blue cross blue shield of north dakota drug formulary, april 2020€¦ · or check if a particular...

2626 ND © Prime Therapeutics LLC 07/20

Blue Cross Blue Shield of North Dakota Drug Formulary July 2020

Please consider talking to your doctor about prescribing formulary 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.

The drug formulary is regularly updated. Please visit bcbsnd.com for the most up-to-date information.

Contents Introduction ..................................................................... I Formulary ........................................................................ I Members ......................................................................... I Specialty Products .......................................................... I Providers ........................................................................ II Generic Utilization .......................................................... II Prior Approval ................................................................ II Dispensing Limits ........................................................... II How to Use This List ..................................................... III Abbreviation key .......................................................... IV

Therapeutic Class Drug List Anti-Infective Agents ...................................................... 1 Immunizing Agents ........................................................ 6 Cancer Drugs................................................................. 6 Hormones, Diabetes and Related Drugs ......................10 Heart and Circulatory Drugs ........................................ 18 Respiratory Agents ...................................................... 26 Gastrointestinal Drugs ................................................. 29 Genitourinary Drugs .................................................... 31 Central Nervous System Drugs ................................... 31 Pain Relief Drugs ......................................................... 40 Neuromuscular Drugs .................................................. 44 Blood Modifying Drugs ................................................ 48 Topical Products .......................................................... 49 Miscellaneous Categories ........................................... 54 Index ............................................................................ 57

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.

Blue Cross Blue Shield of North Dakota Drug Formulary, July 2020 I

Introduction

Formulary The goal of the Blue Cross Blue Shield of North Dakota (BCBSND) formulary is to provide our members broad access to drugs and supplies at a reasonable overall cost. The BCBSND Drug Formulary is the list of products (drugs and supplies) that reflect the current recommendations of the BCBSND Pharmacy & Therapeutics (P&T) Committee. The formulary is intended for use in the ambulatory setting. Drugs are selected for addition to the formulary after considering safety, efficacy, uniqueness, and market considerations. Providers are encouraged to prescribe formulary drugs.

Benefits are not limited to the drugs on this formulary list. Products not listed in this formulary are non-formulary (NF). The P&T committee may choose to not add a drug or remove a drug from formulary for reasons including safety or efficacy concerns, or because a clinically similar, more cost-effective drug is already on formulary. Newly marketed drugs are non-formulary until reviewed by the P&T Committee. The entire formulary is reviewed annually by the P&T Committee. This formulary list is subject to change. Drug coverage is dependent on individual plan benefits.

Members To save the most money on prescription drugs, take this Formulary with you each time you visit your physician. Consider asking your physician to prescribe drugs listed in this Formulary, if appropriate. Any and all decisions that require or pertain to independent professional medical judgment or training, or the need for, and dosage of, a prescription drug, must be made solely by you and your physician in accordance with the patient/physician relationship.

The current version and recent changes to this Formulary is available at the BCBSND website at www.bcbsnd.com or by calling the customer service number listed on your identification card. Online pharmacy tools are available through the Prime Therapeutics® website at www.MyPrime.com. BCBSND members can find drug cost estimates or check if a particular drug is on the BCBSND formulary.

Under some circumstances, formulary drugs may be excluded from coverage under the drug benefit (e.g., oral contraceptives, nicotine replacement therapy, Retin-A, various injectables, etc.). In all cases, plan inclusions/exclusions determine specific coverage regardless of formulary status. Drugs not listed are non-formulary.

Specialty Products 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. These high cost medications also have one or more of the following characteristics:

• Unique storage or shipment requirements

• Additional education and support required from a health care professional

• Usually not stocked at retail pharmacies

Blue Cross Blue Shield of North Dakota Drug Formulary, July 2020 II

Providers

Generic Utilization The BCBSND Committee encourages generic utilization as a way to provide high-quality drugs at a reduced cost. By prescribing drugs listed in this formulary that are available generically, you are providing a product that can be expected to have the same effectiveness and safety profile as the brand product while lowering overall medical insurance costs for your patients. In addition, your patient will likely have a lower cost share for generic drugs because most benefit plans are based on a tiered or brand/generic copayment and coinsurance structure.

Prior Approval Use of some products may be approved only after certain criteria are met. If prior approval is not obtained, benefits may be denied. A physician (or clinic personnel) should submit a written request to the address shown below for prior approval consideration. The Prior Approval Request form is available at https://www.bcbsnd.com/web/providers/forms. A list of the products requiring prior approval may be found at https://www.bcbsnd.com/web/providers/pharmacy under Restricted-Use Drugs.

Fax to: (701) 277-2253 Mail to: BCBSND Attn: Medical Management 4510 13th Ave S Fargo, ND 58121

Dispensing Limits Products in certain drug categories may have dispensing limits to encourage appropriate prescribing quantities as recommended by the FDA approved product labeling, or as otherwise clinically appropriate. Requests for a quantity that exceeds the dispensing limit should be submitted for consideration on the Dispensing Limits Authorization form available at https://www.myprime.com/v/BCBSND/COMMERCIAL/en/forms.html. A list of products with dispensing limits may also be found at at this site and at https://www.bcbsnd.com/web/providers/pharmacy under Restricted-Use Drugs.

Fax to: (877) 480-8130

Mail to: Prime Therapeutics LLC, Clinical Review Department 1305 Corporate Center Drive Eagan, Minnesota 55121

https://www.bcbsnd.com/web/providers/forms

https://www.bcbsnd.com/web/providers/forms

https://www.bcbsnd.com/web/providers/pharmacy


https://www.myprime.com/v/BCBSND/COMMERCIAL/en/forms.html

https://www.myprime.com/v/BCBSND/COMMERCIAL/en/forms.html



Blue Cross Blue Shield of North Dakota Drug Formulary, July 2020 III

How to use this list The Formulary is organized into broad categories (e.g. Anti-Infective drugs). Within most categories, drugs are sub-grouped by drug class (e.g. Penicillins) or by use for a specific medical condition (e.g. Diabetes). These categories can help determine which specific product is on formulary. The graphic below shows the information that is provided in each column of the medication list and is an example only. Please use the drug search function to find current information for drugs on the medication list.

The first column of the chart lists the drug name. Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). The reference brand is a non-formulary drug. Some generic products have no reference brand.

Brand prescription drugs are shown in capital letters followed by the generic name.

The second column indicates if the drug is a specialty drug. Note: Additional information about specialty drugs can be found in this document under the header for Specialty Products.

The columns indicates the Utilization Management (UM) program(s) that apply to the prescription drug (e.g., Prior Approval and Dispensing Limits). If an indicator is present in the column(s), then the UM program noted is possibly applied to your benefit. Some plans may have UM on additional medications beyond those noted in this document.

Blue Cross Blue Shield of North Dakota Drug Formulary, July 2020 IV

Abbreviation key aer..................................................................... aerosol cap ................................................................. capsules chew ............................................................. chewable conc .......................................................... concentrate cr...................................................... controlled release dr ........................................................ delayed release ec ........................................................... enteric coated equiv ........................................................... equivalent er....................................................... extended release gm........................................................................ gram inhal................................................................... inhaler inj .................................................................... injection liqd....................................................................... liquid mg.................................................................. milligram ml ..................................................................... milliliter

nebu .............................................................. nebulizer odt. ....................................... orally disintegrating tabs oint ................................................................ ointment ophth .......................................................... ophthalmic osm ..................................................... osmotic release pack ................................................................. packets powd .................................................................powder pttw ................................................ twice-weekly patch sl .................................................................. sublingual soln .................................................................. solution suppos ................................................... suppositories susp ........................................................... suspension tab ...................................................................... tablets td ............................................................... transdermal w/ ........................................................................... with

2020

Blue Cross Blue Shield of North Dakota Drug Formulary, July 2020 1

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

ANTI-INFECTIVE AGENTSPENICILLINSAMOXICILLIN – amoxicillin (trihydrate)

chew tab 125 mgAMOXICILLIN – amoxicillin (trihydrate)

chew tab 250 mgamoxicillin (trihydrate) cap 250 mgamoxicillin (trihydrate) cap 500 mgamoxicillin (trihydrate) for susp

125 mg/5mlamoxicillin (trihydrate) for susp



400 mg/5mlamoxicillin (trihydrate) tab 500 mgamoxicillin (trihydrate) tab 875 mgamoxicillin & k clavulanate for susp

200-28.5 mg/5mlamoxicillin & k clavulanate for susp

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

400-57 mg/5mlamoxicillin & k clavulanate for susp

600-42.9 mg/5ml (Augmentin es-600)amoxicillin & k clavulanate tab

250-125 mgamoxicillin & k clavulanate tab

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

875-125 mg (Augmentin)AMOXICILLIN/CLAVULANATE P –

amoxicillin & k clavulanate tab er 12hr1000-62.5 mg

AMOXICILLIN/CLAVULANATE P –amoxicillin & k clavulanate chew tab200-28.5 mg

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

AMOXICILLIN/CLAVULANATE P –amoxicillin & k clavulanate chew tab400-57 mg

AMPICILLIN – ampicillin cap 500 mgAUGMENTIN – amoxicillin & k clavulanate

for susp 125-31.25 mg/5mldicloxacillin sodium cap 250 mgdicloxacillin sodium cap 500 mgPENICILLIN V POTASSIUM – penicillin v

potassium for soln 125 mg/5mlPENICILLIN V POTASSIUM – penicillin v

potassium for soln 250 mg/5mlpenicillin v potassium tab 250 mgpenicillin v potassium tab 500 mgCEPHALOSPORINScefaclor cap 250 mgcefaclor cap 500 mgcefadroxil cap 500 mgcefadroxil for susp 250 mg/5mlcefadroxil for susp 500 mg/5mlcefadroxil tab 1 gmcefdinir cap 300 mgcefdinir for susp 125 mg/5mlcefdinir for susp 250 mg/5mlcefixime cap 400 mg (Suprax)cefixime for susp 100 mg/5ml (Suprax)cefixime for susp 200 mg/5ml (Suprax)cefpodoxime proxetil for susp 50 mg/5mlcefpodoxime proxetil for susp

100 mg/5mlcefpodoxime proxetil tab 100 mgcefpodoxime proxetil tab 200 mgcefprozil for susp 125 mg/5mlcefprozil for susp 250 mg/5mlcefprozil tab 250 mgcefprozil tab 500 mg

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

cefuroxime axetil tab 250 mg (Ceftin)cefuroxime axetil tab 500 mg (Ceftin)cephalexin cap 250 mg (Keflex)cephalexin cap 500 mg (Keflex)cephalexin for susp 125 mg/5mlcephalexin for susp 250 mg/5mlSUPRAX – cefixime for susp 500 mg/5mlSUPRAX – cefixime chew tab 100 mgSUPRAX – cefixime chew tab 200 mgMACROLIDESAZITHROMYCIN – azithromycin powd pack

for susp 1 gmazithromycin for susp 100 mg/5ml

(Zithromax)azithromycin for susp 200 mg/5ml

(Zithromax)azithromycin tab 250 mg (Zithromax)azithromycin tab 500 mg (Zithromax)azithromycin tab 600 mg (Zithromax)CLARITHROMYCIN – clarithromycin for

susp 125 mg/5mlCLARITHROMYCIN – clarithromycin for

susp 250 mg/5mlclarithromycin tab er 24hr 500 mgclarithromycin tab 250 mg (Biaxin)clarithromycin tab 500 mg (Biaxin)TETRACYCLINESdemeclocycline hcl tab 150 mgdemeclocycline hcl tab 300 mgdoxycycline hyclate cap 50 mgdoxycycline hyclate cap 100 mg

(Vibramycin)doxycycline hyclate tab 20 mgdoxycycline hyclate tab 100 mgdoxycycline monohydrate cap 50 mgdoxycycline monohydrate cap 75 mg

(Monodox)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

doxycycline monohydrate cap 100 mg(Monodox)

doxycycline monohydrate cap 150 mg(Adoxa)

doxycycline monohydrate tab 50 mg(Adoxa)

doxycycline monohydrate tab 75 mg(Adoxa)

doxycycline monohydrate tab 100 mg(Adoxa pak 1/100)

doxycycline monohydrate tab 150 mg(Adoxa pak 1/150)

minocycline hcl cap 50 mg (Minocin)minocycline hcl cap 75 mg (Minocin)minocycline hcl cap 100 mg (Minocin)minocycline hcl tab 50 mgminocycline hcl tab 75 mgminocycline hcl tab 100 mgtetracycline hcl cap 250 mg (Tetracycline

hcl)tetracycline hcl cap 500 mg (Tetracycline

hcl)FLUOROQUINOLONESCIPRO – ciprofloxacin for oral susp 500

mg/5ml (10%) (10 gm/100ml)CIPROFLOXACIN HCL – ciprofloxacin hcl

tab 100 mg (base equiv)ciprofloxacin hcl tab 250 mg (base equiv)

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

(Cipro)ciprofloxacin hcl tab 750 mg (base equiv)levofloxacin oral soln 25 mg/ml

(Levaquin)levofloxacin tab 250 mg (Levaquin)levofloxacin tab 500 mg (Levaquin)levofloxacin tab 750 mg (Levaquin)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

moxifloxacin hcl tab 400 mg (base equiv)(Avelox)

ofloxacin tab 400 mgAMINOGLYCOSIDESneomycin sulfate tab 500 mgPAROMOMYCIN SULFATE – paromomycin

sulfate cap 250 mgtobramycin nebu soln 300 mg/5ml (Tobi) •TUBERCULOSISethambutol hcl tab 100 mg (Myambutol)ethambutol hcl tab 400 mg (Myambutol)ISONIAZID – isoniazid syrup 50 mg/5mlisoniazid tab 100 mgisoniazid tab 300 mgPRIFTIN – rifapentine tab 150 mgpyrazinamide tab 500 mgrifabutin cap 150 mg (Mycobutin)rifampin cap 150 mg (Rifadin)rifampin cap 300 mg (Rifadin)FUNGAL INFECTIONSfluconazole for susp 10 mg/ml (Diflucan)fluconazole for susp 40 mg/ml (Diflucan)fluconazole tab 50 mg (Diflucan)fluconazole tab 100 mg (Diflucan)fluconazole tab 150 mg (Diflucan)fluconazole tab 200 mg (Diflucan)flucytosine cap 250 mg (Ancobon)flucytosine cap 500 mg (Ancobon)griseofulvin microsize susp 125 mg/5mlgriseofulvin microsize tab 500 mg

(Grifulvin v)itraconazole cap 100 mg (Sporanox)itraconazole oral soln 10 mg/ml

(Sporanox)NOXAFIL – posaconazole susp 40 mg/ml •nystatin tab 500000 unit

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

posaconazole tab delayed release100 mg (Noxafil)

•

terbinafine hcl tab 250 mg (Lamisil)voriconazole for susp 40 mg/ml (Vfend) •voriconazole tab 50 mg (Vfend) •voriconazole tab 200 mg (Vfend) •VIRAL INFECTIONSCytomegalovirusvalganciclovir hcl for soln 50 mg/ml

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

equivalent) (Valcyte)Hepatitisadefovir dipivoxil tab 10 mg (Hepsera)BARACLUDE – entecavir oral soln 0.05 mg/

mlentecavir tab 0.5 mg (Baraclude)entecavir tab 1 mg (Baraclude)EPCLUSA – sofosbuvir-velpatasvir tab

400-100 mg• • •

EPIVIR HBV – lamivudine oral soln 5 mg/ml(hbv)

HARVONI – ledipasvir-sofosbuvir tab45-200 mg

• • •

HARVONI – ledipasvir-sofosbuvir tab90-400 mg

• • •

lamivudine tab 100 mg (hbv) (Epivir hbv)LEDIPASVIR/SOFOSBUVIR – ledipasvir-

sofosbuvir tab 90-400 mg• • •

MAVYRET – glecaprevir-pibrentasvir tab100-40 mg

• • •

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

•

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

•

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

•

ribavirin cap 200 mg (Rebetol) •

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

ribavirin tab 200 mg (Copegus) •SOFOSBUVIR/VELPATASVIR – sofosbuvir-

velpatasvir tab 400-100 mg• • •

SOVALDI – sofosbuvir tab 200 mg • • •SOVALDI – sofosbuvir tab 400 mg • • •VOSEVI – sofosbuvir-velpatasvir-

voxilaprevir tab 400-100-100 mg• • •

Herpesacyclovir cap 200 mg (Zovirax)acyclovir susp 200 mg/5ml (Zovirax)acyclovir tab 400 mg (Zovirax)acyclovir tab 800 mg (Zovirax)famciclovir tab 125 mg (Famvir)famciclovir tab 250 mg (Famvir)famciclovir tab 500 mg (Famvir)valacyclovir hcl tab 500 mg (Valtrex)valacyclovir hcl tab 1 gm (Valtrex)HIV/AIDSabacavir sulfate soln 20 mg/ml (base

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

(Ziagen)abacavir sulfate-lamivudine tab

600-300 mg (Epzicom)abacavir sulfate-lamivudine-zidovudine

tab 300-150-300 mg (Trizivir)atazanavir sulfate cap 150 mg (base

equiv) (Reyataz)atazanavir sulfate cap 200 mg (base

equiv) (Reyataz)atazanavir sulfate cap 300 mg (base

equiv) (Reyataz)ATRIPLA – efavirenz-emtricitabine-tenofovir

df tab 600-200-300 mgBIKTARVY – bictegravir-emtricitabine-

tenofovir af tab 50-200-25 mgCIMDUO – lamivudine-tenofovir disoproxil

fumarate tab 300-300 mg

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

COMPLERA – emtricitabine-rilpivirine-tenofovir df tab 200-25-300 mg

DELSTRIGO – doravirine-lamivudine-tenofovir df tab 100-300-300 mg

DESCOVY – emtricitabine-tenofoviralafenamide fumarate tab 200-25 mg

DIDANOSINE – didanosine delayed releasecapsule 200 mg



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

300-150 mg (base equiv)GENVOYA – elvitegrav-cobic-emtricitab-

tenofov af tab 150-150-200-10 mgINTELENCE – etravirine tab 25 mgINTELENCE – etravirine tab 100 mgINTELENCE – etravirine tab 200 mgISENTRESS – raltegravir potassium packet

for susp 100 mg (base equiv)ISENTRESS – raltegravir potassium tab

400 mg (base equiv)ISENTRESS – raltegravir potassium chew

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

tab 100 mg (base equiv)ISENTRESS HD – raltegravir potassium tab

600 mg (base equiv)KALETRA – lopinavir-ritonavir tab 100-25

mgKALETRA – lopinavir-ritonavir tab 200-50

mglamivudine oral soln 10 mg/ml (Epivir)lamivudine tab 150 mg (Epivir)lamivudine tab 300 mg (Epivir)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

lamivudine-zidovudine tab 150-300 mg(Combivir)

lopinavir-ritonavir soln 400-100 mg/5ml(80-20 mg/ml) (Kaletra)

NEVIRAPINE ER – nevirapine tab er 24hr100 mg

nevirapine susp 50 mg/5ml (Viramune)nevirapine tab er 24hr 400 mg (Viramune

xr)nevirapine tab 200 mg (Viramune)NORVIR – ritonavir oral soln 80 mg/mlNORVIR – ritonavir powder packet 100 mgODEFSEY – emtricitabine-rilpivirine-

tenofovir af tab 200-25-25 mgPREZCOBIX – darunavir-cobicistat tab

800-150 mgPREZISTA – darunavir ethanolate susp 100

mg/ml (base equiv)PREZISTA – darunavir ethanolate tab 75

mg (base equiv)PREZISTA – darunavir ethanolate tab 150



mg (base equiv)ritonavir tab 100 mg (Norvir)stavudine cap 15 mg (Zerit)stavudine cap 20 mg (Zerit)stavudine cap 30 mg (Zerit)stavudine cap 40 mg (Zerit)STRIBILD – elvitegrav-cobic-emtricitab-

tenofovdf tab 150-150-200-300 mgSYMFI – efavirenz-lamivudine-tenofovir df

tab 600-300-300 mgSYMFI LO – efavirenz-lamivudine-tenofovir

df tab 400-300-300 mgTEMIXYS – lamivudine-tenofovir disoproxil

fumarate tab 300-300 mg

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

tenofovir disoproxil fumarate tab 300 mg(Viread)

TIVICAY – dolutegravir sodium tab 10 mg(base equiv)



TRIUMEQ – abacavir-dolutegravir-lamivudine tab 600-50-300 mg

TRUVADA – emtricitabine-tenofovirdisoproxil fumarate tab 100-150 mg




VIREAD – tenofovir disoproxil fumarate oralpowder 40 mg/gm

VIREAD – tenofovir disoproxil fumarate tab150 mg



zidovudine cap 100 mg (Retrovir)zidovudine syrup 10 mg/ml (Retrovir)zidovudine tab 300 mgInfluenzaoseltamivir phosphate cap 30 mg (base

equiv) (Tamiflu)oseltamivir phosphate cap 45 mg (base

equiv) (Tamiflu)oseltamivir phosphate cap 75 mg (base

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

(base equiv) (Tamiflu)RELENZA DISKHALER – zanamivir aero

powder breath activated 5 mg/blister

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

MALARIAatovaquone-proguanil hcl tab 62.5-25 mg

(Malarone)atovaquone-proguanil hcl tab

250-100 mg (Malarone)CHLOROQUINE PHOSPHATE –

chloroquine phosphate tab 500 mgchloroquine phosphate tab 250 mgCOARTEM – artemether-lumefantrine tab

20-120 mgDARAPRIM – pyrimethamine tab 25 mghydroxychloroquine sulfate tab 200 mg

(Plaquenil)MEFLOQUINE HCL – mefloquine hcl tab

250 mgprimaquine phosphate tab 26.3 mg

(15 mg base) (Primaquine phosphate)pyrimethamine tab 25 mg (Daraprim)WORM INFECTIONSalbendazole tab 200 mg (Albenza)BENZNIDAZOLE – benznidazole tab 12.5

mgBENZNIDAZOLE – benznidazole tab 100

mgivermectin tab 3 mg (Stromectol)praziquantel tab 600 mg (Biltricide)SULFONAMIDESsulfamethoxazole-trimethoprim susp

200-40 mg/5mlsulfamethoxazole-trimethoprim tab

400-80 mg (Bactrim)sulfamethoxazole-trimethoprim tab

800-160 mg (Bactrim ds)OTHER ANTI-INFECTIVESALINIA – nitazoxanide tab 500 mgALINIA – nitazoxanide for susp 100 mg/5mlclindamycin hcl cap 75 mg (Cleocin)clindamycin hcl cap 150 mg (Cleocin)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

clindamycin hcl cap 300 mg (Cleocin)clindamycin palmitate hcl for soln

75 mg/5ml (base equiv) (Cleocinpediatric gr)

dapsone tab 25 mgdapsone tab 100 mgIMPAVIDO – miltefosine cap 50 mglinezolid for susp 100 mg/5ml (Zyvox)linezolid tab 600 mg (Zyvox)metronidazole tab 250 mg (Flagyl)metronidazole tab 500 mg (Flagyl)pentamidine isethionate for nebulization

soln 300 mg (Nebupent)SIVEXTRO – tedizolid phosphate tab 200

mgSULFADIAZINE – sulfadiazine tab 500 mgtrimethoprim tab 100 mgvancomycin hcl cap 125 mg (base

equivalent) (Vancocin hcl)vancomycin hcl cap 250 mg (base

equivalent) (Vancocin hcl)XIFAXAN – rifaximin tab 550 mgIMMUNIZING AGENTSGRASTEK – timothy grass pollen allergen

ext sl tab 2800 bau• •

ORALAIR – grass mixed pollen ext sl tab300 ir (index of reactivity)

• •

RAGWITEK – short ragweed pollen allergenextract sl tab 12 amb a 1-u

• •

CANCER DRUGSabiraterone acetate tab 250 mg (Zytiga) • • •ACTIMMUNE – interferon gamma-1b inj

100 mcg/0.5ml (2000000 unit/0.5ml)•

AFINITOR – everolimus tab 10 mg • • •AFINITOR DISPERZ – everolimus tab for

oral susp 2 mg• • •

AFINITOR DISPERZ – everolimus tab fororal susp 3 mg

• • •

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

AFINITOR DISPERZ – everolimus tab fororal susp 5 mg

• • •

ALECENSA – alectinib hcl cap 150 mg(base equivalent)

• • •

ALUNBRIG – brigatinib tab initiation therapypack 90 mg & 180 mg

• • •

ALUNBRIG – brigatinib tab 30 mg • • •ALUNBRIG – brigatinib tab 90 mg • • •ALUNBRIG – brigatinib tab 180 mg • • •anastrozole tab 1 mg (Arimidex)AYVAKIT – avapritinib tab 100 mg • • •AYVAKIT – avapritinib tab 200 mg • • •AYVAKIT – avapritinib tab 300 mg • • •bexarotene cap 75 mg (Targretin) • •bicalutamide tab 50 mg (Casodex)BOSULIF – bosutinib tab 100 mg • • •BOSULIF – bosutinib tab 400 mg • • •BOSULIF – bosutinib tab 500 mg • • •CABOMETYX – cabozantinib s-malate tab

20 mg (base equivalent)• • •

CABOMETYX – cabozantinib s-malate tab40 mg (base equivalent)

• • •

CABOMETYX – cabozantinib s-malate tab60 mg (base equivalent)

• • •

capecitabine tab 150 mg (Xeloda) • •capecitabine tab 500 mg (Xeloda) • •CAPRELSA – vandetanib tab 100 mg • • •CAPRELSA – vandetanib tab 300 mg • • •COMETRIQ – cabozantinib s-malate cap 3

x 20 mg (60 mg dose) kit• • •

COMETRIQ – cabozantinib s-mal cap 1 x80 mg & 1 x 20 mg (100 dose) kit

• • •

COMETRIQ – cabozantinib s-mal cap 1 x80 mg & 3 x 20 mg (140 dose) kit

• • •

COTELLIC – cobimetinib fumarate tab 20mg (base equivalent)

• • •

cyclophosphamide cap 25 mg(Cyclophosphamide)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

cyclophosphamide cap 50 mg(Cyclophosphamide)

EMCYT – estramustine phosphate sodiumcap 140 mg

ERIVEDGE – vismodegib cap 150 mg • • •ERLEADA – apalutamide tab 60 mg • • •erlotinib hcl tab 25 mg (base equivalent)

(Tarceva)• • •

erlotinib hcl tab 100 mg (base equivalent)(Tarceva)

• • •

erlotinib hcl tab 150 mg (base equivalent)(Tarceva)

• • •

ETOPOSIDE – etoposide cap 50 mg •everolimus tab 2.5 mg (Afinitor) • • •everolimus tab 5 mg (Afinitor) • • •everolimus tab 7.5 mg (Afinitor) • • •exemestane tab 25 mg (Aromasin)FARYDAK – panobinostat lactate cap 10

mg (base equivalent)• • •

FARYDAK – panobinostat lactate cap 20mg (base equivalent)

• • •

flutamide cap 125 mgGILOTRIF – afatinib dimaleate tab 20 mg

(base equivalent)• • •

GILOTRIF – afatinib dimaleate tab 30 mg(base equivalent)

• • •

GILOTRIF – afatinib dimaleate tab 40 mg(base equivalent)

• • •

GLEOSTINE – lomustine cap 10 mgGLEOSTINE – lomustine cap 40 mgGLEOSTINE – lomustine cap 100 mgHYCAMTIN – topotecan hcl cap 0.25 mg

(base equiv)• •

HYCAMTIN – topotecan hcl cap 1 mg (baseequiv)

• •

hydroxyurea cap 500 mg (Hydrea)IBRANCE – palbociclib cap 75 mg • • •IBRANCE – palbociclib cap 100 mg • • •

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

IBRANCE – palbociclib cap 125 mg • • •IBRANCE – palbociclib tab 75 mg • • •IBRANCE – palbociclib tab 100 mg • • •IBRANCE – palbociclib tab 125 mg • • •ICLUSIG – ponatinib hcl tab 15 mg (base

equiv)• • •

ICLUSIG – ponatinib hcl tab 45 mg (baseequiv)

• • •

imatinib mesylate tab 100 mg (baseequivalent) (Gleevec)

• • •

imatinib mesylate tab 400 mg (baseequivalent) (Gleevec)

• • •

IMBRUVICA – ibrutinib cap 70 mg • • •IMBRUVICA – ibrutinib cap 140 mg • • •IMBRUVICA – ibrutinib tab 140 mg • • •IMBRUVICA – ibrutinib tab 280 mg • • •IMBRUVICA – ibrutinib tab 420 mg • • •IMBRUVICA – ibrutinib tab 560 mg • • •INLYTA – axitinib tab 1 mg • • •INLYTA – axitinib tab 5 mg • • •IRESSA – gefitinib tab 250 mg • • •JAKAFI – ruxolitinib phosphate tab 5 mg


JAKAFI – ruxolitinib phosphate tab 10 mg(base equivalent)

• • •


• • •


• • •


• • •

KISQALI – ribociclib succinate tab pack 200mg daily dose

• • •

KISQALI – ribociclib succinate tab pack 400mg daily dose (200 mg tab)

• • •

KISQALI – ribociclib succinate tab pack 600mg daily dose (200 mg tab)

• • •

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

KISQALI FEMARA 200 DOSE – ribociclib200 mg dose (200 mg tab) & letrozole 2.5mg tbpk

• • •


• • •


• • •

LENVIMA 10 MG DAILY DOSE – lenvatinibcap therapy pack 10 mg (10 mg dailydose)

• • •

LENVIMA 12MG DAILY DOSE – lenvatinibcap therapy pack 3 x 4 mg (12 mg dailydose)

• • •

LENVIMA 14 MG DAILY DOSE – lenvatinibcap therapy pack 10 & 4 mg (14 mg dailydose)

• • •

LENVIMA 18 MG DAILY DOSE – lenvatinibcap ther pack 10 mg & 2 x 4 mg (18 mgdaily dose)

• • •

LENVIMA 20 MG DAILY DOSE – lenvatinibcap therapy pack 2 x 10 mg (20 mg dailydose)

• • •

LENVIMA 24 MG DAILY DOSE – lenvatinibcap ther pack 2 x 10 mg & 4 mg (24 mgdaily dose)

• • •

LENVIMA 4 MG DAILY DOSE – lenvatinibcap therapy pack 4 mg (4 mg daily dose)

• • •

LENVIMA 8 MG DAILY DOSE – lenvatinibcap therapy pack 2 x 4 mg (8 mg dailydose)

• • •

letrozole tab 2.5 mg (Femara)LEUCOVORIN CALCIUM – leucovorin

calcium tab 10 mgLEUCOVORIN CALCIUM – leucovorin

calcium tab 15 mgleucovorin calcium tab 5 mgleucovorin calcium tab 25 mgLEUKERAN – chlorambucil tab 2 mg

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

LONSURF – trifluridine-tipiracil tab 15-6.14mg

• • •

LONSURF – trifluridine-tipiracil tab 20-8.19mg

• • •

LYNPARZA – olaparib tab 100 mg • • •LYNPARZA – olaparib tab 150 mg • • •LYSODREN – mitotane tab 500 mg • •MATULANE – procarbazine hcl cap 50 mg • •megestrol acetate susp 40 mg/ml

(Megace oral)megestrol acetate tab 20 mgmegestrol acetate tab 40 mgMEKINIST – trametinib dimethyl sulfoxide

tab 0.5 mg (base equivalent)• • •

MEKINIST – trametinib dimethyl sulfoxidetab 2 mg (base equivalent)

• • •

melphalan tab 2 mg (Alkeran) •mercaptopurine tab 50 mg (Purinethol)MESNEX – mesna tab 400 mgmethotrexate sodium tab 2.5 mg (base

equiv)MYLERAN – busulfan tab 2 mg •NEXAVAR – sorafenib tosylate tab 200 mg


nilutamide tab 150 mg (Nilandron)NINLARO – ixazomib citrate cap 2.3 mg


NINLARO – ixazomib citrate cap 3 mg(base equivalent)

• • •

NINLARO – ixazomib citrate cap 4 mg(base equivalent)

• • •

NUBEQA – darolutamide tab 300 mg • • •ODOMZO – sonidegib phosphate cap 200


PIQRAY 200MG DAILY DOSE – alpelisibtab therapy pack 200 mg daily dose

• • •

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

PIQRAY 250MG DAILY DOSE – alpelisibtab pack 250 mg daily dose (200 mg & 50mg tabs)

• • •

PIQRAY 300MG DAILY DOSE – alpelisibtab pack 300 mg daily dose (2x150 mgtab)

• • •

POMALYST – pomalidomide cap 1 mg • • •POMALYST – pomalidomide cap 2 mg • • •POMALYST – pomalidomide cap 3 mg • • •POMALYST – pomalidomide cap 4 mg • • •PURIXAN – mercaptopurine susp 2000

mg/100ml (20 mg/ml)•

ROZLYTREK – entrectinib cap 100 mg • • •ROZLYTREK – entrectinib cap 200 mg • • •RUBRACA – rucaparib camsylate tab 200


RUBRACA – rucaparib camsylate tab 250mg (base equivalent)

• • •

RUBRACA – rucaparib camsylate tab 300mg (base equivalent)

• • •

RYDAPT – midostaurin cap 25 mg • • •SOLTAMOX – tamoxifen citrate oral soln 10

mg/5ml (base equivalent)SPRYCEL – dasatinib tab 20 mg • • •SPRYCEL – dasatinib tab 50 mg • • •SPRYCEL – dasatinib tab 70 mg • • •SPRYCEL – dasatinib tab 80 mg • • •SPRYCEL – dasatinib tab 100 mg • • •SPRYCEL – dasatinib tab 140 mg • • •STIVARGA – regorafenib tab 40 mg • • •SUTENT – sunitinib malate cap 12.5 mg


SUTENT – sunitinib malate cap 25 mg(base equivalent)

• • •

SUTENT – sunitinib malate cap 37.5 mg(base equivalent)

• • •

SUTENT – sunitinib malate cap 50 mg(base equivalent)

• • •

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

SYLATRON – peginterferon alfa-2b for injkit 200 mcg

• •


• •


• •

TABLOID – thioguanine tab 40 mgTAFINLAR – dabrafenib mesylate cap 50


TAFINLAR – dabrafenib mesylate cap 75mg (base equivalent)

• • •

TAGRISSO – osimertinib mesylate tab 40mg (base equivalent)

• • •

TAGRISSO – osimertinib mesylate tab 80mg (base equivalent)

• • •

tamoxifen citrate tab 10 mg (baseequivalent)

tamoxifen citrate tab 20 mg (baseequivalent)

TASIGNA – nilotinib hcl cap 50 mg (baseequivalent)

• • •


• • •


• • •

temozolomide cap 5 mg (Temodar) • •temozolomide cap 20 mg (Temodar) • •temozolomide cap 100 mg (Temodar) • •temozolomide cap 140 mg (Temodar) • •temozolomide cap 180 mg (Temodar) • •temozolomide cap 250 mg (Temodar) • •toremifene citrate tab 60 mg (base

equivalent) (Fareston)tretinoin cap 10 mg • •TYKERB – lapatinib ditosylate tab 250 mg

(base equiv)• • •

VENCLEXTA – venetoclax tab 10 mg • • •VENCLEXTA – venetoclax tab 50 mg • • •

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

VENCLEXTA – venetoclax tab 100 mg • • •VENCLEXTA STARTING PACK –

venetoclax tab therapy starter pack 10 &50 & 100 mg

• • •

VERZENIO – abemaciclib tab 50 mg • • •VERZENIO – abemaciclib tab 100 mg • • •VERZENIO – abemaciclib tab 150 mg • • •VERZENIO – abemaciclib tab 200 mg • • •VITRAKVI – larotrectinib sulfate oral soln 20

mg/ml (base equivalent)• • •

VITRAKVI – larotrectinib sulfate cap 25 mg(base equivalent)

• • •

VITRAKVI – larotrectinib sulfate cap 100 mg(base equivalent)

• • •

VOTRIENT – pazopanib hcl tab 200 mg(base equiv)

• • •

XALKORI – crizotinib cap 200 mg • • •XALKORI – crizotinib cap 250 mg • • •XTANDI – enzalutamide cap 40 mg • • •YONSA – abiraterone acetate tab 125 mg • • •ZEJULA – niraparib tosylate cap 100 mg


ZELBORAF – vemurafenib tab 240 mg • • •ZOLINZA – vorinostat cap 100 mg • • •ZYDELIG – idelalisib tab 100 mg • • •ZYDELIG – idelalisib tab 150 mg • • •ZYKADIA – ceritinib tab 150 mg • • •ZYTIGA – abiraterone acetate tab 500 mg • • •HORMONES, DIABETES AND RELATED DRUGSCORTICOSTEROIDSbudesonide delayed release particles

cap 3 mg (Entocort ec)CORTISONE ACETATE – cortisone acetate

tab 25 mgDEXAMETHASONE – dexamethasone soln

0.5 mg/5mlDEXAMETHASONE – dexamethasone tab

1 mg

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

DEXAMETHASONE – dexamethasone tab2 mg

dexamethasone elixir 0.5 mg/5mlDEXAMETHASONE INTENSOL –

dexamethasone conc 1 mg/mldexamethasone tab 0.5 mgdexamethasone tab 0.75 mgdexamethasone tab 1.5 mgdexamethasone tab 4 mgdexamethasone tab 6 mgfludrocortisone acetate tab 0.1 mghydrocortisone tab 5 mg (Cortef)hydrocortisone tab 10 mg (Cortef)hydrocortisone tab 20 mg (Cortef)methylprednisolone tab therapy pack

4 mg (21) (Medrol dosepak)methylprednisolone tab 4 mg (Medrol)methylprednisolone tab 8 mg (Medrol)methylprednisolone tab 16 mg (Medrol)methylprednisolone tab 32 mg (Medrol)PREDNISOLONE – prednisolone syrup 15

mg/5ml (usp solution equivalent)prednisolone sod phosph oral soln

6.7 mg/5ml (5 mg/5ml base) (Pediapred)prednisolone sod phosphate oral soln

15 mg/5ml (base equiv)PREDNISONE – prednisone oral soln 5

mg/5mlprednisone tab therapy pack 5 mg (21)prednisone tab therapy pack 5 mg (48)prednisone tab therapy pack 10 mg (21)prednisone tab therapy pack 10 mg (48)prednisone tab 1 mgprednisone tab 2.5 mgprednisone tab 5 mgprednisone tab 10 mgprednisone tab 20 mg

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

prednisone tab 50 mgMALE HORMONESdanazol cap 50 mgdanazol cap 100 mgdanazol cap 200 mgtestosterone td gel 25 mg/2.5gm (1%)

(Androgel)•

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

•

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

•

testosterone td gel 20.25 mg/1.25gm(1.62%) (Androgel)

•

testosterone td gel 40.5 mg/2.5gm(1.62%) (Androgel)

•

testosterone td gel 20.25 mg/act (1.62%)(Androgel pump)

•

testosterone td soln 30 mg/act (Axiron) •ESTROGENSCLIMARA PRO – estradiol-levonorgestrel td

patch weekly 0.045-0.015 mg/dayDIVIGEL – estradiol td gel 0.25 mg/0.25gm

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

(0.1%)DIVIGEL – estradiol td gel 0.75 mg/0.75gm

(0.1%)DIVIGEL – estradiol td gel 1 mg/gm (0.1%)DIVIGEL – estradiol td gel 1.25 mg/1.25gm

(0.1%)estradiol & norethindrone acetate tab

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

1-0.5 mg (Activella)estradiol tab 0.5 mg (Estrace)estradiol tab 1 mg (Estrace)estradiol tab 2 mg (Estrace)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

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





estradiol td patch weekly 0.025 mg/24hr(Climara)

estradiol td patch weekly 0.0375 mg/24hr(37.5 mcg/24hr) (Climara)





norethindrone acetate-ethinyl estradioltab 0.5 mg-2.5 mcg (Femhrt low dose)

norethindrone acetate-ethinyl estradioltab 1 mg-5 mcg

PREFEST – estradiol tab 1 mg(15)/estrad-norgestimate tab 1-0.09mg(15)

PREMARIN – estrogens, conjugated tab 0.3mg

PREMARIN – estrogens, conjugated tab0.45 mg


PREMARIN – estrogens, conjugated tab 0.9mg


PREMPHASE – conj est 0.625(14)/conj est-medroxypro ac tab 0.625-5mg(14)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

