formulary (list of drugs) · the drug list (sometimes called a formulary) is a list showing the...

IL_BCCHP_RX_FORMULARY18a Approved 12122017

Formulary (List of Drugs)

Effective Date: 03/01/2019

Member Services: 1-877-860-2837

(TTY/TDD: 711)

| 2

WHEN YOU NEED TO CONTACT MEMBER SERVICES

Our goal is to serve your health care needs through all of life’s changes. If you have any questions, our team stands ready to help.

Call 1-877-860-2837 (TTY/TDD: 711)

We are open 24 hours a day, seven (7) days a week. The call is free.

Website www.bcchpil.com

Blue Cross Community Health Plans • c/o Member Services • P.O. Box 3418 • Scranton, PA 18505 Write

What is the Blue Cross Community Health Plans (the “Plan”) drug list? The drug list (sometimes called a formulary) is a list showing the drugs that can be covered by the plan.

The drugs listed will be covered as long as you:

•••

Have a medical need for them

Fill the medication orders at an in-network pharmacy

Follow the other plan rules

For more information on how to fill your medication orders, please review your Member Handbook.

What will I pay? You do not pay for covered drugs.

Can the drug list change? Yes, it can change. Coverage may change if:

••

A new, less expensive generic drug becomes available

New information about a drug shows it to be unsafe or less effective

You will be told in writing when the drug list does change.

How do I use the drug list? There are two ways to find your drug in the list beginning on page 1.

1. Category

• The list of covered drugs that begins on page 1 gives you information about the drugs covered by

Blue Cross Community Health Plans. If you have trouble finding your drug in the list, turn to the Index

that begins at the back of this book.

The first column of the chart has the name of the drug. Brand name drugs are capitalized (e.g., CIPRO)

and generic drugs are listed in lower-case italics (e.g. ciprofloxacin).

•

- The information in the “Necessary actions, restrictions, or limits on use” column tells you if Blue

Cross Community Health Plans has any rules for covering your drug.

• The drugs are listed in categories, or groups, based on the type of medical conditions they treat.

(For example, drugs used to treat a heart condition are listed under Cardiovascular Agents).

If you know what your drug is used for, look for the group in the drug list.

Then, look under that group for your drug.

••

2. Alphabetical Listing

••

Look for your drug in the back of this book.

Next to your drug, you will see the page number where you can find coverage information.

i

What are generic drugs? A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the brand name drug, but often costs less. The plan covers both brand name drugs and generic drugs.

Are there any limits on my coverage? Added conditions or limits on some covered drugs may include:

• Prior Authorization: You or your doctor may need to get approval before you fill your medication

orders. If you do not get approval, the plan may not cover the drug.

Quantity Limits: For certain drugs, the plan limits the amount that will be covered.

Step Therapy: In some cases, the plan requires you to first try certain drugs before another drug can be

covered. For example, if Drug A and Drug B both treat your medical condition, the plan may not cover

Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.

••

You can find out if your drug has any added conditions or limits by looking at the list that begins on page 1. You will find our contact information below, and the date we last updated the list, on the front and back cover pages.

Does the plan pay for over-the-counter (OTC) drugs? Yes, the plan pays for certain OTC drugs with a valid medication order from your doctor, and you may get those at no cost. Generic products are to be prescribed and given out when available. These products are to be filled at a plan network pharmacy and for quantities up to a 30-day supply.

What if my drug is not on the drug list? Contact Member Services and ask if your drug is covered. If you learn that the plan does not cover your drug, you have two options:

• Talk to your doctor to decide if you should first try a different drug on our list before you request anexception.

Ask Member Services about making an exception to cover your drug. Send in a statement from yourdoctor backing your request. We must decide within 24 hours of getting your doctor’s statement.

•

We usually only approve requests for exceptions if the other drugs included on our list or the added use limits would make your treatment less effective and/or would be harmful to your health.

Which drug categories are not covered by the plan drug list? The following drug categories are not covered by your plan:

•••

•

•

••

•

Anorexia, weight loss, or weight gain drugs

Bulk chemicals

Cosmetic enhancing drugs

Diagnostic agents

Drug Efficacy Study Implementation (DESI)

that are classified as ineffective

Experimental and investigational drugs

Erectile dysfunction drugs prescribed to

treat impotence

Fertility drugs

General anesthetic drugs

Over-the-counter products not otherwise

included on the plan’s drug list

Surgical supply/medical devices

Medications considered “unreasonable,

unnecessary, and/or excessive” according to

the standards of Medicaid, clinical practice

guidelines, and FDA labeling.

••

••

ii

For More Information For more details about your plan’s drug coverage, please review your Member Handbook and other plan

materials.

If you have any questions, please call Member Services at: 1-877-860-2837 (TTY/TDD 711). We are available

24 hours a day, seven (7) days a week.The call is free.

For Language Assistance

Interpreter Services

We can arrange for someone to help you speak with us in any language. These services are free. If your doctor

does not speak your language, we can arrange for a translator to help you. Please call Member Services at the

number above.

Hearing and Vision Problems

For our members with hearing problems, we offer TTY/TDD service free of charge. The line is open 24 hours a

day/seven day a week at 711.

Other Languages and Formats

You can get this document in Spanish, or speak with someone about this information in other languages for

free. Call 1-877-860-2837 (TTY/TDD: 711). The call is free. You can also call Member Services, toll-free, to

request this information in other alternative formats such as Braille, large print and other forms. Call Toll Free:

1-877-860-2837 (TTY/TDD: 711). We are available 24 hours a day, seven (7) days a week. The call is free.

If any information in this Formulary (List of Drugs) is missing or inaccurate, please [email protected]. You can also call Member Services toll-free at: 1-877-860-2837,TTY/TDD 711. The call is free.

iii

2019

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mailorder

2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty3 = Over the Counter Drugs ST = Step Therapy

1

Name of Drug

Tier level Necessary actions,restrictions, or limits onuse

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

(Augmentin)(1)

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

es-600)(1)

amoxicillin & k clavulanate tab 250-125 mg (1)amoxicillin & k clavulanate tab 500-125 mg (Augmentin) (1)amoxicillin & k clavulanate tab 875-125 mg (Augmentin) (1)AMPICILLIN – ampicillin cap 500 mg (2)dicloxacillin sodium cap 250 mg (1)dicloxacillin sodium cap 500 mg (1)PENICILLIN V POTASSIUM – penicillin v potassium for soln

125 mg/5ml(2)

PENICILLIN V POTASSIUM – penicillin v potassium for soln250 mg/5ml

(2)

penicillin v potassium tab 250 mg (1)penicillin v potassium tab 500 mg (1)

CEPHALOSPORINScefaclor cap 250 mg (1)cefaclor cap 500 mg (1)cefadroxil cap 500 mg (1)cefadroxil for susp 250 mg/5ml (1)cefadroxil for susp 500 mg/5ml (1)cefadroxil tab 1 gm (1)

2019



2

Name of Drug


cefdinir cap 300 mg (1)cefdinir for susp 125 mg/5ml (1)cefdinir for susp 250 mg/5ml (1)cefprozil for susp 125 mg/5ml (1)cefprozil for susp 250 mg/5ml (1)cefprozil tab 250 mg (1)cefprozil tab 500 mg (1)ceftriaxone sodium for inj 250 mg (1)ceftriaxone sodium for inj 500 mg (1)ceftriaxone sodium for inj 1 gm (1)ceftriaxone sodium for inj 2 gm (1)cefuroxime axetil tab 250 mg (1)cefuroxime axetil tab 500 mg (1)cephalexin cap 250 mg (Keflex) (1)cephalexin cap 500 mg (Keflex) (1)cephalexin for susp 125 mg/5ml (1)cephalexin for susp 250 mg/5ml (1)

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

TETRACYCLINESdemeclocycline hcl tab 150 mg (1)doxycycline hyclate cap 50 mg (1)doxycycline hyclate cap 100 mg (Vibramycin) (1)doxycycline hyclate tab 20 mg (1)doxycycline hyclate tab 100 mg (1)doxycycline monohydrate cap 50 mg (1)doxycycline monohydrate cap 100 mg (Monodox) (1)

2019



3

Name of Drug


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

FLUOROQUINOLONESciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml)

(Cipro)(1)

ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) (1)ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) (1)ciprofloxacin hcl tab 750 mg (base equiv) (1)levofloxacin oral soln 25 mg/ml (1)levofloxacin tab 250 mg (Levaquin) (1)levofloxacin tab 500 mg (Levaquin) (1)levofloxacin tab 750 mg (Levaquin) (1)SULFADIAZINE – sulfadiazine tab 500 mg (2)

AMINOGLYCOSIDESGENTAMICIN SULFATE PEDIAT – gentamicin sulfate inj 10 mg/

ml(2)

neomycin sulfate tab 500 mg (1)paromomycin sulfate cap 250 mg (1)tobramycin nebu soln 300 mg/5ml (Tobi) (1) PA, QL (56 ampules/56

days), SP

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

2019



4

Name of Drug


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

FUNGAL INFECTIONSfluconazole for susp 10 mg/ml (Diflucan) (1) QL (35 mls/30 days)fluconazole for susp 40 mg/ml (Diflucan) (1) QL (35 mls/30 days)fluconazole tab 50 mg (Diflucan) (1) QL (30 tablets/30 days)fluconazole tab 100 mg (Diflucan) (1) QL (30 tablets/30 days)fluconazole tab 150 mg (Diflucan) (1) QL (30 tablets/30 days)fluconazole tab 200 mg (Diflucan) (1) QL (30 tablets/30 days)flucytosine cap 250 mg (Ancobon) (1)flucytosine cap 500 mg (Ancobon) (1)griseofulvin microsize susp 125 mg/5ml (1)griseofulvin microsize tab 500 mg (1)griseofulvin ultramicrosize tab 125 mg (Gris-peg) (1)griseofulvin ultramicrosize tab 250 mg (Gris-peg) (1)itraconazole cap 100 mg (Sporanox) (1) QL (120 capsules/30 days)NOXAFIL – posaconazole tab delayed release 100 mg (2) PANOXAFIL – posaconazole susp 40 mg/ml (2) PAnystatin tab 500000 unit (1)terbinafine hcl tab 250 mg (Lamisil) (1) QL (90 tablets/365 days)voriconazole for susp 40 mg/ml (Vfend) (1) PAvoriconazole tab 50 mg (Vfend) (1) PAvoriconazole tab 200 mg (Vfend) (1) PA

VIRAL INFECTIONSCytomegalovirusvalganciclovir hcl tab 450 mg (base equivalent) (Valcyte) (1)

HepatitisBARACLUDE – entecavir oral soln 0.05 mg/ml (2)entecavir tab 0.5 mg (Baraclude) (1)entecavir tab 1 mg (Baraclude) (1)lamivudine tab 100 mg (hbv) (Epivir hbv) (1)ribavirin cap 200 mg (Rebetol) (1) SPSOFOSBUVIR/VELPATASVIR – sofosbuvir-velpatasvir tab

400-100 mg(2) PA, SP

SOVALDI – sofosbuvir tab 400 mg (2) PA, SP

2019



5

Name of Drug


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

HIV/AIDSabacavir sulfate soln 20 mg/ml (base equiv) (Ziagen) (1) QL (960 mls/30 days)abacavir sulfate tab 300 mg (base equiv) (Ziagen) (1) QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg (Epzicom) (1) QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg

(Trizivir)(1) QL (60 tablets/30 days)

APTIVUS – tipranavir cap 250 mg (2) QL (120 capsules/30 days)APTIVUS – tipranavir oral soln 100 mg/ml (2) QL (4 bottles/30 days)atazanavir sulfate cap 150 mg (base equiv) (Reyataz) (1) QL (30 capsules/30 days)atazanavir sulfate cap 200 mg (base equiv) (Reyataz) (1) QL (60 capsules/30 days)atazanavir sulfate cap 300 mg (base equiv) (Reyataz) (1) QL (30 capsules/30 days)ATRIPLA – efavirenz-emtricitabine-tenofovir df tab

600-200-300 mg(2) QL (30 tablets/30 days)

CRIXIVAN – indinavir sulfate cap 200 mg (2) QL (270 capsules/30 days)CRIXIVAN – indinavir sulfate cap 400 mg (2) QL (180 capsules/30 days)DESCOVY – emtricitabine-tenofovir alafenamide fumarate tab

200-25 mg(2) QL (30 tablets/30 days)

didanosine delayed release capsule 200 mg (Videx ec) (1) QL (30 capsules/30 days)didanosine delayed release capsule 250 mg (Videx ec) (1) QL (30 capsules/30 days)didanosine delayed release capsule 400 mg (Videx ec) (1) QL (30 capsules/30 days)EDURANT – rilpivirine hcl tab 25 mg (base equivalent) (2) QL (30 tablets/30 days)efavirenz cap 50 mg (Sustiva) (1) QL (90 capsules/30 days)efavirenz cap 200 mg (Sustiva) (1) QL (60 capsules/30 days)efavirenz tab 600 mg (Sustiva) (1) QL (30 tablets/30 days)EMTRIVA – emtricitabine caps 200 mg (2) QL (30 capsules/30 days)EMTRIVA – emtricitabine soln 10 mg/ml (2) QL (720 mls/30 days)fosamprenavir calcium tab 700 mg (base equiv) (Lexiva) (1) QL (120 tablets/30 days)GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg(2) QL (30 tablets/30 days)

2019



6

Name of Drug


INTELENCE – etravirine tab 25 mg (2) QL (120 tablets/30 days)INTELENCE – etravirine tab 100 mg (2) QL (60 tablets/30 days)INTELENCE – etravirine tab 200 mg (2) QL (60 tablets/30 days)INVIRASE – saquinavir mesylate cap 200 mg (2) QL (300 capsules/30 days)INVIRASE – saquinavir mesylate tab 500 mg (2) QL (120 tablets/30 days)ISENTRESS – raltegravir potassium packet for susp 100 mg

(base equiv)(2) QL (60 packets/30 days)

ISENTRESS – raltegravir potassium tab 400 mg (base equiv) (2) QL (60 tablets/30 days)ISENTRESS – raltegravir potassium chew tab 25 mg (base

equiv)(2) QL (180 tablets/30 days)

ISENTRESS – raltegravir potassium chew tab 100 mg (baseequiv)

(2) QL (180 tablets/30 days)

ISENTRESS HD – raltegravir potassium tab 600 mg (base equiv) (2) QL (60 tablets/30 days), 90KALETRA – lopinavir-ritonavir tab 100-25 mg (2) QL (180 tablets/30 days)KALETRA – lopinavir-ritonavir tab 200-50 mg (2) QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml (Epivir) (1) QL (4 bottles/30 days)lamivudine tab 150 mg (Epivir) (1) QL (30 tablets/30 days)lamivudine tab 300 mg (Epivir) (1) QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg (Combivir) (1) QL (60 tablets/30 days)LEXIVA – fosamprenavir calcium susp 50 mg/ml (base equiv) (2) QL (8 bottles/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) (Kaletra) (1) QL (480 mls/30 days)nevirapine susp 50 mg/5ml (Viramune) (1) QL (1200 mls/30 days)nevirapine tab er 24hr 100 mg (Viramune xr) (1) QL (90 tablets/30 days)nevirapine tab er 24hr 400 mg (Viramune xr) (1) QL (30 tablets/30 days)nevirapine tab 200 mg (Viramune) (1) QL (60 tablets/30 days)NORVIR – ritonavir oral soln 80 mg/ml (2) QL (2 bottles/30 days)PREZISTA – darunavir ethanolate susp 100 mg/ml (base equiv) (2) QL (2 bottles/30 days)PREZISTA – darunavir ethanolate tab 75 mg (base equiv) (2) QL (300 tablets/30 days)PREZISTA – darunavir ethanolate tab 150 mg (base equiv) (2) QL (180 tablets/30 days)PREZISTA – darunavir ethanolate tab 600 mg (base equiv) (2) QL (60 tablets/30 days)PREZISTA – darunavir ethanolate tab 800 mg (base equiv) (2) QL (30 tablets/30 days)RESCRIPTOR – delavirdine mesylate tab 200 mg (2) QL (180 tablets/30 days)REYATAZ – atazanavir sulfate oral powder packet 50 mg (base

equiv)(2) QL (240 packets/30 days)

ritonavir tab 100 mg (Norvir) (1) QL (180 tablets/30 days)SELZENTRY – maraviroc tab 25 mg (2) QL (240 tablets/30 days)

2019



7

Name of Drug


SELZENTRY – maraviroc tab 75 mg (2) QL (60 tablets/30 days)SELZENTRY – maraviroc tab 300 mg (2) QL (120 tablets/30 days)stavudine cap 15 mg (Zerit) (1) QL (60 capsules/30 days)stavudine cap 20 mg (Zerit) (1) QL (60 capsules/30 days)stavudine cap 30 mg (Zerit) (1) QL (60 capsules/30 days)stavudine cap 40 mg (Zerit) (1) QL (60 capsules/30 days)tenofovir disoproxil fumarate tab 300 mg (Viread) (1) QL (30 tablets/30 days)TIVICAY – dolutegravir sodium tab 10 mg (base equiv) (2) QL (60 tablets/30 days)TIVICAY – dolutegravir sodium tab 25 mg (base equiv) (2) QL (60 tablets/30 days)TIVICAY – dolutegravir sodium tab 50 mg (base equiv) (2) QL (60 tablets/30 days)TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab

100-150 mg(2) QL (30 tablets/30 days)

TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab133-200 mg






VIDEX – didanosine for soln 2 gm (2) QL (1200 mls/30 days)VIDEX – didanosine for soln 4 gm (2) QL (1200 mls/30 days)VIRACEPT – nelfinavir mesylate tab 250 mg (2) QL (270 tablets/30 days)VIRACEPT – nelfinavir mesylate tab 625 mg (2) QL (120 tablets/30 days)VIREAD – tenofovir disoproxil fumarate oral powder 40 mg/gm (2) QL (4 bottles/30 days)VIREAD – tenofovir disoproxil fumarate tab 150 mg (2) QL (30 tablets/30 days)VIREAD – tenofovir disoproxil fumarate tab 200 mg (2) QL (30 tablets/30 days)VIREAD – tenofovir disoproxil fumarate tab 250 mg (2) QL (30 tablets/30 days)zidovudine cap 100 mg (Retrovir) (1) QL (180 capsules/30 days)zidovudine syrup 10 mg/ml (Retrovir) (1) QL (8 bottles/30 days)zidovudine tab 300 mg (1) QL (60 tablets/30 days)

Influenzaoseltamivir phosphate cap 30 mg (base equiv) (Tamiflu) (1) QL (20 capsules/120 days)oseltamivir phosphate cap 45 mg (base equiv) (Tamiflu) (1) QL (20 capsules/120 days)oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu) (1) QL (20 capsules/120 days)oseltamivir phosphate for susp 6 mg/ml (base equiv) (Tamiflu) (1) QL (360 mls/120 days)RELENZA DISKHALER – zanamivir aero powder breath

activated 5 mg/blister(2) QL (40 blisters/120 days)

MALARIA

2019



8

Name of Drug


atovaquone-proguanil hcl tab 62.5-25 mg (Malarone) (1) QL (30 tablets/90 days)atovaquone-proguanil hcl tab 250-100 mg (Malarone) (1) QL (30 tablets/90 days)CHLOROQUINE PHOSPHATE – chloroquine phosphate tab

250 mg(2)

chloroquine phosphate tab 500 mg (1)DARAPRIM – pyrimethamine tab 25 mg (2) PA, QL (90 tablets/30 days)hydroxychloroquine sulfate tab 200 mg (Plaquenil) (1)MEFLOQUINE HCL – mefloquine hcl tab 250 mg (2)primaquine phosphate tab 26.3 mg (15 mg base) (Primaquine

phosphate)(1)

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

OTHER ANTI-INFECTIVESatovaquone susp 750 mg/5ml (Mepron) (1)clindamycin hcl cap 75 mg (Cleocin) (1)clindamycin hcl cap 150 mg (Cleocin) (1)clindamycin hcl cap 300 mg (Cleocin) (1)clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)

(Cleocin pediatric gr)(1)

dapsone tab 25 mg (1)dapsone tab 100 mg (1)linezolid for susp 100 mg/5ml (Zyvox) (1) QL (600 mls/180 days)linezolid tab 600 mg (Zyvox) (1) QL (56 tablets/180 days)metronidazole cap 375 mg (Flagyl) (1)metronidazole tab 250 mg (Flagyl) (1)metronidazole tab 500 mg (Flagyl) (1)sulfamethoxazole-trimethoprim susp 200-40 mg/5ml (1)sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim) (1)sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds) (1)trimethoprim tab 100 mg (1)vancomycin hcl cap 125 mg (base equivalent) (Vancocin hcl) (1)vancomycin hcl cap 250 mg (base equivalent) (Vancocin hcl) (1)

2019



9

Name of Drug


XIFAXAN – rifaximin tab 200 mg (2) PA, QL (9 tablets/30 days)XIFAXAN – rifaximin tab 550 mg (2) PA, QL (60 tablets/30 days)ZYVOX – linezolid for susp 100 mg/5ml (2) QL (4 bottles/180 days)

IMMUNIZING AGENTSADACEL – tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-

mcg/0.5ml(2)

AFLURIA QUADRIVALENT 2018 – influenza virus vaccine splitquadrivalent im inj

(2)

AFLURIA 2018-2019 – influenza virus vaccine split im susp (2)BOOSTRIX – tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-

mcg/0.5ml(2)

ENGERIX-B – hepatitis b vaccine (recombinant) susp10 mcg/0.5ml

(2)

ENGERIX-B – hepatitis b vaccine (recombinant) susp 20 mcg/ml (2)ENGERIX-B – hepatitis b vaccine (recombinant) 10 mcg/0.5ml (2)ENGERIX-B – hepatitis b vaccine (recombinant) 20 mcg/ml (2)FLUARIX QUADRIVALENT 2018 – influenza virus vac split

quadrivalent susp pref syr 0.5ml(2)

FLUCELVAX QUADRIVALENT 20 – influenza vac tiss-cult subuntquad susp pref syr 0.5 ml

(2)

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

(2)

FLUZONE HIGH-DOSE PF 2018 – influenza virus vac split high-dose pf susp pref syr 0.5ml

(2)

FLUZONE QUADRIVALENT 2018 – influenza virus vac splitquadrivalent susp pref syr 0.25 ml

(2)

HEPLISAV-B – hepatitis b vaccine recomb adjuvanted pref syr20 mcg/0.5ml

(2)

HEPLISAV-B – hepatitis b vaccine recombinant adjuvanted20 mcg/0.5ml

(2)

IMOVAX RABIES (H.D.C.V.) – rabies virus vaccine, hdc inj (2)PNEUMOVAX 23 – pneumococcal vaccine polyvalent inj

25 mcg/0.5ml(2)

PNEUMOVAX 23/1 DOSE – pneumococcal vaccine polyvalent inj25 mcg/0.5ml

(2)

RABAVERT – rabies vaccine, pcec for inj (2)RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml(2)

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

(2)

2019



10

Name of Drug


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

(2)

SHINGRIX – zoster vac recombinant adjuvanted for im inj50 mcg/0.5ml

(2) QL (2 vaccines/1 lifetime)

SYNAGIS – palivizumab im soln 50 mg/0.5ml (2) PA, SPSYNAGIS – palivizumab im soln 100 mg/ml (2) PA, SPZOSTAVAX – zoster vaccine live for subcutaneous susp 19400

unit/0.65ml(2) QL (1 vaccine/1 lifetime)

CANCER DRUGSabiraterone acetate tab 250 mg (Zytiga) (1) PA, QL (120

tablets/30 days), SPACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml

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

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

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

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

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

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



ALKERAN – melphalan tab 2 mg (2) SPanastrozole tab 1 mg (Arimidex) (1) 90bexarotene cap 75 mg (Targretin) (1) PA, SPbicalutamide tab 50 mg (Casodex) (1)BRAFTOVI – encorafenib cap 50 mg (2) PA, QL (180

capsules/30 days), SPBRAFTOVI – encorafenib cap 75 mg (2) PA, QL (180

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

days), SPcapecitabine tab 150 mg (Xeloda) (1) PA, SPcapecitabine tab 500 mg (Xeloda) (1) PA, SP

2019



11

Name of Drug


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

cyclophosphamide cap 25 mg (Cyclophosphamide) (1)cyclophosphamide cap 50 mg (Cyclophosphamide) (1)CYTARABINE – cytarabine inj 20 mg/ml (2)ERLEADA – apalutamide tab 60 mg (2) PA, QL (120

tablets/30 days), SPETOPOSIDE – etoposide cap 50 mg (2) SPexemestane tab 25 mg (Aromasin) (1) 90flutamide cap 125 mg (1)hydroxyurea cap 500 mg (Hydrea) (1)IBRANCE – palbociclib cap 75 mg (2) PA, QL (21 capsules/28

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

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

days), SPimatinib mesylate tab 100 mg (base equivalent) (Gleevec) (1) PA, QL (90 tablets/30

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

days), SPIMBRUVICA – ibrutinib cap 70 mg (2) PA, QL (30 capsules/30

days), SPIMBRUVICA – ibrutinib cap 140 mg (2) PA, QL (120

capsules/30 days), SPIMBRUVICA – ibrutinib tab 140 mg (2) PA, QL (30 tablets/30

days), SPIMBRUVICA – ibrutinib tab 280 mg (2) PA, QL (30 tablets/30



days), SPKISQALI – ribociclib succinate tab 200 mg (base equiv) (2) PA, QL (63 tablets/28

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

tab 2.5 mg therapy pack(2) PA, QL (91 tablets/28

days), SP

2019



12

Name of Drug


KISQALI FEMARA 400 DOSE – ribociclib tab 200 mg & letrozoletab 2.5 mg therapy pack

(2) PA, QL (91 tablets/28days), SP

KISQALI FEMARA 600 DOSE – ribociclib tab 200 mg & letrozoletab 2.5 mg therapy pack

(2) PA, QL (91 tablets/28days), SP

LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapy pack10 mg (10 mg daily dose)

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

LENVIMA 12MG DAILY DOSE – lenvatinib cap therapy pack 4(3) mg (12 mg daily dose)


LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy pack 10& 4 mg (14 mg daily dose)


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


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


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


LENVIMA 4 MG DAILY DOSE – lenvatinib cap therapy pack4 mg (4 mg daily dose)


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


letrozole tab 2.5 mg (Femara) (1) 90LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg (2)LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg (2)leucovorin calcium tab 5 mg (1)leucovorin calcium tab 25 mg (1)LEUKERAN – chlorambucil tab 2 mg (2) SPLUPRON DEPOT (1-MONTH) – leuprolide acetate for inj kit

3.75 mg(2) PA, SP

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

(2) PA, SP

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

(2) PA, SP

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

(2) PA, SP

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

(2) PA, SP

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

(2) PA, SP

2019



13

Name of Drug


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

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

megestrol acetate susp 40 mg/ml (1)megestrol acetate tab 20 mg (1)megestrol acetate tab 40 mg (1)MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg (base

equivalent)(2) PA, QL (90 tablets/30

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

equivalent)(2) PA, QL (30 tablets/30

days), SPMEKTOVI – binimetinib tab 15 mg (2) PA, QL (180

tablets/30 days), SPmelphalan tab 2 mg (Alkeran) (1) SPmercaptopurine tab 50 mg (1)METHOTREXATE SODIUM – methotrexate sodium inj

250 mg/10ml (25 mg/ml)(2)

methotrexate sodium tab 2.5 mg (base equiv) (1)MYLERAN – busulfan tab 2 mg (2) SPNERLYNX – neratinib maleate tab 40 mg (base equivalent) (2) PA, QL (180

tablets/30 days), SPNEXAVAR – sorafenib tosylate tab 200 mg (base equivalent) (2) PA, QL (120

tablets/30 days), SPRUBRACA – rucaparib camsylate tab 200 mg (base equivalent) (2) PA, QL (120



tablets/30 days), SPRYDAPT – midostaurin cap 25 mg (2) PA, QL (240

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

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

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

days), SP

2019



14

Name of Drug


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



STIVARGA – regorafenib tab 40 mg (2) PA, QL (84 tablets/28days), SP

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

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

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

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

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

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

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

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

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

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

capsules/30 days), SPtemozolomide cap 5 mg (Temodar) (1) PA, SPtemozolomide cap 20 mg (Temodar) (1) PA, SPtemozolomide cap 100 mg (Temodar) (1) PA, SPtemozolomide cap 140 mg (Temodar) (1) PA, SPtemozolomide cap 180 mg (Temodar) (1) PA, SPtemozolomide cap 250 mg (Temodar) (1) PA, SPTIBSOVO – ivosidenib tab 250 mg (2) PA, QL (60 tablets/30

days), SP

2019



15

Name of Drug


tretinoin cap 10 mg (1) PA, SPVENCLEXTA – venetoclax tab 10 mg (2) PA, QL (60 tablets/30

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

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

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

pack 10 & 50 & 100 mg(2) PA, QL (1 pack/180 days), SP

VERZENIO – abemaciclib tab 50 mg (2) PA, QL (60 tablets/30days), SP




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

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

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

XTANDI – enzalutamide cap 40 mg (2) PA, QL (120capsules/30 days), SP

YONSA – abiraterone acetate tab 125 mg (2) PA, QL (120tablets/30 days), SP

ZELBORAF – vemurafenib tab 240 mg (2) PA, QL (240tablets/30 days), SP

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

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

HORMONES, DIABETES AND RELATED DRUGSCORTICOSTEROIDSbudesonide delayed release particles cap 3 mg (Entocort ec) (1)CORTISONE ACETATE – cortisone acetate tab 25 mg (2)DEXAMETHASONE – dexamethasone soln 0.5 mg/5ml (2)

2019



16

Name of Drug


dexamethasone elixir 0.5 mg/5ml (1)dexamethasone tab 0.5 mg (1)dexamethasone tab 0.75 mg (1)dexamethasone tab 1.5 mg (1)dexamethasone tab 4 mg (1)dexamethasone tab 6 mg (1)fludrocortisone acetate tab 0.1 mg (1) 90hydrocortisone tab 5 mg (Cortef) (1)hydrocortisone tab 10 mg (Cortef) (1)hydrocortisone tab 20 mg (Cortef) (1)methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak) (1)methylprednisolone tab 4 mg (Medrol) (1)methylprednisolone tab 8 mg (Medrol) (1)methylprednisolone tab 16 mg (Medrol) (1)methylprednisolone tab 32 mg (Medrol) (1)PREDNISOLONE – prednisolone syrup 15 mg/5ml (usp solution

equivalent)(2)

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

(1)

prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) (1)PREDNISONE – prednisone tab 50 mg (2)PREDNISONE – prednisone oral soln 5 mg/5ml (2)prednisone tab 1 mg (1)prednisone tab 2.5 mg (1)prednisone tab 5 mg (1)prednisone tab 10 mg (1)prednisone tab 20 mg (1)

MALE HORMONESdanazol cap 50 mg (1)danazol cap 100 mg (1)danazol cap 200 mg (1)testosterone cypionate im inj in oil 100 mg/ml (Depo-

testosterone)(1) PA, QL (10 mls/28 days)

testosterone cypionate im inj in oil 200 mg/ml (Depo-testosterone)

(1) PA, QL (10 mls/28 days)

testosterone enanthate im inj in oil 200 mg/ml (1) PA, QL (1 vial/28 days)

2019



17

Name of Drug


ESTROGENSCOMBIPATCH – estradiol-norethindrone ace td pttw

0.05-0.14 mg/day(2) 90

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

(2) 90

estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella) (1) 90estradiol & norethindrone acetate tab 1-0.5 mg (Activella) (1) 90estradiol tab 0.5 mg (Estrace) (1) 90estradiol tab 1 mg (Estrace) (1) 90estradiol tab 2 mg (Estrace) (1) 90estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot) (1) QL (8 patches/30 days), 90estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot) (1) QL (8 patches/30 days), 90estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot) (1) QL (8 patches/30 days), 90estradiol td patch twice weekly 0.075 mg/24hr (Vivelle-dot) (1) QL (8 patches/30 days), 90estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-dot) (1) QL (8 patches/30 days), 90estradiol td patch weekly 0.025 mg/24hr (Climara) (1) QL (4 patches/30 days), 90estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)

(Climara)(1) QL (4 patches/30 days), 90

estradiol td patch weekly 0.05 mg/24hr (Climara) (1) QL (4 patches/30 days), 90estradiol td patch weekly 0.06 mg/24hr (Climara) (1) QL (4 patches/30 days), 90estradiol td patch weekly 0.075 mg/24hr (Climara) (1) QL (4 patches/30 days), 90estradiol td patch weekly 0.1 mg/24hr (Climara) (1) QL (4 patches/30 days), 90ESTROPIPATE – estropipate tab 1.5 mg (2) 90norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg (1) 90PREMPRO – conjugated estrogen-medroxyprogest acetate tab

0.3-1.5 mg(2) 90

PREMPRO – conjugated estrogen-medroxyprogest acetate tab0.45-1.5 mg

(2) 90

PREMPRO – conjugated estrogen-medroxyprogest acetate tab0.625-5 mg

(2) 90

PROGESTINSmedroxyprogesterone acetate tab 2.5 mg (Provera) (1) 90medroxyprogesterone acetate tab 5 mg (Provera) (1) 90medroxyprogesterone acetate tab 10 mg (Provera) (1) 90megestrol acetate susp 625 mg/5ml (Megace es) (1) 90norethindrone acetate tab 5 mg (Aygestin) (1) 90progesterone im in oil 50 mg/ml (1)

2019



18

Name of Drug


progesterone micronized cap 100 mg (Prometrium) (1) 90progesterone micronized cap 200 mg (Prometrium) (1) 90

BIRTH CONTROLdesogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)

(Mircette)(1) QL (28 tablets/21 days), 90

desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen) (1) QL (28 tablets/21 days), 90drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28) (1) QL (28 tablets/21 days), 90ELLA – ulipristal acetate tab 30 mg (2)ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg (1) QL (28 tablets/21 days), 90KYLEENA – levonorgestrel releasing iud 17.5 mcg/day (19.5 mg

total)(2)

levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg (1) QL (28 tablets/21 days), 90levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg (1) QL (28 tablets/21 days), 90levonorgestrel tab 1.5 mg (1)levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg (1) QL (28 tablets/21 days), 90medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera

contrac)(1) QL, 90

MIRENA – levonorgestrel releasing iud 20 mcg/day (52 mg total) (2)NEXPLANON – etonogestrel subdermal implant 68 mg (2)norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin

1/20-21)(1) QL (28 tablets/21 days), 90

norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg(Loestrin 1.5/30-21)

(1) QL (28 tablets/21 days), 90

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


norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Ortho-cyclen)


norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg(Ortho tri-cyclen lo)


norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg(Ortho tri-cyclen)


NUVARING – etonogestrel-ethinyl estradiol va ring0.120-0.015 mg/24hr

(2) QL (1 ring/21 days), 90

PARAGARD INTRAUTERINE COP – copper iud (2)PLAN B ONE-STEP – levonorgestrel tab 1.5 mg (2)SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5 mg total) (2)XULANE – norelgestromin-ethinyl estradiol td ptwk

150-35 mcg/24hr(2) QL (3 patches/21 days), 90

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

(2) PA, SP

2019



19

Name of Drug



(2) PA, SP

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

(2) PA, SP

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

(2) PA, SP

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

(2) PA, SP

DIABETESacarbose tab 25 mg (Precose) (1) QL (180 tablets/30 days), 90acarbose tab 50 mg (Precose) (1) QL (180 tablets/30 days), 90acarbose tab 100 mg (Precose) (1) QL (90 tablets/30 days), 90ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (base equiv) (2) QL (30 tablets/30

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

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

days), ST, 90ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab

12.5-500 mg(2) QL (60 tablets/30

days), ST, 90ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab

12.5-1000 mg(2) QL (60 tablets/30

days), ST, 90ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab

12.5-15 mg(2) QL (30 tablets/30


12.5-30 mg(2) QL (30 tablets/30


12.5-45 mg(2) QL (30 tablets/30


25-15 mg(2) QL (30 tablets/30


25-30 mg(2) QL (30 tablets/30


25-45 mg(2) QL (30 tablets/30

days), ST, 90glimepiride tab 1 mg (Amaryl) (1) QL (60 tablets/30 days), 90glimepiride tab 2 mg (Amaryl) (1) QL (60 tablets/30 days), 90glimepiride tab 4 mg (Amaryl) (1) QL (60 tablets/30 days), 90glipizide tab er 24hr 2.5 mg (Glucotrol xl) (1) QL (60 tablets/30 days), 90glipizide tab er 24hr 5 mg (Glucotrol xl) (1) QL (90 tablets/30 days), 90

2019



20

Name of Drug


glipizide tab er 24hr 10 mg (Glucotrol xl) (1) QL (60 tablets/30 days), 90glipizide tab 5 mg (Glucotrol) (1) QL (120 tablets/30 days), 90glipizide tab 10 mg (Glucotrol) (1) QL (120 tablets/30 days), 90GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj kit 1 mg (2) QL (6 pens/365 days)glyburide micronized tab 1.5 mg (Glynase) (1) QL (120 tablets/30 days), 90glyburide micronized tab 3 mg (Glynase) (1) QL (60 tablets/30 days), 90glyburide micronized tab 6 mg (Glynase) (1) QL (60 tablets/30 days), 90glyburide tab 1.25 mg (1) QL (60 tablets/30 days), 90glyburide tab 2.5 mg (1) QL (60 tablets/30 days), 90glyburide tab 5 mg (1) QL (120 tablets/30 days), 90glyburide-metformin tab 1.25-250 mg (1) QL (120 tablets/30 days), 90glyburide-metformin tab 2.5-500 mg (Glucovance) (1) QL (120 tablets/30 days), 90glyburide-metformin tab 5-500 mg (Glucovance) (1) QL (120 tablets/30 days), 90metformin hcl tab er 24hr 500 mg (Glucophage xr) (1) QL (120 tablets/30 days), 90metformin hcl tab er 24hr 750 mg (Glucophage xr) (1) QL (60 tablets/30 days), 90metformin hcl tab 500 mg (Glucophage) (1) QL (120 tablets/30 days), 90metformin hcl tab 850 mg (Glucophage) (1) QL (90 tablets/30 days), 90metformin hcl tab 1000 mg (Glucophage) (1) QL (60 tablets/30 days), 90nateglinide tab 60 mg (Starlix) (1) QL (120 tablets/30 days), 90nateglinide tab 120 mg (Starlix) (1) QL (90 tablets/30 days), 90pioglitazone hcl tab 15 mg (base equiv) (Actos) (1) QL (30 tablets/30 days), 90pioglitazone hcl tab 30 mg (base equiv) (Actos) (1) QL (30 tablets/30 days), 90pioglitazone hcl tab 45 mg (base equiv) (Actos) (1) QL (30 tablets/30 days), 90STEGLATRO – ertugliflozin l-pyroglutamic acid tab 5 mg (base

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

STEGLATRO – ertugliflozin l-pyroglutamic acid tab 15 mg (baseequiv)

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

TOLAZAMIDE – tolazamide tab 250 mg (2) QL (90 tablets/30 days), 90TRULICITY – dulaglutide soln pen-injector 0.75 mg/0.5ml (2) QL (4 pens/28 days), STTRULICITY – dulaglutide soln pen-injector 1.5 mg/0.5ml (2) QL (4 pens/28 days), STVICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) (2) QL (3 pens/30 days), ST

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

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

2019



21

Name of Drug


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

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

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

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

(2) QL (45 mls/30 days), 90

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

(2) QL (45 mls/30 days), 90

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

(2) QL (45 mls/30 days), 90

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

pen-injector 100 unit/ml(2) QL (45 mls/30 days), 90

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

(2) QL (45 mls/30 days), 90

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

(2) QL (45 mls/30 days), 90

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


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

(2) QL (45 mls/30 days), 90

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

(2) QL (45 mls/30 days), 90

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

(2) QL (45 mls/30 days), 90

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

(2) QL (45 mls/30 days), 90

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

(2) QL (45 mls/30 days), 90

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

(2) QL (45 mls/30 days), 90

Basal InsulinsBASAGLAR KWIKPEN – insulin glargine soln pen-injector 100


THYROID REGULATIONlevothyroxine sodium tab 25 mcg (Synthroid) (1) 90

2019



22

Name of Drug


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

GROWTH HORMONEOMNITROPE – somatropin for inj 5.8 mg (2) PA, SP

OTHER HORMONES AND RELATED DRUGSALENDRONATE SODIUM – alendronate sodium tab 40 mg (2) QL (30 tablets/30 days)alendronate sodium tab 5 mg (1) QL (30 tablets/30 days), 90alendronate sodium tab 10 mg (1) QL (30 tablets/30 days), 90alendronate sodium tab 35 mg (1) QL (4 tablets/28 days), 90alendronate sodium tab 70 mg (Fosamax) (1) QL (4 tablets/28 days), 90cabergoline tab 0.5 mg (1)calcitonin (salmon) nasal soln 200 unit/act (1) 90calcitriol cap 0.25 mcg (Rocaltrol) (1) 90calcitriol cap 0.5 mcg (Rocaltrol) (1) 90calcitriol oral soln 1 mcg/ml (Rocaltrol) (1) 90desmopressin acetate nasal spray soln 0.01% (Ddavp) (1)desmopressin acetate nasal spray soln 0.01% (refrigerated) (1)

