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4157-D AL © Prime Therapeutics LLC 07/18

findJuly 2018

Blue Cross and Blue Shield of Alabama Generics Plus Drug Guide

Please consider talking to your doctor about prescribing preferred generic and brand

medications, which may help reduce your out-of-pocket costs. This list may help guide you

and your doctor in selecting an appropriate medication for you.

For questions about the Blue Cross and Blue Shield of Alabama 2018 Prescription Drug

Guide, call the customer service number on the back of your Blue Cross ID card or visit

AlabamaBlue.com/pharmacy.

The Prescription Drug Guide is regularly updated. Please visit

AlabamaBlue.com/pharmacy for the most up-to-date information.

Contents

Introduction ...................................................................... I

Member Prescription Benefit ........................................... I

Pharmacy and Therapeutics (P&T) Committee ............... I

Brand Drugs and Generic Drugs .................................... II

Classification ................................................................... II

Generic Substitution ....................................................... II

Specialty Drugs ............................................................... II

Compound Drugs ............................................................ II

Contraceptives ............................................................... III

Utilization Management ................................................. III

Prior Authorization ......................................................... III

Dispensing Limits ........................................................... III

Step Therapy ................................................................. III

Notice ............................................................................. III

Key ................................................................................. IV

Generic and Brand Name Drugs not Covered ............... 1

Therapeutic Class Drug List

Anti-Infective Drugs .................................................... 2

Cancer Drugs ............................................................. 8

Hormones, Diabetes and Related Drugs ................. 12Heart and Circulatory Drugs..................................... 20Respiratory Agents ................................................... 29Gastrointestinal Drugs .............................................. 31Genitourinary Drugs ................................................. 34Central Nervous System Drugs................................ 35Pain Relief Drugs ..................................................... 43Neuromuscular Drugs .............................................. 47Supplements ............................................................ 50Blood Modifying Drugs ............................................. 50Topical Drugs ........................................................... 51Miscellaneous Categories ........................................ 56Index ......................................................................... 60

To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or

go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for

and click on Search.

Prime Therapeutics LLC®, an independent company, provides pharmacy benefit management services for Blue Cross and Blue Shield of Alabama, an independent licensee of the Blue Cross and Blue Shield Association.

Blue Cross and Blue Shield of Alabama July 2018 Generics Plus Drug Guide I

Blue Cross and Blue Shield of Alabama July 2018 Generics Plus Drug Guide I

Introduction

Blue Cross and Blue Shield of Alabama is pleased to present the January 2018 Generics Plus Drug Guide.

The Generics Plus Drug Guide includes all Preferred Brand and a partial listing of Generic drugs. Brand name

drugs not listed in this Generics Plus Drug Guide are Non-Preferred Brands. Blue Cross may choose to not add a

drug to the Preferred Brand tier for reasons including safety or effectiveness, or because a similar, more cost-

effective drug is already available as a Preferred Brand or Generic drug. New brand drugs are Non-Preferred until

reviewed and approved for inclusion by the Pharmacy and Therapeutics (P&T) Committee.

Physicians are encouraged to prescribe drugs listed in this Generics Plus Drug Guide. Members are encouraged

to show this Generics Plus Drug Guide to their physician and pharmacist.

Member Prescription Benefit

The Blue Cross prescription benefit is multi-tiered, placing prescription drugs into one of the following copayment

levels.

Tier 1 – Lowest copayment – Generic drugs and select Preferred Brand drugs– listed and unlisted generic drugs

Tier 2 – Middle copayment – Preferred Brand drugs – all shown in the Prescription Drug Guide

Tier 3 – Highest copayment – Non-Preferred Brand drugs – unlisted

Tier 4 – Specialty (if applicable)

Coverage is limited to prescription products approved by the Food and Drug Administration (FDA) as evidenced

by a New Drug Application (NDA), Abbreviated New Drug Application (ANDA), or Biologics License Application

(BLA) on file. Any legal requirements or group specific benefits for coverage will supersede this (e.g., preventive

drugs per the Affordable Care Act).

In addition, some benefits (e.g., closed plan designs) do not provide coverage of the Non-Preferred Brand drugs

(Tier 3). The drug benefit includes most prescription drug classes, although some restrictions and exclusions

apply. For example, investigational drugs and drugs indicated for cosmetic purposes (e.g., Propecia for hair

growth) are not covered. Coverage and copayment levels vary depending on the plan. Drugs that require Prior

Authorization, Step Therapy, or that have Dispensing Limits are noted in the Generics Plus Drug Guide.

Pharmacy and Therapeutics (P&T) Committee

The P&T Committee is comprised of independent practicing physicians and pharmacists. The Committee meets

at least quarterly. Decisions to add or remove drugs from the Generics Plus Drug Guide are based on the drug’s

safety, efficacy, uniqueness and cost.

Members and physicians can view the most up-to-date version of the Generics Plus Drug Guide at

AlabamaBlue.com/pharmacy.

Blue Cross and Blue Shield of Alabama July 2018 Generics Plus Drug Guide II

Brand Drugs and Generic Drugs

Classification

Prescription drugs are classified as either a Brand drug or a Generic drug. Blue Cross uses the Brand or Generic

status provided by a nationally recognized company providing drug product information. The Brand/Generic status

for a specific drug/specific marketer can sometimes change over the life of a product in the marketplace and

change from Brand to Generic (or Generic to Brand). Such changes might change your copayment share. Brand

drug or Generic drug status is never based upon a product having a trade name. Generic drugs often have trade

names.

Generic Substitution

Blue Cross encourages generic utilization as a way to provide high quality drugs at a reduced cost. Generic drugs

are as safe and effective as their brand counterparts, but are usually less expensive. Generic drugs are

manufactured under the same strict requirements of FDA’s current Good Manufacturing Practice regulations

required for Brand drugs and cover the manufacturing, identity, strength, purity and quality.

An FDA-approved Generic drug may be substituted for the Brand counterpart when it:

• Contains the same active ingredient(s) as the brand drug

• Is identical in strength, dosage form, and route of administration

• Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile

To encourage use of Generic drugs, Tier 2 Preferred Brand drugs typically move to Tier 3 after an equivalent

generic version becomes available.

Specialty Drugs

Specialty drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis and

rheumatoid arthritis. Specialty drugs may be oral or injectable medications that can either be self-

administered or administered by a health care professional.

Some Blue Cross members must obtain their specialty drugs from the Pharmacy Select Network as the

preferred provider. If the preferred provider is not utilized you may be responsible for up to 100 percent of the

drug cost. Your plan may have a different coverage level for self-administered specialty drugs. If you have

questions about your coverage for specialty drugs or your prescription drug benefit, call the number on the

back of your ID card. A complete listing of specialty drugs is also available at AlabamaBlue.com/pharmacy.

Compound Drugs

Compound drugs are defined as a drug product made or modified to have characteristics that are specifically

prescribed for an individual patient when commercial drug products are not available or appropriate. To be

eligible for coverage, compounded drugs must contain at least one FDA-approved prescription ingredient and

must not be a copy of a commercially available product. All compounded drugs are subject to review and may

require prior authorization. Drugs used in compounded drugs may be subject to additional coverage criteria and

utilization management edits. Compounds are covered only when medically necessary. Compound drugs are

always classified as the highest cost-sharing non-specialty drug Tier.

Blue Cross and Blue Shield of Alabama July 2018 Generics Plus Drug Guide III

Contraceptives

Some or all of the contraceptive methods or prescription drugs listed in this Prescription Drug Guide may not be

covered under your plan because of your employer’s religious beliefs. To find out if contraceptive methods and

prescription drugs are excluded, you may find this information in the exclusions section of your benefit booklet or

you may contact your group administrator.

Utilization Management

Blue Cross is committed to supporting proper selection and use of drugs for its members. To help assure these

goals are met, several programs have been developed to promote drug selection that encourages both

effectiveness and safety. Detailed coverage criteria can be found at AlabamaBlue.com/pharmacy. Preferred

generic or brand drugs requiring Prior Authorization or Step Therapy, or drugs with Dispensing Limits will be

noted in the Therapeutic Class Drug List portion of the Generics Plus Drug Guide.

Prior Authorization

Some drugs require Prior Authorization (PA) because of their high potential for misuse or overuse. Drugs selected

for Prior Authorization may require that specific clinical criteria are met before the drugs will be covered under a

member’s prescription benefit. Approval is required for claims to process at network pharmacies.

Dispensing Limits

Dispensing Limits (DL) identify gender or age restrictions, and/or the maximum quantity that can be dispensed

over a specific period of time. Limits are in place to encourage appropriate drug utilization, enhance member

outcomes, and reduce drug benefit costs. Limits are typically developed based upon FDA-approved drug labeling.

Step Therapy

Step Therapy (ST) programs help manage the cost of expensive drugs by redirecting members to safe, effective

and less expensive alternatives. Drugs included in the Step Therapy program require a more cost-effective

prerequisite drug be tried before the Step Therapy drug will be approved for coverage. If the member meets the

prerequisite requirement, the requested drug will be covered automatically without requiring review. If prerequisite

drugs are not found in the claims history, Prior Authorization may be required. Drugs and drug categories included

in the Step Therapy program are subject to change.

Notice

The purpose of the Blue Cross Generics Plus Drug Guide is to provide a guide to coverage. The Generics Plus

Drug Guide is not intended to dictate to physicians how to practice medicine. Physicians should exercise their

medical judgment in providing the care they feel is most appropriate for their patients.

Neither this Generics Plus Drug Guide, nor the successful adjudication of a pharmacy claim, is guarantee of

payment.

Blue Cross and Blue Shield of Alabama July 2018 Generics Plus Drug Guide IV

Key cap ................................................................. capsules

chew ............................................................. chewable

conc .......................................................... concentrate

cr...................................................... controlled release

dr ........................................................ delayed release

ec ........................................................... enteric coated

effe............................................................ effervescent

equiv ........................................................... equivalent

er....................................................... extended release

inhal.............................................................. inhalation

inj .................................................................... injection

liq ......................................................................... liquid

lotn ...................................................................... lotion

nebu .............................................................. nebulizer

odt. ....................................... orally disintegrating tabs

oint ................................................................ ointment

ophth .......................................................... ophthalmic

osm ..................................................... osmotic release

powd ................................................................ powder

sa ....................................................... sustained action

sl .................................................................. sublingual

soln .................................................................. solution

sr ...................................................... sustained release

suppos ................................................... suppositories

susp ........................................................... suspension

tab ...................................................................... tablets

td ............................................................... transdermal

Selected generic and brand name drugs are not covered because of safety or effectiveness concerns. This list issubject to change.

Blue Cross and Blue Shield of Alabama July 2018 Generics Plus Drug Guide 1

Ala-QuinAlcortin AAmoxapineArmour ThyroidbenzphetamineButisolcarisoprodolcarisoprodol/aspirincarisoprodol/aspirin/codeinechlordiazepoxide/clidiniumCortane-B lotionCortane-B AqueousCortane-B-OticDemerol tabsDidrexdiethylpropionDiethylpropiondiethylpropion ext-releaseDonnatalDuraxinEgriftaEpifoamErgoloid mesylatesesterified estrogens/methyltestosteroneExodermExondys 51flavoxateFlumadineHalcionhydrocortisone/iodoquinolhydrocortisone/pramoxine/chloroxylenoliodoquinol/hydrocortisone/aloeisoxsuprine 10 mgIsoxsuprine 20 mgketoconazole tabsLibraxMeperidine oral solnmeperidine tabsmeprobamateMezparox-HC Forte

Nature-ThroidNefazodone 100 mg, 150 mg, 200 mgnefazodone 50 mg, 250 mgNovacortOpana ERopium tinctureOticin HC NRParegoricpb/hyoscy/atrop/scopol tabspentazocine/naloxonephendimetrazinePhendimetrazine ext-releasePhospholine IodidePramosonePramosone EPramoticpramoxinepramoxine/hydrocortisone topicalRegimexrimantadineSeconalSomathioridazinethyroid tabs, 15 mg, 30 mg, 60 mg, 90 mg, 120 mgThyrolarTriazolam 0.125 mgtriazolam 0.25 mgWesthroidWP Thyroidzileuton ext-releaseZyfloZyflo CR

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ANTI-INFECTIVE DRUGSPENICILLINSamoxicillin (trihydrate) cap

250 mg1

amoxicillin (trihydrate) cap500 mg

1

amoxicillin (trihydrate) for susp125 mg/5ml

1


1


1


1

amoxicillin (trihydrate) tab500 mg

1

amoxicillin (trihydrate) tab875 mg

1

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

1

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

1

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

1

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

1

amoxicillin & k clavulanate tab er12hr 1000-62.5 mg (Augmentinxr)

1

amoxicillin & k clavulanate tab250-125 mg

1

amoxicillin & k clavulanate tab500-125 mg (Augmentin)

1

amoxicillin & k clavulanate tab875-125 mg (Augmentin)

1

AMOXICILLIN/CLAVULANATE P– amoxicillin & k clavulanatechew tab 200-28.5 mg

2

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

2

AMPICILLIN – ampicillin cap 500mg

2

dicloxacillin sodium cap 250 mg 1

dicloxacillin sodium cap 500 mg 1

PENICILLIN V POTASSIUM –penicillin v potassium for soln125 mg/5ml

2

PENICILLIN V POTASSIUM –penicillin v potassium for soln250 mg/5ml

2

penicillin v potassium tab250 mg

1

penicillin v potassium tab500 mg

1

CEPHALOSPORINScefaclor cap 250 mg 1

cefaclor cap 500 mg 1

cefadroxil cap 500 mg 1

cefadroxil for susp 250 mg/5ml 1

cefadroxil for susp 500 mg/5ml 1

cefadroxil tab 1 gm 1

cefdinir cap 300 mg 1

cefdinir for susp 125 mg/5ml 1

cefdinir for susp 250 mg/5ml 1

cefixime for susp 100 mg/5ml(Suprax)

1

cefixime for susp 200 mg/5ml(Suprax)

1

cefpodoxime proxetil for susp50 mg/5ml

1

cefpodoxime proxetil for susp100 mg/5ml

1

cefpodoxime proxetil tab 100 mg 1

cefpodoxime proxetil tab 200 mg 1

cefprozil for susp 125 mg/5ml 1

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cefprozil for susp 250 mg/5ml 1

cefprozil tab 250 mg 1

cefprozil tab 500 mg 1

ceftriaxone sodium for inj250 mg

1

ceftriaxone sodium for inj500 mg (Rocephin)

1

ceftriaxone sodium for inj 1 gm(Rocephin)

1

ceftriaxone sodium for inj 2 gm 1

cefuroxime axetil tab 250 mg(Ceftin)

1

cefuroxime axetil tab 500 mg(Ceftin)

1

cephalexin cap 250 mg (Keflex) 1

cephalexin cap 500 mg (Keflex) 1

cephalexin for susp 125 mg/5ml 1

cephalexin for susp 250 mg/5ml 1

SUPRAX – cefixime cap 400 mg 2

SUPRAX – cefixime chew tab 100mg

2

SUPRAX – cefixime chew tab 200mg

2

SUPRAX – cefixime for susp 100mg/5ml

2


2


2

MACROLIDESazithromycin for susp

100 mg/5ml (Zithromax)1

azithromycin for susp200 mg/5ml (Zithromax)

1

azithromycin tab 250 mg(Zithromax)

1


1

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1

CLARITHROMYCIN –clarithromycin for susp 125mg/5ml

2

CLARITHROMYCIN –clarithromycin for susp 250mg/5ml

2

clarithromycin tab er 24hr500 mg

1

clarithromycin tab 250 mg(Biaxin)

1

clarithromycin tab 500 mg(Biaxin)

1

TETRACYCLINESdemeclocycline hcl tab 150 mg 1

demeclocycline hcl tab 300 mg 1

doxycycline hyclate cap 50 mg 1

doxycycline hyclate cap 100 mg(Vibramycin)

1

doxycycline hyclate tab 20 mg 1

doxycycline hyclate tab 100 mg 1

doxycycline monohydrate cap50 mg

1

doxycycline monohydrate cap75 mg (Monodox)

1

doxycycline monohydrate cap100 mg (Monodox)

1

doxycycline monohydrate cap150 mg (Adoxa)

1

doxycycline monohydrate tab50 mg (Adoxa)

1

doxycycline monohydrate tab75 mg (Adoxa)

1

doxycycline monohydrate tab100 mg (Adoxa pak 1/100)

1

doxycycline monohydrate tab150 mg (Adoxa pak 1/150)

1

minocycline hcl cap 50 mg(Minocin)

1

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1


1

minocycline hcl tab 50 mg 1



tetracycline hcl cap 250 mg(Tetracycline hcl)

1

tetracycline hcl cap 500 mg(Tetracycline hcl)

1

FLUOROQUINOLONESCIPRO – ciprofloxacin for oral

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

2

ciprofloxacin for oralsusp 500 mg/5ml (10%)(10 gm/100ml) (Cipro)

1

CIPROFLOXACIN HCL –ciprofloxacin hcl tab 100 mg(base equiv)

2

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

1

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

1

ciprofloxacin hcl tab 750 mg(base equiv)

1

ciprofloxacin-ciprofloxacin hcltab er 24hr 500 mg (base eq)(Cipro xr)

1

ciprofloxacin-ciprofloxacin hcltab er 24hr 1000 mg(base eq)(Cipro xr)

1

LEVOFLOXACIN – levofloxacinoral soln 25 mg/ml

2

levofloxacin tab 250 mg(Levaquin)

1


1

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1

ofloxacin tab 400 mg 1

SULFADIAZINE – sulfadiazine tab500 mg

2

AMINOGLYCOSIDESneomycin sulfate tab 500 mg 1

paromomycin sulfate cap250 mg

1

tobramycin nebu soln300 mg/5ml (Tobi)

1 • •

TUBERCULOSISethambutol hcl tab 100 mg

(Myambutol)1

ethambutol hcl tab 400 mg(Myambutol)

1

isoniazid tab 100 mg 1

isoniazid tab 300 mg 1

PRIFTIN – rifapentine tab 150 mg 2

pyrazinamide tab 500 mg 1

rifabutin cap 150 mg (Mycobutin) 1

rifampin cap 150 mg (Rifadin) 1

rifampin cap 300 mg (Rifadin) 1

FUNGAL INFECTIONSfluconazole for susp 10 mg/ml

(Diflucan)1

fluconazole for susp 40 mg/ml(Diflucan)

1

fluconazole tab 50 mg (Diflucan) 1




flucytosine cap 250 mg(Ancobon)

1

flucytosine cap 500 mg(Ancobon)

1

griseofulvin microsize susp125 mg/5ml

1

2018


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griseofulvin microsize tab500 mg (Grifulvin v)

1

itraconazole cap 100 mg(Sporanox)

1

NOXAFIL – posaconazole susp40 mg/ml

2

nystatin tab 500000 unit 1

terbinafine hcl tab 250 mg(Lamisil)

1

voriconazole for susp 40 mg/ml(Vfend)

1

voriconazole tab 50 mg (Vfend) 1

voriconazole tab 200 mg (Vfend) 1

VIRAL INFECTIONSCytomegalovirusvalganciclovir hcl for soln

50 mg/ml (base equiv) (Valcyte)1

valganciclovir hcl tab 450 mg(base equivalent) (Valcyte)

1

Hepatitisadefovir dipivoxil tab 10 mg

(Hepsera)1

BARACLUDE – entecavir oralsoln 0.05 mg/ml

2

entecavir tab 0.5 mg (Baraclude) 1

entecavir tab 1 mg (Baraclude) 1

EPCLUSA – sofosbuvir-velpatasvir tab 400-100 mg

2 • •

HARVONI – ledipasvir-sofosbuvir tab 90-400 mg

2 • •

lamivudine tab 100 mg (hbv)(Epivir hbv)

1

MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg

2 • •

PEGASYS – peginterferonalfa-2a inj 180 mcg/ml

2 • •

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

2 • •

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PEGASYS PROCLICK –peginterferon alfa-2a inj 135mcg/0.5ml

2 • •

PEGASYS PROCLICK –peginterferon alfa-2a inj 180mcg/0.5ml

2 • •

ribavirin cap 200 mg (Rebetol) 1 •ribavirin tab 200 mg (Copegus) 1 •SOVALDI – sofosbuvir tab 400

mg2 • •

VOSEVI – sofosbuvir-velpatasvir-voxilaprevir tab400-100-100 mg

2 • •

Herpesacyclovir cap 200 mg (Zovirax) 1

acyclovir susp 200 mg/5ml(Zovirax)

1

acyclovir tab 400 mg (Zovirax) 1

acyclovir tab 800 mg (Zovirax) 1

famciclovir tab 125 mg (Famvir) 1



valacyclovir hcl tab 500 mg(Valtrex)

1

valacyclovir hcl tab 1 gm(Valtrex)

1

HIV/AIDSabacavir sulfate soln 20 mg/ml

(base equiv) (Ziagen)1 •

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

1 •

abacavir sulfate-lamivudine tab600-300 mg (Epzicom)

1 •

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

1 •

atazanavir sulfate cap 150 mg(base equiv) (Reyataz)

1 •

2018


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1 •

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

2 •

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

2 •

DESCOVY – emtricitabine-tenofovir alafenamide fumaratetab 200-25 mg

2 •

didanosine delayed releasecapsule 200 mg (Videx ec)

1 •


1 •


1 •

efavirenz cap 50 mg (Sustiva) 1 •efavirenz cap 200 mg (Sustiva) 1 •efavirenz tab 600 mg (Sustiva) 1 •EVOTAZ – atazanavir sulfate-

cobicistat tab 300-150 mg(base equiv)

2 •

GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab150-150-200-10 mg

2 •

INTELENCE – etravirine tab 25mg

2 •


2 •


2 •

ISENTRESS – raltegravirpotassium packet for susp 100mg (base equiv)

2 •

ISENTRESS – raltegravirpotassium tab 400 mg (baseequiv)

2 •

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ISENTRESS – raltegravirpotassium chew tab 25 mg(base equiv)

2 •

ISENTRESS – raltegravirpotassium chew tab 100 mg(base equiv)

2 •

ISENTRESS HD – raltegravirpotassium tab 600 mg (baseequiv)

2 •

KALETRA – lopinavir-ritonavirtab 100-25 mg

2 •

KALETRA – lopinavir-ritonavirtab 200-50 mg

2 •

lamivudine oral soln 10 mg/ml(Epivir)

1 •

lamivudine tab 150 mg (Epivir) 1 •lamivudine tab 300 mg (Epivir) 1 •lamivudine-zidovudine tab

150-300 mg (Combivir)1 •

lopinavir-ritonavir soln400-100 mg/5ml (80-20 mg/ml)(Kaletra)

1 •

nevirapine tab er 24hr 100 mg(Viramune xr)

1 •

nevirapine tab er 24hr 400 mg(Viramune xr)

1 •

nevirapine tab 200 mg (Viramune) 1 •NORVIR – ritonavir tab 100 mg 2 •NORVIR – ritonavir oral soln 80

mg/ml2 •

ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab200-25-25 mg

2 •

PREZCOBIX – darunavir-cobicistat tab 800-150 mg

2 •

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

2 •

PREZISTA – darunavirethanolate tab 75 mg (baseequiv)

2 •

2018


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2 •


2 •


2 •

REYATAZ – atazanavir sulfatecap 150 mg (base equiv)

2 •


2 •


2 •

ritonavir tab 100 mg (Norvir) 1 •stavudine cap 15 mg (Zerit) 1 •stavudine cap 20 mg (Zerit) 1 •stavudine cap 30 mg (Zerit) 1 •stavudine cap 40 mg (Zerit) 1 •STRIBILD – elvitegrav-cobic-

emtricitab-tenofovdf tab150-150-200-300 mg

2 •

SUSTIVA – efavirenz tab 600 mg 2 •tenofovir disoproxil fumarate tab

300 mg (Viread)1 •

TIVICAY – dolutegravir sodiumtab 10 mg (base equiv)

2 •


2 •


2 •

TRIUMEQ – abacavir-dolutegravir-lamivudine tab600-50-300 mg

2 •

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 100-150 mg

2 •

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2 •


2 •


2 •

VIRAMUNE – nevirapine susp 50mg/5ml

2 •

VIREAD – tenofovir disoproxilfumarate oral powder 40 mg/gm

2 •

VIREAD – tenofovir disoproxilfumarate tab 150 mg

2 •


2 •


2 •


2 •

zidovudine cap 100 mg (Retrovir) 1 •zidovudine syrup 10 mg/ml

(Retrovir)1 •

zidovudine tab 300 mg 1 •Influenzaoseltamivir phosphate cap

30 mg (base equiv) (Tamiflu)1 •

oseltamivir phosphate cap45 mg (base equiv) (Tamiflu)

1 •

oseltamivir phosphate cap75 mg (base equiv) (Tamiflu)

1 •

oseltamivir phosphate for susp6 mg/ml (base equiv) (Tamiflu)

1 •

MALARIAatovaquone-proguanil hcl tab

62.5-25 mg (Malarone)1

atovaquone-proguanil hcl tab250-100 mg (Malarone)

1

2018


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chloroquine phosphate tab500 mg (Aralen)

1

DARAPRIM – pyrimethamine tab25 mg

2

hydroxychloroquine sulfate tab200 mg (Plaquenil)

1

MEFLOQUINE HCL – mefloquinehcl tab 250 mg

2

PRIMAQUINE PHOSPHATE –primaquine phosphate tab 26.3mg (15 mg base)

2

WORM INFECTIONSALBENZA – albendazole tab 200

mg2

BENZNIDAZOLE – benznidazoletab 12.5 mg

2

BENZNIDAZOLE – benznidazoletab 100 mg

2

BILTRICIDE – praziquantel tab600 mg

2

ivermectin tab 3 mg (Stromectol) 1

praziquantel tab 600 mg(Biltricide)

1

OTHER ANTI-INFECTIVESclindamycin hcl cap 75 mg

(Cleocin)1

clindamycin hcl cap 150 mg(Cleocin)

1

clindamycin hcl cap 300 mg(Cleocin)

1

clindamycin palmitate hcl forsoln 75 mg/5ml (base equiv)(Cleocin pediatric gr)

1

dapsone tab 25 mg 1

dapsone tab 100 mg 1

IMPAVIDO – miltefosine cap 50mg

2

linezolid for susp 100 mg/5ml(Zyvox)

1

linezolid tab 600 mg (Zyvox) 1

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metronidazole tab 250 mg(Flagyl)

1

metronidazole tab 500 mg(Flagyl)

1

sulfamethoxazole-trimethoprimsusp 200-40 mg/5ml

1

sulfamethoxazole-trimethoprimtab 400-80 mg (Bactrim)

1

sulfamethoxazole-trimethoprimtab 800-160 mg (Bactrim ds)

1

trimethoprim tab 100 mg 1

vancomycin hcl cap 125 mg(Vancocin hcl)

1

vancomycin hcl cap 250 mg(Vancocin hcl)

1

XIFAXAN – rifaximin tab 550 mg 2

CANCER DRUGSACTIMMUNE – interferon

gamma-1b inj 100 mcg/0.5ml(2000000 unit/0.5ml)

2 •

AFINITOR – everolimus tab 2.5mg

2 • • •

AFINITOR – everolimus tab 5 mg 2 • • •AFINITOR – everolimus tab 7.5

mg2 • • •

AFINITOR – everolimus tab 10mg

2 • • •

AFINITOR DISPERZ – everolimustab for oral susp 2 mg

2 • • •


2 • • •


2 • • •

ALECENSA – alectinib hcl cap150 mg (base equivalent)

2 • • •

ALUNBRIG – brigatinib tabinitiation therapy pack 90 mg &180 mg

2 • • •

ALUNBRIG – brigatinib tab 30 mg 2 • • •ALUNBRIG – brigatinib tab 90 mg 2 • • •

2018


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ALUNBRIG – brigatinib tab 180mg

2 • • •

anastrozole tab 1 mg (Arimidex) 1

bexarotene cap 75 mg (Targretin) 1 • •bicalutamide tab 50 mg

(Casodex)1

BOSULIF – bosutinib tab 100 mg 2 • • •BOSULIF – bosutinib tab 400 mg 2 • • •BOSULIF – bosutinib tab 500 mg 2 • • •capecitabine tab 150 mg (Xeloda) 1 • •capecitabine tab 500 mg (Xeloda) 1 • •CAPRELSA – vandetanib tab 100

mg2 • • •

CAPRELSA – vandetanib tab 300mg

2 • • •

COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 mgdose) kit

2 • • •

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

2 • • •

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

2 • • •

COTELLIC – cobimetinibfumarate tab 20 mg (baseequivalent)

2 • • •

CYCLOPHOSPHAMIDE –cyclophosphamide cap 25 mg

2

CYCLOPHOSPHAMIDE –cyclophosphamide cap 50 mg

2

cyclophosphamide cap 25 mg(Cyclophosphamide)

1

cyclophosphamide cap 50 mg(Cyclophosphamide)

1

EMCYT – estramustinephosphate sodium cap 140 mg

2

ERIVEDGE – vismodegib cap150 mg

2 • • •

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ETOPOSIDE – etoposide cap 50mg

2

exemestane tab 25 mg(Aromasin)

1

FARESTON – toremifene citratetab 60 mg (base equivalent)

2

FARYDAK – panobinostat lactatecap 10 mg (base equivalent)

2 • • •


2 • • •


2 • • •

flutamide cap 125 mg 1

GILOTRIF – afatinib dimaleatetab 20 mg (base equivalent)

2 • • •


2 • • •


2 • • •

GLEOSTINE – lomustine cap 5mg

2


2


2


2

HEXALEN – altretamine cap 50mg

2 • •

HYCAMTIN – topotecan hcl cap0.25 mg (base equiv)

2 • •

HYCAMTIN – topotecan hcl cap 1mg (base equiv)

2 • •

hydroxyurea cap 500 mg(Hydrea)

1

IBRANCE – palbociclib cap 75mg

2 • • •


2 • • •

2018


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2 • • •

ICLUSIG – ponatinib hcl tab 15mg (base equiv)

2 • • •

ICLUSIG – ponatinib hcl tab 45mg (base equiv)

2 • • •

imatinib mesylate tab 100 mg(base equivalent) (Gleevec)

1 • • •

imatinib mesylate tab 400 mg(base equivalent) (Gleevec)

1 • • •

IMBRUVICA – ibrutinib cap 70mg

2 • • •

IMBRUVICA – ibrutinib cap 140mg

2 • • •

IMBRUVICA – ibrutinib tab 140mg

2 • • •


2 • • •


2 • • •


2 • • •

INLYTA – axitinib tab 1 mg 2 • • •INLYTA – axitinib tab 5 mg 2 • • •IRESSA – gefitinib tab 250 mg 2 • • •JAKAFI – ruxolitinib phosphate

tab 5 mg (base equivalent)2 • • •

JAKAFI – ruxolitinib phosphatetab 10 mg (base equivalent)

2 • • •


2 • • •


2 • • •


2 • • •

KISQALI – ribociclib succinatetab 200 mg (base equiv)

2 • • •

KISQALI FEMARA 200 DOSE– ribociclib tab 200 mg &

2 • • •

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letrozole tab 2.5 mg therapypack

KISQALI FEMARA 400 DOSE– ribociclib tab 200 mg &letrozole tab 2.5 mg therapypack

2 • • •

KISQALI FEMARA 600 DOSE– ribociclib tab 200 mg &letrozole tab 2.5 mg therapypack

2 • • •

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

2 • • •

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

2 • • •

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

2 • • •

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

2 • • •

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

2 • • •

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

2 • • •

letrozole tab 2.5 mg (Femara) 1

LEUCOVORIN CALCIUM –leucovorin calcium tab 10 mg

2

LEUCOVORIN CALCIUM –leucovorin calcium tab 15 mg

2

leucovorin calcium tab 5 mg 1

leucovorin calcium tab 25 mg 1

LEUKERAN – chlorambucil tab 2mg

2

LONSURF – trifluridine-tipiraciltab 15-6.14 mg

2 • • •

LONSURF – trifluridine-tipiraciltab 20-8.19 mg

2 • • •

2018


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LYNPARZA – olaparib cap 50 mg 2 • • •LYNPARZA – olaparib tab 100 mg 2 • • •LYNPARZA – olaparib tab 150 mg 2 • • •LYSODREN – mitotane tab 500

mg2 • •

MATULANE – procarbazine hclcap 50 mg

2 • •

megestrol acetate susp 40 mg/ml(Megace oral)

1

megestrol acetate tab 20 mg 1

megestrol acetate tab 40 mg 1

MEKINIST – trametinib dimethylsulfoxide tab 0.5 mg (baseequivalent)

2 • • •

MEKINIST – trametinib dimethylsulfoxide tab 2 mg (baseequivalent)

2 • • •

melphalan tab 2 mg (Alkeran) 1

mercaptopurine tab 50 mg(Purinethol)

1

methotrexate sodium tab 2.5 mg(base equiv)

1

MYLERAN – busulfan tab 2 mg 2

NEXAVAR – sorafenib tosylatetab 200 mg (base equivalent)

2 • • •

nilutamide tab 150 mg (Nilandron) 1

NINLARO – ixazomib citrate cap2.3 mg (base equivalent)

2 • • •

NINLARO – ixazomib citrate cap3 mg (base equivalent)

2 • • •

NINLARO – ixazomib citrate cap4 mg (base equivalent)

2 • • •

ODOMZO – sonidegib phosphatecap 200 mg (base equivalent)

2 • • •

POMALYST – pomalidomide cap1 mg

2 • • •


2 • • •

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2 • • •


2 • • •

PURIXAN – mercaptopurine susp2000 mg/100ml (20 mg/ml)

2 •

RYDAPT – midostaurin cap 25mg

2 • • •

SPRYCEL – dasatinib tab 20 mg 2 • • •SPRYCEL – dasatinib tab 50 mg 2 • • •SPRYCEL – dasatinib tab 70 mg 2 • • •SPRYCEL – dasatinib tab 80 mg 2 • • •SPRYCEL – dasatinib tab 100 mg 2 • • •SPRYCEL – dasatinib tab 140 mg 2 • • •STIVARGA – regorafenib tab 40

mg2 • • •

SUTENT – sunitinib malate cap12.5 mg (base equivalent)

2 • • •

SUTENT – sunitinib malate cap25 mg (base equivalent)

2 • • •

SUTENT – sunitinib malate cap37.5 mg (base equivalent)

2 • • •

SUTENT – sunitinib malate cap50 mg (base equivalent)

2 • • •

SYLATRON – peginterferonalfa-2b for inj kit 200 mcg

2 • •


2 • •


2 • •

TABLOID – thioguanine tab 40mg

2

TAFINLAR – dabrafenib mesylatecap 50 mg (base equivalent)

2 • • •

TAFINLAR – dabrafenib mesylatecap 75 mg (base equivalent)

2 • • •

TAGRISSO – osimertinibmesylate tab 40 mg (baseequivalent)

2 • • •

2018


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TAGRISSO – osimertinibmesylate tab 80 mg (baseequivalent)

2 • • •

tamoxifen citrate tab 10 mg(base equivalent)

1

tamoxifen citrate tab 20 mg(base equivalent)

1

TARCEVA – erlotinib hcl tab 25mg (base equivalent)

2 • • •


2 • • •


2 • • •

TASIGNA – nilotinib hcl cap 50mg (base equivalent)

2 • • •


2 • • •


2 • • •

temozolomide cap 5 mg(Temodar)

1 • •


1 • •


1 • •


1 • •


1 • •


1 • •

tretinoin cap 10 mg 1 • •TYKERB – lapatinib ditosylate

tab 250 mg (base equiv)2 • • •

VOTRIENT – pazopanib hcl tab200 mg (base equiv)

2 • • •

XALKORI – crizotinib cap 200 mg 2 • • •XALKORI – crizotinib cap 250 mg 2 • • •XTANDI – enzalutamide cap 40

mg2 • • •

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ZELBORAF – vemurafenib tab240 mg

2 • • •

ZOLINZA – vorinostat cap 100mg

2 • • •

ZYDELIG – idelalisib tab 100 mg 2 • • •ZYDELIG – idelalisib tab 150 mg 2 • • •ZYKADIA – ceritinib cap 150 mg 2 • • •ZYTIGA – abiraterone acetate tab