PREMPRO – conjugated estrogen-medroxyprogest acetate tab 0.3-1.5 mg



PREMPRO – conjugated estrogen-medroxyprogest acetate tab 0.625-5 mg

PROGESTINSmedroxyprogesterone acetate tab 2.5 mg

(Provera)medroxyprogesterone acetate tab 5 mg

(Provera)medroxyprogesterone acetate tab 10 mg

(Provera)norethindrone acetate tab 5 mg

(Aygestin)progesterone micronized cap 100 mg

(Prometrium)progesterone micronized cap 200 mg

(Prometrium)BIRTH CONTROLMost generic oral contraceptives are formulary products.Selected brands that are not available generically arealso on the formulary and appear as: TRADE NAMEfollowed by the generic name, e.g., OGESTREL –norgestrel/ethinyl estradiol.desogest-eth estrad & eth estrad tab

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

0.1-0.025/0.125-0.025/0.15-0.025mg-mg(Cyclessa)

desogestrel & ethinyl estradiol tab0.15 mg-30 mcg (Desogen)

drospirenone-ethinyl estradiol tab3-0.02 mg (Yaz)

drospirenone-ethinyl estradiol tab3-0.03 mg (Yasmin 28)

ELLA – ulipristal acetate tab 30 mgethynodiol diacetate & ethinyl estradiol

tab 1 mg-35 mcg

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

ethynodiol diacetate & ethinyl estradioltab 1 mg-50 mcg (Zovia 1/50e)

levonorg-eth est tab 0.1-0.02mg(84) & ethest tab 0.01mg(7) (Loseasonique)

levonorg-eth est tab 0.15-0.03mg(84) &eth est tab 0.01mg(7) (Seasonique)

levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg

levonorgestrel & ethinyl estradiol tab0.1 mg-20 mcg

levonorgestrel & ethinyl estradiol tab0.15 mg-30 mcg

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

MIRENA – levonorgestrel releasing iud 20mcg/day (52 mg total)

norethindrone & ethinyl estradiol tab0.4 mg-35 mcg (Ovcon-35)

norethindrone & ethinyl estradiol tab0.5 mg-35 mcg (Brevicon-28)

norethindrone & ethinyl estradiol tab1 mg-35 mcg (Norinyl 1+35)

norethindrone ac-ethinyl estrad-fe tab1-20/1-30/1-35 mg-mcg (Estrostep fe)

norethindrone ace & ethinyl estradiol tab1 mg-20 mcg (Loestrin 1/20-21)

norethindrone ace & ethinyl estradiol tab1.5 mg-30 mcg (Loestrin 1.5/30-21)

norethindrone ace & ethinyl estradiol-fetab 1 mg-20 mcg (Loestrin fe 1/20)

norethindrone ace & ethinyl estradiol-fetab 1.5 mg-30 mcg (Loestrin fe 1.5/30)

norethindrone tab 0.35 mg (Nor-qd)norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg (Ortho-novum 7/7/7)

norethindrone-eth estradiol tab0.5-35/1-35/0.5-35 mg-mcg (Tri-norinyl28)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

norgestimate & ethinyl estradiol tab0.25 mg-35 mcg (Ortho-cyclen)

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

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

norgestrel & ethinyl estradiol tab0.3 mg-30 mcg

NUVARING – etonogestrel-ethinyl estradiolva ring 0.120-0.015 mg/24hr

SKYLA – levonorgestrel releasing iud 14mcg/day (13.5 mg total)

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

INFERTILITYCETROTIDE – cetrorelix acetate for inj kit

0.25 mg•

CLOMIPHENE CITRATE – clomiphenecitrate tab 50 mg

FOLLISTIM AQ – follitropin beta inj 300unit/0.36ml

•


•


•

ganirelix acetate soln prefilled syringe250 mcg/0.5ml (Ganirelix acetate)

•

GONAL-F – follitropin alfa for inj 450 unit •GONAL-F – follitropin alfa for inj 1050 unit •GONAL-F RFF – follitropin alfa for

subcutaneous inj 75 unit•

GONAL-F RFF REDIJECT – follitropin alfainj 300 unit/0.5ml

•


•


•

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

MENOPUR – menotropins forsubcutaneous inj 75 unit

•

OVIDREL – choriogonadotropin alfa inj 250mcg/0.5ml

•

DIABETESacarbose tab 25 mg (Precose)acarbose tab 50 mg (Precose)acarbose tab 100 mg (Precose)diazoxide susp 50 mg/ml (Proglycem)glimepiride tab 1 mg (Amaryl)glimepiride tab 2 mg (Amaryl)glimepiride tab 4 mg (Amaryl)glipizide tab er 24hr 2.5 mg (Glucotrol xl)glipizide tab er 24hr 5 mg (Glucotrol xl)glipizide tab er 24hr 10 mg (Glucotrol xl)glipizide tab 5 mg (Glucotrol)glipizide tab 10 mg (Glucotrol)glipizide-metformin hcl tab 2.5-250 mgglipizide-metformin hcl tab 2.5-500 mgglipizide-metformin hcl tab 5-500 mgGLUCAGON EMERGENCY KIT – glucagon

(rdna) for inj kit 1 mgglyburide micronized tab 1.5 mg

(Glynase)glyburide micronized tab 3 mg (Glynase)glyburide micronized tab 6 mg (Glynase)glyburide tab 1.25 mgglyburide tab 2.5 mgglyburide tab 5 mgglyburide-metformin tab 1.25-250 mg

(Glucovance)glyburide-metformin tab 2.5-500 mg

(Glucovance)glyburide-metformin tab 5-500 mg

(Glucovance)GLYXAMBI – empagliflozin-linagliptin tab

10-5 mg

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

GLYXAMBI – empagliflozin-linagliptin tab25-5 mg

GVOKE HYPOPEN – glucagonsubcutaneous solution auto-injector 0.5mg/0.1ml

GVOKE HYPOPEN – glucagonsubcutaneous solution auto-injector 1mg/0.2ml

GVOKE PFS – glucagon subcutaneous solnpref syringe 0.5 mg/0.1ml

GVOKE PFS – glucagon subcutaneous solnpref syringe 1 mg/0.2ml

INVOKAMET – canagliflozin-metformin hcltab 50-500 mg




INVOKAMET XR – canagliflozin-metforminhcl tab er 24hr 50-500 mg




INVOKANA – canagliflozin tab 100 mgINVOKANA – canagliflozin tab 300 mgJANUMET – sitagliptin-metformin hcl tab

50-500 mgJANUMET – sitagliptin-metformin hcl tab

50-1000 mgJANUMET XR – sitagliptin-metformin hcl

tab er 24hr 50-500 mgJANUMET XR – sitagliptin-metformin hcl

tab er 24hr 50-1000 mgJANUMET XR – sitagliptin-metformin hcl

tab er 24hr 100-1000 mg

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

JANUVIA – sitagliptin phosphate tab 25 mg(base equiv)

JANUVIA – sitagliptin phosphate tab 50 mg(base equiv)

JANUVIA – sitagliptin phosphate tab 100mg (base equiv)

JARDIANCE – empagliflozin tab 10 mgJARDIANCE – empagliflozin tab 25 mgKOMBIGLYZE XR – saxagliptin-metformin

hcl tab er 24hr 2.5-1000 mgKOMBIGLYZE XR – saxagliptin-metformin

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

hcl tab er 24hr 5-1000 mgmetformin hcl tab er 24hr 500 mg

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

(Glucophage xr)metformin hcl tab 500 mg (Glucophage)metformin hcl tab 850 mg (Glucophage)metformin hcl tab 1000 mg (Glucophage)nateglinide tab 60 mg (Starlix)nateglinide tab 120 mg (Starlix)ONGLYZA – saxagliptin hcl tab 2.5 mg

(base equiv)ONGLYZA – saxagliptin hcl tab 5 mg (base

equiv)OZEMPIC – semaglutide soln pen-inj 0.25

or 0.5 mg/dose (2 mg/1.5ml)•

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

•

pioglitazone hcl tab 15 mg (base equiv)(Actos)



pioglitazone hcl-metformin hcl tab15-500 mg (Actoplus met)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

pioglitazone hcl-metformin hcl tab15-850 mg (Actoplus met)

PROGLYCEM – diazoxide susp 50 mg/mlRYBELSUS – semaglutide tab 3 mg •RYBELSUS – semaglutide tab 7 mg •RYBELSUS – semaglutide tab 14 mg •SYMLINPEN 120 – pramlintide acetate pen-

inj 2700 mcg/2.7ml (1000 mcg/ml)SYMLINPEN 60 – pramlintide acetate pen-

inj 1500 mcg/1.5ml (1000 mcg/ml)SYNJARDY – empagliflozin-metformin hcl

tab 5-500 mgSYNJARDY – empagliflozin-metformin hcl

tab 5-1000 mgSYNJARDY – empagliflozin-metformin hcl

tab 12.5-500 mgSYNJARDY – empagliflozin-metformin hcl

tab 12.5-1000 mgSYNJARDY XR – empagliflozin-metformin

hcl tab er 24hr 5-1000 mgSYNJARDY XR – empagliflozin-metformin

hcl tab er 24hr 10-1000 mgSYNJARDY XR – empagliflozin-metformin

hcl tab er 24hr 12.5-1000 mgSYNJARDY XR – empagliflozin-metformin

hcl tab er 24hr 25-1000 mgTRULICITY – dulaglutide soln pen-injector

0.75 mg/0.5ml•

TRULICITY – dulaglutide soln pen-injector1.5 mg/0.5ml

•

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

•

DIABETES - INSULINSRapid-Acting InsulinsFIASP – insulin aspart (with niacinamide) inj

100 unit/mlFIASP FLEXTOUCH – insulin aspart (with

niacinamide) sol pen-inj 100 unit/ml

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

FIASP PENFILL – insulin aspart (withniacinamide) soln cartridge 100 unit/ml

INSULIN ASPART – insulin aspart inj 100unit/ml

INSULIN ASPART FLEXPEN – insulinaspart soln pen-injector 100 unit/ml

INSULIN ASPART PENFILL – insulin aspartsoln cartridge 100 unit/ml

NOVOLOG – insulin aspart inj 100 unit/mlNOVOLOG FLEXPEN – insulin aspart soln

pen-injector 100 unit/mlNOVOLOG PENFILL – insulin aspart soln

cartridge 100 unit/mlShort-Acting InsulinsHUMULIN R U-500 (CONCENTR – insulin

regular (human) inj 500 unit/mlHUMULIN R U-500 KWIKPEN – insulin

regular (human) soln pen-injector 500unit/ml

NOVOLIN R – insulin regular (human) inj100 unit/ml

NOVOLIN R FLEXPEN – insulin regular(human) soln pen-injector 100 unit/ml

Intermediate-Acting InsulinsINSULIN ASPART PROTAMINE/ – insulin

aspart prot & aspart sus pen-inj 100 unit/ml (70-30)

INSULIN ASPART PROTAMINE/ – insulinaspart prot & aspart (human) inj 100 unit/ml (70-30)

NOVOLIN N – insulin nph (human)(isophane) inj 100 unit/ml

NOVOLIN N FLEXPEN – insulin nph(human) (isophane) susp pen-injector 100unit/ml

NOVOLIN 70/30 – insulin nph isophane &regular human inj 100 unit/ml (70-30)

NOVOLIN 70/30 FLEXPEN – insulin nph &regular susp pen-inj 100 unit/ml (70-30)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

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

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

Basal InsulinsLANTUS – insulin glargine inj 100 unit/mlLANTUS SOLOSTAR – insulin glargine soln

pen-injector 100 unit/mlLEVEMIR – insulin detemir inj 100 unit/mlLEVEMIR FLEXTOUCH – insulin detemir

soln pen-injector 100 unit/mlTOUJEO MAX SOLOSTAR – insulin

glargine soln pen-injector 300 unit/ml (2unit dial)

TOUJEO SOLOSTAR – insulin glargine solnpen-injector 300 unit/ml (1 unit dial)

TRESIBA – insulin degludec inj 100 unit/mlTRESIBA FLEXTOUCH – insulin degludec

soln pen-injector 100 unit/mlTRESIBA FLEXTOUCH – insulin degludec

soln pen-injector 200 unit/mlTHYROID REGULATIONlevothyroxine sodium tab 25 mcg

(Synthroid)levothyroxine sodium tab 50 mcg







(Synthroid)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

levothyroxine sodium tab 150 mcg(Synthroid)




liothyronine sodium tab 5 mcg (Cytomel)liothyronine sodium tab 25 mcg

(Cytomel)liothyronine sodium tab 50 mcg

(Cytomel)methimazole tab 5 mg (Tapazole)methimazole tab 10 mg (Tapazole)propylthiouracil tab 50 mgGROWTH HORMONEINCRELEX – mecasermin inj 40 mg/4ml (10

mg/ml)•

NORDITROPIN FLEXPRO – somatropin inj5 mg/1.5ml

• •


• •


• •

NORDITROPIN FLEXPRO – somatropin inj30 mg/3ml

• •

OTHER HORMONES AND RELATED DRUGSALENDRONATE SODIUM – alendronate

sodium tab 5 mgalendronate sodium tab 10 mgalendronate sodium tab 35 mgalendronate sodium tab 70 mg (Fosamax)cabergoline tab 0.5 mgcalcitonin (salmon) nasal soln 200 unit/

act (Miacalcin)calcitriol cap 0.25 mcg (Rocaltrol)calcitriol cap 0.5 mcg (Rocaltrol)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

calcitriol oral soln 1 mcg/ml (Rocaltrol)cinacalcet hcl tab 30 mg (base equiv)

(Sensipar)•

cinacalcet hcl tab 60 mg (base equiv)(Sensipar)

•

cinacalcet hcl tab 90 mg (base equiv)(Sensipar)

•

CYSTADANE – betaine powder for oralsolution

desmopressin acetate nasal spray soln0.01% (Ddavp)

desmopressin acetate nasal spray soln0.01% (refrigerated)

desmopressin acetate tab 0.1 mg (Ddavp)desmopressin acetate tab 0.2 mg (Ddavp)FORTEO – teriparatide (recombinant) soln

pen-inj 600 mcg/2.4ml• • •

ibandronate sodium tab 150 mg (baseequivalent) (Boniva)

KUVAN – sapropterin dihydrochloridesoluble tab 100 mg

• •

KUVAN – sapropterin dihydrochloridepowder packet 100 mg

• •

KUVAN – sapropterin dihydrochloridepowder packet 500 mg

• •

levocarnitine oral soln 1 gm/10ml (10%)(Carnitor)

levocarnitine tab 330 mg (Carnitor)LUPRON DEPOT-PED (1-MONTH –

leuprolide acetate for inj pediatric kit 7.5mg

•

LUPRON DEPOT-PED (1-MONTH –leuprolide acetate for inj pediatric kit 11.25mg

•

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

•

methylergonovine maleate tab 0.2 mgNITYR – nitisinone tab 2 mg •NITYR – nitisinone tab 5 mg •

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

NITYR – nitisinone tab 10 mg •ORILISSA – elagolix sodium tab 150 mg

(base equiv)• •

ORILISSA – elagolix sodium tab 200 mg(base equiv)

• •

paricalcitol cap 1 mcg (Zemplar)paricalcitol cap 2 mcg (Zemplar)paricalcitol cap 4 mcg (Zemplar)PROLIA – denosumab inj soln prefilled

syringe 60 mg/mlraloxifene hcl tab 60 mg (Evista)STIMATE – desmopressin acetate nasal

soln 1.5 mg/mlSTRENSIQ – asfotase alfa subcutaneous

inj 18 mg/0.45ml• •

STRENSIQ – asfotase alfa subcutaneousinj 28 mg/0.7ml

• •

STRENSIQ – asfotase alfa subcutaneousinj 40 mg/ml

• •

STRENSIQ – asfotase alfa subcutaneousinj 80 mg/0.8ml

• •

TYMLOS – abaloparatide subcutaneoussoln pen-injector 3120 mcg/1.56ml

• • •

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

5-6.25 mgbenazepril & hydrochlorothiazide tab

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

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

20-25 mg (Lotensin hct)benazepril hcl tab 5 mgbenazepril hcl tab 10 mg (Lotensin)benazepril hcl tab 20 mg (Lotensin)benazepril hcl tab 40 mg (Lotensin)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

captopril tab 12.5 mgcaptopril tab 25 mgcaptopril tab 50 mgcaptopril tab 100 mgCAPTOPRIL/HYDROCHLOROTHIA –

captopril & hydrochlorothiazide tab 25-15mg

CAPTOPRIL/HYDROCHLOROTHIA –captopril & hydrochlorothiazide tab 25-25mg



enalapril maleate & hydrochlorothiazidetab 5-12.5 mg

enalapril maleate & hydrochlorothiazidetab 10-25 mg (Vaseretic)

enalapril maleate tab 2.5 mg (Vasotec)enalapril maleate tab 5 mg (Vasotec)enalapril maleate tab 10 mg (Vasotec)enalapril maleate tab 20 mg (Vasotec)fosinopril sodium & hydrochlorothiazide

tab 10-12.5 mgfosinopril sodium & hydrochlorothiazide

tab 20-12.5 mgfosinopril sodium tab 10 mgfosinopril sodium tab 20 mgfosinopril sodium tab 40 mglisinopril & hydrochlorothiazide tab

10-12.5 mg (Zestoretic)lisinopril & hydrochlorothiazide tab

20-12.5 mg (Zestoretic)lisinopril & hydrochlorothiazide tab

20-25 mg (Zestoretic)lisinopril tab 2.5 mg (Zestril)lisinopril tab 5 mg (Prinivil)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

lisinopril tab 10 mg (Prinivil)lisinopril tab 20 mg (Prinivil)lisinopril tab 30 mg (Zestril)lisinopril tab 40 mg (Zestril)moexipril hcl tab 7.5 mg (Univasc)moexipril hcl tab 15 mg (Univasc)perindopril erbumine tab 2 mgperindopril erbumine tab 4 mg (Aceon)perindopril erbumine tab 8 mg (Aceon)quinapril hcl tab 5 mg (Accupril)quinapril hcl tab 10 mg (Accupril)quinapril hcl tab 20 mg (Accupril)quinapril hcl tab 40 mg (Accupril)quinapril-hydrochlorothiazide tab

10-12.5 mg (Accuretic)quinapril-hydrochlorothiazide tab

20-12.5 mg (Accuretic)quinapril-hydrochlorothiazide tab

20-25 mg (Accuretic)ramipril cap 1.25 mg (Altace)ramipril cap 2.5 mg (Altace)ramipril cap 5 mg (Altace)ramipril cap 10 mg (Altace)trandolapril tab 1 mg (Mavik)trandolapril tab 2 mg (Mavik)trandolapril tab 4 mg (Mavik)ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)AND COMBINATIONSamlodipine-valsartan-

hydrochlorothiazide tab 5-160-12.5 mg(Exforge hct)

•

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

•

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

•

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its


•


•

candesartan cilexetil tab 4 mg (Atacand) •candesartan cilexetil tab 8 mg (Atacand) •candesartan cilexetil tab 16 mg (Atacand) •candesartan cilexetil tab 32 mg (Atacand) •candesartan cilexetil-

hydrochlorothiazide tab 16-12.5 mg(Atacand hct)

•

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

•

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

•

irbesartan tab 75 mg (Avapro) •irbesartan tab 150 mg (Avapro) •irbesartan tab 300 mg (Avapro) •irbesartan-hydrochlorothiazide tab

150-12.5 mg (Avalide)•

irbesartan-hydrochlorothiazide tab300-12.5 mg (Avalide)

•

losartan potassium &hydrochlorothiazide tab 50-12.5 mg(Hyzaar)

•

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

•

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

•

losartan potassium tab 25 mg (Cozaar) •losartan potassium tab 50 mg (Cozaar) •losartan potassium tab 100 mg (Cozaar) •telmisartan tab 20 mg (Micardis) •telmisartan tab 40 mg (Micardis) •

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

telmisartan tab 80 mg (Micardis) •telmisartan-hydrochlorothiazide tab

40-12.5 mg (Micardis hct)•

telmisartan-hydrochlorothiazide tab80-12.5 mg (Micardis hct)

•

telmisartan-hydrochlorothiazide tab80-25 mg (Micardis hct)

•

valsartan tab 40 mg (Diovan) •valsartan tab 80 mg (Diovan) •valsartan tab 160 mg (Diovan) •valsartan tab 320 mg (Diovan) •valsartan-hydrochlorothiazide tab

80-12.5 mg (Diovan hct)•

valsartan-hydrochlorothiazide tab160-12.5 mg (Diovan hct)

•

valsartan-hydrochlorothiazide tab160-25 mg (Diovan hct)

•

valsartan-hydrochlorothiazide tab320-12.5 mg (Diovan hct)

•

valsartan-hydrochlorothiazide tab320-25 mg (Diovan hct)

•

BETA BLOCKERS AND COMBINATIONSacebutolol hcl cap 200 mg (Sectral)acebutolol hcl cap 400 mg (Sectral)atenolol & chlorthalidone tab 50-25 mg

(Tenoretic 50)atenolol & chlorthalidone tab 100-25 mg

(Tenoretic 100)atenolol tab 25 mg (Tenormin)atenolol tab 50 mg (Tenormin)atenolol tab 100 mg (Tenormin)bisoprolol & hydrochlorothiazide tab

2.5-6.25 mg (Ziac)bisoprolol & hydrochlorothiazide tab

5-6.25 mg (Ziac)bisoprolol & hydrochlorothiazide tab

10-6.25 mg (Ziac)bisoprolol fumarate tab 5 mg (Zebeta)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

bisoprolol fumarate tab 10 mg (Zebeta)carvedilol tab 3.125 mg (Coreg)carvedilol tab 6.25 mg (Coreg)carvedilol tab 12.5 mg (Coreg)carvedilol tab 25 mg (Coreg)labetalol hcl tab 100 mg (Trandate)labetalol hcl tab 200 mg (Trandate)labetalol hcl tab 300 mg (Trandate)metoprolol & hydrochlorothiazide tab

50-25 mg (Lopressor hct)metoprolol & hydrochlorothiazide tab

100-25 mg (Lopressor hct)metoprolol succinate tab er 24hr 25 mg

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



(tartrate equiv) (Toprol xl)metoprolol tartrate tab 25 mgmetoprolol tartrate tab 50 mg (Lopressor)metoprolol tartrate tab 100 mg

(Lopressor)METOPROLOL/HYDROCHLOROTHI –

metoprolol & hydrochlorothiazide tab100-50 mg

nadolol tab 20 mg (Corgard)nadolol tab 40 mg (Corgard)nadolol tab 80 mg (Corgard)pindolol tab 5 mgpindolol tab 10 mgPROPRANOLOL HCL – propranolol hcl oral

soln 20 mg/5mlPROPRANOLOL HCL – propranolol hcl oral

soln 40 mg/5mlpropranolol hcl cap er 24hr 60 mg

(Inderal la)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

propranolol hcl cap er 24hr 80 mg(Inderal la)



propranolol hcl tab 10 mgpropranolol hcl tab 20 mgpropranolol hcl tab 40 mgpropranolol hcl tab 60 mgpropranolol hcl tab 80 mgPROPRANOLOL/HYDROCHLOROTH –

propranolol & hydrochlorothiazide tab40-25 mg

PROPRANOLOL/HYDROCHLOROTH –propranolol & hydrochlorothiazide tab80-25 mg

timolol maleate tab 5 mgtimolol maleate tab 10 mgtimolol maleate tab 20 mgCALCIUM CHANNEL BLOCKERS ANDCOMBINATIONSamlodipine besylate tab 2.5 mg (base

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

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

equivalent) (Norvasc)amlodipine besylate-benazepril hcl cap

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

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



10-20 mg (Lotrel)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

amlodipine besylate-benazepril hcl cap10-40 mg (Lotrel)

amlodipine besylate-valsartan tab5-160 mg (Exforge)

•


•


•


•

DILT-XR – diltiazem hcl cap er 24hr 120 mgDILT-XR – diltiazem hcl cap er 24hr 180 mgDILT-XR – diltiazem hcl cap er 24hr 240 mgdiltiazem hcl coated beads cap er 24hr

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



300 mgdiltiazem hcl coated beads cap er 24hr

360 mg (Cardizem cd)diltiazem hcl extended release beads cap

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





er 24hr 420 mg (Tiazac)diltiazem hcl tab 30 mg (Cardizem)diltiazem hcl tab 60 mg (Cardizem)diltiazem hcl tab 90 mgdiltiazem hcl tab 120 mg (Cardizem)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

ENTRESTO – sacubitril-valsartan tab 24-26mg

ENTRESTO – sacubitril-valsartan tab 49-51mg

ENTRESTO – sacubitril-valsartan tab97-103 mg

felodipine tab er 24hr 2.5 mgfelodipine tab er 24hr 5 mgfelodipine tab er 24hr 10 mgnifedipine tab er 24hr 30 mg (Adalat cc)nifedipine tab er 24hr 60 mg (Adalat cc)nifedipine tab er 24hr 90 mg (Adalat cc)nifedipine tab er 24hr osmotic release

30 mg (Procardia xl)nifedipine tab er 24hr osmotic release

60 mg (Procardia xl)nifedipine tab er 24hr osmotic release

90 mg (Procardia xl)nimodipine cap 30 mgverapamil hcl cap er 24hr 120 mg

(Verelan)verapamil hcl cap er 24hr 180 mg

(Verelan)verapamil hcl cap er 24hr 240 mg

(Verelan)VERAPAMIL HCL ER – verapamil hcl cap

er 24hr 100 mgVERAPAMIL HCL ER – verapamil hcl cap

er 24hr 300 mgVERAPAMIL HCL SR – verapamil hcl cap

er 24hr 360 mgverapamil hcl tab er 120 mg (Calan sr)verapamil hcl tab er 180 mg (Calan sr)verapamil hcl tab er 240 mg (Calan sr)verapamil hcl tab 40 mgverapamil hcl tab 80 mg (Calan)verapamil hcl tab 120 mg (Calan)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

VERAPAMIL HYDROCHLORIDE E –verapamil hcl cap er 24hr 200 mg

CHEST PAIN (ANGINA)isosorbide dinitrate tab 5 mg (Isordil

titradose)isosorbide dinitrate tab 10 mgisosorbide dinitrate tab 20 mgisosorbide dinitrate tab 30 mgisosorbide mononitrate tab er 24hr

30 mgisosorbide mononitrate tab er 24hr

60 mgisosorbide mononitrate tab er 24hr

120 mgisosorbide mononitrate tab 10 mgisosorbide mononitrate tab 20 mgNITRO-BID – nitroglycerin oint 2%NITRO-TIME – nitroglycerin cap er 2.5 mgNITRO-TIME – nitroglycerin cap er 6.5 mgNITRO-TIME – nitroglycerin cap er 9 mgnitroglycerin sl tab 0.3 mg (Nitrostat)nitroglycerin sl tab 0.4 mg (Nitrostat)nitroglycerin sl tab 0.6 mg (Nitrostat)nitroglycerin td patch 24hr 0.1 mg/hr

(Nitro-dur)nitroglycerin td patch 24hr 0.2 mg/hr



(Nitro-dur)CHOLESTEROL LOWERINGatorvastatin calcium tab 10 mg (base

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

equivalent) (Lipitor)atorvastatin calcium tab 40 mg (base

equivalent) (Lipitor)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

atorvastatin calcium tab 80 mg (baseequivalent) (Lipitor)

cholestyramine light powder packets4 gm

cholestyramine light powder 4 gm/dose(Questran light)

cholestyramine powder packets 4 gm(Questran)

cholestyramine powder 4 gm/dose(Questran)

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

choline fenofibrate cap dr 135 mg(fenofibric acid equiv) (Trilipix)

colesevelam hcl packet for susp 3.75 gm(Welchol)

colesevelam hcl tab 625 mg (Welchol)colestipol hcl granule packets 5 gm

(Colestid flavored)colestipol hcl granules 5 gm (Colestid

flavored)colestipol hcl tab 1 gm (Colestid)ezetimibe tab 10 mg (Zetia)ezetimibe-simvastatin tab 10-10 mg

(Vytorin)ezetimibe-simvastatin tab 10-20 mg



(Vytorin)fenofibrate micronized cap 43 mg

(Antara)fenofibrate micronized cap 67 mg

(Lofibra)fenofibrate micronized cap 130 mg

(Antara)fenofibrate micronized cap 134 mg

(Lofibra)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

fenofibrate micronized cap 200 mg(Lofibra)

fenofibrate tab 48 mg (Tricor)fenofibrate tab 54 mg (Lofibra)fenofibrate tab 145 mg (Tricor)fenofibrate tab 160 mg (Lofibra)gemfibrozil tab 600 mg (Lopid)JUXTAPID – lomitapide mesylate cap 5 mg

(base equiv)• • •

JUXTAPID – lomitapide mesylate cap 10mg (base equiv)

• • •


• • •


• • •


• • •


• • •

lovastatin tab 10 mglovastatin tab 20 mg (Mevacor)lovastatin tab 40 mg (Mevacor)niacin tab er 500 mg (antihyperlipidemic)

(Niaspan)niacin tab er 750 mg (antihyperlipidemic)

(Niaspan)niacin tab er 1000 mg

(antihyperlipidemic) (Niaspan)omega-3-acid ethyl esters cap 1 gm

(Lovaza)pravastatin sodium tab 10 mgpravastatin sodium tab 20 mg (Pravachol)pravastatin sodium tab 40 mg (Pravachol)pravastatin sodium tab 80 mg (Pravachol)REPATHA – evolocumab subcutaneous

soln prefilled syringe 140 mg/ml• •

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

REPATHA PUSHTRONEX SYSTEM –evolocumab subcutaneous soln cartridge/infusor 420 mg/3.5ml

• •

REPATHA SURECLICK – evolocumabsubcutaneous soln auto-injector 140 mg/ml

• •

rosuvastatin calcium tab 5 mg (Crestor)rosuvastatin calcium tab 10 mg (Crestor)rosuvastatin calcium tab 20 mg (Crestor)rosuvastatin calcium tab 40 mg (Crestor)simvastatin tab 5 mg (Zocor)simvastatin tab 10 mg (Zocor)simvastatin tab 20 mg (Zocor)simvastatin tab 40 mg (Zocor)simvastatin tab 80 mg (Zocor)VASCEPA – icosapent ethyl cap 0.5 gm • •VASCEPA – icosapent ethyl cap 1 gm • •FLUID REDUCTIONacetazolamide cap er 12hr 500 mg

(Diamox)acetazolamide tab 125 mgacetazolamide tab 250 mgamiloride & hydrochlorothiazide tab

5-50 mgamiloride hcl tab 5 mgbumetanide tab 0.5 mgbumetanide tab 1 mgbumetanide tab 2 mgCHLOROTHIAZIDE – chlorothiazide tab

250 mgCHLOROTHIAZIDE – chlorothiazide tab

500 mgchlorthalidone tab 25 mgchlorthalidone tab 50 mgfurosemide oral soln 10 mg/mlfurosemide tab 20 mg (Lasix)furosemide tab 40 mg (Lasix)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

furosemide tab 80 mg (Lasix)hydrochlorothiazide cap 12.5 mg

(Microzide)hydrochlorothiazide tab 12.5 mghydrochlorothiazide tab 25 mghydrochlorothiazide tab 50 mgindapamide tab 1.25 mgindapamide tab 2.5 mgmetolazone tab 2.5 mg (Zaroxolyn)metolazone tab 5 mg (Zaroxolyn)metolazone tab 10 mgspironolactone & hydrochlorothiazide

tab 25-25 mg (Aldactazide)spironolactone tab 25 mg (Aldactone)spironolactone tab 50 mg (Aldactone)spironolactone tab 100 mg (Aldactone)torsemide tab 5 mg (Demadex)torsemide tab 10 mg (Demadex)torsemide tab 20 mg (Demadex)torsemide tab 100 mg (Demadex)triamterene & hydrochlorothiazide cap

37.5-25 mg (Dyazide)triamterene & hydrochlorothiazide tab

37.5-25 mg (Maxzide-25)triamterene & hydrochlorothiazide tab

75-50 mg (Maxzide)HEART RHYTHMamiodarone hcl tab 100 mgamiodarone hcl tab 200 mg (Cordarone)amiodarone hcl tab 400 mgdisopyramide phosphate cap 100 mg

(Norpace)disopyramide phosphate cap 150 mg

(Norpace)flecainide acetate tab 50 mgflecainide acetate tab 100 mgflecainide acetate tab 150 mg

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

MEXILETINE HCL – mexiletine hcl cap 150mg



MULTAQ – dronedarone hcl tab 400 mg(base equivalent)

NORPACE CR – disopyramide phosphatecap er 12hr 100 mg

propafenone hcl cap er 12hr 225 mg(Rythmol sr)



propafenone hcl tab 150 mg (Rythmol)propafenone hcl tab 225 mg (Rythmol)propafenone hcl tab 300 mgquinidine gluconate tab er 324 mgQUINIDINE SULFATE – quinidine sulfate

tab 200 mgQUINIDINE SULFATE – quinidine sulfate

tab 300 mgsotalol hcl (afib/afl) tab 80 mg (Betapace

af)sotalol hcl (afib/afl) tab 120 mg (Betapace

af)sotalol hcl (afib/afl) tab 160 mg (Betapace

af)sotalol hcl tab 80 mg (Betapace)sotalol hcl tab 120 mg (Betapace)sotalol hcl tab 160 mg (Betapace)sotalol hcl tab 240 mgOTHER HEART RELATED DRUGSambrisentan tab 5 mg (Letairis) • • •ambrisentan tab 10 mg (Letairis) • • •bosentan tab 62.5 mg (Tracleer) • • •

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

bosentan tab 125 mg (Tracleer) • • •clonidine hcl tab 0.1 mg (Catapres)clonidine hcl tab 0.2 mg (Catapres)clonidine hcl tab 0.3 mg (Catapres)clonidine td patch weekly 0.1 mg/24hr

(Catapres-tts-1)clonidine td patch weekly 0.2 mg/24hr

(Catapres-tts-2)clonidine td patch weekly 0.3 mg/24hr

(Catapres-tts-3)digoxin oral soln 0.05 mg/ml (Digoxin)digoxin tab 125 mcg (0.125 mg) (Lanoxin)digoxin tab 250 mcg (0.25 mg) (Lanoxin)doxazosin mesylate tab 1 mg (Cardura)doxazosin mesylate tab 2 mg (Cardura)doxazosin mesylate tab 4 mg (Cardura)doxazosin mesylate tab 8 mg (Cardura)eplerenone tab 25 mg (Inspra)eplerenone tab 50 mg (Inspra)guanfacine hcl tab 1 mg (Tenex)guanfacine hcl tab 2 mg (Tenex)hydralazine hcl tab 10 mghydralazine hcl tab 25 mghydralazine hcl tab 50 mghydralazine hcl tab 100 mgmethyldopa tab 250 mgmethyldopa tab 500 mgmidodrine hcl tab 2.5 mgmidodrine hcl tab 5 mgmidodrine hcl tab 10 mgminoxidil tab 2.5 mgminoxidil tab 10 mgOPSUMIT – macitentan tab 10 mg • • •phenoxybenzamine hcl cap 10 mg

(Dibenzyline)prazosin hcl cap 1 mg (Minipress)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

prazosin hcl cap 2 mg (Minipress)prazosin hcl cap 5 mg (Minipress)sildenafil citrate tab 20 mg (Revatio) • • •tadalafil tab 20 mg (pah) (Adcirca) • • •terazosin hcl cap 1 mg (base equivalent)terazosin hcl cap 2 mg (base equivalent)terazosin hcl cap 5 mg (base equivalent)terazosin hcl cap 10 mg (base

equivalent)TRACLEER – bosentan tab for oral susp 32

mg• • •

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

• • •

UPTRAVI – selexipag tab 200 mcg • • •UPTRAVI – selexipag tab 400 mcg • • •UPTRAVI – selexipag tab 600 mcg • • •UPTRAVI – selexipag tab 800 mcg • • •UPTRAVI – selexipag tab 1000 mcg • • •UPTRAVI – selexipag tab 1200 mcg • • •UPTRAVI – selexipag tab 1400 mcg • • •UPTRAVI – selexipag tab 1600 mcg • • •VENTAVIS – iloprost inhalation solution 10

mcg/ml• • •

VENTAVIS – iloprost inhalation solution 20mcg/ml

• • •

VYNDAMAX – tafamidis cap 61 mg • • •VYNDAQEL – tafamidis meglumine

(cardiac) cap 20 mg• • •

BEE STING KITSepinephrine solution auto-injector

0.15 mg/0.3ml (1:2000) (Epipen-jr 2-pak)epinephrine solution auto-injector

0.3 mg/0.3ml (1:1000) (Epipen 2-pak)SYMJEPI – epinephrine soln prefilled

syringe 0.15 mg/0.3ml (1:2000)SYMJEPI – epinephrine solution prefilled

syringe 0.3 mg/0.3ml (1:1000)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

RESPIRATORY AGENTSANTIHISTAMINEScyproheptadine hcl syrup 2 mg/5mlcyproheptadine hcl tab 4 mgpromethazine hcl suppos 12.5 mgpromethazine hcl suppos 25 mgpromethazine hcl syrup 6.25 mg/5mlpromethazine hcl tab 12.5 mgpromethazine hcl tab 25 mgpromethazine hcl tab 50 mgPROMETHEGAN – promethazine hcl

suppos 50 mgNASAL PRODUCTSazelastine hcl nasal spray 0.1%

(137 mcg/spray)•

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

•

FLUNISOLIDE – flunisolide nasal soln 25mcg/act (0.025%)

•

fluticasone propionate nasal susp50 mcg/act (Flonase)

•

ipratropium bromide nasal soln 0.03%(21 mcg/spray) (Atrovent)

•

ipratropium bromide nasal soln 0.06%(42 mcg/spray) (Atrovent)

•

COUGH/COLD/ALLERGYacetylcysteine inhal soln 10%acetylcysteine inhal soln 20%promethazine w/ codeine syrup

6.25-10 mg/5mlsodium chloride soln nebu 3%sodium chloride soln nebu 7% (Hyper-

sal)ASTHMA/COPDADVAIR DISKUS – fluticasone-salmeterol

aer powder ba 100-50 mcg/dose•

ADVAIR DISKUS – fluticasone-salmeterolaer powder ba 250-50 mcg/dose

•

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

ADVAIR DISKUS – fluticasone-salmeterolaer powder ba 500-50 mcg/dose

•

ADVAIR HFA – fluticasone-salmeterol inhalaerosol 45-21 mcg/act

•


•


•

ALBUTEROL SULFATE ER – albuterolsulfate tab er 12hr 4 mg

ALBUTEROL SULFATE ER – albuterolsulfate tab er 12hr 8 mg

albuterol sulfate soln nebu 0.083%(2.5 mg/3ml)

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

albuterol sulfate soln nebu 0.63 mg/3ml(base equiv)

albuterol sulfate soln nebu 1.25 mg/3ml(base equiv)

albuterol sulfate syrup 2 mg/5mlalbuterol sulfate tab 2 mgalbuterol sulfate tab 4 mgANORO ELLIPTA – umeclidinium-vilanterol

aero powd ba 62.5-25 mcg/inh•

ARNUITY ELLIPTA – fluticasone furoateaerosol powder breath activ 50 mcg/act

•


•


•

ASMANEX HFA – mometasone furoateinhal aerosol suspension 100 mcg/act

•

ASMANEX HFA – mometasone furoateinhal aerosol suspension 200 mcg/act

•

ASMANEX TWISTHALER 120 ME –mometasone furoate inhal powd 220 mcg/inh (breath activated)

•

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

ASMANEX TWISTHALER 30 MET –mometasone furoate inhal powd 110 mcg/inh (breath activated)

•


•


•

ATROVENT HFA – ipratropium bromide hfainhal aerosol 17 mcg/act

•

BREO ELLIPTA – fluticasone furoate-vilanterol aero powd ba 100-25 mcg/inh

•

BREO ELLIPTA – fluticasone furoate-vilanterol aero powd ba 200-25 mcg/inh

•

budesonide inhalation susp 0.25 mg/2ml(Pulmicort)

budesonide inhalation susp 0.5 mg/2ml(Pulmicort)

budesonide inhalation susp 1 mg/2ml(Pulmicort)