2019



23

Name of Drug


desmopressin acetate tab 0.1 mg (Ddavp) (1) 90desmopressin acetate tab 0.2 mg (Ddavp) (1) 90KANUMA – sebelipase alfa iv soln 20 mg/10ml (2 mg/ml) (2) PA, SPlevocarnitine oral soln 1 gm/10ml (10%) (Carnitor) (1) 90levocarnitine tab 330 mg (Carnitor) (1) 90LUPRON DEPOT-PED (1-MONTH – leuprolide acetate for inj

pediatric kit 7.5 mg(2) PA, SP


(2) PA, SP

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

(2) PA, SP

methylergonovine maleate tab 0.2 mg (1)NITYR – nitisinone tab 2 mg (2) PA, SPNITYR – nitisinone tab 5 mg (2) PA, SPNITYR – nitisinone tab 10 mg (2) PA, SPoctreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin) (1) PA, QL (90 mls/30 days), SPoctreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin) (1) PA, QL (90 mls/30 days), SPoctreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin) (1) PA, QL (90 mls/30 days), SPoctreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin) (1) PA, QL (30 vials/30 days), SPoctreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin) (1) PA, QL (30 vials/30 days), SPraloxifene hcl tab 60 mg (Evista) (1) 90SENSIPAR – cinacalcet hcl tab 30 mg (base equiv) (2) PASENSIPAR – cinacalcet hcl tab 60 mg (base equiv) (2) PASENSIPAR – cinacalcet hcl tab 90 mg (base equiv) (2) PASTIMATE – desmopressin acetate nasal soln 1.5 mg/ml (2)STRENSIQ – asfotase alfa subcutaneous inj 18 mg/0.45ml (2) PA, SPSTRENSIQ – asfotase alfa subcutaneous inj 28 mg/0.7ml (2) PA, SPSTRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml (2) PA, SPSTRENSIQ – asfotase alfa subcutaneous inj 80 mg/0.8ml (2) PA, SPTYMLOS – abaloparatide subcutaneous soln pen-injector

3120 mcg/1.56ml(2) PA, QL (1 pen/30 days), SP

HEART AND CIRCULATORY DRUGSANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIONSbenazepril & hydrochlorothiazide tab 5-6.25 mg (1) 90benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) (1) 90benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct) (1) 90

2019



24

Name of Drug


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

hydrochlorothiazide tab 25-15 mg(2) 90

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

(2) 90


(2) 90


(2) 90

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg (1) 90enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic) (1) 90enalapril maleate tab 2.5 mg (Vasotec) (1) 90enalapril maleate tab 5 mg (Vasotec) (1) 90enalapril maleate tab 10 mg (Vasotec) (1) 90enalapril maleate tab 20 mg (Vasotec) (1) 90fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg (1) 90fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg (1) 90fosinopril sodium tab 10 mg (1) 90fosinopril sodium tab 20 mg (1) 90fosinopril sodium tab 40 mg (1) 90lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic) (1) 90lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) (1) 90lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic) (1) 90lisinopril tab 2.5 mg (Zestril) (1) 90lisinopril tab 5 mg (Prinivil) (1) 90lisinopril tab 10 mg (Prinivil) (1) 90lisinopril tab 20 mg (Prinivil) (1) 90lisinopril tab 30 mg (Zestril) (1) 90

2019



25

Name of Drug


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

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONSirbesartan tab 75 mg (Avapro) (1) QL (30 tablets/30 days), 90irbesartan tab 150 mg (Avapro) (1) QL (30 tablets/30 days), 90irbesartan tab 300 mg (Avapro) (1) QL (30 tablets/30 days), 90irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide) (1) QL (30 tablets/30 days), 90irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide) (1) QL (30 tablets/30 days), 90losartan potassium & hydrochlorothiazide tab 50-12.5 mg

(Hyzaar)(1) QL (30 tablets/30 days), 90

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


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


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

2019



26

Name of Drug


losartan potassium tab 50 mg (Cozaar) (1) QL (60 tablets/30 days), 90losartan potassium tab 100 mg (Cozaar) (1) QL (30 tablets/30 days), 90valsartan tab 40 mg (Diovan) (1) QL (60 tablets/30 days), 90valsartan tab 80 mg (Diovan) (1) QL (60 tablets/30 days), 90valsartan tab 160 mg (Diovan) (1) QL (60 tablets/30 days), 90valsartan tab 320 mg (Diovan) (1) QL (30 tablets/30 days), 90valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct) (1) QL (30 tablets/30 days), 90valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct) (1) QL (30 tablets/30 days), 90valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct) (1) QL (30 tablets/30 days), 90valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan hct) (1) QL (30 tablets/30 days), 90valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct) (1) QL (30 tablets/30 days), 90

BETA BLOCKERS AND COMBINATIONSacebutolol hcl cap 200 mg (1) 90acebutolol hcl cap 400 mg (1) 90atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) (1) 90atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100) (1) 90atenolol tab 25 mg (Tenormin) (1) 90atenolol tab 50 mg (Tenormin) (1) 90atenolol tab 100 mg (Tenormin) (1) 90betaxolol hcl tab 10 mg (1) 90betaxolol hcl tab 20 mg (1) 90bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac) (1) 90bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac) (1) 90bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac) (1) 90bisoprolol fumarate tab 5 mg (1) 90bisoprolol fumarate tab 10 mg (1) 90carvedilol tab 3.125 mg (Coreg) (1) 90carvedilol tab 6.25 mg (Coreg) (1) 90carvedilol tab 12.5 mg (Coreg) (1) 90carvedilol tab 25 mg (Coreg) (1) 90labetalol hcl tab 100 mg (1) 90labetalol hcl tab 200 mg (1) 90labetalol hcl tab 300 mg (1) 90metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct) (1) 90metoprolol & hydrochlorothiazide tab 100-25 mg (1) 90

2019



27

Name of Drug


metoprolol succinate tab er 24hr 25 mg (tartrate equiv) (Toprol xl) (1) 90metoprolol succinate tab er 24hr 50 mg (tartrate equiv) (Toprol xl) (1) 90metoprolol succinate tab er 24hr 100 mg (tartrate equiv) (Toprol

xl)(1) 90

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

(1) 90

metoprolol tartrate tab 25 mg (1) 90metoprolol tartrate tab 50 mg (Lopressor) (1) 90metoprolol tartrate tab 100 mg (Lopressor) (1) 90METOPROLOL/HYDROCHLOROTHI – metoprolol &


nadolol tab 20 mg (Corgard) (1) 90nadolol tab 40 mg (Corgard) (1) 90nadolol tab 80 mg (Corgard) (1) 90propranolol hcl tab 10 mg (1) 90propranolol hcl tab 20 mg (1) 90propranolol hcl tab 40 mg (1) 90propranolol hcl tab 60 mg (1) 90propranolol hcl tab 80 mg (1) 90PROPRANOLOL/HYDROCHLOROTH – propranolol &


CALCIUM CHANNEL BLOCKERS AND COMBINATIONSamlodipine besylate tab 2.5 mg (base equivalent) (Norvasc) (1) 90amlodipine besylate tab 5 mg (base equivalent) (Norvasc) (1) 90amlodipine besylate tab 10 mg (base equivalent) (Norvasc) (1) 90amlodipine besylate-benazepril hcl cap 2.5-10 mg (1) 90amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel) (1) 90amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel) (1) 90amlodipine besylate-benazepril hcl cap 5-40 mg (1) 90amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel) (1) 90amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel) (1) 90amlodipine besylate-valsartan tab 5-160 mg (Exforge) (1) QL (30 tablets/30 days), 90amlodipine besylate-valsartan tab 5-320 mg (Exforge) (1) QL (30 tablets/30 days), 90amlodipine besylate-valsartan tab 10-160 mg (Exforge) (1) QL (30 tablets/30 days), 90amlodipine besylate-valsartan tab 10-320 mg (Exforge) (1) QL (30 tablets/30 days), 90diltiazem hcl cap er 12hr 60 mg (1) 90

2019



28

Name of Drug


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

(Tiazac)(1) 90

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

(1) 90


(1) 90


(1) 90


(1) 90


(1) 90

diltiazem hcl tab 30 mg (Cardizem) (1) 90diltiazem hcl tab 60 mg (Cardizem) (1) 90diltiazem hcl tab 90 mg (1) 90diltiazem hcl tab 120 mg (Cardizem) (1) 90felodipine tab er 24hr 2.5 mg (1) 90felodipine tab er 24hr 5 mg (1) 90felodipine tab er 24hr 10 mg (1) 90nifedipine cap 10 mg (Procardia) (1) 90nifedipine tab er 24hr 30 mg (Adalat cc) (1) 90nifedipine tab er 24hr 60 mg (Adalat cc) (1) 90nifedipine tab er 24hr 90 mg (Adalat cc) (1) 90nifedipine tab er 24hr osmotic release 30 mg (Procardia xl) (1) 90nifedipine tab er 24hr osmotic release 60 mg (Procardia xl) (1) 90nifedipine tab er 24hr osmotic release 90 mg (Procardia xl) (1) 90verapamil hcl cap er 24hr 100 mg (Verelan pm) (1) 90verapamil hcl cap er 24hr 120 mg (Verelan) (1) 90verapamil hcl cap er 24hr 180 mg (Verelan) (1) 90verapamil hcl cap er 24hr 200 mg (Verelan pm) (1) 90

2019



29

Name of Drug


verapamil hcl cap er 24hr 240 mg (Verelan) (1) 90verapamil hcl cap er 24hr 300 mg (Verelan pm) (1) 90VERAPAMIL HCL SR – verapamil hcl cap er 24hr 360 mg (2) 90verapamil hcl tab er 120 mg (Calan sr) (1) 90verapamil hcl tab er 180 mg (Calan sr) (1) 90verapamil hcl tab er 240 mg (Calan sr) (1) 90verapamil hcl tab 40 mg (1) 90verapamil hcl tab 80 mg (Calan) (1) 90verapamil hcl tab 120 mg (Calan) (1) 90

CHEST PAINISOSORBIDE DINITRATE ER – isosorbide dinitrate tab er 40 mg (2) 90isosorbide dinitrate tab 5 mg (Isordil titradose) (1) 90isosorbide dinitrate tab 10 mg (1) 90isosorbide dinitrate tab 20 mg (1) 90isosorbide dinitrate tab 30 mg (1) 90isosorbide mononitrate tab er 24hr 30 mg (1) 90isosorbide mononitrate tab er 24hr 60 mg (1) 90isosorbide mononitrate tab er 24hr 120 mg (1) 90isosorbide mononitrate tab 10 mg (1) 90isosorbide mononitrate tab 20 mg (1) 90nitroglycerin cap er 2.5 mg (1) 90nitroglycerin cap er 6.5 mg (1) 90nitroglycerin cap er 9 mg (1) 90nitroglycerin sl tab 0.3 mg (Nitrostat) (1)nitroglycerin sl tab 0.4 mg (Nitrostat) (1)nitroglycerin sl tab 0.6 mg (Nitrostat) (1)nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) (1) 90nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) (1) 90nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) (1) 90nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur) (1) 90

CHOLESTEROL LOWERINGatorvastatin calcium tab 10 mg (base equivalent) (Lipitor) (1) QL (30 tablets/30 days), 90atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) (1) QL (30 tablets/30 days), 90atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) (1) QL (30 tablets/30 days), 90atorvastatin calcium tab 80 mg (base equivalent) (Lipitor) (1) QL (30 tablets/30 days), 90

2019



30

Name of Drug


cholestyramine light powder packets 4 gm (1) 90cholestyramine light powder 4 gm/dose (Questran light) (1) 90cholestyramine powder packets 4 gm (Questran) (1) 90cholestyramine powder 4 gm/dose (Questran) (1) 90choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix) (1) QL (60 capsules/30 days), 90choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix) (1) QL (30 capsules/30 days), 90colestipol hcl granule packets 5 gm (Colestid flavored) (1) 90colestipol hcl granules 5 gm (Colestid) (1) 90colestipol hcl tab 1 gm (Colestid) (1) 90fenofibrate micronized cap 43 mg (1) QL (60 capsules/30 days), 90fenofibrate micronized cap 67 mg (Lofibra) (1) QL (30 capsules/30 days), 90fenofibrate micronized cap 134 mg (Lofibra) (1) QL (30 capsules/30 days), 90fenofibrate micronized cap 200 mg (Lofibra) (1) QL (30 capsules/30 days), 90fenofibrate tab 48 mg (Tricor) (1) QL (60 tablets/30 days), 90fenofibrate tab 54 mg (Lofibra) (1) QL (60 tablets/30 days), 90fenofibrate tab 145 mg (Tricor) (1) QL (30 tablets/30 days), 90fenofibrate tab 160 mg (1) QL (30 tablets/30 days), 90gemfibrozil tab 600 mg (Lopid) (1) QL (60 tablets/30 days), 90lovastatin tab 10 mg (1) QL (60 tablets/30 days), 90lovastatin tab 20 mg (1) QL (60 tablets/30 days), 90lovastatin tab 40 mg (1) QL (60 tablets/30 days), 90pravastatin sodium tab 10 mg (1) QL (45 tablets/30 days), 90pravastatin sodium tab 20 mg (Pravachol) (1) QL (45 tablets/30 days), 90pravastatin sodium tab 40 mg (Pravachol) (1) QL (45 tablets/30 days), 90pravastatin sodium tab 80 mg (Pravachol) (1) QL (30 tablets/30 days), 90REPATHA – evolocumab subcutaneous soln prefilled syringe

140 mg/ml(2) PA, QL (2 syringes/28

days), SPREPATHA PUSHTRONEX SYSTEM – evolocumab

subcutaneous soln cartridge/infusor 420 mg/3.5ml(2) PA, QL (1 syringe/30

days), SPREPATHA SURECLICK – evolocumab subcutaneous soln auto-

injector 140 mg/ml(2) PA, QL (2 syringes/28

days), SProsuvastatin calcium tab 5 mg (Crestor) (1) QL (30 tablets/30 days), 90rosuvastatin calcium tab 10 mg (Crestor) (1) QL (30 tablets/30 days), 90rosuvastatin calcium tab 20 mg (Crestor) (1) QL (30 tablets/30 days), 90rosuvastatin calcium tab 40 mg (Crestor) (1) QL (30 tablets/30 days), 90

2019



31

Name of Drug


simvastatin tab 5 mg (Zocor) (1) QL (30 tablets/30 days), 90simvastatin tab 10 mg (Zocor) (1) QL (30 tablets/30 days), 90simvastatin tab 20 mg (Zocor) (1) QL (30 tablets/30 days), 90simvastatin tab 40 mg (Zocor) (1) QL (30 tablets/30 days), 90

FLUID RETENTIONacetazolamide cap er 12hr 500 mg (Diamox) (1) 90acetazolamide tab 125 mg (1) 90acetazolamide tab 250 mg (1) 90amiloride & hydrochlorothiazide tab 5-50 mg (1) 90amiloride hcl tab 5 mg (1) 90bumetanide tab 0.5 mg (Bumex) (1) 90bumetanide tab 1 mg (Bumex) (1) 90bumetanide tab 2 mg (Bumex) (1) 90CHLOROTHIAZIDE – chlorothiazide tab 250 mg (2) 90chlorothiazide tab 500 mg (1) 90chlorthalidone tab 25 mg (1) 90chlorthalidone tab 50 mg (1) 90furosemide oral soln 10 mg/ml (1) 90furosemide tab 20 mg (Lasix) (1) 90furosemide tab 40 mg (Lasix) (1) 90furosemide tab 80 mg (Lasix) (1) 90hydrochlorothiazide cap 12.5 mg (Microzide) (1) 90hydrochlorothiazide tab 12.5 mg (1) 90hydrochlorothiazide tab 25 mg (1) 90hydrochlorothiazide tab 50 mg (1) 90indapamide tab 1.25 mg (1) 90indapamide tab 2.5 mg (1) 90metolazone tab 2.5 mg (1) 90metolazone tab 5 mg (1) 90metolazone tab 10 mg (1) 90spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide) (1) 90spironolactone tab 25 mg (Aldactone) (1) 90spironolactone tab 50 mg (Aldactone) (1) 90spironolactone tab 100 mg (Aldactone) (1) 90torsemide tab 5 mg (1) 90

2019



32

Name of Drug


torsemide tab 10 mg (Demadex) (1) 90torsemide tab 20 mg (Demadex) (1) 90torsemide tab 100 mg (1) 90triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide) (1) 90triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25) (1) 90triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) (1) 90

HEART RHYTHMamiodarone hcl tab 200 mg (1) 90disopyramide phosphate cap 100 mg (Norpace) (1) 90disopyramide phosphate cap 150 mg (Norpace) (1) 90dofetilide cap 125 mcg (0.125 mg) (Tikosyn) (1)dofetilide cap 250 mcg (0.25 mg) (Tikosyn) (1)dofetilide cap 500 mcg (0.5 mg) (Tikosyn) (1)flecainide acetate tab 50 mg (1) 90flecainide acetate tab 100 mg (1) 90flecainide acetate tab 150 mg (1) 90mexiletine hcl cap 150 mg (1) 90mexiletine hcl cap 200 mg (1) 90mexiletine hcl cap 250 mg (1) 90propafenone hcl tab 150 mg (1) 90propafenone hcl tab 225 mg (1) 90propafenone hcl tab 300 mg (1) 90quinidine gluconate tab er 324 mg (1) 90QUINIDINE SULFATE – quinidine sulfate tab 200 mg (2) 90QUINIDINE SULFATE – quinidine sulfate tab 300 mg (2) 90sotalol hcl tab 80 mg (Betapace) (1) 90sotalol hcl tab 120 mg (Betapace) (1) 90sotalol hcl tab 160 mg (Betapace) (1) 90sotalol hcl tab 240 mg (1) 90

OTHER HEART RELATED DRUGSclonidine hcl tab 0.1 mg (Catapres) (1) 90clonidine hcl tab 0.2 mg (Catapres) (1) 90clonidine hcl tab 0.3 mg (Catapres) (1) 90clonidine td patch weekly 0.1 mg/24hr (Catapres-tts-1) (1)clonidine td patch weekly 0.2 mg/24hr (Catapres-tts-2) (1)

2019



33

Name of Drug


clonidine td patch weekly 0.3 mg/24hr (Catapres-tts-3) (1)DIGOXIN – digoxin oral soln 0.05 mg/ml (2) 90digoxin tab 125 mcg (0.125 mg) (Lanoxin) (1) 90digoxin tab 250 mcg (0.25 mg) (Lanoxin) (1) 90doxazosin mesylate tab 1 mg (Cardura) (1) QL (30 tablets/30 days), 90doxazosin mesylate tab 2 mg (Cardura) (1) QL (30 tablets/30 days), 90doxazosin mesylate tab 4 mg (Cardura) (1) QL (30 tablets/30 days), 90doxazosin mesylate tab 8 mg (Cardura) (1) QL (60 tablets/30 days), 90ENTRESTO – sacubitril-valsartan tab 24-26 mg (2) PA, QL (60 tablets/30

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

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

days), 90EPINEPHRINE HCL – epinephrine inj 30 mg/30ml (2)guanfacine hcl tab 1 mg (1) 90guanfacine hcl tab 2 mg (1) 90hydralazine hcl tab 10 mg (1) 90hydralazine hcl tab 25 mg (1) 90hydralazine hcl tab 50 mg (1) 90hydralazine hcl tab 100 mg (1) 90methyldopa tab 250 mg (1) 90methyldopa tab 500 mg (1) 90midodrine hcl tab 2.5 mg (1)midodrine hcl tab 5 mg (1)midodrine hcl tab 10 mg (1)minoxidil tab 2.5 mg (1) 90minoxidil tab 10 mg (1) 90PAPAVERINE HCL – papaverine hcl inj 30 mg/ml (2)phenoxybenzamine hcl cap 10 mg (Dibenzyline) (1)prazosin hcl cap 1 mg (Minipress) (1) 90prazosin hcl cap 2 mg (Minipress) (1) 90prazosin hcl cap 5 mg (Minipress) (1) 90sildenafil citrate tab 20 mg (Revatio) (1) PA, QL (90 tablets/30

days), SP

2019



34

Name of Drug


tadalafil tab 20 mg (pah) (Adcirca) (1) PA, QL (60 tablets/30days), SP

terazosin hcl cap 1 mg (base equivalent) (1) QL (30 capsules/30 days), 90terazosin hcl cap 2 mg (base equivalent) (1) QL (30 capsules/30 days), 90terazosin hcl cap 5 mg (base equivalent) (1) QL (30 capsules/30 days), 90terazosin hcl cap 10 mg (base equivalent) (1) QL (60 capsules/30 days), 90TRACLEER – bosentan tab for oral susp 32 mg (2) PA, QL (120

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

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

days), SP

ANAPHYLAXISEPINEPHRINE – epinephrine solution auto-injector

0.15 mg/0.3ml (1:2000)(2) QL (4 pens/1 prescription)

epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) (Epipen2-pak)

(1) QL (4 pens/1 prescription)

RESPIRATORY AGENTSANTIHISTAMINEScarbinoxamine maleate soln 4 mg/5ml (1)carbinoxamine maleate tab 4 mg (1)cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) (1)cetirizine hcl tab 5 mg (1)cetirizine hcl tab 10 mg (1)chlorpheniramine maleate syrup 2 mg/5ml (1)chlorpheniramine maleate tab er 12 mg (1)chlorpheniramine maleate tab 4 mg (1)clemastine fumarate tab 1.34 mg (1 mg base equiv) (1)cyproheptadine hcl syrup 2 mg/5ml (1)cyproheptadine hcl tab 4 mg (1)desloratadine tab 5 mg (Clarinex) (1)diphenhydramine hcl cap 25 mg (1)diphenhydramine hcl cap 50 mg (1)diphenhydramine hcl elixir 12.5 mg/5ml (1)diphenhydramine hcl liquid 12.5 mg/5ml (1)diphenhydramine hcl tab disint 12.5 mg (1)

2019



35

Name of Drug


diphenhydramine hcl tab 25 mg (1)fexofenadine hcl tab 60 mg (1)fexofenadine hcl tab 180 mg (1)levocetirizine dihydrochloride tab 5 mg (1)loratadine syrup 5 mg/5ml (1)loratadine tab 10 mg (1)promethazine hcl suppos 12.5 mg (1)promethazine hcl suppos 25 mg (1)promethazine hcl syrup 6.25 mg/5ml (1)promethazine hcl tab 12.5 mg (1)promethazine hcl tab 25 mg (1)promethazine hcl tab 50 mg (1)

NASAL PRODUCTSazelastine hcl nasal spray 0.1% (137 mcg/spray) (1) QL (2 bottles/30 days)FLUNISOLIDE – flunisolide nasal soln 25 mcg/act (0.025%) (2) QL (3 bottles/30 days)fluticasone propionate nasal susp 50 mcg/act (1) QL (1 bottle/30 days)phenylephrine hcl tab 10 mg (1)saline nasal gel (1)saline nasal spray 0.65% (1)

COUGH/COLD/ALLERGYacetylcysteine inhal soln 10% (1)acetylcysteine inhal soln 20% (1)BROHIST D – brompheniramine & phenylephrine tab 4-10 mg (2)brompheniramine & phenylephrine elixir 1-2.5 mg/5ml (1)dextromethorphan-guaifenesin liquid 10-100 mg/5ml (1)diphenhydramine-phenylephrine liq 6.25-2.5 mg/5ml (1)guaifenesin liquid 100 mg/5ml (1)guaifenesin tab 200 mg (1)guaifenesin tab 400 mg (1)guaifenesin-codeine soln 100-10 mg/5ml (1) MEphenylephrine w/ dm-gg liqd 5-10-200 mg/5ml (1)phenylephrine-guaifenesin tab 10-400 mg (1)promethazine w/ codeine syrup 6.25-10 mg/5ml (1) MERU-HIST D – brompheniramine & phenylephrine tab 4-10 mg (2)sodium chloride soln nebu 0.9% (1)

2019



36

Name of Drug


sodium chloride soln nebu 3% (1)sodium chloride soln nebu 7% (Hyper-sal) (1)sodium chloride soln nebu 10% (1)TRIAMINIC NIGHT TIME COLD – diphenhydramine-

phenylephrine syrup 6.25-2.5 mg/5ml(2)

ASTHMA/COPDALBUTEROL SULFATE HFA – albuterol sulfate inhal aero

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

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) (1) QL (125 containers/30 days)albuterol sulfate soln nebu 0.5% (5 mg/ml) (1) QL (60 mls/30 days)albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) (1) QL (125 containers/30 days)albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) (1) QL (125 containers/30 days)albuterol sulfate syrup 2 mg/5ml (1)ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath

activ 50 mcg/act(2) QL (30 blisters/30 days)

ARNUITY ELLIPTA – fluticasone furoate aerosol powder breathactiv 100 mcg/act

(2) QL (30 blisters/30 days), 90

ARNUITY ELLIPTA – fluticasone furoate aerosol powder breathactiv 200 mcg/act


ATROVENT HFA – ipratropium bromide hfa inhal aerosol17 mcg/act

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

budesonide inhalation susp 0.25 mg/2ml (Pulmicort) (1) QL (2 packages/30 days), 90budesonide inhalation susp 0.5 mg/2ml (Pulmicort) (1) QL (2 packages/30 days), 90budesonide inhalation susp 1 mg/2ml (Pulmicort) (1) QL (60 mls/30 days), 90COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol

soln 20-100 mcg/act(2) QL (2 inhalers/30 days), 90

cromolyn sodium soln nebu 20 mg/2ml (1) QL (240 mls/30 days), 90FLOVENT DISKUS – fluticasone propionate aer pow ba 50 mcg/

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

FLOVENT DISKUS – fluticasone propionate aer pow ba100 mcg/blister

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

FLOVENT DISKUS – fluticasone propionate aer pow ba250 mcg/blister

(2) AL, QL (4 inhalers/30days), 90

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


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


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

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

2019



37

Name of Drug


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

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





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


ipratropium bromide inhal soln 0.02% (1) QL (150 vials/30 days), 90ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml (1) QL (180 containers/30

days), 90montelukast sodium chew tab 4 mg (base equiv) (Singulair) (1) QL (30 tablets/30 days), 90montelukast sodium chew tab 5 mg (base equiv) (Singulair) (1) QL (30 tablets/30 days), 90montelukast sodium oral granules packet 4 mg (base equiv)

(Singulair)(1) QL (30 packets/30 days), 90

montelukast sodium tab 10 mg (base equiv) (Singulair) (1) QL (30 tablets/30 days), 90QVAR – beclomethasone diprop inhal aero soln 40 mcg/act (50/

valve)(2) AL, PA, QL (2

inhalers/30 days), 90QVAR – beclomethasone diprop inhal aero soln 80 mcg/act (100/

valve)(2) AL, PA, QL (2

inhalers/30 days), 90QVAR REDIHALER – beclomethasone diprop hfa breath act inh

aer 40 mcg/act(2) AL, QL (1 inhaler/30 days)

QVAR REDIHALER – beclomethasone diprop hfa breath act inhaer 80 mcg/act

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

STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln2.5 mcg/act (base equiv)


SYMBICORT – budesonide-formoterol fumarate dihyd aerosol80-4.5 mcg/act


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


terbutaline sulfate tab 2.5 mg (1) 90terbutaline sulfate tab 5 mg (1) 90theophylline soln 80 mg/15ml (1) 90theophylline tab er 12hr 100 mg (1) 90theophylline tab er 12hr 200 mg (1) 90theophylline tab er 12hr 300 mg (1) 90theophylline tab er 12hr 450 mg (1) 90theophylline tab er 24hr 400 mg (1) 90theophylline tab er 24hr 600 mg (1) 90

2019



38

Name of Drug


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

(2) QL (3 inhalers/30 days)

OTHER RESPIRATORY DRUGSKALYDECO – ivacaftor tab 150 mg (2) PA, QL (60 tablets/30

days), SPKALYDECO – ivacaftor packet 50 mg (2) PA, QL (56 packets/28

days), SPKALYDECO – ivacaftor packet 75 mg (2) PA, QL (56 packets/28

days), SPPULMOZYME – dornase alfa inhal soln 1 mg/ml (2) PA, SP

GASTROINTESTINAL DRUGSLAXATIVESbisacodyl tab delayed release 5 mg (1)docusate sodium cap 100 mg (1)docusate sodium cap 250 mg (1)docusate sodium liquid 150 mg/15ml (1)FLEET LIQUID GLYCERIN SUP – glycerin enema adult 5.4 gm/

average delivered dose(2)

glycerin suppos 1 gm (1)glycerin suppos 2 gm (1)KONSYL – psyllium powder 60.3% (2)KONSYL – psyllium powder 71.67% (2)KONSYL DAILY FIBER – psyllium powder 60.3% (2)KONSYL-D – psyllium powder 52.3% (2)lactulose solution 10 gm/15ml (1) 90magnesium citrate soln (1)METAMUCIL MULTIHEALTH FIB – psyllium powder 55.46% (2)METAMUCIL MULTIHEALTH FIB – psyllium powder 63% (2)METAMUCIL SMOOTH TEXTURE – psyllium powder 63% (2)PEDIA-LAX – glycerin liquid suppos 2.8 gm (2.7 ml) (2)peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor

pack)(1)

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

flavor packs)(1)

polyethylene glycol 3350 oral powder (1)psyllium powder 28.3% (1)

2019



39

Name of Drug


psyllium powder 30.9% (1)psyllium powder 48.57% (1)psyllium powder 58.6% (1)psyllium powder 95% (1)sennosides tab 8.6 mg (1)

ANTIDIARRHEALSbismuth subsalicylate susp 262 mg/15ml (1)diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil) (1)loperamide hcl cap 2 mg (1)loperamide hcl tab 2 mg (1)

ANTACIDSalum & mag hydroxide-simethicone susp 200-200-20 mg/5ml (1)alum & mag hydroxide-simethicone susp 400-400-40 mg/5ml (1)calcium carbonate (antacid) chew tab 500 mg (1)calcium carbonate (antacid) chew tab 750 mg (1)calcium carbonate (antacid) chew tab 1000 mg (1)magnesium oxide tab 400 mg (1)

ULCER/GERDATROPINE SULFATE – atropine sulfate inj 1 mg/ml (2)CIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml (2) 90dicyclomine hcl cap 10 mg (Bentyl) (1)dicyclomine hcl oral soln 10 mg/5ml (1)dicyclomine hcl tab 20 mg (1)famotidine for susp 40 mg/5ml (Pepcid) (1) 90famotidine tab 10 mg (1)famotidine tab 20 mg (Pepcid) (1) 90famotidine tab 40 mg (Pepcid) (1) 90glycopyrrolate tab 1 mg (Robinul) (1)glycopyrrolate tab 2 mg (Robinul forte) (1)hyoscyamine sulfate elixir 0.125 mg/5ml (1) 90hyoscyamine sulfate sl tab 0.125 mg (Levsin/sl) (1) 90hyoscyamine sulfate soln 0.125 mg/ml (1) 90hyoscyamine sulfate tab disint 0.125 mg (Anaspaz) (1) 90hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid) (1) 90hyoscyamine sulfate tab 0.125 mg (Levsin) (1) 90

2019



40

Name of Drug


lansoprazole cap delayed release 15 mg (Prevacid) (1) QL (120 capsules/365 days)lansoprazole cap delayed release 30 mg (Prevacid) (1) QL (120 capsules/365 days)misoprostol tab 100 mcg (Cytotec) (1) 90misoprostol tab 200 mcg (Cytotec) (1) 90NIZATIDINE – nizatidine oral soln 15 mg/ml (2) 90nizatidine cap 150 mg (1) 90nizatidine cap 300 mg (1) 90omeprazole cap delayed release 20 mg (1) QL (120 capsules/365 days)omeprazole cap delayed release 40 mg (1) QL (120 capsules/365 days)pantoprazole sodium ec tab 20 mg (base equiv) (Protonix) (1) QL (120 tablets/365 days)pantoprazole sodium ec tab 40 mg (base equiv) (Protonix) (1) QL (120 tablets/365 days)ranitidine hcl syrup 15 mg/ml (75 mg/5ml) (1) 90ranitidine hcl tab 75 mg (1)ranitidine hcl tab 150 mg (Zantac) (1) 90ranitidine hcl tab 300 mg (Zantac) (1) 90sucralfate tab 1 gm (Carafate) (1) 90

NAUSEA AND VOMITINGaprepitant capsule 40 mg (Emend) (1) QL (2 capsules/30 days)aprepitant capsule 80 mg (Emend) (1) QL (6 capsules/30 days)aprepitant capsule 125 mg (Emend) (1) QL (3 capsules/30 days)fructose-dextrose-phosphoric acid oral soln (1)meclizine hcl chew tab 25 mg (1)meclizine hcl tab 12.5 mg (1)meclizine hcl tab 25 mg (1)ondansetron hcl oral soln 4 mg/5ml (Zofran) (1) QL (300 mls/30 days)ondansetron hcl tab 4 mg (Zofran) (1) QL (30 tablets/30 days)ondansetron hcl tab 8 mg (Zofran) (1) QL (30 tablets/30 days)ondansetron hcl tab 24 mg (1) QL (1 tablet/30 days)ondansetron orally disintegrating tab 4 mg (Zofran odt) (1) QL (30 tablets/30 days)ondansetron orally disintegrating tab 8 mg (Zofran odt) (1) QL (30 tablets/30 days)prochlorperazine maleate tab 5 mg (base equivalent) (1)prochlorperazine maleate tab 10 mg (base equivalent) (1)prochlorperazine suppos 25 mg (1)

DIGESTIVE ENZYMES

2019



41

Name of Drug


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

(2)

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

(2)

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

(2)


(2)


(2)

ZENPEP – pancrelipase (lip-prot-amyl) dr cap3000-10000-14000 unit

(2)


(2)


(2)


(2)


(2)


(2)


(2)

OTHER GASTROINTESTINAL DRUGSbalsalazide disodium cap 750 mg (Colazal) (1)calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (1)calcium acetate (phosphate binder) tab 667 mg (Eliphos) (1)cromolyn sodium oral conc 100 mg/5ml (Gastrocrom) (1) 90KINEVAC – sincalide for inj 5 mcg (2)lactulose (encephalopathy) solution 10 gm/15ml (1) 90lanthanum carbonate chew tab 500 mg (elemental) (Fosrenol) (1)lanthanum carbonate chew tab 750 mg (elemental) (Fosrenol) (1)lanthanum carbonate chew tab 1000 mg (elemental) (Fosrenol) (1)mesalamine enema 4 gm (1)mesalamine suppos 1000 mg (Canasa) (1)mesalamine tab delayed release 800 mg (Asacol hd) (1)metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv) (1)metoclopramide hcl tab 5 mg (base equivalent) (Reglan) (1)metoclopramide hcl tab 10 mg (base equivalent) (Reglan) (1)

2019



42

Name of Drug


sevelamer carbonate packet 0.8 gm (Renvela) (1)sevelamer carbonate packet 2.4 gm (Renvela) (1)sevelamer carbonate tab 800 mg (Renvela) (1)simethicone chew tab 80 mg (1)simethicone susp 40 mg/0.6ml (1)sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs) (1)sulfasalazine tab 500 mg (Azulfidine) (1)ursodiol cap 300 mg (Actigall) (1) 90ursodiol tab 250 mg (Urso 250) (1) 90ursodiol tab 500 mg (Urso forte) (1) 90

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

(Macrobid)(1)

nitrofurantoin susp 25 mg/5ml (Furadantin) (1)

URINARY TRACT SPASMSbethanechol chloride tab 5 mg (Urecholine) (1)bethanechol chloride tab 10 mg (Urecholine) (1)bethanechol chloride tab 25 mg (Urecholine) (1)bethanechol chloride tab 50 mg (Urecholine) (1)oxybutynin chloride syrup 5 mg/5ml (1) QL (600 mls/30 days)oxybutynin chloride tab er 24hr 5 mg (Ditropan xl) (1) QL (30 tablets/30 days)oxybutynin chloride tab er 24hr 10 mg (Ditropan xl) (1) QL (60 tablets/30 days)oxybutynin chloride tab er 24hr 15 mg (Ditropan xl) (1) QL (60 tablets/30 days)oxybutynin chloride tab 5 mg (1) QL (120 tablets/30 days)

VAGINAL PRODUCTSclindamycin phosphate vaginal cream 2% (Cleocin) (1)clotrimazole vaginal cream 2% (1)estradiol vaginal tab 10 mcg (Vagifem) (1)metronidazole vaginal gel 0.75% (Metrogel-vaginal) (1)miconazole nitrate vaginal cream 2% (1)TERCONAZOLE – terconazole vaginal cream 0.8% (2)

2019



43

Name of Drug


terconazole vaginal cream 0.4% (Terazol 7) (1)terconazole vaginal suppos 80 mg (1)tioconazole vaginal oint 6.5% (1)

OTHER GENITOURINARY DRUGSalfuzosin hcl tab er 24hr 10 mg (Uroxatral) (1) QL (30 tablets/30 days)finasteride tab 5 mg (Proscar) (1) QL (30 tablets/30 days)phenazopyridine hcl tab 100 mg (Pyridium) (1)phenazopyridine hcl tab 200 mg (Pyridium) (1)potassium citrate & citric acid powder pack 3300-1002 mg (1)potassium citrate & citric acid soln 1100-334 mg/5ml (1)potassium citrate tab er 5 meq (540 mg) (Urocit-k 5) (1)potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10) (1)potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15) (1)sodium chloride irrigation soln 0.9% (1)sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution

modi)(1)

tamsulosin hcl cap 0.4 mg (Flomax) (1) QL (60 capsules/30 days)TRICITRATES – pot & sod citrates w/ cit ac soln

550-500-334 mg/5ml(2)

CENTRAL NERVOUS SYSTEM DRUGSANXIETYalprazolam tab 0.25 mg (Xanax) (1) QL (120 tablets/30 days)alprazolam tab 0.5 mg (Xanax) (1) QL (120 tablets/30 days)alprazolam tab 1 mg (Xanax) (1) QL (120 tablets/30 days)alprazolam tab 2 mg (Xanax) (1) QL (90 tablets/30 days)buspirone hcl tab 5 mg (1)buspirone hcl tab 10 mg (1)buspirone hcl tab 15 mg (1)buspirone hcl tab 30 mg (1)chlordiazepoxide hcl cap 5 mg (1) QL (120 capsules/30 days)chlordiazepoxide hcl cap 10 mg (1) QL (120 capsules/30 days)chlordiazepoxide hcl cap 25 mg (1) QL (120 capsules/30 days)clorazepate dipotassium tab 3.75 mg (1) QL (90 tablets/30 days)clorazepate dipotassium tab 7.5 mg (Tranxene t) (1) QL (90 tablets/30 days)clorazepate dipotassium tab 15 mg (1) QL (120 tablets/30 days)

2019



44

Name of Drug


diazepam conc 5 mg/ml (1) QL (240 mls/30 days)diazepam tab 2 mg (Valium) (1) QL (120 tablets/30 days)diazepam tab 5 mg (Valium) (1) QL (120 tablets/30 days)diazepam tab 10 mg (Valium) (1) QL (120 tablets/30 days)HYDROXYZINE HCL – hydroxyzine hcl im soln 25 mg/ml (2)hydroxyzine hcl syrup 10 mg/5ml (1)hydroxyzine hcl tab 10 mg (1)hydroxyzine hcl tab 25 mg (1)hydroxyzine hcl tab 50 mg (1)hydroxyzine pamoate cap 25 mg (Vistaril) (1)hydroxyzine pamoate cap 50 mg (Vistaril) (1)lorazepam conc 2 mg/ml (1) QL (150 mls/30 days)lorazepam tab 0.5 mg (Ativan) (1) QL (90 tablets/30 days)lorazepam tab 1 mg (Ativan) (1) QL (90 tablets/30 days)lorazepam tab 2 mg (Ativan) (1) QL (150 tablets/30 days)

DEPRESSIONamitriptyline hcl tab 10 mg (1)amitriptyline hcl tab 25 mg (Elavil) (1)amitriptyline hcl tab 50 mg (1)amitriptyline hcl tab 75 mg (1)amitriptyline hcl tab 100 mg (1)amitriptyline hcl tab 150 mg (1)bupropion hcl tab er 12hr 100 mg (Wellbutrin sr) (1) QL (60 tablets/30 days)bupropion hcl tab er 12hr 150 mg (Wellbutrin sr) (1) QL (60 tablets/30 days)bupropion hcl tab er 12hr 200 mg (Wellbutrin sr) (1) QL (60 tablets/30 days)bupropion hcl tab er 24hr 150 mg (Wellbutrin xl) (1) QL (30 tablets/30 days)bupropion hcl tab er 24hr 300 mg (Wellbutrin xl) (1) QL (30 tablets/30 days)bupropion hcl tab 75 mg (1) QL (60 tablets/30 days)bupropion hcl tab 100 mg (1) QL (120 tablets/30 days)citalopram hydrobromide oral soln 10 mg/5ml (1) QL (600 mls/30 days)citalopram hydrobromide tab 10 mg (base equiv) (Celexa) (1) QL (30 tablets/30 days)citalopram hydrobromide tab 20 mg (base equiv) (Celexa) (1) QL (30 tablets/30 days)citalopram hydrobromide tab 40 mg (base equiv) (Celexa) (1) QL (30 tablets/30 days)doxepin hcl cap 10 mg (1)doxepin hcl cap 25 mg (1)

