blue cross community centennial lista de medicamentos … · muchos de los medicamentos de venta...

Esta Lista de medicamentos (Formulary, en inglés) está actualizada hasta su fecha de publicación, 1.° de julio de 2018.

Blue Cross Community CentennialSM

Lista de medicamentos 2018 Medicamentos incluidos en esta cobertura médica.

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Blue Cross Community Centennial

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¿Qué es la Lista de medicamentos de Blue Cross Community Centennial?La Lista de medicamentos (conocida también como Formulary, en inglés) es una lista que muestra los medicamentos que su seguro de gastos médicos de Blue Cross Community Centennial incluye. Los medicamentos que figuran en la lista tendrán cobertura siempre y cuando usted: • tenga una necesidad médica para usarlos,

• surta las órdenes de los medicamentos en una farmacia que forme parte de la red,

• siga las otras normas de su seguro de gastos médicos de Blue Cross Community Centennial.

Para obtener más información acerca de cómo surtir sus órdenes de medicamentos, por favor revise su Manual del asegurado. También puede comunicarse con Servicio al Cliente de Blue Cross and Blue Shield of New Mexico (BCBSNM) al 1-866-689-1523 (TTY/TDD 7-1-1).

¿Qué tendré que pagar?En la mayoría de los casos, usted no paga por los medicamentos incluidos. Algunos asegurados tendrán que realizar copagos por los medicamentos con receta según la categoría de elegibilidad.

¿Puede haber cambios en la Lista de medicamentos?Sí, la lista puede cambiar por diversas razones; por ejemplo, cuando un medicamento genérico nuevo y menos costoso se encuentre disponible.

Se le informará por escrito cuando se realicen cambios en la lista de medicamentos.

¿Cómo debo usar la Lista de medicamentos?Hay dos formas para encontrar su medicamento en la lista empezando en la página 1.

1. Categoría• La Lista de medicamentos con cobertura que comienza en

la página 1 le brinda información acerca de los medicamentos incluidos por Blue Cross Community Centennial. Si tiene dificultad para encontrar su medicamento en la lista, diríjase al Índice que comienza en el reverso de este manual.

– La primera columna del cuadro indica el nombre del medicamento. Los medicamentos de marca aparecen en mayúsculas (por ejemplo, CIPRO) y los medicamentos genéricos aparecen en letra minúscula cursiva (por ejemplo, ciprofloxacina).

– La información en la columna “Acciones necesarias, restricciones o límites sobre el uso” le indica si Blue Cross Community Centennial tiene alguna regla para que su medicamento tenga cobertura.

• Los medicamentos se enumeran en categorías o grupos, según el tipo de problema médico que tratan. (Por ejemplo, los medicamentos que se usan para tratar un problema médico cardíaco se incluyen debajo de Medicamentos para el corazón y la circulación).

• Si usted sabe para qué se usa su medicamento, busque el grupo en la Lista de medicamentos. Luego, busque su medicamento bajo ese grupo.

2. Listado alfabético• Busque su medicamento en el índice en la parte posterior

de esta guía.

• Junto al nombre de su medicamento, verá el número de página en donde puede encontrar la información de la cobertura.

¿La cobertura incluye los medicamentos de venta libre (OTC, en inglés)?Sí, Blue Cross Community Centennial incluye cobertura de ciertos medicamentos de venta libre con una orden válida de medicamento de su profesional de la salud, y puede obtenerlos sin ningún costo. Su farmacia debe recetar y surtir los medicamentos genéricos de venta libre cuando estén disponibles. Estos medicamentos de venta libre se deben surtir en una farmacia que participe en una red de Blue Cross Community Centennial y por cantidades de hasta un suministro de 30 días. Muchos de los medicamentos de venta libre que se encuentran en la Lista de medicamentos tienen una restricción de edad según el tipo de cobertura que tenga.

Lista de medicamentos

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¿Qué son los medicamentos genéricos?La Administración de Alimentos y Medicamentos (FDA, en inglés) autoriza la fabricación de un medicamento genérico cuando este tiene el mismo ingrediente activo que el medicamento de marca; sin embargo, con frecuencia es menos costoso.

¿Existe algún límite en mi cobertura?En algunos medicamentos con cobertura, los límites o condiciones agregados pueden incluir:• Autorización previa: Usted o su profesional de la salud

necesitarán obtener aprobación de Blue Cross and Blue Shield of New Mexico (BCBSNM) antes de surtir algunas de las órdenes de sus medicamentos. Los medicamentos que necesitan autorización previa se identifican en la Lista de medicamentos por medio de “AP” en la columna “Acciones necesarias, restricciones o límites sobre el uso”. Si no obtiene aprobación, es posible que Blue Cross Community Centennial no incluya (pague) el medicamento.

– ¿Qué sucede si mi medicamento requiere una autorización previa?

ú Comuníquese con Servicio al Cliente de BCBSNM al 1-866-689-1523 (TTY/TDD 7-1-1) y pregunte cómo usted o su profesional de la salud pueden enviar una solicitud de autorización previa (excepción).

ú Puede hablar con su profesional de la salud para decidir si primero debe probar un medicamento diferente de nuestra lista antes de solicitar una excepción.

• Cantidades límite: Para algunos medicamentos, Blue Cross Community Centennial limita la cantidad de un medicamento que tendrá cobertura durante un período (por ejemplo, no más de 60 tabletas durante 30 días). Los medicamentos que tienen cantidad límite se identifican en la Lista de medicamentos por medio de “CL” en la columna “Acciones necesarias, restricciones o límites sobre el uso”.

– ¿Qué sucede si mi medicamento no tiene cobertura porque supera la cantidad límite?

ú Comuníquese con Servicio al Cliente de BCBSNM al 1-866-689-1523 (TTY/TDD 7-1-1) y pregunte cómo usted o su profesional de la salud pueden enviar una solicitud de excepción de la cantidad límite.

ú Puede hablar también con su profesional de la salud para decidir si debe probar primero un medicamento diferente de nuestra lista o una dosis diferente de su medicamento antes de solicitar una excepción.

• Terapia escalonada: En algunos casos, Blue Cross Community Centennial requiere que usted pruebe primero ciertos medicamentos antes de que se pueda cubrir otro medicamento. Por ejemplo, si el medicamento A y el medicamento B se usan para tratar su problema médico, es posible que su seguro médico no incluya en su cobertura el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no funciona, su seguro médico incluirá en su cobertura el medicamento B. Los medicamentos que están sujetos a la terapia escalonada se identifican en la Lista de medicamentos por un “TE” en la columna de “Acciones necesarias, restricciones o límites sobre el uso”.

– ¿Qué sucede si mi medicamento no tiene cobertura ya que no he cumplido con la terapia escalonada?

ú Comuníquese con Servicio al Cliente de BCBSNM al 1-866-689-1523 (TTY/TDD 7-1-1) y pregunte cómo usted o su profesional de la salud pueden enviar una solicitud de excepción de la terapia escalonada.

ú Puede hablar con su profesional de la salud para decidir si debe probar primero un medicamento diferente de nuestra lista que no requiera de una terapia escalonada.

• Cálculo de dosis de equivalentes de morfina (ME, en inglés): La tabla de conversión de equivalencias de morfina es una herramienta que se usa para ayudar a prevenir que los asegurados tomen medicamentos para el dolor (opioides) en exceso. Este método le permite a BCBSNM calcular la dosis diaria total de analgésicos que un asegurado está tomando, independientemente del opioide que se le recete. El límite diario actual de dosificación con equivalentes de morfina (ME) en New Mexico es de 90 miligramos por día. Si está tomando una dosis superior a los 90 miligramos, deberá obtener autorización (aprobación) previa de BCBSNM para que Blue Cross Community Centennial pague por la(s) receta(s). Los medicamentos que tienen equivalentes de morfina se identifican en la lista de medicamentos con las siglas “ME” en la columna “Acciones necesarias, restricciones o límites de uso”.

Puede averiguar si su medicamento tiene cualquier otra condición o límite al buscar en la Lista de medicamentos que inicia en la página 1.


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¿Qué sucede si mi medicamento no está incluido en la Lista de medicamentos?Comuníquese con Servicio al Cliente de BCBSNM al 1-866-689-1523 (TTY/TDD 7-1-1) y pregunte si su medicamento tiene cobertura. Si Blue Cross Community Centennial no incluye su medicamento, tiene dos opciones:• Puede hablar con su profesional de la salud para decidir si

primero debe probar un medicamento diferente de nuestra lista antes de solicitar una excepción.

• Puede pedir a Servicio al Cliente que se haga una excepción para cubrir su medicamento. Servicio al Cliente le indicará cómo usted o su profesional de la salud pueden pedir que hagan una excepción a la Lista de medicamentos.

La fecha en que realizamos la actualización más reciente se encuentra en la página de la portada.

Farmacia de medicamentos especializados (SP, en inglés)Los medicamentos especializados son ciertos medicamentos con receta que se usan para tratar padecimientos complejos y crónicos como el cáncer, la artritis reumatoide y la esclerosis múltiple. Los medicamentos especializados a menudo requieren un manejo especial (como refrigeración durante el envío) y administración (como una inyección o infusión). Los medicamentos especializados requieren de autorización previa antes de que se pueda surtir una receta médica. Se pueden surtir en un suministro hasta de 30 días. Esto debe hacerse por medio de un proveedor de medicamentos especializados que forme parte de la red de Blue Cross Community Centennial. AllianceRx Walgreens Prime es el proveedor de medicamentos especializados preferido de BCBSNM. La mayoría de estos medicamentos se encuentra bajo el beneficio de farmacia y estos se deben surtir por medio de AllianceRx Walgreens Prime. Los medicamentos especializados que se encuentran dentro del beneficio de farmacia y que no están disponibles en AllianceRx Walgreens Prime se pueden obtener de un proveedor de farmacia de distribución limitada. Estos proveedores son conocidos por los fabricantes farmacéuticos por tener los estándares más altos en experiencia clínica, educación para pacientes, servicio, seguimiento terapéutico y apoyo. Para obtener más información sobre los medicamentos especializados, llame a Servicio al Cliente al 1-866-689-1523 (TTY/TDD 7-1-1).

¿Cuáles categorías de medicamentos no tienen cobertura según la Lista de medicamentos de su seguro médico?Las siguientes categorías de medicamentos no tienen cobertura por su seguro de gastos médicos de Blue Cross Community Centennial:• medicamentos para el tratamiento de la anorexia, pérdida de

peso o aumento de peso,

• productos químicos a granel,

• medicamentos para el mejoramiento cosmético,

• agentes para diagnóstico,

• implementación del estudio de eficacia de medicamentos (DESI, en inglés). Estos son medicamentos que no han demostrado ser seguros ni eficaces,

• medicamentos experimentales y de investigación,

• medicamentos para la disfunción eréctil recetados para tratar la impotencia,

• medicamentos para la fertilidad,

• medicamentos para anestesia general,

• productos de venta libre que no se incluyan en la lista de medicamentos de la cobertura,

• suministros quirúrgicos/dispositivos médicos.

Los asegurados de Blue Cross Community Centennial que tienen doble cobertura bajo Medicare y Medicaid se darán cuenta que la mayoría de sus medicamentos tendrán cobertura de Medicare. Sin embargo, un número limitado de medicamentos tendrá cobertura de Blue Cross Community Centennial.

Para los medicamentos con cobertura de la Parte B de Medicare, los asegurados de Blue Cross Community Centennial que están inscritos tanto en Medicare como en Medicaid pueden tener sus coseguros incluidos en sus beneficios de Medicaid. Sin embargo, algunos medicamentos únicamente tienen cobertura bajo la Parte B de Medicare si un asegurado tiene un problema médico específico o recibió un tratamiento médico específico. Para estos medicamentos, es necesario revisar primero la información sobre el historial médico para cubrir el coseguro del asegurado. Los asegurados deben llamar a Servicio al Cliente al 1-866-689-1523 (TTY/TDD: 7-1-1) para completar esta determinación de cobertura.


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Para obtener más información Para obtener más detalles sobre la cobertura de medicamentos de su seguro de gastos médicos de Blue Cross Community Centennial, por favor lea su Manual del asegurado y otros materiales de la cobertura médica.

Si tiene alguna pregunta, por favor llame a Servicio al Cliente de BCBSNM al: 1-866-689-1523, (TTY/TDD 7-1-1). Nuestro horario de atención es de lunes a viernes, de 8:00 a. m. a 5:00 p. m., Hora Montaña.

Asistencia lingüística para la Lista de medicamentosServicios de interpretación Podemos coordinar que alguien le ayude a comunicarse con nosotros en cualquier idioma. Estos servicios son gratuitos. Si su profesional de la salud no habla su idioma, podemos ofrecerle la ayuda de un intérprete. Por favor llame a Servicio al Cliente al 1-866-689-1523 (TTY/TDD 7-1-1).

Problemas auditivos y de la vistaPara nuestros asegurados con problemas auditivos, ofrecemos el servicio de TTY/TDD sin ningún cargo. La línea está abierta las 24 horas del día, los siete días de la semana en el 7-1-1.

Otros idiomas y formatosPuede obtener este documento en inglés o hablar con alguien acerca de esta información en otros idiomas sin costo alguno. Llame al 1-866-689-1523 (TTY/TDD: 7-1-1). La llamada es gratuita. También puede llamar gratis a Servicio al Cliente, para solicitar esta información en otros formatos diferentes como Braille, letra grande y otros formatos. Llame sin costo al: 1-866-689-1523 (TTY/TDD: 7-1-1). Nuestro horario de atención es de lunes a viernes, de 8:00 a. m. a 5:00 p. m., Hora Montaña.


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ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-710-6984 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-710-6984 (TTY: 711).

Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dę́ę́’, t’áá jiik’eh, éí ná hólǫ́, kojį’ hódíílnih 1-855-710-6984 (TTY: 711).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-710-6984 (TTY: 711).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-710-6984 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-710-6984 (TTY: 711)。

6984-710-855-1ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم ).711(رقم ھاتف الصم والبكم:

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

1-855-710-6984 (TTY: 711) 번으로 전화해 주십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-710-6984 (TTY: 711).

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-855-710-6984 （TTY: 711）まで、お電話にてご連絡ください。

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-710-6984 (ATS: 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-710-6984 (TTY: 711).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-710-6984 (телетайп: 711).

!यान द': य)द आप ,हदी बोलते ह4 तो आपके िलए मु:त म' भाषा सहायता सेवाएं उपलAध ह4। 1-855-710-6984 (TTY: 711) पर कॉल कर'।

ھجوت: رگا ھب نابز یسراف وگتفگ یم دینک، تالیھست ینابز ھب تروص ناگیار یارب امش مھارف یم دشاب. اب 1-855-710-6984 (TTY: 711) سامت دیریگب.

เรียน: ถLาคุณพูดภาษาไทยคุณสามารถใชLบริการช_วยเหลือทางภาษาไดLฟรี โทร 1-855-710-6984 (TTY: 711).

Blue Cross and Blue Shield of New Mexico cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Blue Cross and Blue Shield of New Mexico no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo.

Blue Cross and Blue Shield of New Mexico:

Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que secomuniquen de manera eficaz con nosotros, como los siguientes:

o Intérpretes de lenguaje de señas capacitados.o Información escrita en otros formatos (letra grande, audio, formatos electrónicos

accesibles, otros formatos). Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como

los siguientes:o Intérpretes capacitados.o Información escrita en otros idiomas.

Si necesita recibir estos servicios, comuníquese con Civil Rights Coordinator.

Si considera que Blue Cross and Blue Shield of New Mexico no le proporcionó estos servicios o lo discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago, Illinois 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960, [email protected]. Puede presentar el reclamo en persona o por correo postal, fax o correo electrónico. Si necesita ayuda para hacerlo, Civil Rights Coordinator está a su disposición para brindársela.

También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación:

U.S. Department of Health and Human Services 200 Independence Avenue, SW

Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.

Para obtener asistencia y servicios auxiliares, o materiales en formatos alternativos u otros idiomas sin costo,

llame al 1-866-689-1523 (TTY/TDD: 7-1-1).


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ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-710-6984 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-710-6984 (TTY: 711).

Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dę́ę́’, t’áá jiik’eh, éí ná hólǫ́, kojį’ hódíílnih 1-855-710-6984 (TTY: 711).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-710-6984 (TTY: 711).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-710-6984 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-710-6984 (TTY: 711)。

6984-710-855-1ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم ).711(رقم ھاتف الصم والبكم:

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

1-855-710-6984 (TTY: 711) 번으로 전화해 주십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-710-6984 (TTY: 711).

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-855-710-6984 （TTY: 711）まで、お電話にてご連絡ください。

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-710-6984 (ATS: 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-710-6984 (TTY: 711).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-710-6984 (телетайп: 711).

!यान द': य)द आप ,हदी बोलते ह4 तो आपके िलए मु:त म' भाषा सहायता सेवाएं उपलAध ह4। 1-855-710-6984 (TTY: 711) पर कॉल कर'।

ھجوت: رگا ھب نابز یسراف وگتفگ یم دینک، تالیھست ینابز ھب تروص ناگیار یارب امش مھارف یم دشاب. اب 1-855-710-6984 (TTY: 711) سامت دیریگب.

เรียน: ถLาคุณพูดภาษาไทยคุณสามารถใชLบริการช_วยเหลือทางภาษาไดLฟรี โทร 1-855-710-6984 (TTY: 711).

2018

1 = Medicamentos genéricos AL = Límite de edad ME90 = Equivalente a la morfina ST = Terapia escalonada2 = Medicamentos de marca PA = Autorización previa QL = Límites de cantidad SP = Medicamento especializado90 = Suministro de 90 díasdisponible al realizar el pedido deenvío por correo

1

Nombre del medicamento

Cuánto le costaráel medicamento de(nivel)

Acciones necesarias,restricciones o límitesen el uso

ANTI-INFECTIVE AGENTSPENICILLINSAMOXICILLIN – amoxicillin (trihydrate) chew tab 125 mg 2AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 mg 2amoxicillin (trihydrate) cap 250 mg 1amoxicillin (trihydrate) cap 500 mg 1amoxicillin (trihydrate) for susp 125 mg/5ml 1amoxicillin (trihydrate) for susp 200 mg/5ml 1amoxicillin (trihydrate) for susp 250 mg/5ml 1amoxicillin (trihydrate) for susp 400 mg/5ml 1amoxicillin (trihydrate) tab 875 mg 1amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 1amoxicillin & k clavulanate for susp 250-62.5 mg/5ml

(Augmentin)1

amoxicillin & k clavulanate for susp 400-57 mg/5ml 1amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin

es-600)1

amoxicillin & k clavulanate tab 250-125 mg 1amoxicillin & k clavulanate tab 500-125 mg (Augmentin) 1amoxicillin & k clavulanate tab 875-125 mg (Augmentin) 1AMOXICILLIN/CLAVULANATE P – amoxicillin & k clavulanate

chew tab 200-28.5 mg2

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

2

ampicillin cap 250 mg 1ampicillin cap 500 mg 1dicloxacillin sodium cap 250 mg 1dicloxacillin sodium cap 500 mg 1penicillin v potassium for soln 125 mg/5ml 1penicillin v potassium for soln 250 mg/5ml 1penicillin v potassium tab 250 mg 1penicillin v potassium tab 500 mg 1

CEPHALOSPORINScefaclor cap 250 mg 1cefaclor cap 500 mg 1cefadroxil cap 500 mg 1

2018


2




cefadroxil for susp 250 mg/5ml 1cefadroxil for susp 500 mg/5ml 1cefadroxil tab 1 gm 1cefdinir cap 300 mg 1cefdinir for susp 125 mg/5ml 1cefdinir for susp 250 mg/5ml 1cefixime for susp 100 mg/5ml (Suprax) 1cefixime for susp 200 mg/5ml (Suprax) 1cefprozil for susp 125 mg/5ml 1cefprozil for susp 250 mg/5ml 1cefprozil tab 250 mg 1cefprozil tab 500 mg 1cefuroxime axetil tab 250 mg 1cefuroxime axetil tab 500 mg (Ceftin) 1cephalexin cap 250 mg (Keflex) 1cephalexin cap 500 mg (Keflex) 1cephalexin for susp 125 mg/5ml 1cephalexin for susp 250 mg/5ml 1

MACROLIDESAZITHROMYCIN – azithromycin powd pack for susp 1 gm 2azithromycin for susp 100 mg/5ml (Zithromax) 1azithromycin for susp 200 mg/5ml (Zithromax) 1azithromycin tab 250 mg (Zithromax) 1 QL (60 tablets/180 days)azithromycin tab 500 mg (Zithromax) 1 QL (60 tablets/180 days)azithromycin tab 600 mg (Zithromax) 1 QL (60 tablets/180 days)clarithromycin for susp 125 mg/5ml 1clarithromycin for susp 250 mg/5ml (Biaxin) 1clarithromycin tab 250 mg (Biaxin) 1clarithromycin tab 500 mg (Biaxin) 1

TETRACYCLINESdemeclocycline hcl tab 150 mg 1demeclocycline hcl tab 300 mg 1doxycycline hyclate cap 50 mg 1doxycycline hyclate cap 100 mg (Vibramycin) 1doxycycline hyclate tab delayed release 50 mg (Doryx) 1 PA

2018


3




doxycycline hyclate tab 20 mg 1doxycycline hyclate tab 100 mg 1doxycycline monohydrate cap 50 mg 1doxycycline monohydrate cap 100 mg (Monodox) 1doxycycline monohydrate for susp 25 mg/5ml (Vibramycin) 1doxycycline monohydrate tab 50 mg (Adoxa) 1doxycycline monohydrate tab 75 mg (Adoxa) 1doxycycline monohydrate tab 100 mg (Adoxa pak 1/100) 1minocycline hcl cap 50 mg (Minocin) 1minocycline hcl cap 75 mg (Minocin) 1minocycline hcl cap 100 mg (Minocin) 1

FLUOROQUINOLONESciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro) 1ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml)

(Cipro)1

ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) 1ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) 1ciprofloxacin hcl tab 750 mg (base equiv) 1levofloxacin oral soln 25 mg/ml 1levofloxacin tab 250 mg (Levaquin) 1levofloxacin tab 500 mg (Levaquin) 1levofloxacin tab 750 mg (Levaquin) 1

AMINOGLYCOSIDESneomycin sulfate tab 500 mg 1paromomycin sulfate cap 250 mg 1TOBRAMYCIN – tobramycin nebu soln 300 mg/5ml 2 SPtobramycin nebu soln 300 mg/5ml (Tobi) 1 SP

TUBERCULOSISethambutol hcl tab 100 mg (Myambutol) 1ethambutol hcl tab 400 mg (Myambutol) 1isoniazid tab 100 mg 1 90isoniazid tab 300 mg 1 90PRIFTIN – rifapentine tab 150 mg 2pyrazinamide tab 500 mg 1rifabutin cap 150 mg (Mycobutin) 1

2018


4




rifampin cap 150 mg (Rifadin) 1rifampin cap 300 mg (Rifadin) 1

FUNGAL INFECTIONSfluconazole for susp 10 mg/ml (Diflucan) 1 QL (35 mls/30 days)fluconazole for susp 40 mg/ml (Diflucan) 1 QL (35 mls/30 days)fluconazole tab 50 mg (Diflucan) 1 QL (14 tablets/30 days)fluconazole tab 100 mg (Diflucan) 1 QL (14 tablets/30 days)fluconazole tab 150 mg (Diflucan) 1 QL (14 tablets/30 days)fluconazole tab 200 mg (Diflucan) 1 QL (14 tablets/30 days)flucytosine cap 250 mg (Ancobon) 1flucytosine cap 500 mg (Ancobon) 1griseofulvin microsize susp 125 mg/5ml 1griseofulvin microsize tab 500 mg 1griseofulvin ultramicrosize tab 125 mg (Gris-peg) 1griseofulvin ultramicrosize tab 250 mg (Gris-peg) 1ketoconazole tab 200 mg 1NOXAFIL – posaconazole tab delayed release 100 mg 2 PA, 90NOXAFIL – posaconazole susp 40 mg/ml 2 PA, 90nystatin oral powder 1nystatin tab 500000 unit 1terbinafine hcl tab 250 mg (Lamisil) 1 QL (90 tablets/365 days)voriconazole for susp 40 mg/ml (Vfend) 1 PAvoriconazole tab 50 mg (Vfend) 1 PAvoriconazole tab 200 mg (Vfend) 1 PA

VIRAL INFECTIONSCytomegalovirusvalganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte) 1 90valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) 1 90

Hepatitisadefovir dipivoxil tab 10 mg (Hepsera) 1 90BARACLUDE – entecavir oral soln 0.05 mg/ml 2 90entecavir tab 0.5 mg (Baraclude) 1 90entecavir tab 1 mg (Baraclude) 1 90lamivudine tab 100 mg (hbv) (Epivir hbv) 1 90MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg 2 PA, SP

2018


5




ribavirin cap 200 mg (Rebetol) 1 PA, SPribavirin tab 200 mg (Copegus) 1 PA, SP

Herpesacyclovir cap 200 mg (Zovirax) 1acyclovir susp 200 mg/5ml (Zovirax) 1acyclovir tab 400 mg (Zovirax) 1acyclovir tab 800 mg (Zovirax) 1famciclovir tab 125 mg (Famvir) 1valacyclovir hcl tab 500 mg (Valtrex) 1valacyclovir hcl tab 1 gm (Valtrex) 1

HIV/AIDSabacavir sulfate soln 20 mg/ml (base equiv) (Ziagen) 1 QL (960 mls/30 days), 90abacavir sulfate tab 300 mg (base equiv) (Ziagen) 1 QL (60 tablets/30

days), 90abacavir sulfate-lamivudine tab 600-300 mg (Epzicom) 1 QL (30 tablets/30

days), 90abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg

(Trizivir)1 QL (60 tablets/30

days), 90APTIVUS – tipranavir cap 250 mg 2 QL (120 capsules/30

days), 90APTIVUS – tipranavir oral soln 100 mg/ml 2 QL (380 mls/30 days), 90atazanavir sulfate cap 150 mg (base equiv) (Reyataz) 1 QL (30 capsules/30

days), 90atazanavir sulfate cap 200 mg (base equiv) (Reyataz) 1 QL (60 capsules/30

days), 90atazanavir sulfate cap 300 mg (base equiv) (Reyataz) 1 QL (30 capsules/30

days), 90ATRIPLA – efavirenz-emtricitabine-tenofovir df tab

600-200-300 mg2 QL (30 tablets/30

days), 90COMPLERA – emtricitabine-rilpivirine-tenofovir df tab

200-25-300 mg2 QL (30 tablets/30

days), 90CRIXIVAN – indinavir sulfate cap 200 mg 2 QL (270 capsules/30

days), 90CRIXIVAN – indinavir sulfate cap 400 mg 2 QL (180 capsules/30

days), 90DESCOVY – emtricitabine-tenofovir alafenamide fumarate tab

200-25 mg2 QL (30 tablets/30

days), 90

2018


6




didanosine delayed release capsule 200 mg (Videx ec) 1 QL (30 capsules/30days), 90



EDURANT – rilpivirine hcl tab 25 mg (base equivalent) 2 QL (30 tablets/30days), 90

efavirenz cap 50 mg (Sustiva) 1 QL (90 capsules/30days), 90

efavirenz cap 200 mg (Sustiva) 1 QL (60 capsules/30days), 90

efavirenz tab 600 mg (Sustiva) 1 QL (30 tablets/30days), 90

EMTRIVA – emtricitabine caps 200 mg 2 QL (30 capsules/30days), 90

EMTRIVA – emtricitabine soln 10 mg/ml 2 QL (720 mls/30 days), 90EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg (base

equiv)2 QL (30 tablets/30

days), 90fosamprenavir calcium tab 700 mg (base equiv) (Lexiva) 1 QL (120 tablets/30

days), 90FUZEON – enfuvirtide for inj 90 mg 2 QL (1 kit/30 days), SP, 90GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg2 QL (30 tablets/30

days), 90INTELENCE – etravirine tab 25 mg 2 QL (120 tablets/30



days), 90INVIRASE – saquinavir mesylate cap 200 mg 2 QL (300 capsules/30

days), 90INVIRASE – saquinavir mesylate tab 500 mg 2 QL (120 tablets/30

days), 90ISENTRESS – raltegravir potassium packet for susp 100 mg

(base equiv)2 QL (60 packets/30

days), 90ISENTRESS – raltegravir potassium tab 400 mg (base equiv) 2 QL (60 tablets/30

days), 90

2018


7




ISENTRESS – raltegravir potassium chew tab 25 mg (baseequiv)

2 QL (180 tablets/30days), 90

ISENTRESS – raltegravir potassium chew tab 100 mg (baseequiv)


ISENTRESS HD – raltegravir potassium tab 600 mg (base equiv) 2 QL (60 tablets/30days), 90

JULUCA – dolutegravir sodium-rilpivirine hcl tab 50-25 mg (baseeq)

2 QL (30 tablets/30 days)

KALETRA – lopinavir-ritonavir tab 100-25 mg 2 QL (180 tablets/30days), 90

KALETRA – lopinavir-ritonavir tab 200-50 mg 2 QL (120 tablets/30days), 90

lamivudine oral soln 10 mg/ml (Epivir) 1 QL (960 mls/30 days), 90lamivudine tab 150 mg (Epivir) 1 QL (30 tablets/30

days), 90lamivudine tab 300 mg (Epivir) 1 QL (30 tablets/30

days), 90lamivudine-zidovudine tab 150-300 mg (Combivir) 1 QL (60 tablets/30

days), 90LEXIVA – fosamprenavir calcium susp 50 mg/ml (base equiv) 2 QL (1800 mls/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) (Kaletra) 1 QL (480 mls/30 days), 90nevirapine tab er 24hr 100 mg (Viramune xr) 1 QL (90 tablets/30

days), 90nevirapine tab er 24hr 400 mg (Viramune xr) 1 QL (30 tablets/30

days), 90nevirapine tab 200 mg (Viramune) 1 QL (60 tablets/30

days), 90NORVIR – ritonavir cap 100 mg 2 QL (180 capsules/30

days), 90NORVIR – ritonavir oral soln 80 mg/ml 2 QL (480 mls/30 days), 90ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab

200-25-25 mg2 QL (30 tablets/30

days), 90PREZCOBIX – darunavir-cobicistat tab 800-150 mg 2 QL (30 tablets/30

days), 90PREZISTA – darunavir ethanolate susp 100 mg/ml (base equiv) 2 QL (400 mls/30 days), 90PREZISTA – darunavir ethanolate tab 75 mg (base equiv) 2 QL (300 tablets/30

days), 90

2018


8




PREZISTA – darunavir ethanolate tab 150 mg (base equiv) 2 QL (180 tablets/30days), 90



RESCRIPTOR – delavirdine mesylate tab 100 mg 2 QL (90 tablets/30days), 90

RESCRIPTOR – delavirdine mesylate tab 200 mg 2 QL (180 tablets/30days), 90

ritonavir tab 100 mg (Norvir) 1 QL (180 tablets/30days), 90

SELZENTRY – maraviroc tab 150 mg 2 QL (60 tablets/30days), 90

SELZENTRY – maraviroc tab 300 mg 2 QL (120 capsules/30days), 90

stavudine cap 15 mg (Zerit) 1 QL (60 capsules/30days), 90




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


SUSTIVA – efavirenz tab 600 mg 2 QL (30 tablets/30days), 90

SUSTIVA – efavirenz cap 50 mg 2 QL (90 capsules/30days), 90

SUSTIVA – efavirenz cap 200 mg 2 QL (60 capsules/30days), 90

tenofovir disoproxil fumarate tab 300 mg (Viread) 1 QL (30 tablets/30days), 90

TIVICAY – dolutegravir sodium tab 50 mg (base equiv) 2 QL (60 tablets/30days), 90

TRIUMEQ – abacavir-dolutegravir-lamivudine tab 600-50-300 mg 2 QL (30 tablets/30days), 90

2018


9




TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab100-150 mg








TYBOST – cobicistat tab 150 mg 2 QL (30 tablets/30days), 90

VIDEX – didanosine for soln 2 gm 2 QL (1200 mls/30days), 90

VIDEX – didanosine for soln 4 gm 2 QL (1200 mls/30days), 90

VIRACEPT – nelfinavir mesylate tab 250 mg 2 QL (270 tablets/30days), 90

VIRACEPT – nelfinavir mesylate tab 625 mg 2 QL (120 tablets/30days), 90

VIRAMUNE – nevirapine susp 50 mg/5ml 2 QL (1200 mls/30days), 90

VIREAD – tenofovir disoproxil fumarate oral powder 40 mg/gm 2 QL (4 bottles/30 days), 90VIREAD – tenofovir disoproxil fumarate tab 150 mg 2 QL (30 tablets/30

days), 90VIREAD – tenofovir disoproxil fumarate tab 200 mg 2 QL (30 tablets/30



days), 90VITEKTA – elvitegravir tab 85 mg 2 QL (30 tablets/30

days), 90VITEKTA – elvitegravir tab 150 mg 2 QL (30 tablets/30

days), 90zidovudine cap 100 mg (Retrovir) 1 QL (180 capsules/30

days), 90zidovudine syrup 10 mg/ml (Retrovir) 1 QL (1920 mls/30

days), 90zidovudine tab 300 mg 1 QL (60 tablets/30

days), 90

2018


10




InfluenzaRELENZA DISKHALER – zanamivir aero powder breath

activated 5 mg/blister2 QL (20 disks/120 days)

MALARIAatovaquone-proguanil hcl tab 62.5-25 mg (Malarone) 1 QL (30 tablets/90 days)atovaquone-proguanil hcl tab 250-100 mg (Malarone) 1 QL (30 tablets/90 days)chloroquine phosphate tab 500 mg (Aralen) 1 90DARAPRIM – pyrimethamine tab 25 mg 2 PA, SPhydroxychloroquine sulfate tab 200 mg (Plaquenil) 1 90MEFLOQUINE HCL – mefloquine hcl tab 250 mg 2 90mefloquine hcl tab 250 mg 1 90PRIMAQUINE PHOSPHATE – primaquine phosphate tab

26.3 mg (15 mg base)2

WORM INFECTIONSALBENZA – albendazole tab 200 mg 2BENZNIDAZOLE – benznidazole tab 12.5 mg 2BENZNIDAZOLE – benznidazole tab 100 mg 2ivermectin tab 3 mg (Stromectol) 1praziquantel tab 600 mg (Biltricide) 1

OTHER ANTI-INFECTIVESCAYSTON – aztreonam lysine for inhal soln 75 mg (base

equivalent)2 PA

clindamycin hcl cap 75 mg (Cleocin) 1clindamycin hcl cap 150 mg (Cleocin) 1clindamycin hcl cap 300 mg (Cleocin) 1clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)

(Cleocin pediatric gr)1

dapsone tab 25 mg 1 90dapsone tab 100 mg 1 90ENGERIX-B – hepatitis b vaccine (recombinant) susp

10 mcg/0.5ml2

ENGERIX-B – hepatitis b vaccine (recombinant) susp 20 mcg/ml 2ENGERIX-B – hepatitis b vaccine (recombinant) 10 mcg/0.5ml 2ENGERIX-B – hepatitis b vaccine (recombinant) 20 mcg/ml 2IMOVAX RABIES (H.D.C.V.) – rabies virus vaccine, hdc inj 2linezolid for susp 100 mg/5ml (Zyvox) 1 PA, QL (600

mls/180 days)

2018


11




linezolid tab 600 mg (Zyvox) 1 PA, QL (56tablets/180 days)

metronidazole cap 375 mg (Flagyl) 1metronidazole tab 250 mg (Flagyl) 1metronidazole tab 500 mg (Flagyl) 1RABAVERT – rabies vaccine, pcec for inj 2RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml2

RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp10 mcg/ml

2

RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp40 mcg/ml

2

sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 1sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim) 1sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds) 1trimethoprim tab 100 mg 1vancomycin hcl cap 125 mg (Vancocin hcl) 1vancomycin hcl cap 250 mg (Vancocin hcl) 1XIFAXAN – rifaximin tab 550 mg 2 PA, QL (60 tablets/30

days), 90ZYVOX – linezolid for susp 100 mg/5ml 2 PA, QL (600

mls/180 days)AFLURIA PF 2017-2018 – influenza virus vaccine split pf susp

pref syringe 0.5 ml2

AFLURIA QUADRIVALENT 2017 – influenza virus vac splitquadrivalent susp pref syr 0.5ml

2

AFLURIA QUADRIVALENT 2017 – influenza virus vaccine splitquadrivalent im inj

2

AFLURIA 2017-2018 – influenza virus vaccine split im susp 2FLUARIX QUADRIVALENT 2017 – influenza virus vac split

quadrivalent susp pref syr 0.5ml2

FLUCELVAX QUADRIVALENT 20 – influenza vac tissue-culturedsubunit quadrivalent im susp

2

FLULAVAL QUADRIVALENT 201 – influenza virus vac splitquadrivalent susp pref syr 0.5ml

2

FLUVIRIN 2017-2018 – influenza vac type a&b surface antigensusp pref syr 0.5 ml

2

FLUVIRIN 2017-2018 – influenza virus vaccine types a & bsurface antigen im susp

2

2018


12




FLUZONE HIGH-DOSE PF 2017 – influenza virus vac split high-dose pf susp pref syr 0.5ml

2

FLUZONE QUADRIVALENT 2015 – influenza virus vac splitquadrivalent susp pref syr 0.5ml

2

FLUZONE QUADRIVALENT 2017 – influenza virus vac splitquadrivalent susp pref syr 0.5ml

2

FLUZONE QUADRIVALENT 2017 – influenza virus vaccine splitquadrivalent im inj

2

SHINGRIX – zoster vaccine recombinant adjuvanted for im inj50 mcg

2 QL (2 vaccines/days)

CANCER DRUGSACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml

(2000000 unit/0.5ml)2 PA, QL (12 vials/28

days), SP, 90AFINITOR – everolimus tab 2.5 mg 2 PA, QL (30 tablets/30

days), SPAFINITOR – everolimus tab 5 mg 2 PA, QL (30 tablets/30

days), SPAFINITOR – everolimus tab 7.5 mg 2 PA, QL (30 tablets/30

days), SPAFINITOR – everolimus tab 10 mg 2 PA, QL (30 tablets/30

days), SPAFINITOR DISPERZ – everolimus tab for oral susp 2 mg 2 PA, QL (60 tablets/30



days), SPALECENSA – alectinib hcl cap 150 mg (base equivalent) 2 PA, QL (240

capsules/30 days), SPALKERAN – melphalan tab 2 mg 2anastrozole tab 1 mg (Arimidex) 1 90bexarotene cap 75 mg (Targretin) 1 PA, SPbicalutamide tab 50 mg (Casodex) 1BOSULIF – bosutinib tab 100 mg 2 PA, QL (120

tablets/30 days), SPBOSULIF – bosutinib tab 500 mg 2 PA, QL (30 tablets/30

days), SPCABOMETYX – cabozantinib s-malate tab 20 mg (base

equivalent)2 PA, QL (30 tablets/30

days), SP

2018


13




CABOMETYX – cabozantinib s-malate tab 40 mg (baseequivalent)

2 PA, QL (30 tablets/30days), SP

CABOMETYX – cabozantinib s-malate tab 60 mg (baseequivalent)

2 PA, QL (30 tablets/30days), SP

CALQUENCE – acalabrutinib cap 100 mg 2 PA, QL (60capsules/30 days)

capecitabine tab 150 mg (Xeloda) 1 PA, SPcapecitabine tab 500 mg (Xeloda) 1 PA, SPCAPRELSA – vandetanib tab 100 mg 2 PA, QL (60 tablets/30

days), SPCAPRELSA – vandetanib tab 300 mg 2 PA, QL (30 tablets/30

days), SPCOMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 mg dose)

kit2 PA, QL (1 carton/28

days), SPCOMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg

(100 dose) kit2 PA, QL (1 carton/28

days), SPCOMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg

(140 dose) kit2 PA, QL (1 carton/28

days), SPCOTELLIC – cobimetinib fumarate tab 20 mg (base equivalent) 2 PA, QL (63 tablets/28

days), SPcyclophosphamide cap 25 mg (Cyclophosphamide) 1cyclophosphamide cap 50 mg (Cyclophosphamide) 1ELIGARD – leuprolide acetate for subcutaneous inj kit 7.5 mg 2 SPELIGARD – leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg2 SP

ELIGARD – leuprolide acetate (4 month) for subcutaneous inj kit30 mg

2 SP

ELIGARD – leuprolide acetate (6 month) for subcutaneous inj kit45 mg

2 SP

ERIVEDGE – vismodegib cap 150 mg 2 PA, QL (30 capsules/30days), SP

exemestane tab 25 mg (Aromasin) 1 90flutamide cap 125 mg 1GILOTRIF – afatinib dimaleate tab 20 mg (base equivalent) 2 PA, QL (30 tablets/30

days), SPGILOTRIF – afatinib dimaleate tab 30 mg (base equivalent) 2 PA, QL (30 tablets/30

days), SPGILOTRIF – afatinib dimaleate tab 40 mg (base equivalent) 2 PA, QL (30 tablets/30

days), SP

2018


14




HEXALEN – altretamine cap 50 mg 2 PA, SPHYCAMTIN – topotecan hcl cap 0.25 mg (base equiv) 2 PA, SPHYCAMTIN – topotecan hcl cap 1 mg (base equiv) 2 PA, SPhydroxyurea cap 500 mg (Hydrea) 1IBRANCE – palbociclib cap 75 mg 2 PA, QL (21 capsules/28

days), SPIBRANCE – palbociclib cap 100 mg 2 PA, QL (21 capsules/28

days), SPIBRANCE – palbociclib cap 125 mg 2 PA, QL (21 capsules/28

days), SPICLUSIG – ponatinib hcl tab 15 mg (base equiv) 2 PA, QL (60 tablets/30

days), SPICLUSIG – ponatinib hcl tab 45 mg (base equiv) 2 PA, QL (30 tablets/30

days), SPimatinib mesylate tab 100 mg (base equivalent) (Gleevec) 1 PA, QL (90

tablets/30), SPimatinib mesylate tab 400 mg (base equivalent) (Gleevec) 1 PA, QL (60 tablets/30

days), SPINLYTA – axitinib tab 1 mg 2 PA, QL (180

tablets/30 days), SPINLYTA – axitinib tab 5 mg 2 PA, QL (120

tablets/30 days), SPJAKAFI – ruxolitinib phosphate tab 5 mg (base equivalent) 2 PA, QL (60 tablets/30

days), SPJAKAFI – ruxolitinib phosphate tab 10 mg (base equivalent) 2 PA, QL (60 tablets/30




days), SPKISQALI FEMARA 600 DOSE – ribociclib tab 200 mg & letrozole

tab 2.5 mg therapy pack2 PA, QL (91

tablets/28 days)LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapy pack

10 mg (10 mg daily dose)2 PA, QL (30 capsules/30

days), SPLENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy pack 10

& 4 mg (14 mg daily dose)2 PA, QL (60 capsules/30

days), SP

2018


15




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

2 PA, QL (90 capsules/30days), SP

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


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


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


letrozole tab 2.5 mg (Femara) 1 90LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg 2LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg 2leucovorin calcium tab 5 mg 1leucovorin calcium tab 25 mg 1LEUKERAN – chlorambucil tab 2 mg 2LONSURF – trifluridine-tipiracil tab 15-6.14 mg 2 PA, QL (100

tablets/28 days), SPLONSURF – trifluridine-tipiracil tab 20-8.19 mg 2 PA, QL (80 tablets/28

days), SPLUPRON DEPOT (1-MONTH) – leuprolide acetate for inj kit

3.75 mg2 PA, SP

LUPRON DEPOT (1-MONTH) – leuprolide acetate for inj kit7.5 mg

2 PA, SP

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3 month) forinj kit 11.25 mg

