blue cross and blue shield of alabama prescription drug ...€¦ · blue cross and blue shield of...

4157 AL © Prime Therapeutics LLC 07/18

July 2018

Blue Cross and Blue Shield of Alabama Prescription 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

Therapeutic Class Drug List

Anti-Infective Drugs .......................................................... 1

Cancer Drugs .................................................................... 7

Hormones, Diabetes and Related Drugs ........................ 11

Heart and Circulatory Drugs ........................................... 19

Respiratory Agents ......................................................... 28

Gastrointestinal Drugs .................................................... 32

Genitourinary Drugs ........................................................ 34

Central Nervous System Drugs ...................................... 35

Pain Relief Drugs ............................................................ 43

Neuromuscular Drugs ..................................................... 47

Supplements ................................................................... 50

Blood Modifying Drugs .................................................... 50

Topical Drugs .................................................................. 52

Miscellaneous Categories ............................................... 57

Index ............................................................................... 61

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 Prescription Drug Guide, July 2018 I

Introduction

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

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

drugs not listed in this Prescription 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.

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

show this Prescription 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).

The drug benefit includes most prescription drugs, although some restrictions and exclusions apply. 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 Prescription 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. Newly marketed prescription drugs may not be covered until the P&T Committee has had an

opportunity to review the drug, to determine whether the drug will be covered and if so, which tier will apply based on

safety, efficacy, and the availability of other products within that class of drugs. If your physician feels that a new drug

is medically necessary prior to P&T Committee evaluation, a non-formulary exception request for coverage may be

submitted.

Members and physicians can view the most up-to-date version of the Prescription Drug Guide at AlabamaBlue.com/pharmacy.

Blue Cross and Blue Shield of Alabama Prescription Drug Guide, July 2018 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, and 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 Prescription Drug Guide, July 2018 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 Prescription 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 Prescription Drug Guide is to provide a guide to coverage. The Prescription 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 Prescription Drug Guide, nor the successful adjudication of a pharmacy claim, is guarantee of payment.

Blue Cross and Blue Shield of Alabama Prescription Drug Guide, July 2018 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

2018

Blue Cross and Blue Shield of Alabama July 2018 Prescription Drug Guide 1

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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

dicloxacillin sodium cap 250 mg 1

dicloxacillin sodium cap 500 mg 1

Drug Name Tier

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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

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

2018


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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


1

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

Drug Name Tier

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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


1


1

minocycline hcl tab 50 mg 1



tetracycline hcl cap 250 mg(Tetracycline hcl)

1

tetracycline hcl cap 500 mg(Tetracycline hcl)

1

FLUOROQUINOLONESciprofloxacin for oral

susp 500 mg/5ml (10%)(10 gm/100ml) (Cipro)

1

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

1

2018


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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 tab 250 mg(Levaquin)

1


1


1

ofloxacin tab 400 mg 1

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

Drug Name Tier

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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

griseofulvin microsize tab500 mg (Grifulvin v)

1

itraconazole cap 100 mg(Sporanox)

1

NOXAFIL – posaconazole tabdelayed release 100 mg

2

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

2018


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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 • •

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

Drug Name Tier

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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 •


1 •


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 •

2018


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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 •

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 •

Drug Name Tier

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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 •


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 •

2018


Drug Name Tier

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tenofovir disoproxil fumarate tab300 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 •


2 •


2 •


2 •

VIDEX – didanosine for soln 2gm

2 •

VIDEX – didanosine for soln 4gm

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 •

Drug Name Tier

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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

chloroquine phosphate tab500 mg (Aralen)

1

DARAPRIM – pyrimethamine tab25 mg

2

hydroxychloroquine sulfate tab200 mg (Plaquenil)

1

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-INFECTIVES

2018


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clindamycin hcl cap 75 mg(Cleocin)

1


1


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

metronidazole tab 250 mg(Flagyl)

1

metronidazole tab 500 mg(Flagyl)

1

SULFADIAZINE – sulfadiazine tab500 mg

2

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 • • •

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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 • • •ALUNBRIG – brigatinib tab 180

mg2 • • •

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 • • •

2018


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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 • • •

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

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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 • • •


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 • • •

2018


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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 &letrozole tab 2.5 mg therapypack

2 • • •


2 • • •


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 • • •

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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 • • •

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

2018


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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 • • •


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 • • •

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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 • • •

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 • •

2018


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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 • • •

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 elixir 0.5 mg/5ml 1

dexamethasone tab 0.5 mg 1

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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


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 tab 1 mg 1

prednisone tab 2.5 mg 1




MALE HORMONESANDROGEL – testosterone td gel

20.25 mg/1.25gm (1.62%)2 • •

2018


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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

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

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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

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

2018


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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

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

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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

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

2018


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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

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

INFERTILITYFOLLISTIM AQ – follitropin beta

inj 300 unit/0.36ml2 •

FOLLISTIM AQ – follitropin betainj 600 unit/0.72ml

2 •

FOLLISTIM AQ – follitropin betainj 900 unit/1.08ml

2 •

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

2 •


2 •

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

BYDUREON – exenatide for injextended release susp 2 mg

2 • •

BYDUREON BCISE – exenatideextended release susp auto-injector 2 mg/0.85ml

2 • •

BYDUREON PEN – exenatideextended release for susp pen-injector 2 mg

2 • •

BYETTA – exenatide soln pen-injector 5 mcg/0.02ml

2 • •

BYETTA – exenatide soln pen-injector 10 mcg/0.04ml

2 • •

glimepiride tab 1 mg (Amaryl) 1



2018


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its

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

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 •

INVOKAMET – canagliflozin-metformin hcl tab 50-500 mg

2 •


2 •

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2 •


2 •

INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr50-500 mg

2 •


2 •


2 •


2 •

INVOKANA – canagliflozin tab100 mg

2 •

INVOKANA – canagliflozin tab300 mg

2 •

JANUMET – sitagliptin-metformin hcl tab 50-500 mg

2 •

JANUMET – sitagliptin-metformin hcl tab 50-1000 mg

2 •

JANUMET XR – sitagliptin-metformin hcl tab er 24hr50-500 mg

2 •


2 •


2 •

JANUVIA – sitagliptin phosphatetab 25 mg (base equiv)

2 •


2 •


2 •

JARDIANCE – empagliflozin tab10 mg

2 •

2018


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its

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

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 •

Drug Name Tier

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Lim

its

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 •

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

2 •


2 •

TRULICITY – dulaglutide solnpen-injector 0.75 mg/0.5ml

2 • •

TRULICITY – dulaglutide solnpen-injector 1.5 mg/0.5ml

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

2018


Drug Name Tier

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ty

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y

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ing

Lim

its

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

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

Drug Name Tier

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Spe

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ty

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its

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

2

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

2

TRESIBA FLEXTOUCH – insulindegludec soln pen-injector 100unit/ml

2

TRESIBA FLEXTOUCH – insulindegludec soln pen-injector 200unit/ml

2

THYROID REGULATIONlevothyroxine sodium tab

25 mcg (Synthroid)1

levothyroxine sodium tab50 mcg (Synthroid)

1


1


1


1


1


1


1


1


1


1


1

liothyronine sodium tab 5 mcg(Cytomel)

1


1

2018


Drug Name Tier

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ty

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its


1

methimazole tab 5 mg (Tapazole) 1

methimazole tab 10 mg(Tapazole)

1

propylthiouracil tab 50 mg 1

SYNTHROID – levothyroxinesodium tab 25 mcg

2


2


2


2


2


2


2


2


2


2


2


2

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 DRUGS

Drug Name Tier

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ing

Lim

its

alendronate 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

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 •

NITYR – nitisinone tab 2 mg 2 •NITYR – nitisinone tab 5 mg 2 •

2018


Drug Name Tier

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ty

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ing

Lim

its

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 •


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 •

Drug Name Tier

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its

SENSIPAR – cinacalcet hcl tab30 mg (base equiv)

2


2


2

STIMATE – desmopressinacetate nasal soln 1.5 mg/ml

2

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 COMBINATIbenazepril &

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

2018


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

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horiz

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n

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y

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pens

ing

Lim

its

captopril tab 12.5 mg 1

captopril tab 25 mg 1



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



lisinopril tab 30 mg (Zestril) 1

lisinopril tab 40 mg (Zestril) 1

Drug Name Tier

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igna

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ty

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ing

Lim

its

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-valsartan-

hydrochlorothiazide tab5-160-12.5 mg (Exforge hct)

1

2018


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

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n

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y

Dis

pens

ing

Lim

its

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



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

Drug Name Tier

Des

igna

tion

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ty

Prio

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n

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ing

Lim

its

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

telmisartan-hydrochlorothiazidetab 80-25 mg (Micardis hct)

1

valsartan tab 40 mg (Diovan) 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

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



carvedilol tab 25 mg (Coreg) 1

labetalol hcl tab 100 mg(Trandate)

1

Drug Name Tier

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its


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


1


1

propranolol hcl tab 10 mg 1


2018


Drug Name Tier

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its




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-atorvastatincalcium tab 2.5-10 mg (Caduet)

1


1


1

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

1


1


1


1


1


1


1


1

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

1

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

1


1

Drug Name Tier

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its


1


1


1

amlodipine besylate-valsartantab 5-160 mg (Exforge)

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

diltiazem hcl coated beads caper 24hr 300 mg

1


1

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

1


1


1


1

2018


Drug Name Tier

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ty

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y

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Lim

its


1


1

diltiazem hcl tab 30 mg(Cardizem)

1


1

diltiazem hcl tab 90 mg 1


1

ENTRESTO – sacubitril-valsartantab 24-26 mg

2 • •


2 • •


2 • •

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


1


1

nimodipine cap 30 mg 1

verapamil hcl cap er 24hr 120 mg(Verelan)

1


1

Drug Name Tier

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ty

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its


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

nitroglycerin sl tab 0.3 mg(Nitrostat)

1


1


1

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

1


1

2018


Drug Name Tier

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its


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

colestipol hcl tab 1 gm (Colestid) 1

ezetimibe tab 10 mg (Zetia) 1

ezetimibe-simvastatin tab10-10 mg (Vytorin)

1


1


1


1

Drug Name Tier

Des

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tion

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ty

Prio

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Lim

its

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

LIPOFEN – fenofibrate cap 50 mg 2

LIPOFEN – fenofibrate cap 150mg

2

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

PRALUENT – alirocumabsubcutaneous soln pen-injector 75 mg/ml

2 • • •

PRALUENT – alirocumabsubcutaneous soln pen-injector 150 mg/ml

2 • • •

pravastatin sodium tab 10 mg 1

pravastatin sodium tab 20 mg(Pravachol)

1


1


1

REPATHA – evolocumabsubcutaneous soln prefilledsyringe 140 mg/ml

2 • • •

2018


Drug Name Tier

Des

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Lim

its

REPATHA PUSHTRONEXSYSTEM – evolocumabsubcutaneous soln cartridge/infusor 420 mg/3.5ml

2 • • •

REPATHA SURECLICK –evolocumab subcutaneoussoln auto-injector 140 mg/ml

2 • • •

rosuvastatin calcium tab 5 mg(Crestor)

1


1


1


1

simvastatin tab 5 mg (Zocor) 1





VASCEPA – icosapent ethyl cap0.5 gm

2

VASCEPA – icosapent ethyl cap1 gm

2

WELCHOL – colesevelam hcl tab625 mg

2

WELCHOL – colesevelam hclpacket for susp 3.75 gm

2

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

Drug Name Tier

Des

igna

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Spe

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ty

Prio

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Lim

its

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

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

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

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

disopyramide phosphate cap150 mg (Norpace)

1

flecainide acetate tab 50 mg 1



mexiletine hcl cap 150 mg 1



MULTAQ – dronedarone hcl tab400 mg (base equivalent)

2

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

Drug Name Tier

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1


1

sotalol hcl tab 80 mg (Betapace) 1



sotalol hcl tab 240 mg 1

OTHER HEART RELATED DRUGSclonidine hcl tab 0.1 mg

(Catapres)1

clonidine hcl tab 0.2 mg(Catapres)

1

clonidine hcl tab 0.3 mg(Catapres)

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

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

2018


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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


1


1


1

TRACLEER – bosentan tab fororal susp 32 mg

2 • • •

TRACLEER – bosentan tab 62.5mg

2 • • •

TRACLEER – bosentan tab 125mg

2 • • •

Drug Name Tier

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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

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

cyproheptadine hcl syrup2 mg/5ml

1

cyproheptadine hcl tab 4 mg 1

desloratadine tab 5 mg (Clarinex) 1

2018


Drug Name Tier

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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 •

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 •

Drug Name Tier

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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 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 •

ARNUITY ELLIPTA – fluticasonefuroate aerosol powder breathactiv 100 mcg/act

2 •

ARNUITY ELLIPTA – fluticasonefuroate aerosol powder breathactiv 200 mcg/act

2 •

ASMANEX HFA – mometasonefuroate inhal aerosolsuspension 100 mcg/act

2 •

ASMANEX HFA – mometasonefuroate inhal aerosolsuspension 200 mcg/act

2 •

2018


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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 •

ATROVENT HFA – ipratropiumbromide hfa inhal aerosol 17mcg/act

2 •

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

2 •

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

2 •

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

1

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

1

budesonide inhalation susp1 mg/2ml (Pulmicort)

1

COMBIVENT RESPIMAT –ipratropium-albuterol inhalaerosol soln 20-100 mcg/act

2 •

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 •

Drug Name Tier

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FLOVENT DISKUS – fluticasonepropionate aer pow ba 50 mcg/blister

2 •

FLOVENT DISKUS – fluticasonepropionate aer pow ba 100mcg/blister

2 •

FLOVENT DISKUS – fluticasonepropionate aer pow ba 250mcg/blister

2 •

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

2 •

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

2 •

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

2 •

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

2 •


2 •


2 •

INCRUSE ELLIPTA –umeclidinium br aero powdbreath act 62.5 mcg/inh (baseeq)

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

2018


Drug Name Tier

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1


1

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

1 •

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 •

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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 •

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

2 •

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 80-4.5 mcg/act

2 •

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 160-4.5 mcg/act

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 •

VENTOLIN HFA – albuterolsulfate inhal aero 108 mcg/act(90mcg base equiv)

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 • • •

2018


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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

ANTIDIARRHEALSdiphenoxylate w/ atropine tab

2.5-0.025 mg (Lomotil)1

loperamide hcl cap 2 mg 1

ULCER/GERDcimetidine tab 300 mg 1

cimetidine tab 400 mg 1

cimetidine tab 800 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

Drug Name Tier

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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

NEXIUM – esomeprazolemagnesium for delayedrelease susp pack 2.5 mg

2 • •

NEXIUM – esomeprazolemagnesium for delayedrelease susp packet 5 mg

2 • •


2 • •


2 • •


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

2018


Drug Name Tier

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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


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

Drug Name Tier

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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


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

2018


Drug Name Tier

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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

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

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VELPHORO – sucroferricoxyhydroxide chew tab 500 mg

2

VIBERZI – eluxadoline tab 75 mg 2

VIBERZI – eluxadoline tab 100mg

2

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

nitrofurantoin susp 25 mg/5ml(Furadantin)