2019



45

Name of Drug


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

(Cymbalta)(1) QL (60 capsules/30 days)

duloxetine hcl enteric coated pellets cap 30 mg (base eq)(Cymbalta)

(1) QL (90 capsules/30 days)

duloxetine hcl enteric coated pellets cap 60 mg (base eq)(Cymbalta)

(1) QL (60 capsules/30 days)

escitalopram oxalate soln 5 mg/5ml (base equiv) (1) QL (600 mls/30 days)escitalopram oxalate tab 5 mg (base equiv) (Lexapro) (1) QL (30 tablets/30 days)escitalopram oxalate tab 10 mg (base equiv) (Lexapro) (1) QL (30 tablets/30 days)escitalopram oxalate tab 20 mg (base equiv) (Lexapro) (1) QL (30 tablets/30 days)fluoxetine hcl cap 10 mg (Prozac) (1) QL (30 capsules/30 days)fluoxetine hcl cap 20 mg (Prozac) (1) QL (120 capsules/30 days)fluoxetine hcl solution 20 mg/5ml (1) QL (600 mls/30 days)fluvoxamine maleate tab 25 mg (1) QL (30 tablets/30 days)fluvoxamine maleate tab 50 mg (1) QL (30 tablets/30 days)fluvoxamine maleate tab 100 mg (1) QL (90 tablets/30 days)imipramine hcl tab 10 mg (Tofranil) (1)imipramine hcl tab 25 mg (Tofranil) (1)imipramine hcl tab 50 mg (Tofranil) (1)mirtazapine orally disintegrating tab 15 mg (Remeron soltab) (1) QL (30 tablets/30 days)mirtazapine orally disintegrating tab 30 mg (Remeron soltab) (1) QL (30 tablets/30 days)mirtazapine orally disintegrating tab 45 mg (Remeron soltab) (1) QL (30 tablets/30 days)mirtazapine tab 15 mg (Remeron) (1) QL (30 tablets/30 days)mirtazapine tab 30 mg (Remeron) (1) QL (30 tablets/30 days)mirtazapine tab 45 mg (Remeron) (1) QL (30 tablets/30 days)nortriptyline hcl cap 10 mg (Pamelor) (1)nortriptyline hcl cap 25 mg (Pamelor) (1)nortriptyline hcl cap 50 mg (Pamelor) (1)nortriptyline hcl cap 75 mg (Pamelor) (1)paroxetine hcl tab 10 mg (Paxil) (1) QL (30 tablets/30 days)paroxetine hcl tab 20 mg (Paxil) (1) QL (30 tablets/30 days)

2019



46

Name of Drug


paroxetine hcl tab 30 mg (Paxil) (1) QL (60 tablets/30 days)paroxetine hcl tab 40 mg (Paxil) (1) QL (30 tablets/30 days)sertraline hcl oral concentrate for solution 20 mg/ml (Zoloft) (1) QL (300 mls/30 days)sertraline hcl tab 25 mg (Zoloft) (1) QL (30 tablets/30 days)sertraline hcl tab 50 mg (Zoloft) (1) QL (30 tablets/30 days)sertraline hcl tab 100 mg (Zoloft) (1) QL (60 tablets/30 days)trazodone hcl tab 50 mg (1)trazodone hcl tab 100 mg (1)trazodone hcl tab 150 mg (1)venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) (Effexor

xr)(1) QL (30 capsules/30 days)

venlafaxine hcl cap er 24hr 75 mg (base equivalent) (Effexor xr) (1) QL (90 capsules/30 days)venlafaxine hcl cap er 24hr 150 mg (base equivalent) (Effexor xr) (1) QL (30 capsules/30 days)venlafaxine hcl tab 25 mg (1) QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg (1) QL (90 tablets/30 days)venlafaxine hcl tab 50 mg (1) QL (90 tablets/30 days)venlafaxine hcl tab 75 mg (1) QL (90 tablets/30 days)venlafaxine hcl tab 100 mg (1) QL (90 tablets/30 days)

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

syringe 300 mg(2) QL (1 syringe/28 days), ST

ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 400 mg

(2) QL (1 syringe/28 days), ST

ABILIFY MAINTENA – aripiprazole im for extended release susp300 mg


ABILIFY MAINTENA – aripiprazole im for extended release susp400 mg


aripiprazole oral solution 1 mg/ml (1) QL (150 mls/30 days)aripiprazole tab 2 mg (Abilify) (1) QL (30 tablets/30 days)aripiprazole tab 5 mg (Abilify) (1) QL (30 tablets/30 days)aripiprazole tab 10 mg (Abilify) (1) QL (30 tablets/30 days)aripiprazole tab 15 mg (Abilify) (1) QL (30 tablets/30 days)aripiprazole tab 20 mg (Abilify) (1) QL (30 tablets/30 days)aripiprazole tab 30 mg (Abilify) (1) QL (30 tablets/30 days)ARISTADA – aripiprazole lauroxil im er susp prefilled syr

441 mg/1.6ml(2) QL (1 syringe/28 days), ST

ARISTADA – aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml


2019



47

Name of Drug






ARISTADA INITIO – aripiprazole lauroxil im er susp prefilled syr675 mg/2.4ml

(2) QL (1 kit/180 days), ST

clozapine orally disintegrating tab 25 mg (Fazaclo) (1) QL (60 tablets/30 days)clozapine orally disintegrating tab 100 mg (Fazaclo) (1) QL (60 tablets/30 days)clozapine tab 25 mg (Clozaril) (1) QL (90 tablets/30 days)clozapine tab 50 mg (1) QL (90 tablets/30 days)clozapine tab 100 mg (Clozaril) (1) QL (270 tablets/30 days)clozapine tab 200 mg (1) QL (120 tablets/30 days)fluphenazine decanoate inj 25 mg/ml (1)FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 mg/5ml (2)FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml (2)fluphenazine hcl tab 1 mg (1)fluphenazine hcl tab 2.5 mg (1)fluphenazine hcl tab 5 mg (1)fluphenazine hcl tab 10 mg (1)haloperidol decanoate im soln 50 mg/ml (Haldol decanoate 50) (1)haloperidol decanoate im soln 100 mg/ml (Haldol decanoate 100) (1)haloperidol lactate oral conc 2 mg/ml (1)haloperidol tab 0.5 mg (1)haloperidol tab 1 mg (1)haloperidol tab 2 mg (1)haloperidol tab 5 mg (1)haloperidol tab 10 mg (1)haloperidol tab 20 mg (1)INVEGA SUSTENNA – paliperidone palmitate im extended-

release susp 39 mg/0.25ml(2) QL (1 kit/28 days), ST

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


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


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


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


2019



48

Name of Drug


LATUDA – lurasidone hcl tab 20 mg (2) QL (30 tablets/30 days), STLATUDA – lurasidone hcl tab 40 mg (2) QL (30 tablets/30 days), STLATUDA – lurasidone hcl tab 60 mg (2) QL (30 tablets/30 days), STLATUDA – lurasidone hcl tab 80 mg (2) QL (60 tablets/30 days), STLATUDA – lurasidone hcl tab 120 mg (2) QL (30 tablets/30 days), STLITHIUM – lithium oral solution 8 meq/5ml (2)lithium carbonate cap 150 mg (Lithium carbonate) (1)lithium carbonate cap 300 mg (1)lithium carbonate cap 600 mg (Lithium carbonate) (1)lithium carbonate tab er 300 mg (Lithobid) (1)lithium carbonate tab er 450 mg (1)lithium carbonate tab 300 mg (1)loxapine succinate cap 5 mg (1)loxapine succinate cap 10 mg (1)loxapine succinate cap 25 mg (1)loxapine succinate cap 50 mg (1)olanzapine for im inj 10 mg (Zyprexa) (1) QL (90 vials/30 days)olanzapine orally disintegrating tab 5 mg (Zyprexa zydis) (1) QL (30 tablets/30 days)olanzapine orally disintegrating tab 10 mg (Zyprexa zydis) (1) QL (30 tablets/30 days)olanzapine orally disintegrating tab 15 mg (Zyprexa zydis) (1) QL (30 tablets/30 days)olanzapine orally disintegrating tab 20 mg (Zyprexa zydis) (1) QL (30 tablets/30 days)olanzapine tab 2.5 mg (Zyprexa) (1) QL (30 tablets/30 days)olanzapine tab 5 mg (Zyprexa) (1) QL (30 tablets/30 days)olanzapine tab 7.5 mg (Zyprexa) (1) QL (30 tablets/30 days)olanzapine tab 10 mg (Zyprexa) (1) QL (30 tablets/30 days)olanzapine tab 15 mg (Zyprexa) (1) QL (30 tablets/30 days)olanzapine tab 20 mg (Zyprexa) (1) QL (30 tablets/30 days)perphenazine tab 2 mg (1)perphenazine tab 4 mg (1)perphenazine tab 8 mg (1)perphenazine tab 16 mg (1)quetiapine fumarate tab 25 mg (Seroquel) (1) QL (90 tablets/30 days)quetiapine fumarate tab 50 mg (Seroquel) (1) QL (90 tablets/30 days)quetiapine fumarate tab 100 mg (Seroquel) (1) QL (90 tablets/30 days)quetiapine fumarate tab 200 mg (Seroquel) (1) QL (90 tablets/30 days)

2019



49

Name of Drug


quetiapine fumarate tab 300 mg (Seroquel) (1) QL (60 tablets/30 days)quetiapine fumarate tab 400 mg (Seroquel) (1) QL (60 tablets/30 days)RISPERIDONE ODT – risperidone orally disintegrating tab

0.25 mg(2) QL (60 tablets/30 days)

risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab) (1) QL (60 tablets/30 days)risperidone orally disintegrating tab 1 mg (Risperdal m-tab) (1) QL (60 tablets/30 days)risperidone orally disintegrating tab 2 mg (Risperdal m-tab) (1) QL (60 tablets/30 days)risperidone orally disintegrating tab 3 mg (Risperdal m-tab) (1) QL (60 tablets/30 days)risperidone orally disintegrating tab 4 mg (Risperdal m-tab) (1) QL (120 tablets/30 days)risperidone soln 1 mg/ml (Risperdal) (1) QL (480 mls/30 days)risperidone tab 0.25 mg (Risperdal) (1) QL (120 tablets/30 days)risperidone tab 0.5 mg (Risperdal) (1) QL (120 tablets/30 days)risperidone tab 1 mg (Risperdal) (1) QL (120 tablets/30 days)risperidone tab 2 mg (Risperdal) (1) QL (120 tablets/30 days)risperidone tab 3 mg (Risperdal) (1) QL (60 tablets/30 days)risperidone tab 4 mg (Risperdal) (1) QL (120 tablets/30 days)thioridazine hcl tab 10 mg (1)thioridazine hcl tab 25 mg (1)thioridazine hcl tab 50 mg (1)thioridazine hcl tab 100 mg (1)thiothixene cap 1 mg (1)thiothixene cap 2 mg (1)thiothixene cap 5 mg (1)thiothixene cap 10 mg (1)trifluoperazine hcl tab 1 mg (base equivalent) (1)trifluoperazine hcl tab 2 mg (base equivalent) (1)trifluoperazine hcl tab 5 mg (base equivalent) (1)trifluoperazine hcl tab 10 mg (base equivalent) (1)ziprasidone hcl cap 20 mg (Geodon) (1) QL (60 capsules/30 days)ziprasidone hcl cap 40 mg (Geodon) (1) QL (60 capsules/30 days)ziprasidone hcl cap 60 mg (Geodon) (1) QL (60 capsules/30 days)ziprasidone hcl cap 80 mg (Geodon) (1) QL (60 capsules/30 days)

SLEEP AIDSestazolam tab 1 mg (1) QL (30 tablets/30 days)estazolam tab 2 mg (1) QL (30 tablets/30 days)

2019



50

Name of Drug


eszopiclone tab 1 mg (Lunesta) (1) QL (30 tablets/30 days)eszopiclone tab 2 mg (Lunesta) (1) QL (30 tablets/30 days)eszopiclone tab 3 mg (Lunesta) (1) QL (30 tablets/30 days)phenobarbital elixir 20 mg/5ml (1)PHENOBARBITAL SODIUM – phenobarbital sodium inj 65 mg/ml (2)PHENOBARBITAL SODIUM – phenobarbital sodium inj 130 mg/

ml(2)

phenobarbital tab 15 mg (1)phenobarbital tab 16.2 mg (1)phenobarbital tab 30 mg (1)phenobarbital tab 32.4 mg (1)phenobarbital tab 60 mg (1)phenobarbital tab 64.8 mg (1)phenobarbital tab 97.2 mg (1)phenobarbital tab 100 mg (1)temazepam cap 15 mg (Restoril) (1) QL (30 capsules/30 days)temazepam cap 30 mg (Restoril) (1) QL (30 capsules/30 days)zaleplon cap 5 mg (Sonata) (1) QL (30 capsules/30 days)zaleplon cap 10 mg (Sonata) (1) QL (30 capsules/30 days)zolpidem tartrate tab 5 mg (Ambien) (1) QL (30 tablets/30 days)zolpidem tartrate tab 10 mg (Ambien) (1) QL (30 tablets/30 days)

HYPERACTIVITY/NARCOLEPSYamphetamine-dextroamphetamine cap er 24hr 5 mg (Adderall xr) (1) AL, QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 10 mg (Adderall

xr)(1) AL, QL (30 capsules/30 days)

amphetamine-dextroamphetamine cap er 24hr 15 mg (Adderallxr)

(1) AL, QL (30 capsules/30 days)







amphetamine-dextroamphetamine tab 5 mg (Adderall) (1) AL, QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 7.5 mg (Adderall) (1) AL, QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 10 mg (Adderall) (1) AL, QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 12.5 mg (Adderall) (1) AL, QL (60 tablets/30 days)

2019



51

Name of Drug


amphetamine-dextroamphetamine tab 15 mg (Adderall) (1) AL, QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 20 mg (Adderall) (1) AL, QL (90 tablets/30 days)amphetamine-dextroamphetamine tab 30 mg (Adderall) (1) AL, QL (60 tablets/30 days)caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) (1)dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin xr) (1) AL, QL (30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin xr) (1) AL, QL (30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 15 mg (Focalin xr) (1) AL, QL (30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 20 mg (Focalin xr) (1) AL, QL (30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 30 mg (Focalin xr) (1) AL, QL (30 capsules/30 days)dexmethylphenidate hcl cap er 24 hr 40 mg (Focalin xr) (1) AL, QL (30 capsules/30 days)dexmethylphenidate hcl tab 2.5 mg (Focalin) (1) AL, QL (60 tablets/30 days)dexmethylphenidate hcl tab 5 mg (Focalin) (1) AL, QL (60 tablets/30 days)dexmethylphenidate hcl tab 10 mg (Focalin) (1) AL, QL (60 tablets/30 days)guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv) (1) QL (30 tablets/30 days)guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv) (1) QL (30 tablets/30 days)guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv) (1) QL (30 tablets/30 days)guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv) (1) QL (30 tablets/30 days)methylphenidate hcl cap er 10 mg (cd) (1) AL, QL (30 capsules/30 days)methylphenidate hcl cap er 20 mg (cd) (1) AL, QL (30 capsules/30 days)methylphenidate hcl cap er 30 mg (cd) (1) AL, QL (30 capsules/30 days)methylphenidate hcl cap er 40 mg (cd) (1) AL, QL (30 capsules/30 days)methylphenidate hcl cap er 50 mg (cd) (1) AL, QL (30 capsules/30 days)methylphenidate hcl cap er 60 mg (cd) (1) AL, QL (30 capsules/30 days)methylphenidate hcl cap er 24hr 20 mg (la) (Ritalin la) (1) AL, QL (30 capsules/30 days)methylphenidate hcl cap er 24hr 30 mg (la) (Ritalin la) (1) AL, QL (60 capsules/30 days)methylphenidate hcl cap er 24hr 40 mg (la) (Ritalin la) (1) AL, QL (30 capsules/30 days)methylphenidate hcl tab er osmotic release (osm) 18 mg

(Concerta)(1) AL, QL (30 tablets/30 days)

methylphenidate hcl tab er osmotic release (osm) 27 mg(Concerta)

(1) AL, QL (30 tablets/30 days)





methylphenidate hcl tab er 10 mg (1) AL, QL (90 tablets/30 days)methylphenidate hcl tab 5 mg (Ritalin) (1) AL, QL (90 tablets/30 days)

2019



52

Name of Drug


methylphenidate hcl tab 10 mg (Ritalin) (1) AL, QL (90 tablets/30 days)methylphenidate hcl tab 20 mg (Ritalin) (1) AL, QL (90 tablets/30 days)METHYLPHENIDATE HYDROCHLO – methylphenidate hcl tab

er 24hr 18 mg(2) AL, QL (30 tablets/30 days)

METHYLPHENIDATE HYDROCHLO – methylphenidate hcl taber 24hr 27 mg






modafinil tab 100 mg (Provigil) (1) PA, QL (30 tablets/30 days)modafinil tab 200 mg (Provigil) (1) PA, QL (30 tablets/30 days)

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

days), SPAUBAGIO – teriflunomide tab 14 mg (2) PA, QL (30 tablets/30

days), SPAVONEX – interferon beta-1a im prefilled syringe kit

30 mcg/0.5ml(2) PA, QL (1 kit/28 days), SP

AVONEX – interferon beta-1a for im inj kit 30mcg (33mcg(6.6mu)/vial)

(2) PA, QL (4 vials/28 days), SP

AVONEX PEN – interferon beta-1a im auto-injector kit30 mcg/0.5ml

(2) PA, QL (1 kit/28 days), SP

dalfampridine tab er 12hr 10 mg (Ampyra) (1) PA, QL (60 tablets/30days), SP

EXTAVIA – interferon beta-1b for inj kit 0.3 mg (2) PA, QL (14 vials/28 days), SPglatiramer acetate soln prefilled syringe 40 mg/ml (Copaxone) (1) PA, QL (12 syringes/28

days), SP

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

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

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

(2) QL (180 days/365 days)

disulfiram tab 250 mg (Antabuse) (1)disulfiram tab 500 mg (Antabuse) (1)

2019



53

Name of Drug


donepezil hydrochloride orally disintegrating tab 5 mg (1) QL (30 tablets/30 days)donepezil hydrochloride orally disintegrating tab 10 mg (1) QL (30 tablets/30 days)donepezil hydrochloride tab 5 mg (Aricept) (1) QL (30 tablets/30 days)donepezil hydrochloride tab 10 mg (Aricept) (1) QL (30 tablets/30 days)naltrexone hcl tab 50 mg (1)nicotine polacrilex gum 2 mg (1) QL (180 days/365 days)nicotine polacrilex gum 4 mg (1) QL (180 days/365 days)nicotine td patch 24hr 7 mg/24hr (1) QL (180 days/365 days)nicotine td patch 24hr 14 mg/24hr (1) QL (180 days/365 days)nicotine td patch 24hr 21 mg/24hr (1) QL (180 days/365 days)PIMOZIDE – pimozide tab 1 mg (2)PIMOZIDE – pimozide tab 2 mg (2)VIVITROL – naltrexone for im extended release susp 380 mg (2) QL (1 vial/28 days), SPXYREM – sodium oxybate oral solution 500 mg/ml (2) PA, QL (3 bottles/30

days), SP

PAIN RELIEF DRUGSNON-NARCOTIC DRUGSacetaminophen cap 500 mg (1)acetaminophen chew tab 80 mg (1)acetaminophen chew tab 160 mg (1)acetaminophen disintegrating tab 80 mg (1)acetaminophen liquid 160 mg/5ml (1)acetaminophen soln 160 mg/5ml (1)acetaminophen suppos 120 mg (1)acetaminophen susp 160 mg/5ml (1)acetaminophen tab 325 mg (1)acetaminophen tab 500 mg (1)aspirin chew tab 81 mg (1)aspirin tab delayed release 81 mg (1)aspirin tab delayed release 325 mg (1)aspirin tab 325 mg (1)butalbital-acetaminophen tab 50-325 mg (1) QL (180 tablets/30 days)butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet) (1) QL (180 capsules/30 days)butalbital-acetaminophen-caffeine cap 50-325-40 mg (1) QL (180 capsules/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic) (1) QL (180 tablets/30 days)

2019



54

Name of Drug


butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal) (1) QL (180 capsules/30 days)NORTEMP INFANTS – acetaminophen susp 80 mg/0.8ml (2)salsalate tab 500 mg (1)salsalate tab 750 mg (1)

NARCOTIC DRUGSacetaminophen w/ codeine soln 120-12 mg/5ml (1) ME, QL (2700 mls/30 days)acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine) (1) ME, QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3) (1) ME, QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4) (1) ME, QL (180 tablets/30 days)ACETAMINOPHEN/CAFFEINE/DI – acetaminophen-caffeine-

dihydrocodeine cap 320.5-30-16 mg(2) ME, QL (300

capsules/30 days)BUNAVAIL – buprenorphine-naloxone buccal film 2.1-0.3 mg

(base equiv)(2) QL (330 films/30 days)

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

(2) QL (150 films/30 days)

BUNAVAIL – buprenorphine-naloxone buccal film 6.3-1 mg (baseequiv)


buprenorphine hcl sl tab 2 mg (base equiv) (1) QL (360 tablets/30 days)buprenorphine hcl sl tab 8 mg (base equiv) (1) QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) (1) QL (360 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) (1) QL (90 tablets/30 days)butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg (1) ME, QL (180

capsules/30 days)butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/

codeine #3)(1) ME, QL (180

capsules/30 days)codeine sulfate tab 30 mg (Codeine sulfate) (1) ME, QL (180 tablets/30 days)fentanyl td patch 72hr 12 mcg/hr (Duragesic) (1) ME, QL (15 patches/30 days)fentanyl td patch 72hr 25 mcg/hr (Duragesic) (1) ME, QL (15 patches/30 days)fentanyl td patch 72hr 50 mcg/hr (Duragesic) (1) ME, QL (15 patches/30 days)fentanyl td patch 72hr 75 mcg/hr (Duragesic) (1) ME, QL (15 patches/30 days)fentanyl td patch 72hr 100 mcg/hr (Duragesic) (1) ME, QL (15 patches/30 days)hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet) (1) ME, QL (3600 mls/30 days)hydrocodone-acetaminophen tab 10-325 mg (Norco) (1) ME, QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-325 mg (Norco) (1) ME, QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-325 mg (Norco) (1) ME, QL (180 tablets/30 days)HYDROMORPHONE HCL – hydromorphone hcl inj 4 mg/ml (2) MEhydromorphone hcl liqd 1 mg/ml (Dilaudid) (1) ME, QL (1440 mls/30 days)

2019



55

Name of Drug


hydromorphone hcl tab 2 mg (Dilaudid) (1) ME, QL (180 tablets/30 days)hydromorphone hcl tab 4 mg (Dilaudid) (1) ME, QL (180 tablets/30 days)hydromorphone hcl tab 8 mg (Dilaudid) (1) ME, QL (180 tablets/30 days)meperidine hcl tab 50 mg (1) ME, QL (240 tablets/30 days)meperidine hcl tab 100 mg (Demerol) (1) ME, QL (240 tablets/30 days)MORPHINE SULFATE – morphine sulfate inj 8 mg/ml (2) MEMORPHINE SULFATE – morphine sulfate tab 15 mg (2) ME, QL (240 tablets/30 days)MORPHINE SULFATE – morphine sulfate tab 30 mg (2) ME, QL (180 tablets/30 days)MORPHINE SULFATE – morphine sulfate suppos 5 mg (2) MEMORPHINE SULFATE – morphine sulfate suppos 10 mg (2) MEMORPHINE SULFATE – morphine sulfate suppos 20 mg (2) MEMORPHINE SULFATE – morphine sulfate suppos 30 mg (2) MEmorphine sulfate oral soln 10 mg/5ml (1) ME, QL (2700 mls/30 days)morphine sulfate oral soln 20 mg/5ml (1) ME, QL (1350 mls/30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml) (1) ME, QL (270 mls/30 days)morphine sulfate tab er 15 mg (Ms contin) (1) ME, QL (90 tablets/30 days)morphine sulfate tab er 30 mg (Ms contin) (1) ME, QL (90 tablets/30 days)morphine sulfate tab er 60 mg (Ms contin) (1) ME, QL (90 tablets/30 days)morphine sulfate tab er 100 mg (Ms contin) (1) ME, QL (90 tablets/30 days)morphine sulfate tab er 200 mg (Ms contin) (1) ME, QL (90 tablets/30 days)oxycodone hcl conc 100 mg/5ml (20 mg/ml) (1) ME, QL (270 mls/30 days)oxycodone hcl soln 5 mg/5ml (1) ME, QL (5400 mls/30 days)oxycodone hcl tab 5 mg (Roxicodone) (1) ME, QL (360 tablets/30 days)oxycodone hcl tab 10 mg (1) ME, QL (180 tablets/30 days)oxycodone hcl tab 15 mg (Roxicodone) (1) ME, QL (180 tablets/30 days)oxycodone hcl tab 20 mg (1) ME, QL (180 tablets/30 days)oxycodone hcl tab 30 mg (Roxicodone) (1) ME, QL (180 tablets/30 days)oxycodone w/ acetaminophen tab 5-325 mg (Percocet) (1) ME, QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet) (1) ME, QL (240 tablets/30 days)oxycodone w/ acetaminophen tab 10-325 mg (Percocet) (1) ME, QL (180 tablets/30 days)oxycodone-aspirin tab 4.8355-325 mg (1) ME, QL (360 tablets/30 days)PROBUPHINE IMPLANT KIT – buprenorphine hcl subdermal

implant 74.2 mg (base equiv)(2)

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 2-0.5 mg(base equiv)


2019



56

Name of Drug


SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 mg(base equiv)






tramadol hcl tab 50 mg (Ultram) (1) ME, QL (240 tablets/30 days)ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 1.4-0.36 mg

(base eq)(2) QL (510 tablets/30 days)

ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 2.9-0.71 mg(base eq)








RHEUMATOID AND OSTEOARTHRITIScelecoxib cap 50 mg (Celebrex) (1) QL (60 capsules/30 days)celecoxib cap 100 mg (Celebrex) (1) QL (60 capsules/30 days)celecoxib cap 200 mg (Celebrex) (1) QL (60 capsules/30 days)celecoxib cap 400 mg (Celebrex) (1) QL (30 capsules/30 days)diclofenac potassium tab 50 mg (1) QL (120 tablets/30 days)diclofenac sodium gel 1% (Voltaren) (1) QL (200 grams/30 days)diclofenac sodium tab delayed release 50 mg (1) QL (120 tablets/30 days)diclofenac sodium tab delayed release 75 mg (1) QL (60 tablets/30 days)diclofenac sodium tab er 24hr 100 mg (1) QL (60 tablets/30 days)ENBREL – etanercept for subcutaneous inj 25 mg (2) PA, QL (8 vials/28 days), SPENBREL – etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml(2) PA, QL (4 syringes/28

days), SPENBREL – etanercept subcutaneous soln prefilled syringe


days), SPENBREL MINI – etanercept subcutaneous solution cartridge

50 mg/ml(2) PA, QL (4 cartridges/28

days), SPENBREL SURECLICK – etanercept subcutaneous solution auto-

injector 50 mg/ml(2) PA, QL (4 syringes/28

days), SPflurbiprofen tab 50 mg (1) QL (180 tablets/30 days)flurbiprofen tab 100 mg (1) QL (90 tablets/30 days)

2019



57

Name of Drug


HUMIRA – adalimumab prefilled syringe kit 10 mg/0.1ml (2) PA, QL (2 syringes/28days), SP






HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringekit 40 mg/0.8ml

(2) PA, QL (3 syringes/180days), SP

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


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


HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.8ml (2) PA, QL (2 pens/180 days), SPHUMIRA PEN – adalimumab pen-injector kit 40 mg/0.4ml (2) PA, QL (2 pens/28 days), SPHUMIRA PEN-CD/UC/HS START – adalimumab pen-injector kit

40 mg/0.8ml(2) PA, QL (6 pens/180 days), SP

HUMIRA PEN-CD/UC/HS START – adalimumab pen-injector kit80 mg/0.8ml


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

(2) PA, QL (4 pens/28 days), SP

HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit80 mg/0.8ml & 40 mg/0.4ml


ibuprofen cap 200 mg (1)ibuprofen susp 100 mg/5ml (1) QL (1000 mls/30 days)ibuprofen tab 200 mg (1)ibuprofen tab 400 mg (1) QL (120 tablets/30 days)ibuprofen tab 600 mg (1) QL (150 tablets/30 days)ibuprofen tab 800 mg (1) QL (120 tablets/30 days)indomethacin cap er 75 mg (1) QL (60 capsules/30 days)indomethacin cap 25 mg (1) QL (90 capsules/30 days)indomethacin cap 50 mg (1) QL (60 capsules/30 days)KETOPROFEN – ketoprofen cap 25 mg (2) QL (360 capsules/30 days)

2019



58

Name of Drug


ketoprofen cap 75 mg (1) QL (120 capsules/30 days)ketorolac tromethamine tab 10 mg (1) QL (20 tablets/30 days)leflunomide tab 10 mg (Arava) (1)leflunomide tab 20 mg (Arava) (1)meloxicam tab 7.5 mg (Mobic) (1) QL (60 tablets/30 days)meloxicam tab 15 mg (Mobic) (1) QL (30 tablets/30 days)nabumetone tab 500 mg (1) QL (120 tablets/30 days)nabumetone tab 750 mg (1) QL (60 tablets/30 days)naproxen sodium tab 220 mg (1)naproxen sodium tab 275 mg (1) QL (150 tablets/30 days)naproxen sodium tab 550 mg (Anaprox ds) (1) QL (90 tablets/30 days)naproxen tab ec 375 mg (Ec-naprosyn) (1) QL (120 tablets/30 days)naproxen tab ec 500 mg (Ec-naprosyn) (1) QL (90 tablets/30 days)naproxen tab 250 mg (1) QL (150 tablets/30 days)naproxen tab 375 mg (1) QL (120 tablets/30 days)naproxen tab 500 mg (Naprosyn) (1) QL (90 tablets/30 days)OLUMIANT – baricitinib tab 2 mg (2) PA, QL (30 tablets/30

days), SPOTEZLA – apremilast tab starter therapy pack 10 mg & 20 mg &

30 mg(2) PA, QL (55 tablets/180

days), SPOTEZLA – apremilast tab 30 mg (2) PA, QL (60 tablets/30

days), SPpiroxicam cap 10 mg (Feldene) (1) QL (60 capsules/30 days)piroxicam cap 20 mg (Feldene) (1) QL (30 capsules/30 days)sulindac tab 150 mg (1) QL (60 tablets/30 days)sulindac tab 200 mg (1) QL (60 tablets/30 days)

MIGRAINE HEADACHESrizatriptan benzoate oral disintegrating tab 5 mg (base eq)

(Maxalt-mlt)(1) QL (18 tablets/30 days)

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


rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt) (1) QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt) (1) QL (18 tablets/30 days)sumatriptan succinate inj 6 mg/0.5ml (Imitrex) (1) QL (12 vials/30 days)sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex

statdose sys)(1) QL (12 doses/30 days)

2019



59

Name of Drug


sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrexstatdose sys)

(1) QL (12 doses/30 days)

sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrexstatdose ref)

(1) QL (6 packages/30 days)

sumatriptan succinate tab 25 mg (Imitrex) (1) QL (18 tablets/30 days)sumatriptan succinate tab 50 mg (Imitrex) (1) QL (18 tablets/30 days)sumatriptan succinate tab 100 mg (Imitrex) (1) QL (18 tablets/30 days)

GOUTallopurinol tab 100 mg (Zyloprim) (1)allopurinol tab 300 mg (Zyloprim) (1)colchicine w/ probenecid tab 0.5-500 mg (1)probenecid tab 500 mg (1)LIDOCAINE HCL – lidocaine hcl local preservative free (pf) inj

4%(2)

NEUROMUSCULAR DRUGSSEIZURESAPTIOM – eslicarbazepine acetate tab 200 mg (2)APTIOM – eslicarbazepine acetate tab 400 mg (2)APTIOM – eslicarbazepine acetate tab 600 mg (2)APTIOM – eslicarbazepine acetate tab 800 mg (2)BANZEL – rufinamide susp 40 mg/ml (2)BANZEL – rufinamide tab 200 mg (2)BANZEL – rufinamide tab 400 mg (2)BRIVIACT – brivaracetam tab 10 mg (2)BRIVIACT – brivaracetam tab 25 mg (2)BRIVIACT – brivaracetam tab 50 mg (2)BRIVIACT – brivaracetam tab 75 mg (2)BRIVIACT – brivaracetam tab 100 mg (2)BRIVIACT – brivaracetam oral soln 10 mg/ml (2)BRIVIACT – brivaracetam iv soln 50 mg/5ml (2)carbamazepine chew tab 100 mg (1)carbamazepine susp 100 mg/5ml (Tegretol) (1)carbamazepine tab er 12hr 100 mg (Tegretol-xr) (1)carbamazepine tab er 12hr 200 mg (Tegretol-xr) (1)carbamazepine tab er 12hr 400 mg (Tegretol-xr) (1)carbamazepine tab 200 mg (Tegretol) (1)

2019



60

Name of Drug


CARBATROL – carbamazepine cap er 12hr 100 mg (2)CARBATROL – carbamazepine cap er 12hr 200 mg (2)CARBATROL – carbamazepine cap er 12hr 300 mg (2)CELONTIN – methsuximide cap 300 mg (2)CEREBYX – fosphenytoin sodium inj 100 mg/2ml (phenytoin

equiv)(2)

CEREBYX – fosphenytoin sodium inj 500 mg/10ml (phenytoinequiv)

(2)

clobazam suspension 2.5 mg/ml (Onfi) (1) QL (480 mls/30 days)clobazam tab 10 mg (Onfi) (1) QL (60 tablets/30 days)clobazam tab 20 mg (Onfi) (1) QL (60 tablets/30 days)clonazepam orally disintegrating tab 0.125 mg (1) QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg (1) QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg (1) QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg (1) QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg (1) QL (60 tablets/30 days)clonazepam tab 0.5 mg (Klonopin) (1) QL (90 tablets/30 days)clonazepam tab 1 mg (Klonopin) (1) QL (90 tablets/30 days)clonazepam tab 2 mg (Klonopin) (1) QL (60 tablets/30 days)DEPACON – valproate sodium inj 100 mg/ml (2)DEPAKENE – valproic acid cap 250 mg (2)DEPAKENE – valproate sodium oral soln 250 mg/5ml (base

equiv)(2)

DEPAKOTE – divalproex sodium tab delayed release 125 mg (2)DEPAKOTE – divalproex sodium tab delayed release 250 mg (2)DEPAKOTE – divalproex sodium tab delayed release 500 mg (2)DEPAKOTE ER – divalproex sodium tab er 24 hr 250 mg (2)DEPAKOTE ER – divalproex sodium tab er 24 hr 500 mg (2)DEPAKOTE SPRINKLES – divalproex sodium cap delayed

release sprinkle 125 mg(2)

DIAZEPAM RECTAL GEL – diazepam rectal gel delivery system2.5 mg

(2) QL (2 packs/30 days)

DIAZEPAM RECTAL GEL – diazepam rectal gel delivery system10 mg


DIAZEPAM RECTAL GEL – diazepam rectal gel delivery system20 mg


DILANTIN – phenytoin sodium extended cap 30 mg (2)DILANTIN – phenytoin sodium extended cap 100 mg (2)

2019



61

Name of Drug


DILANTIN INFATABS – phenytoin chew tab 50 mg (2)DILANTIN-125 – phenytoin susp 125 mg/5ml (2)divalproex sodium cap delayed release sprinkle 125 mg

(Depakote sprinkles)(1)

divalproex sodium tab delayed release 125 mg (Depakote) (1)divalproex sodium tab delayed release 250 mg (Depakote) (1)divalproex sodium tab delayed release 500 mg (Depakote) (1)divalproex sodium tab er 24 hr 250 mg (Depakote er) (1)divalproex sodium tab er 24 hr 500 mg (Depakote er) (1)ethosuximide cap 250 mg (Zarontin) (1)ethosuximide soln 250 mg/5ml (Zarontin) (1)felbamate susp 600 mg/5ml (Felbatol) (1)felbamate tab 400 mg (Felbatol) (1)felbamate tab 600 mg (Felbatol) (1)FELBATOL – felbamate susp 600 mg/5ml (2)FELBATOL – felbamate tab 400 mg (2)FELBATOL – felbamate tab 600 mg (2)FYCOMPA – perampanel susp 0.5 mg/ml (2)FYCOMPA – perampanel tab 2 mg (2)FYCOMPA – perampanel tab 4 mg (2)FYCOMPA – perampanel tab 6 mg (2)FYCOMPA – perampanel tab 8 mg (2)FYCOMPA – perampanel tab 10 mg (2)FYCOMPA – perampanel tab 12 mg (2)gabapentin cap 100 mg (Neurontin) (1) QL (720 capsules/30 days)gabapentin cap 300 mg (Neurontin) (1) QL (240 capsules/30 days)gabapentin cap 400 mg (Neurontin) (1) QL (180 capsules/30 days)gabapentin oral soln 250 mg/5ml (Neurontin) (1) QL (1500 mls/30 days)gabapentin tab 600 mg (Neurontin) (1) QL (120 tablets/30 days)gabapentin tab 800 mg (Neurontin) (1) QL (90 tablets/30 days)GABITRIL – tiagabine hcl tab 2 mg (2)GABITRIL – tiagabine hcl tab 4 mg (2)GABITRIL – tiagabine hcl tab 12 mg (2)GABITRIL – tiagabine hcl tab 16 mg (2)KEPPRA – levetiracetam tab 250 mg (2)

2019



62

Name of Drug


KEPPRA – levetiracetam tab 500 mg (2)KEPPRA – levetiracetam tab 750 mg (2)KEPPRA – levetiracetam tab 1000 mg (2)KEPPRA – levetiracetam oral soln 100 mg/ml (2)KEPPRA – levetiracetam inj 500 mg/5ml (100 mg/ml) (2)KEPPRA XR – levetiracetam tab er 24hr 500 mg (2)KEPPRA XR – levetiracetam tab er 24hr 750 mg (2)LAMICTAL – lamotrigine tab 25 mg (2)LAMICTAL – lamotrigine tab 100 mg (2)LAMICTAL – lamotrigine tab 150 mg (2)LAMICTAL – lamotrigine tab 200 mg (2)LAMICTAL CHEWABLE DISPERS – lamotrigine tab chewable

dispersible 5 mg(2)

LAMICTAL CHEWABLE DISPERS – lamotrigine tab chewabledispersible 25 mg

(2)

LAMICTAL ODT – lamotrigine tab disint 25 mg (21) & 50 mg (7)titration kit

(2)

LAMICTAL ODT – lamotrigine tab disint 50 mg (42)- 100 mg(14)titration kit

(2)

LAMICTAL ODT – lamotrigine tab disint 25 (14) & 50 mg (14) &100 mg (7) kit

(2)

LAMICTAL ODT – lamotrigine orally disintegrating tab 25 mg (2)LAMICTAL ODT – lamotrigine orally disintegrating tab 50 mg (2)LAMICTAL ODT – lamotrigine orally disintegrating tab 100 mg (2)LAMICTAL ODT – lamotrigine orally disintegrating tab 200 mg (2)LAMICTAL STARTER/NOT TAKI – lamotrigine tab 25 mg (42) &

100 mg (7) starter kit(2)

LAMICTAL STARTER/TAKING C – lamotrigine tab 25 mg (84) &100 mg (14) starter kit

(2)

LAMICTAL STARTER/TAKING V – lamotrigine tab 25 mg (35)starter kit

(2)

LAMICTAL XR – lamotrigine tab er 24hr 25 mg (21) & 50 mg (7)titration kit

(2)

LAMICTAL XR – lamotrigine tab er 24hr 25 (14) & 50 mg (14) &100 mg(7) kit

(2)

LAMICTAL XR – lamotrigine tab er 24hr 50 (14) & 100 mg(14) &200 mg(7) kit

(2)

LAMICTAL XR – lamotrigine tab er 24hr 25 mg (2)LAMICTAL XR – lamotrigine tab er 24hr 50 mg (2)

2019



63

Name of Drug


LAMICTAL XR – lamotrigine tab er 24hr 100 mg (2)LAMICTAL XR – lamotrigine tab er 24hr 200 mg (2)LAMICTAL XR – lamotrigine tab er 24hr 250 mg (2)LAMICTAL XR – lamotrigine tab er 24hr 300 mg (2)lamotrigine orally disintegrating tab 25 mg (Lamictal odt) (1)lamotrigine orally disintegrating tab 50 mg (Lamictal odt) (1)lamotrigine orally disintegrating tab 100 mg (Lamictal odt) (1)lamotrigine orally disintegrating tab 200 mg (Lamictal odt) (1)lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di) (1)lamotrigine tab chewable dispersible 25 mg (Lamictal chewable

di)(1)

lamotrigine tab er 24hr 25 mg (Lamictal xr) (1)lamotrigine tab er 24hr 50 mg (Lamictal xr) (1)lamotrigine tab er 24hr 100 mg (Lamictal xr) (1)lamotrigine tab er 24hr 200 mg (Lamictal xr) (1)lamotrigine tab er 24hr 250 mg (Lamictal xr) (1)lamotrigine tab er 24hr 300 mg (Lamictal xr) (1)lamotrigine tab 25 mg (Lamictal) (1)lamotrigine tab 100 mg (Lamictal) (1)lamotrigine tab 150 mg (Lamictal) (1)lamotrigine tab 200 mg (Lamictal) (1)lamotrigine tab 25 mg (35) starter kit (Lamictal starter/tak) (1)lamotrigine tab 25 mg (42) & 100 mg (7) starter kit (Lamictal

starter/not)(1)

lamotrigine tab 25 mg (84) & 100 mg (14) starter kit (Lamictalstarter/tak)

