caremark confidential and proprietary information. not for ...caremark confidential and proprietary...

Caremark Confidential and Proprietary Information. Not for distribution

© 2017 Caremark. All rights reserved. This document contains

confidential and proprietary information of Caremark and

cannot be reproduced, distributed or printed without the prior

written consent of Caremark.

MAC drugs and prices are subject to change. Accordingly, the

drugs and prices on this MAC list are applicable only as to the

date of this list.

Indicated MAC prices are the lowest MAC unit price applicable

across all pharmacies for the Highmark Health Options

pharmacy network.

Highmark Health Options MAC List

June 1, 2020

Drug Name Dosage Form Strength Pkg Size MAC/unit

Penicillin V Potassium TAB 250mg 999 0.0001

Penicillin V Potassium TAB 500mg 999 0.0001

Penicillin VK SOL 125mg/5ml 200 0.0279




Amoxicillin CAP 250mg 999 0.0001

Amoxicillin CAP 500mg 999 0.0001

Amoxicillin TAB 500mg 999 0.0001

Amoxicillin TAB 875mg 999 0.0001

Amoxicillin TAB, CHEW 125mg 999 0.0001

Amoxicillin TAB, CHEW 250mg 999 0.0001

Amoxicillin PDR 125mg / 5ml, 80ml 80 0.0142



Amoxicillin SUS 200/5ml, 75ml 75 0.0100









Ampicillin / Ampicillin Trihydrate CAP 500mg 999 0.0001

Dicloxacillin Sodium CAP 250mg 999 0.0001

Dicloxacillin Sodium CAP 500mg 999 0.0001

Amoxicillin/Clavulanic Acid TAB 250mg 999 0.0001



Amoxicillin/Clavulanic Acid TAB, CHEW 200mg 999 0.1925

Amoxicillin/Clavulanic Acid TAB, CHEW 400mg 999 0.0001

Amoxicillin/Clavulanic Acid SUS 200mg, 75ml 75 0.0484



Amoxicillin/Clavulanic Acid SUS 250mg/5ml 100 0.0100



Amoxicillin/Clavulanic Acid SUS 400mg, 50mg 50 0.0100



Amoxicillin/Clavulanic Acid SUS 600-42.9mg/5ml 200 0.0100



Amoxicillin/Clavulanic Acid TAB, XR 1000-62.5mg 999 0.0001

Cefadroxil CAP 500mg 999 0.0001

Cefadroxil TAB 1GM 999 0.0001

Cefadroxil SUS 250mg/5ml 50 0.0822




Cephalexin CAP 250mg 999 0.0001



Cephalexin TAB 250mg 999 0.3133

Cephalexin TAB 500mg 999 0.0001

Cephalexin PDR 125mg/5ml, 100ml 100 0.0100










date of this list.



pharmacy network.


June 1, 2020



Cefaclor CAP 250mg 999 0.0001

Cefaclor CAP 500mg 999 0.0001

Cefprozil TAB 250mg 999 0.0001

Cefprozil TAB 500mg 999 0.0001

Cefprozil SUS 125mg/5ml 75 0.0466






Cefuroxime TAB 250mg 999 0.0001

Cefuroxime TAB 500mg 999 0.0001

Cefdinir CAP 300mg 999 0.0001

Cefdinir SUS 125mg/5ml 60 0.0100




Cefixime CAP 400mg 999 9.3834

Cefixime SUS 100mg/5ml 999 1.2387



Cefpodoxime Proxetil TAB 100mg 999 0.0001

Cefpodoxime Proxetil TAB 200mg 999 0.0001

Cefpodoxime Proxetil SUS 50mg / 5ml 100 0.4306




Ceftibuten CAP 400mg 999 16.4040

Ceftriaxone Sodium INJ 1gm 999 0.7135

Erythromycin TAB 250mg 999 0.0001





Erythromycin CAP, ER 250mg 999 0.2004

Erythromycin Stearate TAB 250mg 999 0.0001

Erythromycin Ethylsuccinate TAB 400mg 999 0.0001

Erythromycin Ethylsuccinate SUS 200mg/5ml 200 1.1711



Azithromycin TAB 250 mg 999 0.0001



Azithromycin SUS, PDR 100mg / 5 ml 15 0.0100


Azithromycin SUS, PDR 200mg / 5 ml 22.5 0.0100


Azithromycin PKT 1gm/SDP 3 0.0100

Azithromycin PKT 1gm/SDP 10 0.0100

Clarithromycin TAB 250mg 999 0.0001

Clarithromycin TAB 500mg 999 0.0001

Clarithromycin SUS 125/5ml, 50ml 50 0.1656




Clarithromycin XL TAB, ER 500mg 999 0.0001

Demeclocycline TAB 150mg 999 0.4439

Demeclocycline TAB 300mg 999 0.9247








date of this list.



pharmacy network.


June 1, 2020


Doxycycline Monohydrate CAP 50mg 999 0.0001




Doxycycline Monohydrate TAB 50mg 999 0.0001




Doxycycline Monohydrate SUSP 25mg/5ml 999 0.0001

Doxycycline Hyclate CAP 50mg 999 0.0001

Doxycycline Hyclate CAP 100mg 999 0.0001

Doxycycline TAB 20mg 999 0.0001

Doxycycline Hyclate TAB 50mg 999 0.0001




Doxycycline Hyclate TAB, DR 50mg 999 0.0001





Minocycline Hydrochloride CAP 50mg 999 0.0001



Minocycline Hydrochloride TAB 50 mg 999 0.0001



Minocycline Hydrochloride TAB, ER 45mg 999 0.0001

Minocycline HCl TAB, ER 55mg 999 14.4438







Tetracycline Hydrochloride CAP 250mg 999 0.0001

Tetracycline Hydrochloride CAP 500mg 999 0.0001

Ciprofloxacin TAB 100mg 999 2.2750




Levofloxacin TAB 250mg 999 0.0001

Levofloxacin TAB 500MG 999 0.0001

Levofloxacin TAB 750MG 999 0.0001

Levofloxacin SOL 25mg/ml 200 0.4157



Moxifloxacin TAB 400mg 999 0.0001

Ofloxacin TAB 300mg 999 5.0347

Ofloxacin TAB 400mg 999 2.8469

Gentamycin INJ 40mg/ml 999 0.0001

Neomycin Sulfate TAB 500mg 999 0.0001

Paromomycin CAP 250mg 999 2.0259

Tobramycin NEB 300mg/5ml 999 3.3825

Cycloserine CAP 250mg 999 24.2564

Ethambutol TAB 100mg 999 0.1265

Ethambutol TAB 400mg 999 0.0001

Isoniazid TAB 100mg 999 0.0100

Isoniazid TAB 300mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020


Pyrazinamide TAB 500MG 999 0.7082

Rifabutin CAP 150mg 999 0.0001

Rifampin CAP 150mg 999 0.0001

Rifampin CAP 300mg 999 0.0001

Flucytosine CAP 250mg 999 12.4273

Flucytosine CAP 500mg 999 24.0552

Griseofulvin Microsize TAB 500mg 999 0.0001

Griseofulvin, microsize SUS 125 mg/5 ml 999 0.0001

Griseofulvin Ultramicrosize TAB 125mg 999 0.0001

Griseofulvin Ultramicrosize TAB 250mg 999 1.2813

Nystatin TAB 500,000 units 999 0.0001

Terbinafine TAB 250mg 999 0.0001

Ketoconazole TAB 200mg 999 0.0001

Fluconazole TAB 50mg 999 0.0001




Fluconazole SUS 10mg/ml 999 0.0001

Fluconazole SUS 40mg/ml 999 0.0001

Itraconazole CAP 100 mg 999 0.0001

Itraconazole SOL 10mg/ml 999 0.0001

Posaconazole TAB, DR 100mg 999 0.0001

Voriconazole TAB 50mg 999 0.4183

Voriconazole TAB 200mg 999 0.0001

Voriconazole SUS 40mg/ml 999 4.0911

Voriconazole INJ 200mg 1 29.8970

Atazanavir Sulfate CAP 150mg 999 2.7372



Fosamprenavir Calcium TAB 700mg 999 8.9115

Ritonavir TAB 100mg 999 0.7214

Abacavir Sulfate TAB 300mg 999 0.2423

Abacavir Sulfate SOL 20mg/ml 999 0.2818

Didanosine CAP 250mg 999 1.9754

Didanosine CAP 400mg 999 2.6424

Lamivudine TAB 150mg 999 0.0445


Lamivudine SOL 10mg/ml 999 0.1633

Stavudine CAP 15mg 999 0.6814




Zidovudine CAP 100mg 999 0.4307

Zidovudine TAB 300mg 999 0.1393

Zidovudine SYP 50mg/5ml 999 0.0930

Tenofovir disoproxil fumarate TAB 300mg 999 0.5438

Efavirenz CAP 50mg 999 1.2409

Efavirenz CAP 200mg 999 4.9607

Efavirenz TAB 600mg 999 1.0592

Nevirapine TAB 200mg 999 0.0100

Nevirapine SUS 50mg/5ml 999 0.2265

Nevirapine TAB, ER 100mg 999 2.8710

Nevirapine TAB,ER 400mg 999 1.1413

Abacavir / Lamivudine TAB 600-300mg 999 1.2067

Lamivudine / Zidovudine TAB 150mg - 300mg 999 0.2860

Lopinavir/Ritonavir SOL 400-100mg/5ml 999 1.4014

Abacavir/Lamivudine/Zidovudine TAB 300mg-150mg-300mg 999 11.7156

Valganciclovir TAB 450mg 999 0.0001

Valganciclovir SOL 50mg/ml 999 4.5470








date of this list.



pharmacy network.


June 1, 2020


Adefovir Dipivoxil TAB 10mg 999 15.4605

Entecavir TAB 0.5mg 999 0.7324

Entecavir TAB 1mg 999 0.7114


Ribavirin CAP 200mg 999 0.3669

Ribavirin TAB 200mg 999 0.2528

Acyclovir CAP 200mg 999 0.0001

Acyclovir TAB 400mg 999 0.0001

Acyclovir TAB 800mg 999 0.0001

Acyclovir SUS 200/5ml 999 0.0001

Valacyclovir TAB 500mg 999 0.0001

Valacyclovir TAB 1Gm 999 0.0001

Famciclovir TAB 125mg 999 0.0001



Rimantadine TAB 100mg 999 0.6248

Oseltamivir Phosphate CAP 30mg 999 0.0001



Oseltamivir Phosphate SUS 6mg/ml 999 0.0001

Chloroquine Phosphate TAB 250mg 999 0.0001

Chloroquine Phosphate TAB 500mg 999 0.0001

Hydroxychloroquine Sulfate TAB 200mg 999 0.0001

Mefloquine TAB 250mg 999 0.0001

Primaquine Phosphate TAB 26.3mg 999 0.2134

Pyrimethamine TAB 25mg 999 278.9063

Quinine Sulfate CAP 324mg 999 0.0001

Atovaquone / Proguanil HCL TAB 62.5-25mg 999 0.0001

Atovaquone / Proguanil HCL TAB 250-100mg 999 0.0001

Albendazole TAB 200mg 999 65.5932

Ivermectin TAB 3mg 999 0.0001

Praziquantel TAB 600mg 999 38.3621

Metronidazole CAP 375mg 999 0.2318

Metronidazole TAB 250mg 999 0.0001

Metronidazole TAB 500mg 999 0.0001

Pentamidine Isethionate INH 300mg 999 63.1750

Tinidazole TAB 250mg 999 0.0001

Tinidazole TAB 500mg 999 0.0001

Trimethoprim TAB 100mg 999 0.0001

Chloramphenical Sod Succinate INJ 1G 999 6.4525

Clindamycin Hydrochloride CAP 75mg 999 0.2318



Clindamycin Palmitate HCL SOL 75mg/5ml 999 0.0001

Linezolid TAB 600mg 999 0.0001

Linezolid SUS 100mg/5ml 999 1.6087

Vancomycin CAP 125mg 999 0.0001

Vancomycin CAP 250mg 999 0.0001

Vancomycin VIA 1 GM 999 2.6950

Dapsone TAB 25mg 999 0.0001

Dapsone TAB 100mg 999 0.0001

Atovaquone SUS 750mg/5ml 999 0.0001

Sulfamethoxazole / Trimethoprim TAB 400 / 80mg 999 0.0001

Sulfamethoxazole / Trimethoprim TAB 800 / 160mg 999 0.0001

Sulfamethoxazole / Trimethoprim SUS 200-40mg / 5ml 473 0.0100

Sulfamethoxazole / Trimethoprim SUS 200-40mg / 5ml 20 0.0540

Cyclophosphamide CAP 25mg 999 3.3619

Cyclophosphamide CAP 50mg 999 4.9267

Melphalan TAB 2mg 999 5.2299








date of this list.



pharmacy network.


June 1, 2020


Temozolomide CAP 5mg 999 0.9360






Capecitabine TAB 150mg 999 0.3252

Capecitabine TAB 500mg 999 1.1358

Mercaptopurine TAB 50mg 999 0.0001

Methotrexate TAB 2.5mg 999 0.0001

Methotrexate INJ, PF 25mg/ml, 2ml 2 1.2800



Bicalutamide TAB 50MG 999 0.0001

Flutamide CAP 125mg 999 0.0001

Nilutamide TAB 150mg 999 51.8813

Tamoxifen TAB 10mg 999 0.0001

Tamoxifen TAB 20mg 999 0.0001

Toremifene Citrate TAB 60mg 999 16.0403

Anastrozole TAB 1mg 999 0.0001

Exemestane TAB 25mg 999 0.0001

Letrozole TAB 2.5mg 999 0.0001

Megestrol Acetate TAB 20mg 999 0.0001

Megestrol Acetate TAB 40mg 999 0.0001

Megestrol Acetate SUS 40mg/ml 240 0.0100



Leuprolide KIT 2 week 999 269.2800

Abiraterone TAB 250mg 999 6.1886

Etoposide CAP 50mg 999 36.9658

Everolimus TAB 2.5mg 999 199.8117

Everolimus TAB 5mg 999 208.9997

Everolimus TAB 7.5mg 999 208.9997

Erlotinib TAB 25mg 999 8.5000



Imatinib Mesylate TAB 100mg 999 1.4481

Imatinib Mesylate TAB 400mg 999 2.8450

Hydroxyurea CAP 500mg 999 0.0001

Tretinoin CAP 10mg 999 7.8439

Bexarotene CAP 75mg 999 59.5447

Leucovorin Calcium TAB 5mg 999 0.0001




Budesonide CAP, EC 3mg 999 0.0001

Budesonide TAB, ER 9mg 999 0.0001

Cortisone Acetate TAB 25mg 999 0.0001

Dexamethasone TAB 0.5mg 999 0.0001


Dexamethasone TAB 1mg 999 0.0001





Dexamethasone ELIX 0.5mg/5ml 999 0.0001

Dexamethasone SOL 0.5mg/5ml 500 0.0215

Dexamethasone SOL 0.5mg/5ml 240 0.0100

Hydrocortisone TAB 5mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020




Methylprednisolone TAB 4mg 999 0.0001




Methylprednisolone TAB 4mg, DosePak 999 0.0001

Prednisolone SYR 15mg / 5ml 999 0.0001

Prednisolone Sodium Phosphate SOL 15 mg/5ml 999 0.0001

Prednisolone Sodium Phosphate SOL 25 mg/5ml 999 0.0001

Prednisolone Sodium Phosphate LIQ 5mg/5ml 999 0.0001

Prednisolone SOL 10mg/5ml 999 1.5698

Prednisolone SOL 20mg/5ml 999 2.1284

Prednisolone Sodium Phosphate TAB, ODT 10mg 999 6.9111



Prednisone TAB 1mg 999 0.0001

Prednisone TAB 2.5mg 999 0.0001





Prednisone SOL 5mg/5ml 999 0.0001

Prednisone TAB 5mg PAK, #21 21 0.2181

Prednisone TAB 5mg PAK, #48 48 0.1653

Prednisone TAB 10mg, PAK, #21 21 0.0100

Prednisone TAB 10mg, PAK, #48 48 0.0100

Fludrocortisone TAB 0.1mg 999 0.0001

Danazol CAP 50mg 999 0.0001

Danazol CAP 100 MG 999 1.5555

Danazol CAP 200mg 999 0.0001

Methyltestosterone CAP 10mg 999 38.0048

Testosterone SOL 30mg/act 999 0.0001

Testosterone GEL, TD 1%, 25mg/2.5GM 999 0.0001

Testosterone GEL, TD 1%, 50mg/5GM 999 0.0001

Testosterone GEL, PUMP 1%, 12.5mg/ACT 999 0.0001

Testosterone GEL, TD 1.62%, 20.25mg/1.25GM 999 0.0001

Testosterone GEL, TD 1.62%, 40.5mg/2.5GM 999 0.0001

Testosterone GEL, PUMP 1.62%, 20.25mg/ACT 999 0.0001

Testosterone GEL, PUMP 2% 999 0.0001

Testosterone Cypionate MDV 200mg/ml 1 0.0100

Testosterone Cypionate MDV 200mg/ml 10 0.0100

Oxandrolone TAB 2.5mg 999 0.9329

Oxandrolone TAB 10mg 999 0.0001

Estradiol TAB 0.5mg 999 0.0001

Estradiol TAB 1mg 999 0.0001

Estradiol TAB 2mg 999 0.0001

Estradiol DIS, Biweekly 0.025mg/24hr 999 0.0001





Estradiol DIS, Weekly 0.025mg/24hr 999 8.8725






Estradiol Valerate MDV 20mg/ml 999 0.0001








date of this list.



pharmacy network.


