formulario (lista de medicamentos) - anthem · de 60 días del medicamento antes de que se realice...

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Formulario (Lista de medicamentos)

Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care Plan

Virginia

Servicios al Miembro: 1-855-817-5787 (TTY 711) Lunes a viernes de 8 a.m. a 8 p.m. hora local

H0147_16_24596_T_009_SP CMS Approved 09/18/2015 ID del Formulario: 16234 Versión: 15

Publicado 11/01/2016

H0147_16_24596_T_009_SP CMS Approved 09/18/2015

Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care Plan | 2016 Lista de medicamentos cubiertos (Formulario) Esta es una lista de los medicamentos que los miembros pueden obtener en Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care plan ofrecido por HealthKeepers, Inc.

HealthKeepers, Inc. es un plan de salud que tiene contrato con ambos Medicare y el Virginia Department of Medical Assistance Services para ofrecer beneficios de ambos programas a los inscritos.

La lista de medicamentos cubiertos y/o las redes de farmacias y proveedores pueden cambiar a lo largo del año. Le enviaremos una notificación antes de hacer un cambio que le afecte.

Los beneficios y/o los copagos pueden cambiar el 1 de enero de cada año.

Siempre puede revisar la lista actualizada de medicamentos cubiertos en línea de Anthem HealthKeepers MMP en mss.anthem.com/ccc.

Puede obtener esta información gratuitamente en otros formatos, tales como letras grandes, braille o audio. Llame al 1-855-817-5787 (TTY 711). La llamada es gratuita.

Pueden aplicarse limitaciones, copagos y restricciones. Para obtener más información, llame a Anthem HealthKeepers MMP Member Services o lea el manual del miembro de Anthem HealthKeepers MMP.

Los copagos para medicamentos recetados pueden variar con base en el nivel de Ayuda adicional (Extra Help) que usted recibe. Póngase en contacto con el plan para mayores detalles.

You can get this information for free in other languages. Call 1-855-817-5787 (TTY 711). The call is free. Puede recibir esta información sin cargo en otros idiomas. Llame al 1-855-817-5787 (TTY 711). La llamada es gratuita.

HealthKeepers, Inc. es un licenciatario independiente de Blue Cross and Blue Shield Association. ANTHEM es una marca comercial registrada de Anthem Insurance Companies, Inc. Los nombres y símbolos de Blue Cross and Blue Shield son marcas registradas de Blue Cross and Blue Shield Association.

? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc.

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H0147_16_24596_T_009_SP CMS Approved 09/18/2015

Preguntas frecuentes (FAQ)

Encuentre aquí respuestas a las preguntas que tenga sobre esta Lista de medicamentos cubiertos. Puede leer todas las preguntas frecuentes para aprender más o buscar una pregunta y respuesta.

1. ¿Qué medicamentos recetados se encuentran en la lista de medicamentos cubiertos? (Llamamos a la lista de medicamentos cubiertos la “lista de medicamentos” para abreviar).

Los medicamentos en la Lista de medicamentos cubiertos que comienza en la página 9 son los medicamentos cubiertos por HealthKeepers, Inc. Estos medicamentos están disponibles en farmacias de nuestra red. Una farmacia se encuentra en nuestra red si tiene un acuerdo para trabajar con nosotros y proporcionarle sus servicios. Nos referimos a estas farmacias como “farmacias de la red”.

HealthKeepers, Inc. cubrirá todos los medicamentos necesarios por motivos médicos en la Lista de medicamentos si:

su doctor u otro recetante afirma que los necesita para estar mejor o para estar sano, y

usted abastece la receta en una farmacia de la red de Anthem HealthKeepers MMP.

Es posible que HealthKeepers, Inc. tenga pasos adicionales para acceder a ciertos medicamentos (ver pregunta #5 más adelante).

Puede ver una lista actualizada de los medicamentos que cubrimos en nuestro sitio web en mss.anthem.com/ccc o llamar a Member Services al 1-855-817-5787 (TTY 711).

2. ¿Cambia alguna vez la lista de medicamentos?

Sí. Anthem HealthKeepers MMP puede agregar o eliminar medicamentos de la Lista de medicamentos durante el año. Por lo general, la lista de medicamentos solo cambiará si:

surge un medicamento más barato que funciona tan bien como el medicamento en la lista de medicamentos ahora, o

nos enteramos de que un medicamento no es seguro.

También podemos cambiar nuestras reglas sobre medicamentos. Por ejemplo, podríamos:

Decidir la exigencia o no de aprobación previa para un medicamento. (Aprobación previa es permiso de HealthKeepers, Inc. antes de recibir un medicamento).

Agregar o cambiar la cantidad de un medicamento que puede recibir (llamado “límites de cantidad”).


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Agregar o cambiar restricciones de terapia escalonada para un medicamento. (Terapia escalonada significa que debe probar un medicamento antes de que cubramos otro medicamento).

(Para obtener más información sobre estas reglas de medicamentos, vea la página 4).

Le informaremos cuando un medicamento que usted toma es retirado de la Lista de medicamentos. También le avisaremos cuando cambiemos nuestras reglas para cubrir un medicamento. Las preguntas 3, 4 y 7 a continuación tienen más información sobre lo que ocurre cuando cambia la lista de medicamentos.

Siempre puede revisar la lista actualizada de medicamentos en línea de Anthem HealthKeepers MMP en mss.anthem.com/ccc.

También puede llamar a Member Services para revisar la Lista de medicamentos actual al 1-855-817-5787 (TTY 711).

3. ¿Qué ocurre cuando surge un medicamento más barato que funciona tan bien como un medicamento en la lista de medicamentos ahora?

Si toma un medicamento que es retirado debido a la aparición de un medicamento más económico que funciona bien, le informaremos. Le avisaremos al menos 60 días antes de retirarlo de la lista de medicamentos o cuando usted solicita un reabastecimiento. Luego puede recibir un suministro de 60 días del medicamento antes de que se realice el cambio a la lista de medicamentos.

En el caso de cambios a la lista de medicamentos durante el año, le enviaremos una carta sobre estos cambios 60 días antes de su entrada en vigencia. También publicaremos una copia de la carta en nuestro sitio web en mss.anthem.com/ccc.

4. ¿Qué ocurre cuando averiguamos que un medicamento no es seguro?

Si la Administración de Alimentos y Medicamentos (Food and Drug Administration (FDA)) informa que un medicamento que usted está tomando no es seguro, lo eliminaremos de la lista de medicamentos de inmediato. También le enviaremos una carta informándole esta situación. Si recibe un aviso acerca de un medicamento poco seguro, llame de inmediato a su doctor. Su doctor puede ayudarle a encontrar otro medicamento que le sea de utilidad.

También puede llamar a Member Services o a su encargado de cuidado quien puede ayudar a encontrar un medicamento similar o ayudar a contactar a su proveedor. Llámenos al 1-855-817-5787 (TTY 711).


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5. ¿Hay alguna restricción o límite en la cobertura de medicamentos? ¿O existen acciones requeridas que se deben realizar para obtener ciertos medicamentos?

Sí, algunos medicamentos tienen reglas de cobertura o límites en la cantidad que puede recibir. En algunos casos usted o su doctor u otro recetante debe realizar algo antes de poder recibir el medicamento. Por ejemplo:

Aprobación previa (o autorización previa): Para algunos medicamentos, usted o su doctor u otro recetante deben obtener la aprobación de HealthKeepers, Inc. antes de completar su receta. Si no obtiene aprobación, puede que HealthKeepers, Inc. no cubra el medicamento.

Límites de cantidad: En ocasiones HealthKeepers, Inc. limita la cantidad de un medicamento que usted puede recibir.

Terapia escalonada: En ocasiones HealthKeepers, Inc. requiere que usted realice una terapia escalonada. Esto significa que tendrá que probar los medicamentos en un cierto orden para su condición médica. Es posible que deba probar un medicamento antes de que cubramos otro medicamento. Si su doctor cree que el primer medicamento no funciona en su caso, entonces cubriremos el segundo.

Usted puede saber si su medicamento tiene requisitos adicionales o límites buscando en las tablas en las páginas 11-152. Hemos publicado en línea documentos que explican nuestras restricciones de autorización previa y terapia escalonada. También puede obtener información al visitar nuestro sitio web en mss.anthem.com/ccc. También puede pedirnos que le enviemos una copia.

Puede pedir una “excepción” de estos límites. Vea la pregunta 11 para obtener más información sobre las excepciones.

Si se encuentra en un asilo de ancianos u otro centro de cuidado a largo plazo y necesita un medicamento que no está en la Lista de medicamentos o si no puede obtener con facilidad el medicamento que necesita, podemos ayudarlo. Cubriremos un suministro de emergencia de 31 días del medicamento que necesite (a menos que tenga una receta por menos días), aunque sea un nuevo miembro de Anthem HealthKeepers MMP o no. Esto le dará tiempo para conversar con su doctor u otro recetante. Este profesional puede ayudarle a decidir si existe un medicamento similar en la lista de medicamentos que usted puede tomar o si solicita una excepción. Vea la pregunta 11 para obtener más información sobre las excepciones.

6. ¿Cómo sabrá si el medicamento que desea tiene limitaciones o si existen acciones requeridas que realizar para obtener el medicamento?

La Lista de medicamentos cubiertos en la página 9 tiene una columna llamada “Acciones necesarias, restricciones o límites de uso”.


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7. ¿Qué ocurre si cambiamos nuestras reglas sobre cómo cubrimos algunos medicamentos? Por ejemplo, si agregamos autorización (aprobación) previa, límites de cantidad y/o restricciones de terapia escalonada a un medicamento.

Le informaremos si agregamos aprobación previa, límites de cantidad y/o restricciones de terapia escalonada a un medicamento. Le indicaremos al menos 60 días antes de incluir la restricción o cuando solicite reabastecimiento. Luego, puede recibir un suministro de 60 días del medicamento antes de que se realice el cambio a la lista de medicamentos. Esto le permitirá contar con tiempo para conversar con su doctor u otro recetante acerca de lo que debe hacer a continuación.

8. ¿Cómo puede encontrar un medicamento en la lista de medicamentos?

Hay dos formas de encontrar un medicamento:

Puede buscar en forma alfabética (si sabe cómo deletrear el medicamento) o

Puede buscar por condición médica.

Para buscar en forma alfabética, vaya a la sección Listado alfabético. Puede encontrarlo al buscar en el índice de medicamentos, desde la página 153.

Para buscar por condición médica, busque la sección llamada “Lista de medicamentos por condición médica” en la página 9. Los medicamentos en esta sección están agrupados en categorías, dependiendo del tipo de condiciones médicas para los que se utilizan. Por ejemplo, si tiene una condición cardiaca, debe buscar en la categoría Cardiovascular/hipertensión/lípidos. Es donde encontrará medicamentos para tratar condiciones cardiacas.

9. ¿Qué pasa si el medicamento que desea tomar no está en la lista de medicamentos?

Si no encuentra su medicamento en la Lista de medicamentos, llame a Member Services al 1-855-817-5787 (TTY 711) y pregunte por el mismo. Si se entera que HealthKeepers, Inc. no cubrirá el medicamento, puede seguir uno de estos dos pasos:

Pida a Member Services una lista de los medicamentos similares al que desea tomar. Luego muestre la lista a su doctor u otro recetante. Él o ella puede recetar un medicamento de la lista de medicamentos que sea similar al que usted desea tomar. O

Puede pedirle al plan de salud que haga una excepción y cubra su medicamento. Vea la pregunta 11 para obtener más información sobre las excepciones.


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10. ¿Qué ocurre si usted es un nuevo miembro de Anthem HealthKeepers MMP y no puede encontrar su medicamento en la Lista de medicamentos o tiene un problema para obtener su medicamento?

Podemos ayudar. Podemos cubrir un suministro temporal de 31 días de su medicamento durante los primeros 90 días en que usted es miembro de Anthem HealthKeepers MMP. Esto le dará tiempo para conversar con su doctor u otro recetante. Este profesional puede ayudarle a decidir si existe un medicamento similar en la lista de medicamentos que usted puede tomar o si solicita una excepción.

Cubriremos un suministro de 31 días de su medicamento si:

usted toma un medicamento que no está en nuestra Lista de medicamentos, o

las reglas del plan de salud no le permiten recibir la cantidad establecida por su recetante, o

el medicamento requiere aprobación previa de Anthem HealthKeepers MMP, o

usted toma un medicamento que es parte de una restricción de terapia escalonada.

Si vive en un asilo de ancianos u otro centro de cuidado a largo plazo, puede reabastecer su receta hasta por 98 días. Puede reabastecer el medicamento múltiples veces durante sus primeros 90 días en el plan. Esto le brinda a su recetante tiempo para cambiar sus medicamentos a los que están en la lista de medicamentos o pedir una excepción.

Si experimenta un cambio en el nivel de cuidado que recibe, que le exige pasar de una instalación o centro de tratamiento a otro, puede ser elegible para un reabastecimiento temporal único de la receta que tiene actualmente. Por ejemplo, si recibe el alta del hospital y se le entrega una lista de medicamentos basada en el formulario del hospital, es posible que reciba un reabastecimiento único del medicamento. Puede recibir la excepción temporal única sin importar si se encuentra o no en sus primeros 90 días de afiliación al programa. Pida a su recetante que nos llame para indicarnos los detalles. Si tiene alguna pregunta, llame a su encargado de cuidado al 1-855-817-5787 (TTY 711).

11. ¿Puede pedir una excepción para cubrir su medicamento?

Sí. Puede solicitar a HealthKeepers, Inc. que realice una excepción para cubrir un medicamento que no esté en la Lista de medicamentos.

También nos puede pedir que cambiemos las reglas sobre su medicamento.

Por ejemplo, HealthKeepers, Inc. puede limitar la cantidad del medicamento que cubriremos. Si su medicamento tiene un límite, puede pedirnos que cambiemos el límite y cubramos más.

Otros ejemplos: Puede pedirnos que eliminemos las restricciones de terapia escalonada o requisitos de aprobación previa.


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12. ¿Cuánto tiempo toma obtener una excepción?

Primero, debemos recibir una declaración de su recetante que apoye su solicitud para una excepción. Después de recibir la declaración, le daremos una decisión sobre su solicitud de excepción dentro de 72 horas.

Si usted o su recetante piensan que su salud se puede ver afectada si tiene que esperar 72 horas para recibir una decisión, puede solicitar una excepción acelerada. Esta es una decisión más rápida. Si su recetante apoya su solicitud, le daremos una decisión dentro de 24 horas de recibir la declaración de apoyo de su recetante.

13. ¿Cómo puede pedir una excepción?

Para pedir una excepción, llame a Member Services al 1-855-817-5787 (TTY 711). Un representante de Member Services trabajará con usted y su proveedor para ayudarlo a pedir una excepción.

14. ¿Qué son medicamentos genéricos?

Los medicamentos genéricos están elaborados con los mismos ingredientes activos que los medicamentos de marca. Por lo general tienen un menor valor que el medicamento de marca y no tienen nombres muy conocidos. Los medicamentos genéricos son aprobados por la Administración de Alimentos y Medicamentos (Food and Drug Administration (FDA)).

HealthKeepers, Inc. cubre medicamentos tanto de marca como genéricos.

15. ¿Qué son medicamentos OTC?

OTC significa “de venta libre”. HealthKeepers, Inc. cubre algunos medicamentos de venta libre, cuando están escritos como recetas por parte de su proveedor.

Puede leer la Lista de medicamentos de Anthem HealthKeepers MMP para ver qué medicamentos de venta libre están cubiertos.

16. ¿Cubre HealthKeepers, Inc. productos de venta libre que no son medicamentos?

HealthKeepers, Inc. cubre algunos productos de venta libre que no son medicamentos, cuando están escritos como recetas por parte de su proveedor.

Puede leer la Lista de medicamentos de Anthem HealthKeepers MMP para ver qué productos de venta libre, que no son medicamentos, están cubiertos.


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17. ¿Cuál es su copago?

Puede leer la Lista de medicamentos de Anthem HealthKeepers MMP para conocer el copago de cada medicamento.

Los miembros de Anthem HealthKeepers MMP que viven en asilos de ancianos u otros centros de cuidado a largo plazo no tendrán copagos. Algunos miembros que reciben cuidado a largo plazo en la comunidad tampoco tendrán copago.

Los copagos se enumeran por niveles. Los niveles son grupos de medicamentos con el mismo copago.

Nivel 1 – Medicamentos preferidos de Medicare Part D. Este nivel tiene medicamentos de marca y genéricos. El copago es $0.

Nivel 2 – Medicamentos preferidos y no preferidos de Medicare Part D. Este nivel tiene medicamentos de marca y genéricos. El copago es de $0 a $7.40 dependiendo de sus ingresos.

Nivel 3 – Medicamentos recetados aprobados por Medicaid (estado). Este nivel tiene medicamentos de marca y genéricos. Estos son medicamentos cubiertos por Medicaid, no son medicamentos de Part D. Tienen un copago de $0.

Nivel 4 – Medicamentos de venta libre (OTC) aprobados por Medicaid (estado). Estos son medicamentos cubiertos por Medicaid, no son medicamentos de Part D. Tienen un copago de $0. Necesita una receta de su proveedor para obtener medicamentos en este nivel.


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Lista de medicamentos cubiertos La lista de medicamentos cubiertos que comienza en la siguiente página le da información sobre los medicamentos cubiertos por HealthKeepers, Inc. Si tiene problemas para encontrar su medicamento en la lista, consulte el índice que comienza en la página 153.

La primera columna del cuadro lista el nombre del medicamento. Los medicamentos de marca están en mayúsculas (por ejemplo: AZOPT) y los medicamentos genéricos están listados en minúsculas cursivas (por ejemplo: amoxicilina).

La información en la columna sobre las acciones necesarias, restricciones y límites de uso le indica si Anthem HealthKeepers MMP tiene alguna regla que cubre su medicamento.

Lista de abreviaturas

B/D: Este medicamento recetado puede estar cubierto bajo Medicare Part B o D dependiendo de las circunstancias. Tal vez se tenga que presentar información que describa el uso y entorno del medicamento para tomar la determinación.

HI: Infusión en el hogar. Este medicamento recetado puede ser cubierto bajo nuestro beneficio médico. Para obtener más información, llame a Member Services al 1-855-817-5787 (TTY 711).

LA: Disponibilidad limitada. Esta receta puede estar disponible solamente en ciertas farmacias. Para obtener más información, llame a Member Services al 1-855-817-5787 (TTY 711).

MO: Medicamento de pedido por correo. Este medicamento recetado está disponible a través de nuestro servicio de pedido por correo, como también a través de nuestras farmacias minoristas de la red. Considere el uso del pedido por correo para sus medicamentos a largo plazo (mantenimiento) (como medicamentos para la presión arterial alta). Las farmacias minoristas de la red pueden ser más adecuadas para recetas de corto plazo (como antibióticos).

PAR: Se requiere autorización previa. El plan requiere que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que usted tendrá que obtener aprobación antes de abastecer sus recetas. Si no obtiene aprobación, puede que no cubramos el medicamento.

QLL: Límite de cantidad. Para ciertos medicamentos, el plan limita la cantidad del medicamento que cubriremos.

ST: Terapia escalonada. En algunos casos, el plan requiere que usted intente primero tomar ciertos medicamentos para tratar su condición médica antes de que cubramos otro medicamento para esa condición. Por ejemplo, si los Medicamentos A y B tratan su condición médica, puede que no cubramos el Medicamento B a menos que intente primero con el Medicamento A. Si el Medicamento A no funciona para usted, entonces cubriremos el Medicamento B.

Nota: El (*) junto a un medicamento significa que el medicamento no es un “Medicamento de la Parte D”. El monto que paga al abastecer una receta para este medicamento no cuenta para sus costos totales de medicamentos (o sea, el monto que usted paga no lo ayuda para calificar para cobertura catastrófica). Además, si usted está recibiendo ayuda adicional para pagar sus recetas, no recibirá ninguna ayuda adicional para pagar por estos medicamentos. Estos medicamentos también tienen reglas diferentes para las apelaciones. Una apelación es una


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manera formal de pedirnos que revisemos una decisión de cobertura y que la cambiemos si usted cree que cometimos un error. Por ejemplo, podríamos decidir que un medicamento que usted desea no está cubierto o ya no está cubierto por Medicare o Commonwealth Coordinated Care. Si usted o su doctor están en desacuerdo con nuestra decisión, puede apelar. Para pedir instrucciones sobre cómo apelar, llame a Member Services al 1-855-817-5787 (TTY 711). También puede leer el manual del miembro para aprender cómo apelar a una decisión.


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Lista de medicamentos por condición médica

Los medicamentos en esta sección están agrupados en categorías, dependiendo del tipo de condiciones médicas para los que se utilizan. Por ejemplo, si tiene una condición cardiaca, debe buscar en la categoría Cardiovascular/hipertensión/lípidos. Es donde encontrará medicamentos para tratar condiciones cardiacas.

Acciones necesarias, restricciones, o límites sobre el uso

Qué le costará el medicamento (nivel

de clase)

Nombre del medicamento

ANTI - INFECTIVES ANTIFUNGAL AGENTS

B/D PAR; MO $0-$7.40 (Tier 2) ABELCET

B/D PAR; MO $0-$7.40 (Tier 2) AMBISOME

B/D PAR; MO $0-$7.40 (Tier 2) amphotericin b

B/D PAR; MO $0-$7.40 (Tier 2) CANCIDAS

MO $0-$7.40 (Tier 2) clotrimazole mucous membrane

PAR; MO $0-$7.40 (Tier 2) ERAXIS(WATER DILUENT)

MO $0-$7.40 (Tier 2) fluconazole

$0-$7.40 (Tier 2) fluconazole in dextrose(iso-o)

$0-$7.40 (Tier 2) FLUCONAZOLE IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML

MO $0-$7.40 (Tier 2) fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml

$0-$7.40 (Tier 2) fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml

MO $0-$7.40 (Tier 2) flucytosine

MO $0-$7.40 (Tier 2) griseofulvin microsize oral suspension

MO $0-$7.40 (Tier 2) griseofulvin ultramicrosize

PAR; MO $0-$7.40 (Tier 2) itraconazole

MO $0-$7.40 (Tier 2) ketoconazole oral

PAR; MO; QLL (630 per 30 days) $0-$7.40 (Tier 2) NOXAFIL ORAL SUSPENSION

MO $0-$7.40 (Tier 2) nystatin oral suspension

MO $0-$7.40 (Tier 2) nystatin oral tablet

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) terbinafine hcl oral

? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 11



de clase)


MO $0-$7.40 (Tier 2) voriconazole intravenous

PAR; MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) voriconazole oral suspension for reconstitution

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) voriconazole oral tablet 200 mg

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) voriconazole oral tablet 50 mg

ANTIVIRALS MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) abacavir

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) abacavir-lamivudine-zidovudine

MO $0-$7.40 (Tier 2) acyclovir oral capsule

MO $0-$7.40 (Tier 2) acyclovir oral suspension 200 mg/5 ml

MO $0-$7.40 (Tier 2) acyclovir oral tablet

B/D PAR; MO $0-$7.40 (Tier 2) acyclovir sodium intravenous solution

MO $0-$7.40 (Tier 2) adefovir

MO $0-$7.40 (Tier 2) amantadine hcl oral capsule

MO $0-$7.40 (Tier 2) amantadine hcl oral tablet

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) APTIVUS ORAL CAPSULE

QLL (380 per 30 days) $0-$7.40 (Tier 2) APTIVUS ORAL SOLUTION

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) ATRIPLA

PAR; MO $0-$7.40 (Tier 2) BARACLUDE ORAL SOLUTION

B/D PAR; MO $0-$7.40 (Tier 2) cidofovir

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) COMPLERA

MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) CRIXIVAN ORAL CAPSULE 200 MG

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) CRIXIVAN ORAL CAPSULE 400 MG

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) DAKLINZA ORAL TABLET 30 MG, 60 MG

PAR; QLL (30 per 30 days) $0-$7.40 (Tier 2) DAKLINZA ORAL TABLET 90 MG

QLL (30 per 30 days) $0-$7.40 (Tier 2) DESCOVY

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) didanosine oral capsule,delayed release(dr/ec) 125 mg

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) didanosine oral capsule,delayed release(dr/ec) 200 mg

B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 12



de clase)


MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) EDURANT

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) EMTRIVA ORAL CAPSULE

MO; QLL (850 per 30 days) $0-$7.40 (Tier 2) EMTRIVA ORAL SOLUTION

PAR; MO $0-$7.40 (Tier 2) entecavir

MO $0-$7.40 (Tier 2) EPIVIR HBV ORAL SOLUTION

MO; QLL (900 per 30 days) $0-$7.40 (Tier 2) EPIVIR ORAL SOLUTION

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) EPZICOM

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) EVOTAZ

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) famciclovir oral tablet 125 mg, 250 mg

MO; QLL (21 per 7 days) $0-$7.40 (Tier 2) famciclovir oral tablet 500 mg

B/D PAR $0-$7.40 (Tier 2) foscarnet

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) FUZEON SUBCUTANEOUS RECON SOLN

MO $0-$7.40 (Tier 2) ganciclovir sodium

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) GENVOYA

PAR; MO; QLL (28 per 28 days) $0-$7.40 (Tier 2) HARVONI

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) INTELENCE ORAL TABLET 100 MG



MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) INVIRASE ORAL CAPSULE

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) INVIRASE ORAL TABLET

MO $0-$7.40 (Tier 2) ISENTRESS ORAL POWDER IN PACKET

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) ISENTRESS ORAL TABLET

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) ISENTRESS ORAL TABLET,CHEWABLE 100 MG

MO; QLL (720 per 30 days) $0-$7.40 (Tier 2) ISENTRESS ORAL TABLET,CHEWABLE 25 MG

MO; QLL (480 per 30 days) $0-$7.40 (Tier 2) KALETRA ORAL SOLUTION

MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) KALETRA ORAL TABLET 100-25 MG




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MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) KALETRA ORAL TABLET 200-50 MG

MO; QLL (900 per 30 days) $0-$7.40 (Tier 2) lamivudine oral solution

MO $0-$7.40 (Tier 2) lamivudine oral tablet 100 mg

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) lamivudine oral tablet 150 mg

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) lamivudine oral tablet 300 mg

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) lamivudine-zidovudine

MO; QLL (1800 per 30 days) $0-$7.40 (Tier 2) LEXIVA ORAL SUSPENSION

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) LEXIVA ORAL TABLET

MO; QLL (1200 per 30 days) $0-$7.40 (Tier 2) nevirapine oral suspension

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) nevirapine oral tablet

MO $0-$7.40 (Tier 2) nevirapine oral tablet extended release 24 hr 100 mg

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) nevirapine oral tablet extended release 24 hr 400 mg

MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) NORVIR ORAL CAPSULE

MO; QLL (480 per 30 days) $0-$7.40 (Tier 2) NORVIR ORAL SOLUTION

MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) NORVIR ORAL TABLET

QLL (30 per 30 days) $0-$7.40 (Tier 2) ODEFSEY

PAR; MO $0-$7.40 (Tier 2) OLYSIO

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) PREZCOBIX

MO; QLL (400 per 30 days) $0-$7.40 (Tier 2) PREZISTA ORAL SUSPENSION

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) PREZISTA ORAL TABLET 150 MG

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) PREZISTA ORAL TABLET 600 MG, 800 MG

MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) PREZISTA ORAL TABLET 75 MG

MO; QLL (60 per 180 days) $0-$7.40 (Tier 2) RELENZA DISKHALER

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) RESCRIPTOR ORAL TABLET

MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) RESCRIPTOR ORAL TABLET, DISPERSIBLE

MO $0-$7.40 (Tier 2) RETROVIR INTRAVENOUS

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) REYATAZ ORAL CAPSULE 150 MG, 200 MG




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MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) REYATAZ ORAL CAPSULE 300 MG

MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) REYATAZ ORAL POWDER IN PACKET

PAR; MO $0-$7.40 (Tier 2) ribasphere oral capsule

PAR; MO $0-$7.40 (Tier 2) ribasphere oral tablet 200 mg

PAR; MO $0-$7.40 (Tier 2) ribavirin oral capsule

PAR; MO $0-$7.40 (Tier 2) ribavirin oral tablet 200 mg

MO $0-$7.40 (Tier 2) rimantadine

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) SELZENTRY

PAR; MO $0-$7.40 (Tier 2) SOVALDI

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) stavudine oral capsule 15 mg, 20 mg

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) stavudine oral capsule 30 mg, 40 mg

MO; QLL (2400 per 30 days) $0-$7.40 (Tier 2) stavudine oral recon soln

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) STRIBILD

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) SUSTIVA ORAL CAPSULE 200 MG

MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) SUSTIVA ORAL CAPSULE 50 MG

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) SUSTIVA ORAL TABLET

PAR; MO; LA $0-$7.40 (Tier 2) SYNAGIS

MO $0-$7.40 (Tier 2) TAMIFLU

PAR; MO; QLL (56 per 28 days) $0-$7.40 (Tier 2) TECHNIVIE

QLL (60 per 30 days) $0-$7.40 (Tier 2) TIVICAY ORAL TABLET 10 MG, 25 MG

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) TIVICAY ORAL TABLET 50 MG

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) TRIUMEQ

QLL (30 per 30 days) $0-$7.40 (Tier 2) TRUVADA ORAL TABLET 100-150 MG, 133- 200 MG, 167-250 MG

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) TRUVADA ORAL TABLET 200-300 MG

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) TYBOST

PAR; MO $0-$7.40 (Tier 2) TYZEKA

MO; QLL (30 per 2 days) $0-$7.40 (Tier 2) valacyclovir

MO $0-$7.40 (Tier 2) valganciclovir




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MO; QLL (1200 per 30 days) $0-$7.40 (Tier 2) VIDEX 2 GRAM PEDIATRIC

MO; QLL (1200 per 30 days) $0-$7.40 (Tier 2) VIDEX 4 GRAM PEDIATRIC

PAR; MO $0-$7.40 (Tier 2) VIEKIRA PAK

MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) VIRACEPT ORAL TABLET 250 MG

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) VIRACEPT ORAL TABLET 625 MG

MO $0-$7.40 (Tier 2) VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG

PAR; MO $0-$7.40 (Tier 2) VIRAZOLE

MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) VIREAD ORAL POWDER

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) VIREAD ORAL TABLET

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) VITEKTA

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) ZEPATIER

MO; QLL (960 per 30 days) $0-$7.40 (Tier 2) ZIAGEN ORAL SOLUTION

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) zidovudine oral capsule

MO; QLL (1920 per 30 days) $0-$7.40 (Tier 2) zidovudine oral syrup

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) zidovudine oral tablet

CEPHALOSPORINS MO $0-$7.40 (Tier 2) cefaclor oral capsule

$0-$7.40 (Tier 2) cefaclor oral suspension for reconstitution 125 mg/ 5 ml

MO $0-$7.40 (Tier 2) cefaclor oral suspension for reconstitution 250 mg/ 5 ml, 375 mg/5 ml

MO $0-$7.40 (Tier 2) cefaclor oral tablet extended release 12 hr

MO $0-$7.40 (Tier 2) cefadroxil oral capsule

MO $0-$7.40 (Tier 2) cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

MO $0-$7.40 (Tier 2) cefadroxil oral tablet

MO $0-$7.40 (Tier 2) cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml




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MO $0-$7.40 (Tier 2) CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/50 ML

MO $0-$7.40 (Tier 2) cefazolin injection recon soln 1 gram, 500 mg

$0-$7.40 (Tier 2) cefazolin injection recon soln 10 gram, 20 gram

$0-$7.40 (Tier 2) CEFAZOLIN INJECTION RECON SOLN 100 GRAM, 300 G

$0-$7.40 (Tier 2) cefazolin intravenous

MO $0-$7.40 (Tier 2) cefdinir

MO $0-$7.40 (Tier 2) cefepime

$0-$7.40 (Tier 2) cefoxitin in dextrose, iso-osm

MO $0-$7.40 (Tier 2) cefoxitin intravenous recon soln 1 gram

$0-$7.40 (Tier 2) cefoxitin intravenous recon soln 10 gram, 2 gram

MO $0-$7.40 (Tier 2) cefpodoxime

MO $0-$7.40 (Tier 2) cefprozil

MO $0-$7.40 (Tier 2) ceftazidime injection recon soln 1 gram, 2 gram

$0-$7.40 (Tier 2) ceftazidime injection recon soln 6 gram

MO $0-$7.40 (Tier 2) ceftriaxone in dextrose,iso-os

MO $0-$7.40 (Tier 2) ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg

$0-$7.40 (Tier 2) ceftriaxone injection recon soln 10 gram

$0-$7.40 (Tier 2) CEFTRIAXONE INJECTION RECON SOLN 100 GRAM

MO $0-$7.40 (Tier 2) ceftriaxone intravenous

MO $0-$7.40 (Tier 2) cefuroxime axetil oral tablet

MO $0-$7.40 (Tier 2) cefuroxime sodium injection recon soln 1.5 gram, 750 mg

$0-$7.40 (Tier 2) cefuroxime sodium intravenous vial

MO $0-$7.40 (Tier 2) cephalexin oral capsule 250 mg, 500 mg

MO $0-$7.40 (Tier 2) cephalexin oral suspension for reconstitution

MO $0-$7.40 (Tier 2) cephalexin oral tablet




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MO $0-$7.40 (Tier 2) TEFLARO

ERYTHROMYCINS / OTHER MACROLIDES MO $0-$7.40 (Tier 2) azithromycin intravenous recon soln 500 mg

$0-$7.40 (Tier 2) azithromycin intravenous recon soln 500 mg (2 mg/ ml)

MO $0-$7.40 (Tier 2) azithromycin oral

MO $0-$7.40 (Tier 2) clarithromycin oral suspension for reconstitution

MO $0-$7.40 (Tier 2) clarithromycin oral tablet

MO; QLL (28 per 2 days) $0-$7.40 (Tier 2) clarithromycin oral tablet extended release 24 hr

MO $0-$7.40 (Tier 2) e.e.s. 400 oral tablet

MO $0-$7.40 (Tier 2) ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

MO $0-$7.40 (Tier 2) ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

MO $0-$7.40 (Tier 2) erythrocin (as stearate) oral tablet 250 mg

$0-$7.40 (Tier 2) ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG

MO $0-$7.40 (Tier 2) erythromycin ethylsuccinate oral tablet

MO $0-$7.40 (Tier 2) erythromycin oral tablet

MISCELLANEOUS ANTIINFECTIVES MO $0-$7.40 (Tier 2) ALBENZA

MO; QLL (180 per 3 days) $0-$7.40 (Tier 2) ALINIA ORAL SUSPENSION FOR RECONSTITUTION

MO $0-$7.40 (Tier 2) ALINIA ORAL TABLET

MO $0-$7.40 (Tier 2) AMIKACIN INJECTION SOLUTION 1,000 MG/ 4 ML

MO $0-$7.40 (Tier 2) amikacin injection solution 500 mg/2 ml

PAR; MO $0-$7.40 (Tier 2) atovaquone

MO $0-$7.40 (Tier 2) atovaquone-proguanil

$0-$7.40 (Tier 2) AZACTAM IN DEXTROSE (ISO-OSM)




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MO $0-$7.40 (Tier 2) aztreonam

$0-$7.40 (Tier 2) baciim

MO $0-$7.40 (Tier 2) BILTRICIDE

$0-$7.40 (Tier 2) CAPASTAT

PAR; MO; LA $0-$7.40 (Tier 2) CAYSTON

$0-$7.40 (Tier 2) chloramphenicol sod succinate

MO $0-$7.40 (Tier 2) chloroquine phosphate oral

MO $0-$7.40 (Tier 2) clindamycin hcl

MO $0-$7.40 (Tier 2) clindamycin phosphate injection

$0-$7.40 (Tier 2) CLINDAMYCIN PHOSPHATE INTRAVENOUS SOLUTION 300 MG/2 ML

MO $0-$7.40 (Tier 2) clindamycin phosphate intravenous solution 600 mg/4 ml

$0-$7.40 (Tier 2) clindamycin phosphate intravenous solution 900 mg/6 ml

MO $0-$7.40 (Tier 2) colistin (colistimethate na)

MO $0-$7.40 (Tier 2) DAPSONE

MO $0-$7.40 (Tier 2) DARAPRIM

MO $0-$7.40 (Tier 2) ethambutol

MO $0-$7.40 (Tier 2) gentamicin injection

MO $0-$7.40 (Tier 2) GENTAMICIN SULFATE (PED) (PF)

MO $0-$7.40 (Tier 2) GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 100 MG/10 ML

$0-$7.40 (Tier 2) GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML

$0-$7.40 (Tier 2) gentamicin sulfate (pf) intravenous solution 80 mg/ 8 ml

MO $0-$7.40 (Tier 2) hydroxychloroquine oral

MO $0-$7.40 (Tier 2) imipenem-cilastatin

MO $0-$7.40 (Tier 2) INVANZ INJECTION




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MO $0-$7.40 (Tier 2) isoniazid oral

MO $0-$7.40 (Tier 2) ivermectin oral

$0-$7.40 (Tier 2) linezolid intravenous

PAR; MO; QLL (1800 per 2 days) $0-$7.40 (Tier 2) linezolid oral suspension for reconstitution

PAR; MO; QLL (28 per 2 days) $0-$7.40 (Tier 2) linezolid oral tablet

$0-$7.40 (Tier 2) LINEZOLID-0.9% SODIUM CHLORIDE

MO $0-$7.40 (Tier 2) mefloquine

MO $0-$7.40 (Tier 2) meropenem

MO $0-$7.40 (Tier 2) METRO I.V.

MO $0-$7.40 (Tier 2) metronidazole in nacl (iso-os)

MO $0-$7.40 (Tier 2) metronidazole oral

B/D PAR; MO $0-$7.40 (Tier 2) NEBUPENT

MO $0-$7.40 (Tier 2) neomycin

MO $0-$7.40 (Tier 2) paromomycin

MO $0-$7.40 (Tier 2) PASER

MO $0-$7.40 (Tier 2) PENTAM

MO $0-$7.40 (Tier 2) PRIFTIN

MO $0-$7.40 (Tier 2) PRIMAQUINE

MO $0-$7.40 (Tier 2) pyrazinamide

MO $0-$7.40 (Tier 2) rifabutin

MO $0-$7.40 (Tier 2) rifampin

MO $0-$7.40 (Tier 2) RIFATER

PAR; MO; LA $0-$7.40 (Tier 2) SIRTURO

MO $0-$7.40 (Tier 2) STREPTOMYCIN INTRAMUSCULAR

$0-$7.40 (Tier 2) SYNERCID

B/D PAR; MO; QLL (280 per 28 days) $0-$7.40 (Tier 2) tobramycin in 0.225 % nacl

$0-$7.40 (Tier 2) tobramycin sulfate injection recon soln

MO $0-$7.40 (Tier 2) tobramycin sulfate injection solution

MO $0-$7.40 (Tier 2) TRECATOR




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MO $0-$7.40 (Tier 2) TYGACIL

$0-$7.40 (Tier 2) ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML

MO $0-$7.40 (Tier 2) ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML

PAR; MO; QLL (1800 per 2 days) $0-$7.40 (Tier 2) ZYVOX ORAL SUSPENSION FOR RECONSTITUTION

PENICILLINS MO $0-$7.40 (Tier 2) amoxicillin oral capsule

MO $0-$7.40 (Tier 2) amoxicillin oral suspension for reconstitution

MO $0-$7.40 (Tier 2) amoxicillin oral tablet

MO $0-$7.40 (Tier 2) amoxicillin oral tablet,chewable 125 mg, 250 mg

MO $0-$7.40 (Tier 2) amoxicillin-pot clavulanate

MO $0-$7.40 (Tier 2) ampicillin

MO $0-$7.40 (Tier 2) ampicillin sodium injection

$0-$7.40 (Tier 2) ampicillin sodium intravenous

MO $0-$7.40 (Tier 2) ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram

$0-$7.40 (Tier 2) ampicillin-sulbactam injection recon soln 15 gram

MO $0-$7.40 (Tier 2) ampicillin-sulbactam intravenous recon soln 3 gram

MO $0-$7.40 (Tier 2) BICILLIN C-R

MO $0-$7.40 (Tier 2) BICILLIN L-A

MO $0-$7.40 (Tier 2) dicloxacillin

MO $0-$7.40 (Tier 2) nafcillin injection

MO $0-$7.40 (Tier 2) nafcillin intravenous recon soln 2 gram

MO $0-$7.40 (Tier 2) oxacillin injection

$0-$7.40 (Tier 2) oxacillin intravenous

$0-$7.40 (Tier 2) PENICILLIN G POT IN DEXTROSE

MO $0-$7.40 (Tier 2) penicillin g potassium




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MO $0-$7.40 (Tier 2) penicillin g procaine intramuscular syringe 1.2 million unit/2 ml

$0-$7.40 (Tier 2) penicillin g procaine intramuscular syringe 600,000 unit/ml

MO $0-$7.40 (Tier 2) penicillin g sodium

MO $0-$7.40 (Tier 2) penicillin v potassium

MO $0-$7.40 (Tier 2) piperacillin-tazobactam

QUINOLONES $0-$7.40 (Tier 2) ciprofloxacin

MO; QLL (14 per 2 days) $0-$7.40 (Tier 2) ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg

MO; QLL (3 per 2 days) $0-$7.40 (Tier 2) ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 500 mg

MO $0-$7.40 (Tier 2) ciprofloxacin hcl oral tablet oral tablet 100 mg, 250 mg, 500 mg, 750 mg

MO $0-$7.40 (Tier 2) ciprofloxacin lactate intravenous solution 200 mg/ 20 ml

$0-$7.40 (Tier 2) ciprofloxacin lactate intravenous solution 400 mg/ 40 ml

MO $0-$7.40 (Tier 2) levofloxacin intravenous

MO; QLL (14 per 2 days) $0-$7.40 (Tier 2) levofloxacin oral tablet

MO; QLL (21 per 2 days) $0-$7.40 (Tier 2) moxifloxacin

MO $0-$7.40 (Tier 2) ofloxacin oral tablet 400 mg

SULFA'S / RELATED AGENTS MO $0-$7.40 (Tier 2) sulfadiazine oral

MO $0-$7.40 (Tier 2) sulfamethoxazole-trimethoprim

TETRACYCLINES MO $0-$7.40 (Tier 2) demeclocycline

MO $0-$7.40 (Tier 2) DOXY-100

$0-$7.40 (Tier 2) doxycycline hyclate intravenous

MO $0-$7.40 (Tier 2) doxycycline hyclate oral capsule




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MO $0-$7.40 (Tier 2) doxycycline hyclate oral tablet

MO $0-$7.40 (Tier 2) doxycycline hyclate oral tablet,delayed release (dr/ ec) 100 mg, 150 mg, 75 mg

MO $0-$7.40 (Tier 2) doxycycline monohydrate oral capsule

MO $0-$7.40 (Tier 2) doxycycline monohydrate oral tablet

MO $0-$7.40 (Tier 2) minocycline oral capsule

MO $0-$7.40 (Tier 2) minocycline oral tablet

$0-$7.40 (Tier 2) morgidox oral capsule 50 mg

MO $0-$7.40 (Tier 2) tetracycline

URINARY TRACT AGENTS MO $0-$7.40 (Tier 2) methenamine hippurate

PAR; MO $0-$7.40 (Tier 2) nitrofurantoin macrocrystal oral capsule 50 mg

MO $0-$7.40 (Tier 2) trimethoprim

VANCOMYCIN $0-$7.40 (Tier 2) VANCOMYCIN IN 0.9% SODIUM CL

INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML

MO $0-$7.40 (Tier 2) vancomycin in dextrose 5 % intravenous piggyback 1 gram/200 ml

$0-$7.40 (Tier 2) vancomycin in dextrose 5 % intravenous piggyback 500 mg/100 ml

$0-$7.40 (Tier 2) VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 750 MG/150 ML

MO $0-$7.40 (Tier 2) vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg

MO $0-$7.40 (Tier 2) VANCOMYCIN INTRAVENOUS RECON SOLN 5 GRAM, 750 MG

PAR; MO; QLL (40 per 2 days) $0-$7.40 (Tier 2) vancomycin oral capsule 125 mg

PAR; MO; QLL (80 per 2 days) $0-$7.40 (Tier 2) vancomycin oral capsule 250 mg




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ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS

PAR; MO $0-$7.40 (Tier 2) amifostine crystalline

$0-$7.40 (Tier 2) dexrazoxane hcl intravenous recon soln 250 mg

MO $0-$7.40 (Tier 2) dexrazoxane hcl intravenous recon soln 500 mg

PAR; MO $0-$7.40 (Tier 2) ELITEK

MO $0-$7.40 (Tier 2) FUSILEV

$0-$7.40 (Tier 2) KEPIVANCE

MO $0-$7.40 (Tier 2) leucovorin calcium injection recon soln 100 mg, 350 mg, 50 mg

MO $0-$7.40 (Tier 2) LEUCOVORIN CALCIUM INJECTION RECON SOLN 200 MG

$0-$7.40 (Tier 2) LEUCOVORIN CALCIUM INJECTION RECON SOLN 500 MG

MO $0-$7.40 (Tier 2) leucovorin calcium oral

$0-$7.40 (Tier 2) levoleucovorin calcium intravenous recon soln

MO $0-$7.40 (Tier 2) mesna

MO $0-$7.40 (Tier 2) MESNEX ORAL

PAR; MO; QLL (1.7 per 28 days) $0-$7.40 (Tier 2) XGEVA

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS MO $0-$7.40 (Tier 2) ABRAXANE

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 5 MG

PAR; MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 3 MG

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) AFINITOR ORAL TABLET 10 MG

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) AFINITOR ORAL TABLET 2.5 MG

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) AFINITOR ORAL TABLET 5 MG

PAR; MO; QLL (40 per 30 days) $0-$7.40 (Tier 2) AFINITOR ORAL TABLET 7.5 MG

MO $0-$7.40 (Tier 2) ALECENSA




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PAR; MO $0-$7.40 (Tier 2) ALIMTA

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) anastrozole

$0-$7.40 (Tier 2) ARRANON

PAR; MO $0-$7.40 (Tier 2) ARZERRA

PAR; MO $0-$7.40 (Tier 2) AVASTIN

PAR; MO $0-$7.40 (Tier 2) azacitidine

B/D PAR; MO $0-$7.40 (Tier 2) azathioprine

B/D PAR $0-$7.40 (Tier 2) azathioprine sodium

PAR; MO $0-$7.40 (Tier 2) BELEODAQ

MO $0-$7.40 (Tier 2) BENDEKA

PAR; MO $0-$7.40 (Tier 2) bexarotene

MO $0-$7.40 (Tier 2) bicalutamide

MO $0-$7.40 (Tier 2) BICNU

$0-$7.40 (Tier 2) bleo 15k

MO $0-$7.40 (Tier 2) bleomycin

PAR; MO $0-$7.40 (Tier 2) BLINCYTO

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) BOSULIF ORAL TABLET 100 MG

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) BOSULIF ORAL TABLET 500 MG

$0-$7.40 (Tier 2) BUSULFEX

PAR; LA; QLL (90 per 30 days) $0-$7.40 (Tier 2) CABOMETYX ORAL TABLET 20 MG

PAR; LA; QLL (30 per 30 days) $0-$7.40 (Tier 2) CABOMETYX ORAL TABLET 40 MG, 60 MG

PAR; MO; LA; QLL (90 per 30 days) $0-$7.40 (Tier 2) CAPRELSA ORAL TABLET 100 MG

PAR; MO; LA; QLL (30 per 30 days) $0-$7.40 (Tier 2) CAPRELSA ORAL TABLET 300 MG

MO $0-$7.40 (Tier 2) carboplatin intravenous solution

B/D PAR; MO $0-$7.40 (Tier 2) CELLCEPT INTRAVENOUS

MO $0-$7.40 (Tier 2) cisplatin

MO $0-$7.40 (Tier 2) cladribine

MO $0-$7.40 (Tier 2) CLOLAR




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PAR; MO; QLL (56 per 28 days) $0-$7.40 (Tier 2) COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1)

PAR; MO; QLL (112 per 28 days) $0-$7.40 (Tier 2) COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3)

PAR; MO; QLL (84 per 28 days) $0-$7.40 (Tier 2) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY)

PAR; MO; LA; QLL (90 per 30 days) $0-$7.40 (Tier 2) COTELLIC

B/D PAR; MO $0-$7.40 (Tier 2) cyclophosphamide oral capsule

B/D PAR $0-$7.40 (Tier 2) cyclosporine intravenous

B/D PAR; MO $0-$7.40 (Tier 2) cyclosporine modified

B/D PAR; MO $0-$7.40 (Tier 2) cyclosporine oral capsule

PAR; MO $0-$7.40 (Tier 2) CYRAMZA

MO $0-$7.40 (Tier 2) cytarabine

MO $0-$7.40 (Tier 2) CYTARABINE (PF) INJECTION SOLUTION 100 MG/5 ML (20 MG/ML)

MO $0-$7.40 (Tier 2) cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml)

$0-$7.40 (Tier 2) CYTARABINE (PF) INJECTION SOLUTION 20 MG/ML

MO $0-$7.40 (Tier 2) dacarbazine

MO; LA $0-$7.40 (Tier 2) DARZALEX

$0-$7.40 (Tier 2) daunorubicin intravenous solution

MO $0-$7.40 (Tier 2) decitabine

$0-$7.40 (Tier 2) DOCEFREZ INTRAVENOUS RECON SOLN 20 MG

$0-$7.40 (Tier 2) DOCETAXEL INTRAVENOUS SOLUTION 10 MG/ML, 160 MG/16 ML (10 MG/ML), 160 MG/ 8 ML (20 MG/ML), 20 MG/2 ML (10 MG/ML)

MO $0-$7.40 (Tier 2) docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)

$0-$7.40 (Tier 2) doxorubicin intravenous recon soln

MO $0-$7.40 (Tier 2) doxorubicin intravenous solution




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MO $0-$7.40 (Tier 2) doxorubicin, peg-liposomal

MO $0-$7.40 (Tier 2) DROXIA

MO $0-$7.40 (Tier 2) EMCYT

B/D PAR; MO $0-$7.40 (Tier 2) EMPLICITI

B/D PAR; MO $0-$7.40 (Tier 2) ENVARSUS XR

$0-$7.40 (Tier 2) epirubicin intravenous solution 200 mg/100 ml

MO $0-$7.40 (Tier 2) epirubicin intravenous solution 50 mg/25 ml

PAR; MO $0-$7.40 (Tier 2) ERBITUX

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) ERIVEDGE

PAR; MO $0-$7.40 (Tier 2) ERWINAZE

MO $0-$7.40 (Tier 2) ETOPOPHOS

MO $0-$7.40 (Tier 2) etoposide intravenous

$0-$7.40 (Tier 2) EVOMELA

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) exemestane

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) FARESTON

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) FARYDAK ORAL CAPSULE 10 MG

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) FARYDAK ORAL CAPSULE 15 MG, 20 MG

PAR; MO $0-$7.40 (Tier 2) FASLODEX

PAR; MO $0-$7.40 (Tier 2) FIRMAGON KIT W DILUENT SYRINGE

MO $0-$7.40 (Tier 2) fludarabine intravenous recon soln

$0-$7.40 (Tier 2) FLUDARABINE INTRAVENOUS SOLUTION

MO $0-$7.40 (Tier 2) FLUOROURACIL INTRAVENOUS SOLUTION 1 GRAM/20 ML

MO $0-$7.40 (Tier 2) fluorouracil intravenous solution 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml

MO $0-$7.40 (Tier 2) flutamide

MO $0-$7.40 (Tier 2) FOLOTYN

PAR; MO $0-$7.40 (Tier 2) GAZYVA

MO $0-$7.40 (Tier 2) gemcitabine intravenous recon soln 1 gram, 200 mg




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$0-$7.40 (Tier 2) GEMCITABINE INTRAVENOUS RECON SOLN 2 GRAM

MO $0-$7.40 (Tier 2) GEMCITABINE INTRAVENOUS SOLUTION 1 GRAM/26.3 ML (38 MG/ML), 200 MG/5.26 ML (38 MG/ML)

$0-$7.40 (Tier 2) GEMCITABINE INTRAVENOUS SOLUTION 2 GRAM/52.6 ML (38 MG/ML)

B/D PAR; MO $0-$7.40 (Tier 2) gengraf oral capsule 100 mg, 25 mg

B/D PAR $0-$7.40 (Tier 2) gengraf oral capsule 50 mg

B/D PAR; MO $0-$7.40 (Tier 2) gengraf oral solution

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) GILOTRIF

PAR; MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) GLEEVEC ORAL TABLET 100 MG

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) GLEEVEC ORAL TABLET 400 MG

MO $0-$7.40 (Tier 2) GLEOSTINE

PAR; MO $0-$7.40 (Tier 2) HALAVEN

PAR; MO $0-$7.40 (Tier 2) HERCEPTIN

MO $0-$7.40 (Tier 2) HEXALEN

MO $0-$7.40 (Tier 2) hydroxyurea

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) IBRANCE

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) ICLUSIG ORAL TABLET 15 MG

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) ICLUSIG ORAL TABLET 45 MG

$0-$7.40 (Tier 2) idarubicin

MO $0-$7.40 (Tier 2) ifosfamide intravenous recon soln

$0-$7.40 (Tier 2) IFOSFAMIDE INTRAVENOUS SOLUTION

PAR; MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) imatinib oral tablet 100 mg

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) imatinib oral tablet 400 mg

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) IMBRUVICA

PAR; MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) INLYTA ORAL TABLET 1 MG

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) INLYTA ORAL TABLET 5 MG

MO $0-$7.40 (Tier 2) IRESSA




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MO $0-$7.40 (Tier 2) irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml

$0-$7.40 (Tier 2) IRINOTECAN INTRAVENOUS SOLUTION 500 MG/25 ML

PAR; MO $0-$7.40 (Tier 2) ISTODAX

MO $0-$7.40 (Tier 2) IXEMPRA

PAR; MO; QLL (150 per 30 days) $0-$7.40 (Tier 2) JAKAFI ORAL TABLET 10 MG





MO $0-$7.40 (Tier 2) JEVTANA

PAR; MO $0-$7.40 (Tier 2) KADCYLA

PAR; MO $0-$7.40 (Tier 2) KEYTRUDA INTRAVENOUS RECON SOLN

PAR; MO $0-$7.40 (Tier 2) KEYTRUDA INTRAVENOUS SOLUTION

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY)

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2)

PAR; QLL (90 per 30 days) $0-$7.40 (Tier 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2)

PAR; MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) LENVIMA ORAL CAPSULE 24 MG/DAY(10 MG X 2-4 MG X 1)

PAR; QLL (60 per 30 days) $0-$7.40 (Tier 2) LENVIMA ORAL CAPSULE 8 MG/DAY (4 MG X 2), 8 MG/DAY (4 MG X 2) (60 PACK)

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) letrozole

MO $0-$7.40 (Tier 2) LEUKERAN

PAR; MO $0-$7.40 (Tier 2) leuprolide subcutaneous kit

PAR; MO $0-$7.40 (Tier 2) LONSURF

PAR; MO; QLL (1 per 28 days) $0-$7.40 (Tier 2) LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG




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PAR; MO $0-$7.40 (Tier 2) LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG

PAR; MO; QLL (1 per 28 days) $0-$7.40 (Tier 2) LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED)

PAR; MO; QLL (480 per 30 days) $0-$7.40 (Tier 2) LYNPARZA

MO $0-$7.40 (Tier 2) LYSODREN

MO $0-$7.40 (Tier 2) MATULANE

PAR $0-$7.40 (Tier 2) MEGESTROL ORAL SUSPENSION 400 MG/10 ML (10 ML), 800 MG/20 ML (20 ML)

PAR; MO $0-$7.40 (Tier 2) megestrol oral suspension 400 mg/10 ml (40 mg/ ml)

PAR; MO $0-$7.40 (Tier 2) megestrol oral tablet

PAR; QLL (90 per 30 days) $0-$7.40 (Tier 2) MEKINIST ORAL TABLET 0.5 MG

PAR; QLL (30 per 30 days) $0-$7.40 (Tier 2) MEKINIST ORAL TABLET 2 MG

$0-$7.40 (Tier 2) melphalan hcl

MO $0-$7.40 (Tier 2) mercaptopurine

MO $0-$7.40 (Tier 2) methotrexate sodium

$0-$7.40 (Tier 2) methotrexate sodium (pf) injection recon soln

MO $0-$7.40 (Tier 2) methotrexate sodium (pf) injection solution

MO $0-$7.40 (Tier 2) mitomycin

MO $0-$7.40 (Tier 2) mitoxantrone

MO $0-$7.40 (Tier 2) MUSTARGEN

B/D PAR; MO $0-$7.40 (Tier 2) mycophenolate mofetil

B/D PAR; MO $0-$7.40 (Tier 2) mycophenolate sodium

PAR; MO; LA; QLL (120 per 30 days) $0-$7.40 (Tier 2) NEXAVAR

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) NILANDRON

QLL (30 per 30 days) $0-$7.40 (Tier 2) nilutamide

PAR; MO; QLL (3 per 28 days) $0-$7.40 (Tier 2) NINLARO

MO $0-$7.40 (Tier 2) NIPENT

PAR; MO $0-$7.40 (Tier 2) NULOJIX




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PAR; MO $0-$7.40 (Tier 2) octreotide acetate injection solution

PAR; MO $0-$7.40 (Tier 2) OCTREOTIDE ACETATE INJECTION SYRINGE

PAR; MO; LA; QLL (30 per 30 days) $0-$7.40 (Tier 2) ODOMZO

PAR; MO $0-$7.40 (Tier 2) ONCASPAR

PAR; MO $0-$7.40 (Tier 2) OPDIVO

MO $0-$7.40 (Tier 2) oxaliplatin intravenous recon soln 100 mg

$0-$7.40 (Tier 2) oxaliplatin intravenous recon soln 50 mg

MO $0-$7.40 (Tier 2) oxaliplatin intravenous solution

MO $0-$7.40 (Tier 2) paclitaxel

PAR; MO $0-$7.40 (Tier 2) PERJETA

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) POMALYST ORAL CAPSULE 1 MG

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) POMALYST ORAL CAPSULE 2 MG

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) POMALYST ORAL CAPSULE 3 MG, 4 MG

