pharmacy program and preferred drug list march 1, 2018 ... 1, 2018 introduction pharmacy program ......

Tufts Health Together Accountable Care Organization (ACO)

Pharmacy program and Preferred Drug List

May 1, 2018

Introduction

Pharmacy program

We aim to provide high-quality, cost-effective options for drug therapy. We work with your health care providers and pharmacists to make sure we cover the most important

and useful drugs for a variety of conditions and diseases. We cover both first-time prescriptions and refills. We also cover some over-the-counter (OTC) drugs if your provider writes a prescription and it is filled at a pharmacy.

Our pharmacy program doesn’t cover all drugs and prescriptions. Some drugs must meet certain clinical guidelines before we can cover them. Your provider must ask us

for prior authorization before we’ll cover these drugs.

Preferred Drug List (PDL)

We list all drugs according to their therapeutic category and drug class followed by

generic or brand drug name. Use the index to find a drug according to its generic or brand name. We cover brand-name medications only when a generic medication is not available or if we give prior authorization for the brand-name drug.

With a doctor’s prescription, covered drugs are available to members under the age of 21 for FREE, and to members age 21 and older with a small co-payment. Some

members age 21 and older do not need to pay the co-payment. To find out if you do not need to pay a co-payment, see your Member Handbook.

Co-payments:

Most members who are age 21 and older must pay the following pharmacy co-

payments:

• $1 for certain covered generic drugs mainly used for diabetes, high blood

pressure, and high cholesterol. These drugs are called antihyperglycemics (such

as metformin),

antihypertensives (such as lisinopril), and antihyperlipidemics (such as

simvastatin).

• $3.65 for certain over-the-counter (OTC) drugs for which you have a

prescription from the doctor

• $3.65 for both first-time prescriptions and refills for certain covered generic and

OTC drugs

• $3.65 for both first-time prescriptions and refills of covered brand-name drugs

The PDL applies only to drugs you get at retail and specialty pharmacies. The PDL doesn’t apply to drugs you get if you’re in the hospital. Drugs you get while in the hospital are covered as part of your stay.

For the most current PDL coverage information, please visit tuftshealthplan.com or call us at 888.257.1985 (TTY: 888.391.5535).

Prior authorization (PA)

Some drugs always require prior authorization, which means your provider must ask us

for approval before we’ll cover the drug. One of our clinicians will review this request.

We’ll cover the drug according to our clinical guidelines if:

There is a medical reason you need the particular drug

Depending on the drug, other drugs on the PDL have not worked

If we don’t approve the request for prior authorization, you or your authorized representative, if you identify one, can appeal the decision. See your Member Handbook

for our member grievances and appeals information. Step therapy program (STPA)

We cover some types of drugs only through our step therapy program. Our step therapy program requires you to try first-level drugs before we’ll cover another drug of that

type. If you and your provider feel a certain drug isn’t appropriate for treating your health condition, your provider can ask us for prior authorization for the other drug. One of our clinicians will review the request. We’ll cover the drug according to our clinical

guidelines. If we don’t approve the request for prior authorization, you or your authorized representative, if you identify one, can appeal the decision. See your Member Handbook for our grievances and appeals information.

Quantity limit (QL)

To make sure the drugs you take are safe and that you are getting the right amount, we may limit how much you can get at one time. Your provider can ask us for prior

authorization if you need more than we cover. One of our clinicians will review the request. We’ll cover the drug according to our clinical guidelines if there is a medical reason you need this particular amount. If we don’t approve the request for prior

authorization, you or your authorized representative, if you identify one, can appeal the decision. See your Member Handbook for our grievances and appeals information.

Generic drugs

Generic drugs have the same active ingredients and work the same as brand-name

drugs. When generic drugs are available, we won’t cover the brand-name drug without giving prior authorization. If you and your provider feel a generic drug is not right for treating your health condition and that the brand-name drug is medically necessary,

your provider can ask for prior authorization. One of our clinicians will review the request. If we don’t approve the request for prior authorization, you or your authorized representative, if you identify one, can appeal the decision. See your Member Handbook

for our grievances and appeals information.

New-to-market drugs (NTM)

We review new drugs for safety and effectiveness before we add them to our PDL. A provider who feels a new-to-market drug is medically necessary for you before we’ve

reviewed it can submit a request for prior authorization. One of our clinicians will review this request. If we approve the request, we’ll cover the drug according to our clinical guidelines. If we don’t approve the request, you or your authorized representative, if

you identify one, can appeal the decision. See your Member Handbook for our grievances and appeals information.

Coverage limits

The Requirements/Limits column in the PDL shows when a drug has a certain requirement or limit for coverage. Coverage limits include:

AGE — Age restriction may apply This medication requires prior authorization if the drug is not covered based on your age. Your provider should send us a prior authorization request if the drug

is medically necessary.

PA — Prior authorization This medication requires prior authorization. Your provider may prescribe a

different medication on the PDL or send us a prior authorization request.

QL — Quantity limit This medication is limited to a specific amount. If a larger amount is medically

necessary, your provider should send us a prior authorization request.

SP — Specialty medication This medication is only available through our specialty pharmacy vendor, CVS/specialty.

ST — Step therapy This medication requires prior authorization if you have not already used a first-line medication on the PDL. Your provider may prescribe another medication on the PDL or send us a prior authorization request.

Medicare Part D

If you have Medicare coverage, your Medicare prescription drug coverage (Part D) plan

will cover most of your prescription drugs. You should have a separate ID card for your Medicare prescription drug coverage. Please show your pharmacist your Medicare Part D

ID card when you fill a prescription. Even if you have Medicare Part D, we’ll cover some drugs, such as select OTC drugs. The

co-payment amounts and exceptions still apply to these covered drugs. For more information, please call us at 888.257.1985 (TTY: 888.391.5535). You can also find out more about your Medicare prescription drug coverage by calling Medicare at

800.633.4227 (TTY: 877.486.2048), visiting Medicare’s website at medicare.gov, or referring to your Medicare and You handbook. Remember to carry all your ID cards with you when you go to the pharmacy. When you fill a prescription, please show both your

Tufts Health Together and MassHealth member ID cards, as well as your Medicare Prescription ID card.

Specialty pharmacy program

A specialty pharmacy needs to supply you with some drugs often used to treat chronic

conditions like hepatitis C or multiple sclerosis. These types of drugs need additional expertise and support. Specialty pharmacies have knowledge in these areas. These pharmacies can give extra support to members and providers.

CVS/specialty is our specialty pharmacy and can provide you with these drugs. In

addition to providing specific specialty drugs, CVS/specialty will:

Deliver drugs to your home, provider’s office or any delivery address you choose (except for a P.O. box)

Answer your questions and offer help with your drugs

Give you information, materials and ongoing support to help you manage your

health condition and make sure you take your drugs the right way

Have staff pharmacists available who can help you 24 hours a day, seven days a

week, at 800.237.2767

Synagis

Every year from November 1 to March 31, CVS/specialty will supply Tufts Health

Together members with Synagis, which is used to prevent serious respiratory disease caused by respiratory syncytial virus (RSV). We will review requests for Synagis according to the most recent American Academy of Pediatrics guidelines.

Tufts Health Plan complies with applicable Federal civil rights laws and does not discriminate on

the basis of race, color, national origin, age, disability, or sex. Tufts Health Plan does not exclude

people or treat them differently because of race, color, national origin, age, disability, or sex.

Tufts Health Plan:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

— Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

— Qualified interpreters

— Information written in other languages

If you need these services, contact Tufts Health Plan at 888.257.1985.

If you believe that Tufts Health Plan has failed to provide these services or discriminated in another way on

the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Tufts Health Plan

Attention: Civil Rights Coordinator, Legal Dept.

705 Mount Auburn St.

Watertown, MA 02472

Phone: 888.880.8699 ext. 48000, [TTY number— 711 or 800.439.2370]

Fax: 617.972.9048

Email: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a

grievance, the Tufts Health Plan Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services,

Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available

at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

Phone: 800.368.1019, 800.537.7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

tuftshealthplan.com | 888.257.1985

For no cost translation in English, call the number on your ID card.

Arabic الترجمة المجانية باللغة العربية، يرجى االتصال على الرقم المدون على بطاقة الهوية الخاصة بك. للحصول على خدمة

Chinese 若需免費的中文版本，請撥打ID卡上的電話號碼。

French Pour demander une traduction gratuite en français, composez le numéro indiqué sur votre carte d’identité.

German Um eine kostenlose deutsche Übersetzung zu erhalten, rufen Sie bitte die Telefonnummer auf Ihrer Ausweiskarte an.

Greek Για δωρεάν μετάφραση στα Ελληνικά, καλέστε τον αριθμό που αναγράφεται στην αναγνωριστική κάρτας σας.

Haitian Creole Pou jwenn tradiksyon gratis nan lang Kreyòl Ayisyen, rele nimewo ki sou kat ID ou.

Italian Per la traduzione in italiano senza costi aggiuntivi, è possibile chiamare il numero indicato sulla tessera identificativa.

Japanese 日本語の無料翻訳についてはIDカードに書いてある番号に電話してください。

Khmer (Cambodian) សម្រាបស់សវាបកប្ម្របសោយឥតគតិថ្លៃជា ភាសាប្មែរ សមូទរូសព័្ទសៅកានស់េមប្ែេានសៅសេើបណ័្ណសាា េ់សាជកិរបសអ់្នក។

Korean 한국어로 무료 통역을 원하시면, ID 카드에 있는 번호로 연락하십시오.

Laotian ສໍ າລັບການແປພາສາເປັນພາສາລາວທ ີ່ ບໍີ່ ໄດ້ເສຍຄີ່ າໃຊ້ຈີ່ າຍ, ໃຫ້ໂທຫາເບ ທ ີ່ ຢ ີ່ ເທິ ງບັດປະຈໍ າຕົວຂອງທີ່ ານ.

Navajo

naisrePبه شماره تلفن مندرج در کارت شناسائی تان زنگ بزنید. فارسی برای ترجمه رایگا

Polish Aby uzyskać bezpłatne tłumaczenie w języku polskim, należy zadzwonić na numer znajdujący się na Pana/i dowodzie tożsamości.

Portuguese Para tradução grátis para português, ligue para o número no seu cartão de identificação.

Russian Для получения услуг бесплатного перевода на русский язык позвоните по номеру, указанному на идентификационной карточке.

Spanish Por servicio de traducción gratuito en español, llame al número de su tarjeta de miembro.

Tagalog Para sa walang bayad na pagsasalin sa Tagalog, tawagan ang numero na nasa inyong ID card.

Vietnamese Để có bản dịch tiếng Việt không phải trả phí, gọi theo số trên thẻ căn cước của bạn.

Table of Contents

BLOOD DISORDER................................................................................................................................................. 3CALORIC UNDERNUTRITION..............................................................................................................................7CHRONIC LUNG OR BREATHING PASSAGE PROBLEM................................................................................ 9COLD SYMPTOMS................................................................................................................................................13COLLAGEN VASCULAR DISEASE.................................................................................................................... 15CONDITION RESULTING FROM A DEFECTIVE IMMUNE SYSTEM...........................................................18DISEASE AFFECTING THE BODY'S METABOLISM.......................................................................................26DISEASE OF THE HEART AND BLOOD VESSELS..........................................................................................36DISEASE OF THE URINARY TRACT................................................................................................................. 48DISORDER OF NERVE......................................................................................................................................... 52DISORDER OF NERVOUS SYSTEM................................................................................................................... 71DISORDER OF REPRODUCTIVE SYSTEM....................................................................................................... 89DISORDER OF RESPIRATORY SYSTEM...........................................................................................................97DISORDER OF THE DIGESTIVE SYSTEM...................................................................................................... 104DISORDER OF THE ENDOCRINE GLANDS....................................................................................................112EAR PROBLEM....................................................................................................................................................120EYE DISORDER................................................................................................................................................... 121FEVER................................................................................................................................................................... 125INFECTION...........................................................................................................................................................125INFLAMMATION OF THE SEROUS MEMBRANES IN THE BODY.............................................................136INFLAMMATORY DISORDER.......................................................................................................................... 136INJURY TO A MUCOUS MEMBRANE............................................................................................................. 154LUNG DISEASE................................................................................................................................................... 155MAJOR TRAUMATIC INJURY.......................................................................................................................... 161MARGINAL ZONE LYMPHOMA...................................................................................................................... 161MUSCLE OR BONE DISORDER........................................................................................................................ 161NEUROPSYCHIATRIC DISORDER...................................................................................................................175NOT FEELING WELL..........................................................................................................................................197NUTRITIONAL DISORDER................................................................................................................................197OTHER OVER-THE-COUNTER DRUGS...........................................................................................................199OTHER PRESCRIPTION DRUGS.......................................................................................................................204OVERDOSE...........................................................................................................................................................233PAIN.......................................................................................................................................................................233PATIENT DEMOGRAPHICS...............................................................................................................................244PREGNANCY....................................................................................................................................................... 246PROCEDURE........................................................................................................................................................ 246REACTION DUE TO AN ALLERGEN............................................................................................................... 251RECENT OPERATION.........................................................................................................................................253SKIN CONDITION............................................................................................................................................... 255SLOW DRUG ELIMINATION BY KIDNEY......................................................................................................266TUMOR................................................................................................................................................................. 266

1

Drug Status NotesBLOOD DISORDER

ACTIMMUNE SUBCUTANEOUS SOLUTION $3.65 PA; SP

ADEMPAS ORAL TABLET $3.65 PA; SP

Advate Intravenous Solution Reconstituted MB/RX SP

Adynovate Intravenous Solution Reconstituted MB/RX SP

Afstyla Intravenous Kit MB/RX SP

Alphanate/VWF Complex/Human Intravenous Solution Reconstituted

MB/RX SP

AlphaNine SD Intravenous Solution Reconstituted

MB/RX SP

Alprolix Intravenous Solution Reconstituted MB/RX SP

ANADROL-50 ORAL TABLET $3.65 PA

anagrelide hcl oral capsule $3.65

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.4ML, 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

$3.65 SP; QL (4 ML per 30 days)

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML


Arzerra Intravenous Concentrate MB/RX SP

aspirin-dipyridamole er oral capsule extended release 12 hour

$3.65 PA; QL (60 EA per 30 days)

AURYXIA ORAL TABLET $3.65 PA

Bebulin Intravenous Solution Reconstituted MB/RX SP

BeneFIX Intravenous Kit MB/RX SP

BRILINTA ORAL TABLET 60 MG $3.65 QL (60 EA per 30 days)

BRILINTA ORAL TABLET 90 MG $3.65 PA; QL (60 EA per 30 days)

Carimune NF Intravenous Solution Reconstituted 12 GM, 6 GM

MB/RX PA; SP

Coagadex Intravenous Solution Reconstituted MB/RX

Corifact Intravenous Kit MB/RX SP

DARZALEX INTRAVENOUS SOLUTION Medical Benefit

^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsPBHMI = Pediatric Behavioral Health Medication Initiative

3

Drug Status Notesdipyridamole oral tablet $3.65

DROXIA ORAL CAPSULE $3.65

ELIQUIS ORAL TABLET $3.65 QL (60 EA per 30 days)

Eloctate Intravenous Solution Reconstituted MB/RX SP

ENDARI ORAL PACKET $3.65 PA

enoxaparin sodium injection solution $3.65

enoxaparin sodium subcutaneous solution $3.65

EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

$3.65 SP

EXJADE ORAL TABLET SOLUBLE $3.65 SP

Eylea Intraocular Solution MB/RX SP

FARYDAK ORAL CAPSULE $3.65 PA; SP

Feiba Intravenous Solution Reconstituted MB/RX SP

folic acid oral tablet 1 mg $3.65

fondaparinux sodium subcutaneous solution $3.65

FRAGMIN SUBCUTANEOUS SOLUTION10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML

$3.65

Gammagard S/D Less IgA Intravenous Solution Reconstituted

MB/RX PA; SP

Gamunex-C Injection Solution MB/RX PA; SP

Gazyva Intravenous Solution MB/RX SP

GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP

Helixate FS Intravenous Kit MB/RX PA; SP

Hemofil M Intravenous Solution Reconstituted 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT

MB/RX SP

heparin sodium (porcine) injection solution10000 unit/ml, 20000 unit/ml, 5000 unit/ml

$3.65

Humate-P Intravenous Solution Reconstituted 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT

MB/RX SP

Idelvion Intravenous Solution Reconstituted MB/RX SP

IMBRUVICA ORAL CAPSULE 70 MG $3.65 PA


4

Drug Status NotesIMBRUVICA ORAL TABLET 140 MG $3.65 PA

IPRIVASK SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 QL (24 vials per 12 days)

Ixinity Intravenous Solution Reconstituted MB/RX SP

JADENU ORAL TABLET $3.65 SP

JADENU SPRINKLE ORAL PACKET $3.65 SP

JAKAFI ORAL TABLET $3.65 PA; SP

JANTOVEN ORAL TABLET $3.65

Koate-DVI Intravenous Solution Reconstituted MB/RX SP

Kogenate FS Bio-Set Intravenous Kit MB/RX SP

Kogenate FS Intravenous Kit MB/RX SP

Kovaltry Intravenous Solution Reconstituted MB/RX SP

leucovorin calcium oral tablet $3.65

LEUKERAN ORAL TABLET $3.65

Lucentis Intraocular Solution MB/RX SP

Lucentis Intravitreal Solution Prefilled Syringe 0.5 MG/0.05ML

MB/RX SP

Lupron Depot (1-Month) Intramuscular Kit 3.75 MG

MB/RX PA; SP


MB/RX PA; SP

MEPHYTON ORAL TABLET $3.65

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML

$3.65 QL (2 Syringes per 28 days)

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 150 MCG/0.3ML, 30 MCG/0.3ML


Mitoxantrone HCl Intravenous Concentrate MB/RX SP

Monoclate-P Intravenous Kit 1000 UNIT, 1500 UNIT

MB/RX SP

Mononine Intravenous Solution Reconstituted 1000 UNIT

MB/RX SP

MOZOBIL SUBCUTANEOUS SOLUTION Medical Benefit SP


5

Drug Status NotesNEULASTA DELIVERY KIT SUBCUTANEOUS PREFILLED SYRINGE KIT

$3.65 SP

NEULASTA DELIVERY KIT SUBCUTANEOUS SOLUTION $3.65 SP

NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT $3.65 SP

NEULASTA SUBCUTANEOUS SOLUTION $3.65 SP

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 SP

NEUPOGEN INJECTION SOLUTION $3.65 PA; SP

NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE $3.65 PA; SP

NINLARO ORAL CAPSULE $3.65 PA; SP

Novoeight Intravenous Solution Reconstituted MB/RX SP

NovoSeven RT Intravenous Solution Reconstituted

MB/RX SP

Nplate Subcutaneous Solution Reconstituted MB/RX PA; SP

Nuwiq Intravenous Kit MB/RX SP

Nuwiq Intravenous Solution Reconstituted MB/RX SP

Obizur Intravenous Solution Reconstituted MB/RX SP

Octagam Intravenous Solution 10 GM/100ML, 2 GM/20ML, 20 GM/200ML, 5 GM/50ML

MB/RX PA; SP

Oncaspar Injection Solution MB/RX SP

prasugrel hcl oral tablet $3.65

Privigen Intravenous Solution MB/RX PA; SP

PROCRIT INJECTION SOLUTION $3.65 SP

Profilnine Intravenous Solution Reconstituted MB/RX SP

Profilnine SD Intravenous Solution Reconstituted MB/RX SP

PROMACTA ORAL TABLET $3.65 PA; SP

Recombinate Intravenous Solution Reconstituted MB/RX SP

Rhophylac Injection Solution Prefilled Syringe MB/RX SP

RiaSTAP Intravenous Solution Reconstituted MB/RX SP

Rixubis Intravenous Solution Reconstituted MB/RX SP

Soliris Intravenous Solution 10 MG/ML MB/RX PA; SP

STIMATE NASAL SOLUTION $3.65 SP


6

Drug Status NotesSynribo Subcutaneous Solution Reconstituted MB/RX SP

TABLOID ORAL TABLET $3.65

THALOMID ORAL CAPSULE $3.65 SP

Tretten Intravenous Solution Reconstituted MB/RX SP

VENCLEXTA ORAL TABLET $3.65 PA

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK $3.65 PA

Vonvendi Intravenous Solution Reconstituted MB/RX SP

warfarin sodium oral tablet $3.65

Wilate Intravenous Kit MB/RX SP

WinRho SDF Injection Solution MB/RX SP

XARELTO ORAL TABLET $3.65 QL (30 EA per 30 days)

XARELTO STARTER PACK ORAL TABLET THERAPY PACK $3.65

¥ (1 Fill per life of plan); QL (51 EA per 21 days)

XATMEP ORAL SOLUTION $3.65 PA

Xyntha Intravenous Kit MB/RX SP

Xyntha Solofuse Intravenous Kit MB/RX SP

ZARXIO INJECTION SOLUTION PREFILLED SYRINGE $3.65 SP

Zoledronic Acid Intravenous Concentrate MB/RX

Zoledronic Acid Intravenous Solution 4 MG/100ML

MB/RX

ZONTIVITY ORAL TABLET $3.65

CALORIC UNDERNUTRITION


calcium acetate (phos binder) oral capsule $3.65

calcium acetate (phos binder) oral tablet $3.65

cyanocobalamin injection solution $3.65

ergocalciferol oral capsule $3.65

ESCAVITE D ORAL TABLET CHEWABLE $3.65 Age Limit (Max 6 Years)

ESCAVITE ORAL TABLET CHEWABLE $3.65 Age Limit (Max 6 Years)

folbee oral tablet $3.65


FOSRENOL ORAL PACKET $3.65


7

Drug Status NotesGENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED

$3.65 PA; SP

GENOTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP

HUMATROPE INJECTION SOLUTION RECONSTITUTED $3.65 PA; SP

lanthanum carbonate oral tablet chewable $3.65


levocarnitine oral solution $3.65

levocarnitine oral tablet $3.65

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml

$3.65

multi vitamin/fluoride oral tablet chewable $3.65

multi vitamin/minerals oral tablet $3.65

multi-vit/fluoride oral solution $3.65

multi-vit/fluoride/iron oral solution $3.65

multi-vitamin/fluoride oral tablet chewable 0.5 mg

$3.65

multivitamin/fluoride oral tablet chewable 1 mg $3.65

MYKIDZ IRON FL ORAL SUSPENSION $3.65

mynephrocaps oral capsule $3.65

NEPHROCAPS QT ORAL TABLET DISPERSIBLE $3.65

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION $3.65 PA; SP

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION $3.65 PA; SP



OMNITROPE SUBCUTANEOUS SOLUTION $3.65 PA; SP

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP

PHOSLYRA ORAL SOLUTION $3.65


8

Drug Status NotesPOLY-VI-FLOR ORAL SUSPENSION $3.65

RENAGEL ORAL TABLET $3.65

RENAL ORAL CAPSULE $3.65

SAIZEN CLICK.EASY INJECTION SOLUTION RECONSTITUTED $3.65 PA; SP

SAIZEN INJECTION SOLUTION RECONSTITUTED $3.65 PA; SP

SAIZENPREP INJECTION SOLUTION RECONSTITUTED $3.65 PA; SP

SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG $3.65 PA; SP

sevelamer carbonate oral packet $3.65

tri-vit/fluoride/iron oral solution $3.65

tri-vitamin/fluoride oral solution $3.65

vitamin d (ergocalciferol) oral capsule $3.65

ZOMACTON SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP

ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP

CHRONIC LUNG OR BREATHING PASSAGE PROBLEM

ADCIRCA ORAL TABLET $3.65 PA; SP; QL (60 EA per 30 days)


ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE

$3.65PA; Age Limit (Min 4 Years and Max 11 Years)

ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250-50 MCG/DOSE, 500-50 MCG/DOSE

$3.65 PA

ADVAIR HFA INHALATION AEROSOL $3.65 PA

AEROSPAN INHALATION AEROSOL SOLUTION $3.65

albuterol sulfate er oral tablet extended release 12 hour

$3.65

albuterol sulfate inhalation nebulization solution $3.65

albuterol sulfate oral syrup $3.65

albuterol sulfate oral tablet $3.65


9

Drug Status NotesALVESCO INHALATION AEROSOL SOLUTION $3.65

ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65 PA

Aralast NP Intravenous Solution Reconstituted 1000 MG, 500 MG

MB/RX SP

ARCAPTA NEOHALER INHALATION CAPSULE $3.65 QL (1 EA per 30 days)

ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65


$3.65


$3.65


$3.65


$3.65

ASMANEX HFA INHALATION AEROSOL $3.65

ATROVENT HFA INHALATION AEROSOL SOLUTION $3.65

azelastine hcl nasal solution 0.1 % $3.65

BECONASE AQ NASAL SUSPENSION $3.65 PA

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED $3.65 PA; QL (1 EA per 30 days)

budesonide inhalation suspension $3.65

CAYSTON INHALATION SOLUTION RECONSTITUTED $3.65

CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR $3.65 PA

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION $3.65

cromolyn sodium inhalation nebulization solution $3.65


10

Drug Status NotesDALIRESP ORAL TABLET $3.65 PA; STPA

DULERA INHALATION AEROSOL $3.65 PA

ELIXOPHYLLIN ORAL ELIXIR $3.65

Epoprostenol Sodium Intravenous Solution Reconstituted 0.5 MG

MB/RX PA; SP; QL (4 EA per 30 days)



ESBRIET ORAL CAPSULE $3.65 PA; SP; QL (270 EA per 30 days)

ESBRIET ORAL TABLET $3.65 PA; SP; QL (270 EA per 30 days)

Fasenra Subcutaneous Solution Prefilled Syringe MB/RX PA; SP

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65

FLOVENT HFA INHALATION AEROSOL $3.65

fluticasone propionate nasal suspension $3.65

fluticasone-salmeterol inhalation aerosol powder breath activated

$3.65

FORADIL AEROLIZER INHALATION CAPSULE $3.65

Glassia Intravenous Solution MB/RX SP

INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65

ipratropium bromide inhalation solution $3.65

ipratropium bromide nasal solution $3.65

ipratropium-albuterol inhalation solution $3.65

KALYDECO ORAL PACKET $3.65 PA; QL (60 EA per 30 days)

KALYDECO ORAL TABLET $3.65 PA; QL (60 EA per 30 days)

LETAIRIS ORAL TABLET $3.65 PA; SP; QL (30 EA per 30 days)

levalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml

$3.65

levalbuterol tartrate inhalation aerosol $3.65 PA

metaproterenol sulfate oral syrup $3.65

metaproterenol sulfate oral tablet $3.65

montelukast sodium oral packet $3.65 STPA; QL (30 EA per 30 days)

montelukast sodium oral tablet $3.65 QL (30 EA per 30 days)


11

Drug Status Notesmontelukast sodium oral tablet chewable $3.65 QL (30 EA per 30 days)

NEBUPENT INHALATION SOLUTION RECONSTITUTED $3.65

NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA

OFEV ORAL CAPSULE $3.65 PA; QL (60 EA per 30 days)

OMNARIS NASAL SUSPENSION $3.65 PA

OPSUMIT ORAL TABLET $3.65 PA; SP

ORALAIR SUBLINGUAL TABLET SUBLINGUAL $3.65 PA; QL (30 EA per 30 days)

ORENITRAM ORAL TABLET EXTENDED RELEASE $3.65 PA; SP

ORKAMBI ORAL TABLET $3.65 PA; QL (120 EA per 30 days)

PERFOROMIST INHALATION NEBULIZATION SOLUTION $3.65

PROAIR HFA INHALATION AEROSOL SOLUTION $3.65 PA

PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65 PA

PROVENTIL HFA INHALATION AEROSOL SOLUTION $3.65 PA

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65

PULMOZYME INHALATION SOLUTION $3.65 SP

QVAR INHALATION AEROSOL SOLUTION $3.65

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED $3.65 QL (10.6 GM per 30 days)

REMODULIN INJECTION SOLUTION $3.65 PA; SP

REVATIO ORAL SUSPENSION RECONSTITUTED $3.65 PA; SP

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65

sildenafil citrate oral tablet 20 mg $3.65 PA; SP; QL (90 EA per 30 days)


12

Drug Status NotesSPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION $3.65

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION $3.65

SYMBICORT INHALATION AEROSOL $3.65 PA

terbutaline sulfate oral tablet $3.65

THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 300 MG, 400 MG $3.65

THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

$3.65

theophylline er oral tablet extended release 12 hour

$3.65


$3.65

theophylline oral solution $3.65

TOBI PODHALER INHALATION CAPSULE $3.65 PA; SP; QL (1 EA per 60 days)

tobramycin inhalation nebulization solution $3.65 SP

TRACLEER ORAL TABLET $3.65 PA; SP; QL (60 EA per 30 days)

TRACLEER ORAL TABLET SOLUBLE $3.65 PA; SP; QL (120 EA per 30 days)

TYVASO INHALATION SOLUTION $3.65 PA; SP

TYVASO REFILL INHALATION SOLUTION $3.65 PA; SP

TYVASO STARTER INHALATION SOLUTION $3.65 PA; SP

UPTRAVI ORAL TABLET $3.65 PA; SP

UPTRAVI ORAL TABLET THERAPY PACK $3.65 PA; SP

Veletri Intravenous Solution Reconstituted MB/RX SP

VENTAVIS INHALATION SOLUTION $3.65 PA; SP; QL (9 Vials per 1 day)

VENTOLIN HFA INHALATION AEROSOL SOLUTION $3.65

Xolair Subcutaneous Solution Reconstituted MB/RX PA; SP; QL (6 vials per 28 days)

zafirlukast oral tablet $3.65

ZETONNA NASAL AEROSOL SOLUTION $3.65 PA

COLD SYMPTOMS



13

Drug Status NotesBECONASE AQ NASAL SUSPENSION $3.65 PA

benzonatate oral capsule 100 mg, 200 mg $3.65

budesonide nasal suspension $3.65 PA

cetirizine hcl oral solution 1 mg/ml $3.65 PA

cetirizine hcl oral syrup 1 mg/ml $3.65 PA

CLARINEX ORAL SYRUP $3.65 PA


clemastine fumarate oral tablet 2.68 mg $3.65

cyproheptadine hcl oral syrup $3.65

cyproheptadine hcl oral tablet $3.65

desloratadine oral tablet $3.65 PA

flunisolide nasal solution 25 mcg/act (0.025%) $3.65


GILPHEX TR ORAL TABLET $3.65

guaifenesin er oral tablet extended release 12 hour 600 mg

$3.65

hydrocod polst-cpm polst er oral suspension extended release

$3.65

hydrocodone-homatropine oral syrup $3.65

hydrocodone-homatropine oral tablet $3.65

hydromet oral syrup $3.65


levocetirizine dihydrochloride oral solution $3.65 PA

levocetirizine dihydrochloride oral tablet $3.65 PA

mometasone furoate nasal suspension $3.65 PA



montelukast sodium oral tablet chewable $3.65 QL (30 EA per 30 days)



phenyleph-promethazine-cod oral syrup $3.65

promethazine vc plain oral syrup $3.65

promethazine vc/codeine oral syrup $3.65


14

Drug Status Notespromethazine-codeine oral syrup $3.65

promethazine-dm oral syrup $3.65

promethazine-phenylephrine oral syrup $3.65

pseudoephedrine hcl oral tablet 60 mg $3.65

QNASL CHILDRENS NASAL AEROSOL SOLUTION $3.65 PA

QNASL NASAL AEROSOL SOLUTION $3.65 PA

SEMPREX-D ORAL CAPSULE $3.65 PA

triamcinolone acetonide nasal aerosol $3.65

TUSSIGON ORAL TABLET $3.65

VERAMYST NASAL SUSPENSION $3.65 PA


COLLAGEN VASCULAR DISEASE

Actemra Intravenous Solution 200 MG/10ML MB/RX PA; SP; QL (4 vials per 28 days)



ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65

PA; SP; QL (4 syringes per 28 days)

azathioprine oral tablet $3.65

Benlysta Intravenous Solution Reconstituted MB/RX PA; SP

BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65 PA; SP

BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP

celecoxib oral capsule $3.65 STPA; QL (60 EA per 30 days)

cevimeline hcl oral capsule $3.65

CIMZIA PREFILLED SUBCUTANEOUS KIT $3.65 PA; SP; QL (2 EA per 28 days)

CIMZIA STARTER KIT SUBCUTANEOUS KIT $3.65

PA; SP; ¥ (For first 4 weeks of treatment); QL (6 Syringes per 28 days)

CIMZIA SUBCUTANEOUS KIT 2 X 200 MG $3.65 PA; SP; QL (2 EA per 28 days)

COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

$3.65 PA; SP


15

Drug Status NotesCOSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP

diclofenac sodium er oral tablet extended release 24 hour

$3.65

EGRIFTA SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP

ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE $3.65 PA; SP; QL (4 ea per 28 days)

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML $3.65


ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML $3.65


ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65


ENBREL SURECLICK SUBCUTANEOUS SOLUTION $3.65


ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65


etodolac er oral tablet extended release 24 hour $3.65

flurbiprofen oral tablet $3.65

HP Acthar Injection Gel MB/RX SP

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML

$3.65 PA; SP; ¥ (1 Fill per life of plan)

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT $3.65 PA; SP; QL (2 EA per 28 days)

HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT $3.65 PA; SP; ¥ (1 Fill per life of plan)

HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT $3.65 PA; SP; ¥ (1 Fill per life of plan)

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT $3.65 PA; SP; QL (2 EA per 28 days)

hydroxychloroquine sulfate oral tablet $3.65

Inflectra Intravenous Solution Reconstituted MB/RX PA

KENALOG INJECTION SUSPENSION 10 MG/ML $3.65

ketoprofen er oral capsule extended release 24 hour

$3.65


16

Drug Status NotesKEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (2.28 ML per 30 days)

KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; QL (28 Syringes per 28 days)

Lartruvo Intravenous Solution MB/RX

leflunomide oral tablet $3.65

meloxicam oral suspension $3.65

meloxicam oral tablet $3.65

methotrexate oral tablet $3.65

MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; QL (30 Vials per 30 days)

nabumetone oral tablet $3.65

ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65 PA; SP; QL (4 ML per 28 days)

Orencia Intravenous Solution Reconstituted MB/RXPA; SP; QL (4 VIALS per 28 days)

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (4 ML per 28 days)

oxaprozin oral tablet $3.65

PANRETIN EXTERNAL GEL $3.65 PA

pilocarpine hcl oral tablet $3.65

piroxicam oral capsule $3.65

Remicade Intravenous Solution Reconstituted MB/RX PA; SP

Renflexis Intravenous Solution Reconstituted MB/RX PA; SP

RHEUMATREX ORAL TABLET 2.5 MG $3.65

Rituxan Intravenous Solution MB/RX PA; SP

salsalate oral tablet $3.65

Simponi Aria Intravenous Solution MB/RX PA; SP; QL (5 vials per 8 Weeks)

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65

PA; SP; QL (1 syringe per 28 days)

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65


sulfasalazine oral tablet delayed release $3.65

tolmetin sodium oral capsule $3.65

tolmetin sodium oral tablet $3.65

TREXALL ORAL TABLET $3.65


17

Drug Status NotesXELJANZ ORAL TABLET $3.65 PA; SP; QL (60 EA per 30 days)

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65 PA; SP; QL (30 EA per 30 days)

YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit

CONDITION RESULTING FROM A DEFECTIVE IMMUNE SYSTEM

abacavir sulfate oral solution $3.65

abacavir sulfate oral tablet $3.65

abacavir sulfate-lamivudine oral tablet $3.65

abacavir-lamivudine-zidovudine oral tablet $3.65








MB/RX SP

ANADROL-50 ORAL TABLET $3.65 PA

APTIVUS ORAL CAPSULE $3.65

APTIVUS ORAL SOLUTION $3.65

ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP; QL (4 Vials per 28 days)

ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65

atazanavir sulfate oral capsule $3.65

ATRIPLA ORAL TABLET $3.65





Berinert Intravenous Kit MB/RX SP


18

Drug Status NotesCarimune NF Intravenous Solution Reconstituted 12 GM, 6 GM

MB/RX PA; SP







COMPLERA ORAL TABLET $3.65

cortisone acetate oral tablet $3.65


$3.65 PA; SP

COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG $3.65

cromolyn sodium oral concentrate $3.65

cyclosporine modified oral capsule $3.65

cyclosporine modified oral solution $3.65

cyclosporine oral capsule $3.65

Cytogam Intravenous Injectable MB/RX PA; SP

DESCOVY ORAL TABLET $3.65 # (Preferred product)


$3.65

didanosine oral capsule delayed release $3.65

dronabinol oral capsule $3.65

EDURANT ORAL TABLET $3.65

efavirenz oral capsule $3.65

efavirenz oral tablet $3.65


EMTRIVA ORAL CAPSULE $3.65

EMTRIVA ORAL SOLUTION $3.65


19

Drug Status NotesENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE $3.65 PA; SP; QL (4 ea per 28 days)












EVOTAZ ORAL TABLET $3.65

FIRAZYR SUBCUTANEOUS SOLUTION $3.65 PA; SP; QL (3 ML per 1 Fill)

Flebogamma DIF Intravenous Solution MB/RX PA; SP


fosamprenavir calcium oral tablet $3.65

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 SP

GAMMAGARD INJECTION SOLUTION Medical Benefit PA; SP


MB/RX PA; SP


GENGRAF ORAL CAPSULE 100 MG, 25 MG $3.65

GENGRAF ORAL SOLUTION $3.65

GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED

$3.65 PA; SP


GENVOYA ORAL TABLET $3.65 # (Preferred product)


guanidine hcl oral tablet $3.65 PA


20

Drug Status NotesHizentra Subcutaneous Solution 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML

MB/RX PA; SP



MB/RX SP








hydrocortisone oral tablet $3.65


Hyqvia Subcutaneous Kit MB/RX PA; SP

Ilaris (150mg Delivered) Subcutaneous Solution Reconstituted

MB/RX PA; SP

Ilaris Subcutaneous Solution MB/RX PA; SP


INTELENCE ORAL TABLET $3.65

INVIRASE ORAL CAPSULE $3.65

INVIRASE ORAL TABLET $3.65

ISENTRESS HD ORAL TABLET $3.65 QL (60 EA per 30 days)

ISENTRESS ORAL PACKET $3.65 QL (60 EA per 30 days)

ISENTRESS ORAL TABLET $3.65

ISENTRESS ORAL TABLET CHEWABLE $3.65

JULUCA ORAL TABLET $3.65

KALETRA ORAL TABLET $3.65

KENALOG INJECTION SUSPENSION $3.65


21

Drug Status Notesketoprofen er oral capsule extended release 24 hour

$3.65

KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (2.28 ML per 30 days)


lamivudine oral solution $3.65

lamivudine oral tablet 150 mg, 300 mg $3.65

lamivudine-zidovudine oral tablet $3.65



LEXIVA ORAL SUSPENSION $3.65

lopinavir-ritonavir oral solution $3.65

MEDROL ORAL TABLET 2 MG $3.65


$3.65



MESTINON ORAL SYRUP $3.65


methylprednisolone oral tablet $3.65

methylprednisolone oral tablet therapy pack $3.65

methylprednisolone sodium succ injection solution reconstituted 125 mg, 40 mg

$3.65

MILLIPRED DP ORAL TABLET THERAPY PACK $3.65

MILLIPRED ORAL TABLET $3.65



mycophenolate mofetil oral capsule $3.65

mycophenolate mofetil oral suspension reconstituted

$3.65

mycophenolate mofetil oral tablet $3.65

mycophenolic acid oral tablet delayed release $3.65



22

Drug Status NotesNEBUPENT INHALATION SOLUTION RECONSTITUTED $3.65

NEULASTA DELIVERY KIT SUBCUTANEOUS PREFILLED SYRINGE KIT

$3.65 SP







nevirapine er oral tablet extended release 24 hour $3.65

nevirapine oral suspension $3.65

nevirapine oral tablet $3.65


NORVIR ORAL CAPSULE $3.65 # (Preferred product)

NORVIR ORAL SOLUTION $3.65 # (Preferred product)

NORVIR ORAL TABLET $3.65 # (Preferred product)

NOXAFIL ORAL SUSPENSION $3.65 PA

NOXAFIL ORAL TABLET DELAYED RELEASE $3.65 PA






Octagam Intravenous Solution MB/RX PA; SP

ODEFSEY ORAL TABLET $3.65 # (Preferred product)


23

Drug Status NotesOMNITROPE SUBCUTANEOUS SOLUTION $3.65 PA; SP









prednisolone oral solution $3.65

prednisolone oral syrup 15 mg/5ml $3.65

prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

$3.65

prednisolone sodium phosphate oral tablet dispersible

$3.65

Prevymis Intravenous Solution MB/RX PA

PREVYMIS ORAL TABLET $3.65 PA

PREZCOBIX ORAL TABLET $3.65

PREZISTA ORAL SUSPENSION $3.65

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG $3.65



pyridostigmine bromide er oral tablet extended release

$3.65

pyridostigmine bromide oral tablet $3.65

RAPAMUNE ORAL SOLUTION $3.65



RESCRIPTOR ORAL TABLET $3.65

REYATAZ ORAL PACKET $3.65


24

Drug Status NotesRHEUMATREX ORAL TABLET 2.5 MG $3.65



Ruconest Intravenous Solution Reconstituted MB/RX SP





SANDIMMUNE ORAL SOLUTION $3.65

SELZENTRY ORAL SOLUTION $3.65 QL (1800 ML per 30 days)