June 1, 2020


Estradiol Valerate MDV 40mg/ml 999 21.3268

Esterified Estrogen/Methyltestosterone TAB 0.625mg/1.25mg 999 0.0001

Esterified Estrogen/Methyltestosterone TAB 1.25mg/5mg 999 0.0001

Estradiol / Norethindrone Acetate TAB 0.5mg-0.1mg 999 0.0001

Estradiol / Norethindrone Acetate TAB 1mg-0.5mg 999 0.0001

Norethindrone / Ethinyl Estradiol TAB 0.5mg-2.5mcg 999 0.0001

Norethindrone / Ethinyl Estradiol TAB 1mg-5mcg 999 0.0001

Norethindrone TAB 0.35mg 999 0.0001

Medroxyprogesterone INJ 150mg/ml 999 0.0001

Medroxyprogesterone INJ, SYR 150mg/ml 999 0.0001

Ethinyl Estradiol / Norelgestromin PATCH 35mcg-150mcg/24 HR 999 0.0001

Etonogestrel-Ethinyl Estradiol VA RING 0.120-0.015mg/24HR 999 53.3600

Ethinyl Estradiol / Desogestrel TAB 30mcg - 15mg 999 0.0001

Drospirenone / Ethinyl Estradiol TAB 3mg- 0.02mg 999 0.0001

Drospirenone / Ethinyl Estradiol TAB 3mg/0.03mg 999 0.0001

Ethinyl Estradiol / Ethynodiol Diacetate TAB 35 mcg - 1 mg 999 0.0001

Ethinyl Estradiol / Ethynodiol Diacetate TAB 50mcg/1mg 999 0.0001

Ethinyl Estradiol / Levonorgestrel TAB 20mcg - 0.1mg, 28-day 999 0.0001

Ethinyl Estradiol / Levonorgestrel TAB 30mcg - 0.15mg, 28-day 999 0.0001

Ethinyl Estradiol / Norethindrone TAB 0.4 / 0.035 mg 999 0.0001

Ethinyl Estradiol / Norethindrone TAB 35/0.5 999 0.0001

Ethinyl Estradiol / Norethindrone TAB 35 mcg - 1 mg, 28-day 999 0.0001

Ethinyl Estradiol / Norethindrone TAB 20mcg-1mg 999 0.0001

Ethinyl Estradiol / Norethindrone TAB 30mcg-1.5mg 999 0.0001

Ethinyl Estradiol / Norgestrel TAB 30mcg-0.3mg, 28-day 999 0.0001

Ethinyl Estradiol / Norgestrel TAB 50mcg/0.5mg 999 0.0001

Ethinyl Estradiol / Norgestimate TAB 35mcg-0.25mg, 28-day 999 0.0001

Drospirenone/Ethinyl Estradiol/Levomefolate TAB 3mg-0.02mg-0.451mg 999 0.0001

Drospirenone/Ethinyl Estradiol/Levomefolate TAB 3mg-0.03mg-0.451mg 999 0.0001

Ethinyl Estradiol / Norethindrone FE TAB, CHEW 35mcg/0.4mg 999 0.0001

Norethindrone/Ethinyl Estradiol/FE TAB, CHEW 0.8mg-25mcg-75mg 999 0.0001

Ethinyl Estradiol / Norethindrone / Fe TAB 20mcg-1mg-75mg, 28-day 999 0.0001

Ethinyl Estradiol/Norethindrone FE TAB 20mcg-1mg-75mg 999 0.0001

Ethinyl Estradiol / Norethindrone / Fe TAB 30mcg-1.5mg-75mg, 28-day 999 0.0001

Ethinyl Estradiol / Norethindrone / Fe TAB, CHEW 20mcg-1mg-75mg 999 0.0001

Desogestrel / Ethinyl Estradiol TAB 28 day 999 0.0001

Desogestrel/Ethinyl Estradiol TAB 28 day 999 0.0001

Ethinyl Estradiol / Levonorgestrel TAB 28-day 999 0.0001

Ethinyl Estradiol / Norethindrone TAB 7/7/7-28- day 999 0.0001

Ethinyl Estradiol/Norethindrone TAB 28-day 999 0.0001

Ethinyl Estradiol / Norgestimate TAB 25-0.18/0.215/0.25 mcg-mg 999 0.0001

Ethinyl Estradiol/Norgestimate TAB 28-day 999 0.0001

Norethindrone Acetate/Ethinyl/Estradiol TAB 999 0.0001

Levonorgestrel/Ethinyl Estradiol TAB 0.1-0.02mg 999 0.0001

Ethinyl Estradiol / Levonorgestrel TAB 0.03 / 0.15 mg 999 0.0001

Levonorgestrel/Ethinyl Estradiol TAB 0.15-0.03mg 999 0.0001

Levonorgestrel - Ethinyl Estradiol TAB 0.15-0.02/0.025/0.03mg&0.01mg 999 0.0001

Ethinyl Estradiol / Levonorgestrel TAB 20-90mg 999 0.0001

Hydroxyprogesterone Caproate INJ 250mg/ml 5 355.7000

Hydroxyprogesterone Caproate INJ 250mg/ml 1 118.9607

Medroxyprogesterone Acetate TAB 2.5mg 999 0.0001

Medroxyprogesterone Acetate TAB 5mg 999 0.0001

Medroxyprogesterone Acetate TAB 10mg 999 0.0001

Megestrol Acetate SUS 650mg/5ml 999 1.5952

Norethindrone Acetate TAB 5mg 999 0.0001

Progesterone CAP 100mg 999 0.0001

Progesterone CAP 200mg 999 0.0001

Glimepiride TAB 1mg 999 0.0001









date of this list.



pharmacy network.


June 1, 2020



Glipizide TAB 5mg 999 0.0001

Glipizide TAB 10mg 999 0.0001

Glipizide TAB 2.5mg CR 999 0.0001

Glipizide TAB 5mg CR 999 0.0001

Glipizide TAB 10mg CR 999 0.0001

Glyburide TAB 1.25mg 999 0.0001

Glyburide TAB 2.5mg 999 0.0001

Glyburide TAB 5mg 999 0.0001

Glyburide TAB, MICRO 1.5mg 999 0.0001

Glyburide TAB, MICRO 3mg 999 0.0228

Glyburide TAB, MICRO 6mg 999 0.0001

Tolbutamide TAB 500mg 999 0.3032

Metformin TAB 500mg 999 0.0001



Metformin SOL 500mg/5ml 999 0.4725

Metformin TAB, ER 500mg (GP) 999 0.0001

Metformin TAB, ER 750mg (GP) 999 0.0001

Metformin TAB, ER 500mg (F) 999 0.0001

Metformin TAB, ER 1000mg (F) 999 0.0001

Metformin TAB, ER 500mg (GZ) 999 0.0001

Metformin TAB, ER 1000mg (GZ) 999 0.0001

Nateglinide TAB 60mg 999 0.1072

Nateglinide TAB 120mg 999 0.0001

Repaglinide TAB 0.5mg 999 0.0001

Repaglinide TAB 1mg 999 0.0001

Repaglinide TAB 2mg 999 0.0001

Diazoxide SUS 50mg/ml 999 5.4852

Acarbose TAB 25mg 999 0.0001



Miglitol TAB 25mg 999 0.8887



Alogliptin Benzoate TAB 6.25mg 999 3.5178

Alogliptin Benzoate TAB 12.5mg 999 0.0001

Alogliptin Benzoate TAB 25mg 999 0.0001

Pioglitazone HCL TAB 15mg 999 0.0001



Alogliptin Benzoate / Metformin TAB 12.5mg-500mg 999 1.5951

Alogliptin Benzoate / Metformin TAB 12.5mg-1000mg 999 0.0001

Alogliptin Benzoate / Pioglitazone TAB 12.5mg-15mg 999 3.4836



Alogliptin Benzoate / Pioglitazone TAB 25mg-15mg 999 3.1903



Glipizide/Metformin TAB 2.5/250mg 999 0.0100

Glipizide/Metformin TAB 2.5/500mg 999 0.0001

Glipizide/Metformin TAB 5/500mg 999 0.0001

Glyburide/Metformin TAB 1.25mg/250mg 999 0.0186

Glyburide/Metformin TAB 2.5mg/500mg 999 0.0001

Glyburide/Metformin TAB 5mg/500mg 999 0.0001

Pioglitazone HCL / Glimepiride TAB 30mg-2mg 999 5.9203

Pioglitazone HCL / Glimepiride TAB 30mg-4mg 999 0.0001

Pioglitazone HCL / Metformin TAB 15-500mg 999 0.0001

Pioglitazone HCL / Metformin TAB 15-850mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020


Levothyroxine TAB 0.025mg 999 0.1086

Levothyroxine-Levoxyl TAB 0.025mg 999 0.1086

Levothyroxine-Unithroid TAB 0.025mg 999 0.4303

































Liothyronine TAB 5mcg 999 0.0952



Thyroid TAB 15mg 999 0.2400





Methimazole TAB 5mg 999 0.0001

Methimazole TAB 10mg 999 0.0001

Propylthiouracil TAB 50mg 999 0.0001

Methylergon TAB 0.2mg 999 0.0001

Alendronate TAB 5mg 999 0.0100




Alendronate SOL 70/75mg 999 0.2672

Ibandronate Sodium TAB 150mg 999 0.0001

Risedronate Sodium TAB 5mg 999 0.0001




Risedronate Sodium TAB, DR 35mg 999 20.6969

Zoledronic Acid INJ 5mg/100ml 999 0.7125








date of this list.



pharmacy network.


June 1, 2020


Calcitonin, Salmon SOL 200U 999 0.0001

Raloxifene TAB 60mg 999 0.0001

Clomiphene TAB 50mg 999 0.0001

Ganirelix Acetate INJ 250mcg/0.5ml 999 230.0300

Desmopressin Acetate TAB 0.1mg 999 0.0001

Desmopressin Acetate TAB 0.2mg 999 0.0001

Desmopressin Acetate SPR 0.01%, 5ml (refrigerated) 999 0.0001

Desmopressin Acetate SPR 0.01%, 5ml 999 0.0001

Cabergoline TAB 0.5mg 999 0.0001

Levocarnitine TAB 330 mg 999 0.0001

Levocarnitine SOL 100 mg/ml 999 0.0001

Nitisinone CAP 2mg 999 34.3292



Calcitriol CAP 0.25mcg 999 0.0001

Calcitriol CAP 0.5mcg 999 0.0001

Calcitriol SOL 1mcg / ml 999 0.0001

Doxercalciferol CAP 0.5mcg 999 2.9400

Doxercalciferol CAP 1mcg 999 5.8800

Doxercalciferol CAP 2.5mcg 999 6.8600

Paricalcitol Cap 1mcg 999 0.0001

Paricalcitol Cap 2mcg 999 0.0001

Paricalcitol CAP 4mcg 999 5.4600

Cinacalcet TAB 30mg 999 8.1260



Sodium Phenylbutyrate TAB 500mg 999 11.4570

Sodium Phenylbutyrate POW 3GM/tsp 999 7.7439

Digoxin TAB 0.125mg 999 0.0001

Digoxin TAB 0.25mg 999 0.0001

Digoxin ELIX 0.05mg/ml 999 0.2502

Isosorbide Dinitrate TAB 5mg 999 0.0001





Isosorbide Dinitrate TAB 40mg ER 999 0.5687

Isosorbide Mononitrate TAB 10mg 999 0.0001

Isosorbide Mononitrate TAB 20mg 999 0.0001

Isosorbide Mononitrate TAB, ER 30mg 999 0.0001



Nitroglycerin CAP 2.5mg 999 0.1957

Nitroglycerin CAP 6.5mg 999 0.2237

Nitroglycerin CAP 9mg 999 0.1405

Nitroglycerin TAB, SL 0.3mg 999 0.0001




Nitroglycerin PMP 0.4mg/spray 4.9 15.4271

Nitroglycerin PMP 0.4mg/spray 12 9.2610

Nitroglycerin PATCH 0.1mg/hr 999 0.0001




Ranolazine TAB, ER 500mg 999 0.3424

Ranolazine TAB, ER 1000mg 999 0.5527

Nadolol TAB 20mg 999 0.0001









date of this list.



pharmacy network.


June 1, 2020



Pindolol TAB 5mg 999 0.0001

Pindolol TAB 10mg 999 0.0001

Propranolol TAB 10mg 999 0.0001





Propranolol HCL SOL 20mg/5ml 999 0.0001

Propranolol CAP, LA 60mg 999 0.0001



Propranolol CAP, LA 160MG 999 0.0001

Sotalol TAB 80mg 999 0.0001




Sotalol AF TAB 80mg 999 0.0001



Timolol Maleate TAB 5mg 999 0.0001



Acebutolol Hydrochloride CAP 200 mg 999 0.0001

Acebutolol Hydrochloride CAP 400 mg 999 0.0001

Atenolol TAB 25mg 999 0.0001



Betaxolol HCL TAB 10mg 999 0.0001

Betaxolol HCL TAB 20mg 999 0.0001

Bisoprolol TAB 5mg 999 0.0001

Bisoprolol TAB 10mg 999 0.0001

Metoprolol Succinate TAB, ER 25mg 999 0.0001




Metoprolol Tartrate TAB 25mg 999 0.0001

Metoprolol Tartrate TAB 37.5mg 999 0.0001




Carvedilol TAB 3.125mg 999 0.0001



Carvedilol TAB 25mg 999 0.0001

Carvedilol CAP ER 10mg 999 0.0001




Labetalol TAB 100mg 999 0.0001



Amlodipine TAB 2.5mg 999 0.0001

Amlodipine TAB 5mg 999 0.0001

Amlodipine Besylate TAB 10mg 999 0.0001

Diltiazem TAB 30mg 999 0.0001











date of this list.



pharmacy network.


June 1, 2020


Diltiazem CAP, SR 60mg 999 0.0001



Diltiazem CAP, XR 120mg 999 0.0001



Diltiazem CAP, ER 120mg 999 0.0001






Diltiazem CAP, CD 120mg 999 0.0001





Diltiazem TAB, LA 180mg 999 0.0001





Felodipine TAB, ER 2.5mg 999 0.0001

Felodipine TAB, ER 5mg 999 0.0001

Felodipine TAB, ER 10mg 999 0.0001

Isradipine CAP 2.5mg 999 0.6591

Isradipine CAP 5mg 999 0.0001

Nicardipine CAP 20mg 999 0.0001

Nicardipine CAP 30mg 999 0.3409

Nifedipine CAP 10mg 999 0.0001

Nifedipine CAP 20mg 999 0.8258

Nifedipine TAB, ER 30mg 999 0.0001



Nifedipine TAB, XL 30mg 999 0.0001



Nimodipine CAP 30mg 999 1.2456

Nisoldipine TAB, ER 8.5mg 999 0.0001

Nisoldipine TAB, ER 17mg 999 0.0001


Nisoldipine TAB, ER 25.5mg 999 3.9815




Verapamil HCL TAB 40mg 999 0.0001



Verapamil HCL TAB, ER 120mg 999 0.0001



Verapamil HCL CAP, ER 100mg 999 0.0001

Verapamil HCL CAP, SR 120mg 999 0.0001




Verapamil HCL CAP, ER 300mg 999 0.0001


Disopyramide Phosphate CAP 100mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020


Disopyramide Phosphate CAP 150mg 999 0.0001

Quinidine Gluconate TAB, ER 324mg 999 4.2818

Quinidine Sulfate TAB 200 MG 999 0.0001

Quinidine Sulfate TAB 300MG 999 0.1365

Mexiletine Hydrochoride CAP 150mg 999 0.0001



Flecainide TAB 50mg 999 0.0001



Propafenone HCL TAB 150mg 999 0.0001



Propafenone CAP, ER 225mg 999 0.0001



Amiodarone TAB 100mg 999 0.0001



Dofetilide CAP 125mcg 999 1.0827



Benazepril TAB 5mg 999 0.0001




Captopril TAB 12.5mg 999 0.0001

Captopril TAB 25mg 999 0.0001



Enalapril TAB 2.5mg 999 0.0001

Enalapril TAB 5mg 999 0.0001



Fosinopril TAB 10mg 999 0.0001



Lisinopril TAB 2.5mg 999 0.0001

Lisinopril TAB 5mg 999 0.0001





Moexipril TAB 7.5mg 999 0.0660

Moexipril TAB 15mg 999 0.0001

Perindopril Erbumine TAB 2mg 999 0.2436



Quinapril TAB 5mg 999 0.0001




Ramipril CAP 1.25mg 999 0.0001

Ramipril CAP 2.5mg 999 0.0001

Ramipril CAP 5mg 999 0.0001

Ramipril CAP 10mg 999 0.0001

Trandolapril TAB 1mg 999 0.0001










date of this list.



pharmacy network.


June 1, 2020


Candesartan TAB 4mg 999 0.0001

Candesartan TAB 8 mg 999 0.0001



Eprosartan Mesylate TAB 600mg 999 1.9184

Irbesartan TAB 75mg 999 0.0001



Losartan TAB 25mg 999 0.0001



Olmesartan Medoxomil TAB 5mg 999 0.0001



Telmisartan TAB 20mg 999 0.0001



Valsartan TAB 40mg 999 0.0001




Aliskiren Fumarate TAB 150mg 999 3.5990

Aliskiren Fumarate TAB 300mg 999 4.7975

Clonidine HCL PATCH 0.1mg/24 hour 999 0.0001



Clonidine HCL TAB 0.1mg 999 0.0001



Guanfacine Hydrochloride TAB 1mg 999 0.0001

Guanfacine Hydrochloride TAB 2mg 999 0.0001

Methyldopa TAB 250mg 999 0.0634

Methyldopa TAB 500mg 999 0.0107

Doxazosin TAB 1mg 999 0.0001




Prazosin Hydrochloride CAP 1mg 999 0.0001



Terazosin CAP 1mg 999 0.0001




Eplerenone TAB 25mg 999 0.0001

Eplerenone TAB 50mg 999 0.0001

Phenoxybenzamine HCL CAP 10mg 999 36.8581

Hydralazine Hydrochloride TAB 10mg 999 0.0001




Minoxidil TAB 2.5mg 999 0.0001

Minoxidil TAB 10mg 999 0.0001

Amlodipine / Benazepril CAP 2.5/10mg 999 0.0001

Amlodipine / Benazepril CAP 5/10mg 999 0.0001












date of this list.



pharmacy network.