1

URINARY TRACT SPASMSMYRBETRIQ – mirabegron tab er

24 hr 25 mg2

MYRBETRIQ – mirabegron tab er24 hr 50 mg

2

oxybutynin chloride syrup5 mg/5ml

1

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

2018


Drug Name Tier

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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 vaginal cream 0.4%(Terazol 7)

1

terconazole vaginal suppos80 mg

1

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 DRUGS

Drug Name Tier

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ANXIETYalprazolam 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




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


2018


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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 •

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

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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 •


1 •

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

1 •

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

1 •


1 •


1 •

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 •

2018


Drug Name Tier

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ty

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ing

Lim

its

imipramine hcl tab 10 mg(Tofranil)

1


1


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


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

Drug Name Tier

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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 •

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




2018


Drug Name Tier

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ing

Lim

its

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

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



Drug Name Tier

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Lim

its

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 •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 •

2018


Drug Name Tier

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Lim

its


1 •


1 •


1 •


1 •

risperidone orally disintegratingtab 0.5 mg (Risperdal m-tab)

1 •

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

Drug Name Tier

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1

ziprasidone hcl cap 20 mg(Geodon)

1 •


1 •


1 •


1 •

SLEEP AIDSestazolam 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 •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/NARCOLEPSYADDERALL XR – amphetamine-

dextroamphetamine cap er24hr 5 mg

1 •

2018


Drug Name Tier

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Lim

its

ADDERALL XR – amphetamine-dextroamphetamine cap er24hr 10 mg

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 • •armodafinil tab 250 mg (Nuvigil) 1 • •

Drug Name Tier

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its

atomoxetine hcl cap 10 mg (baseequiv) (Strattera)

1 •


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 •


1 •

2018


Drug Name Tier

Des

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Lim

its

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 •


2 •

Drug Name Tier

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Lim

its


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 • •

glatiramer acetate soln prefilledsyringe 20 mg/ml (Copaxone)

1 • •

2018


Drug Name Tier

Des

igna

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ty

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y

Dis

pens

ing

Lim

its

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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Lim

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

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 caper 24hr 8 mg (Razadyne er)

1


1


1

galantamine hydrobromide tab4 mg (Razadyne)

1

2018


Drug Name Tier

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Lim

its


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 DRUGSbutalbital-acetaminophen tab

50-325 mg1 •

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

1 •

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

1 •

Drug Name Tier

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its

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

1 •

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 • •


1 • •

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

1 • •


1 • •


1 • •

2018


Drug Name Tier

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Lim

its


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 • •

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 • •

Drug Name Tier

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Lim

its

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 • •

NUCYNTA ER – tapentadol hcltab er 12hr 50 mg

2 • •


2 • •


2 • •


2 • •


2 • •

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 • •

2018


Drug Name Tier

Des

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Spe

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ty

Prio

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Lim

its

oxycodone hcl tab 30 mg(Roxicodone)

1 • •

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

Drug Name Tier

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its


1


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

Des

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Dis

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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



OTEZLA – apremilast tab startertherapy pack 10 mg & 20 mg &30 mg

2 • • •

OTEZLA – apremilast tab 30 mg 2 • • •oxaprozin tab 600 mg (Daypro) 1

Drug Name Tier

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its

piroxicam cap 10 mg (Feldene) 1

piroxicam cap 20 mg (Feldene) 1

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 •

2018


Drug Name Tier

Des

igna

tion

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its

sumatriptan succinate inj6 mg/0.5ml (Imitrex)

1 •

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

Drug Name Tier

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carbamazepine cap er 12hr300 mg (Carbatrol)

1

carbamazepine chew tab 100 mg 1

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

DILANTIN – phenytoin sodiumextended cap 100 mg

2

divalproex sodium cap delayedrelease sprinkle 125 mg(Depakote sprinkles)

1

divalproex sodium tab delayedrelease 125 mg (Depakote)

1


1


1

2018


Drug Name Tier

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Lim

its

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

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

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1


1

LYRICA – pregabalin soln 20 mg/ml

2 •

LYRICA – pregabalin cap 25 mg 2 •LYRICA – pregabalin cap 50 mg 2 •LYRICA – pregabalin cap 75 mg 2 •LYRICA – pregabalin cap 100 mg 2 •LYRICA – pregabalin cap 150 mg 2 •LYRICA – pregabalin cap 200 mg 2 •LYRICA – pregabalin cap 225 mg 2 •LYRICA – pregabalin cap 300 mg 2 •oxcarbazepine susp 300 mg/5ml

(60 mg/ml) (Trileptal)1

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

2018


Drug Name Tier

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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 DISEASEamantadine 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

Drug Name Tier

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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

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

2018


Drug Name Tier

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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

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

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 ELECTROLYTES

Drug Name Tier

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pot phos monobasic w/sodphos 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

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

2018


Drug Name Tier

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its

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 •


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 •

EPOGEN – epoetin alfa inj 2000unit/ml

2 •


2 •


2 •


2 •


2 •

Drug Name Tier

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its

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

2 • • •

folic acid tab 1 mg 1

GRANIX – tbo-filgrastim solnprefilled syringe 300 mcg/0.5ml

2 •

GRANIX – tbo-filgrastim solnprefilled syringe 480 mcg/0.8ml

2 •

HAEGARDA – c1 esteraseinhibitor (human) forsubcutaneous inj 2000 unit

2 • • •

HAEGARDA – c1 esteraseinhibitor (human) forsubcutaneous inj 3000 unit

2 • • •

NEULASTA – pegfilgrastim solnprefilled syringe 6 mg/0.6ml

2 •

NEULASTA ONPRO KIT –pegfilgrastim soln prefilledsyringe kit 6 mg/0.6ml

2 •

NEUPOGEN – filgrastim solnprefilled syringe 300 mcg/0.5ml

2 •

NEUPOGEN – filgrastim solnprefilled syringe 480 mcg/0.8ml(600 mcg/ml)

2 •

NEUPOGEN – filgrastim inj 300mcg/ml

2 •

NEUPOGEN – filgrastim inj 480mcg/1.6ml (300 mcg/ml)

2 •

pentoxifylline tab er 400 mg 1

prasugrel hcl tab 5 mg (baseequiv) (Effient)

1

prasugrel hcl tab 10 mg (baseequiv) (Effient)

1

PROCRIT – epoetin alfa inj 2000unit/ml

2 •


2 •


2 •


2 •

2018


Drug Name Tier

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its


2 •


2 •

warfarin sodium tab 1 mg(Coumadin)

1


1

warfarin sodium tab 2.5 mg(Coumadin)

1


1


1


1


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

Drug Name Tier

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its

bacitracin-polymyxin b ophthoint

1

ciprofloxacin hcl ophth soln0.3% (Ciloxan)

1

erythromycin ophth oint 5 mg/gm

1

gentamicin sulfate ophth soln0.3% (Garamycin)

1

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

1

NATACYN – natamycin ophthsusp 5%

2

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

LOTEMAX – loteprednoletabonate ophth susp 0.5%

2

LOTEMAX – loteprednoletabonate ophth gel 0.5%

2

LOTEMAX – loteprednoletabonate ophth oint 0.5%

2

2018


Drug Name Tier

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ty

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its

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

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

LUMIGAN – bimatoprost ophthsoln 0.01%

2 •

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

Drug Name Tier

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its

TRAVATAN Z – travoprost ophthsoln 0.004% (benzalkoniumfree) (bak free)

2 •

Other Eye Productsazelastine 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

PAZEO – olopatadine hcl ophthsoln 0.7% (base equivalent)

2

tropicamide ophth soln 0.5% 1

tropicamide ophth soln 1%(Mydriacyl)

1

EARacetic acid otic soln 2% 1

CIPRODEX – ciprofloxacin-dexamethasone otic susp0.3-0.1%

2

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

2018


Drug Name Tier

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its

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

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

Drug Name Tier

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its

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

DIFFERIN – adapalene lotion0.1%

2

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

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



2018


Drug Name Tier

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Lim

its

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 • •

CORTISPORIN – neomycin-polymyxin-hc crm 3.5 mg/gm-10000 unt/gm-0.5%

2

CORTISPORIN – bacitracin-polymyxin-neomycin hc oint1%

2

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

MENTAX – butenafine hcl cream1%

2

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

Drug Name Tier

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its

Corticosteroidsalclometasone dipropionate

cream 0.05% (Aclovate)1

alclometasone dipropionate oint0.05%

1

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

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

2018


Drug Name Tier

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ty

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Lim

its

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

ENSTILAR – calcipotriene-betamethasone dipropionatefoam 0.005-0.064%

2 •

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

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

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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

TACLONEX – calcipotriene-betamethasone dipropionatesusp 0.005-0.064%

2 •

triamcinolone acetonide cream0.025%

1


1


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

2018


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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 • •

diclofenac sodium gel 1%(Voltaren)

1

ELIDEL – pimecrolimus cream1%

2

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

PICATO – ingenol mebutate gel0.015%

2 • •

PICATO – ingenol mebutate gel0.05%

2 • •

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 • • •

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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

BAYER CONTOUR HIGHCONTRO – blood glucosecalibration - liquid - high

2

BAYER CONTOUR LINK BLOOD– blood glucose monitoring kitw/ device

2

2018


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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

BAYER MICROLET LANCETS –lancets

2

FINGERSTIX LANCETS – lancets 2

MICROLET LANCETS – lancets 2

MONOJECT ALLERGIST TRAY/P – allergy tray kit 1/2 ml 28 x1/2"

2

MONOJECT ALLERGIST TRAY/P– allergy tray kit 1 ml 28 x 1/2"

2

MONOJECT INSULIN SYRINGE –insulin syringe (disp) u-100 1ml

2

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MONOJECT INSULIN SYRINGE/– insulin syringe (disp) u-100 1ml

2

MONOJECT INSULIN SYRINGE/– insulin syringe/needle u-1000.3 ml 29 x 1/2"

2

MONOJECT INSULIN SYRINGE/– insulin syringe/needle u-1000.3 ml 30 x 5/16"

2

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

2


2


2

MONOJECT INSULIN SYRINGE/ –insulin syringe/needle u-100 1ml 25 x 5/8"

2


2


2


2


2


2

MONOJECT ULTRA COMFORT IN– insulin syringe/needle u-1000.3 ml 29 x 1/2"

2


2

2018


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MONOJECT ULTRA COMFORT IN– insulin syringe/needle u-1001/2 ml 31 x 5/16"

2


2


2


2

MONOJECT ULTRA COMFORT IN– insulin syringe/needle u-1001 ml 28 x 1/2"

2

MONOJECT ULTRA COMFORT IN– insulin syringe/needle u-1001 ml 29 x 1/2"

2


2

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

2

REALITY INSULIN SYRINGE/U –insulin syringe/needle u-1001/2 ml 29 x 1/2"

2

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

2

REALITY INSULIN SYRINGE/U –insulin syringe/needle u-100 1ml 29 x 1/2"

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

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cyclosporine cap 25 mg(Sandimmune)

1

cyclosporine cap 100 mg(Sandimmune)

1

CYCLOSPORINE MODIFIED –cyclosporine modified cap 50mg

2

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

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

2018


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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 • • •


2 • • •


2 • • •


2 • • •

SANDIMMUNE – cyclosporineoral soln 100 mg/ml

2

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

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tacrolimus cap 5 mg (Prograf) 1

THALOMID – thalidomide cap 50mg

2 • • •

THALOMID – thalidomide cap100 mg

2 • • •


2 • • •


2 • • •

ZORTRESS – everolimus tab0.25 mg

2

ZORTRESS – everolimus tab 0.5mg

2

ZORTRESS – everolimus tab0.75 mg

2

2018


INDEX

Aabacavir sulfate-lamivudine tab 600-300 mg(Epzicom)............................................................................4

abacavir sulfate-lamivudine-zidovudine tab300-150-300 mg (Trizivir).................................................. 4

abacavir sulfate soln 20 mg/ml (base equiv)(Ziagen)............................................................................... 4

abacavir sulfate tab 300 mg (base equiv) (Ziagen).........4acamprosate calcium tab delayed release 333 mg(Campral).......................................................................... 42

acarbose tab 25 mg (Precose)........................................ 14acarbose tab 50 mg (Precose)........................................ 14acarbose tab 100 mg (Precose)...................................... 14acebutolol 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)....................................57acitretin cap 25 mg (Soriatane).......................................57ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml(2000000 unit/0.5ml)........................................................... 7

acyclovir cap 200 mg (Zovirax).........................................4acyclovir susp 200 mg/5ml (Zovirax)............................... 4acyclovir tab 400 mg (Zovirax)..........................................4acyclovir tab 800 mg (Zovirax)..........................................4adapalene-benzoyl peroxide gel 0.1-2.5% (Epiduo)......54adapalene cream 0.1% (Differin).....................................54adapalene gel 0.1% (Differin).......................................... 54adapalene gel 0.3% (Differin).......................................... 54ADDERALL XR – amphetamine-dextroamphetamine caper 24hr 5 mg..................................................................... 39

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





adefovir dipivoxil tab 10 mg (Hepsera)............................3ADVAIR 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........................................................................................ 7



AFINITOR – everolimus tab 2.5 mg.....................................7AFINITOR – everolimus tab 5 mg........................................7AFINITOR – everolimus tab 7.5 mg.....................................7AFINITOR – everolimus tab 10 mg......................................7ALBENZA – albendazole tab 200 mg.................................. 6albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..........29albuterol sulfate soln nebu 0.5% (5 mg/ml)...................29albuterol sulfate soln nebu 0.63 mg/3ml (baseequiv).................................................................................29

albuterol sulfate soln nebu 1.25 mg/3ml (baseequiv).................................................................................29

albuterol sulfate syrup 2 mg/5ml....................................29albuterol sulfate tab 2 mg................................................29albuterol sulfate tab 4 mg................................................29alclometasone dipropionate cream 0.05%(Aclovate)..........................................................................55

alclometasone dipropionate oint 0.05%.........................55ALECENSA – alectinib hcl cap 150 mg (baseequivalent)............................................................................7

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)......................................35alprazolam tab 0.5 mg (Xanax)........................................35alprazolam tab 1 mg (Xanax)...........................................35alprazolam tab 2 mg (Xanax)...........................................35

2018


ALUNBRIG – brigatinib tab initiation therapy pack 90 mg &180 mg.................................................................................7

ALUNBRIG – brigatinib tab 30 mg.......................................7ALUNBRIG – brigatinib tab 90 mg.......................................7ALUNBRIG – brigatinib tab 180 mg.....................................7amantadine 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.............................................27amiodarone hcl tab 400 mg.............................................27amiodarone hcl tab 200 mg (Cordarone)....................... 27amitriptyline hcl tab 10 mg..............................................35amitriptyline hcl tab 25 mg..............................................35amitriptyline hcl tab 50 mg..............................................35amitriptyline hcl tab 75 mg..............................................36amitriptyline hcl tab 100 mg............................................36amitriptyline hcl tab 150 mg............................................36amlodipine besylate-atorvastatin calcium tab 2.5-10mg (Caduet)......................................................................23

amlodipine besylate-atorvastatin calcium tab 2.5-20mg (Caduet)......................................................................23

amlodipine besylate-atorvastatin calcium tab 2.5-40mg (Caduet)......................................................................23

amlodipine besylate-atorvastatin calcium tab 5-10 mg(Caduet).............................................................................23