(1)

LEVETIRACETAM – levetiracetam in sodium chloride iv soln500 mg/100ml

(2)


(2)


(2)

levetiracetam oral soln 100 mg/ml (Keppra) (1)levetiracetam tab er 24hr 500 mg (Keppra xr) (1)levetiracetam tab er 24hr 750 mg (Keppra xr) (1)levetiracetam tab 250 mg (Keppra) (1)levetiracetam tab 500 mg (Keppra) (1)

2019



64

Name of Drug


levetiracetam tab 750 mg (Keppra) (1)levetiracetam tab 1000 mg (Keppra) (1)LYRICA – pregabalin soln 20 mg/ml (2) QL (900 mls/30 days), STLYRICA – pregabalin cap 25 mg (2) QL (90 capsules/30 days), STLYRICA – pregabalin cap 50 mg (2) QL (90 capsules/30 days), STLYRICA – pregabalin cap 75 mg (2) QL (90 capsules/30 days), STLYRICA – pregabalin cap 100 mg (2) QL (90 capsules/30 days), STLYRICA – pregabalin cap 150 mg (2) QL (90 capsules/30 days), STLYRICA – pregabalin cap 200 mg (2) QL (90 capsules/30 days), STLYRICA – pregabalin cap 225 mg (2) QL (90 capsules/30 days), STLYRICA – pregabalin cap 300 mg (2) QL (90 capsules/30 days), STMYSOLINE – primidone tab 50 mg (2)MYSOLINE – primidone tab 250 mg (2)NEURONTIN – gabapentin oral soln 250 mg/5ml (2) QL (1500 mls/30 days)NEURONTIN – gabapentin cap 100 mg (2) QL (720 capsules/30 days)NEURONTIN – gabapentin cap 300 mg (2) QL (240 capsules/30 days)NEURONTIN – gabapentin cap 400 mg (2) QL (180 capsules/30 days)NEURONTIN – gabapentin tab 600 mg (2) QL (120 tablets/30 days)NEURONTIN – gabapentin tab 800 mg (2) QL (90 tablets/30 days)ONFI – clobazam suspension 2.5 mg/ml (2) QL (480 mls/30 days)ONFI – clobazam tab 10 mg (2) QL (60 tablets/30 days)ONFI – clobazam tab 20 mg (2) QL (60 tablets/30 days)oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal) (1)oxcarbazepine tab 150 mg (Trileptal) (1)oxcarbazepine tab 300 mg (Trileptal) (1)oxcarbazepine tab 600 mg (Trileptal) (1)OXTELLAR XR – oxcarbazepine tab er 24hr 150 mg (2)OXTELLAR XR – oxcarbazepine tab er 24hr 300 mg (2)OXTELLAR XR – oxcarbazepine tab er 24hr 600 mg (2)PEGANONE – ethotoin tab 250 mg (2)PHENYTEK – phenytoin sodium extended cap 200 mg (2)PHENYTEK – phenytoin sodium extended cap 300 mg (2)phenytoin chew tab 50 mg (Dilantin infatabs) (1)phenytoin sodium extended cap 100 mg (Dilantin) (1)phenytoin sodium extended cap 200 mg (Phenytek) (1)

2019



65

Name of Drug


phenytoin sodium extended cap 300 mg (Phenytek) (1)phenytoin susp 125 mg/5ml (Dilantin-125) (1)primidone tab 50 mg (Mysoline) (1)primidone tab 250 mg (Mysoline) (1)QUDEXY XR – topiramate cap er 24hr sprinkle 25 mg (2) PA, QL (30 capsules/30 days)QUDEXY XR – topiramate cap er 24hr sprinkle 50 mg (2) PA, QL (30 capsules/30 days)QUDEXY XR – topiramate cap er 24hr sprinkle 100 mg (2) PA, QL (30 capsules/30 days)QUDEXY XR – topiramate cap er 24hr sprinkle 150 mg (2) PA, QL (30 capsules/30 days)QUDEXY XR – topiramate cap er 24hr sprinkle 200 mg (2) PA, QL (60 capsules/30 days)SABRIL – vigabatrin tab 500 mg (2) SPSABRIL – vigabatrin powd pack 500 mg (2) SPTEGRETOL – carbamazepine tab 200 mg (2)TEGRETOL – carbamazepine susp 100 mg/5ml (2)TEGRETOL-XR – carbamazepine tab er 12hr 100 mg (2)TEGRETOL-XR – carbamazepine tab er 12hr 200 mg (2)TEGRETOL-XR – carbamazepine tab er 12hr 400 mg (2)tiagabine hcl tab 2 mg (Gabitril) (1)tiagabine hcl tab 4 mg (Gabitril) (1)tiagabine hcl tab 12 mg (Gabitril) (1)tiagabine hcl tab 16 mg (Gabitril) (1)TOPAMAX – topiramate tab 25 mg (2)TOPAMAX – topiramate tab 50 mg (2)TOPAMAX – topiramate tab 100 mg (2)TOPAMAX – topiramate tab 200 mg (2)TOPAMAX SPRINKLE – topiramate sprinkle cap 15 mg (2)TOPAMAX SPRINKLE – topiramate sprinkle cap 25 mg (2)TOPIRAMATE ER – topiramate cap er 24hr sprinkle 25 mg (2) PA, QL (30 capsules/30 days)TOPIRAMATE ER – topiramate cap er 24hr sprinkle 50 mg (2) PA, QL (30 capsules/30 days)TOPIRAMATE ER – topiramate cap er 24hr sprinkle 100 mg (2) PA, QL (30 capsules/30 days)TOPIRAMATE ER – topiramate cap er 24hr sprinkle 150 mg (2) PA, QL (30 capsules/30 days)TOPIRAMATE ER – topiramate cap er 24hr sprinkle 200 mg (2) PA, QL (60 capsules/30 days)topiramate sprinkle cap 15 mg (Topamax sprinkle) (1)topiramate sprinkle cap 25 mg (Topamax sprinkle) (1)topiramate tab 25 mg (Topamax) (1)topiramate tab 50 mg (Topamax) (1)

2019



66

Name of Drug


topiramate tab 100 mg (Topamax) (1)topiramate tab 200 mg (Topamax) (1)TRILEPTAL – oxcarbazepine susp 300 mg/5ml (60 mg/ml) (2)TRILEPTAL – oxcarbazepine tab 150 mg (2)TRILEPTAL – oxcarbazepine tab 300 mg (2)TRILEPTAL – oxcarbazepine tab 600 mg (2)TROKENDI XR – topiramate cap er 24hr 25 mg (2) PA, QL (30 capsules/30 days)TROKENDI XR – topiramate cap er 24hr 50 mg (2) PA, QL (30 capsules/30 days)TROKENDI XR – topiramate cap er 24hr 100 mg (2) PA, QL (30 capsules/30 days)TROKENDI XR – topiramate cap er 24hr 200 mg (2) PA, QL (60 capsules/30 days)valproate sodium oral soln 250 mg/5ml (base equiv) (Depakene) (1)valproic acid cap 250 mg (Depakene) (1)vigabatrin powd pack 500 mg (Sabril) (1) SPvigabatrin tab 500 mg (Sabril) (1) SPVIMPAT – lacosamide tab 50 mg (2)VIMPAT – lacosamide tab 100 mg (2)VIMPAT – lacosamide tab 150 mg (2)VIMPAT – lacosamide tab 200 mg (2)VIMPAT – lacosamide iv inj 200 mg/20ml (10 mg/ml) (2)VIMPAT – lacosamide oral solution 10 mg/ml (2)ZARONTIN – ethosuximide cap 250 mg (2)ZARONTIN – ethosuximide soln 250 mg/5ml (2)zonisamide cap 25 mg (Zonegran) (1)zonisamide cap 50 mg (Zonegran) (1)zonisamide cap 100 mg (Zonegran) (1)

PARKINSON'S DISEASEamantadine hcl cap 100 mg (1)amantadine hcl syrup 50 mg/5ml (1)benztropine mesylate tab 0.5 mg (1)benztropine mesylate tab 1 mg (1)benztropine mesylate tab 2 mg (1)bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel) (1)carbidopa & levodopa tab er 25-100 mg (Sinemet cr) (1)carbidopa & levodopa tab er 50-200 mg (Sinemet cr) (1)carbidopa & levodopa tab 10-100 mg (Sinemet) (1)

2019



67

Name of Drug


carbidopa & levodopa tab 25-100 mg (Sinemet) (1)carbidopa & levodopa tab 25-250 mg (Sinemet) (1)carbidopa tab 25 mg (Lodosyn) (1)DUOPA – carbidopa-levodopa enteral susp 4.63-20 mg/ml (2)entacapone tab 200 mg (Comtan) (1)pramipexole dihydrochloride tab 0.125 mg (Mirapex) (1)pramipexole dihydrochloride tab 0.25 mg (Mirapex) (1)pramipexole dihydrochloride tab 0.5 mg (Mirapex) (1)pramipexole dihydrochloride tab 0.75 mg (Mirapex) (1)pramipexole dihydrochloride tab 1 mg (Mirapex) (1)pramipexole dihydrochloride tab 1.5 mg (Mirapex) (1)ropinirole hydrochloride tab 0.25 mg (Requip) (1)ropinirole hydrochloride tab 0.5 mg (Requip) (1)ropinirole hydrochloride tab 1 mg (Requip) (1)ropinirole hydrochloride tab 2 mg (Requip) (1)ropinirole hydrochloride tab 3 mg (Requip) (1)ropinirole hydrochloride tab 4 mg (Requip) (1)ropinirole hydrochloride tab 5 mg (Requip) (1)selegiline hcl cap 5 mg (Eldepryl) (1)selegiline hcl tab 5 mg (1)trihexyphenidyl hcl elixir 0.4 mg/ml (1)trihexyphenidyl hcl tab 2 mg (1)trihexyphenidyl hcl tab 5 mg (1)

MUSCLE RELAXANTSbaclofen tab 10 mg (1)baclofen tab 20 mg (1)CHLORZOXAZONE – chlorzoxazone tab 500 mg (2)cyclobenzaprine hcl tab 5 mg (1)cyclobenzaprine hcl tab 10 mg (1)dantrolene sodium cap 25 mg (Dantrium) (1)dantrolene sodium cap 50 mg (Dantrium) (1)dantrolene sodium cap 100 mg (1)methocarbamol tab 500 mg (Robaxin) (1)methocarbamol tab 750 mg (Robaxin-750) (1)orphenadrine citrate tab er 12hr 100 mg (1)

2019



68

Name of Drug


tizanidine hcl tab 2 mg (base equivalent) (1) QL (180 tablets/30 days)tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) (1) QL (180 tablets/30 days)

OTHER NEUROMUSCULAR DRUGSBOTOX – onabotulinumtoxina for inj 100 unit (2) PABOTOX – onabotulinumtoxina for inj 200 unit (2) PApyridostigmine bromide tab 60 mg (Mestinon) (1)riluzole tab 50 mg (Rilutek) (1)

SUPPLEMENTSVITAMINSascorbic acid cap er 500 mg (1)ascorbic acid tab 250 mg (1)ascorbic acid tab 500 mg (1)cholecalciferol cap 1000 unit (1)cholecalciferol cap 2000 unit (1)cholecalciferol cap 5000 unit (1)cholecalciferol cap 10000 unit (1)cholecalciferol cap 50000 unit (1)cholecalciferol oral liquid 400 unit/ml (1)cholecalciferol tab 400 unit (1)cholecalciferol tab 1000 unit (1)cholecalciferol tab 2000 unit (1)cholecalciferol tab 50000 unit (1)cyanocobalamin inj 1000 mcg/ml (1)cyanocobalamin tab er 1000 mcg (1)cyanocobalamin tab 100 mcg (1)cyanocobalamin tab 250 mcg (1)cyanocobalamin tab 500 mcg (1)cyanocobalamin tab 1000 mcg (1)DECARA – cholecalciferol cap 25000 unit (2)ergocalciferol cap 50000 unit (1)folic acid tab 400 mcg (1)folic acid tab 800 mcg (1)folic acid tab 1 mg (1)folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg (1)folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx) (1)

2019



69

Name of Drug


folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg (1)iron combination cap (1)iron polysacch complex-vit b12-fa cap 150-0.025-1 mg (1)iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg

(Hematron-af)(1)

iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite150)

(1)

niacin cap er 250 mg (1)niacin cap er 500 mg (1)niacin tab er 250 mg (1)niacin tab er 500 mg (1)niacin tab er 750 mg (1)niacin tab 100 mg (1)niacin tab 500 mg (1)NIACIN TR – niacin tab er 1000 mg (2)phytonadione tab 5 mg (Mephyton) (1)PYRIDOXINE HCL – pyridoxine hcl inj 100 mg/ml (2)pyridoxine hcl tab 25 mg (1)pyridoxine hcl tab 50 mg (1)pyridoxine hcl tab 100 mg (1)SLO-NIACIN – niacin tab er 500 mg (2)SLO-NIACIN – niacin tab er 750 mg (2)thiamine hcl tab 50 mg (1)thiamine hcl tab 100 mg (1)

MULTIVITAMINSb-complex w/ c & folic acid cap 1 mg (Nephrocaps) (1)b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx) (1)b-complex w/ c & folic acid tab 5 mg (1)EQ MULTIVITAMINS ADULT GU – multiple vitamins w/ minerals

chew tab(2)

FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals & folic acidtab 5 mg

(2)

ICAPS AREDS 2 – multiple vitamins w/ minerals chew tab (2)multiple vitamin tab (1)multiple vitamins w/ iron tab (1)multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite) (1)

2019



70

Name of Drug


multiple vitamins w/ minerals cap (1)multiple vitamins w/ minerals tab (Strovite forte) (1)pediatric multiple vitamin w/ c & fa chew tab (1)pediatric multiple vitamin w/ minerals & c drops 45 mg/ml (1)POLY-VI-SOL – pediatric multiple vitamin w/ c soln 35 mg/ml (2)PRESERVISION AREDS 2 – multiple vitamins w/ minerals cap (2)TRI-VI-SOL – pediatric vitamins adc drops 750 unit-400

unit-35 mg/ml(2)

MINERALS AND ELECTROLYTEScalcium carbonate tab 1250 mg (500 mg elemental ca) (1)calcium carbonate-cholecalciferol tab 500 mg-200 unit (1)calcium carbonate-cholecalciferol tab 600 mg-400 unit (1)calcium carbonate-vitamin d tab 250 mg-125 unit (1)calcium carbonate-vitamin d tab 500 mg-200 unit (1)calcium carbonate-vitamin d tab 600 mg-400 unit (1)calcium citrate tab 950 mg (200 mg elemental ca) (1)fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap

(Tandem plus)(1)

fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg (1)fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg (1)ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg (1)ferrous fumarate-folic acid tab 324-1 mg (1)ferrous sulfate tab ec 325 mg (65 mg fe equivalent) (1)ferrous sulfate tab 325 mg (65 mg elemental fe) (1)K-PHOS – potassium phosphate monobasic tab 500 mg (2)MAGNESIUM CHLORIDE – magnesium chloride inj 200 mg/ml (2)magnesium oxide tab 400 mg (241.3 mg elemental mg) (1)oral electrolyte solution (1)pot phos monobasic w/sod phos di & monobas tab

155-852-130mg (K-phos neutral)(1)

potassium bicarbonate effer tab 25 meq (1)potassium chloride cap er 8 meq (Micro-k) (1)potassium chloride cap er 10 meq (Micro-k) (1)POTASSIUM CHLORIDE ER – potassium chloride tab er 8 meq

(600 mg)(2)

potassium chloride microencapsulated crys er tab 10 meq (1)

2019



71

Name of Drug


potassium chloride microencapsulated crys er tab 20 meq (1)potassium chloride oral soln 10% (20 meq/15ml) (1)potassium chloride oral soln 20% (40 meq/15ml) (1)potassium chloride powder packet 20 meq (1)potassium chloride tab er 8 meq (600 mg) (1)potassium chloride tab er 10 meq (K-tab) (1)sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (1)sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (1)sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (1)sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (1)

OTHER SUPPLEMENTSFISH OIL ULTRA – omega-3 fatty acids cap 1400 mg (2)OMEGA-3 – omega-3 fatty acids cap 1400 mg (2)OMEGA-3 IQ – omega-3 fatty acids chew tab 240 mg (2)omega-3 fatty acids cap 500 mg (1)omega-3 fatty acids cap 435 mg (1)omega-3 fatty acids cap 1000 mg (1)omega-3 fatty acids cap 1200 mg (1)omega-3 fatty acids cap delayed release 1000 mg (1)omega-3 fatty acids cap delayed release 1200 mg (1)PRO NUTRIENTS OMEGA 3 – omega-3 fatty acids cap delayed

release 332.5 mg(2)

BLOOD MODIFYING DRUGSADVATE – antihemophilic factor rahf-pfm for inj 250 unit (2) PA, SPADVATE – antihemophilic factor rahf-pfm for inj 500 unit (2) PA, SPADVATE – antihemophilic factor rahf-pfm for inj 1000 unit (2) PA, SPADVATE – antihemophilic factor rahf-pfm for inj 1500 unit (2) PA, SPADVATE – antihemophilic factor rahf-pfm for inj 2000 unit (2) PA, SPADVATE – antihemophilic factor rahf-pfm for inj 3000 unit (2) PA, SPADVATE – antihemophilic factor rahf-pfm for inj 4000 unit (2) PA, SPADYNOVATE – antihemophilic factor recomb pegylated for inj

250 unit(2) PA, SP

ADYNOVATE – antihemophilic factor recomb pegylated for inj500 unit

(2) PA, SP


(2) PA, SP

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72

Name of Drug



(2) PA, SP


(2) PA, SP


(2) PA, SP


(2) PA, SP

ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf(human) for inj 250 unit

(2) PA, SP


(2) PA, SP


(2) PA, SP


(2) PA, SP


(2) PA, SP

ALPHANINE SD – coagulation factor ix for inj 500 unit (2) PA, SPALPHANINE SD – coagulation factor ix for inj 1000 unit (2) PA, SPALPHANINE SD – coagulation factor ix for inj 1500 unit (2) PA, SPanagrelide hcl cap 0.5 mg (Agrylin) (1)anagrelide hcl cap 1 mg (1)ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled

syringe 10 mcg/0.4ml(2) PA, SP

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilledsyringe 25 mcg/0.42ml

(2) PA, SP


(2) PA, SP


(2) PA, SP


(2) PA, SP


(2) PA, SP


(2) PA, SP


(2) PA, SP

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilledsyringe 500 mcg/ml

(2) PA, SP

2019



73

Name of Drug


ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25 mcg/ml

(2) PA, SP


(2) PA, SP


(2) PA, SP


(2) PA, SP


(2) PA, SP


(2) PA, SP

aspirin-dipyridamole cap er 12hr 25-200 mg (Aggrenox) (1)BENEFIX – coagulation factor ix (recombinant) for inj kit 250 unit (2) PA, SPBENEFIX – coagulation factor ix (recombinant) for inj kit 500 unit (2) PA, SPBENEFIX – coagulation factor ix (recombinant) for inj kit 1000

unit(2) PA, SP

BENEFIX – coagulation factor ix (recombinant) for inj kit 2000unit

(2) PA, SP

BENEFIX – coagulation factor ix (recombinant) for inj kit 3000unit

(2) PA, SP

BRILINTA – ticagrelor tab 60 mg (2) PA, QL (60 tablets/30 days)BRILINTA – ticagrelor tab 90 mg (2) PA, QL (60 tablets/30 days)cilostazol tab 50 mg (1)cilostazol tab 100 mg (1)clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) (1)clopidogrel bisulfate tab 300 mg (base equiv) (Plavix) (1)COAGADEX – coagulation factor x (human) for inj 250 unit (2) PA, SPCOAGADEX – coagulation factor x (human) for inj 500 unit (2) PA, SPdipyridamole tab 25 mg (1)dipyridamole tab 50 mg (1)dipyridamole tab 75 mg (1)ELIQUIS – apixaban tab 2.5 mg (2) PA, QL (60 tablets/30 days)ELIQUIS – apixaban tab 5 mg (2) PA, QL (74 tablets/30 days)ELIQUIS STARTER PACK – apixaban tab 5 mg (2) PA, QL (74 tablets/180 days)enoxaparin sodium inj 30 mg/0.3ml (Lovenox) (1) QL (30 syringes/365 days)enoxaparin sodium inj 40 mg/0.4ml (Lovenox) (1) QL (30 syringes/365 days)enoxaparin sodium inj 60 mg/0.6ml (Lovenox) (1) QL (30 syringes/365 days)

2019



74

Name of Drug


enoxaparin sodium inj 80 mg/0.8ml (Lovenox) (1) QL (30 syringes/365 days)enoxaparin sodium inj 100 mg/ml (Lovenox) (1) QL (30 syringes/365 days)enoxaparin sodium inj 120 mg/0.8ml (Lovenox) (1) QL (30 syringes/365 days)enoxaparin sodium inj 150 mg/ml (Lovenox) (1) QL (30 syringes/365 days)enoxaparin sodium inj 300 mg/3ml (Lovenox) (1) QL (30 vials/365 days)FIRAZYR – icatibant acetate inj 30 mg/3ml (base equivalent) (2) PA, QL (6 syringes/30

days), SPFULPHILA – pegfilgrastim-jmdb soln prefilled syringe 6 mg/0.6ml (2) PA, SPHEMOFIL M – antihemophilic factor (human) for inj 250 unit (2) PA, SPHEMOFIL M – antihemophilic factor (human) for inj 500 unit (2) PA, SPHEMOFIL M – antihemophilic factor (human) for inj 1000 unit (2) PA, SPHEMOFIL M – antihemophilic factor (human) for inj 1700 unit (2) PA, SPHUMATE-P – antihemophilic factor/vwf (human) for inj 250-600

unit(2) PA, SP

HUMATE-P – antihemophilic factor/vwf (human) for inj 500-1200unit

(2) PA, SP

HUMATE-P – antihemophilic factor/vwf (human) for inj1000-2400 unit

(2) PA, SP

IXINITY – coagulation factor ix (recombinant) for inj 250 unit (2) PA, SPIXINITY – coagulation factor ix (recombinant) for inj 500 unit (2) PA, SPIXINITY – coagulation factor ix (recombinant) for inj 1000 unit (2) PA, SPIXINITY – coagulation factor ix (recombinant) for inj 1500 unit (2) PA, SPIXINITY – coagulation factor ix (recombinant) for inj 2000 unit (2) PA, SPIXINITY – coagulation factor ix (recombinant) for inj 3000 unit (2) PA, SPKOATE – antihemophilic factor (human) for inj 250 unit (2) PA, SPKOATE – antihemophilic factor (human) for inj 500 unit (2) PA, SPKOATE – antihemophilic factor (human) for inj 1000 unit (2) PA, SPKOATE-DVI – antihemophilic factor (human) for inj 250 unit (2) PA, SPKOATE-DVI – antihemophilic factor (human) for inj 500 unit (2) PA, SPKOATE-DVI – antihemophilic factor (human) for inj 1000 unit (2) PA, SPKOGENATE FS – antihemophilic factor (recombinant) for inj kit

250 unit(2) PA, SP

KOGENATE FS – antihemophilic factor (recombinant) for inj kit500 unit

(2) PA, SP


(2) PA, SP


(2) PA, SP

2019



75

Name of Drug



(2) PA, SP

LMD 10% DEXTROSE 5% – dextran 40 inj 10% in d5w (2)MONOCLATE-P – antihemophilic factor (human) for inj kit 1000

unit(2) PA, SP

MONONINE – coagulation factor ix for inj 1000 unit (2) PA, SPpentoxifylline tab er 400 mg (1)PROFILNINE – factor ix complex for inj 500 unit (2) PA, SPPROFILNINE – factor ix complex for inj 1000 unit (2) PA, SPPROFILNINE – factor ix complex for inj 1500 unit (2) PA, SPPROFILNINE SD – factor ix complex for inj 500 unit (2) PA, SPPROFILNINE SD – factor ix complex for inj 1000 unit (2) PA, SPPROFILNINE SD – factor ix complex for inj 1500 unit (2) PA, SPRECOMBINATE – antihemophilic factor (recombinant) for inj

220-400 unit(2) PA, SP

RECOMBINATE – antihemophilic factor (recombinant) for inj401-800 unit

(2) PA, SP


(2) PA, SP


(2) PA, SP


(2) PA, SP

RETACRIT – epoetin alfa-epbx inj 2000 unit/ml (2) PA, SPRETACRIT – epoetin alfa-epbx inj 3000 unit/ml (2) PA, SPRETACRIT – epoetin alfa-epbx inj 4000 unit/ml (2) PA, SPRETACRIT – epoetin alfa-epbx inj 10000 unit/ml (2) PA, SPRETACRIT – epoetin alfa-epbx inj 40000 unit/ml (2) PA, SPRIXUBIS – coagulation factor ix (recombinant) for inj 250 unit (2) PA, SPRIXUBIS – coagulation factor ix (recombinant) for inj 500 unit (2) PA, SPRIXUBIS – coagulation factor ix (recombinant) for inj 1000 unit (2) PA, SPRIXUBIS – coagulation factor ix (recombinant) for inj 2000 unit (2) PA, SPRIXUBIS – coagulation factor ix (recombinant) for inj 3000 unit (2) PA, SPtranexamic acid tab 650 mg (Lysteda) (1)warfarin sodium tab 1 mg (Coumadin) (1)warfarin sodium tab 2 mg (Coumadin) (1)warfarin sodium tab 2.5 mg (Coumadin) (1)warfarin sodium tab 3 mg (Coumadin) (1)

2019



76

Name of Drug


warfarin sodium tab 4 mg (Coumadin) (1)warfarin sodium tab 5 mg (Coumadin) (1)warfarin sodium tab 6 mg (Coumadin) (1)warfarin sodium tab 7.5 mg (Coumadin) (1)warfarin sodium tab 10 mg (Coumadin) (1)XARELTO – rivaroxaban tab 10 mg (2) QL (35 tablets/365 days)XARELTO – rivaroxaban tab 15 mg (2) PA, QL (60 tablets/30 days)XARELTO – rivaroxaban tab 20 mg (2) PA, QL (30 tablets/30 days)XARELTO STARTER PACK – rivaroxaban tab starter therapy

pack 15 mg & 20 mg(2) PA, QL (51 tablets/30 days)

XYNTHA – antihemophilic factor recombinant paf for inj kit 250unit

(2) PA, SP


(2) PA, SP


(2) PA, SP


(2) PA, SP

XYNTHA SOLOFUSE – antihemophilic factor recombinant paf forinj kit 250 unit

(2) PA, SP


(2) PA, SP


(2) PA, SP


(2) PA, SP


(2) PA, SP

ZARXIO – filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml (2) PA, SPZARXIO – filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml (2) PA, SP

TOPICAL DRUGSEYEAnti-infectivesBACITRACIN – bacitracin ophth oint 500 unit/gm (2)bacitracin-polymyxin b ophth oint (1)ciprofloxacin hcl ophth soln 0.3% (Ciloxan) (1)erythromycin ophth oint 5 mg/gm (1)GENTAK – gentamicin sulfate ophth oint 0.3% (2)gentamicin sulfate ophth soln 0.3% (1)

2019



77

Name of Drug


levofloxacin ophth soln 0.5% (1)moxifloxacin hcl ophth soln 0.5% (base equiv) (Vigamox) (1)NATACYN – natamycin ophth susp 5% (2)neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin (1)NEOMYCIN/POLYMYXIN/GRAMIC – neomycin-polymy-gramicid

op sol 1.75-10000-0.025mg-unt-mg/ml(2)

ofloxacin ophth soln 0.3% (Ocuflox) (1)polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%

(Polytrim)(1)

sulfacetamide sodium ophth soln 10% (Bleph-10) (1)tobramycin ophth soln 0.3% (Tobrex) (1)trifluridine ophth soln 1% (Viroptic) (1)

Steroids and Combination Productsbacitracin-polymyxin-neomycin-hc ophth oint 1% (1)DEXAMETHASONE SODIUM PHOS – dexamethasone sodium

phosphate ophth soln 0.1%(2)

fluorometholone ophth susp 0.1% (Fml liquifilm) (1)neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol) (1)neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol) (1)prednisolone acetate ophth susp 1% (Pred forte) (1)PREDNISOLONE SODIUM PHOSP – prednisolone sodium

phosphate ophth soln 1%(2)

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

(2)

tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex) (1)

GlaucomaALPHAGAN P – brimonidine tartrate ophth soln 0.1% (2)apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine) (1)betaxolol hcl ophth soln 0.5% (1)brimonidine tartrate ophth soln 0.2% (1)CARTEOLOL HCL – carteolol hcl ophth soln 1% (2)dorzolamide hcl ophth soln 2% (Trusopt) (1)dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml

(Cosopt)(1)

latanoprost ophth soln 0.005% (Xalatan) (1) QL (1 bottle/30 days)levobunolol hcl ophth soln 0.5% (Betagan) (1)pilocarpine hcl ophth soln 1% (Isopto carpine) (1)

2019



78

Name of Drug


pilocarpine hcl ophth soln 2% (Isopto carpine) (1)pilocarpine hcl ophth soln 4% (Isopto carpine) (1)timolol maleate ophth soln 0.25% (Timoptic) (1)timolol maleate ophth soln 0.5% (Timoptic) (1)

Other Eye Productsartificial tear ophth solution (1)ATROPINE SULFATE – atropine sulfate ophth oint 1% (2)ATROPINE SULFATE – atropine sulfate ophth soln 1% (2)azelastine hcl ophth soln 0.05% (1)cromolyn sodium ophth soln 4% (1)cyclopentolate hcl ophth soln 0.5% (Cyclogyl) (1)cyclopentolate hcl ophth soln 1% (Cyclogyl) (1)cyclopentolate hcl ophth soln 2% (Cyclogyl) (1)diclofenac sodium ophth soln 0.1% (1)flurbiprofen sodium ophth soln 0.03% (Ocufen) (1)ISOPTO ATROPINE – atropine sulfate ophth soln 1% (2)ketorolac tromethamine ophth soln 0.4% (Acular ls) (1)ketorolac tromethamine ophth soln 0.5% (Acular) (1)ketotifen fumarate ophth soln 0.025% (base equiv) (1)proparacaine hcl ophth soln 0.5% (1)tetracaine hcl ophth soln 0.5% (1)tetrahydroz-dextran-peg-povidone ophth soln 0.05-0.1-1-1% (1)

EARacetic acid otic soln 2% (1)carbamide peroxide 6.5% otic soln (1)hydrocortisone w/ acetic acid otic soln 1-2% (1)neomycin-polymyxin-hc otic soln 1% (1)neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% (1)ofloxacin otic soln 0.3% (Floxin otic) (1)

MOUTH AND THROAT (local)chlorhexidine gluconate soln 0.12% (Peridex) (1)clotrimazole troche 10 mg (1)lidocaine hcl viscous soln 2% (1)nystatin susp 100000 unit/ml (1)pilocarpine hcl tab 5 mg (Salagen) (1)

2019



79

Name of Drug


pilocarpine hcl tab 7.5 mg (Salagen) (1)sodium fluoride cream 1.1% (Prevident 5000 plus) (1)sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) (1)triamcinolone acetonide dental paste 0.1% (1)

ANORECTAL AGENTShydrocortisone enema 100 mg/60ml (Cortenema) (1)hydrocortisone rectal cream 1% (Proctocort) (1)hydrocortisone rectal cream 2.5% (Anusol-hc) (1)

SKIN CONDITIONS/PRODUCTSAcnebenzoyl peroxide lotion 6% (1) ALclindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5%

(Duac)(1) AL

clindamycin phosphate gel 1% (Cleocin-t) (1) ALclindamycin phosphate lotion 1% (Cleocin-t) (1) ALclindamycin phosphate soln 1% (Cleocin-t) (1) ALclindamycin phosphate swab 1% (Cleocin-t) (1) ALDIFFERIN – adapalene gel 0.1% (2) ALerythromycin gel 2% (Erygel) (1) ALerythromycin pads 2% (1) ALerythromycin soln 2% (1) ALisotretinoin cap 10 mg (1) ALisotretinoin cap 20 mg (1) ALmetronidazole cream 0.75% (Metrocream) (1) ALmetronidazole gel 0.75% (1) ALmetronidazole gel 1% (Metrogel) (1) ALsulfacetamide sodium w/ sulfur emulsion 10-5% (1) ALtazarotene cream 0.1% (Tazorac) (1) ALTAZORAC – tazarotene gel 0.05% (2) ALTAZORAC – tazarotene gel 0.1% (2) ALtretinoin cream 0.025% (Retin-a) (1) ALtretinoin cream 0.05% (Retin-a) (1) ALtretinoin cream 0.1% (Retin-a) (1) ALtretinoin gel 0.01% (Retin-a) (1) ALtretinoin gel 0.025% (Retin-a) (1) AL

2019



80

Name of Drug


Anti-infectivesbacitracin oint 500 unit/gm (1)bacitracin zinc oint 500 unit/gm (1)bacitracin-polymyxin b oint (1)ciclopirox olamine cream 0.77% (base equiv) (Loprox) (1)clotrimazole cream 1% (1)clotrimazole soln 1% (1)clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone) (1)diclofenac sodium gel 1% (Voltaren) (1) QL (200 grams/30 days)econazole nitrate cream 1% (1)gentamicin sulfate cream 0.1% (1)gentamicin sulfate oint 0.1% (1)ketoconazole cream 2% (1)ketoconazole shampoo 2% (Nizoral) (1)miconazole nitrate cream 2% (1)mupirocin oint 2% (1)neomycin-bacitracin-polymyxin oint (1)nystatin cream 100000 unit/gm (1)nystatin oint 100000 unit/gm (1)nystatin topical powder 100000 unit/gm (1)silver sulfadiazine cream 1% (Silvadene) (1)tolnaftate aerosol 1% (1)

Corticosteroidsalclometasone dipropionate cream 0.05% (1)alclometasone dipropionate oint 0.05% (1)AUGMENTED BETAMETHASONE D – betamethasone

dipropionate augmented gel 0.05%(2) QL (180 grams/90 days)

betamethasone dipropionate augmented cream 0.05%(Diprolene af)

(1) QL (180 grams/90 days)

betamethasone dipropionate augmented lotion 0.05% (Diprolene) (1) QL (180 mls/90 days)betamethasone dipropionate augmented oint 0.05% (Diprolene) (1) QL (180 grams/90 days)betamethasone dipropionate cream 0.05% (1) QL (180 grams/90 days)betamethasone dipropionate lotion 0.05% (1) QL (180 mls/90 days)betamethasone dipropionate oint 0.05% (1) QL (180 grams/90 days)betamethasone valerate cream 0.1% (base equivalent) (1)

2019



81

Name of Drug


betamethasone valerate lotion 0.1% (base equivalent) (1)betamethasone valerate oint 0.1% (base equivalent) (1)clobetasol propionate cream 0.05% (Temovate) (1) QL (180 grams/90 days)clobetasol propionate emollient base cream 0.05% (1)clobetasol propionate gel 0.05% (Temovate) (1)clobetasol propionate oint 0.05% (Temovate) (1) QL (180 grams/90 days)clobetasol propionate soln 0.05% (Temovate) (1) QL (180 mls/90 days)desoximetasone cream 0.25% (Topicort) (1) QL (180 grams/90 days)fluocinolone acetonide cream 0.01% (1)fluocinolone acetonide cream 0.025% (Synalar) (1)fluocinolone acetonide oint 0.025% (Synalar) (1)fluocinolone acetonide soln 0.01% (Synalar) (1)fluocinonide cream 0.05% (1) QL (180 grams/90 days)fluocinonide emulsified base cream 0.05% (1) QL (180 grams/90 days)fluocinonide gel 0.05% (1) QL (180 grams/90 days)fluocinonide oint 0.05% (1) QL (180 grams/90 days)fluocinonide soln 0.05% (1) QL (180 mls/90 days)fluticasone propionate cream 0.05% (Cutivate) (1)fluticasone propionate oint 0.005% (1)halobetasol propionate cream 0.05% (Ultravate) (1) QL (180 grams/90 days)halobetasol propionate oint 0.05% (Ultravate) (1) QL (180 grams/90 days)hydrocortisone butyrate oint 0.1% (Locoid) (1)hydrocortisone cream 0.5% (1)hydrocortisone cream 1% (1)hydrocortisone cream 2.5% (1)hydrocortisone lotion 2.5% (1)hydrocortisone oint 0.5% (1)hydrocortisone oint 1% (1)hydrocortisone oint 2.5% (1)hydrocortisone valerate cream 0.2% (1)hydrocortisone valerate oint 0.2% (Westcort) (1)mometasone furoate cream 0.1% (Elocon) (1)mometasone furoate oint 0.1% (Elocon) (1) QL (180 grams/90 days)mometasone furoate solution 0.1% (lotion) (1)PREDNICARBATE – prednicarbate cream 0.1% (2)

2019



82

Name of Drug


PREDNICARBATE – prednicarbate oint 0.1% (2)triamcinolone acetonide cream 0.025% (1)triamcinolone acetonide cream 0.1% (1)triamcinolone acetonide cream 0.5% (1) QL (180 grams/90 days)triamcinolone acetonide lotion 0.025% (1)triamcinolone acetonide lotion 0.1% (1)triamcinolone acetonide oint 0.025% (1)triamcinolone acetonide oint 0.1% (1)

Other Skin Productscalcipotriene cream 0.005% (Dovonex) (1)calcipotriene oint 0.005% (1)calcipotriene soln 0.005% (50 mcg/ml) (1)COSENTYX – secukinumab subcutaneous soln prefilled syringe


days), SPCOSENTYX SENSOREADY PEN – secukinumab subcutaneous

soln auto-injector 150 mg/ml(2) PA, QL (2 pens/28 days), SP

FLUOROURACIL – fluorouracil soln 2% (2)FLUOROURACIL – fluorouracil soln 5% (2)fluorouracil cream 5% (Efudex) (1) QL (240 grams/180 days)imiquimod cream 5% (Aldara) (1) QL (48 packets/180 days)lactic acid (ammonium lactate) lotion 5% (1)lactic acid (ammonium lactate) lotion 12% (Lac-hydrin) (1)lidocaine hcl cream 3% (1) QL (120 grams/30 days)lidocaine hcl gel 2% (1) QL (120 grams/30 days)lidocaine hcl soln 4% (Xylocaine) (1) QL (120 grams/30 days)lidocaine oint 5% (1) PA, QL (71 grams/25 days)lidocaine patch 5% (Lidoderm) (1) PA, QL (90 patches/30 days)lidocaine-prilocaine cream kit 2.5-2.5% (1)lidocaine-prilocaine cream 2.5-2.5% (1) QL (30 grams/60 days)malathion lotion 0.5% (Ovide) (1)methoxsalen rapid cap 10 mg (Oxsoralen ultra) (1)permethrin cream 5% (Elimite) (1)permethrin creme rinse 1% (1)podofilox soln 0.5% (1)QC CALAMINE – calamine lotion (2)

2019



83

Name of Drug


selenium sulfide lotion 2.5% (1)tacrolimus oint 0.03% (Protopic) (1) QL (60 days

supply/120 days), STtacrolimus oint 0.1% (Protopic) (1) QL (60 days

supply/120 days), STVALCHLOR – mechlorethamine hcl gel 0.016% (base equivalent) (2) PA, SPvitamins a & d oint (1)zinc oxide oint 20% (1)zinc oxide oint 10% (1)ZYCLARA – imiquimod cream 3.75% (2) PA, QL (56 packets/180 days)ZYCLARA PUMP – imiquimod cream 2.5% (2) PA, QL (15 grams/180 days)ZYCLARA PUMP – imiquimod cream 3.75% (2) PA, QL (15 grams/180 days)

MISCELLANEOUS CATEGORIES (includes supplies and devices)DIABETIC SUPPLIESONETOUCH ULTRA BLUE TEST STRIP – glucose blood test

strip(2) QL (153 strips/30 days), ST

ONETOUCH ULTRA CONTROL – blood glucose calibration -liquid

(2)

ONETOUCH ULTRA MINI – blood glucose monitoring kit w/device

(2)

ONETOUCH ULTRA 2 – blood glucose monitoring kit w/ device (2)ONETOUCH VERIO – blood glucose monitoring kit w/ device (2)ONETOUCH VERIO CONTROL SO – blood glucose calibration -

liquid - high(2)

ONETOUCH VERIO FLEX BLOOD – blood glucose monitoringkit w/ device

(2)

ONETOUCH VERIO IQ BLOOD G – blood glucose monitoring kitw/ device

(2)

ONETOUCH VERIO MID CONTRO – blood glucose calibration -liquid

(2)

ONETOUCH VERIO TEST STRIP – glucose blood test strip (2) QL (153 strips/30 days), ST– ALCOHOL PREP PADS (2) QL (200 swabs/30 days)– INSULIN SYRINGES - TECHLITE AND TRUEPLUS (2) QL (200 syringes/30 days)– LANCETS - ONETOUCH AND LIFESCAN (2) QL (200 units/30 days)– ONETOUCH DELICA LANCING DEVICE (2)– ONETOUCH SURESOFT LANCING DEVICE (2)– INSULIN PEN NEEDLES- TECHLITE AND TRUEPLUS (2) QL (200 insulin pen

needles/30 days)