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

•

cromolyn sodium soln nebu 20 mg/2mlDULERA – mometasone furoate-formoterol

fumarate aerosol 100-5 mcg/act•

DULERA – mometasone furoate-formoterolfumarate aerosol 200-5 mcg/act

•

FLOVENT DISKUS – fluticasone propionateaer pow ba 50 mcg/blister

•


•


•

FLOVENT HFA – fluticasone propionate hfainhal aero 44 mcg/act (50/valve)

•

FLOVENT HFA – fluticasone propionate hfainhal aer 110 mcg/act (125/valve)

•

FLOVENT HFA – fluticasone propionate hfainhal aer 220 mcg/act (250/valve)

•

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

FLUTICASONE PROPIONATE/SA –fluticasone-salmeterol aer powder ba55-14 mcg/act

•


•


•

INCRUSE ELLIPTA – umeclidinium br aeropowd breath act 62.5 mcg/inh (base eq)

•

ipratropium bromide inhal soln 0.02%ipratropium-albuterol nebu soln

0.5-2.5(3) mg/3ml (Duoneb)levalbuterol hcl soln nebu conc

1.25 mg/0.5ml (base equiv)levalbuterol hcl soln nebu 0.31 mg/3ml

(base equiv) (Xopenex)levalbuterol hcl soln nebu 0.63 mg/3ml

(base equiv) (Xopenex)levalbuterol hcl soln nebu 1.25 mg/3ml

(base equiv) (Xopenex)montelukast sodium chew tab 4 mg

(base equiv) (Singulair)montelukast sodium chew tab 5 mg

(base equiv) (Singulair)montelukast sodium oral granules

packet 4 mg (base equiv) (Singulair)montelukast sodium tab 10 mg (base

equiv) (Singulair)PROAIR HFA – albuterol sulfate inhal aero

108 mcg/act (90mcg base equiv)•

PROAIR RESPICLICK – albuterol sulfateaer pow ba 108 mcg/act (90 mcg baseequiv)

•

QVAR REDIHALER – beclomethasonediprop hfa breath act inh aer 40 mcg/act

•

QVAR REDIHALER – beclomethasonediprop hfa breath act inh aer 80 mcg/act

•

SEREVENT DISKUS – salmeterol xinafoateaer pow ba 50 mcg/dose (base equiv)

•

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

SPIRIVA HANDIHALER – tiotropiumbromide monohydrate inhal cap 18 mcg(base equiv)

•

SPIRIVA RESPIMAT – tiotropium bromidemonohydrate inhal aerosol 1.25 mcg/act

•

SPIRIVA RESPIMAT – tiotropium bromidemonohydrate inhal aerosol 2.5 mcg/act

•

STIOLTO RESPIMAT – tiotropium br-olodaterol inhal aero soln 2.5-2.5 mcg/act

•

SYMBICORT – budesonide-formoterolfumarate dihyd aerosol 80-4.5 mcg/act

•

SYMBICORT – budesonide-formoterolfumarate dihyd aerosol 160-4.5 mcg/act

•

terbutaline sulfate tab 2.5 mgterbutaline sulfate tab 5 mgTHEOPHYLLINE ER – theophylline tab er

12hr 300 mgTHEOPHYLLINE ER – theophylline tab er

12hr 450 mgtheophylline tab er 24hr 400 mgtheophylline tab er 24hr 600 mgTRELEGY ELLIPTA – fluticasone-

umeclidinium-vilanterol aepb 100-62.5-25mcg/inh

•

VENTOLIN HFA – albuterol sulfate inhalaero 108 mcg/act (90mcg base equiv)

•

XOLAIR – omalizumab for inj 150 mg •XOLAIR – omalizumab subcutaneous soln

prefilled syringe 75 mg/0.5ml•

XOLAIR – omalizumab subcutaneous solnprefilled syringe 150 mg/ml

•

zafirlukast tab 10 mg (Accolate)zafirlukast tab 20 mg (Accolate)OTHER RESPIRATORY DRUGSESBRIET – pirfenidone cap 267 mg • • •ESBRIET – pirfenidone tab 267 mg • • •ESBRIET – pirfenidone tab 801 mg • • •KALYDECO – ivacaftor tab 150 mg • • •

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

KALYDECO – ivacaftor packet 25 mg • • •KALYDECO – ivacaftor packet 50 mg • • •KALYDECO – ivacaftor packet 75 mg • • •OFEV – nintedanib esylate cap 100 mg


OFEV – nintedanib esylate cap 150 mg(base equivalent)

• • •

PULMOZYME – dornase alfa inhal soln 1mg/ml

•

SYMDEKO – tezacaftor-ivacaftor 50-75 mg& ivacaftor 75 mg tab tbpk

• • •

SYMDEKO – tezacaftor-ivacaftor 100-150mg & ivacaftor 150 mg tab tbpk

• • •

TRIKAFTA – elexacaf-tezacaf-ivacaf100-50-75 mg &ivacaftor 150 mg tbpk

• • •

GASTROINTESTINAL DRUGSLAXATIVESGAVILYTE-C – peg 3350-kcl-na bicarb-nacl-

na sulfate for soln 240 gmlactulose solution 10 gm/15mlpeg 3350-kcl-sod bicarb-nacl for soln

420 gm (Nulytely/flavor pack)peg 3350-kcl-na bicarb-nacl-na sulfate

for soln 236 gm (Golytely)ULCER/GERDamoxicillin cap-clarithro tab-lansopraz

cap dr therapy pack (Prevpac)CIMETIDINE HCL – cimetidine hcl soln 300

mg/5mlcimetidine tab 300 mgcimetidine tab 400 mgcimetidine tab 800 mgdicyclomine hcl cap 10 mg (Bentyl)dicyclomine hcl oral soln 10 mg/5mldicyclomine hcl tab 20 mg (Bentyl)esomeprazole magnesium cap delayed

release 20 mg (base eq) (Nexium)•

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

esomeprazole magnesium cap delayedrelease 40 mg (base eq) (Nexium)

•

esomeprazole magnesium for delayedrelease susp packet 10 mg (Nexium)

•


•


•

famotidine tab 40 mg (Pepcid)glycopyrrolate tab 1 mg (Robinul)glycopyrrolate tab 2 mg (Robinul forte)lansoprazole cap delayed release 15 mg

(Prevacid)•

lansoprazole cap delayed release 30 mg(Prevacid)

•

misoprostol tab 100 mcg (Cytotec)misoprostol tab 200 mcg (Cytotec)NEXIUM – esomeprazole magnesium for

delayed release susp pack 2.5 mg•

NEXIUM – esomeprazole magnesium fordelayed release susp packet 5 mg

•


•


•


•

omeprazole cap delayed release 10 mg(Prilosec)

•


•


•

pantoprazole sodium ec tab 20 mg (baseequiv) (Protonix)

•

pantoprazole sodium ec tab 40 mg (baseequiv) (Protonix)

•

rabeprazole sodium ec tab 20 mg(Aciphex)

•

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

sucralfate tab 1 gm (Carafate)NAUSEA AND VOMITINGaprepitant capsule therapy pack 80 &

125 mg (Emend)•

aprepitant capsule 40 mg (Emend)aprepitant capsule 80 mg (Emend) •aprepitant capsule 125 mg (Emend) •EMEND – aprepitant for oral susp 125 mg

(125 mg/5ml)•

ONDANSETRON HCL – ondansetron hcltab 24 mg

•

ondansetron hcl inj 4 mg/2ml (2 mg/ml)ondansetron hcl inj 40 mg/20ml (2 mg/

ml) (Zofran)ondansetron hcl oral soln 4 mg/5ml

(Zofran)•

ondansetron hcl tab 4 mg (Zofran) •ondansetron hcl tab 8 mg (Zofran) •ondansetron orally disintegrating tab

4 mg (Zofran odt)•

ondansetron orally disintegrating tab8 mg (Zofran odt)

•

trimethobenzamide hcl cap 300 mg(Tigan)

DIGESTIVE ENZYMESCREON – pancrelipase (lip-prot-amyl) dr

cap 3000-9500-15000 unitCREON – pancrelipase (lip-prot-amyl) dr




cap 36000-114000-180000 unitZENPEP – pancrelipase (lip-prot-amyl) dr

cap 3000-10000-14000 unitZENPEP – pancrelipase (lip-prot-amyl) dr

cap 5000-17000-24000 unit

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

ZENPEP – pancrelipase (lip-prot-amyl) drcap 10000-32000-42000 unit





OTHER GASTROINTESTINAL DRUGSbalsalazide disodium cap 750 mg

(Colazal)calcium acetate (phosphate binder) cap

667 mg (169 mg ca) (Phoslo)calcium acetate (phosphate binder) tab

667 mg (Eliphos)CHENODAL – chenodiol tab 250 mg •lactulose (encephalopathy) solution

10 gm/15mlmesalamine cap dr 400 mg (Delzicol)mesalamine cap er 24hr 0.375 gm

(Apriso)mesalamine enema 4 gmmesalamine suppos 1000 mg (Canasa)mesalamine tab delayed release 800 mg

(Asacol hd)mesalamine tab delayed release 1.2 gm

(Lialda)metoclopramide hcl soln 5 mg/5ml

(10 mg/10ml) (base equiv)metoclopramide hcl tab 5 mg (base

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

equivalent) (Reglan)RELISTOR – methylnaltrexone bromide inj

8 mg/0.4ml (20 mg/ml)RELISTOR – methylnaltrexone bromide inj

12 mg/0.6ml (20 mg/ml)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

sevelamer carbonate packet 0.8 gm(Renvela)

sevelamer carbonate packet 2.4 gm(Renvela)

sevelamer carbonate tab 800 mg(Renvela)

sulfasalazine tab delayed release 500 mg(Azulfidine en-tabs)

sulfasalazine tab 500 mg (Azulfidine)ursodiol cap 300 mg (Actigall)ursodiol tab 250 mg (Urso 250)ursodiol tab 500 mg (Urso forte)VIBERZI – eluxadoline tab 75 mgVIBERZI – eluxadoline tab 100 mgGENITOURINARY DRUGSURINARY TRACT INFECTIONSnitrofurantoin macrocrystalline cap

50 mg (Macrodantin)nitrofurantoin macrocrystalline cap

100 mg (Macrodantin)nitrofurantoin monohydrate

macrocrystalline cap 100 mg (Macrobid)nitrofurantoin susp 25 mg/5ml

(Furadantin)URINARY TRACT SPASMSMYRBETRIQ – mirabegron tab er 24 hr 25

mgMYRBETRIQ – mirabegron tab er 24 hr 50

mgoxybutynin chloride syrup 5 mg/5mloxybutynin chloride tab er 24hr 5 mg

(Ditropan xl)oxybutynin chloride tab er 24hr 10 mg

(Ditropan xl)oxybutynin chloride tab er 24hr 15 mg

(Ditropan xl)oxybutynin chloride tab 5 mgsolifenacin succinate tab 5 mg (Vesicare)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

solifenacin succinate tab 10 mg(Vesicare)

tolterodine tartrate cap er 24hr 2 mg(Detrol la)

tolterodine tartrate cap er 24hr 4 mg(Detrol la)

tolterodine tartrate tab 1 mg (Detrol)tolterodine tartrate tab 2 mg (Detrol)VAGINAL PRODUCTSclindamycin phosphate vaginal cream

2% (Cleocin)estradiol vaginal tab 10 mcg (Vagifem)metronidazole vaginal gel 0.75%

(Metrogel-vaginal)PREMARIN – estrogens, conjugated

vaginal cream 0.625 mg/gmTERCONAZOLE – terconazole vaginal

cream 0.8%terconazole vaginal cream 0.4% (Terazol

7)terconazole vaginal suppos 80 mgOTHER GENITOURINARY DRUGSalfuzosin hcl tab er 24hr 10 mg (Uroxatral)CYSTAGON – cysteamine bitartrate cap 50

mg•

CYSTAGON – cysteamine bitartrate cap150 mg

•

finasteride tab 5 mg (Proscar)potassium citrate tab er 5 meq (540 mg)

(Urocit-k 5)potassium citrate tab er 10 meq

(1080 mg) (Urocit-k 10)potassium citrate tab er 15 meq

(1620 mg) (Urocit-k 15)sodium citrate & citric acid soln

500-334 mg/5ml (Shohls solution modi)tamsulosin hcl cap 0.4 mg (Flomax)CENTRAL NERVOUS SYSTEM DRUGS

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

ANXIETYALPRAZOLAM INTENSOL – alprazolam

conc 1 mg/mlalprazolam tab er 24hr 0.5 mg (Xanax xr)alprazolam tab er 24hr 1 mg (Xanax xr)alprazolam tab er 24hr 2 mg (Xanax xr)alprazolam tab er 24hr 3 mg (Xanax xr)alprazolam tab 0.25 mg (Xanax)alprazolam tab 0.5 mg (Xanax)alprazolam tab 1 mg (Xanax)alprazolam tab 2 mg (Xanax)buspirone hcl tab 5 mgbuspirone hcl tab 7.5 mgbuspirone hcl tab 10 mgbuspirone hcl tab 15 mgbuspirone hcl tab 30 mgclorazepate dipotassium tab 3.75 mg

(Tranxene t)clorazepate dipotassium tab 7.5 mg

(Tranxene t)clorazepate dipotassium tab 15 mg

(Tranxene t)DIAZEPAM – diazepam oral soln 1 mg/mldiazepam conc 5 mg/mldiazepam tab 2 mg (Valium)diazepam tab 5 mg (Valium)diazepam tab 10 mg (Valium)hydroxyzine hcl syrup 10 mg/5mlhydroxyzine hcl tab 10 mghydroxyzine hcl tab 25 mghydroxyzine hcl tab 50 mgHYDROXYZINE PAMOATE – hydroxyzine

pamoate cap 100 mghydroxyzine pamoate cap 25 mg (Vistaril)hydroxyzine pamoate cap 50 mg (Vistaril)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

lorazepam conc 2 mg/ml (Lorazepamintensol)

lorazepam tab 0.5 mg (Ativan)lorazepam tab 1 mg (Ativan)lorazepam tab 2 mg (Ativan)DEPRESSIONamitriptyline hcl tab 10 mgamitriptyline hcl tab 25 mgamitriptyline hcl tab 50 mgamitriptyline hcl tab 75 mgamitriptyline hcl tab 100 mgamitriptyline hcl tab 150 mgbupropion hcl tab er 12hr 100 mg

(Wellbutrin sr)•

bupropion hcl tab er 12hr 150 mg(Wellbutrin sr)

•

bupropion hcl tab er 12hr 200 mg(Wellbutrin sr)

•

bupropion hcl tab er 24hr 150 mg(Wellbutrin xl)

•

bupropion hcl tab er 24hr 300 mg(Wellbutrin xl)

•

bupropion hcl tab 75 mg (Wellbutrin) •bupropion hcl tab 100 mg (Wellbutrin) •citalopram hydrobromide oral soln

10 mg/5ml•

citalopram hydrobromide tab 10 mg(base equiv) (Celexa)

•


•


•

clomipramine hcl cap 25 mg (Anafranil)clomipramine hcl cap 50 mg (Anafranil)clomipramine hcl cap 75 mg (Anafranil)desipramine hcl tab 10 mg (Norpramin)desipramine hcl tab 25 mg (Norpramin)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

desipramine hcl tab 50 mg (Norpramin)desipramine hcl tab 75 mg (Norpramin)desipramine hcl tab 100 mg (Norpramin)desipramine hcl tab 150 mg (Norpramin)desvenlafaxine succinate tab er 24hr

25 mg (base equiv) (Pristiq)•

desvenlafaxine succinate tab er 24hr50 mg (base equiv) (Pristiq)

•

desvenlafaxine succinate tab er 24hr100 mg (base equiv) (Pristiq)

•

DOXEPIN HCL – doxepin hcl cap 150 mgdoxepin hcl cap 10 mgdoxepin hcl cap 25 mgdoxepin hcl cap 50 mgdoxepin hcl cap 75 mgdoxepin hcl cap 100 mgdoxepin hcl conc 10 mg/mlduloxetine hcl enteric coated pellets cap

20 mg (base eq) (Cymbalta)•

duloxetine hcl enteric coated pellets cap30 mg (base eq) (Cymbalta)

•

duloxetine hcl enteric coated pellets cap60 mg (base eq) (Cymbalta)

•

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

•

escitalopram oxalate tab 5 mg (baseequiv) (Lexapro)

•


•


•

fluoxetine hcl cap 10 mg (Prozac) •fluoxetine hcl cap 20 mg (Prozac) •fluoxetine hcl cap 40 mg (Prozac) •fluoxetine hcl solution 20 mg/5ml •fluoxetine hcl tab 10 mg •fluoxetine hcl tab 20 mg •

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

fluvoxamine maleate tab 25 mg •fluvoxamine maleate tab 50 mg •fluvoxamine maleate tab 100 mg •imipramine hcl tab 10 mg (Tofranil)imipramine hcl tab 25 mg (Tofranil)imipramine hcl tab 50 mg (Tofranil)imipramine pamoate cap 75 mg (Tofranil-

pm)imipramine pamoate cap 100 mg (Tofranil-



pm)mirtazapine orally disintegrating tab

15 mg (Remeron soltab)•

mirtazapine orally disintegrating tab30 mg (Remeron soltab)

•

mirtazapine orally disintegrating tab45 mg (Remeron soltab)

•

mirtazapine tab 7.5 mg •mirtazapine tab 15 mg (Remeron) •mirtazapine tab 30 mg (Remeron) •mirtazapine tab 45 mg (Remeron) •NORTRIPTYLINE HCL – nortriptyline hcl

soln 10 mg/5mlnortriptyline hcl cap 10 mg (Pamelor)nortriptyline hcl cap 25 mg (Pamelor)nortriptyline hcl cap 50 mg (Pamelor)nortriptyline hcl cap 75 mg (Pamelor)paroxetine hcl tab er 24hr 12.5 mg (Paxil

cr)•

paroxetine hcl tab er 24hr 25 mg (Paxil cr) •paroxetine hcl tab er 24hr 37.5 mg (Paxil

cr)•

paroxetine hcl tab 10 mg (Paxil) •paroxetine hcl tab 20 mg (Paxil) •

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

paroxetine hcl tab 30 mg (Paxil) •paroxetine hcl tab 40 mg (Paxil) •phenelzine sulfate tab 15 mg (Nardil)sertraline hcl oral concentrate for

solution 20 mg/ml (Zoloft)•

sertraline hcl tab 25 mg (Zoloft) •sertraline hcl tab 50 mg (Zoloft) •sertraline hcl tab 100 mg (Zoloft) •tranylcypromine sulfate tab 10 mg

(Parnate)trazodone hcl tab 50 mgtrazodone hcl tab 100 mgtrazodone hcl tab 150 mgtrazodone hcl tab 300 mgvenlafaxine hcl cap er 24hr 37.5 mg

(base equivalent) (Effexor xr)•

venlafaxine hcl cap er 24hr 75 mg (baseequivalent) (Effexor xr)

•

venlafaxine hcl cap er 24hr 150 mg (baseequivalent) (Effexor xr)

•

venlafaxine hcl tab 25 mg (baseequivalent)

•

venlafaxine hcl tab 37.5 mg (baseequivalent)

•


•


•


•

PSYCHOTIC AND BIPOLAR DISORDERSaripiprazole tab 2 mg (Abilify) •aripiprazole tab 5 mg (Abilify) •aripiprazole tab 10 mg (Abilify) •aripiprazole tab 15 mg (Abilify) •aripiprazole tab 20 mg (Abilify) •aripiprazole tab 30 mg (Abilify) •

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

chlorpromazine hcl tab 10 mgchlorpromazine hcl tab 25 mgchlorpromazine hcl tab 50 mgchlorpromazine hcl tab 100 mgchlorpromazine hcl tab 200 mgclozapine tab 25 mg (Clozaril) •clozapine tab 50 mg •clozapine tab 100 mg (Clozaril) •clozapine tab 200 mg •FLUPHENAZINE HCL – fluphenazine hcl

oral conc 5 mg/mlFLUPHENAZINE HCL – fluphenazine hcl

tab 1 mgFLUPHENAZINE HCL – fluphenazine hcl

tab 2.5 mgFLUPHENAZINE HCL – fluphenazine hcl

tab 5 mgFLUPHENAZINE HCL – fluphenazine hcl

tab 10 mgFLUPHENAZINE HYDROCHLORID –

fluphenazine hcl elixir 2.5 mg/5mlhaloperidol lactate oral conc 2 mg/mlhaloperidol tab 0.5 mghaloperidol tab 1 mghaloperidol tab 2 mghaloperidol tab 5 mghaloperidol tab 10 mghaloperidol tab 20 mgLITHIUM – lithium oral solution 8 meq/5mlLITHIUM CARBONATE – lithium carbonate

cap 150 mglithium carbonate cap 150 mg (Lithium

carbonate)lithium carbonate cap 300 mglithium carbonate cap 600 mg (Lithium

carbonate)lithium carbonate tab er 300 mg (Lithobid)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

lithium carbonate tab er 450 mglithium carbonate tab 300 mgloxapine succinate cap 5 mg (Loxitane)loxapine succinate cap 10 mgloxapine succinate cap 25 mgloxapine succinate cap 50 mgolanzapine orally disintegrating tab 5 mg

(Zyprexa zydis)•

olanzapine orally disintegrating tab10 mg (Zyprexa zydis)

•


•


•

olanzapine tab 2.5 mg (Zyprexa) •olanzapine tab 5 mg (Zyprexa) •olanzapine tab 7.5 mg (Zyprexa) •olanzapine tab 10 mg (Zyprexa) •olanzapine tab 15 mg (Zyprexa) •olanzapine tab 20 mg (Zyprexa) •perphenazine tab 2 mgperphenazine tab 4 mgperphenazine tab 8 mgperphenazine tab 16 mgprochlorperazine maleate tab 5 mg (base

equivalent) (Compazine)prochlorperazine maleate tab 10 mg

(base equivalent) (Compazine)prochlorperazine suppos 25 mgquetiapine fumarate tab er 24hr 50 mg

(Seroquel xr)•

quetiapine fumarate tab er 24hr 150 mg(Seroquel xr)

•


•


•

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its


•

quetiapine fumarate tab 25 mg (Seroquel) •quetiapine fumarate tab 50 mg (Seroquel) •quetiapine fumarate tab 100 mg

(Seroquel)•

quetiapine fumarate tab 200 mg(Seroquel)

•


•


•

RISPERIDONE ODT – risperidone orallydisintegrating tab 0.25 mg

•

risperidone orally disintegrating tab0.5 mg (Risperdal m-tab)

•

risperidone orally disintegrating tab1 mg (Risperdal m-tab)

•


•


•


•

risperidone soln 1 mg/ml (Risperdal) •risperidone tab 0.25 mg (Risperdal) •risperidone tab 0.5 mg (Risperdal) •risperidone tab 1 mg (Risperdal) •risperidone tab 2 mg (Risperdal) •risperidone tab 3 mg (Risperdal) •risperidone tab 4 mg (Risperdal) •thiothixene cap 1 mgthiothixene cap 2 mgthiothixene cap 5 mgthiothixene cap 10 mgtrifluoperazine hcl tab 1 mg (base

equivalent)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

trifluoperazine hcl tab 2 mg (baseequivalent)



ziprasidone hcl cap 20 mg (Geodon) •ziprasidone hcl cap 40 mg (Geodon) •ziprasidone hcl cap 60 mg (Geodon) •ziprasidone hcl cap 80 mg (Geodon) •SLEEP AIDSestazolam tab 1 mgestazolam tab 2 mgeszopiclone tab 1 mg (Lunesta) •eszopiclone tab 2 mg (Lunesta) •eszopiclone tab 3 mg (Lunesta) •phenobarbital elixir 20 mg/5mlphenobarbital tab 15 mgphenobarbital tab 16.2 mgphenobarbital tab 30 mgphenobarbital tab 32.4 mgphenobarbital tab 60 mgphenobarbital tab 64.8 mgphenobarbital tab 97.2 mgphenobarbital tab 100 mgtemazepam cap 7.5 mg (Restoril)temazepam cap 15 mg (Restoril)temazepam cap 22.5 mg (Restoril)temazepam cap 30 mg (Restoril)zaleplon cap 5 mg (Sonata) •zaleplon cap 10 mg (Sonata) •zolpidem tartrate tab er 6.25 mg (Ambien

cr)•

zolpidem tartrate tab er 12.5 mg (Ambiencr)

•

zolpidem tartrate tab 5 mg (Ambien) •

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

zolpidem tartrate tab 10 mg (Ambien) •HYPERACTIVITY/NARCOLEPSYamphetamine-dextroamphetamine cap er

24hr 5 mg (Adderall xr)•

amphetamine-dextroamphetamine cap er24hr 10 mg (Adderall xr)

•


•


•


•


•

amphetamine-dextroamphetamine tab5 mg (Adderall)

•

amphetamine-dextroamphetamine tab7.5 mg (Adderall)

•


•

amphetamine-dextroamphetamine tab12.5 mg (Adderall)

•


•


•


•

atomoxetine hcl cap 10 mg (base equiv)(Strattera)

•


•


•


•


•


•

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its


•

caffeine citrate oral soln 60 mg/3ml(10 mg/ml base equiv) (Cafcit)

dexmethylphenidate hcl cap er 24 hr5 mg (Focalin xr)

•


•


•


•


•


•


•


•

dexmethylphenidate hcl tab 2.5 mg(Focalin)

•

dexmethylphenidate hcl tab 5 mg(Focalin)

•

dexmethylphenidate hcl tab 10 mg(Focalin)

•

dextroamphetamine sulfate cap er 24hr5 mg (Dexedrine)

•


•


•

dextroamphetamine sulfate tab 5 mg •dextroamphetamine sulfate tab 10 mg •methylphenidate hcl cap er 10 mg (cd) •methylphenidate hcl cap er 20 mg (cd) •methylphenidate hcl cap er 30 mg (cd) •methylphenidate hcl cap er 40 mg (cd) •methylphenidate hcl cap er 50 mg (cd) •

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

methylphenidate hcl cap er 60 mg (cd) •methylphenidate hcl cap er 24hr 20 mg

(la) (Ritalin la)•

methylphenidate hcl cap er 24hr 30 mg(la) (Ritalin la)

•

methylphenidate hcl cap er 24hr 40 mg(la) (Ritalin la)

•

methylphenidate hcl tab er osmoticrelease (osm) 18 mg (Concerta)

•


•


•


•

methylphenidate hcl tab er 10 mg •methylphenidate hcl tab er 20 mg •methylphenidate hcl tab er 24hr 27 mg •methylphenidate hcl tab er 24hr 36 mg •methylphenidate hcl tab er 24hr 54 mg •methylphenidate hcl tab 5 mg (Ritalin) •methylphenidate hcl tab 10 mg (Ritalin) •methylphenidate hcl tab 20 mg (Ritalin) •METHYLPHENIDATE HYDROCHLO –

methylphenidate hcl tab er 24hr 18 mg•

modafinil tab 100 mg (Provigil) •modafinil tab 200 mg (Provigil) •SUNOSI – solriamfetol hcl tab 75 mg (base

equiv)• •

SUNOSI – solriamfetol hcl tab 150 mg(base equiv)

• •

VYVANSE – lisdexamfetamine dimesylatecap 10 mg

•


•


•

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its


•


•


•


•

VYVANSE – lisdexamfetamine dimesylatechew tab 10 mg

•


•


•


•


•


•

MULTIPLE SCLEROSISAUBAGIO – teriflunomide tab 7 mg • • •AUBAGIO – teriflunomide tab 14 mg • • •AVONEX – interferon beta-1a im prefilled

syringe kit 30 mcg/0.5ml• • •

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

• • •

BETASERON – interferon beta-1b for inj kit0.3 mg

• • •

COPAXONE – glatiramer acetate solnprefilled syringe 20 mg/ml

• • •

COPAXONE – glatiramer acetate solnprefilled syringe 40 mg/ml

• • •

GILENYA – fingolimod hcl cap 0.5 mg (baseequiv)

• • •

glatiramer acetate soln prefilled syringe20 mg/ml (Copaxone)

• • •

glatiramer acetate soln prefilled syringe40 mg/ml (Copaxone)

• • •

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

MAVENCLAD – cladribine tab therapy pack10 mg (4 tabs)

• • •


• • •


• • •


• • •


• • •


• • •


• • •

MAYZENT – siponimod fumarate tab 0.25mg (base equiv)

• • •

MAYZENT – siponimod fumarate tab 2 mg(base equiv)

• • •

PLEGRIDY – peginterferon beta-1a solnpen-injector 125 mcg/0.5ml

• • •

PLEGRIDY – peginterferon beta-1a solnprefilled syringe 125 mcg/0.5ml

• • •

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

• • •

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

• • •

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

• • •

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

• • •

REBIF REBIDOSE – interferon beta-1a solnauto-inj 22 mcg/0.5ml (12mu/ml)

• • •

REBIF REBIDOSE – interferon beta-1a solnauto-inj 44 mcg/0.5ml (24mu/ml)

• • •

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

• • •

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

REBIF TITRATION PACK – interferonbeta-1a pref syr 6x8.8 mcg/0.2ml & 6x22mcg/0.5ml

• • •

TECFIDERA – dimethyl fumarate capsuledelayed release 120 mg

• • •

TECFIDERA – dimethyl fumarate capsuledelayed release 240 mg

• • •

TECFIDERA STARTER PACK – dimethylfumarate capsule dr starter pack 120 mg& 240 mg

• • •

TOBACCO CESSATIONbupropion hcl (smoking deterrent) tab er

12hr 150 mg (Zyban)CHANTIX – varenicline tartrate tab 0.5 mg

(base equiv)CHANTIX – varenicline tartrate tab 1 mg

(base equiv)CHANTIX CONTINUING MONTH –

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

varenicline tartrate tab 0.5 mg x 11 & tab 1mg x 42 pack

NICODERM CQ – nicotine td patch 24hr 7mg/24hr



NICORETTE – nicotine polacrilex gum 2 mgNICORETTE – nicotine polacrilex gum 4 mgNICORETTE – nicotine polacrilex lozenge 2

mgNICORETTE – nicotine polacrilex lozenge 4

mgNICORETTE MINI – nicotine polacrilex

lozenge 2 mgNICORETTE MINI – nicotine polacrilex

lozenge 4 mgNICORETTE STARTER KIT – nicotine

polacrilex gum 2 mg

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

NICORETTE STARTER KIT – nicotinepolacrilex gum 4 mg

nicotine polacrilex gum 2 mgnicotine polacrilex gum 4 mgnicotine polacrilex lozenge 2 mgnicotine polacrilex lozenge 4 mgnicotine td patch 24hr 7 mg/24hrnicotine td patch 24hr 14 mg/24hrnicotine td patch 24hr 21 mg/24hrNICOTINE TRANSDERMAL SYST –

nicotine td patch 24 hr kit 21-14-7mg/24hr

NICOTROL INHALER – nicotine inhalersystem 10 mg (4 mg delivered)

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

OTHER CENTRAL NERVOUS SYSTEM DRUGSacamprosate calcium tab delayed

release 333 mg (Campral)AUSTEDO – deutetrabenazine tab 6 mg • • •AUSTEDO – deutetrabenazine tab 9 mg • • •AUSTEDO – deutetrabenazine tab 12 mg • • •disulfiram tab 250 mg (Antabuse)disulfiram tab 500 mg (Antabuse)donepezil hydrochloride orally

disintegrating tab 5 mg (Aricept odt)donepezil hydrochloride orally

disintegrating tab 10 mg (Aricept odt)donepezil hydrochloride tab 5 mg

(Aricept)donepezil hydrochloride tab 10 mg

(Aricept)galantamine hydrobromide cap er 24hr

8 mg (Razadyne er)galantamine hydrobromide cap er 24hr

16 mg (Razadyne er)galantamine hydrobromide cap er 24hr

24 mg (Razadyne er)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

galantamine hydrobromide tab 4 mg(Razadyne)



INGREZZA – valbenazine tosylate captherapy pack 40 mg (7) & 80 mg (21)

• • •

INGREZZA – valbenazine tosylate cap 40mg (base equiv)

• • •

INGREZZA – valbenazine tosylate cap 80mg (base equiv)

• • •

memantine hcl cap er 24hr 7 mg(Namenda xr)




memantine hcl oral solution 2 mg/ml(Namenda)

memantine hcl tab 5 mg (Namenda)memantine hcl tab 10 mg (Namenda)memantine hcl tab 28 x 5 mg & 21 x

10 mg titration pack (Namenda titrationpa)

NAMENDA XR TITRATION PACK –memantine hcl cap er 24hr 7 mg & 14 mg& 21 mg & 28 mg pack

olanzapine-fluoxetine hcl cap 3-25 mg(Symbyax)





Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

PIMOZIDE – pimozide tab 1 mgPIMOZIDE – pimozide tab 2 mgrivastigmine tartrate cap 1.5 mg (base

equivalent)rivastigmine tartrate cap 3 mg (base

equivalent)rivastigmine tartrate cap 4.5 mg (base

equivalent)rivastigmine tartrate cap 6 mg (base

equivalent)tetrabenazine tab 12.5 mg (Xenazine) • • •tetrabenazine tab 25 mg (Xenazine) • • •PAIN RELIEF DRUGSNON-NARCOTIC DRUGSbutalbital-acetaminophen-caffeine tab

50-325-40 mg•

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

•

NARCOTIC DRUGSacetaminophen w/ codeine soln

120-12 mg/5ml•

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

•

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

•

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

•

buprenorphine hcl sl tab 2 mg (baseequiv)

•

buprenorphine hcl sl tab 8 mg (baseequiv)

•

butalbital-aspirin-caff w/ codeine cap50-325-40-30 mg (Fiorinal/codeine #3)

•

codeine sulfate tab 30 mg •fentanyl citrate lozenge on a handle

200 mcg (Actiq)•

fentanyl citrate lozenge on a handle400 mcg (Actiq)

•

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its


•


•


•


•

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

• •


• •


• •


• •


• •

hydrocodone-acetaminophen soln7.5-325 mg/15ml (Hycet)

•

hydrocodone-acetaminophen tab10-325 mg (Norco)

•

hydrocodone-acetaminophen tab5-300 mg (Xodol)

•

hydrocodone-acetaminophen tab5-325 mg (Norco)

•

hydrocodone-acetaminophen tab7.5-325 mg (Norco)

•

hydrocodone-ibuprofen tab 5-200 mg(Reprexain)

•

hydrocodone-ibuprofen tab 7.5-200 mg(Vicoprofen)

•

hydrocodone-ibuprofen tab 10-200 mg(Ibudone)

•

hydromorphone hcl liqd 1 mg/ml(Dilaudid)

•

hydromorphone hcl tab 2 mg (Dilaudid) •hydromorphone hcl tab 4 mg (Dilaudid) •hydromorphone hcl tab 8 mg (Dilaudid) •

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

methadone hcl conc 10 mg/ml(Methadose)

•

methadone hcl soln 5 mg/5ml (Methadonehcl)

•

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

•

methadone hcl tab for oral susp 40 mg •methadone hcl tab 5 mg (Dolophine hcl) •methadone hcl tab 10 mg (Dolophine) •morphine sulfate oral soln 10 mg/5ml •morphine sulfate oral soln 20 mg/5ml •morphine sulfate oral soln 100 mg/5ml

(20 mg/ml)•

morphine sulfate tab er 15 mg (Ms contin) • •morphine sulfate tab er 30 mg (Ms contin) • •morphine sulfate tab er 60 mg (Ms contin) • •morphine sulfate tab er 100 mg (Ms

contin)• •

morphine sulfate tab er 200 mg (Mscontin)

• •

morphine sulfate tab 15 mg (Morphinesulfate)

•

morphine sulfate tab 30 mg (Morphinesulfate)

•

oxycodone hcl cap 5 mg •oxycodone hcl conc 100 mg/5ml (20 mg/

ml) (Oxycodone hcl)•

oxycodone hcl soln 5 mg/5ml (Oxycodonehcl)

•

oxycodone hcl tab 5 mg (Roxicodone) •oxycodone hcl tab 10 mg •oxycodone hcl tab 15 mg (Roxicodone) •oxycodone hcl tab 20 mg •oxycodone hcl tab 30 mg (Roxicodone) •oxycodone w/ acetaminophen tab

5-325 mg (Percocet)•

oxycodone w/ acetaminophen tab7.5-325 mg (Percocet)

•

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

oxycodone w/ acetaminophen tab10-325 mg (Percocet)

•

OXYCODONE/ASPIRIN – oxycodone-aspirin tab 4.8355-325 mg

•

OXYCONTIN – oxycodone hcl tab er 12hrdeter 10 mg

• •


• •


• •


• •


• •


• •


• •

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

37.5-325 mg (Ultracet)•

RHEUMATOID AND OSTEOARTHRITISACTEMRA – tocilizumab subcutaneous soln

prefilled syringe 162 mg/0.9ml• • •

ACTEMRA ACTPEN – tocilizumabsubcutaneous soln auto-injector 162mg/0.9ml

• • •

celecoxib cap 50 mg (Celebrex) •celecoxib cap 100 mg (Celebrex) •celecoxib cap 200 mg (Celebrex) •celecoxib cap 400 mg (Celebrex) •diclofenac potassium tab 50 mg

(Cataflam)diclofenac sodium tab delayed release

25 mg

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

diclofenac sodium tab delayed release50 mg

diclofenac sodium tab delayed release75 mg

diclofenac sodium tab er 24hr 100 mgENBREL – etanercept for subcutaneous inj

25 mg• • •

ENBREL – etanercept subcutaneous solnprefilled syringe 25 mg/0.5ml

• • •

ENBREL – etanercept subcutaneous solnprefilled syringe 50 mg/ml

• • •

ENBREL MINI – etanercept subcutaneoussolution cartridge 50 mg/ml

• • •

ENBREL SURECLICK – etanerceptsubcutaneous solution auto-injector 50mg/ml

• • •

etodolac cap 200 mgetodolac cap 300 mgetodolac tab er 24hr 400 mgetodolac tab er 24hr 500 mgetodolac tab er 24hr 600 mgetodolac tab 400 mgetodolac tab 500 mgflurbiprofen tab 50 mgflurbiprofen tab 100 mgHUMIRA – adalimumab prefilled syringe kit

10 mg/0.1ml• • •

HUMIRA – adalimumab prefilled syringe kit10 mg/0.2ml

• • •


• • •


• • •


• • •


• • •

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

HUMIRA PEDIATRIC CROHNS D –adalimumab prefilled syringe kit 80mg/0.8ml

• • •

HUMIRA PEDIATRIC CROHNS D –adalimumab prefilled syringe kit 80mg/0.8ml & 40 mg/0.4ml

• • •

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

• • •

HUMIRA PEN – adalimumab pen-injector kit40 mg/0.4ml

• • •

HUMIRA PEN-CD/UC/HS START –adalimumab pen-injector kit 40 mg/0.8ml

• • •

HUMIRA PEN-CD/UC/HS START –adalimumab pen-injector kit 80 mg/0.8ml

• • •

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

• • •

HUMIRA PEN-PS/UV STARTER –adalimumab pen-injector kit 80 mg/0.8ml& 40 mg/0.4ml

• • •

ibuprofen susp 100 mg/5mlibuprofen tab 400 mgibuprofen tab 600 mgibuprofen tab 800 mgILARIS – canakinumab subcutaneous inj

150 mg/ml• • •

indomethacin cap 25 mgindomethacin cap 50 mgketorolac tromethamine tab 10 mg •leflunomide tab 10 mg (Arava)leflunomide tab 20 mg (Arava)meloxicam tab 7.5 mg (Mobic)meloxicam tab 15 mg (Mobic)nabumetone tab 500 mgnabumetone tab 750 mgnaproxen sodium tab 275 mg (Anaprox)naproxen sodium tab 550 mg (Anaprox

ds)naproxen susp 125 mg/5ml (Naprosyn)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

naproxen tab ec 375 mg (Ec-naprosyn)naproxen tab ec 500 mg (Ec-naprosyn)naproxen tab 250 mg (Naprosyn)naproxen tab 375 mg (Naprosyn)naproxen tab 500 mg (Naprosyn)OTEZLA – apremilast tab starter therapy

pack 10 mg & 20 mg & 30 mg• • •

OTEZLA – apremilast tab 30 mg • • •oxaprozin tab 600 mg (Daypro)piroxicam cap 10 mg (Feldene)piroxicam cap 20 mg (Feldene)RIDAURA – auranofin cap 3 mgRINVOQ – upadacitinib tab er 24hr 15 mg • • •SIMPONI – golimumab subcutaneous soln

auto-injector 100 mg/ml• • •

SIMPONI – golimumab subcutaneous solnprefilled syringe 100 mg/ml

• • •

sulindac tab 150 mgsulindac tab 200 mgXELJANZ – tofacitinib citrate tab 5 mg


XELJANZ – tofacitinib citrate tab 10 mg(base equivalent)