SELZENTRY ORAL TABLET $3.65







sirolimus oral tablet $3.65


SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG, 1000 MG $3.65

stavudine oral capsule $3.65

stavudine oral solution reconstituted $3.65

STRIBILD ORAL TABLET $3.65


SYNDROS ORAL SOLUTION $3.65 PA

tacrolimus oral capsule $3.65

tenofovir disoproxil fumarate oral tablet $3.65

TIVICAY ORAL TABLET $3.65





25

Drug Status NotesTRIUMEQ ORAL TABLET $3.65

TRUVADA ORAL TABLET 200-300 MG $3.65

TYBOST ORAL TABLET $3.65

VIDEX ORAL SOLUTION RECONSTITUTED $3.65

VIRACEPT ORAL TABLET $3.65

VIREAD ORAL POWDER $3.65

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG $3.65

VITEKTA ORAL TABLET $3.65



XELJANZ ORAL TABLET $3.65 PA; SP; QL (60 EA per 30 days)




zidovudine oral capsule $3.65

zidovudine oral syrup $3.65

zidovudine oral tablet $3.65



ZORTRESS ORAL TABLET $3.65 SP

DISEASE AFFECTING THE BODY'S METABOLISM

acarbose oral tablet $1

acetazolamide oral tablet $3.65

ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR $1

ADVICOR ORAL TABLET EXTENDED RELEASE 24 HOUR $1

ALDACTAZIDE ORAL TABLET 50-50 MG $1


26

Drug Status NotesAldurazyme Intravenous Solution MB/RX PA; SP

alendronate sodium oral tablet 40 mg $3.65 QL (1 EA per 6 Months)

allopurinol oral tablet $3.65

alogliptin benzoate oral tablet $1 PA; QL (30 EA per 30 days)

alogliptin-metformin hcl oral tablet $1 PA; QL (60 EA per 30 days)

alogliptin-pioglitazone oral tablet $1 PA; QL (30 EA per 30 days)

ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HOUR $1

amiloride hcl oral tablet $1

amlodipine-atorvastatin oral tablet $1 PA; QL (30 EA per 30 days)

ANTARA ORAL CAPSULE 30 MG, 90 MG $1 PA; QL (30 EA per 30 days)


MB/RX SP


atorvastatin calcium oral tablet $1


AVANDAMET ORAL TABLET $1

AVANDARYL ORAL TABLET $1

AVANDIA ORAL TABLET $1


Brineura Solution MB/RX PA

bumetanide oral tablet $1

calcitriol oral capsule $3.65

calcitriol oral solution $3.65



captopril oral tablet $1

CARBAGLU ORAL TABLET $3.65 PA


CERDELGA ORAL CAPSULE $3.65 PA; SP

Cerezyme Intravenous Solution Reconstituted 400 UNIT

MB/RX PA; SP



27

Drug Status Notescetirizine hcl oral syrup 1 mg/ml $3.65 PA

chlorothiazide oral tablet $1

chlorpropamide oral tablet $1

chlorthalidone oral tablet 25 mg, 50 mg $1

CHOLBAM ORAL CAPSULE $3.65 PA

cholestyramine light oral packet $1

cholestyramine light oral powder $1

cholestyramine oral packet $1

cholestyramine oral powder $1

Cinryze Intravenous Solution Reconstituted MB/RX PA; SP

colchicine oral tablet $3.65

colchicine-probenecid oral tablet $3.65

colestipol hcl oral packet $1

colestipol hcl oral tablet $1

constulose oral solution $3.65

CUPRIMINE ORAL CAPSULE 250 MG $3.65

CYSTAGON ORAL CAPSULE $3.65 PA; SP

danazol oral capsule $3.65

DEPEN TITRATABS ORAL TABLET $3.65

desmopressin ace rhinal tube nasal solution $3.65

desmopressin ace spray refrig nasal solution $3.65

desmopressin acetate oral tablet $3.65

desmopressin acetate spray nasal solution $3.65

DIABETA ORAL TABLET $1

DIURIL ORAL SUSPENSION $1


DUZALLO ORAL TABLET $3.65 PA

DYRENIUM ORAL CAPSULE $1


Elaprase Intravenous Solution MB/RX SP

enulose oral solution $3.65

Ethacrynate Sodium Intravenous Solution Reconstituted

MB/RX


28

Drug Status Notesethacrynic acid oral tablet $1 PA

etidronate disodium oral tablet $3.65


ezetimibe-simvastatin oral tablet $1 PA; QL (30 EA per 30 days)

FARXIGA ORAL TABLET $3.65 PA; QL (30 EA per 30 days)

fenofibrate micronized oral capsule 130 mg, 43 mg

$1 PA; QL (30 EA per 30 days)

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

$1 QL (30 EA per 30 days)

fenofibrate oral capsule $1 PA; QL (30 EA per 30 days)

fenofibrate oral tablet 120 mg, 145 mg, 40 mg, 48 mg


fenofibrate oral tablet 160 mg, 54 mg $1 QL (30 EA per 30 days)

fenofibric acid oral capsule delayed release $1 PA; QL (30 EA per 30 days)

fenofibric acid oral tablet $1 PA; QL (30 EA per 30 days)

FIBRICOR ORAL TABLET $3.65 QL (30 EA per 30 days)


flolipid oral suspension $3.65 PA

fluvastatin sodium er oral tablet extended release 24 hour


fluvastatin sodium oral capsule 20 mg $1 PA; QL (30 EA per 30 days)

fluvastatin sodium oral capsule 40 mg $3.65 PA; QL (30 EA per 30 days)


furosemide injection solution 10 mg/ml $1

furosemide oral solution 10 mg/ml, 8 mg/ml $1

furosemide oral tablet $1

gemfibrozil oral tablet $1

generlac oral solution $3.65


$3.65 PA; SP



glimepiride oral tablet $1

glipizide er oral tablet extended release 24 hour $1


29

Drug Status Notesglipizide oral tablet $1

glipizide xl oral tablet extended release 24 hour $1

glipizide-metformin hcl oral tablet $1

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED $3.65

GLUCAGON EMERGENCY INJECTION KIT $3.65

glyburide micronized oral tablet $1

glyburide oral tablet $1

glyburide-metformin oral tablet $1

HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP


HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION $1

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION $1

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

$1


MB/RX PA; SP


indapamide oral tablet $1

INDOCIN ORAL SUSPENSION $3.65

indomethacin er oral capsule extended release $3.65

indomethacin oral capsule $3.65

INVOKAMET ORAL TABLET $3.65 STPA; QL (60 EA per 30 days)

INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65

STPA; QL (60 Tablets per 30 days)

INVOKANA ORAL TABLET 100 MG $3.65 STPA; QL (30 EA per 30 days)


JARDIANCE ORAL TABLET $3.65 STPA; QL (30 EA per 30 days)

JUXTAPID ORAL CAPSULE $3.65 PA; QL (30 EA per 30 days)



30

Drug Status NotesKALYDECO ORAL TABLET $3.65 PA; QL (60 EA per 30 days)

KANUMA INTRAVENOUS SOLUTION Medical Benefit PA

KEVEYIS ORAL TABLET $3.65 PA

KIONEX ORAL POWDER $3.65

KIONEX ORAL SUSPENSION $3.65

KLOR-CON M15 ORAL TABLET EXTENDED RELEASE $3.65

KORLYM ORAL TABLET $3.65 PA

Krystexxa Intravenous Solution MB/RX PA; SP

KUVAN ORAL TABLET SOLUBLE $3.65 PA; SP

KYNAMRO SUBCUTANEOUS SOLUTION $3.65 PA; SP; QL (4 EA per 28 days)

KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (4 EA per 28 days)

lactulose encephalopathy oral solution $3.65

lactulose oral solution $3.65




LIVALO ORAL TABLET $1 PA; QL (30 EA per 30 days)

lovastatin oral tablet $1



MB/RX SP

Lumizyme Intravenous Solution Reconstituted MB/RX SP

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65

PA; ¥ (Additional PA requirements for members 5 years and under; PBHMI polypharmacy for members less than 18 years of age); QL (30 EA per 30 days)

LYRICA ORAL CAPSULE $3.65



31

Drug Status Notes

LYRICA ORAL SOLUTION $3.65

PA; ¥ (Additional PA requirements for members 5 years and under; PBHMI polypharmacy for members less than 18 years of age); QL (900 ML per 30 days)

magdelay oral tablet delayed release $3.65


$3.65

metformin hcl er (mod) oral tablet extended release 24 hour

$1 PA

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg

$1 PA

metformin hcl er oral tablet extended release 24 hour

$1

metformin hcl oral tablet $1

methamphetamine hcl oral tablet $3.65

PA; ¥ (PA applies to members 2 years and under and 25 years and older; PBHMI polypharmacy for members less than 18 years of age); QL (150 EA per 30 days)

methyclothiazide oral tablet $1

metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml

$3.65

metoclopramide hcl oral tablet $3.65

metolazone oral tablet $3.65

micronized colestipol hcl oral tablet $3.65

miglitol oral tablet $1


Naglazyme Intravenous Solution MB/RX SP

nateglinide oral tablet $1

NATPARA SUBCUTANEOUS CARTRIDGE $3.65PA; SP; QL (2 Cartridges per 21 days)

niacin er (antihyperlipidemic) oral tablet extended release

$1

niacin er oral capsule extended release $1

NIACOR ORAL TABLET $1

NITYR ORAL TABLET $3.65 PA


32

Drug Status NotesNORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION $3.65 PA; SP

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR $3.65 PA




octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

$3.65 PA; SP; QL (30 ML per 30 days)



ORFADIN ORAL CAPSULE $3.65 PA

ORFADIN ORAL SUSPENSION $3.65 PA


oxandrolone oral tablet 10 mg $3.65 PA; QL (60 EA per 30 days)

oxandrolone oral tablet 2.5 mg $3.65 PA; QL (240 EA per 30 days)

Pamidronate Disodium Intravenous Solution MB/RX

Pamidronate Disodium Intravenous Solution Reconstituted

MB/RX


PHOSPHA 250 NEUTRAL ORAL TABLET $3.65

pioglitazone hcl oral tablet $1

pioglitazone hcl-glimepiride oral tablet $1

pioglitazone hcl-metformin hcl oral tablet $1

pot bicarb-pot chloride oral tablet effervescent $3.65

potassium bicarbonate oral tablet effervescent $3.65

potassium chloride crys er oral tablet extended release

$3.65

potassium chloride er oral capsule extended release

$3.65

potassium chloride er oral tablet extended release $3.65


33

Drug Status Notespotassium chloride oral packet $3.65

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

$3.65

PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65 PA; SP; QL (2 ML per 28 days)

pravastatin sodium oral tablet $1

probenecid oral tablet $3.65

PROGLYCEM ORAL SUSPENSION $3.65


RAVICTI ORAL LIQUID $3.65 PA; SP

REGRANEX EXTERNAL GEL $3.65


repaglinide oral tablet $1

repaglinide-metformin hcl oral tablet $1

REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE $3.65

PA; SP; # (Preferred product); QL (3.5 ML per 28 days)

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65

PA; SP; # (Preferred product); QL (2 ML per 28 days)

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65


RIOMET ORAL SOLUTION $1

risedronate sodium oral tablet 30 mg $3.65 PA; QL (30 EA per 30 days)

rosuvastatin calcium oral tablet $1 PA; QL (30 EA per 30 days)





SAMSCA ORAL TABLET 15 MG $3.65 SP; QL (30 EA per 30 days)


SandoSTATIN LAR Depot Intramuscular Kit MB/RX PA; SP; QL (1 vial per 28 days)




34

Drug Status NotesSIMCOR ORAL TABLET EXTENDED RELEASE 24 HOUR $1

simvastatin oral tablet $1

sodium polystyrene sulfonate oral powder $3.65

sodium polystyrene sulfonate oral suspension $3.65

sodium polystyrene sulfonate rectal suspension $3.65


Somatuline Depot Subcutaneous Solution MB/RX SP; QL (1 ML per 28 days)

SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 PA; SP; QL (30 EA per 30 days)

spironolactone oral tablet $3.65

spironolactone-hctz oral tablet $3.65

SPS ORAL SUSPENSION $3.65

STRENSIQ SUBCUTANEOUS SOLUTION $3.65 PA; QL (24 Vials per 28 days)

SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65



SYNJARDY ORAL TABLET $3.65 STPA; QL (60 EA per 30 days)

SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 25-1000 MG

$3.65 STPA; QL (30 EA per 30 days)

SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-1000 MG, 5-1000 MG




tolazamide oral tablet $1

tolbutamide oral tablet $1

torsemide oral tablet $3.65

triamterene-hctz oral capsule $1

triamterene-hctz oral tablet $3.65

trientine hcl oral capsule $3.65 PA

TRIGLIDE ORAL TABLET 160 MG $3.65 PA; QL (30 EA per 30 days)


35

Drug Status NotesTRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65 QL (4 pens per 28 days)

ULORIC ORAL TABLET $3.65STPA; QL (30 Tablets per 30 days)

VELTASSA ORAL PACKET $3.65

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65 QL (3 pens per 28 days)

Vpriv Intravenous Solution Reconstituted MB/RX PA; SP

WELCHOL ORAL TABLET $3.65 PA

Xgeva Subcutaneous Solution MB/RX PA; SP; QL (1 vial per 30 days)

XIFAXAN ORAL TABLET 200 MG $3.65 QL (9 EA per 30 days)


XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG


XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG, 5-500 MG $3.65 PA; QL (60 EA per 30 days)


XURIDEN ORAL PACKET $3.65 PA; QL (120 Packets per 30 days)

ZETIA ORAL TABLET $1 PA; QL (30 EA per 30 days)



MB/RX



ZURAMPIC ORAL TABLET $3.65 PA

DISEASE OF THE HEART AND BLOOD VESSELS

acebutolol hcl oral capsule $1



ADRENALIN INJECTION SOLUTION $3.65



36

Drug Status NotesAFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR $1

ALDACTAZIDE ORAL TABLET 50-50 MG $1

almotriptan malate oral tablet $3.65 PA; QL (9 EA per 30 days)


MB/RX SP

AMICAR ORAL SOLUTION $3.65

AMICAR ORAL SYRUP $3.65

AMICAR ORAL TABLET $3.65

amiloride hcl oral tablet $1

amiloride-hydrochlorothiazide oral tablet $1

amiodarone hcl oral tablet $3.65

amlodipine besy-benazepril hcl oral capsule $1 QL (30 EA per 30 days)

amlodipine besylate oral tablet $1

amlodipine besylate-valsartan oral tablet $1 PA; QL (30 EA per 30 days)


amlodipine-valsartan-hctz oral tablet $1 PA; QL (30 EA per 30 days)


anucort-hc rectal suppository $3.65

ANUSOL-HC RECTAL SUPPOSITORY $3.65



atenolol oral tablet $1

atenolol-chlorthalidone oral tablet $1

AZOR ORAL TABLET $1 PA

benazepril hcl oral tablet $1

benazepril-hydrochlorothiazide oral tablet $1

BENICAR HCT ORAL TABLET $1 STPA

BENICAR ORAL TABLET $1 STPA

betaxolol hcl oral tablet $1

BIDIL ORAL TABLET $3.65 PA

bisoprolol fumarate oral tablet $1

bisoprolol-hydrochlorothiazide oral tablet $1

Botox Injection Solution Reconstituted MB/RX PA; SP



37

Drug Status NotesBRILINTA ORAL TABLET 90 MG $3.65 PA; QL (60 EA per 30 days)

bumetanide oral tablet $1

BYSTOLIC ORAL TABLET $1 STPA; QL (30 EA per 30 days)

CAFERGOT ORAL TABLET $3.65

candesartan cilexetil oral tablet $1 PA


captopril-hydrochlorothiazide oral tablet $1

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG $1 PA


MB/RX PA; SP

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR $1

carvedilol oral tablet $1

carvedilol phosphate er oral capsule extended release 24 hour

$1PA; STPA; QL (30 EA per 30 days)

cilostazol oral tablet $3.65

clonidine hcl oral tablet $1

PA; ¥ (PA applies to members 2 years and under; PBHMI polypharmacy for members less than 18 years of age)

clonidine hcl transdermal patch weekly $1


clopidogrel bisulfate oral tablet $3.65

CLORPRES ORAL TABLET $1

CORLANOR ORAL TABLET $3.65 PA

DEMSER ORAL CAPSULE $1

DIGITEK ORAL TABLET $3.65

DIGOX ORAL TABLET $3.65

digoxin oral solution $3.65

digoxin oral tablet $3.65

dihydroergotamine mesylate nasal solution $3.65

DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE $3.65


38

Drug Status Notesdilt-cd oral capsule extended release 24 hour 120 mg, 240 mg, 300 mg

$1

diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

$1

diltiazem hcl er beads oral capsule extended release 24 hour

$1

diltiazem hcl er coated beads oral capsule extended release 24 hour

$1

diltiazem hcl er coated beads oral tablet extended release 24 hour

$1

diltiazem hcl er oral capsule extended release 12 hour

$1

diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

$1

diltiazem hcl oral tablet $1

dilt-xr oral capsule extended release 24 hour $1

diltzac oral capsule extended release 24 hour $1

disopyramide phosphate oral capsule $3.65

divalproex sodium er oral tablet extended release 24 hour

$3.65

PA; ¥ (PA applies to members 5 years of age and under; PBHMI polypharmacy for members less than 18 years of age)

divalproex sodium oral capsule delayed release sprinkle

$3.65


divalproex sodium oral tablet delayed release $3.65


dofetilide oral capsule $3.65 SP

doxazosin mesylate oral tablet $1

EDARBI ORAL TABLET $3.65 PA

eletriptan hydrobromide oral tablet $3.65 PA; QL (9 EA per 30 days)


enalapril maleate oral tablet $1

enalapril-hydrochlorothiazide oral tablet $1



39

Drug Status Notesenoxaparin sodium subcutaneous solution $3.65

ENTRESTO ORAL TABLET $3.65 PA

EPANED ORAL SOLUTION RECONSTITUTED $3.65

epinephrine hcl injection solution 1 mg/ml $3.65

eplerenone oral tablet $1 PA; QL (60 EA per 30 days)





eprosartan mesylate oral tablet $1 PA

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL $3.65


MB/RX

ethacrynic acid oral tablet $1 PA


Feiba Intravenous Solution Reconstituted MB/RX SP

felodipine er oral tablet extended release 24 hour $1

flecainide acetate oral tablet $3.65


fosinopril sodium oral tablet $1

fosinopril sodium-hctz oral tablet $1


$3.65

frovatriptan succinate oral tablet $3.65 PA; QL (9 EA per 30 days)

furosemide oral solution 10 mg/ml, 8 mg/ml $1

furosemide oral tablet $1


MB/RX PA; SP



40

Drug Status Notes

guanfacine hcl oral tablet $1


HEMMOREX-HC RECTAL SUPPOSITORY $3.65

heparin (porcine) in nacl intravenous solution5000-0.9 ut/500ml-%

$3.65


$3.65


MB/RX SP

hydralazine hcl oral tablet $1

hydrochlorothiazide oral capsule $1

hydrochlorothiazide oral tablet $1

hydrocortisone ace-pramoxine external cream2.5-1 %

$3.65

hydrocortisone ace-pramoxine rectal cream $3.65

hydrocortisone acetate rectal suppository $3.65

Hydroxyprogesterone Caproate Intramuscular Oil MB/RX

Hydroxyprogesterone Caproate Intramuscular Solution

MB/RX

indapamide oral tablet $1


irbesartan oral tablet $1 STPA

irbesartan-hydrochlorothiazide oral tablet $1 STPA

ISORDIL TITRADOSE ORAL TABLET 40 MG $3.65

isosorbide dinitrate er oral tablet extended release

$3.65

isosorbide dinitrate oral tablet $3.65

isosorbide mononitrate er oral tablet extended release 24 hour

$3.65

isosorbide mononitrate oral tablet $3.65

isradipine oral capsule $1 PA

JANTOVEN ORAL TABLET $3.65


41

Drug Status Noteslabetalol hcl oral tablet $1

LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG $3.65


LEVATOL ORAL TABLET $1 PA

lisinopril oral tablet $1

lisinopril-hydrochlorothiazide oral tablet $1

losartan potassium oral tablet $1

losartan potassium-hctz oral tablet $1



MB/RX SP



MB/RX PA; SP


MB/RX PA; SP

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR $1 PA

meclizine hcl oral tablet $3.65

medroxyprogesterone acetate oral tablet $3.65

MESNEX ORAL TABLET $3.65

methyldopa oral tablet $1

methyldopa-hydrochlorothiazide oral tablet $1

methylergonovine maleate oral tablet $3.65

metoprolol succinate er oral tablet extended release 24 hour

$1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

$1

metoprolol tartrate oral tablet 37.5 mg, 75 mg $3.65 PA

metoprolol-hydrochlorothiazide oral tablet $1

mexiletine hcl oral capsule $3.65

midodrine hcl oral tablet $3.65

MIGERGOT RECTAL SUPPOSITORY $3.65

MIGRANAL NASAL SOLUTION $3.65 QL (8 Units per 30 days)


42

Drug Status NotesMINITRAN TRANSDERMAL PATCH 24 HOUR $3.65

minoxidil oral tablet $1

moexipril hcl oral tablet $1

moexipril-hydrochlorothiazide oral tablet $1

MULTAQ ORAL TABLET $3.65

nadolol oral tablet 20 mg, 40 mg, 80 mg $1

nadolol-bendroflumethiazide oral tablet $1

naratriptan hcl oral tablet $3.65 STPA; QL (9 EA per 30 days)

NATAZIA ORAL TABLET $0

nicardipine hcl oral capsule $1

NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR $1

nifedipine er oral tablet extended release 24 hour30 mg, 60 mg

$1

nifedipine er oral tablet extended release 24 hour90 mg

$3.65

nifedipine er osmotic release oral tablet extended release 24 hour

$1

nifedipine oral capsule $1

nimodipine oral capsule $1 PA

nisoldipine er oral tablet extended release 24 hour

$1

NITRO-BID TRANSDERMAL OINTMENT $3.65

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR $3.65

nitroglycerin sublingual tablet sublingual $3.65

nitroglycerin transdermal patch 24 hour $3.65

nitroglycerin translingual aerosol solution $3.65

nitroglycerin translingual solution $3.65

norepinephrine bitartrate intravenous solution Medical Benefit

norepinephrine-dextrose intravenous solution 4-5 mg/250ml-%, 8-5 mg/250ml-%

Medical Benefit

norepinephrine-sodium chloride intravenous solution 4-0.9 mg/250ml-%, 8-0.9 mg/250ml-%

Medical Benefit

norethindrone acetate oral tablet $3.65


43

Drug Status NotesNORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR $3.65

NORTHERA ORAL CAPSULE $3.65 PA

NovoSeven RT Intravenous Solution Reconstituted

MB/RX SP





MB/RX PA; SP

omeprazole-sodium bicarbonate oral packet $3.65 PA



PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG $3.65

pentoxifylline er oral tablet extended release $3.65

perindopril erbumine oral tablet $1

phenoxybenzamine hcl oral capsule $1

pindolol oral tablet $1

PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65 PA; SP; QL (2 ML per 28 days)

pramcort rectal cream $3.65


prazosin hcl oral capsule $1


PROCTOFOAM HC RECTAL FOAM $3.65

progesterone intramuscular oil $3.65 PA


propafenone hcl er oral capsule extended release 12 hour

$3.65

propafenone hcl oral tablet $3.65

propranolol hcl er oral capsule extended release 24 hour

$1

propranolol hcl oral solution 40 mg/5ml $1


44

Drug Status Notespropranolol hcl oral tablet $1

propranolol-hctz oral tablet $1

quinapril hcl oral tablet $1

quinapril-hydrochlorothiazide oral tablet $1

quinidine gluconate er oral tablet extended release

$3.65

quinidine sulfate er oral tablet extended release $3.65

quinidine sulfate oral tablet $3.65

ramipril oral capsule $1

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR $3.65 PA; QL (60 EA per 30 days)

ranitidine hcl oral capsule $3.65

ranitidine hcl oral syrup $3.65

ranitidine hcl oral tablet 150 mg, 300 mg $3.65


REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE $3.65

PA; SP; # (Preferred product); QL (3.5 ML per 28 days)

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65


REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65


reserpine oral tablet $1



rizatriptan benzoate oral tablet $3.65 STPA; QL (9 EA per 30 days)

rizatriptan benzoate oral tablet dispersible $3.65 STPA; QL (9 EA per 30 days)



SORINE ORAL TABLET $1

sotalol hcl (af) oral tablet 120 mg, 80 mg $1

sotalol hcl oral tablet $1

SOTYLIZE ORAL SOLUTION $3.65


spironolactone-hctz oral tablet $3.65


45

Drug Status Notessumatriptan nasal solution $3.65 QL (6 Units per 30 days)

sumatriptan succinate oral tablet $3.65 QL (9 EA per 30 days)

sumatriptan succinate refill subcutaneous solution cartridge

$3.65 QL (4 EA per 30 days)

sumatriptan succinate subcutaneous solution 6 mg/0.5ml


sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml


sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml


TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR $1

TEKTURNA HCT ORAL TABLET $1 PA; QL (30 EA per 30 days)

TEKTURNA ORAL TABLET $1 PA; QL (30 EA per 30 days)

telmisartan oral tablet $1 PA

telmisartan-hctz oral tablet $1 PA

terazosin hcl oral capsule $1

timolol maleate oral tablet $1

topiramate er oral capsule er 24 hour sprinkle $3.65

PA; ¥ (Additional PA requirements for members 5 years and under; PBHMI polypharmacy for members less than 18 years of age)

topiramate oral capsule sprinkle $3.65

PA; ¥ (PA applies to members 5 years of age and under; PBHMI polypharmacy for members less than 18 years of age); QL (180 EA per 30 days)

topiramate oral tablet 100 mg, 50 mg $3.65


topiramate oral tablet 200 mg $3.65



46

Drug Status Notes



torsemide oral tablet $3.65



trandolapril oral tablet $1

trandolapril-verapamil hcl er oral tablet extended release

$1

tranexamic acid oral tablet $3.65 PA

triamterene-hctz oral capsule $1

triamterene-hctz oral tablet $3.65

TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65 PA






valsartan oral tablet $1 STPA

valsartan-hydrochlorothiazide oral tablet $1 STPA



verapamil hcl er oral capsule extended release 24 hour

$1

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg

$1

verapamil hcl oral tablet $1

warfarin sodium oral tablet $3.65





47

Drug Status NotesXARELTO STARTER PACK ORAL TABLET THERAPY PACK $3.65


zolmitriptan oral tablet $3.65 STPA; QL (9 EA per 30 days)

zolmitriptan oral tablet dispersible $3.65 STPA; QL (9 EA per 30 days)

ZOMIG NASAL SOLUTION $3.65 STPA; QL (6 Units per 30 days)


DISEASE OF THE URINARY TRACT

AFINITOR ORAL TABLET $3.65 PA; SP; QL (30 EA per 30 days)

alfuzosin hcl er oral tablet extended release 24 hour

$3.65








Avastin Intravenous Solution MB/RX SP

AVC VAGINAL VAGINAL CREAM $3.65


bethanechol chloride oral tablet $3.65




CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR $1

CLEOCIN VAGINAL SUPPOSITORY $3.65

clindamycin phosphate vaginal cream $3.65




48

Drug Status Notescyclosporine oral capsule $3.65

darifenacin hydrobromide er oral tablet extended release 24 hour

$3.65 PA

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML $3.65


DIVIGEL TRANSDERMAL GEL $3.65


doxercalciferol oral capsule $3.65

dutasteride oral capsule $3.65 PA; QL (30 EA per 30 days)

dutasteride-tamsulosin hcl oral capsule $3.65 PA; QL (30 EA per 30 days)

ELESTRIN TRANSDERMAL GEL $3.65

Eligard Subcutaneous Kit MB/RX PA; SP

ELMIRON ORAL CAPSULE $3.65

EMCYT ORAL CAPSULE $3.65

EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

$3.65 SP

estradiol vaginal cream $3.65

estradiol vaginal tablet $3.65

ESTRING VAGINAL RING $3.65

ESTROGEL TRANSDERMAL GEL $3.65

FEMRING VAGINAL RING $3.65

finasteride oral tablet 5 mg $3.65

flavoxate hcl oral tablet $3.65


GELNIQUE TRANSDERMAL GEL $3.65 PA



GLYDO EXTERNAL GEL $3.65

GYNAZOLE-1 VAGINAL CREAM $3.65



MB/RX


49

Drug Status Notes

imipramine hcl oral tablet $3.65


INTRAROSA VAGINAL INSERT $3.65 PA; QL (28 EA per 28 days)


Leuprolide Acetate Injection Kit MB/RX PA; SP

lidocaine hcl external gel 2 % $3.65


MB/RX PA; SP


MB/RX PA; SP

Lupron Depot (4-Month) Intramuscular Kit MB/RX PA; SP




methenamine hippurate oral tablet $3.65

methenamine mandelate oral tablet $3.65

metolazone oral tablet $3.65

metronidazole vaginal gel $3.65

miconazole 3 vaginal suppository $3.65

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML


MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 150 MCG/0.3ML, 30 MCG/0.3ML



MONUROL ORAL PACKET $3.65



$3.65



MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65 PA


50

Drug Status NotesNATAZIA ORAL TABLET $0


OSPHENA ORAL TABLET $3.65 PA

oxybutynin chloride er oral tablet extended release 24 hour

$3.65

oxybutynin chloride oral syrup $3.65

oxybutynin chloride oral tablet $3.65

OXYTROL TRANSDERMAL PATCH TWICE WEEKLY $3.65 PA

paricalcitol oral capsule $3.65 PA

phenazopyridine hcl oral tablet 100 mg, 200 mg $3.65


PREMARIN VAGINAL CREAM $3.65

PREMPHASE ORAL TABLET $3.65

PREMPRO ORAL TABLET $3.65



RAPAFLO ORAL CAPSULE $3.65 PA




SENSIPAR ORAL TABLET $3.65 STPA; SP





tamsulosin hcl oral capsule $3.65


terconazole vaginal cream $3.65

terconazole vaginal suppository $3.65

tinidazole oral tablet $3.65

tolterodine tartrate er oral capsule extended release 24 hour

$3.65

tolterodine tartrate oral tablet $3.65

Torisel Intravenous Solution MB/RX SP


51

Drug Status NotesTOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65


TRELSTAR INTRAMUSCULAR SUSPENSION RECONSTITUTED Medical Benefit SP

TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED Medical Benefit SP

trimethoprim oral tablet $3.65

trospium chloride er oral capsule extended release 24 hour

$3.65

trospium chloride oral tablet $3.65

VANDAZOLE VAGINAL GEL $3.65

Vantas Subcutaneous Kit MB/RX SP

VESICARE ORAL TABLET $3.65 PA

Zoladex Subcutaneous Implant 10.8 MG MB/RX SP; QL (1 EA per 84 days)



DISORDER OF NERVE

ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65


ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE $3.65


AFINITOR DISPERZ ORAL TABLET SOLUBLE $3.65 PA; SP; QL (60 EA per 30 days)


amantadine hcl oral capsule $3.65

amantadine hcl oral syrup $3.65

amantadine hcl oral tablet $3.65



52

Drug Status Notes

amphetamine-dextroamphetamine oral tablet $3.65


AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR $3.65

PA; SP; QL (60 Tablets per 30 days)

APOKYN SUBCUTANEOUS SOLUTION $3.65 SP; QL (15 ML per 30 days)

APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65


APTIOM ORAL TABLET $3.65


armodafinil oral tablet 150 mg, 200 mg, 250 mg $3.65 PA; QL (30 Tablets per 30 days)

armodafinil oral tablet 50 mg $3.65 PA; QL (60 Tablets per 30 days)



atomoxetine hcl oral capsule $3.65


atropine sulfate ophthalmic ointment $3.65

atropine sulfate ophthalmic solution $3.65

AUBAGIO ORAL TABLET $3.65 PA; SP; QL (30 EA per 30 days)

AUSTEDO ORAL TABLET $3.65 PA; QL (60 EA per 30 days)

AVONEX INTRAMUSCULAR KIT $3.65 SP

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT $3.65 SP

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT $3.65 SP

baclofen oral tablet $3.65


53

Drug Status Notes

BELSOMRA ORAL TABLET $3.65


benztropine mesylate oral tablet $3.65

BETASERON SUBCUTANEOUS KIT $3.65 SP

BETASERON SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 SP


BRIVIACT INTRAVENOUS SOLUTION Medical Benefit


BRIVIACT ORAL SOLUTION $3.65


BRIVIACT ORAL TABLET $3.65


bromocriptine mesylate oral capsule $3.65

bromocriptine mesylate oral tablet $3.65


caffeine citrate oral solution $3.65

carbamazepine er oral capsule extended release 12 hour

$3.65


carbamazepine er oral tablet extended release 12 hour

$3.65


carbamazepine oral suspension $3.65



54

Drug Status Notes

carbamazepine oral tablet $3.65


carbamazepine oral tablet chewable $3.65


carbidopa oral tablet $3.65

carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

$3.65

carbidopa-levodopa oral tablet $3.65

carbidopa-levodopa oral tablet dispersible $3.65

carbidopa-levodopa-entacapone oral tablet $3.65

CELONTIN ORAL CAPSULE $3.65


chlordiazepoxide hcl oral capsule $3.65


clonazepam oral tablet $3.65


clonidine hcl er oral tablet extended release 12 hour

$3.65


clorazepate dipotassium oral tablet $3.65


CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 MG, 54 MG $3.65



55

Drug Status Notes

CONCERTA ORAL TABLET EXTENDED RELEASE 36 MG $3.65



COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE $3.65



dantrolene sodium oral capsule $3.65

DAYTRANA TRANSDERMAL PATCH $3.65

PA; ¥ (Additional PA requirements for members 2 years and under; PBHMI polypharmacy for members less than 18 years of age); QL (30 patches per 30 days)


DEXEDRINE ORAL TABLET $3.65PA; ¥ (PA applies to members less than 3 years old or 25 and older); QL (90 EA per 30 days)

dexmethylphenidate hcl oral tablet $3.65


dextroamphetamine sulfate er oral capsule extended release 24 hour

$3.65


dextroamphetamine sulfate oral solution $3.65

PA; ¥ (PA applies to members 2 years and under and 25 years and older; PBHMI polypharmacy for members less than 18 years of age); QL (1200 mL per 30 days)


56

Drug Status Notes

dextroamphetamine sulfate oral tablet $3.65


DIAZEPAM INTENSOL ORAL CONCENTRATE $3.65


diazepam oral concentrate $3.65


diazepam oral solution 1 mg/ml $3.65


diazepam oral tablet $3.65


diazepam rectal gel $3.65 QL (1 System per 1 Rx)


DILANTIN ORAL CAPSULE 30 MG $3.65


diphenhydramine hcl oral capsule $3.65

diphenhydramine hcl oral elixir $3.65


$3.65



$3.65





57

Drug Status Notesdonepezil hcl oral tablet 10 mg, 5 mg $3.65

donepezil hcl oral tablet dispersible $3.65

DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE $3.65


Dysport Intramuscular Solution Reconstituted MB/RX PA; SP

EDLUAR SUBLINGUAL TABLET SUBLINGUAL $3.65 PA; QL (30 EA per 30 days)


EMFLAZA ORAL SUSPENSION $3.65 PA; QL (26 ML per 30 days)

EMFLAZA ORAL TABLET $3.65 PA; QL (30 EA per 30 days)

entacapone oral tablet $3.65


EPITOL ORAL TABLET $3.65PA; ¥ (PA applies to members 6 years and under)

ergoloid mesylates oral tablet $3.65


estazolam oral tablet 1 mg $3.65


eszopiclone oral tablet $3.65


ethosuximide oral capsule $3.65


ethosuximide oral solution $3.65


Exondys 51 Intravenous Solution MB/RX PA

EXTAVIA SUBCUTANEOUS KIT $3.65 SP


58

Drug Status NotesEXTAVIA SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 SP

flurazepam hcl oral capsule $3.65


FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65



FYCOMPA ORAL SUSPENSION $3.65


FYCOMPA ORAL TABLET $3.65


gabapentin oral capsule $3.65


gabapentin oral solution 250 mg/5ml $3.65


gabapentin oral tablet $3.65


GABITRIL ORAL TABLET 12 MG, 16 MG $3.65


galantamine hydrobromide er oral capsule extended release 24 hour

$3.65

galantamine hydrobromide oral solution $3.65

galantamine hydrobromide oral tablet $3.65



59

Drug Status Notesgenerlac oral solution $3.65

GILENYA ORAL CAPSULE $3.65STPA; SP; QL (30 EA per 30 days)

glatiramer acetate subcutaneous solution prefilled syringe

$3.65 SP

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML $3.65 SP

GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65 PA

GRALISE ORAL TABLET $3.65


GRALISE STARTER ORAL $3.65


guanfacine hcl er oral tablet extended release 24 hour

$3.65

PA; STPA; ¥ (Additional PA requirements for members 2 years and under; PBHMI polypharmacy for members less than 18 years of age); QL (30 EA per 30 days)


HETLIOZ ORAL CAPSULE $3.65 PA; QL (30 EA per 30 days)

HORIZANT ORAL TABLET EXTENDED RELEASE $3.65



hydroxyzine hcl oral syrup $3.65

hydroxyzine hcl oral tablet $3.65

hydroxyzine pamoate oral capsule $3.65

INCRELEX SUBCUTANEOUS SOLUTION $3.65 PA; SP

INGREZZA ORAL CAPSULE $3.65 PA





60

Drug Status Notes

lamotrigine er oral tablet extended release 24 hour

$3.65


lamotrigine odt oral tablet dispersible $3.65


lamotrigine oral kit 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 50 (42)-100(14) mg

$3.65


lamotrigine oral tablet 100 mg, 150 mg $3.65


lamotrigine oral tablet 200 mg $3.65


lamotrigine oral tablet 25 mg $3.65PA; ¥ (PA applies to members 6 years and under); QL (180 EA per 30 days)

lamotrigine oral tablet chewable $3.65PA; ¥ (PA applies to members 6 years and under); QL (180 EA per 30 days)

lamotrigine oral tablet dispersible $3.65PA; ¥ (PA applies to members 6 years and under)

lamotrigine starter kit-blue oral kit $3.65


lamotrigine starter kit-green oral kit $3.65


lamotrigine starter kit-orange oral kit $3.65



61

Drug Status Notes

lamotrigine titration oral kit $3.65PA; ¥ (PA applies to members 6 years and under)

levetiracetam er oral tablet extended release 24 hour 500 mg

$3.65



$3.65


levetiracetam oral solution $3.65


levetiracetam oral tablet $3.65


lidocaine external patch 5 % $3.65








memantine hcl oral solution $3.65

memantine hcl oral tablet $3.65



62

Drug Status Notes



methylphenidate hcl er (cd) oral capsule extended release

$3.65


methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg, 40 mg, 60 mg

$3.65


methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg

$3.65


methylphenidate hcl er oral tablet extended release 10 mg, 20 mg

$3.65PA; ¥ (PA applies to members less than 3 years old or 25 and older); QL (30 EA per 30 days)

methylphenidate hcl er oral tablet extended release 24 hour


methylphenidate hcl oral solution $3.65PA; ¥ (PA applies to members less than 3 years old or 25 and older); QL (900 mL per 30 days)

methylphenidate hcl oral tablet $3.65PA; ¥ (PA applies to members less than 3 years old or 25 and older); QL (90 EA per 30 days)

methylphenidate hcl oral tablet chewable $3.65PA; ¥ (PA applies to members less than 3 years old or 25 and older); QL (90 EA per 30 days)



MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 3.75 MG $3.65


modafinil oral tablet $3.65 PA; QL (30 EA per 30 days)


63

Drug Status Notes

MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65


Myobloc Intramuscular Solution MB/RX PA; SP

NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65

NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65


NEUPRO TRANSDERMAL PATCH 24 HOUR $3.65 PA; QL (30 EA per 30 days)



NUPLAZID ORAL TABLET $3.65PA; SP; QL (60 Tablets per 30 days)

Ocrevus Intravenous Solution MB/RX PA; SP



ONFI ORAL SUSPENSION $3.65


ONFI ORAL TABLET 10 MG, 20 MG $3.65


oxazepam oral capsule $3.65


oxcarbazepine oral suspension $3.65



64

Drug Status Notes

oxcarbazepine oral tablet $3.65


OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG

$3.65


OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 600 MG $3.65


PEGANONE ORAL TABLET $3.65


PHENYTOIN INFATABS ORAL TABLET CHEWABLE $3.65


phenytoin oral suspension 125 mg/5ml $3.65


phenytoin oral tablet chewable $3.65


phenytoin sodium extended oral capsule $3.65


pimozide oral tablet $3.65


pramipexole dihydrochloride er oral tablet extended release 24 hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 4.5 mg

$3.65

pramipexole dihydrochloride oral tablet $3.65


65

Drug Status Notespropranolol hcl er oral capsule extended release 24 hour

$1

propranolol hcl oral solution $1

propranolol hcl oral tablet $1


$3.65


QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE $3.65


QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED $3.65

PA; ¥ (Additional PA requirements for members 2 years and under; PBHMI polypharmacy for members less than 18 years of age); QL (360 mL per 30 days)

Radicava Intravenous Solution MB/RX PA

rasagiline mesylate oral tablet $3.65

REBIF REBIDOSE SUBCUTANEOUS SOLUTION $3.65 SP

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65 SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION $3.65 SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

$3.65 SP

REBIF SUBCUTANEOUS SOLUTION $3.65 SP

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION $3.65 SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

$3.65 SP


riluzole oral tablet $3.65

rivastigmine tartrate oral capsule $3.65


66

Drug Status Notesrivastigmine transdermal patch 24 hour $3.65



ropinirole hcl er oral tablet extended release 24 hour

$3.65

ropinirole hcl oral tablet $3.65

ROZEREM ORAL TABLET $3.65 PA; QL (30 EA per 30 days)

SABRIL ORAL TABLET $3.65



selegiline hcl oral capsule $3.65

selegiline hcl oral tablet $3.65




Spinraza Intrathecal Solution MB/RX PA

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE $3.65


sumatriptan nasal solution $3.65 QL (6 Units per 30 days)










TECFIDERA ORAL $3.65 PA; SP; QL (60 EA per 30 days)

TECFIDERA ORAL CAPSULE DELAYED RELEASE $3.65 PA; SP; QL (60 EA per 30 days)


67

Drug Status Notes

temazepam oral capsule $3.65


tetrabenazine oral tablet 12.5 mg $3.65 PA; SP; QL (240 EA per 30 days)

tetrabenazine oral tablet 25 mg $3.65 PA; SP; QL (120 EA per 30 days)

tiagabine hcl oral tablet 2 mg, 4 mg $3.65


tolcapone oral tablet $3.65 PA; QL (180 EA per 30 days)












trihexyphenidyl hcl oral elixir $3.65

trihexyphenidyl hcl oral tablet $3.65


Tysabri Intravenous Concentrate MB/RX PA; SP; QL (1 vial per 28 days)