June 1, 2020


Trandolapril / Verapamil TAB, ER 1-240mg 999 1.7340




Benazepril/HCTZ TAB 5mg / 6.25mg 999 0.0001



Benazepril/HCTZ TAB 20 mg / 25mg 999 0.0001

Captopril / HCTZ TAB 25mg / 15mg 999 0.0001




Enalapril / HCTZ TAB 5mg / 12.5 mg 999 0.0001

Enalapril / HCTZ TAB 10mg / 25 mg 999 0.0001

Fosinopril / HCTZ TAB 10mg / 12.5mg 999 0.1404

Fosinopril / HCTZ TAB 20mg / 12.5mg 999 0.0001

Lisinopril / HCTZ TAB 10mg / 12.5mg 999 0.0001

Lisinopril / HCTZ TAB 20mg / 12.5mg 999 0.0001

Lisinopril / HCTZ TAB 20mg / 25mg 999 0.0001

Hydrochlorothiazide/Quinapril TAB 12.5mg / 10mg 999 0.0001

Hydrochlorothiazide/Quinapril TAB 12.5mg / 20mg 999 0.0001

Hydrochlorothiazide/Quinapril TAB 25mg / 20mg 999 0.0001

Atenolol / Chlorthalidone TAB 50 / 25mg 999 0.0001

Atenolol / Chlorthalidone TAB 100 / 25mg 999 0.0001

Bisoprolol / HCTZ TAB 2.5mg / 6.25mg 999 0.0001

Bisoprolol / HCTZ TAB 5mg / 6.25mg 999 0.0001

Bisoprolol / HCTZ TAB 10mg / 6.25mg 999 0.0001

Metoprolol / Hydrochlorothiazide TAB 50mg / 25mg 999 0.0001



Propranolol HCL / Hydrochlorothiazide TAB 40mg / 25mg 999 0.5993

Propranolol HCL / Hydrochlorothiazide TAB 80mg / 25mg 999 0.0001

Amlodipine / Olmesartan Medoxomil TAB 5-20mg 999 0.0001




Amlodipine / Valsartan TAB 5-160mg 999 0.0001




Telmisartan/Amlodipine TAB 40-5mg 999 0.1362




Candesartan / HCTZ TAB 16-12.5mg 999 0.0001

Candesartan / HCTZ TAB 32-12.5mg 999 0.0001

Candesartan / HCTZ TAB 32-25mg 999 0.0001

Irbesartan/HCTZ TAB 150-12.5mg 999 0.0001

Irbesartan/HCTZ TAB 300-12.5mg 999 0.0001

Losartan/HCTZ TAB 50-12.5mg 999 0.0001

Losartan/HCTZ TAB 100-12.5mg 999 0.0001

Losartan/HCTZ TAB 100-25mg 999 0.0001

Olmesartan Medoxomil / HCTZ TAB 20-12.5mg 999 0.0001

Olmesartan Medoxomil / HCTZ TAB 40-12.5mg 999 0.0001

Olmesartan Medoxomil / HCTZ TAB 40-25mg 999 0.0001

Telmisartan / HCTZ TAB 40-12.5mg 999 0.0001

Telmisartan / HCTZ TAB 80-12.5mg 999 0.0001

Telmisartan / HCTZ TAB 80-25mg 999 0.0001

Valsartan / HCTZ TAB 80-12.5mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020



Valsartan / HCTZ TAB 160-25mg 999 0.0001


Valsartan / HCTZ TAB 320-25mg 999 0.0001

Amlodipine / Valsartan / HCTZ TAB 5-160-12.5mg 999 0.0001

Amlodipine / Valsartan / HCTZ TAB 5-160-25mg 999 0.0001

Amlodipine / Valsartan / HCTZ TAB 10-160-12.5mg 999 0.0001



Olmesartan Medoxomil / Amlodipine / HCTZ TAB 20-5-12.5mg 999 0.0001


Olmesartan Medoxomil / Amlodipine / HCTZ TAB 40-5-25mg 999 0.0001


Olmesartan Medoxomil / Amlodipine / HCTZ TAB 40-10-25mg 999 0.0001

Methyldopa / Hydrochlorothiazide TAB 250mg / 15mg 999 0.4597

Methyldopa / Hydrochlorothiazide TAB 250mg / 25mg 999 0.5419

Acetazolamide TAB 125mg 999 0.0001

Acetazolamide TAB 250mg 999 0.0001

Acetazolamide CAP, ER 500mg 999 0.0001

Methazolamide TAB 25mg 999 0.0001

Methazolamide TAB 50mg 999 3.3538

Bumetanide TAB 0.5mg 999 0.0001

Bumetanide TAB 1mg 999 0.0001

Bumetanide TAB 2mg 999 0.0001

Ethacrynic Acid TAB 25mg 999 1.6960

Furosemide TAB 20mg 999 0.0001



Furosemide SOL 8mg/ml, 500ml 500 0.0540

Furosemide SOL 10mg / ml, 120ml 120 0.0552

Furosemide SOL 10mg / ml, 60ml 60 0.0624

Torsemide TAB 5mg 999 0.0001




Amiloride TAB 5mg 999 0.0001

Spironolactone TAB 25mg 999 0.0001



Triamterene CAP 50mg 999 0.0001

Triamterene CAP 100mg 999 0.0001

Chlorothiazide TAB 250mg 999 0.0784

Chlorothiazide TAB 500mg 999 0.4729

Chlorthalidone TAB 25mg 999 0.0001

Chlorthalidone TAB 50mg 999 0.0001

Hydrochlorothiazide CAP 12.5mg 999 0.0001

Hydrochlorothiazide TAB 12.5mg 999 0.0001

Hydrochlorothiazide TAB 25mg 999 0.0001

Hydrochlorothiazide TAB 50mg 999 0.0001

Indapamide TAB 1.25mg 999 0.0001

Indapamide TAB 2.5mg 999 0.0001

Metolazone TAB 2.5mg 999 0.0001

Metolazone TAB 5mg 999 0.0001

Metolazone TAB 10mg 999 0.0625

Amiloride Hydrochloride / Hydrochlorothiazide TAB 5mg / 50mg 999 0.0001

Spironolactone / HCTZ TAB 25mg / 25mg 999 0.0001

Triamterene / Hydrochlorothiazide CAP 37.5mg / 25mg 999 0.0001

Triamterene / Hydrochlorothiazide TAB 37.5mg / 25mg 999 0.0001

Triamterene / Hydrochlorothiazide TAB 75mg / 50mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020


Midodrine TAB 2.5mg 999 0.0001

Midodrine TAB 5mg 999 0.0001

Midodrine TAB 10mg 999 0.0001

Cholestyramine POW 4gm/scoop 999 0.0001

Cholestyramine POW 4gm, Packet 1 0.4374

Cholestyramine POW 4gm, Packet 60 0.0100

Cholestyramine POW, LITE 4gm/scoop, 239.4gm 239.4 0.0100

Cholestyramine POW, LITE 4gm/scoop, 231gm 231 0.0100

Cholestyramine POW, LITE 4gm/scoop, 210gm 210 0.0100

Cholestyramine POW, LITE 4gm, Packet 60 0.0100



Colesevelam HCL TAB 625mg 999 0.0001

Colesevelam HCL PACK 3.75gm 999 0.0001

Colestipol TAB 1gm 999 0.0001

Colestipol GRA 500gm 500 0.1072



Colestipol Hydrochloride PKT 5gm 90 0.5371

Colestipol Hydrochloride PKT 5gm 30 0.5371

Fenofibrate CAP, DR 45mg 999 0.0001

Fenofibrate CAP, DR 135mg 999 0.0001

Fenofibrate TAB 35mg 999 0.4164

Fenofibric Acid TAB 105mg 999 0.0100

Fenofibrate CAP 150mg 999 0.0001












Gemfibrozil TAB 600mg 999 0.0001

Ezetimibe TAB 10mg 999 0.0001

Atorvastatin Calcium TAB 10mg 999 0.0001




Fluvastatin CAP 20mg 999 0.0001

Fluvastatin CAP 40mg 999 0.0001

Fluvastatin TAB, ER 80mg 999 0.0001

Lovastatin TAB 10mg 999 0.0001



Rosuvastatin Calcium TAB 5mg 999 0.0001




Pravastatin TAB 10mg 999 0.0001




Simvastatin TAB 5mg 999 0.0001










date of this list.



pharmacy network.


June 1, 2020




Niacin TAB 500mg 999 0.7000

Niacin TAB, ER 500mg 999 0.0001



Omega-3 Acid CAP 1GM 999 0.0001

Ezetimibe / Simvastatin TAB 10-10mg 999 0.0001




Sildenafil Citrate TAB 20mg 999 0.0726

Sildenafil Citrate SUS 10mg/ml 999 13.6297

Tadalafil (A) TAB 20mg 999 0.7078

Ambrisentan TAB 5mg 999 34.2952

Ambrisentan TAB 10mg 999 34.2952

Bosentan monohydrate TAB 62.5mg 999 16.5619

Bosentan monohydrate TAB 125mg 999 16.5619




Tadalafil TAB 2.5mg 999 0.0001

Tadalafil TAB 5mg 999 0.0001



Vardenafil HCL TAB 2.5mg 999 8.9894

Vardenafil HCL TAB 5mg 999 0.0001



Vardenafil HCL TAB, ODT 10mg 999 0.0001

Amlodipine / Atorvastatin TAB 2.5mg - 10mg 999 0.0001



Amlodipine / Atorvastatin TAB 5mg - 10mg 999 0.0001








Chlorpheniramine TAB 4mg 999 0.0086

Chlorpheniramine Maleate SYP 2mg / 5ml 999 0.0173

Dexchlorpheniramine SYP 2mg/5ml 999 1.3214

Carbinoxamine TAB 4mg 999 0.0001

Carbinoxamine TAB 6mg 999 3.6101

Carbinoxamine Maleate LIQ 4mg/5ml 999 0.0001

Clemastine Fumarate TAB 1.34mg 999 0.2114

Diphenhydramine Hydrochloride CAP 25mg 999 0.0001


Diphenhydramine TAB 25mg 999 0.0001

Diphenhydramine Hydrochloride LIQ 12.5mg / 5ml 999 0.0001

Diphenhydramine Hydrochloride ELIX 12.5mg / 5ml 999 0.0060

Promethazine Hydrochloride TAB 12.5mg 999 0.0001

Promethazine Hydrochloride TAB 25mg 999 0.0001

Promethazine Hydrochloride TAB 50mg 999 0.0001

Promethazine Hydrochloride SYP 6.25mg / 5ml 999 0.0113

Promethazine SUPP 12.5mg 999 0.0001

Promethazine Hydrochloride SUPP 25mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020


Promethazine Hydrochloride SUPP 50mg 999 0.0001

Cyproheptadine Hydrochloride TAB 4mg 999 0.0001

Cyproheptadine HCL SYP 2mg / 5ml 999 0.0001

Cetirizine TAB 5mg 999 0.0351

Cetirizine TAB 10mg 999 0.0001

Cetirizine TAB, CHEW 5mg 999 0.0001

Cetirizine TAB, CHEW 10mg 999 0.0001

Cetirizine SYP 1mg/ml 999 0.0001

Desloratadine TAB 5mg 999 0.0001

Desloratadine ODT TAB 2.5mg 999 0.0001

Desloratadine ODT TAB 5mg 999 2.5033

Fexofenadine TAB 60mg 999 0.1022

Fexofenadine TAB 180mg 999 0.0001

Levocetirizine Dihydrochloride TAB 5mg 999 0.0001

Levocetirizine SOLUTION 2.5mg/5ml 999 0.0001

Loratadine TAB 10mg 999 0.0001

Loratadine SYP 5mg / 5ml 999 0.0001

Loratidine TAB, DIS 10mg 999 0.2111

Pseudoephedrine HCL TAB 30mg 999 0.0176

Pseudoephedrine HCL TAB 60mg 999 0.0270

Oxymetazoline HCL SOL, NAS 0.05% 30 0.0242





Budesonide Nasal SPR 32mcg/spray 5 1.5410

Budesonide Nasal SPR 32mcg/spray 8.43 0.0100

Flunisolide SPY, NASAL 25mcg/ACT 999 0.0001

Fluticasone Propionate SPY 0.05%, 9.9ml 9.9 0.0100

Fluticasone Propionate SPY 0.05%, 16gm 16 0.0100

Fluticasone Propionate SPY 0.05%, 15.8ml 15.8 0.0100

Mometasone SPR, NASAL 50mcg 999 0.0001

Triamcinolone Acetonide Nasal AER 55mcg/act 10.8 0.4275

Triamcinolone Acetonide Nasal AER 55mcg/act 16.9 0.0100

Ipratropium Bromide SPY, NASAL 0.03%, 30ml 999 0.0001

Ipratropium Bromide SPY, NASAL 0.06%, 15ml 999 0.0001

Azelastine Nasal SPR 137mcg 999 0.0001

Azelastine SPRAY, NASAL 0.15% 999 0.0001

Olopatadine HCL SPRAY, Nasal 0.6% 999 0.0001

Saline SPY, NASAL 0.65%, 45ml 999 0.0120

Azelastine / Fluticasone Nasal SPR 137-50mcg/act 999 3.5922

Hydrocodone Bitartrate / Homatropine Methylbromide TAB 5mg/1.5mg 999 0.4219

Hydrocodone Bitartrate / Homatropine Methylbromide SYP 5-1.5mg / 5ml 999 0.0001

Benzonatate CAP 100mg 999 0.0001



Guaifenesin TAB 200mg 999 0.0100

Guaifenesin SYP 100mg / 5ml 999 0.0065

Guaifenesin TAB 600 mg 999 0.0001

Acetylcysteine SOL 10% Inhalation, 4ml 4 0.0100






Sodium Chloride NEB 0.90% 5 0.0100



Bromphenirmine / PE ELIX 1-2.5mg/5ml 999 0.0100








date of this list.



pharmacy network.


June 1, 2020


Brompheniramine / PSE SOL 1-15 mg / 5 ml 999 0.0080

Cetririzine / PSE TAB 5-120mg 999 0.0001

Loratadine / PSE TAB 5mg / 120mg 999 0.0001

Loratadine / PSE TAB 10mg / 240mg 999 0.0001

Fexofenadine / PSE TAB, ER 60-120mg 999 0.7199

Promethazine HCL / Phenylephrine HCL SYR 6.25-5mg / 5ml 999 0.0001

Pseudoephedrine HCL / Triprolidine HCL TAB 60-2.5mg 999 0.0361

Promethazine HCL / Codeine Phosphate SYR 6.25-10mg / 5ml 999 0.0001

Hydrocodone / Chlorpheniramine SUS, ER 10mg-8mg/5ml 999 0.0001

Promethazine HCL / Phenylephrine / Codine Phos SYR 6.25-5-10mg / 5ml 999 0.0726

Dextromethorphan Hydrobromide / Promethazine Hydrochloride SYP 15mg / 6.25mg/5ml 999 0.0001

Brompheniramine/Dextromethorphan/PSE SYP 2-10-30mg/5ml 999 0.0001

Guaifenesin / PSE / SYP 100-30 / 5ml 999 0.0134

Codeine Phosphate / Guaifenesin SOL 10mg-100mg / 5ml 999 0.0001

Dextromethorphan/Guaifenesin LIQ 10mg-100mg/5ml 999 0.0001

Dextromethorphan / Guaifenesin SYP 100-10mg/5ml 999 0.0082

Dextromethorphan/Guaifenesin TAB 60mg / 1200mg 999 0.3912

Codeine Phosphate / Guaifenesin / Pseudoephedrine Hydrochloride SOL 10-100-30mg / 5ml 999 0.0084

Ipratropium Bromide INH SOL 0.02% 999 0.0001

Cromolyn Sodium NEB 20mg/2ml, 2ml 999 2.3939

Albuterol Sulfate TAB 2mg 999 0.0001

Albuterol Sulfate TAB 4mg 999 0.0001

Albuterol Sulfate SYR 2mg / 5ml 999 0.0001

Albuterol Sulfate SOL 0.083%, Inhalation, 3ml 999 0.0001

Albuterol Sulfate SOL 0.50% 999 0.0001

Albuterol NEB .63/3ml 999 0.0001

Albuterol NEB 1.25mg 999 0.0001

Albuterol Sulfate HFA INH 108mcg/Act, 8.5gm 8.5 1.4635

Albuterol Sulfate HFA INH 108mcg/Act, 6.7gm 6.7 0.0100

Albuterol Sulfate HFA INH 108mcg/Act, 18gm 18 0.0100

Albuterol Sulfate TAB, ER 4mg 999 0.6107

Albuterol Sulfate TAB, ER 8mg 999 1.2502

Levalbuterol HCL NEB 0.31mg/3ml 999 0.0001





Levalbuterol Tartrate INH AER 45mcg 999 0.0001

Metaproterenol Sulfate SYR 10mg / 5ml 999 0.0211

Terbutaline Sulfate TAB 2.5mg 999 1.8627

Terbutaline Sulfate TAB 5mg 999 0.0001

Ipratropium Bromide / Albuterol INH SOL 0.5-3mg/3ml 999 0.0001

Fluticasone / Salmeterol INH 55-14mcg/act 999 0.0001






Theophylline SOL 80mg/15ml 999 0.0691

Theophylline TAB, ER 300mg 999 0.0001




Budesonide INH SOL 0.25mg/2ml 999 0.0001

Budesonide INH SOL 0.5mg/2ml 999 0.0001

Budesonide RES 1mg/2ml 999 0.0001

Zileuton TAB 600mg 999 0.0001

Montelukast Sodium TAB 10mg 999 0.0001

Montelukast Sodium TAB, CHEW 4mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020