2 PA, SP

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3 month) forinj kit 22.5 mg

2 PA, SP

LUPRON DEPOT (4-MONTH) – leuprolide acetate (4 month) forinj kit 30 mg

2 PA, SP

LUPRON DEPOT (6-MONTH) – leuprolide acetate (6 month) forinj kit 45 mg

2 PA, SP

LYNPARZA – olaparib cap 50 mg 2 PA, QL (480capsules/30 days), SP

LYNPARZA – olaparib tab 100 mg 2 PA, QL (120tablets/30 days)

LYNPARZA – olaparib tab 150 mg 2 PA, QL (120tablets/30 days)

LYSODREN – mitotane tab 500 mg 2 PA, SPMATULANE – procarbazine hcl cap 50 mg 2 PA, SPmegestrol acetate susp 40 mg/ml (Megace oral) 1

2018


16




megestrol acetate tab 20 mg 1megestrol acetate tab 40 mg 1MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg (base


days), SPMEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base


days), SPmercaptopurine tab 50 mg 1methotrexate sodium tab 2.5 mg (base equiv) 1MYLERAN – busulfan tab 2 mg 2NEXAVAR – sorafenib tosylate tab 200 mg (base equivalent) 2 PA, QL (120

tablets/30 days), SPNINLARO – ixazomib citrate cap 2.3 mg (base equivalent) 2 PA, QL (3 capsules/28

days), SPNINLARO – ixazomib citrate cap 3 mg (base equivalent) 2 PA, QL (3 capsules/28

days), SPNINLARO – ixazomib citrate cap 4 mg (base equivalent) 2 PA, QL (3 capsules/28

days), SPPOMALYST – pomalidomide cap 1 mg 2 PA, QL (21 capsules/30




days), SPPURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml) 2 PA, SPRUBRACA – rucaparib camsylate tab 200 mg (base equivalent) 2 PA, QL (120

tablets/30 days)RUBRACA – rucaparib camsylate tab 250 mg (base equivalent) 2 PA, QL (120

tablets/30 days)RUBRACA – rucaparib camsylate tab 300 mg (base equivalent) 2 PA, QL (120

tablets/30 days)SPRYCEL – dasatinib tab 20 mg 2 PA, QL (90 tablets/30

days), SPSPRYCEL – dasatinib tab 50 mg 2 PA, QL (30 tablets/30

days), SPSPRYCEL – dasatinib tab 70 mg 2 PA, QL (30 tablets/30

days), SP

2018


17




SPRYCEL – dasatinib tab 80 mg 2 PA, QL (30 tablets/30days), SP



STIVARGA – regorafenib tab 40 mg 2 PA, QL (90 tablets/30days), SP

SUTENT – sunitinib malate cap 12.5 mg (base equivalent) 2 PA, QL (90 capsules/30days), SP

SUTENT – sunitinib malate cap 25 mg (base equivalent) 2 PA, QL (30 capsules/30days), SP

SUTENT – sunitinib malate cap 37.5 mg (base equivalent) 2 PA, QL (30 capsules/30days), SP

SUTENT – sunitinib malate cap 50 mg (base equivalent) 2 PA, QL (30 capsules/30days), SP

SYLATRON – peginterferon alfa-2b for inj kit 200 mcg 2 PA, SPSYLATRON – peginterferon alfa-2b for inj kit 300 mcg 2 PA, SPSYLATRON – peginterferon alfa-2b for inj kit 600 mcg 2 PA, SPTAFINLAR – dabrafenib mesylate cap 50 mg (base equivalent) 2 PA, QL (120

capsules/30 days), SPTAFINLAR – dabrafenib mesylate cap 75 mg (base equivalent) 2 PA, QL (120

capsules/30 days), SPtamoxifen citrate tab 10 mg (base equivalent) 1 90tamoxifen citrate tab 20 mg (base equivalent) 1 90TARCEVA – erlotinib hcl tab 25 mg (base equivalent) 2 PA, QL (60 tablets/30

days), SPTARCEVA – erlotinib hcl tab 100 mg (base equivalent) 2 PA, QL (30 tablets/30

days), SPTARCEVA – erlotinib hcl tab 150 mg (base equivalent) 2 PA, QL (30 tablets/30

days), SPTARGRETIN – bexarotene cap 75 mg 2 PA, SPTASIGNA – nilotinib hcl cap 50 mg (base equivalent) 2 PA, QL (120

capsules/30 days)TASIGNA – nilotinib hcl cap 150 mg (base equivalent) 2 PA, QL (120

capsules/30 days), SPTASIGNA – nilotinib hcl cap 200 mg (base equivalent) 2 PA, QL (120

capsules/30 days), SP

2018


18




temozolomide cap 5 mg (Temodar) 1 PA, SPtemozolomide cap 20 mg (Temodar) 1 PA, SPtemozolomide cap 100 mg (Temodar) 1 PA, SPtemozolomide cap 140 mg (Temodar) 1 PA, SPtemozolomide cap 180 mg (Temodar) 1 PA, SPtemozolomide cap 250 mg (Temodar) 1 PA, SPtretinoin cap 10 mg 1 PA, SPTYKERB – lapatinib ditosylate tab 250 mg (base equiv) 2 PA, QL (180

tablets/30 days), SPVENCLEXTA – venetoclax tab 10 mg 2 PA, QL (60 tablets/30

days), SPVENCLEXTA – venetoclax tab 50 mg 2 PA, QL (30 tablets/30

days), SPVENCLEXTA – venetoclax tab 100 mg 2 PA, QL (120

tablets/30 days), SPVENCLEXTA STARTING PACK – venetoclax tab therapy starter

pack 10 & 50 & 100 mg2 PA, QL (1 pack/180

days), SPVERZENIO – abemaciclib tab 50 mg 2 PA, QL (60

tablets/30 days)VERZENIO – abemaciclib tab 100 mg 2 PA, QL (60



tablets/30 days)VOTRIENT – pazopanib hcl tab 200 mg (base equiv) 2 PA, QL (120

tablets/30 days), SPXALKORI – crizotinib cap 200 mg 2 PA, QL (60 capsules/30

days), SPXALKORI – crizotinib cap 250 mg 2 PA, QL (60 capsules/30

days), SPXTANDI – enzalutamide cap 40 mg 2 PA, QL (120

capsules/30 days), SPZELBORAF – vemurafenib tab 240 mg 2 PA, QL (240

tablets/30 days), SPZOLINZA – vorinostat cap 100 mg 2 PA, QL (120

capsules/30 days), SP

2018


19




ZYKADIA – ceritinib cap 150 mg 2 PA, QL (150capsules/30 days), SP

ZYTIGA – abiraterone acetate tab 250 mg 2 PA, QL (120tablets/30 days), SP

ZYTIGA – abiraterone acetate tab 500 mg 2 PA, QL (60tablets/30 days)

HORMONES, DIABETES AND RELATED DRUGSCORTICOSTEROIDSbudesonide delayed release particles cap 3 mg (Entocort ec) 1CORTISONE ACETATE – cortisone acetate tab 25 mg 2DEXAMETHASONE – dexamethasone soln 0.5 mg/5ml 2dexamethasone elixir 0.5 mg/5ml 1dexamethasone tab 0.5 mg 1dexamethasone tab 0.75 mg 1dexamethasone tab 1.5 mg 1dexamethasone tab 4 mg 1dexamethasone tab 6 mg 1fludrocortisone acetate tab 0.1 mg 1 90hydrocortisone tab 5 mg (Cortef) 1hydrocortisone tab 10 mg (Cortef) 1hydrocortisone tab 20 mg (Cortef) 1methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak) 1methylprednisolone tab 4 mg (Medrol) 1methylprednisolone tab 8 mg (Medrol) 1methylprednisolone tab 16 mg (Medrol) 1methylprednisolone tab 32 mg (Medrol) 1PREDNISOLONE – prednisolone syrup 15 mg/5ml (usp solution

equivalent)2

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

1

prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) 1prednisolone syrup 15 mg/5ml (usp solution equivalent) 1PREDNISONE – prednisone tab 50 mg 2PREDNISONE – prednisone oral soln 5 mg/5ml 2PREDNISONE – prednisone tab therapy pack 5 mg (21) 2PREDNISONE – prednisone tab therapy pack 5 mg (48) 2

2018


20




PREDNISONE – prednisone tab therapy pack 10 mg (21) 2PREDNISONE – prednisone tab therapy pack 10 mg (48) 2prednisone tab 1 mg 1prednisone tab 2.5 mg 1prednisone tab 5 mg 1prednisone tab 10 mg 1prednisone tab 20 mg 1SOLU-CORTEF – hydrocortisone sodium succinate pf for inj

100 mg2

SOLU-CORTEF – hydrocortisone sodium succinate pf for inj250 mg

2


2


2

MALE HORMONESdanazol cap 50 mg 1danazol cap 100 mg 1danazol cap 200 mg 1testosterone td gel 25 mg/2.5gm (1%) (Androgel) 1 PA, QL (60 packets/30

days), 90testosterone td gel 50 mg/5gm (1%) (Androgel) 1 PA, QL (300

grams/30 days), 90testosterone td gel 12.5 mg/act (1%) (Androgel pump) 1 PA, QL (300

grams/30 days), 90

ESTROGENSCOMBIPATCH – estradiol-norethindrone ace td pttw

0.05-0.14 mg/day2 90

COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.25 mg/day

2 90

ENJUVIA – estrogens, conjugated synthetic b tab 0.3 mg 2 90ENJUVIA – estrogens, conjugated synthetic b tab 0.45 mg 2 90ENJUVIA – estrogens, conjugated synthetic b tab 0.625 mg 2 90ENJUVIA – estrogens, conjugated synthetic b tab 0.9 mg 2 90estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella) 1 90estradiol & norethindrone acetate tab 1-0.5 mg (Activella) 1 90estradiol tab 0.5 mg (Estrace) 1 90estradiol tab 1 mg (Estrace) 1 90

2018


21




estradiol tab 2 mg (Estrace) 1 90estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot) 1 QL (8 patches/28

days), 90estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot) 1 QL (8 patches/28




days), 90estradiol td patch weekly 0.025 mg/24hr (Climara) 1 QL (4 patches/28

days), 90estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)

(Climara)1 QL (4 patches/28



days), 90estradiol td patch weekly 0.075 mg/24hr (Climara) 1 QL (4 patches/28 days)estradiol td patch weekly 0.1 mg/24hr (Climara) 1 QL (4 patches/28

days), 90ESTROPIPATE – estropipate tab 3 mg 2 90norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg

(Femhrt low dose)1 90

norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg 1 90

PROGESTINSmedroxyprogesterone acetate tab 2.5 mg (Provera) 1 90medroxyprogesterone acetate tab 5 mg (Provera) 1 90medroxyprogesterone acetate tab 10 mg (Provera) 1 90megestrol acetate susp 625 mg/5ml (Megace es) 1 90norethindrone acetate tab 5 mg (Aygestin) 1 90progesterone micronized cap 100 mg (Prometrium) 1 90progesterone micronized cap 200 mg (Prometrium) 1 90

BIRTH CONTROLELLA – ulipristal acetate tab 30 mg 2 QL (3 tablets/365 days)

2018


22




KYLEENA – levonorgestrel releasing iud 17.5 mcg/day (19.5 mgtotal)

2

LILETTA – levonorgestrel releasing iud 18.6 mcg/day (52 mgtotal)

2

MIRENA – levonorgestrel releasing iud 20 mcg/day (52 mg total) 2 90NEXPLANON – etonogestrel subdermal implant 68 mg 2 90NUVARING – etonogestrel-ethinyl estradiol va ring

0.120-0.015 mg/24hr2 QL (1 ring/21 days), 90

PARAGARD INTRAUTERINE COP – copper iud 2 90XULANE – norelgestromin-ethinyl estradiol td ptwk

150-35 mcg/24hr2 QL (4 patches/28

days), 90

ENDOMETRIOSISLUPANETA PACK – leuprolide (1 mon) inj 3.75 mg &

norethindrone tab 5 mg kit2 PA, SP

LUPANETA PACK – leuprolide (3 mon) inj 11.25 mg &norethindrone tab 5 mg kit

2 PA, SP

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

2 PA


2 PA

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

2 PA

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

2 PA

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

2 PA

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

2 SP

DIABETESacarbose tab 25 mg (Precose) 1 QL (180 tablets/30

days), 90acarbose tab 50 mg (Precose) 1 QL (180 tablets/30

days), 90acarbose tab 100 mg (Precose) 1 QL (90 tablets/30

days), 90ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (base equiv) 2 QL (30 tablets/30

days), ST, 90ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (base equiv) 2 QL (30 tablets/30

days), ST, 90

2018


23




ALOGLIPTIN – alogliptin benzoate tab 25 mg (base equiv) 2 QL (30 tablets/30days), ST, 90

ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab12.5-500 mg

2 QL (60 tablets/30days), ST, 90

ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab12.5-1000 mg


ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab12.5-15 mg






ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab25-15 mg






glimepiride tab 1 mg (Amaryl) 1 QL (60 tablets/30days), 90



glipizide tab er 24hr 2.5 mg (Glucotrol xl) 1 QL (60 tablets/30days), 90

glipizide tab er 24hr 5 mg (Glucotrol xl) 1 QL (90 tablets/30days), 90

glipizide tab er 24hr 10 mg (Glucotrol xl) 1 QL (60 tablets/30days), 90

glipizide tab 5 mg (Glucotrol) 1 QL (120 tablets/30days), 90

glipizide tab 10 mg (Glucotrol) 1 QL (120 tablets/30days), 90

glipizide-metformin hcl tab 2.5-250 mg 1 QL (120 tablets/30days), 90

glipizide-metformin hcl tab 2.5-500 mg 1 QL (120 tablets/30days), 90

2018


24




glipizide-metformin hcl tab 5-500 mg 1 QL (120 tablets/30days), 90

GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj kit 1 mg 2 QL (6 pens/365 days)glyburide micronized tab 1.5 mg (Glynase) 1 QL (120 tablets/30

days), 90glyburide micronized tab 3 mg (Glynase) 1 QL (60 tablets/30

days), 90glyburide micronized tab 6 mg (Glynase) 1 QL (60 tablets/30

days), 90glyburide tab 1.25 mg 1 QL (60 tablets/30

days), 90glyburide tab 2.5 mg 1 QL (60 tablets/30

days), 90glyburide tab 5 mg 1 QL (120 tablets/30

days), 90glyburide-metformin tab 1.25-250 mg (Glucovance) 1 QL (120 tablets/30

days), 90glyburide-metformin tab 2.5-500 mg (Glucovance) 1 QL (120 tablets/30

days), 90glyburide-metformin tab 5-500 mg (Glucovance) 1 QL (120 tablets/30

days), 90KORLYM – mifepristone tab 300 mg 2 PA, QL (120 tablets/30

days), SP, 90metformin hcl tab er 24hr 500 mg (Glucophage xr) 1 QL (120 tablets/30

days), 90metformin hcl tab er 24hr 750 mg (Glucophage xr) 1 QL (60 tablets/30

days), 90metformin hcl tab 500 mg (Glucophage) 1 QL (120 tablets/30



days), 90miglitol tab 25 mg (Glyset) 1 QL (120 tablets/30



days), 90

2018


25




nateglinide tab 60 mg (Starlix) 1 QL (120 tablets/30days), 90

nateglinide tab 120 mg (Starlix) 1 QL (90 tablets/30days), 90

pioglitazone hcl tab 15 mg (base equiv) (Actos) 1 QL (30 tablets/30days), 90



VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 2 PA, QL (3 pens/30days), 90

DIABETES - INSULINSRapid-Acting InsulinsADMELOG – insulin lispro inj 100 unit/ml 2 QL (45 mls/30 days), 90ADMELOG SOLOSTAR – insulin lispro soln pen-injector 100

unit/ml2 QL (45 mls/30 days), 90

Short-Acting InsulinsHUMULIN R – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90NOVOLIN R – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90NOVOLIN R RELION – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90RELION R – insulin regular (human) inj 100 unit/ml 2 QL (45 mls/30 days), 90

Intermediate-Acting InsulinsHUMALOG MIX 50/50 – insulin lispro protamine & lispro inj 100

unit/ml (50-50)2 QL (45 mls/30 days), 90

HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot & lispro suspen-inj 100 unit/ml (50-50)

2 QL (45 mls/30 days), 90

HUMALOG MIX 75/25 – insulin lispro prot & lispro inj 100 unit/ml(75-25)

2 QL (45 mls/30 days), 90

HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot & lispro suspen-inj 100 unit/ml (75-25)

2 QL (45 mls/30 days), 90

HUMULIN N – insulin nph (human) (isophane) inj 100 unit/ml 2 QL (45 mls/30 days), 90HUMULIN N KWIKPEN – insulin nph (human) (isophane) susp

pen-injector 100 unit/ml2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

HUMULIN 70/30 KWIKPEN – insulin nph & regular susp pen-inj100 unit/ml (70-30)

2 QL (45 mls/30 days), 90

NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml 2 QL (45 mls/30 days), 90

2018


26




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

2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

NOVOLOG MIX 70/30 – insulin aspart prot & aspart (human) inj100 unit/ml (70-30)

2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

Basal InsulinsBASAGLAR KWIKPEN – insulin glargine soln pen-injector 100

unit/ml2 QL (45 mls/30 days), 90

THYROID REGULATIONlevothyroxine sodium tab 25 mcg (Synthroid) 1 90levothyroxine sodium tab 50 mcg (Synthroid) 1 90levothyroxine sodium tab 75 mcg (Synthroid) 1 90levothyroxine sodium tab 88 mcg (Synthroid) 1 90levothyroxine sodium tab 100 mcg (Synthroid) 1 90levothyroxine sodium tab 112 mcg (Synthroid) 1 90levothyroxine sodium tab 125 mcg (Synthroid) 1 90levothyroxine sodium tab 137 mcg (Synthroid) 1 90levothyroxine sodium tab 150 mcg (Synthroid) 1 90levothyroxine sodium tab 175 mcg (Synthroid) 1 90levothyroxine sodium tab 200 mcg (Synthroid) 1 90levothyroxine sodium tab 300 mcg (Synthroid) 1 90liothyronine sodium tab 5 mcg (Cytomel) 1 90liothyronine sodium tab 25 mcg (Cytomel) 1 90liothyronine sodium tab 50 mcg (Cytomel) 1 90methimazole tab 5 mg (Tapazole) 1 90methimazole tab 10 mg (Tapazole) 1 90propylthiouracil tab 50 mg 1 90thyroid tab 30 mg (1/2 grain) (Armour thyroid) 1 90thyroid tab 60 mg (1 grain) (Armour thyroid) 1 90thyroid tab 90 mg (1 1/2 grain) (Armour thyroid) 1 90

GROWTH HORMONEINCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml) 2 PA, SP, 90

2018


27




OMNITROPE – somatropin for inj 5.8 mg 2 PA, SP, 90SEROSTIM – somatropin (non-refrigerated) for subcutaneous inj

4 mg2 PA, SP, 90

SEROSTIM – somatropin (non-refrigerated) for subcutaneous inj5 mg

2 PA, SP, 90

SEROSTIM – somatropin (non-refrigerated) for subcutaneous inj6 mg

2 PA, SP, 90

ZORBTIVE – somatropin (non-refrigerated) for subcutaneous inj8.8 mg

2 PA, SP, 90

OTHER HORMONES AND RELATED DRUGSALENDRONATE SODIUM – alendronate sodium tab 40 mg 2 QL (30 tablets/30 days)alendronate sodium tab 5 mg 1 QL (30 tablets/30

days), 90alendronate sodium tab 10 mg 1 QL (30 tablets/30

days), 90alendronate sodium tab 35 mg 1 QL (4 tablets/28 days), 90alendronate sodium tab 70 mg (Fosamax) 1 QL (4 tablets/28 days), 90BUPHENYL – sodium phenylbutyrate tab 500 mg 2 PA, SP, 90cabergoline tab 0.5 mg 1calcitonin (salmon) nasal soln 200 unit/act (Miacalcin) 1 90calcitriol cap 0.25 mcg (Rocaltrol) 1 90calcitriol cap 0.5 mcg (Rocaltrol) 1 90calcitriol oral soln 1 mcg/ml (Rocaltrol) 1 90CARBAGLU – carglumic acid tab 200 mg 2 PA, SP, 90desmopressin acetate nasal spray soln 0.01% (Ddavp) 1 90desmopressin acetate nasal spray soln 0.01% (refrigerated) 1 90desmopressin acetate tab 0.1 mg (Ddavp) 1 90desmopressin acetate tab 0.2 mg (Ddavp) 1 90ETIDRONATE DISODIUM – etidronate disodium tab 200 mg 2H.P. ACTHAR – corticotropin inj gel 80 unit/ml 2 PA, SPibandronate sodium tab 150 mg (base equivalent) (Boniva) 1 QL (1 tablets/30 days), 90KUVAN – sapropterin dihydrochloride soluble tab 100 mg 2 PA, SP, 90KUVAN – sapropterin dihydrochloride powder packet 100 mg 2 PA, SP, 90KUVAN – sapropterin dihydrochloride powder packet 500 mg 2 PA, SP, 90levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) 1 90levocarnitine tab 330 mg (Carnitor) 1 90

2018


28





2 PA


2 PA

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

2 PA

methylergonovine maleate tab 0.2 mg 1NITYR – nitisinone tab 2 mg 2 PA, 90NITYR – nitisinone tab 5 mg 2 PA, 90NITYR – nitisinone tab 10 mg 2 PA, 90raloxifene hcl tab 60 mg (Evista) 1 90RAVICTI – glycerol phenylbutyrate liquid 1.1 gm/ml 2 PA, SP, 90risedronate sodium tab delayed release 35 mg (Atelvia) 1 QL (4 tablets/28 days), 90SAMSCA – tolvaptan tab 15 mg 2 PA, QL (30 tablets/365

days), SPSAMSCA – tolvaptan tab 30 mg 2 PA, QL (60 tablets/365

days), SPSIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (base equiv) 2 PA, QL (60 mls/30

days), SP, 90SIGNIFOR – pasireotide diaspartate inj 0.6 mg/ml (base equiv) 2 PA, QL (60 mls/30

days), SP, 90SIGNIFOR – pasireotide diaspartate inj 0.9 mg/ml (base equiv) 2 PA, QL (60 mls/30

days), SP, 90SOMAVERT – pegvisomant for inj 10 mg (as protein) 2 PA, QL (30 vials/30





days), SP, 90STIMATE – desmopressin acetate nasal soln 1.5 mg/ml 2 90XURIDEN – uridine triacetate oral granules packet 2 gm 2 SP, 90

HEART AND CIRCULATORY DRUGSANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIbenazepril & hydrochlorothiazide tab 5-6.25 mg 1 90

2018


29




benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) 1 90benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct) 1 90benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct) 1 90benazepril hcl tab 5 mg 1 90benazepril hcl tab 10 mg (Lotensin) 1 90benazepril hcl tab 20 mg (Lotensin) 1 90benazepril hcl tab 40 mg (Lotensin) 1 90captopril tab 12.5 mg 1 90captopril tab 25 mg 1 90captopril tab 50 mg 1 90captopril tab 100 mg 1 90CAPTOPRIL/HYDROCHLOROTHIA – captopril &

hydrochlorothiazide tab 25-15 mg2 90

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

2 90


2 90


2 90

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1 90enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic) 1 90enalapril maleate tab 2.5 mg (Vasotec) 1 90enalapril maleate tab 5 mg (Vasotec) 1 90enalapril maleate tab 10 mg (Vasotec) 1 90enalapril maleate tab 20 mg (Vasotec) 1 90fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg 1 90fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg 1 90fosinopril sodium tab 10 mg 1 90fosinopril sodium tab 20 mg 1 90fosinopril sodium tab 40 mg 1 90lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic) 1 90lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) 1 90lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic) 1 90lisinopril tab 2.5 mg (Zestril) 1 90lisinopril tab 5 mg (Prinivil) 1 90lisinopril tab 10 mg (Prinivil) 1 90

2018


30




lisinopril tab 20 mg (Prinivil) 1 90lisinopril tab 30 mg (Zestril) 1 90lisinopril tab 40 mg (Zestril) 1 90moexipril hcl tab 7.5 mg 1 90moexipril hcl tab 15 mg 1 90moexipril-hydrochlorothiazide tab 7.5-12.5 mg 1 90moexipril-hydrochlorothiazide tab 15-12.5 mg 1 90moexipril-hydrochlorothiazide tab 15-25 mg 1 90perindopril erbumine tab 2 mg 1 90perindopril erbumine tab 4 mg (Aceon) 1 90perindopril erbumine tab 8 mg (Aceon) 1 90quinapril hcl tab 5 mg (Accupril) 1 90quinapril hcl tab 10 mg (Accupril) 1 90quinapril hcl tab 20 mg (Accupril) 1 90quinapril hcl tab 40 mg (Accupril) 1 90quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic) 1 90quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic) 1 90quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic) 1 90ramipril cap 1.25 mg (Altace) 1 90ramipril cap 2.5 mg (Altace) 1 90ramipril cap 5 mg (Altace) 1 90ramipril cap 10 mg (Altace) 1 90trandolapril tab 1 mg (Mavik) 1 90trandolapril tab 2 mg (Mavik) 1 90trandolapril tab 4 mg 1 90

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONSirbesartan tab 75 mg (Avapro) 1 QL (30 tablets/30

days), 90irbesartan tab 150 mg (Avapro) 1 QL (30 tablets/30

days), 90irbesartan tab 300 mg (Avapro) 1 QL (30 tablets/30

days), 90irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide) 1 QL (30 tablets/30

days), 90irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide) 1 QL (30 tablets/30

days), 90

2018


31




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


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


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


losartan potassium tab 25 mg (Cozaar) 1 QL (60 tablets/30days), 90



olmesartan medoxomil tab 5 mg (Benicar) 1 QL (60 tablets/30days), 90



olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg(Benicar hct)


olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg(Benicar hct)


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


valsartan tab 40 mg (Diovan) 1 QL (60 tablets/30days), 90




valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct) 1 QL (30 tablets/30days), 90


valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct) 1 QL (30 tablets/30days), 90

2018


32





valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct) 1 QL (30 tablets/30days), 90

BETA BLOCKERS AND COMBINATIONSacebutolol hcl cap 200 mg (Sectral) 1 90acebutolol hcl cap 400 mg (Sectral) 1 90atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) 1 90atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100) 1 90atenolol tab 25 mg (Tenormin) 1 90atenolol tab 50 mg (Tenormin) 1 90atenolol tab 100 mg (Tenormin) 1 90betaxolol hcl tab 10 mg (Kerlone) 1 90betaxolol hcl tab 20 mg (Kerlone) 1 90bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac) 1 90bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac) 1 90bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac) 1 90bisoprolol fumarate tab 5 mg (Zebeta) 1 90bisoprolol fumarate tab 10 mg (Zebeta) 1 90carvedilol tab 3.125 mg (Coreg) 1 90carvedilol tab 6.25 mg (Coreg) 1 90carvedilol tab 12.5 mg (Coreg) 1 90carvedilol tab 25 mg (Coreg) 1 90labetalol hcl tab 100 mg 1 90labetalol hcl tab 200 mg 1 90labetalol hcl tab 300 mg 1 90metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct) 1 90metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct) 1 90metoprolol & hydrochlorothiazide tab 100-50 mg 1 90metoprolol succinate tab er 24hr 25 mg (tartrate equiv) (Toprol xl) 1 90metoprolol succinate tab er 24hr 50 mg (tartrate equiv) (Toprol xl) 1 90metoprolol succinate tab er 24hr 100 mg (tartrate equiv) (Toprol

xl)1 90

metoprolol succinate tab er 24hr 200 mg (tartrate equiv) (Toprolxl)

1 90

metoprolol tartrate tab 25 mg 1 90

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33




metoprolol tartrate tab 50 mg (Lopressor) 1 90metoprolol tartrate tab 100 mg (Lopressor) 1 90METOPROLOL/HYDROCHLOROTHI – metoprolol &


nadolol tab 20 mg (Corgard) 1 90nadolol tab 40 mg (Corgard) 1 90nadolol tab 80 mg (Corgard) 1 90pindolol tab 5 mg 1 90propranolol hcl cap er 24hr 60 mg (Inderal la) 1 90propranolol hcl cap er 24hr 80 mg (Inderal la) 1 90propranolol hcl cap er 24hr 120 mg (Inderal la) 1 90propranolol hcl cap er 24hr 160 mg (Inderal la) 1 90propranolol hcl tab 10 mg 1 90propranolol hcl tab 20 mg 1 90propranolol hcl tab 40 mg 1 90propranolol hcl tab 60 mg 1 90propranolol hcl tab 80 mg 1 90PROPRANOLOL/HYDROCHLOROTH – propranolol &


PROPRANOLOL/HYDROCHLOROTH – propranolol &hydrochlorothiazide tab 80-25 mg

2 90

CALCIUM CHANNEL BLOCKERS AND COMBINATIONSamlodipine besylate tab 2.5 mg (base equivalent) (Norvasc) 1 90amlodipine besylate tab 5 mg (base equivalent) (Norvasc) 1 90amlodipine besylate tab 10 mg (base equivalent) (Norvasc) 1 90amlodipine besylate-benazepril hcl cap 2.5-10 mg 1 90amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel) 1 90amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel) 1 90amlodipine besylate-benazepril hcl cap 5-40 mg 1 90amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel) 1 90amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel) 1 90diltiazem hcl cap er 12hr 60 mg 1 90diltiazem hcl cap er 12hr 90 mg 1 90diltiazem hcl cap er 12hr 120 mg 1 90diltiazem hcl cap er 24hr 120 mg 1 90diltiazem hcl cap er 24hr 180 mg 1 90

2018


34




diltiazem hcl cap er 24hr 240 mg 1 90diltiazem hcl coated beads cap er 24hr 120 mg (Cardizem cd) 1 90diltiazem hcl coated beads cap er 24hr 180 mg (Cardizem cd) 1 90diltiazem hcl coated beads cap er 24hr 240 mg (Cardizem cd) 1 90diltiazem hcl coated beads cap er 24hr 300 mg 1 90diltiazem hcl extended release beads cap er 24hr 120 mg

(Tiazac)1 90

diltiazem hcl extended release beads cap er 24hr 180 mg(Tiazac)

1 90


1 90


1 90


1 90


1 90

diltiazem hcl tab 30 mg (Cardizem) 1 90diltiazem hcl tab 60 mg (Cardizem) 1 90diltiazem hcl tab 90 mg 1 90diltiazem hcl tab 120 mg (Cardizem) 1 90ENTRESTO – sacubitril-valsartan tab 24-26 mg 2 PA, QL (60 tablets/30

days), 90ENTRESTO – sacubitril-valsartan tab 49-51 mg 2 PA, QL (60 tablets/30

days), 90ENTRESTO – sacubitril-valsartan tab 97-103 mg 2 PA, QL (60 tablets/30

days), 90felodipine tab er 24hr 2.5 mg 1 90felodipine tab er 24hr 5 mg 1 90felodipine tab er 24hr 10 mg 1 90isradipine cap 2.5 mg 1 90isradipine cap 5 mg 1 90nicardipine hcl cap 20 mg 1 90nifedipine cap 10 mg (Procardia) 1 90nifedipine cap 20 mg 1 90nifedipine tab er 24hr 30 mg (Adalat cc) 1 90nifedipine tab er 24hr 60 mg (Adalat cc) 1 90nifedipine tab er 24hr 90 mg (Adalat cc) 1 90

2018


35




nifedipine tab er 24hr osmotic release 30 mg (Procardia xl) 1 90nifedipine tab er 24hr osmotic release 60 mg (Procardia xl) 1 90nifedipine tab er 24hr osmotic release 90 mg (Procardia xl) 1 90nimodipine cap 30 mg 1 90trandolapril-verapamil hcl tab er 1-240 mg (Tarka) 1 90trandolapril-verapamil hcl tab er 2-180 mg (Tarka) 1 90trandolapril-verapamil hcl tab er 2-240 mg (Tarka) 1 90trandolapril-verapamil hcl tab er 4-240 mg (Tarka) 1 90TRANDOLAPRIL/VERAPAMIL HC – trandolapril-verapamil hcl

tab er 1-240 mg2 90

verapamil hcl cap er 24hr 100 mg (Verelan pm) 1 90verapamil hcl cap er 24hr 120 mg (Verelan) 1 90verapamil hcl cap er 24hr 180 mg (Verelan) 1 90verapamil hcl cap er 24hr 200 mg (Verelan pm) 1 90verapamil hcl cap er 24hr 240 mg (Verelan) 1 90verapamil hcl cap er 24hr 300 mg (Verelan pm) 1 90verapamil hcl cap er 24hr 360 mg (Verelan) 1 90verapamil hcl tab er 120 mg (Calan sr) 1 90verapamil hcl tab er 180 mg (Calan sr) 1 90verapamil hcl tab er 240 mg (Calan sr) 1 90verapamil hcl tab 40 mg 1 90verapamil hcl tab 80 mg (Calan) 1 90verapamil hcl tab 120 mg (Calan) 1 90

CHEST PAINisosorbide mononitrate tab er 24hr 30 mg 1 90isosorbide mononitrate tab er 24hr 60 mg 1 90isosorbide mononitrate tab er 24hr 120 mg 1 90isosorbide mononitrate tab 10 mg 1 90isosorbide mononitrate tab 20 mg 1 90nitroglycerin cap er 2.5 mg 1 90nitroglycerin cap er 6.5 mg 1 90nitroglycerin cap er 9 mg 1 90nitroglycerin sl tab 0.3 mg (Nitrostat) 1 90nitroglycerin sl tab 0.4 mg (Nitrostat) 1 90nitroglycerin sl tab 0.6 mg (Nitrostat) 1 90

2018


36




nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) 1 90nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) 1 90nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) 1 90nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur) 1 90

CHOLESTEROL LOWERINGatorvastatin calcium tab 10 mg (base equivalent) (Lipitor) 1 QL (30 tablets/30

days), 90atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) 1 QL (30 tablets/30



days), 90cholestyramine light powder packets 4 gm 1 90cholestyramine light powder 4 gm/dose (Questran light) 1 90cholestyramine powder packets 4 gm (Questran) 1 90cholestyramine powder 4 gm/dose (Questran) 1 90choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix) 1 QL (60 tablets/30

days), 90colestipol hcl granule packets 5 gm (Colestid flavored) 1 90colestipol hcl granules 5 gm (Colestid flavored) 1 90colestipol hcl tab 1 gm (Colestid) 1 90fenofibrate micronized cap 43 mg 1 QL (60 capsules/30

days), 90fenofibrate micronized cap 67 mg (Lofibra) 1 QL (30 capsules/30



days), 90fenofibrate tab 48 mg (Tricor) 1 QL (60 tablets/30

days), 90fenofibrate tab 54 mg (Lofibra) 1 QL (60 tablets/30

days), 90fenofibrate tab 145 mg (Tricor) 1 QL (30 tablets/30

days), 90

2018


37




fenofibrate tab 160 mg (Lofibra) 1 QL (30 tablets/30days), 90

fluvastatin sodium tab er 24 hr 80 mg (Lescol xl) 1 QL (30 tablets/30days), 90

gemfibrozil tab 600 mg (Lopid) 1 QL (60 tablets/30days), 90

JUXTAPID – lomitapide mesylate cap 5 mg (base equiv) 2 PA, QL (30 capsules/30days), SP, 90






lovastatin tab 10 mg 1 QL (60 tablets/30days), 90

lovastatin tab 20 mg 1 QL (60 tablets/30days), 90

lovastatin tab 40 mg (Mevacor) 1 QL (60 tablets/30days), 90

PRALUENT – alirocumab subcutaneous soln pen-injector 75 mg/ml

2 PA, QL (2 pens/28days), SP, 90

PRALUENT – alirocumab subcutaneous soln pen-injector150 mg/ml

2 PA, QL (2 pens/28days), SP, 90

PRALUENT – alirocumab subcutaneous soln prefilled syringe75 mg/ml

2 PA, QL (2 syringes/28days), SP, 90

PRALUENT – alirocumab subcutaneous soln prefilled syringe150 mg/ml


pravastatin sodium tab 10 mg 1 QL (45 tablets/30days), 90

pravastatin sodium tab 20 mg (Pravachol) 1 QL (45 tablets/30days), 90


2018


38





REPATHA – evolocumab subcutaneous soln prefilled syringe140 mg/ml


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

2 PA, QL (1 syringe/30days), SP, 90

REPATHA SURECLICK – evolocumab subcutaneous soln auto-injector 140 mg/ml


rosuvastatin calcium tab 5 mg (Crestor) 1 QL (30 tablets/30days), 90




simvastatin tab 5 mg (Zocor) 1 QL (30 tablets/30days), 90





FLUID RETENTIONacetazolamide cap er 12hr 500 mg (Diamox) 1 90acetazolamide tab 250 mg 1 90amiloride & hydrochlorothiazide tab 5-50 mg 1 90amiloride hcl tab 5 mg 1 90bumetanide tab 0.5 mg (Bumex) 1 90bumetanide tab 1 mg (Bumex) 1 90bumetanide tab 2 mg (Bumex) 1 90CHLOROTHIAZIDE – chlorothiazide tab 250 mg 2 90chlorothiazide tab 500 mg 1 90chlorthalidone tab 25 mg 1 90

2018


39




furosemide oral soln 10 mg/ml 1 90furosemide tab 20 mg (Lasix) 1 90furosemide tab 40 mg (Lasix) 1 90furosemide tab 80 mg (Lasix) 1 90hydrochlorothiazide cap 12.5 mg (Microzide) 1 90hydrochlorothiazide tab 12.5 mg 1 90hydrochlorothiazide tab 25 mg 1 90hydrochlorothiazide tab 50 mg 1 90indapamide tab 1.25 mg 1 90indapamide tab 2.5 mg 1 90metolazone tab 2.5 mg 1 90metolazone tab 5 mg 1 90metolazone tab 10 mg 1 90spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide) 1 90spironolactone tab 25 mg (Aldactone) 1 90spironolactone tab 50 mg (Aldactone) 1 90spironolactone tab 100 mg (Aldactone) 1 90torsemide tab 5 mg 1 90torsemide tab 10 mg (Demadex) 1 90torsemide tab 20 mg (Demadex) 1 90torsemide tab 100 mg 1 90triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide) 1 90triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25) 1 90triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) 1 90

HEART RHYTHMamiodarone hcl tab 200 mg (Cordarone) 1 90disopyramide phosphate cap 100 mg (Norpace) 1 90disopyramide phosphate cap 150 mg (Norpace) 1 90dofetilide cap 125 mcg (0.125 mg) (Tikosyn) 1 90dofetilide cap 250 mcg (0.25 mg) (Tikosyn) 1 90dofetilide cap 500 mcg (0.5 mg) (Tikosyn) 1 90flecainide acetate tab 50 mg 1 90flecainide acetate tab 100 mg 1 90flecainide acetate tab 150 mg 1 90propafenone hcl tab 150 mg 1 90

2018


40




propafenone hcl tab 225 mg (Rythmol) 1 90propafenone hcl tab 300 mg 1 90quinidine gluconate tab er 324 mg 1 90QUINIDINE SULFATE – quinidine sulfate tab 200 mg 2 90QUINIDINE SULFATE – quinidine sulfate tab 300 mg 2 90sotalol hcl (afib/afl) tab 80 mg (Betapace af) 1 90sotalol hcl (afib/afl) tab 120 mg (Betapace af) 1 90sotalol hcl (afib/afl) tab 160 mg (Betapace af) 1 90sotalol hcl tab 80 mg (Betapace) 1 90sotalol hcl tab 120 mg (Betapace) 1 90sotalol hcl tab 160 mg (Betapace) 1 90sotalol hcl tab 240 mg 1 90

OTHER HEART RELATED DRUGSADCIRCA – tadalafil tab 20 mg (pah) 2 PA, QL (60 tablets/30

days), SP, 90ADEMPAS – riociguat tab 0.5 mg 2 PA, QL (90 tablets/30

days), SP, 90ADEMPAS – riociguat tab 1 mg 2 PA, QL (90 tablets/30


days), SP, 90ADEMPAS – riociguat tab 2 mg 2 PA, QL (90 tablets/30


days), SP, 90clonidine hcl tab 0.1 mg (Catapres) 1 90clonidine hcl tab 0.2 mg (Catapres) 1 90clonidine hcl tab 0.3 mg (Catapres) 1 90clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1) 1 90clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2) 1 90clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3) 1 90DIGOXIN – digoxin oral soln 0.05 mg/ml 2 90digoxin tab 125 mcg (0.125 mg) (Lanoxin) 1 90digoxin tab 250 mcg (0.25 mg) (Lanoxin) 1 90doxazosin mesylate tab 1 mg (Cardura) 1 QL (30 tablets/30

days), 90

2018


41




doxazosin mesylate tab 2 mg (Cardura) 1 QL (30 tablets/30days), 90



guanfacine hcl tab 1 mg (Tenex) 1 90guanfacine hcl tab 2 mg (Tenex) 1 90hydralazine hcl tab 10 mg 1 90hydralazine hcl tab 25 mg 1 90hydralazine hcl tab 50 mg 1 90hydralazine hcl tab 100 mg 1 90LETAIRIS – ambrisentan tab 5 mg 2 PA, QL (30 tablets/30

days), SP, 90LETAIRIS – ambrisentan tab 10 mg 2 PA, QL (30 tablets/30

days), SP, 90methyldopa tab 250 mg 1 90methyldopa tab 500 mg 1 90midodrine hcl tab 2.5 mg 1midodrine hcl tab 5 mg 1midodrine hcl tab 10 mg 1minoxidil tab 2.5 mg 1 90minoxidil tab 10 mg 1 90phenoxybenzamine hcl cap 10 mg (Dibenzyline) 1prazosin hcl cap 1 mg (Minipress) 1 90prazosin hcl cap 2 mg (Minipress) 1 90prazosin hcl cap 5 mg (Minipress) 1 90REVATIO – sildenafil citrate for suspension 10 mg/ml 2 PA, QL (2 bottles/30

days), SP, 90terazosin hcl cap 1 mg (base equivalent) 1 QL (30 capsules/30

days), 90terazosin hcl cap 2 mg (base equivalent) 1 QL (30 capsules/30



days), 90

2018


42




TRACLEER – bosentan tab for oral susp 32 mg 2 PA, QL (120tablets/30 days)

TRACLEER – bosentan tab 62.5 mg 2 PA, QL (60 tablets/30days), SP, 90

TRACLEER – bosentan tab 125 mg 2 PA, QL (60 tablets/30days), SP, 90

TYVASO – treprostinil inhalation solution 0.6 mg/ml 2 PA, QL (81.2 mls/28days), SP, 90

TYVASO REFILL – treprostinil inhalation solution 0.6 mg/ml 2 PA, QL (81.2 mls/28days), SP, 90

TYVASO STARTER – treprostinil inhalation solution 0.6 mg/ml 2 PA, QL (1 kit/180days), SP, 90

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

2 PA, QL (200tablets/180 days), SP

UPTRAVI – selexipag tab 200 mcg 2 PA, QL (60 tablets/30days), SP, 90








VENTAVIS – iloprost inhalation solution 10 mcg/ml 2 SP, 90VENTAVIS – iloprost inhalation solution 20 mcg/ml 2 SP, 90

