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Los Angeles County, CA

Anthem Blue Cross Cal MediConnect Plan(Medicare-Medicaid Plan)

Danh Sách Thuốc Được Chi Trả(Danh Mục Thuốc) năm 2020

VUI LÒNG ĐỌC: TÀI LIỆU NÀY CHỨA THÔNG TIN VỀ NHỮNG LOẠI THUỐC ĐƯỢC CHÚNG TÔI CHI TRẢ TRONG CHƯƠNG TRÌNH NÀY.

Danh mục thuốc này được cập nhật vào ngày 1/28/2020.Để biết thêm thông tin gần đây hoặc các câu hỏi khác, hãy liên hệ với chúng

tôi theo số

1-833-214-3606 (TTY: 711)24 giờ một ngày, 7 ngày một tuần

hoặc truy cập vào duals.anthem.com.

H6229_20_107845_T_VN_0002 CMS Approved 09/11/2019 ID danh mục thuốc: CM_MMP_20210_v9_2002_1 Phiên bản: v9

Đã phát hành 2/1/2020

Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan)

Danh Sách Thuốc Được Chi Trả năm 2020Giơi Thiêu

Tài liệu này là Danh Sách Thuốc Được Chi Trả (hay còn gọi là Danh Sách Thuốc). Danh sách này cho quý vị biết những loại thuốc theo toa, thuốc mua tự do và các mục nào được Anthem Blue Cross Cal MediConnect Plan chi trả. Qua đây, quý vị cũng biết được các quy định hoặc hạn chế đặc biệt đối với bất kỳ loại thuốc nào được Anthem Blue Cross Cal MediConnect Plan chi trả. Quý vị có thể xem những thuật ngữ chính và định nghĩa ở chương cuối của Sổ Tay Thành Viên.

Mục Lục

A. Tuyên bố miễn trừ trách nhiệm ................................................................................................3

B. Câu Hỏi Thường Gặp (FAQ) ....................................................................................................5

B1. Những loại thuốc theo toa nào có trong Danh Sách Thuốc Được Chi Trả? (Chúng tôi gọi tắt Danh Sách Thuốc Được Chi Trả là “Danh Sách Thuốc”.) .......................................... 5

B2. Danh Sách Thuốc có bao giờ thay đổi không? ................................................................ 5

B3. Điều gì sẽ xảy ra nếu Danh Sách Thuốc có sự thay đổi? ............................................... 6

B4. Có giới hạn hoặc hạn chế nào về việc chi trả thuốc không? Hoặc có hành động nào bắt buộc phải thực hiện để nhận được một số loại thuốc nhất định không? ......................... 7

B5. Làm thế nào quý vị biết liệu loại thuốc mà mình cần có các giới hạn hoặc có hành động nào bắt buộc phải thực hiện để nhận được thuốc hay không? ........................................ 8

B6. Điều gì sẽ xảy ra nếu chúng tôi thay đổi quy định về một số loại thuốc (ví dụ: nếu chúng tôi yêu cầu phải có thêm sự phê duyệt (chấp thuận) trước, giới hạn số lượng và/hoặc hạn chế về trị liệu từng bước)? ...............................................................................................8

B7. Quý vị có thể tìm một loại thuốc trong Danh Sách Thuốc bằng cách nào? ..................... 8

B8. Nêu thuốc quý vị cần không có trong Danh Sách Thuốc thì sao? ................................... 9

B9. Nếu quý vị là thành viên mới của Anthem Blue Cross Cal MediConnect Plan và không thể tìm thấy loại thuốc của mình trong Danh Sách Thuốc hoặc gặp khó khăn trong việc nhận thuốc thì sao? ..................................................................................................................9

B10.Quý vị có thể yêu cầu trường hợp ngoại lệ để chi trả cho loại thuốc của mình hay không? ...........................................................................................................................10

B11. Làm thế nào để có thể yêu cầu trường hợp ngoại lệ? ................................................... 10

B12.Mất bao lâu để được cấp trường hợp ngoại lệ? ............................................................. 10

B13. Thuốc gốc là gì? ............................................................................................................11

H6229_20_107845_T_VN_0002 CMS Approved 09/11/2019

? Nếu quý vị có thắc mắc, vui lòng gọi Anthem Blue Cross Cal MediConnect Plan theo số1-833-214-3606 (TTY: 711), 24 giờ một ngày, 7 ngày một tuần. Cuộc gọi này miễn phí. Để biết thêm thông tin, hãy truy cập vào duals.anthem.com.

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B14. Thuốc mua tự do (OTC) là gì? .......................................................................................11

B15.Anthem Blue Cross Cal MediConnect Plan có chi trả cho sản phẩm mua tự do không phải là thuốc không? .............................................................................................................11

B16.Khoảng đồng thanh toán của quý vị là gì? ....................................................................11

B17.Bậc thuốc là gì? .............................................................................................................11

C. Danh Sách Thuốc Được Chi Trả ...........................................................................................12

D. Danh Sách Thuốc theo Tình Trạng Bệnh Lý .........................................................................13

E. Danh Mục Thuốc Được Chi Trả ...........................................................................................153


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A. Tuyên bố miễn trừ trách nhiệm

Đây là danh sách các loại thuốc mà thành viên có thể được Anthem Blue Cross Cal MediConnect Plan chi trả.

Anthem Blue Cross Cal MediConnect Plan là một chương trình bảo hiểm sức khỏe có hợp đồng với cả Medicare và Medi-Cal để cung cấp phúc lợi của cả hai chương trình cho các thành viên.

Quý vị lúc nào cũng có thể kiểm tra Danh Sách Thuốc Được Chi Trả mới nhất của Anthem Blue Cross Cal MediConnect Plan trên mạng tại địa chỉ duals.anthem.com hoặc bằng cách gọi đến 1-833-214-3606 (TTY 711), 24 giờ một ngày, 7 ngày một tuần

Giới hạn, khoản đồng chi trả và hạn chế có thể được áp dụng. Để biết thêm thông tin, hãy gọi Dịch Vụ Thành Viên Nhà Thuốc của Anthem Blue Cross Cal MediConnect Plan hoặc đọc Sổ Tay Thành Viên của Anthem Blue Cross Cal MediConnect Plan.

ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե դուք խոսում եք հայերեն լեզվով, լեզվական օգնության անվճար ծառայությունները հասանելի են ձեզ համար: Զանգահարեք 1-833-214-3606 (TTY: 711) հեռախոսահամարով՝ օրը 24 ժամ, շաբաթը 7 օր: Այս զանգն անվճար է: Armenian注意：如果您使用中文，您可以免費獲得語言援助服務。請致電 1-833-214-3606(TTY:711), 一週7 天，全天24 小時。通話免費。 Chinese تنبیه: إذا كنت تتحدث العربیة، فإن خدمات المساعدة اللغویة تتوفر لك مجانا. اتصل على الرقم

3606-214-833-1 (الهاتف النصي: 711 )ساعة في اليوم، 7 أيام في األسبوع. 24 وتكونالمكالمة مجانیة. Arabic

توجه: اگر به زبان فارسی صحبت می کنید، خدمات کمک در زمینه زبان، به صورت رایگان،برای شما در دسترس می باشد. 24 ساعت شبانروز و 7 روز هفته با شماره1-833-214-3606

( TTY: 711 ) تماس بگیرید. این تماس رایگان می باشد. Farsi

안내: 한국어를 사용할 경우 무료 언어 지원 서비스를 이용하실 수 있습니다. 주 7일 하루 24시간 언제든 1-833-214-3606 (TTY: 711) 번으로 전화하십시오. 통화료는 무료입니다. KoreanВНИМАНИЕ: если вы говорите по-русски, вам могут предоставить бесплатные услуги перевода. Звоните по тел. 1-833-214-3606 (TTY: 711) 24 часа в день, 7 дней в неделю. Звонок бесплатный. RussianATENCIÓN: Si usted habla español, tiene a su disposición servicios gratuitos de asistencia de idiomas. Llame al 1-833-214-3606 (TTY: 711), las 24 horas del día, los 7 días de la semana. La llamada es gratuita. Spanishសមជរាប៖ ជរបសនបបើបោកអនកនយាយភាសាខមែរ បសវាកមែជនយភាសា មានផដលជនបោកអនកបោយឥតគតថលៃ។ សមទរសពទមកបលម 1-833-214-3606 (TTY: 711) 24 មោងកនងមយថងៃ, 7 ថងៃកនងមយសបដាហ ទរសពទមកបលមបនេះគឥតគតថលៃ។ Khmer


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PAALALA: Kung nagsasalita ka ng Tagalog, magagamit mo nang walang bayad ang mga serbisyo ng tulong sa wika. Tumawag sa 1-833-214-3606(TTY: 711), 24 na oras sa isang araw, 7 araw sa isang linggo. Libre ang tawag. TagalogCHU Ý: Nếu quý vị nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ, miễn phí, cho quý vị. Xin gọi số 1-833-214-3606 (TTY: 711), 24 giờ mỗi ngày, 7 ngày mỗi tuần. Cuộc gọi được miễn tính cước phí. Vietnamese

Quý vị có thể nhận tài liệu này miễn phí ở các ngôn ngữ và định dạng khác, chẳng hạn như chữ in lớn, chữ nổi braille hoặc âm thanh. Hãy gọi 1-833-214-3606 (TTY 711), 24 giờ một ngày, 7 ngày một tuần Cuộc gọi này miễn phí.

Khi quý vị gọi, hãy cho chúng tôi biết nếu quý vị muốn đây là một yêu cầu định kỳ. Điều này có nghĩa là hàng năm chúng tôi sẽ gửi cùng một tài liệu theo ngôn ngữ và định dạng quý vị yêu cầu.

Quý vị cũng có thể gọi cho chúng tôi để thay đổi hoặc hủy một yêu cầu định kỳ. Quý vị cũng có thể tìm tài liệu trực tuyến tại địa chỉ duals.anthem.com.


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B. Câu Hỏi Thường Gặp (FAQ)

Hãy tìm câu trả lời tại đây cho các câu hỏi của quý vị về Danh Sách Thuốc Được Chi Trả này. Quý vị có thể đọc tất cả các câu hỏi thường gặp để tìm hiểu thêm hoặc để tìm kiếm câu hỏi và câu trả lời.

B1. Những loại thuốc theo toa nào có trong Danh Sách Thuốc Được Chi Trả? (Chúng tôi gọi tắt Danh Sách Thuốc Được Chi Trả là “Danh Sách Thuốc”.)

Các thuốc trong Danh Sách Thuốc là những loại thuốc được Anthem Blue Cross Cal MediConnect Plan chi trả. Những thuốc này có bán tại các nhà thuốc trong mạng lưới của chúng tôi. Một nhà thuốc được xem là nằm trong mạng lưới của chúng tôi nếu chúng tôi có thỏa thuận làm việc với họ và họ cung cấp dịch vụ cho quý vị. Chúng tôi gọi những nhà thuốc này là “nhà thuốc trong mạng lưới”.

Anthem Blue Cross Cal MediConnect Plan sẽ chi trả cho tất cả các loại thuốc cần thiết về mặt y tế có trong Danh Sách Thuốc nếu:

bác sĩ hoặc người kê toa khác cho rằng quý vị cần những loại thuốc này để cải thiện hoặc giữ gìn sức khỏe, và

quý vị mua thuốc theo toa tại một nhà thuốc trong mạng lưới của Anthem Blue Cross Cal MediConnect Plan.

Trong một số trường hợp, quý vị phải thực hiện một số thao tác trước khi có thể nhận thuốc (xem câu hỏi B4 bên dưới).

Nếu chúng tôi chỉ chi trả một loại thuốc cho một số tình trạng bệnh lý, chúng tôi sẽ chỉ rõ thuốc đó trong Danh Sách Thuốc cùng với các tình trạng bệnh lý cụ thể được chi trả.

Quý vị cũng có thể xem danh sách thuốc được chúng tôi chi trả đã cập nhật trên trang web của chúng tôi tại duals.anthem.com hoặc gọi Dịch Vụ Thành Viên Nhà Thuốc theo số 1-833-214-3606 (TTY: 711), 24 giờ một ngày, 7 ngày một tuần.

B2. Danh Sách Thuốc có bao giờ thay đổi không?Có, và Anthem Blue Cross Cal MediConnect Plan phải tuân theo các quy định của Medicare và Medicaid khi thực hiện thay đổi. Chúng tôi có thể thêm vào hoặc loại bỏ thuốc ra khỏi Danh Sách Thuốc trong cả năm.

Chúng tôi cũng có thể thay đổi các quy định về thuốc. Ví dụ, chúng tôi có thể:

Quyết định yêu cầu hoặc không yêu cầu sự chấp thuận trước cho một loại thuốc. (Chấp thuận trước là sự cho phép của Anthem Blue Cross Cal MediConnect Plan trước khi quý vị có thể nhận thuốc.)

Bổ sung hoặc thay đổi lượng thuốc mà quý vị được cấp (gọi là giới hạn số lượng).


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Bổ sung hoặc thay đổi các hạn chế về trị liệu từng bước đối với một loại thuốc. (Trị liệu từng bước nghĩa là quý vị phải dùng thử một loại thuốc trước khi chúng tôi chi trả cho một loại thuốc khác.)

Hãy xem câu hỏi B4 để biết thêm thông tin về các quy định về thuốc.

Nếu quý vị đang dùng một loại thuốc đã được chi trả vào đầu năm, thì chúng tôi thường không loại bỏ hoặc thay đổi việc chi trả cho loại thuốc đó cho đến hết năm trừ khi:

xuất hiện một loại thuốc mới rẻ hơn có tác dụng giống như thuốc có trong Danh Sách Thuốc hiện tại, hoặc

chúng tôi phát hiện ra một loại thuốc không an toàn, hoặc

một loại thuốc bị ngừng lưu hành trên thị trường.

Các câu hỏi B3 và B6 bên dưới có thêm thông tin về điều sẽ xảy ra khi Danh Sách Thuốc thay đổi.

Quý vị lúc nào cũng có thể kiểm tra Danh Sách Thuốc mới nhất của Anthem Blue Cross Cal MediConnect Plan trên mạng tại duals.anthem.com.

Quý vị cũng có thể gọi Dịch Vụ Thành Viên Nhà Thuốc để kiểm tra Danh Sách Thuốc hiện tại theo số 1-833-214-3606 (TTY: 711), 24 giờ một ngày, 7 ngày một tuần.

B3. Điều gì sẽ xảy ra nếu Danh Sách Thuốc có sự thay đổi?Một số thay đổi về Danh Sách Thuốc sẽ có hiệu lực ngay lập tức. Ví dụ:

Xuất hiện một loại thuốc gốc mới. Đôi khi sẽ xuất hiện một loại thuốc gốc mới rẻ hơn có tác dụng giống như thuốc chính hiệu có trong Danh Sách Thuốc hiện tại. Khi điều này xảy ra, chúng tôi có thể sẽ loại bỏ thuốc chính hiệu và thêm thuốc gốc mới, nhưng giá tiền phải trả cho thuốc mới vẫn không thay đổi. Khi thêm một loại thuốc gốc mới, chúng tôi cũng có thể quyết định vẫn giữ thuốc chính hiệu trong danh sách nhưng sẽ thay đổi quy định hoặc giới hạn chi trả cho loại thuốc đó.

Chúng tôi có thể không báo trước cho quý vị về sự thay đổi này, nhưng chúng tôi sẽ gửi cho quý vị thông tin khi những thay đổi cụ thể có hiệu lực.

Quý vị hoặc nhà cung cấp của quý vị có thể yêu cầu trường hợp ngoại lệ với các thay đổi này. Chúng tôi sẽ gửi cho quý vị một thông báo có các bước cần thực hiện để yêu cầu trường hợp ngoại lệ. Vui lòng xem câu hỏi B10 để biết thêm thông tin về các trường hợp ngoại lệ.

Một loại thuốc bị ngừng lưu hành trên thị trường. Nếu Cơ Quan Quản Lý Thực Phẩm và Dược Phẩm (FDA) cho rằng loại thuốc quý vị đang dùng không an toàn hoặc bị nhà sản xuất ngừng lưu hành trên thị trường, thì chúng tôi sẽ loại bỏ thuốc đó ra khỏi Danh Sách Thuốc. Chúng tôi sẽ thông báo cho quý vị biết nếu quý vị đang dùng loại thuốc này. Vui lòng liên hệ với bác sĩ kê toa của quý vị ngay khi nhận được thư.


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Chúng tôi có thể thực hiện những thay đổi khác gây ảnh hưởng đến loại thuốc quý vị dùng. Chúng tôi sẽ báo trước cho quý vị những thay đổi khác về Danh Sách Thuốc. Những thay đổi này có thể được áp dụng nếu:

FDA cung cấp hướng dẫn mới hoặc có các hướng dẫn điều trị mới cho một loại thuốc.

Chúng tôi bổ sung một loại thuốc gốc đã có trên thị trường và

Thay thế một loại thuốc chính hiệu hiện có trong Danh Sách Thuốc hoặc

Thay đổi quy định hoặc giới hạn chi trả cho loại thuốc chính hiệu này.

Khi những thay đổi này diễn ra, chúng tôi sẽ:

Cho quý vị biết ít nhất 30 ngày trước khi chúng tôi thay đổi Danh Sách Thuốc hoặc

Cho quý vị biết và cấp lượng thuốc dùng trong 31 ngày sau khi quý vị yêu cầu thêm thuốc.

Như vậy, quý vị sẽ có thời gian để trao đổi với bác sĩ hoặc người kê toa khác của mình. Họ có thể giúp quý vị quyết định:

Liệu có thuốc thay thế tương tự trong Danh Sách Thuốc quý vị có thể dùng hay không hoặc

Yêu cầu trường hợp ngoại lệ cho những thay đổi này hay không. Để tìm hiểu thêm về trường hợp ngoại lệ, hãy xem câu hỏi B10.

B4. Có giới hạn hoặc hạn chế nào về việc chi trả thuốc không? Hay có hành động nào bắt buộc phải thực hiện để nhận được một số loại thuốc nhất định không?

Có, một số loại thuốc có các quy định về việc chi trả hoặc giới hạn về số lượng thuốc quý vị có thể nhận được. Trong một số trường hợp, quý vị hoặc bác sĩ hay người kê toa khác của quý vị phải thực hiện việc gì đó trước khi quý vị có thể nhận thuốc. Ví dụ:

Chấp thuận trước (hoặc phê duyệt trước): Đối với một số loại thuốc, quý vị hoặc bác sĩ hay người kê toa khác của quý vị phải nhận được sự chấp thuận từ Anthem Blue Cross Cal MediConnect Plan trước khi quý vị có thể mua thuốc. Anthem Blue Cross Cal MediConnect Plan có thể không chi trả cho loại thuốc này nếu quý vị không được chấp thuận.

Giới hạn số lượng: Đôi khi Anthem Blue Cross Cal MediConnect Plan sẽ giới hạn số lượng thuốc mà quý vị được cấp.

Trị liệu từng bước: Đôi khi Anthem Blue Cross Cal MediConnect Plan sẽ yêu cầu quý vị tiến hành trị liệu từng bước. Điều này có nghĩa là quý vị sẽ phải dùng thử các loại thuốc theo một thứ tự nhất định cho tình trạng bệnh lý của mình. Quý vị có thể phải dùng thử một loại thuốc trước khi chúng tôi chi trả cho một loại thuốc khác. Nếu bác sĩ cho rằng loại thuốc đầu tiên không có tác dụng đối với quý vị thì chúng tôi sẽ chi trả cho loại thuốc thứ hai.


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Chi trả theo chỉ định: Nếu Anthem Blue Cross Cal MediConnect Plan chỉ chi trả một loại thuốc cho một số tình trạng bệnh lý. Chúng tôi sẽ chỉ rõ thuốc đó trong Danh Sách Thuốc cùng với các tình trạng bệnh lý cụ thể được chi trả.

Quý vị có thể tìm hiểu xem thuốc của mình có yêu cầu hay giới hạn bổ sung nào không bằng cách xem các bảng ở trang 13 - 152. Quý vị cũng có thể truy cập vào trang web của chúng tôi tạiduals.anthem.com để biết thêm thông tin. Chúng tôi đã đăng tải trên mạng những tài liệu giải thích các hạn chế về sự phê duyệt trước và trị liệu từng bước. Quý vị cũng có thể yêu cầu chúng tôi gửi cho quý vị một bản sao.

Quý vị cũng có thể yêu cầu một trường hợp ngoại lệ với những giới hạn này. Như vậy, quý vị sẽ có thời gian để trao đổi với bác sĩ hoặc người kê toa khác của mình. Họ có thể giúp quý vị quyết định liệu có thể dùng một loại thuốc tương tự trong Danh Sách Thuốc để thay thế hoặc liệu có cần yêu cầu trường hợp ngoại lệ hay không. Vui lòng xem các câu hỏi B10- B12 để biết thêm thông tin về các trường hợp ngoại lệ.

B5. Làm thế nào quý vị biết liệu loại thuốc mà mình cần có các giới hạn hoặc có hành động nào bắt buộc phải thực hiện để nhận được thuốc hay không?

Danh Sách Thuốc Được Chi Trả ở trang 13 có một cột tên là “Hành Động Cần Thiết, Quy Định Hạn Chế hoặc Giới Hạn Sử Dụng”.

B6. Điều gì sẽ xảy ra nếu chúng tôi thay đổi quy định về một số loại thuốc (ví dụ: nếu chúng tôi yêu cầu phải có thêm sự phê duyệt (chấp thuận) trước, giới hạn số lượng và/hoặc hạn chế về trị liệu từng bước).

Trong một số trường hợp, chúng tôi sẽ thông báo trước cho quý vị nếu chúng tôi bổ sung hoặc thay đổi yêu cầu có thêm sự chấp thuận trước, giới hạn số lượng và/hoặc hạn chế về trị liệu từng bước đối với một loại thuốc. Hãy xem câu hỏi B3 để biết thêm thông tin về thông báo trước này và những tình huống mà chúng tôi không thể báo trước cho quý vị khi quy định về thuốc trong Danh Sách Thuốc có thay đổi.

B7. Quý vị có thể tìm một loại thuốc trong Danh Sách Thuốc bằng cách nào?

Có hai cách để tìm kiếm một loại thuốc:

Quý vị có thể tìm theo thứ tự bảng chữ cái (nếu quý vị biết cách đánh vần tên thuốc), hoặc

Quý vị có thể tìm theo tình trạng bệnh lý.

Để tìm kiếm theo thứ tự bảng chữ cái, hãy xem phần Danh Mục Thuốc Được Chi Trả. Quý vị có thể tìm thấy thuốc bằng cách chuyển đến danh sách bắt đầu ở trang 153, sau đó tìm tên thuốc trong danh sách.


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Để tìm kiếm theo tình trạng bệnh lý, hãy tìm phần có tên “Danh Sách Thuốc Theo Tình Trạng Bệnh Lý” ở trang 13. Thuốc trong phần này được nhóm thành các mục theo tình trạng bệnh lý mà chúng được dùng để điều trị. Ví dụ: nếu bị bệnh về tim thì quý vị cần tìm mục Thuốc Tim Mạch. Đó là nơi quý vị sẽ tìm thấy thuốc điều trị bệnh về tim.

B8. Nêu thuốc quý vị cần không có trong Danh Sách Thuốc thì sao?Nếu quý vị không tìm thấy thuốc của mình trong Danh Sách Thuốc, hãy gọi cho Dịch Vụ Thành Viên Nhà Thuốc theo số 1-833-214-3606 (TTY: 711), 24 giờ một ngày, 7 ngày một tuần và hỏi về thuốc đó. Nếu biết rằng Anthem Blue Cross Cal MediConnect Plan sẽ không chi trả cho loại thuốc đó, quý vị có thể thực hiện một trong những điều sau đây:

Yêu cầu Dịch Vụ Thành Viên Nhà Thuốc cung cấp một danh sách các loại thuốc giống loại quý vị muốn dùng. Sau đó, cho bác sĩ hoặc người kê toa khác của quý vị xem danh sách đó. Họ có thể kê một loại thuốc có trong Danh Sách Thuốc giống loại thuốc quý vị muốn dùng.Hoặc

Quý vị có thể yêu cầu chương trình bảo hiểm sức khỏe đưa ra ngoại lệ để chi trả cho loại thuốc của quý vị. Vui lòng xem các câu hỏi B10- B12 để biết thêm thông tin về các trường hợp ngoại lệ.

B9. Nếu quý vị là thành viên mới củaAnthem Blue Cross Cal MediConnect Plan và không thể tìm thấy loại thuốc của mình trong Danh Sách Thuốc hoặc gặp khó khăn trong việc nhận thuốc thì sao?

Chúng tôi có thể trợ giúp. Chúng tôi có thể chi trả lượng thuốc tạm thời đủ dùng trong 31 ngày cho quý vị trong suốt 90 ngày đầu tiên quý vị là thành viên của Anthem Blue Cross Cal MediConnect Plan. Như vậy, quý vị sẽ có thời gian để trao đổi với bác sĩ hoặc người kê toa khác của mình. Họ có thể giúp quý vị quyết định liệu có thể dùng một loại thuốc tương tự trong Danh Sách Thuốc để thay thế hoặc liệu có cần yêu cầu trường hợp ngoại lệ hay không.

Nếu thuốc theo toa của quý vị được kê với số ngày ít hơn, thì chúng tôi sẽ cho phép mua thuốc nhiều lần để cung cấp tối đa 31 ngày dùng thuốc.

Chúng tôi sẽ chi trả cho lượng thuốc dùng trong 31 ngày của quý vị nếu:

quý vị đang dùng một loại thuốc không có trong Danh Sách Thuốc của chúng tôi, hoặc

các quy định của chương trình bảo hiểm sức khỏe không cho phép quý vị nhận được số lượng thuốc do người kê toa chỉ định, hoặc

loại thuốc này phải có sự chấp thuận trước của Anthem Blue Cross Cal MediConnect Plan,hoặc

quý vị đang dùng một loại thuốc phải chịu hạn chế về trị liệu từng bước.

Nếu quý vị sống trong viện dưỡng lão hoặc cơ sở chăm sóc lâu dài khác và cần một loại thuốc không có trong Danh Sách Thuốc hoặc nếu quý vị không thể dễ dàng nhận được loại thuốc mình


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cần, chúng tôi có thể trợ giúp. Nếu quý vị đã tham gia chương trình này trên 90 ngày, sống trong cơ sở chăm sóc lâu dài và cần cấp thuốc ngay:

Chúng tôi sẽ chi trả cho lượng thuốc dùng trong 34 ngày (trừ khi thuốc theo toa của quý vị được kê với số ngày ít hơn), dù quý vị có phải là thành viên mới của Anthem Blue Cross Cal MediConnect Plan hay không.

Đây là phần bổ sung thêm cho lượng thuốc được cấp tạm thời trong 90 ngày đầu tiên quý vị là thành viên của Anthem Blue Cross Cal MediConnect Plan.

Nếu việc thay đổi về mức độ chăm sóc của quý vị yêu cầu quý vị phải chuyển từ một cơ sở hoặc trung tâm điều trị này sang một cơ sở hoặc trung tâm điều trị khác, thì quý vị có thể đủ điều kiện mua thuốc tạm thời một lần theo toa thuốc hiện tại. Ví dụ: nếu quý vị xuất viện và được cung cấp một danh sách thuốc khi xuất viện dựa trên danh mục thuốc của bệnh viện, thì quý vị có thể mua thuốc đó một lần. Quý vị có thể xin ngoại lệ để mua thuốc một lần tạm thời bất kể quý vị có đang trong giai đoạn 90 ngày đầu tiên kể từ khi tham gia chương trình hay không. Hãy yêu cầu người kê toa của quý vị gọi cho chúng tôi để biết thông tin chi tiết.

B10. Quý vị có thể yêu cầu trường hợp ngoại lệ để chi trả cho loại thuốc của mình hay không?

Có. Quý vị có thể yêu cầu Anthem Blue Cross Cal MediConnect Plan đưa ra trường hợp ngoại lệ để chi trả cho một loại thuốc không có trong Danh Sách Thuốc.

Quý vị cũng có thể yêu cầu chúng tôi thay đổi quy định về loại thuốc của quý vị.

Ví dụ: Anthem Blue Cross Cal MediConnect Plan có thể giới hạn số lượng của một loại thuốc chúng tôi sẽ chi trả. Nếu loại thuốc của quý vị có giới hạn thì quý vị có thể yêu cầu chúng tôi thay đổi giới hạn đó và chi trả cho số lượng lớn hơn.

Các ví dụ khác: Quý vị có thể yêu cầu chúng tôi hủy bỏ quy định hạn chế về trị liệu từng bước hoặc yêu cầu về sự chấp thuận trước.

B11. Làm thế nào để có thể yêu cầu trường hợp ngoại lệ?Để yêu cầu trường hợp ngoại lệ, vui lòng gọi Dịch Vụ Thành Viên Nhà Thuốc. Đại diện của Dịch Vụ Thành Viên Nhà Thuốc sẽ làm việc với quý vị và nhà cung cấp của quý vị để giúp quý vị yêu cầu trường hợp ngoại lệ.

Quý vị cũng có thể đọc Chương 9 trong Sổ Tay Thành Viên để tìm hiểu thêm về các trường hợp ngoại lệ.

B12. Mất bao lâu để được cấp trường hợp ngoại lệ?Đầu tiên, chúng tôi phải nhận được tờ khai từ người kê toa của quý vị với nội dung ủng hộ việc quý vị yêu cầu trường hợp ngoại lệ. Sau khi nhận được tờ khai, chúng tôi sẽ đưa ra quyết định cho yêu cầu trường hợp ngoại lệ của quý vị trong vòng 72 giờ.


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Khi quý vị hoặc người kê toa của quý vị cho rằng nếu phải chờ đợi quyết định trong 72 giờ sẽ gây tổn hại đến sức khỏe của quý vị, thì quý vị có thể yêu cầu trường hợp ngoại lệ khẩn cấp. Quyết định này được đưa ra nhanh hơn. Nếu người kê toa của quý vị ủng hộ yêu cầu này, thì chúng tôi sẽ đưa ra quyết định trong vòng 24 giờ kể từ khi nhận được tờ khai ủng hộ của người kê toa.

B13. Thuốc gốc là gì?Thuốc gốc được sản xuất từ những thành phần tương tự như thuốc chính hiệu. Thuốc này thường rẻ hơn thuốc chính hiệu và thường ít được biết đến hơn. Thuôc gốc đươc Cơ Quan Quan Ly Thưc Phâm va Dươc Phâm (FDA) phê duyệt.

Anthem Blue Cross Cal MediConnect Plan chi trả cho cả thuốc chính hiệu và thuốc gốc.

B14. Thuốc mua tự do (OTC) là gì?OTC là viết tắt của từ “over-the-counter” (mua tự do). Anthem Blue Cross Cal MediConnect Plan chi trả cho một số loại thuốc OTC khi các thuốc này được nhà cung cấp của quý vị kê theo toa.

Quý vị có thể đọc Danh Sách Thuốc của Anthem Blue Cross Cal MediConnect Plan để xem những loại thuốc OTC nào được chi trả.

B15. Anthem Blue Cross Cal MediConnect Plan có chi trả cho các sản phẩm OTC không phải thuốc hay không?

Anthem Blue Cross Cal MediConnect Plan chi trả cho một số sản phẩm OTC không phải là thuốc khi các sản phẩm này được nhà cung cấp của quý vị kê theo toa.

Ví dụ về sản phẩm OTC không phải thuốc bao gồm mặt nạ, bao cao su và máy đo lưu lượng khí tối đa.

Quý vị có thể đọc Danh Sách Thuốc của Anthem Blue Cross Cal MediConnect Plan để xem những sản phẩm OTC không phải thuốc nào được chi trả.

B16. Khoản đồng chi trả là gì?Với tư cách là thành viên của Anthem Blue Cross Cal MediConnect Plan, quý vị không phải đồng chi trả cho các loại thuốc theo toa và OTC với điều kiện quý vị phải tuân thủ các quy định của Anthem Blue Cross Cal MediConnect Plan.

B17. Bậc thuốc là gì?Bậc là các nhóm thuốc trong Danh Sách Thuốc. Tất cả các bậc thuốc không có khoản đồng chi trả.


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Bậc 1 – Các loại thuốc gốc và thuốc chính hiệu ưu tiên của Medicare Phần D

Bậc 2 – Các loại thuốc gốc và thuốc chính hiệu ưu tiên và không ưu tiên của Medicare Phần D

Bậc 3 – Các loại thuốc gốc và thuốc chính hiệu không phải của Medicare được Medi-Cal (tiểu bang) phê duyệt

Bậc 4 – Các loại thuốc mua tự do (OTC) có toa của nhà cung cấp, không phải của Medicare, được Medi-Cal (tiểu bang) phê duyệt

C. Danh Sách Thuốc Được Chi Trả

Danh sách thuốc được chi trả sau đây cung cấp cho quý vị thông tin về các loại thuốc được Anthem Blue Cross Cal MediConnect Plan chi trả. Nếu quý vị gặp khó khăn khi tìm loại thuốc của mình trong danh sách, hãy chuyển đến phần Chỉ Mục bắt đầu ở trang 153. Phần Chỉ Mục liệt kê tất cả các loại thuốc được Anthem Blue Cross Cal MediConnect Plan chi trả theo thứ tự bảng chữ cái.

Cột đầu tiên của bảng liệt kê tên thuốc. Thuốc chính hiệu được viết hoa (ví dụ: SPIRIVA) còn thuốc gốc được viết bằng chữ thường, in nghiêng (ví dụ: atenolol).

Thông tin trong cột “Hành Động Cần Thiết, Quy Định Hạn Chế hoặc Giới Hạn Sử Dụng” cho quý vị biết liệu Anthem Blue Cross Cal MediConnect Plan có quy định nào về việc chi trả cho loại thuốc của quý vị hay không.

Lưu ý: Dấu sao (*) cạnh một loại thuốc có nghĩa là thuốc này không phải “thuốc Phần D.” Quý vị sẽ không phải chịu khoản đồng chi trả nào cho những loại thuốc này. Những loại thuốc này cũng có các quy định khác nhau về thủ tục kháng nghị.

Kháng nghị là cách chính thức để yêu cầu chúng tôi xem xét lại một quyết định chi trả cho quý vị và thay đổi quyết định đó nếu quý vị cho rằng chúng tôi đã có nhầm lẫn. Ví dụ: chúng tôi có thể đã quyết định rằng loại thuốc mà quý vị cần không được hoặc không còn được Medicare hay Medi-Cal chi trả nữa.

Nếu quý vị hoặc bác sĩ của quý vị không đồng tình với quyết định của chúng tôi thì quý vị có thể kháng nghị. Nếu quý vị có thắc mắc, hãy gọi cho Dịch Vụ Thành Viên Nhà Thuốc theo số 1-833-214-3606 (TTY: 711), 24 giờ một ngày, 7 ngày một tuần Quý vị cũng có thể đọc Chương 9 của Sổ Tay Thành Viên để tìm hiểu cách kháng nghị quyết định.


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D. Danh Sách Thuốc theo Tình Trạng Bệnh Lý

Thuốc trong phần này được nhóm thành các mục theo tình trạng bệnh lý mà chúng được dùng để điều trị. Ví dụ: nếu bị bệnh về tim thì quý vị cần tìm mục Thuốc Tim Mạch. Đó là nơi quý vị sẽ tìm thấy thuốc điều trị bệnh về tim.

Dưới đây là ý nghĩa của các chữ viết tắt trong cột “Hành Động Cần Thiết, Quy Định Hạn Chế hoặc Giới Hạn Sử Dụng”:

GIẢI THÍCHMÔ TẢCHỮ VIẾT TẮT

Loại thuốc theo toa này được chi trả theo Medicare Phần B hay Phần D tùy từng trường hợp. Cần cung cấp thông tin mô tả cách dùng và liều lượng của thuốc để xác định.

Xác định Phần B hay Phần D

B/D PAR

Toa thuốc này có thể chỉ được bán tại một số nhà thuốc nhất định. Để biết thêm thông tin, vui lòng gọi Dịch Vụ

Giới Hạn Về Tính Sẵn Có

LA

Thành Viên Nhà Thuốc theo số 1-833-214-3606 (TTY:711), 24 giờ một ngày, 7 ngày một tuần.

Loại thuốc theo toa này được bán thông qua dịch vụ đặt hàng qua bưu điện, cũng như thông qua các nhà thuốc

Thuôc Đăt Qua Đường Bưu Điện

MO

bán lẻ trong mạng lưới của chúng tôi. Hãy cân nhắc sử dụng dịch vụ đặt hàng qua bưu điện cho các thuốc dùng lâu dài (duy trì) (chẳng hạn như thuốc điều trị cao huyết áp). Các nhà thuốc bán lẻ trong mạng lưới có thể phù hợp để mua các toa thuốc ngắn hạn (chẳng hạn như kháng sinh).

Những loại thuốc không gia hạn số ngày cấp bao gồm các thuốc biệt dược. Thuốc biệt dược được cấp trong 31

Không gia hạn NE

ngày thuốc. Quý vị có thể tìm hiểu xem việc cấp thuốc biệt dược hoặc thuốc không gia hạn số ngày cấp có bị giới hạn trong 31 ngày thuốc hay không bằng cách kiểm tra bảng phúc lợi ở mặt trước của Sổ Tay Thành Viên.

Anthem Blue Cross Cal MediConnect Plan yêu cầu quý vị hoặc bác sĩ của quý vị phải nhận được sự phê duyệt trước

Cần Phê Duyệt Trước

PAR

đối với một số loại thuốc nhất định. Điều này có nghĩa là quý vị phải nhận được sự chấp thuận trước khi mua thuốc theo toa. Nếu quý vị không nhận được sự chấp thuận thì chúng tôi có thể sẽ không chi trả cho loại thuốc đó.

Đối với những loại thuốc nhất định, Anthem Blue Cross Cal MediConnect Plan giới hạn số lượng thuốc mà chúng tôi sẽ chi trả.

Giới Hạn Số Lượng

QLL

Trong một số trường hợp, Anthem Blue Cross Cal MediConnect Plan yêu cầu quý vị

Trị liệu từng bước. ST

phải dùng thử những loại thuốc nhất định để điều trị trình trạng bệnh lý của mình, sau đó chúng tôi mới chi trả cho loại thuốc khác để điều trị bệnh đó. Ví dụ: nếu Thuốc A và Thuốc B đều chữa trị trình trạng bệnh lý của quý vị, thì chúng tôi sẽ không chi trả cho Thuốc B trừ khi quý vị dùng thử Thuốc A trước. Nếu Thuốc A không có tác dụng đối với quý vị thì chúng tôi sẽ chi trả cho Thuốc B.