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)........................................................................... 23




amlodipine-valsartan-hydrochlorothiazide tab5-160-12.5 mg (Exforge hct)...........................................20

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 & k clavulanate for susp 200-28.5mg/5ml.................................................................................1

amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1amoxicillin & k clavulanate for susp 250-62.5 mg/5ml(Augmentin)........................................................................1

amoxicillin & k clavulanate for susp 600-42.9 mg/5ml(Augmentin es-600)...........................................................1

amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg(Augmentin xr)...................................................................1

amoxicillin & k clavulanate tab 250-125 mg.................... 1amoxicillin & k clavulanate tab 500-125 mg(Augmentin)........................................................................1

amoxicillin & k clavulanate tab 875-125 mg(Augmentin)........................................................................1

amoxicillin (trihydrate) cap 250 mg..................................1amoxicillin (trihydrate) cap 500 mg..................................1amoxicillin (trihydrate) for susp 125 mg/5ml...................1amoxicillin (trihydrate) for susp 200 mg/5ml...................1amoxicillin (trihydrate) for susp 250 mg/5ml...................1amoxicillin (trihydrate) for susp 400 mg/5ml...................1amoxicillin (trihydrate) tab 500 mg...................................1amoxicillin (trihydrate) tab 875 mg...................................1amphetamine-dextroamphetamine tab 5 mg(Adderall).......................................................................... 40

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

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

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




2018


anagrelide hcl cap 1 mg.................................................. 50anagrelide hcl cap 0.5 mg (Agrylin)............................... 50anastrozole tab 1 mg (Arimidex).......................................7ANDROGEL PUMP – testosterone td gel 20.25 mg/act(1.62%)...............................................................................12

ANDROGEL – testosterone td gel 20.25 mg/1.25gm(1.62%)...............................................................................11

ANDROGEL – testosterone td gel 40.5 mg/2.5gm(1.62%)...............................................................................12

ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba62.5-25 mcg/inh.................................................................29

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

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).....................................40ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 100 mcg/act.................................................. 29

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 200 mcg/act.................................................. 29

ASACOL HD – mesalamine tab delayed release 800mg...................................................................................... 34

ASMANEX HFA – mometasone furoate inhal aerosolsuspension 100 mcg/act................................................... 29

ASMANEX HFA – mometasone furoate inhal aerosolsuspension 200 mcg/act................................................... 29

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)............................................................................. 4



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

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

atenolol tab 25 mg (Tenormin)........................................ 22

atenolol 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)...........................................................................6

atovaquone-proguanil hcl tab 250-100 mg(Malarone)...........................................................................6

ATRIPLA – efavirenz-emtricitabine-tenofovir df tab600-200-300 mg.................................................................. 4

ATROVENT HFA – ipratropium bromide hfa inhal aerosol17 mcg/act......................................................................... 30

AUBAGIO – teriflunomide tab 7 mg...................................41AUBAGIO – teriflunomide tab 14 mg.................................41AVONEX – 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).....................................59azelastine 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)..................... 53azithromycin for susp 100 mg/5ml (Zithromax).............. 2azithromycin for susp 200 mg/5ml (Zithromax).............. 2azithromycin tab 250 mg (Zithromax).............................. 2azithromycin tab 500 mg (Zithromax).............................. 2azithromycin tab 600 mg (Zithromax).............................. 2B

BACITRACIN – bacitracin ophth oint 500 unit/gm............. 52bacitracin-polymyxin b ophth oint..................................52bacitracin-polymyxin-neomycin-hc ophth oint 1%.......52baclofen tab 10 mg...........................................................50baclofen tab 20 mg...........................................................50balsalazide disodium cap 750 mg (Colazal).................. 34BARACLUDE – entecavir oral soln 0.05 mg/ml...................3BAYER BREEZE 2 BLOOD GLUC – blood glucosemonitoring kit w/ device.................................................... 57

2018


BAYER BREEZE 2 HIGH CONTR – blood glucosecalibration - liquid - high................................................... 57

BAYER BREEZE 2 LOW CONTRO – blood glucosecalibration - liquid - low.....................................................57

BAYER BREEZE 2 NORMAL CON – blood glucosecalibration - liquid - normal............................................... 57

BAYER BREEZE 2 TEST DISC – glucose blood testdisk.....................................................................................57

BAYER CONTOUR BLOOD GLUCO – blood glucosemonitoring devices............................................................ 57

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

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

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.....................................................58

BAYER CONTOUR NEXT BLOOD – blood glucosemonitoring kit w/ device.................................................... 58

BAYER CONTOUR NEXT BLOOD – glucose blood teststrip.....................................................................................58

BAYER CONTOUR NEXT CONTRO – blood glucosecalibration - liquid - low.....................................................58

BAYER CONTOUR NEXT CONTRO – blood glucosecalibration - liquid - normal............................................... 58

BAYER CONTOUR NEXT EZ BLO – blood glucosemonitoring kit w/ device.................................................... 58

BAYER CONTOUR NEXT LINK B – blood glucosemonitoring kit w/ device.................................................... 58

BAYER CONTOUR NEXT LINK W – blood glucosemonitoring kit w/ device.................................................... 58

BAYER CONTOUR NORMAL CONT – blood glucosecalibration - liquid - normal............................................... 58

BAYER MICROLET LANCETS – lancets...........................58benazepril & hydrochlorothiazide tab 5-6.25 mg.......... 19benazepril & hydrochlorothiazide tab 10-12.5 mg(Lotensin hct)...................................................................19

benazepril & hydrochlorothiazide tab 20-12.5 mg(Lotensin hct)...................................................................19

benazepril & hydrochlorothiazide tab 20-25 mg(Lotensin hct)...................................................................19

benazepril hcl tab 5 mg................................................... 19benazepril hcl tab 10 mg (Lotensin)...............................19benazepril hcl tab 20 mg (Lotensin)...............................19benazepril hcl tab 40 mg (Lotensin)...............................19BENZNIDAZOLE – benznidazole tab 12.5 mg.................... 6BENZNIDAZOLE – benznidazole tab 100 mg..................... 6benzoyl peroxide-erythromycin gel 5-3%(Benzamycin)....................................................................54

benztropine mesylate tab 0.5 mg....................................49benztropine mesylate tab 1 mg.......................................49benztropine mesylate tab 2 mg.......................................49

betamethasone dipropionate augmented cream 0.05%(Diprolene af)................................................................... 55

betamethasone dipropionate augmented lotion 0.05%(Diprolene)........................................................................ 55

betamethasone dipropionate augmented oint 0.05%(Diprolene)........................................................................ 55

betamethasone dipropionate cream 0.05%................... 55betamethasone dipropionate lotion 0.05%....................55betamethasone dipropionate oint 0.05%....................... 55betamethasone valerate cream 0.1% (baseequivalent)........................................................................ 55

betamethasone valerate lotion 0.1% (baseequivalent)........................................................................ 55

betamethasone valerate oint 0.1% (baseequivalent)........................................................................ 55

BETASERON – interferon beta-1b for inj kit 0.3 mg.......... 41bexarotene cap 75 mg (Targretin).....................................7bicalutamide tab 50 mg (Casodex)...................................7BILTRICIDE – praziquantel tab 600 mg...............................6bisoprolol & 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........................................ 7BOSULIF – bosutinib tab 400 mg........................................ 7BOSULIF – bosutinib tab 500 mg........................................ 7BREO 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%.............................53brimonidine tartrate ophth soln 0.15% (Alphaganp)........................................................................................ 53

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).................................................................... 11

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).................................................................................59

2018


buprenorphine hcl-naloxone hcl sl tab 8-2 mg (baseequiv).................................................................................59

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).........36bupropion hcl tab er 12hr 150 mg (Wellbutrin sr).........36bupropion hcl tab er 12hr 200 mg (Wellbutrin sr).........36bupropion hcl tab er 24hr 150 mg (Wellbutrin xl)......... 36bupropion hcl tab er 24hr 300 mg (Wellbutrin xl)......... 36bupropion hcl tab 75 mg (Wellbutrin)............................ 36bupropion 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)....................................................... 43

BYDUREON BCISE – exenatide extended release suspauto-injector 2 mg/0.85ml................................................. 14

BYDUREON – exenatide for inj extended release susp 2mg...................................................................................... 14

BYDUREON PEN – exenatide extended release for susppen-injector 2 mg.............................................................. 14

BYETTA – exenatide soln pen-injector 5 mcg/0.02ml........14BYETTA – exenatide soln pen-injector 10 mcg/0.04ml......14

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

calcipotriene cream 0.005% (Dovonex)..........................57calcipotriene oint 0.005%.................................................57calcipotriene soln 0.005% (50 mcg/ml).......................... 57calcitonin (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).........................18calcium acetate (phosphate binder) cap 667 mg (169mg ca) (Phoslo)............................................................... 34

calcium acetate (phosphate binder) tab 667 mg(Eliphos)............................................................................34

CANASA – mesalamine suppos 1000 mg......................... 34candesartan 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).................................... 7capecitabine tab 500 mg (Xeloda).................................... 7CAPRELSA – vandetanib tab 100 mg................................. 7CAPRELSA – vandetanib tab 300 mg................................. 7captopril 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)........................................22carvedilol tab 12.5 mg (Coreg)........................................22carvedilol tab 25 mg (Coreg)...........................................22cefaclor cap 250 mg........................................................... 1cefaclor cap 500 mg........................................................... 1cefadroxil cap 500 mg........................................................1cefadroxil for susp 250 mg/5ml........................................ 1cefadroxil for susp 500 mg/5ml........................................ 1cefadroxil tab 1 gm.............................................................1cefdinir cap 300 mg............................................................1cefdinir for susp 125 mg/5ml............................................ 1cefdinir for susp 250 mg/5ml............................................ 1cefixime for susp 100 mg/5ml (Suprax)........................... 1cefixime for susp 200 mg/5ml (Suprax)........................... 1cefpodoxime proxetil for susp 50 mg/5ml....................... 1cefpodoxime proxetil for susp 100 mg/5ml..................... 1cefpodoxime proxetil tab 100 mg..................................... 1cefpodoxime proxetil tab 200 mg..................................... 1cefprozil for susp 125 mg/5ml...........................................1

2018


cefprozil for susp 250 mg/5ml...........................................1cefprozil tab 250 mg...........................................................1cefprozil tab 500 mg...........................................................1ceftriaxone sodium for inj 2 gm........................................1ceftriaxone sodium for inj 1 gm (Rocephin)....................1ceftriaxone sodium for inj 250 mg....................................1ceftriaxone sodium for inj 500 mg (Rocephin)................1cefuroxime axetil tab 250 mg (Ceftin).............................. 1cefuroxime axetil tab 500 mg (Ceftin).............................. 2celecoxib cap 50 mg (Celebrex)......................................45celecoxib cap 100 mg (Celebrex)....................................45celecoxib cap 200 mg (Celebrex)....................................45celecoxib cap 400 mg (Celebrex)....................................45cephalexin cap 250 mg (Keflex)........................................2cephalexin cap 500 mg (Keflex)........................................2cephalexin for susp 125 mg/5ml.......................................2cephalexin for susp 250 mg/5ml.......................................2cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)................... 28cevimeline 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......................................59CHENODAL – chenodiol tab 250 mg.................................34chlorhexidine gluconate soln 0.12% (Peridex)..............54chloroquine phosphate tab 500 mg (Aralen)...................6chlorothiazide 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.................................................26cholestyramine light powder 4 gm/dose (Questranlight)...................................................................................25

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)......................................... 55ciclopirox olamine cream 0.77% (base equiv)...............55ciclopirox olamine susp 0.77% (base equiv).................55ciclopirox shampoo 1% (Loprox shampoo).................. 55ciclopirox solution 8% (Penlac nail lacquer).................55

cilostazol tab 50 mg (Pletal)............................................50cilostazol tab 100 mg (Pletal)..........................................50cimetidine tab 300 mg......................................................32cimetidine tab 400 mg......................................................32cimetidine tab 800 mg......................................................32CIPRODEX – ciprofloxacin-dexamethasone otic susp0.3-0.1%.............................................................................53

ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000mg(base eq) (Cipro xr)..................................................... 3

ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg(base eq) (Cipro xr)...........................................................3

ciprofloxacin for oral susp 500 mg/5ml (10%) (10gm/100ml) (Cipro)..............................................................2

ciprofloxacin hcl ophth soln 0.3% (Ciloxan)................. 52ciprofloxacin hcl tab 750 mg (base equiv).......................3ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)..........2ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)..........3citalopram 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 tab er 24hr 500 mg................................... 2clarithromycin tab 250 mg (Biaxin).................................. 2clarithromycin tab 500 mg (Biaxin).................................. 2CLIMARA PRO – estradiol-levonorgestrel td patch weekly0.045-0.015 mg/day.......................................................... 12

clindamycin hcl cap 75 mg (Cleocin)...............................7clindamycin hcl cap 150 mg (Cleocin).............................7clindamycin hcl cap 300 mg (Cleocin).............................7clindamycin palmitate hcl for soln 75 mg/5ml (baseequiv) (Cleocin pediatric gr)............................................ 7

clindamycin phosphate-benzoyl peroxide gel 1-5%(Benzaclin)........................................................................54

clindamycin phosphate gel 1% (Cleocin-t)....................54clindamycin phosphate lotion 1% (Cleocin-t)............... 54clindamycin phosphate soln 1% (Cleocin-t)..................54clindamycin phosphate swab 1% (Cleocin-t)................ 54clindamycin phosphate vaginal cream 2%(Cleocin)............................................................................35

clindamycin phosph-benzoyl peroxide (refrig) gel 1.2(1)-5% (Duac)....................................................................54

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).............. 55clomipramine 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)....................................47

2018


clonazepam 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).............................................................................. 51

clotrimazole troche 10 mg............................................... 54clozapine tab 50 mg......................................................... 38clozapine tab 200 mg....................................................... 38clozapine tab 25 mg (Clozaril).........................................38clozapine tab 100 mg (Clozaril).......................................38codeine 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)...................................25COMBIVENT RESPIMAT – ipratropium-albuterol inhalaerosol soln 20-100 mcg/act............................................ 30

COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60mg dose) kit.........................................................................7

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20mg (100 dose) kit................................................................ 7

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20mg (140 dose) kit................................................................ 8

COMPLERA – emtricitabine-rilpivirine-tenofovir df tab200-25-300 mg.................................................................... 4

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




CONTOUR NEXT ONE BLOOD GL – blood glucosemonitoring kit..................................................................... 58

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)..................................................................... 54

CORTISONE ACETATE – cortisone acetate tab 25mg...................................................................................... 11

CORTISPORIN – bacitracin-polymyxin-neomycin hc oint1%...................................................................................... 55

CORTISPORIN – neomycin-polymyxin-hc crm 3.5 mg/gm-10000 unt/gm-0.5%.....................................................55

COSENTYX – secukinumab subcutaneous soln prefilledsyringe 150 mg/ml.............................................................57

COSENTYX SENSOREADY PEN – secukinumabsubcutaneous soln auto-injector 150 mg/ml.....................57

