (Capsule) ..................................... 42 Sorilux (Foam) ............................................. 42 Sotalol HCl (AF) (Tablet) ............................... 35 Sotalol HCl (Injection) ................................. 35 Sotalol HCl (Tablet) ...................................... 35 Sotradecol (Injection) ................................. 36 Sotylize (Oral Solution) ............................... 35 Sovaldi (Tablet) ........................................... 28 Spectracef (Tablet) ...................................... 16 Spinosad (Suspension) ................................ 26 Spiriva HandiHaler (Capsule) ...................... 63 Spiriva Respimat (Aerosol Solution) ........... 63 Spironolactone (100mg Tablet, 25mg Tablet,

50mg Tablet) ........................................... 37 Spironolactone/Hydrochlorothiazide (Tablet)

................................................................ 37 Sporanox (100mg Capsule, 10mg/ml Oral

Solution) ................................................. 23 Sporanox Pulsepak (Capsule) ..................... 23 Sprix (Nasal Solution) .................................. 10 Sprycel (Tablet) ........................................... 26 SSKI (Oral Solution) ..................................... 64 Stalevo 100 (Tablet) .................................... 27 Stalevo 125 (Tablet) .................................... 27 Stalevo 150 (Tablet) .................................... 27 Stalevo 200 (Tablet) .................................... 27 Stalevo 50 (Tablet) ...................................... 27 Stalevo 75 (Tablet) ...................................... 27 Starlix (Tablet) ............................................. 31 Stavudine (Capsule) ..................................... 29 Stelara (130mg/26ml Injection) .................. 51 Stelara (45mg/0.5ml Injection, 90mg/ml

Injection) ................................................ 42 Stendra (Tablet) .......................................... 46 Sterilance PA ............................................... 58 Sterilance Tl ................................................. 58 Sterile Diluent for Epoprostenol Sodium

(Injection) ............................................... 58 Sterile Diluent for Remodoulin (Solution) .. 58 Stimate (Nasal Solution) ............................. 47 Stiolto Respimat (Aerosol Solution) ........... 64 Stivarga (Tablet) .......................................... 26 Strattera (Capsule) ...................................... 39 Strensiq (Injection)...................................... 44 Streptomycin Sulfate (1gm Injection)......... 14 Striant .......................................................... 48 Stribild (Tablet) ........................................... 28 Striverdi Respimat (Aerosol Solution) ........ 63

95

Stromectol (Tablet) ..................................... 26 Strovite Forte (Syrup) ................................. 68 Suboxone (Film) .......................................... 11 Subsys (Liquid) ............................................ 12 Succinylcholine Chloride (100mg/5ml

Injection, 200mg/10ml Injection) .......... 64 Sucraid (Oral Solution) ................................ 44 Sucralfate (1gm Tablet) ............................... 45 Sular (Tablet Extended-Release 24 Hour) .. 36 Sulfacetamide Sodium (10% Lotion, 10%

Suspension) ............................................ 42 Sulfacetamide Sodium (10% Ophthalmic

Ointment) ............................................... 18 Sulfacetamide Sodium (10% Ophthalmic

Solution) ................................................. 18 Sulfacetamide Sodium/Prednisolone Sodium

Phosphate (Ophthalmic Solution) ........... 18 Sulfacetamide Sodium/Sulfur ...................... 42 Sulfadiazine (500mg Tablet) ........................ 18 Sulfamethoxazole/Trimethoprim

(200mg/5ml-40mg/5ml Suspension, 400mg-80mg Tablet) .............................. 18

Sulfamethoxazole/Trimethoprim (400mg/5ml-80mg/5ml Injection) ......... 18

Sulfamethoxazole/Trimethoprim DS (Tablet) ................................................................ 18

Sulfamylon (5% Packet, 85mg/gm Cream) . 15 Sulfasalazine (500mg Tablet, 500mg Tablet

Delayed-Release) .................................... 51 Sulfoam (Shampoo) .................................... 43 Sulfurated Lime (External Solution) ........... 26 Sulfzix (500mcg/0.25gm-0-0-0 Powder) ..... 66 Sulfzix (500mcg-0-0-Capsule)...................... 66 Sulindac (150mg Tablet, 200mg Tablet) ...... 10 Sumatriptan (Nasal Solution)....................... 24 Sumatriptan Succinate (100mg Tablet, 25mg

Tablet, 50mg Tablet, 4mg/0.5ml Injection, 6mg/0.5ml Injection) .............................. 24

Sumavel DosePro (Injection) ...................... 24 Supartz (Injection) ...................................... 58 Supartz Fx (Injection) .................................. 58 Supervite (Liquid) ........................................ 68 Support-500 (Capsule) ................................ 68 Supprelin LA (Injection) .............................. 50 Suprax (100mg Tablet Chewable, 200mg

Tablet Chewable, 100mg/5ml Suspension, 200mg/5ml Suspension, 500mg/5ml Suspension, 400mg Capsule) ................. 16

Suprep Bowel Prep (Oral Solution) ............ 45 Sure-Fine Pen Needles 29gx1/2" 12.7mm .. 58 Sure-Fine Pen Needles 31gx3/16" 5mm ..... 58 Sure-Fine Pen Needles 31gx5/16" 8mm ..... 58 Sure-Lance Lancets 26g ............................... 58 Sure-Lance Thin Lancets 28g ....................... 58 Surelite Lancets ........................................... 58 Sure-Touch Lancets Universal ..................... 58 Surmontil (Capsule) .................................... 21 Survanta Intratracheal (Suspension) .......... 64 Suspension Vehicle (Suspension) ............... 58 Sustiva (200mg Capsule, 50mg Capsule,

600mg Tablet) ........................................ 28

Sustol (Injection) ........................................ 46 Sutent (Capsule) ......................................... 26 Sylatron (Injection) ..................................... 25 Sylvant (Injection) ...................................... 26 Symax Duotab (Tablet Extended-Release) 30 Symbicort (Aerosol) .................................... 62 Symbyax (Capsule) ..................................... 30 SymlinPen 120 (Injection) .......................... 31 SymlinPen 60 (Injection) ............................ 31 Synagex (Capsule)....................................... 68 Synagis (Injection) ...................................... 51 Synalar (0.01% External Solution, 0.025%

Cream, 0.025% Ointment) ..................... 43 Synalar Cream Kit (Kit) ............................... 64 Synalar TS (Kit) ........................................... 43 Synalgos-DC (Capsule) ................................ 12 Synarel (Nasal Solution) ............................. 50 Synatek (Capsule) ....................................... 68 Synera (Patch) ............................................ 13 Synercid (Injection) .................................... 15 Synerderm (Emulsion) ................................ 43 Synjardy (Tablet), Synjardy XR (Tablet) ..... 31 Synribo (Injection) ...................................... 60 Synthroid (Tablet)....................................... 49 Synvisc (Injection) ...................................... 58 Synvisc One (Injection) ............................... 58 Syprine (Capsule) ........................................ 65