B/D PAR: Cần Phê Duyệt Trước, Chỉ Để Xác Định Phần D hay Phần B LA: Giới Hạn Về Tính Sẵn Có MO: Đặt Qua Đường Bưu Điện NE: Không gia hạn số ngày cấp PAR: Cần Phê Duyệt TrướcQLL: Giới Hạn Mức Số Lượng ST: Trị Liệu Từng Bước 13

Hành Động Cần Thiết, Quy Định Hạn Chế hoặc Giới Hạn Sử Dụng

Giá Thuốc

(Theo Bậc)

Tên Thuốc

ANALGESICS

MO; NE; QLL (180 per 30 days)$0 (Tier 2)acetaminophen-codeine #3MO; NE; QLL (180 per 30 days)$0 (Tier 2)acetaminophen-codeine #4MO; NE; QLL (900 per 30 days)$0 (Tier 2)acetaminophen-codeine oral solutionMO; NE; QLL (180 per 30 days)$0 (Tier 2)acetaminophen-codeine oral tablet 300-15 mg,

300-60 mg[*]$0 (Tier 4)all day relief tablet 220 mg oral[*]$0 (Tier 4)aspir-low tablet delayed release 81 mg oral[*]$0 (Tier 4)aspirin 81 tablet delayed release 81 mg oral[*]$0 (Tier 4)aspirin adult low strength tablet chewable 81

mg oral[*]$0 (Tier 4)aspirin ec tablet delayed release 325 mg oral[*]$0 (Tier 4)aspirin ec tablet delayed release 81 mg oral[*]$0 (Tier 4)aspirin low dose tablet chewable 81 mg oral[*]$0 (Tier 4)aspirin low dose tablet delayed release 81 mg

oral[*]$0 (Tier 4)aspirin low strength tablet chewable 81 mg oral[*]$0 (Tier 4)aspirin tablet 325 mg oral[*]$0 (Tier 4)aspirin tablet chewable 81 mg oral[*]$0 (Tier 4)aspirin tablet delayed release 81 mg oralMO; NE; QLL (90 per 30 days)$0 (Tier 2)buprenorphine hcl injectionMO; QLL (240 per 30 days)$0 (Tier 2)buprenorphine hcl sublingual tablet sublingual

2 mgMO; QLL (60 per 30 days)$0 (Tier 2)buprenorphine hcl sublingual tablet sublingual

8 mgMO; NE; QLL (240 per 30 days)$0 (Tier 2)butorphanol tartrate injection solution 1 mg/mlMO; NE; QLL (120 per 30 days)$0 (Tier 2)butorphanol tartrate injection solution 2 mg/mlMO; NE; QLL (5 per 28 days)$0 (Tier 2)butorphanol tartrate nasalPAR; MO$0 (Tier 2)celecoxib oral[*]$0 (Tier 4)childrens aspirin low strength tablet chewable

81 mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)diclofenac potassiumMO$0 (Tier 2)diclofenac sodium erMO$0 (Tier 2)diclofenac sodium oralMO$0 (Tier 2)diflunisal oralMO; NE; QLL (180 per 30 days)$0 (Tier 2)duramorph[*]$0 (Tier 4)ecpirin tablet delayed release 325 mg oralPAR; NE; QLL (8 per 28 days)$0 (Tier 2)ENBREL MINIMO; NE; QLL (180 per 30 days)$0 (Tier 2)endocet oral tablet 10-325 mg, 5-325 mg, 7.5-

325 mgMO; NE; QLL (180 per 30 days)$0 (Tier 2)endocet oral tablet 2.5-325 mgMO$0 (Tier 2)etodolac oralMO$0 (Tier 2)fenoprofen calcium oral tabletPAR; MO; NE; QLL (120 per 30 days)$0 (Tier 2)fentanyl citrate buccal lozenge on a handlePAR; MO; NE; QLL (120 per 30 days)$0 (Tier 2)fentanyl citrate buccal lozenge on a handlePAR; MO; NE; QLL (15 per 30 days)$0 (Tier 2)fentanyl transdermal patch 72 hour 100 mcg/

hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/ hr

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

MO$0 (Tier 2)flurbiprofen oral[*]$0 (Tier 4)gnp adult aspirin low strength tablet chewable

81 mg oral[*]$0 (Tier 4)gnp aspirin low dose tablet delayed release 81

mg oral[*]$0 (Tier 4)gnp aspirin tablet 325 mg oral[*]$0 (Tier 4)gnp aspirin tablet delayed release 325 mg oral[*]$0 (Tier 4)goodsense aspirin tablet 325 mg oral[*]$0 (Tier 4)goodsense aspirin tablet chewable 81 mg oral[*]$0 (Tier 4)hm aspirin ec low dose tablet delayed release

81 mg oral[*]$0 (Tier 4)hm aspirin ec tablet delayed release 325 mg

oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)hm aspirin tablet 325 mg oral[*]$0 (Tier 4)hm aspirin tablet chewable 81 mg oral[*]$0 (Tier 3)hydrocod polst-cpm polst er suspension

extended release 10-8 mg/5ml oralMO; NE; QLL (2700 per 30 days)$0 (Tier 2)hydrocodone-acetaminophen oral solution 7.5-

325 mg/15mlMO; NE; QLL (180 per 30 days)$0 (Tier 2)hydrocodone-acetaminophen oral tablet 10-325

mg, 5-325 mg, 7.5-325 mg[*]$0 (Tier 3)hydrocodone-homatropine syrup 5-1.5 mg/5ml

oral[*]$0 (Tier 3)HYDROCODONE-HOMATROPINE SYRUP

5-1.5 MG/5ML ORAL[*]$0 (Tier 3)hydrocodone-homatropine tablet 5-1.5 mg oralMO; NE; QLL (50 per 10 days)$0 (Tier 2)hydrocodone-ibuprofen oral tablet 5-200 mg,

7.5-200 mg[*]$0 (Tier 3)hydromet syrup 5-1.5 mg/5ml oralMO; NE; QLL (180 per 30 days)$0 (Tier 2)hydromorphone hcl oral tabletMO$0 (Tier 2)ibu oral tablet 600 mg, 800 mgMO$0 (Tier 2)ibuprofen oral suspensionMO$0 (Tier 2)ibuprofen oral tablet 400 mg, 600 mg, 800 mgPAR; LA; NE$0 (Tier 2)ILARIS SUBCUTANEOUS SOLUTIONPAR; MO$0 (Tier 2)indomethacin erPAR; MO$0 (Tier 2)indomethacin oralMO; NE; QLL (180 per 30 days)$0 (Tier 2)levorphanol tartrate oral tablet 2 mgMO; NE; QLL (180 per 30 days)$0 (Tier 2)lorcetMO; NE; QLL (180 per 30 days)$0 (Tier 2)lorcet hdMO; NE; QLL (180 per 30 days)$0 (Tier 2)lorcet plus oral tablet 7.5-325 mgMO$0 (Tier 2)meclofenamate sodium oralMO$0 (Tier 2)meloxicam oral tabletMO; NE; QLL (20 per 30 days)$0 (Tier 2)METHADONE HCL INJECTIONMO; NE; QLL (180 per 30 days)$0 (Tier 2)methadone hcl intensolMO; NE; QLL (180 per 30 days)$0 (Tier 2)methadone hcl oral concentrate



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; NE; QLL (900 per 30 days)$0 (Tier 2)methadone hcl oral solutionPAR; MO; NE; QLL (180 per 30 days)$0 (Tier 2)methadone hcl oral tabletMO; NE; QLL (180 per 30 days)$0 (Tier 2)morphine sulfate (concentrate) oral solution

100 mg/5mlMO; NE; QLL (180 per 30 days)$0 (Tier 2)morphine sulfate (concentrate) oral solution

100 mg/5ml, 20 mg/mlMO; NE; QLL (180 per 30 days)$0 (Tier 2)morphine sulfate (pf) injection solution 0.5 mg/

ml, 1 mg/mlMO; NE; QLL (180 per 30 days)$0 (Tier 2)MORPHINE SULFATE (PF) INJECTION

SOLUTION 10 MG/ML, 4 MG/ML, 8 MG/MLMO; NE; QLL (180 per 30 days)$0 (Tier 2)MORPHINE SULFATE (PF) INTRAVENOUS

SOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 8 MG/ML

PAR; MO; NE; QLL (60 per 30 days)$0 (Tier 2)morphine sulfate er oral tablet extended release 100 mg, 200 mg

PAR; MO; NE; QLL (90 per 30 days)$0 (Tier 2)morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg

MO; NE; QLL (180 per 30 days)$0 (Tier 2)morphine sulfate intravenous solution 1 mg/mlMO; NE; QLL (120 per 30 days)$0 (Tier 2)morphine sulfate intravenous solution 25 mg/

mlMO; NE; QLL (60 per 30 days)$0 (Tier 2)morphine sulfate intravenous solution 50 mg/

mlMO; NE; QLL (900 per 30 days)$0 (Tier 2)morphine sulfate oral solution 20 mg/5mlMO; NE; QLL (900 per 30 days)$0 (Tier 2)morphine sulfate oral solution 20 mg/5mlMO; NE; QLL (180 per 30 days)$0 (Tier 2)morphine sulfate oral tabletMO; NE; QLL (180 per 30 days)$0 (Tier 2)morphine sulfate oral tabletMO$0 (Tier 2)nabumetone oralMO; QLL (60 per 30 days)$0 (Tier 2)nalbuphine hcl injection solution 10 mg/mlMO; QLL (90 per 30 days)$0 (Tier 2)nalbuphine hcl injection solution 20 mg/mlMO$0 (Tier 2)naproxen drMO$0 (Tier 2)naproxen oral tabletMO$0 (Tier 2)naproxen sodium oral tablet 275 mg, 550 mgMO$0 (Tier 2)oxaprozin



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; NE; QLL (180 per 30 days)$0 (Tier 2)oxycodone hcl oral capsuleMO; NE; QLL (180 per 30 days)$0 (Tier 2)oxycodone hcl oral concentrate 10 mg/0.5mlMO; NE; QLL (180 per 30 days)$0 (Tier 2)oxycodone hcl oral concentrate 100 mg/5mlMO; NE; QLL (180 per 30 days)$0 (Tier 2)oxycodone hcl oral tabletMO; NE; QLL (180 per 30 days)$0 (Tier 2)oxycodone-acetaminophen oral tablet 10-325

mg, 2.5-325 mg, 5-325 mg, 7.5-325 mgMO; NE; QLL (180 per 30 days)$0 (Tier 2)oxycodone-aspirin oral tablet 4.8355-325 mgMO$0 (Tier 2)piroxicam oral[*]$0 (Tier 4)qc aspirin low dose tablet chewable 81 mg oral[*]$0 (Tier 4)qc aspirin tablet 325 mg oral[*]$0 (Tier 4)qc enteric aspirin tablet delayed release 325

mg oral[*]$0 (Tier 4)qc naproxen sodium tablet 220 mg oral[*]$0 (Tier 4)sb aspirin tablet 325 mg oral[*]$0 (Tier 4)sb ibuprofen tablet 200 mg oral[*]$0 (Tier 4)sm aspirin adult low strength tablet chewable

81 mg oral[*]$0 (Tier 4)sm aspirin adult low strength tablet delayed

release 81 mg oral[*]$0 (Tier 4)sm aspirin ec low strength tablet delayed

release 81 mg oral[*]$0 (Tier 4)sm aspirin ec tablet delayed release 325 mg

oral[*]$0 (Tier 4)sm aspirin low dose tablet chewable 81 mg oral[*]$0 (Tier 4)sm aspirin tablet 325 mg oral[*]$0 (Tier 4)sm childrens aspirin tablet chewable 81 mg

oral[*]$0 (Tier 4)sm urinary pain relief tablet 95 mg oralMO$0 (Tier 2)sulindac oralMO; NE; QLL (240 per 30 days)$0 (Tier 2)tramadol hcl oralMO; NE; QLL (40 per 5 days)$0 (Tier 2)tramadol-acetaminophen



Giá Thuốc

(Theo Bậc)

Tên Thuốc

ANESTHETICS

MO$0 (Tier 2)glydo external prefilled syringePAR; MO; QLL (150 per 30 days)$0 (Tier 2)lidocaine external ointmentPAR; MO; QLL (90 per 30 days)$0 (Tier 2)lidocaine external patch 5 %MO$0 (Tier 2)lidocaine hcl (pf) injection solution 2 %PAR; MO; QLL (300 per 30 days)$0 (Tier 2)lidocaine hcl external solutionPAR; MO; QLL (300 per 30 days)$0 (Tier 2)lidocaine hcl mouth/throatMO$0 (Tier 2)lidocaine hcl urethral/mucosalMO$0 (Tier 2)lidocaine viscous hclMO; QLL (30 per 30 days)$0 (Tier 2)lidocaine-prilocaine external cream

ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS

MO$0 (Tier 2)acamprosate calciumMO; QLL (240 per 30 days)$0 (Tier 2)buprenorphine hcl sublingual tablet sublingual

2 mgMO; QLL (60 per 30 days)$0 (Tier 2)buprenorphine hcl sublingual tablet sublingual

8 mgMO; QLL (360 per 30 days)$0 (Tier 1)buprenorphine hcl-naloxone hcl sublingual

tablet sublingual 2-0.5 mgMO; QLL (90 per 30 days)$0 (Tier 1)buprenorphine hcl-naloxone hcl sublingual

tablet sublingual 8-2 mgMO; QLL (60 per 30 days)$0 (Tier 2)bupropion hcl er (smoking det)PAR; MO; QLL (56 per 28 days)$0 (Tier 2)CHANTIX CONTINUING MONTH PAKPAR; MO; QLL (60 per 30 days)$0 (Tier 2)CHANTIX ORAL TABLET 0.5 MGPAR; MO; QLL (56 per 28 days)$0 (Tier 2)CHANTIX ORAL TABLET 1 MGPAR; MO; NE; QLL (106 per 365 days)

$0 (Tier 2)CHANTIX STARTING MONTH PAK

MO$0 (Tier 2)disulfiram oral[*]; QLL (20 per 1 day)$0 (Tier 4)gnp nicotine mini lozenge 2 mg mouth/throat[*]$0 (Tier 4)gnp nicotine polacrilex gum 2 mg mouth/throat[*]$0 (Tier 4)gnp nicotine polacrilex gum 4 mg mouth/throat



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]; QLL (20 per 1 day)$0 (Tier 4)gnp nicotine polacrilex lozenge 2 mg mouth/ throat

[*]; QLL (20 per 1 day)$0 (Tier 4)gnp nicotine polacrilex lozenge 4 mg mouth/ throat

[*]$0 (Tier 4)goodsense nicotine gum 4 mg mouth/throat[*]; QLL (20 per 1 day)$0 (Tier 4)goodsense nicotine lozenge 4 mg mouth/throat[*]; QLL (30 per 30 days)$0 (Tier 4)hm nicotine patch 24 hour 14 mg/24hr

transdermal[*]; QLL (30 per 30 days)$0 (Tier 4)hm nicotine patch 24 hour 21 mg/24hr

transdermal[*]; QLL (30 per 30 days)$0 (Tier 4)hm nicotine patch 24 hour 7 mg/24hr

transdermal[*]$0 (Tier 4)hm nicotine polacrilex gum 2 mg mouth/throat[*]$0 (Tier 4)hm nicotine polacrilex gum 4 mg mouth/throat[*]; QLL (20 per 1 day)$0 (Tier 4)hm nicotine polacrilex lozenge 2 mg mouth/

throat[*]; QLL (20 per 1 day)$0 (Tier 4)hm nicotine polacrilex lozenge 4 mg mouth/

throatMO$0 (Tier 1)naloxone hcl injection solution 0.4 mg/ml, 4 mg/

10mlMO$0 (Tier 1)naloxone hcl injection solution cartridgeMO$0 (Tier 1)naloxone hcl injection solution prefilled syringeMO$0 (Tier 2)naltrexone hcl oralMO$0 (Tier 2)naltrexone hcl oralMO$0 (Tier 2)NARCAN[*]$0 (Tier 4)nicorelief gum 2 mg mouth/throat[*]; QLL (20 per 1 day)$0 (Tier 4)NICORETTE LOZENGE 2 MG MOUTH/

THROAT[*]; QLL (20 per 1 day)$0 (Tier 4)NICORETTE LOZENGE 4 MG MOUTH/

THROAT[*]; QLL (20 per 1 day)$0 (Tier 4)NICORETTE MINI LOZENGE 2 MG MOUTH/

THROAT[*]; QLL (20 per 1 day)$0 (Tier 4)NICORETTE MINI LOZENGE 4 MG MOUTH/

THROAT



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]; QLL (30 per 30 days)$0 (Tier 4)nicotine kit 21-14-7 mg/24hr transdermal[*]; QLL (30 per 30 days)$0 (Tier 4)nicotine patch 24 hour 14 mg/24hr transdermal

(otc)[*]; QLL (30 per 30 days)$0 (Tier 4)nicotine patch 24 hour 21 mg/24hr transdermal

(otc)[*]; QLL (30 per 30 days)$0 (Tier 4)nicotine patch 24 hour 7 mg/24hr transdermal

(otc)[*]$0 (Tier 4)nicotine polacrilex gum 2 mg mouth/throat[*]$0 (Tier 4)nicotine polacrilex gum 4 mg mouth/throat[*]; QLL (20 per 1 day)$0 (Tier 4)nicotine polacrilex lozenge 2 mg mouth/throat[*]; QLL (20 per 1 day)$0 (Tier 4)nicotine polacrilex lozenge 4 mg mouth/throatMO; QLL (120 per 30 days)$0 (Tier 2)NICOTROL NS[*]$0 (Tier 4)sm nicotine gum 4 mg mouth/throat[*]; QLL (20 per 1 day)$0 (Tier 4)sm nicotine lozenge 2 mg mouth/throat[*]; QLL (30 per 30 days)$0 (Tier 4)sm nicotine patch 24 hour 14 mg/24hr

transdermal[*]; QLL (30 per 30 days)$0 (Tier 4)sm nicotine patch 24 hour 21 mg/24hr

transdermal[*]; QLL (30 per 30 days)$0 (Tier 4)sm nicotine patch 24 hour 7 mg/24hr

transdermal[*]$0 (Tier 4)sm nicotine polacrilex gum 2 mg mouth/throat[*]$0 (Tier 4)sm nicotine polacrilex gum 4 mg mouth/throat[*]; QLL (20 per 1 day)$0 (Tier 4)sm nicotine polacrilex lozenge 4 mg mouth/

throat

ANTI-INFLAMMATORY AGENTS

[*]$0 (Tier 4)all day pain relief tablet 220 mg oralMO$0 (Tier 2)betamethasone dipropionate aug external

creamMO$0 (Tier 2)betamethasone dipropionate aug external lotionMO$0 (Tier 2)betamethasone dipropionate aug external

ointmentMO$0 (Tier 2)betamethasone dipropionate external



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)betamethasone valerate external creamMO$0 (Tier 2)betamethasone valerate external lotionMO$0 (Tier 2)betamethasone valerate external ointmentMO$0 (Tier 2)BLEPHAMIDE S.O.P.PAR; MO$0 (Tier 2)celecoxib oralMO$0 (Tier 2)cortisone acetate oralMO$0 (Tier 2)decadron oral tabletMO$0 (Tier 2)dexamethasone oral elixirMO$0 (Tier 2)dexamethasone oral solutionMO$0 (Tier 2)dexamethasone oral tabletMO$0 (Tier 2)DEXAMETHASONE SOD PHOSPHATE PF

INJECTION SOLUTIONMO$0 (Tier 2)dexamethasone sodium phosphate injectionMO$0 (Tier 2)diclofenac potassiumMO$0 (Tier 2)diclofenac sodium erMO$0 (Tier 2)diclofenac sodium oralMO$0 (Tier 2)diflunisal oralMO$0 (Tier 2)etodolac oral capsule 200 mgMO$0 (Tier 2)etodolac oral tabletMO$0 (Tier 2)fenoprofen calcium oral tabletMO$0 (Tier 2)flurbiprofen oral[*]$0 (Tier 4)gnp all day pain relief tablet 220 mg oral[*]$0 (Tier 4)gnp ibuprofen capsule 200 mg oral[*]$0 (Tier 4)gnp ibuprofen tablet 200 mg oral[*]$0 (Tier 4)gnp naproxen sodium capsule 220 mg oral[*]$0 (Tier 4)goodsense ibuprofen tablet 200 mg oral[*]$0 (Tier 4)hm ibuprofen capsule 200 mg oral[*]$0 (Tier 4)hm ibuprofen ib tablet 200 mg oral[*]$0 (Tier 4)hm ibuprofen tablet 200 mg oral[*]$0 (Tier 4)hm naproxen sodium capsule 220 mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)hm naproxen sodium tablet 220 mg oralMO$0 (Tier 2)hydrocortisone oral tablet 20 mg, 5 mgMO$0 (Tier 2)ibu[*]$0 (Tier 4)ibu-200 tablet 200 mg oralMO$0 (Tier 2)ibuprofen oral suspensionMO$0 (Tier 2)ibuprofen oral tablet 400 mg, 600 mg, 800 mg[*]$0 (Tier 4)ibuprofen tablet 200 mg oralPAR; MO$0 (Tier 2)indomethacin erPAR; MO$0 (Tier 2)indomethacin oralMO$0 (Tier 2)meclofenamate sodium oralMO$0 (Tier 2)meloxicam oral tabletMO$0 (Tier 2)methylprednisolone acetate injection

suspension 40 mg/mlMO$0 (Tier 2)METHYLPREDNISOLONE ACETATE

INJECTION SUSPENSION 80 MG/MLMO$0 (Tier 2)methylprednisolone oral tabletMO$0 (Tier 2)methylprednisolone sodium succ injection

solution reconstituted 1000 mg, 125 mg, 40 mgMO$0 (Tier 2)nabumetone oralMO$0 (Tier 2)naproxen drMO$0 (Tier 2)naproxen oral tablet[*]$0 (Tier 4)naproxen sodium capsule 220 mg oralMO$0 (Tier 2)naproxen sodium oral tablet 275 mg, 550 mg[*]$0 (Tier 4)naproxen sodium tablet 220 mg oralMO$0 (Tier 2)oxaprozinMO$0 (Tier 2)piroxicam oralMO$0 (Tier 2)prednisolone acetate ophthalmicMO$0 (Tier 2)prednisolone oral solutionMO$0 (Tier 2)PREDNISOLONE SODIUM PHOSPHATE

OPHTHALMIC



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)prednisolone sodium phosphate oral solution 15 mg/5ml, 6.7 (5 base) mg/5ml

MO$0 (Tier 2)PREDNISONE INTENSOLMO$0 (Tier 2)prednisone oral[*]$0 (Tier 4)provil tablet 200 mg oral[*]$0 (Tier 4)qc ibuprofen ib tablet 200 mg oral[*]$0 (Tier 4)qc ibuprofen tablet 200 mg oral[*]$0 (Tier 4)sb naproxen sodium tablet 220 mg oral[*]$0 (Tier 4)sm ibuprofen ib tablet 200 mg oral[*]$0 (Tier 4)sm ibuprofen tablet 200 mg oral[*]$0 (Tier 4)sm naproxen sodium tablet 220 mg oralMO$0 (Tier 2)sulfacetamide-prednisolone ophthalmic solutionMO$0 (Tier 2)sulfazineMO$0 (Tier 2)sulindac oralMO$0 (Tier 2)triamcinolone acetonide injection suspension

40 mg/ml

ANTIBACTERIALS

MO$0 (Tier 2)acetic acid oticMO$0 (Tier 2)amikacin sulfate injection solution 1 gm/4ml,

500 mg/2mlMO$0 (Tier 2)amoxicillin oral capsuleMO$0 (Tier 2)amoxicillin oral suspension reconstitutedMO$0 (Tier 2)amoxicillin oral tabletMO$0 (Tier 2)amoxicillin oral tablet chewable 125 mg, 250

mgMO$0 (Tier 2)amoxicillin-pot clavulanate erMO$0 (Tier 2)amoxicillin-pot clavulanate oralMO$0 (Tier 2)ampicillin oral capsule 500 mgMO$0 (Tier 2)ampicillin sodium injection solution

reconstituted 1 gm, 125 mg, 2 gm, 250 mg, 500 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)ampicillin sodium intravenousMO$0 (Tier 2)ampicillin-sulbactam sodium injection solution

reconstituted 1.5 (1-0.5) gm, 3 (2-1) gmMO$0 (Tier 2)ampicillin-sulbactam sodium intravenousMO$0 (Tier 2)azithromycin intravenousMO$0 (Tier 2)azithromycin oral suspension reconstituted

$0 (Tier 2)azithromycin oral tablet 250 mg (6 pack)MO$0 (Tier 2)azithromycin oral tablet 250 mg, 500 mg, 600

mgMO$0 (Tier 2)aztreonam injection solution reconstituted 1 gmMO$0 (Tier 2)aztreonam injection solution reconstituted 2 gm[*]$0 (Tier 4)bacitracin ointment 500 unit/gm externalMO$0 (Tier 2)bacitracin ophthalmic[*]$0 (Tier 4)bacitracin zinc ointment 500 unit/gm external

(otc)MO$0 (Tier 2)BICILLIN C-RPAR; LA; NE$0 (Tier 2)CAYSTONMO$0 (Tier 2)cefaclorMO$0 (Tier 2)CEFACLOR ERMO$0 (Tier 2)cefadroxilMO$0 (Tier 2)cefazolin sodium injection solution reconstituted

1 gm, 10 gm, 500 mgMO$0 (Tier 2)CEFAZOLIN SODIUM INJECTION SOLUTION

RECONSTITUTED 100 GM, 300 GMMO$0 (Tier 2)cefazolin sodium intravenous solution

reconstitutedMO$0 (Tier 2)CEFAZOLIN SODIUM-DEXTROSE

INTRAVENOUS SOLUTION 1-4 GM/50ML-%MO$0 (Tier 2)CEFAZOLIN SODIUM-DEXTROSE

INTRAVENOUS SOLUTION RECONSTITUTED 1-4 GM-%(50ML)

MO$0 (Tier 2)cefdinirMO$0 (Tier 2)cefepime hcl injection



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)cefoxitin sodiumMO$0 (Tier 2)CEFOXITIN SODIUM-DEXTROSE

INTRAVENOUS SOLUTION RECONSTITUTED 1-4 GM-%(50ML), 2-2.2 GM-%(50ML)

MO$0 (Tier 2)cefpodoxime proxetilMO$0 (Tier 2)cefprozilMO$0 (Tier 2)ceftazidime injection solution reconstituted 1

gm, 2 gm, 6 gmMO$0 (Tier 2)ceftriaxone sodium in dextroseMO$0 (Tier 2)ceftriaxone sodium injection solution

reconstituted 1 gm, 2 gm, 250 mg, 500 mgMO$0 (Tier 2)CEFTRIAXONE SODIUM INJECTION

SOLUTION RECONSTITUTED 100 GMMO$0 (Tier 2)ceftriaxone sodium intravenousMO$0 (Tier 2)CEFTRIAXONE SODIUM-DEXTROSE

INTRAVENOUS SOLUTION RECONSTITUTED 1-3.74 GM-%(50ML), 2- 2.22 GM-%(50ML)

MO$0 (Tier 2)cefuroxime axetil oral tabletMO$0 (Tier 2)cefuroxime sodium injection solution

reconstituted 7.5 gm, 750 mgMO$0 (Tier 2)cefuroxime sodium intravenous solution

reconstituted 1.5 gmMO$0 (Tier 2)cephalexin oral capsule 250 mg, 500 mgMO$0 (Tier 2)cephalexin oral suspension reconstitutedMO$0 (Tier 2)chloramphenicol sod succinateMO$0 (Tier 2)ciprofloxacin hcl ophthalmicMO$0 (Tier 2)ciprofloxacin hcl oral tablet 250 mg, 500 mg,

750 mgMO$0 (Tier 2)ciprofloxacin in d5w intravenous solution 200

mg/100mlMO$0 (Tier 2)clarithromycin erMO$0 (Tier 2)clarithromycin oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)clindacin-pMO$0 (Tier 2)clindamycin hcl oralMO$0 (Tier 2)clindamycin phosphate externalMO$0 (Tier 2)clindamycin phosphate injection solution 300

mg/2ml, 600 mg/4ml, 9 gm/60ml, 9000 mg/60mlMO$0 (Tier 2)clindamycin phosphate vaginalMO$0 (Tier 2)colistimethate sodium (cba)MO$0 (Tier 2)colistimethate sodium (cba)MO; NE$0 (Tier 2)DAPTOMYCIN INTRAVENOUS SOLUTION

RECONSTITUTED 350 MGMO; NE$0 (Tier 2)daptomycin intravenous solution reconstituted

500 mgMO$0 (Tier 2)demeclocycline hcl oralMO$0 (Tier 2)dicloxacillin sodiumMO$0 (Tier 2)doxy 100

$0 (Tier 2)doxycycline hyclate intravenousMO$0 (Tier 2)doxycycline hyclate oral capsuleMO$0 (Tier 2)doxycycline hyclate oral tablet 100 mg, 20 mgMO$0 (Tier 2)doxycycline monohydrate oral capsule 100 mg,

50 mg, 75 mgMO$0 (Tier 2)doxycycline monohydrate oral tablet 100 mg,

50 mgMO$0 (Tier 2)e.e.s. 400 oral tabletMO$0 (Tier 2)ertapenem sodiumMO$0 (Tier 2)eryMO$0 (Tier 2)ery-tabMO$0 (Tier 2)ERYTHROCIN LACTOBIONATE

INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

MO$0 (Tier 2)erythrocin stearate oral tablet 250 mgMO$0 (Tier 2)erythromycin base oral tablet delayed releaseMO$0 (Tier 2)erythromycin ethylsuccinate oral tablet



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)erythromycin external gelMO$0 (Tier 2)erythromycin external solutionMO$0 (Tier 2)erythromycin ophthalmicMO$0 (Tier 2)erythromycin stearate oral tablet 250 mgMO$0 (Tier 2)gentak ophthalmic ointmentMO$0 (Tier 2)gentamicin sulfate externalMO$0 (Tier 2)gentamicin sulfate injectionMO$0 (Tier 2)gentamicin sulfate ophthalmic solutionMO$0 (Tier 1)GLOBAL ALCOHOL PREP EASE[*]$0 (Tier 4)hm triple antibiotic ointment 3.5-400-5000

externalMO$0 (Tier 2)imipenem-cilastatinMO$0 (Tier 2)levofloxacin in d5wMO$0 (Tier 2)levofloxacin intravenousMO$0 (Tier 2)levofloxacin oral tabletMO$0 (Tier 2)linezolid in sodium chlorideMO$0 (Tier 2)linezolid intravenous solution 600 mg/300mlPAR; MO; NE; QLL (1800 per 30 days)

$0 (Tier 2)linezolid oral suspension reconstituted

PAR; MO; NE; QLL (56 per 28 days)$0 (Tier 2)linezolid oral tabletMO$0 (Tier 2)meropenemMO$0 (Tier 2)methenamine hippurateMO$0 (Tier 2)metronidazole external creamMO$0 (Tier 2)metronidazole external gel 0.75 %MO$0 (Tier 2)metronidazole external lotionMO$0 (Tier 2)metronidazole in nacl intravenous solution 5-

0.79 mg/ml-%, 500-0.79 mg/100ml-%MO$0 (Tier 2)METRONIDAZOLE IN NACL INTRAVENOUS

SOLUTION 500-0.74 MG/100ML-%MO$0 (Tier 2)metronidazole oralMO$0 (Tier 2)metronidazole vaginal



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)minocycline hcl oralMO$0 (Tier 2)mondoxyne nl oral capsule 100 mg, 75 mgMO$0 (Tier 2)MONUROLMO$0 (Tier 2)morgidox oralMO$0 (Tier 2)moxifloxacin hcl ophthalmicMO$0 (Tier 2)moxifloxacin hcl oralMO$0 (Tier 2)mupirocin calciumMO$0 (Tier 2)mupirocin externalMO$0 (Tier 2)nafcillin sodium injection solution reconstituted

1 gm, 2 gmMO; NE$0 (Tier 2)NAFCILLIN SODIUM INJECTION SOLUTION

RECONSTITUTED 10 GMMO; NE$0 (Tier 2)nafcillin sodium intravenous solution

reconstituted 10 gmMO$0 (Tier 2)nafcillin sodium intravenous solution

reconstituted 2 gmMO$0 (Tier 2)neomycin sulfate oralMO$0 (Tier 2)nitrofurantoin macrocrystal oral capsule 100

mg, 50 mgMO$0 (Tier 2)nitrofurantoin monohyd macroMO$0 (Tier 2)ofloxacin ophthalmicMO$0 (Tier 2)ofloxacin oral tablet 400 mgMO$0 (Tier 2)ofloxacin oticMO$0 (Tier 2)okebo oral capsule 75 mgMO$0 (Tier 2)oxacillin sodiumMO$0 (Tier 2)paromomycin sulfate oralMO$0 (Tier 2)PENICILLIN G POT IN DEXTROSEMO$0 (Tier 2)penicillin g potassiumMO$0 (Tier 2)PENICILLIN G PROCAINEMO$0 (Tier 2)penicillin g sodiumMO$0 (Tier 2)penicillin v potassium



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)pfizerpenMO$0 (Tier 2)piperacillin sod-tazobactam so intravenous

solution reconstituted 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm

MO$0 (Tier 2)silver sulfadiazine external[*]$0 (Tier 4)sm double antibiotic ointment 500-10000 unit/

gm external[*]$0 (Tier 4)sm triple antibiotic ointment 3.5-400-5000

externalMO$0 (Tier 2)ssdMO; NE$0 (Tier 2)streptomycin sulfate intramuscularMO$0 (Tier 2)sulfacetamide sodium (acne)MO$0 (Tier 2)sulfacetamide sodium ophthalmic solutionMO$0 (Tier 2)SULFADIAZINE ORALMO$0 (Tier 2)sulfamethoxazole-trimethoprim intravenousMO$0 (Tier 2)sulfamethoxazole-trimethoprim oral suspension

200-40 mg/5mlMO$0 (Tier 2)sulfamethoxazole-trimethoprim oral tabletMO$0 (Tier 2)SULFAMYLON EXTERNAL CREAMMO; NE$0 (Tier 2)SYNERCIDMO$0 (Tier 2)tazicef injectionMO; NE$0 (Tier 2)TEFLAROMO$0 (Tier 2)tetracycline hcl oralMO; NE$0 (Tier 2)tigecyclineB/D PAR; NE; QLL (280 per 28 days)$0 (Tier 2)tobramycin inhalationMO$0 (Tier 2)tobramycin ophthalmicMO$0 (Tier 2)tobramycin sulfate injection solutionMO; NE$0 (Tier 2)tobramycin sulfate injection solution

reconstitutedMO$0 (Tier 2)trimethoprim oral[*]$0 (Tier 4)triple antibiotic ointment 3.5-400-5000 external[*]$0 (Tier 4)triple antibiotic ointment 5-400-5000 external



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS SOLUTION 1-5 GM/200ML- %, 500-5 MG/100ML-%, 750-5 MG/150ML-%

MO$0 (Tier 2)VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1-0.9 GM/200ML-%, 500-0.9 MG/ 100ML-%, 750-0.9 MG/150ML-%

MO$0 (Tier 2)vancomycin hcl intravenous solution reconstituted 1 gm, 10 gm, 5 gm, 500 mg

MO$0 (Tier 2)VANCOMYCIN HCL INTRAVENOUS SOLUTION RECONSTITUTED 1.25 GM, 1.5 GM, 250 MG

B/D PAR; MO$0 (Tier 2)vancomycin hcl intravenous solution reconstituted 750 mg

PAR; MO; NE; QLL (40 per 10 days)$0 (Tier 2)vancomycin hcl oral capsule 125 mgPAR; MO; NE; QLL (80 per 10 days)$0 (Tier 2)vancomycin hcl oral capsule 250 mgMO$0 (Tier 2)vandazole

ANTICONVULSANTS

ST; MO; NE$0 (Tier 2)APTIOMPAR; MO; NE; QLL (2400 per 30 days)

$0 (Tier 2)BANZEL ORAL SUSPENSION

PAR; MO; NE; QLL (480 per 30 days)$0 (Tier 2)BANZEL ORAL TABLET 200 MGPAR; MO; NE; QLL (240 per 30 days)$0 (Tier 2)BANZEL ORAL TABLET 400 MGPAR; MO$0 (Tier 2)BRIVIACT INTRAVENOUSPAR; MO; NE; QLL (600 per 30 days)$0 (Tier 2)BRIVIACT ORAL SOLUTIONPAR; MO; NE; QLL (600 per 30 days)$0 (Tier 2)BRIVIACT ORAL TABLET 10 MGPAR; MO; NE; QLL (60 per 30 days)$0 (Tier 2)BRIVIACT ORAL TABLET 100 MG, 75 MGPAR; MO; NE; QLL (240 per 30 days)$0 (Tier 2)BRIVIACT ORAL TABLET 25 MGPAR; MO; NE; QLL (120 per 30 days)$0 (Tier 2)BRIVIACT ORAL TABLET 50 MGMO$0 (Tier 2)carbamazepine er oral tablet extended release

12 hourMO$0 (Tier 2)carbamazepine oralMO$0 (Tier 2)CELONTINPAR; MO; NE; QLL (480 per 30 days)$0 (Tier 2)clobazam oral suspension



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; MO; QLL (120 per 30 days)$0 (Tier 2)clobazam oral tablet 10 mgPAR; MO; NE; QLL (60 per 30 days)$0 (Tier 2)clobazam oral tablet 20 mgMO; QLL (1200 per 30 days)$0 (Tier 2)clonazepam oral tablet 0.5 mgMO; QLL (600 per 30 days)$0 (Tier 2)clonazepam oral tablet 1 mgMO; QLL (300 per 30 days)$0 (Tier 2)clonazepam oral tablet 2 mgMO; QLL (4800 per 30 days)$0 (Tier 2)clonazepam oral tablet dispersible 0.125 mgMO; QLL (2400 per 30 days)$0 (Tier 2)clonazepam oral tablet dispersible 0.25 mgMO; QLL (1200 per 30 days)$0 (Tier 2)clonazepam oral tablet dispersible 0.5 mgMO; QLL (600 per 30 days)$0 (Tier 2)clonazepam oral tablet dispersible 1 mgMO; QLL (300 per 30 days)$0 (Tier 2)clonazepam oral tablet dispersible 2 mgMO$0 (Tier 2)clorazepate dipotassiumMO$0 (Tier 2)DIASTAT ACUDIAL RECTAL GEL 10 MGMO$0 (Tier 2)DIASTAT ACUDIAL RECTAL GEL 10 MGMO; NE$0 (Tier 2)DIASTAT ACUDIAL RECTAL GEL 20 MGMO; NE$0 (Tier 2)DIASTAT ACUDIAL RECTAL GEL 20 MGMO$0 (Tier 2)DIASTAT PEDIATRICMO$0 (Tier 2)DIASTAT PEDIATRICMO; QLL (240 per 30 days)$0 (Tier 2)diazepam oral concentrateMO; QLL (240 per 30 days)$0 (Tier 2)diazepam oral concentrateMO; QLL (1200 per 30 days)$0 (Tier 2)diazepam oral solution 5 mg/5mlMO; QLL (1200 per 30 days)$0 (Tier 2)diazepam oral solution 5 mg/5mlMO; QLL (120 per 30 days)$0 (Tier 2)diazepam oral tablet 10 mgMO; QLL (120 per 30 days)$0 (Tier 2)diazepam oral tablet 10 mgMO; QLL (600 per 30 days)$0 (Tier 2)diazepam oral tablet 2 mgMO; QLL (600 per 30 days)$0 (Tier 2)diazepam oral tablet 2 mgMO; QLL (240 per 30 days)$0 (Tier 2)diazepam oral tablet 5 mgMO; QLL (240 per 30 days)$0 (Tier 2)diazepam oral tablet 5 mgMO$0 (Tier 2)diazepam rectalMO$0 (Tier 2)DILANTIN INFATABSMO$0 (Tier 2)DILANTIN ORAL CAPSULE