250 mg2 • • •

ZYTIGA – abiraterone acetate tab500 mg

2 • • •

HORMONES, DIABETES AND RELATED DRUGSCORTICOSTEROIDSbudesonide delayed release

particles cap 3 mg (Entocort ec)1

CORTISONE ACETATE –cortisone acetate tab 25 mg

2

DEXAMETHASONE –dexamethasone soln 0.5mg/5ml

2

dexamethasone elixir 0.5 mg/5ml 1

dexamethasone tab 0.5 mg 1



dexamethasone tab 4 mg 1

dexamethasone tab 6 mg 1

fludrocortisone acetate tab0.1 mg

1

hydrocortisone tab 5 mg (Cortef) 1

hydrocortisone tab 10 mg(Cortef)

1

hydrocortisone tab 20 mg(Cortef)

1

methylprednisolone tab therapypack 4 mg (21) (Medroldosepak)

1

methylprednisolone tab 4 mg(Medrol)

1

2018


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1


1


1

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

1

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

1

prednisolone syrup 15 mg/5ml(usp solution equivalent)(Prelone)

1

PREDNISONE – prednisone oralsoln 5 mg/5ml

2

prednisone tab 1 mg 1

prednisone tab 2.5 mg 1




MALE HORMONESANDROGEL – testosterone td gel

20.25 mg/1.25gm (1.62%)2 • •

ANDROGEL – testosterone td gel40.5 mg/2.5gm (1.62%)

2 • •

ANDROGEL PUMP –testosterone td gel 20.25 mg/act (1.62%)

2 • •

danazol cap 50 mg 1 •danazol cap 100 mg 1 •danazol cap 200 mg 1 •testosterone cypionate im

inj in oil 100 mg/ml (Depo-testosterone)

1

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

1

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testosterone enanthate im inj inoil 200 mg/ml

1

testosterone td gel 25 mg/2.5gm(1%) (Androgel)

1 • •

testosterone td gel 50 mg/5gm(1%) (Androgel)

1 • •

testosterone td gel 12.5 mg/act(1%) (Androgel pump)

1 • •

testosterone td soln 30 mg/act(Axiron)

1 • •

ESTROGENSCLIMARA PRO – estradiol-

levonorgestrel td patch weekly0.045-0.015 mg/day

2

DIVIGEL – estradiol td gel 0.25mg/0.25gm (0.1%)

2

DIVIGEL – estradiol td gel 0.5mg/0.5gm (0.1%)

2

DIVIGEL – estradiol td gel 1 mg/gm (0.1%)

2

estradiol & norethindroneacetate tab 0.5-0.1 mg(Activella)

1

estradiol & norethindroneacetate tab 1-0.5 mg (Activella)

1

estradiol tab 0.5 mg (Estrace) 1

estradiol tab 1 mg (Estrace) 1

estradiol tab 2 mg (Estrace) 1

estradiol td patch twice weekly0.025 mg/24hr (Vivelle-dot)

1


1


1


1


1

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

1

2018


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

1


1


1


1


1

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

1

norethindrone acetate-ethinylestradiol tab 1 mg-5 mcg

1

PREMARIN – estrogens,conjugated tab 0.3 mg

2


2


2


2


2

PREMPHASE – conj est0.625(14)/conj est-medroxyproac tab 0.625-5mg(14)

2

PREMPRO – conjugatedestrogen-medroxyprogestacetate tab 0.3-1.5 mg

2


2


2

PREMPRO – conjugatedestrogen-medroxyprogestacetate tab 0.625-5 mg

2

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PROGESTINSmedroxyprogesterone acetate

tab 2.5 mg (Provera)1

medroxyprogesterone acetatetab 5 mg (Provera)

1

medroxyprogesterone acetatetab 10 mg (Provera)

1

norethindrone acetate tab 5 mg(Aygestin)

1

progesterone micronized cap100 mg (Prometrium)

1

progesterone micronized cap200 mg (Prometrium)

1

BIRTH CONTROLdesogest-eth estrad & eth estrad

tab 0.15-0.02/0.01 mg(21/5)(Mircette)

1

desogest-ethin est tab0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa)

1

desogestrel & ethinyl estradioltab 0.15 mg-30 mcg (Desogen)

1

drospirenone-ethinyl estradioltab 3-0.02 mg (Yaz)

1

drospirenone-ethinyl estradioltab 3-0.03 mg (Yasmin 28)

1

ELLA – ulipristal acetate tab 30mg

2

ethynodiol diacetate & ethinylestradiol tab 1 mg-35 mcg

1

ethynodiol diacetate & ethinylestradiol tab 1 mg-50 mcg(Zovia 1/50e)

1

levonorg-eth est tab0.1-0.02mg(84) & eth est tab0.01mg(7) (Loseasonique)

1

levonorg-eth est tab0.15-0.03mg(84) & eth est tab0.01mg(7) (Seasonique)

1

2018


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levonorgestrel & ethinylestradiol (91-day) tab0.15-0.03 mg

1

levonorgestrel & ethinylestradiol tab 0.1 mg-20 mcg

1

levonorgestrel & ethinylestradiol tab 0.15 mg-30 mcg

1

levonorgestrel-eth estra tab0.05-30/0.075-40/0.125-30mg-mcg

1

medroxyprogesterone acetate imsusp prefilled syr 150 mg/ml(Depo-provera contrac)

1

medroxyprogesterone acetate imsusp 150 mg/ml (Depo-proveracontrac)

1

norethindrone & ethinyl estradioltab 0.4 mg-35 mcg (Ovcon-35)

1

norethindrone & ethinylestradiol tab 0.5 mg-35 mcg(Brevicon-28)

1

norethindrone & ethinyl estradioltab 1 mg-35 mcg (Norinyl 1+35)

1

norethindrone & ethinylestradiol-fe chew tab0.4 mg-35 mcg (Femcon fe)

1

norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg(Estrostep fe)

1

norethindrone ace & ethinylestradiol tab 1 mg-20 mcg(Loestrin 1/20-21)

1

norethindrone ace & ethinylestradiol tab 1.5 mg-30 mcg(Loestrin 1.5/30-21)

1

norethindrone ace & ethinylestradiol-fe tab 1 mg-20 mcg(Loestrin fe 1/20)

1

norethindrone ace & ethinylestradiol-fe tab 1.5 mg-30 mcg(Loestrin fe 1.5/30)

1

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norethindrone tab 0.35 mg (Nor-qd)

1

norethindrone-eth estradiol tab0.5-35/0.75-35/1-35 mg-mcg(Ortho-novum 7/7/7)

1

norethindrone-eth estradiol tab0.5-35/1-35/0.5-35 mg-mcg (Tri-norinyl 28)

1

norgestimate & ethinyl estradioltab 0.25 mg-35 mcg (Ortho-cyclen)

1

norgestimate-eth estrad tab0.18-25/0.215-25/0.25-25 mg-mcg (Ortho tri-cyclen lo)

1

norgestimate-eth estrad tab0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-cyclen)

1

norgestrel & ethinyl estradiol tab0.3 mg-30 mcg

1

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

2

XULANE – norelgestromin-ethinyl estradiol td ptwk 150-35mcg/24hr

2

INFERTILITYCLOMIPHENE CITRATE –

clomiphene citrate tab 50 mg2

FOLLISTIM AQ – follitropin betainj 300 unit/0.36ml

2 •


2 •


2 •

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

2 •


2 •

2018


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

2 •

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

2 •

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

2 •

PREGNYL W/DILUENT BENZYL –chorionic gonadotropin for iminj 10000 unit

2 •

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

2

DIABETESacarbose tab 25 mg (Precose) 1

acarbose tab 50 mg (Precose) 1

acarbose tab 100 mg (Precose) 1

glimepiride tab 1 mg (Amaryl) 1



glipizide tab er 24hr 2.5 mg(Glucotrol xl)

1

glipizide tab er 24hr 5 mg(Glucotrol xl)

1

glipizide tab er 24hr 10 mg(Glucotrol xl)

1

glipizide tab 5 mg (Glucotrol) 1

glipizide tab 10 mg (Glucotrol) 1

glipizide-metformin hcl tab2.5-250 mg

1

glipizide-metformin hcl tab2.5-500 mg

1

glipizide-metformin hcl tab5-500 mg

1

GLUCAGON EMERGENCY KIT –glucagon (rdna) for inj kit 1 mg

2

glyburide micronized tab 1.5 mg(Glynase)

1

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glyburide micronized tab 3 mg(Glynase)

1

glyburide micronized tab 6 mg(Glynase)

1

glyburide tab 1.25 mg 1

glyburide tab 2.5 mg 1

glyburide tab 5 mg 1

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

1

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

1

glyburide-metformin tab5-500 mg (Glucovance)

1

GLYXAMBI – empagliflozin-linagliptin tab 10-5 mg

2 •

GLYXAMBI – empagliflozin-linagliptin tab 25-5 mg

2 •

JARDIANCE – empagliflozin tab10 mg

2 •

JARDIANCE – empagliflozin tab25 mg

2 •

KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr2.5-1000 mg

2 •

KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr 5-500mg

2 •

KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr5-1000 mg

2 •

metformin hcl tab er 24hr 500 mg(Glucophage xr)

1

metformin hcl tab er 24hr 750 mg(Glucophage xr)

1

metformin hcl tab 500 mg(Glucophage)

1


1


1

2018


Drug Name Tier

Des

igna

tion

Spe

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ty

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n

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p Th

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y

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pens

ing

Lim

its

nateglinide tab 60 mg (Starlix) 1

nateglinide tab 120 mg (Starlix) 1

ONGLYZA – saxagliptin hcl tab2.5 mg (base equiv)

2 •

ONGLYZA – saxagliptin hcl tab 5mg (base equiv)

2 •

OZEMPIC – semaglutide solnpen-inj 0.25 or 0.5 mg/dose (2mg/1.5ml)

2 • •

OZEMPIC – semaglutide solnpen-inj 1 mg/dose (2 mg/1.5ml)

2 • •

pioglitazone hcl tab 15 mg (baseequiv) (Actos)

1 •


1 •


1 •

pioglitazone hcl-metformin hcltab 15-500 mg (Actoplus met)

1 •

pioglitazone hcl-metformin hcltab 15-850 mg (Actoplus met)

1 •

repaglinide tab 0.5 mg (Prandin) 1

repaglinide tab 1 mg (Prandin) 1

repaglinide tab 2 mg (Prandin) 1

SYNJARDY – empagliflozin-metformin hcl tab 5-500 mg

2 •

SYNJARDY – empagliflozin-metformin hcl tab 5-1000 mg

2 •

SYNJARDY – empagliflozin-metformin hcl tab 12.5-500 mg

2 •

SYNJARDY – empagliflozin-metformin hcl tab 12.5-1000mg

2 •

SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr5-1000 mg

2 •


2 •

Drug Name Tier

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its

SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr12.5-1000 mg

2 •


2 •

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

2 • •

DIABETES - INSULINSRapid-Acting InsulinsFIASP – insulin aspart inj 100

unit/ml2

FIASP FLEXTOUCH – insulinaspart soln pen-injector 100unit/ml

2

NOVOLOG – insulin aspart inj100 unit/ml

2

NOVOLOG FLEXPEN – insulinaspart soln pen-injector 100unit/ml

2

NOVOLOG PENFILL – insulinaspart soln cartridge 100 unit/ml

2

Short-Acting InsulinsHUMULIN R U-500 (CONCENTR –

insulin regular (human) inj 500unit/ml

2

HUMULIN R U-500 KWIKPEN –insulin regular (human) solnpen-injector 500 unit/ml

2

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

2

Intermediate-Acting InsulinsNOVOLIN N – insulin nph

(human) (isophane) inj 100unit/ml

2

NOVOLIN 70/30 – insulin nphisophane & regular human inj100 unit/ml (70-30)

2

2018


Drug Name Tier

Des

igna

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Spe

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ty

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y

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ing

Lim

its

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

2

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

2

Basal InsulinsLANTUS – insulin glargine inj

100 unit/ml2

LANTUS SOLOSTAR – insulinglargine soln pen-injector 100unit/ml

2

LEVEMIR – insulin detemir inj100 unit/ml

2

LEVEMIR FLEXTOUCH – insulindetemir soln pen-injector 100unit/ml

2

TOUJEO MAX SOLOSTAR –insulin glargine soln pen-injector 300 unit/ml

2

TOUJEO SOLOSTAR – insulinglargine soln pen-injector 300unit/ml

2

THYROID REGULATIONlevothyroxine sodium tab

25 mcg (Synthroid)1

levothyroxine sodium tab50 mcg (Synthroid)

1


1


1


1


1


1


1

Drug Name Tier

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its


1


1


1


1

liothyronine sodium tab 5 mcg(Cytomel)

1


1


1

methimazole tab 5 mg (Tapazole) 1

methimazole tab 10 mg(Tapazole)

1

propylthiouracil tab 50 mg 1

GROWTH HORMONEINCRELEX – mecasermin inj 40

mg/4ml (10 mg/ml)2 •

OMNITROPE – somatropin for inj5.8 mg

2 • •

OMNITROPE – somatropin inj 5mg/1.5ml

2 • •

OMNITROPE – somatropin inj 10mg/1.5ml

2 • •

OTHER HORMONES AND RELATED DRUGSalendronate sodium tab 5 mg 1 •alendronate sodium tab 10 mg 1 •alendronate sodium tab 35 mg 1 •alendronate sodium tab 70 mg

(Fosamax)1 •

cabergoline tab 0.5 mg 1

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

1

calcitriol cap 0.25 mcg (Rocaltrol) 1

calcitriol cap 0.5 mcg (Rocaltrol) 1

2018


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

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horiz

atio

n

Ste

p Th

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y

Dis

pens

ing

Lim

its

calcitriol oral soln 1 mcg/ml(Rocaltrol)

1

desmopressin acetate inj 4 mcg/ml (Ddavp)

1

desmopressin acetate nasalspray soln 0.01% (Ddavp)

1

desmopressin acetate nasalspray soln 0.01% (refrigerated)

1

desmopressin acetate tab 0.1 mg(Ddavp)

1

desmopressin acetate tab 0.2 mg(Ddavp)

1

ibandronate sodium tab 150 mg(base equivalent) (Boniva)

1 •

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

1

levocarnitine tab 330 mg(Carnitor)

1


2 •


2 •

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

2 •

METHERGINE –methylergonovine maleate tab0.2 mg

2

NITYR – nitisinone tab 2 mg 2 •NITYR – nitisinone tab 5 mg 2 •NITYR – nitisinone tab 10 mg 2 •octreotide acetate inj 50 mcg/ml

(0.05 mg/ml) (Sandostatin)1 •

octreotide acetate inj 100 mcg/ml(0.1 mg/ml) (Sandostatin)

1 •


1 •

Drug Name Tier

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its


1 •

octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin)

1 •

ORFADIN – nitisinone susp 4mg/ml

2 •

ORFADIN – nitisinone cap 2 mg 2 •ORFADIN – nitisinone cap 5 mg 2 •ORFADIN – nitisinone cap 10 mg 2 •ORFADIN – nitisinone cap 20 mg 2 •paricalcitol cap 1 mcg (Zemplar) 1

paricalcitol cap 2 mcg (Zemplar) 1

paricalcitol cap 4 mcg (Zemplar) 1

raloxifene hcl tab 60 mg (Evista) 1

risedronate sodium tab 5 mg(Actonel)

1 •


1 •


1 •


1 •

SANDOSTATIN LAR DEPOT –octreotide acetate for im inj kit10 mg

2 •


2 •


2 •

SENSIPAR – cinacalcet hcl tab30 mg (base equiv)

2


2


2

STIMATE – desmopressinacetate nasal soln 1.5 mg/ml

2

2018


Drug Name Tier

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Lim

its

STRENSIQ – asfotase alfasubcutaneous inj 18 mg/0.45ml

2 • •


2 • •

STRENSIQ – asfotase alfasubcutaneous inj 40 mg/ml

2 • •


2 • •

TYMLOS – abaloparatidesubcutaneous soln pen-injector 3120 mcg/1.56ml

2 • • •

HEART AND CIRCULATORY DRUGSANGIOTENSIN CONVERTING ENZYME (ACE)INHIBITORS AND COMBINATIONSbenazepril &

hydrochlorothiazide tab5-6.25 mg

1

benazepril &hydrochlorothiazide tab10-12.5 mg (Lotensin hct)

1

benazepril &hydrochlorothiazide tab20-12.5 mg (Lotensin hct)

1

benazepril &hydrochlorothiazide tab20-25 mg (Lotensin hct)

1

benazepril hcl tab 5 mg 1

benazepril hcl tab 10 mg(Lotensin)

1


1


1

captopril tab 12.5 mg 1

captopril tab 25 mg 1



CAPTOPRIL/HYDROCHLOROTHIA– captopril &

2

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

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n

Ste

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y

Dis

pens

ing

Lim

its

hydrochlorothiazide tab 25-15mg

CAPTOPRIL/HYDROCHLOROTHIA– captopril &hydrochlorothiazide tab 50-15mg

2

enalapril maleate &hydrochlorothiazide tab5-12.5 mg

1

enalapril maleate &hydrochlorothiazide tab10-25 mg (Vaseretic)

1

enalapril maleate tab 2.5 mg(Vasotec)

1

enalapril maleate tab 5 mg(Vasotec)

1


1


1

fosinopril sodium &hydrochlorothiazide tab10-12.5 mg

1

fosinopril sodium &hydrochlorothiazide tab20-12.5 mg

1

fosinopril sodium tab 10 mg 1



lisinopril & hydrochlorothiazidetab 10-12.5 mg (Zestoretic)

1

lisinopril & hydrochlorothiazidetab 20-12.5 mg (Zestoretic)

1

lisinopril & hydrochlorothiazidetab 20-25 mg (Zestoretic)

1

lisinopril tab 2.5 mg (Zestril) 1

lisinopril tab 5 mg (Prinivil) 1



2018


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

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n

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y

Dis

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ing

Lim

its

lisinopril tab 30 mg (Zestril) 1

lisinopril tab 40 mg (Zestril) 1

moexipril hcl tab 7.5 mg(Univasc)

1

moexipril hcl tab 15 mg (Univasc) 1

moexipril-hydrochlorothiazidetab 7.5-12.5 mg

1

moexipril-hydrochlorothiazidetab 15-12.5 mg (Uniretic)

1

moexipril-hydrochlorothiazidetab 15-25 mg

1

perindopril erbumine tab 2 mg 1

perindopril erbumine tab 4 mg(Aceon)

1

perindopril erbumine tab 8 mg(Aceon)

1

quinapril hcl tab 5 mg (Accupril) 1




quinapril-hydrochlorothiazidetab 10-12.5 mg (Accuretic)

1

quinapril-hydrochlorothiazidetab 20-12.5 mg (Accuretic)

1

quinapril-hydrochlorothiazidetab 20-25 mg (Accuretic)

1

ramipril cap 1.25 mg (Altace) 1

ramipril cap 2.5 mg (Altace) 1

ramipril cap 5 mg (Altace) 1

ramipril cap 10 mg (Altace) 1

trandolapril tab 1 mg (Mavik) 1



ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)AND COMBINATIONSamlodipine besylate-valsartan

tab 5-160 mg (Exforge)1

Drug Name Tier

Des

igna

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Spe

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ty

Prio

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n

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ing

Lim

its

amlodipine besylate-valsartantab 5-320 mg (Exforge)

1


1


1

amlodipine-valsartan-hydrochlorothiazide tab5-160-12.5 mg (Exforge hct)

1

amlodipine-valsartan-hydrochlorothiazide tab5-160-25 mg (Exforge hct)

1

amlodipine-valsartan-hydrochlorothiazide tab10-160-12.5 mg (Exforge hct)

1


1


1

candesartan cilexetil tab 4 mg(Atacand)

1


1


1


1

candesartan cilexetil-hydrochlorothiazide tab16-12.5 mg (Atacand hct)

1

candesartan cilexetil-hydrochlorothiazide tab32-12.5 mg (Atacand hct)

1

candesartan cilexetil-hydrochlorothiazide tab32-25 mg (Atacand hct)

1

irbesartan tab 75 mg (Avapro) 1



2018


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

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atio

n

Ste

p Th

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y

Dis

pens

ing

Lim

its

irbesartan-hydrochlorothiazidetab 150-12.5 mg (Avalide)

1

irbesartan-hydrochlorothiazidetab 300-12.5 mg (Avalide)

1

losartan potassium &hydrochlorothiazide tab50-12.5 mg (Hyzaar)

1

losartan potassium &hydrochlorothiazide tab100-12.5 mg (Hyzaar)

1

losartan potassium &hydrochlorothiazide tab100-25 mg (Hyzaar)

1

losartan potassium tab 25 mg(Cozaar)

1


1


1

olmesartan medoxomil tab 5 mg(Benicar)

1

olmesartan medoxomil tab20 mg (Benicar)

1

olmesartan medoxomil tab40 mg (Benicar)

1

olmesartan medoxomil-hydrochlorothiazide tab20-12.5 mg (Benicar hct)

1

olmesartan medoxomil-hydrochlorothiazide tab40-12.5 mg (Benicar hct)

1

olmesartan medoxomil-hydrochlorothiazide tab40-25 mg (Benicar hct)

1

telmisartan tab 20 mg (Micardis) 1



telmisartan-hydrochlorothiazidetab 40-12.5 mg (Micardis hct)

1

telmisartan-hydrochlorothiazidetab 80-12.5 mg (Micardis hct)

1

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

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n

Ste

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y

Dis

pens

ing

Lim

its

telmisartan-hydrochlorothiazidetab 80-25 mg (Micardis hct)

1

valsartan tab 40 mg (Diovan) 1




valsartan-hydrochlorothiazidetab 80-12.5 mg (Diovan hct)

1


1

valsartan-hydrochlorothiazidetab 160-25 mg (Diovan hct)

1


1

valsartan-hydrochlorothiazidetab 320-25 mg (Diovan hct)

1

BETA BLOCKERS AND COMBINATIONSacebutolol hcl cap 200 mg

(Sectral)1

acebutolol hcl cap 400 mg(Sectral)

1

atenolol & chlorthalidone tab50-25 mg (Tenoretic 50)

1

atenolol & chlorthalidone tab100-25 mg (Tenoretic 100)

1

atenolol tab 25 mg (Tenormin) 1



bisoprolol & hydrochlorothiazidetab 2.5-6.25 mg (Ziac)

1

bisoprolol & hydrochlorothiazidetab 5-6.25 mg (Ziac)

1

bisoprolol & hydrochlorothiazidetab 10-6.25 mg (Ziac)

1

bisoprolol fumarate tab 5 mg(Zebeta)

1

bisoprolol fumarate tab 10 mg(Zebeta)

1

carvedilol tab 3.125 mg (Coreg) 1

2018


Drug Name Tier

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ty

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ing

Lim

its



carvedilol tab 25 mg (Coreg) 1

labetalol hcl tab 100 mg(Trandate)

1


1


1

metoprolol &hydrochlorothiazide tab50-25 mg (Lopressor hct)

1

metoprolol &hydrochlorothiazide tab100-25 mg (Lopressor hct)

1

metoprolol succinate tab er 24hr25 mg (tartrate equiv) (Toprol xl)

1

metoprolol succinate tab er 24hr50 mg (tartrate equiv) (Toprol xl)

1

metoprolol succinate tab er 24hr100 mg (tartrate equiv) (Toprolxl)

1

metoprolol succinate tab er 24hr200 mg (tartrate equiv) (Toprolxl)

1

metoprolol tartrate tab 25 mg 1

metoprolol tartrate tab 50 mg(Lopressor)

1

metoprolol tartrate tab 100 mg(Lopressor)

1

nadolol tab 20 mg (Corgard) 1



pindolol tab 5 mg 1

pindolol tab 10 mg 1

propranolol hcl cap er 24hr60 mg (Inderal la)

1


1

Drug Name Tier

Des

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tion

Spe

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ty

Prio

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n

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y

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ing

Lim

its


1


1

propranolol hcl tab 10 mg 1





CALCIUM CHANNEL BLOCKERS ANDCOMBINATIONSamlodipine besylate tab 2.5 mg

(base equivalent) (Norvasc)1

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

1

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

1

amlodipine besylate-benazeprilhcl cap 2.5-10 mg (Lotrel)

1

amlodipine besylate-benazeprilhcl cap 5-10 mg (Lotrel)

1


1


1


1


1

diltiazem hcl cap er 24hr 120 mg 1



diltiazem hcl coated beads caper 24hr 120 mg (Cardizem cd)

1


1


1

2018


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

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horiz

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n

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y

Dis

pens

ing

Lim

its

diltiazem hcl coated beads caper 24hr 300 mg

1


1

diltiazem hcl extended releasebeads cap er 24hr 120 mg(Tiazac)

1


1


1


1


1


1

diltiazem hcl tab 30 mg(Cardizem)

1


1

diltiazem hcl tab 90 mg 1


1

felodipine tab er 24hr 2.5 mg 1

felodipine tab er 24hr 5 mg 1

felodipine tab er 24hr 10 mg 1

nifedipine tab er 24hr 30 mg(Adalat cc)

1


1


1

nifedipine tab er 24hr osmoticrelease 30 mg (Procardia xl)

1

Drug Name Tier

Des

igna

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Spe

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ty

Prio

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n

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y

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ing

Lim

its


1


1

nimodipine cap 30 mg 1

verapamil hcl cap er 24hr 120 mg(Verelan)

1


1


1


1

verapamil hcl tab er 120 mg(Calan sr)

1


1


1

verapamil hcl tab 40 mg 1

verapamil hcl tab 80 mg (Calan) 1

verapamil hcl tab 120 mg (Calan) 1

CHEST PAINisosorbide dinitrate tab 5 mg

(Isordil titradose)1

isosorbide dinitrate tab 10 mg 1



isosorbide mononitrate tab er24hr 30 mg

1


1


1

isosorbide mononitrate tab10 mg

1

isosorbide mononitrate tab20 mg

1

2018


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

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y

Dis

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ing

Lim

its

nitroglycerin sl tab 0.3 mg(Nitrostat)

1


1


1

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

1


1


1


1

CHOLESTEROL LOWERINGatorvastatin calcium tab 10 mg

(base equivalent) (Lipitor)1

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

1


1


1

cholestyramine light powderpackets 4 gm

1

cholestyramine light powder4 gm/dose (Questran light)

1

cholestyramine powder packets4 gm (Questran)

1

cholestyramine powder 4 gm/dose (Questran)

1

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

1

choline fenofibrate cap dr135 mg (fenofibric acid equiv)(Trilipix)

1

colestipol hcl granule packets5 gm (Colestid flavored)

1

colestipol hcl granules 5 gm(Colestid flavored)

1

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

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n

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Dis

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ing

Lim

its

colestipol hcl tab 1 gm (Colestid) 1

ezetimibe tab 10 mg (Zetia) 1

ezetimibe-simvastatin tab10-10 mg (Vytorin)

1


1


1


1

fenofibrate micronized cap67 mg (Lofibra)

1


1


1

fenofibrate tab 48 mg (Tricor) 1

fenofibrate tab 54 mg (Lofibra) 1

fenofibrate tab 145 mg (Tricor) 1

fenofibrate tab 160 mg (Lofibra) 1

gemfibrozil tab 600 mg (Lopid) 1

lovastatin tab 10 mg 1

lovastatin tab 20 mg (Mevacor) 1

lovastatin tab 40 mg (Mevacor) 1

niacin tab er 500 mg(antihyperlipidemic) (Niaspan)

1


1


1

pravastatin sodium tab 10 mg 1

pravastatin sodium tab 20 mg(Pravachol)

1


1


1

2018


Drug Name Tier

Des

igna

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Spe

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ty

Prio

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n

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y

Dis

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ing

Lim

its

rosuvastatin calcium tab 5 mg(Crestor)

1


1


1


1

simvastatin tab 5 mg (Zocor) 1





FLUID RETENTIONacetazolamide cap er 12hr

500 mg (Diamox)1

acetazolamide tab 125 mg 1

acetazolamide tab 250 mg 1

amiloride & hydrochlorothiazidetab 5-50 mg

1

amiloride hcl tab 5 mg 1

bumetanide tab 0.5 mg 1

bumetanide tab 1 mg 1

bumetanide tab 2 mg 1

chlorothiazide tab 500 mg 1

chlorthalidone tab 25 mg 1

chlorthalidone tab 50 mg 1

furosemide oral soln 10 mg/ml 1

furosemide tab 20 mg (Lasix) 1



hydrochlorothiazide cap 12.5 mg(Microzide)

1

hydrochlorothiazide tab 12.5 mg 1

hydrochlorothiazide tab 25 mg 1

hydrochlorothiazide tab 50 mg 1

indapamide tab 1.25 mg 1

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

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n

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y

Dis

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ing

Lim

its

indapamide tab 2.5 mg 1

methazolamide tab 25 mg(Neptazane)

1

methazolamide tab 50 mg(Neptazane)

1

metolazone tab 2.5 mg(Zaroxolyn)

1

metolazone tab 5 mg (Zaroxolyn) 1

metolazone tab 10 mg 1

spironolactone &hydrochlorothiazide tab25-25 mg (Aldactazide)

1

spironolactone tab 25 mg(Aldactone)

1


1


1

torsemide tab 5 mg (Demadex) 1




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

1

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

1

triamterene &hydrochlorothiazide tab75-50 mg (Maxzide)

1

HEART RHYTHMamiodarone hcl tab 100 mg 1

amiodarone hcl tab 200 mg(Cordarone)

1

amiodarone hcl tab 400 mg 1

disopyramide phosphate cap100 mg (Norpace)

1

2018


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

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n

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y

Dis

pens

ing

Lim

its

disopyramide phosphate cap150 mg (Norpace)

1

flecainide acetate tab 50 mg 1



mexiletine hcl cap 150 mg 1



propafenone hcl cap er 12hr225 mg (Rythmol sr)

1


1


1

propafenone hcl tab 150 mg(Rythmol)

1

propafenone hcl tab 225 mg(Rythmol)

1

propafenone hcl tab 300 mg 1

quinidine gluconate tab er324 mg

1

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

1


1


1

sotalol hcl tab 80 mg (Betapace) 1



sotalol hcl tab 240 mg 1

OTHER HEART RELATED DRUGSamlodipine besylate-atorvastatin

calcium tab 2.5-10 mg (Caduet)1

amlodipine besylate-atorvastatincalcium tab 2.5-20 mg (Caduet)

1

amlodipine besylate-atorvastatincalcium tab 2.5-40 mg (Caduet)

1

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amlodipine besylate-atorvastatincalcium tab 5-10 mg (Caduet)

1


1


1


1


1


1


1


1

clonidine hcl tab 0.1 mg(Catapres)

1


1


1

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

1


1


1

digoxin tab 125 mcg (0.125 mg)(Lanoxin)

1

digoxin tab 250 mcg (0.25 mg)(Lanoxin)

1

doxazosin mesylate tab 1 mg(Cardura)

1


1


1


1

2018


Drug Name Tier

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ENTRESTO – sacubitril-valsartantab 24-26 mg

2 • •


2 • •


2 • •

eplerenone tab 25 mg (Inspra) 1

eplerenone tab 50 mg (Inspra) 1

guanfacine hcl tab 1 mg (Tenex) 1

guanfacine hcl tab 2 mg (Tenex) 1

hydralazine hcl tab 10 mg 1




LETAIRIS – ambrisentan tab 5mg

2 • • •

LETAIRIS – ambrisentan tab 10mg

2 • • •

methyldopa tab 250 mg 1

methyldopa tab 500 mg 1

midodrine hcl tab 2.5 mg 1

midodrine hcl tab 5 mg 1

midodrine hcl tab 10 mg 1

minoxidil tab 2.5 mg 1

minoxidil tab 10 mg 1

OPSUMIT – macitentan tab 10mg

2 • • •

phenoxybenzamine hcl cap10 mg (Dibenzyline)

1

prazosin hcl cap 1 mg (Minipress) 1



sildenafil citrate tab 20 mg(Revatio)

1 • • •

terazosin hcl cap 1 mg (baseequivalent)

1

Drug Name Tier

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1


1


1

TRACLEER – bosentan tab fororal susp 32 mg

2 • • •

TRACLEER – bosentan tab 62.5mg

2 • • •

TRACLEER – bosentan tab 125mg

2 • • •

UPTRAVI – selexipag tab therapypack 200 mcg (140) & 800 mcg(60)

2 • • •

UPTRAVI – selexipag tab 200mcg

2 • • •


2 • • •


2 • • •


2 • • •


2 • • •


2 • • •


2 • • •


2 • • •

ERECTILE DYSFUNCTIONCIALIS – tadalafil tab 2.5 mg 2 •CIALIS – tadalafil tab 5 mg 2 •CIALIS – tadalafil tab 10 mg 2 •CIALIS – tadalafil tab 20 mg 2 •BEE STING KITSEPINEPHRINE (Mylan products)

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

1

2018


Drug Name Tier

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EPINEPHRINE (Mylan products)– epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)

1

RESPIRATORY AGENTSANTIHISTAMINEScetirizine hcl oral soln 1 mg/ml

(5 mg/5ml)1

CLEMASTINE FUMARATE –clemastine fumarate tab 2.68mg

2

cyproheptadine hcl syrup2 mg/5ml

1

cyproheptadine hcl tab 4 mg 1

DESLORATADINE ODT –desloratadine tab orallydisintegrating 2.5 mg

2

DESLORATADINE ODT –desloratadine tab orallydisintegrating 5 mg

2

desloratadine tab 5 mg (Clarinex) 1

levocetirizine dihydrochloridesoln 2.5 mg/5ml (0.5 mg/ml)(Xyzal)

1

levocetirizine dihydrochloridetab 5 mg (Xyzal)

1

promethazine hcl suppos12.5 mg

1

promethazine hcl suppos 25 mg 1

promethazine hcl suppos 50 mg 1

promethazine hcl syrup6.25 mg/5ml

1

promethazine hcl tab 12.5 mg 1

promethazine hcl tab 25 mg 1

promethazine hcl tab 50 mg 1

NASAL PRODUCTSazelastine hcl nasal spray 0.1%

(137 mcg/spray)1 •

azelastine hcl nasal spray 0.15%(205.5 mcg/spray) (Astepro)

1 •

Drug Name Tier

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FLUNISOLIDE – flunisolide nasalsoln 25 mcg/act (0.025%)

2 •

fluticasone propionate nasalsusp 50 mcg/act (Flonase)

1 •

ipratropium bromide nasal soln0.03% (21 mcg/spray) (Atrovent)

1 •

ipratropium bromide nasal soln0.06% (42 mcg/spray) (Atrovent)

1 •

mometasone furoate nasal susp50 mcg/act (Nasonex)

1 •

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

1 •

COUGH/COLD/ALLERGYacetylcysteine inhal soln 10% 1

acetylcysteine inhal soln 20% 1

ASTHMA/COPDADVAIR DISKUS – fluticasone-

salmeterol aer powder ba100-50 mcg/dose

2 •

ADVAIR DISKUS – fluticasone-salmeterol aer powder ba250-50 mcg/dose

2 •

ADVAIR DISKUS – fluticasone-salmeterol aer powder ba500-50 mcg/dose

2 •

ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21mcg/act

2 •


2 •


2 •

ALBUTEROL SULFATE ER –albuterol sulfate tab er 12hr 4mg

2

ALBUTEROL SULFATE ER –albuterol sulfate tab er 12hr 8mg

2

2018


Drug Name Tier

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

1

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

1

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

1

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

1

albuterol sulfate syrup 2 mg/5ml 1

albuterol sulfate tab 2 mg 1

albuterol sulfate tab 4 mg 1

ANORO ELLIPTA –umeclidinium-vilanterol aeropowd ba 62.5-25 mcg/inh

2 •

ASMANEX HFA – mometasonefuroate inhal aerosolsuspension 100 mcg/act

2 •

ASMANEX HFA – mometasonefuroate inhal aerosolsuspension 200 mcg/act

2 •

ASMANEX TWISTHALER 120 ME– mometasone furoate inhalpowd 220 mcg/inh (breathactivated)

2 •

ASMANEX TWISTHALER 30 MET– mometasone furoate inhalpowd 110 mcg/inh (breathactivated)

2 •


2 •


2 •

BREO ELLIPTA – fluticasonefuroate-vilanterol aero powdba 100-25 mcg/inh

2 •

BREO ELLIPTA – fluticasonefuroate-vilanterol aero powdba 200-25 mcg/inh

2 •

Drug Name Tier

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

1

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

1

budesonide inhalation susp1 mg/2ml (Pulmicort)

1

cromolyn sodium soln nebu20 mg/2ml

1

DULERA – mometasone furoate-formoterol fumarate aerosol100-5 mcg/act

2 •

DULERA – mometasone furoate-formoterol fumarate aerosol200-5 mcg/act

2 •

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

2 •


2 •


2 •

ipratropium bromide inhal soln0.02%

1

ipratropium-albuterol nebu soln0.5-2.5(3) mg/3ml (Duoneb)