T

Tabloid (Tablet) .......................................... 25 Taclonex (0.064%-0.005% Ointment, 0.064%-

0.005% Suspension) ............................... 43 Tacrolimus (0.03% Ointment, 0.1% Ointment)

............................................................... 43 Tacrolimus (0.5mg Capsule, 1mg Capsule,

5mg Capsule) .......................................... 50 Tafinlar (Capsule) ....................................... 26 Tagrisso (Tablet) ......................................... 26 Taltz (Injection) ........................................... 43 Talwin (Injection)........................................ 12 Tamiflu (30mg Capsule, 45mg Capsule, 75mg

Capsule, 6mg/ml Suspension) ............... 29 Tamoxifen Citrate (Tablet) .......................... 25 Tamsulosin HCl (Capsule) ............................ 46 Tanzeum (Injection).................................... 31 Tapazole (Tablet) ........................................ 50 Tarceva (Tablet) .......................................... 26 Targadox (Tablet) ....................................... 18 Targretin (1% Gel, 75mg Capsule) .............. 26 Tarka (Tablet Extended-Release) ............... 34 Taron-BC ..................................................... 68 Taron-C DHA (Capsule) ............................... 68 Tasigna (Capsule) ........................................ 26 Tasmar (Tablet) .......................................... 26 Taxotere (Injection) .................................... 25 Taytulla (Capsule) ....................................... 49 Tazicef (1gm/50ml-4.4% Injection) ............ 16 Tazorac (0.05% Cream, 0.1% Cream, 0.05%

Gel, 0.1% Gel) ........................................ 43 Tecentriq (Injection) ................................... 26

Tecfidera (Capsule Delayed-Release) ......... 40 Tecfidera Starter Pack ................................. 40 Techlite Ast Lancets .................................... 58 TechLite Lancets .......................................... 58 Techlite Lancets 30g .................................... 58 Techlite Pen Needles/31g X 5mm............... 58 Techlite Pen Needles/32g X 8mm............... 58 Technivie (Tablet) ....................................... 28 Teflaro (Injection) ....................................... 16 Tegretol (100mg/5ml Suspension, 200mg

Tablet) .................................................... 20 Tegretol-XR (Tablet Extended-Release 12

Hour) ...................................................... 20 Tekturna (Tablet) ........................................ 36 Tekturna HCT (Tablet) ................................. 37 Telfa AMD Antimicrobial Island Dressing

4"x5" ....................................................... 43 Telfa AMD Antimicrobial Island

Dressing4"x8" ......................................... 43 Telfa AMD Antimicrobial Non-Adherent Pad

3"x8" ....................................................... 43 Telmisartan (Tablet) .................................... 34 Telmisartan/Amlodipine (Tablet) ................ 34 Telmisartan/Hydrochlorothiazide (Tablet) .. 34 Temazepam (Capsule) ................................. 29 Temodar (100mg Capsule, 140mg Capsule,

180mg Capsule, 20mg Capsule, 250mg Capsule, 5mg Capsule) ........................... 24

Temodar (100mg Injection) ........................ 24 Temovate (0.05% Cream, 0.05% External

Solution, 0.05% Gel, 0.05% Ointment) .. 43 Temovate E (Cream) ................................... 43 Temozolomide (Capsule) ............................. 24 Tena Cls+ Md Brf ......................................... 43 Teniposide (Injection) ................................. 25 Tenoretic 100 (Tablet)................................. 35 Tenoretic 50 (Tablet)................................... 35 Tenormin (Tablet) ....................................... 35 Terazol 7 (Cream) ........................................ 23 Terazosin HCl (Capsule) ............................... 33 Terbinafine HCl (Tablet) ............................... 23 Terbutaline Sulfate (1mg/ml Injection, 2.5mg

Tablet, 5mg Tablet) ................................. 63 Terconazole (0.4% Cream, 0.8% Cream, 80mg

Suppository)............................................ 23 Tessalon Perles (Capsule) ........................... 64 Testim (Gel) ................................................. 48 Testopel (Pellet) .......................................... 48 Testosterone (100mg Pellet, 200mg Pellet,

87.5mg Pellet) ........................................ 48 Testosterone (25mg/2.5gm Gel, 50mg/5gm

Gel) ......................................................... 48 Testosterone Cypionate (Injection) ............. 48 Testosterone Enanthate (Injection) ............. 48 Testosterone Pump (Gel) ............................. 48 Testred (Capsule) ........................................ 48 Tetrabenazine (Tablet) ................................ 40 Tetracaine HCl (0.5% Ophthalmic Solution) 60 Tetracycline HCl (Capsule) ........................... 18 Tetrix (Cream) ............................................. 43 Texacort (External Solution) ....................... 43

96

Thalomid (Capsule) ..................................... 25 Theo-24 (Capsule Extended-Release 24 Hour)

................................................................ 63 Theophylline (Oral Solution) ........................ 63 Theophylline CR (Tablet Extended-Release 12

Hour) ....................................................... 63 Theophylline ER (Tablet Extended-Release 12

Hour, Tablet Extended-Release 24 Hou) . 63 Theophylline/D5W (Injection) .................... 63 Theracys (Injection) .................................... 51 Theramine (Capsule) ................................... 66 Theramine Plus (Packet) ............................. 66 Theranatal Core Nutrition (Tablet) ............. 67 Thiamine HCl (100mg/ml Injection) ............. 67 Thinlets GP Lancets ..................................... 58 Thinlets Lancet ............................................ 58 Thiola (Tablet) ............................................. 46 Thioridazine HCl (Tablet) ............................. 27 Thiotepa (Injection) ..................................... 24 Thiothixene (Capsule) .................................. 27 Thrombin-JMI Diluent (External Solution) . 33 Thrombin-JMI Epistaxis (Kit) ....................... 33 Thrombin-JMI Syringe Spray Kit (Kit) ......... 33 Thrombin-JMI w/Dil Spray Pump Actuator

(Kit) ......................................................... 33 Thrombogen (10000unit Kit, 10000unit

Solution, 1000unit Solution) .................. 33 Thymoglobulin (Injection) .......................... 51 Thyrogen (Injection) ................................... 52 Thyrolar (Tablet) ......................................... 49 Tiagabine HCl (Tablet) ................................. 19 Tiazac (Capsule Extended-Release 24 Hour)