ANAPHYLAXISEPINEPHRINE – epinephrine solution auto-injector

0.15 mg/0.3ml (1:2000)2 QL (2 pens/1

prescription)EPINEPHRINE – epinephrine solution auto-injector 0.3 mg/0.3ml

(1:1000)2 QL (2 pens/1

prescription)

RESPIRATORY AGENTS

2018


43




ANTIHISTAMINEScarbinoxamine maleate soln 4 mg/5ml 1carbinoxamine maleate tab 4 mg 1cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) 1cyproheptadine hcl syrup 2 mg/5ml 1cyproheptadine hcl tab 4 mg 1desloratadine tab 5 mg (Clarinex) 1diphenhydramine hcl cap 50 mg 1levocetirizine dihydrochloride tab 5 mg (Xyzal) 1promethazine hcl suppos 12.5 mg 1promethazine hcl suppos 25 mg 1promethazine hcl syrup 6.25 mg/5ml 1promethazine hcl tab 12.5 mg 1promethazine hcl tab 25 mg 1promethazine hcl tab 50 mg 1

NASAL PRODUCTSazelastine hcl nasal spray 0.1% (137 mcg/spray) 1 QL (2 bottles/30 days)FLUNISOLIDE – flunisolide nasal soln 25 mcg/act (0.025%) 2 QL (3 bottles/30 days)fluticasone propionate nasal susp 50 mcg/act 1 QL (1 inhaler/30 days)ipratropium bromide nasal soln 0.03% (21 mcg/spray) 1 QL (2 bottles/30 days), 90ipratropium bromide nasal soln 0.06% (42 mcg/spray) 1 QL (3 bottles/30 days), 90triamcinolone acetonide nasal aerosol suspension 55 mcg/act 1 QL (1 bottle/30 days)

COUGH/COLD/ALLERGYacetylcysteine inhal soln 10% 1acetylcysteine inhal soln 20% 1HYDROCODONE BITARTRATE/CH – pseudoeph-chlorphen w/

hydrocodone soln 60-4-5 mg/5ml2 ME90

phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml 1phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml 1phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml 1promethazine w/ codeine syrup 6.25-10 mg/5ml 1 ME90pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml

(Zutripro)1 ME90

sodium chloride soln nebu 0.9% 1sodium chloride soln nebu 3% 1

2018


44




sodium chloride soln nebu 7% (Hyper-sal) 1sodium chloride soln nebu 10% 1

ASTHMA/COPDALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr 4 mg 2 90ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr 8 mg 2 90albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 1 QL (125 containers/30

days), 90albuterol sulfate soln nebu 0.5% (5 mg/ml) 1 QL (60 mls/30 days), 90albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) 1 QL (125 containers/30

days), 90albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) 1 QL (125 containers/30

days), 90albuterol sulfate syrup 2 mg/5ml 1 90albuterol sulfate tab er 12hr 4 mg (Vospire er) 1 90albuterol sulfate tab er 12hr 8 mg (Vospire er) 1 90albuterol sulfate tab 2 mg 1 90albuterol sulfate tab 4 mg 1 90ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath

activ 100 mcg/act2 QL (30 blisters/30

days), 90ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath

activ 200 mcg/act2 QL (30 blisters/30

days), 90ATROVENT HFA – ipratropium bromide hfa inhal aerosol

17 mcg/act2 QL (2 inhalers/30

days), 90budesonide inhalation susp 0.25 mg/2ml (Pulmicort) 1 QL (60 containers/30

days), 90budesonide inhalation susp 0.5 mg/2ml (Pulmicort) 1 QL (60 containers/30

days), 90budesonide inhalation susp 1 mg/2ml (Pulmicort) 1 QL (60 mls/30 days), 90COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol

soln 20-100 mcg/act2 QL (2 inhalers/30

days), 90dyphylline-guaifenesin liqd 100-100 mg/5ml 1FLOVENT DISKUS – fluticasone propionate aer pow ba 50 mcg/

blister2 AL, QL (1 inhaler/30

days), 90FLOVENT DISKUS – fluticasone propionate aer pow ba

100 mcg/blister2 AL, QL (1 inhaler/30

days), 90FLOVENT DISKUS – fluticasone propionate aer pow ba

250 mcg/blister2 AL, QL (4 inhalers/30

days), 90

2018


45




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

2 AL, QL (1 inhaler/30days), 90

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


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

2 AL, QL (2 inhalers/30days), 90

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

2 QL (1 inhaler/30days), 90





INCRUSE ELLIPTA – umeclidinium br aero powd breath act62.5 mcg/inh (base eq)

2 QL (30 blisters/30days), 90

ipratropium bromide inhal soln 0.02% 1 QL (125 cartridges/30days), 90

ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml 1 QL (180 containers/30days), 90

montelukast sodium chew tab 4 mg (base equiv) (Singulair) 1 QL (30 tablets/30days), 90

montelukast sodium chew tab 5 mg (base equiv) (Singulair) 1 QL (30 tablets/30days), 90

montelukast sodium oral granules packet 4 mg (base equiv)(Singulair)

1 QL (30 packets/30days), 90

montelukast sodium tab 10 mg (base equiv) (Singulair) 1 QL (30 tablets/30days), 90

NUCALA – mepolizumab for inj 100 mg 2 SP, 90QVAR – beclomethasone diprop inhal aero soln 40 mcg/act (50/

valve)2 AL, QL (2 containers/30

days), 90QVAR – beclomethasone diprop inhal aero soln 80 mcg/act (100/

valve)2 AL, QL (2 containers/30

days), 90QVAR REDIHALER – beclomethasone diprop hfa breath act inh

aer 40 mcg/act2 AL, QL (1

inhaler/30 days)QVAR REDIHALER – beclomethasone diprop hfa breath act inh

aer 80 mcg/act2 AL, QL (2

inhalers/30 days)STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln

2.5 mcg/act (base equiv)2 QL (1 inhaler/30

days), 90SYMBICORT – budesonide-formoterol fumarate dihyd aerosol

80-4.5 mcg/act2 AL, QL (1 inhaler/30

days), 90

2018


46




SYMBICORT – budesonide-formoterol fumarate dihyd aerosol160-4.5 mcg/act


terbutaline sulfate tab 2.5 mg 1 90terbutaline sulfate tab 5 mg 1 90theophylline soln 80 mg/15ml 1 90theophylline tab er 12hr 100 mg 1 90theophylline tab er 12hr 200 mg 1 90theophylline tab er 12hr 300 mg 1 90theophylline tab er 12hr 450 mg 1 90theophylline tab er 24hr 400 mg 1 90theophylline tab er 24hr 600 mg 1 90VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act

(90mcg base equiv)2 QL (3 inhalers/30

days), 90

OTHER RESPIRATORY DRUGSESBRIET – pirfenidone cap 267 mg 2 PA, QL (180 capsules/30

days), SP, 90KALYDECO – ivacaftor tab 150 mg 2 PA, QL (60 tablets/30

days), SP, 90KALYDECO – ivacaftor packet 50 mg 2 PA, QL (60 packets/30

days), SP, 90KALYDECO – ivacaftor packet 75 mg 2 PA, QL (60 packets/30

days), SP, 90OFEV – nintedanib esylate cap 100 mg (base equivalent) 2 PA, QL (60 capsules/30

days), SP, 90OFEV – nintedanib esylate cap 150 mg (base equivalent) 2 PA, QL (60 capsules/30

days), SP, 90ORKAMBI – lumacaftor-ivacaftor tab 100-125 mg 2 PA, QL (120 tablets/30

days), SP, 90ORKAMBI – lumacaftor-ivacaftor tab 200-125 mg 2 PA, QL (120 tablets/30

days), SP, 90PULMOZYME – dornase alfa inhal soln 1 mg/ml 2 PA, SP, 90

GASTROINTESTINAL DRUGSLAXATIVESbisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit 1lactulose solution 10 gm/15ml 1 90peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor

pack)1

2018


47




peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely) 1peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte-

flavor packs)1

polyethylene glycol 3350 oral packet 1polyethylene glycol 3350 oral powder 1

ANTIDIARRHEALSdiphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil) 1loperamide hcl cap 2 mg 1

ULCER/GERDchlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg (Librax) 1CIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml 2 90cimetidine tab 200 mg 1cimetidine tab 300 mg 1 90cimetidine tab 400 mg 1 90cimetidine tab 800 mg 1 90dicyclomine hcl cap 10 mg (Bentyl) 1dicyclomine hcl oral soln 10 mg/5ml 1dicyclomine hcl tab 20 mg (Bentyl) 1famotidine for susp 40 mg/5ml (Pepcid) 1 90famotidine tab 20 mg (Pepcid) 1 90famotidine tab 40 mg (Pepcid) 1 90glycopyrrolate tab 1 mg (Robinul) 1glycopyrrolate tab 2 mg (Robinul forte) 1hyoscyamine sulfate elixir 0.125 mg/5ml 1 90hyoscyamine sulfate soln 0.125 mg/ml 1 90hyoscyamine sulfate tab disint 0.125 mg (Anaspaz) 1 90hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid) 1 90hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl) 1 90hyoscyamine sulfate tab 0.125 mg (Levsin) 1 90lansoprazole cap delayed release 15 mg (Prevacid) 1 QL (120 capsules/365

days), 90lansoprazole cap delayed release 30 mg (Prevacid) 1 QL (120 capsules/365

days), 90methscopolamine bromide tab 2.5 mg (Pamine) 1misoprostol tab 100 mcg (Cytotec) 1 90

2018


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misoprostol tab 200 mcg (Cytotec) 1 90nizatidine cap 150 mg 1 90nizatidine cap 300 mg 1 90omeprazole cap delayed release 10 mg (Prilosec) 1 QL (120 capsules/365

days), 90omeprazole cap delayed release 20 mg (Prilosec) 1 QL (120 capsules/365

days), 90omeprazole cap delayed release 40 mg (Prilosec) 1 QL (120 capsules/365

days), 90pantoprazole sodium ec tab 20 mg (base equiv) (Protonix) 1 QL (120 packets/365

days), 90pantoprazole sodium ec tab 40 mg (base equiv) (Protonix) 1 QL (120 packets/365

days), 90rabeprazole sodium ec tab 20 mg (Aciphex) 1 QL (120 capsules/365

days), 90ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1 90ranitidine hcl tab 150 mg (Zantac) 1 90ranitidine hcl tab 300 mg (Zantac) 1 90sucralfate tab 1 gm (Carafate) 1 90

NAUSEA AND VOMITINGmeclizine hcl tab 12.5 mg 1meclizine hcl tab 25 mg 1ondansetron hcl oral soln 4 mg/5ml (Zofran) 1 QL (300 mls/30 days)ondansetron hcl tab 4 mg (Zofran) 1 QL (30 tablets/30 days)ondansetron hcl tab 8 mg (Zofran) 1 QL (30 tablets/30 days)ondansetron hcl tab 24 mg 1 QL (1 tablet/30 days)ondansetron orally disintegrating tab 4 mg (Zofran odt) 1 QL (30 tablets/30 days)ondansetron orally disintegrating tab 8 mg (Zofran odt) 1 QL (30 tablets/30 days)trimethobenzamide hcl cap 300 mg (Tigan) 1

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

unit2 90

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

2 90

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

2 90

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2 90


2 90

SUCRAID – sacrosidase soln 8500 unit/ml 2 PA, SP, 90ZENPEP – pancrelipase (lip-prot-amyl) dr cap

3000-10000-16000 unit2 90

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

2


2 90


2


2 90


2


2 90


2


2 90


2 90


2


2


2 90

OTHER GASTROINTESTINAL DRUGSalosetron hcl tab 0.5 mg (base equiv) (Lotronex) 1 PA, QL (60 tablets/30

days), 90alosetron hcl tab 1 mg (base equiv) (Lotronex) 1 PA, QL (60 tablets/30

days), 90balsalazide disodium cap 750 mg (Colazal) 1calcium acetate (phosphate binder) cap 667 mg (169 mg ca)

(Phoslo)1 90

calcium acetate (phosphate binder) tab 667 mg (Eliphos) 1CANASA – mesalamine suppos 1000 mg 2CHENODAL – chenodiol tab 250 mg 2 PA, SP

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CHOLBAM – cholic acid cap 50 mg 2 90CHOLBAM – cholic acid cap 250 mg 2 90CIMZIA – certolizumab pegol for inj kit 2 x 200 mg 2 PA, QL (2 vials/28

days), SPCIMZIA – certolizumab pegol inj kit 2 x 200 mg/ml 2 PA, QL (2 syringes/28

days), SP, 90CIMZIA STARTER KIT – certolizumab pegol inj kit 6 x 200 mg/ml 2 PA, QL (1 kit/180

days), SP, 90GATTEX – teduglutide (rdna) for inj kit 5 mg 2 PA, SP, 90lactulose (encephalopathy) solution 10 gm/15ml 1 90MESALAMINE DR – mesalamine tab delayed release 800 mg 2mesalamine enema 4 gm 1mesalamine rectal enema 4 gm & cleanser wipe kit (Rowasa) 1metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv) 1metoclopramide hcl tab 5 mg (base equivalent) (Reglan) 1metoclopramide hcl tab 10 mg (base equivalent) (Reglan) 1 90PENTASA – mesalamine cap er 250 mg 2 90PENTASA – mesalamine cap er 500 mg 2 90sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs) 1 90sulfasalazine tab 500 mg (Azulfidine) 1 90ursodiol cap 300 mg (Actigall) 1 90ursodiol tab 250 mg (Urso 250) 1 90ursodiol tab 500 mg (Urso forte) 1 90

GENITOURINARY DRUGSURINARY TRACT INFECTIONSnitrofurantoin macrocrystalline cap 25 mg (Macrodantin) 1nitrofurantoin macrocrystalline cap 50 mg (Macrodantin) 1nitrofurantoin macrocrystalline cap 100 mg (Macrodantin) 1nitrofurantoin monohydrate macrocrystalline cap 100 mg

(Macrobid)1

URINARY TRACT SPASMSbethanechol chloride tab 5 mg (Urecholine) 1bethanechol chloride tab 10 mg (Urecholine) 1bethanechol chloride tab 25 mg (Urecholine) 1bethanechol chloride tab 50 mg (Urecholine) 1

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darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv)(Enablex)


darifenacin hydrobromide tab er 24hr 15 mg (base equiv)(Enablex)


flavoxate hcl tab 100 mg 1 90oxybutynin chloride syrup 5 mg/5ml 1 QL (600 mls/30 days), 90oxybutynin chloride tab er 24hr 5 mg (Ditropan xl) 1 QL (30 tablets/30

days), 90oxybutynin chloride tab er 24hr 10 mg (Ditropan xl) 1 QL (60 tablets/30

days), 90oxybutynin chloride tab er 24hr 15 mg (Ditropan xl) 1 QL (60 tablets/30

days), 90oxybutynin chloride tab 5 mg 1 QL (120 tablets/30

days), 90tolterodine tartrate tab 2 mg (Detrol) 1 QL (60 tablets/30

days), 90trospium chloride cap er 24hr 60 mg 1 QL (30 capsules/30

days), 90trospium chloride tab 20 mg 1 QL (60 tablets/30

days), 90

VAGINAL PRODUCTSclindamycin phosphate vaginal cream 2% (Cleocin) 1estradiol vaginal tab 10 mcg (Vagifem) 1 90metronidazole vaginal gel 0.75% (Metrogel-vaginal) 1TERCONAZOLE – terconazole vaginal cream 0.8% 2terconazole vaginal cream 0.4% (Terazol 7) 1terconazole vaginal cream 0.8% (Terazol 3) 1terconazole vaginal suppos 80 mg 1

OTHER GENITOURINARY DRUGSacetic acid irrigation soln 0.25% 1alfuzosin hcl tab er 24hr 10 mg (Uroxatral) 1 QL (30 tablets/30

days), 90CYSTAGON – cysteamine bitartrate cap 50 mg 2 PA, SP, 90CYSTAGON – cysteamine bitartrate cap 150 mg 2 PA, SP, 90dutasteride cap 0.5 mg (Avodart) 1 QL (30 capsules/30

days), 90

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dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn) 1 QL (30 capsules/30days), 90

finasteride tab 5 mg (Proscar) 1 QL (30 tablets/30days), 90

glycine irrigation soln 1.5% 1neomycin-polymyxin b gu irrigation soln (Neosporin gu irrigan) 1phenazopyridine hcl tab 100 mg (Pyridium) 1phenazopyridine hcl tab 200 mg (Pyridium) 1pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml 1potassium citrate & citric acid powder pack 3300-1002 mg 1potassium citrate & citric acid soln 1100-334 mg/5ml 1potassium citrate tab er 5 meq (540 mg) (Urocit-k 5) 1potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10) 1potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15) 1POTASSIUM CITRATE/SODIUM – pot & sod citrates w/ cit ac

soln 550-500-334 mg/5ml2

PROCYSBI – cysteamine bitartrate cap delayed release 25 mg(base equiv)

2 PA, SP, 90

PROCYSBI – cysteamine bitartrate cap delayed release 75 mg(base equiv)

2 PA, SP, 90

sodium chloride irrigation soln 0.9% 1sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution

modi)1

tamsulosin hcl cap 0.4 mg (Flomax) 1 QL (60 capsules/30days), 90

TRICITRATES – pot & sod citrates w/ cit ac soln550-500-334 mg/5ml

2

CENTRAL NERVOUS SYSTEM DRUGSANXIETYALPRAZOLAM INTENSOL – alprazolam conc 1 mg/ml 2 QL (180 mls/30 days)alprazolam tab er 24hr 0.5 mg (Xanax xr) 1 QL (30 tablets/30 days)alprazolam tab er 24hr 1 mg (Xanax xr) 1 QL (30 tablets/30 days)alprazolam tab er 24hr 2 mg (Xanax xr) 1 QL (90 tablets/30 days)alprazolam tab er 24hr 3 mg (Xanax xr) 1 QL (60 tablets/30 days)alprazolam tab 0.25 mg (Xanax) 1 QL (120 tablets/30 days)alprazolam tab 0.5 mg (Xanax) 1 QL (120 tablets/30 days)alprazolam tab 1 mg (Xanax) 1 QL (120 tablets/30 days)

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alprazolam tab 2 mg (Xanax) 1 QL (90 tablets/30 days)buspirone hcl tab 5 mg 1buspirone hcl tab 10 mg 1buspirone hcl tab 15 mg 1buspirone hcl tab 30 mg 1chlordiazepoxide hcl cap 5 mg 1 QL (120

capsules/30 days)chlordiazepoxide hcl cap 10 mg 1 QL (120

capsules/30 days)chlordiazepoxide hcl cap 25 mg 1 QL (120

capsules/30 days)clorazepate dipotassium tab 3.75 mg 1 QL (90 tablets/30 days)clorazepate dipotassium tab 7.5 mg (Tranxene t) 1 QL (90 tablets/30 days)clorazepate dipotassium tab 15 mg 1 QL (120 tablets/30 days)DIAZEPAM – diazepam im solution auto-inj 10 mg/2ml 2 PADIAZEPAM – diazepam oral soln 1 mg/ml 2 QL (1200 mls/30 days)diazepam conc 5 mg/ml 1 QL (240 mls/30 days)diazepam tab 2 mg (Valium) 1 QL (120 tablets/30 days)diazepam tab 5 mg (Valium) 1 QL (120 tablets/30 days)diazepam tab 10 mg (Valium) 1 QL (120 tablets/30 days)hydroxyzine hcl syrup 10 mg/5ml 1hydroxyzine hcl tab 10 mg 1hydroxyzine hcl tab 25 mg 1hydroxyzine hcl tab 50 mg 1hydroxyzine pamoate cap 25 mg (Vistaril) 1hydroxyzine pamoate cap 50 mg (Vistaril) 1lorazepam conc 2 mg/ml 1 QL (150 mls/30 days)lorazepam tab 0.5 mg (Ativan) 1 QL (90 tablets/30 days)lorazepam tab 1 mg (Ativan) 1 QL (90 tablets/30 days)lorazepam tab 2 mg (Ativan) 1 QL (150 tablets/30 days)

DEPRESSIONamitriptyline hcl tab 10 mg 1 90amitriptyline hcl tab 25 mg (Elavil) 1 90amitriptyline hcl tab 50 mg 1 90amitriptyline hcl tab 75 mg 1 90

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amitriptyline hcl tab 100 mg 1 90amitriptyline hcl tab 150 mg 1 90AMOXAPINE – amoxapine tab 25 mg 2 PA, 90AMOXAPINE – amoxapine tab 50 mg 2 PA, 90AMOXAPINE – amoxapine tab 100 mg 2 PA, 90AMOXAPINE – amoxapine tab 150 mg 2 PA, 90APLENZIN – bupropion hbr tab er 24hr 174 mg 2 PA, QL (30 tablets/30

days), 90APLENZIN – bupropion hbr tab er 24hr 348 mg 2 PA, QL (30 tablets/30

days), 90APLENZIN – bupropion hbr tab er 24hr 522 mg 2 PA, QL (30 tablets/30

days), 90BRINTELLIX – vortioxetine hbr tab 5 mg (base equiv) 2 QL (30 tablets/30



days), 90bupropion hcl tab er 12hr 100 mg (Wellbutrin sr) 1 QL (60 tablets/30



days), 90bupropion hcl tab er 24hr 150 mg (Wellbutrin xl) 1 QL (30 tablets/30

days), 90bupropion hcl tab er 24hr 300 mg (Wellbutrin xl) 1 QL (30 tablets/30

days), 90bupropion hcl tab 75 mg 1 QL (60 tablets/30

days), 90bupropion hcl tab 100 mg 1 QL (120 tablets/30

days), 90citalopram hydrobromide oral soln 10 mg/5ml 1 QL (600 mls/30 days), 90citalopram hydrobromide tab 10 mg (base equiv) (Celexa) 1 QL (30 tablets/30

days), 90citalopram hydrobromide tab 20 mg (base equiv) (Celexa) 1 QL (30 tablets/30

days), 90

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citalopram hydrobromide tab 40 mg (base equiv) (Celexa) 1 QL (30 tablets/30days), 90

desipramine hcl tab 10 mg (Norpramin) 1 90desipramine hcl tab 25 mg (Norpramin) 1 90desipramine hcl tab 50 mg 1 90desipramine hcl tab 75 mg 1 90desipramine hcl tab 100 mg 1 90desipramine hcl tab 150 mg 1 90doxepin hcl cap 10 mg 1 90doxepin hcl cap 25 mg 1 90doxepin hcl cap 50 mg 1 90doxepin hcl cap 75 mg 1 90doxepin hcl cap 100 mg 1 90doxepin hcl cap 150 mg 1 90doxepin hcl conc 10 mg/ml 1 90duloxetine hcl enteric coated pellets cap 20 mg (base eq)

(Cymbalta)1 QL (60 capsules/30

days), 90duloxetine hcl enteric coated pellets cap 30 mg (base eq)


days), 90duloxetine hcl enteric coated pellets cap 60 mg (base eq)


days), 90EMSAM – selegiline td patch 24hr 6 mg/24hr 2 PA, 90EMSAM – selegiline td patch 24hr 9 mg/24hr 2 PA, 90EMSAM – selegiline td patch 24hr 12 mg/24hr 2 PA, 90escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro) 1 QL (600 mls/30 days), 90escitalopram oxalate tab 5 mg (base equiv) (Lexapro) 1 QL (30 tablets/30

days), 90escitalopram oxalate tab 10 mg (base equiv) (Lexapro) 1 QL (30 tablets/30

days), 90escitalopram oxalate tab 20 mg (base equiv) (Lexapro) 1 QL (30 tablets/30

days), 90FETZIMA – levomilnacipran hcl cap er 24hr 20 mg (base

equivalent)2 PA, QL (30 capsules/30





days), 90

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FETZIMA – levomilnacipran hcl cap er 24hr 120 mg (baseequivalent)

2 PA, QL (30 capsules/30days), 90

FETZIMA TITRATION PACK – levomilnacipran hcl cap er 24hr20 & 40 mg therapy pack

2 PA, QL (28 tablets/180days), 90

fluoxetine hcl cap 10 mg (Prozac) 1 QL (30 capsules/30days), 90



fluoxetine hcl solution 20 mg/5ml 1 QL (600 mls/30 days), 90fluoxetine hcl tab 10 mg 1 QL (30 tablets/30

days), 90fluoxetine hcl tab 20 mg 1 QL (120 tablets/30

days), 90fluvoxamine maleate tab 25 mg 1 QL (30 tablets/30



days), 90FORFIVO XL – bupropion hcl tab er 24hr 450 mg 2 PA, QL (30 tablets/30

days), 90imipramine hcl tab 10 mg (Tofranil) 1 90imipramine hcl tab 25 mg (Tofranil) 1 90imipramine hcl tab 50 mg (Tofranil) 1 90MAPROTILINE HCL – maprotiline hcl tab 25 mg 2 PA, QL (90 tablets/30

days), 90MAPROTILINE HCL – maprotiline hcl tab 50 mg 2 PA, QL (90 tablets/30

days), 90MAPROTILINE HCL – maprotiline hcl tab 75 mg 2 PA, QL (90 tablets/30

days), 90MARPLAN – isocarboxazid tab 10 mg 2 PA, 90mirtazapine tab 15 mg (Remeron) 1 QL (30 tablets/30

days), 90mirtazapine tab 30 mg (Remeron) 1 QL (30 tablets/30

days), 90

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mirtazapine tab 45 mg (Remeron) 1 QL (30 tablets/30days), 90

NEFAZODONE HCL – nefazodone hcl tab 100 mg 2 PA, 90NEFAZODONE HCL – nefazodone hcl tab 150 mg 2 PA, 90NEFAZODONE HCL – nefazodone hcl tab 200 mg 2 PA, 90nortriptyline hcl cap 10 mg (Pamelor) 1 90nortriptyline hcl cap 25 mg (Pamelor) 1 90nortriptyline hcl cap 50 mg (Pamelor) 1 90nortriptyline hcl cap 75 mg (Pamelor) 1 90paroxetine hcl tab 10 mg (Paxil) 1 QL (30 tablets/30

days), 90paroxetine hcl tab 20 mg (Paxil) 1 QL (30 tablets/30



days), 90PAXIL – paroxetine hcl oral susp 10 mg/5ml (base equiv) 2 PA, QL (900

mls/30 days), 90PEXEVA – paroxetine mesylate tab 10 mg (base equiv) 2 PA, QL (30 tablets/30

days), 90PEXEVA – paroxetine mesylate tab 20 mg (base equiv) 2 PA, QL (30 tablets/30



days), 90sertraline hcl oral concentrate for solution 20 mg/ml (Zoloft) 1 QL (300 mls/30 days), 90sertraline hcl tab 25 mg (Zoloft) 1 QL (30 tablets/30

days), 90sertraline hcl tab 50 mg (Zoloft) 1 QL (30 tablets/30

days), 90sertraline hcl tab 100 mg (Zoloft) 1 QL (60 tablets/30

days), 90trazodone hcl tab 50 mg 1 90trazodone hcl tab 100 mg 1 90trazodone hcl tab 150 mg 1 90

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venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) (Effexorxr)

1 QL (30 capsules/30days), 90

venlafaxine hcl cap er 24hr 75 mg (base equivalent) (Effexor xr) 1 QL (90 capsules/30days), 90

venlafaxine hcl cap er 24hr 150 mg (base equivalent) (Effexor xr) 1 QL (30 capsules/30days), 90

venlafaxine hcl tab 25 mg 1 QL (90 tablets/30days), 90

venlafaxine hcl tab 37.5 mg 1 QL (90 tablets/30days), 90




VIIBRYD – vilazodone hcl tab 10 mg 2 PA, QL (30 tablets/30days), 90



VIIBRYD STARTER PACK – vilazodone hcl tab starter kit 10 (7)& 20 (23) mg


PSYCHOTIC AND BIPOLAR DISORDERSABILIFY MAINTENA – aripiprazole im for er susp prefilled

syringe 300 mg2 AL, PA, QL (1

vials/28 days)ABILIFY MAINTENA – aripiprazole im for er susp prefilled

syringe 400 mg2 AL, PA, QL (1

vials/28 days)ABILIFY MAINTENA – aripiprazole im for extended release susp

300 mg2 PA, QL (1 vials/28 days)

ABILIFY MAINTENA – aripiprazole im for extended release susp400 mg

2 PA, QL (1 vials/28 days)

ADASUVE – loxapine aerosol powder breath activated 10 mg 2 PAaripiprazole oral solution 1 mg/ml 1 PA, QL (150

mls/30 days), 90aripiprazole orally disintegrating tab 15 mg 1 AL, PA, QL (30

tablets/30 days), 90

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aripiprazole tab 2 mg (Abilify) 1 AL, PA, QL (30tablets/30 days), 90






ARISTADA – aripiprazole lauroxil im er susp prefilled syr441 mg/1.6ml

2 PA, QL (1 syringe/28days), 90







CHLORPROMAZINE HCL – chlorpromazine hcl inj 50 mg/2ml 2 PAchlorpromazine hcl tab 10 mg 1 PA, 90chlorpromazine hcl tab 25 mg 1 PA, 90chlorpromazine hcl tab 50 mg 1 PA, 90chlorpromazine hcl tab 100 mg 1 PA, 90chlorpromazine hcl tab 200 mg 1 PA, 90clozapine orally disintegrating tab 12.5 mg (Fazaclo) 1 AL, PA, QL (60

tablets/30 days)clozapine orally disintegrating tab 25 mg (Fazaclo) 1 AL, PA, QL (60

tablets/30 days)clozapine orally disintegrating tab 100 mg (Fazaclo) 1 AL, PA, QL (60

tablets/30 days)clozapine tab 25 mg (Clozaril) 1 AL, PA, QL (90

tablets/30 days)clozapine tab 50 mg 1 AL, PA, QL (90

tablets/30 days)clozapine tab 100 mg (Clozaril) 1 AL, PA, QL (270

tablets/30 days)

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clozapine tab 200 mg 1 AL, PA, QL (120tablets/30 days)

EQUETRO – carbamazepine (antipsychotic) cap er 12hr 100 mg 2 PA, 90EQUETRO – carbamazepine (antipsychotic) cap er 12hr 200 mg 2 PA, 90EQUETRO – carbamazepine (antipsychotic) cap er 12hr 300 mg 2 PA, 90FANAPT – iloperidone tab 1 mg 2 PA, QL (60 tablets/30

days), 90FANAPT – iloperidone tab 2 mg 2 PA, QL (60 tablets/30






days), 90FANAPT TITRATION PACK – iloperidone tab 1 mg & 2 mg &

4 mg & 6 mg titration pak2 PA, QL (8

tablets/180 days)FAZACLO – clozapine orally disintegrating tab 150 mg 2 PA, QL (60

tablets/30 days)FAZACLO – clozapine orally disintegrating tab 200 mg 2 PA, QL (120

tablets/30 days)FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 mg/5ml 2 PA, 90FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml 2 PA, 90FLUPHENAZINE HCL – fluphenazine hcl inj 2.5 mg/ml 2 PAfluphenazine hcl tab 1 mg 1 90fluphenazine hcl tab 2.5 mg 1 90fluphenazine hcl tab 5 mg 1 90fluphenazine hcl tab 10 mg 1 90GEODON – ziprasidone mesylate for inj 20 mg (base equivalent) 2 PAhaloperidol lactate oral conc 2 mg/ml 1 AL, PA, 90haloperidol tab 0.5 mg 1 AL, PA, 90haloperidol tab 1 mg 1 AL, PA, 90haloperidol tab 2 mg 1 AL, PA, 90

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haloperidol tab 5 mg 1 AL, PA, 90haloperidol tab 10 mg 1 AL, PA, 90haloperidol tab 20 mg 1 AL, PA, 90INVEGA – paliperidone tab er 24hr 1.5 mg 2 PA, QL (30 tablets/30

days), 90INVEGA – paliperidone tab er 24hr 3 mg 2 PA, QL (30 tablets/30



days), 90INVEGA SUSTENNA – paliperidone palmitate im extended-

release susp 39 mg/0.25ml2 PA, QL (1 kit/28 days)

INVEGA SUSTENNA – paliperidone palmitate im extended-release susp 78 mg/0.5ml

2 PA, QL (1 kit/28 days)

INVEGA SUSTENNA – paliperidone palmitate im extend-releasesusp 117 mg/0.75ml


INVEGA SUSTENNA – paliperidone palmitate im extended-release susp 156 mg/ml


INVEGA SUSTENNA – paliperidone palmitate im extended-release susp 234 mg/1.5ml


INVEGA TRINZA – paliperidone palmitate im extend-releasesusp 273 mg/0.875ml








LATUDA – lurasidone hcl tab 20 mg 2 PA, QL (30 tablets/30days), 90





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LITHIUM – lithium oral solution 8 meq/5ml 2 PA, 90lithium carbonate cap 150 mg (Lithium carbonate) 1 90lithium carbonate cap 300 mg 1 90lithium carbonate cap 600 mg (Lithium carbonate) 1 90lithium carbonate tab er 300 mg (Lithobid) 1 90lithium carbonate tab er 450 mg 1 90lithium carbonate tab 300 mg 1 90loxapine succinate cap 5 mg 1 AL, PA, 90loxapine succinate cap 10 mg 1 AL, PA, 90loxapine succinate cap 25 mg 1 AL, PA, 90loxapine succinate cap 50 mg 1 AL, PA, 90MOLINDONE HYDROCHLORIDE – molindone hcl tab 5 mg 2 90MOLINDONE HYDROCHLORIDE – molindone hcl tab 10 mg 2 90MOLINDONE HYDROCHLORIDE – molindone hcl tab 25 mg 2 90olanzapine orally disintegrating tab 5 mg (Zyprexa zydis) 1 AL, PA, QL (30

tablets/30 days), 90olanzapine orally disintegrating tab 10 mg (Zyprexa zydis) 1 AL, PA, QL (30



tablets/30 days), 90olanzapine tab 2.5 mg (Zyprexa) 1 AL, PA, QL (30

tablets/30 days), 90olanzapine tab 5 mg (Zyprexa) 1 AL, PA, QL (30

tablets/30 days), 90olanzapine tab 7.5 mg (Zyprexa) 1 AL, PA, QL (30




tablets/30 days), 90paliperidone tab er 24hr 1.5 mg (Invega) 1 PA, QL (30 tablets/30

days), 90

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paliperidone tab er 24hr 3 mg (Invega) 1 PA, QL (30 tablets/30days), 90



perphenazine tab 2 mg 1 AL, PA, 90perphenazine tab 4 mg 1 AL, PA, 90perphenazine tab 8 mg 1 AL, PA, 90perphenazine tab 16 mg 1 AL, PA, 90quetiapine fumarate tab er 24hr 400 mg (Seroquel xr) 1 AL, PA, QL (60

tablets/30 days), 90quetiapine fumarate tab 25 mg (Seroquel) 1 AL, PA, QL (90






tablets/30 days), 90REXULTI – brexpiprazole tab 0.25 mg 2 PA, QL (30 tablets/30

days), 90REXULTI – brexpiprazole tab 0.5 mg 2 PA, QL (30 tablets/30

days), 90REXULTI – brexpiprazole tab 1 mg 2 PA, QL (30 tablets/30




days), 90RISPERDAL CONSTA – risperidone microspheres for inj

12.5 mg2 PA

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RISPERDAL CONSTA – risperidone microspheres for inj 25 mg 2 PARISPERDAL CONSTA – risperidone microspheres for inj

37.5 mg2 PA

RISPERDAL CONSTA – risperidone microspheres for inj 50 mg 2 PARISPERIDONE ODT – risperidone orally disintegrating tab

0.25 mg2 AL, PA, QL (60

tablets/30 days), 90risperidone orally disintegrating tab 0.25 mg 1 AL, PA, QL (60

tablets/30 days), 90risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab) 1 AL, PA, QL (60

tablets/30 days), 90risperidone orally disintegrating tab 1 mg (Risperdal m-tab) 1 AL, PA, QL (60




tablets/30 days), 90risperidone soln 1 mg/ml (Risperdal) 1 AL, PA, QL (480

mls/30 days), 90risperidone tab 0.25 mg (Risperdal) 1 AL, PA, QL (120

tablets/30 days), 90risperidone tab 0.5 mg (Risperdal) 1 AL, PA, QL (120

tablets/30 days), 90risperidone tab 1 mg (Risperdal) 1 AL, PA, QL (120




tablets/30 days), 90SAPHRIS – asenapine maleate sl tab 2.5 mg (base equiv) 2 PA, QL (60 tablets/30

days), 90SAPHRIS – asenapine maleate sl tab 5 mg (base equiv) 2 PA, QL (60 tablets/30

days), 90SAPHRIS – asenapine maleate sl tab 10 mg (base equiv) 2 PA, QL (60 tablets/30

days), 90thioridazine hcl tab 10 mg 1 AL, PA, 90

2018


65




thioridazine hcl tab 25 mg 1 AL, PA, 90thioridazine hcl tab 50 mg 1 AL, PA, 90thioridazine hcl tab 100 mg 1 AL, PA, 90thiothixene cap 1 mg 1 AL, PA, 90thiothixene cap 2 mg 1 AL, PA, 90thiothixene cap 5 mg 1 AL, PA, 90thiothixene cap 10 mg 1 AL, PA, 90trifluoperazine hcl tab 1 mg (base equivalent) 1 AL, PA, 90trifluoperazine hcl tab 2 mg (base equivalent) 1 AL, PA, 90trifluoperazine hcl tab 5 mg (base equivalent) 1 AL, PA, 90trifluoperazine hcl tab 10 mg (base equivalent) 1 AL, PA, 90VERSACLOZ – clozapine susp 50 mg/ml 2 PA, QL (540 mls/30 days)ziprasidone hcl cap 20 mg (Geodon) 1 AL, PA, QL (60

capsules/30 days), 90ziprasidone hcl cap 40 mg (Geodon) 1 AL, PA, QL (60



capsules/30 days), 90ZYPREXA RELPREVV – olanzapine pamoate for extended rel im

susp 210 mg (base eq)2 PA, QL (2 vials/28 days)

ZYPREXA RELPREVV – olanzapine pamoate for extended rel imsusp 300 mg (base eq)

2 PA, QL (2 vials/28 days)

ZYPREXA RELPREVV – olanzapine pamoate for extended rel imsusp 405 mg (base eq)

2 PA, QL (1 vial/28 days)

SLEEP AIDSestazolam tab 1 mg 1 QL (30 tablets/30 days)estazolam tab 2 mg 1 QL (30 tablets/30 days)eszopiclone tab 1 mg (Lunesta) 1 QL (30 tablets/30 days)eszopiclone tab 2 mg (Lunesta) 1 QL (30 tablets/30 days)eszopiclone tab 3 mg (Lunesta) 1 QL (30 tablets/30 days)PHENOBARBITAL – phenobarbital tab 15 mg 2 90PHENOBARBITAL – phenobarbital tab 30 mg 2 90PHENOBARBITAL – phenobarbital tab 60 mg 2 90PHENOBARBITAL – phenobarbital tab 100 mg 2 90phenobarbital elixir 20 mg/5ml 1 90

2018


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phenobarbital tab 16.2 mg 1 90phenobarbital tab 32.4 mg 1 90phenobarbital tab 64.8 mg 1 90phenobarbital tab 97.2 mg 1 90QUAZEPAM – quazepam tab 15 mg 2 QL (30 tablets/30 days)temazepam cap 15 mg (Restoril) 1 QL (30 capsules/30 days)temazepam cap 30 mg (Restoril) 1 QL (30 capsules/30 days)zaleplon cap 5 mg (Sonata) 1 QL (30 capsules/30 days)zaleplon cap 10 mg (Sonata) 1 QL (30 capsules/30 days)zolpidem tartrate tab 5 mg (Ambien) 1 QL (30 tablets/30 days)zolpidem tartrate tab 10 mg (Ambien) 1 QL (30 tablets/30 days)

HYPERACTIVITY/NARCOLEPSYamphetamine-dextroamphetamine cap er 24hr 5 mg (Adderall xr) 1 PA, QL (30 capsules/30

days), 90amphetamine-dextroamphetamine cap er 24hr 10 mg (Adderall

xr)1 PA, QL (30 capsules/30









days), 90amphetamine-dextroamphetamine tab 5 mg (Adderall) 1 PA, QL (60 tablets/30

days), 90amphetamine-dextroamphetamine tab 7.5 mg (Adderall) 1 PA, QL (60 tablets/30


days), 90amphetamine-dextroamphetamine tab 12.5 mg (Adderall) 1 PA, QL (60 tablets/30



days), 90

2018


67




amphetamine-dextroamphetamine tab 30 mg (Adderall) 1 PA, QL (60 tablets/30days), 90

armodafinil tab 50 mg (Nuvigil) 1 PA, QL (30 tablets/30days), 90



caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) 1clonidine hcl tab er 12hr 0.1 mg (Kapvay) 1 QL (120 tablets/30

days), 90dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin xr) 1 PA, QL (30 capsules/30






days), 90dexmethylphenidate hcl tab 2.5 mg (Focalin) 1 PA, QL (60 tablets/30

days), 90dexmethylphenidate hcl tab 5 mg (Focalin) 1 PA, QL (60 tablets/30

days), 90dexmethylphenidate hcl tab 10 mg (Focalin) 1 PA, QL (60 tablets/30

days), 90dextroamphetamine sulfate cap er 24hr 5 mg (Dexedrine) 1 PA, QL (90 capsules/30

days), 90dextroamphetamine sulfate cap er 24hr 10 mg (Dexedrine) 1 PA, QL (120

capsules/30 days), 90dextroamphetamine sulfate cap er 24hr 15 mg (Dexedrine) 1 PA, QL (120

capsules/30 days), 90dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra) 1 PA, QL (1800

ml/30 days), 90dextroamphetamine sulfate tab 5 mg 1 PA, QL (90 tablets/30

days), 90

2018


68




dextroamphetamine sulfate tab 10 mg 1 PA, QL (180tablets/30 days), 90

guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv) 1 QL (30 tablets/30days), 90




methylphenidate hcl cap er 10 mg (cd) 1 PA, QL (30 capsules/30days), 90






methylphenidate hcl cap er 24hr 20 mg (la) (Ritalin la) 1 PA, QL (30 capsules/30days), 90



methylphenidate hcl chew tab 2.5 mg 1 PA, QL (90 tablets/30days), 90

methylphenidate hcl chew tab 5 mg 1 PA, QL (90 tablets/30days), 90

methylphenidate hcl chew tab 10 mg 1 PA, QL (180tablets/30 days), 90

METHYLPHENIDATE HCL ER – methylphenidate hcl tab er 24hr18 mg




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69








methylphenidate hcl soln 5 mg/5ml (Methylin) 1 PA, QL (450ml/30 days), 90

methylphenidate hcl soln 10 mg/5ml (Methylin) 1 PA, QL (900ml/30 days), 90

methylphenidate hcl tab er 10 mg 1 PA, QL (90 tablets/30days), 90

methylphenidate hcl tab er 20 mg 1 PA, QL (90 tablets/30days), 90

methylphenidate hcl tab 5 mg (Ritalin) 1 PA, QL (90 tablets/30days), 90



modafinil tab 100 mg (Provigil) 1 PA, QL (30 tablets/30days), 90

modafinil tab 200 mg (Provigil) 1 PA, QL (30 tablets/30days), 90

MULTIPLE SCLEROSISAUBAGIO – teriflunomide tab 7 mg 2 PA, QL (30 tablets/30

days), SP, 90AUBAGIO – teriflunomide tab 14 mg 2 PA, QL (30 tablets/30

days), SP, 90AVONEX – interferon beta-1a im prefilled syringe kit

30 mcg/0.5ml2 PA, QL (1 kit/28

days), SP, 90AVONEX – interferon beta-1a for im inj kit 30mcg (33mcg(6.6

mu)/vial)2 PA, QL (4 vials/28

days), SP, 90AVONEX PEN – interferon beta-1a im auto-injector kit

30 mcg/0.5ml2 PA, QL (1 kit/28

days), SP, 90EXTAVIA – interferon beta-1b for inj kit 0.3 mg 2 PA, QL (14 vials/28

days), SP, 90glatiramer acetate soln prefilled syringe 20 mg/ml (Glatopa) 1 PA, QL (30 syringes/30

days), SP, 90glatiramer acetate soln prefilled syringe 40 mg/ml (Copaxone) 1 PA, QL (12 syringes/28

days), SP, 90

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OTHER CENTRAL NERVOUS SYSTEM DRUGSacamprosate calcium tab delayed release 333 mg 1 90bupropion hcl (smoking deterrent) tab er 12hr 150 mg (Zyban) 1 QL (180 days/365 days)CHANTIX – varenicline tartrate tab 0.5 mg (base equiv) 2 QL (180 days/365 days)CHANTIX – varenicline tartrate tab 1 mg (base equiv) 2 QL (180 days/365 days)CHANTIX CONTINUING MONTH – varenicline tartrate tab 1 mg

