Drug Name
Tier
Notes
Drug Name
Tier
Notes
morphine sul cap 60mg er
1
ANALGESICS
morphine sul cap 60mg er
1
Opioid Analgesics, Long-acting
morphine
sul
cap
75mg
er
1
BUTRANS DIS 15MCG/HR
1
morphine sul cap 80mg er
1
EMBEDA CAP 100-4MG
1
QL 60
morphine
sul
cap
90mg
er
1
EMBEDA CAP 20-0.8MG
1
QL 60
morphine sul tab 100mg er
1
EMBEDA CAP 30-1.2MG
1
QL 60
morphine
sul
tab
15mg
er
1
EMBEDA CAP 50-2MG
1
QL 60
morphine sul tab 30mg er
1
EMBEDA CAP 60-2.4MG
1
QL 60
morphine sul tab 60mg er
1
EMBEDA CAP 80-3.2MG
1
QL 60
NUCYNTA ER TAB 100MG
1
fentanyl dis 100mcg/h
1
QL 10 ST
NUCYNTA ER TAB 150MG
1
fentanyl dis 12mcg/hr
1
QL 10 ST
NUCYNTA
ER
TAB
200MG
1
fentanyl dis 25mcg/hr
1
QL 10 ST
NUCYNTA ER TAB 250MG
1
FENTANYL DIS 37.5MCG
1
NUCYNTA
ER
TAB
50MG
1
fentanyl dis 50mcg/hr
1
QL 10 ST
OPANA ER TAB 10MG
1
FENTANYL DIS 62.5MCG
1
OPANA
ER
TAB
15MG
1
fentanyl dis 75mcg/hr
1
QL 10 ST
OPANA ER TAB 20MG
1
FENTANYL DIS 87.5MCG
1
OPANA ER TAB 30MG
1
lorcet plus tab 7.5-325
1
QL 370
OPANA ER TAB 40MG
1
METHADONE INJ 10MG/ML
1
OPANA ER TAB 5MG
1
methadone sol 10mg/5ml
1
OPANA ER TAB 7.5MG
1
methadone sol 5mg/5ml
1
oxymorphone tab 10mg er
1
methadone tab 10mg
1
oxymorphone
tab
15mg
er
1
methadone tab 5mg
1
oxymorphone tab 20mg er
1
morphine sul cap 100mg er
1
oxymorphone
tab
30mg
er
1
morphine sul cap 10mg er
1
oxymorphone tab 40mg er
1
morphine sul cap 120mg er
1
oxymorphone
tab
5mg
er
1
morphine sul cap 20mg er
1
oxymorphone tab 7.5mg er
1
morphine sul cap 30mg er
1
ZOHYDRO ER CAP 10MG
1
PA
morphine sul cap 30mg er
1
ZOHYDRO ER CAP 15MG
1
PA
morphine sul cap 45mg er
1
ZOHYDRO ER CAP 20MG
1
PA
morphine sul cap 50mg er
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
1
Drug Name
Tier
Notes
Drug Name
Tier
Notes
ZOHYDRO ER CAP 30MG
1
PA
LAZANDA SPR 400MCG
1
PA
ZOHYDRO ER CAP 40MG
1
PA
morphine sul sol 10mg/5ml
1
ZOHYDRO ER CAP 50MG
1
PA
morphine sul sol 20mg/5ml
1
morphine sul sol 20mg/ml
1
Opioid Analgesics, Short-acting
apap/codeine sol 120-12/5
1
QL 5000
morphine sul tab 15mg
1
apap/codeine tab 300-15mg
1
QL 400
morphine sul tab 30mg
1
apap/codeine tab 300-30mg
1
QL 400
nalbuphine inj 10mg/ml
1
apap/codeine tab 300-60mg
1
QL 400
nalbuphine inj 20mg/ml
1
ascomp/cod cap 30mg
1
PA
NUCYNTA TAB 100MG
1
but/apap/caf cap codeine
1
PA QL 370
NUCYNTA TAB 50MG
1
duramorph inj 0.5mg/ml
1
NUCYNTA TAB 75MG
1
duramorph inj 1mg/ml
1
oxycod/apap tab 10-325mg
1
QL 370
endocet tab 10-325mg
1
QL 370
oxycod/apap tab 2.5-325
1
QL 370
endocet tab 5-325mg
1
QL 370
oxycod/apap tab 5-325mg
1
QL 370
endocet tab 7.5-325
1
QL 370
oxycod/apap tab 7.5-325
1
QL 370
FENTORA TAB 200MCG
1
PA
oxycod/asa tab
1
FENTORA TAB 400MCG
1
PA
oxycod/ibu tab 5-400mg
1
FENTORA TAB 600MCG
1
PA
oxycodone cap 5mg
1
FENTORA TAB 800MCG
1
PA
oxycodone tab 10mg
1
hydroco/apap sol 7.5-325
1
QL 5500
oxycodone tab 15mg
1
hydroco/apap tab 10-325mg
1
QL 370
oxycodone tab 20mg
1
hydroco/apap tab 2.5-325
1
QL 370
oxycodone tab 30mg
1
hydroco/apap tab 5-325mg
1
QL 370
oxycodone tab 5mg
1
hydroco/apap tab 7.5-325
1
QL 370
oxymorphone tab hcl 10mg
1
hydrocod/ibu tab 7.5-200
1
oxymorphone tab hcl 5mg
1
hydromorphon inj 500/50ml
1
pentaz/nalox tab 50-0.5mg
1
PA
hydromorphon liq 1mg/ml
1
tramadl/apap tab 37.5-325
1
QL 370
hydromorphon tab 2mg
1
tramadol hcl tab 50mg
1
QL 240
hydromorphon tab 4mg
1
ANESTHETICS
hydromorphon tab 8mg
1
Local Anesthetics
LAZANDA SPR 100MCG
1
PA
lido/prilocn cre 2.5-2.5%
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
2
Drug Name
lidocaine gel 2% jelly
lidocaine inj 0.5%
lidocaine inj 2%
Tier
Notes
Drug Name
Tier
Notes
1
celecoxib cap 200mg
1
1
celecoxib cap 400mg
1
1
celecoxib cap 50mg
1
diclofen pot tab 50mg
1
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT
diclofenac
tab
100mg
er
1
AGENTS
diclofenac tab 25mg dr
1
Alcohol Deterrents/Anti-craving
diclofenac
tab
50mg
dr
1
acampro cal tab 333mg
1
diclofenac tab 75mg dr
1
disulfiram tab 250mg
1
diflunisal
tab
500mg
1
disulfiram tab 500mg
1
etodolac cap 200mg
1
naltrexone tab 50mg
1
etodolac
cap
300mg
1
Opioid Antagonists
etodolac
er
tab
400mg
1
bupren/nalox sub 2-0.5mg
1
etodolac er tab 500mg
1
bupren/nalox sub 8-2mg
1
etodolac
er
tab
600mg
1
buprenorphin inj 0.3mg/ml
1
etodolac tab 400mg
1
buprenorphin sub 2mg
1
etodolac
tab
500mg
1
buprenorphin sub 8mg
1
fenoprofen tab 600mg
1
NALOXONE INJ 1MG/ML
1
flurbiprofen
tab
100mg
1
SUBOXONE MIS 12-3MG
1
flurbiprofen tab 50mg
1
SUBOXONE MIS 4-1MG
1
ibuprofen
sus
100/5ml
1
ZUBSOLV SUB 1.4-0.36
1
ibuprofen tab 400mg
1
ZUBSOLV SUB 5.7-1.4
1
ibuprofen
tab
600mg
1
ZUBSOLV SUB 8.6-2.1
1
ibuprofen
tab
800mg
1
Smoking Cessation Agents
indomethacin cap 25mg
1
PA
CHANTIX PAK 0.5& 1MG
1
QL 53
indomethacin
cap
50mg
1
PA
CHANTIX PAK 1MG
1
QL 56/28
indomethacin cap 75mg er
1
PA
CHANTIX TAB 0.5MG
1
QL 11
ketoprofen
cap
200mg
er
1
CHANTIX TAB 1MG
1
QL 180/90
ketoprofen cap 50mg
1
NICOTROL INH
1
ketoprofen
cap
75mg
1
ANTI-INFLAMMATORY AGENTS
ketorolac inj 15mg/ml
1
PA
Nonsteroidal Anti-inflammatory Drugs
ketorolac
inj
30mg/ml
1
PA
celecoxib cap 100mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
3
Drug Name
ketorolac tab 10mg
meclofen sod cap 100mg
meclofen sod cap 50mg
meloxicam sus 7.5/5ml
meloxicam tab 15mg
meloxicam tab 7.5mg
nabumetone tab 500mg
nabumetone tab 750mg
naproxen dr tab 375mg
naproxen dr tab 500mg
naproxen sod tab 275mg
naproxen sod tab 550mg
naproxen sus 125/5ml
naproxen tab 250mg
naproxen tab 375mg
naproxen tab 500mg
oxaprozin tab 600mg
piroxicam cap 10mg
piroxicam cap 20mg
sulindac tab 150mg
sulindac tab 200mg
tolmetin sod cap 400mg
tolmetin sod tab 600mg
Tier
Notes
Drug Name
Tier
Notes
1
PA
gentamicin inj 40mg/ml
1
1
neomycin tab 500mg
1
1
paromomycin cap 250mg
1
1
streptomycin inj 1gm
1
1
tobramycin inj 10mg/ml
1
1
tobramycin inj 80mg/2ml
1
1
tobramycin neb 300/5ml
1
BD
1
Antibacterials, Other
1
baciim inj 50000unt
1
1
chloramphen inj 1gm
1
1
clindamycin cap 150mg
1
1
clindamycin cap 300mg
1
1
clindamycin cap 75mg
1
1
clindamycin inj 150mg/ml
1
1
clindamycin inj 300mg
1
1
clindamycin inj 600mg
1
1
clindamycin inj 900mg
1
1
clindamycin sol 75mg/5ml
1
1
colistimeth inj 150mg
1
1
CUBICIN SOL 500MG
1
1
LINCOCIN INJ 300MG/ML
1
1
linezolid inj 2mg/ml
1
1
metron/nacl inj 500mg
1
BD
metronidazol cap 375mg
1
ANTIBACTERIALS
metronidazol
tab
250mg
1
Aminoglycosides
metronidazol tab 500mg
1
gentam/nacl inj 0.9mg/ml
1
nitrofur
mac
cap
50mg
1
PA
gentam/nacl inj 1.4mg/ml
1
nitrofurantn cap 100mg
1
PA
gentam/nacl inj 100mg
1
SYNERCID INJ 500MG
1
gentam/nacl inj 60mg
1
trimethoprim tab 100mg
1
gentam/nacl inj 80mg
1
TYGACIL INJ 50MG
1
gentamicin inj 10mg/ml
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
4
Drug Name
Tier
Notes
Drug Name
Tier
Notes
vancomycin cap 125mg
1
cefprozil tab 500mg
1
vancomycin cap 250mg
1
ceftriaxone inj 10gm
1
vancomycin inj 1000mg
1
ceftriaxone inj 1gm
1
vancomycin inj 10gm
1
ceftriaxone inj 250mg
1
vancomycin inj 500mg
1
ceftriaxone inj 2gm
1
XIFAXAN TAB 550MG
1
ceftriaxone inj 500mg
1
ZYVOX SUS 100MG/5M
1
cefuroxime inj 1.5gm
1
ZYVOX TAB 600MG
1
cefuroxime inj 7.5gm
1
cefuroxime inj 750mg
1
Beta-lactam, Cephalosporins
cefaclor cap 250mg
1
cefuroxime tab 250mg
1
cefaclor cap 500mg
1
cephalexin cap 250mg
1
cefaclor er tab 500mg
1
cephalexin cap 500mg
1
cefazolin inj 10gm
1
cephalexin sus 125/5ml
1
cefazolin inj 1gm
1
cephalexin sus 250/5ml
1
cefazolin inj 1gm/50ml
1
cephalexin tab 250mg
1
cefazolin inj 500mg
1
cephalexin tab 500mg
1
cefdinir cap 300mg
1
SUPRAX CAP 400MG
1
cefdinir sus 125/5ml
1
SUPRAX SUS 200/5ML
1
cefdinir sus 250/5ml
1
TEFLARO INJ 400MG
1
cefepime inj 1gm
1
TEFLARO INJ 600MG
1
cefepime inj 2gm
1
Beta-lactam, Other
cefoxitin inj 10gm
1
AZACTAM/DEX INJ 1GM
1
cefoxitin inj 1gm
1
AZACTAM/DEX INJ 2GM
1
cefoxitin inj 2gm
1
aztreonam inj 1gm
1
cefpodo prox sus 100/5ml
1
CAYSTON INH 75MG
1
cefpodo prox sus 50mg/5ml
1
imipenem/cil inj 250mg
1
cefpodoxime tab 100mg
1
imipenem/cil inj 500mg
1
cefpodoxime tab 200mg
1
INVANZ INJ 1GM
1
cefprozil sus 125/5ml
1
meropenem inj 500mg
1
cefprozil sus 250/5ml
1
Beta-lactam, Penicillins
cefprozil tab 250mg
1
amox/k clav chw 200mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
5
Drug Name
Tier
Notes
Drug Name
Tier
Notes
amox/k clav chw 400mg
1
pen g sod inj 5000000
1
amox/k clav sus 200/5ml
1
penicill gk/ inj dex 2mu
1
amox/k clav sus 400/5ml
1
penicill gk/ inj dex 3mu
1
amox/k clav sus 600/5ml
1
penicilln gk inj 5mu
1
amox/k clav tab 250mg
1
penicilln vk sol 125/5ml
1
amox/k clav tab 500mg
1
penicilln vk sol 250/5ml
1
amox/k clav tab 875mg
1
penicilln vk tab 250mg
1
amoxicillin cap 250mg
1
penicilln vk tab 500mg
1
amoxicillin cap 500mg
1
piper/tazoba inj 3-0.375g
1
amoxicillin chw 125mg
1
piper/tazoba inj 4-0.5gm
1
amoxicillin chw 250mg
1
Macrolides
amoxicillin sus 125/5ml
1
azithromycin inj 500mg
1
amoxicillin sus 200/5ml
1
azithromycin pow 1gm pak
1
amoxicillin sus 250/5ml
1
azithromycin sus 100/5ml
1
amoxicillin sus 400/5ml
1
azithromycin sus 200/5ml
1
amoxicillin tab 500mg
1
azithromycin tab 250mg
1
amoxicillin tab 875mg
1
azithromycin tab 500mg
1
amp-sulbacta inj 1.5gm
1
azithromycin tab 600mg
1
amp-sulbacta inj 15gm
1
clarithromyc tab 250mg
1
ampicillin cap 250mg
1
clarithromyc tab 500mg
1
ampicillin cap 500mg
1
DIFICID TAB 200MG
1
ST
ampicillin inj 10gm
1
erythrocin inj 500mg
1
ampicillin inj 125mg
1
erythrocin tab 250mg
1
ampicillin inj 1gm
1
erythrom eth tab 400mg
1
ampicillin sus 125/5ml
1
KETEK TAB 300MG
1
ampicillin sus 250/5ml
1
KETEK TAB 400MG
1
BICILLIN L-A INJ 600000
1
Quinolones
dicloxacill cap 250mg
1
ciprofloxacn inj 200mg
1
dicloxacill cap 500mg
1
ciprofloxacn inj 400mg
1
nafcillin inj 10gm
1
ciprofloxacn sus 250mg/5
1
nafcillin inj 1gm
1
ciprofloxacn sus 500mg/5
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
6
Drug Name
Tier
Notes
Drug Name
Tier
Notes
ciprofloxacn tab 1000mg
1
minocycline cap 50mg
1
ciprofloxacn tab 100mg
1
minocycline cap 75mg
1
ciprofloxacn tab 250mg
1
minocycline tab 100mg
1
ciprofloxacn tab 500mg
1
minocycline tab 50mg
1
ciprofloxacn tab 500mg er
1
minocycline tab 75mg
1
ciprofloxacn tab 750mg
1
ANTICONVULSANTS
levoflox/d5w inj 500/100m
1
Anticonvulsants, Other
levofloxacin inj 25mg/ml
1
LEVETIRACETA INJ 10MG/ML
1
levofloxacin sol 25mg/ml
1
LEVETIRACETA INJ 15MG/ML
1
levofloxacin tab 250mg
1
LEVETIRACETA INJ 5MG/ML
1
levofloxacin tab 500mg
1
levetiraceta sol 100mg/ml
1
levofloxacin tab 750mg
1
levetiraceta tab 1000mg
1
ofloxacin tab 300mg
1
levetiraceta tab 250mg
1
ofloxacin tab 400mg
1
levetiraceta tab 500mg
1
Sulfonamides
levetiraceta tab 500mg er
1
smz-tmp inj 400-80/5
1
levetiraceta tab 750mg
1
smz-tmp sus 200-40/5
1
levetiraceta tab 750mg er
1
smz-tmp tab 400-80mg
1
levetiracetm inj 500/5ml
1
smz/tmp ds tab 800-160
1
POTIGA TAB 200MG
1
sulfadiazine tab 500mg
1
POTIGA TAB 300MG
1
Tetracyclines
POTIGA TAB 400MG
1
doxy 100 inj 100mg
1
POTIGA TAB 50MG
1
doxycyc mono tab 50mg
1
Barbiturates
doxycyc mono tab 75mg
1
phenobarb elx 20mg/5ml
1
doxycycl hyc cap 100mg
1
phenobarb tab 100mg
1
doxycycl hyc cap 50mg
1
phenobarb tab 15mg
1
doxycycl hyc inj 100mg
1
phenobarb tab 16.2mg
1
doxycycl hyc tab 100mg
1
phenobarb tab 30mg
1
doxycycline sus 25mg/5ml
1
phenobarb tab 32.4mg
1
doxycycline tab 20mg
1
phenobarb tab 60mg
1
minocycline cap 100mg
1
phenobarb tab 64.8mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
7
Drug Name
Tier
Notes
Drug Name
Tier
Notes
phenobarb tab 97.2mg
1
divalproex tab 250mg dr
1
divalproex tab 250mg er
1
Benzodiazepines
clonazep odt tab 0.125mg
1
divalproex tab 500mg dr
1
clonazep odt tab 0.25mg
1
divalproex tab 500mg er
1
clonazep odt tab 0.5mg
1
FYCOMPA TAB 10MG
1
clonazep odt tab 1mg
1
FYCOMPA TAB 12MG
1
clonazep odt tab 2mg
1
FYCOMPA TAB 2MG
1
clonazepam tab 0.5mg
1
FYCOMPA TAB 4MG
1
clonazepam tab 1mg
1
FYCOMPA TAB 6MG
1
clonazepam tab 2mg
1
FYCOMPA TAB 8MG
1
diazepam gel 10mg
1
gabapentin cap 100mg
1
diazepam gel 2.5mg
1
gabapentin cap 300mg
1
diazepam gel 20mg
1
gabapentin cap 400mg
1
ONFI SUS 2.5MG/ML
1
gabapentin sol 250/5ml
1
ONFI TAB 10MG
1
gabapentin tab 600mg
1
ONFI TAB 20MG
1
gabapentin tab 800mg
1
GABITRIL TAB 12MG
1
Calcium Channel Modifying Agents
CELONTIN CAP 300MG
1
GABITRIL TAB 16MG
1
ethosuximide cap 250mg
1
primidone tab 250mg
1
ethosuximide sol 250/5ml
1
primidone tab 50mg
1
LYRICA CAP 200MG
1
SABRIL POW 500MG
1
LYRICA CAP 225MG
1
SABRIL TAB 500MG
1
LYRICA CAP 25MG
1
tiagabine tab 2mg
1
LYRICA CAP 300MG
1
tiagabine tab 4mg
1
LYRICA CAP 50MG
1
valproate inj 500/5ml
1
LYRICA CAP 75MG
1
valproic acd cap 250mg
1
LYRICA SOL 20MG/ML
1
valproic acd syp 250/5ml
1
zonisamide cap 100mg
1
Glutamate Reducing Agents
zonisamide cap 25mg
1
felbamate sus 600/5ml
1
zonisamide cap 50mg
1
felbamate tab 400mg
1
felbamate tab 600mg
1
Gamma-aminobutyric Acid (GABA) Augmenting Agents
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
8
Drug Name
Tier
Notes
Drug Name
Tier
Notes
LAMICTAL KIT START 35
1
PA
TOPIRAMATE CAP ER 200MG
1
LAMICTAL KIT START 49
1
PA
TOPIRAMATE CAP ER 25MG
1
LAMICTAL KIT START 98
1
PA
TOPIRAMATE CAP ER 50MG
1
LAMICTAL XR KIT
1
PA
topiramate tab 200mg
1
LAMICTAL XR KIT
1
PA
topiramate tab 25mg
1
LAMICTAL XR KIT
1
PA
topiramate tab 50mg
1
lamotrigine chw 25mg
1
TROKENDI XR CAP 100MG
1
lamotrigine chw 5mg
1
TROKENDI XR CAP 200MG
1
lamotrigine tab 100mg
1
TROKENDI XR CAP 25MG
1
lamotrigine tab 100mg er
1
TROKENDI XR CAP 50MG
1
lamotrigine tab 150mg
1
Sodium Channel Agents
lamotrigine tab 200mg
1
APTIOM TAB 200MG
1
lamotrigine tab 200mg er
1
APTIOM TAB 400MG
1
lamotrigine tab 250mg er
1
APTIOM TAB 600MG
1
lamotrigine tab 25mg
1
APTIOM TAB 800MG
1
lamotrigine tab 25mg er
1
BANZEL SUS 40MG/ML
1
lamotrigine tab 300mg er
1
BANZEL TAB 200MG
1
lamotrigine tab 50mg er
1
BANZEL TAB 400MG
1
lamotrigine tab odt 25mg
1
carbamazepin cap 200mg er
1
lamotrigine tab odt 50mg
1
carbamazepin cap 300mg er
1
lamotrigine tab odt/100
1
carbamazepin sus 100/5ml
1
lamotrigine tab odt/200
1
carbamazepin tab 200mg
1
QUDEXY XR CAP 100/24HR
1
carbamazepin tab 200mg er
1
QUDEXY XR CAP 150/24HR
1
carbamazepin tab 400mg er
1
QUDEXY XR CAP 200/24HR
1
CEREBYX INJ 500/10ML
1
QUDEXY XR CAP 25/24HR
1
DILANTIN CAP 30MG
1
PA
QUDEXY XR CAP 50/24HR
1
epitol tab 200mg
1
topiramate cap 15mg
1
EQUETRO CAP 100MG
1
PA
topiramate cap 25mg
1
EQUETRO CAP 200MG
1
PA
TOPIRAMATE CAP ER 100MG
1
EQUETRO CAP 300MG
1
PA
TOPIRAMATE CAP ER 150MG
1
fosphenytoin inj 100/2ml
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
9
Drug Name
oxcarbazepin sus 300mg/5m
oxcarbazepin tab 150mg
oxcarbazepin tab 300mg
oxcarbazepin tab 600mg
OXTELLAR XR TAB 150MG
OXTELLAR XR TAB 300MG
OXTELLAR XR TAB 600MG
PEGANONE TAB 250MG
phenytoin chw 50mg
phenytoin ex cap 100mg
phenytoin ex cap 200mg
phenytoin ex cap 300mg
phenytoin inj 50mg/ml
phenytoin sus 125/5ml
TEGRETOL-XR TAB 100MG
VIMPAT INJ 200MG/20
VIMPAT SOL 10MG/ML
VIMPAT TAB 100MG
VIMPAT TAB 150MG
VIMPAT TAB 200MG
VIMPAT TAB 50MG
ANTIDEMENTIA AGENTS
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Notes
Drug Name
Tier
EXELON DIS 4.6MG/24
1
EXELON DIS 9.5MG/24
1
galantamine cap 16mg er
1
galantamine cap 24mg er
1
galantamine cap 8mg er
1
GALANTAMINE SOL 4MG/ML
1
galantamine tab 12mg
1
galantamine tab 4mg
1
galantamine tab 8mg
1
rivastigmine cap 1.5mg
1
rivastigmine cap 3mg
1
rivastigmine cap 4.5mg
1
rivastigmine cap 6mg
1
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA SOL 10MG/5ML
1
NAMENDA XR CAP 14MG
1
NAMENDA XR CAP 21MG
1
NAMENDA XR CAP 28MG
1
NAMENDA XR CAP 7MG
1
NAMENDA XR CAP TITRATIO
1
Notes
ANTIDEPRESSANTS
Antidepressants, Other
APLENZIN TAB 174MG
1
Antidementia Agents, Other
ergoloid mes tab 1mg oral
1
APLENZIN TAB 348MG
1
APLENZIN TAB 522MG
1
PA
Cholinesterase Inhibitors
donepezil tab 10mg
1
BRINTELLIX TAB 10MG
1
ST
donepezil tab 10mg odt
1
BRINTELLIX TAB 20MG
1
ST
donepezil tab 5mg
1
BRINTELLIX TAB 5MG
1
ST
donepezil tab 5mg odt
1
buproban tab 150mg
1
donepezil tab hcl 23mg
1
bupropion tab 100mg
1
EXELON DIS 13.3/24
1
bupropion tab 100mg sr
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
10
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
bupropion tab 150mg sr
1
EMSAM DIS 6MG/24HR
1
bupropion tab 200mg sr
1
EMSAM DIS 9MG/24HR
1
bupropion tab 75mg
1
MARPLAN TAB 10MG
1
bupropn hcl tab 150mg xl
1
phenelzine tab 15mg
1
bupropn hcl tab 300mg xl
1
tranylcyprom tab 10mg
1
FORFIVO XL TAB 450MG
1
Serotonin/Norepinephrine Reuptake Inhibitors
maprotiline tab 25mg
1
BRISDELLE CAP 7.5MG
1
maprotiline tab 50mg
1
citalopram sol 10mg/5ml
1
maprotiline tab 75mg
1
citalopram tab 10mg
1
mirtazapine tab 15mg
1
citalopram tab 20mg
1
mirtazapine tab 15mg odt
1
citalopram tab 40mg
1
mirtazapine tab 30mg
1
DESVENLAFAX TAB 100MG ER
1
mirtazapine tab 30mg odt
1
DESVENLAFAX TAB 50MG ER
1
mirtazapine tab 45mg
1
duloxetine cap 20mg
1
mirtazapine tab 45mg odt
1
duloxetine cap 30mg
1
mirtazapine tab 7.5mg
1
duloxetine cap 60mg
1
nefazodone tab 100mg
1
escitalopram sol 5mg/5ml
1
nefazodone tab 150mg
1
escitalopram tab 10mg
1
nefazodone tab 200mg
1
escitalopram tab 20mg
1
nefazodone tab 250mg
1
escitalopram tab 5mg
1
nefazodone tab 50mg
1
FETZIMA CAP 120MG
1
trazodone tab 100mg
1
FETZIMA CAP 20MG
1
trazodone tab 150mg
1
FETZIMA CAP 40MG
1
trazodone tab 300mg
1
FETZIMA CAP 80MG
1
trazodone tab 50mg
1
fluoxetine cap 10mg
1
VIIBRYD KIT
1
fluoxetine cap 20mg
1
VIIBRYD TAB 10MG
1
fluoxetine cap 40mg
1
VIIBRYD TAB 20MG
1
fluoxetine cap 90mg dr
1
VIIBRYD TAB 40MG
1
fluoxetine sol 20mg/5ml
1
fluoxetine tab 10mg
1
Monoamine Oxidase Inhibitors
EMSAM DIS 12MG/24H
1
fluoxetine tab 20mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
11
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
FLUOXETINE TAB 60MG
1
sertraline tab 50mg
1
fluvoxamine cap 100mg er
1
venlafaxine cap 150mg er
1
fluvoxamine cap 150mg er
1
venlafaxine cap 37.5 er
1
fluvoxamine tab 100mg
1
venlafaxine cap 75mg er
1
fluvoxamine tab 25mg
1
venlafaxine tab 100mg
1
fluvoxamine tab 50mg
1
venlafaxine tab 150mg er
1
KHEDEZLA TAB 100MG ER
1
venlafaxine tab 225mg er
1
KHEDEZLA TAB 50MG ER
1
venlafaxine tab 25mg
1
olanza/fluox cap 12-25mg
1
venlafaxine tab 37.5 er
1
olanza/fluox cap 12-50mg
1
venlafaxine tab 37.5mg
1
olanza/fluox cap 3-25mg
1
venlafaxine tab 50mg
1
olanza/fluox cap 6-25mg
1
venlafaxine tab 75mg
1
olanza/fluox cap 6-50mg
1
venlafaxine tab 75mg er
1
paroxetin er tab 12.5mg
1
Tricyclics
paroxetin er tab 37.5mg
1
amitriptylin tab 100mg
1
PA
paroxetine tab 10mg
1
amitriptylin tab 10mg
1
PA
paroxetine tab 20mg
1
amitriptylin tab 150mg
1
PA
paroxetine tab 25mg er
1
amitriptylin tab 25mg
1
PA
paroxetine tab 30mg
1
amitriptylin tab 50mg
1
PA
paroxetine tab 40mg
1
amitriptylin tab 75mg
1
PA
PAXIL SUS 10MG/5ML
1
amoxapine tab 100mg
1
PEXEVA TAB 10MG
1
amoxapine tab 150mg
1
PEXEVA TAB 20MG
1
amoxapine tab 25mg
1
PEXEVA TAB 30MG
1
amoxapine tab 50mg
1
PEXEVA TAB 40MG
1
cdp/amitrip tab 10-25mg
1
PA
PRISTIQ TAB 100MG
1
cdp/amitrip tab 5-12.5mg
1
PA
PRISTIQ TAB 25MG
1
clomipramine cap 25mg
1
PA
PRISTIQ TAB 50MG
1
clomipramine cap 50mg
1
PA
sertraline con 20mg/ml
1
clomipramine cap 75mg
1
PA
sertraline tab 100mg
1
desipramine tab 100mg
1
sertraline tab 25mg
1
desipramine tab 10mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
12
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
desipramine tab 150mg
desipramine tab 25mg
desipramine tab 50mg
desipramine tab 75mg
doxepin hcl cap 100mg
doxepin hcl cap 10mg
doxepin hcl cap 150mg
doxepin hcl cap 25mg
doxepin hcl cap 50mg
doxepin hcl cap 75mg
doxepin hcl con 10mg/ml
imipram hcl tab 10mg
imipram hcl tab 25mg
imipram hcl tab 50mg
imipram pam cap 100mg
imipram pam cap 125mg
imipram pam cap 150mg
imipram pam cap 75mg
nortriptylin cap 10mg
nortriptylin cap 25mg
nortriptylin cap 50mg
nortriptylin cap 75mg
NORTRIPTYLIN SOL 10MG/5ML
protriptylin tab 10mg
protriptylin tab 5mg
SURMONTIL CAP 100MG
SURMONTIL CAP 25MG
SURMONTIL CAP 50MG
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Notes
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Drug Name
meclizine tab 25mg
metoclopram tab 5mg
TRANSDERM-SC DIS 1.5MG
Emetogenic Therapy Adjuncts
dronabinol cap 10mg
dronabinol cap 2.5mg
dronabinol cap 5mg
EMEND CAP 125MG
EMEND CAP 40MG
EMEND CAP 80MG
EMEND PAK 80 & 125
granisetron inj 0.1mg/ml
granisetron inj 1mg/ml
granisetron tab 1mg
ondansetron inj 4mg/2ml
ondansetron inj 4mg/2ml
ondansetron sol 4mg/5ml
ondansetron tab 24mg
ondansetron tab 4mg
ondansetron tab 4mg odt
ondansetron tab 8mg
ondansetron tab 8mg odt
SANCUSO DIS 3.1MG
Tier
Notes
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL 60 BD
QL 60 BD
QL 60 BD
QL 30 BD
QL 30 BD
QL 30 BD
QL 12 BD
QL 60 BD
QL 60 BD
QL 60 BD
QL 160 BD
BD
QL 30 BD
QL 60 BD
QL 60 BD
QL 60 BD
QL 60 BD
QL 4
ANTIFUNGALS
Antifungals
ABELCET INJ 5MG/ML
1
AMBISOME INJ 50MG
1
amphotericin inj 50mg
1
CANCIDAS INJ 50MG
1
ANTIEMETICS
CANCIDAS INJ 70MG
1
Antiemetics, Other
meclizine tab 12.5mg
1
clotrimazole tro 10mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
13
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
ERAXIS INJ 100MG
fluconazole sus 10mg/ml
fluconazole sus 40mg/ml
fluconazole tab 100mg
fluconazole tab 150mg
fluconazole tab 200mg
fluconazole tab 50mg
fluconazole/ inj dex 400
flucytosine cap 250mg
flucytosine cap 500mg
griseofulvin sus 125/5ml
itraconazole cap 100mg
ketoconazole tab 200mg
MYCAMINE INJ 100MG
MYCAMINE INJ 50MG
NOXAFIL SUS 40MG/ML
NOXAFIL TAB 100MG
nystatin tab 500000
voriconazole inj 200mg