................................................................ 35 Tice BCG (Injection) ..................................... 60 Tigan (100mg/ml Injection, 300mg Capsule)

................................................................ 22 Tikosyn (Capsule) ........................................ 35 Timolol Maleate (0.25% Ophthalmic Solution,

0.5% Ophthalmic Solution) ..................... 61 Timolol Maleate (10mg Tablet, 20mg Tablet,

5mg Tablet) ............................................. 35 Timolol Maleate Ophthalmic Gel Forming

(Solution) ................................................ 61 Timoptic (Ophthalmic Solution) ................. 61 Timoptic Ocudose (Ophthalmic Solution) .. 61 Timoptic-XE (Gel Form Solution) ................ 61 Tindamax (Tablet) ....................................... 26 Tinidazole (Tablet) ....................................... 26 Tirosint (Capsule) ........................................ 49 Tisseel (External Solution) .......................... 43 Tisseel VH (Kit) ............................................ 43 Tivicay (Tablet) ............................................ 28 Tivorbex (Capsule) ...................................... 38 Tizanidine Comfort Pac ............................... 28 Tizanidine HCl (2mg Capsule, 4mg Capsule,

6mg Capsule, 2mg Tablet, 4mg Tablet) .. 28 Tl G-Fol Os (Tablet) ..................................... 68 Tnkase (Injection) ....................................... 32 TOBI (Nebulized Solution) .......................... 14 TOBI Podhaler (Capsule) ............................. 14 Tobradex (0.3%-0.1% Ophthalmic Ointment,

0.3%-0.1% Ophthalmic Suspension)...... 14 Tobradex ST (Ophthalmic Suspension) ...... 14 Tobramycin (300mg/5ml Nebulized Solution)

............................................................... 14 Tobramycin Sulfate (0.3% Ophthalmic

Solution, 1.2gm Injection, 1.2gm/30ml Injection, 10mg/ml Injection, 80mg/2ml Injection) ................................................ 14

Tobramycin/Dexamethasone (Ophthalmic Suspension) ............................................ 14

Tobrex (0.3% Ophthalmic Ointment, 0.3% Ophthalmic Solution) ............................ 14

Tofranil (Tablet) .......................................... 21 Tolak (Cream) ............................................. 43 Tolazamide (Tablet) .................................... 31 Tolbutamide (Tablet) .................................. 31 Tolcapone (Tablet) ...................................... 26 Tolmetin Sodium (200mg Tablet, 600mg

Tablet, 400mg Capsule) .......................... 10 Tolterodine Tartrate (Tablet) ...................... 46 Tolterodine Tartrate ER (Capsule Extended-

Release 24 Hour) .................................... 46 Topamax (Tablet) ....................................... 19 Topamax Sprinkle (Capsule Sprinkle) ........ 19 Topicort (0.05% Cream) .............................. 43 Topicort (0.05% Gel, 0.05% Ointment, 0.25%

Ointment, 0.25% Cream, 0.25% Liquid) 43 Topiramate (Tablet Immediate-Release,

Capsule Sprinkle Immediate-Release) .... 19 Topiramate ER (Capsule Extended-Release

24 Hour Sprinkle) ................................... 19 Topotecan HCl (Injection) ........................... 25 Toprol XL (Tablet Extended-Release 24 Hour)

............................................................... 35 Torisel (Injection) ....................................... 51 Torsemide (Tablet) ...................................... 37 Toujeo SoloStar (Injection)......................... 32 Toviaz (Tablet Extended-Release 24 Hour) 46 Tracleer (Tablet) ......................................... 63 Tradjenta (Tablet) ....................................... 31 Tramadol HCl (Tablet Immediate-Release) . 12 Tramadol HCl ER (100mg Tablet Extended-

Release 24 Hour, 200mg Tablet Extended-Release 24 Hour, 300mg Tablet Extended-Release 24 Hour, 150mg Capsule Extended-Release 24 Hour) .................... 11

Tramadol HCl/Acetaminophen (Tablet) ...... 12 Trandolapril (Tablet) ................................... 34 Trandolapril/Verapamil HCl ER (Tablet

Extended-Release) ................................. 34 Tranexamic Acid (1000mg/10ml Injection,

650mg Tablet) ........................................ 33 Transderm-Scop (Patch 72 Hour) ............... 22 Tranxene T (Tablet) .................................... 19 Tranylcypromine Sulfate (Tablet) ................ 31 Travasol (Injection) ..................................... 66 Travatan Z (Ophthalmic Solution) .............. 60 Travel Lancets Advanced 28g ..................... 58 Trazodone HCl (100mg Tablet, 150mg Tablet,

300mg Tablet, 50mg Tablet) .................. 20 Treanda (Injection) ..................................... 24

Trecator (Tablet) ......................................... 24 Trelstar (Injection) ...................................... 50 Trelstar Mixject (11.25mg Suspension,

3.75mg Suspension, 22.5mg Injection) .. 50 Trepadone (Capsule) ................................... 66 Tresiba FlexTouch (Injection)...................... 32 Tretinoin (0.01% Gel, 0.05% Gel, 0.025%

Cream, 0.05% Cream, 0.1% Cream, 0.025% Gel) ......................................................... 43

Tretinoin (10mg Capsule) ............................ 26 Tretinoin (Powder) ...................................... 64 Tretinoin Microsphere (Gel) ........................ 43 Tretinoin Microsphere Pump (Gel) .............. 43 Tretin-X (Cream).......................................... 43 Trexall (Tablet) ............................................ 51 Treximet (500mg-85mg Tablet) .................. 24 Treximet (60mg-10mg Tablet) .................... 23 Trezix (Capsule) ........................................... 12 Triamcinolone (Injection) ............................ 47 Triamcinolone Acetonide (0.025% Cream,

0.1% Cream, 0.5% Cream, 0.025% Lotion, 0.1% Lotion, 0.025% Ointment, 0.1% Ointment, 0.5% Ointment, 0.147mg/gm Aerosol Solution) .................................... 43

Triamcinolone Acetonide (0.1% Paste) ........ 40 Triamcinolone Acetonide (55mcg/act

Aerosol) .................................................. 62 Triamcinolone Acetonide Pf (Injection)...... 60 Triamcinolone in Orabase (Paste)................ 40 Triamcinolone Pf (Injection) ....................... 46 Triamterene/Hydrochlorothiazide (25mg-

37.5mg Tablet, 50mg-75mg Tablet, 37.5mg-25mg Capsule, 50mg-25mg Capsule) .................................................. 37