68

Drug Status Notes

valproic acid oral capsule $3.65


valproic acid oral solution $3.65


valproic acid oral syrup $3.65


vigabatrin oral packet $3.65


VIMPAT ORAL SOLUTION $3.65


VIMPAT ORAL TABLET $3.65


VYVANSE ORAL CAPSULE $3.65


VYVANSE ORAL TABLET CHEWABLE $3.65


XADAGO ORAL TABLET $3.65 PA

Xeomin Intramuscular Solution Reconstituted MB/RX PA; SP




69

Drug Status NotesXYREM ORAL SOLUTION $3.65 PA

zaleplon oral capsule $3.65


ZELAPAR ORAL TABLET DISPERSIBLE $3.65 PA; QL (60 EA per 30 days)

ZENZEDI ORAL TABLET 10 MG, 5 MG $3.65PA; ¥ (PA applies to members less than 3 years old or 25 and older); QL (90 EA per 30 days)

ZINBRYTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65

PA; SP; QL (1 Injection per 30 days)



zolpidem tartrate er oral tablet extended release $3.65


zolpidem tartrate oral tablet $3.65


zolpidem tartrate sublingual tablet sublingual $3.65



zonisamide oral capsule $3.65




70

Drug Status NotesDISORDER OF NERVOUS SYSTEM















APOKYN SUBCUTANEOUS SOLUTION $3.65 SP; QL (15 ML per 30 days)










71

Drug Status Notes





AUBAGIO ORAL TABLET $3.65 PA; SP; QL (30 EA per 30 days)


AVONEX INTRAMUSCULAR KIT $3.65 SP

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT $3.65 SP

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT $3.65 SP


BELSOMRA ORAL TABLET $3.65


benztropine mesylate oral tablet $3.65

BETASERON SUBCUTANEOUS KIT $3.65 SP

BETASERON SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 SP


BRIVIACT INTRAVENOUS SOLUTION Medical Benefit


BRIVIACT ORAL SOLUTION $3.65


BRIVIACT ORAL TABLET $3.65





72

Drug Status NotesCAFERGOT ORAL TABLET $3.65



$3.65



$3.65









carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

$3.65

carbidopa-levodopa oral tablet $3.65

carbidopa-levodopa oral tablet dispersible $3.65

carbidopa-levodopa-entacapone oral tablet $3.65

CELONTIN ORAL CAPSULE $3.65







73

Drug Status Notes


$3.65




















74

Drug Status Notes


$3.65














diazepam rectal gel $3.65 QL (1 System per 1 Rx)


DILANTIN ORAL CAPSULE 30 MG $3.65





75

Drug Status Notes


$3.65



$3.65




donepezil hcl oral tablet 10 mg, 5 mg $3.65





EDLUAR SUBLINGUAL TABLET SUBLINGUAL $3.65 PA; QL (30 EA per 30 days)




entacapone oral tablet $3.65





estazolam oral tablet 1 mg $3.65



76

Drug Status Notes

eszopiclone oral tablet $3.65


ethosuximide oral capsule $3.65


ethosuximide oral solution $3.65



EXTAVIA SUBCUTANEOUS KIT $3.65 SP

EXTAVIA SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 SP

flurazepam hcl oral capsule $3.65












77

Drug Status Notes





GABITRIL ORAL TABLET 12 MG, 16 MG $3.65



$3.65





GILENYA ORAL CAPSULE $3.65STPA; SP; QL (30 EA per 30 days)

glatiramer acetate subcutaneous solution prefilled syringe

$3.65 SP

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML $3.65 SP

GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65 PA






$3.65



78

Drug Status Notesguanidine hcl oral tablet $3.65 PA

HETLIOZ ORAL CAPSULE $3.65 PA; QL (30 EA per 30 days)

HORIZANT ORAL TABLET EXTENDED RELEASE $3.65











lamotrigine er oral tablet extended release 24 hour

$3.65





$3.65







79

Drug Status Notes












$3.65



$3.65








80

Drug Status Notes














$3.65



$3.65



$3.65



81

Drug Status Notes










MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 3.75 MG $3.65









NEUPRO TRANSDERMAL PATCH 24 HOUR $3.65 PA; QL (30 EA per 30 days)





82

Drug Status NotesOcrevus Intravenous Solution MB/RX PA; SP









oxcarbazepine oral suspension $3.65


oxcarbazepine oral tablet $3.65


OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG

$3.65


OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 600 MG $3.65





83

Drug Status Notes

PHENYTOIN INFATABS ORAL TABLET CHEWABLE $3.65


phenytoin oral suspension 125 mg/5ml $3.65


phenytoin oral tablet chewable $3.65


phenytoin sodium extended oral capsule $3.65





$3.65

pramipexole dihydrochloride oral tablet $3.65


$1




$3.65







84

Drug Status NotesRadicava Intravenous Solution MB/RX PA


REBIF REBIDOSE SUBCUTANEOUS SOLUTION $3.65 SP

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65 SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION $3.65 SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

$3.65 SP

REBIF SUBCUTANEOUS SOLUTION $3.65 SP

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION $3.65 SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

$3.65 SP




rivastigmine transdermal patch 24 hour $3.65



ropinirole hcl er oral tablet extended release 24 hour

$3.65

ropinirole hcl oral tablet $3.65

ROZEREM ORAL TABLET $3.65 PA; QL (30 EA per 30 days)




selegiline hcl oral capsule $3.65

selegiline hcl oral tablet $3.65


85

Drug Status NotesSoliris Intravenous Solution 10 MG/ML MB/RX PA; SP



Spinraza Intrathecal Solution MB/RX PA













TECFIDERA ORAL $3.65 PA; SP; QL (60 EA per 30 days)

TECFIDERA ORAL CAPSULE DELAYED RELEASE $3.65 PA; SP; QL (60 EA per 30 days)

temazepam oral capsule $3.65




tiagabine hcl oral tablet 2 mg, 4 mg $3.65






86

Drug Status Notes










trihexyphenidyl hcl oral elixir $3.65

trihexyphenidyl hcl oral tablet $3.65



valproic acid oral capsule $3.65


valproic acid oral solution $3.65


valproic acid oral syrup $3.65



87

Drug Status Notes



VIMPAT ORAL SOLUTION $3.65


VIMPAT ORAL TABLET $3.65






XADAGO ORAL TABLET $3.65 PA




XYREM ORAL SOLUTION $3.65 PA

zaleplon oral capsule $3.65


ZELAPAR ORAL TABLET DISPERSIBLE $3.65 PA; QL (60 EA per 30 days)


ZINBRYTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65

PA; SP; QL (1 Injection per 30 days)


88

Drug Status Noteszolmitriptan oral tablet $3.65 STPA; QL (9 EA per 30 days)


zolpidem tartrate er oral tablet extended release $3.65


zolpidem tartrate oral tablet $3.65


zolpidem tartrate sublingual tablet sublingual $3.65



zonisamide oral capsule $3.65



DISORDER OF REPRODUCTIVE SYSTEM


alendronate sodium oral tablet 10 mg, 5 mg $3.65 QL (30 EA per 30 days)


ALTAVERA ORAL TABLET $0

alyacen 1/35 oral tablet $0

alyacen 7/7/7 oral tablet $0

AMETHIA LO ORAL TABLET $0

AMETHIA ORAL TABLET $0

AMETHYST ORAL TABLET $0

ANDRODERM TRANSDERMAL PATCH 24 HOUR $3.65 PA

ANDROGEL PUMP TRANSDERMAL GEL20.25 MG/ACT (1.62%) $3.65 PA


89

Drug Status NotesANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%), 50 MG/5GM (1%)

$3.65 PA

ANDROXY ORAL TABLET $3.65

APRI ORAL TABLET $0

ARANELLE ORAL TABLET $0

ASHLYNA ORAL TABLET $0

AUBRA ORAL TABLET $0


AVIANE ORAL TABLET $0

AZURETTE ORAL TABLET $0

BALZIVA ORAL TABLET $0

BEKYREE ORAL TABLET $0

BEYAZ ORAL TABLET $0

BLISOVI 24 FE ORAL TABLET $0

BLISOVI FE 1.5/30 ORAL TABLET $0

BLISOVI FE 1/20 ORAL TABLET $0

briellyn oral tablet $0

calcitonin (salmon) nasal solution $3.65

CAMILA ORAL TABLET $0

CAMRESE LO ORAL TABLET $0

CAMRESE ORAL TABLET $0

CAZIANT ORAL TABLET $0

CHATEAL ORAL TABLET $0

CIALIS ORAL TABLET 5 MG $3.65 PA; QL (30 EA per 30 days)


CLIMARA PRO TRANSDERMAL PATCH WEEKLY $3.65


COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY $3.65

CRINONE VAGINAL GEL 8 % $3.65 PA

CRYSELLE-28 ORAL TABLET $0

CYCLAFEM 1/35 ORAL TABLET $0

CYCLAFEM 7/7/7 ORAL TABLET $0


90

Drug Status NotesCYRED ORAL TABLET $0

danazol oral capsule $3.65

DASETTA 1/35 ORAL TABLET $0

DASETTA 7/7/7 ORAL TABLET $0

DAYSEE ORAL TABLET $0

DEBLITANE ORAL TABLET $0

DELYLA ORAL TABLET $0


DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION $0

DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML $3.65 PA

desogestrel-ethinyl estradiol oral tablet $0


drospiren-eth estrad-levomefol oral tablet 3-0.03-0.451 mg

$0

drospirenone-ethinyl estradiol oral tablet $0

DUAVEE ORAL TABLET $3.65 PA


ELINEST ORAL TABLET $0

ELLA ORAL TABLET $0

EMOQUETTE ORAL TABLET $0

ENPRESSE-28 ORAL TABLET $0

ENSKYCE ORAL TABLET $0

ERRIN ORAL TABLET $0

ESTARYLLA ORAL TABLET $0

estradiol oral tablet $3.65

estradiol transdermal patch twice weekly $3.65

estradiol transdermal patch weekly $3.65





estropipate oral tablet $3.65


91

Drug Status NotesEVAMIST TRANSDERMAL SOLUTION $3.65

exemestane oral tablet $3.65

FALMINA ORAL TABLET $0

FAYOSIM ORAL TABLET $0


FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML $3.65 PA; SP; QL (1 vial per 30 days)

FORTICAL NASAL SOLUTION $3.65

FOSAMAX PLUS D ORAL TABLET $3.65 PA; QL (4 EA per 28 days)

GIANVI ORAL TABLET $0

GILDAGIA ORAL TABLET $0

GILDESS 1.5/30 ORAL TABLET $0

GILDESS 1/20 ORAL TABLET $0

GILDESS 24 FE ORAL TABLET $0

GILDESS FE 1.5/30 ORAL TABLET $0

GILDESS FE 1/20 ORAL TABLET $0

GYNAZOLE-1 VAGINAL CREAM $3.65

HEATHER ORAL TABLET $0



MB/RX

Ibandronate Sodium Intravenous Solution 3 MG/3ML

MB/RX QL (3 ML per 90 days)

ibandronate sodium oral tablet $3.65 PA; QL (1 EA per 28 days)


INTROVALE ORAL TABLET $0

JENCYCLA ORAL TABLET $0

JOLESSA ORAL TABLET $0

JOLIVETTE ORAL TABLET $0

JULEBER ORAL TABLET $0

JUNEL 1.5/30 ORAL TABLET $0

JUNEL 1/20 ORAL TABLET $0

JUNEL FE 1.5/30 ORAL TABLET $0

JUNEL FE 1/20 ORAL TABLET $0

JUNEL FE 24 ORAL TABLET $0


92

Drug Status NotesKAITLIB FE ORAL TABLET CHEWABLE $0

KARIVA ORAL TABLET $0

KELNOR 1/35 ORAL TABLET $0

KIMIDESS ORAL TABLET $0

KURVELO ORAL TABLET $0

KYLEENA INTRAUTERINE INTRAUTERINE DEVICE Medical Benefit

LARIN 1.5/30 ORAL TABLET $0

LARIN 1/20 ORAL TABLET $0

LARIN 24 FE ORAL TABLET $0

LARIN FE 1.5/30 ORAL TABLET $0

LARIN FE 1/20 ORAL TABLET $0

LAYOLIS FE ORAL TABLET CHEWABLE $0

LEENA ORAL TABLET $0

LESSINA ORAL TABLET $0

letrozole oral tablet $3.65

LEVONEST ORAL TABLET $0

levonorgest-eth estrad 91-day oral tablet $0

levonorgestrel oral tablet $0

levonorgestrel-ethinyl estrad oral tablet $0

levonorg-eth estrad triphasic oral tablet $0

LEVORA 0.15/30 (28) ORAL TABLET $0

LO LOESTRIN FE ORAL TABLET $0

LOMEDIA 24 FE ORAL TABLET $0

LORYNA ORAL TABLET $0

LOW-OGESTREL ORAL TABLET $0


MB/RX PA; SP


MB/RX PA; SP

LUTERA ORAL TABLET $0

LYNPARZA ORAL CAPSULE $3.65 PA

LYZA ORAL TABLET $0

marlissa oral tablet $0



93

Drug Status Notesmefenamic acid oral capsule $3.65 PA

MENEST ORAL TABLET $3.65


methitest oral tablet $3.65 PA

methyltestosterone oral capsule $3.65


MIACALCIN INJECTION SOLUTION $3.65


MICROGESTIN 1.5/30 ORAL TABLET $0

MICROGESTIN 1/20 ORAL TABLET $0

MICROGESTIN 24 FE ORAL TABLET $0

MICROGESTIN FE 1.5/30 ORAL TABLET $0

MICROGESTIN FE 1/20 ORAL TABLET $0

MONO-LINYAH ORAL TABLET $0

MONONESSA ORAL TABLET $0

MY WAY ORAL TABLET $0

MYZILRA ORAL TABLET $0

NATAZIA ORAL TABLET $0

NECON 0.5/35 (28) ORAL TABLET $0

NECON 1/35 (28) ORAL TABLET $0



NECON 7/7/7 ORAL TABLET $0

NEXT CHOICE ONE DOSE ORAL TABLET $0

NIKKI ORAL TABLET $0

NORA-BE ORAL TABLET $0

norethin ace-eth estrad-fe oral tablet $0

norethin ace-eth estrad-fe oral tablet chewable $0


norethindrone acet-ethinyl est oral tablet $0

norethindrone oral tablet $0

norethindrone-eth estradiol oral tablet $3.65

norethin-eth estradiol-fe oral tablet chewable 0.8-25 mg-mcg

$0


94

Drug Status Notesnorgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

$0

norgestim-eth estrad triphasic oral tablet $0

NORLYROC ORAL TABLET $0

NORTREL 0.5/35 (28) ORAL TABLET $0

NORTREL 1/35 (21) ORAL TABLET $0

NORTREL 1/35 (28) ORAL TABLET $0

NORTREL 7/7/7 ORAL TABLET $0

NUVARING VAGINAL RING $0

OCELLA ORAL TABLET $0

OGESTREL ORAL TABLET $0

ORSYTHIA ORAL TABLET $0


PHILITH ORAL TABLET $0

PIMTREA ORAL TABLET $0

PIRMELLA 1/35 ORAL TABLET $0

PIRMELLA 7/7/7 ORAL TABLET $0

PORTIA-28 ORAL TABLET $0

PREMARIN ORAL TABLET $3.65




PREVIFEM ORAL TABLET $0


progesterone micronized oral capsule $3.65

Prolia Subcutaneous Solution MB/RXPA; SP; QL (1 syringe per 180 days)

QUASENSE ORAL TABLET $0

raloxifene hcl oral tablet $3.65

RECLIPSEN ORAL TABLET $0




risedronate sodium oral tablet delayed release $3.65 PA; QL (4 EA per 28 days)


95

Drug Status NotesSEROPHENE ORAL TABLET $3.65 PA

SETLAKIN ORAL TABLET $0

SHAROBEL ORAL TABLET $0

SOLTAMOX ORAL SOLUTION $3.65

SPRINTEC 28 ORAL TABLET $0

SRONYX ORAL TABLET $0

STRIANT BUCCAL $3.65 PA

SYNAREL NASAL SOLUTION $3.65 PA

tamoxifen citrate oral tablet $3.65

TARINA FE 1/20 ORAL TABLET $0



TESTOPEL IMPLANT PELLET $3.65 PA

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

$3.65 PA

testosterone enanthate intramuscular solution $3.65 PA

testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

$3.65 PA

testosterone transdermal solution $3.65 PA

TILIA FE ORAL TABLET $0



TRI-ESTARYLLA ORAL TABLET $0

TRI-LEGEST FE ORAL TABLET $0

TRI-LINYAH ORAL TABLET $0

TRI-LO-ESTARYLLA ORAL TABLET $0

TRI-LO-MARZIA ORAL TABLET $0

TRI-LO-SPRINTEC ORAL TABLET $0

TRINESSA (28) ORAL TABLET $0

TRINESSA LO ORAL TABLET $0

TRI-PREVIFEM ORAL TABLET $0

TRI-SPRINTEC ORAL TABLET $0

TRIVORA (28) ORAL TABLET $0

TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65 PA; SP; QL (2 ML per 30 days)


96

Drug Status NotesVANDAZOLE VAGINAL GEL $3.65

VELIVET ORAL TABLET $0

VESTURA ORAL TABLET $0

VIENVA ORAL TABLET $0

viorele oral tablet $0

VYFEMLA ORAL TABLET $0

WERA ORAL TABLET $0

WYMZYA FE ORAL TABLET CHEWABLE $0

Xiaflex Injection Solution Reconstituted MB/RX PA

XULANE TRANSDERMAL PATCH WEEKLY $0

ZARAH ORAL TABLET $0

ZENCHENT FE ORAL TABLET CHEWABLE $0

ZENCHENT ORAL TABLET $0



MB/RX

ZOVIA 1/35E (28) ORAL TABLET $0

ZOVIA 1/50E (28) ORAL TABLET $0

DISORDER OF RESPIRATORY SYSTEM


acetylcysteine inhalation solution $3.65






$3.65 PA




$3.65


97

Drug Status Notesalbuterol sulfate inhalation nebulization solution $3.65



ALVESCO INHALATION AEROSOL SOLUTION $3.65


$3.65 PA


MB/RX SP





$3.65


$3.65


$3.65


$3.65


$3.65









98

Drug Status Notesbudesonide inhalation suspension $3.65






chlorpromazine hcl oral tablet $3.65





clotrimazole mouth/throat lozenge $3.65

clotrimazole mouth/throat troche $3.65





DALIRESP ORAL TABLET $3.65 PA; STPA












MB/RX



99

Drug Status NotesFasenra Subcutaneous Solution Prefilled Syringe MB/RX PA; SP


$3.65





$3.65







$3.65


$3.65





$3.65








$3.65





100

Drug Status Noteslidocaine external ointment $3.65 QL (50 GM per 30 days)




















PASER ORAL PACKET $3.65 PA



PORTRAZZA INTRAVENOUS SOLUTION Medical Benefit

PRIFTIN ORAL TABLET $3.65 PA



$3.65 PA


101

Drug Status Notespromethazine vc plain oral syrup $3.65


promethazine-codeine oral syrup $3.65






$3.65











$3.65



SIRTURO ORAL TABLET $3.65 PA

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION $3.65



Synagis Intramuscular Solution MB/RX PA; SP



102

Drug Status NotesTHEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 300 MG, 400 MG $3.65


$3.65


$3.65


$3.65

















VIRAZOLE INHALATION SOLUTION RECONSTITUTED $3.65








103

Drug Status NotesDISORDER OF THE DIGESTIVE SYSTEM

ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE $3.65 PA

adefovir dipivoxil oral tablet $3.65


AKYNZEO ORAL CAPSULE $3.65 QL (1 EA per 1 Fill)

ALINIA ORAL SUSPENSION RECONSTITUTED $3.65

ALINIA ORAL TABLET $3.65

alosetron hcl oral tablet $3.65

Aloxi Intravenous Solution 0.25 MG/5ML MB/RX QL (20 ML per 1 Rx)

AMITIZA ORAL CAPSULE $3.65 PA; QL (60 EA per 30 days)

amoxicill-clarithro-lansopraz oral $3.65



ANZEMET ORAL TABLET 100 MG $3.65 QL (10 EA per 1 fill)


APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65


balsalazide disodium oral capsule $3.65

BARACLUDE ORAL SOLUTION $3.65

BILTRICIDE ORAL TABLET $3.65

budesonide oral capsule delayed release particles $3.65

CANASA RECTAL SUPPOSITORY $3.65

CANTIL ORAL TABLET $3.65 PA

CARAFATE ORAL SUSPENSION $3.65PA; ¥ (PA applies to members 12 years and older)

CESAMET ORAL CAPSULE $3.65 PA


chlordiazepoxide-clidinium oral capsule $3.65


chlorhexidine gluconate mouth/throat solution $3.65

CHOLBAM ORAL CAPSULE $3.65 PA


104

Drug Status Notescimetidine hcl oral solution $3.65

cimetidine oral tablet $3.65





Cinvanti Intravenous Emulsion MB/RX QL (18 ML per 1 Fill)

CLINPRO 5000 DENTAL PASTE $3.65

COLOCORT RECTAL ENEMA $3.65

COMPAZINE RECTAL SUPPOSITORY $3.65

COMPRO RECTAL SUPPOSITORY $3.65


CORTIFOAM RECTAL FOAM $3.65

CREON ORAL CAPSULE DELAYED RELEASE PARTICLES $3.65


CUVPOSA ORAL SOLUTION $3.65




DAKLINZA ORAL TABLET $3.65 PA; SP

DELZICOL ORAL CAPSULE DELAYED RELEASE $3.65

DENAVIR EXTERNAL CREAM $3.65 PA; QL (5 GM per 1 Fill)

DENTA 5000 PLUS DENTAL CREAM $3.65

DENTAGEL DENTAL GEL $3.65


DEXILANT ORAL CAPSULE DELAYED RELEASE 60 MG $3.65 PA

DICLEGIS ORAL TABLET DELAYED RELEASE $3.65 PA

dicyclomine hcl oral capsule $3.65

dicyclomine hcl oral solution $3.65

dicyclomine hcl oral tablet $3.65


105

Drug Status NotesDIFICID ORAL TABLET $3.65 QL (20 EA per 1 Fill)

dimenhydrinate oral tablet $3.65

DIPENTUM ORAL CAPSULE $3.65

diphenoxylate-atropine oral liquid $3.65

diphenoxylate-atropine oral tablet $3.65



Emend Intravenous Solution Reconstituted 150 MG

MB/RX QL (2 vials per 1 Rx)

EMEND ORAL CAPSULE $3.65 QL (6 EA per 1 Rx)

EMEND ORAL SUSPENSION RECONSTITUTED $3.65 QL (3 Units per 7 days)

entecavir oral tablet $3.65

Entyvio Intravenous Solution Reconstituted MB/RX PA; SP


EPCLUSA ORAL TABLET $3.65 PA; SP



famotidine oral suspension reconstituted $3.65

famotidine oral tablet 20 mg, 40 mg $3.65

FLUORABON ORAL SOLUTION $3.65

FLUOR-A-DAY ORAL SOLUTION $3.65

FLUOR-A-DAY ORAL TABLET CHEWABLE $3.65

FLUORIDEX DAILY DEFENSE DENTAL GEL $3.65

FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE $3.65

FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP $3.65

GamaSTAN S/D Intramuscular Injectable MB/RX PA; SP


MB/RX PA; SP

GATTEX SUBCUTANEOUS KIT $3.65 PA; SP; QL (1 Kit per 1 day)

GAVILYTE-C ORAL SOLUTION RECONSTITUTED $3.65


106

Drug Status NotesGAVILYTE-G ORAL SOLUTION RECONSTITUTED $3.65

GAVILYTE-H ORAL KIT $3.65




GIAZO ORAL TABLET $3.65 PA

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM $3.65

granisetron hcl oral tablet $3.65 QL (14 EA per 1 Fill)

HARVONI ORAL TABLET $3.65 PA; SP









$3.65

hydrocortisone ace-pramoxine rectal cream $3.65


hydrocortisone rectal enema $3.65


Intron A Injection Solution MB/RX SP

Intron A Injection Solution Reconstituted MB/RX SP

ivermectin oral tablet $3.65



lamivudine oral tablet 100 mg $3.65


107

Drug Status Noteslansoprazole oral capsule delayed release $3.65 PA

LINZESS ORAL CAPSULE $3.65 PA; QL (30 EA per 30 days)

LONSURF ORAL TABLET $3.65 PA; SP

loperamide hcl oral capsule $3.65

MAVYRET ORAL TABLET $3.65 PA; SP


mesalamine oral tablet delayed release 1.2 gm $3.65 STPA; QL (120 EA per 30 days)

mesalamine oral tablet delayed release 800 mg $3.65

mesalamine rectal enema $3.65


$3.65


misoprostol oral tablet $3.65

MODERIBA ORAL TABLET 200 MG $3.65 QL (210 EA per 30 days)

MOVANTIK ORAL TABLET $3.65 PA

MOVIPREP ORAL SOLUTION RECONSTITUTED $3.65





$3.65




$3.65


NAFRINSE DAILY/NEUTRAL MOUTH/THROAT SOLUTION RECONSTITUTED

$3.65

neomycin sulfate oral tablet $3.65

neutral sodium fluoride mouth/throat solution $3.65

NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE $3.65 PA

NEXIUM ORAL PACKET $3.65 PA

nizatidine oral capsule $3.65


108

Drug Status Notesnizatidine oral solution $3.65

NUTRESTORE ORAL PACKET $3.65 PA

OCALIVA ORAL TABLET $3.65PA; SP; QL (30 TABS per 30 days)



omeprazole oral capsule delayed release $3.65


ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml

$3.65

ondansetron hcl oral solution $3.65 QL (105 ML per 1 Fill)

ondansetron hcl oral tablet $3.65 QL (21 EA per 1 Fill)

ondansetron oral tablet dispersible $3.65 QL (21 EA per 1 Fill)

OSMOPREP ORAL TABLET $3.65 QL (32 EA per 1 Fill)

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200 UNIT

$3.65

paregoric oral tincture $3.65

PAROEX MOUTH/THROAT SOLUTION $3.65

paromomycin sulfate oral capsule $3.65

peg 3350/electrolytes oral solution reconstituted $3.65

peg 3350-kcl-na bicarb-nacl oral solution reconstituted

$3.65

peg-3350/electrolytes oral solution reconstituted $3.65

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION $3.65 SP; QL (4 ML per 28 days)

PEGASYS SUBCUTANEOUS SOLUTION $3.65 SP; QL (4 ML per 28 days)

PEG-INTRON REDIPEN PAK 4 SUBCUTANEOUS KIT 120 MCG/0.5ML $3.65 SP; QL (4 EA per 28 days)

PEG-INTRON REDIPEN SUBCUTANEOUS KIT $3.65 SP; QL (4 EA per 28 days)

PEGINTRON SUBCUTANEOUS KIT $3.65 SP; QL (4 EA per 28 days)

PEG-INTRON SUBCUTANEOUS KIT $3.65 SP; QL (4 EA per 28 days)

PENTASA ORAL CAPSULE EXTENDED RELEASE $3.65


109

Drug Status NotesPERIOGARD MOUTH/THROAT SOLUTION $3.65

PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES $3.65

PHENADOZ RECTAL SUPPOSITORY $3.65

PHENERGAN RECTAL SUPPOSITORY $3.65


polyethylene glycol 3350 oral powder $3.65

POLY-VI-FLOR ORAL SUSPENSION $3.65

pramcort rectal cream $3.65

PREPOPIK ORAL PACKET $3.65

PREVACID SOLUTAB ORAL TABLET DISPERSIBLE $3.65 PA; Age Limit (Max 2 Years)

PRILOSEC ORAL PACKET $3.65 PA

prochlorperazine edisylate injection solution $3.65

prochlorperazine maleate oral tablet $3.65

prochlorperazine rectal suppository $3.65

PROCTOFOAM HC RECTAL FOAM $3.65



promethazine hcl oral solution $3.65

promethazine hcl oral syrup $3.65

promethazine hcl oral tablet $3.65

promethazine hcl rectal suppository $3.65

PROMETHEGAN RECTAL SUPPOSITORY $3.65

PYLERA ORAL CAPSULE $3.65

rabeprazole sodium oral tablet delayed release $3.65 PA




REBETOL ORAL SOLUTION $3.65 SP; QL (35 ML per 1 day)

RELISTOR ORAL TABLET $3.65 PA; QL (90 Tablets per 30 days)

RELISTOR SUBCUTANEOUS SOLUTION12 MG/0.6ML, 8 MG/0.4ML $3.65 PA



110

Drug Status NotesRenflexis Intravenous Solution Reconstituted MB/RX PA; SP

RIBASPHERE ORAL CAPSULE $3.65 QL (210 EA per 30 days)

RIBASPHERE ORAL TABLET 200 MG $3.65 QL (210 EA per 30 days)

ribavirin oral capsule $3.65 SP; QL (210 EA per 30 days)

ribavirin oral tablet 200 mg $3.65 SP; QL (210 EA per 30 days)

SANCUSO TRANSDERMAL PATCH $3.65 PA; QL (4 EA per 28 days)



scopolamine transdermal patch 72 hour $3.65

sf 5000 plus dental cream $3.65

sf dental gel $3.65

SFROWASA RECTAL ENEMA $3.65

sodium fluoride oral solution $3.65

sodium fluoride oral tablet 1.1 (0.5 f) mg $3.65

sodium fluoride oral tablet chewable $3.65

SOVALDI ORAL TABLET $3.65 PA; SP


Stelara Intravenous Solution MB/RXPA; SP; ¥ (1 Fill per life of plan); QL (4 VIALS per 1 Fill)

Stelara Subcutaneous Solution 45 MG/0.5ML MB/RX PA; QL (4 Vials per 1 Lifetime)

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65

PA; SP; QL (1 Syringe per 84 days)

sucralfate oral tablet $3.65

sulfasalazine oral tablet $3.65


SUPREP BOWEL PREP KIT ORAL SOLUTION $3.65

SUSTOL SUBCUTANEOUS PREFILLED SYRINGE Medical Benefit

SYMPROIC ORAL TABLET $3.65 PA







111

Drug Status NotesTRILYTE ORAL SOLUTION RECONSTITUTED $3.65

trimethobenzamide hcl oral capsule $3.65




TYZEKA ORAL TABLET $3.65

UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65 PA

UCERIS RECTAL FOAM $3.65 PA

ursodiol oral capsule $3.65

ursodiol oral tablet $3.65

Varubi Intravenous Emulsion MB/RX

VARUBI ORAL TABLET $3.65¥ (Max of 6 tablets per 30 days); QL (2 Tablets per 1 Fill)

VEMLIDY ORAL TABLET $3.65

VIBERZI ORAL TABLET $3.65



VOSEVI ORAL TABLET $3.65 PA; SP

XERMELO ORAL TABLET $3.65 PA



ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000 UNIT, 20000-63000 UNIT, 20000-68000 UNIT, 25000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 40000-136000 UNIT, 5000 UNIT, 5000-24000 UNIT

$3.65

ZEPATIER ORAL TABLET $3.65 PA; SP

Zinplava Intravenous Solution MB/RX PA


DISORDER OF THE ENDOCRINE GLANDS

acarbose oral tablet $1


112

Drug Status NotesACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR $1

Aldurazyme Intravenous Solution MB/RX PA; SP





alogliptin-pioglitazone oral tablet $1 PA; QL (30 EA per 30 days)

ANDRODERM TRANSDERMAL PATCH 24 HOUR $3.65 PA

ANDROGEL PUMP TRANSDERMAL GEL20.25 MG/ACT (1.62%) $3.65 PA

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%), 50 MG/5GM (1%)

$3.65 PA

ANDROXY ORAL TABLET $3.65


AVANDAMET ORAL TABLET $1

AVANDARYL ORAL TABLET $1

AVANDIA ORAL TABLET $1



cabergoline oral tablet $3.65





chlorpropamide oral tablet $1


COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY $3.65


CRINONE VAGINAL GEL 8 % $3.65 PA

DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML $3.65 PA


113

Drug Status Notesdesmopressin ace rhinal tube nasal solution $3.65

desmopressin ace spray refrig nasal solution $3.65


desmopressin acetate spray nasal solution $3.65

DEXAMETHASONE INTENSOL ORAL CONCENTRATE $3.65

dexamethasone oral elixir $3.65

dexamethasone oral solution $3.65

dexamethasone oral tablet $3.65

DEXPAK 10 DAY ORAL TABLET THERAPY PACK $3.65



DIABETA ORAL TABLET $1







estradiol transdermal patch weekly $3.65





estropipate oral tablet $3.65




fludrocortisone acetate oral tablet $3.65




114

Drug Status NotesFOSAMAX PLUS D ORAL TABLET $3.65 PA; QL (4 EA per 28 days)



$3.65 PA; SP


glimepiride oral tablet $1

glipizide er oral tablet extended release 24 hour $1

glipizide oral tablet $1

glipizide xl oral tablet extended release 24 hour $1

glipizide-metformin hcl oral tablet $1

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED $3.65

GLUCAGON EMERGENCY INJECTION KIT $3.65

glyburide micronized oral tablet $1

glyburide oral tablet $1

glyburide-metformin oral tablet $1


HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION $1

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION $1

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

$1




MB/RX







115

Drug Status NotesINVOKAMET ORAL TABLET $3.65 STPA; QL (60 EA per 30 days)

INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65

STPA; QL (60 Tablets per 30 days)



JARDIANCE ORAL TABLET $3.65 STPA; QL (30 EA per 30 days)


KORLYM ORAL TABLET $3.65 PA



LEVO-T ORAL TABLET $3.65

levothyroxine sodium oral tablet $3.65

LEVOXYL ORAL TABLET $3.65

liothyronine sodium oral tablet $3.65



MB/RX SP

Lupron Depot-Ped (1-Month) Intramuscular Kit MB/RX PA; SP

Lupron Depot-Ped (3-Month) Intramuscular Kit MB/RX PA; SP







LYSODREN ORAL TABLET $3.65




116

Drug Status NotesMENEST ORAL TABLET $3.65


$1 PA

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg

$1 PA

metformin hcl er oral tablet extended release 24 hour

$1

metformin hcl oral tablet $1

methimazole oral tablet $3.65

methitest oral tablet $3.65 PA




$3.65



$3.65






Naglazyme Intravenous Solution MB/RX SP

nateglinide oral tablet $1

NATPARA SUBCUTANEOUS CARTRIDGE $3.65PA; SP; QL (2 Cartridges per 21 days)








117

Drug Status NotesNUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION $3.65 PA; SP






paricalcitol oral capsule $3.65 PA


pioglitazone hcl oral tablet $1

pioglitazone hcl-glimepiride oral tablet $1

pioglitazone hcl-metformin hcl oral tablet $1




$3.65


$3.65

PREMARIN ORAL TABLET $3.65







propylthiouracil oral tablet $3.65






RIOMET ORAL SOLUTION $1


118

Drug Status Notesrisedronate sodium oral tablet 150 mg $3.65 PA; QL (1 EA per 30 days)













SIGNIFOR SUBCUTANEOUS SOLUTION $3.65 PA; QL (60 ML per 30 days)




STRIANT BUCCAL $3.65 PA

Supprelin LA Subcutaneous Kit MB/RX SP



SYNAREL NASAL SOLUTION $3.65 PA

SYNJARDY ORAL TABLET $3.65 STPA; QL (60 EA per 30 days)

SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 25-1000 MG


SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-1000 MG, 5-1000 MG



119

Drug Status NotesTESTOPEL IMPLANT PELLET $3.65 PA

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

$3.65 PA

testosterone enanthate intramuscular solution $3.65 PA

testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

$3.65 PA


Thyrogen Intramuscular Solution Reconstituted MB/RX SP

THYROLAR-1 ORAL TABLET $3.65

THYROLAR-1/2 ORAL TABLET $3.65

THYROLAR-1/4 ORAL TABLET $3.65



tolazamide oral tablet $1

tolbutamide oral tablet $1

Triptodur Intramuscular Suspension Reconstituted ER

MB/RX

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65 QL (4 pens per 28 days)


UNITHROID ORAL TABLET $3.65

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65 QL (3 pens per 28 days)

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG


XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG, 5-500 MG $3.65 PA; QL (60 EA per 30 days)


MB/RX



EAR PROBLEM

ACETASOL HC OTIC SOLUTION $3.65


120

Drug Status Notesacetic acid otic solution $3.65

acetic acid-aluminum acetate otic solution $3.65


CIPRO HC OTIC SUSPENSION $3.65

CIPRODEX OTIC SUSPENSION $3.65

dexamethasone sodium phosphate ophthalmic solution

$3.65

fluocinolone acetonide otic oil $3.65

hydrocortisone-acetic acid otic solution $3.65


MB/RX PA; SP


neomycin-polymyxin-hc otic solution $3.65

neomycin-polymyxin-hc otic suspension $3.65

ofloxacin otic solution $3.65

OTIPRIO INTRATYMPANIC SUSPENSION Medical Benefit

EYE DISORDER


ADRENALIN INJECTION SOLUTION 1 MG/ML $3.65

ALOCRIL OPHTHALMIC SOLUTION $3.65 PA

ALPHAGAN P OPHTHALMIC SOLUTION0.1 % $3.65 PA

ALREX OPHTHALMIC SUSPENSION $3.65



AZASITE OPHTHALMIC SOLUTION $3.65 QL (2.5 mL per 1 fill)

azelastine hcl ophthalmic solution $3.65 PA

AZOPT OPHTHALMIC SUSPENSION $3.65 PA

bacitracin ophthalmic ointment $3.65

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

$3.65

BEPREVE OPHTHALMIC SOLUTION $3.65 PA

betaxolol hcl ophthalmic solution $3.65


121

Drug Status NotesBETIMOL OPHTHALMIC SOLUTION $3.65

BETOPTIC-S OPHTHALMIC SUSPENSION $3.65

bimatoprost ophthalmic solution $3.65 PA

BLEPHAMIDE OPHTHALMIC SUSPENSION $3.65

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT $3.65

brimonidine tartrate ophthalmic solution 0.15 % $3.65 PA

brimonidine tartrate ophthalmic solution 0.2 % $3.65

bromfenac sodium (once-daily) ophthalmic solution

$3.65

bromfenac sodium ophthalmic solution $3.65

carteolol hcl ophthalmic solution $3.65


COMBIGAN OPHTHALMIC SOLUTION $3.65 PA

COSOPT PF OPHTHALMIC SOLUTION $3.65

cromolyn sodium ophthalmic solution $3.65

cyclopentolate hcl ophthalmic solution $3.65 QL (2 ML per 30 days)


$3.65

diclofenac sodium ophthalmic solution $3.65

dorzolamide hcl ophthalmic solution $3.65

dorzolamide hcl-timolol mal ophthalmic solution $3.65

DUREZOL OPHTHALMIC EMULSION $3.65

EMADINE OPHTHALMIC SOLUTION $3.65 PA

epinastine hcl ophthalmic solution $3.65 PA

erythromycin ophthalmic ointment $3.65


FLAREX OPHTHALMIC SUSPENSION $3.65

fluorometholone ophthalmic suspension $3.65

flurbiprofen sodium ophthalmic solution $3.65

FML FORTE OPHTHALMIC SUSPENSION $3.65

FML OPHTHALMIC OINTMENT $3.65


MB/RX PA; SP


122

Drug Status NotesHOMATROPAIRE OPHTHALMIC SOLUTION $3.65

homatropine hbr ophthalmic solution $3.65

ILEVRO OPHTHALMIC SUSPENSION $3.65

ILOTYCIN OPHTHALMIC OINTMENT $3.65

ISOPTO CARBACHOL OPHTHALMIC SOLUTION $3.65

ketorolac tromethamine ophthalmic solution $3.65

ketotifen fumarate ophthalmic solution $3.65

LASTACAFT OPHTHALMIC SOLUTION $3.65 PA

latanoprost ophthalmic solution $3.65

levobunolol hcl ophthalmic solution $3.65

LOTEMAX OPHTHALMIC GEL $3.65

LOTEMAX OPHTHALMIC OINTMENT $3.65

LOTEMAX OPHTHALMIC SUSPENSION $3.65



MB/RX SP

LUMIGAN OPHTHALMIC SOLUTION 0.01 % $3.65 PA

Macugen Intraocular Solution MB/RX SP

MAXIDEX OPHTHALMIC SUSPENSION $3.65

methazolamide oral tablet $3.65

metipranolol ophthalmic solution $3.65

naphazoline hcl ophthalmic solution $3.65

NATACYN OPHTHALMIC SUSPENSION $3.65 PA

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

$3.65

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

$3.65

neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1

$3.65

NEO-POLYCIN OPHTHALMIC OINTMENT $3.65

NEVANAC OPHTHALMIC SUSPENSION $3.65

olopatadine hcl ophthalmic solution $3.65 PA


123

Drug Status NotesPHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED $3.65

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

$3.65


POLYCIN OPHTHALMIC OINTMENT $3.65

polymyxin b-trimethoprim ophthalmic solution $3.65

polyvinyl alcohol ophthalmic solution $3.65

PRED MILD OPHTHALMIC SUSPENSION $3.65

prednisolone acetate ophthalmic suspension $3.65

prednisolone sodium phosphate ophthalmic solution

$3.65

proparacaine hcl ophthalmic solution $3.65

RESCULA OPHTHALMIC SOLUTION $3.65 PA

RESTASIS OPHTHALMIC EMULSION $3.65 PA; QL (60 EA per 30 days)