1

levalbuterol hcl soln nebu conc1.25 mg/0.5ml (base equiv)

1

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

1


1


1

montelukast sodium chew tab4 mg (base equiv) (Singulair)

1 •

2018


Drug Name Tier

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montelukast sodium chew tab5 mg (base equiv) (Singulair)

1 •

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

1 •

montelukast sodium tab 10 mg(base equiv) (Singulair)

1 •

PROAIR HFA – albuterol sulfateinhal aero 108 mcg/act (90mcgbase equiv)

2 •

PROAIR RESPICLICK – albuterolsulfate aer pow ba 108 mcg/act(90 mcg base equiv)

2 •

QVAR – beclomethasone dipropinhal aero soln 40 mcg/act (50/valve)

2 •

QVAR – beclomethasone dipropinhal aero soln 80 mcg/act(100/valve)

2 •

QVAR REDIHALER –beclomethasone diprop hfabreath act inh aer 40 mcg/act

2 •

QVAR REDIHALER –beclomethasone diprop hfabreath act inh aer 80 mcg/act

2 •

SEREVENT DISKUS – salmeterolxinafoate aer pow ba 50 mcg/dose (base equiv)

2 •

SPIRIVA HANDIHALER– tiotropium bromidemonohydrate inhal cap 18 mcg(base equiv)

2 •

SPIRIVA RESPIMAT – tiotropiumbromide monohydrate inhalaerosol 1.25 mcg/act

2 •

SPIRIVA RESPIMAT – tiotropiumbromide monohydrate inhalaerosol 2.5 mcg/act

2 •

STIOLTO RESPIMAT – tiotropiumbr-olodaterol inhal aero soln2.5-2.5 mcg/act

2 •

Drug Name Tier

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STRIVERDI RESPIMAT –olodaterol hcl inhal aerosolsoln 2.5 mcg/act (base equiv)

2 •

terbutaline sulfate tab 2.5 mg 1

terbutaline sulfate tab 5 mg 1

theophylline tab er 12hr 100 mg 1






TRELEGY ELLIPTA – fluticasone-umeclidinium-vilanterol aepb100-62.5-25 mcg/inh

2 •

zafirlukast tab 10 mg (Accolate) 1 •zafirlukast tab 20 mg (Accolate) 1 •OTHER RESPIRATORY DRUGSKALYDECO – ivacaftor tab 150

mg2 • • •

KALYDECO – ivacaftor packet 50mg

2 • • •

KALYDECO – ivacaftor packet 75mg

2 • • •

PULMOZYME – dornase alfainhal soln 1 mg/ml

2 •

GASTROINTESTINAL DRUGSLAXATIVESlactulose solution 10 gm/15ml 1

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

1

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

1

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

1

ANTIDIARRHEALS

2018


Drug Name Tier

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

1

loperamide hcl cap 2 mg 1

ULCER/GERDCIMETIDINE HCL – cimetidine

hcl soln 300 mg/5ml2

cimetidine tab 300 mg 1



dicyclomine hcl cap 10 mg(Bentyl)

1

dicyclomine hcl oral soln10 mg/5ml

1

dicyclomine hcl tab 20 mg(Bentyl)

1

esomeprazole magnesium capdelayed release 20 mg (baseeq) (Nexium)

1 •

esomeprazole magnesium capdelayed release 40 mg (baseeq) (Nexium)

1 •

famotidine tab 20 mg (Pepcid) 1

famotidine tab 40 mg (Pepcid) 1

glycopyrrolate tab 1 mg (Robinul) 1

glycopyrrolate tab 2 mg (Robinulforte)

1

lansoprazole cap delayedrelease 15 mg (Prevacid)

1 •

lansoprazole cap delayedrelease 30 mg (Prevacid)

1 •

methscopolamine bromide tab2.5 mg (Pamine)

1

methscopolamine bromide tab5 mg (Pamine forte)

1

misoprostol tab 100 mcg(Cytotec)

1

misoprostol tab 200 mcg(Cytotec)

1

Drug Name Tier

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NEXIUM – esomeprazolemagnesium for delayedrelease susp pack 2.5 mg

2 • •

NEXIUM – esomeprazolemagnesium for delayedrelease susp packet 5 mg

2 • •


2 • •


2 • •


2 • •

NIZATIDINE – nizatidine oral soln15 mg/ml

2

omeprazole cap delayed release10 mg (Prilosec)

1 •


1 •


1 •

pantoprazole sodium ec tab20 mg (base equiv) (Protonix)

1 •

pantoprazole sodium ec tab40 mg (base equiv) (Protonix)

1 •

ranitidine hcl cap 150 mg 1

ranitidine hcl cap 300 mg 1

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

1

ranitidine hcl tab 150 mg (Zantac) 1

ranitidine hcl tab 300 mg (Zantac) 1

sucralfate tab 1 gm (Carafate) 1

NAUSEA AND VOMITINGaprepitant capsule therapy pack

80 & 125 mg (Emend)1 •

aprepitant capsule 40 mg(Emend)

1

2018


Drug Name Tier

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1 •


1 •

EMEND – aprepitant for oralsusp 125 mg (125 mg/5ml)

2 •

granisetron hcl tab 1 mg 1 •meclizine hcl tab 12.5 mg 1

meclizine hcl tab 25 mg 1

ondansetron hcl inj 4 mg/2ml(2 mg/ml)

1

ondansetron hcl inj 40 mg/20ml(2 mg/ml) (Zofran)

1

ondansetron hcl oral soln4 mg/5ml (Zofran)

1 •

ondansetron hcl tab 4 mg(Zofran)

1 •

ondansetron hcl tab 8 mg(Zofran)

1 •

ondansetron hcl tab 24 mg 1 •ondansetron orally

disintegrating tab 4 mg (Zofranodt)

1 •

ondansetron orallydisintegrating tab 8 mg (Zofranodt)

1 •

scopolamine td patch 72hr1 mg/3days (Transderm-scop)

1

trimethobenzamide hcl cap300 mg (Tigan)

1

DIGESTIVE ENZYMESCREON – pancrelipase (lip-prot-

amyl) dr cap 3000-9500-15000unit

2

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

2

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

2

Drug Name Tier

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2


2

ZENPEP – pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000unit

2

ZENPEP – pancrelipase (lip-prot-amyl) dr cap 5000-17000-24000unit

2

ZENPEP – pancrelipase(lip-prot-amyl) dr cap10000-32000-42000 unit

2


2


2


2


2

OTHER GASTROINTESTINAL DRUGSAPRISO – mesalamine cap er

24hr 0.375 gm2

ASACOL HD – mesalamine tabdelayed release 800 mg

2

balsalazide disodium cap750 mg (Colazal)

1

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

1

calcium acetate (phosphatebinder) tab 667 mg (Eliphos)

1

CANASA – mesalamine suppos1000 mg

2

2018


Drug Name Tier

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CHENODAL – chenodiol tab 250mg

2 •

DELZICOL – mesalamine cap dr400 mg

2

lactulose (encephalopathy)solution 10 gm/15ml

1

mesalamine enema 4 gm 1

mesalamine tab delayed release1.2 gm (Lialda)

1

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

1

metoclopramide hcl tab 5 mg(base equivalent) (Reglan)

1

metoclopramide hcl tab 10 mg(base equivalent) (Reglan)

1

sevelamer carbonate packet0.8 gm (Renvela)

1

sevelamer carbonate packet2.4 gm (Renvela)

1

sevelamer carbonate tab 800 mg(Renvela)

1

sulfasalazine tab delayed release500 mg (Azulfidine en-tabs)

1

sulfasalazine tab 500 mg(Azulfidine)

1

ursodiol cap 300 mg (Actigall) 1

ursodiol tab 250 mg (Urso 250) 1

ursodiol tab 500 mg (Urso forte) 1

GENITOURINARY DRUGSURINARY TRACT INFECTIONSnitrofurantoin macrocrystalline

cap 25 mg (Macrodantin)1

nitrofurantoin macrocrystallinecap 50 mg (Macrodantin)

1

nitrofurantoin macrocrystallinecap 100 mg (Macrodantin)

1

nitrofurantoin monohydratemacrocrystalline cap 100 mg(Macrobid)

1

Drug Name Tier

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nitrofurantoin susp 25 mg/5ml(Furadantin)

1

URINARY TRACT SPASMSoxybutynin chloride syrup

5 mg/5ml1

oxybutynin chloride tab er 24hr5 mg (Ditropan xl)

1


1


1

oxybutynin chloride tab 5 mg 1

tolterodine tartrate cap er 24hr2 mg (Detrol la)

1

tolterodine tartrate cap er 24hr4 mg (Detrol la)

1

tolterodine tartrate tab 1 mg(Detrol)

1

tolterodine tartrate tab 2 mg(Detrol)

1

VESICARE – solifenacinsuccinate tab 5 mg

2

VESICARE – solifenacinsuccinate tab 10 mg

2

VAGINAL PRODUCTSclindamycin phosphate vaginal

cream 2% (Cleocin)1

ESTRACE – estradiol vaginalcream 0.1 mg/gm

2

estradiol vaginal cream 0.1 mg/gm (Estrace)

1

metronidazole vaginal gel 0.75%(Metrogel-vaginal)

1

TERCONAZOLE – terconazolevaginal cream 0.8%

2

terconazole vaginal cream 0.4%(Terazol 7)

1

terconazole vaginal suppos80 mg

1

2018


Drug Name Tier

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VAGIFEM – estradiol vaginal tab10 mcg

1

OTHER GENITOURINARY DRUGSalfuzosin hcl tab er 24hr 10 mg

(Uroxatral)1

CYSTAGON – cysteaminebitartrate cap 50 mg

2 •

CYSTAGON – cysteaminebitartrate cap 150 mg

2 •

dutasteride cap 0.5 mg (Avodart) 1

finasteride tab 5 mg (Proscar) 1

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

1


1


1

sodium citrate & citric acid soln500-334 mg/5ml (Shohls solutionmodi)

1

tamsulosin hcl cap 0.4 mg(Flomax)

1

CENTRAL NERVOUS SYSTEM DRUGSANXIETYalprazolam tab er 24hr 0.5 mg

(Xanax xr)1

alprazolam tab er 24hr 1 mg(Xanax xr)

1


1


1

alprazolam tab 0.25 mg (Xanax) 1

alprazolam tab 0.5 mg (Xanax) 1

alprazolam tab 1 mg (Xanax) 1

alprazolam tab 2 mg (Xanax) 1

buspirone hcl tab 5 mg 1


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diazepam tab 2 mg (Valium) 1



hydroxyzine hcl syrup 10 mg/5ml 1

hydroxyzine hcl tab 10 mg 1



hydroxyzine pamoate cap 25 mg(Vistaril)

1

hydroxyzine pamoate cap 50 mg(Vistaril)

1

lorazepam conc 2 mg/ml(Lorazepam intensol)

1

lorazepam tab 0.5 mg (Ativan) 1

lorazepam tab 1 mg (Ativan) 1

lorazepam tab 2 mg (Ativan) 1

DEPRESSIONamitriptyline hcl tab 10 mg 1

amitriptyline hcl tab 25 mg 1





bupropion hcl tab er 12hr100 mg (Wellbutrin sr)

1 •


1 •


1 •

bupropion hcl tab er 24hr150 mg (Wellbutrin xl)

1 •

bupropion hcl tab er 24hr300 mg (Wellbutrin xl)

1 •

bupropion hcl tab 75 mg(Wellbutrin)

1 •

2018


Drug Name Tier

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its

bupropion hcl tab 100 mg(Wellbutrin)

1 •

citalopram hydrobromide oralsoln 10 mg/5ml

1 •

citalopram hydrobromide tab10 mg (base equiv) (Celexa)

1 •


1 •


1 •

clomipramine hcl cap 25 mg(Anafranil)

1


1


1

desipramine hcl tab 10 mg(Norpramin)

1


1


1


1


1


1

doxepin hcl cap 10 mg 1





doxepin hcl conc 10 mg/ml 1

duloxetine hcl enteric coatedpellets cap 20 mg (base eq)(Cymbalta)

1 •


1 •

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1 •

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

1 •

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

1 •


1 •


1 •

FLUOXETINE DR – fluoxetine hclcap delayed release 90 mg

2 •

fluoxetine hcl cap 10 mg (Prozac) 1 •fluoxetine hcl cap 20 mg (Prozac) 1 •fluoxetine hcl cap 40 mg (Prozac) 1 •fluoxetine hcl solution

20 mg/5ml1 •

fluoxetine hcl tab 10 mg 1 •fluoxetine hcl tab 20 mg 1 •fluvoxamine maleate tab 25 mg 1 •fluvoxamine maleate tab 50 mg 1 •fluvoxamine maleate tab 100 mg 1 •imipramine hcl tab 10 mg

(Tofranil)1

imipramine hcl tab 25 mg(Tofranil)

1

imipramine hcl tab 50 mg(Tofranil)

1

mirtazapine tab 7.5 mg 1 •mirtazapine tab 15 mg (Remeron) 1 •mirtazapine tab 30 mg (Remeron) 1 •mirtazapine tab 45 mg (Remeron) 1 •nortriptyline hcl cap 10 mg

(Pamelor)1

nortriptyline hcl cap 25 mg(Pamelor)

1

2018


Drug Name Tier

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1


1

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

1 •

paroxetine hcl tab er 24hr 25 mg(Paxil cr)

1 •

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

1 •

paroxetine hcl tab 10 mg (Paxil) 1 •paroxetine hcl tab 20 mg (Paxil) 1 •paroxetine hcl tab 30 mg (Paxil) 1 •paroxetine hcl tab 40 mg (Paxil) 1 •phenelzine sulfate tab 15 mg

(Nardil)1

sertraline hcl oral concentratefor solution 20 mg/ml (Zoloft)

1 •

sertraline hcl tab 25 mg (Zoloft) 1 •sertraline hcl tab 50 mg (Zoloft) 1 •sertraline hcl tab 100 mg (Zoloft) 1 •tranylcypromine sulfate tab

10 mg (Parnate)1

trazodone hcl tab 50 mg 1




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

1 •

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

1 •

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

1 •

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

1 •

Drug Name Tier

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venlafaxine hcl tab er 24hr 75 mg(base equivalent) (Venlafaxinehcl er)

1 •

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

1 •

venlafaxine hcl tab 25 mg 1 •venlafaxine hcl tab 37.5 mg 1 •venlafaxine hcl tab 50 mg 1 •venlafaxine hcl tab 75 mg 1 •venlafaxine hcl tab 100 mg 1 •PSYCHOTIC AND BIPOLAR DISORDERSaripiprazole tab 2 mg (Abilify) 1 •aripiprazole tab 5 mg (Abilify) 1 •aripiprazole tab 10 mg (Abilify) 1 •aripiprazole tab 15 mg (Abilify) 1 •aripiprazole tab 20 mg (Abilify) 1 •aripiprazole tab 30 mg (Abilify) 1 •chlorpromazine hcl tab 10 mg 1

chlorpromazine hcl tab 25 mg 1




clozapine tab 25 mg (Clozaril) 1 •clozapine tab 50 mg 1 •clozapine tab 100 mg (Clozaril) 1 •clozapine tab 200 mg 1 •fluphenazine decanoate inj

25 mg/ml1

fluphenazine hcl tab 1 mg 1

fluphenazine hcl tab 2.5 mg 1



haloperidol decanoate im soln50 mg/ml (Haldol decanoate 50)

1

2018


Drug Name Tier

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its

haloperidol decanoate im soln100 mg/ml (Haldol decanoate100)

1

haloperidol lactate oral conc2 mg/ml

1

haloperidol tab 0.5 mg 1

haloperidol tab 1 mg 1





lithium carbonate cap 150 mg(Lithium carbonate)

1

lithium carbonate cap 300 mg 1

lithium carbonate cap 600 mg(Lithium carbonate)

1

lithium carbonate tab er 300 mg(Lithobid)

1

lithium carbonate tab er 450 mg 1

lithium carbonate tab 300 mg 1

loxapine succinate cap 5 mg(Loxitane)

1

loxapine succinate cap 10 mg 1



olanzapine orally disintegratingtab 5 mg (Zyprexa zydis)

1 •


1 •


1 •


1 •

olanzapine tab 2.5 mg (Zyprexa) 1 •olanzapine tab 5 mg (Zyprexa) 1 •olanzapine tab 7.5 mg (Zyprexa) 1 •olanzapine tab 10 mg (Zyprexa) 1 •olanzapine tab 15 mg (Zyprexa) 1 •

Drug Name Tier

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its

olanzapine tab 20 mg (Zyprexa) 1 •perphenazine tab 2 mg 1

perphenazine tab 4 mg 1



prochlorperazine maleatetab 5 mg (base equivalent)(Compazine)

1

prochlorperazine maleate tab10 mg (base equivalent)(Compazine)

1

prochlorperazine suppos 25 mg 1

quetiapine fumarate tab er 24hr50 mg (Seroquel xr)

1 •


1 •


1 •


1 •


1 •

quetiapine fumarate tab 25 mg(Seroquel)

1 •


1 •


1 •


1 •


1 •


1 •

RISPERIDONE ODT– risperidone orallydisintegrating tab 0.25 mg

2 • •

risperidone orally disintegratingtab 0.5 mg (Risperdal m-tab)

1 •

2018


Drug Name Tier

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Lim

its

risperidone orally disintegratingtab 1 mg (Risperdal m-tab)

1 •


1 •


1 •


1 •

risperidone soln 1 mg/ml(Risperdal)

1 •

risperidone tab 0.25 mg(Risperdal)

1 •

risperidone tab 0.5 mg(Risperdal)

1 •

risperidone tab 1 mg (Risperdal) 1 •risperidone tab 2 mg (Risperdal) 1 •risperidone tab 3 mg (Risperdal) 1 •risperidone tab 4 mg (Risperdal) 1 •thiothixene cap 1 mg 1

thiothixene cap 2 mg 1



trifluoperazine hcl tab 1 mg(base equivalent)

1


1


1


1

ziprasidone hcl cap 20 mg(Geodon)

1 •


1 •


1 •


1 •

SLEEP AIDS

Drug Name Tier

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estazolam tab 1 mg 1

estazolam tab 2 mg 1

eszopiclone tab 1 mg (Lunesta) 1 •eszopiclone tab 2 mg (Lunesta) 1 •eszopiclone tab 3 mg (Lunesta) 1 •FLURAZEPAM HCL – flurazepam

hcl cap 15 mg2

FLURAZEPAM HCL – flurazepamhcl cap 30 mg

2

PHENOBARBITAL –phenobarbital tab 15 mg

2


2


2


2

phenobarbital elixir 20 mg/5ml 1

phenobarbital tab 16.2 mg 1

phenobarbital tab 32.4 mg 1

temazepam cap 7.5 mg (Restoril) 1

temazepam cap 15 mg (Restoril) 1

temazepam cap 22.5 mg(Restoril)

1

temazepam cap 30 mg (Restoril) 1

zaleplon cap 5 mg (Sonata) 1 •zaleplon cap 10 mg (Sonata) 1 •zolpidem tartrate tab er 6.25 mg

(Ambien cr)1 •

zolpidem tartrate tab er 12.5 mg(Ambien cr)

1 •

zolpidem tartrate tab 5 mg(Ambien)

1 •

zolpidem tartrate tab 10 mg(Ambien)

1 •

HYPERACTIVITY/NARCOLEPSY

2018


Drug Name Tier

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its

ADDERALL XR – amphetamine-dextroamphetamine cap er24hr 5 mg

1 •


1 •


1 •


1 •


1 •


1 •

amphetamine-dextroamphetamine tab 5 mg(Adderall)

1 •

amphetamine-dextroamphetamine tab 7.5 mg(Adderall)

1 •


1 •

amphetamine-dextroamphetamine tab12.5 mg (Adderall)

1 •


1 •


1 •


1 •

armodafinil tab 50 mg (Nuvigil) 1 • •armodafinil tab 150 mg (Nuvigil) 1 • •armodafinil tab 200 mg (Nuvigil) 1 • •

Drug Name Tier

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its

armodafinil tab 250 mg (Nuvigil) 1 • •atomoxetine hcl cap 10 mg (base

equiv) (Strattera)1 •

atomoxetine hcl cap 18 mg (baseequiv) (Strattera)

1 •


1 •


1 •


1 •


1 •

atomoxetine hcl cap 100 mg(base equiv) (Strattera)

1 •

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

1

CONCERTA – methylphenidatehcl tab er osmotic release(osm) 18 mg

1 •


1 •


1 •


1 •

dexmethylphenidate hcl cap er24 hr 5 mg (Focalin xr)

1 •


1 •


1 •


1 •


1 •

2018


Drug Name Tier

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its


1 •

dextroamphetamine sulfate caper 24hr 5 mg (Dexedrine)

1 •


1 •


1 •

dextroamphetamine sulfate tab5 mg

1 •

dextroamphetamine sulfate tab10 mg

1 •

guanfacine hcl tab er 24hr 1 mg(base equiv) (Intuniv)

1 •


1 •


1 •


1 •

methylphenidate hcl tab er10 mg

1 •

methylphenidate hcl tab er20 mg

1 •

methylphenidate hcl tab 5 mg(Ritalin)

1 •


1 •


1 •

modafinil tab 100 mg (Provigil) 1 • •modafinil tab 200 mg (Provigil) 1 • •VYVANSE – lisdexamfetamine

dimesylate cap 10 mg2 •

VYVANSE – lisdexamfetaminedimesylate cap 20 mg

2 •


2 •


2 •

Drug Name Tier

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2 •


2 •


2 •

VYVANSE – lisdexamfetaminedimesylate chew tab 10 mg

2 •


2 •


2 •


2 •


2 •


2 •

MULTIPLE SCLEROSISAUBAGIO – teriflunomide tab 7

mg2 • •

AUBAGIO – teriflunomide tab 14mg

2 • •

AVONEX – interferon beta-1aim prefilled syringe kit 30mcg/0.5ml

2 • •

AVONEX – interferon beta-1a forim inj kit 30mcg (33mcg(6.6mu)/vial)

2 • •

AVONEX PEN – interferonbeta-1a im auto-injector kit 30mcg/0.5ml

2 • •

BETASERON – interferon beta-1bfor inj kit 0.3 mg

2 • •

COPAXONE – glatiramer acetatesoln prefilled syringe 20 mg/ml

2 • •

COPAXONE – glatiramer acetatesoln prefilled syringe 40 mg/ml

2 • •

GILENYA – fingolimod hcl cap0.5 mg (base equiv)

2 • •

2018


Drug Name Tier

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Lim

its

glatiramer acetate soln prefilledsyringe 20 mg/ml (Copaxone)

1 • •

glatiramer acetate soln prefilledsyringe 40 mg/ml (Copaxone)

1 • •

PLEGRIDY – peginterferonbeta-1a soln pen-injector 125mcg/0.5ml

2 • •

PLEGRIDY – peginterferonbeta-1a soln prefilled syringe125 mcg/0.5ml

2 • •

PLEGRIDY STARTER PACK –peginterferon beta-1a solnpen-inj 63 & 94 mcg/0.5ml pack

2 • •

PLEGRIDY STARTER PACK –peginterferon beta-1a soln prefsyr 63 & 94 mcg/0.5ml pack

2 • •

REBIF – interferon beta-1a solnpref syr 22 mcg/0.5ml (12mu/ml)

2 • •

REBIF – interferon beta-1a solnpref syr 44 mcg/0.5ml (24mu/ml)

2 • •

REBIF REBIDOSE – interferonbeta-1a soln auto-inj 22mcg/0.5ml (12mu/ml)

2 • •

REBIF REBIDOSE – interferonbeta-1a soln auto-inj 44mcg/0.5ml (24mu/ml)

2 • •

REBIF REBIDOSE TITRATION– interferon beta-1a auto-inj 6x8.8 mcg/0.2ml & 6x22mcg/0.5ml

2 • •

REBIF TITRATION PACK –interferon beta-1a pref syr6x8.8 mcg/0.2ml & 6x22mcg/0.5ml

2 • •

TECFIDERA – dimethyl fumaratecapsule delayed release 120mg

2 • •

TECFIDERA – dimethyl fumaratecapsule delayed release 240mg

2 • •

Drug Name Tier

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its

TECFIDERA STARTER PACK –dimethyl fumarate capsule drstarter pack 120 mg & 240 mg

2 • •

OTHER CENTRAL NERVOUS SYSTEM DRUGSacamprosate calcium tab

delayed release 333 mg(Campral)

1

bupropion hcl (smokingdeterrent) tab er 12hr 150 mg(Zyban)

1

CHANTIX – varenicline tartratetab 0.5 mg (base equiv)

2

CHANTIX – varenicline tartratetab 1 mg (base equiv)

2

CHANTIX CONTINUING MONTH– varenicline tartrate tab 1 mg(base equiv)

2

CHANTIX STARTING MONTH PA– varenicline tartrate tab 0.5mg x 11 & tab 1 mg x 42 pack

2

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

2

disulfiram tab 250 mg (Antabuse) 1

disulfiram tab 500 mg (Antabuse) 1

donepezil hydrochloride orallydisintegrating tab 5 mg (Ariceptodt)

1

donepezil hydrochloride orallydisintegrating tab 10 mg(Aricept odt)

1

donepezil hydrochloride tab5 mg (Aricept)

1

donepezil hydrochloride tab10 mg (Aricept)

1

GALANTAMINE HYDROBROMIDE– galantamine hydrobromideoral soln 4 mg/ml

2

galantamine hydrobromide caper 24hr 8 mg (Razadyne er)

1

2018


Drug Name Tier

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its


1


1

galantamine hydrobromide tab4 mg (Razadyne)

1


1


1

memantine hcl oral solution2 mg/ml (Namenda)

1

memantine hcl tab 5 mg(Namenda)

1

memantine hcl tab 10 mg(Namenda)

1

memantine hcl tab 5 mg (28)& 10 mg (21) titration pak(Namenda titration pa)

1

NICOTROL INHALER – nicotineinhaler system 10 mg (4 mgdelivered)

2

NICOTROL NS – nicotine nasalspray 10 mg/ml (0.5 mg/spray)

2

pimozide tab 1 mg (Orap) 1

pimozide tab 2 mg (Orap) 1

rivastigmine tartrate cap 1.5 mg(Exelon)

1

rivastigmine tartrate cap 3 mg(Exelon)

1

rivastigmine tartrate cap 4.5 mg(Exelon)

1

rivastigmine tartrate cap 6 mg(Exelon)

1

tetrabenazine tab 12.5 mg(Xenazine)

1 •

tetrabenazine tab 25 mg(Xenazine)

1 •

PAIN RELIEF DRUGSNON-NARCOTIC DRUGS

Drug Name Tier

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its

butalbital-acetaminophen tab50-325 mg

1 •

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

1 •

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

1 •

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

1 •

TENCON – butalbital-acetaminophen tab 50-325 mg

2 •

NARCOTIC DRUGSacetaminophen w/ codeine soln

120-12 mg/5ml1 • •

acetaminophen w/ codeine tab300-15 mg (Tylenol/codeine)

1 • •

acetaminophen w/ codeine tab300-30 mg (Tylenol/codeine #3)

1 • •

acetaminophen w/ codeine tab300-60 mg (Tylenol/codeine #4)

1 • •

buprenorphine hcl sl tab 2 mg(base equiv)

1 • •

buprenorphine hcl sl tab 8 mg(base equiv)

1 • •

butalbital-aspirin-caff w/ codeinecap 50-325-40-30 mg (Fiorinal/codeine #3)

1 • •

codeine sulfate tab 15 mg(Codeine sulfate)

1 • •

codeine sulfate tab 30 mg 1 • •codeine sulfate tab 60 mg 1 • •fentanyl citrate lozenge on a

handle 200 mcg (Actiq)1 • •

fentanyl citrate lozenge on ahandle 400 mcg (Actiq)

1 • •


1 • •


1 • •


1 • •

2018


Drug Name Tier

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its


1 • •

fentanyl td patch 72hr 12 mcg/hr(Duragesic)

1 • •


1 • •


1 • •


1 • •

fentanyl td patch 72hr 100 mcg/hr (Duragesic)

1 • •

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

1 • •

hydrocodone-acetaminophentab 10-325 mg (Norco)

1 • •

hydrocodone-acetaminophentab 5-325 mg (Norco)

1 • •

hydrocodone-acetaminophentab 7.5-325 mg (Norco)

1 • •

hydrocodone-ibuprofen tab5-200 mg (Reprexain)

1 • •

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

1 • •

hydrocodone-ibuprofen tab10-200 mg (Ibudone)

1 • •

hydromorphone hcl liqd 1 mg/ml(Dilaudid)

1 • •

hydromorphone hcl tab 2 mg(Dilaudid)

1 • •


1 • •


1 • •

methadone hcl conc 10 mg/ml(Methadose)

1 • •

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

1 • •

methadone hcl soln 10 mg/5ml(Methadone hcl)

1 • •

Drug Name Tier

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Lim

its

methadone hcl tab for oral susp40 mg

1 • •

methadone hcl tab 5 mg(Dolophine hcl)

1 • •

methadone hcl tab 10 mg(Dolophine)

1 • •

MORPHINE SULFATE – morphinesulfate tab 15 mg

2 • •

MORPHINE SULFATE – morphinesulfate tab 30 mg

2 • •

morphine sulfate oral soln10 mg/5ml

1 • •

morphine sulfate oral soln20 mg/5ml

1 • •

morphine sulfate oral soln100 mg/5ml (20 mg/ml)

1 • •

morphine sulfate tab er 15 mg(Ms contin)

1 • •


1 • •


1 • •


1 • •


1 • •

oxycodone hcl cap 5 mg 1 • •oxycodone hcl conc 100 mg/5ml

(20 mg/ml) (Oxycodone hcl)1 • •

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

1 • •

oxycodone hcl tab 5 mg(Roxicodone)

1 • •

oxycodone hcl tab 10 mg 1 • •oxycodone hcl tab 15 mg

(Roxicodone)1 • •

oxycodone hcl tab 20 mg 1 • •oxycodone hcl tab 30 mg

(Roxicodone)1 • •

2018


Drug Name Tier

Des

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Lim

its

oxycodone w/ acetaminophentab 5-325 mg (Percocet)

1 • •

oxycodone w/ acetaminophentab 7.5-325 mg (Percocet)

1 • •

oxycodone w/ acetaminophentab 10-325 mg (Percocet)

1 • •

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

1 • •

OXYCONTIN – oxycodone hcltab er 12hr deter 10 mg

2 • •


2 • •


2 • •


2 • •


2 • •


2 • •


2 • •

tramadol hcl tab er 24hr 100 mg 1 • •tramadol hcl tab er 24hr 200 mg 1 • •tramadol hcl tab er 24hr 300 mg 1 • •tramadol hcl tab 50 mg (Ultram) 1 • •tramadol-acetaminophen tab

37.5-325 mg (Ultracet)1 • •

RHEUMATOID AND OSTEOARTHRITIScelecoxib cap 50 mg (Celebrex) 1 •celecoxib cap 100 mg (Celebrex) 1 •celecoxib cap 200 mg (Celebrex) 1 •celecoxib cap 400 mg (Celebrex) 1 •diclofenac potassium tab 50 mg

(Cataflam)1

diclofenac sodium tab delayedrelease 25 mg

1


1

Drug Name Tier

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its


1

diclofenac sodium tab er 24hr100 mg

1

ENBREL – etanercept forsubcutaneous inj 25 mg

2 • • •

ENBREL – etanerceptsubcutaneous soln prefilledsyringe 25 mg/0.5ml

2 • • •

ENBREL – etanerceptsubcutaneous soln prefilledsyringe 50 mg/ml

2 • • •

ENBREL MINI – etanerceptsubcutaneous solutioncartridge 50 mg/ml

2 • • •

ENBREL SURECLICK –etanercept subcutaneoussolution auto-injector 50 mg/ml

2 • • •

etodolac cap 200 mg 1

etodolac cap 300 mg 1

etodolac tab er 24hr 400 mg 1



etodolac tab 400 mg 1

etodolac tab 500 mg 1

flurbiprofen tab 50 mg 1

flurbiprofen tab 100 mg 1

HUMIRA – adalimumab prefilledsyringe kit 10 mg/0.2ml

2 • • •


2 • • •


2 • • •

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

2 • • •

HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.8ml

2 • • •

2018


Drug Name Tier

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erap

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Lim

its

HUMIRA PEN-CROHNS DISEASE– adalimumab pen-injector kit40 mg/0.8ml

2 • • •

HUMIRA PEN-PSORIASIS STAR –adalimumab pen-injector kit 40mg/0.8ml

2 • • •

ibuprofen susp 100 mg/5ml 1

ibuprofen tab 400 mg 1



ILARIS – canakinumabsubcutaneous inj 150 mg/ml

2 • • •

indomethacin cap 25 mg 1

indomethacin cap 50 mg 1

leflunomide tab 10 mg (Arava) 1

leflunomide tab 20 mg (Arava) 1

meloxicam tab 7.5 mg (Mobic) 1

meloxicam tab 15 mg (Mobic) 1

nabumetone tab 500 mg 1

nabumetone tab 750 mg 1

naproxen sodium tab 275 mg(Anaprox)

1

naproxen sodium tab 550 mg(Anaprox ds)

1

naproxen susp 125 mg/5ml(Naprosyn)

1

naproxen tab ec 375 mg (Ec-naprosyn)

1

naproxen tab ec 500 mg (Ec-naprosyn)

1

naproxen tab 250 mg (Naprosyn) 1



oxaprozin tab 600 mg (Daypro) 1

piroxicam cap 10 mg (Feldene) 1

piroxicam cap 20 mg (Feldene) 1

Drug Name Tier

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Lim

its

SIMPONI – golimumabsubcutaneous soln auto-injector 50 mg/0.5ml

2 • • •

SIMPONI – golimumabsubcutaneous soln auto-injector 100 mg/ml

2 • • •

SIMPONI – golimumabsubcutaneous soln prefilledsyringe 50 mg/0.5ml

2 • • •

SIMPONI – golimumabsubcutaneous soln prefilledsyringe 100 mg/ml

2 • • •

sulindac tab 150 mg 1

sulindac tab 200 mg 1

MIGRAINE HEADACHESeletriptan hydrobromide tab

20 mg (base equivalent)(Relpax)

1 •

eletriptan hydrobromide tab40 mg (base equivalent)(Relpax)

1 •

naratriptan hcl tab 1 mg (baseequiv) (Amerge)

1 •

naratriptan hcl tab 2.5 mg (baseequiv) (Amerge)

1 •

rizatriptan benzoate oraldisintegrating tab 5 mg (baseeq) (Maxalt-mlt)

1 •

rizatriptan benzoate oraldisintegrating tab 10 mg (baseeq) (Maxalt-mlt)

1 •

rizatriptan benzoate tab 5 mg(base equivalent) (Maxalt)

1 •

rizatriptan benzoate tab 10 mg(base equivalent) (Maxalt)

1 •

sumatriptan nasal spray 5 mg/act (Imitrex)

1 •

sumatriptan nasal spray 20 mg/act (Imitrex)

1 •

sumatriptan succinate inj6 mg/0.5ml (Imitrex)

1 •

2018


Drug Name Tier

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its

sumatriptan succinate solutionauto-injector 4 mg/0.5ml(Imitrex statdose sys)

1 •

sumatriptan succinate solutionauto-injector 6 mg/0.5ml(Imitrex statdose sys)

1 •

sumatriptan succinate solutioncartridge 4 mg/0.5ml (Imitrexstatdose ref)

1 •

sumatriptan succinate solutioncartridge 6 mg/0.5ml (Imitrexstatdose ref)

1 •

sumatriptan succinate tab 25 mg(Imitrex)

1 •

sumatriptan succinate tab 50 mg(Imitrex)

1 •

sumatriptan succinate tab100 mg (Imitrex)

1 •

GOUTallopurinol tab 100 mg (Zyloprim) 1

allopurinol tab 300 mg (Zyloprim) 1

colchicine w/ probenecid tab0.5-500 mg

1

COLCRYS – colchicine tab 0.6mg

2

probenecid tab 500 mg 1

LOCAL ANESTHETICS INJECTABLElidocaine hcl local inj 1%

(Xylocaine)1

lidocaine hcl local preservativefree (pf) inj 1% (Xylocaine-mpf)

1

NEUROMUSCULAR DRUGSSEIZUREScarbamazepine cap er 12hr

100 mg (Carbatrol)1

carbamazepine cap er 12hr200 mg (Carbatrol)