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)divalproex sodium er oral tablet extended release 24 hour

MO$0 (Tier 2)divalproex sodium oral capsule delayed release sprinkle

MO$0 (Tier 2)divalproex sodium oral tablet delayed releasePAR; LA; NE$0 (Tier 2)EPIDIOLEXMO$0 (Tier 2)epitolMO$0 (Tier 2)ethosuximide oralMO$0 (Tier 2)felbamateMO$0 (Tier 2)fosphenytoin sodiumMO; QLL (720 per 30 days)$0 (Tier 2)FYCOMPA ORAL SUSPENSIONMO; NE; QLL (30 per 30 days)$0 (Tier 2)FYCOMPA ORAL TABLET 10 MG, 12 MGMO; QLL (180 per 30 days)$0 (Tier 2)FYCOMPA ORAL TABLET 2 MGMO; NE; QLL (90 per 30 days)$0 (Tier 2)FYCOMPA ORAL TABLET 4 MGMO; NE; QLL (60 per 30 days)$0 (Tier 2)FYCOMPA ORAL TABLET 6 MGMO; NE; QLL (45 per 30 days)$0 (Tier 2)FYCOMPA ORAL TABLET 8 MGMO; QLL (1080 per 30 days)$0 (Tier 1)gabapentin oral capsule 100 mgMO; QLL (360 per 30 days)$0 (Tier 1)gabapentin oral capsule 300 mgMO; QLL (270 per 30 days)$0 (Tier 1)gabapentin oral capsule 400 mgMO; QLL (2160 per 30 days)$0 (Tier 2)gabapentin oral solutionMO; QLL (180 per 30 days)$0 (Tier 1)gabapentin oral tablet 600 mgMO; QLL (120 per 30 days)$0 (Tier 1)gabapentin oral tablet 800 mgMO$0 (Tier 2)lamotrigine oral tabletMO$0 (Tier 2)lamotrigine oral tablet chewableMO; QLL (180 per 30 days)$0 (Tier 2)levetiracetam er oral tablet extended release

24 hour 500 mgMO; QLL (120 per 30 days)$0 (Tier 2)levetiracetam er oral tablet extended release

24 hour 750 mgMO$0 (Tier 2)LEVETIRACETAM IN NACL INTRAVENOUS

SOLUTION 1000 MG/100ML, 1500 MG/100MLMO; NE$0 (Tier 2)LEVETIRACETAM IN NACL INTRAVENOUS

SOLUTION 500 MG/100ML



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)levetiracetam intravenousMO$0 (Tier 2)levetiracetam oralMO; QLL (300 per 30 days)$0 (Tier 2)lorazepam oral concentrate 1 mg/0.5mlMO; QLL (150 per 30 days)$0 (Tier 2)lorazepam oral concentrate 2 mg/mlMO; QLL (90 per 30 days)$0 (Tier 2)lorazepam oral tablet 0.5 mg, 1 mgMO; QLL (150 per 30 days)$0 (Tier 2)lorazepam oral tablet 2 mg

$0 (Tier 2)NAYZILAMMO$0 (Tier 2)oxcarbazepineMO$0 (Tier 2)PEGANONEPAR; MO; QLL (3000 per 30 days)$0 (Tier 2)phenobarbital oral elixirPAR; MO; QLL (120 per 30 days)$0 (Tier 2)phenobarbital oral tablet 100 mgPAR; MO; QLL (800 per 30 days)$0 (Tier 2)phenobarbital oral tablet 15 mgPAR; MO; QLL (741 per 30 days)$0 (Tier 2)phenobarbital oral tablet 16.2 mgPAR; MO; QLL (400 per 30 days)$0 (Tier 2)phenobarbital oral tablet 30 mgPAR; MO; QLL (370 per 30 days)$0 (Tier 2)phenobarbital oral tablet 32.4 mgPAR; MO; QLL (200 per 30 days)$0 (Tier 2)phenobarbital oral tablet 60 mgPAR; MO; QLL (185 per 30 days)$0 (Tier 2)phenobarbital oral tablet 64.8 mgPAR; MO; QLL (123 per 30 days)$0 (Tier 2)phenobarbital oral tablet 97.2 mgMO$0 (Tier 2)PHENYTEKMO$0 (Tier 2)phenytoin oral suspension 125 mg/5mlMO$0 (Tier 2)phenytoin oral tablet chewableMO$0 (Tier 2)phenytoin sodium extendedMO$0 (Tier 2)phenytoin sodium injectionMO; QLL (180 per 30 days)$0 (Tier 2)pregabalin oral capsule 100 mgMO; QLL (120 per 30 days)$0 (Tier 2)pregabalin oral capsule 150 mgMO; QLL (90 per 30 days)$0 (Tier 2)pregabalin oral capsule 200 mgMO; QLL (60 per 30 days)$0 (Tier 2)pregabalin oral capsule 225 mg, 300 mgMO; QLL (720 per 30 days)$0 (Tier 2)pregabalin oral capsule 25 mgMO; QLL (360 per 30 days)$0 (Tier 2)pregabalin oral capsule 50 mgMO; QLL (240 per 30 days)$0 (Tier 2)pregabalin oral capsule 75 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (900 per 30 days)$0 (Tier 2)pregabalin oral solutionMO$0 (Tier 2)primidone oralMO$0 (Tier 2)roweepraMO; QLL (180 per 30 days)$0 (Tier 2)roweepra xr oral tablet extended release 24

hour 500 mgMO; QLL (120 per 30 days)$0 (Tier 2)roweepra xr oral tablet extended release 24

hour 750 mgPAR; LA; QLL (180 per 30 days)$0 (Tier 2)SABRIL ORAL PACKETPAR; MO; QLL (60 per 30 days)$0 (Tier 2)SPRITAM ORAL TABLET DISINTEGRATING

SOLUBLE 1000 MG, 250 MG, 500 MGPAR; MO; QLL (120 per 30 days)$0 (Tier 2)SPRITAM ORAL TABLET DISINTEGRATING

SOLUBLE 750 MGMO$0 (Tier 2)subvenitePAR; MO; NE; QLL (60 per 30 days)$0 (Tier 2)SYMPAZAN ORAL FILM 10 MG, 20 MGPAR; MO; QLL (30 per 30 days)$0 (Tier 2)SYMPAZAN ORAL FILM 5 MGMO$0 (Tier 2)tiagabine hclMO$0 (Tier 2)topiramate oral capsule sprinkleMO; QLL (480 per 30 days)$0 (Tier 2)topiramate oral tablet 100 mgMO; QLL (240 per 30 days)$0 (Tier 2)topiramate oral tablet 200 mgMO; QLL (1920 per 30 days)$0 (Tier 2)topiramate oral tablet 25 mgMO; QLL (960 per 30 days)$0 (Tier 2)topiramate oral tablet 50 mgMO$0 (Tier 2)valproate sodium intravenousMO$0 (Tier 2)valproic acid oral capsuleMO$0 (Tier 2)valproic acid oral solutionPAR; LA; NE; QLL (180 per 30 days)$0 (Tier 2)vigabatrinPAR; LA; NE; QLL (180 per 30 days)$0 (Tier 2)vigadroneMO; QLL (1200 per 30 days)$0 (Tier 2)VIMPAT INTRAVENOUSMO; NE; QLL (1200 per 30 days)$0 (Tier 2)VIMPAT ORAL SOLUTIONMO; NE; QLL (120 per 30 days)$0 (Tier 2)VIMPAT ORAL TABLET 100 MGMO; NE; QLL (60 per 30 days)$0 (Tier 2)VIMPAT ORAL TABLET 150 MG, 200 MGMO; QLL (240 per 30 days)$0 (Tier 2)VIMPAT ORAL TABLET 50 MG



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)zonisamide oral

ANTIDEMENTIA AGENTS

MO; QLL (30 per 30 days)$0 (Tier 2)donepezil hcl oral tablet 10 mg, 5 mgMO; QLL (30 per 30 days)$0 (Tier 2)donepezil hcl oral tablet dispersiblePAR; MO$0 (Tier 2)ergoloid mesylates oralPAR; MO; QLL (30 per 30 days)$0 (Tier 2)memantine hcl erPAR; QLL (300 per 30 days)$0 (Tier 2)memantine hcl oral solution 10 mg/5mlPAR; MO; QLL (300 per 30 days)$0 (Tier 2)memantine hcl oral solution 2 mg/mlPAR; MO; QLL (60 per 30 days)$0 (Tier 2)memantine hcl oral tablet 10 mgPAR; MO; QLL (90 per 30 days)$0 (Tier 2)memantine hcl oral tablet 5 mgPAR; MO$0 (Tier 2)NAMZARICMO; QLL (30 per 30 days)$0 (Tier 2)rivastigmineMO; QLL (60 per 30 days)$0 (Tier 2)rivastigmine tartrate

ANTIDEPRESSANTS

MO; NE; QLL (1 per 28 days)$0 (Tier 2)ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE

MO; NE; QLL (1 per 28 days)$0 (Tier 2)ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

PAR; MO$0 (Tier 2)amitriptyline hcl oralPAR; MO$0 (Tier 2)amoxapineMO; QLL (900 per 30 days)$0 (Tier 1)aripiprazole oral solutionMO; QLL (90 per 30 days)$0 (Tier 1)aripiprazole oral tablet 10 mgMO; QLL (60 per 30 days)$0 (Tier 1)aripiprazole oral tablet 15 mgMO; QLL (450 per 30 days)$0 (Tier 1)aripiprazole oral tablet 2 mgMO; NE; QLL (30 per 30 days)$0 (Tier 1)aripiprazole oral tablet 20 mg, 30 mgMO; QLL (180 per 30 days)$0 (Tier 1)aripiprazole oral tablet 5 mgMO; NE; QLL (90 per 30 days)$0 (Tier 1)aripiprazole oral tablet dispersible 10 mgMO; NE; QLL (60 per 30 days)$0 (Tier 1)aripiprazole oral tablet dispersible 15 mgMO; QLL (120 per 30 days)$0 (Tier 2)bupropion hcl er (sr) oral tablet extended

release 12 hour 100 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (60 per 30 days)$0 (Tier 2)bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg, 200 mg

MO; QLL (90 per 30 days)$0 (Tier 2)bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg

MO; QLL (30 per 30 days)$0 (Tier 2)bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg

MO; QLL (135 per 30 days)$0 (Tier 2)bupropion hcl oral tablet 100 mgMO; QLL (180 per 30 days)$0 (Tier 2)bupropion hcl oral tablet 75 mgMO; QLL (600 per 30 days)$0 (Tier 2)citalopram hydrobromide oral solutionMO; QLL (120 per 30 days)$0 (Tier 2)citalopram hydrobromide oral tablet 10 mgMO; QLL (60 per 30 days)$0 (Tier 2)citalopram hydrobromide oral tablet 20 mgMO; QLL (30 per 30 days)$0 (Tier 2)citalopram hydrobromide oral tablet 40 mgPAR; MO$0 (Tier 2)clomipramine hcl oralPAR; MO$0 (Tier 2)desipramine hcl oralMO; QLL (120 per 30 days)$0 (Tier 2)DESVENLAFAXINE ER ORAL TABLET

EXTENDED RELEASE 24 HOUR 100 MGMO; QLL (240 per 30 days)$0 (Tier 2)DESVENLAFAXINE ER ORAL TABLET

EXTENDED RELEASE 24 HOUR 50 MGMO; QLL (120 per 30 days)$0 (Tier 2)desvenlafaxine succinate er oral tablet

extended release 24 hour 100 mgMO; QLL (480 per 30 days)$0 (Tier 2)desvenlafaxine succinate er oral tablet

extended release 24 hour 25 mgMO; QLL (240 per 30 days)$0 (Tier 2)desvenlafaxine succinate er oral tablet

extended release 24 hour 50 mgPAR; MO$0 (Tier 2)doxepin hcl oral capsulePAR; MO$0 (Tier 2)doxepin hcl oral concentrateMO; QLL (180 per 30 days)$0 (Tier 2)duloxetine hcl oral capsule delayed release

particles 20 mgMO; QLL (120 per 30 days)$0 (Tier 2)duloxetine hcl oral capsule delayed release



particles 60 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; MO; NE; QLL (30 per 30 days)$0 (Tier 2)EMSAMMO; QLL (600 per 30 days)$0 (Tier 2)escitalopram oxalate oral solutionMO; QLL (60 per 30 days)$0 (Tier 2)escitalopram oxalate oral tablet 10 mgMO; QLL (30 per 30 days)$0 (Tier 2)escitalopram oxalate oral tablet 20 mgMO; QLL (120 per 30 days)$0 (Tier 2)escitalopram oxalate oral tablet 5 mgPAR; MO; QLL (30 per 30 days)$0 (Tier 2)FETZIMA ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 120 MG, 80 MGPAR; MO; QLL (180 per 30 days)$0 (Tier 2)FETZIMA ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 20 MGPAR; MO; QLL (90 per 30 days)$0 (Tier 2)FETZIMA ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 40 MGPAR; MO; NE; QLL (56 per 365 days)$0 (Tier 2)FETZIMA TITRATIONMO; QLL (240 per 30 days)$0 (Tier 2)fluoxetine hcl oral capsule 10 mgMO; QLL (120 per 30 days)$0 (Tier 2)fluoxetine hcl oral capsule 20 mgMO; QLL (60 per 30 days)$0 (Tier 2)fluoxetine hcl oral capsule 40 mgMO; QLL (600 per 30 days)$0 (Tier 2)fluoxetine hcl oral solutionMO; QLL (90 per 30 days)$0 (Tier 2)fluvoxamine maleate oral tablet 100 mgMO; QLL (360 per 30 days)$0 (Tier 2)fluvoxamine maleate oral tablet 25 mgMO; QLL (180 per 30 days)$0 (Tier 2)fluvoxamine maleate oral tablet 50 mgPAR; NE; QLL (30 per 30 days)$0 (Tier 2)GILENYA ORAL CAPSULE 0.25 MGPAR; MO$0 (Tier 2)imipramine hcl oralMO; QLL (120 per 30 days)$0 (Tier 2)KHEDEZLA ORAL TABLET EXTENDED

RELEASE 24 HOUR 100 MGMO; QLL (240 per 30 days)$0 (Tier 2)KHEDEZLA ORAL TABLET EXTENDED

RELEASE 24 HOUR 50 MGMO; QLL (270 per 30 days)$0 (Tier 2)maprotiline hcl oral tablet 25 mgMO; QLL (135 per 30 days)$0 (Tier 2)maprotiline hcl oral tablet 50 mgMO$0 (Tier 2)maprotiline hcl oral tablet 75 mgMO$0 (Tier 2)MARPLANMO; QLL (90 per 30 days)$0 (Tier 2)mirtazapine oral tablet 15 mgMO; QLL (45 per 30 days)$0 (Tier 2)mirtazapine oral tablet 30 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (30 per 30 days)$0 (Tier 2)mirtazapine oral tablet 45 mgMO; QLL (180 per 30 days)$0 (Tier 2)mirtazapine oral tablet 7.5 mgMO; QLL (90 per 30 days)$0 (Tier 2)mirtazapine oral tablet dispersible 15 mgMO; QLL (45 per 30 days)$0 (Tier 2)mirtazapine oral tablet dispersible 30 mgMO; QLL (30 per 30 days)$0 (Tier 2)mirtazapine oral tablet dispersible 45 mgMO; QLL (180 per 30 days)$0 (Tier 2)nefazodone hcl oral tablet 100 mgMO; QLL (120 per 30 days)$0 (Tier 2)nefazodone hcl oral tablet 150 mgMO; QLL (90 per 30 days)$0 (Tier 2)nefazodone hcl oral tablet 200 mgMO; QLL (72 per 30 days)$0 (Tier 2)nefazodone hcl oral tablet 250 mgMO; QLL (360 per 30 days)$0 (Tier 2)nefazodone hcl oral tablet 50 mgPAR; MO$0 (Tier 2)nortriptyline hcl oralMO; QLL (180 per 30 days)$0 (Tier 2)paroxetine hcl oral tablet 10 mgMO; QLL (90 per 30 days)$0 (Tier 2)paroxetine hcl oral tablet 20 mgMO; QLL (60 per 30 days)$0 (Tier 2)paroxetine hcl oral tablet 30 mgMO; QLL (45 per 30 days)$0 (Tier 2)paroxetine hcl oral tablet 40 mgMO; QLL (900 per 30 days)$0 (Tier 2)PAXIL ORAL SUSPENSIONMO$0 (Tier 2)phenelzine sulfate oralPAR; MO$0 (Tier 2)protriptyline hclPAR; MO; QLL (150 per 30 days)$0 (Tier 2)quetiapine fumarate er oral tablet extended

release 24 hour 150 mgPAR; MO; QLL (120 per 30 days)$0 (Tier 2)quetiapine fumarate er oral tablet extended




release 24 hour 50 mgMO; QLL (240 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 100 mgMO; QLL (120 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 200 mgMO; QLL (960 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 25 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (80 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 300 mgMO; QLL (60 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 400 mgMO; QLL (480 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 50 mgMO; QLL (300 per 30 days)$0 (Tier 2)sertraline hcl oral concentrateMO; QLL (60 per 30 days)$0 (Tier 2)sertraline hcl oral tablet 100 mgMO; QLL (240 per 30 days)$0 (Tier 2)sertraline hcl oral tablet 25 mgMO; QLL (120 per 30 days)$0 (Tier 2)sertraline hcl oral tablet 50 mgPAR; NE; QLL (4 per 30 days)$0 (Tier 2)SPRAVATO (56 MG DOSE)PAR; NE; QLL (4 per 30 days)$0 (Tier 2)SPRAVATO (84 MG DOSE)MO$0 (Tier 2)tranylcypromine sulfateMO$0 (Tier 2)trazodone hcl oralMO$0 (Tier 2)trimipramine maleate oralST; MO; QLL (60 per 30 days)$0 (Tier 2)TRINTELLIX ORAL TABLET 10 MGST; MO; QLL (30 per 30 days)$0 (Tier 2)TRINTELLIX ORAL TABLET 20 MGST; MO; QLL (120 per 30 days)$0 (Tier 2)TRINTELLIX ORAL TABLET 5 MGMO; QLL (60 per 30 days)$0 (Tier 2)venlafaxine hcl er oral capsule extended

release 24 hour 150 mgMO; QLL (180 per 30 days)$0 (Tier 2)venlafaxine hcl er oral capsule extended

release 24 hour 37.5 mgMO; QLL (90 per 30 days)$0 (Tier 2)venlafaxine hcl er oral capsule extended

release 24 hour 75 mgMO; QLL (60 per 30 days)$0 (Tier 2)venlafaxine hcl er oral tablet extended release

24 hour 150 mgMO; QLL (180 per 30 days)$0 (Tier 2)venlafaxine hcl er oral tablet extended release

24 hour 37.5 mgMO; QLL (90 per 30 days)$0 (Tier 2)venlafaxine hcl er oral tablet extended release

24 hour 75 mgMO; QLL (113 per 30 days)$0 (Tier 2)venlafaxine hcl oral tablet 100 mgMO; QLL (450 per 30 days)$0 (Tier 2)venlafaxine hcl oral tablet 25 mgMO; QLL (300 per 30 days)$0 (Tier 2)venlafaxine hcl oral tablet 37.5 mgMO; QLL (225 per 30 days)$0 (Tier 2)venlafaxine hcl oral tablet 50 mgMO; QLL (150 per 30 days)$0 (Tier 2)venlafaxine hcl oral tablet 75 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

ST; MO; QLL (120 per 30 days)$0 (Tier 2)VIIBRYD ORAL TABLET 10 MGST; MO; QLL (60 per 30 days)$0 (Tier 2)VIIBRYD ORAL TABLET 20 MGST; MO; QLL (30 per 30 days)$0 (Tier 2)VIIBRYD ORAL TABLET 40 MG

ANTIEMETICS

B/D PAR; MO; QLL (5 per 30 days)$0 (Tier 2)aprepitant oral capsule 125 mgB/D PAR; MO; QLL (1 per 28 days)$0 (Tier 2)aprepitant oral capsule 40 mgB/D PAR; MO; QLL (10 per 30 days)$0 (Tier 2)aprepitant oral capsule 80 mgMO$0 (Tier 2)chlorpromazine hcl oralMO$0 (Tier 2)comproB/D PAR; MO; NE; QLL (120 per 30 days)

$0 (Tier 2)dronabinol oral capsule 10 mg

B/D PAR; MO; QLL (120 per 30 days)$0 (Tier 2)dronabinol oral capsule 2.5 mg, 5 mg[*]$0 (Tier 4)gnp motion sickness relief tablet 25 mg oral[*]$0 (Tier 4)hm motion relief tablet 25 mg oralPAR; MO$0 (Tier 2)hydroxyzine hcl oral tabletPAR; MO$0 (Tier 2)hydroxyzine pamoate oral capsule 25 mg, 50

mgMO$0 (Tier 2)meclizine hcl oral tablet[*]$0 (Tier 4)meclizine hcl tablet chewable 25 mg oral (otc)MO$0 (Tier 2)metoclopramide hcl oral solution 5 mg/5mlMO$0 (Tier 2)metoclopramide hcl oral tablet[*]$0 (Tier 4)motion-time tablet chewable 25 mg oralB/D PAR; MO; QLL (90 per 30 days)$0 (Tier 2)ondansetronMO$0 (Tier 2)ondansetron hcl injectionB/D PAR; MO; QLL (30 per 30 days)$0 (Tier 2)ondansetron hcl oral tablet 24 mgB/D PAR; MO; QLL (90 per 30 days)$0 (Tier 2)ondansetron hcl oral tablet 4 mg, 8 mgMO$0 (Tier 1)perphenazine oralMO$0 (Tier 2)prochlorperazineMO$0 (Tier 2)prochlorperazine maleate oralPAR; MO$0 (Tier 2)promethazine hcl oral tablet



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (10 per 28 days)$0 (Tier 2)scopolamine[*]$0 (Tier 4)sm motion sickness tablet 25 mg oralMO; QLL (10 per 28 days)$0 (Tier 2)TRANSDERM SCOP (1.5 MG)[*]$0 (Tier 4)travel sickness tablet chewable 25 mg oral

ANTIFUNGALS

B/D PAR; MO; NE$0 (Tier 2)ABELCETB/D PAR; MO$0 (Tier 2)AMBISOMEB/D PAR; MO$0 (Tier 2)amphotericin b intravenous[*]$0 (Tier 4)antifungal cream 1 % external[*]$0 (Tier 4)athletes foot af cream 1 % external[*]$0 (Tier 4)athletes foot spray aerosol 1 % external[*]$0 (Tier 4)carrington antifungal cream 2 % externalMO$0 (Tier 2)ciclopiroxMO$0 (Tier 2)ciclopirox olamine external[*]$0 (Tier 4)clotrimazole cream 1 % external (otc)[*]$0 (Tier 4)clotrimazole cream 1 % vaginalMO$0 (Tier 2)clotrimazole external creamMO$0 (Tier 2)clotrimazole external solutionMO$0 (Tier 2)clotrimazole mouth/throat lozenge[*]$0 (Tier 4)clotrimazole solution 1 % external (otc)PAR; MO; NE$0 (Tier 2)ERAXIS INTRAVENOUS SOLUTION

RECONSTITUTED 100 MGMO$0 (Tier 2)fluconazole in sodium chloride intravenous

solution 200-0.9 mg/100ml-%, 400-0.9 mg/ 200ml-%

MO$0 (Tier 2)fluconazole oralMO$0 (Tier 2)flucytosine oral capsule 250 mgMO; NE$0 (Tier 2)flucytosine oral capsule 500 mg[*]$0 (Tier 4)fungoid-d cream 1 % external[*]$0 (Tier 4)gnp athletes foot cream 1 % external



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)gnp terbinafine hydrochloride cream 1 % external

[*]$0 (Tier 4)gnp tolnaftate cream 1 % externalMO$0 (Tier 2)griseofulvin microsize oral suspensionMO$0 (Tier 2)griseofulvin ultramicrosizePAR; MO$0 (Tier 2)itraconazole oral capsule[*]$0 (Tier 4)jock itch spray aerosol powder 1 % externalMO$0 (Tier 2)ketoconazole external creamMO$0 (Tier 2)ketoconazole external shampoo 2 %MO$0 (Tier 2)ketoconazole oral[*]$0 (Tier 4)lamisil at cream 1 % external[*]$0 (Tier 4)LOTRIMIN AF CREAM 1 % EXTERNALMO$0 (Tier 2)miconazole 3 vaginal suppositoryMO$0 (Tier 2)NATACYNPAR; MO; NE$0 (Tier 2)NOXAFIL ORAL SUSPENSIONMO$0 (Tier 2)nyamycMO$0 (Tier 2)nystatin externalMO$0 (Tier 2)nystatin mouth/throatMO$0 (Tier 2)nystatin oral tabletMO$0 (Tier 2)nystop[*]$0 (Tier 4)qc tolnaftate cream 1 % external[*]$0 (Tier 4)sm antifungal clotrimazole cream 1 % external[*]$0 (Tier 4)sm antifungal miconazole cream 2 % external[*]$0 (Tier 4)sm antifungal tolnaftate cream 1 % external[*]$0 (Tier 4)sm athletes foot cream 1 % external[*]$0 (Tier 4)sm miconazole 3 kit 200 & 2 mg-% (9gm)

vaginal[*]$0 (Tier 4)sm miconazole 7 suppository 100 mg vaginal[*]$0 (Tier 4)soothe & cool inzo antifungal cream 2 %

external[*]$0 (Tier 4)terbinafine hcl cream 1 % external



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)terbinafine hcl oralMO$0 (Tier 2)terconazole[*]$0 (Tier 4)tolnaftate cream 1 % externalMO; NE$0 (Tier 2)voriconazole intravenousPAR; MO; NE$0 (Tier 2)voriconazole oral suspension reconstitutedPAR; MO; NE$0 (Tier 2)voriconazole oral tablet 200 mgPAR; MO$0 (Tier 2)voriconazole oral tablet 50 mgPAR; NE; QLL (120 per 30 days)$0 (Tier 2)ZOLINZA

ANTIGOUT AGENTS

MO$0 (Tier 2)allopurinol oralMO$0 (Tier 1)colchicine oralMO$0 (Tier 2)colchicine-probenecidMO$0 (Tier 2)COLCRYSMO$0 (Tier 2)febuxostatMO$0 (Tier 2)probenecid oralST; MO$0 (Tier 2)ULORIC

ANTIMIGRAINE AGENTS

MO; NE; QLL (8 per 28 days)$0 (Tier 2)dihydroergotamine mesylate nasalMO$0 (Tier 2)divalproex sodium er oral tablet extended

release 24 hourMO$0 (Tier 2)divalproex sodium oral capsule delayed release

sprinkleMO$0 (Tier 2)divalproex sodium oral tablet delayed releaseMO$0 (Tier 2)ERGOMARMO$0 (Tier 2)ergotamine-caffeineMO; QLL (12 per 30 days)$0 (Tier 2)rizatriptan benzoateMO$0 (Tier 2)sumatriptan nasalMO; QLL (9 per 30 days)$0 (Tier 2)sumatriptan succinate oralMO$0 (Tier 2)sumatriptan succinate subcutaneous solution

auto-injector



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 1)timolol maleate oralMO$0 (Tier 2)topiramate oral capsule sprinkleMO; QLL (480 per 30 days)$0 (Tier 2)topiramate oral tablet 100 mgMO; QLL (240 per 30 days)$0 (Tier 2)topiramate oral tablet 200 mgMO; QLL (1920 per 30 days)$0 (Tier 2)topiramate oral tablet 25 mgMO; QLL (960 per 30 days)$0 (Tier 2)topiramate oral tablet 50 mgMO$0 (Tier 2)valproic acid oral capsuleMO$0 (Tier 2)valproic acid oral solutionMO; QLL (9 per 30 days)$0 (Tier 2)zolmitriptan oral

ANTIMYASTHENIC AGENTS

MO$0 (Tier 2)GUANIDINE HCL ORALMO; NE$0 (Tier 2)MESTINON ORAL SOLUTIONMO; NE$0 (Tier 2)pyridostigmine bromide oral solutionMO$0 (Tier 2)PYRIDOSTIGMINE BROMIDE ORAL TABLET

30 MGMO$0 (Tier 2)pyridostigmine bromide oral tablet 60 mg

ANTIMYCOBACTERIALS

MO$0 (Tier 2)CAPASTAT SULFATEMO$0 (Tier 2)dapsone oralMO$0 (Tier 2)ethambutol hcl oralMO$0 (Tier 2)isoniazid oralMO$0 (Tier 2)PASERMO$0 (Tier 2)PRIFTINMO$0 (Tier 2)pyrazinamide oralMO$0 (Tier 2)rifabutinMO$0 (Tier 2)rifampin intravenousMO$0 (Tier 2)rifampin oralMO$0 (Tier 2)RIFATERPAR; MO; LA; NE$0 (Tier 2)SIRTUROMO$0 (Tier 2)TRECATOR



Giá Thuốc

(Theo Bậc)

Tên Thuốc

ANTINEOPLASTICS

PAR; NE; QLL (120 per 30 days)$0 (Tier 2)abiraterone acetatePAR; NE$0 (Tier 2)ABRAXANEB/D PAR$0 (Tier 2)adriamycin intravenous solutionB/D PAR$0 (Tier 2)adriamycin intravenous solution reconstituted

10 mg, 50 mgB/D PAR$0 (Tier 2)adrucilPAR; NE$0 (Tier 2)AFINITORPAR; LA; NE; QLL (240 per 30 days)$0 (Tier 2)ALECENSAPAR; LA; NE$0 (Tier 2)ALIQOPAPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)ALUNBRIG ORAL TABLET 180 MGPAR; LA; NE; QLL (180 per 30 days)$0 (Tier 2)ALUNBRIG ORAL TABLET 30 MGPAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)ALUNBRIG ORAL TABLET 90 MGPAR; LA; NE; QLL (30 per 180 days)$0 (Tier 2)ALUNBRIG ORAL TABLET THERAPY PACKMO; QLL (30 per 30 days)$0 (Tier 2)anastrozole oralB/D PAR$0 (Tier 2)ARRANONB/D PAR; NE$0 (Tier 2)arsenic trioxide intravenousPAR; NE$0 (Tier 2)ARZERRAPAR; LA; NE$0 (Tier 2)AVASTINPAR; MO; QLL (45 per 30 days)$0 (Tier 2)avitaPAR; NE$0 (Tier 2)azacitidinePAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)BALVERSA ORAL TABLET 3 MGPAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)BALVERSA ORAL TABLET 4 MGPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)BALVERSA ORAL TABLET 5 MGPAR; LA; NE$0 (Tier 2)BAVENCIOPAR; NE$0 (Tier 2)BELEODAQB/D PAR; NE$0 (Tier 2)BENDEKAB/D PAR; LA; NE$0 (Tier 2)BESPONSAPAR; NE; QLL (300 per 30 days)$0 (Tier 2)bexaroteneMO; QLL (30 per 30 days)$0 (Tier 2)bicalutamide



Giá Thuốc

(Theo Bậc)

Tên Thuốc

B/D PAR$0 (Tier 2)bleomycin sulfatePAR; NE$0 (Tier 2)BLINCYTOPAR; NE$0 (Tier 2)BORTEZOMIBPAR; NE; QLL (120 per 30 days)$0 (Tier 2)BOSULIF ORAL TABLET 100 MGPAR; NE; QLL (30 per 30 days)$0 (Tier 2)BOSULIF ORAL TABLET 400 MG, 500 MGPAR; LA; NE; QLL (180 per 30 days)$0 (Tier 2)BRAFTOVI ORAL CAPSULE 75 MGB/D PAR$0 (Tier 2)busulfanB/D PAR$0 (Tier 2)BUSULFEXPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)CABOMETYXPAR; LA; NE$0 (Tier 2)CALQUENCEPAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)CAPRELSA ORAL TABLET 100 MGPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)CAPRELSA ORAL TABLET 300 MGB/D PAR$0 (Tier 2)carboplatin intravenous solutionB/D PAR; NE$0 (Tier 2)carmustineB/D PAR$0 (Tier 2)cisplatin intravenous solution 100 mg/100ml,

200 mg/200ml, 50 mg/50mlB/D PAR; NE$0 (Tier 2)cladribine intravenous solution 10 mg/10mlB/D PAR; NE$0 (Tier 2)clofarabineB/D PAR; NE$0 (Tier 2)CLOLARPAR; LA; NE; QLL (56 per 28 days)$0 (Tier 2)COMETRIQ (100 MG DAILY DOSE)PAR; LA; NE; QLL (112 per 28 days)$0 (Tier 2)COMETRIQ (140 MG DAILY DOSE)PAR; LA; NE; QLL (84 per 28 days)$0 (Tier 2)COMETRIQ (60 MG DAILY DOSE)PAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)COPIKTRAPAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)COTELLICB/D PAR$0 (Tier 2)cyclophosphamide oral capsulePAR; LA; NE$0 (Tier 2)CYRAMZAB/D PAR$0 (Tier 2)cytarabine (pf)B/D PAR$0 (Tier 2)cytarabine injection solutionB/D PAR$0 (Tier 2)dacarbazine intravenousB/D PAR; NE$0 (Tier 2)dactinomycin



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; LA; NE$0 (Tier 2)DARZALEXB/D PAR$0 (Tier 2)daunorubicin hcl intravenous solution 20 mg/

4mlB/D PAR$0 (Tier 2)DAUNORUBICIN HCL INTRAVENOUS

SOLUTION 50 MG/10MLPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)DAURISMO ORAL TABLET 100 MGPAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)DAURISMO ORAL TABLET 25 MGB/D PAR; NE$0 (Tier 2)decitabineB/D PAR; NE$0 (Tier 2)dexrazoxane hclB/D PAR; NE$0 (Tier 2)DOCETAXEL INTRAVENOUS

CONCENTRATE 160 MG/8ML, 20 MG/ML, 200 MG/10ML, 80 MG/4ML

B/D PAR; NE$0 (Tier 2)DOCETAXEL INTRAVENOUS SOLUTION 160 MG/16ML, 20 MG/2ML, 80 MG/8ML

B/D PAR; NE$0 (Tier 2)doxorubicin hcl intravenous solutionPAR; NE$0 (Tier 2)doxorubicin hcl liposomalMO$0 (Tier 2)DROXIAPAR; NE$0 (Tier 2)ELITEK

$0 (Tier 2)EMCYTPAR; LA; NE$0 (Tier 2)EMPLICITIB/D PAR$0 (Tier 2)epirubicin hcl intravenous solution 200 mg/

100ml, 50 mg/25mlPAR; NE$0 (Tier 2)ERBITUXPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)ERIVEDGEPAR; LA; NE$0 (Tier 2)ERLEADAPAR; NE; QLL (30 per 30 days)$0 (Tier 2)erlotinib hcl oral tablet 100 mg, 150 mgPAR; NE; QLL (90 per 30 days)$0 (Tier 2)erlotinib hcl oral tablet 25 mgPAR; LA; NE$0 (Tier 2)ERWINAZE INJECTIONB/D PAR; NE$0 (Tier 2)ETOPOPHOSB/D PAR$0 (Tier 2)etoposide intravenous solution 1 gm/50ml, 100

mg/5ml, 500 mg/25mlPAR; NE$0 (Tier 2)everolimus



Giá Thuốc

(Theo Bậc)

Tên Thuốc

B/D PAR; NE$0 (Tier 2)EVOMELAMO; QLL (60 per 30 days)$0 (Tier 2)exemestanePAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)FARYDAK ORAL CAPSULE 10 MGPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)FARYDAK ORAL CAPSULE 15 MG, 20 MGPAR; NE$0 (Tier 2)FASLODEX INTRAMUSCULAR SOLUTION

250 MG/5MLB/D PAR; NE$0 (Tier 2)fludarabine phosphate intravenous solutionB/D PAR$0 (Tier 2)fludarabine phosphate intravenous solution

reconstitutedB/D PAR$0 (Tier 2)fluorouracil intravenousMO$0 (Tier 2)flutamideB/D PAR; NE$0 (Tier 2)FOLOTYNPAR; NE$0 (Tier 2)fulvestrantPAR; LA; NE$0 (Tier 2)GAZYVAB/D PAR; NE$0 (Tier 2)GEMCITABINE HCL INTRAVENOUS

SOLUTION 1 GM/10ML, 2 GM/20MLB/D PAR; NE$0 (Tier 2)gemcitabine hcl intravenous solution 1 gm/

26.3ml, 2 gm/52.6ml, 200 mg/2ml, 200 mg/ 5.26ml

B/D PAR$0 (Tier 2)gemcitabine hcl intravenous solution reconstituted 1 gm, 200 mg

B/D PAR; NE$0 (Tier 2)gemcitabine hcl intravenous solution reconstituted 2 gm

PAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)GILOTRIFPAR; MO$0 (Tier 2)GLEOSTINE ORAL CAPSULE 10 MG, 100

MG, 40 MGPAR; NE$0 (Tier 2)HALAVENB/D PAR; NE$0 (Tier 2)HERCEPTIN HYLECTAB/D PAR; NE$0 (Tier 2)HERCEPTIN INTRAVENOUS SOLUTION