• • •

XELJANZ XR – tofacitinib citrate tab er 24hr11 mg (base equivalent)

• • •

XELJANZ XR – tofacitinib citrate tab er 24hr22 mg (base equivalent)

• • •

MIGRAINE HEADACHESAIMOVIG – erenumab-aooe subcutaneous

soln auto-injector 70 mg/ml• •

AIMOVIG – erenumab-aooe subcutaneoussoln auto-injector 140 mg/ml

• •

dihydroergotamine mesylate nasal spray4 mg/ml (Migranal)

EMGALITY – galcanezumab-gnlmsubcutaneous soln auto-injector 120 mg/ml

• •

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

EMGALITY – galcanezumab-gnlmsubcutaneous soln prefilled syr 100 mg/ml

• •

EMGALITY – galcanezumab-gnlmsubcutaneous soln prefilled syr 120 mg/ml

• •

MIGRANAL – dihydroergotamine mesylatenasal spray 4 mg/ml

naratriptan hcl tab 1 mg (base equiv)(Amerge)

•

naratriptan hcl tab 2.5 mg (base equiv)(Amerge)

•

rizatriptan benzoate oral disintegratingtab 5 mg (base eq) (Maxalt-mlt)

•

rizatriptan benzoate oral disintegratingtab 10 mg (base eq) (Maxalt-mlt)

•

rizatriptan benzoate tab 5 mg (baseequivalent) (Maxalt)

•

rizatriptan benzoate tab 10 mg (baseequivalent) (Maxalt)

•

sumatriptan nasal spray 5 mg/act(Imitrex)

•

sumatriptan nasal spray 20 mg/act(Imitrex)

•

SUMATRIPTAN SUCCINATE – sumatriptansuccinate solution prefilled syringe 6mg/0.5ml

•

sumatriptan succinate inj 6 mg/0.5ml(Imitrex)

•

sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex statdosesys)

•

sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdosesys)

•

sumatriptan succinate solution cartridge4 mg/0.5ml (Imitrex statdose ref)

•

sumatriptan succinate solution cartridge6 mg/0.5ml (Imitrex statdose ref)

•

sumatriptan succinate tab 25 mg (Imitrex) •sumatriptan succinate tab 50 mg (Imitrex) •

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

sumatriptan succinate tab 100 mg(Imitrex)

•

zolmitriptan orally disintegrating tab2.5 mg (Zomig zmt)

•

zolmitriptan orally disintegrating tab5 mg (Zomig zmt)

•

zolmitriptan tab 2.5 mg (Zomig) •zolmitriptan tab 5 mg (Zomig) •GOUTallopurinol tab 100 mg (Zyloprim)allopurinol tab 300 mg (Zyloprim)COLCHICINE – colchicine cap 0.6 mgcolchicine tab 0.6 mg (Colcrys)colchicine w/ probenecid tab 0.5-500 mgprobenecid tab 500 mgNEUROMUSCULAR DRUGSSEIZURESBANZEL – rufinamide susp 40 mg/mlBANZEL – rufinamide tab 200 mgBANZEL – rufinamide tab 400 mgcarbamazepine cap er 12hr 100 mg

(Carbatrol)carbamazepine cap er 12hr 200 mg

(Carbatrol)carbamazepine cap er 12hr 300 mg

(Carbatrol)carbamazepine chew tab 100 mgcarbamazepine susp 100 mg/5ml

(Tegretol)carbamazepine tab er 12hr 100 mg

(Tegretol-xr)carbamazepine tab er 12hr 200 mg

(Tegretol-xr)carbamazepine tab er 12hr 400 mg

(Tegretol-xr)carbamazepine tab 200 mg (Tegretol)clonazepam orally disintegrating tab

0.125 mg

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

clonazepam orally disintegrating tab0.25 mg

clonazepam orally disintegrating tab0.5 mg

clonazepam orally disintegrating tab1 mg

clonazepam orally disintegrating tab2 mg

clonazepam tab 0.5 mg (Klonopin)clonazepam tab 1 mg (Klonopin)clonazepam tab 2 mg (Klonopin)DIASTAT ACUDIAL – diazepam rectal gel

delivery system 10 mgDIASTAT ACUDIAL – diazepam rectal gel

delivery system 20 mgDIASTAT PEDIATRIC – diazepam rectal gel

delivery system 2.5 mgDILANTIN – phenytoin sodium extended

cap 30 mgDILANTIN – phenytoin sodium extended

cap 100 mgDILANTIN-125 – phenytoin susp 125

mg/5mldivalproex sodium cap delayed release

sprinkle 125 mg (Depakote sprinkles)divalproex sodium tab delayed release

125 mg (Depakote)divalproex sodium tab delayed release

250 mg (Depakote)divalproex sodium tab delayed release

500 mg (Depakote)divalproex sodium tab er 24 hr 250 mg

(Depakote er)divalproex sodium tab er 24 hr 500 mg

(Depakote er)EPIDIOLEX – cannabidiol soln 100 mg/ml • •ethosuximide cap 250 mg (Zarontin)ethosuximide soln 250 mg/5ml (Zarontin)felbamate susp 600 mg/5ml (Felbatol)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

felbamate tab 400 mg (Felbatol)felbamate tab 600 mg (Felbatol)gabapentin cap 100 mg (Neurontin)gabapentin cap 300 mg (Neurontin)gabapentin cap 400 mg (Neurontin)gabapentin oral soln 250 mg/5ml

(Neurontin)gabapentin tab 600 mg (Neurontin)gabapentin tab 800 mg (Neurontin)lamotrigine tab chewable dispersible

5 mg (Lamictal chewable di)lamotrigine tab chewable dispersible

25 mg (Lamictal chewable di)lamotrigine tab 25 mg (Lamictal)lamotrigine tab 100 mg (Lamictal)lamotrigine tab 150 mg (Lamictal)lamotrigine tab 200 mg (Lamictal)levetiracetam oral soln 100 mg/ml

(Keppra)levetiracetam tab er 24hr 500 mg (Keppra

xr)levetiracetam tab er 24hr 750 mg (Keppra

xr)levetiracetam tab 250 mg (Keppra)levetiracetam tab 500 mg (Keppra)levetiracetam tab 750 mg (Keppra)levetiracetam tab 1000 mg (Keppra)oxcarbazepine susp 300 mg/5ml (60 mg/

ml) (Trileptal)oxcarbazepine tab 150 mg (Trileptal)oxcarbazepine tab 300 mg (Trileptal)oxcarbazepine tab 600 mg (Trileptal)phenytoin chew tab 50 mg (Dilantin

infatabs)phenytoin sodium extended cap 100 mg

(Dilantin)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

phenytoin sodium extended cap 200 mg(Phenytek)

phenytoin sodium extended cap 300 mg(Phenytek)

phenytoin susp 125 mg/5ml (Dilantin)primidone tab 50 mg (Mysoline)primidone tab 250 mg (Mysoline)topiramate sprinkle cap 15 mg (Topamax

sprinkle)topiramate sprinkle cap 25 mg (Topamax

sprinkle)topiramate tab 25 mg (Topamax)topiramate tab 50 mg (Topamax)topiramate tab 100 mg (Topamax)topiramate tab 200 mg (Topamax)valproate sodium oral soln 250 mg/5ml

(base equiv) (Depakene)valproic acid cap 250 mg (Depakene)vigabatrin powd pack 500 mg (Sabril)vigabatrin tab 500 mg (Sabril)zonisamide cap 25 mg (Zonegran)zonisamide cap 50 mgzonisamide cap 100 mg (Zonegran)PARKINSON'S DISEASEbenztropine mesylate tab 0.5 mgbenztropine mesylate tab 1 mgbenztropine mesylate tab 2 mgcarbidopa & levodopa orally

disintegrating tab 10-100 mgcarbidopa & levodopa orally

disintegrating tab 25-100 mgcarbidopa & levodopa orally

disintegrating tab 25-250 mgcarbidopa & levodopa tab er 25-100 mg

(Sinemet cr)carbidopa & levodopa tab er 50-200 mg

(Sinemet cr)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

carbidopa & levodopa tab 10-100 mg(Sinemet)



CARBIDOPA/LEVODOPA/ENTACA –carbidopa-levodopa-entacapone tabs12.5-50-200 mg


CARBIDOPA/LEVODOPA/ENTACA –carbidopa-levodopa-entacapone tabs25-100-200 mg



CARBIDOPA/LEVODOPA/ENTACA –carbidopa-levodopa-entacapone tabs50-200-200 mg

entacapone tab 200 mg (Comtan)INBRIJA – levodopa inhal powder cap 42

mg•

pramipexole dihydrochloride tab0.125 mg (Mirapex)

pramipexole dihydrochloride tab 0.25 mg(Mirapex)



pramipexole dihydrochloride tab 1 mg(Mirapex)


ropinirole hydrochloride tab 0.25 mg(Requip)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

ropinirole hydrochloride tab 0.5 mg(Requip)

ropinirole hydrochloride tab 1 mg(Requip)





SELEGILINE HCL – selegiline hcl tab 5 mgselegiline hcl cap 5 mg (Eldepryl)trihexyphenidyl hcl oral soln 0.4 mg/mltrihexyphenidyl hcl tab 2 mgtrihexyphenidyl hcl tab 5 mgMUSCLE RELAXANTSbaclofen tab 10 mgbaclofen tab 20 mgchlorzoxazone tab 500 mgcyclobenzaprine hcl tab 5 mgcyclobenzaprine hcl tab 10 mgdantrolene sodium cap 25 mg (Dantrium)dantrolene sodium cap 50 mg (Dantrium)dantrolene sodium cap 100 mg

(Dantrolene sodium)methocarbamol tab 500 mg (Robaxin)methocarbamol tab 750 mg (Robaxin-750)orphenadrine citrate tab er 12hr 100 mgOTHER NEUROMUSCULAR DRUGSpyridostigmine bromide oral soln

60 mg/5ml (Mestinon)pyridostigmine bromide tab er 180 mg

(Mestinon timespan)pyridostigmine bromide tab 60 mg

(Mestinon)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

riluzole tab 50 mg (Rilutek) •VITAMINSergocalciferol cap 1.25 mg (50000 unit)

(Drisdol)phytonadione tab 5 mg (Mephyton)MULTIVITAMINSPRENATABS RX – prenatal vit w/ iron

carbonyl-fa tab 29-1 mgPRENATAL PLUS IRON – prenatal vit w/

iron carbonyl-fa tab 29-1 mgPRENATAL 19 – prenatal vit w/ fe fumarate-

fa chew tab 29-1 mgPRENATAL 19 – prenatal vit w/ dss-fe

fumarate-fa tab 29-1 mgPRENATAL-U – prenatal w/o a vit w/ fe

fumarate-fa cap 106.5-1 mgTRINATE – prenatal vit w/ fe fumarate-fa

tab 28-1 mgVINATE DHA RF – prenat w/o a w/fefum-

methylfol-omegas cap 27-1.13 mgVINATE II – prenatal vit w/ fe bisglycinate

chelate-fa tab 29-1 mgVINATE M – prenatal vit w/ sel-fe fumarate-

fa tab 27-1 mgVINATE ONE – prenatal vit w/ fe fumarate-

fa tab 60-1 mgMINERALS AND ELECTROLYTESFLURA-DROPS – sodium fluoride soln 0.25

mg/drop f (from 0.55 mg/drop naf)pot phos monobasic w/sod phos di &

monobas tab 155-852-130mg (K-phosneutral)

potassium chloride cap er 8 meq (Micro-k)

potassium chloride cap er 10 meq (Micro-k)

POTASSIUM CHLORIDE ER – potassiumchloride tab er 8 meq (600 mg)

potassium chloride microencapsulatedcrys er tab 10 meq

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

potassium chloride microencapsulatedcrys er tab 20 meq

potassium chloride oral soln 10% (20meq/15ml)

potassium chloride oral soln 20% (40meq/15ml)

potassium chloride powder packet 20meq

potassium chloride tab er 8 meq(600 mg)

potassium chloride tab er 10 meq (K-tab)SODIUM FLUORIDE – sodium fluoride tab

0.5 mg f (from 1.1 mg naf)SODIUM FLUORIDE – sodium fluoride tab

1 mg f (from 2.2 mg naf)sodium fluoride chew tab 0.25 mg f (from

0.55 mg naf) (Luride)sodium fluoride chew tab 0.5 mg f (from

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

2.2 mg naf) (Luride)sodium fluoride soln 0.125 mg/drop f

(0.275 mg/drop naf)sodium fluoride soln 0.5 mg/ml f (from

1.1 mg/ml naf) (Luride)BLOOD MODIFYING DRUGSaminocaproic acid tab 500 mg (Amicar)anagrelide hcl cap 0.5 mg (Agrylin)anagrelide hcl cap 1 mgaspirin-dipyridamole cap er 12hr

25-200 mg (Aggrenox)BRILINTA – ticagrelor tab 60 mgBRILINTA – ticagrelor tab 90 mgCERDELGA – eliglustat tartrate cap 84 mg


cilostazol tab 50 mg (Pletal)cilostazol tab 100 mg (Pletal)clopidogrel bisulfate tab 75 mg (base

equiv) (Plavix)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

clopidogrel bisulfate tab 300 mg (baseequiv) (Plavix)

dipyridamole tab 25 mg (Persantine)dipyridamole tab 50 mg (Persantine)dipyridamole tab 75 mg (Persantine)ELIQUIS – apixaban tab 2.5 mg •ELIQUIS – apixaban tab 5 mg •ELIQUIS STARTER PACK – apixaban tab 5

mg•

enoxaparin sodium inj 30 mg/0.3ml(Lovenox)

•


•


•


•

enoxaparin sodium inj 100 mg/ml(Lovenox)

•


•

enoxaparin sodium inj 150 mg/ml(Lovenox)

•

enoxaparin sodium inj 300 mg/3ml(Lovenox)

•

folic acid tab 1 mgfondaparinux sodium subcutaneous inj

2.5 mg/0.5ml (Arixtra)•

fondaparinux sodium subcutaneous inj5 mg/0.4ml (Arixtra)

•

fondaparinux sodium subcutaneous inj7.5 mg/0.6ml (Arixtra)

•

fondaparinux sodium subcutaneous inj10 mg/0.8ml (Arixtra)

•

FULPHILA – pegfilgrastim-jmdb solnprefilled syringe 6 mg/0.6ml

•

GRANIX – tbo-filgrastim soln prefilledsyringe 300 mcg/0.5ml

•

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

GRANIX – tbo-filgrastim soln prefilledsyringe 480 mcg/0.8ml

•

GRANIX – tbo-filgrastim subcutaneous inj300 mcg/ml

•

GRANIX – tbo-filgrastim subcutaneous inj480 mcg/1.6ml (300 mcg/ml)

•

icatibant acetate inj 30 mg/3ml (baseequivalent) (Firazyr)

• • •

NEULASTA – pegfilgrastim soln prefilledsyringe 6 mg/0.6ml

•

NEULASTA ONPRO KIT – pegfilgrastimsoln prefilled syringe kit 6 mg/0.6ml

•

NPLATE – romiplostim for inj 125 mcg • •NPLATE – romiplostim for inj 250 mcg • •NPLATE – romiplostim for inj 500 mcg • •pentoxifylline tab er 400 mgprasugrel hcl tab 5 mg (base equiv)

(Effient)prasugrel hcl tab 10 mg (base equiv)

(Effient)PROMACTA – eltrombopag olamine tab

12.5 mg (base equiv)• • •

PROMACTA – eltrombopag olamine tab 25mg (base equiv)

• • •


• • •


• • •

PROMACTA – eltrombopag olamine powderpack for susp 25 mg (base equiv)

• • •

PROMACTA – eltrombopag olamine powderpack for susp 12.5 mg (base eq)

• • •

UDENYCA – pegfilgrastim-cbqv solnprefilled syringe 6 mg/0.6ml

•

warfarin sodium tab 1 mg (Coumadin)warfarin sodium tab 2 mg (Coumadin)warfarin sodium tab 2.5 mg (Coumadin)warfarin sodium tab 3 mg (Coumadin)warfarin sodium tab 4 mg (Coumadin)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

warfarin sodium tab 5 mg (Coumadin)warfarin sodium tab 6 mg (Coumadin)warfarin sodium tab 7.5 mg (Coumadin)warfarin sodium tab 10 mg (Coumadin)XARELTO – rivaroxaban tab 2.5 mg •XARELTO – rivaroxaban tab 10 mg •XARELTO – rivaroxaban tab 15 mg •XARELTO – rivaroxaban tab 20 mg •XARELTO STARTER PACK – rivaroxaban

tab starter therapy pack 15 mg & 20 mg•

TOPICAL PRODUCTSEYEAnti-infectivesBACITRACIN – bacitracin ophth oint 500

unit/gmbacitracin-polymyxin b ophth ointCILOXAN – ciprofloxacin hcl ophth oint

0.3%ciprofloxacin hcl ophth soln 0.3% (base

equivalent) (Ciloxan)erythromycin ophth oint 5 mg/gmGENTAK – gentamicin sulfate ophth oint

0.3%gentamicin sulfate ophth soln 0.3%

(Garamycin)moxifloxacin hcl ophth soln 0.5% (base

equiv) (Vigamox)NATACYN – natamycin ophth susp 5%neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oinNEOMYCIN/POLYMYXIN/GRAMIC –

neomycin-polymy-gramicid op sol1.75-10000-0.025mg-unt-mg/ml

ofloxacin ophth soln 0.3% (Ocuflox)polymyxin b-trimethoprim ophth soln

10000 unit/ml-0.1% (Polytrim)sulfacetamide sodium ophth soln 10%

(Bleph-10)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

tobramycin ophth soln 0.3% (Tobrex)TRIFLURIDINE – trifluridine ophth soln 1%Steroids and Combination ProductsALREX – loteprednol etabonate ophth susp

0.2%bacitracin-polymyxin-neomycin-hc ophth

oint 1%BLEPHAMIDE – sulfacetamide sodium-

prednisolone ophth susp 10-0.2%BLEPHAMIDE S.O.P. – sulfacetamide

sodium-prednisolone ophth oint 10-0.2%DEXAMETHASONE SODIUM PHOS –

dexamethasone sodium phosphate ophthsoln 0.1%

fluorometholone ophth susp 0.1% (Fmlliquifilm)

FML – fluorometholone ophth oint 0.1%LOTEMAX – loteprednol etabonate ophth

oint 0.5%LOTEMAX – loteprednol etabonate ophth

gel 0.5%LOTEMAX SM – loteprednol etabonate

ophth gel 0.38%loteprednol etabonate ophth susp 0.5%

(Lotemax)neomycin-polymyxin-dexamethasone

ophth oint 0.1% (Maxitrol)neomycin-polymyxin-dexamethasone

ophth susp 0.1% (Maxitrol)PREDNISOLONE ACETATE – prednisolone

acetate ophth susp 1%PREDNISOLONE SODIUM PHOSP –

prednisolone sodium phosphate ophthsoln 1%

SULFACETAMIDE SODIUM/PRED –sulfacetamide sodium-prednisolone ophthsoln 10-0.23(0.25)%

TOBRADEX – tobramycin-dexamethasoneophth oint 0.3-0.1%

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

tobramycin-dexamethasone ophth susp0.3-0.1% (Tobradex)

ZYLET – loteprednol etabonate-tobramycinophth susp 0.5-0.3%

GlaucomaALPHAGAN P – brimonidine tartrate ophth

soln 0.1%AZOPT – brinzolamide ophth susp 1%BETOPTIC-S – betaxolol hcl ophth susp

0.25%brimonidine tartrate ophth soln 0.15%

(Alphagan p)brimonidine tartrate ophth soln 0.2%CARTEOLOL HCL – carteolol hcl ophth

soln 1%dorzolamide hcl ophth soln 2% (Trusopt)dorzolamide hcl-timolol maleate ophth

soln 22.3-6.8 mg/ml (Cosopt)latanoprost ophth soln 0.005% (Xalatan) •LEVOBUNOLOL HCL – levobunolol hcl

ophth soln 0.5%LUMIGAN – bimatoprost ophth soln 0.01% •pilocarpine hcl ophth soln 1% (Isopto

carpine)pilocarpine hcl ophth soln 2% (Isopto

carpine)pilocarpine hcl ophth soln 4% (Isopto

carpine)SIMBRINZA – brinzolamide-brimonidine

tartrate ophth susp 1-0.2%timolol maleate ophth soln 0.25%

(Timoptic)timolol maleate ophth soln 0.5%

(Timoptic)TIMOLOL MALEATE OPHTHALMI – timolol

maleate ophth gel forming soln 0.25%TIMOLOL MALEATE OPHTHALMI – timolol

maleate ophth gel forming soln 0.5%

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

travoprost ophth soln 0.004%(benzalkonium free) (bak free) (Travatanz)

•

Other Eye ProductsATROPINE SULFATE – atropine sulfate

ophth soln 1%azelastine hcl ophth soln 0.05% (Optivar)cromolyn sodium ophth soln 4%cyclopentolate hcl ophth soln 1%

(Cyclogyl)diclofenac sodium ophth soln 0.1%FLURBIPROFEN SODIUM – flurbiprofen

sodium ophth soln 0.03%ketorolac tromethamine ophth soln 0.4%

(Acular ls)ketorolac tromethamine ophth soln 0.5%

(Acular)olopatadine hcl ophth soln 0.1% (base

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

equivalent) (Pataday)PAZEO – olopatadine hcl ophth soln 0.7%

(base equivalent)EARacetic acid otic soln 2%CIPRO HC – ciprofloxacin-hydrocortisone

otic susp 0.2-1%CIPRODEX – ciprofloxacin-dexamethasone

otic susp 0.3-0.1%hydrocortisone w/ acetic acid otic soln

1-2%neomycin-polymyxin-hc otic soln 1%

(Cortisporin)neomycin-polymyxin-hc otic susp

3.5 mg/ml-10000 unit/ml-1%ofloxacin otic soln 0.3%MOUTH AND THROAT (LOCAL)chlorhexidine gluconate soln 0.12%

(Peridex)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

lidocaine hcl viscous soln 2%nystatin susp 100000 unit/mlpilocarpine hcl tab 5 mg (Salagen)pilocarpine hcl tab 7.5 mg (Salagen)sodium fluoride cream 1.1% (Prevident

5000 plus)sodium fluoride gel 1.1% (0.5% f)

(Prevident fluoride)triamcinolone acetonide dental paste

0.1%ANORECTALhydrocortisone acetate suppos 25 mghydrocortisone enema 100 mg/60ml

(Cortenema)hydrocortisone perianal cream 2.5%

(Anusol-hc)SKIN CONDITIONS/PRODUCTSAcneadapalene cream 0.1% (Differin) •adapalene gel 0.1% (Differin) •azelaic acid gel 15% (Finacea)benzoyl peroxide-erythromycin gel 5-3%

(Benzamycin)clindamycin phosph-benzoyl peroxide

(refrig) gel 1.2 (1)-5%, NF = Neuac(Duac)

clindamycin phosphate gel 1% (Cleocin-t)clindamycin phosphate lotion 1%

(Cleocin-t)clindamycin phosphate soln 1% (Cleocin-

t)clindamycin phosphate swab 1%

(Cleocin-t)clindamycin phosphate-benzoyl

peroxide gel 1-5% (Benzaclin)ERY – erythromycin pads 2%erythromycin gel 2% (Erygel)erythromycin soln 2%

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

FINACEA – azelaic acid foam 15%isotretinoin cap 10 mgisotretinoin cap 20 mgisotretinoin cap 30 mgisotretinoin cap 40 mgmetronidazole cream 0.75% (Metrocream)metronidazole gel 0.75%metronidazole gel 1% (Metrogel)metronidazole lotion 0.75% (Metrolotion)SOOLANTRA – ivermectin cream 1%sulfacetamide sodium lotion 10% (acne)

(Klaron)tazarotene cream 0.1% (Tazorac) •TAZORAC – tazarotene cream 0.05%TAZORAC – tazarotene gel 0.05%TAZORAC – tazarotene gel 0.1%tretinoin cream 0.025% (Retin-a) •tretinoin cream 0.05% (Retin-a) •tretinoin cream 0.1% (Retin-a) •tretinoin gel 0.01% (Retin-a) •tretinoin gel 0.025%, NF = Avita gel

(Retin-a)•

tretinoin microsphere gel 0.04% (Retin-amicro)

•

tretinoin microsphere gel 0.1% (Retin-amicro)

•

Anti-infectivesciclopirox gel 0.77% (Loprox)ciclopirox olamine cream 0.77% (base

equiv)ciclopirox olamine susp 0.77% (base

equiv)ciclopirox shampoo 1% (Loprox shampoo)clotrimazole w/ betamethasone cream

1-0.05% (Lotrisone)clotrimazole w/ betamethasone lotion

1-0.05%

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

econazole nitrate cream 1%gentamicin sulfate cream 0.1%gentamicin sulfate oint 0.1%ketoconazole cream 2%ketoconazole shampoo 2% (Nizoral)mupirocin oint 2% (Bactroban)nystatin cream 100000 unit/gmnystatin oint 100000 unit/gmnystatin topical powder 100000 unit/gmsilver sulfadiazine cream 1% (Silvadene)Corticosteroidsalclometasone dipropionate cream 0.05%

(Aclovate)alclometasone dipropionate oint 0.05%AMCINONIDE – amcinonide cream 0.1%AUGMENTED BETAMETHASONE D –

betamethasone dipropionate augmentedgel 0.05%

betamethasone dipropionate augmentedcream 0.05% (Diprolene af)

betamethasone dipropionate augmentedlotion 0.05% (Diprolene)

betamethasone dipropionate augmentedoint 0.05% (Diprolene)

betamethasone dipropionate cream0.05%

betamethasone dipropionate lotion0.05%

betamethasone dipropionate oint 0.05%betamethasone valerate cream 0.1%

(base equivalent)betamethasone valerate lotion 0.1%

(base equivalent)betamethasone valerate oint 0.1% (base

equivalent)clobetasol propionate cream 0.05%

(Temovate)

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

clobetasol propionate emollient basecream 0.05% (Temovate e)

clobetasol propionate foam 0.05% (Olux)clobetasol propionate gel 0.05%

(Temovate)clobetasol propionate oint 0.05%

(Temovate)clobetasol propionate soln 0.05%

(Temovate)desonide cream 0.05% (Desowen)desonide lotion 0.05% (Desowen)desonide oint 0.05% (Desowen)desoximetasone cream 0.25% (Topicort)desoximetasone gel 0.05% (Topicort)desoximetasone oint 0.25% (Topicort)DIFLORASONE DIACETATE – diflorasone

diacetate cream 0.05%diflorasone diacetate oint 0.05%fluocinolone acetonide cream 0.01%fluocinolone acetonide cream 0.025%

(Synalar)fluocinolone acetonide oint 0.025%

(Synalar)fluocinolone acetonide soln 0.01%

(Synalar)fluocinonide cream 0.05%fluocinonide emulsified base cream

0.05%fluocinonide gel 0.05%fluocinonide oint 0.05%fluocinonide soln 0.05%fluticasone propionate cream 0.05%

(Cutivate)fluticasone propionate oint 0.005%

(Cutivate)halobetasol propionate cream 0.05%

(Ultravate)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

halobetasol propionate oint 0.05%(Ultravate)

hydrocortisone cream 2.5%hydrocortisone lotion 2.5%hydrocortisone oint 2.5%hydrocortisone valerate cream 0.2%hydrocortisone valerate oint 0.2%

(Westcort)mometasone furoate cream 0.1% (Elocon)mometasone furoate oint 0.1% (Elocon)mometasone furoate solution 0.1%

(lotion) (Elocon)nystatin-triamcinolone cream 100000-0.1

unit/gm-%nystatin-triamcinolone oint 100000-0.1

unit/gm-%triamcinolone acetonide cream 0.025%triamcinolone acetonide cream 0.1%triamcinolone acetonide cream 0.5%triamcinolone acetonide lotion 0.025%triamcinolone acetonide lotion 0.1%triamcinolone acetonide oint 0.025%triamcinolone acetonide oint 0.1%triamcinolone acetonide oint 0.5%Other Productsacitretin cap 10 mg (Soriatane)acitretin cap 17.5 mg (Soriatane)acitretin cap 25 mg (Soriatane)calcipotriene cream 0.005% (Dovonex)calcipotriene oint 0.005%calcipotriene soln 0.005% (50 mcg/ml)CARAC – fluorouracil cream 0.5%COSENTYX – secukinumab subcutaneous

soln prefilled syringe 150 mg/ml• • •

COSENTYX – secukinumab subcutaneouspref syr 150 mg/ml (300 mg dose)

• • •

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

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

• • •

COSENTYX SENSOREADY PEN –secukinumab subcutaneous auto-inj 150mg/ml (300 mg dose)

• • •

diclofenac sodium (actinic keratoses) gel3% (Solaraze)

diclofenac sodium gel 1% (Voltaren) •DUPIXENT – dupilumab subcutaneous soln

prefilled syringe 300 mg/2ml• • •

FLUOROPLEX – fluorouracil cream 1%FLUOROURACIL – fluorouracil soln 2%FLUOROURACIL – fluorouracil soln 5%fluorouracil cream 5% (Efudex)imiquimod cream 5% (Aldara)lidocaine-prilocaine cream 2.5-2.5%

(Emla)LINDANE – lindane shampoo 1%malathion lotion 0.5% (Ovide)methoxsalen rapid cap 10 mg (Oxsoralen

ultra)permethrin cream 5% (Elimite)PICATO – ingenol mebutate gel 0.015%PICATO – ingenol mebutate gel 0.05%pimecrolimus cream 1% (Elidel)podofilox soln 0.5% (Condylox)selenium sulfide lotion 2.5%SKYRIZI – risankizumab-rzaa sol prefilled

syringe 2 x 75 mg/0.83ml kit• • •

STELARA – ustekinumab inj 45 mg/0.5ml • • •STELARA – ustekinumab soln prefilled

syringe 45 mg/0.5ml• • •

STELARA – ustekinumab soln prefilledsyringe 90 mg/ml

• • •

SYNERA – lidocaine-tetracaine topicalpatch 70-70 mg

tacrolimus oint 0.03% (Protopic)

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

tacrolimus oint 0.1% (Protopic)TREMFYA – guselkumab soln pen-injector

100 mg/ml• • •

TREMFYA – guselkumab soln prefilledsyringe 100 mg/ml

• • •

VALCHLOR – mechlorethamine hcl gel0.016% (base equivalent)

•

ZYCLARA – imiquimod cream 3.75%ZYCLARA PUMP – imiquimod cream 2.5%ZYCLARA PUMP – imiquimod cream 3.75%MISCELLANEOUS CATEGORIESDIABETIC SUPPLIESCALIBRATION LIQUID - ASCENSIA

CONTOUR, CONTOUR NEXTDEXCOM G5 MOBILE RECEIVER –

continuous blood glucose system receiver• •

DEXCOM G5 MOBILE TRANSMIT –continuous blood glucose systemtransmitter

• •

DEXCOM G5 MOBILE/G4 PLATI –continuous blood glucose system sensor

• •

DEXCOM G5 RECEIVER KIT – continuousblood glucose system receiver

• •

DEXCOM G6 RECEIVER – continuousblood glucose system receiver

• •

DEXCOM G6 SENSOR – continuous bloodglucose system sensor

• •

DEXCOM G6 TRANSMITTER – continuousblood glucose system transmitter

• •

FREESTYLE LIBRE 14 DAY/RE –continuous blood glucose system receiver

• •

FREESTYLE LIBRE 14 DAY/SE –continuous blood glucose system sensor

• •

FREESTYLE LIBRE/READER/FL –continuous blood glucose system receiver

• •

FREESTYLE LIBRE/SENSOR/FL –continuous blood glucose system sensor

• •

INSULIN PEN NEEDLES – NOVOFINE,NOVOTWIST; various

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

INSULIN SYRINGES – variousLANCETS – variousTEST STRIPS – ASCENSIA CONTOUR,

CONTOUR NEXT•

MEDICAL DEVICESINHALER ASSIST DEVICES – spacersMISCELLANEOUS DRUGSazathioprine tab 50 mg (Imuran)BUNAVAIL – buprenorphine-naloxone

buccal film 2.1-0.3 mg (base equiv)•

BUNAVAIL – buprenorphine-naloxonebuccal film 4.2-0.7 mg (base equiv)

•

BUNAVAIL – buprenorphine-naloxonebuccal film 6.3-1 mg (base equiv)

•

buprenorphine hcl-naloxone hcl sl film2-0.5 mg (base equiv) (SUBOXONE)

•

buprenorphine hcl-naloxone hcl sl film4-1 mg (base equiv) (SUBOXONE)

•

buprenorphine hcl-naloxone hcl sl film8-2 mg (base equiv) (Suboxone)

•

buprenorphine hcl-naloxone hcl sl film12-3 mg (base equiv) (SUBOXONE)

•

buprenorphine hcl-naloxone hcl sl tab2-0.5 mg (base equiv)

•

buprenorphine hcl-naloxone hcl sl tab8-2 mg (base equiv)

•

CHEMET – succimer cap 100 mgcyclosporine cap 25 mg (Sandimmune)cyclosporine cap 100 mg (Sandimmune)cyclosporine modified cap 25 mg

(Neoral)cyclosporine modified cap 100 mg

(Neoral)cyclosporine modified oral soln 100 mg/

ml (Neoral)deferasirox tab for oral susp 125 mg

(EXJADE)•

deferasirox tab for oral susp 250 mg(EXJADE)

•

Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

deferasirox tab for oral susp 500 mg(EXJADE)

•

deferasirox tab 90 mg (Jadenu) •deferasirox tab 180 mg •deferasirox tab 360 mg (Jadenu) •everolimus tab 0.25 mg (Zortress)everolimus tab 0.5 mg (Zortress)everolimus tab 0.75 mg (Zortress)JADENU – deferasirox tab 180 mg •JADENU SPRINKLE – deferasirox granules

packet 90 mg•

JADENU SPRINKLE – deferasirox granulespacket 180 mg

•

JADENU SPRINKLE – deferasirox granulespacket 360 mg

•

mycophenolate mofetil cap 250 mg(Cellcept)

mycophenolate mofetil for oral susp200 mg/ml (Cellcept)

mycophenolate mofetil tab 500 mg(Cellcept)

mycophenolate sodium tab dr 180 mg(mycophenolic acid equiv) (Myfortic)

mycophenolate sodium tab dr 360 mg(mycophenolic acid equiv) (Myfortic)

NALOXONE HCL – naloxone hcl solncartridge 0.4 mg/ml

naloxone hcl inj 0.4 mg/mlnaloxone hcl inj 4 mg/10mlnaltrexone hcl tab 50 mg (Revia)NARCAN – naloxone hcl nasal spray 4

mg/0.1mlpenicillamine tab 250 mg (Depen titratabs) •REVLIMID – lenalidomide caps 2.5 mg • • •REVLIMID – lenalidomide cap 5 mg • • •REVLIMID – lenalidomide cap 10 mg • • •REVLIMID – lenalidomide cap 15 mg • • •REVLIMID – lenalidomide cap 20 mg • • •

2020


Drug Name Spe

cial

ty

Prio

r App

rova

l

Dis

pens

ing

Lim

its

REVLIMID – lenalidomide cap 25 mg • • •sirolimus oral soln 1 mg/ml (Rapamune)sirolimus tab 0.5 mg (Rapamune)sirolimus tab 1 mg (Rapamune)sirolimus tab 2 mg (Rapamune)sodium polystyrene sulfonate oral susp

15 gm/60ml (Sps)sodium polystyrene sulfonate powder

(Kayexalate)sodium polystyrene sulfonate rectal

susp 30 gm/120mltacrolimus cap 0.5 mg (Prograf)tacrolimus cap 1 mg (Prograf)tacrolimus cap 5 mg (Prograf)THALOMID – thalidomide cap 50 mg • • •THALOMID – thalidomide cap 100 mg • • •THALOMID – thalidomide cap 150 mg • • •THALOMID – thalidomide cap 200 mg • • •ZORTRESS – everolimus tab 0.25 mgZORTRESS – everolimus tab 0.5 mgZORTRESS – everolimus tab 0.75 mgZORTRESS – everolimus tab 1 mgZUBSOLV – buprenorphine hcl-naloxone

hcl sl tab 0.7-0.18 mg (base eq)•

ZUBSOLV – buprenorphine hcl-naloxonehcl sl tab 1.4-0.36 mg (base eq)

•


•


•


•


•

2020


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).........4abiraterone acetate tab 250 mg (Zytiga).......................... 6acamprosate calcium tab delayed release 333 mg(Campral).......................................................................... 39

acarbose tab 25 mg (Precose)........................................ 14acarbose tab 50 mg (Precose)........................................ 14acarbose tab 100 mg (Precose)...................................... 14acebutolol hcl cap 200 mg (Sectral)...............................20acebutolol hcl cap 400 mg (Sectral)...............................20acetaminophen w/ codeine soln 120-12 mg/5ml........... 40acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine)............................................................................ 40

acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3).......................................................................40

acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4).......................................................................40

acetazolamide cap er 12hr 500 mg (Diamox)................ 24acetazolamide tab 125 mg............................................... 24acetazolamide tab 250 mg............................................... 24acetic acid otic soln 2%...................................................51acetylcysteine inhal soln 10%.........................................26acetylcysteine inhal soln 20%.........................................26acitretin cap 10 mg (Soriatane).......................................53acitretin cap 17.5 mg (Soriatane)....................................53acitretin cap 25 mg (Soriatane).......................................53ACTEMRA ACTPEN – tocilizumab subcutaneous solnauto-injector 162 mg/0.9ml............................................... 42

ACTEMRA – tocilizumab subcutaneous soln prefilledsyringe 162 mg/0.9ml........................................................42

ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml(2000000 unit/0.5ml)........................................................... 6

acyclovir cap 200 mg (Zovirax).........................................4acyclovir susp 200 mg/5ml (Zovirax)............................... 4acyclovir tab 400 mg (Zovirax)..........................................4acyclovir tab 800 mg (Zovirax)..........................................4adapalene cream 0.1% (Differin).....................................51adapalene gel 0.1% (Differin).......................................... 51adefovir dipivoxil tab 10 mg (Hepsera)............................3ADVAIR DISKUS – fluticasone-salmeterol aer powder ba100-50 mcg/dose...............................................................26

ADVAIR DISKUS – fluticasone-salmeterol aer powder ba250-50 mcg/dose...............................................................26

ADVAIR DISKUS – fluticasone-salmeterol aer powder ba500-50 mcg/dose...............................................................27

ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21mcg/act...............................................................................27

ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21mcg/act...............................................................................27

ADVAIR HFA – fluticasone-salmeterol inhal aerosol230-21 mcg/act..................................................................27

AFINITOR DISPERZ – everolimus tab for oral susp 2mg........................................................................................ 6



AFINITOR – everolimus tab 10 mg......................................6AIMOVIG – erenumab-aooe subcutaneous soln auto-injector 70 mg/ml...............................................................43

AIMOVIG – erenumab-aooe subcutaneous soln auto-injector 140 mg/ml.............................................................43

albendazole tab 200 mg (Albenza)....................................6ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr4 mg...................................................................................27

ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr8 mg...................................................................................27

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..........27albuterol sulfate soln nebu 0.5% (5 mg/ml)...................27albuterol sulfate soln nebu 0.63 mg/3ml (baseequiv).................................................................................27

albuterol sulfate soln nebu 1.25 mg/3ml (baseequiv).................................................................................27

albuterol sulfate syrup 2 mg/5ml....................................27albuterol sulfate tab 2 mg................................................27albuterol sulfate tab 4 mg................................................27alclometasone dipropionate cream 0.05%(Aclovate)..........................................................................52

alclometasone dipropionate oint 0.05%.........................52ALECENSA – alectinib hcl cap 150 mg (baseequivalent)............................................................................7