1

carbamazepine cap er 12hr300 mg (Carbatrol)

1

carbamazepine chew tab 100 mg 1

Drug Name Tier

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Lim

its

carbamazepine susp 100 mg/5ml(Tegretol)

1

carbamazepine tab er 12hr100 mg (Tegretol-xr)

1


1


1

carbamazepine tab 200 mg(Tegretol)

1

clonazepam tab 0.5 mg(Klonopin)

1

clonazepam tab 1 mg (Klonopin) 1

clonazepam tab 2 mg (Klonopin) 1

DIASTAT ACUDIAL – diazepamrectal gel delivery system 10mg

2

DIASTAT ACUDIAL – diazepamrectal gel delivery system 20mg

2

DIASTAT PEDIATRIC – diazepamrectal gel delivery system 2.5mg

2

DILANTIN – phenytoin sodiumextended cap 30 mg

2

divalproex sodium cap delayedrelease sprinkle 125 mg(Depakote sprinkles)

1

divalproex sodium tab delayedrelease 125 mg (Depakote)

1


1


1

divalproex sodium tab er 24 hr250 mg (Depakote er)

1

divalproex sodium tab er 24 hr500 mg (Depakote er)

1

ethosuximide cap 250 mg(Zarontin)

1

2018


Drug Name Tier

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Lim

its

ethosuximide soln 250 mg/5ml(Zarontin)

1

gabapentin cap 100 mg(Neurontin)

1 •


1 •


1 •

gabapentin oral soln 250 mg/5ml(Neurontin)

1 •

gabapentin tab 600 mg(Neurontin)

1 •

gabapentin tab 800 mg(Neurontin)

1 •

lamotrigine tab chewabledispersible 5 mg (Lamictalchewable di)

1

lamotrigine tab chewabledispersible 25 mg (Lamictalchewable di)

1

lamotrigine tab 25 mg (Lamictal) 1




levetiracetam oral soln 100 mg/ml (Keppra)

1

levetiracetam tab er 24hr 500 mg(Keppra xr)

1

levetiracetam tab er 24hr 750 mg(Keppra xr)

1

levetiracetam tab 250 mg(Keppra)

1


1


1


1

oxcarbazepine susp 300 mg/5ml(60 mg/ml) (Trileptal)

1

Drug Name Tier

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ty

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its

oxcarbazepine tab 150 mg(Trileptal)

1


1


1

phenytoin chew tab 50 mg(Dilantin infatabs)

1

phenytoin sodium extended cap100 mg (Dilantin)

1

phenytoin sodium extended cap200 mg (Phenytek)

1

phenytoin sodium extended cap300 mg (Phenytek)

1

phenytoin susp 125 mg/5ml(Dilantin)

1

primidone tab 50 mg (Mysoline) 1

primidone tab 250 mg (Mysoline) 1

topiramate sprinkle cap 15 mg(Topamax sprinkle)

1

topiramate sprinkle cap 25 mg(Topamax sprinkle)

1

topiramate tab 25 mg (Topamax) 1




valproate sodium oral soln250 mg/5ml (base equiv)(Depakene)

1

valproic acid cap 250 mg(Depakene)

1

vigabatrin powd pack 500 mg(Sabril)

1

zonisamide cap 25 mg(Zonegran)

1

zonisamide cap 50 mg 1

zonisamide cap 100 mg(Zonegran)

1

PARKINSON'S DISEASE

2018


Drug Name Tier

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ing

Lim

its

amantadine hcl cap 100 mg 1

amantadine hcl syrup 50 mg/5ml 1

benztropine mesylate tab 0.5 mg 1

benztropine mesylate tab 1 mg 1

benztropine mesylate tab 2 mg 1

bromocriptine mesylate cap5 mg (base equivalent)(Parlodel)

1

bromocriptine mesylate tab2.5 mg (base equivalent)(Parlodel)

1

carbidopa & levodopa orallydisintegrating tab 10-100 mg

1


1


1

carbidopa & levodopa tab er25-100 mg (Sinemet cr)

1

carbidopa & levodopa tab er50-200 mg (Sinemet cr)

1

carbidopa & levodopa tab10-100 mg (Sinemet)

1


1


1

entacapone tab 200 mg (Comtan) 1

pramipexole dihydrochloride tab0.125 mg (Mirapex)

1


1


1


1

pramipexole dihydrochloride tab1 mg (Mirapex)

1


1

Drug Name Tier

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tion

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ty

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n

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ing

Lim

its

rasagiline mesylate tab 0.5 mg(base equiv) (Azilect)

1

rasagiline mesylate tab 1 mg(base equiv) (Azilect)

1

ropinirole hydrochloride tab0.25 mg (Requip)

1

ropinirole hydrochloride tab0.5 mg (Requip)

1

ropinirole hydrochloride tab1 mg (Requip)

1


1


1


1


1

selegiline hcl cap 5 mg (Eldepryl) 1

selegiline hcl tab 5 mg 1

trihexyphenidyl hcl elixir 0.4 mg/ml

1

trihexyphenidyl hcl tab 2 mg 1

trihexyphenidyl hcl tab 5 mg 1

MUSCLE RELAXANTSbaclofen tab 10 mg 1

baclofen tab 20 mg 1

CHLORZOXAZONE –chlorzoxazone tab 500 mg

2

cyclobenzaprine hcl tab 5 mg 1

cyclobenzaprine hcl tab 10 mg 1

dantrolene sodium cap 25 mg(Dantrium)

1

dantrolene sodium cap 50 mg(Dantrium)

1

dantrolene sodium cap 100 mg(Dantrolene sodium)

1

metaxalone tab 800 mg (Skelaxin) 1

2018


Drug Name Tier

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its

methocarbamol tab 500 mg(Robaxin)

1

methocarbamol tab 750 mg(Robaxin-750)

1

orphenadrine citrate tab er 12hr100 mg

1

tizanidine hcl tab 2 mg (baseequivalent)

1

tizanidine hcl tab 4 mg (baseequivalent) (Zanaflex)

1

OTHER NEUROMUSCULAR DRUGSpyridostigmine bromide tab

60 mg (Mestinon)1

RILUTEK – riluzole tab 50 mg 2

riluzole tab 50 mg (Rilutek) 1

SUPPLEMENTSVITAMINSergocalciferol cap 50000 unit

(Drisdol)1

MEPHYTON – phytonadione tab5 mg

2

MINERALS AND ELECTROLYTESpot phos monobasic w/sod

phos di & monobas tab155-852-130mg (K-phos neutral)

1

potassium chloride cap er 8 meq(Micro-k)

1

potassium chloride cap er 10meq (Micro-k)

1

potassium chloridemicroencapsulated crys er tab10 meq

1

potassium chloridemicroencapsulated crys er tab20 meq

1

potassium chloride oral soln10% (20 meq/15ml)

1

potassium chloride powderpacket 20 meq

1

Drug Name Tier

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its

potassium chloride tab er 8 meq(600 mg)

1

potassium chloride tab er 10meq (K-tab)

1

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

1

sodium fluoride chew tab 0.5 mgf (from 1.1 mg naf) (Luride)

1

sodium fluoride chew tab 1 mg f(from 2.2 mg naf) (Luride)

1

sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf)

1

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

1

BLOOD MODIFYING DRUGSanagrelide hcl cap 0.5 mg

(Agrylin)1

anagrelide hcl cap 1 mg 1

BRILINTA – ticagrelor tab 60 mg 2

BRILINTA – ticagrelor tab 90 mg 2

cilostazol tab 50 mg (Pletal) 1

cilostazol tab 100 mg (Pletal) 1

clopidogrel bisulfate tab 75 mg(base equiv) (Plavix)

1

cyanocobalamin inj 1000 mcg/ml 1

dipyridamole tab 25 mg(Persantine)

1


1


1

ELIQUIS – apixaban tab 2.5 mg 2 •ELIQUIS – apixaban tab 5 mg 2 •ELIQUIS STARTER PACK –

apixaban tab 5 mg2 •

enoxaparin sodium inj30 mg/0.3ml (Lovenox)

1 •

2018


Drug Name Tier

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its


1 •


1 •


1 •

enoxaparin sodium inj 100 mg/ml (Lovenox)

1 •


1 •

enoxaparin sodium inj 150 mg/ml (Lovenox)

1 •

enoxaparin sodium inj300 mg/3ml (Lovenox)

1 •

FIRAZYR – icatibant acetate inj30 mg/3ml (base equivalent)

2 • • •

folic acid tab 1 mg 1

HAEGARDA – c1 esteraseinhibitor (human) forsubcutaneous inj 2000 unit

2 • • •

HAEGARDA – c1 esteraseinhibitor (human) forsubcutaneous inj 3000 unit

2 • • •

pentoxifylline tab er 400 mg 1

prasugrel hcl tab 5 mg (baseequiv) (Effient)

1

prasugrel hcl tab 10 mg (baseequiv) (Effient)

1

warfarin sodium tab 1 mg(Coumadin)

1


1

warfarin sodium tab 2.5 mg(Coumadin)

1


1


1


1

Drug Name Tier

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1

warfarin sodium tab 7.5 mg(Coumadin)

1


1

XARELTO – rivaroxaban tab 10mg

2 •


2 •


2 •

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

2 •

ZARXIO – filgrastim-sndz solnprefilled syringe 300 mcg/0.5ml

2 •

ZARXIO – filgrastim-sndz solnprefilled syringe 480 mcg/0.8ml

2 •

TOPICAL DRUGSEYEAnti-infectivesBACITRACIN – bacitracin ophth

oint 500 unit/gm2

bacitracin-polymyxin b ophthoint

1

ciprofloxacin hcl ophth soln0.3% (Ciloxan)

1

erythromycin ophth oint 5 mg/gm

1

GENTAK – gentamicin sulfateophth oint 0.3%

2

gentamicin sulfate ophth soln0.3% (Garamycin)

1

moxifloxacin hcl ophth soln0.5% (base equiv) (Vigamox)

1

NATACYN – natamycin ophthsusp 5%

2

2018


Drug Name Tier

Des

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ty

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Lim

its

neomycin-bacitrac zn-polymyx5(3.5)mg-400unt-10000unt opoin

1

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

1

ofloxacin ophth soln 0.3%(Ocuflox)

1

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

1

sulfacetamide sodium ophthsoln 10% (Bleph-10)

1

tobramycin ophth soln 0.3%(Tobrex)

1

trifluridine ophth soln 1%(Viroptic)

1

Steroids and Combination Productsbacitracin-polymyxin-neomycin-

hc ophth oint 1%1

fluorometholone ophth susp0.1% (Fml liquifilm)

1

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

1

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

1

prednisolone acetate ophth susp1% (Pred forte)

1

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

1

tobramycin-dexamethasoneophth susp 0.3-0.1% (Tobradex)

1

Glaucomabrimonidine tartrate ophth soln

0.15% (Alphagan p)1

brimonidine tartrate ophth soln0.2%

1

Drug Name Tier

Des

igna

tion

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Lim

its

dorzolamide hcl ophth soln 2%(Trusopt)

1

dorzolamide hcl-timolol maleateophth soln 22.3-6.8 mg/ml(Cosopt)

1

latanoprost ophth soln 0.005%(Xalatan)

1 •

levobunolol hcl ophth soln 0.5%(Betagan)

1

pilocarpine hcl ophth soln 1%(Isopto carpine)

1


1


1

timolol maleate ophth soln0.25% (Timoptic)

1

timolol maleate ophth soln 0.5%(Timoptic)

1

TIMOLOL MALEATE OPHTHALMI– timolol maleate ophth gelforming soln 0.25%

2

Other Eye ProductsATROPINE SULFATE – atropine

sulfate ophth soln 1%2

azelastine hcl ophth soln 0.05%(Optivar)

1

cromolyn sodium ophth soln 4% 1

cyclopentolate hcl ophth soln1% (Cyclogyl)

1

diclofenac sodium ophth soln0.1%

1

ketorolac tromethamine ophthsoln 0.4% (Acular ls)

1

ketorolac tromethamine ophthsoln 0.5% (Acular)

1

olopatadine hcl ophth soln 0.1%(base equivalent) (Patanol)

1

olopatadine hcl ophth soln 0.2%(base equivalent) (Pataday)

1

2018


Drug Name Tier

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Lim

its

tropicamide ophth soln 0.5% 1

tropicamide ophth soln 1%(Mydriacyl)

1

EARacetic acid otic soln 2% 1

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

1

neomycin-polymyxin-hc oticsoln 1% (Cortisporin)

1

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

1

ofloxacin otic soln 0.3% 1

MOUTH AND THROAT (local)cevimeline hcl cap 30 mg

(Evoxac)1

chlorhexidine gluconate soln0.12% (Peridex)

1

clotrimazole troche 10 mg 1

lidocaine hcl viscous soln 2% 1

nystatin susp 100000 unit/ml 1

pilocarpine hcl tab 5 mg(Salagen)

1

pilocarpine hcl tab 7.5 mg(Salagen)

1

sodium fluoride cream 1.1%(Prevident 5000 plus)

1

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

1

triamcinolone acetonide dentalpaste 0.1%

1

ANORECTAL AGENTSCORTIFOAM – hydrocortisone

acetate rectal foam 10% (90mg/dose)

2

hydrocortisone enema100 mg/60ml (Cortenema)

1

hydrocortisone rectal cream2.5% (Anusol-hc)

1

Drug Name Tier

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SKIN CONDITIONS/PRODUCTSAcneadapalene cream 0.1% (Differin) 1

adapalene gel 0.1% (Differin) 1

adapalene gel 0.3% (Differin) 1

adapalene-benzoyl peroxide gel0.1-2.5% (Epiduo)

1

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

1

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

1

clindamycin phosphate gel 1%(Cleocin-t)

1

clindamycin phosphate lotion1% (Cleocin-t)

1

clindamycin phosphate soln 1%(Cleocin-t)

1

clindamycin phosphate swab 1%(Cleocin-t)

1

clindamycin phosphate-benzoylperoxide gel 1-5% (Benzaclin)

1

erythromycin gel 2% (Erygel) 1

erythromycin pads 2% 1

erythromycin soln 2% 1

FINACEA – azelaic acid foam15%

2

FINACEA – azelaic acid gel 15% 2

isotretinoin cap 10 mg 1


isotretinoin cap 30 mg (Claravis) 1


metronidazole cream 0.75%(Metrocream)

1

metronidazole gel 0.75% 1

metronidazole gel 1% (Metrogel) 1

2018


Drug Name Tier

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Lim

its

metronidazole lotion 0.75%(Metrolotion)

1

SOOLANTRA – ivermectin cream1%

2

sulfacetamide sodium lotion10% (acne) (Klaron)

1

tazarotene cream 0.1% (Tazorac) 1

TAZORAC – tazarotene cream0.05%

2

TAZORAC – tazarotene gel 0.05% 2

TAZORAC – tazarotene gel 0.1% 2

tretinoin cream 0.025% (Retin-a) 1



tretinoin gel 0.01% (Retin-a) 1

tretinoin gel 0.025% (Retin-a) 1

tretinoin microsphere gel 0.04%(Retin-a micro)

1

tretinoin microsphere gel 0.1%(Retin-a micro)

1

Anti-infectivesciclopirox gel 0.77% (Loprox) 1

ciclopirox olamine cream 0.77%(base equiv)

1

ciclopirox olamine susp 0.77%(base equiv)

1

ciclopirox shampoo 1% (Loproxshampoo)

1

ciclopirox solution 8% (Penlacnail lacquer)

1 • •

diclofenac sodium gel 1%(Voltaren)

1

econazole nitrate cream 1% 1

gentamicin sulfate cream 0.1% 1

gentamicin sulfate oint 0.1% 1

ketoconazole cream 2% 1

ketoconazole shampoo 2%(Nizoral)

1

Drug Name Tier

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Lim

its

mupirocin calcium cream 2%(Bactroban)

1

mupirocin oint 2% (Bactroban) 1

nystatin cream 100000 unit/gm 1

nystatin oint 100000 unit/gm 1

nystatin topical powder 100000unit/gm

1

silver sulfadiazine cream 1%(Silvadene)

1

Corticosteroidsalclometasone dipropionate

cream 0.05% (Aclovate)1

alclometasone dipropionate oint0.05%

1

AUGMENTED BETAMETHASONED – betamethasonedipropionate augmented gel0.05%

2

betamethasone dipropionateaugmented cream 0.05%(Diprolene af)

1

betamethasone dipropionateaugmented lotion 0.05%(Diprolene)

1

betamethasone dipropionateaugmented oint 0.05%(Diprolene)

1

betamethasone dipropionatecream 0.05%

1

betamethasone dipropionatelotion 0.05%

1

betamethasone dipropionateoint 0.05%

1

betamethasone valerate cream0.1% (base equivalent)

1

betamethasone valerate lotion0.1% (base equivalent)

1

betamethasone valerate oint0.1% (base equivalent)

1

2018


Drug Name Tier

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its

clobetasol propionate cream0.05% (Temovate)

1

clobetasol propionate emollientbase cream 0.05% (Temovate e)

1

clobetasol propionate foam0.05% (Olux)

1 •

clobetasol propionate gel 0.05%(Temovate)

1

clobetasol propionate oint 0.05%(Temovate)

1

clobetasol propionate soln0.05% (Temovate)

1

desonide cream 0.05%(Desowen)

1

desonide lotion 0.05% (Desowen) 1

desonide oint 0.05% (Desowen) 1

desoximetasone cream 0.05%(Topicort)

1

desoximetasone cream 0.25%(Topicort)

1

desoximetasone gel 0.05%(Topicort)

1

desoximetasone oint 0.25%(Topicort)

1

fluocinolone acetonide cream0.01%

1

fluocinolone acetonide cream0.025% (Synalar)

1

fluocinolone acetonide oil 0.01%(body oil) (Derma-smoothe/fsbod)

1

fluocinolone acetonide oil 0.01%(scalp oil) (Derma-smoothe/fssca)

1

fluocinolone acetonide oint0.025% (Synalar)

1

fluocinolone acetonide soln0.01% (Synalar)

1

fluocinonide cream 0.05% 1

Drug Name Tier

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its

fluocinonide emulsified basecream 0.05%

1

fluocinonide gel 0.05% 1

fluocinonide oint 0.05% 1

fluocinonide soln 0.05% 1

fluticasone propionate cream0.05% (Cutivate)

1

fluticasone propionate oint0.005% (Cutivate)

1

halobetasol propionate cream0.05% (Ultravate)

1

halobetasol propionate oint0.05% (Ultravate)

1

hydrocortisone cream 2.5% 1

hydrocortisone lotion 2.5% 1

hydrocortisone oint 2.5% 1

hydrocortisone valerate cream0.2%

1

hydrocortisone valerate oint0.2% (Westcort)

1

mometasone furoate cream 0.1%(Elocon)

1

mometasone furoate oint 0.1%(Elocon)

1

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

1

nystatin-triamcinolone cream100000-0.1 unit/gm-%

1

nystatin-triamcinolone oint100000-0.1 unit/gm-%

1

PREDNICARBATE –prednicarbate cream 0.1%

2

PREDNICARBATE –prednicarbate oint 0.1%

2

triamcinolone acetonide cream0.025%

1


1

2018


Drug Name Tier

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its


1

triamcinolone acetonide lotion0.025%

1

triamcinolone acetonide lotion0.1%

1

triamcinolone acetonide oint0.025%

1


1


1

Other Skin Productsacitretin cap 10 mg (Soriatane) 1

acitretin cap 17.5 mg (Soriatane) 1

acitretin cap 25 mg (Soriatane) 1

calcipotriene cream 0.005%(Dovonex)

1 •

calcipotriene oint 0.005% 1 •calcipotriene soln 0.005%

(50 mcg/ml)1 •

COSENTYX – secukinumabsubcutaneous soln prefilledsyringe 150 mg/ml

2 • • •

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

2 • • •

diclofenac sodium (actinickeratoses) gel 3% (Solaraze)

1 • •

fluorouracil cream 5% (Efudex) 1 •imiquimod cream 5% (Aldara) 1 •lidocaine hcl gel 2% 1

lidocaine hcl soln 4% (Xylocaine) 1

lidocaine patch 5% (Lidoderm) 1

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

1

malathion lotion 0.5% (Ovide) 1

permethrin cream 5% (Elimite) 1

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podofilox soln 0.5% (Condylox) 1

selenium sulfide lotion 2.5% 1

STELARA – ustekinumab inj 45mg/0.5ml

2 • • •

STELARA – ustekinumab solnprefilled syringe 45 mg/0.5ml

2 • • •

STELARA – ustekinumab solnprefilled syringe 90 mg/ml

2 • • •

tacrolimus oint 0.03% (Protopic) 1

tacrolimus oint 0.1% (Protopic) 1

VALCHLOR – mechlorethaminehcl gel 0.016% (baseequivalent)

2 •

MISCELLANEOUS CATEGORIES (includes suppliesand devices)DIABETIC SUPPLIESBAYER BREEZE 2 BLOOD GLUC

– blood glucose monitoring kitw/ device

2

BAYER BREEZE 2 HIGH CONTR– blood glucose calibration -liquid - high

2

BAYER BREEZE 2 LOW CONTRO– blood glucose calibration -liquid - low

2

BAYER BREEZE 2 NORMAL CON– blood glucose calibration -liquid - normal

2

BAYER BREEZE 2 TEST DISC –glucose blood test disk

2 •

BAYER CONTOUR BLOODGLUCO – blood glucosemonitoring devices

2

BAYER CONTOUR BLOODGLUCO – glucose blood teststrip

2 •

BAYER CONTOUR BLOODGLUCO – blood glucosemonitoring kit w/ device

2

2018


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BAYER CONTOUR HIGHCONTRO – blood glucosecalibration - liquid - high

2

BAYER CONTOUR LINK BLOOD– blood glucose monitoring kitw/ device

2

BAYER CONTOUR LOWCONTROL – blood glucosecalibration - liquid - low

2

BAYER CONTOUR NEXT BLOOD– glucose blood test strip

2 •

BAYER CONTOUR NEXT BLOOD– blood glucose monitoring kitw/ device

2

BAYER CONTOUR NEXTCONTRO – blood glucosecalibration - liquid - normal

2

BAYER CONTOUR NEXTCONTRO – blood glucosecalibration - liquid - low

2

BAYER CONTOUR NEXT EZ BLO– blood glucose monitoring kitw/ device

2

BAYER CONTOUR NEXT LINK B– blood glucose monitoring kitw/ device

2

BAYER CONTOUR NEXT LINK W– blood glucose monitoring kitw/ device

2

BAYER CONTOUR NORMALCONT – blood glucosecalibration - liquid - normal

2

CONTOUR NEXT ONE BLOODGL – blood glucose monitoringkit

2

B-D INSULIN SYRINGE MICRO –insulin syringe/needle u-100 1ml 28 x 1/2"

2

B-D INSULIN SYRINGE ULTRA –insulin syringe/needle u-1000.3 ml 30 x 1/2"

2

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B-D INSULIN SYRINGE ULTRA –insulin syringe/needle u-100 1ml 31 x 5/16"

2

B-D INSULIN SYRINGE ULTRA –insulin syringe/needle u-1000.3 ml 31 x 5/16"

2

BAYER MICROLET LANCETS –lancets

2

BAYER MICROLET 2 LANCING –lancet devices

2

BD AUTOSHIELD 29G X 3/16" –insulin pen needle 29 g x 5 mm(3/16")

2

BD AUTOSHIELD 29G X 5/16" –insulin pen needle 29 g x 8 mm(5/16")

2

BD INSULIN SYRINGE LUER-L –insulin syringe (disp) u-100 1ml

2

BD INSULIN SYRINGE MICROF– insulin syringe/needle u-1000.3 ml 28 x 1/2"

2

BD INSULIN SYRINGE MICROF– insulin syringe/needle u-1001/2 ml 28 x 1/2"

2

BD INSULIN SYRINGE MICROF –insulin syringe/needle u-100 1ml 27 x 5/8"

2

BD INSULIN SYRINGE MICROF –insulin syringe/needle u-100 1ml 28 x 1/2"

2

BD INSULIN SYRINGE SAFETY– insulin syringe/needle u-1000.3 ml 31 x 15/64"

2

BD INSULIN SYRINGE SAFETY– insulin syringe/needle u-1001/2 ml 31 x 15/64"

2

BD INSULIN SYRINGE ULTRAF– insulin syringe/needle u-1000.3 ml 30 x 1/2"

2

2018


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BD INSULIN SYRINGE ULTRAF– insulin syringe/needle u-1001/2 ml 31 x 5/16"

2


2


2

BD INSULIN SYRINGE ULTRAF –insulin syringe/needle u-100 1ml 30 x 1/2"

2


2


2


2


2

BD INSULIN SYRINGE/U-100/ –insulin syringe/needle u-1001/2 ml 30 x 1/2"

2

BD INSULIN SYRINGE/U-500/ –insulin syringe/needle u-5000.5 ml 31g x 6mm (15/64")

2

BD LANCET ULTRAFINE 30G –lancets

2

BD LANCET ULTRAFINE 33G –lancets

2

BD MICROTAINER LANCETS –lancets

2

BD PEN NEEDLE/MINI/ULTRAF –insulin pen needle 31 g x 5 mm(3/16")

2

BD PEN NEEDLE/NANO/ULTRA –insulin pen needle 32 g x 4 mm(5/32")

2

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BD PEN NEEDLE/SHORT/ULTRA– insulin pen needle 31 g x 8mm (1/3" or 5/16")

2

BD PEN NEEDLE/ULTRAFINE/2 –insulin pen needle 29 g x 12.7mm

2

BD PEN NEEDLES SHORT/ULTR– insulin pen needle 31 g x 8mm (1/3" or 5/16")

2

BD SYRINGE LUER-LOK/1ML –syringe (disposable) 1 ml

2

BD ULTRA-FINE MICRO PEN N –insulin pen needle 32 g x 6 mm(1/4")

2

BD 1ML TUBERCULIN SYRINGE– syringe (disposable) 1 ml

2

FINGERSTIX LANCETS – lancets 2

MICROLET LANCETS – lancets 2

MICROLET NEXT – lancetdevices

2

SINGLE-LET – lancets 2

MISCELLANEOUS DRUGSazathioprine tab 50 mg (Imuran) 1

buprenorphine hcl-naloxone hclsl tab 2-0.5 mg (base equiv)

1 •

buprenorphine hcl-naloxone hclsl tab 8-2 mg (base equiv)

1 •

CHEMET – succimer cap 100 mg 2

cyclosporine cap 25 mg(Sandimmune)

1

cyclosporine cap 100 mg(Sandimmune)

1

cyclosporine modified cap25 mg (Neoral)

1

cyclosporine modified cap50 mg (Cyclosporine modifie)

1

cyclosporine modified cap100 mg (Neoral)

1

cyclosporine modified oral soln100 mg/ml (Neoral)

1

2018


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DEPEN TITRATABS –penicillamine tab 250 mg

2 •

JADENU – deferasirox tab 90 mg 2 •JADENU – deferasirox tab 180

mg2 •

JADENU – deferasirox tab 360mg

2 •

mycophenolate mofetil cap250 mg (Cellcept)

1

mycophenolate mofetil for oralsusp 200 mg/ml (Cellcept)

1

mycophenolate mofetil tab500 mg (Cellcept)

1

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

1

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

1

NALOXONE HCL – naloxone hclsoln cartridge 0.4 mg/ml

2 •

NALOXONE HCL – naloxone hclsoln prefilled syringe 2 mg/2ml

2 •

naloxone hcl inj 0.4 mg/ml 1

naloxone hcl inj 4 mg/10ml 1

naltrexone hcl tab 50 mg (Revia) 1

NARCAN – naloxone hcl nasalspray 4 mg/0.1ml

1 •

RAPAMUNE – sirolimus oral soln1 mg/ml

2

REVLIMID – lenalidomide caps2.5 mg

2 • • •

REVLIMID – lenalidomide cap 5mg

2 • • •


2 • • •


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sirolimus tab 0.5 mg (Rapamune) 1

sirolimus tab 1 mg (Rapamune) 1

sirolimus tab 2 mg (Rapamune) 1

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

1

sodium polystyrene sulfonatepowder (Kayexalate)

1

SUBOXONE – buprenorphinehcl-naloxone hcl sl film 2-0.5mg (base equiv)

2 •

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

2 •

SUBOXONE – buprenorphinehcl-naloxone hcl sl film 8-2 mg(base equiv)

2 •

SUBOXONE – buprenorphinehcl-naloxone hcl sl film 12-3mg (base equiv)

2 •

tacrolimus cap 0.5 mg (Prograf) 1

tacrolimus cap 1 mg (Prograf) 1

tacrolimus cap 5 mg (Prograf) 1

THALOMID – thalidomide cap 50mg

2 • • •

THALOMID – thalidomide cap100 mg

2 • • •


2 • • •


2 • • •

2018


INDEX

Aabacavir sulfate-lamivudine tab 600-300 mg(Epzicom)............................................................................5

abacavir sulfate-lamivudine-zidovudine tab300-150-300 mg (Trizivir).................................................. 5

abacavir sulfate soln 20 mg/ml (base equiv)(Ziagen)............................................................................... 5

abacavir sulfate tab 300 mg (base equiv) (Ziagen).........5acamprosate calcium tab delayed release 333 mg(Campral).......................................................................... 42

acarbose tab 25 mg (Precose)........................................ 16acarbose tab 50 mg (Precose)........................................ 16acarbose tab 100 mg (Precose)...................................... 16acebutolol hcl cap 200 mg (Sectral)...............................22acebutolol hcl cap 400 mg (Sectral)...............................22acetaminophen w/ codeine soln 120-12 mg/5ml........... 43acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine)............................................................................ 43

acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3).......................................................................43

acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4).......................................................................43

acetazolamide cap er 12hr 500 mg (Diamox)................ 26acetazolamide tab 125 mg............................................... 26acetazolamide tab 250 mg............................................... 26acetic acid otic soln 2%...................................................53acetylcysteine inhal soln 10%.........................................29acetylcysteine inhal soln 20%.........................................29acitretin cap 10 mg (Soriatane).......................................56acitretin cap 17.5 mg (Soriatane)....................................56acitretin cap 25 mg (Soriatane).......................................56ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml(2000000 unit/0.5ml)........................................................... 8

acyclovir cap 200 mg (Zovirax).........................................5acyclovir susp 200 mg/5ml (Zovirax)............................... 5acyclovir tab 400 mg (Zovirax)..........................................5acyclovir tab 800 mg (Zovirax)..........................................5adapalene-benzoyl peroxide gel 0.1-2.5% (Epiduo)......53adapalene cream 0.1% (Differin).....................................53adapalene gel 0.1% (Differin).......................................... 53adapalene gel 0.3% (Differin).......................................... 53ADDERALL XR – amphetamine-dextroamphetamine caper 24hr 5 mg..................................................................... 40

ADDERALL XR – amphetamine-dextroamphetamine caper 24hr 10 mg................................................................... 40





adefovir dipivoxil tab 10 mg (Hepsera)............................5ADVAIR DISKUS – fluticasone-salmeterol aer powder ba100-50 mcg/dose...............................................................29

ADVAIR DISKUS – fluticasone-salmeterol aer powder ba250-50 mcg/dose...............................................................29

ADVAIR DISKUS – fluticasone-salmeterol aer powder ba500-50 mcg/dose...............................................................29

ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21mcg/act...............................................................................29

ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21mcg/act...............................................................................29

ADVAIR HFA – fluticasone-salmeterol inhal aerosol230-21 mcg/act..................................................................29

AFINITOR DISPERZ – everolimus tab for oral susp 2mg........................................................................................ 8



AFINITOR – everolimus tab 2.5 mg.....................................8AFINITOR – everolimus tab 5 mg........................................8AFINITOR – everolimus tab 7.5 mg.....................................8AFINITOR – everolimus tab 10 mg......................................8ALBENZA – albendazole tab 200 mg.................................. 8ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr4 mg...................................................................................29

ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr8 mg...................................................................................29

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..........30albuterol sulfate soln nebu 0.5% (5 mg/ml)...................30albuterol sulfate soln nebu 0.63 mg/3ml (baseequiv).................................................................................30

albuterol sulfate soln nebu 1.25 mg/3ml (baseequiv).................................................................................30

albuterol sulfate syrup 2 mg/5ml....................................30albuterol sulfate tab 2 mg................................................30albuterol sulfate tab 4 mg................................................30alclometasone dipropionate cream 0.05%(Aclovate)..........................................................................54

alclometasone dipropionate oint 0.05%.........................54ALECENSA – alectinib hcl cap 150 mg (baseequivalent)............................................................................8

alendronate sodium tab 5 mg......................................... 18alendronate sodium tab 10 mg....................................... 18alendronate sodium tab 35 mg....................................... 18alendronate sodium tab 70 mg (Fosamax).................... 18alfuzosin hcl tab er 24hr 10 mg (Uroxatral)................... 35allopurinol tab 100 mg (Zyloprim).................................. 47allopurinol tab 300 mg (Zyloprim).................................. 47alprazolam tab er 24hr 0.5 mg (Xanax xr)......................35alprazolam tab er 24hr 1 mg (Xanax xr).........................35alprazolam tab er 24hr 2 mg (Xanax xr).........................35alprazolam tab er 24hr 3 mg (Xanax xr).........................35alprazolam tab 0.25 mg (Xanax)......................................35

2018


alprazolam tab 0.5 mg (Xanax)........................................35alprazolam tab 1 mg (Xanax)...........................................35alprazolam tab 2 mg (Xanax)...........................................35ALUNBRIG – brigatinib tab initiation therapy pack 90 mg &180 mg.................................................................................8

ALUNBRIG – brigatinib tab 30 mg.......................................8ALUNBRIG – brigatinib tab 90 mg.......................................8ALUNBRIG – brigatinib tab 180 mg.....................................9amantadine hcl cap 100 mg............................................ 49amantadine hcl syrup 50 mg/5ml....................................49amiloride & hydrochlorothiazide tab 5-50 mg............... 26amiloride hcl tab 5 mg..................................................... 26amiodarone hcl tab 100 mg.............................................26amiodarone hcl tab 400 mg.............................................26amiodarone hcl tab 200 mg (Cordarone)....................... 26amitriptyline hcl tab 10 mg..............................................35amitriptyline hcl tab 25 mg..............................................35amitriptyline hcl tab 50 mg..............................................35amitriptyline hcl tab 75 mg..............................................35amitriptyline hcl tab 100 mg............................................35amitriptyline hcl tab 150 mg............................................35amlodipine besylate-atorvastatin calcium tab 2.5-10mg (Caduet)......................................................................27

amlodipine besylate-atorvastatin calcium tab 2.5-20mg (Caduet)......................................................................27

amlodipine besylate-atorvastatin calcium tab 2.5-40mg (Caduet)......................................................................27

amlodipine besylate-atorvastatin calcium tab 5-10 mg(Caduet).............................................................................27








amlodipine besylate-benazepril hcl cap 2.5-10 mg(Lotrel)...............................................................................23

amlodipine besylate-benazepril hcl cap 5-10 mg(Lotrel)...............................................................................23





amlodipine besylate tab 2.5 mg (base equivalent)(Norvasc)...........................................................................23

amlodipine besylate tab 5 mg (base equivalent)(Norvasc)...........................................................................23

amlodipine besylate tab 10 mg (base equivalent)(Norvasc)...........................................................................23

amlodipine besylate-valsartan tab 5-160 mg(Exforge)........................................................................... 21




amlodipine-valsartan-hydrochlorothiazide tab5-160-12.5 mg (Exforge hct)...........................................21

amlodipine-valsartan-hydrochlorothiazide tab 5-160-25mg (Exforge hct)..............................................................21

amlodipine-valsartan-hydrochlorothiazide tab10-160-12.5 mg (Exforge hct).........................................21

amlodipine-valsartan-hydrochlorothiazide tab10-160-25 mg (Exforge hct)............................................21

amlodipine-valsartan-hydrochlorothiazide tab10-320-25 mg (Exforge hct)............................................21

AMOXICILLIN/CLAVULANATE P – amoxicillin & kclavulanate chew tab 200-28.5 mg.....................................2