COTELLIC – cobimetinib fumarate tab 20 mg (baseequivalent)............................................................................8

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%....................................53cromolyn sodium soln nebu 20 mg/2ml........................ 30cyanocobalamin inj 1000 mcg/ml................................... 51cyclobenzaprine hcl tab 5 mg.........................................50cyclobenzaprine hcl tab 10 mg.......................................50cyclopentolate hcl ophth soln 1% (Cyclogyl)................53cyclophosphamide cap 25 mg (Cyclophosphamide)..... 8cyclophosphamide cap 50 mg (Cyclophosphamide)..... 8CYCLOPHOSPHAMIDE – cyclophosphamide cap 25mg........................................................................................ 8

CYCLOPHOSPHAMIDE – cyclophosphamide cap 50mg........................................................................................ 8

cyclosporine cap 25 mg (Sandimmune)........................ 59cyclosporine cap 100 mg (Sandimmune)...................... 59cyclosporine modified cap 50 mg (Cyclosporinemodifie)............................................................................. 59

cyclosporine modified cap 25 mg (Neoral)....................59cyclosporine modified cap 100 mg (Neoral)..................59CYCLOSPORINE MODIFIED – cyclosporine modified cap50 mg.................................................................................59

cyclosporine modified oral soln 100 mg/ml(Neoral)..............................................................................59

cyproheptadine hcl syrup 2 mg/5ml...............................28cyproheptadine hcl tab 4 mg.......................................... 28CYSTAGON – cysteamine bitartrate cap 50 mg................35CYSTAGON – cysteamine bitartrate cap 150 mg..............35

Ddanazol cap 50 mg............................................................12danazol cap 100 mg..........................................................12danazol cap 200 mg..........................................................12dantrolene sodium cap 25 mg (Dantrium)..................... 50dantrolene sodium cap 50 mg (Dantrium)..................... 50dantrolene sodium cap 100 mg (Dantrolenesodium)............................................................................. 50

dapsone tab 25 mg.............................................................7dapsone tab 100 mg...........................................................7DARAPRIM – pyrimethamine tab 25 mg............................. 6

2018


DELZICOL – mesalamine cap dr 400 mg..........................34demeclocycline hcl tab 150 mg........................................ 2demeclocycline hcl tab 300 mg........................................ 2DEPEN TITRATABS – penicillamine tab 250 mg.............. 59DESCOVY – emtricitabine-tenofovir alafenamide fumaratetab 200-25 mg..................................................................... 4

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 tab 5 mg (Clarinex).................................. 28desmopressin acetate inj 4 mcg/ml (Ddavp).................18desmopressin acetate nasal spray soln 0.01%(Ddavp)..............................................................................18

desmopressin acetate nasal spray soln 0.01%(refrigerated).....................................................................18

desmopressin acetate tab 0.1 mg (Ddavp)....................18desmopressin acetate tab 0.2 mg (Ddavp)....................18desogest-eth estrad & eth estrad tab 0.15-0.02/0.01mg(21/5) (Mircette).......................................................... 13

desogest-ethin est tab0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa).....13

desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg(Desogen)......................................................................... 13

desonide cream 0.05% (Desowen)................................. 55desonide lotion 0.05% (Desowen).................................. 56desonide oint 0.05% (Desowen)......................................56desoximetasone cream 0.05% (Topicort).......................56desoximetasone cream 0.25% (Topicort).......................56desoximetasone gel 0.05% (Topicort)............................ 56desoximetasone oint 0.25% (Topicort)...........................56dexamethasone elixir 0.5 mg/5ml................................... 11dexamethasone tab 0.5 mg............................................. 11dexamethasone tab 0.75 mg........................................... 11dexamethasone tab 1.5 mg............................................. 11dexamethasone tab 4 mg................................................ 11dexamethasone tab 6 mg................................................ 11dexmethylphenidate 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)..........................................................................57

diclofenac sodium gel 1% (Voltaren)..............................57diclofenac sodium ophth soln 0.1%...............................53diclofenac 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...................................... 1dicloxacillin sodium cap 500 mg...................................... 1dicyclomine 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)........................................................................................ 4

didanosine delayed release capsule 250 mg (Videxec)........................................................................................ 4

didanosine delayed release capsule 400 mg (Videxec)........................................................................................ 4

DIFFERIN – adapalene lotion 0.1%...................................54digoxin tab 125 mcg (0.125 mg) (Lanoxin).................... 27digoxin tab 250 mcg (0.25 mg) (Lanoxin)...................... 27DILANTIN – phenytoin sodium extended cap 30 mg.........47DILANTIN – phenytoin sodium extended cap 100 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............23diltiazem 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).......................................................................23



2018





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)............................. 51dipyridamole tab 50 mg (Persantine)............................. 51dipyridamole tab 75 mg (Persantine)............................. 51disopyramide phosphate cap 100 mg (Norpace).......... 27disopyramide 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).......................................................................................48

divalproex sodium tab er 24 hr 500 mg (Depakoteer).......................................................................................48

DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%)...........12DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%)...............12DIVIGEL – estradiol td gel 1 mg/gm (0.1%).......................12donepezil 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)..................... 53dorzolamide hcl-timolol maleate ophth soln 22.3-6.8mg/ml (Cosopt)................................................................ 53

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.........................................2doxycycline hyclate cap 100 mg (Vibramycin)................2doxycycline hyclate tab 20 mg......................................... 2

doxycycline hyclate tab 100 mg....................................... 2doxycycline monohydrate cap 50 mg.............................. 2doxycycline monohydrate cap 150 mg (Adoxa)..............2doxycycline monohydrate cap 75 mg (Monodox)...........2doxycycline monohydrate cap 100 mg (Monodox).........2doxycycline monohydrate tab 50 mg (Adoxa)................ 2doxycycline monohydrate tab 75 mg (Adoxa)................ 2doxycycline monohydrate tab 100 mg (Adoxa pak1/100)................................................................................... 2

doxycycline monohydrate tab 150 mg (Adoxa pak1/150)................................................................................... 2

drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin28)...................................................................................... 13

drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)......13DULERA – 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%............................................ 55efavirenz cap 50 mg (Sustiva)...........................................4efavirenz cap 200 mg (Sustiva).........................................4efavirenz tab 600 mg (Sustiva)..........................................4eletriptan hydrobromide tab 20 mg (base equivalent)(Relpax).............................................................................46

eletriptan hydrobromide tab 40 mg (base equivalent)(Relpax).............................................................................46

ELIDEL – pimecrolimus cream 1%.................................... 57ELIQUIS – apixaban tab 2.5 mg........................................ 51ELIQUIS – apixaban tab 5 mg........................................... 51ELIQUIS STARTER PACK – apixaban tab 5 mg............... 51ELLA – ulipristal acetate tab 30 mg...................................13EMCYT – estramustine phosphate sodium cap 140 mg......8EMEND – 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

2018


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)............. 51enoxaparin 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).............. 51ENSTILAR – calcipotriene-betamethasone dipropionatefoam 0.005-0.064%...........................................................56

entacapone tab 200 mg (Comtan)...................................49entecavir tab 0.5 mg (Baraclude)......................................4entecavir tab 1 mg (Baraclude).........................................4ENTRESTO – sacubitril-valsartan tab 24-26 mg............... 24ENTRESTO – sacubitril-valsartan tab 49-51 mg............... 24ENTRESTO – sacubitril-valsartan tab 97-103 mg............. 24EPCLUSA – sofosbuvir-velpatasvir tab 400-100 mg........... 4EPINEPHRINE (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)..................................28

eplerenone tab 25 mg (Inspra)........................................27eplerenone tab 50 mg (Inspra)........................................27EPOGEN – epoetin alfa inj 2000 unit/ml............................51EPOGEN – epoetin alfa inj 3000 unit/ml............................51EPOGEN – epoetin alfa inj 4000 unit/ml............................51EPOGEN – epoetin alfa inj 10000 unit/ml..........................51EPOGEN – epoetin alfa inj 20000 unit/ml..........................51ergocalciferol cap 50000 unit (Drisdol)..........................50ERIVEDGE – vismodegib cap 150 mg................................ 8erythromycin gel 2% (Erygel)..........................................54erythromycin ophth oint 5 mg/gm..................................52erythromycin pads 2%..................................................... 54erythromycin soln 2%...................................................... 54escitalopram oxalate soln 5 mg/5ml (base equiv)(Lexapro)...........................................................................36

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...............35estradiol & norethindrone acetate tab 0.5-0.1 mg(Activella)..........................................................................12

estradiol & norethindrone acetate tab 1-0.5 mg(Activella)..........................................................................12

estradiol tab 0.5 mg (Estrace).........................................12estradiol tab 1 mg (Estrace)............................................12estradiol tab 2 mg (Estrace)............................................12estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot).....................................................................................12

estradiol td patch twice weekly 0.0375 mg/24hr(Vivelle-dot)...................................................................... 12

estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot).....................................................................................12



estradiol td patch weekly 0.025 mg/24hr (Climara).......12estradiol td patch weekly 0.05 mg/24hr (Climara).........12estradiol td patch weekly 0.06 mg/24hr (Climara).........12estradiol td patch weekly 0.075 mg/24hr (Climara).......12estradiol td patch weekly 0.1 mg/24hr (Climara)...........12estradiol td patch weekly 0.0375 mg/24hr (37.5mcg/24hr) (Climara).........................................................12

estradiol vaginal cream 0.1 mg/gm (Estrace)................35eszopiclone tab 1 mg (Lunesta)......................................39eszopiclone tab 2 mg (Lunesta)......................................39eszopiclone tab 3 mg (Lunesta)......................................39ethambutol hcl tab 100 mg (Myambutol)......................... 3ethambutol hcl tab 400 mg (Myambutol)......................... 3ethosuximide cap 250 mg (Zarontin)..............................48ethosuximide soln 250 mg/5ml (Zarontin)..................... 48ethynodiol diacetate & ethinyl estradiol tab 1 mg-35mcg....................................................................................13

ethynodiol diacetate & ethinyl estradiol tab 1 mg-50mcg (Zovia 1/50e)............................................................13

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.........................................................45ETOPOSIDE – etoposide cap 50 mg...................................8EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg(base equiv).........................................................................4

exemestane tab 25 mg (Aromasin)...................................8ezetimibe-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)....................................... 4famciclovir tab 250 mg (Famvir)....................................... 4famciclovir tab 500 mg (Famvir)....................................... 4famotidine tab 20 mg (Pepcid)........................................32

2018


famotidine tab 40 mg (Pepcid)........................................32FARESTON – toremifene citrate tab 60 mg (baseequivalent)............................................................................8

FARYDAK – panobinostat lactate cap 10 mg (baseequivalent)............................................................................8



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)...............43fentanyl td patch 72hr 25 mcg/hr (Duragesic)...............43fentanyl td patch 72hr 50 mcg/hr (Duragesic)...............43fentanyl td patch 72hr 75 mcg/hr (Duragesic)...............44fentanyl td patch 72hr 100 mcg/hr (Duragesic).............44FIASP FLEXTOUCH – insulin aspart soln pen-injector 100unit/ml.................................................................................16

FIASP – insulin aspart inj 100 unit/ml................................ 16FINACEA – azelaic acid foam 15%................................... 54FINACEA – azelaic acid gel 15%.......................................54finasteride 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......................................... 27FLOVENT DISKUS – fluticasone propionate aer pow ba50 mcg/blister.................................................................... 30

FLOVENT DISKUS – fluticasone propionate aer pow ba100 mcg/blister.................................................................. 30

FLOVENT DISKUS – fluticasone propionate aer pow ba250 mcg/blister.................................................................. 30

FLOVENT HFA – fluticasone propionate hfa inhal aer 110mcg/act (125/valve)...........................................................30

FLOVENT HFA – fluticasone propionate hfa inhal aer 220mcg/act (250/valve)...........................................................30

FLOVENT HFA – fluticasone propionate hfa inhal aero 44mcg/act (50/valve)............................................................. 30

fluconazole for susp 10 mg/ml (Diflucan)........................3fluconazole for susp 40 mg/ml (Diflucan)........................3fluconazole tab 50 mg (Diflucan)......................................3fluconazole tab 100 mg (Diflucan)....................................3fluconazole tab 150 mg (Diflucan)....................................3fluconazole tab 200 mg (Diflucan)....................................3flucytosine cap 250 mg (Ancobon)...................................3flucytosine cap 500 mg (Ancobon)...................................3fludrocortisone acetate tab 0.1 mg.................................11fluocinolone acetonide cream 0.01%............................. 56fluocinolone acetonide cream 0.025% (Synalar)...........56fluocinolone acetonide oil 0.01% (body oil) (Derma-smoothe/fs bod).............................................................. 56

fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs sca)............................................................... 56

fluocinolone acetonide oint 0.025% (Synalar)...............56fluocinolone acetonide soln 0.01% (Synalar)................56fluocinonide cream 0.05%............................................... 56fluocinonide emulsified base cream 0.05%...................56fluocinonide gel 0.05%.....................................................56fluocinonide oint 0.05%....................................................56fluocinonide soln 0.05%...................................................56fluorometholone ophth susp 0.1% (Fml liquifilm)........ 52fluorouracil cream 5% (Efudex)...................................... 57fluoxetine 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.............................38fluphenazine hcl tab 1 mg............................................... 38fluphenazine hcl tab 2.5 mg............................................ 38fluphenazine hcl tab 5 mg............................................... 38fluphenazine hcl tab 10 mg............................................. 38flurbiprofen tab 50 mg......................................................45flurbiprofen tab 100 mg................................................... 45flutamide cap 125 mg.........................................................8FLUTICASONE 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)............ 56fluticasone propionate nasal susp 50 mcg/act(Flonase)........................................................................... 29

fluticasone propionate oint 0.005% (Cutivate).............. 56fluvoxamine maleate tab 25 mg......................................36fluvoxamine maleate tab 50 mg......................................36fluvoxamine maleate tab 100 mg....................................36folic acid tab 1 mg............................................................51

2018


FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml..........14FOLLISTIM AQ – follitropin beta inj 600 unit/0.72ml..........14FOLLISTIM AQ – follitropin beta inj 900 unit/1.08ml..........14fosinopril 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)...................................................................42

galantamine hydrobromide cap er 24hr 24 mg(Razadyne er)...................................................................42

galantamine hydrobromide tab 4 mg (Razadyne).........42galantamine hydrobromide tab 8 mg (Razadyne).........43galantamine hydrobromide tab 12 mg (Razadyne).......43gemfibrozil tab 600 mg (Lopid).......................................25gentamicin sulfate cream 0.1%.......................................55gentamicin sulfate oint 0.1%........................................... 55gentamicin sulfate ophth soln 0.3% (Garamycin).........52GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab150-150-200-10 mg.............................................................5

GILENYA – fingolimod hcl cap 0.5 mg (base equiv)..........41GILOTRIF – afatinib dimaleate tab 20 mg (baseequivalent)............................................................................8

GILOTRIF – afatinib dimaleate tab 30 mg (baseequivalent)............................................................................8