MO $0-$7.40 (Tier 2) PORTRAZZA

B/D PAR; MO $0-$7.40 (Tier 2) PROGRAF INTRAVENOUS

PAR; MO $0-$7.40 (Tier 2) PURIXAN

B/D PAR; MO $0-$7.40 (Tier 2) RAPAMUNE ORAL SOLUTION

PAR; MO; LA; QLL (60 per 30 days) $0-$7.40 (Tier 2) REVLIMID ORAL CAPSULE 10 MG

PAR; MO; LA; QLL (30 per 30 days) $0-$7.40 (Tier 2) REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG

PAR; MO; LA; QLL (150 per 30 days) $0-$7.40 (Tier 2) REVLIMID ORAL CAPSULE 5 MG

PAR; MO $0-$7.40 (Tier 2) RITUXAN

MO $0-$7.40 (Tier 2) SIGNIFOR

B/D PAR $0-$7.40 (Tier 2) SIMULECT INTRAVENOUS RECON SOLN 10 MG

B/D PAR; MO $0-$7.40 (Tier 2) SIMULECT INTRAVENOUS RECON SOLN 20 MG

B/D PAR; MO $0-$7.40 (Tier 2) sirolimus

MO $0-$7.40 (Tier 2) SOLTAMOX

PAR; MO $0-$7.40 (Tier 2) SOMATULINE DEPOT




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PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) SPRYCEL

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) STIVARGA

PAR; MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) SUTENT ORAL CAPSULE 12.5 MG

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG

PAR; MO $0-$7.40 (Tier 2) SYNRIBO

MO $0-$7.40 (Tier 2) TABLOID

B/D PAR; MO $0-$7.40 (Tier 2) tacrolimus oral

PAR; QLL (120 per 30 days) $0-$7.40 (Tier 2) TAFINLAR

PAR; MO; LA; QLL (60 per 30 days) $0-$7.40 (Tier 2) TAGRISSO ORAL TABLET 40 MG

PAR; MO; LA; QLL (30 per 30 days) $0-$7.40 (Tier 2) TAGRISSO ORAL TABLET 80 MG

MO $0-$7.40 (Tier 2) tamoxifen

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) TARCEVA ORAL TABLET 100 MG, 150 MG

PAR; MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) TARCEVA ORAL TABLET 25 MG

PAR; MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) TARGRETIN ORAL

PAR; MO $0-$7.40 (Tier 2) TARGRETIN TOPICAL

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) TASIGNA

LA; QLL (20 per 21 days) $0-$7.40 (Tier 2) TECENTRIQ

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) THALOMID ORAL CAPSULE 100 MG, 50 MG

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) THALOMID ORAL CAPSULE 150 MG, 200 MG

MO $0-$7.40 (Tier 2) thiotepa

MO $0-$7.40 (Tier 2) toposar

$0-$7.40 (Tier 2) topotecan intravenous recon soln

MO $0-$7.40 (Tier 2) TOPOTECAN INTRAVENOUS SOLUTION

MO $0-$7.40 (Tier 2) TORISEL

MO $0-$7.40 (Tier 2) TREANDA INTRAVENOUS RECON SOLN

MO; QLL (1 per 168 days) $0-$7.40 (Tier 2) TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

MO $0-$7.40 (Tier 2) TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML, 3.75 MG/2 ML




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MO; QLL (1 per 168 days) $0-$7.40 (Tier 2) TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML

MO $0-$7.40 (Tier 2) tretinoin (chemotherapy)

MO $0-$7.40 (Tier 2) TREXALL

MO $0-$7.40 (Tier 2) TRISENOX

PAR; MO; LA; QLL (180 per 30 days) $0-$7.40 (Tier 2) TYKERB

MO $0-$7.40 (Tier 2) UNITUXIN

PAR; MO $0-$7.40 (Tier 2) VECTIBIX

PAR; MO $0-$7.40 (Tier 2) VELCADE

PAR; LA; QLL (60 per 30 days) $0-$7.40 (Tier 2) VENCLEXTA ORAL TABLET 10 MG



PAR; LA; QLL (42 per 365 days) $0-$7.40 (Tier 2) VENCLEXTA STARTING PACK

MO $0-$7.40 (Tier 2) vinblastine intravenous solution

$0-$7.40 (Tier 2) VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML

MO $0-$7.40 (Tier 2) VINCASAR PFS INTRAVENOUS SOLUTION 2 MG/2 ML

MO $0-$7.40 (Tier 2) vincristine

MO $0-$7.40 (Tier 2) vinorelbine

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) VOTRIENT

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) XALKORI

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) XTANDI

PAR; MO $0-$7.40 (Tier 2) YERVOY

MO $0-$7.40 (Tier 2) YONDELIS

PAR; MO $0-$7.40 (Tier 2) ZALTRAP

MO $0-$7.40 (Tier 2) ZANOSAR

PAR; MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) ZELBORAF

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) ZOLINZA

B/D PAR; MO $0-$7.40 (Tier 2) ZORTRESS




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PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) ZYDELIG

PAR; MO; QLL (150 per 30 days) $0-$7.40 (Tier 2) ZYKADIA

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) ZYTIGA

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS

ST; MO $0-$7.40 (Tier 2) APTIOM

PAR; MO; QLL (2400 per 30 days) $0-$7.40 (Tier 2) BANZEL ORAL SUSPENSION

PAR; MO; QLL (480 per 30 days) $0-$7.40 (Tier 2) BANZEL ORAL TABLET 200 MG

PAR; MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) BANZEL ORAL TABLET 400 MG

PAR $0-$7.40 (Tier 2) BRIVIACT INTRAVENOUS

PAR; QLL (600 per 30 days) $0-$7.40 (Tier 2) BRIVIACT ORAL SOLUTION

PAR; QLL (600 per 30 days) $0-$7.40 (Tier 2) BRIVIACT ORAL TABLET 10 MG

PAR; QLL (60 per 30 days) $0-$7.40 (Tier 2) BRIVIACT ORAL TABLET 100 MG, 75 MG



MO $0-$7.40 (Tier 2) carbamazepine oral capsule, er multiphase 12 hr

MO $0-$7.40 (Tier 2) carbamazepine oral suspension 100 mg/5 ml

$0-$7.40 (Tier 2) carbamazepine oral suspension 200 mg/10 ml

MO $0-$7.40 (Tier 2) carbamazepine oral tablet

$0-$7.40 (Tier 2) carbamazepine oral tablet extended release 12 hr 100 mg

MO $0-$7.40 (Tier 2) carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg

MO $0-$7.40 (Tier 2) carbamazepine oral tablet,chewable

MO $0-$7.40 (Tier 2) CELONTIN ORAL CAPSULE 300 MG

PAR; MO; QLL (1200 per 30 days) $0-$7.40 (Tier 2) clonazepam oral tablet 0.5 mg

PAR; MO; QLL (600 per 30 days) $0-$7.40 (Tier 2) clonazepam oral tablet 1 mg

PAR; MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) clonazepam oral tablet 2 mg

PAR; MO; QLL (4800 per 30 days) $0-$7.40 (Tier 2) clonazepam oral tablet,disintegrating 0.125 mg




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PAR; MO; QLL (600 per 30 days) $0-$7.40 (Tier 2) clonazepam oral tablet,disintegrating 1 mg

PAR; MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) clonazepam oral tablet,disintegrating 2 mg

MO $0-$7.40 (Tier 2) diazepam rectal kit 12.5-15-17.5-20 mg

MO; QLL (2 per 2 days) $0-$7.40 (Tier 2) diazepam rectal kit 2.5 mg, 5-7.5-10 mg

MO $0-$7.40 (Tier 2) DILANTIN EXTENDED ORAL CAPSULES

MO $0-$7.40 (Tier 2) DILANTIN INFATABS

MO $0-$7.40 (Tier 2) DILANTIN ORAL CAPSULES 30 MG

MO $0-$7.40 (Tier 2) divalproex

MO $0-$7.40 (Tier 2) epitol

MO; QLL (480 per 30 days) $0-$7.40 (Tier 2) EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG



MO $0-$7.40 (Tier 2) ethosuximide

MO $0-$7.40 (Tier 2) felbamate

MO $0-$7.40 (Tier 2) fosphenytoin

QLL (720 per 30 days) $0-$7.40 (Tier 2) FYCOMPA ORAL SUSPENSION

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) FYCOMPA ORAL TABLET 10 MG, 12 MG

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) FYCOMPA ORAL TABLET 2 MG




MO; QLL (1080 per 30 days) $0 (Tier 1) gabapentin oral capsule 100 mg



MO; QLL (2160 per 30 days) $0-$7.40 (Tier 2) gabapentin oral solution 250 mg/5 ml




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QLL (2160 per 30 days) $0-$7.40 (Tier 2) GABAPENTIN ORAL SOLUTION 250 MG/5 ML (5 ML), 300 MG/6 ML (6 ML)

MO; QLL (180 per 30 days) $0 (Tier 1) gabapentin oral tablet 600 mg

MO; QLL (135 per 30 days) $0 (Tier 1) gabapentin oral tablet 800 mg

MO $0-$7.40 (Tier 2) GABITRIL ORAL TABLET 12 MG, 16 MG

MO $0-$7.40 (Tier 2) lamotrigine oral tablet

MO $0-$7.40 (Tier 2) lamotrigine oral tablet, chewable dispersible

$0-$7.40 (Tier 2) levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml

MO $0-$7.40 (Tier 2) levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml

MO $0-$7.40 (Tier 2) levetiracetam intravenous

MO $0-$7.40 (Tier 2) levetiracetam oral solution 100 mg/ml

$0-$7.40 (Tier 2) LEVETIRACETAM ORAL SOLUTION 500 MG/ 5 ML (5 ML)

MO $0-$7.40 (Tier 2) levetiracetam oral tablet

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) levetiracetam oral tablet extended release 24 hr 500 mg

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) levetiracetam oral tablet extended release 24 hr 750 mg

PAR; MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) LYRICA ORAL CAPSULE 100 MG



PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) LYRICA ORAL CAPSULE 225 MG, 300 MG




PAR; MO; QLL (900 per 30 days) $0-$7.40 (Tier 2) LYRICA ORAL SOLUTION

PAR; MO; QLL (480 per 30 days) $0-$7.40 (Tier 2) ONFI ORAL SUSPENSION

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) ONFI ORAL TABLET 10 MG




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PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) ONFI ORAL TABLET 20 MG

MO $0-$7.40 (Tier 2) oxcarbazepine

MO; QLL (480 per 30 days) $0-$7.40 (Tier 2) OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG



MO $0-$7.40 (Tier 2) PEGANONE

PAR; MO; QLL (3000 per 30 days) $0-$7.40 (Tier 2) phenobarbital oral elixir

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) phenobarbital oral tablet 100 mg


PAR; MO; QLL (741 per 30 days) $0-$7.40 (Tier 2) phenobarbital oral tablet 16.2 mg






MO $0-$7.40 (Tier 2) PHENYTEK

$0-$7.40 (Tier 2) PHENYTOIN ORAL SUSPENSION 100 MG/4 ML

MO $0-$7.40 (Tier 2) phenytoin oral suspension 125 mg/5 ml

MO $0-$7.40 (Tier 2) phenytoin oral tablet,chewable

MO $0-$7.40 (Tier 2) phenytoin sodium extended

MO $0-$7.40 (Tier 2) phenytoin sodium intravenous solution

$0-$7.40 (Tier 2) phenytoin sodium intravenous syringe

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG

MO; QLL (270 per 30 days) $0-$7.40 (Tier 2) POTIGA ORAL TABLET 50 MG

MO $0-$7.40 (Tier 2) primidone




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$0-$7.40 (Tier 2) roweepra

PAR; MO; LA; QLL (180 per 30 days) $0-$7.40 (Tier 2) SABRIL

PAR; QLL (60 per 30 days) $0-$7.40 (Tier 2) SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG

PAR; QLL (120 per 30 days) $0-$7.40 (Tier 2) SPRITAM ORAL TABLET FOR SUSPENSION 750 MG

MO $0-$7.40 (Tier 2) tiagabine

PAR; MO $0-$7.40 (Tier 2) topiramate oral capsule, sprinkle

PAR; MO; QLL (480 per 30 days) $0-$7.40 (Tier 2) topiramate oral tablet 100 mg




MO $0-$7.40 (Tier 2) valproate sodium

MO $0-$7.40 (Tier 2) valproic acid

MO $0-$7.40 (Tier 2) valproic acid (as sodium salt) oral solution 250 mg/ 5 ml

$0-$7.40 (Tier 2) VALPROIC ACID (AS SODIUM SALT) ORAL SOLUTION 250 MG/5 ML (5 ML), 500 MG/10 ML (10 ML)

QLL (1200 per 30 days) $0-$7.40 (Tier 2) VIMPAT INTRAVENOUS

MO; QLL (1200 per 30 days) $0-$7.40 (Tier 2) VIMPAT ORAL SOLUTION

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) VIMPAT ORAL TABLET 100 MG




MO $0-$7.40 (Tier 2) zonisamide

ANTIPARKINSONISM AGENTS PAR; MO; LA $0-$7.40 (Tier 2) APOKYN

MO $0-$7.40 (Tier 2) AZILECT

PAR; MO $0-$7.40 (Tier 2) benztropine oral




de clase)


MO $0-$7.40 (Tier 2) bromocriptine

MO $0-$7.40 (Tier 2) carbidopa-levodopa

MO $0-$7.40 (Tier 2) entacapone

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) NEUPRO

MO $0-$7.40 (Tier 2) pramipexole oral tablet

MO $0-$7.40 (Tier 2) ropinirole oral tablet

MO $0-$7.40 (Tier 2) selegiline hcl

MO $0-$7.40 (Tier 2) tolcapone

MIGRAINE / CLUSTER HEADACHE THERAPY PAR; MO $0-$7.40 (Tier 2) dihydroergotamine injection

MO $0-$7.40 (Tier 2) ERGOMAR

MO; QLL (12 per 30 days) $0-$7.40 (Tier 2) rizatriptan

MO; QLL (9 per 30 days) $0-$7.40 (Tier 2) sumatriptan succinate oral

MO; QLL (4 per 30 days) $0-$7.40 (Tier 2) sumatriptan succinate subcutaneous cartridge

MO; QLL (4 per 30 days) $0-$7.40 (Tier 2) sumatriptan succinate subcutaneous pen injector

MO; QLL (4 per 30 days) $0-$7.40 (Tier 2) sumatriptan succinate subcutaneous solution

QLL (4 per 30 days) $0-$7.40 (Tier 2) sumatriptan succinate subcutaneous syringe 6 mg/ 0.5 ml

MO; QLL (9 per 30 days) $0-$7.40 (Tier 2) zolmitriptan

MO; QLL (6 per 30 days) $0-$7.40 (Tier 2) ZOMIG NASAL

MISCELLANEOUS NEUROLOGICAL THERAPY PAR; MO; LA; QLL (60 per 30 days) $0-$7.40 (Tier 2) AMPYRA

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML

PAR; MO; QLL (12 per 28 days) $0-$7.40 (Tier 2) COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) donepezil oral tablet 10 mg, 5 mg

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) donepezil oral tablet,disintegrating

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) galantamine oral capsule,ext rel. pellets 24 hr




de clase)


MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) galantamine oral solution

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) galantamine oral tablet

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) GILENYA

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) GLATOPA

MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) memantine oral solution

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) memantine oral tablet 10 mg

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) memantine oral tablet 5 mg

MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) NAMENDA ORAL SOLUTION

MO; QLL (56 per 365 days) $0-$7.40 (Tier 2) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) NAMENDA XR ORAL CAPSULE,SPRINKLE, ER 24HR

MO $0-$7.40 (Tier 2) NAMZARIC

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) NUEDEXTA

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) rivastigmine

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) rivastigmine tartrate

PAR; MO $0-$7.40 (Tier 2) TECFIDERA

PAR; MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) tetrabenazine oral tablet 12.5 mg

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) tetrabenazine oral tablet 25 mg

PAR; MO; LA $0-$7.40 (Tier 2) TYSABRI

PAR; MO; LA; QLL (240 per 30 days) $0-$7.40 (Tier 2) XENAZINE ORAL TABLET 12.5 MG

PAR; MO; LA; QLL (120 per 30 days) $0-$7.40 (Tier 2) XENAZINE ORAL TABLET 25 MG

MUSCLE RELAXANTS / ANTISPASMODIC THERAPY MO $0-$7.40 (Tier 2) baclofen

PAR; MO $0-$7.40 (Tier 2) cyclobenzaprine oral tablet

MO $0-$7.40 (Tier 2) dantrolene

MO $0-$7.40 (Tier 2) MESTINON ORAL SYRUP

MO $0-$7.40 (Tier 2) MESTINON TIMESPAN

MO $0-$7.40 (Tier 2) pyridostigmine bromide




de clase)


MO $0-$7.40 (Tier 2) tizanidine oral tablet

NARCOTIC ANALGESICS QLL (4500 per 30 days) $0-$7.40 (Tier 2) acetaminophen-codeine oral solution 120 mg-12

mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml

MO; QLL (4500 per 30 days) $0-$7.40 (Tier 2) acetaminophen-codeine oral solution 120-12 mg/5 ml

QLL (4500 per 30 days) $0-$7.40 (Tier 2) ACETAMINOPHEN-CODEINE ORAL SOLUTION 240 MG-24 MG /10 ML (10 ML)

MO; QLL (390 per 30 days) $0-$7.40 (Tier 2) acetaminophen-codeine oral tablet 300-15 mg



MO; QLL (150 per 30 days) $0-$7.40 (Tier 2) buprenorphine hcl injection solution

QLL (150 per 30 days) $0-$7.40 (Tier 2) buprenorphine hcl injection syringe

PAR; MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) buprenorphine hcl sublingual tablet 2 mg

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) buprenorphine hcl sublingual tablet 8 mg

PAR; MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) BUTALBITAL COMPOUND W/CODEINE

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) duramorph (pf) injection solution 0.5 mg/ml

QLL (180 per 30 days) $0-$7.40 (Tier 2) duramorph (pf) injection solution 1 mg/ml

MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) fentanyl citrate

ST; MO; QLL (15 per 30 days) $0-$7.40 (Tier 2) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

QLL (2700 per 30 days) $0-$7.40 (Tier 2) HYDROCODONE-ACETAMINOPHEN ORAL SOLUTION 2.5-167 MG/5 ML

MO; QLL (2700 per 30 days) $0-$7.40 (Tier 2) hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

MO; QLL (390 per 30 days) $0-$7.40 (Tier 2) hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg

MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg




de clase)


MO; QLL (480 per 30 days) $0-$7.40 (Tier 2) hydrocodone-ibuprofen oral tablet 10-200 mg, 5- 200 mg, 7.5-200 mg

MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) hydromorphone oral tablet 2 mg, 4 mg

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) hydromorphone oral tablet 8 mg

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) levorphanol tartrate

QLL (150 per 30 days) $0-$7.40 (Tier 2) methadone injection

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) METHADONE INTENSOL

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) methadone oral concentrate

MO; QLL (900 per 30 days) $0-$7.40 (Tier 2) methadone oral solution 10 mg/5 ml

MO; QLL (1800 per 30 days) $0-$7.40 (Tier 2) methadone oral solution 5 mg/5 ml

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) methadone oral tablet 10 mg

MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) methadone oral tablet 5 mg

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) METHADOSE ORAL CONCENTRATE

$0-$7.40 (Tier 2) morphine (pf) injection solution 0.5 mg/ml

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) morphine (pf) injection solution 1 mg/ml

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) MORPHINE (PF) INTRAVENOUS PATIENT CONTROL.ANALGESIA SOLN 150 MG/30 ML

QLL (180 per 30 days) $0-$7.40 (Tier 2) MORPHINE (PF) INTRAVENOUS PATIENT CONTROL.ANALGESIA SOLN 30 MG/30 ML

MO; QLL (270 per 30 days) $0-$7.40 (Tier 2) morphine concentrate oral solution

QLL (120 per 30 days) $0-$7.40 (Tier 2) MORPHINE INTRAVENOUS CARTRIDGE 10 MG/ML, 2 MG/ML, 4 MG/ML, 8 MG/ML

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) MORPHINE INTRAVENOUS SOLUTION 10 MG/ML, 50 MG/ML

QLL (120 per 30 days) $0-$7.40 (Tier 2) MORPHINE INTRAVENOUS SOLUTION 100 MG/4 ML, 25 MG/ML, 250 MG/10 ML

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) MORPHINE INTRAVENOUS SOLUTION 4 MG/ ML, 8 MG/ML

QLL (120 per 30 days) $0-$7.40 (Tier 2) morphine intravenous syringe 2 mg/ml, 4 mg/ml

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) morphine oral capsule, er multiphase 24 hr 120 mg, 75 mg, 90 mg




de clase)


MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) morphine oral capsule,extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg

MO; QLL (1350 per 30 days) $0-$7.40 (Tier 2) morphine oral solution 20 mg/5 ml (4 mg/ml)

MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) morphine oral tablet 15 mg

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) morphine oral tablet 30 mg

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) morphine oral tablet extended release 200 mg

MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) oxycodone oral capsule

MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) oxycodone oral concentrate

MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) oxycodone oral tablet 10 mg, 5 mg

MO; QLL (540 per 30 days) $0-$7.40 (Tier 2) oxycodone oral tablet 15 mg

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) oxycodone oral tablet 20 mg, 30 mg

QLL (1800 per 30 days) $0-$7.40 (Tier 2) oxycodone-acetaminophen oral solution

MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) oxycodone-aspirin

NON-NARCOTIC ANALGESICS MO; [*] $0 (Tier 4) 8 HOUR PAIN RELIEVER

MO; [*] $0 (Tier 4) ACEPHEN RECTAL SUPPOSITORY 120 MG, 650 MG

[*] $0 (Tier 4) ACEPHEN RECTAL SUPPOSITORY 325 MG

[*] $0 (Tier 4) ACETA-GESIC

[*] $0 (Tier 4) ACETADRYL

[*] $0 (Tier 4) ACETAMINOPHEN EXTRA STRENGTH

[*] $0 (Tier 4) acetaminophen oral drops,suspension

[*] $0 (Tier 4) acetaminophen oral elixir

[*] $0 (Tier 4) acetaminophen oral liquid 160 mg/5 ml




de clase)


MO; [*] $0 (Tier 4) acetaminophen oral solution 160 mg/5 ml (5 ml)

[*] $0 (Tier 4) acetaminophen oral solution 325 mg/10.15 ml

[*] $0 (Tier 4) acetaminophen oral suspension 160 mg/5 ml

MO; [*] $0 (Tier 4) acetaminophen oral tablet

[*] $0 (Tier 4) acetaminophen oral tablet extended release

[*] $0 (Tier 4) acetaminophen oral tablet,disintegrating

[*] $0 (Tier 4) ACETAMINOPHEN PAIN RELIEF

[*] $0 (Tier 4) ACETAMINOPHEN PM

[*] $0 (Tier 4) ACETAMINOPHEN PM EXTRA STR

[*] $0 (Tier 4) acetaminophen rectal

MO; [*] $0 (Tier 4) ADVIL

MO; [*] $0 (Tier 4) ADVIL LIQUI-GEL

[*] $0 (Tier 4) ADVIL MIGRAINE

MO; [*] $0 (Tier 4) ADVIL PM

[*] $0 (Tier 4) ADVIL PM LIQUI-GELS

[*] $0 (Tier 4) ALKA-SELTZER ORIGINAL

[*] $0 (Tier 4) ALL DAY PAIN RELIEF

MO; [*] $0 (Tier 4) ALL DAY RELIEF

[*] $0 (Tier 4) ANTACID AND PAIN RELIEF

[*] $0 (Tier 4) ARTHRITIS PAIN RELIEF (ACETAM)

[*] $0 (Tier 4) ARTHRITIS PAIN RELIEVER

[*] $0 (Tier 4) ASPIR-81

MO; [*] $0 (Tier 4) ASPIR-LOW

MO; [*] $0 (Tier 4) ASPIR-TRIN

[*] $0 (Tier 4) ASPIRIN CHILDRENS

MO; [*] $0 (Tier 4) ASPIRIN LOW DOSE

MO; [*] $0 (Tier 4) aspirin oral tablet

MO; [*] $0 (Tier 4) aspirin oral tablet,chewable




de clase)


MO; [*] $0 (Tier 4) aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg

[*] $0 (Tier 4) ATHENOL

MO; [*] $0 (Tier 4) BAYER ASPIRIN

[*] $0 (Tier 4) BETATEMP

PAR; MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) buprenorphine-naloxone sublingual tablet 2-0.5 mg

PAR; MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) buprenorphine-naloxone sublingual tablet 8-2 mg

MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) butorphanol tartrate injection solution 1 mg/ml

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) butorphanol tartrate injection solution 2 mg/ml

MO; QLL (5 per 28 days) $0-$7.40 (Tier 2) butorphanol tartrate nasal

[*] $0 (Tier 4) CHILD ASPIRIN

[*] $0 (Tier 4) CHILD IBUPROFEN

[*] $0 (Tier 4) CHILD PAIN REL-FEVER REDUCER

[*] $0 (Tier 4) CHILDREN'S ACETAMINOPHEN ORAL SUSPENSION

[*] $0 (Tier 4) CHILDREN'S ACETAMINOPHEN ORAL TABLET,CHEWABLE

[*] $0 (Tier 4) CHILDREN'S ACETAMINOPHEN ORAL TABLET,DISINTEGRATING

MO; [*] $0 (Tier 4) CHILDREN'S ADVIL

MO; [*] $0 (Tier 4) CHILDREN'S ASPIRIN

[*] $0 (Tier 4) CHILDREN'S EASY-MELTS

[*] $0 (Tier 4) CHILDREN'S FEVER REDUCING

MO; [*] $0 (Tier 4) CHILDREN'S IBUPROFEN

[*] $0 (Tier 4) CHILDREN'S MAPAP

[*] $0 (Tier 4) CHILDREN'S MOTRIN

[*] $0 (Tier 4) CHILDREN'S NON-ASPIRIN ORAL SUSPENSION

[*] $0 (Tier 4) CHILDREN'S NON-ASPIRIN ORAL TABLET, CHEWABLE




de clase)


[*] $0 (Tier 4) CHILDREN'S NON-ASPIRIN PAIN

[*] $0 (Tier 4) CHILDREN'S PAIN RELIEF ORAL SUSPENSION

[*] $0 (Tier 4) CHILDREN'S PAIN RELIEVER ORAL SUSPENSION

[*] $0 (Tier 4) CHILDREN'S PAIN RELIEVER ORAL TABLET, DISINTEGRATING

MO; [*] $0 (Tier 4) CHILDREN'S PAIN-FEVER RELIEF ORAL LIQUID

MO; [*] $0 (Tier 4) CHILDREN'S PAIN-FEVER RELIEF ORAL SUSPENSION

MO; [*] $0 (Tier 4) CHILDREN'S PAIN-FEVER RELIEF ORAL TABLET,CHEWABLE

[*] $0 (Tier 4) CHILDREN'S PAIN-FEVER RELIEF ORAL TABLET,DISINTEGRATING

[*] $0 (Tier 4) CHILDREN'S PROFEN IB

MO; [*] $0 (Tier 4) CHILDREN'S Q-PAP

[*] $0 (Tier 4) CHILDREN'S SILAPAP

[*] $0 (Tier 4) CHILDREN'S TACTINAL

[*] $0 (Tier 4) CORICIDIN HBP COLD AND FLU

MO $0-$7.40 (Tier 2) diclofenac potassium

MO $0-$7.40 (Tier 2) diclofenac sodium oral

QLL (1000 per 30 days) $0-$7.40 (Tier 2) diclofenac sodium topical gel 1 %

MO $0-$7.40 (Tier 2) diflunisal

[*] $0 (Tier 4) diphenhydramine-acetaminophen

[*] $0 (Tier 4) E.C. PRIN

[*] $0 (Tier 4) EAZZZE THE PAIN

MO; [*] $0 (Tier 4) ECOTRIN

MO; [*] $0 (Tier 4) ECOTRIN LOW STRENGTH

[*] $0 (Tier 4) ED-APAP

[*] $0 (Tier 4) EFFERVES PAIN RELIEF ANTACID




de clase)


[*] $0 (Tier 4) EFFERVESCENT PAIN RELIEF ORAL TABLET, EFFERVESCENT 325-1,916-1,000 MG

[*] $0 (Tier 4) ENTERIC COATED ASPIRIN

MO $0-$7.40 (Tier 2) etodolac oral capsule 200 mg

MO $0-$7.40 (Tier 2) etodolac oral tablet

MO $0-$7.40 (Tier 2) etodolac oral tablet extended release 24 hr

MO; [*] $0 (Tier 4) EXCEDRIN EXTRA STRENGTH

MO; [*] $0 (Tier 4) EXCEDRIN MIGRAINE

MO $0-$7.40 (Tier 2) fenoprofen oral tablet

[*] $0 (Tier 4) FEVER REDUCER

[*] $0 (Tier 4) FEVER REDUCER AN PAIN RELIEVER ORAL SUSPENSION

[*] $0 (Tier 4) FEVERALL

[*] $0 (Tier 4) FLANAX (NAPROXEN)

MO $0-$7.40 (Tier 2) flurbiprofen

[*] $0 (Tier 4) HEADACHE PM

[*] $0 (Tier 4) HEADACHE RELIEF (ASA-ACET-CAF)

[*] $0 (Tier 4) I-PRIN

[*] $0 (Tier 4) IBU-DROPS

[*] $0 (Tier 4) IBUPROFEN IB

[*] $0 (Tier 4) IBUPROFEN JR STRENGTH

[*] $0 (Tier 4) ibuprofen oral capsule

[*] $0 (Tier 4) ibuprofen oral drops,suspension

MO $0-$7.40 (Tier 2) ibuprofen oral suspension

[*] $0 (Tier 4) ibuprofen oral tablet 100 mg

MO; [*] $0 (Tier 4) ibuprofen oral tablet 200 mg

MO $0-$7.40 (Tier 2) ibuprofen oral tablet 400 mg, 600 mg, 800 mg

[*] $0 (Tier 4) IBUPROFEN PM ORAL TABLET

[*] $0 (Tier 4) ibuprofen-diphenhydramine cit




de clase)


[*] $0 (Tier 4) INFANT FEVER REDUCER-PAIN RELF

[*] $0 (Tier 4) INFANT PAIN RELIEVER

[*] $0 (Tier 4) INFANT'S IBUPROFEN

[*] $0 (Tier 4) INFANT'S NON-ASPIRIN ORAL DROPS

[*] $0 (Tier 4) INFANT'S NON-ASPIRIN ORAL DROPS, SUSPENSION 100 MG/ML

[*] $0 (Tier 4) INFANT'S PAIN RELIEF ORAL DROPS, SUSPENSION 80 MG/0.8 ML

[*] $0 (Tier 4) INFANT'S PAIN RELIEF ORAL SUSPENSION

[*] $0 (Tier 4) INFANT'S PAIN RELIEVER

[*] $0 (Tier 4) INFANTS IBU-DROPS

[*] $0 (Tier 4) INFANTS PROFENIB

[*] $0 (Tier 4) INFANTS' PAIN AND FEVER

[*] $0 (Tier 4) INFANTS' PAIN RELIEF

[*] $0 (Tier 4) JR. ACETAMINOPHEN

[*] $0 (Tier 4) JR. STR NON-ASPIRIN PAIN

[*] $0 (Tier 4) JR. STRENGTH PAIN RELIEVER

MO; [*] $0 (Tier 4) JUNIOR MAPAP

[*] $0 (Tier 4) LITE COAT ASPIRIN

[*] $0 (Tier 4) LITTLE REMEDIES FEVER AND PAIN

MO; [*] $0 (Tier 4) MAPAP (ACETAMINOPHEN) ORAL CAPSULE

[*] $0 (Tier 4) MAPAP (ACETAMINOPHEN) ORAL DROPS, SUSPENSION

MO; [*] $0 (Tier 4) MAPAP (ACETAMINOPHEN) ORAL LIQUID

[*] $0 (Tier 4) MAPAP (ACETAMINOPHEN) ORAL SUSPENSION

MO; [*] $0 (Tier 4) MAPAP (ACETAMINOPHEN) ORAL TABLET

MO; [*] $0 (Tier 4) MAPAP (ACETAMINOPHEN) ORAL TABLET, CHEWABLE

MO; [*] $0 (Tier 4) MAPAP ARTHRITIS PAIN




de clase)


MO; [*] $0 (Tier 4) MAPAP EXTRA STRENGTH

MO; [*] $0 (Tier 4) MAPAP PM

[*] $0 (Tier 4) MASOPHEN

MO $0-$7.40 (Tier 2) meclofenamate oral

[*] $0 (Tier 4) MEDIPROXEN

MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) meloxicam oral suspension

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) meloxicam oral tablet

[*] $0 (Tier 4) MIGRAINE FORMULA

[*] $0 (Tier 4) MIGRAINE RELIEF

MO; [*] $0 (Tier 4) MOTRIN IB

[*] $0 (Tier 4) MOTRIN PM

MO $0-$7.40 (Tier 2) nabumetone

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) nalbuphine injection solution 10 mg/ml

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) nalbuphine injection solution 20 mg/ml

MO $0-$7.40 (Tier 2) naloxone

MO $0-$7.40 (Tier 2) naltrexone

MO $0-$7.40 (Tier 2) naproxen

[*] $0 (Tier 4) naproxen sodium oral capsule

MO; [*] $0 (Tier 4) naproxen sodium oral tablet 220 mg

MO $0-$7.40 (Tier 2) naproxen sodium oral tablet 275 mg, 550 mg

[*] $0 (Tier 4) NIGHT TIME PAIN MEDICINE

[*] $0 (Tier 4) NON-ASPIRIN CHILDREN'S

[*] $0 (Tier 4) NON-ASPIRIN CHILDRENS

[*] $0 (Tier 4) NON-ASPIRIN EXTRA STRENGTH ORAL LIQUID

[*] $0 (Tier 4) NON-ASPIRIN EXTRA STRENGTH ORAL TABLET

[*] $0 (Tier 4) NON-ASPIRIN NIGHTIME

[*] $0 (Tier 4) NON-ASPIRIN ORAL ELIXIR




de clase)


[*] $0 (Tier 4) NON-ASPIRIN ORAL SUSPENSION

[*] $0 (Tier 4) NON-ASPIRIN ORAL TABLET

[*] $0 (Tier 4) NON-ASPIRIN ORAL TABLET,CHEWABLE 80 MG

[*] $0 (Tier 4) NON-ASPIRIN PAIN RELIEF ORAL TABLET 500 MG

[*] $0 (Tier 4) NON-ASPIRIN PAIN RELIEF PM

[*] $0 (Tier 4) NON-ASPIRIN PM

MO $0-$7.40 (Tier 2) oxaprozin

MO; [*] $0 (Tier 4) PAIN AND FEVER

[*] $0 (Tier 4) PAIN RELIEF (ACETAMIN-ASP-CAF)

[*] $0 (Tier 4) PAIN RELIEF ADULT

[*] $0 (Tier 4) PAIN RELIEF EXTRA STRENGTH

[*] $0 (Tier 4) PAIN RELIEF ORAL LIQUID

[*] $0 (Tier 4) PAIN RELIEF ORAL TABLET

[*] $0 (Tier 4) PAIN RELIEF ORAL TABLET EXTENDED RELEASE

[*] $0 (Tier 4) PAIN RELIEF PM

[*] $0 (Tier 4) PAIN RELIEF PM RAPID RELEASE

[*] $0 (Tier 4) PAIN RELIEF REGULAR STRENGTH

[*] $0 (Tier 4) PAIN RELIEVER

[*] $0 (Tier 4) PAIN RELIEVER (ACETAM-ASPIRIN)

[*] $0 (Tier 4) PAIN RELIEVER EXTRA STRENGTH

MO; [*] $0 (Tier 4) PAIN RELIEVER PLUS

[*] $0 (Tier 4) PAIN RELIEVER PM EX-STRENGTH

[*] $0 (Tier 4) PAIN RELIEVER PM ORAL TABLET 25-500 MG

[*] $0 (Tier 4) PAIN-OFF

[*] $0 (Tier 4) PAMPRIN MAX

[*] $0 (Tier 4) PEDIACARE FEVER REDUCER




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[*] $0 (Tier 4) PERCOGESIC

[*] $0 (Tier 4) PHARBETOL

MO $0-$7.40 (Tier 2) piroxicam

[*] $0 (Tier 4) PROVIL

MO; [*] $0 (Tier 4) Q-PAP EXTRA STRENGTH

MO; [*] $0 (Tier 4) Q-PAP ORAL DROPS

MO; [*] $0 (Tier 4) Q-PAP ORAL LIQUID

[*] $0 (Tier 4) Q-PAP ORAL TABLET 325 MG

MO; [*] $0 (Tier 4) Q-PAP ORAL TABLET 500 MG

[*] $0 (Tier 4) SHAKE THAT ACHE

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) SUBOXONE SUBLINGUAL FILM 12-3 MG

PAR; MO; QLL (360 per 30 days) $0-$7.40 (Tier 2) SUBOXONE SUBLINGUAL FILM 2-0.5 MG



MO $0-$7.40 (Tier 2) sulindac oral

[*] $0 (Tier 4) SUPER PAIN RELIEF

[*] $0 (Tier 4) TACTINAL

[*] $0 (Tier 4) TACTINAL EXTRA STRENGTH

[*] $0 (Tier 4) TENSION HEADACHE

[*] $0 (Tier 4) TENSION HEADACHE PAIN RELIEVER

MO $0-$7.40 (Tier 2) tolmetin

MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) tramadol oral tablet

MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) tramadol-acetaminophen

[*] $0 (Tier 4) TYLOPHEN

MO; QLL (1000 per 30 days) $0-$7.40 (Tier 2) VOLTAREN GEL TOPICAL GEL 1 %

[*] $0 (Tier 4) WAL-PROFEN

[*] $0 (Tier 4) WAL-PROXEN

PSYCHOTHERAPEUTIC DRUGS MO; QLL (1 per 28 days) $0-$7.40 (Tier 2) ABILIFY MAINTENA




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$0-$7.40 (Tier 2) ADASUVE

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) alprazolam oral tablet

PAR; MO $0-$7.40 (Tier 2) amitriptyline

MO $0-$7.40 (Tier 2) amoxapine

PAR; MO; QLL (900 per 30 days) $0 (Tier 1) aripiprazole oral solution

PAR; MO; QLL (90 per 30 days) $0 (Tier 1) aripiprazole oral tablet 10 mg



PAR; MO; QLL (30 per 30 days) $0 (Tier 1) aripiprazole oral tablet 20 mg, 30 mg


PAR; MO; QLL (90 per 30 days) $0 (Tier 1) aripiprazole oral tablet,disintegrating 10 mg

PAR; MO; QLL (60 per 30 days) $0 (Tier 1) aripiprazole oral tablet,disintegrating 15 mg

PAR; MO; QLL (1.6 per 30 days) $0-$7.40 (Tier 2) ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 441 MG/1.6 ML



MO; QLL (135 per 30 days) $0-$7.40 (Tier 2) bupropion hcl oral tablet 100 mg

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) bupropion hcl oral tablet 75 mg

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) bupropion hcl oral tablet extended release 100 mg

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) bupropion hcl oral tablet extended release 150 mg, 200 mg

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) bupropion hcl oral tablet extended release 24 hr 150 mg

MO; QLL (45 per 30 days) $0-$7.40 (Tier 2) bupropion hcl oral tablet extended release 24 hr 300 mg

MO $0-$7.40 (Tier 2) buspirone

PAR; MO $0-$7.40 (Tier 2) chlorpromazine

MO; QLL (600 per 30 days) $0-$7.40 (Tier 2) citalopram oral solution




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MO; QLL (120 per 30 days) $0 (Tier 1) citalopram oral tablet 10 mg



PAR; MO $0-$7.40 (Tier 2) clomipramine

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) clorazepate dipotassium

MO; QLL (270 per 30 days) $0 (Tier 1) clozapine oral tablet 100 mg




QLL (270 per 30 days) $0 (Tier 1) clozapine oral tablet,disintegrating 100 mg

QLL (2160 per 30 days) $0 (Tier 1) clozapine oral tablet,disintegrating 12.5 mg




MO $0-$7.40 (Tier 2) desipramine oral

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG

MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG

MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG

QLL (120 per 30 days) $0-$7.40 (Tier 2) desvenlafaxine oral tablet extended release 24hr 100 mg

QLL (240 per 30 days) $0-$7.40 (Tier 2) desvenlafaxine oral tablet extended release 24hr 50 mg

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) dextroamphetamine oral capsule, extended release 10 mg, 5 mg

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) dextroamphetamine oral capsule, extended release 15 mg




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MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) dextroamphetamine oral tablet 10 mg

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) dextroamphetamine oral tablet 5 mg

PAR; MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) dextroamphetamine-amphetamine oral tablet 30 mg

$0-$7.40 (Tier 2) diazepam injection solution

MO $0-$7.40 (Tier 2) diazepam injection syringe

PAR; MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) diazepam intensol

PAR; MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) diazepam oral concentrate

PAR; MO; QLL (1200 per 30 days) $0-$7.40 (Tier 2) diazepam oral solution 5 mg/5 ml (1 mg/ml)

PAR; QLL (1200 per 30 days) $0-$7.40 (Tier 2) DIAZEPAM ORAL SOLUTION 5 MG/5 ML (1 MG/ML, 5 ML)

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) diazepam oral tablet 10 mg



PAR; MO $0-$7.40 (Tier 2) doxepin oral

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) duloxetine oral capsule,delayed release(dr/ec) 20 mg




PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) EMSAM

PAR; MO $0-$7.40 (Tier 2) ergoloid

MO; QLL (600 per 30 days) $0-$7.40 (Tier 2) escitalopram oxalate oral solution

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) escitalopram oxalate oral tablet 10 mg






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ST; MO; QLL (720 per 30 days) $0-$7.40 (Tier 2) FANAPT ORAL TABLET 1 MG

ST; QLL (72 per 30 days) $0-$7.40 (Tier 2) FANAPT ORAL TABLET 10 MG






ST; MO; QLL (16 per 365 days) $0-$7.40 (Tier 2) FANAPT ORAL TABLETS,DOSE PACK

PAR; MO; QLL (56 per 365 days) $0-$7.40 (Tier 2) FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG

PAR; MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG

PAR; MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG

MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) fluoxetine oral capsule 10 mg



MO; QLL (600 per 30 days) $0-$7.40 (Tier 2) fluoxetine oral solution

MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) fluoxetine oral tablet 10 mg

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) fluoxetine oral tablet 20 mg

MO $0 (Tier 1) fluphenazine decanoate

MO $0 (Tier 1) fluphenazine hcl

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) fluvoxamine oral tablet 100 mg



MO $0-$7.40 (Tier 2) GEODON INTRAMUSCULAR

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) guanfacine oral tablet extended release 24 hr

MO $0-$7.40 (Tier 2) guanidine




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MO $0 (Tier 1) haloperidol

MO $0 (Tier 1) haloperidol decanoate

MO $0 (Tier 1) haloperidol lactate

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) HETLIOZ

PAR; MO $0-$7.40 (Tier 2) imipramine hcl

PAR; MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG



MO; QLL (2 per 28 days) $0-$7.40 (Tier 2) INVEGA SUSTENNA

MO; QLL (0.875 per 90 days) $0-$7.40 (Tier 2) INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML




MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG

MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) LATUDA ORAL TABLET 120 MG





MO $0 (Tier 1) lithium carbonate




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MO $0 (Tier 1) lithium citrate oral solution 8 meq/5 ml

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) lorazepam oral tablet

MO $0-$7.40 (Tier 2) loxapine succinate

MO; QLL (270 per 30 days) $0-$7.40 (Tier 2) maprotiline oral tablet 25 mg

MO; QLL (135 per 30 days) $0-$7.40 (Tier 2) maprotiline oral tablet 50 mg

MO $0-$7.40 (Tier 2) maprotiline oral tablet 75 mg

MO $0-$7.40 (Tier 2) MARPLAN

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) methylphenidate oral tablet

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) mirtazapine oral tablet 15 mg



MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) mirtazapine oral tablet 7.5 mg

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) mirtazapine oral tablet,disintegrating 15 mg



PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) modafinil oral tablet 100 mg

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) modafinil oral tablet 200 mg

$0-$7.40 (Tier 2) molindone

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) nefazodone oral tablet 100 mg





MO $0-$7.40 (Tier 2) nortriptyline

PAR; LA; QLL (60 per 30 days) $0-$7.40 (Tier 2) NUPLAZID

MO; QLL (60 per 30 days) $0 (Tier 1) olanzapine intramuscular

MO; QLL (60 per 30 days) $0 (Tier 1) olanzapine oral tablet 10 mg


MO; QLL (240 per 30 days) $0 (Tier 1) olanzapine oral tablet 2.5 mg




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MO; QLL (80 per 30 days) $0 (Tier 1) olanzapine oral tablet 7.5 mg

MO; QLL (60 per 30 days) $0 (Tier 1) olanzapine oral tablet,disintegrating 10 mg




MO $0-$7.40 (Tier 2) ORAP

PAR; MO; QLL (240 per 30 days) $0 (Tier 1) paliperidone oral tablet extended release 24hr 1.5 mg

PAR; MO; QLL (120 per 30 days) $0 (Tier 1) paliperidone oral tablet extended release 24hr 3 mg



MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) paroxetine hcl oral tablet 10 mg




MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) paroxetine hcl oral tablet extended release 24 hr 12.5 mg

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) paroxetine hcl oral tablet extended release 24 hr 25 mg

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) paroxetine hcl oral tablet extended release 24 hr 37.5 mg

MO; QLL (900 per 30 days) $0-$7.40 (Tier 2) PAXIL ORAL SUSPENSION

MO $0 (Tier 1) perphenazine

MO $0 (Tier 1) phenelzine

MO $0-$7.40 (Tier 2) pimozide

MO $0-$7.40 (Tier 2) protriptyline




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MO; QLL (240 per 30 days) $0 (Tier 1) quetiapine oral tablet 100 mg






PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) REXULTI ORAL TABLET 3 MG, 4 MG

MO; QLL (2 per 28 days) $0-$7.40 (Tier 2) RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/ 2 ML

MO $0-$7.40 (Tier 2) RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML

MO; QLL (480 per 30 days) $0 (Tier 1) risperidone oral solution

MO; QLL (1920 per 30 days) $0 (Tier 1) risperidone oral tablet 0.25 mg

MO; QLL (960 per 30 days) $0 (Tier 1) risperidone oral tablet 0.5 mg

MO; QLL (480 per 30 days) $0 (Tier 1) risperidone oral tablet 1 mg




MO; QLL (1920 per 30 days) $0 (Tier 1) risperidone oral tablet,disintegrating 0.25 mg

MO; QLL (960 per 30 days) $0 (Tier 1) risperidone oral tablet,disintegrating 0.5 mg

MO; QLL (480 per 30 days) $0 (Tier 1) risperidone oral tablet,disintegrating 1 mg




MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) ROZEREM

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG




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PAR; MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG

PAR; MO; QLL (150 per 30 days) $0-$7.40 (Tier 2) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG





MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) sertraline oral concentrate

MO; QLL (60 per 30 days) $0 (Tier 1) sertraline oral tablet 100 mg



PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG

PAR; MO $0-$7.40 (Tier 2) SURMONTIL

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) temazepam oral capsule 15 mg, 22.5 mg, 30 mg

PAR; MO $0 (Tier 1) thioridazine

MO $0 (Tier 1) thiothixene

MO $0-$7.40 (Tier 2) tranylcypromine

MO $0-$7.40 (Tier 2) trazodone

MO $0 (Tier 1) trifluoperazine

ST; QLL (60 per 30 days) $0-$7.40 (Tier 2) TRINTELLIX ORAL TABLET 10 MG





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MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) venlafaxine oral capsule,extended release 24hr 150 mg

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) venlafaxine oral capsule,extended release 24hr 37.5 mg

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) venlafaxine oral capsule,extended release 24hr 75 mg

MO; QLL (113 per 30 days) $0-$7.40 (Tier 2) venlafaxine oral tablet 100 mg


MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) venlafaxine oral tablet 37.5 mg



MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) venlafaxine oral tablet extended release 24hr 150 mg

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) venlafaxine oral tablet extended release 24hr 37.5 mg

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) venlafaxine oral tablet extended release 24hr 75 mg

QLL (600 per 30 days) $0-$7.40 (Tier 2) VERSACLOZ

ST; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) VIIBRYD ORAL TABLET 10 MG



ST; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)

PAR; QLL (30 per 30 days) $0-$7.40 (Tier 2) VRAYLAR ORAL CAPSULE

PAR; QLL (7 per 365 days) $0-$7.40 (Tier 2) VRAYLAR ORAL CAPSULE,DOSE PACK

PAR; MO; LA; QLL (540 per 30 days) $0-$7.40 (Tier 2) XYREM

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) zaleplon oral capsule 10 mg

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) zaleplon oral capsule 5 mg

PAR; MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) zenzedi oral tablet 10 mg

PAR; MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) zenzedi oral tablet 5 mg




de clase)


MO; QLL (240 per 30 days) $0 (Tier 1) ziprasidone hcl oral capsule 20 mg

MO; QLL (120 per 30 days) $0 (Tier 1) ziprasidone hcl oral capsule 40 mg

MO; QLL (60 per 30 days) $0 (Tier 1) ziprasidone hcl oral capsule 60 mg, 80 mg

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) zolpidem oral tablet

PAR; QLL (2 per 28 days) $0-$7.40 (Tier 2) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG

PAR; MO; QLL (2 per 28 days) $0-$7.40 (Tier 2) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG

CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS

B/D PAR; MO $0-$7.40 (Tier 2) amiodarone intravenous solution

B/D PAR $0-$7.40 (Tier 2) AMIODARONE INTRAVENOUS SYRINGE

MO $0-$7.40 (Tier 2) amiodarone oral

$0-$7.40 (Tier 2) dofetilide

MO $0-$7.40 (Tier 2) flecainide

MO $0-$7.40 (Tier 2) lidocaine (pf) intravenous solution

$0-$7.40 (Tier 2) LIDOCAINE (PF) INTRAVENOUS SYRINGE

MO $0-$7.40 (Tier 2) mexiletine

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) MULTAQ

MO $0-$7.40 (Tier 2) pacerone oral tablet 100 mg, 200 mg, 400 mg

MO $0-$7.40 (Tier 2) procainamide injection solution 100 mg/ml

$0-$7.40 (Tier 2) procainamide injection solution 500 mg/ml

MO $0-$7.40 (Tier 2) propafenone oral tablet

MO $0-$7.40 (Tier 2) quinidine sulfate oral tablet 200 mg, 300 mg

MO $0 (Tier 1) sorine oral tablet 120 mg, 160 mg, 80 mg

$0 (Tier 1) sorine oral tablet 240 mg

MO $0 (Tier 1) sotalol af oral tablet 120 mg

MO $0-$7.40 (Tier 2) SOTALOL AF ORAL TABLET 160 MG, 80 MG




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MO $0-$7.40 (Tier 2) sotalol oral tablet 120 mg

MO $0 (Tier 1) sotalol oral tablet 160 mg, 240 mg, 80 mg

MO $0-$7.40 (Tier 2) TIKOSYN

ANTIHYPERTENSIVE THERAPY MO $0 (Tier 1) acebutolol

MO $0 (Tier 1) afeditab cr

MO $0-$7.40 (Tier 2) amiloride

MO $0-$7.40 (Tier 2) amiloride-hydrochlorothiazide

MO; QLL (30 per 30 days) $0 (Tier 1) amlodipine besylate oral tablet 10 mg, 2.5 mg

MO; QLL (45 per 30 days) $0 (Tier 1) amlodipine besylate oral tablet 5 mg

MO $0 (Tier 1) amlodipine-benazepril

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) amlodipine-valsartan

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) amlodipine-valsartan-hcthiazid

MO $0 (Tier 1) atenolol

MO $0 (Tier 1) atenolol-chlorthalidone

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) AZOR

MO $0 (Tier 1) benazepril

MO $0 (Tier 1) benazepril-hydrochlorothiazide

MO $0 (Tier 1) betaxolol oral

MO $0 (Tier 1) bisoprolol fumarate

MO $0 (Tier 1) bisoprolol-hydrochlorothiazide

MO $0-$7.40 (Tier 2) bumetanide

MO $0-$7.40 (Tier 2) BYSTOLIC

MO; QLL (60 per 30 days) $0 (Tier 1) candesartan oral tablet 16 mg, 4 mg, 8 mg

MO; QLL (30 per 30 days) $0 (Tier 1) candesartan oral tablet 32 mg

MO; QLL (60 per 30 days) $0 (Tier 1) candesartan-hydrochlorothiazid oral tablet 16-12.5 mg

MO; QLL (30 per 30 days) $0 (Tier 1) candesartan-hydrochlorothiazid oral tablet 32-12.5 mg, 32-25 mg




de clase)


MO $0 (Tier 1) captopril

MO $0 (Tier 1) captopril-hydrochlorothiazide

MO $0 (Tier 1) cartia xt

MO $0 (Tier 1) carvedilol

MO $0-$7.40 (Tier 2) chlorothiazide

MO $0-$7.40 (Tier 2) chlorothiazide sodium

MO $0-$7.40 (Tier 2) chlorthalidone oral tablet 25 mg, 50 mg

MO $0-$7.40 (Tier 2) clonidine hcl oral tablet

MO; QLL (4 per 28 days) $0-$7.40 (Tier 2) clonidine transdermal patches

ST; MO $0-$7.40 (Tier 2) COREG CR

MO $0-$7.40 (Tier 2) DEMSER

MO $0 (Tier 1) dilt-xr

$0 (Tier 1) diltiazem hcl intravenous

MO $0 (Tier 1) diltiazem hcl oral capsule, extended release 120 mg, 180 mg, 360 mg, 420 mg

MO $0-$7.40 (Tier 2) diltiazem hcl oral capsule, extended release 240 mg, 300 mg

MO $0-$7.40 (Tier 2) diltiazem hcl oral capsule,ext release degradable

MO $0 (Tier 1) diltiazem hcl oral capsule,extended release 12 hr

MO $0 (Tier 1) diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg

MO $0-$7.40 (Tier 2) diltiazem hcl oral capsule,extended release 24hr 180 mg, 360 mg

MO $0 (Tier 1) diltiazem hcl oral tablet

MO $0-$7.40 (Tier 2) diltiazem hcl oral tablet extended release 24 hr

MO $0 (Tier 1) doxazosin

MO $0 (Tier 1) enalapril maleate

MO $0 (Tier 1) enalapril-hydrochlorothiazide

MO $0-$7.40 (Tier 2) eplerenone

MO; QLL (30 per 30 days) $0 (Tier 1) eprosartan




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MO $0 (Tier 1) felodipine er

MO $0 (Tier 1) fosinopril

MO $0 (Tier 1) fosinopril-hydrochlorothiazide

MO $0-$7.40 (Tier 2) furosemide injection

MO $0-$7.40 (Tier 2) furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

MO $0 (Tier 1) furosemide oral tablet

MO $0-$7.40 (Tier 2) hydralazine

MO $0 (Tier 1) hydrochlorothiazide

MO $0-$7.40 (Tier 2) indapamide

MO; QLL (30 per 30 days) $0 (Tier 1) irbesartan

MO; QLL (60 per 30 days) $0 (Tier 1) irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg

MO; QLL (30 per 30 days) $0 (Tier 1) irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg

MO $0 (Tier 1) isradipine

MO $0 (Tier 1) labetalol intravenous solution

MO $0 (Tier 1) labetalol oral

MO $0 (Tier 1) lisinopril

MO $0 (Tier 1) lisinopril-hydrochlorothiazide

MO; QLL (30 per 30 days) $0 (Tier 1) losartan oral tablet 100 mg

MO; QLL (60 per 30 days) $0 (Tier 1) losartan oral tablet 25 mg, 50 mg

MO; QLL (30 per 30 days) $0 (Tier 1) losartan-hydrochlorothiazide

MO $0-$7.40 (Tier 2) methyclothiazide

MO $0-$7.40 (Tier 2) metolazone

MO $0 (Tier 1) metoprolol succinate

MO $0 (Tier 1) metoprolol ta-hydrochlorothiaz

MO $0 (Tier 1) metoprolol tartrate intravenous solution

$0-$7.40 (Tier 2) metoprolol tartrate intravenous syringe




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MO $0 (Tier 1) metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

$0 (Tier 1) metoprolol tartrate oral tablet 37.5 mg, 75 mg

MO $0-$7.40 (Tier 2) minoxidil oral

MO $0 (Tier 1) moexipril

MO $0 (Tier 1) moexipril-hydrochlorothiazide

MO $0 (Tier 1) nadolol

MO $0 (Tier 1) nadolol-bendroflumethiazide

MO $0 (Tier 1) nicardipine intravenous solution

MO $0 (Tier 1) nicardipine oral

MO $0 (Tier 1) nifedical xl

MO $0 (Tier 1) nifedipine oral tablet extended release

MO $0-$7.40 (Tier 2) nifedipine oral tablet extended release 24hr

MO $0 (Tier 1) nimodipine

MO $0 (Tier 1) perindopril erbumine

MO $0 (Tier 1) pindolol

MO $0 (Tier 1) prazosin oral

$0 (Tier 1) propranolol intravenous

MO $0 (Tier 1) propranolol oral

MO $0 (Tier 1) propranolol-hydrochlorothiazid

MO $0 (Tier 1) quinapril

MO $0 (Tier 1) quinapril-hydrochlorothiazide

MO $0 (Tier 1) ramipril

MO $0-$7.40 (Tier 2) spironolacton-hydrochlorothiaz

MO $0-$7.40 (Tier 2) spironolactone

MO $0 (Tier 1) taztia xt

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) TEKTURNA

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) TEKTURNA HCT

MO; QLL (30 per 30 days) $0 (Tier 1) telmisartan oral tablet 20 mg, 40 mg




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MO; QLL (60 per 30 days) $0 (Tier 1) telmisartan oral tablet 80 mg

MO; QLL (30 per 30 days) $0 (Tier 1) telmisartan-amlodipine

MO; QLL (30 per 30 days) $0 (Tier 1) telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg

MO; QLL (60 per 30 days) $0 (Tier 1) telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg

MO $0 (Tier 1) terazosin

MO $0 (Tier 1) timolol maleate oral

MO $0-$7.40 (Tier 2) torsemide oral

MO $0 (Tier 1) trandolapril

MO $0-$7.40 (Tier 2) triamterene-hydrochlorothiazid oral capsule 37.5- 25 mg

MO $0-$7.40 (Tier 2) triamterene-hydrochlorothiazid oral tablet

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) TRIBENZOR

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) valsartan oral tablet 160 mg

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) valsartan oral tablet 320 mg

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) valsartan oral tablet 40 mg, 80 mg

MO; QLL (30 per 30 days) $0 (Tier 1) valsartan-hydrochlorothiazide

MO $0 (Tier 1) verapamil intravenous solution

$0-$7.40 (Tier 2) verapamil intravenous syringe

MO $0 (Tier 1) verapamil oral capsule, 24 hr er pellet ct

MO $0 (Tier 1) verapamil oral capsule,ext rel. pellets 24 hr

MO $0 (Tier 1) verapamil oral tablet

MO $0-$7.40 (Tier 2) verapamil oral tablet extended release 120 mg (24 hours)

MO $0 (Tier 1) verapamil oral tablet extended release 120 mg, 180 mg, 240 mg

CARDIAC GLYCOSIDES MO $0-$7.40 (Tier 2) DIGITEK ORAL TABLET 125 MCG

MO $0-$7.40 (Tier 2) DIGOX ORAL TABLET 125 MCG




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MO $0-$7.40 (Tier 2) digoxin oral solution 50 mcg/ml

MO $0-$7.40 (Tier 2) digoxin oral tablet 125 mcg

MO $0-$7.40 (Tier 2) LANOXIN ORAL TABLET 125 MCG, 62.5 MCG

COAGULATION THERAPY ST; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) AGGRENOX

ST; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) aspirin-dipyridamole

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) BRILINTA

MO $0-$7.40 (Tier 2) cilostazol

MO; QLL (1 per 30 days) $0 (Tier 1) clopidogrel oral tablet 300 mg

MO; QLL (30 per 30 days) $0 (Tier 1) clopidogrel oral tablet 75 mg

MO $0-$7.40 (Tier 2) COUMADIN ORAL

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) EFFIENT

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) ELIQUIS ORAL TABLET 2.5 MG

MO; QLL (74 per 30 days) $0-$7.40 (Tier 2) ELIQUIS ORAL TABLET 5 MG

MO; QLL (84 per 30 days) $0-$7.40 (Tier 2) enoxaparin subcutaneous solution

MO; QLL (28 per 30 days) $0-$7.40 (Tier 2) enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml

MO; QLL (22.4 per 30 days) $0-$7.40 (Tier 2) enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml

MO; QLL (8.4 per 30 days) $0-$7.40 (Tier 2) enoxaparin subcutaneous syringe 30 mg/0.3 ml



MO; QLL (24 per 30 days) $0-$7.40 (Tier 2) fondaparinux subcutaneous syringe 10 mg/0.8 ml

MO; QLL (15 per 30 days) $0-$7.40 (Tier 2) fondaparinux subcutaneous syringe 2.5 mg/0.5 ml

MO; QLL (12 per 30 days) $0-$7.40 (Tier 2) fondaparinux subcutaneous syringe 5 mg/0.4 ml

MO; QLL (18 per 30 days) $0-$7.40 (Tier 2) fondaparinux subcutaneous syringe 7.5 mg/0.6 ml

B/D PAR $0-$7.40 (Tier 2) HEPARIN (PORCINE) IN 5 % DEX INTRAVENOUS PARENTERAL SOLUTION 12, 500 UNIT/250 ML




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MO $0-$7.40 (Tier 2) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

B/D PAR $0-$7.40 (Tier 2) HEPARIN (PORCINE) IN NACL (PF) INTRAVENOUS PARENTERAL SOLUTION 1, 000 UNIT/500 ML, 2,000 UNIT/1,000 ML

B/D PAR; MO $0-$7.40 (Tier 2) HEPARIN (PORCINE) INJECTION CARTRIDGE

B/D PAR; MO $0-$7.40 (Tier 2) heparin (porcine) injection solution

B/D PAR $0-$7.40 (Tier 2) HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12, 500 UNIT/250 ML

$0-$7.40 (Tier 2) HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 25, 000 UNIT/250 ML

B/D PAR; MO $0-$7.40 (Tier 2) HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 25, 000 UNIT/500 ML

MO $0-$7.40 (Tier 2) HEPARIN, PORCINE (PF) INJECTION SOLUTION

MO $0-$7.40 (Tier 2) jantoven

MO; [*] $0 (Tier 3) MEPHYTON

MO $0-$7.40 (Tier 2) pentoxifylline

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) PRADAXA

PAR; MO; LA; QLL (30 per 30 days) $0-$7.40 (Tier 2) PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG

PAR; MO; LA; QLL (60 per 30 days) $0-$7.40 (Tier 2) PROMACTA ORAL TABLET 50 MG

MO $0-$7.40 (Tier 2) tranexamic acid intravenous

MO; [*] $0 (Tier 3) VITAMIN K

MO; [*] $0 (Tier 3) VITAMIN K1 INJECTION

MO $0 (Tier 1) warfarin

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) XARELTO ORAL TABLET 10 MG, 20 MG

MO; QLL (42 per 30 days) $0-$7.40 (Tier 2) XARELTO ORAL TABLET 15 MG




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MO; QLL (102 per 365 days) $0-$7.40 (Tier 2) XARELTO ORAL TABLETS,DOSE PACK

LIPID/CHOLESTEROL LOWERING AGENTS PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) ALTOPREV

MO; QLL (30 per 30 days) $0 (Tier 1) amlodipine-atorvastatin

MO; QLL (30 per 30 days) $0 (Tier 1) atorvastatin

MO $0-$7.40 (Tier 2) cholestyramine (with sugar)

MO $0-$7.40 (Tier 2) CHOLESTYRAMINE LIGHT ORAL POWDER

MO $0-$7.40 (Tier 2) cholestyramine light oral powder in packet

MO $0-$7.40 (Tier 2) colestipol

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) CRESTOR

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

MO $0-$7.40 (Tier 2) fenofibrate nanocrystallized 48 mg, 145 mg

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) fenofibrate oral tablet 160 mg, 54 mg

MO $0-$7.40 (Tier 2) gemfibrozil oral

PAR; MO; LA $0-$7.40 (Tier 2) JUXTAPID

MO; QLL (30 per 30 days) $0 (Tier 1) lovastatin oral tablet 10 mg, 20 mg

MO; QLL (60 per 30 days) $0 (Tier 1) lovastatin oral tablet 40 mg

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) niacin oral tablet extended release 24 hr 1,000 mg, 750 mg

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) niacin oral tablet extended release 24 hr 500 mg

MO $0-$7.40 (Tier 2) NIACOR

PAR; MO $0-$7.40 (Tier 2) omega-3 acid ethyl esters

PAR; MO; QLL (2 per 28 days) $0-$7.40 (Tier 2) PRALUENT PEN

PAR; MO; QLL (2 per 28 days) $0-$7.40 (Tier 2) PRALUENT SYRINGE

MO; QLL (30 per 30 days) $0 (Tier 1) pravastatin

MO $0-$7.40 (Tier 2) prevalite oral powder

MO $0-$7.40 (Tier 2) PREVALITE ORAL POWDER IN PACKET

PAR; MO; QLL (3 per 28 days) $0-$7.40 (Tier 2) REPATHA SURECLICK




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PAR; MO; QLL (3 per 28 days) $0-$7.40 (Tier 2) REPATHA SYRINGE

QLL (30 per 30 days) $0-$7.40 (Tier 2) rosuvastatin

MO; QLL (30 per 30 days) $0 (Tier 1) simvastatin

MO $0-$7.40 (Tier 2) VASCEPA

MO $0-$7.40 (Tier 2) WELCHOL

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) ZETIA

MISCELLANEOUS CARDIOVASCULAR AGENTS MO $0-$7.40 (Tier 2) RANEXA

$0-$7.40 (Tier 2) VECAMYL

NITRATES MO $0-$7.40 (Tier 2) isosorbide dinitrate oral

MO $0-$7.40 (Tier 2) isosorbide mononitrate

MO $0-$7.40 (Tier 2) nitro-bid

B/D PAR $0-$7.40 (Tier 2) nitroglycerin intravenous

MO $0-$7.40 (Tier 2) nitroglycerin transdermal patch 24 hour

MO $0-$7.40 (Tier 2) NITROSTAT

DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC

MO $0-$7.40 (Tier 2) acitretin

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) calcipotriene scalp

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) calcipotriene topical

MO $0-$7.40 (Tier 2) selenium sulfide topical lotion

BURN THERAPY MO $0-$7.40 (Tier 2) silver sulfadiazine

MO $0-$7.40 (Tier 2) ssd

MO $0-$7.40 (Tier 2) THERMAZENE

KERATOLYTICS [*] $0 (Tier 4) CALLUS REMOVER




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[*] $0 (Tier 4) CALLUS REMOVERS

[*] $0 (Tier 4) CORN REMOVER

[*] $0 (Tier 4) DR SCHOLL'S CLEAR AWAY

[*] $0 (Tier 4) MEDICATED CORN REMOVERS

MO; [*] $0 (Tier 4) MEDIPLAST CORN-CALLUS-WART

[*] $0 (Tier 4) MOSCO CORN REMOVER

[*] $0 (Tier 4) PLANTAR WART REMOVER

[*] $0 (Tier 4) WART REMOVER TOPICAL ADHESIVE PATCH,MEDICATED

MISCELLANEOUS DERMATOLOGICALS MO; [*] $0 (Tier 4) A + D (LAN, PET)

MO $0-$7.40 (Tier 2) ammonium lactate

[*] $0 (Tier 4) ARCTIC RELIEF

[*] $0 (Tier 4) CHEST RUB TOPICAL OINTMENT

PAR; MO; QLL (100 per 90 days) $0-$7.40 (Tier 2) ELIDEL

MO $0-$7.40 (Tier 2) fluorouracil topical cream 5 %

MO $0-$7.40 (Tier 2) fluorouracil topical solution

MO $0-$7.40 (Tier 2) imiquimod

PAR; MO $0-$7.40 (Tier 2) methoxsalen rapid

MO $0-$7.40 (Tier 2) OXSORALEN

MO $0-$7.40 (Tier 2) PANRETIN

MO $0-$7.40 (Tier 2) PICATO

MO $0-$7.40 (Tier 2) podofilox

[*] $0 (Tier 4) SKIN PROTECTANT A AND D

PAR; MO; QLL (100 per 90 days) $0-$7.40 (Tier 2) tacrolimus topical

$0-$7.40 (Tier 2) UVADEX

MO $0-$7.40 (Tier 2) VALCHLOR

[*] $0 (Tier 4) VICKS VAPORUB TOPICAL OINTMENT 4.8- 1.2-2.6 %




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[*] $0 (Tier 4) vitamin a and d

[*] $0 (Tier 4) VITAMIN A AND D DIAPER RASH

MO; [*] $0 (Tier 4) vits a and d-white pet-lanolin topical ointment

[*] $0 (Tier 4) ZIKS ARTHRITIS PAIN RELIEF

MO; [*] $0 (Tier 4) ZINC OXIDE TOPICAL OINTMENT 20 %

THERAPY FOR ACNE [*] $0 (Tier 4) ACNE CONTROL CLEANSER

[*] $0 (Tier 4) ACNE FOAMING WASH

MO; [*] $0 (Tier 4) ACNE MEDICATION TOPICAL GEL 10 %

[*] $0 (Tier 4) ACNE TREATMENT (BENZOYL PEROX)

[*] $0 (Tier 4) ACNE VANISHING

[*] $0 (Tier 4) ACNE-CLEAR

MO $0-$7.40 (Tier 2) adapalene topical gel 0.3 %

MO $0-$7.40 (Tier 2) adapalene topical gel with pump

MO; [*] $0 (Tier 4) benzoyl peroxide topical cleanser 10 %, 5 %, 6 %

MO; [*] $0 (Tier 4) benzoyl peroxide topical gel 10 %, 2.5 %, 5 %

MO; [*] $0 (Tier 4) benzoyl peroxide topical lotion 10 %

[*] $0 (Tier 4) BP

MO; [*] $0 (Tier 4) BP WASH TOPICAL CLEANSER 10 %, 5 %

[*] $0 (Tier 4) BPO-10

[*] $0 (Tier 4) BPO-5

MO $0-$7.40 (Tier 2) clindamycin phosphate topical

[*] $0 (Tier 4) CREAMY ACNE FACE

MO $0-$7.40 (Tier 2) ery pads

MO $0-$7.40 (Tier 2) erythromycin with ethanol

MO $0-$7.40 (Tier 2) erythromycin-benzoyl peroxide

[*] $0 (Tier 4) FOAMING ACNE FACE WASH

MO $0-$7.40 (Tier 2) metronidazole topical cream

MO $0-$7.40 (Tier 2) metronidazole topical gel 0.75 %




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MO $0-$7.40 (Tier 2) metronidazole topical lotion

MO; [*] $0 (Tier 4) PANOXYL TOPICAL CLEANSER

MO; [*] $0 (Tier 4) PANOXYL-4

[*] $0 (Tier 4) PERSA-GEL

MO $0-$7.40 (Tier 2) ROSADAN TOPICAL CREAM

PAR; MO $0-$7.40 (Tier 2) TAZORAC

MO; QLL (45 per 30 days) $0-$7.40 (Tier 2) tretinoin topical cream

MO; QLL (45 per 30 days) $0-$7.40 (Tier 2) tretinoin topical gel 0.01 %, 0.025 %

TOPICAL ANESTHETICS [*] $0 (Tier 4) ALOE BURN RELIEF

[*] $0 (Tier 4) BURN RELIEF

[*] $0 (Tier 4) BURN RELIEF WITH ALOE TOPICAL AEROSOL,SPRAY

[*] $0 (Tier 4) CALACLEAR

[*] $0 (Tier 4) CALAHIST CLEAR

[*] $0 (Tier 4) CALDYPHEN CLEAR TOPICAL LOTION

[*] $0 (Tier 4) CALLERGY CLEAR

$0-$7.40 (Tier 2) LIDOCAINE (PF) INJECTION SOLUTION 15 MG/ML (1.5 %)

MO $0-$7.40 (Tier 2) lidocaine (pf) injection solution 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %)

MO $0-$7.40 (Tier 2) lidocaine hcl injection solution 20 mg/ml (2 %)

$0-$7.40 (Tier 2) lidocaine hcl injection solution 5 mg/ml (0.5 %)

MO $0-$7.40 (Tier 2) lidocaine hcl laryngotracheal

MO $0-$7.40 (Tier 2) lidocaine hcl mucous membrane

MO $0-$7.40 (Tier 2) lidocaine hcl urethral

PAR; MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) lidocaine topical adhesive patch,medicated

MO $0-$7.40 (Tier 2) lidocaine topical ointment

MO $0-$7.40 (Tier 2) LIDOCAINE VISCOUS




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MO $0-$7.40 (Tier 2) lidocaine-prilocaine topical cream

TOPICAL ANTIBACTERIALS [*] $0 (Tier 4) ANTIBIOTIC (NEOMY-BACIT-POLYM)

[*] $0 (Tier 4) ANTIBIOTIC-PAIN RELIEF (BACIT)

MO $0-$7.40 (Tier 2) gentamicin topical

MO $0-$7.40 (Tier 2) mupirocin calcium

MO $0-$7.40 (Tier 2) mupirocin topical ointment

[*] $0 (Tier 4) NEOSPORIN PLUS PAINRELIEF(BAC)

MO $0-$7.40 (Tier 2) sulfacetamide sodium (acne)

MO $0-$7.40 (Tier 2) SULFAMYLON TOPICAL CREAM

[*] $0 (Tier 4) TRI-BIOZENE

[*] $0 (Tier 4) TRIPLE ANTIBIOTIC (PRAM) EXTRA

[*] $0 (Tier 4) TRIPLE ANTIBIOTIC PLUS

MO; [*] $0 (Tier 4) TRIPLE ANTIBIOTIC TOPICAL OINTMENT

MO; [*] $0 (Tier 4) TRIPLE ANTIBIOTIC TOPICAL OINTMENT IN PACKET

[*] $0 (Tier 4) TRIPLE ANTIBIOTIC-PAIN RELIEF

TOPICAL ANTIFUNGALS [*] $0 (Tier 4) AF

[*] $0 (Tier 4) ALOE VESTA ANTIFUNGAL (MICON)

[*] $0 (Tier 4) ANTI-FUNGAL TOPICAL POWDER

[*] $0 (Tier 4) ANTIFUNGAL (CLOTRIMAZOLE)

[*] $0 (Tier 4) ANTIFUNGAL (TOLNAFTATE) TOPICAL AEROSOL,SPRAY

[*] $0 (Tier 4) ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM

MO; [*] $0 (Tier 4) ANTIFUNGAL (TOLNAFTATE) TOPICAL POWDER

[*] $0 (Tier 4) ANTIFUNGAL CREAM

[*] $0 (Tier 4) ANTIFUNGAL SPRAY




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[*] $0 (Tier 4) ANTIFUNGAL TOPICAL SOLUTION

[*] $0 (Tier 4) ATHLETE'S FOOT

[*] $0 (Tier 4) ATHLETE'S FOOT (CLOTRIMAZOLE)

[*] $0 (Tier 4) ATHLETE'S FOOT (TERBINAFINE)

[*] $0 (Tier 4) ATHLETE'S FOOT (TOLNAFTATE)

[*] $0 (Tier 4) ATHLETE'S FOOT AF

[*] $0 (Tier 4) ATHLETIC FOOT CREAM

[*] $0 (Tier 4) AZOLEN TINCTURE

MO; [*] $0 (Tier 4) BAZA ANTIFUNGAL

[*] $0 (Tier 4) BLIS-TO-SOL (TOLNAFTATE)

PAR; MO $0-$7.40 (Tier 2) CICLODAN TOPICAL SOLUTION

MO $0-$7.40 (Tier 2) ciclopirox topical cream

MO $0-$7.40 (Tier 2) ciclopirox topical gel

MO $0-$7.40 (Tier 2) ciclopirox topical shampoo

PAR; MO $0-$7.40 (Tier 2) ciclopirox topical solution

MO $0-$7.40 (Tier 2) ciclopirox topical suspension

[*] $0 (Tier 4) CLOTRIMAZOLE AF

MO $0-$7.40 (Tier 2) clotrimazole topical

MO $0-$7.40 (Tier 2) clotrimazole-betamethasone

MO; [*] $0 (Tier 4) CRITIC-AID CLEAR AF

[*] $0 (Tier 4) DERMAFUNGAL

[*] $0 (Tier 4) DESENEX SPRAY

[*] $0 (Tier 4) DESENEX TOPICAL AEROSOL,SPRAY

MO; [*] $0 (Tier 4) DESENEX TOPICAL POWDER

MO $0-$7.40 (Tier 2) econazole topical

[*] $0 (Tier 4) ELON DUAL DEFENSE

[*] $0 (Tier 4) FOOT AND SNEAKER

MO; [*] $0 (Tier 4) FUNGOID TINCTURE

[*] $0 (Tier 4) FUNGOID-D




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[*] $0 (Tier 4) INZO ANTIFUNGAL

[*] $0 (Tier 4) ITCH RELIEF (CLOTRIMAZOLE)

[*] $0 (Tier 4) JOCK ITCH

[*] $0 (Tier 4) JOCK ITCH (CLOTRIMAZOLE)

[*] $0 (Tier 4) JOCK ITCH (TERBINAFINE)

MO $0-$7.40 (Tier 2) ketoconazole topical

MO; [*] $0 (Tier 4) LAMISIL (AEROSOL)

MO; [*] $0 (Tier 4) LAMISIL AF TOPICAL AEROSOL POWDER

[*] $0 (Tier 4) LAMISIL AF TOPICAL POWDER

MO; [*] $0 (Tier 4) LAMISIL AT

[*] $0 (Tier 4) LOTRIMIN AF JOCK ITCH POWDER

MO; [*] $0 (Tier 4) LOTRIMIN AF POWDER

[*] $0 (Tier 4) LOTRIMIN AF TOPICAL AEROSOL,SPRAY

MO; [*] $0 (Tier 4) LOTRIMIN AF TOPICAL CREAM

MO; [*] $0 (Tier 4) LOTRIMIN AF TOPICAL POWDER

MO; [*] $0 (Tier 4) LOTRIMIN ULTRA

[*] $0 (Tier 4) MICATIN

[*] $0 (Tier 4) miconazole nitrate topical aerosol powder

MO; [*] $0 (Tier 4) miconazole nitrate topical cream

[*] $0 (Tier 4) MICONAZORB AF

MO; [*] $0 (Tier 4) MICRO-GUARD

[*] $0 (Tier 4) MYCO NAIL A

MO $0-$7.40 (Tier 2) nystatin topical

MO $0-$7.40 (Tier 2) nystatin-triamcinolone

MO $0-$7.40 (Tier 2) nystop

[*] $0 (Tier 4) ODOR CONTROL FOOT-SNEAKER

[*] $0 (Tier 4) REMEDY ANTIFUNGAL TOPICAL CREAM

[*] $0 (Tier 4) REMEDY PHYTOPLEX ANTIFUNGAL

[*] $0 (Tier 4) RINGWORM




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MO; [*] $0 (Tier 4) SECURA ANTIFUNGAL

[*] $0 (Tier 4) SECURA ANTIFUNGAL EXTRA THICK

MO; [*] $0 (Tier 4) terbinafine hcl topical

MO; [*] $0 (Tier 4) TINACTIN TOPICAL AEROSOL POWDER

[*] $0 (Tier 4) TINACTIN TOPICAL AEROSOL,SPRAY

MO; [*] $0 (Tier 4) TINACTIN TOPICAL CREAM

MO; [*] $0 (Tier 4) TINACTIN TOPICAL POWDER

[*] $0 (Tier 4) tolnaftate topical aerosol powder

[*] $0 (Tier 4) tolnaftate topical cream

[*] $0 (Tier 4) tolnaftate topical powder

MO; [*] $0 (Tier 4) TRIPLE PASTE AF

MO; [*] $0 (Tier 4) ZEASORB (MICONAZOLE)

TOPICAL ANTIVIRALS MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) acyclovir topical

MO; QLL (5 per 2 days) $0-$7.40 (Tier 2) DENAVIR

TOPICAL CORTICOSTEROIDS MO $0-$7.40 (Tier 2) ala-cort topical cream

MO $0-$7.40 (Tier 2) alclometasone

MO $0-$7.40 (Tier 2) amcinonide

[*] $0 (Tier 4) ANTI-ITCH (HC) TOPICAL CREAM

MO $0-$7.40 (Tier 2) betamethasone dipropionate

MO $0-$7.40 (Tier 2) betamethasone valerate topical cream

MO $0-$7.40 (Tier 2) betamethasone valerate topical lotion

MO $0-$7.40 (Tier 2) betamethasone valerate topical ointment

MO $0-$7.40 (Tier 2) betamethasone, augmented

MO $0-$7.40 (Tier 2) CAPEX

MO $0-$7.40 (Tier 2) clobetasol scalp

MO $0-$7.40 (Tier 2) clobetasol topical cream




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MO $0-$7.40 (Tier 2) clobetasol topical foam

MO $0-$7.40 (Tier 2) clobetasol topical gel

MO $0-$7.40 (Tier 2) clobetasol topical ointment

MO $0-$7.40 (Tier 2) clobetasol-emollient topical cream

$0-$7.40 (Tier 2) cormax scalp

[*] $0 (Tier 4) CORTISONE (HYDROCORTISONE) TOPICAL CREAM

[*] $0 (Tier 4) CORTIZONE-10 PLUS

[*] $0 (Tier 4) CORTIZONE-10 TOPICAL CREAM

MO $0-$7.40 (Tier 2) DERMATOP TOPICAL OINTMENT

MO $0-$7.40 (Tier 2) desonide

MO $0-$7.40 (Tier 2) desoximetasone

MO $0-$7.40 (Tier 2) diflorasone

[*] $0 (Tier 4) ECZEMA ANTI-ITCH

MO $0-$7.40 (Tier 2) fluocinolone

MO $0-$7.40 (Tier 2) fluocinolone and shower cap

MO $0-$7.40 (Tier 2) fluocinonide topical cream 0.05 %

MO $0-$7.40 (Tier 2) fluocinonide topical gel

MO $0-$7.40 (Tier 2) fluocinonide topical ointment

MO $0-$7.40 (Tier 2) fluocinonide topical solution

MO $0-$7.40 (Tier 2) fluocinonide-e

MO $0-$7.40 (Tier 2) fluticasone topical

MO $0-$7.40 (Tier 2) halobetasol propionate

MO $0-$7.40 (Tier 2) HALOG

[*] $0 (Tier 4) hydrocortisone acetate topical cream 0.5 %

[*] $0 (Tier 4) HYDROCORTISONE PLUS

MO; [*] $0 (Tier 4) hydrocortisone topical cream 0.5 %

MO $0-$7.40 (Tier 2) hydrocortisone topical cream 1 %, 2.5 %

MO $0-$7.40 (Tier 2) hydrocortisone topical lotion 2.5 %




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MO; [*] $0 (Tier 4) hydrocortisone topical ointment 0.5 %

MO $0-$7.40 (Tier 2) hydrocortisone topical ointment 1 %, 2.5 %

MO $0-$7.40 (Tier 2) hydrocortisone valerate

MO $0-$7.40 (Tier 2) HYDROCORTISONE-MIN OIL-WHT PET

[*] $0 (Tier 4) HYDROCREAM

MO $0-$7.40 (Tier 2) mometasone topical

[*] $0 (Tier 4) NEOSPORIN ANTI-ITCH

[*] $0 (Tier 4) NOBLE FORMULA HC TOPICAL CREAM

MO; [*] $0 (Tier 4) PREPARATION H HYDROCORTISONE

[*] $0 (Tier 4) RECORT PLUS

[*] $0 (Tier 4) SOOTHING CARE (HYDROCORTISONE)

MO $0-$7.40 (Tier 2) triamcinolone acetonide topical cream

MO $0-$7.40 (Tier 2) triamcinolone acetonide topical lotion

MO $0-$7.40 (Tier 2) triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

MO $0-$7.40 (Tier 2) trianex

MO $0-$7.40 (Tier 2) triderm topical cream

TOPICAL ENZYMES MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) SANTYL

TOPICAL SCABICIDES / PEDICULICIDES [*] $0 (Tier 4) COMPLETE LICE TREATMENT

[*] $0 (Tier 4) LICE COMPLETE KIT 1-2-3

[*] $0 (Tier 4) LICE KILLING (PERMETHRIN)

[*] $0 (Tier 4) LICE KILLING TOPICAL SHAMPOO

[*] $0 (Tier 4) LICE PYRINYL SHAMPOO

[*] $0 (Tier 4) LICE SOLUTION

[*] $0 (Tier 4) LICE TREATMENT (PERMETHRIN)

[*] $0 (Tier 4) LICE TREATMENT TOPICAL LIQUID 1 %

[*] $0 (Tier 4) LICE TREATMENT TOPICAL SHAMPOO




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MO $0-$7.40 (Tier 2) lindane topical shampoo

MO $0-$7.40 (Tier 2) permethrin topical cream

MO; [*] $0 (Tier 4) permethrin topical liquid

[*] $0 (Tier 4) RID COMPLETE LICE ELIM KIT TOPICAL

DIAGNOSTICS / MISCELLANEOUS AGENTS ANOREXIANTS

MO; [*] $0 (Tier 3) ADIPEX-P

MO; [*] $0 (Tier 3) BELVIQ

MO; [*] $0 (Tier 3) benzphetamine oral tablet 50 mg

MO; [*] $0 (Tier 3) diethylpropion

MO; [*] $0 (Tier 3) phendimetrazine tartrate

MO; [*] $0 (Tier 3) phentermine

MO; [*] $0 (Tier 3) QSYMIA

MO; [*] $0 (Tier 3) XENICAL

ANTIDOTES MO $0-$7.40 (Tier 2) acetylcysteine intravenous

IRRIGATING SOLUTIONS MO $0-$7.40 (Tier 2) lactated ringers irrigation

MO $0-$7.40 (Tier 2) neomycin-polymyxin b gu

MO $0-$7.40 (Tier 2) ringers irrigation

MISCELLANEOUS AGENTS MO $0-$7.40 (Tier 2) acamprosate

MO $0-$7.40 (Tier 2) ADAGEN

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) alendronate oral tablet 40 mg

MO $0-$7.40 (Tier 2) anagrelide

PAR; MO; LA $0-$7.40 (Tier 2) ARALAST NP

PAR; MO $0-$7.40 (Tier 2) BUPHENYL ORAL TABLET

PAR; MO; LA $0-$7.40 (Tier 2) CARBAGLU




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B/D PAR $0-$7.40 (Tier 2) CLINIMIX 4.25%/D5W SULFIT FREE

B/D PAR $0-$7.40 (Tier 2) CLINIMIX E 2.75%/D10W SUL FREE

B/D PAR $0-$7.40 (Tier 2) CLINIMIX E 2.75%/D5W SULF FREE

$0-$7.40 (Tier 2) d10 %-0.45 % sodium chloride

$0-$7.40 (Tier 2) d2.5 %-0.45 % sodium chloride

MO $0-$7.40 (Tier 2) d5 % and 0.9 % sodium chloride

MO $0-$7.40 (Tier 2) d5 %-0.45 % sodium chloride

$0-$7.40 (Tier 2) dextrose 10 % and 0.2 % nacl

MO $0-$7.40 (Tier 2) dextrose 10 % in water (d10w)

$0-$7.40 (Tier 2) dextrose 25 % in water (d25w)

$0-$7.40 (Tier 2) DEXTROSE 30 % IN WATER (D30W)

$0-$7.40 (Tier 2) DEXTROSE 40 % IN WATER (D40W)

MO $0-$7.40 (Tier 2) dextrose 5 % in water (d5w) intravenous parenteral solution

MO $0-$7.40 (Tier 2) DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK

MO $0-$7.40 (Tier 2) dextrose 5 %-lactated ringers

$0-$7.40 (Tier 2) dextrose 5%-0.2 % sod chloride

$0-$7.40 (Tier 2) dextrose 5%-0.3 % sod.chloride

MO $0-$7.40 (Tier 2) DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS PARENTERAL SOLUTION

$0-$7.40 (Tier 2) DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE

MO $0-$7.40 (Tier 2) dextrose 70 % in water (d70w)

$0-$7.40 (Tier 2) dextrose with sodium chloride

MO $0-$7.40 (Tier 2) disulfiram

PAR; MO; LA $0-$7.40 (Tier 2) EXJADE

MO; [*] $0 (Tier 3) FERRLECIT

PAR; MO; LA $0-$7.40 (Tier 2) INCRELEX

MO $0-$7.40 (Tier 2) kionex oral powder




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MO $0-$7.40 (Tier 2) KIONEX ORAL SUSPENSION

B/D PAR; MO $0-$7.40 (Tier 2) levocarnitine (with sugar)

MO $0-$7.40 (Tier 2) levocarnitine oral tablet

MO $0-$7.40 (Tier 2) midodrine

LA $0-$7.40 (Tier 2) ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG

$0-$7.40 (Tier 2) ORFADIN ORAL CAPSULE 20 MG

MO $0-$7.40 (Tier 2) pilocarpine hcl oral

PAR; LA $0-$7.40 (Tier 2) PROLASTIN-C

PAR; MO; QLL (525 per 30 days) $0-$7.40 (Tier 2) RAVICTI

ST; MO $0-$7.40 (Tier 2) RENAGEL

MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) RENVELA ORAL POWDER IN PACKET 0.8 GRAM

MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) RENVELA ORAL POWDER IN PACKET 2.4 GRAM

MO; QLL (270 per 30 days) $0-$7.40 (Tier 2) RENVELA ORAL TABLET

MO $0-$7.40 (Tier 2) riluzole

MO $0-$7.40 (Tier 2) sodium chloride 0.9 % intravenous parenteral solution

MO $0-$7.40 (Tier 2) SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK

MO $0-$7.40 (Tier 2) sodium chloride irrigation

MO $0-$7.40 (Tier 2) sodium polystyrene (sorb free)

MO $0-$7.40 (Tier 2) sodium polystyrene sulfonate oral powder

$0-$7.40 (Tier 2) sodium polystyrene sulfonate oral suspension

$0-$7.40 (Tier 2) sodium polystyrene sulfonate rectal enema 30 gram/ 120 ml

$0-$7.40 (Tier 2) SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML

MO $0-$7.40 (Tier 2) SPS ORAL

$0-$7.40 (Tier 2) SPS RECTAL




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MO $0-$7.40 (Tier 2) SYPRINE

MO $0-$7.40 (Tier 2) water for irrigation, sterile

MISCELLANEOUS DEVICES [*] $0 (Tier 4) ALCOHOL, RUBBING

MO; [*] $0 (Tier 4) isopropyl alcohol solution 70 %

SMOKING DETERRENTS MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) bupropion hcl (smoking deter)

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) CHANTIX

PAR; MO; QLL (56 per 28 days) $0-$7.40 (Tier 2) CHANTIX CONTINUING MONTH BOX

PAR; MO; QLL (106 per 365 days) $0-$7.40 (Tier 2) CHANTIX STARTING MONTH BOX

MO; [*]; QLL (30 per 30 days) $0 (Tier 4) NICODERM CQ

MO; [*] $0 (Tier 4) NICORELIEF

MO; [*] $0 (Tier 4) NICORETTE BUCCAL GUM

MO; [*]; QLL (20 per 1 day) $0 (Tier 4) NICORETTE BUCCAL LOZENGE

MO; [*] $0 (Tier 4) nicotine (polacrilex) buccal gum

MO; [*]; QLL (20 per 1 day) $0 (Tier 4) nicotine (polacrilex) buccal lozenge

MO; [*]; QLL (30 per 30 days) $0 (Tier 4) nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) NICOTROL NS

[*]; QLL (30 per 30 days) $0 (Tier 4) NTS STEP 1

[*] $0 (Tier 4) QUIT 2 BUCCAL GUM

[*]; QLL (20 per 1 day) $0 (Tier 4) QUIT 2 BUCCAL LOZENGE

[*] $0 (Tier 4) QUIT 4 BUCCAL GUM

[*]; QLL (20 per 1 day) $0 (Tier 4) QUIT 4 BUCCAL LOZENGE

[*]; QLL (20 per 1 day) $0 (Tier 4) STOP SMOKING AID

EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS

[*] $0 (Tier 4) 12 HOUR NASAL RELIEF SPRAY

[*] $0 (Tier 4) 12 HOUR NASAL SPRAY




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MO; [*] $0 (Tier 4) AFRIN (OXYMETAZOLINE)

[*] $0 (Tier 4) AFRIN NO DRIP(OXYMETAZOLIN)

[*] $0 (Tier 4) ANEFRIN

MO; QLL (30 per 25 days) $0-$7.40 (Tier 2) azelastine nasal

MO $0-$7.40 (Tier 2) chlorhexidine gluconate mucous membrane

[*] $0 (Tier 4) DRISTAN LONG LASTING

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) ipratropium bromide nasal

[*] $0 (Tier 4) MUCINEX SINUS-MAX

MO; [*] $0 (Tier 4) NASAL DECONGESTANT (OXYMETAZL)

[*] $0 (Tier 4) NASAL RELIEF

[*] $0 (Tier 4) NASAL SPRAY (OXYMETAZOLINE)

[*] $0 (Tier 4) NASAL SPRAY 12 HOUR

[*] $0 (Tier 4) NASAL SPRAY EXTRA MOISTURIZING

[*] $0 (Tier 4) NASAL SPRAY LONG ACTING

[*] $0 (Tier 4) NASAL SPRAY SINUS

[*] $0 (Tier 4) NO DRIP

[*] $0 (Tier 4) NRS NASAL RELIEF

[*] $0 (Tier 4) ORIGINAL NASAL SPRAY

[*] $0 (Tier 4) oxymetazoline

MO $0-$7.40 (Tier 2) PAROEX ORAL RINSE

MO $0-$7.40 (Tier 2) periogard

[*] $0 (Tier 4) SINEX ULTRA FINE MIST 12-HOUR

[*] $0 (Tier 4) SINUS NASAL SPRAY

[*] $0 (Tier 4) SINUS RELIEF (OXYMETAZOLINE)

MO $0-$7.40 (Tier 2) triamcinolone acetonide dental

MO $0-$7.40 (Tier 2) TYZINE NASAL DROPS 0.05 %

[*] $0 (Tier 4) VICKS QLEARQUIL(OXYMETAZOLINE)

[*] $0 (Tier 4) VICKS SINEX 12-HOUR




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MISCELLANEOUS OTIC PREPARATIONS MO $0-$7.40 (Tier 2) acetic acid otic

MO $0-$7.40 (Tier 2) acetic acid-aluminum acetate

[*] $0 (Tier 4) CARBAMOXIDE EAR DROPS

[*] $0 (Tier 4) EAR DROPS (CARBAMIDE PEROXIDE)

[*] $0 (Tier 4) EAR DROPS OTC

[*] $0 (Tier 4) EAR WAX REMOVAL DROPS

[*] $0 (Tier 4) EAR WAX REMOVAL KIT

[*] $0 (Tier 4) EAR WAX REMOVAL SYSTEM OTIC DROPS

[*] $0 (Tier 4) EAR WAX TREATMENT

MO $0-$7.40 (Tier 2) fluocinolone acetonide oil

MO $0-$7.40 (Tier 2) hydrocortisone-acetic acid

MO; [*] $0 (Tier 4) MURINE EAR WAX REMOVAL SYSTEM

MO $0-$7.40 (Tier 2) ofloxacin otic

OTIC STEROID / ANTIBIOTIC MO $0-$7.40 (Tier 2) CIPRODEX

MO $0-$7.40 (Tier 2) COLY-MYCIN S

MO $0-$7.40 (Tier 2) neomycin-polymyxin-hc otic

ENDOCRINE/DIABETES ADRENAL HORMONES

PAR; MO $0-$7.40 (Tier 2) ACTHAR H.P.

MO $0-$7.40 (Tier 2) cortisone

MO $0-$7.40 (Tier 2) dexamethasone

MO $0-$7.40 (Tier 2) DEXAMETHASONE SODIUM PHOS (PF)

MO $0-$7.40 (Tier 2) dexamethasone sodium phosphate injection

MO $0-$7.40 (Tier 2) fludrocortisone

MO $0-$7.40 (Tier 2) hydrocortisone oral

MO $0-$7.40 (Tier 2) methylprednisolone acetate




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MO $0-$7.40 (Tier 2) methylprednisolone oral tablets

MO $0-$7.40 (Tier 2) methylprednisolone sodium succ injection recon soln 125 mg, 40 mg

MO $0-$7.40 (Tier 2) methylprednisolone sodium succ intravenous

MO $0-$7.40 (Tier 2) prednisolone oral solution 15 mg/5 ml

MO $0-$7.40 (Tier 2) prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

MO $0-$7.40 (Tier 2) prednisolone sodium phosphate oral tablet, disintegrating

MO $0-$7.40 (Tier 2) prednisone

MO $0-$7.40 (Tier 2) prednisone intensol

MO $0-$7.40 (Tier 2) triamcinolone acetonide injection suspension 10 mg/ml

$0-$7.40 (Tier 2) triamcinolone acetonide injection suspension 40 mg/ml

ANTITHYROID AGENTS MO $0-$7.40 (Tier 2) methimazole oral tablet 10 mg, 5 mg

MO $0-$7.40 (Tier 2) propylthiouracil

DIABETES THERAPY MO; QLL (90 per 30 days) $0 (Tier 1) acarbose oral tablet 100 mg

MO; QLL (360 per 30 days) $0 (Tier 1) acarbose oral tablet 25 mg

MO; QLL (180 per 30 days) $0 (Tier 1) acarbose oral tablet 50 mg

MO $0 (Tier 1) alcohol pads

MO; QLL (4 per 28 days) $0-$7.40 (Tier 2) BYDUREON

MO; QLL (2.4 per 30 days) $0-$7.40 (Tier 2) BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML

MO; QLL (1.2 per 30 days) $0-$7.40 (Tier 2) BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML

ST; MO; QLL (180 per 30 days) $0-$7.40 (Tier 2) CYCLOSET

MO; QLL (200 per 30 days) $0 (Tier 1) GAUZE PADS 2 X 2

MO; QLL (240 per 30 days) $0 (Tier 1) glimepiride oral tablet 1 mg




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MO; QLL (120 per 30 days) $0 (Tier 1) glipizide oral tablet 10 mg

MO; QLL (240 per 30 days) $0 (Tier 1) glipizide oral tablet 5 mg

MO; QLL (60 per 30 days) $0 (Tier 1) glipizide oral tablet extended release 24hr 10 mg

MO; QLL (240 per 30 days) $0 (Tier 1) glipizide oral tablet extended release 24hr 2.5 mg

MO; QLL (120 per 30 days) $0 (Tier 1) glipizide oral tablet extended release 24hr 5 mg

MO; QLL (240 per 30 days) $0 (Tier 1) glipizide-metformin oral tablet 2.5-250 mg

MO; QLL (120 per 30 days) $0 (Tier 1) glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg

MO $0 (Tier 1) GLUCAGEN HYPOKIT

MO $0 (Tier 1) GLUCAGON EMERGENCY KIT (HUMAN)

MO $0 (Tier 1) HUMALOG

MO $0 (Tier 1) HUMALOG KWIKPEN

MO $0 (Tier 1) HUMALOG MIX 50-50

MO $0 (Tier 1) HUMALOG MIX 50-50 KWIKPEN

MO $0 (Tier 1) HUMALOG MIX 75-25

MO $0 (Tier 1) HUMALOG MIX 75-25 KWIKPEN

MO; QLL (200 per 30 days) $0 (Tier 1) HUMAPEN LUXURA HD

MO $0 (Tier 1) HUMULIN 70/30

MO $0 (Tier 1) HUMULIN 70/30 KWIKPEN

MO $0 (Tier 1) HUMULIN N

MO $0 (Tier 1) HUMULIN N KWIKPEN

MO $0 (Tier 1) HUMULIN R

$0 (Tier 1) HUMULIN R U-500 (CONC) KWIKPEN

MO $0 (Tier 1) HUMULIN R U-500 (CONCENTRATED)

MO; QLL (200 per 30 days) $0 (Tier 1) insulin pen needle

MO; QLL (200 per 30 days) $0 (Tier 1) INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML




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MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) JANUMET

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) JANUVIA ORAL TABLET 100 MG



PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) JARDIANCE

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) JENTADUETO

MO $0 (Tier 1) LANTUS

MO $0 (Tier 1) LANTUS SOLOSTAR

MO $0 (Tier 1) LEVEMIR

MO $0 (Tier 1) LEVEMIR FLEXTOUCH

MO; QLL (76 per 30 days) $0 (Tier 1) metformin oral tablet 1,000 mg

MO; QLL (153 per 30 days) $0 (Tier 1) metformin oral tablet 500 mg

MO; QLL (90 per 30 days) $0 (Tier 1) metformin oral tablet 850 mg

MO; QLL (120 per 30 days) $0 (Tier 1) metformin oral tablet extended release 24 hr 500 mg

MO; QLL (80 per 30 days) $0 (Tier 1) metformin oral tablet extended release 24 hr 750 mg

MO; QLL (75 per 30 days) $0 (Tier 1) metformin oral tablet extended release 24hr 1,000 mg

MO; QLL (150 per 30 days) $0 (Tier 1) metformin oral tablet extended release 24hr 500 mg

MO; QLL (90 per 30 days) $0 (Tier 1) nateglinide oral tablet 120 mg

MO; QLL (180 per 30 days) $0 (Tier 1) nateglinide oral tablet 60 mg

MO; QLL (200 per 30 days) $0 (Tier 1) needles, insulin disp.,safety

MO; QLL (200 per 30 days) $0 (Tier 1) NOVOPEN ECHO

MO; QLL (90 per 30 days) $0 (Tier 1) pioglitazone oral tablet 15 mg




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MO; QLL (30 per 30 days) $0 (Tier 1) pioglitazone-glimepiride

MO; QLL (90 per 30 days) $0 (Tier 1) pioglitazone-metformin

MO $0-$7.40 (Tier 2) PROGLYCEM

MO; QLL (150 per 30 days) $0-$7.40 (Tier 2) repaglinide-metformin

PAR; MO; QLL (11 per 30 days) $0-$7.40 (Tier 2) SYMLINPEN 120

PAR; MO; QLL (6 per 30 days) $0-$7.40 (Tier 2) SYMLINPEN 60

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) SYNJARDY

MO; QLL (4 per 28 days) $0-$7.40 (Tier 2) TANZEUM

MO; QLL (120 per 30 days) $0 (Tier 1) tolazamide oral tablet 250 mg

MO; QLL (60 per 30 days) $0 (Tier 1) tolazamide oral tablet 500 mg

MO; QLL (180 per 30 days) $0 (Tier 1) tolbutamide

MO $0-$7.40 (Tier 2) TOUJEO SOLOSTAR

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) TRADJENTA

MO; QLL (2 per 28 days) $0-$7.40 (Tier 2) TRULICITY

MO; QLL (9 per 30 days) $0-$7.40 (Tier 2) VICTOZA 2-PAK

MO; QLL (9 per 30 days) $0-$7.40 (Tier 2) VICTOZA 3-PAK

MISCELLANEOUS HORMONES PAR; MO $0-$7.40 (Tier 2) ALDURAZYME

PAR; MO; QLL (150 per 30 days) $0-$7.40 (Tier 2) ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)

PAR; MO; QLL (112.5 per 30 days) $0-$7.40 (Tier 2) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM)

PAR; MO; QLL (150 per 30 days) $0-$7.40 (Tier 2) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM)

PAR; MO $0-$7.40 (Tier 2) ANDROXY

MO $0-$7.40 (Tier 2) cabergoline

MO; QLL (4 per 30 days) $0-$7.40 (Tier 2) calcitonin (salmon)




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MO $0-$7.40 (Tier 2) calcitriol intravenous solution 1 mcg/ml

B/D PAR; MO $0-$7.40 (Tier 2) calcitriol oral

PAR; MO $0-$7.40 (Tier 2) CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

MO $0-$7.40 (Tier 2) danazol oral

MO $0-$7.40 (Tier 2) desmopressin injection

MO $0-$7.40 (Tier 2) desmopressin nasal

MO $0-$7.40 (Tier 2) desmopressin oral

B/D PAR $0-$7.40 (Tier 2) doxercalciferol intravenous

B/D PAR; MO $0-$7.40 (Tier 2) doxercalciferol oral

PAR; MO $0-$7.40 (Tier 2) ELAPRASE

PAR; MO $0-$7.40 (Tier 2) FABRAZYME

PAR; MO $0-$7.40 (Tier 2) KORLYM

PAR; MO $0-$7.40 (Tier 2) KUVAN ORAL TABLET,SOLUBLE

B/D PAR; MO $0-$7.40 (Tier 2) MIACALCIN INJECTION

PAR; MO $0-$7.40 (Tier 2) MYOZYME

PAR; MO; LA $0-$7.40 (Tier 2) NAGLAZYME

PAR; MO; LA; QLL (2 per 28 days) $0-$7.40 (Tier 2) NATPARA

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) oxandrolone oral tablet 10 mg

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) oxandrolone oral tablet 2.5 mg

MO $0-$7.40 (Tier 2) pamidronate intravenous recon soln

MO $0-$7.40 (Tier 2) pamidronate intravenous solution 30 mg/10 ml (3 mg/ml), 90 mg/10 ml (9 mg/ml)

B/D PAR; MO $0-$7.40 (Tier 2) pamidronate intravenous solution 60 mg/10 ml (6 mg/ml)

B/D PAR; MO $0-$7.40 (Tier 2) paricalcitol oral

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) SENSIPAR ORAL TABLET 30 MG, 60 MG

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) SENSIPAR ORAL TABLET 90 MG

PAR; MO $0-$7.40 (Tier 2) SOMAVERT

MO $0-$7.40 (Tier 2) STIMATE




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PAR; MO $0-$7.40 (Tier 2) SYNAREL

MO $0-$7.40 (Tier 2) testosterone cypionate

MO $0-$7.40 (Tier 2) testosterone enanthate

PAR; MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) testosterone transdermal gel

PAR; MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) testosterone transdermal gel in metered-dose pump 1.25 gram/ actuation (1 %)

PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation

PAR; MO; QLL (225 per 30 days) $0-$7.40 (Tier 2) testosterone transdermal gel in packet 1 % (25 mg/ 2.5gram)

PAR; MO; QLL (300 per 30 days) $0-$7.40 (Tier 2) testosterone transdermal gel in packet 1 % (50 mg/ 5 gram)

PAR; MO $0-$7.40 (Tier 2) VPRIV

PAR; MO; LA $0-$7.40 (Tier 2) ZAVESCA

B/D PAR; MO $0-$7.40 (Tier 2) ZEMPLAR INTRAVENOUS

PAR $0-$7.40 (Tier 2) zoledronic acid intravenous recon soln 4 mg

PAR; MO $0-$7.40 (Tier 2) zoledronic acid intravenous solution 4 mg/5 ml

PAR; MO $0-$7.40 (Tier 2) ZOMETA INTRAVENOUS SOLUTION 4 MG/ 100 ML

THYROID HORMONES MO $0 (Tier 1) levothyroxine oral

MO $0-$7.40 (Tier 2) levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

MO $0-$7.40 (Tier 2) liothyronine oral

MO $0-$7.40 (Tier 2) SYNTHROID

MO $0-$7.40 (Tier 2) UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG




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GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS

[*] $0 (Tier 4) ANTI-DIARRHEA

[*] $0 (Tier 4) ANTI-DIARRHEAL

[*] $0 (Tier 4) ANTI-DIARRHEAL (LOPERAMIDE) ORAL CAPSULE

[*] $0 (Tier 4) ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/5 ML

MO; [*] $0 (Tier 4) ANTI-DIARRHEAL (LOPERAMIDE) ORAL TABLET

$0-$7.40 (Tier 2) atropine injection syringe 0.05 mg/ml, 0.1 mg/ml

MO; [*] $0 (Tier 4) BISMATROL ORAL SUSPENSION 262 MG/15 ML

[*] $0 (Tier 4) BISMATROL ORAL SUSPENSION 525 MG/15 ML

[*] $0 (Tier 4) BISMATROL ORAL TABLET,CHEWABLE

[*] $0 (Tier 4) BISMUTH

[*] $0 (Tier 4) BISMUTH MAXIMUM STRENGTH

[*] $0 (Tier 4) bismuth subsalicylate oral tablet,chewable

[*] $0 (Tier 4) DIAMODE

[*] $0 (Tier 4) DIARRHEA RELIEF (BISMUTH SUBS)

MO $0-$7.40 (Tier 2) dicyclomine oral capsule

MO $0-$7.40 (Tier 2) dicyclomine oral solution

MO $0-$7.40 (Tier 2) dicyclomine oral tablet

[*] $0 (Tier 4) DIOTAME

MO $0-$7.40 (Tier 2) diphenoxylate-atropine

[*] $0 (Tier 4) GERI-PECTATE

MO $0-$7.40 (Tier 2) glycopyrrolate oral

MO; [*] $0 (Tier 4) IMODIUM A-D ORAL LIQUID

[*] $0 (Tier 4) K-PEC ANTIDIARRHEAL (BISM SUB)




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[*] $0 (Tier 4) KAO-TIN (BISMUTH SUBSALICYLAT)

MO; [*] $0 (Tier 4) KAOPECTATE (BISMUTH SUBSALICY)

[*] $0 (Tier 4) KAOPECTATE EX STR (BISMUTH SS)

MO $0-$7.40 (Tier 2) loperamide oral capsule

MO; [*] $0 (Tier 4) loperamide oral liquid 1 mg/5 ml

[*] $0 (Tier 4) loperamide oral liquid 1 mg/7.5 ml

[*] $0 (Tier 4) loperamide oral tablet

MO $0-$7.40 (Tier 2) OPIUM TINCTURE

[*] $0 (Tier 4) PEPTIC RELIEF

MO; [*] $0 (Tier 4) PEPTO-BISMOL

MO; [*] $0 (Tier 4) PEPTO-BISMOL MAX ST

[*] $0 (Tier 4) PEPTO-BISMOL TO-GO

[*] $0 (Tier 4) PINK BISMUTH MAXIMUM STRENGTH

[*] $0 (Tier 4) PINK BISMUTH ORAL SUSPENSION

[*] $0 (Tier 4) PINK BISMUTH ORAL TABLET

MO; [*] $0 (Tier 4) PINK BISMUTH ORAL TABLET,CHEWABLE

[*] $0 (Tier 4) SOOTHE (BISMUTH SUBSALICYLATE)

[*] $0 (Tier 4) SOOTHE REGULAR STRENGTH

[*] $0 (Tier 4) STOMACH RELIEF

[*] $0 (Tier 4) STOMACH RELIEF MAX STRENGTH

[*] $0 (Tier 4) STOMACH RELIEF ORIGINAL

MISCELLANEOUS GASTROINTESTINAL AGENTS [*] $0 (Tier 4) ACID GONE ANTACID

[*] $0 (Tier 4) ACID GONE ANTACID E.STRENGTH

[*] $0 (Tier 4) ADVANCED ANTACID-ANTIGAS

[*] $0 (Tier 4) ALMACONE ORAL SUSPENSION

MO; [*] $0 (Tier 4) ALMACONE ORAL TABLET,CHEWABLE

[*] $0 (Tier 4) ALMACONE-2

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) alosetron




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MO; [*] $0 (Tier 4) aluminum hydroxide gel oral suspension 320 mg/5 ml

[*] $0 (Tier 4) aluminum hydroxide gel oral suspension 600 mg/5 ml

MO $0-$7.40 (Tier 2) AMITIZA

[*] $0 (Tier 4) ANTACID

[*] $0 (Tier 4) ANTACID ANTI-GAS

[*] $0 (Tier 4) ANTACID ANTI-GAS DOUBLE STR

[*] $0 (Tier 4) ANTACID EXST (MAG CARB-AL HYD)

[*] $0 (Tier 4) ANTACID EXTRA-STRENGTH ORAL SUSPENSION 200-200-20 MG/5 ML

[*] $0 (Tier 4) ANTACID LIQUID

[*] $0 (Tier 4) ANTACID M

[*] $0 (Tier 4) ANTACID MAXIMUM STRENGTH

[*] $0 (Tier 4) ANTACID PLUS ANTI-GAS

[*] $0 (Tier 4) ANTACID REGULAR STRENGTH

[*] $0 (Tier 4) ANTACID WITH SIMETHICONE

[*] $0 (Tier 4) ANTACID-ANTIGAS

[*] $0 (Tier 4) ANTACID-SIMETHICONE

[*] $0 (Tier 4) ANTI-GAS ULTRA STRENGTH

MO $0-$7.40 (Tier 2) APRISO

MO $0-$7.40 (Tier 2) ASACOL HD

MO $0-$7.40 (Tier 2) balsalazide

MO; [*] $0 (Tier 4) BISAC-EVAC

MO; [*] $0 (Tier 4) bisacodyl rectal

MO; [*] $0 (Tier 4) BISCOLAX

MO $0-$7.40 (Tier 2) budesonide oral

MO $0-$7.40 (Tier 2) CANASA

[*] $0 (Tier 4) CHILDREN'S PEPTO

[*] $0 (Tier 4) CHILDREN'S SOOTHE




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PAR; MO; QLL (6 per 28 days) $0-$7.40 (Tier 2) CIMZIA

PAR; MO; QLL (6 per 28 days) $0-$7.40 (Tier 2) CIMZIA POWDER FOR RECONST

PAR; MO; QLL (6 per 28 days) $0-$7.40 (Tier 2) CIMZIA STARTER KIT

[*] $0 (Tier 4) CITRATE OF MAGNESIA

[*] $0 (Tier 4) CITROMA

MO; [*] $0 (Tier 4) CITRUCEL

[*] $0 (Tier 4) CLEARLAX

[*] $0 (Tier 4) COL-RITE ORAL CAPSULE 250 MG

MO $0-$7.40 (Tier 2) colocort

[*] $0 (Tier 4) COMFORT GEL

[*] $0 (Tier 4) COMFORT GEL EXTRA STRENGTH

PAR; MO $0-$7.40 (Tier 2) compro

MO $0-$7.40 (Tier 2) constulose

MO $0-$7.40 (Tier 2) CREON

MO $0-$7.40 (Tier 2) CYSTADANE

$0-$7.40 (Tier 2) DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS)

MO $0-$7.40 (Tier 2) DIPENTUM

[*] $0 (Tier 4) docusate sodium oral capsule 250 mg

[*] $0 (Tier 4) DOK ORAL CAPSULE 250 MG

B/D PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) dronabinol

[*] $0 (Tier 4) DSS

B/D PAR; MO; QLL (5 per 30 days) $0-$7.40 (Tier 2) EMEND ORAL CAPSULE 125 MG



B/D PAR; MO; QLL (15 per 30 days) $0-$7.40 (Tier 2) EMEND ORAL CAPSULE,DOSE PACK

B/D PAR; QLL (15 per 30 days) $0-$7.40 (Tier 2) EMEND ORAL SUSPENSION FOR RECONSTITUTION

MO $0-$7.40 (Tier 2) enulose




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[*] $0 (Tier 4) EVAC-U-GEN (SENNOSIDES)

MO; [*] $0 (Tier 4) FIBER (CALCIUM POLYCARBOPHIL)

[*] $0 (Tier 4) FIBER (PSYLLIUM HUSK)

[*] $0 (Tier 4) FIBER LAXATIVE (CA POLYCARBO)

[*] $0 (Tier 4) FIBER LAXATIVE (METHYLCELLULO)

MO; [*] $0 (Tier 4) FIBER LAXATIVE (PSYLLIUM HUSK)

[*] $0 (Tier 4) FIBER THERAPY (CA POLYCARBOPH)

[*] $0 (Tier 4) FIBER THERAPY (M-CELLULOSE)

[*] $0 (Tier 4) FIBER THERAPY LAXATIVE (HUSK)

[*] $0 (Tier 4) FIBER-CAPS (PSYLLIUM HUSK)