AMOXICILLIN/CLAVULANATE P – amoxicillin & kclavulanate chew tab 400-57 mg........................................2

amoxicillin & k clavulanate for susp 200-28.5mg/5ml.................................................................................2

amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 2amoxicillin & k clavulanate for susp 250-62.5 mg/5ml(Augmentin)........................................................................2

amoxicillin & k clavulanate for susp 600-42.9 mg/5ml(Augmentin es-600)...........................................................2

amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg(Augmentin xr)...................................................................2

amoxicillin & k clavulanate tab 250-125 mg.................... 2amoxicillin & k clavulanate tab 500-125 mg(Augmentin)........................................................................2

amoxicillin & k clavulanate tab 875-125 mg(Augmentin)........................................................................2

amoxicillin (trihydrate) cap 250 mg..................................2amoxicillin (trihydrate) cap 500 mg..................................2amoxicillin (trihydrate) for susp 125 mg/5ml...................2amoxicillin (trihydrate) for susp 200 mg/5ml...................2amoxicillin (trihydrate) for susp 250 mg/5ml...................2amoxicillin (trihydrate) for susp 400 mg/5ml...................2amoxicillin (trihydrate) tab 500 mg...................................2amoxicillin (trihydrate) tab 875 mg...................................2amphetamine-dextroamphetamine tab 5 mg(Adderall).......................................................................... 40

amphetamine-dextroamphetamine tab 7.5 mg(Adderall).......................................................................... 40

amphetamine-dextroamphetamine tab 10 mg(Adderall).......................................................................... 40

2018


amphetamine-dextroamphetamine tab 12.5 mg(Adderall).......................................................................... 40




AMPICILLIN – ampicillin cap 500 mg.................................. 2anagrelide hcl cap 1 mg.................................................. 50anagrelide hcl cap 0.5 mg (Agrylin)............................... 50anastrozole tab 1 mg (Arimidex).......................................9ANDROGEL PUMP – testosterone td gel 20.25 mg/act(1.62%)...............................................................................13

ANDROGEL – testosterone td gel 20.25 mg/1.25gm(1.62%)...............................................................................13

ANDROGEL – testosterone td gel 40.5 mg/2.5gm(1.62%)...............................................................................13

ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba62.5-25 mcg/inh.................................................................30

aprepitant capsule 40 mg (Emend).................................32aprepitant capsule 80 mg (Emend).................................33aprepitant capsule 125 mg (Emend)...............................33aprepitant capsule therapy pack 80 & 125 mg(Emend).............................................................................32

APRISO – mesalamine cap er 24hr 0.375 gm...................33aripiprazole tab 2 mg (Abilify).........................................37aripiprazole tab 5 mg (Abilify).........................................37aripiprazole tab 10 mg (Abilify).......................................37aripiprazole tab 15 mg (Abilify).......................................37aripiprazole tab 20 mg (Abilify).......................................37aripiprazole tab 30 mg (Abilify).......................................37armodafinil tab 50 mg (Nuvigil).......................................40armodafinil tab 150 mg (Nuvigil).....................................40armodafinil tab 200 mg (Nuvigil).....................................40armodafinil tab 250 mg (Nuvigil).....................................40ASACOL HD – mesalamine tab delayed release 800mg...................................................................................... 33

ASMANEX HFA – mometasone furoate inhal aerosolsuspension 100 mcg/act................................................... 30

ASMANEX HFA – mometasone furoate inhal aerosolsuspension 200 mcg/act................................................... 30

ASMANEX TWISTHALER 120 ME – mometasone furoateinhal powd 220 mcg/inh (breath activated)...................... 30

ASMANEX TWISTHALER 30 MET – mometasone furoateinhal powd 110 mcg/inh (breath activated).......................30

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

ASMANEX TWISTHALER 60 MET – mometasone furoateinhal powd 220 mcg/inh (breath activated)...................... 30

atazanavir sulfate cap 150 mg (base equiv)(Reyataz)............................................................................. 5



atenolol & chlorthalidone tab 50-25 mg (Tenoretic50)...................................................................................... 22

atenolol & chlorthalidone tab 100-25 mg (Tenoretic100).................................................................................... 22

atenolol tab 25 mg (Tenormin)........................................ 22atenolol tab 50 mg (Tenormin)........................................ 22atenolol tab 100 mg (Tenormin)...................................... 22atomoxetine hcl cap 10 mg (base equiv) (Strattera).....40atomoxetine hcl cap 18 mg (base equiv) (Strattera).....40atomoxetine hcl cap 25 mg (base equiv) (Strattera).....40atomoxetine hcl cap 40 mg (base equiv) (Strattera).....40atomoxetine hcl cap 60 mg (base equiv) (Strattera).....40atomoxetine hcl cap 80 mg (base equiv) (Strattera).....40atomoxetine hcl cap 100 mg (base equiv)(Strattera)..........................................................................40

atorvastatin calcium tab 10 mg (base equivalent)(Lipitor)..............................................................................25




atovaquone-proguanil hcl tab 62.5-25 mg(Malarone)...........................................................................7

atovaquone-proguanil hcl tab 250-100 mg(Malarone)...........................................................................7

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

ATROPINE SULFATE – atropine sulfate ophth soln1%...................................................................................... 52

AUBAGIO – teriflunomide tab 7 mg...................................41AUBAGIO – teriflunomide tab 14 mg.................................41AUGMENTED BETAMETHASONE D – betamethasonedipropionate augmented gel 0.05%..................................54

AVONEX – interferon beta-1a for im inj kit 30mcg(33mcg(6.6 mu)/vial)......................................................... 41

AVONEX – interferon beta-1a im prefilled syringe kit 30mcg/0.5ml...........................................................................41

AVONEX PEN – interferon beta-1a im auto-injector kit 30mcg/0.5ml...........................................................................41

azathioprine tab 50 mg (Imuran).....................................58azelastine hcl nasal spray 0.1% (137 mcg/spray)......... 29azelastine hcl nasal spray 0.15% (205.5 mcg/spray)(Astepro)........................................................................... 29

azelastine hcl ophth soln 0.05% (Optivar)..................... 52azithromycin for susp 100 mg/5ml (Zithromax).............. 3azithromycin for susp 200 mg/5ml (Zithromax).............. 3azithromycin tab 250 mg (Zithromax).............................. 3azithromycin tab 500 mg (Zithromax).............................. 3azithromycin tab 600 mg (Zithromax).............................. 3B

BACITRACIN – bacitracin ophth oint 500 unit/gm............. 51bacitracin-polymyxin b ophth oint..................................51bacitracin-polymyxin-neomycin-hc ophth oint 1%.......52

2018


baclofen tab 10 mg...........................................................49baclofen tab 20 mg...........................................................49balsalazide disodium cap 750 mg (Colazal).................. 33BARACLUDE – entecavir oral soln 0.05 mg/ml...................5BAYER BREEZE 2 BLOOD GLUC – blood glucosemonitoring kit w/ device.................................................... 56

BAYER BREEZE 2 HIGH CONTR – blood glucosecalibration - liquid - high................................................... 56

BAYER BREEZE 2 LOW CONTRO – blood glucosecalibration - liquid - low.....................................................56

BAYER BREEZE 2 NORMAL CON – blood glucosecalibration - liquid - normal............................................... 56

BAYER BREEZE 2 TEST DISC – glucose blood testdisk.....................................................................................56

BAYER CONTOUR BLOOD GLUCO – blood glucosemonitoring devices............................................................ 56

BAYER CONTOUR BLOOD GLUCO – blood glucosemonitoring kit w/ device.................................................... 56

BAYER CONTOUR BLOOD GLUCO – glucose blood teststrip.....................................................................................56

BAYER CONTOUR HIGH CONTRO – blood glucosecalibration - liquid - high................................................... 57

BAYER CONTOUR LINK BLOOD – blood glucosemonitoring kit w/ device.................................................... 57

BAYER CONTOUR LOW CONTROL – blood glucosecalibration - liquid - low.....................................................57

BAYER CONTOUR NEXT BLOOD – blood glucosemonitoring kit w/ device.................................................... 57

BAYER CONTOUR NEXT BLOOD – glucose blood teststrip.....................................................................................57

BAYER CONTOUR NEXT CONTRO – blood glucosecalibration - liquid - low.....................................................57

BAYER CONTOUR NEXT CONTRO – blood glucosecalibration - liquid - normal............................................... 57

BAYER CONTOUR NEXT EZ BLO – blood glucosemonitoring kit w/ device.................................................... 57

BAYER CONTOUR NEXT LINK B – blood glucosemonitoring kit w/ device.................................................... 57

BAYER CONTOUR NEXT LINK W – blood glucosemonitoring kit w/ device.................................................... 57

BAYER CONTOUR NORMAL CONT – blood glucosecalibration - liquid - normal............................................... 57

BAYER MICROLET LANCETS – lancets...........................57BAYER MICROLET 2 LANCING – lancet devices.............57BD AUTOSHIELD 29G X 3/16" – insulin pen needle 29 g x5 mm (3/16")......................................................................57

BD AUTOSHIELD 29G X 5/16" – insulin pen needle 29 g x8 mm (5/16")......................................................................57

BD INSULIN SYRINGE/U-100/ – insulin syringe/needleu-100 1/2 ml 30 x 1/2"...................................................... 58

BD INSULIN SYRINGE/U-500/ – insulin syringe/needleu-500 0.5 ml 31g x 6mm (15/64").....................................58

BD INSULIN SYRINGE LUER-L – insulin syringe (disp)u-100 1 ml......................................................................... 57

BD INSULIN SYRINGE MICROF – insulin syringe/needleu-100 1/2 ml 28 x 1/2"...................................................... 57

BD INSULIN SYRINGE MICROF – insulin syringe/needleu-100 0.3 ml 28 x 1/2"...................................................... 57

BD INSULIN SYRINGE MICROF – insulin syringe/needleu-100 1 ml 27 x 5/8"......................................................... 57

BD INSULIN SYRINGE MICROF – insulin syringe/needleu-100 1 ml 28 x 1/2"......................................................... 57

B-D INSULIN SYRINGE MICRO – insulin syringe/needleu-100 1 ml 28 x 1/2"......................................................... 57

BD INSULIN SYRINGE SAFETY – insulin syringe/needleu-100 1/2 ml 31 x 15/64".................................................. 57

BD INSULIN SYRINGE SAFETY – insulin syringe/needleu-100 0.3 ml 31 x 15/64".................................................. 57

BD INSULIN SYRINGE ULTRAF – insulin syringe/needleu-100 1/2 ml 31 x 5/16".................................................... 58

BD INSULIN SYRINGE ULTRAF – insulin syringe/needleu-100 1/2 ml 30 x 1/2"...................................................... 58

BD INSULIN SYRINGE ULTRAF – insulin syringe/needleu-100 1/2 ml 31 x 15/64".................................................. 58

BD INSULIN SYRINGE ULTRAF – insulin syringe/needleu-100 0.3 ml 30 x 1/2"...................................................... 57

BD INSULIN SYRINGE ULTRAF – insulin syringe/needleu-100 0.3 ml 31 x 15/64".................................................. 58

BD INSULIN SYRINGE ULTRAF – insulin syringe/needleu-100 1 ml 30 x 1/2"......................................................... 58

BD INSULIN SYRINGE ULTRAF – insulin syringe/needleu-100 1 ml 31 x 5/16"....................................................... 58

BD INSULIN SYRINGE ULTRAF – insulin syringe/needleu-100 0.3 ml 31 x 5/16".................................................... 58

BD INSULIN SYRINGE ULTRAF – insulin syringe/needleu-100 1 ml 31 x 15/64"..................................................... 58

B-D INSULIN SYRINGE ULTRA – insulin syringe/needleu-100 0.3 ml 30 x 1/2"...................................................... 57

B-D INSULIN SYRINGE ULTRA – insulin syringe/needleu-100 1 ml 31 x 5/16"....................................................... 57

B-D INSULIN SYRINGE ULTRA – insulin syringe/needleu-100 0.3 ml 31 x 5/16".................................................... 57

BD LANCET ULTRAFINE 30G – lancets...........................58BD LANCET ULTRAFINE 33G – lancets...........................58BD MICROTAINER LANCETS – lancets........................... 58BD 1ML TUBERCULIN SYRINGE – syringe (disposable) 1ml........................................................................................58

BD PEN NEEDLE/MINI/ULTRAF – insulin pen needle 31 gx 5 mm (3/16").................................................................. 58

BD PEN NEEDLE/NANO/ULTRA – insulin pen needle 32g x 4 mm (5/32")............................................................... 58

BD PEN NEEDLE/SHORT/ULTRA – insulin pen needle 31g x 8 mm (1/3" or 5/16")...................................................58

BD PEN NEEDLE/ULTRAFINE/2 – insulin pen needle 29 gx 12.7 mm..........................................................................58

BD PEN NEEDLES SHORT/ULTR – insulin pen needle 31g x 8 mm (1/3" or 5/16")...................................................58

BD SYRINGE LUER-LOK/1ML – syringe (disposable) 1ml........................................................................................58

BD ULTRA-FINE MICRO PEN N – insulin pen needle 32 gx 6 mm (1/4").................................................................... 58

benazepril & hydrochlorothiazide tab 5-6.25 mg.......... 20

2018


benazepril & hydrochlorothiazide tab 10-12.5 mg(Lotensin hct)...................................................................20

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

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

benazepril hcl tab 5 mg................................................... 20benazepril hcl tab 10 mg (Lotensin)...............................20benazepril hcl tab 20 mg (Lotensin)...............................20benazepril hcl tab 40 mg (Lotensin)...............................20BENZNIDAZOLE – benznidazole tab 12.5 mg.................... 8BENZNIDAZOLE – benznidazole tab 100 mg..................... 8benzoyl peroxide-erythromycin gel 5-3%(Benzamycin)....................................................................53

benztropine mesylate tab 0.5 mg....................................49benztropine mesylate tab 1 mg.......................................49benztropine mesylate tab 2 mg.......................................49betamethasone dipropionate augmented cream 0.05%(Diprolene af)................................................................... 54

betamethasone dipropionate augmented lotion 0.05%(Diprolene)........................................................................ 54

betamethasone dipropionate augmented oint 0.05%(Diprolene)........................................................................ 54

betamethasone dipropionate cream 0.05%................... 54betamethasone dipropionate lotion 0.05%....................54betamethasone dipropionate oint 0.05%....................... 54betamethasone valerate cream 0.1% (baseequivalent)........................................................................ 54

betamethasone valerate lotion 0.1% (baseequivalent)........................................................................ 54

betamethasone valerate oint 0.1% (baseequivalent)........................................................................ 54

BETASERON – interferon beta-1b for inj kit 0.3 mg.......... 41bexarotene cap 75 mg (Targretin).....................................9bicalutamide tab 50 mg (Casodex)...................................9BILTRICIDE – praziquantel tab 600 mg...............................8bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg(Ziac)..................................................................................22

bisoprolol & hydrochlorothiazide tab 5-6.25 mg(Ziac)..................................................................................22

bisoprolol & hydrochlorothiazide tab 10-6.25 mg(Ziac)..................................................................................22

bisoprolol fumarate tab 5 mg (Zebeta)...........................22bisoprolol fumarate tab 10 mg (Zebeta).........................22BOSULIF – bosutinib tab 100 mg........................................ 9BOSULIF – bosutinib tab 400 mg........................................ 9BOSULIF – bosutinib tab 500 mg........................................ 9BREO ELLIPTA – fluticasone furoate-vilanterol aero powdba 100-25 mcg/inh............................................................ 30

BREO ELLIPTA – fluticasone furoate-vilanterol aero powdba 200-25 mcg/inh............................................................ 30

BRILINTA – ticagrelor tab 60 mg....................................... 50BRILINTA – ticagrelor tab 90 mg....................................... 50brimonidine tartrate ophth soln 0.2%.............................52brimonidine tartrate ophth soln 0.15% (Alphaganp)........................................................................................ 52

bromocriptine mesylate cap 5 mg (base equivalent)(Parlodel)...........................................................................49

bromocriptine mesylate tab 2.5 mg (base equivalent)(Parlodel)...........................................................................49

budesonide delayed release particles cap 3 mg(Entocort ec).................................................................... 12

budesonide inhalation susp 0.25 mg/2ml(Pulmicort)........................................................................ 30

budesonide inhalation susp 0.5 mg/2ml(Pulmicort)........................................................................ 30

budesonide inhalation susp 1 mg/2ml (Pulmicort).......30bumetanide tab 0.5 mg.................................................... 26bumetanide tab 1 mg........................................................26bumetanide tab 2 mg........................................................26buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (baseequiv).................................................................................58

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (baseequiv).................................................................................58

buprenorphine hcl sl tab 2 mg (base equiv)................. 43buprenorphine hcl sl tab 8 mg (base equiv)................. 43bupropion hcl (smoking deterrent) tab er 12hr 150 mg(Zyban).............................................................................. 42

bupropion hcl tab er 12hr 100 mg (Wellbutrin sr).........35bupropion hcl tab er 12hr 150 mg (Wellbutrin sr).........35bupropion hcl tab er 12hr 200 mg (Wellbutrin sr).........35bupropion hcl tab er 24hr 150 mg (Wellbutrin xl)......... 35bupropion hcl tab er 24hr 300 mg (Wellbutrin xl)......... 35bupropion hcl tab 75 mg (Wellbutrin)............................ 35bupropion hcl tab 100 mg (Wellbutrin).......................... 36buspirone hcl tab 5 mg....................................................35buspirone hcl tab 10 mg..................................................35buspirone hcl tab 15 mg..................................................35buspirone hcl tab 30 mg..................................................35butalbital-acetaminophen-caffeine cap 50-325-40mg...................................................................................... 43

butalbital-acetaminophen-caffeine tab 50-325-40mg...................................................................................... 43

butalbital-acetaminophen tab 50-325 mg.......................43butalbital-aspirin-caffeine cap 50-325-40 mg(Fiorinal)............................................................................43

butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg(Fiorinal/codeine #3)....................................................... 43C

cabergoline tab 0.5 mg.................................................... 18caffeine citrate oral soln 60 mg/3ml (10 mg/ml baseequiv) (Cafcit)...................................................................40

calcipotriene cream 0.005% (Dovonex)..........................56calcipotriene oint 0.005%.................................................56calcipotriene soln 0.005% (50 mcg/ml).......................... 56calcitonin (salmon) nasal soln 200 unit/act(Miacalcin)........................................................................ 18

calcitriol cap 0.25 mcg (Rocaltrol)..................................18calcitriol cap 0.5 mcg (Rocaltrol)....................................18calcitriol oral soln 1 mcg/ml (Rocaltrol).........................19

2018


calcium acetate (phosphate binder) cap 667 mg (169mg ca) (Phoslo)............................................................... 33

calcium acetate (phosphate binder) tab 667 mg(Eliphos)............................................................................33

CANASA – mesalamine suppos 1000 mg......................... 33candesartan cilexetil-hydrochlorothiazide tab 16-12.5mg (Atacand hct).............................................................21

candesartan cilexetil-hydrochlorothiazide tab 32-12.5mg (Atacand hct).............................................................21

candesartan cilexetil-hydrochlorothiazide tab 32-25mg (Atacand hct).............................................................21

candesartan cilexetil tab 4 mg (Atacand)...................... 21candesartan cilexetil tab 8 mg (Atacand)...................... 21candesartan cilexetil tab 16 mg (Atacand).................... 21candesartan cilexetil tab 32 mg (Atacand).................... 21capecitabine tab 150 mg (Xeloda).................................... 9capecitabine tab 500 mg (Xeloda).................................... 9CAPRELSA – vandetanib tab 100 mg................................. 9CAPRELSA – vandetanib tab 300 mg................................. 9CAPTOPRIL/HYDROCHLOROTHIA – captopril &hydrochlorothiazide tab 25-15 mg.................................... 20

CAPTOPRIL/HYDROCHLOROTHIA – captopril &hydrochlorothiazide tab 50-15 mg.................................... 20

captopril tab 12.5 mg........................................................20captopril tab 25 mg...........................................................20captopril tab 50 mg...........................................................20captopril tab 100 mg.........................................................20carbamazepine cap er 12hr 100 mg (Carbatrol)............47carbamazepine cap er 12hr 200 mg (Carbatrol)............47carbamazepine cap er 12hr 300 mg (Carbatrol)............47carbamazepine chew tab 100 mg................................... 47carbamazepine susp 100 mg/5ml (Tegretol)..................47carbamazepine tab er 12hr 100 mg (Tegretol-xr).......... 47carbamazepine tab er 12hr 200 mg (Tegretol-xr).......... 47carbamazepine tab er 12hr 400 mg (Tegretol-xr).......... 47carbamazepine tab 200 mg (Tegretol)............................47carbidopa & levodopa orally disintegrating tab 10-100mg...................................................................................... 49

carbidopa & levodopa orally disintegrating tab 25-100mg...................................................................................... 49

carbidopa & levodopa orally disintegrating tab 25-250mg...................................................................................... 49

carbidopa & levodopa tab er 25-100 mg (Sinemetcr).......................................................................................49

carbidopa & levodopa tab er 50-200 mg (Sinemetcr).......................................................................................49

carbidopa & levodopa tab 10-100 mg (Sinemet)...........49carbidopa & levodopa tab 25-100 mg (Sinemet)...........49carbidopa & levodopa tab 25-250 mg (Sinemet)...........49carvedilol tab 3.125 mg (Coreg)......................................22carvedilol tab 6.25 mg (Coreg)........................................23carvedilol tab 12.5 mg (Coreg)........................................23carvedilol tab 25 mg (Coreg)...........................................23cefaclor cap 250 mg........................................................... 2cefaclor cap 500 mg........................................................... 2cefadroxil cap 500 mg........................................................2

cefadroxil for susp 250 mg/5ml........................................ 2cefadroxil for susp 500 mg/5ml........................................ 2cefadroxil tab 1 gm.............................................................2cefdinir cap 300 mg............................................................2cefdinir for susp 125 mg/5ml............................................ 2cefdinir for susp 250 mg/5ml............................................ 2cefixime for susp 100 mg/5ml (Suprax)........................... 2cefixime for susp 200 mg/5ml (Suprax)........................... 2cefpodoxime proxetil for susp 50 mg/5ml....................... 2cefpodoxime proxetil for susp 100 mg/5ml..................... 2cefpodoxime proxetil tab 100 mg..................................... 2cefpodoxime proxetil tab 200 mg..................................... 2cefprozil for susp 125 mg/5ml...........................................2cefprozil for susp 250 mg/5ml...........................................3cefprozil tab 250 mg...........................................................3cefprozil tab 500 mg...........................................................3ceftriaxone sodium for inj 2 gm........................................3ceftriaxone sodium for inj 1 gm (Rocephin)....................3ceftriaxone sodium for inj 250 mg....................................3ceftriaxone sodium for inj 500 mg (Rocephin)................3cefuroxime axetil tab 250 mg (Ceftin).............................. 3cefuroxime axetil tab 500 mg (Ceftin).............................. 3celecoxib cap 50 mg (Celebrex)......................................45celecoxib cap 100 mg (Celebrex)....................................45celecoxib cap 200 mg (Celebrex)....................................45celecoxib cap 400 mg (Celebrex)....................................45cephalexin cap 250 mg (Keflex)........................................3cephalexin cap 500 mg (Keflex)........................................3cephalexin for susp 125 mg/5ml.......................................3cephalexin for susp 250 mg/5ml.......................................3cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)................... 29cevimeline hcl cap 30 mg (Evoxac)................................53CHANTIX CONTINUING MONTH – varenicline tartrate tab1 mg (base equiv).............................................................42

CHANTIX STARTING MONTH PA – varenicline tartratetab 0.5 mg x 11 & tab 1 mg x 42 pack............................. 42

CHANTIX – varenicline tartrate tab 0.5 mg (baseequiv)................................................................................. 42

CHANTIX – varenicline tartrate tab 1 mg (base equiv)......42CHEMET – succimer cap 100 mg......................................58CHENODAL – chenodiol tab 250 mg.................................34CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide-amitriptyline tab 5-12.5 mg............................................... 42

chlorhexidine gluconate soln 0.12% (Peridex)..............53chloroquine phosphate tab 500 mg (Aralen)...................8chlorothiazide tab 500 mg............................................... 26chlorpromazine hcl tab 10 mg........................................ 37chlorpromazine hcl tab 25 mg........................................ 37chlorpromazine hcl tab 50 mg........................................ 37chlorpromazine hcl tab 100 mg...................................... 37chlorpromazine hcl tab 200 mg...................................... 37chlorthalidone tab 25 mg.................................................26chlorthalidone tab 50 mg.................................................26CHLORZOXAZONE – chlorzoxazone tab 500 mg............ 49cholestyramine light powder 4 gm/dose (Questranlight)...................................................................................25

2018


cholestyramine light powder packets 4 gm.................. 25cholestyramine powder 4 gm/dose (Questran).............25cholestyramine powder packets 4 gm (Questran)........25choline fenofibrate cap dr 45 mg (fenofibric acidequiv) (Trilipix).................................................................25

choline fenofibrate cap dr 135 mg (fenofibric acidequiv) (Trilipix).................................................................25

CIALIS – tadalafil tab 2.5 mg............................................. 28CIALIS – tadalafil tab 5 mg................................................ 28CIALIS – tadalafil tab 10 mg.............................................. 28CIALIS – tadalafil tab 20 mg.............................................. 28ciclopirox gel 0.77% (Loprox)......................................... 54ciclopirox olamine cream 0.77% (base equiv)...............54ciclopirox olamine susp 0.77% (base equiv).................54ciclopirox shampoo 1% (Loprox shampoo).................. 54ciclopirox solution 8% (Penlac nail lacquer).................54cilostazol tab 50 mg (Pletal)............................................50cilostazol tab 100 mg (Pletal)..........................................50CIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml.........32cimetidine tab 300 mg......................................................32cimetidine tab 400 mg......................................................32cimetidine tab 800 mg......................................................32CIPRO – ciprofloxacin for oral susp 250 mg/5ml (5%) (5gm/100ml)............................................................................ 4

ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000mg(base eq) (Cipro xr)..................................................... 4

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

ciprofloxacin for oral susp 500 mg/5ml (10%) (10gm/100ml) (Cipro)..............................................................4

CIPROFLOXACIN HCL – ciprofloxacin hcl tab 100 mg(base equiv).........................................................................4

ciprofloxacin hcl ophth soln 0.3% (Ciloxan)................. 51ciprofloxacin hcl tab 750 mg (base equiv).......................4ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)..........4ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)..........4citalopram hydrobromide oral soln 10 mg/5ml............. 36citalopram hydrobromide tab 10 mg (base equiv)(Celexa)............................................................................. 36

citalopram hydrobromide tab 20 mg (base equiv)(Celexa)............................................................................. 36

citalopram hydrobromide tab 40 mg (base equiv)(Celexa)............................................................................. 36

CLARITHROMYCIN – clarithromycin for susp 125mg/5ml..................................................................................3

CLARITHROMYCIN – clarithromycin for susp 250mg/5ml..................................................................................3

clarithromycin tab er 24hr 500 mg................................... 3clarithromycin tab 250 mg (Biaxin).................................. 3clarithromycin tab 500 mg (Biaxin).................................. 3CLEMASTINE FUMARATE – clemastine fumarate tab2.68 mg..............................................................................29

CLIMARA PRO – estradiol-levonorgestrel td patch weekly0.045-0.015 mg/day.......................................................... 13

clindamycin hcl cap 75 mg (Cleocin)...............................8clindamycin hcl cap 150 mg (Cleocin).............................8

clindamycin hcl cap 300 mg (Cleocin).............................8clindamycin palmitate hcl for soln 75 mg/5ml (baseequiv) (Cleocin pediatric gr)............................................ 8

clindamycin phosphate-benzoyl peroxide gel 1-5%(Benzaclin)........................................................................53

clindamycin phosphate gel 1% (Cleocin-t)....................53clindamycin phosphate lotion 1% (Cleocin-t)............... 53clindamycin phosphate soln 1% (Cleocin-t)..................53clindamycin phosphate swab 1% (Cleocin-t)................ 53clindamycin phosphate vaginal cream 2%(Cleocin)............................................................................34

clindamycin phosph-benzoyl peroxide (refrig) gel 1.2(1)-5% (Duac)....................................................................53

clobetasol propionate cream 0.05% (Temovate)...........55clobetasol propionate emollient base cream 0.05%(Temovate e).....................................................................55

clobetasol propionate foam 0.05% (Olux)......................55clobetasol propionate gel 0.05% (Temovate)................ 55clobetasol propionate oint 0.05% (Temovate)...............55clobetasol propionate soln 0.05% (Temovate).............. 55CLOMIPHENE CITRATE – clomiphene citrate tab 50mg...................................................................................... 15

clomipramine hcl cap 25 mg (Anafranil)........................36clomipramine hcl cap 50 mg (Anafranil)........................36clomipramine hcl cap 75 mg (Anafranil)........................36clonazepam tab 0.5 mg (Klonopin).................................47clonazepam tab 1 mg (Klonopin)....................................47clonazepam tab 2 mg (Klonopin)....................................47clonidine hcl tab 0.1 mg (Catapres)............................... 27clonidine hcl tab 0.2 mg (Catapres)............................... 27clonidine hcl tab 0.3 mg (Catapres)............................... 27clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1)...................................................................................27

clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2)...................................................................................27

clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3)...................................................................................27

clopidogrel bisulfate tab 75 mg (base equiv)(Plavix).............................................................................. 50

clotrimazole troche 10 mg............................................... 53clozapine tab 50 mg......................................................... 37clozapine tab 200 mg....................................................... 37clozapine tab 25 mg (Clozaril).........................................37clozapine tab 100 mg (Clozaril).......................................37codeine sulfate tab 30 mg............................................... 43codeine sulfate tab 60 mg............................................... 43codeine sulfate tab 15 mg (Codeine sulfate).................43colchicine w/ probenecid tab 0.5-500 mg...................... 47COLCRYS – colchicine tab 0.6 mg....................................47colestipol hcl granule packets 5 gm (Colestidflavored)............................................................................25

colestipol hcl granules 5 gm (Colestid flavored).......... 25colestipol hcl tab 1 gm (Colestid)...................................25COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60mg dose) kit.........................................................................9

2018


COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20mg (100 dose) kit................................................................ 9

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20mg (140 dose) kit................................................................ 9

COMPLERA – emtricitabine-rilpivirine-tenofovir df tab200-25-300 mg.................................................................... 6

CONCERTA – methylphenidate hcl tab er osmotic release(osm) 18 mg...................................................................... 40




CONTOUR NEXT ONE BLOOD GL – blood glucosemonitoring kit..................................................................... 57

COPAXONE – glatiramer acetate soln prefilled syringe 20mg/ml..................................................................................41

COPAXONE – glatiramer acetate soln prefilled syringe 40mg/ml..................................................................................41

CORTIFOAM – hydrocortisone acetate rectal foam 10%(90 mg/dose)..................................................................... 53

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

COSENTYX – secukinumab subcutaneous soln prefilledsyringe 150 mg/ml.............................................................56

COSENTYX SENSOREADY PEN – secukinumabsubcutaneous soln auto-injector 150 mg/ml.....................56

COTELLIC – cobimetinib fumarate tab 20 mg (baseequivalent)............................................................................9

CREON – pancrelipase (lip-prot-amyl) dr cap3000-9500-15000 unit....................................................... 33

CREON – pancrelipase (lip-prot-amyl) dr cap6000-19000-30000 unit..................................................... 33

CREON – pancrelipase (lip-prot-amyl) dr cap12000-38000-60000 unit...................................................33

CREON – pancrelipase (lip-prot-amyl) dr cap24000-76000-120000 unit.................................................33

CREON – pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit............................................... 33

cromolyn sodium ophth soln 4%....................................52cromolyn sodium soln nebu 20 mg/2ml........................ 30cyanocobalamin inj 1000 mcg/ml................................... 50cyclobenzaprine hcl tab 5 mg.........................................49cyclobenzaprine hcl tab 10 mg.......................................49cyclopentolate hcl ophth soln 1% (Cyclogyl)................52cyclophosphamide cap 25 mg (Cyclophosphamide)..... 9cyclophosphamide cap 50 mg (Cyclophosphamide)..... 9CYCLOPHOSPHAMIDE – cyclophosphamide cap 25mg........................................................................................ 9

CYCLOPHOSPHAMIDE – cyclophosphamide cap 50mg........................................................................................ 9

cyclosporine cap 25 mg (Sandimmune)........................ 58cyclosporine cap 100 mg (Sandimmune)...................... 58cyclosporine modified cap 50 mg (Cyclosporinemodifie)............................................................................. 58

cyclosporine modified cap 25 mg (Neoral)....................58cyclosporine modified cap 100 mg (Neoral)..................58cyclosporine modified oral soln 100 mg/ml(Neoral)..............................................................................58

cyproheptadine hcl syrup 2 mg/5ml...............................29cyproheptadine hcl tab 4 mg.......................................... 29CYSTAGON – cysteamine bitartrate cap 50 mg................35CYSTAGON – cysteamine bitartrate cap 150 mg..............35

Ddanazol cap 50 mg............................................................13danazol cap 100 mg..........................................................13danazol cap 200 mg..........................................................13dantrolene sodium cap 25 mg (Dantrium)..................... 49dantrolene sodium cap 50 mg (Dantrium)..................... 49dantrolene sodium cap 100 mg (Dantrolenesodium)............................................................................. 49

dapsone tab 25 mg.............................................................8dapsone tab 100 mg...........................................................8DARAPRIM – pyrimethamine tab 25 mg............................. 8DELZICOL – mesalamine cap dr 400 mg..........................34demeclocycline hcl tab 150 mg........................................ 3demeclocycline hcl tab 300 mg........................................ 3DEPEN TITRATABS – penicillamine tab 250 mg.............. 59DESCOVY – emtricitabine-tenofovir alafenamide fumaratetab 200-25 mg..................................................................... 6

desipramine hcl tab 10 mg (Norpramin)........................ 36desipramine hcl tab 25 mg (Norpramin)........................ 36desipramine hcl tab 50 mg (Norpramin)........................ 36desipramine hcl tab 75 mg (Norpramin)........................ 36desipramine hcl tab 100 mg (Norpramin)...................... 36desipramine hcl tab 150 mg (Norpramin)...................... 36DESLORATADINE ODT – desloratadine tab orallydisintegrating 2.5 mg.........................................................29

DESLORATADINE ODT – desloratadine tab orallydisintegrating 5 mg............................................................29

desloratadine tab 5 mg (Clarinex).................................. 29desmopressin acetate inj 4 mcg/ml (Ddavp).................19desmopressin acetate nasal spray soln 0.01%(Ddavp)..............................................................................19

desmopressin acetate nasal spray soln 0.01%(refrigerated).....................................................................19

desmopressin acetate tab 0.1 mg (Ddavp)....................19desmopressin acetate tab 0.2 mg (Ddavp)....................19desogest-eth estrad & eth estrad tab 0.15-0.02/0.01mg(21/5) (Mircette).......................................................... 14

desogest-ethin est tab0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa).....14

desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg(Desogen)......................................................................... 14

desonide cream 0.05% (Desowen)................................. 55desonide lotion 0.05% (Desowen).................................. 55desonide oint 0.05% (Desowen)......................................55desoximetasone cream 0.05% (Topicort).......................55desoximetasone cream 0.25% (Topicort).......................55desoximetasone gel 0.05% (Topicort)............................ 55

2018


desoximetasone oint 0.25% (Topicort)...........................55DEXAMETHASONE – dexamethasone soln 0.5mg/5ml............................................................................... 12

dexamethasone elixir 0.5 mg/5ml................................... 12dexamethasone tab 0.5 mg............................................. 12dexamethasone tab 0.75 mg........................................... 12dexamethasone tab 1.5 mg............................................. 12dexamethasone tab 4 mg................................................ 12dexamethasone tab 6 mg................................................ 12dexmethylphenidate hcl cap er 24 hr 5 mg (Focalinxr).......................................................................................40

dexmethylphenidate hcl cap er 24 hr 10 mg (Focalinxr).......................................................................................40





dextroamphetamine sulfate cap er 24hr 5 mg(Dexedrine)....................................................................... 41



dextroamphetamine sulfate tab 5 mg.............................41dextroamphetamine sulfate tab 10 mg...........................41DIASTAT ACUDIAL – diazepam rectal gel delivery system10 mg.................................................................................47

DIASTAT ACUDIAL – diazepam rectal gel delivery system20 mg.................................................................................47