2019



84

Name of Drug


MISCELLANEOUS DRUGSazathioprine tab 50 mg (Imuran) (1)CHEMET – succimer cap 100 mg (2)cyclosporine cap 25 mg (Sandimmune) (1)cyclosporine cap 100 mg (Sandimmune) (1)cyclosporine modified cap 50 mg (2)cyclosporine modified cap 25 mg (Neoral) (1)cyclosporine modified cap 100 mg (Neoral) (1)cyclosporine modified oral soln 100 mg/ml (Neoral) (1)D-PENAMINE – penicillamine tab 125 mg (2) PADEPEN TITRATABS – penicillamine tab 250 mg (2) PA, SPirrigation solution, physiological (1)lactated ringer's for irrigation (1)mycophenolate mofetil cap 250 mg (Cellcept) (1)mycophenolate mofetil for oral susp 200 mg/ml (Cellcept) (1)mycophenolate mofetil tab 500 mg (Cellcept) (1)mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)

(Myfortic)(1)

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

(1)

NALOXONE HCL – naloxone hcl soln cartridge 0.4 mg/ml (2)NALOXONE HCL – naloxone hcl soln prefilled syringe 2 mg/2ml (2)NARCAN – naloxone hcl nasal spray 4 mg/0.1ml (2)REVLIMID – lenalidomide caps 2.5 mg (2) PA, QL (30 capsules/30

days), SPREVLIMID – lenalidomide cap 5 mg (2) PA, QL (30 capsules/30





days), SPringer's solution for irrigation (1)sirolimus tab 0.5 mg (Rapamune) (1)

2019



85

Name of Drug


sirolimus tab 1 mg (Rapamune) (1)sirolimus tab 2 mg (Rapamune) (1)sodium polystyrene sulfonate oral susp 15 gm/60ml (1)sodium polystyrene sulfonate powder (1)sodium polystyrene sulfonate rectal susp 30 gm/120ml (1)tacrolimus cap 0.5 mg (Prograf) (1)tacrolimus cap 1 mg (Prograf) (1)tacrolimus cap 5 mg (Prograf) (1)THALOMID – thalidomide cap 50 mg (2) PA, QL (30 capsules/30

days), SPTHALOMID – thalidomide cap 100 mg (2) PA, QL (30 capsules/30

days), SPTHALOMID – thalidomide cap 150 mg (2) PA, QL (60 capsules/30

days), SPwater for irrigation, sterile irrigation soln (1)ZORTRESS – everolimus tab 0.25 mg (2)ZORTRESS – everolimus tab 0.5 mg (2)ZORTRESS – everolimus tab 0.75 mg (2)ZORTRESS – everolimus tab 1 mg (2)

2019

86

INDEX

Aabacavir sulfate-lamivudine tab 600-300 mg (Epzicom)..... 5abacavir sulfate-lamivudine-zidovudine tab 300-150-300mg (Trizivir)......................................................................... 5

abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen)........ 5abacavir sulfate tab 300 mg (base equiv) (Ziagen).............5ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 300 mg.................................................................46

ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 400 mg.................................................................46

ABILIFY MAINTENA – aripiprazole im for extendedrelease susp 300 mg........................................................46

ABILIFY MAINTENA – aripiprazole im for extendedrelease susp 400 mg........................................................46

abiraterone acetate tab 250 mg (Zytiga)...........................10acamprosate calcium tab delayed release 333 mg...........52acarbose tab 25 mg (Precose)..........................................19acarbose tab 50 mg (Precose)..........................................19acarbose tab 100 mg (Precose)........................................19acebutolol hcl cap 200 mg.................................................26acebutolol hcl cap 400 mg.................................................26ACETAMINOPHEN/CAFFEINE/DI – acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg................. 54

acetaminophen cap 500 mg.............................................. 53acetaminophen chew tab 80 mg....................................... 53acetaminophen chew tab 160 mg..................................... 53acetaminophen disintegrating tab 80 mg.......................... 53acetaminophen liquid 160 mg/5ml.....................................53acetaminophen soln 160 mg/5ml.......................................53acetaminophen suppos 120 mg........................................ 53acetaminophen susp 160 mg/5ml......................................53acetaminophen tab 325 mg............................................... 53acetaminophen tab 500 mg............................................... 53acetaminophen w/ codeine soln 120-12 mg/5ml...............54acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine).............................................................................54

acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3)....................................................................... 54

acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4)....................................................................... 54

acetazolamide cap er 12hr 500 mg (Diamox)................... 31acetazolamide tab 125 mg................................................ 31acetazolamide tab 250 mg................................................ 31acetic acid otic soln 2%..................................................... 78acetylcysteine inhal soln 10%............................................35acetylcysteine inhal soln 20%............................................35ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml(2000000 unit/0.5ml).........................................................10

acyclovir cap 200 mg (Zovirax)........................................... 5acyclovir susp 200 mg/5ml (Zovirax)...................................5acyclovir tab 400 mg (Zovirax)............................................ 5acyclovir tab 800 mg (Zovirax)............................................ 5

ADACEL – tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml............................................................................9

ADMELOG – insulin lispro inj 100 unit/ml......................... 20ADMELOG SOLOSTAR – insulin lispro soln pen-injector100 unit/ml........................................................................ 20

ADVATE – antihemophilic factor rahf-pfm for inj 250unit.....................................................................................71







ADYNOVATE – antihemophilic factor recomb pegylatedfor inj 250 unit.................................................................. 71



ADYNOVATE – antihemophilic factor recomb pegylatedfor inj 1000 unit................................................................ 72




AFINITOR DISPERZ – everolimus tab for oral susp 2mg......................................................................................10



AFINITOR – everolimus tab 2.5 mg.................................. 10AFINITOR – everolimus tab 5 mg..................................... 10AFINITOR – everolimus tab 7.5 mg.................................. 10AFINITOR – everolimus tab 10 mg................................... 10AFLURIA 2018-2019 – influenza virus vaccine split imsusp.....................................................................................9

AFLURIA QUADRIVALENT 2018 – influenza virusvaccine split quadrivalent im inj.........................................9

albendazole tab 200 mg (Albenza)......................................8ALBUTEROL SULFATE HFA – albuterol sulfate inhal aero108 mcg/act (90mcg base equiv).................................... 36

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..............36albuterol sulfate soln nebu 0.5% (5 mg/ml).......................36albuterol sulfate soln nebu 0.63 mg/3ml (base equiv).......36albuterol sulfate soln nebu 1.25 mg/3ml (base equiv).......36albuterol sulfate syrup 2 mg/5ml....................................... 36alclometasone dipropionate cream 0.05%........................ 80

2019

87

alclometasone dipropionate oint 0.05%............................ 80ALCOHOL PREP PADS – ALCOHOL PREP PADS......... 83ALENDRONATE SODIUM – alendronate sodium tab 40mg......................................................................................22

alendronate sodium tab 5 mg............................................22alendronate sodium tab 10 mg..........................................22alendronate sodium tab 35 mg..........................................22alendronate sodium tab 70 mg (Fosamax)....................... 22alfuzosin hcl tab er 24hr 10 mg (Uroxatral).......................43ALKERAN – melphalan tab 2 mg......................................10allopurinol tab 100 mg (Zyloprim)......................................59allopurinol tab 300 mg (Zyloprim)......................................59ALOGLIPTIN/METFORMIN HCL – alogliptin-metforminhcl tab 12.5-500 mg......................................................... 19

ALOGLIPTIN/METFORMIN HCL – alogliptin-metforminhcl tab 12.5-1000 mg....................................................... 19

ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazonetab 12.5-15 mg................................................................. 19



ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazonetab 25-15 mg.................................................................... 19



ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (baseequiv).................................................................................19

ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (baseequiv).................................................................................19

ALOGLIPTIN – alogliptin benzoate tab 25 mg (baseequiv).................................................................................19

ALPHAGAN P – brimonidine tartrate ophth soln 0.1%..... 77ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for inj 250 unit.............................................72

ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for inj 500 unit.............................................72

ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for inj 1000 unit...........................................72



ALPHANINE SD – coagulation factor ix for inj 500unit.....................................................................................72



alprazolam tab 0.25 mg (Xanax)....................................... 43alprazolam tab 0.5 mg (Xanax)......................................... 43alprazolam tab 1 mg (Xanax)............................................ 43alprazolam tab 2 mg (Xanax)............................................ 43

alum & mag hydroxide-simethicone susp 200-200-20mg/5ml...............................................................................39

alum & mag hydroxide-simethicone susp 400-400-40mg/5ml...............................................................................39

amantadine hcl cap 100 mg.............................................. 66amantadine hcl syrup 50 mg/5ml...................................... 66amiloride & hydrochlorothiazide tab 5-50 mg....................31amiloride hcl tab 5 mg....................................................... 31amiodarone hcl tab 200 mg...............................................32amitriptyline hcl tab 10 mg.................................................44amitriptyline hcl tab 50 mg.................................................44amitriptyline hcl tab 75 mg.................................................44amitriptyline hcl tab 100 mg...............................................44amitriptyline hcl tab 150 mg...............................................44amitriptyline hcl tab 25 mg (Elavil).................................... 44amlodipine besylate-benazepril hcl cap 2.5-10 mg...........27amlodipine besylate-benazepril hcl cap 5-40 mg..............27amlodipine besylate-benazepril hcl cap 5-10 mg(Lotrel)............................................................................... 27

amlodipine besylate-benazepril hcl cap 5-20 mg(Lotrel)............................................................................... 27



amlodipine besylate tab 2.5 mg (base equivalent)(Norvasc)...........................................................................27

amlodipine besylate tab 5 mg (base equivalent)(Norvasc)...........................................................................27

amlodipine besylate tab 10 mg (base equivalent)(Norvasc)...........................................................................27

amlodipine besylate-valsartan tab 5-160 mg(Exforge)............................................................................27




amoxicillin & k clavulanate for susp 200-28.5 mg/5ml........ 1amoxicillin & k clavulanate for susp 400-57 mg/5ml........... 1amoxicillin & k clavulanate for susp 250-62.5 mg/5ml(Augmentin).........................................................................1

amoxicillin & k clavulanate for susp 600-42.9 mg/5ml(Augmentin es-600)............................................................ 1

amoxicillin & k clavulanate tab 250-125 mg........................1amoxicillin & k clavulanate tab 500-125 mg(Augmentin).........................................................................1

amoxicillin & k clavulanate tab 875-125 mg(Augmentin).........................................................................1

AMOXICILLIN – amoxicillin (trihydrate) chew tab 125mg........................................................................................1

AMOXICILLIN – amoxicillin (trihydrate) chew tab 250mg........................................................................................1

amoxicillin (trihydrate) cap 250 mg......................................1amoxicillin (trihydrate) cap 500 mg......................................1

2019

88

amoxicillin (trihydrate) for susp 125 mg/5ml........................1amoxicillin (trihydrate) for susp 200 mg/5ml........................1amoxicillin (trihydrate) for susp 250 mg/5ml........................1amoxicillin (trihydrate) for susp 400 mg/5ml........................1amoxicillin (trihydrate) tab 875 mg...................................... 1amphetamine-dextroamphetamine cap er 24hr 5 mg(Adderall xr)...................................................................... 50

amphetamine-dextroamphetamine cap er 24hr 10 mg(Adderall xr)...................................................................... 50





amphetamine-dextroamphetamine tab 5 mg(Adderall)...........................................................................50

amphetamine-dextroamphetamine tab 7.5 mg(Adderall)...........................................................................50


amphetamine-dextroamphetamine tab 12.5 mg(Adderall)...........................................................................50




AMPICILLIN – ampicillin cap 500 mg..................................1anagrelide hcl cap 1 mg.................................................... 72anagrelide hcl cap 0.5 mg (Agrylin)...................................72anastrozole tab 1 mg (Arimidex)....................................... 10apraclonidine hcl ophth soln 0.5% (base equivalent)(Iopidine)........................................................................... 77

aprepitant capsule 40 mg (Emend)................................... 40aprepitant capsule 80 mg (Emend)................................... 40aprepitant capsule 125 mg (Emend)................................. 40APTIOM – eslicarbazepine acetate tab 200 mg................59APTIOM – eslicarbazepine acetate tab 400 mg................59APTIOM – eslicarbazepine acetate tab 600 mg................59APTIOM – eslicarbazepine acetate tab 800 mg................59APTIVUS – tipranavir cap 250 mg...................................... 5APTIVUS – tipranavir oral soln 100 mg/ml......................... 5ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25mcg/ml...............................................................................73

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40mcg/ml...............................................................................73

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60mcg/ml...............................................................................73

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj100 mcg/ml....................................................................... 73



ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 10 mcg/0.4ml.........................................72

ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 25 mcg/0.42ml.......................................72







ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 500 mcg/ml............................................ 72

aripiprazole oral solution 1 mg/ml......................................46aripiprazole tab 2 mg (Abilify)............................................46aripiprazole tab 5 mg (Abilify)............................................46aripiprazole tab 10 mg (Abilify)..........................................46aripiprazole tab 15 mg (Abilify)..........................................46aripiprazole tab 20 mg (Abilify)..........................................46aripiprazole tab 30 mg (Abilify)..........................................46ARISTADA – aripiprazole lauroxil im er susp prefilled syr441 mg/1.6ml....................................................................46

ARISTADA – aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml....................................................................46

ARISTADA – aripiprazole lauroxil im er susp prefilled syr882 mg/3.2ml....................................................................47

ARISTADA – aripiprazole lauroxil im er susp prefilled syr1064 mg/3.9ml..................................................................47

ARISTADA INITIO – aripiprazole lauroxil im er suspprefilled syr 675 mg/2.4ml................................................47

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 50 mcg/act....................................................36

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 100 mcg/act..................................................36

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 200 mcg/act..................................................36

artificial tear ophth solution................................................78ascorbic acid cap er 500 mg............................................. 68ascorbic acid tab 250 mg.................................................. 68ascorbic acid tab 500 mg.................................................. 68aspirin chew tab 81 mg..................................................... 53aspirin-dipyridamole cap er 12hr 25-200 mg(Aggrenox)........................................................................ 73

aspirin tab delayed release 81 mg.................................... 53aspirin tab delayed release 325 mg.................................. 53aspirin tab 325 mg............................................................. 53atazanavir sulfate cap 150 mg (base equiv) (Reyataz).......5atazanavir sulfate cap 200 mg (base equiv) (Reyataz).......5atazanavir sulfate cap 300 mg (base equiv) (Reyataz).......5

2019

89

atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)......26atenolol & chlorthalidone tab 100-25 mg (Tenoretic100)................................................................................... 26

atenolol tab 25 mg (Tenormin).......................................... 26atenolol tab 50 mg (Tenormin).......................................... 26atenolol tab 100 mg (Tenormin)........................................ 26atorvastatin calcium tab 10 mg (base equivalent)(Lipitor).............................................................................. 29

atorvastatin calcium tab 20 mg (base equivalent)(Lipitor).............................................................................. 29



atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)........ 8atovaquone-proguanil hcl tab 250-100 mg (Malarone)....... 8atovaquone susp 750 mg/5ml (Mepron)............................. 8ATRIPLA – efavirenz-emtricitabine-tenofovir df tab600-200-300 mg................................................................. 5

ATROPINE SULFATE – atropine sulfate inj 1 mg/ml........ 39ATROPINE SULFATE – atropine sulfate ophth oint1%..................................................................................... 78

ATROPINE SULFATE – atropine sulfate ophth soln1%..................................................................................... 78

ATROVENT HFA – ipratropium bromide hfa inhal aerosol17 mcg/act........................................................................ 36

AUBAGIO – teriflunomide tab 7 mg.................................. 52AUBAGIO – teriflunomide tab 14 mg................................ 52AUGMENTED BETAMETHASONE D – betamethasonedipropionate augmented gel 0.05%.................................80

AVONEX – interferon beta-1a for im inj kit 30mcg(33mcg(6.6 mu)/vial).........................................................52

AVONEX – interferon beta-1a im prefilled syringe kit 30mcg/0.5ml..........................................................................52

AVONEX PEN – interferon beta-1a im auto-injector kit 30mcg/0.5ml..........................................................................52

azathioprine tab 50 mg (Imuran)....................................... 84azelastine hcl nasal spray 0.1% (137 mcg/spray).............35azelastine hcl ophth soln 0.05%........................................78azithromycin for susp 100 mg/5ml (Zithromax)...................2azithromycin for susp 200 mg/5ml (Zithromax)...................2azithromycin tab 250 mg (Zithromax)..................................2azithromycin tab 500 mg (Zithromax)..................................2azithromycin tab 600 mg (Zithromax)..................................2

BBACITRACIN – bacitracin ophth oint 500 unit/gm............ 76bacitracin oint 500 unit/gm.................................................80bacitracin-polymyxin b oint................................................ 80bacitracin-polymyxin b ophth oint...................................... 76bacitracin-polymyxin-neomycin-hc ophth oint 1%............. 77bacitracin zinc oint 500 unit/gm.........................................80baclofen tab 10 mg............................................................ 67baclofen tab 20 mg............................................................ 67balsalazide disodium cap 750 mg (Colazal)......................41BANZEL – rufinamide susp 40 mg/ml...............................59

BANZEL – rufinamide tab 200 mg.................................... 59BANZEL – rufinamide tab 400 mg.................................... 59BARACLUDE – entecavir oral soln 0.05 mg/ml.................. 4BASAGLAR KWIKPEN – insulin glargine soln pen-injector100 unit/ml........................................................................ 21

b-complex w/ c & folic acid cap 1 mg (Nephrocaps)......... 69b-complex w/ c & folic acid tab 5 mg................................ 69b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx).......69BD INSULIN SYRINGE ULTRAF – INSULIN SYRINGES -TECHLITE AND TRUEPLUS...........................................83

benazepril & hydrochlorothiazide tab 5-6.25 mg...............23benazepril & hydrochlorothiazide tab 10-12.5 mg(Lotensin hct)....................................................................23

benazepril & hydrochlorothiazide tab 20-12.5 mg(Lotensin hct)....................................................................23

benazepril & hydrochlorothiazide tab 20-25 mg (Lotensinhct).....................................................................................24

benazepril hcl tab 5 mg..................................................... 24benazepril hcl tab 10 mg................................................... 24benazepril hcl tab 20 mg (Lotensin)..................................24benazepril hcl tab 40 mg (Lotensin)..................................24BENEFIX – coagulation factor ix (recombinant) for inj kit250 unit............................................................................. 73

BENEFIX – coagulation factor ix (recombinant) for inj kit500 unit............................................................................. 73

BENEFIX – coagulation factor ix (recombinant) for inj kit1000 unit........................................................................... 73



BENZNIDAZOLE – benznidazole tab 12.5 mg................... 8BENZNIDAZOLE – benznidazole tab 100 mg.................... 8benzoyl peroxide lotion 6%................................................79benztropine mesylate tab 0.5 mg...................................... 66benztropine mesylate tab 1 mg......................................... 66benztropine mesylate tab 2 mg......................................... 66betamethasone dipropionate augmented cream 0.05%(Diprolene af)....................................................................80

betamethasone dipropionate augmented lotion 0.05%(Diprolene)........................................................................ 80

betamethasone dipropionate augmented oint 0.05%(Diprolene)........................................................................ 80

betamethasone dipropionate cream 0.05%.......................80betamethasone dipropionate lotion 0.05%........................80betamethasone dipropionate oint 0.05%...........................80betamethasone valerate cream 0.1% (baseequivalent).........................................................................80

betamethasone valerate lotion 0.1% (baseequivalent).........................................................................81

betamethasone valerate oint 0.1% (base equivalent).......81betaxolol hcl ophth soln 0.5%............................................77betaxolol hcl tab 10 mg..................................................... 26betaxolol hcl tab 20 mg..................................................... 26bethanechol chloride tab 5 mg (Urecholine)..................... 42bethanechol chloride tab 10 mg (Urecholine)................... 42

2019

90

bethanechol chloride tab 25 mg (Urecholine)................... 42bethanechol chloride tab 50 mg (Urecholine)................... 42bexarotene cap 75 mg (Targretin)..................................... 10bicalutamide tab 50 mg (Casodex)....................................10bisacodyl tab delayed release 5 mg..................................38bismuth subsalicylate susp 262 mg/15ml..........................39bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg(Ziac)................................................................................. 26

bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)......26bisoprolol & hydrochlorothiazide tab 10-6.25 mg(Ziac)................................................................................. 26

bisoprolol fumarate tab 5 mg.............................................26bisoprolol fumarate tab 10 mg...........................................26BOOSTRIX – tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml.........................................................................9

BOTOX – onabotulinumtoxina for inj 100 unit...................68BOTOX – onabotulinumtoxina for inj 200 unit...................68BRAFTOVI – encorafenib cap 50 mg................................10BRAFTOVI – encorafenib cap 75 mg................................10BRILINTA – ticagrelor tab 60 mg...................................... 73BRILINTA – ticagrelor tab 90 mg...................................... 73brimonidine tartrate ophth soln 0.2%.................................77BRIVIACT – brivaracetam iv soln 50 mg/5ml....................59BRIVIACT – brivaracetam oral soln 10 mg/ml.................. 59BRIVIACT – brivaracetam tab 10 mg................................59BRIVIACT – brivaracetam tab 25 mg................................59BRIVIACT – brivaracetam tab 50 mg................................59BRIVIACT – brivaracetam tab 75 mg................................59BRIVIACT – brivaracetam tab 100 mg..............................59BROHIST D – brompheniramine & phenylephrine tab 4-10mg......................................................................................35

bromocriptine mesylate tab 2.5 mg (base equivalent)(Parlodel)...........................................................................66

brompheniramine & phenylephrine elixir 1-2.5 mg/5ml.....35budesonide delayed release particles cap 3 mg (Entocortec)......................................................................................15

budesonide inhalation susp 0.25 mg/2ml (Pulmicort)....... 36budesonide inhalation susp 0.5 mg/2ml (Pulmicort)......... 36budesonide inhalation susp 1 mg/2ml (Pulmicort)............ 36bumetanide tab 0.5 mg (Bumex).......................................31bumetanide tab 1 mg (Bumex)..........................................31bumetanide tab 2 mg (Bumex)..........................................31BUNAVAIL – buprenorphine-naloxone buccal film 2.1-0.3mg (base equiv)................................................................54

BUNAVAIL – buprenorphine-naloxone buccal film 4.2-0.7mg (base equiv)................................................................54

BUNAVAIL – buprenorphine-naloxone buccal film 6.3-1mg (base equiv)................................................................54

buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (baseequiv).................................................................................54

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (baseequiv).................................................................................54

buprenorphine hcl sl tab 2 mg (base equiv)......................54buprenorphine hcl sl tab 8 mg (base equiv)......................54bupropion hcl (smoking deterrent) tab er 12hr 150 mg(Zyban).............................................................................. 52

bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)..............44bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)..............44bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)..............44bupropion hcl tab er 24hr 150 mg (Wellbutrin xl).............. 44bupropion hcl tab er 24hr 300 mg (Wellbutrin xl).............. 44bupropion hcl tab 75 mg....................................................44bupropion hcl tab 100 mg..................................................44buspirone hcl tab 5 mg...................................................... 43buspirone hcl tab 10 mg....................................................43buspirone hcl tab 15 mg....................................................43buspirone hcl tab 30 mg....................................................43butalbital-acetaminophen-caffeine cap 50-325-40 mg......53butalbital-acetaminophen-caffeine cap 50-300-40 mg(Fioricet)............................................................................ 53

butalbital-acetaminophen-caffeine tab 50-325-40 mg(Esgic)............................................................................... 53

butalbital-acetaminophen-caff w/ cod cap 50-325-40-30mg......................................................................................54

butalbital-acetaminophen tab 50-325 mg..........................53butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal).....54butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg(Fiorinal/codeine #3).........................................................54

Ccabergoline tab 0.5 mg...................................................... 22caffeine citrate oral soln 60 mg/3ml (10 mg/ml baseequiv).................................................................................51

calcipotriene cream 0.005% (Dovonex)............................ 82calcipotriene oint 0.005%...................................................82calcipotriene soln 0.005% (50 mcg/ml)............................. 82calcitonin (salmon) nasal soln 200 unit/act....................... 22calcitriol cap 0.25 mcg (Rocaltrol)..................................... 22calcitriol cap 0.5 mcg (Rocaltrol)....................................... 22calcitriol oral soln 1 mcg/ml (Rocaltrol)............................. 22calcium acetate (phosphate binder) cap 667 mg (169 mgca)......................................................................................41

calcium acetate (phosphate binder) tab 667 mg(Eliphos)............................................................................ 41

calcium carbonate (antacid) chew tab 500 mg..................39calcium carbonate (antacid) chew tab 750 mg..................39calcium carbonate (antacid) chew tab 1000 mg................39calcium carbonate-cholecalciferol tab 500 mg-200unit.....................................................................................70

calcium carbonate-cholecalciferol tab 600 mg-400unit.....................................................................................70

calcium carbonate tab 1250 mg (500 mg elementalca)......................................................................................70

calcium carbonate-vitamin d tab 250 mg-125 unit............ 70calcium carbonate-vitamin d tab 500 mg-200 unit............ 70calcium carbonate-vitamin d tab 600 mg-400 unit............ 70calcium citrate tab 950 mg (200 mg elemental ca)........... 70CALQUENCE – acalabrutinib cap 100 mg........................10capecitabine tab 150 mg (Xeloda).....................................10capecitabine tab 500 mg (Xeloda).....................................10CAPTOPRIL/HYDROCHLOROTHIA – captopril &hydrochlorothiazide tab 25-15 mg................................... 24

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CAPTOPRIL/HYDROCHLOROTHIA – captopril &hydrochlorothiazide tab 25-25 mg................................... 24



captopril tab 12.5 mg......................................................... 24captopril tab 25 mg............................................................ 24captopril tab 50 mg............................................................ 24captopril tab 100 mg.......................................................... 24carbamazepine chew tab 100 mg..................................... 59carbamazepine susp 100 mg/5ml (Tegretol).....................59carbamazepine tab er 12hr 100 mg (Tegretol-xr)..............59carbamazepine tab er 12hr 200 mg (Tegretol-xr)..............59carbamazepine tab er 12hr 400 mg (Tegretol-xr)..............59carbamazepine tab 200 mg (Tegretol).............................. 59carbamide peroxide 6.5% otic soln................................... 78CARBATROL – carbamazepine cap er 12hr 100 mg........60CARBATROL – carbamazepine cap er 12hr 200 mg........60CARBATROL – carbamazepine cap er 12hr 300 mg........60carbidopa & levodopa tab er 25-100 mg (Sinemet cr)...... 66carbidopa & levodopa tab er 50-200 mg (Sinemet cr)...... 66carbidopa & levodopa tab 10-100 mg (Sinemet)...............66carbidopa & levodopa tab 25-100 mg (Sinemet)...............67carbidopa & levodopa tab 25-250 mg (Sinemet)...............67carbidopa tab 25 mg (Lodosyn).........................................67carbinoxamine maleate soln 4 mg/5ml..............................34carbinoxamine maleate tab 4 mg...................................... 34CARTEOLOL HCL – carteolol hcl ophth soln 1%............. 77carvedilol tab 3.125 mg (Coreg)........................................26carvedilol tab 6.25 mg (Coreg)..........................................26carvedilol tab 12.5 mg (Coreg)..........................................26carvedilol tab 25 mg (Coreg).............................................26cefaclor cap 250 mg............................................................ 1cefaclor cap 500 mg............................................................ 1cefadroxil cap 500 mg..........................................................1cefadroxil for susp 250 mg/5ml........................................... 1cefadroxil for susp 500 mg/5ml........................................... 1cefadroxil tab 1 gm.............................................................. 1cefdinir cap 300 mg............................................................. 2cefdinir for susp 125 mg/5ml............................................... 2cefdinir for susp 250 mg/5ml............................................... 2cefprozil for susp 125 mg/5ml............................................. 2cefprozil for susp 250 mg/5ml............................................. 2cefprozil tab 250 mg............................................................ 2cefprozil tab 500 mg............................................................ 2ceftriaxone sodium for inj 1 gm........................................... 2ceftriaxone sodium for inj 2 gm........................................... 2ceftriaxone sodium for inj 250 mg....................................... 2ceftriaxone sodium for inj 500 mg....................................... 2cefuroxime axetil tab 250 mg.............................................. 2cefuroxime axetil tab 500 mg.............................................. 2celecoxib cap 50 mg (Celebrex)........................................56celecoxib cap 100 mg (Celebrex)......................................56celecoxib cap 200 mg (Celebrex)......................................56celecoxib cap 400 mg (Celebrex)......................................56

CELONTIN – methsuximide cap 300 mg..........................60cephalexin cap 250 mg (Keflex)..........................................2cephalexin cap 500 mg (Keflex)..........................................2cephalexin for susp 125 mg/5ml..........................................2cephalexin for susp 250 mg/5ml..........................................2CEREBYX – fosphenytoin sodium inj 100 mg/2ml(phenytoin equiv).............................................................. 60

CEREBYX – fosphenytoin sodium inj 500 mg/10ml(phenytoin equiv).............................................................. 60

cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)........................34cetirizine hcl tab 5 mg........................................................34cetirizine hcl tab 10 mg......................................................34CHANTIX CONTINUING MONTH – varenicline tartratetab 1 mg (base equiv)......................................................52

CHANTIX STARTING MONTH PA – varenicline tartratetab 0.5 mg x 11 & tab 1 mg x 42 pack............................ 52

CHANTIX – varenicline tartrate tab 0.5 mg (baseequiv).................................................................................52

CHANTIX – varenicline tartrate tab 1 mg (base equiv).....52CHEMET – succimer cap 100 mg.....................................84chlordiazepoxide hcl cap 5 mg..........................................43chlordiazepoxide hcl cap 10 mg........................................43chlordiazepoxide hcl cap 25 mg........................................43chlorhexidine gluconate soln 0.12% (Peridex).................. 78CHLOROQUINE PHOSPHATE – chloroquine phosphatetab 250 mg..........................................................................8

chloroquine phosphate tab 500 mg.....................................8CHLOROTHIAZIDE – chlorothiazide tab 250 mg............. 31chlorothiazide tab 500 mg................................................. 31chlorpheniramine maleate syrup 2 mg/5ml....................... 34chlorpheniramine maleate tab er 12 mg............................34chlorpheniramine maleate tab 4 mg..................................34chlorthalidone tab 25 mg................................................... 31chlorthalidone tab 50 mg................................................... 31CHLORZOXAZONE – chlorzoxazone tab 500 mg............67cholecalciferol cap 1000 unit............................................. 68cholecalciferol cap 2000 unit............................................. 68cholecalciferol cap 5000 unit............................................. 68cholecalciferol cap 10000 unit........................................... 68cholecalciferol cap 50000 unit........................................... 68cholecalciferol oral liquid 400 unit/ml.................................68cholecalciferol tab 400 unit................................................ 68cholecalciferol tab 1000 unit..............................................68cholecalciferol tab 2000 unit..............................................68cholecalciferol tab 50000 unit............................................68cholestyramine light powder 4 gm/dose (Questranlight)...................................................................................30

cholestyramine light powder packets 4 gm....................... 30cholestyramine powder 4 gm/dose (Questran)................. 30cholestyramine powder packets 4 gm (Questran).............30choline fenofibrate cap dr 45 mg (fenofibric acid equiv)(Trilipix)..............................................................................30

choline fenofibrate cap dr 135 mg (fenofibric acid equiv)(Trilipix)..............................................................................30

ciclopirox olamine cream 0.77% (base equiv)(Loprox).............................................................................80

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cilostazol tab 50 mg...........................................................73cilostazol tab 100 mg.........................................................73CIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml........39ciprofloxacin for oral susp 500 mg/5ml (10%) (10gm/100ml) (Cipro)...............................................................3

ciprofloxacin hcl ophth soln 0.3% (Ciloxan)...................... 76ciprofloxacin hcl tab 750 mg (base equiv)...........................3ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)...............3ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)...............3citalopram hydrobromide oral soln 10 mg/5ml.................. 44citalopram hydrobromide tab 10 mg (base equiv)(Celexa).............................................................................44

citalopram hydrobromide tab 20 mg (base equiv)(Celexa).............................................................................44

citalopram hydrobromide tab 40 mg (base equiv)(Celexa).............................................................................44

CLARITHROMYCIN – clarithromycin for susp 125mg/5ml.................................................................................2

CLARITHROMYCIN – clarithromycin for susp 250mg/5ml.................................................................................2

clarithromycin tab 250 mg................................................... 2clarithromycin tab 500 mg (Biaxin)......................................2clemastine fumarate tab 1.34 mg (1 mg base equiv)........34clindamycin hcl cap 75 mg (Cleocin)...................................8clindamycin hcl cap 150 mg (Cleocin).................................8clindamycin hcl cap 300 mg (Cleocin).................................8clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)(Cleocin pediatric gr).......................................................... 8

clindamycin phosphate gel 1% (Cleocin-t)........................ 79clindamycin phosphate lotion 1% (Cleocin-t).................... 79clindamycin phosphate soln 1% (Cleocin-t)...................... 79clindamycin phosphate swab 1% (Cleocin-t).................... 79clindamycin phosphate vaginal cream 2% (Cleocin).........42clindamycin phosph-benzoyl peroxide (refrig) gel 1.2(1)-5% (Duac)................................................................... 79

clobazam suspension 2.5 mg/ml (Onfi).............................60clobazam tab 10 mg (Onfi)................................................60clobazam tab 20 mg (Onfi)................................................60clobetasol propionate cream 0.05% (Temovate)...............81clobetasol propionate emollient base cream 0.05%..........81clobetasol propionate gel 0.05% (Temovate)....................81clobetasol propionate oint 0.05% (Temovate)...................81clobetasol propionate soln 0.05% (Temovate).................. 81clonazepam orally disintegrating tab 0.125 mg.................60clonazepam orally disintegrating tab 0.25 mg...................60clonazepam orally disintegrating tab 0.5 mg.....................60clonazepam orally disintegrating tab 1 mg........................60clonazepam orally disintegrating tab 2 mg........................60clonazepam tab 0.5 mg (Klonopin)....................................60clonazepam tab 1 mg (Klonopin).......................................60clonazepam tab 2 mg (Klonopin).......................................60clonidine hcl tab 0.1 mg (Catapres).................................. 32clonidine hcl tab 0.2 mg (Catapres).................................. 32clonidine hcl tab 0.3 mg (Catapres).................................. 32clonidine td patch weekly 0.1 mg/24hr (Catapres-tts-1).................................................................................. 32

clonidine td patch weekly 0.2 mg/24hr (Catapres-tts-2).................................................................................. 32

clonidine td patch weekly 0.3 mg/24hr (Catapres-tts-3).................................................................................. 33

clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)........73clopidogrel bisulfate tab 300 mg (base equiv) (Plavix)......73clorazepate dipotassium tab 3.75 mg................................43clorazepate dipotassium tab 15 mg...................................43clorazepate dipotassium tab 7.5 mg (Tranxene t).............43clotrimazole cream 1%.......................................................80clotrimazole soln 1%.......................................................... 80clotrimazole troche 10 mg................................................. 78clotrimazole vaginal cream 2%..........................................42clotrimazole w/ betamethasone cream 1-0.05%(Lotrisone)......................................................................... 80

clozapine orally disintegrating tab 25 mg (Fazaclo)..........47clozapine orally disintegrating tab 100 mg (Fazaclo)........47clozapine tab 50 mg...........................................................47clozapine tab 200 mg.........................................................47clozapine tab 25 mg (Clozaril)...........................................47clozapine tab 100 mg (Clozaril).........................................47COAGADEX – coagulation factor x (human) for inj 250unit.....................................................................................73

COAGADEX – coagulation factor x (human) for inj 500unit.....................................................................................73

codeine sulfate tab 30 mg (Codeine sulfate).................... 54colchicine w/ probenecid tab 0.5-500 mg..........................59colestipol hcl granule packets 5 gm (Colestidflavored)............................................................................ 30

colestipol hcl granules 5 gm (Colestid)............................. 30colestipol hcl tab 1 gm (Colestid)...................................... 30COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.14 mg/day..............................................................17

COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.25 mg/day..............................................................17

COMBIVENT RESPIMAT – ipratropium-albuterol inhalaerosol soln 20-100 mcg/act............................................36

CORTISONE ACETATE – cortisone acetate tab 25mg......................................................................................15

COSENTYX – secukinumab subcutaneous soln prefilledsyringe 150 mg/ml............................................................82

COSENTYX SENSOREADY PEN – secukinumabsubcutaneous soln auto-injector 150 mg/ml....................82

COTELLIC – cobimetinib fumarate tab 20 mg (baseequivalent).........................................................................11

CREON – pancrelipase (lip-prot-amyl) dr cap3000-9500-15000 unit...................................................... 41

CREON – pancrelipase (lip-prot-amyl) dr cap6000-19000-30000 unit.................................................... 41

CREON – pancrelipase (lip-prot-amyl) dr cap12000-38000-60000 unit.................................................. 41

CREON – pancrelipase (lip-prot-amyl) dr cap24000-76000-120000 unit................................................ 41

CREON – pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit.............................................. 41

CRIXIVAN – indinavir sulfate cap 200 mg...........................5

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CRIXIVAN – indinavir sulfate cap 400 mg...........................5cromolyn sodium ophth soln 4%....................................... 78cromolyn sodium oral conc 100 mg/5ml (Gastrocrom)..... 41cromolyn sodium soln nebu 20 mg/2ml.............................36cyanocobalamin inj 1000 mcg/ml...................................... 68cyanocobalamin tab er 1000 mcg..................................... 68cyanocobalamin tab 100 mcg............................................68cyanocobalamin tab 250 mcg............................................68cyanocobalamin tab 500 mcg............................................68cyanocobalamin tab 1000 mcg..........................................68cyclobenzaprine hcl tab 5 mg............................................67cyclobenzaprine hcl tab 10 mg..........................................67cyclopentolate hcl ophth soln 0.5% (Cyclogyl)..................78cyclopentolate hcl ophth soln 1% (Cyclogyl).....................78cyclopentolate hcl ophth soln 2% (Cyclogyl).....................78cyclophosphamide cap 25 mg (Cyclophosphamide).........11cyclophosphamide cap 50 mg (Cyclophosphamide).........11cyclosporine cap 25 mg (Sandimmune)............................84cyclosporine cap 100 mg (Sandimmune)..........................84CYCLOSPORINE MODIFIED............................................84cyclosporine modified cap 25 mg (Neoral)........................84cyclosporine modified cap 100 mg (Neoral)......................84cyclosporine modified oral soln 100 mg/ml (Neoral)......... 84cyproheptadine hcl syrup 2 mg/5ml...................................34cyproheptadine hcl tab 4 mg............................................. 34CYTARABINE – cytarabine inj 20 mg/ml.......................... 11

Ddalfampridine tab er 12hr 10 mg (Ampyra)....................... 52danazol cap 50 mg............................................................ 16danazol cap 100 mg.......................................................... 16danazol cap 200 mg.......................................................... 16dantrolene sodium cap 100 mg.........................................67dantrolene sodium cap 25 mg (Dantrium).........................67dantrolene sodium cap 50 mg (Dantrium).........................67dapsone tab 25 mg..............................................................8dapsone tab 100 mg............................................................8DARAPRIM – pyrimethamine tab 25 mg.............................8DECARA – cholecalciferol cap 25000 unit........................68demeclocycline hcl tab 150 mg........................................... 2DEPACON – valproate sodium inj 100 mg/ml...................60DEPAKENE – valproate sodium oral soln 250 mg/5ml(base equiv)...................................................................... 60

DEPAKENE – valproic acid cap 250 mg...........................60DEPAKOTE – divalproex sodium tab delayed release 125mg......................................................................................60

DEPAKOTE – divalproex sodium tab delayed release 250mg......................................................................................60

DEPAKOTE – divalproex sodium tab delayed release 500mg......................................................................................60

DEPAKOTE ER – divalproex sodium tab er 24 hr 250mg......................................................................................60

DEPAKOTE ER – divalproex sodium tab er 24 hr 500mg......................................................................................60

DEPAKOTE SPRINKLES – divalproex sodium capdelayed release sprinkle 125 mg.....................................60

DEPEN TITRATABS – penicillamine tab 250 mg..............84DESCOVY – emtricitabine-tenofovir alafenamide fumaratetab 200-25 mg.................................................................... 5

desloratadine tab 5 mg (Clarinex)..................................... 34desmopressin acetate nasal spray soln 0.01%(Ddavp)..............................................................................22

desmopressin acetate nasal spray soln 0.01%(refrigerated)..................................................................... 22

desmopressin acetate tab 0.1 mg (Ddavp)....................... 23desmopressin acetate tab 0.2 mg (Ddavp)....................... 23desogest-eth estrad & eth estrad tab 0.15-0.02/0.01mg(21/5) (Mircette)...........................................................18

desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg(Desogen)......................................................................... 18

desoximetasone cream 0.25% (Topicort)..........................81DEXAMETHASONE – dexamethasone soln 0.5mg/5ml...............................................................................15

dexamethasone elixir 0.5 mg/5ml......................................16DEXAMETHASONE SODIUM PHOS – dexamethasonesodium phosphate ophth soln 0.1%................................ 77

dexamethasone tab 0.5 mg............................................... 16dexamethasone tab 0.75 mg.............................................16dexamethasone tab 1.5 mg............................................... 16dexamethasone tab 4 mg.................................................. 16dexamethasone tab 6 mg.................................................. 16dexmethylphenidate hcl cap er 24 hr 5 mg (Focalinxr)...................................................................................... 51

dexmethylphenidate hcl cap er 24 hr 10 mg (Focalinxr)...................................................................................... 51





dexmethylphenidate hcl tab 2.5 mg (Focalin)................... 51dexmethylphenidate hcl tab 5 mg (Focalin)...................... 51dexmethylphenidate hcl tab 10 mg (Focalin).................... 51dextromethorphan-guaifenesin liquid 10-100 mg/5ml.......35diazepam conc 5 mg/ml.....................................................44DIAZEPAM RECTAL GEL – diazepam rectal gel deliverysystem 2.5 mg..................................................................60