voriconazole sus 40mg/ml
voriconazole tab 200mg
ANTIGOUT AGENTS
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Notes
Drug Name
Tier
Antimigraine Agents, Prophylactic
divalproex cap 125mg
1
divalproex tab 125mg dr
1
topiramate tab 100mg
1
Ergot Alkaloids
dihydroergot inj 1mg/ml
1
ERGOMAR SUB 2MG
1
Serotonin (5-HT) 1b/1d Receptor Agonists
RELPAX TAB 20MG
1
RELPAX TAB 40MG
1
sumatriptan inj 6mg/0.5
1
sumatriptan inj 6mg/0.5
1
sumatriptan tab 100mg
1
sumatriptan tab 25mg
1
sumatriptan tab 50mg
1
Notes
QL 9
QL 9
QL 10
QL 4.5
QL 9
QL 9
QL 9
ANTIMYASTHENIC AGENTS
Parasympathomimetics
GUANIDINE TAB 125MG
MESTINON SYP 60MG/5ML
pyridostigm tab 60mg
1
1
1
ANTIMYCOBACTERIALS
Antimycobacterials, Other
dapsone tab 100mg
1
1
dapsone tab 25mg
1
1
rifabutin cap 150mg
1
1
Antituberculars
1
CAPASTAT SUL INJ 1GM
1
1
ethambutol tab 100mg
1
1
ST
ethambutol tab 400mg
1
1
ST
isoniazid inj 100mg/ml
1
isoniazid syp 50mg/5ml
1
ANTIMIGRAINE AGENTS
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
14
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Antigout Agents
allopurinol tab 100mg
allopurinol tab 300mg
COLCHICINE CAP 0.6MG
COLCHICINE TAB 0.6MG
probenecid tab 500mg
ULORIC TAB 40MG
ULORIC TAB 80MG
Drug Name
isoniazid tab 100mg
isoniazid tab 300mg
PASER GRA 4GM
PRIFTIN TAB 150MG
pyrazinamide tab 500mg
rifampin cap 150mg
rifampin cap 300mg
rifampin inj 600 mg
RIFATER TAB
SIRTURO TAB 100MG
TRECATOR TAB 250MG
Tier
Notes
Drug Name
Tier
Notes
1
REVLIMID CAP 5MG
1
LA
1
SYPRINE CAP 250MG
1
1
THALOMID CAP 100MG
1
1
THALOMID CAP 150MG
1
1
THALOMID CAP 200MG
1
1
THALOMID CAP 50MG
1
1
Antimetabolites
1
ALIMTA INJ 500MG
1
1
azacitidine inj 100mg
1
1
DACOGEN INJ 50MG
1
1
decitabine inj 50mg
1
fludarabine
inj
50mg
1
ANTINEOPLASTICS
gemcitabine inj 1gm
1
Alkylating Agents
mercaptopur
tab
50mg
1
CYCLOPHOSPH CAP 25MG
1
BD
methotrexate inj 1gm
1
BD
CYCLOPHOSPH CAP 50MG
1
BD
methotrexate
inj
1gm/40ml
1
BD
GLEOSTINE CAP 100MG
1
methotrexate tab 2.5mg
1
BD
GLEOSTINE CAP 10MG
1
PRIMAQUINE TAB 26.3MG
1
GLEOSTINE CAP 40MG
1
PURIXAN SUS 20MG/ML
1
HEXALEN CAP 50MG
1
TABLOID TAB 40MG
1
LEUKERAN TAB 2MG
1
Antineoplastics
lomustine cap 100mg
1
ABRAXANE INJ 100MG
1
BD
lomustine cap 10mg
1
ACTIMMUNE
INJ
2MU/0.5
1
LA
lomustine cap 40mg
1
adrucil inj 500/10ml
1
BD
Antiangiogenic Agents
AFINITOR
DIS
TAB
2MG
1
AVASTIN INJ
1
AFINITOR DIS TAB 3MG
1
DEPEN TITRA TAB 250MG
1
AFINITOR
DIS
TAB
5MG
1
REVLIMID CAP 10MG
1
LA
AFINITOR TAB 10MG
1
REVLIMID CAP 15MG
1
LA
AFINITOR TAB 2.5MG
1
REVLIMID CAP 2.5MG
1
AFINITOR TAB 5MG
1
REVLIMID CAP 20MG
1
AFINITOR TAB 7.5MG
1
REVLIMID CAP 25MG
1
LA
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
15
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
amifostine inj 500mg
1
BD
DOCETAXEL INJ 80MG/4ML
1
ARRANON INJ 5MG/ML
1
BD
DOCETAXEL INJ 80MG/8ML
1
ARZERRA CON 100/5ML
1
BD
DOXIL INJ 2MG/ML
1
BD
AZASAN TAB 100MG
1
BD
doxorubicin inj 50mg
1
BD
AZASAN TAB 75 MG
1
BD
ELIGARD INJ 22.5MG
1
BD
BELEODAQ INJ 500MG
1
ELIGARD INJ 30MG
1
BD
bicalutamide tab 50mg
1
ELIGARD INJ 45MG
1
BD
BICNU INJ 100MG
1
BD
ELIGARD INJ 7.5MG
1
BD
bleomycin inj 30unit
1
ELITEK INJ 1.5MG
1
BD
BOSULIF TAB 100MG
1
PA
ELLENCE INJ 2MG/ML
1
BD
BOSULIF TAB 500MG
1
PA
EMCYT CAP 140MG
1
BUSULFEX INJ 6MG/ML
1
BD
epirubicin inj 50/25ml
1
BD
CAPRELSA TAB 100MG
1
ERBITUX INJ 100MG
1
BD
CAPRELSA TAB 300MG
1
ERIVEDGE CAP 150MG
1
CARAC CRE 0.5%
1
PA
ERWINAZE INJ 10000UNT
1
PA
carboplatin inj 150/15ml
1
BD
ETOPOPHOS INJ 100MG
1
BD
cisplatin inj 100mg
1
BD
etoposide inj 500/25ml
1
BD
cladribine inj 1mg/ml
1
BD
FARESTON TAB 60MG
1
CLOLAR INJ 1MG/ML
1
BD
FARYDAK CAP 10MG
1
PA
COMETRIQ KIT 100MG
1
FARYDAK CAP 15MG
1
PA
COMETRIQ KIT 140MG
1
FARYDAK CAP 20MG
1
PA
COMETRIQ KIT 60MG
1
FASLODEX INJ 250MG
1
BD
COSMEGEN INJ 0.5MG
1
BD
FIRMAGON INJ 120MG
1
BD
cytarabine inj 100mg/ml
1
BD
FIRMAGON INJ 80MG
1
BD
cytarabine inj 20mg/ml
1
BD
fluorouracil inj 2.5g/50m
1
BD
dacarbazine inj 200mg
1
BD
fluorouracil sol 2%
1
daunorubicin inj 5mg/ml
1
BD
fluorouracil sol 5%
1
DAUNOXOME INJ 2MG/ML
1
BD
flutamide cap 125mg
1
DEPO-PROVERA INJ 400/ML
1
BD
FOLOTYN INJ 40MG/2ML
1
BD
dexrazoxane inj 250mg
1
BD
FUSILEV INJ 50MG
1
BD
DOCEFREZ INJ 20MG
1
BD
GILOTRIF TAB 20MG
1
PA
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
16
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
GILOTRIF TAB 30MG
1
PA
JEVTANA INJ 60/1.5ML
1
BD
GILOTRIF TAB 40MG
1
PA
KADCYLA INJ 100MG
1
GLEEVEC TAB 100MG
1
KEPIVANCE INJ 6.25MG
1
BD
GLEEVEC TAB 400MG
1
KEYTRUDA SOL 50MG
1
PA
HALAVEN INJ 1MG/2ML
1
LENVIMA CAP 10MG
1
HERCEPTIN INJ 440MG
1
BD
LENVIMA CAP 14MG
1
hydroxyurea cap 500mg
1
LENVIMA CAP 20MG
1
IBRANCE CAP 100MG
1
PA
LENVIMA CAP 24MG
1
IBRANCE CAP 125MG
1
PA
leucovor ca inj 100mg
1
BD
IBRANCE CAP 75MG
1
PA
leucovor ca inj 350mg
1
BD
ICLUSIG TAB 15MG
1
PA
leucovor ca tab 10mg
1
ICLUSIG TAB 45MG
1
PA
leucovor ca tab 15mg
1
IDAMYCIN PFS INJ 20/20ML
1
BD
leucovor ca tab 25mg
1
idarubicin inj 10/10ml
1
BD
leucovor ca tab 5mg
1
IFEX INJ 1GM
1
BD
leuprolide inj 1mg/0.2
1
ifosfamide inj 1gm
1
BD
LEVOLEUCOVOR INJ 50MG
1
BD
IMBRUVICA CAP 140MG
1
PA
LUPRON DEPOT INJ 22.5MG
1
INLYTA TAB 1MG
1
LUPRON DEPOT INJ 3.75MG
1
INLYTA TAB 5MG
1
LUPRON DEPOT INJ 30MG
1
INTRON A INJ 18MU
1
LUPRON DEPOT INJ 45MG
1
INTRON A INJ 50MU
1
LUPRON DEPOT INJ 7.5MG
1
INTRON-A INJ 10MU
1
LYNPARZA CAP 50MG
1
PA
INTRON-A INJ 18MU
1
LYSODREN TAB 500MG
1
irinotecan inj 100/5ml
1
BD
MATULANE CAP 50MG
1
ISTODAX INJ 10MG
1
MEGACE ES SUS 625/5ML
1
PA
IXEMPRA KIT INJ 45MG
1
BD
megestrol ac sus 40mg/ml
1
PA
JAKAFI TAB 10MG
1
megestrol ac tab 20mg
1
PA
JAKAFI TAB 15MG
1
megestrol ac tab 40mg
1
PA
JAKAFI TAB 20MG
1
MEKINIST TAB 0.5MG
1
LA
JAKAFI TAB 25MG
1
MEKINIST TAB 2MG
1
LA
JAKAFI TAB 5MG
1
melphalan inj 50mg
1
BD
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
17
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
mesna inj 1gm
1
BD
SYLATRON KIT 296MCG
1
MESNEX TAB 400MG
1
SYLATRON KIT 444MCG
1
mitomycin inj 20mg
1
BD
SYLATRON KIT 888MCG
1
mitoxantron inj 2mg/ml
1
SYNRIBO INJ 3.5MG
1
MUSTARGEN INJ 10MG
1
BD
TAFINLAR CAP 50MG
1
LA
NEXAVAR TAB 200MG
1
LA
TAFINLAR CAP 75MG
1
LA
NILANDRON TAB 150MG
1
tamoxifen tab 10mg
1
NIPENT INJ 10MG
1
PA
tamoxifen tab 20mg
1
ONCASPAR INJ 750/ML
1
BD
TARCEVA TAB 100MG
1
OPDIVO INJ 40MG/4ML
1
PA
TARCEVA TAB 150MG
1
oxaliplatin inj 100mg
1
BD
TARCEVA TAB 25MG
1
paclitaxel inj 300/50ml
1
BD
TARGRETIN CAP 75MG
1
PERJETA INJ 420/14ML
1
TASIGNA CAP 150MG
1
POMALYST CAP 1MG
1
LA
TASIGNA CAP 200MG
1
POMALYST CAP 2MG
1
LA
TAXOTERE INJ 80MG/4ML
1
BD
POMALYST CAP 3MG
1
LA
toposar inj 1gm/50ml
1
BD
POMALYST CAP 4MG
1
LA
topotecan inj 4mg
1
BD
PROLEUKIN INJ 22MU
1
BD
TORISEL SOL 25MG/ML
1
BD
RHEUMATREX TAB 2.5MG
1
BD
TREANDA INJ 100MG
1
BD
RITUXAN INJ 500MG
1
TREANDA INJ 45/0.5ML
1
SPRYCEL TAB 100MG
1
TRELSTAR DEP INJ 3.75MG
1
BD
SPRYCEL TAB 140MG
1
TRELSTAR LA INJ 11.25MG
1
BD
SPRYCEL TAB 20MG
1
TRELSTAR MIX INJ 22.5MG
1
BD
SPRYCEL TAB 50MG
1
tretinoin cap 10mg
1
SPRYCEL TAB 70MG
1
TRISENOX SOL 10MG/10M
1
BD
SPRYCEL TAB 80MG
1
TYKERB TAB 250MG
1
STIVARGA TAB 40MG
1
PA
UVADEX INJ 20MCG/ML
1
BD
SUTENT CAP 12.5MG
1
VECTIBIX INJ 100MG
1
BD
SUTENT CAP 25MG
1
VELCADE INJ 3.5MG
1
SUTENT CAP 37.5MG
1
vinblastine inj 1mg/ml
1
BD
SUTENT CAP 50MG
1
vincasar pfs inj 1mg/ml
1
BD
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
18
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
vincristine inj 1mg/ml
vinorelbine inj 10mg/ml
VOTRIENT TAB 200MG
XALKORI CAP 200MG
XALKORI CAP 250MG
XTANDI CAP 40MG
YERVOY INJ 50MG
ZALTRAP INJ 100/4ML
ZANOSAR INJ 1GM
ZELBORAF TAB 240MG
ZINECARD INJ 250MG
ZOLINZA CAP 100MG
ZYDELIG TAB 100MG
ZYDELIG TAB 150MG
ZYKADIA CAP 150MG
ZYTIGA TAB 250MG
Aromatase Inhibitors, 3rd Generation
anastrozole tab 1mg
exemestane tab 25mg
letrozole tab 2.5mg
Tier
Notes
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
BD
BD
PA
PA
PA
Drug Name
COARTEM TAB 20-120MG
DARAPRIM TAB 25MG
hydroxychlor tab 200mg
mefloquine tab 250mg
NEBUPENT INH 300MG
PENTAM 300 INJ 300MG
quinine sulf cap 324mg
Tier
1
1
1
1
1
1
1
Notes
BD
ANTIPARKINSON AGENTS
PA
Anticholinergics
benztropine inj 1mg/ml
1
BD
benztropine tab 0.5mg
1
PA
benztropine tab 1mg
1
PA
benztropine tab 2mg
1
PA
trihexyphen elx 0.4mg/ml
1
PA
trihexyphen tab 2mg
1
PA
trihexyphen tab 5mg
1
PA
Antiparkinson Agents, Other
1
amantadine cap 100mg
1
1
amantadine syp 50mg/5ml
1
1
amantadine tab 100mg
1
entacapone tab 200mg
1
ANTIPARASITICS
Anthelmintics
Dopamine Agonists
ALBENZA TAB 200MG
1
APOKYN INJ 10MG/ML
1
LA
ivermectin tab 3mg
1
bromocriptin cap 5mg
1
bromocriptin tab 2.5mg
1
Antiprotozoals
ALINIA SUS 100/5ML
1
NEUPRO DIS 1MG/24HR
1
ALINIA TAB 500MG
1
NEUPRO DIS 2MG/24HR
1
atovaq/progu tab 250-100
1
NEUPRO DIS 3MG/24HR
1
atovaquone sus 750/5ml
1
NEUPRO DIS 4MG/24HR
1
chloroquine tab 250mg
1
NEUPRO DIS 6MG/24HR
1
chloroquine tab 500mg
1
NEUPRO DIS 8MG/24HR
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
19
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
pramipexole tab 0.125mg
1
pramipexole tab 0.25mg
1
pramipexole tab 0.5mg
1
pramipexole tab 0.75mg
1
pramipexole tab 1.5mg
1
pramipexole tab 1mg
1
ropinirole tab 0.25mg
1
ropinirole tab 0.5mg
1
ropinirole tab 1mg
1
ropinirole tab 2mg
1
ropinirole tab 3mg
1
ropinirole tab 4mg
1
ropinirole tab 5mg
1
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors
carb/levo er tab 25-100mg
1
carb/levo er tab 50-200mg
1
carb/levo tab 10-100mg
1
carb/levo tab 10-100mg
1
carb/levo tab 25-100mg
1
carb/levo tab 25-100mg
1
carb/levo tab 25-250mg
1
carb/levo tab 25-250mg
1
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT TAB 0.5MG
1
AZILECT TAB 1MG
1
selegiline cap 5mg
1
selegiline tab 5mg
1
Drug Name
Tier
Notes
chlorpromaz tab 10mg
1
BD
chlorpromaz tab 200mg
1
chlorpromaz tab 25mg
1
chlorpromaz tab 50mg
1
compro sup 25mg
1
fluphenaz de inj 25mg/ml
1
fluphenazine con 5mg/ml
1
fluphenazine elx 2.5/5ml
1
fluphenazine inj 2.5mg/ml
1
fluphenazine tab 10mg
1
fluphenazine tab 1mg
1
fluphenazine tab 2.5mg
1
fluphenazine tab 5mg
1
haloper dec inj 100mg/ml
1
haloper dec inj 50mg/ml
1
haloper lac inj 5mg/ml
1
haloperidol con 2mg/ml
1
haloperidol tab 0.5mg
1
haloperidol tab 10mg
1
haloperidol tab 1mg
1
haloperidol tab 20mg
1
haloperidol tab 2mg
1
haloperidol tab 5mg
1
loxapine cap 10mg
1
loxapine cap 25mg
1
loxapine cap 50mg
1
loxapine cap 5mg
1
ORAP TAB 1MG
1
ANTIPSYCHOTICS
ORAP TAB 2MG
1
1st Generation/Typical
perphen/amit tab 2-10mg
1
PA
chlorpromaz inj 25mg/ml
1
BD
perphen/amit tab 2-25mg
1
PA
chlorpromaz tab 100mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
20
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
perphen/amit tab 4-10mg
1
PA
ABILIFY TAB 15MG
1
perphen/amit tab 4-25mg
1
PA
ABILIFY TAB 20MG
1
perphen/amit tab 4-50mg
1
PA
ABILIFY TAB 2MG
1
perphenazine tab 16mg
1
ABILIFY TAB 30MG
1
perphenazine tab 2mg
1
ABILIFY TAB 5MG
1
perphenazine tab 4mg
1
FANAPT PAK
1
perphenazine tab 8mg
1
FANAPT TAB 10MG
1
prochlorper inj 10mg/2ml
1
FANAPT TAB 12MG
1
prochlorper sup 25mg
1
FANAPT TAB 1MG
1
prochlorper tab 10mg
1
FANAPT TAB 2MG
1
prochlorper tab 5mg
1
FANAPT TAB 4MG
1
thioridazine tab 100mg
1
PA
FANAPT TAB 6MG
1
thioridazine tab 10mg
1
PA
FANAPT TAB 8MG
1
thioridazine tab 25mg
1
PA
GEODON INJ 20MG
1
thioridazine tab 50mg
1
PA
INVEGA SUST INJ 117/0.75
1
thiothixene cap 10mg
1
INVEGA SUST INJ 156MG/ML
1
thiothixene cap 1mg
1
INVEGA SUST INJ 234/1.5
1
thiothixene cap 2mg
1
INVEGA SUST INJ 39/0.25
1
thiothixene cap 5mg
1
INVEGA SUST INJ 78/0.5ML
1
trifluoperaz tab 10mg
1
INVEGA TAB 1.5MG
1
trifluoperaz tab 1mg
1
INVEGA TAB 3MG
1
trifluoperaz tab 2mg
1
INVEGA TAB 6MG
1
trifluoperaz tab 5mg
1
INVEGA TAB 9MG
1
LATUDA TAB 120MG
1
2nd Generation/Atypical
ABILIFY DISC TAB 10MG
1
LATUDA TAB 20MG
1
ABILIFY DISC TAB 15MG
1
LATUDA TAB 40MG
1
ABILIFY INJ 9.75MG
1
LATUDA TAB 60MG
1
ABILIFY MAIN INJ 300MG
1
LATUDA TAB 80MG
1
ABILIFY MAIN INJ 300MG
1
olanzapine inj 10mg
1
ABILIFY MAIN INJ 400MG
1
olanzapine tab 10mg
1
ABILIFY TAB 10MG
1
olanzapine tab 10mg odt
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
21
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
olanzapine tab 15mg
1
SAPHRIS SUB 10MG
1
olanzapine tab 15mg odt
1
SAPHRIS SUB 5MG
1
olanzapine tab 2.5mg
1
SEROQUEL XR TAB 150MG
1
olanzapine tab 20mg
1
SEROQUEL XR TAB 200MG
1
olanzapine tab 20mg odt
1
SEROQUEL XR TAB 300MG
1
olanzapine tab 5mg
1
SEROQUEL XR TAB 400MG
1
olanzapine tab 5mg odt
1
SEROQUEL XR TAB 50MG
1
olanzapine tab 7.5mg
1
ziprasidone cap 20mg
1
quetiapine tab 100mg
1
ziprasidone cap 40mg
1
quetiapine tab 200mg
1
ziprasidone cap 60mg
1
quetiapine tab 25mg
1
ziprasidone cap 80mg
1
quetiapine tab 300mg
1
ZYPREXA RELP INJ 210MG
1
quetiapine tab 400mg
1
Treatment-Resistant
quetiapine tab 50mg
1
CLOZAPINE TAB 100/ODT
1
RISPERDAL INJ 12.5MG
1
clozapine tab 100mg
1
RISPERDAL INJ 25MG
1
CLOZAPINE TAB 12.5/ODT
1
RISPERDAL INJ 37.5MG
1
clozapine tab 200mg
1
RISPERDAL INJ 50MG
1
clozapine tab 25mg
1
risperidone sol 1mg/ml
1
CLOZAPINE TAB 25MG ODT
1
risperidone tab 0.25 odt
1
clozapine tab 50mg
1
risperidone tab 0.25mg
1
FAZACLO TAB 150MG
1
risperidone tab 0.5mg
1
FAZACLO TAB 200MG
1
risperidone tab 0.5mg od
1
VERSACLOZ SUS 50MG/ML
1
risperidone tab 1mg
1
ANTIVIRALS
risperidone tab 1mg odt
1
Anti-cytomegalovirus (CMV) Agents
risperidone tab 2mg
1
foscarnet inj 24mg/ml
1
risperidone tab 2mg odt
1
ganciclovir inj 500mg
1
BD
risperidone tab 3mg
1
VALCYTE SOL 50MG/ML
1
risperidone tab 3mg odt
1
valganciclov tab 450mg
1
risperidone tab 4mg
1
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
risperidone tab 4mg odt
1
Inhibitors
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
22
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
ATRIPLA TAB
1
lamivudine tab 100mg
1
COMPLERA TAB
1
lamivudine tab 150mg
1
EDURANT TAB 25MG
1
lamivudine tab 300mg
1
INTELENCE TAB 100MG
1
PREZCOBIX TAB 800-150
1
INTELENCE TAB 200MG
1
RETROVIR INJ 10MG/ML
1
INTELENCE TAB 25MG
1
stavudine cap 15mg
1
NEVIRAPINE SUS 50MG/5ML
1
stavudine cap 20mg
1
nevirapine tab 200mg
1
stavudine cap 30mg
1
nevirapine tab 400mg er
1
stavudine cap 40mg
1
RESCRIPTOR TAB 100 MG
1
TRIUMEQ TAB
1
RESCRIPTOR TAB 200MG
1
TRUVADA TAB 200-300
1
SUSTIVA CAP 200MG
1
VIDEX SOL 2GM
1
SUSTIVA CAP 50MG
1
VIREAD POW 40MG/GM
1
SUSTIVA TAB 600MG
1
VIREAD TAB 150MG
1
VIRAMUNE XR TAB 100MG
1
VIREAD TAB 200MG
1
VIREAD TAB 250MG
1
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
VIREAD TAB 300MG
1
Transcriptase Inhibitors
abacav/lamiv tab /zidovud
1
ZIAGEN SOL 20MG/ML
1
abacavir tab 300mg
1
zidovudine cap 100mg
1
desloratadin tab 5mg odt
1
zidovudine syp 50mg/5ml
1
didanosine cap 125mg
1
zidovudine tab 300mg
1
didanosine cap 200mg
1
Anti-HIV Agents, Other
didanosine cap 250mg
1
FUZEON INJ 90MG
1
didanosine cap 400mg
1
ISENTRESS CHW 100MG
1
EMTRIVA CAP 200MG
1
ISENTRESS CHW 25MG
1
EMTRIVA SOL 10MG/ML
1
ISENTRESS POW 100MG
1
EPIVIR HBV SOL 5MG/ML
1
ISENTRESS TAB 400MG
1
EPZICOM TAB 600-300
1
SELZENTRY TAB 150MG
1
EVOTAZ TAB 300-150
1
SELZENTRY TAB 300MG
1
lamivud/zido tab 150-300
1
STRIBILD TAB
1
lamivudine sol 10mg/ml
1
TIVICAY TAB 50MG
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
23
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
TYBOST TAB 150MG
1
rimantadine tab 100mg
1
VITEKTA TAB 150MG
1
TAMIFLU CAP 30MG
1
VITEKTA TAB 85MG
1
TAMIFLU CAP 45MG
1
TAMIFLU CAP 75MG
1
Anti-HIV Agents, Protease Inhibitors
APTIVUS CAP 250MG
1
TAMIFLU SUS 6MG/ML
1
APTIVUS SOL
1
VIRAZOLE INH 6GM
1
CRIXIVAN CAP 200MG
1
Antihepatitis Agents
CRIXIVAN CAP 400MG
1
adefov dipiv tab 10mg
1
INVIRASE CAP 200MG
1
BARACLUDE SOL .05MG/ML
1
INVIRASE TAB 500MG
1
entecavir tab 0.5mg
1
KALETRA SOL
1
entecavir tab 1mg
1
KALETRA TAB 100-25MG
1
HARVONI TAB 90-400MG
1
PA
KALETRA TAB 200-50MG
1
OLYSIO CAP 150MG
1
PA
LEXIVA SUS 50MG/ML
1
PEGASYS INJ
1
LEXIVA TAB 700MG
1
PEGASYS INJ 180MCG/M
1
NORVIR CAP 100MG
1
PEGASYS INJ PROCLICK
1
NORVIR SOL 80MG/ML
1
ribapak pak 1000/day
1
NORVIR TAB 100MG
1
ribapak pak 800/day
1
PREZISTA SUS 100MG/ML
1
ribasphere cap 200mg
1
PREZISTA TAB 150MG
1
ribasphere tab 200mg
1
PREZISTA TAB 600MG
1
RIBASPHERE TAB 400MG
1
PREZISTA TAB 75MG
1
ribavirin cap 200mg
1
PREZISTA TAB 800MG
1
ribavirin tab 200mg
1
REYATAZ CAP 150MG
1
SOVALDI TAB 400MG
1
PA
REYATAZ CAP 200MG
1
TYZEKA TAB 600MG
1
REYATAZ CAP 300MG
1
VICTRELIS CAP 200MG
1
PA
REYATAZ POW 50MG
1
Antiherpetic Agents
VIRACEPT TAB 250MG
1
acyclovir cap 200mg
1
VIRACEPT TAB 625MG
1
acyclovir na inj 50mg/ml
1
BD
acyclovir sus 200/5ml
1
Anti-influenza Agents
RELENZA MIS DISKHALE
1
acyclovir tab 400mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
24
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
acyclovir tab 800mg
famciclovir tab 125mg
famciclovir tab 250mg
famciclovir tab 500mg
valacyclovir tab 1gm
valacyclovir tab 500mg
ANXIOLYTICS
Tier
1
1
1
1
1
1
Notes
Drug Name
alprazolam tab 1mg
alprazolam tab 1mg er
alprazolam tab 1mg odt
alprazolam tab 2mg
alprazolam tab 2mg er
alprazolam tab 2mg odt
alprazolam tab 3mg er
chlordiazep cap 10mg
chlordiazep cap 25mg
chlordiazep cap 5mg
cloraz dipot tab 15mg
cloraz dipot tab 3.75mg
cloraz dipot tab 7.5mg
DIAZEPAM CON 5MG/ML
DIAZEPAM SOL 1MG/ML
diazepam tab 10mg
diazepam tab 2mg
diazepam tab 5mg
lorazepam con 2mg/ml
lorazepam tab 0.5mg
lorazepam tab 1mg
lorazepam tab 2mg
oxazepam cap 10mg
oxazepam cap 15mg
oxazepam cap 30mg
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Notes
QL 120
QL 360
QL 120
QL 120
QL 120
QL 120
QL 120
QL 90
QL 90
QL 240
QL 1200
QL 120
QL 600
QL 240
Anxiolytics, Other
buspirone tab 10mg
1
buspirone tab 15mg
1
buspirone tab 30mg
1
buspirone tab 5mg
1
buspirone tab 7.5mg
1
hydroxyz hcl inj 25mg/ml
1
PA
hydroxyz hcl inj 50mg/ml
1
PA
hydroxyz hcl sol 10mg/5ml
1
PA
hydroxyz hcl tab 10mg
1
PA
hydroxyz hcl tab 25mg
1
PA
hydroxyz hcl tab 50mg
1
PA
QL 120
hydroxyz pam cap 100mg
1
PA
QL 90
hydroxyz pam cap 25mg
1
PA
QL 60
hydroxyz pam cap 50mg
1
PA
QL
120
meprobamate tab 200mg
1
PA
QL 120
meprobamate tab 400mg
1
PA
QL 120
Benzodiazepines
ALPRAZOLAM CON 1 MG/ML
1
BIPOLAR AGENTS
alprazolam tab 0.25 odt
1
QL 720
Mood Stabilizers
alprazolam tab 0.25mg
1
carbamazepin cap 100mg er
1
alprazolam tab 0.5mg
1
carbamazepin chw 100mg
1
alprazolam tab 0.5mg er
1
QL 120
lithium carb cap 150mg
1
alprazolam tab 0.5mg od
1
QL 180
lithium carb cap 300mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
25
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
lithium carb cap 600mg
lithium carb tab 300mg
lithium carb tab 300mg er
lithium carb tab 450mg er
lithium sol 8meq/5ml
Tier
Notes
Drug Name
Tier
Notes
1
glimepiride tab 4mg
1
1
glip/metform tab 2.5-250m
1
1
glip/metform tab 2.5-500m
1
1
glip/metform tab 5-500mg
1
1
glipizide er tab 10mg
1
glipizide er tab 2.5mg
1
BLOOD GLUCOSE REGULATORS
glipizide
er
tab
5mg
1
Antidiabetic Agents
glipizide tab 10mg
1
acarbose tab 100mg
1
glipizide tab 5mg
1
acarbose tab 25mg
1
GLUMETZA TAB 1000MG
1
acarbose tab 50mg
1
GLUMETZA TAB 500MG
1
ACTOPLUS MET TAB XR
1
glyb/metform
tab
1.25-250
1
PA
ACTOPLUS MET TAB XR
1
glyb/metform tab 2.5-500
1
PA
AVANDAMET TAB 2-1000MG
1
glyb/metform
tab
5-500mg
1
PA
AVANDAMET TAB 2-500MG
1
glyburid mcr tab 1.5mg
1
PA
AVANDAMET TAB 4-500MG
1
glyburid
mcr
tab
3mg
1
PA
AVANDARYL TAB 4-1MG
1
glyburid mcr tab 6mg
1
PA
AVANDARYL TAB 4-2MG
1
glyburide tab 1.25mg
1
PA
AVANDARYL TAB 8-4MG
1
glyburide tab 2.5mg
1
PA
AVANDIA TAB 2MG
1
glyburide tab 5mg
1
PA
AVANDIA TAB 4MG
1
INSULIN PEN NEEDLE
1
AVANDIA TAB 8MG
1
INSULIN SYRINGE (DISP) U-100
1
BYETTA INJ 10MCG
1
INSULIN
SYRINGE
(DISP)
U-100
1
BYETTA INJ 5MCG
1
INSULIN SYRINGE (DISP) U-100
1
chlorpropam tab 100mg
1
PA
INVOKAMET
TAB
150-1000
1
chlorpropam tab 250mg
1
PA
INVOKAMET TAB 150-500
1
CYCLOSET TAB 0.8MG
1
INVOKAMET
TAB
50-1000
1
FARXIGA TAB 10MG
1
INVOKAMET TAB 50-500MG
1
FARXIGA TAB 5MG
1
INVOKANA TAB 100MG
1
GAUZE PADS & DRESSINGS - PADS
1
INVOKANA TAB 300MG
1
glimepiride tab 1mg
1
ISOPROPYL ALCOHOL 0.7 ML/ML
1
glimepiride tab 2mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
26
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
JANUMET TAB 50-1000
1
OSENI TAB 25-30MG
1
JANUMET TAB 50-500MG
1
OSENI TAB 25-45MG
1
JANUMET XR TAB 100-1000
1
pioglit/glim tab 30-4mg
1
JANUMET XR TAB 50-1000
1
pioglita/met tab 15-500mg
1
JANUMET XR TAB 50-500MG
1
pioglita/met tab 15-850mg
1
JANUVIA TAB 100MG
1
pioglitazone tab 15mg
1
JANUVIA TAB 25MG
1
pioglitazone tab 30mg
1
JANUVIA TAB 50MG
1
pioglitazone tab 45mg
1
KAZANO 12.5- TAB 1000MG
1
PRANDIMET TAB 1-500MG
1
KAZANO 12.5- TAB 500MG
1
PRANDIMET TAB 2-500MG
1
KOMBIGLYZE TAB 2.5-1000
1
PRANDIN TAB 0.5MG
1
KOMBIGLYZE TAB 5-1000MG
1
PRANDIN TAB 1MG
1
KOMBIGLYZE TAB 5-500MG
1
PRANDIN TAB 2MG
1
metformin er tab 1000mg
1
repaglinide tab 0.5mg
1
metformin tab 1000mg
1
repaglinide tab 1mg
1
metformin tab 500mg
1
repaglinide tab 2mg
1
metformin tab 500mg er
1
RIOMET SOL
1
metformin tab 750mg er
1
SYMLINPEN 60 INJ 1000MCG
1
metformin tab 850mg
1
SYMLNPEN 120 INJ 1000MCG
1
nateglinide tab 120mg
1
tolazamide tab 250mg
1
nateglinide tab 60mg
1
tolazamide tab 500mg
1
NEEDLES, INSULIN DISP., SAFET
1
tolbutamide tab 500mg
1
NESINA TAB 12.5MG
1
valsart/hctz tab 160-12.5
1
NESINA TAB 25MG
1
Glycemic Agents
NESINA TAB 6.25MG
1
GLUCAGEN INJ HYPOKIT
1
ONGLYZA TAB 2.5MG
1
GLUCAGON KIT 1MG
1
ONGLYZA TAB 5MG
1
PROGLYCEM SUS 50MG/ML
1
OSENI TAB 12.5-15
1
Insulins
OSENI TAB 12.5-30
1
APIDRA INJ SOLOSTAR
1
OSENI TAB 12.5-45