SIMBRINZA OPHTHALMIC SUSPENSION $3.65 PA

sulfacetamide sodium ophthalmic ointment $3.65

sulfacetamide sodium ophthalmic solution $3.65

sulfacetamide-prednisolone ophthalmic solution $3.65

timolol maleate ophthalmic gel forming solution $3.65

timolol maleate ophthalmic solution 0.25 %, 0.5 %

$3.65

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 % $3.65

TOBRADEX OPHTHALMIC OINTMENT $3.65

tobramycin-dexamethasone ophthalmic suspension

$3.65

TRAVATAN Z OPHTHALMIC SOLUTION $3.65 PA

TRIESENCE INTRAOCULAR SUSPENSION $3.65

trifluridine ophthalmic solution $3.65

tropicamide ophthalmic solution $3.65

VEXOL OPHTHALMIC SUSPENSION $3.65

Visudyne Intravenous Solution Reconstituted MB/RX SP


ZIOPTAN OPHTHALMIC SOLUTION $3.65 PA


124

Drug Status NotesZIRGAN OPHTHALMIC GEL $3.65 PA

ZYLET OPHTHALMIC SUSPENSION $3.65 QL (5 mL per 30 days)

FEVER



MB/RX PA; SP

INFECTION


abacavir sulfate oral tablet $3.65


abacavir-lamivudine-zidovudine oral tablet $3.65

acyclovir external ointment $3.65



Alferon N Injection Solution MB/RX SP

ALINIA ORAL SUSPENSION RECONSTITUTED $3.65

ALINIA ORAL TABLET $3.65

ALTABAX EXTERNAL OINTMENT $3.65 STPA; QL (15 GM per 1 Fill)





APTIVUS ORAL CAPSULE $3.65

APTIVUS ORAL SOLUTION $3.65


atovaquone-proguanil hcl oral tablet $3.65

ATRIPLA ORAL TABLET $3.65




bacitracin ophthalmic ointment $3.65

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

$3.65

BACTROBAN NASAL NASAL OINTMENT $3.65


125

Drug Status NotesBARACLUDE ORAL SOLUTION $3.65



BILTRICIDE ORAL TABLET $3.65


CENTANY EXTERNAL OINTMENT $3.65




chloroquine phosphate oral tablet $3.65

CICLODAN EXTERNAL CREAM $3.65

CICLODAN EXTERNAL SOLUTION $3.65

ciclopirox external gel $3.65

ciclopirox external solution $3.65

ciclopirox olamine external cream $3.65

ciclopirox olamine external suspension $3.65 PA

CIPRODEX OTIC SUSPENSION $3.65






clotrimazole anti-fungal external cream $3.65

clotrimazole external cream $3.65

clotrimazole external solution $3.65



clotrimazole-betamethasone external cream $3.65

clotrimazole-betamethasone external lotion $3.65

COARTEM ORAL TABLET $3.65 QL (24 EA per 30 days)

COMPLERA ORAL TABLET $3.65

CONDYLOX EXTERNAL GEL $3.65

CORTISPORIN EXTERNAL CREAM $3.65


126

Drug Status NotesCRESEMBA ORAL CAPSULE $3.65

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG $3.65





dapsone oral tablet $3.65


DESCOVY ORAL TABLET $3.65 # (Preferred product)


didanosine oral capsule delayed release $3.65

DIFICID ORAL TABLET $3.65 QL (20 EA per 1 Fill)


econazole nitrate external cream $3.65

ECOZA EXTERNAL FOAM $3.65 PA

EDURANT ORAL TABLET $3.65




EMTRIVA ORAL CAPSULE $3.65

EMTRIVA ORAL SOLUTION $3.65




erythromycin ophthalmic ointment $3.65

EURAX EXTERNAL CREAM $3.65

EURAX EXTERNAL LOTION $3.65

EVOTAZ ORAL TABLET $3.65

EXELDERM EXTERNAL CREAM $3.65 PA

EXELDERM EXTERNAL SOLUTION $3.65 PA




127

Drug Status Notesfosamprenavir calcium oral tablet $3.65

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED $3.65 SP









$3.65 PA; SP


gentamicin sulfate external cream $3.65

gentamicin sulfate external ointment $3.65

GENVOYA ORAL TABLET $3.65 # (Preferred product)






griseofulvin microsize oral suspension $3.65

griseofulvin microsize oral tablet $3.65

griseofulvin ultramicrosize oral tablet $3.65


$3.65


128

Drug Status NotesGYNAZOLE-1 VAGINAL CREAM $3.65




$3.65




ILOTYCIN OPHTHALMIC OINTMENT $3.65

imiquimod external cream $3.65

IMPAVIDO ORAL CAPSULE $3.65

INTELENCE ORAL TABLET $3.65



INVIRASE ORAL CAPSULE $3.65

INVIRASE ORAL TABLET $3.65


ISENTRESS HD ORAL TABLET $3.65 QL (60 EA per 30 days)

ISENTRESS ORAL PACKET $3.65 QL (60 EA per 30 days)

ISENTRESS ORAL TABLET $3.65

ISENTRESS ORAL TABLET CHEWABLE $3.65

isoniazid oral syrup $3.65

isoniazid oral tablet $3.65


JUBLIA EXTERNAL SOLUTION $3.65 PA

JULUCA ORAL TABLET $3.65

KALETRA ORAL TABLET $3.65

ketoconazole external cream $3.65

ketoconazole external shampoo $3.65

kp clotrimazole external cream $3.65

LAMISIL ORAL PACKET $3.65PA; ¥ (Max of 6 weeks); QL (2 Packets per 1 day)


lamivudine oral tablet $3.65


129

Drug Status Noteslamivudine-zidovudine oral tablet $3.65



LEXIVA ORAL SUSPENSION $3.65


lindane external lotion $3.65

lindane external shampoo $3.65


LUZU EXTERNAL CREAM $3.65 PA



malathion external lotion $3.65


mefloquine hcl oral tablet $3.65


$3.65

methenamine hippurate oral tablet $3.65

methenamine mandelate oral tablet $3.65








MONUROL ORAL PACKET $3.65

mupirocin calcium external cream $3.65 PA

mupirocin external ointment $3.65

naftifine hcl external cream $3.65 PA

NAFTIN EXTERNAL GEL 1 % $3.65 PA



130

Drug Status NotesNEBUPENT INHALATION SOLUTION RECONSTITUTED $3.65

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

$3.65

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

$3.65

neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1

$3.65

NEO-POLYCIN OPHTHALMIC OINTMENT $3.65

nevirapine er oral tablet extended release 24 hour $3.65

nevirapine oral suspension $3.65

nevirapine oral tablet $3.65


NORVIR ORAL CAPSULE $3.65 # (Preferred product)

NORVIR ORAL SOLUTION $3.65 # (Preferred product)

NORVIR ORAL TABLET $3.65 # (Preferred product)






NYAMYC EXTERNAL POWDER $3.65

nystatin external cream $3.65

nystatin external ointment $3.65

nystatin external powder $3.65

nystatin mouth/throat suspension $3.65

nystatin oral powder $3.65

nystatin oral tablet $3.65

nystatin-triamcinolone external cream $3.65

nystatin-triamcinolone external ointment $3.65


131

Drug Status NotesNYSTOP EXTERNAL POWDER $3.65

ODEFSEY ORAL TABLET $3.65 # (Preferred product)





oseltamivir phosphate oral capsule 30 mg $3.65¥ (Max of 2 fills per year); QL (20 EA per 1 Fill)

oseltamivir phosphate oral capsule 45 mg, 75 mg $3.65¥ (Max of 2 fills per year); QL (10 EA per 1 Fill)

oseltamivir phosphate oral suspension reconstituted

$3.65¥ (Max of 2 fills per year); QL (180 ML per 1 Fill)

OTIPRIO INTRATYMPANIC SUSPENSION Medical Benefit

oxiconazole nitrate external cream $3.65 PA

OXISTAT EXTERNAL LOTION $3.65 PA


paromomycin sulfate oral capsule $3.65







PEG-INTRON SUBCUTANEOUS KIT $3.65 SP; QL (4 EA per 28 days)

PERIOGARD MOUTH/THROAT SOLUTION $3.65

permethrin external cream $3.65


podofilox external solution $3.65

POLYCIN OPHTHALMIC OINTMENT $3.65


132

Drug Status Notespolymyxin b-trimethoprim ophthalmic solution $3.65



PREZCOBIX ORAL TABLET $3.65

PREZISTA ORAL SUSPENSION $3.65

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG $3.65


primaquine phosphate oral tablet $3.65












RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED

$3.65¥ (Max of 2 fills per year); QL (20 Blisters per 1 Rx)

RESCRIPTOR ORAL TABLET $3.65

REYATAZ ORAL PACKET $3.65




ribavirin oral tablet 200 mg $3.65 SP; QL (210 EA per 30 days)

rimantadine hcl oral tablet $3.65




133

Drug Status NotesSAIZENPREP INJECTION SOLUTION RECONSTITUTED $3.65 PA; SP

SELZENTRY ORAL SOLUTION $3.65 QL (1800 ML per 30 days)

SELZENTRY ORAL TABLET $3.65



silver sulfadiazine external cream $3.65


SKLICE EXTERNAL LOTION $3.65 STPA; QL (117 GM per 1 day)


spinosad external suspension $3.65 STPA; QL (120 ML per 1 Fill)

SSD EXTERNAL CREAM $3.65

stavudine oral capsule $3.65

stavudine oral solution reconstituted $3.65

STRIBILD ORAL TABLET $3.65



SULFAMYLON EXTERNAL CREAM $3.65 PA







TIVICAY ORAL TABLET $3.65





$3.65

TRECATOR ORAL TABLET $3.65 PA



trimethoprim oral tablet $3.65


134

Drug Status NotesTRIUMEQ ORAL TABLET $3.65

TRUVADA ORAL TABLET 200-300 MG $3.65


TYBOST ORAL TABLET $3.65


ULESFIA EXTERNAL LOTION $3.65 PA; QL (12 Bottles per 1 Rx)

VANDAZOLE VAGINAL GEL $3.65



VEREGEN EXTERNAL OINTMENT $3.65 PA

VIDEX ORAL SOLUTION RECONSTITUTED $3.65

VIRACEPT ORAL TABLET $3.65




VITEKTA ORAL TABLET $3.65






zidovudine oral capsule $3.65

zidovudine oral syrup $3.65

zidovudine oral tablet $3.65


ZIRGAN OPHTHALMIC GEL $3.65 PA





135

Drug Status NotesINFLAMMATION OF THE SEROUS MEMBRANES IN THE BODY


INFLAMMATORY DISORDER











$3.65 PA



ala-cort external cream 1 % $3.65

alclometasone dipropionate external cream $3.65

alclometasone dipropionate external ointment $3.65




MB/RX SP




amcinonide external cream $3.65 PA

amcinonide external lotion $3.65 PA

amcinonide external ointment $3.65 PA



136

Drug Status NotesANALPRAM-HC RECTAL LOTION 2.5-1 % $3.65


$3.65 PA



APEXICON E EXTERNAL CREAM $3.65 PA

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65




$3.65


$3.65


$3.65


$3.65


$3.65






balsalazide disodium oral capsule $3.65

BARACLUDE ORAL SOLUTION $3.65




137

Drug Status NotesBENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65 PA; SP




betamethasone dipropionate aug external cream $3.65

betamethasone dipropionate aug external gel $3.65

betamethasone dipropionate aug external lotion $3.65

betamethasone dipropionate aug external ointment

$3.65

betamethasone dipropionate external cream $3.65

betamethasone dipropionate external lotion $3.65

betamethasone dipropionate external ointment $3.65

betamethasone valerate external cream $3.65

betamethasone valerate external lotion $3.65

betamethasone valerate external ointment $3.65

BLEPHAMIDE OPHTHALMIC SUSPENSION $3.65

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT $3.65



$3.65




budesonide oral capsule delayed release particles $3.65

CANASA RECTAL SUPPOSITORY $3.65

CAPEX EXTERNAL SHAMPOO $3.65 PA

CARAFATE ORAL SUSPENSION $3.65PA; ¥ (PA applies to members 12 years and older)


MB/RX PA; SP



138

Drug Status NotesCENTANY EXTERNAL OINTMENT $3.65




chlordiazepoxide-clidinium oral capsule $3.65


choline-mag trisalicylate oral liquid $3.65



ciclopirox external shampoo $3.65 PA



cimetidine hcl oral solution $3.65

cimetidine oral tablet 300 mg, 400 mg, 800 mg $3.65








clobetasol propionate e external cream $3.65

clobetasol propionate external cream $3.65 PA

clobetasol propionate external foam $3.65

clobetasol propionate external gel $3.65 PA

clobetasol propionate external lotion $3.65

clobetasol propionate external ointment $3.65 PA

clocortolone pivalate external cream $3.65 PA

clocortolone pivalate pump external cream $3.65 PA




139

Drug Status Notesclotrimazole external solution $3.65







COLOCORT RECTAL ENEMA $3.65


CORDRAN EXTERNAL OINTMENT $3.65 PA

CORDRAN EXTERNAL TAPE $3.65 PA

CORTIFOAM RECTAL FOAM $3.65




$3.65 PA; SP








DELZICOL ORAL CAPSULE DELAYED RELEASE $3.65


desonide external cream $3.65 PA

desonide external lotion $3.65 PA

desonide external ointment $3.65 PA

desoximetasone external cream 0.05 % $3.65 PA

desoximetasone external cream 0.25 % $3.65

desoximetasone external gel $3.65

desoximetasone external ointment 0.05 % $3.65 PA


140

Drug Status Notesdesoximetasone external ointment 0.25 % $3.65


$3.65

diclofenac potassium oral tablet $3.65


$3.65


diclofenac sodium transdermal gel 1 % $3.65 STPA

diclofenac sodium transdermal solution $3.65 PA

DIFICID ORAL TABLET $3.65 QL (20 EA per 1 Fill)

diflorasone diacetate external cream $3.65 PA

diflorasone diacetate external ointment $3.65 PA

DIPENTUM ORAL CAPSULE $3.65


DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (4 ML per 28 days)






ELIDEL EXTERNAL CREAM $3.65 PA













141

Drug Status NotesENBREL SURECLICK SUBCUTANEOUS SOLUTION $3.65





Entyvio Intravenous Solution Reconstituted MB/RX PA; SP


EPIFOAM EXTERNAL FOAM $3.65



etodolac oral capsule $3.65

etodolac oral tablet $3.65

EUCRISA EXTERNAL OINTMENT $3.65 PA

EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE Medical Benefit PA; SP





FINACEA EXTERNAL FOAM $3.65 QL (50 GM per 1 Rx)

FINACEA EXTERNAL GEL $3.65 QL (50 GM per 1 Rx)

FLAREX OPHTHALMIC SUSPENSION $3.65


$3.65



fluocinolone acetonide body external oil $3.65

fluocinolone acetonide external cream $3.65

fluocinolone acetonide external ointment $3.65

fluocinolone acetonide external solution $3.65


fluocinolone acetonide scalp external oil $3.65

fluocinonide external cream 0.05 % $3.65 QL (60 GM per 30 days)

fluocinonide external cream 0.1 % $3.65 PA; QL (120 GM per 30 days)


142

Drug Status Notesfluocinonide external gel $3.65 QL (60 GM per 30 days)

fluocinonide external ointment $3.65 QL (60 GM per 30 days)

fluocinonide external solution $3.65 QL (60 ML per 30 days)

fluorometholone ophthalmic suspension $3.65

flurandrenolide external cream $3.65 PA

flurandrenolide external lotion $3.65 PA


fluticasone propionate external cream $3.65

fluticasone propionate external lotion $3.65

fluticasone propionate external ointment $3.65



$3.65

FML FORTE OPHTHALMIC SUSPENSION $3.65

FML OPHTHALMIC OINTMENT $3.65





MB/RX PA; SP


GIAZO ORAL TABLET $3.65 PA



$3.65


halobetasol propionate external cream $3.65 PA

halobetasol propionate external ointment $3.65 PA

HALOG EXTERNAL CREAM $3.65 PA

HALOG EXTERNAL OINTMENT $3.65 PA



HOMATROPAIRE OPHTHALMIC SOLUTION $3.65


143

Drug Status Noteshomatropine hbr ophthalmic solution $3.65



MB/RX SP








$3.65




$3.65


hydrocortisone butyrate external cream $3.65 PA

hydrocortisone butyrate external lotion $3.65

hydrocortisone butyrate external ointment $3.65 PA

hydrocortisone butyrate external solution $3.65 PA

hydrocortisone external cream 1 %, 2.5 % $3.65

hydrocortisone external lotion $3.65

hydrocortisone external ointment 1 %, 2.5 % $3.65


hydrocortisone rectal cream $3.65

hydrocortisone rectal enema $3.65

hydrocortisone valerate external cream $3.65

hydrocortisone valerate external ointment $3.65



144

Drug Status Noteshydroxychloroquine sulfate oral tablet $3.65

ibuprofen oral suspension $3.65

ibuprofen oral tablet 400 mg, 600 mg, 800 mg $3.65


MB/RX PA; SP





$3.65









KENALOG INJECTION SUSPENSION $3.65


ketoconazole external foam $3.65


KETODAN EXTERNAL FOAM $3.65


$3.65

ketoprofen oral capsule $3.65








145

Drug Status Notes



lansoprazole oral capsule delayed release $3.65 PA






LOTEMAX OPHTHALMIC GEL $3.65

LOTEMAX OPHTHALMIC OINTMENT $3.65

LOTEMAX OPHTHALMIC SUSPENSION $3.65



MAXIDEX OPHTHALMIC SUSPENSION $3.65

meclofenamate sodium oral capsule $3.65






mesalamine rectal enema $3.65






$3.65

metronidazole external cream $3.65

metronidazole external gel 0.75 % $3.65

metronidazole external gel 1 % $3.65 PA

metronidazole external lotion $3.65




146

Drug Status NotesMIRVASO EXTERNAL GEL $3.65 PA


mometasone furoate external cream $3.65

mometasone furoate external ointment $3.65

mometasone furoate external solution $3.65











naproxen dr oral tablet delayed release $3.65

naproxen oral suspension $3.65

naproxen oral tablet $3.65

naproxen sodium oral tablet $3.65




nizatidine oral capsule $3.65

nizatidine oral solution $3.65

NORITATE EXTERNAL CREAM $3.65 PA








147

Drug Status Notesnystatin external ointment $3.65




NYSTOP EXTERNAL POWDER $3.65



MB/RX PA; SP


omeprazole oral capsule delayed release $3.65







OTEZLA ORAL TABLET $3.65 PA; SP; QL (60 EA per 30 days)

OTEZLA ORAL TABLET THERAPY PACK $3.65 PA; SP; QL (60 EA per 30 days)




PANDEL EXTERNAL CREAM $3.65









148

Drug Status NotesPEG-INTRON SUBCUTANEOUS KIT $3.65 SP; QL (4 EA per 28 days)

PENNSAID TRANSDERMAL SOLUTION 2 % $3.65 PA

PENTASA ORAL CAPSULE EXTENDED RELEASE $3.65







PRAMOSONE E EXTERNAL CREAM $3.65

PRAMOSONE EXTERNAL CREAM 1-1 % $3.65

PRAMOSONE EXTERNAL LOTION $3.65

PRAMOSONE EXTERNAL OINTMENT $3.65

PRED MILD OPHTHALMIC SUSPENSION $3.65

prednicarbate external cream $3.65

prednisolone acetate ophthalmic suspension $3.65



prednisolone sodium phosphate ophthalmic solution

$3.65


$3.65


$3.65

PREVACID SOLUTAB ORAL TABLET DISPERSIBLE $3.65 PA; Age Limit (Max 2 Years)


PRILOSEC ORAL PACKET $3.65 PA



PROCTO-PAK RECTAL CREAM $3.65

PROCTOSOL HC RECTAL CREAM $3.65

PROCTOZONE-HC RECTAL CREAM $3.65


149

Drug Status NotesPROMACTA ORAL TABLET $3.65 PA; SP







psorcon external cream $3.65 PA


$3.65



$3.65




















150

Drug Status Notesribavirin oral tablet 200 mg $3.65 SP; QL (210 EA per 30 days)


ROSADAN EXTERNAL CREAM $3.65

ROSADAN EXTERNAL GEL $3.65


SAVELLA ORAL TABLET $3.65 STPA; QL (60 EA per 30 days)

SAVELLA TITRATION PACK ORAL $3.65 STPA; QL (60 EA per 30 days)

selenium sulfide external lotion $3.65

selenium sulfide external shampoo 2.25 % $3.65

selenium sulf-pyrithione-urea external shampoo $3.65

SELRX EXTERNAL SHAMPOO $3.65



$3.65

SFROWASA RECTAL ENEMA $3.65









SOOLANTRA EXTERNAL CREAM $3.65 PA









151

Drug Status Notessucralfate oral tablet $3.65



sulfacetamide-prednisolone ophthalmic solution $3.65

sulfasalazine oral tablet $3.65


sulindac oral tablet $3.65



SYNALAR (CREAM) EXTERNAL KIT $3.65 PA

SYNALAR (OINTMENT) EXTERNAL KIT $3.65 PA

tacrolimus external ointment $3.65 PA

TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR $3.65

PA; SP; ¥ (One 80 mg auto-injector/syringe per 28 days); QL (1 Injection per 28 days)

TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65



TERSI EXTERNAL FOAM $3.65



$3.65


$3.65


$3.65






$3.65



152

Drug Status Notestolmetin sodium oral tablet $3.65


triamcinolone acetonide external aerosol solution $3.65 PA

triamcinolone acetonide external cream $3.65

triamcinolone acetonide external lotion $3.65

triamcinolone acetonide external ointment $3.65


TRIDERM EXTERNAL CREAM 0.1 % $3.65






UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65 PA

UCERIS RECTAL FOAM $3.65 PA









VOLTAREN TRANSDERMAL GEL $3.65 STPA; QL (32 GM per 1 day)








153

Drug Status NotesXolair Subcutaneous Solution Reconstituted MB/RX PA; SP; QL (6 vials per 28 days)

XOLEGEL EXTERNAL GEL $3.65






ZIRGAN OPHTHALMIC GEL $3.65 PA



INJURY TO A MUCOUS MEMBRANE












doxycycline hyclate oral tablet 20 mg $3.65










MB/RX PA; SP


154

Drug Status NotesINTRAROSA VAGINAL INSERT $3.65 PA; QL (28 EA per 28 days)





nystatin mouth/throat suspension $3.65

nystatin oral powder $3.65

nystatin oral tablet $3.65


ORALONE MOUTH/THROAT PASTE $3.65



PERIOGARD MOUTH/THROAT SOLUTION $3.65








triamcinolone acetonide mouth/throat paste $3.65


LUNG DISEASE








$3.65 PA



155

Drug Status NotesAEROSPAN INHALATION AEROSOL SOLUTION $3.65


$3.65

albuterol sulfate inhalation nebulization solution $3.65





$3.65 PA


MB/RX SP





$3.65


$3.65


$3.65


$3.65


$3.65






156

Drug Status NotesBREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED $3.65 PA; QL (1 EA per 30 days)



















MB/RX




$3.65



$3.65





157

Drug Status NotesGLYDO EXTERNAL GEL $3.65


$3.65


$3.65





$3.65







$3.65


lidocaine external ointment $3.65 QL (50 GM per 30 days)















158

Drug Status NotesOPSUMIT ORAL TABLET $3.65 PA; SP










$3.65 PA






$3.65








$3.65




159

Drug Status NotesSIRTURO ORAL TABLET $3.65 PA








$3.65


$3.65


$3.65

















160

Drug Status NotesXARELTO ORAL TABLET $3.65 QL (30 EA per 30 days)





MAJOR TRAUMATIC INJURY

CIDALEAZE EXTERNAL CREAM $3.65

FLECTOR TRANSDERMAL PATCH $3.65PA; ¥ (Max of 3 months); QL (60 Patches per 30 days)

lidocaine hcl external cream 3 % $3.65

lidocaine hcl external lotion $3.65

lidopin external cream 3 % $3.65


SANTYL EXTERNAL OINTMENT $3.65 QL (30 GM per 1 Rx)




MARGINAL ZONE LYMPHOMA



IMBRUVICA ORAL TABLET 140 MG $3.65 PA

MUSCLE OR BONE DISORDER










161

Drug Status Notes





alendronate sodium oral tablet 40 mg $3.65 QL (1 EA per 6 Months)















Brineura Solution MB/RX PA







162

Drug Status Notes





carisoprodol oral tablet 350 mg $3.65

carisoprodol-aspirin oral tablet $3.65


chlorzoxazone oral tablet 500 mg $3.65

choline-mag trisalicylate oral liquid $3.65










$3.65







163

Drug Status Notes




$3.65 PA; SP





cyclobenzaprine hcl oral tablet 10 mg, 5 mg $3.65



$3.65 PA








$3.65



164

Drug Status Notes















$3.65




duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg

$3.65



165

Drug Status Notes

duloxetine hcl oral capsule delayed release particles 30 mg

$3.65




















etidronate disodium oral tablet $3.65




EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE Medical Benefit PA; SP


FLECTOR TRANSDERMAL PATCH $3.65PA; ¥ (Max of 3 months); QL (60 Patches per 30 days)



166

Drug Status Notes





FOSAMAX PLUS D ORAL TABLET $3.65 PA; QL (4 EA per 28 days)







GELNIQUE TRANSDERMAL GEL $3.65 PA



$3.65











167

Drug Status Noteshydroxychloroquine sulfate oral tablet $3.65







MB/RX PA; SP









$3.65









$3.65





168

Drug Status Notes
























169

Drug Status NotesMESTINON ORAL SYRUP $3.65

metaxalone oral tablet 800 mg $3.65 STPA; QL (120 EA per 30 days)



methocarbamol oral tablet $3.65



$3.65



$3.65



$3.65











170

Drug Status Notes




MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65 PA


naproxen dr oral tablet delayed release $3.65










orphenadrine citrate er oral tablet extended release 12 hour

$3.65

orphenadrine-aspirin-caffeine oral tablet 25-385-30 mg

$3.65


OTEZLA ORAL TABLET THERAPY PACK $3.65 PA; SP; QL (60 EA per 30 days)


oxybutynin chloride er oral tablet extended release 24 hour

$3.65

oxybutynin chloride oral syrup $3.65

oxybutynin chloride oral tablet $3.65

OXYTROL TRANSDERMAL PATCH TWICE WEEKLY $3.65 PA


171

Drug Status Notes














$3.65






Radicava Intravenous Solution MB/RX PA








172

Drug Status Notesrisedronate sodium oral tablet 150 mg $3.65 PA; QL (1 EA per 30 days)

risedronate sodium oral tablet 30 mg, 5 mg $3.65 PA; QL (30 EA per 30 days)









SAVELLA TITRATION PACK ORAL $3.65 STPA; QL (60 EA per 30 days)

















sulindac oral tablet $3.65


173

Drug Status Notes







tizanidine hcl oral tablet $3.65




$3.65

tolterodine tartrate oral tablet $3.65

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65



trospium chloride er oral capsule extended release 24 hour

$3.65

trospium chloride oral tablet $3.65



VESICARE ORAL TABLET $3.65 PA



VOLTAREN TRANSDERMAL GEL $3.65 STPA; QL (32 GM per 1 day)




174

Drug Status Notes








Xiaflex Injection Solution Reconstituted MB/RX PA

XYREM ORAL SOLUTION $3.65 PA



Zoledronic Acid Intravenous Solution MB/RX


NEUROPSYCHIATRIC DISORDER

Abilify Maintena Intramuscular Suspension Reconstituted 300 MG, 400 MG

MB/RX

PA; ¥ (Additional PA requirements for members 5 years and under; PBHMI polypharmacy for members less than 18 years of age); QL (1 Syringe per 28 days)

acamprosate calcium oral tablet delayed release $3.65 QL (180 EA per 30 days)






175

Drug Status Notes

alprazolam er oral tablet extended release 24 hour

$3.65


ALPRAZOLAM INTENSOL ORAL CONCENTRATE $3.65


alprazolam oral tablet $3.65


alprazolam oral tablet dispersible $3.65


alprazolam xr oral tablet extended release 24 hour

$3.65


amoxapine oral tablet $3.65






aripiprazole oral solution $3.65



176

Drug Status Notes

aripiprazole oral tablet $3.65


aripiprazole oral tablet dispersible $3.65


Aristada Intramuscular Prefilled Syringe MB/RX


ASCOMP-CODEINE ORAL CAPSULE $3.65 QL (180 EA per 30 days)





BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 6.3-1 MG $3.65

PA; ¥ (Max of 32 mg/day for the first 6 months); QL (30 EA per 30 days)

BUNAVAIL BUCCAL FILM 4.2-0.7 MG $3.65PA; ¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)

buprenorphine hcl sublingual tablet sublingual $3.65 PA

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg

$3.65PA; ¥ (Max of 32 mg/day for the first 6 months); QL (90 EA per 30 days)

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg


BUPROBAN ORAL TABLET EXTENDED RELEASE 12 HOUR $3.65

bupropion hcl er (smoking det) oral tablet extended release 12 hour

$3.65


177

Drug Status Notes

bupropion hcl er (sr) oral tablet extended release 12 hour

$3.65


bupropion hcl er (xl) oral tablet extended release 24 hour

$3.65


bupropion hcl oral tablet $3.65


buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg

$3.65


buspirone hcl oral tablet 30 mg $3.65


butalbital-acetaminophen oral tablet 50-325 mg $3.65 QL (180 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-325-40 mg

$3.65 QL (180 EA per 30 days)

butalbital-apap-caffeine oral tablet 50-325-40 mg $3.65 QL (180 EA per 30 days)

butalbital-asa-caff-codeine oral capsule $3.65 QL (180 EA per 30 days)

butalbital-aspirin-caffeine oral capsule $3.65 QL (180 EA per 30 days)

CAPACET ORAL CAPSULE $3.65 QL (180 EA per 30 days)


$3.65



$3.65





178

Drug Status NotesCHANTIX CONTINUING MONTH PAK ORAL TABLET $3.65 QL (60 EA per 30 days)

CHANTIX ORAL TABLET $3.65 QL (60 EA per 30 days)

CHANTIX STARTING MONTH PAK ORAL TABLET $3.65 QL (60 EA per 30 days)





citalopram hydrobromide oral solution $3.65


citalopram hydrobromide oral tablet $3.65


clomipramine hcl oral capsule $3.65





$3.65





179

Drug Status Notes

clozapine oral tablet $3.65


clozapine oral tablet dispersible $3.65










desipramine hcl oral tablet $3.65


desvenlafaxine er oral tablet extended release 24 hour

$3.65

PA; STPA; ¥ (Additional PA requirements for members 5 years and under; PBHMI polypharmacy for members less than 18 years of age)


180

Drug Status Notes

desvenlafaxine fumarate er oral tablet extended release 24 hour

$3.65


desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 50 mg

$3.65






$3.65











181

Drug Status Notes





disulfiram oral tablet $3.65


$3.65



$3.65




donepezil hcl oral tablet 10 mg, 5 mg $3.65


doxepin hcl oral capsule $3.65


doxepin hcl oral concentrate $3.65


drospirenone-ethinyl estradiol oral tablet 3-0.02 mg

$0


$3.65



182

Drug Status Notes


$3.65




EMSAM TRANSDERMAL PATCH 24 HOUR $3.65


eq nicotine mouth/throat lozenge $3.65

eq nicotine polacrilex mouth/throat gum $3.65

eq nicotine polacrilex mouth/throat lozenge $3.65

eq nicotine step 3 transdermal patch 24 hour $3.65

eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr

$3.65

eql nicotine polacrilex mouth/throat gum $3.65

eql nicotine polacrilex mouth/throat lozenge $3.65

eql nicotine transdermal patch 24 hour $3.65


escitalopram oxalate oral solution $3.65


escitalopram oxalate oral tablet $3.65


FANAPT ORAL TABLET $3.65



183

Drug Status Notes

FANAPT TITRATION PACK ORAL TABLET $3.65


FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65


FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK $3.65


fluoxetine hcl (pmdd) oral tablet $3.65 PA

fluoxetine hcl oral capsule $3.65


fluoxetine hcl oral solution $3.65


fluoxetine hcl oral tablet 10 mg, 20 mg $3.65


fluphenazine decanoate injection solution $3.65


fluphenazine hcl oral concentrate $3.65


fluphenazine hcl oral elixir $3.65



184

Drug Status Notes

fluphenazine hcl oral tablet $3.65


fluvoxamine maleate er oral capsule extended release 24 hour

$3.65


fluvoxamine maleate oral tablet $3.65





$3.65



Geodon Intramuscular Solution Reconstituted MB/RX



gnp nicotine mini mouth/throat lozenge $3.65

gnp nicotine polacrilex mouth/throat gum $3.65

gnp nicotine polacrilex mouth/throat lozenge $3.65


$3.65


haloperidol decanoate intramuscular solution100 mg/ml, 50 mg/ml

$3.65



185

Drug Status Notes

haloperidol lactate injection solution 5 mg/ml $3.65


haloperidol lactate oral concentrate $3.65


haloperidol oral tablet $3.65


hm nicotine polacrilex mouth/throat gum $3.65

hm nicotine polacrilex mouth/throat lozenge $3.65

hm nicotine transdermal patch 24 hour $3.65




imipramine hcl oral tablet $3.65


imipramine pamoate oral capsule $3.65


Invega Sustenna Intramuscular Suspension MB/RX

PA; ¥ (Additional PA requirements for members 5 years and under; PBHMI polypharmacy for members less than 18 years of age); 2 vials first month; QL (1 Syringe per 30 days)

Invega Trinza Intramuscular Suspension MB/RX





186

Drug Status Notes


$3.65
















LATUDA ORAL TABLET $3.65



187

Drug Status Notes

lithium carbonate er oral tablet extended release $3.65


lithium carbonate oral capsule $3.65


lithium carbonate oral tablet $3.65


lithium oral solution $3.65


LORAZEPAM INTENSOL ORAL CONCENTRATE $3.65


lorazepam oral concentrate $3.65


lorazepam oral tablet $3.65



loxapine succinate oral capsule $3.65


maprotiline hcl oral tablet $3.65


margesic oral capsule $3.65 QL (180 EA per 30 days)

marten-tab oral tablet $3.65 QL (180 EA per 30 days)




188

Drug Status Notes

meprobamate oral tablet $3.65


METHADONE HCL INTENSOL ORAL CONCENTRATE $3.65 QL (6 ML per 1 day)

methadone hcl oral concentrate $3.65 QL (6 ML per 1 day)

methadone hcl oral solution 10 mg/5ml $3.65 QL (30 ML per 1 day)


methadone hcl oral tablet 10 mg $3.65 QL (6 EA per 1 day)


methadone hcl oral tablet soluble Medical Benefit

METHADOSE ORAL TABLET SOLUBLE Medical Benefit




$3.65



$3.65



$3.65







189

Drug Status Notes




mirtazapine oral tablet $3.65


mirtazapine oral tablet dispersible $3.65




naltrexone hcl oral tablet $3.65



nefazodone hcl oral tablet $3.65


NICORELIEF MOUTH/THROAT GUM $3.65

nicotine mini mouth/throat lozenge $3.65

nicotine polacrilex mouth/throat gum $3.65

nicotine polacrilex mouth/throat lozenge $3.65

nicotine step 1 transdermal patch 24 hour $3.65



nicotine transdermal patch 24 hour $3.65


190

Drug Status NotesNICOTROL INHALATION INHALER $3.65

NICOTROL NS NASAL SOLUTION $3.65


nortriptyline hcl oral capsule $3.65


nortriptyline hcl oral solution $3.65


NUEDEXTA ORAL CAPSULE $3.65 PA


OLANZapine Intramuscular Solution Reconstituted

MB/RX


olanzapine oral tablet $3.65


olanzapine oral tablet dispersible $3.65


olanzapine-fluoxetine hcl oral capsule $3.65


OLEPTRO ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65 STPA




191

Drug Status Notes

paliperidone er oral tablet extended release 24 hour

$3.65


paroxetine hcl er oral tablet extended release 24 hour

$3.65


paroxetine hcl oral tablet $3.65


PAXIL ORAL SUSPENSION $3.65


perphenazine oral tablet $3.65


phenelzine sulfate oral tablet $3.65




PROBUPHINE IMPLANT KIT SUBCUTANEOUS IMPLANT Medical Benefit PA

protriptyline hcl oral tablet $3.65


quetiapine fumarate er oral tablet extended release 24 hour

$3.65



192

Drug Status Notes

quetiapine fumarate oral tablet $3.65






ra mini nicotine mouth/throat lozenge $3.65

ra nicotine mouth/throat gum $3.65

ra nicotine polacrilex mouth/throat gum $3.65

ra nicotine polacrilex mouth/throat lozenge $3.65

ra nicotine transdermal patch 24 hour $3.65

REXULTI ORAL TABLET $3.65


RisperDAL Consta Intramuscular Suspension Reconstituted

MB/RX

PA; ¥ (PA applies to members 5 years of age and under; PBHMI polypharmacy for members less than 18 years of age); QL (2 injections per 28 days)

RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE $3.65


risperidone oral solution $3.65



193

Drug Status Notes

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg

$3.65


risperidone oral tablet 4 mg $3.65


risperidone oral tablet dispersible $3.65



rivastigmine transdermal patch 24 hour $3.65

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL $3.65


SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65 PA

sertraline hcl oral concentrate $3.65


sertraline hcl oral tablet $3.65


sm nicotine mouth/throat gum $3.65

sm nicotine mouth/throat lozenge $3.65

sm nicotine polacrilex mouth/throat gum $3.65

sm nicotine polacrilex mouth/throat lozenge $3.65

sm nicotine transdermal patch 24 hour $3.65

SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG $3.65

¥ (Max of 32 mg/day for the first 6 months); QL (30 EA per 30 days)

SUBOXONE SUBLINGUAL FILM 2-0.5 MG $3.65¥ (Max of 32 mg/day for the first 6 months); QL (90 EA per 30 days)


194

Drug Status Notes

SUBOXONE SUBLINGUAL FILM 8-2 MG $3.65¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)

sw nicotine polacrilex mouth/throat gum $3.65

sw nicotine polacrilex mouth/throat lozenge $3.65

TENCON ORAL TABLET 50-325 MG $3.65 QL (180 EA per 30 days)



tgt nicotine mouth/throat gum 4 mg $3.65

tgt nicotine polacrilex mouth/throat gum $3.65

tgt nicotine polacrilex mouth/throat lozenge $3.65

tgt nicotine step one transdermal patch 24 hour $3.65

tgt nicotine step three transdermal patch 24 hour $3.65

tgt nicotine step two transdermal patch 24 hour $3.65

thioridazine hcl oral tablet $3.65


thiothixene oral capsule $3.65


tranylcypromine sulfate oral tablet $3.65


trazodone hcl oral tablet $3.65


trifluoperazine hcl oral tablet $3.65


trimipramine maleate oral capsule $3.65



195

Drug Status Notes

TRINTELLIX ORAL TABLET $3.65


venlafaxine hcl er oral capsule extended release 24 hour

$3.65


venlafaxine hcl er oral tablet extended release 24 hour

$3.65


venlafaxine hcl oral tablet $3.65


VERSACLOZ ORAL SUSPENSION $3.65



VIIBRYD ORAL TABLET $3.65


VIIBRYD STARTER PACK ORAL KIT $3.65


VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED $3.65

VRAYLAR ORAL CAPSULE $3.65


VRAYLAR ORAL CAPSULE THERAPY PACK $3.65



196

Drug Status Notes





ZEBUTAL ORAL CAPSULE 50-325-40 MG $3.65 QL (180 EA per 30 days)


ziprasidone hcl oral capsule $3.65


ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG


ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG, 8.6-2.1 MG $3.65


ZyPREXA Relprevv Intramuscular Suspension Reconstituted 210 MG, 300 MG

MB/RX

PA; ¥ (PA applies to members 5 years of age and under; PBHMI polypharmacy for members less than 18 years of age); QL (2 vials per 28 days)

ZyPREXA Relprevv Intramuscular Suspension Reconstituted 405 MG

MB/RX

PA; ¥ (PA applies to members 5 years of age and under; PBHMI polypharmacy for members less than 18 years of age); QL (1 vial per 28 days)

NOT FEELING WELL


NUTRITIONAL DISORDER




197

Drug Status Notescalcium acetate (phos binder) oral tablet $3.65

cyanocobalamin injection solution $3.65

ergocalciferol oral capsule $3.65



folbee oral tablet $3.65




$3.65 PA; SP






levocarnitine oral tablet $3.65


$3.65


multi vitamin/minerals oral tablet $3.65




$3.65


MYKIDZ IRON FL ORAL SUSPENSION $3.65

mynephrocaps oral capsule $3.65

NEPHROCAPS QT ORAL TABLET DISPERSIBLE $3.65




198

Drug Status NotesNUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION $3.65 PA; SP





POLY-VI-FLOR ORAL SUSPENSION $3.65


RENAL ORAL CAPSULE $3.65








vitamin d (ergocalciferol) oral capsule $3.65



OTHER OVER-THE-COUNTER DRUGS

ACCU-CHEK SAFE-T PRO LANCETS $3.65

ACCU-CHEK SOFT TOUCH LANCETS $3.65

ACCU-CHEK SOFTCLIX LANCETS $3.65

AT LAST LANCETS $3.65


199

Drug Status NotesBD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 27G X 1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 29G X 1/2" 2 ML, U-100 1 ML

$3.65

BD INSULIN SYRINGE MICROFINE $3.65

BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML

$3.65

BD LANCET ULTRAFINE 33G $3.65

BD SAFETY-LOK INSULIN SYRINGE $3.65

BD SYRINGE SLIP TIP 3 ML $3.65

CLEANLET LANCETS 28G $3.65


comfort lancets $3.65

COPASIL EXTERNAL GEL $3.65

daily multi oral tablet $3.65

diphenhydramine hcl oral capsule 25 mg $3.65

eq nicotine mouth/throat gum 4 mg $3.65

eq nicotine polacrilex mouth/throat lozenge $3.65


eq nicotine transdermal patch 24 hour 7 mg/24hr $3.65

EZ-LETS LANCETS 26G $3.65

ferrous sulfate granules $3.65

FINGERSTIX LANCETS $3.65

FREESTYLE INSULINX TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

FREESTYLE LANCETS $3.65

FREESTYLE LITE TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

FREESTYLE PRECISION NEO TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

FREESTYLE TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

GEBAUERS PAIN EASE EXTERNAL AEROSOL $3.65

GENTLE-LET GP LANCETS $3.65


200

Drug Status NotesGENTLE-LET LANCETS $3.65

GLUCOSOURCE LANCETS $3.65

gnp lancets $3.65

gnp ultra com insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml

$3.65

HAEMOLANCE LOW FLOW LANCETS $3.65

hm nicotine transdermal patch 24 hour 7 mg/24hr $3.65

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

$1

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION $1

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR $1

HUMULIN N SUBCUTANEOUS SUSPENSION $1

HUMULIN R INJECTION SOLUTION $1

HY-VEE LANCETS $3.65

hy-vee thin lancets $3.65

insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1" 0.3 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