MO; [*] $0 (Tier 4) FIBER-LAX

[*] $0 (Tier 4) FIBER-TABS

[*] $0 (Tier 4) FLANAX ANTACID

[*] $0 (Tier 4) FLEET GLYCERIN (ADULT)

[*] $0 (Tier 4) FOAMING ANTACID ORAL SUSPENSION

[*] $0 (Tier 4) GAS RELIEF 80

[*] $0 (Tier 4) GAS RELIEF EXTRA STRENGTH

[*] $0 (Tier 4) GAS RELIEF ORAL CAPSULE

MO; [*] $0 (Tier 4) GAS RELIEF ORAL DROPS,SUSPENSION

MO; [*] $0 (Tier 4) GAS RELIEF ORAL TABLET,CHEWABLE

[*] $0 (Tier 4) GAS RELIEF ULTRA STRENGTH

MO; [*] $0 (Tier 4) GAS-X EXTRA STRENGTH

MO; [*] $0 (Tier 4) GAS-X ORAL TABLET,CHEWABLE

[*] $0 (Tier 4) GAS-X ULTRA-STRENGTH

MO $0-$7.40 (Tier 2) GATTEX 30-VIAL

MO $0-$7.40 (Tier 2) GATTEX ONE-VIAL

MO; [*] $0 (Tier 4) GAVILAX ORAL POWDER

MO $0-$7.40 (Tier 2) gavilyte-c

MO $0-$7.40 (Tier 2) gavilyte-g




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MO $0-$7.40 (Tier 2) gavilyte-n

MO; [*] $0 (Tier 4) GAVISCON EXTRA STRENGTH

MO; [*] $0 (Tier 4) GAVISCON ORAL SUSPENSION

MO; [*] $0 (Tier 4) GELUSIL ANTACID AND ANTI-GAS ORAL TABLET,CHEWABLE

MO $0-$7.40 (Tier 2) generlac

[*] $0 (Tier 4) GENTLE LAXATIVE RECTAL

[*] $0 (Tier 4) GENTLELAX

[*] $0 (Tier 4) GERI-KOT

[*] $0 (Tier 4) GERI-LANTA

[*] $0 (Tier 4) GERI-MOX ANTACID-ANTIGAS

[*] $0 (Tier 4) glycerin (adult)

[*] $0 (Tier 4) glycerin (child)

[*] $0 (Tier 4) GLYCOLAX ORAL POWDER

[*] $0 (Tier 4) HEALTHYLAX

[*] $0 (Tier 4) HEARTBURN ANTACID

[*] $0 (Tier 4) HEARTBURN RELIEF

$0-$7.40 (Tier 2) hydrocortisone rectal cream 2.5 %

MO $0-$7.40 (Tier 2) hydrocortisone rectal enema

[*] $0 (Tier 4) INFANTS GAS RELIEF

[*] $0 (Tier 4) KONSYL FIBER

MO; [*] $0 (Tier 4) KONSYL SUGAR-FREE ORAL CAPSULE

MO $0-$7.40 (Tier 2) lactulose oral solution 10 gram/15 ml

MO $0-$7.40 (Tier 2) LACTULOSE ORAL SOLUTION 10 GRAM/15 ML (15 ML), 20 GRAM/30 ML

[*] $0 (Tier 4) LAXA CLEAR

[*] $0 (Tier 4) LAXATIVE (BISACODYL) RECTAL

[*] $0 (Tier 4) LAXATIVE (GLYCERIN-PEDIATRIC)

[*] $0 (Tier 4) LAXATIVE PEG 3350 ORAL POWDER




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MO $0-$7.40 (Tier 2) LIALDA

MO $0-$7.40 (Tier 2) LINZESS

[*] $0 (Tier 4) LIQUID ANTACID

MO; [*] $0 (Tier 4) MAALOX MAXIMUM STRENGTH

[*] $0 (Tier 4) MAG-AL PLUS

[*] $0 (Tier 4) MAG-AL PLUS EXTRA STRENGTH

MO; [*] $0 (Tier 4) magnesium citrate oral solution

[*] $0 (Tier 4) MASANTI DOUBLE STRENGTH

MO $0-$7.40 (Tier 2) meclizine oral tablet 12.5 mg, 25 mg

[*] $0 (Tier 4) meclizine oral tablet,chewable

$0-$7.40 (Tier 2) MESALAMINE ORAL

MO $0-$7.40 (Tier 2) mesalamine rectal

MO $0-$7.40 (Tier 2) mesalamine with cleansing wipe

MO $0-$7.40 (Tier 2) metoclopramide hcl injection solution

$0-$7.40 (Tier 2) METOCLOPRAMIDE HCL INJECTION SYRINGE

MO $0-$7.40 (Tier 2) metoclopramide hcl oral solution

MO $0-$7.40 (Tier 2) metoclopramide hcl oral tablet

[*] $0 (Tier 4) MI-ACID GAS RELIEF

MO; [*] $0 (Tier 4) MI-ACID ORAL SUSPENSION

[*] $0 (Tier 4) MI-ACID ORAL TABLET,CHEWABLE

MO; [*] $0 (Tier 4) MILK OF MAGNESIA

MO; [*] $0 (Tier 4) MINTOX

MO; [*] $0 (Tier 4) MINTOX MAXIMUM STRENGTH

MO; [*] $0 (Tier 4) MINTOX PLUS

MO; [*] $0 (Tier 4) MIRALAX

[*] $0 (Tier 4) MOTION SICKNESS RELIEF(MECLIZ) ORAL TABLET,CHEWABLE

[*] $0 (Tier 4) MOTION-TIME




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MO $0-$7.40 (Tier 2) MOVIPREP

[*] $0 (Tier 4) MYTAB GAS

[*] $0 (Tier 4) MYTAB GAS MAXIMUM STRENGTH

[*] $0 (Tier 4) NATURAL FIBER LAXATIVE

[*] $0 (Tier 4) NATURAL VEG LAXATIVE(SENNOSID)

MO $0-$7.40 (Tier 2) ondansetron hcl (pf) injection solution

$0-$7.40 (Tier 2) ondansetron hcl (pf) injection syringe

MO $0-$7.40 (Tier 2) ondansetron hcl intravenous

B/D PAR; MO; QLL (450 per 30 days) $0-$7.40 (Tier 2) ondansetron hcl oral solution

B/D PAR; QLL (30 per 30 days) $0-$7.40 (Tier 2) ondansetron hcl oral tablet 24 mg

B/D PAR; MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) ondansetron hcl oral tablet 4 mg, 8 mg

B/D PAR; MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) ondansetron odt

MO $0-$7.40 (Tier 2) peg 3350-electrolytes oral recon soln 236-22.74- 6.74 -5.86 gram

$0-$7.40 (Tier 2) peg 3350-electrolytes oral recon soln 240-22.72- 6.72 -5.84 gram

$0-$7.40 (Tier 2) peg-electrolyte soln

[*] $0 (Tier 4) PEG3350

MO $0-$7.40 (Tier 2) PENTASA

MO; [*] $0 (Tier 4) PHAZYME ORAL CAPSULE 180 MG

MO $0-$7.40 (Tier 2) polyethylene glycol 3350 oral powder

MO; [*] $0 (Tier 4) polyethylene glycol 3350 oral powder in packet

[*] $0 (Tier 4) POWDERLAX

PAR; MO $0-$7.40 (Tier 2) prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml)

PAR; MO $0-$7.40 (Tier 2) prochlorperazine maleate oral

PAR; MO $0-$7.40 (Tier 2) prochlorperazine maleate rectal

MO $0-$7.40 (Tier 2) procto-pak

MO $0-$7.40 (Tier 2) proctosol hc

MO $0-$7.40 (Tier 2) proctozone-hc




de clase)


[*] $0 (Tier 4) psyllium husk oral capsule 0.52 gram

[*] $0 (Tier 4) PURELAX

[*] $0 (Tier 4) REGULOID ORAL CAPSULE

PAR; MO $0-$7.40 (Tier 2) RELISTOR SUBCUTANEOUS SOLUTION

PAR; MO $0-$7.40 (Tier 2) RELISTOR SUBCUTANEOUS SYRINGE

PAR; MO $0-$7.40 (Tier 2) REMICADE

[*] $0 (Tier 4) RI-GEL

[*] $0 (Tier 4) RI-GEL II

[*] $0 (Tier 4) RI-MOX

[*] $0 (Tier 4) RI-MOX PLUS

[*] $0 (Tier 4) RULOX

MO; [*] $0 (Tier 4) SANI-SUPP (ADULT)

MO; [*] $0 (Tier 4) SANI-SUPP (INFANT)

[*] $0 (Tier 4) SEN-O-TAB

MO; [*] $0 (Tier 4) SENEXON ORAL TABLET

MO; [*] $0 (Tier 4) SENNA LAX

[*] $0 (Tier 4) SENNA LAXATIVE ORAL TABLET 8.6 MG

[*] $0 (Tier 4) SENNA ORAL TABLET

MO; [*] $0 (Tier 4) SENNA-GEN

[*] $0 (Tier 4) SENNO

[*] $0 (Tier 4) simethicone oral

[*] $0 (Tier 4) SMOOTHLAX

MO; [*] $0 (Tier 4) sodium bicarbonate oral

[*] $0 (Tier 4) SOLUBLE FIBER

MO; [*] $0 (Tier 4) STOOL SOFTENER ORAL CAPSULE 250 MG

MO $0-$7.40 (Tier 2) sulfasalazine

[*] $0 (Tier 4) SUPPOSITORY ADULT

MO; [*] $0 (Tier 4) THE MAGIC BULLET

MO; [*] $0 (Tier 4) TRAVEL SICKNESS (MECLIZINE)




de clase)


MO $0-$7.40 (Tier 2) ursodiol

[*] $0 (Tier 4) VEGETABLE LAXATIVE

[*] $0 (Tier 4) WAL-MUCIL FIBER

MO $0-$7.40 (Tier 2) ZENPEP

ULCER THERAPY [*] $0 (Tier 4) ACID CONTROL (RANITIDINE) ORAL TABLET

150 MG

[*] $0 (Tier 4) ACID CONTROLLER

[*] $0 (Tier 4) ACID CONTROLLER COMPLETE

[*] $0 (Tier 4) ACID REDUCER (CIMETIDINE)

[*] $0 (Tier 4) ACID REDUCER (FAMOTIDINE)

[*] $0 (Tier 4) ACID REDUCER (RANITIDINE)

[*] $0 (Tier 4) ACID REDUCER COMPLETE (FAMOT)

MO; [*] $0 (Tier 4) cimetidine oral tablet 200 mg

[*] $0 (Tier 4) COMPLETE ORAL TABLET,CHEWABLE

ST; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) DEXILANT

[*] $0 (Tier 4) DUAL ACTION COMPLETE

MO $0-$7.40 (Tier 2) famotidine (pf)

$0-$7.40 (Tier 2) famotidine (pf)-nacl (iso-os)

MO $0-$7.40 (Tier 2) famotidine intravenous

MO $0-$7.40 (Tier 2) famotidine oral suspension

MO; [*] $0 (Tier 4) famotidine oral tablet 10 mg

MO $0-$7.40 (Tier 2) famotidine oral tablet 20 mg, 40 mg

[*] $0 (Tier 4) HEARTBURN PREVENTION ORAL TABLET 10 MG

[*] $0 (Tier 4) HEARTBURN RELIEF (CIMETIDINE)

[*] $0 (Tier 4) HEARTBURN RELIEF (FAMOTIDINE)

[*] $0 (Tier 4) HEARTBURN RELIEF (RANITIDINE)

[*]; QLL (30 per 30 days) $0 (Tier 4) HEARTBURN TREATMENT 24 HOUR




de clase)


MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) lansoprazole oral capsule,delayed release(dr/ec)

MO $0-$7.40 (Tier 2) misoprostol

[*] $0 (Tier 4) OMEPRAZOLE MAGNESIUM

MO; QLL (30 per 30 days) $0 (Tier 1) omeprazole oral capsule,delayed release(dr/ec)

MO; [*] $0 (Tier 4) OMEPRAZOLE ORAL TABLET,DELAYED RELEASE (DR/EC)

MO $0-$7.40 (Tier 2) pantoprazole intravenous

MO; QLL (30 per 30 days) $0 (Tier 1) pantoprazole oral

MO; [*] $0 (Tier 4) PEPCID AC ORAL TABLET 20 MG

MO; [*]; QLL (30 per 30 days) $0 (Tier 4) PREVACID 24HR

MO $0-$7.40 (Tier 2) PROTONIX INTRAVENOUS

MO $0-$7.40 (Tier 2) ranitidine hcl injection solution 25 mg/ml

MO $0-$7.40 (Tier 2) ranitidine hcl oral syrup

MO $0-$7.40 (Tier 2) ranitidine hcl oral tablet 150 mg, 300 mg

MO; [*] $0 (Tier 4) ranitidine hcl oral tablet 75 mg

MO $0-$7.40 (Tier 2) sucralfate oral tablet

MO; [*] $0 (Tier 4) TAGAMET HB

[*] $0 (Tier 4) TUMS DUAL ACTION (FAMOTIDINE)

[*] $0 (Tier 4) WAL-ZAN 150

[*] $0 (Tier 4) WAL-ZAN 75

MO; [*] $0 (Tier 4) ZANTAC 75

MO; [*] $0 (Tier 4) ZANTAC MAXIMUM STRENGTH

MO; [*] $0 (Tier 4) zantac oral tablet 150 mg

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS

PAR; MO $0-$7.40 (Tier 2) ACTIMMUNE

PAR; MO $0-$7.40 (Tier 2) ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ ML




de clase)


PAR; MO $0-$7.40 (Tier 2) ARANESP (IN POLYSORBATE) INJECTION SYRINGE

PAR; MO $0-$7.40 (Tier 2) ARCALYST

PAR; MO; QLL (4 per 28 days) $0-$7.40 (Tier 2) AVONEX (WITH ALBUMIN)

PAR; MO; QLL (4 per 28 days) $0-$7.40 (Tier 2) AVONEX INTRAMUSCULAR PEN INJECTOR KIT

PAR; MO; QLL (4 per 28 days) $0-$7.40 (Tier 2) AVONEX INTRAMUSCULAR SYRINGE

PAR; MO; QLL (4 per 28 days) $0-$7.40 (Tier 2) AVONEX INTRAMUSCULAR SYRINGE KIT

PAR; MO $0-$7.40 (Tier 2) EXTAVIA SUBCUTANEOUS KIT

PAR $0-$7.40 (Tier 2) EXTAVIA SUBCUTANEOUS RECON SOLN

PAR; MO; LA $0-$7.40 (Tier 2) ILARIS (PF)

PAR; MO $0-$7.40 (Tier 2) INTRON A INJECTION

PAR; MO $0-$7.40 (Tier 2) NEUPOGEN

PAR; MO $0-$7.40 (Tier 2) NORDITROPIN FLEXPRO

PAR; MO $0-$7.40 (Tier 2) OMNITROPE

PAR; MO $0-$7.40 (Tier 2) PEGASYS

PAR; MO $0-$7.40 (Tier 2) PEGASYS PROCLICK

PAR; MO $0-$7.40 (Tier 2) PEGINTRON

PAR; MO $0-$7.40 (Tier 2) PEGINTRON REDIPEN

PAR; MO; QLL (12 per 28 days) $0-$7.40 (Tier 2) PROCRIT

MO $0-$7.40 (Tier 2) PROLEUKIN

PAR; MO $0-$7.40 (Tier 2) REBIF (WITH ALBUMIN)

PAR; MO $0-$7.40 (Tier 2) REBIF REBIDOSE

PAR; MO $0-$7.40 (Tier 2) REBIF TITRATION PACK

PAR; MO $0-$7.40 (Tier 2) SYLATRON

VACCINES / MISCELLANEOUS IMMUNOLOGICALS MO $0 (Tier 1) ACTHIB (PF)

MO $0 (Tier 1) ADACEL(TDAP ADOLESN/ADULT)(PF)

B/D PAR $0-$7.40 (Tier 2) ATGAM




de clase)


MO $0-$7.40 (Tier 2) BCG VACCINE, LIVE (PF)

MO $0-$7.40 (Tier 2) BEXSERO (PF)

MO $0 (Tier 1) BOOSTRIX TDAP

PAR; MO $0-$7.40 (Tier 2) CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM

MO $0 (Tier 1) CERVARIX VACCINE (PF)

MO $0 (Tier 1) DAPTACEL (DTAP PEDIATRIC) (PF)

B/D PAR; MO $0 (Tier 1) ENGERIX-B (PF)

B/D PAR; MO $0 (Tier 1) ENGERIX-B PEDIATRIC (PF)

PAR; MO $0-$7.40 (Tier 2) GAMASTAN S/D

PAR; MO $0-$7.40 (Tier 2) GAMMAGARD LIQUID

PAR; MO $0-$7.40 (Tier 2) GAMMAGARD S-D (IGA < 1 MCG/ML)

PAR; MO $0-$7.40 (Tier 2) GAMMAPLEX

PAR; MO $0-$7.40 (Tier 2) GAMUNEX-C

MO $0-$7.40 (Tier 2) GARDASIL (PF)

MO $0-$7.40 (Tier 2) GARDASIL 9 (PF)

MO $0 (Tier 1) HAVRIX (PF) INTRAMUSCULAR SUSPENSION

MO $0 (Tier 1) HAVRIX (PF) INTRAMUSCULAR SYRINGE 1, 440 ELISA UNIT/ML

$0 (Tier 1) HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML

$0 (Tier 1) HIBERIX (PF)

MO $0-$7.40 (Tier 2) IMOVAX RABIES VACCINE (PF)

MO $0-$7.40 (Tier 2) INFANRIX (DTAP) (PF)

MO $0 (Tier 1) IPOL INJECTION SUSPENSION

MO $0-$7.40 (Tier 2) IXIARO (PF)

MO $0 (Tier 1) M-M-R II (PF)

MO $0-$7.40 (Tier 2) MENACTRA (PF) INTRAMUSCULAR SOLUTION




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$0-$7.40 (Tier 2) MENOMUNE - A/C/Y/W-135

MO $0-$7.40 (Tier 2) MENOMUNE - A/C/Y/W-135 (PF)

MO $0-$7.40 (Tier 2) MENVEO A-C-Y-W-135-DIP (PF)

PAR; MO $0-$7.40 (Tier 2) OCTAGAM

MO $0 (Tier 1) PEDVAX HIB (PF)

PAR; MO $0-$7.40 (Tier 2) PRIVIGEN

MO $0-$7.40 (Tier 2) PROQUAD (PF)

$0-$7.40 (Tier 2) QUADRACEL (PF)

MO $0-$7.40 (Tier 2) RABAVERT (PF)

B/D PAR; MO $0 (Tier 1) RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

MO $0 (Tier 1) RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML

$0 (Tier 1) RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML

$0-$7.40 (Tier 2) ROTARIX

MO $0 (Tier 1) ROTATEQ VACCINE

MO $0-$7.40 (Tier 2) tetanus,diphtheria tox ped(pf)

MO $0 (Tier 1) TETANUS-DIPHTHERIA TOXOIDS-TD

B/D PAR $0-$7.40 (Tier 2) THYMOGLOBULIN

MO $0-$7.40 (Tier 2) TICE BCG

MO $0-$7.40 (Tier 2) TRUMENBA

MO $0 (Tier 1) TWINRIX (PF)

$0-$7.40 (Tier 2) TYPHIM VI INTRAMUSCULAR SOLUTION

MO $0-$7.40 (Tier 2) TYPHIM VI INTRAMUSCULAR SYRINGE

MO $0-$7.40 (Tier 2) VAQTA (PF) INTRAMUSCULAR SUSPENSION

$0-$7.40 (Tier 2) VAQTA (PF) INTRAMUSCULAR SYRINGE

MO $0-$7.40 (Tier 2) VARIVAX (PF)

MO $0-$7.40 (Tier 2) VARIZIG

MO $0-$7.40 (Tier 2) YF-VAX (PF)




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MO $0-$7.40 (Tier 2) ZOSTAVAX (PF)

MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY

MO $0-$7.40 (Tier 2) allopurinol

MO $0-$7.40 (Tier 2) colchicine-probenecid

MO $0-$7.40 (Tier 2) COLCRYS

MO $0-$7.40 (Tier 2) probenecid

ST; MO $0-$7.40 (Tier 2) ULORIC

OSTEOPOROSIS THERAPY MO; QLL (300 per 28 days) $0-$7.40 (Tier 2) alendronate oral solution

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) alendronate oral tablet 10 mg, 5 mg

MO; QLL (4 per 28 days) $0-$7.40 (Tier 2) alendronate oral tablet 35 mg, 70 mg

B/D PAR; MO $0-$7.40 (Tier 2) BONIVA INTRAVENOUS

PAR; MO; QLL (3 per 28 days) $0-$7.40 (Tier 2) FORTEO

B/D PAR; MO $0-$7.40 (Tier 2) ibandronate intravenous solution

MO $0-$7.40 (Tier 2) ibandronate intravenous syringe

MO; QLL (1 per 28 days) $0-$7.40 (Tier 2) ibandronate oral

PAR; MO; QLL (2 per 365 days) $0-$7.40 (Tier 2) PROLIA

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) raloxifene

OTHER RHEUMATOLOGICALS PAR; MO $0-$7.40 (Tier 2) ACTEMRA INTRAVENOUS

PAR; MO $0-$7.40 (Tier 2) ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML)

PAR; MO $0-$7.40 (Tier 2) BENLYSTA

MO $0-$7.40 (Tier 2) DEPEN TITRATABS

PAR; MO; QLL (8 per 28 days) $0-$7.40 (Tier 2) ENBREL SUBCUTANEOUS RECON SOLN

PAR; MO; QLL (4.08 per 28 days) $0-$7.40 (Tier 2) ENBREL SUBCUTANEOUS SYRINGE 25 MG/ 0.5ML (0.51)




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PAR; MO; QLL (8 per 28 days) $0-$7.40 (Tier 2) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ ML (0.98 ML)

PAR; MO; QLL (8 per 28 days) $0-$7.40 (Tier 2) ENBREL SURECLICK

PAR; MO; QLL (4.8 per 365 days) $0-$7.40 (Tier 2) HUMIRA PEDIATRIC CROHN'S START

PAR; MO; QLL (3.2 per 28 days) $0-$7.40 (Tier 2) HUMIRA PEN

PAR; MO; QLL (9.6 per 365 days) $0-$7.40 (Tier 2) HUMIRA PEN CROHN'S-UC-HS START

PAR; MO; QLL (3.2 per 28 days) $0-$7.40 (Tier 2) HUMIRA PEN PSORIASIS-UVEITIS

PAR; MO; QLL (2 per 28 days) $0-$7.40 (Tier 2) HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML

PAR; MO; QLL (3.2 per 28 days) $0-$7.40 (Tier 2) HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML

PAR; MO; QLL (28 per 28 days) $0-$7.40 (Tier 2) KINERET

MO $0-$7.40 (Tier 2) leflunomide

PAR; MO; QLL (4 per 28 days) $0-$7.40 (Tier 2) ORENCIA

PAR; MO $0-$7.40 (Tier 2) ORENCIA (WITH MALTOSE)

MO $0-$7.40 (Tier 2) RIDAURA

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) SAVELLA ORAL TABLET 100 MG

MO; QLL (480 per 30 days) $0-$7.40 (Tier 2) SAVELLA ORAL TABLET 12.5 MG



MO; QLL (110 per 365 days) $0-$7.40 (Tier 2) SAVELLA ORAL TABLETS,DOSE PACK

PAR; MO; QLL (1 per 28 days) $0-$7.40 (Tier 2) SIMPONI

OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS

MO $0-$7.40 (Tier 2) camila

MO $0-$7.40 (Tier 2) DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML

MO $0-$7.40 (Tier 2) errin

MO $0-$7.40 (Tier 2) ESTRACE VAGINAL

PAR; MO $0-$7.40 (Tier 2) estradiol oral




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PAR; MO; QLL (4 per 28 days) $0-$7.40 (Tier 2) estradiol transdermal patch weekly

MO; QLL (1 per 90 days) $0-$7.40 (Tier 2) ESTRING

MO; QLL (1 per 90 days) $0-$7.40 (Tier 2) FEMRING

$0-$7.40 (Tier 2) hydroxyprogesterone caproate

MO $0-$7.40 (Tier 2) lyza

MO $0-$7.40 (Tier 2) medroxyprogesterone

PAR; MO $0-$7.40 (Tier 2) MENEST

MO $0-$7.40 (Tier 2) nora-be

MO $0-$7.40 (Tier 2) norethindrone (contraceptive)

MO $0-$7.40 (Tier 2) norethindrone acetate

MO $0-$7.40 (Tier 2) ORTHO MICRONOR

PAR; MO $0-$7.40 (Tier 2) PREMARIN ORAL

MO $0-$7.40 (Tier 2) PREMARIN VAGINAL

PAR; MO $0-$7.40 (Tier 2) PREMPRO

ST; MO $0-$7.40 (Tier 2) progesterone micronized

MISCELLANEOUS OB/GYN [*] $0 (Tier 4) 1-DAY

[*] $0 (Tier 4) 3 DAY VAGINAL

MO; [*] $0 (Tier 4) 3-DAY VAGINAL

MO $0-$7.40 (Tier 2) clindamycin phosphate vaginal

[*] $0 (Tier 4) CLOTRIMAZOLE 3 DAY

MO; [*] $0 (Tier 4) clotrimazole vaginal cream

[*] $0 (Tier 4) CLOTRIMAZOLE-3

[*] $0 (Tier 4) CLOTRIMAZOLE-7

MO $0-$7.40 (Tier 2) metronidazole vaginal

MO; [*] $0 (Tier 4) MICONAZOLE 7

[*] $0 (Tier 4) miconazole nitrate vaginal comb pack,prefill appl, cream

MO; [*] $0 (Tier 4) miconazole nitrate vaginal cream




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[*] $0 (Tier 4) miconazole nitrate vaginal kit 1,200-2 mg-%

[*] $0 (Tier 4) miconazole nitrate vaginal suppository

[*] $0 (Tier 4) MICONAZOLE-3 VAGINAL KIT

MO; QLL (6 per 30 days) $0-$7.40 (Tier 2) miconazole-3 vaginal suppository

[*] $0 (Tier 4) MONISTAT 1 COMBO PACK

MO $0-$7.40 (Tier 2) NUVARING

MO $0-$7.40 (Tier 2) terconazole

[*] $0 (Tier 4) tioconazole

[*] $0 (Tier 4) TIOCONAZOLE-1

MO $0-$7.40 (Tier 2) tranexamic acid oral

[*] $0 (Tier 4) VAGISTAT-3

MO $0-$7.40 (Tier 2) XULANE

ORAL CONTRACEPTIVES / RELATED AGENTS [*] $0 (Tier 4) AFTERA

MO $0-$7.40 (Tier 2) ALTAVERA (28)

MO $0-$7.40 (Tier 2) ALYACEN 1/35 (28)

MO $0-$7.40 (Tier 2) ALYACEN 7/7/7 (28)

MO $0-$7.40 (Tier 2) apri

MO $0-$7.40 (Tier 2) aranelle (28)

MO $0-$7.40 (Tier 2) aviane

MO $0-$7.40 (Tier 2) AZURETTE (28)

MO $0-$7.40 (Tier 2) blisovi fe 1.5/30 (28)

MO $0-$7.40 (Tier 2) CAZIANT (28)

MO $0-$7.40 (Tier 2) cryselle (28)

MO $0-$7.40 (Tier 2) cyclafem 1/35 (28)

MO $0-$7.40 (Tier 2) cyclafem 7/7/7 (28)

MO $0-$7.40 (Tier 2) drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

[*] $0 (Tier 4) ECONTRA EZ




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MO $0-$7.40 (Tier 2) ELINEST

MO $0-$7.40 (Tier 2) ELLA

MO $0-$7.40 (Tier 2) enpresse

[*] $0 (Tier 4) FALLBACK SOLO

MO $0-$7.40 (Tier 2) falmina (28)

MO $0-$7.40 (Tier 2) gildagia

MO $0-$7.40 (Tier 2) GILDESS FE 1.5/30 (28)

MO $0-$7.40 (Tier 2) GILDESS FE 1/20 (28)

MO $0-$7.40 (Tier 2) junel 1.5/30 (21)

MO $0-$7.40 (Tier 2) junel 1/20 (21)

MO $0-$7.40 (Tier 2) junel fe 1.5/30 (28)

MO $0-$7.40 (Tier 2) junel fe 1/20 (28)

MO $0-$7.40 (Tier 2) kariva (28)

MO $0-$7.40 (Tier 2) kelnor 1/35 (28)

MO $0-$7.40 (Tier 2) LARIN 1/20 (21)

MO $0-$7.40 (Tier 2) LARIN FE 1.5/30 (28)

MO $0-$7.40 (Tier 2) LARIN FE 1/20 (28)

MO $0-$7.40 (Tier 2) lessina

MO $0-$7.40 (Tier 2) levonest (28)

$0-$7.40 (Tier 2) levonorg-eth estrad triphasic

MO $0-$7.40 (Tier 2) levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 mg

MO $0-$7.40 (Tier 2) levonorgestrel-ethinyl estrad oral tablets,dose pack, 3 month

MO $0-$7.40 (Tier 2) LOW-OGESTREL (28)

MO $0-$7.40 (Tier 2) lutera (28)

MO $0-$7.40 (Tier 2) marlissa

MO $0-$7.40 (Tier 2) MICROGESTIN 1.5/30 (21)

MO $0-$7.40 (Tier 2) MICROGESTIN 1/20 (21)




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MO $0-$7.40 (Tier 2) MICROGESTIN FE 1.5/30 (28)

MO $0-$7.40 (Tier 2) MICROGESTIN FE 1/20 (28)

MO $0-$7.40 (Tier 2) MONO-LINYAH

MO $0-$7.40 (Tier 2) mononessa (28)

[*] $0 (Tier 4) MY WAY

MO $0-$7.40 (Tier 2) MYZILRA

$0-$7.40 (Tier 2) necon 0.5/35 (28)

MO $0-$7.40 (Tier 2) necon 1/35 (28)

MO $0-$7.40 (Tier 2) necon 1/50 (28)

MO $0-$7.40 (Tier 2) necon 10/11 (28)

MO $0-$7.40 (Tier 2) necon 7/7/7 (28)

[*] $0 (Tier 4) NEXT CHOICE ONE DOSE

MO $0-$7.40 (Tier 2) norgestimate-ethinyl estradiol oral tablet 0.18/ 0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg

MO $0-$7.40 (Tier 2) nortrel 0.5/35 (28)

MO $0-$7.40 (Tier 2) nortrel 1/35 (21)

MO $0-$7.40 (Tier 2) nortrel 1/35 (28)

MO $0-$7.40 (Tier 2) nortrel 7/7/7 (28)

MO $0-$7.40 (Tier 2) ocella

MO $0-$7.40 (Tier 2) ogestrel (28)

[*] $0 (Tier 4) OPCICON ONE-STEP

MO; [*] $0 (Tier 4) PLAN B ONE-STEP

MO $0-$7.40 (Tier 2) portia

MO $0-$7.40 (Tier 2) previfem

MO $0-$7.40 (Tier 2) reclipsen (28)

MO $0-$7.40 (Tier 2) sprintec (28)

MO $0-$7.40 (Tier 2) SYEDA

[*] $0 (Tier 4) TAKE ACTION

MO $0-$7.40 (Tier 2) tri-previfem (28)




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MO $0-$7.40 (Tier 2) tri-sprintec (28)

MO $0-$7.40 (Tier 2) trivora (28)

MO $0-$7.40 (Tier 2) velivet triphasic regimen (28)

MO $0-$7.40 (Tier 2) VIORELE (28)

MO $0-$7.40 (Tier 2) ZARAH

MO $0-$7.40 (Tier 2) zenchent (28)

MO $0-$7.40 (Tier 2) zovia 1/35e (28)

MO $0-$7.40 (Tier 2) zovia 1/50e (28)

OXYTOCICS MO $0-$7.40 (Tier 2) methylergonovine oral

OPHTHALMOLOGY ANTIBIOTICS

MO $0-$7.40 (Tier 2) bacitracin ophthalmic

MO $0-$7.40 (Tier 2) bacitracin-polymyxin b ophthalmic

MO $0-$7.40 (Tier 2) BESIVANCE

MO $0-$7.40 (Tier 2) ciprofloxacin hcl oral tablet ophthalmic drops 0.3 %

MO $0-$7.40 (Tier 2) erythromycin ophthalmic

MO $0-$7.40 (Tier 2) gentak ophthalmic ointment

MO $0-$7.40 (Tier 2) gentamicin ophthalmic

MO $0-$7.40 (Tier 2) NEO-POLYCIN

MO $0-$7.40 (Tier 2) neomycin-bacitracin-polymyxin

MO $0-$7.40 (Tier 2) neomycin-polymyxin-gramicidin

MO $0-$7.40 (Tier 2) ofloxacin ophthalmic

$0-$7.40 (Tier 2) POLYCIN

MO $0-$7.40 (Tier 2) polymyxin b sulf-trimethoprim

MO $0-$7.40 (Tier 2) tobramycin

MO $0-$7.40 (Tier 2) VIGAMOX




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ANTIVIRALS MO $0-$7.40 (Tier 2) trifluridine

MO $0-$7.40 (Tier 2) ZIRGAN

BETA-BLOCKERS MO $0-$7.40 (Tier 2) betaxolol ophthalmic

MO $0-$7.40 (Tier 2) BETIMOL

MO $0-$7.40 (Tier 2) BETOPTIC S

MO $0-$7.40 (Tier 2) carteolol

MO $0-$7.40 (Tier 2) levobunolol ophthalmic drops 0.5 %

$0-$7.40 (Tier 2) metipranolol

MO $0-$7.40 (Tier 2) timolol maleate ophthalmic

MO $0-$7.40 (Tier 2) TIMOPTIC OCUDOSE (PF)

CHOLINESTERASE INHIBITOR MIOTICS MO $0-$7.40 (Tier 2) PHOSPHOLINE IODIDE

DIRECT ACTING MIOTICS MO $0-$7.40 (Tier 2) PILOCARPINE HCL OPHTHALMIC DROPS 1

%, 2 %, 4 %

MISCELLANEOUS OPHTHALMOLOGICS MO; [*] $0 (Tier 4) ADVANCED EYE RELIEF

MO; [*] $0 (Tier 4) AKWA TEARS (POLYVINYL ALCOHOL)

MO; [*] $0 (Tier 4) ALAWAY

[*] $0 (Tier 4) ALLERGY EYE (KETOTIFEN)

[*] $0 (Tier 4) ALTACHLORE OPHTHALMIC OINTMENT

MO; [*] $0 (Tier 4) ARTIFICIAL TEARS (PETRO/MIN)

MO; [*] $0 (Tier 4) ARTIFICIAL TEARS (POLYVIN ALC)

[*] $0 (Tier 4) ARTIFICIAL TEARS(DEXT70-HYPRO) OPHTHALMIC DROPS

[*] $0 (Tier 4) ARTIFICIAL TEARS(GLYCERIN-PEG)

[*] $0 (Tier 4) ARTIFICIAL TEARS(PVALCH-POVID)




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MO $0-$7.40 (Tier 2) azelastine ophthalmic

[*] $0 (Tier 4) CHILDREN'S ALAWAY

MO $0-$7.40 (Tier 2) cromolyn ophthalmic

MO; [*] $0 (Tier 4) EYE ITCH RELIEF

[*] $0 (Tier 4) ITCHY EYE DROPS

MO; [*] $0 (Tier 4) ketotifen fumarate

MO; [*] $0 (Tier 4) LIQUITEARS

[*] $0 (Tier 4) LUBRICANT EYE (PG-PEG 400)

[*] $0 (Tier 4) LUBRICANT EYE (PG-PEG 400)(PF)

[*] $0 (Tier 4) LUBRICANT EYE DROPS

[*] $0 (Tier 4) LUBRICANT EYE DROPS (GLYC-PG)

[*] $0 (Tier 4) LUBRICATING PLUS

[*] $0 (Tier 4) MOISTURE DROPS

MO; [*] $0 (Tier 4) MURO 128 OPHTHALMIC DROPS 2 %

MO; [*] $0 (Tier 4) MURO 128 OPHTHALMIC OINTMENT

MO $0-$7.40 (Tier 2) PATADAY

MO $0-$7.40 (Tier 2) PAZEO

[*] $0 (Tier 4) polyvinyl alcohol

MO; [*] $0 (Tier 4) REFRESH CLASSIC (PF)

MO; [*] $0 (Tier 4) REFRESH LACRI-LUBE

MO; [*] $0 (Tier 4) REFRESH TEARS

MO $0-$7.40 (Tier 2) RESTASIS

[*] $0 (Tier 4) RESTORE TEARS

[*] $0 (Tier 4) RETAINE CMC

[*] $0 (Tier 4) REVIVE PLUS

[*] $0 (Tier 4) SOCHLOR OPHTHALMIC OINTMENT

MO; [*] $0 (Tier 4) sodium chloride ophthalmic ointment

MO; [*] $0 (Tier 4) SYSTANE (PF)

MO; [*] $0 (Tier 4) SYSTANE (PROPYLENE GLYCOL)




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MO; [*] $0 (Tier 4) SYSTANE ULTRA

MO; [*] $0 (Tier 4) SYSTANE ULTRA (PF)

MO; [*] $0 (Tier 4) TEARS AGAIN

MO; [*] $0 (Tier 4) TEARS AGAIN (PVA)

[*] $0 (Tier 4) TEARS PURE

[*] $0 (Tier 4) ULTRA FRESH

[*] $0 (Tier 4) ULTRA LUBRICANT EYE

[*] $0 (Tier 4) WAL-ZYR (KETOTIFEN)

MO; [*] $0 (Tier 4) ZADITOR

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS MO $0-$7.40 (Tier 2) flurbiprofen sodium drops

MO $0-$7.40 (Tier 2) ILEVRO

MO $0-$7.40 (Tier 2) ketorolac ophthalmic

MO $0-$7.40 (Tier 2) NEVANAC

ORAL DRUGS FOR GLAUCOMA MO $0-$7.40 (Tier 2) acetazolamide

MO $0-$7.40 (Tier 2) acetazolamide sodium

MO $0-$7.40 (Tier 2) methazolamide oral

OTHER GLAUCOMA DRUGS MO $0-$7.40 (Tier 2) AZOPT

MO $0-$7.40 (Tier 2) bimatoprost

MO $0-$7.40 (Tier 2) COMBIGAN

MO $0-$7.40 (Tier 2) dorzolamide

MO $0-$7.40 (Tier 2) dorzolamide-timolol

MO $0-$7.40 (Tier 2) latanoprost

MO $0-$7.40 (Tier 2) LUMIGAN OPHTHALMIC DROPS 0.01 %

MO; QLL (5 per 30 days) $0-$7.40 (Tier 2) TRAVATAN Z




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STEROID-ANTIBIOTIC COMBINATIONS $0-$7.40 (Tier 2) NEO-POLYCIN HC

MO $0-$7.40 (Tier 2) neomycin-bacitracin-poly-hc

MO $0-$7.40 (Tier 2) neomycin-polymyxin b-dexameth

MO $0-$7.40 (Tier 2) neomycin-polymyxin-hc ophthalmic

MO $0-$7.40 (Tier 2) tobramycin-dexamethasone opth susp

STEROID-SULFONAMIDE COMBINATIONS MO $0-$7.40 (Tier 2) BLEPHAMIDE S.O.P.

MO $0-$7.40 (Tier 2) sulfacetamide-prednisolone

STEROIDS MO $0-$7.40 (Tier 2) dexamethasone sodium phosphate ophthalmic

MO $0-$7.40 (Tier 2) fluorometholone

MO $0-$7.40 (Tier 2) prednisolone acetate

MO $0-$7.40 (Tier 2) prednisolone sodium phosphate ophthalmic

SULFONAMIDES MO $0-$7.40 (Tier 2) sulfacetamide sodium ophthalmic drops

SYMPATHOMIMETICS MO $0-$7.40 (Tier 2) ALPHAGAN P OPHTHALMIC DROPS 0.1 %

MO $0-$7.40 (Tier 2) apraclonidine

MO $0-$7.40 (Tier 2) brimonidine

RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS

[*] $0 (Tier 4) 12 HOUR COLD RELIEF

[*] $0 (Tier 4) 12 HOUR DECONGESTANT

MO; [*] $0 (Tier 4) ADT ROBITUSSIN PEAK CLD DM MAX

[*] $0 (Tier 4) ADULT COUGH FORMULA DM MAX

MO; [*] $0 (Tier 4) ADULT ROBITUSSIN PEAK COLD DM

[*] $0 (Tier 4) ADULT ROBITUSSIN PEAK COLD M-S




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[*] $0 (Tier 4) ADULT TUSSIN CHEST CONGESTION

[*] $0 (Tier 4) ADULT TUSSIN COUGH CONGEST DM

[*] $0 (Tier 4) ADULT TUSSIN DM

[*] $0 (Tier 4) ADULT TUSSIN MULTI-SYMP COLD

[*] $0 (Tier 4) ADULT WAL-TUSSIN

[*] $0 (Tier 4) ADULT WAL-TUSSIN DM MAX

[*] $0 (Tier 4) ADVIL ALLERGY SINUS

[*] $0 (Tier 4) ADVIL ALLERGY-CONGESTION RLF

MO; [*] $0 (Tier 4) ADVIL COLD AND SINUS ORAL CAPSULE

[*] $0 (Tier 4) ADVIL COLD AND SINUS ORAL TABLET

[*] $0 (Tier 4) ADVIL CONGESTION RELIEF

MO; [*] $0 (Tier 4) ALA-HIST DM

MO; [*] $0 (Tier 4) ALA-HIST IR

MO; [*]; QLL (30 per 30 days) $0 (Tier 4) ALAVERT

MO; [*] $0 (Tier 4) ALAVERT D-12 ALLERGY-SINUS

[*] $0 (Tier 4) ALER-CAP

[*] $0 (Tier 4) ALEVE COLD AND SINUS

[*] $0 (Tier 4) ALEVE SINUS AND HEADACHE

MO; [*] $0 (Tier 4) ALEVE-D SINUS AND COLD

[*] $0 (Tier 4) ALEVE-D SINUS AND HEADACHE

[*] $0 (Tier 4) ALKA-SELTZER PLUS ALLERGY

[*] $0 (Tier 4) ALKA-SELTZER PLUS DAY

[*] $0 (Tier 4) ALKA-SELTZER PLUS MUCUS-CONGES

[*] $0 (Tier 4) ALKA-SELTZER PLUS SINUS-COUGH

[*]; QLL (300 per 30 days) $0 (Tier 4) ALL DAY ALLERGY (CETIRIZINE) ORAL SOLUTION

[*]; QLL (30 per 30 days) $0 (Tier 4) ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET

MO; [*] $0 (Tier 4) ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET,CHEWABLE




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[*]; QLL (30 per 30 days) $0 (Tier 4) ALL DAY ALLERGY RELIEF(CETIR)

MO; [*] $0 (Tier 4) ALL DAY ALLERGY-D

[*] $0 (Tier 4) ALL DAY PAIN RELIEF SINUS,COLD

[*] $0 (Tier 4) ALL-NITE COLD-FLU

MO; [*] $0 (Tier 4) ALLER-CHLOR

[*] $0 (Tier 4) ALLER-EASE

[*] $0 (Tier 4) ALLER-FEX

[*] $0 (Tier 4) ALLER-G-TIME

[*]; QLL (30 per 30 days) $0 (Tier 4) ALLER-TEC

[*] $0 (Tier 4) ALLER-TEC D

[*]; QLL (30 per 30 days) $0 (Tier 4) ALLERCLEAR

[*] $0 (Tier 4) ALLERCLEAR D-12HR

MO; [*] $0 (Tier 4) ALLERCLEAR D-24HR

MO; [*] $0 (Tier 4) ALLERGY (CHLORPHENIRAMINE)

[*] $0 (Tier 4) ALLERGY (DIPHENHYDRAMINE)

[*] $0 (Tier 4) ALLERGY 4-HOUR

[*] $0 (Tier 4) ALLERGY AND CONGESTION RELIEF

[*] $0 (Tier 4) ALLERGY COMPLETE-D

[*] $0 (Tier 4) ALLERGY D-12

[*] $0 (Tier 4) ALLERGY M-S NIGHTTIME

[*] $0 (Tier 4) ALLERGY MEDICATION

[*] $0 (Tier 4) ALLERGY MEDICINE

[*] $0 (Tier 4) ALLERGY MULTI-SYMPTOM

[*] $0 (Tier 4) ALLERGY PLUS SEVERE SINUS HA

[*]; QLL (300 per 30 days) $0 (Tier 4) ALLERGY RELIEF (CETIRIZINE) ORAL SOLUTION

[*]; QLL (30 per 30 days) $0 (Tier 4) ALLERGY RELIEF (CETIRIZINE) ORAL TABLET

MO; [*] $0 (Tier 4) ALLERGY RELIEF (CLEMASTINE)




de clase)


[*] $0 (Tier 4) ALLERGY RELIEF (FEXOFENADINE)

[*] $0 (Tier 4) ALLERGY RELIEF (LORATADINE) ORAL SOLUTION

MO; [*]; QLL (30 per 30 days) $0 (Tier 4) ALLERGY RELIEF (LORATADINE) ORAL TABLET

[*]; QLL (30 per 30 days) $0 (Tier 4) ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING

[*] $0 (Tier 4) ALLERGY RELIEF D-24

[*] $0 (Tier 4) ALLERGY RELIEF D12

[*] $0 (Tier 4) ALLERGY RELIEF MULTI-SYMPTOM

[*] $0 (Tier 4) ALLERGY RELIEF(CHLORPHENIRAMN)

[*] $0 (Tier 4) ALLERGY RELIEF(DIPHENHYDRAMIN)

MO; [*] $0 (Tier 4) ALLERGY RELIEF,NASAL DECONGEST

[*] $0 (Tier 4) ALLERGY RELIEF-D (CETIRIZINE)

[*] $0 (Tier 4) ALLERGY RELIEF-D (LORATADINE)

[*] $0 (Tier 4) ALLERGY RELIEF-D(FEXOFENADINE)

[*] $0 (Tier 4) ALLERGY SINUS PE

[*] $0 (Tier 4) ALLERGY-CONGEST RELIEF-D (CET)

[*] $0 (Tier 4) ALLERGY-CONGESTION RELIEF-D ORAL TABLET EXTENDED RELEASE 24 HR

[*] $0 (Tier 4) ALLERGY-TIME

[*] $0 (Tier 4) ALLERHIST-1

[*] $0 (Tier 4) ALLFEN

MO; [*] $0 (Tier 4) ALLFEN DM

MO; [*] $0 (Tier 4) AMBI 60PSE-400GFN

[*] $0 (Tier 4) ANTITUSSIVE DM

[*] $0 (Tier 4) AP-HIST DM

PAR; MO $0-$7.40 (Tier 2) arbinoxa

MO; [*] $0 (Tier 4) BANOPHEN ALLERGY

MO; [*] $0 (Tier 4) BANOPHEN ORAL CAPSULE 25 MG




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[*] $0 (Tier 4) BANOPHEN ORAL CAPSULE 50 MG

MO; [*] $0 (Tier 4) BANOPHEN ORAL LIQUID

[*] $0 (Tier 4) BANOPHEN ORAL TABLET

MO; [*] $0 (Tier 3) benzonatate oral capsule 100 mg

[*] $0 (Tier 4) BIOCOTRON

[*] $0 (Tier 4) BIONEL

[*] $0 (Tier 4) BIONEL PEDIATRIC

MO; [*] $0 (Tier 3) BROMFED DM

MO; [*] $0 (Tier 3) brompheniramine-pseudoeph-dm oral syrup

[*] $0 (Tier 4) BRONCHIAL ASTHMA RELIEF

MO; [*] $0 (Tier 4) BROTAPP DM

MO; [*] $0 (Tier 3) CAPCOF

MO; [*] $0 (Tier 4) CAPMIST DM

[*] $0 (Tier 4) CAPRON DM

[*] $0 (Tier 4) CETIRI-D

MO; [*]; QLL (300 per 30 days) $0 (Tier 4) cetirizine oral solution 1 mg/ml

[*] $0 (Tier 4) cetirizine oral solution 5 mg/5 ml

MO; [*]; QLL (30 per 30 days) $0 (Tier 4) cetirizine oral tablet

MO; [*] $0 (Tier 4) cetirizine oral tablet,chewable

MO; [*] $0 (Tier 4) cetirizine-pseudoephedrine

MO; [*] $0 (Tier 3) CHERATUSSIN AC

MO; [*] $0 (Tier 3) CHERATUSSIN DAC

[*] $0 (Tier 4) CHEST CONGESTION RELIEF

[*] $0 (Tier 4) CHEST CONGESTION RELIEF + DM

[*] $0 (Tier 4) CHEST CONGESTION RELIEF PE

[*] $0 (Tier 4) CHEST CONGESTION-COUGH RELIEF

[*] $0 (Tier 4) CHEST-SINUS CONGESTION RELIEF

[*]; QLL (300 per 30 days) $0 (Tier 4) CHILD ALLERGY RELF(CETIRIZINE) ORAL SOLUTION




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[*] $0 (Tier 4) CHILD ALLERGY RELF(CETIRIZINE) ORAL TABLET,CHEWABLE

[*] $0 (Tier 4) CHILD CHEST CONGESTION + COUGH

[*] $0 (Tier 4) CHILD DELSYM COUGH+CHEST DM

[*] $0 (Tier 4) CHILD DELSYM COUGH+COLD

[*] $0 (Tier 4) CHILD MUCINEX CHEST CONGESTION

[*] $0 (Tier 4) CHILD MUCINEX CONGESTION-COUGH

MO; [*] $0 (Tier 4) CHILD MUCINEX STUFFY NOSE-COLD

[*] $0 (Tier 4) CHILD MUCUS RELIEF COUGH

[*] $0 (Tier 4) CHILD MUCUS RELIEF EXPECTORANT

[*] $0 (Tier 4) CHILD MULTI-SYMPTOM COLD/COUGH

[*] $0 (Tier 4) CHILD TRIAMINIC MS FEVER-COLD

[*]; QLL (300 per 30 days) $0 (Tier 4) CHILD'S ALL DAY ALLERGY(CETIR)

[*] $0 (Tier 4) CHILD'S MUCUS RELIEF M-S COLD

[*] $0 (Tier 4) CHILDREN NIGHT TIME COLD-COUGH

[*]; QLL (300 per 30 days) $0 (Tier 4) CHILDREN'S ALLER-TEC

[*] $0 (Tier 4) CHILDREN'S ALLERGY (DIPHENHYD) ORAL ELIXIR

[*] $0 (Tier 4) children's allergy (diphenhyd) oral liquid

[*]; QLL (300 per 30 days) $0 (Tier 4) CHILDREN'S ALLERGY COMPLETE

[*] $0 (Tier 4) CHILDREN'S ALLERGY RELIEF(LOR)

[*]; QLL (300 per 30 days) $0 (Tier 4) CHILDREN'S ALLERGY(CETIRIZINE)

[*]; QLL (300 per 30 days) $0 (Tier 4) CHILDREN'S CETIRIZINE ORAL SOLUTION

MO; [*] $0 (Tier 4) CHILDREN'S CETIRIZINE ORAL TABLET, CHEWABLE

[*] $0 (Tier 4) CHILDREN'S CHEST CONGESTION

MO; [*] $0 (Tier 4) CHILDREN'S CLARITIN

[*] $0 (Tier 4) CHILDREN'S COLD AND COUGH (PE)

[*] $0 (Tier 4) CHILDREN'S COLD AND COUGH DM

[*] $0 (Tier 4) CHILDREN'S COUGH




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[*] $0 (Tier 4) CHILDREN'S DIBROMM DM COLD-COU

[*] $0 (Tier 4) CHILDREN'S FLU RELIEF

[*] $0 (Tier 4) CHILDREN'S MUCINEX COLD-FEVER

[*] $0 (Tier 4) CHILDREN'S MUCINEX COUGH

[*] $0 (Tier 4) CHILDREN'S MUCINEX MULTI-SYMP

[*] $0 (Tier 4) CHILDREN'S MUCINEX NIGHT TIME

[*] $0 (Tier 4) CHILDREN'S PLUS FLU

[*] $0 (Tier 4) CHILDREN'S SILFEDRINE

[*] $0 (Tier 4) CHILDREN'S STUFFY NOSE-COLD

[*] $0 (Tier 4) CHILDREN'S SUDAFED PE COUGH

[*] $0 (Tier 4) CHILDREN'S WAL-DRYL ALLERGY ORAL LIQUID

[*] $0 (Tier 4) CHILDREN'S WAL-DRYL ALLERGY ORAL PREFILLED SPOON

[*]; QLL (300 per 30 days) $0 (Tier 4) CHILDREN'S WAL-ZYR ORAL SOLUTION

[*] $0 (Tier 4) CHILDREN'S WAL-ZYR ORAL TABLET, CHEWABLE

[*] $0 (Tier 4) CHILDRENS PLUS MULTI-SYMP COLD

[*] $0 (Tier 4) CHILDS TRIACTING COLD-COUGH

MO; [*] $0 (Tier 4) CHLO TUSS

[*] $0 (Tier 4) CHLORHIST

[*] $0 (Tier 4) chlorpheniramine maleate oral tablet

MO; [*] $0 (Tier 4) chlorpheniramine maleate oral tablet extended release

[*] $0 (Tier 4) CHLORTABS

MO; [*] $0 (Tier 4) CLARITIN LIQUI-GEL

[*] $0 (Tier 4) CLARITIN ORAL SOLUTION

MO; [*]; QLL (30 per 30 days) $0 (Tier 4) CLARITIN ORAL TABLET

MO; [*]; QLL (30 per 30 days) $0 (Tier 4) CLARITIN REDITABS ORAL TABLET, DISINTEGRATING 10 MG




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MO; [*] $0 (Tier 4) CLARITIN REDITABS ORAL TABLET, DISINTEGRATING 5 MG

MO; [*] $0 (Tier 4) CLARITIN-D 12 HOUR

MO; [*] $0 (Tier 4) CLARITIN-D 24 HOUR

MO; [*] $0 (Tier 4) clemastine oral tablet 1.34 mg

PAR; MO $0-$7.40 (Tier 2) clemastine oral tablet 2.68 mg

MO; [*] $0 (Tier 3) codeine-guaifenesin

[*] $0 (Tier 4) COLD AND COUGH (DIPHENHYDR-PE)

[*] $0 (Tier 4) COLD AND COUGH DM

[*] $0 (Tier 4) COLD AND COUGH ELIXIR

[*] $0 (Tier 4) COLD AND FLU RELIEF(DIPHEN-PE)

[*] $0 (Tier 4) COLD AND FLU SEVERE

[*] $0 (Tier 4) COLD AND SINUS PAIN RELIEF

[*] $0 (Tier 4) COLD HEAD CONGESTION DAY/NITE

[*] $0 (Tier 4) COLD HEAD CONGESTION DAYTIME

[*] $0 (Tier 4) COLD HEAD CONGESTION NIGHTTIME

[*] $0 (Tier 4) COLD HEAD CONGESTION SEVER DAY

[*] $0 (Tier 4) COLD MULTI-SYMPTOM

[*] $0 (Tier 4) COLD MULTI-SYMPTOM (CHLORPHEN)

[*] $0 (Tier 4) COLD MULTI-SYMPTOM DAY/NIGHT

[*] $0 (Tier 4) COLD MULTI-SYMPTOM NIGHTTIME

[*] $0 (Tier 4) COLD RELIEF M/S DAY/NIGHT

[*] $0 (Tier 4) COLD RELIEF PLUS

[*] $0 (Tier 4) COLD SEVERE CONGESTION

[*] $0 (Tier 4) COLD-FLU RELIEF

[*] $0 (Tier 4) COLD-FLU RELIEF, DAY/NIGHT

[*] $0 (Tier 4) COLD-SINUS RELIEF

[*] $0 (Tier 4) COMPLETE ALLERGY

[*] $0 (Tier 4) COMPLETE ALLERGY MEDICINE




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[*] $0 (Tier 4) CONGESTAC

[*] $0 (Tier 4) CONTAC COLD-FLU NIGHT

[*] $0 (Tier 4) CORICIDIN HBP COUGH AND COLD

[*] $0 (Tier 4) CORICIDIN HBP ORAL CAPSULE

[*] $0 (Tier 4) COUGH AND COLD BP

[*] $0 (Tier 4) COUGH AND COLD MUCUS RELIEF CF

[*] $0 (Tier 4) COUGH AND COLD ORAL LIQUID

[*] $0 (Tier 4) COUGH AND COLD ORAL TABLET

[*] $0 (Tier 4) COUGH AND SEVERE COLD

[*] $0 (Tier 4) COUGH CONTROL (DEXTROMETHORPH)

[*] $0 (Tier 4) COUGH CONTROL (GUAIFENESIN)

[*] $0 (Tier 4) COUGH CONTROL CF (PE)

[*] $0 (Tier 4) COUGH CONTROL DM

[*] $0 (Tier 4) COUGH DM ER

[*] $0 (Tier 4) COUGH FORMULA DM

[*] $0 (Tier 4) COUGH RELIEF ORAL LIQUID

[*] $0 (Tier 4) COUGH SUPPRESSANT-EXPECTORANT

[*] $0 (Tier 4) COUGH SYRUP

[*] $0 (Tier 4) COUGH SYRUP DM

[*] $0 (Tier 4) COUGH-SORE THROAT NIGHT

[*] $0 (Tier 4) COUGHTAB

[*] $0 (Tier 4) DAY TIME PE

[*] $0 (Tier 4) DAY-TIME COUGH

[*] $0 (Tier 4) DAY-TIME ORAL CAPSULE 30-15-325 MG

[*] $0 (Tier 4) DAYHIST ALLERGY

[*] $0 (Tier 4) DAYTIME

[*] $0 (Tier 4) DAYTIME AND NIGHTTIME COLD

[*] $0 (Tier 4) DAYTIME COLD AND COUGH

[*] $0 (Tier 4) DAYTIME COLD-FLU




de clase)


[*] $0 (Tier 4) DAYTIME COLD-FLU RELIEF (PE)