1
APIDRA INJ U-100
1
OSENI TAB 25-15MG
1
LANTUS INJ 100/ML
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
27
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
LANTUS INJ SOLOSTAR
LEVEMIR INJ
LEVEMIR INJ FLEXTOUC
NOVOLIN INJ 70/30
NOVOLIN N INJ U-100
NOVOLIN R INJ U-100
NOVOLOG INJ 100/ML
NOVOLOG INJ FLEXPEN
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ FLEXPEN
Tier
Notes
Drug Name
Tier
Notes
1
heparin sod inj 10000/ml
1
1
heparin sod inj 20000/ml
1
1
heparin sod inj 5000/ml
1
1
jantoven tab 10mg
1
1
jantoven tab 1mg
1
1
jantoven tab 2.5mg
1
1
jantoven tab 2mg
1
1
jantoven tab 3mg
1
1
jantoven tab 4mg
1
1
jantoven tab 5mg
1
jantoven tab 6mg
1
BLOOD PRODUCTS/MODIFIERS/ VOLUME
jantoven
tab
7.5mg
1
EXPANDERS
PRADAXA CAP 150MG
1
Anticoagulants
PRADAXA
CAP
75MG
1
enoxaparin inj 100mg/ml
1
warfarin tab 10mg
1
enoxaparin inj 120/0.8
1
warfarin
tab
1mg
1
enoxaparin inj 150mg/ml
1
warfarin tab 2.5mg
1
enoxaparin inj 30/0.3ml
1
warfarin
tab
2mg
1
enoxaparin inj 300/3ml
1
warfarin tab 3mg
1
enoxaparin inj 40/0.4ml
1
warfarin
tab
4mg
1
enoxaparin inj 60/0.6ml
1
warfarin tab 5mg
1
enoxaparin inj 80/0.8ml
1
warfarin
tab
6mg
1
fondaparinux sol 10/0.8
1
warfarin
tab
7.5mg
1
fondaparinux sol 2.5/0.5
1
XARELTO STAR TAB 15/20MG
1
fondaparinux sol 5.0/0.4
1
XARELTO
TAB
10MG
1
fondaparinux sol 7.5/0.6
1
XARELTO TAB 15MG
1
FRAGMIN INJ 7500/0.3
1
XARELTO
TAB
20MG
1
FRAGMIN INJ 95000UNT
1
Blood Formation Modifiers
hep sod/d5w inj 20000unt
1
LEUKINE INJ 250MCG
1
hep sod/d5w inj 25000unt
1
MIRCERA INJ 100MCG
1
BD
hep sod/d5w inj 25000unt
1
MIRCERA
INJ
50MCG
1
BD
heparin sod inj 1000/ml
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
28
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
MIRCERA INJ 75MCG
1
BD
ticlopidine tab 250mg
1
PA
MOZOBIL INJ
1
CARDIOVASCULAR AGENTS
NEUMEGA INJ 5MG
1
Alpha-adrenergic Agonists
NEUPOGEN INJ 300/0.5
1
clonidine tab 0.1mg
1
NEUPOGEN INJ 480/0.8
1
clonidine tab 0.2mg
1
NEUPOGEN INJ 480MCG
1
clonidine tab 0.3mg
1
PROCRIT INJ 10000/ML
1
PA QL 12/28
methyldopa tab 250mg
1
PA
PROCRIT INJ 2000/ML
1
PA QL 23
methyldopa tab 500mg
1
PA
PROCRIT INJ 20000/ML
1
PA QL 12/28
methyldopate inj 250/5ml
1
PA
PROCRIT INJ 3000/ML
1
PA QL 16
midodrine tab 10mg
1
PROCRIT INJ 4000/ML
1
PA QL 12/28
midodrine tab 2.5mg
1
PROCRIT INJ 40000/ML
1
PA QL 12
midodrine tab 5mg
1
PROMACTA TAB 12.5MG
1
Alpha-adrenergic Blocking Agents
PROMACTA TAB 25MG
1
doxazosin tab 1mg
1
PROMACTA TAB 50MG
1
doxazosin tab 2mg
1
PROMACTA TAB 75MG
1
doxazosin tab 4mg
1
tranex acid inj 100mg/ml
1
doxazosin tab 8mg
1
tranex acid tab 650mg
1
prazosin hcl cap 1mg
1
Platelet Modifying Agents
prazosin hcl cap 2mg
1
AGGRENOX CAP 25-200MG
1
prazosin hcl cap 5mg
1
anagrelide cap 0.5mg
1
terazosin cap 10mg
1
BRILINTA TAB 90MG
1
terazosin cap 1mg
1
cilostazol tab 100mg
1
terazosin cap 2mg
1
cilostazol tab 50mg
1
terazosin cap 5mg
1
clopidogrel tab 300mg
1
Angiotensin II Receptor Antagonists
clopidogrel tab 75mg
1
ATACAND TAB 16MG
1
dipyridamole tab 25mg
1
PA
ATACAND TAB 32MG
1
dipyridamole tab 50mg
1
PA
BENICAR TAB 20MG
1
dipyridamole tab 75mg
1
PA
BENICAR TAB 40MG
1
EFFIENT TAB 10MG
1
BENICAR TAB 5MG
1
EFFIENT TAB 5MG
1
candesartan tab 16mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
29
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
candesartan tab 32mg
1
lisinopril tab 10mg
1
candesartan tab 4mg
1
lisinopril tab 2.5mg
1
candesartan tab 8mg
1
lisinopril tab 20mg
1
EDARBI TAB 40MG
1
ST
lisinopril tab 30mg
1
EDARBI TAB 80MG
1
ST
lisinopril tab 40mg
1
eprosart mes tab 600mg
1
lisinopril tab 5mg
1
irbesartan tab 150mg
1
moexipril tab 15mg
1
irbesartan tab 300mg
1
moexipril tab 7.5mg
1
irbesartan tab 75mg
1
perindopril tab 2mg
1
losartan pot tab 100mg
1
perindopril tab 4mg
1
losartan pot tab 25mg
1
perindopril tab 8mg
1
losartan pot tab 50mg
1
quinapril tab 10mg
1
telmisartan tab 20mg
1
quinapril tab 20mg
1
telmisartan tab 40mg
1
quinapril tab 40mg
1
telmisartan tab 80mg
1
quinapril tab 5mg
1
ramipril cap 1.25mg
1
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril tab 10mg
1
ramipril cap 10mg
1
benazepril tab 20mg
1
ramipril cap 2.5mg
1
benazepril tab 40mg
1
ramipril cap 5mg
1
benazepril tab 5mg
1
trandolapril tab 1mg
1
captopril tab 100mg
1
trandolapril tab 2mg
1
captopril tab 12.5mg
1
trandolapril tab 4mg
1
captopril tab 25mg
1
Antiarrhythmics
captopril tab 50mg
1
amiodarone inj 50mg/ml
1
enalapril tab 10mg
1
amiodarone tab 200mg
1
enalapril tab 2.5mg
1
amiodarone tab 400mg
1
enalapril tab 20mg
1
disopyramide cap 100mg
1
PA
enalapril tab 5mg
1
disopyramide cap 150mg
1
PA
fosinopril tab 10mg
1
flecainide tab 100mg
1
fosinopril tab 20mg
1
flecainide tab 150mg
1
fosinopril tab 40mg
1
flecainide tab 50mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
30
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
mexiletine cap 150mg
1
amlod/valsar tab 10-320mg
1
mexiletine cap 200mg
1
amlod/valsar tab 5-160mg
1
mexiletine cap 250mg
1
amlod/valsar tab 5-320mg
1
MULTAQ TAB 400MG
1
atenol/chlor tab 100-25mg
1
pacerone tab 100mg
1
atenol/chlor tab 50-25mg
1
pacerone tab 200mg
1
AZOR TAB 10-20MG
1
procainamide inj 100mg/ml
1
AZOR TAB 10-40MG
1
propafenone tab 150mg
1
AZOR TAB 5-20MG
1
propafenone tab 225mg
1
AZOR TAB 5-40MG
1
propafenone tab 300mg
1
benazep/hctz tab 10-12.5
1
quinidine gl tab 324mg cr
1
benazep/hctz tab 20-12.5
1
quinidine su tab 200mg
1
benazep/hctz tab 20-25mg
1
quinidine su tab 300mg
1
benazep/hctz tab 5-6.25
1
quinidine su tab 300mg er
1
BENICAR HCT TAB 20-12.5
1
TIKOSYN CAP 125MCG
1
BENICAR HCT TAB 40-12.5
1
TIKOSYN CAP 250MCG
1
BENICAR HCT TAB 40-25MG
1
TIKOSYN CAP 500MCG
1
bisoprl/hctz tab 10/6.25
1
bisoprl/hctz tab 2.5/6.25
1
Antihypertensive Combinations
amilor/hctz tab 5-50
1
bisoprl/hctz tab 5-6.25mg
1
amlod/benazp cap 10-20mg
1
candesa/hctz tab 16-12.5
1
amlod/benazp cap 10-40mg
1
candesa/hctz tab 32-12.5
1
amlod/benazp cap 2.5-10mg
1
candesa/hctz tab 32-25mg
1
amlod/benazp cap 5-10mg
1
captopr/hctz tab 25-15mg
1
amlod/benazp cap 5-20mg
1
captopr/hctz tab 25-25mg
1
amlod/benazp cap 5-40mg
1
captopr/hctz tab 50-15mg
1
amlod/valsar tab /hctz
1
captopr/hctz tab 50-25mg
1
amlod/valsar tab /hctz
1
EDARBYCLOR TAB 40-12.5
1
ST
amlod/valsar tab /hctz
1
EDARBYCLOR TAB 40-25MG
1
ST
amlod/valsar tab /hctz
1
enalapr/hctz tab 10-25mg
1
amlod/valsar tab /hctz
1
enalapr/hctz tab 5-12.5mg
1
amlod/valsar tab 10-160mg
1
fosinop/hctz tab 10/12.5
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
31
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
fosinop/hctz tab 20/12.5
1
TEKAMLO TAB 300-5MG
1
lisinop/hctz tab 10-12.5
1
TEKTURNA HCT TAB 150-12.5
1
lisinop/hctz tab 20-12.5
1
TEKTURNA HCT TAB 150-25MG
1
lisinop/hctz tab 20-25mg
1
TEKTURNA HCT TAB 300-12.5
1
losartan/hct tab 100-12.5
1
TEKTURNA HCT TAB 300-25MG
1
losartan/hct tab 100-25
1
telmis/amlod tab 40-10mg
1
losartan/hct tab 50-12.5
1
telmis/amlod tab 40-5mg
1
methyld/hctz tab 250/15
1
PA
telmis/amlod tab 80-10mg
1
methyld/hctz tab 250/25
1
PA
telmis/amlod tab 80-5mg
1
metoprl/hctz tab 100-25mg
1
TEVETEN HCT TAB 600-12.5
1
metoprl/hctz tab 100-50mg
1
TEVETEN HCT TAB 600-25MG
1
metoprl/hctz tab 50-25mg
1
trando/verap tab 1-240 cr
1
moexipr/hctz tab 15-12.5
1
trando/verap tab 2-180 cr
1
moexipr/hctz tab 15-25mg
1
trando/verap tab 2-240 cr
1
moexipr/hctz tab 7.5-12.5
1
trando/verap tab 4-240 cr
1
nadolol/bend tab 40-5mg
1
triamt/hctz cap 50-25mg
1
nadolol/bend tab 80-5mg
1
triamt/hctz tab 37.5-25
1
pioglit/glim tab 30-2mg
1
triamt/hctz tab 75-50mg
1
propran/hctz tab 40/25
1
TRIBENZOR20- TAB 5-12.5MG
1
propran/hctz tab 80/25
1
TRIBENZOR40- TAB 10-12.5
1
qnapril/hctz tab 10-12.5
1
TRIBENZOR40- TAB 10-25MG
1
qnapril/hctz tab 20-12.5
1
TRIBENZOR40- TAB 5-12.5MG
1
qnapril/hctz tab 20-25mg
1
TRIBENZOR40- TAB 5-25MG
1
spirono/hctz tab 25/25
1
valsart/hctz tab 160-25mg
1
TARKA TAB 1-240 CR
1
valsart/hctz tab 320-12.5
1
TARKA TAB 2-180 CR
1
valsart/hctz tab 320-25mg
1
TARKA TAB 2-240 CR
1
valsart/hctz tab 80-12.5
1
TARKA TAB 4-240 CR
1
Beta-adrenergic Blocking Agents
TEKAMLO TAB 150-10MG
1
acebutolol cap 200mg
1
TEKAMLO TAB 150-5MG
1
acebutolol cap 400mg
1
TEKAMLO TAB 300-10MG
1
atenolol tab 100mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
32
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
atenolol tab 25mg
1
propranolol inj 1mg/ml
1
atenolol tab 50mg
1
propranolol sol 20mg/5ml
1
betaxolol tab 10mg
1
propranolol sol 40mg/5ml
1
betaxolol tab 20mg
1
propranolol tab 10mg
1
bisoprol fum tab 10mg
1
propranolol tab 20mg
1
bisoprol fum tab 5mg
1
propranolol tab 40mg
1
carvedilol tab 12.5mg
1
propranolol tab 60mg
1
carvedilol tab 25mg
1
propranolol tab 80mg
1
carvedilol tab 3.125mg
1
sorine tab 120mg
1
carvedilol tab 6.25mg
1
sorine tab 160mg
1
labetalol inj 5mg/ml
1
sorine tab 240mg
1
labetalol tab 100mg
1
sorine tab 80mg
1
labetalol tab 200mg
1
sotalol af tab 120mg
1
labetalol tab 300mg
1
sotalol hcl tab 160mg
1
metoprol tar tab 100mg
1
sotalol hcl tab 240mg
1
metoprol tar tab 25mg
1
sotalol hcl tab 80mg
1
metoprol tar tab 50mg
1
timolol mal tab 10mg
1
metoprolol inj 1mg/ml
1
timolol mal tab 20mg
1
metoprolol tab 100mg er
1
timolol mal tab 5mg
1
metoprolol tab 200mg er
1
Calcium Channel Blocking Agents
metoprolol tab 25mg er
1
afeditab tab 30mg cr
1
metoprolol tab 50mg er
1
afeditab tab 60mg cr
1
nadolol tab 20mg
1
amlodipine tab 10mg
1
nadolol tab 40mg
1
amlodipine tab 2.5mg
1
nadolol tab 80mg
1
amlodipine tab 5mg
1
pindolol tab 10mg
1
cartia xt cap 120/24hr
1
pindolol tab 5mg
1
cartia xt cap 180/24hr
1
propranolol cap 120mg er
1
cartia xt cap 240/24hr
1
propranolol cap 160mg er
1
cartia xt cap 300/24hr
1
propranolol cap 60mg er
1
dilt-xr cap 120mg
1
propranolol cap 80mg er
1
dilt-xr cap 180mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
33
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
dilt-xr cap 240mg
1
nisoldipine tab 20mg
1
diltiazem cap 120mg er
1
nisoldipine tab 30mg
1
diltiazem cap 120mg er
1
nisoldipine tab 40mg
1
diltiazem cap 180mg/24
1
taztia xt cap 120mg/24
1
diltiazem cap 240mg cd
1
taztia xt cap 180mg/24
1
diltiazem cap 300mg er
1
taztia xt cap 240mg/24
1
diltiazem cap 360mg/24
1
taztia xt cap 300mg/24
1
diltiazem cap 420mg/24
1
taztia xt cap 360mg/24
1
diltiazem cap 60mg er
1
verapamil cap 100mg er
1
diltiazem cap 90mg er
1
verapamil cap 120mg er
1
diltiazem inj 100mg
1
verapamil cap 180mg er
1
diltiazem inj 50/10ml
1
verapamil cap 200mg er
1
diltiazem tab 120mg
1
verapamil cap 240mg er
1
diltiazem tab 30mg
1
verapamil cap 300mg er
1
diltiazem tab 60mg
1
verapamil cap 360mg sr
1
diltiazem tab 90mg
1
verapamil inj 2.5mg/ml
1
felodipine tab 10mg er
1
verapamil tab 120mg
1
felodipine tab 2.5mg er
1
verapamil tab 120mg er
1
felodipine tab 5mg er
1
verapamil tab 180mg er
1
isradipine cap 2.5mg
1
verapamil tab 240mg er
1
isradipine cap 5mg
1
verapamil tab 40mg
1
nicardipine cap 20mg
1
verapamil tab 80mg
1
nicardipine cap 30mg
1
Cardiovascular Agents, Other
nifedical xl tab 30mg
1
digitek tab 0.125mg
1
PA
nifedical xl tab 60mg
1
digitek tab 0.25mg
1
PA
nifedipine cap 10mg
1
PA
digoxin inj 0.25mg/1
1
nifedipine cap 20mg
1
PA
digoxin sol 50mcg/ml
1
nifedipine tab 30mg er
1
digoxin tab 0.125mg
1
PA QL 30
nifedipine tab 60mg er
1
digoxin tab 0.25mg
1
PA
nifedipine tab 90mg er
1
NORTHERA CAP 100MG
1
PA
nimodipine cap 30mg
1
NORTHERA CAP 200MG
1
PA
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
34
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
NORTHERA CAP 300MG
1
PA
DYRENIUM CAP 100MG
1
pentoxifylli tab 400mg er
1
DYRENIUM CAP 50MG
1
RANEXA TAB 1000MG
1
eplerenone tab 25mg
1
RANEXA TAB 500MG
1
eplerenone tab 50mg
1
reserpine tab 0.1mg
1
PA
spironolact tab 100mg
1
TEKTURNA TAB 150MG
1
spironolact tab 25mg
1
TEKTURNA TAB 300MG
1
spironolact tab 50mg
1
Diuretics, Carbonic Anhydrase Inhibitors
Diuretics, Thiazide
acetazolamid cap 500mg er
1
chlorothiaz tab 250mg
1
acetazolamid tab 125mg
1
chlorothiaz tab 500mg
1
acetazolamid tab 250mg
1
chlorthalid tab 25mg
1
methazolamid tab 25mg
1
CHLORTHALID TAB 50MG
1
methazolamid tab 50mg
1
hydrochlorot cap 12.5mg
1
hydrochlorot tab 12.5mg
1
Diuretics, Loop
bumetanide inj 0.25/ml
1
hydrochlorot tab 25mg
1
bumetanide tab 0.5mg
1
hydrochlorot tab 50mg
1
bumetanide tab 1mg
1
indapamide tab 1.25mg
1
bumetanide tab 2mg
1
indapamide tab 2.5mg
1
furosemide inj 10mg/ml
1
methyclothia tab 5mg
1
furosemide sol 10mg/ml
1
metolazone tab 10mg
1
furosemide sol 8mg/ml
1
metolazone tab 2.5mg
1
furosemide tab 20mg
1
metolazone tab 5mg
1
furosemide tab 40mg
1
Dyslipidemics, Combinations
furosemide tab 80mg
1
VYTORIN TAB 10-10MG
1
torsemide tab 100mg
1
VYTORIN TAB 10-20MG
1
torsemide tab 10mg
1
VYTORIN TAB 10-40MG
1
torsemide tab 20mg
1
VYTORIN TAB 10-80MG
1
torsemide tab 5mg
1
Dyslipidemics, Fibric Acid Derivatives
fenofibrate cap 134mg
1
Diuretics, Potassium-sparing
amiloride tab 5mg
1
fenofibrate cap 150mg
1
DEMSER CAP 250MG
1
fenofibrate cap 200mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
35
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
fenofibrate cap 50mg
1
lovastatin tab 40mg
1
fenofibrate cap 67mg
1
pravastatin tab 10mg
1
fenofibrate tab 145mg
1
pravastatin tab 20mg
1
fenofibrate tab 160mg
1
pravastatin tab 40mg
1
fenofibrate tab 48mg
1
pravastatin tab 80mg
1
fenofibrate tab 54mg
1
simvastatin tab 10mg
1
gemfibrozil tab 600mg
1
simvastatin tab 20mg
1
simvastatin tab 40mg
1
Dyslipidemics, HMG CoA Reductase Inhibitors
ADVICOR TAB 1000-20
1
simvastatin tab 5mg
1
ADVICOR TAB 1000-40
1
simvastatin tab 80mg
1
ADVICOR TAB 500-20MG
1
Dyslipidemics, Other
ADVICOR TAB 750-20MG
1
cholestyram pow 4gm lite
1
ALTOPREV TAB 20MG ER
1
colestipol gra 5gm
1
ALTOPREV TAB 40MG ER
1
colestipol tab 1gm
1
ALTOPREV TAB 60MG ER
1
JUXTAPID CAP 10MG
1
atorvastatin tab 10mg
1
JUXTAPID CAP 20MG
1
atorvastatin tab 20mg
1
JUXTAPID CAP 5MG
1
atorvastatin tab 40mg
1
KYNAMRO INJ 200MG/ML
1
atorvastatin tab 80mg
1
niacin er tab 1000mg
1
CRESTOR TAB 10MG
1
niacin er tab 500mg
1
CRESTOR TAB 20MG
1
niacin er tab 750mg
1
CRESTOR TAB 40MG
1
NIACOR TAB 500MG
1
CRESTOR TAB 5MG
1
omega-3-acid cap 1gm
1
fluvastatin cap 20mg
1
prevalite pow 4gm
1
fluvastatin cap 40mg
1
WELCHOL PAK 3.75GM
1
LESCOL XL TAB 80MG
1
WELCHOL TAB 625MG
1
LIVALO TAB 1MG
1
ZETIA TAB 10MG
1
LIVALO TAB 2MG
1
Vasodilators, Direct-acting Arterial
LIVALO TAB 4MG
1
hydralazine inj 20mg/ml
1
lovastatin tab 10mg
1
hydralazine tab 100mg
1
lovastatin tab 20mg
1
hydralazine tab 10mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
36
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
hydralazine tab 25mg
1
hydralazine tab 50mg
1
minoxidil tab 10mg
1
minoxidil tab 2.5mg
1
Vasodilators, Direct-acting Arterial/Venous
isosorb din tab 10mg
1
isosorb din tab 20mg
1
isosorb din tab 30mg
1
isosorb din tab 40mg er
1
isosorb din tab 5mg
1
isosorb mono tab 10mg
1
isosorb mono tab 120mg er
1
isosorb mono tab 20mg
1
isosorb mono tab 30mg er
1
isosorb mono tab 60mg er
1
minitran dis 0.1mg/hr
1
minitran dis 0.2mg/hr
1
minitran dis 0.4mg/hr
1
minitran dis 0.6mg/hr
1
nitroglycer dis 0.1mg/hr
1
nitroglycer dis 0.2mg/hr
1
nitroglycer dis 0.4mg/hr
1
nitroglycer inj 5mg/ml
1
nitroglyceri dis 0.6mg/hr
1
nitroglycrn spr 0.4mg
1
NITROSTAT SUB 0.3MG
1
NITROSTAT SUB 0.4MG
1
NITROSTAT SUB 0.6MG
1
Notes
Drug Name
Tier
Notes
amphetamine tab 12.5mg
1
amphetamine tab 15mg
1
amphetamine tab 20mg
1
amphetamine tab 30mg
1
amphetamine tab 5mg
1
amphetamine tab 7.5mg
1
dextroamphet cap 10mg er
1
dextroamphet cap 15mg er
1
dextroamphet cap 5mg er
1
dextroamphet tab 10mg
1
dextroamphet tab 5mg
1
Attention Deficit Hyperactivity Disorder Agents, Nonamphetamines
guanfacine tab 1mg er
1
PA
guanfacine tab 2mg er
1
PA
guanfacine tab 3mg er
1
PA
guanfacine tab 4mg er
1
PA
metadate tab 20mg er
1
methylin chw 10mg
1
methylin chw 2.5mg
1
methylin chw 5mg
1
methylphenid cap 10mg
1
methylphenid sol 10mg/5ml
1
methylphenid sol 5mg/5ml
1
methylphenid tab 10mg
1
methylphenid tab 20mg
1
methylphenid tab 20mg er
1
methylphenid tab 27mg er
1
PA
methylphenid tab 5mg
1
CENTRAL NERVOUS SYSTEM AGENTS
STRATTERA CAP 100MG
1
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
STRATTERA CAP 10MG
1
amphetamine tab 10mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
37
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
STRATTERA CAP 18MG
1
TYSABRI INJ 300/15ML
1
BD
STRATTERA CAP 25MG
1
DENTAL AND ORAL AGENTS
STRATTERA CAP 40MG
1
Dental and Oral Agents
STRATTERA CAP 60MG
1
chlorhex glu sol 0.12%
1
STRATTERA CAP 80MG
1
nystatin sus 100000
1
Central Nervous System, Other
periogard sol 0.12%
1
NUEDEXTA CAP 20-10MG
1
pilocarpine tab 5mg
1
riluzole tab 50mg
1
pilocarpine tab 7.5mg
1
XENAZINE TAB 12.5MG
1
triamcin/ora pst 0.1%
1
XENAZINE TAB 25MG
1
DERMATOLOGICAL AGENTS
Fibromyalgia Agents
Dermatological Agents
LYRICA CAP 100MG
1
8-MOP CAP 10MG
1
LYRICA CAP 150MG
1
acitretin cap 10mg
1
SAVELLA MIS TITR PAK
1
acitretin cap 17.5mg
1
SAVELLA TAB 100MG
1
acitretin cap 25mg
1
SAVELLA TAB 12.5MG
1
ala cort cre 1%
1
SAVELLA TAB 25MG
1
amcinonide cre 0.1%
1
SAVELLA TAB 50MG
1
amcinonide lot 0.1%
1
Multiple Sclerosis Agents
amcinonide oin 0.1%
1
AMPYRA TAB 10MG
1
ammonium lac lot 12%
1
AUBAGIO TAB 14MG
1
ST
amnesteem cap 10mg
1
AUBAGIO TAB 7MG
1
ST
amnesteem cap 20mg
1
BETASERON INJ 0.3MG
1
amnesteem cap 40mg
1
COPAXONE INJ 40MG/ML
1
aug betamet lot 0.05%
1
COPAXONE KIT 20MG/ML
1
betameth dip cre 0.05%
1
EXTAVIA INJ 0.3MG
1
betameth dip oin 0.05%
1
GILENYA CAP 0.5MG
1
betameth val cre 0.1%
1
REBIF INJ 22/0.5
1
betameth val lot 0.1%
1
REBIF INJ 44/0.5
1
betameth val oin 0.1%
1
REBIF TITRTN SOL PACK
1
calcipotrien sol 0.005%
1
SOLTAMOX SOL 10MG/5ML
1
ciclopirox cre 0.77%
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
38
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
ciclopirox gel 0.77%
1
diflorasone cre 0.05%
1
ciclopirox sol 8%
1
diflorasone oin 0.05%
1
ciclopirox sus 0.77%
1
econazole cre 1%
1
claravis cap 10mg
1
ELIDEL CRE 1%
1
claravis cap 20mg
1
erythromycin gel /benzoyl
1
claravis cap 30mg
1
erythromycin gel 2%
1
claravis cap 40mg
1
erythromycin sol 2%
1
CLINDACIN KIT PAC 1%
1
EURAX CRE 10%
1
clindamy/ben gel 1-5%
1
fluocin acet cre 0.01%
1
clindamycin gel 1%
1
fluocin acet cre 0.025%
1
clindamycin lot 1%
1
fluocin acet oil body
1
clindamycin pad 1%
1
fluocin acet oin 0.025%
1
clindamycin sol 1%
1
fluocin acet sol 0.01%
1
clobetasol e cre 0.05%
1
fluocinonide cre -e 0.05%
1
clobetasol gel 0.05%
1
fluocinonide gel 0.05%
1
clobetasol oin 0.05%
1
fluocinonide oin 0.05%
1
clobetasol sol 0.05%
1
fluocinonide sol 0.05%
1
clotrim/beta cre diprop
1
FLUOROURACIL CRE 0.5%
1
PA
clotrim/beta lot diprop
1
fluorouracil cre 5%
1
clotrimazole cre 1%
1
fluticasone cre 0.05%
1
clotrimazole sol 1%
1
fluticasone oin 0.005%
1
CONDYLOX GEL 0.5%
1
gentamicin cre 0.1%
1
cormax scalp sol 0.05%
1
gentamicin oin 0.1%
1
desonide cre 0.05%
1
halobetasol cre 0.05%
1
desonide lot 0.05%
1
halobetasol oin 0.05%
1
desonide oin 0.05%
1
hc valerate cre 0.2%
1
desoximetas cre 0.05%
1
hc valerate oin 0.2%
1
desoximetas cre 0.25%
1
hydrocort cre 1%
1
desoximetas gel 0.05%
1
hydrocort cre 2.5%
1
desoximetas oin 0.25%
1
hydrocort lot 2.5%
1
diclofenac gel 3%
1
hydrocort oin 1%
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
39
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
hydrocort oin 2.5%
1
prednicarbat oin 0.1%
1
imiquimod cre 5%
1
procto-pak cre 1%
1
ketoconazole cre 2%
1
proctozone cre -hc 2.5%
1
ketoconazole sha 2%
1
REGRANEX GEL 0.01%
1
PA
lidocaine gel 2% jelly
1
SANTYL OIN 250/GM
1
lidocaine oin 5%
1
selenium sul lot 2.5%
1
lidocaine sol 4%
1
silver sulfa cre 1%
1
LIDODERM DIS 5%
1
PA QL 90
SOLARAZE GEL 3% W/W
1
QL 200
lindane lot 1%
1
ssd cre 1%
1
lindane sha 1%
1
sulfacetamid sus 10%
1
lokara lot 0.05%
1
TAZORAC CRE 0.05%
1
methoxsalen cap 10mg
1
TAZORAC CRE 0.1%
1
metronidazol cre 0.75%
1
TAZORAC GEL 0.05%
1
metronidazol gel 0.75%
1
TAZORAC GEL 0.1%
1
metronidazol lot 0.75%
1
triamcinolon cre 0.025%
1
mometasone cre 0.1%
1
triamcinolon cre 0.1%
1
mometasone oin 0.1%
1
triamcinolon cre 0.5%
1
mupirocin oin 2%
1
triamcinolon lot 0.025%
1
nyamyc pow 100000
1
triamcinolon lot 0.1%
1
nystat/triam cre
1
triamcinolon oin 0.025%
1
nystat/triam oin
1
triamcinolon oin 0.1%
1
nystatin cre 100000
1
triamcinolon oin 0.5%
1
nystatin oin 100000
1
triderm cre 0.1%
1
nystatin pow 100000
1
u-cort cre 1%
1
nystop pow 100000
1
VALCHLOR GEL 0.016%
1
PANRETIN GEL 0.1%
1
VOLTAREN GEL 1%
1
permethrin cre 5%
1
ENZYME REPLACEMENT/ MODIFIERS
PICATO GEL 0.015%
1
Enzyme Replacement/ Modifiers
PICATO GEL 0.05%
1
ADAGEN INJ 250/ML
1
LA
podofilox sol 0.5%
1
ALDURAZYME INJ 2.9MG/5M
1
LA BD
prednicarbat cre 0.1%
1
CEREZYME INJ 400UNIT
1
LA BD
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
40
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
CREON CAP 36000UNT
CYSTADANE POW
ELAPRASE INJ 6MG/3ML
FABRAZYME INJ 35MG
KUVAN TAB 100MG
levocarnitin inj 200mg/ml
levocarnitin sol 1gm/10ml
levocarnitin tab 330mg
LUMIZYME INJ 50MG
NAGLAZYME INJ 1MG/ML
ORFADIN CAP 10MG
ORFADIN CAP 2MG
ORFADIN CAP 5MG
ZAVESCA CAP 100MG
ZENPEP CAP 10000UNT
ZENPEP CAP 15000UNT
ZENPEP CAP 20000UNT
ZENPEP CAP 25000UNT
ZENPEP CAP 3000UNIT
ZENPEP CAP 5000UNIT
Tier
Notes
Drug Name
Tier
Notes
1
FULYZAQ TAB 125MG
1
PA
1
loperamide cap 2mg
1
1
BD
metoclopram inj 5mg/ml
1
1
LA BD
metoclopram sol 5mg/5ml
1
1
LA