Montelukast Sodium TAB, CHEW 5mg 999 0.0001

Montelukast GRA PKT 4mg 999 0.0001

Zafirlukast TAB 10mg 999 0.0001

Zafirlukast TAB 20mg 999 0.0001

Magnesium Hydroxide SUS 400mg / 5ml 999 0.0027

Magnesium Citrate SOL 1.745 GM / 30 ml 999 0.0034

Sodium Phosphate SOL, ENE 230 0.0056





Bisacodyl EC TAB 5mg 999 0.0100

Bisacodyl SUPP 10mg 999 0.0001

Sennosides TAB 8.6mg 999 0.0113

Sennosides SYP 8.8 mg / 5ml 999 0.0392

Calcium Polycarbophil TAB 625mg 999 0.0358

Docusate Calcium CAP 240mg 999 0.0376

Docusate Sodium CAP 100mg 999 0.0001

Docusate Sodium CAP 250mg 999 0.0243

Docusate Sodium LIQ 150mg / 15ml 999 0.0055

Docusate Sodium SYP 60mg / 15ml 999 0.0050

Lactulose SOL 10mg / 15ml 237 0.0091





Lactulose PAK 10gm 999 20.9720

Polyethylene Glycol POW 3350 999 0.0001

Polyethylene Glycol PKT 3350 999 0.0001

Senosides/Docusate Sodium TAB 8.6-50 MG 999 0.0001

Polyethylene Glycol SOL 999 0.0001

Bisacodyl/PEG 3350/Sod Bicarb/NaCL KIT 999 36.0043

PEG 3350 SOL 999 0.0001

PEG 3350 SOL, PKT 999 0.0001

Diphenoxylate / Atropine TAB 2.5mg/0.025mg 999 0.0001

Atropine / Diphenoxylate LIQ 0.025-2.5mg/5ml 999 0.0001

Loperamide HCL CAP 2mg 999 0.0001

Loperamide HCL TAB 2mg 999 0.0680

Loperimide HCL LIQ 1mg / 5ml 999 0.0166

Opium Tincture TIN 1% 473 2.4753

Opium Tincture TIN 1% 118 0.0100

Bismuth Subsalicylate TAB, CHEW 262mg 999 0.0455

Bismuth Subsalicylate SUS 262mg / 15ml 999 0.0066

Sodium Bicarbonate TAB 650mg 999 0.0069

Calcium Carbonate TAB, CHEW 500mg 999 0.0094

Calcium Carbonate TAB, CHEW 750mg 999 0.0186

Magnesium Oxide TAB 400mg 999 0.0001

AlumOH / MagOH / Simethicone SUS 200-200-20 999 0.0043

Aluminum / Magnesium / Simethicone SUS 400-400-40 / 5 ml 999 0.0052

Hyoscyamine TAB 0.125mg 999 0.0001

Hyoscyamine TAB, SL 0.125mg 999 0.0001

Hyoscyamine DRO 0.125mg/ml 999 0.5112

Hyoscyamine Sulfate TAB, ODT 0.125mg 999 0.0001

Hyoscyamine TAB, SR 0.375mg 999 0.0001

Glycopyrrolate TAB 1mg 999 0.0001

Glycopyrrolate TAB 2mg 999 0.0001

Methscopolamine TAB 2.5mg 999 0.0001

Methscopolamine TAB 5mg 999 0.0001

Propantheline Bromide TAB 15mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020


Dicyclomine Hydrochloride CAP 10mg 999 0.0001

Dicyclomine Hydrochloride TAB 20mg 999 0.0001

Dicyclomine Hydrochloride SOL 10mg/5ml 999 0.0001

Chlordiazepoxide Hydrochloride / Clidinium Bromide CAP 5mg / 2.5mg 999 0.0001

PB-Hyoscy-Atrop-Scopol TAB 16.2-0.1037-0.0194-0.0065mg 999 0.0001

Cimetidine TAB 200mg 999 0.0001




Cimetidine SOL 300mg / 5ml 999 0.0001

Famotidine TAB 10mg 999 0.0484



Famotidine SUS 40mg/5ml 999 0.0001

Nizatidine CAP 150mg 999 0.0001

Nizatidine CAP 300mg 999 0.0001

Nizatidine SOL 15mg/ml 999 0.0001

Misoprostol TAB 100mcg 999 0.0001

Misoprostol TAB 200mcg 999 0.0001

Esomeprazole Magnesium SUS PKT 10mg 999 4.5218



Esomeprazole Magnesium CAP 20mg 999 0.0001

Esomeprazole Magnesium CAP 40mg 999 0.0001

Lansoprazole CAP 15mg 999 0.0001

Lansoprazole CAP 30mg 999 0.0001

Lansoprazole ODT TAB 15mg 999 0.0001

Lansoprazole ODT TAB 30mg 999 0.0001

Omeprazole TAB 20mg 999 0.0001

Omeprazole CAP 10mg 999 0.0001



Omeprazole TAB, ODT 20mg 999 0.1944

Omeprazole Magnesium CAP, DR 20.6mg 999 0.0001

Pantoprazole TAB 20mg 999 0.0001

Pantoprazole TAB 40mg 999 0.0001

Rabeprazole TAB 20mg 999 0.0001

Sucralfate TAB 1GM 999 0.0001

Sucralfate SUS 1gm/10ml 999 0.0001

Amoxicillin/Clarithromycin/Lansoprazole KIT 500mg-500mg-30mg 14 days kit 999 0.0001

Omeprazole / Sod Bicarbonate CAP 20-1100mg 999 0.4834

Omeprazole / Sod Bicarbonate CAP 40-1100mg 999 0.0001

Omeprazole / Sod Bicarbonate POW PKT 20-1680mg 999 12.6496

Omeprazole / Sod Bicarbonate POW PKT 40-1680mg 999 15.7389

Dimenhydrinate TAB 50mg 999 0.0106

Meclizine Hydrochloride TAB 12.5mg 999 0.0001

Meclizine Hydrochloride TAB 25mg 999 0.0001

Scopolamine DIS 1mg/3Day 999 0.0001

Trimethobenzamide CAP 300mg 999 0.0001

Granisetron TAB 1mg 999 0.0001

Ondansetron TAB, ODT 4mg 999 0.0001

Ondansetron TAB, ODT 8mg 999 0.0001

Ondansetron TAB 4mg 999 0.0001



Ondansetron INJ 4mg/2ml 999 0.1523

Ondansetron INJ 40mg/20ml 999 0.0420

Ondansetron SOL 4mg/5ml 999 0.0001

Aprepitant CAP 40mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020




Aprepitant CAP 125mg-80mg 999 0.0001

Dronabinol CAP 2.5mg 999 0.0001

Dronabinol CAP 5mg 999 0.0001

Dronabinol CAP 10mg 999 0.0001

Doxylamine / Pyridoxine TAB, DR 10-10mg 999 2.8461

Ursodiol CAP 300mg 999 0.0001

Ursodiol TAB 250mg 999 0.0001

Ursodiol TAB 500mg 999 0.0001

Cromolyn Sodium CONC 100mg/5ml 999 0.0001

Simethicone TAB, CHEW 80 MG 999 0.0001

Simethicone TAB, CHEW 125MG 999 0.0237

Simethicone DRO 40mg / 0.6ml 45 0.0480



Metoclopramide Hydrochloride TAB 5mg 999 0.0001

Metoclopramide Hydrochloride TAB 10mg 999 0.0001

Metoclopramide Hydrochloride SOL 5mg/5ml 999 0.0001

Metoclopramide TAB, ODT 5mg 999 0.0001


Balsalazide CAP 750mg 999 0.0001

Mesalamine TAB, DR 800mg 999 0.0001

Mesalamine TAB, DR 1.2gm 999 0.0001

Mesalamine ENE 4gm 999 0.0541

Mesalamine SUP 1000mg 999 0.0001

Mesalamine CAP 400mg 999 1.3386

Mesalamine CAP 0.375gm 999 0.0001

Mesalamine ENE, KIT 4gm 999 0.0001

Sulfasalazine TAB 500mg 999 0.0001

Sulfasalazine TAB, EC 500mg 999 0.0001

Alosetron TAB 0.5mg 999 0.0001

Alosetron TAB 1mg 999 0.0001

Calcium Acetate CAP 667mg 999 0.0001

Calcium Acetate TAB 667mg 999 0.0001

Lanthanum Carbonate CHEW, TAB 500mg 999 0.0001



Sevelamer TAB 800mg 999 0.0001

Sevelamer Carbonate POW 0.8 GM 999 0.0001

Sevelamer Carbonate POW 2.4 GM 999 5.7812



Methanamine Mandelate TAB 500mg 999 0.4022

Methenamine Mandelate TAB 1GM 999 0.0001

Methenamine Hippurate TAB 1gm 999 0.0001

Nitrofurantoin SUS 25mg/5ml 999 0.0001

Nitrofurantoin Macrocrystal CAP 25mg 999 0.0001



Nitrofurantoin Monohydrate CAP 100mg 999 0.0001

Methenamine/Hyosc/meth blue/sod phos TAB 81.6mg 999 1.7062

Methenamine/Hyosc/meth blue/sod phos/phenyl salicy TAB 118mg 999 0.0001

Methenamine/Hyosc/meth blue/sod phos/phenyl salicy TAB 81mg 999 2.7806

Urogesic Blue TAB 999 0.6818

Darifenacin Hydrobromide TAB, ER 7.5mg 999 0.0001

Darifenacin Hydrobromide TAB, ER 15mg 999 0.0001

Oxybutynin Chloride TAB 5mg 999 0.0001

Oxybutynin Chloride SYP 5mg/5ml 999 0.0227








date of this list.



pharmacy network.


June 1, 2020


Oxybutynin Chloride TAB,ER 5mg 999 0.0001



Solifenacin Succinate TAB 5mg 999 0.0001

Solifenacin Succinate TAB 10mg 999 0.0001

Tolterodine Tartrate TAB 1mg 999 0.0001

Tolterodine Tartrate TAB 2mg 999 0.0001

Tolterodine Tartrate CAP, ER 2mg 999 0.0001

Tolterodine Tartrate CAP, ER 4mg 999 0.0001

Trospium Chloride TAB 20mg 999 0.0001

Trospium Chloride CAP,ER 60mg 999 0.0001

Bethanechol TAB 5mg 999 0.0001




Flavoxate HCL TAB 100mg 999 0.0001

Clindamycin CRE, VAG 2% 999 0.0001

Metronidazole GEL, VAG 0.75% 999 0.0001

Clotrimazole CRE, VAG 1%, 45gm 999 0.0510

Miconazole Nitrate VAG, CRE 2%, 45gm 999 0.0726

Miconazole Nitrate VAG, SUPP 100mg, #7 999 0.6637

Miconazole Nitrate VAG, SUPP 200mg, #3 999 10.6958

Miconazole Nitrate KIT 999 5.4721

Terconazole CRE, VAG 0.40% 999 0.0001

Terconazole CRE, VAG 0.80% 999 0.0001

Terconazole SUP 80mg 999 0.0001

Estradiol Hemihydrate TAB, VAG 10mcg 999 0.0001

Estradiol CRE, VAG 0.01% 999 0.0001

Potassium Citrate TAB, ER 5 meq 999 0.0001

Potassium Citrate TAB, ER 10 meq 999 0.0001

Potassium Citrate TAB, ER 15meq 999 0.0001

Citric Acid / Sodium Citrate SOL 15 0.0149



Potassium Citrate/Citric Acid SOL 999 0.0001

Phenazopyridine TAB 100mg 999 0.0001

Phenazopyridine TAB 200mg 999 0.0001

Sodium Chloride IRR SOL 0.9%, 500ml 500 0.0024



Dutasteride CAP 0.5mg 999 0.0001

Finasteride TAB 5mg 999 0.0001

Alfuzosin HCL TAB, ER 10mg 999 0.0001

Silodosin CAP 4mg 999 0.0001

Silodosin CAP 8mg 999 0.0001

Tamsulosin CAP 0.4mg 999 0.0001

Dutasteride/Tamsulosin CAP 0.5mg-0.4mg 999 0.0001

Alprazolam TAB 0.25mg 999 0.0001

Alprazolam TAB 0.5mg 999 0.0001

Alprazolam TAB 1mg 999 0.0001

Alprazolam TAB 2mg 999 0.0001

Alprazolam ODT TAB 0.25mg 999 0.0001

Alprazolam ODT TAB 0.5mg 999 0.0001

Alprazolam ODT TAB 1mg 999 0.0001

Alprazolam ODT TAB 2mg 999 1.7814

Alprazolam TAB, XR 0.5mg 999 0.0001

Alprazolam TAB, XR 1mg 999 0.0001










date of this list.



pharmacy network.


June 1, 2020


Chlordiazepoxide Hydrochloride CAP 5mg 999 0.0001



Clorazepate Dipotassium TAB 3.75mg 999 0.0001

Clorazepate Dipotassium TAB 7.5mg 999 0.0001

Clorazepate Dipotassium TAB 15mg 999 0.0001

Diazepam TAB 2mg 999 0.0001



Diazepam SOL 1mg/ml 999 0.0001

Lorazepam TAB 0.5mg 999 0.0001

Lorazepam TAB 1mg 999 0.0001

Lorazepam TAB 2mg 999 0.0001

Lorazepam CONC 2mg/ml 999 0.0001

Oxazepam CAP 10mg 999 0.0001



Buspirone TAB 5mg 999 0.0001

Buspirone TAB 7.5mg 999 0.0001




Hydroxyzine Hydrochloride TAB 10mg 999 0.0001



Hydroxyzine Hydrochloride SYP 10mg / 5ml 999 0.0001

Hydroxyzine Pamoate CAP 25mg 999 0.0001



Meprobamate TAB 200 mg 999 1.3202

Meprobamate TAB 400mg 999 2.0118

Mirtazapine TAB 7.5mg 999 0.0001

Mirtazapine TAB 15mg 999 0.0001



Mirtazapine TAB, DISP 15mg 999 0.0001



Phenelzine Sulfate TAB 15mg 999 0.0001

Tranylcypromine TAB 10mg 999 0.0001

Nefazodone TAB 50mg 999 0.0001





Trazodone Hydrochloride TAB 50mg 999 0.0001




Citalopram TAB 10mg 999 0.0001



Citalopram SOL 10mg / 5ml 999 0.0001

Escitalopram Oxalate TAB 5mg 999 0.0001

Escitalopram Oxalate TAB 10MG 999 0.0001

Escitalopram Oxalate TAB 20mg 999 0.0001

Escitalopram SOL 5mg/5ml 999 0.0001

Fluoxetine CAP 10mg 999 0.0001









date of this list.



pharmacy network.


June 1, 2020



Fluoxetine TAB 10mg 999 0.0001



Fluoxetine LIQ 20mg/5ml 999 0.0001


Fluvoxamine TAB 25mg 999 0.0001



Fluvoxamine Maleate CAP, CR 100mg 999 0.0001

Fluvoxamine Maleate CAP, CR 150mg 999 0.0001

Paroxetine TAB 10mg 999 0.0001




Paroxetine TAB, ER 12.5mg 999 0.0001

Paroxetine TAB, ER 25mg 999 0.0001

Paroxetine TAB, ER 37.5mg 999 0.0001

Sertraline Hydrochloride TAB 25mg 999 0.0001



Sertraline Hydrochloride SOL 20mg/ml 999 0.0001

Desvenlafaxine TAB, ER 25mg 999 0.0001



Duloxetine HCL CAP 20mg 999 0.0001




Venlafaxine Hydrochloride TAB 25mg 999 0.0001

Venlafaxine Hydrochloride TAB 37.5mg 999 0.0001




Venlafaxine Hydrochloride CAP, ER 37.5mg 999 0.0001

Venlafaxine Hydrochloride CAP, ER 75mg 999 0.0001

Venlafaxine Hydrochloride CAP, ER 150mg 999 0.0001

Venlafaxine Hydrochloride TAB, ER 37.5 mg 999 0.0001

Venlafaxine Hydrochloride TAB, ER 75mg 999 0.0001



Amitriptyline TAB 10mg 999 0.0001






Amoxapine TAB 50mg 999 0.4819



Clomipramine Hydrochloride CAP 25mg 999 0.0001



Desipramine HCL TAB 10mg 999 0.0001













date of this list.



pharmacy network.