DIASTAT PEDIATRIC – diazepam rectal gel deliverysystem 2.5 mg...................................................................47

diazepam tab 2 mg (Valium)............................................35diazepam tab 5 mg (Valium)............................................35diazepam tab 10 mg (Valium)..........................................35diclofenac potassium tab 50 mg (Cataflam)..................45diclofenac sodium (actinic keratoses) gel 3%(Solaraze)..........................................................................56

diclofenac sodium gel 1% (Voltaren)..............................54diclofenac sodium ophth soln 0.1%...............................52diclofenac sodium tab delayed release 25 mg..............45diclofenac sodium tab delayed release 50 mg..............45diclofenac sodium tab delayed release 75 mg..............45diclofenac sodium tab er 24hr 100 mg.......................... 45dicloxacillin sodium cap 250 mg...................................... 2dicloxacillin sodium cap 500 mg...................................... 2dicyclomine hcl cap 10 mg (Bentyl)...............................32dicyclomine hcl oral soln 10 mg/5ml............................. 32dicyclomine hcl tab 20 mg (Bentyl)................................32didanosine delayed release capsule 200 mg (Videxec)........................................................................................ 6

didanosine delayed release capsule 250 mg (Videxec)........................................................................................ 6

didanosine delayed release capsule 400 mg (Videxec)........................................................................................ 6

digoxin tab 125 mcg (0.125 mg) (Lanoxin).................... 27digoxin tab 250 mcg (0.25 mg) (Lanoxin)...................... 27DILANTIN – phenytoin sodium extended cap 30 mg.........47diltiazem hcl cap er 24hr 120 mg....................................23diltiazem hcl cap er 24hr 180 mg....................................23diltiazem hcl cap er 24hr 240 mg....................................23diltiazem hcl coated beads cap er 24hr 300 mg............24diltiazem hcl coated beads cap er 24hr 120 mg(Cardizem cd)...................................................................23

diltiazem hcl coated beads cap er 24hr 180 mg(Cardizem cd)...................................................................23



diltiazem hcl extended release beads cap er 24hr 120mg (Tiazac).......................................................................24






diltiazem hcl tab 90 mg....................................................24diltiazem hcl tab 30 mg (Cardizem)................................24diltiazem hcl tab 60 mg (Cardizem)................................24diltiazem hcl tab 120 mg (Cardizem)..............................24diphenoxylate w/ atropine tab 2.5-0.025 mg(Lomotil)............................................................................32

dipyridamole tab 25 mg (Persantine)............................. 50dipyridamole tab 50 mg (Persantine)............................. 50dipyridamole tab 75 mg (Persantine)............................. 50disopyramide phosphate cap 100 mg (Norpace).......... 26disopyramide phosphate cap 150 mg (Norpace).......... 27disulfiram tab 250 mg (Antabuse).................................. 42disulfiram tab 500 mg (Antabuse).................................. 42divalproex sodium cap delayed release sprinkle 125mg (Depakote sprinkles)................................................ 47

divalproex sodium tab delayed release 125 mg(Depakote)........................................................................ 47



divalproex sodium tab er 24 hr 250 mg (Depakoteer).......................................................................................47

divalproex sodium tab er 24 hr 500 mg (Depakoteer).......................................................................................47

DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%)...........13DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%)...............13

2018


DIVIGEL – estradiol td gel 1 mg/gm (0.1%).......................13donepezil hydrochloride orally disintegrating tab 5 mg(Aricept odt)..................................................................... 42

donepezil hydrochloride orally disintegrating tab 10mg (Aricept odt).............................................................. 42

donepezil hydrochloride tab 5 mg (Aricept)..................42donepezil hydrochloride tab 10 mg (Aricept)................42dorzolamide hcl ophth soln 2% (Trusopt)..................... 52dorzolamide hcl-timolol maleate ophth soln 22.3-6.8mg/ml (Cosopt)................................................................ 52

doxazosin mesylate tab 1 mg (Cardura)........................27doxazosin mesylate tab 2 mg (Cardura)........................27doxazosin mesylate tab 4 mg (Cardura)........................27doxazosin mesylate tab 8 mg (Cardura)........................27doxepin hcl cap 10 mg.....................................................36doxepin hcl cap 25 mg.....................................................36doxepin hcl cap 50 mg.....................................................36doxepin hcl cap 75 mg.....................................................36doxepin hcl cap 100 mg...................................................36doxepin hcl conc 10 mg/ml............................................. 36doxycycline hyclate cap 50 mg.........................................3doxycycline hyclate cap 100 mg (Vibramycin)................3doxycycline hyclate tab 20 mg......................................... 3doxycycline hyclate tab 100 mg....................................... 3doxycycline monohydrate cap 50 mg.............................. 3doxycycline monohydrate cap 150 mg (Adoxa)..............3doxycycline monohydrate cap 75 mg (Monodox)...........3doxycycline monohydrate cap 100 mg (Monodox).........3doxycycline monohydrate tab 50 mg (Adoxa)................ 3doxycycline monohydrate tab 75 mg (Adoxa)................ 3doxycycline monohydrate tab 100 mg (Adoxa pak1/100)................................................................................... 3

doxycycline monohydrate tab 150 mg (Adoxa pak1/150)................................................................................... 3

drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin28)...................................................................................... 14

drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)......14DULERA – mometasone furoate-formoterol fumarateaerosol 100-5 mcg/act...................................................... 30

DULERA – mometasone furoate-formoterol fumarateaerosol 200-5 mcg/act...................................................... 30

duloxetine hcl enteric coated pellets cap 20 mg (baseeq) (Cymbalta)..................................................................36



dutasteride cap 0.5 mg (Avodart)................................... 35E

econazole nitrate cream 1%............................................ 54efavirenz cap 50 mg (Sustiva)...........................................6efavirenz cap 200 mg (Sustiva).........................................6efavirenz tab 600 mg (Sustiva)..........................................6eletriptan hydrobromide tab 20 mg (base equivalent)(Relpax).............................................................................46

eletriptan hydrobromide tab 40 mg (base equivalent)(Relpax).............................................................................46

ELIQUIS – apixaban tab 2.5 mg........................................ 50ELIQUIS – apixaban tab 5 mg........................................... 50ELIQUIS STARTER PACK – apixaban tab 5 mg............... 50ELLA – ulipristal acetate tab 30 mg...................................14EMCYT – estramustine phosphate sodium cap 140 mg......9EMEND – aprepitant for oral susp 125 mg (125mg/5ml).............................................................................. 33

enalapril maleate & hydrochlorothiazide tab 5-12.5mg...................................................................................... 20

enalapril maleate & hydrochlorothiazide tab 10-25 mg(Vaseretic).........................................................................20

enalapril maleate tab 2.5 mg (Vasotec)..........................20enalapril maleate tab 5 mg (Vasotec).............................20enalapril maleate tab 10 mg (Vasotec)...........................20enalapril maleate tab 20 mg (Vasotec)...........................20ENBREL – etanercept for subcutaneous inj 25 mg........... 45ENBREL – etanercept subcutaneous soln prefilled syringe25 mg/0.5ml.......................................................................45

ENBREL – etanercept subcutaneous soln prefilled syringe50 mg/ml............................................................................45

ENBREL MINI – etanercept subcutaneous solutioncartridge 50 mg/ml............................................................ 45

ENBREL SURECLICK – etanercept subcutaneoussolution auto-injector 50 mg/ml.........................................45

enoxaparin sodium inj 30 mg/0.3ml (Lovenox)............. 50enoxaparin sodium inj 40 mg/0.4ml (Lovenox)............. 51enoxaparin sodium inj 60 mg/0.6ml (Lovenox)............. 51enoxaparin sodium inj 80 mg/0.8ml (Lovenox)............. 51enoxaparin sodium inj 100 mg/ml (Lovenox)................ 51enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........... 51enoxaparin sodium inj 150 mg/ml (Lovenox)................ 51enoxaparin sodium inj 300 mg/3ml (Lovenox).............. 51entacapone tab 200 mg (Comtan)...................................49entecavir tab 0.5 mg (Baraclude)......................................5entecavir tab 1 mg (Baraclude).........................................5ENTRESTO – sacubitril-valsartan tab 24-26 mg............... 28ENTRESTO – sacubitril-valsartan tab 49-51 mg............... 28ENTRESTO – sacubitril-valsartan tab 97-103 mg............. 28EPCLUSA – sofosbuvir-velpatasvir tab 400-100 mg........... 5EPINEPHRINE (Mylan products) – epinephrine solutionauto-injector 0.15 mg/0.3ml (1:2000)................................28

EPINEPHRINE (Mylan products) – epinephrine solutionauto-injector 0.3 mg/0.3ml (1:1000)..................................29

eplerenone tab 25 mg (Inspra)........................................28eplerenone tab 50 mg (Inspra)........................................28ergocalciferol cap 50000 unit (Drisdol)..........................50ERIVEDGE – vismodegib cap 150 mg................................ 9erythromycin gel 2% (Erygel)..........................................53erythromycin ophth oint 5 mg/gm..................................51erythromycin pads 2%..................................................... 53erythromycin soln 2%...................................................... 53escitalopram oxalate soln 5 mg/5ml (base equiv)(Lexapro)...........................................................................36

2018


escitalopram oxalate tab 5 mg (base equiv)(Lexapro)...........................................................................36



esomeprazole magnesium cap delayed release 20 mg(base eq) (Nexium)..........................................................32

esomeprazole magnesium cap delayed release 40 mg(base eq) (Nexium)..........................................................32

estazolam tab 1 mg.......................................................... 39estazolam tab 2 mg.......................................................... 39ESTRACE – estradiol vaginal cream 0.1 mg/gm...............34estradiol & norethindrone acetate tab 0.5-0.1 mg(Activella)..........................................................................13

estradiol & norethindrone acetate tab 1-0.5 mg(Activella)..........................................................................13

estradiol tab 0.5 mg (Estrace).........................................13estradiol tab 1 mg (Estrace)............................................13estradiol tab 2 mg (Estrace)............................................13estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot).....................................................................................13

estradiol td patch twice weekly 0.0375 mg/24hr(Vivelle-dot)...................................................................... 13

estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot).....................................................................................13



estradiol td patch weekly 0.025 mg/24hr (Climara).......13estradiol td patch weekly 0.05 mg/24hr (Climara).........14estradiol td patch weekly 0.06 mg/24hr (Climara).........14estradiol td patch weekly 0.075 mg/24hr (Climara).......14estradiol td patch weekly 0.1 mg/24hr (Climara)...........14estradiol td patch weekly 0.0375 mg/24hr (37.5mcg/24hr) (Climara).........................................................14

estradiol vaginal cream 0.1 mg/gm (Estrace)................34eszopiclone tab 1 mg (Lunesta)......................................39eszopiclone tab 2 mg (Lunesta)......................................39eszopiclone tab 3 mg (Lunesta)......................................39ethambutol hcl tab 100 mg (Myambutol)......................... 4ethambutol hcl tab 400 mg (Myambutol)......................... 4ethosuximide cap 250 mg (Zarontin)..............................47ethosuximide soln 250 mg/5ml (Zarontin)..................... 48ethynodiol diacetate & ethinyl estradiol tab 1 mg-35mcg....................................................................................14

ethynodiol diacetate & ethinyl estradiol tab 1 mg-50mcg (Zovia 1/50e)............................................................14

etodolac cap 200 mg........................................................ 45etodolac cap 300 mg........................................................ 45etodolac tab er 24hr 400 mg........................................... 45etodolac tab er 24hr 500 mg........................................... 45etodolac tab er 24hr 600 mg........................................... 45etodolac tab 400 mg.........................................................45etodolac tab 500 mg.........................................................45

ETOPOSIDE – etoposide cap 50 mg...................................9EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg(base equiv).........................................................................6

exemestane tab 25 mg (Aromasin)...................................9ezetimibe-simvastatin tab 10-10 mg (Vytorin)...............25ezetimibe-simvastatin tab 10-20 mg (Vytorin)...............25ezetimibe-simvastatin tab 10-40 mg (Vytorin)...............25ezetimibe-simvastatin tab 10-80 mg (Vytorin)...............25ezetimibe tab 10 mg (Zetia)............................................. 25F

famciclovir tab 125 mg (Famvir)....................................... 5famciclovir tab 250 mg (Famvir)....................................... 5famciclovir tab 500 mg (Famvir)....................................... 5famotidine tab 20 mg (Pepcid)........................................32famotidine tab 40 mg (Pepcid)........................................32FARESTON – toremifene citrate tab 60 mg (baseequivalent)............................................................................9

FARYDAK – panobinostat lactate cap 10 mg (baseequivalent)............................................................................9



felodipine tab er 24hr 2.5 mg.......................................... 24felodipine tab er 24hr 5 mg............................................. 24felodipine tab er 24hr 10 mg........................................... 24fenofibrate micronized cap 67 mg (Lofibra).................. 25fenofibrate micronized cap 134 mg (Lofibra)................ 25fenofibrate micronized cap 200 mg (Lofibra)................ 25fenofibrate tab 54 mg (Lofibra)....................................... 25fenofibrate tab 160 mg (Lofibra)..................................... 25fenofibrate tab 48 mg (Tricor)......................................... 25fenofibrate tab 145 mg (Tricor)....................................... 25fentanyl citrate lozenge on a handle 200 mcg(Actiq)................................................................................43

fentanyl citrate lozenge on a handle 400 mcg(Actiq)................................................................................43





fentanyl td patch 72hr 12 mcg/hr (Duragesic)...............44fentanyl td patch 72hr 25 mcg/hr (Duragesic)...............44fentanyl td patch 72hr 50 mcg/hr (Duragesic)...............44fentanyl td patch 72hr 75 mcg/hr (Duragesic)...............44fentanyl td patch 72hr 100 mcg/hr (Duragesic).............44FIASP FLEXTOUCH – insulin aspart soln pen-injector 100unit/ml.................................................................................17

FIASP – insulin aspart inj 100 unit/ml................................ 17FINACEA – azelaic acid foam 15%................................... 53FINACEA – azelaic acid gel 15%.......................................53

2018


finasteride tab 5 mg (Proscar)........................................ 35FINGERSTIX LANCETS – lancets.....................................58FIRAZYR – icatibant acetate inj 30 mg/3ml (baseequivalent)......................................................................... 51

flecainide acetate tab 50 mg........................................... 27flecainide acetate tab 100 mg......................................... 27flecainide acetate tab 150 mg......................................... 27fluconazole for susp 10 mg/ml (Diflucan)........................4fluconazole for susp 40 mg/ml (Diflucan)........................4fluconazole tab 50 mg (Diflucan)......................................4fluconazole tab 100 mg (Diflucan)....................................4fluconazole tab 150 mg (Diflucan)....................................4fluconazole tab 200 mg (Diflucan)....................................4flucytosine cap 250 mg (Ancobon)...................................4flucytosine cap 500 mg (Ancobon)...................................4fludrocortisone acetate tab 0.1 mg.................................12FLUNISOLIDE – flunisolide nasal soln 25 mcg/act(0.025%).............................................................................29

fluocinolone acetonide cream 0.01%............................. 55fluocinolone acetonide cream 0.025% (Synalar)...........55fluocinolone acetonide oil 0.01% (body oil) (Derma-smoothe/fs bod).............................................................. 55

fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs sca)............................................................... 55

fluocinolone acetonide oint 0.025% (Synalar)...............55fluocinolone acetonide soln 0.01% (Synalar)................55fluocinonide cream 0.05%............................................... 55fluocinonide emulsified base cream 0.05%...................55fluocinonide gel 0.05%.....................................................55fluocinonide oint 0.05%....................................................55fluocinonide soln 0.05%...................................................55fluorometholone ophth susp 0.1% (Fml liquifilm)........ 52fluorouracil cream 5% (Efudex)...................................... 56FLUOXETINE DR – fluoxetine hcl cap delayed release 90mg...................................................................................... 36

fluoxetine hcl cap 10 mg (Prozac)..................................36fluoxetine hcl cap 20 mg (Prozac)..................................36fluoxetine hcl cap 40 mg (Prozac)..................................36fluoxetine hcl solution 20 mg/5ml.................................. 36fluoxetine hcl tab 10 mg.................................................. 36fluoxetine hcl tab 20 mg.................................................. 36fluphenazine decanoate inj 25 mg/ml.............................37fluphenazine hcl tab 1 mg............................................... 37fluphenazine hcl tab 2.5 mg............................................ 37fluphenazine hcl tab 5 mg............................................... 37fluphenazine hcl tab 10 mg............................................. 37FLURAZEPAM HCL – flurazepam hcl cap 15 mg..............39FLURAZEPAM HCL – flurazepam hcl cap 30 mg..............39flurbiprofen tab 50 mg......................................................45flurbiprofen tab 100 mg................................................... 45flutamide cap 125 mg.........................................................9FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 55-14 mcg/act.........................30

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 113-14 mcg/act....................... 30

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 232-14 mcg/act.......................30

fluticasone propionate cream 0.05% (Cutivate)............ 55fluticasone propionate nasal susp 50 mcg/act(Flonase)........................................................................... 29

fluticasone propionate oint 0.005% (Cutivate).............. 55fluvoxamine maleate tab 25 mg......................................36fluvoxamine maleate tab 50 mg......................................36fluvoxamine maleate tab 100 mg....................................36folic acid tab 1 mg............................................................51FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml..........15FOLLISTIM AQ – follitropin beta inj 600 unit/0.72ml..........15FOLLISTIM AQ – follitropin beta inj 900 unit/1.08ml..........15fosinopril sodium & hydrochlorothiazide tab 10-12.5mg...................................................................................... 20

fosinopril sodium & hydrochlorothiazide tab 20-12.5mg...................................................................................... 20

fosinopril sodium tab 10 mg........................................... 20fosinopril sodium tab 20 mg........................................... 20fosinopril sodium tab 40 mg........................................... 20furosemide oral soln 10 mg/ml....................................... 26furosemide tab 20 mg (Lasix)......................................... 26furosemide tab 40 mg (Lasix)......................................... 26furosemide tab 80 mg (Lasix)......................................... 26G

gabapentin cap 100 mg (Neurontin)...............................48gabapentin cap 300 mg (Neurontin)...............................48gabapentin cap 400 mg (Neurontin)...............................48gabapentin oral soln 250 mg/5ml (Neurontin)...............48gabapentin tab 600 mg (Neurontin)................................48gabapentin tab 800 mg (Neurontin)................................48galantamine hydrobromide cap er 24hr 8 mg(Razadyne er)...................................................................42

galantamine hydrobromide cap er 24hr 16 mg(Razadyne er)...................................................................43

galantamine hydrobromide cap er 24hr 24 mg(Razadyne er)...................................................................43

GALANTAMINE HYDROBROMIDE – galantaminehydrobromide oral soln 4 mg/ml.......................................42

galantamine hydrobromide tab 4 mg (Razadyne).........43galantamine hydrobromide tab 8 mg (Razadyne).........43galantamine hydrobromide tab 12 mg (Razadyne).......43gemfibrozil tab 600 mg (Lopid).......................................25GENTAK – gentamicin sulfate ophth oint 0.3%................. 51gentamicin sulfate cream 0.1%.......................................54gentamicin sulfate oint 0.1%........................................... 54gentamicin sulfate ophth soln 0.3% (Garamycin).........51GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab150-150-200-10 mg.............................................................6

GILENYA – fingolimod hcl cap 0.5 mg (base equiv)..........41GILOTRIF – afatinib dimaleate tab 20 mg (baseequivalent)............................................................................9

GILOTRIF – afatinib dimaleate tab 30 mg (baseequivalent)............................................................................9

2018


GILOTRIF – afatinib dimaleate tab 40 mg (baseequivalent)............................................................................9

glatiramer acetate soln prefilled syringe 20 mg/ml(Copaxone)....................................................................... 42

glatiramer acetate soln prefilled syringe 40 mg/ml(Copaxone)....................................................................... 42

GLEOSTINE – lomustine cap 5 mg..................................... 9GLEOSTINE – lomustine cap 10 mg................................... 9GLEOSTINE – lomustine cap 40 mg................................... 9GLEOSTINE – lomustine cap 100 mg................................. 9glimepiride tab 1 mg (Amaryl).........................................16glimepiride tab 2 mg (Amaryl).........................................16glimepiride tab 4 mg (Amaryl).........................................16glipizide-metformin hcl tab 2.5-250 mg..........................16glipizide-metformin hcl tab 2.5-500 mg..........................16glipizide-metformin hcl tab 5-500 mg.............................16glipizide tab er 24hr 2.5 mg (Glucotrol xl)..................... 16glipizide tab er 24hr 5 mg (Glucotrol xl)........................ 16glipizide tab er 24hr 10 mg (Glucotrol xl)...................... 16glipizide tab 5 mg (Glucotrol)..........................................16glipizide tab 10 mg (Glucotrol)........................................16GLUCAGON EMERGENCY KIT – glucagon (rdna) for injkit 1 mg..............................................................................16

glyburide-metformin tab 1.25-250 mg(Glucovance).................................................................... 16

glyburide-metformin tab 2.5-500 mg (Glucovance)...... 16glyburide-metformin tab 5-500 mg (Glucovance)......... 16glyburide micronized tab 1.5 mg (Glynase)...................16glyburide micronized tab 3 mg (Glynase)......................16glyburide micronized tab 6 mg (Glynase)......................16glyburide tab 1.25 mg.......................................................16glyburide tab 2.5 mg.........................................................16glyburide tab 5 mg............................................................16glycopyrrolate tab 1 mg (Robinul)..................................32glycopyrrolate tab 2 mg (Robinul forte).........................32GLYXAMBI – empagliflozin-linagliptin tab 10-5 mg........... 16GLYXAMBI – empagliflozin-linagliptin tab 25-5 mg........... 16granisetron hcl tab 1 mg................................................. 33griseofulvin microsize susp 125 mg/5ml......................... 4griseofulvin microsize tab 500 mg (Grifulvin v)..............5guanfacine hcl tab er 24hr 1 mg (base equiv)(Intuniv).............................................................................41

guanfacine hcl tab er 24hr 2 mg (base equiv)(Intuniv).............................................................................41



guanfacine hcl tab 1 mg (Tenex).................................... 28guanfacine hcl tab 2 mg (Tenex).................................... 28H

HAEGARDA – c1 esterase inhibitor (human) forsubcutaneous inj 2000 unit...............................................51

HAEGARDA – c1 esterase inhibitor (human) forsubcutaneous inj 3000 unit...............................................51

halobetasol propionate cream 0.05% (Ultravate)..........55halobetasol propionate oint 0.05% (Ultravate)..............55haloperidol decanoate im soln 50 mg/ml (Haldoldecanoate 50)...................................................................37

haloperidol decanoate im soln 100 mg/ml (Haldoldecanoate 100).................................................................38

haloperidol lactate oral conc 2 mg/ml............................38haloperidol tab 0.5 mg..................................................... 38haloperidol tab 1 mg........................................................ 38haloperidol tab 2 mg........................................................ 38haloperidol tab 5 mg........................................................ 38haloperidol tab 10 mg...................................................... 38haloperidol tab 20 mg...................................................... 38HARVONI – ledipasvir-sofosbuvir tab 90-400 mg................5HEXALEN – altretamine cap 50 mg.....................................9HUMIRA – adalimumab prefilled syringe kit 10mg/0.2ml............................................................................ 45

HUMIRA – adalimumab prefilled syringe kit 20mg/0.4ml............................................................................ 45

HUMIRA – adalimumab prefilled syringe kit 40mg/0.8ml............................................................................ 45

HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 40 mg/0.8ml.....................................................45

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.8ml............................................................................ 45

HUMIRA PEN-CROHNS DISEASE – adalimumab pen-injector kit 40 mg/0.8ml.....................................................46

HUMIRA PEN-PSORIASIS STAR – adalimumab pen-injector kit 40 mg/0.8ml.....................................................46

HUMULIN R U-500 (CONCENTR – insulin regular(human) inj 500 unit/ml..................................................... 17

HUMULIN R U-500 KWIKPEN – insulin regular (human)soln pen-injector 500 unit/ml.............................................17

HYCAMTIN – topotecan hcl cap 0.25 mg (base equiv)....... 9HYCAMTIN – topotecan hcl cap 1 mg (base equiv)............ 9hydralazine hcl tab 10 mg............................................... 28hydralazine hcl tab 25 mg............................................... 28hydralazine hcl tab 50 mg............................................... 28hydralazine hcl tab 100 mg............................................. 28hydrochlorothiazide cap 12.5 mg (Microzide)............... 26hydrochlorothiazide tab 12.5 mg.................................... 26hydrochlorothiazide tab 25 mg....................................... 26hydrochlorothiazide tab 50 mg....................................... 26hydrocodone-acetaminophen soln 7.5-325 mg/15ml(Hycet)............................................................................... 44

hydrocodone-acetaminophen tab 7.5-325 mg(Norco).............................................................................. 44

hydrocodone-acetaminophen tab 5-325 mg(Norco).............................................................................. 44

hydrocodone-acetaminophen tab 10-325 mg(Norco).............................................................................. 44

hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........ 44hydrocodone-ibuprofen tab 5-200 mg (Reprexain).......44hydrocodone-ibuprofen tab 7.5-200 mg(Vicoprofen)......................................................................44

hydrocortisone cream 2.5%.............................................55

2018


hydrocortisone enema 100 mg/60ml (Cortenema)........53hydrocortisone lotion 2.5%............................................. 55hydrocortisone oint 2.5%.................................................55hydrocortisone rectal cream 2.5% (Anusol-hc)............ 53hydrocortisone tab 5 mg (Cortef)................................... 12hydrocortisone tab 10 mg (Cortef)................................. 12hydrocortisone tab 20 mg (Cortef)................................. 12hydrocortisone valerate cream 0.2%..............................55hydrocortisone valerate oint 0.2% (Westcort)...............55hydrocortisone w/ acetic acid otic soln 1-2% (Vosolhc)...................................................................................... 53

hydromorphone hcl liqd 1 mg/ml (Dilaudid)..................44hydromorphone hcl tab 2 mg (Dilaudid)........................44hydromorphone hcl tab 4 mg (Dilaudid)........................44hydromorphone hcl tab 8 mg (Dilaudid)........................44hydroxychloroquine sulfate tab 200 mg (Plaquenil).......8hydroxyurea cap 500 mg (Hydrea)................................... 9hydroxyzine hcl syrup 10 mg/5ml...................................35hydroxyzine hcl tab 10 mg.............................................. 35hydroxyzine hcl tab 25 mg.............................................. 35hydroxyzine hcl tab 50 mg.............................................. 35hydroxyzine pamoate cap 25 mg (Vistaril).................... 35hydroxyzine pamoate cap 50 mg (Vistaril).................... 35I

ibandronate sodium tab 150 mg (base equivalent)(Boniva).............................................................................19

IBRANCE – palbociclib cap 75 mg...................................... 9IBRANCE – palbociclib cap 100 mg.................................... 9IBRANCE – palbociclib cap 125 mg.................................. 10ibuprofen susp 100 mg/5ml.............................................46ibuprofen tab 400 mg....................................................... 46ibuprofen tab 600 mg....................................................... 46ibuprofen tab 800 mg....................................................... 46ICLUSIG – ponatinib hcl tab 15 mg (base equiv).............. 10ICLUSIG – ponatinib hcl tab 45 mg (base equiv).............. 10ILARIS – canakinumab subcutaneous inj 150 mg/ml........ 46imatinib mesylate tab 100 mg (base equivalent)(Gleevec)...........................................................................10

imatinib mesylate tab 400 mg (base equivalent)(Gleevec)...........................................................................10

IMBRUVICA – ibrutinib cap 70 mg.....................................10IMBRUVICA – ibrutinib cap 140 mg...................................10IMBRUVICA – ibrutinib tab 140 mg................................... 10IMBRUVICA – ibrutinib tab 280 mg................................... 10IMBRUVICA – ibrutinib tab 420 mg................................... 10IMBRUVICA – ibrutinib tab 560 mg................................... 10imipramine hcl tab 10 mg (Tofranil)............................... 36imipramine hcl tab 25 mg (Tofranil)............................... 36imipramine hcl tab 50 mg (Tofranil)............................... 36imiquimod cream 5% (Aldara).........................................56IMPAVIDO – miltefosine cap 50 mg.....................................8INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml).........18indapamide tab 1.25 mg...................................................26indapamide tab 2.5 mg.....................................................26indomethacin cap 25 mg................................................. 46

indomethacin cap 50 mg................................................. 46INLYTA – axitinib tab 1 mg.................................................10INLYTA – axitinib tab 5 mg.................................................10INTELENCE – etravirine tab 25 mg.....................................6INTELENCE – etravirine tab 100 mg...................................6INTELENCE – etravirine tab 200 mg...................................6ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml(Duoneb)........................................................................... 30

ipratropium bromide inhal soln 0.02%...........................30ipratropium bromide nasal soln 0.03% (21 mcg/spray)(Atrovent)..........................................................................29

ipratropium bromide nasal soln 0.06% (42 mcg/spray)(Atrovent)..........................................................................29

irbesartan-hydrochlorothiazide tab 150-12.5 mg(Avalide)............................................................................ 22

irbesartan-hydrochlorothiazide tab 300-12.5 mg(Avalide)............................................................................ 22

irbesartan tab 75 mg (Avapro)........................................ 21irbesartan tab 150 mg (Avapro)...................................... 21irbesartan tab 300 mg (Avapro)...................................... 21IRESSA – gefitinib tab 250 mg.......................................... 10ISENTRESS HD – raltegravir potassium tab 600 mg (baseequiv)....................................................................................6

ISENTRESS – raltegravir potassium chew tab 25 mg(base equiv).........................................................................6

ISENTRESS – raltegravir potassium chew tab 100 mg(base equiv).........................................................................6

ISENTRESS – raltegravir potassium packet for susp 100mg (base equiv).................................................................. 6

ISENTRESS – raltegravir potassium tab 400 mg (baseequiv)....................................................................................6

isoniazid tab 100 mg.......................................................... 4isoniazid tab 300 mg.......................................................... 4isosorbide dinitrate tab 10 mg........................................24isosorbide dinitrate tab 20 mg........................................24isosorbide dinitrate tab 30 mg........................................24isosorbide dinitrate tab 5 mg (Isordil titradose)........... 24isosorbide mononitrate tab er 24hr 30 mg.................... 24isosorbide mononitrate tab er 24hr 60 mg.................... 24isosorbide mononitrate tab er 24hr 120 mg.................. 24isosorbide mononitrate tab 10 mg................................. 24isosorbide mononitrate tab 20 mg................................. 24isotretinoin cap 10 mg..................................................... 53isotretinoin cap 20 mg..................................................... 53isotretinoin cap 40 mg..................................................... 53isotretinoin cap 30 mg (Claravis)....................................53itraconazole cap 100 mg (Sporanox)................................5ivermectin tab 3 mg (Stromectol)..................................... 8J

JADENU – deferasirox tab 90 mg......................................59JADENU – deferasirox tab 180 mg....................................59JADENU – deferasirox tab 360 mg....................................59JAKAFI – ruxolitinib phosphate tab 5 mg (baseequivalent)......................................................................... 10

2018


JAKAFI – ruxolitinib phosphate tab 10 mg (baseequivalent)......................................................................... 10




JARDIANCE – empagliflozin tab 10 mg.............................16JARDIANCE – empagliflozin tab 25 mg.............................16

KKALETRA – lopinavir-ritonavir tab 100-25 mg.....................6KALETRA – lopinavir-ritonavir tab 200-50 mg.....................6KALYDECO – ivacaftor packet 50 mg............................... 31KALYDECO – ivacaftor packet 75 mg............................... 31KALYDECO – ivacaftor tab 150 mg................................... 31ketoconazole cream 2%................................................... 54ketoconazole shampoo 2% (Nizoral)..............................54ketorolac tromethamine ophth soln 0.5% (Acular)....... 52ketorolac tromethamine ophth soln 0.4% (Acularls)....................................................................................... 52

KISQALI FEMARA 200 DOSE – ribociclib tab 200 mg &letrozole tab 2.5 mg therapy pack....................................10



KISQALI – ribociclib succinate tab 200 mg (baseequiv)................................................................................. 10

KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr2.5-1000 mg...................................................................... 16

KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr5-500 mg............................................................................16

KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr5-1000 mg......................................................................... 16

Llabetalol hcl tab 100 mg (Trandate)................................23labetalol hcl tab 200 mg (Trandate)................................23labetalol hcl tab 300 mg (Trandate)................................23lactulose (encephalopathy) solution 10 gm/15ml......... 34lactulose solution 10 gm/15ml........................................ 31lamivudine oral soln 10 mg/ml (Epivir)............................ 6lamivudine tab 150 mg (Epivir)......................................... 6lamivudine tab 300 mg (Epivir)......................................... 6lamivudine tab 100 mg (hbv) (Epivir hbv)........................5lamivudine-zidovudine tab 150-300 mg (Combivir)........ 6lamotrigine tab chewable dispersible 5 mg (Lamictalchewable di)..................................................................... 48

lamotrigine tab chewable dispersible 25 mg (Lamictalchewable di)..................................................................... 48

lamotrigine tab 25 mg (Lamictal)....................................48lamotrigine tab 100 mg (Lamictal)..................................48lamotrigine tab 150 mg (Lamictal)..................................48lamotrigine tab 200 mg (Lamictal)..................................48

lansoprazole cap delayed release 15 mg(Prevacid)..........................................................................32

lansoprazole cap delayed release 30 mg(Prevacid)..........................................................................32

LANTUS – insulin glargine inj 100 unit/ml......................... 18LANTUS SOLOSTAR – insulin glargine soln pen-injector100 unit/ml......................................................................... 18

latanoprost ophth soln 0.005% (Xalatan).......................52leflunomide tab 10 mg (Arava)........................................46leflunomide tab 20 mg (Arava)........................................46LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 mg (14 mg daily dose)................................. 10

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

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

LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapypack 10 mg (10 mg daily dose)........................................10

LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapypack 10 (2) mg (20 mg daily dose).................................. 10

LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapypack 4 (2) mg (8 mg daily dose)...................................... 10

LETAIRIS – ambrisentan tab 5 mg.................................... 28LETAIRIS – ambrisentan tab 10 mg.................................. 28letrozole tab 2.5 mg (Femara)......................................... 10LEUCOVORIN CALCIUM – leucovorin calcium tab 10mg...................................................................................... 10

LEUCOVORIN CALCIUM – leucovorin calcium tab 15mg...................................................................................... 10

leucovorin calcium tab 5 mg...........................................10leucovorin calcium tab 25 mg.........................................10LEUKERAN – chlorambucil tab 2 mg................................ 10levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (baseequiv).................................................................................30

levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)(Xopenex)..........................................................................30



LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector100 unit/ml......................................................................... 18

LEVEMIR – insulin detemir inj 100 unit/ml.........................18levetiracetam oral soln 100 mg/ml (Keppra)..................48levetiracetam tab er 24hr 500 mg (Keppra xr)...............48levetiracetam tab er 24hr 750 mg (Keppra xr)...............48levetiracetam tab 250 mg (Keppra).................................48levetiracetam tab 500 mg (Keppra).................................48levetiracetam tab 750 mg (Keppra).................................48levetiracetam tab 1000 mg (Keppra)...............................48levobunolol hcl ophth soln 0.5% (Betagan).................. 52levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 19levocarnitine tab 330 mg (Carnitor)................................19levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) (Xyzal).........................................................................29

levocetirizine dihydrochloride tab 5 mg (Xyzal)............29

2018


LEVOFLOXACIN – levofloxacin oral soln 25 mg/ml............ 4levofloxacin tab 250 mg (Levaquin)................................. 4levofloxacin tab 500 mg (Levaquin)................................. 4levofloxacin tab 750 mg (Levaquin)................................. 4levonorgestrel & ethinyl estradiol (91-day) tab0.15-0.03 mg.....................................................................15

levonorgestrel & ethinyl estradiol tab 0.1 mg-20mcg....................................................................................15

levonorgestrel & ethinyl estradiol tab 0.15 mg-30mcg....................................................................................15

levonorgestrel-eth estra tab0.05-30/0.075-40/0.125-30mg-mcg................................. 15