metoclopram tab 10mg
1
1
RELISTOR INJ 12/0.6ML
1
1
RELISTOR INJ 12/0.6ML
1
1
RELISTOR INJ 8/0.4ML
1
1
ursodiol tab 250mg
1
1
BD
ursodiol tab 500mg
1
1
Histamine2 (H2) Receptor Antagonists
1
famotidine inj 10mg/ml
1
1
FAMOTIDINE INJ 20MG/50M
1
1
famotidine tab 20mg
1
1
famotidine tab 40mg
1
1
ranitidine cap 150mg
1
1
ranitidine cap 300mg
1
1
ranitidine inj 150/6ml
1
1
ranitidine syp 15mg/ml
1
1
ranitidine tab 150mg
1
ranitidine tab 300mg
1
GASTROINTESTINAL AGENTS
Irritable Bowel Syndrome Agents
Antispasmodics, Gastrointestinal
AMITIZA CAP 24MCG
1
atropine sul inj 0.05mg/1
1
AMITIZA CAP 8MCG
1
atropine sul inj 0.1mg/ml
1
LOTRONEX
TAB
0.5MG
1
dicyclomine cap 10mg
1
LOTRONEX TAB 1MG
1
dicyclomine sol 10mg/5ml
1
Laxatives
dicyclomine tab 20mg
1
constulose sol 10gm/15
1
methscopolam tab 2.5mg
1
enulose sol 10gm/15
1
Gastrointestinal Agents, Other
generlac sol 10gm/15
1
diphen/atrop liq 2.5/5
1
lactulose sol 10gm/15
1
diphen/atrop tab 2.5mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
41
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
polyeth glyc pow 3350 nf
PREPOPIK PAK
Protectants
CARAFATE SUS 1GM/10ML
misoprostol tab 100mcg
misoprostol tab 200mcg
sucralfate tab 1gm
Proton Pump Inhibitors
DEXILANT CAP 30MG DR
DEXILANT CAP 60MG DR
esomepra mag cap 40mg dr
ESOMEPRAZOLE CAP 49.3MG
omeprazole cap 10mg
omeprazole cap 20mg
omeprazole cap 40mg
Tier
Notes
Drug Name
Tier
Notes
1
AVODART CAP 0.5MG
1
1
CIALIS TAB 2.5MG
1
PA QL 30
CIALIS TAB 5MG
1
PA QL 30
1
finasteride tab 5mg
1
1
JALYN CAP
1
1
RAPAFLO CAP 4MG
1
1
RAPAFLO CAP 8MG
1
tamsulosin cap 0.4mg
1
1
Genitourinary Agents, Other
1
CYSTAGON CAP 150MG
1
1
CYSTAGON CAP 50MG
1
1
ELMIRON CAP 100MG
1
1
neo/poly gu sol 40/ml ir
1
1
sodium chlor sol 0.9% irr
1
1
Phosphate Binders
AURYXIA TAB 210MG
1
GENITOURINARY AGENTS
calc acetate cap 667mg
1
Antispasmodics, Urinary
FOSRENOL CHW 1000MG
1
ENABLEX TAB 15MG
1
ST
FOSRENOL CHW 500MG
1
ENABLEX TAB 7.5MG
1
ST
FOSRENOL CHW 750MG
1
MYRBETRIQ TAB 25MG
1
ST
RENVELA PAK 0.8GM
1
MYRBETRIQ TAB 50MG
1
ST
RENVELA PAK 2.4GM
1
oxybutynin syp 5mg/5ml
1
RENVELA
TAB
800MG
1
oxybutynin tab 10mg er
1
Vaginal Products
oxybutynin tab 15mg er
1
clindamycin cre 2% vag
1
oxybutynin tab 5mg
1
metronidazol gel 0.75%vag
1
oxybutynin tab 5mg er
1
miconazole
3
sup
200mg
1
tolterodine tab 1mg
1
PREMARIN VAG CRE 0.625MG
1
tolterodine tab 2mg
1
terconazole cre 0.4%
1
VESICARE TAB 10MG
1
terconazole sup 80mg
1
VESICARE TAB 5MG
1
vandazole gel 0.75%
1
Benign Prostatic Hypertrophy Agents
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
42
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
zazole cre 0.4%
zazole cre 0.8%
Tier
Notes
1
1
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/
MODIFYING (ADRENAL)
Drug Name
prednisolone sol 25mg/5ml
prednisolone tab 10mg odt
prednisolone tab 15mg odt
prednisolone tab 30mg odt
prednisone sol 5mg/5ml
prednisone tab 10mg
prednisone tab 1mg
prednisone tab 2.5mg
prednisone tab 20mg
prednisone tab 50mg
prednisone tab 5mg
triamcin ace inj 10mg/ml
triamcin ace inj 40mg/ml
UCERIS TAB 9MG
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Notes
Glucocorticoids/Mineralocorticoids
budesonide cap 3mg/24hr
1
dexameth pho inj 10mg/ml
1
dexameth pho inj 120mg/30
1
dexamethason elx 0.5/5ml
1
dexamethason tab 0.5mg
1
dexamethason tab 0.75mg
1
dexamethason tab 1.5mg
1
dexamethason tab 1mg
1
ST
dexamethason tab 2mg
1
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/
dexamethason tab 4mg
1
dexamethason tab 6mg
1
MODIFYING (SEX HORMONES/ MODIFIERS)
fludrocort tab 0.1mg
1
Anabolic Steroids
hydrocort tab 10mg
1
oxandrolone tab 10mg
1
hydrocort tab 5mg
1
oxandrolone tab 2.5mg
1
methylpr ace inj 40mg/ml
1
Androgens
methylpr ace inj 80mg/ml
1
ANDRODERM DIS 2MG/24HR
1
methylpr ss inj 125mg
1
ANDRODERM DIS 4MG/24HR
1
methylpr ss inj 40mg
1
ANDROID CAP 10MG
1
PA
methylpred pak 4mg
1
danazol cap 100mg
1
methylpred tab 16mg
1
danazol cap 200mg
1
methylpred tab 32mg
1
danazol cap 50mg
1
methylpred tab 4mg
1
testost cyp inj 200mg/ml
1
methylpred tab 8mg
1
testost enan inj 200mg/ml
1
ORAPRED ODT TAB 10MG
1
TESTRED CAP 10MG
1
PA
pred sod pho sol 5mg/5ml
1
Contraceptives
prednisolone sol 15mg/5ml
1
ELLA TAB 30MG
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
43
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
lyza tab 0.35mg
1
medroxypr ac tab 5mg
1
medroxypr ac inj 150mg/ml
1
norethin ace tab 5mg
1
norethindron tab 0.35mg
1
Selective Estrogen Receptor Modifying Agents
pirmella tab 1/35
1
raloxifene tab 60mg
1
tri-previfem tab
1
HORMONAL AGENTS, STIMULANT/REPLACEMENT/
tri-sprintec tab
1
MODIFYING (PITUITARY)
trinessa tab
1
Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary)
vyfemla tab 0.4-35
1
cabergoline tab 0.5mg
1
Estrogens
chor gonadot inj 10000unt
1
DELESTROGEN INJ 10MG/ML
1
PA
desmopressin inj 4mcg/ml
1
estradiol tab 0.5mg
1
PA
desmopressin sol 0.01%
1
estradiol tab 1mg
1
PA
desmopressin spr 0.01%
1
estradiol tab 2mg
1
PA
desmopressin tab 0.1mg
1
MENEST TAB 0.3MG
1
PA
desmopressin tab 0.2mg
1
MENEST TAB 0.625MG
1
PA
HUMATROPE INJ 12MG
1
PA
MENEST TAB 1.25MG
1
PA
HUMATROPE INJ 24MG
1
PA
MENEST TAB 2.5MG
1
PA
INCRELEX INJ 40MG/4ML
1
LA
PREMARIN INJ 25MG
1
NUTROPIN AQ INJ 20MG/2ML
1
PA
PREMARIN TAB 0.3MG
1
PA
NUTROPIN AQ INJ NUSPIN 5
1
PA
PREMARIN TAB 0.45MG
1
PA
SAIZEN INJ 5MG
1
PA
PREMARIN TAB 0.625MG
1
PA
SAIZEN INJ 8.8MG
1
PA
PREMARIN TAB 0.9MG
1
PA
SAIZEN INJ 8.8MG
1
PA
PREMARIN TAB 1.25MG
1
PA
HORMONAL AGENTS, STIMULANT/REPLACEMENT/
PREMPHASE TAB
1
PA
MODIFYING (THYROID)
PREMPRO TAB .625-2.5
1
PA
Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid)
PREMPRO TAB 0.3-1.5
1
PA
levothyroxin tab 100mcg
1
PREMPRO TAB 0.45-1.5
1
PA
levothyroxin tab 112mcg
1
PREMPRO TAB 0.625-5
1
levothyroxin tab 125mcg
1
Progestins
levothyroxin tab 137mcg
1
medroxypr ac tab 10mg
1
levothyroxin tab 150mcg
1
medroxypr ac tab 2.5mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
44
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
levothyroxin tab 175mcg
1
SYNTHROID TAB 75MCG
1
levothyroxin tab 200mcg
1
SYNTHROID TAB 88MCG
1
levothyroxin tab 25mcg
1
unithroid tab 100mcg
1
levothyroxin tab 300mcg
1
unithroid tab 112mcg
1
levothyroxin tab 50mcg
1
unithroid tab 125mcg
1
levothyroxin tab 75mcg
1
unithroid tab 150mcg
1
levothyroxin tab 88mcg
1
unithroid tab 175mcg
1
levoxyl tab 100mcg
1
unithroid tab 200mcg
1
levoxyl tab 112mcg
1
unithroid tab 25mcg
1
levoxyl tab 125mcg
1
unithroid tab 300mcg
1
levoxyl tab 137mcg
1
unithroid tab 50mcg
1
levoxyl tab 150mcg
1
unithroid tab 75mcg
1
levoxyl tab 175mcg
1
unithroid tab 88mcg
1
levoxyl tab 200mcg
1
HORMONAL AGENTS, SUPPRESSANT
levoxyl tab 25mcg
1
(PARATHYROID)
levoxyl tab 50mcg
1
Hormonal Agents, Suppressant (Parathyroid)
levoxyl tab 75mcg
1
SENSIPAR TAB 30MG
1
levoxyl tab 88mcg
1
SENSIPAR TAB 60MG
1
liothyronine tab 25mcg
1
SENSIPAR TAB 90MG
1
liothyronine tab 50mcg
1
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
liothyronine tab 5mcg
1
Hormonal Agents, Suppressant (Pituitary)
SYNTHROID TAB 100MCG
1
KORLYM TAB 300MG
1
PA LA
SYNTHROID TAB 112MCG
1
LUPR DEP-PED INJ 11.25MG
1
SYNTHROID TAB 125MCG
1
LUPR DEP-PED INJ 15MG
1
SYNTHROID TAB 137MCG
1
LUPRON DEPOT INJ 11.25MG
1
SYNTHROID TAB 150MCG
1
octreotide inj 1000mcg
1
SYNTHROID TAB 175MCG
1
octreotide inj 100mcg
1
SYNTHROID TAB 200MCG
1
octreotide inj 200mcg
1
SYNTHROID TAB 25MCG
1
octreotide inj 500mcg
1
SYNTHROID TAB 300MCG
1
octreotide inj 50mcg/ml
1
SYNTHROID TAB 50MCG
1
SANDOSTATIN KIT LAR 10MG
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
45
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
SANDOSTATIN KIT LAR 20MG
SANDOSTATIN KIT LAR 30MG
SIGNIFOR INJ 0.3MG/ML
SIGNIFOR INJ 0.6MG/ML
SIGNIFOR INJ 0.9MG/ML
SOMATULINE INJ 120/.5ML
SOMATULINE INJ 60/0.2ML
SOMATULINE INJ 90/0.3ML
SOMAVERT INJ 10MG
SOMAVERT INJ 15MG
SOMAVERT INJ 20MG
SYNAREL SOL 2MG/ML
Tier
Notes
Drug Name
Tier
Notes
1
cyclosporine sol modified
1
BD
1
ENBREL INJ 25/0.5ML
1
1
ENBREL INJ 25MG
1
1
ENBREL INJ 50MG/ML
1
1
gengraf cap 100mg
1
BD
1
gengraf cap 25mg
1
BD
1
gengraf sol 100mg/ml
1
BD
1
HUMIRA INJ 10MG/0.2
1
1
LA
HUMIRA KIT 20MG/0.4
1
1
LA
HUMIRA KIT 40MG/0.8
1
1
LA
HUMIRA PEN KIT CROHNS
1
1
KINERET INJ
1
mycophenolat cap 250mg
1
BD
HORMONAL AGENTS, SUPPRESSANT (THYROID)
mycophenolat
sus
200mg/ml
1
BD
Antithyroid Agents
mycophenolat tab 500mg
1
BD
methimazole tab 10mg
1
mycophenolic
tab
180mg
dr
1
BD
methimazole tab 5mg
1
mycophenolic tab 360mg dr
1
BD
propylthiour tab 50mg
1
NULOJIX
INJ
250MG
1
BD
IMMUNOLOGICAL AGENTS
PROGRAF INJ 5MG/ML
1
BD
Immune Suppressants
RAPAMUNE
SOL
1MG/ML
1
BD
ASTAGRAF XL CAP 0.5MG
1
BD
REMICADE INJ 100MG
1
BD
ASTAGRAF XL CAP 1MG
1
BD
SANDIMMUNE
CAP
100MG
1
BD
ASTAGRAF XL CAP 5MG
1
BD
SANDIMMUNE
CAP
25MG
1
BD
azathioprine tab 50mg
1
BD
SANDIMMUNE SOL 100MG/ML
1
BD
BENLYSTA INJ 120MG
1
BD
SIMULECT
INJ
20MG
1
PA
CELLCEPT IV INJ 500MG
1
BD
sirolimus tab 0.5mg
1
BD
cyclosporine cap 100mg
1
BD
sirolimus
tab
1mg
1
BD
cyclosporine cap 100mg md
1
BD
sirolimus tab 2mg
1
BD
cyclosporine cap 25mg
1
BD
tacrolimus
cap
0.5mg
1
BD
cyclosporine cap 25mg mod
1
BD
tacrolimus cap 1mg
1
BD
cyclosporine cap 50mg mod
1
BD
tacrolimus
cap
5mg
1
BD
cyclosporine inj 50mg/ml
1
BD
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
46
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
TREXALL TAB 10MG
1
BD
BEXSERO INJ
1
TREXALL TAB 15MG
1
BD
BOOSTRIX INJ
1
TREXALL TAB 5MG
1
BD
BOOSTRIX INJ
1
TREXALL TAB 7.5MG
1
BD
CERVARIX INJ
1
ZORTRESS TAB 0.25MG
1
BD
COMVAX INJ
1
ZORTRESS TAB 0.5MG
1
BD
DAPTACEL INJ
1
ZORTRESS TAB 0.75MG
1
BD
DIP/TET PED INJ 25-5LFU
1
ENGERIX-B INJ 10/0.5ML
1
BD
Immunizing Agents, Passive
ATGAM INJ 250MG
1
BD
ENGERIX-B INJ 10/0.5ML
1
BD
BIVIGAM INJ 10%
1
BD
ENGERIX-B INJ 20MCG/ML
1
BD
CARIMUNE NF INJ 6GM
1
BD
GARDASIL 9 INJ
1
FLEBOGAMMA INJ DIF 10%
1
GARDASIL 9 INJ
1
GAMASTAN S/D INJ
1
PA
GARDASIL INJ
1
GAMMAGARD INJ 2.5GM/25
1
BD
GARDASIL INJ
1
GAMMAKED INJ 1GM/10ML
1
HAVRIX INJ 1440UNIT
1
GAMMAPLEX INJ 10GM
1
BD
HAVRIX INJ 720UNIT
1
GAMUNEX-C INJ 1GM/10ML
1
PA
IMOVAX RABIE INJ 2.5/ML
1
BD
PRIVIGEN INJ 20GRAMS
1
PA
INFANRIX INJ
1
SYNAGIS INJ 50MG
1
IPOL INJ INACTIVE
1
THYMOGLOBULN INJ 25MG
1
BD
IPOL INJ INACTIVE
1
IXIARO INJ
1
Immunomodulators
ARCALYST INJ 220MG
1
BD
M-M-R II INJ LIVE
1
ILARIS INJ 180MG
1
MENACTRA INJ
1
leflunomide tab 10mg
1
MENOMUNE INJ A/C/Y/W
1
leflunomide tab 20mg
1
MENVEO INJ
1
ORENCIA INJ 125MG/ML
1
PEDVAX HIB INJ
1
ORENCIA INJ 250MG
1
PROQUAD INJ
1
QUADRACEL INJ
1
Vaccines
ACTHIB INJ
1
RABAVERT INJ
1
BD
ADACEL INJ
1
RECOMBIVA HB INJ 10MCG/ML
1
BD
BCG VACCINE INJ
1
RECOMBIVA HB INJ 10MCG/ML
1
BD
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
47
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
RECOMBIVA HB INJ 5MCG/0.5
RECOMBIVA-HB INJ 40MCG/ML
ROTARIX SUS
ROTATEQ SOL
TENIVAC INJ 5-2LF
TET/DIP TOX INJ 2-2 LF
TETANUS TOX INJ 5LF ADS
TRUMENBA INJ
TWINRIX INJ
TYPHIM VI INJ
TYPHIM VI INJ
VAQTA INJ 25/0.5ML
VAQTA INJ 25/0.5ML
VAQTA INJ 50UNT/ML
VARIVAX INJ
YF-VAX INJ
ZOSTAVAX INJ
Tier
Notes
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
BD
BD
INFLAMMATORY BOWEL DISEASE AGENTS
Aminosalicylates
APRISO CAP 0.375GM
ASACOL HD TAB 800MG
balsalazide cap 750mg
DIPENTUM CAP 250MG
mesalamine kit 4gm
Sulfonamides
sulfasalazin tab 500mg
sulfazine ec tab 500mg
1
1
1
1
1
1
1
BD
Drug Name
alendronate tab 40mg
alendronate tab 5mg
alendronate tab 70mg
ATELVIA TAB
calcitonin spr 200/act
calcitriol cap 0.25mcg
calcitriol cap 0.5mcg
calcitriol inj 1mcg/ml
calcitriol sol 1mcg/ml
FORTEO SOL 600/2.4
FOSAMAX + D TAB 70-2800
FOSAMAX + D TAB 70-5600
MIACALCIN INJ 200/ML
pamidronate inj 30/10ml
pamidronate inj 6mg/ml
pamidronate inj 90/10ml
PARICALCITOL INJ 2MCG/ML
PARICALCITOL INJ 5MCG/ML
PROLIA SOL 60MG/ML
RECLAST INJ 5/100ML
XGEVA INJ
ZEMPLAR CAP 1MCG
ZEMPLAR CAP 2MCG
zoledronic inj 4mg/5ml
ZOMETA INJ 4MG/100
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Notes
BD
QL 4
BD
BD
BD
BD
BD
PA
MISCELLANEOUS
Miscellaneous
EPIPEN 2-PAK INJ 0.3MG
1
EPIPEN-JR
INJ
2-PAK
1
Metabolic Bone Disease Agents
FETZIMA CAP TITRATIO
1
alendronate tab 10mg
1
FIRAZYR
INJ
30MG/3ML
1
alendronate tab 35mg
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
48
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
METABOLIC BONE DISEASE AGENTS
Drug Name
lactated rin sol irrigat
physiolyte sol
physiosol sol irrigat
ringers irr sol
Tier
Notes
Drug Name
Tier
Notes
1
azelastine dro 0.05%
1
1
cromolyn sod sol 4% op
1
1
PATADAY SOL 0.2%
1
1
PATANOL SOL 0.1% OP
1
Ophthalmic
Anti-inflammatories
OPHTHALMIC AGENTS
dexameth pho sol 0.1% op
1
Ophthalmic Prostaglandin and Prostamide Analogs
diclofenac
sol
0.1%
op
1
latanoprost sol 0.005%
1
DUREZOL EMU 0.05%
1
LUMIGAN SOL 0.01%
1
flurbiprofen sol 0.03% op
1
TRAVATAN Z DRO 0.004%
1
ketorolac sol 0.4%
1
Ophthalmic Agents, Other
ketorolac sol 0.5%
1
atropine sul sol 1% op
1
neo/poly/bac
oin
/hc
1%op
1
naphazoline sol 0.1% op
1
neo/poly/dex oin 0.1% op
1
RESTASIS EMU 0.05%
1
neo/poly/dex
sus
0.1%
op
1
Ophthalmic Anti Infectives
neo/poly/hc sus op
1
bacit/polymy oin op
1
NEVANAC
SUS
0.1%
1
bacitracin oin op
1
pred sod pho sol 1% op
1
ciprofloxacn sol 0.3% op
1
prednisolone sus 1% op
1
erythromycin oin op
1
sulf/pred na sol op
1
gentak oin 0.3% op
1
tobra/dexame sus 0.3-0.1%
1
gentamicin sol 0.3% op
1
Ophthalmic Antiglaucoma Agents
MOXEZA SOL 0.5%
1
ALPHAGAN P SOL 0.1%
1
neo/bac/poly oin op
1
apraclonidin
sol
0.5%
op
1
neo/poly/gra sol op
1
AZOPT SUS 1% OP
1
ofloxacin dro 0.3% op
1
betaxolol
sol
0.5%
op
1
polymyxin b/ sol trimethp
1
brimonidine sol 0.15%
1
sod sulfacet sol 10% op
1
brimonidine
sol
0.2%
op
1
tobramycin sol 0.3% op
1
carteolol sol 1% op
1
trifluridine sol 1% op
1
COMBIGAN SOL 0.2/0.5%
1
VIGAMOX DRO 0.5%
1
dorzol/timol sol 2-0.5%op
1
ZIRGAN GEL 0.15%
1
dorzolamide sol 2% op
1
Ophthalmic Anti-allergy Agents
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
49
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
levobunolol sol 0.5% op
1
metipranolol sol 0.3% oph
1
PHOSPHOLINE SOL 0.125%OP
1
timolol gel sol 0.25% op
1
timolol gel sol 0.5% op
1
timolol mal sol 0.25% op
1
timolol mal sol 0.5% op
1
Ophthalmic Prostaglandin and Prostamide Analogs
BIMATOPROST SOL 0.03%
1
Notes
Drug Name
Tier
Notes
desloratadin tab 5mg
1
diphenhydram inj 50mg/ml
1
stavudine sol 1mg/ml
1
Antileukotrienes
montelukast chw 4mg
1
montelukast chw 5mg
1
montelukast gra 4mg
1
montelukast tab 10mg
1
zafirlukast tab 10mg
1
zafirlukast tab 20mg
1
OTIC AGENTS
ZYFLO CR TAB 600MG
1
Otic Agents
ZYFLO
TAB
600MG
1
acetic acid sol 2% otic
1
Bronchodilators, Anticholinergic
CIPRODEX SUS 0.3-0.1%
1
ATROVENT HFA AER 17MCG
1
fluocin acet oil 0.01%
1
ipratropium sol 0.02%inh
1
BD
neo/poly/hc sol 1% otic
1
SPIRIVA
CAP
HANDIHLR
1
neo/poly/hc sus 1% otic
1
SPIRIVA SPR RESPIMAT
1
ofloxacin dro 0.3%otic
1
Bronchodilators,
Phosphodiesterase
Inhibitors
(Xanthines)
RESPIRATORY TRACT AGENTS
aminophyllin inj 25mg/ml
1
Anti-inflammatories, Inhaled Corticosteroids
theophylline
tab
100mg
cr
1
FLOVENT DISK AER 100MCG
1
theophylline tab 200mg cr
1
FLOVENT DISK AER 250MCG
1
theophylline
tab
300mg
er
1
FLOVENT DISK AER 50MCG
1
theophylline
tab
450mg
er
1
FLOVENT HFA AER 110MCG
1
theophylline tab 600mg er
1
FLOVENT HFA AER 220MCG
1
Bronchodilators,
Sympathomimetic
FLOVENT HFA AER 44MCG
1
ADVAIR DISKU AER 100/50
1
QVAR AER 40MCG
1
ADVAIR
DISKU
AER
250/50
1
QVAR AER 80MCG
1
ADVAIR DISKU AER 500/50
1
Antihistamines
ADVAIR
HFA
AER
115/21
1
cetirizine syp 1mg/ml
1
ADVAIR HFA AER 230/21
1
cyproheptad tab 4mg
1
PA
ADVAIR
HFA
AER
45/21
1
desloratadin tab 2.5 odt
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
50
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
albuterol neb 0.083%
1
BD
LETAIRIS TAB 5MG
1
albuterol neb 0.5%
1
BD
OPSUMIT TAB 10MG
1
albuterol neb 0.63mg/3
1
BD
REVATIO INJ
1
PA
albuterol neb 1.25mg/3
1
BD
sildenafil tab 20mg
1
PA
albuterol syp 2mg/5ml
1
TRACLEER TAB 125MG
1
LA
albuterol tab 2mg
1
TRACLEER TAB 62.5MG
1
LA
albuterol tab 4mg
1
VENTAVIS SOL 10MCG/ML
1
BD
albuterol tab 4mg er
1
VENTAVIS SOL 20MCG/ML
1
BD
albuterol tab 8mg er
1
Respiratory Tract Agents, Other
ANORO ELLIPT AER 62.5-25
1
DALIRESP TAB 500MCG
1
BREO ELLIPTA INH 100-25
1
ESBRIET CAP 267MG
1
PA
COMBIVENT AER RESPIMAT
1
KALYDECO PAK 50MG
1
PA
ipratropium/ sol albuter
1
BD
KALYDECO PAK 75MG
1
PA
PROAIR HFA AER
1
KALYDECO TAB 150MG
1
PA
SEREVENT DIS AER 50MCG
1
PROLASTIN-C INJ 1000MG
1
BD
SYMBICORT AER 160-4.5
1
PULMOZYME SOL 1MG/ML
1
BD
SYMBICORT AER 80-4.5
1
XOLAIR SOL 150MG
1
LA
terbutaline inj 1mg/ml
1
SKELETAL MUSCLE RELAXANTS
VENTOLIN HFA AER
1
Skeletal Muscle Relaxants
Mast Cell Stabilizers
baclofen tab 10mg
1
CROMOLYN SOD NEB 20MG/2ML
1
BD
baclofen tab 20mg
1
Nasal Agents
cyclobenzapr tab 10mg
1
PA
azelastine spr 0.1%
1
cyclobenzapr tab 5mg
1
PA
azelastine spr 0.15%
1
methocarbam tab 500mg
1
PA
flunisolide spr 0.025%
1
methocarbam tab 750mg
1
PA
fluticasone spr 50mcg
1
orphenadrine inj 30mg/ml
1
PA
ipratropium spr 0.03%
1
orphenadrine tab 100mg er
1
PA
ipratropium spr 0.06%
1
tizanidine tab 2mg
1
TYZINE PED DRO 0.05%
1
tizanidine tab 4mg
1
Pulmonary Antihypertensives
SLEEP DISORDER AGENTS
LETAIRIS TAB 10MG
1
Barbiturates
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
51
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
BUTISOL SOD TAB 30MG
SECONAL CAP 100MG
Benzodiazepines
estazolam tab 1mg
estazolam tab 2mg
flurazepam cap 15mg
flurazepam cap 30mg
temazepam cap 15mg
temazepam cap 22.5mg
temazepam cap 30mg
temazepam cap 7.5mg
triazolam tab 0.125mg
triazolam tab 0.25mg
GABA Receptor Modulators
ROZEREM TAB 8MG
zaleplon cap 10mg
zaleplon cap 5mg
zolpidem tab 10mg
zolpidem tab 5mg
Sleep Disorders, Other
modafinil tab 100mg
modafinil tab 200mg
XYREM SOL 500MG/ML
Tier
Notes
Drug Name
Tier
Notes
1
PA
SAMSCA TAB 30MG
1
PA
1
PA
sod poly sul sus 15gm/60
1
Electrolyte/Mineral Replacement
1
QL 60
CARBAGLU TAB 200MG
1
1
QL 30
D10W/NACL INJ 0.2%
1
1
QL 60
d2.5w/nacl inj 0.45%
1
1
QL 30
d5w/lr inj
1
1
QL 30
d5w/nacl inj 0.2%
1
1
QL 30
d5w/nacl inj 0.33%
1
1
QL 30
d5w/nacl inj 0.45%
1
1
QL 120
d5w/nacl inj 0.9%
1
1
QL 30
ISOLYTE-P INJ /D5W
1
1
QL 60
ISOLYTE-S INJ
1
kcl in nacl inj
1
1
kcl/d5w inj 0.15%
1
1
PA
kcl/d5w inj 0.3%
1
1
kcl/d5w/lr inj 0.15%
1
1
PA
kcl/d5w/nacl inj .075/.45
1
1
PA
kcl/d5w/nacl inj .15/.33%
1
kcl/d5w/nacl inj .15/.45%
1
1
PA
kcl/d5w/nacl inj .22/.45
1
1
PA
kcl/d5w/nacl inj 0.15/0.2
1
1
LA
kcl/d5w/nacl inj 0.15/0.2
1
kcl/d5w/nacl inj 0.3/0.45
1
THERAPEUTIC NUTRIENTS/ MINERALS/
KCL/NACL
INJ
0.15-0.9
1
ELECTROLYTES
klor-con 10 tab 10meq er
1
Electrolyte/Mineral Modifiers
klor-con
8
tab
8meq
er
1
EXJADE TAB 125MG
1
klor-con m20 tab 20meq er
1
EXJADE TAB 250MG
1
lactated
rin
inj
1
EXJADE TAB 500MG
1
magnesium su inj 50%
1
kionex pow
1
magnesium
su
inj
50%
1
SAMSCA TAB 15MG
1
PA
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
52
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
Tier
Notes
Drug Name
Tier
Notes
normosol -m inj /d5w
1
AMINOSYN II INJ 8.5%
1
BD
NORMOSOL -R INJ /D5W
1
aminosyn ii inj 8.5/lyte
1
BD
NORMOSOL-R INJ PH 7.4
1
aminosyn inj 8.5/lyte
1
BD
PLASMA-LYTE INJ -148
1
AMINOSYN M INJ 3.5%
1
BD
PLASMA-LYTE INJ 56/D5W
1
AMINOSYN-HBC INJ 7%
1
BD
pot chloride cap 10meq er
1
AMINOSYN-PF INJ 10%
1
BD
pot chloride cap 8meq er
1
AMINOSYN-PF INJ 7%
1
BD
POT CHLORIDE INJ 10MEQ
1
AMINOSYN-RF INJ 5.2%
1
BD
pot chloride inj 20meq
1
CLINIMIX E INJ 2.75/D10
1
BD
pot chloride inj 2meq/ml
1
CLINIMIX E INJ 2.75/D5W
1
BD
POT CHLORIDE INJ 40MEQ
1
CLINIMIX E INJ 4.25/D10
1
BD
pot chloride liq 10%
1
CLINIMIX E INJ 4.25/D25
1
BD
pot chloride liq 20%
1
CLINIMIX E INJ 4.25/D5W
1
BD
pot chloride tab 8meq er
1
CLINIMIX E INJ 5%/D15W
1
BD
pot citrate tab 1080mg
1
CLINIMIX E INJ 5%/D20W
1
BD
pot citrate tab 1620mg
1
CLINIMIX E INJ 5%/D25W
1
BD
pot citrate tab 540mg er
1
CLINIMIX INJ 2.75/D5W
1
BD
pot cl micro tab 10meq er
1
CLINIMIX INJ 4.25/D10
1
BD
pot cl micro tab 20meq er
1
CLINIMIX INJ 4.25/D20
1
BD
ringers inj
1
CLINIMIX INJ 4.25/D25
1
BD
sod chloride inj 0.45%
1
CLINIMIX INJ 4.25/D5W
1
BD
sod chloride inj 0.9%
1
CLINIMIX INJ 5%/D15W
1
BD
sod chloride inj 2.5/ml
1
CLINIMIX INJ 5%/D20W
1
BD
sod chloride inj 3%
1
CLINIMIX INJ 5%/D25W
1
BD
sod chloride inj 5%
1
dextrose inj 10%
1
BD
SOD LACTATE INJ 5MEQ/ML
1
dextrose inj 5%
1
BD
tpn electrol inj
1
FREAMINE HBC INJ 6.9%
1
BD
hepatamine sol 8%
1
BD
Nutrients
AMINOSYN 7% INJ /LYTES
1
BD
intralipid inj 20%
1
BD
AMINOSYN II INJ 10%
1
BD
NEPHRAMINE INJ 5.4%
1
BD
AMINOSYN II INJ 7%
1
BD
premasol sol 6%
1
BD
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
53
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
Drug Name
PROCALAMINE INJ 3%
PROSOL INJ 20%
TRAVASOL INJ 10%
Vitamins
PRENATAL VITAMIN TABLET
SODIUM FLUORIDE 2.2 MG
Tier
Notes
1
1
1
BD
BD
BD
Drug Name
Tier
Notes
1
1
PA=Prior Authorization Required; ST=Step Therapy Exception Required; QL=Quantity Limit, dispense limit for 30 days, unless otherwise
54
noted; LA=Limited Access, This prescription may be available only at certain pharmacies. For more information consult your Pharmacy
Directory or call Member Services at 1-855-522-2870, Monday through Sunday, 8 a.m.to 8 p.m. from October 1, 2014 to February 14, 2015, and
Monday through Friday, 8.a.m. to 5 p.m. from February 15, 2015 to September 30, 2015. TTY/TDD users should call 1-855-522-2973 during the
same business hours.