June 1, 2020


Doxepin Hydrochloride CAP 10mg 999 0.0001






Doxepin Hydrochloride LIQ 10mg/ml, Conc 999 0.0001

Imipramine HCL TAB 10mg 999 0.0001



Imipramine Pamoate CAP 75mg 999 0.0001




Nortriptyline Hydrochloride CAP 10mg 999 0.0001




Nortriptyline Hydrochloride SOL 10mg/5ml 999 0.0001

Protriptyline TAB 5mg 999 0.8456

Protriptyline TAB 10mg 999 0.0001

Trimipramine Maleate CAP 25mg 999 1.1968



Maprotiline Hydrochloride TAB 25mg 999 0.3713



Bupropion HCL TAB 75mg 999 0.0001

Bupropion TAB 100mg 999 0.0001

Bupropion HCL TAB, SR 100mg 999 0.0001



Bupropion HCL TAB, XL 150mg 999 0.0001

Bupropion HCL TAB, XL 300mg 999 0.0001

Bupropion ER TAB 450mg 999 0.0001

Paliperidone TAB, ER 1.5mg 999 5.6312

Paliperidone TAB, ER 3mg 999 0.0001



Risperidone TAB 0.25mg 999 0.0001

Risperidone TAB 0.5mg 999 0.0001

Risperidone TAB 1mg 999 0.0001




Risperidone SOL 1mg/ml 999 0.0001

Risperidone TAB, ODT 0.5mg 999 0.0001

Risperidone TAB, ODT 1mg 999 0.0001




Haloperidol TAB 0.5mg 999 0.0001

Haloperidol TAB 1mg 999 0.0001





Haloperidol Lactate CONC 2mg / ml 5 0.2702









date of this list.



pharmacy network.


June 1, 2020



Haloperidol Decanoate INJ 100mg/ml 1 0.0100

Haloperidol Decanoate INJ 100mg/ml 5 23.8882

Clozapine TAB 25mg 999 0.0001




Clozapine TAB, ODT 12.5mg 999 1.0024

Clozapine TAB, ODT 25mg 999 1.1993




Quetiapine Fumarate TAB 25mg 999 0.0001






Quetiapine Fumarate TAB, ER 50mg 999 0.0001





Loxapine Succinate CAP 5mg 999 0.0001




Olanzapine TAB 2.5mg 999 0.0001

Olanzapine TAB 5mg 999 0.0001

Olanzapine TAB 7.5mg 999 0.0001



Olanzapine TAB 20 mg 999 0.0001

Olanzapine ODT TAB 5 mg 999 0.0001




Molindone HCL TAB 5mg 999 2.6040



Chlorpromazine HCL TAB 10mg 999 0.0001





Fluphenazine Hydrochloride TAB 1mg 999 0.0100

Fluphenazine Hydrochloride TAB 2.5mg 999 0.0100



Fluphenazine HCL CONC 5mg / ml 999 0.9814

Perphenazine TAB 2mg 999 0.0001




Prochlorperazine SUPP 25mg, #12 999 0.0001

Prochlorperazine TAB 5mg 999 0.0001

Prochlorperazine TAB 10mg 999 0.0001

Thioridazine Hydrochloride TAB 10mg 999 0.0993









date of this list.



pharmacy network.


June 1, 2020




Trifluoperazine HCL TAB 1mg 999 0.0516




Aripiprazole TAB, ER 2mg 999 0.0001






Aripiprazole SOL 1mg/ml 999 0.0001

Aripiprazole TAB, ODT 10mg 999 13.5779

Aripiprazole TAB, ODT 15mg 999 15.2845

Thiothixene CAP 1mg 999 0.1236




Ziprasidone Hydrochloride CAP 20mg 999 0.0001




Lithium Carbonate CAP 150mg 999 0.0001



Lithium Carbonate TAB 300mg 999 0.0001

Lithium Carbonate TAB, ER 300mg 999 0.0001

Lithium Carbonate TAB, ER 450mg 999 0.0001

Phenobarbital TAB 15mg 999 0.0001

Phenobarbital TAB 16.2mg 999 0.0001







Phenobarbital ELIX 20mg/5ml 999 0.0001

Estazolam TAB 1mg 999 0.0001

Estazolam TAB 2mg 999 0.0001

Flurazepam Hydrochloride CAP 15mg 999 0.0392

Flurazepam Hydrochloride CAP 30mg 999 0.0001

Midazolam SYP 2mg/ml 999 0.0001

Temazepam CAP 7.5mg 999 0.0001

Temazepam CAP 15mg 999 0.0001

Temazepam CAP 22.5mg 999 0.0001

Temazepam CAP 30mg 999 0.0001

Triazolam TAB 0.125mg 999 0.0001

Triazolam TAB 0.25mg 999 0.0001

Eszopiclone TAB 1mg 999 0.0001



Zaleplon CAP 5mg 999 0.0001

Zaleplon CAP 10mg 999 0.0001

Zolpidem TAB 5mg 999 0.0001

Zolpidem TAB 10mg 999 0.0001

Zolpidem TAB, ER 6.25mg 999 0.0001

Zolpidem TAB, ER 12.5mg 999 0.0001

Zolpidem TAB, SL 1.75mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020


Zolpidem TAB, SL 3.5mg 999 0.0001

Ramelteon TAB 8mg 999 0.0001



Doxepin Hydrochloride TAB 3mg 999 0.0001

Doxepin Hydrochloride TAB 6mg 999 0.0001

Amphetamine SUS, ER 1.25mg/ml 999 0.8098

Amphetamine sulfate TAB 5mg 999 0.0001

Amphetamine sulfate TAB 10mg 999 0.0001

Dextroamphetamine TAB 5mg 999 0.0001

Dextroamphetamine TAB 10mg 999 0.0001

Dextroamphetamine Sulfate SOL 5mg/5ml 999 0.0001

Dextroamphetamine CAP, CR 5mg 999 0.0001



Methamphetamine HCL TAB 5mg 999 0.0001

Amphetamine/Dextroamphetamine TAB 5mg 999 0.0001

Amphetamine/Dextroamphetamine TAB 7.5mg 999 0.0001


Amphetamine/Dextroamphetamine TAB 12.5mg 999 0.0001




Amphetamine/Dextroamphetamine CAP, ER 5mg 999 0.0001






Benzphetamine TAB 50mg 999 0.0001

Diethylpropion HCL TAB 25 MG 999 0.0001

Diethylpropion Hydrochloride TAB, CR 75mg 999 0.0001

Phendimetrazine TAB 35mg 999 0.0001

Phendimetrazine CAP, ER 105mg 999 0.0100

Phentermine CAP 15mg 999 0.0001

Phentermine CAP 30mg 999 0.0001

Phentermine CAP 37.5mg 999 0.0001

Phentermine TAB 37.5mg 999 0.0001

Caffeine Citrate SOL 20mg/ml 999 2.0960

Clonidine HCL TAB, ER 0.1mg 999 0.0001

Guanfacin TAB, ER 1mg 999 0.0001




Atomoxetine HCL CAP 10mg 999 0.0001







Armodafinil TAB 50mg 999 0.0001




Dexmethylphenidate HCL TAB 2.5mg 999 0.0001

Dexmethylphenidate HCL TAB 5mg 999 0.0001

Dexmethylphenidate HCL TAB 10mg 999 0.0001

Dexmethylphenidate HCL CAP, ER 5mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020









Methylphenidate CAP, CD 10mg 999 0.0001






Methylphenidate Hydrochloride TAB 5mg 999 0.0001



Methylphenidate Hydrochloride TAB, ER 10mg 999 0.0001






Methylphenidate Hydrochloride TAB, CHEW 2.5mg 999 0.0001

Methylphenidate Hydrochloride TAB, CHEW 5mg 999 2.1070

Methylphenidate Hydrochloride TAB, CHEW 10mg 999 2.9937

Methylphenidate SOL 5mg/5ml 999 0.0001

Methylphenidate HCL SOL 10mg/5ml 999 0.0001

Methylphenidate Hydrochloride CAP, ER 10mg 999 0.0001





Methylphenidate Hydrochloride TAB, SR 24hr 18mg 999 3.0465




Modafinil TAB 100mg 999 0.0001

Modafinil TAB 200mg 999 0.0001

Ergoloid Mesylates TAB 1mg 999 2.6934

Pimozide TAB 1mg 999 0.0001

Pimozide TAB 2mg 999 0.0001

Donepezil HCL TAB 5mg 999 0.0001



Donepezil HCL ODT 5mg 999 0.1000

Donepezil HCL ODT 10mg 999 0.1209

Galantamine TAB 4mg 999 0.0001



Galantamine ER CAP 8mg 999 0.0001



Rivastigmine DIS 4.6mg/24hr 999 0.0001



Rivastigmine CAP 1.5mg 999 0.1327

Rivastigmine CAP 3mg 999 0.0001

Rivastigmine CAP 4.5mg 999 0.1669

Rivastigmine CAP 6mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020


Memantine HCL TAB 5mg 999 0.0001

Memantine HCL TAB 10mg 999 0.0001

Memantine HCL PAK 5mg&10mg 999 0.0001

Memantine HCL SOL 10mg/5ml 999 0.0001

Memantine HCL CAP, ER 7mg 999 0.0001





Nicotine DIS 7mg / 24hr 999 0.0001

Nicotine DIS 14mg / 24hr 999 0.0001

Nicotine DIS 21mg / 24 hr 999 0.0001

Nicotine Polacrilex GUM 2 mg 999 0.0001

Nicotine Polacrilex GUM 4 mg 999 0.0001

Nicotine LOZ 2mg 999 0.0001

Nicotine LOZ 4mg 999 0.0001

Fluoxetine (S) TAB 10mg 999 6.3906

Fluoxetine (S) TAB 20mg 999 7.1269

Paroxetine Mesylate CAP 7.5mg 999 0.0001

Tetrabenazine TAB 12.5mg 999 8.2231

Tetrabenazine TAB 25mg 999 17.5895

Glatiramer Acetate INJ 20mg/ml 999 35.5884

Glatiramer Acetate INJ 40mg/ml 999 90.0270

Dalfampridine TAB, ER 10mg 999 1.0546

Acamprosate Calcium TAB 333mg 999 0.0001

Disulfiram TAB 250mg 999 0.0001

Disulfiram TAB 500mg 999 0.0001

Chlordiazepoxide / Amitriptyline TAB 5-12.5mg 999 0.0500

Chlordiazepoxide / Amitriptyline TAB 10-25mg 999 0.8859

Perphenazine / Amitriptyline TAB 2-10mg 999 0.3090





Olanzapine / Fluoxetine CAP 3-25mg 999 3.6600





Aspirin TAB 325mg 999 0.0051

Aspirin TAB, CHEW 81mg 999 0.0001

Aspirin TAB 81mg 999 0.0001

Aspirin TAB, EC 325mg 999 0.0080

Aspirin TAB, DR 500MG 999 0.0362

Diflunisal TAB 500mg 999 0.0001

Salsalate TAB 500mg 999 0.0001

Salsalate TAB 750mg 999 0.0001

Acetaminophen TAB 325mg 999 0.0067

Acetaminophen TAB 500mg 999 0.0092

Acetaminophen TAB, CR 650mg 999 0.0412

Acetaminophen TAB, CHEW 80mg 999 0.0309

Acetaminophen LIQ 160mg/5ml 999 0.0001

Acetaminophen ELIX 160mg/5ml 999 0.0068

Acetaminophen SUS 160MG/5ML 118 0.0139













date of this list.



pharmacy network.


June 1, 2020




Acetaminophen SOL 160mg/5ml 10.15 0.0812

Acetaminophen SOL 160mg/5ml 20.3 0.0424

Acetaminophen SOL 160mg/5ml 473 0.0040



Acetaminophen SUPP 120mg 999 0.0878



Acetaminophen / Butalbital TAB 300mg/50mg 999 3.4377

Acetaminophen / Butalbital TAB 325mg/50mg 999 0.0001

Acetaminophen / Butalbital / Caffeine CAP 300-50-40mg 999 0.0001

Acetaminophen / Butalbital / Caffeine CAP 325-50-40mg 999 0.0001

Acetaminophen / Butalbital / Caffeine TAB 325/50/40mg 999 0.0001

Butalbital / Aspirin / Caffeine CAP 50/325/40mg 999 0.0001

Codeine Sulfate TAB 30mg 999 0.0001

Fentanyl PATCH 12mcg/hr 999 0.0001

Fentanyl PATCH 25 mcg/ hr 999 0.0001

Fentanyl PATCH 37.5mcg/hr 999 0.0001

Fentanyl PATCH 50 mcg/hr 999 0.0001





Fentanyl Citrate TAB 100mcg 999 26.4648





Fentanyl Citrate LOLLIPOP 200mcg 999 0.0001






Hydrocodone Bitartrate CAP, ER 10mg 999 3.4779






Hydromorphone TAB 2mg 999 0.0001



Hydromorphone TAB, ER 8mg 999 0.0001




Levorphanol Tartrate TAB 2mg 999 23.4737

Meperidine Hydrochloride TAB 50mg 999 0.0001

Meperidine Hydrochloride TAB 100mg 999 0.0001

Meperidine Hydrochloride SYR 50mg/5ml 999 0.1222

Methadone Hydrochloride TAB 5mg 999 0.0001



Morphine Sulfate TAB 15mg 999 0.0001

Morphine Sulfate TAB 30mg 999 0.0001

Morphine Sulfate TAB, CR 15mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020






Morphine Sulfate SOL 10mg/5ml 100 0.0100







Morphine Sulfate SOL 20mg/ml 999 0.0001

Morphine Sulfate SUPP 5mg 999 3.5315



Morphine Sulfate CAP, ER 10mg 999 0.0001








Morphine Sulfate Beads CAP, ER 30mg 999 3.5214






Oxycodone HCL CAP 5mg 999 0.0001

Oxycodone HCL TAB 5mg 999 0.0001





Oxycodone HCL CONC 20mg/ml 30 0.0100

Oxycodone HCL SOL 5mg/5ml 5 0.3584



Oxycodone HCL TAB, CR 10 mg 999 2.1079



Oxycodone HCL TAB, CR 80mg 999 5.8173

Oxymorphone HCL TAB 5mg 999 0.0001

Oxymorphone HCL TAB 10mg 999 0.0001

Oxymorphone HCL TAB, ER 5mg 999 0.0001

Oxymorphone HCL TAB, ER 7.5mg 999 0.0001






Tramadol TAB 50mg 999 0.0001

Tramadol TAB, ER 100mg 999 0.0001

Tramadol TAB, ER 200MG 999 0.0001

Tramadol TAB, ER 300mg 999 0.0001

Tramadol TAB, ER Biphasic Release 100mg 999 0.0001

Tramadol TAB, ER Biphasic Release 200mg 999 0.0001

Tramadol TAB 300mg 999 1.3920








date of this list.



pharmacy network.


June 1, 2020


Buprenorphine PATCH 5mcg/hr 999 0.0001

Buprenorphine PATCH 7.5mcg/hr 999 49.4477




Buprenorphine TAB, SL 2mg 999 0.0001

Buprenorphine TAB, SL 8MG 999 0.0001

Buprenorphine / Naloxone TAB, SUB 2mg-0.5mg 999 0.0001

Buprenorphine / Naloxone TAB, SUB 8mg-2mg 999 0.0001

Buprenorphine HCl-Naloxone HCl FILM, SL 2-0.5mg 999 2.8633

Buprenorphine HCl-Naloxone HCl FILM, SL 4-1mg 999 5.3557



Butorphanol SOL 10mg/ml , 2.5ml 999 0.0001

Pentazocine / Naloxone TAB 50mg / 0.5mg 999 1.3399

Oxycodone HCL / Acetaminophen TAB 2.5-325mg 999 0.8632

Oxycodone HCL / Acetaminophen TAB 5-325 mg 999 0.0001

Oxycodone HCL / Acetaminophen TAB 7.5-325 mg 999 0.0001

Oxycodone HCL / Acetaminophen TAB 10-325 mg 999 0.0001

Oxycodone / Aspirin TAB 4.8355 / 325mg 999 0.2105

Oxycodone / Ibuprofen TAB 5-400mg 999 0.7531

Acetaminophen / Codeine Phosphate TAB 300-15 mg 999 0.0001



Acetaminophen / Codeine Phosphate SOL 120-12mg / 5ml 999 0.0099

Butalbital / APAP / Caffeine / Codeine CAP 50/300/40/30mg 999 4.8095

Acetaminophen / Butalbital / Caffeine / Codeine CAP 325/50/40/30mg 999 0.0001

Aspirin / Butalb / Caffeine / Codeine CAP 325-50-40-30mg 999 0.0001

Acetaminophen / Caffeine / Dihydrocodeine TAB 320.5mg / 30mg / 16mg 999 0.0001

Acetaminophen / Hydrocodone Bitartrate TAB 325-10 mg 999 0.0001


Acetaminophen / Hydrocodone Bitartrate TAB 300-7.5 mg 999 0.0001

Acetaminophen / Hydrocodone Bitartrate TAB 325-5mg 999 0.0001

Acetaminophen / Hydrocodone Bitartrate TAB 325-7.5mg 999 0.0001


Acetaminophen / Hydrocodone Bitartrate SOL 325-7.5mg / 15ml 999 0.0001

Hydrocodone Bitartrate / Ibuprofen TAB 5-200mg 999 0.8325

Hydrocodone Bitartrate / Ibuprofen TAB 7.5mg/200mg 999 0.0001

Hydrocodone Bitartrate / Ibuprofen TAB 10-200mg 999 0.0001

Acetaminophen / Tramadol TAB 325 / 37.5 mg 999 0.0001

Diclofenac Potassium TAB 50mg 999 0.0001

Diclofenac Sodium TAB, EC 25mg 999 0.0001



Diclofenac Sodium TAB, SR 100mg 999 0.0001

Etodolac CAP 200mg 999 0.0001

Etodolac CAP 300mg 999 0.0001

Etodolac TAB 400mg 999 0.0001

Etodolac TAB 500mg 999 0.0001

Etodolac TAB, ER 400mg 999 0.0001



Fenoprofen CAP 200mg 999 8.7900

Fenoprofen CAP 400mg 999 1.6853

Fenoprofen Calcium TAB 600mg 999 0.0001

Flurbiprofen TAB 50mg 999 0.0804

Flurbiprofen TAB 100mg 999 0.0001

Ibuprofen TAB 100mg 999 0.1263









date of this list.



pharmacy network.