(base equiv)2 QL (180 days/365 days)

CHANTIX STARTING MONTH PA – varenicline tartrate tab0.5 mg x 11 & tab 1 mg x 42 pack

2 QL (180 days/365 days)

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


CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide-amitriptyline tab 10-25 mg


disulfiram tab 250 mg (Antabuse) 1 90disulfiram tab 500 mg (Antabuse) 1 90donepezil hydrochloride orally disintegrating tab 5 mg 1 QL (30 tablets/30

days), 90donepezil hydrochloride orally disintegrating tab 10 mg 1 QL (30 tablets/30

days), 90donepezil hydrochloride tab 5 mg (Aricept) 1 QL (30 tablets/30

days), 90donepezil hydrochloride tab 10 mg (Aricept) 1 QL (30 tablets/30

days), 90GALANTAMINE HYDROBROMIDE – galantamine hydrobromide

oral soln 4 mg/ml2 QL (200 mls/30 days), 90

galantamine hydrobromide cap er 24hr 8 mg (Razadyne er) 1 QL (30 capsules/30days), 90



galantamine hydrobromide tab 4 mg (Razadyne) 1 QL (60 tablets/30days), 90



memantine hcl oral solution 2 mg/ml (Namenda) 1 QL (360 mls/30 days), 90

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71




memantine hcl tab 5 mg (Namenda) 1 QL (60 tablets/30days), 90

memantine hcl tab 10 mg (Namenda) 1 QL (60 tablets/30days), 90

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


NICOTROL INHALER – nicotine inhaler system 10 mg (4 mgdelivered)

2 QL (180 days/365 days)

NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray) 2 QL (180 days/365 days)PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline

tab 2-10 mg2 PA, 90

PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptylinetab 2-25 mg

2 PA, 90


2 PA, 90


2 PA, 90


2 PA, 90

pimozide tab 1 mg (Orap) 1 90pimozide tab 2 mg (Orap) 1 90rivastigmine tartrate cap 4.5 mg (Exelon) 1 QL (60 capsules/30

days), 90

PAIN RELIEF DRUGSNON-NARCOTIC DRUGSbutalbital-acetaminophen tab 50-325 mg 1 QL (180 tablets/30 days)butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet) 1 QL (180

capsules/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic) 1 QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal) 1 QL (180

capsules/30 days)

NARCOTIC DRUGSacetaminophen w/ codeine soln 120-12 mg/5ml 1 ME90, QL (2700

mls/30 days)acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine) 1 ME90, QL (360

tablets/30 days)acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3) 1 ME90, QL (360

tablets/30 days)

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acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4) 1 ME90, QL (180tablets/30 days)

ACETAMINOPHEN/CAFFEINE/DI – acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg

2 ME90, QL (300capsules/30 days)

buprenorphine hcl sl tab 2 mg (base equiv) 1 QL (90 tablets/30 days)buprenorphine hcl sl tab 8 mg (base equiv) 1 QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) 1 QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) 1 QL (60 tablets/30 days)butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg 1 ME90, QL (180

capsules/30 days)butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/

codeine #3)1 ME90, QL (180

capsules/30 days)butorphanol tartrate nasal soln 10 mg/ml 1 ME90, QL (2

bottles/30 days)codeine sulfate tab 15 mg (Codeine sulfate) 1 ME90, QL (180

tablets/30 days)codeine sulfate tab 30 mg (Codeine sulfate) 1 ME90, QL (180

tablets/30 days)codeine sulfate tab 60 mg (Codeine sulfate) 1 ME90, QL (180

tablets/30 days)fentanyl td patch 72hr 12 mcg/hr (Duragesic) 1 ME90, QL (15

patches/30 days)fentanyl td patch 72hr 25 mcg/hr (Duragesic) 1 ME90, QL (15




patches/30 days)hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet) 1 ME90, QL (3600

mls/30 days)hydrocodone-acetaminophen soln 10-325 mg/15ml (Zamicet) 1 ME90, QL (2700

mls/30 days)hydrocodone-acetaminophen tab 2.5-325 mg 1 ME90, QL (360

tablets/30 days)hydrocodone-acetaminophen tab 10-325 mg (Norco) 1 ME90, QL (180

tablets/30 days)

2018


73




hydrocodone-acetaminophen tab 7.5-300 mg (Xodol) 1 ME90, QL (180tablets/30 days)

hydrocodone-acetaminophen tab 5-325 mg (Norco) 1 ME90, QL (360tablets/30 days)

hydrocodone-acetaminophen tab 7.5-325 mg (Norco) 1 ME90, QL (180tablets/30 days)

hydrocodone-acetaminophen tab 10-300 mg (Xodol) 1 ME90, QL (180tablets/30 days)

hydrocodone-ibuprofen tab 5-200 mg (Reprexain) 1 ME90, QL (150tablets/30 days)

hydrocodone-ibuprofen tab 7.5-200 mg 1 ME90, QL (150tablets/30 days)

hydromorphone hcl liqd 1 mg/ml (Dilaudid) 1 ME90, QL (1440mls/30 days)

hydromorphone hcl tab 2 mg (Dilaudid) 1 ME90, QL (180tablets/30 days)



methadone hcl conc 10 mg/ml (Methadose) 1 ME90, QL (90mls/30 days)

methadone hcl soln 5 mg/5ml (Methadone hcl) 1 ME90, QL (900mls/30 days)

methadone hcl soln 10 mg/5ml (Methadone hcl) 1 ME90, QL (450mls/30 days)

methadone hcl tab for oral susp 40 mg 1 ME90, QL (90tablets/30 days)

methadone hcl tab 5 mg (Dolophine) 1 ME90, QL (90tablets/30 days)

methadone hcl tab 10 mg (Dolophine) 1 ME90, QL (90tablets/30 days)

MORPHINE SULFATE – morphine sulfate tab 15 mg 2 ME90, QL (240tablets/30 days)

MORPHINE SULFATE – morphine sulfate tab 30 mg 2 ME90, QL (180tablets/30 days)

MORPHINE SULFATE – morphine sulfate suppos 5 mg 2 ME90MORPHINE SULFATE – morphine sulfate suppos 10 mg 2 ME90MORPHINE SULFATE – morphine sulfate suppos 20 mg 2 ME90

2018


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MORPHINE SULFATE – morphine sulfate suppos 30 mg 2 ME90morphine sulfate cap er 24hr 100 mg (Kadian) 1 ME90, QL (60

tablets/30 days)MORPHINE SULFATE ER – morphine sulfate beads cap er 24hr

60 mg2 ME90, QL (30

capsules/30 days)MORPHINE SULFATE ER – morphine sulfate beads cap er 24hr

75 mg2 ME90, QL (30

capsules/30 days)MORPHINE SULFATE ER – morphine sulfate beads cap er 24hr

120 mg2 ME90, QL (30

capsules/30 days)morphine sulfate oral soln 10 mg/5ml 1 ME90, QL (2700

mls/30 days)morphine sulfate oral soln 20 mg/5ml 1 ME90, QL (1350

mls/30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 1 ME90, QL (270

mls/30 days)morphine sulfate tab er 15 mg (Ms contin) 1 ME90, QL (90

tablets/30 days)morphine sulfate tab er 30 mg (Ms contin) 1 ME90, QL (90




tablets/30 days)oxycodone hcl conc 100 mg/5ml (20 mg/ml) 1 ME90, QL (270

mls/30 days)oxycodone hcl soln 5 mg/5ml 1 ME90, QL (5400

mls/30 days)oxycodone hcl tab 5 mg (Roxicodone) 1 ME90, QL (360

tablets/30 days)oxycodone hcl tab 10 mg 1 ME90, QL (180

tablets/30 days)oxycodone hcl tab 15 mg (Roxicodone) 1 ME90, QL (180

tablets/30 days)oxycodone hcl tab 20 mg 1 ME90, QL (180

tablets/30 days)oxycodone hcl tab 30 mg (Roxicodone) 1 ME90, QL (180

tablets/30 days)

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75




oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet) 1 ME90, QL (360tablets/30 days)

oxycodone w/ acetaminophen tab 5-325 mg (Percocet) 1 ME90, QL (360tablets/30 days)

oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet) 1 ME90, QL (240tablets/30 days)

oxycodone w/ acetaminophen tab 10-325 mg (Percocet) 1 ME90, QL (180tablets/30 days)

oxycodone-aspirin tab 4.8355-325 mg 1 ME90, QL (360tablets/30 days)

OXYCODONE/ACETAMINOPHEN – oxycodone w/acetaminophen soln 5-325 mg/5ml

2 ME90, QL (1800mls/30 days)

OXYCODONE/IBUPROFEN – oxycodone-ibuprofen tab5-400 mg

2 ME90, QL (120tablets/30 days)

oxymorphone hcl tab er 12hr 5 mg 1 ME90, QL (60tablets/30 days)

oxymorphone hcl tab er 12hr 7.5 mg 1 ME90, QL (60tablets/30 days)






oxymorphone hcl tab 5 mg (Opana) 1 ME90, QL (180tablets/30 days)

oxymorphone hcl tab 10 mg (Opana) 1 ME90, QL (180tablets/30 days)

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

2 QL (90 films/30 days)

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






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tramadol hcl tab 50 mg (Ultram) 1 ME90, QL (240tablets/30 days)

tramadol-acetaminophen tab 37.5-325 mg (Ultracet) 1 ME90, QL (240tablets/30 days)

RHEUMATOID AND OSTEOARTHRITISARCALYST – rilonacept for inj 220 mg 2 PA, QL (4 vials/28

days), SP, 90celecoxib cap 50 mg (Celebrex) 1 QL (60 capsules/30

days), ST, 90celecoxib cap 100 mg (Celebrex) 1 QL (60 capsules/30



days), STdiclofenac potassium tab 50 mg 1 QL (120 tablets/30

days), 90diclofenac sodium tab delayed release 50 mg 1 QL (120 tablets/30

days), 90diclofenac sodium tab delayed release 75 mg 1 QL (60 tablets/30

days), 90diclofenac sodium tab er 24hr 100 mg 1 QL (60 tablets/30

days), 90ENBREL – etanercept for subcutaneous inj 25 mg 2 PA, QL (8 vials/28

days), SP, 90ENBREL – etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml2 PA, QL (8 syringes/28

days), SP, 90ENBREL – etanercept subcutaneous soln prefilled syringe

50 mg/ml2 PA, QL (4 syringes/28

days), SP, 90ENBREL SURECLICK – etanercept subcutaneous solution auto-

injector 50 mg/ml2 PA, QL (4 syringes/28

days), SP, 90flurbiprofen tab 50 mg 1 QL (180 tablets/30

days), 90flurbiprofen tab 100 mg 1 QL (90 tablets/30

days), 90HUMIRA – adalimumab prefilled syringe kit 10 mg/0.1ml 2 PA, QL (2

syringes/28 days)HUMIRA – adalimumab prefilled syringe kit 10 mg/0.2ml 2 PA, QL (2 syringes/28

days), SP, 90

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HUMIRA – adalimumab prefilled syringe kit 20 mg/0.2ml 2 PA, QL (2syringes/28 days)

HUMIRA – adalimumab prefilled syringe kit 20 mg/0.4ml 2 PA, QL (2 syringes/28days), SP, 90

HUMIRA – adalimumab prefilled syringe kit 40 mg/0.8ml 2 PA, QL (2 syringes/28days), SP, 90

HUMIRA – adalimumab prefilled syringe kit 40 mg/0.4ml 2 PA, QL (2syringes/28 days)

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



2 PA, QL (6 syringes/180days), 90


2 PA, QL (3syringes/180 days)

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

2 PA, QL (2syringes/180 days)

HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.8ml 2 PA, QL (2 pens/180days), SP, 90

HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.4ml 2 PA, QL (2 pens/28 days)HUMIRA PEN-CROHNS DISEASE – adalimumab pen-injector kit

40 mg/0.8ml2 PA, QL (6 pens/180

days), SP, 90HUMIRA PEN-PSORIASIS STAR – adalimumab pen-injector kit

40 mg/0.8ml2 PA, QL (4 pens/28

days), SP, 90ibuprofen susp 100 mg/5ml 1 QL (1000 mls/30 days)ibuprofen tab 400 mg 1 QL (120 tablets/30

days), 90ibuprofen tab 600 mg 1 QL (150 tablets/30

days), 90ibuprofen tab 800 mg 1 QL (120 tablets/30

days), 90indomethacin cap er 75 mg 1 QL (60 capsules/30

days), 90indomethacin cap 25 mg 1 QL (90 capsules/30

days), 90indomethacin cap 50 mg 1 QL (60 capsules/30

days), 90KETOPROFEN – ketoprofen cap 50 mg 2 QL (180 capsules/30

days), 90

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KETOPROFEN – ketoprofen cap 75 mg 2 QL (120 capsules/30days), 90

ketoprofen cap 50 mg 1 QL (180 capsules/30days), 90

ketoprofen cap 75 mg 1 QL (120 capsules/30days), 90

ketorolac tromethamine tab 10 mg 1 QL (20 tablets/30 days)KINERET – anakinra subcutaneous soln prefilled syringe

100 mg/0.67ml2 PA, QL (30 syringes/30

days), SP, 90leflunomide tab 10 mg (Arava) 1 90leflunomide tab 20 mg (Arava) 1 90meloxicam tab 7.5 mg (Mobic) 1 QL (60 tablets/30

days), 90meloxicam tab 15 mg (Mobic) 1 QL (30 tablets/30

days), 90nabumetone tab 500 mg 1 QL (120 tablets/30

days), 90nabumetone tab 750 mg 1 QL (60 tablets/30

days), 90naproxen sodium tab er 24hr 375 mg (base equiv) (Naprelan) 1 QL (120 tablets/30

days), 90naproxen sodium tab 275 mg 1 QL (150 tablets/30

days), 90naproxen sodium tab 550 mg (Anaprox ds) 1 QL (90 tablets/30

days), 90naproxen susp 125 mg/5ml (Naprosyn) 1 QL (900 mls/30 days), 90naproxen tab ec 375 mg (Ec-naprosyn) 1 QL (120 tablets/30

days), 90naproxen tab ec 500 mg (Ec-naprosyn) 1 QL (90 tablets/30

days), 90naproxen tab 250 mg 1 QL (150 tablets/30

days), 90naproxen tab 375 mg 1 QL (120 tablets/30

days), 90naproxen tab 500 mg (Naprosyn) 1 QL (90 tablets/30

days), 90ORENCIA – abatacept subcutaneous soln prefilled syringe


days), SP, 90

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ORENCIA CLICKJECT – abatacept subcutaneous soln auto-injector 125 mg/ml


piroxicam cap 10 mg (Feldene) 1 QL (60 capsules/30days), 90

piroxicam cap 20 mg (Feldene) 1 QL (30 capsules/30days), 90

SIMPONI – golimumab subcutaneous soln auto-injector50 mg/0.5ml


SIMPONI – golimumab subcutaneous soln auto-injector 100 mg/ml


SIMPONI – golimumab subcutaneous soln prefilled syringe50 mg/0.5ml


SIMPONI – golimumab subcutaneous soln prefilled syringe100 mg/ml


sulindac tab 150 mg 1 QL (60 tablets/30days), 90

sulindac tab 200 mg 1 QL (60 tablets/30days), 90

XELJANZ – tofacitinib citrate tab 5 mg (base equivalent) 2 PA, QL (120 tablets/30days), SP, 90

XELJANZ XR – tofacitinib citrate tab er 24hr 11 mg (baseequivalent)

2 PA, QL (30 tablets/30days), SP, 90

MIGRAINE HEADACHESalmotriptan malate tab 6.25 mg (Axert) 1 QL (18 tablets/30 days)almotriptan malate tab 12.5 mg (Axert) 1 QL (18 tablets/30 days)frovatriptan succinate tab 2.5 mg (base equivalent) (Frova) 1 QL (18 tablets/30 days)IMITREX – sumatriptan nasal spray 5 mg/act 2 QL (12 units/30 days)IMITREX – sumatriptan nasal spray 20 mg/act 2 QL (12 units/30 days)rizatriptan benzoate oral disintegrating tab 5 mg (base eq)

(Maxalt-mlt)1 QL (18 tablets/30 days)

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


rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt) 1 QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt) 1 QL (18 tablets/30 days)sumatriptan nasal spray 5 mg/act (Imitrex) 1 QL (12 units/30 days)sumatriptan nasal spray 20 mg/act (Imitrex) 1 QL (12 units/30 days)SUMATRIPTAN SUCCINATE – sumatriptan succinate solution

prefilled syringe 6 mg/0.5ml2 QL (12 doses/30 days)

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sumatriptan succinate inj 6 mg/0.5ml (Imitrex) 1 QL (12 vials/30 days)sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex

statdose sys)1 QL (12 doses/30 days)

sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrexstatdose sys)

1 QL (12 doses/30 days)

sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrexstatdose ref)


sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrexstatdose ref)


sumatriptan succinate tab 25 mg (Imitrex) 1 QL (18 tablets/30 days)sumatriptan succinate tab 50 mg (Imitrex) 1 QL (18 tablets/30 days)sumatriptan succinate tab 100 mg (Imitrex) 1 QL (18 tablets/30 days)

GOUTallopurinol tab 100 mg (Zyloprim) 1 90allopurinol tab 300 mg (Zyloprim) 1 90colchicine w/ probenecid tab 0.5-500 mg 1 90COLCRYS – colchicine tab 0.6 mg 2probenecid tab 500 mg 1 90

NEUROMUSCULAR DRUGSSEIZURESAPTIOM – eslicarbazepine acetate tab 200 mg 2 90APTIOM – eslicarbazepine acetate tab 400 mg 2 90APTIOM – eslicarbazepine acetate tab 600 mg 2 90APTIOM – eslicarbazepine acetate tab 800 mg 2 90carbamazepine cap er 12hr 100 mg (Carbatrol) 1 90carbamazepine cap er 12hr 200 mg (Carbatrol) 1 90carbamazepine cap er 12hr 300 mg (Carbatrol) 1 90carbamazepine chew tab 100 mg 1 90carbamazepine susp 100 mg/5ml (Tegretol) 1 90carbamazepine tab er 12hr 100 mg (Tegretol-xr) 1 90carbamazepine tab er 12hr 200 mg (Tegretol-xr) 1 90carbamazepine tab er 12hr 400 mg (Tegretol-xr) 1 90carbamazepine tab 200 mg (Tegretol) 1 90clonazepam orally disintegrating tab 0.125 mg 1 QL (90 tablets/30

days), 90clonazepam orally disintegrating tab 0.25 mg 1 QL (90 tablets/30

days), 90

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clonazepam orally disintegrating tab 0.5 mg 1 QL (90 tablets/30days), 90

clonazepam orally disintegrating tab 1 mg 1 QL (90 tablets/30days), 90

clonazepam orally disintegrating tab 2 mg 1 QL (60 tablets/30days), 90

clonazepam tab 0.5 mg (Klonopin) 1 QL (90 tablets/30days), 90

clonazepam tab 1 mg (Klonopin) 1 QL (90 tablets/30days), 90

clonazepam tab 2 mg (Klonopin) 1 QL (60 tablets/30days), 90

DIAZEPAM – diazepam rectal gel delivery system 2.5 mg 2 QL (2 packs/30 days)DIAZEPAM – diazepam rectal gel delivery system 10 mg 2 QL (2 packs/30 days)DIAZEPAM – diazepam rectal gel delivery system 20 mg 2 QL (2 packs/30 days)DILANTIN – phenytoin sodium extended cap 30 mg 2 90divalproex sodium cap delayed release sprinkle 125 mg

(Depakote sprinkles)1 90

divalproex sodium tab delayed release 125 mg (Depakote) 1 90divalproex sodium tab delayed release 250 mg (Depakote) 1 90divalproex sodium tab delayed release 500 mg (Depakote) 1 90divalproex sodium tab er 24 hr 250 mg (Depakote er) 1 90divalproex sodium tab er 24 hr 500 mg (Depakote er) 1 90ethosuximide cap 250 mg (Zarontin) 1 90ethosuximide soln 250 mg/5ml (Zarontin) 1 90felbamate susp 600 mg/5ml (Felbatol) 1 90felbamate tab 400 mg (Felbatol) 1 90felbamate tab 600 mg (Felbatol) 1 90gabapentin cap 100 mg (Neurontin) 1 QL (720 capsules/30

days), 90gabapentin cap 300 mg (Neurontin) 1 QL (240 capsules/30

days), 90gabapentin cap 400 mg (Neurontin) 1 QL (180 capsules/30

days), 90gabapentin oral soln 250 mg/5ml (Neurontin) 1 QL (1500 mls/30

days), 90

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gabapentin tab 600 mg (Neurontin) 1 QL (120 tablets/30days), 90

gabapentin tab 800 mg (Neurontin) 1 QL (90 tablets/30days), 90

LAMICTAL STARTER/NOT TAKI – lamotrigine tab 25 mg (42) &100 mg (7) starter kit

2 PA

LAMICTAL STARTER/TAKING C – lamotrigine tab 25 mg (84) &100 mg (14) starter kit

2 PA

LAMICTAL STARTER/TAKING V – lamotrigine tab 25 mg (35)starter kit

2 PA

LAMICTAL XR – lamotrigine tab er 24hr 25 mg (21) & 50 mg (7)titration kit

2 PA

LAMICTAL XR – lamotrigine tab er 24hr 25 (14) & 50 mg (14) &100 mg(7) kit

2 PA

LAMICTAL XR – lamotrigine tab er 24hr 50 (14) & 100 mg(14) &200 mg(7) kit

2 PA

lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di) 1 90lamotrigine tab chewable dispersible 25 mg (Lamictal chewable

di)1 90

lamotrigine tab disint 25 mg (21) & 50 mg (7) titration kit (Lamictalodt)

1 PA

lamotrigine tab disint 50 mg (42)- 100 mg(14) titration kit(Lamictal odt)

1 PA

lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg (7) kit(Lamictal odt)

1 PA

lamotrigine tab er 24hr 25 mg (Lamictal xr) 1 90lamotrigine tab er 24hr 50 mg (Lamictal xr) 1 90lamotrigine tab er 24hr 100 mg (Lamictal xr) 1 90lamotrigine tab er 24hr 200 mg (Lamictal xr) 1 90lamotrigine tab er 24hr 250 mg (Lamictal xr) 1 90lamotrigine tab er 24hr 300 mg (Lamictal xr) 1 90lamotrigine tab 25 mg (Lamictal) 1 90lamotrigine tab 100 mg (Lamictal) 1 90lamotrigine tab 150 mg (Lamictal) 1 90lamotrigine tab 200 mg (Lamictal) 1 90levetiracetam oral soln 100 mg/ml (Keppra) 1 90levetiracetam tab er 24hr 500 mg (Keppra xr) 1 90levetiracetam tab er 24hr 750 mg (Keppra xr) 1 90levetiracetam tab 250 mg (Keppra) 1 90

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levetiracetam tab 500 mg (Keppra) 1 90levetiracetam tab 750 mg (Keppra) 1 90levetiracetam tab 1000 mg (Keppra) 1 90oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal) 1 90oxcarbazepine tab 150 mg (Trileptal) 1 90oxcarbazepine tab 300 mg (Trileptal) 1 90oxcarbazepine tab 600 mg (Trileptal) 1 90OXTELLAR XR – oxcarbazepine tab er 24hr 150 mg 2 PA, 90OXTELLAR XR – oxcarbazepine tab er 24hr 300 mg 2 PA, 90OXTELLAR XR – oxcarbazepine tab er 24hr 600 mg 2 PA, 90phenytoin chew tab 50 mg (Dilantin infatabs) 1 90phenytoin sodium extended cap 100 mg (Dilantin) 1 90phenytoin sodium extended cap 200 mg (Phenytek) 1 90phenytoin sodium extended cap 300 mg (Phenytek) 1 90phenytoin susp 125 mg/5ml (Dilantin-125) 1 90primidone tab 50 mg (Mysoline) 1 90primidone tab 250 mg (Mysoline) 1 90SABRIL – vigabatrin tab 500 mg 2 PA, QL (180 tablets/30

days), SP, 90tiagabine hcl tab 2 mg (Gabitril) 1 90tiagabine hcl tab 4 mg (Gabitril) 1 90topiramate sprinkle cap 15 mg (Topamax sprinkle) 1 90topiramate sprinkle cap 25 mg (Topamax sprinkle) 1 90topiramate tab 25 mg (Topamax) 1 90topiramate tab 50 mg (Topamax) 1 90topiramate tab 100 mg (Topamax) 1 90topiramate tab 200 mg (Topamax) 1 90valproic acid cap 250 mg (Depakene) 1 90vigabatrin powd pack 500 mg (Sabril) 1 PA, QL (180 packets/30

days), SP, 90zonisamide cap 25 mg (Zonegran) 1 90zonisamide cap 50 mg 1 90zonisamide cap 100 mg (Zonegran) 1 90

PARKINSON'S DISEASEamantadine hcl cap 100 mg 1 90

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amantadine hcl syrup 50 mg/5ml 1 90benztropine mesylate tab 0.5 mg 1 90benztropine mesylate tab 1 mg 1 90benztropine mesylate tab 2 mg 1 90bromocriptine mesylate cap 5 mg (base equivalent) 1 90bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel) 1 90carbidopa & levodopa orally disintegrating tab 10-100 mg 1 90carbidopa & levodopa orally disintegrating tab 25-100 mg 1 90carbidopa & levodopa orally disintegrating tab 25-250 mg 1 90carbidopa & levodopa tab er 25-100 mg (Sinemet cr) 1 90carbidopa & levodopa tab er 50-200 mg (Sinemet cr) 1 90carbidopa & levodopa tab 10-100 mg (Sinemet) 1 90carbidopa & levodopa tab 25-100 mg (Sinemet) 1 90carbidopa & levodopa tab 25-250 mg (Sinemet) 1 90carbidopa tab 25 mg (Lodosyn) 1 90entacapone tab 200 mg (Comtan) 1 90pramipexole dihydrochloride tab er 24hr 2.25 mg (Mirapex er) 1 90pramipexole dihydrochloride tab 0.125 mg (Mirapex) 1 90pramipexole dihydrochloride tab 0.25 mg (Mirapex) 1 90pramipexole dihydrochloride tab 0.5 mg (Mirapex) 1 90pramipexole dihydrochloride tab 0.75 mg (Mirapex) 1 90pramipexole dihydrochloride tab 1 mg (Mirapex) 1 90pramipexole dihydrochloride tab 1.5 mg (Mirapex) 1 90ropinirole hydrochloride tab 0.25 mg (Requip) 1 90ropinirole hydrochloride tab 0.5 mg (Requip) 1 90ropinirole hydrochloride tab 1 mg (Requip) 1 90ropinirole hydrochloride tab 2 mg (Requip) 1 90ropinirole hydrochloride tab 3 mg (Requip) 1 90ropinirole hydrochloride tab 4 mg (Requip) 1 90ropinirole hydrochloride tab 5 mg (Requip) 1 90selegiline hcl cap 5 mg (Eldepryl) 1 90selegiline hcl tab 5 mg 1 90tolcapone tab 100 mg (Tasmar) 1 90trihexyphenidyl hcl elixir 0.4 mg/ml 1 90trihexyphenidyl hcl tab 2 mg 1 90

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trihexyphenidyl hcl tab 5 mg 1 90

MUSCLE RELAXANTSbaclofen tab 10 mg 1 90baclofen tab 20 mg 1 90carisoprodol tab 250 mg (Soma) 1CHLORZOXAZONE – chlorzoxazone tab 500 mg 2cyclobenzaprine hcl tab 5 mg 1cyclobenzaprine hcl tab 10 mg 1dantrolene sodium cap 25 mg (Dantrium) 1dantrolene sodium cap 50 mg (Dantrium) 1dantrolene sodium cap 100 mg 1methocarbamol tab 500 mg (Robaxin) 1methocarbamol tab 750 mg (Robaxin-750) 1orphenadrine citrate tab er 12hr 100 mg 1tizanidine hcl tab 2 mg (base equivalent) 1 QL (180 tablets/30

days), 90tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) 1 QL (180 tablets/30

days), 90

OTHER NEUROMUSCULAR DRUGSpyridostigmine bromide tab 60 mg (Mestinon) 1riluzole tab 50 mg (Rilutek) 1 90

SUPPLEMENTSVITAMINSergocalciferol cap 50000 unit 1 90MEPHYTON – phytonadione tab 5 mg 2

MULTIVITAMINSb-complex w/ c & folic acid cap 1 mg (Nephrocaps) 1b-complex w/ c & folic acid tab 1b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx) 1b-complex w/ c & folic acid tab 5 mg 1CLASSIC PRENATAL – prenatal vit w/ fe fumarate-fa tab

28-0.8 mg2

EQL PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab28-0.8 mg

2

FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals & folic acidtab 5 mg

2

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GNP PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2GOODSENSE PRENATAL VITAMI – prenatal vit w/ fe fumarate-

fa tab 28-0.8 mg2

HM PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2KP PRENATAL MULTIVITAMINS – prenatal vit w/ fe fumarate-fa

tab 28-0.8 mg2

M-VIT – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2MULTI PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 2multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite) 1multiple vitamins w/ minerals cap 1multiple vitamins w/ minerals tab (Strovite forte) 1NAT-RUL PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa

tab 28-0.8 mg2

NIVA-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2O-CAL FA – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2pediatric multiple vitamin w/ minerals & c drops 45 mg/ml 1pediatric vitamins acd w/ fluoride soln 0.25 mg/ml 1PNV FOLIC ACID + IRON MUL – prenatal vit w/ fe fumarate-fa

tab 27-1 mg2

PNV PRENATAL PLUS MULTIVI – prenatal vit w/ fe fumarate-fatab 27-1 mg

2

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab0.25 mg

2

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab0.5 mg

2

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab1 mg

2

PRE-NATAL FORMULA – prenatal multivitamins & minerals w/iron & fa tab 0.8 mg

2

PRENATAL – prenatal multivitamins & minerals w/iron & fa tab0.8 mg

2

PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 2PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2PRENATAL AND IRON – prenatal multivitamins & minerals w/

iron & fa tab 0.8 mg2

PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab28-0.8 mg

2

PRENATAL FORTE – prenatal multivitamins & minerals w/iron &fa tab 0.8 mg

2

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PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa tab27-0.8 mg

2

PRENATAL MULTI +DHA – prenatal vit w/ fe fum-fa-omega 3 cap27-0.8-228 mg

2

PRENATAL ONE DAILY – prenatal vit w/ fe fumarate-fa tab27-0.8 mg

2

PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2PRENATAL PLUS DHA – prenatal mv & min w/fe carbonyl-fa-dha

tab 7-0.4-100 mg2

prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 1PRENATAL VITAMIN – prenatal vit w/ fe fumarate-fa tab

27-0.8 mg2

PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab28-0.8 mg

2

PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 2PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 2PREPLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2PX PRENATAL MULTIVITAMINS – prenatal vit w/ fe fumarate-fa

tab 28-0.8 mg2

QC PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2RA PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2RA PRENATAL FORMULA/FOLIC – prenatal vit w/ fe fumarate-fa

tab 28-0.8 mg2

RIGHT STEP PRENATAL – prenatal vit w/ fe fumarate-fa tab27-0.8 mg

2

SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 2SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 2SM PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab

28-0.8 mg2

speciality vitamin product tab 1TRI-VIT/FLUORIDE/IRON – pediatric vitamins acd fluoride & fe

drops 0.25-10 mg/ml2

TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1 mg 2VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg 2VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1 mg 2VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2

MINERALS AND ELECTROLYTESK-PHOS – potassium phosphate monobasic tab 500 mg 2 90

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pot bicarbonate & chloride effer tab 25 meq 1 90pot phos monobasic w/sod phos di & monobas tab

155-852-130mg (K-phos neutral)1 90

potassium bicarbonate effer tab 25 meq 1 90potassium chloride cap er 8 meq (Micro-k) 1 90potassium chloride cap er 10 meq (Micro-k) 1 90POTASSIUM CHLORIDE ER – potassium chloride tab er 8 meq

(600 mg)2 90

potassium chloride microencapsulated crys er tab 10 meq 1 90potassium chloride microencapsulated crys er tab 20 meq 1 90potassium chloride oral soln 10% (20 meq/15ml) 1 90potassium chloride oral soln 20% (40 meq/15ml) 1 90potassium chloride tab er 8 meq (600 mg) 1 90potassium chloride tab er 10 meq (K-tab) 1 90SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from 1.1 mg

naf)2 90

SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from 2.2 mgnaf)

2 90

sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride) 1 90sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride) 1 90sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride) 1 90sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) 1 90sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride) 1 90

OTHER SUPPLEMENTSacetylcysteine cap 600 mg 1amino acids cap 1folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2 mg 1

BLOOD MODIFYING DRUGSBLOOD MODIFYING DRUGSanagrelide hcl cap 0.5 mg (Agrylin) 1 90anagrelide hcl cap 1 mg 1 90ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled

syringe 10 mcg/0.4ml2 PA, SP

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilledsyringe 25 mcg/0.42ml

2 PA, SP


2 PA, SP

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2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilledsyringe 500 mcg/ml

2 PA, SP

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25 mcg/ml

2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP

BRILINTA – ticagrelor tab 60 mg 2 PA, QL (60 tablets/30days), 90

BRILINTA – ticagrelor tab 90 mg 2 PA, QL (60 tablets/30days), 90

cilostazol tab 50 mg 1 90cilostazol tab 100 mg 1 90clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) 1 90clopidogrel bisulfate tab 300 mg (base equiv) (Plavix) 1cyanocobalamin inj 1000 mcg/ml 1dipyridamole tab 25 mg 1 90dipyridamole tab 50 mg 1 90dipyridamole tab 75 mg 1 90ELIQUIS – apixaban tab 2.5 mg 2 PA, QL (60 tablets/30

days), 90ELIQUIS – apixaban tab 5 mg 2 PA, QL (120

tablets/30 days), 90

2018


90




ELIQUIS STARTER PACK – apixaban tab 5 mg 2 PA, QL (74 tablets/180days), 90

enoxaparin sodium inj 30 mg/0.3ml (Lovenox) 1 QL (30 syringes/365days)




enoxaparin sodium inj 100 mg/ml (Lovenox) 1 QL (30 syringes/365days)


enoxaparin sodium inj 150 mg/ml (Lovenox) 1 QL (30 syringes/365days)

EPOGEN – epoetin alfa inj 2000 unit/ml 2 PA, SPEPOGEN – epoetin alfa inj 3000 unit/ml 2 PA, SPEPOGEN – epoetin alfa inj 4000 unit/ml 2 PA, SPEPOGEN – epoetin alfa inj 10000 unit/ml 2 PA, SPEPOGEN – epoetin alfa inj 20000 unit/ml 2 PA, SPfe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap

(Tandem plus)1

fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg 1fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg 1ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg 1ferrous fumarate-folic acid tab 324-1 mg 1FIRAZYR – icatibant acetate inj 30 mg/3ml (base equivalent) 2 PA, QL (6 syringes/30

days), SPfolic acid tab 1 mg 1 90folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg 1folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx) 1folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg 1INFED – iron dextran inj 50 mg/ml (elemental iron) 2IPRIVASK – desirudin for inj 15 mg 2 SPiron combination cap 1iron polysacch complex-vit b12-fa cap 150-0.025-1 mg 1

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iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg(Hematron-af)

1

iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite150)

1

miglustat cap 100 mg (Zavesca) 1 PA, QL (90 capsules/30days), SP, 90

NEULASTA – pegfilgrastim soln prefilled syringe 6 mg/0.6ml 2 SPNEULASTA ONPRO KIT – pegfilgrastim soln prefilled syringe kit

6 mg/0.6ml2 SP

pentoxifylline tab er 400 mg 1 90PROCRIT – epoetin alfa inj 2000 unit/ml 2 PA, SPPROCRIT – epoetin alfa inj 3000 unit/ml 2 PA, SPPROCRIT – epoetin alfa inj 4000 unit/ml 2 PA, SPPROCRIT – epoetin alfa inj 10000 unit/ml 2 PA, SPPROCRIT – epoetin alfa inj 20000 unit/ml 2 PA, SPPROCRIT – epoetin alfa inj 40000 unit/ml 2 PA, SPPROMACTA – eltrombopag olamine tab 12.5 mg (base equiv) 2 PA, QL (30 tablets/30

days), SP, 90PROMACTA – eltrombopag olamine tab 25 mg (base equiv) 2 PA, QL (30 tablets/30



days), SP, 90tranexamic acid tab 650 mg (Lysteda) 1warfarin sodium tab 1 mg (Coumadin) 1 90warfarin sodium tab 2 mg (Coumadin) 1 90warfarin sodium tab 2.5 mg (Coumadin) 1 90warfarin sodium tab 3 mg (Coumadin) 1 90warfarin sodium tab 4 mg (Coumadin) 1 90warfarin sodium tab 5 mg (Coumadin) 1 90warfarin sodium tab 6 mg (Coumadin) 1 90warfarin sodium tab 7.5 mg (Coumadin) 1 90warfarin sodium tab 10 mg (Coumadin) 1 90XARELTO – rivaroxaban tab 10 mg 2 QL (35 tablets/365

days), 90

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XARELTO – rivaroxaban tab 15 mg 2 PA, QL (60 tablets/30days), 90

XARELTO – rivaroxaban tab 20 mg 2 PA, QL (30 tablets/30days), 90

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

2 PA, QL (51tablets/30 days)

TOPICAL PRODUCTSEYEAnti-infectivesBACITRACIN – bacitracin ophth oint 500 unit/gm 2bacitracin-polymyxin b ophth oint 1ciprofloxacin hcl ophth soln 0.3% (Ciloxan) 1erythromycin ophth oint 5 mg/gm 1gentamicin sulfate ophth oint 0.3% 1gentamicin sulfate ophth soln 0.3% 1NATACYN – natamycin ophth susp 5% 2neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 1neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/

ml (Neosporin)1

ofloxacin ophth soln 0.3% (Ocuflox) 1polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%

(Polytrim)1

sulfacetamide sodium ophth soln 10% (Bleph-10) 1tobramycin ophth soln 0.3% (Tobrex) 1trifluridine ophth soln 1% (Viroptic) 1

Steroids and Combination Productsbacitracin-polymyxin-neomycin-hc ophth oint 1% 1DEXAMETHASONE SODIUM PHOS – dexamethasone sodium

phosphate ophth soln 0.1%2

fluorometholone ophth susp 0.1% (Fml liquifilm) 1neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol) 1neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol) 1prednisolone acetate ophth susp 1% (Pred forte) 1PREDNISOLONE SODIUM PHOSP – prednisolone sodium

phosphate ophth soln 1%2

sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% 1

Glaucoma

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apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine) 1betaxolol hcl ophth soln 0.5% 1 90brimonidine tartrate ophth soln 0.2% 1 90CARTEOLOL HCL – carteolol hcl ophth soln 1% 2 90carteolol hcl ophth soln 1% 1 90dorzolamide hcl ophth soln 2% (Trusopt) 1 90dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml

(Cosopt)1 90

latanoprost ophth soln 0.005% (Xalatan) 1 QL (1 bottle/30 days), 90levobunolol hcl ophth soln 0.5% (Betagan) 1 90METIPRANOLOL – metipranolol ophth soln 0.3% 2 90pilocarpine hcl ophth soln 1% (Isopto carpine) 1 90pilocarpine hcl ophth soln 2% (Isopto carpine) 1 90pilocarpine hcl ophth soln 4% (Isopto carpine) 1 90timolol maleate ophth soln 0.25% (Timoptic) 1 90timolol maleate ophth soln 0.5% (Timoptic) 1 90

Other Eye ProductsATROPINE SULFATE – atropine sulfate ophth soln 1% 2 90ATROPINE SULFATE – atropine sulfate ophth oint 1% 2 90azelastine hcl ophth soln 0.05% 1cromolyn sodium ophth soln 4% 1cyclopentolate hcl ophth soln 0.5% (Cyclogyl) 1 90cyclopentolate hcl ophth soln 1% (Cyclogyl) 1 90cyclopentolate hcl ophth soln 2% (Cyclogyl) 1 90diclofenac sodium ophth soln 0.1% 1epinastine hcl ophth soln 0.05% (Elestat) 1flurbiprofen sodium ophth soln 0.03% (Ocufen) 1homatropine hbr ophth soln 5% 1 90ketorolac tromethamine ophth soln 0.4% (Acular ls) 1ketorolac tromethamine ophth soln 0.5% (Acular) 1olopatadine hcl ophth soln 0.1% (base equivalent) (Patanol) 1phenylephrine hcl ophth soln 2.5% 1proparacaine hcl ophth soln 0.5% (Alcaine) 1tetracaine hcl ophth soln 0.5% 1

EAR

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acetic acid otic soln 2% 1hydrocortisone w/ acetic acid otic soln 1-2% 1neomycin-polymyxin-hc otic soln 1% 1neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% 1ofloxacin otic soln 0.3% (Floxin otic) 1

MOUTH AND THROAT (LOCAL)chlorhexidine gluconate soln 0.12% (Peridex) 1clotrimazole troche 10 mg 1lidocaine hcl viscous soln 2% 1nystatin susp 100000 unit/ml 1pilocarpine hcl tab 5 mg (Salagen) 1 90pilocarpine hcl tab 7.5 mg (Salagen) 1 90PREVIDENT FLUORIDE – sodium fluoride gel 1.1% (0.5% f) 2 90PREVIDENT 5000 DRY MOUTH – sodium fluoride gel 1.1%

(0.5% f)2 90

sodium fluoride cream 1.1% (Prevident 5000 plus) 1 90sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) 1 90sodium fluoride paste 1.1% (Prevident 5000 boost) 1 90sodium fluoride rinse 0.2% 1 90sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000

sensi)1

stannous fluoride gel 0.4% 1THERA-FLUR-N – sodium fluoride gel 1.1% (0.5% f) 2 90triamcinolone acetonide dental paste 0.1% 1

ANORECTAL AGENTShydrocortisone enema 100 mg/60ml (Cortenema) 1hydrocortisone rectal cream 1% (Proctocort) 1hydrocortisone rectal cream 2.5% (Anusol-hc) 1