Formulary last updated date: 06/24/2015
8
8-mop cap 10mg ....................................... 38
A
abacav/lamiv tab /zidovud ........................ 23
abacavir tab 300mg ................................... 23
abelcet inj 5mg/ml..................................... 13
abilify disc tab 10mg ................................. 21
abilify disc tab 15mg ................................. 21
abilify inj 9.75mg ...................................... 21
abilify main inj 300mg .............................. 21
abilify main inj 400mg .............................. 21
abilify tab 10mg ........................................ 21
abilify tab 15mg ........................................ 21
abilify tab 20mg ........................................ 21
abilify tab 2mg .......................................... 21
abilify tab 30mg ........................................ 21
abilify tab 5mg .......................................... 21
abraxane inj 100mg ................................... 15
acampro cal tab 333mg ............................... 3
acarbose tab 100mg................................... 26
acarbose tab 25mg..................................... 26
acarbose tab 50mg..................................... 26
acebutolol cap 200mg ............................... 32
acebutolol cap 400mg ............................... 32
acetazolamid cap 500mg er ....................... 35
acetazolamid tab 125mg ........................... 35
acetazolamid tab 250mg ........................... 35
acetic acid sol 2% otic............................... 50
acitretin cap 10mg ..................................... 38
acitretin cap 17.5mg .................................. 38
acitretin cap 25mg ..................................... 38
acthib inj.................................................... 47
actimmune inj 2mu/0.5 ............................. 15
actoplus met tab xr .................................... 26
acyclovir cap 200mg ................................. 24
acyclovir na inj 50mg/ml .......................... 24
55
acyclovir sus 200/5ml ............................... 24
acyclovir tab 400mg .................................. 24
acyclovir tab 800mg .................................. 25
adacel inj ................................................... 47
adagen inj 250/ml ...................................... 40
adefov dipiv tab 10mg .............................. 24
adrucil inj 500/10ml .................................. 15
advair disku aer 100/50 ............................. 50
advair disku aer 250/50 ............................. 50
advair disku aer 500/50 ............................. 50
advair hfa aer 115/21 ................................ 50
advair hfa aer 230/21 ................................ 50
advair hfa aer 45/21 .................................. 50
advicor tab 1000-20 .................................. 36
advicor tab 1000-40 .................................. 36
advicor tab 500-20mg ............................... 36
advicor tab 750-20mg ............................... 36
afeditab tab 30mg cr.................................. 33
afeditab tab 60mg cr.................................. 33
afinitor dis tab 2mg ................................... 15
afinitor dis tab 3mg ................................... 15
afinitor dis tab 5mg ................................... 15
afinitor tab 10mg ....................................... 15
afinitor tab 2.5mg ...................................... 15
afinitor tab 5mg ......................................... 15
afinitor tab 7.5mg ...................................... 15
aggrenox cap 25-200mg ............................ 29
ala cort cre 1% .......................................... 38
albenza tab 200mg .................................... 19
albuterol neb 0.083% ................................ 51
albuterol neb 0.5% .................................... 51
albuterol neb 0.63mg/3 ............................. 51
albuterol neb 1.25mg/3 ............................. 51
albuterol syp 2mg/5ml .............................. 51
albuterol tab 2mg ...................................... 51
albuterol tab 4mg ...................................... 51
albuterol tab 4mg er .................................. 51
albuterol tab 8mg er .................................. 51
aldurazyme inj 2.9mg/5m ......................... 40
alendronate tab 10mg ................................ 48
alendronate tab 35mg ................................ 48
alendronate tab 40mg ................................ 48
alendronate tab 5mg .................................. 48
alendronate tab 70mg ................................ 48
alimta inj 500mg ....................................... 15
alinia sus 100/5ml ..................................... 19
alinia tab 500mg ........................................ 19
allopurinol tab 100mg ............................... 14
allopurinol tab 300mg ............................... 14
alphagan p sol 0.1% .................................. 49
alprazolam con 1 mg/ml............................ 25
alprazolam tab 0.25 odt ............................. 25
alprazolam tab 0.25mg .............................. 25
alprazolam tab 0.5mg ................................ 25
alprazolam tab 0.5mg er ............................ 25
alprazolam tab 0.5mg od ........................... 25
alprazolam tab 1mg ................................... 25
alprazolam tab 1mg er ............................... 25
alprazolam tab 1mg odt ............................. 25
alprazolam tab 2mg ................................... 25
alprazolam tab 2mg er ............................... 25
alprazolam tab 2mg odt ............................. 25
alprazolam tab 3mg er ............................... 25
altoprev tab 20mg er ................................. 36
altoprev tab 40mg er ................................. 36
altoprev tab 60mg er ................................. 36
amantadine cap 100mg ............................. 19
amantadine syp 50mg/5ml ........................ 19
amantadine tab 100mg .............................. 19
ambisome inj 50mg ................................... 13
amcinonide cre 0.1% ................................. 38
amcinonide lot 0.1% ................................. 38
amcinonide oin 0.1% ................................ 38
amifostine inj 500mg ................................ 16
amilor/hctz tab 5-50 .................................. 31
amiloride tab 5mg ..................................... 35
aminophyllin inj 25mg/ml......................... 50
aminosyn 7% inj /lytes .............................. 53
aminosyn ii inj 10% .................................. 53
aminosyn ii inj 7% .................................... 53
aminosyn ii inj 8.5% ................................. 53
aminosyn ii inj 8.5/lyte ............................. 53
aminosyn inj 8.5/lyte ................................. 53
aminosyn m inj 3.5% ................................ 53
aminosyn-hbc inj 7% ................................ 53
aminosyn-pf inj 10% ................................. 53
aminosyn-pf inj 7% ................................... 53
aminosyn-rf inj 5.2% ................................ 53
amiodarone inj 50mg/ml ........................... 30
amiodarone tab 200mg .............................. 30
amiodarone tab 400mg .............................. 30
amitiza cap 24mcg .................................... 41
amitiza cap 8mcg ...................................... 41
amitriptylin tab 100mg .............................. 12
amitriptylin tab 10mg ................................ 12
amitriptylin tab 150mg .............................. 12
amitriptylin tab 25mg ................................ 12
amitriptylin tab 50mg ................................ 12
amitriptylin tab 75mg ................................ 12
amlod/benazp cap 10-20mg ...................... 31
amlod/benazp cap 10-40mg ...................... 31
amlod/benazp cap 2.5-10mg ..................... 31
amlod/benazp cap 5-10mg ........................ 31
amlod/benazp cap 5-20mg ........................ 31
amlod/benazp cap 5-40mg ........................ 31
amlod/valsar tab /hctz ............................... 31
amlod/valsar tab 10-160mg....................... 31
amlod/valsar tab 10-320mg....................... 31
amlod/valsar tab 5-160mg......................... 31
56
amlod/valsar tab 5-320mg......................... 31
amlodipine tab 10mg................................. 33
amlodipine tab 2.5mg................................ 33
amlodipine tab 5mg................................... 33
ammonium lac lot 12% ............................. 38
amnesteem cap 10mg ................................ 38
amnesteem cap 20mg ................................ 38
amnesteem cap 40mg ................................ 38
amox/k clav chw 200mg ............................. 5
amox/k clav chw 400mg ............................. 6
amox/k clav sus 200/5ml ............................ 6
amox/k clav sus 400/5ml ............................ 6
amox/k clav sus 600/5ml ............................ 6
amox/k clav tab 250mg ............................... 6
amox/k clav tab 500mg ............................... 6
amox/k clav tab 875mg ............................... 6
amoxapine tab 100mg ............................... 12
amoxapine tab 150mg ............................... 12
amoxapine tab 25mg ................................. 12
amoxapine tab 50mg ................................. 12
amoxicillin cap 250mg................................ 6
amoxicillin cap 500mg................................ 6
amoxicillin chw 125mg............................... 6
amoxicillin chw 250mg............................... 6
amoxicillin sus 125/5ml .............................. 6
amoxicillin sus 200/5ml .............................. 6
amoxicillin sus 250/5ml .............................. 6
amoxicillin sus 400/5ml .............................. 6
amoxicillin tab 500mg ................................ 6
amoxicillin tab 875mg ................................ 6
amphetamine tab 10mg ............................. 37
amphetamine tab 12.5mg .......................... 37
amphetamine tab 15mg ............................. 37
amphetamine tab 20mg ............................. 37
amphetamine tab 30mg ............................. 37
amphetamine tab 5mg ............................... 37
amphetamine tab 7.5mg ............................ 37
amphotericin inj 50mg .............................. 13
ampicillin cap 250mg .................................. 6
ampicillin cap 500mg .................................. 6
ampicillin inj 10gm ..................................... 6
ampicillin inj 125mg ................................... 6
ampicillin inj 1gm ....................................... 6
ampicillin sus 125/5ml ................................ 6
ampicillin sus 250/5ml ................................ 6
amp-sulbacta inj 1.5gm ............................... 6
amp-sulbacta inj 15gm ................................ 6
ampyra tab 10mg....................................... 38
anagrelide cap 0.5mg ................................ 29
anastrozole tab 1mg .................................. 19
androderm dis 2mg/24hr ........................... 43
androderm dis 4mg/24hr ........................... 43
android cap 10mg ...................................... 43
anoro ellipt aer 62.5-25 ............................. 51
apap/codeine sol 120-12/5 .......................... 2
apap/codeine tab 300-15mg ........................ 2
apap/codeine tab 300-30mg ........................ 2
apap/codeine tab 300-60mg ........................ 2
apidra inj solostar ...................................... 27
apidra inj u-100 ......................................... 27
aplenzin tab 174mg ................................... 10
aplenzin tab 348mg ................................... 10
aplenzin tab 522mg ................................... 10
apokyn inj 10mg/ml .................................. 19
apraclonidin sol 0.5% op........................... 49
apriso cap 0.375gm ................................... 48
aptiom tab 200mg ....................................... 9
aptiom tab 400mg ....................................... 9
aptiom tab 600mg ....................................... 9
aptiom tab 800mg ....................................... 9
aptivus cap 250mg .................................... 24
aptivus sol ................................................. 24
arcalyst inj 220mg ..................................... 47
arranon inj 5mg/ml .................................... 16
arzerra con 100/5ml .................................. 16
asacol hd tab 800mg.................................. 48
ascomp/cod cap 30mg ................................. 2
astagraf xl cap 0.5mg ................................ 46
astagraf xl cap 1mg ................................... 46
astagraf xl cap 5mg ................................... 46
atacand tab 16mg ...................................... 29
atacand tab 32mg ...................................... 29
atelvia tab .................................................. 48
atenol/chlor tab 100-25mg ........................ 31
atenol/chlor tab 50-25mg .......................... 31
atenolol tab 100mg .................................... 32
atenolol tab 25mg ...................................... 33
atenolol tab 50mg ...................................... 33
atgam inj 250mg ....................................... 47
atorvastatin tab 10mg ................................ 36
atorvastatin tab 20mg ................................ 36
atorvastatin tab 40mg ................................ 36
atorvastatin tab 80mg ................................ 36
atovaq/progu tab 250-100 ......................... 19
atovaquone sus 750/5ml ............................ 19
atripla tab .................................................. 23
atropine sul inj 0.05mg/1 .......................... 41
atropine sul inj 0.1mg/ml .......................... 41
atropine sul sol 1% op ............................... 49
atrovent hfa aer 17mcg.............................. 50
aubagio tab 14mg ...................................... 38
aubagio tab 7mg ........................................ 38
aug betamet lot 0.05%............................... 38
auryxia tab 210mg..................................... 42
avandamet tab 2-1000mg .......................... 26
avandamet tab 2-500mg ............................ 26
avandamet tab 4-500mg ............................ 26
avandaryl tab 4-1mg ................................. 26
avandaryl tab 4-2mg ................................. 26
avandaryl tab 8-4mg ................................. 26
avandia tab 2mg ........................................ 26
57
avandia tab 4mg ........................................ 26
avandia tab 8mg ........................................ 26
avastin inj .................................................. 15
avodart cap 0.5mg ..................................... 42
azacitidine inj 100mg ................................ 15
azactam/dex inj 1gm ................................... 5
azactam/dex inj 2gm ................................... 5
azasan tab 100mg ...................................... 16
azasan tab 75 mg ....................................... 16
azathioprine tab 50mg ............................... 46
azelastine dro 0.05% ................................. 49
azelastine spr 0.1%.................................... 51
azelastine spr 0.15%.................................. 51
azilect tab 0.5mg ....................................... 20
azilect tab 1mg .......................................... 20
azithromycin inj 500mg .............................. 6
azithromycin pow 1gm pak ......................... 6
azithromycin sus 100/5ml ........................... 6
azithromycin sus 200/5ml ........................... 6
azithromycin tab 250mg ............................. 6
azithromycin tab 500mg ............................. 6
azithromycin tab 600mg ............................. 6
azopt sus 1% op ........................................ 49
azor tab 10-20mg ...................................... 31
azor tab 10-40mg ...................................... 31
azor tab 5-20mg ........................................ 31
azor tab 5-40mg ........................................ 31
aztreonam inj 1gm....................................... 5
B
baciim inj 50000unt .................................... 4
bacit/polymy oin op .................................. 49
bacitracin oin op ........................................ 49
baclofen tab 10mg ..................................... 51
baclofen tab 20mg ..................................... 51
balsalazide cap 750mg .............................. 48
banzel sus 40mg/ml..................................... 9
banzel tab 200mg ........................................ 9
banzel tab 400mg ........................................ 9
baraclude sol .05mg/ml ............................. 24
bcg vaccine inj .......................................... 47
beleodaq inj 500mg ................................... 16
benazep/hctz tab 10-12.5 .......................... 31
benazep/hctz tab 20-12.5 .......................... 31
benazep/hctz tab 20-25mg ........................ 31
benazep/hctz tab 5-6.25 ............................ 31
benazepril tab 10mg .................................. 30
benazepril tab 20mg .................................. 30
benazepril tab 40mg .................................. 30
benazepril tab 5mg .................................... 30
benicar hct tab 20-12.5 .............................. 31
benicar hct tab 40-12.5 .............................. 31
benicar hct tab 40-25mg............................ 31
benicar tab 20mg ....................................... 29
benicar tab 40mg ....................................... 29
benicar tab 5mg ......................................... 29
benlysta inj 120mg .................................... 46
benztropine inj 1mg/ml ............................. 19
benztropine tab 0.5mg ............................... 19
benztropine tab 1mg .................................. 19
benztropine tab 2mg .................................. 19
betameth dip cre 0.05%............................. 38
betameth dip oin 0.05% ............................ 38
betameth val cre 0.1% ............................... 38
betameth val lot 0.1% ............................... 38
betameth val oin 0.1%............................... 38
betaseron inj 0.3mg ................................... 38
betaxolol sol 0.5% op................................ 49
betaxolol tab 10mg.................................... 33
betaxolol tab 20mg.................................... 33
bexsero inj ................................................. 47
bicalutamide tab 50mg .............................. 16
bicillin l-a inj 600000 .................................. 6
bicnu inj 100mg ........................................ 16
bimatoprost sol 0.03% .............................. 50
bisoprl/hctz tab 10/6.25............................. 31
bisoprl/hctz tab 2.5/6.25............................ 31
bisoprl/hctz tab 5-6.25mg ......................... 31
bisoprol fum tab 10mg .............................. 33
bisoprol fum tab 5mg ................................ 33
bivigam inj 10% ........................................ 47
bleomycin inj 30unit ................................. 16
boostrix inj ................................................ 47
bosulif tab 100mg ..................................... 16
bosulif tab 500mg ..................................... 16
breo ellipta inh 100-25 .............................. 51
brilinta tab 90mg ....................................... 29
brimonidine sol 0.15% .............................. 49
brimonidine sol 0.2% op ........................... 49
brintellix tab 10mg .................................... 10
brintellix tab 20mg .................................... 10
brintellix tab 5mg ...................................... 10
brisdelle cap 7.5mg ................................... 11
bromocriptin cap 5mg ............................... 19
bromocriptin tab 2.5mg ............................. 19
budesonide cap 3mg/24hr ......................... 43
bumetanide inj 0.25/ml ............................. 35
bumetanide tab 0.5mg ............................... 35
bumetanide tab 1mg .................................. 35
bumetanide tab 2mg .................................. 35
bupren/nalox sub 2-0.5mg .......................... 3
bupren/nalox sub 8-2mg ............................. 3
buprenorphin inj 0.3mg/ml ......................... 3
buprenorphin sub 2mg ................................ 3
buprenorphin sub 8mg ................................ 3
buproban tab 150mg ................................. 10
bupropion tab 100mg ................................ 10
bupropion tab 100mg sr ............................ 10
bupropion tab 150mg sr ............................ 11
bupropion tab 200mg sr ............................ 11
bupropion tab 75mg .................................. 11
bupropn hcl tab 150mg xl ......................... 11
58
bupropn hcl tab 300mg xl ......................... 11
buspirone tab 10mg ................................... 25
buspirone tab 15mg ................................... 25
buspirone tab 30mg ................................... 25
buspirone tab 5mg ..................................... 25
buspirone tab 7.5mg .................................. 25
busulfex inj 6mg/ml .................................. 16
but/apap/caf cap codeine ............................. 2
butisol sod tab 30mg ................................. 52
butrans dis 15mcg/hr ................................... 1
byetta inj 10mcg ........................................ 26
byetta inj 5mcg .......................................... 26
C
cabergoline tab 0.5mg ............................... 44
calc acetate cap 667mg ............................. 42
calcipotrien sol 0.005% ............................. 38
calcitonin spr 200/act ................................ 48
calcitriol cap 0.25mcg ............................... 48
calcitriol cap 0.5mcg ................................. 48
calcitriol inj 1mcg/ml ................................ 48
calcitriol sol 1mcg/ml ............................... 48
cancidas inj 50mg ..................................... 13
cancidas inj 70mg ..................................... 13
candesa/hctz tab 16-12.5 ........................... 31
candesa/hctz tab 32-12.5 ........................... 31
candesa/hctz tab 32-25mg ......................... 31
candesartan tab 16mg ................................ 29
candesartan tab 32mg ................................ 30
candesartan tab 4mg .................................. 30
candesartan tab 8mg .................................. 30
capastat sul inj 1gm ................................... 14
caprelsa tab 100mg ................................... 16
caprelsa tab 300mg ................................... 16
captopr/hctz tab 25-15mg ......................... 31
captopr/hctz tab 25-25mg ......................... 31
captopr/hctz tab 50-15mg ......................... 31
captopr/hctz tab 50-25mg ......................... 31
captopril tab 100mg .................................. 30
captopril tab 12.5mg ................................. 30
captopril tab 25mg .................................... 30
captopril tab 50mg .................................... 30
carac cre 0.5% ........................................... 16
carafate sus 1gm/10ml .............................. 42
carb/levo er tab 25-100mg ........................ 20
carb/levo er tab 50-200mg ........................ 20
carb/levo tab 10-100mg ............................ 20
carb/levo tab 25-100mg ............................ 20
carb/levo tab 25-250mg ............................ 20
carbaglu tab 200mg ................................... 52
carbamazepin cap 100mg er...................... 25
carbamazepin cap 200mg er........................ 9
carbamazepin cap 300mg er........................ 9
carbamazepin chw 100mg......................... 25
carbamazepin sus 100/5ml .......................... 9
carbamazepin tab 200mg ............................ 9
carbamazepin tab 200mg er ........................ 9
carbamazepin tab 400mg er ........................ 9
carboplatin inj 150/15ml ........................... 16
carimune nf inj 6gm .................................. 47
carteolol sol 1% op.................................... 49
cartia xt cap 120/24hr................................ 33
cartia xt cap 180/24hr................................ 33
cartia xt cap 240/24hr................................ 33
cartia xt cap 300/24hr................................ 33
carvedilol tab 12.5mg................................ 33
carvedilol tab 25mg................................... 33
carvedilol tab 3.125mg.............................. 33
carvedilol tab 6.25mg................................ 33
cayston inh 75mg ........................................ 5
cdp/amitrip tab 10-25mg ........................... 12
cdp/amitrip tab 5-12.5mg .......................... 12
cefaclor cap 250mg ..................................... 5
cefaclor cap 500mg ..................................... 5
cefaclor er tab 500mg.................................. 5
cefazolin inj 10gm....................................... 5
cefazolin inj 1gm......................................... 5
cefazolin inj 1gm/50ml ............................... 5
cefazolin inj 500mg..................................... 5
cefdinir cap 300mg ..................................... 5
cefdinir sus 125/5ml .................................... 5
cefdinir sus 250/5ml .................................... 5
cefepime inj 1gm......................................... 5
cefepime inj 2gm......................................... 5
cefoxitin inj 10gm ....................................... 5
cefoxitin inj 1gm ......................................... 5
cefoxitin inj 2gm ......................................... 5
cefpodo prox sus 100/5ml ........................... 5
cefpodo prox sus 50mg/5ml ........................ 5
cefpodoxime tab 100mg .............................. 5
cefpodoxime tab 200mg .............................. 5
cefprozil sus 125/5ml .................................. 5
cefprozil sus 250/5ml .................................. 5
cefprozil tab 250mg .................................... 5
cefprozil tab 500mg .................................... 5
ceftriaxone inj 10gm ................................... 5
ceftriaxone inj 1gm ..................................... 5
ceftriaxone inj 250mg ................................. 5
ceftriaxone inj 2gm ..................................... 5
ceftriaxone inj 500mg ................................. 5
cefuroxime inj 1.5gm .................................. 5
cefuroxime inj 7.5gm .................................. 5
cefuroxime inj 750mg ................................. 5
cefuroxime tab 250mg ................................ 5
celecoxib cap 100mg................................... 3
celecoxib cap 200mg................................... 3
celecoxib cap 400mg................................... 3
celecoxib cap 50mg..................................... 3
cellcept iv inj 500mg ................................. 46
celontin cap 300mg ..................................... 8
cephalexin cap 250mg................................. 5
cephalexin cap 500mg................................. 5
59
cephalexin sus 125/5ml ............................... 5
cephalexin sus 250/5ml ............................... 5
cephalexin tab 250mg ................................. 5
cephalexin tab 500mg ................................. 5
cerebyx inj 500/10ml .................................. 9
cerezyme inj 400unit ................................. 40
cervarix inj ................................................ 47
cetirizine syp 1mg/ml ................................ 50
chantix pak 0.5& 1mg ................................. 3
chantix pak 1mg .......................................... 3
chantix tab 0.5mg ........................................ 3
chantix tab 1mg ........................................... 3
chloramphen inj 1gm .................................. 4
chlordiazep cap 10mg ............................... 25
chlordiazep cap 25mg ............................... 25
chlordiazep cap 5mg ................................. 25
chlorhex glu sol 0.12% ............................. 38
chloroquine tab 250mg ............................. 19
chloroquine tab 500mg ............................. 19
chlorothiaz tab 250mg............................... 35
chlorothiaz tab 500mg............................... 35
chlorpromaz inj 25mg/ml .......................... 20
chlorpromaz tab 100mg ............................ 20
chlorpromaz tab 10mg .............................. 20
chlorpromaz tab 200mg ............................ 20
chlorpromaz tab 25mg .............................. 20
chlorpromaz tab 50mg .............................. 20
chlorpropam tab 100mg ............................ 26
chlorpropam tab 250mg ............................ 26
chlorthalid tab 25mg ................................. 35
chlorthalid tab 50mg ................................. 35
cholestyram pow 4gm lite ......................... 36
chor gonadot inj 10000unt ........................ 44
cialis tab 2.5mg ......................................... 42
cialis tab 5mg ............................................ 42
ciclopirox cre 0.77% ................................. 38
ciclopirox gel 0.77% ................................. 39
ciclopirox sol 8% ...................................... 39
ciclopirox sus 0.77% ................................. 39
cilostazol tab 100mg ................................. 29
cilostazol tab 50mg ................................... 29
ciprodex sus 0.3-0.1% ............................... 50
ciprofloxacn inj 200mg ............................... 6
ciprofloxacn inj 400mg ............................... 6
ciprofloxacn sol 0.3% op .......................... 49
ciprofloxacn sus 250mg/5 ........................... 6
ciprofloxacn sus 500mg/5 ........................... 6
ciprofloxacn tab 1000mg ............................ 7
ciprofloxacn tab 100mg .............................. 7
ciprofloxacn tab 250mg .............................. 7
ciprofloxacn tab 500mg .............................. 7
ciprofloxacn tab 500mg er .......................... 7
ciprofloxacn tab 750mg .............................. 7
cisplatin inj 100mg.................................... 16
citalopram sol 10mg/5ml .......................... 11
citalopram tab 10mg ................................. 11
citalopram tab 20mg ................................. 11
citalopram tab 40mg ................................. 11
cladribine inj 1mg/ml ................................ 16
claravis cap 10mg ..................................... 39
claravis cap 20mg ..................................... 39
claravis cap 30mg ..................................... 39
claravis cap 40mg ..................................... 39
clarithromyc tab 250mg .............................. 6
clarithromyc tab 500mg .............................. 6
clindacin kit pac 1% .................................. 39
clindamy/ben gel 1-5% ............................. 39
clindamycin cap 150mg .............................. 4
clindamycin cap 300mg .............................. 4
clindamycin cap 75mg ................................ 4
clindamycin cre 2% vag ............................ 42
clindamycin gel 1%................................... 39
clindamycin inj 150mg/ml .......................... 4
clindamycin inj 300mg ............................... 4
clindamycin inj 600mg ............................... 4
clindamycin inj 900mg ............................... 4
clindamycin lot 1% ................................... 39
clindamycin pad 1% .................................. 39
clindamycin sol 1% ................................... 39
clindamycin sol 75mg/5ml.......................... 4
clinimix e inj 2.75/d10 .............................. 53
clinimix e inj 2.75/d5w ............................. 53
clinimix e inj 4.25/d10 .............................. 53
clinimix e inj 4.25/d25 .............................. 53
clinimix e inj 4.25/d5w ............................. 53
clinimix e inj 5%/d15w ............................. 53
clinimix e inj 5%/d20w ............................. 53
clinimix e inj 5%/d25w ............................. 53
clinimix inj 2.75/d5w ................................ 53
clinimix inj 4.25/d10 ................................. 53
clinimix inj 4.25/d20 ................................. 53
clinimix inj 4.25/d25 ................................. 53
clinimix inj 4.25/d5w ................................ 53
clinimix inj 5%/d15w................................ 53
clinimix inj 5%/d20w................................ 53
clinimix inj 5%/d25w................................ 53
clobetasol e cre 0.05% .............................. 39
clobetasol gel 0.05% ................................. 39
clobetasol oin 0.05% ................................. 39
clobetasol sol 0.05% ................................. 39
clolar inj 1mg/ml ....................................... 16
clomipramine cap 25mg ............................ 12
clomipramine cap 50mg ............................ 12
clomipramine cap 75mg ............................ 12
clonazep odt tab 0.125mg ........................... 8
clonazep odt tab 0.25mg ............................. 8
clonazep odt tab 0.5mg ............................... 8
clonazep odt tab 1mg .................................. 8
clonazep odt tab 2mg .................................. 8
clonazepam tab 0.5mg ................................ 8
clonazepam tab 1mg ................................... 8
60
clonazepam tab 2mg ................................... 8
clonidine tab 0.1mg ................................... 29
clonidine tab 0.2mg ................................... 29
clonidine tab 0.3mg ................................... 29
clopidogrel tab 300mg .............................. 29
clopidogrel tab 75mg ................................ 29
cloraz dipot tab 15mg................................ 25
cloraz dipot tab 3.75mg............................. 25
cloraz dipot tab 7.5mg............................... 25
clotrim/beta cre diprop .............................. 39
clotrim/beta lot diprop............................... 39
clotrimazole cre 1% .................................. 39
clotrimazole sol 1%................................... 39
clotrimazole tro 10mg ............................... 13
clozapine tab 100/odt ................................ 22
clozapine tab 100mg ................................. 22
clozapine tab 12.5/odt ............................... 22
clozapine tab 200mg ................................. 22
clozapine tab 25mg ................................... 22
clozapine tab 25mg odt ............................. 22
clozapine tab 50mg ................................... 22
coartem tab 20-120mg .............................. 19
colchicine cap 0.6mg ................................ 14
colchicine tab 0.6mg ................................. 14
colestipol gra 5gm ..................................... 36
colestipol tab 1gm ..................................... 36
colistimeth inj 150mg ................................. 4
combigan sol 0.2/0.5% .............................. 49
combivent aer respimat ............................. 51
cometriq kit 100mg ................................... 16
cometriq kit 140mg ................................... 16
cometriq kit 60mg ..................................... 16
complera tab .............................................. 23
compro sup 25mg ...................................... 20
comvax inj................................................. 47
condylox gel 0.5% .................................... 39
constulose sol 10gm/15 ............................. 41
copaxone inj 40mg/ml............................... 38
copaxone kit 20mg/ml............................... 38
cormax scalp sol 0.05% ............................ 39
cosmegen inj 0.5mg .................................. 16
creon cap 36000unt ................................... 41
crestor tab 10mg ........................................ 36
crestor tab 20mg ........................................ 36
crestor tab 40mg ........................................ 36
crestor tab 5mg .......................................... 36
crixivan cap 200mg ................................... 24
crixivan cap 400mg ................................... 24
cromolyn sod neb 20mg/2ml .................... 51
cromolyn sod sol 4% op ............................ 49
cubicin sol 500mg ....................................... 4
cyclobenzapr tab 10mg ............................. 51
cyclobenzapr tab 5mg ............................... 51
cyclophosph cap 25mg .............................. 15
cyclophosph cap 50mg .............................. 15
cycloset tab 0.8mg .................................... 26
cyclosporine cap 100mg ........................... 46
cyclosporine cap 100mg md ..................... 46
cyclosporine cap 25mg ............................. 46
cyclosporine cap 25mg mod ..................... 46
cyclosporine cap 50mg mod ..................... 46
cyclosporine inj 50mg/ml ......................... 46
cyclosporine sol modified ......................... 46
cyproheptad tab 4mg ................................. 50
cystadane pow ........................................... 41
cystagon cap 150mg .................................. 42
cystagon cap 50mg .................................... 42
cytarabine inj 100mg/ml ........................... 16
cytarabine inj 20mg/ml ............................. 16
D
d10w/nacl inj 0.2% ................................... 52
d2.5w/nacl inj 0.45% ................................ 52
d5w/lr inj ................................................... 52
d5w/nacl inj 0.2% ..................................... 52
d5w/nacl inj 0.33% ................................... 52
d5w/nacl inj 0.45% ................................... 52
d5w/nacl inj 0.9% ..................................... 52
dacarbazine inj 200mg .............................. 16
dacogen inj 50mg ...................................... 15
daliresp tab 500mcg .................................. 51
danazol cap 100mg ................................... 43
danazol cap 200mg ................................... 43
danazol cap 50mg ..................................... 43
dapsone tab 100mg ................................... 14
dapsone tab 25mg ..................................... 14
daptacel inj ................................................ 47
daraprim tab 25mg .................................... 19
daunorubicin inj 5mg/ml ........................... 16
daunoxome inj 2mg/ml ............................. 16
decitabine inj 50mg ................................... 15
delestrogen inj 10mg/ml ........................... 44
demser cap 250mg .................................... 35
depen titra tab 250mg................................ 15
depo-provera inj 400/ml ............................ 16
desipramine tab 100mg ............................. 12
desipramine tab 10mg ............................... 12
desipramine tab 150mg ............................. 13
desipramine tab 25mg ............................... 13
desipramine tab 50mg ............................... 13
desipramine tab 75mg ............................... 13
desloratadin tab 2.5 odt ............................. 50
desloratadin tab 5mg ................................. 50
desloratadin tab 5mg odt ........................... 23
desmopressin inj 4mcg/ml ........................ 44
desmopressin sol 0.01% ............................ 44
desmopressin spr 0.01%............................ 44
desmopressin tab 0.1mg ............................ 44
desmopressin tab 0.2mg ............................ 44
desonide cre 0.05% ................................... 39
desonide lot 0.05% .................................... 39
desonide oin 0.05% ................................... 39
61
desoximetas cre 0.05%.............................. 39
desoximetas cre 0.25%.............................. 39
desoximetas gel 0.05%.............................. 39
desoximetas oin 0.25% ............................. 39
desvenlafax tab 100mg er ......................... 11
desvenlafax tab 50mg er ........................... 11
dexameth pho inj 10mg/ml ....................... 43
dexameth pho inj 120mg/30...................... 43
dexameth pho sol 0.1% op ........................ 49
dexamethason elx 0.5/5ml ........................ 43
dexamethason tab 0.5mg ........................... 43
dexamethason tab 0.75mg ......................... 43
dexamethason tab 1.5mg ........................... 43
dexamethason tab 1mg .............................. 43
dexamethason tab 2mg .............................. 43
dexamethason tab 4mg .............................. 43
dexamethason tab 6mg .............................. 43
dexilant cap 30mg dr ................................. 42
dexilant cap 60mg dr ................................. 42
dexrazoxane inj 250mg ............................. 16
dextroamphet cap 10mg er ........................ 37
dextroamphet cap 15mg er ........................ 37
dextroamphet cap 5mg er .......................... 37
dextroamphet tab 10mg............................. 37
dextroamphet tab 5mg............................... 37
dextrose inj 10% ....................................... 53
dextrose inj 5% ......................................... 53
diazepam con 5mg/ml ............................... 25
diazepam gel 10mg ..................................... 8
diazepam gel 2.5mg .................................... 8
diazepam gel 20mg ..................................... 8
diazepam sol 1mg/ml ................................ 25
diazepam tab 10mg ................................... 25
diazepam tab 2mg ..................................... 25
diazepam tab 5mg ..................................... 25
diclofen pot tab 50mg ................................. 3
diclofenac gel 3% ...................................... 39
diclofenac sol 0.1% op .............................. 49
diclofenac tab 100mg er .............................. 3
diclofenac tab 25mg dr................................ 3
diclofenac tab 50mg dr................................ 3
diclofenac tab 75mg dr................................ 3
dicloxacill cap 250mg ................................. 6
dicloxacill cap 500mg ................................. 6
dicyclomine cap 10mg .............................. 41
dicyclomine sol 10mg/5ml ........................ 41
dicyclomine tab 20mg ............................... 41
didanosine cap 125mg............................... 23
didanosine cap 200mg............................... 23
didanosine cap 250mg............................... 23
didanosine cap 400mg............................... 23
dificid tab 200mg ........................................ 6
diflorasone cre 0.05% ............................... 39
diflorasone oin 0.05% ............................... 39
diflunisal tab 500mg ................................... 3
digitek tab 0.125mg .................................. 34
digitek tab 0.25mg .................................... 34
digoxin inj 0.25mg/1 ................................. 34
digoxin sol 50mcg/ml ............................... 34
digoxin tab 0.125mg ................................. 34
digoxin tab 0.25mg ................................... 34
dihydroergot inj 1mg/ml ........................... 14
dilantin cap 30mg ........................................ 9
diltiazem cap 120mg er ............................. 34
diltiazem cap 180mg/24 ............................ 34
diltiazem cap 240mg cd ............................ 34
diltiazem cap 300mg er ............................. 34
diltiazem cap 360mg/24 ............................ 34