GILOTRIF – afatinib dimaleate tab 40 mg (baseequivalent)............................................................................8

glatiramer acetate soln prefilled syringe 20 mg/ml(Copaxone)....................................................................... 41

glatiramer acetate soln prefilled syringe 40 mg/ml(Copaxone)....................................................................... 42

GLEOSTINE – lomustine cap 5 mg..................................... 8GLEOSTINE – lomustine cap 10 mg................................... 8GLEOSTINE – lomustine cap 40 mg................................... 8GLEOSTINE – lomustine cap 100 mg................................. 8glimepiride tab 1 mg (Amaryl).........................................14glimepiride tab 2 mg (Amaryl).........................................14glimepiride tab 4 mg (Amaryl).........................................14glipizide-metformin hcl tab 2.5-250 mg..........................15

glipizide-metformin hcl tab 2.5-500 mg..........................15glipizide-metformin hcl tab 5-500 mg.............................15glipizide tab er 24hr 2.5 mg (Glucotrol xl)..................... 15glipizide tab er 24hr 5 mg (Glucotrol xl)........................ 15glipizide tab er 24hr 10 mg (Glucotrol xl)...................... 15glipizide tab 5 mg (Glucotrol)..........................................15glipizide tab 10 mg (Glucotrol)........................................15GLUCAGON EMERGENCY KIT – glucagon (rdna) for injkit 1 mg..............................................................................15

glyburide-metformin tab 1.25-250 mg(Glucovance).................................................................... 15

glyburide-metformin tab 2.5-500 mg (Glucovance)...... 15glyburide-metformin tab 5-500 mg (Glucovance)......... 15glyburide micronized tab 1.5 mg (Glynase)...................15glyburide micronized tab 3 mg (Glynase)......................15glyburide micronized tab 6 mg (Glynase)......................15glyburide tab 1.25 mg.......................................................15glyburide tab 2.5 mg.........................................................15glyburide tab 5 mg............................................................15glycopyrrolate tab 1 mg (Robinul)..................................32glycopyrrolate tab 2 mg (Robinul forte).........................32GLYXAMBI – empagliflozin-linagliptin tab 10-5 mg........... 15GLYXAMBI – empagliflozin-linagliptin tab 25-5 mg........... 15granisetron hcl tab 1 mg................................................. 33GRANIX – tbo-filgrastim soln prefilled syringe 300mcg/0.5ml...........................................................................51

GRANIX – tbo-filgrastim soln prefilled syringe 480mcg/0.8ml...........................................................................51

griseofulvin microsize susp 125 mg/5ml......................... 3griseofulvin microsize tab 500 mg (Grifulvin v)..............3guanfacine 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).................................... 27guanfacine hcl tab 2 mg (Tenex).................................... 27H

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)..........56halobetasol propionate oint 0.05% (Ultravate)..............56haloperidol decanoate im soln 50 mg/ml (Haldoldecanoate 50)...................................................................38

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........................................................ 38

2018


haloperidol tab 5 mg........................................................ 38haloperidol tab 10 mg...................................................... 38haloperidol tab 20 mg...................................................... 38HARVONI – ledipasvir-sofosbuvir tab 90-400 mg................4HEXALEN – altretamine cap 50 mg.....................................8HUMIRA – 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)....... 8HYCAMTIN – topotecan hcl cap 1 mg (base equiv)............ 8hydralazine hcl tab 10 mg............................................... 27hydralazine 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%.............................................56hydrocortisone enema 100 mg/60ml (Cortenema)........54hydrocortisone lotion 2.5%............................................. 56hydrocortisone oint 2.5%.................................................56hydrocortisone rectal cream 2.5% (Anusol-hc)............ 54hydrocortisone tab 5 mg (Cortef)................................... 11hydrocortisone tab 10 mg (Cortef)................................. 11hydrocortisone tab 20 mg (Cortef)................................. 11hydrocortisone valerate cream 0.2%..............................56hydrocortisone valerate oint 0.2% (Westcort)...............56

hydrocortisone 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).......6hydroxyurea cap 500 mg (Hydrea)................................... 8hydroxyzine 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).............................................................................18

IBRANCE – palbociclib cap 75 mg...................................... 8IBRANCE – palbociclib cap 100 mg.................................... 8IBRANCE – palbociclib cap 125 mg.................................... 8ibuprofen susp 100 mg/5ml.............................................46ibuprofen tab 400 mg....................................................... 46ibuprofen tab 600 mg....................................................... 46ibuprofen tab 800 mg....................................................... 46ICLUSIG – ponatinib hcl tab 15 mg (base equiv)................ 8ICLUSIG – ponatinib hcl tab 45 mg (base equiv)................ 8ILARIS – canakinumab subcutaneous inj 150 mg/ml........ 46imatinib mesylate tab 100 mg (base equivalent)(Gleevec).............................................................................8

imatinib mesylate tab 400 mg (base equivalent)(Gleevec).............................................................................8

IMBRUVICA – ibrutinib cap 70 mg.......................................8IMBRUVICA – ibrutinib cap 140 mg.....................................8IMBRUVICA – ibrutinib tab 140 mg..................................... 8IMBRUVICA – ibrutinib tab 280 mg..................................... 8IMBRUVICA – ibrutinib tab 420 mg..................................... 8IMBRUVICA – ibrutinib tab 560 mg..................................... 8imipramine hcl tab 10 mg (Tofranil)............................... 37imipramine hcl tab 25 mg (Tofranil)............................... 37imipramine hcl tab 50 mg (Tofranil)............................... 37imiquimod cream 5% (Aldara).........................................57IMPAVIDO – miltefosine cap 50 mg.....................................7INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml).........18INCRUSE ELLIPTA – umeclidinium br aero powd breathact 62.5 mcg/inh (base eq)...............................................30

indapamide tab 1.25 mg...................................................26indapamide tab 2.5 mg.....................................................26indomethacin cap 25 mg................................................. 46indomethacin cap 50 mg................................................. 46INLYTA – axitinib tab 1 mg...................................................9INLYTA – axitinib tab 5 mg...................................................9INTELENCE – etravirine tab 25 mg.....................................5INTELENCE – etravirine tab 100 mg...................................5INTELENCE – etravirine tab 200 mg...................................5

2018


INVOKAMET – canagliflozin-metformin hcl tab 50-500mg...................................................................................... 15




INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr50-500 mg......................................................................... 15

INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr50-1000 mg....................................................................... 15

INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr150-500 mg....................................................................... 15

INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr150-1000 mg..................................................................... 15

INVOKANA – canagliflozin tab 100 mg..............................15INVOKANA – canagliflozin tab 300 mg..............................15ipratropium-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)............................................................................ 21

irbesartan-hydrochlorothiazide tab 300-12.5 mg(Avalide)............................................................................ 21

irbesartan tab 75 mg (Avapro)........................................ 21irbesartan tab 150 mg (Avapro)...................................... 21irbesartan tab 300 mg (Avapro)...................................... 21IRESSA – gefitinib tab 250 mg............................................ 9ISENTRESS HD – raltegravir potassium tab 600 mg (baseequiv)....................................................................................5

ISENTRESS – raltegravir potassium chew tab 25 mg(base equiv).........................................................................5

ISENTRESS – raltegravir potassium chew tab 100 mg(base equiv).........................................................................5

ISENTRESS – raltegravir potassium packet for susp 100mg (base equiv).................................................................. 5

ISENTRESS – raltegravir potassium tab 400 mg (baseequiv)....................................................................................5

isoniazid tab 100 mg.......................................................... 3isoniazid tab 300 mg.......................................................... 3isosorbide 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..................................................... 54isotretinoin cap 20 mg..................................................... 54

isotretinoin cap 40 mg..................................................... 54isotretinoin cap 30 mg (Claravis)....................................54itraconazole cap 100 mg (Sporanox)................................3ivermectin tab 3 mg (Stromectol)..................................... 6J

JADENU – deferasirox tab 90 mg......................................59JADENU – deferasirox tab 180 mg....................................59JADENU – deferasirox tab 360 mg....................................59JAKAFI – ruxolitinib phosphate tab 5 mg (baseequivalent)............................................................................9

JAKAFI – ruxolitinib phosphate tab 10 mg (baseequivalent)............................................................................9




JANUMET – sitagliptin-metformin hcl tab 50-500 mg........15JANUMET – sitagliptin-metformin hcl tab 50-1000 mg......15JANUMET XR – sitagliptin-metformin hcl tab er 24hr50-500 mg......................................................................... 15

JANUMET XR – sitagliptin-metformin hcl tab er 24hr50-1000 mg....................................................................... 15

JANUMET XR – sitagliptin-metformin hcl tab er 24hr100-1000 mg..................................................................... 15

JANUVIA – sitagliptin phosphate tab 25 mg (baseequiv)................................................................................. 15



JARDIANCE – empagliflozin tab 10 mg.............................15JARDIANCE – empagliflozin tab 25 mg.............................16

KKALETRA – lopinavir-ritonavir tab 100-25 mg.....................5KALETRA – lopinavir-ritonavir tab 200-50 mg.....................5KALYDECO – ivacaftor packet 50 mg............................... 31KALYDECO – ivacaftor packet 75 mg............................... 32KALYDECO – ivacaftor tab 150 mg................................... 31ketoconazole cream 2%................................................... 55ketoconazole shampoo 2% (Nizoral)..............................55ketorolac tromethamine ophth soln 0.5% (Acular)....... 53ketorolac tromethamine ophth soln 0.4% (Acularls)....................................................................................... 53

KISQALI FEMARA 200 DOSE – ribociclib tab 200 mg &letrozole tab 2.5 mg therapy pack......................................9



KISQALI – ribociclib succinate tab 200 mg (base equiv).....9KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr2.5-1000 mg...................................................................... 16

2018


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)................................22labetalol hcl tab 200 mg (Trandate)................................22labetalol hcl tab 300 mg (Trandate)................................22lactulose (encephalopathy) solution 10 gm/15ml......... 34lactulose solution 10 gm/15ml........................................ 32lamivudine oral soln 10 mg/ml (Epivir)............................ 5lamivudine tab 150 mg (Epivir)......................................... 5lamivudine tab 300 mg (Epivir)......................................... 5lamivudine tab 100 mg (hbv) (Epivir hbv)........................4lamivudine-zidovudine tab 150-300 mg (Combivir)........ 5lamotrigine 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)..................................48lansoprazole cap delayed release 15 mg(Prevacid)..........................................................................32

lansoprazole cap delayed release 30 mg(Prevacid)..........................................................................32

LANTUS – insulin glargine inj 100 unit/ml......................... 17LANTUS SOLOSTAR – insulin glargine soln pen-injector100 unit/ml......................................................................... 17

latanoprost ophth soln 0.005% (Xalatan).......................53leflunomide tab 10 mg (Arava)........................................46leflunomide tab 20 mg (Arava)........................................46LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 mg (14 mg daily dose)................................... 9

LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 (2) mg (18 mg daily dose)..............................9

LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapypack 10 (2) & 4 mg (24 mg daily dose)..............................9

LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapypack 10 mg (10 mg daily dose)..........................................9

LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapypack 10 (2) mg (20 mg daily dose).................................... 9

LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapypack 4 (2) mg (8 mg daily dose)........................................ 9

LETAIRIS – ambrisentan tab 5 mg.................................... 28LETAIRIS – ambrisentan tab 10 mg.................................. 28letrozole tab 2.5 mg (Femara)........................................... 9LEUCOVORIN CALCIUM – leucovorin calcium tab 10mg........................................................................................ 9

LEUCOVORIN CALCIUM – leucovorin calcium tab 15mg........................................................................................ 9

leucovorin calcium tab 5 mg.............................................9leucovorin calcium tab 25 mg...........................................9LEUKERAN – chlorambucil tab 2 mg.................................. 9

levalbuterol 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......................................................................... 17

LEVEMIR – insulin detemir inj 100 unit/ml.........................17levetiracetam 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).................. 53levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 18levocarnitine tab 330 mg (Carnitor)................................18levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) (Xyzal).........................................................................29

levocetirizine dihydrochloride tab 5 mg (Xyzal)............29levofloxacin tab 250 mg (Levaquin)................................. 3levofloxacin tab 500 mg (Levaquin)................................. 3levofloxacin tab 750 mg (Levaquin)................................. 3levonorgestrel & ethinyl estradiol (91-day) tab0.15-0.03 mg.....................................................................13

levonorgestrel & ethinyl estradiol tab 0.1 mg-20mcg....................................................................................13

levonorgestrel & ethinyl estradiol tab 0.15 mg-30mcg....................................................................................13

levonorgestrel-eth estra tab0.05-30/0.075-40/0.125-30mg-mcg................................. 13

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab0.01mg(7) (Loseasonique)..............................................13

levonorg-eth est tab 0.15-0.03mg(84) & eth est tab0.01mg(7) (Seasonique)..................................................13

levothyroxine sodium tab 25 mcg (Synthroid)..............17levothyroxine sodium tab 50 mcg (Synthroid)..............17levothyroxine sodium tab 75 mcg (Synthroid)..............17levothyroxine sodium tab 88 mcg (Synthroid)..............17levothyroxine sodium tab 100 mcg (Synthroid)............17levothyroxine sodium tab 112 mcg (Synthroid)............ 17levothyroxine sodium tab 125 mcg (Synthroid)............17levothyroxine sodium tab 137 mcg (Synthroid)............17levothyroxine sodium tab 150 mcg (Synthroid)............17levothyroxine sodium tab 175 mcg (Synthroid)............17levothyroxine sodium tab 200 mcg (Synthroid)............17levothyroxine sodium tab 300 mcg (Synthroid)............17lidocaine hcl gel 2%......................................................... 57lidocaine hcl local inj 1% (Xylocaine)............................ 47lidocaine hcl local preservative free (pf) inj 1%(Xylocaine-mpf)................................................................47

lidocaine hcl soln 4% (Xylocaine)...................................57

2018


lidocaine hcl viscous soln 2%........................................ 54lidocaine patch 5% (Lidoderm)....................................... 57lidocaine-prilocaine cream 2.5-2.5% (Emla).................. 57linezolid for susp 100 mg/5ml (Zyvox)............................. 7linezolid tab 600 mg (Zyvox)............................................. 7liothyronine sodium tab 5 mcg (Cytomel)..................... 17liothyronine sodium tab 25 mcg (Cytomel)................... 17liothyronine sodium tab 50 mcg (Cytomel)................... 18LIPOFEN – fenofibrate cap 50 mg.....................................25LIPOFEN – fenofibrate cap 150 mg...................................25lisinopril & 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)............................................ 20lisinopril tab 40 mg (Zestril)............................................ 20lithium carbonate cap 300 mg.........................................38lithium carbonate cap 150 mg (Lithium carbonate)......38lithium carbonate cap 600 mg (Lithium carbonate)......38lithium 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...................9LONSURF – trifluridine-tipiracil tab 20-8.19 mg...................9loperamide hcl cap 2 mg................................................. 32lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)(Kaletra)...............................................................................5