SKIN CONDITIONS/PRODUCTSAcneadapalene cream 0.1% (Differin) 1 PAbenzoyl peroxide cloth 6% 1 PAbenzoyl peroxide-erythromycin gel 5-3% (Benzamycin) 1 PAclindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5%

(Duac)1 PA

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

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clindamycin phosphate lotion 1% (Cleocin-t) 1 PAclindamycin phosphate soln 1% (Cleocin-t) 1 PAclindamycin phosphate swab 1% (Cleocin-t) 1 PAerythromycin pads 2% 1 PAerythromycin soln 2% 1 PAFINACEA – azelaic acid gel 15% 2 PAisotretinoin cap 10 mg 1 PAisotretinoin cap 20 mg 1 PAisotretinoin cap 30 mg 1 PAisotretinoin cap 40 mg 1 PAmetronidazole cream 0.75% (Metrocream) 1 PAmetronidazole gel 0.75% 1 PAsulfacetamide sodium lotion 10% (acne) (Klaron) 1 PAtazarotene cream 0.1% (Tazorac) 1 PATAZORAC – tazarotene cream 0.05% 2 PATAZORAC – tazarotene gel 0.05% 2 PATAZORAC – tazarotene gel 0.1% 2 PAtretinoin cream 0.025% (Retin-a) 1 PAtretinoin cream 0.05% (Retin-a) 1 PAtretinoin cream 0.1% (Retin-a) 1 PAtretinoin gel 0.01% (Retin-a) 1 PAtretinoin gel 0.025% (Retin-a) 1 PAtretinoin gel 0.05% (Atralin) 1 PA

Anti-infectivesacyclovir oint 5% (Zovirax) 1ciclopirox olamine cream 0.77% (base equiv) (Loprox) 1ciclopirox olamine susp 0.77% (base equiv) 1ciclopirox solution 8% (Penlac Nail Lacquer) 1 PA, QL (6.6 mls/30 days)clotrimazole cream 1% 1clotrimazole soln 1% 1clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone) 1diclofenac sodium gel 1% (Voltaren) 1 QL (200 grams/30 days)gentamicin sulfate oint 0.1% 1ketoconazole cream 2% 1ketoconazole shampoo 2% (Nizoral) 1

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mupirocin oint 2% 1naftifine hcl cream 2% (Naftin) 1nystatin cream 100000 unit/gm 1nystatin oint 100000 unit/gm 1oxiconazole nitrate cream 1% (Oxistat) 1salicylic acid cream 6% 1salicylic acid cream 6% & cleanser liqd kit (Salex cream) 1salicylic acid film forming liquid 27.5% (Virasal) 1salicylic acid foam 6% (Salvax) 1salicylic acid gel 6% (Keralyt) 1salicylic acid lotion 6% 1salicylic acid lotion 6% & cleanser liqd kit (Salex lotion) 1salicylic acid shampoo 6% (Salex) 1silver sulfadiazine cream 1% (Silvadene) 1

Corticosteroidsalclometasone dipropionate cream 0.05% (Aclovate) 1alclometasone dipropionate oint 0.05% 1AUGMENTED BETAMETHASONE D – betamethasone

dipropionate augmented gel 0.05%2 QL (180 grams/90 days)

betamethasone dipropionate augmented cream 0.05%(Diprolene af)

1 QL (180 grams/90 days)

betamethasone dipropionate augmented gel 0.05% 1 QL (180 grams/90 days)betamethasone dipropionate augmented lotion 0.05% (Diprolene) 1 QL (180 grams/90 days)betamethasone dipropionate augmented oint 0.05% (Diprolene) 1 QL (180 grams/90 days)betamethasone dipropionate cream 0.05% 1 QL (180 grams/90 days)betamethasone dipropionate lotion 0.05% 1 QL (180 grams/90 days)betamethasone dipropionate oint 0.05% 1 QL (180 grams/90 days)betamethasone valerate cream 0.1% (base equivalent) 1betamethasone valerate lotion 0.1% (base equivalent) 1betamethasone valerate oint 0.1% (base equivalent) 1clobetasol propionate emollient base cream 0.05% (Temovate e) 1clobetasol propionate soln 0.05% (Temovate) 1 QL (180 grams/90 days)desonide cream 0.05% (Desowen) 1desonide oint 0.05% 1desoximetasone cream 0.25% (Topicort) 1 QL (180 grams/90 days)desoximetasone gel 0.05% (Topicort) 1 QL (180 grams/90 days)

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fluocinolone acetonide cream 0.01% 1fluocinolone acetonide cream 0.025% (Synalar) 1fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs

sca)1

fluocinolone acetonide oint 0.025% (Synalar) 1fluocinolone acetonide soln 0.01% (Synalar) 1fluocinonide cream 0.05% 1 QL (180 grams/90 days)fluocinonide emulsified base cream 0.05% 1 QL (180 grams/90 days)fluocinonide gel 0.05% 1 QL (180 grams/90 days)fluocinonide oint 0.05% 1 QL (180 grams/90 days)fluocinonide soln 0.05% 1 QL (180 grams/90 days)flurandrenolide cream 0.05% (Cordran) 1fluticasone propionate cream 0.05% (Cutivate) 1fluticasone propionate oint 0.005% 1halobetasol propionate cream 0.05% (Ultravate) 1 QL (180 grams/90 days)halobetasol propionate oint 0.05% (Ultravate) 1 QL (180 grams/90 days)hydrocortisone butyrate oint 0.1% (Locoid) 1hydrocortisone butyrate soln 0.1% (Locoid) 1hydrocortisone cream 1% 1hydrocortisone cream 2.5% 1hydrocortisone lotion 2% (Ala scalp) 1hydrocortisone lotion 2.5% 1hydrocortisone oint 1% 1hydrocortisone oint 2.5% 1hydrocortisone valerate cream 0.2% 1hydrocortisone valerate oint 0.2% (Westcort) 1mometasone furoate cream 0.1% (Elocon) 1mometasone furoate oint 0.1% (Elocon) 1 QL (180 grams/90 days)mometasone furoate solution 0.1% (lotion) (Elocon) 1PREDNICARBATE – prednicarbate cream 0.1% 2PREDNICARBATE – prednicarbate oint 0.1% 2prednicarbate cream 0.1% (Dermatop) 1triamcinolone acetonide aerosol soln 0.147 mg/gm (Kenalog) 1triamcinolone acetonide cream 0.025% 1triamcinolone acetonide cream 0.1% 1

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triamcinolone acetonide cream 0.5% 1 QL (180 grams/90 days)triamcinolone acetonide lotion 0.025% 1triamcinolone acetonide lotion 0.1% 1triamcinolone acetonide oint 0.025% 1triamcinolone acetonide oint 0.1% 1

Other Skin Productsacitretin cap 10 mg (Soriatane) 1acitretin cap 17.5 mg (Soriatane) 1acitretin cap 25 mg (Soriatane) 1calcipotriene cream 0.005% (Dovonex) 1calcipotriene oint 0.005% 1calcipotriene soln 0.005% (50 mcg/ml) 1CEM-UREA – urea soln 45% 2COSENTYX – secukinumab subcutaneous soln prefilled syringe


days), SP, 90COSENTYX – secukinumab subcutaneous soln prefilled syringe

150 mg/ml2 PA, QL (1 syringe/28

days), 90COSENTYX SENSOREADY PEN – secukinumab subcutaneous

soln auto-injector 150 mg/ml2 PA, QL (2 pens/28

days), SP, 90COSENTYX SENSOREADY PEN – secukinumab subcutaneous

soln auto-injector 150 mg/ml2 PA, QL (1 pen/28

days), 90CUTTER BACKWOODS – diethyltoluamide (deet) aerosol 2CUTTER SKINSATIONS – diethyltoluamide (deet) liquid 2fluorouracil cream 5% (Efudex) 1 QL (240 grams/180 days)imiquimod cream 5% (Aldara) 1 QL (48 grams/180 days)lidocaine hcl gel 2% 1 QL (120 grams/30 days)lidocaine hcl soln 4% (Xylocaine) 1 QL (120 grams/30 days)lidocaine patch 5% (Lidoderm) 1 PA, QL (120

patches/30 days)lidocaine-prilocaine cream 2.5-2.5% 1 QL (30 grams/60 days)methoxsalen rapid cap 10 mg (Oxsoralen ultra) 1NATRAPEL 12-HOUR TICK & I – picaridin aerosol 2OFF ACTIVE – diethyltoluamide (deet) aerosol 2OFF DEEP WOODS – diethyltoluamide (deet) aerosol 2OFF DEEP WOODS DRY – diethyltoluamide (deet) aerosol 2OFF SMOOTH & DRY – diethyltoluamide (deet) aerosol 2

2018


99




permethrin cream 5% (Elimite) 1podofilox soln 0.5% (Condylox) 1REPEL SPORTSMEN – diethyltoluamide (deet) aerosol 2REPEL SPORTSMEN MAX – diethyltoluamide (deet) aerosol 2SAWYER PREMIUM INSECT REP – picaridin liquid 2selenium sulfide lotion 2.5% 1selenium sulfide shampoo 2.25% 1skin protectants misc - cream 1STELARA – ustekinumab soln prefilled syringe 45 mg/0.5ml 2 PA, QL (1 syringe/84

days), SP, 90STELARA – ustekinumab soln prefilled syringe 90 mg/ml 2 PA, QL (1 syringe/56

days), SP, 90tacrolimus oint 0.03% (Protopic) 1 QL (60 days

supply/120 days), STtacrolimus oint 0.1% (Protopic) 1 QL (60 days

supply/120 days), ST

MISCELLANEOUS CATEGORIESDIABETIC SUPPLIESBAYER CONTOUR BLOOD GLUCO – blood glucose monitoring

devices2

CALIBRATION LIQUID - BAYER BREEZE 2, CONTOUR,CONTOUR NEXT

2

KETOSTIX – acetone (urine) test strip 2TEST STRIPS – BAYER ASCENCIA 2 QL (150 strips/ 30

days), ST, 90INSULIN SYRINGES - TECHLITE AND TRUEPLUS 2 QL (200 syringes/30

days), 90INUSLIN PEN NEEDLES - TECHLITE AND TRUEPLUS 2 QL (200 insulin pen

needles/30 days), 90LANCETS - BAYER ASCENCIA 2 QL (200 units/30

days), 90

RESPIRATORY INHALER-ASSIST DEVICESAEROCHAMBER 2BREATHERITE 2

MISCELLANEOUS DRUGSazathioprine tab 50 mg (Imuran) 1 90CHEMET – succimer cap 100 mg 2

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CUPRIMINE – penicillamine cap 250 mg 2 PA, SPcyclosporine cap 25 mg (Sandimmune) 1 90cyclosporine cap 100 mg (Sandimmune) 1 90CYCLOSPORINE MODIFIED – cyclosporine modified cap 50 mg 2 90cyclosporine modified cap 25 mg (Neoral) 1 90cyclosporine modified cap 50 mg (Cyclosporine modifie) 1 90cyclosporine modified cap 100 mg (Neoral) 1 90cyclosporine modified oral soln 100 mg/ml (Neoral) 1 90DEPEN TITRATABS – penicillamine tab 250 mg 2 PA, SPEXJADE – deferasirox tab for oral susp 125 mg 2 PA, QL (30 tablets/30

days), SP, 90EXJADE – deferasirox tab for oral susp 250 mg 2 PA, QL (30 tablets/30

days), SP, 90EXJADE – deferasirox tab for oral susp 500 mg 2 PA, QL (90 tablets/30

days), SP, 90FERRIPROX – deferiprone tab 500 mg 2 PA, QL (540 tablets/30

days), SP, 90FERRIPROX – deferiprone oral soln 100 mg/ml 2 PA, QL (2700 mls/30

days), SP, 90irrigation solution, physiological 1lactated ringer's for irrigation 1METHYLENE BLUE – methylene blue inj 1% 2mycophenolate mofetil cap 250 mg (Cellcept) 1 90mycophenolate mofetil for oral susp 200 mg/ml (Cellcept) 1 90mycophenolate mofetil tab 500 mg (Cellcept) 1 90mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)

(Myfortic)1 90

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

1 90

naltrexone hcl tab 50 mg 1NARCAN – naloxone hcl nasal spray 4 mg/0.1ml 2NEXAVIR – liver derivative complex inj 25.5 mg/ml 2REVLIMID – lenalidomide caps 2.5 mg 2 PA, QL (30 capsules/30

days), SPREVLIMID – lenalidomide cap 5 mg 2 PA, QL (30 capsules/30

days), SP

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101




REVLIMID – lenalidomide cap 10 mg 2 PA, QL (30 capsules/30days), SP




ringer's solution for irrigation 1sirolimus tab 0.5 mg (Rapamune) 1 90sirolimus tab 1 mg (Rapamune) 1 90sirolimus tab 2 mg (Rapamune) 1 90sodium polystyrene sulfonate oral susp 15 gm/60ml 1sodium polystyrene sulfonate powder (Kayexalate) 1sodium polystyrene sulfonate rectal susp 30 gm/120ml 1tacrolimus cap 0.5 mg (Prograf) 1 90tacrolimus cap 1 mg (Prograf) 1 90tacrolimus cap 5 mg (Prograf) 1 90THALOMID – thalidomide cap 50 mg 2 PA, QL (30 capsules/30

days), SP, 90THALOMID – thalidomide cap 100 mg 2 PA, QL (30 capsules/30



days), SP, 90trientine hcl cap 250 mg (Syprine) 1 PAwater for irrigation, sterile irrigation soln 1ZORTRESS – everolimus tab 0.25 mg 2 90ZORTRESS – everolimus tab 0.5 mg 2 90ZORTRESS – everolimus tab 0.75 mg 2 90

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INDEX

Aabacavir sulfate-lamivudine tab 600-300 mg (Epzicom)..... 5abacavir sulfate-lamivudine-zidovudine tab 300-150-300mg (Trizivir)......................................................................... 5

abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen)........ 5abacavir sulfate tab 300 mg (base equiv) (Ziagen).............5ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 300 mg.................................................................58

ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 400 mg.................................................................58

ABILIFY MAINTENA – aripiprazole im for extendedrelease susp 300 mg........................................................58

ABILIFY MAINTENA – aripiprazole im for extendedrelease susp 400 mg........................................................58

acamprosate calcium tab delayed release 333 mg...........70acarbose tab 25 mg (Precose)..........................................22acarbose tab 50 mg (Precose)..........................................22acarbose tab 100 mg (Precose)........................................22acebutolol hcl cap 200 mg (Sectral)..................................32acebutolol hcl cap 400 mg (Sectral)..................................32ACETAMINOPHEN/CAFFEINE/DI – acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg................. 72

acetaminophen w/ codeine soln 120-12 mg/5ml...............71acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine).............................................................................71

acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3)....................................................................... 71

acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4)....................................................................... 72

acetazolamide cap er 12hr 500 mg (Diamox)................... 38acetazolamide tab 250 mg................................................ 38acetic acid irrigation soln 0.25%........................................51acetic acid otic soln 2%..................................................... 94acetylcysteine cap 600 mg................................................ 88acetylcysteine inhal soln 10%............................................43acetylcysteine inhal soln 20%............................................43acitretin cap 10 mg (Soriatane)......................................... 98acitretin cap 17.5 mg (Soriatane)...................................... 98acitretin cap 25 mg (Soriatane)......................................... 98ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml(2000000 unit/0.5ml).........................................................12

acyclovir cap 200 mg (Zovirax)........................................... 5acyclovir oint 5% (Zovirax)................................................ 95acyclovir susp 200 mg/5ml (Zovirax)...................................5acyclovir tab 400 mg (Zovirax)............................................ 5acyclovir tab 800 mg (Zovirax)............................................ 5adapalene cream 0.1% (Differin).......................................94ADASUVE – loxapine aerosol powder breath activated 10mg......................................................................................58

ADCIRCA – tadalafil tab 20 mg (pah)............................... 40adefovir dipivoxil tab 10 mg (Hepsera)................................4ADEMPAS – riociguat tab 0.5 mg..................................... 40ADEMPAS – riociguat tab 1 mg........................................ 40

ADEMPAS – riociguat tab 1.5 mg..................................... 40ADEMPAS – riociguat tab 2 mg........................................ 40ADEMPAS – riociguat tab 2.5 mg..................................... 40ADMELOG – insulin lispro inj 100 unit/ml......................... 25ADMELOG SOLOSTAR – insulin lispro soln pen-injector100 unit/ml........................................................................ 25

AEROCHAMBER................................................................99AFINITOR DISPERZ – everolimus tab for oral susp 2mg......................................................................................12

AFINITOR DISPERZ – everolimus tab for oral susp 3mg......................................................................................12

AFINITOR DISPERZ – everolimus tab for oral susp 5mg......................................................................................12

AFINITOR – everolimus tab 2.5 mg.................................. 12AFINITOR – everolimus tab 5 mg..................................... 12AFINITOR – everolimus tab 7.5 mg.................................. 12AFINITOR – everolimus tab 10 mg................................... 12AFLURIA 2017-2018 – influenza virus vaccine split imsusp...................................................................................11

AFLURIA PF 2017-2018 – influenza virus vaccine split pfsusp pref syringe 0.5 ml.................................................. 11

AFLURIA QUADRIVALENT 2017 – influenza virusvaccine split quadrivalent im inj.......................................11

AFLURIA QUADRIVALENT 2017 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml.............................. 11

ALBENZA – albendazole tab 200 mg............................... 10ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr4 mg.................................................................................. 44

ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr8 mg.................................................................................. 44

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..............44albuterol sulfate soln nebu 0.5% (5 mg/ml).......................44albuterol sulfate soln nebu 0.63 mg/3ml (base equiv).......44albuterol sulfate soln nebu 1.25 mg/3ml (base equiv).......44albuterol sulfate syrup 2 mg/5ml....................................... 44albuterol sulfate tab er 12hr 4 mg (Vospire er)..................44albuterol sulfate tab er 12hr 8 mg (Vospire er)..................44albuterol sulfate tab 2 mg..................................................44albuterol sulfate tab 4 mg..................................................44alclometasone dipropionate cream 0.05% (Aclovate).......96alclometasone dipropionate oint 0.05%............................ 96ALECENSA – alectinib hcl cap 150 mg (baseequivalent).........................................................................12

ALENDRONATE SODIUM – alendronate sodium tab 40mg......................................................................................27

alendronate sodium tab 5 mg............................................27alendronate sodium tab 10 mg..........................................27alendronate sodium tab 35 mg..........................................27alendronate sodium tab 70 mg (Fosamax)....................... 27alfuzosin hcl tab er 24hr 10 mg (Uroxatral).......................51ALKERAN – melphalan tab 2 mg......................................12allopurinol tab 100 mg (Zyloprim)......................................80allopurinol tab 300 mg (Zyloprim)......................................80almotriptan malate tab 6.25 mg (Axert).............................79almotriptan malate tab 12.5 mg (Axert).............................79

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ALOGLIPTIN/METFORMIN HCL – alogliptin-metforminhcl tab 12.5-500 mg......................................................... 23

ALOGLIPTIN/METFORMIN HCL – alogliptin-metforminhcl tab 12.5-1000 mg....................................................... 23

ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazonetab 12.5-15 mg................................................................. 23



ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazonetab 25-15 mg.................................................................... 23



ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (baseequiv).................................................................................22

ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (baseequiv).................................................................................22

ALOGLIPTIN – alogliptin benzoate tab 25 mg (baseequiv).................................................................................23

alosetron hcl tab 0.5 mg (base equiv) (Lotronex)............. 49alosetron hcl tab 1 mg (base equiv) (Lotronex)................ 49ALPRAZOLAM INTENSOL – alprazolam conc 1 mg/ml.......................................................................................52

alprazolam tab er 24hr 0.5 mg (Xanax xr)........................ 52alprazolam tab er 24hr 1 mg (Xanax xr)........................... 52alprazolam tab er 24hr 2 mg (Xanax xr)........................... 52alprazolam tab er 24hr 3 mg (Xanax xr)........................... 52alprazolam tab 0.25 mg (Xanax)....................................... 52alprazolam tab 0.5 mg (Xanax)......................................... 52alprazolam tab 1 mg (Xanax)............................................ 52alprazolam tab 2 mg (Xanax)............................................ 53amantadine hcl cap 100 mg.............................................. 83amantadine hcl syrup 50 mg/5ml...................................... 84amiloride & hydrochlorothiazide tab 5-50 mg....................38amiloride hcl tab 5 mg....................................................... 38amino acids cap................................................................. 88amiodarone hcl tab 200 mg (Cordarone).......................... 39amitriptyline hcl tab 10 mg.................................................53amitriptyline hcl tab 50 mg.................................................53amitriptyline hcl tab 75 mg.................................................53amitriptyline hcl tab 100 mg...............................................54amitriptyline hcl tab 150 mg...............................................54amitriptyline hcl tab 25 mg (Elavil).................................... 53amlodipine besylate-benazepril hcl cap 2.5-10 mg...........33amlodipine besylate-benazepril hcl cap 5-40 mg..............33amlodipine besylate-benazepril hcl cap 5-10 mg(Lotrel)............................................................................... 33

amlodipine besylate-benazepril hcl cap 5-20 mg(Lotrel)............................................................................... 33



amlodipine besylate tab 2.5 mg (base equivalent)(Norvasc)...........................................................................33

amlodipine besylate tab 5 mg (base equivalent)(Norvasc)...........................................................................33

amlodipine besylate tab 10 mg (base equivalent)(Norvasc)...........................................................................33

AMOXAPINE – amoxapine tab 25 mg.............................. 54AMOXAPINE – amoxapine tab 50 mg.............................. 54AMOXAPINE – amoxapine tab 100 mg............................ 54AMOXAPINE – amoxapine tab 150 mg............................ 54AMOXICILLIN/CLAVULANATE P – amoxicillin & kclavulanate chew tab 200-28.5 mg....................................1

AMOXICILLIN/CLAVULANATE P – amoxicillin & kclavulanate chew tab 400-57 mg.......................................1

amoxicillin & k clavulanate for susp 200-28.5 mg/5ml........ 1amoxicillin & k clavulanate for susp 400-57 mg/5ml........... 1amoxicillin & k clavulanate for susp 250-62.5 mg/5ml(Augmentin).........................................................................1

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

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

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

AMOXICILLIN – amoxicillin (trihydrate) chew tab 125mg........................................................................................1

AMOXICILLIN – amoxicillin (trihydrate) chew tab 250mg........................................................................................1

amoxicillin (trihydrate) cap 250 mg......................................1amoxicillin (trihydrate) cap 500 mg......................................1amoxicillin (trihydrate) for susp 125 mg/5ml........................1amoxicillin (trihydrate) for susp 200 mg/5ml........................1amoxicillin (trihydrate) for susp 250 mg/5ml........................1amoxicillin (trihydrate) for susp 400 mg/5ml........................1amoxicillin (trihydrate) tab 875 mg...................................... 1amphetamine-dextroamphetamine cap er 24hr 5 mg(Adderall xr)...................................................................... 66

amphetamine-dextroamphetamine cap er 24hr 10 mg(Adderall xr)...................................................................... 66





amphetamine-dextroamphetamine tab 5 mg(Adderall)...........................................................................66

amphetamine-dextroamphetamine tab 7.5 mg(Adderall)...........................................................................66


amphetamine-dextroamphetamine tab 12.5 mg(Adderall)...........................................................................66

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ampicillin cap 250 mg.......................................................... 1ampicillin cap 500 mg.......................................................... 1anagrelide hcl cap 1 mg.................................................... 88anagrelide hcl cap 0.5 mg (Agrylin)...................................88anastrozole tab 1 mg (Arimidex)....................................... 12APLENZIN – bupropion hbr tab er 24hr 174 mg...............54APLENZIN – bupropion hbr tab er 24hr 348 mg...............54APLENZIN – bupropion hbr tab er 24hr 522 mg...............54apraclonidine hcl ophth soln 0.5% (base equivalent)(Iopidine)........................................................................... 93

APTIOM – eslicarbazepine acetate tab 200 mg................80APTIOM – eslicarbazepine acetate tab 400 mg................80APTIOM – eslicarbazepine acetate tab 600 mg................80APTIOM – eslicarbazepine acetate tab 800 mg................80APTIVUS – tipranavir cap 250 mg...................................... 5APTIVUS – tipranavir oral soln 100 mg/ml......................... 5ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25mcg/ml...............................................................................89

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40mcg/ml...............................................................................89

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60mcg/ml...............................................................................89

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj100 mcg/ml....................................................................... 89



ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 10 mcg/0.4ml......................................... 88

ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 25 mcg/0.42ml.......................................88







ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 500 mcg/ml............................................ 89

ARCALYST – rilonacept for inj 220 mg.............................76aripiprazole orally disintegrating tab 15 mg.......................58aripiprazole oral solution 1 mg/ml......................................58aripiprazole tab 2 mg (Abilify)............................................59

aripiprazole tab 5 mg (Abilify)............................................59aripiprazole tab 10 mg (Abilify)..........................................59aripiprazole tab 15 mg (Abilify)..........................................59aripiprazole tab 20 mg (Abilify)..........................................59aripiprazole tab 30 mg (Abilify)..........................................59ARISTADA – aripiprazole lauroxil im er susp prefilled syr441 mg/1.6ml....................................................................59

ARISTADA – aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml....................................................................59

ARISTADA – aripiprazole lauroxil im er susp prefilled syr882 mg/3.2ml....................................................................59

ARISTADA – aripiprazole lauroxil im er susp prefilled syr1064 mg/3.9ml..................................................................59

armodafinil tab 50 mg (Nuvigil)..........................................67armodafinil tab 150 mg (Nuvigil)........................................67armodafinil tab 250 mg (Nuvigil)........................................67ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 100 mcg/act..................................................44

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 200 mcg/act..................................................44

atazanavir sulfate cap 150 mg (base equiv) (Reyataz).......5atazanavir sulfate cap 200 mg (base equiv) (Reyataz).......5atazanavir sulfate cap 300 mg (base equiv) (Reyataz).......5atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)......32atenolol & chlorthalidone tab 100-25 mg (Tenoretic100)................................................................................... 32

atenolol tab 25 mg (Tenormin).......................................... 32atenolol tab 50 mg (Tenormin).......................................... 32atenolol tab 100 mg (Tenormin)........................................ 32atorvastatin calcium tab 10 mg (base equivalent)(Lipitor).............................................................................. 36

atorvastatin calcium tab 20 mg (base equivalent)(Lipitor).............................................................................. 36



atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)...... 10atovaquone-proguanil hcl tab 250-100 mg (Malarone)..... 10ATRIPLA – efavirenz-emtricitabine-tenofovir df tab600-200-300 mg................................................................. 5

ATROPINE SULFATE – atropine sulfate ophth oint1%..................................................................................... 93

ATROPINE SULFATE – atropine sulfate ophth soln1%..................................................................................... 93

ATROVENT HFA – ipratropium bromide hfa inhal aerosol17 mcg/act........................................................................ 44

AUBAGIO – teriflunomide tab 7 mg.................................. 69AUBAGIO – teriflunomide tab 14 mg................................ 69AUGMENTED BETAMETHASONE D – betamethasonedipropionate augmented gel 0.05%.................................96

AVONEX – interferon beta-1a for im inj kit 30mcg(33mcg(6.6 mu)/vial).........................................................69

AVONEX – interferon beta-1a im prefilled syringe kit 30mcg/0.5ml..........................................................................69

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105

AVONEX PEN – interferon beta-1a im auto-injector kit 30mcg/0.5ml..........................................................................69

azathioprine tab 50 mg (Imuran)....................................... 99azelastine hcl nasal spray 0.1% (137 mcg/spray).............43azelastine hcl ophth soln 0.05%........................................93AZITHROMYCIN – azithromycin powd pack for susp 1gm........................................................................................2

azithromycin for susp 100 mg/5ml (Zithromax)...................2azithromycin for susp 200 mg/5ml (Zithromax)...................2azithromycin tab 250 mg (Zithromax)..................................2azithromycin tab 500 mg (Zithromax)..................................2azithromycin tab 600 mg (Zithromax)..................................2

BBACITRACIN – bacitracin ophth oint 500 unit/gm............ 92bacitracin-polymyxin b ophth oint...................................... 92bacitracin-polymyxin-neomycin-hc ophth oint 1%............. 92baclofen tab 10 mg............................................................ 85baclofen tab 20 mg............................................................ 85balsalazide disodium cap 750 mg (Colazal)......................49BARACLUDE – entecavir oral soln 0.05 mg/ml.................. 4BASAGLAR KWIKPEN – insulin glargine soln pen-injector100 unit/ml........................................................................ 26

BAYER CONTOUR BLOOD GLUCO – blood glucosemonitoring devices............................................................99

b-complex w/ c & folic acid cap 1 mg (Nephrocaps)......... 85b-complex w/ c & folic acid tab..........................................85b-complex w/ c & folic acid tab 5 mg................................ 85b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx).......85benazepril & hydrochlorothiazide tab 5-6.25 mg...............28benazepril & hydrochlorothiazide tab 10-12.5 mg(Lotensin hct)....................................................................29

benazepril & hydrochlorothiazide tab 20-12.5 mg(Lotensin hct)....................................................................29

benazepril & hydrochlorothiazide tab 20-25 mg (Lotensinhct).....................................................................................29

benazepril hcl tab 5 mg..................................................... 29benazepril hcl tab 10 mg (Lotensin)..................................29benazepril hcl tab 20 mg (Lotensin)..................................29benazepril hcl tab 40 mg (Lotensin)..................................29BENZNIDAZOLE – benznidazole tab 12.5 mg................. 10BENZNIDAZOLE – benznidazole tab 100 mg.................. 10benzoyl peroxide cloth 6%.................................................94benzoyl peroxide-erythromycin gel 5-3%(Benzamycin).................................................................... 94

benztropine mesylate tab 0.5 mg...................................... 84benztropine mesylate tab 1 mg......................................... 84benztropine mesylate tab 2 mg......................................... 84betamethasone dipropionate augmented cream 0.05%(Diprolene af)....................................................................96

betamethasone dipropionate augmented gel 0.05%.........96betamethasone dipropionate augmented lotion 0.05%(Diprolene)........................................................................ 96

betamethasone dipropionate augmented oint 0.05%(Diprolene)........................................................................ 96

betamethasone dipropionate cream 0.05%.......................96

betamethasone dipropionate lotion 0.05%........................96betamethasone dipropionate oint 0.05%...........................96betamethasone valerate cream 0.1% (baseequivalent).........................................................................96

betamethasone valerate lotion 0.1% (baseequivalent).........................................................................96

betamethasone valerate oint 0.1% (base equivalent).......96betaxolol hcl ophth soln 0.5%............................................93betaxolol hcl tab 10 mg (Kerlone)..................................... 32betaxolol hcl tab 20 mg (Kerlone)..................................... 32bethanechol chloride tab 5 mg (Urecholine)..................... 50bethanechol chloride tab 10 mg (Urecholine)................... 50bethanechol chloride tab 25 mg (Urecholine)................... 50bethanechol chloride tab 50 mg (Urecholine)................... 50bexarotene cap 75 mg (Targretin)..................................... 12bicalutamide tab 50 mg (Casodex)....................................12bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for solnkit....................................................................................... 46

bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg(Ziac)................................................................................. 32

bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)......32bisoprolol & hydrochlorothiazide tab 10-6.25 mg(Ziac)................................................................................. 32

bisoprolol fumarate tab 5 mg (Zebeta)..............................32bisoprolol fumarate tab 10 mg (Zebeta)............................32BOSULIF – bosutinib tab 100 mg..................................... 12BOSULIF – bosutinib tab 500 mg..................................... 12BREATHERITE...................................................................99BRILINTA – ticagrelor tab 60 mg...................................... 89BRILINTA – ticagrelor tab 90 mg...................................... 89brimonidine tartrate ophth soln 0.2%.................................93BRINTELLIX – vortioxetine hbr tab 5 mg (base equiv)..... 54BRINTELLIX – vortioxetine hbr tab 10 mg (baseequiv).................................................................................54

BRINTELLIX – vortioxetine hbr tab 20 mg (baseequiv).................................................................................54

bromocriptine mesylate cap 5 mg (base equivalent).........84bromocriptine mesylate tab 2.5 mg (base equivalent)(Parlodel)...........................................................................84

budesonide delayed release particles cap 3 mg (Entocortec)......................................................................................19

budesonide inhalation susp 0.25 mg/2ml (Pulmicort)....... 44budesonide inhalation susp 0.5 mg/2ml (Pulmicort)......... 44budesonide inhalation susp 1 mg/2ml (Pulmicort)............ 44bumetanide tab 0.5 mg (Bumex).......................................38bumetanide tab 1 mg (Bumex)..........................................38bumetanide tab 2 mg (Bumex)..........................................38BUPHENYL – sodium phenylbutyrate tab 500 mg............27buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (baseequiv).................................................................................72

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (baseequiv).................................................................................72

buprenorphine hcl sl tab 2 mg (base equiv)......................72buprenorphine hcl sl tab 8 mg (base equiv)......................72bupropion hcl (smoking deterrent) tab er 12hr 150 mg(Zyban).............................................................................. 70

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106

bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)..............54bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)..............54bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)..............54bupropion hcl tab er 24hr 150 mg (Wellbutrin xl).............. 54bupropion hcl tab er 24hr 300 mg (Wellbutrin xl).............. 54bupropion hcl tab 75 mg....................................................54bupropion hcl tab 100 mg..................................................54buspirone hcl tab 5 mg...................................................... 53buspirone hcl tab 10 mg....................................................53buspirone hcl tab 15 mg....................................................53buspirone hcl tab 30 mg....................................................53butalbital-acetaminophen-caffeine cap 50-300-40 mg(Fioricet)............................................................................ 71

butalbital-acetaminophen-caffeine tab 50-325-40 mg(Esgic)............................................................................... 71

butalbital-acetaminophen-caff w/ cod cap 50-325-40-30mg......................................................................................72

butalbital-acetaminophen tab 50-325 mg..........................71butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal).....71butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg(Fiorinal/codeine #3).........................................................72

butorphanol tartrate nasal soln 10 mg/ml..........................72

Ccabergoline tab 0.5 mg...................................................... 27CABOMETYX – cabozantinib s-malate tab 20 mg (baseequivalent).........................................................................12

CABOMETYX – cabozantinib s-malate tab 40 mg (baseequivalent).........................................................................13

CABOMETYX – cabozantinib s-malate tab 60 mg (baseequivalent).........................................................................13

caffeine citrate oral soln 60 mg/3ml (10 mg/ml baseequiv).................................................................................67

calcipotriene cream 0.005% (Dovonex)............................ 98calcipotriene oint 0.005%...................................................98calcipotriene soln 0.005% (50 mcg/ml)............................. 98calcitonin (salmon) nasal soln 200 unit/act (Miacalcin).....27calcitriol cap 0.25 mcg (Rocaltrol)..................................... 27calcitriol cap 0.5 mcg (Rocaltrol)....................................... 27calcitriol oral soln 1 mcg/ml (Rocaltrol)............................. 27calcium acetate (phosphate binder) cap 667 mg (169 mgca) (Phoslo)...................................................................... 49

calcium acetate (phosphate binder) tab 667 mg(Eliphos)............................................................................ 49

CALIBRATION LIQUID - BAYER BREEZE 2, CONTOUR,CONTOUR NEXT.............................................................99

CALQUENCE – acalabrutinib cap 100 mg........................13CANASA – mesalamine suppos 1000 mg........................ 49capecitabine tab 150 mg (Xeloda).....................................13capecitabine tab 500 mg (Xeloda).....................................13CAPRELSA – vandetanib tab 100 mg.............................. 13CAPRELSA – vandetanib tab 300 mg.............................. 13CAPTOPRIL/HYDROCHLOROTHIA – captopril &hydrochlorothiazide tab 25-15 mg................................... 29

CAPTOPRIL/HYDROCHLOROTHIA – captopril &hydrochlorothiazide tab 25-25 mg................................... 29



captopril tab 12.5 mg......................................................... 29captopril tab 25 mg............................................................ 29captopril tab 50 mg............................................................ 29captopril tab 100 mg.......................................................... 29CARBAGLU – carglumic acid tab 200 mg........................ 27carbamazepine cap er 12hr 100 mg (Carbatrol)............... 80carbamazepine cap er 12hr 200 mg (Carbatrol)............... 80carbamazepine cap er 12hr 300 mg (Carbatrol)............... 80carbamazepine chew tab 100 mg..................................... 80carbamazepine susp 100 mg/5ml (Tegretol).....................80carbamazepine tab er 12hr 100 mg (Tegretol-xr)..............80carbamazepine tab er 12hr 200 mg (Tegretol-xr)..............80carbamazepine tab er 12hr 400 mg (Tegretol-xr)..............80carbamazepine tab 200 mg (Tegretol).............................. 80carbidopa & levodopa orally disintegrating tab 10-100mg......................................................................................84

carbidopa & levodopa orally disintegrating tab 25-100mg......................................................................................84

carbidopa & levodopa orally disintegrating tab 25-250mg......................................................................................84

carbidopa & levodopa tab er 25-100 mg (Sinemet cr)...... 84carbidopa & levodopa tab er 50-200 mg (Sinemet cr)...... 84carbidopa & levodopa tab 10-100 mg (Sinemet)...............84carbidopa & levodopa tab 25-100 mg (Sinemet)...............84carbidopa & levodopa tab 25-250 mg (Sinemet)...............84carbidopa tab 25 mg (Lodosyn).........................................84carbinoxamine maleate soln 4 mg/5ml..............................43carbinoxamine maleate tab 4 mg...................................... 43carisoprodol tab 250 mg (Soma).......................................85CARTEOLOL HCL – carteolol hcl ophth soln 1%............. 93carteolol hcl ophth soln 1%............................................... 93carvedilol tab 3.125 mg (Coreg)........................................32carvedilol tab 6.25 mg (Coreg)..........................................32carvedilol tab 12.5 mg (Coreg)..........................................32carvedilol tab 25 mg (Coreg).............................................32CAYSTON – aztreonam lysine for inhal soln 75 mg (baseequivalent).........................................................................10

cefaclor cap 250 mg............................................................ 1cefaclor cap 500 mg............................................................ 1cefadroxil cap 500 mg..........................................................1cefadroxil for susp 250 mg/5ml........................................... 2cefadroxil for susp 500 mg/5ml........................................... 2cefadroxil tab 1 gm.............................................................. 2cefdinir cap 300 mg............................................................. 2cefdinir for susp 125 mg/5ml............................................... 2cefdinir for susp 250 mg/5ml............................................... 2cefixime for susp 100 mg/5ml (Suprax)...............................2cefixime for susp 200 mg/5ml (Suprax)...............................2cefprozil for susp 125 mg/5ml............................................. 2cefprozil for susp 250 mg/5ml............................................. 2cefprozil tab 250 mg............................................................ 2cefprozil tab 500 mg............................................................ 2

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cefuroxime axetil tab 250 mg.............................................. 2cefuroxime axetil tab 500 mg (Ceftin)................................. 2celecoxib cap 50 mg (Celebrex)........................................76celecoxib cap 100 mg (Celebrex)......................................76celecoxib cap 200 mg (Celebrex)......................................76celecoxib cap 400 mg (Celebrex)......................................76CEM-UREA – urea soln 45%............................................ 98cephalexin cap 250 mg (Keflex)..........................................2cephalexin cap 500 mg (Keflex)..........................................2cephalexin for susp 125 mg/5ml..........................................2cephalexin for susp 250 mg/5ml..........................................2cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)........................43CHANTIX CONTINUING MONTH – varenicline tartratetab 1 mg (base equiv)......................................................70

CHANTIX STARTING MONTH PA – varenicline tartratetab 0.5 mg x 11 & tab 1 mg x 42 pack............................ 70

CHANTIX – varenicline tartrate tab 0.5 mg (baseequiv).................................................................................70

CHANTIX – varenicline tartrate tab 1 mg (base equiv)..... 70CHEMET – succimer cap 100 mg.....................................99CHENODAL – chenodiol tab 250 mg................................49CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide-amitriptyline tab 5-12.5 mg.............................................. 70

CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide-amitriptyline tab 10-25 mg............................................... 70

chlordiazepoxide hcl cap 5 mg..........................................53chlordiazepoxide hcl cap 10 mg........................................53chlordiazepoxide hcl cap 25 mg........................................53chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg(Librax).............................................................................. 47

chlorhexidine gluconate soln 0.12% (Peridex).................. 94chloroquine phosphate tab 500 mg (Aralen).....................10CHLOROTHIAZIDE – chlorothiazide tab 250 mg............. 38chlorothiazide tab 500 mg................................................. 38CHLORPROMAZINE HCL – chlorpromazine hcl inj 50mg/2ml...............................................................................59

chlorpromazine hcl tab 10 mg........................................... 59chlorpromazine hcl tab 25 mg........................................... 59chlorpromazine hcl tab 50 mg........................................... 59chlorpromazine hcl tab 100 mg......................................... 59chlorpromazine hcl tab 200 mg......................................... 59chlorthalidone tab 25 mg................................................... 38CHLORZOXAZONE – chlorzoxazone tab 500 mg............85CHOLBAM – cholic acid cap 50 mg..................................50CHOLBAM – cholic acid cap 250 mg................................50cholestyramine light powder 4 gm/dose (Questranlight)...................................................................................36

cholestyramine light powder packets 4 gm....................... 36cholestyramine powder 4 gm/dose (Questran)................. 36cholestyramine powder packets 4 gm (Questran).............36choline fenofibrate cap dr 45 mg (fenofibric acid equiv)(Trilipix)..............................................................................36

ciclopirox olamine cream 0.77% (base equiv)(Loprox).............................................................................95

ciclopirox olamine susp 0.77% (base equiv).....................95ciclopirox solution 8% (Penlac Nail Lacquer)....................95

cilostazol tab 50 mg...........................................................89cilostazol tab 100 mg.........................................................89CIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml........47cimetidine tab 200 mg........................................................47cimetidine tab 300 mg........................................................47cimetidine tab 400 mg........................................................47cimetidine tab 800 mg........................................................47CIMZIA – certolizumab pegol for inj kit 2 x 200 mg.......... 50CIMZIA – certolizumab pegol inj kit 2 x 200 mg/ml...........50CIMZIA STARTER KIT – certolizumab pegol inj kit 6 x 200mg/ml.................................................................................50

ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml)(Cipro)..................................................................................3

ciprofloxacin for oral susp 500 mg/5ml (10%) (10gm/100ml) (Cipro)...............................................................3

ciprofloxacin hcl ophth soln 0.3% (Ciloxan)...................... 92ciprofloxacin hcl tab 750 mg (base equiv)...........................3ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)...............3ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)...............3citalopram hydrobromide oral soln 10 mg/5ml.................. 54citalopram hydrobromide tab 10 mg (base equiv)(Celexa).............................................................................54

citalopram hydrobromide tab 20 mg (base equiv)(Celexa).............................................................................54

citalopram hydrobromide tab 40 mg (base equiv)(Celexa).............................................................................55

clarithromycin for susp 125 mg/5ml.....................................2clarithromycin for susp 250 mg/5ml (Biaxin)....................... 2clarithromycin tab 250 mg (Biaxin)......................................2clarithromycin tab 500 mg (Biaxin)......................................2CLASSIC PRENATAL – prenatal vit w/ fe fumarate-fa tab28-0.8 mg..........................................................................85

clindamycin hcl cap 75 mg (Cleocin).................................10clindamycin hcl cap 150 mg (Cleocin)...............................10clindamycin hcl cap 300 mg (Cleocin)...............................10clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)(Cleocin pediatric gr)........................................................ 10

clindamycin phosphate gel 1% (Cleocin-t)........................ 94clindamycin phosphate lotion 1% (Cleocin-t).................... 95clindamycin phosphate soln 1% (Cleocin-t)...................... 95clindamycin phosphate swab 1% (Cleocin-t).................... 95clindamycin phosphate vaginal cream 2% (Cleocin).........51clindamycin phosph-benzoyl peroxide (refrig) gel 1.2(1)-5% (Duac)................................................................... 94

clobetasol propionate emollient base cream 0.05%(Temovate e).....................................................................96

clobetasol propionate soln 0.05% (Temovate).................. 96clonazepam orally disintegrating tab 0.125 mg.................80clonazepam orally disintegrating tab 0.25 mg...................80clonazepam orally disintegrating tab 0.5 mg.....................81clonazepam orally disintegrating tab 1 mg........................81clonazepam orally disintegrating tab 2 mg........................81clonazepam tab 0.5 mg (Klonopin)....................................81clonazepam tab 1 mg (Klonopin).......................................81clonazepam tab 2 mg (Klonopin).......................................81clonidine hcl tab er 12hr 0.1 mg (Kapvay)........................ 67