diltiazem cap 420mg/24 ............................ 34
diltiazem cap 60mg er ............................... 34
diltiazem cap 90mg er ............................... 34
diltiazem inj 100mg .................................. 34
diltiazem inj 50/10ml ................................ 34
diltiazem tab 120mg.................................. 34
diltiazem tab 30mg.................................... 34
diltiazem tab 60mg.................................... 34
diltiazem tab 90mg.................................... 34
dilt-xr cap 120mg ...................................... 33
dilt-xr cap 180mg ...................................... 33
dilt-xr cap 240mg ...................................... 34
dip/tet ped inj 25-5lfu................................ 47
dipentum cap 250mg ................................. 48
diphen/atrop liq 2.5/5 ................................ 41
diphen/atrop tab 2.5mg ............................. 41
diphenhydram inj 50mg/ml ....................... 50
dipyridamole tab 25mg ............................. 29
dipyridamole tab 50mg ............................. 29
dipyridamole tab 75mg ............................. 29
disopyramide cap 100mg .......................... 30
disopyramide cap 150mg .......................... 30
disulfiram tab 250mg .................................. 3
disulfiram tab 500mg .................................. 3
divalproex cap 125mg ............................... 14
divalproex tab 125mg dr ........................... 14
divalproex tab 250mg dr ............................. 8
divalproex tab 250mg er ............................. 8
divalproex tab 500mg dr ............................. 8
divalproex tab 500mg er ............................. 8
docefrez inj 20mg ..................................... 16
docetaxel inj 80mg/4ml............................. 16
docetaxel inj 80mg/8ml............................. 16
donepezil tab 10mg ................................... 10
donepezil tab 10mg odt ............................. 10
donepezil tab 5mg ..................................... 10
donepezil tab 5mg odt ............................... 10
donepezil tab hcl 23mg ............................. 10
dorzol/timol sol 2-0.5%op ........................ 49
dorzolamide sol 2% op.............................. 49
doxazosin tab 1mg .................................... 29
doxazosin tab 2mg .................................... 29
doxazosin tab 4mg .................................... 29
62
doxazosin tab 8mg .................................... 29
doxepin hcl cap 100mg ............................. 13
doxepin hcl cap 10mg ............................... 13
doxepin hcl cap 150mg ............................. 13
doxepin hcl cap 25mg ............................... 13
doxepin hcl cap 50mg ............................... 13
doxepin hcl cap 75mg ............................... 13
doxepin hcl con 10mg/ml.......................... 13
doxil inj 2mg/ml........................................ 16
doxorubicin inj 50mg ................................ 16
doxy 100 inj 100mg .................................... 7
doxycyc mono tab 50mg ............................. 7
doxycyc mono tab 75mg ............................. 7
doxycycl hyc cap 100mg ............................ 7
doxycycl hyc cap 50mg .............................. 7
doxycycl hyc inj 100mg .............................. 7
doxycycl hyc tab 100mg ............................. 7
doxycycline sus 25mg/5ml ......................... 7
doxycycline tab 20mg ................................. 7
dronabinol cap 10mg................................. 13
dronabinol cap 2.5mg................................ 13
dronabinol cap 5mg................................... 13
duloxetine cap 20mg ................................. 11
duloxetine cap 30mg ................................. 11
duloxetine cap 60mg ................................. 11
duramorph inj 0.5mg/ml ............................. 2
duramorph inj 1mg/ml ................................ 2
durezol emu 0.05% ................................... 49
dyrenium cap 100mg................................. 35
dyrenium cap 50mg................................... 35
E
econazole cre 1% ...................................... 39
edarbi tab 40mg......................................... 30
edarbi tab 80mg......................................... 30
edarbyclor tab 40-12.5 .............................. 31
edarbyclor tab 40-25mg ............................ 31
edurant tab 25mg....................................... 23
effient tab 10mg ........................................ 29
effient tab 5mg .......................................... 29
elaprase inj 6mg/3ml ................................. 41
elidel cre 1% ............................................. 39
eligard inj 22.5mg ..................................... 16
eligard inj 30mg ........................................ 16
eligard inj 45mg ........................................ 16
eligard inj 7.5mg ....................................... 16
elitek inj 1.5mg ......................................... 16
ella tab 30mg ............................................. 43
ellence inj 2mg/ml..................................... 16
elmiron cap 100mg ................................... 42
embeda cap 100-4mg .................................. 1
embeda cap 20-0.8mg ................................. 1
embeda cap 30-1.2mg ................................. 1
embeda cap 50-2mg .................................... 1
embeda cap 60-2.4mg ................................. 1
embeda cap 80-3.2mg ................................. 1
emcyt cap 140mg ...................................... 16
emend cap 125mg ..................................... 13
emend cap 40mg ....................................... 13
emend cap 80mg ....................................... 13
emend pak 80 & 125 ................................. 13
emsam dis 12mg/24h ................................ 11
emsam dis 6mg/24hr ................................. 11
emsam dis 9mg/24hr ................................. 11
emtriva cap 200mg .................................... 23
emtriva sol 10mg/ml ................................. 23
enablex tab 15mg ...................................... 42
enablex tab 7.5mg ..................................... 42
enalapr/hctz tab 10-25mg .......................... 31
enalapr/hctz tab 5-12.5mg ......................... 31
enalapril tab 10mg..................................... 30
enalapril tab 2.5mg.................................... 30
enalapril tab 20mg..................................... 30
enalapril tab 5mg....................................... 30
enbrel inj 25/0.5ml .................................... 46
enbrel inj 25mg ......................................... 46
enbrel inj 50mg/ml .................................... 46
endocet tab 10-325mg ................................. 2
endocet tab 5-325mg ................................... 2
endocet tab 7.5-325 ..................................... 2
engerix-b inj 10/0.5ml............................... 47
engerix-b inj 20mcg/ml ............................. 47
enoxaparin inj 100mg/ml .......................... 28
enoxaparin inj 120/0.8 .............................. 28
enoxaparin inj 150mg/ml .......................... 28
enoxaparin inj 30/0.3ml ............................ 28
enoxaparin inj 300/3ml ............................. 28
enoxaparin inj 40/0.4ml ............................ 28
enoxaparin inj 60/0.6ml ............................ 28
enoxaparin inj 80/0.8ml ............................ 28
entacapone tab 200mg............................... 19
entecavir tab 0.5mg ................................... 24
entecavir tab 1mg ...................................... 24
enulose sol 10gm/15 ................................. 41
epipen 2-pak inj 0.3mg ............................. 48
epipen-jr inj 2-pak ..................................... 48
epirubicin inj 50/25ml ............................... 16
epitol tab 200mg ......................................... 9
epivir hbv sol 5mg/ml ............................... 23
eplerenone tab 25mg ................................. 35
eplerenone tab 50mg ................................. 35
eprosart mes tab 600mg ............................ 30
epzicom tab 600-300 ................................. 23
equetro cap 100mg ...................................... 9
equetro cap 200mg ...................................... 9
equetro cap 300mg ...................................... 9
eraxis inj 100mg........................................ 14
erbitux inj 100mg ...................................... 16
ergoloid mes tab 1mg oral......................... 10
ergomar sub 2mg....................................... 14
erivedge cap 150mg .................................. 16
erwinaze inj 10000unt ............................... 16
63
erythrocin inj 500mg ................................... 6
erythrocin tab 250mg .................................. 6
erythrom eth tab 400mg .............................. 6
erythromycin gel /benzoyl ........................ 39
erythromycin gel 2% ................................. 39
erythromycin oin op .................................. 49
erythromycin sol 2% ................................. 39
esbriet cap 267mg ..................................... 51
escitalopram sol 5mg/5ml ......................... 11
escitalopram tab 10mg .............................. 11
escitalopram tab 20mg .............................. 11
escitalopram tab 5mg ................................ 11
esomepra mag cap 40mg dr ...................... 42
esomeprazole cap 49.3mg ......................... 42
estazolam tab 1mg..................................... 52
estazolam tab 2mg..................................... 52
estradiol tab 0.5mg .................................... 44
estradiol tab 1mg ....................................... 44
estradiol tab 2mg ....................................... 44
ethambutol tab 100mg............................... 14
ethambutol tab 400mg............................... 14
ethosuximide cap 250mg ............................ 8
ethosuximide sol 250/5ml ........................... 8
etodolac cap 200mg .................................... 3
etodolac cap 300mg .................................... 3
etodolac er tab 400mg ................................. 3
etodolac er tab 500mg ................................. 3
etodolac er tab 600mg ................................. 3
etodolac tab 400mg ..................................... 3
etodolac tab 500mg ..................................... 3
etopophos inj 100mg ................................. 16
etoposide inj 500/25ml.............................. 16
eurax cre 10% ........................................... 39
evotaz tab 300-150 .................................... 23
exelon dis 13.3/24 ..................................... 10
exelon dis 4.6mg/24 .................................. 10
exelon dis 9.5mg/24 .................................. 10
exemestane tab 25mg ................................ 19
exjade tab 125mg ...................................... 52
exjade tab 250mg ...................................... 52
exjade tab 500mg ...................................... 52
extavia inj 0.3mg....................................... 38
F
fabrazyme inj 35mg .................................. 41
famciclovir tab 125mg .............................. 25
famciclovir tab 250mg .............................. 25
famciclovir tab 500mg .............................. 25
famotidine inj 10mg/ml............................. 41
famotidine inj 20mg/50m .......................... 41
famotidine tab 20mg ................................. 41
famotidine tab 40mg ................................. 41
fanapt pak .................................................. 21
fanapt tab 10mg......................................... 21
fanapt tab 12mg......................................... 21
fanapt tab 1mg........................................... 21
fanapt tab 2mg........................................... 21
fanapt tab 4mg........................................... 21
fanapt tab 6mg........................................... 21
fanapt tab 8mg........................................... 21
fareston tab 60mg ...................................... 16
farxiga tab 10mg ....................................... 26
farxiga tab 5mg ......................................... 26
farydak cap 10mg ...................................... 16
farydak cap 15mg ...................................... 16
farydak cap 20mg ...................................... 16
faslodex inj 250mg.................................... 16
fazaclo tab 150mg ..................................... 22
fazaclo tab 200mg ..................................... 22
felbamate sus 600/5ml ................................ 8
felbamate tab 400mg ................................... 8
felbamate tab 600mg ................................... 8
felodipine tab 10mg er .............................. 34
felodipine tab 2.5mg er ............................. 34
felodipine tab 5mg er ................................ 34
fenofibrate cap 134mg .............................. 35
fenofibrate cap 150mg .............................. 35
fenofibrate cap 200mg .............................. 35
fenofibrate cap 50mg ................................ 36
fenofibrate cap 67mg ................................ 36
fenofibrate tab 145mg ............................... 36
fenofibrate tab 160mg ............................... 36
fenofibrate tab 48mg ................................. 36
fenofibrate tab 54mg ................................. 36
fenoprofen tab 600mg ................................. 3
fentanyl dis 100mcg/h ................................. 1
fentanyl dis 12mcg/hr ................................. 1
fentanyl dis 25mcg/hr ................................. 1
fentanyl dis 37.5mcg ................................... 1
fentanyl dis 50mcg/hr ................................. 1
fentanyl dis 62.5mcg ................................... 1
fentanyl dis 75mcg/hr ................................. 1
fentanyl dis 87.5mcg ................................... 1
fentora tab 200mcg ..................................... 2
fentora tab 400mcg ..................................... 2
fentora tab 600mcg ..................................... 2
fentora tab 800mcg ..................................... 2
fetzima cap 120mg .................................... 11
fetzima cap 20mg ...................................... 11
fetzima cap 40mg ...................................... 11
fetzima cap 80mg ...................................... 11
fetzima cap titratio .................................... 48
finasteride tab 5mg .................................... 42
firazyr inj 30mg/3ml ................................. 48
firmagon inj 120mg................................... 16
firmagon inj 80mg..................................... 16
flebogamma inj dif 10%............................ 47
flecainide tab 100mg ................................. 30
flecainide tab 150mg ................................. 30
flecainide tab 50mg ................................... 30
flovent disk aer 100mcg ............................ 50
flovent disk aer 250mcg ............................ 50
64
flovent disk aer 50mcg .............................. 50
flovent hfa aer 110mcg ............................. 50
flovent hfa aer 220mcg ............................. 50
flovent hfa aer 44mcg ............................... 50
fluconazole sus 10mg/ml .......................... 14
fluconazole sus 40mg/ml .......................... 14
fluconazole tab 100mg .............................. 14
fluconazole tab 150mg .............................. 14
fluconazole tab 200mg .............................. 14
fluconazole tab 50mg ................................ 14
fluconazole/ inj dex 400 ............................ 14
flucytosine cap 250mg .............................. 14
flucytosine cap 500mg .............................. 14
fludarabine inj 50mg ................................. 15
fludrocort tab 0.1mg.................................. 43
flunisolide spr 0.025% .............................. 51
fluocin acet cre 0.01%............................... 39
fluocin acet cre 0.025%............................. 39
fluocin acet oil 0.01% ............................... 50
fluocin acet oil body.................................. 39
fluocin acet oin 0.025% ............................ 39
fluocin acet sol 0.01% ............................... 39
fluocinonide cre -e 0.05% ......................... 39
fluocinonide gel 0.05% ............................. 39
fluocinonide oin 0.05% ............................. 39
fluocinonide sol 0.05% ............................. 39
fluorouracil cre 0.5% ................................ 39
fluorouracil cre 5% ................................... 39
fluorouracil inj 2.5g/50m .......................... 16
fluorouracil sol 2% .................................... 16
fluorouracil sol 5% .................................... 16
fluoxetine cap 10mg .................................. 11
fluoxetine cap 20mg .................................. 11
fluoxetine cap 40mg .................................. 11
fluoxetine cap 90mg dr ............................. 11
fluoxetine sol 20mg/5ml ........................... 11
fluoxetine tab 10mg .................................. 11
fluoxetine tab 20mg .................................. 11
fluoxetine tab 60mg .................................. 12
fluphenaz de inj 25mg/ml ......................... 20
fluphenazine con 5mg/ml .......................... 20
fluphenazine elx 2.5/5ml........................... 20
fluphenazine inj 2.5mg/ml ........................ 20
fluphenazine tab 10mg .............................. 20
fluphenazine tab 1mg ................................ 20
fluphenazine tab 2.5mg ............................. 20
fluphenazine tab 5mg ................................ 20
flurazepam cap 15mg ................................ 52
flurazepam cap 30mg ................................ 52
flurbiprofen sol 0.03% op ......................... 49
flurbiprofen tab 100mg ............................... 3
flurbiprofen tab 50mg ................................. 3
flutamide cap 125mg................................. 16
fluticasone cre 0.05% ................................ 39
fluticasone oin 0.005%.............................. 39
fluticasone spr 50mcg ............................... 51
fluvastatin cap 20mg ................................. 36
fluvastatin cap 40mg ................................. 36
fluvoxamine cap 100mg er........................ 12
fluvoxamine cap 150mg er........................ 12
fluvoxamine tab 100mg ............................ 12
fluvoxamine tab 25mg .............................. 12
fluvoxamine tab 50mg .............................. 12
folotyn inj 40mg/2ml ................................ 16
fondaparinux sol 10/0.8 ............................ 28
fondaparinux sol 2.5/0.5 ........................... 28
fondaparinux sol 5.0/0.4 ........................... 28
fondaparinux sol 7.5/0.6 ........................... 28
forfivo xl tab 450mg ................................. 11
forteo sol 600/2.4 ...................................... 48
fosamax + d tab 70-2800 .......................... 48
fosamax + d tab 70-5600 .......................... 48
foscarnet inj 24mg/ml ............................... 22
fosinop/hctz tab 10/12.5 ............................ 31
fosinop/hctz tab 20/12.5 ............................ 32
fosinopril tab 10mg ................................... 30
fosinopril tab 20mg ................................... 30
fosinopril tab 40mg ................................... 30
fosphenytoin inj 100/2ml ............................ 9
fosrenol chw 1000mg ................................ 42
fosrenol chw 500mg .................................. 42
fosrenol chw 750mg .................................. 42
fragmin inj 7500/0.3.................................. 28
fragmin inj 95000unt................................. 28
freamine hbc inj 6.9% ............................... 53
fulyzaq tab 125mg..................................... 41
furosemide inj 10mg/ml ............................ 35
furosemide sol 10mg/ml ........................... 35
furosemide sol 8mg/ml ............................. 35
furosemide tab 20mg................................. 35
furosemide tab 40mg................................. 35
furosemide tab 80mg................................. 35
fusilev inj 50mg ........................................ 16
fuzeon inj 90mg ........................................ 23
fycompa tab 10mg....................................... 8
fycompa tab 12mg....................................... 8
fycompa tab 2mg......................................... 8
fycompa tab 4mg......................................... 8
fycompa tab 6mg......................................... 8
fycompa tab 8mg......................................... 8
G
gabapentin cap 100mg ................................ 8
gabapentin cap 300mg ................................ 8
gabapentin cap 400mg ................................ 8
gabapentin sol 250/5ml ............................... 8
gabapentin tab 600mg ................................. 8
gabapentin tab 800mg ................................. 8
gabitril tab 12mg ......................................... 8
gabitril tab 16mg ......................................... 8
galantamine cap 16mg er .......................... 10
galantamine cap 24mg er .......................... 10
65
galantamine cap 8mg er ............................ 10
galantamine sol 4mg/ml ............................ 10
galantamine tab 12mg ............................... 10
galantamine tab 4mg ................................. 10
galantamine tab 8mg ................................. 10
gamastan s/d inj......................................... 47
gammagard inj 2.5gm/25 .......................... 47
gammaked inj 1gm/10ml .......................... 47
gammaplex inj 10gm................................. 47
gamunex-c inj 1gm/10ml .......................... 47
ganciclovir inj 500mg ............................... 22
gardasil 9 inj .............................................. 47
gardasil inj ................................................. 47
gauze pads & dressings - pads .................. 26
gemcitabine inj 1gm .................................. 15
gemfibrozil tab 600mg .............................. 36
generlac sol 10gm/15 ................................ 41
gengraf cap 100mg .................................... 46
gengraf cap 25mg ...................................... 46
gengraf sol 100mg/ml ............................... 46
gentak oin 0.3% op ................................... 49
gentam/nacl inj 0.9mg/ml ........................... 4
gentam/nacl inj 1.4mg/ml ........................... 4
gentam/nacl inj 100mg ................................ 4
gentam/nacl inj 60mg .................................. 4
gentam/nacl inj 80mg .................................. 4
gentamicin cre 0.1%.................................. 39
gentamicin inj 10mg/ml .............................. 4
gentamicin inj 40mg/ml .............................. 4
gentamicin oin 0.1% ................................. 39
gentamicin sol 0.3% op ............................. 49
geodon inj 20mg ....................................... 21
gilenya cap 0.5mg ..................................... 38
gilotrif tab 20mg ....................................... 16
gilotrif tab 30mg ....................................... 17
gilotrif tab 40mg ....................................... 17
gleevec tab 100mg .................................... 17
gleevec tab 400mg .................................... 17
gleostine cap 100mg ................................. 15
gleostine cap 10mg ................................... 15
gleostine cap 40mg ................................... 15
glimepiride tab 1mg .................................. 26
glimepiride tab 2mg .................................. 26
glimepiride tab 4mg .................................. 26
glip/metform tab 2.5-250m ....................... 26
glip/metform tab 2.5-500m ....................... 26
glip/metform tab 5-500mg ........................ 26
glipizide er tab 10mg ................................ 26
glipizide er tab 2.5mg ............................... 26
glipizide er tab 5mg .................................. 26
glipizide tab 10mg..................................... 26
glipizide tab 5mg....................................... 26
glucagen inj hypokit .................................. 27
glucagon kit 1mg....................................... 27
glumetza tab 1000mg ................................ 26
glumetza tab 500mg .................................. 26
glyb/metform tab 1.25-250 ....................... 26
glyb/metform tab 2.5-500 ......................... 26
glyb/metform tab 5-500mg ....................... 26
glyburid mcr tab 1.5mg ............................. 26
glyburid mcr tab 3mg ................................ 26
glyburid mcr tab 6mg ................................ 26
glyburide tab 1.25mg ................................ 26
glyburide tab 2.5mg .................................. 26
glyburide tab 5mg ..................................... 26
granisetron inj 0.1mg/ml ........................... 13
granisetron inj 1mg/ml .............................. 13
granisetron tab 1mg................................... 13
griseofulvin sus 125/5ml ........................... 14
guanfacine tab 1mg er ............................... 37
guanfacine tab 2mg er ............................... 37
guanfacine tab 3mg er ............................... 37
guanfacine tab 4mg er ............................... 37
guanidine tab 125mg ................................. 14
H
halaven inj 1mg/2ml ................................. 17
halobetasol cre 0.05% ............................... 39
halobetasol oin 0.05% ............................... 39
haloper dec inj 100mg/ml ......................... 20
haloper dec inj 50mg/ml ........................... 20
haloper lac inj 5mg/ml .............................. 20
haloperidol con 2mg/ml ............................ 20
haloperidol tab 0.5mg ............................... 20
haloperidol tab 10mg ................................ 20
haloperidol tab 1mg .................................. 20
haloperidol tab 20mg ................................ 20
haloperidol tab 2mg .................................. 20
haloperidol tab 5mg .................................. 20
harvoni tab 90-400mg ............................... 24
havrix inj 1440unit .................................... 47
havrix inj 720unit ...................................... 47
hc valerate cre 0.2% .................................. 39
hc valerate oin 0.2% .................................. 39
hep sod/d5w inj 20000unt ......................... 28
hep sod/d5w inj 25000unt ......................... 28
heparin sod inj 1000/ml ............................ 28
heparin sod inj 10000/ml .......................... 28
heparin sod inj 20000/ml .......................... 28
heparin sod inj 5000/ml ............................ 28
hepatamine sol 8% .................................... 53
herceptin inj 440mg .................................. 17
hexalen cap 50mg ..................................... 15
humatrope inj 12mg .................................. 44
humatrope inj 24mg .................................. 44
humira inj 10mg/0.2 .................................. 46
humira kit 20mg/0.4 .................................. 46
humira kit 40mg/0.8 .................................. 46
humira pen kit crohns................................ 46
hydralazine inj 20mg/ml ........................... 36
hydralazine tab 100mg .............................. 36
hydralazine tab 10mg ................................ 36
66
hydralazine tab 25mg ................................ 37
hydralazine tab 50mg ................................ 37
hydrochlorot cap 12.5mg .......................... 35
hydrochlorot tab 12.5mg ........................... 35
hydrochlorot tab 25mg .............................. 35
hydrochlorot tab 50mg .............................. 35
hydroco/apap sol 7.5-325 ............................ 2
hydroco/apap tab 10-325mg ....................... 2
hydroco/apap tab 2.5-325............................ 2
hydroco/apap tab 5-325mg ......................... 2
hydroco/apap tab 7.5-325............................ 2
hydrocod/ibu tab 7.5-200 ............................ 2
hydrocort cre 1% ....................................... 39
hydrocort cre 2.5% .................................... 39
hydrocort lot 2.5% .................................... 39
hydrocort oin 1%....................................... 39
hydrocort oin 2.5%.................................... 40
hydrocort tab 10mg ................................... 43
hydrocort tab 5mg ..................................... 43
hydromorphon inj 500/50ml ....................... 2
hydromorphon liq 1mg/ml .......................... 2
hydromorphon tab 2mg ............................... 2
hydromorphon tab 4mg ............................... 2
hydromorphon tab 8mg ............................... 2
hydroxychlor tab 200mg ........................... 19
hydroxyurea cap 500mg ............................ 17
hydroxyz hcl inj 25mg/ml ......................... 25
hydroxyz hcl inj 50mg/ml ......................... 25
hydroxyz hcl sol 10mg/5ml ...................... 25
hydroxyz hcl tab 10mg.............................. 25
hydroxyz hcl tab 25mg.............................. 25
hydroxyz hcl tab 50mg.............................. 25
hydroxyz pam cap 100mg ......................... 25
hydroxyz pam cap 25mg ........................... 25
hydroxyz pam cap 50mg ........................... 25
I
ibrance cap 100mg .................................... 17
ibrance cap 125mg .................................... 17
ibrance cap 75mg ...................................... 17
ibuprofen sus 100/5ml................................. 3
ibuprofen tab 400mg ................................... 3
ibuprofen tab 600mg ................................... 3
ibuprofen tab 800mg ................................... 3
iclusig tab 15mg ........................................ 17
iclusig tab 45mg ........................................ 17
idamycin pfs inj 20/20ml .......................... 17
idarubicin inj 10/10ml ............................... 17
ifex inj 1gm ............................................... 17
ifosfamide inj 1gm .................................... 17
ilaris inj 180mg ......................................... 47
imbruvica cap 140mg ................................ 17
imipenem/cil inj 250mg .............................. 5
imipenem/cil inj 500mg .............................. 5
imipram hcl tab 10mg ............................... 13
imipram hcl tab 25mg ............................... 13
imipram hcl tab 50mg ............................... 13
imipram pam cap 100mg .......................... 13
imipram pam cap 125mg .......................... 13
imipram pam cap 150mg .......................... 13
imipram pam cap 75mg ............................ 13
imiquimod cre 5% ..................................... 40
imovax rabie inj 2.5/ml ............................. 47
increlex inj 40mg/4ml ............................... 44
indapamide tab 1.25mg ............................. 35
indapamide tab 2.5mg ............................... 35
indomethacin cap 25mg .............................. 3
indomethacin cap 50mg .............................. 3
indomethacin cap 75mg er .......................... 3
infanrix inj................................................. 47
inlyta tab 1mg ........................................... 17
inlyta tab 5mg ........................................... 17
insulin pen needle ..................................... 26
insulin syringe (disp) u-100 ...................... 26
intelence tab 100mg .................................. 23
intelence tab 200mg .................................. 23
intelence tab 25mg .................................... 23
intralipid inj 20% ...................................... 53
intron a inj 18mu ....................................... 17
intron a inj 50mu ....................................... 17
intron-a inj 10mu....................................... 17
intron-a inj 18mu....................................... 17
invanz inj 1gm............................................. 5
invega sust inj 117/0.75 ............................ 21
invega sust inj 156mg/ml .......................... 21
invega sust inj 234/1.5 .............................. 21
invega sust inj 39/0.25 .............................. 21
invega sust inj 78/0.5ml ............................ 21
invega tab 1.5mg ....................................... 21
invega tab 3mg .......................................... 21
invega tab 6mg .......................................... 21
invega tab 9mg .......................................... 21
invirase cap 200mg ................................... 24
invirase tab 500mg .................................... 24
invokamet tab 150-1000 ........................... 26
invokamet tab 150-500 ............................. 26
invokamet tab 50-1000 ............................. 26
invokamet tab 50-500mg .......................... 26
invokana tab 100mg .................................. 26
invokana tab 300mg .................................. 26
ipol inj inactive ......................................... 47
ipratropium sol 0.02%inh.......................... 50
ipratropium spr 0.03% .............................. 51
ipratropium spr 0.06% .............................. 51
ipratropium/ sol albuter ............................. 51
irbesartan tab 150mg ................................. 30
irbesartan tab 300mg ................................. 30
irbesartan tab 75mg ................................... 30
irinotecan inj 100/5ml ............................... 17
isentress chw 100mg ................................. 23
isentress chw 25mg ................................... 23
isentress pow 100mg ................................. 23
67
isentress tab 400mg ................................... 23
isolyte-p inj /d5w ...................................... 52
isolyte-s inj ................................................ 52
isoniazid inj 100mg/ml ............................. 14
isoniazid syp 50mg/5ml ............................ 14
isoniazid tab 100mg .................................. 15
isoniazid tab 300mg .................................. 15
isopropyl alcohol 0.7 ml/ml ...................... 26
isosorb din tab 10mg ................................. 37
isosorb din tab 20mg ................................. 37
isosorb din tab 30mg ................................. 37
isosorb din tab 40mg er ............................. 37
isosorb din tab 5mg ................................... 37
isosorb mono tab 10mg ............................. 37
isosorb mono tab 120mg er ....................... 37
isosorb mono tab 20mg ............................. 37
isosorb mono tab 30mg er ......................... 37
isosorb mono tab 60mg er ......................... 37
isradipine cap 2.5mg ................................. 34
isradipine cap 5mg .................................... 34
istodax inj 10mg........................................ 17
itraconazole cap 100mg ............................ 14
ivermectin tab 3mg ................................... 19
ixempra kit inj 45mg ................................. 17
ixiaro inj .................................................... 47
J
jakafi tab 10mg ......................................... 17
jakafi tab 15mg ......................................... 17
jakafi tab 20mg ......................................... 17
jakafi tab 25mg ......................................... 17
jakafi tab 5mg ........................................... 17
jalyn cap .................................................... 42
jantoven tab 10mg ..................................... 28
jantoven tab 1mg ....................................... 28
jantoven tab 2.5mg .................................... 28
jantoven tab 2mg ....................................... 28
jantoven tab 3mg ....................................... 28
jantoven tab 4mg ....................................... 28
jantoven tab 5mg ....................................... 28
jantoven tab 6mg ....................................... 28
jantoven tab 7.5mg .................................... 28
janumet tab 50-1000 ................................. 27
janumet tab 50-500mg .............................. 27
janumet xr tab 100-1000 ........................... 27
janumet xr tab 50-1000 ............................. 27
janumet xr tab 50-500mg .......................... 27
januvia tab 100mg ..................................... 27
januvia tab 25mg ....................................... 27
januvia tab 50mg ....................................... 27
jevtana inj 60/1.5ml .................................. 17
juxtapid cap 10mg ..................................... 36
juxtapid cap 20mg ..................................... 36
juxtapid cap 5mg ....................................... 36
K
kadcyla inj 100mg ..................................... 17
kaletra sol .................................................. 24
kaletra tab 100-25mg ................................ 24
kaletra tab 200-50mg ................................ 24
kalydeco pak 50mg ................................... 51
kalydeco pak 75mg ................................... 51
kalydeco tab 150mg .................................. 51
kazano 12.5- tab 1000mg .......................... 27
kazano 12.5- tab 500mg ............................ 27
kcl in nacl inj ............................................. 52
kcl/d5w inj 0.15% ..................................... 52
kcl/d5w inj 0.3% ....................................... 52
kcl/d5w/lr inj 0.15%.................................. 52
kcl/d5w/nacl inj .075/.45........................... 52
kcl/d5w/nacl inj .15/.33% ......................... 52
kcl/d5w/nacl inj .15/.45% ......................... 52
kcl/d5w/nacl inj .22/.45............................. 52
kcl/d5w/nacl inj 0.15/0.2........................... 52
kcl/d5w/nacl inj 0.3/0.45........................... 52
kcl/nacl inj 0.15-0.9 .................................. 52
kepivance inj 6.25mg ................................ 17
ketek tab 300mg .......................................... 6
ketek tab 400mg .......................................... 6
ketoconazole cre 2% ................................. 40
ketoconazole sha 2% ................................. 40
ketoconazole tab 200mg ........................... 14
ketoprofen cap 200mg er ............................ 3
ketoprofen cap 50mg................................... 3
ketoprofen cap 75mg................................... 3
ketorolac inj 15mg/ml ................................. 3
ketorolac inj 30mg/ml ................................. 3
ketorolac sol 0.4% ..................................... 49
ketorolac sol 0.5% ..................................... 49
ketorolac tab 10mg ...................................... 4
keytruda sol 50mg ..................................... 17
khedezla tab 100mg er .............................. 12
khedezla tab 50mg er ................................ 12
kineret inj .................................................. 46
kionex pow ................................................ 52
klor-con 10 tab 10meq er .......................... 52
klor-con 8 tab 8meq er .............................. 52
klor-con m20 tab 20meq er ....................... 52
kombiglyze tab 2.5-1000 .......................... 27
kombiglyze tab 5-1000mg ........................ 27
kombiglyze tab 5-500mg .......................... 27
korlym tab 300mg ..................................... 45
kuvan tab 100mg ....................................... 41
kynamro inj 200mg/ml .............................. 36
L
labetalol inj 5mg/ml .................................. 33
labetalol tab 100mg ................................... 33
labetalol tab 200mg ................................... 33
labetalol tab 300mg ................................... 33
lactated rin inj ........................................... 52
lactated rin sol irrigat ................................ 49
lactulose sol 10gm/15 ............................... 41
lamictal kit start 35...................................... 9
68
lamictal kit start 49...................................... 9
lamictal kit start 98...................................... 9
lamictal xr kit .............................................. 9
lamivud/zido tab 150-300 ......................... 23
lamivudine sol 10mg/ml ........................... 23
lamivudine tab 100mg............................... 23
lamivudine tab 150mg............................... 23
lamivudine tab 300mg............................... 23
lamotrigine chw 25mg ................................ 9
lamotrigine chw 5mg .................................. 9
lamotrigine tab 100mg ................................ 9
lamotrigine tab 100mg er ............................ 9
lamotrigine tab 150mg ................................ 9
lamotrigine tab 200mg ................................ 9
lamotrigine tab 200mg er ............................ 9
lamotrigine tab 250mg er ............................ 9
lamotrigine tab 25mg .................................. 9
lamotrigine tab 25mg er .............................. 9
lamotrigine tab 300mg er ............................ 9
lamotrigine tab 50mg er .............................. 9
lamotrigine tab odt 25mg ............................ 9
lamotrigine tab odt 50mg ............................ 9
lamotrigine tab odt/100 ............................... 9
lamotrigine tab odt/200 ............................... 9
lantus inj 100/ml ....................................... 27
lantus inj solostar ...................................... 28
latanoprost sol 0.005% .............................. 49
latuda tab 120mg ....................................... 21
latuda tab 20mg ......................................... 21
latuda tab 40mg ......................................... 21
latuda tab 60mg ......................................... 21
latuda tab 80mg ......................................... 21
lazanda spr 100mcg..................................... 2
lazanda spr 400mcg..................................... 2
leflunomide tab 10mg ............................... 47
leflunomide tab 20mg ............................... 47
lenvima cap 10mg ..................................... 17
lenvima cap 14mg ..................................... 17
lenvima cap 20mg ..................................... 17
lenvima cap 24mg ..................................... 17
lescol xl tab 80mg ..................................... 36
letairis tab 10mg ........................................ 51
letairis tab 5mg .......................................... 51
letrozole tab 2.5mg.................................... 19
leucovor ca inj 100mg ............................... 17
leucovor ca inj 350mg ............................... 17
leucovor ca tab 10mg ................................ 17
leucovor ca tab 15mg ................................ 17
leucovor ca tab 25mg ................................ 17
leucovor ca tab 5mg .................................. 17
leukeran tab 2mg ....................................... 15
leukine inj 250mcg .................................... 28
leuprolide inj 1mg/0.2 ............................... 17
levemir inj ................................................. 28
levemir inj flextouc ................................... 28
levetiraceta inj 10mg/ml ............................. 7
levetiraceta inj 15mg/ml ............................. 7
levetiraceta inj 5mg/ml ............................... 7
levetiraceta sol 100mg/ml ........................... 7