Trianex (Ointment) ..................................... 43 Triazolam (Tablet) ........................................ 29 Tribenzor (Tablet) ....................................... 34 Tricare Prenatal (Tablet Chewable) ............ 68 Tricare Prenatal Compleat .......................... 68 Tricare Prenatal DHA One (Capsule)........... 68 Tricor (Tablet) ............................................. 37 Tridesilon (Cream)....................................... 43 Triferic (272mg Packet) ............................... 30 Trifluoperazine HCl (Tablet) ......................... 27 Trifluridine (Ophthalmic Solution) ............... 29 Triglide (Tablet) ........................................... 37 Trihexyphenidyl HCl (0.4mg/ml Elixir, 2mg

Tablet, 5mg Tablet) ................................. 26 Trileptal (150mg Tablet, 300mg Tablet,

600mg Tablet, 300mg/5ml Suspension) 20 Trilipix (Capsule Delayed-Release) ............. 37 Trimethobenzamide HCl (Capsule) .............. 22 Trimethoprim (100mg Tablet) ..................... 15 Trimethoprim Sulfate/Polymyxin B Sulfate

(Ophthalmic Solution) ............................. 15 Trimipramine Maleate (100mg Capsule, 25mg

Capsule, 50mg Capsule) .......................... 21 Tri-Norinyl 28 (Tablet)................................. 49 Trintellix (Tablet) ........................................ 20 Triostat (Injection) ...................................... 49 Triple Dye (Liquid) ....................................... 23

97

Trisenox (Injection) ..................................... 60 Triumeq (Tablet) ......................................... 29 Triveen-Duo DHA ........................................ 67 Tri-Vi-Flor (Suspension) .............................. 68 Trizivir (Tablet) ............................................ 29 Trokendi XR (Capsule Extended-Release 24

Hour) ...................................................... 19 Trophamine (Injection) ............................... 66 Trospium Chloride (Tablet) .......................... 46 Trospium Chloride ER (Capsule Extended-

Release 24 Hour) .................................... 46 TruePlus Lancets 26g .................................. 58 TruePlus Lancets 28g .................................. 58 TruePlus Lancets 30g .................................. 58 TruePlus Lancets 33g .................................. 58 Trueplus Lancets 33g Micro Thin ................ 58 Trulance (Tablet) ......................................... 44 Trulicity (Injection) ...................................... 31 Trusopt (Ophthalmic Solution) ................... 37 Truvada (Tablet) .......................................... 29 Tryptophan (500mg Capsule) ..................... 65 Tudorza Pressair (Aerosol Powder) ............ 63 Turkel Paracentesis Procedure Tray/8french

(Kit) ......................................................... 13 Tussionex Pennkinetic Extended-Release

(Suspension Extended-Release)............. 62 Twynsta (Tablet) ......................................... 34 Tybost (Tablet) ............................................ 29 Tygacil (Injection) ........................................ 15 Tykerb (Tablet) ............................................ 26 Tylactin Restore 5PE (Packet) ..................... 66 Tylenol/Codeine #3 (Tablet) ....................... 12 Tylenol/Codeine #4 (Tablet) ....................... 12 Tysabri (Injection) ....................................... 60 Tyvaso (Inhalation Solution) ....................... 63 Tyvaso Refill (Inhalation Solution) ............. 64 Tyvaso Starter (Inhalation Solution) .......... 64 Tyzine Pediatric Nasal Drops (Nasal Solution)

................................................................ 64

U

Uceris (2mg/act Foam, 9mg Tablet Extended-Release 24 Hour) ................... 47

Udamin Sp (Tablet) ..................................... 68 Ulesfia (Lotion) ............................................ 26 Uloric (Tablet) ............................................. 23 Ulticare Insulin Safety Syringe/0.5ml/29g X

1/2" ........................................................ 58 Ulticare Insulin Safety Syringe/1ml/29g X

1/2" ........................................................ 58 Ulticare Insulin Syringe/0.3ml/29g X 1/2" . 58 Ulticare Insulin Syringe/0.5ml/28g X 1/2" . 58 Ulticare Insulin Syringe/U-100/0.3ml/30g X

1/2" ........................................................ 58 Ulticare Insulin Syringe/U-100/0.3ml/31g X

5/16" ...................................................... 58 Ulticare Insulin Syringe/U-100/0.5ml/31g X

5/16" ...................................................... 58 Ulticare Micro Pen Needles/32g X 4mm .... 58 Ulticare Pen Needles/29g X 12.7mm.......... 58

Ulticare Thin Lancets 30g ........................... 58 Ulticare U-100 Insulin Syringes/0.3ml/31g

X1/4" ...................................................... 58 Ulticare U-100 Insulin Syringes/0.5ml/31g X

1/4" ........................................................ 58 Ulticare U-100 Insulin Syringes/1ml/31g X

1/4" ........................................................ 58 Ultiguard Insulin Syringe/U-100/0.5ml/30g X

5/16" ...................................................... 58 Ultilet Classic Lancets ................................. 58 Ultilet Insulin Syringe/Short/1ml/31g X

5/16" ...................................................... 58 Ultilet Lancets ............................................. 58 Ultilet Lancets 33g ...................................... 58 Ultilet Pen Needle 32gx4mm/Short ........... 58 Ultilet Safety Lancets 23g ........................... 58 Ultilet Short Pen Needles 31gx5/16" ......... 58 Ultilet Short Pen Needles31gx3/16" .......... 58 Ultiva (Injection) ......................................... 12 Ultracet (Tablet) ......................................... 12 Ultralance ................................................... 58 Ultram (Tablet) ........................................... 12 Ultra-Thin II Auto Lancet ............................ 58 Ultra-Thin II Lancets 28g............................. 58 Ultra-Thin II Lancets 30g............................. 58 Ultra-Thin II Pen Needles 29gx1/2" ........... 58 Ultra-Thin II Safety Autolancets 26g .......... 58 Ultravate (0.05% Cream, 0.05% Lotion,

0.05% Ointment) ................................... 43 Ultravate X (Kit) .......................................... 64 Unasyn (Injection) ...................................... 17 Unasyn Bulk Pack (Injection) ...................... 17 Unifine Pentips 32gx4mm .......................... 58 Unilet ComforTouch Lancet ....................... 58 Unilet Excelite ............................................. 58 Unilet Excelite II .......................................... 58 Unilet G.P. Lancet ....................................... 58 Unilet G.P. SuperLite Lancet ...................... 58 Unilet GP 28 Ultra Thin............................... 58 Unilet Lancet............................................... 58 Unilet Lancets Micro-Thin33g .................... 58 Unilet Lancets Super-Thin30g .................... 58 Unilet SuperLite Lancet ............................. 58 Unistik 1 ...................................................... 58 Unistik 2 ...................................................... 58 Unistik 2 Comfort ....................................... 58 Unistik 2 Extra ............................................ 58 Unistik 2 Neonatal ...................................... 58 Unistik 2 Normal ......................................... 58 Unistik 2 Super ........................................... 58 Unistik 3 ...................................................... 59 Unistik 3 Comfort ....................................... 59 Unistik 3 Extra ............................................ 59 Unistik 3 Extra Single Use Safety Lancets/21g