$3.65

insulin syringe 29g x 1/2" 1 ml, 30g x 5/16" 1 ml $3.65

insulin syringe/needle $3.65

kinney lancets $3.65

kinney thin lancets $3.65

kinray insulin syringe 29g x 1/2" 0.5 ml $3.65

lancets $3.65

lancets thin $3.65

lavare wound wash external gel $3.65


LIFESCAN UNISTIK II LANCETS $3.65

lite touch lancets $3.65

longs lancets thin $3.65


201

Drug Status NotesMEDISENSE THIN LANCETS $3.65

MEIJER LANCETS $3.65

MICROTAINER SAFETY FLOW LANCET $3.65

MONOJECT FILTER ASPIRATOR $3.65

MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML, 27G X 1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 30G X 5/16" 1 ML, U-100 1 ML

$3.65

MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML $3.65

MONOJECT PHARMACY TRAY 20 ML , 3 ML , 35 ML , 6 ML , 60 ML $3.65

MONOJECT PISTON SYRINGE $3.65

MONOJECT SAFETY SYRINGE/SHIELD 12 ML , 20G X 1-1/2" 12 ML, 21G X 1" 3 ML, 21G X 1-1/2" 3 ML, 3 ML

$3.65

MONOJECT SYRINGE 12 ML , 18G X 1" 12 ML, 20G X 1" 3 ML, 20G X 1-1/2" 12 ML, 20G X 1-1/2" 3 ML, 20G X 1-1/2" 6 ML, 20G X 3/4" 3 ML, 21G X 1" 12 ML, 21G X 1" 3 ML, 21G X 1" 6 ML, 21G X 1-1/2" 12 ML, 21G X 1-1/2" 3 ML, 21G X 1-1/2" 6 ML, 22G X 1" 3 ML, 22G X 1-1/2" 3 ML, 23G X 1" 3 ML, 25G X 1" 3 ML, 25G X 1-1/4" 3 ML, 25G X 5/8" 3 ML, 27G X 1-1/4" 3 ML, 3 ML

$3.65

MONOJECT SYRINGE CATH TIP $3.65

MONOJECT SYRINGE ECC LUER 35 ML $3.65

MONOJECT SYRINGE LUER LOCK $3.65

MONOJECT SYRINGE REG LUER 12 ML , 20 ML , 3 ML , 35 ML , 6 ML $3.65

MONOJECT TB SAFETY SYRINGE 28G X 1/2" 1 ML $3.65

MONOJECT TB SYRINGE 25G X 5/8" 1 ML, 26G X 3/8" 1 ML, 28G X 1/2" 1 ML $3.65

MONOJECT ULTRA COMFORT SYRINGE28G X 1/2" 0.5 ML $3.65

MONOLET LANCETS $3.65

MULTI COMPLETE ORAL CAPSULE $3.65

n-acetyl-l-cysteine oral capsule $3.65


202

Drug Status NotesNEXIUM 24HR ORAL CAPSULE DELAYED RELEASE $3.65 PA

NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION $1

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION $1

NOVOLIN N RELION SUBCUTANEOUS SUSPENSION $1

NOVOLIN N SUBCUTANEOUS SUSPENSION $1

NOVOLIN R INJECTION SOLUTION $1

NOVOLIN R RELION INJECTION SOLUTION $1

ONETOUCH CLUB LANCETS FINE PT $3.65

ONETOUCH FINEPOINT LANCETS $3.65

ONETOUCH LANCETS $3.65

ONETOUCH ULTRASOFT LANCETS $3.65

potassium bicarbonate granules $3.65

potassium chloride granules $3.65

potassium citrate monohydrate granules $3.65

PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML

$3.65

PRECISION THIN LANCETS $3.65

PRECISION THINS GP LANCETS $3.65

PRECISION ULTRA LANCET $3.65

PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP $0 QL (150 strips per 30 days)

preferred plus lancets colored $3.65

preferred plus lancets thin $3.65

prenatal 19 oral tablet $3.65

prenatal 19 oral tablet chewable $3.65

PSS SELECT GP LANCETS $3.65

PSS SELECT SAFETY LANCETS $3.65

qc nicotine polacrilex mouth/throat gum $3.65

reality lancets $3.65


203

Drug Status Notesreality trigger lancets $3.65

sb lancets thin $3.65

sb lancets ultra thin $3.65

sr nicotine mouth/throat gum $3.65

super thin lancets $3.65

sure comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml

$3.65

SURELITE LANCETS $3.65

tb syringe 1 ml $3.65

TECHLITE LANCETS $3.65

tgt nicotine mouth/throat gum $3.65

THINLETS GP LANCETS $3.65

THINLETS LANCET $3.65

topco insulin syringe $3.65

ULTICARE TUBERCULIN SAFETY SYR28G X 1/2" 1 ML $3.65

ULTILET CLASSIC LANCETS $3.65

ULTILET LANCETS $3.65

ULTRA-THIN II AUTO LANCET $3.65

ULTRA-THIN II LANCETS $3.65

UNILET COMFORTOUCH LANCET $3.65

UNILET G.P. LANCET $3.65

UNILET G.P. SUPERLITE LANCET $3.65

UNILET LANCET $3.65

UNILET SUPERLITE LANCET $3.65

UNISTIK 1 $3.65

VITALET PRO LANCETS $3.65

VITALET PRO PLUS LANCETS $3.65

W&F LANCETS 26G $3.65

W&F LANCETS COLORED 21G $3.65

OTHER PRESCRIPTION DRUGS




204

Drug Status Notesabacavir-lamivudine-zidovudine oral tablet $3.65

acamprosate calcium oral tablet delayed release $3.65 QL (180 EA per 30 days)

acetaminophen-codeine oral tablet $3.65¥ (Max of 4 g of acetaminophen or 360 mg of codeine)

acetazolamide er oral capsule extended release 12 hour

$3.65


acitretin oral capsule $3.65 QL (60 EA per 30 days)



acyclovir oral capsule $3.65

acyclovir oral suspension $3.65

acyclovir oral tablet $3.65



ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65

ADMELOG SUBCUTANEOUS SOLUTION $3.65

ADRENALIN NASAL SOLUTION $3.65


ALBENZA ORAL TABLET $3.65

ALECENSA ORAL CAPSULE $3.65 PA; SP

Aliqopa Intravenous Solution Reconstituted MB/RX PA




alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 25-30 mg, 25-45 mg


ALOMIDE OPHTHALMIC SOLUTION $3.65 PA

alosetron hcl oral tablet 0.5 mg $3.65

alphatrex external gel $3.65

ALUNBRIG ORAL TABLET $3.65 PA; SP

amiodarone hcl oral tablet 100 mg $3.65


205

Drug Status Notes

amitriptyline hcl oral tablet $3.65


amlodipine besylate-valsartan oral tablet $1 PA; QL (30 EA per 30 days)

amlodipine-valsartan-hctz oral tablet $1 PA; QL (30 EA per 30 days)


amoxicillin oral capsule $3.65

amoxicillin oral suspension reconstituted $3.65

amoxicillin oral tablet $3.65

amoxicillin oral tablet chewable 125 mg, 250 mg $3.65

amoxicillin-pot clavulanate er oral tablet extended release 12 hour

$3.65

amoxicillin-pot clavulanate oral suspension reconstituted

$3.65

amoxicillin-pot clavulanate oral tablet $3.65

amoxicillin-pot clavulanate oral tablet chewable $3.65

amphetamine-dextroamphetamine oral tablet 12.5 mg, 15 mg, 7.5 mg

$3.65


ampicillin oral capsule $3.65

ampicillin oral suspension reconstituted $3.65

ANALPRAM-HC RECTAL LOTION 1-2.5 % $3.65

anastrozole oral tablet $3.65


$3.65 PA

ANTARA ORAL CAPSULE 30 MG, 90 MG $1 PA; QL (30 EA per 30 days)

antipyrine-benzocaine otic solution 5.4-1.4 %, 54-14 mg/ml

$3.65

APIDRA INJECTION SOLUTION $1

APIDRA OPTICLIK SUBCUTANEOUS SOLUTION $1

APIDRA OPTICLIK SUBCUTANEOUS SOLUTION CARTRIDGE $1


206

Drug Status NotesAPIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR $1

APPFORMIN-D ORAL $1



aripiprazole oral tablet 2 mg $3.65


aripiprazole oral tablet dispersible $3.65


ARMOUR THYROID ORAL TABLET $3.65







atovaquone oral suspension $3.65

AUBRA ORAL TABLET $0

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML $3.65


AVAR CLEANSER EXTERNAL EMULSION $3.65

avidoxy oral tablet $3.65

AzaCITIDine Injection Suspension Reconstituted MB/RX

azithromycin oral packet $3.65

azithromycin oral suspension reconstituted $3.65

azithromycin oral tablet 250 mg, 500 mg, 600 mg $3.65


207

Drug Status Notesbacitra-neomycin-polymyxin-hc ophthalmic ointment

$3.65

BANZEL ORAL SUSPENSION $3.65


BANZEL ORAL TABLET $3.65


BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65

Bavencio Intravenous Solution MB/RX

Beleodaq Intravenous Solution Reconstituted MB/RX SP

BENDEKA INTRAVENOUS SOLUTION Medical Benefit

BESIVANCE OPHTHALMIC SUSPENSION $3.65

Besponsa Intravenous Solution Reconstituted MB/RX

bexarotene oral capsule $3.65 SP

bicalutamide oral tablet $3.65

bimatoprost ophthalmic solution $3.65 PA

BOSULIF ORAL TABLET 100 MG $3.65 PA; SP; QL (120 EA per 30 days)

BOSULIF ORAL TABLET 500 MG $3.65 PA; SP; QL (30 EA per 30 days)

bp multinatal plus oral tablet $3.65

bp multinatal plus oral tablet chewable $3.65


$3.65

budesonide inhalation suspension 1 mg/2ml $3.65

buprenorphine transdermal patch weekly 10 mcg/hr, 20 mcg/hr, 5 mcg/hr



CABOMETYX ORAL TABLET $3.65 PA; SP

calcipotriene-betameth diprop external ointment $3.65 PA

CALQUENCE ORAL CAPSULE $3.65 PA

capecitabine oral tablet 150 mg $3.65 SP; QL (84 EA per 14 days)

capecitabine oral tablet 500 mg $3.65 SP; QL (168 EA per 14 days)

CAPRELSA ORAL TABLET 100 MG $3.65 PA; QL (60 EA per 30 days)


208

Drug Status NotesCAPRELSA ORAL TABLET 300 MG $3.65 PA; QL (30 EA per 30 days)

carbamazepine er oral tablet extended release 12 hour 100 mg

$3.65



carvedilol phosphate er oral capsule extended release 24 hour

$1PA; STPA; QL (30 EA per 30 days)

CAVAREST DENTAL GEL $3.65

CAVIRINSE MOUTH/THROAT SOLUTION $3.65

CEDAX ORAL SUSPENSION RECONSTITUTED 90 MG/5ML $3.65

cefaclor er oral tablet extended release 12 hour $3.65

cefaclor oral capsule $3.65

cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

$3.65

cefadroxil oral capsule $3.65

cefadroxil oral suspension reconstituted $3.65

cefadroxil oral tablet $3.65

cefdinir oral capsule $3.65

cefdinir oral suspension reconstituted $3.65

cefditoren pivoxil oral tablet $3.65

cefixime oral suspension reconstituted $3.65

cefpodoxime proxetil oral suspension reconstituted

$3.65

cefpodoxime proxetil oral tablet $3.65

cefprozil oral suspension reconstituted $3.65

cefprozil oral tablet $3.65

ceftibuten oral capsule $3.65

CEFTIN ORAL SUSPENSION RECONSTITUTED $3.65

CefTRIAXone Sodium Intravenous Solution Reconstituted 1 GM, 2 GM

MB/RX

cefuroxime axetil oral tablet $3.65


cephalexin oral capsule $3.65


209

Drug Status Notescephalexin oral suspension reconstituted $3.65

cephalexin oral tablet $3.65

Cerezyme Intravenous Solution Reconstituted 200 UNIT

MB/RX PA; SP

CEROVEL EXTERNAL LOTION $3.65

chlorthalidone oral tablet 100 mg $1

choline & mag trisalicylate oral tablet 1000 mg $3.65

CILOXAN OPHTHALMIC OINTMENT $3.65

ciprofloxacin hcl ophthalmic solution $3.65

ciprofloxacin hcl oral tablet $3.65

ciprofloxacin oral suspension reconstituted $3.65

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour

$3.65

clarithromycin er oral tablet extended release 24 hour

$3.65

clarithromycin oral suspension reconstituted $3.65

clarithromycin oral tablet $3.65

CLEARPLEX X EXTERNAL GEL $3.65

CLINDAMAX EXTERNAL GEL $3.65

clindamycin hcl oral capsule $3.65

clindamycin palmitate hcl oral solution reconstituted

$3.65

clobetasol propionate external liquid $3.65 PA




$3.65


clozapine oral tablet dispersible 150 mg, 200 mg $3.65


COMETRIQ (100 MG DAILY DOSE) ORAL KIT $3.65 PA


210

Drug Status NotesCOMETRIQ (140 MG DAILY DOSE) ORAL KIT $3.65 PA

COMETRIQ (60 MG DAILY DOSE) ORAL KIT $3.65 PA

COMPAZINE RECTAL SUPPOSITORY $3.65

CONTROLRX DENTAL CREAM $3.65

CORTISPORIN-TC OTIC SUSPENSION $3.65

COTELLIC ORAL TABLET $3.65 PA; SP

COVERA-HS ORAL TABLET EXTENDED RELEASE 24 HOUR $1

cyclopentolate hcl ophthalmic solution 0.5 % $3.65 QL (2 ML per 30 days)

cyclophosphamide injection solution reconstituted $1 SP

cyclophosphamide oral capsule $3.65 SP

cycloserine oral capsule $3.65

cytra-2 oral solution $3.65


$3.65 PA

Decitabine Intravenous Solution Reconstituted MB/RX SP

DELTASONE ORAL TABLET $3.65

DEPRIZINE FUSEPAQ ORAL SUSPENSION RECONSTITUTED $3.65

desogestrel-ethinyl estradiol oral tablet $0

desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 50 mg

$3.65




diazepam oral solution 5 mg/5ml $3.65


diclofenac sodium oral tablet delayed release $3.65



211

Drug Status Notes

diclofenac sodium transdermal gel 3 % $3.65¥ (Max of 90 days per year); QL (200 GM per 30 days)


dicloxacillin sodium oral capsule $3.65

DICOPANOL FUSEPAQ ORAL SUSPENSION RECONSTITUTED $3.65

dicyclomine hcl oral solution $3.65

dilt-cd oral capsule extended release 24 hour 180 mg

$1


$1


DONNATAL ORAL ELIXIR $3.65

DONNATAL ORAL TABLET $3.65

doxepin hcl external cream $3.65 QL (45 grams per 1 Fill)


doxycycline hyclate oral capsule $3.65

doxycycline hyclate oral tablet 100 mg $3.65

doxycycline monohydrate oral capsule 100 mg, 50 mg

$3.65

doxycycline monohydrate oral suspension reconstituted

$3.65

doxycycline monohydrate oral tablet 100 mg, 50 mg

$3.65

DRITHO-CREME HP EXTERNAL CREAM $3.65

drospiren-eth estrad-levomefol oral tablet 3-0.03-0.451 mg

$0


$0



$3.65



212

Drug Status Notes


$3.65




DYNACIRC CR ORAL TABLET EXTENDED RELEASE 24 HOUR $1

E.E.S. 400 ORAL TABLET $3.65

EASYGEL DENTAL GEL $3.65





Elspar Injection Solution Reconstituted MB/RX SP



EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit


EPANED ORAL SOLUTION RECONSTITUTED $3.65

Epirubicin HCl Intravenous Solution 200 MG/100ML, 50 MG/25ML

MB/RX

Erbitux Intravenous Solution MB/RX SP

ERYPED 400 ORAL SUSPENSION RECONSTITUTED $3.65

ERY-TAB ORAL TABLET DELAYED RELEASE $3.65

ERYTHROCIN STEARATE ORAL TABLET250 MG $3.65

erythromycin base oral capsule delayed release particles

$3.65

erythromycin base oral tablet $3.65

erythromycin ethylsuccinate oral suspension reconstituted

$3.65


213

Drug Status Noteserythromycin ethylsuccinate oral tablet $3.65

est estrogens-methyltest hs oral tablet $3.65

est estrogens-methyltest oral tablet $3.65




estradiol-norethindrone acet oral tablet $3.65


MB/RX


ethambutol hcl oral tablet $3.65

etoposide oral capsule $3.65

ezetimibe-simvastatin oral tablet $1 PA; QL (30 EA per 30 days)

FABIOR EXTERNAL FOAM $3.65 PA

FACTIVE ORAL TABLET $3.65

famciclovir oral tablet $3.65

FARESTON ORAL TABLET $3.65


felbamate oral suspension $3.65


felbamate oral tablet $3.65


fenofibrate oral capsule $1 PA; QL (30 EA per 30 days)

fenofibrate oral tablet 120 mg, 40 mg $1 PA; QL (30 EA per 30 days)

fenofibric acid oral capsule delayed release $1 PA; QL (30 EA per 30 days)

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR $3.65



214

Drug Status Notes

FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK $3.65


FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65

FIASP SUBCUTANEOUS SOLUTION $3.65

Firmagon Subcutaneous Solution Reconstituted MB/RX SP

FIRST-BXN MOUTHWASH MOUTH/THROAT SUSPENSION $3.65

FIRST-DUKES MOUTHWASH MOUTH/THROAT SUSPENSION $3.65

FIRST-HYDROCORTISONE EXTERNAL GEL $3.65

FIRST-LANSOPRAZOLE ORAL SUSPENSION $3.65 PA

FIRST-MARYS MOUTHWASH MOUTH/THROAT SUSPENSION $3.65

FIRST-MOUTHWASH BLM MOUTH/THROAT SUSPENSION $3.65

FIRST-OMEPRAZOLE ORAL SUSPENSION $3.65 PA

FIRST-PROGESTERONE VGS 100 VAGINAL SUPPOSITORY $3.65





FIRST-TESTOSTERONE MC TRANSDERMAL CREAM $3.65

FIRST-TESTOSTERONE TRANSDERMAL OINTMENT $3.65

FIRST-VANCOMYCIN 25 ORAL SOLUTION $3.65


215

Drug Status NotesFIRST-VANCOMYCIN 50 ORAL SOLUTION $3.65

FLAGYL ER ORAL TABLET EXTENDED RELEASE 24 HOUR $3.65

Flebogamma Intravenous Solution MB/RX PA; SP

fluconazole oral suspension reconstituted $3.65

fluconazole oral tablet $3.65

flucytosine oral capsule $3.65 PA


FLUORIDEX ENHANCED WHITENING DENTAL GEL $3.65

FLUORIDEX SENSITIVITY RELIEF DENTAL GEL $3.65

fluoxetine hcl (pmdd) oral tablet $3.65 PA



flutamide oral capsule $3.65

fluvastatin sodium er oral tablet extended release 24 hour


fosamprenavir calcium oral tablet $3.65




gatifloxacin ophthalmic solution $3.65


GEBAUERS SPRAY AND STRETCH EXTERNAL AEROSOL $3.65

GENTAK OPHTHALMIC OINTMENT $3.65

gentamicin sulfate ophthalmic ointment $3.65

gentamicin sulfate ophthalmic solution $3.65

GILOTRIF ORAL TABLET $3.65 PA

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG $3.65

glycopyrrolate oral tablet 1 mg, 2 mg $3.65


216

Drug Status Notesglycron oral tablet 1.5 mg, 3 mg, 6 mg $1

GORDONS UREA EXTERNAL OINTMENT40 % $3.65


Halaven Intravenous Solution MB/RX SP

Hemofil M Intravenous Solution Reconstituted 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT

MB/RX SP

heparin sodium (porcine) injection solution 2500 unit/ml

$3.65

Herceptin Intravenous Solution Reconstituted MB/RX SP

HEXALEN ORAL CAPSULE $3.65

Hizentra Subcutaneous Solution 10 GM/50ML MB/RX PA; SP

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML $1

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 200 UNIT/ML $3.65

HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

$1

HUMALOG MIX 50/50 PEN SUBCUTANEOUS SUSPENSION $1

HUMALOG MIX 50/50 PEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

$1

HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION $1

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

$1

HUMALOG MIX 75/25 PEN SUBCUTANEOUS SUSPENSION $1

HUMALOG MIX 75/25 PEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

$1

HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION $1

HUMALOG PEN SUBCUTANEOUS SOLUTION $1


217

Drug Status NotesHUMALOG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR $1

HUMALOG SUBCUTANEOUS SOLUTION $1

HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE $1

HYCAMTIN ORAL CAPSULE 0.25 MG $3.65 PA; SP; QL (15 EA per 21 days)

HYCAMTIN ORAL CAPSULE 1 MG $3.65 PA; SP; QL (25 EA per 21 days)

hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml

$3.65 QL (480 ML per 1 day)




HYOPHEN ORAL TABLET $3.65

hyoscyamine sulfate er oral tablet extended release 12 hour

$3.65

hyoscyamine sulfate oral elixir $3.65

hyoscyamine sulfate oral solution $3.65

hyoscyamine sulfate oral tablet $3.65

hyoscyamine sulfate oral tablet dispersible $3.65

hyoscyamine sulfate sublingual tablet sublingual $3.65

hyosyne oral elixir $3.65

hyosyne oral solution $3.65

HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 % $3.65



IBRANCE ORAL CAPSULE $3.65 PA; SP

ICLUSIG ORAL TABLET $3.65 PA

IDHIFA ORAL TABLET $3.65 PA; SP; QL (30 EA per 30 days)

imatinib mesylate oral tablet $3.65


Imfinzi Intravenous Solution MB/RX

INLYTA ORAL TABLET $3.65 PA; SP

INTROL ORAL SOLUTION $1

IRESSA ORAL TABLET $3.65 PA


218

Drug Status Notesisometheptene-dichloral-apap oral capsule $3.65 QL (300 EA per 30 days)

ISOPTO HYOSCINE OPHTHALMIC SOLUTION $3.65

itraconazole oral capsule $3.65


Ixempra Kit Intravenous Solution Reconstituted MB/RX SP

Jevtana Intravenous Solution MB/RX SP

K.B.G.L IN TERODERM EXTERNAL CREAM $3.65

Kadcyla Intravenous Solution Reconstituted MB/RX SP

KARIGEL DENTAL GEL $3.65

KARIGEL-N DENTAL GEL $3.65

KETEK ORAL TABLET $3.65

ketoconazole oral tablet $3.65

KISQALI 200 DOSE ORAL TABLET $3.65 PA



Kogenate FS Intravenous Kit MB/RX SP

K-PHOS NO 2 ORAL TABLET $3.65

K-PHOS ORAL TABLET $3.65

LAMISIL SPRAY EXTERNAL SOLUTION $3.65



LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG $3.65


LARIN FE 1.5/30 ORAL TABLET $0

LARIN FE 1/20 ORAL TABLET $0

LATRIX EXTERNAL SUSPENSION $3.65

LATUDA ORAL TABLET 60 MG $3.65


LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK $3.65 PA


219

Drug Status NotesLENVIMA 14 MG DAILY DOSE ORAL CAPSULE THERAPY PACK $3.65 PA



Leukine Intravenous Solution Reconstituted MB/RX SP


levofloxacin ophthalmic solution $3.65

levofloxacin oral solution $3.65

levofloxacin oral tablet $3.65

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 &0.01 mg

$0

levonorgestrel oral tablet 1.5 mg $0

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

$0

levonorg-eth estrad triphasic oral tablet $0


LIDOPROFEN EXTERNAL CREAM $3.65

linezolid oral suspension reconstituted $3.65 QL (840 ML per 14 days)

linezolid oral tablet $3.65 QL (28 EA per 14 days)

lofene oral tablet $3.65

LOKARA EXTERNAL LOTION $3.65 PA

LOMEDIA 24 FE ORAL TABLET $0

lomustine oral capsule $3.65


LOZI-FLUR MOUTH/THROAT LOZENGE $3.65

LUFYLLIN ORAL TABLET 400 MG $3.65 PA

LUPRON INJECTION KIT Medical Benefit PA; SP

LUPRON SUBCUTANEOUS SOLUTION Medical Benefit PA; SP


LYNPARZA ORAL TABLET $3.65 PA

LYZA ORAL TABLET $0

MATULANE ORAL CAPSULE $3.65

me/naphos/mb/hyo1 oral tablet $3.65


220

Drug Status Notesmegestrol acetate oral suspension 625 mg/5ml $3.65

megestrol acetate oral tablet $3.65

MEKINIST ORAL TABLET $3.65 PA; SP

melphalan oral tablet $3.65



meperidine hcl oral tablet 100 mg $3.65 QL (12 EA per 1 day)

mercaptopurine oral tablet $3.65




$1 PA

methoxsalen rapid oral capsule $3.65


$3.65




metronidazole oral capsule $3.65

metronidazole oral tablet $3.65

MICROCYN EXTERNAL GEL $3.65

MICROCYN SKIN AND WOUND EXTERNAL GEL $3.65


migragesic ida oral capsule $3.65 QL (300 EA per 30 days)

MILLIPRED DP 12-DAY ORAL TABLET THERAPY PACK $3.65

minocycline hcl oral capsule $3.65

MIRVASO EXTERNAL GEL $3.65 PA




221

Drug Status NotesMONDOXYNE NL ORAL CAPSULE 100 MG, 50 MG $3.65

Monoclate-P Intravenous Kit 1500 UNIT MB/RX SP

MONOJECT CONTROL SYRINGE $3.65

MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML

$3.65

MONOJECT SAFETY SYRINGE/SHIELD21G X 1-1/2" 12 ML, 22G X 1-1/2" 3 ML $3.65

MONOJECT SYRINGE 22G X 1-1/2" 12 ML, 22G X 1-1/2" 6 ML, 3 ML , 6 ML $3.65

MONOJECT SYRINGE LUER LOCK 6 ML , 60 ML $3.65

MONOJECT SYRINGE REG LUER 12 ML $3.65

Mononine Intravenous Solution Reconstituted 1000 UNIT

MB/RX SP

MORGIDOX ORAL CAPSULE 100 MG $3.65

morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 90 mg

$3.65 PA; QL (2 EA per 1 day)

morphine sulfate er beads oral capsule extended release 24 hour 30 mg








morphine sulfate er oral capsule extended release 24 hour 10 mg


MOXEZA OPHTHALMIC SOLUTION $3.65

moxifloxacin hcl ophthalmic solution $3.65

moxifloxacin hcl oral tablet $3.65






222

Drug Status Notesmycophenolate mofetil oral suspension reconstituted

$3.65


MYLERAN ORAL TABLET $3.65

Mylotarg Intravenous Solution Reconstituted 4.5 MG

MB/RX

NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION RECONSTITUTED

$3.65

NAFRINSE WEEKLY MOUTH/THROAT SOLUTION RECONSTITUTED $3.65


napro external cream $3.65

NATURE-THROID ORAL TABLET $3.65

NEBUSAL INHALATION NEBULIZATION SOLUTION 6 % $3.65

neomycin-polymyxin-dexameth ophthalmic ointment

$3.65

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

$3.65

neomycin-polymyxin-hc otic solution 1 % $3.65

NEO-POLYCIN HC OPHTHALMIC OINTMENT $3.65

NERLYNX ORAL TABLET $3.65 PA; SP

NEUTRAGARD ADVANCED DENTAL GEL $3.65

nevirapine er oral tablet extended release 24 hour400 mg

$3.65

NEXAVAR ORAL TABLET $3.65 PA; SP; QL (120 EA per 30 days)

NEXT CHOICE ORAL TABLET $0

niacin er (antihyperlipidemic) oral tablet extended release

$1

NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG $3.65

nilutamide oral tablet $3.65

nitrofurantoin macrocrystal oral capsule $3.65

nitrofurantoin monohyd macro oral capsule $3.65

nitrofurantoin oral suspension $3.65


223

Drug Status NotesNODOLOR ORAL CAPSULE $3.65 QL (300 EA per 30 days)

norepinephrine-dextrose intravenous solution 4-5 mg/500ml-%

Medical Benefit

norepinephrine-sodium chloride intravenous solution prefilled syringe 0.08-0.9 mg/10ml-%, 0.16-0.9 mg/10ml-%

Medical Benefit

norethin ace-eth estrad-fe oral tablet $0

norethin ace-eth estrad-fe oral tablet chewable $0

norethindrone acet-ethinyl est oral tablet $0


norethin-eth estradiol-fe oral tablet chewable 0.8-25 mg-mcg

$0

norgestim-eth estrad triphasic oral tablet0.18/0.215/0.25 mg-25 mcg

$0

norgestrel-ethinyl estradiol oral tablet $0

nortuss-ex oral liquid $3.65

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR $1

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

$1

NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION $1

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE $1

NOVOLOG SUBCUTANEOUS SOLUTION $1


np thyroid oral tablet 30 mg, 60 mg, 90 mg $3.65


ofloxacin ophthalmic solution $3.65

ofloxacin oral tablet 400 mg $3.65


OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION $3.65



224

Drug Status Notes





Opdivo Intravenous Solution MB/RX

opium oral tincture $3.65


OSCION CLEANSER EXTERNAL LOTION6 % $3.65 PA

oseltamivir phosphate oral capsule 30 mg $3.65¥ (Max of 2 fills per year); QL (20 EA per 1 Fill)

oseltamivir phosphate oral capsule 45 mg, 75 mg $3.65¥ (Max of 2 fills per year); QL (10 EA per 1 Fill)

oseltamivir phosphate oral suspension reconstituted

$3.65¥ (Max of 2 fills per year); QL (180 ML per 1 Fill)

otic care otic solution $3.65


OXSORALEN EXTERNAL LOTION $3.65

oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 20 mg, 40 mg, 80 mg

$3.65 QL (90 EA per 30 days)

oxycodone-acetaminophen oral solution $3.65¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 15 MG $3.65 QL (90 EA per 30 days)

PACLitaxel Intravenous Concentrate MB/RX

paliperidone er oral tablet extended release 24 hour

$3.65


PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200 UNIT

$3.65

pantoprazole sodium oral tablet delayed release $3.65


225

Drug Status Notesparicalcitol oral capsule $3.65 PA

PCE ORAL TABLET DELAYED RELEASE $3.65



penicillin g procaine intramuscular suspension $3.65

penicillin v potassium oral solution reconstituted $3.65

penicillin v potassium oral tablet $3.65


Perjeta Intravenous Solution MB/RX SP

phenobarbital oral elixir $3.65

phenobarbital oral solution $3.65

phenobarbital oral tablet $3.65

PHENOHYTRO ORAL TABLET $3.65



phenylephrine-guaifenesin oral liquid $3.65

PHOS-FLUR DENTAL GEL $3.65

PHOSPHASAL ORAL TABLET $3.65

pimozide oral tablet 2 mg $3.65


PIMTREA ORAL TABLET $0

PIRMELLA 7/7/7 ORAL TABLET $0

POMALYST ORAL CAPSULE $3.65 PA; SP

potassium chloride er oral tablet extended release20 meq

$3.65

potassium chloride oral packet $3.65

potassium citrate er oral tablet extended release $3.65


$3.65

PRASCION EXTERNAL EMULSION $3.65


226

Drug Status Notesprasugrel hcl oral tablet $3.65

PRED-G OPHTHALMIC SUSPENSION $3.65

PRED-G S.O.P. OPHTHALMIC OINTMENT $3.65


$3.65

PREDNISONE INTENSOL ORAL CONCENTRATE $3.65

prednisone oral solution $3.65

prednisone oral tablet $3.65

prednisone oral tablet therapy pack $3.65

premium lidocaine external ointment $3.65 QL (50 GM per 30 days)

primidone oral tablet $3.65


PRIMSOL ORAL SOLUTION $3.65



progesterone micronized transdermal cream $3.65

Proleukin Intravenous Solution Reconstituted MB/RX SP

promethazine hcl rectal suppository 50 mg $3.65


PROTONIX ORAL PACKET $3.65 PA

PULMOSAL INHALATION NEBULIZATION SOLUTION $3.65

PURIXAN ORAL SUSPENSION $3.65

pyrazinamide oral tablet $3.65


$3.65

quetiapine fumarate er oral tablet extended release 24 hour

$3.65


quinaretic oral tablet 10-12.5 mg, 20-25 mg $1

quinine sulfate oral capsule $3.65 PA



227

Drug Status Notesraloxifene hcl oral tablet $3.65


REA LO 40 EXTERNAL CREAM $3.65

REA LO 40 EXTERNAL LOTION $3.65


REMEVEN EXTERNAL CREAM $3.65



REVLIMID ORAL CAPSULE $3.65 PA; SP

rexaphenac transdermal cream $3.65

rifabutin oral capsule $3.65

RIFAMATE ORAL CAPSULE $3.65

rifampin oral capsule $3.65

RIFATER ORAL TABLET $3.65


risedronate sodium oral tablet 30 mg, 5 mg $3.65 PA; QL (30 EA per 30 days)



RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE $3.65


Rituxan Hycela Subcutaneous Solution MB/RX PA; SP

rivastigmine transdermal patch 24 hour 4.6 mg/24hr, 9.5 mg/24hr

$3.65

Rixubis Intravenous Solution Reconstituted MB/RX SP

ropivacaine hcl-nacl injection solution 0.1-0.9 % Medical Benefit

ROSANIL CLEANSER EXTERNAL EMULSION $3.65

rosuvastatin calcium oral tablet $1 PA; QL (30 EA per 30 days)

RUBRACA ORAL TABLET $3.65 PA; SP; QL (120 EA per 30 days)

RYDAPT ORAL CAPSULE $3.65 PA; SP





228

Drug Status NotesSimponi Aria Intravenous Solution MB/RX PA; SP; QL (5 vials per 8 Weeks)


SIVEXTRO ORAL TABLET $3.65 QL (6 EA per 365 days)

sodium chloride irrigation solution 0.9 % $3.65 PA

sodium fluoride oral tablet 2.2 (1 f) mg $3.65

sodium polystyrene sulfonate oral powder $3.65


SPORANOX ORAL SOLUTION $3.65

SPRYCEL ORAL TABLET 100 MG, 140 MG $3.65 PA; SP; QL (30 EA per 30 days)

SPRYCEL ORAL TABLET 20 MG, 50 MG, 70 MG, 80 MG $3.65 PA; SP; QL (60 EA per 30 days)

STIVARGA ORAL TABLET $3.65 PA; SP; QL (84 EA per 28 days)

sulfacetamide sodium-sulfur external emulsion $3.65

sulfacetamide sodium-sulfur external lotion 10-5 %

$3.65

sulfadiazine oral tablet $3.65

sulfamethoxazole-trimethoprim oral suspension200-40 mg/5ml

$3.65

sulfamethoxazole-trimethoprim oral tablet $3.65


SULFATRIM PEDIATRIC ORAL SUSPENSION $3.65

SUPRAX ORAL CAPSULE $3.65

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML $3.65

SUPRAX ORAL TABLET CHEWABLE $3.65

SUTENT ORAL CAPSULE $3.65 PA; SP

SYEDA ORAL TABLET $0


TAFINLAR ORAL CAPSULE $3.65 PA; SP

TAGRISSO ORAL TABLET 40 MG $3.65 PA; QL (30 Tablets per 30 days)

TAGRISSO ORAL TABLET 80 MG $3.65 PA

TARCEVA ORAL TABLET 100 MG, 150 MG $3.65 SP; QL (30 EA per 30 days)

TARCEVA ORAL TABLET 25 MG $3.65 SP; QL (90 EA per 30 days)


229

Drug Status NotesTASIGNA ORAL CAPSULE 150 MG, 200 MG $3.65 PA; SP

Tecentriq Intravenous Solution MB/RX


telmisartan-hctz oral tablet $1 PA

Temodar Intravenous Solution Reconstituted MB/RX SP

temozolomide oral capsule $3.65 SP


terbinafine hcl oral tablet $3.65¥ (Max of 90 tablets per 365 days); QL (30 EA per 30 days)

testosterone transdermal gel 10 mg/act (2%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

$3.65 PA




tetracycline hcl oral capsule $3.65

THALITONE ORAL TABLET $1

TIVICAY ORAL TABLET 50 MG $3.65


tobramycin ophthalmic solution $3.65

TOBREX OPHTHALMIC OINTMENT $3.65



$3.65

Treanda Intravenous Solution Reconstituted MB/RX SP

TRELSTAR DEPOT INTRAMUSCULAR SUSPENSION RECONSTITUTED Medical Benefit SP


TRELSTAR LA INTRAMUSCULAR SUSPENSION RECONSTITUTED Medical Benefit SP

TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR $3.65

tretinoin external gel 0.05 % $3.65 PA

tretinoin oral capsule $3.65



230

Drug Status Notestrientine hcl oral capsule $3.65 PA

TRI-LO-SPRINTEC ORAL TABLET $0

TRILYTE ORAL SOLUTION RECONSTITUTED $3.65


TYKERB ORAL TABLET $3.65 PA; SP; QL (180 EA per 30 days)

U-KERA E EXTERNAL CREAM $3.65

UMECTA EXTERNAL EMULSION $3.65

UNITHROID DIRECT ORAL TABLET $3.65

UNITHROID ORAL TABLET 137 MCG $3.65

urea external cream 40 %, 50 % $3.65

urea external lotion 40 % $3.65

urea external suspension $3.65

urea nail film external suspension $3.65

urea-c40 external lotion $3.65

ure-k external cream $3.65

URETRON D/S ORAL TABLET $3.65

URIMAR-T ORAL TABLET $3.65

UROLET MB ORAL TABLET $3.65

UROPHEN MB ORAL TABLET $3.65

URYL ORAL TABLET $3.65

Vabomere Intravenous Solution Reconstituted MB/RX

valacyclovir hcl oral tablet $3.65

VALCHLOR EXTERNAL GEL $3.65

valganciclovir hcl oral solution reconstituted $3.65

valganciclovir hcl oral tablet $3.65

valsartan oral tablet $1 STPA

Valstar Intravesical Solution MB/RX SP

vancomycin hcl oral capsule $3.65 QL (40 EA per 10 days)

Vectibix Intravenous Solution 100 MG/5ML, 400 MG/20ML

MB/RX SP

Velcade Injection Solution Reconstituted MB/RX SP


231

Drug Status Notes

VERSACLOZ ORAL SUSPENSION $3.65


VERZENIO ORAL TABLET $3.65 PA; SP

Vidaza Injection Suspension Reconstituted MB/RX SP



voriconazole oral suspension reconstituted $3.65 PA

voriconazole oral tablet $3.65 PA; QL (180 EA per 30 days)

VOTRIENT ORAL TABLET $3.65 PA; SP; QL (120 EA per 30 days)

VYFEMLA ORAL TABLET $0

Vyxeos Intravenous Suspension Reconstituted MB/RX

WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG $3.65

WP THYROID ORAL TABLET $3.65

XALKORI ORAL CAPSULE $3.65 PA; SP

XTANDI ORAL CAPSULE $3.65 PA; SP; QL (120 EA per 30 days)

Yervoy Intravenous Solution MB/RX SP

Zaltrap Intravenous Solution MB/RX SP

ZAZOLE VAGINAL CREAM 0.8 % $3.65

ZAZOLE VAGINAL SUPPOSITORY $3.65


ZEJULA ORAL CAPSULE $3.65 PA

ZELBORAF ORAL TABLET $3.65 PA; SP

ZMAX ORAL SUSPENSION RECONSTITUTED $3.65

Zoledronic Acid Intravenous Solution MB/RX

ZOMIG NASAL SOLUTION 2.5 MG $3.65 STPA; QL (6 Units per 30 days)

ZOVIRAX EXTERNAL CREAM $3.65 PA; QL (5 GM per 1 Rx)

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 5.7-1.4 MG $3.65


ZYDELIG ORAL TABLET $3.65


232

Drug Status NotesZYKADIA ORAL CAPSULE $3.65 PA; SP

ZYTIGA ORAL TABLET 250 MG $3.65 PA; SP; QL (120 EA per 30 days)

ZYTIGA ORAL TABLET 500 MG $3.65 PA; SP; QL (60 EA per 30 days)

OVERDOSE


AMITIZA ORAL CAPSULE $3.65 PA; QL (60 EA per 30 days)

CHEMET ORAL CAPSULE $3.65



EVZIO INJECTION SOLUTION AUTO-INJECTOR $3.65

PA; ¥ (Max of 4 units per 30 days); QL (2 Units per 1 Rx)


FERRIPROX ORAL SOLUTION $3.65 PA

FERRIPROX ORAL TABLET $3.65 PA




MOVANTIK ORAL TABLET $3.65 PA

naloxone hcl injection solution 0.4 mg/ml, 1 mg/ml

$3.65

NARCAN NASAL LIQUID $3.65¥ (Max of 4 units per 30 days); QL (2 Units per 1 Rx)

RELISTOR ORAL TABLET $3.65 PA; QL (90 Tablets per 30 days)

RELISTOR SUBCUTANEOUS SOLUTION12 MG/0.6ML, 8 MG/0.4ML $3.65 PA

SYMPROIC ORAL TABLET $3.65 PA


VISTOGARD ORAL PACKET $3.65 QL (20 EA per 30 days)

PAIN

ABSTRAL SUBLINGUAL TABLET SUBLINGUAL $3.65 PA

acetaminophen-codeine #2 oral tablet $3.65¥ (Max of 4 g of acetaminophen or 360 mg of codeine)