ALENDRONATE SODIUM – alendronate sodium tab 5mg...................................................................................... 17

alendronate sodium tab 10 mg....................................... 17alendronate sodium tab 35 mg....................................... 17alendronate sodium tab 70 mg (Fosamax).................... 17alfuzosin hcl tab er 24hr 10 mg (Uroxatral)................... 31ALINIA – nitazoxanide for susp 100 mg/5ml........................6ALINIA – nitazoxanide tab 500 mg...................................... 6allopurinol tab 100 mg (Zyloprim).................................. 44allopurinol tab 300 mg (Zyloprim).................................. 44ALPHAGAN P – brimonidine tartrate ophth soln 0.1%...... 50ALPRAZOLAM INTENSOL – alprazolam conc 1 mg/ml........................................................................................32

alprazolam tab er 24hr 0.5 mg (Xanax xr)......................32alprazolam tab er 24hr 1 mg (Xanax xr).........................32alprazolam tab er 24hr 2 mg (Xanax xr).........................32alprazolam tab er 24hr 3 mg (Xanax xr).........................32alprazolam tab 0.25 mg (Xanax)......................................32alprazolam tab 0.5 mg (Xanax)........................................32alprazolam tab 1 mg (Xanax)...........................................32

2020


alprazolam tab 2 mg (Xanax)...........................................32ALREX – loteprednol etabonate ophth susp 0.2%.............50ALUNBRIG – 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.....................................7ambrisentan tab 5 mg (Letairis)......................................25ambrisentan tab 10 mg (Letairis)....................................25AMCINONIDE – amcinonide cream 0.1%......................... 52amiloride & hydrochlorothiazide tab 5-50 mg............... 24amiloride hcl tab 5 mg..................................................... 24aminocaproic acid tab 500 mg (Amicar)........................48amiodarone hcl tab 100 mg.............................................24amiodarone hcl tab 400 mg.............................................24amiodarone hcl tab 200 mg (Cordarone)....................... 24amitriptyline hcl tab 10 mg..............................................32amitriptyline hcl tab 25 mg..............................................32amitriptyline hcl tab 50 mg..............................................32amitriptyline hcl tab 75 mg..............................................32amitriptyline hcl tab 100 mg............................................32amitriptyline hcl tab 150 mg............................................32amlodipine besylate-benazepril hcl cap 2.5-10 mg(Lotrel)...............................................................................21

amlodipine besylate-benazepril hcl cap 5-10 mg(Lotrel)...............................................................................21





amlodipine besylate tab 2.5 mg (base equivalent)(Norvasc)...........................................................................21

amlodipine besylate tab 5 mg (base equivalent)(Norvasc)...........................................................................21

amlodipine besylate tab 10 mg (base equivalent)(Norvasc)...........................................................................21

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




amlodipine-valsartan-hydrochlorothiazide tab5-160-12.5 mg (Exforge hct)...........................................19

amlodipine-valsartan-hydrochlorothiazide tab 5-160-25mg (Exforge hct)..............................................................19

amlodipine-valsartan-hydrochlorothiazide tab10-160-12.5 mg (Exforge hct).........................................19

amlodipine-valsartan-hydrochlorothiazide tab10-160-25 mg (Exforge hct)............................................19

amlodipine-valsartan-hydrochlorothiazide tab10-320-25 mg (Exforge hct)............................................19

AMOXICILLIN/CLAVULANATE P – amoxicillin & kclavulanate chew tab 200-28.5 mg.....................................1

AMOXICILLIN/CLAVULANATE P – amoxicillin & kclavulanate chew tab 400-57 mg........................................1

AMOXICILLIN/CLAVULANATE P – amoxicillin & kclavulanate tab er 12hr 1000-62.5 mg............................... 1

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

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

AMOXICILLIN – amoxicillin (trihydrate) chew tab 125mg........................................................................................ 1

AMOXICILLIN – amoxicillin (trihydrate) chew tab 250mg........................................................................................ 1

amoxicillin cap-clarithro tab-lansopraz cap dr therapypack (Prevpac).................................................................29

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 cap er 24hr 5 mg(Adderall xr)..................................................................... 36

amphetamine-dextroamphetamine cap er 24hr 10 mg(Adderall xr)..................................................................... 36





amphetamine-dextroamphetamine tab 5 mg(Adderall).......................................................................... 36

amphetamine-dextroamphetamine tab 7.5 mg(Adderall).......................................................................... 36


amphetamine-dextroamphetamine tab 12.5 mg(Adderall).......................................................................... 36


2020




AMPICILLIN – ampicillin cap 500 mg.................................. 1anagrelide hcl cap 1 mg.................................................. 48anagrelide hcl cap 0.5 mg (Agrylin)............................... 48anastrozole tab 1 mg (Arimidex).......................................7ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba62.5-25 mcg/inh.................................................................27

aprepitant capsule 40 mg (Emend).................................30aprepitant capsule 80 mg (Emend).................................30aprepitant capsule 125 mg (Emend)...............................30aprepitant capsule therapy pack 80 & 125 mg(Emend).............................................................................30

aripiprazole tab 2 mg (Abilify).........................................34aripiprazole tab 5 mg (Abilify).........................................34aripiprazole tab 10 mg (Abilify).......................................34aripiprazole tab 15 mg (Abilify).......................................34aripiprazole tab 20 mg (Abilify).......................................34aripiprazole tab 30 mg (Abilify).......................................34ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 50 mcg/act.....................................................27

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 100 mcg/act.................................................. 27

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 200 mcg/act.................................................. 27

ASMANEX HFA – mometasone furoate inhal aerosolsuspension 100 mcg/act................................................... 27

ASMANEX HFA – mometasone furoate inhal aerosolsuspension 200 mcg/act................................................... 27

ASMANEX TWISTHALER 120 ME – mometasone furoateinhal powd 220 mcg/inh (breath activated)...................... 27

ASMANEX TWISTHALER 30 MET – mometasone furoateinhal powd 110 mcg/inh (breath activated).......................27

ASMANEX TWISTHALER 30 MET – mometasone furoateinhal powd 220 mcg/inh (breath activated)...................... 27

ASMANEX TWISTHALER 60 MET – mometasone furoateinhal powd 220 mcg/inh (breath activated)...................... 27

aspirin-dipyridamole cap er 12hr 25-200 mg(Aggrenox)........................................................................48

atazanavir sulfate cap 150 mg (base equiv)(Reyataz)............................................................................. 4



atenolol & chlorthalidone tab 50-25 mg (Tenoretic50)...................................................................................... 20

atenolol & chlorthalidone tab 100-25 mg (Tenoretic100).................................................................................... 20

atenolol tab 25 mg (Tenormin)........................................ 20atenolol tab 50 mg (Tenormin)........................................ 20atenolol tab 100 mg (Tenormin)...................................... 20atomoxetine hcl cap 10 mg (base equiv) (Strattera).....36atomoxetine hcl cap 18 mg (base equiv) (Strattera).....36

atomoxetine hcl cap 25 mg (base equiv) (Strattera).....36atomoxetine hcl cap 40 mg (base equiv) (Strattera).....36atomoxetine hcl cap 60 mg (base equiv) (Strattera).....36atomoxetine hcl cap 80 mg (base equiv) (Strattera).....36atomoxetine hcl cap 100 mg (base equiv)(Strattera)..........................................................................37

atorvastatin calcium tab 10 mg (base equivalent)(Lipitor)..............................................................................22




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

ATROPINE SULFATE – atropine sulfate ophth soln1%...................................................................................... 51

ATROVENT HFA – ipratropium bromide hfa inhal aerosol17 mcg/act......................................................................... 27

AUBAGIO – teriflunomide tab 7 mg...................................38AUBAGIO – teriflunomide tab 14 mg.................................38AUGMENTED BETAMETHASONE D – betamethasonedipropionate augmented gel 0.05%..................................52

AUGMENTIN – amoxicillin & k clavulanate for susp125-31.25 mg/5ml............................................................... 1

AUSTEDO – deutetrabenazine tab 6 mg...........................39AUSTEDO – deutetrabenazine tab 9 mg...........................39AUSTEDO – deutetrabenazine tab 12 mg.........................39AVONEX – interferon beta-1a im prefilled syringe kit 30mcg/0.5ml...........................................................................38

AVONEX PEN – interferon beta-1a im auto-injector kit 30mcg/0.5ml...........................................................................38

AYVAKIT – avapritinib tab 100 mg.......................................7AYVAKIT – avapritinib tab 200 mg.......................................7AYVAKIT – avapritinib tab 300 mg.......................................7azathioprine tab 50 mg (Imuran).....................................55azelaic acid gel 15% (Finacea)........................................51azelastine hcl nasal spray 0.1% (137 mcg/spray)......... 26azelastine hcl nasal spray 0.15% (205.5 mcg/spray)(Astepro)........................................................................... 26

azelastine hcl ophth soln 0.05% (Optivar)..................... 51AZITHROMYCIN – azithromycin powd pack for susp 1gm........................................................................................ 2

azithromycin 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).............................. 2AZOPT – brinzolamide ophth susp 1%..............................50

2020


BBACITRACIN – bacitracin ophth oint 500 unit/gm............. 49bacitracin-polymyxin b ophth oint..................................49bacitracin-polymyxin-neomycin-hc ophth oint 1%.......50baclofen tab 10 mg...........................................................47baclofen tab 20 mg...........................................................47balsalazide disodium cap 750 mg (Colazal).................. 30BANZEL – rufinamide susp 40 mg/ml................................44BANZEL – rufinamide tab 200 mg..................................... 44BANZEL – rufinamide tab 400 mg..................................... 44BARACLUDE – entecavir oral soln 0.05 mg/ml...................3benazepril & hydrochlorothiazide tab 5-6.25 mg.......... 18benazepril & hydrochlorothiazide tab 10-12.5 mg(Lotensin hct)...................................................................18

benazepril & hydrochlorothiazide tab 20-12.5 mg(Lotensin hct)...................................................................18

benazepril & hydrochlorothiazide tab 20-25 mg(Lotensin hct)...................................................................18

benazepril hcl tab 5 mg................................................... 18benazepril hcl tab 10 mg (Lotensin)...............................18benazepril hcl tab 20 mg (Lotensin)...............................18benazepril hcl tab 40 mg (Lotensin)...............................18BENZNIDAZOLE – benznidazole tab 12.5 mg.................... 6BENZNIDAZOLE – benznidazole tab 100 mg..................... 6benzoyl peroxide-erythromycin gel 5-3%(Benzamycin)....................................................................51

benztropine mesylate tab 0.5 mg....................................46benztropine mesylate tab 1 mg.......................................46benztropine mesylate tab 2 mg.......................................46betamethasone dipropionate augmented cream 0.05%(Diprolene af)................................................................... 52

betamethasone dipropionate augmented lotion 0.05%(Diprolene)........................................................................ 52

betamethasone dipropionate augmented oint 0.05%(Diprolene)........................................................................ 52

betamethasone dipropionate cream 0.05%................... 52betamethasone dipropionate lotion 0.05%....................52betamethasone dipropionate oint 0.05%....................... 52betamethasone valerate cream 0.1% (baseequivalent)........................................................................ 52

betamethasone valerate lotion 0.1% (baseequivalent)........................................................................ 52

betamethasone valerate oint 0.1% (baseequivalent)........................................................................ 52

BETASERON – interferon beta-1b for inj kit 0.3 mg.......... 38BETOPTIC-S – betaxolol hcl ophth susp 0.25%................50bexarotene cap 75 mg (Targretin).....................................7bicalutamide tab 50 mg (Casodex)...................................7BIKTARVY – bictegravir-emtricitabine-tenofovir af tab50-200-25 mg...................................................................... 4

bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg(Ziac)..................................................................................20

bisoprolol & hydrochlorothiazide tab 5-6.25 mg(Ziac)..................................................................................20

bisoprolol & hydrochlorothiazide tab 10-6.25 mg(Ziac)..................................................................................20

bisoprolol fumarate tab 5 mg (Zebeta)...........................20bisoprolol fumarate tab 10 mg (Zebeta).........................20BLEPHAMIDE S.O.P. – sulfacetamide sodium-prednisolone ophth oint 10-0.2%......................................50

BLEPHAMIDE – sulfacetamide sodium-prednisoloneophth susp 10-0.2%.......................................................... 50

bosentan tab 62.5 mg (Tracleer)..................................... 25bosentan tab 125 mg (Tracleer)...................................... 25BOSULIF – 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............................................................ 27

BREO ELLIPTA – fluticasone furoate-vilanterol aero powdba 200-25 mcg/inh............................................................ 27

BRILINTA – ticagrelor tab 60 mg....................................... 48BRILINTA – ticagrelor tab 90 mg....................................... 48brimonidine tartrate ophth soln 0.2%.............................50brimonidine tartrate ophth soln 0.15% (Alphaganp)........................................................................................ 50

budesonide delayed release particles cap 3 mg(Entocort ec).................................................................... 10

budesonide inhalation susp 0.25 mg/2ml(Pulmicort)........................................................................ 27

budesonide inhalation susp 0.5 mg/2ml(Pulmicort)........................................................................ 27

budesonide inhalation susp 1 mg/2ml (Pulmicort).......27bumetanide tab 0.5 mg.................................................... 24bumetanide tab 1 mg........................................................24bumetanide tab 2 mg........................................................24BUNAVAIL – buprenorphine-naloxone buccal film 2.1-0.3mg (base equiv)................................................................ 55

BUNAVAIL – buprenorphine-naloxone buccal film 4.2-0.7mg (base equiv)................................................................ 55

BUNAVAIL – buprenorphine-naloxone buccal film 6.3-1 mg(base equiv).......................................................................55

buprenorphine hcl-naloxone hcl sl film 8-2 mg (baseequiv) (Suboxone)........................................................... 55

buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (baseequiv) (SUBOXONE)........................................................55

buprenorphine hcl-naloxone hcl sl film 4-1 mg (baseequiv) (SUBOXONE)........................................................55

buprenorphine hcl-naloxone hcl sl film 12-3 mg (baseequiv) (SUBOXONE)........................................................55

buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (baseequiv).................................................................................55

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (baseequiv).................................................................................55

buprenorphine hcl sl tab 2 mg (base equiv)................. 40buprenorphine hcl sl tab 8 mg (base equiv)................. 40bupropion hcl (smoking deterrent) tab er 12hr 150 mg(Zyban).............................................................................. 39

bupropion hcl tab er 12hr 100 mg (Wellbutrin sr).........32bupropion hcl tab er 12hr 150 mg (Wellbutrin sr).........32

2020


bupropion hcl tab er 12hr 200 mg (Wellbutrin sr).........32bupropion hcl tab er 24hr 150 mg (Wellbutrin xl)......... 32bupropion hcl tab er 24hr 300 mg (Wellbutrin xl)......... 32bupropion hcl tab 75 mg (Wellbutrin)............................ 32bupropion hcl tab 100 mg (Wellbutrin).......................... 32buspirone hcl tab 5 mg....................................................32buspirone hcl tab 7.5 mg.................................................32buspirone hcl tab 10 mg..................................................32buspirone hcl tab 15 mg..................................................32buspirone hcl tab 30 mg..................................................32butalbital-acetaminophen-caffeine tab 50-325-40mg...................................................................................... 40

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

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

cabergoline tab 0.5 mg.................................................... 17CABOMETYX – cabozantinib s-malate tab 20 mg (baseequivalent)............................................................................7

CABOMETYX – cabozantinib s-malate tab 40 mg (baseequivalent)............................................................................7

CABOMETYX – cabozantinib s-malate tab 60 mg (baseequivalent)............................................................................7

caffeine citrate oral soln 60 mg/3ml (10 mg/ml baseequiv) (Cafcit)...................................................................37

calcipotriene cream 0.005% (Dovonex)..........................53calcipotriene oint 0.005%.................................................53calcipotriene soln 0.005% (50 mcg/ml).......................... 53calcitonin (salmon) nasal soln 200 unit/act(Miacalcin)........................................................................ 17

calcitriol cap 0.25 mcg (Rocaltrol)..................................17calcitriol cap 0.5 mcg (Rocaltrol)....................................17calcitriol oral soln 1 mcg/ml (Rocaltrol).........................17calcium acetate (phosphate binder) cap 667 mg (169mg ca) (Phoslo)............................................................... 30

calcium acetate (phosphate binder) tab 667 mg(Eliphos)............................................................................30

CALIBRATION LIQUID - ASCENSIA CONTOUR,CONTOUR NEXT..............................................................54

candesartan cilexetil-hydrochlorothiazide tab 16-12.5mg (Atacand hct).............................................................19

candesartan cilexetil-hydrochlorothiazide tab 32-12.5mg (Atacand hct).............................................................19

candesartan cilexetil-hydrochlorothiazide tab 32-25mg (Atacand hct).............................................................19

candesartan cilexetil tab 4 mg (Atacand)...................... 19candesartan cilexetil tab 8 mg (Atacand)...................... 19candesartan cilexetil tab 16 mg (Atacand).................... 19candesartan cilexetil tab 32 mg (Atacand).................... 19capecitabine tab 150 mg (Xeloda).................................... 7capecitabine tab 500 mg (Xeloda).................................... 7CAPRELSA – vandetanib tab 100 mg................................. 7CAPRELSA – vandetanib tab 300 mg................................. 7

CAPTOPRIL/HYDROCHLOROTHIA – captopril &hydrochlorothiazide tab 25-15 mg.................................... 18




captopril tab 12.5 mg........................................................18captopril tab 25 mg...........................................................18captopril tab 50 mg...........................................................18captopril tab 100 mg.........................................................18CARAC – fluorouracil cream 0.5%.....................................53carbamazepine cap er 12hr 100 mg (Carbatrol)............44carbamazepine cap er 12hr 200 mg (Carbatrol)............44carbamazepine cap er 12hr 300 mg (Carbatrol)............44carbamazepine chew tab 100 mg................................... 44carbamazepine susp 100 mg/5ml (Tegretol)..................44carbamazepine tab er 12hr 100 mg (Tegretol-xr).......... 44carbamazepine tab er 12hr 200 mg (Tegretol-xr).......... 44carbamazepine tab er 12hr 400 mg (Tegretol-xr).......... 44carbamazepine tab 200 mg (Tegretol)............................44CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa-entacapone tabs 12.5-50-200 mg.....................................46

CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa-entacapone tabs 18.75-75-200 mg...................................46

CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa-entacapone tabs 25-100-200 mg......................................46

CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa-entacapone tabs 31.25-125-200 mg................................ 46

CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa-entacapone tabs 37.5-150-200 mg...................................46

CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa-entacapone tabs 50-200-200 mg......................................46

carbidopa & levodopa orally disintegrating tab 10-100mg...................................................................................... 46



carbidopa & levodopa tab er 25-100 mg (Sinemetcr).......................................................................................46

carbidopa & levodopa tab er 50-200 mg (Sinemetcr).......................................................................................46

carbidopa & levodopa tab 10-100 mg (Sinemet)...........46carbidopa & levodopa tab 25-100 mg (Sinemet)...........46carbidopa & levodopa tab 25-250 mg (Sinemet)...........46CARTEOLOL HCL – carteolol hcl ophth soln 1%..............50carvedilol tab 3.125 mg (Coreg)......................................20carvedilol tab 6.25 mg (Coreg)........................................20carvedilol tab 12.5 mg (Coreg)........................................20carvedilol tab 25 mg (Coreg)...........................................20cefaclor cap 250 mg........................................................... 1cefaclor cap 500 mg........................................................... 1cefadroxil cap 500 mg........................................................1cefadroxil for susp 250 mg/5ml........................................ 1

2020


cefadroxil 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 cap 400 mg (Suprax)...........................................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...........................................1cefprozil for susp 250 mg/5ml...........................................1cefprozil tab 250 mg...........................................................1cefprozil tab 500 mg...........................................................1cefuroxime axetil tab 250 mg (Ceftin).............................. 2cefuroxime axetil tab 500 mg (Ceftin).............................. 2celecoxib cap 50 mg (Celebrex)......................................42celecoxib cap 100 mg (Celebrex)....................................42celecoxib cap 200 mg (Celebrex)....................................42celecoxib cap 400 mg (Celebrex)....................................42cephalexin cap 250 mg (Keflex)........................................2cephalexin cap 500 mg (Keflex)........................................2cephalexin for susp 125 mg/5ml.......................................2cephalexin for susp 250 mg/5ml.......................................2CERDELGA – eliglustat tartrate cap 84 mg (baseequivalent)......................................................................... 48

CETROTIDE – cetrorelix acetate for inj kit 0.25 mg.......... 13CHANTIX CONTINUING MONTH – varenicline tartrate tab1 mg (base equiv).............................................................39

CHANTIX STARTING MONTH PA – varenicline tartratetab 0.5 mg x 11 & tab 1 mg x 42 pack............................. 39

CHANTIX – varenicline tartrate tab 0.5 mg (baseequiv)................................................................................. 39

CHANTIX – varenicline tartrate tab 1 mg (base equiv)......39CHEMET – succimer cap 100 mg......................................55CHENODAL – chenodiol tab 250 mg.................................30chlorhexidine gluconate soln 0.12% (Peridex)..............51CHLOROQUINE PHOSPHATE – chloroquine phosphatetab 500 mg.......................................................................... 6

chloroquine phosphate tab 250 mg..................................6CHLOROTHIAZIDE – chlorothiazide tab 250 mg..............24CHLOROTHIAZIDE – chlorothiazide tab 500 mg..............24chlorpromazine hcl tab 10 mg........................................ 34chlorpromazine hcl tab 25 mg........................................ 34chlorpromazine hcl tab 50 mg........................................ 34chlorpromazine hcl tab 100 mg...................................... 34chlorpromazine hcl tab 200 mg...................................... 34chlorthalidone tab 25 mg.................................................24chlorthalidone tab 50 mg.................................................24chlorzoxazone tab 500 mg...............................................47cholestyramine light powder 4 gm/dose (Questranlight)...................................................................................23

cholestyramine light powder packets 4 gm.................. 23cholestyramine powder 4 gm/dose (Questran).............23

cholestyramine powder packets 4 gm (Questran)........23choline fenofibrate cap dr 45 mg (fenofibric acidequiv) (Trilipix).................................................................23

choline fenofibrate cap dr 135 mg (fenofibric acidequiv) (Trilipix).................................................................23

ciclopirox gel 0.77% (Loprox)......................................... 52ciclopirox olamine cream 0.77% (base equiv)...............52ciclopirox olamine susp 0.77% (base equiv).................52ciclopirox shampoo 1% (Loprox shampoo).................. 52cilostazol tab 50 mg (Pletal)............................................48cilostazol tab 100 mg (Pletal)..........................................48CILOXAN – ciprofloxacin hcl ophth oint 0.3%................... 49CIMDUO – lamivudine-tenofovir disoproxil fumarate tab300-300 mg......................................................................... 4

CIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml.........29cimetidine tab 300 mg......................................................29cimetidine tab 400 mg......................................................29cimetidine tab 800 mg......................................................29cinacalcet hcl tab 30 mg (base equiv) (Sensipar).........17cinacalcet hcl tab 60 mg (base equiv) (Sensipar).........17cinacalcet hcl tab 90 mg (base equiv) (Sensipar).........17CIPRO – ciprofloxacin for oral susp 500 mg/5ml (10%) (10gm/100ml)............................................................................ 2

CIPRODEX – ciprofloxacin-dexamethasone otic susp0.3-0.1%.............................................................................51

CIPROFLOXACIN HCL – ciprofloxacin hcl tab 100 mg(base equiv).........................................................................2

ciprofloxacin hcl ophth soln 0.3% (base equivalent)(Ciloxan)............................................................................49

ciprofloxacin hcl tab 750 mg (base equiv).......................2ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)..........2ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)..........2CIPRO HC – ciprofloxacin-hydrocortisone otic susp0.2-1%................................................................................51

citalopram hydrobromide oral soln 10 mg/5ml............. 32citalopram hydrobromide tab 10 mg (base equiv)(Celexa)............................................................................. 32

citalopram hydrobromide tab 20 mg (base equiv)(Celexa)............................................................................. 32

citalopram hydrobromide tab 40 mg (base equiv)(Celexa)............................................................................. 32

CLARITHROMYCIN – clarithromycin for susp 125mg/5ml..................................................................................2

CLARITHROMYCIN – clarithromycin for susp 250mg/5ml..................................................................................2

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.......................................................... 11

clindamycin hcl cap 75 mg (Cleocin)...............................6clindamycin hcl cap 150 mg (Cleocin).............................6clindamycin hcl cap 300 mg (Cleocin).............................6clindamycin palmitate hcl for soln 75 mg/5ml (baseequiv) (Cleocin pediatric gr)............................................ 6

2020


clindamycin phosphate-benzoyl peroxide gel 1-5%(Benzaclin)........................................................................51

clindamycin phosphate gel 1% (Cleocin-t)....................51clindamycin phosphate lotion 1% (Cleocin-t)............... 51clindamycin phosphate soln 1% (Cleocin-t)..................51clindamycin phosphate swab 1% (Cleocin-t)................ 51clindamycin phosphate vaginal cream 2%(Cleocin)............................................................................31

clindamycin phosph-benzoyl peroxide (refrig) gel 1.2(1)-5%, NF = Neuac (Duac).............................................51

clobetasol propionate cream 0.05% (Temovate)...........52clobetasol propionate emollient base cream 0.05%(Temovate e).....................................................................53

clobetasol propionate foam 0.05% (Olux)......................53clobetasol propionate gel 0.05% (Temovate)................ 53clobetasol propionate oint 0.05% (Temovate)...............53clobetasol propionate soln 0.05% (Temovate).............. 53CLOMIPHENE CITRATE – clomiphene citrate tab 50mg...................................................................................... 13

clomipramine hcl cap 25 mg (Anafranil)........................32clomipramine hcl cap 50 mg (Anafranil)........................32clomipramine hcl cap 75 mg (Anafranil)........................32clonazepam orally disintegrating tab 0.125 mg............ 44clonazepam orally disintegrating tab 0.25 mg.............. 45clonazepam orally disintegrating tab 0.5 mg................ 45clonazepam orally disintegrating tab 1 mg................... 45clonazepam orally disintegrating tab 2 mg................... 45clonazepam tab 0.5 mg (Klonopin).................................45clonazepam tab 1 mg (Klonopin)....................................45clonazepam tab 2 mg (Klonopin)....................................45clonidine hcl tab 0.1 mg (Catapres)............................... 25clonidine hcl tab 0.2 mg (Catapres)............................... 25clonidine hcl tab 0.3 mg (Catapres)............................... 25clonidine td patch weekly 0.1 mg/24hr (Catapres-tts-1)...................................................................................25

clonidine td patch weekly 0.2 mg/24hr (Catapres-tts-2)...................................................................................25

clonidine td patch weekly 0.3 mg/24hr (Catapres-tts-3)...................................................................................25

clopidogrel bisulfate tab 75 mg (base equiv)(Plavix).............................................................................. 48

clopidogrel bisulfate tab 300 mg (base equiv)(Plavix).............................................................................. 48

clorazepate dipotassium tab 3.75 mg (Tranxene t).......32clorazepate dipotassium tab 7.5 mg (Tranxene t).........32clorazepate dipotassium tab 15 mg (Tranxene t)..........32clotrimazole w/ betamethasone cream 1-0.05%(Lotrisone)........................................................................ 52

clotrimazole w/ betamethasone lotion 1-0.05%.............52clozapine tab 50 mg......................................................... 34clozapine tab 200 mg....................................................... 34clozapine tab 25 mg (Clozaril).........................................34clozapine tab 100 mg (Clozaril).......................................34COARTEM – artemether-lumefantrine tab 20-120 mg........ 6codeine sulfate tab 30 mg............................................... 40COLCHICINE – colchicine cap 0.6 mg.............................. 44

colchicine tab 0.6 mg (Colcrys)...................................... 44colchicine w/ probenecid tab 0.5-500 mg...................... 44colesevelam hcl packet for susp 3.75 gm(Welchol)........................................................................... 23

colesevelam hcl tab 625 mg (Welchol).......................... 23colestipol hcl granule packets 5 gm (Colestidflavored)............................................................................23

colestipol hcl granules 5 gm (Colestid flavored).......... 23colestipol hcl tab 1 gm (Colestid)...................................23COMBIVENT RESPIMAT – ipratropium-albuterol inhalaerosol soln 20-100 mcg/act............................................ 27

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................................................................ 7

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

COPAXONE – glatiramer acetate soln prefilled syringe 20mg/ml..................................................................................38

COPAXONE – glatiramer acetate soln prefilled syringe 40mg/ml..................................................................................38

CORTISONE ACETATE – cortisone acetate tab 25mg...................................................................................... 10

COSENTYX – secukinumab subcutaneous pref syr 150mg/ml (300 mg dose)........................................................53

COSENTYX – secukinumab subcutaneous soln prefilledsyringe 150 mg/ml.............................................................53

COSENTYX SENSOREADY PEN – secukinumabsubcutaneous auto-inj 150 mg/ml (300 mg dose)............54

COSENTYX SENSOREADY PEN – secukinumabsubcutaneous soln auto-injector 150 mg/ml.....................54

COTELLIC – cobimetinib fumarate tab 20 mg (baseequivalent)............................................................................7

CREON – pancrelipase (lip-prot-amyl) dr cap3000-9500-15000 unit....................................................... 30

CREON – pancrelipase (lip-prot-amyl) dr cap6000-19000-30000 unit..................................................... 30

CREON – pancrelipase (lip-prot-amyl) dr cap12000-38000-60000 unit...................................................30

CREON – pancrelipase (lip-prot-amyl) dr cap24000-76000-120000 unit.................................................30

CREON – pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit............................................... 30

cromolyn sodium ophth soln 4%....................................51cromolyn sodium soln nebu 20 mg/2ml........................ 27cyclobenzaprine hcl tab 5 mg.........................................47cyclobenzaprine hcl tab 10 mg.......................................47cyclopentolate hcl ophth soln 1% (Cyclogyl)................51cyclophosphamide cap 25 mg (Cyclophosphamide)..... 7cyclophosphamide cap 50 mg (Cyclophosphamide)..... 7cyclosporine cap 25 mg (Sandimmune)........................ 55cyclosporine cap 100 mg (Sandimmune)...................... 55cyclosporine modified cap 25 mg (Neoral)....................55cyclosporine modified cap 100 mg (Neoral)..................55

2020


cyclosporine modified oral soln 100 mg/ml(Neoral)..............................................................................55

cyproheptadine hcl syrup 2 mg/5ml...............................26cyproheptadine hcl tab 4 mg.......................................... 26CYSTADANE – betaine powder for oral solution...............17CYSTAGON – cysteamine bitartrate cap 50 mg................31CYSTAGON – cysteamine bitartrate cap 150 mg..............31

Ddanazol cap 50 mg............................................................11danazol cap 100 mg..........................................................11danazol cap 200 mg..........................................................11dantrolene sodium cap 25 mg (Dantrium)..................... 47dantrolene sodium cap 50 mg (Dantrium)..................... 47dantrolene sodium cap 100 mg (Dantrolenesodium)............................................................................. 47

dapsone tab 25 mg.............................................................6dapsone tab 100 mg...........................................................6DARAPRIM – pyrimethamine tab 25 mg............................. 6deferasirox tab for oral susp 125 mg (EXJADE)........... 55deferasirox tab for oral susp 250 mg (EXJADE)........... 55deferasirox tab for oral susp 500 mg (EXJADE)........... 55deferasirox tab 180 mg.................................................... 55deferasirox tab 90 mg (Jadenu)......................................55deferasirox tab 360 mg (Jadenu)....................................55DELSTRIGO – doravirine-lamivudine-tenofovir df tab100-300-300 mg.................................................................. 4

demeclocycline hcl tab 150 mg........................................ 2demeclocycline hcl tab 300 mg........................................ 2DESCOVY – emtricitabine-tenofovir alafenamide fumaratetab 200-25 mg..................................................................... 4

desipramine hcl tab 10 mg (Norpramin)........................ 32desipramine hcl tab 25 mg (Norpramin)........................ 32desipramine hcl tab 50 mg (Norpramin)........................ 33desipramine hcl tab 75 mg (Norpramin)........................ 33desipramine hcl tab 100 mg (Norpramin)...................... 33desipramine hcl tab 150 mg (Norpramin)...................... 33desmopressin acetate nasal spray soln 0.01%(Ddavp)..............................................................................17

desmopressin acetate nasal spray soln 0.01%(refrigerated).....................................................................17

desmopressin acetate tab 0.1 mg (Ddavp)....................17desmopressin acetate tab 0.2 mg (Ddavp)....................17desogest-eth estrad & eth estrad tab 0.15-0.02/0.01mg(21/5) (Mircette).......................................................... 12

desogest-ethin est tab0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa).....12

desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg(Desogen)......................................................................... 12

desonide cream 0.05% (Desowen)................................. 53desonide lotion 0.05% (Desowen).................................. 53desonide oint 0.05% (Desowen)......................................53desoximetasone cream 0.25% (Topicort).......................53desoximetasone gel 0.05% (Topicort)............................ 53desoximetasone oint 0.25% (Topicort)...........................53

desvenlafaxine succinate tab er 24hr 25 mg (baseequiv) (Pristiq)................................................................. 33



DEXAMETHASONE – dexamethasone soln 0.5mg/5ml............................................................................... 10

DEXAMETHASONE – dexamethasone tab 1 mg..............10DEXAMETHASONE – dexamethasone tab 2 mg..............11dexamethasone elixir 0.5 mg/5ml................................... 11DEXAMETHASONE INTENSOL – dexamethasone conc 1mg/ml..................................................................................11

DEXAMETHASONE SODIUM PHOS – dexamethasonesodium phosphate ophth soln 0.1%................................. 50

dexamethasone tab 0.5 mg............................................. 11dexamethasone tab 0.75 mg........................................... 11dexamethasone tab 1.5 mg............................................. 11dexamethasone tab 4 mg................................................ 11dexamethasone tab 6 mg................................................ 11DEXCOM G5 MOBILE/G4 PLATI – continuous bloodglucose system sensor..................................................... 54

DEXCOM G5 MOBILE RECEIVER – continuous bloodglucose system receiver................................................... 54

DEXCOM G5 MOBILE TRANSMIT – continuous bloodglucose system transmitter............................................... 54

DEXCOM G6 RECEIVER – continuous blood glucosesystem receiver................................................................. 54

DEXCOM G5 RECEIVER KIT – continuous blood glucosesystem receiver................................................................. 54

DEXCOM G6 SENSOR – continuous blood glucosesystem sensor................................................................... 54

DEXCOM G6 TRANSMITTER – continuous blood glucosesystem transmitter............................................................. 54

dexmethylphenidate hcl cap er 24 hr 5 mg (Focalinxr).......................................................................................37








dexmethylphenidate hcl tab 2.5 mg (Focalin)............... 37dexmethylphenidate hcl tab 5 mg (Focalin).................. 37dexmethylphenidate hcl tab 10 mg (Focalin)................ 37dextroamphetamine sulfate cap er 24hr 5 mg(Dexedrine)....................................................................... 37

2020


dextroamphetamine sulfate cap er 24hr 10 mg(Dexedrine)....................................................................... 37

dextroamphetamine sulfate cap er 24hr 15 mg(Dexedrine)....................................................................... 37

dextroamphetamine sulfate tab 5 mg.............................37dextroamphetamine sulfate tab 10 mg...........................37DIASTAT ACUDIAL – diazepam rectal gel delivery system10 mg.................................................................................45

DIASTAT ACUDIAL – diazepam rectal gel delivery system20 mg.................................................................................45

DIASTAT PEDIATRIC – diazepam rectal gel deliverysystem 2.5 mg...................................................................45

diazepam conc 5 mg/ml................................................... 32DIAZEPAM – diazepam oral soln 1 mg/ml.........................32diazepam tab 2 mg (Valium)............................................32diazepam tab 5 mg (Valium)............................................32diazepam tab 10 mg (Valium)..........................................32diazoxide susp 50 mg/ml (Proglycem)...........................14diclofenac potassium tab 50 mg (Cataflam)..................42diclofenac sodium (actinic keratoses) gel 3%(Solaraze)..........................................................................54

diclofenac sodium gel 1% (Voltaren)..............................54diclofenac sodium ophth soln 0.1%...............................51diclofenac sodium tab delayed release 25 mg..............42diclofenac sodium tab delayed release 50 mg..............42diclofenac sodium tab delayed release 75 mg..............42diclofenac sodium tab er 24hr 100 mg.......................... 42dicloxacillin sodium cap 250 mg...................................... 1dicloxacillin sodium cap 500 mg...................................... 1dicyclomine hcl cap 10 mg (Bentyl)...............................29dicyclomine hcl oral soln 10 mg/5ml............................. 29dicyclomine hcl tab 20 mg (Bentyl)................................29DIDANOSINE – didanosine delayed release capsule 200mg........................................................................................ 4

DIDANOSINE – didanosine delayed release capsule 250mg........................................................................................ 4

DIDANOSINE – didanosine delayed release capsule 400mg........................................................................................ 4

DIFLORASONE DIACETATE – diflorasone diacetatecream 0.05%..................................................................... 53

diflorasone diacetate oint 0.05%.....................................53digoxin oral soln 0.05 mg/ml (Digoxin).......................... 25digoxin tab 125 mcg (0.125 mg) (Lanoxin).................... 25digoxin tab 250 mcg (0.25 mg) (Lanoxin)...................... 25dihydroergotamine mesylate nasal spray 4 mg/ml(Migranal)..........................................................................43

DILANTIN – phenytoin sodium extended cap 30 mg.........45DILANTIN – phenytoin sodium extended cap 100 mg.......45DILANTIN-125 – phenytoin susp 125 mg/5ml................... 45diltiazem hcl coated beads cap er 24hr 300 mg............21diltiazem hcl coated beads cap er 24hr 120 mg(Cardizem cd)...................................................................21

diltiazem hcl coated beads cap er 24hr 180 mg(Cardizem cd)...................................................................21



diltiazem hcl extended release beads cap er 24hr 120mg (Tiazac).......................................................................21






diltiazem hcl tab 90 mg....................................................21diltiazem hcl tab 30 mg (Cardizem)................................21diltiazem hcl tab 60 mg (Cardizem)................................21diltiazem hcl tab 120 mg (Cardizem)..............................21DILT-XR – diltiazem hcl cap er 24hr 120 mg.....................21DILT-XR – diltiazem hcl cap er 24hr 180 mg.....................21DILT-XR – diltiazem hcl cap er 24hr 240 mg.....................21dipyridamole tab 25 mg (Persantine)............................. 48dipyridamole tab 50 mg (Persantine)............................. 48dipyridamole tab 75 mg (Persantine)............................. 48disopyramide phosphate cap 100 mg (Norpace).......... 24disopyramide phosphate cap 150 mg (Norpace).......... 24disulfiram tab 250 mg (Antabuse).................................. 39disulfiram tab 500 mg (Antabuse).................................. 39divalproex sodium cap delayed release sprinkle 125mg (Depakote sprinkles)................................................ 45

divalproex sodium tab delayed release 125 mg(Depakote)........................................................................ 45



divalproex sodium tab er 24 hr 250 mg (Depakoteer).......................................................................................45

divalproex sodium tab er 24 hr 500 mg (Depakoteer).......................................................................................45

DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%)...........11DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%)...............11DIVIGEL – estradiol td gel 0.75 mg/0.75gm (0.1%)...........11DIVIGEL – estradiol td gel 1 mg/gm (0.1%).......................11DIVIGEL – estradiol td gel 1.25 mg/1.25gm (0.1%)...........11donepezil hydrochloride orally disintegrating tab 5 mg(Aricept odt)..................................................................... 39

donepezil hydrochloride orally disintegrating tab 10mg (Aricept odt).............................................................. 39

donepezil hydrochloride tab 5 mg (Aricept)..................39donepezil hydrochloride tab 10 mg (Aricept)................39dorzolamide hcl ophth soln 2% (Trusopt)..................... 50dorzolamide hcl-timolol maleate ophth soln 22.3-6.8mg/ml (Cosopt)................................................................ 50

doxazosin mesylate tab 1 mg (Cardura)........................25doxazosin mesylate tab 2 mg (Cardura)........................25