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108

clonidine hcl tab 0.1 mg (Catapres).................................. 40clonidine hcl tab 0.2 mg (Catapres).................................. 40clonidine hcl tab 0.3 mg (Catapres).................................. 40clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1).................................................................................. 40

clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2).................................................................................. 40

clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3).................................................................................. 40

clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)........89clopidogrel bisulfate tab 300 mg (base equiv) (Plavix)......89clorazepate dipotassium tab 3.75 mg................................53clorazepate dipotassium tab 15 mg...................................53clorazepate dipotassium tab 7.5 mg (Tranxene t).............53clotrimazole cream 1%.......................................................95clotrimazole soln 1%.......................................................... 95clotrimazole troche 10 mg................................................. 94clotrimazole w/ betamethasone cream 1-0.05%(Lotrisone)......................................................................... 95

clozapine orally disintegrating tab 12.5 mg (Fazaclo).......59clozapine orally disintegrating tab 25 mg (Fazaclo)..........59clozapine orally disintegrating tab 100 mg (Fazaclo)........59clozapine tab 50 mg...........................................................59clozapine tab 200 mg.........................................................60clozapine tab 25 mg (Clozaril)...........................................59clozapine tab 100 mg (Clozaril).........................................59codeine sulfate tab 15 mg (Codeine sulfate).................... 72codeine sulfate tab 30 mg (Codeine sulfate).................... 72codeine sulfate tab 60 mg (Codeine sulfate).................... 72colchicine w/ probenecid tab 0.5-500 mg..........................80COLCRYS – colchicine tab 0.6 mg................................... 80colestipol hcl granule packets 5 gm (Colestidflavored)............................................................................ 36

colestipol hcl granules 5 gm (Colestid flavored)................36colestipol hcl tab 1 gm (Colestid)...................................... 36COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.14 mg/day..............................................................20

COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.25 mg/day..............................................................20

COMBIVENT RESPIMAT – ipratropium-albuterol inhalaerosol soln 20-100 mcg/act............................................44

COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60mg dose) kit......................................................................13

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20mg (100 dose) kit............................................................. 13

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20mg (140 dose) kit............................................................. 13

COMPLERA – emtricitabine-rilpivirine-tenofovir df tab200-25-300 mg................................................................... 5

CORTISONE ACETATE – cortisone acetate tab 25mg......................................................................................19

COSENTYX – secukinumab subcutaneous soln prefilledsyringe 150 mg/ml............................................................98

COSENTYX SENSOREADY PEN – secukinumabsubcutaneous soln auto-injector 150 mg/ml....................98

COTELLIC – cobimetinib fumarate tab 20 mg (baseequivalent).........................................................................13

CREON – pancrelipase (lip-prot-amyl) dr cap3000-9500-15000 unit...................................................... 48

CREON – pancrelipase (lip-prot-amyl) dr cap6000-19000-30000 unit.................................................... 48

CREON – pancrelipase (lip-prot-amyl) dr cap12000-38000-60000 unit.................................................. 48

CREON – pancrelipase (lip-prot-amyl) dr cap24000-76000-120000 unit................................................ 49

CREON – pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit.............................................. 49

CRIXIVAN – indinavir sulfate cap 200 mg...........................5CRIXIVAN – indinavir sulfate cap 400 mg...........................5cromolyn sodium ophth soln 4%....................................... 93CUPRIMINE – penicillamine cap 250 mg....................... 100CUTTER BACKWOODS – diethyltoluamide (deet)aerosol...............................................................................98

CUTTER SKINSATIONS – diethyltoluamide (deet)liquid.................................................................................. 98

cyanocobalamin inj 1000 mcg/ml...................................... 89cyclobenzaprine hcl tab 5 mg............................................85cyclobenzaprine hcl tab 10 mg..........................................85cyclopentolate hcl ophth soln 0.5% (Cyclogyl)..................93cyclopentolate hcl ophth soln 1% (Cyclogyl).....................93cyclopentolate hcl ophth soln 2% (Cyclogyl).....................93cyclophosphamide cap 25 mg (Cyclophosphamide).........13cyclophosphamide cap 50 mg (Cyclophosphamide).........13cyclosporine cap 25 mg (Sandimmune)..........................100cyclosporine cap 100 mg (Sandimmune)........................100cyclosporine modified cap 50 mg (Cyclosporinemodifie)............................................................................100

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

cyclosporine modified oral soln 100 mg/ml (Neoral)....... 100cyproheptadine hcl syrup 2 mg/5ml...................................43cyproheptadine hcl tab 4 mg............................................. 43CYSTAGON – cysteamine bitartrate cap 50 mg............... 51CYSTAGON – cysteamine bitartrate cap 150 mg............. 51

Ddanazol cap 50 mg............................................................ 20danazol cap 100 mg.......................................................... 20danazol cap 200 mg.......................................................... 20dantrolene sodium cap 100 mg.........................................85dantrolene sodium cap 25 mg (Dantrium).........................85dantrolene sodium cap 50 mg (Dantrium).........................85dapsone tab 25 mg............................................................10dapsone tab 100 mg..........................................................10DARAPRIM – pyrimethamine tab 25 mg...........................10darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv)(Enablex)...........................................................................51

darifenacin hydrobromide tab er 24hr 15 mg (base equiv)(Enablex)...........................................................................51

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demeclocycline hcl tab 150 mg........................................... 2demeclocycline hcl tab 300 mg........................................... 2DEPEN TITRATABS – penicillamine tab 250 mg............100DESCOVY – emtricitabine-tenofovir alafenamide fumaratetab 200-25 mg.................................................................... 5

desipramine hcl tab 50 mg................................................ 55desipramine hcl tab 75 mg................................................ 55desipramine hcl tab 100 mg.............................................. 55desipramine hcl tab 150 mg.............................................. 55desipramine hcl tab 10 mg (Norpramin)............................55desipramine hcl tab 25 mg (Norpramin)............................55desloratadine tab 5 mg (Clarinex)..................................... 43desmopressin acetate nasal spray soln 0.01%(Ddavp)..............................................................................27

desmopressin acetate nasal spray soln 0.01%(refrigerated)..................................................................... 27

desmopressin acetate tab 0.1 mg (Ddavp)....................... 27desmopressin acetate tab 0.2 mg (Ddavp)....................... 27desonide cream 0.05% (Desowen)................................... 96desonide oint 0.05%.......................................................... 96desoximetasone cream 0.25% (Topicort)..........................96desoximetasone gel 0.05% (Topicort)............................... 96DEXAMETHASONE – dexamethasone soln 0.5mg/5ml...............................................................................19

dexamethasone elixir 0.5 mg/5ml......................................19DEXAMETHASONE SODIUM PHOS – dexamethasonesodium phosphate ophth soln 0.1%................................ 92

dexamethasone tab 0.5 mg............................................... 19dexamethasone tab 0.75 mg.............................................19dexamethasone tab 1.5 mg............................................... 19dexamethasone tab 4 mg.................................................. 19dexamethasone tab 6 mg.................................................. 19dexmethylphenidate hcl cap er 24 hr 5 mg (Focalinxr)...................................................................................... 67

dexmethylphenidate hcl cap er 24 hr 10 mg (Focalinxr)...................................................................................... 67





dexmethylphenidate hcl tab 2.5 mg (Focalin)................... 67dexmethylphenidate hcl tab 5 mg (Focalin)...................... 67dexmethylphenidate hcl tab 10 mg (Focalin).................... 67dextroamphetamine sulfate cap er 24hr 5 mg(Dexedrine)....................................................................... 67

dextroamphetamine sulfate cap er 24hr 10 mg(Dexedrine)....................................................................... 67

dextroamphetamine sulfate cap er 24hr 15 mg(Dexedrine)....................................................................... 67

dextroamphetamine sulfate oral solution 5 mg/5ml(Procentra)........................................................................ 67

dextroamphetamine sulfate tab 5 mg................................67

dextroamphetamine sulfate tab 10 mg..............................68diazepam conc 5 mg/ml.....................................................53DIAZEPAM – diazepam im solution auto-inj 10mg/2ml...............................................................................53

DIAZEPAM – diazepam oral soln 1 mg/ml........................53DIAZEPAM – diazepam rectal gel delivery system 2.5mg......................................................................................81

DIAZEPAM – diazepam rectal gel delivery system 10mg......................................................................................81

DIAZEPAM – diazepam rectal gel delivery system 20mg......................................................................................81

diazepam tab 2 mg (Valium)..............................................53diazepam tab 5 mg (Valium)..............................................53diazepam tab 10 mg (Valium)............................................53diclofenac potassium tab 50 mg........................................76diclofenac sodium gel 1% (Voltaren).................................95diclofenac sodium ophth soln 0.1%...................................93diclofenac sodium tab delayed release 50 mg..................76diclofenac sodium tab delayed release 75 mg..................76diclofenac sodium tab er 24hr 100 mg..............................76dicloxacillin sodium cap 250 mg..........................................1dicloxacillin sodium cap 500 mg..........................................1dicyclomine hcl cap 10 mg (Bentyl)...................................47dicyclomine hcl oral soln 10 mg/5ml................................. 47dicyclomine hcl tab 20 mg (Bentyl)................................... 47didanosine delayed release capsule 200 mg (Videx ec).....6didanosine delayed release capsule 250 mg (Videx ec).....6didanosine delayed release capsule 400 mg (Videx ec).....6DIGOXIN – digoxin oral soln 0.05 mg/ml.......................... 40digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................... 40digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................... 40DILANTIN – phenytoin sodium extended cap 30 mg........81diltiazem hcl cap er 12hr 60 mg........................................33diltiazem hcl cap er 12hr 90 mg........................................33diltiazem hcl cap er 12hr 120 mg......................................33diltiazem hcl cap er 24hr 120 mg......................................33diltiazem hcl cap er 24hr 180 mg......................................33diltiazem hcl cap er 24hr 240 mg......................................34diltiazem hcl coated beads cap er 24hr 300 mg............... 34diltiazem hcl coated beads cap er 24hr 120 mg (Cardizemcd)......................................................................................34

diltiazem hcl coated beads cap er 24hr 180 mg (Cardizemcd)......................................................................................34

diltiazem hcl coated beads cap er 24hr 240 mg (Cardizemcd)......................................................................................34

diltiazem hcl extended release beads cap er 24hr 120 mg(Tiazac)............................................................................. 34





2017

110


diltiazem hcl tab 90 mg......................................................34diltiazem hcl tab 30 mg (Cardizem)...................................34diltiazem hcl tab 60 mg (Cardizem)...................................34diltiazem hcl tab 120 mg (Cardizem).................................34diphenhydramine hcl cap 50 mg....................................... 43diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)...... 47dipyridamole tab 25 mg..................................................... 89dipyridamole tab 50 mg..................................................... 89dipyridamole tab 75 mg..................................................... 89disopyramide phosphate cap 100 mg (Norpace).............. 39disopyramide phosphate cap 150 mg (Norpace).............. 39disulfiram tab 250 mg (Antabuse)..................................... 70disulfiram tab 500 mg (Antabuse)..................................... 70divalproex sodium cap delayed release sprinkle 125 mg(Depakote sprinkles).........................................................81

divalproex sodium tab delayed release 125 mg(Depakote)........................................................................ 81



divalproex sodium tab er 24 hr 250 mg (Depakote er)......81divalproex sodium tab er 24 hr 500 mg (Depakote er)......81dofetilide cap 125 mcg (0.125 mg) (Tikosyn)....................39dofetilide cap 250 mcg (0.25 mg) (Tikosyn)......................39dofetilide cap 500 mcg (0.5 mg) (Tikosyn)........................39donepezil hydrochloride orally disintegrating tab 5 mg..... 70donepezil hydrochloride orally disintegrating tab 10mg......................................................................................70

donepezil hydrochloride tab 5 mg (Aricept).......................70donepezil hydrochloride tab 10 mg (Aricept).....................70dorzolamide hcl ophth soln 2% (Trusopt)..........................93dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt)....................................................................... 93

doxazosin mesylate tab 1 mg (Cardura)........................... 40doxazosin mesylate tab 2 mg (Cardura)........................... 41doxazosin mesylate tab 4 mg (Cardura)........................... 41doxazosin mesylate tab 8 mg (Cardura)........................... 41doxepin hcl cap 10 mg...................................................... 55doxepin hcl cap 25 mg...................................................... 55doxepin hcl cap 50 mg...................................................... 55doxepin hcl cap 75 mg...................................................... 55doxepin hcl cap 100 mg.................................................... 55doxepin hcl cap 150 mg.................................................... 55doxepin hcl conc 10 mg/ml................................................55doxycycline hyclate cap 50 mg............................................2doxycycline hyclate cap 100 mg (Vibramycin).................... 2doxycycline hyclate tab delayed release 50 mg (Doryx).....2doxycycline hyclate tab 20 mg............................................ 3doxycycline hyclate tab 100 mg.......................................... 3doxycycline monohydrate cap 50 mg..................................3doxycycline monohydrate cap 100 mg (Monodox)..............3doxycycline monohydrate for susp 25 mg/5ml(Vibramycin)........................................................................ 3

doxycycline monohydrate tab 50 mg (Adoxa).....................3doxycycline monohydrate tab 75 mg (Adoxa).....................3doxycycline monohydrate tab 100 mg (Adoxa pak1/100).................................................................................. 3

duloxetine hcl enteric coated pellets cap 20 mg (base eq)(Cymbalta).........................................................................55



dutasteride cap 0.5 mg (Avodart)...................................... 51dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)............52dyphylline-guaifenesin liqd 100-100 mg/5ml..................... 44

EEDURANT – rilpivirine hcl tab 25 mg (base equivalent)..... 6efavirenz cap 50 mg (Sustiva).............................................6efavirenz cap 200 mg (Sustiva)...........................................6efavirenz tab 600 mg (Sustiva)............................................6ELIGARD – leuprolide acetate for subcutaneous inj kit 7.5mg......................................................................................13

ELIGARD – leuprolide acetate (3 month) forsubcutaneous inj kit 22.5mg............................................ 13

ELIGARD – leuprolide acetate (4 month) forsubcutaneous inj kit 30 mg.............................................. 13

ELIGARD – leuprolide acetate (6 month) forsubcutaneous inj kit 45 mg.............................................. 13

ELIQUIS – apixaban tab 2.5 mg....................................... 89ELIQUIS – apixaban tab 5 mg.......................................... 89ELIQUIS STARTER PACK – apixaban tab 5 mg.............. 90ELLA – ulipristal acetate tab 30 mg.................................. 21EMSAM – selegiline td patch 24hr 6 mg/24hr...................55EMSAM – selegiline td patch 24hr 9 mg/24hr...................55EMSAM – selegiline td patch 24hr 12 mg/24hr.................55EMTRIVA – emtricitabine caps 200 mg.............................. 6EMTRIVA – emtricitabine soln 10 mg/ml.............................6enalapril maleate & hydrochlorothiazide tab 5-12.5mg......................................................................................29

enalapril maleate & hydrochlorothiazide tab 10-25 mg(Vaseretic)......................................................................... 29

enalapril maleate tab 2.5 mg (Vasotec).............................29enalapril maleate tab 5 mg (Vasotec)............................... 29enalapril maleate tab 10 mg (Vasotec)............................. 29enalapril maleate tab 20 mg (Vasotec)............................. 29ENBREL – etanercept for subcutaneous inj 25 mg...........76ENBREL – etanercept subcutaneous soln prefilled syringe25 mg/0.5ml...................................................................... 76

ENBREL – etanercept subcutaneous soln prefilled syringe50 mg/ml........................................................................... 76

ENBREL SURECLICK – etanercept subcutaneoussolution auto-injector 50 mg/ml........................................76

ENGERIX-B – hepatitis b vaccine (recombinant) 10mcg/0.5ml..........................................................................10

ENGERIX-B – hepatitis b vaccine (recombinant) 20 mcg/ml.......................................................................................10

2017

111

ENGERIX-B – hepatitis b vaccine (recombinant) susp 10mcg/0.5ml..........................................................................10

ENGERIX-B – hepatitis b vaccine (recombinant) susp 20mcg/ml...............................................................................10

ENJUVIA – estrogens, conjugated synthetic b tab 0.3mg......................................................................................20




enoxaparin sodium inj 30 mg/0.3ml (Lovenox)................. 90enoxaparin sodium inj 40 mg/0.4ml (Lovenox)................. 90enoxaparin sodium inj 60 mg/0.6ml (Lovenox)................. 90enoxaparin sodium inj 80 mg/0.8ml (Lovenox)................. 90enoxaparin sodium inj 100 mg/ml (Lovenox).................... 90enoxaparin sodium inj 120 mg/0.8ml (Lovenox)............... 90enoxaparin sodium inj 150 mg/ml (Lovenox).................... 90entacapone tab 200 mg (Comtan).....................................84entecavir tab 0.5 mg (Baraclude)........................................ 4entecavir tab 1 mg (Baraclude)........................................... 4ENTRESTO – sacubitril-valsartan tab 24-26 mg.............. 34ENTRESTO – sacubitril-valsartan tab 49-51 mg.............. 34ENTRESTO – sacubitril-valsartan tab 97-103 mg............ 34epinastine hcl ophth soln 0.05% (Elestat).........................93EPINEPHRINE – epinephrine solution auto-injector 0.15mg/0.3ml (1:2000)............................................................ 42

EPINEPHRINE – epinephrine solution auto-injector 0.3mg/0.3ml (1:1000)............................................................ 42

EPOGEN – epoetin alfa inj 2000 unit/ml...........................90EPOGEN – epoetin alfa inj 3000 unit/ml...........................90EPOGEN – epoetin alfa inj 4000 unit/ml...........................90EPOGEN – epoetin alfa inj 10000 unit/ml.........................90EPOGEN – epoetin alfa inj 20000 unit/ml.........................90EQL PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...............................................................85

EQUETRO – carbamazepine (antipsychotic) cap er 12hr100 mg..............................................................................60



ergocalciferol cap 50000 unit.............................................85ERIVEDGE – vismodegib cap 150 mg..............................13erythromycin ophth oint 5 mg/gm......................................92erythromycin pads 2%....................................................... 95erythromycin soln 2%.........................................................95ESBRIET – pirfenidone cap 267 mg................................. 46escitalopram oxalate soln 5 mg/5ml (base equiv)(Lexapro)...........................................................................55

escitalopram oxalate tab 5 mg (base equiv) (Lexapro).....55escitalopram oxalate tab 10 mg (base equiv)(Lexapro)...........................................................................55

escitalopram oxalate tab 20 mg (base equiv)(Lexapro)...........................................................................55

estazolam tab 1 mg........................................................... 65estazolam tab 2 mg........................................................... 65estradiol & norethindrone acetate tab 0.5-0.1 mg(Activella)...........................................................................20

estradiol & norethindrone acetate tab 1-0.5 mg(Activella)...........................................................................20

estradiol tab 0.5 mg (Estrace)........................................... 20estradiol tab 1 mg (Estrace).............................................. 20estradiol tab 2 mg (Estrace).............................................. 21estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot).................................................................................... 21

estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot).................................................................................... 21




estradiol td patch weekly 0.025 mg/24hr (Climara)...........21estradiol td patch weekly 0.05 mg/24hr (Climara).............21estradiol td patch weekly 0.06 mg/24hr (Climara).............21estradiol td patch weekly 0.075 mg/24hr (Climara)...........21estradiol td patch weekly 0.1 mg/24hr (Climara)...............21estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)(Climara)............................................................................21

estradiol vaginal tab 10 mcg (Vagifem).............................51ESTROPIPATE – estropipate tab 3 mg.............................21eszopiclone tab 1 mg (Lunesta)........................................ 65eszopiclone tab 2 mg (Lunesta)........................................ 65eszopiclone tab 3 mg (Lunesta)........................................ 65ethambutol hcl tab 100 mg (Myambutol).............................3ethambutol hcl tab 400 mg (Myambutol).............................3ethosuximide cap 250 mg (Zarontin).................................81ethosuximide soln 250 mg/5ml (Zarontin)......................... 81ETIDRONATE DISODIUM – etidronate disodium tab 200mg......................................................................................27

EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg(base equiv)........................................................................ 6

exemestane tab 25 mg (Aromasin)................................... 13EXJADE – deferasirox tab for oral susp 125 mg............ 100EXJADE – deferasirox tab for oral susp 250 mg............ 100EXJADE – deferasirox tab for oral susp 500 mg............ 100EXTAVIA – interferon beta-1b for inj kit 0.3 mg.................69

Ffamciclovir tab 125 mg (Famvir)..........................................5famotidine for susp 40 mg/5ml (Pepcid)............................47famotidine tab 20 mg (Pepcid).......................................... 47famotidine tab 40 mg (Pepcid).......................................... 47FANAPT – iloperidone tab 1 mg........................................60FANAPT – iloperidone tab 2 mg........................................60FANAPT – iloperidone tab 4 mg........................................60FANAPT – iloperidone tab 6 mg........................................60FANAPT – iloperidone tab 8 mg........................................60FANAPT – iloperidone tab 10 mg......................................60

2017

112

FANAPT – iloperidone tab 12 mg......................................60FANAPT TITRATION PACK – iloperidone tab 1 mg & 2mg & 4 mg & 6 mg titration pak...................................... 60

FAZACLO – clozapine orally disintegrating tab 150mg......................................................................................60

FAZACLO – clozapine orally disintegrating tab 200mg......................................................................................60

fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1mg......................................................................................90

fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240mg......................................................................................90

fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap(Tandem plus)...................................................................90

felbamate susp 600 mg/5ml (Felbatol)..............................81felbamate tab 400 mg (Felbatol)....................................... 81felbamate tab 600 mg (Felbatol)....................................... 81felodipine tab er 24hr 2.5 mg............................................ 34felodipine tab er 24hr 5 mg............................................... 34felodipine tab er 24hr 10 mg............................................. 34fenofibrate micronized cap 43 mg..................................... 36fenofibrate micronized cap 67 mg (Lofibra).......................36fenofibrate micronized cap 134 mg (Lofibra).....................36fenofibrate micronized cap 200 mg (Lofibra).....................36fenofibrate tab 54 mg (Lofibra)..........................................36fenofibrate tab 160 mg (Lofibra)........................................37fenofibrate tab 48 mg (Tricor)............................................ 36fenofibrate tab 145 mg (Tricor).......................................... 36fentanyl td patch 72hr 12 mcg/hr (Duragesic)...................72fentanyl td patch 72hr 25 mcg/hr (Duragesic)...................72fentanyl td patch 72hr 50 mcg/hr (Duragesic)...................72fentanyl td patch 72hr 75 mcg/hr (Duragesic)...................72fentanyl td patch 72hr 100 mcg/hr (Duragesic).................72FERRIPROX – deferiprone oral soln 100 mg/ml.............100FERRIPROX – deferiprone tab 500 mg..........................100ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1mg......................................................................................90

ferrous fumarate-folic acid tab 324-1 mg.......................... 90FETZIMA – levomilnacipran hcl cap er 24hr 20 mg (baseequivalent).........................................................................55

FETZIMA – levomilnacipran hcl cap er 24hr 40 mg (baseequivalent).........................................................................55



FETZIMA TITRATION PACK – levomilnacipran hcl cap er24hr 20 & 40 mg therapy pack........................................56

FINACEA – azelaic acid gel 15%......................................95finasteride tab 5 mg (Proscar)...........................................52FIRAZYR – icatibant acetate inj 30 mg/3ml (baseequivalent).........................................................................90

flavoxate hcl tab 100 mg................................................... 51flecainide acetate tab 50 mg............................................. 39flecainide acetate tab 100 mg........................................... 39flecainide acetate tab 150 mg........................................... 39

FLOVENT DISKUS – fluticasone propionate aer pow ba50 mcg/blister................................................................... 44

FLOVENT DISKUS – fluticasone propionate aer pow ba100 mcg/blister................................................................. 44

FLOVENT DISKUS – fluticasone propionate aer pow ba250 mcg/blister................................................................. 44

FLOVENT HFA – fluticasone propionate hfa inhal aer 110mcg/act (125/valve).......................................................... 45

FLOVENT HFA – fluticasone propionate hfa inhal aer 220mcg/act (250/valve).......................................................... 45

FLOVENT HFA – fluticasone propionate hfa inhal aero 44mcg/act (50/valve)............................................................ 45

FLUARIX QUADRIVALENT 2017 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml.............................. 11

FLUCELVAX QUADRIVALENT 20 – influenza vac tissue-cultured subunit quadrivalent im susp............................. 11

fluconazole for susp 10 mg/ml (Diflucan)............................4fluconazole for susp 40 mg/ml (Diflucan)............................4fluconazole tab 50 mg (Diflucan).........................................4fluconazole tab 100 mg (Diflucan).......................................4fluconazole tab 150 mg (Diflucan).......................................4fluconazole tab 200 mg (Diflucan).......................................4flucytosine cap 250 mg (Ancobon)......................................4flucytosine cap 500 mg (Ancobon)......................................4fludrocortisone acetate tab 0.1 mg....................................19FLULAVAL QUADRIVALENT 201 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml.............................. 11

FLUNISOLIDE – flunisolide nasal soln 25 mcg/act(0.025%)............................................................................43

fluocinolone acetonide cream 0.01%................................ 97fluocinolone acetonide cream 0.025% (Synalar)...............97fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs sca)................................................................ 97

fluocinolone acetonide oint 0.025% (Synalar)...................97fluocinolone acetonide soln 0.01% (Synalar).................... 97fluocinonide cream 0.05%................................................. 97fluocinonide emulsified base cream 0.05%.......................97fluocinonide gel 0.05%.......................................................97fluocinonide oint 0.05%......................................................97fluocinonide soln 0.05%.....................................................97fluorometholone ophth susp 0.1% (Fml liquifilm).............. 92fluorouracil cream 5% (Efudex)......................................... 98fluoxetine hcl cap 10 mg (Prozac).....................................56fluoxetine hcl cap 20 mg (Prozac).....................................56fluoxetine hcl cap 40 mg (Prozac).....................................56fluoxetine hcl solution 20 mg/5ml...................................... 56fluoxetine hcl tab 10 mg.................................................... 56fluoxetine hcl tab 20 mg.................................................... 56FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5mg/5ml...............................................................................60

FLUPHENAZINE HCL – fluphenazine hcl inj 2.5 mg/ml.......................................................................................60

FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml.......................................................................................60

fluphenazine hcl tab 1 mg................................................. 60fluphenazine hcl tab 2.5 mg.............................................. 60

2017

113

fluphenazine hcl tab 5 mg................................................. 60fluphenazine hcl tab 10 mg............................................... 60flurandrenolide cream 0.05% (Cordran)............................ 97flurbiprofen sodium ophth soln 0.03% (Ocufen)................93flurbiprofen tab 50 mg........................................................76flurbiprofen tab 100 mg......................................................76flutamide cap 125 mg........................................................ 13FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 55-14 mcg/act........................ 45

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 113-14 mcg/act...................... 45

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 232-14 mcg/act...................... 45

fluticasone propionate cream 0.05% (Cutivate)................ 97fluticasone propionate nasal susp 50 mcg/act.................. 43fluticasone propionate oint 0.005%................................... 97fluvastatin sodium tab er 24 hr 80 mg (Lescol xl)............. 37FLUVIRIN 2017-2018 – influenza vac type a&b surfaceantigen susp pref syr 0.5 ml............................................ 11

FLUVIRIN 2017-2018 – influenza virus vaccine types a &b surface antigen im susp................................................11

fluvoxamine maleate tab 25 mg........................................ 56fluvoxamine maleate tab 50 mg........................................ 56fluvoxamine maleate tab 100 mg...................................... 56FLUZONE HIGH-DOSE PF 2017 – influenza virus vacsplit high-dose pf susp pref syr 0.5ml..............................12

FLUZONE QUADRIVALENT 2017 – influenza virusvaccine split quadrivalent im inj.......................................12

FLUZONE QUADRIVALENT 2015 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml.............................. 12

FLUZONE QUADRIVALENT 2017 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml.............................. 12

FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals &folic acid tab 5 mg............................................................85

folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2 mg.....88folic acid tab 1 mg............................................................. 90folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg..........90folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg.............90folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgardrx)...................................................................................... 90

FORFIVO XL – bupropion hcl tab er 24hr 450 mg............56fosamprenavir calcium tab 700 mg (base equiv)(Lexiva)................................................................................6

fosinopril sodium & hydrochlorothiazide tab 10-12.5mg......................................................................................29

fosinopril sodium & hydrochlorothiazide tab 20-12.5mg......................................................................................29

fosinopril sodium tab 10 mg.............................................. 29fosinopril sodium tab 20 mg.............................................. 29fosinopril sodium tab 40 mg.............................................. 29frovatriptan succinate tab 2.5 mg (base equivalent)(Frova)...............................................................................79

furosemide oral soln 10 mg/ml.......................................... 39furosemide tab 20 mg (Lasix)............................................39furosemide tab 40 mg (Lasix)............................................39furosemide tab 80 mg (Lasix)............................................39

FUZEON – enfuvirtide for inj 90 mg....................................6

Ggabapentin cap 100 mg (Neurontin)..................................81gabapentin cap 300 mg (Neurontin)..................................81gabapentin cap 400 mg (Neurontin)..................................81gabapentin oral soln 250 mg/5ml (Neurontin)...................81gabapentin tab 600 mg (Neurontin)...................................82gabapentin tab 800 mg (Neurontin)...................................82galantamine hydrobromide cap er 24hr 8 mg (Razadyneer)...................................................................................... 70

galantamine hydrobromide cap er 24hr 16 mg (Razadyneer)...................................................................................... 70

galantamine hydrobromide cap er 24hr 24 mg (Razadyneer)...................................................................................... 70

GALANTAMINE HYDROBROMIDE – galantaminehydrobromide oral soln 4 mg/ml...................................... 70

galantamine hydrobromide tab 4 mg (Razadyne).............70galantamine hydrobromide tab 8 mg (Razadyne).............70galantamine hydrobromide tab 12 mg (Razadyne)...........70GATTEX – teduglutide (rdna) for inj kit 5 mg.................... 50gemfibrozil tab 600 mg (Lopid)..........................................37gentamicin sulfate oint 0.1%..............................................95gentamicin sulfate ophth oint 0.3%................................... 92gentamicin sulfate ophth soln 0.3%...................................92GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab150-150-200-10 mg............................................................ 6

GEODON – ziprasidone mesylate for inj 20 mg (baseequivalent).........................................................................60

GILOTRIF – afatinib dimaleate tab 20 mg (baseequivalent).........................................................................13



glatiramer acetate soln prefilled syringe 40 mg/ml(Copaxone)....................................................................... 69

glatiramer acetate soln prefilled syringe 20 mg/ml(Glatopa)........................................................................... 69

glimepiride tab 1 mg (Amaryl)........................................... 23glimepiride tab 2 mg (Amaryl)........................................... 23glimepiride tab 4 mg (Amaryl)........................................... 23glipizide-metformin hcl tab 2.5-250 mg............................. 23glipizide-metformin hcl tab 2.5-500 mg............................. 23glipizide-metformin hcl tab 5-500 mg................................ 24glipizide tab er 24hr 2.5 mg (Glucotrol xl)......................... 23glipizide tab er 24hr 5 mg (Glucotrol xl)............................ 23glipizide tab er 24hr 10 mg (Glucotrol xl).......................... 23glipizide tab 5 mg (Glucotrol).............................................23glipizide tab 10 mg (Glucotrol)...........................................23GLUCAGON EMERGENCY KIT – glucagon (rdna) for injkit 1 mg.............................................................................24

glyburide-metformin tab 1.25-250 mg (Glucovance).........24glyburide-metformin tab 2.5-500 mg (Glucovance)...........24glyburide-metformin tab 5-500 mg (Glucovance)..............24glyburide micronized tab 1.5 mg (Glynase).......................24

2017

114

glyburide micronized tab 3 mg (Glynase)..........................24glyburide micronized tab 6 mg (Glynase)..........................24glyburide tab 1.25 mg........................................................ 24glyburide tab 2.5 mg.......................................................... 24glyburide tab 5 mg............................................................. 24glycine irrigation soln 1.5%................................................52glycopyrrolate tab 1 mg (Robinul)..................................... 47glycopyrrolate tab 2 mg (Robinul forte).............................47GNP PRENATAL – prenatal vit w/ fe fumarate-fa tab28-0.8 mg..........................................................................86

GOODSENSE PRENATAL VITAMI – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 86

griseofulvin microsize susp 125 mg/5ml..............................4griseofulvin microsize tab 500 mg.......................................4griseofulvin ultramicrosize tab 125 mg (Gris-peg)...............4griseofulvin ultramicrosize tab 250 mg (Gris-peg)...............4guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv).....68guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv).....68guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv).....68guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv).....68guanfacine hcl tab 1 mg (Tenex).......................................41guanfacine hcl tab 2 mg (Tenex).......................................41

Hhalobetasol propionate cream 0.05% (Ultravate)..............97halobetasol propionate oint 0.05% (Ultravate).................. 97haloperidol lactate oral conc 2 mg/ml................................60haloperidol tab 0.5 mg....................................................... 60haloperidol tab 1 mg.......................................................... 60haloperidol tab 2 mg.......................................................... 60haloperidol tab 5 mg.......................................................... 61haloperidol tab 10 mg........................................................ 61haloperidol tab 20 mg........................................................ 61HEXALEN – altretamine cap 50 mg..................................14HM PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................86

homatropine hbr ophth soln 5%........................................ 93H.P. ACTHAR – corticotropin inj gel 80 unit/ml................. 27HUMALOG MIX 75/25 – insulin lispro prot & lispro inj 100unit/ml (75-25)...................................................................25

HUMALOG MIX 50/50 – insulin lispro protamine & lisproinj 100 unit/ml (50-50)...................................................... 25

HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot &lispro sus pen-inj 100 unit/ml (50-50).............................. 25

HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot &lispro sus pen-inj 100 unit/ml (75-25).............................. 25

HUMIRA – adalimumab prefilled syringe kit 10mg/0.1ml............................................................................76






HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 40 mg/0.8ml....................................................77

HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 80 mg/0.8ml....................................................77

HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 80 mg/0.8ml & 40 mg/0.4ml........................... 77

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.8ml............................................................................77

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.4ml............................................................................77

HUMIRA PEN-CROHNS DISEASE – adalimumab pen-injector kit 40 mg/0.8ml....................................................77

HUMIRA PEN-PSORIASIS STAR – adalimumab pen-injector kit 40 mg/0.8ml....................................................77

HUMULIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30)...................................................... 25

HUMULIN 70/30 KWIKPEN – insulin nph & regular susppen-inj 100 unit/ml (70-30)...............................................25

HUMULIN N – insulin nph (human) (isophane) inj 100unit/ml................................................................................25

HUMULIN N KWIKPEN – insulin nph (human) (isophane)susp pen-injector 100 unit/ml...........................................25

HUMULIN R – insulin regular (human) inj 100 unit/ml...... 25HYCAMTIN – topotecan hcl cap 0.25 mg (baseequiv).................................................................................14

HYCAMTIN – topotecan hcl cap 1 mg (base equiv)......... 14hydralazine hcl tab 10 mg................................................. 41hydralazine hcl tab 25 mg................................................. 41hydralazine hcl tab 50 mg................................................. 41hydralazine hcl tab 100 mg............................................... 41hydrochlorothiazide cap 12.5 mg (Microzide)................... 39hydrochlorothiazide tab 12.5 mg....................................... 39hydrochlorothiazide tab 25 mg.......................................... 39hydrochlorothiazide tab 50 mg.......................................... 39hydrocodone-acetaminophen soln 7.5-325 mg/15ml(Hycet)...............................................................................72

hydrocodone-acetaminophen soln 10-325 mg/15ml(Zamicet)........................................................................... 72

hydrocodone-acetaminophen tab 2.5-325 mg...................72hydrocodone-acetaminophen tab 7.5-325 mg (Norco)..... 73hydrocodone-acetaminophen tab 5-325 mg (Norco)........ 73hydrocodone-acetaminophen tab 10-325 mg (Norco)...... 72hydrocodone-acetaminophen tab 7.5-300 mg (Xodol)......73hydrocodone-acetaminophen tab 10-300 mg (Xodol).......73HYDROCODONE BITARTRATE/CH – pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml.............. 43

hydrocodone-ibuprofen tab 7.5-200 mg............................ 73hydrocodone-ibuprofen tab 5-200 mg (Reprexain)........... 73hydrocortisone butyrate oint 0.1% (Locoid).......................97hydrocortisone butyrate soln 0.1% (Locoid)......................97hydrocortisone cream 1%.................................................. 97hydrocortisone cream 2.5%............................................... 97hydrocortisone enema 100 mg/60ml (Cortenema)............94hydrocortisone lotion 2.5%................................................ 97

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hydrocortisone lotion 2% (Ala scalp).................................97hydrocortisone oint 1%...................................................... 97hydrocortisone oint 2.5%................................................... 97hydrocortisone rectal cream 2.5% (Anusol-hc)................. 94hydrocortisone rectal cream 1% (Proctocort)....................94hydrocortisone tab 5 mg (Cortef).......................................19hydrocortisone tab 10 mg (Cortef).....................................19hydrocortisone tab 20 mg (Cortef).....................................19hydrocortisone valerate cream 0.2%.................................97hydrocortisone valerate oint 0.2% (Westcort)................... 97hydrocortisone w/ acetic acid otic soln 1-2%.................... 94hydromorphone hcl liqd 1 mg/ml (Dilaudid).......................73hydromorphone hcl tab 2 mg (Dilaudid)............................73hydromorphone hcl tab 4 mg (Dilaudid)............................73hydromorphone hcl tab 8 mg (Dilaudid)............................73hydroxychloroquine sulfate tab 200 mg (Plaquenil).......... 10hydroxyurea cap 500 mg (Hydrea)....................................14hydroxyzine hcl syrup 10 mg/5ml......................................53hydroxyzine hcl tab 10 mg.................................................53hydroxyzine hcl tab 25 mg.................................................53hydroxyzine hcl tab 50 mg.................................................53hydroxyzine pamoate cap 25 mg (Vistaril)........................ 53hydroxyzine pamoate cap 50 mg (Vistaril)........................ 53hyoscyamine sulfate elixir 0.125 mg/5ml.......................... 47hyoscyamine sulfate soln 0.125 mg/ml............................. 47hyoscyamine sulfate tab disint 0.125 mg (Anaspaz).........47hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid)......... 47hyoscyamine sulfate tab 0.125 mg (Levsin)......................47hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)...............47

Iibandronate sodium tab 150 mg (base equivalent)(Boniva).............................................................................27

IBRANCE – palbociclib cap 75 mg....................................14IBRANCE – palbociclib cap 100 mg..................................14IBRANCE – palbociclib cap 125 mg..................................14ibuprofen susp 100 mg/5ml............................................... 77ibuprofen tab 400 mg.........................................................77ibuprofen tab 600 mg.........................................................77ibuprofen tab 800 mg.........................................................77ICLUSIG – ponatinib hcl tab 15 mg (base equiv)..............14ICLUSIG – ponatinib hcl tab 45 mg (base equiv)..............14imatinib mesylate tab 100 mg (base equivalent)(Gleevec)...........................................................................14

imatinib mesylate tab 400 mg (base equivalent)(Gleevec)...........................................................................14

imipramine hcl tab 10 mg (Tofranil)...................................56imipramine hcl tab 25 mg (Tofranil)...................................56imipramine hcl tab 50 mg (Tofranil)...................................56imiquimod cream 5% (Aldara)........................................... 98IMITREX – sumatriptan nasal spray 5 mg/act...................79IMITREX – sumatriptan nasal spray 20 mg/act.................79IMOVAX RABIES (H.D.C.V.) – rabies virus vaccine, hdcinj....................................................................................... 10

INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)........26

INCRUSE ELLIPTA – umeclidinium br aero powd breathact 62.5 mcg/inh (base eq).............................................. 45

indapamide tab 1.25 mg.................................................... 39indapamide tab 2.5 mg...................................................... 39indomethacin cap er 75 mg...............................................77indomethacin cap 25 mg................................................... 77indomethacin cap 50 mg................................................... 77INFED – iron dextran inj 50 mg/ml (elemental iron)..........90INLYTA – axitinib tab 1 mg................................................14INLYTA – axitinib tab 5 mg................................................14INTELENCE – etravirine tab 25 mg.................................... 6INTELENCE – etravirine tab 100 mg.................................. 6INTELENCE – etravirine tab 200 mg.................................. 6INVEGA – paliperidone tab er 24hr 1.5 mg...................... 61INVEGA – paliperidone tab er 24hr 3 mg......................... 61INVEGA – paliperidone tab er 24hr 6 mg......................... 61INVEGA – paliperidone tab er 24hr 9 mg......................... 61INVEGA SUSTENNA – paliperidone palmitate imextended-release susp 39 mg/0.25ml............................. 61

INVEGA SUSTENNA – paliperidone palmitate imextended-release susp 78 mg/0.5ml............................... 61

INVEGA SUSTENNA – paliperidone palmitate imextended-release susp 156 mg/ml...................................61

INVEGA SUSTENNA – paliperidone palmitate imextended-release susp 234 mg/1.5ml............................. 61

INVEGA SUSTENNA – paliperidone palmitate im extend-release susp 117 mg/0.75ml............................................61

INVEGA TRINZA – paliperidone palmitate im extend-release susp 273 mg/0.875ml..........................................61


INVEGA TRINZA – paliperidone palmitate im extend-release susp 546 mg/1.75ml............................................61


INVIRASE – saquinavir mesylate cap 200 mg....................6INVIRASE – saquinavir mesylate tab 500 mg.....................6ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml........... 45ipratropium bromide inhal soln 0.02%...............................45ipratropium bromide nasal soln 0.03% (21 mcg/spray).....43ipratropium bromide nasal soln 0.06% (42 mcg/spray).....43IPRIVASK – desirudin for inj 15 mg.................................. 90irbesartan-hydrochlorothiazide tab 150-12.5 mg(Avalide)............................................................................ 30

irbesartan-hydrochlorothiazide tab 300-12.5 mg(Avalide)............................................................................ 30

irbesartan tab 75 mg (Avapro)...........................................30irbesartan tab 150 mg (Avapro).........................................30irbesartan tab 300 mg (Avapro).........................................30iron combination cap..........................................................90iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg(Hematron-af)....................................................................91

iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg(Corvite 150)..................................................................... 91

iron polysacch complex-vit b12-fa cap 150-0.025-1mg......................................................................................90

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irrigation solution, physiological.......................................100ISENTRESS HD – raltegravir potassium tab 600 mg(base equiv)........................................................................ 7

ISENTRESS – raltegravir potassium chew tab 25 mg(base equiv)........................................................................ 7