[*] $0 (Tier 4) DAYTIME SINUS

[*] $0 (Tier 4) DAYTIME-NIGHTTIME

MO; [*] $0 (Tier 4) DECONEX DMX ORAL TABLET 10-15-380 MG

MO; [*] $0 (Tier 4) DECONEX IR ORAL TABLET 10-380 MG

MO; [*] $0 (Tier 4) DELSYM 12 HOUR

[*] $0 (Tier 4) DELSYM COUGH-CHEST CONGEST DM

[*] $0 (Tier 4) DELSYM COUGH-COLD DAYTIME

[*] $0 (Tier 4) DELSYM COUGH-COLD NIGHTTIME

[*] $0 (Tier 4) DESGEN DM ORAL LIQUID 5-10-100 MG/5 ML

[*] $0 (Tier 4) DESPEC-DM (PHENYLEPH-DM-GUAIF) ORAL LIQUID 5-10-100 MG/5 ML

[*] $0 (Tier 4) dexchlorphen-pse-chlophedianol

[*] $0 (Tier 4) dextromethorphan polistirex

[*] $0 (Tier 4) dextromethorphan-guaifenesin oral syrup

[*] $0 (Tier 4) dextromethorphan-guaifenesin oral tablet

[*] $0 (Tier 4) DIABETIC SILTUSSIN DAS-NA

[*] $0 (Tier 4) DIABETIC SILTUSSIN-DM

[*] $0 (Tier 4) DIABETIC SILTUSSIN-DM MAX STR

MO; [*] $0 (Tier 4) DIABETIC TUSSIN DM ORAL LIQUID 10-100 MG/5 ML

[*] $0 (Tier 4) DIABETIC TUSSIN DM ORAL LIQUID 10-200 MG/5 ML

MO; [*] $0 (Tier 4) DIABETIC TUSSIN EX

MO; [*] $0 (Tier 4) DIMAPHEN DM

[*] $0 (Tier 4) DIMETAPP COLD-CONGESTION

[*] $0 (Tier 4) DIMETAPP DM COLD-COUGH (PE)

[*] $0 (Tier 4) DIMETAPP LONG-ACTING (CPM-DM)

[*] $0 (Tier 4) DIPHEDRYL ALLERGY

[*] $0 (Tier 4) DIPHEDRYL ORAL CAPSULE




de clase)


MO; [*] $0 (Tier 4) DIPHEDRYL ORAL TABLET

[*] $0 (Tier 4) DIPHENHIST ORAL CAPSULE

MO; [*] $0 (Tier 4) DIPHENHIST ORAL LIQUID

MO; [*] $0 (Tier 4) DIPHENHIST ORAL TABLET 25 MG

PAR; MO $0-$7.40 (Tier 2) diphenhydramine hcl injection solution 50 mg/ml

PAR; MO $0-$7.40 (Tier 2) diphenhydramine hcl injection syringe

MO; [*] $0 (Tier 4) diphenhydramine hcl oral capsule 25 mg

PAR; MO; [*] $0 (Tier 4) diphenhydramine hcl oral capsule 50 mg

PAR; [*] $0 (Tier 4) diphenhydramine hcl oral elixir

PAR; [*] $0 (Tier 4) diphenhydramine hcl oral liquid

[*] $0 (Tier 4) diphenhydramine hcl oral syrup

[*] $0 (Tier 4) diphenhydramine hcl oral tablet 25 mg

[*] $0 (Tier 4) DM MAX

MO; [*] $0 (Tier 4) DONATUSSIN

[*] $0 (Tier 4) DRISTAN COLD

MO; [*] $0 (Tier 4) DURAFLU ORAL TABLET 60-20-200-500 MG

MO; [*] $0 (Tier 4) ed a-hist dm oral liquid

[*] $0 (Tier 4) ED BRON GP

[*] $0 (Tier 4) ED CHLORPED JR

[*] $0 (Tier 4) ED-CHLORPED

MO; [*] $0 (Tier 4) ED-CHLORTAN

[*] $0 (Tier 4) ENDACOF - DM

MO; [*] $0 (Tier 4) ENTEX T

[*] $0 (Tier 4) ENTRE-COUGH

MO $0-$7.40 (Tier 2) epinephrine injection syringe 0.1 mg/ml

MO; QLL (2 per 2 days) $0-$7.40 (Tier 2) EPIPEN 2-PAK

MO; QLL (2 per 2 days) $0-$7.40 (Tier 2) EPIPEN JR 2-PAK

[*] $0 (Tier 4) EXAPHEX TR

[*] $0 (Tier 4) EXPECTORANT COUGH SYRUP




de clase)


[*] $0 (Tier 4) EXPECTORANT ORAL LIQUID

[*] $0 (Tier 4) FENESIN IR

[*] $0 (Tier 4) FENESIN PE IR

MO; [*] $0 (Tier 4) fexofenadine oral tablet 180 mg, 60 mg

[*] $0 (Tier 4) fexofenadine-pseudoephedrine

[*] $0 (Tier 4) FLU AND SEVERE COLD-DAYTIME

[*] $0 (Tier 4) FLU HBP

[*] $0 (Tier 4) FLU RELIEF THERAPY DAYTIME

[*] $0 (Tier 4) FLU-SEVERE COLD-COUGH DAYTIME

[*] $0 (Tier 4) FLU-SEVERE COLD-COUGH NIGHT

[*] $0 (Tier 4) G-TRON

[*] $0 (Tier 4) GENCONTUSS

[*] $0 (Tier 4) GERI-DRYL

[*] $0 (Tier 4) GERI-TUSSIN

[*] $0 (Tier 4) GERI-TUSSIN DM

[*] $0 (Tier 4) GILPHEX TR

[*] $0 (Tier 4) GUAIASORB DM

[*] $0 (Tier 3) GUAIFENESIN AC

MO; [*] $0 (Tier 3) GUAIFENESIN DAC

[*] $0 (Tier 4) guaifenesin oral liquid

MO; [*] $0 (Tier 4) guaifenesin oral tablet 200 mg

[*] $0 (Tier 4) guaifenesin oral tablet 400 mg

MO; [*] $0 (Tier 4) guaifenesin oral tablet extended release 12hr 600 mg

[*] $0 (Tier 4) GUAIFENESIN-DM

[*] $0 (Tier 4) HEAD CONGESTION COLD RELIEF

[*] $0 (Tier 4) HEAD CONGESTION DAY-NIGHT

[*] $0 (Tier 4) HISTEX (TRIPROLIDINE)

[*] $0 (Tier 4) HISTEX DM




de clase)


[*] $0 (Tier 4) HISTEX PD

[*] $0 (Tier 4) HOT STEAM LIQUID

MO; [*] $0 (Tier 3) hydrocodone-chlorpheniramine

MO; [*] $0 (Tier 3) hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml

[*] $0 (Tier 3) HYDROCODONE-HOMATROPINE ORAL SYRUP 5-1.5 MG/5 ML (5 ML)

MO; [*] $0 (Tier 3) hydrocodone-homatropine oral tablet

MO; [*] $0 (Tier 3) HYDROMET

[*] $0 (Tier 4) IBUPROFEN COLD

[*] $0 (Tier 4) IBUPROFEN COLD-SINUS(WITH PSE)

MO; [*] $0 (Tier 3) IOPHEN C-NR

MO; [*] $0 (Tier 4) IOPHEN DM-NR

MO; [*] $0 (Tier 4) IOPHEN-NR

MO; [*] $0 (Tier 4) J-MAX

MO; [*] $0 (Tier 4) J-TAN PD

[*] $0 (Tier 4) KIDKARE COUGH/COLD

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) levocetirizine oral tablet

[*] $0 (Tier 4) LIQUITUSS GG

MO; [*]; QLL (30 per 30 days) $0 (Tier 4) LORADAMED

[*] $0 (Tier 4) LORATA-D

[*] $0 (Tier 4) LORATA-DINE D

MO; [*] $0 (Tier 4) loratadine oral solution

MO; [*]; QLL (30 per 30 days) $0 (Tier 4) loratadine oral tablet

MO; [*]; QLL (30 per 30 days) $0 (Tier 4) loratadine oral tablet,disintegrating

MO; [*] $0 (Tier 4) LORATADINE-D

[*] $0 (Tier 4) LORTUSS DM

[*] $0 (Tier 3) LORTUSS EX ORAL SYRUP

MO; [*] $0 (Tier 3) M-CLEAR WC




de clase)


[*] $0 (Tier 4) M-END DMX

MO; [*] $0 (Tier 3) M-END MAX D

MO; [*] $0 (Tier 3) M-END PE

[*] $0 (Tier 4) MAPAP COLD FORMULA

[*] $0 (Tier 4) MAPAP SINUS MAX STRENGTH (PE)

[*] $0 (Tier 3) MAR-COF BP

MO; [*] $0 (Tier 3) MAR-COF CG

[*] $0 (Tier 4) MAXIMUM STRENGTH FLU

MO; [*] $0 (Tier 4) MAXIPHEN

[*] $0 (Tier 4) MAXIPHEN DM

[*] $0 (Tier 4) MEDICIDIN-D

[*] $0 (Tier 4) MUCAPHED

[*] $0 (Tier 4) MUCINEX COLD,FLU,SORE THROAT

[*] $0 (Tier 4) MUCINEX FAST-MAX COLD-FLU-THRT ORAL TABLET

[*] $0 (Tier 4) MUCINEX FAST-MAX COLD-SINUS

MO; [*] $0 (Tier 4) MUCINEX FAST-MAX CONGEST-COUGH ORAL LIQUID

[*] $0 (Tier 4) MUCINEX FAST-MAX CONGEST-COUGH ORAL TABLET

[*] $0 (Tier 4) MUCINEX FAST-MAX DAY-NITE CONG ORAL LIQUID, SEQUENTIAL

[*] $0 (Tier 4) MUCINEX FAST-MAX DM MAX

[*] $0 (Tier 4) MUCINEX FAST-MAX NITE COLD-FLU ORAL LIQUID

[*] $0 (Tier 4) MUCINEX FAST-MAX SEVERE COLD

[*] $0 (Tier 4) MUCINEX FST-MX DY-NT COLD(DPH)

MO; [*] $0 (Tier 4) MUCINEX MINI-MELTS ORAL GRANULES IN PACKET 100 MG

MO; [*] $0 (Tier 4) MUCINEX ORAL TABLET EXTENDED RELEASE 12HR 600 MG




de clase)


[*] $0 (Tier 4) MUCINEX SINUS-MAX D-N (DIPHEN) ORAL TABLETS, SEQUENTIAL

[*] $0 (Tier 4) MUCINEX SINUS-MAX PRESSUR-PAIN ORAL TABLET

[*] $0 (Tier 4) MUCINEX SINUS-MAX SEV CONGESTN ORAL TABLET

[*] $0 (Tier 4) MUCOSA

[*] $0 (Tier 4) MUCOSA DM

[*] $0 (Tier 4) MUCUS AND COUGH RELIEF

[*] $0 (Tier 4) MUCUS RELIEF CHEST

[*] $0 (Tier 4) MUCUS RELIEF COLD AND SINUS ORAL TABLET

[*] $0 (Tier 4) MUCUS RELIEF COLD-FLU-SORE THR

[*] $0 (Tier 4) MUCUS RELIEF CONGESTION-COUGH

[*] $0 (Tier 4) MUCUS RELIEF COUGH

MO; [*] $0 (Tier 4) MUCUS RELIEF DM

[*] $0 (Tier 4) MUCUS RELIEF DM MAX

[*] $0 (Tier 4) MUCUS RELIEF ER ORAL TABLET EXTENDED RELEASE 12HR 600 MG

[*] $0 (Tier 4) MUCUS RELIEF ORAL TABLET 200 MG

MO; [*] $0 (Tier 4) MUCUS RELIEF ORAL TABLET 400 MG

[*] $0 (Tier 4) MUCUS RELIEF PE

[*] $0 (Tier 4) MUCUS RELIEF PLUS

[*] $0 (Tier 4) MUCUS RELIEF SEV CONGEST-COLD

[*] $0 (Tier 4) MUCUS RELIEF SEVERE COLD ORAL LIQUID

[*] $0 (Tier 4) MUCUS RELIEF SINUS

[*] $0 (Tier 4) MUCUS RELIEF SINUSPRESSUR-PAIN

[*] $0 (Tier 4) MUCUS RLF SEVERE SINUS CONGEST

[*] $0 (Tier 4) MULTI-SYMPTOM COLD (PE)

[*] $0 (Tier 4) MULTI-SYMPTOM COLD (PE-CPM)




de clase)


[*] $0 (Tier 4) MULTI-SYMPTOM COLD DAYTIME

[*] $0 (Tier 4) MULTI-SYMPTOM COLD NIGHT TIME

[*] $0 (Tier 4) NASAL DECONGESTANT (PE) ORAL TABLET 10 MG

[*] $0 (Tier 4) NASAL DECONGESTANT (PSEUDOEPH) ORAL LIQUID

[*] $0 (Tier 4) NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET

[*] $0 (Tier 4) NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET EXTENDED RELEASE

[*] $0 (Tier 4) NEO-TUSS

[*] $0 (Tier 4) NIGHT TIME COLD AND FLU RELIEF

[*] $0 (Tier 4) NIGHT TIME COLD-FLU ORAL LIQUID

[*] $0 (Tier 4) NIGHT TIME ORAL CAPSULE 6.25-15-325 MG

[*] $0 (Tier 4) NIGHTIME SLEEP

[*] $0 (Tier 4) NIGHTTIME ALLERGY RELIEF

[*] $0 (Tier 4) NIGHTTIME COLD-FLU

[*] $0 (Tier 4) NIGHTTIME COLD-FLU RELIEF

[*] $0 (Tier 4) NIGHTTIME COUGH

[*] $0 (Tier 4) NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 50 MG

[*] $0 (Tier 4) NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET

[*] $0 (Tier 4) NITE TIME COLD-FLU

[*] $0 (Tier 4) NITE TIME COLD-FLU FORMULA

[*] $0 (Tier 4) NITE TIME COLD-FLU RELIEF ORAL CAPSULE

[*] $0 (Tier 4) NITE TIME COUGH

[*] $0 (Tier 4) NITE TIME-D COLD-FLU RELIEF

[*] $0 (Tier 4) NITE-TIME

[*] $0 (Tier 4) NITETIME MULTI-SYMPTOM




de clase)


MO; [*] $0 (Tier 4) NIVA-HIST DM

MO; [*] $0 (Tier 4) NIVANEX DMX

MO; [*] $0 (Tier 4) NOHIST-DM

[*]; QLL (30 per 30 days) $0 (Tier 4) NON-DROWSY ALLERGY

MO; [*] $0 (Tier 4) NOREL AD

MO; [*] $0 (Tier 4) ORGAN-I NR

[*] $0 (Tier 4) ORMIR

[*] $0 (Tier 4) PAIN RELIEF ALLERGY SINUS

[*] $0 (Tier 4) PAIN RELIEF COLD AND COUGH

[*] $0 (Tier 4) PAIN RELIEF SINUS PE

[*] $0 (Tier 4) PEDIA RELIEF COUGH-COLD

[*] $0 (Tier 4) PEDIACARE MULTI-SYMPTOM COLD

[*] $0 (Tier 4) PEDIATRIC COUGH AND COLD ORAL LIQUID 1-15-5 MG/5 ML

[*] $0 (Tier 4) PHARBECHLOR

[*] $0 (Tier 4) PHARBEDRYL

MO; [*] $0 (Tier 3) PHENYLHISTINE DH

[*] $0 (Tier 4) POLY HIST PD

[*] $0 (Tier 4) POLY-HIST DM (THONZYLAMINE)

MO; [*] $0 (Tier 4) POLY-TUSSIN AC ORAL LIQUID 4-10-10 MG/ 5 ML

[*] $0 (Tier 4) POLY-VENT DM ORAL TABLET 60-20-380 MG

MO; [*] $0 (Tier 4) POLY-VENT IR ORAL TABLET 60-380 MG

[*] $0 (Tier 4) PRES GEN

[*] $0 (Tier 4) PRESGEN B

MO; [*] $0 (Tier 4) PRIMATENE ASTHMA

[*] $0 (Tier 3) PRO-RED AC (W/ DEXCHLORPHENIR)

PAR; MO $0-$7.40 (Tier 2) promethazine injection solution

PAR; MO $0-$7.40 (Tier 2) promethazine oral tablet 12.5 mg, 25 mg




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MO; [*] $0 (Tier 3) PROMETHAZINE VC-CODEINE

MO; [*] $0 (Tier 3) promethazine-codeine

MO; [*] $0 (Tier 3) promethazine-dm

MO; [*] $0 (Tier 3) promethazine-phenyleph-codeine

PAR; MO $0-$7.40 (Tier 2) PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG

[*] $0 (Tier 4) pseudoephed-chlophedianol-gg

MO; [*] $0 (Tier 4) pseudoephedrine hcl oral liquid

MO; [*] $0 (Tier 4) pseudoephedrine hcl oral tablet 30 mg

[*] $0 (Tier 4) pseudoephedrine hcl oral tablet 60 mg

MO; [*] $0 (Tier 4) pseudoephedrine hcl oral tablet extended release

[*] $0 (Tier 4) Q-DRYL ORAL CAPSULE

MO; [*] $0 (Tier 4) Q-DRYL ORAL LIQUID

MO; [*] $0 (Tier 4) Q-TAPP DM

[*] $0 (Tier 4) Q-TUSSIN

[*] $0 (Tier 4) Q-TUSSIN DM

[*] $0 (Tier 4) QUENALIN

[*] $0 (Tier 4) REFENESEN DM

[*] $0 (Tier 4) REFENESEN ORAL TABLET 400 MG

[*] $0 (Tier 4) REFENESEN PE

[*] $0 (Tier 3) RELCOF C

MO; [*] $0 (Tier 4) RESCON-DM

MO; [*] $0 (Tier 4) RESCON-GG

MO; [*] $0 (Tier 4) RESPAIRE-30

[*] $0 (Tier 4) REST SIMPLY NIGHTTIME SLEEP

[*] $0 (Tier 4) RESTFULLY SLEEP

[*] $0 (Tier 4) RI-TUSSIN

[*] $0 (Tier 4) RI-TUSSIN DM

MO; [*] $0 (Tier 4) ROBAFEN




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MO; [*] $0 (Tier 4) ROBAFEN CF (PHENYLEPHRINE)

MO; [*] $0 (Tier 4) ROBAFEN COUGH

MO; [*] $0 (Tier 4) ROBAFEN DM

[*] $0 (Tier 4) ROBAFEN DM COUGH

MO; [*] $0 (Tier 4) ROBITUSSIN COUGH AND COLD CF

MO; [*] $0 (Tier 4) ROBITUSSIN COUGH-CHEST CONG DM ORAL CAPSULE

[*] $0 (Tier 4) ROBITUSSIN LONG-ACTING

[*] $0 (Tier 4) ROBITUSSIN NIGHTTIME COUGH DM

MO; [*] $0 (Tier 4) ROBITUSSIN PEDIATRIC

[*] $0 (Tier 4) RYCONTUSS

[*] $0 (Tier 3) RYDEX

[*] $0 (Tier 4) RYNEX DM

[*] $0 (Tier 4) SCOT-TUSSIN DIABETES CF

[*] $0 (Tier 4) SCOT-TUSSIN DM

[*] $0 (Tier 4) SCOT-TUSSIN EXPECTORANT

[*] $0 (Tier 4) SCOT-TUSSIN SENIOR

[*] $0 (Tier 4) SEVERE ALLERGY-SINUS HEADACHE

[*] $0 (Tier 4) SEVERE COLD

[*] $0 (Tier 4) SEVERE COLD AND FLU (PE) ORAL TABLET

[*] $0 (Tier 4) SEVERE COLD AND FLU NIGHTTIME

[*] $0 (Tier 4) SEVERE COLD MULTI-SYMPTOM

[*] $0 (Tier 4) SEVERE SINUS

[*] $0 (Tier 4) SILADRYL SA

[*] $0 (Tier 4) SILPHEN COUGH

[*] $0 (Tier 4) SILTUSSIN DM DAS

MO; [*] $0 (Tier 4) SILTUSSIN SA

[*] $0 (Tier 4) SILTUSSIN-DM

[*] $0 (Tier 4) SINUS 12 HOUR




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[*] $0 (Tier 4) SINUS AND COLD-D

[*] $0 (Tier 4) SINUS CONGEST-PAIN DAY-NIGHT

[*] $0 (Tier 4) SINUS CONGESTION AND PAIN

[*] $0 (Tier 4) SINUS CONGESTION-PAIN(CHLORPH)

[*] $0 (Tier 4) SINUS CONGESTION-PAIN(GUAIF)

[*] $0 (Tier 4) SINUS DECONGESTANT (PE)

[*] $0 (Tier 4) SINUS HEADACHE PE

[*] $0 (Tier 4) SINUS PAIN RELIEF

[*] $0 (Tier 4) SINUS RELIEF (NON-DROWSY)

[*] $0 (Tier 4) SLEEP

[*] $0 (Tier 4) SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG

[*] $0 (Tier 4) SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET

[*] $0 (Tier 4) SLEEP AID MAX STR (DIPHENHYDR)

[*] $0 (Tier 4) SLEEP II

[*] $0 (Tier 4) SLEEP TABLET (DIPHENHYDRAMINE)

[*] $0 (Tier 4) SLEEP-TABS

[*] $0 (Tier 4) SORBUGEN NR

[*] $0 (Tier 4) SUDAFED PE PRESSURE+PAIN+COUGH

MO; [*] $0 (Tier 4) SUDOGEST

MO; [*] $0 (Tier 4) SUDOGEST 12-HOUR

MO; [*] $0 (Tier 4) SUDOGEST PE

[*] $0 (Tier 4) SUPHEDRIN

[*] $0 (Tier 4) SUPHEDRIN 12 HOUR

[*] $0 (Tier 4) SUPHEDRINE

[*] $0 (Tier 4) SUPHEDRINE 12 HOUR

[*] $0 (Tier 4) SUPHEDRINE PE

[*] $0 (Tier 4) SUPHEDRINE PE DAY-NIGHT




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[*] $0 (Tier 4) SUPHEDRINE PE SINUS HEADACHE

[*] $0 (Tier 4) TAB TUSSIN

[*] $0 (Tier 4) TAB TUSSIN DM

MO; [*] $0 (Tier 3) TESSALON PERLES

[*] $0 (Tier 4) TG 10PEH-380GFN

[*] $0 (Tier 4) TG 10PEH-380GFN-15DM

[*] $0 (Tier 4) THERAFLU DAYTIME COLD-COUGH

[*] $0 (Tier 4) THERAFLU FLU-SORE THROAT

[*] $0 (Tier 4) THERAFLU NIGHT SEVERE COLD-CGH

[*] $0 (Tier 4) TOTAL ALLERGY MEDICINE

[*] $0 (Tier 4) TRIAMINIC COLD AND COUGH (PE)

[*] $0 (Tier 4) TRIAMINIC COLD AND COUGHNT(PE)

[*] $0 (Tier 4) TUSICOF ORAL TABLET

[*] $0 (Tier 3) TUSNEL C

[*] $0 (Tier 4) tusnel diabetic

[*] $0 (Tier 4) TUSNEL NEW FORMULA

[*] $0 (Tier 4) TUSNEL PEDIATRIC

[*] $0 (Tier 4) TUSNEL-DM PEDIATRIC

[*] $0 (Tier 4) TUSSI PRES-B ORAL LIQUID 4-10-20 MG/5 ML

[*] $0 (Tier 4) TUSSI-PRES ORAL LIQUID

MO; [*] $0 (Tier 3) TUSSICAPS

MO; [*] $0 (Tier 3) TUSSIGON

[*] $0 (Tier 4) TUSSIN

MO; [*] $0 (Tier 4) TUSSIN CF (PE-DM-GUAIF)

[*] $0 (Tier 4) TUSSIN CF COUGH-COLD

[*] $0 (Tier 4) TUSSIN CF MAX

[*] $0 (Tier 4) TUSSIN CHEST CONGESTION

[*] $0 (Tier 4) TUSSIN COUGH (DM ONLY)

[*] $0 (Tier 4) TUSSIN COUGH-CHEST CONGESTION




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[*] $0 (Tier 4) TUSSIN DM CLEAR

[*] $0 (Tier 4) TUSSIN DM COUGH

[*] $0 (Tier 4) TUSSIN DM COUGH AND CHEST

[*] $0 (Tier 4) TUSSIN DM MAX ORAL LIQUID 10-200 MG/5 ML

[*] $0 (Tier 4) TUSSIN DM ORAL LIQUID

MO; [*] $0 (Tier 4) TUSSIN DM ORAL SYRUP 10-100 MG/5 ML

[*] $0 (Tier 4) TUSSIN DM ORAL TABLET

[*] $0 (Tier 4) TUSSIN EXPECTORANT

[*] $0 (Tier 4) TUSSIN HONEY

[*] $0 (Tier 4) TUSSIN MAXIMUM STRENGTH

[*] $0 (Tier 4) TUSSIN MAXIMUM STRENGTH COUGH

MO; [*] $0 (Tier 3) TUSSIONEX PENNKINETIC ER

[*] $0 (Tier 4) TYLENOL COLD MULTI-SYMPT NIGHT ORAL LIQUID

[*] $0 (Tier 4) UNISOM SLEEPGELS

[*] $0 (Tier 4) VALU-DRYL ALLERGY ORAL CAPSULE

MO; [*] $0 (Tier 4) VANACOF

[*] $0 (Tier 4) VANAHIST PD

[*] $0 (Tier 4) VAPORIZING STEAM

[*] $0 (Tier 4) VICKS CHILDREN'S NYQUIL COLD-C

[*] $0 (Tier 4) VICKS DAYQUIL COLD-FLU RELIEF

[*] $0 (Tier 4) VICKS DAYQUIL COUGH

[*] $0 (Tier 4) VICKS DAYQUIL MUCUS CONTROL DM

[*] $0 (Tier 4) VICKS DAYQUIL SEVERE COLD-FLU

[*] $0 (Tier 4) VICKS NYQUIL COLD/FLU (CPM)

[*] $0 (Tier 4) VICKS NYQUIL COLD/FLU LIQUICAP

[*] $0 (Tier 4) VICKS NYQUIL COUGH

[*] $0 (Tier 4) VICKS NYQUIL NIGHTTIME RELIEF




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[*] $0 (Tier 4) VICKS NYQUIL SEVERE COLD-FLU

[*]; QLL (30 per 30 days) $0 (Tier 4) VICKS QLEARQUIL ALLERGY

[*] $0 (Tier 4) VICKS QLEARQUIL DAYTIME SINUS

[*] $0 (Tier 4) VICKS QLEARQUIL NIGHTIME SINUS

[*] $0 (Tier 4) VICKS QLEARQUIL NIGHTTIME RLF

[*] $0 (Tier 4) VICKS VAPOSTEAM

MO; [*] $0 (Tier 3) VIRTUSSIN AC

[*] $0 (Tier 3) VIRTUSSIN DAC

[*] $0 (Tier 4) WAL-DRYL ALLERGY

[*] $0 (Tier 4) WAL-DRYL SEVERE ALLERGY-SINUS

[*] $0 (Tier 4) WAL-FEX ALLERGY

[*] $0 (Tier 4) WAL-FEX D 12 HOUR

[*] $0 (Tier 4) WAL-FINATE

[*] $0 (Tier 4) WAL-FLU NIGHT TIME

[*] $0 (Tier 4) WAL-FLU SEVERE COLD AND COUGH

[*] $0 (Tier 4) WAL-FLU SEVERE COLD-COUGH

[*] $0 (Tier 4) WAL-ITIN D

[*] $0 (Tier 4) WAL-ITIN D 12 HOUR

[*] $0 (Tier 4) WAL-ITIN ORAL SOLUTION

[*]; QLL (30 per 30 days) $0 (Tier 4) WAL-ITIN ORAL TABLET

[*]; QLL (30 per 30 days) $0 (Tier 4) WAL-ITIN ORAL TABLET,DISINTEGRATING

[*] $0 (Tier 4) WAL-PHED 12 HOUR

[*] $0 (Tier 4) WAL-PHED ORAL TABLET 30 MG

[*] $0 (Tier 4) WAL-PHED PE

[*] $0 (Tier 4) WAL-PHED PE NIGHTTIME COLD

[*] $0 (Tier 4) WAL-PHED PE SINUS HEADACHE

[*] $0 (Tier 4) WAL-PHED PE TRIPLE RELIEF

[*] $0 (Tier 4) WAL-PROFEN COLD-SINUS

[*] $0 (Tier 4) WAL-PROFEN D COLD AND SINUS




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[*] $0 (Tier 4) WAL-SOM (DIPHENHYDRAMINE) ORAL CAPSULE

[*] $0 (Tier 4) WAL-TAP DM

[*] $0 (Tier 4) WAL-TUSSIN COUGH

[*] $0 (Tier 4) WAL-TUSSIN COUGH AND COLD CF

[*] $0 (Tier 4) WAL-TUSSIN DM

[*] $0 (Tier 4) WAL-TUSSIN MAX STRENGTH COUGH

[*]; QLL (300 per 30 days) $0 (Tier 4) WAL-ZYR (CETIRIZINE) ORAL SOLUTION

[*]; QLL (30 per 30 days) $0 (Tier 4) WAL-ZYR (CETIRIZINE) ORAL TABLET

[*] $0 (Tier 4) WAL-ZYR D

MO; [*] $0 (Tier 3) Z-TUSS AC

[*] $0 (Tier 3) ZODRYL AC 25






[*] $0 (Tier 3) ZODRYL DEC 25






MO; [*]; QLL (30 per 30 days) $0 (Tier 4) ZYRTEC ORAL TABLET

PULMONARY AGENTS B/D PAR; MO $0 (Tier 1) acetylcysteine

PAR; MO; LA $0-$7.40 (Tier 2) ADEMPAS

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) ADVAIR DISKUS

MO; QLL (12 per 30 days) $0-$7.40 (Tier 2) ADVAIR HFA




de clase)


QLL (18 per 30 days) $0-$7.40 (Tier 2) AEROSPAN

B/D PAR; MO; QLL (360 per 30 days) $0 (Tier 1) albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %)

B/D PAR; MO; QLL (60 per 30 days) $0 (Tier 1) ALBUTEROL SULFATE INHALATION SOLUTION FOR NEBULIZATION 2.5 MG/0.5 ML

B/D PAR; MO; QLL (60 per 30 days) $0 (Tier 1) albuterol sulfate inhalation solution for nebulization 5 mg/ml

MO $0 (Tier 1) albuterol sulfate oral

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) ANORO ELLIPTA

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) ARNUITY ELLIPTA

MO; QLL (13 per 30 days) $0-$7.40 (Tier 2) ASMANEX HFA

MO; QLL (0.14 per 30 days) $0-$7.40 (Tier 2) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES)

$0-$7.40 (Tier 2) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES)

MO; QLL (0.24 per 30 days) $0-$7.40 (Tier 2) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)

MO; QLL (26 per 30 days) $0-$7.40 (Tier 2) ATROVENT HFA

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) BREO ELLIPTA

PAR; MO $0-$7.40 (Tier 2) CINRYZE

MO; QLL (8 per 30 days) $0-$7.40 (Tier 2) COMBIVENT RESPIMAT

B/D PAR; MO; QLL (240 per 30 days) $0 (Tier 1) cromolyn inhalation

PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) DALIRESP

MO; QLL (13 per 30 days) $0-$7.40 (Tier 2) DULERA

PAR; QLL (270 per 30 days) $0-$7.40 (Tier 2) ESBRIET

PAR; MO $0-$7.40 (Tier 2) FIRAZYR




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MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION

MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION, 50 MCG/ ACTUATION

MO; QLL (12 per 30 days) $0-$7.40 (Tier 2) FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION



MO; QLL (75 per 30 days) $0 (Tier 1) flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)

MO; QLL (16 per 30 days) $0 (Tier 1) fluticasone nasal

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) FORADIL AEROLIZER

B/D PAR; MO $0 (Tier 1) ipratropium bromide inhalation

B/D PAR; MO; QLL (540 per 30 days) $0-$7.40 (Tier 2) ipratropium-albuterol

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) KALYDECO ORAL TABLET

PAR; MO; LA; QLL (30 per 30 days) $0-$7.40 (Tier 2) LETAIRIS

B/D PAR; MO; QLL (270 per 30 days) $0 (Tier 1) levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml

B/D PAR; MO; QLL (540 per 30 days) $0 (Tier 1) levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml

MO $0 (Tier 1) metaproterenol

QLL (17 per 30 days) $0-$7.40 (Tier 2) mometasone nasal

MO; QLL (30 per 30 days) $0 (Tier 1) montelukast

MO; QLL (17 per 30 days) $0-$7.40 (Tier 2) NASONEX

PAR; MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) OFEV ORAL CAPSULE 150 MG

B/D PAR; MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) PERFOROMIST

MO; QLL (18 per 30 days) $0-$7.40 (Tier 2) PROAIR HFA

MO; QLL (2 per 30 days) $0-$7.40 (Tier 2) PROAIR RESPICLICK




de clase)


B/D PAR; MO $0-$7.40 (Tier 2) PULMOZYME

MO; QLL (9 per 30 days) $0-$7.40 (Tier 2) QVAR INHALATION AEROSOL 40 MCG/ ACTUATION

MO; QLL (18 per 30 days) $0-$7.40 (Tier 2) QVAR INHALATION AEROSOL 80 MCG/ ACTUATION

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) SEREVENT DISKUS

PAR; MO; QLL (90 per 30 days) $0-$7.40 (Tier 2) sildenafil oral

MO; QLL (4 per 30 days) $0-$7.40 (Tier 2) SPIRIVA RESPIMAT

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) SPIRIVA WITH HANDIHALER

MO; QLL (4 per 30 days) $0-$7.40 (Tier 2) STIOLTO RESPIMAT

MO $0 (Tier 1) terbutaline oral

MO $0 (Tier 1) terbutaline subcutaneous

MO $0 (Tier 1) theophylline oral tablet extended release 12 hr

MO $0 (Tier 1) theophylline oral tablet extended release 24 hr

PAR; MO; LA; QLL (60 per 30 days) $0-$7.40 (Tier 2) TRACLEER

PAR; MO $0-$7.40 (Tier 2) VENTAVIS

MO; QLL (36 per 30 days) $0-$7.40 (Tier 2) VENTOLIN HFA

PAR; MO; LA; QLL (6 per 28 days) $0-$7.40 (Tier 2) XOLAIR

MO; QLL (45 per 30 days) $0-$7.40 (Tier 2) XOPENEX HFA

MO; QLL (60 per 30 days) $0 (Tier 1) zafirlukast

UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) MYRBETRIQ

MO; QLL (600 per 30 days) $0-$7.40 (Tier 2) oxybutynin chloride oral syrup

MO; QLL (120 per 30 days) $0-$7.40 (Tier 2) oxybutynin chloride oral tablet

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) oxybutynin chloride oral tablet extended release 24hr 5 mg

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) tolterodine oral capsule,extended release 24hr




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MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) tolterodine oral tablet

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) TOVIAZ

MO; QLL (60 per 30 days) $0-$7.40 (Tier 2) trospium oral tablet

MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) VESICARE

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY MO $0-$7.40 (Tier 2) alfuzosin

MO $0-$7.40 (Tier 2) finasteride oral tablet 5 mg

MO $0-$7.40 (Tier 2) tamsulosin

CHOLINERGIC STIMULANTS MO $0-$7.40 (Tier 2) bethanechol chloride

MISCELLANEOUS UROLOGICALS PAR; MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) CIALIS ORAL TABLET 2.5 MG, 5 MG

MO; LA $0-$7.40 (Tier 2) CYSTAGON

MO $0-$7.40 (Tier 2) potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg)

VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES

[*] $0 (Tier 4) ANTACID (CALCIUM CARBONATE)

[*] $0 (Tier 4) ANTACID CALCIUM ORAL TABLET, CHEWABLE 215 MG CALCIUM (500 MG)

[*] $0 (Tier 4) ANTACID EXT STR (CALCIUM CARB)

[*] $0 (Tier 4) ANTACID EXTRA-STRENGTH ORAL TABLET, CHEWABLE 300 MG (750 MG)

[*] $0 (Tier 4) ANTACID ULTRA STRENGTH ORAL TABLET, CHEWABLE 400 MG (1,000 MG)

MO; [*] $0 (Tier 4) CAL-GEST ANTACID

[*] $0 (Tier 4) CALCIUM 600

MO $0-$7.40 (Tier 2) calcium acetate oral capsule

MO; [*] $0 (Tier 4) CALCIUM ANTACID ORAL TABLET, CHEWABLE 200 MG CALCIUM (500 MG)




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[*] $0 (Tier 4) CALCIUM ANTACID ORAL TABLET, CHEWABLE 300 MG (750 MG), 320 MG (750 MG), 400 MG (1,000 MG)

[*] $0 (Tier 4) CALCIUM ANTACID TROPICAL

[*] $0 (Tier 4) CALCIUM ANTACID ULTRA MAX ST

MO; [*] $0 (Tier 4) CALCIUM CARBONATE ORAL SUSPENSION

MO; [*] $0 (Tier 4) CALCIUM CARBONATE ORAL TABLET 260 MG CALCIUM (648 MG)

MO; [*] $0 (Tier 4) calcium carbonate oral tablet 500 mg calcium (1, 250 mg), 600 mg (1,500 mg)

[*] $0 (Tier 4) calcium carbonate oral tablet,chewable 200 mg calcium (500 mg), 300 mg (750 mg), 400 mg (1,000 mg)

[*] $0 (Tier 3) CALCIUM CHLORIDE INTRAVENOUS SYRINGE

MO; [*] $0 (Tier 3) chromium chloride

MO; [*] $0 (Tier 3) COPPER CHLORIDE

MO $0-$7.40 (Tier 2) dextrose-kcl-nacl

[*] $0 (Tier 4) FLAVOR CHEWS ANTACID

$0-$7.40 (Tier 2) K-TAB ORAL TABLET EXTENDED RELEASE 8 MEQ

MO $0-$7.40 (Tier 2) KLOR-CON 10

MO $0-$7.40 (Tier 2) KLOR-CON 8

MO $0-$7.40 (Tier 2) KLOR-CON M10



MO $0-$7.40 (Tier 2) lactated ringers intravenous

MO; [*] $0 (Tier 4) magnesium oxide oral tablet 400 mg, 420 mg

$0-$7.40 (Tier 2) MAGNESIUM SULFATE IN WATER INTRAVENOUS PARENTERAL SOLUTION




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$0-$7.40 (Tier 2) MAGNESIUM SULFATE IN WATER INTRAVENOUS PIGGYBACK 2 GRAM/50 ML (4 %), 4 GRAM/50 ML (8 %)

MO $0-$7.40 (Tier 2) MAGNESIUM SULFATE IN WATER INTRAVENOUS PIGGYBACK 4 GRAM/100 ML (4 %)

MO $0-$7.40 (Tier 2) magnesium sulfate injection solution

$0-$7.40 (Tier 2) magnesium sulfate injection syringe

[*] $0 (Tier 3) manganese chloride

[*] $0 (Tier 3) manganese sulfate intravenous

[*] $0 (Tier 4) MGO

$0-$7.40 (Tier 2) NORMOSOL-R

$0-$7.40 (Tier 2) NORMOSOL-R IN 5 % DEXTROSE

MO; [*] $0 (Tier 4) OYSCO D

MO; [*] $0 (Tier 4) OYSCO-500

[*] $0 (Tier 4) OYST-CAL-500

[*] $0 (Tier 4) OYSTER SHELL + D3

MO; [*] $0 (Tier 4) OYSTER SHELL CALCIUM

MO; [*] $0 (Tier 4) OYSTER SHELL CALCIUM 500

MO; [*] $0 (Tier 4) OYSTER SHELL CALCIUM-VIT D3 ORAL TABLET 250-125 MG-UNIT

$0-$7.40 (Tier 2) potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l

MO $0-$7.40 (Tier 2) potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l

$0-$7.40 (Tier 2) potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l

$0-$7.40 (Tier 2) potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l

MO $0-$7.40 (Tier 2) potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l




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$0-$7.40 (Tier 2) potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l

$0-$7.40 (Tier 2) potassium chloride intravenous piggyback 10 meq/ 100 ml, 20 meq/100 ml, 40 meq/100 ml

MO $0-$7.40 (Tier 2) POTASSIUM CHLORIDE INTRAVENOUS PIGGYBACK 10 MEQ/50 ML

$0-$7.40 (Tier 2) POTASSIUM CHLORIDE INTRAVENOUS PIGGYBACK 20 MEQ/50 ML, 30 MEQ/100 ML

MO $0-$7.40 (Tier 2) potassium chloride intravenous solution

MO $0 (Tier 1) potassium chloride oral capsule, extended release

MO $0 (Tier 1) potassium chloride oral tablet extended release

MO $0 (Tier 1) potassium chloride oral tablet,er particles/crystals

$0-$7.40 (Tier 2) potassium chloride-0.45 % nacl

MO $0-$7.40 (Tier 2) potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l

$0-$7.40 (Tier 2) potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l

$0-$7.40 (Tier 2) potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l

MO $0-$7.40 (Tier 2) potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l

$0-$7.40 (Tier 2) potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/l

$0-$7.40 (Tier 2) ringers intravenous

[*] $0 (Tier 4) SMOOTH ANTACID

MO $0-$7.40 (Tier 2) sodium chloride 0.45 % intravenous parenteral solution

$0-$7.40 (Tier 2) SODIUM CHLORIDE 0.45 % INTRAVENOUS PIGGYBACK

MO $0-$7.40 (Tier 2) sodium chloride 3 %

$0-$7.40 (Tier 2) sodium chloride 5 %

MO $0-$7.40 (Tier 2) sodium chloride intravenous




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[*] $0 (Tier 4) SUPER CALCIUM

MO; [*] $0 (Tier 4) TUMS

MO; [*] $0 (Tier 4) TUMS E-X

[*] $0 (Tier 4) TUMS EXTRA STRENGTH SMOOTHIES

[*] $0 (Tier 4) TUMS FRESHERS

MO; [*] $0 (Tier 4) TUMS ULTRA ORAL TABLET,CHEWABLE 400 MG (1,000 MG)

[*] $0 (Tier 4) ULTRA STRENGTH ANTACID

[*] $0 (Tier 4) ULTRA STRENGTH CALCIUM ANTACID

MO; [*] $0 (Tier 3) zinc chloride intraveneous solution

MISCELLANEOUS NUTRITION PRODUCTS B/D PAR $0-$7.40 (Tier 2) AMINOSYN 8.5 %

B/D PAR $0-$7.40 (Tier 2) AMINOSYN 8.5 %-ELECTROLYTES

B/D PAR $0-$7.40 (Tier 2) AMINOSYN II 10 %

B/D PAR $0-$7.40 (Tier 2) AMINOSYN II 7 %

B/D PAR $0-$7.40 (Tier 2) AMINOSYN II 8.5 %

B/D PAR $0-$7.40 (Tier 2) AMINOSYN II 8.5 %-ELECTROLYTES

B/D PAR $0-$7.40 (Tier 2) AMINOSYN M 3.5 %

B/D PAR $0-$7.40 (Tier 2) AMINOSYN-HBC 7%

B/D PAR $0-$7.40 (Tier 2) AMINOSYN-PF 10 %

B/D PAR $0-$7.40 (Tier 2) AMINOSYN-PF 7 % (SULFITE-FREE)

B/D PAR $0-$7.40 (Tier 2) CLINIMIX 5%/D15W SULFITE FREE

B/D PAR $0-$7.40 (Tier 2) CLINIMIX 5%/D25W SULFITE-FREE

B/D PAR $0-$7.40 (Tier 2) CLINIMIX 2.75%/D5W SULFIT FREE

B/D PAR $0-$7.40 (Tier 2) CLINIMIX 4.25%-D20W SULF-FREE

B/D PAR $0-$7.40 (Tier 2) CLINIMIX 4.25%-D25W SULF-FREE

B/D PAR $0-$7.40 (Tier 2) CLINIMIX 4.25%/D10W SULF FREE

B/D PAR $0-$7.40 (Tier 2) CLINIMIX 5%-D20W(SULFITE-FREE)





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B/D PAR $0-$7.40 (Tier 2) CLINIMIX E 4.25%/D5W SULF FREE

B/D PAR $0-$7.40 (Tier 2) CLINIMIX E 5%/D15W SULFIT FREE



B/D PAR $0-$7.40 (Tier 2) FREAMINE III 10 %

B/D PAR $0-$7.40 (Tier 2) HEPATAMINE 8%

B/D PAR; MO $0-$7.40 (Tier 2) intralipid intravenous emulsion 20 %

$0-$7.40 (Tier 2) ISOLYTE-P IN 5 % DEXTROSE

$0-$7.40 (Tier 2) NORMOSOL-M IN 5 % DEXTROSE

$0-$7.40 (Tier 2) NORMOSOL-R PH 7.4

$0-$7.40 (Tier 2) PLASMA-LYTE 148

$0-$7.40 (Tier 2) PLASMA-LYTE-56 IN 5 % DEXTROSE

B/D PAR; MO $0-$7.40 (Tier 2) travasol 10 %

B/D PAR; MO $0-$7.40 (Tier 2) TROPHAMINE 10 %

B/D PAR $0-$7.40 (Tier 2) TROPHAMINE 6%

[*] $0 (Tier 4) WAL-FLU COLD AND SORE THROAT

VITAMINS / HEMATINICS [*] $0 (Tier 4) A THRU Z ADVANCED FORMULA

MO; [*] $0 (Tier 3) AQUASOL A

[*] $0 (Tier 4) ascorbic acid (vitamin c) oral tablet 250 mg

[*] $0 (Tier 4) CALCIUM CARBONATE-VIT D3-MIN ORAL TABLET,CHEWABLE 600 MG (1,500 MG)-400 UNIT

[*] $0 (Tier 4) CENTRAL-VITE ORAL TABLET 18-400 MG- MCG

[*] $0 (Tier 4) CENTURY ORAL TABLET 18-400 MG-MCG

[*] $0 (Tier 4) CENTURY ULTIMATE WOMEN'S ORAL TABLET 18-400 MG-MCG

MO; [*] $0 (Tier 4) CEROVITE ADVANCED FORMULA




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MO; [*] $0 (Tier 4) CERTAVITE-ANTIOXIDANT

[*] $0 (Tier 4) COMPLETE MULTIVITAMIN-MINERAL ORAL TABLET

MO; [*] $0 (Tier 3) cyanocobalamin (vitamin b-12) injection

[*] $0 (Tier 4) DAILY MULTI-VITAMINS/IRON

[*] $0 (Tier 4) DAILY MULTIPLE ORAL TABLET 18-400 MG- MCG

[*] $0 (Tier 4) DAILY MULTIPLE VITAMINS/IRON

[*] $0 (Tier 4) DAILY MULTIVITAMIN WITH IRON

[*] $0 (Tier 4) DAILY VITAMIN FORMULA + IRON

[*] $0 (Tier 4) DAILY VITAMIN WITH IRON

MO; [*] $0 (Tier 4) DAILY VITES/IRON

MO; [*] $0 (Tier 3) DRISDOL ORAL CAPSULE

MO; [*] $0 (Tier 3) ergocalciferol (vitamin d2) oral capsule

[*] $0 (Tier 4) ESSENTIA

MO; [*] $0 (Tier 3) FERAHEME

MO $0-$7.40 (Tier 2) FLUORITAB ORAL TABLET,CHEWABLE 1 MG FLUORIDE (2.2 MG)

MO; [*] $0 (Tier 3) folic acid injection

MO; [*] $0 (Tier 3) folic acid oral tablet 1 mg

[*] $0 (Tier 4) HAIR VITAMINS

MO; [*] $0 (Tier 3) hydroxocobalamin

MO; [*] $0 (Tier 3) INFED

MO; [*] $0 (Tier 3) INFUVITE ADULT

MO; [*] $0 (Tier 3) INFUVITE PEDIATRIC

MO $0-$7.40 (Tier 2) LUDENT FLUORIDE ORAL TABLET, CHEWABLE 1 MG FLUORIDE (2.2 MG)

[*] $0 (Tier 3) M.V.I. ADULT

[*] $0 (Tier 3) M.V.I. PEDIATRIC

[*] $0 (Tier 3) M.V.I.-12 (WITHOUT VITAMIN K)




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[*] $0 (Tier 4) MULTI COMPLETE WITH IRON

[*] $0 (Tier 4) MULTI-DAY WITH IRON

[*] $0 (Tier 4) multivitamin with iron

MO; [*] $0 (Tier 3) NASCOBAL

[*] $0 (Tier 4) ONE DAILY MULTI-VIT W-MINERAL

[*] $0 (Tier 4) ONE DAILY MULTIVIT-IRON(FOLIC)

[*] $0 (Tier 4) ONE DAILY PLUS IRON

[*] $0 (Tier 4) ONE DAILY WITH IRON

[*] $0 (Tier 4) ONE-A-DAY TEEN ADVANTAGE ORAL TABLET 18-400 MG-MCG

MO $0-$7.40 (Tier 2) prenatal vitamin oral tablet

MO; [*] $0 (Tier 3) pyridoxine (vitamin b6) injection

[*] $0 (Tier 4) SENTRY ORAL TABLET 18-400 MG-MCG

MO $0-$7.40 (Tier 2) sodium fluoride oral tablet

MO $0-$7.40 (Tier 2) sodium fluoride oral tablet,chewable 1 mg fluoride (2.2 mg)

[*] $0 (Tier 4) SPECTRAVITE ADVANCED FORMULA ORAL TABLET 18-400 MG-MCG

[*] $0 (Tier 4) SPECTRAVITE ULTRA WOMEN

MO; [*] $0 (Tier 4) TAB-A-VITE/IRON

MO; [*] $0 (Tier 3) thiamine hcl (vitamin b1) injection

MO; [*] $0 (Tier 3) VENOFER INTRAVENOUS SOLUTION 100 MG IRON/5 ML, 200 MG IRON/10 ML

[*] $0 (Tier 3) VENOFER INTRAVENOUS SOLUTION 50 MG IRON/2.5 ML

MO; [*] $0 (Tier 4) VITAMIN C ORAL TABLET 250 MG

MO; [*] $0 (Tier 3) VITAMIN D2

[*] $0 (Tier 4) VITAMIN E (DL, ACETATE) ORAL CAPSULE 1,000 UNIT

[*] $0 (Tier 4) vitamin e mixed oral capsule 1,000 unit




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MO; [*] $0 (Tier 4) vitamin e oral capsule 1,000 unit

[*] $0 (Tier 4) YELETS


Índice 1 1-DAY ............................ 109 12 HOUR COLD RELIEF ........................... 117 12 HOUR DECONGESTANT ........ 117 12 HOUR NASAL RELIEF SPRAY ............................. 84 12 HOUR NASAL SPRAY ............................. 84 3 3 DAY VAGINAL ......... 109 3-DAY VAGINAL ......... 109 8 8 HOUR PAIN RELIEVER ....................... 43 A A + D (LAN, PET) ........... 72 A THRU Z ADVANCED FORMULA ..................... 149 abacavir ............................ 12 abacavir-lamivudine- zidovudine ......................... 12 ABELCET ........................ 11 ABILIFY MAINTENA .... 51 ABRAXANE .................... 24 acamprosate ..................... 81 acarbose oral tablet 100 mg ..................................... 87 acarbose oral tablet 25 mg ..................................... 87 acarbose oral tablet 50 mg ..................................... 87 acebutolol ......................... 63 ACEPHEN RECTAL SUPPOSITORY 120 MG, 650 MG .................................... 43 ACEPHEN RECTAL SUPPOSITORY 325 MG .................................... 43 ACETA-GESIC ................ 43 ACETADRYL .................. 43 ACETAMINOPHEN EXTRA STRENGTH ..................... 43

acetaminophen oral drops, suspension ......................... 43 acetaminophen oral elixir .................................. 43 acetaminophen oral liquid 160 mg/5 ml ............................. 43 acetaminophen oral solution 160 mg/5 ml (5 ml) ........... 44 acetaminophen oral solution 325 mg/10.15 ml ............... 44 acetaminophen oral suspension 160 mg/5 ml .... 44 acetaminophen oral tablet ................................. 44 acetaminophen oral tablet extended release ............... 44 acetaminophen oral tablet, disintegrating .................... 44 ACETAMINOPHEN PAIN RELIEF ............................. 44 ACETAMINOPHEN PM .................................... 44 ACETAMINOPHEN PM EXTRA STR .................... 44 acetaminophen rectal ....... 44 acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml ...................................... 41 acetaminophen-codeine oral solution 120-12 mg/5 ml .... 41 ACETAMINOPHEN- CODEINE ORAL SOLUTION 240 MG-24 MG /10 ML (10 ML) ................................... 41 acetaminophen-codeine oral tablet 300-15 mg ............... 41 acetaminophen-codeine oral tablet 300-30 mg ............... 41 acetaminophen-codeine oral tablet 300-60 mg ............... 41 acetazolamide ................. 116 acetazolamide sodium .... 116 acetic acid otic .................. 86

acetic acid-aluminum acetate ............................... 86 acetylcysteine .................. 140 acetylcysteine intravenous ....................... 81 ACID CONTROL (RANITIDINE) ORAL TABLET 150 MG .......... 102 ACID CONTROLLER .... 102 ACID CONTROLLER COMPLETE ................... 102 ACID GONE ANTACID ... 94 ACID GONE ANTACID E.STRENGTH .................. 94 ACID REDUCER COMPLETE (FAMOT) ... 102 ACID REDUCER (CIMETIDINE) .............. 102 ACID REDUCER (FAMOTIDINE) ............. 102 ACID REDUCER (RANITIDINE) .............. 102 acitretin ............................. 71 ACNE CONTROL CLEANSER ..................... 73 ACNE FOAMING WASH .............................. 73 ACNE MEDICATION TOPICAL GEL 10 % ....... 73 ACNE TREATMENT (BENZOYL PEROX) ....... 73 ACNE VANISHING ........ 73 ACNE-CLEAR ................. 73 ACTEMRA INTRAVENOUS ............ 107 ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML) ................... 107 ACTHAR H.P. .................. 86 ACTHIB (PF) ................. 104 ACTIMMUNE ............... 103 acyclovir oral capsule ...... 12 acyclovir oral suspension 200 mg/5 ml ............................. 12 acyclovir oral tablet .......... 12


153

acyclovir sodium intravenous solution ............................. 12 acyclovir topical ............... 78 ADACEL(TDAP ADOLESN/ ADULT)(PF) .................. 104 ADAGEN ......................... 81 adapalene topical gel 0.3 % ....................................... 73 adapalene topical gel with pump ................................. 73 ADASUVE ....................... 52 adefovir ............................. 12 ADEMPAS ..................... 140 ADIPEX-P ........................ 81 ADT ROBITUSSIN PEAK CLD DM MAX .............. 117 ADULT COUGH FORMULA DM MAX ....................... 117 ADULT ROBITUSSIN PEAK COLD DM ...................... 117 ADULT ROBITUSSIN PEAK COLD M-S ..................... 117 ADULT TUSSIN CHEST CONGESTION ............... 118 ADULT TUSSIN COUGH CONGEST DM .............. 118 ADULT TUSSIN DM .... 118 ADULT TUSSIN MULTI- SYMP COLD ................. 118 ADULT WAL-TUSSIN ... 118 ADULT WAL-TUSSIN DM MAX ............................... 118 ADVAIR DISKUS ......... 140 ADVAIR HFA ................ 140 ADVANCED ANTACID- ANTIGAS ......................... 94 ADVANCED EYE RELIEF ........................... 114 ADVIL .............................. 44 ADVIL ALLERGY SINUS ............................. 118 ADVIL ALLERGY- CONGESTION RLF ...... 118 ADVIL COLD AND SINUS ORAL CAPSULE .......... 118 ADVIL COLD AND SINUS ORAL TABLET ............. 118

ADVIL CONGESTION RELIEF ........................... 118 ADVIL LIQUI-GEL ......... 44 ADVIL MIGRAINE ......... 44 ADVIL PM ....................... 44 ADVIL PM LIQUI- GELS ................................ 44 AEROSPAN ................... 141 AF ..................................... 75 afeditab cr ......................... 63 AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 5 MG ..................... 24 AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 3 MG ................................. 24 AFINITOR ORAL TABLET 10 MG ............................... 24 AFINITOR ORAL TABLET 2.5 MG .............................. 24 AFINITOR ORAL TABLET 5 MG ................................. 24 AFINITOR ORAL TABLET 7.5 MG .............................. 24 AFRIN NO DRIP (OXYMETAZOLIN) ....... 85 AFRIN (OXYMETAZOLINE) ..... 85 AFTERA ......................... 110 AGGRENOX .................... 68 AKWA TEARS (POLYVINYL ALCOHOL) .................... 114 ala-cort topical cream ...... 78 ALA-HIST DM .............. 118 ALA-HIST IR ................. 118 ALAVERT ..................... 118 ALAVERT D-12 ALLERGY- SINUS ............................. 118 ALAWAY ...................... 114 ALBENZA ....................... 18 albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) ............... 141 ALBUTEROL SULFATE INHALATION SOLUTION

FOR NEBULIZATION 2.5 MG/0.5 ML ..................... 141 albuterol sulfate inhalation solution for nebulization 5 mg/ ml .................................... 141 albuterol sulfate oral ...... 141 alclometasone ................... 78 alcohol pads ...................... 87 ALCOHOL, RUBBING .... 84 ALDURAZYME .............. 90 ALECENSA ..................... 24 alendronate oral solution ........................... 107 alendronate oral tablet 10 mg, 5 mg ................................ 107 alendronate oral tablet 35 mg, 70 mg .............................. 107 alendronate oral tablet 40 mg ..................................... 81 ALER-CAP ..................... 118 ALEVE COLD AND SINUS ............................. 118 ALEVE SINUS AND HEADACHE .................. 118 ALEVE-D SINUS AND COLD ............................. 118 ALEVE-D SINUS AND HEADACHE .................. 118 alfuzosin .......................... 144 ALIMTA ........................... 25 ALINIA ORAL SUSPENSION FOR RECONSTITUTION ........ 18 ALINIA ORAL TABLET ........................... 18 ALKA-SELTZER ORIGINAL ....................... 44 ALKA-SELTZER PLUS ALLERGY ..................... 118 ALKA-SELTZER PLUS DAY ............................... 118 ALKA-SELTZER PLUS MUCUS-CONGES ......... 118 ALKA-SELTZER PLUS SINUS-COUGH ............. 118 ALL DAY ALLERGY RELIEF(CETIR) ............ 119