June 1, 2020





Ibuprofen SUS 100mg / 5ml 999 0.0001

Indomethacin CAP 25mg 999 0.0001

Indomethacin CAP 50mg 999 0.0001

Indomethacin CAP, ER 75mg 999 0.0001

Ketoprofen CAP, ER 200mg 999 0.0001

Ketorolac TAB 10mg 999 0.0001

Meclofenamate Sodium CAP 50mg 999 2.3158

Meclofenamate Sodium CAP 100mg 999 4.0342

Mefenamic Acid CAP 250mg 999 0.0001

Meloxicam TAB 7.5mg 999 0.0001

Meloxicam TAB 15mg 999 0.0001

Nabumetone TAB 500mg 999 0.0001

Nabumetone TAB 750mg 999 0.0001

Naproxen TAB 250mg 999 0.0001



Naproxen TAB, EC 375mg 999 0.0001

Naproxen TAB, EC 500mg 999 0.0001

Naproxen SUS 125mg/5ml 999 0.0001

Naproxen Sodium TAB 220mg 999 0.0328



Naproxen Sodium TAB, ER 375mg 999 4.9281

Naproxen TAB, CR 500mg 999 0.4255

Oxaprozin TAB 600mg 999 0.0001

Piroxicam CAP 10mg 999 0.0001

Piroxicam CAP 20mg 999 0.0001

Sulindac TAB 150mg 999 0.0001

Sulindac TAB 200mg 999 0.0001

Tolmetin CAP 400mg 999 0.0001

Tolmetin TAB 600mg 999 1.8351

Celecoxib TAB 50mg 999 0.0001




Diclofenac/Misoprostol TAB 50-0.2mg 999 0.0001

Diclofenac/Misoprostol TAB 75-0.2mg 999 0.0001

Naproxen / Esomeprazole Magnesium TAB, DR 375-20mg 999 10.2542

Naproxen / Esomeprazole Magnesium TAB, DR 500-20mg 999 10.2542

Leflunomide TAB 10mg 999 0.0001

Leflunomide TAB 20mg 999 0.0001

Dihydroergotamine Mesylate Nasal SPR 4mg/ml 999 0.0001

Almotriptan Malate TAB 6.25mg 999 17.5805

Almotriptan Malate TAB 12.5mg 999 0.0001

Eletriptan Hydrobromide TAB 20mg 999 0.0001

Eletriptan Hydrobromide TAB 40mg 999 0.0001

Frovatriptan TAB 2.5mg 999 0.0001

Naratriptan TAB 1mg 999 0.0001

Naratriptan TAB 2.5mg 999 0.0001

Rizatriptan TAB 5mg 999 0.0001

Rizatriptan TAB 10mg 999 0.0001

Rizatriptan TAB, ODT 5mg 999 0.0001

Rizatriptan TAB, ODT 10mg 999 0.0001

Sumatriptan SPR, NASAL 5mg/ACT 999 0.0001

Sumatriptan SPR, NASAL 20mg/ACT 999 0.0001

Sumatriptan TAB 25mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020




Sumaptriptan INJ 6mg/0.5 999 0.0001

Sumatriptan INJ, Statdose Auto -injector 4mg/0.5ml 999 0.0001

Sumaptriptan INJ, Auto-injector 6mg/0.5 999 0.0001

Sumatriptan INJ, Statdose Cartridge 4mg/0.5ml 999 0.0001

Sumatriptan INJ, Cartridge 6mg/0.5 999 0.0001

Zolmitriptan TAB 2.5mg 999 0.0001

Zolmitriptan TAB 5mg 999 0.0001

Zolmitriptan TAB, ODT 2.5mg 999 0.0001

Zolmitriptan TAB, ODT 5mg 999 0.0001

Isometh/APAP CAP 65 / 325 mg 999 2.0559

Ergotamine/Caffeine TAB 1mg-100mg 999 0.0001

Sumatriptan/Naproxen TAB 85-500mg 999 0.0001

Allopurinol TAB 100mg 999 0.0001

Allopurinol TAB 300mg 999 0.0001

Colchicine CAP 0.6mg 999 0.0001

Colchicine TAB 0.6mg 999 0.0001

Febuxostat TAB 40mg 999 0.0001

Febuxostat TAB 80mg 999 0.0001

Probenecid TAB 500mg 999 0.0001

Probenecid / Colchicine TAB 500mg/0.5mg 999 0.0001

Clobazam TAB 10mg 999 0.0001

Clobazam TAB 20mg 999 0.0001

Clobazam SUS 2.5mg/ml 999 0.0001

Clonazepam TAB 0.5mg 999 0.0001

Clonazepam TAB 1mg 999 0.0001

Clonazepam TAB 2mg 999 0.0001

Clonazepam ODT TAB 0.125mg 999 0.0001



Clonazepam ODT TAB 1mg 999 0.0001

Clonazepam ODT TAB 2mg 999 0.5938

Diazepam GEL 2.5mg 999 0.0001

Diazepam GEL 10mg 999 0.0001

Diazepam GEL 20mg 999 0.0001

Felbamate TAB 400mg 999 0.4127

Felbamate TAB 600mg 999 0.0001

Felbamate SUS 600mg/5ml 999 0.0358

Tiagabine HCL TAB 2mg 999 1.4593




Vigabatrin TAB 500mg 999 65.0110

Vigabatrin POW 500mg 999 22.5372

Phenytoin TAB, CHEW 50mg 999 0.0001

Phenytoin SUS 125mg / 5ml 999 0.0543

Phenytoin CAP 100mg 999 0.0001

Phenytoin Sodium CAP, EX 200mg 999 0.3045

Phenytoin Sodium CAP, EX 300mg 999 0.7498

Ethosuximide CAP 250mg 999 0.0001

Ethosuximide SYP 250mg / 5ml 999 0.0001

Divalproex TAB, DR 125mg 999 0.0001



Divalproex TAB, ER 250mg 999 0.0001

Divalproex TAB, ER 500mg 999 0.0001

Divalproex CAP, SPR 125mg 999 0.0001

Valproic Acid SYP 250mg / 5ml 999 0.0001








date of this list.



pharmacy network.


June 1, 2020


Valproic Acid CAP 250mg 999 0.0001

Carbamazepine TAB 200mg 999 0.0001

Carbamazepine TAB, CHEW 100mg 999 0.0001

Carbamazepine SUS 100mg / 5ml 999 0.0001

Carbamazepine CAP, ER 100mg 999 0.0001



Carbamazepine TAB, ER 100mg 999 0.0001



Gabapentin CAP 100mg 999 0.0001



Gabapentin TAB 600mg 999 0.0001

Gabapentin TAB 800mg 999 0.0001

Gabapentin SOL 250mg/5ml 999 0.0001

Lamotrigine TAB 25mg 999 0.0001




Lamotrigine TAB, DIS 5 mg 999 0.0001

Lamotrigine TAB, DIS 25 mg 999 0.0001

Lamotrigine TAB, ODT 25mg 999 0.0001




Lamotrigine TAB,ER 25mg 999 0.0001






Levetiracetam TAB 250mg 999 0.0001




Levetiracetam SOL 100mg/ml 999 0.0001

Levetiracetam TAB, ER 500mg 999 0.0001

Levetiracetam TAB, ER 750mg 999 0.0001

Oxcarbazepine TAB 150mg 999 0.0001



Oxcarbazepine SUS 300mg/5ml 999 0.0001

Pregabalin CAP 25mg 999 0.0001








Pregabalin SOL 20mg/ml 999 0.0962

Primidone TAB 50mg 999 0.0001

Primidone TAB 250mg 999 0.0001

Topiramate TAB 25mg 999 0.0001




Topiramate CAP, Sprinkle 15mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020


Topiramate CAP, Sprinkle 25mg 999 0.0001

Topiramate CAP, ER 25mg 999 0.0001





Zonisamide CAP 25mg 999 0.0001



Benztropine Mesylate TAB 0.5mg 999 0.0001

Benztropine Mesylate TAB 1mg 999 0.0001

Benztropine Mesylate TAB 2mg 999 0.0001

Trihexyphenidyl Hydrochloride TAB 2mg 999 0.0001

Trihexyphenidyl Hydrochloride TAB 5mg 999 0.0001

Tolcapone TAB 100mg 999 25.5121

Entacapone TAB 200mg 999 0.0001

Amantadine Hydrochloride CAP 100mg 999 0.0001

Amantadine Hydrochloride TAB 100mg 999 0.0001

Amantadine Hydrochloride SYR 50mg / 5ml 999 0.0001

Bromocriptine CAP 5mg 999 0.1557

Bromocriptine Mesylate TAB 2.5mg 999 0.0001

Pramipexole Dihydrochloride TAB 0.125 mg 999 0.0001



Pramipexole Dihydrochloride TAB 0.75ng 999 0.0001

Pramipexole Dihydrochloride TAB 1 mg 999 0.0001


Pramipexole Dihydrochloride TAB, ER 0.375mg 999 0.0001




Pramipexole Dihydrochloride TAB, ER 3mg 999 0.0001



Ropinirole TAB 0.25mg 999 0.0001

Ropinirole TAB 0.5mg 999 0.0001

Ropinirole TAB 1mg 999 0.0001





Ropinirole TAB, ER 2mg 999 0.0001





Carbidopa / Levodopa TAB 10 / 100mg 999 0.0001



Carbidopa / Levodopa TAB, ER 25 / 100mg 999 0.0001

Carbidopa / Levodopa TAB, ER 50 / 200mg 999 0.0001

Carbidopa/Levodopa TAB, ODT 10-100mg 999 0.3710



Carbidopa/Levodopa/Entacapone TAB 12.5-50-200mg 999 0.3664


Carbidopa/Levodopa/Entacapone TAB 25-100-200mg 999 0.0001










date of this list.



pharmacy network.


June 1, 2020


Carbidopa/Levodopa/Entacapone TAB 50-200-200mg 999 0.0001

Rasagiline Mesylate TAB 0.5mg 999 0.0001

Rasagiline Mesylate TAB 1mg 999 0.0001

Selegiline Hydrochloride CAP 5mg 999 0.0001

Selegiline Hydrochloride TAB 5mg 999 0.0001

Carbidopa TAB 25mg 999 0.0001

Riluzole TAB 50mg 999 0.0001

Baclofen TAB 5mg 999 0.6045



Carisoprodol TAB 250mg 999 0.0001

Carisoprodol TAB 350mg 999 0.0001

Chlorzoxazone TAB 375mg 999 3.3564



Cyclobenzaprine Hydrochloride TAB 5mg 999 0.0001

Cyclobenzaprine Hydrochloride TAB 7.5mg 999 0.0001

Cyclobenzaprine Hydrochloride TAB 10mg 999 0.0001

Cyclobenzaprine HCL CAP, ER 15mg 999 0.0001

Cyclobenzaprine HCL CAP, ER 30mg 999 4.6422

Metaxalone TAB 400mg 999 0.0001

Metaxalone TAB 800mg 999 0.0001

Methocarbamol TAB 500mg 999 0.0001

Methocarbamol TAB 750mg 999 0.0001

Orphenadrine Citrate TAB, ER 100mg 999 0.0001

Tizanidine CAP 2mg 999 0.0001



Tizanidine HCL TAB 2mg 999 0.0001

Tizanidine HCL TAB 4mg 999 0.0001

Dantrolene CAP 25 mg 999 0.0001



Carisoprodol / Aspirin TAB 200mg-325mg 999 0.5072

Carisoprodol / Aspirin / Codeine TAB 200mg-325mg-16mg 999 0.6499

Orphenadrine / Aspirin / Caffeine TAB 50mg / 770mg / 60mg 999 7.8400

Pyridostigmine TAB 30mg 999 3.0462

Pyridostigmine TAB 60mg 999 0.0001

Pyridostigmine TAB, ER 180mg 999 1.0551

Pyridostigmine SOL 60mg/5ml 999 1.2597

Niacin TAB 500mg 999 0.0160

Niacin TAB, CR 500mg 999 0.0219

Ascorbic Acid TAB 500mg 999 0.0153

Ergocalciferol CAP 50000 IU 999 0.0001

Ergocalciferol SOL 8000 unit/ml 999 0.0001

Cholecalciferol CAP 1000 unit 999 0.0001

Cholecalciferol TAB 1000 unit 999 0.0001

Phytonadione TAB 5mg 999 0.0001

B-Complex w/ C & Folic Acid TAB 1mg 999 0.0001

B-Complex w/ C & Folic Acid TAB 999 0.0315

Vitamin B Complex w/ C & Folic Acid TAB 1mg 999 0.0392

Multi-Vitamins TAB 999 0.2433

Multi-Vitamins w/ Minerals & FA CAP 999 0.1156

Multi-Vitamins w/ Minerals TAB 999 0.0270

Pediatric Multiple Vitamin TAB CHEW 999 0.0129

Multi-Vitamins Pediatric w/ Iron DRO 10mg/ml 999 0.0670

Multi-Vitamins Pediatric ACD w/ Fluoride DRO 0.25mg/ml 999 0.0001

Multi-Vitamins Pediatric ACD w/ Fluoride DRO 0.5mg/ml 999 0.0001

Multi-Vitamins Pediatric w/ Fluoride TAB, CHEW 0.25mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020


Multi-Vitamins Pediatric w/ Fluoride TAB, CHEW 0.5mg 999 0.0001

Multi-Vitamins Pediatric w/ Fluoride TAB, CHEW 1mg 999 0.0001

Multi-Vitamins Pediatric w/ Fluoride DRO 0.25mg/ml 999 0.0001

Multi-Vitamins Pediatric w/ Fluoride DRO 0.5mg/ml 999 0.0001

Multi-Vitamins Pediatric w/ Fluoride & Iron DRO 0.25-10mg/ml 999 0.0001

Prenatal Vitamins TAB 29-1mg 999 0.0001

Prenatal Vitamins TAB 999 0.1507


Prenatal Vit w/ Fe Fumerate-Methylfolate-FA TAB 27-0.6-0.4mg 999 0.0001



Prenatal Vit w/ Fe Fumerate-Methylfolate-FA-DHA CAP 27-0.6-0.4mg 999 0.0001

Calcium Carbonate TAB 600mg 999 0.0163

Calcium, Oyster Shell TAB 500mg 999 0.0081

Calcium Carbonate / /Vit D2 TAB 250mg / 125mg 999 0.0133

Sodium Fluoride TAB, CHEW 1mg 999 0.0001

Sodium Fluoride DRO 0.1mg / ml 999 0.0001

Magnesium Oxide TAB 400mg 999 0.0160

Potassium Phos / Sodium Phos TAB 250mg 999 0.0001

Potassium Bicarbonate TAB, EFF 25meq 999 0.0001

Potassium Chloride CAP, SA 8meq 999 0.0001

Potassium Chloride CAP, CR 10meq 999 0.0001

Potassium Chloride TAB, CR 8meq (600mg) 999 0.0001

Potassium Chloride TAB, CR 10meq 999 0.0001

Potassium Chloride TAB, CR 20meq 999 0.0001

Potassium Chloride SOL 10% 473 0.0100





Potassium Chloride POW 20meq 999 0.0001

Potassium Chloride TAB, ER 10meq 999 0.0001



Potassium Chloride / Potassium Bicarbonate / Citric Acid TAB , EFF 25meq 999 0.7574

Electrolyte SOL 999 0.0013

L-Methylfolate TAB 7.5mg 999 0.0001

L-Methylfolate TAB 15mg 999 0.0001

Folic Acid / Vit B6 / Vit B12 TAB 2.5mg-25mg-2mg 999 0.0001

Cyanocobalamin INJ 1000mcg 1 0.0100



Folic Acid TAB 400mcg 999 0.0076

Folic Acid TAB 800mcg 999 0.0088

Folic Acid TAB 1mg 999 0.0001

Iron SUS 15mg/1.25ml 999 0.2353

Ferrous Sulfate TAB 325mg 999 0.0001

Ferrous Sulfate TAB, DR 325mg (65) 999 0.0001

Ferrous Sulfate ELIX 220mg / 5ml 999 0.0087

Ferrous Sulfate SOL 75mg/ml 999 0.0001

Ferrous Sulfate, Dried TAB 160mg 999 0.0426

Ferrous Gluconate TAB 240mg 999 0.0119

Ferrous Fumarate TAB 325mg 999 0.0726

Iron Polysaccharide Complex CAP 150mg 999 0.0001

Miglustat CAP 100mg 999 90.8400

Folic Acid / Vit B6 / Vit B12 TAB 2.2mg-25mg-500mcg 999 0.0001

Folic Acid/Vit B6/Vit B12 TAB 2.2-25-1mg 999 0.0001

Folic Acid / Vit B6 / Vit B12 TAB 2.5mg-25mg-1mg 999 0.0001

Iron Combination CAP 999 0.1803








date of this list.



pharmacy network.