RECONSTITUTED 150 MGPAR; NE; QLL (25 per 147 days)$0 (Tier 2)hydroxyprogesterone caproate intramuscular

solutionMO$0 (Tier 2)hydroxyurea oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)IBRANCEPAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)ICLUSIG ORAL TABLET 15 MGPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)ICLUSIG ORAL TABLET 45 MGB/D PAR; NE$0 (Tier 2)idarubicin hclPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)IDHIFA ORAL TABLET 100 MGPAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)IDHIFA ORAL TABLET 50 MGB/D PAR$0 (Tier 2)IFEX INTRAVENOUS SOLUTION

RECONSTITUTED 3 GMB/D PAR$0 (Tier 2)ifosfamide intravenous solutionB/D PAR$0 (Tier 2)ifosfamide intravenous solution reconstituted

1 gmB/D PAR$0 (Tier 2)IFOSFAMIDE INTRAVENOUS SOLUTION

RECONSTITUTED 3 GMPAR; NE; QLL (240 per 30 days)$0 (Tier 2)imatinib mesylate oral tablet 100 mgPAR; NE; QLL (60 per 30 days)$0 (Tier 2)imatinib mesylate oral tablet 400 mgPAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)IMBRUVICA ORAL CAPSULE 140 MGPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)IMBRUVICA ORAL CAPSULE 70 MGPAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)IMBRUVICA ORAL TABLET 140 MGPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)IMBRUVICA ORAL TABLET 280 MG, 420 MG,

560 MGPAR; LA; NE$0 (Tier 2)IMFINZIPAR; LA; NE; QLL (240 per 30 days)$0 (Tier 2)INLYTA ORAL TABLET 1 MGPAR; LA; NE; QLL (120 per 30 days)$0 (Tier 2)INLYTA ORAL TABLET 5 MGPAR; LA; NE; QLL (120 per 30 days)$0 (Tier 2)INREBICLA; NE$0 (Tier 2)IRESSAB/D PAR$0 (Tier 2)irinotecan hcl intravenous solution 100 mg/5ml,

500 mg/25mlB/D PAR; NE$0 (Tier 2)irinotecan hcl intravenous solution 40 mg/2mlPAR; NE$0 (Tier 2)ISTODAX (OVERFILL)PAR; NE$0 (Tier 2)IXEMPRA KITPAR; LA; NE; QLL (150 per 30 days)$0 (Tier 2)JAKAFI ORAL TABLET 10 MG



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; LA; NE; QLL (100 per 30 days)$0 (Tier 2)JAKAFI ORAL TABLET 15 MGPAR; LA; NE; QLL (75 per 30 days)$0 (Tier 2)JAKAFI ORAL TABLET 20 MGPAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)JAKAFI ORAL TABLET 25 MGPAR; LA; NE; QLL (300 per 30 days)$0 (Tier 2)JAKAFI ORAL TABLET 5 MGPAR; NE$0 (Tier 2)JEVTANAPAR; NE$0 (Tier 2)KADCYLAMO$0 (Tier 2)KEPIVANCEPAR; NE$0 (Tier 2)KHAPZORYPAR; NE; QLL (21 per 21 days)$0 (Tier 2)KISQALI (200 MG DOSE)PAR; NE; QLL (42 per 21 days)$0 (Tier 2)KISQALI (400 MG DOSE)PAR; NE; QLL (63 per 21 days)$0 (Tier 2)KISQALI (600 MG DOSE)PAR; NE; QLL (70 per 28 days)$0 (Tier 2)KISQALI FEMARA (400 MG DOSE)PAR; NE; QLL (91 per 28 days)$0 (Tier 2)KISQALI FEMARA (600 MG DOSE)PAR; NE; QLL (49 per 28 days)$0 (Tier 2)KISQALI FEMARA(200 MG DOSE)PAR; LA; NE$0 (Tier 2)KYPROLISPAR; LA; NE$0 (Tier 2)LARTRUVOPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)LENVIMA (10 MG DAILY DOSE)PAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)LENVIMA (12 MG DAILY DOSE)PAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)LENVIMA (14 MG DAILY DOSE)PAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)LENVIMA (18 MG DAILY DOSE)PAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)LENVIMA (20 MG DAILY DOSE)PAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)LENVIMA (24 MG DAILY DOSE)PAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)LENVIMA (4 MG DAILY DOSE)PAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)LENVIMA (8 MG DAILY DOSE)MO; QLL (30 per 30 days)$0 (Tier 2)letrozole oralMO$0 (Tier 2)leucovorin calcium injection solution 100 mg/

10mlB/D PAR; MO$0 (Tier 2)leucovorin calcium injection solution

reconstitutedMO$0 (Tier 2)leucovorin calcium oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)leucovorin calcium oralMO$0 (Tier 2)LEUKERANPAR; NE$0 (Tier 2)levoleucovorin calcium intravenous solution

reconstituted 50 mgPAR; LA; NE$0 (Tier 2)LIBTAYOPAR; NE$0 (Tier 2)LONSURFPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)LORBRENA ORAL TABLET 100 MGPAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)LORBRENA ORAL TABLET 25 MGPAR; LA; NE$0 (Tier 2)LUMOXITIPAR; LA; NE; QLL (120 per 30 days)$0 (Tier 2)LYNPARZA ORAL TABLETNE$0 (Tier 2)MARQIBOLA; NE$0 (Tier 2)MATULANEPAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)MEKINIST ORAL TABLET 0.5 MGPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)MEKINIST ORAL TABLET 2 MGPAR; LA; NE; QLL (180 per 30 days)$0 (Tier 2)MEKTOVIB/D PAR$0 (Tier 2)melphalan hclMO$0 (Tier 2)mesnaMO; NE$0 (Tier 2)MESNEX ORALMO$0 (Tier 2)methotrexate sodium (pf) injection solution 1

gm/40ml, 250 mg/10mlMO$0 (Tier 2)methotrexate sodium injection solution 250 mg/

10mlMO$0 (Tier 2)methotrexate sodium injection solution

reconstitutedB/D PAR$0 (Tier 2)mitomycin intravenous solution reconstituted

20 mg, 5 mgB/D PAR; NE$0 (Tier 2)mitomycin intravenous solution reconstituted

40 mgB/D PAR$0 (Tier 2)mitoxantrone hclB/D PAR$0 (Tier 2)mutamycin intravenous solution reconstituted

20 mg, 5 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

B/D PAR; NE$0 (Tier 2)mutamycin intravenous solution reconstituted 40 mg

PAR; LA; NE$0 (Tier 2)MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 4.5 MG

PAR; LA; NE; QLL (180 per 30 days)$0 (Tier 2)NERLYNXPAR; LA; NE; QLL (120 per 30 days)$0 (Tier 2)NEXAVARMO; NE; QLL (30 per 30 days)$0 (Tier 2)nilutamidePAR; NE; QLL (3 per 28 days)$0 (Tier 2)NINLAROB/D PAR; NE$0 (Tier 2)NIPENTPAR; LA; NE; QLL (120 per 30 days)$0 (Tier 2)NUBEQAPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)ODOMZOPAR; NE; QLL (60 per 30 days)$0 (Tier 2)OFEVPAR; LA; NE$0 (Tier 2)OPDIVOB/D PAR$0 (Tier 2)oxaliplatin intravenous solutionB/D PAR; NE$0 (Tier 2)oxaliplatin intravenous solution reconstitutedB/D PAR$0 (Tier 2)paclitaxel intravenous concentrate 100 mg/

16.7ml, 150 mg/25ml, 30 mg/5ml$0 (Tier 2)paclitaxel intravenous concentrate 300 mg/50ml

NE$0 (Tier 2)PANRETINPAR; NE$0 (Tier 2)PERJETAPAR; NE; QLL (28 per 28 days)$0 (Tier 2)PIQRAY (200 MG DAILY DOSE)PAR; NE; QLL (56 per 28 days)$0 (Tier 2)PIQRAY (250 MG DAILY DOSE)PAR; NE; QLL (56 per 28 days)$0 (Tier 2)PIQRAY (300 MG DAILY DOSE)B/D PAR; NE$0 (Tier 2)POLIVYPAR; LA; NE; QLL (120 per 30 days)$0 (Tier 2)POMALYST ORAL CAPSULE 1 MGPAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)POMALYST ORAL CAPSULE 2 MGPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)POMALYST ORAL CAPSULE 3 MG, 4 MGLA; NE$0 (Tier 2)PORTRAZZAB/D PAR; LA; NE$0 (Tier 2)POTELIGEOB/D PAR; NE$0 (Tier 2)PROLEUKINPAR; NE$0 (Tier 2)PURIXAN



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)REVLIMID ORAL CAPSULE 10 MGPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)REVLIMID ORAL CAPSULE 15 MG, 25 MGPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)REVLIMID ORAL CAPSULE 2.5 MG, 20 MGPAR; LA; NE; QLL (150 per 30 days)$0 (Tier 2)REVLIMID ORAL CAPSULE 5 MGB/D PAR; MO; LA; NE$0 (Tier 2)RITUXAN HYCELAB/D PAR; LA; NE$0 (Tier 2)RITUXAN INTRAVENOUS SOLUTIONPAR; NE$0 (Tier 2)romidepsinPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)ROZLYTREK ORAL CAPSULE 100 MGPAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)ROZLYTREK ORAL CAPSULE 200 MGPAR; LA; NE; QLL (180 per 30 days)$0 (Tier 2)RUBRACA ORAL TABLET 200 MGPAR; LA; NE; QLL (120 per 30 days)$0 (Tier 2)RUBRACA ORAL TABLET 250 MG, 300 MGPAR; NE; QLL (240 per 30 days)$0 (Tier 2)RYDAPTMO; NE$0 (Tier 2)SOLTAMOXPAR; NE; QLL (30 per 30 days)$0 (Tier 2)SPRYCELPAR; LA; NE; QLL (120 per 30 days)$0 (Tier 2)STIVARGAPAR; NE; QLL (90 per 30 days)$0 (Tier 2)SUTENT ORAL CAPSULE 12.5 MGPAR; NE; QLL (30 per 30 days)$0 (Tier 2)SUTENT ORAL CAPSULE 25 MG, 37.5 MG,

50 MGPAR; NE$0 (Tier 2)SYLATRON SUBCUTANEOUS KIT 200 MCG,

300 MCG, 600 MCGPAR; NE$0 (Tier 2)SYNRIBOMO$0 (Tier 2)TABLOIDPAR; LA; NE; QLL (120 per 30 days)$0 (Tier 2)TAFINLARPAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)TAGRISSO ORAL TABLET 40 MGPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)TAGRISSO ORAL TABLET 80 MGPAR; LA; NE; QLL (180 per 30 days)$0 (Tier 2)TALZENNA ORAL CAPSULE 0.25 MGPAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)TALZENNA ORAL CAPSULE 1 MGMO$0 (Tier 2)tamoxifen citrate oralPAR; NE; QLL (60 per 30 days)$0 (Tier 2)TARGRETIN EXTERNALPAR; NE; QLL (112 per 28 days)$0 (Tier 2)TASIGNA



Giá Thuốc

(Theo Bậc)

Tên Thuốc

B/D PAR; NE$0 (Tier 2)TAXOTERE INTRAVENOUS CONCENTRATE 20 MG/ML, 80 MG/4ML

PAR; LA; NE; QLL (20 per 21 days)$0 (Tier 2)TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML

PAR; LA; NE; QLL (28 per 30 days)$0 (Tier 2)TECENTRIQ INTRAVENOUS SOLUTION 840 MG/14ML

PAR; NE$0 (Tier 2)temsirolimusPAR; NE; QLL (30 per 30 days)$0 (Tier 2)THALOMID ORAL CAPSULE 100 MG, 50 MGPAR; NE; QLL (60 per 30 days)$0 (Tier 2)THALOMID ORAL CAPSULE 150 MG, 200

MGB/D PAR$0 (Tier 2)thiotepa injectionPAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)TIBSOVOB/D PAR$0 (Tier 2)TICE BCGB/D PAR$0 (Tier 2)toposar intravenous solution 1 gm/50ml, 100

mg/5mlB/D PAR; NE$0 (Tier 2)TOPOTECAN HCL INTRAVENOUS

SOLUTIONB/D PAR; NE$0 (Tier 2)topotecan hcl intravenous solution reconstitutedNE; QLL (30 per 30 days)$0 (Tier 2)toremifene citrateB/D PAR; NE$0 (Tier 2)TREANDA INTRAVENOUS SOLUTION

RECONSTITUTEDPAR; MO; QLL (45 per 30 days)$0 (Tier 2)tretinoin external creamPAR; MO; QLL (45 per 30 days)$0 (Tier 2)tretinoin external gel 0.01 %, 0.025 %MO; NE$0 (Tier 2)tretinoin oralB/D PAR; NE$0 (Tier 2)TRISENOX INTRAVENOUS SOLUTION 12

MG/6MLPAR; LA; NE; QLL (120 per 30 days)$0 (Tier 2)TURALIOPAR; LA; NE; QLL (180 per 30 days)$0 (Tier 2)TYKERBPAR; LA; NE$0 (Tier 2)VALCHLORPAR; NE$0 (Tier 2)VECTIBIX INTRAVENOUS SOLUTION 100

MG/5ML, 400 MG/20MLPAR; NE$0 (Tier 2)VELCADE INJECTIONPAR; LA; QLL (60 per 30 days)$0 (Tier 2)VENCLEXTA ORAL TABLET 10 MG



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; LA; NE; QLL (180 per 30 days)$0 (Tier 2)VENCLEXTA ORAL TABLET 100 MGPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)VENCLEXTA ORAL TABLET 50 MGPAR; LA; NE; QLL (84 per 365 days)$0 (Tier 2)VENCLEXTA STARTING PACKPAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)VERZENIOB/D PAR$0 (Tier 2)vinblastine sulfate intravenous solutionB/D PAR$0 (Tier 2)vincristine sulfate intravenousB/D PAR$0 (Tier 2)vinorelbine tartratePAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)VITRAKVI ORAL CAPSULE 100 MGPAR; LA; NE; QLL (180 per 30 days)$0 (Tier 2)VITRAKVI ORAL CAPSULE 25 MGPAR; LA; NE; QLL (300 per 30 days)$0 (Tier 2)VITRAKVI ORAL SOLUTIONPAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)VIZIMPRO ORAL TABLET 15 MGPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)VIZIMPRO ORAL TABLET 30 MG, 45 MGPAR; LA; NE; QLL (120 per 30 days)$0 (Tier 2)VOTRIENTB/D PAR; NE$0 (Tier 2)VYXEOS INTRAVENOUS SUSPENSION

RECONSTITUTED 44-100 MGPAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)XALKORIPAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)XOSPATAPAR; LA; NE; QLL (20 per 28 days)$0 (Tier 2)XPOVIO (100 MG ONCE WEEKLY)PAR; LA; NE; QLL (12 per 28 days)$0 (Tier 2)XPOVIO (60 MG ONCE WEEKLY)PAR; LA; NE; QLL (16 per 28 days)$0 (Tier 2)XPOVIO (80 MG ONCE WEEKLY)PAR; LA; NE; QLL (32 per 28 days)$0 (Tier 2)XPOVIO (80 MG TWICE WEEKLY)PAR; LA; NE; QLL (120 per 30 days)$0 (Tier 2)XTANDIPAR; NE$0 (Tier 2)YERVOYB/D PAR; NE$0 (Tier 2)YONDELISPAR; NE; QLL (120 per 30 days)$0 (Tier 2)YONSAPAR; LA; NE$0 (Tier 2)ZALTRAPB/D PAR; NE$0 (Tier 2)ZANOSARPAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)ZEJULAPAR; LA; NE; QLL (240 per 30 days)$0 (Tier 2)ZELBORAFPAR; NE; QLL (120 per 30 days)$0 (Tier 2)ZOLINZA



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)ZYDELIGPAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)ZYKADIA ORAL TABLETPAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)ZYTIGA ORAL TABLET 500 MG

ANTIPARASITICS

MO$0 (Tier 2)albendazole oralMO; QLL (180 per 30 days)$0 (Tier 2)ALINIA ORAL SUSPENSION

RECONSTITUTEDMO; QLL (6 per 30 days)$0 (Tier 2)ALINIA ORAL TABLETPAR; MO; NE$0 (Tier 2)atovaquone oralMO$0 (Tier 2)atovaquone-proguanil hcl oral tablet 250-100

mgMO$0 (Tier 2)chloroquine phosphate oralMO; NE$0 (Tier 2)DARAPRIMMO$0 (Tier 2)hydroxychloroquine sulfate oralMO$0 (Tier 2)ivermectin oralMO$0 (Tier 2)lindane external shampooMO$0 (Tier 2)mefloquine hclB/D PAR; MO$0 (Tier 2)NEBUPENTMO$0 (Tier 2)PENTAMB/D PAR; MO$0 (Tier 2)pentamidine isethionate inhalationMO$0 (Tier 2)pentamidine isethionate injectionMO$0 (Tier 2)permethrin external creamMO$0 (Tier 2)praziquantel oralMO$0 (Tier 2)primaquine phosphate oral

ANTIPARKINSON AGENTS

MO$0 (Tier 2)amantadine hcl oralPAR; LA; NE$0 (Tier 2)APOKYN SUBCUTANEOUS SOLUTION

CARTRIDGEPAR; MO$0 (Tier 2)benztropine mesylate oralMO$0 (Tier 2)bromocriptine mesylate oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)carbidopa oralMO$0 (Tier 2)carbidopa oralMO$0 (Tier 2)carbidopa-levodopaMO$0 (Tier 2)carbidopa-levodopa er oral tablet extended

release 25-100 mg, 50-200 mgMO$0 (Tier 2)carbidopa-levodopa-entacaponeMO$0 (Tier 2)carbidopa-levodopa-entacaponeMO$0 (Tier 2)entacaponeMO; QLL (30 per 30 days)$0 (Tier 2)NEUPROMO$0 (Tier 2)pramipexole dihydrochlorideMO$0 (Tier 2)rasagiline mesylate oralMO$0 (Tier 2)ropinirole hclMO$0 (Tier 2)selegiline hcl oralPAR; MO; NE; QLL (180 per 30 days)$0 (Tier 2)tolcaponePAR; MO$0 (Tier 2)trihexyphenidyl hcl

ANTIPSYCHOTICS

MO; NE; QLL (1 per 28 days)$0 (Tier 2)ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE

MO; NE; QLL (1 per 28 days)$0 (Tier 2)ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

MO; QLL (900 per 30 days)$0 (Tier 1)aripiprazole oral solutionMO; QLL (90 per 30 days)$0 (Tier 1)aripiprazole oral tablet 10 mgMO; QLL (60 per 30 days)$0 (Tier 1)aripiprazole oral tablet 15 mgMO; QLL (450 per 30 days)$0 (Tier 1)aripiprazole oral tablet 2 mgMO; NE; QLL (30 per 30 days)$0 (Tier 1)aripiprazole oral tablet 20 mg, 30 mgMO; QLL (180 per 30 days)$0 (Tier 1)aripiprazole oral tablet 5 mgMO; NE; QLL (90 per 30 days)$0 (Tier 1)aripiprazole oral tablet dispersible 10 mgMO; NE; QLL (60 per 30 days)$0 (Tier 1)aripiprazole oral tablet dispersible 15 mgMO$0 (Tier 2)CHLORPROMAZINE HCL INJECTIONMO$0 (Tier 2)chlorpromazine hcl oralMO; QLL (270 per 30 days)$0 (Tier 1)clozapine oral tablet 100 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (120 per 30 days)$0 (Tier 1)clozapine oral tablet 200 mgMO; QLL (1080 per 30 days)$0 (Tier 1)clozapine oral tablet 25 mgMO; QLL (540 per 30 days)$0 (Tier 1)clozapine oral tablet 50 mgMO; QLL (270 per 30 days)$0 (Tier 1)clozapine oral tablet dispersible 100 mgMO; QLL (2160 per 30 days)$0 (Tier 1)clozapine oral tablet dispersible 12.5 mgMO; NE; QLL (180 per 30 days)$0 (Tier 1)clozapine oral tablet dispersible 150 mgMO; NE; QLL (120 per 30 days)$0 (Tier 1)clozapine oral tablet dispersible 200 mgMO; QLL (1080 per 30 days)$0 (Tier 1)clozapine oral tablet dispersible 25 mgST; MO; QLL (720 per 30 days)$0 (Tier 2)FANAPT ORAL TABLET 1 MGST; MO; NE; QLL (60 per 30 days)$0 (Tier 2)FANAPT ORAL TABLET 10 MG, 12 MGST; MO; QLL (360 per 30 days)$0 (Tier 2)FANAPT ORAL TABLET 2 MGST; MO; NE; QLL (180 per 30 days)$0 (Tier 2)FANAPT ORAL TABLET 4 MGST; MO; NE; QLL (120 per 30 days)$0 (Tier 2)FANAPT ORAL TABLET 6 MGST; MO; NE; QLL (90 per 30 days)$0 (Tier 2)FANAPT ORAL TABLET 8 MGST; MO; NE; QLL (16 per 365 days)$0 (Tier 2)FANAPT TITRATION PACKMO$0 (Tier 1)fluphenazine decanoate injectionMO$0 (Tier 1)fluphenazine hcl injectionMO$0 (Tier 1)fluphenazine hcl oralMO; QLL (6 per 28 days)$0 (Tier 2)GEODON INTRAMUSCULAR

$0 (Tier 1)haloperidol decanoate intramuscular solution 100 mg/ml 1 ml

MO$0 (Tier 1)haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml

MO$0 (Tier 1)haloperidol lactateMO$0 (Tier 1)haloperidol oralMO; NE; QLL (0.75 per 28 days)$0 (Tier 2)INVEGA SUSTENNA INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML

MO; NE; QLL (1 per 28 days)$0 (Tier 2)INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 156 MG/ML



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; NE; QLL (1.5 per 28 days)$0 (Tier 2)INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 234 MG/1.5ML

MO; QLL (0.25 per 28 days)$0 (Tier 2)INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 39 MG/ 0.25ML

MO; NE; QLL (0.5 per 28 days)$0 (Tier 2)INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 78 MG/ 0.5ML

MO; NE; QLL (0.875 per 90 days)$0 (Tier 2)INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML




PAR; MO; NE; QLL (30 per 30 days)$0 (Tier 2)LATUDA ORAL TABLET 120 MG, 60 MGPAR; MO; NE; QLL (240 per 30 days)$0 (Tier 2)LATUDA ORAL TABLET 20 MGPAR; MO; NE; QLL (120 per 30 days)$0 (Tier 2)LATUDA ORAL TABLET 40 MGPAR; MO; NE; QLL (60 per 30 days)$0 (Tier 2)LATUDA ORAL TABLET 80 MGMO$0 (Tier 2)loxapine succinate oralMO$0 (Tier 2)molindone hclPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)NUPLAZID ORAL CAPSULEPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)NUPLAZID ORAL TABLET 10 MGMO; QLL (60 per 30 days)$0 (Tier 1)olanzapine intramuscularMO; QLL (60 per 30 days)$0 (Tier 1)olanzapine oral tablet 10 mgMO; QLL (40 per 30 days)$0 (Tier 1)olanzapine oral tablet 15 mgMO; QLL (240 per 30 days)$0 (Tier 1)olanzapine oral tablet 2.5 mgMO; QLL (30 per 30 days)$0 (Tier 1)olanzapine oral tablet 20 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (120 per 30 days)$0 (Tier 1)olanzapine oral tablet 5 mgMO; QLL (80 per 30 days)$0 (Tier 1)olanzapine oral tablet 7.5 mgMO; QLL (60 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 10 mgMO; QLL (40 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 15 mgMO; QLL (30 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 20 mgMO; QLL (120 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 5 mgMO; QLL (240 per 30 days)$0 (Tier 1)paliperidone er oral tablet extended release 24

hour 1.5 mgMO; QLL (120 per 30 days)$0 (Tier 1)paliperidone er oral tablet extended release 24

hour 3 mgMO; NE; QLL (60 per 30 days)$0 (Tier 1)paliperidone er oral tablet extended release 24

hour 6 mgMO; NE; QLL (30 per 30 days)$0 (Tier 1)paliperidone er oral tablet extended release 24

hour 9 mgMO$0 (Tier 1)perphenazine oralMO$0 (Tier 2)pimozideMO$0 (Tier 2)prochlorperazine edisylate injection solution 10

mg/2ml, 50 mg/10mlMO$0 (Tier 2)prochlorperazine maleate oralPAR; MO; QLL (150 per 30 days)$0 (Tier 2)quetiapine fumarate er oral tablet extended





release 24 hour 50 mgMO; QLL (240 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 100 mgMO; QLL (120 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 200 mgMO; QLL (960 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 25 mgMO; QLL (80 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 300 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (60 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 400 mgMO; QLL (480 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 50 mgPAR; MO; NE; QLL (60 per 30 days)$0 (Tier 2)REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1

MG, 2 MGPAR; MO; NE; QLL (30 per 30 days)$0 (Tier 2)REXULTI ORAL TABLET 3 MG, 4 MGMO; QLL (2 per 28 days)$0 (Tier 2)RISPERDAL CONSTA INTRAMUSCULAR

SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG

MO; NE; QLL (2 per 28 days)$0 (Tier 2)RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 37.5 MG, 50 MG

MO; QLL (480 per 30 days)$0 (Tier 1)risperidone oral solutionMO; QLL (1920 per 30 days)$0 (Tier 1)risperidone oral tablet 0.25 mgMO; QLL (960 per 30 days)$0 (Tier 1)risperidone oral tablet 0.5 mgMO; QLL (480 per 30 days)$0 (Tier 1)risperidone oral tablet 1 mgMO; QLL (240 per 30 days)$0 (Tier 1)risperidone oral tablet 2 mgMO; QLL (150 per 30 days)$0 (Tier 1)risperidone oral tablet 3 mgMO; QLL (120 per 30 days)$0 (Tier 1)risperidone oral tablet 4 mgMO; QLL (1920 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 0.25 mgMO; QLL (960 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 0.5 mgMO; QLL (480 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 1 mgMO; QLL (240 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 2 mgMO; QLL (150 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 3 mgMO; QLL (120 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 4 mgMO; NE; QLL (60 per 30 days)$0 (Tier 2)SAPHRIS SUBLINGUAL TABLET

SUBLINGUAL 10 MGMO; QLL (240 per 30 days)$0 (Tier 2)SAPHRIS SUBLINGUAL TABLET

SUBLINGUAL 2.5 MGMO; QLL (120 per 30 days)$0 (Tier 2)SAPHRIS SUBLINGUAL TABLET

SUBLINGUAL 5 MGST; MO$0 (Tier 1)thioridazine hcl oralMO$0 (Tier 1)thiothixene oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 1)trifluoperazine hcl oralMO; QLL (600 per 30 days)$0 (Tier 2)VERSACLOZPAR; MO; NE; QLL (30 per 30 days)$0 (Tier 2)VRAYLAR ORAL CAPSULEPAR; MO; NE; QLL (14 per 365 days)$0 (Tier 2)VRAYLAR ORAL CAPSULE THERAPY PACKMO; QLL (240 per 30 days)$0 (Tier 1)ziprasidone hcl oral capsule 20 mgMO; QLL (120 per 30 days)$0 (Tier 1)ziprasidone hcl oral capsule 40 mgMO; QLL (60 per 30 days)$0 (Tier 1)ziprasidone hcl oral capsule 60 mg, 80 mgMO; QLL (2 per 28 days)$0 (Tier 2)ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION RECONSTITUTED 210 MGMO; NE; QLL (2 per 28 days)$0 (Tier 2)ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION RECONSTITUTED 300 MG, 405 MG

ANTISPASTICITY AGENTS

MO$0 (Tier 2)baclofen oralMO$0 (Tier 2)dantrolene sodium oralMO$0 (Tier 2)tizanidine hcl oral tablet

ANTIVIRALS

QLL (960 per 30 days)$0 (Tier 2)abacavir sulfate oral solutionQLL (60 per 30 days)$0 (Tier 2)abacavir sulfate oral tabletNE; QLL (30 per 30 days)$0 (Tier 2)abacavir sulfate-lamivudineNE; QLL (60 per 30 days)$0 (Tier 2)abacavir-lamivudine-zidovudineMO; QLL (30 per 30 days)$0 (Tier 2)acyclovir external ointmentMO$0 (Tier 2)acyclovir oralB/D PAR; MO$0 (Tier 2)acyclovir sodium intravenous solutionPAR$0 (Tier 2)adefovir dipivoxilMO$0 (Tier 2)amantadine hcl oralNE; QLL (120 per 30 days)$0 (Tier 2)APTIVUS ORAL CAPSULENE; QLL (380 per 30 days)$0 (Tier 2)APTIVUS ORAL SOLUTIONNE; QLL (60 per 30 days)$0 (Tier 2)atazanavir sulfate oral capsule 150 mg, 200

mgNE; QLL (30 per 30 days)$0 (Tier 2)atazanavir sulfate oral capsule 300 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

NE; QLL (30 per 30 days)$0 (Tier 2)ATRIPLAPAR; NE$0 (Tier 2)BARACLUDE ORAL SOLUTIONNE; QLL (30 per 30 days)$0 (Tier 2)BIKTARVYNE; QLL (30 per 30 days)$0 (Tier 2)CIMDUONE; QLL (30 per 30 days)$0 (Tier 2)COMPLERAQLL (360 per 30 days)$0 (Tier 2)CRIXIVAN ORAL CAPSULE 200 MGQLL (180 per 30 days)$0 (Tier 2)CRIXIVAN ORAL CAPSULE 400 MGNE; QLL (30 per 30 days)$0 (Tier 2)DELSTRIGOMO; NE; QLL (5 per 30 days)$0 (Tier 2)DENAVIRNE; QLL (30 per 30 days)$0 (Tier 2)DESCOVYQLL (60 per 30 days)$0 (Tier 2)didanosine oral capsule delayed release 200

mgQLL (30 per 30 days)$0 (Tier 2)didanosine oral capsule delayed release 250

mg, 400 mgNE; QLL (30 per 30 days)$0 (Tier 2)DOVATONE; QLL (30 per 30 days)$0 (Tier 2)EDURANTQLL (120 per 30 days)$0 (Tier 2)efavirenz oral capsule 200 mgQLL (360 per 30 days)$0 (Tier 2)efavirenz oral capsule 50 mgNE; QLL (30 per 30 days)$0 (Tier 2)efavirenz oral tabletQLL (30 per 30 days)$0 (Tier 2)EMTRIVA ORAL CAPSULEQLL (850 per 30 days)$0 (Tier 2)EMTRIVA ORAL SOLUTIONPAR; NE$0 (Tier 2)entecavirPAR; NE; QLL (30 per 30 days)$0 (Tier 2)EPCLUSAPAR; NE; QLL (30 per 30 days)$0 (Tier 2)EPCLUSA

$0 (Tier 2)EPIVIR HBV ORAL SOLUTIONNE; QLL (30 per 30 days)$0 (Tier 2)EVOTAZMO; QLL (60 per 30 days)$0 (Tier 2)famciclovir oral tablet 125 mg, 250 mgMO; QLL (21 per 7 days)$0 (Tier 2)famciclovir oral tablet 500 mgNE; QLL (120 per 30 days)$0 (Tier 2)fosamprenavir calciumNE; QLL (60 per 30 days)$0 (Tier 2)FUZEON SUBCUTANEOUS SOLUTION

RECONSTITUTED



Giá Thuốc

(Theo Bậc)

Tên Thuốc

B/D PAR$0 (Tier 2)ganciclovir sodium intravenous solution reconstituted

NE; QLL (30 per 30 days)$0 (Tier 2)GENVOYAPAR; NE; QLL (28 per 28 days)$0 (Tier 2)HARVONIPAR; NE; QLL (28 per 28 days)$0 (Tier 2)HARVONI ORAL TABLET 90-400 MGNE; QLL (120 per 30 days)$0 (Tier 2)INTELENCE ORAL TABLET 100 MGNE; QLL (60 per 30 days)$0 (Tier 2)INTELENCE ORAL TABLET 200 MGQLL (480 per 30 days)$0 (Tier 2)INTELENCE ORAL TABLET 25 MGB/D PAR; NE$0 (Tier 2)INTRON A INJECTION SOLUTIONB/D PAR; NE$0 (Tier 2)INTRON A INJECTION SOLUTION 6000000

UNIT/MLB/D PAR$0 (Tier 2)INTRON A INJECTION SOLUTION

RECONSTITUTED 10000000 UNITB/D PAR$0 (Tier 2)INTRON A INJECTION SOLUTION

RECONSTITUTED 10000000 UNIT, 18000000 UNIT

B/D PAR; NE$0 (Tier 2)INTRON A INJECTION SOLUTION RECONSTITUTED 50000000 UNIT

NE; QLL (120 per 30 days)$0 (Tier 2)INVIRASE ORAL TABLETNE; QLL (60 per 30 days)$0 (Tier 2)ISENTRESS HDNE; QLL (180 per 30 days)$0 (Tier 2)ISENTRESS ORAL PACKETNE; QLL (120 per 30 days)$0 (Tier 2)ISENTRESS ORAL TABLETNE; QLL (180 per 30 days)$0 (Tier 2)ISENTRESS ORAL TABLET CHEWABLE 100

MGQLL (720 per 30 days)$0 (Tier 2)ISENTRESS ORAL TABLET CHEWABLE 25

MGNE; QLL (30 per 30 days)$0 (Tier 2)JULUCAQLL (300 per 30 days)$0 (Tier 2)KALETRA ORAL TABLET 100-25 MGNE; QLL (120 per 30 days)$0 (Tier 2)KALETRA ORAL TABLET 200-50 MGQLL (960 per 30 days)$0 (Tier 2)lamivudine oral solutionQLL (960 per 30 days)$0 (Tier 2)lamivudine oral solution

$0 (Tier 2)lamivudine oral tablet 100 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

$0 (Tier 2)lamivudine oral tablet 100 mgQLL (60 per 30 days)$0 (Tier 2)lamivudine oral tablet 150 mgQLL (60 per 30 days)$0 (Tier 2)lamivudine oral tablet 150 mgQLL (30 per 30 days)$0 (Tier 2)lamivudine oral tablet 300 mgQLL (30 per 30 days)$0 (Tier 2)lamivudine oral tablet 300 mgQLL (60 per 30 days)$0 (Tier 2)lamivudine-zidovudinePAR; NE; QLL (28 per 28 days)$0 (Tier 2)LEDIPASVIR-SOFOSBUVIRQLL (1800 per 30 days)$0 (Tier 2)LEXIVA ORAL SUSPENSIONQLL (480 per 30 days)$0 (Tier 2)lopinavir-ritonavirQLL (90 per 30 days)$0 (Tier 2)nevirapine er oral tablet extended release 24

hour 100 mgQLL (30 per 30 days)$0 (Tier 2)nevirapine er oral tablet extended release 24

hour 400 mgQLL (1200 per 30 days)$0 (Tier 2)nevirapine oral suspensionQLL (60 per 30 days)$0 (Tier 2)nevirapine oral tabletQLL (360 per 30 days)$0 (Tier 2)NORVIR ORAL PACKETQLL (480 per 30 days)$0 (Tier 2)NORVIR ORAL SOLUTIONNE; QLL (30 per 30 days)$0 (Tier 2)ODEFSEYMO$0 (Tier 2)oseltamivir phosphate oralNE$0 (Tier 2)PEGASYS PROCLICK SUBCUTANEOUS

SOLUTION 180 MCG/0.5MLNE$0 (Tier 2)PEGASYS SUBCUTANEOUS SOLUTIONNE$0 (Tier 2)PEGINTRON SUBCUTANEOUS KIT 50 MCG/

0.5MLNE; QLL (30 per 30 days)$0 (Tier 2)PIFELTRONE; QLL (30 per 30 days)$0 (Tier 2)PREZCOBIXNE; QLL (400 per 30 days)$0 (Tier 2)PREZISTA ORAL SUSPENSIONQLL (180 per 30 days)$0 (Tier 2)PREZISTA ORAL TABLET 150 MGNE; QLL (60 per 30 days)$0 (Tier 2)PREZISTA ORAL TABLET 600 MG, 800 MGQLL (300 per 30 days)$0 (Tier 2)PREZISTA ORAL TABLET 75 MGMO; NE; QLL (60 per 180 days)$0 (Tier 2)RELENZA DISKHALER



Giá Thuốc

(Theo Bậc)

Tên Thuốc

QLL (180 per 30 days)$0 (Tier 2)RESCRIPTOR ORAL TABLET 200 MG$0 (Tier 2)RETROVIR INTRAVENOUS

QLL (240 per 30 days)$0 (Tier 2)REYATAZ ORAL PACKETMO$0 (Tier 2)ribavirin oral capsuleMO$0 (Tier 2)ribavirin oral capsuleNE$0 (Tier 2)ribavirin oral tablet 200 mgNE$0 (Tier 2)ribavirin oral tablet 200 mgMO$0 (Tier 2)rimantadine hclQLL (360 per 30 days)$0 (Tier 2)ritonavirNE; QLL (1840 per 30 days)$0 (Tier 2)SELZENTRY ORAL SOLUTIONNE; QLL (120 per 30 days)$0 (Tier 2)SELZENTRY ORAL TABLET 150 MG, 300 MGQLL (120 per 30 days)$0 (Tier 2)SELZENTRY ORAL TABLET 25 MGQLL (60 per 30 days)$0 (Tier 2)SELZENTRY ORAL TABLET 75 MGPAR; NE; QLL (30 per 30 days)$0 (Tier 2)SOFOSBUVIR-VELPATASVIRQLL (120 per 30 days)$0 (Tier 2)stavudine oral capsule 15 mg, 20 mgQLL (60 per 30 days)$0 (Tier 2)stavudine oral capsule 30 mg, 40 mgNE; QLL (30 per 30 days)$0 (Tier 2)STRIBILDPAR; NE$0 (Tier 2)SYLATRON SUBCUTANEOUS KIT 200 MCG,

300 MCG, 600 MCGNE; QLL (30 per 30 days)$0 (Tier 2)SYMFINE; QLL (30 per 30 days)$0 (Tier 2)SYMFI LONE; QLL (30 per 30 days)$0 (Tier 2)SYMTUZANE; QLL (30 per 30 days)$0 (Tier 2)TEMIXYSNE; QLL (30 per 30 days)$0 (Tier 2)tenofovir disoproxil fumarateNE; QLL (30 per 30 days)$0 (Tier 2)tenofovir disoproxil fumarateQLL (60 per 30 days)$0 (Tier 2)TIVICAY ORAL TABLET 10 MGNE; QLL (60 per 30 days)$0 (Tier 2)TIVICAY ORAL TABLET 25 MG, 50 MGMO$0 (Tier 2)trifluridine ophthalmicNE; QLL (30 per 30 days)$0 (Tier 2)TRIUMEQ



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; LA; NE; QLL (10.64 per 28 days)