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)...................................................................... 21

losartan potassium & hydrochlorothiazide tab 100-12.5mg (Hyzaar)...................................................................... 21

losartan potassium & hydrochlorothiazide tab 100-25mg (Hyzaar)...................................................................... 21

losartan potassium tab 25 mg (Cozaar).........................21losartan potassium tab 50 mg (Cozaar).........................21losartan potassium tab 100 mg (Cozaar).......................21LOTEMAX – loteprednol etabonate ophth gel 0.5%..........52LOTEMAX – loteprednol etabonate ophth oint 0.5%.........52LOTEMAX – loteprednol etabonate ophth susp 0.5%....... 52lovastatin 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)........................38

LUMIGAN – bimatoprost ophth soln 0.01%.......................53LUPRON DEPOT-PED (1-MONTH – leuprolide acetate forinj pediatric kit 7.5 mg..................................................14,18

LUPRON DEPOT-PED (1-MONTH – leuprolide acetate forinj pediatric kit 11.25 mg..............................................14,18

LUPRON DEPOT-PED (1-MONTH – leuprolide acetate forinj pediatric kit 15 mg...................................................14,18

LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3month) for inj pediatric kit 11.25 mg................................. 14

LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3month) for inj pediatric kit 30 mg......................................14

LYNPARZA – olaparib cap 50 mg........................................9LYNPARZA – olaparib tab 100 mg.......................................9LYNPARZA – olaparib tab 150 mg.......................................9LYRICA – pregabalin cap 25 mg........................................48LYRICA – pregabalin cap 50 mg........................................48LYRICA – pregabalin cap 75 mg........................................48LYRICA – pregabalin cap 100 mg......................................48LYRICA – pregabalin cap 150 mg......................................48LYRICA – pregabalin cap 200 mg......................................48LYRICA – pregabalin cap 225 mg......................................48LYRICA – pregabalin cap 300 mg......................................48LYRICA – pregabalin soln 20 mg/ml.................................. 48LYSODREN – mitotane tab 500 mg.....................................9

Mmalathion lotion 0.5% (Ovide).........................................57MATULANE – procarbazine hcl cap 50 mg......................... 9MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg.......... 4meclizine hcl tab 12.5 mg................................................ 33meclizine hcl tab 25 mg................................................... 33medroxyprogesterone acetate im susp 150 mg/ml(Depo-provera contrac).................................................. 13

medroxyprogesterone acetate im susp prefilled syr150 mg/ml (Depo-provera contrac)............................... 13

medroxyprogesterone acetate tab 2.5 mg(Provera)........................................................................... 13

medroxyprogesterone acetate tab 5 mg (Provera).......13medroxyprogesterone acetate tab 10 mg (Provera).....13megestrol acetate susp 40 mg/ml (Megace oral)............ 9megestrol acetate tab 20 mg.............................................9megestrol acetate tab 40 mg.............................................9MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg(base equivalent).................................................................9

MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (baseequivalent)............................................................................9

meloxicam tab 7.5 mg (Mobic)........................................46meloxicam tab 15 mg (Mobic).........................................46melphalan tab 2 mg (Alkeran)...........................................9memantine 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)............................ 43MENTAX – butenafine hcl cream 1%.................................55MEPHYTON – phytonadione tab 5 mg.............................. 50

2018


mercaptopurine tab 50 mg (Purinethol)...........................9mesalamine enema 4 gm................................................. 34mesalamine tab delayed release 1.2 gm (Lialda)..........34metaxalone tab 800 mg (Skelaxin)..................................50metformin 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)..........................26methimazole 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)..............10methscopolamine 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)..........................11methylprednisolone tab 8 mg (Medrol)..........................11methylprednisolone tab 16 mg (Medrol)........................11methylprednisolone tab 32 mg (Medrol)........................11methylprednisolone tab therapy pack 4 mg (21)(Medrol dosepak).............................................................11

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)................................................................ 22

metoprolol & hydrochlorothiazide tab 100-25 mg(Lopressor hct)................................................................ 22

metoprolol succinate tab er 24hr 25 mg (tartrate equiv)(Toprol xl)......................................................................... 22

metoprolol succinate tab er 24hr 50 mg (tartrate equiv)(Toprol xl)......................................................................... 22

metoprolol succinate tab er 24hr 100 mg (tartrateequiv) (Toprol xl)............................................................. 22

metoprolol succinate tab er 24hr 200 mg (tartrateequiv) (Toprol xl)............................................................. 22

metoprolol tartrate tab 25 mg......................................... 22metoprolol tartrate tab 50 mg (Lopressor).................... 22metoprolol tartrate tab 100 mg (Lopressor).................. 22metronidazole cream 0.75% (Metrocream).................... 54metronidazole gel 0.75%..................................................54metronidazole gel 1% (Metrogel).................................... 54metronidazole lotion 0.75% (Metrolotion)......................54metronidazole tab 250 mg (Flagyl)................................... 7metronidazole tab 500 mg (Flagyl)................................... 7metronidazole vaginal gel 0.75% (Metrogel-vaginal)..............................................................................35

mexiletine hcl cap 150 mg...............................................27mexiletine hcl cap 200 mg...............................................27mexiletine hcl cap 250 mg...............................................27MICROLET LANCETS – lancets........................................58midodrine hcl tab 2.5 mg.................................................28midodrine hcl tab 5 mg....................................................28midodrine hcl tab 10 mg..................................................28minocycline hcl cap 50 mg (Minocin).............................. 2minocycline hcl cap 75 mg (Minocin).............................. 2minocycline hcl cap 100 mg (Minocin)............................ 2minocycline hcl tab 50 mg................................................ 2minocycline hcl tab 75 mg................................................ 2minocycline hcl tab 100 mg.............................................. 2minoxidil tab 2.5 mg.........................................................28minoxidil tab 10 mg..........................................................28mirtazapine tab 7.5 mg.....................................................37mirtazapine tab 15 mg (Remeron).................................. 37mirtazapine tab 30 mg (Remeron).................................. 37mirtazapine tab 45 mg (Remeron).................................. 37misoprostol tab 100 mcg (Cytotec)................................ 32misoprostol tab 200 mcg (Cytotec)................................ 32modafinil tab 100 mg (Provigil).......................................41modafinil tab 200 mg (Provigil).......................................41moexipril hcl tab 7.5 mg (Univasc).................................20moexipril hcl tab 15 mg (Univasc)..................................20moexipril-hydrochlorothiazide tab 7.5-12.5 mg.............20moexipril-hydrochlorothiazide tab 15-25 mg.................20moexipril-hydrochlorothiazide tab 15-12.5 mg(Uniretic)........................................................................... 20

mometasone furoate cream 0.1% (Elocon)................... 56mometasone furoate nasal susp 50 mcg/act(Nasonex)..........................................................................29

mometasone furoate oint 0.1% (Elocon)........................56mometasone furoate solution 0.1% (lotion)(Elocon).............................................................................56

MONOJECT ALLERGIST TRAY/P – allergy tray kit 1/2 ml28 x 1/2"............................................................................ 58

MONOJECT ALLERGIST TRAY/P – allergy tray kit 1 ml28 x 1/2"............................................................................ 58

MONOJECT INSULIN SYRINGE/ – insulin syringe/needleu-100 1/2 ml 28 x 1/2"...................................................... 58

2018


MONOJECT INSULIN SYRINGE/ – insulin syringe/needleu-100 1/2 ml 29 x 1/2"...................................................... 58

MONOJECT INSULIN SYRINGE/ – insulin syringe/needleu-100 1/2 ml 30 x 5/16".................................................... 58

MONOJECT INSULIN SYRINGE/ – insulin syringe/needleu-100 0.3 ml 29 x 1/2"...................................................... 58

MONOJECT INSULIN SYRINGE/ – insulin syringe/needleu-100 0.3 ml 30 x 5/16".................................................... 58

MONOJECT INSULIN SYRINGE/ – insulin syringe/needleu-100 1 ml 25 x 5/8"......................................................... 58




MONOJECT INSULIN SYRINGE/ – insulin syringe/needleu-100 1 ml 30 x 5/16"....................................................... 58

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

MONOJECT INSULIN SYRINGE/ – insulin syringe (disp)u-100 1 ml......................................................................... 58

MONOJECT INSULIN SYRINGE – insulin syringe (disp)u-100 1 ml......................................................................... 58

MONOJECT ULTRA COMFORT IN – insulin syringe/needle u-100 1/2 ml 31 x 5/16"........................................ 59

MONOJECT ULTRA COMFORT IN – insulin syringe/needle u-100 1/2 ml 28 x 1/2".......................................... 59

MONOJECT ULTRA COMFORT IN – insulin syringe/needle u-100 1/2 ml 29 x 1/2".......................................... 59

MONOJECT ULTRA COMFORT IN – insulin syringe/needle u-100 1/2 ml 30 x 5/16"........................................ 59

MONOJECT ULTRA COMFORT IN – insulin syringe/needle u-100 0.3 ml 29 x 1/2".......................................... 58

MONOJECT ULTRA COMFORT IN – insulin syringe/needle u-100 0.3 ml 30 x 5/16"........................................ 58

MONOJECT ULTRA COMFORT IN – insulin syringe/needle u-100 1 ml 28 x 1/2"............................................. 59

MONOJECT ULTRA COMFORT IN – insulin syringe/needle u-100 1 ml 29 x 1/2"............................................. 59

MONOJECT ULTRA COMFORT IN – insulin syringe/needle u-100 0.3 ml 31 x 5/16"........................................ 59

montelukast sodium chew tab 4 mg (base equiv)(Singulair)......................................................................... 31

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)................... 44

morphine 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)..........................................................................52

MULTAQ – dronedarone hcl tab 400 mg (baseequivalent)......................................................................... 27

mupirocin calcium cream 2% (Bactroban).................... 55mupirocin oint 2% (Bactroban).......................................55mycophenolate 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.........................................10MYRBETRIQ – mirabegron tab er 24 hr 25 mg.................34MYRBETRIQ – mirabegron tab er 24 hr 50 mg.................34

Nnabumetone tab 500 mg.................................................. 46nabumetone tab 750 mg.................................................. 46nadolol tab 20 mg (Corgard)........................................... 22nadolol tab 40 mg (Corgard)........................................... 22nadolol tab 80 mg (Corgard)........................................... 22naloxone 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)....................................60naproxen 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............. 60NATACYN – natamycin ophth susp 5%............................. 52nateglinide tab 60 mg (Starlix)........................................16nateglinide tab 120 mg (Starlix)......................................16neomycin-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)...........................................................................53

2018


neomycin-polymyxin-dexamethasone ophth susp0.1% (Maxitrol)................................................................. 53

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............................................3NEULASTA ONPRO KIT – pegfilgrastim soln prefilledsyringe kit 6 mg/0.6ml.......................................................51

NEULASTA – pegfilgrastim soln prefilled syringe 6mg/0.6ml............................................................................ 51

NEUPOGEN – filgrastim inj 300 mcg/ml............................51NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ml)...................................................................................... 51

NEUPOGEN – filgrastim soln prefilled syringe 300mcg/0.5ml...........................................................................51

NEUPOGEN – filgrastim soln prefilled syringe 480mcg/0.8ml (600 mcg/ml)................................................... 51

nevirapine tab er 24hr 100 mg (Viramune xr)..................5nevirapine tab er 24hr 400 mg (Viramune xr)..................5nevirapine tab 200 mg (Viramune)....................................5NEXAVAR – sorafenib tosylate tab 200 mg (baseequivalent)......................................................................... 10

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)........................24nifedipine 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)................................. 10nimodipine cap 30 mg......................................................24NINLARO – ixazomib citrate cap 2.3 mg (baseequivalent)......................................................................... 10

NINLARO – ixazomib citrate cap 3 mg (baseequivalent)......................................................................... 10

NINLARO – ixazomib citrate cap 4 mg (baseequivalent)......................................................................... 10

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)............................ 24nitroglycerin sl tab 0.4 mg (Nitrostat)............................ 24nitroglycerin sl tab 0.6 mg (Nitrostat)............................ 24nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)..........24nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)..........24nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)..........25nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)..........25NITYR – nitisinone tab 2 mg..............................................18NITYR – nitisinone tab 5 mg..............................................18NITYR – nitisinone tab 10 mg............................................19norethindrone & ethinyl estradiol-fe chew tab 0.4mg-35 mcg (Femcon fe)................................................. 13

norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg(Brevicon-28)....................................................................13

norethindrone & ethinyl estradiol tab 1 mg-35 mcg(Norinyl 1+35)...................................................................13

norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg(Ovcon-35)........................................................................ 13

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20mcg (Loestrin fe 1/20).....................................................14

norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30mcg (Loestrin fe 1.5/30)..................................................14

norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg(Loestrin 1/20-21).............................................................14

norethindrone ace & ethinyl estradiol tab 1.5 mg-30mcg (Loestrin 1.5/30-21).................................................14

norethindrone acetate-ethinyl estradiol tab 1 mg-5mcg....................................................................................12

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5mcg (Femhrt low dose).................................................. 12

norethindrone acetate tab 5 mg (Aygestin)...................13norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35mg-mcg (Estrostep fe)....................................................13

norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg (Ortho-novum 7/7/7)............................................... 14

norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg (Tri-norinyl 28).........................................................14

norethindrone tab 0.35 mg (Nor-qd)...............................14norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg(Ortho-cyclen).................................................................. 14

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35mg-mcg (Ortho tri-cyclen)..............................................14

2018


norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25mg-mcg (Ortho tri-cyclen lo)......................................... 14

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg.........14nortriptyline hcl cap 10 mg (Pamelor)............................37nortriptyline hcl cap 25 mg (Pamelor)............................37nortriptyline hcl cap 50 mg (Pamelor)............................37nortriptyline hcl cap 75 mg (Pamelor)............................37NORVIR – ritonavir oral soln 80 mg/ml................................5NORVIR – ritonavir tab 100 mg........................................... 5NOVOLIN 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)........................................ 17

NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &aspart sus pen-inj 100 unit/ml (70-30)..............................17

NOVOLOG PENFILL – insulin aspart soln cartridge 100unit/ml.................................................................................17

NOXAFIL – posaconazole susp 40 mg/ml...........................3NOXAFIL – posaconazole tab delayed release 100 mg......3NUCYNTA ER – tapentadol hcl tab er 12hr 50 mg............44NUCYNTA ER – tapentadol hcl tab er 12hr 100 mg..........44NUCYNTA ER – tapentadol hcl tab er 12hr 150 mg..........44NUCYNTA ER – tapentadol hcl tab er 12hr 200 mg..........44NUCYNTA ER – tapentadol hcl tab er 12hr 250 mg..........44NUVARING – etonogestrel-ethinyl estradiol va ring0.120-0.015 mg/24hr.........................................................14

nystatin cream 100000 unit/gm.......................................55nystatin oint 100000 unit/gm........................................... 55nystatin susp 100000 unit/ml.......................................... 54nystatin tab 500000 unit.....................................................3nystatin topical powder 100000 unit/gm........................55nystatin-triamcinolone cream 100000-0.1 unit/gm-%........................................................................................ 56

nystatin-triamcinolone oint 100000-0.1 unit/gm-%....... 56O

octreotide acetate inj 50 mcg/ml (0.05 mg/ml)(Sandostatin)....................................................................19




octreotide acetate inj 1000 mcg/ml (1 mg/ml)(Sandostatin)....................................................................19

ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab200-25-25 mg...................................................................... 5