levetiraceta tab 1000mg .............................. 7
levetiraceta tab 250mg ................................ 7
levetiraceta tab 500mg ................................ 7
levetiraceta tab 500mg er ............................ 7
levetiraceta tab 750mg ................................ 7
levetiraceta tab 750mg er ............................ 7
levetiracetm inj 500/5ml ............................. 7
levobunolol sol 0.5% op ........................... 50
levocarnitin inj 200mg/ml ......................... 41
levocarnitin sol 1gm/10ml ........................ 41
levocarnitin tab 330mg ............................. 41
levoflox/d5w inj 500/100m ......................... 7
levofloxacin inj 25mg/ml ............................ 7
levofloxacin sol 25mg/ml ........................... 7
levofloxacin tab 250mg............................... 7
levofloxacin tab 500mg............................... 7
levofloxacin tab 750mg............................... 7
levoleucovor inj 50mg .............................. 17
levothyroxin tab 100mcg .......................... 44
levothyroxin tab 112mcg .......................... 44
levothyroxin tab 125mcg .......................... 44
levothyroxin tab 137mcg .......................... 44
levothyroxin tab 150mcg .......................... 44
levothyroxin tab 175mcg .......................... 45
levothyroxin tab 200mcg .......................... 45
levothyroxin tab 25mcg ............................ 45
levothyroxin tab 300mcg .......................... 45
levothyroxin tab 50mcg ............................ 45
levothyroxin tab 75mcg ............................ 45
levothyroxin tab 88mcg ............................ 45
levoxyl tab 100mcg ................................... 45
levoxyl tab 112mcg ................................... 45
levoxyl tab 125mcg ................................... 45
levoxyl tab 137mcg ................................... 45
levoxyl tab 150mcg ................................... 45
levoxyl tab 175mcg ................................... 45
levoxyl tab 200mcg ................................... 45
levoxyl tab 25mcg ..................................... 45
levoxyl tab 50mcg ..................................... 45
levoxyl tab 75mcg ..................................... 45
levoxyl tab 88mcg ..................................... 45
lexiva sus 50mg/ml ................................... 24
lexiva tab 700mg ....................................... 24
lido/prilocn cre 2.5-2.5% ............................ 2
lidocaine gel 2% jelly............................ 3, 40
lidocaine inj 0.5% ....................................... 3
lidocaine inj 2% .......................................... 3
lidocaine oin 5% ....................................... 40
lidocaine sol 4% ........................................ 40
lidoderm dis 5% ........................................ 40
lincocin inj 300mg/ml ................................. 4
lindane lot 1% ........................................... 40
69
lindane sha 1% .......................................... 40
linezolid inj 2mg/ml .................................... 4
liothyronine tab 25mcg ............................. 45
liothyronine tab 50mcg ............................. 45
liothyronine tab 5mcg ............................... 45
lisinop/hctz tab 10-12.5 ............................. 32
lisinop/hctz tab 20-12.5 ............................. 32
lisinop/hctz tab 20-25mg........................... 32
lisinopril tab 10mg .................................... 30
lisinopril tab 2.5mg ................................... 30
lisinopril tab 20mg .................................... 30
lisinopril tab 30mg .................................... 30
lisinopril tab 40mg .................................... 30
lisinopril tab 5mg ...................................... 30
lithium carb cap 150mg ............................ 25
lithium carb cap 300mg ............................ 25
lithium carb cap 600mg ............................ 26
lithium carb tab 300mg ............................. 26
lithium carb tab 300mg er ......................... 26
lithium carb tab 450mg er ......................... 26
lithium sol 8meq/5ml ................................ 26
livalo tab 1mg ........................................... 36
livalo tab 2mg ........................................... 36
livalo tab 4mg ........................................... 36
lokara lot 0.05% ........................................ 40
lomustine cap 100mg ................................ 15
lomustine cap 10mg .................................. 15
lomustine cap 40mg .................................. 15
loperamide cap 2mg .................................. 41
lorazepam con 2mg/ml .............................. 25
lorazepam tab 0.5mg ................................. 25
lorazepam tab 1mg .................................... 25
lorazepam tab 2mg .................................... 25
lorcet plus tab 7.5-325................................. 1
losartan pot tab 100mg .............................. 30
losartan pot tab 25mg ................................ 30
losartan pot tab 50mg ................................ 30
losartan/hct tab 100-12.5 ........................... 32
losartan/hct tab 100-25 .............................. 32
losartan/hct tab 50-12.5 ............................. 32
lotronex tab 0.5mg .................................... 41
lotronex tab 1mg ....................................... 41
lovastatin tab 10mg ................................... 36
lovastatin tab 20mg ................................... 36
lovastatin tab 40mg ................................... 36
loxapine cap 10mg .................................... 20
loxapine cap 25mg .................................... 20
loxapine cap 50mg .................................... 20
loxapine cap 5mg ...................................... 20
lumigan sol 0.01% .................................... 49
lumizyme inj 50mg ................................... 41
lupr dep-ped inj 11.25mg .......................... 45
lupr dep-ped inj 15mg ............................... 45
lupron depot inj 11.25mg .......................... 45
lupron depot inj 22.5mg ............................ 17
lupron depot inj 3.75mg ............................ 17
lupron depot inj 30mg ............................... 17
lupron depot inj 45mg ............................... 17
lupron depot inj 7.5mg .............................. 17
lynparza cap 50mg .................................... 17
lyrica cap 100mg ....................................... 38
lyrica cap 150mg ....................................... 38
lyrica cap 200mg ......................................... 8
lyrica cap 225mg ......................................... 8
lyrica cap 25mg ........................................... 8
lyrica cap 300mg ......................................... 8
lyrica cap 50mg ........................................... 8
lyrica cap 75mg ........................................... 8
lyrica sol 20mg/ml ...................................... 8
lysodren tab 500mg ................................... 17
lyza tab 0.35mg ......................................... 44
M
magnesium su inj 50% .............................. 52
maprotiline tab 25mg ................................ 11
maprotiline tab 50mg ................................ 11
maprotiline tab 75mg ................................ 11
marplan tab 10mg ..................................... 11
matulane cap 50mg ................................... 17
meclizine tab 12.5mg ................................ 13
meclizine tab 25mg ................................... 13
meclofen sod cap 100mg ............................ 4
meclofen sod cap 50mg .............................. 4
medroxypr ac inj 150mg/ml ...................... 44
medroxypr ac tab 10mg ............................ 44
medroxypr ac tab 2.5mg ........................... 44
medroxypr ac tab 5mg .............................. 44
mefloquine tab 250mg .............................. 19
megace es sus 625/5ml.............................. 17
megestrol ac sus 40mg/ml ......................... 17
megestrol ac tab 20mg .............................. 17
megestrol ac tab 40mg .............................. 17
mekinist tab 0.5mg .................................... 17
mekinist tab 2mg ....................................... 17
meloxicam sus 7.5/5ml ............................... 4
meloxicam tab 15mg ................................... 4
meloxicam tab 7.5mg .................................. 4
melphalan inj 50mg................................... 17
menactra inj ............................................... 47
menest tab 0.3mg ...................................... 44
menest tab 0.625mg .................................. 44
menest tab 1.25mg .................................... 44
menest tab 2.5mg ...................................... 44
menomune inj a/c/y/w ............................... 47
menveo inj ................................................. 47
meprobamate tab 200mg ........................... 25
meprobamate tab 400mg ........................... 25
mercaptopur tab 50mg .............................. 15
meropenem inj 500mg ................................ 5
mesalamine kit 4gm .................................. 48
mesna inj 1gm ........................................... 18
mesnex tab 400mg .................................... 18
70
mestinon syp 60mg/5ml ............................ 14
metadate tab 20mg er ................................ 37
metformin er tab 1000mg.......................... 27
metformin tab 1000mg .............................. 27
metformin tab 500mg ................................ 27
metformin tab 500mg er............................ 27
metformin tab 750mg er............................ 27
metformin tab 850mg ................................ 27
methadone inj 10mg/ml .............................. 1
methadone sol 10mg/5ml ............................ 1
methadone sol 5mg/5ml .............................. 1
methadone tab 10mg ................................... 1
methadone tab 5mg ..................................... 1
methazolamid tab 25mg ............................ 35
methazolamid tab 50mg ............................ 35
methimazole tab 10mg .............................. 46
methimazole tab 5mg ................................ 46
methocarbam tab 500mg ........................... 51
methocarbam tab 750mg ........................... 51
methotrexate inj 1gm ................................ 15
methotrexate inj 1gm/40ml ....................... 15
methotrexate tab 2.5mg ............................. 15
methoxsalen cap 10mg .............................. 40
methscopolam tab 2.5mg .......................... 41
methyclothia tab 5mg ................................ 35
methyld/hctz tab 250/15 ............................ 32
methyld/hctz tab 250/25 ............................ 32
methyldopa tab 250mg .............................. 29
methyldopa tab 500mg .............................. 29
methyldopate inj 250/5ml ......................... 29
methylin chw 10mg................................... 37
methylin chw 2.5mg.................................. 37
methylin chw 5mg..................................... 37
methylphenid cap 10mg ............................ 37
methylphenid sol 10mg/5ml ..................... 37
methylphenid sol 5mg/5ml ....................... 37
methylphenid tab 10mg............................. 37
methylphenid tab 20mg............................. 37
methylphenid tab 20mg er ........................ 37
methylphenid tab 27mg er ........................ 37
methylphenid tab 5mg............................... 37
methylpr ace inj 40mg/ml ......................... 43
methylpr ace inj 80mg/ml ......................... 43
methylpr ss inj 125mg ............................... 43
methylpr ss inj 40mg ................................. 43
methylpred pak 4mg ................................. 43
methylpred tab 16mg ................................ 43
methylpred tab 32mg ................................ 43
methylpred tab 4mg .................................. 43
methylpred tab 8mg .................................. 43
metipranolol sol 0.3% oph ........................ 50
metoclopram inj 5mg/ml ........................... 41
metoclopram sol 5mg/5ml ........................ 41
metoclopram tab 10mg ............................. 41
metoclopram tab 5mg ............................... 13
metolazone tab 10mg ................................ 35
metolazone tab 2.5mg ............................... 35
metolazone tab 5mg .................................. 35
metoprl/hctz tab 100-25mg ....................... 32
metoprl/hctz tab 100-50mg ....................... 32
metoprl/hctz tab 50-25mg ......................... 32
metoprol tar tab 100mg ............................. 33
metoprol tar tab 25mg ............................... 33
metoprol tar tab 50mg ............................... 33
metoprolol inj 1mg/ml .............................. 33
metoprolol tab 100mg er ........................... 33
metoprolol tab 200mg er ........................... 33
metoprolol tab 25mg er ............................. 33
metoprolol tab 50mg er ............................. 33
metron/nacl inj 500mg ................................ 4
metronidazol cap 375mg ............................. 4
metronidazol cre 0.75% ............................ 40
metronidazol gel 0.75% ............................ 40
metronidazol gel 0.75%vag ...................... 42
metronidazol lot 0.75% ............................. 40
metronidazol tab 250mg ............................. 4
metronidazol tab 500mg ............................. 4
mexiletine cap 150mg ............................... 31
mexiletine cap 200mg ............................... 31
mexiletine cap 250mg ............................... 31
miacalcin inj 200/ml ................................. 48
miconazole 3 sup 200mg .......................... 42
midodrine tab 10mg .................................. 29
midodrine tab 2.5mg ................................. 29
midodrine tab 5mg .................................... 29
minitran dis 0.1mg/hr ................................ 37
minitran dis 0.2mg/hr ................................ 37
minitran dis 0.4mg/hr ................................ 37
minitran dis 0.6mg/hr ................................ 37
minocycline cap 100mg .............................. 7
minocycline cap 50mg ................................ 7
minocycline cap 75mg ................................ 7
minocycline tab 100mg ............................... 7
minocycline tab 50mg ................................. 7
minocycline tab 75mg ................................. 7
minoxidil tab 10mg ................................... 37
minoxidil tab 2.5mg .................................. 37
mircera inj 100mcg ................................... 28
mircera inj 50mcg ..................................... 28
mircera inj 75mcg ..................................... 29
mirtazapine tab 15mg ................................ 11
mirtazapine tab 15mg odt.......................... 11
mirtazapine tab 30mg ................................ 11
mirtazapine tab 30mg odt.......................... 11
mirtazapine tab 45mg ................................ 11
mirtazapine tab 45mg odt.......................... 11
mirtazapine tab 7.5mg ............................... 11
misoprostol tab 100mcg ............................ 42
misoprostol tab 200mcg ............................ 42
mitomycin inj 20mg .................................. 18
mitoxantron inj 2mg/ml ............................ 18
71
m-m-r ii inj live ......................................... 47
modafinil tab 100mg ................................. 52
modafinil tab 200mg ................................. 52
moexipr/hctz tab 15-12.5 .......................... 32
moexipr/hctz tab 15-25mg ........................ 32
moexipr/hctz tab 7.5-12.5 ......................... 32
moexipril tab 15mg ................................... 30
moexipril tab 7.5mg .................................. 30
mometasone cre 0.1% ............................... 40
mometasone oin 0.1% ............................... 40
montelukast chw 4mg ............................... 50
montelukast chw 5mg ............................... 50
montelukast gra 4mg ................................. 50
montelukast tab 10mg ............................... 50
morphine sul cap 100mg er ......................... 1
morphine sul cap 10mg er ........................... 1
morphine sul cap 120mg er ......................... 1
morphine sul cap 20mg er ........................... 1
morphine sul cap 30mg er ........................... 1
morphine sul cap 45mg er ........................... 1
morphine sul cap 50mg er ........................... 1
morphine sul cap 60mg er ........................... 1
morphine sul cap 75mg er ........................... 1
morphine sul cap 80mg er ........................... 1
morphine sul cap 90mg er ........................... 1
morphine sul sol 10mg/5ml ........................ 2
morphine sul sol 20mg/5ml ........................ 2
morphine sul sol 20mg/ml .......................... 2
morphine sul tab 100mg er ......................... 1
morphine sul tab 15mg................................ 2
morphine sul tab 15mg er ........................... 1
morphine sul tab 30mg................................ 2
morphine sul tab 30mg er ........................... 1
morphine sul tab 60mg er ........................... 1
moxeza sol 0.5% ....................................... 49
mozobil inj ................................................ 29
multaq tab 400mg ..................................... 31
mupirocin oin 2% ...................................... 40
mustargen inj 10mg................................... 18
mycamine inj 100mg................................. 14
mycamine inj 50mg................................... 14
mycophenolat cap 250mg ......................... 46
mycophenolat sus 200mg/ml .................... 46
mycophenolat tab 500mg .......................... 46
mycophenolic tab 180mg dr...................... 46
mycophenolic tab 360mg dr...................... 46
myrbetriq tab 25mg ................................... 42
myrbetriq tab 50mg ................................... 42
N
nabumetone tab 500mg ............................... 4
nabumetone tab 750mg ............................... 4
nadolol tab 20mg....................................... 33
nadolol tab 40mg....................................... 33
nadolol tab 80mg....................................... 33
nadolol/bend tab 40-5mg .......................... 32
nadolol/bend tab 80-5mg .......................... 32
nafcillin inj 10gm ........................................ 6
nafcillin inj 1gm .......................................... 6
naglazyme inj 1mg/ml............................... 41
nalbuphine inj 10mg/ml .............................. 2
nalbuphine inj 20mg/ml .............................. 2
naloxone inj 1mg/ml ................................... 3
naltrexone tab 50mg .................................... 3
namenda sol 10mg/5ml ............................. 10
namenda xr cap 14mg ............................... 10
namenda xr cap 21mg ............................... 10
namenda xr cap 28mg ............................... 10
namenda xr cap 7mg ................................. 10
namenda xr cap titratio.............................. 10
naphazoline sol 0.1% op ........................... 49
naproxen dr tab 375mg ............................... 4
naproxen dr tab 500mg ............................... 4
naproxen sod tab 275mg ............................. 4
naproxen sod tab 550mg ............................. 4
naproxen sus 125/5ml ................................. 4
naproxen tab 250mg .................................... 4
naproxen tab 375mg .................................... 4
naproxen tab 500mg .................................... 4
nateglinide tab 120mg ............................... 27
nateglinide tab 60mg ................................. 27
nebupent inh 300mg .................................. 19
needles, insulin disp., safet ....................... 27
nefazodone tab 100mg .............................. 11
nefazodone tab 150mg .............................. 11
nefazodone tab 200mg .............................. 11
nefazodone tab 250mg .............................. 11
nefazodone tab 50mg ................................ 11
neo/bac/poly oin op ................................... 49
neo/poly gu sol 40/ml ir ............................ 42
neo/poly/bac oin /hc 1%op........................ 49
neo/poly/dex oin 0.1% op ......................... 49
neo/poly/dex sus 0.1% op ......................... 49
neo/poly/gra sol op .................................... 49
neo/poly/hc sol 1% otic ............................. 50
neo/poly/hc sus 1% otic ............................ 50
neo/poly/hc sus op..................................... 49
neomycin tab 500mg ................................... 4
nephramine inj 5.4% ................................. 53
nesina tab 12.5mg ..................................... 27
nesina tab 25mg ........................................ 27
nesina tab 6.25mg ..................................... 27
neumega inj 5mg ....................................... 29
neupogen inj 300/0.5 ................................. 29
neupogen inj 480/0.8 ................................. 29
neupogen inj 480mcg ................................ 29
neupro dis 1mg/24hr ................................. 19
neupro dis 2mg/24hr ................................. 19
neupro dis 3mg/24hr ................................. 19
neupro dis 4mg/24hr ................................. 19
neupro dis 6mg/24hr ................................. 19
neupro dis 8mg/24hr ................................. 19
72
nevanac sus 0.1% ...................................... 49
nevirapine sus 50mg/5ml .......................... 23
nevirapine tab 200mg ................................ 23
nevirapine tab 400mg er............................ 23
nexavar tab 200mg .................................... 18
niacin er tab 1000mg ................................. 36
niacin er tab 500mg ................................... 36
niacin er tab 750mg ................................... 36
niacor tab 500mg....................................... 36
nicardipine cap 20mg ................................ 34
nicardipine cap 30mg ................................ 34
nicotrol inh .................................................. 3
nifedical xl tab 30mg ................................ 34
nifedical xl tab 60mg ................................ 34
nifedipine cap 10mg .................................. 34
nifedipine cap 20mg .................................. 34
nifedipine tab 30mg er .............................. 34
nifedipine tab 60mg er .............................. 34
nifedipine tab 90mg er .............................. 34
nilandron tab 150mg ................................. 18
nimodipine cap 30mg ................................ 34
nipent inj 10mg ......................................... 18
nisoldipine tab 20mg ................................. 34
nisoldipine tab 30mg ................................. 34
nisoldipine tab 40mg ................................. 34
nitrofur mac cap 50mg ................................ 4
nitrofurantn cap 100mg ............................... 4
nitroglycer dis 0.1mg/hr ............................ 37
nitroglycer dis 0.2mg/hr ............................ 37
nitroglycer dis 0.4mg/hr ............................ 37
nitroglycer inj 5mg/ml .............................. 37
nitroglyceri dis 0.6mg/hr ........................... 37
nitroglycrn spr 0.4mg ................................ 37
nitrostat sub 0.3mg .................................... 37
nitrostat sub 0.4mg .................................... 37
nitrostat sub 0.6mg .................................... 37
norethin ace tab 5mg ................................. 44
norethindron tab 0.35mg ........................... 44
normosol -m inj /d5w ................................ 53
normosol -r inj /d5w.................................. 53
normosol-r inj ph 7.4................................. 53
northera cap 100mg................................... 34
northera cap 200mg................................... 34
northera cap 300mg................................... 35
nortriptylin cap 10mg ................................ 13
nortriptylin cap 25mg ................................ 13
nortriptylin cap 50mg ................................ 13
nortriptylin cap 75mg ................................ 13
nortriptylin sol 10mg/5ml ......................... 13
norvir cap 100mg ...................................... 24
norvir sol 80mg/ml .................................... 24
norvir tab 100mg ....................................... 24
novolin inj 70/30 ....................................... 28
novolin n inj u-100 .................................... 28
novolin r inj u-100 .................................... 28
novolog inj 100/ml .................................... 28
novolog inj flexpen ................................... 28
novolog mix inj 70/30 ............................... 28
novolog mix inj flexpen ............................ 28
noxafil sus 40mg/ml.................................. 14
noxafil tab 100mg ..................................... 14
nucynta er tab 100mg .................................. 1
nucynta er tab 150mg .................................. 1
nucynta er tab 200mg .................................. 1
nucynta er tab 250mg .................................. 1
nucynta er tab 50mg .................................... 1
nucynta tab 100mg ...................................... 2
nucynta tab 50mg ........................................ 2
nucynta tab 75mg ........................................ 2
nuedexta cap 20-10mg .............................. 38
nulojix inj 250mg ...................................... 46
nutropin aq inj 20mg/2ml.......................... 44
nutropin aq inj nuspin 5 ............................ 44
nyamyc pow 100000 ................................. 40
nystat/triam cre.......................................... 40
nystat/triam oin ......................................... 40
nystatin cre 100000 ................................... 40
nystatin oin 100000 ................................... 40
nystatin pow 100000 ................................. 40
nystatin sus 100000 ................................... 38
nystatin tab 500000 ................................... 14
nystop pow 100000 ................................... 40
O
octreotide inj 1000mcg ............................. 45
octreotide inj 100mcg ............................... 45
octreotide inj 200mcg ............................... 45
octreotide inj 500mcg ............................... 45
octreotide inj 50mcg/ml ............................ 45
ofloxacin dro 0.3% op ............................... 49
ofloxacin dro 0.3%otic .............................. 50
ofloxacin tab 300mg ................................... 7
ofloxacin tab 400mg ................................... 7
olanza/fluox cap 12-25mg......................... 12
olanza/fluox cap 12-50mg......................... 12
olanza/fluox cap 3-25mg........................... 12
olanza/fluox cap 6-25mg........................... 12
olanza/fluox cap 6-50mg........................... 12
olanzapine inj 10mg .................................. 21
olanzapine tab 10mg ................................. 21
olanzapine tab 10mg odt ........................... 21
olanzapine tab 15mg ................................. 22
olanzapine tab 15mg odt ........................... 22
olanzapine tab 2.5mg ................................ 22
olanzapine tab 20mg ................................. 22
olanzapine tab 20mg odt ........................... 22
olanzapine tab 5mg ................................... 22
olanzapine tab 5mg odt ............................. 22
olanzapine tab 7.5mg ................................ 22
olysio cap 150mg ...................................... 24
omega-3-acid cap 1gm .............................. 36
omeprazole cap 10mg ............................... 42
73
omeprazole cap 20mg ............................... 42
omeprazole cap 40mg ............................... 42
oncaspar inj 750/ml ................................... 18
ondansetron inj 4mg/2ml .......................... 13
ondansetron sol 4mg/5ml .......................... 13
ondansetron tab 24mg ............................... 13
ondansetron tab 4mg ................................. 13
ondansetron tab 4mg odt ........................... 13
ondansetron tab 8mg ................................. 13
ondansetron tab 8mg odt ........................... 13
onfi sus 2.5mg/ml........................................ 8
onfi tab 10mg .............................................. 8
onfi tab 20mg .............................................. 8
onglyza tab 2.5mg ..................................... 27
onglyza tab 5mg ........................................ 27
opana er tab 10mg ....................................... 1
opana er tab 15mg ....................................... 1
opana er tab 20mg ....................................... 1
opana er tab 30mg ....................................... 1
opana er tab 40mg ....................................... 1
opana er tab 5mg ......................................... 1
opana er tab 7.5mg ...................................... 1
opdivo inj 40mg/4ml ................................. 18
opsumit tab 10mg...................................... 51
orap tab 1mg ............................................. 20
orap tab 2mg ............................................. 20
orapred odt tab 10mg ................................ 43
orencia inj 125mg/ml ................................ 47
orencia inj 250mg ..................................... 47
orfadin cap 10mg ...................................... 41
orfadin cap 2mg ........................................ 41
orfadin cap 5mg ........................................ 41
orphenadrine inj 30mg/ml ......................... 51
orphenadrine tab 100mg er ....................... 51
oseni tab 12.5-15 ....................................... 27
oseni tab 12.5-30 ....................................... 27
oseni tab 12.5-45 ....................................... 27
oseni tab 25-15mg ..................................... 27
oseni tab 25-30mg ..................................... 27
oseni tab 25-45mg ..................................... 27
oxaliplatin inj 100mg ................................ 18
oxandrolone tab 10mg............................... 43
oxandrolone tab 2.5mg.............................. 43
oxaprozin tab 600mg................................... 4
oxazepam cap 10mg .................................. 25
oxazepam cap 15mg .................................. 25
oxazepam cap 30mg .................................. 25
oxcarbazepin sus 300mg/5m ..................... 10
oxcarbazepin tab 150mg ........................... 10
oxcarbazepin tab 300mg ........................... 10
oxcarbazepin tab 600mg ........................... 10
oxtellar xr tab 150mg ................................ 10
oxtellar xr tab 300mg ................................ 10
oxtellar xr tab 600mg ................................ 10
oxybutynin syp 5mg/5ml .......................... 42
oxybutynin tab 10mg er ............................ 42
oxybutynin tab 15mg er ............................ 42
oxybutynin tab 5mg .................................. 42
oxybutynin tab 5mg er .............................. 42
oxycod/apap tab 10-325mg ......................... 2
oxycod/apap tab 2.5-325 ............................. 2
oxycod/apap tab 5-325mg ........................... 2
oxycod/apap tab 7.5-325 ............................. 2
oxycod/asa tab ............................................. 2
oxycod/ibu tab 5-400mg ............................. 2
oxycodone cap 5mg .................................... 2
oxycodone tab 10mg ................................... 2
oxycodone tab 15mg ................................... 2
oxycodone tab 20mg ................................... 2
oxycodone tab 30mg ................................... 2
oxycodone tab 5mg ..................................... 2
oxymorphone tab 10mg er .......................... 1
oxymorphone tab 15mg er .......................... 1
oxymorphone tab 20mg er .......................... 1
oxymorphone tab 30mg er .......................... 1
oxymorphone tab 40mg er .......................... 1
oxymorphone tab 5mg er ............................ 1
oxymorphone tab 7.5mg er ......................... 1
oxymorphone tab hcl 10mg ........................ 2
oxymorphone tab hcl 5mg .......................... 2
P
pacerone tab 100mg .................................. 31
pacerone tab 200mg .................................. 31
paclitaxel inj 300/50ml ............................. 18
pamidronate inj 30/10ml ........................... 48
pamidronate inj 6mg/ml ............................ 48
pamidronate inj 90/10ml ........................... 48
panretin gel 0.1% ...................................... 40
paricalcitol inj 2mcg/ml ............................ 48
paricalcitol inj 5mcg/ml ............................ 48
paromomycin cap 250mg ............................ 4
paroxetin er tab 12.5mg ............................ 12
paroxetin er tab 37.5mg ............................ 12
paroxetine tab 10mg .................................. 12
paroxetine tab 20mg .................................. 12
paroxetine tab 25mg er.............................. 12
paroxetine tab 30mg .................................. 12
paroxetine tab 40mg .................................. 12
paser gra 4gm ............................................ 15
pataday sol 0.2% ....................................... 49
patanol sol 0.1% op ................................... 49
paxil sus 10mg/5ml ................................... 12
pedvax hib inj............................................ 47
peganone tab 250mg ................................. 10
pegasys inj ................................................. 24
pegasys inj 180mcg/m............................... 24
pegasys inj proclick................................... 24
pen g sod inj 5000000 ................................. 6
penicill gk/ inj dex 2mu .............................. 6
penicill gk/ inj dex 3mu .............................. 6
penicilln gk inj 5mu .................................... 6
74
penicilln vk sol 125/5ml.............................. 6
penicilln vk sol 250/5ml.............................. 6
penicilln vk tab 250mg................................ 6
penicilln vk tab 500mg................................ 6
pentam 300 inj 300mg .............................. 19
pentaz/nalox tab 50-0.5mg .......................... 2
pentoxifylli tab 400mg er .......................... 35
perindopril tab 2mg ................................... 30
perindopril tab 4mg ................................... 30
perindopril tab 8mg ................................... 30
periogard sol 0.12% .................................. 38
perjeta inj 420/14ml .................................. 18
permethrin cre 5% ..................................... 40
perphen/amit tab 2-10mg .......................... 20
perphen/amit tab 2-25mg .......................... 20
perphen/amit tab 4-10mg .......................... 21
perphen/amit tab 4-25mg .......................... 21
perphen/amit tab 4-50mg .......................... 21
perphenazine tab 16mg ............................. 21
perphenazine tab 2mg ............................... 21
perphenazine tab 4mg ............................... 21
perphenazine tab 8mg ............................... 21
pexeva tab 10mg ....................................... 12
pexeva tab 20mg ....................................... 12
pexeva tab 30mg ....................................... 12
pexeva tab 40mg ....................................... 12
phenelzine tab 15mg ................................. 11
phenobarb elx 20mg/5ml ............................ 7
phenobarb tab 100mg .................................. 7
phenobarb tab 15mg .................................... 7
phenobarb tab 16.2mg ................................. 7
phenobarb tab 30mg .................................... 7
phenobarb tab 32.4mg ................................. 7
phenobarb tab 60mg .................................... 7
phenobarb tab 64.8mg ................................. 7
phenobarb tab 97.2mg ................................. 8
phenytoin chw 50mg ................................. 10
phenytoin ex cap 100mg ........................... 10
phenytoin ex cap 200mg ........................... 10
phenytoin ex cap 300mg ........................... 10
phenytoin inj 50mg/ml .............................. 10
phenytoin sus 125/5ml .............................. 10
phospholine sol 0.125%op ........................ 50
physiolyte sol ............................................ 49
physiosol sol irrigat ................................... 49
picato gel 0.015%...................................... 40
picato gel 0.05%........................................ 40
pilocarpine tab 5mg................................... 38
pilocarpine tab 7.5mg................................ 38
pindolol tab 10mg ..................................... 33
pindolol tab 5mg ....................................... 33
pioglit/glim tab 30-2mg ............................ 32
pioglit/glim tab 30-4mg ............................ 27
pioglita/met tab 15-500mg ........................ 27
pioglita/met tab 15-850mg ........................ 27
pioglitazone tab 15mg ............................... 27
pioglitazone tab 30mg ............................... 27
pioglitazone tab 45mg ............................... 27
piper/tazoba inj 3-0.375g ............................ 6
piper/tazoba inj 4-0.5gm ............................. 6
pirmella tab 1/35 ....................................... 44
piroxicam cap 10mg .................................... 4
piroxicam cap 20mg .................................... 4
plasma-lyte inj -148 .................................. 53
plasma-lyte inj 56/d5w .............................. 53
podofilox sol 0.5% .................................... 40
polyeth glyc pow 3350 nf ......................... 42
polymyxin b/ sol trimethp ......................... 49
pomalyst cap 1mg ..................................... 18
pomalyst cap 2mg ..................................... 18
pomalyst cap 3mg ..................................... 18
pomalyst cap 4mg ..................................... 18
pot chloride cap 10meq er ......................... 53
pot chloride cap 8meq er ........................... 53
pot chloride inj 10meq .............................. 53
pot chloride inj 20meq .............................. 53
pot chloride inj 2meq/ml ........................... 53
pot chloride inj 40meq .............................. 53
pot chloride liq 10% .................................. 53
pot chloride liq 20% .................................. 53
pot chloride tab 8meq er ........................... 53
pot citrate tab 1080mg .............................. 53
pot citrate tab 1620mg .............................. 53
pot citrate tab 540mg er ............................ 53
pot cl micro tab 10meq er ......................... 53
pot cl micro tab 20meq er ......................... 53
potiga tab 200mg......................................... 7
potiga tab 300mg......................................... 7
potiga tab 400mg......................................... 7
potiga tab 50mg........................................... 7
pradaxa cap 150mg ................................... 28
pradaxa cap 75mg ..................................... 28
pramipexole tab 0.125mg.......................... 20
pramipexole tab 0.25mg............................ 20
pramipexole tab 0.5mg.............................. 20
pramipexole tab 0.75mg............................ 20
pramipexole tab 1.5mg.............................. 20
pramipexole tab 1mg................................. 20
prandimet tab 1-500mg ............................. 27
prandimet tab 2-500mg ............................. 27
prandin tab 0.5mg ..................................... 27
prandin tab 1mg ........................................ 27
prandin tab 2mg ........................................ 27
pravastatin tab 10mg ................................. 36
pravastatin tab 20mg ................................. 36
pravastatin tab 40mg ................................. 36
pravastatin tab 80mg ................................. 36
prazosin hcl cap 1mg ................................ 29
prazosin hcl cap 2mg ................................ 29
prazosin hcl cap 5mg ................................ 29
pred sod pho sol 1% op ............................. 49
75
pred sod pho sol 5mg/5ml ......................... 43
prednicarbat cre 0.1% ............................... 40
prednicarbat oin 0.1% ............................... 40
prednisolone sol 15mg/5ml ....................... 43
prednisolone sol 25mg/5ml ....................... 43
prednisolone sus 1% op ............................ 49
prednisolone tab 10mg odt ........................ 43
prednisolone tab 15mg odt ........................ 43
prednisolone tab 30mg odt ........................ 43
prednisone sol 5mg/5ml ............................ 43
prednisone tab 10mg ................................. 43
prednisone tab 1mg ................................... 43
prednisone tab 2.5mg ................................ 43
prednisone tab 20mg ................................. 43
prednisone tab 50mg ................................. 43
prednisone tab 5mg ................................... 43
premarin inj 25mg ..................................... 44
premarin tab 0.3mg ................................... 44
premarin tab 0.45mg ................................. 44
premarin tab 0.625mg ............................... 44
premarin tab 0.9mg ................................... 44
premarin tab 1.25mg ................................. 44
premarin vag cre 0.625mg ........................ 42
premasol sol 6% ........................................ 53
premphase tab ........................................... 44
prempro tab .625-2.5 ................................. 44
prempro tab 0.3-1.5 ................................... 44
prempro tab 0.45-1.5 ................................. 44
prempro tab 0.625-5 .................................. 44
prenatal vitamin tablet............................... 54
prepopik pak.............................................. 42
prevalite pow 4gm..................................... 36
prezcobix tab 800-150............................... 23
prezista sus 100mg/ml............................... 24
prezista tab 150mg .................................... 24
prezista tab 600mg .................................... 24
prezista tab 75mg ...................................... 24
prezista tab 800mg .................................... 24
priftin tab 150mg....................................... 15
primaquine tab 26.3mg ............................. 15
primidone tab 250mg .................................. 8
primidone tab 50mg .................................... 8
pristiq tab 100mg ...................................... 12
pristiq tab 25mg ........................................ 12
pristiq tab 50mg ........................................ 12
privigen inj 20grams ................................. 47
proair hfa aer ............................................. 51
probenecid tab 500mg ............................... 14
procainamide inj 100mg/ml ...................... 31
procalamine inj 3% ................................... 54
prochlorper inj 10mg/2ml ......................... 21
prochlorper sup 25mg ............................... 21
prochlorper tab 10mg ................................ 21