$0 (Tier 2)TROGARZO

NE; QLL (30 per 30 days)$0 (Tier 2)TRUVADAQLL (30 per 30 days)$0 (Tier 2)TYBOSTMO; QLL (30 per 30 days)$0 (Tier 2)valacyclovir hcl oral tablet 1 gmMO; QLL (60 per 30 days)$0 (Tier 2)valacyclovir hcl oral tablet 500 mgNE$0 (Tier 2)valganciclovir hcl oral tabletPAR; NE; QLL (30 per 30 days)$0 (Tier 2)VEMLIDYQLL (90 per 30 days)$0 (Tier 2)VIDEX EC ORAL CAPSULE DELAYED

RELEASE 125 MGQLL (1200 per 30 days)$0 (Tier 2)VIDEX ORAL SOLUTION RECONSTITUTED

2 GMNE; QLL (300 per 30 days)$0 (Tier 2)VIRACEPT ORAL TABLET 250 MGNE; QLL (120 per 30 days)$0 (Tier 2)VIRACEPT ORAL TABLET 625 MGPAR; MO; NE$0 (Tier 2)VIRAZOLENE; QLL (240 per 30 days)$0 (Tier 2)VIREAD ORAL POWDERNE; QLL (240 per 30 days)$0 (Tier 2)VIREAD ORAL POWDERNE; QLL (30 per 30 days)$0 (Tier 2)VIREAD ORAL TABLET 150 MG, 200 MG, 250

MGNE; QLL (30 per 30 days)$0 (Tier 2)VIREAD ORAL TABLET 150 MG, 200 MG, 250

MGPAR; NE; QLL (30 per 30 days)$0 (Tier 2)VOSEVIMO$0 (Tier 2)XOFLUZAQLL (180 per 30 days)$0 (Tier 2)zidovudine oral capsuleQLL (1920 per 30 days)$0 (Tier 2)zidovudine oral syrupQLL (60 per 30 days)$0 (Tier 2)zidovudine oral tabletMO$0 (Tier 2)ZIRGAN

ANXIOLYTICS

MO; QLL (120 per 30 days)$0 (Tier 2)alprazolam oral tabletMO$0 (Tier 2)buspirone hcl oralMO; QLL (1200 per 30 days)$0 (Tier 2)clonazepam oral tablet 0.5 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (600 per 30 days)$0 (Tier 2)clonazepam oral tablet 1 mgMO; QLL (300 per 30 days)$0 (Tier 2)clonazepam oral tablet 2 mgMO; QLL (4800 per 30 days)$0 (Tier 2)clonazepam oral tablet dispersible 0.125 mgMO; QLL (2400 per 30 days)$0 (Tier 2)clonazepam oral tablet dispersible 0.25 mgMO; QLL (1200 per 30 days)$0 (Tier 2)clonazepam oral tablet dispersible 0.5 mgMO; QLL (600 per 30 days)$0 (Tier 2)clonazepam oral tablet dispersible 1 mgMO; QLL (300 per 30 days)$0 (Tier 2)clonazepam oral tablet dispersible 2 mgMO$0 (Tier 2)clorazepate dipotassiumMO$0 (Tier 2)DIASTAT ACUDIAL RECTAL GEL 10 MGMO; NE$0 (Tier 2)DIASTAT ACUDIAL RECTAL GEL 20 MGMO$0 (Tier 2)DIASTAT PEDIATRICMO; QLL (240 per 30 days)$0 (Tier 2)diazepam oral concentrateMO; QLL (1200 per 30 days)$0 (Tier 2)diazepam oral solution 5 mg/5mlMO; QLL (120 per 30 days)$0 (Tier 2)diazepam oral tablet 10 mgMO; QLL (600 per 30 days)$0 (Tier 2)diazepam oral tablet 2 mgMO; QLL (240 per 30 days)$0 (Tier 2)diazepam oral tablet 5 mgPAR; MO$0 (Tier 2)doxepin hcl oral capsulePAR; MO$0 (Tier 2)doxepin hcl oral concentrateMO; QLL (180 per 30 days)$0 (Tier 2)duloxetine hcl oral capsule delayed release




particles 60 mgMO; QLL (600 per 30 days)$0 (Tier 2)escitalopram oxalate oral solutionMO; QLL (60 per 30 days)$0 (Tier 2)escitalopram oxalate oral tablet 10 mgMO; QLL (30 per 30 days)$0 (Tier 2)escitalopram oxalate oral tablet 20 mgMO; QLL (120 per 30 days)$0 (Tier 2)escitalopram oxalate oral tablet 5 mgPAR; MO$0 (Tier 2)hydroxyzine hcl oral tablet



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; MO$0 (Tier 2)hydroxyzine pamoate oral capsule 25 mg, 50 mg

MO; QLL (150 per 30 days)$0 (Tier 2)lorazepam oral concentrate 2 mg/mlMO; QLL (90 per 30 days)$0 (Tier 2)lorazepam oral tablet 0.5 mg, 1 mgMO; QLL (150 per 30 days)$0 (Tier 2)lorazepam oral tablet 2 mg

$0 (Tier 2)NAYZILAMMO; QLL (180 per 30 days)$0 (Tier 2)paroxetine hcl oral tablet 10 mgMO; QLL (90 per 30 days)$0 (Tier 2)paroxetine hcl oral tablet 20 mgMO; QLL (60 per 30 days)$0 (Tier 2)paroxetine hcl oral tablet 30 mgMO; QLL (45 per 30 days)$0 (Tier 2)paroxetine hcl oral tablet 40 mgMO; QLL (900 per 30 days)$0 (Tier 2)PAXIL ORAL SUSPENSIONMO; QLL (300 per 30 days)$0 (Tier 2)sertraline hcl oral concentrateMO; QLL (60 per 30 days)$0 (Tier 2)sertraline hcl oral tablet 100 mgMO; QLL (240 per 30 days)$0 (Tier 2)sertraline hcl oral tablet 25 mgMO; QLL (120 per 30 days)$0 (Tier 2)sertraline hcl oral tablet 50 mgMO; QLL (60 per 30 days)$0 (Tier 2)venlafaxine hcl er oral capsule extended

release 24 hour 150 mgMO; QLL (180 per 30 days)$0 (Tier 2)venlafaxine hcl er oral capsule extended

release 24 hour 37.5 mgMO; QLL (90 per 30 days)$0 (Tier 2)venlafaxine hcl er oral capsule extended

release 24 hour 75 mgMO; QLL (60 per 30 days)$0 (Tier 2)venlafaxine hcl er oral tablet extended release

24 hour 150 mgMO; QLL (180 per 30 days)$0 (Tier 2)venlafaxine hcl er oral tablet extended release

24 hour 37.5 mgMO; QLL (90 per 30 days)$0 (Tier 2)venlafaxine hcl er oral tablet extended release

24 hour 75 mgMO; QLL (113 per 30 days)$0 (Tier 2)venlafaxine hcl oral tablet 100 mgMO; QLL (450 per 30 days)$0 (Tier 2)venlafaxine hcl oral tablet 25 mgMO; QLL (300 per 30 days)$0 (Tier 2)venlafaxine hcl oral tablet 37.5 mgMO; QLL (225 per 30 days)$0 (Tier 2)venlafaxine hcl oral tablet 50 mgMO; QLL (150 per 30 days)$0 (Tier 2)venlafaxine hcl oral tablet 75 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

BIPOLAR AGENTS

MO$0 (Tier 2)carbamazepine er oral capsule extended release 12 hour

MO$0 (Tier 2)carbamazepine er oral tablet extended release 12 hour 100 mg

MO$0 (Tier 2)carbamazepine oralMO$0 (Tier 2)divalproex sodium er oral tablet extended

release 24 hourMO$0 (Tier 2)divalproex sodium oral capsule delayed release

sprinkleMO$0 (Tier 2)divalproex sodium oral tablet delayed releaseMO$0 (Tier 2)epitolMO; QLL (6 per 28 days)$0 (Tier 2)GEODON INTRAMUSCULARMO$0 (Tier 2)lamotrigine oral tabletMO$0 (Tier 2)lamotrigine oral tablet chewableMO$0 (Tier 2)LITHIUMMO$0 (Tier 1)lithium carbonate erMO$0 (Tier 1)lithium carbonate oralMO; QLL (60 per 30 days)$0 (Tier 1)olanzapine intramuscularMO; QLL (60 per 30 days)$0 (Tier 1)olanzapine oral tablet 10 mgMO; QLL (40 per 30 days)$0 (Tier 1)olanzapine oral tablet 15 mgMO; QLL (240 per 30 days)$0 (Tier 1)olanzapine oral tablet 2.5 mgMO; QLL (30 per 30 days)$0 (Tier 1)olanzapine oral tablet 20 mgMO; QLL (120 per 30 days)$0 (Tier 1)olanzapine oral tablet 5 mgMO; QLL (80 per 30 days)$0 (Tier 1)olanzapine oral tablet 7.5 mgMO; QLL (60 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 10 mgMO; QLL (40 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 15 mgMO; QLL (30 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 20 mgMO; QLL (120 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 5 mgPAR; MO; QLL (150 per 30 days)$0 (Tier 2)quetiapine fumarate er oral tablet extended

release 24 hour 150 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; MO; QLL (120 per 30 days)$0 (Tier 2)quetiapine fumarate er oral tablet extended release 24 hour 200 mg




MO; QLL (240 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 100 mgMO; QLL (120 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 200 mgMO; QLL (960 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 25 mgMO; QLL (80 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 300 mgMO; QLL (60 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 400 mgMO; QLL (480 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 50 mgMO; QLL (2 per 28 days)$0 (Tier 2)RISPERDAL CONSTA INTRAMUSCULAR

SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG

MO; NE; QLL (2 per 28 days)$0 (Tier 2)RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 37.5 MG, 50 MG

MO; QLL (480 per 30 days)$0 (Tier 1)risperidone oral solutionMO; QLL (1920 per 30 days)$0 (Tier 1)risperidone oral tablet 0.25 mgMO; QLL (960 per 30 days)$0 (Tier 1)risperidone oral tablet 0.5 mgMO; QLL (480 per 30 days)$0 (Tier 1)risperidone oral tablet 1 mgMO; QLL (240 per 30 days)$0 (Tier 1)risperidone oral tablet 2 mgMO; QLL (150 per 30 days)$0 (Tier 1)risperidone oral tablet 3 mgMO; QLL (120 per 30 days)$0 (Tier 1)risperidone oral tablet 4 mgMO; QLL (1920 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 0.25 mgMO; QLL (960 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 0.5 mgMO; QLL (480 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 1 mgMO; QLL (240 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 2 mgMO; QLL (150 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 3 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (120 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 4 mgMO; NE; QLL (60 per 30 days)$0 (Tier 2)SAPHRIS SUBLINGUAL TABLET

SUBLINGUAL 10 MGMO; QLL (240 per 30 days)$0 (Tier 2)SAPHRIS SUBLINGUAL TABLET

SUBLINGUAL 2.5 MGMO; QLL (120 per 30 days)$0 (Tier 2)SAPHRIS SUBLINGUAL TABLET

SUBLINGUAL 5 MGMO$0 (Tier 2)valproic acid oral capsuleMO$0 (Tier 2)valproic acid oral solutionPAR; MO; NE; QLL (30 per 30 days)$0 (Tier 2)VRAYLAR ORAL CAPSULEPAR; MO; NE; QLL (14 per 365 days)$0 (Tier 2)VRAYLAR ORAL CAPSULE THERAPY PACKMO; QLL (240 per 30 days)$0 (Tier 1)ziprasidone hcl oral capsule 20 mgMO; QLL (120 per 30 days)$0 (Tier 1)ziprasidone hcl oral capsule 40 mgMO; QLL (60 per 30 days)$0 (Tier 1)ziprasidone hcl oral capsule 60 mg, 80 mgMO; QLL (2 per 28 days)$0 (Tier 2)ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION RECONSTITUTED 210 MG

BLOOD GLUCOSE REGULATORS

MO$0 (Tier 1)1ST TIER UNIFINE PENTIPS 29G X 12MMMO; QLL (90 per 30 days)$0 (Tier 1)acarbose oral tablet 100 mgMO; QLL (360 per 30 days)$0 (Tier 1)acarbose oral tablet 25 mgMO; QLL (180 per 30 days)$0 (Tier 1)acarbose oral tablet 50 mg[*]$0 (Tier 4)ACCU-CHEK AVIVA PLUS STRIP IN VITRO[*]$0 (Tier 4)ACCU-CHEK COMPACT PLUS STRIP IN

VITRO[*]$0 (Tier 4)ACCU-CHEK FASTCLIX LANCETS[*]$0 (Tier 4)ACCU-CHEK MULTICLIX LANCETS[*]$0 (Tier 4)ACCU-CHEK SMARTVIEW STRIP IN VITRO[*]$0 (Tier 4)ACCU-CHEK SOFT TOUCH LANCETS[*]$0 (Tier 4)ACCU-CHEK SOFTCLIX LANCETS[*]$0 (Tier 4)AGAMATRIX ULTRA-THIN LANCETS



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (200 per 30 days)$0 (Tier 1)ASSURE ID INSULIN SAFETY SYR 29G X 1/ 2" 1 ML

MO; QLL (4 per 28 days)$0 (Tier 2)BYDUREON BCISEMO; QLL (4 per 28 days)$0 (Tier 2)BYDUREON SUBCUTANEOUS PEN-

INJECTORMO; QLL (2.4 per 30 days)$0 (Tier 2)BYETTA 10 MCG PEN SUBCUTANEOUS

SOLUTION PEN-INJECTORMO; QLL (1.2 per 30 days)$0 (Tier 2)BYETTA 5 MCG PEN SUBCUTANEOUS

SOLUTION PEN-INJECTORMO$0 (Tier 1)CAREONE UNIFINE PENTIPS PLUS 29G X

12MMMO$0 (Tier 1)CLEVER CHOICE COMFORT EZ 29G X 12MMMO; QLL (200 per 30 days)$0 (Tier 1)COMFORT ASSIST INSULIN SYRINGE 29G

X 1/2" 1 MLMO; QLL (200 per 30 days)$0 (Tier 1)CVS GAUZE STERILE PAD 2"X2"[*]$0 (Tier 4)cvs glucose gel 40 % oral[*]$0 (Tier 4)cvs glucose tablet chewable 4 gm oral[*]$0 (Tier 4)cvs glucose tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)CVS LANCETS MICRO THIN 33G[*]$0 (Tier 4)CVS LANCETS THIN 26G[*]$0 (Tier 4)CVS LANCETS ULTRA THIN 30GST; MO; QLL (180 per 30 days)$0 (Tier 2)CYCLOSET[*]$0 (Tier 4)dex4 glucose tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)dex4 naturals tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)dex4 pouch pack tablet chewable 4-6 gm-mg

oral[*]$0 (Tier 4)dex4 quick dissolve glucose tablet chewable 4

gm oral[*]$0 (Tier 4)dex4 tablet chewable 4-6 gm-mg oralMO$0 (Tier 1)DROPLET PEN NEEDLES 30G X 8 MMMO$0 (Tier 1)EASY TOUCH PEN NEEDLES 29G X 12MMMO$0 (Tier 1)EASY TOUCH SAFETY PEN NEEDLES 30G

X 8 MM



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (200 per 30 days)$0 (Tier 1)EXEL COMFORT POINT PEN NEEDLE 29G X 12MM

MO; QLL (240 per 30 days)$0 (Tier 1)glimepiride oral tablet 1 mgMO; QLL (120 per 30 days)$0 (Tier 1)glimepiride oral tablet 2 mgMO; QLL (60 per 30 days)$0 (Tier 1)glimepiride oral tablet 4 mgMO; QLL (60 per 30 days)$0 (Tier 1)glipizide er oral tablet extended release 24 hour

10 mgMO; QLL (240 per 30 days)$0 (Tier 1)glipizide er oral tablet extended release 24 hour

2.5 mgMO; QLL (120 per 30 days)$0 (Tier 1)glipizide er oral tablet extended release 24 hour

5 mgMO; QLL (120 per 30 days)$0 (Tier 1)glipizide oral tablet 10 mgMO; QLL (240 per 30 days)$0 (Tier 1)glipizide oral tablet 5 mgMO; QLL (60 per 30 days)$0 (Tier 1)glipizide xl oral tablet extended release 24 hour

10 mgMO; QLL (240 per 30 days)$0 (Tier 1)glipizide xl oral tablet extended release 24 hour

2.5 mgMO; QLL (120 per 30 days)$0 (Tier 1)glipizide xl oral tablet extended release 24 hour

5 mgMO; QLL (240 per 30 days)$0 (Tier 1)glipizide-metformin hcl oral tablet 2.5-250 mgMO; QLL (120 per 30 days)$0 (Tier 1)glipizide-metformin hcl oral tablet 2.5-500 mg,

5-500 mg$0 (Tier 1)GLOBAL EASY GLIDE INSULIN SYR 31G X

15/64" 1 MLMO$0 (Tier 1)GLUCAGEN HYPOKITMO$0 (Tier 1)GLUCAGON EMERGENCY INJECTION KIT[*]$0 (Tier 4)gluco burst gel 40 % oral[*]$0 (Tier 4)glucose tablet chewable 4 gm oral[*]$0 (Tier 4)glucose tablet chewable 4-6 gm-mg oralPAR; MO; QLL (480 per 30 days)$0 (Tier 2)glyburide oral tablet 1.25 mgPAR; MO; QLL (240 per 30 days)$0 (Tier 2)glyburide oral tablet 2.5 mgPAR; MO; QLL (120 per 30 days)$0 (Tier 2)glyburide oral tablet 5 mg[*]$0 (Tier 4)gnp glucose tablet chewable 4 gm oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)gnp glucose tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)gnp quick dissolve glucose tablet chewable 4

gm oral[*]$0 (Tier 4)goodsense glucose tablet chewable 4-6 gm-

mg oralMO$0 (Tier 1)H-E-B INCONTROL PEN NEEDLES 29G X

12MM[*]$0 (Tier 4)hm glucose tablet chewable 4-6 gm-mg oralMO$0 (Tier 1)HUMALOG JUNIOR KWIKPENMO$0 (Tier 1)HUMALOG KWIKPEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR 200 UNIT/MLMO$0 (Tier 1)HUMALOG MIX 50/50MO$0 (Tier 1)HUMALOG MIX 50/50 KWIKPEN

SUBCUTANEOUS SUSPENSION PEN- INJECTOR

MO$0 (Tier 1)HUMALOG MIX 75/25MO$0 (Tier 1)HUMALOG MIX 75/25 KWIKPEN

SUBCUTANEOUS SUSPENSION PEN- INJECTOR

MO$0 (Tier 1)HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE

MO$0 (Tier 1)HUMULIN 70/30MO$0 (Tier 1)HUMULIN 70/30 KWIKPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTORMO$0 (Tier 1)HUMULIN NMO$0 (Tier 1)HUMULIN N KWIKPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTORMO$0 (Tier 1)HUMULIN RPAR; MO; NE$0 (Tier 1)HUMULIN R U-500 (CONCENTRATED)PAR; MO; NE$0 (Tier 1)HUMULIN R U-500 KWIKPEN

SUBCUTANEOUS SOLUTION PEN- INJECTOR

MO$0 (Tier 1)INSULIN LISPRO (1 UNIT DIAL)



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MO$0 (Tier 1)INSULIN LISPRO SUBCUTANEOUS SOLUTION

MO$0 (Tier 1)INSUPEN PEN NEEDLES 29G X 12MMMO$0 (Tier 1)INSUPEN ULTRAFIN 29G X 12MMMO; QLL (60 per 30 days)$0 (Tier 2)JANUMETMO; QLL (30 per 30 days)$0 (Tier 2)JANUMET XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 100-1000 MGMO; QLL (60 per 30 days)$0 (Tier 2)JANUMET XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 50-1000 MG, 50-500 MGMO; QLL (30 per 30 days)$0 (Tier 2)JANUVIA ORAL TABLET 100 MGMO; QLL (120 per 30 days)$0 (Tier 2)JANUVIA ORAL TABLET 25 MGMO; QLL (60 per 30 days)$0 (Tier 2)JANUVIA ORAL TABLET 50 MGMO; QLL (30 per 30 days)$0 (Tier 2)JARDIANCEMO; QLL (60 per 30 days)$0 (Tier 2)JENTADUETOMO; QLL (60 per 30 days)$0 (Tier 2)JENTADUETOMO; QLL (60 per 30 days)$0 (Tier 2)JENTADUETO XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 2.5-1000 MGMO; QLL (60 per 30 days)$0 (Tier 2)JENTADUETO XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 2.5-1000 MGMO; QLL (30 per 30 days)$0 (Tier 2)JENTADUETO XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 5-1000 MGMO; QLL (30 per 30 days)$0 (Tier 2)JENTADUETO XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 5-1000 MGPAR; LA; NE$0 (Tier 2)KORLYM[*]$0 (Tier 4)kroger glucose tablet chewable 4-6 gm-mg oralMO$0 (Tier 1)KROGER PEN NEEDLES 31G X 8 MM[*]$0 (Tier 4)LANCETS ULTRA THINMO$0 (Tier 1)LANTUSMO$0 (Tier 1)LANTUS SOLOSTAR SUBCUTANEOUS

SOLUTION PEN-INJECTOR[*]$0 (Tier 4)leader glucose tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)leader quick dissolve glucose tablet chewable

4 gm oral



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MO$0 (Tier 1)LEVEMIRMO$0 (Tier 1)LEVEMIR FLEXTOUCH[*]$0 (Tier 4)longs glucose tablet chewable 4-6 gm-mg oralMO$0 (Tier 1)MARATHON MEDICAL PENTIPS 29G X 12MM[*]$0 (Tier 4)meijer glucose tablet chewable 4-6 gm-mg oralMO; QLL (120 per 30 days)$0 (Tier 1)metformin hcl er oral tablet extended release

24 hour 500 mgMO; QLL (60 per 30 days)$0 (Tier 1)metformin hcl er oral tablet extended release

24 hour 750 mgMO; QLL (60 per 30 days)$0 (Tier 1)metformin hcl oral tablet 1000 mgMO; QLL (150 per 30 days)$0 (Tier 1)metformin hcl oral tablet 500 mgMO; QLL (90 per 30 days)$0 (Tier 1)metformin hcl oral tablet 850 mgMO; QLL (90 per 30 days)$0 (Tier 1)nateglinide oral tablet 120 mgMO; QLL (180 per 30 days)$0 (Tier 1)nateglinide oral tablet 60 mg[*]$0 (Tier 4)ONETOUCH DELICA LANCETS 30G[*]$0 (Tier 4)ONETOUCH DELICA LANCETS 33G[*]$0 (Tier 4)ONETOUCH ULTRA BLUE STRIP IN VITRO[*]$0 (Tier 4)ONETOUCH VERIO STRIP IN VITROMO$0 (Tier 2)OZEMPIC (0.25 OR 0.5 MG/DOSE)MO$0 (Tier 2)OZEMPIC (1 MG/DOSE)MO$0 (Tier 1)PC UNIFINE PENTIPS 29G X 12MMMO; QLL (90 per 30 days)$0 (Tier 1)pioglitazone hcl oral tablet 15 mgMO; QLL (45 per 30 days)$0 (Tier 1)pioglitazone hcl oral tablet 30 mgMO; QLL (30 per 30 days)$0 (Tier 1)pioglitazone hcl oral tablet 45 mg[*]$0 (Tier 4)preferred plus glucose tablet chewable 4-6 gm-

mg oralMO; QLL (200 per 30 days)$0 (Tier 1)PREFERRED PLUS INSULIN SYRINGE 28G

X 1/2" 0.5 ML[*]$0 (Tier 4)PRODIGY TWIST TOP LANCETS 28GMO; NE$0 (Tier 2)PROGLYCEM[*]$0 (Tier 4)px glucose tablet chewable 4-6 gm-mg oral



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[*]$0 (Tier 4)ra glucose tablet chewable 6-4 mg-gm oralMO; QLL (200 per 30 days)$0 (Tier 1)RELI-ON INSULIN SYRINGE 29G 0.3 ML[*]$0 (Tier 4)relion glucose gel 15 gm/38gm oral[*]$0 (Tier 4)relion glucose tablet chewable 4-6 gm-mg oralMO$0 (Tier 1)RELION PEN NEEDLES 29G X 12MMMO; QLL (960 per 30 days)$0 (Tier 1)repaglinide oral tablet 0.5 mgMO; QLL (480 per 30 days)$0 (Tier 1)repaglinide oral tablet 1 mgMO; QLL (240 per 30 days)$0 (Tier 1)repaglinide oral tablet 2 mg[*]$0 (Tier 4)sm glucose tablet chewable 4 gm oral[*]$0 (Tier 4)sm glucose tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)SMART SENSE COLOR LANCETS 33G[*]$0 (Tier 4)smart sense glucose tablet chewable 4-6 gm-

mg oral[*]$0 (Tier 4)SMART SENSE SUPER THIN LANCETS[*]$0 (Tier 4)SMART SENSE THIN LANCETS 26GPAR; MO; NE; QLL (11 per 30 days)$0 (Tier 2)SYMLINPEN 120 SUBCUTANEOUS

SOLUTION PEN-INJECTORPAR; MO; NE; QLL (6 per 30 days)$0 (Tier 2)SYMLINPEN 60 SUBCUTANEOUS SOLUTION

PEN-INJECTORMO; QLL (60 per 30 days)$0 (Tier 2)SYNJARDYMO; QLL (60 per 30 days)$0 (Tier 2)SYNJARDY XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 5-1000 MG

MO; QLL (30 per 30 days)$0 (Tier 2)SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 25-1000 MG

MO$0 (Tier 1)TECHLITE PEN NEEDLES 29G X 12MM[*]$0 (Tier 4)tgt glucose tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)TGT LANCET MICRO THIN 33G[*]$0 (Tier 4)TGT LANCET THIN 26G[*]$0 (Tier 4)TGT LANCET ULTRA THIN 30GMO$0 (Tier 2)TOUJEO MAX SOLOSTARMO$0 (Tier 2)TOUJEO SOLOSTAR



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Tên Thuốc

MO; QLL (30 per 30 days)$0 (Tier 2)TRADJENTAMO; QLL (2 per 28 days)$0 (Tier 2)TRULICITYMO$0 (Tier 1)UNIFINE PENTIPS 30G X 5 MM[*]$0 (Tier 4)UNILET COMFORTOUCH LANCET[*]$0 (Tier 4)UNILET GP 28 ULTRA THIN[*]$0 (Tier 4)UNILET MICRO-THIN 33G[*]$0 (Tier 4)UNILET SUPER-THIN 30G[*]$0 (Tier 4)UNILET ULTRA-THIN 28G[*]$0 (Tier 4)UNIVERSAL 1 LANCETS ULTRA THIN[*]$0 (Tier 4)up & up glucose tablet chewable 4-6 gm-mg

oralMO; QLL (9 per 30 days)$0 (Tier 2)VICTOZA SUBCUTANEOUS SOLUTION PEN-

INJECTOR[*]$0 (Tier 4)walgreens glucose tablet chewable 4 gm oral[*]$0 (Tier 4)walgreens glucose tablet chewable 4-6 gm-mg

oral

BLOOD PRODUCTS/ MODIFIERS/ VOLUME EXPANDERS

MO$0 (Tier 2)anagrelide hclST; MO; QLL (60 per 30 days)$0 (Tier 2)aspirin-dipyridamole erMO; QLL (60 per 30 days)$0 (Tier 2)BRILINTAMO$0 (Tier 2)cilostazolMO; QLL (1 per 30 days)$0 (Tier 1)clopidogrel bisulfate oral tablet 300 mgMO; QLL (30 per 30 days)$0 (Tier 1)clopidogrel bisulfate oral tablet 75 mgMO$0 (Tier 2)COUMADIN ORALMO; QLL (60 per 30 days)$0 (Tier 2)ELIQUISMO; NE; QLL (74 per 180 days)$0 (Tier 2)ELIQUIS STARTER PACKMO; QLL (168 per 28 days)$0 (Tier 2)enoxaparin sodium injectionMO; QLL (56 per 28 days)$0 (Tier 2)enoxaparin sodium subcutaneous solution 100

mg/ml, 150 mg/mlMO; QLL (44.8 per 28 days)$0 (Tier 2)enoxaparin sodium subcutaneous solution 120

mg/0.8ml, 80 mg/0.8ml



Giá Thuốc

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Tên Thuốc

MO; QLL (16.8 per 28 days)$0 (Tier 2)enoxaparin sodium subcutaneous solution 30 mg/0.3ml



MO; NE; QLL (24 per 30 days)$0 (Tier 2)fondaparinux sodium subcutaneous solution 10 mg/0.8ml

MO; QLL (15 per 30 days)$0 (Tier 2)fondaparinux sodium subcutaneous solution 2.5 mg/0.5ml

MO; NE; QLL (12 per 30 days)$0 (Tier 2)fondaparinux sodium subcutaneous solution 5 mg/0.4ml

MO; NE; QLL (18 per 30 days)$0 (Tier 2)fondaparinux sodium subcutaneous solution 7.5 mg/0.6ml

PAR; NE; QLL (1.2 per 28 days)$0 (Tier 2)FULPHILAB/D PAR; MO$0 (Tier 2)HEPARIN (PORCINE) IN NACL

INTRAVENOUS SOLUTION 12500-0.45 UT/ 250ML-%, 25000-0.45 UT/500ML-%

MO$0 (Tier 2)HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 25000-0.45 UT/ 250ML-%

MO$0 (Tier 2)HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS SOLUTION 100 UNIT/ML, 25000-5 UT/500ML-%

MO$0 (Tier 2)heparin sod (porcine) in d5w intravenous solution 40-5 unit/ml-%

B/D PAR; MO$0 (Tier 2)heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml

MO$0 (Tier 1)jantovenPAR; NE; QLL (1.2 per 28 days)$0 (Tier 2)NEULASTA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGEMO; QLL (60 per 30 days)$0 (Tier 2)PRADAXAMO; QLL (30 per 30 days)$0 (Tier 2)prasugrel hcl



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Tên Thuốc

PAR$0 (Tier 2)PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

PAR; NE$0 (Tier 2)PROCRIT INJECTION SOLUTION 20000 UNIT/ML, 40000 UNIT/ML

PAR; LA; NE; QLL (360 per 30 days)$0 (Tier 2)PROMACTA ORAL PACKETPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)PROMACTA ORAL TABLET 12.5 MG, 25 MG,

75 MGPAR; LA; NE; QLL (90 per 30 days)$0 (Tier 2)PROMACTA ORAL TABLET 50 MG

$0 (Tier 2)tranexamic acid intravenous solution 1000 mg/ 10ml

MO$0 (Tier 2)tranexamic acid oralMO$0 (Tier 1)warfarin sodium oralMO; QLL (30 per 30 days)$0 (Tier 2)XARELTO ORAL TABLET 10 MG, 20 MGMO; QLL (42 per 30 days)$0 (Tier 2)XARELTO ORAL TABLET 15 MGMO; QLL (60 per 30 days)$0 (Tier 2)XARELTO ORAL TABLET 2.5 MGMO; NE$0 (Tier 2)XARELTO STARTER PACKPAR; NE$0 (Tier 2)ZARXIO

CARDIOVASCULAR AGENTS

MO$0 (Tier 1)acebutolol hcl oralMO$0 (Tier 2)acetazolamide erMO$0 (Tier 2)acetazolamide oralMO$0 (Tier 2)acetazolamide sodiumMO$0 (Tier 1)afeditab cr oral tablet extended release 24 hour

30 mg$0 (Tier 1)afeditab cr oral tablet extended release 24 hour

60 mgMO$0 (Tier 2)aliskiren fumarateMO$0 (Tier 2)aliskiren fumarateMO$0 (Tier 2)amiloride hcl oralMO$0 (Tier 2)amiloride-hydrochlorothiazideB/D PAR; MO$0 (Tier 2)amiodarone hcl intravenous



Giá Thuốc

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Tên Thuốc

MO$0 (Tier 2)amiodarone hcl oralMO$0 (Tier 1)amlodipine besy-benazepril hclMO$0 (Tier 1)amlodipine besylate oralMO$0 (Tier 2)amlodipine besylate-valsartanMO$0 (Tier 2)amlodipine-olmesartanMO$0 (Tier 2)amlodipine-valsartan-hctzMO$0 (Tier 1)atenolol oralMO$0 (Tier 1)atenolol-chlorthalidoneMO$0 (Tier 1)atorvastatin calcium oralMO$0 (Tier 1)benazepril hcl oralMO$0 (Tier 1)benazepril-hydrochlorothiazideMO$0 (Tier 1)betaxolol hcl oralMO$0 (Tier 1)bisoprolol fumarateMO$0 (Tier 1)bisoprolol-hydrochlorothiazideMO$0 (Tier 2)bumetanide injectionMO$0 (Tier 2)bumetanide oralMO$0 (Tier 1)candesartan cilexetilMO$0 (Tier 1)candesartan cilexetil-hctzMO$0 (Tier 1)cartia xtMO$0 (Tier 1)carvedilolMO$0 (Tier 2)chlorothiazide oralMO$0 (Tier 2)chlorthalidone oral tablet 25 mg, 50 mgMO$0 (Tier 2)cholestyramine lightMO$0 (Tier 2)cholestyramine oralMO; QLL (4 per 28 days)$0 (Tier 2)clonidineMO$0 (Tier 2)clonidine hcl oralMO$0 (Tier 2)colestipol hclPAR; MO; QLL (560 per 28 days)$0 (Tier 2)CORLANOR ORAL SOLUTIONPAR; MO; QLL (60 per 30 days)$0 (Tier 2)CORLANOR ORAL TABLETMO; NE$0 (Tier 2)DEMSER



Giá Thuốc

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Tên Thuốc

MO$0 (Tier 2)digitek oral tablet 125 mcgPAR; MO$0 (Tier 2)digitek oral tablet 250 mcgMO$0 (Tier 2)digox oral tablet 125 mcgPAR; MO$0 (Tier 2)digox oral tablet 250 mcgMO$0 (Tier 2)digoxin oral solutionMO$0 (Tier 2)digoxin oral tablet 125 mcgPAR; MO$0 (Tier 2)digoxin oral tablet 250 mcgMO$0 (Tier 1)dilt-xr

$0 (Tier 1)diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

MO$0 (Tier 1)diltiazem hcl er beads oral capsule extended release 24 hour 360 mg

MO$0 (Tier 1)diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

MO$0 (Tier 2)diltiazem hcl er coated beads oral capsule extended release 24 hour 360 mg

MO$0 (Tier 1)diltiazem hcl er oral capsule extended release 12 hour

MO$0 (Tier 1)diltiazem hcl er oral capsule extended release 24 hour 120 mg

MO$0 (Tier 1)diltiazem hcl oral$0 (Tier 2)dofetilide

MO$0 (Tier 1)doxazosin mesylate oralMO$0 (Tier 1)enalapril maleate oralMO$0 (Tier 1)enalapril-hydrochlorothiazidePAR; MO$0 (Tier 2)ENTRESTOMO$0 (Tier 2)eplerenoneMO$0 (Tier 1)eprosartan mesylateMO$0 (Tier 2)ezetimibeMO$0 (Tier 1)felodipine er



Giá Thuốc

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Tên Thuốc

MO$0 (Tier 2)fenofibrate micronizedMO$0 (Tier 2)fenofibrate oral tablet 145 mg, 160 mg, 48 mg,

54 mgMO$0 (Tier 2)fenofibric acid oral capsule delayed releaseMO$0 (Tier 2)flecainide acetateMO$0 (Tier 1)fosinopril sodiumMO$0 (Tier 1)fosinopril sodium-hctzMO$0 (Tier 2)furosemide injection solution 10 mg/ml

$0 (Tier 2)furosemide injection solution 10 mg/ml (4ml syringe)

MO$0 (Tier 2)furosemide oral solution 10 mg/ml, 8 mg/mlMO$0 (Tier 1)furosemide oral tabletMO$0 (Tier 2)gemfibrozil oralMO$0 (Tier 2)hydralazine hcl injectionMO$0 (Tier 2)hydralazine hcl oralMO$0 (Tier 1)hydrochlorothiazide oralMO$0 (Tier 2)indapamide oralMO$0 (Tier 1)irbesartanMO$0 (Tier 1)irbesartan-hydrochlorothiazideMO$0 (Tier 1)irbesartan-hydrochlorothiazideMO$0 (Tier 2)isosorbide dinitrate erMO$0 (Tier 2)isosorbide dinitrate oral tablet 10 mg, 20 mg,

30 mg, 5 mgMO$0 (Tier 2)isosorbide mononitrateMO$0 (Tier 2)isosorbide mononitrate erPAR; LA; NE$0 (Tier 2)JUXTAPID ORAL CAPSULE 10 MG, 20 MG,

5 MGPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)JUXTAPID ORAL CAPSULE 30 MG, 40 MG,

60 MGMO$0 (Tier 1)labetalol hcl intravenous solutionMO$0 (Tier 1)labetalol hcl oral



Giá Thuốc

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Tên Thuốc

PAR; MO$0 (Tier 2)LANOXIN ORAL TABLET 250 MCGMO$0 (Tier 2)LANOXIN ORAL TABLET 62.5 MCGMO$0 (Tier 2)lidocaine hcl (cardiac) pf intravenous solution

prefilled syringe 100 mg/5mlMO$0 (Tier 1)lisinopril oralMO$0 (Tier 1)lisinopril-hydrochlorothiazideMO$0 (Tier 1)losartan potassiumMO$0 (Tier 1)losartan potassium-hctzMO$0 (Tier 1)lovastatinMO$0 (Tier 2)methazolamide oralMO$0 (Tier 2)metolazoneMO$0 (Tier 1)metoprolol succinate erMO$0 (Tier 1)metoprolol tartrate intravenous solution 5 mg/

5mlMO$0 (Tier 2)metoprolol tartrate intravenous solution

cartridgeMO$0 (Tier 1)metoprolol tartrate oralMO$0 (Tier 1)metoprolol-hydrochlorothiazideMO$0 (Tier 2)mexiletine hcl oralMO$0 (Tier 2)midodrine hclMO$0 (Tier 2)minitranMO$0 (Tier 2)minoxidil oralMO; QLL (60 per 30 days)$0 (Tier 2)MULTAQMO$0 (Tier 1)nadolol oral tablet 20 mg, 40 mg, 80 mgMO$0 (Tier 2)niacin (antihyperlipidemic)MO$0 (Tier 2)niacin er (antihyperlipidemic)MO$0 (Tier 2)niacorMO$0 (Tier 1)nicardipine hcl oralMO$0 (Tier 1)nifedical xl oral tablet extended release 24 hour