............................................................... 59 Unistik 3 Gentle .......................................... 59 Unistik 3 Neonatal ...................................... 59 Unistik 3 Normal ......................................... 59 Unistik CZT Comfort ................................... 59 Unistik CZT Normal ..................................... 59 Unistik Safety Lancets 28g.......................... 59

Unistik Safety Lancets 30g .......................... 59 Unistik Touch Safety Lancets 21g ............... 59 Unistik Touch Safety Lancets 23g ............... 59 Unistik Touch Safety Lancets 28g ............... 59 Unistik Touch Safety Lancets 30g ............... 59 Unituxin (Injection) ..................................... 26 Universal 1 Lancets Thin 26g ...................... 59 Universal 1 Lancets Ultra Thin 30g ............. 59 Universal 1 Lancets/33g/Micro-Thin .......... 59 Uptravi (Tablet) ........................................... 64 Uramaxin (45% Gel) .................................... 43 Urea (40% Cream, 45% Lotion) .................... 43 Urea Topical (Suspension) ........................... 43 Urecholine (Tablet) ..................................... 46 Urocit-K (Tablet Extended-Release) ........... 66 Uroxatral (Tablet Extended-Release 24 Hour)

................................................................ 46 Urso (Tablet) ............................................... 45 Ursodiol (250mg Tablet, 500mg Tablet,

300mg Capsule) ...................................... 45 Utibron Neohaler (Capsule) ........................ 30 Uvadex (Injection) ....................................... 43

V

Vagifem (Tablet) ......................................... 49 Valacyclovir HCl (Tablet) .............................. 29 Valchlor (Gel) .............................................. 43 Valcyte (450mg Tablet, 50mg/ml Oral

Solution) ................................................. 28 Valganciclovir (Tablet) ................................. 28 Valganciclovir Hydrochlorde (Oral Solution) 28 Valium (Tablet) ........................................... 19 Valproate Sodium (100mg/ml Injection) ..... 19 Valproic Acid (250mg Capsule, 250mg/5ml

Oral Solution, 250mg/5ml Syrup) ........... 19 Valsartan (Tablet) ........................................ 34 Valsartan/Hydrochlorothiazide (Tablet) ...... 34 Valtrex (Tablet) ........................................... 29 Valumark Lancet Ultra Thin 28g ................. 59 Vanatol LQ (Oral Solution) .......................... 10 Vancocin HCl (Capsule) ............................... 15 Vancomycin (Injection) ................................ 15 Vancomycin HCl (0.9%-1gm/200ml Injection,

1000mg Injection, 10gm Injection, 5000mg Injection, 125mg Capsule, 250mg Capsule) ................................................................ 15

Vancomycin HCl + Syrspendsf Ph4 (Suspension) ........................................... 13

Vancomycin HCl in Dextrose (Injection) ..... 15 Vancomycin HCl/Dextrose (5%-

1.25gm/250ml Solution, 5%-1.5gm/500ml Solution, 5%-1.75gm/500ml Solution) .. 13

Vancomycin HCl/Dextrose (5%-1.5gm/250ml Injection) ................................................. 13

Vancomycin HCl/Dextrose (5%-1gm/100ml Injection) ................................................ 15

Vancomycin HCl/Dextrose (5%-1gm/250ml Injection, 5%-2gm/500ml Injection) ....... 15

Vancomycin HCl/Sodium Chloride (0.9%-1.25gm/250ml Injection, 0.9%-

98

1.5gm/250ml Injection, 0.9%-1gm/250ml Solution) ................................................. 15

Vancomycin HCl/Sodium Chloride (0.9%-1.5gm/150ml Injection, 0.9%-1gm/150ml Injection, 0.9%-750mg/150ml Injection) 15

Vancomycin HCl/Sodium Chloride (0.9%-1.5gm/500ml Injection) .......................... 13

Vancomycin HCl/Sodium Chloride (0.9%-1.75gm/300ml Solution, 0.9%-2.5gm/500ml Solution, 0.9%-2gm/250ml Solution, 0.9%-2gm/500ml Solution) .... 13

Vancomycin HCl/Sodium Chloride (Solution) ................................................................ 13

Vanishpoint Insulin Syringe/0.5ml/30g X 5/16" ...................................................... 59

Vanishpoint Insulin Syringe/1ml/29g X 5/16" ................................................................ 43

Vanishpoint Insulin Syringe/1ml/30g X 5/16" ................................................................ 59

Vanos (Cream)............................................. 43 Vantas (Injection) ........................................ 50 Vaprisol (Injection) ..................................... 47 Varithena (Injection) ................................... 36 Varubi (Tablet) ............................................ 22 Vascazen (Capsule) ..................................... 67 Vascepa (Capsule) ....................................... 38 Vasculera (Tablet) ....................................... 66 Vaseretic (Tablet) ........................................ 34 Vasopressin/Sodium Chloride (0.9%-

40unit/100ml Injection, 0.9%-50unit/50ml Injection) ........................... 47

Vasopressin/Sodium Chloride (0.9%-60unit/100ml Solution) .......................... 50

Vasostrict (Injection) ................................... 47 Vasotec (Tablet) .......................................... 34 Vayacog (Capsule) ....................................... 67 Vayarin (Capsule) ........................................ 67 Vayarol (Capsule) ........................................ 67 Vazculep (Injection) .................................... 33 Vecamyl (Tablet) ......................................... 36 Vectibix (Injection) ...................................... 26 Vectical (Ointment) ..................................... 43 Vecuronium Bromide (10mg Injection, 20mg

Injection) ................................................. 64 Vecuronium Bromide/Sodium Chloride

(Injection) ............................................... 64 Velcade (Injection) ...................................... 60 Veletri (Injection) ........................................ 64 Velphoro (Tablet Chewable) ....................... 46 Veltassa (Packet) ......................................... 65 Veltin (Gel) .................................................. 43 Vemlidy (Tablet) ......................................... 13 Venclexta (Tablet) ....................................... 25 Venclexta Starting Pack (Tablet Therapy

Pack) ....................................................... 25 Venlafaxine HCl (Tablet Immediate-Release)

................................................................ 21 Venlafaxine HCl Extended-Release 24 Hour

(Capsule, Tablet) ..................................... 21 Venofer (Injection) ...................................... 66 Ventavis (Inhalation Solution) .................... 64