June 1, 2020


Iron Polysacch Complex / Vit B12 / FA CAP 999 0.0001

Ferrous Fumarate / B12 / Vit C / FA / IFC CAP 999 0.0001

Enoxaparin Sodium INJ 30mg/0.3ml 999 0.0001




Enoxaparin Sodium INJ 100mg/ml 999 0.0001


Enoxaparin Sodium INJ 150mg/ml 999 0.0001

Enoxaparin Sodium INJ 300mg/3ml 999 9.0000

Fondaparinux Sodium INJ 2.5mg/0.5ml 999 0.0001

Fondaparinux Sodium INJ 5mg/0.4ml 999 80.0071

Fondaparinux Sodium INJ 7.5mg/0.6ml 999 46.5511

Fondaparinux Sodium INJ 10mg/0.8ml 999 33.7642

Warfarin TAB 1mg 999 0.0001


Warfarin TAB 2.5mg 999 0.0001





Warfarin TAB 7.5mg 999 0.0001


Aminocaproic Acid TAB 500mg 999 8.8781

Aminocaproic Acid TAB 1000mg 999 16.8600

Aminocaproic Acid SOLN 0.25gm/ml 999 0.0001

Tranexamic Acid TAB 650mg 999 0.0001

Dipyridamole TAB 25mg 999 0.0428



Cilostazol TAB 50mg 999 0.0001

Cilostazol TAB 100mg 999 0.0001

Anagrelide CAP 0.5mg 999 0.1064

Anagrelide CAP 1mg 999 0.0001

Clopidogrel TAB 75mg 999 0.0001

Clopidogrel TAB 300mg 999 8.9129

Prasugrel TAB 5mg 999 0.0001

Prasugrel TAB 10mg 999 0.0001

Aspirin / Dipyridamole CAP 25mg-200mg 999 0.0001

Pentoxyphylline TAB 400mg 999 0.0001

Icatibant INJ 30mg/3ml 999 885.6380

Bacitracin OIN, OPTH 500u / gm 999 0.0001

Ciprofloxacin HCl SOL 0.3%, 5ml 5 0.0100

Ciprofloxacin HCl SOL 0.3%, 2.5ml 2.5 0.0100

Ciprofloxacin HCl SOL 0.3%, 10ml 10 0.0100

Erythromycin OIN, OPTH 5mg/gm, Ophth 3.5 0.0100

Erythromycin OIN, OPTH 5mg/gm, Ophth 1 0.0100

Gatifloxacin SOL, OPTH 2.50% 999 0.0001

Gentamicin Sulfate SOL, OPTH 0.30% 5 0.0100

Gentamicin Sulfate OPTH OIN 0.3%, 3.5gm 999 0.0001

Levofloxacin OPTH SOL 0.50% 999 3.6000

Moxifloxacin SOL, OPTH 0.5% 999 0.0001

Moxifloxacin HCL SOL, OPTH 0.5%, BID 999 28.1022

Ofloxacin SOL, OPTH 0.30% 5 0.0100

Ofloxacin SOL, OPTH 0.30% 10 0.0100

Tobramycin Sulfate SOL, OPTH 0.30% 999 0.0001

Sulfacetamide Sodium SOL, OPTH 10% 15 0.0100

Sulfacetamide Sodium SOL, OPTH 10% 5 0.0100

Trifluridine SOL, OPTH 1%, 7.5ml 999 0.0001








date of this list.



pharmacy network.


June 1, 2020


Bacitracin Zinc / Polymyxin B sulfate OIN, OPTH 500U-10000U / gm, 3.5gm 999 0.0001

Polymyxin B Sulf / Trimethoprim Sulf SOL, OPTH 10,000 units-1mg/ml 999 0.0001

Neomycin / Bacitracin / Polymyxin B Sulf OIN, OPTH 3.5mg/400U/10,000U 999 0.0001

Neomycin Sulf / Polymyxin B Sulf / Gramicidin SOL, OPTH 1.75mg-10,000U-0.025mg/ml 999 0.0001

Polyvinyl Alcohol DRO 999 0.0726

Dextran / Hpromellose / Glycerin DRO 0.1-.3-.2% 15 0.1293








Betaxolol HCL SOL 0.5%, 15ml 15 7.7372



Carteolol HCL SOL, OPTH 1%, 10ml 10 0.5719



Metipranolol SOL 0.3% Opth, 10ml 10 2.4480

Metipranolol SOL 0.3% Opth, 5ml 5 2.8968

Levobunolol HCL SOL, OPTH 0.5%, 5ml 5 0.6120

Timolol Maleate SOL, OPTH 0.25% 15 0.1214



Timolol Maleate SOL, OPTH 0.5%, 15ml 15 0.0100




Timolol Maleate SOL, OPTH 0.5%, 2.5ml 2.5 0.0100

Timolol Maleate XE SOL, OPTH 0.25%, 5ml 999 0.0001

Timolol Maleate XE SOL, OPTH 0.5%, 5ml 999 0.0001

Dorzolamide / Timolol SOL, OPTH 2% - 0.5% 999 0.0001

Dorzolamide / Timolol SOL, OPTH (PF) 2%-0.5% 999 0.0001

Dexamethasone SOL, OPTH 0.10% 999 0.0001

Fluorometholone SUS, OPTH 0.1%, 5ml 5 0.0100

Fluorometholone SUS, OPTH 0.1%, 10ml 10 0.0100

Loteprednol Etabonate Opth.Susp. 0.5% 5 0.0100



Prednisolone Acetate SUS, OPTH 1%, 15ml 15 0.0100



Prednisolone / Sulfacetamide SOL 0.25%-10%, 5ml 5 0.0100

Tobramycin/Dexamethasone OPTH SUS 0.3%-0.1% 2.5 0.0100

Tobramycin/Dexamethasone OPTH SUS 0.3%-0.1% 5 0.0100

Tobramycin/Dexamethasone OPTH SUS 0.3%-0.1% 10 0.0100

Neomycin / Polymyxin B Sulf / Dexamethasone SUS, OPTH 0.35%-10,000U-0.1%, 5ml 999 0.0001

Neomycin / Polymyxin B Sulf / Dexamethasone OIN, OPTH 0.35%-10,000U-0.1% 999 0.0001

Neomycin/Polymyxin/Hydrocortisone SUS, OPTH 1% 999 0.0001

Bacitracin / Neomycin / Polymixin B Sulf / HC OIN, OPTH 400U/1%/5mg/10,000U 3.5gm 999 0.0001

Bimatoprost OPTH SOL 0.03% 2.5 0.0100

Bimatoprost OPTH SOL 0.03% 5 13.7323

Bimatoprost OPTH SOL 0.03% 7.5 13.7323

Latanoprost OPTH SOL 0.005% 999 0.0001

Travoprost SOL, OPTH 0.004%, 2.5ml 2.5 0.0100

Travoprost SOL, OPTH 0.004%, 5ml 5 0.0100

Cyclopentolate HCL SOL, OPTH 0.50% 999 2.0507

Cyclopentolate HCL SOL, OPTH 1%, 15ml 15 0.0100








date of this list.



pharmacy network.


June 1, 2020


Cyclopentolate HCL SOL, OPTH 1%, 2ml 2 0.0100

Phenylephrine SOL 10% 999 1.5880

Tropicamide SOL, OPTH 0.5%, Ophthalmic 999 0.0001

Tropicamide SOL, OPTH 1%, Ophthalmic 2 2.6686



Tetrahydrozoline HCL SOL, OPTH 0.05% 999 0.0677

Pilocarpine SOL, OPTH 1% 15ml 999 0.0001



Apraclonidine HCL OPH SOL 0.50% 10 6.9555

Apraclonidine HCL OPH SOL 0.50% 5 0.0100

Brimonidine Tartrate SOL 0.15% 5 0.0100






Proparacaine Hydrochloride SOL, OPTH 0.50% 999 0.0001

Azelastine OPTH SOL 0.05% 999 0.0001

Cromolyn Sodium SOL, OPTH 4% 999 0.0001

Epinastine OPTH SOL 0.05% 999 0.0001

Ketotifen Fumarate SOL, OPTH 0.025% 5 0.0100

Ketotifen Fumarate SOL, OPTH 0.025% 10 0.7563

Olopatadine OPTH SOL 0.10% 999 0.0001

Olopatadine HCl OPTH SOL 0.2% 999 0.0001

Dorzolamide SOL, OPTH 2% 999 0.0001

Bromfenac OPTH SOL 0.09% (B) 999 69.8593

Diclofenac Sodium SOL, OPTH 0.1%, 2.5ml 2.5 0.0100

Diclofenac Sodium SOL, OPTH 0.1%, 5ml 5 0.0100

Flurbiprofen Sodium SOL, OPTH 0.03% 999 0.0001

Ketorolac OPTH SOL 0.40% 999 0.0001




Ciprofloxacin SOL, OTIC 0.20% 999 0.0001

Ofloxacin SOL, OTIC 0.3% 10 0.0100

Ofloxacin SOL, OTIC 0.3% 5 0.0100

Fluocinolone Acetonide OTIC OIL 0.01% 999 0.0001

Acetic Acid / Hydrocortisone SOL 2% / 1%, Otic, 10ml 999 0.0001

Acetic Acid SOL 2%, Otic, 15ml 999 0.0001

Carbamide Peroxide DRO, OTIC 6.5% 999 0.0001

Hydrocortisone / Neomycin / Polymyxin B Sulf SUS, OTIC 1%, 10ml 999 0.0001

Hydrocortisone / Neomycin / Polymyxin B Sulf SOL, OTIC 1%, 10ml 999 0.0001

Hydrocortisone/Pramoxine/Chloroxylenol SOL, OTIC 1%-10%-1% 15 1.2068

Hydrocortisone/Pramoxine/Chloroxylenol SOL, OTIC 1%-10%-1% 10 1.2068

Nystatin SUS 100,000 units/ml 5 0.0350




Clotrimazole Troche 10mg 999 0.0001

Chlorhexidine Gluconate SOL 0.12% Dental Sol 118 0.0046



Triamcinolone Acetonide PASTE 0.1%, Dental Paste 999 0.0001

Lidocaine HCL SOL 2% 15 0.0136

Lidocaine HCL SOL 2% 100 0.0100

Sodium Fluoride CRE, DENTAL 1.10% 999 0.0001

Cevimeline CAP 30mg 999 0.0001








date of this list.



pharmacy network.


June 1, 2020


Pilocarpine TAB 5mg 999 0.0001

Pilocarpine TAB 7.5mg 999 0.5258

Hydrocortisone CRE, RECTAL 2.50% 999 0.0001

Hydrocortisone SUPP 25mg, #100 100 0.8567



Hydrocortisone SUPP 30mg 999 0.0001

Hydrocortisone ENE 100mg/60ml 999 0.0001

Lidocaine HCL / Hydrocortisone CRE, RECT 3% / 0.5% 7 0.4755

Lidocaine HCL / Hydrocortisone CRE, RECT 3% / 0.5% 85 0.6139

Lidocaine HCL / Hydrocortisone CRE, RECT 3% / 0.5% 28.35 0.6139

Lidocaine HCL / Hydrocortisone CRE, RECT 3% / 0.5% 28.3 0.6139

Lidocaine HCL / Hydrocortisone CRE, KIT 2%-2% 999 88.8916

Lidocaine HCL / Hydrocortisone CRE, KIT 3%-0.5% 999 90.2265

Lidocaine HCL / Hydrocortisone CRE, KIT 3%-1% 999 45.3275

Lidocaine HCL / Hydrocortisone GEL, KIT 3%-2.50% 999 116.2584

Hydrocortisone Acetate/Pramoxine HCL CRE 1-1% 999 0.0001

Hydrocortisone Acetate/Pramoxine HCL CRE 2.5% 4 0.9523

Hydrocortisone Acetate/Pramoxine HCL CRE 2.5% 30 0.0100

Adapalene CRE 0.10% 999 0.0001

Adapalene GEL 0.10% 999 0.0001

Adapalene GEL 0.30% 999 0.0001

Benzoyl Peroxide LIQ WASH 5% 142 0.0309

Benzoyl Peroxide LIQ 5% 237 0.0301




Benzoyl Peroxide LIQ WASH 7%, 180gm 180 0.7105

Benzoyl Peroxide LIQ WASH 7%, 473ml 473 0.0100







Benzoyl Peroxide FOAM 5.3% 60 0.8959




Benzoyl Peroxide GEL 5% 42.5 0.0419

Benzoyl Peroxide GEL 5% 90 0.0449


Benzoyl Peroxide GEL 10% 42.5 0.1197





Benzoyl Peroxide CLOTH 0.06 999 0.0001

Isotretinoin CAP 10mg 999 0.0001




Tretinoin CRE 0.025%, 20gm 20 0.0100

Tretinoin CRE 0.025%, 45gm 45 0.0100

Tretinoin CRE 0.05%, 20gm 20 0.0100




Tretinoin GEL 0.01%, 15gm 15 0.0100








date of this list.



pharmacy network.


June 1, 2020


Tretinoin GEL 0.01%, 45gm 45 0.0100

Tretinoin GEL 0.025%, 45gm 45 0.0100

Tretinoin GEL 0.025%, 20gm 20 0.0100

Tretinoin GEL 0.025%, 15gm 15 0.0100

Tretinoin GEL 0.05% 999 0.0001

Tretinoin GEL, MICRO 0.04%, 20gm 20 0.0100






Clindamycin Phosphate SOL 1%, 60ml 60 0.0100

Clindamycin Phosphate SOL 1%, 30ml 30 0.0100

Clindamycin Phosphate FOAM 1% 50 0.0100

Clindamycin Phosphate FOAM 1% 100 0.0100

Clindamycin Phosphate GEL 1% 30 0.0100



Clindamycin Phosphate LOT 1% 999 0.0001

Clindamycin Phosphate TOP, SWAB 1% 69 5.8727

Clindamycin Phosphate TOP, SWAB 1% 60 0.0100

Dapsone GEL 5% 90 0.0100

Dapsone GEL 5% 60 0.0100

Dapsone GEL 7.5% 60 0.0100

Dapsone GEL 7.5% 90 0.0100

Erythromycin SOL 2%, Topical 999 0.0001

Erythromycin GEL 2%, Topical, 60gm 60 0.0100

Erythromycin GEL 2%, Topical, 30gm 30 0.0100

Erythromycin PAD 2% Topical, #60 999 0.0001

Sulfacetamide Sodium LOT 10% 999 0.0001

Adapalene / Benzoyl Peroxide GEL 0.1%-2.5% 999 0.0001

Erythromycin / Benzoyl Peroxide GEL 3%-5%, 46.6gm 46.6 0.0100

Erythromycin / Benzoyl Peroxide GEL 3%-5%, 23.3gm 23.3 0.0100

Clindamycin Phosphate / Benzoyl peroxide GEL 1%-5% 25 0.0100



Clindamycin / Benzoyl Peroxide GEL 1.2-2.5% 50 0.0100

Clindamycin / Benzoyl Peroxide Gel 1.2-5% 999 0.0001

Clindamycin / Tretinoin GEL 1.2%-0.025% 30 0.0100

Clindamycin / Tretinoin GEL 1.2%-0.025% 60 0.0100

Sulfacetamide Sodium/Sulfur WASH 9%-4% 999 0.0001

Sulfacetamide Sodium/Sulfur WASH 9%-4.5% 999 0.0893

Sulfacetamide Sodium/Sulfur LIQ 9.8%-4.8% 285 0.4036

Sulfacetamide Sodium/Sulfur LIQ 10%-2% 999 0.0100

Sulfacetamide Sodium/Sulfur EMU 10%-5% 340.2 0.0702

Sulfacetamide Sodium/Sulfur EMU 10%-5% 170.3 0.1144

Sulfacetamide Sodium/Sulfur EMU 10%-5% 170 0.0100



Sulfacetamide Sodium/Sulfur SUS 8%-4% 999 0.0001

Sulfacetamide Sodium/Sulfur CRE 10%-2% 999 3.8949



Sulfacetamide Sodium/Sulfur LOT 10%/5% 25 0.0100



Sulfacetamide Sodium/Sulfur KIT 9%-4.5% 999 291.8791

Azelaic Acid GEL 15% 999 0.0001









date of this list.



pharmacy network.


June 1, 2020


Metronidazole CRE 0.75% 999 0.0001

Metronidazole GEL 0.75% 999 0.0001

Metronidazole GEL 1%, 55gm 55 0.0100

Metronidazole GEL 1%, 60gm 60 0.0100

Metronidazole LOT 0.75% 999 0.0001

Bacitracin OIN 500u / gram 1 0.0500


Bacitracin OIN 500u / gram 28.4 0.0465











Gentamicin Sulfate CRE 0.10% 15 0.0100

Gentamicin Sulfate CRE 0.10% 30 0.0100

Gentamicin Sulfate OIN 0.10% 15 0.0100

Gentamicin Sulfate OIN 0.10% 30 0.0100

Mupirocin OIN 2%, 15gm 15 0.0100

Mupirocin OIN 2%, 22gm 22 0.0100

Mupirocin CRE 2% 30 0.0100

Mupirocin CRE 2% 15 1.6446

Bacitracin / Polymyxin OIN 28.4 0.0442

Bacitracin / Polymyxin OIN 28 0.0804






Neomycin / Bacitracin / Polymyxin B Sulf OIN 5mg/400U/5,000U 999 0.0599

Ciclopirox SOL 8% 999 0.0001

Ciclopirox GEL 0.77% 100 0.0100



Ciclopirox Shampoo 1% 999 0.0001

Ciclopirox SUS 0.77%, 60ml 60 0.0100

Ciclopirox SUS 0.77%, 30ml 30 0.0100

Ciclopirox CRE 0.77%, 90gm 90 0.0100



Naftifine HCL CRE 1%, 90gm 90 1.6597




Naftifine HCl GEL 1% 40 4.7750



Nystatin POW 100,000 units/gm 60 0.0100



Nystatin CRE 100,000 units/gm 15 0.0100

Nystatin CRE 100,000 units/gm 30 0.0100

Nystatin OIN 100,000 units/gm 30 0.0100

Nystatin OIN 100,000 units/gm 15 0.0100

Tolnaftate POW 1% 45 0.0387








date of this list.



pharmacy network.