2020


doxazosin mesylate tab 4 mg (Cardura)........................25doxazosin mesylate tab 8 mg (Cardura)........................25doxepin hcl cap 10 mg.....................................................33doxepin hcl cap 25 mg.....................................................33doxepin hcl cap 50 mg.....................................................33doxepin hcl cap 75 mg.....................................................33doxepin hcl cap 100 mg...................................................33doxepin hcl conc 10 mg/ml............................................. 33DOXEPIN HCL – doxepin hcl cap 150 mg........................ 33doxycycline hyclate cap 50 mg.........................................2doxycycline hyclate cap 100 mg (Vibramycin)................2doxycycline hyclate tab 20 mg......................................... 2doxycycline 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)...................................................................................... 12

drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)......12DULERA – mometasone furoate-formoterol fumarateaerosol 100-5 mcg/act...................................................... 27

DULERA – mometasone furoate-formoterol fumarateaerosol 200-5 mcg/act...................................................... 27

duloxetine hcl enteric coated pellets cap 20 mg (baseeq) (Cymbalta)..................................................................33



DUPIXENT – dupilumab subcutaneous soln prefilledsyringe 300 mg/2ml...........................................................54

Eeconazole nitrate cream 1%............................................ 52efavirenz cap 50 mg (Sustiva)...........................................4efavirenz cap 200 mg (Sustiva).........................................4efavirenz tab 600 mg (Sustiva)..........................................4ELIQUIS – apixaban tab 2.5 mg........................................ 48ELIQUIS – apixaban tab 5 mg........................................... 48ELIQUIS STARTER PACK – apixaban tab 5 mg............... 48ELLA – ulipristal acetate tab 30 mg...................................12EMCYT – estramustine phosphate sodium cap 140 mg......7EMEND – aprepitant for oral susp 125 mg (125mg/5ml).............................................................................. 30

EMGALITY – galcanezumab-gnlm subcutaneous solnauto-injector 120 mg/ml.................................................... 43

EMGALITY – galcanezumab-gnlm subcutaneous solnprefilled syr 100 mg/ml......................................................44

EMGALITY – galcanezumab-gnlm subcutaneous solnprefilled syr 120 mg/ml......................................................44

enalapril maleate & hydrochlorothiazide tab 5-12.5mg...................................................................................... 18

enalapril maleate & hydrochlorothiazide tab 10-25 mg(Vaseretic).........................................................................18

enalapril maleate tab 2.5 mg (Vasotec)..........................18enalapril maleate tab 5 mg (Vasotec).............................18enalapril maleate tab 10 mg (Vasotec)...........................18enalapril maleate tab 20 mg (Vasotec)...........................18ENBREL – etanercept for subcutaneous inj 25 mg........... 42ENBREL – etanercept subcutaneous soln prefilled syringe25 mg/0.5ml.......................................................................42

ENBREL – etanercept subcutaneous soln prefilled syringe50 mg/ml............................................................................42

ENBREL MINI – etanercept subcutaneous solutioncartridge 50 mg/ml............................................................ 42

ENBREL SURECLICK – etanercept subcutaneoussolution auto-injector 50 mg/ml.........................................42

enoxaparin sodium inj 30 mg/0.3ml (Lovenox)............. 48enoxaparin sodium inj 40 mg/0.4ml (Lovenox)............. 48enoxaparin sodium inj 60 mg/0.6ml (Lovenox)............. 48enoxaparin sodium inj 80 mg/0.8ml (Lovenox)............. 48enoxaparin sodium inj 100 mg/ml (Lovenox)................ 48enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........... 48enoxaparin sodium inj 150 mg/ml (Lovenox)................ 48enoxaparin sodium inj 300 mg/3ml (Lovenox).............. 48entacapone tab 200 mg (Comtan)...................................46entecavir tab 0.5 mg (Baraclude)......................................3entecavir tab 1 mg (Baraclude).........................................3ENTRESTO – sacubitril-valsartan tab 24-26 mg............... 22ENTRESTO – sacubitril-valsartan tab 49-51 mg............... 22ENTRESTO – sacubitril-valsartan tab 97-103 mg............. 22EPCLUSA – sofosbuvir-velpatasvir tab 400-100 mg........... 3EPIDIOLEX – cannabidiol soln 100 mg/ml........................ 45epinephrine solution auto-injector 0.15 mg/0.3ml(1:2000) (Epipen-jr 2-pak)...............................................26

epinephrine solution auto-injector 0.3 mg/0.3ml(1:1000) (Epipen 2-pak)...................................................26

EPIVIR HBV – lamivudine oral soln 5 mg/ml (hbv)..............3eplerenone tab 25 mg (Inspra)........................................25eplerenone tab 50 mg (Inspra)........................................25ergocalciferol cap 1.25 mg (50000 unit) (Drisdol).........47ERIVEDGE – vismodegib cap 150 mg................................ 7ERLEADA – apalutamide tab 60 mg....................................7erlotinib hcl tab 25 mg (base equivalent) (Tarceva)........7erlotinib hcl tab 100 mg (base equivalent) (Tarceva)......7erlotinib hcl tab 150 mg (base equivalent) (Tarceva)......7ERY – erythromycin pads 2%............................................ 51erythromycin gel 2% (Erygel)..........................................51erythromycin ophth oint 5 mg/gm..................................49erythromycin soln 2%...................................................... 51ESBRIET – pirfenidone cap 267 mg..................................28ESBRIET – pirfenidone tab 267 mg...................................28ESBRIET – pirfenidone tab 801 mg...................................28

2020


escitalopram oxalate soln 5 mg/5ml (base equiv)(Lexapro)...........................................................................33

escitalopram oxalate tab 5 mg (base equiv)(Lexapro)...........................................................................33



esomeprazole magnesium cap delayed release 20 mg(base eq) (Nexium)..........................................................29

esomeprazole magnesium cap delayed release 40 mg(base eq) (Nexium)..........................................................29

esomeprazole magnesium for delayed release susppacket 10 mg (Nexium)...................................................29



estazolam tab 1 mg.......................................................... 36estazolam tab 2 mg.......................................................... 36estradiol & norethindrone acetate tab 0.5-0.1 mg(Activella)..........................................................................11

estradiol & norethindrone acetate tab 1-0.5 mg(Activella)..........................................................................11

estradiol tab 0.5 mg (Estrace).........................................11estradiol tab 1 mg (Estrace)............................................11estradiol tab 2 mg (Estrace)............................................11estradiol 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 tab 10 mcg (Vagifem)..........................31eszopiclone tab 1 mg (Lunesta)......................................36eszopiclone tab 2 mg (Lunesta)......................................36eszopiclone tab 3 mg (Lunesta)......................................36ethambutol hcl tab 100 mg (Myambutol)......................... 3ethambutol hcl tab 400 mg (Myambutol)......................... 3ethosuximide cap 250 mg (Zarontin)..............................45ethosuximide soln 250 mg/5ml (Zarontin)..................... 45ethynodiol diacetate & ethinyl estradiol tab 1 mg-35mcg....................................................................................12

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

etodolac cap 200 mg........................................................ 42etodolac cap 300 mg........................................................ 42etodolac tab er 24hr 400 mg........................................... 42etodolac tab er 24hr 500 mg........................................... 42etodolac tab er 24hr 600 mg........................................... 42etodolac tab 400 mg.........................................................42etodolac tab 500 mg.........................................................42ETOPOSIDE – etoposide cap 50 mg...................................7everolimus tab 2.5 mg (Afinitor)....................................... 7everolimus tab 5 mg (Afinitor).......................................... 7everolimus tab 7.5 mg (Afinitor)....................................... 7everolimus tab 0.25 mg (Zortress)..................................55everolimus tab 0.5 mg (Zortress)....................................55everolimus tab 0.75 mg (Zortress)..................................55EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg(base equiv).........................................................................4

exemestane tab 25 mg (Aromasin)...................................7ezetimibe-simvastatin tab 10-10 mg (Vytorin)...............23ezetimibe-simvastatin tab 10-20 mg (Vytorin)...............23ezetimibe-simvastatin tab 10-40 mg (Vytorin)...............23ezetimibe-simvastatin tab 10-80 mg (Vytorin)...............23ezetimibe tab 10 mg (Zetia)............................................. 23F

famciclovir tab 125 mg (Famvir)....................................... 4famciclovir tab 250 mg (Famvir)....................................... 4famciclovir tab 500 mg (Famvir)....................................... 4famotidine tab 40 mg (Pepcid)........................................29FARYDAK – panobinostat lactate cap 10 mg (baseequivalent)............................................................................7

FARYDAK – panobinostat lactate cap 20 mg (baseequivalent)............................................................................7

felbamate susp 600 mg/5ml (Felbatol)........................... 45felbamate tab 400 mg (Felbatol)..................................... 45felbamate tab 600 mg (Felbatol)..................................... 45felodipine tab er 24hr 2.5 mg.......................................... 22felodipine tab er 24hr 5 mg............................................. 22felodipine tab er 24hr 10 mg........................................... 22fenofibrate micronized cap 43 mg (Antara)................... 23fenofibrate micronized cap 130 mg (Antara)................. 23fenofibrate micronized cap 67 mg (Lofibra).................. 23fenofibrate micronized cap 134 mg (Lofibra)................ 23fenofibrate micronized cap 200 mg (Lofibra)................ 23fenofibrate tab 54 mg (Lofibra)....................................... 23fenofibrate tab 160 mg (Lofibra)..................................... 23fenofibrate tab 48 mg (Tricor)......................................... 23fenofibrate tab 145 mg (Tricor)....................................... 23fentanyl citrate lozenge on a handle 200 mcg(Actiq)................................................................................40

fentanyl citrate lozenge on a handle 400 mcg(Actiq)................................................................................40



2020




fentanyl td patch 72hr 12 mcg/hr (Duragesic)...............41fentanyl td patch 72hr 25 mcg/hr (Duragesic)...............41fentanyl td patch 72hr 50 mcg/hr (Duragesic)...............41fentanyl td patch 72hr 75 mcg/hr (Duragesic)...............41fentanyl td patch 72hr 100 mcg/hr (Duragesic).............41FIASP FLEXTOUCH – insulin aspart (with niacinamide)sol pen-inj 100 unit/ml.......................................................15

FIASP – insulin aspart (with niacinamide) inj 100 unit/ml........................................................................................15

FIASP PENFILL – insulin aspart (with niacinamide) solncartridge 100 unit/ml......................................................... 16

FINACEA – azelaic acid foam 15%................................... 52finasteride tab 5 mg (Proscar)........................................ 31flecainide acetate tab 50 mg........................................... 24flecainide acetate tab 100 mg......................................... 24flecainide acetate tab 150 mg......................................... 24FLOVENT DISKUS – fluticasone propionate aer pow ba50 mcg/blister.................................................................... 27

FLOVENT DISKUS – fluticasone propionate aer pow ba100 mcg/blister.................................................................. 27

FLOVENT DISKUS – fluticasone propionate aer pow ba250 mcg/blister.................................................................. 27

FLOVENT HFA – fluticasone propionate hfa inhal aer 110mcg/act (125/valve)...........................................................27

FLOVENT HFA – fluticasone propionate hfa inhal aer 220mcg/act (250/valve)...........................................................27

FLOVENT HFA – fluticasone propionate hfa inhal aero 44mcg/act (50/valve)............................................................. 27

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.................................11FLUNISOLIDE – flunisolide nasal soln 25 mcg/act(0.025%).............................................................................26

fluocinolone acetonide cream 0.01%............................. 53fluocinolone acetonide cream 0.025% (Synalar)...........53fluocinolone acetonide oint 0.025% (Synalar)...............53fluocinolone acetonide soln 0.01% (Synalar)................53fluocinonide cream 0.05%............................................... 53fluocinonide emulsified base cream 0.05%...................53fluocinonide gel 0.05%.....................................................53fluocinonide oint 0.05%....................................................53fluocinonide soln 0.05%...................................................53fluorometholone ophth susp 0.1% (Fml liquifilm)........ 50FLUOROPLEX – fluorouracil cream 1%............................ 54fluorouracil cream 5% (Efudex)...................................... 54FLUOROURACIL – fluorouracil soln 2%............................54

FLUOROURACIL – fluorouracil soln 5%............................54fluoxetine hcl cap 10 mg (Prozac)..................................33fluoxetine hcl cap 20 mg (Prozac)..................................33fluoxetine hcl cap 40 mg (Prozac)..................................33fluoxetine hcl solution 20 mg/5ml.................................. 33fluoxetine hcl tab 10 mg.................................................. 33fluoxetine hcl tab 20 mg.................................................. 33FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml........................................................................................34

FLUPHENAZINE HCL – fluphenazine hcl tab 1 mg.......... 34FLUPHENAZINE HCL – fluphenazine hcl tab 2.5 mg....... 34FLUPHENAZINE HCL – fluphenazine hcl tab 5 mg.......... 34FLUPHENAZINE HCL – fluphenazine hcl tab 10 mg........ 34FLUPHENAZINE HYDROCHLORID – fluphenazine hclelixir 2.5 mg/5ml................................................................34

FLURA-DROPS – sodium fluoride soln 0.25 mg/drop f(from 0.55 mg/drop naf)....................................................47

FLURBIPROFEN SODIUM – flurbiprofen sodium ophthsoln 0.03%.........................................................................51

flurbiprofen tab 50 mg......................................................42flurbiprofen tab 100 mg................................................... 42flutamide cap 125 mg.........................................................7FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 55-14 mcg/act.........................28

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 113-14 mcg/act....................... 28

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 232-14 mcg/act.......................28

fluticasone propionate cream 0.05% (Cutivate)............ 53fluticasone propionate nasal susp 50 mcg/act(Flonase)........................................................................... 26

fluticasone propionate oint 0.005% (Cutivate).............. 53fluvoxamine maleate tab 25 mg......................................33fluvoxamine maleate tab 50 mg......................................33fluvoxamine maleate tab 100 mg....................................33FML – fluorometholone ophth oint 0.1%............................50folic acid tab 1 mg............................................................48FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml..........13FOLLISTIM AQ – follitropin beta inj 600 unit/0.72ml..........13FOLLISTIM AQ – follitropin beta inj 900 unit/1.08ml..........13fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml(Arixtra)............................................................................. 48

fondaparinux sodium subcutaneous inj 5 mg/0.4ml(Arixtra)............................................................................. 48

fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml(Arixtra)............................................................................. 48

fondaparinux sodium subcutaneous inj 10 mg/0.8ml(Arixtra)............................................................................. 48

FORTEO – teriparatide (recombinant) soln pen-inj 600mcg/2.4ml...........................................................................17

fosinopril sodium & hydrochlorothiazide tab 10-12.5mg...................................................................................... 18

fosinopril sodium & hydrochlorothiazide tab 20-12.5mg...................................................................................... 18

fosinopril sodium tab 10 mg........................................... 18fosinopril sodium tab 20 mg........................................... 18

2020


fosinopril sodium tab 40 mg........................................... 18FREESTYLE LIBRE/READER/FL – continuous bloodglucose system receiver................................................... 54

FREESTYLE LIBRE/SENSOR/FL – continuous bloodglucose system sensor..................................................... 54

FREESTYLE LIBRE 14 DAY/RE – continuous bloodglucose system receiver................................................... 54

FREESTYLE LIBRE 14 DAY/SE – continuous bloodglucose system sensor..................................................... 54

FULPHILA – pegfilgrastim-jmdb soln prefilled syringe 6mg/0.6ml............................................................................ 48

furosemide oral soln 10 mg/ml....................................... 24furosemide tab 20 mg (Lasix)......................................... 24furosemide tab 40 mg (Lasix)......................................... 24furosemide tab 80 mg (Lasix)......................................... 24G

gabapentin cap 100 mg (Neurontin)...............................45gabapentin cap 300 mg (Neurontin)...............................45gabapentin cap 400 mg (Neurontin)...............................45gabapentin oral soln 250 mg/5ml (Neurontin)...............45gabapentin tab 600 mg (Neurontin)................................45gabapentin tab 800 mg (Neurontin)................................45galantamine hydrobromide cap er 24hr 8 mg(Razadyne er)...................................................................39

galantamine hydrobromide cap er 24hr 16 mg(Razadyne er)...................................................................39

galantamine hydrobromide cap er 24hr 24 mg(Razadyne er)...................................................................39

galantamine hydrobromide tab 4 mg (Razadyne).........40galantamine hydrobromide tab 8 mg (Razadyne).........40galantamine hydrobromide tab 12 mg (Razadyne).......40ganirelix acetate soln prefilled syringe 250 mcg/0.5ml(Ganirelix acetate)........................................................... 13

GAVILYTE-C – peg 3350-kcl-na bicarb-nacl-na sulfate forsoln 240 gm.......................................................................29

gemfibrozil tab 600 mg (Lopid).......................................23GENTAK – gentamicin sulfate ophth oint 0.3%................. 49gentamicin sulfate cream 0.1%.......................................52gentamicin sulfate oint 0.1%........................................... 52gentamicin sulfate ophth soln 0.3% (Garamycin).........49GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab150-150-200-10 mg.............................................................4

GILENYA – fingolimod hcl cap 0.5 mg (base equiv)..........38GILOTRIF – afatinib dimaleate tab 20 mg (baseequivalent)............................................................................7

GILOTRIF – afatinib dimaleate tab 30 mg (baseequivalent)............................................................................7

GILOTRIF – afatinib dimaleate tab 40 mg (baseequivalent)............................................................................7

glatiramer acetate soln prefilled syringe 20 mg/ml(Copaxone)....................................................................... 38

glatiramer acetate soln prefilled syringe 40 mg/ml(Copaxone)....................................................................... 38

GLEOSTINE – lomustine cap 10 mg................................... 7GLEOSTINE – lomustine cap 40 mg................................... 7

GLEOSTINE – lomustine cap 100 mg................................. 7glimepiride tab 1 mg (Amaryl).........................................14glimepiride tab 2 mg (Amaryl).........................................14glimepiride tab 4 mg (Amaryl).........................................14glipizide-metformin hcl tab 2.5-250 mg..........................14glipizide-metformin hcl tab 2.5-500 mg..........................14glipizide-metformin hcl tab 5-500 mg.............................14glipizide tab er 24hr 2.5 mg (Glucotrol xl)..................... 14glipizide tab er 24hr 5 mg (Glucotrol xl)........................ 14glipizide tab er 24hr 10 mg (Glucotrol xl)...................... 14glipizide tab 5 mg (Glucotrol)..........................................14glipizide tab 10 mg (Glucotrol)........................................14GLUCAGON EMERGENCY KIT – glucagon (rdna) for injkit 1 mg..............................................................................14

glyburide-metformin tab 1.25-250 mg(Glucovance).................................................................... 14

glyburide-metformin tab 2.5-500 mg (Glucovance)...... 14glyburide-metformin tab 5-500 mg (Glucovance)......... 14glyburide micronized tab 1.5 mg (Glynase)...................14glyburide micronized tab 3 mg (Glynase)......................14glyburide micronized tab 6 mg (Glynase)......................14glyburide tab 1.25 mg.......................................................14glyburide tab 2.5 mg.........................................................14glyburide tab 5 mg............................................................14glycopyrrolate tab 1 mg (Robinul)..................................29glycopyrrolate tab 2 mg (Robinul forte).........................29GLYXAMBI – empagliflozin-linagliptin tab 10-5 mg........... 14GLYXAMBI – empagliflozin-linagliptin tab 25-5 mg........... 14GONAL-F – follitropin alfa for inj 450 unit..........................13GONAL-F – follitropin alfa for inj 1050 unit........................13GONAL-F RFF – follitropin alfa for subcutaneous inj 75unit......................................................................................13

GONAL-F RFF REDIJECT – follitropin alfa inj 300unit/0.5ml............................................................................13

GONAL-F RFF REDIJECT – follitropin alfa inj 450unit/0.75ml......................................................................... 13

GONAL-F RFF REDIJECT – follitropin alfa inj 900unit/1.5ml............................................................................13

GRANIX – tbo-filgrastim soln prefilled syringe 300mcg/0.5ml...........................................................................48

GRANIX – tbo-filgrastim soln prefilled syringe 480mcg/0.8ml...........................................................................49

GRANIX – tbo-filgrastim subcutaneous inj 300 mcg/ml.....49GRANIX – tbo-filgrastim subcutaneous inj 480 mcg/1.6ml(300 mcg/ml)......................................................................49

GRASTEK – timothy grass pollen allergen ext sl tab 2800bau....................................................................................... 6

griseofulvin microsize susp 125 mg/5ml......................... 3griseofulvin microsize tab 500 mg (Grifulvin v)..............3guanfacine hcl tab 1 mg (Tenex).................................... 25guanfacine hcl tab 2 mg (Tenex).................................... 25GVOKE HYPOPEN – glucagon subcutaneous solutionauto-injector 0.5 mg/0.1ml................................................ 14

GVOKE HYPOPEN – glucagon subcutaneous solutionauto-injector 1 mg/0.2ml................................................... 14

2020


GVOKE PFS – glucagon subcutaneous soln pref syringe0.5 mg/0.1ml......................................................................14

GVOKE PFS – glucagon subcutaneous soln pref syringe 1mg/0.2ml............................................................................ 14

Hhalobetasol propionate cream 0.05% (Ultravate)..........53halobetasol propionate oint 0.05% (Ultravate)..............53haloperidol lactate oral conc 2 mg/ml............................34haloperidol tab 0.5 mg..................................................... 34haloperidol tab 1 mg........................................................ 34haloperidol tab 2 mg........................................................ 34haloperidol tab 5 mg........................................................ 34haloperidol tab 10 mg...................................................... 34haloperidol tab 20 mg...................................................... 34HARVONI – ledipasvir-sofosbuvir tab 45-200 mg................3HARVONI – ledipasvir-sofosbuvir tab 90-400 mg................3HUMIRA – adalimumab prefilled syringe kit 10mg/0.1ml............................................................................ 42

HUMIRA – adalimumab prefilled syringe kit 10mg/0.2ml............................................................................ 42





HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 80 mg/0.8ml.....................................................43

HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 80 mg/0.8ml & 40 mg/0.4ml............................43

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.8ml............................................................................ 43

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.4ml............................................................................ 43

HUMIRA PEN-CD/UC/HS START – adalimumab pen-injector kit 40 mg/0.8ml.....................................................43

HUMIRA PEN-CD/UC/HS START – adalimumab pen-injector kit 80 mg/0.8ml.....................................................43

HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit 40 mg/0.8ml.....................................................43

HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit 80 mg/0.8ml & 40 mg/0.4ml............................43

HUMULIN R U-500 (CONCENTR – insulin regular(human) inj 500 unit/ml..................................................... 16

HUMULIN R U-500 KWIKPEN – insulin regular (human)soln pen-injector 500 unit/ml.............................................16

HYCAMTIN – topotecan hcl cap 0.25 mg (base equiv)....... 7HYCAMTIN – topotecan hcl cap 1 mg (base equiv)............ 7hydralazine hcl tab 10 mg............................................... 25hydralazine hcl tab 25 mg............................................... 25hydralazine hcl tab 50 mg............................................... 25hydralazine hcl tab 100 mg............................................. 25hydrochlorothiazide cap 12.5 mg (Microzide)............... 24

hydrochlorothiazide tab 12.5 mg.................................... 24hydrochlorothiazide tab 25 mg....................................... 24hydrochlorothiazide tab 50 mg....................................... 24hydrocodone-acetaminophen soln 7.5-325 mg/15ml(Hycet)............................................................................... 41

hydrocodone-acetaminophen tab 7.5-325 mg(Norco).............................................................................. 41

hydrocodone-acetaminophen tab 5-325 mg(Norco).............................................................................. 41

hydrocodone-acetaminophen tab 10-325 mg(Norco).............................................................................. 41

hydrocodone-acetaminophen tab 5-300 mg(Xodol)...............................................................................41

hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........ 41hydrocodone-ibuprofen tab 5-200 mg (Reprexain).......41hydrocodone-ibuprofen tab 7.5-200 mg(Vicoprofen)......................................................................41

hydrocortisone acetate suppos 25 mg.......................... 51hydrocortisone cream 2.5%.............................................53hydrocortisone enema 100 mg/60ml (Cortenema)........51hydrocortisone lotion 2.5%............................................. 53hydrocortisone oint 2.5%.................................................53hydrocortisone perianal cream 2.5% (Anusol-hc)........ 51hydrocortisone tab 5 mg (Cortef)................................... 11hydrocortisone tab 10 mg (Cortef)................................. 11hydrocortisone tab 20 mg (Cortef)................................. 11hydrocortisone valerate cream 0.2%..............................53hydrocortisone valerate oint 0.2% (Westcort)...............53hydrocortisone w/ acetic acid otic soln 1-2%............... 51hydromorphone hcl liqd 1 mg/ml (Dilaudid)..................41hydromorphone hcl tab 2 mg (Dilaudid)........................41hydromorphone hcl tab 4 mg (Dilaudid)........................41hydromorphone hcl tab 8 mg (Dilaudid)........................41hydroxychloroquine sulfate tab 200 mg (Plaquenil).......6hydroxyurea cap 500 mg (Hydrea)................................... 7hydroxyzine hcl syrup 10 mg/5ml...................................32hydroxyzine hcl tab 10 mg.............................................. 32hydroxyzine hcl tab 25 mg.............................................. 32hydroxyzine hcl tab 50 mg.............................................. 32hydroxyzine pamoate cap 25 mg (Vistaril).................... 32hydroxyzine pamoate cap 50 mg (Vistaril).................... 32HYDROXYZINE PAMOATE – hydroxyzine pamoate cap100 mg...............................................................................32

Iibandronate sodium tab 150 mg (base equivalent)(Boniva).............................................................................17

IBRANCE – palbociclib cap 75 mg...................................... 7IBRANCE – palbociclib cap 100 mg.................................... 7IBRANCE – palbociclib cap 125 mg.................................... 8IBRANCE – palbociclib tab 75 mg....................................... 8IBRANCE – palbociclib tab 100 mg..................................... 8IBRANCE – palbociclib tab 125 mg..................................... 8ibuprofen susp 100 mg/5ml.............................................43ibuprofen tab 400 mg....................................................... 43ibuprofen tab 600 mg....................................................... 43

2020


ibuprofen tab 800 mg....................................................... 43icatibant acetate inj 30 mg/3ml (base equivalent)(Firazyr).............................................................................49

ICLUSIG – ponatinib hcl tab 15 mg (base equiv)................ 8ICLUSIG – ponatinib hcl tab 45 mg (base equiv)................ 8ILARIS – canakinumab subcutaneous inj 150 mg/ml........ 43imatinib 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)............................... 33imipramine hcl tab 25 mg (Tofranil)............................... 33imipramine hcl tab 50 mg (Tofranil)............................... 33imipramine pamoate cap 75 mg (Tofranil-pm).............. 33imipramine pamoate cap 100 mg (Tofranil-pm)............ 33imipramine pamoate cap 125 mg (Tofranil-pm)............ 33imipramine pamoate cap 150 mg (Tofranil-pm)............ 33imiquimod cream 5% (Aldara).........................................54IMPAVIDO – miltefosine cap 50 mg.....................................6INBRIJA – levodopa inhal powder cap 42 mg................... 46INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml).........17INCRUSE ELLIPTA – umeclidinium br aero powd breathact 62.5 mcg/inh (base eq)...............................................28

indapamide tab 1.25 mg...................................................24indapamide tab 2.5 mg.....................................................24indomethacin cap 25 mg................................................. 43indomethacin cap 50 mg................................................. 43INGREZZA – valbenazine tosylate cap 40 mg (baseequiv)................................................................................. 40

INGREZZA – valbenazine tosylate cap 80 mg (baseequiv)................................................................................. 40

INGREZZA – valbenazine tosylate cap therapy pack 40mg (7) & 80 mg (21).........................................................40

INHALER ASSIST DEVICES – spacers............................ 55INLYTA – axitinib tab 1 mg...................................................8INLYTA – axitinib tab 5 mg...................................................8INSULIN ASPART FLEXPEN – insulin aspart soln pen-injector 100 unit/ml............................................................16

INSULIN ASPART – insulin aspart inj 100 unit/ml............. 16INSULIN ASPART PENFILL – insulin aspart soln cartridge100 unit/ml......................................................................... 16

INSULIN ASPART PROTAMINE/ – insulin aspart prot &aspart (human) inj 100 unit/ml (70-30).............................16

INSULIN ASPART PROTAMINE/ – insulin aspart prot &aspart sus pen-inj 100 unit/ml (70-30)..............................16

INSULIN PEN NEEDLES – NOVOFIN, NOVOTWIST;various................................................................................54

INSULIN SYRINGES – various..........................................55INTELENCE – etravirine tab 25 mg.....................................4INTELENCE – etravirine tab 100 mg...................................4

INTELENCE – etravirine tab 200 mg...................................4INVOKAMET – canagliflozin-metformin hcl tab 50-500mg...................................................................................... 14

INVOKAMET – canagliflozin-metformin hcl tab 50-1000mg...................................................................................... 14



INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr50-500 mg......................................................................... 14

INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr50-1000 mg....................................................................... 14

INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr150-500 mg....................................................................... 14

INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr150-1000 mg..................................................................... 14

INVOKANA – canagliflozin tab 100 mg..............................14INVOKANA – canagliflozin tab 300 mg..............................14ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml(Duoneb)........................................................................... 28

ipratropium bromide inhal soln 0.02%...........................28ipratropium bromide nasal soln 0.03% (21 mcg/spray)(Atrovent)..........................................................................26

ipratropium bromide nasal soln 0.06% (42 mcg/spray)(Atrovent)..........................................................................26

irbesartan-hydrochlorothiazide tab 150-12.5 mg(Avalide)............................................................................ 19

irbesartan-hydrochlorothiazide tab 300-12.5 mg(Avalide)............................................................................ 19

irbesartan tab 75 mg (Avapro)........................................ 19irbesartan tab 150 mg (Avapro)...................................... 19irbesartan tab 300 mg (Avapro)...................................... 19IRESSA – gefitinib tab 250 mg............................................ 8ISENTRESS HD – raltegravir potassium tab 600 mg (baseequiv)....................................................................................4

ISENTRESS – raltegravir potassium chew tab 25 mg(base equiv).........................................................................4

ISENTRESS – raltegravir potassium chew tab 100 mg(base equiv).........................................................................4

ISENTRESS – raltegravir potassium packet for susp 100mg (base equiv).................................................................. 4

ISENTRESS – raltegravir potassium tab 400 mg (baseequiv)....................................................................................4

ISONIAZID – isoniazid syrup 50 mg/5ml............................. 3isoniazid tab 100 mg.......................................................... 3isoniazid tab 300 mg.......................................................... 3isosorbide dinitrate tab 10 mg........................................22isosorbide dinitrate tab 20 mg........................................22isosorbide dinitrate tab 30 mg........................................22isosorbide dinitrate tab 5 mg (Isordil titradose)........... 22isosorbide mononitrate tab er 24hr 30 mg.................... 22isosorbide mononitrate tab er 24hr 60 mg.................... 22isosorbide mononitrate tab er 24hr 120 mg.................. 22isosorbide mononitrate tab 10 mg................................. 22isosorbide mononitrate tab 20 mg................................. 22

2020


isotretinoin cap 10 mg..................................................... 52isotretinoin cap 20 mg..................................................... 52isotretinoin cap 30 mg..................................................... 52isotretinoin cap 40 mg..................................................... 52itraconazole cap 100 mg (Sporanox)................................3itraconazole oral soln 10 mg/ml (Sporanox)................... 3ivermectin tab 3 mg (Stromectol)..................................... 6J

JADENU – deferasirox tab 180 mg....................................55JADENU SPRINKLE – deferasirox granules packet 90mg...................................................................................... 55

JADENU SPRINKLE – deferasirox granules packet 180mg...................................................................................... 55

JADENU SPRINKLE – deferasirox granules packet 360mg...................................................................................... 55

JAKAFI – ruxolitinib phosphate tab 5 mg (baseequivalent)............................................................................8





JANUMET – sitagliptin-metformin hcl tab 50-500 mg........14JANUMET – sitagliptin-metformin hcl tab 50-1000 mg......14JANUMET XR – sitagliptin-metformin hcl tab er 24hr50-500 mg......................................................................... 14

JANUMET XR – sitagliptin-metformin hcl tab er 24hr50-1000 mg....................................................................... 14

JANUMET XR – sitagliptin-metformin hcl tab er 24hr100-1000 mg..................................................................... 14

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



JARDIANCE – empagliflozin tab 10 mg.............................15JARDIANCE – empagliflozin tab 25 mg.............................15JUXTAPID – lomitapide mesylate cap 5 mg (baseequiv)................................................................................. 23

JUXTAPID – lomitapide mesylate cap 10 mg (baseequiv)................................................................................. 23





KKALETRA – lopinavir-ritonavir tab 100-25 mg.....................4KALETRA – lopinavir-ritonavir tab 200-50 mg.....................4KALYDECO – ivacaftor packet 25 mg............................... 29KALYDECO – ivacaftor packet 50 mg............................... 29KALYDECO – ivacaftor packet 75 mg............................... 29KALYDECO – ivacaftor tab 150 mg................................... 28ketoconazole cream 2%................................................... 52ketoconazole shampoo 2% (Nizoral)..............................52ketorolac tromethamine ophth soln 0.5% (Acular)....... 51ketorolac tromethamine ophth soln 0.4% (Acularls)....................................................................................... 51

ketorolac tromethamine tab 10 mg.................................43KISQALI FEMARA 200 DOSE – ribociclib 200 mg dose(200 mg tab) & letrozole 2.5 mg tbpk.................................8

KISQALI FEMARA 400 DOSE – ribociclib 400 mg dose(200 mg tab) & letrozole 2.5 mg tbpk.................................8

KISQALI FEMARA 600 DOSE – ribociclib 600 mg dose(200 mg tab) & letrozole 2.5 mg tbpk.................................8

KISQALI – ribociclib succinate tab pack 200 mg dailydose......................................................................................8

KISQALI – ribociclib succinate tab pack 400 mg daily dose(200 mg tab)........................................................................8

KISQALI – ribociclib succinate tab pack 600 mg daily dose(200 mg tab)........................................................................8

KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr2.5-1000 mg...................................................................... 15

KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr5-500 mg............................................................................15

KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr5-1000 mg......................................................................... 15

KUVAN – sapropterin dihydrochloride powder packet 100mg...................................................................................... 17

KUVAN – sapropterin dihydrochloride powder packet 500mg...................................................................................... 17

KUVAN – sapropterin dihydrochloride soluble tab 100mg...................................................................................... 17

Llabetalol hcl tab 100 mg (Trandate)................................20labetalol hcl tab 200 mg (Trandate)................................20labetalol hcl tab 300 mg (Trandate)................................20lactulose (encephalopathy) solution 10 gm/15ml......... 30lactulose solution 10 gm/15ml........................................ 29lamivudine oral soln 10 mg/ml (Epivir)............................ 4lamivudine tab 150 mg (Epivir)......................................... 4lamivudine tab 300 mg (Epivir)......................................... 4lamivudine tab 100 mg (hbv) (Epivir hbv)........................3lamivudine-zidovudine tab 150-300 mg (Combivir)........ 5lamotrigine tab chewable dispersible 5 mg (Lamictalchewable di)..................................................................... 45

lamotrigine tab chewable dispersible 25 mg (Lamictalchewable di)..................................................................... 45

lamotrigine tab 25 mg (Lamictal)....................................45lamotrigine tab 100 mg (Lamictal)..................................45

2020


lamotrigine tab 150 mg (Lamictal)..................................45lamotrigine tab 200 mg (Lamictal)..................................45LANCETS – various............................................................55lansoprazole cap delayed release 15 mg(Prevacid)..........................................................................29

lansoprazole cap delayed release 30 mg(Prevacid)..........................................................................29

LANTUS – insulin glargine inj 100 unit/ml......................... 16LANTUS SOLOSTAR – insulin glargine soln pen-injector100 unit/ml......................................................................... 16

latanoprost ophth soln 0.005% (Xalatan).......................50LEDIPASVIR/SOFOSBUVIR – ledipasvir-sofosbuvir tab90-400 mg............................................................................3

leflunomide tab 10 mg (Arava)........................................43leflunomide tab 20 mg (Arava)........................................43LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 mg (14 mg daily dose)................................... 8

LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapypack 10 mg (10 mg daily dose)..........................................8

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

LENVIMA 12MG DAILY DOSE – lenvatinib cap therapypack 3 x 4 mg (12 mg daily dose)......................................8

LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapypack 2 x 10 mg (20 mg daily dose)....................................8

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

LENVIMA 18 MG DAILY DOSE – lenvatinib cap ther pack10 mg & 2 x 4 mg (18 mg daily dose)................................8

LENVIMA 24 MG DAILY DOSE – lenvatinib cap ther pack2 x 10 mg & 4 mg (24 mg daily dose)................................8

letrozole tab 2.5 mg (Femara)........................................... 8LEUCOVORIN CALCIUM – leucovorin calcium tab 10mg........................................................................................ 8

LEUCOVORIN CALCIUM – leucovorin calcium tab 15mg........................................................................................ 8

leucovorin calcium tab 5 mg.............................................8leucovorin calcium tab 25 mg...........................................8LEUKERAN – chlorambucil tab 2 mg.................................. 8levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (baseequiv).................................................................................28

levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)(Xopenex)..........................................................................28



LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector100 unit/ml......................................................................... 16

LEVEMIR – insulin detemir inj 100 unit/ml.........................16levetiracetam oral soln 100 mg/ml (Keppra)..................45levetiracetam tab er 24hr 500 mg (Keppra xr)...............45levetiracetam tab er 24hr 750 mg (Keppra xr)...............45levetiracetam tab 250 mg (Keppra).................................45levetiracetam tab 500 mg (Keppra).................................45levetiracetam tab 750 mg (Keppra).................................45

levetiracetam tab 1000 mg (Keppra)...............................45LEVOBUNOLOL HCL – levobunolol hcl ophth soln0.5%................................................................................... 50

levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 17levocarnitine tab 330 mg (Carnitor)................................17levofloxacin oral soln 25 mg/ml (Levaquin).................... 2levofloxacin tab 250 mg (Levaquin)................................. 2levofloxacin tab 500 mg (Levaquin)................................. 2levofloxacin tab 750 mg (Levaquin)................................. 2levonorgestrel & 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)..............16levothyroxine sodium tab 50 mcg (Synthroid)..............16levothyroxine sodium tab 75 mcg (Synthroid)..............16levothyroxine sodium tab 88 mcg (Synthroid)..............16levothyroxine sodium tab 100 mcg (Synthroid)............16levothyroxine sodium tab 112 mcg (Synthroid)............ 16levothyroxine sodium tab 125 mcg (Synthroid)............16levothyroxine sodium tab 137 mcg (Synthroid)............16levothyroxine 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 viscous soln 2%........................................ 51lidocaine-prilocaine cream 2.5-2.5% (Emla).................. 54LINDANE – lindane shampoo 1%......................................54linezolid for susp 100 mg/5ml (Zyvox)............................. 6linezolid tab 600 mg (Zyvox)............................................. 6liothyronine sodium tab 5 mcg (Cytomel)..................... 17liothyronine sodium tab 25 mcg (Cytomel)................... 17liothyronine sodium tab 50 mcg (Cytomel)................... 17lisinopril & hydrochlorothiazide tab 10-12.5 mg(Zestoretic)....................................................................... 18

lisinopril & hydrochlorothiazide tab 20-12.5 mg(Zestoretic)....................................................................... 18

lisinopril & hydrochlorothiazide tab 20-25 mg(Zestoretic)....................................................................... 18

lisinopril tab 5 mg (Prinivil)............................................. 18lisinopril tab 10 mg (Prinivil)........................................... 19lisinopril tab 20 mg (Prinivil)........................................... 19lisinopril tab 2.5 mg (Zestril)........................................... 18lisinopril tab 30 mg (Zestril)............................................ 19lisinopril tab 40 mg (Zestril)............................................ 19lithium carbonate cap 300 mg.........................................34lithium carbonate cap 150 mg (Lithium carbonate)......34lithium carbonate cap 600 mg (Lithium carbonate)......34