154

ALL DAY ALLERGY (CETIRIZINE) ORAL SOLUTION .................... 118 ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET ......................... 118 ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET,CHEWABLE ... 118 ALL DAY ALLERGY- D ..................................... 119 ALL DAY PAIN RELIEF ............................. 44 ALL DAY PAIN RELIEF SINUS,COLD ................. 119 ALL DAY RELIEF .......... 44 ALL-NITE COLD-FLU ... 119 ALLER-CHLOR ............ 119 ALLER-EASE ................ 119 ALLER-FEX .................. 119 ALLER-G-TIME ............ 119 ALLER-TEC .................. 119 ALLER-TEC D .............. 119 ALLERCLEAR .............. 119 ALLERCLEAR D- 12HR ............................... 119 ALLERCLEAR D- 24HR ............................... 119 ALLERGY 4-HOUR ...... 119 ALLERGY AND CONGESTION RELIEF ........................... 119 ALLERGY COMPLETE- D ..................................... 119 ALLERGY D-12 ............ 119 ALLERGY EYE (KETOTIFEN) ............... 114 ALLERGY M-S NIGHTTIME .................. 119 ALLERGY MEDICATION ............... 119 ALLERGY MEDICINE ..................... 119 ALLERGY MULTI- SYMPTOM .................... 119 ALLERGY PLUS SEVERE SINUS HA ...................... 119

ALLERGY RELIEF D- 24 .................................... 120 ALLERGY RELIEF D12 ................................. 120 ALLERGY RELIEF MULTI- SYMPTOM .................... 120 ALLERGY RELIEF (CETIRIZINE) ORAL SOLUTION .................... 119 ALLERGY RELIEF (CETIRIZINE) ORAL TABLET ......................... 119 ALLERGY RELIEF (CLEMASTINE) ............ 119 ALLERGY RELIEF (FEXOFENADINE) ....... 120 ALLERGY RELIEF (LORATADINE) ORAL SOLUTION .................... 120 ALLERGY RELIEF (LORATADINE) ORAL TABLET ......................... 120 ALLERGY RELIEF (LORATADINE) ORAL TABLET, DISINTEGRATING ....... 120 ALLERGY RELIEF,NASAL DECONGEST ................ 120 ALLERGY RELIEF-D (CETIRIZINE) ............... 120 ALLERGY RELIEF-D (LORATADINE) ............ 120 ALLERGY RELIEF-D (FEXOFENADINE) ....... 120 ALLERGY RELIEF (CHLORPHENIRAMN) ... 120 ALLERGY RELIEF (DIPHENHYDRAMIN) ... 120 ALLERGY SINUS PE .... 120 ALLERGY (CHLORPHENIRAMINE)... 119 ALLERGY (DIPHENHYDRAMINE) ... 119 ALLERGY-CONGEST RELIEF-D (CET) ........... 120 ALLERGY-CONGESTION RELIEF-D ORAL TABLET

EXTENDED RELEASE 24 HR ................................... 120 ALLERGY-TIME .......... 120 ALLERHIST-1 ............... 120 ALLFEN ......................... 120 ALLFEN DM ................. 120 allopurinol ...................... 107 ALMACONE ORAL SUSPENSION .................. 94 ALMACONE ORAL TABLET,CHEWABLE .... 94 ALMACONE-2 ................ 94 ALOE BURN RELIEF ..... 74 ALOE VESTA ANTIFUNGAL (MICON) .......................... 75 alosetron ........................... 94 ALPHAGAN P OPHTHALMIC DROPS 0.1 % ..................................... 117 alprazolam oral tablet ...... 52 ALTACHLORE OPHTHALMIC OINTMENT ................... 114 ALTAVERA (28) ........... 110 ALTOPREV ..................... 70 aluminum hydroxide gel oral suspension 320 mg/5 ml .... 95 aluminum hydroxide gel oral suspension 600 mg/5 ml .... 95 ALYACEN 1/35 (28) ..... 110 ALYACEN 7/7/7 (28) .... 110 amantadine hcl oral capsule .............................. 12 amantadine hcl oral tablet ................................. 12 AMBI 60PSE-400GFN ... 120 AMBISOME ..................... 11 amcinonide ....................... 78 amifostine crystalline ........ 24 AMIKACIN INJECTION SOLUTION 1,000 MG/4 ML .................................... 18 amikacin injection solution 500 mg/2 ml ...................... 18 amiloride ........................... 63 amiloride- hydrochlorothiazide .......... 63


155

AMINOSYN 8.5 % ........ 148 AMINOSYN 8.5 %- ELECTROLYTES .......... 148 AMINOSYN II 10 % ...... 148 AMINOSYN II 7 % ........ 148 AMINOSYN II 8.5 % ..... 148 AMINOSYN II 8.5 %- ELECTROLYTES .......... 148 AMINOSYN M 3.5 % .... 148 AMINOSYN-HBC 7% .... 148 AMINOSYN-PF 10 % .... 148 AMINOSYN-PF 7 % (SULFITE-FREE) .......... 148 amiodarone intravenous solution ............................. 62 AMIODARONE INTRAVENOUS SYRINGE ......................... 62 amiodarone oral ............... 62 AMITIZA ......................... 95 amitriptyline ..................... 52 amlodipine besylate oral tablet 10 mg, 2.5 mg ................... 63 amlodipine besylate oral tablet 5 mg .................................. 63 amlodipine-atorvastatin .... 70 amlodipine-benazepril ...... 63 amlodipine-valsartan ........ 63 amlodipine-valsartan- hcthiazid ........................... 63 ammonium lactate ............ 72 amoxapine ......................... 52 amoxicillin oral capsule .... 21 amoxicillin oral suspension for reconstitution .................... 21 amoxicillin oral tablet ...... 21 amoxicillin oral tablet, chewable 125 mg, 250 mg ..................................... 21 amoxicillin-pot clavulanate ....................... 21 amphotericin b .................. 11 ampicillin .......................... 21 ampicillin sodium injection ............................ 21 ampicillin sodium intravenous ....................... 21

ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram .................................. 21 ampicillin-sulbactam injection recon soln 15 gram ........... 21 ampicillin-sulbactam intravenous recon soln 3 gram .................................. 21 AMPYRA ......................... 39 anagrelide ......................... 81 anastrozole ....................... 25 ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ..................................... 90 ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/ 1.25 GRAM) ..................... 90 ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/ 2.5 GRAM) ....................... 90 ANDROXY ...................... 90 ANEFRIN ......................... 85 ANORO ELLIPTA ......... 141 ANTACID ........................ 95 ANTACID AND PAIN RELIEF ............................. 44 ANTACID ANTI-GAS .... 95 ANTACID ANTI-GAS DOUBLE STR .................. 95 ANTACID CALCIUM ORAL TABLET,CHEWABLE 215 MG CALCIUM (500 MG) ................................ 144 ANTACID EXST (MAG CARB-AL HYD) .............. 95 ANTACID EXT STR (CALCIUM CARB) ....... 144 ANTACID EXTRA- STRENGTH ORAL SUSPENSION 200-200-20 MG/5 ML .......................... 95 ANTACID EXTRA- STRENGTH ORAL TABLET,

CHEWABLE 300 MG (750 MG) ................................ 144 ANTACID LIQUID ......... 95 ANTACID M .................... 95 ANTACID MAXIMUM STRENGTH ..................... 95 ANTACID PLUS ANTI- GAS .................................. 95 ANTACID REGULAR STRENGTH ..................... 95 ANTACID ULTRA STRENGTH ORAL TABLET, CHEWABLE 400 MG (1,000 MG) ................................ 144 ANTACID WITH SIMETHICONE ............... 95 ANTACID (CALCIUM CARBONATE) .............. 144 ANTACID-ANTIGAS ..... 95 ANTACID- SIMETHICONE ............... 95 ANTI-DIARRHEA ........... 93 ANTI-DIARRHEAL ........ 93 ANTI-DIARRHEAL (LOPERAMIDE) ORAL CAPSULE ........................ 93 ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/5 ML ........ 93 ANTI-DIARRHEAL (LOPERAMIDE) ORAL TABLET ........................... 93 ANTI-FUNGAL TOPICAL POWDER ......................... 75 ANTI-GAS ULTRA STRENGTH ..................... 95 ANTI-ITCH (HC) TOPICAL CREAM ............................ 78 ANTIBIOTIC (NEOMY- BACIT-POLYM) ............. 75 ANTIBIOTIC-PAIN RELIEF (BACIT) ........................... 75 ANTIFUNGAL CREAM ... 75 ANTIFUNGAL SPRAY ... 75 ANTIFUNGAL TOPICAL SOLUTION ...................... 76 ANTIFUNGAL (CLOTRIMAZOLE) ........ 75


156

ANTIFUNGAL (TOLNAFTATE) TOPICAL AEROSOL,SPRAY .......... 75 ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM ............................ 75 ANTIFUNGAL (TOLNAFTATE) TOPICAL POWDER ......................... 75 ANTITUSSIVE DM ....... 120 AP-HIST DM ................. 120 APOKYN ......................... 38 apraclonidine .................. 117 apri ................................. 110 APRISO ............................ 95 APTIOM ........................... 34 APTIVUS ORAL CAPSULE ........................ 12 APTIVUS ORAL SOLUTION ...................... 12 AQUASOL A ................. 149 ARALAST NP .................. 81 aranelle (28) ................... 110 ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ ML .................................. 103 ARANESP (IN POLYSORBATE) INJECTION SYRINGE ... 104 arbinoxa .......................... 120 ARCALYST ................... 104 ARCTIC RELIEF ............. 72 aripiprazole oral solution ............................. 52 aripiprazole oral tablet 10 mg ..................................... 52 aripiprazole oral tablet 15 mg ..................................... 52 aripiprazole oral tablet 2 mg ..................................... 52 aripiprazole oral tablet 20 mg, 30 mg ................................ 52 aripiprazole oral tablet 5 mg ..................................... 52

aripiprazole oral tablet, disintegrating 10 mg ......... 52 aripiprazole oral tablet, disintegrating 15 mg ......... 52 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML .................................... 52 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML .................................... 52 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML .................................... 52 ARNUITY ELLIPTA ..... 141 ARRANON ...................... 25 ARTHRITIS PAIN RELIEF (ACETAM) ....................... 44 ARTHRITIS PAIN RELIEVER ....................... 44 ARTIFICIAL TEARS (PETRO/MIN) ................ 114 ARTIFICIAL TEARS (POLYVIN ALC) ........... 114 ARTIFICIAL TEARS (DEXT70-HYPRO) OPHTHALMIC DROPS ........................... 114 ARTIFICIAL TEARS (GLYCERIN-PEG) ........ 114 ARTIFICIAL TEARS (PVALCH-POVID) ........ 114 ARZERRA ....................... 25 ASACOL HD ................... 95 ascorbic acid (vitamin c) oral tablet 250 mg .................. 149 ASMANEX HFA ........... 141 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES) .......................... 141

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES) .......................... 141 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) .......................... 141 ASPIR-81 ......................... 44 ASPIR-LOW .................... 44 ASPIR-TRIN .................... 44 ASPIRIN CHILDRENS .... 44 ASPIRIN LOW DOSE ..... 44 aspirin oral tablet ............. 44 aspirin oral tablet, chewable ........................... 44 aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg ..................................... 45 aspirin-dipyridamole ........ 68 atenolol ............................. 63 atenolol-chlorthalidone .... 63 ATGAM ......................... 104 ATHENOL ....................... 45 ATHLETE'S FOOT .......... 76 ATHLETE'S FOOT AF .... 76 ATHLETE'S FOOT (CLOTRIMAZOLE) ........ 76 ATHLETE'S FOOT (TERBINAFINE) ............. 76 ATHLETE'S FOOT (TOLNAFTATE) ............. 76 ATHLETIC FOOT CREAM ............................ 76 atorvastatin ....................... 70 atovaquone ....................... 18 atovaquone-proguanil ...... 18 ATRIPLA ......................... 12 atropine injection syringe 0.05 mg/ml, 0.1 mg/ml .............. 93 ATROVENT HFA .......... 141 AVASTIN ......................... 25 aviane ............................. 110


157

AVONEX INTRAMUSCULAR PEN INJECTOR KIT .............. 104 AVONEX INTRAMUSCULAR SYRINGE ....................... 104 AVONEX INTRAMUSCULAR SYRINGE KIT ............... 104 AVONEX (WITH ALBUMIN) .................... 104 azacitidine ......................... 25 AZACTAM IN DEXTROSE (ISO-OSM) ....................... 18 azathioprine ...................... 25 azathioprine sodium ......... 25 azelastine nasal ................ 85 azelastine ophthalmic ..... 115 AZILECT ......................... 38 azithromycin intravenous recon soln 500 mg ............ 18 azithromycin intravenous recon soln 500 mg (2 mg/ ml) ..................................... 18 azithromycin oral .............. 18 AZOLEN TINCTURE ..... 76 AZOPT ........................... 116 AZOR ............................... 63 aztreonam ......................... 19 AZURETTE (28) ............ 110 B baciim ............................... 19 bacitracin ophthalmic ..... 113 bacitracin-polymyxin b ophthalmic ...................... 113 baclofen ............................ 40 balsalazide ........................ 95 BANOPHEN ALLERGY ..................... 120 BANOPHEN ORAL CAPSULE 25 MG .......... 120 BANOPHEN ORAL CAPSULE 50 MG .......... 121 BANOPHEN ORAL LIQUID .......................... 121 BANOPHEN ORAL TABLET ......................... 121

BANZEL ORAL SUSPENSION .................. 34 BANZEL ORAL TABLET 200 MG ............................. 34 BANZEL ORAL TABLET 400 MG ............................. 34 BARACLUDE ORAL SOLUTION ...................... 12 BAYER ASPIRIN ............ 45 BAZA ANTIFUNGAL .... 76 BCG VACCINE, LIVE (PF) ................................. 105 BELEODAQ ..................... 25 BELVIQ ........................... 81 benazepril ......................... 63 benazepril- hydrochlorothiazide .......... 63 BENDEKA ....................... 25 BENLYSTA ................... 107 benzonatate oral capsule 100 mg ................................... 121 benzoyl peroxide topical cleanser 10 %, 5 %, 6 % .... 73 benzoyl peroxide topical gel 10 %, 2.5 %, 5 % .............. 73 benzoyl peroxide topical lotion 10 % .................................. 73 benzphetamine oral tablet 50 mg ..................................... 81 benztropine oral ................ 38 BESIVANCE .................. 113 betamethasone dipropionate ..................... 78 betamethasone valerate topical cream ................................ 78 betamethasone valerate topical lotion ................................. 78 betamethasone valerate topical ointment ............................ 78 betamethasone, augmented ......................... 78 BETATEMP ..................... 45 betaxolol ophthalmic ...... 114 betaxolol oral .................... 63 bethanechol chloride ...... 144 BETIMOL ...................... 114 BETOPTIC S .................. 114 bexarotene ........................ 25

BEXSERO (PF) .............. 105 bicalutamide ..................... 25 BICILLIN C-R ................. 21 BICILLIN L-A ................. 21 BICNU .............................. 25 BILTRICIDE .................... 19 bimatoprost ..................... 116 BIOCOTRON ................. 121 BIONEL ......................... 121 BIONEL PEDIATRIC .... 121 BISAC-EVAC .................. 95 bisacodyl rectal ................ 95 BISCOLAX ...................... 95 BISMATROL ORAL SUSPENSION 262 MG/15 ML .................................... 93 BISMATROL ORAL SUSPENSION 525 MG/15 ML .................................... 93 BISMATROL ORAL TABLET,CHEWABLE .... 93 BISMUTH ........................ 93 BISMUTH MAXIMUM STRENGTH ..................... 93 bismuth subsalicylate oral tablet,chewable ................. 93 bisoprolol fumarate .......... 63 bisoprolol- hydrochlorothiazide .......... 63 bleo 15k ............................ 25 bleomycin .......................... 25 BLEPHAMIDE S.O.P. .... 117 BLINCYTO ...................... 25 BLIS-TO-SOL (TOLNAFTATE) ............. 76 blisovi fe 1.5/30 (28) ....... 110 BONIVA INTRAVENOUS ............ 107 BOOSTRIX TDAP ......... 105 BOSULIF ORAL TABLET 100 MG ............................. 25 BOSULIF ORAL TABLET 500 MG ............................. 25 BP ..................................... 73 BP WASH TOPICAL CLEANSER 10 %, 5 % .... 73 BPO-10 ............................. 73 BPO-5 ............................... 73


158

BREO ELLIPTA ............ 141 BRILINTA ....................... 68 brimonidine ..................... 117 BRIVIACT INTRAVENOUS .............. 34 BRIVIACT ORAL SOLUTION ...................... 34 BRIVIACT ORAL TABLET 10 MG ............................... 34 BRIVIACT ORAL TABLET 100 MG, 75 MG ............... 34 BRIVIACT ORAL TABLET 25 MG ............................... 34 BRIVIACT ORAL TABLET 50 MG ............................... 34 BROMFED DM ............. 121 bromocriptine ................... 39 brompheniramine-pseudoeph- dm oral syrup .................. 121 BRONCHIAL ASTHMA RELIEF ........................... 121 BROTAPP DM ............... 121 budesonide oral ................ 95 bumetanide ....................... 63 BUPHENYL ORAL TABLET ........................... 81 buprenorphine hcl injection solution ............................. 41 buprenorphine hcl injection syringe .............................. 41 buprenorphine hcl sublingual tablet 2 mg ........................ 41 buprenorphine hcl sublingual tablet 8 mg ........................ 41 buprenorphine-naloxone sublingual tablet 2-0.5 mg ..................................... 45 buprenorphine-naloxone sublingual tablet 8-2 mg .... 45 bupropion hcl oral tablet 100 mg ..................................... 52 bupropion hcl oral tablet 75 mg ..................................... 52 bupropion hcl oral tablet extended release 100 mg .... 52 bupropion hcl oral tablet extended release 150 mg, 200 mg ..................................... 52

bupropion hcl oral tablet extended release 24 hr 150 mg ..................................... 52 bupropion hcl oral tablet extended release 24 hr 300 mg ..................................... 52 bupropion hcl (smoking deter) ................................. 84 BURN RELIEF ................ 74 BURN RELIEF WITH ALOE TOPICAL AEROSOL, SPRAY ............................. 74 buspirone .......................... 52 BUSULFEX ..................... 25 BUTALBITAL COMPOUND W/CODEINE .................... 41 butorphanol tartrate injection solution 1 mg/ml ............... 45 butorphanol tartrate injection solution 2 mg/ml ............... 45 butorphanol tartrate nasal ................................. 45 BYDUREON .................... 87 BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/ DOSE(250 MCG/ML) 2.4 ML .................................... 87 BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/ DOSE (250 MCG/ML) 1.2 ML .................................... 87 BYSTOLIC ....................... 63 C cabergoline ....................... 90 CABOMETYX ORAL TABLET 20 MG .............. 25 CABOMETYX ORAL TABLET 40 MG, 60 MG .................................... 25 CAL-GEST ANTACID ... 144 CALACLEAR .................. 74 CALAHIST CLEAR ........ 74 calcipotriene scalp ............ 71 calcipotriene topical ......... 71 calcitonin (salmon) ........... 90 calcitriol intravenous solution 1 mcg/ml ........................... 91 calcitriol oral .................... 91

CALCIUM 600 ............... 144 calcium acetate oral capsule ............................ 144 CALCIUM ANTACID ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG) ................................ 144 CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG), 320 MG (750 MG), 400 MG (1,000 MG) ................................ 145 CALCIUM ANTACID TROPICAL ..................... 145 CALCIUM ANTACID ULTRA MAX ST ........... 145 CALCIUM CARBONATE ORAL SUSPENSION .... 145 CALCIUM CARBONATE ORAL TABLET 260 MG CALCIUM (648 MG) ..... 145 calcium carbonate oral tablet 500 mg calcium (1,250 mg), 600 mg (1,500 mg) .......... 145 calcium carbonate oral tablet, chewable 200 mg calcium (500 mg), 300 mg (750 mg), 400 mg (1,000 mg) ....................... 145 CALCIUM CARBONATE- VIT D3-MIN ORAL TABLET,CHEWABLE 600 MG (1,500 MG)-400 UNIT ............................... 149 CALCIUM CHLORIDE INTRAVENOUS SYRINGE ....................... 145 CALDYPHEN CLEAR TOPICAL LOTION ......... 74 CALLERGY CLEAR ....... 74 CALLUS REMOVER ...... 71 CALLUS REMOVERS .... 72 camila ............................. 108 CANASA .......................... 95 CANCIDAS ...................... 11 candesartan oral tablet 16 mg, 4 mg, 8 mg ........................ 63 candesartan oral tablet 32 mg ..................................... 63


159

candesartan- hydrochlorothiazid oral tablet 16-12.5 mg ........................ 63 candesartan- hydrochlorothiazid oral tablet 32-12.5 mg, 32-25 mg ....... 63 CAPASTAT ..................... 19 CAPCOF ......................... 121 CAPEX ............................. 78 CAPMIST DM ............... 121 CAPRELSA ORAL TABLET 100 MG ............................. 25 CAPRELSA ORAL TABLET 300 MG ............................. 25 CAPRON DM ................ 121 captopril ........................... 64 captopril- hydrochlorothiazide .......... 64 CARBAGLU .................... 81 carbamazepine oral capsule, er multiphase 12 hr ........... 34 carbamazepine oral suspension 100 mg/5 ml .... 34 carbamazepine oral suspension 200 mg/10 ml ... 34 carbamazepine oral tablet ................................. 34 carbamazepine oral tablet extended release 12 hr 100 mg ..................................... 34 carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg .............................. 34 carbamazepine oral tablet, chewable ........................... 34 CARBAMOXIDE EAR DROPS ............................. 86 carbidopa-levodopa .......... 39 carboplatin intravenous solution ............................. 25 CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM ............................ 105 carteolol .......................... 114 cartia xt ............................. 64 carvedilol .......................... 64

CAYSTON ....................... 19 CAZIANT (28) ............... 110 cefaclor oral capsule ........ 16 cefaclor oral suspension for reconstitution 125 mg/5 ml ...................................... 16 cefaclor oral suspension for reconstitution 250 mg/5 ml, 375 mg/5 ml ...................... 16 cefaclor oral tablet extended release 12 hr ..................... 16 cefadroxil oral capsule ..... 16 cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml ...................... 16 cefadroxil oral tablet ........ 16 cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/ 50 ml ................................. 16 CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/50 ML .................................... 17 cefazolin injection recon soln 1 gram, 500 mg ................. 17 cefazolin injection recon soln 10 gram, 20 gram ............. 17 CEFAZOLIN INJECTION RECON SOLN 100 GRAM, 300 G ................................ 17 cefazolin intravenous ........ 17 cefdinir .............................. 17 cefepime ............................ 17 cefoxitin in dextrose, iso- osm .................................... 17 cefoxitin intravenous recon soln 1 gram ....................... 17 cefoxitin intravenous recon soln 10 gram, 2 gram ........ 17 cefpodoxime ...................... 17 cefprozil ............................ 17 ceftazidime injection recon soln 1 gram, 2 gram .......... 17 ceftazidime injection recon soln 6 gram ....................... 17 ceftriaxone in dextrose,iso- os ....................................... 17

ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg .............................. 17 ceftriaxone injection recon soln 10 gram ..................... 17 CEFTRIAXONE INJECTION RECON SOLN 100 GRAM .............................. 17 ceftriaxone intravenous .... 17 cefuroxime axetil oral tablet ................................. 17 cefuroxime sodium injection recon soln 1.5 gram, 750 mg ..................................... 17 cefuroxime sodium intravenous vial .................................... 17 CELLCEPT INTRAVENOUS .............. 25 CELONTIN ORAL CAPSULE 300 MG .......... 34 CENTRAL-VITE ORAL TABLET 18-400 MG- MCG ............................... 149 CENTURY ORAL TABLET 18-400 MG-MCG ........... 149 CENTURY ULTIMATE WOMEN'S ORAL TABLET 18-400 MG-MCG ........... 149 cephalexin oral capsule 250 mg, 500 mg ....................... 17 cephalexin oral suspension for reconstitution .................... 17 cephalexin oral tablet ....... 17 CEREZYME INTRAVENOUS RECON SOLN 400 UNIT .............. 91 CEROVITE ADVANCED FORMULA ..................... 149 CERTAVITE- ANTIOXIDANT ............ 150 CERVARIX VACCINE (PF) ................................. 105 CETIRI-D ....................... 121 cetirizine oral solution 1 mg/ ml .................................... 121 cetirizine oral solution 5 mg/5 ml .................................... 121 cetirizine oral tablet ........ 121


160

cetirizine oral tablet, chewable ......................... 121 cetirizine- pseudoephedrine ............. 121 CHANTIX ........................ 84 CHANTIX CONTINUING MONTH BOX .................. 84 CHANTIX STARTING MONTH BOX .................. 84 CHERATUSSIN AC ...... 121 CHERATUSSIN DAC .... 121 CHEST CONGESTION RELIEF ........................... 121 CHEST CONGESTION RELIEF + DM ................ 121 CHEST CONGESTION RELIEF PE ..................... 121 CHEST CONGESTION- COUGH RELIEF ........... 121 CHEST RUB TOPICAL OINTMENT ..................... 72 CHEST-SINUS CONGESTION RELIEF ........................... 121 CHILD ALLERGY RELF (CETIRIZINE) ORAL SOLUTION .................... 121 CHILD ALLERGY RELF (CETIRIZINE) ORAL TABLET,CHEWABLE ... 122 CHILD ASPIRIN ............. 45 CHILD CHEST CONGESTION + COUGH .......................... 122 CHILD DELSYM COUGH+CHEST DM .... 122 CHILD DELSYM COUGH+COLD ............. 122 CHILD IBUPROFEN ....... 45 CHILD MUCINEX CHEST CONGESTION ............... 122 CHILD MUCINEX CONGESTION- COUGH .......................... 122 CHILD MUCINEX STUFFY NOSE-COLD ................. 122 CHILD MUCUS RELIEF COUGH .......................... 122

CHILD MUCUS RELIEF EXPECTORANT ........... 122 CHILD MULTI-SYMPTOM COLD/COUGH .............. 122 CHILD PAIN REL-FEVER REDUCER ....................... 45 CHILD TRIAMINIC MS FEVER-COLD ............... 122 CHILD'S ALL DAY ALLERGY(CETIR) ....... 122 CHILD'S MUCUS RELIEF M-S COLD ..................... 122 CHILDREN NIGHT TIME COLD-COUGH .............. 122 CHILDREN'S ACETAMINOPHEN ORAL SUSPENSION .................. 45 CHILDREN'S ACETAMINOPHEN ORAL TABLET,CHEWABLE .... 45 CHILDREN'S ACETAMINOPHEN ORAL TABLET, DISINTEGRATING ......... 45 CHILDREN'S ADVIL ...... 45 CHILDREN'S ALAWAY ...................... 115 CHILDREN'S ALLER- TEC ................................. 122 CHILDREN'S ALLERGY COMPLETE ................... 122 CHILDREN'S ALLERGY RELIEF(LOR) ................ 122 CHILDREN'S ALLERGY (DIPHENHYD) ORAL ELIXIR ........................... 122 children's allergy (diphenhyd) oral liquid ....................... 122 CHILDREN'S ALLERGY (CETIRIZINE) ............... 122 CHILDREN'S ASPIRIN ... 45 CHILDREN'S CETIRIZINE ORAL SOLUTION ........ 122 CHILDREN'S CETIRIZINE ORAL TABLET, CHEWABLE .................. 122 CHILDREN'S CHEST CONGESTION ............... 122

CHILDREN'S CLARITIN ..................... 122 CHILDREN'S COLD AND COUGH DM .................. 122 CHILDREN'S COLD AND COUGH (PE) .................. 122 CHILDREN'S COUGH ... 122 CHILDREN'S DIBROMM DM COLD-COU ............ 123 CHILDREN'S EASY- MELTS ............................. 45 CHILDREN'S FEVER REDUCING ..................... 45 CHILDREN'S FLU RELIEF ........................... 123 CHILDREN'S IBUPROFEN .................... 45 CHILDREN'S MAPAP .... 45 CHILDREN'S MOTRIN ... 45 CHILDREN'S MUCINEX COLD-FEVER ............... 123 CHILDREN'S MUCINEX COUGH .......................... 123 CHILDREN'S MUCINEX MULTI-SYMP ............... 123 CHILDREN'S MUCINEX NIGHT TIME ................. 123 CHILDREN'S NON-ASPIRIN ORAL SUSPENSION ...... 45 CHILDREN'S NON-ASPIRIN ORAL TABLET, CHEWABLE .................... 45 CHILDREN'S NON-ASPIRIN PAIN ................................. 46 CHILDREN'S PAIN RELIEF ORAL SUSPENSION ...... 46 CHILDREN'S PAIN RELIEVER ORAL SUSPENSION .................. 46 CHILDREN'S PAIN RELIEVER ORAL TABLET, DISINTEGRATING ......... 46 CHILDREN'S PAIN-FEVER RELIEF ORAL LIQUID ... 46 CHILDREN'S PAIN-FEVER RELIEF ORAL SUSPENSION .................. 46


161

CHILDREN'S PAIN-FEVER RELIEF ORAL TABLET, CHEWABLE .................... 46 CHILDREN'S PAIN-FEVER RELIEF ORAL TABLET, DISINTEGRATING ......... 46 CHILDREN'S PEPTO ...... 95 CHILDREN'S PLUS FLU ................................. 123 CHILDREN'S PROFEN IB ...................................... 46 CHILDREN'S Q-PAP ...... 46 CHILDREN'S SILAPAP ... 46 CHILDREN'S SILFEDRINE ................. 123 CHILDREN'S SOOTHE ... 95 CHILDREN'S STUFFY NOSE-COLD ................. 123 CHILDREN'S SUDAFED PE COUGH .......................... 123 CHILDREN'S TACTINAL ...................... 46 CHILDREN'S WAL-DRYL ALLERGY ORAL LIQUID .......................... 123 CHILDREN'S WAL-DRYL ALLERGY ORAL PREFILLED SPOON ..... 123 CHILDREN'S WAL-ZYR ORAL SOLUTION ........ 123 CHILDREN'S WAL-ZYR ORAL TABLET, CHEWABLE .................. 123 CHILDRENS PLUS MULTI- SYMP COLD ................. 123 CHILDS TRIACTING COLD- COUGH .......................... 123 CHLO TUSS .................. 123 chloramphenicol sod succinate ........................... 19 chlorhexidine gluconate mucous membrane ............ 85 CHLORHIST .................. 123 chloroquine phosphate oral ................................... 19 chlorothiazide ................... 64 chlorothiazide sodium ...... 64

chlorpheniramine maleate oral tablet ............................... 123 chlorpheniramine maleate oral tablet extended release .... 123 chlorpromazine ................. 52 CHLORTABS ................ 123 chlorthalidone oral tablet 25 mg, 50 mg ......................... 64 CHOLESTYRAMINE LIGHT ORAL POWDER ............. 70 cholestyramine light oral powder in packet ............... 70 cholestyramine (with sugar) ................................ 70 chromium chloride .......... 145 CIALIS ORAL TABLET 2.5 MG, 5 MG ...................... 144 CICLODAN TOPICAL SOLUTION ...................... 76 ciclopirox topical cream .... 76 ciclopirox topical gel ........ 76 ciclopirox topical shampoo ............................ 76 ciclopirox topical solution ............................. 76 ciclopirox topical suspension ......................... 76 cidofovir ............................ 12 cilostazol ........................... 68 cimetidine oral tablet 200 mg ................................... 102 CIMZIA ............................ 96 CIMZIA POWDER FOR RECONST ........................ 96 CIMZIA STARTER KIT ... 96 CINRYZE ....................... 141 CIPRODEX ...................... 86 ciprofloxacin ..................... 22 ciprofloxacin hcl oral tablet ophthalmic drops 0.3 % ... 113 ciprofloxacin hcl oral tablet oral tablet 100 mg, 250 mg, 500 mg, 750 mg ................ 22 ciprofloxacin lactate intravenous solution 200 mg/ 20 ml ................................. 22

ciprofloxacin lactate intravenous solution 400 mg/ 40 ml ................................. 22 ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1, 000 mg .............................. 22 ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 500 mg ..................................... 22 cisplatin ............................ 25 citalopram oral solution .... 52 citalopram oral tablet 10 mg ..................................... 53 citalopram oral tablet 20 mg ..................................... 53 citalopram oral tablet 40 mg ..................................... 53 CITRATE OF MAGNESIA ..................... 96 CITROMA ........................ 96 CITRUCEL ....................... 96 cladribine .......................... 25 clarithromycin oral suspension for reconstitution .............. 18 clarithromycin oral tablet ................................. 18 clarithromycin oral tablet extended release 24 hr ...... 18 CLARITIN LIQUI- GEL ................................ 123 CLARITIN ORAL SOLUTION .................... 123 CLARITIN ORAL TABLET ......................... 123 CLARITIN REDITABS ORAL TABLET, DISINTEGRATING 10 MG .................................. 123 CLARITIN REDITABS ORAL TABLET, DISINTEGRATING 5 MG .................................. 124 CLARITIN-D 12 HOUR ............................. 124 CLARITIN-D 24 HOUR ............................. 124 CLEARLAX ..................... 96


162

clemastine oral tablet 1.34 mg ................................... 124 clemastine oral tablet 2.68 mg ................................... 124 clindamycin hcl ................. 19 clindamycin phosphate injection ............................ 19 CLINDAMYCIN PHOSPHATE INTRAVENOUS SOLUTION 300 MG/2 ML ................... 19 clindamycin phosphate intravenous solution 600 mg/4 ml ...................................... 19 clindamycin phosphate intravenous solution 900 mg/6 ml ...................................... 19 clindamycin phosphate topical ............................... 73 clindamycin phosphate vaginal ............................ 109 CLINIMIX 2.75%/D5W SULFIT FREE ................ 148 CLINIMIX 4.25%-D20W SULF-FREE ................... 148 CLINIMIX 4.25%-D25W SULF-FREE ................... 148 CLINIMIX 4.25%/D10W SULF FREE .................... 148 CLINIMIX 4.25%/D5W SULFIT FREE .................. 82 CLINIMIX 5%-D20W (SULFITE-FREE) .......... 148 CLINIMIX 5%/D15W SULFITE FREE ............. 148 CLINIMIX 5%/D25W SULFITE-FREE ............. 148 CLINIMIX E 2.75%/D10W SUL FREE ........................ 82 CLINIMIX E 2.75%/D5W SULF FREE ...................... 82 CLINIMIX E 4.25%/D10W SUL FREE ...................... 148 CLINIMIX E 4.25%/D25W SUL FREE ...................... 149 CLINIMIX E 4.25%/D5W SULF FREE .................... 149

CLINIMIX E 5%/D15W SULFIT FREE ................ 149 CLINIMIX E 5%/D20W SULFIT FREE ................ 149 CLINIMIX E 5%/D25W SULFIT FREE ................ 149 clobetasol scalp ................ 78 clobetasol topical cream .... 78 clobetasol topical foam ..... 79 clobetasol topical gel ........ 79 clobetasol topical ointment ............................ 79 clobetasol-emollient topical cream ................................ 79 CLOLAR .......................... 25 clomipramine .................... 53 clonazepam oral tablet 0.5 mg ..................................... 34 clonazepam oral tablet 1 mg ..................................... 34 clonazepam oral tablet 2 mg ..................................... 34 clonazepam oral tablet, disintegrating 0.125 mg .... 34 clonazepam oral tablet, disintegrating 0.25 mg ...... 35 clonazepam oral tablet, disintegrating 0.5 mg ........ 35 clonazepam oral tablet, disintegrating 1 mg ........... 35 clonazepam oral tablet, disintegrating 2 mg ........... 35 clonidine hcl oral tablet .... 64 clonidine transdermal patches .............................. 64 clopidogrel oral tablet 300 mg ..................................... 68 clopidogrel oral tablet 75 mg ..................................... 68 clorazepate dipotassium .... 53 CLOTRIMAZOLE 3 DAY ............................... 109 CLOTRIMAZOLE AF ..... 76 clotrimazole mucous membrane ......................... 11 clotrimazole topical .......... 76 clotrimazole vaginal cream .............................. 109

CLOTRIMAZOLE-3 ...... 109 CLOTRIMAZOLE-7 ...... 109 clotrimazole- betamethasone .................. 76 clozapine oral tablet 100 mg ..................................... 53 clozapine oral tablet 200 mg ..................................... 53 clozapine oral tablet 25 mg ..................................... 53 clozapine oral tablet 50 mg ..................................... 53 clozapine oral tablet, disintegrating 100 mg ....... 53 clozapine oral tablet, disintegrating 12.5 mg ...... 53 clozapine oral tablet, disintegrating 150 mg ....... 53 clozapine oral tablet, disintegrating 200 mg ....... 53 clozapine oral tablet, disintegrating 25 mg ......... 53 codeine-guaifenesin ........ 124 COL-RITE ORAL CAPSULE 250 MG ............................. 96 colchicine-probenecid .... 107 COLCRYS ...................... 107 COLD AND COUGH DM .................................. 124 COLD AND COUGH ELIXIR ........................... 124 COLD AND COUGH (DIPHENHYDR-PE) ..... 124 COLD AND FLU RELIEF (DIPHEN-PE) ................. 124 COLD AND FLU SEVERE ......................... 124 COLD AND SINUS PAIN RELIEF ........................... 124 COLD HEAD CONGESTION DAY/NITE ..................... 124 COLD HEAD CONGESTION DAYTIME ...................... 124 COLD HEAD CONGESTION NIGHTTIME .................. 124 COLD HEAD CONGESTION SEVER DAY .................. 124


163

COLD MULTI- SYMPTOM .................... 124 COLD MULTI-SYMPTOM DAY/NIGHT .................. 124 COLD MULTI-SYMPTOM NIGHTTIME .................. 124 COLD MULTI-SYMPTOM (CHLORPHEN) ............. 124 COLD RELIEF M/S DAY/ NIGHT ............................ 124 COLD RELIEF PLUS .... 124 COLD SEVERE CONGESTION ............... 124 COLD-FLU RELIEF ...... 124 COLD-FLU RELIEF, DAY/ NIGHT ............................ 124 COLD-SINUS RELIEF ... 124 colestipol ........................... 70 colistin (colistimethate na) ..................................... 19 colocort ............................. 96 COLY-MYCIN S ............. 86 COMBIGAN .................. 116 COMBIVENT RESPIMAT .................... 141 COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) .......... 26 COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) .......... 26 COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) .................. 26 COMFORT GEL .............. 96 COMFORT GEL EXTRA STRENGTH ..................... 96 COMPLERA .................... 12 COMPLETE ALLERGY ..................... 124 COMPLETE ALLERGY MEDICINE ..................... 124 COMPLETE LICE TREATMENT .................. 80 COMPLETE MULTIVITAMIN-MINERAL ORAL TABLET ............. 150

COMPLETE ORAL TABLET, CHEWABLE .................. 102 compro .............................. 96 CONGESTAC ................ 125 constulose ......................... 96 CONTAC COLD-FLU NIGHT ............................ 125 COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML ........................ 39 COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML ........................ 39 COPPER CHLORIDE .... 145 COREG CR ...................... 64 CORICIDIN HBP COLD AND FLU ......................... 46 CORICIDIN HBP COUGH AND COLD .................... 125 CORICIDIN HBP ORAL CAPSULE ...................... 125 cormax scalp ..................... 79 CORN REMOVER .......... 72 cortisone ........................... 86 CORTISONE (HYDROCORTISONE) TOPICAL CREAM .......... 79 CORTIZONE-10 PLUS .... 79 CORTIZONE-10 TOPICAL CREAM ............................ 79 COTELLIC ....................... 26 COUGH AND COLD BP ................................... 125 COUGH AND COLD MUCUS RELIEF CF ..... 125 COUGH AND COLD ORAL LIQUID .......................... 125 COUGH AND COLD ORAL TABLET ......................... 125 COUGH AND SEVERE COLD ............................. 125 COUGH CONTROL CF (PE) ................................. 125 COUGH CONTROL DM .................................. 125 COUGH CONTROL (DEXTROMETHORPH) ... 125

COUGH CONTROL (GUAIFENESIN) ........... 125 COUGH DM ER ............ 125 COUGH FORMULA DM .................................. 125 COUGH RELIEF ORAL LIQUID .......................... 125 COUGH SUPPRESSANT- EXPECTORANT ........... 125 COUGH SYRUP ............ 125 COUGH SYRUP DM ..... 125 COUGH-SORE THROAT NIGHT ............................ 125 COUGHTAB .................. 125 COUMADIN ORAL ........ 68 CREAMY ACNE FACE ... 73 CREON ............................. 96 CRESTOR ........................ 70 CRITIC-AID CLEAR AF ..................................... 76 CRIXIVAN ORAL CAPSULE 200 MG ............................. 12 CRIXIVAN ORAL CAPSULE 400 MG ............................. 12 cromolyn inhalation ........ 141 cromolyn ophthalmic ...... 115 cryselle (28) .................... 110 cyanocobalamin (vitamin b-12) injection .......................... 150 cyclafem 1/35 (28) .......... 110 cyclafem 7/7/7 (28) ......... 110 cyclobenzaprine oral tablet ................................. 40 cyclophosphamide oral capsule .............................. 26 CYCLOSET ..................... 87 cyclosporine intravenous ... 26 cyclosporine modified ....... 26 cyclosporine oral capsule .............................. 26 CYRAMZA ...................... 26 CYSTADANE .................. 96 CYSTAGON .................. 144 cytarabine ......................... 26 CYTARABINE (PF) INJECTION SOLUTION 100 MG/5 ML (20 MG/ML) .... 26


164

cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml) ............................... 26 CYTARABINE (PF) INJECTION SOLUTION 20 MG/ML ............................. 26 D d10 %-0.45 % sodium chloride ............................. 82 d2.5 %-0.45 % sodium chloride ............................. 82 d5 % and 0.9 % sodium chloride ............................. 82 d5 %-0.45 % sodium chloride ............................. 82 dacarbazine ...................... 26 DAILY MULTI-VITAMINS/ IRON .............................. 150 DAILY MULTIPLE ORAL TABLET 18-400 MG- MCG ............................... 150 DAILY MULTIPLE VITAMINS/IRON .......... 150 DAILY MULTIVITAMIN WITH IRON ................... 150 DAILY VITAMIN FORMULA + IRON ....... 150 DAILY VITAMIN WITH IRON .............................. 150 DAILY VITES/IRON .... 150 DAKLINZA ORAL TABLET 30 MG, 60 MG ................. 12 DAKLINZA ORAL TABLET 90 MG ............................... 12 DALIRESP ..................... 141 danazol oral ...................... 91 dantrolene ......................... 40 DAPSONE ........................ 19 DAPTACEL (DTAP PEDIATRIC) (PF) .......... 105 DARAPRIM ..................... 19 DARZALEX ..................... 26 daunorubicin intravenous solution ............................. 26 DAY TIME PE ............... 125 DAY-TIME COUGH ..... 125 DAY-TIME ORAL CAPSULE 30-15-325 MG ................ 125

DAYHIST ALLERGY .... 125 DAYTIME ...................... 125 DAYTIME AND NIGHTTIME COLD ...... 125 DAYTIME COLD AND COUGH .......................... 125 DAYTIME COLD- FLU ................................. 125 DAYTIME COLD-FLU RELIEF (PE) .................. 126 DAYTIME SINUS ......... 126 DAYTIME- NIGHTTIME .................. 126 decitabine ......................... 26 DECONEX DMX ORAL TABLET 10-15-380 MG .................................. 126 DECONEX IR ORAL TABLET 10-380 MG ..... 126 DELSYM 12 HOUR ...... 126 DELSYM COUGH-CHEST CONGEST DM .............. 126 DELSYM COUGH-COLD DAYTIME ...................... 126 DELSYM COUGH-COLD NIGHTTIME .................. 126 DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) ....................... 96 demeclocycline .................. 22 DEMSER .......................... 64 DENAVIR ........................ 78 DEPEN TITRATABS .... 107 DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ ML .................................. 108 DERMAFUNGAL ........... 76 DERMATOP TOPICAL OINTMENT ..................... 79 DESCOVY ....................... 12 DESENEX SPRAY .......... 76 DESENEX TOPICAL AEROSOL,SPRAY .......... 76 DESENEX TOPICAL POWDER ......................... 76 DESGEN DM ORAL LIQUID 5-10-100 MG/5 ML ........ 126

desipramine oral ............... 53 desmopressin injection ..... 91 desmopressin nasal ........... 91 desmopressin oral ............. 91 desonide ............................ 79 desoximetasone ................. 79 DESPEC-DM (PHENYLEPH- DM-GUAIF) ORAL LIQUID 5-10-100 MG/5 ML ........ 126 DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG ............................. 53 DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG ............................... 53 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG .................................... 53 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG .................................... 53 desvenlafaxine oral tablet extended release 24hr 100 mg ..................................... 53 desvenlafaxine oral tablet extended release 24hr 50 mg ..................................... 53 dexamethasone ................. 86 DEXAMETHASONE SODIUM PHOS (PF) ....... 86 dexamethasone sodium phosphate injection ........... 86 dexamethasone sodium phosphate ophthalmic ..... 117 dexchlorphen-pse- chlophedianol ................. 126 DEXILANT .................... 102 dexrazoxane hcl intravenous recon soln 250 mg ............ 24 dexrazoxane hcl intravenous recon soln 500 mg ............ 24 dextroamphetamine oral capsule, extended release 10 mg, 5 mg ........................... 53


165

dextroamphetamine oral capsule, extended release 15 mg ..................................... 53 dextroamphetamine oral tablet 10 mg ................................ 54 dextroamphetamine oral tablet 5 mg .................................. 54 dextroamphetamine- amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg ........................ 54 dextroamphetamine- amphetamine oral tablet 30 mg ..................................... 54 dextromethorphan polistirex ......................... 126 dextromethorphan-guaifenesin oral syrup ........................ 126 dextromethorphan-guaifenesin oral tablet ....................... 126 dextrose 10 % and 0.2 % nacl ................................... 82 dextrose 10 % in water (d10w) ............................... 82 dextrose 25 % in water (d25w) ............................... 82 DEXTROSE 30 % IN WATER (D30W) .............. 82 DEXTROSE 40 % IN WATER (D40W) .............. 82 dextrose 5 % in water (d5w) intravenous parenteral solution ............................. 82 DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK ................... 82 dextrose 5 %-lactated ringers ............................... 82 dextrose 5%-0.2 % sod chloride ............................. 82 dextrose 5%-0.3 % sod.chloride ...................... 82 DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS PARENTERAL SOLUTION ...................... 82

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE ......................... 82 dextrose 70 % in water (d70w) ............................... 82 dextrose with sodium chloride ............................. 82 dextrose-kcl-nacl ............ 145 DIABETIC SILTUSSIN DAS- NA .................................. 126 DIABETIC SILTUSSIN- DM .................................. 126 DIABETIC SILTUSSIN-DM MAX STR ...................... 126 DIABETIC TUSSIN DM ORAL LIQUID 10-100 MG/5 ML .................................. 126 DIABETIC TUSSIN DM ORAL LIQUID 10-200 MG/5 ML .................................. 126 DIABETIC TUSSIN EX ................................... 126 DIAMODE ....................... 93 DIARRHEA RELIEF (BISMUTH SUBS) .......... 93 diazepam injection solution ............................. 54 diazepam injection syringe .............................. 54 diazepam intensol ............. 54 diazepam oral concentrate ....................... 54 diazepam oral solution 5 mg/5 ml (1 mg/ml) ..................... 54 DIAZEPAM ORAL SOLUTION 5 MG/5 ML (1 MG/ML, 5 ML) ................ 54 diazepam oral tablet 10 mg ..................................... 54 diazepam oral tablet 2 mg ..................................... 54 diazepam oral tablet 5 mg ..................................... 54 diazepam rectal kit 12.5-15- 17.5-20 mg ........................ 35 diazepam rectal kit 2.5 mg, 5- 7.5-10 mg .......................... 35

diclofenac potassium ........ 46 diclofenac sodium oral ..... 46 diclofenac sodium topical gel 1 % .................................... 46 dicloxacillin ...................... 21 dicyclomine oral capsule ... 93 dicyclomine oral solution ... 93 dicyclomine oral tablet ..... 93 didanosine oral capsule, delayed release(dr/ec) 125 mg ..................................... 12 didanosine oral capsule, delayed release(dr/ec) 200 mg ..................................... 12 didanosine oral capsule, delayed release(dr/ec) 250 mg, 400 mg .............................. 13 diethylpropion ................... 81 diflorasone ........................ 79 diflunisal ........................... 46 DIGITEK ORAL TABLET 125 MCG .......................... 67 DIGOX ORAL TABLET 125 MCG ................................. 67 digoxin oral solution 50 mcg/ ml ...................................... 68 digoxin oral tablet 125 mcg ................................... 68 dihydroergotamine injection ............................ 39 DILANTIN EXTENDED ORAL CAPSULES .......... 35 DILANTIN INFATABS ... 35 DILANTIN ORAL CAPSULES 30 MG .......... 35 dilt-xr ................................ 64 diltiazem hcl intravenous ... 64 diltiazem hcl oral capsule, extended release 120 mg, 180 mg, 360 mg, 420 mg ......... 64 diltiazem hcl oral capsule, extended release 240 mg, 300 mg ..................................... 64 diltiazem hcl oral capsule,ext release degradable ........... 64 diltiazem hcl oral capsule, extended release 12 hr ...... 64


166

diltiazem hcl oral capsule, extended release 24hr 120 mg, 240 mg, 300 mg ................ 64 diltiazem hcl oral capsule, extended release 24hr 180 mg, 360 mg .............................. 64 diltiazem hcl oral tablet .... 64 diltiazem hcl oral tablet extended release 24 hr ...... 64 DIMAPHEN DM ............ 126 DIMETAPP COLD- CONGESTION ............... 126 DIMETAPP DM COLD- COUGH (PE) .................. 126 DIMETAPP LONG-ACTING (CPM-DM) ..................... 126 DIOTAME ........................ 93 DIPENTUM ..................... 96 DIPHEDRYL ALLERGY ..................... 126 DIPHEDRYL ORAL CAPSULE ...................... 126 DIPHEDRYL ORAL TABLET ......................... 127 DIPHENHIST ORAL CAPSULE ...................... 127 DIPHENHIST ORAL LIQUID .......................... 127 DIPHENHIST ORAL TABLET 25 MG ............ 127 diphenhydramine hcl injection solution 50 mg/ml ........... 127 diphenhydramine hcl injection syringe ............................ 127 diphenhydramine hcl oral capsule 25 mg ................. 127 diphenhydramine hcl oral capsule 50 mg ................. 127 diphenhydramine hcl oral elixir ................................ 127 diphenhydramine hcl oral liquid ............................... 127 diphenhydramine hcl oral syrup ............................... 127 diphenhydramine hcl oral tablet 25 mg .................... 127 diphenhydramine- acetaminophen .................. 46

diphenoxylate-atropine ..... 93 disulfiram .......................... 82 divalproex ......................... 35 DM MAX ....................... 127 DOCEFREZ INTRAVENOUS RECON SOLN 20 MG ..... 26 DOCETAXEL INTRAVENOUS SOLUTION 10 MG/ML, 160 MG/16 ML (10 MG/ML), 160 MG/8 ML (20 MG/ML), 20 MG/2 ML (10 MG/ML) ..................... 26 docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) ............................... 26 docusate sodium oral capsule 250 mg .............................. 96 dofetilide ........................... 62 DOK ORAL CAPSULE 250 MG .................................... 96 DONATUSSIN ............... 127 donepezil oral tablet 10 mg, 5 mg ..................................... 39 donepezil oral tablet, disintegrating .................... 39 dorzolamide .................... 116 dorzolamide-timolol ....... 116 doxazosin .......................... 64 doxepin oral ...................... 54 doxercalciferol intravenous ....................... 91 doxercalciferol oral .......... 91 doxorubicin intravenous recon soln ................................... 26 doxorubicin intravenous solution ............................. 26 doxorubicin, peg- liposomal .......................... 27 DOXY-100 ....................... 22 doxycycline hyclate intravenous ....................... 22 doxycycline hyclate oral capsule .............................. 22 doxycycline hyclate oral tablet ................................. 23

doxycycline hyclate oral tablet, delayed release (dr/ec) 100 mg, 150 mg, 75 mg ........... 23 doxycycline monohydrate oral capsule .............................. 23 doxycycline monohydrate oral tablet ................................. 23 DR SCHOLL'S CLEAR AWAY .............................. 72 DRISDOL ORAL CAPSULE ...................... 150 DRISTAN COLD ........... 127 DRISTAN LONG LASTING ......................... 85 dronabinol ........................ 96 drospirenone-ethinyl estradiol oral tablet 3-0.03 mg ...... 110 DROXIA ........................... 27 DSS ................................... 96 DUAL ACTION COMPLETE ................... 102 DULERA ........................ 141 duloxetine oral capsule, delayed release(dr/ec) 20 mg ..................................... 54 duloxetine oral capsule, delayed release(dr/ec) 30 mg ..................................... 54 duloxetine oral capsule, delayed release(dr/ec) 40 mg ..................................... 54 duloxetine oral capsule, delayed release(dr/ec) 60 mg ..................................... 54 DURAFLU ORAL TABLET 60-20-200-500 MG ......... 127 duramorph (pf) injection solution 0.5 mg/ml ............ 41 duramorph (pf) injection solution 1 mg/ml ............... 41 E E.C. PRIN ......................... 46 e.e.s. 400 oral tablet ......... 18 EAR DROPS OTC ........... 86 EAR DROPS (CARBAMIDE PEROXIDE) ..................... 86 EAR WAX REMOVAL DROPS ............................. 86


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EAR WAX REMOVAL KIT ................................... 86 EAR WAX REMOVAL SYSTEM OTIC DROPS ... 86 EAR WAX TREATMENT .................. 86 EAZZZE THE PAIN ........ 46 econazole topical .............. 76 ECONTRA EZ ............... 110 ECOTRIN ......................... 46 ECOTRIN LOW STRENGTH ..................... 46 ECZEMA ANTI-ITCH .... 79 ed a-hist dm oral liquid ... 127 ED BRON GP ................. 127 ED CHLORPED JR ....... 127 ED-APAP ......................... 46 ED-CHLORPED ............ 127 ED-CHLORTAN ............ 127 EDURANT ....................... 13 EFFERVES PAIN RELIEF ANTACID ........................ 46 EFFERVESCENT PAIN RELIEF ORAL TABLET, EFFERVESCENT 325-1,916- 1,000 MG .......................... 47 EFFIENT .......................... 68 ELAPRASE ...................... 91 ELIDEL ............................ 72 ELINEST ........................ 111 ELIQUIS ORAL TABLET 2.5 MG .................................... 68 ELIQUIS ORAL TABLET 5 MG .................................... 68 ELITEK ............................ 24 ELLA .............................. 111 ELON DUAL DEFENSE ......................... 76 EMCYT ............................ 27 EMEND ORAL CAPSULE 125 MG ............................. 96 EMEND ORAL CAPSULE 40 MG .................................... 96 EMEND ORAL CAPSULE 80 MG .................................... 96 EMEND ORAL CAPSULE, DOSE PACK .................... 96

EMEND ORAL SUSPENSION FOR RECONSTITUTION ........ 96 EMPLICITI ...................... 27 EMSAM ........................... 54 EMTRIVA ORAL CAPSULE ........................ 13 EMTRIVA ORAL SOLUTION ...................... 13 enalapril maleate .............. 64 enalapril- hydrochlorothiazide .......... 64 ENBREL SUBCUTANEOUS RECON SOLN ............... 107 ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) .............................. 107 ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ................................. 108 ENBREL SURECLICK ... 108 ENDACOF - DM ........... 127 endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg ....... 41 ENGERIX-B PEDIATRIC (PF) ................................. 105 ENGERIX-B (PF) .......... 105 enoxaparin subcutaneous solution ............................. 68 enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ ml ...................................... 68 enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/ 0.8 ml ................................ 68 enoxaparin subcutaneous syringe 30 mg/0.3 ml ........ 68 enoxaparin subcutaneous syringe 40 mg/0.4 ml ........ 68 enoxaparin subcutaneous syringe 60 mg/0.6 ml ........ 68 enpresse .......................... 111 entacapone ........................ 39 entecavir ........................... 13 ENTERIC COATED ASPIRIN ........................... 47 ENTEX T ........................ 127 ENTRE-COUGH ............ 127

enulose .............................. 96 ENVARSUS XR .............. 27 epinephrine injection syringe 0.1 mg/ml ........................ 127 EPIPEN 2-PAK .............. 127 EPIPEN JR 2-PAK ......... 127 epirubicin intravenous solution 200 mg/100 ml .................. 27 epirubicin intravenous solution 50 mg/25 ml ...................... 27 epitol ................................. 35 EPIVIR HBV ORAL SOLUTION ...................... 13 EPIVIR ORAL SOLUTION ...................... 13 eplerenone ........................ 64 eprosartan ......................... 64 EPZICOM ......................... 13 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG .................................... 35 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG .................................... 35 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG .................................... 35 ERAXIS(WATER DILUENT) ....................... 11 ERBITUX ......................... 27 ergocalciferol (vitamin d2) oral capsule .................... 150 ergoloid ............................. 54 ERGOMAR ...................... 39 ERIVEDGE ...................... 27 errin ................................ 108 ERWINAZE ..................... 27 ery pads ............................ 73 ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ..................................... 18 ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/ EC) 500 MG ..................... 18 ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG ................. 18