ODOMZO – sonidegib phosphate cap 200 mg (baseequivalent)......................................................................... 10

ofloxacin ophth soln 0.3% (Ocuflox)..............................52ofloxacin otic soln 0.3%...................................................53ofloxacin tab 400 mg..........................................................3olanzapine 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)................................................ 21

olmesartan medoxomil-hydrochlorothiazide tab40-12.5 mg (Benicar hct)................................................ 21

olmesartan medoxomil-hydrochlorothiazide tab 40-25mg (Benicar hct)..............................................................21

olmesartan medoxomil tab 5 mg (Benicar)................... 21olmesartan medoxomil tab 20 mg (Benicar)................. 21olmesartan medoxomil tab 40 mg (Benicar)................. 21olopatadine hcl ophth soln 0.2% (base equivalent)(Pataday)...........................................................................53

olopatadine hcl ophth soln 0.1% (base equivalent)(Patanol)............................................................................53

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).........16ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)............16OPSUMIT – macitentan tab 10 mg....................................28ORFADIN – nitisinone cap 2 mg........................................19ORFADIN – 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....................... 50

2018


oseltamivir phosphate cap 30 mg (base equiv)(Tamiflu).............................................................................. 6



oseltamivir phosphate for susp 6 mg/ml (base equiv)(Tamiflu).............................................................................. 6

OTEZLA – apremilast tab 30 mg....................................... 46OTEZLA – apremilast tab starter therapy pack 10 mg & 20mg & 30 mg.......................................................................46

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)........................ 45oxycodone 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







OZEMPIC – semaglutide soln pen-inj 1 mg/dose (2mg/1.5ml)........................................................................... 16

OZEMPIC – semaglutide soln pen-inj 0.25 or 0.5 mg/dose(2 mg/1.5ml)...................................................................... 16

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.................................... 3paroxetine 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).....................................37PAZEO – olopatadine hcl ophth soln 0.7% (baseequivalent)......................................................................... 53

PEGASYS – peginterferon alfa-2a inj 180 mcg/ml.............. 4PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml......... 4PEGASYS PROCLICK – peginterferon alfa-2a inj 135mcg/0.5ml.............................................................................4

PEGASYS PROCLICK – peginterferon alfa-2a inj 180mcg/0.5ml.............................................................................4

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm(Colyte-flavor packs).......................................................32

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm(Golytely)...........................................................................32

peg 3350-kcl-sod bicarb-nacl for soln 420 gm(Nulytely/flavor pack)......................................................32

penicillin v potassium tab 250 mg....................................1penicillin v potassium tab 500 mg....................................1pentoxifylline tab er 400 mg............................................51perindopril erbumine tab 2 mg....................................... 20perindopril erbumine tab 4 mg (Aceon).........................20perindopril erbumine tab 8 mg (Aceon).........................20permethrin cream 5% (Elimite)........................................57perphenazine 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 tab 16.2 mg...............................................39phenobarbital tab 32.4 mg...............................................39phenoxybenzamine 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)........................... 48

2018


PICATO – ingenol mebutate gel 0.015%........................... 57PICATO – ingenol mebutate gel 0.05%............................. 57pilocarpine hcl ophth soln 1% (Isopto carpine)............ 53pilocarpine hcl ophth soln 2% (Isopto carpine)............ 53pilocarpine hcl ophth soln 4% (Isopto carpine)............ 53pilocarpine hcl tab 5 mg (Salagen).................................54pilocarpine hcl tab 7.5 mg (Salagen)..............................54pimozide tab 1 mg (Orap)................................................ 43pimozide tab 2 mg (Orap)................................................ 43pindolol tab 5 mg..............................................................22pindolol tab 10 mg............................................................22pioglitazone hcl-metformin hcl tab 15-500 mg(Actoplus met)................................................................. 16

pioglitazone hcl-metformin hcl tab 15-850 mg(Actoplus met)................................................................. 16

pioglitazone hcl tab 15 mg (base equiv) (Actos)...........16pioglitazone hcl tab 30 mg (base equiv) (Actos)...........16pioglitazone hcl tab 45 mg (base equiv) (Actos)...........16piroxicam 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)......................................57polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% (Polytrim)...........................................................52

POMALYST – pomalidomide cap 1 mg............................. 10POMALYST – pomalidomide cap 2 mg............................. 10POMALYST – pomalidomide cap 3 mg............................. 10POMALYST – pomalidomide cap 4 mg............................. 10potassium 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

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

PRALUENT – alirocumab subcutaneous soln pen-injector75 mg/ml............................................................................25

PRALUENT – alirocumab subcutaneous soln pen-injector150 mg/ml..........................................................................25

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)................................. 6prazosin hcl cap 1 mg (Minipress)................................. 28prazosin hcl cap 2 mg (Minipress)................................. 28prazosin hcl cap 5 mg (Minipress)................................. 28prednisolone acetate ophth susp 1% (Pred forte)........ 53prednisolone sod phosphate oral soln 15 mg/5ml(base equiv)......................................................................11

prednisolone sod phosph oral soln 6.7 mg/5ml (5mg/5ml base) (Pediapred).............................................. 11

prednisolone syrup 15 mg/5ml (usp solutionequivalent) (Prelone).......................................................11

prednisone tab 1 mg........................................................ 11prednisone tab 2.5 mg..................................................... 11prednisone tab 5 mg........................................................ 11prednisone tab 10 mg...................................................... 11prednisone tab 20 mg...................................................... 11PREGNYL W/DILUENT BENZYL – chorionic gonadotropinfor im inj 10000 unit.......................................................... 14

PREMARIN – estrogens, conjugated tab 0.3 mg...............12PREMARIN – estrogens, conjugated tab 0.45 mg.............12PREMARIN – estrogens, conjugated tab 0.625 mg...........12PREMARIN – estrogens, conjugated tab 0.9 mg...............12PREMARIN – estrogens, conjugated tab 1.25 mg.............12PREMPHASE – conj est 0.625(14)/conj est-medroxyproac tab 0.625-5mg(14)........................................................13

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.3-1.5 mg......................................................13

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.45-1.5 mg....................................................13

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.625-2.5 mg..................................................13

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.625-5 mg.....................................................13

PREZCOBIX – darunavir-cobicistat tab 800-150 mg...........5PREZISTA – darunavir ethanolate susp 100 mg/ml (baseequiv)....................................................................................5

PREZISTA – darunavir ethanolate tab 75 mg (baseequiv)....................................................................................5

2018





PRIFTIN – rifapentine tab 150 mg....................................... 3PRIMAQUINE PHOSPHATE – primaquine phosphate tab26.3 mg (15 mg base)........................................................ 6

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.....................................38PROCRIT – epoetin alfa inj 2000 unit/ml...........................51PROCRIT – epoetin alfa inj 3000 unit/ml...........................51PROCRIT – epoetin alfa inj 4000 unit/ml...........................51PROCRIT – epoetin alfa inj 10000 unit/ml.........................51PROCRIT – epoetin alfa inj 20000 unit/ml.........................52PROCRIT – epoetin alfa inj 40000 unit/ml.........................52progesterone micronized cap 100 mg(Prometrium).................................................................... 13

progesterone micronized cap 200 mg(Prometrium).................................................................... 13

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)..............22propranolol hcl cap er 24hr 80 mg (Inderal la)..............22propranolol hcl cap er 24hr 120 mg (Inderal la)............22propranolol hcl cap er 24hr 160 mg (Inderal la)............22propranolol hcl tab 10 mg............................................... 22propranolol hcl tab 20 mg............................................... 22propranolol 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.............. 32

PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml)...................................................................................... 10

pyrazinamide tab 500 mg...................................................3pyridostigmine 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).................. 39quetiapine fumarate tab 200 mg (Seroquel).................. 39quetiapine fumarate tab 300 mg (Seroquel).................. 39quetiapine fumarate tab 400 mg (Seroquel).................. 39quinapril hcl tab 5 mg (Accupril).................................... 20quinapril hcl tab 10 mg (Accupril).................................. 20quinapril hcl tab 20 mg (Accupril).................................. 20quinapril hcl tab 40 mg (Accupril).................................. 20quinapril-hydrochlorothiazide tab 10-12.5 mg(Accuretic)........................................................................ 20

quinapril-hydrochlorothiazide tab 20-12.5 mg(Accuretic)........................................................................ 20

quinapril-hydrochlorothiazide tab 20-25 mg(Accuretic)........................................................................ 20

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).......................................... 20ramipril cap 2.5 mg (Altace)............................................ 20ramipril cap 5 mg (Altace)............................................... 20ramipril cap 10 mg (Altace)............................................. 20ranitidine hcl cap 150 mg................................................ 32ranitidine hcl cap 300 mg................................................ 32ranitidine hcl syrup 15 mg/ml (75 mg/5ml).................... 33ranitidine hcl tab 150 mg (Zantac)..................................33ranitidine hcl tab 300 mg (Zantac)..................................33RAPAMUNE – sirolimus oral soln 1 mg/ml........................ 60rasagiline mesylate tab 0.5 mg (base equiv)(Azilect)............................................................................. 49

2018


rasagiline mesylate tab 1 mg (base equiv) (Azilect)..... 49REALITY INSULIN SYRINGE/U – insulin syringe/needleu-100 1/2 ml 28 x 1/2"...................................................... 59

REALITY INSULIN SYRINGE/U – insulin syringe/needleu-100 1/2 ml 29 x 1/2"...................................................... 59

REALITY INSULIN SYRINGE/U – insulin syringe/needleu-100 1 ml 28 x 1/2"......................................................... 59

REALITY INSULIN SYRINGE/U – insulin syringe/needleu-100 1 ml 29 x 1/2"......................................................... 59

REBIF – 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).................................... 16repaglinide tab 1 mg (Prandin)....................................... 16repaglinide tab 2 mg (Prandin)....................................... 16REPATHA – evolocumab subcutaneous soln prefilledsyringe 140 mg/ml.............................................................25

REPATHA PUSHTRONEX SYSTEM – evolocumabsubcutaneous soln cartridge/infusor 420 mg/3.5ml..........26

REPATHA SURECLICK – evolocumab subcutaneous solnauto-injector 140 mg/ml.................................................... 26

REVLIMID – lenalidomide cap 5 mg..................................60REVLIMID – lenalidomide cap 10 mg................................60REVLIMID – lenalidomide cap 15 mg................................60REVLIMID – lenalidomide cap 20 mg................................60REVLIMID – lenalidomide cap 25 mg................................60REVLIMID – lenalidomide caps 2.5 mg............................. 60REYATAZ – atazanavir sulfate cap 150 mg (baseequiv)....................................................................................5

REYATAZ – atazanavir sulfate cap 200 mg (baseequiv)....................................................................................5

REYATAZ – atazanavir sulfate cap 300 mg (baseequiv)....................................................................................5

ribavirin cap 200 mg (Rebetol)..........................................4ribavirin tab 200 mg (Copegus)........................................ 4rifabutin cap 150 mg (Mycobutin).....................................3rifampin cap 150 mg (Rifadin)...........................................3rifampin cap 300 mg (Rifadin)...........................................3RILUTEK – 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 orally disintegrating tab 0.5 mg (Risperdalm-tab)................................................................................ 39

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).............................................5rivastigmine 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.................................... 10

SSANDIMMUNE – cyclosporine oral soln 100 mg/ml..........60SANDOSTATIN 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%........................................... 57SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)..........19SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)..........19

2018


SENSIPAR – 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)...................... 55SIMPONI – 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....................................................... 59sirolimus tab 0.5 mg (Rapamune)...................................60sirolimus tab 1 mg (Rapamune)......................................60sirolimus tab 2 mg (Rapamune)......................................60sodium 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)...... 54sodium fluoride gel 1.1% (0.5% f) (Previdentfluoride).............................................................................54

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).................................................................................. 60

sodium polystyrene sulfonate powder(Kayexalate)......................................................................60

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)..................................27

sotalol hcl tab 160 mg (Betapace)..................................27SOVALDI – sofosbuvir tab 400 mg...................................... 4SPIRIVA 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.......................................10SPRYCEL – dasatinib tab 50 mg.......................................10SPRYCEL – dasatinib tab 70 mg.......................................10SPRYCEL – dasatinib tab 80 mg.......................................10SPRYCEL – dasatinib tab 100 mg.....................................10SPRYCEL – dasatinib tab 140 mg.....................................10stavudine cap 15 mg (Zerit)...............................................5stavudine cap 20 mg (Zerit)...............................................5stavudine cap 30 mg (Zerit)...............................................5stavudine cap 40 mg (Zerit)...............................................5STELARA – ustekinumab inj 45 mg/0.5ml.........................57STELARA – ustekinumab soln prefilled syringe 45mg/0.5ml............................................................................ 57

STELARA – ustekinumab soln prefilled syringe 90 mg/ml........................................................................................57

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..................................10STRENSIQ – asfotase alfa subcutaneous inj 18mg/0.45ml.......................................................................... 19

STRENSIQ – asfotase alfa subcutaneous inj 28mg/0.7ml............................................................................ 19

STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml........................................................................................19

STRENSIQ – asfotase alfa subcutaneous inj 80mg/0.8ml............................................................................ 19

STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab150-150-200-300 mg...........................................................5

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).......................................................60

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1mg (base equiv)................................................................ 60



sucralfate tab 1 gm (Carafate).........................................33sulfacetamide sodium lotion 10% (acne) (Klaron)........54sulfacetamide sodium ophth soln 10% (Bleph-10)....... 52

2018


sulfacetamide sodium-prednisolone ophth soln10-0.23(0.25)%.................................................................. 53

SULFADIAZINE – sulfadiazine tab 500 mg......................... 7sulfamethoxazole-trimethoprim susp 200-40mg/5ml.................................................................................7

sulfamethoxazole-trimethoprim tab 400-80 mg(Bactrim)............................................................................. 7

sulfamethoxazole-trimethoprim tab 800-160 mg(Bactrim ds)........................................................................7

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).............47sumatriptan 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......................................... 2SUPRAX – cefixime chew tab 100 mg................................ 2SUPRAX – cefixime chew tab 200 mg................................ 2SUPRAX – cefixime for susp 100 mg/5ml........................... 2SUPRAX – cefixime for susp 200 mg/5ml........................... 2SUPRAX – cefixime for susp 500 mg/5ml........................... 2SUSTIVA – efavirenz tab 600 mg........................................ 5SUTENT – sunitinib malate cap 12.5 mg (baseequivalent)......................................................................... 10

SUTENT – sunitinib malate cap 25 mg (baseequivalent)......................................................................... 10

SUTENT – sunitinib malate cap 37.5 mg (baseequivalent)......................................................................... 10

SUTENT – sunitinib malate cap 50 mg (baseequivalent)......................................................................... 10

SYLATRON – peginterferon alfa-2b for inj kit 200 mcg..... 10SYLATRON – peginterferon alfa-2b for inj kit 300 mcg..... 10SYLATRON – peginterferon alfa-2b for inj kit 600 mcg..... 10SYMBICORT – budesonide-formoterol fumarate dihydaerosol 80-4.5 mcg/act..................................................... 31

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 160-4.5 mcg/act................................................... 31