2020


LITHIUM CARBONATE – lithium carbonate cap 150mg...................................................................................... 34

lithium carbonate tab er 450 mg.....................................35lithium carbonate tab er 300 mg (Lithobid)................... 34lithium carbonate tab 300 mg......................................... 35LITHIUM – lithium oral solution 8 meq/5ml........................34LONSURF – trifluridine-tipiracil tab 15-6.14 mg...................9LONSURF – trifluridine-tipiracil tab 20-8.19 mg...................9lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)(Kaletra)...............................................................................5

lorazepam conc 2 mg/ml (Lorazepam intensol)............ 32lorazepam tab 0.5 mg (Ativan)........................................ 32lorazepam tab 1 mg (Ativan)........................................... 32lorazepam tab 2 mg (Ativan)........................................... 32losartan potassium & hydrochlorothiazide tab 50-12.5mg (Hyzaar)...................................................................... 19

losartan potassium & hydrochlorothiazide tab 100-12.5mg (Hyzaar)...................................................................... 19

losartan potassium & hydrochlorothiazide tab 100-25mg (Hyzaar)...................................................................... 19

losartan potassium tab 25 mg (Cozaar).........................19losartan potassium tab 50 mg (Cozaar).........................19losartan potassium tab 100 mg (Cozaar).......................19LOTEMAX – loteprednol etabonate ophth gel 0.5%..........50LOTEMAX – loteprednol etabonate ophth oint 0.5%.........50LOTEMAX SM – loteprednol etabonate ophth gel0.38%................................................................................. 50

loteprednol etabonate ophth susp 0.5% (Lotemax)......50lovastatin tab 10 mg.........................................................23lovastatin tab 20 mg (Mevacor).......................................23lovastatin tab 40 mg (Mevacor).......................................23loxapine succinate cap 10 mg........................................ 35loxapine succinate cap 25 mg........................................ 35loxapine succinate cap 50 mg........................................ 35loxapine succinate cap 5 mg (Loxitane)........................35LUMIGAN – bimatoprost ophth soln 0.01%.......................50LUPRON DEPOT-PED (1-MONTH – leuprolide acetate forinj pediatric kit 7.5 mg.......................................................17

LUPRON DEPOT-PED (1-MONTH – leuprolide acetate forinj pediatric kit 11.25 mg...................................................17

LUPRON DEPOT-PED (1-MONTH – leuprolide acetate forinj pediatric kit 15 mg........................................................17

LYNPARZA – olaparib tab 100 mg.......................................9LYNPARZA – olaparib tab 150 mg.......................................9LYSODREN – mitotane tab 500 mg.....................................9

Mmalathion lotion 0.5% (Ovide).........................................54MATULANE – procarbazine hcl cap 50 mg......................... 9MAVENCLAD – cladribine tab therapy pack 10 mg (4tabs)................................................................................... 38

MAVENCLAD – cladribine tab therapy pack 10 mg (5tabs)................................................................................... 38






MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg.......... 3MAYZENT – siponimod fumarate tab 0.25 mg (baseequiv)................................................................................. 38

MAYZENT – siponimod fumarate tab 2 mg (baseequiv)................................................................................. 38

medroxyprogesterone acetate tab 2.5 mg(Provera)........................................................................... 12

medroxyprogesterone acetate tab 5 mg (Provera).......12medroxyprogesterone acetate tab 10 mg (Provera).....12MEFLOQUINE HCL – mefloquine hcl tab 250 mg...............6megestrol 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)........................................43meloxicam tab 15 mg (Mobic).........................................43melphalan tab 2 mg (Alkeran)...........................................9memantine hcl cap er 24hr 7 mg (Namenda xr)............ 40memantine hcl cap er 24hr 14 mg (Namenda xr).......... 40memantine hcl cap er 24hr 21 mg (Namenda xr).......... 40memantine hcl cap er 24hr 28 mg (Namenda xr).......... 40memantine hcl oral solution 2 mg/ml (Namenda)......... 40memantine hcl tab 5 mg (Namenda).............................. 40memantine hcl tab 10 mg (Namenda)............................ 40memantine hcl tab 28 x 5 mg & 21 x 10 mg titrationpack (Namenda titration pa).......................................... 40

MENOPUR – menotropins for subcutaneous inj 75unit......................................................................................14

mercaptopurine tab 50 mg (Purinethol)...........................9mesalamine cap dr 400 mg (Delzicol)............................ 30mesalamine cap er 24hr 0.375 gm (Apriso)...................30mesalamine enema 4 gm................................................. 30mesalamine suppos 1000 mg (Canasa)......................... 30mesalamine tab delayed release 1.2 gm (Lialda)..........30mesalamine tab delayed release 800 mg (Asacolhd)......................................................................................30

MESNEX – mesna tab 400 mg............................................9metformin hcl tab er 24hr 500 mg (Glucophage xr)......15metformin hcl tab er 24hr 750 mg (Glucophage xr)......15metformin hcl tab 500 mg (Glucophage)....................... 15metformin hcl tab 850 mg (Glucophage)....................... 15metformin hcl tab 1000 mg (Glucophage)..................... 15methadone hcl conc 10 mg/ml (Methadose)................. 41methadone hcl soln 5 mg/5ml (Methadone hcl)............41methadone hcl soln 10 mg/5ml (Methadone hcl).......... 41

2020


methadone hcl tab for oral susp 40 mg.........................41methadone hcl tab 10 mg (Dolophine)...........................41methadone hcl tab 5 mg (Dolophine hcl).......................41methimazole tab 5 mg (Tapazole)................................... 17methimazole tab 10 mg (Tapazole)................................. 17methocarbamol tab 750 mg (Robaxin-750)....................47methocarbamol tab 500 mg (Robaxin)...........................47methotrexate sodium tab 2.5 mg (base equiv)................9methoxsalen rapid cap 10 mg (Oxsoralen ultra)...........54methyldopa tab 250 mg................................................... 25methyldopa tab 500 mg................................................... 25methylergonovine maleate tab 0.2 mg...........................17methylphenidate hcl cap er 24hr 20 mg (la) (Ritalinla)....................................................................................... 37

methylphenidate hcl cap er 24hr 30 mg (la) (Ritalinla)....................................................................................... 37

methylphenidate hcl cap er 24hr 40 mg (la) (Ritalinla)....................................................................................... 37

methylphenidate hcl cap er 10 mg (cd)......................... 37methylphenidate hcl cap er 20 mg (cd)......................... 37methylphenidate hcl cap er 30 mg (cd)......................... 37methylphenidate hcl cap er 40 mg (cd)......................... 37methylphenidate hcl cap er 50 mg (cd)......................... 37methylphenidate hcl cap er 60 mg (cd)......................... 37methylphenidate hcl tab er 24hr 27 mg......................... 37methylphenidate hcl tab er 24hr 36 mg......................... 37methylphenidate hcl tab er 24hr 54 mg......................... 37methylphenidate hcl tab er 10 mg..................................37methylphenidate hcl tab er 20 mg..................................37methylphenidate hcl tab er osmotic release (osm) 18mg (Concerta).................................................................. 37

methylphenidate hcl tab er osmotic release (osm) 27mg (Concerta).................................................................. 37



methylphenidate hcl tab 5 mg (Ritalin).......................... 37methylphenidate hcl tab 10 mg (Ritalin)........................ 37methylphenidate hcl tab 20 mg (Ritalin)........................ 37METHYLPHENIDATE HYDROCHLO – methylphenidatehcl tab er 24hr 18 mg....................................................... 37

methylprednisolone 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).................................................................................30

metoclopramide hcl tab 5 mg (base equivalent)(Reglan).............................................................................30

metoclopramide hcl tab 10 mg (base equivalent)(Reglan).............................................................................30

metolazone tab 10 mg......................................................24metolazone tab 2.5 mg (Zaroxolyn)................................24

metolazone tab 5 mg (Zaroxolyn)...................................24METOPROLOL/HYDROCHLOROTHI – metoprolol &hydrochlorothiazide tab 100-50 mg.................................. 20

metoprolol & hydrochlorothiazide tab 50-25 mg(Lopressor hct)................................................................ 20

metoprolol & hydrochlorothiazide tab 100-25 mg(Lopressor hct)................................................................ 20

metoprolol succinate tab er 24hr 25 mg (tartrate equiv)(Toprol xl)......................................................................... 20

metoprolol succinate tab er 24hr 50 mg (tartrate equiv)(Toprol xl)......................................................................... 20

metoprolol succinate tab er 24hr 100 mg (tartrateequiv) (Toprol xl)............................................................. 20

metoprolol succinate tab er 24hr 200 mg (tartrateequiv) (Toprol xl)............................................................. 20

metoprolol tartrate tab 25 mg......................................... 20metoprolol tartrate tab 50 mg (Lopressor).................... 20metoprolol tartrate tab 100 mg (Lopressor).................. 20metronidazole cream 0.75% (Metrocream).................... 52metronidazole gel 0.75%..................................................52metronidazole gel 1% (Metrogel).................................... 52metronidazole lotion 0.75% (Metrolotion)......................52metronidazole tab 250 mg (Flagyl)................................... 6metronidazole tab 500 mg (Flagyl)................................... 6metronidazole vaginal gel 0.75% (Metrogel-vaginal)..............................................................................31

MEXILETINE HCL – mexiletine hcl cap 150 mg................25MEXILETINE HCL – mexiletine hcl cap 200 mg................25MEXILETINE HCL – mexiletine hcl cap 250 mg................25midodrine hcl tab 2.5 mg.................................................25midodrine hcl tab 5 mg....................................................25midodrine hcl tab 10 mg..................................................25MIGRANAL – dihydroergotamine mesylate nasal spray 4mg/ml..................................................................................44

minocycline 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.........................................................25minoxidil tab 10 mg..........................................................25MIRENA – levonorgestrel releasing iud 20 mcg/day (52mg total).............................................................................13

mirtazapine orally disintegrating tab 15 mg (Remeronsoltab)............................................................................... 33



mirtazapine tab 7.5 mg.....................................................33mirtazapine tab 15 mg (Remeron).................................. 33mirtazapine tab 30 mg (Remeron).................................. 33mirtazapine tab 45 mg (Remeron).................................. 33misoprostol tab 100 mcg (Cytotec)................................ 29misoprostol tab 200 mcg (Cytotec)................................ 29

2020


modafinil tab 100 mg (Provigil).......................................37modafinil tab 200 mg (Provigil).......................................37moexipril hcl tab 7.5 mg (Univasc).................................19moexipril hcl tab 15 mg (Univasc)..................................19mometasone furoate cream 0.1% (Elocon)................... 53mometasone furoate oint 0.1% (Elocon)........................53mometasone furoate solution 0.1% (lotion)(Elocon).............................................................................53

montelukast sodium chew tab 4 mg (base equiv)(Singulair)......................................................................... 28

montelukast sodium chew tab 5 mg (base equiv)(Singulair)......................................................................... 28

montelukast sodium oral granules packet 4 mg (baseequiv) (Singulair)............................................................. 28

montelukast sodium tab 10 mg (base equiv)(Singulair)......................................................................... 28

morphine sulfate oral soln 10 mg/5ml........................... 41morphine sulfate oral soln 20 mg/5ml........................... 41morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...... 41morphine sulfate tab er 15 mg (Ms contin)................... 41morphine sulfate tab er 30 mg (Ms contin)................... 41morphine sulfate tab er 60 mg (Ms contin)................... 41morphine sulfate tab er 100 mg (Ms contin)................. 41morphine sulfate tab er 200 mg (Ms contin)................. 41morphine sulfate tab 15 mg (Morphine sulfate)............41morphine sulfate tab 30 mg (Morphine sulfate)............41moxifloxacin hcl ophth soln 0.5% (base equiv)(Vigamox)..........................................................................49

moxifloxacin hcl tab 400 mg (base equiv) (Avelox)........3MULTAQ – dronedarone hcl tab 400 mg (baseequivalent)......................................................................... 25

mupirocin oint 2% (Bactroban).......................................52mycophenolate mofetil cap 250 mg (Cellcept)..............55mycophenolate mofetil for oral susp 200 mg/ml(Cellcept)...........................................................................55

mycophenolate mofetil tab 500 mg (Cellcept)...............55mycophenolate sodium tab dr 180 mg (mycophenolicacid equiv) (Myfortic)......................................................55

mycophenolate sodium tab dr 360 mg (mycophenolicacid equiv) (Myfortic)......................................................55

MYLERAN – busulfan tab 2 mg...........................................9MYRBETRIQ – mirabegron tab er 24 hr 25 mg.................31MYRBETRIQ – mirabegron tab er 24 hr 50 mg.................31

Nnabumetone tab 500 mg.................................................. 43nabumetone tab 750 mg.................................................. 43nadolol tab 20 mg (Corgard)........................................... 20nadolol tab 40 mg (Corgard)........................................... 20nadolol tab 80 mg (Corgard)........................................... 20naloxone hcl inj 0.4 mg/ml.............................................. 55naloxone hcl inj 4 mg/10ml............................................. 55NALOXONE HCL – naloxone hcl soln cartridge 0.4 mg/ml........................................................................................55

naltrexone hcl tab 50 mg (Revia)....................................55

NAMENDA XR TITRATION PACK – memantine hcl cap er24hr 7 mg & 14 mg & 21 mg & 28 mg pack.....................40

naproxen sodium tab 275 mg (Anaprox)....................... 43naproxen sodium tab 550 mg (Anaprox ds)..................43naproxen susp 125 mg/5ml (Naprosyn).........................43naproxen tab ec 375 mg (Ec-naprosyn).........................43naproxen tab ec 500 mg (Ec-naprosyn).........................43naproxen tab 250 mg (Naprosyn)................................... 43naproxen tab 375 mg (Naprosyn)................................... 43naproxen tab 500 mg (Naprosyn)................................... 43naratriptan hcl tab 1 mg (base equiv) (Amerge)........... 44naratriptan hcl tab 2.5 mg (base equiv) (Amerge)........ 44NARCAN – naloxone hcl nasal spray 4 mg/0.1ml............. 55NATACYN – natamycin ophth susp 5%............................. 49nateglinide tab 60 mg (Starlix)........................................15nateglinide tab 120 mg (Starlix)......................................15NEOMYCIN/POLYMYXIN/GRAMIC – neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml..............49

neomycin-bacitrac zn-polymyx5(3.5)mg-400unt-10000unt op oin..................................49

neomycin-polymyxin-dexamethasone ophth oint 0.1%(Maxitrol)...........................................................................50

neomycin-polymyxin-dexamethasone ophth susp0.1% (Maxitrol)................................................................. 50

neomycin-polymyxin-hc otic soln 1% (Cortisporin)..... 51neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000unit/ml-1%.........................................................................51

neomycin sulfate tab 500 mg............................................3NEULASTA ONPRO KIT – pegfilgrastim soln prefilledsyringe kit 6 mg/0.6ml.......................................................49

NEULASTA – pegfilgrastim soln prefilled syringe 6mg/0.6ml............................................................................ 49

NEVIRAPINE ER – nevirapine tab er 24hr 100 mg............. 5nevirapine susp 50 mg/5ml (Viramune)........................... 5nevirapine tab er 24hr 400 mg (Viramune xr)..................5nevirapine tab 200 mg (Viramune)....................................5NEXAVAR – sorafenib tosylate tab 200 mg (baseequivalent)............................................................................9

NEXIUM – esomeprazole magnesium for delayed releasesusp packet 5 mg..............................................................29

NEXIUM – esomeprazole magnesium for delayed releasesusp packet 10 mg............................................................29



NEXIUM – esomeprazole magnesium for delayed releasesusp pack 2.5 mg..............................................................29

niacin tab er 500 mg (antihyperlipidemic)(Niaspan)...........................................................................23



NICODERM CQ – nicotine td patch 24hr 7 mg/24hr......... 39NICODERM CQ – nicotine td patch 24hr 14 mg/24hr....... 39

2020


NICODERM CQ – nicotine td patch 24hr 21 mg/24hr....... 39NICORETTE MINI – nicotine polacrilex lozenge 2 mg...... 39NICORETTE MINI – nicotine polacrilex lozenge 4 mg...... 39NICORETTE – nicotine polacrilex gum 2 mg.................... 39NICORETTE – nicotine polacrilex gum 4 mg.................... 39NICORETTE – nicotine polacrilex lozenge 2 mg...............39NICORETTE – nicotine polacrilex lozenge 4 mg...............39NICORETTE STARTER KIT – nicotine polacrilex gum 2mg...................................................................................... 39

NICORETTE STARTER KIT – nicotine polacrilex gum 4mg...................................................................................... 39

nicotine polacrilex gum 2 mg..........................................39nicotine polacrilex gum 4 mg..........................................39nicotine polacrilex lozenge 2 mg....................................39nicotine polacrilex lozenge 4 mg....................................39nicotine td patch 24hr 7 mg/24hr....................................39nicotine td patch 24hr 14 mg/24hr..................................39nicotine td patch 24hr 21 mg/24hr..................................39NICOTINE TRANSDERMAL SYST – nicotine td patch 24hr kit 21-14-7 mg/24hr...................................................... 39

NICOTROL INHALER – nicotine inhaler system 10 mg (4mg delivered).....................................................................39

NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray)................................................................................. 39

nifedipine tab er 24hr 30 mg (Adalat cc)........................22nifedipine tab er 24hr 60 mg (Adalat cc)........................22nifedipine tab er 24hr 90 mg (Adalat cc)........................22nifedipine tab er 24hr osmotic release 30 mg(Procardia xl)....................................................................22

nifedipine tab er 24hr osmotic release 60 mg(Procardia xl)....................................................................22

nifedipine tab er 24hr osmotic release 90 mg(Procardia xl)....................................................................22

nilutamide tab 150 mg (Nilandron)................................... 9nimodipine cap 30 mg......................................................22NINLARO – ixazomib citrate cap 2.3 mg (baseequivalent)............................................................................9

NINLARO – ixazomib citrate cap 3 mg (baseequivalent)............................................................................9

NINLARO – ixazomib citrate cap 4 mg (baseequivalent)............................................................................9

NITRO-BID – nitroglycerin oint 2%.................................... 22nitrofurantoin macrocrystalline cap 50 mg(Macrodantin)................................................................... 31

nitrofurantoin macrocrystalline cap 100 mg(Macrodantin)................................................................... 31

nitrofurantoin monohydrate macrocrystalline cap 100mg (Macrobid)..................................................................31

nitrofurantoin susp 25 mg/5ml (Furadantin)..................31nitroglycerin sl tab 0.3 mg (Nitrostat)............................ 22nitroglycerin sl tab 0.4 mg (Nitrostat)............................ 22nitroglycerin sl tab 0.6 mg (Nitrostat)............................ 22nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)..........22nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)..........22nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)..........22nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)..........22

NITRO-TIME – nitroglycerin cap er 2.5 mg....................... 22NITRO-TIME – nitroglycerin cap er 6.5 mg....................... 22NITRO-TIME – nitroglycerin cap er 9 mg.......................... 22NITYR – nitisinone tab 2 mg..............................................17NITYR – nitisinone tab 5 mg..............................................17NITYR – nitisinone tab 10 mg............................................18NORDITROPIN FLEXPRO – somatropin inj 5mg/1.5ml............................................................................ 17

NORDITROPIN FLEXPRO – somatropin inj 10mg/1.5ml............................................................................ 17

NORDITROPIN FLEXPRO – somatropin inj 15mg/1.5ml............................................................................ 17

NORDITROPIN FLEXPRO – somatropin inj 30mg/3ml............................................................................... 17

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).....................................................13

norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30mcg (Loestrin fe 1.5/30)..................................................13

norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg(Loestrin 1/20-21).............................................................13

norethindrone ace & ethinyl estradiol tab 1.5 mg-30mcg (Loestrin 1.5/30-21).................................................13

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)...................12norethindrone 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)............................................... 13

norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg (Tri-norinyl 28).........................................................13

norethindrone tab 0.35 mg (Nor-qd)...............................13norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg(Ortho-cyclen).................................................................. 13

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35mg-mcg (Ortho tri-cyclen)..............................................13

norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25mg-mcg (Ortho tri-cyclen lo)......................................... 13

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg.........13NORPACE CR – disopyramide phosphate cap er 12hr 100mg...................................................................................... 25

nortriptyline hcl cap 10 mg (Pamelor)............................33nortriptyline hcl cap 25 mg (Pamelor)............................33nortriptyline hcl cap 50 mg (Pamelor)............................33nortriptyline hcl cap 75 mg (Pamelor)............................33NORTRIPTYLINE HCL – nortriptyline hcl soln 10mg/5ml............................................................................... 33

NORVIR – ritonavir oral soln 80 mg/ml................................5

2020


NORVIR – ritonavir powder packet 100 mg.........................5NOVOLIN 70/30 FLEXPEN – insulin nph & regular susppen-inj 100 unit/ml (70-30)................................................16

NOVOLIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30).......................................................16

NOVOLIN N FLEXPEN – insulin nph (human) (isophane)susp pen-injector 100 unit/ml............................................16

NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml........................................................................................16

NOVOLIN R FLEXPEN – insulin regular (human) solnpen-injector 100 unit/ml.....................................................16

NOVOLIN R – insulin regular (human) inj 100 unit/ml....... 16NOVOLOG FLEXPEN – insulin aspart soln pen-injector100 unit/ml......................................................................... 16

NOVOLOG – insulin aspart inj 100 unit/ml........................ 16NOVOLOG MIX 70/30 – insulin aspart prot & aspart(human) inj 100 unit/ml (70-30)........................................ 16

NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &aspart sus pen-inj 100 unit/ml (70-30)..............................16

NOVOLOG PENFILL – insulin aspart soln cartridge 100unit/ml.................................................................................16

NOXAFIL – posaconazole susp 40 mg/ml...........................3NPLATE – romiplostim for inj 125 mcg.............................. 49NPLATE – romiplostim for inj 250 mcg.............................. 49NPLATE – romiplostim for inj 500 mcg.............................. 49NUBEQA – darolutamide tab 300 mg..................................9NUVARING – etonogestrel-ethinyl estradiol va ring0.120-0.015 mg/24hr.........................................................13

nystatin cream 100000 unit/gm.......................................52nystatin oint 100000 unit/gm........................................... 52nystatin susp 100000 unit/ml.......................................... 51nystatin tab 500000 unit.....................................................3nystatin topical powder 100000 unit/gm........................52nystatin-triamcinolone cream 100000-0.1 unit/gm-%........................................................................................ 53

nystatin-triamcinolone oint 100000-0.1 unit/gm-%....... 53O

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

ODOMZO – sonidegib phosphate cap 200 mg (baseequivalent)............................................................................9

OFEV – nintedanib esylate cap 100 mg (baseequivalent)......................................................................... 29

OFEV – nintedanib esylate cap 150 mg (baseequivalent)......................................................................... 29

ofloxacin ophth soln 0.3% (Ocuflox)..............................49ofloxacin otic soln 0.3%...................................................51ofloxacin tab 400 mg..........................................................3olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)....... 40olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax)....... 40olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax)....... 40olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax)..... 40olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax)..... 40olanzapine orally disintegrating tab 5 mg (Zyprexazydis)................................................................................. 35

olanzapine orally disintegrating tab 10 mg (Zyprexazydis)................................................................................. 35



olanzapine tab 2.5 mg (Zyprexa).....................................35olanzapine tab 5 mg (Zyprexa)........................................35olanzapine tab 7.5 mg (Zyprexa).....................................35olanzapine tab 10 mg (Zyprexa)......................................35olanzapine tab 15 mg (Zyprexa)......................................35olanzapine tab 20 mg (Zyprexa)......................................35olopatadine hcl ophth soln 0.2% (base equivalent)(Pataday)...........................................................................51

olopatadine hcl ophth soln 0.1% (base equivalent)(Patanol)............................................................................51

omega-3-acid ethyl esters cap 1 gm (Lovaza)...............23omeprazole cap delayed release 10 mg (Prilosec)....... 29omeprazole cap delayed release 20 mg (Prilosec)....... 29omeprazole cap delayed release 40 mg (Prilosec)....... 29ondansetron hcl inj 4 mg/2ml (2 mg/ml)........................ 30ondansetron hcl inj 40 mg/20ml (2 mg/ml) (Zofran)......30ONDANSETRON HCL – ondansetron hcl tab 24 mg........ 30ondansetron hcl oral soln 4 mg/5ml (Zofran)................30ondansetron hcl tab 4 mg (Zofran).................................30ondansetron hcl tab 8 mg (Zofran).................................30ondansetron orally disintegrating tab 4 mg (Zofranodt).....................................................................................30

ondansetron orally disintegrating tab 8 mg (Zofranodt).....................................................................................30

ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv).........15ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)............15OPSUMIT – macitentan tab 10 mg....................................25ORALAIR – grass mixed pollen ext sl tab 300 ir (index ofreactivity)..............................................................................6

ORILISSA – elagolix sodium tab 150 mg (base equiv)......18ORILISSA – elagolix sodium tab 200 mg (base equiv)......18orphenadrine citrate tab er 12hr 100 mg....................... 47oseltamivir phosphate cap 30 mg (base equiv)(Tamiflu).............................................................................. 5

oseltamivir phosphate cap 45 mg (base equiv)(Tamiflu).............................................................................. 5

oseltamivir phosphate cap 75 mg (base equiv)(Tamiflu).............................................................................. 5

oseltamivir phosphate for susp 6 mg/ml (base equiv)(Tamiflu).............................................................................. 5

OTEZLA – apremilast tab 30 mg....................................... 43OTEZLA – apremilast tab starter therapy pack 10 mg & 20mg & 30 mg.......................................................................43

OVIDREL – choriogonadotropin alfa inj 250mcg/0.5ml...........................................................................14

oxaprozin tab 600 mg (Daypro).......................................43oxcarbazepine susp 300 mg/5ml (60 mg/ml)(Trileptal)...........................................................................45

oxcarbazepine tab 150 mg (Trileptal)............................. 45oxcarbazepine tab 300 mg (Trileptal)............................. 45

2020


oxcarbazepine tab 600 mg (Trileptal)............................. 45oxybutynin chloride syrup 5 mg/5ml..............................31oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)......31oxybutynin chloride tab er 24hr 10 mg (Ditropanxl)....................................................................................... 31

oxybutynin chloride tab er 24hr 15 mg (Ditropanxl)....................................................................................... 31

oxybutynin chloride tab 5 mg......................................... 31OXYCODONE/ASPIRIN – oxycodone-aspirin tab4.8355-325 mg.................................................................. 42

oxycodone hcl cap 5 mg................................................. 41oxycodone hcl conc 100 mg/5ml (20 mg/ml)(Oxycodone hcl).............................................................. 41

oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)............41oxycodone hcl tab 10 mg................................................ 41oxycodone hcl tab 20 mg................................................ 41oxycodone hcl tab 5 mg (Roxicodone).......................... 41oxycodone hcl tab 15 mg (Roxicodone)........................ 41oxycodone hcl tab 30 mg (Roxicodone)........................ 41oxycodone w/ acetaminophen tab 5-325 mg(Percocet)......................................................................... 41

oxycodone w/ acetaminophen tab 7.5-325 mg(Percocet)......................................................................... 41

oxycodone w/ acetaminophen tab 10-325 mg(Percocet)......................................................................... 42

OXYCONTIN – oxycodone hcl tab er 12hr deter 10mg...................................................................................... 42







OZEMPIC – semaglutide soln pen-inj 1 mg/dose (2mg/1.5ml)........................................................................... 15

OZEMPIC – semaglutide soln pen-inj 0.25 or 0.5 mg/dose(2 mg/1.5ml)...................................................................... 15

Ppantoprazole sodium ec tab 20 mg (base equiv)(Protonix).......................................................................... 29

pantoprazole sodium ec tab 40 mg (base equiv)(Protonix).......................................................................... 29

paricalcitol cap 1 mcg (Zemplar).................................... 18paricalcitol cap 2 mcg (Zemplar).................................... 18paricalcitol cap 4 mcg (Zemplar).................................... 18PAROMOMYCIN SULFATE – paromomycin sulfate cap250 mg.................................................................................3

paroxetine hcl tab er 24hr 12.5 mg (Paxil cr)................ 33paroxetine hcl tab er 24hr 25 mg (Paxil cr)................... 33

paroxetine hcl tab er 24hr 37.5 mg (Paxil cr)................ 33paroxetine hcl tab 10 mg (Paxil).....................................33paroxetine hcl tab 20 mg (Paxil).....................................33paroxetine hcl tab 30 mg (Paxil).....................................34paroxetine hcl tab 40 mg (Paxil).....................................34PAZEO – olopatadine hcl ophth soln 0.7% (baseequivalent)......................................................................... 51

PEGASYS – peginterferon alfa-2a inj 180 mcg/ml.............. 3PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml......... 3PEGASYS PROCLICK – peginterferon alfa-2a inj 180mcg/0.5ml.............................................................................3

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm(Golytely)...........................................................................29

peg 3350-kcl-sod bicarb-nacl for soln 420 gm(Nulytely/flavor pack)......................................................29

penicillamine tab 250 mg (Depen titratabs)...................55PENICILLIN V POTASSIUM – penicillin v potassium forsoln 125 mg/5ml..................................................................1

PENICILLIN V POTASSIUM – penicillin v potassium forsoln 250 mg/5ml..................................................................1

penicillin v potassium tab 250 mg....................................1penicillin v potassium tab 500 mg....................................1pentamidine isethionate for nebulization soln 300 mg(Nebupent).......................................................................... 6

pentoxifylline tab er 400 mg............................................49perindopril erbumine tab 2 mg....................................... 19perindopril erbumine tab 4 mg (Aceon).........................19perindopril erbumine tab 8 mg (Aceon).........................19permethrin cream 5% (Elimite)........................................54perphenazine tab 2 mg.................................................... 35perphenazine tab 4 mg.................................................... 35perphenazine tab 8 mg.................................................... 35perphenazine tab 16 mg.................................................. 35phenelzine sulfate tab 15 mg (Nardil)............................ 34phenobarbital elixir 20 mg/5ml........................................36phenobarbital tab 15 mg..................................................36phenobarbital tab 16.2 mg...............................................36phenobarbital tab 30 mg..................................................36phenobarbital tab 32.4 mg...............................................36phenobarbital tab 60 mg..................................................36phenobarbital tab 64.8 mg...............................................36phenobarbital tab 97.2 mg...............................................36phenobarbital tab 100 mg................................................36phenoxybenzamine hcl cap 10 mg (Dibenzyline)......... 25phenytoin chew tab 50 mg (Dilantin infatabs)...............45phenytoin sodium extended cap 100 mg (Dilantin)...... 45phenytoin sodium extended cap 200 mg(Phenytek).........................................................................46

phenytoin sodium extended cap 300 mg(Phenytek).........................................................................46

phenytoin susp 125 mg/5ml (Dilantin)........................... 46phytonadione tab 5 mg (Mephyton)............................... 47PICATO – ingenol mebutate gel 0.015%........................... 54PICATO – ingenol mebutate gel 0.05%............................. 54pilocarpine hcl ophth soln 1% (Isopto carpine)............ 50pilocarpine hcl ophth soln 2% (Isopto carpine)............ 50

2020


pilocarpine hcl ophth soln 4% (Isopto carpine)............ 50pilocarpine hcl tab 5 mg (Salagen).................................51pilocarpine hcl tab 7.5 mg (Salagen)..............................51pimecrolimus cream 1% (Elidel)..................................... 54PIMOZIDE – pimozide tab 1 mg........................................ 40PIMOZIDE – pimozide tab 2 mg........................................ 40pindolol tab 5 mg..............................................................20pindolol tab 10 mg............................................................20pioglitazone hcl-metformin hcl tab 15-500 mg(Actoplus met)................................................................. 15

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

pioglitazone hcl tab 15 mg (base equiv) (Actos)...........15pioglitazone hcl tab 30 mg (base equiv) (Actos)...........15pioglitazone hcl tab 45 mg (base equiv) (Actos)...........15PIQRAY 250MG DAILY DOSE – alpelisib tab pack 250 mgdaily dose (200 mg & 50 mg tabs)..................................... 9

PIQRAY 300MG DAILY DOSE – alpelisib tab pack 300 mgdaily dose (2x150 mg tab).................................................. 9

PIQRAY 200MG DAILY DOSE – alpelisib tab therapy pack200 mg daily dose...............................................................9

piroxicam cap 10 mg (Feldene).......................................43piroxicam cap 20 mg (Feldene).......................................43PLEGRIDY – peginterferon beta-1a soln pen-injector 125mcg/0.5ml...........................................................................38

PLEGRIDY – peginterferon beta-1a soln prefilled syringe125 mcg/0.5ml...................................................................38

PLEGRIDY STARTER PACK – peginterferon beta-1a solnpen-inj 63 & 94 mcg/0.5ml pack.......................................38

PLEGRIDY STARTER PACK – peginterferon beta-1a solnpref syr 63 & 94 mcg/0.5ml pack..................................... 38

podofilox soln 0.5% (Condylox)......................................54polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% (Polytrim)...........................................................49

POMALYST – pomalidomide cap 1 mg............................... 9POMALYST – pomalidomide cap 2 mg............................... 9POMALYST – pomalidomide cap 3 mg............................... 9POMALYST – pomalidomide cap 4 mg............................... 9posaconazole tab delayed release 100 mg (Noxafil)...... 3potassium chloride cap er 8 meq (Micro-k)...................47potassium chloride cap er 10 meq (Micro-k).................47POTASSIUM CHLORIDE ER – potassium chloride tab er8 meq (600 mg)................................................................ 47

potassium chloride microencapsulated crys er tab 10meq....................................................................................47

potassium chloride microencapsulated crys er tab 20meq....................................................................................48

potassium chloride oral soln 10% (20 meq/15ml).........48potassium chloride oral soln 20% (40 meq/15ml).........48potassium chloride powder packet 20 meq.................. 48potassium chloride tab er 10 meq (K-tab)..................... 48potassium chloride tab er 8 meq (600 mg)....................48potassium citrate tab er 5 meq (540 mg) (Urocit-k5)........................................................................................ 31

potassium citrate tab er 10 meq (1080 mg) (Urocit-k10)...................................................................................... 31

potassium citrate tab er 15 meq (1620 mg) (Urocit-k15)...................................................................................... 31

pot phos monobasic w/sod phos di & monobas tab155-852-130mg (K-phos neutral)................................... 47

pramipexole dihydrochloride tab 0.125 mg(Mirapex)........................................................................... 46

pramipexole dihydrochloride tab 0.25 mg(Mirapex)........................................................................... 46

pramipexole dihydrochloride tab 0.5 mg (Mirapex)......46pramipexole dihydrochloride tab 0.75 mg(Mirapex)........................................................................... 46

pramipexole dihydrochloride tab 1 mg (Mirapex).........46pramipexole dihydrochloride tab 1.5 mg (Mirapex)......46prasugrel hcl tab 5 mg (base equiv) (Effient)................49prasugrel hcl tab 10 mg (base equiv) (Effient)..............49pravastatin sodium tab 10 mg........................................ 23pravastatin sodium tab 20 mg (Pravachol)....................23pravastatin sodium tab 40 mg (Pravachol)....................23pravastatin sodium tab 80 mg (Pravachol)....................23praziquantel tab 600 mg (Biltricide)................................. 6prazosin hcl cap 1 mg (Minipress)................................. 25prazosin hcl cap 2 mg (Minipress)................................. 26prazosin hcl cap 5 mg (Minipress)................................. 26PREDNISOLONE ACETATE – prednisolone acetate ophthsusp 1%.............................................................................50

PREDNISOLONE – prednisolone syrup 15 mg/5ml (uspsolution equivalent)........................................................... 11

PREDNISOLONE SODIUM PHOSP – prednisolonesodium phosphate ophth soln 1%.................................... 50

prednisolone sod phosphate oral soln 15 mg/5ml(base equiv)......................................................................11

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

PREDNISONE – prednisone oral soln 5 mg/5ml...............11prednisone tab 1 mg........................................................ 11prednisone tab 2.5 mg..................................................... 11prednisone tab 5 mg........................................................ 11prednisone tab 10 mg...................................................... 11prednisone tab 20 mg...................................................... 11prednisone tab 50 mg...................................................... 11prednisone tab therapy pack 5 mg (21)......................... 11prednisone tab therapy pack 5 mg (48)......................... 11prednisone tab therapy pack 10 mg (21)....................... 11prednisone tab therapy pack 10 mg (48)....................... 11PREFEST – estradiol tab 1 mg(15)/estrad-norgestimatetab 1-0.09mg(15)...............................................................12

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.............12PREMARIN – estrogens, conjugated vaginal cream 0.625mg/gm................................................................................ 31

PREMPHASE – conj est 0.625(14)/conj est-medroxyproac tab 0.625-5mg(14)........................................................12

2020


PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.3-1.5 mg......................................................12

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.45-1.5 mg....................................................12

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.625-2.5 mg..................................................12

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.625-5 mg.....................................................12

PRENATABS RX – prenatal vit w/ iron carbonyl-fa tab 29-1mg...................................................................................... 47

PRENATAL PLUS IRON – prenatal vit w/ iron carbonyl-fatab 29-1 mg....................................................................... 47

PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab29-1 mg..............................................................................47

PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab29-1 mg..............................................................................47

PRENATAL-U – prenatal w/o a vit w/ fe fumarate-fa cap106.5-1 mg........................................................................ 47

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

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




PRIFTIN – rifapentine tab 150 mg....................................... 3primaquine phosphate tab 26.3 mg (15 mg base)(Primaquine phosphate)................................................... 6

primidone tab 50 mg (Mysoline)..................................... 46primidone tab 250 mg (Mysoline)................................... 46PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act(90mcg base equiv).......................................................... 28

PROAIR RESPICLICK – albuterol sulfate aer pow ba 108mcg/act (90 mcg base equiv)........................................... 28

probenecid tab 500 mg.................................................... 44prochlorperazine maleate tab 5 mg (base equivalent)(Compazine)..................................................................... 35

prochlorperazine maleate tab 10 mg (base equivalent)(Compazine)..................................................................... 35

prochlorperazine suppos 25 mg.....................................35progesterone micronized cap 100 mg(Prometrium).................................................................... 12

progesterone micronized cap 200 mg(Prometrium).................................................................... 12

PROGLYCEM – diazoxide susp 50 mg/ml.........................15PROLIA – denosumab inj soln prefilled syringe 60 mg/ml........................................................................................18

PROMACTA – eltrombopag olamine powder pack for susp12.5 mg (base eq).............................................................49

PROMACTA – eltrombopag olamine powder pack for susp25 mg (base equiv)...........................................................49

PROMACTA – eltrombopag olamine tab 12.5 mg (baseequiv)................................................................................. 49

PROMACTA – eltrombopag olamine tab 25 mg (baseequiv)................................................................................. 49



promethazine hcl suppos 12.5 mg................................. 26promethazine hcl suppos 25 mg.................................... 26promethazine hcl syrup 6.25 mg/5ml............................. 26promethazine hcl tab 12.5 mg.........................................26promethazine hcl tab 25 mg............................................26promethazine hcl tab 50 mg............................................26promethazine w/ codeine syrup 6.25-10 mg/5ml...........26PROMETHEGAN – promethazine hcl suppos 50 mg........26propafenone hcl cap er 12hr 225 mg (Rythmol sr)....... 25propafenone hcl cap er 12hr 325 mg (Rythmol sr)....... 25propafenone hcl cap er 12hr 425 mg (Rythmol sr)....... 25propafenone hcl tab 300 mg........................................... 25propafenone hcl tab 150 mg (Rythmol)......................... 25propafenone hcl tab 225 mg (Rythmol)......................... 25PROPRANOLOL/HYDROCHLOROTH – propranolol &hydrochlorothiazide tab 40-25 mg.................................... 21

PROPRANOLOL/HYDROCHLOROTH – propranolol &hydrochlorothiazide tab 80-25 mg.................................... 21

propranolol hcl cap er 24hr 60 mg (Inderal la)..............20propranolol hcl cap er 24hr 80 mg (Inderal la)..............21propranolol hcl cap er 24hr 120 mg (Inderal la)............21propranolol hcl cap er 24hr 160 mg (Inderal la)............21PROPRANOLOL HCL – propranolol hcl oral soln 20mg/5ml............................................................................... 20