Ventolin HFA (Aerosol Solution) ................ 63 Verapamil HCl (Tablet Immediate-Release,

2.5mg/ml Injection) ................................ 36 Verapamil HCl Extended-Release 24 Hour

(100mg Capsule, 120mg Capsule, 180mg Capsule, 200mg Capsule, 240mg Capsule, 300mg Capsule, 120mg Tablet, 180mg Tablet, 240mg Tablet) ............................ 36

Verapamil HCl SR (Capsule Extended-Release 24 Hour) ................................................. 36

Verdeso (Foam) .......................................... 43 Veregen (Ointment) ................................... 43 Verelan (Capsule Extended-Release 24 Hour)

............................................................... 36 Verelan PM (Capsule Extended-Release 24

Hour) ...................................................... 36 Veripred 20 (Oral Solution) ........................ 47 Versacloz (Suspension) ............................... 27 Vesicare (Tablet) ......................................... 46 Vfend (200mg Tablet, 50mg Tablet, 40mg/ml

Suspension)............................................ 23 Vfend IV (Injection) .................................... 23 Viagra (Tablet) ............................................ 46 Vibativ (Injection) ....................................... 15 Viberzi (Tablet) ........................................... 45 Vibramycin (100mg Capsule, 25mg/5ml

Suspension, 50mg/5ml Syrup) .............. 18 Victoza (Injection) ...................................... 31 Vida Mia Unifine Pentips 32gx4mm........... 59 Vida Mia Unifine Pentips Original 29gx12mm

............................................................... 59 Vida Mia Unipfine Pentipsshort 31gx8mm 59 Vidaza (Injection)........................................ 60 Videx EC (Capsule Delayed-Release) .......... 29 Videx Pediatric (Oral Solution) ................... 29 Viekira Pak (Tablet Therapy Pack) ............. 28 Viekira XR (Tablet Extended-Release 24

Hour) ...................................................... 28 Vigamox (Ophthalmic Solution) ................. 17 Viibryd (Tablet) ........................................... 21 Viibryd Starter Pack (Kit) ............................ 21 Vimizim (Injection) ..................................... 44 Vimpat (Tablet, Oral Solution, Injection) ... 20 Vinate Care (Tablet Chewable) .................. 67 Vinate DHA RF (Capsule) ............................ 68 Vinblastine Sulfate (Injection).................... 25 Vincristine Sulfate (Injection) ...................... 60 Vinorelbine Tartrate (Injection) .................. 25 Viokace (Tablet).......................................... 44 Viracept (Tablet) ......................................... 29 Viramune (200mg Tablet) .......................... 28 Viramune (50mg/5ml Suspension) ............ 28 Viramune XR (Tablet Extended-Release 24

Hour) ...................................................... 28 Virazole (Inhalation Solution) .................... 64 Viread (150mg Tablet, 200mg Tablet, 250mg

Tablet, 300mg Tablet, 40mg/gm Powder) ............................................................... 29

Viroptic (Ophthalmic Solution) .................. 29 Visbiome (Packet) ....................................... 66 Vistaril (Capsule) ........................................ 22

Vistogard (Packet) ....................................... 59 Visudyne (Injection) .................................... 60 Vitafol Gummies (Tablet Chewable) .......... 68 Vitafol-Nano (Tablet) .................................. 68 Vitalet Pro Lancets ...................................... 59 Vitalet Pro Plus Lancets .............................. 59 Vitamedmd One Rx/Quatrefolic (Capsule) 68 Vitamedmd Redichew Rx (Tablet Chewable)

................................................................ 68 Vitamin A (Capsule) .................................... 68 Vitamin C 222mg (Injection) ........................ 67 Vitamin D (50000unit Capsule) .................... 67 Vitamin K1 (10mg/ml Injection) ................. 67 Vitamin K1 (1mg/0.5ml Injection) ............... 67 Vitapearl (Capsule Extended-Release) ....... 68 Vita-Pren (Tablet)........................................ 68 Vitaroca Plus (Tablet) .................................. 67 Vitrase (Injection) ....................................... 13 Viva DHA (Capsule) ..................................... 68 Vivelle-Dot (Patch Twice Weekly) .............. 49 Vivitrol (Injection) ....................................... 13 Vivlodex (Capsule) ...................................... 39 Vogelxo (Gel) ............................................... 48 Vogelxo Pump (Gel) .................................... 48 Voltaren (Gel) .............................................. 43 Voluven (Injection) ..................................... 32 Voraxaze (Injection) .................................... 59 Voriconazole (200mg Injection, 200mg

Tablet, 50mg Tablet, 40mg/ml Suspension) ................................................................ 23

Vortex Valved Holding Chamber (Device) .. 59 Vospire ER (Tablet Extended-Release 12

Hour) ...................................................... 63 Votrient (Tablet) ......................................... 26 VPRIV (Injection) ......................................... 44 Vraylar (Capsule Therapy Pack, 1.5mg

Capsule, 3mg Capsule, 4.5mg Capsule, 6mg Capsule) .......................................... 20

VSL#3 DS (Packet) ....................................... 45 Vusion (Ointment) ...................................... 23 Vytorin (Tablet) ........................................... 38 Vyvanse (10mg Capsule, 20mg Capsule,

30mg Capsule, 40mg Capsule, 50mg Capsule, 60mg Capsule, 70mg Capsule) 39

Vyvanse (10mg Tablet Chewable, 20mg Tablet Chewable, 30mg Tablet Chewable, 40mg Tablet Chewable, 50mg Tablet Chewable, 60mg Tablet Chewable) ....... 39

W

W&F Lancets 26g......................................... 59 W&F Lancets Colored 21g ........................... 59 Walgreens Lancets ...................................... 59 Walgreens Thin Lancets .............................. 59 Walgreens Ultra Thin Lancets ..................... 59 Warfarin Sodium (Tablet) ............................ 32 WatchHaler (Device) ................................... 59 Welchol (3.75gm Packet, 625mg Tablet) .... 31 Wellbutrin SR (Tablet Extended-Release 12

Hour) ...................................................... 13

99

Wellbutrin XL (Tablet Extended-Release 24 Hour) ...................................................... 13

Westcort (Ointment) .................................. 43 Westhroid (Tablet) ...................................... 49 Wheat Germ (Oil) ........................................ 67 WinRho SDF (Injection) ............................... 51 WP Thyroid (Tablet) .................................... 49

X

Xalatan (Ophthalmic Solution) ................... 60 Xalkori (Capsule) ......................................... 26 Xanax (Tablet) ............................................. 29 Xanax XR (Tablet Extended-Release 24 Hour)