SYNAREL – nafarelin acetate nasal soln 2 mg/ml (200mcg/act) (base eq)............................................................ 14

SYNJARDY – empagliflozin-metformin hcl tab 5-500mg...................................................................................... 16

SYNJARDY – empagliflozin-metformin hcl tab 5-1000mg...................................................................................... 16

SYNJARDY – empagliflozin-metformin hcl tab 12.5-500mg...................................................................................... 16

SYNJARDY – empagliflozin-metformin hcl tab 12.5-1000mg...................................................................................... 16

SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr5-1000 mg......................................................................... 16

SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr10-1000 mg....................................................................... 16

SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr12.5-1000 mg.................................................................... 16

SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr25-1000 mg....................................................................... 16

SYNTHROID – levothyroxine sodium tab 25 mcg............. 18SYNTHROID – levothyroxine sodium tab 50 mcg............. 18SYNTHROID – levothyroxine sodium tab 75 mcg............. 18SYNTHROID – levothyroxine sodium tab 88 mcg............. 18SYNTHROID – levothyroxine sodium tab 100 mcg........... 18SYNTHROID – levothyroxine sodium tab 112 mcg........... 18SYNTHROID – levothyroxine sodium tab 125 mcg........... 18SYNTHROID – levothyroxine sodium tab 137 mcg........... 18SYNTHROID – levothyroxine sodium tab 150 mcg........... 18SYNTHROID – levothyroxine sodium tab 175 mcg........... 18SYNTHROID – levothyroxine sodium tab 200 mcg........... 18SYNTHROID – levothyroxine sodium tab 300 mcg........... 18

TTABLOID – thioguanine tab 40 mg.................................... 10TACLONEX – calcipotriene-betamethasone dipropionatesusp 0.005-0.064%........................................................... 56

tacrolimus cap 0.5 mg (Prograf)..................................... 60tacrolimus cap 1 mg (Prograf)........................................ 60tacrolimus cap 5 mg (Prograf)........................................ 60tacrolimus oint 0.03% (Protopic).................................... 57tacrolimus oint 0.1% (Protopic)...................................... 57TAFINLAR – dabrafenib mesylate cap 50 mg (baseequivalent)......................................................................... 10

TAFINLAR – dabrafenib mesylate cap 75 mg (baseequivalent)......................................................................... 10

TAGRISSO – osimertinib mesylate tab 40 mg (baseequivalent)......................................................................... 10

TAGRISSO – osimertinib mesylate tab 80 mg (baseequivalent)......................................................................... 10

tamoxifen citrate tab 10 mg (base equivalent)..............10tamoxifen citrate tab 20 mg (base equivalent)..............10tamsulosin hcl cap 0.4 mg (Flomax).............................. 35TARCEVA – erlotinib hcl tab 25 mg (base equivalent).......10TARCEVA – erlotinib hcl tab 100 mg (base equivalent).....10TARCEVA – erlotinib hcl tab 150 mg (base equivalent).....10TASIGNA – nilotinib hcl cap 50 mg (base equivalent)....... 10TASIGNA – nilotinib hcl cap 150 mg (base equivalent)..... 10TASIGNA – nilotinib hcl cap 200 mg (base equivalent)..... 10tazarotene cream 0.1% (Tazorac)....................................54TAZORAC – tazarotene cream 0.05%...............................54TAZORAC – tazarotene gel 0.05%.................................... 54TAZORAC – tazarotene gel 0.1%...................................... 54

2018


TECFIDERA – 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)................................................................... 21

telmisartan-hydrochlorothiazide tab 80-12.5 mg(Micardis hct)................................................................... 21

telmisartan-hydrochlorothiazide tab 80-25 mg(Micardis hct)................................................................... 21

telmisartan tab 20 mg (Micardis).................................... 21telmisartan tab 40 mg (Micardis).................................... 21telmisartan tab 80 mg (Micardis).................................... 21temazepam 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)................................ 10temozolomide cap 20 mg (Temodar)..............................11temozolomide cap 100 mg (Temodar)............................11temozolomide cap 140 mg (Temodar)............................11temozolomide cap 180 mg (Temodar)............................11temozolomide cap 250 mg (Temodar)............................11tenofovir disoproxil fumarate tab 300 mg (Viread)......... 6terazosin 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).................................3terbutaline sulfate tab 2.5 mg......................................... 31terbutaline sulfate tab 5 mg............................................ 31terconazole vaginal cream 0.4% (Terazol 7).................. 35terconazole vaginal suppos 80 mg.................................35testosterone cypionate im inj in oil 100 mg/ml (Depo-testosterone).................................................................... 12

testosterone cypionate im inj in oil 200 mg/ml (Depo-testosterone).................................................................... 12

testosterone enanthate im inj in oil 200 mg/ml.............12testosterone td gel 12.5 mg/act (1%) (Androgelpump)................................................................................ 12

testosterone td gel 25 mg/2.5gm (1%) (Androgel)........ 12testosterone td gel 50 mg/5gm (1%) (Androgel)........... 12testosterone td soln 30 mg/act (Axiron)........................ 12tetrabenazine tab 12.5 mg (Xenazine)............................ 43tetrabenazine tab 25 mg (Xenazine)............................... 43tetracycline hcl cap 250 mg (Tetracycline hcl)................2tetracycline hcl cap 500 mg (Tetracycline hcl)................2THALOMID – thalidomide cap 50 mg................................ 60THALOMID – thalidomide cap 100 mg.............................. 60THALOMID – thalidomide cap 150 mg.............................. 60THALOMID – thalidomide cap 200 mg.............................. 60theophylline tab er 12hr 100 mg.....................................31theophylline tab er 12hr 200 mg.....................................31theophylline tab er 12hr 300 mg.....................................31

theophylline 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 ophth soln 0.25% (Timoptic)................53timolol maleate ophth soln 0.5% (Timoptic)..................53TIVICAY – dolutegravir sodium tab 10 mg (base equiv)...... 6TIVICAY – dolutegravir sodium tab 25 mg (base equiv)...... 6TIVICAY – dolutegravir sodium tab 50 mg (base equiv)...... 6tizanidine hcl tab 2 mg (base equivalent)......................50tizanidine hcl tab 4 mg (base equivalent)(Zanaflex).......................................................................... 50

tobramycin-dexamethasone ophth susp 0.3-0.1%(Tobradex).........................................................................53

tobramycin nebu soln 300 mg/5ml (Tobi)........................ 3tobramycin 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).................................... 49topiramate tab 50 mg (Topamax).................................... 49topiramate tab 100 mg (Topamax).................................. 49topiramate tab 200 mg (Topamax).................................. 49torsemide tab 5 mg (Demadex).......................................26torsemide tab 10 mg (Demadex).....................................26torsemide tab 20 mg (Demadex).....................................26torsemide tab 100 mg (Demadex)...................................26TOUJEO MAX SOLOSTAR – insulin glargine soln pen-injector 300 unit/ml............................................................17

TOUJEO SOLOSTAR – insulin glargine soln pen-injector300 unit/ml......................................................................... 17

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).......................................... 20trandolapril tab 2 mg (Mavik).......................................... 20trandolapril tab 4 mg (Mavik).......................................... 20tranylcypromine sulfate tab 10 mg (Parnate)................37TRAVATAN Z – travoprost ophth soln 0.004%(benzalkonium free) (bak free)......................................... 53

trazodone hcl tab 50 mg.................................................. 37trazodone hcl tab 100 mg................................................ 37trazodone hcl tab 150 mg................................................ 37trazodone hcl tab 300 mg................................................ 37

2018


TRELEGY ELLIPTA – fluticasone-umeclidinium-vilanterolaepb 100-62.5-25 mcg/inh................................................31

TRESIBA FLEXTOUCH – insulin degludec soln pen-injector 100 unit/ml............................................................17

TRESIBA FLEXTOUCH – insulin degludec soln pen-injector 200 unit/ml............................................................17

tretinoin cap 10 mg...........................................................11tretinoin cream 0.025% (Retin-a).....................................54tretinoin cream 0.05% (Retin-a).......................................54tretinoin cream 0.1% (Retin-a).........................................54tretinoin gel 0.01% (Retin-a)............................................ 55tretinoin gel 0.025% (Retin-a)..........................................55tretinoin microsphere gel 0.04% (Retin-a micro).......... 55tretinoin microsphere gel 0.1% (Retin-a micro)............ 55triamcinolone acetonide cream 0.025%......................... 56triamcinolone acetonide cream 0.1%............................. 56triamcinolone acetonide cream 0.5%............................. 56triamcinolone acetonide dental paste 0.1%.................. 54triamcinolone 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)..................................................................... 27

triamterene & hydrochlorothiazide tab 75-50 mg(Maxzide)...........................................................................27

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............................... 50trihexyphenidyl hcl tab 2 mg...........................................50trihexyphenidyl hcl tab 5 mg...........................................50trimethobenzamide hcl cap 300 mg (Tigan).................. 33trimethoprim tab 100 mg................................................... 7TRIUMEQ – abacavir-dolutegravir-lamivudine tab600-50-300 mg.................................................................... 6

tropicamide ophth soln 0.5%.......................................... 53tropicamide ophth soln 1% (Mydriacyl)......................... 53TRULICITY – dulaglutide soln pen-injector 0.75mg/0.5ml............................................................................ 16

TRULICITY – dulaglutide soln pen-injector 1.5mg/0.5ml............................................................................ 16

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 100-150 mg...................................................................6

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 133-200 mg................................................................... 6

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 167-250 mg...................................................................6

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 200-300 mg................................................................... 6

TYKERB – lapatinib ditosylate tab 250 mg (baseequiv)................................................................................. 11

TYMLOS – abaloparatide subcutaneous soln pen-injector3120 mcg/1.56ml...............................................................19

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)................................... 4valacyclovir hcl tab 500 mg (Valtrex)............................... 4VALCHLOR – mechlorethamine hcl gel 0.016% (baseequivalent)......................................................................... 57

valganciclovir hcl for soln 50 mg/ml (base equiv)(Valcyte).............................................................................. 3

valganciclovir hcl tab 450 mg (base equivalent)(Valcyte).............................................................................. 3

valproate sodium oral soln 250 mg/5ml (base equiv)(Depakene)........................................................................49

valproic acid cap 250 mg (Depakene)............................49valsartan-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

valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovanhct).....................................................................................22

valsartan-hydrochlorothiazide tab 320-25 mg (Diovanhct).....................................................................................22

valsartan tab 40 mg (Diovan).......................................... 21valsartan tab 80 mg (Diovan).......................................... 21valsartan tab 160 mg (Diovan)........................................ 21valsartan tab 320 mg (Diovan)........................................ 21vancomycin hcl cap 125 mg (Vancocin hcl)....................7vancomycin hcl cap 250 mg (Vancocin hcl)....................7VASCEPA – icosapent ethyl cap 0.5 gm............................26VASCEPA – icosapent ethyl cap 1 gm...............................26VELPHORO – sucroferric oxyhydroxide chew tab 500mg...................................................................................... 34

2018


venlafaxine 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..............................................37VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act(90mcg base equiv).......................................................... 31

verapamil 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.................... 35VESICARE – solifenacin succinate tab 10 mg...................35VIBERZI – eluxadoline tab 75 mg......................................34VIBERZI – eluxadoline tab 100 mg....................................34VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml)...................................................................................... 16

VIDEX – didanosine for soln 2 gm.......................................6VIDEX – didanosine for soln 4 gm.......................................6vigabatrin powd pack 500 mg (Sabril)........................... 49VIRAMUNE – nevirapine susp 50 mg/5ml...........................6VIREAD – tenofovir disoproxil fumarate oral powder 40mg/gm.................................................................................. 6

VIREAD – tenofovir disoproxil fumarate tab 150 mg........... 6VIREAD – tenofovir disoproxil fumarate tab 200 mg........... 6VIREAD – tenofovir disoproxil fumarate tab 250 mg........... 6VIREAD – tenofovir disoproxil fumarate tab 300 mg........... 6voriconazole for susp 40 mg/ml (Vfend)..........................3voriconazole tab 50 mg (Vfend)........................................3voriconazole tab 200 mg (Vfend)......................................3VOSEVI – sofosbuvir-velpatasvir-voxilaprevir tab400-100-100 mg.................................................................. 4

VOTRIENT – pazopanib hcl tab 200 mg (base equiv).......11VYVANSE – lisdexamfetamine dimesylate cap 10 mg...... 41VYVANSE – lisdexamfetamine dimesylate cap 20 mg...... 41VYVANSE – lisdexamfetamine dimesylate cap 30 mg...... 41VYVANSE – lisdexamfetamine dimesylate cap 40 mg...... 41VYVANSE – lisdexamfetamine dimesylate cap 50 mg...... 41

VYVANSE – 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).......................... 52warfarin sodium tab 2 mg (Coumadin).......................... 52warfarin sodium tab 2.5 mg (Coumadin)....................... 52warfarin sodium tab 3 mg (Coumadin).......................... 52warfarin sodium tab 4 mg (Coumadin).......................... 52warfarin sodium tab 5 mg (Coumadin).......................... 52warfarin sodium tab 6 mg (Coumadin).......................... 52warfarin sodium tab 7.5 mg (Coumadin)....................... 52warfarin sodium tab 10 mg (Coumadin)........................ 52WELCHOL – colesevelam hcl packet for susp 3.75gm...................................................................................... 26

WELCHOL – colesevelam hcl tab 625 mg........................ 26

XXALKORI – crizotinib cap 200 mg..................................... 11XALKORI – crizotinib cap 250 mg..................................... 11XARELTO – rivaroxaban tab 10 mg...................................52XARELTO – rivaroxaban tab 15 mg...................................52XARELTO – rivaroxaban tab 20 mg...................................52XARELTO STARTER PACK – rivaroxaban tab startertherapy pack 15 mg & 20 mg...........................................52

XIFAXAN – rifaximin tab 550 mg......................................... 7XTANDI – enzalutamide cap 40 mg...................................11

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...........................................................................52

ZARXIO – filgrastim-sndz soln prefilled syringe 480mcg/0.8ml...........................................................................52

ZELBORAF – vemurafenib tab 240 mg............................. 11ZENPEP – pancrelipase (lip-prot-amyl) dr cap3000-10000-16000 unit..................................................... 33

ZENPEP – pancrelipase (lip-prot-amyl) dr cap5000-17000-24000 unit..................................................... 33

2018


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).....................................6zidovudine syrup 10 mg/ml (Retrovir)..............................6zidovudine tab 300 mg.......................................................6ziprasidone 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.................................... 11zolpidem 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..................................................... 49zonisamide cap 25 mg (Zonegran)................................. 49zonisamide cap 100 mg (Zonegran)............................... 49ZORTRESS – everolimus tab 0.25 mg.............................. 60ZORTRESS – everolimus tab 0.5 mg................................ 60ZORTRESS – everolimus tab 0.75 mg.............................. 60ZYDELIG – idelalisib tab 100 mg.......................................11ZYDELIG – idelalisib tab 150 mg.......................................11ZYKADIA – ceritinib cap 150 mg....................................... 11ZYTIGA – abiraterone acetate tab 250 mg........................11ZYTIGA – abiraterone acetate tab 500 mg........................11

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