prochlorper tab 5mg .................................. 21
procrit inj 10000/ml .................................. 29
procrit inj 2000/ml .................................... 29
procrit inj 20000/ml .................................. 29
procrit inj 3000/ml .................................... 29
procrit inj 4000/ml .................................... 29
procrit inj 40000/ml .................................. 29
procto-pak cre 1% ..................................... 40
proctozone cre -hc 2.5% ........................... 40
proglycem sus 50mg/ml ............................ 27
prograf inj 5mg/ml .................................... 46
prolastin-c inj 1000mg .............................. 51
proleukin inj 22mu .................................... 18
prolia sol 60mg/ml .................................... 48
promacta tab 12.5mg ................................. 29
promacta tab 25mg .................................... 29
promacta tab 50mg .................................... 29
promacta tab 75mg .................................... 29
propafenone tab 150mg............................. 31
propafenone tab 225mg............................. 31
propafenone tab 300mg............................. 31
propran/hctz tab 40/25 .............................. 32
propran/hctz tab 80/25 .............................. 32
propranolol cap 120mg er ......................... 33
propranolol cap 160mg er ......................... 33
propranolol cap 60mg er ........................... 33
propranolol cap 80mg er ........................... 33
propranolol inj 1mg/ml ............................. 33
propranolol sol 20mg/5ml ......................... 33
propranolol sol 40mg/5ml ......................... 33
propranolol tab 10mg ................................ 33
propranolol tab 20mg ................................ 33
propranolol tab 40mg ................................ 33
propranolol tab 60mg ................................ 33
propranolol tab 80mg ................................ 33
propylthiour tab 50mg............................... 46
proquad inj ................................................ 47
prosol inj 20% ........................................... 54
protriptylin tab 10mg ................................ 13
protriptylin tab 5mg .................................. 13
pulmozyme sol 1mg/ml............................. 51
purixan sus 20mg/ml ................................. 15
pyrazinamide tab 500mg ........................... 15
pyridostigm tab 60mg ............................... 14
Q
qnapril/hctz tab 10-12.5 ............................ 32
qnapril/hctz tab 20-12.5 ............................ 32
qnapril/hctz tab 20-25mg .......................... 32
quadracel inj .............................................. 47
qudexy xr cap 100/24hr .............................. 9
qudexy xr cap 150/24hr .............................. 9
qudexy xr cap 200/24hr .............................. 9
qudexy xr cap 25/24hr ................................ 9
qudexy xr cap 50/24hr ................................ 9
quetiapine tab 100mg ................................ 22
quetiapine tab 200mg ................................ 22
quetiapine tab 25mg .................................. 22
quetiapine tab 300mg ................................ 22
76
quetiapine tab 400mg ................................ 22
quetiapine tab 50mg .................................. 22
quinapril tab 10mg .................................... 30
quinapril tab 20mg .................................... 30
quinapril tab 40mg .................................... 30
quinapril tab 5mg ...................................... 30
quinidine gl tab 324mg cr ......................... 31
quinidine su tab 200mg ............................. 31
quinidine su tab 300mg ............................. 31
quinidine su tab 300mg er ......................... 31
quinine sulf cap 324mg ............................. 19
qvar aer 40mcg .......................................... 50
qvar aer 80mcg .......................................... 50
R
rabavert inj ................................................ 47
raloxifene tab 60mg .................................. 44
ramipril cap 1.25mg .................................. 30
ramipril cap 10mg ..................................... 30
ramipril cap 2.5mg .................................... 30
ramipril cap 5mg ....................................... 30
ranexa tab 1000mg .................................... 35
ranexa tab 500mg ...................................... 35
ranitidine cap 150mg................................. 41
ranitidine cap 300mg................................. 41
ranitidine inj 150/6ml................................ 41
ranitidine syp 15mg/ml ............................. 41
ranitidine tab 150mg ................................. 41
ranitidine tab 300mg ................................. 41
rapaflo cap 4mg......................................... 42
rapaflo cap 8mg......................................... 42
rapamune sol 1mg/ml ................................ 46
rebif inj 22/0.5 ........................................... 38
rebif inj 44/0.5 ........................................... 38
rebif titrtn sol pack .................................... 38
reclast inj 5/100ml..................................... 48
recombiva hb inj 10mcg/ml ...................... 47
recombiva hb inj 5mcg/0.5 ....................... 48
recombiva-hb inj 40mcg/ml ...................... 48
regranex gel 0.01% ................................... 40
relenza mis diskhale .................................. 24
relistor inj 12/0.6ml................................... 41
relistor inj 8/0.4ml..................................... 41
relpax tab 20mg......................................... 14
relpax tab 40mg......................................... 14
remicade inj 100mg................................... 46
renvela pak 0.8gm ..................................... 42
renvela pak 2.4gm ..................................... 42
renvela tab 800mg ..................................... 42
repaglinide tab 0.5mg................................ 27
repaglinide tab 1mg................................... 27
repaglinide tab 2mg................................... 27
rescriptor tab 100 mg ................................ 23
rescriptor tab 200mg ................................. 23
reserpine tab 0.1mg ................................... 35
restasis emu 0.05%.................................... 49
retrovir inj 10mg/ml .................................. 23
revatio inj .................................................. 51
revlimid cap 10mg .................................... 15
revlimid cap 15mg .................................... 15
revlimid cap 2.5mg ................................... 15
revlimid cap 20mg .................................... 15
revlimid cap 25mg .................................... 15
revlimid cap 5mg ...................................... 15
reyataz cap 150mg .................................... 24
reyataz cap 200mg .................................... 24
reyataz cap 300mg .................................... 24
reyataz pow 50mg ..................................... 24
rheumatrex tab 2.5mg ............................... 18
ribapak pak 1000/day ................................ 24
ribapak pak 800/day .................................. 24
ribasphere cap 200mg ............................... 24
ribasphere tab 200mg ................................ 24
ribasphere tab 400mg ................................ 24
ribavirin cap 200mg .................................. 24
ribavirin tab 200mg ................................... 24
rifabutin cap 150mg .................................. 14
rifampin cap 150mg .................................. 15
rifampin cap 300mg .................................. 15
rifampin inj 600 mg .................................. 15
rifater tab ................................................... 15
riluzole tab 50mg ...................................... 38
rimantadine tab 100mg ............................. 24
ringers inj .................................................. 53
ringers irr sol ............................................. 49
riomet sol .................................................. 27
risperdal inj 12.5mg .................................. 22
risperdal inj 25mg ..................................... 22
risperdal inj 37.5mg .................................. 22
risperdal inj 50mg ..................................... 22
risperidone sol 1mg/ml ............................. 22
risperidone tab 0.25 odt............................. 22
risperidone tab 0.25mg.............................. 22
risperidone tab 0.5mg................................ 22
risperidone tab 0.5mg od........................... 22
risperidone tab 1mg................................... 22
risperidone tab 1mg odt ............................ 22
risperidone tab 2mg................................... 22
risperidone tab 2mg odt ............................ 22
risperidone tab 3mg................................... 22
risperidone tab 3mg odt ............................ 22
risperidone tab 4mg................................... 22
risperidone tab 4mg odt ............................ 22
rituxan inj 500mg ...................................... 18
rivastigmine cap 1.5mg ............................. 10
rivastigmine cap 3mg ................................ 10
rivastigmine cap 4.5mg ............................. 10
rivastigmine cap 6mg ................................ 10
ropinirole tab 0.25mg ................................ 20
ropinirole tab 0.5mg .................................. 20
ropinirole tab 1mg ..................................... 20
ropinirole tab 2mg ..................................... 20
77
ropinirole tab 3mg ..................................... 20
ropinirole tab 4mg ..................................... 20
ropinirole tab 5mg ..................................... 20
rotarix sus .................................................. 48
rotateq sol .................................................. 48
rozerem tab 8mg ....................................... 52
S
sabril pow 500mg ........................................ 8
sabril tab 500mg .......................................... 8
saizen inj 5mg ........................................... 44
saizen inj 8.8mg ........................................ 44
samsca tab 15mg ....................................... 52
samsca tab 30mg ....................................... 52
sancuso dis 3.1mg ..................................... 13
sandimmune cap 100mg ........................... 46
sandimmune cap 25mg ............................. 46
sandimmune sol 100mg/ml ....................... 46
sandostatin kit lar 10mg ............................ 45
sandostatin kit lar 20mg ............................ 46
sandostatin kit lar 30mg ............................ 46
santyl oin 250/gm ...................................... 40
saphris sub 10mg....................................... 22
saphris sub 5mg......................................... 22
savella mis titr pak .................................... 38
savella tab 100mg ..................................... 38
savella tab 12.5mg .................................... 38
savella tab 25mg ....................................... 38
savella tab 50mg ....................................... 38
seconal cap 100mg .................................... 52
selegiline cap 5mg..................................... 20
selegiline tab 5mg ..................................... 20
selenium sul lot 2.5% ................................ 40
selzentry tab 150mg .................................. 23
selzentry tab 300mg .................................. 23
sensipar tab 30mg ..................................... 45
sensipar tab 60mg ..................................... 45
sensipar tab 90mg ..................................... 45
serevent dis aer 50mcg .............................. 51
seroquel xr tab 150mg ............................... 22
seroquel xr tab 200mg ............................... 22
seroquel xr tab 300mg ............................... 22
seroquel xr tab 400mg ............................... 22
seroquel xr tab 50mg ................................. 22
sertraline con 20mg/ml ............................. 12
sertraline tab 100mg .................................. 12
sertraline tab 25mg .................................... 12
sertraline tab 50mg .................................... 12
signifor inj 0.3mg/ml ................................ 46
signifor inj 0.6mg/ml ................................ 46
signifor inj 0.9mg/ml ................................ 46
sildenafil tab 20mg .................................... 51
silver sulfa cre 1% ..................................... 40
simulect inj 20mg...................................... 46
simvastatin tab 10mg ................................ 36
simvastatin tab 20mg ................................ 36
simvastatin tab 40mg ................................ 36
simvastatin tab 5mg .................................. 36
simvastatin tab 80mg ................................ 36
sirolimus tab 0.5mg................................... 46
sirolimus tab 1mg...................................... 46
sirolimus tab 2mg...................................... 46
sirturo tab 100mg ...................................... 15
smz/tmp ds tab 800-160 .............................. 7
smz-tmp inj 400-80/5 .................................. 7
smz-tmp sus 200-40/5 ................................. 7
smz-tmp tab 400-80mg ............................... 7
sod chloride inj 0.45% .............................. 53
sod chloride inj 0.9% ................................ 53
sod chloride inj 2.5/ml .............................. 53
sod chloride inj 3% ................................... 53
sod chloride inj 5% ................................... 53
sod lactate inj 5meq/ml ............................. 53
sod poly sul sus 15gm/60 .......................... 52
sod sulfacet sol 10% op............................. 49
sodium chlor sol 0.9% irr .......................... 42
sodium fluoride 2.2 mg ............................. 54
solaraze gel 3% w/w ................................. 40
soltamox sol 10mg/5ml ............................. 38
somatuline inj 120/.5ml ............................ 46
somatuline inj 60/0.2ml ............................ 46
somatuline inj 90/0.3ml ............................ 46
somavert inj 10mg..................................... 46
somavert inj 15mg..................................... 46
somavert inj 20mg..................................... 46
sorine tab 120mg ....................................... 33
sorine tab 160mg ....................................... 33
sorine tab 240mg ....................................... 33
sorine tab 80mg ......................................... 33
sotalol af tab 120mg .................................. 33
sotalol hcl tab 160mg ................................ 33
sotalol hcl tab 240mg ................................ 33
sotalol hcl tab 80mg .................................. 33
sovaldi tab 400mg ..................................... 24
spiriva cap handihlr ................................... 50
spiriva spr respimat ................................... 50
spirono/hctz tab 25/25 ............................... 32
spironolact tab 100mg ............................... 35
spironolact tab 25mg ................................. 35
spironolact tab 50mg ................................. 35
sprycel tab 100mg ..................................... 18
sprycel tab 140mg ..................................... 18
sprycel tab 20mg ....................................... 18
sprycel tab 50mg ....................................... 18
sprycel tab 70mg ....................................... 18
sprycel tab 80mg ....................................... 18
ssd cre 1% ................................................. 40
stavudine cap 15mg................................... 23
stavudine cap 20mg................................... 23
stavudine cap 30mg................................... 23
stavudine cap 40mg................................... 23
stavudine sol 1mg/ml ................................ 50
78
stivarga tab 40mg ...................................... 18
strattera cap 100mg ................................... 37
strattera cap 10mg ..................................... 37
strattera cap 18mg ..................................... 38
strattera cap 25mg ..................................... 38
strattera cap 40mg ..................................... 38
strattera cap 60mg ..................................... 38
strattera cap 80mg ..................................... 38
streptomycin inj 1gm .................................. 4
stribild tab ................................................. 23
suboxone mis 12-3mg ................................. 3
suboxone mis 4-1mg ................................... 3
sucralfate tab 1gm ..................................... 42
sulf/pred na sol op ..................................... 49
sulfacetamid sus 10% ................................ 40
sulfadiazine tab 500mg ............................... 7
sulfasalazin tab 500mg .............................. 48
sulfazine ec tab 500mg.............................. 48
sulindac tab 150mg ..................................... 4
sulindac tab 200mg ..................................... 4
sumatriptan inj 6mg/0.5 ............................ 14
sumatriptan tab 100mg .............................. 14
sumatriptan tab 25mg ................................ 14
sumatriptan tab 50mg ................................ 14
suprax cap 400mg ....................................... 5
suprax sus 200/5ml ..................................... 5
surmontil cap 100mg................................. 13
surmontil cap 25mg................................... 13
surmontil cap 50mg................................... 13
sustiva cap 200mg ..................................... 23
sustiva cap 50mg ....................................... 23
sustiva tab 600mg ..................................... 23
sutent cap 12.5mg ..................................... 18
sutent cap 25mg ........................................ 18
sutent cap 37.5mg ..................................... 18
sutent cap 50mg ........................................ 18
sylatron kit 296mcg................................... 18
sylatron kit 444mcg................................... 18
sylatron kit 888mcg................................... 18
symbicort aer 160-4.5 ............................... 51
symbicort aer 80-4.5 ................................. 51
symlinpen 60 inj 1000mcg ........................ 27
symlnpen 120 inj 1000mcg ....................... 27
synagis inj 50mg ....................................... 47
synarel sol 2mg/ml .................................... 46
synercid inj 500mg ...................................... 4
synribo inj 3.5mg ...................................... 18
synthroid tab 100mcg ................................ 45
synthroid tab 112mcg ................................ 45
synthroid tab 125mcg ................................ 45
synthroid tab 137mcg ................................ 45
synthroid tab 150mcg ................................ 45
synthroid tab 175mcg ................................ 45
synthroid tab 200mcg ................................ 45
synthroid tab 25mcg .................................. 45
synthroid tab 300mcg ................................ 45
synthroid tab 50mcg .................................. 45
synthroid tab 75mcg .................................. 45
synthroid tab 88mcg .................................. 45
syprine cap 250mg .................................... 15
T
tabloid tab 40mg ....................................... 15
tacrolimus cap 0.5mg ................................ 46
tacrolimus cap 1mg ................................... 46
tacrolimus cap 5mg ................................... 46
tafinlar cap 50mg ...................................... 18
tafinlar cap 75mg ...................................... 18
tamiflu cap 30mg ...................................... 24
tamiflu cap 45mg ...................................... 24
tamiflu cap 75mg ...................................... 24
tamiflu sus 6mg/ml ................................... 24
tamoxifen tab 10mg .................................. 18
tamoxifen tab 20mg .................................. 18
tamsulosin cap 0.4mg................................ 42
tarceva tab 100mg ..................................... 18
tarceva tab 150mg ..................................... 18
tarceva tab 25mg ....................................... 18
targretin cap 75mg .................................... 18
tarka tab 1-240 cr ...................................... 32
tarka tab 2-180 cr ...................................... 32
tarka tab 2-240 cr ...................................... 32
tarka tab 4-240 cr ...................................... 32
tasigna cap 150mg..................................... 18
tasigna cap 200mg..................................... 18
taxotere inj 80mg/4ml ............................... 18
tazorac cre 0.05% ...................................... 40
tazorac cre 0.1% ........................................ 40
tazorac gel 0.05% ...................................... 40
tazorac gel 0.1% ........................................ 40
taztia xt cap 120mg/24 .............................. 34
taztia xt cap 180mg/24 .............................. 34
taztia xt cap 240mg/24 .............................. 34
taztia xt cap 300mg/24 .............................. 34
taztia xt cap 360mg/24 .............................. 34
teflaro inj 400mg ......................................... 5
teflaro inj 600mg ......................................... 5
tegretol-xr tab 100mg ................................ 10
tekamlo tab 150-10mg .............................. 32
tekamlo tab 150-5mg ................................ 32
tekamlo tab 300-10mg .............................. 32
tekamlo tab 300-5mg ................................ 32
tekturna hct tab 150-12.5 .......................... 32
tekturna hct tab 150-25mg ........................ 32
tekturna hct tab 300-12.5 .......................... 32
tekturna hct tab 300-25mg ........................ 32
tekturna tab 150mg ................................... 35
tekturna tab 300mg ................................... 35
telmis/amlod tab 40-10mg ........................ 32
telmis/amlod tab 40-5mg .......................... 32
telmis/amlod tab 80-10mg ........................ 32
telmis/amlod tab 80-5mg .......................... 32
79
telmisartan tab 20mg ................................. 30
telmisartan tab 40mg ................................. 30
telmisartan tab 80mg ................................. 30
temazepam cap 15mg ................................ 52
temazepam cap 22.5mg ............................. 52
temazepam cap 30mg ................................ 52
temazepam cap 7.5mg ............................... 52
tenivac inj 5-2lf ......................................... 48
terazosin cap 10mg ................................... 29
terazosin cap 1mg ..................................... 29
terazosin cap 2mg ..................................... 29
terazosin cap 5mg ..................................... 29
terbutaline inj 1mg/ml ............................... 51
terconazole cre 0.4% ................................. 42
terconazole sup 80mg ............................... 42
testost cyp inj 200mg/ml ........................... 43
testost enan inj 200mg/ml ......................... 43
testred cap 10mg ....................................... 43
tet/dip tox inj 2-2 lf ................................... 48
tetanus tox inj 5lf ads ................................ 48
teveten hct tab 600-12.5 ............................ 32
teveten hct tab 600-25mg .......................... 32
thalomid cap 100mg .................................. 15
thalomid cap 150mg .................................. 15
thalomid cap 200mg .................................. 15
thalomid cap 50mg .................................... 15
theophylline tab 100mg cr ........................ 50
theophylline tab 200mg cr ........................ 50
theophylline tab 300mg er ........................ 50
theophylline tab 450mg er ........................ 50
theophylline tab 600mg er ........................ 50
thioridazine tab 100mg ............................. 21
thioridazine tab 10mg ............................... 21
thioridazine tab 25mg ............................... 21
thioridazine tab 50mg ............................... 21
thiothixene cap 10mg ................................ 21
thiothixene cap 1mg .................................. 21
thiothixene cap 2mg .................................. 21
thiothixene cap 5mg .................................. 21
thymoglobuln inj 25mg ............................. 47
tiagabine tab 2mg ........................................ 8
tiagabine tab 4mg ........................................ 8
ticlopidine tab 250mg ............................... 29
tikosyn cap 125mcg .................................. 31
tikosyn cap 250mcg .................................. 31
tikosyn cap 500mcg .................................. 31
timolol gel sol 0.25% op ........................... 50
timolol gel sol 0.5% op ............................. 50
timolol mal sol 0.25% op .......................... 50
timolol mal sol 0.5% op ............................ 50
timolol mal tab 10mg ................................ 33
timolol mal tab 20mg ................................ 33
timolol mal tab 5mg .................................. 33
tivicay tab 50mg ........................................ 23
tizanidine tab 2mg ..................................... 51
tizanidine tab 4mg ..................................... 51
tobra/dexame sus 0.3-0.1% ....................... 49
tobramycin inj 10mg/ml .............................. 4
tobramycin inj 80mg/2ml ............................ 4
tobramycin neb 300/5ml ............................. 4
tobramycin sol 0.3% op ............................ 49
tolazamide tab 250mg ............................... 27
tolazamide tab 500mg ............................... 27
tolbutamide tab 500mg ............................. 27
tolmetin sod cap 400mg .............................. 4
tolmetin sod tab 600mg............................... 4
tolterodine tab 1mg ................................... 42
tolterodine tab 2mg ................................... 42
topiramate cap 15mg ................................... 9
topiramate cap 25mg ................................... 9
topiramate cap er 100mg ............................. 9
topiramate cap er 150mg ............................. 9
topiramate cap er 200mg ............................. 9
topiramate cap er 25mg ............................... 9
topiramate cap er 50mg ............................... 9
topiramate tab 100mg ............................... 14
topiramate tab 200mg ................................. 9
topiramate tab 25mg ................................... 9
topiramate tab 50mg ................................... 9
toposar inj 1gm/50ml ................................ 18
topotecan inj 4mg ...................................... 18
torisel sol 25mg/ml ................................... 18
torsemide tab 100mg ................................. 35
torsemide tab 10mg ................................... 35
torsemide tab 20mg ................................... 35
torsemide tab 5mg ..................................... 35
tpn electrol inj ........................................... 53
tracleer tab 125mg..................................... 51
tracleer tab 62.5mg.................................... 51
tramadl/apap tab 37.5-325 .......................... 2
tramadol hcl tab 50mg ................................ 2
trando/verap tab 1-240 cr .......................... 32
trando/verap tab 2-180 cr .......................... 32
trando/verap tab 2-240 cr .......................... 32
trando/verap tab 4-240 cr .......................... 32
trandolapril tab 1mg .................................. 30
trandolapril tab 2mg .................................. 30
trandolapril tab 4mg .................................. 30
tranex acid inj 100mg/ml .......................... 29
tranex acid tab 650mg ............................... 29
transderm-sc dis 1.5mg ............................. 13
tranylcyprom tab 10mg ............................. 11
travasol inj 10% ........................................ 54
travatan z dro 0.004% ............................... 49
trazodone tab 100mg ................................. 11
trazodone tab 150mg ................................. 11
trazodone tab 300mg ................................. 11
trazodone tab 50mg ................................... 11
treanda inj 100mg ..................................... 18
treanda inj 45/0.5ml .................................. 18
trecator tab 250mg .................................... 15
80
trelstar dep inj 3.75mg .............................. 18
trelstar la inj 11.25mg ............................... 18
trelstar mix inj 22.5mg .............................. 18
tretinoin cap 10mg .................................... 18
trexall tab 10mg ........................................ 47
trexall tab 15mg ........................................ 47
trexall tab 5mg .......................................... 47
trexall tab 7.5mg ....................................... 47
triamcin ace inj 10mg/ml .......................... 43
triamcin ace inj 40mg/ml .......................... 43
triamcin/ora pst 0.1% ................................ 38
triamcinolon cre 0.025% ........................... 40
triamcinolon cre 0.1% ............................... 40
triamcinolon cre 0.5% ............................... 40
triamcinolon lot 0.025%............................ 40
triamcinolon lot 0.1%................................ 40
triamcinolon oin 0.025%........................... 40
triamcinolon oin 0.1%............................... 40
triamcinolon oin 0.5%............................... 40
triamt/hctz cap 50-25mg ........................... 32
triamt/hctz tab 37.5-25 .............................. 32
triamt/hctz tab 75-50mg ............................ 32
triazolam tab 0.125mg .............................. 52
triazolam tab 0.25mg ................................ 52
tribenzor20- tab 5-12.5mg ........................ 32
tribenzor40- tab 10-12.5............................ 32
tribenzor40- tab 10-25mg ......................... 32
tribenzor40- tab 5-12.5mg ........................ 32
tribenzor40- tab 5-25mg ........................... 32
triderm cre 0.1%........................................ 40
trifluoperaz tab 10mg ................................ 21
trifluoperaz tab 1mg .................................. 21
trifluoperaz tab 2mg .................................. 21
trifluoperaz tab 5mg .................................. 21
trifluridine sol 1% op ................................ 49
trihexyphen elx 0.4mg/ml ......................... 19
trihexyphen tab 2mg ................................. 19
trihexyphen tab 5mg ................................. 19
trimethoprim tab 100mg ............................. 4
trinessa tab ................................................ 44
tri-previfem tab ......................................... 44
trisenox sol 10mg/10m.............................. 18
tri-sprintec tab ........................................... 44
triumeq tab ................................................ 23
trokendi xr cap 100mg ................................ 9
trokendi xr cap 200mg ................................ 9
trokendi xr cap 25mg .................................. 9
trokendi xr cap 50mg .................................. 9
trumenba inj .............................................. 48
truvada tab 200-300 .................................. 23
twinrix inj .................................................. 48
tybost tab 150mg ....................................... 24
tygacil inj 50mg .......................................... 4
tykerb tab 250mg ...................................... 18
typhim vi inj .............................................. 48
tysabri inj 300/15ml .................................. 38
tyzeka tab 600mg ...................................... 24
tyzine ped dro 0.05% ................................ 51
U
uceris tab 9mg ........................................... 43
u-cort cre 1% ............................................. 40
uloric tab 40mg ......................................... 14
uloric tab 80mg ......................................... 14
unithroid tab 100mcg ................................ 45
unithroid tab 112mcg ................................ 45
unithroid tab 125mcg ................................ 45
unithroid tab 150mcg ................................ 45
unithroid tab 175mcg ................................ 45
unithroid tab 200mcg ................................ 45
unithroid tab 25mcg .................................. 45
unithroid tab 300mcg ................................ 45
unithroid tab 50mcg .................................. 45
unithroid tab 75mcg .................................. 45
unithroid tab 88mcg .................................. 45
ursodiol tab 250mg ................................... 41
ursodiol tab 500mg ................................... 41
uvadex inj 20mcg/ml................................. 18
V
valacyclovir tab 1gm ................................. 25
valacyclovir tab 500mg ............................. 25
valchlor gel 0.016% .................................. 40
valcyte sol 50mg/ml .................................. 22
valganciclov tab 450mg ............................ 22
valproate inj 500/5ml .................................. 8
valproic acd cap 250mg .............................. 8
valproic acd syp 250/5ml ............................ 8
valsart/hctz tab 160-12.5 ........................... 27
valsart/hctz tab 160-25mg ......................... 32
valsart/hctz tab 320-12.5 ........................... 32
valsart/hctz tab 320-25mg ......................... 32
valsart/hctz tab 80-12.5 ............................. 32
vancomycin cap 125mg .............................. 5
vancomycin cap 250mg .............................. 5
vancomycin inj 1000mg .............................. 5
vancomycin inj 10gm .................................. 5
vancomycin inj 500mg ................................ 5
vandazole gel 0.75% ................................. 42
vaqta inj 25/0.5ml ..................................... 48
vaqta inj 50unt/ml ..................................... 48
varivax inj ................................................. 48
vectibix inj 100mg .................................... 18
velcade inj 3.5mg ...................................... 18
venlafaxine cap 150mg er ......................... 12
venlafaxine cap 37.5 er ............................. 12
venlafaxine cap 75mg er ........................... 12
venlafaxine tab 100mg .............................. 12
venlafaxine tab 150mg er .......................... 12
venlafaxine tab 225mg er .......................... 12
venlafaxine tab 25mg ................................ 12
venlafaxine tab 37.5 er .............................. 12
venlafaxine tab 37.5mg ............................. 12
81
venlafaxine tab 50mg ................................ 12
venlafaxine tab 75mg ................................ 12
venlafaxine tab 75mg er ............................ 12
ventavis sol 10mcg/ml .............................. 51
ventavis sol 20mcg/ml .............................. 51
ventolin hfa aer ......................................... 51
verapamil cap 100mg er ............................ 34
verapamil cap 120mg er ............................ 34
verapamil cap 180mg er ............................ 34
verapamil cap 200mg er ............................ 34
verapamil cap 240mg er ............................ 34
verapamil cap 300mg er ............................ 34
verapamil cap 360mg sr ............................ 34
verapamil inj 2.5mg/ml ............................. 34
verapamil tab 120mg................................. 34
verapamil tab 120mg er ............................ 34
verapamil tab 180mg er ............................ 34
verapamil tab 240mg er ............................ 34
verapamil tab 40mg................................... 34
verapamil tab 80mg................................... 34
versacloz sus 50mg/ml .............................. 22
vesicare tab 10mg ..................................... 42
vesicare tab 5mg ....................................... 42
victrelis cap 200mg ................................... 24
videx sol 2gm ............................................ 23
vigamox dro 0.5% ..................................... 49
viibryd kit .................................................. 11
viibryd tab 10mg ....................................... 11
viibryd tab 20mg ....................................... 11
viibryd tab 40mg ....................................... 11
vimpat inj 200mg/20 ................................. 10
vimpat sol 10mg/ml .................................. 10
vimpat tab 100mg ..................................... 10
vimpat tab 150mg ..................................... 10
vimpat tab 200mg ..................................... 10
vimpat tab 50mg ....................................... 10
vinblastine inj 1mg/ml .............................. 18
vincasar pfs inj 1mg/ml ............................. 18
vincristine inj 1mg/ml ............................... 19
vinorelbine inj 10mg/ml ............................ 19
viracept tab 250mg .................................... 24
viracept tab 625mg .................................... 24
viramune xr tab 100mg ............................. 23
virazole inh 6gm ....................................... 24
viread pow 40mg/gm ................................ 23
viread tab 150mg....................................... 23
viread tab 200mg....................................... 23
viread tab 250mg....................................... 23
viread tab 300mg....................................... 23
vitekta tab 150mg ...................................... 24
vitekta tab 85mg ........................................ 24
voltaren gel 1% ......................................... 40
voriconazole inj 200mg............................. 14
voriconazole sus 40mg/ml ........................ 14
voriconazole tab 200mg ............................ 14
votrient tab 200mg .................................... 19
vyfemla tab 0.4-35 .................................... 44
vytorin tab 10-10mg .................................. 35
vytorin tab 10-20mg .................................. 35
vytorin tab 10-40mg .................................. 35
vytorin tab 10-80mg .................................. 35
W
warfarin tab 10mg ..................................... 28
warfarin tab 1mg ....................................... 28
warfarin tab 2.5mg .................................... 28
warfarin tab 2mg ....................................... 28
warfarin tab 3mg ....................................... 28
warfarin tab 4mg ....................................... 28
warfarin tab 5mg ....................................... 28
warfarin tab 6mg ....................................... 28
warfarin tab 7.5mg .................................... 28
welchol pak 3.75gm .................................. 36
welchol tab 625mg .................................... 36
X
xalkori cap 200mg..................................... 19
xalkori cap 250mg..................................... 19
xarelto star tab 15/20mg............................ 28
xarelto tab 10mg ....................................... 28
xarelto tab 15mg ....................................... 28
xarelto tab 20mg ....................................... 28
xenazine tab 12.5mg ................................. 38
xenazine tab 25mg .................................... 38
xgeva inj .................................................... 48
xifaxan tab 550mg....................................... 5
xolair sol 150mg ....................................... 51
xtandi cap 40mg ........................................ 19
xyrem sol 500mg/ml ................................. 52
Y
yervoy inj 50mg ........................................ 19
yf-vax inj ................................................... 48
Z
zafirlukast tab 10mg .................................. 50
zafirlukast tab 20mg .................................. 50
zaleplon cap 10mg .................................... 52
zaleplon cap 5mg ...................................... 52
zaltrap inj 100/4ml .................................... 19
zanosar inj 1gm ......................................... 19
zavesca cap 100mg ................................... 41
zazole cre 0.4% ......................................... 43
82
zazole cre 0.8% ......................................... 43
zelboraf tab 240mg ................................... 19
zemplar cap 1mcg ..................................... 48
zemplar cap 2mcg ..................................... 48
zenpep cap 10000unt................................. 41
zenpep cap 15000unt................................. 41
zenpep cap 20000unt................................. 41
zenpep cap 25000unt................................. 41
zenpep cap 3000unit ................................. 41
zenpep cap 5000unit ................................. 41
zetia tab 10mg ........................................... 36
ziagen sol 20mg/ml ................................... 23
zidovudine cap 100mg .............................. 23
zidovudine syp 50mg/5ml ......................... 23
zidovudine tab 300mg ............................... 23
zinecard inj 250mg .................................... 19
ziprasidone cap 20mg ............................... 22
ziprasidone cap 40mg ............................... 22
ziprasidone cap 60mg ............................... 22
ziprasidone cap 80mg ............................... 22
zirgan gel 0.15% ....................................... 49
zohydro er cap 10mg ................................... 1
zohydro er cap 15mg ................................... 1
zohydro er cap 20mg ................................... 1
zohydro er cap 30mg ................................... 2
zohydro er cap 40mg ................................... 2
zohydro er cap 50mg ................................... 2
zoledronic inj 4mg/5ml ............................. 48
zolinza cap 100mg .................................... 19
zolpidem tab 10mg.................................... 52
zolpidem tab 5mg...................................... 52
zometa inj 4mg/100................................... 48
zonisamide cap 100mg ................................ 8
zonisamide cap 25mg .................................. 8
zonisamide cap 50mg .................................. 8
zortress tab 0.25mg ................................... 47
zortress tab 0.5mg ..................................... 47
zortress tab 0.75mg ................................... 47
zostavax inj ............................................... 48
zubsolv sub 1.4-0.36 ................................... 3
zubsolv sub 5.7-1.4 ..................................... 3
zubsolv sub 8.6-2.1 ..................................... 3
zydelig tab 100mg ..................................... 19
zydelig tab 150mg ..................................... 19
zyflo cr tab 600mg .................................... 50
zyflo tab 600mg ........................................ 50
zykadia cap 150mg ................................... 19
zyprexa relp inj 210mg ............................. 22
zytiga tab 250mg ....................................... 19
zyvox sus 100mg/5m .................................. 5
zyvox tab 600mg ......................................... 5