................................................................ 30 Xarelto (Tablet) ........................................... 32 Xarelto Starter Pack (Tablet Therapy Pack) 32 Xartemis XR (Tablet Extended-Release) ..... 11 Xeljanz (Tablet) ........................................... 51 Xeljanz XR (Tablet Extended-Release 24

Hour) ...................................................... 51 Xeloda (Tablet) ............................................ 25 Xenazine (Tablet) ........................................ 40 Xeomin (100unit Injection, 50unit Injection)

................................................................ 59 Xeomin (200unit Injection) ......................... 60 Xeralux (Cream) .......................................... 43 Xerese (Cream)............................................ 13 Xermelo (Tablet) ......................................... 52 Xgeva (Injection) ......................................... 52 Xiaflex (Injection) ........................................ 44 Xifaxan (Tablet) ........................................... 15 Xigduo XR (Tablet Extended-Release 24

Hour) ...................................................... 31 Xiidra (Ophthalmic Solution) ...................... 44 Xodol (Tablet) ............................................. 12 Xofigo (Injection) ........................................ 25 Xolair (Injection) ......................................... 64 Xolegel (Gel) ................................................ 23 Xolegel Corepak (Kit) .................................. 23 Xolegel Duo/Head & Shoulders (Kit) .......... 23 Xolegel Duo/Xolex (Kit) .............................. 23 Xopenex (Nebulized Solution) .................... 63 Xopenex Concentrate (Nebulized Solution)

................................................................ 63 Xopenex HFA (Aerosol) ............................... 63 Xtampza ER (Capsule Extended-Release 12

Hour Abuse-Deterrent) .......................... 11 Xtandi (Capsule) .......................................... 25 Xultophy (Solution Pen injector) ................ 50 Xuriden (Packet) ......................................... 59 Xylocaine (0.5% Injection, 1% Injection, 2%

Injection, 4% External Solution) ............ 13 Xylocaine/Epinephrine (Injection) .............. 13 Xylocaine-MPF (Injection) .......................... 13 Xylocaine-Mpf/Epinephrine (Injection) ..... 13 Xyntha (Injection) ....................................... 33 Xyntha Solofuse (Injection) ........................ 33 Xyrem (Oral Solution) ................................. 65 Xyzal (2.5mg/5ml Oral Solution, 5mg Tablet)

................................................................ 62

Y

Yasmin 28 (Tablet) ...................................... 49 Yaz (Tablet) ................................................. 49 Yervoy (Injection) ....................................... 26 Yondelis (Injection) .................................... 24 Yosprala (Tablet Delayed-Release) ............ 30 Your Life Multi Prenatal (Capsule) ............. 67

Z

Zacare 4% Kit (Kit) ...................................... 43 Zacare 8% Kit (Kit) ...................................... 43 Zafirlukast (Tablet) ...................................... 62 Zaleplon (Capsule) ....................................... 65 Zaltrap (Injection) ....................................... 60 Zamicet (Oral Solution) .............................. 12 Zanaflex (2mg Capsule, 4mg Capsule, 6mg

Capsule, 4mg Tablet) ............................. 28 Zanosar (Injection) ..................................... 24 Zantac (150mg Tablet, 300mg Tablet,

25mg/ml Injection, 50mg/2ml Solution) ............................................................... 45

Zarontin (250mg Capsule, 250mg/5ml Oral Solution) ................................................ 18

Zarxio (Injection) ........................................ 32 Zatean-PN DHA (Capsule) ........................... 67 Zatean-PN Plus (Capsule) ........................... 68 Zavesca (Capsule) ....................................... 44 Zebeta (Tablet) ........................................... 35 Zegerid (20mg-1100mg Capsule, 40mg-

1100mg Capsule, 20mg-1680mg Packet, 40mg-1680mg Packet) ........................... 46

Zelapar (Tablet Dispersible) ....................... 20 Zelboraf (Tablet) ......................................... 26 Zemaira (Injection) ..................................... 64 Zembrace Symtouch (Injection) ................. 24 Zemplar (1mcg Capsule, 2mcg Capsule,

2mcg/ml Injection, 5mcg/ml Injection) 52 Zenpep (Capsule Delayed-Release) ............ 44 Zenzedi (15mg Tablet, 2.5mg Tablet, 20mg

Tablet, 30mg Tablet, 7.5mg Tablet) ...... 39 Zepatier (Tablet) ......................................... 28 Zerbaxa (Injection) ..................................... 16 Zerit (15mg Capsule, 20mg Capsule, 30mg

Capsule, 40mg Capsule) ......................... 29 Zerit (1mg/ml Oral Solution) ...................... 29 Zestoretic (Tablet) ...................................... 34 Zestril (Tablet) ............................................ 34 Zetia (Tablet) .............................................. 38 Zetonna (Aerosol Solution) ........................ 62 Zevalin Y-90 (Injection)............................... 26 Ziac (Tablet) ................................................ 35 Ziagen (20mg/ml Oral Solution) ................. 29 Ziagen (300mg Tablet) ................................ 29 Ziana (Gel) .................................................. 43 Zidovudine (100mg Capsule, 300mg Tablet,

50mg/5ml Syrup).................................... 29 Zinacef (Injection) ....................................... 16 Zinbryta (Injection) ..................................... 60 Zinc Trace Metal (Injection) ....................... 65

Zinecard (Injection) ..................................... 60 Zinplava (Injection) ..................................... 28 Zioptan (Ophthalmic Solution) ................... 60 Ziprasidone HCl (Capsule) ............................ 27 Zirgan (Gel) .................................................. 28 Zithromax (100mg/5ml Suspension,

200mg/5ml Suspension, 250mg Tablet, 500mg Tablet, 600mg Tablet, 500mg Injection) ................................................ 17

Zithromax (1gm Packet) .............................. 17 Zithromax Tri-Pak (Tablet) .......................... 17 Zithromax Z-Pak (Tablet) ............................ 17 Zmax (Suspension) ...................................... 17 Zocor (Tablet) .............................................. 37 Zofran (4mg Tablet, 8mg Tablet, 4mg/5ml

Oral Solution) ......................................... 22 Zofran ODT (Tablet Dispersible) ................. 22 Zohydro ER (Capsule Extended-Release 12

Hour Abuse-Deterrent) .......................... 11 Zoladex (10.8mg Injection) ......................... 50 Zoladex (3.6mg Injection) ........................... 50 Zoledronic Acid (4mg/100ml Injection) ...... 52 Zoledronic Acid (4mg/5ml Injection,

5mg/100ml Injection) ............................. 52 Zolinza (Capsule) ......................................... 25 Zolmitriptan (Tablet) ................................... 24 Zolmitriptan ODT (Tablet Dispersible) ......... 24 Zoloft (100mg Tablet, 25mg Tablet, 50mg