168

erythrocin (as stearate) oral tablet 250 mg .................... 18 erythromycin ethylsuccinate oral tablet ......................... 18 erythromycin ophthalmic ...................... 113 erythromycin oral tablet .... 18 erythromycin with ethanol .............................. 73 erythromycin-benzoyl peroxide ............................ 73 ESBRIET ........................ 141 escitalopram oxalate oral solution ............................. 54 escitalopram oxalate oral tablet 10 mg ...................... 54 escitalopram oxalate oral tablet 20 mg ...................... 54 escitalopram oxalate oral tablet 5 mg ........................ 54 ESSENTIA ..................... 150 ESTRACE VAGINAL .... 108 estradiol oral .................. 108 estradiol transdermal patch weekly ............................. 109 ESTRING ....................... 109 ethambutol ........................ 19 ethosuximide ..................... 35 etodolac oral capsule 200 mg ..................................... 47 etodolac oral tablet ........... 47 etodolac oral tablet extended release 24 hr ..................... 47 ETOPOPHOS ................... 27 etoposide intravenous ....... 27 EVAC-U-GEN (SENNOSIDES) ............... 97 EVOMELA ....................... 27 EVOTAZ .......................... 13 EXAPHEX TR ............... 127 EXCEDRIN EXTRA STRENGTH ..................... 47 EXCEDRIN MIGRAINE ...................... 47 exemestane ........................ 27 EXJADE ........................... 82 EXPECTORANT COUGH SYRUP ........................... 127

EXPECTORANT ORAL LIQUID .......................... 128 EXTAVIA SUBCUTANEOUS KIT ................................. 104 EXTAVIA SUBCUTANEOUS RECON SOLN .............................. 104 EYE ITCH RELIEF ....... 115 F FABRAZYME ................. 91 FALLBACK SOLO ........ 111 falmina (28) .................... 111 famciclovir oral tablet 125 mg, 250 mg .............................. 13 famciclovir oral tablet 500 mg ..................................... 13 famotidine intravenous .... 102 famotidine oral suspension ....................... 102 famotidine oral tablet 10 mg ................................... 102 famotidine oral tablet 20 mg, 40 mg .............................. 102 famotidine (pf) ................ 102 famotidine (pf)-nacl (iso- os) ................................... 102 FANAPT ORAL TABLET 1 MG .................................... 55 FANAPT ORAL TABLET 10 MG .................................... 55 FANAPT ORAL TABLET 12 MG .................................... 55 FANAPT ORAL TABLET 2 MG .................................... 55 FANAPT ORAL TABLET 4 MG .................................... 55 FANAPT ORAL TABLET 6 MG .................................... 55 FANAPT ORAL TABLET 8 MG .................................... 55 FANAPT ORAL TABLETS, DOSE PACK .................... 55 FARESTON ..................... 27 FARYDAK ORAL CAPSULE 10 MG ............................... 27 FARYDAK ORAL CAPSULE 15 MG, 20 MG ................. 27

FASLODEX ..................... 27 felbamate .......................... 35 felodipine er ...................... 65 FEMRING ...................... 109 FENESIN IR ................... 128 FENESIN PE IR ............. 128 fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg ..................................... 70 fenofibrate nanocrystallized 48 mg, 145 mg ....................... 70 fenofibrate oral tablet 160 mg, 54 mg ................................ 70 fenoprofen oral tablet ....... 47 fentanyl citrate .................. 41 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/ hr ....................................... 41 FERAHEME ................... 150 FERRLECIT ..................... 82 FETZIMA ORAL CAPSULE, EXT REL 24HR DOSE PACK ............................... 55 FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 120 MG, 80 MG ......... 55 FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 20 MG ........................ 55 FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 40 MG ........................ 55 FEVER REDUCER .......... 47 FEVER REDUCER AN PAIN RELIEVER ORAL SUSPENSION .................. 47 FEVERALL ...................... 47 fexofenadine oral tablet 180 mg, 60 mg ....................... 128 fexofenadine- pseudoephedrine ............. 128 FIBER LAXATIVE (CA POLYCARBO) ................. 97 FIBER LAXATIVE (METHYLCELLULO) ..... 97 FIBER LAXATIVE (PSYLLIUM HUSK) ........ 97


169

FIBER THERAPY LAXATIVE (HUSK) ....... 97 FIBER THERAPY (CA POLYCARBOPH) ........... 97 FIBER THERAPY (M- CELLULOSE) .................. 97 FIBER (CALCIUM POLYCARBOPHIL) ........ 97 FIBER (PSYLLIUM HUSK) .............................. 97 FIBER-CAPS (PSYLLIUM HUSK) .............................. 97 FIBER-LAX ..................... 97 FIBER-TABS ................... 97 finasteride oral tablet 5 mg ................................... 144 FIRAZYR ....................... 141 FIRMAGON KIT W DILUENT SYRINGE ...... 27 FLANAX ANTACID ....... 97 FLANAX (NAPROXEN) .................. 47 FLAVOR CHEWS ANTACID ...................... 145 flecainide .......................... 62 FLEET GLYCERIN (ADULT) .......................... 97 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ ACTUATION ................. 142 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ ACTUATION, 50 MCG/ ACTUATION ................. 142 FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION ....... 142 FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION ....... 142 FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION ....... 142

FLU AND SEVERE COLD- DAYTIME ...................... 128 FLU HBP ........................ 128 FLU RELIEF THERAPY DAYTIME ...................... 128 FLU-SEVERE COLD- COUGH DAYTIME ...... 128 FLU-SEVERE COLD- COUGH NIGHT ............ 128 fluconazole ........................ 11 fluconazole in dextrose(iso- o) ....................................... 11 FLUCONAZOLE IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML .................................... 11 fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/ 100 ml ............................... 11 fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/ 200 ml ............................... 11 flucytosine ......................... 11 fludarabine intravenous recon soln ................................... 27 FLUDARABINE INTRAVENOUS SOLUTION ...................... 27 fludrocortisone ................. 86 flunisolide nasal spray,non- aerosol 25 mcg (0.025 %) ................................... 142 fluocinolone ...................... 79 fluocinolone acetonide oil ...................................... 86 fluocinolone and shower cap .................................... 79 fluocinonide topical cream 0.05 % ............................... 79 fluocinonide topical gel .... 79 fluocinonide topical ointment ............................ 79 fluocinonide topical solution ............................. 79 fluocinonide-e ................... 79 FLUORITAB ORAL TABLET,CHEWABLE 1 MG FLUORIDE (2.2 MG) .... 150

fluorometholone .............. 117 FLUOROURACIL INTRAVENOUS SOLUTION 1 GRAM/20 ML ............... 27 fluorouracil intravenous solution 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml ...................................... 27 fluorouracil topical cream 5 % ....................................... 72 fluorouracil topical solution ............................. 72 fluoxetine oral capsule 10 mg ..................................... 55 fluoxetine oral capsule 20 mg ..................................... 55 fluoxetine oral capsule 40 mg ..................................... 55 fluoxetine oral solution ..... 55 fluoxetine oral tablet 10 mg ..................................... 55 fluoxetine oral tablet 20 mg ..................................... 55 fluphenazine decanoate .... 55 fluphenazine hcl ................ 55 flurbiprofen ....................... 47 flurbiprofen sodium drops ............................... 116 flutamide ........................... 27 fluticasone nasal ............. 142 fluticasone topical ............. 79 fluvoxamine oral tablet 100 mg ..................................... 55 fluvoxamine oral tablet 25 mg ..................................... 55 fluvoxamine oral tablet 50 mg ..................................... 55 FOAMING ACNE FACE WASH .............................. 73 FOAMING ANTACID ORAL SUSPENSION .................. 97 folic acid injection .......... 150 folic acid oral tablet 1 mg ................................... 150 FOLOTYN ....................... 27 fondaparinux subcutaneous syringe 10 mg/0.8 ml ........ 68


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fondaparinux subcutaneous syringe 2.5 mg/0.5 ml ....... 68 fondaparinux subcutaneous syringe 5 mg/0.4 ml .......... 68 fondaparinux subcutaneous syringe 7.5 mg/0.6 ml ....... 68 FOOT AND SNEAKER .... 76 FORADIL AEROLIZER .................. 142 FORTEO ......................... 107 foscarnet ........................... 13 fosinopril ........................... 65 fosinopril- hydrochlorothiazide .......... 65 fosphenytoin ...................... 35 FREAMINE III 10 % ..... 149 FUNGOID TINCTURE .... 76 FUNGOID-D .................... 76 furosemide injection ......... 65 furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ ml) ..................................... 65 furosemide oral tablet ....... 65 FUSILEV .......................... 24 FUZEON SUBCUTANEOUS RECON SOLN ................. 13 FYCOMPA ORAL SUSPENSION .................. 35 FYCOMPA ORAL TABLET 10 MG, 12 MG ................. 35 FYCOMPA ORAL TABLET 2 MG ................................. 35 FYCOMPA ORAL TABLET 4 MG ................................. 35 FYCOMPA ORAL TABLET 6 MG ................................. 35 FYCOMPA ORAL TABLET 8 MG ................................. 35 G G-TRON ......................... 128 gabapentin oral capsule 100 mg ..................................... 35 gabapentin oral capsule 300 mg ..................................... 35 gabapentin oral capsule 400 mg ..................................... 35 gabapentin oral solution 250 mg/5 ml ............................. 35

GABAPENTIN ORAL SOLUTION 250 MG/5 ML (5 ML), 300 MG/6 ML (6 ML) ................................... 36 gabapentin oral tablet 600 mg ..................................... 36 gabapentin oral tablet 800 mg ..................................... 36 GABITRIL ORAL TABLET 12 MG, 16 MG ................. 36 galantamine oral capsule,ext rel. pellets 24 hr ................ 39 galantamine oral solution ............................. 40 galantamine oral tablet .... 40 GAMASTAN S/D .......... 105 GAMMAGARD LIQUID .......................... 105 GAMMAGARD S-D (IGA < 1 MCG/ML) .................... 105 GAMMAPLEX .............. 105 GAMUNEX-C ................ 105 ganciclovir sodium ........... 13 GARDASIL 9 (PF) ......... 105 GARDASIL (PF) ............ 105 GAS RELIEF 80 ............... 97 GAS RELIEF EXTRA STRENGTH ..................... 97 GAS RELIEF ORAL CAPSULE ........................ 97 GAS RELIEF ORAL DROPS, SUSPENSION .................. 97 GAS RELIEF ORAL TABLET,CHEWABLE .... 97 GAS RELIEF ULTRA STRENGTH ..................... 97 GAS-X EXTRA STRENGTH ..................... 97 GAS-X ORAL TABLET, CHEWABLE .................... 97 GAS-X ULTRA- STRENGTH ..................... 97 GATTEX 30-VIAL .......... 97 GATTEX ONE-VIAL ...... 97 GAUZE PADS 2 X 2 ....... 87 GAVILAX ORAL POWDER ......................... 97 gavilyte-c .......................... 97

gavilyte-g .......................... 97 gavilyte-n .......................... 98 GAVISCON EXTRA STRENGTH ..................... 98 GAVISCON ORAL SUSPENSION .................. 98 GAZYVA ......................... 27 GELUSIL ANTACID AND ANTI-GAS ORAL TABLET, CHEWABLE .................... 98 gemcitabine intravenous recon soln 1 gram, 200 mg ......... 27 GEMCITABINE INTRAVENOUS RECON SOLN 2 GRAM ................ 28 GEMCITABINE INTRAVENOUS SOLUTION 1 GRAM/26.3 ML (38 MG/ ML), 200 MG/5.26 ML (38 MG/ML) ........................... 28 GEMCITABINE INTRAVENOUS SOLUTION 2 GRAM/52.6 ML (38 MG/ ML) ................................... 28 gemfibrozil oral ................ 70 GENCONTUSS .............. 128 generlac ............................ 98 gengraf oral capsule 100 mg, 25 mg ................................ 28 gengraf oral capsule 50 mg ..................................... 28 gengraf oral solution ........ 28 gentak ophthalmic ointment .......................... 113 gentamicin injection ......... 19 gentamicin ophthalmic .... 113 GENTAMICIN SULFATE (PED) (PF) ........................ 19 GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 100 MG/10 ML .................................... 19 GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML .................................... 19


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gentamicin sulfate (pf) intravenous solution 80 mg/8 ml ...................................... 19 gentamicin topical ............ 75 GENTLE LAXATIVE RECTAL ........................... 98 GENTLELAX .................. 98 GENVOYA ...................... 13 GEODON INTRAMUSCULAR ........ 55 GERI-DRYL ................... 128 GERI-KOT ....................... 98 GERI-LANTA .................. 98 GERI-MOX ANTACID- ANTIGAS ......................... 98 GERI-PECTATE .............. 93 GERI-TUSSIN ............... 128 GERI-TUSSIN DM ........ 128 gildagia ........................... 111 GILDESS FE 1.5/30 (28) ................................. 111 GILDESS FE 1/20 (28) ... 111 GILENYA ........................ 40 GILOTRIF ........................ 28 GILPHEX TR ................. 128 GLATOPA ....................... 40 GLEEVEC ORAL TABLET 100 MG ............................. 28 GLEEVEC ORAL TABLET 400 MG ............................. 28 GLEOSTINE .................... 28 glimepiride oral tablet 1 mg ..................................... 87 glimepiride oral tablet 2 mg ..................................... 88 glimepiride oral tablet 4 mg ..................................... 88 glipizide oral tablet 10 mg ..................................... 88 glipizide oral tablet 5 mg ... 88 glipizide oral tablet extended release 24hr 10 mg ........... 88 glipizide oral tablet extended release 24hr 2.5 mg .......... 88 glipizide oral tablet extended release 24hr 5 mg ............. 88 glipizide-metformin oral tablet 2.5-250 mg ........................ 88

glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg ....... 88 GLUCAGEN HYPOKIT ... 88 GLUCAGON EMERGENCY KIT (HUMAN) ................. 88 glycerin (adult) ................. 98 glycerin (child) ................. 98 GLYCOLAX ORAL POWDER ......................... 98 glycopyrrolate oral ........... 93 griseofulvin microsize oral suspension ......................... 11 griseofulvin ultramicrosize ................... 11 GUAIASORB DM ......... 128 GUAIFENESIN AC ....... 128 GUAIFENESIN DAC .... 128 guaifenesin oral liquid .... 128 guaifenesin oral tablet 200 mg ................................... 128 guaifenesin oral tablet 400 mg ................................... 128 guaifenesin oral tablet extended release 12hr 600 mg ................................... 128 GUAIFENESIN-DM ...... 128 guanfacine oral tablet extended release 24 hr ...... 55 guanidine .......................... 55 H HAIR VITAMINS .......... 150 HALAVEN ....................... 28 halobetasol propionate ..... 79 HALOG ............................ 79 haloperidol ....................... 56 haloperidol decanoate ...... 56 haloperidol lactate ............ 56 HARVONI ........................ 13 HAVRIX (PF) INTRAMUSCULAR SUSPENSION ................ 105 HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML ....................... 105 HAVRIX (PF) INTRAMUSCULAR

SYRINGE 720 ELISA UNIT/ 0.5 ML ............................ 105 HEAD CONGESTION COLD RELIEF ........................... 128 HEAD CONGESTION DAY- NIGHT ............................ 128 HEADACHE PM ............. 47 HEADACHE RELIEF (ASA- ACET-CAF) ..................... 47 HEALTHYLAX ............... 98 HEARTBURN ANTACID ........................ 98 HEARTBURN PREVENTION ORAL TABLET 10 MG ............ 102 HEARTBURN RELIEF .... 98 HEARTBURN RELIEF (CIMETIDINE) .............. 102 HEARTBURN RELIEF (FAMOTIDINE) ............. 102 HEARTBURN RELIEF (RANITIDINE) .............. 102 HEARTBURN TREATMENT 24 HOUR ........................ 102 HEPARIN (PORCINE) IN 5 % DEX INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML ...... 68 heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml (100 unit/ml), 25,000 unit/500 ml (50 unit/ml) .................. 69 HEPARIN (PORCINE) IN NACL (PF) INTRAVENOUS PARENTERAL SOLUTION 1,000 UNIT/500 ML, 2,000 UNIT/1,000 ML ............... 69 HEPARIN (PORCINE) INJECTION CARTRIDGE ................... 69 heparin (porcine) injection solution ............................. 69 HEPARIN, PORCINE (PF) INJECTION SOLUTION ...................... 69 HEPARIN(PORCINE) IN 0.45% NACL


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INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML ...... 69 HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 25,000 UNIT/250 ML ...... 69 HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 25,000 UNIT/500 ML ...... 69 HEPATAMINE 8% ........ 149 HERCEPTIN .................... 28 HETLIOZ ......................... 56 HEXALEN ....................... 28 HIBERIX (PF) ................ 105 HISTEX DM .................. 128 HISTEX PD .................... 129 HISTEX (TRIPROLIDINE) .......... 128 HOT STEAM LIQUID .... 129 HUMALOG ...................... 88 HUMALOG KWIKPEN ... 88 HUMALOG MIX 50-50 .... 88 HUMALOG MIX 50-50 KWIKPEN ........................ 88 HUMALOG MIX 75-25 .... 88 HUMALOG MIX 75-25 KWIKPEN ........................ 88 HUMAPEN LUXURA HD .................................... 88 HUMIRA PEDIATRIC CROHN'S START .......... 108 HUMIRA PEN ............... 108 HUMIRA PEN CROHN'S- UC-HS START .............. 108 HUMIRA PEN PSORIASIS- UVEITIS ......................... 108 HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML ........ 108 HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML .................................. 108 HUMULIN 70/30 ............. 88

HUMULIN 70/30 KWIKPEN ........................ 88 HUMULIN N ................... 88 HUMULIN N KWIKPEN ........................ 88 HUMULIN R .................... 88 HUMULIN R U-500 (CONC) KWIKPEN ........................ 88 HUMULIN R U-500 (CONCENTRATED) ....... 88 hydralazine ....................... 65 hydrochlorothiazide .......... 65 HYDROCODONE- ACETAMINOPHEN ORAL SOLUTION 2.5-167 MG/5 ML .................................... 41 hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml ...................................... 41 hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg ................. 41 hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg ................. 41 hydrocodone- chlorpheniramine ........... 129 hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml ........ 129 HYDROCODONE- HOMATROPINE ORAL SYRUP 5-1.5 MG/5 ML (5 ML) ................................. 129 hydrocodone-homatropine oral tablet ............................... 129 hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg ........................ 42 hydrocortisone acetate topical cream 0.5 % ...................... 79 hydrocortisone oral .......... 86 HYDROCORTISONE PLUS ................................ 79 hydrocortisone rectal cream 2.5 % ................................. 98 hydrocortisone rectal enema ................................ 98

hydrocortisone topical cream 0.5 % ................................. 79 hydrocortisone topical cream 1 %, 2.5 % ........................ 79 hydrocortisone topical lotion 2.5 % ................................. 79 hydrocortisone topical ointment 0.5 % .................. 80 hydrocortisone topical ointment 1 %, 2.5 % ......... 80 hydrocortisone valerate .... 80 hydrocortisone-acetic acid ................................... 86 HYDROCORTISONE-MIN OIL-WHT PET ................. 80 HYDROCREAM .............. 80 HYDROMET ................. 129 hydromorphone oral tablet 2 mg, 4 mg ........................... 42 hydromorphone oral tablet 8 mg ..................................... 42 hydroxocobalamin .......... 150 hydroxychloroquine oral ... 19 hydroxyprogesterone caproate .......................... 109 hydroxyurea ...................... 28 I I-PRIN .............................. 47 ibandronate intravenous solution ........................... 107 ibandronate intravenous syringe ............................ 107 ibandronate oral ............. 107 IBRANCE ......................... 28 IBU-DROPS ..................... 47 IBUPROFEN COLD ...... 129 IBUPROFEN COLD-SINUS (WITH PSE) ................... 129 IBUPROFEN IB ............... 47 IBUPROFEN JR STRENGTH ..................... 47 ibuprofen oral capsule ...... 47 ibuprofen oral drops, suspension ......................... 47 ibuprofen oral suspension ......................... 47 ibuprofen oral tablet 100 mg ..................................... 47


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ibuprofen oral tablet 200 mg ..................................... 47 ibuprofen oral tablet 400 mg, 600 mg, 800 mg ................ 47 IBUPROFEN PM ORAL TABLET ........................... 47 ibuprofen-diphenhydramine cit ...................................... 47 ICLUSIG ORAL TABLET 15 MG .................................... 28 ICLUSIG ORAL TABLET 45 MG .................................... 28 idarubicin ......................... 28 ifosfamide intravenous recon soln ................................... 28 IFOSFAMIDE INTRAVENOUS SOLUTION ...................... 28 ILARIS (PF) ................... 104 ILEVRO ......................... 116 imatinib oral tablet 100 mg ..................................... 28 imatinib oral tablet 400 mg ..................................... 28 IMBRUVICA ................... 28 imipenem-cilastatin .......... 19 imipramine hcl .................. 56 imiquimod ......................... 72 IMODIUM A-D ORAL LIQUID ............................ 93 IMOVAX RABIES VACCINE (PF) ................................. 105 INCRELEX ...................... 82 indapamide ....................... 65 INFANRIX (DTAP) (PF) ................................. 105 INFANT FEVER REDUCER- PAIN RELF ...................... 48 INFANT PAIN RELIEVER ....................... 48 INFANT'S IBUPROFEN ... 48 INFANT'S NON-ASPIRIN ORAL DROPS ................. 48 INFANT'S NON-ASPIRIN ORAL DROPS,SUSPENSION 100 MG/ML ...................... 48

INFANT'S PAIN RELIEF ORAL DROPS,SUSPENSION 80 MG/0.8 ML .................. 48 INFANT'S PAIN RELIEF ORAL SUSPENSION ...... 48 INFANT'S PAIN RELIEVER ....................... 48 INFANTS GAS RELIEF ... 98 INFANTS IBU-DROPS .... 48 INFANTS PROFENIB ..... 48 INFANTS' PAIN AND FEVER ............................. 48 INFANTS' PAIN RELIEF ............................. 48 INFED ............................ 150 INFUVITE ADULT ....... 150 INFUVITE PEDIATRIC ................... 150 INLYTA ORAL TABLET 1 MG .................................... 28 INLYTA ORAL TABLET 5 MG .................................... 28 insulin pen needle ............. 88 INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML .................................... 88 INTELENCE ORAL TABLET 100 MG ............................. 13 INTELENCE ORAL TABLET 200 MG ............................. 13 INTELENCE ORAL TABLET 25 MG ............................... 13 intralipid intravenous emulsion 20 % ................................ 149 INTRON A INJECTION .................... 104 INVANZ INJECTION ..... 19 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG .............................. 56 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG ................................. 56 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG ................................. 56

INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG ................................. 56 INVEGA SUSTENNA ..... 56 INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML .................................... 56 INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML .................................... 56 INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML .................................... 56 INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML .................................... 56 INVIRASE ORAL CAPSULE ........................ 13 INVIRASE ORAL TABLET ........................... 13 INZO ANTIFUNGAL ...... 77 IOPHEN C-NR ............... 129 IOPHEN DM-NR ........... 129 IOPHEN-NR ................... 129 IPOL INJECTION SUSPENSION ................ 105 ipratropium bromide inhalation ........................ 142 ipratropium bromide nasal ................................. 85 ipratropium-albuterol ..... 142 irbesartan ......................... 65 irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg .... 65 irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg .... 65 IRESSA ............................ 28 irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml ... 29 IRINOTECAN INTRAVENOUS SOLUTION 500 MG/25 ML ................. 29 ISENTRESS ORAL POWDER IN PACKET .... 13


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ISENTRESS ORAL TABLET ........................... 13 ISENTRESS ORAL TABLET, CHEWABLE 100 MG ..... 13 ISENTRESS ORAL TABLET, CHEWABLE 25 MG ....... 13 ISOLYTE-P IN 5 % DEXTROSE ................... 149 isoniazid oral .................... 20 isopropyl alcohol solution 70 % ....................................... 84 isosorbide dinitrate oral .... 71 isosorbide mononitrate ..... 71 isradipine .......................... 65 ISTODAX ......................... 29 ITCH RELIEF (CLOTRIMAZOLE) ........ 77 ITCHY EYE DROPS ..... 115 itraconazole ...................... 11 ivermectin oral .................. 20 IXEMPRA ........................ 29 IXIARO (PF) .................. 105 J J-MAX ............................ 129 J-TAN PD ....................... 129 JAKAFI ORAL TABLET 10 MG .................................... 29 JAKAFI ORAL TABLET 15 MG .................................... 29 JAKAFI ORAL TABLET 20 MG .................................... 29 JAKAFI ORAL TABLET 25 MG .................................... 29 JAKAFI ORAL TABLET 5 MG .................................... 29 jantoven ............................ 69 JANUMET ....................... 89 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG ....... 89 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG .................................... 89 JANUVIA ORAL TABLET 100 MG ............................. 89 JANUVIA ORAL TABLET 25 MG ............................... 89

JANUVIA ORAL TABLET 50 MG ............................... 89 JARDIANCE .................... 89 JENTADUETO ................ 89 JEVTANA ........................ 29 JOCK ITCH ...................... 77 JOCK ITCH (CLOTRIMAZOLE) ........ 77 JOCK ITCH (TERBINAFINE) ............. 77 JR. ACETAMINOPHEN ... 48 JR. STR NON-ASPIRIN PAIN ................................. 48 JR. STRENGTH PAIN RELIEVER ....................... 48 junel 1.5/30 (21) ............. 111 junel 1/20 (21) ................ 111 junel fe 1.5/30 (28) ......... 111 junel fe 1/20 (28) ............ 111 JUNIOR MAPAP ............. 48 JUXTAPID ....................... 70 K K-PEC ANTIDIARRHEAL (BISM SUB) ..................... 93 K-TAB ORAL TABLET EXTENDED RELEASE 8 MEQ ............................... 145 KADCYLA ....................... 29 KALETRA ORAL SOLUTION ...................... 13 KALETRA ORAL TABLET 100-25 MG ....................... 13 KALETRA ORAL TABLET 200-50 MG ....................... 14 KALYDECO ORAL TABLET ......................... 142 KAO-TIN (BISMUTH SUBSALICYLAT) ........... 94 KAOPECTATE EX STR (BISMUTH SS) ................ 94 KAOPECTATE (BISMUTH SUBSALICY) ................... 94 kariva (28) ...................... 111 kelnor 1/35 (28) .............. 111 KEPIVANCE ................... 24 ketoconazole oral .............. 11 ketoconazole topical ......... 77 ketorolac ophthalmic ...... 116

ketotifen fumarate ........... 115 KEYTRUDA INTRAVENOUS RECON SOLN ................................ 29 KEYTRUDA INTRAVENOUS SOLUTION ...................... 29 KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG ............................. 56 KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG ............................... 56 KIDKARE COUGH/ COLD ............................. 129 KINERET ....................... 108 kionex oral powder ........... 82 KIONEX ORAL SUSPENSION .................. 83 KLOR-CON 10 .............. 145 KLOR-CON 8 ................ 145 KLOR-CON M10 ........... 145 KLOR-CON M15 ........... 145 KLOR-CON M20 ........... 145 KONSYL FIBER .............. 98 KONSYL SUGAR-FREE ORAL CAPSULE ............ 98 KORLYM ......................... 91 KUVAN ORAL TABLET, SOLUBLE ........................ 91 L labetalol intravenous solution ............................. 65 labetalol oral .................... 65 lactated ringers intravenous ..................... 145 lactated ringers irrigation ........................... 81 lactulose oral solution 10 gram/15 ml ........................ 98 LACTULOSE ORAL SOLUTION 10 GRAM/15 ML (15 ML), 20 GRAM/30 ML .................................... 98 LAMISIL AF TOPICAL AEROSOL POWDER ...... 77 LAMISIL AF TOPICAL POWDER ......................... 77


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LAMISIL AT .................... 77 LAMISIL (AEROSOL) .... 77 lamivudine oral solution .... 14 lamivudine oral tablet 100 mg ..................................... 14 lamivudine oral tablet 150 mg ..................................... 14 lamivudine oral tablet 300 mg ..................................... 14 lamivudine-zidovudine ...... 14 lamotrigine oral tablet ...... 36 lamotrigine oral tablet, chewable dispersible ......... 36 LANOXIN ORAL TABLET 125 MCG, 62.5 MCG ....... 68 lansoprazole oral capsule, delayed release(dr/ec) .... 103 LANTUS .......................... 89 LANTUS SOLOSTAR ..... 89 LARIN 1/20 (21) ............ 111 LARIN FE 1.5/30 (28) .... 111 LARIN FE 1/20 (28) ...... 111 latanoprost ...................... 116 LATUDA ORAL TABLET 120 MG ............................. 56 LATUDA ORAL TABLET 20 MG .................................... 56 LATUDA ORAL TABLET 40 MG .................................... 56 LATUDA ORAL TABLET 60 MG .................................... 56 LATUDA ORAL TABLET 80 MG .................................... 56 LAXA CLEAR ................. 98 LAXATIVE PEG 3350 ORAL POWDER ......................... 98 LAXATIVE (BISACODYL) RECTAL ........................... 98 LAXATIVE (GLYCERIN- PEDIATRIC) .................... 98 leflunomide ..................... 108 LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/ DAY) ................................ 29 LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2) ........................... 29

LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2) ............................ 29 LENVIMA ORAL CAPSULE 24 MG/DAY(10 MG X 2-4 MG X 1) ........................... 29 LENVIMA ORAL CAPSULE 8 MG/DAY (4 MG X 2), 8 MG/DAY (4 MG X 2) (60 PACK) .............................. 29 lessina ............................. 111 LETAIRIS ...................... 142 letrozole ............................ 29 leucovorin calcium injection recon soln 100 mg, 350 mg, 50 mg ..................................... 24 LEUCOVORIN CALCIUM INJECTION RECON SOLN 200 MG ............................. 24 LEUCOVORIN CALCIUM INJECTION RECON SOLN 500 MG ............................. 24 leucovorin calcium oral .... 24 LEUKERAN ..................... 29 leuprolide subcutaneous kit ...................................... 29 levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml ........................... 142 levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml ........................... 142 LEVEMIR ........................ 89 LEVEMIR FLEXTOUCH .................. 89 levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml ...................................... 36 levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/ 100 ml ............................... 36 levetiracetam intravenous ....................... 36 levetiracetam oral solution 100 mg/ml ................................ 36

LEVETIRACETAM ORAL SOLUTION 500 MG/5 ML (5 ML) ................................... 36 levetiracetam oral tablet .... 36 levetiracetam oral tablet extended release 24 hr 500 mg ..................................... 36 levetiracetam oral tablet extended release 24 hr 750 mg ..................................... 36 levobunolol ophthalmic drops 0.5 % ............................... 114 levocarnitine oral tablet .... 83 levocarnitine (with sugar) ................................ 83 levocetirizine oral tablet ............................... 129 levofloxacin intravenous .... 22 levofloxacin oral tablet ..... 22 levoleucovorin calcium intravenous recon soln ..... 24 levonest (28) ................... 111 levonorg-eth estrad triphasic .......................... 111 levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 mg ... 111 levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month .............................. 111 levorphanol tartrate .......... 42 levothyroxine oral ............. 92 levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg ................................... 92 LEXIVA ORAL SUSPENSION .................. 14 LEXIVA ORAL TABLET ........................... 14 LIALDA ........................... 99 LICE COMPLETE KIT 1-2- 3 ........................................ 80 LICE KILLING TOPICAL SHAMPOO ....................... 80 LICE KILLING (PERMETHRIN) .............. 80


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LICE PYRINYL SHAMPOO ....................... 80 LICE SOLUTION ............ 80 LICE TREATMENT TOPICAL LIQUID 1 % .... 80 LICE TREATMENT TOPICAL SHAMPOO ..... 80 LICE TREATMENT (PERMETHRIN) .............. 80 lidocaine hcl injection solution 20 mg/ml (2 %) ................. 74 lidocaine hcl injection solution 5 mg/ml (0.5 %) ................ 74 lidocaine hcl laryngotracheal ................ 74 lidocaine hcl mucous membrane ......................... 74 lidocaine hcl urethral ....... 74 lidocaine topical adhesive patch,medicated ................ 74 lidocaine topical ointment ............................ 74 LIDOCAINE VISCOUS ... 74 LIDOCAINE (PF) INJECTION SOLUTION 15 MG/ML (1.5 %) ................ 74 lidocaine (pf) injection solution 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) ..................................... 74 lidocaine (pf) intravenous solution ............................. 62 LIDOCAINE (PF) INTRAVENOUS SYRINGE ......................... 62 lidocaine-prilocaine topical cream ................................ 75 lindane topical shampoo .... 81 linezolid intravenous ........ 20 linezolid oral suspension for reconstitution .................... 20 linezolid oral tablet ........... 20 LINEZOLID-0.9% SODIUM CHLORIDE ...................... 20 LINZESS .......................... 99 liothyronine oral ............... 92 LIQUID ANTACID ......... 99 LIQUITEARS ................. 115

LIQUITUSS GG ............. 129 lisinopril ........................... 65 lisinopril- hydrochlorothiazide .......... 65 LITE COAT ASPIRIN ..... 48 lithium carbonate .............. 56 lithium citrate oral solution 8 meq/5 ml ........................... 57 LITTLE REMEDIES FEVER AND PAIN ....................... 48 LONSURF ........................ 29 loperamide oral capsule .... 94 loperamide oral liquid 1 mg/5 ml ...................................... 94 loperamide oral liquid 1 mg/ 7.5 ml ................................ 94 loperamide oral tablet ...... 94 LORADAMED ............... 129 LORATA-D .................... 129 LORATA-DINE D ......... 129 loratadine oral solution ... 129 loratadine oral tablet ...... 129 loratadine oral tablet, disintegrating .................. 129 LORATADINE-D .......... 129 lorazepam oral tablet ....... 57 LORTUSS DM ............... 129 LORTUSS EX ORAL SYRUP ........................... 129 losartan oral tablet 100 mg ..................................... 65 losartan oral tablet 25 mg, 50 mg ..................................... 65 losartan- hydrochlorothiazide .......... 65 LOTRIMIN AF JOCK ITCH POWDER ......................... 77 LOTRIMIN AF POWDER ......................... 77 LOTRIMIN AF TOPICAL AEROSOL,SPRAY .......... 77 LOTRIMIN AF TOPICAL CREAM ............................ 77 LOTRIMIN AF TOPICAL POWDER ......................... 77 LOTRIMIN ULTRA ........ 77 lovastatin oral tablet 10 mg, 20 mg ................................ 70

lovastatin oral tablet 40 mg ..................................... 70 LOW-OGESTREL (28) ... 111 loxapine succinate ............ 57 LUBRICANT EYE DROPS ........................... 115 LUBRICANT EYE DROPS (GLYC-PG) .................... 115 LUBRICANT EYE (PG-PEG 400) ................................. 115 LUBRICANT EYE (PG-PEG 400)(PF) .......................... 115 LUBRICATING PLUS ... 115 LUDENT FLUORIDE ORAL TABLET,CHEWABLE 1 MG FLUORIDE (2.2 MG) .... 150 LUMIGAN OPHTHALMIC DROPS 0.01 % ............... 116 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG ... 29 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG .... 30 LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED) ........................ 30 lutera (28) ....................... 111 LYNPARZA ..................... 30 LYRICA ORAL CAPSULE 100 MG ............................. 36 LYRICA ORAL CAPSULE 150 MG ............................. 36 LYRICA ORAL CAPSULE 200 MG ............................. 36 LYRICA ORAL CAPSULE 225 MG, 300 MG ............. 36 LYRICA ORAL CAPSULE 25 MG ............................... 36 LYRICA ORAL CAPSULE 50 MG ............................... 36 LYRICA ORAL CAPSULE 75 MG ............................... 36 LYRICA ORAL SOLUTION ...................... 36 LYSODREN ..................... 30 lyza .................................. 109


177

M M-CLEAR WC ............... 129 M-END DMX ................. 130 M-END MAX D ............. 130 M-END PE ..................... 130 M-M-R II (PF) ................ 105 M.V.I. ADULT ............... 150 M.V.I. PEDIATRIC ....... 150 M.V.I.-12 (WITHOUT VITAMIN K) .................. 150 MAALOX MAXIMUM STRENGTH ..................... 99 MAG-AL PLUS ............... 99 MAG-AL PLUS EXTRA STRENGTH ..................... 99 magnesium citrate oral solution ............................. 99 magnesium oxide oral tablet 400 mg, 420 mg .............. 145 MAGNESIUM SULFATE IN WATER INTRAVENOUS PARENTERAL SOLUTION .................... 145 MAGNESIUM SULFATE IN WATER INTRAVENOUS PIGGYBACK 2 GRAM/50 ML (4 %), 4 GRAM/50 ML (8 %) ................................... 146 MAGNESIUM SULFATE IN WATER INTRAVENOUS PIGGYBACK 4 GRAM/100 ML (4 %) ........................ 146 magnesium sulfate injection solution ........................... 146 magnesium sulfate injection syringe ............................ 146 manganese chloride ........ 146 manganese sulfate intravenous ..................... 146 MAPAP ARTHRITIS PAIN ................................. 48 MAPAP COLD FORMULA ..................... 130 MAPAP EXTRA STRENGTH ..................... 49 MAPAP PM ...................... 49 MAPAP SINUS MAX STRENGTH (PE) ........... 130

MAPAP (ACETAMINOPHEN) ORAL CAPSULE ........................ 48 MAPAP (ACETAMINOPHEN) ORAL DROPS,SUSPENSION .... 48 MAPAP (ACETAMINOPHEN) ORAL LIQUID ............................ 48 MAPAP (ACETAMINOPHEN) ORAL SUSPENSION .................. 48 MAPAP (ACETAMINOPHEN) ORAL TABLET ........................... 48 MAPAP (ACETAMINOPHEN) ORAL TABLET,CHEWABLE .... 48 maprotiline oral tablet 25 mg ..................................... 57 maprotiline oral tablet 50 mg ..................................... 57 maprotiline oral tablet 75 mg ..................................... 57 MAR-COF BP ................ 130 MAR-COF CG ............... 130 marlissa .......................... 111 MARPLAN ....................... 57 MASANTI DOUBLE STRENGTH ..................... 99 MASOPHEN .................... 49 MATULANE .................... 30 MAXIMUM STRENGTH FLU ................................. 130 MAXIPHEN ................... 130 MAXIPHEN DM ............ 130 meclizine oral tablet 12.5 mg, 25 mg ................................ 99 meclizine oral tablet, chewable ........................... 99 meclofenamate oral .......... 49 MEDICATED CORN REMOVERS .................... 72 MEDICIDIN-D ............... 130 MEDIPLAST CORN- CALLUS-WART ............. 72 MEDIPROXEN ................ 49 medroxyprogesterone ..... 109

mefloquine ........................ 20 MEGESTROL ORAL SUSPENSION 400 MG/10 ML (10 ML), 800 MG/20 ML (20 ML) ............................ 30 megestrol oral suspension 400 mg/10 ml (40 mg/ml) ........ 30 megestrol oral tablet ......... 30 MEKINIST ORAL TABLET 0.5 MG .............................. 30 MEKINIST ORAL TABLET 2 MG ................................. 30 meloxicam oral suspension ......................... 49 meloxicam oral tablet ....... 49 melphalan hcl ................... 30 memantine oral solution .... 40 memantine oral tablet 10 mg ..................................... 40 memantine oral tablet 5 mg ..................................... 40 MENACTRA (PF) INTRAMUSCULAR SOLUTION .................... 105 MENEST ........................ 109 MENOMUNE - A/C/Y/W- 135 .................................. 106 MENOMUNE - A/C/Y/W-135 (PF) ................................. 106 MENVEO A-C-Y-W-135-DIP (PF) ................................. 106 MEPHYTON .................... 69 mercaptopurine ................. 30 meropenem ....................... 20 MESALAMINE ORAL .... 99 mesalamine rectal ............. 99 mesalamine with cleansing wipe ................................... 99 mesna ................................ 24 MESNEX ORAL .............. 24 MESTINON ORAL SYRUP ............................. 40 MESTINON TIMESPAN ...................... 40 metaproterenol ............... 142 metformin oral tablet 1,000 mg ..................................... 89


178

metformin oral tablet 500 mg ..................................... 89 metformin oral tablet 850 mg ..................................... 89 metformin oral tablet extended release 24 hr 500 mg ........ 89 metformin oral tablet extended release 24 hr 750 mg ........ 89 metformin oral tablet extended release 24hr 1,000 mg ...... 89 metformin oral tablet extended release 24hr 500 mg ......... 89 methadone injection .......... 42 METHADONE INTENSOL ....................... 42 methadone oral concentrate ....................... 42 methadone oral solution 10 mg/5 ml ............................. 42 methadone oral solution 5 mg/ 5 ml ................................... 42 methadone oral tablet 10 mg ..................................... 42 methadone oral tablet 5 mg ..................................... 42 METHADOSE ORAL CONCENTRATE ............. 42 methazolamide oral ........ 116 methenamine hippurate .... 23 methimazole oral tablet 10 mg, 5 mg .................................. 87 methotrexate sodium ......... 30 methotrexate sodium (pf) injection recon soln .......... 30 methotrexate sodium (pf) injection solution .............. 30 methoxsalen rapid ............ 72 methyclothiazide ............... 65 methylergonovine oral .... 113 methylphenidate oral tablet ................................. 57 methylprednisolone acetate ............................... 86 methylprednisolone oral tablets ............................... 87 methylprednisolone sodium succ injection recon soln 125 mg, 40 mg ......................... 87

methylprednisolone sodium succ intravenous ............... 87 metipranolol ................... 114 metoclopramide hcl injection solution ............................. 99 METOCLOPRAMIDE HCL INJECTION SYRINGE .... 99 metoclopramide hcl oral solution ............................. 99 metoclopramide hcl oral tablet ................................. 99 metolazone ........................ 65 metoprolol succinate ......... 65 metoprolol ta- hydrochlorothiaz ............... 65 metoprolol tartrate intravenous solution ......... 65 metoprolol tartrate intravenous syringe .......... 65 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg ...... 66 metoprolol tartrate oral tablet 37.5 mg, 75 mg ................. 66 METRO I.V. ..................... 20 metronidazole in nacl (iso- os) ..................................... 20 metronidazole oral ............ 20 metronidazole topical cream ................................ 73 metronidazole topical gel 0.75 % ....................................... 73 metronidazole topical lotion ................................. 74 metronidazole vaginal .... 109 mexiletine .......................... 62 MGO ............................... 146 MI-ACID GAS RELIEF .... 99 MI-ACID ORAL SUSPENSION .................. 99 MI-ACID ORAL TABLET, CHEWABLE .................... 99 MIACALCIN INJECTION ...................... 91 MICATIN ......................... 77 MICONAZOLE 7 ........... 109 miconazole nitrate topical aerosol powder ................. 77

miconazole nitrate topical cream ................................ 77 miconazole nitrate vaginal comb pack,prefill appl, cream .............................. 109 miconazole nitrate vaginal cream .............................. 109 miconazole nitrate vaginal kit 1,200-2 mg-% ................. 110 miconazole nitrate vaginal suppository ..................... 110 MICONAZOLE-3 VAGINAL KIT ................................. 110 miconazole-3 vaginal suppository ..................... 110 MICONAZORB AF ......... 77 MICRO-GUARD ............. 77 MICROGESTIN 1.5/30 (21) ................................. 111 MICROGESTIN 1/20 (21) ................................. 111 MICROGESTIN FE 1.5/30 (28) ................................. 112 MICROGESTIN FE 1/20 (28) ................................. 112 midodrine .......................... 83 MIGRAINE FORMULA ... 49 MIGRAINE RELIEF ........ 49 MILK OF MAGNESIA .... 99 minocycline oral capsule ... 23 minocycline oral tablet ..... 23 minoxidil oral ................... 66 MINTOX .......................... 99 MINTOX MAXIMUM STRENGTH ..................... 99 MINTOX PLUS ............... 99 MIRALAX ....................... 99 mirtazapine oral tablet 15 mg ..................................... 57 mirtazapine oral tablet 30 mg ..................................... 57 mirtazapine oral tablet 45 mg ..................................... 57 mirtazapine oral tablet 7.5 mg ..................................... 57 mirtazapine oral tablet, disintegrating 15 mg ......... 57


179

mirtazapine oral tablet, disintegrating 30 mg ......... 57 mirtazapine oral tablet, disintegrating 45 mg ......... 57 misoprostol ..................... 103 mitomycin ......................... 30 mitoxantrone ..................... 30 modafinil oral tablet 100 mg ..................................... 57 modafinil oral tablet 200 mg ..................................... 57 moexipril ........................... 66 moexipril- hydrochlorothiazide .......... 66 MOISTURE DROPS ...... 115 molindone ......................... 57 mometasone nasal .......... 142 mometasone topical .......... 80 MONISTAT 1 COMBO PACK ............................. 110 MONO-LINYAH ........... 112 mononessa (28) ............... 112 montelukast ..................... 142 morgidox oral capsule 50 mg ..................................... 23 morphine concentrate oral solution ............................. 42 MORPHINE INTRAVENOUS CARTRIDGE 10 MG/ML, 2 MG/ML, 4 MG/ML, 8 MG/ ML .................................... 42 MORPHINE INTRAVENOUS SOLUTION 10 MG/ML, 50 MG/ML ............................. 42 MORPHINE INTRAVENOUS SOLUTION 100 MG/4 ML, 25 MG/ML, 250 MG/10 ML .................................... 42 MORPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ ML .................................... 42 morphine intravenous syringe 2 mg/ml, 4 mg/ml .............. 42 morphine oral capsule, er multiphase 24 hr 120 mg, 75 mg, 90 mg ......................... 42

morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg ......................... 43 morphine oral capsule, extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg ................................ 43 morphine oral solution 20 mg/ 5 ml (4 mg/ml) .................. 43 morphine oral tablet 15 mg ..................................... 43 morphine oral tablet 30 mg ..................................... 43 morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg ................................ 43 morphine oral tablet extended release 200 mg .................. 43 morphine (pf) injection solution 0.5 mg/ml ............ 42 morphine (pf) injection solution 1 mg/ml ............... 42 MORPHINE (PF) INTRAVENOUS PATIENT CONTROL.ANALGESIA SOLN 150 MG/30 ML ..... 42 MORPHINE (PF) INTRAVENOUS PATIENT CONTROL.ANALGESIA SOLN 30 MG/30 ML ....... 42 MOSCO CORN REMOVER ....................... 72 MOTION SICKNESS RELIEF (MECLIZ) ORAL TABLET, CHEWABLE .................... 99 MOTION-TIME ............... 99 MOTRIN IB ..................... 49 MOTRIN PM .................... 49 MOVIPREP .................... 100 moxifloxacin ..................... 22 MUCAPHED .................. 130 MUCINEX COLD,FLU,SORE THROAT ........................ 130 MUCINEX FAST-MAX COLD-FLU-THRT ORAL TABLET ......................... 130 MUCINEX FAST-MAX COLD-SINUS ................ 130

MUCINEX FAST-MAX CONGEST-COUGH ORAL LIQUID .......................... 130 MUCINEX FAST-MAX CONGEST-COUGH ORAL TABLET ......................... 130 MUCINEX FAST-MAX DAY-NITE CONG ORAL LIQUID, SEQUENTIAL ............... 130 MUCINEX FAST-MAX DM MAX ............................... 130 MUCINEX FAST-MAX NITE COLD-FLU ORAL LIQUID .......................... 130 MUCINEX FAST-MAX SEVERE COLD ............. 130 MUCINEX FST-MX DY-NT COLD(DPH) ................... 130 MUCINEX MINI-MELTS ORAL GRANULES IN PACKET 100 MG .......... 130 MUCINEX ORAL TABLET EXTENDED RELEASE 12HR 600 MG ........................... 130 MUCINEX SINUS- MAX ................................. 85 MUCINEX SINUS-MAX D- N (DIPHEN) ORAL TABLETS, SEQUENTIAL ............... 131 MUCINEX SINUS-MAX PRESSUR-PAIN ORAL TABLET ......................... 131 MUCINEX SINUS-MAX SEV CONGESTN ORAL TABLET ......................... 131 MUCOSA ....................... 131 MUCOSA DM ................ 131 MUCUS AND COUGH RELIEF ........................... 131 MUCUS RELIEF CHEST ........................... 131 MUCUS RELIEF COLD AND SINUS ORAL TABLET ......................... 131 MUCUS RELIEF COLD- FLU-SORE THR ............ 131


180

MUCUS RELIEF CONGESTION- COUGH .......................... 131 MUCUS RELIEF COUGH .......................... 131 MUCUS RELIEF DM .... 131 MUCUS RELIEF DM MAX ............................... 131 MUCUS RELIEF ER ORAL TABLET EXTENDED RELEASE 12HR 600 MG .................................. 131 MUCUS RELIEF ORAL TABLET 200 MG .......... 131 MUCUS RELIEF ORAL TABLET 400 MG .......... 131 MUCUS RELIEF PE ...... 131 MUCUS RELIEF PLUS .............................. 131 MUCUS RELIEF SEV CONGEST-COLD ......... 131 MUCUS RELIEF SEVERE COLD ORAL LIQUID .... 131 MUCUS RELIEF SINUS ............................. 131 MUCUS RELIEF SINUSPRESSUR- PAIN ............................... 131 MUCUS RLF SEVERE SINUS CONGEST ......... 131 MULTAQ ......................... 62 MULTI COMPLETE WITH IRON .............................. 151 MULTI-DAY WITH IRON .............................. 151 MULTI-SYMPTOM COLD DAYTIME ...................... 132 MULTI-SYMPTOM COLD NIGHT TIME ................. 132 MULTI-SYMPTOM COLD (PE) ................................. 131 MULTI-SYMPTOM COLD (PE-CPM) ....................... 131 multivitamin with iron .... 151 mupirocin calcium ............ 75 mupirocin topical ointment ............................ 75

MURINE EAR WAX REMOVAL SYSTEM ...... 86 MURO 128 OPHTHALMIC DROPS 2 % .................... 115 MURO 128 OPHTHALMIC OINTMENT ................... 115 MUSTARGEN ................. 30 MY WAY ....................... 112 MYCO NAIL A ................ 77 mycophenolate mofetil ...... 30 mycophenolate sodium ..... 30 MYOZYME ..................... 91 MYRBETRIQ ................. 143 MYTAB GAS ................. 100 MYTAB GAS MAXIMUM STRENGTH ................... 100 MYZILRA ...................... 112 N nabumetone ....................... 49 nadolol .............................. 66 nadolol- bendroflumethiazide ......... 66 nafcillin injection .............. 21 nafcillin intravenous recon soln 2 gram ....................... 21 NAGLAZYME ................. 91 nalbuphine injection solution 10 mg/ml ........................... 49 nalbuphine injection solution 20 mg/ml ........................... 49 naloxone ........................... 49 naltrexone ......................... 49 NAMENDA ORAL SOLUTION ...................... 40 NAMENDA XR ORAL CAP, SPRINKLE,ER 24HR DOSE PACK ............................... 40 NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR ................................. 40 NAMZARIC ..................... 40 naproxen ........................... 49 naproxen sodium oral capsule .............................. 49 naproxen sodium oral tablet 220 mg .............................. 49 naproxen sodium oral tablet 275 mg, 550 mg ................ 49

NASAL DECONGESTANT (OXYMETAZL) ............... 85 NASAL DECONGESTANT (PE) ORAL TABLET 10 MG .................................. 132 NASAL DECONGESTANT (PSEUDOEPH) ORAL LIQUID .......................... 132 NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET ......................... 132 NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET EXTENDED RELEASE ....................... 132 NASAL RELIEF .............. 85 NASAL SPRAY 12 HOUR ............................... 85 NASAL SPRAY EXTRA MOISTURIZING ............. 85 NASAL SPRAY LONG ACTING ........................... 85 NASAL SPRAY SINUS ... 85 NASAL SPRAY (OXYMETAZOLINE) ..... 85 NASCOBAL ................... 151 NASONEX ..................... 142 nateglinide oral tablet 120 mg ..................................... 89 nateglinide oral tablet 60 mg ..................................... 89 NATPARA ....................... 91 NATURAL FIBER LAXATIVE .................... 100 NATURAL VEG LAXATIVE (SENNOSID) .................. 100 NEBUPENT ..................... 20 necon 0.5/35 (28) ............ 112 necon 1/35 (28) ............... 112 necon 1/50 (28) ............... 112 necon 10/11 (28) ............. 112 necon 7/7/7 (28) .............. 112 needles, insulin disp., safety ................................. 89 nefazodone oral tablet 100 mg ..................................... 57 nefazodone oral tablet 150 mg ..................................... 57


181

nefazodone oral tablet 200 mg ..................................... 57 nefazodone oral tablet 250 mg ..................................... 57 nefazodone oral tablet 50 mg ..................................... 57 NEO-POLYCIN ............. 113 NEO-POLYCIN HC ....... 117 NEO-TUSS ..................... 132 neomycin ........................... 20 neomycin-bacitracin-poly- hc .................................... 117 neomycin-bacitracin- polymyxin ........................ 113 neomycin-polymyxin b gu ...................................... 81 neomycin-polymyxin b- dexameth ......................... 117 neomycin-polymyxin- gramicidin ....................... 113 neomycin-polymyxin-hc ophthalmic ...................... 117 neomycin-polymyxin-hc otic .................................... 86 NEOSPORIN ANTI- ITCH ................................. 80 NEOSPORIN PLUS PAINRELIEF(BAC) ........ 75 NEUPOGEN ................... 104 NEUPRO .......................... 39 NEVANAC ..................... 116 nevirapine oral suspension ......................... 14 nevirapine oral tablet ....... 14 nevirapine oral tablet extended release 24 hr 100 mg ........ 14 nevirapine oral tablet extended release 24 hr 400 mg ........ 14 NEXAVAR ....................... 30 NEXT CHOICE ONE DOSE .............................. 112 niacin oral tablet extended release 24 hr 1,000 mg, 750 mg ..................................... 70 niacin oral tablet extended release 24 hr 500 mg ........ 70 NIACOR ........................... 70

nicardipine intravenous solution ............................. 66 nicardipine oral ................ 66 NICODERM CQ .............. 84 NICORELIEF ................... 84 NICORETTE BUCCAL GUM ................................. 84 NICORETTE BUCCAL LOZENGE ........................ 84 nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr ................... 84 nicotine (polacrilex) buccal gum ................................... 84 nicotine (polacrilex) buccal lozenge .............................. 84 NICOTROL NS ................ 84 nifedical xl ........................ 66 nifedipine oral tablet extended release ............................... 66 nifedipine oral tablet extended release 24hr ...................... 66 NIGHT TIME COLD AND FLU RELIEF .................. 132 NIGHT TIME COLD-FLU ORAL LIQUID .............. 132 NIGHT TIME ORAL CAPSULE 6.25-15-325 MG .................................. 132 NIGHT TIME PAIN MEDICINE ....................... 49 NIGHTIME SLEEP ........ 132 NIGHTTIME ALLERGY RELIEF ........................... 132 NIGHTTIME COLD- FLU ................................. 132 NIGHTTIME COLD-FLU RELIEF ........................... 132 NIGHTTIME COUGH .... 132 NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 50 MG ............................. 132 NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET ......................... 132 NILANDRON .................. 30 nilutamide ......................... 30 nimodipine ........................ 66

NINLARO ........................ 30 NIPENT ............................ 30 NITE TIME COLD- FLU ................................. 132 NITE TIME COLD-FLU FORMULA ..................... 132 NITE TIME COLD-FLU RELIEF ORAL CAPSULE ...................... 132 NITE TIME COUGH ..... 132 NITE TIME-D COLD-FLU RELIEF ........................... 132 NITE-TIME .................... 132 NITETIME MULTI- SYMPTOM .................... 132 nitro-bid ............................ 71 nitrofurantoin macrocrystal oral capsule 50 mg ........... 23 nitroglycerin intravenous ... 71 nitroglycerin transdermal patch 24 hour .................... 71 NITROSTAT .................... 71 NIVA-HIST DM ............ 133 NIVANEX DMX ............ 133 NO DRIP .......................... 85 NOBLE FORMULA HC TOPICAL CREAM .......... 80 NOHIST-DM .................. 133 NON-ASPIRIN CHILDREN'S ................... 49 NON-ASPIRIN CHILDRENS .................... 49 NON-ASPIRIN EXTRA STRENGTH ORAL LIQUID ............................ 49 NON-ASPIRIN EXTRA STRENGTH ORAL TABLET ........................... 49 NON-ASPIRIN NIGHTIME ...................... 49 NON-ASPIRIN ORAL ELIXIR ............................. 49 NON-ASPIRIN ORAL SUSPENSION .................. 50 NON-ASPIRIN ORAL TABLET ........................... 50


182

NON-ASPIRIN ORAL TABLET,CHEWABLE 80 MG .................................... 50 NON-ASPIRIN PAIN RELIEF ORAL TABLET 500 MG .................................... 50 NON-ASPIRIN PAIN RELIEF PM .................................... 50 NON-ASPIRIN PM .......... 50 NON-DROWSY ALLERGY ..................... 133 nora-be ........................... 109 NORDITROPIN FLEXPRO ...................... 104 NOREL AD .................... 133 norethindrone acetate ..... 109 norethindrone (contraceptive) ................ 109 norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg- 35 mcg (28), 0.25-35 mg- mcg ................................. 112 NORMOSOL-M IN 5 % DEXTROSE ................... 149 NORMOSOL-R .............. 146 NORMOSOL-R IN 5 % DEXTROSE ................... 146 NORMOSOL-R PH 7.4 ... 149 nortrel 0.5/35 (28) .......... 112 nortrel 1/35 (21) ............. 112 nortrel 1/35 (28) ............. 112 nortrel 7/7/7 (28) ............ 112 nortriptyline ...................... 57 NORVIR ORAL CAPSULE ........................ 14 NORVIR ORAL SOLUTION ...................... 14 NORVIR ORAL TABLET ........................... 14 NOVOPEN ECHO ........... 89 NOXAFIL ORAL SUSPENSION .................. 11 NRS NASAL RELIEF ..... 85 NTS STEP 1 ..................... 84 NUEDEXTA .................... 40 NULOJIX ......................... 30 NUPLAZID ...................... 57 NUVARING ................... 110

nystatin oral suspension .... 11 nystatin oral tablet ............ 11 nystatin topical ................. 77 nystatin-triamcinolone ...... 77 nystop ................................ 77 O ocella .............................. 112 OCTAGAM .................... 106 octreotide acetate injection solution ............................. 31 OCTREOTIDE ACETATE INJECTION SYRINGE .... 31 ODEFSEY ........................ 14 ODOMZO ......................... 31 ODOR CONTROL FOOT- SNEAKER ........................ 77 OFEV ORAL CAPSULE 150 MG .................................. 142 ofloxacin ophthalmic ...... 113 ofloxacin oral tablet 400 mg ..................................... 22 ofloxacin otic .................... 86 ogestrel (28) .................... 112 olanzapine intramuscular ................... 57 olanzapine oral tablet 10 mg ..................................... 57 olanzapine oral tablet 15 mg ..................................... 57 olanzapine oral tablet 2.5 mg ..................................... 57 olanzapine oral tablet 20 mg ..................................... 58 olanzapine oral tablet 5 mg ..................................... 58 olanzapine oral tablet 7.5 mg ..................................... 58 olanzapine oral tablet, disintegrating 10 mg ......... 58 olanzapine oral tablet, disintegrating 15 mg ......... 58 olanzapine oral tablet, disintegrating 20 mg ......... 58 olanzapine oral tablet, disintegrating 5 mg ........... 58 OLYSIO ........................... 14 omega-3 acid ethyl esters ... 70