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab0.01mg(7) (Loseasonique)..............................................14

levonorg-eth est tab 0.15-0.03mg(84) & eth est tab0.01mg(7) (Seasonique)..................................................14

levothyroxine sodium tab 25 mcg (Synthroid)..............18levothyroxine sodium tab 50 mcg (Synthroid)..............18levothyroxine sodium tab 75 mcg (Synthroid)..............18levothyroxine sodium tab 88 mcg (Synthroid)..............18levothyroxine sodium tab 100 mcg (Synthroid)............18levothyroxine sodium tab 112 mcg (Synthroid)............ 18levothyroxine sodium tab 125 mcg (Synthroid)............18levothyroxine sodium tab 137 mcg (Synthroid)............18levothyroxine sodium tab 150 mcg (Synthroid)............18levothyroxine sodium tab 175 mcg (Synthroid)............18levothyroxine sodium tab 200 mcg (Synthroid)............18levothyroxine sodium tab 300 mcg (Synthroid)............18lidocaine hcl gel 2%......................................................... 56lidocaine hcl local inj 1% (Xylocaine)............................ 47lidocaine hcl local preservative free (pf) inj 1%(Xylocaine-mpf)................................................................47

lidocaine hcl soln 4% (Xylocaine)...................................56lidocaine hcl viscous soln 2%........................................ 53lidocaine patch 5% (Lidoderm)....................................... 56lidocaine-prilocaine cream 2.5-2.5% (Emla).................. 56linezolid for susp 100 mg/5ml (Zyvox)............................. 8linezolid tab 600 mg (Zyvox)............................................. 8liothyronine sodium tab 5 mcg (Cytomel)..................... 18liothyronine sodium tab 25 mcg (Cytomel)................... 18liothyronine sodium tab 50 mcg (Cytomel)................... 18lisinopril & hydrochlorothiazide tab 10-12.5 mg(Zestoretic)....................................................................... 20

lisinopril & hydrochlorothiazide tab 20-12.5 mg(Zestoretic)....................................................................... 20

lisinopril & hydrochlorothiazide tab 20-25 mg(Zestoretic)....................................................................... 20

lisinopril tab 5 mg (Prinivil)............................................. 20lisinopril tab 10 mg (Prinivil)........................................... 20lisinopril tab 20 mg (Prinivil)........................................... 20lisinopril tab 2.5 mg (Zestril)........................................... 20lisinopril tab 30 mg (Zestril)............................................ 21lisinopril tab 40 mg (Zestril)............................................ 21lithium carbonate cap 300 mg.........................................38lithium carbonate cap 150 mg (Lithium carbonate)......38lithium carbonate cap 600 mg (Lithium carbonate)......38

lithium carbonate tab er 450 mg.....................................38lithium carbonate tab er 300 mg (Lithobid)................... 38lithium carbonate tab 300 mg......................................... 38LONSURF – trifluridine-tipiracil tab 15-6.14 mg.................10LONSURF – trifluridine-tipiracil tab 20-8.19 mg.................10loperamide hcl cap 2 mg................................................. 32lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)(Kaletra)...............................................................................6

lorazepam conc 2 mg/ml (Lorazepam intensol)............ 35lorazepam tab 0.5 mg (Ativan)........................................ 35lorazepam tab 1 mg (Ativan)........................................... 35lorazepam tab 2 mg (Ativan)........................................... 35losartan potassium & hydrochlorothiazide tab 50-12.5mg (Hyzaar)...................................................................... 22

losartan potassium & hydrochlorothiazide tab 100-12.5mg (Hyzaar)...................................................................... 22

losartan potassium & hydrochlorothiazide tab 100-25mg (Hyzaar)...................................................................... 22

losartan potassium tab 25 mg (Cozaar).........................22losartan potassium tab 50 mg (Cozaar).........................22losartan potassium tab 100 mg (Cozaar).......................22lovastatin tab 10 mg.........................................................25lovastatin tab 20 mg (Mevacor).......................................25lovastatin tab 40 mg (Mevacor).......................................25loxapine succinate cap 10 mg........................................ 38loxapine succinate cap 25 mg........................................ 38loxapine succinate cap 50 mg........................................ 38loxapine succinate cap 5 mg (Loxitane)........................38LUPRON DEPOT-PED (1-MONTH – leuprolide acetate forinj pediatric kit 7.5 mg..................................................15,19

LUPRON DEPOT-PED (1-MONTH – leuprolide acetate forinj pediatric kit 11.25 mg..............................................15,19

LUPRON DEPOT-PED (1-MONTH – leuprolide acetate forinj pediatric kit 15 mg...................................................16,19

LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3month) for inj pediatric kit 11.25 mg................................. 16

LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3month) for inj pediatric kit 30 mg......................................16

LYNPARZA – olaparib cap 50 mg......................................11LYNPARZA – olaparib tab 100 mg.....................................11LYNPARZA – olaparib tab 150 mg.....................................11LYSODREN – mitotane tab 500 mg...................................11

Mmalathion lotion 0.5% (Ovide).........................................56MATULANE – procarbazine hcl cap 50 mg....................... 11MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg.......... 5meclizine hcl tab 12.5 mg................................................ 33meclizine hcl tab 25 mg................................................... 33medroxyprogesterone acetate im susp 150 mg/ml(Depo-provera contrac).................................................. 15

medroxyprogesterone acetate im susp prefilled syr150 mg/ml (Depo-provera contrac)............................... 15

medroxyprogesterone acetate tab 2.5 mg(Provera)........................................................................... 14

medroxyprogesterone acetate tab 5 mg (Provera).......14

2018


medroxyprogesterone acetate tab 10 mg (Provera).....14MEFLOQUINE HCL – mefloquine hcl tab 250 mg...............8megestrol acetate susp 40 mg/ml (Megace oral).......... 11megestrol acetate tab 20 mg...........................................11megestrol acetate tab 40 mg...........................................11MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg(base equivalent)...............................................................11

MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (baseequivalent)......................................................................... 11

meloxicam tab 7.5 mg (Mobic)........................................46meloxicam tab 15 mg (Mobic).........................................46melphalan tab 2 mg (Alkeran).........................................11memantine hcl oral solution 2 mg/ml (Namenda)......... 43memantine hcl tab 5 mg (28) & 10 mg (21) titration pak(Namenda titration pa)....................................................43

memantine hcl tab 5 mg (Namenda).............................. 43memantine hcl tab 10 mg (Namenda)............................ 43MEPHYTON – phytonadione tab 5 mg.............................. 50mercaptopurine tab 50 mg (Purinethol).........................11mesalamine enema 4 gm................................................. 34mesalamine tab delayed release 1.2 gm (Lialda)..........34metaxalone tab 800 mg (Skelaxin)..................................49metformin hcl tab er 24hr 500 mg (Glucophage xr)......16metformin hcl tab er 24hr 750 mg (Glucophage xr)......16metformin hcl tab 500 mg (Glucophage)....................... 16metformin hcl tab 850 mg (Glucophage)....................... 16metformin hcl tab 1000 mg (Glucophage)..................... 16methadone hcl conc 10 mg/ml (Methadose)................. 44methadone hcl soln 5 mg/5ml (Methadone hcl)............44methadone hcl soln 10 mg/5ml (Methadone hcl).......... 44methadone hcl tab for oral susp 40 mg.........................44methadone hcl tab 10 mg (Dolophine)...........................44methadone hcl tab 5 mg (Dolophine hcl).......................44methazolamide tab 25 mg (Neptazane)..........................26methazolamide tab 50 mg (Neptazane)..........................26METHERGINE – methylergonovine maleate tab 0.2mg...................................................................................... 19

methimazole tab 5 mg (Tapazole)................................... 18methimazole tab 10 mg (Tapazole)................................. 18methocarbamol tab 750 mg (Robaxin-750)....................50methocarbamol tab 500 mg (Robaxin)...........................50methotrexate sodium tab 2.5 mg (base equiv)..............11methscopolamine bromide tab 2.5 mg (Pamine).......... 32methscopolamine bromide tab 5 mg (Pamineforte).................................................................................. 32

methyldopa tab 250 mg................................................... 28methyldopa tab 500 mg................................................... 28methylphenidate hcl tab er 10 mg..................................41methylphenidate hcl tab er 20 mg..................................41methylphenidate hcl tab 5 mg (Ritalin).......................... 41methylphenidate hcl tab 10 mg (Ritalin)........................ 41methylphenidate hcl tab 20 mg (Ritalin)........................ 41methylprednisolone tab 4 mg (Medrol)..........................12methylprednisolone tab 8 mg (Medrol)..........................13methylprednisolone tab 16 mg (Medrol)........................13methylprednisolone tab 32 mg (Medrol)........................13

methylprednisolone tab therapy pack 4 mg (21)(Medrol dosepak).............................................................12

metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (baseequiv).................................................................................34

metoclopramide hcl tab 5 mg (base equivalent)(Reglan).............................................................................34

metoclopramide hcl tab 10 mg (base equivalent)(Reglan).............................................................................34

metolazone tab 10 mg......................................................26metolazone tab 2.5 mg (Zaroxolyn)................................26metolazone tab 5 mg (Zaroxolyn)...................................26metoprolol & hydrochlorothiazide tab 50-25 mg(Lopressor hct)................................................................ 23

metoprolol & hydrochlorothiazide tab 100-25 mg(Lopressor hct)................................................................ 23

metoprolol succinate tab er 24hr 25 mg (tartrate equiv)(Toprol xl)......................................................................... 23

metoprolol succinate tab er 24hr 50 mg (tartrate equiv)(Toprol xl)......................................................................... 23

metoprolol succinate tab er 24hr 100 mg (tartrateequiv) (Toprol xl)............................................................. 23

metoprolol succinate tab er 24hr 200 mg (tartrateequiv) (Toprol xl)............................................................. 23

metoprolol tartrate tab 25 mg......................................... 23metoprolol tartrate tab 50 mg (Lopressor).................... 23metoprolol tartrate tab 100 mg (Lopressor).................. 23metronidazole cream 0.75% (Metrocream).................... 53metronidazole gel 0.75%..................................................53metronidazole gel 1% (Metrogel).................................... 53metronidazole lotion 0.75% (Metrolotion)......................54metronidazole tab 250 mg (Flagyl)................................... 8metronidazole tab 500 mg (Flagyl)................................... 8metronidazole vaginal gel 0.75% (Metrogel-vaginal)..............................................................................34

mexiletine hcl cap 150 mg...............................................27mexiletine hcl cap 200 mg...............................................27mexiletine hcl cap 250 mg...............................................27MICROLET LANCETS – lancets........................................58MICROLET NEXT – lancet devices................................... 58midodrine hcl tab 2.5 mg.................................................28midodrine hcl tab 5 mg....................................................28midodrine hcl tab 10 mg..................................................28minocycline hcl cap 50 mg (Minocin).............................. 3minocycline hcl cap 75 mg (Minocin).............................. 4minocycline hcl cap 100 mg (Minocin)............................ 4minocycline hcl tab 50 mg................................................ 4minocycline hcl tab 75 mg................................................ 4minocycline hcl tab 100 mg.............................................. 4minoxidil tab 2.5 mg.........................................................28minoxidil tab 10 mg..........................................................28mirtazapine tab 7.5 mg.....................................................36mirtazapine tab 15 mg (Remeron).................................. 36mirtazapine tab 30 mg (Remeron).................................. 36mirtazapine tab 45 mg (Remeron).................................. 36misoprostol tab 100 mcg (Cytotec)................................ 32misoprostol tab 200 mcg (Cytotec)................................ 32

2018


modafinil tab 100 mg (Provigil).......................................41modafinil tab 200 mg (Provigil).......................................41moexipril hcl tab 7.5 mg (Univasc).................................21moexipril hcl tab 15 mg (Univasc)..................................21moexipril-hydrochlorothiazide tab 7.5-12.5 mg.............21moexipril-hydrochlorothiazide tab 15-25 mg.................21moexipril-hydrochlorothiazide tab 15-12.5 mg(Uniretic)........................................................................... 21

mometasone furoate cream 0.1% (Elocon)................... 55mometasone furoate nasal susp 50 mcg/act(Nasonex)..........................................................................29

mometasone furoate oint 0.1% (Elocon)........................55mometasone furoate solution 0.1% (lotion)(Elocon).............................................................................55

montelukast sodium chew tab 4 mg (base equiv)(Singulair)......................................................................... 30

montelukast sodium chew tab 5 mg (base equiv)(Singulair)......................................................................... 31

montelukast sodium oral granules packet 4 mg (baseequiv) (Singulair)............................................................. 31

montelukast sodium tab 10 mg (base equiv)(Singulair)......................................................................... 31

MORPHINE SULFATE – morphine sulfate tab 15 mg....... 44MORPHINE SULFATE – morphine sulfate tab 30 mg....... 44morphine sulfate oral soln 10 mg/5ml........................... 44morphine sulfate oral soln 20 mg/5ml........................... 44morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...... 44morphine sulfate tab er 15 mg (Ms contin)................... 44morphine sulfate tab er 30 mg (Ms contin)................... 44morphine sulfate tab er 60 mg (Ms contin)................... 44morphine sulfate tab er 100 mg (Ms contin)................. 44morphine sulfate tab er 200 mg (Ms contin)................. 44moxifloxacin hcl ophth soln 0.5% (base equiv)(Vigamox)..........................................................................51

mupirocin calcium cream 2% (Bactroban).................... 54mupirocin oint 2% (Bactroban).......................................54mycophenolate mofetil cap 250 mg (Cellcept)..............59mycophenolate mofetil for oral susp 200 mg/ml(Cellcept)...........................................................................59

mycophenolate mofetil tab 500 mg (Cellcept)...............59mycophenolate sodium tab dr 180 mg (mycophenolicacid equiv) (Myfortic)......................................................59

mycophenolate sodium tab dr 360 mg (mycophenolicacid equiv) (Myfortic)......................................................59

MYLERAN – busulfan tab 2 mg.........................................11

Nnabumetone tab 500 mg.................................................. 46nabumetone tab 750 mg.................................................. 46nadolol tab 20 mg (Corgard)........................................... 23nadolol tab 40 mg (Corgard)........................................... 23nadolol tab 80 mg (Corgard)........................................... 23naloxone hcl inj 0.4 mg/ml.............................................. 59naloxone hcl inj 4 mg/10ml............................................. 59NALOXONE HCL – naloxone hcl soln cartridge 0.4 mg/ml........................................................................................59

NALOXONE HCL – naloxone hcl soln prefilled syringe 2mg/2ml............................................................................... 59

naltrexone hcl tab 50 mg (Revia)....................................59naproxen sodium tab 275 mg (Anaprox)....................... 46naproxen sodium tab 550 mg (Anaprox ds)..................46naproxen susp 125 mg/5ml (Naprosyn).........................46naproxen tab ec 375 mg (Ec-naprosyn).........................46naproxen tab ec 500 mg (Ec-naprosyn).........................46naproxen tab 250 mg (Naprosyn)................................... 46naproxen tab 375 mg (Naprosyn)................................... 46naproxen tab 500 mg (Naprosyn)................................... 46naratriptan hcl tab 1 mg (base equiv) (Amerge)........... 46naratriptan hcl tab 2.5 mg (base equiv) (Amerge)........ 46NARCAN – naloxone hcl nasal spray 4 mg/0.1ml............. 59NATACYN – natamycin ophth susp 5%............................. 51nateglinide tab 60 mg (Starlix)........................................17nateglinide tab 120 mg (Starlix)......................................17neomycin-bacitrac zn-polymyx5(3.5)mg-400unt-10000unt op oin..................................52

neomycin-polymy-gramicid op sol1.75-10000-0.025mg-unt-mg/ml (Neosporin)................52

neomycin-polymyxin-dexamethasone ophth oint 0.1%(Maxitrol)...........................................................................52

neomycin-polymyxin-dexamethasone ophth susp0.1% (Maxitrol)................................................................. 52

neomycin-polymyxin-hc otic soln 1% (Cortisporin)..... 53neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000unit/ml-1%.........................................................................53

neomycin sulfate tab 500 mg............................................4nevirapine tab er 24hr 100 mg (Viramune xr)..................6nevirapine tab er 24hr 400 mg (Viramune xr)..................6nevirapine tab 200 mg (Viramune)....................................6NEXAVAR – sorafenib tosylate tab 200 mg (baseequivalent)......................................................................... 11

NEXIUM – esomeprazole magnesium for delayed releasesusp packet 5 mg..............................................................32

NEXIUM – esomeprazole magnesium for delayed releasesusp packet 10 mg............................................................32



NEXIUM – esomeprazole magnesium for delayed releasesusp pack 2.5 mg..............................................................32

niacin tab er 500 mg (antihyperlipidemic)(Niaspan)...........................................................................25



NICOTROL INHALER – nicotine inhaler system 10 mg (4mg delivered).....................................................................43

NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray)................................................................................. 43

nifedipine tab er 24hr 30 mg (Adalat cc)........................24nifedipine tab er 24hr 60 mg (Adalat cc)........................24

2018


nifedipine tab er 24hr 90 mg (Adalat cc)........................24nifedipine tab er 24hr osmotic release 30 mg(Procardia xl)....................................................................24

nifedipine tab er 24hr osmotic release 60 mg(Procardia xl)....................................................................24

nifedipine tab er 24hr osmotic release 90 mg(Procardia xl)....................................................................24

nilutamide tab 150 mg (Nilandron)................................. 11nimodipine cap 30 mg......................................................24NINLARO – ixazomib citrate cap 2.3 mg (baseequivalent)......................................................................... 11

NINLARO – ixazomib citrate cap 3 mg (baseequivalent)......................................................................... 11

NINLARO – ixazomib citrate cap 4 mg (baseequivalent)......................................................................... 11

nitrofurantoin macrocrystalline cap 25 mg(Macrodantin)................................................................... 34



nitrofurantoin monohydrate macrocrystalline cap 100mg (Macrobid)..................................................................34

nitrofurantoin susp 25 mg/5ml (Furadantin)..................34nitroglycerin sl tab 0.3 mg (Nitrostat)............................ 25nitroglycerin sl tab 0.4 mg (Nitrostat)............................ 25nitroglycerin sl tab 0.6 mg (Nitrostat)............................ 25nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)..........25nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)..........25nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)..........25nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)..........25NITYR – nitisinone tab 2 mg..............................................19NITYR – nitisinone tab 5 mg..............................................19NITYR – nitisinone tab 10 mg............................................19NIZATIDINE – nizatidine oral soln 15 mg/ml......................32norethindrone & ethinyl estradiol-fe chew tab 0.4mg-35 mcg (Femcon fe)................................................. 15

norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg(Brevicon-28)....................................................................15

norethindrone & ethinyl estradiol tab 1 mg-35 mcg(Norinyl 1+35)...................................................................15

norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg(Ovcon-35)........................................................................ 15

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20mcg (Loestrin fe 1/20).....................................................15

norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30mcg (Loestrin fe 1.5/30)..................................................15

norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg(Loestrin 1/20-21).............................................................15

norethindrone ace & ethinyl estradiol tab 1.5 mg-30mcg (Loestrin 1.5/30-21).................................................15

norethindrone acetate-ethinyl estradiol tab 1 mg-5mcg....................................................................................14

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5mcg (Femhrt low dose).................................................. 14

norethindrone acetate tab 5 mg (Aygestin)...................14

norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35mg-mcg (Estrostep fe)....................................................15

norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg (Ortho-novum 7/7/7)............................................... 15

norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg (Tri-norinyl 28).........................................................15

norethindrone tab 0.35 mg (Nor-qd)...............................15norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg(Ortho-cyclen).................................................................. 15

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35mg-mcg (Ortho tri-cyclen)..............................................15

norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25mg-mcg (Ortho tri-cyclen lo)......................................... 15

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg.........15nortriptyline hcl cap 10 mg (Pamelor)............................36nortriptyline hcl cap 25 mg (Pamelor)............................36nortriptyline hcl cap 50 mg (Pamelor)............................37nortriptyline hcl cap 75 mg (Pamelor)............................37NORVIR – ritonavir oral soln 80 mg/ml................................6NORVIR – ritonavir tab 100 mg........................................... 6NOVOLIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30).......................................................17

NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml........................................................................................17

NOVOLIN R – insulin regular (human) inj 100 unit/ml....... 17NOVOLOG FLEXPEN – insulin aspart soln pen-injector100 unit/ml......................................................................... 17

NOVOLOG – insulin aspart inj 100 unit/ml........................ 17NOVOLOG MIX 70/30 – insulin aspart prot & aspart(human) inj 100 unit/ml (70-30)........................................ 18

NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &aspart sus pen-inj 100 unit/ml (70-30)..............................18

NOVOLOG PENFILL – insulin aspart soln cartridge 100unit/ml.................................................................................17

NOXAFIL – posaconazole susp 40 mg/ml...........................5NUVARING – etonogestrel-ethinyl estradiol va ring0.120-0.015 mg/24hr.........................................................15

nystatin cream 100000 unit/gm.......................................54nystatin oint 100000 unit/gm........................................... 54nystatin susp 100000 unit/ml.......................................... 53nystatin tab 500000 unit.....................................................5nystatin topical powder 100000 unit/gm........................54nystatin-triamcinolone cream 100000-0.1 unit/gm-%........................................................................................ 55

nystatin-triamcinolone oint 100000-0.1 unit/gm-%....... 55O

octreotide acetate inj 50 mcg/ml (0.05 mg/ml)(Sandostatin)....................................................................19




2018


octreotide acetate inj 1000 mcg/ml (1 mg/ml)(Sandostatin)....................................................................19

ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab200-25-25 mg...................................................................... 6

ODOMZO – sonidegib phosphate cap 200 mg (baseequivalent)......................................................................... 11

ofloxacin ophth soln 0.3% (Ocuflox)..............................52ofloxacin otic soln 0.3%...................................................53ofloxacin tab 400 mg..........................................................4olanzapine orally disintegrating tab 5 mg (Zyprexazydis)................................................................................. 38

olanzapine orally disintegrating tab 10 mg (Zyprexazydis)................................................................................. 38



olanzapine tab 2.5 mg (Zyprexa).....................................38olanzapine tab 5 mg (Zyprexa)........................................38olanzapine tab 7.5 mg (Zyprexa).....................................38olanzapine tab 10 mg (Zyprexa)......................................38olanzapine tab 15 mg (Zyprexa)......................................38olanzapine tab 20 mg (Zyprexa)......................................38olmesartan medoxomil-hydrochlorothiazide tab20-12.5 mg (Benicar hct)................................................ 22

olmesartan medoxomil-hydrochlorothiazide tab40-12.5 mg (Benicar hct)................................................ 22

olmesartan medoxomil-hydrochlorothiazide tab 40-25mg (Benicar hct)..............................................................22

olmesartan medoxomil tab 5 mg (Benicar)................... 22olmesartan medoxomil tab 20 mg (Benicar)................. 22olmesartan medoxomil tab 40 mg (Benicar)................. 22olopatadine hcl ophth soln 0.2% (base equivalent)(Pataday)...........................................................................52

olopatadine hcl ophth soln 0.1% (base equivalent)(Patanol)............................................................................52

omeprazole cap delayed release 10 mg (Prilosec)....... 32omeprazole cap delayed release 20 mg (Prilosec)....... 32omeprazole cap delayed release 40 mg (Prilosec)....... 32OMNITROPE – somatropin for inj 5.8 mg......................... 18OMNITROPE – somatropin inj 5 mg/1.5ml........................18OMNITROPE – somatropin inj 10 mg/1.5ml......................18ondansetron hcl inj 4 mg/2ml (2 mg/ml)........................ 33ondansetron hcl inj 40 mg/20ml (2 mg/ml) (Zofran)......33ondansetron hcl oral soln 4 mg/5ml (Zofran)................33ondansetron hcl tab 24 mg............................................. 33ondansetron hcl tab 4 mg (Zofran).................................33ondansetron hcl tab 8 mg (Zofran).................................33ondansetron orally disintegrating tab 4 mg (Zofranodt).....................................................................................33

ondansetron orally disintegrating tab 8 mg (Zofranodt).....................................................................................33

ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv).........17ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)............17OPSUMIT – macitentan tab 10 mg....................................28ORFADIN – nitisinone cap 2 mg........................................19

ORFADIN – nitisinone cap 5 mg........................................19ORFADIN – nitisinone cap 10 mg......................................19ORFADIN – nitisinone cap 20 mg......................................19ORFADIN – nitisinone susp 4 mg/ml................................. 19orphenadrine citrate tab er 12hr 100 mg....................... 50oseltamivir phosphate cap 30 mg (base equiv)(Tamiflu).............................................................................. 7

oseltamivir phosphate cap 45 mg (base equiv)(Tamiflu).............................................................................. 7

oseltamivir phosphate cap 75 mg (base equiv)(Tamiflu).............................................................................. 7

oseltamivir phosphate for susp 6 mg/ml (base equiv)(Tamiflu).............................................................................. 7

oxaprozin tab 600 mg (Daypro).......................................46oxcarbazepine susp 300 mg/5ml (60 mg/ml)(Trileptal)...........................................................................48

oxcarbazepine tab 150 mg (Trileptal)............................. 48oxcarbazepine tab 300 mg (Trileptal)............................. 48oxcarbazepine tab 600 mg (Trileptal)............................. 48oxybutynin chloride syrup 5 mg/5ml..............................34oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)......34oxybutynin chloride tab er 24hr 10 mg (Ditropanxl)....................................................................................... 34

oxybutynin chloride tab er 24hr 15 mg (Ditropanxl)....................................................................................... 34

oxybutynin chloride tab 5 mg......................................... 34oxycodone-aspirin tab 4.8355-325 mg (Percodan)....... 45oxycodone hcl cap 5 mg................................................. 44oxycodone hcl conc 100 mg/5ml (20 mg/ml)(Oxycodone hcl).............................................................. 44

oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)............44oxycodone hcl tab 10 mg................................................ 44oxycodone hcl tab 20 mg................................................ 44oxycodone hcl tab 5 mg (Roxicodone).......................... 44oxycodone hcl tab 15 mg (Roxicodone)........................ 44oxycodone hcl tab 30 mg (Roxicodone)........................ 44oxycodone w/ acetaminophen tab 5-325 mg(Percocet)......................................................................... 45

oxycodone w/ acetaminophen tab 7.5-325 mg(Percocet)......................................................................... 45

oxycodone w/ acetaminophen tab 10-325 mg(Percocet)......................................................................... 45

OXYCONTIN – oxycodone hcl tab er 12hr deter 10mg...................................................................................... 45







2018


OZEMPIC – semaglutide soln pen-inj 1 mg/dose (2mg/1.5ml)........................................................................... 17

OZEMPIC – semaglutide soln pen-inj 0.25 or 0.5 mg/dose(2 mg/1.5ml)...................................................................... 17

Ppantoprazole sodium ec tab 20 mg (base equiv)(Protonix).......................................................................... 32

pantoprazole sodium ec tab 40 mg (base equiv)(Protonix).......................................................................... 32

paricalcitol cap 1 mcg (Zemplar).................................... 19paricalcitol cap 2 mcg (Zemplar).................................... 19paricalcitol cap 4 mcg (Zemplar).................................... 19paromomycin sulfate cap 250 mg.................................... 4paroxetine hcl tab er 24hr 12.5 mg (Paxil cr)................ 37paroxetine hcl tab er 24hr 25 mg (Paxil cr)................... 37paroxetine hcl tab er 24hr 37.5 mg (Paxil cr)................ 37paroxetine hcl tab 10 mg (Paxil).....................................37paroxetine hcl tab 20 mg (Paxil).....................................37paroxetine hcl tab 30 mg (Paxil).....................................37paroxetine hcl tab 40 mg (Paxil).....................................37PEGASYS – peginterferon alfa-2a inj 180 mcg/ml.............. 5PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml......... 5PEGASYS PROCLICK – peginterferon alfa-2a inj 135mcg/0.5ml.............................................................................5

PEGASYS PROCLICK – peginterferon alfa-2a inj 180mcg/0.5ml.............................................................................5

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm(Colyte-flavor packs).......................................................31

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm(Golytely)...........................................................................31

peg 3350-kcl-sod bicarb-nacl for soln 420 gm(Nulytely/flavor pack)......................................................31

PENICILLIN V POTASSIUM – penicillin v potassium forsoln 125 mg/5ml..................................................................2

PENICILLIN V POTASSIUM – penicillin v potassium forsoln 250 mg/5ml..................................................................2

penicillin v potassium tab 250 mg....................................2penicillin v potassium tab 500 mg....................................2pentoxifylline tab er 400 mg............................................51perindopril erbumine tab 2 mg....................................... 21perindopril erbumine tab 4 mg (Aceon).........................21perindopril erbumine tab 8 mg (Aceon).........................21permethrin cream 5% (Elimite)........................................56perphenazine tab 2 mg.................................................... 38perphenazine tab 4 mg.................................................... 38perphenazine tab 8 mg.................................................... 38perphenazine tab 16 mg.................................................. 38phenelzine sulfate tab 15 mg (Nardil)............................ 37phenobarbital elixir 20 mg/5ml........................................39PHENOBARBITAL – phenobarbital tab 15 mg.................. 39PHENOBARBITAL – phenobarbital tab 30 mg.................. 39PHENOBARBITAL – phenobarbital tab 60 mg.................. 39PHENOBARBITAL – phenobarbital tab 100 mg................ 39phenobarbital tab 16.2 mg...............................................39phenobarbital tab 32.4 mg...............................................39

phenoxybenzamine hcl cap 10 mg (Dibenzyline)......... 28phenytoin chew tab 50 mg (Dilantin infatabs)...............48phenytoin sodium extended cap 100 mg (Dilantin)...... 48phenytoin sodium extended cap 200 mg(Phenytek).........................................................................48

phenytoin sodium extended cap 300 mg(Phenytek).........................................................................48

phenytoin susp 125 mg/5ml (Dilantin)........................... 48pilocarpine hcl ophth soln 1% (Isopto carpine)............ 52pilocarpine hcl ophth soln 2% (Isopto carpine)............ 52pilocarpine hcl ophth soln 4% (Isopto carpine)............ 52pilocarpine hcl tab 5 mg (Salagen).................................53pilocarpine hcl tab 7.5 mg (Salagen)..............................53pimozide tab 1 mg (Orap)................................................ 43pimozide tab 2 mg (Orap)................................................ 43pindolol tab 5 mg..............................................................23pindolol tab 10 mg............................................................23pioglitazone hcl-metformin hcl tab 15-500 mg(Actoplus met)................................................................. 17

pioglitazone hcl-metformin hcl tab 15-850 mg(Actoplus met)................................................................. 17

pioglitazone hcl tab 15 mg (base equiv) (Actos)...........17pioglitazone hcl tab 30 mg (base equiv) (Actos)...........17pioglitazone hcl tab 45 mg (base equiv) (Actos)...........17piroxicam cap 10 mg (Feldene).......................................46piroxicam cap 20 mg (Feldene).......................................46PLEGRIDY – peginterferon beta-1a soln pen-injector 125mcg/0.5ml...........................................................................42

PLEGRIDY – peginterferon beta-1a soln prefilled syringe125 mcg/0.5ml...................................................................42

PLEGRIDY STARTER PACK – peginterferon beta-1a solnpen-inj 63 & 94 mcg/0.5ml pack.......................................42

PLEGRIDY STARTER PACK – peginterferon beta-1a solnpref syr 63 & 94 mcg/0.5ml pack..................................... 42

podofilox soln 0.5% (Condylox)......................................56polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% (Polytrim)...........................................................52

POMALYST – pomalidomide cap 1 mg............................. 11POMALYST – pomalidomide cap 2 mg............................. 11POMALYST – pomalidomide cap 3 mg............................. 11POMALYST – pomalidomide cap 4 mg............................. 11potassium chloride cap er 8 meq (Micro-k)...................50potassium chloride cap er 10 meq (Micro-k).................50potassium chloride microencapsulated crys er tab 10meq....................................................................................50

potassium chloride microencapsulated crys er tab 20meq....................................................................................50

potassium chloride oral soln 10% (20 meq/15ml).........50potassium chloride powder packet 20 meq.................. 50potassium chloride tab er 10 meq (K-tab)..................... 50potassium chloride tab er 8 meq (600 mg)....................50potassium citrate tab er 5 meq (540 mg) (Urocit-k5)........................................................................................ 35

potassium citrate tab er 10 meq (1080 mg) (Urocit-k10)...................................................................................... 35

2018


potassium citrate tab er 15 meq (1620 mg) (Urocit-k15)...................................................................................... 35

pot phos monobasic w/sod phos di & monobas tab155-852-130mg (K-phos neutral)................................... 50

pramipexole dihydrochloride tab 0.125 mg(Mirapex)........................................................................... 49

pramipexole dihydrochloride tab 0.25 mg(Mirapex)........................................................................... 49

pramipexole dihydrochloride tab 0.5 mg (Mirapex)......49pramipexole dihydrochloride tab 0.75 mg(Mirapex)........................................................................... 49

pramipexole dihydrochloride tab 1 mg (Mirapex).........49pramipexole dihydrochloride tab 1.5 mg (Mirapex)......49prasugrel hcl tab 5 mg (base equiv) (Effient)................51prasugrel hcl tab 10 mg (base equiv) (Effient)..............51pravastatin sodium tab 10 mg........................................ 25pravastatin sodium tab 20 mg (Pravachol)....................25pravastatin sodium tab 40 mg (Pravachol)....................25pravastatin sodium tab 80 mg (Pravachol)....................25praziquantel tab 600 mg (Biltricide)................................. 8prazosin hcl cap 1 mg (Minipress)................................. 28prazosin hcl cap 2 mg (Minipress)................................. 28prazosin hcl cap 5 mg (Minipress)................................. 28PREDNICARBATE – prednicarbate cream 0.1%...............55PREDNICARBATE – prednicarbate oint 0.1%...................55prednisolone acetate ophth susp 1% (Pred forte)........ 52prednisolone sod phosphate oral soln 15 mg/5ml(base equiv)......................................................................13

prednisolone sod phosph oral soln 6.7 mg/5ml (5mg/5ml base) (Pediapred).............................................. 13

prednisolone syrup 15 mg/5ml (usp solutionequivalent) (Prelone).......................................................13

PREDNISONE – prednisone oral soln 5 mg/5ml...............13prednisone tab 1 mg........................................................ 13prednisone tab 2.5 mg..................................................... 13prednisone tab 5 mg........................................................ 13prednisone tab 10 mg...................................................... 13prednisone tab 20 mg...................................................... 13PREGNYL W/DILUENT BENZYL – chorionic gonadotropinfor im inj 10000 unit.......................................................... 16

PREMARIN – estrogens, conjugated tab 0.3 mg...............14PREMARIN – estrogens, conjugated tab 0.45 mg.............14PREMARIN – estrogens, conjugated tab 0.625 mg...........14PREMARIN – estrogens, conjugated tab 0.9 mg...............14PREMARIN – estrogens, conjugated tab 1.25 mg.............14PREMPHASE – conj est 0.625(14)/conj est-medroxyproac tab 0.625-5mg(14)........................................................14

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.3-1.5 mg......................................................14

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.45-1.5 mg....................................................14

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.625-2.5 mg..................................................14

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.625-5 mg.....................................................14

PREZCOBIX – darunavir-cobicistat tab 800-150 mg...........6

PREZISTA – darunavir ethanolate susp 100 mg/ml (baseequiv)....................................................................................6

PREZISTA – darunavir ethanolate tab 75 mg (baseequiv)....................................................................................6




PRIFTIN – rifapentine tab 150 mg....................................... 4PRIMAQUINE PHOSPHATE – primaquine phosphate tab26.3 mg (15 mg base)........................................................ 8

primidone tab 50 mg (Mysoline)..................................... 48primidone tab 250 mg (Mysoline)................................... 48PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act(90mcg base equiv).......................................................... 31