233

Drug Status Notes


acetaminophen-codeine oral solution $3.65¥ (Max of 4 g of acetaminophen or 360 mg of codeine)

acetaminophen-codeine oral tablet $3.65¥ (Max of 4 g of acetaminophen or 360 mg of codeine)


AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR $1


amlodipine besylate oral tablet $1

ASCOMP-CODEINE ORAL CAPSULE $3.65 QL (180 EA per 30 days)

atenolol oral tablet $1

BELBUCA BUCCAL FILM $3.65 PA; QL (60 Films per 30 days)





$3.65


buprenorphine transdermal patch weekly $3.65 PA; QL (4 EA per 28 days)

butalbital-acetaminophen oral tablet 50-325 mg $3.65 QL (180 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-325-40 mg

$3.65 QL (180 EA per 30 days)

butalbital-apap-caffeine oral tablet 50-325-40 mg $3.65 QL (180 EA per 30 days)

butalbital-asa-caff-codeine oral capsule $3.65 QL (180 EA per 30 days)


butorphanol tartrate injection solution $3.65

butorphanol tartrate nasal solution $3.65


CAPACET ORAL CAPSULE $3.65 QL (180 EA per 30 days)

CAPITAL/CODEINE ORAL SUSPENSION $3.65¥ (Max of 4 g of acetaminophen or 360 mg of codeine)

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG $1 PA


234

Drug Status NotesCARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR $1



cimetidine oral tablet 200 mg $3.65

clopidogrel bisulfate oral tablet $3.65

codeine sulfate oral tablet $3.65 QL (360 mg per 1 day)



diflunisal oral tablet $3.65


DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE $3.65

dilt-cd oral capsule extended release 24 hour 120 mg, 240 mg, 300 mg

$1

diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

$1

diltiazem hcl er beads oral capsule extended release 24 hour

$1

diltiazem hcl er coated beads oral capsule extended release 24 hour

$1


$1

diltiazem hcl er oral capsule extended release 12 hour

$1

diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

$1

diltiazem hcl oral tablet $1

dilt-xr oral capsule extended release 24 hour $1

diltzac oral capsule extended release 24 hour $1


$3.65



$3.65



235

Drug Status Notes




$3.65



$3.65




EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG $3.65 PA; QL (2 EA per 1 day)

EMBEDA ORAL CAPSULE EXTENDED RELEASE 20-0.8 MG $3.65 PA; QL (12 EA per 1 day)


EMBEDA ORAL CAPSULE EXTENDED RELEASE 50-2 MG, 60-2.4 MG $3.65 PA; QL (4 EA per 1 day)


ENDOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG $3.65

¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )



eplerenone oral tablet $1 PA; QL (60 EA per 30 days)




famotidine oral suspension reconstituted $3.65

famotidine oral tablet 20 mg, 40 mg $3.65

fenoprofen calcium oral tablet $3.65


236

Drug Status Notesfentanyl citrate buccal lozenge on a handle $3.65 PA; QL (120 EA per 30 days)

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

$3.65 QL (10 EA per 30 days)

fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr


FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG $3.65 PA; QL (4 EA per 1 day)

flavoxate hcl oral tablet $3.65


$3.65













hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml

$3.65 QL (480 ML per 1 day)

hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

$3.65 QL (12 EA per 1 day)


237

Drug Status Noteshydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

$3.65 QL (5 EA per 1 day)

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent

$3.65 PA; QL (64 mg per 1 day)

hydromorphone hcl oral liquid $3.65 QL (64 mg per 1 day)

hydromorphone hcl oral tablet $3.65 QL (64 mg per 1 day)

hydromorphone hcl rectal suppository $3.65

IBUDONE ORAL TABLET $3.65 QL (5 EA per 1 day)





ISORDIL TITRADOSE ORAL TABLET 40 MG $3.65

isosorbide dinitrate er oral tablet extended release

$3.65

isosorbide dinitrate oral tablet $3.65

isosorbide mononitrate er oral tablet extended release 24 hour

$3.65

isosorbide mononitrate oral tablet $3.65

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG $3.65 PA; QL (1 EA per 1 day)

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 MG $3.65 PA; QL (6 EA per 1 day)


ketorolac tromethamine injection solution 15 mg/ml, 30 mg/ml

$3.65¥ (Max of 5 days per Rx); QL (120 mg per 1 day)

ketorolac tromethamine intramuscular solution60 mg/2ml



ketorolac tromethamine oral tablet $3.65 QL (20 EA per 30 days)







238

Drug Status NotesLORCET HD ORAL TABLET $3.65 QL (12 EA per 1 day)

LORCET ORAL TABLET $3.65 QL (12 EA per 1 day)

LORCET PLUS ORAL TABLET 7.5-325 MG $3.65 QL (12 EA per 1 day)

LORTAB ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG $3.65 QL (12 EA per 1 day)



margesic oral capsule $3.65 QL (180 EA per 30 days)

marten-tab oral tablet $3.65 QL (180 EA per 30 days)

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR $1 PA


mefenamic acid oral capsule $3.65 PA

meperidine hcl oral solution $3.65 QL (120 ML per 1 day)



METHADONE HCL INTENSOL ORAL CONCENTRATE $3.65 QL (6 ML per 1 day)

methadone hcl oral concentrate $3.65 QL (6 ML per 1 day)





methadone hcl oral tablet soluble Medical Benefit

METHADOSE ORAL TABLET SOLUBLE Medical Benefit

metoprolol succinate er oral tablet extended release 24 hour

$1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

$1

metoprolol tartrate oral tablet 37.5 mg, 75 mg $3.65 PA




239

Drug Status NotesMINITRAN TRANSDERMAL PATCH 24 HOUR $3.65

morphine sulfate (concentrate) oral solution 100 mg/5ml

$3.65 QL (12 ML per 1 day)

morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 90 mg


















morphine sulfate er oral capsule extended release 24 hour 50 mg, 60 mg




morphine sulfate er oral tablet extended release100 mg



$3.65 QL (16 EA per 1 day)







morphine sulfate oral solution 10 mg/5ml $3.65 QL (120 ML per 1 day)

morphine sulfate oral solution 20 mg/5ml $3.65 QL (60 ML per 1 day)


240

Drug Status Notesmorphine sulfate oral tablet 15 mg $3.65 QL (16 EA per 1 day)

morphine sulfate oral tablet 30 mg $3.65 QL (8 EA per 1 day)

nadolol oral tablet 20 mg, 40 mg, 80 mg $1






nicardipine hcl oral capsule $1

NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR $1

nifedipine er oral tablet extended release 24 hour30 mg, 60 mg

$1

nifedipine er oral tablet extended release 24 hour90 mg

$3.65

nifedipine er osmotic release oral tablet extended release 24 hour

$1

nifedipine oral capsule $1

NITRO-BID TRANSDERMAL OINTMENT $3.65

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR $3.65

nitroglycerin sublingual tablet sublingual $3.65

nitroglycerin transdermal patch 24 hour $3.65

nitroglycerin translingual aerosol solution $3.65

nitroglycerin translingual solution $3.65


NUCYNTA ORAL TABLET $3.65 PA

OPANA ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT $3.65 PA; QL (80 mg per 1 day)


oxycodone hcl er oral tablet er 12 hour abuse-deterrent

$3.65 QL (90 EA per 30 days)

oxycodone hcl oral capsule $3.65 QL (160 mg per 1 day)

oxycodone hcl oral concentrate 100 mg/5ml $3.65 QL (160 mg per 1 day)

oxycodone hcl oral solution $3.65


241

Drug Status Notesoxycodone hcl oral tablet $3.65 QL (160 mg per 1 day)

oxycodone-acetaminophen oral solution $3.65¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

$3.65¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )

oxycodone-aspirin oral tablet 4.8355-325 mg $3.65

oxycodone-ibuprofen oral tablet $3.65 PA

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT $3.65 QL (90 EA per 30 days)

oxymorphone hcl er oral tablet extended release 12 hour

$3.65 PA; QL (80 mg per 1 day)

oxymorphone hcl oral tablet $3.65 PA; QL (80 mg per 1 day)


perindopril erbumine oral tablet $1


phenazopyridine hcl oral tablet 100 mg, 200 mg $3.65










$1

propranolol hcl oral solution 40 mg/5ml $1


RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR $3.65 PA; QL (60 EA per 30 days)

REPREXAIN ORAL TABLET 10-200 MG $3.65 QL (5 EA per 1 day)



ROXICET ORAL TABLET 5-325 MG $3.65¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )



242

Drug Status NotesSAVELLA TITRATION PACK ORAL $3.65 STPA; QL (60 EA per 30 days)

SPRIX NASAL SOLUTION $3.65PA; ¥ (Max of 5 days per Rx); QL (4 units per 1 day)











TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR $1


TENCON ORAL TABLET 50-325 MG $3.65 QL (180 EA per 30 days)

timolol maleate oral tablet $1










243

Drug Status Notes



tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 300 mg

$3.65 PA

tramadol hcl er oral tablet extended release 24 hour


tramadol hcl oral tablet $3.65 QL (240 EA per 30 days)

tramadol-acetaminophen oral tablet $3.65 QL (240 EA per 30 days)

trandolapril oral tablet $1


verapamil hcl oral tablet $1

VERDROCET ORAL TABLET $3.65 QL (12 EA per 1 day)

XYLON ORAL TABLET $3.65 QL (5 EA per 1 day)

ZAMICET ORAL SOLUTION $3.65


ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT $3.65 PA; QL (120 mg per 1 day)





PATIENT DEMOGRAPHICS

BUPROBAN ORAL TABLET EXTENDED RELEASE 12 HOUR $3.65

bupropion hcl er (smoking det) oral tablet extended release 12 hour

$3.65

CHANTIX CONTINUING MONTH PAK ORAL TABLET $3.65 QL (60 EA per 30 days)

CHANTIX ORAL TABLET $3.65 QL (60 EA per 30 days)

CHANTIX STARTING MONTH PAK ORAL TABLET $3.65 QL (60 EA per 30 days)

eq nicotine mouth/throat lozenge $3.65

eq nicotine polacrilex mouth/throat gum $3.65


244

Drug Status Noteseq nicotine polacrilex mouth/throat lozenge $3.65


eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr

$3.65

eql nicotine polacrilex mouth/throat gum $3.65

eql nicotine polacrilex mouth/throat lozenge $3.65

eql nicotine transdermal patch 24 hour $3.65

gnp nicotine mini mouth/throat lozenge $3.65

gnp nicotine polacrilex mouth/throat gum $3.65

gnp nicotine polacrilex mouth/throat lozenge $3.65

hm nicotine polacrilex mouth/throat gum $3.65

hm nicotine polacrilex mouth/throat lozenge $3.65

hm nicotine transdermal patch 24 hour $3.65

NICORELIEF MOUTH/THROAT GUM $3.65

nicotine mini mouth/throat lozenge $3.65

nicotine polacrilex mouth/throat gum $3.65

nicotine polacrilex mouth/throat lozenge $3.65




nicotine transdermal patch 24 hour $3.65

NICOTROL INHALATION INHALER $3.65

NICOTROL NS NASAL SOLUTION $3.65

ra mini nicotine mouth/throat lozenge $3.65

ra nicotine mouth/throat gum $3.65

ra nicotine polacrilex mouth/throat gum $3.65

ra nicotine polacrilex mouth/throat lozenge $3.65

ra nicotine transdermal patch 24 hour $3.65

sm nicotine mouth/throat gum $3.65

sm nicotine mouth/throat lozenge $3.65

sm nicotine polacrilex mouth/throat gum $3.65

sm nicotine polacrilex mouth/throat lozenge $3.65

sm nicotine transdermal patch 24 hour $3.65

sw nicotine polacrilex mouth/throat gum $3.65


245

Drug Status Notessw nicotine polacrilex mouth/throat lozenge $3.65

tgt nicotine mouth/throat gum 4 mg $3.65

tgt nicotine polacrilex mouth/throat gum $3.65

tgt nicotine polacrilex mouth/throat lozenge $3.65

tgt nicotine step one transdermal patch 24 hour $3.65

tgt nicotine step three transdermal patch 24 hour $3.65

tgt nicotine step two transdermal patch 24 hour $3.65

PREGNANCY

bp folinatal plus b oral tablet $3.65


DICLEGIS ORAL TABLET DELAYED RELEASE $3.65 PA

ELITE-OB ORAL TABLET $3.65

INATAL ADVANCE ORAL TABLET $3.65

Makena Intramuscular Oil MB/RX PA; QL (1 ML per 7 days)

methylergonovine maleate oral tablet $3.65

OBSTETRIX EC ORAL TABLET $3.65

pnv folic acid + iron oral tablet $3.65

prenatabs fa oral tablet $3.65

PRENATABS RX ORAL TABLET $3.65

prenatal 19 oral tablet $3.65

prenatal 19 oral tablet chewable $3.65

prenatal oral tablet 27-0.8 mg $3.65


TRINATE ORAL TABLET $3.65


PROCEDURE




MB/RX SP





246

Drug Status Notesaspirin-dipyridamole er oral capsule extended release 12 hour







$3.65








$3.65










FERRIPROX ORAL SOLUTION $3.65 PA

FERRIPROX ORAL TABLET $3.65 PA




$3.65



247

Drug Status NotesGAVILYTE-C ORAL SOLUTION RECONSTITUTED $3.65

GAVILYTE-G ORAL SOLUTION RECONSTITUTED $3.65




GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM $3.65


$3.65


$3.65


MB/RX SP















lidocaine hcl (pf) injection solution 4 % $3.65




lidocaine hcl external solution $3.65


248

Drug Status Noteslidocaine hcl injection solution 0.5 %, 1 %, 1.5 %, 2 %

$3.65

lidocaine viscous mouth/throat solution $3.65

lidocaine-prilocaine external cream $3.65

lidocaine-prilocaine external kit $3.65


liothyronine sodium oral tablet $3.65

MOVIPREP ORAL SOLUTION RECONSTITUTED $3.65




$3.65





$3.65 SP








$3.65

OSMOPREP ORAL TABLET $3.65 QL (32 EA per 1 Fill)


peg 3350/electrolytes oral solution reconstituted $3.65

peg 3350-kcl-na bicarb-nacl oral solution reconstituted

$3.65

peg-3350/electrolytes oral solution reconstituted $3.65


249

Drug Status NotesPHENADOZ RECTAL SUPPOSITORY $3.65



$3.65



PREPOPIK ORAL PACKET $3.65










quinidine gluconate er oral tablet extended release

$3.65

quinidine sulfate er oral tablet extended release $3.65

quinidine sulfate oral tablet $3.65









SUPREP BOWEL PREP KIT ORAL SOLUTION $3.65





250

Drug Status NotesTRILYTE ORAL SOLUTION RECONSTITUTED $3.65









REACTION DUE TO AN ALLERGEN

























251

Drug Status Notesepinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.3 mg/0.3ml

$3.65 QL (2 EA per 1 Fill)

EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR $3.65 PA; QL (2 EA per 1 Fill)

EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR $3.65 PA; QL (2 EA per 1 Fill)




$3.65

























252

Drug Status NotesXolair Subcutaneous Solution Reconstituted MB/RX PA; SP; QL (6 vials per 28 days)


RECENT OPERATION




MB/RX SP









$3.65








$3.65










253

Drug Status NotesGLYDO EXTERNAL GEL $3.65


$3.65


MB/RX SP













lidocaine hcl (pf) injection solution 4 % $3.65




lidocaine hcl external solution $3.65

lidocaine hcl injection solution 0.5 %, 1 %, 1.5 %, 2 %

$3.65

lidocaine viscous mouth/throat solution $3.65

lidocaine-prilocaine external cream $3.65

lidocaine-prilocaine external kit $3.65




$3.65





254

Drug Status NotesNEVANAC OPHTHALMIC SUSPENSION $3.65



$3.65





$3.65
























SKIN CONDITION

8-MOP ORAL CAPSULE $3.65


255

Drug Status NotesABSORICA ORAL CAPSULE $3.65 PA

acitretin oral capsule $3.65 QL (60 EA per 30 days)

acne medication 5 external gel $3.65

acyclovir external ointment $3.65

ACZONE EXTERNAL GEL 7.5 % $3.65 PA; QL (60 GM per 30 days)

adapalene external cream $3.65 STPA

adapalene external gel $3.65 STPA

adapalene external lotion $3.65 STPA

ala-cort external cream 1 % $3.65

alclometasone dipropionate external cream $3.65

alclometasone dipropionate external ointment $3.65



amcinonide external cream $3.65 PA

amcinonide external lotion $3.65 PA

amcinonide external ointment $3.65 PA

ammonium lactate external cream $3.65

ammonium lactate external lotion $3.65

ANALPRAM-HC RECTAL LOTION 2.5-1 % $3.65

APEXICON E EXTERNAL CREAM $3.65 PA

AVITA EXTERNAL CREAM $3.65 PA

AVITA EXTERNAL GEL $3.65 PA

AZELEX EXTERNAL CREAM $3.65 QL (30 grams per 1 fill)




benzoyl peroxide external gel 10 %, 5 % $3.65

benzoyl peroxide wash external liquid 10 % $3.65

benzoyl peroxide-erythromycin external gel $3.65 QL (23 GM per 30 days)


betamethasone dipropionate aug external cream $3.65

betamethasone dipropionate aug external gel $3.65


256

Drug Status Notesbetamethasone dipropionate aug external lotion $3.65

betamethasone dipropionate aug external ointment

$3.65

betamethasone dipropionate external cream $3.65

betamethasone dipropionate external lotion $3.65

betamethasone dipropionate external ointment $3.65

betamethasone valerate external cream $3.65

betamethasone valerate external foam $3.65

betamethasone valerate external lotion $3.65

betamethasone valerate external ointment $3.65




bp foaming wash external liquid $3.65

bp wash external liquid 2.5 % $3.65

bpo external gel $3.65 PA

calcipotriene external cream $3.65

calcipotriene external ointment $3.65

calcipotriene external solution $3.65

calcipotriene-betameth diprop external ointment $3.65 PA

CALCITRENE EXTERNAL OINTMENT $3.65

calcitriol external ointment $3.65

CAPEX EXTERNAL SHAMPOO $3.65 PA

CENTANY EXTERNAL OINTMENT $3.65




CICLODAN EXTERNAL SOLUTION $3.65


ciclopirox external shampoo $3.65 PA

ciclopirox external solution $3.65





257

Drug Status NotesCIMZIA PREFILLED SUBCUTANEOUS KIT $3.65 PA; SP; QL (2 EA per 28 days)




CLARAVIS ORAL CAPSULE $3.65PA; ¥ (Max of 5 months); QL (60 EA per 30 days)


clindamycin phos-benzoyl perox external gel $3.65 PA; QL (50 GM per 30 days)

clindamycin phosphate external foam $3.65 PA

clindamycin phosphate external gel $3.65

clindamycin phosphate external lotion $3.65

clindamycin phosphate external solution $3.65

clobetasol propionate e external cream $3.65

clobetasol propionate external cream $3.65 PA

clobetasol propionate external foam $3.65

clobetasol propionate external gel $3.65 PA

clobetasol propionate external liquid $3.65 PA

clobetasol propionate external lotion $3.65

clobetasol propionate external ointment $3.65 PA

clobetasol propionate external shampoo $3.65

clobetasol propionate external solution $3.65 PA



CLODAN EXTERNAL SHAMPOO $3.65



clotrimazole external solution $3.65




CORDRAN EXTERNAL OINTMENT $3.65 PA

CORDRAN EXTERNAL TAPE $3.65 PA


258

Drug Status NotesCORMAX SCALP APPLICATION EXTERNAL SOLUTION $3.65 PA



$3.65 PA; SP




dapsone external gel $3.65 PA; QL (60 GM per 30 days)

dapsone oral tablet $3.65


desonide external cream $3.65 PA

desonide external lotion $3.65 PA

desonide external ointment $3.65 PA

desoximetasone external cream 0.05 % $3.65 PA

desoximetasone external cream 0.25 % $3.65

desoximetasone external gel $3.65

desoximetasone external ointment 0.05 % $3.65 PA

desoximetasone external ointment 0.25 % $3.65

diclofenac sodium transdermal gel 3 % $3.65¥ (Max of 90 days per year); QL (200 GM per 30 days)

DIFFERIN EXTERNAL GEL 0.1 % $3.65 ^ (OTC only)

diflorasone diacetate external cream $3.65 PA

diflorasone diacetate external ointment $3.65 PA


$0

DRYSOL EXTERNAL SOLUTION $3.65

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (4 ML per 28 days)




ELIDEL EXTERNAL CREAM $3.65 PA


259

Drug Status NotesENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE $3.65 PA; SP; QL (4 ea per 28 days)











EPIFOAM EXTERNAL FOAM $3.65

ERIVEDGE ORAL CAPSULE $3.65 PA; SP

erythromycin external gel $3.65

erythromycin external solution $3.65

EUCRISA EXTERNAL OINTMENT $3.65 PA

EURAX EXTERNAL CREAM $3.65

EURAX EXTERNAL LOTION $3.65



FABIOR EXTERNAL FOAM $3.65 PA

FINACEA EXTERNAL FOAM $3.65 QL (50 GM per 1 Rx)

FINACEA EXTERNAL GEL $3.65 QL (50 GM per 1 Rx)


fluocinolone acetonide body external oil $3.65

fluocinolone acetonide external cream $3.65

fluocinolone acetonide external ointment $3.65

fluocinolone acetonide external solution $3.65


fluocinolone acetonide scalp external oil $3.65

fluocinonide external cream 0.05 % $3.65 QL (60 GM per 30 days)


fluocinonide external gel $3.65 QL (60 GM per 30 days)

fluocinonide external ointment $3.65 QL (60 GM per 30 days)


260

Drug Status Notesfluocinonide external solution $3.65 QL (60 ML per 30 days)

FLUOROPLEX EXTERNAL CREAM $3.65

fluorouracil external cream $3.65

fluorouracil external solution $3.65



fluticasone propionate external cream $3.65

fluticasone propionate external lotion $3.65

fluticasone propionate external ointment $3.65


MB/RX PA; SP

gentamicin sulfate external cream $3.65

gentamicin sulfate external ointment $3.65


griseofulvin microsize oral suspension $3.65

griseofulvin microsize oral tablet $3.65

griseofulvin ultramicrosize oral tablet $3.65

halobetasol propionate external cream $3.65 PA

halobetasol propionate external ointment $3.65 PA

HALOG EXTERNAL CREAM $3.65 PA

HALOG EXTERNAL OINTMENT $3.65 PA








$3.65

hydrocortisone butyrate external cream $3.65 PA



261

Drug Status Noteshydrocortisone butyrate external ointment $3.65 PA

hydrocortisone butyrate external solution $3.65 PA

hydrocortisone external cream 1 %, 2.5 % $3.65

hydrocortisone external lotion $3.65

hydrocortisone external ointment 1 %, 2.5 % $3.65


hydrocortisone valerate external cream $3.65

hydrocortisone valerate external ointment $3.65


hydroxyurea oral capsule $3.65


IMLYGIC INTRALESIONAL SUSPENSION Medical Benefit

IMPAVIDO ORAL CAPSULE $3.65




Istodax Intravenous Solution Reconstituted MB/RX SP



ketoconazole external foam $3.65


KETODAN EXTERNAL FOAM $3.65









lindane external lotion $3.65

lindane external shampoo $3.65



262

Drug Status NotesLUZU EXTERNAL CREAM $3.65 PA

malathion external lotion $3.65


methoxsalen rapid oral capsule $3.65

metronidazole external cream $3.65

metronidazole external gel 0.75 % $3.65

metronidazole external gel 1 % $3.65 PA

metronidazole external lotion $3.65

MIRVASO EXTERNAL GEL $3.65 PA

mometasone furoate external cream $3.65

mometasone furoate external ointment $3.65

mometasone furoate external solution $3.65



MYORISAN ORAL CAPSULE $3.65 PA



NEUAC EXTERNAL GEL $3.65 PA


NORITATE EXTERNAL CREAM $3.65 PA



nystatin external ointment $3.65




NYSTOP EXTERNAL POWDER $3.65

ODOMZO ORAL CAPSULE $3.65 PA






263

Drug Status NotesOTEZLA ORAL TABLET THERAPY PACK $3.65 PA; SP; QL (60 EA per 30 days)



PANDEL EXTERNAL CREAM $3.65


permethrin external cream $3.65

PICATO EXTERNAL GEL $3.65 PA; QL (1 Box per 1 Rx)



PRAMOSONE E EXTERNAL CREAM $3.65

PRAMOSONE EXTERNAL CREAM 1-1 % $3.65

PRAMOSONE EXTERNAL LOTION $3.65

PRAMOSONE EXTERNAL OINTMENT $3.65

prednicarbate external cream $3.65

PROCTO-PAK RECTAL CREAM $3.65



psorcon external cream $3.65 PA




RETIN-A MICRO PUMP EXTERNAL GEL0.08 % $3.65 PA


ROSADAN EXTERNAL CREAM $3.65

ROSADAN EXTERNAL GEL $3.65


SANTYL EXTERNAL OINTMENT $3.65 QL (30 GM per 1 Rx)


selenium sulfide external shampoo 2.25 % $3.65

selenium sulf-pyrithione-urea external shampoo $3.65


SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (3 ML per 28 days)


264

Drug Status NotesSimponi Aria Intravenous Solution MB/RX PA; SP; QL (5 vials per 8 Weeks)

SOLARAZE TRANSDERMAL GEL $3.65¥ (Max of 90 days per year); QL (200 GM per 30 days)

SOOLANTRA EXTERNAL CREAM $3.65 PA

spinosad external suspension $3.65 STPA; QL (120 ML per 1 Fill)





sulfacetamide sodium (acne) external lotion $3.65

sulfacetamide sodium external suspension $3.65

SYLATRON SUBCUTANEOUS KIT 200 MCG, 296 MCG, 300 MCG, 4 X 296 MCG, 4 X 444 MCG, 444 MCG, 600 MCG, 888 MCG

$3.65 SP

SYNALAR (CREAM) EXTERNAL KIT $3.65 PA

SYNALAR (OINTMENT) EXTERNAL KIT $3.65 PA

TACLONEX EXTERNAL SUSPENSION $3.65 PA






TARGRETIN EXTERNAL GEL $3.65

tazarotene external cream $3.65 PA; STPA

TAZORAC EXTERNAL CREAM 0.05 % $3.65 STPA

TAZORAC EXTERNAL GEL $3.65 STPA

TERSI EXTERNAL FOAM $3.65

TILIA FE ORAL TABLET $0

TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE $3.65 PA; SP; QL (1 ML per 54 days)

tretinoin external cream $3.65 PA

tretinoin external gel $3.65 PA

tretinoin microsphere external gel $3.65 PA


265

Drug Status Notestretinoin microsphere pump external gel $3.65 PA



triamcinolone acetonide external cream $3.65

triamcinolone acetonide external lotion $3.65

triamcinolone acetonide external ointment $3.65

TRIDERM EXTERNAL CREAM 0.1 % $3.65

TRI-LEGEST FE ORAL TABLET $0

ULESFIA EXTERNAL LOTION $3.65 PA; QL (12 Bottles per 1 Rx)







XERAC AC EXTERNAL SOLUTION $3.65


XOLEGEL EXTERNAL GEL $3.65

ZENATANE ORAL CAPSULE $3.65 PA

ZOLINZA ORAL CAPSULE $3.65 PA; SP

ZYCLARA EXTERNAL CREAM $3.65 PA; QL (28 EA per 14 days)

ZYCLARA PUMP EXTERNAL CREAM $3.65 PA; QL (2 Pumps per 1 day)

SLOW DRUG ELIMINATION BY KIDNEY


TUMOR

ABSTRAL SUBLINGUAL TABLET SUBLINGUAL $3.65 PA



AKYNZEO ORAL CAPSULE $3.65 QL (1 EA per 1 Fill)

alfuzosin hcl er oral tablet extended release 24 hour

$3.65



266

Drug Status NotesAloxi Intravenous Solution 0.25 MG/5ML MB/RX QL (20 ML per 1 Rx)








Arzerra Intravenous Concentrate MB/RX SP



CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR $1

CESAMET ORAL CAPSULE $3.65 PA

Cinvanti Intravenous Emulsion MB/RX QL (18 ML per 1 Fill)

DARZALEX INTRAVENOUS SOLUTION Medical Benefit

DEMSER ORAL CAPSULE $1






Eligard Subcutaneous Kit MB/RX PA; SP

EMCYT ORAL CAPSULE $3.65




EMEND ORAL SUSPENSION RECONSTITUTED $3.65 QL (3 Units per 7 days)


267

Drug Status NotesEPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

$3.65 SP

ERIVEDGE ORAL CAPSULE $3.65 PA; SP

exemestane oral tablet $3.65

FARYDAK ORAL CAPSULE $3.65 PA; SP

fentanyl citrate buccal lozenge on a handle $3.65 PA; QL (120 EA per 30 days)

FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG $3.65 PA; QL (4 EA per 1 day)

finasteride oral tablet 5 mg $3.65

fluorouracil external cream 5 % $3.65

fluorouracil external solution 5 % $3.65


granisetron hcl oral tablet $3.65 QL (14 EA per 1 Fill)




MB/RX

hydroxyurea oral capsule $3.65




IMLYGIC INTRALESIONAL SUSPENSION Medical Benefit



Istodax Intravenous Solution Reconstituted MB/RX SP

JAKAFI ORAL TABLET $3.65 PA; SP


letrozole oral tablet $3.65

LEUKERAN ORAL TABLET $3.65


LONSURF ORAL TABLET $3.65 PA; SP




268

Drug Status NotesLupron Depot (4-Month) Intramuscular Kit MB/RX PA; SP


LYNPARZA ORAL CAPSULE $3.65 PA

LYSODREN ORAL TABLET $3.65





$3.65 SP







NINLARO ORAL CAPSULE $3.65 PA; SP



ODOMZO ORAL CAPSULE $3.65 PA

Oncaspar Injection Solution MB/RX SP


$3.65

ondansetron hcl oral solution $3.65 QL (105 ML per 1 Fill)

ondansetron hcl oral tablet $3.65 QL (21 EA per 1 Fill)

ondansetron oral tablet dispersible $3.65 QL (21 EA per 1 Fill)

Pamidronate Disodium Intravenous Solution MB/RX

Pamidronate Disodium Intravenous Solution Reconstituted

MB/RX




269

Drug Status Notespilocarpine hcl oral tablet $3.65





RAPAFLO ORAL CAPSULE $3.65 PA


SANCUSO TRANSDERMAL PATCH $3.65 PA; QL (4 EA per 28 days)


SOLTAMOX ORAL SOLUTION $3.65


SUSTOL SUBCUTANEOUS PREFILLED SYRINGE Medical Benefit

SYLATRON SUBCUTANEOUS KIT 200 MCG, 296 MCG, 300 MCG, 4 X 296 MCG, 4 X 444 MCG, 444 MCG, 600 MCG, 888 MCG

$3.65 SP


Synribo Subcutaneous Solution Reconstituted MB/RX SP

TABLOID ORAL TABLET $3.65

tamoxifen citrate oral tablet $3.65

tamsulosin hcl oral capsule $3.65

TARGRETIN EXTERNAL GEL $3.65


THALOMID ORAL CAPSULE $3.65 SP


Torisel Intravenous Solution MB/RX SP


TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED Medical Benefit SP


Vantas Subcutaneous Kit MB/RX SP

Varubi Intravenous Emulsion MB/RX

VARUBI ORAL TABLET $3.65¥ (Max of 6 tablets per 30 days); QL (2 Tablets per 1 Fill)


270

Drug Status NotesVENCLEXTA ORAL TABLET $3.65 PA

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK $3.65 PA


XERMELO ORAL TABLET $3.65 PA








MB/RX

ZOLINZA ORAL CAPSULE $3.65 PA; SP


271


272

Index8-MOP ......................................255abacavir sulfate .......... 18, 125, 204abacavir sulfate-lamivudine.....................................18, 125, 204abacavir-lamivudine-zidovudine.....................................18, 125, 205Abilify Maintena.......................175ABSORICA ............................. 256ABSTRAL ....................... 233, 266acamprosate calcium ........ 175, 205acarbose ..............................26, 112ACCU-CHEK SAFE-T PRO LANCETS ............................... 199ACCU-CHEK SOFT TOUCH LANCETS ............................... 199ACCU-CHEK SOFTCLIX LANCETS ............................... 199acebutolol hcl ..............................36acetaminophen-codeine .... 205, 234acetaminophen-codeine #2 ....... 233acetaminophen-codeine #3 ....... 233acetaminophen-codeine #4 ....... 234ACETASOL HC ..................... 120acetazolamide ....... 26, 97, 121, 155acetazolamide er .......................205acetic acid .................................121acetic acid-aluminum acetate ... 121acetylcysteine .............. 97, 155, 233ACIPHEX SPRINKLE...................................104, 136, 205acitretin .............................205, 256acne medication 5 ..................... 256Actemra.................15, 18, 136, 161ACTEMRA ..15, 18, 136, 161, 205ACTIMMUNE .............. 3, 18, 161ACTOPLUS MET XR ......26, 113acyclovir ....................125, 205, 256ACZONE ................................. 256adapalene ..................................256ADCIRCA ................9, 36, 97, 155ADDERALL XR . 52, 71, 161, 175adefovir dipivoxil...........................104, 125, 136, 205ADEMPAS ...3, 9, 36, 97, 155, 205ADMELOG ............................. 205ADMELOG SOLOSTAR ...... 205

ADRENALIN.....36, 121, 125, 205, 246, 251, 253ADVAIR DISKUS 9, 97, 136, 155ADVAIR HFA .......9, 97, 136, 155Advate...........................................3ADVICOR ................... 26, 36, 234Adynovate.....................................3ADZENYS XR-ODT...............................52, 71, 162, 175AEROSPAN .. 9, 97, 136, 156, 205AFEDITAB CR .................37, 234AFINITOR .......... 48, 89, 104, 266AFINITOR DISPERZ 52, 71, 266Afstyla...........................................3AKYNZEO ...................... 104, 266ala-cort ............................. 136, 256ALBENZA ............................... 205albuterol sulfate .............. 9, 98, 156albuterol sulfate er ..........9, 97, 156alclometasone dipropionate...........................................136, 256ALDACTAZIDE .................26, 37Aldurazyme.........................27, 113ALECENSA .............................205alendronate sodium...............................27, 89, 113, 162Alferon N.................. 125, 136, 256alfuzosin hcl er ....................48, 266ALINIA ............................104, 125Aliqopa..................................... 205allopurinol .................... 27, 48, 266almotriptan malate.........................37, 52, 71, 205, 234ALOCRIL ........121, 136, 154, 251alogliptin benzoate ......27, 113, 205alogliptin-metformin hcl.....................................27, 113, 205alogliptin-pioglitazone 27, 113, 205ALOMIDE ...............................205alosetron hcl ..................... 104, 205Aloxi................. 104, 246, 253, 267ALPHAGAN P ........................ 121

Alphanate/VWF Complex/Human...................3, 18, 37, 136, 246, 253AlphaNine SD...............................3alphatrex ................................... 205alprazolam ................................ 176alprazolam er ............................176ALPRAZOLAM INTENSOL 176alprazolam xr ............................176Alprolix.........................................3ALREX ............ 121, 136, 154, 251ALTABAX ...............125, 136, 256ALTAVERA ..............................89ALTOPREV .............................. 27ALUNBRIG .............................205ALVESCO ........... 10, 98, 136, 156alyacen 1/35 ................................89alyacen 7/7/7 ...............................89amantadine hcl ..............52, 71, 125amcinonide ........................136, 256AMETHIA .................................89AMETHIA LO .......................... 89AMETHYST ............................. 89AMICAR ....................37, 246, 253amiloride hcl .........................27, 37amiloride-hydrochlorothiazide ... 37amiodarone hcl ................... 37, 205AMITIZA ........................ 104, 233amitriptyline hcl ........................206amlodipine besy-benazepril hcl .. 37amlodipine besylate ............ 37, 234amlodipine besylate-valsartan.............................................37, 206amlodipine-atorvastatin...................................27, 37, 52, 71amlodipine-valsartan-hctz .. 37, 206ammonium lactate .....................256amoxapine .................................176amoxicill-clarithro-lansopraz...........................104, 125, 136, 206amoxicillin ................................ 206amoxicillin-pot clavulanate ...... 206amoxicillin-pot clavulanate er ..206


273

amphetamine-dextroamphetamine.......................53, 71, 162, 176, 206ampicillin .................................. 206AMPYRA .....................53, 71, 162ANADROL-50 .......................3, 18anagrelide hcl ................. 3, 37, 267ANALPRAM-HC ....137, 206, 256anastrozole ................................206ANDRODERM ..................89, 113ANDROGEL ..................... 90, 113ANDROGEL PUMP .........89, 113ANDROXY ........................90, 113ANORO ELLIPTA.......................10, 98, 137, 156, 206ANTARA ........................... 27, 206antipyrine-benzocaine ...............206anucort-hc ...................37, 104, 137ANUSOL-HC ............ 37, 104, 137ANZEMET ...................... 104, 267APEXICON E ................. 137, 256APIDRA ...................................206APIDRA OPTICLIK ..............206APIDRA SOLOSTAR ............ 207APOKYN ............................. 53, 71APPFORMIN-D ......................207APRI ...........................................90APRISO ........................... 104, 137APTENSIO XR ... 53, 71, 162, 176APTIOM ......................53, 71, 207APTIVUS ...........................18, 125Aralast NP...............10, 27, 98, 156ARANELLE .............................. 90ARANESP (ALBUMIN FREE) ............................ 3, 48, 267ARCALYST ........ 18, 27, 121, 137ARCAPTA NEOHALER...............................10, 98, 137, 156aripiprazole ...............176, 177, 207Aristada.....................................177armodafinil ............. 53, 71, 98, 156ARMOUR THYROID ............207Arzerra.................................. 3, 267ASCOMP-CODEINE ..... 177, 234ASHLYNA .................................90ASMANEX 120 METERED DOSES ................. 10, 98, 137, 156

ASMANEX 14 METERED DOSES ................. 10, 98, 137, 156ASMANEX 30 METERED DOSES ................. 10, 98, 137, 156ASMANEX 60 METERED DOSES ................. 10, 98, 137, 156ASMANEX 7 METERED DOSES ................. 10, 98, 137, 156ASMANEX HFA .10, 98, 137, 156aspirin-dipyridamole er.....................3, 37, 53, 71, 207, 247ASTAGRAF XL.......................18, 48, 207, 247, 253AT LAST LANCETS ............. 199atazanavir sulfate ........18, 125, 207atenolol ............................... 37, 234atenolol-chlorthalidone .............. 37atomoxetine hcl.......................53, 72, 162, 177, 207atorvastatin calcium ................... 27atovaquone ................................207atovaquone-proguanil hcl .........125ATRIPLA .......................... 18, 125atropine sulfate ..... 53, 72, 121, 162ATROVENT HFA ...... 10, 98, 156AUBAGIO ........................... 53, 72AUBRA .............................. 90, 207AUGMENTIN ......................... 207AURYXIA.......3, 7, 27, 48, 113, 162, 197, 207AUSTEDO ........... 53, 72, 162, 177AVANDAMET ..................27, 113AVANDARYL ...................27, 113AVANDIA ..........................27, 113AVAR CLEANSER ................ 207Avastin..........48, 98, 104, 156, 267AVC VAGINAL ..........48, 90, 125AVIANE .....................................90avidoxy ......................................207AVITA ..................................... 256AVONEX ............................. 53, 72AVONEX PEN .................... 53, 72AVONEX PREFILLED ..... 53, 72AzaCITIDine............................ 207AZASITE .........121, 125, 137, 154

azathioprine.........15, 18, 48, 137, 162, 247, 253azelastine hcl.10, 13, 98, 121, 125, 137, 154, 251AZELEX ..................................256azithromycin ............................. 207AZOPT .....................................121AZOR .........................................37AZURETTE .............................. 90bacitracin ..........................121, 125bacitracin-polymyxin b ..... 121, 125bacitra-neomycin-polymyxin-hc208baclofen .........................53, 72, 162BACTROBAN NASAL .......... 125balsalazide disodium ........ 104, 137BALZIVA .................................. 90BANZEL ..................................208BARACLUDE ......... 104, 126, 137BASAGLAR KWIKPEN ....... 208Bavencio................................... 208BD INSULIN SYRINGE ........200BD INSULIN SYRINGE MICROFINE ...........................200BD INSULIN SYRINGE ULTRAFINE ...........................200BD LANCET ULTRAFINE 33G ........................................... 200BD SAFETY-LOK INSULIN SYRINGE ................................ 200BD SYRINGE SLIP TIP ........ 200Bebulin..........................................3BECONASE AQ.........10, 14, 98, 126, 137, 154, 251BEKYREE .................................90BELBUCA ............................... 234Beleodaq................................... 208BELSOMRA ....................... 54, 72benazepril hcl ..............................37benazepril-hydrochlorothiazide ..37BENDEKA ...............................208BeneFIX........................................3BENICAR ..................................37BENICAR HCT ........................ 37Benlysta................ 15, 18, 137, 256BENLYSTA .........15, 18, 138, 256benzonatate ... 14, 98, 126, 138, 156benzoyl peroxide ....................... 256