60 mgMO$0 (Tier 1)nifedipine er



Giá Thuốc

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Tên Thuốc

MO$0 (Tier 1)nifedipine er osmotic releaseMO$0 (Tier 1)nimodipine oralMO$0 (Tier 2)NITRO-BIDB/D PAR; MO$0 (Tier 2)NITROGLYCERIN INTRAVENOUSMO$0 (Tier 2)nitroglycerin sublingualMO$0 (Tier 2)nitroglycerin transdermal patch 24 hourPAR; LA; NE; QLL (540 per 30 days)$0 (Tier 2)NORTHERA ORAL CAPSULE 100 MGPAR; LA; NE; QLL (270 per 30 days)$0 (Tier 2)NORTHERA ORAL CAPSULE 200 MGPAR; LA; NE; QLL (180 per 30 days)$0 (Tier 2)NORTHERA ORAL CAPSULE 300 MGMO$0 (Tier 2)olmesartan-amlodipine-hctzMO$0 (Tier 2)omega-3-acid ethyl estersMO$0 (Tier 2)pacerone oral tablet 100 mg, 200 mg, 400 mgMO$0 (Tier 2)pentoxifylline erMO$0 (Tier 1)pindololPAR; NE; QLL (2 per 28 days)$0 (Tier 2)PRALUENT SUBCUTANEOUS SOLUTION

AUTO-INJECTORMO$0 (Tier 1)pravastatin sodiumMO$0 (Tier 1)prazosin hcl oralMO$0 (Tier 2)prevaliteMO$0 (Tier 2)procainamide hcl injectionMO$0 (Tier 2)propafenone hclMO$0 (Tier 1)propranolol hcl erMO$0 (Tier 1)propranolol hcl intravenousMO$0 (Tier 1)propranolol hcl oralMO$0 (Tier 1)quinapril hclMO$0 (Tier 1)quinapril-hydrochlorothiazideMO$0 (Tier 2)quinidine sulfate oralMO$0 (Tier 1)ramiprilST; MO$0 (Tier 2)RANEXAST; MO$0 (Tier 2)ranolazine er



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (30 per 30 days)$0 (Tier 2)RECTIVPAR; NE; QLL (3 per 28 days)$0 (Tier 2)REPATHAPAR; NE; QLL (3.5 per 28 days)$0 (Tier 2)REPATHA PUSHTRONEX SYSTEMPAR; NE; QLL (3 per 28 days)$0 (Tier 2)REPATHA SURECLICKMO$0 (Tier 2)rosuvastatin calciumMO$0 (Tier 1)simvastatin oralMO$0 (Tier 1)sorineMO$0 (Tier 1)sotalol hcl (af) oral tablet 120 mgMO$0 (Tier 2)sotalol hcl (af) oral tablet 160 mg, 80 mgMO$0 (Tier 1)sotalol hcl oralMO$0 (Tier 1)sotalol hydrochloride oral tablet 120 mgMO$0 (Tier 2)sotalol hydrochloride oral tablet 160 mg, 80 mgMO$0 (Tier 2)spironolactone oralMO$0 (Tier 2)spironolactone-hctzMO$0 (Tier 1)taztia xtMO$0 (Tier 2)TEKTURNAMO$0 (Tier 2)telmisartanMO$0 (Tier 2)telmisartan-amlodipine oral tablet 80-5 mgMO$0 (Tier 2)telmisartan-hctzMO$0 (Tier 1)terazosin hcl oralMO$0 (Tier 1)tiadylt erMO$0 (Tier 1)timolol maleate oralMO$0 (Tier 2)torsemide oralMO$0 (Tier 1)trandolaprilMO$0 (Tier 2)triamterene-hctz oral capsule 37.5-25 mgMO$0 (Tier 2)triamterene-hctz oral tabletPAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)UPTRAVI ORAL TABLETPAR; LA; NE; QLL (400 per 365 days)

$0 (Tier 2)UPTRAVI ORAL TABLET THERAPY PACK

MO$0 (Tier 2)valsartan



Giá Thuốc

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Tên Thuốc

MO$0 (Tier 1)valsartan-hydrochlorothiazideMO$0 (Tier 2)VASCEPAMO$0 (Tier 1)verapamil hcl er oral capsule extended release

24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg

MO$0 (Tier 2)verapamil hcl er oral capsule extended release 24 hour 360 mg

MO$0 (Tier 1)verapamil hcl er oral tablet extended releaseMO$0 (Tier 1)verapamil hcl intravenousMO$0 (Tier 1)verapamil hcl oral

CENTRAL NERVOUS SYSTEM AGENTS

$0 (Tier 2)acetylcysteine intravenousPAR; MO; QLL (90 per 30 days)$0 (Tier 2)amphetamine-dextroamphetamine oral tablet

10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mgPAR; MO; QLL (60 per 30 days)$0 (Tier 2)amphetamine-dextroamphetamine oral tablet

30 mgMO; QLL (60 per 30 days)$0 (Tier 2)atomoxetine hcl oral capsule 10 mg, 18 mg, 25

mg, 40 mgMO; QLL (30 per 30 days)$0 (Tier 2)atomoxetine hcl oral capsule 100 mg, 60 mg,

80 mgPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)AUBAGIOPAR; NE; QLL (4 per 28 days)$0 (Tier 2)AVONEX PEN INTRAMUSCULAR AUTO-

INJECTOR KITPAR; NE; QLL (4 per 28 days)$0 (Tier 2)AVONEX PREFILLED INTRAMUSCULAR

PREFILLED SYRINGE KIT[*]$0 (Tier 3)benzphetamine hcl tablet 50 mg oralPAR; NE; QLL (15 per 30 days)$0 (Tier 2)BETASERON SUBCUTANEOUS KITPAR; NE; QLL (60 per 30 days)$0 (Tier 2)dalfampridine erMO; QLL (60 per 30 days)$0 (Tier 2)dextroamphetamine sulfate er oral capsule

extended release 24 hour 10 mg, 5 mgMO; QLL (120 per 30 days)$0 (Tier 2)dextroamphetamine sulfate er oral capsule

extended release 24 hour 15 mgMO; QLL (180 per 30 days)$0 (Tier 2)dextroamphetamine sulfate oral tablet 10 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (90 per 30 days)$0 (Tier 2)dextroamphetamine sulfate oral tablet 5 mgMO$0 (Tier 2)diazepam injectionMO; QLL (240 per 30 days)$0 (Tier 2)diazepam intensolMO; QLL (180 per 30 days)$0 (Tier 2)duloxetine hcl oral capsule delayed release




particles 60 mgPAR; NE; QLL (15 per 30 days)$0 (Tier 2)EXTAVIA SUBCUTANEOUS KITPAR; NE; QLL (30 per 30 days)$0 (Tier 2)GILENYA ORAL CAPSULE 0.5 MGPAR; NE; QLL (30 per 30 days)$0 (Tier 2)glatiramer acetate subcutaneous solution

prefilled syringe 20 mg/mlPAR; NE; QLL (12 per 28 days)$0 (Tier 2)glatiramer acetate subcutaneous solution

prefilled syringe 40 mg/mlPAR; NE; QLL (30 per 30 days)$0 (Tier 2)glatopa subcutaneous solution prefilled syringe

20 mg/mlPAR; NE; QLL (12 per 28 days)$0 (Tier 2)glatopa subcutaneous solution prefilled syringe

40 mg/mlPAR; MO; QLL (30 per 30 days)$0 (Tier 2)guanfacine hcl erMO; QLL (150 per 30 days)$0 (Tier 2)lorazepam intensolPAR; MO; QLL (90 per 30 days)$0 (Tier 2)methylphenidate hcl oral tabletPAR; MO; QLL (60 per 30 days)$0 (Tier 2)NUEDEXTA[*]$0 (Tier 3)phentermine hcl capsule 15 mg oral[*]$0 (Tier 3)phentermine hcl capsule 30 mg oral[*]$0 (Tier 3)phentermine hcl capsule 37.5 mg oral[*]$0 (Tier 3)phentermine hcl tablet 37.5 mg oral

$0 (Tier 2)riluzoleMO; QLL (60 per 30 days)$0 (Tier 2)SAVELLA ORAL TABLET 100 MGMO; QLL (480 per 30 days)$0 (Tier 2)SAVELLA ORAL TABLET 12.5 MG



Giá Thuốc

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Tên Thuốc

MO; QLL (240 per 30 days)$0 (Tier 2)SAVELLA ORAL TABLET 25 MGMO; QLL (120 per 30 days)$0 (Tier 2)SAVELLA ORAL TABLET 50 MGMO; NE; QLL (110 per 365 days)$0 (Tier 2)SAVELLA TITRATION PACKPAR; LA; NE$0 (Tier 2)TECFIDERAPAR; NE; QLL (240 per 30 days)$0 (Tier 2)tetrabenazine oral tablet 12.5 mgPAR; NE; QLL (120 per 30 days)$0 (Tier 2)tetrabenazine oral tablet 25 mgPAR; LA; NE$0 (Tier 2)TYSABRIMO$0 (Tier 2)VECAMYLMO; QLL (180 per 30 days)$0 (Tier 2)zenzedi oral tablet 10 mgMO; QLL (90 per 30 days)$0 (Tier 2)zenzedi oral tablet 5 mgPAR; MO; NE$0 (Tier 2)ZULRESSO

DENTAL AND ORAL AGENTS

MO$0 (Tier 2)chlorhexidine gluconate mouth/throatMO$0 (Tier 2)clotrimazole mouth/throat trocheMO$0 (Tier 2)doxycycline hyclate oral capsuleMO$0 (Tier 2)doxycycline hyclate oral tablet 100 mg, 20 mgMO$0 (Tier 2)doxycycline monohydrate oral tablet 50 mgMO$0 (Tier 2)minocycline hcl oralMO$0 (Tier 2)mondoxyne nl oral capsule 100 mg, 75 mgMO$0 (Tier 2)oraloneMO$0 (Tier 2)paroexMO$0 (Tier 2)periogardMO$0 (Tier 2)pilocarpine hcl oralMO$0 (Tier 2)triamcinolone acetonide mouth/throat

DERMATOLOGICAL AGENTS

[*]$0 (Tier 4)3 day vaginal cream 2 % vaginal[*]$0 (Tier 4)ABREVA CREAM 10 % EXTERNALMO$0 (Tier 2)acitretin oral capsule 10 mgMO; NE$0 (Tier 2)acitretin oral capsule 17.5 mg, 25 mg



Giá Thuốc

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Tên Thuốc

[*]$0 (Tier 4)ACNE MEDICATION 10 GEL 10 % EXTERNALMO$0 (Tier 2)adapalene external gel 0.3 %MO$0 (Tier 2)ammonium lactate externalMO$0 (Tier 2)amnesteem[*]$0 (Tier 4)anti-dandruff shampoo 1 % external[*]$0 (Tier 4)anti-itch maximum strength cream 1 % external[*]$0 (Tier 4)antifungal cream 2 % externalPAR; MO; QLL (45 per 30 days)$0 (Tier 2)avita[*]$0 (Tier 4)benzoyl peroxide gel 10 % external (otc)[*]$0 (Tier 4)benzoyl peroxide gel 5 % external (otc)MO$0 (Tier 2)benzoyl peroxide-erythromycinMO$0 (Tier 2)beser external lotionMO$0 (Tier 2)betamethasone dipropionate external lotion[*]$0 (Tier 4)calamine lotion 8-8 % externalMO; QLL (120 per 30 days)$0 (Tier 2)calcipotriene external creamMO; QLL (120 per 30 days)$0 (Tier 2)calcipotriene external ointmentMO; QLL (60 per 30 days)$0 (Tier 2)calcipotriene external solutionMO; QLL (120 per 30 days)$0 (Tier 2)calcitreneMO$0 (Tier 2)ciclodan external solutionMO$0 (Tier 2)claravisMO$0 (Tier 2)clindacin etz external swabMO$0 (Tier 2)clotrimazole-betamethasone external cream[*]$0 (Tier 4)cvs lice killing shampoo 0.33-4 % external[*]$0 (Tier 4)cvs lice solution kit combination[*]$0 (Tier 4)desenex powder 2 % externalMO; QLL (1000 per 30 days)$0 (Tier 2)diclofenac sodium transdermal gel 1 %MO$0 (Tier 2)doxycycline hyclate oral capsule 50 mgMO$0 (Tier 2)doxycycline monohydrate oral capsule 100 mg,

50 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)doxycycline monohydrate oral tablet 100 mg, 50 mg

[*]$0 (Tier 4)eq lice killing max st shampoo 0.33-4 % external

[*]$0 (Tier 4)eql lice killing max st shampoo 0.33-4 % external

MO; QLL (120 per 30 days)$0 (Tier 2)fluocinolone acetonide bodyMO; QLL (240 per 30 days)$0 (Tier 2)fluocinonide external cream 0.05 %MO$0 (Tier 2)fluorouracil external cream 5 %MO$0 (Tier 2)fluorouracil external solutionMO$0 (Tier 2)fluticasone propionate external[*]$0 (Tier 4)gnp calamine lotion 8-8 % external[*]$0 (Tier 4)gnp clotrimazole 3 cream 2 % vaginal[*]$0 (Tier 4)gnp hydrocortisone cream 0.5 % external[*]$0 (Tier 4)gnp hydrocortisone max st ointment 1 %

external[*]$0 (Tier 4)gnp hydrocortisone plus cream 1 % external[*]$0 (Tier 4)gnp hydrocortisone/aloe cream 1 % external[*]$0 (Tier 4)gnp lice treatment liquid 1 % external[*]$0 (Tier 4)gnp lice treatment shampoo 0.33-4 % external[*]$0 (Tier 4)gnp miconazole 3 kit 200 & 2 mg-% (9gm)

vaginal[*]$0 (Tier 4)gnp miconazole 7 cream 2 % vaginal[*]$0 (Tier 4)gnp miconazorb af powder 2 % external[*]$0 (Tier 4)hm calamine lotion 8-8 % external[*]$0 (Tier 4)hm hydrocortisone plus cream 1 % external[*]$0 (Tier 4)hm hydrocortisone-aloe max st cream 1 %

external[*]$0 (Tier 4)hm lice killing max st shampoo 0.33-4 %

external[*]$0 (Tier 4)hm lice treatment liquid 1 % external[*]$0 (Tier 4)hydrocortisone cream 0.5 % external



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)hydrocortisone cream 1 % external (otc)[*]$0 (Tier 4)hydrocortisone max st cream 1 % external[*]$0 (Tier 4)hydrocortisone max st/12 moist cream 1 %

external[*]$0 (Tier 4)hydrocortisone ointment 0.5 % external[*]$0 (Tier 4)hydrocortisone ointment 1 % external (otc)[*]$0 (Tier 4)hydrocortisone-aloe cream 0.5 % externalMO$0 (Tier 2)imiquimod externalMO$0 (Tier 2)isotretinoin oral capsule 10 mg, 20 mg, 30 mgMO; NE$0 (Tier 2)isotretinoin oral capsule 40 mg[*]$0 (Tier 4)lice killing maximum strength shampoo 0.33-4

% externalMO$0 (Tier 2)mafenide acetate externalNE$0 (Tier 2)methoxsalen rapid[*]$0 (Tier 4)miconazole 3 combo pack kit 200 & 2 mg-%

(9gm) vaginal[*]$0 (Tier 4)miconazole 7 cream 2 % vaginal[*]$0 (Tier 4)miconazole 7 suppository 100 mg vaginal[*]$0 (Tier 4)miconazole nitrate cream 2 % external[*]$0 (Tier 4)miconazole nitrate cream 2 % vaginalMO$0 (Tier 2)mondoxyne nl oral capsule 100 mg, 75 mgMO$0 (Tier 2)myorisanMO$0 (Tier 2)nystatin-triamcinolone external creamMO; NE$0 (Tier 2)PICATOPAR; MO; NE; QLL (100 per 90 days)$0 (Tier 2)pimecrolimusMO$0 (Tier 2)podofilox external[*]$0 (Tier 4)qc 3 day cream 4 % vaginal[*]$0 (Tier 4)qc calamine lotion external[*]$0 (Tier 4)qc miconazole 7 cream 2 % vaginal[*]$0 (Tier 4)ra lice maximum strength shampoo 0.33-4 %

external



Giá Thuốc

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Tên Thuốc

[*]$0 (Tier 4)REESES PINWORM MEDICINE SUSPENSION 144 (50 BASE) MG/ML ORAL

[*]$0 (Tier 4)remedy phytoplex antifungal powder 2 % external

[*]$0 (Tier 4)rid complete lice elimination kit combinationMO$0 (Tier 2)rosadan external creamMO$0 (Tier 2)rosadan external gelMO; NE; QLL (30 per 30 days)$0 (Tier 2)SANTYL[*]$0 (Tier 4)sb lice killing max st shampoo 0.33-4 %

external[*]$0 (Tier 4)scalpicin maximum strength solution 1 %

externalMO$0 (Tier 2)selenium sulfide external lotion[*]$0 (Tier 4)sm 3-day vaginal cream 2 % vaginal[*]$0 (Tier 4)sm clotrimazole vaginal cream 1 % vaginal[*]$0 (Tier 4)sm hydrocortisone max st ointment 1 %

external[*]$0 (Tier 4)sm lice killing max strength shampoo 0.33-4 %

external[*]$0 (Tier 4)sm lice killing shampoo 0.33-4 % external[*]$0 (Tier 4)sm lice treatment lotion 1 % external[*]$0 (Tier 4)sm miconazole 7 cream 2 % vaginalPAR; NE; QLL (1 per 28 days)$0 (Tier 2)STELARA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 45 MG/0.5MLPAR; MO; NE; QLL (100 per 90 days)$0 (Tier 2)tacrolimus externalPAR; MO$0 (Tier 2)tazarotene externalPAR; MO$0 (Tier 2)TAZORAC EXTERNAL CREAM 0.05 %PAR; MO$0 (Tier 2)TAZORAC EXTERNAL GELPAR; MO; QLL (45 per 30 days)$0 (Tier 2)tretinoin external creamPAR; MO; QLL (45 per 30 days)$0 (Tier 2)tretinoin external gel 0.01 %, 0.025 %MO$0 (Tier 2)triderm external cream 0.5 %PAR; LA; NE$0 (Tier 2)VALCHLOR



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)zeasorb-af powder 2 % externalMO$0 (Tier 2)zenatane

ELECTROLYTES/MINERALS/METALS/VITAMINS

B/D PAR; MO$0 (Tier 2)AMINOSYN II INTRAVENOUS SOLUTION 10 %, 15 %

B/D PAR; MO$0 (Tier 2)AMINOSYN-PF[*]$0 (Tier 4)antacid calcium extra strength tablet chewable

750 mg oral[*]$0 (Tier 4)antacid calcium tablet chewable 500 mg oral[*]$0 (Tier 4)aqueous vitamin d liquid 10 mcg/ml oral[*]$0 (Tier 4)ascorbic acid tablet 500 mg oral[*]$0 (Tier 4)b-1 tablet 100 mg oral[*]$0 (Tier 4)b-1 tablet 250 mg oral[*]$0 (Tier 4)b-12 dots tablet dispersible 500 mcg oral[*]$0 (Tier 4)b-12 tablet 100 mcg oral[*]$0 (Tier 4)b-12 tablet 500 mcg oral[*]$0 (Tier 4)b-2 tablet 100 mg oral[*]$0 (Tier 4)b-2 tablet 50 mg oral[*]$0 (Tier 4)b-6 tablet 100 mg oral[*]$0 (Tier 4)b-6 tablet 50 mg oral[*]$0 (Tier 4)c 1000 tablet 1000 mg oral[*]$0 (Tier 4)c 250 tablet 250 mg oral[*]$0 (Tier 4)c 500 tablet 500 mg oral[*]$0 (Tier 4)c-1000 tablet 1000 mg oral[*]$0 (Tier 4)c-1000/rose hips tablet 1000 mg oral[*]$0 (Tier 4)c-250 tablet 250 mg oral[*]$0 (Tier 4)c-500 tablet 500 mg oral[*]$0 (Tier 4)c-500/rose hips tablet 500 mg oral[*]$0 (Tier 4)cal-gest antacid tablet chewable 500 mg oral[*]$0 (Tier 4)calcitrate tablet 950 mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)calcitriol intravenous solution 1 mcg/ml[*]$0 (Tier 4)calcium + d3 tablet 600-200 mg-unit oral[*]$0 (Tier 4)calcium 500 + d tablet 500-125 mg-unit oral[*]$0 (Tier 4)calcium 500+d tablet 500-200 mg-unit oral[*]$0 (Tier 4)calcium 500+d tablet 500-400 mg-unit oral[*]$0 (Tier 4)calcium 500/d tablet 500-200 mg-unit oral[*]$0 (Tier 4)calcium 500/d tablet chewable 500-400 mg-unit

oral[*]$0 (Tier 4)calcium 600 high potency tablet 600 mg oral[*]$0 (Tier 4)calcium 600 tablet 1500 (600 ca) mg oral[*]$0 (Tier 4)calcium 600 tablet 600 mg oral[*]$0 (Tier 4)calcium 600+d tablet 600-200 mg-unit oral[*]$0 (Tier 4)calcium 600+d tablet 600-400 mg-unit oral[*]$0 (Tier 4)CALCIUM 600+D TABLET 600-800 MG-UNIT

ORAL[*]$0 (Tier 4)calcium 600+d3 tablet 600-400 mg-unit oral[*]$0 (Tier 4)CALCIUM 600+D3 TABLET 600-800 MG-UNIT

ORAL[*]$0 (Tier 4)calcium 600/vitamin d tablet 600-400 mg-unit

oral[*]$0 (Tier 4)calcium 600/vitamin d3 tablet 600-800 mg-unit

oral[*]$0 (Tier 4)CALCIUM 600/VITAMIN D3 TABLET 600-800

MG-UNIT ORAL[*]$0 (Tier 4)calcium antacid extra strength tablet chewable

750 mg oral[*]$0 (Tier 4)calcium antacid tablet chewable 500 mg oral[*]$0 (Tier 4)calcium ascorbate tablet 500 mg oral[*]$0 (Tier 4)calcium carbonate antacid suspension 1250

mg/5ml oral[*]$0 (Tier 4)calcium carbonate tablet 1250 (500 ca) mg oral[*]$0 (Tier 4)calcium carbonate tablet 1500 (600 ca) mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)calcium carbonate tablet 600 mg oral[*]$0 (Tier 4)calcium carbonate-vitamin d tablet 500-400

mg-unit oral[*]$0 (Tier 4)calcium carbonate-vitamin d tablet 600-400

mg-unit oral[*]$0 (Tier 4)calcium citrate + d tablet 250-200 mg-unit oral[*]$0 (Tier 4)calcium citrate + d tablet 315-200 mg-unit oral[*]$0 (Tier 4)CALCIUM CITRATE + D TABLET 315-200 MG-

UNIT ORAL[*]$0 (Tier 4)CALCIUM CITRATE + D3 MAXIMUM TABLET

315-250 MG-UNIT ORAL[*]$0 (Tier 4)calcium citrate tablet 200 mg oral[*]$0 (Tier 4)calcium citrate tablet 250 mg oral[*]$0 (Tier 4)CALCIUM CITRATE+D3 PETITES TABLET

200-250 MG-UNIT ORAL[*]$0 (Tier 4)CALCIUM CITRATE+D3 TABLET 315-250 MG-

UNIT ORAL[*]$0 (Tier 4)calcium citrate-vitamin d tablet 315-200 mg-unit

oral[*]$0 (Tier 4)CALCIUM CITRATE-VITAMIN D TABLET 315-

250 MG-UNIT ORAL[*]$0 (Tier 4)CALCIUM CITRATE-VITAMIN D3 TABLET

315-250 MG-UNIT ORAL[*]$0 (Tier 4)calcium high potency tablet 600 mg oral[*]$0 (Tier 4)CALCIUM HIGH POTENCY/VITAMIN D

TABLET 600-200 MG-UNIT ORAL[*]$0 (Tier 4)calcium plus vitamin d3 tablet 600-800 mg-unit

oral[*]$0 (Tier 4)CALCIUM TABLET CHEWABLE 500-100 MG-

UNIT ORAL[*]$0 (Tier 4)CALCIUM+D3 TABLET 600-800 MG-UNIT

ORAL[*]$0 (Tier 4)calcium-vitamin d tablet 500-200 mg-unit oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)CALCIUM-VITAMIN D TABLET 600-200 MG- UNIT ORAL

[*]$0 (Tier 4)calcium-vitamin d tablet 600-400 mg-unit oral[*]$0 (Tier 4)calcium-vitamin d3 tablet 250-125 mg-unit oral[*]$0 (Tier 4)calcium-vitamin d3 tablet 500-400 mg-unit oral[*]$0 (Tier 4)calcium-vitamin d3 tablet 600-400 mg-unit oral[*]$0 (Tier 4)calcium/c/d tablet chewable 500-10-250 mg-

mg-unit oral[*]$0 (Tier 4)CALTRATE 600+D3 TABLET 600-800 MG-

UNIT ORALPAR; LA; NE$0 (Tier 2)CARBAGLUPAR; LA; NE$0 (Tier 2)CEREZYME INTRAVENOUS SOLUTION

RECONSTITUTED 400 UNIT[*]$0 (Tier 4)classic prenatal tablet 28-0.8 mg oralB/D PAR; MO$0 (Tier 2)CLINIMIX E/DEXTROSE (2.75/5)B/D PAR; MO$0 (Tier 2)CLINIMIX E/DEXTROSE (4.25/10)B/D PAR; MO$0 (Tier 2)CLINIMIX E/DEXTROSE (4.25/5)B/D PAR; MO$0 (Tier 2)CLINIMIX E/DEXTROSE (5/15)B/D PAR; MO$0 (Tier 2)CLINIMIX E/DEXTROSE (5/20)B/D PAR; MO$0 (Tier 2)CLINIMIX/DEXTROSE (4.25/10)B/D PAR; MO$0 (Tier 2)CLINIMIX/DEXTROSE (4.25/25)B/D PAR; MO$0 (Tier 2)CLINIMIX/DEXTROSE (4.25/5)B/D PAR; MO$0 (Tier 2)CLINIMIX/DEXTROSE (5/15)B/D PAR; MO$0 (Tier 2)CLINIMIX/DEXTROSE (5/20)B/D PAR; MO$0 (Tier 2)CLINIMIX/DEXTROSE (5/25)NE$0 (Tier 2)clovique[*]$0 (Tier 4)cvs b-1 tablet 100 mg oral[*]$0 (Tier 4)cvs b-12 tablet 500 mcg oral[*]$0 (Tier 4)CVS CALCIUM 600 & VITAMIN D3 TABLET

600-800 MG-UNIT ORAL[*]$0 (Tier 4)CVS CALCIUM 600+D TABLET 600-800 MG-

UNIT ORAL



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)CVS CALCIUM CITRATE +D TABLET 315-250 MG-UNIT ORAL

[*]$0 (Tier 4)CVS CALCIUM CITRATE +D3 MINI TABLET 200-250 MG-UNIT ORAL

[*]$0 (Tier 4)cvs d3 capsule 10 mcg (400 unit) oral[*]$0 (Tier 4)cvs d3 capsule 125 mcg (5000 ut) oral[*]$0 (Tier 4)cvs d3 capsule 25 mcg (1000 ut) oral[*]$0 (Tier 4)cvs d3 capsule 50 mcg (2000 ut) oral[*]$0 (Tier 4)cvs iron tablet 325 (65 fe) mg oral[*]$0 (Tier 3)cyanocobalamin solution 1000 mcg/ml injection[*]$0 (Tier 4)d 1000 capsule 25 mcg (1000 ut) oral[*]$0 (Tier 4)d 400 tablet 10 mcg (400 unit) oral[*]$0 (Tier 4)d 5000 capsule 125 mcg (5000 ut) oral[*]$0 (Tier 4)d 5000 tablet 125 mcg (5000 ut) oral[*]$0 (Tier 4)d-3-5 capsule 125 mcg (5000 ut) oral[*]$0 (Tier 4)d-vi-sol liquid 10 mcg/ml oral[*]$0 (Tier 4)d2000 ultra strength capsule 50 mcg (2000 ut)

oral[*]$0 (Tier 4)D3 DOTS TABLET DISPERSIBLE 50 MCG

(2000 UT) ORAL[*]$0 (Tier 4)d3 high potency capsule 25 mcg (1000 ut) oral[*]$0 (Tier 4)d3 super strength capsule 50 mcg (2000 ut)

oral[*]$0 (Tier 4)d3-1000 capsule 25 mcg (1000 ut) oral[*]$0 (Tier 4)d3-1000 tablet 25 mcg (1000 ut) oralPAR; NE$0 (Tier 2)deferasirox oral tablet soluble[*]$0 (Tier 4)delta d3 tablet 10 mcg (400 unit) oralMO; NE$0 (Tier 2)DEPEN TITRATABSMO$0 (Tier 2)dextrose in lactated ringersMO$0 (Tier 2)dextrose intravenous solution 10 %, 5 %MO$0 (Tier 2)DEXTROSE INTRAVENOUS SOLUTION 20

%, 40 %



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)dextrose intravenous solution 250 mg/ml, 30 %, 70 %

$0 (Tier 2)dextrose intravenous solution 50 %MO$0 (Tier 2)DEXTROSE-NACL INTRAVENOUS

SOLUTION 10-0.2 %MO$0 (Tier 2)dextrose-nacl intravenous solution 10-0.45 %,

2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5-0.33 %, 5- 0.45 %, 5-0.9 %

[*]$0 (Tier 4)dialyvite vitamin d 5000 capsule 125 mcg (5000 ut) oral

B/D PAR; MO$0 (Tier 2)doxercalciferol oral capsule 0.5 mcgMO$0 (Tier 2)elite-ob[*]$0 (Tier 4)eq calcium 600+d tablet 600-800 mg-unit oral[*]$0 (Tier 4)EQ CALCIUM CITRATE+D TABLET 315-250

MG-UNIT ORAL[*]$0 (Tier 4)eql b-6 tablet 100 mg oral[*]$0 (Tier 4)eql vitamin b-12 tablet 500 mcg oral[*]$0 (Tier 4)eql vitamin c tablet 1000 mg oral[*]$0 (Tier 4)eql vitamin c tablet 500 mg oral[*]$0 (Tier 4)eql vitamin c/rose hips tablet 1000 mg oral[*]$0 (Tier 4)eql vitamin c/rose hips tablet 500 mg oralPAR; LA; NE$0 (Tier 2)EXJADE[*]$0 (Tier 4)ferate tablet 240 (27 fe) mg oral[*]$0 (Tier 4)ferosul tablet 325 (65 fe) mg oral[*]$0 (Tier 4)ferretts tablet 325 (106 fe) mg oral[*]$0 (Tier 4)ferrex 150 capsule 150 mg oral[*]$0 (Tier 4)ferric x-150 capsule 150 mg oral[*]$0 (Tier 4)ferrous gluconate tablet 240 (27 fe) mg oral[*]$0 (Tier 4)ferrous gluconate tablet 324 (37.5 fe) mg oral[*]$0 (Tier 4)ferrous gluconate tablet 324 (38 fe) mg oral[*]$0 (Tier 4)ferrous sulfate tablet 325 (65 fe) mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)ferrous sulfate tablet delayed release 324 (65 fe) mg oral

[*]$0 (Tier 4)ferrous sulfate tablet delayed release 325 (65 fe) mg oral

[*]$0 (Tier 4)ferrousul tablet 325 (65 fe) mg oral$0 (Tier 2)fluoritab oral tablet chewable 2.2 (1 f) mg

[*]$0 (Tier 4)folic acid tablet 1 mg oral (otc)[*]$0 (Tier 3)folic acid tablet 1 mg oral (rx)[*]$0 (Tier 4)folic acid tablet 400 mcg oral[*]$0 (Tier 4)folic acid tablet 800 mcg oralB/D PAR; MO$0 (Tier 2)FREAMINE III INTRAVENOUS SOLUTION 10

%[*]$0 (Tier 4)gnp antacid anti-gas suspension 200-200-20

mg/5ml oral[*]$0 (Tier 4)gnp calcium 500 +d3 tablet 500-600 mg-unit

oral[*]$0 (Tier 4)GNP CALCIUM 600 +D3 TABLET 600-800

MG-UNIT ORAL[*]$0 (Tier 4)GNP CALCIUM CITRATE +D3 TABLET 315-

250 MG-UNIT ORAL[*]$0 (Tier 4)gnp calcium tablet 600 mg oral[*]$0 (Tier 4)gnp folic acid tablet 400 mcg oral[*]$0 (Tier 4)gnp iron tablet 200 (65 fe) mg oral[*]$0 (Tier 4)gnp milk of magnesia suspension 1200 mg/

15ml oral[*]$0 (Tier 4)gnp niacin tablet 250 mg oral[*]$0 (Tier 4)gnp prenatal tablet 28-0.8 mg oral[*]$0 (Tier 4)gnp vitamin c tablet 1000 mg oral[*]$0 (Tier 4)gnp vitamin c tablet 250 mg oral[*]$0 (Tier 4)gnp vitamin c tablet 500 mg oral[*]$0 (Tier 4)gnp vitamin c w/rose hips tablet 500-37 mg oral[*]$0 (Tier 4)gnp vitamin c/rose hips tablet 1000 mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)gnp vitamin d-400 tablet 10 mcg (400 unit) oralB/D PAR; MO$0 (Tier 2)hepatamine[*]$0 (Tier 4)HM CALCIUM CITRATE+D3 PETITE TABLET

200-250 MG-UNIT ORAL[*]$0 (Tier 4)HM CALCIUM CITRATE+VITAMIN D TABLET

315-250 MG-UNIT ORAL[*]$0 (Tier 4)hm calcium-vitamin d tablet 500-200 mg-unit

oral[*]$0 (Tier 4)hm calcium-vitamin d tablet 600-400 mg-unit

oral[*]$0 (Tier 4)hm calcium-vitamin d tablet 600-800 mg-unit

oral[*]$0 (Tier 4)hm folic acid tablet 400 mcg oral[*]$0 (Tier 4)hm iron tablet 200 (65 fe) mg oral[*]$0 (Tier 4)hm niacin tablet extended release 250 mg oral[*]$0 (Tier 4)hm vitamin b1 tablet 100 mg oral[*]$0 (Tier 4)hm vitamin b12 tablet 500 mcg oral[*]$0 (Tier 4)hm vitamin b6 tablet 100 mg oral[*]$0 (Tier 4)hm vitamin c tablet 1000 mg oral[*]$0 (Tier 4)hm vitamin c tablet 500 mg oral[*]$0 (Tier 4)hm vitamin c/rose hips tablet 500 mg oral[*]$0 (Tier 4)hm vitamin d3 capsule 50 mcg (2000 ut) oralB/D PAR; MO$0 (Tier 2)intralipid intravenous emulsion 20 %B/D PAR; MO$0 (Tier 2)INTRALIPID INTRAVENOUS EMULSION 30

%[*]$0 (Tier 4)iron (ferrous gluconate) tablet 256 (28 fe) mg

oral[*]$0 (Tier 4)iron tablet 325 (65 fe) mg oralMO$0 (Tier 2)kcl in dextrose-nacl intravenous solution 10-5-

0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5- 0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5- 0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)KCL IN DEXTROSE-NACL INTRAVENOUS SOLUTION 20-5-0.225 MEQ/L-%-%

MO$0 (Tier 2)KCL IN DEXTROSE-NACL INTRAVENOUS SOLUTION 40-5-0.9 MEQ/L-%-%

MO$0 (Tier 2)KCL-LACTATED RINGERS-D5WMO$0 (Tier 2)kionex oral suspensionMO$0 (Tier 2)klor-con 10MO$0 (Tier 2)klor-con 10MO$0 (Tier 1)klor-con m10MO$0 (Tier 1)klor-con m10MO$0 (Tier 2)klor-con m15MO$0 (Tier 2)klor-con m15MO$0 (Tier 1)klor-con m20MO$0 (Tier 1)klor-con m20MO$0 (Tier 1)klor-con oral tablet extended releaseMO$0 (Tier 1)klor-con oral tablet extended releaseMO$0 (Tier 1)klor-con sprinkleMO$0 (Tier 1)klor-con sprinkle oral capsule extended release

8 meq[*]$0 (Tier 4)KPN PRENATAL TABLET 0.1 MG ORALMO$0 (Tier 2)lactated ringers intravenousMO$0 (Tier 2)lactated ringers irrigationB/D PAR; MO$0 (Tier 2)levocarnitine oral solutionB/D PAR; MO$0 (Tier 2)LEVOCARNITINE ORAL TABLETB/D PAR; MO$0 (Tier 2)levocarnitine sfMO$0 (Tier 2)ludent oral tablet chewable 2.2 (1 f) mg[*]$0 (Tier 4)magnesium oxide (antacid) capsule 500 mg

oralMO$0 (Tier 2)magnesium sulfate injection solution 50 %

$0 (Tier 2)magnesium sulfate injection solution 50 % (10ml syringe)



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 2)MAGNESIUM SULFATE INTRAVENOUS SOLUTION 2 GM/50ML, 20 GM/500ML, 4 GM/ 100ML, 4 GM/50ML, 40 GM/1000ML

[*]$0 (Tier 4)meijer c tablet 500 mg oral[*]$0 (Tier 3)MEPHYTON TABLET 5 MG ORAL[*]$0 (Tier 4)mi-acid maximum strength suspension 400-

400-40 mg/5ml oral[*]$0 (Tier 4)mi-acid suspension 200-200-20 mg/5ml oral[*]$0 (Tier 4)milk of magnesia concentrate suspension 2400

mg/10ml oral[*]$0 (Tier 4)milk of magnesia suspension 400 mg/5ml oral[*]$0 (Tier 4)milk of magnesia suspension 7.75 % oral[*]$0 (Tier 4)mintox maximum strength suspension 400-400-

40 mg/5ml oralPAR; NE$0 (Tier 2)MOZOBIL[*]$0 (Tier 4)myferon 150 capsule 150 mg oral[*]$0 (Tier 4)natural c/rose hips tablet 1000 mg oral[*]$0 (Tier 4)natural vitamin d-3 tablet 125 mcg (5000 ut)

oralPAR; NE; QLL (1.2 per 28 days)$0 (Tier 2)NEULASTA ONPRO[*]$0 (Tier 4)niacin er capsule extended release 250 mg oral[*]$0 (Tier 4)niacin er capsule extended release 500 mg oral[*]$0 (Tier 4)niacin er tablet extended release 250 mg oral[*]$0 (Tier 4)niacin er tablet extended release 750 mg oral[*]$0 (Tier 4)niacin tablet 100 mg oral[*]$0 (Tier 4)niacin tablet 250 mg oral[*]$0 (Tier 4)niacin tablet 50 mg oral[*]$0 (Tier 4)niacin tablet 500 mg oralMO$0 (Tier 2)NORMOSOL-M IN D5WMO$0 (Tier 2)NORMOSOL-RMO$0 (Tier 2)NORMOSOL-R PH 7.4B/D PAR; MO$0 (Tier 2)nutrilipid