ISENTRESS – raltegravir potassium chew tab 100 mg(base equiv)........................................................................ 7

ISENTRESS – raltegravir potassium packet for susp 100mg (base equiv)..................................................................6

ISENTRESS – raltegravir potassium tab 400 mg (baseequiv)...................................................................................6

isoniazid tab 100 mg............................................................3isoniazid tab 300 mg............................................................3isosorbide mononitrate tab er 24hr 30 mg........................ 35isosorbide mononitrate tab er 24hr 60 mg........................ 35isosorbide mononitrate tab er 24hr 120 mg...................... 35isosorbide mononitrate tab 10 mg.....................................35isosorbide mononitrate tab 20 mg.....................................35isotretinoin cap 10 mg........................................................95isotretinoin cap 20 mg........................................................95isotretinoin cap 30 mg........................................................95isotretinoin cap 40 mg........................................................95isradipine cap 2.5 mg.........................................................34isradipine cap 5 mg............................................................34ivermectin tab 3 mg (Stromectol)...................................... 10

JJAKAFI – ruxolitinib phosphate tab 5 mg (baseequivalent).........................................................................14

JAKAFI – ruxolitinib phosphate tab 10 mg (baseequivalent).........................................................................14




JULUCA – dolutegravir sodium-rilpivirine hcl tab 50-25 mg(base eq).............................................................................7

JUXTAPID – lomitapide mesylate cap 5 mg (baseequiv).................................................................................37






KKALETRA – lopinavir-ritonavir tab 100-25 mg.................... 7KALETRA – lopinavir-ritonavir tab 200-50 mg.................... 7KALYDECO – ivacaftor packet 50 mg...............................46

KALYDECO – ivacaftor packet 75 mg...............................46KALYDECO – ivacaftor tab 150 mg.................................. 46ketoconazole cream 2%.....................................................95ketoconazole shampoo 2% (Nizoral).................................95ketoconazole tab 200 mg.................................................... 4ketoprofen cap 50 mg........................................................78ketoprofen cap 75 mg........................................................78KETOPROFEN – ketoprofen cap 50 mg...........................77KETOPROFEN – ketoprofen cap 75 mg...........................78ketorolac tromethamine ophth soln 0.5% (Acular)............ 93ketorolac tromethamine ophth soln 0.4% (Acular ls).........93ketorolac tromethamine tab 10 mg....................................78KETOSTIX – acetone (urine) test strip..............................99KINERET – anakinra subcutaneous soln prefilled syringe100 mg/0.67ml..................................................................78

KISQALI FEMARA 600 DOSE – ribociclib tab 200 mg &letrozole tab 2.5 mg therapy pack................................... 14

KORLYM – mifepristone tab 300 mg.................................24K-PHOS – potassium phosphate monobasic tab 500mg......................................................................................87

KP PRENATAL MULTIVITAMINS – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 86

KUVAN – sapropterin dihydrochloride powder packet 100mg......................................................................................27

KUVAN – sapropterin dihydrochloride powder packet 500mg......................................................................................27

KUVAN – sapropterin dihydrochloride soluble tab 100mg......................................................................................27

KYLEENA – levonorgestrel releasing iud 17.5 mcg/day(19.5 mg total).................................................................. 22

Llabetalol hcl tab 100 mg.................................................... 32labetalol hcl tab 200 mg.................................................... 32labetalol hcl tab 300 mg.................................................... 32lactated ringer's for irrigation........................................... 100lactulose (encephalopathy) solution 10 gm/15ml.............. 50lactulose solution 10 gm/15ml........................................... 46LAMICTAL STARTER/NOT TAKI – lamotrigine tab 25 mg(42) & 100 mg (7) starter kit............................................ 82

LAMICTAL STARTER/TAKING C – lamotrigine tab 25 mg(84) & 100 mg (14) starter kit.......................................... 82

LAMICTAL STARTER/TAKING V – lamotrigine tab 25 mg(35) starter kit................................................................... 82

LAMICTAL XR – lamotrigine tab er 24hr 25 (14) & 50 mg(14) & 100 mg(7) kit.........................................................82

LAMICTAL XR – lamotrigine tab er 24hr 50 (14) & 100mg(14) & 200 mg(7) kit....................................................82

LAMICTAL XR – lamotrigine tab er 24hr 25 mg (21) & 50mg (7) titration kit............................................................. 82

lamivudine oral soln 10 mg/ml (Epivir)................................ 7lamivudine tab 150 mg (Epivir)............................................7lamivudine tab 300 mg (Epivir)............................................7lamivudine tab 100 mg (hbv) (Epivir hbv)........................... 4lamivudine-zidovudine tab 150-300 mg (Combivir).............7

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lamotrigine tab chewable dispersible 5 mg (Lamictalchewable di)......................................................................82

lamotrigine tab chewable dispersible 25 mg (Lamictalchewable di)......................................................................82

lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg (7)kit (Lamictal odt)...............................................................82

lamotrigine tab disint 25 mg (21) & 50 mg (7) titration kit(Lamictal odt)....................................................................82

lamotrigine tab disint 50 mg (42)- 100 mg(14) titration kit(Lamictal odt)....................................................................82

lamotrigine tab er 24hr 25 mg (Lamictal xr)...................... 82lamotrigine tab er 24hr 50 mg (Lamictal xr)...................... 82lamotrigine tab er 24hr 100 mg (Lamictal xr).................... 82lamotrigine tab er 24hr 200 mg (Lamictal xr).................... 82lamotrigine tab er 24hr 250 mg (Lamictal xr).................... 82lamotrigine tab er 24hr 300 mg (Lamictal xr).................... 82lamotrigine tab 25 mg (Lamictal).......................................82lamotrigine tab 100 mg (Lamictal).....................................82lamotrigine tab 150 mg (Lamictal).....................................82lamotrigine tab 200 mg (Lamictal).....................................82LANCETS - BAYER ASCENCIA....................................... 99lansoprazole cap delayed release 15 mg (Prevacid)........ 47lansoprazole cap delayed release 30 mg (Prevacid)........ 47latanoprost ophth soln 0.005% (Xalatan).......................... 93LATUDA – lurasidone hcl tab 20 mg.................................61LATUDA – lurasidone hcl tab 40 mg.................................61LATUDA – lurasidone hcl tab 60 mg.................................61LATUDA – lurasidone hcl tab 80 mg.................................61LATUDA – lurasidone hcl tab 120 mg...............................61leflunomide tab 10 mg (Arava).......................................... 78leflunomide tab 20 mg (Arava).......................................... 78LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 mg (14 mg daily dose)................................ 14

LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 (2) mg (18 mg daily dose)...........................15

LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapypack 10 (2) & 4 mg (24 mg daily dose)...........................15

LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapypack 10 mg (10 mg daily dose).......................................14

LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapypack 10 (2) mg (20 mg daily dose)................................. 15

LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapypack 4 (2) mg (8 mg daily dose)..................................... 15

LETAIRIS – ambrisentan tab 5 mg....................................41LETAIRIS – ambrisentan tab 10 mg..................................41letrozole tab 2.5 mg (Femara)...........................................15LEUCOVORIN CALCIUM – leucovorin calcium tab 10mg......................................................................................15

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

leucovorin calcium tab 5 mg..............................................15leucovorin calcium tab 25 mg............................................15LEUKERAN – chlorambucil tab 2 mg................................15levetiracetam oral soln 100 mg/ml (Keppra)..................... 82levetiracetam tab er 24hr 500 mg (Keppra xr).................. 82levetiracetam tab er 24hr 750 mg (Keppra xr).................. 82

levetiracetam tab 250 mg (Keppra)...................................82levetiracetam tab 500 mg (Keppra)...................................83levetiracetam tab 750 mg (Keppra)...................................83levetiracetam tab 1000 mg (Keppra).................................83levobunolol hcl ophth soln 0.5% (Betagan).......................93levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...........27levocarnitine tab 330 mg (Carnitor)...................................27levocetirizine dihydrochloride tab 5 mg (Xyzal).................43levofloxacin oral soln 25 mg/ml........................................... 3levofloxacin tab 250 mg (Levaquin).....................................3levofloxacin tab 500 mg (Levaquin).....................................3levofloxacin tab 750 mg (Levaquin).....................................3levothyroxine sodium tab 25 mcg (Synthroid)...................26levothyroxine sodium tab 50 mcg (Synthroid)...................26levothyroxine sodium tab 75 mcg (Synthroid)...................26levothyroxine sodium tab 88 mcg (Synthroid)...................26levothyroxine sodium tab 100 mcg (Synthroid).................26levothyroxine sodium tab 112 mcg (Synthroid)................. 26levothyroxine sodium tab 125 mcg (Synthroid).................26levothyroxine sodium tab 137 mcg (Synthroid).................26levothyroxine sodium tab 150 mcg (Synthroid).................26levothyroxine sodium tab 175 mcg (Synthroid).................26levothyroxine sodium tab 200 mcg (Synthroid).................26levothyroxine sodium tab 300 mcg (Synthroid).................26LEXIVA – fosamprenavir calcium susp 50 mg/ml (baseequiv)...................................................................................7

lidocaine hcl gel 2%...........................................................98lidocaine hcl soln 4% (Xylocaine)......................................98lidocaine hcl viscous soln 2%............................................94lidocaine patch 5% (Lidoderm)..........................................98lidocaine-prilocaine cream 2.5-2.5%................................. 98LILETTA – levonorgestrel releasing iud 18.6 mcg/day (52mg total)............................................................................22

linezolid for susp 100 mg/5ml (Zyvox)...............................10linezolid tab 600 mg (Zyvox)............................................. 11liothyronine sodium tab 5 mcg (Cytomel)..........................26liothyronine sodium tab 25 mcg (Cytomel)........................26liothyronine sodium tab 50 mcg (Cytomel)........................26lisinopril & hydrochlorothiazide tab 10-12.5 mg(Zestoretic)........................................................................ 29

lisinopril & hydrochlorothiazide tab 20-12.5 mg(Zestoretic)........................................................................ 29

lisinopril & hydrochlorothiazide tab 20-25 mg(Zestoretic)........................................................................ 29

lisinopril tab 5 mg (Prinivil)................................................ 29lisinopril tab 10 mg (Prinivil).............................................. 29lisinopril tab 20 mg (Prinivil).............................................. 30lisinopril tab 2.5 mg (Zestril).............................................. 29lisinopril tab 30 mg (Zestril)............................................... 30lisinopril tab 40 mg (Zestril)............................................... 30lithium carbonate cap 300 mg........................................... 62lithium carbonate cap 150 mg (Lithium carbonate)...........62lithium carbonate cap 600 mg (Lithium carbonate)...........62lithium carbonate tab er 450 mg........................................62lithium carbonate tab er 300 mg (Lithobid)....................... 62lithium carbonate tab 300 mg............................................62

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LITHIUM – lithium oral solution 8 meq/5ml....................... 62LONSURF – trifluridine-tipiracil tab 15-6.14 mg................15LONSURF – trifluridine-tipiracil tab 20-8.19 mg................15loperamide hcl cap 2 mg................................................... 47lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)(Kaletra)...............................................................................7

lorazepam conc 2 mg/ml................................................... 53lorazepam tab 0.5 mg (Ativan).......................................... 53lorazepam tab 1 mg (Ativan)............................................. 53lorazepam tab 2 mg (Ativan)............................................. 53losartan potassium & hydrochlorothiazide tab 50-12.5 mg(Hyzaar).............................................................................31

losartan potassium & hydrochlorothiazide tab 100-12.5mg (Hyzaar)...................................................................... 31

losartan potassium & hydrochlorothiazide tab 100-25 mg(Hyzaar).............................................................................31

losartan potassium tab 25 mg (Cozaar)............................31losartan potassium tab 50 mg (Cozaar)............................31losartan potassium tab 100 mg (Cozaar)..........................31lovastatin tab 10 mg...........................................................37lovastatin tab 20 mg...........................................................37lovastatin tab 40 mg (Mevacor).........................................37loxapine succinate cap 5 mg.............................................62loxapine succinate cap 10 mg...........................................62loxapine succinate cap 25 mg...........................................62loxapine succinate cap 50 mg...........................................62LUPANETA PACK – leuprolide (1 mon) inj 3.75 mg &norethindrone tab 5 mg kit...............................................22

LUPANETA PACK – leuprolide (3 mon) inj 11.25 mg &norethindrone tab 5 mg kit...............................................22

LUPRON DEPOT (1-MONTH) – leuprolide acetate for injkit 3.75 mg........................................................................15

LUPRON DEPOT (1-MONTH) – leuprolide acetate for injkit 7.5 mg..........................................................................15

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3month) for inj kit 11.25 mg............................................... 15

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3month) for inj kit 22.5 mg.................................................15

LUPRON DEPOT (4-MONTH) – leuprolide acetate (4month) for inj kit 30 mg....................................................15

LUPRON DEPOT (6-MONTH) – leuprolide acetate (6month) for inj kit 45 mg....................................................15

LUPRON DEPOT-PED (1-MONTH – leuprolide acetatefor inj pediatric kit 7.5 mg........................................... 22,28

LUPRON DEPOT-PED (1-MONTH – leuprolide acetatefor inj pediatric kit 11.25 mg........................................22,28

LUPRON DEPOT-PED (1-MONTH – leuprolide acetatefor inj pediatric kit 15 mg............................................ 22,28

LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3month) for inj pediatric kit 11.25 mg................................ 22

LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3month) for inj pediatric kit 30 mg..................................... 22

LYNPARZA – olaparib cap 50 mg..................................... 15LYNPARZA – olaparib tab 100 mg....................................15LYNPARZA – olaparib tab 150 mg....................................15LYSODREN – mitotane tab 500 mg..................................15

MMAPROTILINE HCL – maprotiline hcl tab 25 mg............. 56MAPROTILINE HCL – maprotiline hcl tab 50 mg............. 56MAPROTILINE HCL – maprotiline hcl tab 75 mg............. 56MARPLAN – isocarboxazid tab 10 mg..............................56MATULANE – procarbazine hcl cap 50 mg.......................15MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg......... 4meclizine hcl tab 12.5 mg..................................................48meclizine hcl tab 25 mg.....................................................48medroxyprogesterone acetate tab 2.5 mg (Provera)........ 21medroxyprogesterone acetate tab 5 mg (Provera)........... 21medroxyprogesterone acetate tab 10 mg (Provera)......... 21MEFLOQUINE HCL – mefloquine hcl tab 250 mg............10mefloquine hcl tab 250 mg................................................ 10megestrol acetate susp 625 mg/5ml (Megace es)............ 21megestrol acetate susp 40 mg/ml (Megace oral)..............15megestrol acetate tab 20 mg.............................................16megestrol acetate tab 40 mg.............................................16MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg(base equivalent).............................................................. 16

MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (baseequivalent).........................................................................16

meloxicam tab 7.5 mg (Mobic).......................................... 78meloxicam tab 15 mg (Mobic)........................................... 78memantine hcl oral solution 2 mg/ml (Namenda)..............70memantine hcl tab 5 mg (28) & 10 mg (21) titration pak(Namenda titration pa)..................................................... 71

memantine hcl tab 5 mg (Namenda).................................71memantine hcl tab 10 mg (Namenda)...............................71MEPHYTON – phytonadione tab 5 mg............................. 85mercaptopurine tab 50 mg.................................................16MESALAMINE DR – mesalamine tab delayed release 800mg......................................................................................50

mesalamine enema 4 gm.................................................. 50mesalamine rectal enema 4 gm & cleanser wipe kit(Rowasa)...........................................................................50

metformin hcl tab er 24hr 500 mg (Glucophage xr).......... 24metformin hcl tab er 24hr 750 mg (Glucophage xr).......... 24metformin hcl tab 500 mg (Glucophage)...........................24metformin hcl tab 850 mg (Glucophage)...........................24metformin hcl tab 1000 mg (Glucophage).........................24methadone hcl conc 10 mg/ml (Methadose).....................73methadone hcl soln 5 mg/5ml (Methadone hcl)................ 73methadone hcl soln 10 mg/5ml (Methadone hcl).............. 73methadone hcl tab for oral susp 40 mg............................ 73methadone hcl tab 5 mg (Dolophine)................................73methadone hcl tab 10 mg (Dolophine)..............................73methimazole tab 5 mg (Tapazole)..................................... 26methimazole tab 10 mg (Tapazole)................................... 26methocarbamol tab 750 mg (Robaxin-750).......................85methocarbamol tab 500 mg (Robaxin)..............................85methotrexate sodium tab 2.5 mg (base equiv)..................16methoxsalen rapid cap 10 mg (Oxsoralen ultra)............... 98methscopolamine bromide tab 2.5 mg (Pamine).............. 47methyldopa tab 250 mg..................................................... 41

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methyldopa tab 500 mg..................................................... 41METHYLENE BLUE – methylene blue inj 1%.................100methylergonovine maleate tab 0.2 mg.............................. 28methylphenidate hcl cap er 24hr 20 mg (la) (Ritalinla).......................................................................................68

methylphenidate hcl cap er 24hr 30 mg (la) (Ritalinla).......................................................................................68

methylphenidate hcl cap er 24hr 40 mg (la) (Ritalinla).......................................................................................68

methylphenidate hcl cap er 10 mg (cd).............................68methylphenidate hcl cap er 20 mg (cd).............................68methylphenidate hcl cap er 30 mg (cd).............................68methylphenidate hcl cap er 40 mg (cd).............................68methylphenidate hcl cap er 50 mg (cd).............................68methylphenidate hcl cap er 60 mg (cd).............................68methylphenidate hcl chew tab 2.5 mg...............................68methylphenidate hcl chew tab 5 mg..................................68methylphenidate hcl chew tab 10 mg................................68METHYLPHENIDATE HCL ER – methylphenidate hcl taber 24hr 18 mg...................................................................68

METHYLPHENIDATE HCL ER – methylphenidate hcl taber 24hr 27 mg...................................................................68



methylphenidate hcl soln 5 mg/5ml (Methylin)..................69methylphenidate hcl soln 10 mg/5ml (Methylin)................69methylphenidate hcl tab er 10 mg.....................................69methylphenidate hcl tab er 20 mg.....................................69methylphenidate hcl tab 5 mg (Ritalin)..............................69methylphenidate hcl tab 10 mg (Ritalin)............................69methylphenidate hcl tab 20 mg (Ritalin)............................69methylprednisolone tab 4 mg (Medrol)..............................19methylprednisolone tab 8 mg (Medrol)..............................19methylprednisolone tab 16 mg (Medrol)............................19methylprednisolone tab 32 mg (Medrol)............................19methylprednisolone tab therapy pack 4 mg (21) (Medroldosepak)............................................................................19

METIPRANOLOL – metipranolol ophth soln 0.3%............93metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (baseequiv).................................................................................50

metoclopramide hcl tab 5 mg (base equivalent)(Reglan).............................................................................50

metoclopramide hcl tab 10 mg (base equivalent)(Reglan).............................................................................50

metolazone tab 2.5 mg...................................................... 39metolazone tab 5 mg......................................................... 39metolazone tab 10 mg....................................................... 39METOPROLOL/HYDROCHLOROTHI – metoprolol &hydrochlorothiazide tab 100-50 mg................................. 33

metoprolol & hydrochlorothiazide tab 100-50 mg..............32metoprolol & hydrochlorothiazide tab 50-25 mg(Lopressor hct)..................................................................32

metoprolol & hydrochlorothiazide tab 100-25 mg(Lopressor hct)..................................................................32

metoprolol succinate tab er 24hr 25 mg (tartrate equiv)(Toprol xl).......................................................................... 32




metoprolol tartrate tab 25 mg............................................ 32metoprolol tartrate tab 50 mg (Lopressor).........................33metoprolol tartrate tab 100 mg (Lopressor).......................33metronidazole cap 375 mg (Flagyl)...................................11metronidazole cream 0.75% (Metrocream).......................95metronidazole gel 0.75%................................................... 95metronidazole tab 250 mg (Flagyl)....................................11metronidazole tab 500 mg (Flagyl)....................................11metronidazole vaginal gel 0.75% (Metrogel-vaginal)........ 51midodrine hcl tab 2.5 mg...................................................41midodrine hcl tab 5 mg...................................................... 41midodrine hcl tab 10 mg....................................................41miglitol tab 25 mg (Glyset).................................................24miglitol tab 50 mg (Glyset).................................................24miglitol tab 100 mg (Glyset)...............................................24miglustat cap 100 mg (Zavesca)....................................... 91minocycline hcl cap 50 mg (Minocin).................................. 3minocycline hcl cap 75 mg (Minocin).................................. 3minocycline hcl cap 100 mg (Minocin)................................ 3minoxidil tab 2.5 mg...........................................................41minoxidil tab 10 mg............................................................41MIRENA – levonorgestrel releasing iud 20 mcg/day (52mg total)............................................................................22

mirtazapine tab 15 mg (Remeron).....................................56mirtazapine tab 30 mg (Remeron).....................................56mirtazapine tab 45 mg (Remeron).....................................57misoprostol tab 100 mcg (Cytotec)....................................47misoprostol tab 200 mcg (Cytotec)....................................48modafinil tab 100 mg (Provigil)..........................................69modafinil tab 200 mg (Provigil)..........................................69moexipril hcl tab 7.5 mg.................................................... 30moexipril hcl tab 15 mg..................................................... 30moexipril-hydrochlorothiazide tab 7.5-12.5 mg................. 30moexipril-hydrochlorothiazide tab 15-12.5 mg.................. 30moexipril-hydrochlorothiazide tab 15-25 mg..................... 30MOLINDONE HYDROCHLORIDE – molindone hcl tab 5mg......................................................................................62

MOLINDONE HYDROCHLORIDE – molindone hcl tab 10mg......................................................................................62

MOLINDONE HYDROCHLORIDE – molindone hcl tab 25mg......................................................................................62

mometasone furoate cream 0.1% (Elocon).......................97mometasone furoate oint 0.1% (Elocon)...........................97mometasone furoate solution 0.1% (lotion) (Elocon)........ 97montelukast sodium chew tab 4 mg (base equiv)(Singulair)..........................................................................45

montelukast sodium chew tab 5 mg (base equiv)(Singulair)..........................................................................45

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120

montelukast sodium oral granules packet 4 mg (baseequiv) (Singulair).............................................................. 45

montelukast sodium tab 10 mg (base equiv)(Singulair)..........................................................................45

morphine sulfate cap er 24hr 100 mg (Kadian).................74MORPHINE SULFATE ER – morphine sulfate beads caper 24hr 60 mg...................................................................74

MORPHINE SULFATE ER – morphine sulfate beads caper 24hr 75 mg...................................................................74

MORPHINE SULFATE ER – morphine sulfate beads caper 24hr 120 mg.................................................................74

MORPHINE SULFATE – morphine sulfate suppos 5mg......................................................................................73




MORPHINE SULFATE – morphine sulfate tab 15 mg...... 73MORPHINE SULFATE – morphine sulfate tab 30 mg...... 73morphine sulfate oral soln 10 mg/5ml............................... 74morphine sulfate oral soln 20 mg/5ml............................... 74morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...........74morphine sulfate tab er 15 mg (Ms contin)....................... 74morphine sulfate tab er 30 mg (Ms contin)....................... 74morphine sulfate tab er 60 mg (Ms contin)....................... 74morphine sulfate tab er 100 mg (Ms contin)..................... 74morphine sulfate tab er 200 mg (Ms contin)..................... 74multiple vitamins w/ minerals & fa tab 1.25 mg(Corvite).............................................................................86

multiple vitamins w/ minerals cap......................................86multiple vitamins w/ minerals tab (Strovite forte)...............86MULTI PRENATAL – prenatal vit w/ fe fumarate-fa tab27-0.8 mg..........................................................................86

mupirocin oint 2%...............................................................96M-VIT – prenatal vit w/ fe fumarate-fa tab 27-1 mg.......... 86mycophenolate mofetil cap 250 mg (Cellcept)................100mycophenolate mofetil for oral susp 200 mg/ml(Cellcept).........................................................................100

mycophenolate mofetil tab 500 mg (Cellcept).................100mycophenolate sodium tab dr 180 mg (mycophenolic acidequiv) (Myfortic)..............................................................100

mycophenolate sodium tab dr 360 mg (mycophenolic acidequiv) (Myfortic)..............................................................100

MYLERAN – busulfan tab 2 mg........................................ 16

Nnabumetone tab 500 mg....................................................78nabumetone tab 750 mg....................................................78nadolol tab 20 mg (Corgard)............................................. 33nadolol tab 40 mg (Corgard)............................................. 33nadolol tab 80 mg (Corgard)............................................. 33naftifine hcl cream 2% (Naftin).......................................... 96naltrexone hcl tab 50 mg.................................................100

naproxen sodium tab er 24hr 375 mg (base equiv)(Naprelan)......................................................................... 78

naproxen sodium tab 275 mg............................................78naproxen sodium tab 550 mg (Anaprox ds)......................78naproxen susp 125 mg/5ml (Naprosyn)............................ 78naproxen tab ec 375 mg (Ec-naprosyn)............................78naproxen tab ec 500 mg (Ec-naprosyn)............................78naproxen tab 250 mg.........................................................78naproxen tab 375 mg.........................................................78naproxen tab 500 mg (Naprosyn)......................................78NARCAN – naloxone hcl nasal spray 4 mg/0.1ml...........100NATACYN – natamycin ophth susp 5%............................ 92nateglinide tab 60 mg (Starlix)...........................................25nateglinide tab 120 mg (Starlix).........................................25NATRAPEL 12-HOUR TICK & I – picaridin aerosol..........98NAT-RUL PRENATAL VITAMINS – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 86

NEFAZODONE HCL – nefazodone hcl tab 100 mg..........57NEFAZODONE HCL – nefazodone hcl tab 150 mg..........57NEFAZODONE HCL – nefazodone hcl tab 200 mg..........57neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000untop oin................................................................................ 92

neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml (Neosporin)......................................................92

neomycin-polymyxin b gu irrigation soln (Neosporin guirrigan)............................................................................... 52

neomycin-polymyxin-dexamethasone ophth oint 0.1%(Maxitrol)........................................................................... 92

neomycin-polymyxin-dexamethasone ophth susp 0.1%(Maxitrol)........................................................................... 92

neomycin-polymyxin-hc otic soln 1%................................ 94neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%................................................................................ 94

neomycin sulfate tab 500 mg.............................................. 3NEULASTA ONPRO KIT – pegfilgrastim soln prefilledsyringe kit 6 mg/0.6ml......................................................91

NEULASTA – pegfilgrastim soln prefilled syringe 6mg/0.6ml............................................................................91

nevirapine tab er 24hr 100 mg (Viramune xr)..................... 7nevirapine tab er 24hr 400 mg (Viramune xr)..................... 7nevirapine tab 200 mg (Viramune)......................................7NEXAVAR – sorafenib tosylate tab 200 mg (baseequivalent).........................................................................16

NEXAVIR – liver derivative complex inj 25.5 mg/ml........100NEXPLANON – etonogestrel subdermal implant 68mg......................................................................................22

nicardipine hcl cap 20 mg..................................................34NICOTROL INHALER – nicotine inhaler system 10 mg (4mg delivered)....................................................................71

NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray)................................................................................ 71

nifedipine cap 20 mg..........................................................34nifedipine cap 10 mg (Procardia)...................................... 34nifedipine tab er 24hr 30 mg (Adalat cc)...........................34nifedipine tab er 24hr 60 mg (Adalat cc)...........................34nifedipine tab er 24hr 90 mg (Adalat cc)...........................34

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121

nifedipine tab er 24hr osmotic release 30 mg (Procardiaxl).......................................................................................35



nimodipine cap 30 mg........................................................35NINLARO – ixazomib citrate cap 2.3 mg (baseequivalent).........................................................................16

NINLARO – ixazomib citrate cap 3 mg (baseequivalent).........................................................................16

NINLARO – ixazomib citrate cap 4 mg (baseequivalent).........................................................................16

nitrofurantoin macrocrystalline cap 25 mg(Macrodantin)....................................................................50



nitrofurantoin monohydrate macrocrystalline cap 100 mg(Macrobid)......................................................................... 50

nitroglycerin cap er 2.5 mg................................................35nitroglycerin cap er 6.5 mg................................................35nitroglycerin cap er 9 mg...................................................35nitroglycerin sl tab 0.3 mg (Nitrostat)................................ 35nitroglycerin sl tab 0.4 mg (Nitrostat)................................ 35nitroglycerin sl tab 0.6 mg (Nitrostat)................................ 35nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)............... 36nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)............... 36nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)............... 36nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)............... 36NITYR – nitisinone tab 2 mg............................................. 28NITYR – nitisinone tab 5 mg............................................. 28NITYR – nitisinone tab 10 mg........................................... 28NIVA-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................86

nizatidine cap 150 mg........................................................48nizatidine cap 300 mg........................................................48norethindrone acetate-ethinyl estradiol tab 1 mg-5mcg....................................................................................21

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5mcg (Femhrt low dose).................................................... 21

norethindrone acetate tab 5 mg (Aygestin).......................21nortriptyline hcl cap 10 mg (Pamelor)............................... 57nortriptyline hcl cap 25 mg (Pamelor)............................... 57nortriptyline hcl cap 50 mg (Pamelor)............................... 57nortriptyline hcl cap 75 mg (Pamelor)............................... 57NORVIR – ritonavir cap 100 mg..........................................7NORVIR – ritonavir oral soln 80 mg/ml...............................7NOVOLIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30)...................................................... 26

NOVOLIN 70/30 RELION – insulin nph isophane &regular human inj 100 unit/ml (70-30)............................. 26

NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml.......................................................................................25

NOVOLIN N RELION – insulin nph (human) (isophane) inj100 unit/ml........................................................................ 26

NOVOLIN R – insulin regular (human) inj 100 unit/ml...... 25NOVOLIN R RELION – insulin regular (human) inj 100unit/ml................................................................................25

NOVOLOG MIX 70/30 – insulin aspart prot & aspart(human) inj 100 unit/ml (70-30)....................................... 26

NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &aspart sus pen-inj 100 unit/ml (70-30).............................26

NOXAFIL – posaconazole susp 40 mg/ml.......................... 4NOXAFIL – posaconazole tab delayed release 100 mg..... 4NUCALA – mepolizumab for inj 100 mg........................... 45NUVARING – etonogestrel-ethinyl estradiol va ring0.120-0.015 mg/24hr........................................................ 22

nystatin cream 100000 unit/gm......................................... 96nystatin oint 100000 unit/gm..............................................96nystatin oral powder.............................................................4nystatin susp 100000 unit/ml.............................................94nystatin tab 500000 unit...................................................... 4

OO-CAL FA – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................86

ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab200-25-25 mg..................................................................... 7

OFEV – nintedanib esylate cap 100 mg (baseequivalent).........................................................................46

OFEV – nintedanib esylate cap 150 mg (baseequivalent).........................................................................46

OFF ACTIVE – diethyltoluamide (deet) aerosol................98OFF DEEP WOODS – diethyltoluamide (deet)aerosol...............................................................................98

OFF DEEP WOODS DRY – diethyltoluamide (deet)aerosol...............................................................................98

OFF SMOOTH & DRY – diethyltoluamide (deet)aerosol...............................................................................98

ofloxacin ophth soln 0.3% (Ocuflox)..................................92ofloxacin otic soln 0.3% (Floxin otic).................................94olanzapine orally disintegrating tab 5 mg (Zyprexazydis)................................................................................. 62

olanzapine orally disintegrating tab 10 mg (Zyprexazydis)................................................................................. 62



olanzapine tab 2.5 mg (Zyprexa).......................................62olanzapine tab 5 mg (Zyprexa)..........................................62olanzapine tab 7.5 mg (Zyprexa).......................................62olanzapine tab 10 mg (Zyprexa)........................................62olanzapine tab 15 mg (Zyprexa)........................................62olanzapine tab 20 mg (Zyprexa)........................................62olmesartan medoxomil-hydrochlorothiazide tab 20-12.5mg (Benicar hct)...............................................................31

olmesartan medoxomil-hydrochlorothiazide tab 40-12.5mg (Benicar hct)...............................................................31

2017

122

olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg(Benicar hct)..................................................................... 31

olmesartan medoxomil tab 5 mg (Benicar)....................... 31olmesartan medoxomil tab 20 mg (Benicar)..................... 31olmesartan medoxomil tab 40 mg (Benicar)..................... 31olopatadine hcl ophth soln 0.1% (base equivalent)(Patanol)............................................................................93

omeprazole cap delayed release 10 mg (Prilosec)...........48omeprazole cap delayed release 20 mg (Prilosec)...........48omeprazole cap delayed release 40 mg (Prilosec)...........48OMNITROPE – somatropin for inj 5.8 mg.........................27ondansetron hcl oral soln 4 mg/5ml (Zofran).................... 48ondansetron hcl tab 24 mg................................................48ondansetron hcl tab 4 mg (Zofran)....................................48ondansetron hcl tab 8 mg (Zofran)....................................48ondansetron orally disintegrating tab 4 mg (Zofranodt).................................................................................... 48

ondansetron orally disintegrating tab 8 mg (Zofranodt).................................................................................... 48

ORENCIA – abatacept subcutaneous soln prefilledsyringe 125 mg/ml............................................................78

ORENCIA CLICKJECT – abatacept subcutaneous solnauto-injector 125 mg/ml....................................................79

ORKAMBI – lumacaftor-ivacaftor tab 100-125 mg............46ORKAMBI – lumacaftor-ivacaftor tab 200-125 mg............46orphenadrine citrate tab er 12hr 100 mg...........................85oxcarbazepine susp 300 mg/5ml (60 mg/ml)(Trileptal)........................................................................... 83

oxcarbazepine tab 150 mg (Trileptal)................................83oxcarbazepine tab 300 mg (Trileptal)................................83oxcarbazepine tab 600 mg (Trileptal)................................83oxiconazole nitrate cream 1% (Oxistat).............................96OXTELLAR XR – oxcarbazepine tab er 24hr 150 mg.......83OXTELLAR XR – oxcarbazepine tab er 24hr 300 mg.......83OXTELLAR XR – oxcarbazepine tab er 24hr 600 mg.......83oxybutynin chloride syrup 5 mg/5ml..................................51oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)........... 51oxybutynin chloride tab er 24hr 10 mg (Ditropan xl)......... 51oxybutynin chloride tab er 24hr 15 mg (Ditropan xl)......... 51oxybutynin chloride tab 5 mg.............................................51OXYCODONE/ACETAMINOPHEN – oxycodone w/acetaminophen soln 5-325 mg/5ml..................................75

OXYCODONE/IBUPROFEN – oxycodone-ibuprofen tab5-400 mg...........................................................................75

oxycodone-aspirin tab 4.8355-325 mg.............................. 75oxycodone hcl conc 100 mg/5ml (20 mg/ml).................... 74oxycodone hcl soln 5 mg/5ml............................................74oxycodone hcl tab 10 mg.................................................. 74oxycodone hcl tab 20 mg.................................................. 74oxycodone hcl tab 5 mg (Roxicodone)..............................74oxycodone hcl tab 15 mg (Roxicodone)............................74oxycodone hcl tab 30 mg (Roxicodone)............................74oxycodone w/ acetaminophen tab 2.5-325 mg(Percocet)..........................................................................75

oxycodone w/ acetaminophen tab 5-325 mg(Percocet)..........................................................................75

oxycodone w/ acetaminophen tab 7.5-325 mg(Percocet)..........................................................................75

oxycodone w/ acetaminophen tab 10-325 mg(Percocet)..........................................................................75

oxymorphone hcl tab er 12hr 5 mg................................... 75oxymorphone hcl tab er 12hr 7.5 mg................................ 75oxymorphone hcl tab er 12hr 10 mg................................. 75oxymorphone hcl tab er 12hr 15 mg................................. 75oxymorphone hcl tab er 12hr 20 mg................................. 75oxymorphone hcl tab er 12hr 30 mg................................. 75oxymorphone hcl tab er 12hr 40 mg................................. 75oxymorphone hcl tab 5 mg (Opana)..................................75oxymorphone hcl tab 10 mg (Opana)................................75

Ppaliperidone tab er 24hr 1.5 mg (Invega)..........................62paliperidone tab er 24hr 3 mg (Invega).............................63paliperidone tab er 24hr 6 mg (Invega).............................63paliperidone tab er 24hr 9 mg (Invega).............................63pantoprazole sodium ec tab 20 mg (base equiv)(Protonix)...........................................................................48

pantoprazole sodium ec tab 40 mg (base equiv)(Protonix)...........................................................................48

PARAGARD INTRAUTERINE COP – copper iud............. 22paromomycin sulfate cap 250 mg....................................... 3paroxetine hcl tab 10 mg (Paxil)........................................57paroxetine hcl tab 20 mg (Paxil)........................................57paroxetine hcl tab 30 mg (Paxil)........................................57paroxetine hcl tab 40 mg (Paxil)........................................57PAXIL – paroxetine hcl oral susp 10 mg/5ml (baseequiv).................................................................................57

pediatric multiple vitamin w/ minerals & c drops 45 mg/ml.......................................................................................86

pediatric vitamins acd w/ fluoride soln 0.25 mg/ml............86peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm(Colyte-flavor packs).........................................................47

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm(Golytely)...........................................................................47

peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack)....................................................................... 46

penicillin v potassium for soln 125 mg/5ml......................... 1penicillin v potassium for soln 250 mg/5ml......................... 1penicillin v potassium tab 250 mg....................................... 1penicillin v potassium tab 500 mg....................................... 1PENTASA – mesalamine cap er 250 mg.......................... 50PENTASA – mesalamine cap er 500 mg.......................... 50pentoxifylline tab er 400 mg.............................................. 91perindopril erbumine tab 2 mg...........................................30perindopril erbumine tab 4 mg (Aceon).............................30perindopril erbumine tab 8 mg (Aceon).............................30permethrin cream 5% (Elimite)..........................................99PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline tab 2-10 mg................................................. 71

PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline tab 2-25 mg................................................. 71

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123




perphenazine tab 2 mg......................................................63perphenazine tab 4 mg......................................................63perphenazine tab 8 mg......................................................63perphenazine tab 16 mg....................................................63PEXEVA – paroxetine mesylate tab 10 mg (baseequiv).................................................................................57

PEXEVA – paroxetine mesylate tab 20 mg (baseequiv).................................................................................57



phenazopyridine hcl tab 100 mg (Pyridium)......................52phenazopyridine hcl tab 200 mg (Pyridium)......................52phenobarbital elixir 20 mg/5ml...........................................65PHENOBARBITAL – phenobarbital tab 15 mg................. 65PHENOBARBITAL – phenobarbital tab 30 mg................. 65PHENOBARBITAL – phenobarbital tab 60 mg................. 65PHENOBARBITAL – phenobarbital tab 100 mg............... 65phenobarbital tab 16.2 mg.................................................66phenobarbital tab 32.4 mg.................................................66phenobarbital tab 64.8 mg.................................................66phenobarbital tab 97.2 mg.................................................66phenoxybenzamine hcl cap 10 mg (Dibenzyline)..............41phenylephrine hcl ophth soln 2.5%................................... 93phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml...............43phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml....................43phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml.................43phenytoin chew tab 50 mg (Dilantin infatabs)................... 83phenytoin sodium extended cap 100 mg (Dilantin)...........83phenytoin sodium extended cap 200 mg (Phenytek)........83phenytoin sodium extended cap 300 mg (Phenytek)........83phenytoin susp 125 mg/5ml (Dilantin-125)........................83pilocarpine hcl ophth soln 1% (Isopto carpine)................. 93pilocarpine hcl ophth soln 2% (Isopto carpine)................. 93pilocarpine hcl ophth soln 4% (Isopto carpine)................. 93pilocarpine hcl tab 5 mg (Salagen)....................................94pilocarpine hcl tab 7.5 mg (Salagen).................................94pimozide tab 1 mg (Orap)..................................................71pimozide tab 2 mg (Orap)..................................................71pindolol tab 5 mg............................................................... 33pioglitazone hcl tab 15 mg (base equiv) (Actos)............... 25pioglitazone hcl tab 30 mg (base equiv) (Actos)............... 25pioglitazone hcl tab 45 mg (base equiv) (Actos)............... 25piroxicam cap 10 mg (Feldene).........................................79piroxicam cap 20 mg (Feldene).........................................79PNV FOLIC ACID + IRON MUL – prenatal vit w/ fefumarate-fa tab 27-1 mg.................................................. 86

PNV PRENATAL PLUS MULTIVI – prenatal vit w/ fefumarate-fa tab 27-1 mg.................................................. 86

podofilox soln 0.5% (Condylox).........................................99polyethylene glycol 3350 oral packet................................ 47polyethylene glycol 3350 oral powder............................... 47polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%(Polytrim)...........................................................................92

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasicchew tab 0.25 mg.............................................................86

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasicchew tab 0.5 mg...............................................................86

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasicchew tab 1 mg..................................................................86

POMALYST – pomalidomide cap 1 mg.............................16POMALYST – pomalidomide cap 2 mg.............................16POMALYST – pomalidomide cap 3 mg.............................16POMALYST – pomalidomide cap 4 mg.............................16pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml.......52potassium bicarbonate effer tab 25 meq...........................88potassium chloride cap er 8 meq (Micro-k).......................88potassium chloride cap er 10 meq (Micro-k).....................88POTASSIUM CHLORIDE ER – potassium chloride tab er8 meq (600 mg)................................................................88

potassium chloride microencapsulated crys er tab 10meq....................................................................................88

potassium chloride microencapsulated crys er tab 20meq....................................................................................88

potassium chloride oral soln 10% (20 meq/15ml)............. 88potassium chloride oral soln 20% (40 meq/15ml)............. 88potassium chloride tab er 10 meq (K-tab).........................88potassium chloride tab er 8 meq (600 mg)....................... 88POTASSIUM CITRATE/SODIUM – pot & sod citrates w/cit ac soln 550-500-334 mg/5ml...................................... 52

potassium citrate & citric acid powder pack 3300-1002mg......................................................................................52

potassium citrate & citric acid soln 1100-334 mg/5ml....... 52potassium citrate tab er 5 meq (540 mg) (Urocit-k 5)........52potassium citrate tab er 10 meq (1080 mg) (Urocit-k10)..................................................................................... 52

potassium citrate tab er 15 meq (1620 mg) (Urocit-k15)..................................................................................... 52

pot bicarbonate & chloride effer tab 25 meq.....................88pot phos monobasic w/sod phos di & monobas tab155-852-130mg (K-phos neutral).....................................88

PRALUENT – alirocumab subcutaneous soln pen-injector75 mg/ml........................................................................... 37

PRALUENT – alirocumab subcutaneous soln pen-injector150 mg/ml......................................................................... 37

PRALUENT – alirocumab subcutaneous soln prefilledsyringe 75 mg/ml..............................................................37

PRALUENT – alirocumab subcutaneous soln prefilledsyringe 150 mg/ml............................................................37

pramipexole dihydrochloride tab er 24hr 2.25 mg (Mirapexer)...................................................................................... 84

pramipexole dihydrochloride tab 0.125 mg (Mirapex).......84pramipexole dihydrochloride tab 0.25 mg (Mirapex).........84pramipexole dihydrochloride tab 0.5 mg (Mirapex)...........84pramipexole dihydrochloride tab 0.75 mg (Mirapex).........84