PROPRANOLOL HCL – propranolol hcl oral soln 40mg/5ml............................................................................... 20

propranolol hcl tab 10 mg............................................... 21propranolol hcl tab 20 mg............................................... 21propranolol hcl tab 40 mg............................................... 21propranolol hcl tab 60 mg............................................... 21propranolol hcl tab 80 mg............................................... 21propylthiouracil tab 50 mg.............................................. 17PULMOZYME – dornase alfa inhal soln 1 mg/ml.............. 29PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml)........................................................................................ 9

pyrazinamide tab 500 mg...................................................3pyridostigmine bromide oral soln 60 mg/5ml(Mestinon).........................................................................47

pyridostigmine bromide tab er 180 mg (Mestinontimespan).......................................................................... 47

pyridostigmine bromide tab 60 mg (Mestinon)............. 47pyrimethamine tab 25 mg (Daraprim)...............................6Q

quetiapine fumarate tab er 24hr 50 mg (Seroquelxr).......................................................................................35


2020





quetiapine fumarate tab 25 mg (Seroquel).................... 35quetiapine fumarate tab 50 mg (Seroquel).................... 35quetiapine fumarate tab 100 mg (Seroquel).................. 35quetiapine fumarate tab 200 mg (Seroquel).................. 35quetiapine fumarate tab 300 mg (Seroquel).................. 35quetiapine fumarate tab 400 mg (Seroquel).................. 35quinapril hcl tab 5 mg (Accupril).................................... 19quinapril hcl tab 10 mg (Accupril).................................. 19quinapril hcl tab 20 mg (Accupril).................................. 19quinapril hcl tab 40 mg (Accupril).................................. 19quinapril-hydrochlorothiazide tab 10-12.5 mg(Accuretic)........................................................................ 19

quinapril-hydrochlorothiazide tab 20-12.5 mg(Accuretic)........................................................................ 19

quinapril-hydrochlorothiazide tab 20-25 mg(Accuretic)........................................................................ 19

quinidine gluconate tab er 324 mg.................................25QUINIDINE SULFATE – quinidine sulfate tab 200 mg.......25QUINIDINE SULFATE – quinidine sulfate tab 300 mg.......25QVAR REDIHALER – beclomethasone diprop hfa breathact inh aer 40 mcg/act...................................................... 28

QVAR REDIHALER – beclomethasone diprop hfa breathact inh aer 80 mcg/act...................................................... 28

Rrabeprazole sodium ec tab 20 mg (Aciphex).................29RAGWITEK – short ragweed pollen allergen extract sl tab12 amb a 1-u.......................................................................6

raloxifene hcl tab 60 mg (Evista)....................................18ramipril cap 1.25 mg (Altace).......................................... 19ramipril cap 2.5 mg (Altace)............................................ 19ramipril cap 5 mg (Altace)............................................... 19ramipril cap 10 mg (Altace)............................................. 19REBIF – interferon beta-1a soln pref syr 22 mcg/0.5ml(12mu/ml)...........................................................................38

REBIF – interferon beta-1a soln pref syr 44 mcg/0.5ml(24mu/ml)...........................................................................38

REBIF REBIDOSE – interferon beta-1a soln auto-inj 22mcg/0.5ml (12mu/ml).........................................................38

REBIF REBIDOSE – interferon beta-1a soln auto-inj 44mcg/0.5ml (24mu/ml).........................................................38

REBIF REBIDOSE TITRATION – interferon beta-1a auto-inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................ 38

REBIF TITRATION PACK – interferon beta-1a pref syr6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml................................. 39

RELENZA DISKHALER – zanamivir aero powder breathactivated 5 mg/blister.......................................................... 5

RELISTOR – methylnaltrexone bromide inj 8 mg/0.4ml (20mg/ml)................................................................................ 30

RELISTOR – methylnaltrexone bromide inj 12 mg/0.6ml(20 mg/ml)..........................................................................30

REPATHA – evolocumab subcutaneous soln prefilledsyringe 140 mg/ml.............................................................23

REPATHA PUSHTRONEX SYSTEM – evolocumabsubcutaneous soln cartridge/infusor 420 mg/3.5ml..........24

REPATHA SURECLICK – evolocumab subcutaneous solnauto-injector 140 mg/ml.................................................... 24

REVLIMID – lenalidomide cap 5 mg..................................55REVLIMID – lenalidomide cap 10 mg................................55REVLIMID – lenalidomide cap 15 mg................................55REVLIMID – lenalidomide cap 20 mg................................55REVLIMID – lenalidomide cap 25 mg................................56REVLIMID – lenalidomide caps 2.5 mg............................. 55ribavirin cap 200 mg (Rebetol)..........................................3ribavirin tab 200 mg (Copegus)........................................ 4RIDAURA – auranofin cap 3 mg........................................43rifabutin cap 150 mg (Mycobutin).....................................3rifampin cap 150 mg (Rifadin)...........................................3rifampin cap 300 mg (Rifadin)...........................................3riluzole tab 50 mg (Rilutek)............................................. 47RINVOQ – upadacitinib tab er 24hr 15 mg........................43RISPERIDONE ODT – risperidone orally disintegrating tab0.25 mg..............................................................................35

risperidone orally disintegrating tab 0.5 mg (Risperdalm-tab)................................................................................ 35

risperidone orally disintegrating tab 1 mg (Risperdalm-tab)................................................................................ 35




risperidone soln 1 mg/ml (Risperdal).............................35risperidone tab 0.25 mg (Risperdal)...............................35risperidone tab 0.5 mg (Risperdal).................................35risperidone tab 1 mg (Risperdal)....................................35risperidone tab 2 mg (Risperdal)....................................35risperidone tab 3 mg (Risperdal)....................................35risperidone tab 4 mg (Risperdal)....................................35ritonavir tab 100 mg (Norvir).............................................5rivastigmine tartrate cap 1.5 mg (base equivalent)...... 40rivastigmine tartrate cap 3 mg (base equivalent)......... 40rivastigmine tartrate cap 4.5 mg (base equivalent)...... 40rivastigmine tartrate cap 6 mg (base equivalent)......... 40rizatriptan benzoate oral disintegrating tab 5 mg (baseeq) (Maxalt-mlt)................................................................44

rizatriptan benzoate oral disintegrating tab 10 mg(base eq) (Maxalt-mlt).....................................................44

rizatriptan benzoate tab 5 mg (base equivalent)(Maxalt)..............................................................................44

rizatriptan benzoate tab 10 mg (base equivalent)(Maxalt)..............................................................................44

ropinirole hydrochloride tab 0.25 mg (Requip)............. 46ropinirole hydrochloride tab 0.5 mg (Requip)............... 47

2020


ropinirole hydrochloride tab 1 mg (Requip).................. 47ropinirole hydrochloride tab 2 mg (Requip).................. 47ropinirole hydrochloride tab 3 mg (Requip).................. 47ropinirole hydrochloride tab 4 mg (Requip).................. 47ropinirole hydrochloride tab 5 mg (Requip).................. 47rosuvastatin calcium tab 5 mg (Crestor)....................... 24rosuvastatin calcium tab 10 mg (Crestor)..................... 24rosuvastatin calcium tab 20 mg (Crestor)..................... 24rosuvastatin calcium tab 40 mg (Crestor)..................... 24ROZLYTREK – entrectinib cap 100 mg............................... 9ROZLYTREK – entrectinib cap 200 mg............................... 9RUBRACA – rucaparib camsylate tab 200 mg (baseequivalent)............................................................................9

RUBRACA – rucaparib camsylate tab 250 mg (baseequivalent)............................................................................9

RUBRACA – rucaparib camsylate tab 300 mg (baseequivalent)............................................................................9

RYBELSUS – semaglutide tab 3 mg................................. 15RYBELSUS – semaglutide tab 7 mg................................. 15RYBELSUS – semaglutide tab 14 mg............................... 15RYDAPT – midostaurin cap 25 mg...................................... 9

Sselegiline hcl cap 5 mg (Eldepryl).................................. 47SELEGILINE HCL – selegiline hcl tab 5 mg......................47selenium sulfide lotion 2.5%........................................... 54SEREVENT DISKUS – salmeterol xinafoate aer pow ba50 mcg/dose (base equiv)................................................ 28

sertraline hcl oral concentrate for solution 20 mg/ml(Zoloft)...............................................................................34

sertraline hcl tab 25 mg (Zoloft)..................................... 34sertraline hcl tab 50 mg (Zoloft)..................................... 34sertraline hcl tab 100 mg (Zoloft)................................... 34sevelamer carbonate packet 0.8 gm (Renvela)............. 31sevelamer carbonate packet 2.4 gm (Renvela)............. 31sevelamer carbonate tab 800 mg (Renvela).................. 31sildenafil citrate tab 20 mg (Revatio)............................. 26silver sulfadiazine cream 1% (Silvadene)...................... 52SIMBRINZA – brinzolamide-brimonidine tartrate ophthsusp 1-0.2%.......................................................................50

SIMPONI – golimumab subcutaneous soln auto-injector100 mg/ml..........................................................................43

SIMPONI – golimumab subcutaneous soln prefilledsyringe 100 mg/ml.............................................................43

simvastatin tab 5 mg (Zocor).......................................... 24simvastatin tab 10 mg (Zocor)........................................ 24simvastatin tab 20 mg (Zocor)........................................ 24simvastatin tab 40 mg (Zocor)........................................ 24simvastatin tab 80 mg (Zocor)........................................ 24sirolimus oral soln 1 mg/ml (Rapamune).......................56sirolimus tab 0.5 mg (Rapamune)...................................56sirolimus tab 1 mg (Rapamune)......................................56sirolimus tab 2 mg (Rapamune)......................................56SIVEXTRO – tedizolid phosphate tab 200 mg.....................6SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5mg total).............................................................................13

SKYRIZI – risankizumab-rzaa sol prefilled syringe 2 x 75mg/0.83ml kit..................................................................... 54

sodium chloride soln nebu 3%....................................... 26sodium chloride soln nebu 7% (Hyper-sal)................... 26sodium citrate & citric acid soln 500-334 mg/5ml(Shohls solution modi)................................................... 31

sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)(Luride)..............................................................................48

sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)(Luride)..............................................................................48

sodium fluoride chew tab 1 mg f (from 2.2 mg naf)(Luride)..............................................................................48

sodium fluoride cream 1.1% (Prevident 5000 plus)...... 51sodium fluoride gel 1.1% (0.5% f) (Previdentfluoride).............................................................................51

SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from1.1 mg naf)........................................................................ 48

SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from2.2 mg naf)........................................................................ 48

sodium fluoride soln 0.125 mg/drop f (0.275 mg/dropnaf).....................................................................................48

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)(Luride)..............................................................................48

sodium polystyrene sulfonate oral susp 15 gm/60ml(Sps).................................................................................. 56

sodium polystyrene sulfonate powder(Kayexalate)......................................................................56

sodium polystyrene sulfonate rectal susp 30gm/120ml...........................................................................56

SOFOSBUVIR/VELPATASVIR – sofosbuvir-velpatasvir tab400-100 mg......................................................................... 4

solifenacin succinate tab 5 mg (Vesicare).....................31solifenacin succinate tab 10 mg (Vesicare)...................31SOLTAMOX – tamoxifen citrate oral soln 10 mg/5ml (baseequivalent)............................................................................9

SOOLANTRA – ivermectin cream 1%............................... 52sotalol hcl (afib/afl) tab 80 mg (Betapace af).................25sotalol hcl (afib/afl) tab 120 mg (Betapace af)...............25sotalol hcl (afib/afl) tab 160 mg (Betapace af)...............25sotalol hcl tab 240 mg......................................................25sotalol hcl tab 80 mg (Betapace)....................................25sotalol hcl tab 120 mg (Betapace)..................................25sotalol hcl tab 160 mg (Betapace)..................................25SOVALDI – sofosbuvir tab 200 mg...................................... 4SOVALDI – sofosbuvir tab 400 mg...................................... 4SPIRIVA HANDIHALER – tiotropium bromidemonohydrate inhal cap 18 mcg (base equiv)................... 28

SPIRIVA RESPIMAT – tiotropium bromide monohydrateinhal aerosol 1.25 mcg/act................................................28

SPIRIVA RESPIMAT – tiotropium bromide monohydrateinhal aerosol 2.5 mcg/act..................................................28

spironolactone & hydrochlorothiazide tab 25-25 mg(Aldactazide).....................................................................24

spironolactone tab 25 mg (Aldactone)...........................24spironolactone tab 50 mg (Aldactone)...........................24spironolactone tab 100 mg (Aldactone).........................24

2020


SPRYCEL – dasatinib tab 20 mg.........................................9SPRYCEL – dasatinib tab 50 mg.........................................9SPRYCEL – dasatinib tab 70 mg.........................................9SPRYCEL – dasatinib tab 80 mg.........................................9SPRYCEL – dasatinib tab 100 mg.......................................9SPRYCEL – dasatinib tab 140 mg.......................................9stavudine 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.........................54STELARA – ustekinumab soln prefilled syringe 45mg/0.5ml............................................................................ 54

STELARA – ustekinumab soln prefilled syringe 90 mg/ml........................................................................................54

STIMATE – desmopressin acetate nasal soln 1.5 mg/ml........................................................................................18

STIOLTO RESPIMAT – tiotropium br-olodaterol inhal aerosoln 2.5-2.5 mcg/act..........................................................28

STIVARGA – regorafenib tab 40 mg....................................9STRENSIQ – asfotase alfa subcutaneous inj 18mg/0.45ml.......................................................................... 18

STRENSIQ – asfotase alfa subcutaneous inj 28mg/0.7ml............................................................................ 18

STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml........................................................................................18

STRENSIQ – asfotase alfa subcutaneous inj 80mg/0.8ml............................................................................ 18

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

sucralfate tab 1 gm (Carafate).........................................30SULFACETAMIDE SODIUM/PRED – sulfacetamidesodium-prednisolone ophth soln 10-0.23(0.25)%............ 50

sulfacetamide sodium lotion 10% (acne) (Klaron)........52sulfacetamide sodium ophth soln 10% (Bleph-10)....... 49SULFADIAZINE – sulfadiazine tab 500 mg......................... 6sulfamethoxazole-trimethoprim susp 200-40mg/5ml.................................................................................6

sulfamethoxazole-trimethoprim tab 400-80 mg(Bactrim)............................................................................. 6

sulfamethoxazole-trimethoprim tab 800-160 mg(Bactrim ds)........................................................................6

sulfasalazine tab delayed release 500 mg (Azulfidineen-tabs)............................................................................. 31

sulfasalazine tab 500 mg (Azulfidine)............................ 31sulindac tab 150 mg......................................................... 43sulindac tab 200 mg......................................................... 43sumatriptan nasal spray 5 mg/act (Imitrex)...................44sumatriptan nasal spray 20 mg/act (Imitrex).................44sumatriptan succinate inj 6 mg/0.5ml (Imitrex).............44sumatriptan succinate solution auto-injector 4mg/0.5ml (Imitrex statdose sys)....................................44

sumatriptan succinate solution auto-injector 6mg/0.5ml (Imitrex statdose sys)....................................44

sumatriptan succinate solution cartridge 4 mg/0.5ml(Imitrex statdose ref)...................................................... 44

sumatriptan succinate solution cartridge 6 mg/0.5ml(Imitrex statdose ref)...................................................... 44

SUMATRIPTAN SUCCINATE – sumatriptan succinatesolution prefilled syringe 6 mg/0.5ml................................44

sumatriptan succinate tab 25 mg (Imitrex)....................44sumatriptan succinate tab 50 mg (Imitrex)....................44sumatriptan succinate tab 100 mg (Imitrex)..................44SUNOSI – solriamfetol hcl tab 75 mg (base equiv)........... 37SUNOSI – solriamfetol hcl tab 150 mg (base equiv)......... 37SUPRAX – cefixime chew tab 100 mg................................ 2SUPRAX – cefixime chew tab 200 mg................................ 2SUPRAX – cefixime for susp 500 mg/5ml........................... 2SUTENT – sunitinib malate cap 12.5 mg (baseequivalent)............................................................................9

SUTENT – sunitinib malate cap 25 mg (baseequivalent)............................................................................9

SUTENT – sunitinib malate cap 37.5 mg (baseequivalent)............................................................................9

SUTENT – sunitinib malate cap 50 mg (baseequivalent)............................................................................9

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..................................................... 28

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 160-4.5 mcg/act................................................... 28

SYMDEKO – tezacaftor-ivacaftor 50-75 mg & ivacaftor 75mg tab tbpk....................................................................... 29

SYMDEKO – tezacaftor-ivacaftor 100-150 mg & ivacaftor150 mg tab tbpk................................................................ 29

SYMFI – efavirenz-lamivudine-tenofovir df tab600-300-300 mg.................................................................. 5

SYMFI LO – efavirenz-lamivudine-tenofovir df tab400-300-300 mg.................................................................. 5

SYMJEPI – epinephrine soln prefilled syringe 0.15mg/0.3ml (1:2000)............................................................. 26

SYMJEPI – epinephrine solution prefilled syringe 0.3mg/0.3ml (1:1000)............................................................. 26

SYMLINPEN 120 – pramlintide acetate pen-inj 2700mcg/2.7ml (1000 mcg/ml)................................................. 15

SYMLINPEN 60 – pramlintide acetate pen-inj 1500mcg/1.5ml (1000 mcg/ml)................................................. 15

SYNERA – lidocaine-tetracaine topical patch 70-70mg...................................................................................... 54

SYNJARDY – empagliflozin-metformin hcl tab 5-500mg...................................................................................... 15

SYNJARDY – empagliflozin-metformin hcl tab 5-1000mg...................................................................................... 15

SYNJARDY – empagliflozin-metformin hcl tab 12.5-500mg...................................................................................... 15

SYNJARDY – empagliflozin-metformin hcl tab 12.5-1000mg...................................................................................... 15

SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr5-1000 mg......................................................................... 15

2020


SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr10-1000 mg....................................................................... 15

SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr12.5-1000 mg.................................................................... 15

SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr25-1000 mg....................................................................... 15

TTABLOID – thioguanine tab 40 mg.................................... 10tacrolimus cap 0.5 mg (Prograf)..................................... 56tacrolimus cap 1 mg (Prograf)........................................ 56tacrolimus cap 5 mg (Prograf)........................................ 56tacrolimus oint 0.03% (Protopic).................................... 54tacrolimus oint 0.1% (Protopic)...................................... 54tadalafil tab 20 mg (pah) (Adcirca)................................. 26TAFINLAR – 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).............................. 31TASIGNA – 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)....................................52TAZORAC – tazarotene cream 0.05%...............................52TAZORAC – tazarotene gel 0.05%.................................... 52TAZORAC – tazarotene gel 0.1%...................................... 52TECFIDERA – dimethyl fumarate capsule delayed release120 mg...............................................................................39

TECFIDERA – dimethyl fumarate capsule delayed release240 mg...............................................................................39

TECFIDERA STARTER PACK – dimethyl fumaratecapsule dr starter pack 120 mg & 240 mg....................... 39

telmisartan-hydrochlorothiazide tab 40-12.5 mg(Micardis hct)................................................................... 20

telmisartan-hydrochlorothiazide tab 80-12.5 mg(Micardis hct)................................................................... 20

telmisartan-hydrochlorothiazide tab 80-25 mg(Micardis hct)................................................................... 20

telmisartan tab 20 mg (Micardis).................................... 19telmisartan tab 40 mg (Micardis).................................... 19telmisartan tab 80 mg (Micardis).................................... 20temazepam cap 7.5 mg (Restoril)................................... 36temazepam cap 15 mg (Restoril).................................... 36temazepam cap 22.5 mg (Restoril)................................. 36temazepam cap 30 mg (Restoril).................................... 36TEMIXYS – lamivudine-tenofovir disoproxil fumarate tab300-300 mg......................................................................... 5

temozolomide cap 5 mg (Temodar)................................ 10temozolomide cap 20 mg (Temodar)..............................10

temozolomide cap 100 mg (Temodar)............................10temozolomide cap 140 mg (Temodar)............................10temozolomide cap 180 mg (Temodar)............................10temozolomide cap 250 mg (Temodar)............................10tenofovir disoproxil fumarate tab 300 mg (Viread)......... 5terazosin hcl cap 1 mg (base equivalent)......................26terazosin hcl cap 2 mg (base equivalent)......................26terazosin hcl cap 5 mg (base equivalent)......................26terazosin hcl cap 10 mg (base equivalent)....................26terbinafine hcl tab 250 mg (Lamisil).................................3terbutaline sulfate tab 2.5 mg......................................... 28terbutaline sulfate tab 5 mg............................................ 28TERCONAZOLE – terconazole vaginal cream 0.8%.........31terconazole vaginal cream 0.4% (Terazol 7).................. 31terconazole vaginal suppos 80 mg.................................31testosterone td gel 12.5 mg/act (1%) (Androgelpump)................................................................................ 11

testosterone td gel 20.25 mg/act (1.62%) (Androgelpump)................................................................................ 11

testosterone td gel 25 mg/2.5gm (1%) (Androgel)........ 11testosterone td gel 50 mg/5gm (1%) (Androgel)........... 11testosterone td gel 20.25 mg/1.25gm (1.62%)(Androgel).........................................................................11

testosterone td gel 40.5 mg/2.5gm (1.62%)(Androgel).........................................................................11

testosterone td soln 30 mg/act (Axiron)........................ 11TEST STRIPS – ASCENSIA CONTOUR, CONTOURNEXT..................................................................................55

tetrabenazine tab 12.5 mg (Xenazine)............................ 40tetrabenazine tab 25 mg (Xenazine)............................... 40tetracycline hcl cap 250 mg (Tetracycline hcl)................2tetracycline hcl cap 500 mg (Tetracycline hcl)................2THALOMID – thalidomide cap 50 mg................................ 56THALOMID – thalidomide cap 100 mg.............................. 56THALOMID – thalidomide cap 150 mg.............................. 56THALOMID – thalidomide cap 200 mg.............................. 56THEOPHYLLINE ER – theophylline tab er 12hr 300mg...................................................................................... 28

THEOPHYLLINE ER – theophylline tab er 12hr 450mg...................................................................................... 28

theophylline tab er 24hr 400 mg.....................................28theophylline tab er 24hr 600 mg.....................................28thiothixene cap 1 mg........................................................35thiothixene cap 2 mg........................................................35thiothixene cap 5 mg........................................................35thiothixene cap 10 mg......................................................35TIMOLOL MALEATE OPHTHALMI – timolol maleate ophthgel forming soln 0.25%..................................................... 50

TIMOLOL MALEATE OPHTHALMI – timolol maleate ophthgel forming soln 0.5%....................................................... 50

timolol maleate ophth soln 0.25% (Timoptic)................50timolol maleate ophth soln 0.5% (Timoptic)..................50timolol maleate tab 5 mg................................................. 21timolol maleate tab 10 mg............................................... 21timolol maleate tab 20 mg............................................... 21TIVICAY – dolutegravir sodium tab 10 mg (base equiv)...... 5

2020


TIVICAY – dolutegravir sodium tab 25 mg (base equiv)...... 5TIVICAY – dolutegravir sodium tab 50 mg (base equiv)...... 5TOBRADEX – tobramycin-dexamethasone ophth oint0.3-0.1%.............................................................................50

tobramycin-dexamethasone ophth susp 0.3-0.1%(Tobradex).........................................................................50

tobramycin nebu soln 300 mg/5ml (Tobi)........................ 3tobramycin ophth soln 0.3% (Tobrex)............................ 50tolterodine tartrate cap er 24hr 2 mg (Detrol la)............31tolterodine tartrate cap er 24hr 4 mg (Detrol la)............31tolterodine tartrate tab 1 mg (Detrol)............................. 31tolterodine tartrate tab 2 mg (Detrol)............................. 31topiramate sprinkle cap 15 mg (Topamax sprinkle)..... 46topiramate sprinkle cap 25 mg (Topamax sprinkle)..... 46topiramate tab 25 mg (Topamax).................................... 46topiramate tab 50 mg (Topamax).................................... 46topiramate tab 100 mg (Topamax).................................. 46topiramate tab 200 mg (Topamax).................................. 46toremifene citrate tab 60 mg (base equivalent)(Fareston)......................................................................... 10

torsemide tab 5 mg (Demadex).......................................24torsemide tab 10 mg (Demadex).....................................24torsemide tab 20 mg (Demadex).....................................24torsemide tab 100 mg (Demadex)...................................24TOUJEO MAX SOLOSTAR – insulin glargine soln pen-injector 300 unit/ml (2 unit dial)........................................ 16

TOUJEO SOLOSTAR – insulin glargine soln pen-injector300 unit/ml (1 unit dial)..................................................... 16

TRACLEER – bosentan tab for oral susp 32 mg............... 26tramadol-acetaminophen tab 37.5-325 mg(Ultracet)........................................................................... 42

tramadol hcl tab er 24hr 100 mg.....................................42tramadol hcl tab er 24hr 200 mg.....................................42tramadol hcl tab er 24hr 300 mg.....................................42tramadol hcl tab 50 mg (Ultram).....................................42trandolapril tab 1 mg (Mavik).......................................... 19trandolapril tab 2 mg (Mavik).......................................... 19trandolapril tab 4 mg (Mavik).......................................... 19tranylcypromine sulfate tab 10 mg (Parnate)................34travoprost ophth soln 0.004% (benzalkonium free)(bak free) (Travatan z).....................................................51

trazodone hcl tab 50 mg.................................................. 34trazodone hcl tab 100 mg................................................ 34trazodone hcl tab 150 mg................................................ 34trazodone hcl tab 300 mg................................................ 34TRELEGY ELLIPTA – fluticasone-umeclidinium-vilanterolaepb 100-62.5-25 mcg/inh................................................28

TREMFYA – guselkumab soln pen-injector 100 mg/ml..... 54TREMFYA – guselkumab soln prefilled syringe 100 mg/ml........................................................................................54

TRESIBA FLEXTOUCH – insulin degludec soln pen-injector 100 unit/ml............................................................16

TRESIBA FLEXTOUCH – insulin degludec soln pen-injector 200 unit/ml............................................................16

TRESIBA – insulin degludec inj 100 unit/ml...................... 16tretinoin cap 10 mg...........................................................10

tretinoin cream 0.025% (Retin-a).....................................52tretinoin cream 0.05% (Retin-a).......................................52tretinoin cream 0.1% (Retin-a).........................................52tretinoin gel 0.025%, NF = Avita gel (Retin-a)................52tretinoin gel 0.01% (Retin-a)............................................ 52tretinoin microsphere gel 0.04% (Retin-a micro).......... 52tretinoin microsphere gel 0.1% (Retin-a micro)............ 52triamcinolone acetonide cream 0.025%......................... 53triamcinolone acetonide cream 0.1%............................. 53triamcinolone acetonide cream 0.5%............................. 53triamcinolone acetonide dental paste 0.1%.................. 51triamcinolone acetonide lotion 0.025%..........................53triamcinolone acetonide lotion 0.1%..............................53triamcinolone acetonide oint 0.025%............................. 53triamcinolone acetonide oint 0.1%................................. 53triamcinolone acetonide oint 0.5%................................. 53triamterene & hydrochlorothiazide cap 37.5-25 mg(Dyazide)........................................................................... 24

triamterene & hydrochlorothiazide tab 37.5-25 mg(Maxzide-25)..................................................................... 24

triamterene & hydrochlorothiazide tab 75-50 mg(Maxzide)...........................................................................24

trifluoperazine hcl tab 1 mg (base equivalent)..............35trifluoperazine hcl tab 2 mg (base equivalent)..............36trifluoperazine hcl tab 5 mg (base equivalent)..............36trifluoperazine hcl tab 10 mg (base equivalent)............36TRIFLURIDINE – trifluridine ophth soln 1%.......................50trihexyphenidyl hcl oral soln 0.4 mg/ml.........................47trihexyphenidyl hcl tab 2 mg...........................................47trihexyphenidyl hcl tab 5 mg...........................................47TRIKAFTA – elexacaf-tezacaf-ivacaf 100-50-75 mg&ivacaftor 150 mg tbpk.....................................................29

trimethobenzamide hcl cap 300 mg (Tigan).................. 30trimethoprim tab 100 mg................................................... 6TRINATE – prenatal vit w/ fe fumarate-fa tab 28-1 mg...... 47TRIUMEQ – abacavir-dolutegravir-lamivudine tab600-50-300 mg.................................................................... 5

TRULICITY – dulaglutide soln pen-injector 0.75mg/0.5ml............................................................................ 15

TRULICITY – dulaglutide soln pen-injector 1.5mg/0.5ml............................................................................ 15

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 100-150 mg................................................................... 5




TYKERB – lapatinib ditosylate tab 250 mg (baseequiv)................................................................................. 10

TYMLOS – abaloparatide subcutaneous soln pen-injector3120 mcg/1.56ml...............................................................18

2020


UUDENYCA – pegfilgrastim-cbqv soln prefilled syringe 6mg/0.6ml............................................................................ 49

UPTRAVI – selexipag tab 200 mcg....................................26UPTRAVI – selexipag tab 400 mcg....................................26UPTRAVI – selexipag tab 600 mcg....................................26UPTRAVI – selexipag tab 800 mcg....................................26UPTRAVI – selexipag tab 1000 mcg..................................26UPTRAVI – selexipag tab 1200 mcg..................................26UPTRAVI – selexipag tab 1400 mcg..................................26UPTRAVI – selexipag tab 1600 mcg..................................26UPTRAVI – selexipag tab therapy pack 200 mcg (140) &800 mcg (60)..................................................................... 26

ursodiol cap 300 mg (Actigall)........................................31ursodiol tab 250 mg (Urso 250)...................................... 31ursodiol tab 500 mg (Urso forte).................................... 31V

valacyclovir hcl tab 1 gm (Valtrex)................................... 4valacyclovir hcl tab 500 mg (Valtrex)............................... 4VALCHLOR – mechlorethamine hcl gel 0.016% (baseequivalent)......................................................................... 54

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)........................................................................46

valproic acid cap 250 mg (Depakene)............................46valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovanhct).....................................................................................20

valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovanhct).....................................................................................20

valsartan-hydrochlorothiazide tab 160-25 mg (Diovanhct).....................................................................................20

valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovanhct).....................................................................................20

valsartan-hydrochlorothiazide tab 320-25 mg (Diovanhct).....................................................................................20

valsartan tab 40 mg (Diovan).......................................... 20valsartan tab 80 mg (Diovan).......................................... 20valsartan tab 160 mg (Diovan)........................................ 20valsartan tab 320 mg (Diovan)........................................ 20vancomycin hcl cap 125 mg (base equivalent)(Vancocin hcl).................................................................... 6

vancomycin hcl cap 250 mg (base equivalent)(Vancocin hcl).................................................................... 6

VASCEPA – icosapent ethyl cap 0.5 gm............................24VASCEPA – icosapent ethyl cap 1 gm...............................24VENCLEXTA STARTING PACK – venetoclax tab therapystarter pack 10 & 50 & 100 mg........................................ 10

VENCLEXTA – venetoclax tab 10 mg................................10VENCLEXTA – venetoclax tab 50 mg................................10VENCLEXTA – venetoclax tab 100 mg..............................10

venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)(Effexor xr)....................................................................... 34

venlafaxine hcl cap er 24hr 75 mg (base equivalent)(Effexor xr)....................................................................... 34

venlafaxine hcl cap er 24hr 150 mg (base equivalent)(Effexor xr)....................................................................... 34

venlafaxine hcl tab 25 mg (base equivalent).................34venlafaxine hcl tab 37.5 mg (base equivalent)..............34venlafaxine hcl tab 50 mg (base equivalent).................34venlafaxine hcl tab 75 mg (base equivalent).................34venlafaxine hcl tab 100 mg (base equivalent)...............34VENTAVIS – iloprost inhalation solution 10 mcg/ml...........26VENTAVIS – iloprost inhalation solution 20 mcg/ml...........26VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act(90mcg base equiv).......................................................... 28

verapamil hcl cap er 24hr 120 mg (Verelan).................. 22verapamil hcl cap er 24hr 180 mg (Verelan).................. 22verapamil hcl cap er 24hr 240 mg (Verelan).................. 22VERAPAMIL HCL ER – verapamil hcl cap er 24hr 100mg...................................................................................... 22

VERAPAMIL HCL ER – verapamil hcl cap er 24hr 300mg...................................................................................... 22

VERAPAMIL HCL SR – verapamil hcl cap er 24hr 360mg...................................................................................... 22

verapamil hcl tab er 120 mg (Calan sr)..........................22verapamil hcl tab er 180 mg (Calan sr)..........................22verapamil hcl tab er 240 mg (Calan sr)..........................22verapamil hcl tab 40 mg.................................................. 22verapamil hcl tab 80 mg (Calan).....................................22verapamil hcl tab 120 mg (Calan)...................................22VERAPAMIL HYDROCHLORIDE E – verapamil hcl cap er24hr 200 mg...................................................................... 22

VERZENIO – abemaciclib tab 50 mg.................................10VERZENIO – abemaciclib tab 100 mg...............................10VERZENIO – abemaciclib tab 150 mg...............................10VERZENIO – abemaciclib tab 200 mg...............................10VIBERZI – eluxadoline tab 75 mg......................................31VIBERZI – eluxadoline tab 100 mg....................................31VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml)...................................................................................... 15

vigabatrin powd pack 500 mg (Sabril)........................... 46vigabatrin tab 500 mg (Sabril).........................................46VINATE DHA RF – prenat w/o a w/fefum-methylfol-omegas cap 27-1.13 mg...................................................47

VINATE II – prenatal vit w/ fe bisglycinate chelate-fa tab29-1 mg..............................................................................47

VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1mg...................................................................................... 47

VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1mg...................................................................................... 47

VIREAD – tenofovir disoproxil fumarate oral powder 40mg/gm.................................................................................. 5

VIREAD – tenofovir disoproxil fumarate tab 150 mg........... 5VIREAD – tenofovir disoproxil fumarate tab 200 mg........... 5VIREAD – tenofovir disoproxil fumarate tab 250 mg........... 5

2020


VITRAKVI – larotrectinib sulfate cap 25 mg (baseequivalent)......................................................................... 10

VITRAKVI – larotrectinib sulfate cap 100 mg (baseequivalent)......................................................................... 10

VITRAKVI – larotrectinib sulfate oral soln 20 mg/ml (baseequivalent)......................................................................... 10

voriconazole 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).......10VYNDAMAX – tafamidis cap 61 mg...................................26VYNDAQEL – tafamidis meglumine (cardiac) cap 20mg...................................................................................... 26

VYVANSE – lisdexamfetamine dimesylate cap 10 mg...... 37VYVANSE – lisdexamfetamine dimesylate cap 20 mg...... 37VYVANSE – lisdexamfetamine dimesylate cap 30 mg...... 37VYVANSE – lisdexamfetamine dimesylate cap 40 mg...... 38VYVANSE – lisdexamfetamine dimesylate cap 50 mg...... 38VYVANSE – lisdexamfetamine dimesylate cap 60 mg...... 38VYVANSE – lisdexamfetamine dimesylate cap 70 mg...... 38VYVANSE – lisdexamfetamine dimesylate chew tab 10mg...................................................................................... 38

VYVANSE – lisdexamfetamine dimesylate chew tab 20mg...................................................................................... 38





Wwarfarin sodium tab 1 mg (Coumadin).......................... 49warfarin sodium tab 2 mg (Coumadin).......................... 49warfarin sodium tab 2.5 mg (Coumadin)....................... 49warfarin sodium tab 3 mg (Coumadin).......................... 49warfarin sodium tab 4 mg (Coumadin).......................... 49warfarin sodium tab 5 mg (Coumadin).......................... 49warfarin sodium tab 6 mg (Coumadin).......................... 49warfarin sodium tab 7.5 mg (Coumadin)....................... 49warfarin sodium tab 10 mg (Coumadin)........................ 49X

XALKORI – crizotinib cap 200 mg..................................... 10XALKORI – crizotinib cap 250 mg..................................... 10XARELTO – rivaroxaban tab 2.5 mg..................................49XARELTO – rivaroxaban tab 10 mg...................................49XARELTO – rivaroxaban tab 15 mg...................................49XARELTO – rivaroxaban tab 20 mg...................................49XARELTO STARTER PACK – rivaroxaban tab startertherapy pack 15 mg & 20 mg...........................................49

XELJANZ – tofacitinib citrate tab 5 mg (baseequivalent)......................................................................... 43

XELJANZ – tofacitinib citrate tab 10 mg (baseequivalent)......................................................................... 43

XELJANZ XR – tofacitinib citrate tab er 24hr 11 mg (baseequivalent)......................................................................... 43

XELJANZ XR – tofacitinib citrate tab er 24hr 22 mg (baseequivalent)......................................................................... 43

XIFAXAN – rifaximin tab 550 mg......................................... 6XOLAIR – omalizumab for inj 150 mg............................... 28XOLAIR – omalizumab subcutaneous soln prefilledsyringe 75 mg/0.5ml..........................................................28

XOLAIR – omalizumab subcutaneous soln prefilledsyringe 150 mg/ml.............................................................28

XTANDI – enzalutamide cap 40 mg...................................10XULANE – norelgestromin-ethinyl estradiol td ptwk 150-35mcg/24hr............................................................................ 13

YYONSA – abiraterone acetate tab 125 mg........................ 10

Zzafirlukast tab 10 mg (Accolate)..................................... 28zafirlukast tab 20 mg (Accolate)..................................... 28zaleplon cap 5 mg (Sonata).............................................36zaleplon cap 10 mg (Sonata)...........................................36ZEJULA – niraparib tosylate cap 100 mg (baseequivalent)......................................................................... 10

ZELBORAF – vemurafenib tab 240 mg............................. 10ZENPEP – pancrelipase (lip-prot-amyl) dr cap3000-10000-14000 unit..................................................... 30

ZENPEP – pancrelipase (lip-prot-amyl) dr cap5000-17000-24000 unit..................................................... 30

ZENPEP – pancrelipase (lip-prot-amyl) dr cap10000-32000-42000 unit...................................................30



ZENPEP – pancrelipase (lip-prot-amyl) dr cap25000-79000-105000 unit.................................................30

ZENPEP – pancrelipase (lip-prot-amyl) dr cap40000-126000-168000 unit...............................................30

zidovudine cap 100 mg (Retrovir).....................................5zidovudine syrup 10 mg/ml (Retrovir)..............................5zidovudine tab 300 mg.......................................................5ziprasidone hcl cap 20 mg (Geodon)............................. 36ziprasidone hcl cap 40 mg (Geodon)............................. 36ziprasidone hcl cap 60 mg (Geodon)............................. 36ziprasidone hcl cap 80 mg (Geodon)............................. 36ZOLINZA – vorinostat cap 100 mg.................................... 10zolmitriptan orally disintegrating tab 2.5 mg (Zomigzmt)....................................................................................44

zolmitriptan orally disintegrating tab 5 mg (Zomigzmt)....................................................................................44

zolmitriptan tab 2.5 mg (Zomig)......................................44

2020


zolmitriptan tab 5 mg (Zomig).........................................44zolpidem tartrate tab er 6.25 mg (Ambien cr)................36zolpidem tartrate tab er 12.5 mg (Ambien cr)................36zolpidem tartrate tab 5 mg (Ambien)..............................36zolpidem tartrate tab 10 mg (Ambien)............................36zonisamide cap 50 mg..................................................... 46zonisamide cap 25 mg (Zonegran)................................. 46zonisamide cap 100 mg (Zonegran)............................... 46ZORTRESS – everolimus tab 0.25 mg.............................. 56ZORTRESS – everolimus tab 0.5 mg................................ 56ZORTRESS – everolimus tab 0.75 mg.............................. 56ZORTRESS – everolimus tab 1 mg................................... 56ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab0.7-0.18 mg (base eq)...................................................... 56

ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab1.4-0.36 mg (base eq)...................................................... 56

ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab2.9-0.71 mg (base eq)...................................................... 56

ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 5.7-1.4mg (base eq)..................................................................... 56

ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 8.6-2.1mg (base eq)..................................................................... 56

ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab11.4-2.9 mg (base eq).......................................................56

ZYCLARA – imiquimod cream 3.75%................................54ZYCLARA PUMP – imiquimod cream 2.5%...................... 54ZYCLARA PUMP – imiquimod cream 3.75%.................... 54ZYDELIG – idelalisib tab 100 mg.......................................10ZYDELIG – idelalisib tab 150 mg.......................................10ZYKADIA – ceritinib tab 150 mg........................................ 10ZYLET – loteprednol etabonate-tobramycin ophth susp0.5-0.3%.............................................................................50

ZYTIGA – abiraterone acetate tab 500 mg........................10

blue cross blue shield of north dakota drug formulary, april 2020€¦ · or check if a particular...

Documents