June 1, 2020


Tolnaftate POW 1% 67.5 0.0400

Tolnaftate CRE 1% 999 0.0392

Terbinafine HCL CRE 1% 999 0.2101

Clotrimazole SOL 1% 10 0.6633

Clotrimazole SOL 1% 30 0.0100

Clotrimazole CRE 1% 999 0.0001

Econazole CRE 1%, 15gm 15 0.0100



Ketoconazole CRE 2%, 15gm 15 0.0100



Ketoconazole AER 2% 50 0.0100

Ketoconazole AER 2% 100 0.0100

Ketoconazole SHAM 2% 999 0.0001

Luliconazole CRE 1% 60 0.0100

Miconazole Nitrate CRE 2% 999 0.0001

Oxiconazole CRE 1%, 60gm 60 2.4232



Betamethasone / Clotrimazole CRE 1%-0/05%, 15gm 15 0.0100

Betamethasone / Clotrimazole CRE 1%-0/05% 45gm 45 0.0100

Betamethazole / Clotrimazole LOT 1%-0/05% 999 0.0001

Hydrocortisone/Iodoquinol CRE 1%-1% 999 0.0001

Nystatin / Triamcinolone Acetonide CRE 100,000 units/gm/0.1% 60 0.0100



Nystatin / Triamcinolone Acetonide OIN 100,000 units/gm/0.1% 60 0.0100



Miconazole Nitrate / Zinc Oxide / Petrolatum OIN 0.25-15-81.35% 50 5.7891

Diclofenac PATCH 1.3% 999 5.6932

Diclofenac Sodium SOL 1.50% 999 0.0001

Diclofenac Sodium GEL 1% 999 0.0001

Diclofenac Sodium / Capsaicin PAK 1.5%-0.025% 268 6.0051

Diclofenac Sodium / Capsaicin PAK 1.5%-0.025% 387 5.6885

Doxepin Hydrochloride CRE 5.00% 999 6.8559

Calcipotriene SOL 0.01% 999 0.7258

Calcipotriene CRE 0.05% 60 0.0100

Calcipotriene CRE 0.05% 120 0.0100

Calcipotriene OIN 0.05% 60 0.0100

Calcipotriene OIN 0.05% 120 0.0100

Calcitriol OIN 3mcg/gm 999 0.0001

Tazarotene CRE 0.10% 30 0.0100

Tazarotene CRE 0.10% 60 0.0100

Acitretin CAP 10mg 999 4.6434

Acitretin CAP 17.5mg 999 0.0001

Acitretin CAP 25mg 999 0.0001

Methoxsalen CAP 10mg 999 23.1866

Selenium Sulfide LOT 2.50% 999 0.0001

Selenium Sulfide SHAMPOO 2.25% 999 0.0001

Selenium Sulfide SHAMPOO 2.3% 999 0.0001

Sulfacetamide Sodium WASH 10% 177 0.0100

Sulfacetamide Sodium WASH 10% 354.8 0.2232



Acyclovir CRE 5% 999 0.0001

Acyclovir OIN 5% 30 0.0100









date of this list.



pharmacy network.


June 1, 2020



Fluorouracil SOL 2% 999 0.2440

Fluorouracil SOL 5% 999 0.0001

Fluorouracil CRE 0.5% 999 28.9372

Fluorouracil CRE 5% 999 0.0001

Diclofenac Sodium GEL 3% 999 0.0001

Silver Sulfadiazine CRE 1% , 85gm 85 0.0100

Silver Sulfadiazine CRE 1%, 1000gm 1000 0.0634




Silver Sulfadiazine CRE 1% , 20gm 20 0.0100

Alclometasone CRE 0.05%, 45gm 45 0.0100



Alclometasone OIN 0.05%, 15gm 15 0.0100



Amcinonide CRE 0.1%, 15gm 15 5.3278



Betamethasone Dipropionate CRE 0.05%, 15gm 15 0.0100

Betamethasone Dipropionate CRE 0.05%, 45gm 45 0.0100

Betamethasone Dipropionate LOT 0.05%, 60ml 999 0.0001

Betamethasone Dipropionate OIN 0.05%, 15gm 15 0.0100

Betamethasone Dipropionate OIN 0.05%, 45gm 45 0.0100

Betamethasone Augmented CRE 0.05%, 15gm 15 0.0100

Betamethasone Augmented CRE 0.05%, 50gm 50 0.0100

Betamethasone Augmented GEL 0.05%, 15gm 15 0.0100

Betamethasone Augmented GEL 0.05%, 50gm 50 1.2755

Betamethasone Augmented LOT 0.05%, 60ml 60 0.0100

Betamethasone Augmented LOT 0.05%, 30ml 30 0.0100

Betamethasone Augmented OIN 0.05%, 45gm 45 0.0100



Betamethasone Valerate CRE 0.10% 15 0.0100

Betamethasone Valerate CRE 0.10% 45 0.0100

Betamethasone Valerate FOAM, AER 0.12%, 50gm 50 0.0100

Betamethasone Valerate FOAM, AER 0.12%, 100gm 100 0.0100

Betamethasone Valerate LOT 0.10% 999 0.0001

Betamethasone Valerate OIN 0.1%, 15gm 15 0.0100

Betamethasone Valerate OIN 0.1%, 45gm 45 0.0100

Clobetasol Propionate SPR 0.05%, 125ml 125 0.0100

Clobetasol Propionate SPR 0.05%, 59ml 59 0.0100

Clobetasol Propionate SOL 0.05%, 25ml 25 0.0100

Clobetasol Propionate SOL 0.05%, 50ml 50 0.0100

Clobetasol Propionate CRE 0.05%, 15gm 15 0.0100




Clobetasol Propionate FOAM 0.05% 100 0.0100

Clobetasol Propionate FOAM 0.05% 50 0.0100

Clobetasol Propionate GEL 0.05%, 30gm 30 0.0100



Clobetasol Propionate LOT 0.05% 59 0.0100

Clobetasol Propionate LOT 0.05% 118 0.0100

Clobetasol Propionate OIN 0.05%, 15gm 15 0.0100









date of this list.



pharmacy network.


June 1, 2020




Clobetasol Propionate SHAMPOO 0.05% 999 0.0001

Clobetasol Propionate CRE, EMOL 0.05%, 60gm 60 0.0100




Clobetasol Propionate AER EMOL 0.05% 100 0.0100

Clobetasol Propionate AER EMOL 0.05% 50 1.9104

Clocortolone Pivalate CRE 0.10% 45 0.0100

Clocortolone Pivalate CRE 0.10% 75 3.4160

Desonide CRE 0.05%, 15gm 15 0.0100

Desonide CRE 0.05%, 60gm 60 0.0100

Desonide LOT 0.05%, 59ml 59 0.0100

Desonide LOT 0.05%, 118ml 118 0.0100

Desonide OIN 0.05%, 15gm 15 0.0100

Desonide OIN 0.05%, 60gm 60 0.0100

Desoximetasone SPR 0.25% 100 0.8984

Desoximetasone CRE 0.05%, 100gm 100 1.6610






Desoximetasone GEL 0.05%, 15gm 15 2.0352

Desoximetasone GEL 0.05%, 60gm 60 1.7833

Desoximetasone OIN 0.05%, 100gm 100 1.3367





Diflorasone Diacetate CRE 0.05%, 60gm 60 2.4865



Diflorasone Diacetate OIN 0.05%, 15gm 15 2.6377



Fluocinolone Acetonide OIL 0.01% (Body Oil) 999 0.0001

Fluocinolone Acetonide OIL 0.01% (Scalp Oil) 999 0.0001

Fluocinolone Acetonide SOL 0.01% 999 0.0001

Fluocinolone Acetonide CRE 0.01%, 15gm 15 0.0100




Fluocinolone Acetonide OIN 0.025%, 15gm 15 0.0100

Fluocinolone Acetonide OIN 0.025%, 60gm 60 0.0100

Fluocinonide SOL 0.05% 60 0.0100

Fluocinonide SOL 0.05% 20 0.0100

Fluocinonide CRE 0.05% 120 0.0100







Fluocinonide GEL 0.05%, 30gm 30 0.0100



Fluocinonide OIN 0.05%, 60gm 60 0.0100








date of this list.



pharmacy network.


June 1, 2020




Fluocinonide Emollient CRE 0.05% 15 0.0100



Flurandrenolide CRE 0.05% 60 2.7301

Flurandrenolide CRE 0.05% 120 0.0100

Flurandrenolide LOT 0.05% 999 0.0001

Flurandrenolide OIN 0.05% 999 4.8116

Fluticasone Propionate CRE 0.05%, 30gm 30 0.0100



Fluticasone Propionate LOT 0.05% 60 0.0100

Fluticasone Propionate LOT 0.05% 120 1.6190

Fluticasone Propionate OIN 0.005%, 30gm 30 0.0100



Halcinonide CRE 0.1% 60 0.0100

Halcinonide CRE 0.1% 30 0.0100

Halobetasol Propionate CRE 0.05%, 15gm 15 0.0100

Halobetasol Propionate CRE 0.05%, 50gm 50 0.0100

Halobetasol Propionate OIN 0.05%, 15gm 15 0.0100

Halobetasol Propionate OIN 0.05%, 50gm 50 0.0100

Hydrocortisone CRE 0.50% 57 0.0367

Hydrocortisone CRE 0.50% 28.35 0.0367



Hydrocortisone CRE 1% 999 0.0001







Hydrocortisone LOT 1% 999 0.0364

Hydrocortisone LOT 2.50% 118 0.0100

Hydrocortisone LOT 2.50% 59 0.0100

Hydrocortisone OIN 0.5% 56 0.1081

Hydrocortisone OIN 0.5% 28.4 0.1081

Hydrocortisone OIN 0.5% 28.35 0.0927

Hydrocortisone OIN 0.5% 30 0.1081

Hydrocortisone OIN 1% 999 0.0001

Hydrocortisone OIN 2.5%, 28.35gm 28.35 0.0100

Hydrocortisone OIN 2.5%, 20gm 20 0.0100

Hydrocortisone OIN 2.5%, 453.6gm 453.6 0.0587

Hydrocortisone OIN 2.5%, 454gm 454 0.0100

Hydrocortisone Acetate CRE 1% 999 0.0365

Hydrocortison Valerate CRE 0.2%, 60gm 60 0.0100



Hydrocortison Valerate OIN 0.2%, 60gm 60 0.0100



Hydrocortisone Butyrate SOL 0.1%, 60ml 60 0.0100

Hydrocortisone Butyrate SOL 0.1%, 20ml 20 1.2915

Hydrocortisone Butyrate CRE 0.1%, 15gm 15 0.0100

Hydrocortisone Butyrate CRE 0.1%, 45gm 45 0.0100

Hydrocortisone Butyrate LOT 0.1%, 59ml 59 0.0100

Hydrocortisone Butyrate LOT 0.1%, 118ml 118 0.0100








date of this list.



pharmacy network.


June 1, 2020


Hydrocortisone Butyrate OIN 0.1%, 15gm 15 0.0100

Hydrocortisone Butyrate OIN 0.1%, 45gm 45 1.3862

Hydrocortisone Butyrate CRE, LIPO 0.1%, 60gm 60 0.0100

Hydrocortisone Butyrate CRE, LIPO 0.1%, 45gm 45 2.3801

Mometasone Furoate SOL 0.1%, 30ml 30 0.0100

Mometasone Furoate SOL 0.1%, 60ml 60 0.0100

Mometasone Furoate CRE 0.1%, 15gm 15 0.0100

Mometasone Furoate CRE 0.1%, 45gm 45 0.0100

Mometasone Furoate OIN 0.10%, 15gm 15 0.0100

Mometasone Furoate OIN 0.10%, 45gm 45 0.0100

Prednicarbate CRE 0.1% 60 1.1229

Prednicarbate OIN 0.1% 60 1.0248

Prednicarbate OIN 0.1% 15 1.4161

Triamcinolone AER SPR 63 1.7733

Triamcinolone AER SPR 100 1.7733

Triamcinolone Acetonide CRE 0.025% 454 0.0211




Triamcinolone Acetonide CRE 0.10% 28.4 0.1881



Triamcinolone Acetonide CRE 0.10% 453.6 0.0256




Triamcinolone Acetonide LOT 0.025%, 60ml 60 0.0100

Triamcinolone Acetonide LOT 0.10% 999 0.0001

Triamcinolone Acetonide OIN 0.025%, 80gm 80 0.0100



Triamcinolone OIN 0.05% 430 0.8159

Triamcinolone Acetonide OIN 0.10% 80 0.0100


Triamcinolone Acetonide OIN 0.10% 453.6 0.0100




Hydrocortisone Acetate/Pramoxine HCL CRE 2.5%, 28.4gm 28.4 0.0100

Hydrocortisone Acetate/Pramoxine HCL CRE 2.5%, 57gm 57 1.0968

Calcipotriene/Betamethasone SUS 0.005%-0.064% 999 0.0001

Calcipotriene/Betamethasone OIN 0.005%-0.064% 100 0.0100

Calcipotriene/Betamethasone OIN 0.005%-0.064% 60 0.0100

Hydrocortisone w/ Aloe CRE 1.00% 28 0.0363

Hydrocortisone w/ Aloe CRE 1.00% 56.8 0.0475

Hydrocortisone w/ Aloe CRE 1.00% 28.4 0.0387



Ammonium Lactate CRE 12% 385 0.0100

Ammonium Lactate CRE 12% 140 0.0100

Ammonium Lactate LOT 12% 999 0.0001

Urea CRE 40% 198.4 0.2943

Urea CRE 40% 85 0.0100

Urea CRE 40% 28.3 1.4401

Urea CRE 41% 227 1.1600

Urea LOT 40% 226.8 0.2486

Urea LOT 40% 325 0.2486

Urea LOT 40% 236.6 0.2486

Granulex AER 113.4 0.0715








date of this list.



pharmacy network.


June 1, 2020


Granulex AER 56.7 0.1790

Bimatoprost SOL 0.03%, 5ml 5 15.4911

Bimatoprost SOL 0.03%, 3ml 3 0.0100

Finasteride TAB 1mg 999 0.0001

Minoxidil SOL 2% 999 0.0475

Podofilox Sol SOL 3.5ml 999 0.0001

Salicylic Acid CRE 6% 454 0.1122



Salicylic Acid LOT 6% 999 0.0475

Salicylic Acid CRE, KIT 6% 999 43.2409

Imiquimod CRE 3.75% 7.5 0.0100

Imiquimod CRE 5% 24 0.0100



Pimecrolimus CRE 1% 30 0.0100



Tacrolimus OIN 0.03% 100 0.0100






Capsaicin CRE 0.025 60 0.0428

Capsaicin CRE 0.025 118 0.0530

Lidocaine CRE 3% 28.35 0.4115

Lidocaine CRE 3% 85 0.3936





Lidocaine OIN 5% 2500 0.2222



Lidocaine OIN 5% 35.44 0.0100

Lidocaine PATCH 5% 30 0.0100



Lidocaine Hcl SOL 4% 999 0.0001






Lidocaine GEL 2%/ml 85 0.1720






Lidocaine/Prilocaine CRE 2.5/2.5% 5 0.0100




Lidocaine/Prilocaine KIT 2.5/2.5% 999 16.4135

Hydroquinone CRE 4% 28.35 0.0100

Hydroquinone CRE 4% 30 0.8334

Hydroquinone w/sunscreens CRE 4% 999 0.5407








date of this list.



pharmacy network.


June 1, 2020


Tretinoin CRE 0.05% 40 2.9700

Lindane SHAMPOO 1%, 60ml 999 1.4822

Malathion LOT 0.50% 999 2.4323

Permethrin LIQ 1% 120 0.1091

Permethrin LIQ 1% 59 0.0695

Permethrin CRE 5% 999 0.0001

Permethrin LOT 1% 999 0.0767

Spinosad SUS 0.9% 999 1.1819

Pyrethrins-Piperonyl Butoxide LIQ 0.3-3% 60 0.0458

Pyrethrins-Piperonyl Butoxide LIQ 0.3-3% 120 0.0458

Hydrogen Peroxide SOL 3% 999 0.0018

Deferasirox TAB 90mg 999 5.5374






Naltrexone TAB 50mg 999 0.0001

Trientine HCL CAP 250mg 999 0.0001

Penicillamine CAP 250mg 999 74.8150

Penicillamine TAB 250mg 999 30.0969

Cyclosporin CAP 25mg 999 0.8233

Cyclosporin CAP 100mg 999 3.5507

Cyclosporine Modified CAP 25mg 999 0.2363



Cyclosporine, modified SOL 100mg/ml 999 2.0830

Mycophenolate Mofetil CAP 250mg 999 0.0726

Mycophenolate Mofetil TAB 500mg 999 0.0841

Mycophenolate Mofetil SUS 200mg/ml 999 2.9940

Mycophenolate Sodium TAB, DR 180mg 999 0.2130

Mycophenolate Sodium TAB, DR 360mg 999 1.2321

Everolimus TAB, DR 0.25mg 999 3.7795



Sirolimus TAB 0.5mg 999 3.5944

Sirolimus TAB 1mg 999 4.5630

Sirolimus TAB 2mg 999 9.5345

Sirolimus SOL 1mg/ml 999 12.2500

Tacrolimus CAP 0.5mg 999 0.0726

Tacrolimus CAP 1mg 999 0.0726

Tacrolimus CAP 5mg 999 0.3219

Azathioprine TAB 50mg 999 0.0001

Sodium Polystyrene Sulfate SUS 15gm/60ml 999 0.0001

Sod Poly Sul Pow POW 999 0.0001

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