DIAZEPAM RECTAL GEL – diazepam rectal gel deliverysystem 10 mg................................................................... 60

DIAZEPAM RECTAL GEL – diazepam rectal gel deliverysystem 20 mg................................................................... 60

diazepam tab 2 mg (Valium)..............................................44diazepam tab 5 mg (Valium)..............................................44diazepam tab 10 mg (Valium)............................................44diclofenac potassium tab 50 mg........................................56diclofenac sodium gel 1% (Voltaren)............................56,80diclofenac sodium ophth soln 0.1%...................................78diclofenac sodium tab delayed release 50 mg..................56diclofenac sodium tab delayed release 75 mg..................56

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diclofenac sodium tab er 24hr 100 mg..............................56dicloxacillin sodium cap 250 mg..........................................1dicloxacillin sodium cap 500 mg..........................................1dicyclomine hcl cap 10 mg (Bentyl)...................................39dicyclomine hcl oral soln 10 mg/5ml................................. 39dicyclomine hcl tab 20 mg.................................................39didanosine delayed release capsule 200 mg (Videx ec).....5didanosine delayed release capsule 250 mg (Videx ec).....5didanosine delayed release capsule 400 mg (Videx ec).....5DIFFERIN – adapalene gel 0.1%......................................79DIGOXIN – digoxin oral soln 0.05 mg/ml.......................... 33digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................... 33digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................... 33DILANTIN INFATABS – phenytoin chew tab 50 mg..........61DILANTIN – phenytoin sodium extended cap 30 mg........60DILANTIN – phenytoin sodium extended cap 100 mg......60DILANTIN-125 – phenytoin susp 125 mg/5ml...................61diltiazem hcl cap er 12hr 60 mg........................................27diltiazem hcl cap er 24hr 120 mg......................................28diltiazem hcl cap er 24hr 180 mg......................................28diltiazem hcl cap er 24hr 240 mg......................................28diltiazem hcl coated beads cap er 24hr 300 mg............... 28diltiazem hcl coated beads cap er 24hr 120 mg (Cardizemcd)......................................................................................28

diltiazem hcl coated beads cap er 24hr 180 mg (Cardizemcd)......................................................................................28

diltiazem hcl coated beads cap er 24hr 240 mg (Cardizemcd)......................................................................................28

diltiazem hcl extended release beads cap er 24hr 120 mg(Tiazac)............................................................................. 28






diltiazem hcl tab 90 mg......................................................28diltiazem hcl tab 30 mg (Cardizem)...................................28diltiazem hcl tab 60 mg (Cardizem)...................................28diltiazem hcl tab 120 mg (Cardizem).................................28diphenhydramine hcl cap 25 mg....................................... 34diphenhydramine hcl cap 50 mg....................................... 34diphenhydramine hcl elixir 12.5 mg/5ml............................34diphenhydramine hcl liquid 12.5 mg/5ml...........................34diphenhydramine hcl tab disint 12.5 mg............................34diphenhydramine hcl tab 25 mg........................................ 35diphenhydramine-phenylephrine liq 6.25-2.5 mg/5ml....... 35diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)...... 39dipyridamole tab 25 mg..................................................... 73dipyridamole tab 50 mg..................................................... 73dipyridamole tab 75 mg..................................................... 73disopyramide phosphate cap 100 mg (Norpace).............. 32

disopyramide phosphate cap 150 mg (Norpace).............. 32disulfiram tab 250 mg (Antabuse)..................................... 52disulfiram tab 500 mg (Antabuse)..................................... 52divalproex sodium cap delayed release sprinkle 125 mg(Depakote sprinkles).........................................................61

divalproex sodium tab delayed release 125 mg(Depakote)........................................................................ 61



divalproex sodium tab er 24 hr 250 mg (Depakote er)......61divalproex sodium tab er 24 hr 500 mg (Depakote er)......61docusate sodium cap 100 mg........................................... 38docusate sodium cap 250 mg........................................... 38docusate sodium liquid 150 mg/15ml................................38dofetilide cap 125 mcg (0.125 mg) (Tikosyn)....................32dofetilide cap 250 mcg (0.25 mg) (Tikosyn)......................32dofetilide cap 500 mcg (0.5 mg) (Tikosyn)........................32donepezil hydrochloride orally disintegrating tab 5 mg..... 53donepezil hydrochloride orally disintegrating tab 10mg......................................................................................53

donepezil hydrochloride tab 5 mg (Aricept).......................53donepezil hydrochloride tab 10 mg (Aricept).....................53dorzolamide hcl ophth soln 2% (Trusopt)..........................77dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt)....................................................................... 77

doxazosin mesylate tab 1 mg (Cardura)........................... 33doxazosin mesylate tab 2 mg (Cardura)........................... 33doxazosin mesylate tab 4 mg (Cardura)........................... 33doxazosin mesylate tab 8 mg (Cardura)........................... 33doxepin hcl cap 10 mg...................................................... 44doxepin hcl cap 25 mg...................................................... 44doxepin hcl cap 50 mg...................................................... 45doxepin hcl cap 75 mg...................................................... 45doxepin hcl cap 100 mg.................................................... 45doxepin hcl cap 150 mg.................................................... 45doxepin hcl conc 10 mg/ml................................................45doxycycline hyclate cap 50 mg............................................2doxycycline hyclate cap 100 mg (Vibramycin).................... 2doxycycline hyclate tab 20 mg............................................ 2doxycycline hyclate tab 100 mg.......................................... 2doxycycline monohydrate cap 50 mg..................................2doxycycline monohydrate cap 100 mg (Monodox)..............2doxycycline monohydrate for susp 25 mg/5ml(Vibramycin)........................................................................ 3

doxycycline monohydrate tab 50 mg...................................3doxycycline monohydrate tab 75 mg...................................3doxycycline monohydrate tab 100 mg.................................3D-PENAMINE – penicillamine tab 125 mg........................84drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin28)..................................................................................... 18

duloxetine hcl enteric coated pellets cap 20 mg (base eq)(Cymbalta).........................................................................45


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DUOPA – carbidopa-levodopa enteral susp 4.63-20 mg/ml.......................................................................................67

Eeconazole nitrate cream 1%..............................................80EDURANT – rilpivirine hcl tab 25 mg (base equivalent)..... 5efavirenz cap 50 mg (Sustiva).............................................5efavirenz cap 200 mg (Sustiva)...........................................5efavirenz tab 600 mg (Sustiva)............................................5ELIQUIS – apixaban tab 2.5 mg....................................... 73ELIQUIS – apixaban tab 5 mg.......................................... 73ELIQUIS STARTER PACK – apixaban tab 5 mg.............. 73ELLA – ulipristal acetate tab 30 mg.................................. 18EMTRIVA – emtricitabine caps 200 mg.............................. 5EMTRIVA – emtricitabine soln 10 mg/ml.............................5enalapril maleate & hydrochlorothiazide tab 5-12.5mg......................................................................................24

enalapril maleate & hydrochlorothiazide tab 10-25 mg(Vaseretic)......................................................................... 24

enalapril maleate tab 2.5 mg (Vasotec).............................24enalapril maleate tab 5 mg (Vasotec)............................... 24enalapril maleate tab 10 mg (Vasotec)............................. 24enalapril maleate tab 20 mg (Vasotec)............................. 24ENBREL – etanercept for subcutaneous inj 25 mg...........56ENBREL – etanercept subcutaneous soln prefilled syringe25 mg/0.5ml...................................................................... 56

ENBREL – etanercept subcutaneous soln prefilled syringe50 mg/ml........................................................................... 56

ENBREL MINI – etanercept subcutaneous solutioncartridge 50 mg/ml............................................................56

ENBREL SURECLICK – etanercept subcutaneoussolution auto-injector 50 mg/ml........................................56

ENGERIX-B – hepatitis b vaccine (recombinant) 10mcg/0.5ml............................................................................9

ENGERIX-B – hepatitis b vaccine (recombinant) 20 mcg/ml.........................................................................................9

ENGERIX-B – hepatitis b vaccine (recombinant) susp 10mcg/0.5ml............................................................................9

ENGERIX-B – hepatitis b vaccine (recombinant) susp 20mcg/ml.................................................................................9

enoxaparin sodium inj 30 mg/0.3ml (Lovenox)................. 73enoxaparin sodium inj 40 mg/0.4ml (Lovenox)................. 73enoxaparin sodium inj 60 mg/0.6ml (Lovenox)................. 73enoxaparin sodium inj 80 mg/0.8ml (Lovenox)................. 74enoxaparin sodium inj 100 mg/ml (Lovenox).................... 74enoxaparin sodium inj 120 mg/0.8ml (Lovenox)............... 74enoxaparin sodium inj 150 mg/ml (Lovenox).................... 74enoxaparin sodium inj 300 mg/3ml (Lovenox).................. 74entacapone tab 200 mg (Comtan).....................................67entecavir tab 0.5 mg (Baraclude)........................................ 4entecavir tab 1 mg (Baraclude)........................................... 4ENTRESTO – sacubitril-valsartan tab 24-26 mg.............. 33ENTRESTO – sacubitril-valsartan tab 49-51 mg.............. 33ENTRESTO – sacubitril-valsartan tab 97-103 mg............ 33

EPINEPHRINE – epinephrine solution auto-injector 0.15mg/0.3ml (1:2000)............................................................ 34

EPINEPHRINE HCL – epinephrine inj 30 mg/30ml.......... 33epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)(Epipen 2-pak).................................................................. 34

EQ MULTIVITAMINS ADULT GU – multiple vitamins w/minerals chew tab............................................................ 69

ergocalciferol cap 50000 unit.............................................68ERLEADA – apalutamide tab 60 mg.................................11erythromycin gel 2% (Erygel)............................................ 79erythromycin ophth oint 5 mg/gm......................................76erythromycin pads 2%....................................................... 79erythromycin soln 2%.........................................................79escitalopram oxalate soln 5 mg/5ml (base equiv).............45escitalopram oxalate tab 5 mg (base equiv) (Lexapro).....45escitalopram oxalate tab 10 mg (base equiv)(Lexapro)...........................................................................45

escitalopram oxalate tab 20 mg (base equiv)(Lexapro)...........................................................................45

estazolam tab 1 mg........................................................... 49estazolam tab 2 mg........................................................... 49estradiol & norethindrone acetate tab 0.5-0.1 mg(Activella)...........................................................................17

estradiol & norethindrone acetate tab 1-0.5 mg(Activella)...........................................................................17

estradiol tab 0.5 mg (Estrace)........................................... 17estradiol tab 1 mg (Estrace).............................................. 17estradiol tab 2 mg (Estrace).............................................. 17estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot).................................................................................... 17

estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot).................................................................................... 17




estradiol td patch weekly 0.025 mg/24hr (Climara)...........17estradiol td patch weekly 0.05 mg/24hr (Climara).............17estradiol td patch weekly 0.06 mg/24hr (Climara).............17estradiol td patch weekly 0.075 mg/24hr (Climara)...........17estradiol td patch weekly 0.1 mg/24hr (Climara)...............17estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)(Climara)............................................................................17

estradiol vaginal tab 10 mcg (Vagifem).............................42ESTROPIPATE – estropipate tab 1.5 mg..........................17eszopiclone tab 1 mg (Lunesta)........................................ 50eszopiclone tab 2 mg (Lunesta)........................................ 50eszopiclone tab 3 mg (Lunesta)........................................ 50ethambutol hcl tab 100 mg (Myambutol).............................3ethambutol hcl tab 400 mg (Myambutol).............................3ethosuximide cap 250 mg (Zarontin).................................61ethosuximide soln 250 mg/5ml (Zarontin)......................... 61ethynodiol diacetate & ethinyl estradiol tab 1 mg-50mcg....................................................................................18

2019

96

ETOPOSIDE – etoposide cap 50 mg................................11exemestane tab 25 mg (Aromasin)................................... 11EXTAVIA – interferon beta-1b for inj kit 0.3 mg.................52

Ffamotidine for susp 40 mg/5ml (Pepcid)............................39famotidine tab 10 mg......................................................... 39famotidine tab 20 mg (Pepcid).......................................... 39famotidine tab 40 mg (Pepcid).......................................... 39fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1mg......................................................................................70

fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240mg......................................................................................70

fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap(Tandem plus)...................................................................70

felbamate susp 600 mg/5ml (Felbatol)..............................61felbamate tab 400 mg (Felbatol)....................................... 61felbamate tab 600 mg (Felbatol)....................................... 61FELBATOL – felbamate susp 600 mg/5ml........................61FELBATOL – felbamate tab 400 mg................................. 61FELBATOL – felbamate tab 600 mg................................. 61felodipine tab er 24hr 2.5 mg............................................ 28felodipine tab er 24hr 5 mg............................................... 28felodipine tab er 24hr 10 mg............................................. 28fenofibrate micronized cap 43 mg..................................... 30fenofibrate micronized cap 67 mg (Lofibra).......................30fenofibrate micronized cap 134 mg (Lofibra).....................30fenofibrate micronized cap 200 mg (Lofibra).....................30fenofibrate tab 160 mg.......................................................30fenofibrate tab 54 mg (Lofibra)..........................................30fenofibrate tab 48 mg (Tricor)............................................ 30fenofibrate tab 145 mg (Tricor).......................................... 30fentanyl td patch 72hr 12 mcg/hr (Duragesic)...................54fentanyl td patch 72hr 25 mcg/hr (Duragesic)...................54fentanyl td patch 72hr 50 mcg/hr (Duragesic)...................54fentanyl td patch 72hr 75 mcg/hr (Duragesic)...................54fentanyl td patch 72hr 100 mcg/hr (Duragesic).................54ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1mg......................................................................................70

ferrous fumarate-folic acid tab 324-1 mg.......................... 70ferrous sulfate tab ec 325 mg (65 mg fe equivalent).........70ferrous sulfate tab 325 mg (65 mg elemental fe).............. 70fexofenadine hcl tab 60 mg............................................... 35fexofenadine hcl tab 180 mg............................................. 35finasteride tab 5 mg (Proscar)...........................................43FIRAZYR – icatibant acetate inj 30 mg/3ml (baseequivalent).........................................................................74

FISH OIL ULTRA – omega-3 fatty acids cap 1400 mg..... 71flecainide acetate tab 50 mg............................................. 32flecainide acetate tab 100 mg........................................... 32flecainide acetate tab 150 mg........................................... 32FLEET LIQUID GLYCERIN SUP – glycerin enema adult5.4 gm/average delivered dose....................................... 38

FLOVENT DISKUS – fluticasone propionate aer pow ba50 mcg/blister................................................................... 36

FLOVENT DISKUS – fluticasone propionate aer pow ba100 mcg/blister................................................................. 36

FLOVENT DISKUS – fluticasone propionate aer pow ba250 mcg/blister................................................................. 36

FLOVENT HFA – fluticasone propionate hfa inhal aer 110mcg/act (125/valve).......................................................... 36

FLOVENT HFA – fluticasone propionate hfa inhal aer 220mcg/act (250/valve).......................................................... 36

FLOVENT HFA – fluticasone propionate hfa inhal aero 44mcg/act (50/valve)............................................................ 36

FLUARIX QUADRIVALENT 2018 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml................................ 9

FLUCELVAX QUADRIVALENT 20 – influenza vac tiss-cultsubunt quad susp pref syr 0.5 ml...................................... 9

fluconazole for susp 10 mg/ml (Diflucan)............................4fluconazole for susp 40 mg/ml (Diflucan)............................4fluconazole tab 50 mg (Diflucan).........................................4fluconazole tab 100 mg (Diflucan).......................................4fluconazole tab 150 mg (Diflucan).......................................4fluconazole tab 200 mg (Diflucan).......................................4flucytosine cap 250 mg (Ancobon)......................................4flucytosine cap 500 mg (Ancobon)......................................4fludrocortisone acetate tab 0.1 mg....................................16FLULAVAL QUADRIVALENT 201 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml................................ 9

FLUNISOLIDE – flunisolide nasal soln 25 mcg/act(0.025%)............................................................................35

fluocinolone acetonide cream 0.01%................................ 81fluocinolone acetonide cream 0.025% (Synalar)...............81fluocinolone acetonide oint 0.025% (Synalar)...................81fluocinolone acetonide soln 0.01% (Synalar).................... 81fluocinonide cream 0.05%................................................. 81fluocinonide emulsified base cream 0.05%.......................81fluocinonide gel 0.05%.......................................................81fluocinonide oint 0.05%......................................................81fluocinonide soln 0.05%.....................................................81fluorometholone ophth susp 0.1% (Fml liquifilm).............. 77fluorouracil cream 5% (Efudex)......................................... 82FLUOROURACIL – fluorouracil soln 2%...........................82FLUOROURACIL – fluorouracil soln 5%...........................82fluoxetine hcl cap 10 mg (Prozac).....................................45fluoxetine hcl cap 20 mg (Prozac).....................................45fluoxetine hcl solution 20 mg/5ml...................................... 45fluphenazine decanoate inj 25 mg/ml................................47FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5mg/5ml...............................................................................47

FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml.......................................................................................47

fluphenazine hcl tab 1 mg................................................. 47fluphenazine hcl tab 2.5 mg.............................................. 47fluphenazine hcl tab 5 mg................................................. 47fluphenazine hcl tab 10 mg............................................... 47flurbiprofen sodium ophth soln 0.03% (Ocufen)................78flurbiprofen tab 50 mg........................................................56flurbiprofen tab 100 mg......................................................56flutamide cap 125 mg........................................................ 11

2019

97

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 55-14 mcg/act........................ 37

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 113-14 mcg/act...................... 37

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 232-14 mcg/act...................... 37

fluticasone propionate cream 0.05% (Cutivate)................ 81fluticasone propionate nasal susp 50 mcg/act.................. 35fluticasone propionate oint 0.005%................................... 81fluvoxamine maleate tab 25 mg........................................ 45fluvoxamine maleate tab 50 mg........................................ 45fluvoxamine maleate tab 100 mg...................................... 45FLUZONE HIGH-DOSE PF 2018 – influenza virus vacsplit high-dose pf susp pref syr 0.5ml................................9

FLUZONE QUADRIVALENT 2018 – influenza virus vacsplit quadrivalent susp pref syr 0.25 ml.............................9

FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals &folic acid tab 5 mg............................................................69

folic acid tab 400 mcg........................................................68folic acid tab 800 mcg........................................................68folic acid tab 1 mg............................................................. 68folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg..........68folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg.............69folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgardrx)...................................................................................... 68

fosamprenavir calcium tab 700 mg (base equiv)(Lexiva)................................................................................5

fosinopril sodium & hydrochlorothiazide tab 10-12.5mg......................................................................................24

fosinopril sodium & hydrochlorothiazide tab 20-12.5mg......................................................................................24

fosinopril sodium tab 10 mg.............................................. 24fosinopril sodium tab 20 mg.............................................. 24fosinopril sodium tab 40 mg.............................................. 24fructose-dextrose-phosphoric acid oral soln......................40FULPHILA – pegfilgrastim-jmdb soln prefilled syringe 6mg/0.6ml............................................................................74

furosemide oral soln 10 mg/ml.......................................... 31furosemide tab 20 mg (Lasix)............................................31furosemide tab 40 mg (Lasix)............................................31furosemide tab 80 mg (Lasix)............................................31FYCOMPA – perampanel susp 0.5 mg/ml........................ 61FYCOMPA – perampanel tab 2 mg...................................61FYCOMPA – perampanel tab 4 mg...................................61FYCOMPA – perampanel tab 6 mg...................................61FYCOMPA – perampanel tab 8 mg...................................61FYCOMPA – perampanel tab 10 mg.................................61FYCOMPA – perampanel tab 12 mg.................................61

Ggabapentin cap 100 mg (Neurontin)..................................61gabapentin cap 300 mg (Neurontin)..................................61gabapentin cap 400 mg (Neurontin)..................................61gabapentin oral soln 250 mg/5ml (Neurontin)...................61gabapentin tab 600 mg (Neurontin)...................................61gabapentin tab 800 mg (Neurontin)...................................61

GABITRIL – tiagabine hcl tab 2 mg.................................. 61GABITRIL – tiagabine hcl tab 4 mg.................................. 61GABITRIL – tiagabine hcl tab 12 mg................................ 61GABITRIL – tiagabine hcl tab 16 mg................................ 61gemfibrozil tab 600 mg (Lopid)..........................................30GENTAK – gentamicin sulfate ophth oint 0.3%.................76gentamicin sulfate cream 0.1%......................................... 80gentamicin sulfate oint 0.1%..............................................80gentamicin sulfate ophth soln 0.3%...................................76GENTAMICIN SULFATE PEDIAT – gentamicin sulfate inj10 mg/ml............................................................................. 3

GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab150-150-200-10 mg............................................................5

glatiramer acetate soln prefilled syringe 40 mg/ml(Copaxone)....................................................................... 52

glimepiride tab 1 mg (Amaryl)........................................... 19glimepiride tab 2 mg (Amaryl)........................................... 19glimepiride tab 4 mg (Amaryl)........................................... 19glipizide tab er 24hr 2.5 mg (Glucotrol xl)......................... 19glipizide tab er 24hr 5 mg (Glucotrol xl)............................ 19glipizide tab er 24hr 10 mg (Glucotrol xl).......................... 20glipizide tab 5 mg (Glucotrol).............................................20glipizide tab 10 mg (Glucotrol)...........................................20GLUCAGON EMERGENCY KIT – glucagon (rdna) for injkit 1 mg.............................................................................20

glyburide-metformin tab 1.25-250 mg............................... 20glyburide-metformin tab 2.5-500 mg (Glucovance)...........20glyburide-metformin tab 5-500 mg (Glucovance)..............20glyburide micronized tab 1.5 mg (Glynase).......................20glyburide micronized tab 3 mg (Glynase)..........................20glyburide micronized tab 6 mg (Glynase)..........................20glyburide tab 1.25 mg........................................................ 20glyburide tab 2.5 mg.......................................................... 20glyburide tab 5 mg............................................................. 20glycerin suppos 1 gm.........................................................38glycerin suppos 2 gm.........................................................38glycopyrrolate tab 1 mg (Robinul)..................................... 39glycopyrrolate tab 2 mg (Robinul forte).............................39griseofulvin microsize susp 125 mg/5ml..............................4griseofulvin microsize tab 500 mg.......................................4griseofulvin ultramicrosize tab 125 mg (Gris-peg)...............4griseofulvin ultramicrosize tab 250 mg (Gris-peg)...............4guaifenesin-codeine soln 100-10 mg/5ml..........................35guaifenesin liquid 100 mg/5ml...........................................35guaifenesin tab 200 mg..................................................... 35guaifenesin tab 400 mg..................................................... 35guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv).....51guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv).....51guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv).....51guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv).....51guanfacine hcl tab 1 mg.................................................... 33guanfacine hcl tab 2 mg.................................................... 33

Hhalobetasol propionate cream 0.05% (Ultravate)..............81halobetasol propionate oint 0.05% (Ultravate).................. 81

2019

98

haloperidol decanoate im soln 50 mg/ml (Haldoldecanoate 50)...................................................................47

haloperidol decanoate im soln 100 mg/ml (Haldoldecanoate 100).................................................................47

haloperidol lactate oral conc 2 mg/ml................................47haloperidol tab 0.5 mg....................................................... 47haloperidol tab 1 mg.......................................................... 47haloperidol tab 2 mg.......................................................... 47haloperidol tab 5 mg.......................................................... 47haloperidol tab 10 mg........................................................ 47haloperidol tab 20 mg........................................................ 47HEMOFIL M – antihemophilic factor (human) for inj 250unit.....................................................................................74

HEMOFIL M – antihemophilic factor (human) for inj 500unit.....................................................................................74



HEPLISAV-B – hepatitis b vaccine recomb adjuvantedpref syr 20 mcg/0.5ml........................................................ 9

HEPLISAV-B – hepatitis b vaccine recombinantadjuvanted 20 mcg/0.5ml...................................................9

HUMALOG MIX 75/25 – insulin lispro prot & lispro inj 100unit/ml (75-25)...................................................................21

HUMALOG MIX 50/50 – insulin lispro protamine & lisproinj 100 unit/ml (50-50)...................................................... 21

HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot &lispro sus pen-inj 100 unit/ml (50-50).............................. 21

HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot &lispro sus pen-inj 100 unit/ml (75-25).............................. 21

HUMATE-P – antihemophilic factor/vwf (human) for inj250-600 unit......................................................................74

HUMATE-P – antihemophilic factor/vwf (human) for inj500-1200 unit....................................................................74

HUMATE-P – antihemophilic factor/vwf (human) for inj1000-2400 unit..................................................................74

HUMIRA – adalimumab prefilled syringe kit 10mg/0.1ml............................................................................57






HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 40 mg/0.8ml....................................................57

HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 80 mg/0.8ml....................................................57

HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 80 mg/0.8ml & 40 mg/0.4ml........................... 57

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.8ml............................................................................57

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.4ml............................................................................57

HUMIRA PEN-CD/UC/HS START – adalimumab pen-injector kit 40 mg/0.8ml....................................................57

HUMIRA PEN-CD/UC/HS START – adalimumab pen-injector kit 80 mg/0.8ml....................................................57

HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit 40 mg/0.8ml....................................................57

HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit 80 mg/0.8ml & 40 mg/0.4ml........................... 57

HUMULIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30)...................................................... 21

HUMULIN 70/30 KWIKPEN – insulin nph & regular susppen-inj 100 unit/ml (70-30)...............................................21

HUMULIN N – insulin nph (human) (isophane) inj 100unit/ml................................................................................21

HUMULIN N KWIKPEN – insulin nph (human) (isophane)susp pen-injector 100 unit/ml...........................................21

HUMULIN R – insulin regular (human) inj 100 unit/ml...... 21hydralazine hcl tab 10 mg................................................. 33hydralazine hcl tab 25 mg................................................. 33hydralazine hcl tab 50 mg................................................. 33hydralazine hcl tab 100 mg............................................... 33hydrochlorothiazide cap 12.5 mg (Microzide)................... 31hydrochlorothiazide tab 12.5 mg....................................... 31hydrochlorothiazide tab 25 mg.......................................... 31hydrochlorothiazide tab 50 mg.......................................... 31hydrocodone-acetaminophen soln 7.5-325 mg/15ml(Hycet)...............................................................................54

hydrocodone-acetaminophen tab 7.5-325 mg (Norco)..... 54hydrocodone-acetaminophen tab 5-325 mg (Norco)........ 54hydrocodone-acetaminophen tab 10-325 mg (Norco)...... 54hydrocortisone butyrate oint 0.1% (Locoid).......................81hydrocortisone cream 0.5%............................................... 81hydrocortisone cream 1%.................................................. 81hydrocortisone cream 2.5%............................................... 81hydrocortisone enema 100 mg/60ml (Cortenema)............79hydrocortisone lotion 2.5%................................................ 81hydrocortisone oint 0.5%................................................... 81hydrocortisone oint 1%...................................................... 81hydrocortisone oint 2.5%................................................... 81hydrocortisone rectal cream 2.5% (Anusol-hc)................. 79hydrocortisone rectal cream 1% (Proctocort)....................79hydrocortisone tab 5 mg (Cortef).......................................16hydrocortisone tab 10 mg (Cortef).....................................16hydrocortisone tab 20 mg (Cortef).....................................16hydrocortisone valerate cream 0.2%.................................81hydrocortisone valerate oint 0.2% (Westcort)................... 81hydrocortisone w/ acetic acid otic soln 1-2%.................... 78HYDROMORPHONE HCL – hydromorphone hcl inj 4 mg/ml.......................................................................................54

hydromorphone hcl liqd 1 mg/ml (Dilaudid).......................54hydromorphone hcl tab 2 mg (Dilaudid)............................55hydromorphone hcl tab 4 mg (Dilaudid)............................55

2019

99

hydromorphone hcl tab 8 mg (Dilaudid)............................55hydroxychloroquine sulfate tab 200 mg (Plaquenil)............ 8hydroxyurea cap 500 mg (Hydrea)....................................11HYDROXYZINE HCL – hydroxyzine hcl im soln 25 mg/ml.......................................................................................44

hydroxyzine hcl syrup 10 mg/5ml......................................44hydroxyzine hcl tab 10 mg.................................................44hydroxyzine hcl tab 25 mg.................................................44hydroxyzine hcl tab 50 mg.................................................44hydroxyzine pamoate cap 25 mg (Vistaril)........................ 44hydroxyzine pamoate cap 50 mg (Vistaril)........................ 44hyoscyamine sulfate elixir 0.125 mg/5ml.......................... 39hyoscyamine sulfate sl tab 0.125 mg (Levsin/sl)...............39hyoscyamine sulfate soln 0.125 mg/ml............................. 39hyoscyamine sulfate tab disint 0.125 mg (Anaspaz).........39hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid)......... 39hyoscyamine sulfate tab 0.125 mg (Levsin)......................39

IIBRANCE – palbociclib cap 75 mg....................................11IBRANCE – palbociclib cap 100 mg..................................11IBRANCE – palbociclib cap 125 mg..................................11ibuprofen cap 200 mg........................................................57ibuprofen susp 100 mg/5ml............................................... 57ibuprofen tab 200 mg.........................................................57ibuprofen tab 400 mg.........................................................57ibuprofen tab 600 mg.........................................................57ibuprofen tab 800 mg.........................................................57ICAPS AREDS 2 – multiple vitamins w/ minerals chewtab......................................................................................69

imatinib mesylate tab 100 mg (base equivalent)(Gleevec)...........................................................................11

imatinib mesylate tab 400 mg (base equivalent)(Gleevec)...........................................................................11

IMBRUVICA – ibrutinib cap 70 mg....................................11IMBRUVICA – ibrutinib cap 140 mg..................................11IMBRUVICA – ibrutinib tab 140 mg...................................11IMBRUVICA – ibrutinib tab 280 mg...................................11IMBRUVICA – ibrutinib tab 420 mg...................................11IMBRUVICA – ibrutinib tab 560 mg...................................11imipramine hcl tab 10 mg (Tofranil)...................................45imipramine hcl tab 25 mg (Tofranil)...................................45imipramine hcl tab 50 mg (Tofranil)...................................45imiquimod cream 5% (Aldara)........................................... 82IMOVAX RABIES (H.D.C.V.) – rabies virus vaccine, hdcinj......................................................................................... 9

INCRUSE ELLIPTA – umeclidinium br aero powd breathact 62.5 mcg/inh (base eq).............................................. 37

indapamide tab 1.25 mg.................................................... 31indapamide tab 2.5 mg...................................................... 31indomethacin cap er 75 mg...............................................57indomethacin cap 25 mg................................................... 57indomethacin cap 50 mg................................................... 57INTELENCE – etravirine tab 25 mg.................................... 6INTELENCE – etravirine tab 100 mg.................................. 6INTELENCE – etravirine tab 200 mg.................................. 6

INVEGA SUSTENNA – paliperidone palmitate imextended-release susp 39 mg/0.25ml............................. 47

INVEGA SUSTENNA – paliperidone palmitate imextended-release susp 78 mg/0.5ml............................... 47

INVEGA SUSTENNA – paliperidone palmitate imextended-release susp 156 mg/ml...................................47

INVEGA SUSTENNA – paliperidone palmitate imextended-release susp 234 mg/1.5ml............................. 47

INVEGA SUSTENNA – paliperidone palmitate im extend-release susp 117 mg/0.75ml............................................47

INVIRASE – saquinavir mesylate cap 200 mg....................6INVIRASE – saquinavir mesylate tab 500 mg.....................6ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml........... 37ipratropium bromide inhal soln 0.02%...............................37irbesartan-hydrochlorothiazide tab 150-12.5 mg(Avalide)............................................................................ 25

irbesartan-hydrochlorothiazide tab 300-12.5 mg(Avalide)............................................................................ 25

irbesartan tab 75 mg (Avapro)...........................................25irbesartan tab 150 mg (Avapro).........................................25irbesartan tab 300 mg (Avapro).........................................25iron combination cap..........................................................69iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg(Hematron-af)....................................................................69

iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg(Corvite 150)..................................................................... 69

iron polysacch complex-vit b12-fa cap 150-0.025-1mg......................................................................................69

irrigation solution, physiological.........................................84ISENTRESS HD – raltegravir potassium tab 600 mg(base equiv)........................................................................ 6

ISENTRESS – raltegravir potassium chew tab 25 mg(base equiv)........................................................................ 6

ISENTRESS – raltegravir potassium chew tab 100 mg(base equiv)........................................................................ 6

ISENTRESS – raltegravir potassium packet for susp 100mg (base equiv)..................................................................6

ISENTRESS – raltegravir potassium tab 400 mg (baseequiv)...................................................................................6

isoniazid tab 100 mg............................................................3isoniazid tab 300 mg............................................................3ISOPTO ATROPINE – atropine sulfate ophth soln 1%..... 78ISOSORBIDE DINITRATE ER – isosorbide dinitrate tab er40 mg................................................................................ 29

isosorbide dinitrate tab 10 mg........................................... 29isosorbide dinitrate tab 20 mg........................................... 29isosorbide dinitrate tab 30 mg........................................... 29isosorbide dinitrate tab 5 mg (Isordil titradose)................. 29isosorbide mononitrate tab er 24hr 30 mg........................ 29isosorbide mononitrate tab er 24hr 60 mg........................ 29isosorbide mononitrate tab er 24hr 120 mg...................... 29isosorbide mononitrate tab 10 mg.....................................29isosorbide mononitrate tab 20 mg.....................................29isotretinoin cap 10 mg........................................................79isotretinoin cap 20 mg........................................................79itraconazole cap 100 mg (Sporanox).................................. 4

2019

100

ivermectin tab 3 mg (Stromectol)........................................ 8IXINITY – coagulation factor ix (recombinant) for inj 250unit.....................................................................................74

IXINITY – coagulation factor ix (recombinant) for inj 500unit.....................................................................................74





J

KKALETRA – lopinavir-ritonavir tab 100-25 mg.................... 6KALETRA – lopinavir-ritonavir tab 200-50 mg.................... 6KALYDECO – ivacaftor packet 50 mg...............................38KALYDECO – ivacaftor packet 75 mg...............................38KALYDECO – ivacaftor tab 150 mg.................................. 38KANUMA – sebelipase alfa iv soln 20 mg/10ml (2 mg/ml)......................................................................................23

KEPPRA – levetiracetam inj 500 mg/5ml (100 mg/ml)......62KEPPRA – levetiracetam oral soln 100 mg/ml..................62KEPPRA – levetiracetam tab 250 mg............................... 61KEPPRA – levetiracetam tab 500 mg............................... 62KEPPRA – levetiracetam tab 750 mg............................... 62KEPPRA – levetiracetam tab 1000 mg............................. 62KEPPRA XR – levetiracetam tab er 24hr 500 mg.............62KEPPRA XR – levetiracetam tab er 24hr 750 mg.............62ketoconazole cream 2%.....................................................80ketoconazole shampoo 2% (Nizoral).................................80ketoprofen cap 75 mg........................................................58KETOPROFEN – ketoprofen cap 25 mg...........................57ketorolac tromethamine ophth soln 0.5% (Acular)............ 78ketorolac tromethamine ophth soln 0.4% (Acular ls).........78ketorolac tromethamine tab 10 mg....................................58ketotifen fumarate ophth soln 0.025% (base equiv)..........78KINEVAC – sincalide for inj 5 mcg....................................41KISQALI FEMARA 200 DOSE – ribociclib tab 200 mg &letrozole tab 2.5 mg therapy pack................................... 11

KISQALI FEMARA 400 DOSE – ribociclib tab 200 mg &letrozole tab 2.5 mg therapy pack................................... 12

KISQALI FEMARA 600 DOSE – ribociclib tab 200 mg &letrozole tab 2.5 mg therapy pack................................... 12

KISQALI – ribociclib succinate tab 200 mg (baseequiv).................................................................................11

KOATE – antihemophilic factor (human) for inj 250unit.....................................................................................74



KOATE-DVI – antihemophilic factor (human) for inj 250unit.....................................................................................74



KOGENATE FS – antihemophilic factor (recombinant) forinj kit 250 unit................................................................... 74

KOGENATE FS – antihemophilic factor (recombinant) forinj kit 500 unit................................................................... 74

KOGENATE FS – antihemophilic factor (recombinant) forinj kit 1000 unit................................................................. 74



KONSYL DAILY FIBER – psyllium powder 60.3%............38KONSYL-D – psyllium powder 52.3%...............................38KONSYL – psyllium powder 60.3%...................................38KONSYL – psyllium powder 71.67%.................................38K-PHOS – potassium phosphate monobasic tab 500mg......................................................................................70

KYLEENA – levonorgestrel releasing iud 17.5 mcg/day(19.5 mg total).................................................................. 18

Llabetalol hcl tab 100 mg.................................................... 26labetalol hcl tab 200 mg.................................................... 26labetalol hcl tab 300 mg.................................................... 26lactated ringer's for irrigation............................................. 84lactic acid (ammonium lactate) lotion 5%..........................82lactic acid (ammonium lactate) lotion 12% (Lac-hydrin)............................................................................... 82

lactulose (encephalopathy) solution 10 gm/15ml.............. 41lactulose solution 10 gm/15ml........................................... 38LAMICTAL CHEWABLE DISPERS – lamotrigine tabchewable dispersible 5 mg.............................................. 62

LAMICTAL CHEWABLE DISPERS – lamotrigine tabchewable dispersible 25 mg............................................ 62

LAMICTAL – lamotrigine tab 25 mg.................................. 62LAMICTAL – lamotrigine tab 100 mg................................ 62LAMICTAL – lamotrigine tab 150 mg................................ 62LAMICTAL – lamotrigine tab 200 mg................................ 62LAMICTAL ODT – lamotrigine orally disintegrating tab 25mg......................................................................................62

LAMICTAL ODT – lamotrigine orally disintegrating tab 50mg......................................................................................62



LAMICTAL ODT – lamotrigine tab disint 25 (14) & 50 mg(14) & 100 mg (7) kit........................................................62

LAMICTAL ODT – lamotrigine tab disint 25 mg (21) & 50mg (7) titration kit............................................................. 62

LAMICTAL ODT – lamotrigine tab disint 50 mg (42)- 100mg(14) titration kit.............................................................62

2019

101

LAMICTAL STARTER/NOT TAKI – lamotrigine tab 25 mg(42) & 100 mg (7) starter kit............................................ 62

LAMICTAL STARTER/TAKING C – lamotrigine tab 25 mg(84) & 100 mg (14) starter kit.......................................... 62

LAMICTAL STARTER/TAKING V – lamotrigine tab 25 mg(35) starter kit................................................................... 62

LAMICTAL XR – lamotrigine tab er 24hr 25 (14) & 50 mg(14) & 100 mg(7) kit.........................................................62

LAMICTAL XR – lamotrigine tab er 24hr 50 (14) & 100mg(14) & 200 mg(7) kit....................................................62

LAMICTAL XR – lamotrigine tab er 24hr 25 mg................62LAMICTAL XR – lamotrigine tab er 24hr 50 mg................62LAMICTAL XR – lamotrigine tab er 24hr 100 mg..............63LAMICTAL XR – lamotrigine tab er 24hr 200 mg..............63LAMICTAL XR – lamotrigine tab er 24hr 250 mg..............63LAMICTAL XR – lamotrigine tab er 24hr 300 mg..............63LAMICTAL XR – lamotrigine tab er 24hr 25 mg (21) & 50mg (7) titration kit............................................................. 62

lamivudine oral soln 10 mg/ml (Epivir)................................ 6lamivudine tab 150 mg (Epivir)............................................6lamivudine tab 300 mg (Epivir)............................................6lamivudine tab 100 mg (hbv) (Epivir hbv)........................... 4lamivudine-zidovudine tab 150-300 mg (Combivir).............6lamotrigine orally disintegrating tab 25 mg (Lamictalodt).................................................................................... 63

lamotrigine orally disintegrating tab 50 mg (Lamictalodt).................................................................................... 63



lamotrigine tab chewable dispersible 5 mg (Lamictalchewable di)......................................................................63

lamotrigine tab chewable dispersible 25 mg (Lamictalchewable di)......................................................................63

lamotrigine tab er 24hr 25 mg (Lamictal xr)...................... 63lamotrigine tab er 24hr 50 mg (Lamictal xr)...................... 63lamotrigine tab er 24hr 100 mg (Lamictal xr).................... 63lamotrigine tab er 24hr 200 mg (Lamictal xr).................... 63lamotrigine tab er 24hr 250 mg (Lamictal xr).................... 63lamotrigine tab er 24hr 300 mg (Lamictal xr).................... 63lamotrigine tab 25 mg (42) & 100 mg (7) starter kit(Lamictal starter/not).........................................................63

lamotrigine tab 25 mg (84) & 100 mg (14) starter kit(Lamictal starter/tak).........................................................63

lamotrigine tab 25 mg (Lamictal).......................................63lamotrigine tab 100 mg (Lamictal).....................................63lamotrigine tab 150 mg (Lamictal).....................................63lamotrigine tab 200 mg (Lamictal).....................................63lamotrigine tab 25 mg (35) starter kit (Lamictal starter/tak).....................................................................................63

lansoprazole cap delayed release 15 mg (Prevacid)........ 40lansoprazole cap delayed release 30 mg (Prevacid)........ 40lanthanum carbonate chew tab 500 mg (elemental)(Fosrenol)..........................................................................41

lanthanum carbonate chew tab 750 mg (elemental)(Fosrenol)..........................................................................41

lanthanum carbonate chew tab 1000 mg (elemental)(Fosrenol)..........................................................................41

latanoprost ophth soln 0.005% (Xalatan).......................... 77LATUDA – lurasidone hcl tab 20 mg.................................48LATUDA – lurasidone hcl tab 40 mg.................................48LATUDA – lurasidone hcl tab 60 mg.................................48LATUDA – lurasidone hcl tab 80 mg.................................48LATUDA – lurasidone hcl tab 120 mg...............................48leflunomide tab 10 mg (Arava).......................................... 58leflunomide tab 20 mg (Arava).......................................... 58LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 mg (14 mg daily dose)................................ 12

LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 (2) mg (18 mg daily dose)...........................12

LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapypack 10 (2) & 4 mg (24 mg daily dose)...........................12

LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapypack 10 mg (10 mg daily dose).......................................12

LENVIMA 12MG DAILY DOSE – lenvatinib cap therapypack 4 (3) mg (12 mg daily dose)................................... 12

LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapypack 10 (2) mg (20 mg daily dose)................................. 12

LENVIMA 4 MG DAILY DOSE – lenvatinib cap therapypack 4 mg (4 mg daily dose)...........................................12

LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapypack 4 (2) mg (8 mg daily dose)..................................... 12

letrozole tab 2.5 mg (Femara)...........................................12LEUCOVORIN CALCIUM – leucovorin calcium tab 10mg......................................................................................12

LEUCOVORIN CALCIUM – leucovorin calcium tab 15mg......................................................................................12

leucovorin calcium tab 5 mg..............................................12leucovorin calcium tab 25 mg............................................12LEUKERAN – chlorambucil tab 2 mg................................12LEVETIRACETAM – levetiracetam in sodium chloride ivsoln 500 mg/100ml...........................................................63

LEVETIRACETAM – levetiracetam in sodium chloride ivsoln 1000 mg/100ml.........................................................63

LEVETIRACETAM – levetiracetam in sodium chloride ivsoln 1500 mg/100ml.........................................................63

levetiracetam oral soln 100 mg/ml (Keppra)..................... 63levetiracetam tab er 24hr 500 mg (Keppra xr).................. 63levetiracetam tab er 24hr 750 mg (Keppra xr).................. 63levetiracetam tab 250 mg (Keppra)...................................63levetiracetam tab 500 mg (Keppra)...................................63levetiracetam tab 750 mg (Keppra)...................................64levetiracetam tab 1000 mg (Keppra).................................64levobunolol hcl ophth soln 0.5% (Betagan).......................77levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...........23levocarnitine tab 330 mg (Carnitor)...................................23levocetirizine dihydrochloride tab 5 mg............................. 35levofloxacin ophth soln 0.5%.............................................77levofloxacin oral soln 25 mg/ml........................................... 3levofloxacin tab 250 mg (Levaquin).....................................3

2019

102

levofloxacin tab 500 mg (Levaquin).....................................3levofloxacin tab 750 mg (Levaquin).....................................3levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg....... 18levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg..... 18levonorgestrel-eth estra tab0.05-30/0.075-40/0.125-30mg-mcg..................................18

levonorgestrel tab 1.5 mg.................................................. 18levothyroxine sodium tab 25 mcg (Synthroid)...................21levothyroxine sodium tab 50 mcg (Synthroid)...................22levothyroxine sodium tab 75 mcg (Synthroid)...................22levothyroxine sodium tab 88 mcg (Synthroid)...................22levothyroxine sodium tab 100 mcg (Synthroid).................22levothyroxine sodium tab 112 mcg (Synthroid)................. 22levothyroxine sodium tab 125 mcg (Synthroid).................22levothyroxine sodium tab 137 mcg (Synthroid).................22levothyroxine sodium tab 150 mcg (Synthroid).................22levothyroxine sodium tab 175 mcg (Synthroid).................22levothyroxine sodium tab 200 mcg (Synthroid).................22levothyroxine sodium tab 300 mcg (Synthroid).................22LEXIVA – fosamprenavir calcium susp 50 mg/ml (baseequiv)...................................................................................6

lidocaine hcl cream 3%......................................................82lidocaine hcl gel 2%...........................................................82LIDOCAINE HCL – lidocaine hcl local preservative free(pf) inj 4%......................................................................... 59

lidocaine hcl soln 4% (Xylocaine)......................................82lidocaine hcl viscous soln 2%............................................78lidocaine oint 5%................................................................82lidocaine patch 5% (Lidoderm)..........................................82lidocaine-prilocaine cream 2.5-2.5%................................. 82lidocaine-prilocaine cream kit 2.5-2.5%.............................82linezolid for susp 100 mg/5ml (Zyvox).................................8linezolid tab 600 mg (Zyvox)............................................... 8liothyronine sodium tab 5 mcg (Cytomel)..........................22liothyronine sodium tab 25 mcg (Cytomel)........................22liothyronine sodium tab 50 mcg (Cytomel)........................22lisinopril & hydrochlorothiazide tab 10-12.5 mg(Zestoretic)........................................................................ 24

lisinopril & hydrochlorothiazide tab 20-12.5 mg(Zestoretic)........................................................................ 24

lisinopril & hydrochlorothiazide tab 20-25 mg(Zestoretic)........................................................................ 24

lisinopril tab 5 mg (Prinivil)................................................ 24lisinopril tab 10 mg (Prinivil).............................................. 24lisinopril tab 20 mg (Prinivil).............................................. 24lisinopril tab 2.5 mg (Zestril).............................................. 24lisinopril tab 30 mg (Zestril)............................................... 24lisinopril tab 40 mg (Zestril)............................................... 25lithium carbonate cap 300 mg........................................... 48lithium carbonate cap 150 mg (Lithium carbonate)...........48lithium carbonate cap 600 mg (Lithium carbonate)...........48lithium carbonate tab er 450 mg........................................48lithium carbonate tab er 300 mg (Lithobid)....................... 48lithium carbonate tab 300 mg............................................48LITHIUM – lithium oral solution 8 meq/5ml....................... 48

LMD 10% DEXTROSE 5% – dextran 40 inj 10% ind5w....................................................................................75

loperamide hcl cap 2 mg................................................... 39loperamide hcl tab 2 mg....................................................39lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)(Kaletra)...............................................................................6

loratadine syrup 5 mg/5ml................................................. 35loratadine tab 10 mg..........................................................35lorazepam conc 2 mg/ml................................................... 44lorazepam tab 0.5 mg (Ativan).......................................... 44lorazepam tab 1 mg (Ativan)............................................. 44lorazepam tab 2 mg (Ativan)............................................. 44losartan potassium & hydrochlorothiazide tab 50-12.5 mg(Hyzaar).............................................................................25

losartan potassium & hydrochlorothiazide tab 100-12.5mg (Hyzaar)...................................................................... 25

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

losartan potassium tab 25 mg (Cozaar)............................25losartan potassium tab 50 mg (Cozaar)............................26losartan potassium tab 100 mg (Cozaar)..........................26lovastatin tab 10 mg...........................................................30lovastatin tab 20 mg...........................................................30lovastatin tab 40 mg...........................................................30loxapine succinate cap 5 mg.............................................48loxapine succinate cap 10 mg...........................................48loxapine succinate cap 25 mg...........................................48loxapine succinate cap 50 mg...........................................48LUPRON DEPOT (1-MONTH) – leuprolide acetate for injkit 3.75 mg........................................................................12

LUPRON DEPOT (1-MONTH) – leuprolide acetate for injkit 7.5 mg..........................................................................12

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3month) for inj kit 11.25 mg............................................... 12

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3month) for inj kit 22.5 mg.................................................12

LUPRON DEPOT (4-MONTH) – leuprolide acetate (4month) for inj kit 30 mg....................................................12

LUPRON DEPOT (6-MONTH) – leuprolide acetate (6month) for inj kit 45 mg....................................................12

LUPRON DEPOT-PED (1-MONTH – leuprolide acetatefor inj pediatric kit 7.5 mg........................................... 18,23

LUPRON DEPOT-PED (1-MONTH – leuprolide acetatefor inj pediatric kit 11.25 mg........................................19,23

LUPRON DEPOT-PED (1-MONTH – leuprolide acetatefor inj pediatric kit 15 mg............................................ 19,23

LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3month) for inj pediatric kit 11.25 mg................................ 19

LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3month) for inj pediatric kit 30 mg..................................... 19

LYNPARZA – olaparib tab 100 mg....................................13LYNPARZA – olaparib tab 150 mg....................................13LYRICA – pregabalin cap 25 mg.......................................64LYRICA – pregabalin cap 50 mg.......................................64LYRICA – pregabalin cap 75 mg.......................................64LYRICA – pregabalin cap 100 mg.....................................64

2019

103

LYRICA – pregabalin cap 150 mg.....................................64LYRICA – pregabalin cap 200 mg.....................................64LYRICA – pregabalin cap 225 mg.....................................64LYRICA – pregabalin cap 300 mg.....................................64LYRICA – pregabalin soln 20 mg/ml................................. 64

MMAGNESIUM CHLORIDE – magnesium chloride inj 200mg/ml.................................................................................70

magnesium citrate soln......................................................38magnesium oxide tab 400 mg........................................... 39magnesium oxide tab 400 mg (241.3 mg elementalmg).................................................................................... 70

malathion lotion 0.5% (Ovide)........................................... 82meclizine hcl chew tab 25 mg........................................... 40meclizine hcl tab 12.5 mg..................................................40meclizine hcl tab 25 mg.....................................................40medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac)............................................................... 18

medroxyprogesterone acetate tab 2.5 mg (Provera)........ 17medroxyprogesterone acetate tab 5 mg (Provera)........... 17medroxyprogesterone acetate tab 10 mg (Provera)......... 17MEFLOQUINE HCL – mefloquine hcl tab 250 mg..............8megestrol acetate susp 40 mg/ml..................................... 13megestrol acetate susp 625 mg/5ml (Megace es)............ 17megestrol acetate tab 20 mg.............................................13megestrol acetate tab 40 mg.............................................13MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg(base equivalent).............................................................. 13

MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (baseequivalent).........................................................................13

MEKTOVI – binimetinib tab 15 mg....................................13meloxicam tab 7.5 mg (Mobic).......................................... 58meloxicam tab 15 mg (Mobic)........................................... 58melphalan tab 2 mg (Alkeran)........................................... 13meperidine hcl tab 50 mg..................................................55meperidine hcl tab 100 mg (Demerol)...............................55mercaptopurine tab 50 mg.................................................13mesalamine enema 4 gm.................................................. 41mesalamine suppos 1000 mg (Canasa)........................... 41mesalamine tab delayed release 800 mg (Asacol hd)...... 41METAMUCIL MULTIHEALTH FIB – psyllium powder55.46%.............................................................................. 38

METAMUCIL MULTIHEALTH FIB – psyllium powder63%................................................................................... 38

METAMUCIL SMOOTH TEXTURE – psyllium powder63%................................................................................... 38

metformin hcl tab er 24hr 500 mg (Glucophage xr).......... 20metformin hcl tab er 24hr 750 mg (Glucophage xr).......... 20metformin hcl tab 500 mg (Glucophage)...........................20metformin hcl tab 850 mg (Glucophage)...........................20metformin hcl tab 1000 mg (Glucophage).........................20methimazole tab 5 mg (Tapazole)..................................... 22methimazole tab 10 mg (Tapazole)................................... 22methocarbamol tab 750 mg (Robaxin-750).......................67methocarbamol tab 500 mg (Robaxin)..............................67

METHOTREXATE SODIUM – methotrexate sodium inj250 mg/10ml (25 mg/ml)..................................................13

methotrexate sodium tab 2.5 mg (base equiv)..................13methoxsalen rapid cap 10 mg (Oxsoralen ultra)............... 82methyldopa tab 250 mg..................................................... 33methyldopa tab 500 mg..................................................... 33methylergonovine maleate tab 0.2 mg.............................. 23methylphenidate hcl cap er 24hr 20 mg (la) (Ritalinla).......................................................................................51

methylphenidate hcl cap er 24hr 30 mg (la) (Ritalinla).......................................................................................51

methylphenidate hcl cap er 24hr 40 mg (la) (Ritalinla).......................................................................................51

methylphenidate hcl cap er 10 mg (cd).............................51methylphenidate hcl cap er 20 mg (cd).............................51methylphenidate hcl cap er 30 mg (cd).............................51methylphenidate hcl cap er 40 mg (cd).............................51methylphenidate hcl cap er 50 mg (cd).............................51methylphenidate hcl cap er 60 mg (cd).............................51methylphenidate hcl tab er 10 mg.....................................51methylphenidate hcl tab er osmotic release (osm) 18 mg(Concerta)......................................................................... 51

methylphenidate hcl tab er osmotic release (osm) 27 mg(Concerta)......................................................................... 51



methylphenidate hcl tab 5 mg (Ritalin)..............................51methylphenidate hcl tab 10 mg (Ritalin)............................52methylphenidate hcl tab 20 mg (Ritalin)............................52METHYLPHENIDATE HYDROCHLO – methylphenidatehcl tab er 24hr 18 mg...................................................... 52

METHYLPHENIDATE HYDROCHLO – methylphenidatehcl tab er 24hr 27 mg...................................................... 52



methylprednisolone tab 4 mg (Medrol)..............................16methylprednisolone tab 8 mg (Medrol)..............................16methylprednisolone tab 16 mg (Medrol)............................16methylprednisolone tab 32 mg (Medrol)............................16methylprednisolone tab therapy pack 4 mg (21) (Medroldosepak)............................................................................16

metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (baseequiv).................................................................................41

metoclopramide hcl tab 5 mg (base equivalent)(Reglan).............................................................................41

metoclopramide hcl tab 10 mg (base equivalent)(Reglan).............................................................................41

metolazone tab 2.5 mg...................................................... 31metolazone tab 5 mg......................................................... 31metolazone tab 10 mg....................................................... 31METOPROLOL/HYDROCHLOROTHI – metoprolol &hydrochlorothiazide tab 100-50 mg................................. 27

2019

104

metoprolol & hydrochlorothiazide tab 100-25 mg..............26metoprolol & hydrochlorothiazide tab 50-25 mg(Lopressor hct)..................................................................26

metoprolol succinate tab er 24hr 25 mg (tartrate equiv)(Toprol xl).......................................................................... 27




metoprolol tartrate tab 25 mg............................................ 27metoprolol tartrate tab 50 mg (Lopressor).........................27metoprolol tartrate tab 100 mg (Lopressor).......................27metronidazole cap 375 mg (Flagyl).....................................8metronidazole cream 0.75% (Metrocream).......................79metronidazole gel 0.75%................................................... 79metronidazole gel 1% (Metrogel).......................................79metronidazole tab 250 mg (Flagyl)......................................8metronidazole tab 500 mg (Flagyl)......................................8metronidazole vaginal gel 0.75% (Metrogel-vaginal)........ 42mexiletine hcl cap 150 mg.................................................32mexiletine hcl cap 200 mg.................................................32mexiletine hcl cap 250 mg.................................................32miconazole nitrate cream 2%............................................ 80miconazole nitrate vaginal cream 2%................................42midodrine hcl tab 2.5 mg...................................................33midodrine hcl tab 5 mg...................................................... 33midodrine hcl tab 10 mg....................................................33minocycline hcl cap 75 mg.................................................. 3minocycline hcl cap 50 mg (Minocin).................................. 3minocycline hcl cap 100 mg (Minocin)................................ 3minocycline hcl tab 50 mg...................................................3minocycline hcl tab 75 mg...................................................3minocycline hcl tab 100 mg.................................................3minoxidil tab 2.5 mg...........................................................33minoxidil tab 10 mg............................................................33MIRENA – levonorgestrel releasing iud 20 mcg/day (52mg total)............................................................................18

mirtazapine orally disintegrating tab 15 mg (Remeronsoltab)................................................................................45



mirtazapine tab 15 mg (Remeron).....................................45mirtazapine tab 30 mg (Remeron).....................................45mirtazapine tab 45 mg (Remeron).....................................45misoprostol tab 100 mcg (Cytotec)....................................40misoprostol tab 200 mcg (Cytotec)....................................40modafinil tab 100 mg (Provigil)..........................................52modafinil tab 200 mg (Provigil)..........................................52moexipril hcl tab 7.5 mg.................................................... 25moexipril hcl tab 15 mg..................................................... 25moexipril-hydrochlorothiazide tab 7.5-12.5 mg................. 25moexipril-hydrochlorothiazide tab 15-12.5 mg.................. 25

moexipril-hydrochlorothiazide tab 15-25 mg..................... 25mometasone furoate cream 0.1% (Elocon).......................81mometasone furoate oint 0.1% (Elocon)...........................81mometasone furoate solution 0.1% (lotion).......................81MONOCLATE-P – antihemophilic factor (human) for inj kit1000 unit........................................................................... 75

MONONINE – coagulation factor ix for inj 1000 unit.........75montelukast sodium chew tab 4 mg (base equiv)(Singulair)..........................................................................37

montelukast sodium chew tab 5 mg (base equiv)(Singulair)..........................................................................37

montelukast sodium oral granules packet 4 mg (baseequiv) (Singulair).............................................................. 37

montelukast sodium tab 10 mg (base equiv)(Singulair)..........................................................................37

MORPHINE SULFATE – morphine sulfate inj 8 mg/ml..... 55MORPHINE SULFATE – morphine sulfate suppos 5mg......................................................................................55

MORPHINE SULFATE – morphine sulfate suppos 10mg......................................................................................55



MORPHINE SULFATE – morphine sulfate tab 15 mg...... 55MORPHINE SULFATE – morphine sulfate tab 30 mg...... 55morphine sulfate oral soln 10 mg/5ml............................... 55morphine sulfate oral soln 20 mg/5ml............................... 55morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...........55morphine sulfate tab er 15 mg (Ms contin)....................... 55morphine sulfate tab er 30 mg (Ms contin)....................... 55morphine sulfate tab er 60 mg (Ms contin)....................... 55morphine sulfate tab er 100 mg (Ms contin)..................... 55morphine sulfate tab er 200 mg (Ms contin)..................... 55moxifloxacin hcl ophth soln 0.5% (base equiv)(Vigamox)..........................................................................77

multiple vitamins w/ iron tab.............................................. 69multiple vitamins w/ minerals & fa tab 1.25 mg(Corvite).............................................................................69

multiple vitamins w/ minerals cap......................................70multiple vitamins w/ minerals tab (Strovite forte)...............70multiple vitamin tab............................................................ 69mupirocin oint 2%...............................................................80mycophenolate mofetil cap 250 mg (Cellcept)..................84mycophenolate mofetil for oral susp 200 mg/ml(Cellcept)...........................................................................84

mycophenolate mofetil tab 500 mg (Cellcept)...................84mycophenolate sodium tab dr 180 mg (mycophenolic acidequiv) (Myfortic)................................................................84

mycophenolate sodium tab dr 360 mg (mycophenolic acidequiv) (Myfortic)................................................................84

MYLERAN – busulfan tab 2 mg........................................ 13MYSOLINE – primidone tab 50 mg...................................64MYSOLINE – primidone tab 250 mg.................................64

2019

105

Nnabumetone tab 500 mg....................................................58nabumetone tab 750 mg....................................................58nadolol tab 20 mg (Corgard)............................................. 27nadolol tab 40 mg (Corgard)............................................. 27nadolol tab 80 mg (Corgard)............................................. 27NALOXONE HCL – naloxone hcl soln cartridge 0.4 mg/ml.......................................................................................84

NALOXONE HCL – naloxone hcl soln prefilled syringe 2mg/2ml...............................................................................84

naltrexone hcl tab 50 mg...................................................53naproxen sodium tab 220 mg............................................58naproxen sodium tab 275 mg............................................58naproxen sodium tab 550 mg (Anaprox ds)......................58naproxen tab ec 375 mg (Ec-naprosyn)............................58naproxen tab ec 500 mg (Ec-naprosyn)............................58naproxen tab 250 mg.........................................................58naproxen tab 375 mg.........................................................58naproxen tab 500 mg (Naprosyn)......................................58NARCAN – naloxone hcl nasal spray 4 mg/0.1ml.............84NATACYN – natamycin ophth susp 5%............................ 77nateglinide tab 60 mg (Starlix)...........................................20nateglinide tab 120 mg (Starlix).........................................20NEOMYCIN/POLYMYXIN/GRAMIC – neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml.............77

neomycin-bacitracin-polymyxin oint...................................80neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000untop oin................................................................................ 77

neomycin-polymyxin-dexamethasone ophth oint 0.1%(Maxitrol)........................................................................... 77

neomycin-polymyxin-dexamethasone ophth susp 0.1%(Maxitrol)........................................................................... 77

neomycin-polymyxin-hc otic soln 1%................................ 78neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%................................................................................ 78

neomycin sulfate tab 500 mg.............................................. 3NERLYNX – neratinib maleate tab 40 mg (baseequivalent).........................................................................13

NEURONTIN – gabapentin cap 100 mg........................... 64NEURONTIN – gabapentin cap 300 mg........................... 64NEURONTIN – gabapentin cap 400 mg........................... 64NEURONTIN – gabapentin oral soln 250 mg/5ml.............64NEURONTIN – gabapentin tab 600 mg............................64NEURONTIN – gabapentin tab 800 mg............................64nevirapine susp 50 mg/5ml (Viramune)...............................6nevirapine tab er 24hr 100 mg (Viramune xr)..................... 6nevirapine tab er 24hr 400 mg (Viramune xr)..................... 6nevirapine tab 200 mg (Viramune)......................................6NEXAVAR – sorafenib tosylate tab 200 mg (baseequivalent).........................................................................13

NEXPLANON – etonogestrel subdermal implant 68mg......................................................................................18

niacin cap er 250 mg......................................................... 69niacin cap er 500 mg......................................................... 69niacin tab er 250 mg..........................................................69

niacin tab er 500 mg..........................................................69niacin tab er 750 mg..........................................................69niacin tab 100 mg.............................................................. 69niacin tab 500 mg.............................................................. 69NIACIN TR – niacin tab er 1000 mg................................. 69nicotine polacrilex gum 2 mg.............................................53nicotine polacrilex gum 4 mg.............................................53nicotine td patch 24hr 7 mg/24hr.......................................53nicotine td patch 24hr 14 mg/24hr.....................................53nicotine td patch 24hr 21 mg/24hr.....................................53nifedipine cap 10 mg (Procardia)...................................... 28nifedipine tab er 24hr 30 mg (Adalat cc)...........................28nifedipine tab er 24hr 60 mg (Adalat cc)...........................28nifedipine tab er 24hr 90 mg (Adalat cc)...........................28nifedipine tab er 24hr osmotic release 30 mg (Procardiaxl).......................................................................................28

nifedipine tab er 24hr osmotic release 60 mg (Procardiaxl).......................................................................................28

nifedipine tab er 24hr osmotic release 90 mg (Procardiaxl).......................................................................................28

nitrofurantoin macrocrystalline cap 25 mg(Macrodantin)....................................................................42



nitrofurantoin monohydrate macrocrystalline cap 100 mg(Macrobid)......................................................................... 42

nitrofurantoin susp 25 mg/5ml (Furadantin)...................... 42nitroglycerin cap er 2.5 mg................................................29nitroglycerin cap er 6.5 mg................................................29nitroglycerin cap er 9 mg...................................................29nitroglycerin sl tab 0.3 mg (Nitrostat)................................ 29nitroglycerin sl tab 0.4 mg (Nitrostat)................................ 29nitroglycerin sl tab 0.6 mg (Nitrostat)................................ 29nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)............... 29nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)............... 29nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)............... 29nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)............... 29NITYR – nitisinone tab 2 mg............................................. 23NITYR – nitisinone tab 5 mg............................................. 23NITYR – nitisinone tab 10 mg........................................... 23nizatidine cap 150 mg........................................................40nizatidine cap 300 mg........................................................40NIZATIDINE – nizatidine oral soln 15 mg/ml.....................40norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg(Loestrin fe 1/20).............................................................. 18

norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg(Loestrin 1/20-21)............................................................. 18

norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg(Loestrin 1.5/30-21).......................................................... 18

norethindrone acetate-ethinyl estradiol tab 1 mg-5mcg....................................................................................17

norethindrone acetate tab 5 mg (Aygestin).......................17norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg(Ortho-cyclen)................................................................... 18

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106

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35mg-mcg (Ortho tri-cyclen)................................................ 18

norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25mg-mcg (Ortho tri-cyclen lo)............................................ 18

NORTEMP INFANTS – acetaminophen susp 80mg/0.8ml............................................................................54

nortriptyline hcl cap 10 mg (Pamelor)............................... 45nortriptyline hcl cap 25 mg (Pamelor)............................... 45nortriptyline hcl cap 50 mg (Pamelor)............................... 45nortriptyline hcl cap 75 mg (Pamelor)............................... 45NORVIR – ritonavir oral soln 80 mg/ml...............................6NOVOLIN 70/30 FLEXPEN – insulin nph & regular susppen-inj 100 unit/ml (70-30)...............................................21

NOVOLIN 70/30 FLEXPEN REL – insulin nph & regularsusp pen-inj 100 unit/ml (70-30)......................................21

NOVOLIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30)...................................................... 21

NOVOLIN 70/30 RELION – insulin nph isophane &regular human inj 100 unit/ml (70-30)............................. 21

NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml.......................................................................................21

NOVOLIN N RELION – insulin nph (human) (isophane) inj100 unit/ml........................................................................ 21

NOVOLIN R – insulin regular (human) inj 100 unit/ml...... 21NOVOLIN R RELION – insulin regular (human) inj 100unit/ml................................................................................21

NOVOLOG MIX 70/30 – insulin aspart prot & aspart(human) inj 100 unit/ml (70-30)....................................... 21

NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &aspart sus pen-inj 100 unit/ml (70-30).............................21

NOXAFIL – posaconazole susp 40 mg/ml.......................... 4NOXAFIL – posaconazole tab delayed release 100 mg..... 4NUVARING – etonogestrel-ethinyl estradiol va ring0.120-0.015 mg/24hr........................................................ 18

nystatin cream 100000 unit/gm......................................... 80nystatin oint 100000 unit/gm..............................................80nystatin susp 100000 unit/ml.............................................78nystatin tab 500000 unit...................................................... 4nystatin topical powder 100000 unit/gm............................80

Ooctreotide acetate inj 50 mcg/ml (0.05 mg/ml)(Sandostatin).....................................................................23

octreotide acetate inj 100 mcg/ml (0.1 mg/ml)(Sandostatin).....................................................................23



octreotide acetate inj 1000 mcg/ml (1 mg/ml)(Sandostatin).....................................................................23

ofloxacin ophth soln 0.3% (Ocuflox)..................................77ofloxacin otic soln 0.3% (Floxin otic).................................78olanzapine for im inj 10 mg (Zyprexa)...............................48olanzapine orally disintegrating tab 5 mg (Zyprexazydis)................................................................................. 48

olanzapine orally disintegrating tab 10 mg (Zyprexazydis)................................................................................. 48



olanzapine tab 2.5 mg (Zyprexa).......................................48olanzapine tab 5 mg (Zyprexa)..........................................48olanzapine tab 7.5 mg (Zyprexa).......................................48olanzapine tab 10 mg (Zyprexa)........................................48olanzapine tab 15 mg (Zyprexa)........................................48olanzapine tab 20 mg (Zyprexa)........................................48OLUMIANT – baricitinib tab 2 mg..................................... 58omega-3 fatty acids cap delayed release 1000 mg...........71omega-3 fatty acids cap delayed release 1200 mg...........71omega-3 fatty acids cap 500 mg.......................................71omega-3 fatty acids cap 435 mg.......................................71omega-3 fatty acids cap 1000 mg.....................................71omega-3 fatty acids cap 1200 mg.....................................71OMEGA-3 IQ – omega-3 fatty acids chew tab 240 mg.....71OMEGA-3 – omega-3 fatty acids cap 1400 mg................ 71omeprazole cap delayed release 20 mg........................... 40omeprazole cap delayed release 40 mg........................... 40OMNITROPE – somatropin for inj 5.8 mg.........................22ondansetron hcl oral soln 4 mg/5ml (Zofran).................... 40ondansetron hcl tab 24 mg................................................40ondansetron hcl tab 4 mg (Zofran)....................................40ondansetron hcl tab 8 mg (Zofran)....................................40ondansetron orally disintegrating tab 4 mg (Zofranodt).................................................................................... 40

ondansetron orally disintegrating tab 8 mg (Zofranodt).................................................................................... 40

ONETOUCH DELICA LANCETS F – LANCETS -ONETOUCH AND LIFESCAN......................................... 83

ONETOUCH DELICA LANCING D – ONETOUCHDELICA LANCING DEVICE.............................................83

ONETOUCH SURESOFT LANCING – ONETOUCHSURESOFT LANCING DEVICE......................................83

ONETOUCH ULTRA 2 – blood glucose monitoring kit w/device................................................................................ 83

ONETOUCH ULTRA BLUE – glucose blood test strip......83ONETOUCH ULTRA CONTROL – blood glucosecalibration - liquid............................................................. 83

ONETOUCH ULTRA MINI – blood glucose monitoring kitw/ device...........................................................................83

ONETOUCH VERIO – blood glucose monitoring kit w/device................................................................................ 83

ONETOUCH VERIO CONTROL SO – blood glucosecalibration - liquid - high...................................................83

ONETOUCH VERIO FLEX BLOOD – blood glucosemonitoring kit w/ device....................................................83

ONETOUCH VERIO IQ BLOOD G – blood glucosemonitoring kit w/ device....................................................83

ONETOUCH VERIO MID CONTRO – blood glucosecalibration - liquid............................................................. 83

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107

ONETOUCH VERIO TEST STRIP – glucose blood teststrip....................................................................................83

ONFI – clobazam suspension 2.5 mg/ml.......................... 64ONFI – clobazam tab 10 mg............................................. 64ONFI – clobazam tab 20 mg............................................. 64oral electrolyte solution...................................................... 70orphenadrine citrate tab er 12hr 100 mg...........................67oseltamivir phosphate cap 30 mg (base equiv)(Tamiflu)...............................................................................7

oseltamivir phosphate cap 45 mg (base equiv)(Tamiflu)...............................................................................7

oseltamivir phosphate cap 75 mg (base equiv)(Tamiflu)...............................................................................7

oseltamivir phosphate for susp 6 mg/ml (base equiv)(Tamiflu)...............................................................................7

OTEZLA – apremilast tab 30 mg.......................................58OTEZLA – apremilast tab starter therapy pack 10 mg & 20mg & 30 mg......................................................................58

oxcarbazepine susp 300 mg/5ml (60 mg/ml)(Trileptal)........................................................................... 64

oxcarbazepine tab 150 mg (Trileptal)................................64oxcarbazepine tab 300 mg (Trileptal)................................64oxcarbazepine tab 600 mg (Trileptal)................................64OXTELLAR XR – oxcarbazepine tab er 24hr 150 mg.......64OXTELLAR XR – oxcarbazepine tab er 24hr 300 mg.......64OXTELLAR XR – oxcarbazepine tab er 24hr 600 mg.......64oxybutynin chloride syrup 5 mg/5ml..................................42oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)........... 42oxybutynin chloride tab er 24hr 10 mg (Ditropan xl)......... 42oxybutynin chloride tab er 24hr 15 mg (Ditropan xl)......... 42oxybutynin chloride tab 5 mg.............................................42oxycodone-aspirin tab 4.8355-325 mg.............................. 55oxycodone hcl conc 100 mg/5ml (20 mg/ml).................... 55oxycodone hcl soln 5 mg/5ml............................................55oxycodone hcl tab 10 mg.................................................. 55oxycodone hcl tab 20 mg.................................................. 55oxycodone hcl tab 5 mg (Roxicodone)..............................55oxycodone hcl tab 15 mg (Roxicodone)............................55oxycodone hcl tab 30 mg (Roxicodone)............................55oxycodone w/ acetaminophen tab 5-325 mg(Percocet)..........................................................................55

oxycodone w/ acetaminophen tab 7.5-325 mg(Percocet)..........................................................................55

oxycodone w/ acetaminophen tab 10-325 mg(Percocet)..........................................................................55

Ppantoprazole sodium ec tab 20 mg (base equiv)(Protonix)...........................................................................40

pantoprazole sodium ec tab 40 mg (base equiv)(Protonix)...........................................................................40

PAPAVERINE HCL – papaverine hcl inj 30 mg/ml............33PARAGARD INTRAUTERINE COP – copper iud............. 18paromomycin sulfate cap 250 mg....................................... 3paroxetine hcl tab 10 mg (Paxil)........................................45paroxetine hcl tab 20 mg (Paxil)........................................45

paroxetine hcl tab 30 mg (Paxil)........................................46paroxetine hcl tab 40 mg (Paxil)........................................46PEDIA-LAX – glycerin liquid suppos 2.8 gm (2.7 ml)........38pediatric multiple vitamin w/ c & fa chew tab.................... 70pediatric multiple vitamin w/ minerals & c drops 45 mg/ml.......................................................................................70

PEGANONE – ethotoin tab 250 mg..................................64peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm(Colyte-flavor packs).........................................................38

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm(Golytely)...........................................................................38

peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack)....................................................................... 38

PENICILLIN V POTASSIUM – penicillin v potassium forsoln 125 mg/5ml.................................................................1

PENICILLIN V POTASSIUM – penicillin v potassium forsoln 250 mg/5ml.................................................................1

penicillin v potassium tab 250 mg....................................... 1penicillin v potassium tab 500 mg....................................... 1pentoxifylline tab er 400 mg.............................................. 75perindopril erbumine tab 2 mg...........................................25perindopril erbumine tab 4 mg (Aceon).............................25perindopril erbumine tab 8 mg (Aceon).............................25permethrin cream 5% (Elimite)..........................................82permethrin creme rinse 1%............................................... 82perphenazine tab 2 mg......................................................48perphenazine tab 4 mg......................................................48perphenazine tab 8 mg......................................................48perphenazine tab 16 mg....................................................48phenazopyridine hcl tab 100 mg (Pyridium)......................43phenazopyridine hcl tab 200 mg (Pyridium)......................43phenobarbital elixir 20 mg/5ml...........................................50PHENOBARBITAL SODIUM – phenobarbital sodium inj65 mg/ml........................................................................... 50

PHENOBARBITAL SODIUM – phenobarbital sodium inj130 mg/ml......................................................................... 50

phenobarbital tab 15 mg....................................................50phenobarbital tab 16.2 mg.................................................50phenobarbital tab 30 mg....................................................50phenobarbital tab 32.4 mg.................................................50phenobarbital tab 60 mg....................................................50phenobarbital tab 64.8 mg.................................................50phenobarbital tab 97.2 mg.................................................50phenobarbital tab 100 mg..................................................50phenoxybenzamine hcl cap 10 mg (Dibenzyline)..............33phenylephrine-guaifenesin tab 10-400 mg........................35phenylephrine hcl tab 10 mg............................................. 35phenylephrine w/ dm-gg liqd 5-10-200 mg/5ml.................35PHENYTEK – phenytoin sodium extended cap 200mg......................................................................................64

PHENYTEK – phenytoin sodium extended cap 300mg......................................................................................64

phenytoin chew tab 50 mg (Dilantin infatabs)................... 64phenytoin sodium extended cap 100 mg (Dilantin)...........64phenytoin sodium extended cap 200 mg (Phenytek)........64phenytoin sodium extended cap 300 mg (Phenytek)........65

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phenytoin susp 125 mg/5ml (Dilantin-125)........................65phytonadione tab 5 mg (Mephyton)...................................69pilocarpine hcl ophth soln 1% (Isopto carpine)................. 77pilocarpine hcl ophth soln 2% (Isopto carpine)................. 78pilocarpine hcl ophth soln 4% (Isopto carpine)................. 78pilocarpine hcl tab 5 mg (Salagen)....................................78pilocarpine hcl tab 7.5 mg (Salagen).................................79PIMOZIDE – pimozide tab 1 mg....................................... 53PIMOZIDE – pimozide tab 2 mg....................................... 53pioglitazone hcl tab 15 mg (base equiv) (Actos)............... 20pioglitazone hcl tab 30 mg (base equiv) (Actos)............... 20pioglitazone hcl tab 45 mg (base equiv) (Actos)............... 20piroxicam cap 10 mg (Feldene).........................................58piroxicam cap 20 mg (Feldene).........................................58PLAN B ONE-STEP – levonorgestrel tab 1.5 mg............. 18PNEUMOVAX 23/1 DOSE – pneumococcal vaccinepolyvalent inj 25 mcg/0.5ml............................................... 9

PNEUMOVAX 23 – pneumococcal vaccine polyvalent inj25 mcg/0.5ml...................................................................... 9

podofilox soln 0.5%............................................................82polyethylene glycol 3350 oral powder............................... 38polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%(Polytrim)...........................................................................77

POLY-VI-SOL – pediatric multiple vitamin w/ c soln 35 mg/ml.......................................................................................70

potassium bicarbonate effer tab 25 meq...........................70potassium chloride cap er 8 meq (Micro-k).......................70potassium chloride cap er 10 meq (Micro-k).....................70POTASSIUM CHLORIDE ER – potassium chloride tab er8 meq (600 mg)................................................................70

potassium chloride microencapsulated crys er tab 10meq....................................................................................70

potassium chloride microencapsulated crys er tab 20meq....................................................................................71

potassium chloride oral soln 10% (20 meq/15ml)............. 71potassium chloride oral soln 20% (40 meq/15ml)............. 71potassium chloride powder packet 20 meq.......................71potassium chloride tab er 10 meq (K-tab).........................71potassium chloride tab er 8 meq (600 mg)....................... 71potassium citrate & citric acid powder pack 3300-1002mg......................................................................................43

potassium citrate & citric acid soln 1100-334 mg/5ml....... 43potassium citrate tab er 5 meq (540 mg) (Urocit-k 5)........43potassium citrate tab er 10 meq (1080 mg) (Urocit-k10)..................................................................................... 43

potassium citrate tab er 15 meq (1620 mg) (Urocit-k15)..................................................................................... 43

pot phos monobasic w/sod phos di & monobas tab155-852-130mg (K-phos neutral).....................................70

pramipexole dihydrochloride tab 0.125 mg (Mirapex).......67pramipexole dihydrochloride tab 0.25 mg (Mirapex).........67pramipexole dihydrochloride tab 0.5 mg (Mirapex)...........67pramipexole dihydrochloride tab 0.75 mg (Mirapex).........67pramipexole dihydrochloride tab 1 mg (Mirapex)..............67pramipexole dihydrochloride tab 1.5 mg (Mirapex)...........67pravastatin sodium tab 10 mg........................................... 30

pravastatin sodium tab 20 mg (Pravachol)........................30pravastatin sodium tab 40 mg (Pravachol)........................30pravastatin sodium tab 80 mg (Pravachol)........................30praziquantel tab 600 mg (Biltricide).....................................8prazosin hcl cap 1 mg (Minipress).................................... 33prazosin hcl cap 2 mg (Minipress).................................... 33prazosin hcl cap 5 mg (Minipress).................................... 33PREDNICARBATE – prednicarbate cream 0.1%..............81PREDNICARBATE – prednicarbate oint 0.1%..................82prednisolone acetate ophth susp 1% (Pred forte).............77PREDNISOLONE – prednisolone syrup 15 mg/5ml (uspsolution equivalent)...........................................................16

PREDNISOLONE SODIUM PHOSP – prednisolonesodium phosphate ophth soln 1%................................... 77

prednisolone sod phosphate oral soln 15 mg/5ml (baseequiv).................................................................................16

prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5mlbase) (Pediapred).............................................................16

PREDNISONE – prednisone oral soln 5 mg/5ml.............. 16PREDNISONE – prednisone tab 50 mg............................16prednisone tab 1 mg..........................................................16prednisone tab 2.5 mg.......................................................16prednisone tab 5 mg..........................................................16prednisone tab 10 mg........................................................16prednisone tab 20 mg........................................................16PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.3-1.5 mg.....................................................17

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.45-1.5 mg...................................................17

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.625-5 mg....................................................17

PRESERVISION AREDS 2 – multiple vitamins w/minerals cap..................................................................... 70

PREZISTA – darunavir ethanolate susp 100 mg/ml (baseequiv)...................................................................................6

PREZISTA – darunavir ethanolate tab 75 mg (baseequiv)...................................................................................6




PRIFTIN – rifapentine tab 150 mg...................................... 3primaquine phosphate tab 26.3 mg (15 mg base)(Primaquine phosphate)..................................................... 8

primidone tab 50 mg (Mysoline)........................................65primidone tab 250 mg (Mysoline)......................................65probenecid tab 500 mg......................................................59PROBUPHINE IMPLANT KIT – buprenorphine hclsubdermal implant 74.2 mg (base equiv)........................ 55

prochlorperazine maleate tab 5 mg (base equivalent)......40prochlorperazine maleate tab 10 mg (baseequivalent).........................................................................40

prochlorperazine suppos 25 mg........................................ 40PROFILNINE – factor ix complex for inj 500 unit..............75