274

benzoyl peroxide wash ..............256benzoyl peroxide-erythromycin .256benztropine mesylate .............54, 72BEPREVE ....... 121, 138, 154, 251Berinert................. 18, 27, 251, 256BESIVANCE ........................... 208Besponsa................................... 208betamethasone dipropionate...........................................138, 257betamethasone dipropionate aug ............................ 138, 256, 257betamethasone valerate .... 138, 257BETASERON ......................54, 72betaxolol hcl ........................37, 121bethanechol chloride ...................48BETIMOL ............................... 122BETOPTIC-S .......................... 122bexarotene .................208, 257, 267BEYAZ .......................90, 177, 257bicalutamide ............................. 208BIDIL ......................................... 37BILTRICIDE .................. 104, 126bimatoprost ....................... 122, 208bisoprolol fumarate .................... 37bisoprolol-hydrochlorothiazide .. 37BLEPHAMIDE ............... 122, 138BLEPHAMIDE S.O.P. ... 122, 138BLISOVI 24 FE .........................90BLISOVI FE 1.5/30 .................. 90BLISOVI FE 1/20 ..................... 90BOSULIF .................................208Botox...............37, 54, 72, 234, 257bp foaming wash ....................... 257bp folinatal plus b ..................... 246bp multinatal plus ..................... 208bp wash ..................................... 257bpo ............................................ 257BREO ELLIPTA 10, 98, 138, 157briellyn ........................................90BRILINTA...................3, 37, 38, 234, 247, 253brimonidine tartrate ..................122Brineura.............................. 27, 162BRIVIACT .......................... 54, 72bromfenac sodium...................122, 138, 234, 247, 253

bromfenac sodium (once-daily)...........122, 138, 208, 234, 247, 253bromocriptine mesylate .54, 72, 113budesonide10, 14, 99, 104, 126, 138, 157, 208, 251bumetanide ............................27, 38BUNAVAIL ............................. 177buprenorphine ...................208, 234buprenorphine hcl .....................177buprenorphine hcl-naloxone hcl...................................................177BUPROBAN ....................177, 244bupropion hcl ............................178bupropion hcl er (smoking det)...........................................177, 244bupropion hcl er (sr) .................178bupropion hcl er (xl) .................178buspirone hcl ............................ 178butalbital-acetaminophen . 178, 234butalbital-apap-caffeine ... 178, 234butalbital-asa-caff-codeine...........................................178, 234butalbital-aspirin-caffeine...................................178, 208, 234butorphanol tartrate ................. 234BYSTOLIC ................................38cabergoline ............................... 113CABOMETYX ........................208CAFERGOT ..........38, 54, 73, 234caffeine citrate.................54, 73, 99, 157, 197, 246calcipotriene ............................. 257calcipotriene-betameth diprop...........................................208, 257calcitonin (salmon) ..... 90, 113, 162CALCITRENE ........................257calcitriol ..............................27, 257calcium acetate (phos binder)...........7, 27, 48, 113, 162, 197, 198CALQUENCE .........................208CAMILA ....................................90CAMRESE ................................ 90CAMRESE LO ..........................90CANASA ..........................104, 138candesartan cilexetil ...................38CANTIL ...................................104

CAPACET ....................... 178, 234capecitabine ..............................208CAPEX .............................138, 257CAPITAL/CODEINE .............234CAPRELSA .....................208, 209captopril ..................27, 38, 48, 113captopril-hydrochlorothiazide ....38CARAFATE .................... 104, 138CARBAGLU ............................. 27carbamazepine.................54, 55, 73, 162, 163, 178carbamazepine er ..54, 73, 178, 209carbidopa ......................55, 73, 209carbidopa-levodopa ..............55, 73carbidopa-levodopa er ..........55, 73carbidopa-levodopa-entacapone...............................................55, 73CARDIZEM LA ................38, 234CARDURA XL ..................48, 267Carimune NF............ 3, 19, 38, 138carisoprodol ..............................163carisoprodol-aspirin ................. 163carteolol hcl .............................. 122CARTIA XT ...................... 38, 235carvedilol .................................... 38carvedilol phosphate er ...... 38, 209CAVAREST ............................ 209CAVIRINSE ............................209CAYSTON .............10, 27, 99, 157CAZIANT ..................................90CEDAX .................................... 209cefaclor ..................................... 209cefaclor er .................................209cefadroxil .................................. 209cefdinir ......................................209cefditoren pivoxil ...................... 209cefixime ..................................... 209cefpodoxime proxetil .................209cefprozil .................................... 209ceftibuten ...................................209CEFTIN ................................... 209CefTRIAXone Sodium............. 209cefuroxime axetil .......................209celecoxib ....... 15, 19, 138, 163, 209CELONTIN ......................... 55, 73CENTANY ...............126, 139, 257cephalexin ......................... 209, 210


275

CERDELGA ..............................27Cerezyme............................ 27, 210CEROVEL ...............................210CESAMET .......................104, 267cetirizine hcl...14, 27, 28, 99, 126, 139, 251, 257cevimeline hcl15, 19, 104, 122, 139CHANTIX ....................... 179, 244CHANTIX CONTINUING MONTH PAK ................. 179, 244CHANTIX STARTING MONTH PAK ................. 179, 244CHATEAL .................................90CHEMET .................................233chlordiazepoxide hcl .....55, 73, 179chlordiazepoxide-clidinium...........................................104, 139chlorhexidine gluconate...................................104, 126, 154chloroquine phosphate ..............126chlorothiazide ............................. 28chlorpromazine hcl ..... 99, 157, 179chlorpropamide ...................28, 113chlorthalidone .....................28, 210chlorzoxazone ........................... 163CHOLBAM ....................... 28, 104cholestyramine ............................28cholestyramine light ....................28choline & mag trisalicylate ...... 210choline-mag trisalicylate .. 139, 163CIALIS .......................................90CICLODAN .............126, 139, 257ciclopirox .................. 126, 139, 257ciclopirox olamine .... 126, 139, 257CIDALEAZE...................161, 235, 247, 253, 257cilostazol ..................... 38, 163, 235CILOXAN ............................... 210cimetidine ..................105, 139, 235cimetidine hcl ....................105, 139CIMZIA...............15, 19, 105, 139, 163, 258CIMZIA PREFILLED...............15, 19, 105, 139, 163, 258CIMZIA STARTER KIT...............15, 19, 105, 139, 163, 258Cinryze........................................28

Cinvanti.............................105, 267CIPRO HC .............................. 121CIPRODEX ..................... 121, 126ciprofloxacin ............................. 210ciprofloxacin hcl ....................... 210ciprofloxacin-ciproflox hcl er ... 210citalopram hydrobromide ......... 179CLARAVIS ............................. 258CLARINEX . 14, 99, 126, 139, 251CLARINEX-D 12 HOUR.................10, 14, 99, 126, 139, 251clarithromycin ...........................210clarithromycin er ...................... 210CLEANLET LANCETS 28G 200CLEARPLEX X ......................210clemastine fumarate...............14, 99, 126, 139, 251, 258CLEOCIN ....................48, 90, 126CLIMARA PRO ....... 90, 113, 163CLINDAMAX ......................... 210clindamycin hcl .........................210clindamycin palmitate hcl .........210clindamycin phos-benzoyl perox...................................................258clindamycin phosphate...............................48, 90, 126, 258CLINPRO 5000 .......................105clobetasol propionate139, 210, 258clobetasol propionate e .....139, 258clocortolone pivalate 139, 210, 258clocortolone pivalate pump...................................139, 210, 258CLODAN ................................. 258clomipramine hcl ...................... 179clonazepam ........... 55, 73, 163, 179clonidine hcl ................................38clonidine hcl er.......................55, 74, 163, 179, 210clopidogrel bisulfate ........... 38, 235clorazepate dipotassium55, 74, 179CLORPRES ...............................38clotrimazole.............99, 126, 139, 140, 154, 258clotrimazole anti-fungal...........................126, 139, 200, 258

clotrimazole-betamethasone...................................126, 140, 258clozapine ........................... 180, 210Coagadex...................................... 3COARTEM ............................. 126codeine sulfate .......................... 235colchicine ....................28, 140, 163colchicine-probenecid .28, 140, 163colestipol hcl ...............................28COLOCORT ................... 105, 140COMBIGAN ........................... 122COMBIPATCH ................ 90, 113COMBIVENT RESPIMAT.......................................10, 99, 157COMETRIQ (100 MG DAILY DOSE) ........................ 210COMETRIQ (140 MG DAILY DOSE) ........................ 211COMETRIQ (60 MG DAILY DOSE) ...................................... 211comfort lancets ..........................200COMPAZINE ................. 105, 211COMPLERA ..................... 19, 126COMPRO ................................ 105CONCERTA.................55, 56, 74, 163, 164, 180CONDYLOX ........... 126, 140, 258constulose ............... 28, 56, 74, 105CONTROLRX ........................ 211COPASIL .................................200CORDRAN ......................140, 258Corifact......................................... 3CORLANOR ............................. 38CORMAX SCALP APPLICATION ...................... 259CORTIFOAM ................. 105, 140cortisone acetate .........19, 113, 140CORTISPORIN ...... 126, 140, 259CORTISPORIN-TC ............... 211COSENTYX 16, 19, 140, 164, 259COSENTYX SENSOREADY PEN .............. 15, 19, 140, 164, 259COSOPT PF ............................ 122COTELLIC ............................. 211COTEMPLA XR-ODT...............................56, 74, 164, 180COVERA-HS .......................... 211


276

CREON ....................................105CRESEMBA ............................127CRINONE ......................... 90, 113CRIXIVAN ........................19, 127cromolyn sodium.10, 19, 99, 122, 140, 154, 157, 251CRYSELLE-28 ......................... 90CUPRIMINE.................28, 56, 74, 105, 164, 233CUVPOSA ............................... 105cyanocobalamin ....................7, 198CYCLAFEM 1/35 ..................... 90CYCLAFEM 7/7/7 .................... 90cyclobenzaprine hcl .................. 164cyclopentolate hcl ............. 122, 211cyclophosphamide .....................211cycloserine ................................ 211cyclosporine ..19, 49, 105, 247, 253cyclosporine modified.......................19, 48, 105, 247, 253cyproheptadine hcl...............14, 99, 127, 140, 251, 259CYRED ...................................... 91CYSTAGON ..............................28Cytogam..............19, 127, 247, 253cytra-2 .......................................211daily multi ................................. 200DAKLINZA .............105, 127, 140DALIRESP .......... 11, 99, 140, 157danazol ..................................28, 91dantrolene sodium 56, 74, 125, 164dapsone ............................. 127, 259darifenacin hydrobromide er.....................................49, 164, 211DARZALEX ........................3, 267DASETTA 1/35 ......................... 91DASETTA 7/7/7 ........................ 91DAYSEE .................................... 91DAYTRANA ........56, 74, 164, 180DEBLITANE .............................91Decitabine................................. 211DELTASONE ..........................211DELYLA ....................................91DELZICOL ..................... 105, 140DEMSER ........................... 38, 267DENAVIR ................105, 127, 259DENTA 5000 PLUS ................ 105

DENTAGEL ............................105DEPEN TITRATABS.................28, 56, 74, 105, 164, 233DEPO-PROVERA ...... 49, 91, 267DEPO-SUBQ PROVERA 104 . 91DEPO-TESTOSTERONE91, 113DEPRIZINE FUSEPAQ ........ 211DESCOVY .........................19, 127desipramine hcl .........................180desloratadine 14, 99, 127, 140, 251desmopressin ace rhinal tube.............................................28, 114desmopressin ace spray refrig.............................................28, 114desmopressin acetate .... 28, 49, 114desmopressin acetate spray 28, 114desogestrel-ethinyl estradiol.............................................91, 211desonide ............................ 140, 259desoximetasone ......... 140, 141, 259desvenlafaxine er ...................... 180desvenlafaxine fumarate er .......181desvenlafaxine succinate er...........................................181, 211dexamethasone ..........................114DEXAMETHASONE INTENSOL ..............................114dexamethasone sodium phosphate ..121, 122, 141, 247, 253DEXEDRINE ...... 56, 74, 164, 181DEXILANT ............................. 105dexmethylphenidate hcl...............................56, 74, 164, 181DEXPAK 10 DAY ...................114DEXPAK 13 DAY ...................114DEXPAK 6 DAY .....................114dextroamphetamine sulfate.........................56, 57, 75, 165, 181dextroamphetamine sulfate er...............................56, 75, 164, 181DIABETA .......................... 28, 114diazepam...............57, 75, 165, 181, 182, 211DIAZEPAM INTENSOL...............................57, 75, 165, 181DICLEGIS .......................105, 246diclofenac potassium 141, 165, 235

diclofenac sodium122, 141, 165, 211, 212, 235, 247, 253, 259diclofenac sodium er...............................16, 19, 141, 165dicloxacillin sodium ..................212DICOPANOL FUSEPAQ ...... 212dicyclomine hcl ................. 105, 212didanosine ...........................19, 127DIFFERIN ............................... 259DIFICID ...................106, 127, 141diflorasone diacetate ........ 141, 259diflunisal ................................... 235DIGITEK ...................................38DIGOX .......................................38digoxin ........................................ 38dihydroergotamine mesylate.................................38, 57, 75, 235DILANTIN .......................... 57, 75DILATRATE-SR .............. 38, 235dilt-cd ..........................39, 212, 235diltiazem cd .........................39, 235diltiazem hcl ........................39, 235diltiazem hcl er ................... 39, 235diltiazem hcl er beads ......... 39, 235diltiazem hcl er coated beads.....................................39, 212, 235dilt-xr .................................. 39, 235diltzac ..................................39, 235dimenhydrinate ......................... 106DIPENTUM .....................106, 141diphenhydramine hcl...............................57, 75, 200, 251diphenoxylate-atropine ............. 106dipyridamole ................................. 4disopyramide phosphate ............. 39disulfiram ..................................182DIURIL ......................................28divalproex sodium.................39, 57, 76, 182, 235, 236divalproex sodium er.........................39, 57, 76, 182, 235DIVIGEL ............. 49, 91, 114, 154dofetilide ..................... 39, 212, 247donepezil hcl ................. 58, 76, 182DONNATAL ........................... 212dorzolamide hcl ........................ 122


277

dorzolamide hcl-timolol mal .....122doxazosin mesylate ....... 39, 49, 267doxepin hcl ........................182, 212doxercalciferol ....49, 114, 212, 247doxycycline hyclate ........... 154, 212doxycycline monohydrate ......... 212DRITHO-CREME HP ........... 212dronabinol .....19, 28, 106, 127, 267drospiren-eth estrad-levomefol.............................................91, 212drospirenone-ethinyl estradiol.............................91, 182, 212, 259DROXIA ...................................... 4DRYSOL ..................................259DUAVEE ........... 91, 114, 165, 212DULERA ............. 11, 99, 141, 157duloxetine hcl...165, 166, 182, 183, 212, 213, 236DUPIXENT ..................... 141, 259DUREZOL...................122, 141, 236, 247, 253dutasteride .................. 49, 213, 267dutasteride-tamsulosin hcl.....................................49, 213, 267DUZALLO .................28, 141, 166DYANAVEL XR .58, 76, 166, 183DYNACIRC CR ......................213DYRENIUM ..............................28Dysport................. 58, 76, 166, 259E.E.S. 400 .................................213EASYGEL ............................... 213econazole nitrate .......127, 141, 259ECOZA ............ 127, 141, 213, 259EDARBI .....................................39EDLUAR ............................. 58, 76EDURANT .........................19, 127efavirenz ......................19, 127, 213EGRIFTA ...... 16, 19, 28, 127, 141Elaprase.......................28, 106, 114ELESTRIN .......... 49, 91, 114, 154eletriptan hydrobromide.........................39, 58, 76, 213, 236ELIDEL ........................... 141, 259Eligard.................................49, 267ELINEST ................................... 91ELIQUIS ..........4, 39, 99, 157, 247ELITE-OB ............................... 246

ELIXOPHYLLIN11, 99, 141, 157ELLA ......................................... 91ELMIRON .................................49Eloctate......................................... 4Elspar........................................ 213EMADINE ....... 122, 141, 154, 251EMBEDA .................................236EMCYT ............................. 49, 267Emend....................... 106, 213, 267EMEND ........... 106, 247, 253, 267EMFLAZA .......... 58, 76, 141, 166EMOQUETTE .......................... 91EMPLICITI .............................213EMSAM ................................... 183EMTRIVA ......................... 19, 127enalapril maleate ........................ 39enalapril-hydrochlorothiazide ....39ENBREL ......16, 20, 141, 166, 260ENBREL MINI.......................16, 20, 141, 166, 260ENBREL SURECLICK.......................16, 20, 142, 166, 260ENDARI .......................................4ENDOCET ...............................236enoxaparin sodium...........................4, 39, 40, 236, 247ENPRESSE-28 .......................... 91ENSKYCE ................................. 91entacapone ............................58, 76entecavir ............106, 127, 142, 213ENTRESTO ...............................40Entyvio..............................106, 142enulose .................... 28, 58, 76, 106EPANED ............................40, 213EPCLUSA ................106, 127, 142EPIFOAM ....................... 142, 260epinastine hcl .... 122, 142, 154, 251epinephrine ............................... 252epinephrine hcl ........... 40, 127, 251EPIPEN 2-PAK .......................252EPIPEN JR 2-PAK ................. 252Epirubicin HCl..........................213EPITOL ....................... 58, 76, 166eplerenone ...........................40, 236EPOGEN ....................... 4, 49, 268

Epoprostenol Sodium.................................11, 40, 99, 157eprosartan mesylate ....................40eq nicotine .........183, 200, 244, 245eq nicotine polacrilex...........................183, 200, 244, 245eq nicotine step 3 ...... 183, 200, 245eql nicotine ........................183, 245eql nicotine polacrilex ...... 183, 245Erbitux...................................... 213ergocalciferol ........................7, 198ergoloid mesylates ........ 58, 76, 183ERGOMAR ........... 40, 58, 76, 236ERIVEDGE ..................... 260, 268ERRIN ....................................... 91ERYPED 400 ...........................213ERY-TAB ................................ 213ERYTHROCIN STEARATE 213erythromycin ............. 122, 127, 260erythromycin base .....................213erythromycin ethylsuccinate...........................................213, 214ESBRIET ..................... 11, 99, 157ESCAVITE ..................7, 106, 198ESCAVITE D .............. 7, 106, 198escitalopram oxalate .................183est estrogens-methyltest ............ 214est estrogens-methyltest hs ........214ESTARYLLA ............................91estazolam .............................. 58, 76estradiol ........ 49, 91, 114, 154, 214estradiol-norethindrone acet .... 214ESTRING ............ 49, 91, 114, 154ESTROGEL ........ 49, 91, 114, 154estropipate .......................... 91, 114eszopiclone ............................58, 77Ethacrynate Sodium.........................28, 40, 99, 157, 214ethacrynic acid29, 40, 99, 157, 214ethambutol hcl .......................... 214ethosuximide ......................... 58, 77etidronate disodium ............ 29, 166etodolac .....................142, 166, 236etodolac er ............ 16, 20, 142, 166etoposide ................................... 214EUCRISA ........................ 142, 260EUFLEXXA .................... 142, 166


278

EURAX ............................ 127, 260EVAMIST ..................................92EVOTAZ ........................... 20, 127EVZIO ..................................... 233EXELDERM ........... 127, 142, 260exemestane .......................... 92, 268EXJADE ...................... 4, 233, 247Exondys 51........... 58, 77, 142, 166EXTAVIA ......................58, 59, 77Eylea................. 4, 29, 40, 114, 122ezetimibe-simvastatin ..........29, 214EZ-LETS LANCETS 26G ..... 200FABIOR ...........................214, 260FACTIVE ................................ 214FALMINA ................................. 92famciclovir ................................ 214famotidine ......................... 106, 236FANAPT .................................. 183FANAPT TITRATION PACK ....................................... 184FARESTON .............................214FARXIGA ..................29, 114, 214FARYDAK .......................... 4, 268Fasenra................11, 100, 142, 157FAYOSIM ................................. 92Feiba....................................... 4, 40felbamate ...................................214felodipine er ................................ 40FEMRING ........... 49, 92, 114, 154fenofibrate ...........................29, 214fenofibrate micronized ................ 29fenofibric acid .....................29, 214fenoprofen calcium ................... 236fentanyl ..................................... 237fentanyl citrate .................. 237, 268FENTORA .......................237, 268FERRIPROX ...................233, 247ferrous sulfate ........................... 200FETZIMA ........................184, 214FETZIMA TITRATION 184, 215FIASP .......................................215FIASP FLEXTOUCH ............ 215FIBRICOR ................................ 29FINACEA ........................ 142, 260finasteride ........................... 49, 268FINGERSTIX LANCETS ......200FIRAZYR ............ 20, 29, 252, 260

Firmagon...................................215FIRST-BXN MOUTHWASH 215FIRST-DUKES MOUTHWASH .......................215FIRST-HYDROCORTISONE...................................................215FIRST-LANSOPRAZOLE .... 215FIRST-MARYS MOUTHWASH .......................215FIRST-MOUTHWASH BLM215FIRST-OMEPRAZOLE ........ 215FIRST-PROGESTERONE VGS 100 ................................... 215FIRST-PROGESTERONE VGS 200 ................................... 215FIRST-PROGESTERONE VGS 25 ..................................... 215FIRST-PROGESTERONE VGS 400 ................................... 215FIRST-PROGESTERONE VGS 50 ..................................... 215FIRST-TESTOSTERONE .....215FIRST-TESTOSTERONE MC ............................................215FIRST-VANCOMYCIN 25 ....215FIRST-VANCOMYCIN 50 ....216FLAGYL ER ........................... 216FLAREX ..........................122, 142flavoxate hcl ........................49, 237Flebogamma............................. 216Flebogamma DIF........................ 20flecainide acetate ........................ 40FLECTOR ....................... 161, 166flolipid .........................................29FLOVENT DISKUS.............................11, 100, 142, 157FLOVENT HFA11, 100, 142, 157fluconazole ................................216flucytosine ................................. 216fludrocortisone acetate ............. 114flunisolide ... 14, 100, 127, 142, 252fluocinolone acetonide...................................121, 142, 260fluocinolone acetonide body...........................................142, 260

fluocinolone acetonide scalp...........................................142, 260fluocinonide...................142, 143, 216, 260, 261FLUORABON .........................106FLUOR-A-DAY ...................... 106FLUORIDEX DAILY DEFENSE ................................106FLUORIDEX ENHANCED WHITENING ..........................216FLUORIDEX SENSITIVITY RELIEF ........................... 106, 216fluorometholone ................122, 143FLUOROPLEX .......................261fluorouracil ....................... 261, 268fluoxetine hcl .............................184fluoxetine hcl (pmdd) ........ 184, 216fluphenazine decanoate .............184fluphenazine hcl ................ 184, 185FLURA-DROPS ......................106flurandrenolide ......... 143, 216, 261flurazepam hcl ...................... 59, 77flurbiprofen ........... 16, 20, 143, 166flurbiprofen sodium .. 122, 247, 253flutamide ................................... 216fluticasone propionate...............11, 14, 100, 127, 143, 261fluticasone-salmeterol.............................11, 100, 143, 157fluvastatin sodium .......................29fluvastatin sodium er ...........29, 216fluvoxamine maleate ................. 185fluvoxamine maleate er .............185FML ................................. 122, 143FML FORTE ...................122, 143FOCALIN XR ..... 59, 77, 167, 185folbee .....................................7, 198folic acid ........................... 4, 7, 198fondaparinux sodium.................................4, 40, 247, 253FORADIL AEROLIZER.............................11, 100, 143, 157FORTEO ................... 92, 114, 167FORTICAL ............... 92, 114, 167FOSAMAX PLUS D . 92, 115, 167fosamprenavir calcium20, 128, 216fosinopril sodium ........................ 40


279

fosinopril sodium-hctz ................ 40FOSRENOL...................7, 29, 49, 115, 167, 198FRAGMIN .............4, 40, 237, 247FREESTYLE INSULINX TEST ........................................ 200FREESTYLE LANCETS .......200FREESTYLE LITE TEST .....200FREESTYLE PRECISION NEO TEST .............................. 200FREESTYLE TEST ............... 200frovatriptan succinate.........................40, 59, 77, 216, 237furosemide .............29, 40, 100, 157FUZEON ............................20, 128FYCOMPA ..........59, 77, 167, 216gabapentin ...... 59, 77, 78, 128, 237GABITRIL .......................... 59, 78galantamine hydrobromide.......................................59, 78, 185galantamine hydrobromide er.......................................59, 78, 185GamaSTAN S/D....... 106, 128, 143GAMMAGARD.........................20, 59, 78, 143, 167Gammagard S/D Less IgA4, 20, 40, 106, 122, 125, 143, 154, 261Gamunex-C...............4, 20, 40, 143gatifloxacin ............................... 216GATTEX ................. 106, 247, 253GAVILYTE-C .................106, 248GAVILYTE-G .................107, 248GAVILYTE-H .........................107Gazyva.................. 4, 161, 216, 268GEBAUERS PAIN EASE ...... 200GEBAUERS SPRAY AND STRETCH ............................... 216GELNIQUE .......................49, 167gemfibrozil .................................. 29generlac .................. 29, 60, 78, 107GENGRAF .. 20, 49, 107, 248, 253GENOTROPIN...................8, 20, 29, 115, 128, 198GENOTROPIN MINIQUICK...................8, 20, 29, 115, 128, 198GENTAK ................................. 216

gentamicin sulfate .....128, 216, 261GENTLE-LET GP LANCETS ............................... 200GENTLE-LET LANCETS .... 201GENVOYA ........................20, 128Geodon......................................185GIANVI ..................... 92, 185, 261GIAZO ............................. 107, 143GILDAGIA ................................92GILDESS 1.5/30 ........................92GILDESS 1/20 ...........................92GILDESS 24 FE ........................92GILDESS FE 1.5/30 ..................92GILDESS FE 1/20 .....................92GILENYA ............................60, 78GILOTRIF .............................. 216GILPHEX TR ... 14, 100, 128, 143Glassia...................11, 29, 100, 157glatiramer acetate .................60, 78GLATOPA ...........................60, 78GLEOSTINE ...........................216glimepiride ..........................29, 115glipizide ...............................30, 115glipizide er .......................... 29, 115glipizide xl ...........................30, 115glipizide-metformin hcl .......30, 115GLUCAGEN HYPOKIT . 30, 115GLUCAGON EMERGENCY.............................................30, 115GLUCOSOURCE LANCETS...................................................201glyburide ............................. 30, 115glyburide micronized .......... 30, 115glyburide-metformin ........... 30, 115glycopyrrolate ...........................216glycron ...................................... 217GLYDO.....49, 100, 158, 167, 237, 248, 254gnp lancets ................................ 201gnp nicotine mini .............. 185, 245gnp nicotine polacrilex ..... 185, 245gnp ultra com insulin syringe ... 201GOCOVRI ...........................60, 78GOLYTELY ....................107, 248GORDONS UREA ..................217GRALISE ............ 60, 78, 128, 237

GRALISE STARTER...............................60, 78, 128, 237granisetron hcl ..................107, 268GRANIX ................ 4, 20, 217, 268griseofulvin microsize .......128, 261griseofulvin ultramicrosize...........................................128, 261guaifenesin er.....................14, 100, 128, 143, 158guanfacine hcl .............................41guanfacine hcl er .. 60, 78, 167, 185guanidine hcl .. 20, 60, 79, 143, 167GYNAZOLE-1 ............ 49, 92, 129HAEGARDA ............................. 30HAEMOLANCE LOW FLOW LANCETS .................. 201Halaven..................................... 217halobetasol propionate ..... 143, 261HALOG ........................... 143, 261haloperidol ................................186haloperidol decanoate .............. 185haloperidol lactate ....................186HARVONI ............... 107, 129, 143HEATHER ................................ 92Helixate FS................................... 4HEMMOREX-HC .... 41, 107, 143Hemofil M............................ 4, 217heparin (porcine) in nacl.....................................41, 248, 254heparin sodium (porcine).................................4, 41, 217, 248Herceptin...................................217HETLIOZ ............................60, 79HEXALEN ...............................217Hizentra...............................21, 217hm nicotine ................186, 201, 245hm nicotine polacrilex ...... 186, 245HOMATROPAIRE ........ 123, 143homatropine hbr ............... 123, 144HORIZANT .........................60, 79HP Acthar. 16, 21, 60, 79, 144, 167HUMALOG .............................218HUMALOG KWIKPEN ........ 217HUMALOG MIX 50/50 ......... 217HUMALOG MIX 50/50 KWIKPEN ...............................217HUMALOG MIX 50/50 PEN 217


280

HUMALOG MIX 75/25 ......... 217HUMALOG MIX 75/25 KWIKPEN ...............................217HUMALOG MIX 75/25 PEN 217HUMALOG PEN ............217, 218Humate-P.. 4, 21, 41, 144, 248, 254HUMATROPE...................8, 21, 30, 115, 129, 198HUMIRA...............16, 21, 107, 144, 167, 261HUMIRA PEDIATRIC CROHNS START...............16, 21, 107, 144, 167, 261HUMIRA PEN...............16, 21, 107, 144, 167, 261HUMIRA PEN-CROHNS STARTER...............16, 21, 107, 144, 167, 261HUMIRA PEN-PSORIASIS STARTER...............16, 21, 107, 144, 167, 261HUMULIN 70/30 .................... 201HUMULIN 70/30 KWIKPEN 201HUMULIN N ...........................201HUMULIN N KWIKPEN ......201HUMULIN R ...........................201HUMULIN R U-500 (CONCENTRATED) ........30, 115HUMULIN R U-500 KWIKPEN .........................30, 115HYCAMTIN ............................218hydralazine hcl ............................41hydrochlorothiazide ....................41hydrocod polst-cpm polst er.............14, 100, 129, 144, 158, 252hydrocodone-acetaminophen...........................................218, 237hydrocodone-homatropine.....................14, 100, 129, 144, 158hydrocodone-ibuprofen .............238hydrocortisone.............21, 107, 115, 144, 218, 262hydrocortisone ace-pramoxine.............................41, 107, 144, 261hydrocortisone acetate41, 107, 144

hydrocortisone butyrate...........................144, 218, 261, 262hydrocortisone valerate .... 144, 262hydrocortisone-acetic acid ....... 121hydromet ..... 14, 100, 129, 144, 158hydromorphone hcl ...................238hydromorphone hcl er ...............238hydroxychloroquine sulfate.......................16, 21, 145, 168, 262Hydroxyprogesterone Caproate.................41, 49, 92, 115, 218, 268hydroxyurea ...................... 262, 268hydroxyzine hcl.......................60, 79, 186, 248, 254hydroxyzine pamoate.......................60, 79, 186, 248, 254HYOPHEN .............................. 218hyoscyamine sulfate .................. 218hyoscyamine sulfate er ..............218hyosyne ......................................218HYPERSAL .............................218Hyqvia.........................................21HY-VEE LANCETS ...............201hy-vee thin lancets .................... 201Ibandronate Sodium.............................92, 115, 168, 218ibandronate sodium .... 92, 115, 168IBRANCE ................................218IBUDONE ................................238ibuprofen ...................145, 168, 238ICLUSIG ................................. 218Idelvion......................................... 4IDHIFA ....................................218Ilaris.............. 21, 30, 121, 145, 168Ilaris (150mg Delivered).......................21, 30, 121, 145, 168ILEVRO ...123, 145, 238, 248, 254ILOTYCIN ...................... 123, 129imatinib mesylate ...................... 218IMBRUVICA .. 4, 5, 161, 218, 268Imfinzi.......................................218imipramine hcl .................... 50, 186imipramine pamoate ................. 186imiquimod ......... 129, 145, 262, 268IMLYGIC ........................262, 268IMPAVIDO ..................... 129, 262INATAL ADVANCE ..............246

INCRELEX ................. 60, 79, 115INCRUSE ELLIPTA.............................11, 100, 145, 158indapamide ........................... 30, 41INDOCIN ...................30, 145, 168indomethacin ...............30, 145, 168indomethacin er .......... 30, 145, 168Inflectra.16, 21, 107, 145, 168, 262INGREZZA ................. 60, 79, 168INLYTA ...................................218insulin syringe ...........................201insulin syringe/needle ............... 201INTELENCE .....................21, 129INTRAROSA.......................50, 92, 115, 155, 238INTROL ...................................218Intron A.....107, 129, 145, 262, 268INTROVALE ............................ 92Invega Sustenna........................ 186Invega Trinza............................ 186INVIRASE .........................21, 129INVOKAMET ...................30, 116INVOKAMET XR ............ 30, 116INVOKANA ...................... 30, 116ipratropium bromide.......11, 14, 100, 129, 145, 158, 252ipratropium-albuterol . 11, 100, 158IPRIVASK .............5, 41, 248, 254irbesartan ....................................41irbesartan-hydrochlorothiazide ..41IRESSA ....................................218ISENTRESS ...................... 21, 129ISENTRESS HD ............... 21, 129isometheptene-dichloral-apap .. 219isoniazid ....................................129ISOPTO CARBACHOL ........ 123ISOPTO HYOSCINE .............219ISORDIL TITRADOSE ...41, 238isosorbide dinitrate .............41, 238isosorbide dinitrate er .........41, 238isosorbide mononitrate ....... 41, 238isosorbide mononitrate er ...41, 238isradipine .................................... 41Istodax...............................262, 268itraconazole .............................. 219ivermectin ..................107, 129, 219Ixempra Kit...............................219


281

Ixinity............................................5JADENU ...................... 5, 233, 248JADENU SPRINKLE .5, 233, 248JAKAFI ............................... 5, 268JANTOVEN .......................... 5, 41JARDIANCE .....................30, 116JENCYCLA ...............................92Jevtana...................................... 219JOLESSA ...................................92JOLIVETTE ............................. 92JUBLIA ....................129, 145, 262JULEBER ..................................92JULUCA ............................ 21, 129JUNEL 1.5/30 ............................ 92JUNEL 1/20 ............................... 92JUNEL FE 1.5/30 ...................... 92JUNEL FE 1/20 ......................... 92JUNEL FE 24 ............................ 92JUXTAPID ................................ 30K.B.G.L IN TERODERM ......219Kadcyla..................................... 219KADIAN .................................. 238KAITLIB FE ............................. 93KALETRA .........................21, 129KALYDECO . 11, 30, 31, 100, 158KANUMA ..................................31KARIGEL ............................... 219KARIGEL-N ........................... 219KARIVA .................................... 93KELNOR 1/35 ...........................93KENALOG ..16, 21, 116, 145, 168KETEK .................................... 219ketoconazole ......129, 145, 219, 262KETODAN ...................... 145, 262ketoprofen ................. 145, 168, 238ketoprofen er .........16, 22, 145, 168ketorolac tromethamine...................123, 145, 238, 248, 254ketotifen fumarate...........................123, 145, 155, 252KEVEYIS .............. 31, 60, 79, 168KEVZARA .......... 17, 22, 145, 168KIMIDESS ................................ 93KINERET ............17, 22, 145, 168kinney lancets ............................201kinney thin lancets .................... 201kinray insulin syringe ............... 201

KIONEX .................................... 31KISQALI 200 DOSE .............. 219KISQALI 400 DOSE .............. 219KISQALI 600 DOSE .............. 219KLOR-CON M15 ......................31Koate-DVI.................................... 5Kogenate FS..........................5, 219Kogenate FS Bio-Set.................... 5KORLYM ..........................31, 116Kovaltry........................................ 5kp clotrimazole ..........129, 145, 262K-PHOS ................................... 219K-PHOS NO 2 ......................... 219Krystexxa....................31, 145, 168KURVELO ................................ 93KUVAN ......................................31KYLEENA .................................93KYNAMRO ...............................31labetalol hcl ................................ 42lactulose ..................31, 60, 79, 107lactulose encephalopathy.................................31, 60, 79, 107LAMISIL ................. 129, 146, 262LAMISIL SPRAY ...................219lamivudine ...22, 107, 129, 146, 219lamivudine-zidovudine ........22, 130lamotrigine.................61, 79, 80, 168, 169, 187lamotrigine er ....................... 61, 79lamotrigine odt ......61, 79, 168, 186lamotrigine starter kit-blue...............................61, 80, 169, 187lamotrigine starter kit-green...............................61, 80, 169, 187lamotrigine starter kit-orange...............................61, 80, 169, 187lamotrigine titration...............................62, 80, 169, 187lancets ....................................... 201lancets thin ................................201LANOXIN ......................... 42, 219lansoprazole ......................108, 146lanthanum carbonate...........8, 31, 50, 116, 169, 198, 219LARIN 1.5/30 ............................ 93LARIN 1/20 ............................... 93LARIN 24 FE ............................ 93

LARIN FE 1.5/30 .............. 93, 219LARIN FE 1/20 ................. 93, 219Lartruvo................ 17, 22, 146, 268LASTACAFT .. 123, 146, 155, 252latanoprost ................................123LATRIX ...................................219LATUDA ......................... 187, 219lavare wound wash ................... 201LAYOLIS FE ............................ 93LEENA .......................................93leflunomide ........... 17, 22, 146, 169LENVIMA 10 MG DAILY DOSE ....................................... 219LENVIMA 14 MG DAILY DOSE ....................................... 220LENVIMA 20 MG DAILY DOSE ....................................... 220LENVIMA 24 MG DAILY DOSE ....................................... 220LESSINA ................................... 93LETAIRIS ........... 11, 42, 100, 158letrozole .............................. 93, 268leucovorin calcium ....5, 8, 198, 233LEUKERAN ........................5, 268Leukine..................................... 220Leuprolide Acetate......50, 116, 268levalbuterol hcl ........... 11, 100, 158levalbuterol tartrate.............................11, 100, 158, 220LEVATOL .................................42levetiracetam .................62, 80, 169levetiracetam er .................... 62, 80levobunolol hcl ..........................123levocarnitine ................. 8, 198, 201levocetirizine dihydrochloride.......14, 31, 100, 130, 146, 252, 262levofloxacin ...............................220LEVONEST ...............................93levonorgest-eth estrad 91-day.............................................93, 220levonorgestrel ..................... 93, 220levonorgestrel-ethinyl estrad.............................................93, 220levonorg-eth estrad triphasic.............................................93, 220LEVORA 0.15/30 (28) .............. 93LEVO-T ................................... 116


282

levothyroxine sodium ................ 116LEVOXYL ...............................116LEXIVA .............................22, 130lidocaine62, 80, 101, 130, 158, 220, 238, 248, 254, 262lidocaine hcl50, 101, 158, 161, 169, 238, 248, 249, 254, 262lidocaine hcl (pf) ...............248, 254lidocaine viscous ...............249, 254lidocaine-prilocaine ..........249, 254lidopin ....... 161, 238, 249, 254, 262LIDOPROFEN ........................220LIFESCAN UNISTIK II LANCETS ............................... 201lindane .............................. 130, 262linezolid .....................................220LINZESS ................................. 108liothyronine sodium .......... 116, 249lisinopril ......................................42lisinopril-hydrochlorothiazide ....42lite touch lancets ....................... 201lithium ....................................... 188lithium carbonate ......................188lithium carbonate er ................. 188LIVALO .....................................31LO LOESTRIN FE ...................93lofene .........................................220LOKARA .................................220LOMEDIA 24 FE ..............93, 220lomustine ...................................220longs lancets thin ...................... 201LONSURF ....................... 108, 268loperamide hcl .......................... 108lopinavir-ritonavir ...... 22, 130, 220lorazepam ................................. 188LORAZEPAM INTENSOL ...188LORCET ................................. 239LORCET HD .......................... 239LORCET PLUS ...................... 239LORTAB ................................. 239LORYNA ................... 93, 188, 262losartan potassium ......................42losartan potassium-hctz .............. 42LOTEMAX ......................123, 146lovastatin .....................................31

LOW-OGESTREL ................... 93loxapine succinate .....................188LOZI-FLUR ............................ 220Lucentis.............5, 31, 42, 116, 123LUFYLLIN ..............................220LUMIGAN ...............................123Lumizyme............. 31, 42, 101, 158LUPRON ................................. 220Lupron Depot (1-Month).............................5, 42, 50, 93, 268Lupron Depot (3-Month).............................5, 42, 50, 93, 268Lupron Depot (4-Month).... 50, 269Lupron Depot (6-Month).... 50, 269Lupron Depot-Ped (1-Month)...116Lupron Depot-Ped (3-Month)...116LUTERA ....................................93LUZU ............... 130, 146, 220, 263LYNPARZA .............. 93, 220, 269LYRICA ...........31, 32, 62, 81, 116LYRICA CR.................31, 62, 81, 116, 130, 239LYSODREN .................... 116, 269LYZA ................................. 93, 220Macugen....................................123magdelay .....................................32Makena......................................246malathion .......................... 130, 263maprotiline hcl ..........................188margesic ............................188, 239marlissa .......................................93marten-tab .........................188, 239MATULANE ........................... 220MATZIM LA .................... 42, 239MAVYRET ..............108, 130, 146MAXIDEX .......................123, 146me/naphos/mb/hyo1 .................. 220meclizine hcl ........... 42, 62, 81, 108meclofenamate sodium...................................146, 169, 239MEDISENSE THIN LANCETS ............................... 202MEDROL .................. 22, 116, 146medroxyprogesterone acetate.................................42, 50, 93, 116mefenamic acid ................... 94, 239mefloquine hcl ...........................130

megestrol acetate...................8, 22, 32, 130, 198, 221MEIJER LANCETS ...............202MEKINIST ..............................221meloxicam ............. 17, 22, 146, 169melphalan ................................. 221memantine hcl .......62, 81, 188, 221MENEST ........................... 94, 117meperidine hcl ...................221, 239MEPHYTON ...............................5meprobamate ............................ 189mercaptopurine .........................221mesalamine ............... 108, 146, 221MESNEX ............... 42, 50, 94, 269MESTINON ...22, 62, 81, 146, 170metaproterenol sulfate 11, 101, 158metaxalone ................................170metformin hcl ...................... 32, 117metformin hcl er ..................32, 117metformin hcl er (mod)32, 117, 221metformin hcl er (osm) ........32, 117methadone hcl ...................189, 239METHADONE HCL INTENSOL ......................189, 239METHADOSE ................ 189, 239methamphetamine hcl.........................32, 63, 81, 170, 189methazolamide .......................... 123methenamine hippurate .......50, 130methenamine mandelate ..... 50, 130methimazole .............................. 117methitest ..............................94, 117methocarbamol ......................... 170methotrexate ..17, 22, 146, 170, 263methoxsalen rapid .............221, 263methyclothiazide ......................... 32methyldopa ..................................42methyldopa-hydrochlorothiazide ....................42methylergonovine maleate .. 42, 246methylphenidate hcl.......................63, 82, 170, 190, 221methylphenidate hcl er...............................63, 82, 170, 189methylphenidate hcl er (cd)...............................63, 81, 170, 189