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[*]$0 (Tier 4)omega-3 capsule 1000 mg oral[*]$0 (Tier 4)oysco 500 tablet 500 mg oral[*]$0 (Tier 4)oysco 500+d tablet 500-200 mg-unit oral[*]$0 (Tier 4)oyster shell calcium + d tablet 500-200 mg-unit

oral[*]$0 (Tier 4)oyster shell calcium + d3 tablet 500-400 mg-

unit oral[*]$0 (Tier 4)oyster shell calcium 250+d tablet 250-125 mg-

unit oral[*]$0 (Tier 4)oyster shell calcium 500 + d tablet 500-125 mg-

unit oral[*]$0 (Tier 4)oyster shell calcium 500+d tablet chewable

500-400 mg-unit oral[*]$0 (Tier 4)oyster shell calcium plus d tablet 500-200 mg-

unit oral[*]$0 (Tier 4)oyster shell calcium tablet 500 mg oral[*]$0 (Tier 4)oyster shell calcium/d tablet 250-125 mg-unit

oral[*]$0 (Tier 4)oyster shell calcium/d tablet 500-200 mg-unit

oral[*]$0 (Tier 4)oyster shell calcium/d3 tablet 500-400 mg-unit

oral[*]$0 (Tier 4)oyster shell calcium/vitamin d tablet 250-125

mg-unit oral[*]$0 (Tier 4)oyster shell calcium/vitamin d tablet 500-200

mg-unit oral[*]$0 (Tier 4)oystercal-d tablet 500-400 mg-unit oralMO$0 (Tier 2)PLASMA-LYTE 148MO$0 (Tier 2)pnv-dha[*]$0 (Tier 4)poly-iron 150 capsule 150 mg oralMO$0 (Tier 1)potassium chloride crys erMO$0 (Tier 1)potassium chloride erMO$0 (Tier 2)potassium chloride in dextrose intravenous

solution 20-5 meq/l-%, 40-5 meq/l-%



Giá Thuốc

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Tên Thuốc

MO$0 (Tier 2)potassium chloride in nacl intravenous solution 20-0.45 meq/l-%, 20-0.9 meq/l-%

MO$0 (Tier 2)potassium chloride intravenous solution 10 meq/100ml, 2 meq/ml, 20 meq/100ml, 40 meq/ 100ml

MO$0 (Tier 2)potassium chloride intravenous solution 10 meq/50ml, 20 meq/50ml

MO$0 (Tier 1)potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

B/D PAR; MO$0 (Tier 2)PREMASOL INTRAVENOUS SOLUTION 10 %

[*]$0 (Tier 4)prenatal low iron tablet 27-0.8 mg oral[*]$0 (Tier 4)prenatal one daily tablet 27-0.8 mg oral[*]$0 (Tier 4)prenatal tablet 27-0.8 mg oral (otc)[*]$0 (Tier 4)prenatal tablet 28-0.8 mg oral[*]$0 (Tier 4)prenatal vitamin and mineral tablet 28-0.8 mg

oral[*]$0 (Tier 4)prenatal vitamins tablet 28-0.8 mg oral[*]$0 (Tier 4)pureway-c tablet 500 mg oral[*]$0 (Tier 4)ra calcium 600 tablet 600 mg oral[*]$0 (Tier 4)RA CALCIUM CIT-VIT D-3 PETITES TABLET

200-250 MG-UNIT ORAL[*]$0 (Tier 4)ra folic acid tablet 400 mcg oral[*]$0 (Tier 4)ra folic acid tablet 800 mcg oral[*]$0 (Tier 4)ra hi cal tablet 500-200 mg-unit oral[*]$0 (Tier 4)ra high potency iron tablet 27 mg oral[*]$0 (Tier 4)ra iron tablet 325 (65 fe) mg oral[*]$0 (Tier 4)ra magnesium capsule 500 mg oral[*]$0 (Tier 4)ra niacin tablet 100 mg oral[*]$0 (Tier 4)ra niacin tablet 500 mg oral[*]$0 (Tier 4)ra oyster shell calcium/d tablet 500-200 mg-unit

oral[*]$0 (Tier 4)ra vitamin c tablet 500 mg oral



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[*]$0 (Tier 4)ra vitamin c/rose hips tablet 1000 mg oral[*]$0 (Tier 4)ra vitamin c/rose hips tablet 500 mg oral[*]$0 (Tier 4)ra vitamin d-3 capsule 125 mcg (5000 ut) oral[*]$0 (Tier 4)ra vitamin d-3 capsule 50 mcg (2000 ut) oralMO$0 (Tier 2)ringersMO$0 (Tier 2)ringers irrigation[*]$0 (Tier 4)risacal-d tablet 105-81-120 mg-mg-unit oral[*]$0 (Tier 4)sb vitamin c tablet 500 mg oral[*]$0 (Tier 4)slow iron tablet extended release 160 (50 fe)

mg oral[*]$0 (Tier 4)slow release iron tablet extended release 160

(50 fe) mg oral[*]$0 (Tier 4)sm antacid/antigas suspension 200-200-20 mg/

5ml oral[*]$0 (Tier 4)sm calcium 600/vitamin d tablet 600-400 mg-

unit oral[*]$0 (Tier 4)SM CALCIUM CITRATE W/VIT D3 TABLET

315-250 MG-UNIT ORAL[*]$0 (Tier 4)SM CALCIUM CITRATE+/VIT D3 TABLET 315-

250 MG-UNIT ORAL[*]$0 (Tier 4)sm calcium-vitamin d tablet 500-200 mg-unit

oral[*]$0 (Tier 4)sm chewable c tablet chewable 500 mg oral[*]$0 (Tier 4)sm folic acid tablet 400 mcg oral[*]$0 (Tier 4)sm iron slow release tablet extended release

160 (50 fe) mg oral[*]$0 (Tier 4)sm iron tablet 325 (65 fe) mg oral[*]$0 (Tier 4)sm niacin cr tablet extended release 250 mg

oral[*]$0 (Tier 4)sm oyster shell calcium/vit d3 tablet 500-400

mg-unit oral[*]$0 (Tier 4)sm prenatal vitamins tablet 28-0.8 mg oral[*]$0 (Tier 4)sm vit c/rose hips tablet 1000 mg oral



Giá Thuốc

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Tên Thuốc

[*]$0 (Tier 4)sm vitamin b-12 tablet 100 mcg oral[*]$0 (Tier 4)sm vitamin b-12 tablet 500 mcg oral[*]$0 (Tier 4)sm vitamin b-6 tablet 100 mg oral[*]$0 (Tier 4)sm vitamin b1 tablet 100 mg oral[*]$0 (Tier 4)sm vitamin c tablet 1000 mg oral[*]$0 (Tier 4)sm vitamin c tablet 250 mg oral[*]$0 (Tier 4)sm vitamin c tablet 500 mg oral[*]$0 (Tier 4)sm vitamin c/rose hips tablet 500 mg oral[*]$0 (Tier 4)sm vitamin d3 capsule 50 mcg (2000 ut) oral[*]$0 (Tier 4)sm vitamin d3 tablet 25 mcg (1000 ut) oral[*]$0 (Tier 4)sm vitamin e capsule 1000 unit oral[*]$0 (Tier 4)sm vitamin e capsule 200 unit oral[*]$0 (Tier 4)sm vitamin e capsule 400 unit oralMO$0 (Tier 2)sodium chloride injection solution 2.5 meq/mlMO$0 (Tier 2)sodium chloride intravenous solution 0.45 %,

0.9 %, 3 %, 5 %MO$0 (Tier 2)sodium chloride intravenous solution 4 meq/mlMO$0 (Tier 2)sodium chloride irrigation solution 0.9 %MO$0 (Tier 2)sodium fluoride oral tablet 2.2 (1 f) mg

$0 (Tier 2)sodium fluoride oral tablet chewable 2.2 (1 f) mg

$0 (Tier 2)sodium polystyrene sulfonate oral powderMO$0 (Tier 2)sodium polystyrene sulfonate oral suspensionMO$0 (Tier 2)sodium polystyrene sulfonate rectalMO$0 (Tier 2)spsMO$0 (Tier 2)sterile water for irrigation[*]$0 (Tier 4)super calcium 600 + d 400 tablet 600-400 mg-

unit oral[*]$0 (Tier 4)super calcium 600 + d3 tablet 600-400 mg-unit

oral[*]$0 (Tier 4)super calcium tablet 600 mg oral



Giá Thuốc

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Tên Thuốc

B/D PAR; MO$0 (Tier 2)SYNTHAMIN 17[*]$0 (Tier 4)TGT CALCIUM + VITAMIN D3 TABLET 600-

800 MG-UNIT ORAL[*]$0 (Tier 4)thera-d rapid repletion tablet 50 mcg (2000 ut)

oral[*]$0 (Tier 4)thiamine hcl tablet 100 mg oralMO$0 (Tier 2)tis-u-solB/D PAR; MO$0 (Tier 2)TRAVASOLNE$0 (Tier 2)trientine hclB/D PAR; MO$0 (Tier 2)TROPHAMINEMO; NE; QLL (180 per 30 days)$0 (Tier 2)VELPHORO[*]$0 (Tier 4)VITAMIN A PALMITATE TABLET 10000 UNIT

ORAL[*]$0 (Tier 4)VITAMIN A PALMITATE TABLET 15000 UNIT

ORAL[*]$0 (Tier 4)vitamin b-1 tablet 100 mg oral[*]$0 (Tier 4)vitamin b-1 tablet 250 mg oral[*]$0 (Tier 4)vitamin b-1 tablet 50 mg oral[*]$0 (Tier 4)vitamin b-12 er tablet extended release 1000

mcg oral[*]$0 (Tier 4)vitamin b-12 tablet 100 mcg oral[*]$0 (Tier 4)vitamin b-12 tablet 1000 mcg oral[*]$0 (Tier 4)vitamin b-12 tablet 250 mcg oral[*]$0 (Tier 4)vitamin b-12 tablet 500 mcg oral[*]$0 (Tier 4)vitamin b-2 tablet 100 mg oral[*]$0 (Tier 4)vitamin b-2 tablet 25 mg oral[*]$0 (Tier 4)vitamin b-2 tablet 50 mg oral[*]$0 (Tier 4)vitamin b-6 tablet 100 mg oral[*]$0 (Tier 4)vitamin b-6 tablet 50 mg oral[*]$0 (Tier 4)vitamin b12 tablet 100 mcg oral[*]$0 (Tier 4)vitamin c tablet 1000 mg oral



Giá Thuốc

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Tên Thuốc

[*]$0 (Tier 4)vitamin c tablet 250 mg oral[*]$0 (Tier 4)vitamin c tablet 500 mg oral[*]$0 (Tier 4)vitamin c-rose hips tablet 1000 mg oral[*]$0 (Tier 4)vitamin c-rose hips tablet 500 mg oral[*]$0 (Tier 4)vitamin c/rose hips tablet 500 mg oral[*]$0 (Tier 4)vitamin d (cholecalciferol) capsule 10 mcg (400

unit) oral[*]$0 (Tier 4)vitamin d (cholecalciferol) capsule 25 mcg

(1000 ut) oral[*]$0 (Tier 4)vitamin d (cholecalciferol) tablet 10 mcg (400

unit) oral[*]$0 (Tier 4)vitamin d (cholecalciferol) tablet 25 mcg (1000

ut) oral[*]$0 (Tier 3)vitamin d (ergocalciferol) capsule 1.25 mg

(50000 ut) oral[*]$0 (Tier 4)vitamin d capsule 50 mcg (2000 ut) oral[*]$0 (Tier 4)vitamin d high potency capsule 25 mcg (1000

ut) oral[*]$0 (Tier 4)vitamin d liquid 10 mcg/ml oral[*]$0 (Tier 4)vitamin d tablet 25 mcg (1000 ut) oral[*]$0 (Tier 4)vitamin d tablet 50 mcg (2000 ut) oral[*]$0 (Tier 4)vitamin d-3 capsule 25 mcg (1000 ut) oral[*]$0 (Tier 4)vitamin d2 tablet 10 mcg (400 unit) oral[*]$0 (Tier 4)vitamin d3 capsule 10 mcg (400 unit) oral[*]$0 (Tier 4)vitamin d3 capsule 125 mcg (5000 ut) oral[*]$0 (Tier 4)vitamin d3 capsule 25 mcg (1000 ut) oral[*]$0 (Tier 4)vitamin d3 capsule 50 mcg (2000 ut) oral[*]$0 (Tier 4)vitamin d3 maximum strength capsule 125 mcg

(5000 ut) oral[*]$0 (Tier 4)vitamin d3 tablet 10 mcg (400 unit) oral[*]$0 (Tier 4)vitamin d3 tablet 125 mcg (5000 ut) oral[*]$0 (Tier 4)vitamin d3 tablet 25 mcg (1000 ut) oral



Giá Thuốc

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Tên Thuốc

[*]$0 (Tier 4)vitamin d3 tablet 50 mcg (2000 ut) oral[*]$0 (Tier 4)vitamin e capsule 100 unit oral[*]$0 (Tier 4)vitamin e capsule 1000 unit oral[*]$0 (Tier 4)vitamin e capsule 200 unit oral[*]$0 (Tier 4)vitamin e capsule 400 unit oral[*]$0 (Tier 4)vitamin e water soluble capsule 1000 unit oralPAR; NE$0 (Tier 2)VPRIV

GASTROINTESTINAL AGENTS

[*]$0 (Tier 4)acid gone suspension 95-358 mg/15ml oral[*]$0 (Tier 4)acid gone tablet chewable 160-105 mg oral[*]$0 (Tier 4)acid reducer maximum strength tablet 20 mg

oral[*]$0 (Tier 4)acid reducer tablet 10 mg oral[*]$0 (Tier 4)acid reducer tablet 75 mg oral[*]$0 (Tier 4)almacone double strength suspension 400-400-

40 mg/5ml oral[*]$0 (Tier 4)almacone suspension 200-200-20 mg/5ml oralPAR; MO; NE; QLL (60 per 30 days)$0 (Tier 2)alosetron hcl[*]$0 (Tier 4)aluminum hydroxide gel suspension 320 mg/

5ml oralMO; QLL (60 per 30 days)$0 (Tier 2)AMITIZA[*]$0 (Tier 4)antacid anti-gas max strength suspension 400-

400-40 mg/5ml oral[*]$0 (Tier 4)antacid extra strength tablet chewable 750 mg

oral[*]$0 (Tier 4)antacid fast relief suspension 200-200-20 mg/

5ml oral[*]$0 (Tier 4)antacid maximum strength suspension 400-

400-40 mg/5ml oral[*]$0 (Tier 4)antacid maximum tablet chewable 1000 mg

oral



Giá Thuốc

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Tên Thuốc

[*]$0 (Tier 4)antacid plus anti-gas fast act suspension 200- 200-20 mg/5ml oral

[*]$0 (Tier 4)antacid plus anti-gas relief suspension 200- 200-20 mg/5ml oral

[*]$0 (Tier 4)antacid plus anti-gas relief suspension 400- 400-40 mg/5ml oral

[*]$0 (Tier 4)antacid suspension 200-200-20 mg/5ml oral[*]$0 (Tier 4)antacid tablet chewable 500 mg oralMO$0 (Tier 2)atropine sulfate injection solution prefilled

syringe 0.25 mg/5ml, 1 mg/10ml$0 (Tier 2)atropine sulfate injection solution prefilled

syringe 0.5 mg/5ml[*]$0 (Tier 4)bisacodyl ec tablet delayed release 5 mg oral[*]$0 (Tier 4)bisacodyl suppository 10 mg rectal[*]$0 (Tier 4)bismatrol maximum strength suspension 525

mg/15ml oral[*]$0 (Tier 4)bismatrol suspension 262 mg/15ml oral[*]$0 (Tier 4)bismatrol tablet chewable 262 mg oral[*]$0 (Tier 4)bismuth subsalicylate tablet chewable 262 mg

oralMO; NE$0 (Tier 2)budesonide oral[*]$0 (Tier 4)calcium antacid ultra max st tablet chewable

1000 mg oral[*]$0 (Tier 4)calcium antacid ultra strength tablet chewable

1000 mg oral[*]$0 (Tier 4)calcium carbonate antacid tablet chewable 750

mg oral[*]$0 (Tier 4)clearlax powder oralMO$0 (Tier 2)constulose[*]$0 (Tier 4)cvs antacid kids tablet chewable 750 mg oral[*]$0 (Tier 4)cvs anti-diarrheal suspension 262 mg/15ml oral[*]$0 (Tier 4)cvs bismuth tablet 262 mg oral[*]$0 (Tier 4)cvs bismuth tablet chewable 262 mg oral



Giá Thuốc

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Tên Thuốc

[*]$0 (Tier 4)cvs chewy not chalky flavor tablet chewable 750 mg oral

[*]$0 (Tier 4)cvs gas relief capsule 125 mg oral[*]$0 (Tier 4)cvs gas relief extra strength tablet chewable

125 mg oral[*]$0 (Tier 4)cvs gas relief ultra strength capsule 180 mg

oral[*]$0 (Tier 4)cvs glycerin adult suppository 2 gm rectal[*]$0 (Tier 4)cvs glycerin adult suppository 2.1 gm rectal[*]$0 (Tier 4)cvs heartburn relief tablet chewable 160-105

mg oral[*]$0 (Tier 4)cvs magnesium citrate solution 1.745 gm/30ml

oral[*]$0 (Tier 4)cvs mineral oil enema enema rectal[*]$0 (Tier 4)cvs mineral oil oil oral[*]$0 (Tier 4)cvs stomach relief suspension 525 mg/15ml

oral[*]$0 (Tier 4)cvs stomach relief tablet chewable 262 mg oral[*]$0 (Tier 4)diarrhea suspension 262 mg/15ml oralMO$0 (Tier 2)dicyclomine hcl oralMO$0 (Tier 2)diphenoxylate-atropine[*]$0 (Tier 4)docu liquid 50 mg/5ml oral[*]$0 (Tier 4)docusate sodium capsule 100 mg oral[*]$0 (Tier 4)docusate sodium liquid 50 mg/5ml oral[*]$0 (Tier 4)docusate sodium tablet 100 mg oral[*]$0 (Tier 4)docusil capsule 100 mg oral[*]$0 (Tier 4)dok capsule 100 mg oral[*]$0 (Tier 4)dok capsule 250 mg oral[*]$0 (Tier 4)ducodyl tablet delayed release 5 mg oral[*]$0 (Tier 4)enema enema 7-19 gm/118ml rectal[*]$0 (Tier 4)enema mineral oil enema rectalMO$0 (Tier 2)enulose



Giá Thuốc

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Tên Thuốc

[*]$0 (Tier 4)eq antacid extra strength tablet chewable 750 mg oral

[*]$0 (Tier 4)eq antacid ultra strength tablet chewable 1000 mg oral

[*]$0 (Tier 4)eq gas relief capsule 125 mg oral[*]$0 (Tier 4)eq magnesium citrate solution 1.745 gm/30ml

oral[*]$0 (Tier 4)eq mineral oil oil oral[*]$0 (Tier 4)eq pink-bismuth tablet chewable 262 mg oral[*]$0 (Tier 4)eq stomach relief suspension 262 mg/15ml oral[*]$0 (Tier 4)eql stomach relief suspension 262 mg/15ml

oralMO$0 (Tier 2)famotidine intravenous solution 20 mg/2ml, 200

mg/20ml, 40 mg/4mlMO$0 (Tier 2)famotidine oral tablet 20 mg, 40 mgMO$0 (Tier 2)famotidine premixed[*]$0 (Tier 4)famotidine tablet 10 mg oral[*]$0 (Tier 4)gas relief capsule 180 mg oral[*]$0 (Tier 4)gas relief extra strength capsule 125 mg oral[*]$0 (Tier 4)gas relief extra strength tablet chewable 125

mg oral[*]$0 (Tier 4)gas relief tablet chewable 80 mg oral[*]$0 (Tier 4)gas relief ultra strength capsule 180 mg oral[*]$0 (Tier 4)GAS-X ULTRA STRENGTH CAPSULE 180

MG ORALPAR; LA; NE$0 (Tier 2)GATTEX[*]$0 (Tier 4)gavilax powder oralMO$0 (Tier 2)gavilyte-cMO$0 (Tier 2)gavilyte-gMO$0 (Tier 2)gavilyte-n with flavor packMO$0 (Tier 2)generlac[*]$0 (Tier 4)geri-pectate suspension 262 mg/15ml oral



Giá Thuốc

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Tên Thuốc

[*]$0 (Tier 4)glycerin (adult) suppository 2 gm rectal[*]$0 (Tier 4)glycerin (adult) suppository 2.1 gm rectal[*]$0 (Tier 4)glycolax powder oralMO$0 (Tier 2)glycopyrrolate injection solution 0.2 mg/mlMO$0 (Tier 2)glycopyrrolate oral tablet 1 mg, 2 mg[*]$0 (Tier 4)gnp acid control 150 max st tablet 150 mg oral[*]$0 (Tier 4)gnp acid reducer max st tablet 20 mg oral[*]$0 (Tier 4)gnp acid reducer tablet 75 mg oral[*]$0 (Tier 4)gnp antacid extra strength tablet chewable 160-

105 mg oral[*]$0 (Tier 4)gnp antacid extra strength tablet chewable 750

mg oral[*]$0 (Tier 4)gnp antacid tablet chewable 500 mg oral[*]$0 (Tier 4)gnp antacid ultra strength tablet chewable 1000

mg oral[*]$0 (Tier 4)gnp anti-gas capsule 180 mg oral[*]$0 (Tier 4)gnp bisa-lax tablet delayed release 5 mg oral[*]$0 (Tier 4)gnp clearlax powder oral[*]$0 (Tier 4)gnp gas relief extra strength capsule 125 mg

oral[*]$0 (Tier 4)gnp gas relief extra strength tablet chewable

125 mg oral[*]$0 (Tier 4)gnp gas relief tablet chewable 80 mg oral[*]$0 (Tier 4)gnp lansoprazole capsule delayed release 15

mg oral[*]$0 (Tier 4)gnp laxative tablet delayed release 5 mg oral[*]$0 (Tier 4)gnp magnesium citrate solution 1.745 gm/30ml

oral[*]$0 (Tier 4)gnp omeprazole tablet delayed release 20 mg

oral[*]$0 (Tier 4)gnp pink bismuth tablet 262 mg oral[*]$0 (Tier 4)gnp pink bismuth tablet chewable 262 mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)gnp stomach relief suspension 262 mg/15ml oral

[*]$0 (Tier 4)gnp stool softener capsule 100 mg oral[*]$0 (Tier 4)gnp stool softener capsule 250 mg oral[*]$0 (Tier 4)goodsense gas relief tablet chewable 125 mg

oral[*]$0 (Tier 4)healthylax packet oral[*]$0 (Tier 4)heartburn antacid ex st tablet chewable 160-

105 mg oral[*]$0 (Tier 4)heartburn relief max st tablet 150 mg oral[*]$0 (Tier 4)heartburn relief max st tablet 20 mg oral[*]$0 (Tier 4)heartburn relief tablet 10 mg oral[*]$0 (Tier 4)hm acid reducer tablet 75 mg oral[*]$0 (Tier 4)hm advanced antacid max st suspension 400-

400-40 mg/5ml oral[*]$0 (Tier 4)hm antacid anti-gas ex st suspension 400-400-

40 mg/5ml oral[*]$0 (Tier 4)hm antacid/antigas suspension 200-200-20

mg/5ml oral[*]$0 (Tier 4)hm calcium antacid ex st tablet chewable 750

mg oral[*]$0 (Tier 4)hm clearlax powder oral[*]$0 (Tier 4)hm enema mineral oil enema rectal[*]$0 (Tier 4)hm famotidine tablet 10 mg oral[*]$0 (Tier 4)hm famotidine tablet 20 mg oral[*]$0 (Tier 4)hm magnesium citrate solution 1.745 gm/30ml

oral[*]$0 (Tier 4)hm milk of magnesia suspension 1200 mg/15ml

oral[*]$0 (Tier 4)hm mineral oil oil oral[*]$0 (Tier 4)hm omeprazole tablet delayed release 20 mg

oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)hm stomach relief suspension 262 mg/15ml oral

[*]$0 (Tier 4)hm stomach relief tablet chewable 262 mg oral[*]$0 (Tier 4)hm stool softener capsule 100 mg oral[*]$0 (Tier 4)hm stool softener capsule 250 mg oral[*]$0 (Tier 4)kao-tin capsule 240 mg oral[*]$0 (Tier 4)kaopectate extra strength suspension 525 mg/

15ml oral[*]$0 (Tier 4)kaopectate suspension 262 mg/15ml oralMO$0 (Tier 2)lactulose encephalopathyMO$0 (Tier 2)lactulose oral solution[*]$0 (Tier 4)lansoprazole capsule delayed release 15 mg

oral (otc)MO$0 (Tier 2)lansoprazole oral capsule delayed release 15

mgMO; QLL (30 per 30 days)$0 (Tier 2)lansoprazole oral capsule delayed release 30

mg[*]$0 (Tier 4)laxative suppository 10 mg rectalMO; QLL (30 per 30 days)$0 (Tier 2)LINZESSMO$0 (Tier 2)loperamide hcl oral capsule[*]$0 (Tier 4)mag-al plus liquid 200-200-20 mg/5ml oral[*]$0 (Tier 4)mag-al plus xs liquid 400-400-40 mg/5ml oral[*]$0 (Tier 4)magnesium citrate solution 1.745 gm/30ml oralMO$0 (Tier 2)mesalamine-cleanserMO$0 (Tier 2)metoclopramide hcl injectionMO$0 (Tier 2)metoclopramide hcl oral solution 10 mg/10ml,

5 mg/5mlMO$0 (Tier 2)metoclopramide hcl oral tablet[*]$0 (Tier 4)mi-acid gas relief tablet chewable 80 mg oral[*]$0 (Tier 4)milk of magnesia suspension 1200 mg/15ml

oral[*]$0 (Tier 4)mineral oil enema rectal



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)mineral oil oil oral[*]$0 (Tier 4)mintox suspension 200-200-20 mg/5ml oralMO$0 (Tier 2)misoprostol oralMO; QLL (30 per 30 days)$0 (Tier 2)MOVANTIKMO$0 (Tier 2)MOVIPREPMO; QLL (30 per 30 days)$0 (Tier 1)omeprazole oral capsule delayed release[*]$0 (Tier 4)omeprazole tablet delayed release 20 mg oralMO$0 (Tier 2)pantoprazole sodium intravenousMO; QLL (30 per 30 days)$0 (Tier 1)pantoprazole sodium oral[*]$0 (Tier 4)peg 3350 packet oral[*]$0 (Tier 4)peg 3350 powder oralMO$0 (Tier 2)peg 3350-kcl-na bicarb-naclMO$0 (Tier 2)peg 3350/electrolytesMO$0 (Tier 2)peg-3350/electrolytes[*]$0 (Tier 4)peptic relief tablet chewable 262 mg oral[*]$0 (Tier 4)pepto-bismol tablet chewable 262 mg oral[*]$0 (Tier 4)pepto-bismol to-go tablet chewable 262 mg

oral[*]$0 (Tier 4)PHAZYME ULTRA STRENGTH CAPSULE

180 MG ORAL$0 (Tier 2)polyethylene glycol 3350 oral packet

MO$0 (Tier 2)polyethylene glycol 3350 oral powder[*]$0 (Tier 4)polyethylene glycol 3350 packet oral (otc)[*]$0 (Tier 4)polyethylene glycol 3350 powder oral (otc)MO$0 (Tier 2)proctozone-hc rectal[*]$0 (Tier 4)px gas relief extra strength capsule 125 mg

oral[*]$0 (Tier 4)px gas relief ultra strength capsule 180 mg oral[*]$0 (Tier 4)px stomach relief max st suspension 525 mg/

15ml oral[*]$0 (Tier 4)px stomach relief suspension 262 mg/15ml oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)px stomach relief tablet chewable 262 mg oral[*]$0 (Tier 4)qc acid controller max st tablet 20 mg oral[*]$0 (Tier 4)qc acid controller tablet 10 mg oral[*]$0 (Tier 4)qc antacid suspension 200-200-20 mg/5ml oral[*]$0 (Tier 4)qc antacid/anti-gas suspension 200-200-20

mg/5ml oral[*]$0 (Tier 4)qc gentle laxative suppository 10 mg rectal[*]$0 (Tier 4)qc heartburn antacid tablet chewable 160-105

mg oral[*]$0 (Tier 4)qc magnesium citrate solution 1.745 gm/30ml

oral[*]$0 (Tier 4)qc milk of magnesia suspension 400 mg/5ml

oral[*]$0 (Tier 4)qc mineral oil heavy oil oral[*]$0 (Tier 4)ra gas relief capsule 125 mg oral[*]$0 (Tier 4)ra gas relief extra strength tablet chewable 125

mg oral[*]$0 (Tier 4)ra glycerin adult suppository 80.7 % rectal[*]$0 (Tier 4)ra mineral oil oil oral[*]$0 (Tier 4)ra pink bismuth tablet 262 mg oral[*]$0 (Tier 4)ra pink bismuth tablet chewable 262 mg oral[*]$0 (Tier 4)ra stomach relief max st suspension 525 mg/

15ml oral[*]$0 (Tier 4)ra stomach relief suspension 262 mg/15ml oralMO$0 (Tier 2)ranitidine hcl injectionMO$0 (Tier 2)ranitidine hcl oral syrupMO$0 (Tier 2)ranitidine hcl oral tablet 150 mg, 300 mg[*]$0 (Tier 4)ranitidine hcl tablet 150 mg oral (otc)PAR; MO; NE; QLL (18 per 30 days)$0 (Tier 2)RELISTOR SUBCUTANEOUS SOLUTION 12

MG/0.6MLPAR; NE; QLL (18 per 30 days)$0 (Tier 2)RELISTOR SUBCUTANEOUS SOLUTION 12

MG/0.6ML (0.6ML SYRINGE)



Giá Thuốc

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Tên Thuốc

PAR; MO; NE; QLL (12 per 30 days)$0 (Tier 2)RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML

PAR; NE$0 (Tier 2)REMICADE[*]$0 (Tier 4)sb antacid anti-gas suspension 200-200-20

mg/5ml oral[*]$0 (Tier 4)sb omeprazole tablet delayed release 20 mg

oralMO; QLL (10 per 28 days)$0 (Tier 2)scopolamine[*]$0 (Tier 4)silace liquid 150 mg/15ml oral[*]$0 (Tier 4)silace syrup 60 mg/15ml oral[*]$0 (Tier 4)simethicone capsule 125 mg oral[*]$0 (Tier 4)simethicone capsule 180 mg oral[*]$0 (Tier 4)simethicone tablet chewable 125 mg oral[*]$0 (Tier 4)simethicone tablet chewable 80 mg oral[*]$0 (Tier 4)sm acid reducer max st tablet 20 mg oral[*]$0 (Tier 4)sm acid reducer tablet 10 mg oral[*]$0 (Tier 4)sm acid reducer tablet 75 mg oral[*]$0 (Tier 4)sm antacid advanced max st suspension 400-

400-40 mg/5ml oral[*]$0 (Tier 4)sm antacid anti-gas suspension 200-200-20

mg/5ml oral[*]$0 (Tier 4)sm calcium antacid ex st tablet chewable 750

mg oral[*]$0 (Tier 4)sm clearlax powder oral[*]$0 (Tier 4)sm foaming antacid tablet chewable 80-20 mg

oral[*]$0 (Tier 4)sm gas relief antiflatuent capsule 180 mg oral[*]$0 (Tier 4)sm magnesium citrate solution 1.745 gm/30ml

oral[*]$0 (Tier 4)sm milk of magnesia suspension 1200 mg/15ml

oral[*]$0 (Tier 4)sm mineral oil enema rectal



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[*]$0 (Tier 4)sm omeprazole tablet delayed release 20 mg oral

[*]$0 (Tier 4)sm stomach relief tablet 262 mg oral[*]$0 (Tier 4)sm stomach relief tablet chewable 262 mg oral[*]$0 (Tier 4)sm stool softener capsule 100 mg oral[*]$0 (Tier 4)sm stool softener capsule 240 mg oral[*]$0 (Tier 4)soothe suspension 262 mg/15ml oral[*]$0 (Tier 4)soothe tablet 262 mg oral[*]$0 (Tier 4)soothe tablet chewable 262 mg oral[*]$0 (Tier 4)stimulant laxative tablet delayed release 5 mg

oral[*]$0 (Tier 4)stomach relief max st suspension 525 mg/15ml

oral[*]$0 (Tier 4)stomach relief suspension 262 mg/15ml oral[*]$0 (Tier 4)stomach relief tablet chewable 262 mg oral[*]$0 (Tier 4)stool softener capsule 100 mg oral[*]$0 (Tier 4)stool softener capsule 240 mg oral[*]$0 (Tier 4)stool softener capsule 250 mg oralMO$0 (Tier 2)sucralfate oral tabletMO$0 (Tier 2)trilyte[*]$0 (Tier 4)tums ultra 1000 tablet chewable 1000 mg oralMO$0 (Tier 2)ursodiol oral

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

PAR; LA; NE$0 (Tier 2)ALDURAZYMEPAR; NE$0 (Tier 2)CERDELGAMO$0 (Tier 2)CREONLA; NE$0 (Tier 2)CYSTADANELA$0 (Tier 2)CYSTAGONPAR; LA; NE$0 (Tier 2)ELAPRASEPAR; LA; NE$0 (Tier 2)FABRAZYMEPAR; LA; NE$0 (Tier 2)KUVAN ORAL TABLET SOLUBLE



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PAR; LA; NE$0 (Tier 2)LUMIZYMEPAR; LA; NE$0 (Tier 2)miglustatPAR; LA; NE$0 (Tier 2)NAGLAZYMEPAR; NE$0 (Tier 2)nitisinonePAR; LA; NE$0 (Tier 2)ORFADINPAR; LA; NE; QLL (525 per 30 days)$0 (Tier 2)RAVICTIPAR; NE$0 (Tier 2)sodium phenylbutyrate oral tabletST; MO$0 (Tier 2)ZENPEP ORAL CAPSULE DELAYED

RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000- 126000 UNIT, 5000-24000 UNIT

GENITOURINARY AGENTS

MO$0 (Tier 2)alfuzosin hcl erMO$0 (Tier 2)bethanechol chloride oralMO$0 (Tier 2)calcium acetate (phos binder) oral capsuleMO; NE$0 (Tier 2)DEPEN TITRATABSMO$0 (Tier 1)doxazosin mesylate oralMO; QLL (30 per 30 days)$0 (Tier 2)dutasteride oralMO; QLL (30 per 30 days)$0 (Tier 2)dutasteride-tamsulosin hclMO$0 (Tier 2)finasteride oral tablet 5 mgMO; QLL (30 per 30 days)$0 (Tier 2)MYRBETRIQMO$0 (Tier 2)neomycin-polymyxin b guMO; QLL (60 per 30 days)$0 (Tier 2)oxybutynin chloride er oral tablet extended

release 24 hour 10 mg, 15 mgMO; QLL (30 per 30 days)$0 (Tier 2)oxybutynin chloride er oral tablet extended

release 24 hour 5 mgMO; QLL (600 per 30 days)$0 (Tier 2)oxybutynin chloride oral syrupMO; QLL (120 per 30 days)$0 (Tier 2)oxybutynin chloride oral tabletMO$0 (Tier 2)PHOSLYRAMO$0 (Tier 2)potassium citrate er



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MO$0 (Tier 1)prazosin hcl oralMO; NE; QLL (540 per 30 days)$0 (Tier 2)sevelamer carbonate oral packet 0.8 gmMO; NE; QLL (180 per 30 days)$0 (Tier 2)sevelamer carbonate oral packet 2.4 gmMO; QLL (540 per 30 days)$0 (Tier 2)sevelamer carbonate oral tabletMO; QLL (30 per 30 days)$0 (Tier 2)solifenacin succinateMO$0 (Tier 2)tamsulosin hclMO$0 (Tier 1)terazosin hcl oralMO; QLL (60 per 30 days)$0 (Tier 2)tolterodine tartrateMO; QLL (30 per 30 days)$0 (Tier 2)tolterodine tartrate erMO; QLL (30 per 30 days)$0 (Tier 2)TOVIAZMO; NE; QLL (180 per 30 days)$0 (Tier 2)VELPHOROMO; QLL (30 per 30 days)$0 (Tier 2)VESICARE

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)

PAR; LA; NE; This medication is covered for the following indication(s): Spasms, Infantile

$0 (Tier 2)ACTHAR

MO$0 (Tier 2)ala-cort external creamMO$0 (Tier 2)alclometasone dipropionateMO$0 (Tier 2)amcinonide external creamMO$0 (Tier 2)amcinonide external lotionMO$0 (Tier 2)AMCINONIDE EXTERNAL OINTMENTMO$0 (Tier 2)betamethasone dipropionate aug external

creamMO$0 (Tier 2)betamethasone dipropionate aug external lotionMO$0 (Tier 2)betamethasone dipropionate aug external

ointmentMO$0 (Tier 2)betamethasone dipropionate external creamMO$0 (Tier 2)betamethasone dipropionate external ointmentMO$0 (Tier 2)betamethasone valerate external creamMO$0 (Tier 2)betamethasone valerate external lotionMO$0 (Tier 2)betamethasone valerate external ointment



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Tên Thuốc

MO$0 (Tier 2)CAPEXMO; QLL (120 per 30 days)$0 (Tier 2)clobetasol prop emollient baseMO; QLL (120 per 30 days)$0 (Tier 2)clobetasol propionate eMO; QLL (120 per 30 days)$0 (Tier 2)clobetasol propionate external creamMO$0 (Tier 2)clobetasol propionate external solutionMO$0 (Tier 2)cortisone acetate oralMO$0 (Tier 2)desoximetasone external creamMO$0 (Tier 2)desoximetasone external gelMO$0 (Tier 2)desoximetasone external ointmentMO$0 (Tier 2)dexamethasone oral elixirMO$0 (Tier 2)dexamethasone oral tabletMO$0 (Tier 2)fludrocortisone acetate oralMO; QLL (120 per 30 days)$0 (Tier 2)fluocinolone acetonide externalMO$0 (Tier 2)fluocinolone acetonide oticMO; QLL (120 per 30 days)$0 (Tier 2)fluocinolone acetonide scalpMO; QLL (240 per 30 days)$0 (Tier 2)fluocinonide emulsified baseMO; QLL (240 per 30 days)$0 (Tier 2)fluocinonide external gelMO; QLL (240 per 30 days)$0 (Tier 2)fluocinonide external ointmentMO; QLL (240 per 30 days)$0 (Tier 2)fluocinonide external solutionMO$0 (Tier 2)fluticasone propionate externalMO$0 (Tier 2)halobetasol propionate external creamMO$0 (Tier 2)halobetasol propionate external ointmentMO$0 (Tier 2)hydrocortisone external cream 1 %, 2.5 %MO$0 (Tier 2)hydrocortisone external lotion 2.5 %MO$0 (Tier 2)hydrocortisone external ointment 1 %, 2.5 %MO$0 (Tier 2)hydrocortisone oralMO$0 (Tier 2)hydrocortisone valerateMO$0 (Tier 2)methylprednisolone oralMO$0 (Tier 2)mometasone furoate externalMO$0 (Tier 2)prednisolone oral solution