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109

PROFILNINE – factor ix complex for inj 1000 unit............75PROFILNINE – factor ix complex for inj 1500 unit............75PROFILNINE SD – factor ix complex for inj 500 unit........75PROFILNINE SD – factor ix complex for inj 1000 unit......75PROFILNINE SD – factor ix complex for inj 1500 unit......75progesterone im in oil 50 mg/ml........................................17progesterone micronized cap 100 mg (Prometrium).........18progesterone micronized cap 200 mg (Prometrium).........18promethazine hcl suppos 12.5 mg.................................... 35promethazine hcl suppos 25 mg....................................... 35promethazine hcl syrup 6.25 mg/5ml................................ 35promethazine hcl tab 12.5 mg...........................................35promethazine hcl tab 25 mg..............................................35promethazine hcl tab 50 mg..............................................35promethazine w/ codeine syrup 6.25-10 mg/5ml.............. 35PRO NUTRIENTS OMEGA 3 – omega-3 fatty acids capdelayed release 332.5 mg............................................... 71

propafenone hcl tab 150 mg..............................................32propafenone hcl tab 225 mg..............................................32propafenone hcl tab 300 mg..............................................32proparacaine hcl ophth soln 0.5%.....................................78PROPRANOLOL/HYDROCHLOROTH – propranolol &hydrochlorothiazide tab 40-25 mg................................... 27

propranolol hcl tab 10 mg..................................................27propranolol hcl tab 20 mg..................................................27propranolol hcl tab 40 mg..................................................27propranolol hcl tab 60 mg..................................................27propranolol hcl tab 80 mg..................................................27propylthiouracil tab 50 mg................................................. 22psyllium powder 28.3%......................................................38psyllium powder 30.9%......................................................39psyllium powder 48.57%....................................................39psyllium powder 58.6%......................................................39psyllium powder 95%......................................................... 39PULMOZYME – dornase alfa inhal soln 1 mg/ml..............38pyrazinamide tab 500 mg.................................................... 3pyridostigmine bromide tab 60 mg (Mestinon)..................68PYRIDOXINE HCL – pyridoxine hcl inj 100 mg/ml........... 69pyridoxine hcl tab 25 mg................................................... 69pyridoxine hcl tab 50 mg................................................... 69pyridoxine hcl tab 100 mg................................................. 69

QQC CALAMINE – calamine lotion......................................82QUDEXY XR – topiramate cap er 24hr sprinkle 25mg......................................................................................65

QUDEXY XR – topiramate cap er 24hr sprinkle 50mg......................................................................................65




quetiapine fumarate tab 25 mg (Seroquel)........................48quetiapine fumarate tab 50 mg (Seroquel)........................48

quetiapine fumarate tab 100 mg (Seroquel)......................48quetiapine fumarate tab 200 mg (Seroquel)......................48quetiapine fumarate tab 300 mg (Seroquel)......................49quetiapine fumarate tab 400 mg (Seroquel)......................49quinapril hcl tab 5 mg (Accupril)........................................25quinapril hcl tab 10 mg (Accupril)......................................25quinapril hcl tab 20 mg (Accupril)......................................25quinapril hcl tab 40 mg (Accupril)......................................25quinapril-hydrochlorothiazide tab 10-12.5 mg(Accuretic)......................................................................... 25

quinapril-hydrochlorothiazide tab 20-12.5 mg(Accuretic)......................................................................... 25

quinapril-hydrochlorothiazide tab 20-25 mg(Accuretic)......................................................................... 25

quinidine gluconate tab er 324 mg....................................32QUINIDINE SULFATE – quinidine sulfate tab 200 mg......32QUINIDINE SULFATE – quinidine sulfate tab 300 mg......32QVAR – beclomethasone diprop inhal aero soln 40 mcg/act (50/valve).................................................................... 37

QVAR – beclomethasone diprop inhal aero soln 80 mcg/act (100/valve).................................................................. 37

QVAR REDIHALER – beclomethasone diprop hfa breathact inh aer 40 mcg/act..................................................... 37

QVAR REDIHALER – beclomethasone diprop hfa breathact inh aer 80 mcg/act..................................................... 37

RRABAVERT – rabies vaccine, pcec for inj...........................9raloxifene hcl tab 60 mg (Evista).......................................23ramipril cap 1.25 mg (Altace)............................................ 25ramipril cap 2.5 mg (Altace).............................................. 25ramipril cap 5 mg (Altace)................................................. 25ramipril cap 10 mg (Altace)............................................... 25ranitidine hcl syrup 15 mg/ml (75 mg/5ml)........................ 40ranitidine hcl tab 75 mg..................................................... 40ranitidine hcl tab 150 mg (Zantac).....................................40ranitidine hcl tab 300 mg (Zantac).....................................40RECOMBINATE – antihemophilic factor (recombinant) forinj 220-400 unit.................................................................75

RECOMBINATE – antihemophilic factor (recombinant) forinj 401-800 unit.................................................................75

RECOMBINATE – antihemophilic factor (recombinant) forinj 801-1240 unit...............................................................75

RECOMBINATE – antihemophilic factor (recombinant) forinj 1241-1800 unit.............................................................75

RECOMBINATE – antihemophilic factor (recombinant) forinj 1801-2400 unit.............................................................75

RECOMBIVAX HB – hepatitis b vaccine (recombinant)susp 5 mcg/0.5ml............................................................... 9

RECOMBIVAX HB – hepatitis b vaccine (recombinant)susp 10 mcg/ml.................................................................. 9

RECOMBIVAX HB – hepatitis b vaccine (recombinant)susp 40 mcg/ml................................................................ 10

RELENZA DISKHALER – zanamivir aero powder breathactivated 5 mg/blister......................................................... 7

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REPATHA – evolocumab subcutaneous soln prefilledsyringe 140 mg/ml............................................................30

REPATHA PUSHTRONEX SYSTEM – evolocumabsubcutaneous soln cartridge/infusor 420 mg/3.5ml.........30

REPATHA SURECLICK – evolocumab subcutaneous solnauto-injector 140 mg/ml....................................................30

RESCRIPTOR – delavirdine mesylate tab 200 mg.............6RETACRIT – epoetin alfa-epbx inj 2000 unit/ml................75RETACRIT – epoetin alfa-epbx inj 3000 unit/ml................75RETACRIT – epoetin alfa-epbx inj 4000 unit/ml................75RETACRIT – epoetin alfa-epbx inj 10000 unit/ml..............75RETACRIT – epoetin alfa-epbx inj 40000 unit/ml..............75REVLIMID – lenalidomide cap 5 mg................................. 84REVLIMID – lenalidomide cap 10 mg............................... 84REVLIMID – lenalidomide cap 15 mg............................... 84REVLIMID – lenalidomide cap 20 mg............................... 84REVLIMID – lenalidomide cap 25 mg............................... 84REVLIMID – lenalidomide caps 2.5 mg............................ 84REYATAZ – atazanavir sulfate oral powder packet 50 mg(base equiv)........................................................................ 6

ribavirin cap 200 mg (Rebetol)............................................ 4rifabutin cap 150 mg (Mycobutin)........................................3rifampin cap 300 mg............................................................ 4rifampin cap 150 mg (Rifadin)............................................. 4riluzole tab 50 mg (Rilutek)................................................68ringer's solution for irrigation..............................................84RISPERIDONE ODT – risperidone orally disintegratingtab 0.25 mg...................................................................... 49

risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab).................................................................................... 49

risperidone orally disintegrating tab 1 mg (Risperdal m-tab).................................................................................... 49




risperidone soln 1 mg/ml (Risperdal).................................49risperidone tab 0.25 mg (Risperdal)..................................49risperidone tab 0.5 mg (Risperdal)....................................49risperidone tab 1 mg (Risperdal).......................................49risperidone tab 2 mg (Risperdal).......................................49risperidone tab 3 mg (Risperdal).......................................49risperidone tab 4 mg (Risperdal).......................................49ritonavir tab 100 mg (Norvir)................................................6RIXUBIS – coagulation factor ix (recombinant) for inj 250unit.....................................................................................75

RIXUBIS – coagulation factor ix (recombinant) for inj 500unit.....................................................................................75




rizatriptan benzoate oral disintegrating tab 5 mg (base eq)(Maxalt-mlt)....................................................................... 58

rizatriptan benzoate oral disintegrating tab 10 mg (baseeq) (Maxalt-mlt).................................................................58

rizatriptan benzoate tab 5 mg (base equivalent)(Maxalt)............................................................................. 58

rizatriptan benzoate tab 10 mg (base equivalent)(Maxalt)............................................................................. 58

ropinirole hydrochloride tab 0.25 mg (Requip)..................67ropinirole hydrochloride tab 0.5 mg (Requip)....................67ropinirole hydrochloride tab 1 mg (Requip).......................67ropinirole hydrochloride tab 2 mg (Requip).......................67ropinirole hydrochloride tab 3 mg (Requip).......................67ropinirole hydrochloride tab 4 mg (Requip).......................67ropinirole hydrochloride tab 5 mg (Requip).......................67rosuvastatin calcium tab 5 mg (Crestor)........................... 30rosuvastatin calcium tab 10 mg (Crestor)......................... 30rosuvastatin calcium tab 20 mg (Crestor)......................... 30rosuvastatin calcium tab 40 mg (Crestor)......................... 30RUBRACA – rucaparib camsylate tab 200 mg (baseequivalent).........................................................................13

RUBRACA – rucaparib camsylate tab 250 mg (baseequivalent).........................................................................13

RUBRACA – rucaparib camsylate tab 300 mg (baseequivalent).........................................................................13

RU-HIST D – brompheniramine & phenylephrine tab 4-10mg......................................................................................35

RYDAPT – midostaurin cap 25 mg................................... 13

SSABRIL – vigabatrin powd pack 500 mg.......................... 65SABRIL – vigabatrin tab 500 mg.......................................65saline nasal gel.................................................................. 35saline nasal spray 0.65%...................................................35salsalate tab 500 mg..........................................................54salsalate tab 750 mg..........................................................54selegiline hcl cap 5 mg (Eldepryl)..................................... 67selegiline hcl tab 5 mg.......................................................67selenium sulfide lotion 2.5%.............................................. 83SELZENTRY – maraviroc tab 25 mg.................................. 6SELZENTRY – maraviroc tab 75 mg.................................. 7SELZENTRY – maraviroc tab 300 mg................................ 7sennosides tab 8.6 mg...................................................... 39SENSIPAR – cinacalcet hcl tab 30 mg (base equiv).........23SENSIPAR – cinacalcet hcl tab 60 mg (base equiv).........23SENSIPAR – cinacalcet hcl tab 90 mg (base equiv).........23sertraline hcl oral concentrate for solution 20 mg/ml(Zoloft)............................................................................... 46

sertraline hcl tab 25 mg (Zoloft)........................................ 46sertraline hcl tab 50 mg (Zoloft)........................................ 46sertraline hcl tab 100 mg (Zoloft)...................................... 46sevelamer carbonate packet 0.8 gm (Renvela)................ 42sevelamer carbonate packet 2.4 gm (Renvela)................ 42sevelamer carbonate tab 800 mg (Renvela).....................42SHINGRIX – zoster vac recombinant adjuvanted for im inj50 mcg/0.5ml.................................................................... 10

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sildenafil citrate tab 20 mg (Revatio).................................33silver sulfadiazine cream 1% (Silvadene)......................... 80simethicone chew tab 80 mg.............................................42simethicone susp 40 mg/0.6ml..........................................42simvastatin tab 5 mg (Zocor).............................................31simvastatin tab 10 mg (Zocor)...........................................31simvastatin tab 20 mg (Zocor)...........................................31simvastatin tab 40 mg (Zocor)...........................................31sirolimus tab 0.5 mg (Rapamune)..................................... 84sirolimus tab 1 mg (Rapamune)........................................ 85sirolimus tab 2 mg (Rapamune)........................................ 85SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5mg total)............................................................................18

SLO-NIACIN – niacin tab er 500 mg.................................69SLO-NIACIN – niacin tab er 750 mg.................................69sodium chloride irrigation soln 0.9%..................................43sodium chloride soln nebu 0.9%....................................... 35sodium chloride soln nebu 3%.......................................... 36sodium chloride soln nebu 10%........................................ 36sodium chloride soln nebu 7% (Hyper-sal)....................... 36sodium citrate & citric acid soln 500-334 mg/5ml (Shohlssolution modi)................................................................... 43

sodium fluoride chew tab 0.25 mg f (from 0.55 mgnaf).................................................................................... 71

sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)........71sodium fluoride chew tab 1 mg f (from 2.2 mg naf)...........71sodium fluoride cream 1.1% (Prevident 5000 plus).......... 79sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)......79sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)......71sodium polystyrene sulfonate oral susp 15 gm/60ml........ 85sodium polystyrene sulfonate powder............................... 85sodium polystyrene sulfonate rectal susp 30gm/120ml...........................................................................85

SOFOSBUVIR/VELPATASVIR – sofosbuvir-velpatasvirtab 400-100 mg.................................................................. 4

sotalol hcl tab 240 mg....................................................... 32sotalol hcl tab 80 mg (Betapace).......................................32sotalol hcl tab 120 mg (Betapace).....................................32sotalol hcl tab 160 mg (Betapace).....................................32SOVALDI – sofosbuvir tab 400 mg..................................... 4spironolactone & hydrochlorothiazide tab 25-25 mg(Aldactazide)..................................................................... 31

spironolactone tab 25 mg (Aldactone)...............................31spironolactone tab 50 mg (Aldactone)...............................31spironolactone tab 100 mg (Aldactone)............................ 31SPRYCEL – dasatinib tab 20 mg...................................... 13SPRYCEL – dasatinib tab 50 mg...................................... 13SPRYCEL – dasatinib tab 70 mg...................................... 13SPRYCEL – dasatinib tab 80 mg...................................... 14SPRYCEL – dasatinib tab 100 mg.................................... 14SPRYCEL – dasatinib tab 140 mg.................................... 14stavudine cap 15 mg (Zerit).................................................7stavudine cap 20 mg (Zerit).................................................7stavudine cap 30 mg (Zerit).................................................7stavudine cap 40 mg (Zerit).................................................7

STEGLATRO – ertugliflozin l-pyroglutamic acid tab 5 mg(base equiv)...................................................................... 20

STEGLATRO – ertugliflozin l-pyroglutamic acid tab 15 mg(base equiv)...................................................................... 20

STIMATE – desmopressin acetate nasal soln 1.5 mg/ml.......................................................................................23

STIVARGA – regorafenib tab 40 mg................................. 14STRENSIQ – asfotase alfa subcutaneous inj 18mg/0.45ml......................................................................... 23

STRENSIQ – asfotase alfa subcutaneous inj 28mg/0.7ml............................................................................23

STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml.......................................................................................23

STRENSIQ – asfotase alfa subcutaneous inj 80mg/0.8ml............................................................................23

STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln2.5 mcg/act (base equiv)................................................. 37

SUBOXONE – buprenorphine hcl-naloxone hcl sl film2-0.5 mg (base equiv)......................................................55

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1mg (base equiv)................................................................56

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2mg (base equiv)................................................................56

SUBOXONE – buprenorphine hcl-naloxone hcl sl film12-3 mg (base equiv).......................................................56

sucralfate tab 1 gm (Carafate)...........................................40SULFACETAMIDE SODIUM/PRED – sulfacetamidesodium-prednisolone ophth soln 10-0.23(0.25)%............77

sulfacetamide sodium ophth soln 10% (Bleph-10)............77sulfacetamide sodium w/ sulfur emulsion 10-5%.............. 79SULFADIAZINE – sulfadiazine tab 500 mg.........................3sulfamethoxazole-trimethoprim susp 200-40 mg/5ml......... 8sulfamethoxazole-trimethoprim tab 400-80 mg(Bactrim)..............................................................................8

sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrimds)........................................................................................8

sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)...................................................................................42

sulfasalazine tab 500 mg (Azulfidine)................................42sulindac tab 150 mg...........................................................58sulindac tab 200 mg...........................................................58sumatriptan succinate inj 6 mg/0.5ml (Imitrex)..................58sumatriptan succinate solution auto-injector 4 mg/0.5ml(Imitrex statdose sys)....................................................... 58

sumatriptan succinate solution auto-injector 6 mg/0.5ml(Imitrex statdose sys)....................................................... 59

sumatriptan succinate solution cartridge 6 mg/0.5ml(Imitrex statdose ref)........................................................ 59

sumatriptan succinate tab 25 mg (Imitrex)........................59sumatriptan succinate tab 50 mg (Imitrex)........................59sumatriptan succinate tab 100 mg (Imitrex)......................59SUTENT – sunitinib malate cap 12.5 mg (baseequivalent).........................................................................14

SUTENT – sunitinib malate cap 25 mg (baseequivalent).........................................................................14

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SUTENT – sunitinib malate cap 37.5 mg (baseequivalent).........................................................................14

SUTENT – sunitinib malate cap 50 mg (baseequivalent).........................................................................14

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 80-4.5 mcg/act.....................................................37

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 160-4.5 mcg/act...................................................37

SYNAGIS – palivizumab im soln 50 mg/0.5ml..................10SYNAGIS – palivizumab im soln 100 mg/ml.....................10

Ttacrolimus cap 0.5 mg (Prograf)........................................85tacrolimus cap 1 mg (Prograf)...........................................85tacrolimus cap 5 mg (Prograf)...........................................85tacrolimus oint 0.03% (Protopic)........................................83tacrolimus oint 0.1% (Protopic)..........................................83tadalafil tab 20 mg (pah) (Adcirca)....................................34tamoxifen citrate tab 10 mg (base equivalent).................. 14tamoxifen citrate tab 20 mg (base equivalent).................. 14tamsulosin hcl cap 0.4 mg (Flomax)................................. 43TARCEVA – erlotinib hcl tab 25 mg (base equivalent)......14TARCEVA – erlotinib hcl tab 100 mg (baseequivalent).........................................................................14

TARCEVA – erlotinib hcl tab 150 mg (baseequivalent).........................................................................14

TASIGNA – nilotinib hcl cap 50 mg (base equivalent)...... 14TASIGNA – nilotinib hcl cap 150 mg (baseequivalent).........................................................................14

TASIGNA – nilotinib hcl cap 200 mg (baseequivalent).........................................................................14

tazarotene cream 0.1% (Tazorac)..................................... 79TAZORAC – tazarotene gel 0.05%................................... 79TAZORAC – tazarotene gel 0.1%..................................... 79TECHLITE PEN NEEDLES 29G – INSULIN PENNEEDLES- TECHLITE AND TRUEPLUS....................... 83

TEGRETOL – carbamazepine susp 100 mg/5ml..............65TEGRETOL – carbamazepine tab 200 mg....................... 65TEGRETOL-XR – carbamazepine tab er 12hr 100 mg.....65TEGRETOL-XR – carbamazepine tab er 12hr 200 mg.....65TEGRETOL-XR – carbamazepine tab er 12hr 400 mg.....65temazepam cap 15 mg (Restoril)...................................... 50temazepam cap 30 mg (Restoril)...................................... 50temozolomide cap 5 mg (Temodar)...................................14temozolomide cap 20 mg (Temodar).................................14temozolomide cap 100 mg (Temodar)...............................14temozolomide cap 140 mg (Temodar)...............................14temozolomide cap 180 mg (Temodar)...............................14temozolomide cap 250 mg (Temodar)...............................14tenofovir disoproxil fumarate tab 300 mg (Viread).............. 7terazosin hcl cap 1 mg (base equivalent)......................... 34terazosin hcl cap 2 mg (base equivalent)......................... 34terazosin hcl cap 5 mg (base equivalent)......................... 34terazosin hcl cap 10 mg (base equivalent)....................... 34terbinafine hcl tab 250 mg (Lamisil).................................... 4terbutaline sulfate tab 2.5 mg............................................37

terbutaline sulfate tab 5 mg...............................................37TERCONAZOLE – terconazole vaginal cream 0.8%........42terconazole vaginal cream 0.4% (Terazol 7).....................43terconazole vaginal suppos 80 mg....................................43testosterone cypionate im inj in oil 100 mg/ml (Depo-testosterone)..................................................................... 16

testosterone cypionate im inj in oil 200 mg/ml (Depo-testosterone)..................................................................... 16

testosterone enanthate im inj in oil 200 mg/ml..................16tetracaine hcl ophth soln 0.5%.......................................... 78tetrahydroz-dextran-peg-povidone ophth soln0.05-0.1-1-1%................................................................... 78

THALOMID – thalidomide cap 50 mg............................... 85THALOMID – thalidomide cap 100 mg............................. 85THALOMID – thalidomide cap 150 mg............................. 85theophylline soln 80 mg/15ml............................................37theophylline tab er 12hr 100 mg........................................37theophylline tab er 12hr 200 mg........................................37theophylline tab er 12hr 300 mg........................................37theophylline tab er 12hr 450 mg........................................37theophylline tab er 24hr 400 mg........................................37theophylline tab er 24hr 600 mg........................................37thiamine hcl tab 50 mg...................................................... 69thiamine hcl tab 100 mg.................................................... 69thioridazine hcl tab 10 mg................................................. 49thioridazine hcl tab 25 mg................................................. 49thioridazine hcl tab 50 mg................................................. 49thioridazine hcl tab 100 mg............................................... 49thiothixene cap 1 mg..........................................................49thiothixene cap 2 mg..........................................................49thiothixene cap 5 mg..........................................................49thiothixene cap 10 mg........................................................49thyroid tab 30 mg (1/2 grain) (Armour thyroid)..................22thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)...............22thyroid tab 60 mg (1 grain) (Armour thyroid).....................22tiagabine hcl tab 2 mg (Gabitril)........................................ 65tiagabine hcl tab 4 mg (Gabitril)........................................ 65tiagabine hcl tab 12 mg (Gabitril)...................................... 65tiagabine hcl tab 16 mg (Gabitril)...................................... 65TIBSOVO – ivosidenib tab 250 mg................................... 14timolol maleate ophth soln 0.25% (Timoptic).................... 78timolol maleate ophth soln 0.5% (Timoptic)...................... 78tioconazole vaginal oint 6.5%............................................43TIVICAY – dolutegravir sodium tab 10 mg (base equiv)..... 7TIVICAY – dolutegravir sodium tab 25 mg (base equiv)..... 7TIVICAY – dolutegravir sodium tab 50 mg (base equiv)..... 7tizanidine hcl tab 2 mg (base equivalent)..........................68tizanidine hcl tab 4 mg (base equivalent) (Zanaflex).........68tobramycin-dexamethasone ophth susp 0.3-0.1%(Tobradex)......................................................................... 77

tobramycin nebu soln 300 mg/5ml (Tobi)............................ 3tobramycin ophth soln 0.3% (Tobrex)................................77TOLAZAMIDE – tolazamide tab 250 mg...........................20tolnaftate aerosol 1%......................................................... 80TOPAMAX SPRINKLE – topiramate sprinkle cap 15mg......................................................................................65

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TOPAMAX SPRINKLE – topiramate sprinkle cap 25mg......................................................................................65

TOPAMAX – topiramate tab 25 mg...................................65TOPAMAX – topiramate tab 50 mg...................................65TOPAMAX – topiramate tab 100 mg.................................65TOPAMAX – topiramate tab 200 mg.................................65TOPIRAMATE ER – topiramate cap er 24hr sprinkle 25mg......................................................................................65

TOPIRAMATE ER – topiramate cap er 24hr sprinkle 50mg......................................................................................65




topiramate sprinkle cap 15 mg (Topamax sprinkle).......... 65topiramate sprinkle cap 25 mg (Topamax sprinkle).......... 65topiramate tab 25 mg (Topamax)...................................... 65topiramate tab 50 mg (Topamax)...................................... 65topiramate tab 100 mg (Topamax).................................... 66topiramate tab 200 mg (Topamax).................................... 66torsemide tab 5 mg............................................................31torsemide tab 100 mg........................................................32torsemide tab 10 mg (Demadex).......................................32torsemide tab 20 mg (Demadex).......................................32TRACLEER – bosentan tab for oral susp 32 mg.............. 34TRACLEER – bosentan tab 62.5 mg................................ 34TRACLEER – bosentan tab 125 mg................................. 34tramadol hcl tab 50 mg (Ultram)........................................56trandolapril tab 1 mg..........................................................25trandolapril tab 4 mg..........................................................25trandolapril tab 2 mg (Mavik).............................................25tranexamic acid tab 650 mg (Lysteda).............................. 75trazodone hcl tab 50 mg....................................................46trazodone hcl tab 100 mg..................................................46trazodone hcl tab 150 mg..................................................46tretinoin cap 10 mg............................................................ 15tretinoin cream 0.025% (Retin-a).......................................79tretinoin cream 0.05% (Retin-a).........................................79tretinoin cream 0.1% (Retin-a)...........................................79tretinoin gel 0.01% (Retin-a)..............................................79tretinoin gel 0.025% (Retin-a)............................................79triamcinolone acetonide cream 0.025%............................ 82triamcinolone acetonide cream 0.1%................................ 82triamcinolone acetonide cream 0.5%................................ 82triamcinolone acetonide dental paste 0.1%...................... 79triamcinolone acetonide lotion 0.025%..............................82triamcinolone acetonide lotion 0.1%..................................82triamcinolone acetonide oint 0.025%................................ 82triamcinolone acetonide oint 0.1%.....................................82TRIAMINIC NIGHT TIME COLD – diphenhydramine-phenylephrine syrup 6.25-2.5 mg/5ml............................. 36

triamterene & hydrochlorothiazide cap 37.5-25 mg(Dyazide)...........................................................................32

triamterene & hydrochlorothiazide tab 37.5-25 mg(Maxzide-25)..................................................................... 32

triamterene & hydrochlorothiazide tab 75-50 mg(Maxzide)...........................................................................32

TRICITRATES – pot & sod citrates w/ cit ac soln550-500-334 mg/5ml........................................................ 43

trifluoperazine hcl tab 1 mg (base equivalent).................. 49trifluoperazine hcl tab 2 mg (base equivalent).................. 49trifluoperazine hcl tab 5 mg (base equivalent).................. 49trifluoperazine hcl tab 10 mg (base equivalent)................ 49trifluridine ophth soln 1% (Viroptic)....................................77trihexyphenidyl hcl elixir 0.4 mg/ml....................................67trihexyphenidyl hcl tab 2 mg..............................................67trihexyphenidyl hcl tab 5 mg..............................................67TRILEPTAL – oxcarbazepine susp 300 mg/5ml (60 mg/ml)......................................................................................66

TRILEPTAL – oxcarbazepine tab 150 mg.........................66TRILEPTAL – oxcarbazepine tab 300 mg.........................66TRILEPTAL – oxcarbazepine tab 600 mg.........................66trimethoprim tab 100 mg......................................................8TRI-VI-SOL – pediatric vitamins adc drops 750 unit-400unit-35 mg/ml....................................................................70

TROKENDI XR – topiramate cap er 24hr 25 mg.............. 66TROKENDI XR – topiramate cap er 24hr 50 mg.............. 66TROKENDI XR – topiramate cap er 24hr 100 mg............ 66TROKENDI XR – topiramate cap er 24hr 200 mg............ 66TRULICITY – dulaglutide soln pen-injector 0.75mg/0.5ml............................................................................20

TRULICITY – dulaglutide soln pen-injector 1.5mg/0.5ml............................................................................20

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 100-150 mg.................................................................. 7




TYMLOS – abaloparatide subcutaneous soln pen-injector3120 mcg/1.56ml.............................................................. 23

Uursodiol cap 300 mg (Actigall)...........................................42ursodiol tab 250 mg (Urso 250).........................................42ursodiol tab 500 mg (Urso forte)....................................... 42

Vvalacyclovir hcl tab 1 gm (Valtrex).......................................5valacyclovir hcl tab 500 mg (Valtrex)...................................5VALCHLOR – mechlorethamine hcl gel 0.016% (baseequivalent).........................................................................83

valganciclovir hcl tab 450 mg (base equivalent)(Valcyte).............................................................................. 4

valproate sodium oral soln 250 mg/5ml (base equiv)(Depakene)....................................................................... 66

valproic acid cap 250 mg (Depakene)...............................66

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valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovanhct).....................................................................................26


valsartan-hydrochlorothiazide tab 160-25 mg (Diovanhct).....................................................................................26


valsartan-hydrochlorothiazide tab 320-25 mg (Diovanhct).....................................................................................26

valsartan tab 40 mg (Diovan)............................................ 26valsartan tab 80 mg (Diovan)............................................ 26valsartan tab 160 mg (Diovan).......................................... 26valsartan tab 320 mg (Diovan).......................................... 26vancomycin hcl cap 125 mg (base equivalent) (Vancocinhcl).......................................................................................8

vancomycin hcl cap 250 mg (base equivalent) (Vancocinhcl).......................................................................................8

VENCLEXTA STARTING PACK – venetoclax tab therapystarter pack 10 & 50 & 100 mg....................................... 15

VENCLEXTA – venetoclax tab 10 mg...............................15VENCLEXTA – venetoclax tab 50 mg...............................15VENCLEXTA – venetoclax tab 100 mg.............................15venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)(Effexor xr)........................................................................ 46

venlafaxine hcl cap er 24hr 75 mg (base equivalent)(Effexor xr)........................................................................ 46

venlafaxine hcl cap er 24hr 150 mg (base equivalent)(Effexor xr)........................................................................ 46

venlafaxine hcl tab 25 mg..................................................46venlafaxine hcl tab 37.5 mg...............................................46venlafaxine hcl tab 50 mg..................................................46venlafaxine hcl tab 75 mg..................................................46venlafaxine hcl tab 100 mg................................................46VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act(90mcg base equiv)..........................................................38

verapamil hcl cap er 24hr 120 mg (Verelan).....................28verapamil hcl cap er 24hr 180 mg (Verelan).....................28verapamil hcl cap er 24hr 240 mg (Verelan).....................29verapamil hcl cap er 24hr 100 mg (Verelan pm)...............28verapamil hcl cap er 24hr 200 mg (Verelan pm)...............28verapamil hcl cap er 24hr 300 mg (Verelan pm)...............29VERAPAMIL HCL SR – verapamil hcl cap er 24hr 360mg......................................................................................29

verapamil hcl tab er 120 mg (Calan sr).............................29verapamil hcl tab er 180 mg (Calan sr).............................29verapamil hcl tab er 240 mg (Calan sr).............................29verapamil hcl tab 40 mg.................................................... 29verapamil hcl tab 80 mg (Calan)....................................... 29verapamil hcl tab 120 mg (Calan)..................................... 29VERZENIO – abemaciclib tab 50 mg................................15VERZENIO – abemaciclib tab 100 mg..............................15VERZENIO – abemaciclib tab 150 mg..............................15VERZENIO – abemaciclib tab 200 mg..............................15VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml)......................................................................................20

VIDEX – didanosine for soln 2 gm......................................7VIDEX – didanosine for soln 4 gm......................................7vigabatrin powd pack 500 mg (Sabril)...............................66vigabatrin tab 500 mg (Sabril)........................................... 66VIMPAT – lacosamide iv inj 200 mg/20ml (10 mg/ml).......66VIMPAT – lacosamide oral solution 10 mg/ml...................66VIMPAT – lacosamide tab 50 mg...................................... 66VIMPAT – lacosamide tab 100 mg.................................... 66VIMPAT – lacosamide tab 150 mg.................................... 66VIMPAT – lacosamide tab 200 mg.................................... 66VIRACEPT – nelfinavir mesylate tab 250 mg..................... 7VIRACEPT – nelfinavir mesylate tab 625 mg..................... 7VIREAD – tenofovir disoproxil fumarate oral powder 40mg/gm..................................................................................7

VIREAD – tenofovir disoproxil fumarate tab 150 mg...........7VIREAD – tenofovir disoproxil fumarate tab 200 mg...........7VIREAD – tenofovir disoproxil fumarate tab 250 mg...........7vitamins a & d oint............................................................. 83VIVITROL – naltrexone for im extended release susp 380mg......................................................................................53

voriconazole for susp 40 mg/ml (Vfend)..............................4voriconazole tab 50 mg (Vfend).......................................... 4voriconazole tab 200 mg (Vfend)........................................ 4VOTRIENT – pazopanib hcl tab 200 mg (base equiv)......15

Wwarfarin sodium tab 1 mg (Coumadin)..............................75warfarin sodium tab 2 mg (Coumadin)..............................75warfarin sodium tab 2.5 mg (Coumadin)...........................75warfarin sodium tab 3 mg (Coumadin)..............................75warfarin sodium tab 4 mg (Coumadin)..............................76warfarin sodium tab 5 mg (Coumadin)..............................76warfarin sodium tab 6 mg (Coumadin)..............................76warfarin sodium tab 7.5 mg (Coumadin)...........................76warfarin sodium tab 10 mg (Coumadin)............................76water for irrigation, sterile irrigation soln........................... 85

XXALKORI – crizotinib cap 200 mg.....................................15XALKORI – crizotinib cap 250 mg.....................................15XARELTO – rivaroxaban tab 10 mg..................................76XARELTO – rivaroxaban tab 15 mg..................................76XARELTO – rivaroxaban tab 20 mg..................................76XARELTO STARTER PACK – rivaroxaban tab startertherapy pack 15 mg & 20 mg.......................................... 76

XIFAXAN – rifaximin tab 200 mg.........................................9XIFAXAN – rifaximin tab 550 mg.........................................9XTANDI – enzalutamide cap 40 mg.................................. 15XULANE – norelgestromin-ethinyl estradiol td ptwk150-35 mcg/24hr.............................................................. 18

XYNTHA – antihemophilic factor recombinant paf for inj kit250 unit............................................................................. 76

XYNTHA – antihemophilic factor recombinant paf for inj kit500 unit............................................................................. 76

XYNTHA – antihemophilic factor recombinant paf for inj kit1000 unit........................................................................... 76

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XYNTHA – antihemophilic factor recombinant paf for inj kit2000 unit........................................................................... 76

XYNTHA SOLOFUSE – antihemophilic factorrecombinant paf for inj kit 250 unit.................................. 76

XYNTHA SOLOFUSE – antihemophilic factorrecombinant paf for inj kit 500 unit.................................. 76

XYNTHA SOLOFUSE – antihemophilic factorrecombinant paf for inj kit 1000 unit................................ 76



XYREM – sodium oxybate oral solution 500 mg/ml..........53

YYONSA – abiraterone acetate tab 125 mg....................... 15

Zzaleplon cap 5 mg (Sonata).............................................. 50zaleplon cap 10 mg (Sonata)............................................ 50ZARONTIN – ethosuximide cap 250 mg...........................66ZARONTIN – ethosuximide soln 250 mg/5ml................... 66ZARXIO – filgrastim-sndz soln prefilled syringe 300mcg/0.5ml..........................................................................76

ZARXIO – filgrastim-sndz soln prefilled syringe 480mcg/0.8ml..........................................................................76

ZELBORAF – vemurafenib tab 240 mg............................ 15ZENPEP – pancrelipase (lip-prot-amyl) dr cap3000-10000-14000 unit.................................................... 41

ZENPEP – pancrelipase (lip-prot-amyl) dr cap5000-17000-24000 unit.................................................... 41

ZENPEP – pancrelipase (lip-prot-amyl) dr cap10000-32000-42000 unit.................................................. 41



ZENPEP – pancrelipase (lip-prot-amyl) dr cap25000-79000-105000 unit................................................ 41

ZENPEP – pancrelipase (lip-prot-amyl) dr cap40000-126000-168000 unit.............................................. 41

zidovudine cap 100 mg (Retrovir)....................................... 7zidovudine syrup 10 mg/ml (Retrovir)..................................7zidovudine tab 300 mg.........................................................7zinc oxide oint 10%............................................................83zinc oxide oint 20%............................................................83ziprasidone hcl cap 20 mg (Geodon)................................ 49ziprasidone hcl cap 40 mg (Geodon)................................ 49ziprasidone hcl cap 60 mg (Geodon)................................ 49ziprasidone hcl cap 80 mg (Geodon)................................ 49zolpidem tartrate tab 5 mg (Ambien).................................50zolpidem tartrate tab 10 mg (Ambien)...............................50zonisamide cap 25 mg (Zonegran)....................................66zonisamide cap 50 mg (Zonegran)....................................66zonisamide cap 100 mg (Zonegran)..................................66ZORTRESS – everolimus tab 0.25 mg............................. 85

ZORTRESS – everolimus tab 0.5 mg............................... 85ZORTRESS – everolimus tab 0.75 mg............................. 85ZORTRESS – everolimus tab 1 mg.................................. 85ZOSTAVAX – zoster vaccine live for subcutaneous susp19400 unit/0.65ml............................................................. 10

ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab1.4-0.36 mg (base eq)......................................................56


ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 5.7-1.4mg (base eq).................................................................... 56

ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 8.6-2.1mg (base eq).................................................................... 56


ZYCLARA – imiquimod cream 3.75%............................... 83ZYCLARA PUMP – imiquimod cream 2.5%......................83ZYCLARA PUMP – imiquimod cream 3.75%....................83ZYTIGA – abiraterone acetate tab 250 mg....................... 15ZYTIGA – abiraterone acetate tab 500 mg....................... 15ZYVOX – linezolid for susp 100 mg/5ml............................. 9

Important Phone Numbers 24/7 Nurseline – 24-hour-a-day help line 1-888-343-2697, TTY/TDD: 711

Emergency Care 911

Blue Cross Community Health Plans Member Services We are available 24 hours a day, seven (7) days a week. The call is free. Website: www.bcchpil.com Service Area: The plan covers members who live in the state of Illinois.

1-877-860-2837, TTY/TDD: 711

1-800-543-0867 Blue Cross Community Health Plans Special Investigation Department (SID)

National Poison Control Center

Calls are routed to the office closest to you. 1-800-222-1222

Non-Emergency Medical Transportation 1-877-860-2837, TTY/TDD: 711

Behavioral Health Services 1-877-860-2837, TTY/TDD: 711

Children’s Mobile Crisis 1-800-345-9049, TTY/TDD: 711

Grievances and Appeals 1-877-860-2837, TTY/TDD: 711

Fraud and Abuse 1-800-543-0867, TTY/TDD: 711

Care Coordination 1-855-334-4780, TTY/TDD: 711

Adult Protective Services 1-866-800-1409 TTY: 1-888-206-1327

Nursing Home Hotline 1-800-252-4343, TTY: 1-800-547-0466

DentaQuest 1-888-291-3763

Davis Vision 1-888-715-6716

Illinois Department of Health 1-217-782-4977

To ask for supportive aids and services, or materials in other formats and languages for free, please call,

1-877-860-2837 TTY/TDD:711.

Blue Cross and Blue Shield of Illinois complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Illinois does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Blue Cross and Blue Shield of Illinois:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:○ Qualified sign language interpreters○ Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:○ Qualified interpreters○ Information written in other languages

If you need these services, contact Civil Rights Coordinator.

If you believe that Blue Cross and Blue Shield of Illinois has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago, Illinois 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

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

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

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

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

English: ATTENTION: If you speak English, language assistance services, free of charge, are available toyou. Call 1-877-860-2837 (TTY/TDD: 711).

Español (Spanish): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencialingüística. Llame al 1-877-860-2837 (TTY/TDD: 711).

繁體中文 (Chinese): 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電

1-877-860-2837 (TTY/TDD: 711).

Tagalog (Tagalog – Filipino): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-860-2837 (TTY/TDD: 711).

Français (French): ATTENTION : Si vous parlez français, des services d'aide linguistique vous sontproposés gratuitement. Appelez le 1-877-860-2837 (ATS : 711).

Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-860-2837 (TTY/TDD: 711).

Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-860-2837 (TTY/TDD: 711).

한국어 (Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

1-877-860-2837 (TTY/TDD: 711)번으로 전화해 주십시오.

Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-877-860-2837 (телетайп: 711).

:(Arabic) العربية . : 1-7382-068-778 (

: 117.)

ह िंदी (Hindi): ध्यान दें: यदद आप द िंदी बोलते ैं तो आपके ललए मुफ्त में भाषा स ायता सेवाएिं उपलब्ध ैं। 1-877-860-2837 (TTY/TDD: 711) पर कॉल करें।

Italiano (Italian): ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-877-860-2837 (TTY/TDD: 711).

ગજુરાતી (Gujarati): સચુના: જો તમે ગજુરાતી બોલતા હો, તો નન:શલુ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે.

ફોન કરો 1-877-860-2837 (TTY/TDD: 711).

کریں کال ۔ ہیں دستیاب میں مفت خدمات کی مدد کی زبان کو آپ تو ،ہیں بولتے اردو آپ اگر :خبردار :(Urdu) اُرُدو1-877-860-2837 (TTY/TDD: 711).

Polski (Polish): UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-877-860-2837 (TTY/TDD: 711).

λληνικά (Greek): ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθε

σή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι

οποίες παρέχονται δωρεάν. Καλέστε 1-877-860-2837 (TTY/TDD: 711).

This Formulary (List of Drugs) was updated on 03/2019.

PrimeMail by Walgreens Mail Service; changing to AllianceRx Walgreens Prime in 2018 is a pharmacy that is contracted to provide mail pharmacy services to members of Blue Cross Community Health Plans.

Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

formulary (list of drugs) · the drug list (sometimes called a formulary) is a list showing the...

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