OMEPRAZOLE MAGNESIUM ............... 103 omeprazole oral capsule, delayed release(dr/ec) .... 103 OMEPRAZOLE ORAL TABLET,DELAYED RELEASE (DR/EC) ....... 103 OMNITROPE ................. 104 ONCASPAR ..................... 31 ondansetron hcl intravenous ..................... 100 ondansetron hcl oral solution ........................... 100 ondansetron hcl oral tablet 24 mg ................................... 100 ondansetron hcl oral tablet 4 mg, 8 mg ......................... 100 ondansetron hcl (pf) injection solution ........................... 100 ondansetron hcl (pf) injection syringe ............................ 100 ondansetron odt .............. 100 ONE DAILY MULTI-VIT W- MINERAL ...................... 151 ONE DAILY MULTIVIT- IRON(FOLIC) ................ 151 ONE DAILY PLUS IRON .............................. 151 ONE DAILY WITH IRON .............................. 151 ONE-A-DAY TEEN ADVANTAGE ORAL TABLET 18-400 MG- MCG ............................... 151 ONFI ORAL SUSPENSION .................. 36 ONFI ORAL TABLET 10 MG .................................... 36 ONFI ORAL TABLET 20 MG .................................... 37 OPCICON ONE-STEP .... 112 OPDIVO ........................... 31 OPIUM TINCTURE ........ 94 ORAP ............................... 58 ORENCIA ...................... 108 ORENCIA (WITH MALTOSE) .................... 108


183

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG ........ 83 ORFADIN ORAL CAPSULE 20 MG ............................... 83 ORGAN-I NR ................. 133 ORIGINAL NASAL SPRAY ............................. 85 ORMIR ........................... 133 ORTHO MICRONOR .... 109 oxacillin injection ............. 21 oxacillin intravenous ........ 21 oxaliplatin intravenous recon soln 100 mg ....................... 31 oxaliplatin intravenous recon soln 50 mg ......................... 31 oxaliplatin intravenous solution ............................. 31 oxandrolone oral tablet 10 mg ..................................... 91 oxandrolone oral tablet 2.5 mg ..................................... 91 oxaprozin .......................... 50 oxcarbazepine ................... 37 OXSORALEN .................. 72 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG .................................... 37 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG .................................... 37 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG .................................... 37 oxybutynin chloride oral syrup ............................... 143 oxybutynin chloride oral tablet ............................... 143 oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg .............................. 143 oxybutynin chloride oral tablet extended release 24hr 5 mg ................................... 143 oxycodone oral capsule .... 43

oxycodone oral concentrate ....................... 43 oxycodone oral tablet 10 mg, 5 mg .................................. 43 oxycodone oral tablet 15 mg ..................................... 43 oxycodone oral tablet 20 mg, 30 mg ................................ 43 oxycodone-acetaminophen oral solution ...................... 43 oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg ..................................... 43 oxycodone-aspirin ............ 43 oxymetazoline ................... 85 OYSCO D ....................... 146 OYSCO-500 ................... 146 OYST-CAL-500 ............. 146 OYSTER SHELL + D3 ... 146 OYSTER SHELL CALCIUM ...................... 146 OYSTER SHELL CALCIUM 500 .................................. 146 OYSTER SHELL CALCIUM- VIT D3 ORAL TABLET 250- 125 MG-UNIT ................ 146 P pacerone oral tablet 100 mg, 200 mg, 400 mg ................ 62 paclitaxel .......................... 31 PAIN AND FEVER ......... 50 PAIN RELIEF ADULT .... 50 PAIN RELIEF ALLERGY SINUS ............................. 133 PAIN RELIEF COLD AND COUGH .......................... 133 PAIN RELIEF EXTRA STRENGTH ..................... 50 PAIN RELIEF ORAL LIQUID ............................ 50 PAIN RELIEF ORAL TABLET ........................... 50 PAIN RELIEF ORAL TABLET EXTENDED RELEASE ......................... 50 PAIN RELIEF PM ........... 50

PAIN RELIEF PM RAPID RELEASE ......................... 50 PAIN RELIEF REGULAR STRENGTH ..................... 50 PAIN RELIEF SINUS PE ................................... 133 PAIN RELIEF (ACETAMIN- ASP-CAF) ........................ 50 PAIN RELIEVER ............ 50 PAIN RELIEVER EXTRA STRENGTH ..................... 50 PAIN RELIEVER PLUS ... 50 PAIN RELIEVER PM EX- STRENGTH ..................... 50 PAIN RELIEVER PM ORAL TABLET 25-500 MG ....... 50 PAIN RELIEVER (ACETAM- ASPIRIN) ......................... 50 PAIN-OFF ........................ 50 paliperidone oral tablet extended release 24hr 1.5 mg ..................................... 58 paliperidone oral tablet extended release 24hr 3 mg ..................................... 58 paliperidone oral tablet extended release 24hr 6 mg ..................................... 58 paliperidone oral tablet extended release 24hr 9 mg ..................................... 58 pamidronate intravenous recon soln ................................... 91 pamidronate intravenous solution 30 mg/10 ml (3 mg/ ml), 90 mg/10 ml (9 mg/ ml) ..................................... 91 pamidronate intravenous solution 60 mg/10 ml (6 mg/ ml) ..................................... 91 PAMPRIN MAX .............. 50 PANOXYL TOPICAL CLEANSER ..................... 74 PANOXYL-4 .................... 74 PANRETIN ...................... 72 pantoprazole intravenous ..................... 103 pantoprazole oral ........... 103


184

paricalcitol oral ................ 91 PAROEX ORAL RINSE ... 85 paromomycin .................... 20 paroxetine hcl oral tablet 10 mg ..................................... 58 paroxetine hcl oral tablet 20 mg ..................................... 58 paroxetine hcl oral tablet 30 mg ..................................... 58 paroxetine hcl oral tablet 40 mg ..................................... 58 paroxetine hcl oral tablet extended release 24 hr 12.5 mg ..................................... 58 paroxetine hcl oral tablet extended release 24 hr 25 mg ..................................... 58 paroxetine hcl oral tablet extended release 24 hr 37.5 mg ..................................... 58 PASER .............................. 20 PATADAY ..................... 115 PAXIL ORAL SUSPENSION .................. 58 PAZEO ........................... 115 PEDIA RELIEF COUGH- COLD ............................. 133 PEDIACARE FEVER REDUCER ....................... 50 PEDIACARE MULTI- SYMPTOM COLD ........ 133 PEDIATRIC COUGH AND COLD ORAL LIQUID 1-15- 5 MG/5 ML ..................... 133 PEDVAX HIB (PF) ........ 106 peg 3350-electrolytes oral recon soln 236-22.74-6.74 - 5.86 gram ........................ 100 peg 3350-electrolytes oral recon soln 240-22.72-6.72 - 5.84 gram ........................ 100 peg-electrolyte soln ......... 100 PEG3350 ......................... 100 PEGANONE ..................... 37 PEGASYS ...................... 104 PEGASYS PROCLICK ... 104 PEGINTRON ................. 104

PEGINTRON REDIPEN ....................... 104 PENICILLIN G POT IN DEXTROSE ..................... 21 penicillin g potassium ....... 21 penicillin g procaine intramuscular syringe 1.2 million unit/2 ml ............... 22 penicillin g procaine intramuscular syringe 600,000 unit/ml ............................... 22 penicillin g sodium ........... 22 penicillin v potassium ....... 22 PENTAM .......................... 20 PENTASA ...................... 100 pentoxifylline .................... 69 PEPCID AC ORAL TABLET 20 MG ............................. 103 PEPTIC RELIEF .............. 94 PEPTO-BISMOL ............. 94 PEPTO-BISMOL MAX ST ..................................... 94 PEPTO-BISMOL TO- GO .................................... 94 PERCOGESIC .................. 51 PERFOROMIST ............. 142 perindopril erbumine ........ 66 periogard .......................... 85 PERJETA ......................... 31 permethrin topical cream ... 81 permethrin topical liquid ... 81 perphenazine ..................... 58 PERSA-GEL ..................... 74 PHARBECHLOR ........... 133 PHARBEDRYL ............. 133 PHARBETOL ................... 51 PHAZYME ORAL CAPSULE 180 MG ........................... 100 phendimetrazine tartrate ... 81 phenelzine ......................... 58 phenobarbital oral elixir ... 37 phenobarbital oral tablet 100 mg ..................................... 37 phenobarbital oral tablet 15 mg ..................................... 37 phenobarbital oral tablet 16.2 mg ..................................... 37

phenobarbital oral tablet 30 mg ..................................... 37 phenobarbital oral tablet 32.4 mg ..................................... 37 phenobarbital oral tablet 60 mg ..................................... 37 phenobarbital oral tablet 64.8 mg ..................................... 37 phenobarbital oral tablet 97.2 mg ..................................... 37 phentermine ...................... 81 PHENYLHISTINE DH ... 133 PHENYTEK ..................... 37 PHENYTOIN ORAL SUSPENSION 100 MG/4 ML .................................... 37 phenytoin oral suspension 125 mg/5 ml ............................. 37 phenytoin oral tablet, chewable ........................... 37 phenytoin sodium extended ............................ 37 phenytoin sodium intravenous solution ............................. 37 phenytoin sodium intravenous syringe .............................. 37 PHOSPHOLINE IODIDE .......................... 114 PICATO ............................ 72 PILOCARPINE HCL OPHTHALMIC DROPS 1 %, 2 %, 4 % ......................... 114 pilocarpine hcl oral .......... 83 pimozide ............................ 58 pindolol ............................. 66 PINK BISMUTH MAXIMUM STRENGTH ..................... 94 PINK BISMUTH ORAL SUSPENSION .................. 94 PINK BISMUTH ORAL TABLET ........................... 94 PINK BISMUTH ORAL TABLET,CHEWABLE .... 94 pioglitazone oral tablet 15 mg ..................................... 89 pioglitazone oral tablet 30 mg ..................................... 90


185

pioglitazone oral tablet 45 mg ..................................... 90 pioglitazone-glimepiride .... 90 pioglitazone-metformin ..... 90 piperacillin-tazobactam .... 22 piroxicam .......................... 51 PLAN B ONE-STEP ...... 112 PLANTAR WART REMOVER ....................... 72 PLASMA-LYTE 148 ..... 149 PLASMA-LYTE-56 IN 5 % DEXTROSE ................... 149 podofilox ........................... 72 POLY HIST PD .............. 133 POLY-HIST DM (THONZYLAMINE) ..... 133 POLY-TUSSIN AC ORAL LIQUID 4-10-10 MG/5 ML .................................. 133 POLY-VENT DM ORAL TABLET 60-20-380 MG .................................. 133 POLY-VENT IR ORAL TABLET 60-380 MG ..... 133 POLYCIN ....................... 113 polyethylene glycol 3350 oral powder ............................ 100 polyethylene glycol 3350 oral powder in packet ............. 100 polymyxin b sulf- trimethoprim ................... 113 polyvinyl alcohol ............. 115 POMALYST ORAL CAPSULE 1 MG .............. 31 POMALYST ORAL CAPSULE 2 MG .............. 31 POMALYST ORAL CAPSULE 3 MG, 4 MG ... 31 portia .............................. 112 PORTRAZZA ................... 31 potassium chlorid-d5- 0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l .......... 146 potassium chlorid-d5- 0.45%nacl intravenous parenteral solution 20 meq/ l ....................................... 146

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/ l ....................................... 146 potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l ............................... 146 potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l ............ 146 potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l ............ 147 potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 40 meq/100 ml .................................... 147 POTASSIUM CHLORIDE INTRAVENOUS PIGGYBACK 10 MEQ/50 ML .................................. 147 POTASSIUM CHLORIDE INTRAVENOUS PIGGYBACK 20 MEQ/50 ML, 30 MEQ/100 ML .... 147 potassium chloride intravenous solution ........................... 147 potassium chloride oral capsule, extended release ............................. 147 potassium chloride oral tablet extended release ............. 147 potassium chloride oral tablet, er particles/crystals ........ 147 potassium chloride-0.45 % nacl ................................. 147 potassium chloride-d5- 0.2%nacl intravenous parenteral solution 20 meq/ l ....................................... 147 potassium chloride-d5- 0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l .......................... 147 potassium chloride-d5- 0.3%nacl intravenous

parenteral solution 20 meq/ l ....................................... 147 potassium chloride-d5- 0.9%nacl intravenous parenteral solution 20 meq/ l ....................................... 147 potassium chloride-d5- 0.9%nacl intravenous parenteral solution 40 meq/ l ....................................... 147 potassium citrate oral tablet extended release 10 meq (1, 080 mg), 5 meq (540 mg) .................................. 144 POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG ..... 37 POTIGA ORAL TABLET 50 MG .................................... 37 POWDERLAX ............... 100 PRADAXA ....................... 69 PRALUENT PEN ............. 70 PRALUENT SYRINGE .... 70 pramipexole oral tablet .... 39 pravastatin ........................ 70 prazosin oral ..................... 66 prednisolone acetate ....... 117 prednisolone oral solution 15 mg/5 ml ............................. 87 prednisolone sodium phosphate ophthalmic ..... 117 prednisolone sodium phosphate oral solution 15 mg/ 5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) .................... 87 prednisolone sodium phosphate oral tablet, disintegrating .................... 87 prednisone ........................ 87 prednisone intensol ........... 87 PREMARIN ORAL ........ 109 PREMARIN VAGINAL ...................... 109 PREMPRO ..................... 109 prenatal vitamin oral tablet ............................... 151 PREPARATION H HYDROCORTISONE ..... 80 PRES GEN ..................... 133


186

PRESGEN B ................... 133 PREVACID 24HR .......... 103 prevalite oral powder ....... 70 PREVALITE ORAL POWDER IN PACKET .... 70 previfem .......................... 112 PREZCOBIX .................... 14 PREZISTA ORAL SUSPENSION .................. 14 PREZISTA ORAL TABLET 150 MG ............................. 14 PREZISTA ORAL TABLET 600 MG, 800 MG ............. 14 PREZISTA ORAL TABLET 75 MG ............................... 14 PRIFTIN ........................... 20 PRIMAQUINE ................. 20 PRIMATENE ASTHMA ....................... 133 primidone .......................... 37 PRIVIGEN ..................... 106 PRO-RED AC (W/ DEXCHLORPHENIR) .... 133 PROAIR HFA ................ 142 PROAIR RESPICLICK ... 142 probenecid ...................... 107 procainamide injection solution 100 mg/ml ........... 62 procainamide injection solution 500 mg/ml ........... 62 prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) ........................ 100 prochlorperazine maleate oral ................................. 100 prochlorperazine maleate rectal ............................... 100 PROCRIT ....................... 104 procto-pak ....................... 100 proctosol hc .................... 100 proctozone-hc ................. 100 progesterone micronized ...................... 109 PROGLYCEM ................. 90 PROGRAF INTRAVENOUS .............. 31 PROLASTIN-C ................ 83 PROLEUKIN ................. 104

PROLIA .......................... 107 PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG .................................... 69 PROMACTA ORAL TABLET 50 MG ............................... 69 promethazine injection solution ........................... 133 promethazine oral tablet 12.5 mg, 25 mg ....................... 133 PROMETHAZINE VC- CODEINE ....................... 134 promethazine-codeine ..... 134 promethazine-dm ............ 134 promethazine-phenyleph- codeine ............................ 134 PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG .................................. 134 propafenone oral tablet .... 62 propranolol intravenous .... 66 propranolol oral ............... 66 propranolol- hydrochlorothiazid ........... 66 propylthiouracil ................ 87 PROQUAD (PF) ............. 106 PROTONIX INTRAVENOUS ............ 103 protriptyline ...................... 58 PROVIL ............................ 51 pseudoephed-chlophedianol- gg .................................... 134 pseudoephedrine hcl oral liquid ............................... 134 pseudoephedrine hcl oral tablet 30 mg .................... 134 pseudoephedrine hcl oral tablet 60 mg .................... 134 pseudoephedrine hcl oral tablet extended release .... 134 psyllium husk oral capsule 0.52 gram ........................ 101 PULMOZYME ............... 143 PURELAX ...................... 101 PURIXAN ........................ 31 pyrazinamide .................... 20 pyridostigmine bromide .... 40

pyridoxine (vitamin b6) injection .......................... 151 Q Q-DRYL ORAL CAPSULE ...................... 134 Q-DRYL ORAL LIQUID .......................... 134 Q-PAP EXTRA STRENGTH ..................... 51 Q-PAP ORAL DROPS ..... 51 Q-PAP ORAL LIQUID .... 51 Q-PAP ORAL TABLET 325 MG .................................... 51 Q-PAP ORAL TABLET 500 MG .................................... 51 Q-TAPP DM ................... 134 Q-TUSSIN ...................... 134 Q-TUSSIN DM .............. 134 QSYMIA .......................... 81 QUADRACEL (PF) ....... 106 QUENALIN ................... 134 quetiapine oral tablet 100 mg ..................................... 59 quetiapine oral tablet 200 mg ..................................... 59 quetiapine oral tablet 25 mg ..................................... 59 quetiapine oral tablet 300 mg ..................................... 59 quetiapine oral tablet 400 mg ..................................... 59 quetiapine oral tablet 50 mg ..................................... 59 quinapril ........................... 66 quinapril- hydrochlorothiazide .......... 66 quinidine sulfate oral tablet 200 mg, 300 mg ................ 62 QUIT 2 BUCCAL GUM ... 84 QUIT 2 BUCCAL LOZENGE ........................ 84 QUIT 4 BUCCAL GUM ... 84 QUIT 4 BUCCAL LOZENGE ........................ 84 QVAR INHALATION AEROSOL 40 MCG/ ACTUATION ................. 143


187

QVAR INHALATION AEROSOL 80 MCG/ ACTUATION ................. 143 R RABAVERT (PF) .......... 106 raloxifene ........................ 107 ramipril ............................. 66 RANEXA ......................... 71 ranitidine hcl injection solution 25 mg/ml ........... 103 ranitidine hcl oral syrup ............................... 103 ranitidine hcl oral tablet 150 mg, 300 mg ..................... 103 ranitidine hcl oral tablet 75 mg ................................... 103 RAPAMUNE ORAL SOLUTION ...................... 31 RAVICTI .......................... 83 REBIF REBIDOSE ........ 104 REBIF TITRATION PACK ............................. 104 REBIF (WITH ALBUMIN) .................... 104 reclipsen (28) .................. 112 RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION ................ 106 RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ ML .................................. 106 RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML .................................. 106 RECORT PLUS ................ 80 REFENESEN DM .......... 134 REFENESEN ORAL TABLET 400 MG .......... 134 REFENESEN PE ............ 134 REFRESH CLASSIC (PF) ................................. 115 REFRESH LACRI- LUBE .............................. 115 REFRESH TEARS ......... 115 REGULOID ORAL CAPSULE ...................... 101

RELCOF C ..................... 134 RELENZA DISKHALER ................... 14 RELISTOR SUBCUTANEOUS SOLUTION .................... 101 RELISTOR SUBCUTANEOUS SYRINGE ....................... 101 REMEDY ANTIFUNGAL TOPICAL CREAM .......... 77 REMEDY PHYTOPLEX ANTIFUNGAL ................ 77 REMICADE ................... 101 RENAGEL ....................... 83 RENVELA ORAL POWDER IN PACKET 0.8 GRAM ... 83 RENVELA ORAL POWDER IN PACKET 2.4 GRAM ... 83 RENVELA ORAL TABLET ........................... 83 repaglinide-metformin ...... 90 REPATHA SURECLICK .................... 70 REPATHA SYRINGE ..... 71 RESCON-DM ................. 134 RESCON-GG ................. 134 RESCRIPTOR ORAL TABLET ........................... 14 RESCRIPTOR ORAL TABLET, DISPERSIBLE ................. 14 RESPAIRE-30 ................ 134 REST SIMPLY NIGHTTIME SLEEP ............................ 134 RESTASIS ...................... 115 RESTFULLY SLEEP ..... 134 RESTORE TEARS ......... 115 RETAINE CMC ............. 115 RETROVIR INTRAVENOUS .............. 14 REVIVE PLUS ............... 115 REVLIMID ORAL CAPSULE 10 MG ............................... 31 REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG .................................... 31

REVLIMID ORAL CAPSULE 5 MG ................................. 31 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG .................................... 59 REXULTI ORAL TABLET 3 MG, 4 MG ........................ 59 REYATAZ ORAL CAPSULE 150 MG, 200 MG ............. 14 REYATAZ ORAL CAPSULE 300 MG ............................. 15 REYATAZ ORAL POWDER IN PACKET ..................... 15 RI-GEL ........................... 101 RI-GEL II ....................... 101 RI-MOX ......................... 101 RI-MOX PLUS ............... 101 RI-TUSSIN ..................... 134 RI-TUSSIN DM ............. 134 ribasphere oral capsule .... 15 ribasphere oral tablet 200 mg ..................................... 15 ribavirin oral capsule ....... 15 ribavirin oral tablet 200 mg ..................................... 15 RID COMPLETE LICE ELIM KIT TOPICAL .................. 81 RIDAURA ...................... 108 rifabutin ............................ 20 rifampin ............................ 20 RIFATER ......................... 20 riluzole .............................. 83 rimantadine ....................... 15 ringers intravenous ......... 147 ringers irrigation .............. 81 RINGWORM ................... 77 RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML .................................... 59 RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML ... 59 risperidone oral solution ... 59 risperidone oral tablet 0.25 mg ..................................... 59


188

risperidone oral tablet 0.5 mg ..................................... 59 risperidone oral tablet 1 mg ..................................... 59 risperidone oral tablet 2 mg ..................................... 59 risperidone oral tablet 3 mg ..................................... 59 risperidone oral tablet 4 mg ..................................... 59 risperidone oral tablet, disintegrating 0.25 mg ...... 59 risperidone oral tablet, disintegrating 0.5 mg ........ 59 risperidone oral tablet, disintegrating 1 mg ........... 59 risperidone oral tablet, disintegrating 2 mg ........... 59 risperidone oral tablet, disintegrating 3 mg ........... 59 risperidone oral tablet, disintegrating 4 mg ........... 59 RITUXAN ........................ 31 rivastigmine ...................... 40 rivastigmine tartrate ......... 40 rizatriptan ......................... 39 ROBAFEN ..................... 134 ROBAFEN CF (PHENYLEPHRINE) ..... 135 ROBAFEN COUGH ...... 135 ROBAFEN DM .............. 135 ROBAFEN DM COUGH .......................... 135 ROBITUSSIN COUGH AND COLD CF ....................... 135 ROBITUSSIN COUGH- CHEST CONG DM ORAL CAPSULE ...................... 135 ROBITUSSIN LONG- ACTING ......................... 135 ROBITUSSIN NIGHTTIME COUGH DM .................. 135 ROBITUSSIN PEDIATRIC ................... 135 ropinirole oral tablet ........ 39 ROSADAN TOPICAL CREAM ............................ 74 rosuvastatin ...................... 71

ROTARIX ...................... 106 ROTATEQ VACCINE .... 106 roweepra ........................... 38 ROZEREM ....................... 59 RULOX .......................... 101 RYCONTUSS ................ 135 RYDEX .......................... 135 RYNEX DM ................... 135 S SABRIL ............................ 38 SANI-SUPP (ADULT) .... 101 SANI-SUPP (INFANT) ... 101 SANTYL .......................... 80 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG .............. 59 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG ............. 60 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG ................ 60 SAVELLA ORAL TABLET 100 MG ........................... 108 SAVELLA ORAL TABLET 12.5 MG .......................... 108 SAVELLA ORAL TABLET 25 MG ............................. 108 SAVELLA ORAL TABLET 50 MG ............................. 108 SAVELLA ORAL TABLETS, DOSE PACK .................. 108 SCOT-TUSSIN DIABETES CF ................................... 135 SCOT-TUSSIN DM ....... 135 SCOT-TUSSIN EXPECTORANT ........... 135 SCOT-TUSSIN SENIOR .......................... 135 SECURA ANTIFUNGAL ................ 78 SECURA ANTIFUNGAL EXTRA THICK ................ 78 selegiline hcl ..................... 39 selenium sulfide topical lotion ................................. 71 SELZENTRY ................... 15 SEN-O-TAB ................... 101

SENEXON ORAL TABLET ......................... 101 SENNA LAX .................. 101 SENNA LAXATIVE ORAL TABLET 8.6 MG ........... 101 SENNA ORAL TABLET ......................... 101 SENNA-GEN ................. 101 SENNO ........................... 101 SENSIPAR ORAL TABLET 30 MG, 60 MG ................. 91 SENSIPAR ORAL TABLET 90 MG ............................... 91 SENTRY ORAL TABLET 18- 400 MG-MCG ................ 151 SEREVENT DISKUS .... 143 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG .................................... 60 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG .................................... 60 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG .................................... 60 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG .................................... 60 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG .................................... 60 sertraline oral concentrate ....................... 60 sertraline oral tablet 100 mg ..................................... 60 sertraline oral tablet 25 mg ..................................... 60 sertraline oral tablet 50 mg ..................................... 60 SEVERE ALLERGY-SINUS HEADACHE .................. 135 SEVERE COLD ............. 135


189

SEVERE COLD AND FLU NIGHTTIME .................. 135 SEVERE COLD AND FLU (PE) ORAL TABLET ..... 135 SEVERE COLD MULTI- SYMPTOM .................... 135 SEVERE SINUS ............ 135 SHAKE THAT ACHE ..... 51 SIGNIFOR ........................ 31 SILADRYL SA .............. 135 sildenafil oral .................. 143 SILPHEN COUGH ........ 135 SILTUSSIN DM DAS .... 135 SILTUSSIN SA .............. 135 SILTUSSIN-DM ............ 135 silver sulfadiazine ............. 71 simethicone oral ............. 101 SIMPONI ........................ 108 SIMULECT INTRAVENOUS RECON SOLN 10 MG ..... 31 SIMULECT INTRAVENOUS RECON SOLN 20 MG ..... 31 simvastatin ........................ 71 SINEX ULTRA FINE MIST 12-HOUR ......................... 85 SINUS 12 HOUR ........... 135 SINUS AND COLD-D .... 136 SINUS CONGEST-PAIN DAY-NIGHT .................. 136 SINUS CONGESTION AND PAIN ............................... 136 SINUS CONGESTION-PAIN (CHLORPH) ................... 136 SINUS CONGESTION-PAIN (GUAIF) ......................... 136 SINUS DECONGESTANT (PE) ................................. 136 SINUS HEADACHE PE ................................... 136 SINUS NASAL SPRAY ... 85 SINUS PAIN RELIEF .... 136 SINUS RELIEF (NON- DROWSY) ..................... 136 SINUS RELIEF (OXYMETAZOLINE) ..... 85 sirolimus ........................... 31 SIRTURO ......................... 20

SKIN PROTECTANT A AND D ....................................... 72 SLEEP ............................ 136 SLEEP AID MAX STR (DIPHENHYDR) ........... 136 SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG .................................. 136 SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET ............. 136 SLEEP II ......................... 136 SLEEP TABLET (DIPHENHYDRAMINE) ... 136 SLEEP-TABS ................. 136 SMOOTH ANTACID .... 147 SMOOTHLAX ............... 101 SOCHLOR OPHTHALMIC OINTMENT ................... 115 sodium bicarbonate oral ................................. 101 sodium chloride 0.45 % intravenous parenteral solution ........................... 147 SODIUM CHLORIDE 0.45 % INTRAVENOUS PIGGYBACK ................. 147 sodium chloride 0.9 % intravenous parenteral solution ............................. 83 SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK ................... 83 sodium chloride 3 % ....... 147 sodium chloride 5 % ....... 147 sodium chloride intravenous ..................... 147 sodium chloride irrigation ........................... 83 sodium chloride ophthalmic ointment .......................... 115 sodium fluoride oral tablet ............................... 151 sodium fluoride oral tablet, chewable 1 mg fluoride (2.2 mg) .................................. 151

sodium polystyrene sulfonate oral powder ...................... 83 sodium polystyrene sulfonate oral suspension ................. 83 sodium polystyrene sulfonate rectal enema 30 gram/120 ml ...................................... 83 SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML .................................... 83 sodium polystyrene (sorb free) ................................... 83 SOLTAMOX .................... 31 SOLUBLE FIBER .......... 101 SOMATULINE DEPOT ... 31 SOMAVERT .................... 91 SOOTHE REGULAR STRENGTH ..................... 94 SOOTHE (BISMUTH SUBSALICYLATE) ........ 94 SOOTHING CARE (HYDROCORTISONE) .... 80 SORBUGEN NR ............ 136 sorine oral tablet 120 mg, 160 mg, 80 mg ......................... 62 sorine oral tablet 240 mg ... 62 sotalol af oral tablet 120 mg ..................................... 62 SOTALOL AF ORAL TABLET 160 MG, 80 MG .................................... 62 sotalol oral tablet 120 mg ..................................... 63 sotalol oral tablet 160 mg, 240 mg, 80 mg ......................... 63 SOVALDI ......................... 15 SPECTRAVITE ADVANCED FORMULA ORAL TABLET 18-400 MG-MCG ........... 151 SPECTRAVITE ULTRA WOMEN ......................... 151 SPIRIVA RESPIMAT .... 143 SPIRIVA WITH HANDIHALER .............. 143 spironolacton- hydrochlorothiaz ............... 66 spironolactone .................. 66


190

sprintec (28) .................... 112 SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG ..... 38 SPRITAM ORAL TABLET FOR SUSPENSION 750 MG .................................... 38 SPRYCEL ......................... 32 SPS ORAL ........................ 83 SPS RECTAL ................... 83 ssd ..................................... 71 stavudine oral capsule 15 mg, 20 mg ................................ 15 stavudine oral capsule 30 mg, 40 mg ................................ 15 stavudine oral recon soln ... 15 STIMATE ......................... 91 STIOLTO RESPIMAT .... 143 STIVARGA ...................... 32 STOMACH RELIEF ........ 94 STOMACH RELIEF MAX STRENGTH ..................... 94 STOMACH RELIEF ORIGINAL ....................... 94 STOOL SOFTENER ORAL CAPSULE 250 MG ........ 101 STOP SMOKING AID ..... 84 STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG ...................... 60 STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG ............................... 60 STREPTOMYCIN INTRAMUSCULAR ........ 20 STRIBILD ........................ 15 SUBOXONE SUBLINGUAL FILM 12-3 MG ................. 51 SUBOXONE SUBLINGUAL FILM 2-0.5 MG ................ 51 SUBOXONE SUBLINGUAL FILM 4-1 MG ................... 51 SUBOXONE SUBLINGUAL FILM 8-2 MG ................... 51 sucralfate oral tablet ...... 103 SUDAFED PE PRESSURE+PAIN+COUGH... 136 SUDOGEST ................... 136

SUDOGEST 12-HOUR ... 136 SUDOGEST PE .............. 136 sulfacetamide sodium ophthalmic drops ............ 117 sulfacetamide sodium (acne) ................................ 75 sulfacetamide- prednisolone ................... 117 sulfadiazine oral ............... 22 sulfamethoxazole- trimethoprim ..................... 22 SULFAMYLON TOPICAL CREAM ............................ 75 sulfasalazine ................... 101 sulindac oral ..................... 51 sumatriptan succinate oral ................................... 39 sumatriptan succinate subcutaneous cartridge .... 39 sumatriptan succinate subcutaneous pen injector .............................. 39 sumatriptan succinate subcutaneous solution ...... 39 sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml ...................................... 39 SUPER CALCIUM ........ 148 SUPER PAIN RELIEF ..... 51 SUPHEDRIN .................. 136 SUPHEDRIN 12 HOUR ............................. 136 SUPHEDRINE ............... 136 SUPHEDRINE 12 HOUR ............................. 136 SUPHEDRINE PE .......... 136 SUPHEDRINE PE DAY- NIGHT ............................ 136 SUPHEDRINE PE SINUS HEADACHE .................. 137 SUPPOSITORY ADULT ........................... 101 SURMONTIL ................... 60 SUSTIVA ORAL CAPSULE 200 MG ............................. 15 SUSTIVA ORAL CAPSULE 50 MG ............................... 15

SUSTIVA ORAL TABLET ........................... 15 SUTENT ORAL CAPSULE 12.5 MG ............................ 32 SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG .................................... 32 SYEDA ........................... 112 SYLATRON ................... 104 SYMLINPEN 120 ............ 90 SYMLINPEN 60 .............. 90 SYNAGIS ......................... 15 SYNAREL ........................ 92 SYNERCID ...................... 20 SYNJARDY ..................... 90 SYNRIBO ......................... 32 SYNTHROID ................... 92 SYPRINE ......................... 84 SYSTANE ULTRA ........ 116 SYSTANE ULTRA (PF) ................................. 116 SYSTANE (PF) .............. 115 SYSTANE (PROPYLENE GLYCOL) ....................... 115 T TAB TUSSIN ................. 137 TAB TUSSIN DM .......... 137 TAB-A-VITE/IRON ....... 151 TABLOID ......................... 32 tacrolimus oral ................. 32 tacrolimus topical ............. 72 TACTINAL ...................... 51 TACTINAL EXTRA STRENGTH ..................... 51 TAFINLAR ...................... 32 TAGAMET HB .............. 103 TAGRISSO ORAL TABLET 40 MG ............................... 32 TAGRISSO ORAL TABLET 80 MG ............................... 32 TAKE ACTION ............. 112 TAMIFLU ........................ 15 tamoxifen .......................... 32 tamsulosin ....................... 144 TANZEUM ....................... 90 TARCEVA ORAL TABLET 100 MG, 150 MG ............. 32


191

TARCEVA ORAL TABLET 25 MG ............................... 32 TARGRETIN ORAL ........ 32 TARGRETIN TOPICAL ... 32 TASIGNA ......................... 32 TAZORAC ....................... 74 taztia xt ............................. 66 TEARS AGAIN .............. 116 TEARS AGAIN (PVA) ... 116 TEARS PURE ................ 116 TECENTRIQ .................... 32 TECFIDERA .................... 40 TECHNIVIE ..................... 15 TEFLARO ........................ 18 TEKTURNA ..................... 66 TEKTURNA HCT ............ 66 telmisartan oral tablet 20 mg, 40 mg ................................ 66 telmisartan oral tablet 80 mg ..................................... 67 telmisartan-amlodipine ..... 67 telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg ..................................... 67 telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg ...... 67 temazepam oral capsule 15 mg, 22.5 mg, 30 mg .......... 60 TENSION HEADACHE ... 51 TENSION HEADACHE PAIN RELIEVER ....................... 51 terazosin ........................... 67 terbinafine hcl oral ........... 11 terbinafine hcl topical ....... 78 terbutaline oral ............... 143 terbutaline subcutaneous .................. 143 terconazole ..................... 110 TESSALON PERLES .... 137 testosterone cypionate ...... 92 testosterone enanthate ...... 92 testosterone transdermal gel ..................................... 92 testosterone transdermal gel in metered-dose pump 1.25 gram/ actuation (1 %) ...... 92

testosterone transdermal gel in metered-dose pump 10 mg/ 0.5 gram /actuation .......... 92 testosterone transdermal gel in packet 1 % (25 mg/ 2.5gram) ........................... 92 testosterone transdermal gel in packet 1 % (50 mg/5 gram) ................................ 92 tetanus,diphtheria tox ped (pf) .................................. 106 TETANUS-DIPHTHERIA TOXOIDS-TD ................ 106 tetrabenazine oral tablet 12.5 mg ..................................... 40 tetrabenazine oral tablet 25 mg ..................................... 40 tetracycline ....................... 23 TG 10PEH-380GFN ....... 137 TG 10PEH-380GFN- 15DM .............................. 137 THALOMID ORAL CAPSULE 100 MG, 50 MG .................................... 32 THALOMID ORAL CAPSULE 150 MG, 200 MG .................................... 32 THE MAGIC BULLET ... 101 theophylline oral tablet extended release 12 hr .... 143 theophylline oral tablet extended release 24 hr .... 143 THERAFLU DAYTIME COLD-COUGH .............. 137 THERAFLU FLU-SORE THROAT ........................ 137 THERAFLU NIGHT SEVERE COLD-CGH ................... 137 THERMAZENE ............... 71 thiamine hcl (vitamin b1) injection .......................... 151 thioridazine ....................... 60 thiotepa ............................. 32 thiothixene ........................ 60 THYMOGLOBULIN ..... 106 tiagabine ........................... 38 TICE BCG ...................... 106 TIKOSYN ......................... 63

timolol maleate ophthalmic ...................... 114 timolol maleate oral ......... 67 TIMOPTIC OCUDOSE (PF) ................................. 114 TINACTIN TOPICAL AEROSOL POWDER ...... 78 TINACTIN TOPICAL AEROSOL,SPRAY .......... 78 TINACTIN TOPICAL CREAM ............................ 78 TINACTIN TOPICAL POWDER ......................... 78 tioconazole ...................... 110 TIOCONAZOLE-1 ......... 110 TIVICAY ORAL TABLET 10 MG, 25 MG ...................... 15 TIVICAY ORAL TABLET 50 MG .................................... 15 tizanidine oral tablet ......... 41 tobramycin ...................... 113 tobramycin in 0.225 % nacl ................................... 20 tobramycin sulfate injection recon soln ......................... 20 tobramycin sulfate injection solution ............................. 20 tobramycin-dexamethasone opth susp ......................... 117 tolazamide oral tablet 250 mg ..................................... 90 tolazamide oral tablet 500 mg ..................................... 90 tolbutamide ....................... 90 tolcapone .......................... 39 tolmetin ............................. 51 tolnaftate topical aerosol powder .............................. 78 tolnaftate topical cream .... 78 tolnaftate topical powder ... 78 tolterodine oral capsule, extended release 24hr ..... 143 tolterodine oral tablet ..... 144 topiramate oral capsule, sprinkle ............................. 38 topiramate oral tablet 100 mg ..................................... 38


192

topiramate oral tablet 200 mg ..................................... 38 topiramate oral tablet 25 mg ..................................... 38 topiramate oral tablet 50 mg ..................................... 38 toposar .............................. 32 topotecan intravenous recon soln ................................... 32 TOPOTECAN INTRAVENOUS SOLUTION ...................... 32 TORISEL .......................... 32 torsemide oral ................... 67 TOTAL ALLERGY MEDICINE ..................... 137 TOUJEO SOLOSTAR ..... 90 TOVIAZ ......................... 144 TRACLEER ................... 143 TRADJENTA ................... 90 tramadol oral tablet .......... 51 tramadol-acetaminophen ... 51 trandolapril ....................... 67 tranexamic acid intravenous ....................... 69 tranexamic acid oral ....... 110 tranylcypromine ................ 60 travasol 10 % .................. 149 TRAVATAN Z ............... 116 TRAVEL SICKNESS (MECLIZINE) ................ 101 trazodone .......................... 60 TREANDA INTRAVENOUS RECON SOLN ................. 32 TRECATOR ..................... 20 TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION ........ 32 TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML, 3.75 MG/2 ML .................. 32 TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML .................................... 33 tretinoin topical cream ..... 74

tretinoin topical gel 0.01 %, 0.025 % ............................. 74 tretinoin (chemotherapy) ... 33 TREXALL ........................ 33 TRI-BIOZENE ................. 75 tri-previfem (28) ............. 112 tri-sprintec (28) .............. 113 triamcinolone acetonide dental ................................ 85 triamcinolone acetonide injection suspension 10 mg/ ml ...................................... 87 triamcinolone acetonide injection suspension 40 mg/ ml ...................................... 87 triamcinolone acetonide topical cream .................... 80 triamcinolone acetonide topical lotion ..................... 80 triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % ........................... 80 TRIAMINIC COLD AND COUGH (PE) .................. 137 TRIAMINIC COLD AND COUGHNT(PE) ............. 137 triamterene- hydrochlorothiazid oral capsule 37.5-25 mg ........... 67 triamterene- hydrochlorothiazid oral tablet ................................. 67 trianex ............................... 80 TRIBENZOR .................... 67 triderm topical cream ....... 80 trifluoperazine .................. 60 trifluridine ....................... 114 trimethoprim ..................... 23 TRINTELLIX ORAL TABLET 10 MG .............. 60 TRINTELLIX ORAL TABLET 20 MG .............. 60 TRINTELLIX ORAL TABLET 5 MG ................ 61 TRIPLE ANTIBIOTIC PLUS ................................ 75 TRIPLE ANTIBIOTIC TOPICAL OINTMENT .... 75

TRIPLE ANTIBIOTIC TOPICAL OINTMENT IN PACKET ........................... 75 TRIPLE ANTIBIOTIC (PRAM) EXTRA .............. 75 TRIPLE ANTIBIOTIC-PAIN RELIEF ............................. 75 TRIPLE PASTE AF ......... 78 TRISENOX ...................... 33 TRIUMEQ ........................ 15 trivora (28) ..................... 113 TROPHAMINE 10 % ..... 149 TROPHAMINE 6% ........ 149 trospium oral tablet ........ 144 TRULICITY ..................... 90 TRUMENBA .................. 106 TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG ..................... 15 TRUVADA ORAL TABLET 200-300 MG ..................... 15 TUMS ............................. 148 TUMS DUAL ACTION (FAMOTIDINE) ............. 103 TUMS E-X ..................... 148 TUMS EXTRA STRENGTH SMOOTHIES ................. 148 TUMS FRESHERS ........ 148 TUMS ULTRA ORAL TABLET,CHEWABLE 400 MG (1,000 MG) .............. 148 TUSICOF ORAL TABLET ......................... 137 TUSNEL C ..................... 137 tusnel diabetic ................. 137 TUSNEL NEW FORMULA ..................... 137 TUSNEL PEDIATRIC .... 137 TUSNEL-DM PEDIATRIC ................... 137 TUSSI PRES-B ORAL LIQUID 4-10-20 MG/5 ML .................................. 137 TUSSI-PRES ORAL LIQUID .......................... 137 TUSSICAPS ................... 137 TUSSIGON .................... 137 TUSSIN .......................... 137


193

TUSSIN CF COUGH- COLD ............................. 137 TUSSIN CF MAX .......... 137 TUSSIN CF (PE-DM- GUAIF) ........................... 137 TUSSIN CHEST CONGESTION ............... 137 TUSSIN COUGH (DM ONLY) ............................ 137 TUSSIN COUGH-CHEST CONGESTION ............... 137 TUSSIN DM CLEAR ..... 138 TUSSIN DM COUGH .... 138 TUSSIN DM COUGH AND CHEST ........................... 138 TUSSIN DM MAX ORAL LIQUID 10-200 MG/5 ML .................................. 138 TUSSIN DM ORAL LIQUID .......................... 138 TUSSIN DM ORAL SYRUP 10-100 MG/5 ML ........... 138 TUSSIN DM ORAL TABLET ......................... 138 TUSSIN EXPECTORANT ........... 138 TUSSIN HONEY ........... 138 TUSSIN MAXIMUM STRENGTH ................... 138 TUSSIN MAXIMUM STRENGTH COUGH .... 138 TUSSIONEX PENNKINETIC ER ................................... 138 TWINRIX (PF) ............... 106 TYBOST ........................... 15 TYGACIL ......................... 21 TYKERB .......................... 33 TYLENOL COLD MULTI- SYMPT NIGHT ORAL LIQUID .......................... 138 TYLOPHEN ..................... 51 TYPHIM VI INTRAMUSCULAR SOLUTION .................... 106 TYPHIM VI INTRAMUSCULAR SYRINGE ....................... 106 TYSABRI ......................... 40

TYZEKA .......................... 15 TYZINE NASAL DROPS 0.05 % ............................... 85 U ULORIC ......................... 107 ULTRA FRESH ............. 116 ULTRA LUBRICANT EYE ................................ 116 ULTRA STRENGTH ANTACID ...................... 148 ULTRA STRENGTH CALCIUM ANTACID .... 148 UNISOM SLEEPGELS ... 138 UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG ................................. 92 UNITUXIN ....................... 33 ursodiol ........................... 102 UVADEX ......................... 72 V VAGISTAT-3 ................. 110 valacyclovir ...................... 15 VALCHLOR .................... 72 valganciclovir ................... 15 valproate sodium .............. 38 valproic acid ..................... 38 valproic acid (as sodium salt) oral solution 250 mg/5 ml ...................................... 38 VALPROIC ACID (AS SODIUM SALT) ORAL SOLUTION 250 MG/5 ML (5 ML), 500 MG/10 ML (10 ML) ................................... 38 valsartan oral tablet 160 mg ..................................... 67 valsartan oral tablet 320 mg ..................................... 67 valsartan oral tablet 40 mg, 80 mg ..................................... 67 valsartan- hydrochlorothiazide .......... 67 VALU-DRYL ALLERGY ORAL CAPSULE .......... 138 VANACOF ..................... 138

VANAHIST PD .............. 138 VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML ....... 23 vancomycin in dextrose 5 % intravenous piggyback 1 gram/ 200 ml ............................... 23 vancomycin in dextrose 5 % intravenous piggyback 500 mg/ 100 ml ............................... 23 VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 750 MG/150 ML .................................... 23 vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg ..................................... 23 VANCOMYCIN INTRAVENOUS RECON SOLN 5 GRAM, 750 MG .................................... 23 vancomycin oral capsule 125 mg ..................................... 23 vancomycin oral capsule 250 mg ..................................... 23 VAPORIZING STEAM ... 138 VAQTA (PF) INTRAMUSCULAR SUSPENSION ................ 106 VAQTA (PF) INTRAMUSCULAR SYRINGE ....................... 106 VARIVAX (PF) .............. 106 VARIZIG ........................ 106 VASCEPA ........................ 71 VECAMYL ...................... 71 VECTIBIX ....................... 33 VEGETABLE LAXATIVE .................... 102 VELCADE ....................... 33 velivet triphasic regimen (28) ................................. 113 VENCLEXTA ORAL TABLET 10 MG .............. 33


194

VENCLEXTA ORAL TABLET 100 MG ............ 33 VENCLEXTA ORAL TABLET 50 MG .............. 33 VENCLEXTA STARTING PACK ............................... 33 venlafaxine oral capsule, extended release 24hr 150 mg ..................................... 61 venlafaxine oral capsule, extended release 24hr 37.5 mg ..................................... 61 venlafaxine oral capsule, extended release 24hr 75 mg ..................................... 61 venlafaxine oral tablet 100 mg ..................................... 61 venlafaxine oral tablet 25 mg ..................................... 61 venlafaxine oral tablet 37.5 mg ..................................... 61 venlafaxine oral tablet 50 mg ..................................... 61 venlafaxine oral tablet 75 mg ..................................... 61 venlafaxine oral tablet extended release 24hr 150 mg ..................................... 61 venlafaxine oral tablet extended release 24hr 37.5 mg ..................................... 61 venlafaxine oral tablet extended release 24hr 75 mg ..................................... 61 VENOFER INTRAVENOUS SOLUTION 100 MG IRON/5 ML, 200 MG IRON/10 ML .................................. 151 VENOFER INTRAVENOUS SOLUTION 50 MG IRON/2.5 ML .................................. 151 VENTAVIS .................... 143 VENTOLIN HFA ........... 143 verapamil intravenous solution ............................. 67 verapamil intravenous syringe .............................. 67

verapamil oral capsule, 24 hr er pellet ct ......................... 67 verapamil oral capsule,ext rel. pellets 24 hr ...................... 67 verapamil oral tablet ........ 67 verapamil oral tablet extended release 120 mg (24 hours) ................................ 67 verapamil oral tablet extended release 120 mg, 180 mg, 240 mg ..................................... 67 VERSACLOZ ................... 61 VESICARE ..................... 144 VICKS CHILDREN'S NYQUIL COLD-C ......... 138 VICKS DAYQUIL COLD- FLU RELIEF .................. 138 VICKS DAYQUIL COUGH .......................... 138 VICKS DAYQUIL MUCUS CONTROL DM .............. 138 VICKS DAYQUIL SEVERE COLD-FLU .................... 138 VICKS NYQUIL COLD/FLU LIQUICAP ..................... 138 VICKS NYQUIL COLD/FLU (CPM) ............................. 138 VICKS NYQUIL COUGH .......................... 138 VICKS NYQUIL NIGHTTIME RELIEF .... 138 VICKS NYQUIL SEVERE COLD-FLU .................... 139 VICKS QLEARQUIL ALLERGY ..................... 139 VICKS QLEARQUIL DAYTIME SINUS ......... 139 VICKS QLEARQUIL NIGHTIME SINUS ........ 139 VICKS QLEARQUIL NIGHTTIME RLF .......... 139 VICKS QLEARQUIL (OXYMETAZOLINE) ..... 85 VICKS SINEX 12- HOUR ............................... 85 VICKS VAPORUB TOPICAL OINTMENT 4.8-1.2-2.6 % ....................................... 72

VICKS VAPOSTEAM .... 139 VICTOZA 2-PAK ............ 90 VICTOZA 3-PAK ............ 90 VIDEX 2 GRAM PEDIATRIC ..................... 16 VIDEX 4 GRAM PEDIATRIC ..................... 16 VIEKIRA PAK ................. 16 VIGAMOX ..................... 113 VIIBRYD ORAL TABLET 10 MG .................................... 61 VIIBRYD ORAL TABLET 20 MG .................................... 61 VIIBRYD ORAL TABLET 40 MG .................................... 61 VIIBRYD ORAL TABLETS, DOSE PACK 10 MG (7)- 20 MG (23) ............................ 61 VIMPAT INTRAVENOUS .............. 38 VIMPAT ORAL SOLUTION ...................... 38 VIMPAT ORAL TABLET 100 MG ............................. 38 VIMPAT ORAL TABLET 150 MG ............................. 38 VIMPAT ORAL TABLET 200 MG ............................. 38 VIMPAT ORAL TABLET 50 MG .................................... 38 vinblastine intravenous solution ............................. 33 VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML .......................... 33 VINCASAR PFS INTRAVENOUS SOLUTION 2 MG/2 ML ....................... 33 vincristine ......................... 33 vinorelbine ........................ 33 VIORELE (28) ............... 113 VIRACEPT ORAL TABLET 250 MG ............................. 16 VIRACEPT ORAL TABLET 625 MG ............................. 16


195

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG .................................... 16 VIRAZOLE ...................... 16 VIREAD ORAL POWDER ......................... 16 VIREAD ORAL TABLET ........................... 16 VIRTUSSIN AC ............. 139 VIRTUSSIN DAC .......... 139 vitamin a and d ................. 73 VITAMIN A AND D DIAPER RASH ............................... 73 VITAMIN C ORAL TABLET 250 MG ........................... 151 VITAMIN D2 ................. 151 vitamin e mixed oral capsule 1,000 unit ........................ 151 vitamin e oral capsule 1,000 unit .................................. 152 VITAMIN E (DL, ACETATE) ORAL CAPSULE 1,000 UNIT ............................... 151 VITAMIN K ..................... 69 VITAMIN K1 INJECTION ...................... 69 VITEKTA ......................... 16 vits a and d-white pet-lanolin topical ointment ................ 73 VOLTAREN GEL TOPICAL GEL 1 % ........................... 51 voriconazole intravenous ... 12 voriconazole oral suspension for reconstitution .............. 12 voriconazole oral tablet 200 mg ..................................... 12 voriconazole oral tablet 50 mg ..................................... 12 VOTRIENT ...................... 33 VPRIV .............................. 92 VRAYLAR ORAL CAPSULE ........................ 61 VRAYLAR ORAL CAPSULE,DOSE PACK ... 61 W WAL-DRYL ALLERGY ..................... 139

WAL-DRYL SEVERE ALLERGY-SINUS ......... 139 WAL-FEX ALLERGY ... 139 WAL-FEX D 12 HOUR ............................. 139 WAL-FINATE ............... 139 WAL-FLU COLD AND SORE THROAT ............. 149 WAL-FLU NIGHT TIME .............................. 139 WAL-FLU SEVERE COLD AND COUGH ................ 139 WAL-FLU SEVERE COLD- COUGH .......................... 139 WAL-ITIN D .................. 139 WAL-ITIN D 12 HOUR ............................. 139 WAL-ITIN ORAL SOLUTION .................... 139 WAL-ITIN ORAL TABLET ......................... 139 WAL-ITIN ORAL TABLET, DISINTEGRATING ....... 139 WAL-MUCIL FIBER .... 102 WAL-PHED 12 HOUR ... 139 WAL-PHED ORAL TABLET 30 MG ............................. 139 WAL-PHED PE .............. 139 WAL-PHED PE NIGHTTIME COLD ............................. 139 WAL-PHED PE SINUS HEADACHE .................. 139 WAL-PHED PE TRIPLE RELIEF ........................... 139 WAL-PROFEN ................ 51 WAL-PROFEN COLD- SINUS ............................. 139 WAL-PROFEN D COLD AND SINUS ................... 139 WAL-PROXEN ................ 51 WAL-SOM (DIPHENHYDRAMINE) ORAL CAPSULE .......... 140 WAL-TAP DM ............... 140 WAL-TUSSIN COUGH .......................... 140 WAL-TUSSIN COUGH AND COLD CF ....................... 140

WAL-TUSSIN DM ........ 140 WAL-TUSSIN MAX STRENGTH COUGH .... 140 WAL-ZAN 150 .............. 103 WAL-ZAN 75 ................ 103 WAL-ZYR D .................. 140 WAL-ZYR (CETIRIZINE) ORAL SOLUTION ........ 140 WAL-ZYR (CETIRIZINE) ORAL TABLET ............. 140 WAL-ZYR (KETOTIFEN) ............... 116 warfarin ............................ 69 WART REMOVER TOPICAL ADHESIVE PATCH, MEDICATED ................... 72 water for irrigation, sterile ................................ 84 WELCHOL ....................... 71 X XALKORI ........................ 33 XARELTO ORAL TABLET 10 MG, 20 MG ................. 69 XARELTO ORAL TABLET 15 MG ............................... 69 XARELTO ORAL TABLETS, DOSE PACK .................... 70 XENAZINE ORAL TABLET 12.5 MG ............................ 40 XENAZINE ORAL TABLET 25 MG ............................... 40 XENICAL ......................... 81 XGEVA ............................ 24 XOLAIR ......................... 143 XOPENEX HFA ............ 143 XTANDI ........................... 33 XULANE ........................ 110 XYREM ............................ 61 Y YELETS ......................... 152 YERVOY ......................... 33 YF-VAX (PF) ................. 106 YONDELIS ...................... 33 Z Z-TUSS AC .................... 140 ZADITOR ....................... 116 zafirlukast ....................... 143


196

zaleplon oral capsule 10 mg ..................................... 61 zaleplon oral capsule 5 mg ..................................... 61 ZALTRAP ........................ 33 ZANOSAR ....................... 33 ZANTAC 75 ................... 103 ZANTAC MAXIMUM STRENGTH ................... 103 zantac oral tablet 150 mg ................................... 103 ZARAH .......................... 113 ZAVESCA ........................ 92 ZEASORB (MICONAZOLE) ............. 78 ZELBORAF ..................... 33 ZEMPLAR INTRAVENOUS .............. 92 zenchent (28) .................. 113 ZENPEP ......................... 102 zenzedi oral tablet 10 mg ... 61 zenzedi oral tablet 5 mg .... 61 ZEPATIER ....................... 16 ZETIA ............................... 71 ZIAGEN ORAL SOLUTION ...................... 16 zidovudine oral capsule .... 16 zidovudine oral syrup ....... 16 zidovudine oral tablet ....... 16 ZIKS ARTHRITIS PAIN RELIEF ............................. 73 zinc chloride intraveneous solution ........................... 148

ZINC OXIDE TOPICAL OINTMENT 20 % ............ 73 ziprasidone hcl oral capsule 20 mg ................................ 62 ziprasidone hcl oral capsule 40 mg ................................ 62 ziprasidone hcl oral capsule 60 mg, 80 mg .................... 62 ZIRGAN ......................... 114 ZODRYL AC 25 ............ 140 ZODRYL AC 30 ............ 140 ZODRYL AC 40 ............ 140 ZODRYL AC 50 ............ 140 ZODRYL AC 60 ............ 140 ZODRYL AC 80 ............ 140 ZODRYL DEC 25 .......... 140 ZODRYL DEC 30 .......... 140 ZODRYL DEC 40 .......... 140 ZODRYL DEC 50 .......... 140 ZODRYL DEC 60 .......... 140 ZODRYL DEC 80 .......... 140 zoledronic acid intravenous recon soln 4 mg ................ 92 zoledronic acid intravenous solution 4 mg/5 ml ............ 92 ZOLINZA ......................... 33 zolmitriptan ....................... 39 zolpidem oral tablet .......... 62 ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML .................................... 92 ZOMIG NASAL ............... 39 zonisamide ........................ 38

ZORTRESS ...................... 33 ZOSTAVAX (PF) .......... 107 zovia 1/35e (28) .............. 113 zovia 1/50e (28) .............. 113 ZYDELIG ......................... 34 ZYKADIA ........................ 34 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG ............................. 62 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG .................................... 62 ZYRTEC ORAL TABLET ......................... 140 ZYTIGA ........................... 34 ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML ............... 21 ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML ............... 21 ZYVOX ORAL SUSPENSION FOR RECONSTITUTION ........ 21


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H0147_16_24596_T_009_SP CMS Approved 09/18/2015 ID del Formulario: 16234 Versión: 15 Publicado 11/01/2016

AVADMKT-0125-16 11.16 SP

formulario (lista de medicamentos) - anthem · de 60 días del medicamento antes de que se realice...

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