283

methylphenidate hcl er (la).......................63, 81, 170, 189, 221methylprednisolone .....22, 117, 146methylprednisolone sodium succ.....................................22, 117, 146methyltestosterone ...... 94, 117, 221metipranolol ..............................123metoclopramide hcl .....32, 108, 117metolazone ............................ 32, 50metoprolol succinate er ...... 42, 239metoprolol tartrate ..............42, 239metoprolol-hydrochlorothiazide . 42metronidazole...............50, 94, 130, 146, 221, 263mexiletine hcl .............................. 42MIACALCIN ............ 94, 117, 170miconazole 3 ................. 50, 94, 130MICROCYN ............................221MICROCYN SKIN AND WOUND ...................................221MICROGESTIN 1.5/30 ............94MICROGESTIN 1/20 ...............94MICROGESTIN 24 FE ............94MICROGESTIN FE 1.5/30 ......94MICROGESTIN FE 1/20 .........94micronized colestipol hcl ............ 32MICROTAINER SAFETY FLOW LANCET .................... 202midodrine hcl .............................. 42MIGERGOT ......... 42, 63, 82, 239miglitol ........................32, 117, 221migragesic ida .......................... 221MIGRANAL ..........42, 63, 82, 239MILLIPRED ............. 22, 117, 146MILLIPRED DP .......22, 117, 146MILLIPRED DP 12-DAY ......221MINITRAN ....................... 43, 240minocycline hcl ......................... 221minoxidil ..................................... 43MIRAPEX ER .....................63, 82MIRCERA .............................5, 50mirtazapine ............................... 190MIRVASO ............... 147, 221, 263misoprostol ............................... 108Mitoxantrone HCl.............................5, 50, 63, 82, 269modafinil ............... 63, 82, 101, 158

MODERIBA ....108, 130, 147, 221moexipril hcl ............................... 43moexipril-hydrochlorothiazide ... 43mometasone furoate.....14, 101, 130, 147, 221, 252, 263MONDOXYNE NL .................222Monoclate-P..........................5, 222MONOJECT CONTROL SYRINGE ................................ 222MONOJECT FILTER ASPIRATOR ...........................202MONOJECT INSULIN SYRINGE ........................ 202, 222MONOJECT PHARMACY TRAY ....................................... 202MONOJECT PISTON SYRINGE ................................ 202MONOJECT SAFETY SYRINGE/SHIELD ........202, 222MONOJECT SYRINGE 202, 222MONOJECT SYRINGE CATH TIP ............................... 202MONOJECT SYRINGE ECC LUER ....................................... 202MONOJECT SYRINGE LUER LOCK .................. 202, 222MONOJECT SYRINGE REG LUER ............................... 202, 222MONOJECT TB SAFETY SYRINGE ................................ 202MONOJECT TB SYRINGE ..202MONOJECT ULTRA COMFORT SYRINGE .......... 202MONOLET LANCETS ..........202MONO-LINYAH ...................... 94MONONESSA ...........................94Mononine..............................5, 222montelukast sodium.11, 12, 14, 101, 130, 147, 158, 252MONUROL ....................... 50, 130MORGIDOX ........................... 222morphine sulfate ............... 240, 241morphine sulfate (concentrate) .240morphine sulfate er ........... 222, 240morphine sulfate er beads .222, 240MOVANTIK ................... 108, 233MOVIPREP .....................108, 249

MOXEZA ................................ 222moxifloxacin hcl ........................222MOZOBIL .....5, 22, 222, 249, 269MULTAQ .................................. 43MULTI COMPLETE .............202multi vitamin/fluoride ... 8, 108, 198multi vitamin/minerals .......... 8, 198multi-vit/fluoride ... 8, 108, 198, 222multi-vit/fluoride/iron...............................8, 108, 198, 222multivitamin/fluoride...............................8, 108, 198, 222multi-vitamin/fluoride ... 8, 108, 198mupirocin ..................130, 147, 263mupirocin calcium .... 130, 147, 263MY WAY ...................................94MYALEPT ............ 17, 22, 32, 147mycophenolate mofetil...............22, 50, 108, 223, 249, 254mycophenolic acid.......................22, 50, 223, 249, 254MYDAYIS ........... 64, 82, 171, 190MYKIDZ IRON FL ............8, 198MYLERAN ..............................223Mylotarg................................... 223mynephrocaps ....................... 8, 198Myobloc........................64, 82, 171MYORISAN ............................ 263MYRBETRIQ ................... 50, 171MYZILRA ................................. 94nabumetone ...........17, 22, 147, 171n-acetyl-l-cysteine .....................202nadolol ................................ 43, 241nadolol-bendroflumethiazide ......43NAFRINSE DAILY ACIDULATED ....................... 223NAFRINSE DAILY/NEUTRAL .................108NAFRINSE WEEKLY ...........223naftifine hcl ....... 130, 147, 223, 263NAFTIN ................... 130, 147, 263Naglazyme.......................... 32, 117naloxone hcl ..............................233naltrexone hcl ........................... 190NAMENDA XR ...........64, 82, 190NAMENDA XR TITRATION PACK ........................... 64, 82, 190


284

naphazoline hcl .........................123napro .........................................223naproxen ................... 147, 171, 241naproxen dr .......................147, 171naproxen sodium .......147, 171, 241naratriptan hcl ........ 43, 64, 82, 241NARCAN ................................. 233NATACYN ...... 123, 130, 147, 155NATAZIA ......................43, 51, 94nateglinide .......................... 32, 117NATPARA .........................32, 117NATURE-THROID ................223NEBUPENT...............12, 23, 101, 131, 147, 158NEBUSAL ............................... 223NECON 0.5/35 (28) ................... 94NECON 1/35 (28) ...................... 94NECON 1/50 (28) ...................... 94NECON 10/11 (28) .................... 94NECON 7/7/7 .............................94nefazodone hcl .......................... 190neomycin sulfate ....... 108, 249, 254neomycin-bacitracin zn-polymyx ............................. 123, 131neomycin-polymyxin-dexameth .223neomycin-polymyxin-gramicidin...........................................123, 131neomycin-polymyxin-hc...........................121, 123, 131, 223NEO-POLYCIN ..............123, 131NEO-POLYCIN HC ...............223NEPHROCAPS QT ............ 8, 198NERLYNX ...............................223NEUAC .................................... 263NEULASTA ...........6, 23, 249, 269NEULASTA DELIVERY KIT ......................... 6, 23, 249, 269NEULASTA ONPRO.................................6, 23, 249, 269NEUPOGEN ..................6, 23, 269NEUPRO ............................. 64, 82NEUTRAGARD ADVANCED ............................223neutral sodium fluoride .............108NEVANAC...................123, 147, 241, 249, 255nevirapine ........................... 23, 131

nevirapine er ...............23, 131, 223NEXAVAR .............................. 223NEXIUM ..................................108NEXIUM 24HR ...............108, 203NEXT CHOICE ...................... 223NEXT CHOICE ONE DOSE .. 94niacin er ...................................... 32niacin er (antihyperlipidemic).............................................32, 223NIACOR .................................... 32nicardipine hcl .................... 43, 241NICORELIEF ................. 190, 245nicotine ............................. 190, 245nicotine mini ..................... 190, 245nicotine polacrilex ............ 190, 245nicotine step 1 ................... 190, 245nicotine step 2 ................... 190, 245nicotine step 3 ................... 190, 245NICOTROL .....................191, 245NICOTROL NS .............. 191, 245NIFEDIAC CC ........................223NIFEDICAL XL ............... 43, 241nifedipine ............................ 43, 241nifedipine er ........................ 43, 241nifedipine er osmotic release.............................................43, 241NIKKI ........................ 94, 191, 263nilutamide ................................. 223nimodipine .............. 43, 64, 82, 161NINLARO ........................... 6, 269nisoldipine er .............................. 43NITRO-BID .......................43, 241NITRO-DUR ..................... 43, 241nitrofurantoin ............................223nitrofurantoin macrocrystal ......223nitrofurantoin monohyd macro .223nitroglycerin ....................... 43, 241NITYR ....................................... 32nizatidine ...................108, 109, 147NODOLOR ..............................224NORA-BE ..................................94NORDITROPIN FLEXPRO...................8, 23, 33, 117, 131, 198norepinephrine bitartrate ........... 43norepinephrine-dextrose .....43, 224

norepinephrine-sodium chloride.............................................43, 224norethin ace-eth estrad-fe ...94, 224norethindrone ............................. 94norethindrone acetate.................................43, 51, 94, 117norethindrone acet-ethinyl est.............................................94, 224norethindrone-eth estradiol.............................94, 117, 171, 224norethin-eth estradiol-fe ..... 94, 224norgestimate-eth estradiol .......... 95norgestim-eth estrad triphasic.............................................95, 224norgestrel-ethinyl estradiol ...... 224NORITATE ..................... 147, 263NORLYROC ............................. 95NORPACE CR ..........................44NORTHERA ............................. 44NORTREL 0.5/35 (28) ..............95NORTREL 1/35 (21) .................95NORTREL 1/35 (28) .................95NORTREL 7/7/7 ....................... 95nortriptyline hcl ........................ 191nortuss-ex ..................................224NORVIR ............................ 23, 131Novoeight..................................... 6NOVOLIN 70/30 ..................... 203NOVOLIN 70/30 RELION .... 203NOVOLIN N ........................... 203NOVOLIN N RELION ...........203NOVOLIN R ........................... 203NOVOLIN R RELION ...........203NOVOLOG ............................. 224NOVOLOG FLEXPEN ..........224NOVOLOG MIX 70/30 .......... 224NOVOLOG MIX 70/30 FLEXPEN ................................224NOVOLOG PENFILL ........... 224NovoSeven RT........................6, 44NOXAFIL.....23, 101, 131, 147, 155, 158, 224np thyroid ..................................224Nplate........................6, 23, 44, 147NUCALA...............12, 44, 101, 147, 158, 252NUCYNTA .............................. 241


285

NUCYNTA ER.........................33, 64, 82, 117, 241NUEDEXTA ............................191NUPLAZID ................. 64, 82, 191NUTRESTORE .......109, 249, 255NUTROPIN AQ NUSPIN 10...................8, 23, 33, 117, 131, 198NUTROPIN AQ NUSPIN 20...................8, 23, 33, 117, 131, 199NUTROPIN AQ NUSPIN 5...................8, 23, 33, 118, 131, 199NUVARING .............................. 95Nuwiq........................................... 6NYAMYC ................ 131, 147, 263nystatin...........131, 147, 148, 155, 224, 263nystatin-triamcinolone...................................131, 148, 263NYSTOP .................. 132, 148, 263Obizur....................... 6, 23, 44, 148OBSTETRIX EC .................... 246OCALIVA ............................... 109OCELLA ................................... 95Ocrevus................................. 64, 83Octagam....................6, 23, 44, 148octreotide acetate.........33, 64, 83, 109, 118, 171, 269ODEFSEY ......................... 23, 132ODOMZO ........................263, 269OFEV ......................... 12, 101, 158ofloxacin ........................... 121, 224OGESTREL .............................. 95OLANZapine............................ 191olanzapine .................................191olanzapine-fluoxetine hcl ..........191OLEPTRO ...............................191olopatadine hcl...................123, 148, 155, 224, 252omeprazole ........................109, 148OMEPRAZOLE+SYRSPEND SF ALKA ............................. 224omeprazole-sodium bicarbonate.............................44, 109, 148, 224OMNARIS...............12, 14, 101, 132, 148, 252

OMNITROPE...................8, 24, 33, 118, 132, 199Oncaspar............................... 6, 269ondansetron ...................... 109, 269ondansetron hcl 109, 249, 255, 269ONETOUCH CLUB LANCETS FINE PT ...............203ONETOUCH FINEPOINT LANCETS ............................... 203ONETOUCH LANCETS ....... 203ONETOUCH ULTRASOFT LANCETS ............................... 203ONFI ............................ 64, 83, 225OPANA ER ..............................241Opdivo...................................... 225opium ........................................ 225OPSUMIT ....12, 44, 101, 159, 225ORALAIR...............12, 14, 101, 132, 148, 252ORALONE .............................. 155Orencia..........17, 24, 148, 171, 263ORENCIA ... 17, 24, 148, 171, 263ORENCIA CLICKJECT.......................17, 24, 148, 171, 263ORENITRAM ..... 12, 44, 101, 159ORFADIN ..................................33ORKAMBI .......... 12, 33, 101, 159orphenadrine citrate er .............171orphenadrine-aspirin-caffeine ..171ORSYTHIA ............................... 95OSCION CLEANSER ............225oseltamivir phosphate .......132, 225OSMOPREP ....................109, 249OSPHENA ... 51, 95, 118, 155, 241OTEZLA ..........148, 171, 263, 264otic care .................................... 225OTIPRIO ......................... 121, 132oxandrolone ................................ 33oxaprozin .............. 17, 24, 148, 171oxazepam ...................... 64, 83, 191oxcarbazepine ................. 64, 65, 83oxiconazole nitrate...........................132, 148, 225, 264OXISTAT ................ 132, 148, 264OXSORALEN ......................... 225OXTELLAR XR ................. 65, 83oxybutynin chloride .............51, 171

oxybutynin chloride er ........ 51, 171oxycodone hcl ................... 241, 242oxycodone hcl er ............... 225, 241oxycodone-acetaminophen225, 242oxycodone-aspirin .....................242oxycodone-ibuprofen 242, 249, 255OXYCONTIN ................. 225, 242oxymorphone hcl .......................242oxymorphone hcl er .................. 242OXYTROL ........................ 51, 171PACERONE ..............................44PACLitaxel............................... 225paliperidone er ..................192, 225Pamidronate Disodium....... 33, 269PANCREAZE ................. 109, 225PANDEL ..........................148, 264PANRETIN . 17, 24, 148, 264, 269pantoprazole sodium .................225paregoric ...................................109paricalcitol ..................51, 118, 226PAROEX ................. 109, 132, 155paromomycin sulfate .........109, 132paroxetine hcl ........................... 192paroxetine hcl er ....................... 192PASER ............. 101, 132, 148, 159PAXIL ......................................192PCE .......................................... 226peg 3350/electrolytes ........ 109, 249peg 3350-kcl-na bicarb-nacl...........................................109, 249peg-3350/electrolytes ........109, 249PEGANONE ........65, 83, 172, 226PEGASYS ................109, 132, 148PEGASYS PROCLICK...................................109, 132, 148PEGINTRON .......... 109, 132, 148PEG-INTRON .........109, 132, 149PEG-INTRON REDIPEN...................................109, 132, 148PEG-INTRON REDIPEN PAK 4 .......................109, 132, 148penicillin g procaine ................. 226penicillin v potassium ............... 226PENNSAID ..............149, 172, 226PENTASA ........................109, 149pentoxifylline er .......... 44, 172, 242


286

PERFOROMIST.............................12, 101, 149, 159perindopril erbumine .......... 44, 242PERIOGARD ..........110, 132, 155Perjeta....................................... 226permethrin .........................132, 264perphenazine .............................192PERTZYE ............................... 110PHENADOZ ....110, 242, 250, 255phenazopyridine hcl ............51, 242phenelzine sulfate ......................192PHENERGAN .110, 242, 250, 255phenobarbital ............................226PHENOHYTRO ..................... 226phenoxybenzamine hcl 44, 226, 269phenyleph-promethazine-cod.............14, 101, 132, 149, 159, 226phenylephrine-guaifenesin ........226phenytoin ...............................65, 84PHENYTOIN INFATABS .65, 84phenytoin sodium extended ...65, 84PHILITH ................................... 95PHOS-FLUR ........................... 226PHOSLYRA...................8, 33, 51, 118, 172, 199PHOSPHA 250 NEUTRAL ..... 33PHOSPHASAL ....................... 226PHOSPHOLINE IODIDE ..... 124PICATO ...................................264pilocarpine hcl17, 24, 110, 124, 149, 250, 255, 270pimozide ........65, 84, 172, 192, 226PIMTREA ......................... 95, 226pindolol ....................................... 44pioglitazone hcl ...................33, 118pioglitazone hcl-glimepiride.............................................33, 118pioglitazone hcl-metformin hcl.............................................33, 118PIRMELLA 1/35 .......................95PIRMELLA 7/7/7 ..............95, 226piroxicam .............. 17, 24, 149, 172pnv folic acid + iron ................. 246podofilox ................... 132, 149, 264POLYCIN ........................124, 132polyethylene glycol 3350 .......... 110

polymyxin b-trimethoprim...........................124, 133, 149, 155POLY-VI-FLOR ......... 9, 110, 199polyvinyl alcohol .......................124POMALYST ............................226PORTIA-28 ............................... 95PORTRAZZA . 101, 159, 264, 270pot bicarb-pot chloride ............... 33potassium bicarbonate ........33, 203potassium chloride ......34, 203, 226potassium chloride crys er ..........33potassium chloride er ......... 33, 226potassium citrate er .................. 226potassium citrate monohydrate .203PRALUENT ........................ 34, 44pramcort ............................. 44, 110pramipexole dihydrochloride65, 84pramipexole dihydrochloride er.......................................65, 84, 226PRAMOSONE ................ 149, 264PRAMOSONE E .............149, 264PRASCION ............................. 226prasugrel hcl.................6, 44, 227, 242, 250, 255pravastatin sodium ......................34prazosin hcl .................................44PRECISION SURE-DOSE SYRINGE ................................ 203PRECISION THIN LANCETS ............................... 203PRECISION THINS GP LANCETS ............................... 203PRECISION ULTRA LANCET ..................................203PRECISION XTRA BLOOD GLUCOSE ...............................203PRED MILD ....................124, 149PRED-G ................................... 227PRED-G S.O.P. ....................... 227prednicarbate ....................149, 264prednisolone ............... 24, 118, 149prednisolone acetate .........124, 149prednisolone sodium phosphate.....................24, 118, 124, 149, 227prednisone .................................227PREDNISONE INTENSOL .. 227preferred plus lancets colored .. 203

preferred plus lancets thin ........ 203PREMARIN 51, 95, 118, 155, 242premium lidocaine .................... 227PREMPHASE ..... 51, 95, 118, 155PREMPRO .......... 51, 95, 118, 155prenatabs fa .............................. 246PRENATABS RX ................... 246prenatal .....................................246prenatal 19 ........................203, 246PREPOPIK ......................110, 250PREVACID SOLUTAB . 110, 149PREVIFEM ............................... 95Prevymis............. 24, 133, 250, 255PREVYMIS ....... 24, 133, 250, 255PREZCOBIX .....................24, 133PREZISTA ........................ 24, 133PRIFTIN ..........101, 133, 149, 159PRILOSEC ......................110, 149primaquine phosphate .............. 133primidone ..................................227PRIMSOL ................................227Privigen.....................6, 24, 44, 149PROAIR HFA ........... 12, 101, 159PROAIR RESPICLICK.....................................12, 101, 159probenecid .. 34, 149, 172, 250, 266PROBUPHINE IMPLANT KIT ........................................... 192prochlorperazine .......................110prochlorperazine edisylate ....... 110prochlorperazine maleate .........110PROCRIT ......................6, 51, 270PROCTOFOAM HC ........ 44, 110PROCTO-PAK ............... 149, 264PROCTOSOL HC .. 149, 227, 264PROCTOZONE-HC...................................149, 227, 264Profilnine...................................... 6Profilnine SD................................ 6progesterone ........... 44, 51, 95, 118progesterone micronized .....95, 227PROGLYCEM ..34, 110, 118, 270Proleukin...................................227Prolia...........................95, 118, 172PROMACTA...................6, 24, 44, 110, 133, 150


287

promethazine hcl...................110, 227, 242, 250, 255promethazine vc plain.....................14, 102, 133, 150, 252promethazine vc/codeine.....................14, 102, 133, 150, 159promethazine-codeine.............15, 102, 133, 150, 159, 252promethazine-dm.............15, 102, 133, 150, 159, 252promethazine-phenylephrine.............15, 102, 133, 150, 227, 252PROMETHEGAN...........................110, 242, 250, 255propafenone hcl .......................... 44propafenone hcl er ......................44proparacaine hcl .......124, 250, 255propranolol hcl...................44, 45, 66, 84, 172, 242propranolol hcl er ...44, 66, 84, 242propranolol-hctz ......................... 45propylthiouracil ........................ 118PROTONIX .............................227protriptyline hcl ........................ 192PROVENTIL HFA ... 12, 102, 159pseudoephedrine hcl.............................15, 102, 133, 150psorcon ............................. 150, 264PSS SELECT GP LANCETS 203PSS SELECT SAFETY LANCETS ............................... 203PULMICORT FLEXHALER.............................12, 102, 150, 159PULMOSAL ............................227PULMOZYME ... 12, 34, 102, 159PURIXAN ................................227PYLERA ..................110, 133, 150pyrazinamide .............................227pyridostigmine bromide.........................24, 66, 84, 150, 172pyridostigmine bromide er.................24, 66, 84, 150, 172, 227qc nicotine polacrilex ................203QNASL .......15, 102, 133, 150, 252QNASL CHILDRENS.....................15, 102, 133, 150, 252QUASENSE ...............................95

quetiapine fumarate .................. 193quetiapine fumarate er ......192, 227QUILLICHEW ER...............................66, 84, 172, 193QUILLIVANT XR...............................66, 84, 172, 193quinapril hcl ................................45quinapril-hydrochlorothiazide ....45quinaretic ..................................227quinidine gluconate er ........ 45, 250quinidine sulfate ..................45, 250quinidine sulfate er ............. 45, 250quinine sulfate ...........................227QVAR .................12, 102, 150, 159QVAR REDIHALER.............................12, 102, 150, 159ra mini nicotine .................193, 245ra nicotine .........................193, 245ra nicotine polacrilex ........193, 245rabeprazole sodium .. 110, 150, 227Radicava........................66, 85, 172raloxifene hcl.....................95, 118, 172, 228, 270ramipril ....................................... 45RANEXA ........................... 45, 242ranitidine hcl ...............45, 110, 150RAPAFLO ......................... 51, 270RAPAMUNE...............24, 51, 102, 159, 250, 255rasagiline mesylate ....... 66, 85, 228RAVICTI ................................... 34REA LO 40 .............................. 228reality lancets ............................203reality trigger lancets ............... 204REBETOL ............... 110, 133, 150REBIF .................................. 66, 85REBIF REBIDOSE ............ 66, 85REBIF REBIDOSE TITRATION PACK ........... 66, 85REBIF TITRATION PACK...............................................66, 85RECLIPSEN ............................. 95Recombinate................................. 6REGRANEX.................34, 66, 85, 118, 228, 264RELENZA DISKHALER ...... 133RELISTOR ......................110, 233

REMEVEN ..............................228Remicade...............17, 24, 110, 150, 172, 264REMODULIN ..... 12, 45, 102, 159RENAGEL...................9, 34, 51, 118, 172, 199RENAL ................................ 9, 199Renflexis...............17, 24, 111, 150, 172, 264repaglinide ..................34, 118, 228repaglinide-metformin hcl.....................................34, 118, 228REPATHA ...........................34, 45REPATHA PUSHTRONEX SYSTEM ..............................34, 45REPATHA SURECLICK .. 34, 45REPREXAIN ...........................242RESCRIPTOR .................. 24, 133RESCULA ............................... 124reserpine ..................................... 45RESTASIS ............... 124, 150, 155RETIN-A MICRO PUMP ......264REVATIO ............12, 45, 102, 159REVLIMID ............................. 228rexaphenac ................................228REXULTI ................................ 193REYATAZ .........................24, 133RHEUMATREX.......................17, 25, 150, 172, 264Rhophylac......... 6, 25, 45, 150, 246RiaSTAP....................................... 6RIBASPHERE ........ 111, 133, 150ribavirin ............ 111, 133, 150, 151rifabutin .................................... 228RIFAMATE .............................228rifampin .....................................228RIFATER ................................ 228riluzole .......................... 66, 85, 172rimantadine hcl .........................133RIOMET ............................34, 118risedronate sodium.......................34, 95, 119, 173, 228RisperDAL Consta....................193risperidone ........................193, 194RISPERIDONE M-TAB 193, 228Rituxan..........17, 25, 151, 173, 270Rituxan Hycela......................... 228


288

rivastigmine .......... 67, 85, 194, 228rivastigmine tartrate ..... 66, 85, 194Rixubis..................................6, 228rizatriptan benzoate 45, 67, 85, 242ropinirole hcl ........................ 67, 85ropinirole hcl er ....................67, 85ropivacaine hcl-nacl ................. 228ROSADAN .......................151, 264ROSANIL CLEANSER ......... 228rosuvastatin calcium ...........34, 228ROXICET ................................242ROZEREM ..........................67, 85RUBRACA .............................. 228Ruconest............... 25, 34, 252, 264RYDAPT ..................................228SABRIL ....................... 67, 85, 173SAIZEN ... 9, 25, 34, 119, 133, 199SAIZEN CLICK.EASY...................9, 25, 34, 119, 133, 199SAIZENPREP...................9, 25, 34, 119, 134, 199salsalate ................ 17, 25, 151, 173SAMSCA ........................... 34, 119SANCUSO ....................... 111, 270SANDIMMUNE.......................25, 51, 111, 250, 255SandoSTATIN LAR Depot.........34, 67, 85, 111, 119, 173, 270SANTYL .......................... 161, 264SAPHRIS ................................. 194SAVELLA ............... 151, 173, 242SAVELLA TITRATION PACK ....................... 151, 173, 243sb lancets thin ........................... 204sb lancets ultra thin .................. 204scopolamine .............................. 111selegiline hcl ......................... 67, 85selenium sulfide ........ 151, 228, 264selenium sulf-pyrithione-urea...........................................151, 264SELRX ..................... 151, 228, 264SELZENTRY .................... 25, 134SEMPREX-D.....................15, 102, 134, 151, 252SENSIPAR .................51, 119, 250

SEREVENT DISKUS.............................12, 102, 151, 159SEROPHENE ............................96SEROQUEL XR ..................... 194SEROSTIM...................9, 25, 34, 119, 134, 199sertraline hcl .............................194SETLAKIN ................................96sevelamer carbonate...........9, 34, 51, 119, 173, 199, 228sf ................................................111sf 5000 plus ............................... 111SFROWASA ....................111, 151SHAROBEL .............................. 96SIGNIFOR ...............................119sildenafil citrate .... 12, 45, 102, 159SILIQ ....................................... 264silver sulfadiazine...........................134, 161, 250, 255SIMBRINZA ........................... 124SIMCOR ....................................35SIMPONI .............17, 25, 151, 173Simponi Aria...............17, 25, 151, 173, 229, 265simvastatin .................................. 35sirolimus.......25, 51, 102, 159, 229, 250, 255SIRTURO ........ 102, 134, 151, 160SIVEXTRO ............................. 229SKLICE ................................... 134sm nicotine ........................ 194, 245sm nicotine polacrilex .......194, 245sodium chloride ........................ 229sodium fluoride ................. 111, 229sodium polystyrene sulfonate.............................................35, 229SOLARAZE ............................ 265Soliris...6, 25, 35, 45, 51, 67, 86, 151, 173SOLTAMOX ..................... 96, 270SOLU-CORTEF ....... 25, 119, 151Somatuline Depot.................35, 67, 86, 119, 173, 270SOMAVERT . 35, 67, 86, 119, 173SOOLANTRA ................. 151, 265SORINE ..................................... 45sotalol hcl ....................................45

sotalol hcl (af) .............................45SOTYLIZE ................................45SOVALDI ........ 111, 134, 151, 229spinosad ............................ 134, 265Spinraza................................ 67, 86SPIRIVA RESPIMAT.............................13, 102, 151, 160spironolactone ...... 35, 45, 111, 136spironolactone-hctz ...............35, 45SPORANOX ............................229SPRINTEC 28 ........................... 96SPRITAM ....................67, 86, 173SPRIX ...................... 243, 250, 255SPRYCEL ................................229SPS ............................................. 35sr nicotine ................................. 204SRONYX ................................... 96SSD ................... 134, 161, 250, 255stavudine ............................. 25, 134Stelara............... 111, 151, 173, 265STELARA ....... 111, 151, 173, 265STIMATE ....................................6STIVARGA ............................. 229STRENSIQ ................................ 35STRIANT ...........................96, 119STRIBILD ......................... 25, 134STRIVERDI RESPIMAT.............................13, 102, 151, 160SUBOXONE ....................194, 195sucralfate .......................... 111, 152sulfacetamide sodium...................124, 134, 152, 155, 265sulfacetamide sodium (acne) .... 265sulfacetamide sodium-sulfur .....229sulfacetamide-prednisolone...........................................124, 152sulfadiazine ............................... 229sulfamethoxazole-trimethoprim 229SULFAMYLON...........................134, 161, 250, 255sulfasalazine...............17, 25, 111, 152, 173, 229SULFATRIM PEDIATRIC ...229sulindac .............................152, 173sumatriptan ............. 46, 67, 86, 243


289

sumatriptan succinate.................................46, 67, 86, 243sumatriptan succinate refill.................................46, 67, 86, 243super thin lancets ......................204Supprelin LA............................ 119SUPRAX .................................. 229SUPREP BOWEL PREP KIT...........................................111, 250sure comfort insulin syringe ..... 204SURELITE LANCETS .......... 204SUSTOL ...........................111, 270SUTENT .................................. 229sw nicotine polacrilex...................................195, 245, 246SYEDA .....................................229SYLATRON .................... 265, 270SYMBICORT ....13, 102, 152, 160SYMLINPEN 120 ............. 35, 119SYMLINPEN 60 ............... 35, 119SYMPROIC .....................111, 233Synagis..............102, 134, 152, 160SYNALAR (CREAM) .... 152, 265SYNALAR (OINTMENT)...........................................152, 265SYNAREL ......................... 96, 119SYNDROS ... 25, 35, 111, 134, 270SYNJARDY .......................35, 119SYNJARDY XR ................ 35, 119Synribo..................................7, 270TABLOID ............................7, 270TACLONEX ............................265tacrolimus25, 51, 111, 152, 229, 250, 255, 265TAFINLAR ............................. 229TAGRISSO ..............................229TALTZ .....................152, 174, 265tamoxifen citrate ................. 96, 270tamsulosin hcl ..................... 51, 270TARCEVA ...............................229TARGRETIN .................. 265, 270TARINA FE 1/20 ...................... 96TASIGNA ................................ 230tazarotene ................................. 265TAZORAC .............................. 265TAZTIA XT ...................... 46, 243tb syringe 1 ml .......................... 204

Tecentriq................................... 230TECFIDERA .......................67, 86TECHLITE LANCETS ..........204TEKTURNA ..............................46TEKTURNA HCT .................... 46telmisartan .................. 46, 230, 243telmisartan-hctz .................. 46, 230temazepam ............................ 68, 86Temodar....................................230temozolomide ............................ 230TENCON ......................... 195, 243tenofovir disoproxil fumarate.....................25, 111, 134, 152, 230terazosin hcl ..................46, 51, 270terbinafine hcl ...........................230terbutaline sulfate ....... 13, 102, 160terconazole ....................51, 96, 134TERSI .............................. 152, 265TESTOPEL ....................... 96, 120testosterone ................. 96, 120, 230testosterone cypionate .........96, 120testosterone enanthate ........ 96, 120tetrabenazine .68, 86, 174, 195, 230tetracycline hcl ..........................230tgt nicotine ................ 195, 204, 246tgt nicotine polacrilex ....... 195, 246tgt nicotine step one .......... 195, 246tgt nicotine step three ........195, 246tgt nicotine step two .......... 195, 246THALITONE .......................... 230THALOMID ........................7, 270THEO-24 ........... 13, 103, 152, 160THEOCHRON ..13, 103, 152, 160theophylline .........13, 103, 152, 160theophylline er .... 13, 103, 152, 160THINLETS GP LANCETS ... 204THINLETS LANCET ............ 204thioridazine hcl ......................... 195thiothixene .................................195Thyrogen...................120, 250, 270THYROLAR-1 ........................120THYROLAR-1/2 .....................120THYROLAR-1/4 .....................120THYROLAR-2 ........................120THYROLAR-3 ........................120tiagabine hcl ......................... 68, 86TILIA FE ...........................96, 265

timolol maleate ........... 46, 124, 243TIMOPTIC OCUDOSE .........124tinidazole ...............51, 96, 111, 134TIVICAY ................... 25, 134, 230tizanidine hcl .............................174TOBI PODHALER...............13, 35, 103, 134, 152, 160TOBRADEX ............124, 134, 152tobramycin.......13, 35, 103, 134, 152, 160, 230tobramycin-dexamethasone...................................124, 134, 152TOBREX ................................. 230tolazamide ...........................35, 120tolbutamide ......................... 35, 120tolcapone .......................68, 86, 230tolmetin sodium.......................17, 25, 152, 153, 174tolterodine tartrate ..............51, 174tolterodine tartrate er . 51, 174, 230topco insulin syringe .................204topiramate .46, 47, 68, 87, 243, 244topiramate er .......... 46, 68, 86, 243Torisel................................. 51, 270torsemide ...............................35, 47TOVIAZ .............................52, 174TRACLEER ........ 13, 47, 103, 160tramadol hcl ..............................244tramadol hcl er ......................... 244tramadol hcl er (biphasic) ........ 244tramadol-acetaminophen ..........244trandolapril .........................47, 244trandolapril-verapamil hcl er ..... 47tranexamic acid ...............47, 52, 96tranylcypromine sulfate ............ 195TRAVATAN Z ........................ 124trazodone hcl ............................ 195Treanda..................................... 230TRECATOR ............................134TRELSTAR ...............52, 230, 270TRELSTAR DEPOT .............. 230TRELSTAR LA ...................... 230TRELSTAR MIXJECT ... 52, 270TREMFYA .............................. 265TRESIBA FLEXTOUCH ...... 230tretinoin .............................230, 265tretinoin microsphere ................265


290

tretinoin microsphere pump ......266Tretten...........................................7TREXALL ... 17, 25, 153, 174, 266triamcinolone acetonide15, 103, 134, 153, 155, 230, 252, 266triamterene-hctz ....................35, 47TRIDERM ....................... 153, 266trientine hcl.........35, 68, 87, 111, 174, 231, 233TRIESENCE ... 124, 153, 250, 255TRI-ESTARYLLA ................... 96trifluoperazine hcl .....................195trifluridine .........124, 134, 153, 155TRIGLIDE ................................ 35trihexyphenidyl hcl ................68, 87TRI-LEGEST FE ..............96, 266TRI-LINYAH ............................96TRI-LO-ESTARYLLA ............ 96TRI-LO-MARZIA .................... 96TRI-LO-SPRINTEC .........96, 231TRILYTE ................ 112, 231, 251trimethobenzamide hcl...................................112, 251, 255trimethoprim ....................... 52, 134trimipramine maleate ................195TRINATE ................................ 246TRINESSA (28) .........................96TRINESSA LO ..........................96TRINTELLIX ......................... 196TRI-PREVIFEM .......................96Triptodur................................... 120TRI-SPRINTEC ........................96TRIUMEQ .........................26, 135tri-vit/fluoride/iron ........9, 112, 199tri-vitamin/fluoride ....... 9, 112, 199TRIVORA (28) ..........................96TROKENDI XR.........................47, 68, 87, 231, 244tropicamide ............................... 124trospium chloride ................52, 174trospium chloride er ........... 52, 174TRULICITY ......................36, 120TRUVADA ........................ 26, 135TUSSIGON 15, 103, 135, 153, 160TYBOST ............................ 26, 135TYKERB ................................. 231

TYMLOS ................... 96, 120, 174Tysabri.................. 68, 87, 112, 153TYVASO ..............13, 47, 103, 160TYVASO REFILL...............................13, 47, 103, 160TYVASO STARTER...............................13, 47, 103, 160TYZEKA ................. 112, 135, 153UCERIS ........................... 112, 153U-KERA E ...............................231ULESFIA ......................... 135, 266ULORIC .................... 36, 153, 174ULTICARE TUBERCULIN SAFETY SYR ..........................204ULTILET CLASSIC LANCETS ............................... 204ULTILET LANCETS .............204ULTRA-THIN II AUTO LANCET ..................................204ULTRA-THIN II LANCETS .204UMECTA .................................231UNILET COMFORTOUCH LANCET ..................................204UNILET G.P. LANCET .........204UNILET G.P. SUPERLITE LANCET ..................................204UNILET LANCET ................. 204UNILET SUPERLITE LANCET ..................................204UNISTIK 1 .............................. 204UNITHROID ...................120, 231UNITHROID DIRECT .......... 231UPTRAVI ............ 13, 47, 103, 160urea ........................................... 231urea nail film .............................231urea-c40 ....................................231ure-k ..........................................231URETRON D/S ....................... 231URIMAR-T ..............................231UROLET MB .......................... 231UROPHEN MB .......................231ursodiol ..................................... 112URYL ....................................... 231Vabomere..................................231valacyclovir hcl .........................231VALCHLOR ........... 231, 266, 270valganciclovir hcl ..................... 231

valproic acid ......................... 69, 87valsartan ............................. 47, 231valsartan-hydrochlorothiazide ... 47Valstar.......................................231vancomycin hcl ......................... 231VANDAZOLE .............52, 97, 135Vantas................................. 52, 270Varubi............................... 112, 270VARUBI ...........................112, 270Vectibix.....................................231Velcade..................................... 231Veletri................... 13, 47, 103, 160VELIVET .................................. 97VELTASSA ............................... 36VEMLIDY ............... 112, 135, 153VENCLEXTA ..................... 7, 271VENCLEXTA STARTING PACK ................................... 7, 271venlafaxine hcl .......................... 196venlafaxine hcl er ......................196VENTAVIS ..........13, 47, 103, 160VENTOLIN HFA ......13, 103, 160VERAMYST.....................15, 103, 135, 153, 252verapamil hcl ...................... 47, 244verapamil hcl er ..........................47VERDROCET .........................244VEREGEN ...............135, 153, 266VERSACLOZ ................. 196, 232VERZENIO ............................. 232VESICARE ........................52, 174VESTURA ................. 97, 196, 266VEXOL ............ 124, 153, 251, 255VIBERZI ................................. 112VICTOZA ..........................36, 120Vidaza....................................... 232VIDEX ............................... 26, 135VIENVA .....................................97vigabatrin ..............69, 88, 174, 232VIIBRYD ................................. 196VIIBRYD STARTER PACK .196VIMPAT .............................. 69, 88viorele ......................................... 97VIRACEPT ....................... 26, 135VIRAZOLE ..... 103, 135, 153, 160VIREAD .............26, 112, 135, 153VISTOGARD .......................... 233


291

Visudyne................................... 124VITALET PRO LANCETS ... 204VITALET PRO PLUS LANCETS ............................... 204vitamin d (ergocalciferol) ..... 9, 199VITEKTA ..........................26, 135VIVITROL .............................. 196VOLTAREN ....................153, 174Vonvendi.......................................7voriconazole ..............................232VOSEVI ................... 112, 135, 153VOTRIENT ............................. 232Vpriv........................................... 36VRAYLAR .............................. 196VYFEMLA ........................ 97, 232VYVANSE ... 69, 88, 174, 175, 197Vyxeos...................................... 232W&F LANCETS 26G .............204W&F LANCETS COLORED 21G ........................................... 204warfarin sodium ......................7, 47WELCHOL ............................... 36WERA ........................................97WESTHROID ......................... 232Wilate........7, 26, 47, 153, 251, 255WinRho SDF.... 7, 26, 47, 153, 246WP THYROID ........................232WYMZYA FE ........................... 97XADAGO .............................69, 88XALKORI ............................... 232XARELTO .....7, 47, 103, 161, 251XARELTO STARTER PACK.........................7, 48, 103, 161, 251XATMEP ............. 7, 153, 175, 271XELJANZ ....18, 26, 153, 175, 266XELJANZ XR.......................18, 26, 153, 175, 266Xeomin......... 69, 88, 124, 175, 266XERAC AC ............................. 266XERMELO ......................112, 271Xgeva..........................36, 175, 271Xiaflex................................ 97, 175XIFAXAN ......36, 69, 88, 112, 135XIGDUO XR ..................... 36, 120Xolair.......13, 36, 103, 154, 161, 253, 266XOLEGEL .......................154, 266

XTANDI ...................................232XULANE ................................... 97XURIDEN ..................................36XYLON ....................................244Xyntha...........................................7Xyntha Solofuse............................7XYREM ....................... 70, 88, 175Yervoy...................................... 232YONDELIS ......... 18, 26, 154, 271zafirlukast ........... 13, 103, 154, 161zaleplon .................................70, 88Zaltrap.......................................232ZAMICET ............................... 244ZARAH ......................................97ZARXIO ........................ 7, 26, 271ZAZOLE ..................................232ZEBUTAL ............... 197, 232, 244ZEJULA ...................................232ZELAPAR ........................... 70, 88ZELBORAF ............................ 232ZENATANE ............................ 266ZENCHENT ..............................97ZENCHENT FE ........................97ZENPEP ...................................112ZENZEDI ............ 70, 88, 175, 197ZEPATIER ..............112, 135, 154ZETIA ........................................36ZETONNA...............13, 15, 103, 135, 154, 253zidovudine ........................... 26, 135ZINBRYTA ......................... 70, 88Zinplava.................... 112, 135, 154ZIOPTAN ................................ 124ziprasidone hcl ..........................197ZIRGAN .................. 125, 135, 154ZMAX ...................................... 232ZOHYDRO ER ....................... 244Zoladex......................... 52, 97, 271Zoledronic Acid...........7, 36, 97, 120, 175, 232, 271ZOLINZA ........................266, 271zolmitriptan .............48, 70, 89, 244zolpidem tartrate ...................70, 89zolpidem tartrate er .............. 70, 89ZOMACTON...................9, 26, 36, 120, 135, 199ZOMIG .......... 48, 70, 89, 232, 244

zonisamide ............................ 70, 89ZONTIVITY.............7, 48, 70, 89, 244, 251, 255ZORBTIVE...................9, 26, 36, 120, 135, 199ZORTRESS . 26, 52, 112, 251, 255ZOVIA 1/35E (28) .....................97ZOVIA 1/50E (28) .....................97ZOVIRAX ............................... 232ZUBSOLV ....................... 197, 232ZURAMPIC .............. 36, 154, 175ZYCLARA ...............................266ZYCLARA PUMP .................. 266ZYDELIG ................................232ZYKADIA ............................... 233ZYLET .....................125, 135, 154ZyPREXA Relprevv................. 197ZYTIGA ...................................233


292

pharmacy program and preferred drug list march 1, 2018 ... 1, 2018 introduction pharmacy program ......

Documents