PROAIR RESPICLICK – albuterol sulfate aer pow ba 108mcg/act (90 mcg base equiv)........................................... 31

probenecid tab 500 mg.................................................... 47prochlorperazine maleate tab 5 mg (base equivalent)(Compazine)..................................................................... 38

prochlorperazine maleate tab 10 mg (base equivalent)(Compazine)..................................................................... 38

prochlorperazine suppos 25 mg.....................................38progesterone micronized cap 100 mg(Prometrium).................................................................... 14

progesterone micronized cap 200 mg(Prometrium).................................................................... 14

promethazine hcl suppos 12.5 mg................................. 29promethazine hcl suppos 25 mg.................................... 29promethazine hcl suppos 50 mg.................................... 29promethazine hcl syrup 6.25 mg/5ml............................. 29promethazine hcl tab 12.5 mg.........................................29promethazine hcl tab 25 mg............................................29promethazine hcl tab 50 mg............................................29propafenone hcl cap er 12hr 225 mg (Rythmol sr)....... 27propafenone hcl cap er 12hr 325 mg (Rythmol sr)....... 27propafenone hcl cap er 12hr 425 mg (Rythmol sr)....... 27propafenone hcl tab 300 mg........................................... 27propafenone hcl tab 150 mg (Rythmol)......................... 27propafenone hcl tab 225 mg (Rythmol)......................... 27propranolol hcl cap er 24hr 60 mg (Inderal la)..............23propranolol hcl cap er 24hr 80 mg (Inderal la)..............23propranolol hcl cap er 24hr 120 mg (Inderal la)............23propranolol hcl cap er 24hr 160 mg (Inderal la)............23propranolol hcl tab 10 mg............................................... 23propranolol hcl tab 20 mg............................................... 23propranolol hcl tab 40 mg............................................... 23propranolol hcl tab 60 mg............................................... 23propranolol hcl tab 80 mg............................................... 23propylthiouracil tab 50 mg.............................................. 18PULMOZYME – dornase alfa inhal soln 1 mg/ml.............. 31PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml)...................................................................................... 11

pyrazinamide tab 500 mg...................................................4

2018


pyridostigmine bromide tab 60 mg (Mestinon)............. 50Q

quetiapine fumarate tab er 24hr 50 mg (Seroquelxr).......................................................................................38





quetiapine fumarate tab 25 mg (Seroquel).................... 38quetiapine fumarate tab 50 mg (Seroquel).................... 38quetiapine fumarate tab 100 mg (Seroquel).................. 38quetiapine fumarate tab 200 mg (Seroquel).................. 38quetiapine fumarate tab 300 mg (Seroquel).................. 38quetiapine fumarate tab 400 mg (Seroquel).................. 38quinapril hcl tab 5 mg (Accupril).................................... 21quinapril hcl tab 10 mg (Accupril).................................. 21quinapril hcl tab 20 mg (Accupril).................................. 21quinapril hcl tab 40 mg (Accupril).................................. 21quinapril-hydrochlorothiazide tab 10-12.5 mg(Accuretic)........................................................................ 21

quinapril-hydrochlorothiazide tab 20-12.5 mg(Accuretic)........................................................................ 21

quinapril-hydrochlorothiazide tab 20-25 mg(Accuretic)........................................................................ 21

quinidine gluconate tab er 324 mg.................................27QVAR – beclomethasone diprop inhal aero soln 40 mcg/act (50/valve).....................................................................31

QVAR – beclomethasone diprop inhal aero soln 80 mcg/act (100/valve)...................................................................31

QVAR REDIHALER – beclomethasone diprop hfa breathact inh aer 40 mcg/act...................................................... 31

QVAR REDIHALER – beclomethasone diprop hfa breathact inh aer 80 mcg/act...................................................... 31

Rraloxifene hcl tab 60 mg (Evista)....................................19ramipril cap 1.25 mg (Altace).......................................... 21ramipril cap 2.5 mg (Altace)............................................ 21ramipril cap 5 mg (Altace)............................................... 21ramipril cap 10 mg (Altace)............................................. 21ranitidine hcl cap 150 mg................................................ 32ranitidine hcl cap 300 mg................................................ 32ranitidine hcl syrup 15 mg/ml (75 mg/5ml).................... 32ranitidine hcl tab 150 mg (Zantac)..................................32ranitidine hcl tab 300 mg (Zantac)..................................32RAPAMUNE – sirolimus oral soln 1 mg/ml........................ 59rasagiline mesylate tab 0.5 mg (base equiv)(Azilect)............................................................................. 49

rasagiline mesylate tab 1 mg (base equiv) (Azilect)..... 49REBIF – interferon beta-1a soln pref syr 22 mcg/0.5ml(12mu/ml)...........................................................................42

REBIF – interferon beta-1a soln pref syr 44 mcg/0.5ml(24mu/ml)...........................................................................42

REBIF REBIDOSE – interferon beta-1a soln auto-inj 22mcg/0.5ml (12mu/ml).........................................................42

REBIF REBIDOSE – interferon beta-1a soln auto-inj 44mcg/0.5ml (24mu/ml).........................................................42

REBIF REBIDOSE TITRATION – interferon beta-1a auto-inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................ 42

REBIF TITRATION PACK – interferon beta-1a pref syr6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml................................. 42

repaglinide tab 0.5 mg (Prandin).................................... 17repaglinide tab 1 mg (Prandin)....................................... 17repaglinide tab 2 mg (Prandin)....................................... 17REVLIMID – lenalidomide cap 5 mg..................................59REVLIMID – lenalidomide cap 10 mg................................59REVLIMID – lenalidomide cap 15 mg................................59REVLIMID – lenalidomide cap 20 mg................................59REVLIMID – lenalidomide cap 25 mg................................59REVLIMID – lenalidomide caps 2.5 mg............................. 59REYATAZ – atazanavir sulfate cap 150 mg (baseequiv)....................................................................................7

REYATAZ – atazanavir sulfate cap 200 mg (baseequiv)....................................................................................7

REYATAZ – atazanavir sulfate cap 300 mg (baseequiv)....................................................................................7

ribavirin cap 200 mg (Rebetol)..........................................5ribavirin tab 200 mg (Copegus)........................................ 5rifabutin cap 150 mg (Mycobutin).....................................4rifampin cap 150 mg (Rifadin)...........................................4rifampin cap 300 mg (Rifadin)...........................................4RILUTEK – riluzole tab 50 mg........................................... 50riluzole tab 50 mg (Rilutek)............................................. 50risedronate sodium tab 5 mg (Actonel)......................... 19risedronate sodium tab 30 mg (Actonel)....................... 19risedronate sodium tab 35 mg (Actonel)....................... 19risedronate sodium tab 150 mg (Actonel)..................... 19RISPERIDONE ODT – risperidone orally disintegrating tab0.25 mg..............................................................................38

risperidone orally disintegrating tab 0.5 mg (Risperdalm-tab)................................................................................ 38

risperidone orally disintegrating tab 1 mg (Risperdalm-tab)................................................................................ 39




risperidone soln 1 mg/ml (Risperdal).............................39risperidone tab 0.25 mg (Risperdal)...............................39risperidone tab 0.5 mg (Risperdal).................................39risperidone tab 1 mg (Risperdal)....................................39risperidone tab 2 mg (Risperdal)....................................39risperidone tab 3 mg (Risperdal)....................................39risperidone tab 4 mg (Risperdal)....................................39ritonavir tab 100 mg (Norvir).............................................7

2018


rivastigmine tartrate cap 1.5 mg (Exelon)......................43rivastigmine tartrate cap 3 mg (Exelon).........................43rivastigmine tartrate cap 4.5 mg (Exelon)......................43rivastigmine tartrate cap 6 mg (Exelon).........................43rizatriptan benzoate oral disintegrating tab 5 mg (baseeq) (Maxalt-mlt)................................................................46

rizatriptan benzoate oral disintegrating tab 10 mg(base eq) (Maxalt-mlt).....................................................46

rizatriptan benzoate tab 5 mg (base equivalent)(Maxalt)..............................................................................46

rizatriptan benzoate tab 10 mg (base equivalent)(Maxalt)..............................................................................46

ropinirole hydrochloride tab 0.25 mg (Requip)............. 49ropinirole hydrochloride tab 0.5 mg (Requip)............... 49ropinirole hydrochloride tab 1 mg (Requip).................. 49ropinirole hydrochloride tab 2 mg (Requip).................. 49ropinirole hydrochloride tab 3 mg (Requip).................. 49ropinirole hydrochloride tab 4 mg (Requip).................. 49ropinirole hydrochloride tab 5 mg (Requip).................. 49rosuvastatin calcium tab 5 mg (Crestor)....................... 26rosuvastatin calcium tab 10 mg (Crestor)..................... 26rosuvastatin calcium tab 20 mg (Crestor)..................... 26rosuvastatin calcium tab 40 mg (Crestor)..................... 26RYDAPT – midostaurin cap 25 mg.................................... 11

SSANDOSTATIN LAR DEPOT – octreotide acetate for iminj kit 10 mg.......................................................................19

SANDOSTATIN LAR DEPOT – octreotide acetate for iminj kit 20 mg.......................................................................19

SANDOSTATIN LAR DEPOT – octreotide acetate for iminj kit 30 mg.......................................................................19

scopolamine td patch 72hr 1 mg/3days (Transderm-scop)..................................................................................33

selegiline hcl cap 5 mg (Eldepryl).................................. 49selegiline hcl tab 5 mg.....................................................49selenium sulfide lotion 2.5%........................................... 56SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)..........19SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)..........19SENSIPAR – cinacalcet hcl tab 90 mg (base equiv)..........19SEREVENT DISKUS – salmeterol xinafoate aer pow ba50 mcg/dose (base equiv)................................................ 31

sertraline hcl oral concentrate for solution 20 mg/ml(Zoloft)...............................................................................37

sertraline hcl tab 25 mg (Zoloft)..................................... 37sertraline hcl tab 50 mg (Zoloft)..................................... 37sertraline hcl tab 100 mg (Zoloft)................................... 37sevelamer carbonate packet 0.8 gm (Renvela)............. 34sevelamer carbonate packet 2.4 gm (Renvela)............. 34sevelamer carbonate tab 800 mg (Renvela).................. 34sildenafil citrate tab 20 mg (Revatio)............................. 28silver sulfadiazine cream 1% (Silvadene)...................... 54SIMPONI – golimumab subcutaneous soln auto-injector50 mg/0.5ml.......................................................................46

SIMPONI – golimumab subcutaneous soln auto-injector100 mg/ml..........................................................................46

SIMPONI – golimumab subcutaneous soln prefilledsyringe 50 mg/0.5ml..........................................................46

SIMPONI – golimumab subcutaneous soln prefilledsyringe 100 mg/ml.............................................................46

simvastatin tab 5 mg (Zocor).......................................... 26simvastatin tab 10 mg (Zocor)........................................ 26simvastatin tab 20 mg (Zocor)........................................ 26simvastatin tab 40 mg (Zocor)........................................ 26simvastatin tab 80 mg (Zocor)........................................ 26SINGLE-LET – lancets....................................................... 58sirolimus tab 0.5 mg (Rapamune)...................................59sirolimus tab 1 mg (Rapamune)......................................59sirolimus tab 2 mg (Rapamune)......................................59sodium citrate & citric acid soln 500-334 mg/5ml(Shohls solution modi)................................................... 35

sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)(Luride)..............................................................................50

sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)(Luride)..............................................................................50

sodium fluoride chew tab 1 mg f (from 2.2 mg naf)(Luride)..............................................................................50

sodium fluoride cream 1.1% (Prevident 5000 plus)...... 53sodium fluoride gel 1.1% (0.5% f) (Previdentfluoride).............................................................................53

sodium fluoride soln 0.125 mg/drop f (0.275 mg/dropnaf).....................................................................................50

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)(Luride)..............................................................................50

sodium polystyrene sulfonate oral susp 15 gm/60ml(Sps).................................................................................. 59

sodium polystyrene sulfonate powder(Kayexalate)......................................................................59

SOOLANTRA – ivermectin cream 1%............................... 54sotalol hcl (afib/afl) tab 80 mg (Betapace af).................27sotalol hcl (afib/afl) tab 120 mg (Betapace af)...............27sotalol hcl (afib/afl) tab 160 mg (Betapace af)...............27sotalol hcl tab 240 mg......................................................27sotalol hcl tab 80 mg (Betapace)....................................27sotalol hcl tab 120 mg (Betapace)..................................27sotalol hcl tab 160 mg (Betapace)..................................27SOVALDI – sofosbuvir tab 400 mg...................................... 5SPIRIVA HANDIHALER – tiotropium bromidemonohydrate inhal cap 18 mcg (base equiv)................... 31

SPIRIVA RESPIMAT – tiotropium bromide monohydrateinhal aerosol 1.25 mcg/act................................................31

SPIRIVA RESPIMAT – tiotropium bromide monohydrateinhal aerosol 2.5 mcg/act..................................................31

spironolactone & hydrochlorothiazide tab 25-25 mg(Aldactazide).....................................................................26

spironolactone tab 25 mg (Aldactone)...........................26spironolactone tab 50 mg (Aldactone)...........................26spironolactone tab 100 mg (Aldactone).........................26SPRYCEL – dasatinib tab 20 mg.......................................11SPRYCEL – dasatinib tab 50 mg.......................................11SPRYCEL – dasatinib tab 70 mg.......................................11SPRYCEL – dasatinib tab 80 mg.......................................11

2018


SPRYCEL – dasatinib tab 100 mg.....................................11SPRYCEL – dasatinib tab 140 mg.....................................11stavudine cap 15 mg (Zerit)...............................................7stavudine cap 20 mg (Zerit)...............................................7stavudine cap 30 mg (Zerit)...............................................7stavudine cap 40 mg (Zerit)...............................................7STELARA – ustekinumab inj 45 mg/0.5ml.........................56STELARA – ustekinumab soln prefilled syringe 45mg/0.5ml............................................................................ 56

STELARA – ustekinumab soln prefilled syringe 90 mg/ml........................................................................................56

STIMATE – desmopressin acetate nasal soln 1.5 mg/ml........................................................................................19

STIOLTO RESPIMAT – tiotropium br-olodaterol inhal aerosoln 2.5-2.5 mcg/act..........................................................31

STIVARGA – regorafenib tab 40 mg..................................11STRENSIQ – asfotase alfa subcutaneous inj 18mg/0.45ml.......................................................................... 20

STRENSIQ – asfotase alfa subcutaneous inj 28mg/0.7ml............................................................................ 20

STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml........................................................................................20

STRENSIQ – asfotase alfa subcutaneous inj 80mg/0.8ml............................................................................ 20

STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab150-150-200-300 mg...........................................................7

STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln2.5 mcg/act (base equiv).................................................. 31

SUBOXONE – buprenorphine hcl-naloxone hcl sl film2-0.5 mg (base equiv).......................................................59

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1mg (base equiv)................................................................ 59



sucralfate tab 1 gm (Carafate).........................................32sulfacetamide sodium lotion 10% (acne) (Klaron)........54sulfacetamide sodium ophth soln 10% (Bleph-10)....... 52sulfacetamide sodium-prednisolone ophth soln10-0.23(0.25)%.................................................................. 52

SULFADIAZINE – sulfadiazine tab 500 mg......................... 4sulfamethoxazole-trimethoprim susp 200-40mg/5ml.................................................................................8

sulfamethoxazole-trimethoprim tab 400-80 mg(Bactrim)............................................................................. 8

sulfamethoxazole-trimethoprim tab 800-160 mg(Bactrim ds)........................................................................8

sulfasalazine tab delayed release 500 mg (Azulfidineen-tabs)............................................................................. 34

sulfasalazine tab 500 mg (Azulfidine)............................ 34sulindac tab 150 mg......................................................... 46sulindac tab 200 mg......................................................... 46sumatriptan nasal spray 5 mg/act (Imitrex)...................46sumatriptan nasal spray 20 mg/act (Imitrex).................46sumatriptan succinate inj 6 mg/0.5ml (Imitrex).............46

sumatriptan succinate solution auto-injector 4mg/0.5ml (Imitrex statdose sys)....................................47

sumatriptan succinate solution auto-injector 6mg/0.5ml (Imitrex statdose sys)....................................47

sumatriptan succinate solution cartridge 4 mg/0.5ml(Imitrex statdose ref)...................................................... 47

sumatriptan succinate solution cartridge 6 mg/0.5ml(Imitrex statdose ref)...................................................... 47

sumatriptan succinate tab 25 mg (Imitrex)....................47sumatriptan succinate tab 50 mg (Imitrex)....................47sumatriptan succinate tab 100 mg (Imitrex)..................47SUPRAX – cefixime cap 400 mg......................................... 3SUPRAX – cefixime chew tab 100 mg................................ 3SUPRAX – cefixime chew tab 200 mg................................ 3SUPRAX – cefixime for susp 100 mg/5ml........................... 3SUPRAX – cefixime for susp 200 mg/5ml........................... 3SUPRAX – cefixime for susp 500 mg/5ml........................... 3SUSTIVA – efavirenz tab 600 mg........................................ 7SUTENT – sunitinib malate cap 12.5 mg (baseequivalent)......................................................................... 11

SUTENT – sunitinib malate cap 25 mg (baseequivalent)......................................................................... 11

SUTENT – sunitinib malate cap 37.5 mg (baseequivalent)......................................................................... 11

SUTENT – sunitinib malate cap 50 mg (baseequivalent)......................................................................... 11

SYLATRON – peginterferon alfa-2b for inj kit 200 mcg..... 11SYLATRON – peginterferon alfa-2b for inj kit 300 mcg..... 11SYLATRON – peginterferon alfa-2b for inj kit 600 mcg..... 11SYNAREL – nafarelin acetate nasal soln 2 mg/ml (200mcg/act) (base eq)............................................................ 16

SYNJARDY – empagliflozin-metformin hcl tab 5-500mg...................................................................................... 17

SYNJARDY – empagliflozin-metformin hcl tab 5-1000mg...................................................................................... 17

SYNJARDY – empagliflozin-metformin hcl tab 12.5-500mg...................................................................................... 17

SYNJARDY – empagliflozin-metformin hcl tab 12.5-1000mg...................................................................................... 17

SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr5-1000 mg......................................................................... 17

SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr10-1000 mg....................................................................... 17

SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr12.5-1000 mg.................................................................... 17

SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr25-1000 mg....................................................................... 17

TTABLOID – thioguanine tab 40 mg.................................... 11tacrolimus cap 0.5 mg (Prograf)..................................... 59tacrolimus cap 1 mg (Prograf)........................................ 59tacrolimus cap 5 mg (Prograf)........................................ 59tacrolimus oint 0.03% (Protopic).................................... 56tacrolimus oint 0.1% (Protopic)...................................... 56

2018


TAFINLAR – dabrafenib mesylate cap 50 mg (baseequivalent)......................................................................... 11

TAFINLAR – dabrafenib mesylate cap 75 mg (baseequivalent)......................................................................... 11

TAGRISSO – osimertinib mesylate tab 40 mg (baseequivalent)......................................................................... 11

TAGRISSO – osimertinib mesylate tab 80 mg (baseequivalent)......................................................................... 12

tamoxifen citrate tab 10 mg (base equivalent)..............12tamoxifen citrate tab 20 mg (base equivalent)..............12tamsulosin hcl cap 0.4 mg (Flomax).............................. 35TARCEVA – erlotinib hcl tab 25 mg (base equivalent).......12TARCEVA – erlotinib hcl tab 100 mg (base equivalent).....12TARCEVA – erlotinib hcl tab 150 mg (base equivalent).....12TASIGNA – nilotinib hcl cap 50 mg (base equivalent)....... 12TASIGNA – nilotinib hcl cap 150 mg (base equivalent)..... 12TASIGNA – nilotinib hcl cap 200 mg (base equivalent)..... 12tazarotene cream 0.1% (Tazorac)....................................54TAZORAC – tazarotene cream 0.05%...............................54TAZORAC – tazarotene gel 0.05%.................................... 54TAZORAC – tazarotene gel 0.1%...................................... 54TECFIDERA – dimethyl fumarate capsule delayed release120 mg...............................................................................42

TECFIDERA – dimethyl fumarate capsule delayed release240 mg...............................................................................42

TECFIDERA STARTER PACK – dimethyl fumaratecapsule dr starter pack 120 mg & 240 mg....................... 42

telmisartan-hydrochlorothiazide tab 40-12.5 mg(Micardis hct)................................................................... 22

telmisartan-hydrochlorothiazide tab 80-12.5 mg(Micardis hct)................................................................... 22

telmisartan-hydrochlorothiazide tab 80-25 mg(Micardis hct)................................................................... 22

telmisartan tab 20 mg (Micardis).................................... 22telmisartan tab 40 mg (Micardis).................................... 22telmisartan tab 80 mg (Micardis).................................... 22temazepam cap 7.5 mg (Restoril)................................... 39temazepam cap 15 mg (Restoril).................................... 39temazepam cap 22.5 mg (Restoril)................................. 39temazepam cap 30 mg (Restoril).................................... 39temozolomide cap 5 mg (Temodar)................................ 12temozolomide cap 20 mg (Temodar)..............................12temozolomide cap 100 mg (Temodar)............................12temozolomide cap 140 mg (Temodar)............................12temozolomide cap 180 mg (Temodar)............................12temozolomide cap 250 mg (Temodar)............................12TENCON – butalbital-acetaminophen tab 50-325 mg....... 43tenofovir disoproxil fumarate tab 300 mg (Viread)......... 7terazosin hcl cap 1 mg (base equivalent)......................28terazosin hcl cap 2 mg (base equivalent)......................28terazosin hcl cap 5 mg (base equivalent)......................28terazosin hcl cap 10 mg (base equivalent)....................28terbinafine hcl tab 250 mg (Lamisil).................................5terbutaline sulfate tab 2.5 mg......................................... 31terbutaline sulfate tab 5 mg............................................ 31TERCONAZOLE – terconazole vaginal cream 0.8%.........34

terconazole vaginal cream 0.4% (Terazol 7).................. 34terconazole vaginal suppos 80 mg.................................34testosterone cypionate im inj in oil 100 mg/ml (Depo-testosterone).................................................................... 13

testosterone cypionate im inj in oil 200 mg/ml (Depo-testosterone).................................................................... 13

testosterone enanthate im inj in oil 200 mg/ml.............13testosterone td gel 12.5 mg/act (1%) (Androgelpump)................................................................................ 13

testosterone td gel 25 mg/2.5gm (1%) (Androgel)........ 13testosterone td gel 50 mg/5gm (1%) (Androgel)........... 13testosterone td soln 30 mg/act (Axiron)........................ 13tetrabenazine tab 12.5 mg (Xenazine)............................ 43tetrabenazine tab 25 mg (Xenazine)............................... 43tetracycline hcl cap 250 mg (Tetracycline hcl)................4tetracycline hcl cap 500 mg (Tetracycline hcl)................4THALOMID – thalidomide cap 50 mg................................ 59THALOMID – thalidomide cap 100 mg.............................. 59THALOMID – thalidomide cap 150 mg.............................. 59THALOMID – thalidomide cap 200 mg.............................. 59theophylline tab er 12hr 100 mg.....................................31theophylline tab er 12hr 200 mg.....................................31theophylline tab er 12hr 300 mg.....................................31theophylline tab er 12hr 450 mg.....................................31theophylline tab er 24hr 400 mg.....................................31theophylline tab er 24hr 600 mg.....................................31thiothixene cap 1 mg........................................................39thiothixene cap 2 mg........................................................39thiothixene cap 5 mg........................................................39thiothixene cap 10 mg......................................................39TIMOLOL MALEATE OPHTHALMI – timolol maleate ophthgel forming soln 0.25%..................................................... 52

timolol maleate ophth soln 0.25% (Timoptic)................52timolol maleate ophth soln 0.5% (Timoptic)..................52TIVICAY – dolutegravir sodium tab 10 mg (base equiv)...... 7TIVICAY – dolutegravir sodium tab 25 mg (base equiv)...... 7TIVICAY – dolutegravir sodium tab 50 mg (base equiv)...... 7tizanidine hcl tab 2 mg (base equivalent)......................50tizanidine hcl tab 4 mg (base equivalent)(Zanaflex).......................................................................... 50

tobramycin-dexamethasone ophth susp 0.3-0.1%(Tobradex).........................................................................52

tobramycin nebu soln 300 mg/5ml (Tobi)........................ 4tobramycin ophth soln 0.3% (Tobrex)............................ 52tolterodine tartrate cap er 24hr 2 mg (Detrol la)............34tolterodine tartrate cap er 24hr 4 mg (Detrol la)............34tolterodine tartrate tab 1 mg (Detrol)............................. 34tolterodine tartrate tab 2 mg (Detrol)............................. 34topiramate sprinkle cap 15 mg (Topamax sprinkle)..... 48topiramate sprinkle cap 25 mg (Topamax sprinkle)..... 48topiramate tab 25 mg (Topamax).................................... 48topiramate tab 50 mg (Topamax).................................... 48topiramate tab 100 mg (Topamax).................................. 48topiramate tab 200 mg (Topamax).................................. 48torsemide tab 5 mg (Demadex).......................................26torsemide tab 10 mg (Demadex).....................................26

2018


torsemide tab 20 mg (Demadex).....................................26torsemide tab 100 mg (Demadex)...................................26TOUJEO MAX SOLOSTAR – insulin glargine soln pen-injector 300 unit/ml............................................................18

TOUJEO SOLOSTAR – insulin glargine soln pen-injector300 unit/ml......................................................................... 18

TRACLEER – bosentan tab for oral susp 32 mg............... 28TRACLEER – bosentan tab 62.5 mg.................................28TRACLEER – bosentan tab 125 mg..................................28tramadol-acetaminophen tab 37.5-325 mg(Ultracet)........................................................................... 45

tramadol hcl tab er 24hr 100 mg.....................................45tramadol hcl tab er 24hr 200 mg.....................................45tramadol hcl tab er 24hr 300 mg.....................................45tramadol hcl tab 50 mg (Ultram).....................................45trandolapril tab 1 mg (Mavik).......................................... 21trandolapril tab 2 mg (Mavik).......................................... 21trandolapril tab 4 mg (Mavik).......................................... 21tranylcypromine sulfate tab 10 mg (Parnate)................37trazodone hcl tab 50 mg.................................................. 37trazodone hcl tab 100 mg................................................ 37trazodone hcl tab 150 mg................................................ 37trazodone hcl tab 300 mg................................................ 37TRELEGY ELLIPTA – fluticasone-umeclidinium-vilanterolaepb 100-62.5-25 mcg/inh................................................31

tretinoin cap 10 mg...........................................................12tretinoin cream 0.025% (Retin-a).....................................54tretinoin cream 0.05% (Retin-a).......................................54tretinoin cream 0.1% (Retin-a).........................................54tretinoin gel 0.01% (Retin-a)............................................ 54tretinoin gel 0.025% (Retin-a)..........................................54tretinoin microsphere gel 0.04% (Retin-a micro).......... 54tretinoin microsphere gel 0.1% (Retin-a micro)............ 54triamcinolone acetonide cream 0.025%......................... 55triamcinolone acetonide cream 0.1%............................. 55triamcinolone acetonide cream 0.5%............................. 56triamcinolone acetonide dental paste 0.1%.................. 53triamcinolone acetonide lotion 0.025%..........................56triamcinolone acetonide lotion 0.1%..............................56triamcinolone acetonide nasal aerosol suspension 55mcg/act (Nasacort aq).................................................... 29

triamcinolone acetonide oint 0.025%............................. 56triamcinolone acetonide oint 0.1%................................. 56triamcinolone acetonide oint 0.5%................................. 56triamterene & hydrochlorothiazide cap 37.5-25 mg(Dyazide)........................................................................... 26

triamterene & hydrochlorothiazide tab 37.5-25 mg(Maxzide-25)..................................................................... 26

triamterene & hydrochlorothiazide tab 75-50 mg(Maxzide)...........................................................................26

trifluoperazine hcl tab 1 mg (base equivalent)..............39trifluoperazine hcl tab 2 mg (base equivalent)..............39trifluoperazine hcl tab 5 mg (base equivalent)..............39trifluoperazine hcl tab 10 mg (base equivalent)............39trifluridine ophth soln 1% (Viroptic)............................... 52trihexyphenidyl hcl elixir 0.4 mg/ml............................... 49

trihexyphenidyl hcl tab 2 mg...........................................49trihexyphenidyl hcl tab 5 mg...........................................49trimethobenzamide hcl cap 300 mg (Tigan).................. 33trimethoprim tab 100 mg................................................... 8TRIUMEQ – abacavir-dolutegravir-lamivudine tab600-50-300 mg.................................................................... 7

tropicamide ophth soln 0.5%.......................................... 53tropicamide ophth soln 1% (Mydriacyl)......................... 53TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 100-150 mg................................................................... 7

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 133-200 mg...................................................................7

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 167-250 mg................................................................... 7

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 200-300 mg...................................................................7

TYKERB – lapatinib ditosylate tab 250 mg (baseequiv)................................................................................. 12

TYMLOS – abaloparatide subcutaneous soln pen-injector3120 mcg/1.56ml...............................................................20

UUPTRAVI – selexipag tab 200 mcg....................................28UPTRAVI – selexipag tab 400 mcg....................................28UPTRAVI – selexipag tab 600 mcg....................................28UPTRAVI – selexipag tab 800 mcg....................................28UPTRAVI – selexipag tab 1000 mcg..................................28UPTRAVI – selexipag tab 1200 mcg..................................28UPTRAVI – selexipag tab 1400 mcg..................................28UPTRAVI – selexipag tab 1600 mcg..................................28UPTRAVI – selexipag tab therapy pack 200 mcg (140) &800 mcg (60)..................................................................... 28

ursodiol cap 300 mg (Actigall)........................................34ursodiol tab 250 mg (Urso 250)...................................... 34ursodiol tab 500 mg (Urso forte).................................... 34V

VAGIFEM – estradiol vaginal tab 10 mcg.......................... 35valacyclovir hcl tab 1 gm (Valtrex)................................... 5valacyclovir hcl tab 500 mg (Valtrex)............................... 5VALCHLOR – mechlorethamine hcl gel 0.016% (baseequivalent)......................................................................... 56

valganciclovir hcl for soln 50 mg/ml (base equiv)(Valcyte).............................................................................. 5

valganciclovir hcl tab 450 mg (base equivalent)(Valcyte).............................................................................. 5

valproate sodium oral soln 250 mg/5ml (base equiv)(Depakene)........................................................................48

valproic acid cap 250 mg (Depakene)............................48valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovanhct).....................................................................................22

valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovanhct).....................................................................................22

valsartan-hydrochlorothiazide tab 160-25 mg (Diovanhct).....................................................................................22

2018


valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovanhct).....................................................................................22

valsartan-hydrochlorothiazide tab 320-25 mg (Diovanhct).....................................................................................22

valsartan tab 40 mg (Diovan).......................................... 22valsartan tab 80 mg (Diovan).......................................... 22valsartan tab 160 mg (Diovan)........................................ 22valsartan tab 320 mg (Diovan)........................................ 22vancomycin hcl cap 125 mg (Vancocin hcl)....................8vancomycin hcl cap 250 mg (Vancocin hcl)....................8venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)(Effexor xr)....................................................................... 37

venlafaxine hcl cap er 24hr 75 mg (base equivalent)(Effexor xr)....................................................................... 37

venlafaxine hcl cap er 24hr 150 mg (base equivalent)(Effexor xr)....................................................................... 37

venlafaxine hcl tab er 24hr 37.5 mg (base equivalent)(Venlafaxine hcl er)......................................................... 37

venlafaxine hcl tab er 24hr 75 mg (base equivalent)(Venlafaxine hcl er)......................................................... 37

venlafaxine hcl tab er 24hr 150 mg (base equivalent)(Venlafaxine hcl er)......................................................... 37

venlafaxine hcl tab 25 mg................................................37venlafaxine hcl tab 37.5 mg.............................................37venlafaxine hcl tab 50 mg................................................37venlafaxine hcl tab 75 mg................................................37venlafaxine hcl tab 100 mg..............................................37verapamil hcl cap er 24hr 120 mg (Verelan).................. 24verapamil hcl cap er 24hr 180 mg (Verelan).................. 24verapamil hcl cap er 24hr 240 mg (Verelan).................. 24verapamil hcl cap er 24hr 360 mg (Verelan).................. 24verapamil hcl tab er 120 mg (Calan sr)..........................24verapamil hcl tab er 180 mg (Calan sr)..........................24verapamil hcl tab er 240 mg (Calan sr)..........................24verapamil hcl tab 40 mg.................................................. 24verapamil hcl tab 80 mg (Calan).....................................24verapamil hcl tab 120 mg (Calan)...................................24VESICARE – solifenacin succinate tab 5 mg.................... 34VESICARE – solifenacin succinate tab 10 mg...................34VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml)...................................................................................... 17

vigabatrin powd pack 500 mg (Sabril)........................... 48VIRAMUNE – nevirapine susp 50 mg/5ml...........................7VIREAD – tenofovir disoproxil fumarate oral powder 40mg/gm.................................................................................. 7

VIREAD – tenofovir disoproxil fumarate tab 150 mg........... 7VIREAD – tenofovir disoproxil fumarate tab 200 mg........... 7VIREAD – tenofovir disoproxil fumarate tab 250 mg........... 7VIREAD – tenofovir disoproxil fumarate tab 300 mg........... 7voriconazole for susp 40 mg/ml (Vfend)..........................5voriconazole tab 50 mg (Vfend)........................................5voriconazole tab 200 mg (Vfend)......................................5VOSEVI – sofosbuvir-velpatasvir-voxilaprevir tab400-100-100 mg.................................................................. 5

VOTRIENT – pazopanib hcl tab 200 mg (base equiv).......12VYVANSE – lisdexamfetamine dimesylate cap 10 mg...... 41

VYVANSE – lisdexamfetamine dimesylate cap 20 mg...... 41VYVANSE – lisdexamfetamine dimesylate cap 30 mg...... 41VYVANSE – lisdexamfetamine dimesylate cap 40 mg...... 41VYVANSE – lisdexamfetamine dimesylate cap 50 mg...... 41VYVANSE – lisdexamfetamine dimesylate cap 60 mg...... 41VYVANSE – lisdexamfetamine dimesylate cap 70 mg...... 41VYVANSE – lisdexamfetamine dimesylate chew tab 10mg...................................................................................... 41

VYVANSE – lisdexamfetamine dimesylate chew tab 20mg...................................................................................... 41





Wwarfarin sodium tab 1 mg (Coumadin).......................... 51warfarin sodium tab 2 mg (Coumadin).......................... 51warfarin sodium tab 2.5 mg (Coumadin)....................... 51warfarin sodium tab 3 mg (Coumadin).......................... 51warfarin sodium tab 4 mg (Coumadin).......................... 51warfarin sodium tab 5 mg (Coumadin).......................... 51warfarin sodium tab 6 mg (Coumadin).......................... 51warfarin sodium tab 7.5 mg (Coumadin)....................... 51warfarin sodium tab 10 mg (Coumadin)........................ 51X

XALKORI – crizotinib cap 200 mg..................................... 12XALKORI – crizotinib cap 250 mg..................................... 12XARELTO – rivaroxaban tab 10 mg...................................51XARELTO – rivaroxaban tab 15 mg...................................51XARELTO – rivaroxaban tab 20 mg...................................51XARELTO STARTER PACK – rivaroxaban tab startertherapy pack 15 mg & 20 mg...........................................51

XIFAXAN – rifaximin tab 550 mg......................................... 8XTANDI – enzalutamide cap 40 mg...................................12XULANE – norelgestromin-ethinyl estradiol td ptwk 150-35mcg/24hr............................................................................ 15

Y

Zzafirlukast tab 10 mg (Accolate)..................................... 31zafirlukast tab 20 mg (Accolate)..................................... 31zaleplon cap 5 mg (Sonata).............................................39zaleplon cap 10 mg (Sonata)...........................................39ZARXIO – filgrastim-sndz soln prefilled syringe 300mcg/0.5ml...........................................................................51

ZARXIO – filgrastim-sndz soln prefilled syringe 480mcg/0.8ml...........................................................................51

ZELBORAF – vemurafenib tab 240 mg............................. 12

2018


ZENPEP – pancrelipase (lip-prot-amyl) dr cap3000-10000-16000 unit..................................................... 33

ZENPEP – pancrelipase (lip-prot-amyl) dr cap5000-17000-24000 unit..................................................... 33

ZENPEP – pancrelipase (lip-prot-amyl) dr cap10000-32000-42000 unit...................................................33



ZENPEP – pancrelipase (lip-prot-amyl) dr cap25000-79000-105000 unit.................................................33

ZENPEP – pancrelipase (lip-prot-amyl) dr cap40000-126000-168000 unit...............................................33

zidovudine cap 100 mg (Retrovir).....................................7zidovudine syrup 10 mg/ml (Retrovir)..............................7zidovudine tab 300 mg.......................................................7ziprasidone hcl cap 20 mg (Geodon)............................. 39ziprasidone hcl cap 40 mg (Geodon)............................. 39ziprasidone hcl cap 60 mg (Geodon)............................. 39ziprasidone hcl cap 80 mg (Geodon)............................. 39ZOLINZA – vorinostat cap 100 mg.................................... 12zolpidem tartrate tab er 6.25 mg (Ambien cr)................39zolpidem tartrate tab er 12.5 mg (Ambien cr)................39zolpidem tartrate tab 5 mg (Ambien)..............................39zolpidem tartrate tab 10 mg (Ambien)............................39zonisamide cap 50 mg..................................................... 48zonisamide cap 25 mg (Zonegran)................................. 48zonisamide cap 100 mg (Zonegran)............................... 48ZYDELIG – idelalisib tab 100 mg.......................................12ZYDELIG – idelalisib tab 150 mg.......................................12ZYKADIA – ceritinib cap 150 mg....................................... 12ZYTIGA – abiraterone acetate tab 250 mg........................12ZYTIGA – abiraterone acetate tab 500 mg........................12

blue cross and blue shield of alabama april 2018 … · blue cross and blue shield of alabama april...

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