Tablet, 20mg/ml Concentrate) .............. 21 Zolpidem Tartrate (Tablet Sublingual, Tablet)

................................................................ 65 Zolpidem Tartrate ER (Tablet Extended-

Release) .................................................. 65 Zolpimist (Oral Solution) ............................. 65 Zomacton (Injection)................................... 47 Zometa (Injection) ...................................... 52 Zomig (2.5mg Nasal Solution, 5mg Nasal

Solution, 2.5mg Tablet, 5mg Tablet) ..... 24 Zomig ZMT (Tablet Dispersible) .................. 24 Zonacort 11 Day (Tablet Therapy Pack) ..... 50 Zonacort 7 Day (Tablet Therapy Pack) ....... 50 Zonalon (Cream) ......................................... 43 Zonegran (Capsule) ..................................... 18 Zonisamide (Capsule) .................................. 18 Zontivity (Tablet) ........................................ 33 Zorbtive (Injection) ..................................... 47 Zortress (Tablet) .......................................... 51 Zorvolex (Capsule) ...................................... 10 Zosyn (Injection) ......................................... 17 Zovirax (200mg Capsule, 200mg/5ml

Suspension, 400mg Tablet, 5% Ointment, 800mg Tablet) ........................................ 29

Zovirax (5% Cream) ..................................... 29 Zubsolv (0.7mg-0.18mg Tablet Sublingual) 39 Zubsolv (1.4mg-0.36mg Tablet Sublingual,

11.4mg-2.9mg Tablet Sublingual, 2.9mg-0.71mg Tablet Sublingual, 5.7mg-1.4mg Tablet Sublingual, 8.6mg-2.1mg Tablet Sublingual).............................................. 13

Zurampic (Tablet) ........................................ 43 Zutripro (Oral Solution) .............................. 62

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Zyclara (Cream) ........................................... 43 Zyclara Pump (Cream)................................. 43 Zydelig (Tablet) ........................................... 25 Zyflo (Tablet) ............................................... 62 Zyflo CR (Tablet Extended-Release 12 Hour)

................................................................ 63 Zykadia (Capsule) ........................................ 26

Zylet (Suspension) ...................................... 14 Zyloprim (Tablet) ........................................ 23 Zymaxid (Ophthalmic Solution) ................. 17 Zyprexa (10mg Injection) ........................... 60 Zyprexa (10mg Tablet, 15mg Tablet, 2.5mg

Tablet, 20mg Tablet, 5mg Tablet, 7.5mg Tablet) .................................................... 27

Zyprexa Relprevv (Injection) ....................... 60 Zyprexa Zydis (Tablet Dispersible) .............. 27 Zytiga (Tablet) ............................................. 25 Zyvox (100mg/5ml Suspension, 600mg

Tablet, 600mg/300ml Injection) ............ 15

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Nondiscrimination Notice and Access to Communication Services

OptumRx and its family of affiliated Optum companies does not discriminate on the basis of

race, color, national origin, age, disability, or sex in its health programs or activities. We provide assistance free of charge to people with disabilities or whose primary language is not English. To request a document in another format such as large print or to get language assistance such as a qualified interpreter, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can send a complaint to

OptumRx Civil Rights Coordinator

11000 Optum Circle

Eden Prairie, MN 55344

Phone: 1-800-562-6223, TTY 711

Fax: 855-351-5495

Email: [email protected]

If you need help filing a complaint, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week. You can also file a complaint directly with the U.S. Dept. of Health and Human services online, by phone, or by mail: Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue,

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

This information is available in other formats like large print. To ask for another format, please call the telephone number listed on your health plan ID card.

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

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Multi-language Interpreter Services

ATTENTION: If you speak English, language assistance services, free of charge, are available to

you.

Please call the toll-free phone number listed on your identification card.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación.

請注意：如果您說中文

(Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列的免付費會員電話號碼。

XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Vui lòng gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị.

알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다.

귀하의 신분증 카드에 기재된 무료 회원 전화번호로 문의하십시오.

PAALALA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng

serbisyo ng tulong sa wika. Pakitawagan ang toll-free na numero ng telepono na nasa iyong

identification card.

ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык является русском (Russian). Позвоните по бесплатному номеру телефона, указанному на вашей идентификационной карте.

على رقم االتصال الرجاء، فإن خدمات المساعدة اللغوية المجانية متاحة لك. (Arabic) العربيةتنبيه: إذا كنت تتحدث العضوية. معّرف الهاتف المجاني الموجود على

ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nimewo gratis ki sou kat idantifikasyon w.

ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposés gratuitement. Veuillez appeler le numéro de téléphone gratuit figurant sur votre carte d’identification.

UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić pod bezpłatny numer telefonu podany na karcie identyfikacyjnej.

ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência de idiomas gratuito. Ligue gratuitamente para o número encontrado no seu cartão de identificação. ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Per favore chiamate il numero di telefono verde indicato sulla vostra tessera identificativa. ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die gebührenfreie Rufnummer auf der Rückseite Ihres Mitgliedsausweises an.

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注意事項：日本語(Japanese)を話される場合、無料の言語支援サービスをご利用いただけま

す。健康保険証に記載されているフリーダイヤルにお電話ください。

شماره با است، خدمات امداد زبانی به طور رايگان در اختيار شما می باشد. لطفا (Farsi) فارسیتوجه: اگر زبان شما بگيريد. شما قيد شده تماس شناسايی کارت تلفن رايگانی که روی

ध्यान दें: यदद आप ह िंदी (Hindi) बोलत ेहै, आपको भाषा सहायता सेबाए,ं नन:शलु्क उपलब्ध हैं। कृपया अपने पहचान पत्र पर सचूीबद्ध टोल-फ्री फोन नबंर पर कॉल करें।

CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus kheej.

ចំណាប់អារម្មណ ៍ៈ បបើសិនអ្នកនិយាយភាសាខ្មមរ(Khmer)បសវាជំនួយភាសាបោយឥតគិតថ្លៃ គឺមានសំរាប់អ្នក។ សូម្ទូរស័ព្ទបៅបេមឥតគិតថ្លៃ ខ្ែេមានបៅបេើអ្តដសញ្ញា ណប័ណណ របស់អ្នក។

PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti telepono nga nakalista ayan iti identification card mo.

DÍÍ BAA'ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti'go, saad bee áka'anída'awo'ígíí, t'áá jíík'eh, bee ná'ahóót'i'. T'áá shǫǫdí ninaaltsoos nitł'izí bee nééhozinígíí bine'dę́ę́' t'áá jíík'ehgo béésh bee hane'í biká'ígíí bee hodíilnih.

OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga aqoonsiga.

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