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124

pramipexole dihydrochloride tab 1 mg (Mirapex)..............84pramipexole dihydrochloride tab 1.5 mg (Mirapex)...........84pravastatin sodium tab 10 mg........................................... 37pravastatin sodium tab 20 mg (Pravachol)........................37pravastatin sodium tab 40 mg (Pravachol)........................37pravastatin sodium tab 80 mg (Pravachol)........................38praziquantel tab 600 mg (Biltricide)...................................10prazosin hcl cap 1 mg (Minipress).................................... 41prazosin hcl cap 2 mg (Minipress).................................... 41prazosin hcl cap 5 mg (Minipress).................................... 41prednicarbate cream 0.1% (Dermatop)............................. 97PREDNICARBATE – prednicarbate cream 0.1%..............97PREDNICARBATE – prednicarbate oint 0.1%..................97prednisolone acetate ophth susp 1% (Pred forte).............92PREDNISOLONE – prednisolone syrup 15 mg/5ml (uspsolution equivalent)...........................................................19

PREDNISOLONE SODIUM PHOSP – prednisolonesodium phosphate ophth soln 1%................................... 92

prednisolone sod phosphate oral soln 15 mg/5ml (baseequiv).................................................................................19

prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5mlbase) (Pediapred).............................................................19

prednisolone syrup 15 mg/5ml (usp solutionequivalent).........................................................................19

PREDNISONE – prednisone oral soln 5 mg/5ml.............. 19PREDNISONE – prednisone tab 50 mg............................19PREDNISONE – prednisone tab therapy pack 5 mg(21).................................................................................... 19

PREDNISONE – prednisone tab therapy pack 5 mg(48).................................................................................... 19



prednisone tab 1 mg..........................................................20prednisone tab 2.5 mg.......................................................20prednisone tab 5 mg..........................................................20prednisone tab 10 mg........................................................20prednisone tab 20 mg........................................................20PRENATAL AND IRON – prenatal multivitamins &minerals w/iron & fa tab 0.8 mg.......................................86

PRE-NATAL FORMULA – prenatal multivitamins &minerals w/iron & fa tab 0.8 mg.......................................86

PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab28-0.8 mg..........................................................................86

PRENATAL FORTE – prenatal multivitamins & mineralsw/iron & fa tab 0.8 mg..................................................... 86

PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fatab 27-0.8 mg................................................................... 87

PRENATAL MULTI +DHA – prenatal vit w/ fe fum-fa-omega 3 cap 27-0.8-228 mg........................................... 87

PRENATAL ONE DAILY – prenatal vit w/ fe fumarate-fatab 27-0.8 mg................................................................... 87

PRENATAL PLUS DHA – prenatal mv & min w/fecarbonyl-fa-dha tab 7-0.4-100 mg................................... 87

PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................87

PRENATAL – prenatal multivitamins & minerals w/iron &fa tab 0.8 mg.................................................................... 86

PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab29-1 mg.............................................................................87

PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab29-1 mg.............................................................................87

PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8mg......................................................................................86

PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................86

PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................86

PRENATAL VITAMIN – prenatal vit w/ fe fumarate-fa tab27-0.8 mg..........................................................................87

PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab28-0.8 mg..........................................................................87

prenatal vit w/ fe fumarate-fa tab 28-0.8 mg..................... 87PREPLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................87

PREVIDENT 5000 DRY MOUTH – sodium fluoride gel1.1% (0.5% f)....................................................................94

PREVIDENT FLUORIDE – sodium fluoride gel 1.1%(0.5% f)............................................................................. 94

PREZCOBIX – darunavir-cobicistat tab 800-150 mg..........7PREZISTA – darunavir ethanolate susp 100 mg/ml (baseequiv)...................................................................................7

PREZISTA – darunavir ethanolate tab 75 mg (baseequiv)...................................................................................7




PRIFTIN – rifapentine tab 150 mg...................................... 3PRIMAQUINE PHOSPHATE – primaquine phosphate tab26.3 mg (15 mg base)..................................................... 10

primidone tab 50 mg (Mysoline)........................................83primidone tab 250 mg (Mysoline)......................................83probenecid tab 500 mg......................................................80PROCRIT – epoetin alfa inj 2000 unit/ml.......................... 91PROCRIT – epoetin alfa inj 3000 unit/ml.......................... 91PROCRIT – epoetin alfa inj 4000 unit/ml.......................... 91PROCRIT – epoetin alfa inj 10000 unit/ml........................ 91PROCRIT – epoetin alfa inj 20000 unit/ml........................ 91PROCRIT – epoetin alfa inj 40000 unit/ml........................ 91PROCYSBI – cysteamine bitartrate cap delayed release25 mg (base equiv).......................................................... 52

PROCYSBI – cysteamine bitartrate cap delayed release75 mg (base equiv).......................................................... 52

progesterone micronized cap 100 mg (Prometrium).........21progesterone micronized cap 200 mg (Prometrium).........21PROMACTA – eltrombopag olamine tab 12.5 mg (baseequiv).................................................................................91

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PROMACTA – eltrombopag olamine tab 25 mg (baseequiv).................................................................................91



promethazine hcl suppos 12.5 mg.................................... 43promethazine hcl suppos 25 mg....................................... 43promethazine hcl syrup 6.25 mg/5ml................................ 43promethazine hcl tab 12.5 mg...........................................43promethazine hcl tab 25 mg..............................................43promethazine hcl tab 50 mg..............................................43promethazine w/ codeine syrup 6.25-10 mg/5ml.............. 43propafenone hcl tab 150 mg..............................................39propafenone hcl tab 300 mg..............................................40propafenone hcl tab 225 mg (Rythmol).............................40proparacaine hcl ophth soln 0.5% (Alcaine)......................93PROPRANOLOL/HYDROCHLOROTH – propranolol &hydrochlorothiazide tab 40-25 mg................................... 33

PROPRANOLOL/HYDROCHLOROTH – propranolol &hydrochlorothiazide tab 80-25 mg................................... 33

propranolol hcl cap er 24hr 60 mg (Inderal la)..................33propranolol hcl cap er 24hr 80 mg (Inderal la)..................33propranolol hcl cap er 24hr 120 mg (Inderal la)................33propranolol hcl cap er 24hr 160 mg (Inderal la)................33propranolol hcl tab 10 mg..................................................33propranolol hcl tab 20 mg..................................................33propranolol hcl tab 40 mg..................................................33propranolol hcl tab 60 mg..................................................33propranolol hcl tab 80 mg..................................................33propylthiouracil tab 50 mg................................................. 26pseudoeph-chlorphen w/ hydrocodone soln 60-4-5mg/5ml (Zutripro).............................................................. 43

PULMOZYME – dornase alfa inhal soln 1 mg/ml..............46PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml)......................................................................................16

PX PRENATAL MULTIVITAMINS – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 87

pyrazinamide tab 500 mg.................................................... 3pyridostigmine bromide tab 60 mg (Mestinon)..................85

QQC PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................87

QUAZEPAM – quazepam tab 15 mg................................ 66quetiapine fumarate tab er 24hr 400 mg (Seroquel xr)..... 63quetiapine fumarate tab 25 mg (Seroquel)........................63quetiapine fumarate tab 50 mg (Seroquel)........................63quetiapine fumarate tab 100 mg (Seroquel)......................63quetiapine fumarate tab 200 mg (Seroquel)......................63quetiapine fumarate tab 300 mg (Seroquel)......................63quetiapine fumarate tab 400 mg (Seroquel)......................63quinapril hcl tab 5 mg (Accupril)........................................30quinapril hcl tab 10 mg (Accupril)......................................30quinapril hcl tab 20 mg (Accupril)......................................30quinapril hcl tab 40 mg (Accupril)......................................30

quinapril-hydrochlorothiazide tab 10-12.5 mg(Accuretic)......................................................................... 30

quinapril-hydrochlorothiazide tab 20-12.5 mg(Accuretic)......................................................................... 30

quinapril-hydrochlorothiazide tab 20-25 mg(Accuretic)......................................................................... 30

quinidine gluconate tab er 324 mg....................................40QUINIDINE SULFATE – quinidine sulfate tab 200 mg......40QUINIDINE SULFATE – quinidine sulfate tab 300 mg......40QVAR – beclomethasone diprop inhal aero soln 40 mcg/act (50/valve).................................................................... 45

QVAR – beclomethasone diprop inhal aero soln 80 mcg/act (100/valve).................................................................. 45

QVAR REDIHALER – beclomethasone diprop hfa breathact inh aer 40 mcg/act..................................................... 45

QVAR REDIHALER – beclomethasone diprop hfa breathact inh aer 80 mcg/act..................................................... 45

RRABAVERT – rabies vaccine, pcec for inj.........................11rabeprazole sodium ec tab 20 mg (Aciphex).................... 48raloxifene hcl tab 60 mg (Evista).......................................28ramipril cap 1.25 mg (Altace)............................................ 30ramipril cap 2.5 mg (Altace).............................................. 30ramipril cap 5 mg (Altace)................................................. 30ramipril cap 10 mg (Altace)............................................... 30ranitidine hcl syrup 15 mg/ml (75 mg/5ml)........................ 48ranitidine hcl tab 150 mg (Zantac).....................................48ranitidine hcl tab 300 mg (Zantac).....................................48RA PRENATAL FORMULA/FOLIC – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 87

RA PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................87

RAVICTI – glycerol phenylbutyrate liquid 1.1 gm/ml......... 28RECOMBIVAX HB – hepatitis b vaccine (recombinant)susp 5 mcg/0.5ml............................................................. 11

RECOMBIVAX HB – hepatitis b vaccine (recombinant)susp 10 mcg/ml................................................................ 11

RECOMBIVAX HB – hepatitis b vaccine (recombinant)susp 40 mcg/ml................................................................ 11

RELENZA DISKHALER – zanamivir aero powder breathactivated 5 mg/blister....................................................... 10

RELION R – insulin regular (human) inj 100 unit/ml......... 25REPATHA – evolocumab subcutaneous soln prefilledsyringe 140 mg/ml............................................................38

REPATHA PUSHTRONEX SYSTEM – evolocumabsubcutaneous soln cartridge/infusor 420 mg/3.5ml.........38

REPATHA SURECLICK – evolocumab subcutaneous solnauto-injector 140 mg/ml....................................................38

REPEL SPORTSMEN – diethyltoluamide (deet)aerosol...............................................................................99

REPEL SPORTSMEN MAX – diethyltoluamide (deet)aerosol...............................................................................99

RESCRIPTOR – delavirdine mesylate tab 100 mg.............8RESCRIPTOR – delavirdine mesylate tab 200 mg.............8REVATIO – sildenafil citrate for suspension 10 mg/ml......41

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REVLIMID – lenalidomide cap 5 mg............................... 100REVLIMID – lenalidomide cap 10 mg............................. 101REVLIMID – lenalidomide cap 15 mg............................. 101REVLIMID – lenalidomide cap 20 mg............................. 101REVLIMID – lenalidomide cap 25 mg............................. 101REVLIMID – lenalidomide caps 2.5 mg.......................... 100REXULTI – brexpiprazole tab 0.25 mg..............................63REXULTI – brexpiprazole tab 0.5 mg................................63REXULTI – brexpiprazole tab 1 mg...................................63REXULTI – brexpiprazole tab 2 mg...................................63REXULTI – brexpiprazole tab 3 mg...................................63REXULTI – brexpiprazole tab 4 mg...................................63ribavirin cap 200 mg (Rebetol)............................................ 5ribavirin tab 200 mg (Copegus)...........................................5rifabutin cap 150 mg (Mycobutin)........................................3rifampin cap 150 mg (Rifadin)............................................. 4rifampin cap 300 mg (Rifadin)............................................. 4RIGHT STEP PRENATAL – prenatal vit w/ fe fumarate-fatab 27-0.8 mg................................................................... 87

riluzole tab 50 mg (Rilutek)................................................85ringer's solution for irrigation............................................101risedronate sodium tab delayed release 35 mg(Atelvia)............................................................................. 28

RISPERDAL CONSTA – risperidone microspheres for inj12.5 mg.............................................................................63

RISPERDAL CONSTA – risperidone microspheres for inj25 mg................................................................................ 64

RISPERDAL CONSTA – risperidone microspheres for inj37.5 mg.............................................................................64

RISPERDAL CONSTA – risperidone microspheres for inj50 mg................................................................................ 64

RISPERIDONE ODT – risperidone orally disintegratingtab 0.25 mg...................................................................... 64

risperidone orally disintegrating tab 0.25 mg.................... 64risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab).................................................................................... 64

risperidone orally disintegrating tab 1 mg (Risperdal m-tab).................................................................................... 64




risperidone soln 1 mg/ml (Risperdal).................................64risperidone tab 0.25 mg (Risperdal)..................................64risperidone tab 0.5 mg (Risperdal)....................................64risperidone tab 1 mg (Risperdal).......................................64risperidone tab 2 mg (Risperdal).......................................64risperidone tab 3 mg (Risperdal).......................................64risperidone tab 4 mg (Risperdal).......................................64ritonavir tab 100 mg (Norvir)................................................8rivastigmine tartrate cap 4.5 mg (Exelon)......................... 71rizatriptan benzoate oral disintegrating tab 5 mg (base eq)(Maxalt-mlt)....................................................................... 79

rizatriptan benzoate oral disintegrating tab 10 mg (baseeq) (Maxalt-mlt).................................................................79

rizatriptan benzoate tab 5 mg (base equivalent)(Maxalt)............................................................................. 79

rizatriptan benzoate tab 10 mg (base equivalent)(Maxalt)............................................................................. 79

ropinirole hydrochloride tab 0.25 mg (Requip)..................84ropinirole hydrochloride tab 0.5 mg (Requip)....................84ropinirole hydrochloride tab 1 mg (Requip).......................84ropinirole hydrochloride tab 2 mg (Requip).......................84ropinirole hydrochloride tab 3 mg (Requip).......................84ropinirole hydrochloride tab 4 mg (Requip).......................84ropinirole hydrochloride tab 5 mg (Requip).......................84rosuvastatin calcium tab 5 mg (Crestor)........................... 38rosuvastatin calcium tab 10 mg (Crestor)......................... 38rosuvastatin calcium tab 20 mg (Crestor)......................... 38rosuvastatin calcium tab 40 mg (Crestor)......................... 38RUBRACA – rucaparib camsylate tab 200 mg (baseequivalent).........................................................................16

RUBRACA – rucaparib camsylate tab 250 mg (baseequivalent).........................................................................16

RUBRACA – rucaparib camsylate tab 300 mg (baseequivalent).........................................................................16

SSABRIL – vigabatrin tab 500 mg.......................................83salicylic acid cream 6%..................................................... 96salicylic acid cream 6% & cleanser liqd kit (Salexcream)............................................................................... 96

salicylic acid film forming liquid 27.5% (Virasal)................96salicylic acid foam 6% (Salvax).........................................96salicylic acid gel 6% (Keralyt)............................................96salicylic acid lotion 6%.......................................................96salicylic acid lotion 6% & cleanser liqd kit (Salexlotion).................................................................................96

salicylic acid shampoo 6% (Salex)....................................96SAMSCA – tolvaptan tab 15 mg....................................... 28SAMSCA – tolvaptan tab 30 mg....................................... 28SAPHRIS – asenapine maleate sl tab 2.5 mg (baseequiv).................................................................................64

SAPHRIS – asenapine maleate sl tab 5 mg (baseequiv).................................................................................64

SAPHRIS – asenapine maleate sl tab 10 mg (baseequiv).................................................................................64

SAWYER PREMIUM INSECT REP – picaridin liquid....... 99selegiline hcl cap 5 mg (Eldepryl)..................................... 84selegiline hcl tab 5 mg.......................................................84selenium sulfide lotion 2.5%.............................................. 99selenium sulfide shampoo 2.25%......................................99SELZENTRY – maraviroc tab 150 mg................................ 8SELZENTRY – maraviroc tab 300 mg................................ 8SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1mg......................................................................................87

SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab29-1 mg.............................................................................87

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SEROSTIM – somatropin (non-refrigerated) forsubcutaneous inj 4 mg.....................................................27



sertraline hcl oral concentrate for solution 20 mg/ml(Zoloft)............................................................................... 57

sertraline hcl tab 25 mg (Zoloft)........................................ 57sertraline hcl tab 50 mg (Zoloft)........................................ 57sertraline hcl tab 100 mg (Zoloft)...................................... 57SHINGRIX – zoster vaccine recombinant adjuvanted forim inj 50 mcg....................................................................12

SIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (baseequiv).................................................................................28



silver sulfadiazine cream 1% (Silvadene)......................... 96SIMPONI – golimumab subcutaneous soln auto-injector50 mg/0.5ml...................................................................... 79

SIMPONI – golimumab subcutaneous soln auto-injector100 mg/ml......................................................................... 79

SIMPONI – golimumab subcutaneous soln prefilledsyringe 50 mg/0.5ml.........................................................79

SIMPONI – golimumab subcutaneous soln prefilledsyringe 100 mg/ml............................................................79

simvastatin tab 5 mg (Zocor).............................................38simvastatin tab 10 mg (Zocor)...........................................38simvastatin tab 20 mg (Zocor)...........................................38simvastatin tab 40 mg (Zocor)...........................................38simvastatin tab 80 mg (Zocor)...........................................38sirolimus tab 0.5 mg (Rapamune)................................... 101sirolimus tab 1 mg (Rapamune)...................................... 101sirolimus tab 2 mg (Rapamune)...................................... 101skin protectants misc - cream............................................99SM PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fatab 28-0.8 mg................................................................... 87

sodium chloride irrigation soln 0.9%..................................52sodium chloride soln nebu 0.9%....................................... 43sodium chloride soln nebu 3%.......................................... 43sodium chloride soln nebu 10%........................................ 44sodium chloride soln nebu 7% (Hyper-sal)....................... 44sodium citrate & citric acid soln 500-334 mg/5ml (Shohlssolution modi)................................................................... 52

sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)(Luride).............................................................................. 88

sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)(Luride).............................................................................. 88

sodium fluoride chew tab 1 mg f (from 2.2 mg naf)(Luride).............................................................................. 88

sodium fluoride cream 1.1% (Prevident 5000 plus).......... 94sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)......94sodium fluoride paste 1.1% (Prevident 5000 boost)......... 94

sodium fluoride-potassium nitrate paste 1.1-5% (Prevident5000 sensi)....................................................................... 94

sodium fluoride rinse 0.2%................................................ 94SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from1.1 mg naf)....................................................................... 88

SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from2.2 mg naf)....................................................................... 88

sodium fluoride soln 0.125 mg/drop f (0.275 mg/dropnaf).................................................................................... 88

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)(Luride).............................................................................. 88

sodium polystyrene sulfonate oral susp 15 gm/60ml...... 101sodium polystyrene sulfonate powder (Kayexalate)........101sodium polystyrene sulfonate rectal susp 30gm/120ml........................................................................ 101

SOLU-CORTEF – hydrocortisone sodium succinate pf forinj 100 mg.........................................................................20



SOLU-CORTEF – hydrocortisone sodium succinate pf forinj 1000 mg.......................................................................20

SOMAVERT – pegvisomant for inj 10 mg (as protein)......28SOMAVERT – pegvisomant for inj 15 mg (as protein)......28SOMAVERT – pegvisomant for inj 20 mg (as protein)......28SOMAVERT – pegvisomant for inj 25 mg (as protein)......28SOMAVERT – pegvisomant for inj 30 mg (as protein)......28sotalol hcl (afib/afl) tab 80 mg (Betapace af).................... 40sotalol hcl (afib/afl) tab 120 mg (Betapace af).................. 40sotalol hcl (afib/afl) tab 160 mg (Betapace af).................. 40sotalol hcl tab 240 mg....................................................... 40sotalol hcl tab 80 mg (Betapace).......................................40sotalol hcl tab 120 mg (Betapace).....................................40sotalol hcl tab 160 mg (Betapace).....................................40speciality vitamin product tab............................................ 87spironolactone & hydrochlorothiazide tab 25-25 mg(Aldactazide)..................................................................... 39

spironolactone tab 25 mg (Aldactone)...............................39spironolactone tab 50 mg (Aldactone)...............................39spironolactone tab 100 mg (Aldactone)............................ 39SPRYCEL – dasatinib tab 20 mg...................................... 16SPRYCEL – dasatinib tab 50 mg...................................... 16SPRYCEL – dasatinib tab 70 mg...................................... 16SPRYCEL – dasatinib tab 80 mg...................................... 17SPRYCEL – dasatinib tab 100 mg.................................... 17SPRYCEL – dasatinib tab 140 mg.................................... 17stannous fluoride gel 0.4%................................................ 94stavudine cap 15 mg (Zerit).................................................8stavudine cap 20 mg (Zerit).................................................8stavudine cap 30 mg (Zerit).................................................8stavudine cap 40 mg (Zerit).................................................8STELARA – ustekinumab soln prefilled syringe 45mg/0.5ml............................................................................99

STELARA – ustekinumab soln prefilled syringe 90 mg/ml.......................................................................................99

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STIMATE – desmopressin acetate nasal soln 1.5 mg/ml.......................................................................................28

STIVARGA – regorafenib tab 40 mg................................. 17STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab150-150-200-300 mg..........................................................8

STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln2.5 mcg/act (base equiv)................................................. 45

SUBOXONE – buprenorphine hcl-naloxone hcl sl film2-0.5 mg (base equiv)......................................................75

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1mg (base equiv)................................................................75

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2mg (base equiv)................................................................75

SUBOXONE – buprenorphine hcl-naloxone hcl sl film12-3 mg (base equiv).......................................................75

SUCRAID – sacrosidase soln 8500 unit/ml.......................49sucralfate tab 1 gm (Carafate)...........................................48sulfacetamide sodium lotion 10% (acne) (Klaron).............95sulfacetamide sodium ophth soln 10% (Bleph-10)............92sulfacetamide sodium-prednisolone ophth soln10-0.23(0.25)%................................................................. 92

sulfamethoxazole-trimethoprim susp 200-40 mg/5ml....... 11sulfamethoxazole-trimethoprim tab 400-80 mg(Bactrim)............................................................................11

sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrimds)......................................................................................11

sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)...................................................................................50

sulfasalazine tab 500 mg (Azulfidine)................................50sulindac tab 150 mg...........................................................79sulindac tab 200 mg...........................................................79sumatriptan nasal spray 5 mg/act (Imitrex).......................79sumatriptan nasal spray 20 mg/act (Imitrex).....................79sumatriptan succinate inj 6 mg/0.5ml (Imitrex)..................80sumatriptan succinate solution auto-injector 4 mg/0.5ml(Imitrex statdose sys)....................................................... 80

sumatriptan succinate solution auto-injector 6 mg/0.5ml(Imitrex statdose sys)....................................................... 80

sumatriptan succinate solution cartridge 4 mg/0.5ml(Imitrex statdose ref)........................................................ 80

sumatriptan succinate solution cartridge 6 mg/0.5ml(Imitrex statdose ref)........................................................ 80

SUMATRIPTAN SUCCINATE – sumatriptan succinatesolution prefilled syringe 6 mg/0.5ml............................... 79

sumatriptan succinate tab 25 mg (Imitrex)........................80sumatriptan succinate tab 50 mg (Imitrex)........................80sumatriptan succinate tab 100 mg (Imitrex)......................80SUSTIVA – efavirenz cap 50 mg.........................................8SUSTIVA – efavirenz cap 200 mg.......................................8SUSTIVA – efavirenz tab 600 mg....................................... 8SUTENT – sunitinib malate cap 12.5 mg (baseequivalent).........................................................................17

SUTENT – sunitinib malate cap 25 mg (baseequivalent).........................................................................17

SUTENT – sunitinib malate cap 37.5 mg (baseequivalent).........................................................................17

SUTENT – sunitinib malate cap 50 mg (baseequivalent).........................................................................17

SYLATRON – peginterferon alfa-2b for inj kit 200 mcg.....17SYLATRON – peginterferon alfa-2b for inj kit 300 mcg.....17SYLATRON – peginterferon alfa-2b for inj kit 600 mcg.....17SYMBICORT – budesonide-formoterol fumarate dihydaerosol 80-4.5 mcg/act.....................................................45

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 160-4.5 mcg/act...................................................46

SYNAREL – nafarelin acetate nasal soln 2 mg/ml (200mcg/act) (base eq)........................................................... 22

Ttacrolimus cap 0.5 mg (Prograf)......................................101tacrolimus cap 1 mg (Prograf).........................................101tacrolimus cap 5 mg (Prograf).........................................101tacrolimus oint 0.03% (Protopic)........................................99tacrolimus oint 0.1% (Protopic)..........................................99TAFINLAR – dabrafenib mesylate cap 50 mg (baseequivalent).........................................................................17

TAFINLAR – dabrafenib mesylate cap 75 mg (baseequivalent).........................................................................17

tamoxifen citrate tab 10 mg (base equivalent).................. 17tamoxifen citrate tab 20 mg (base equivalent).................. 17tamsulosin hcl cap 0.4 mg (Flomax)................................. 52TARCEVA – erlotinib hcl tab 25 mg (base equivalent)......17TARCEVA – erlotinib hcl tab 100 mg (baseequivalent).........................................................................17

TARCEVA – erlotinib hcl tab 150 mg (baseequivalent).........................................................................17

TARGRETIN – bexarotene cap 75 mg..............................17TASIGNA – nilotinib hcl cap 50 mg (base equivalent)...... 17TASIGNA – nilotinib hcl cap 150 mg (baseequivalent).........................................................................17

TASIGNA – nilotinib hcl cap 200 mg (baseequivalent).........................................................................17

tazarotene cream 0.1% (Tazorac)..................................... 95TAZORAC – tazarotene cream 0.05%.............................. 95TAZORAC – tazarotene gel 0.05%................................... 95TAZORAC – tazarotene gel 0.1%..................................... 95TECHLITE PEN NEEDLES 29G....................................... 99temazepam cap 15 mg (Restoril)...................................... 66temazepam cap 30 mg (Restoril)...................................... 66temozolomide cap 5 mg (Temodar)...................................18temozolomide cap 20 mg (Temodar).................................18temozolomide cap 100 mg (Temodar)...............................18temozolomide cap 140 mg (Temodar)...............................18temozolomide cap 180 mg (Temodar)...............................18temozolomide cap 250 mg (Temodar)...............................18tenofovir disoproxil fumarate tab 300 mg (Viread).............. 8terazosin hcl cap 1 mg (base equivalent)......................... 41terazosin hcl cap 2 mg (base equivalent)......................... 41terazosin hcl cap 5 mg (base equivalent)......................... 41terazosin hcl cap 10 mg (base equivalent)....................... 41terbinafine hcl tab 250 mg (Lamisil).................................... 4terbutaline sulfate tab 2.5 mg............................................46

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terbutaline sulfate tab 5 mg...............................................46TERCONAZOLE – terconazole vaginal cream 0.8%........51terconazole vaginal cream 0.4% (Terazol 7).....................51terconazole vaginal cream 0.8% (Terazol 3).....................51terconazole vaginal suppos 80 mg....................................51testosterone td gel 12.5 mg/act (1%) (Androgelpump)................................................................................ 20

testosterone td gel 25 mg/2.5gm (1%) (Androgel)............ 20testosterone td gel 50 mg/5gm (1%) (Androgel)............... 20TEST STRIPS – BAYER ASCENCIA................................99tetracaine hcl ophth soln 0.5%.......................................... 93THALOMID – thalidomide cap 50 mg............................. 101THALOMID – thalidomide cap 100 mg........................... 101THALOMID – thalidomide cap 150 mg........................... 101THALOMID – thalidomide cap 200 mg........................... 101theophylline soln 80 mg/15ml............................................46theophylline tab er 12hr 100 mg........................................46theophylline tab er 12hr 200 mg........................................46theophylline tab er 12hr 300 mg........................................46theophylline tab er 12hr 450 mg........................................46theophylline tab er 24hr 400 mg........................................46theophylline tab er 24hr 600 mg........................................46THERA-FLUR-N – sodium fluoride gel 1.1% (0.5% f).......94thioridazine hcl tab 10 mg................................................. 64thioridazine hcl tab 25 mg................................................. 65thioridazine hcl tab 50 mg................................................. 65thioridazine hcl tab 100 mg............................................... 65thiothixene cap 1 mg..........................................................65thiothixene cap 2 mg..........................................................65thiothixene cap 5 mg..........................................................65thiothixene cap 10 mg........................................................65thyroid tab 30 mg (1/2 grain) (Armour thyroid)..................26thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)...............26thyroid tab 60 mg (1 grain) (Armour thyroid).....................26tiagabine hcl tab 2 mg (Gabitril)........................................ 83tiagabine hcl tab 4 mg (Gabitril)........................................ 83timolol maleate ophth soln 0.25% (Timoptic).................... 93timolol maleate ophth soln 0.5% (Timoptic)...................... 93TIVICAY – dolutegravir sodium tab 50 mg (base equiv)..... 8tizanidine hcl tab 2 mg (base equivalent)..........................85tizanidine hcl tab 4 mg (base equivalent) (Zanaflex).........85tobramycin nebu soln 300 mg/5ml (Tobi)............................ 3tobramycin ophth soln 0.3% (Tobrex)................................92TOBRAMYCIN – tobramycin nebu soln 300 mg/5ml.......... 3tolcapone tab 100 mg (Tasmar)........................................ 84tolterodine tartrate tab 2 mg (Detrol).................................51topiramate sprinkle cap 15 mg (Topamax sprinkle).......... 83topiramate sprinkle cap 25 mg (Topamax sprinkle).......... 83topiramate tab 25 mg (Topamax)...................................... 83topiramate tab 50 mg (Topamax)...................................... 83topiramate tab 100 mg (Topamax).................................... 83topiramate tab 200 mg (Topamax).................................... 83torsemide tab 5 mg............................................................39torsemide tab 100 mg........................................................39torsemide tab 10 mg (Demadex).......................................39torsemide tab 20 mg (Demadex).......................................39

TRACLEER – bosentan tab for oral susp 32 mg.............. 42TRACLEER – bosentan tab 62.5 mg................................ 42TRACLEER – bosentan tab 125 mg................................. 42tramadol-acetaminophen tab 37.5-325 mg (Ultracet)....... 76tramadol hcl tab 50 mg (Ultram)........................................76TRANDOLAPRIL/VERAPAMIL HC – trandolapril-verapamil hcl tab er 1-240 mg.........................................35

trandolapril tab 4 mg..........................................................30trandolapril tab 1 mg (Mavik).............................................30trandolapril tab 2 mg (Mavik).............................................30trandolapril-verapamil hcl tab er 1-240 mg (Tarka)........... 35trandolapril-verapamil hcl tab er 2-180 mg (Tarka)........... 35trandolapril-verapamil hcl tab er 2-240 mg (Tarka)........... 35trandolapril-verapamil hcl tab er 4-240 mg (Tarka)........... 35tranexamic acid tab 650 mg (Lysteda).............................. 91trazodone hcl tab 50 mg....................................................57trazodone hcl tab 100 mg..................................................57trazodone hcl tab 150 mg..................................................57tretinoin cap 10 mg............................................................ 18tretinoin cream 0.025% (Retin-a).......................................95tretinoin cream 0.05% (Retin-a).........................................95tretinoin cream 0.1% (Retin-a)...........................................95tretinoin gel 0.05% (Atralin)............................................... 95tretinoin gel 0.01% (Retin-a)..............................................95tretinoin gel 0.025% (Retin-a)............................................95triamcinolone acetonide aerosol soln 0.147 mg/gm(Kenalog)...........................................................................97

triamcinolone acetonide cream 0.025%............................ 97triamcinolone acetonide cream 0.1%................................ 97triamcinolone acetonide cream 0.5%................................ 98triamcinolone acetonide dental paste 0.1%...................... 94triamcinolone acetonide lotion 0.025%..............................98triamcinolone acetonide lotion 0.1%..................................98triamcinolone acetonide nasal aerosol suspension 55mcg/act..............................................................................43

triamcinolone acetonide oint 0.025%................................ 98triamcinolone acetonide oint 0.1%.....................................98triamterene & hydrochlorothiazide cap 37.5-25 mg(Dyazide)...........................................................................39

triamterene & hydrochlorothiazide tab 37.5-25 mg(Maxzide-25)..................................................................... 39

triamterene & hydrochlorothiazide tab 75-50 mg(Maxzide)...........................................................................39

TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1 mg.....87TRICITRATES – pot & sod citrates w/ cit ac soln550-500-334 mg/5ml........................................................ 52

trientine hcl cap 250 mg (Syprine).................................. 101trifluoperazine hcl tab 1 mg (base equivalent).................. 65trifluoperazine hcl tab 2 mg (base equivalent).................. 65trifluoperazine hcl tab 5 mg (base equivalent).................. 65trifluoperazine hcl tab 10 mg (base equivalent)................ 65trifluridine ophth soln 1% (Viroptic)....................................92trihexyphenidyl hcl elixir 0.4 mg/ml....................................84trihexyphenidyl hcl tab 2 mg..............................................84trihexyphenidyl hcl tab 5 mg..............................................85trimethobenzamide hcl cap 300 mg (Tigan)......................48

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trimethoprim tab 100 mg....................................................11TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1mg......................................................................................87

TRIUMEQ – abacavir-dolutegravir-lamivudine tab600-50-300 mg................................................................... 8

TRI-VIT/FLUORIDE/IRON – pediatric vitamins acdfluoride & fe drops 0.25-10 mg/ml................................... 87

trospium chloride cap er 24hr 60 mg................................ 51trospium chloride tab 20 mg..............................................51TRUEPLUS INSULIN SYRINGE/...................................... 99TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 100-150 mg.................................................................. 9

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 133-200 mg.................................................................. 9



TYBOST – cobicistat tab 150 mg........................................9TYKERB – lapatinib ditosylate tab 250 mg (baseequiv).................................................................................18

TYVASO REFILL – treprostinil inhalation solution 0.6 mg/ml.......................................................................................42

TYVASO STARTER – treprostinil inhalation solution 0.6mg/ml.................................................................................42

TYVASO – treprostinil inhalation solution 0.6 mg/ml.........42

UUPTRAVI – selexipag tab 200 mcg...................................42UPTRAVI – selexipag tab 400 mcg...................................42UPTRAVI – selexipag tab 600 mcg...................................42UPTRAVI – selexipag tab 800 mcg...................................42UPTRAVI – selexipag tab 1000 mcg.................................42UPTRAVI – selexipag tab 1200 mcg.................................42UPTRAVI – selexipag tab 1400 mcg.................................42UPTRAVI – selexipag tab 1600 mcg.................................42UPTRAVI – selexipag tab therapy pack 200 mcg (140) &800 mcg (60).................................................................... 42

ursodiol cap 300 mg (Actigall)...........................................50ursodiol tab 250 mg (Urso 250).........................................50ursodiol tab 500 mg (Urso forte)....................................... 50

Vvalacyclovir hcl tab 1 gm (Valtrex).......................................5valacyclovir hcl tab 500 mg (Valtrex)...................................5valganciclovir hcl for soln 50 mg/ml (base equiv)(Valcyte).............................................................................. 4

valganciclovir hcl tab 450 mg (base equivalent)(Valcyte).............................................................................. 4

valproic acid cap 250 mg (Depakene)...............................83valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovanhct).....................................................................................31

valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovanhct).....................................................................................31

valsartan-hydrochlorothiazide tab 160-25 mg (Diovanhct).....................................................................................31

valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovanhct).....................................................................................32

valsartan-hydrochlorothiazide tab 320-25 mg (Diovanhct).....................................................................................32

valsartan tab 40 mg (Diovan)............................................ 31valsartan tab 80 mg (Diovan)............................................ 31valsartan tab 160 mg (Diovan).......................................... 31valsartan tab 320 mg (Diovan).......................................... 31vancomycin hcl cap 125 mg (Vancocin hcl)......................11vancomycin hcl cap 250 mg (Vancocin hcl)......................11VENCLEXTA STARTING PACK – venetoclax tab therapystarter pack 10 & 50 & 100 mg....................................... 18

VENCLEXTA – venetoclax tab 10 mg...............................18VENCLEXTA – venetoclax tab 50 mg...............................18VENCLEXTA – venetoclax tab 100 mg.............................18venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)(Effexor xr)........................................................................ 58

venlafaxine hcl cap er 24hr 75 mg (base equivalent)(Effexor xr)........................................................................ 58

venlafaxine hcl cap er 24hr 150 mg (base equivalent)(Effexor xr)........................................................................ 58

venlafaxine hcl tab 25 mg..................................................58venlafaxine hcl tab 37.5 mg...............................................58venlafaxine hcl tab 50 mg..................................................58venlafaxine hcl tab 75 mg..................................................58venlafaxine hcl tab 100 mg................................................58VENTAVIS – iloprost inhalation solution 10 mcg/ml..........42VENTAVIS – iloprost inhalation solution 20 mcg/ml..........42VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act(90mcg base equiv)..........................................................46

verapamil hcl cap er 24hr 120 mg (Verelan).....................35verapamil hcl cap er 24hr 180 mg (Verelan).....................35verapamil hcl cap er 24hr 240 mg (Verelan).....................35verapamil hcl cap er 24hr 360 mg (Verelan).....................35verapamil hcl cap er 24hr 100 mg (Verelan pm)...............35verapamil hcl cap er 24hr 200 mg (Verelan pm)...............35verapamil hcl cap er 24hr 300 mg (Verelan pm)...............35verapamil hcl tab er 120 mg (Calan sr).............................35verapamil hcl tab er 180 mg (Calan sr).............................35verapamil hcl tab er 240 mg (Calan sr).............................35verapamil hcl tab 40 mg.................................................... 35verapamil hcl tab 80 mg (Calan)....................................... 35verapamil hcl tab 120 mg (Calan)..................................... 35VERSACLOZ – clozapine susp 50 mg/ml.........................65VERZENIO – abemaciclib tab 50 mg................................18VERZENIO – abemaciclib tab 100 mg..............................18VERZENIO – abemaciclib tab 150 mg..............................18VERZENIO – abemaciclib tab 200 mg..............................18VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml)......................................................................................25

VIDEX – didanosine for soln 2 gm......................................9VIDEX – didanosine for soln 4 gm......................................9vigabatrin powd pack 500 mg (Sabril)...............................83VIIBRYD STARTER PACK – vilazodone hcl tab starter kit10 (7) & 20 (23) mg......................................................... 58

VIIBRYD – vilazodone hcl tab 10 mg................................58

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VIIBRYD – vilazodone hcl tab 20 mg................................58VIIBRYD – vilazodone hcl tab 40 mg................................58VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1mg......................................................................................87

VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1mg......................................................................................87

VIRACEPT – nelfinavir mesylate tab 250 mg..................... 9VIRACEPT – nelfinavir mesylate tab 625 mg..................... 9VIRAMUNE – nevirapine susp 50 mg/5ml.......................... 9VIREAD – tenofovir disoproxil fumarate oral powder 40mg/gm..................................................................................9

VIREAD – tenofovir disoproxil fumarate tab 150 mg...........9VIREAD – tenofovir disoproxil fumarate tab 200 mg...........9VIREAD – tenofovir disoproxil fumarate tab 250 mg...........9VIREAD – tenofovir disoproxil fumarate tab 300 mg...........9VITEKTA – elvitegravir tab 85 mg....................................... 9VITEKTA – elvitegravir tab 150 mg..................................... 9VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................87

voriconazole for susp 40 mg/ml (Vfend)..............................4voriconazole tab 50 mg (Vfend).......................................... 4voriconazole tab 200 mg (Vfend)........................................ 4VOTRIENT – pazopanib hcl tab 200 mg (base equiv)......18

Wwarfarin sodium tab 1 mg (Coumadin)..............................91warfarin sodium tab 2 mg (Coumadin)..............................91warfarin sodium tab 2.5 mg (Coumadin)...........................91warfarin sodium tab 3 mg (Coumadin)..............................91warfarin sodium tab 4 mg (Coumadin)..............................91warfarin sodium tab 5 mg (Coumadin)..............................91warfarin sodium tab 6 mg (Coumadin)..............................91warfarin sodium tab 7.5 mg (Coumadin)...........................91warfarin sodium tab 10 mg (Coumadin)............................91water for irrigation, sterile irrigation soln......................... 101

XXALKORI – crizotinib cap 200 mg.....................................18XALKORI – crizotinib cap 250 mg.....................................18XARELTO – rivaroxaban tab 10 mg..................................91XARELTO – rivaroxaban tab 15 mg..................................92XARELTO – rivaroxaban tab 20 mg..................................92XARELTO STARTER PACK – rivaroxaban tab startertherapy pack 15 mg & 20 mg.......................................... 92

XELJANZ – tofacitinib citrate tab 5 mg (baseequivalent).........................................................................79

XELJANZ XR – tofacitinib citrate tab er 24hr 11 mg (baseequivalent).........................................................................79

XIFAXAN – rifaximin tab 550 mg.......................................11XTANDI – enzalutamide cap 40 mg.................................. 18XULANE – norelgestromin-ethinyl estradiol td ptwk150-35 mcg/24hr.............................................................. 22

XURIDEN – uridine triacetate oral granules packet 2gm......................................................................................28

Y

Zzaleplon cap 5 mg (Sonata).............................................. 66zaleplon cap 10 mg (Sonata)............................................ 66ZELBORAF – vemurafenib tab 240 mg............................ 18ZENPEP – pancrelipase (lip-prot-amyl) dr cap3000-10000-16000 unit.................................................... 49

ZENPEP – pancrelipase (lip-prot-amyl) dr cap5000-17000-24000 unit.................................................... 49

ZENPEP – pancrelipase (lip-prot-amyl) dr cap5000-17000-27000 unit.................................................... 49

ZENPEP – pancrelipase (lip-prot-amyl) dr cap10000-32000-42000 unit.................................................. 49





ZENPEP – pancrelipase (lip-prot-amyl) dr cap20000-68000-109000 unit................................................ 49



ZENPEP – pancrelipase (lip-prot-amyl) dr cap40000-126000-168000 unit.............................................. 49

ZENPEP – pancrelipase (lip-prot-amyl) dr cap40000-136000-218000 unit.............................................. 49

zidovudine cap 100 mg (Retrovir)....................................... 9zidovudine syrup 10 mg/ml (Retrovir)..................................9zidovudine tab 300 mg.........................................................9ziprasidone hcl cap 20 mg (Geodon)................................ 65ziprasidone hcl cap 40 mg (Geodon)................................ 65ziprasidone hcl cap 60 mg (Geodon)................................ 65ziprasidone hcl cap 80 mg (Geodon)................................ 65ZOLINZA – vorinostat cap 100 mg....................................18zolpidem tartrate tab 5 mg (Ambien).................................66zolpidem tartrate tab 10 mg (Ambien)...............................66zonisamide cap 50 mg.......................................................83zonisamide cap 25 mg (Zonegran)....................................83zonisamide cap 100 mg (Zonegran)..................................83ZORBTIVE – somatropin (non-refrigerated) forsubcutaneous inj 8.8 mg..................................................27

ZORTRESS – everolimus tab 0.25 mg........................... 101ZORTRESS – everolimus tab 0.5 mg............................. 101ZORTRESS – everolimus tab 0.75 mg........................... 101ZYKADIA – ceritinib cap 150 mg.......................................19ZYPREXA RELPREVV – olanzapine pamoate forextended rel im susp 210 mg (base eq)..........................65

ZYPREXA RELPREVV – olanzapine pamoate forextended rel im susp 300 mg (base eq)..........................65

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ZYPREXA RELPREVV – olanzapine pamoate forextended rel im susp 405 mg (base eq)..........................65

ZYTIGA – abiraterone acetate tab 250 mg....................... 19ZYTIGA – abiraterone acetate tab 500 mg....................... 19ZYVOX – linezolid for susp 100 mg/5ml........................... 11

Esos servicios reciben financiamiento parcial del estado de New Mexico.

Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 479350.0718

blue cross community centennial lista de medicamentos … · muchos de los medicamentos de venta...

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