Giá Thuốc

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Tên Thuốc

MO$0 (Tier 2)prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml

MO$0 (Tier 2)PREDNISONE INTENSOLMO$0 (Tier 2)prednisone oralMO$0 (Tier 2)procto-pakMO$0 (Tier 2)proctozone-hc rectalMO$0 (Tier 2)triamcinolone acetonide external creamMO$0 (Tier 2)triamcinolone acetonide external lotionMO$0 (Tier 2)triamcinolone acetonide external ointment

0.025 %, 0.1 %, 0.5 %MO$0 (Tier 2)triderm external cream 0.1 %

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)

MO$0 (Tier 2)desmopressin ace spray refrigMO$0 (Tier 2)desmopressin acetate injectionMO$0 (Tier 2)desmopressin acetate oralMO$0 (Tier 2)desmopressin acetate sprayPAR; LA; NE$0 (Tier 2)INCRELEXPAR; NE$0 (Tier 2)NORDITROPIN FLEXPROPAR; LA; NE$0 (Tier 2)OMNITROPENE$0 (Tier 2)STIMATE

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PROSTAGLANDINS)

MO$0 (Tier 2)misoprostol oral tablet 200 mcg

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS)

MO$0 (Tier 2)afirmelle[*]$0 (Tier 4)AFTERA TABLET 1.5 MG ORALMO$0 (Tier 2)altaveraMO$0 (Tier 2)alyacen 1/35MO$0 (Tier 2)alyacen 7/7/7



Giá Thuốc

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Tên Thuốc

PAR; MO; NE$0 (Tier 2)ANADROL-50MO$0 (Tier 2)apriMO$0 (Tier 2)aranelleMO$0 (Tier 2)aubraMO$0 (Tier 2)aubra eqMO$0 (Tier 2)aurovela 1.5/30MO$0 (Tier 2)aurovela 1/20MO$0 (Tier 2)aurovela fe 1.5/30MO$0 (Tier 2)aurovela fe 1/20MO$0 (Tier 2)avianeMO$0 (Tier 2)ayunaMO$0 (Tier 2)azuretteMO$0 (Tier 2)balzivaMO$0 (Tier 2)bekyreeMO$0 (Tier 2)blisovi fe 1.5/30MO$0 (Tier 2)blisovi fe 1/20MO$0 (Tier 2)briellynMO; NE$0 (Tier 2)budesonide oralMO$0 (Tier 2)camilaMO$0 (Tier 2)caziantMO$0 (Tier 2)chatealMO$0 (Tier 2)chateal eqMO$0 (Tier 2)cryselle-28MO$0 (Tier 2)cyclafem 1/35MO$0 (Tier 2)cyclafem 7/7/7MO$0 (Tier 2)cyred

$0 (Tier 2)cyred eqMO$0 (Tier 2)danazol oralMO$0 (Tier 2)dasetta 1/35MO$0 (Tier 2)dasetta 7/7/7



Giá Thuốc

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Tên Thuốc

MO$0 (Tier 2)deblitaneMO$0 (Tier 2)delylaMO$0 (Tier 2)DEPO-PROVERA INTRAMUSCULAR

SUSPENSION 400 MG/MLMO$0 (Tier 2)desogestrel-ethinyl estradiolMO$0 (Tier 2)drospirenone-ethinyl estradiol oral tablet 3-0.03

mg[*]$0 (Tier 4)econtra ez tablet 1.5 mg oralMO$0 (Tier 2)elinest

$0 (Tier 2)ELLAMO$0 (Tier 2)eluryngMO$0 (Tier 2)emoquetteMO$0 (Tier 2)enpresse-28MO$0 (Tier 2)enskyce oral tablet 0.15-30 mg-mcgMO$0 (Tier 2)errinMO$0 (Tier 2)estaryllaPAR; MO$0 (Tier 2)estradiol oralPAR; MO; QLL (4 per 28 days)$0 (Tier 2)estradiol transdermal patch weeklyMO$0 (Tier 2)estradiol vaginal creamMO; NE; QLL (1 per 90 days)$0 (Tier 2)ESTRINGMO$0 (Tier 2)ethynodiol diac-eth estradiolMO$0 (Tier 2)falminaMO$0 (Tier 2)femynor

$0 (Tier 2)hailey 1.5/30MO$0 (Tier 2)heatherMO$0 (Tier 2)incassiaMO$0 (Tier 2)introvaleMO$0 (Tier 2)isibloomMO$0 (Tier 2)jencyclaMO$0 (Tier 2)jolessa



Giá Thuốc

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Tên Thuốc

MO$0 (Tier 2)juleberMO$0 (Tier 2)junel 1.5/30MO$0 (Tier 2)junel 1/20MO$0 (Tier 2)junel fe 1.5/30MO$0 (Tier 2)junel fe 1/20MO$0 (Tier 2)kalligaMO$0 (Tier 2)karivaMO$0 (Tier 2)kelnor 1/35MO$0 (Tier 2)kelnor 1/50MO$0 (Tier 2)kurveloMO$0 (Tier 2)larin 1.5/30MO$0 (Tier 2)larin 1/20MO$0 (Tier 2)larin fe 1.5/30MO$0 (Tier 2)larin fe 1/20MO$0 (Tier 2)larissiaMO$0 (Tier 2)leenaMO$0 (Tier 2)lessinaMO$0 (Tier 2)levonestMO$0 (Tier 2)levonorg-eth estrad triphasic oral tablet 50-30/

75-40/ 125-30 mcgMO$0 (Tier 2)levonorgest-eth estrad 91-day oral tablet 0.15-

0.03 mgMO$0 (Tier 2)levonorgestrel-ethinyl estrad oral tablet 0.1-20

mg-mcg, 0.15-30 mg-mcgMO$0 (Tier 2)levora 0.15/30 (28)MO$0 (Tier 2)lillowMO$0 (Tier 2)low-ogestrelMO$0 (Tier 2)luteraMO$0 (Tier 2)lyzaMO$0 (Tier 2)marlissaMO$0 (Tier 2)marlissa



Giá Thuốc

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Tên Thuốc

MO$0 (Tier 2)marlissaMO$0 (Tier 2)medroxyprogesterone acetate intramuscularMO$0 (Tier 2)medroxyprogesterone acetate oralPAR; MO$0 (Tier 2)megestrol acetate oral suspension 40 mg/ml,

400 mg/10mlPAR; MO$0 (Tier 2)megestrol acetate oral tabletPAR; MO$0 (Tier 2)MENEST ORAL TABLET 0.3 MG, 0.625 MG,

1.25 MGMO$0 (Tier 2)microgestin 1.5/30MO$0 (Tier 2)microgestin 1/20MO$0 (Tier 2)microgestin fe 1.5/30MO$0 (Tier 2)microgestin fe 1/20MO$0 (Tier 2)miliMO$0 (Tier 2)mono-linyahMO$0 (Tier 2)mononessaMO$0 (Tier 2)necon 0.5/35 (28)MO$0 (Tier 2)nora-beMO$0 (Tier 2)norethin ace-eth estrad-fe oral tablet 1-20 mg-

mcgMO$0 (Tier 2)norethindrone acet-ethinyl est oral tabletMO$0 (Tier 2)norethindrone acetate oralMO$0 (Tier 2)norethindrone oralMO$0 (Tier 2)norgestim-eth estrad triphasic oral tablet 0.18/

0.215/0.25 mg-35 mcgMO$0 (Tier 2)norgestimate-eth estradiol oral tablet 0.25-35

mg-mcgMO$0 (Tier 2)norlydaMO$0 (Tier 2)norlyrocMO$0 (Tier 2)nortrel 0.5/35 (28)MO$0 (Tier 2)nortrel 1/35 (21)MO$0 (Tier 2)nortrel 1/35 (28)



Giá Thuốc

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Tên Thuốc

MO$0 (Tier 2)nortrel 7/7/7MO$0 (Tier 2)NUVARINGMO$0 (Tier 2)ocellaMO$0 (Tier 2)ogestrel[*]$0 (Tier 4)opcicon one-step tablet 1.5 mg oralMO$0 (Tier 2)orsythiaPAR; MO; QLL (60 per 30 days)$0 (Tier 2)oxandrolone oral tablet 10 mgPAR; MO; QLL (240 per 30 days)$0 (Tier 2)oxandrolone oral tablet 2.5 mgMO$0 (Tier 2)philithMO$0 (Tier 2)pimtreaMO$0 (Tier 2)pirmella 1/35MO$0 (Tier 2)pirmella 7/7/7[*]$0 (Tier 4)PLAN B ONE-STEP TABLET 1.5 MG ORAL

(OTC)MO$0 (Tier 2)portia-28PAR; MO$0 (Tier 2)PREMARIN ORALMO$0 (Tier 2)PREMARIN VAGINALPAR; MO$0 (Tier 2)PREMPROMO$0 (Tier 2)previfemMO$0 (Tier 2)progesterone micronized oralMO; QLL (30 per 30 days)$0 (Tier 2)raloxifene hclMO$0 (Tier 2)reclipsenMO$0 (Tier 2)setlakinMO$0 (Tier 2)sharobelMO$0 (Tier 2)sprintec 28MO$0 (Tier 2)sronyxMO$0 (Tier 2)syeda[*]$0 (Tier 4)TAKE ACTION TABLET 1.5 MG ORALMO$0 (Tier 2)tarina fe 1/20MO$0 (Tier 2)tarina fe 1/20 eq



Giá Thuốc

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Tên Thuốc

PAR; MO$0 (Tier 2)testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

PAR; MO$0 (Tier 2)testosterone enanthate intramuscular solutionPAR; MO; QLL (112.5 per 30 days)$0 (Tier 2)testosterone transdermal gel 20.25 mg/1.25gm

(1.62%)PAR; MO; QLL (150 per 30 days)$0 (Tier 2)testosterone transdermal gel 20.25 mg/act

(1.62%), 40.5 mg/2.5gm (1.62%)PAR; MO; QLL (300 per 30 days)$0 (Tier 2)testosterone transdermal gel 25 mg/2.5gm

(1%), 50 mg/5gm (1%)MO$0 (Tier 2)tri femynorMO$0 (Tier 2)tri-estaryllaMO$0 (Tier 2)tri-linyahMO$0 (Tier 2)tri-miliMO$0 (Tier 2)tri-previfemMO$0 (Tier 2)tri-sprintecMO$0 (Tier 2)tri-vylibraMO$0 (Tier 2)trinessa (28)MO$0 (Tier 2)trivora (28)MO$0 (Tier 2)tulana[*]$0 (Tier 4)vcf vaginal contraceptive foam 12.5 % vaginalMO$0 (Tier 2)velivetMO$0 (Tier 2)vienvaMO$0 (Tier 2)vioreleMO$0 (Tier 2)vyfemlaMO$0 (Tier 2)vylibraMO$0 (Tier 2)weraMO$0 (Tier 2)zarahMO$0 (Tier 2)zovia 1/35e (28)MO$0 (Tier 2)zumandimine



Giá Thuốc

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Tên Thuốc

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID)

MO$0 (Tier 1)levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

MO$0 (Tier 2)levo-t oral tablet 25 mcgMO$0 (Tier 1)levothyroxine sodium oral tablet 100 mcg, 112

mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

MO$0 (Tier 2)levothyroxine sodium oral tablet 25 mcgMO$0 (Tier 1)levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,

137 mcg, 150 mcg, 175 mcg, 200 mcg, 50 mcg, 75 mcg, 88 mcg

MO$0 (Tier 2)levoxyl oral tablet 25 mcgMO$0 (Tier 2)liothyronine sodium oralMO$0 (Tier 2)SYNTHROIDMO$0 (Tier 1)unithroid oral tablet 100 mcg, 112 mcg, 125

mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

MO$0 (Tier 2)unithroid oral tablet 25 mcg

HORMONAL AGENTS, SUPPRESSANT (ADRENAL)

MO$0 (Tier 2)LYSODREN

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

MO$0 (Tier 2)bromocriptine mesylate oralMO$0 (Tier 2)cabergolinePAR; NE; QLL (4 per 365 days)$0 (Tier 2)FIRMAGON SUBCUTANEOUS SOLUTION

RECONSTITUTED 120 MGPAR; QLL (1 per 28 days)$0 (Tier 2)FIRMAGON SUBCUTANEOUS SOLUTION

RECONSTITUTED 80 MGPAR$0 (Tier 2)leuprolide acetate injectionPAR; NE; QLL (1 per 28 days)$0 (Tier 2)LUPRON DEPOT (1-MONTH)PAR; NE; QLL (1 per 28 days)$0 (Tier 2)LUPRON DEPOT-PED (1-MONTH)

INTRAMUSCULAR KIT 7.5 MG



Giá Thuốc

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Tên Thuốc

PAR$0 (Tier 2)octreotide acetate injection solution 100 mcg/ ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml

PAR; NE$0 (Tier 2)octreotide acetate injection solution 500 mcg/ ml

PAR; LA; NE$0 (Tier 2)SIGNIFORPAR; NE$0 (Tier 2)SOMATULINE DEPOTPAR; LA; NE$0 (Tier 2)SOMAVERTPAR; NE$0 (Tier 2)SYNARELPAR; NE; QLL (1 per 84 days)$0 (Tier 2)TRELSTAR MIXJECT INTRAMUSCULAR

SUSPENSION RECONSTITUTED 11.25 MGPAR; NE; QLL (1 per 168 days)$0 (Tier 2)TRELSTAR MIXJECT INTRAMUSCULAR

SUSPENSION RECONSTITUTED 22.5 MGPAR; NE; QLL (1 per 28 days)$0 (Tier 2)TRELSTAR MIXJECT INTRAMUSCULAR

SUSPENSION RECONSTITUTED 3.75 MG

HORMONAL AGENTS, SUPPRESSANT (THYROID)

MO$0 (Tier 2)methimazole oralMO$0 (Tier 2)propylthiouracil oral

IMMUNOLOGICAL AGENTS

MO$0 (Tier 1)ACTHIBPAR; LA; NE$0 (Tier 2)ACTIMMUNE

$0 (Tier 1)ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 (PREFILLED SYRINGE)

MO$0 (Tier 1)ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF-MCG/0.5

PAR; NE$0 (Tier 2)AFINITOR DISPERZPAR; NE$0 (Tier 2)AFINITOR ORAL TABLET 2.5 MGPAR; NE$0 (Tier 2)ALIMTAPAR; NE$0 (Tier 2)ARCALYSTB/D PAR$0 (Tier 2)ATGAMB/D PAR; MO$0 (Tier 2)azathioprine oralB/D PAR; MO$0 (Tier 2)AZATHIOPRINE SODIUMMO$0 (Tier 2)BCG VACCINE



Giá Thuốc

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Tên Thuốc

PAR; NE$0 (Tier 2)BENLYSTAMO$0 (Tier 2)BEXSERO

$0 (Tier 1)BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 (0.5ML SYRINGE)

MO$0 (Tier 1)BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 , 5-2.5-18.5 LF-MCG/0.5

PAR; LA; NE$0 (Tier 2)CINRYZEB/D PAR$0 (Tier 2)cyclosporine intravenousB/D PAR$0 (Tier 2)cyclosporine modifiedB/D PAR$0 (Tier 2)cyclosporine oral capsuleMO$0 (Tier 1)DAPTACEL INTRAMUSCULAR SUSPENSION

23-15-5MO; NE$0 (Tier 2)DEPEN TITRATABSMO$0 (Tier 2)DIPHTHERIA-TETANUS TOXOIDS DTPAR; NE; QLL (4.08 per 28 days)$0 (Tier 2)ENBREL SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 25 MG/0.5MLPAR; NE; QLL (8 per 28 days)$0 (Tier 2)ENBREL SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 50 MG/MLPAR; NE; QLL (8 per 28 days)$0 (Tier 2)ENBREL SUBCUTANEOUS SOLUTION

RECONSTITUTEDPAR; NE; QLL (8 per 28 days)$0 (Tier 2)ENBREL SURECLICK SUBCUTANEOUS

SOLUTION AUTO-INJECTORB/D PAR; MO$0 (Tier 1)ENGERIX-B INJECTIONPAR; NE$0 (Tier 2)FIRAZYRPAR; NE$0 (Tier 2)GAMUNEX-CMO$0 (Tier 2)GARDASIL 9B/D PAR$0 (Tier 2)gengraf oral capsule 100 mg, 25 mgB/D PAR$0 (Tier 2)gengraf oral solution

$0 (Tier 1)HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML 1 ML, 720 EL U/0.5ML 0.5 ML

MO$0 (Tier 1)HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML

MO$0 (Tier 1)HIBERIX INJECTION



Giá Thuốc

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Tên Thuốc

PAR; NE; QLL (6 per 365 days)$0 (Tier 2)HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 40 MG/0.8ML (6 PACK), 80 MG/ 0.8ML

PAR; NE; QLL (12 per 365 days)$0 (Tier 2)HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML

PAR; NE; QLL (4 per 28 days)$0 (Tier 2)HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT

PAR; NE; QLL (12 per 365 days)$0 (Tier 2)HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

PAR; NE; QLL (6 per 365 days)$0 (Tier 2)HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML

PAR; NE; QLL (8 per 365 days)$0 (Tier 2)HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

PAR; NE; QLL (6 per 365 days)$0 (Tier 2)HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML

PAR; NE; QLL (2 per 28 days)$0 (Tier 2)HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML

PAR; NE; QLL (4 per 28 days)$0 (Tier 2)HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.4ML, 40 MG/0.8ML

NE$0 (Tier 2)HYPERRAB$0 (Tier 2)HYPERRAB S/D INJECTION SOLUTION 300

UNIT/2MLPAR; NE$0 (Tier 2)icatibant acetate

$0 (Tier 2)IMOGAM RABIES-HT INJECTION SOLUTION 300 UNIT/2ML

MO$0 (Tier 2)IMOVAX RABIESMO$0 (Tier 2)INFANRIXMO$0 (Tier 1)IPOLMO$0 (Tier 2)IXIARO



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$0 (Tier 2)KEDRAB INJECTION SOLUTION 300 UNIT/ 2ML

PAR; NE$0 (Tier 2)KEYTRUDA INTRAVENOUS SOLUTIONMO$0 (Tier 2)KINRIX INTRAMUSCULAR SUSPENSION

$0 (Tier 2)KINRIX INTRAMUSCULAR SUSPENSION INJECTION 0.5 ML

MO$0 (Tier 2)leflunomide oralMO$0 (Tier 2)leflunomide oralMO$0 (Tier 1)M-M-R II INJECTIONMO$0 (Tier 2)MENACTRAMO$0 (Tier 2)MENVEOMO$0 (Tier 2)mercaptopurine oralMO$0 (Tier 2)methotrexate oralMO$0 (Tier 2)methotrexate sodium (pf) injection solution 50

mg/2mlMO$0 (Tier 2)methotrexate sodium injection solution 50 mg/

2mlB/D PAR$0 (Tier 2)mycophenolate mofetil hclB/D PAR$0 (Tier 2)mycophenolate mofetil oral capsuleB/D PAR; NE$0 (Tier 2)mycophenolate mofetil oral suspension

reconstitutedB/D PAR$0 (Tier 2)mycophenolate mofetil oral tabletB/D PAR$0 (Tier 2)mycophenolate sodiumPAR; NE$0 (Tier 2)NULOJIXPAR; NE$0 (Tier 2)OCTAGAM INTRAVENOUS SOLUTION 1 GM/

20ML, 2 GM/20ML, 2.5 GM/50ML, 25 GM/ 500ML, 30 GM/300ML, 5 GM/100ML

MO$0 (Tier 2)PEDIARIXMO$0 (Tier 1)PEDVAX HIB INTRAMUSCULAR

SUSPENSIONMO$0 (Tier 2)PENTACELPAR; MO; NE; QLL (100 per 90 days)$0 (Tier 2)pimecrolimus



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B/D PAR; NE$0 (Tier 2)PROGRAF INTRAVENOUSB/D PAR$0 (Tier 2)PROGRAF ORAL PACKETMO$0 (Tier 2)PROQUAD SUBCUTANEOUS SUSPENSION

RECONSTITUTEDMO$0 (Tier 2)QUADRACELMO$0 (Tier 2)RABAVERTB/D PAR$0 (Tier 1)RECOMBIVAX HB INJECTION SUSPENSION

10 MCG/ML (1ML SYRINGE)B/D PAR; MO$0 (Tier 1)RECOMBIVAX HB INJECTION SUSPENSION

10 MCG/ML, 40 MCG/ML, 5 MCG/0.5MLMO; NE$0 (Tier 2)RIDAURAMO$0 (Tier 2)ROTARIXMO$0 (Tier 1)ROTATEQ ORAL SOLUTIONMO$0 (Tier 2)SHINGRIX INTRAMUSCULAR SUSPENSION

RECONSTITUTED 50 MCG/0.5MLB/D PAR; NE$0 (Tier 2)SIMULECTB/D PAR; NE$0 (Tier 2)sirolimus oral solutionB/D PAR$0 (Tier 2)sirolimus oral tabletMO$0 (Tier 2)STAMARILPAR; NE$0 (Tier 2)SYNAGISB/D PAR$0 (Tier 2)tacrolimus oral capsule 0.5 mg, 1 mgB/D PAR; NE$0 (Tier 2)tacrolimus oral capsule 5 mgMO$0 (Tier 1)TDVAXMO$0 (Tier 2)TENIVACB/D PAR; NE$0 (Tier 2)THYMOGLOBULINMO$0 (Tier 2)TREXALLMO$0 (Tier 2)TRUMENBAMO$0 (Tier 1)TWINRIX INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGEMO$0 (Tier 2)TYPHIM VI INTRAMUSCULAR SOLUTION 25

MCG/0.5ML



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$0 (Tier 2)TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML (0.5ML SYRINGE)

$0 (Tier 2)VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML 0.5 ML, 50 UNIT/ML 1 ML

MO$0 (Tier 2)VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML

MO$0 (Tier 2)VARIVAX$0 (Tier 2)VARIZIG INTRAMUSCULAR SOLUTION$0 (Tier 2)XATMEP

PAR; NE; QLL (60 per 30 days)$0 (Tier 2)XELJANZMO$0 (Tier 2)YF-VAXB/D PAR; NE$0 (Tier 2)ZORTRESSMO$0 (Tier 2)ZOSTAVAX SUBCUTANEOUS SUSPENSION

RECONSTITUTED

INFLAMMATORY BOWEL DISEASE AGENTS

MO$0 (Tier 2)APRISOMO$0 (Tier 2)balsalazide disodiumMO; NE$0 (Tier 2)budesonide oralMO$0 (Tier 2)colocortMO$0 (Tier 2)cortisone acetate oralMO$0 (Tier 2)dexamethasone oral elixirMO$0 (Tier 2)dexamethasone oral tabletMO; NE$0 (Tier 2)DIPENTUMMO$0 (Tier 2)hydrocortisone oralMO$0 (Tier 2)hydrocortisone rectalMO$0 (Tier 2)mesalamine erMO$0 (Tier 2)mesalamine oral tablet delayed release 1.2 gmMO$0 (Tier 2)mesalamine rectal enemaMO; NE$0 (Tier 2)mesalamine rectal suppositoryMO$0 (Tier 2)methylprednisolone oral



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MO$0 (Tier 2)PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG

MO; NE$0 (Tier 2)PENTASA ORAL CAPSULE EXTENDED RELEASE 500 MG

MO$0 (Tier 2)prednisolone acetate ophthalmicMO$0 (Tier 2)prednisolone oral solutionMO$0 (Tier 2)prednisolone sodium phosphate oral solution

6.7 (5 base) mg/5mlMO$0 (Tier 2)PREDNISONE INTENSOLMO$0 (Tier 2)prednisone oral solutionMO$0 (Tier 2)prednisone oral tabletMO$0 (Tier 2)procto-med hcMO$0 (Tier 2)proctosol hcMO$0 (Tier 2)sulfasalazine oral

METABOLIC BONE DISEASE AGENTS

MO; QLL (300 per 28 days)$0 (Tier 2)alendronate sodium oral solutionMO; QLL (30 per 30 days)$0 (Tier 2)alendronate sodium oral tablet 10 mg, 40 mg,

5 mgMO; QLL (4 per 28 days)$0 (Tier 2)alendronate sodium oral tablet 35 mg, 70 mgMO; QLL (4 per 30 days)$0 (Tier 2)calcitonin (salmon)B/D PAR; MO$0 (Tier 2)calcitriol oral capsuleB/D PAR; NE; QLL (60 per 30 days)$0 (Tier 2)cinacalcet hcl oral tablet 30 mg, 60 mgB/D PAR; NE; QLL (120 per 30 days)$0 (Tier 2)cinacalcet hcl oral tablet 90 mgB/D PAR; MO$0 (Tier 2)doxercalciferol oral capsule 0.5 mcgPAR; NE; QLL (3 per 28 days)$0 (Tier 2)FORTEO SUBCUTANEOUS SOLUTION 600

MCG/2.4MLMO; QLL (1 per 28 days)$0 (Tier 2)ibandronate sodium oralB/D PAR; MO; NE$0 (Tier 2)MIACALCIN INJECTIONPAR; NE; QLL (2 per 28 days)$0 (Tier 2)NATPARA

$0 (Tier 2)pamidronate disodium intravenous solution 30 mg/10ml, 90 mg/10ml



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B/D PAR$0 (Tier 2)PAMIDRONATE DISODIUM INTRAVENOUS SOLUTION 6 MG/ML

$0 (Tier 2)pamidronate disodium intravenous solution reconstituted

B/D PAR; MO$0 (Tier 2)paricalcitol oral capsule 1 mcg, 2 mcgB/D PAR; MO; NE$0 (Tier 2)paricalcitol oral capsule 4 mcgPAR; NE; QLL (2 per 365 days)$0 (Tier 2)PROLIA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGEPAR; NE; QLL (1.7 per 28 days)$0 (Tier 2)XGEVAPAR$0 (Tier 2)zoledronic acid intravenous concentratePAR; NE$0 (Tier 2)zoledronic acid intravenous solution 4 mg/

100ml

OPHTHALMIC AGENTS

MO$0 (Tier 2)acetazolamide oralMO$0 (Tier 2)ak-poly-bac[*]$0 (Tier 4)alaway childrens allergy solution 0.025 %

ophthalmic[*]$0 (Tier 4)alaway solution 0.025 % ophthalmicMO$0 (Tier 2)ALPHAGAN P OPHTHALMIC SOLUTION 0.1

%MO$0 (Tier 2)apraclonidine hcl[*]$0 (Tier 4)artificial tears solution 1.4 % ophthalmicMO$0 (Tier 2)atropine sulfate ophthalmic solutionMO$0 (Tier 2)azelastine hcl ophthalmicMO$0 (Tier 2)AZOPTMO$0 (Tier 2)bacitra-neomycin-polymyxin-hcMO$0 (Tier 2)bacitracin-polymyxin b ophthalmic ointment

500-10000 unit/gmMO$0 (Tier 2)betaxolol hcl ophthalmicMO$0 (Tier 2)BETIMOLMO$0 (Tier 2)bimatoprost ophthalmicMO$0 (Tier 2)bimatoprost ophthalmic



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MO$0 (Tier 2)BLEPHAMIDE S.O.P.MO$0 (Tier 2)brimonidine tartrate ophthalmicMO$0 (Tier 2)carteolol hclMO$0 (Tier 2)COMBIGANMO$0 (Tier 2)cromolyn sodium ophthalmic[*]$0 (Tier 4)cvs eye wash solution 99.05 % ophthalmicLA; NE$0 (Tier 2)CYSTARANMO$0 (Tier 2)dexamethasone sodium phosphate ophthalmicMO$0 (Tier 2)diclofenac sodium ophthalmicMO$0 (Tier 2)dorzolamide hcl ophthalmicMO$0 (Tier 2)dorzolamide hcl-timolol mal[*]$0 (Tier 4)EYE STREAM SOLUTION OPHTHALMICMO$0 (Tier 2)fluorometholone ophthalmicMO$0 (Tier 2)flurbiprofen sodium[*]$0 (Tier 4)gnp artificial tears solution 5-6 mg/ml

ophthalmic[*]$0 (Tier 4)gnp lubricating plus eye drops solution 0.5 %

ophthalmic[*]$0 (Tier 4)goodsense artificial tears solution 0.5-0.6 %

ophthalmic[*]$0 (Tier 4)goodsense lubricating eye drop solution 0.5 %

ophthalmic[*]$0 (Tier 4)hm eye itch relief solution 0.025 % ophthalmic[*]$0 (Tier 4)hm lubricating plus solution 0.5 % ophthalmicMO$0 (Tier 2)ILEVROMO$0 (Tier 2)isopto atropineMO$0 (Tier 2)ketorolac tromethamine ophthalmic[*]$0 (Tier 4)ketotifen fumarate solution 0.025 % ophthalmic

(otc)MO$0 (Tier 2)latanoprost ophthalmicMO$0 (Tier 2)levobunolol hcl ophthalmic solution 0.5 %



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[*]$0 (Tier 4)liquitears solution 1.4 % ophthalmic[*]$0 (Tier 4)lubricant eye drops pf solution 0.5 %

ophthalmic[*]$0 (Tier 4)LUBRICANT EYE DROPS SOLUTION 0.4-0.3

% OPHTHALMIC[*]$0 (Tier 4)lubricant eye drops solution 0.5 % ophthalmic[*]$0 (Tier 4)lubricating plus eye drops solution 0.5 %

ophthalmicMO$0 (Tier 2)LUMIGAN OPHTHALMIC SOLUTION 0.01 %MO$0 (Tier 2)methazolamide oralMO$0 (Tier 2)neo-polycinMO$0 (Tier 2)neo-polycin hcMO$0 (Tier 2)neomycin-bacitracin zn-polymyx ophthalmic

ointment 5-400-10000MO$0 (Tier 2)neomycin-polymyxin-dexameth ophthalmic

ointmentMO$0 (Tier 2)neomycin-polymyxin-dexameth ophthalmic

suspension 3.5-10000-0.1MO$0 (Tier 2)neomycin-polymyxin-gramicidin ophthalmic

solution 1.75-10000-.025MO$0 (Tier 2)neomycin-polymyxin-hc ophthalmic suspension

3.5-10000-1MO$0 (Tier 2)olopatadine hcl ophthalmicMO$0 (Tier 2)PAZEOMO$0 (Tier 2)PHOSPHOLINE IODIDEMO$0 (Tier 2)pilocarpine hcl ophthalmic solution 1 %, 2 %,

4 %MO$0 (Tier 2)polycinMO$0 (Tier 2)polymyxin b-trimethoprimMO$0 (Tier 2)prednisolone acetate ophthalmicMO$0 (Tier 2)PREDNISOLONE SODIUM PHOSPHATE

OPHTHALMICMO$0 (Tier 2)SIMBRINZA



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[*]$0 (Tier 4)sm eye itch relief solution 0.025 % ophthalmic[*]$0 (Tier 4)sm eye wash solution 0.002 % ophthalmic[*]$0 (Tier 4)SM LUBRICANT EYE DROPS SOLUTION 0.4-

0.3 % OPHTHALMIC[*]$0 (Tier 4)SM LUBRICATING TEARS SOLUTION 0.4-0.3

% OPHTHALMIC[*]$0 (Tier 4)sodium chloride (hypertonic) ointment 5 %

ophthalmic[*]$0 (Tier 4)SODIUM CHLORIDE (HYPERTONIC)

OINTMENT 5 % OPHTHALMIC[*]$0 (Tier 4)sodium chloride (hypertonic) solution 5 %

ophthalmicMO$0 (Tier 2)sulfacetamide-prednisolone ophthalmic solutionMO$0 (Tier 2)timolol maleate ophthalmicMO$0 (Tier 2)tobramycin-dexamethasoneMO$0 (Tier 2)TRAVATAN ZPAR; MO; QLL (60 per 30 days)$0 (Tier 2)XIIDRA

OTC-PRODUCT

[*]$0 (Tier 4)ALLI CAPSULE 60 MG ORAL[*]$0 (Tier 4)cvs nasal mist aerosol solution 0.9 % nasal[*]$0 (Tier 4)FANTASY LUBRICATED[*]$0 (Tier 4)FANTASY LUBRICATED/SPERMICIDE[*]$0 (Tier 4)KIMONO MICRO THIN PLUS[*]$0 (Tier 4)KIMONO SENSATION[*]$0 (Tier 4)KIMONO SENSATION PLUS[*]$0 (Tier 4)nasal mist aerosol solution 0.9 % inhalation[*]$0 (Tier 4)PREMIUM CONDOMS LUBRICATED[*]$0 (Tier 4)TRUSTEX LUB/RIBBED/STUDDED[*]$0 (Tier 4)TRUSTEX LUB/SPERMICIDE EX ST[*]$0 (Tier 4)TRUSTEX LUB/SPERMICIDE XL[*]$0 (Tier 4)TRUSTEX LUBRICATED



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[*]$0 (Tier 4)TRUSTEX LUBRICATED EX LARGE[*]$0 (Tier 4)TRUSTEX LUBRICATED EXTRA ST[*]$0 (Tier 4)TRUSTEX LUBRICATED/SPERMICIDE[*]$0 (Tier 4)TRUSTEX RIA LUB/SPERMICIDE[*]$0 (Tier 4)TRUSTEX RIA LUBRICATED[*]$0 (Tier 4)TRUSTEX-NONOXYNOL-9/RIB/STUD

OTIC AGENTS

MO$0 (Tier 2)CIPRODEXMO$0 (Tier 2)COLY-MYCIN SMO$0 (Tier 2)CORTISPORIN-TCMO$0 (Tier 2)flacMO$0 (Tier 2)hydrocortisone-acetic acidMO$0 (Tier 2)neomycin-polymyxin-hc otic solution 1 %MO$0 (Tier 2)neomycin-polymyxin-hc otic suspensionMO$0 (Tier 2)ofloxacin oral tablet 300 mg

RESPIRATORY TRACT/ PULMONARY AGENTS

B/D PAR; MO$0 (Tier 1)acetylcysteine inhalationPAR; LA; NE$0 (Tier 2)ADEMPASMO; QLL (60 per 30 days)$0 (Tier 2)ADVAIR DISKUSMO; QLL (60 per 30 days)$0 (Tier 2)ADVAIR DISKUSMO; QLL (60 per 30 days)$0 (Tier 2)ADVAIR DISKUSMO; QLL (12 per 30 days)$0 (Tier 2)ADVAIR HFAMO; QLL (12 per 30 days)$0 (Tier 2)ADVAIR HFAMO; QLL (12 per 30 days)$0 (Tier 2)ADVAIR HFAMO$0 (Tier 1)albuterol sulfate erMO$0 (Tier 2)ALBUTEROL SULFATE HFA INHALATION

AEROSOL SOLUTION 108 (90 BASE) MCG/ ACT

B/D PAR; MO; QLL (360 per 30 days)$0 (Tier 1)albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/ 3ml



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B/D PAR; MO; QLL (60 per 30 days)$0 (Tier 1)albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%, 2.5 mg/0.5ml

MO$0 (Tier 1)albuterol sulfate oral[*]$0 (Tier 4)all day allergy tablet 10 mg oral[*]$0 (Tier 4)allergy childrens liquid 12.5 mg/5ml oral[*]$0 (Tier 4)allergy relief capsule 25 mg oral[*]$0 (Tier 4)allergy relief childrens liquid 12.5 mg/5ml oral[*]$0 (Tier 4)allergy relief tablet 10 mg oral[*]$0 (Tier 4)allergy relief tablet 25 mg oral[*]$0 (Tier 4)allergy relief tablet dispersible 10 mg oral[*]$0 (Tier 4)allergy tablet 10 mg oralPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)AMBRISENTANMO; QLL (60 per 30 days)$0 (Tier 2)ANORO ELLIPTA[*]$0 (Tier 4)aprodine tablet 2.5-60 mg oralPAR; LA; NE$0 (Tier 2)ARALAST NP INTRAVENOUS SOLUTION

RECONSTITUTED 1000 MG, 500 MGMO; QLL (30 per 30 days)$0 (Tier 2)ARNUITY ELLIPTAMO; QLL (26 per 30 days)$0 (Tier 2)ATROVENT HFAMO; QLL (30 per 25 days)$0 (Tier 2)azelastine hcl nasal solution 0.1 %, 0.15 %[*]$0 (Tier 4)banophen capsule 25 mg oral[*]$0 (Tier 4)banophen capsule 50 mg oral[*]$0 (Tier 4)banophen liquid 12.5 mg/5ml oral[*]$0 (Tier 4)banophen tablet 25 mg oral[*]$0 (Tier 3)benzonatate capsule 100 mg oral[*]$0 (Tier 3)benzonatate capsule 200 mg oralPAR; LA; NE; QLL (60 per 30 days)$0 (Tier 2)bosentanMO; QLL (60 per 30 days)$0 (Tier 2)BREO ELLIPTAB/D PAR; MO; QLL (120 per 30 days)$0 (Tier 2)budesonide inhalation suspension 0.25 mg/2ml,

0.5 mg/2mlB/D PAR; MO; QLL (60 per 30 days)$0 (Tier 2)budesonide inhalation suspension 1 mg/2mlPAR; MO$0 (Tier 2)carbinoxamine maleate oral solution



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PAR; LA; NE$0 (Tier 2)CAYSTON[*]$0 (Tier 4)cetirizine hcl tablet 10 mg oral[*]$0 (Tier 4)CETIRIZINE HCL TABLET 5 MG ORAL[*]$0 (Tier 4)cheratussin ac syrup 100-10 mg/5ml oralPAR; MO$0 (Tier 2)clemastine fumarate oral tablet 2.68 mgMO; QLL (8 per 30 days)$0 (Tier 2)COMBIVENT RESPIMAT[*]$0 (Tier 4)complete allergy medicine capsule 25 mg oral[*]$0 (Tier 4)cromolyn sodium aerosol solution 5.2 mg/act

nasalB/D PAR; MO; QLL (240 per 30 days)$0 (Tier 1)cromolyn sodium inhalationMO$0 (Tier 2)cromolyn sodium oralPAR; MO$0 (Tier 2)cyproheptadine hcl oral tabletPAR; MO; QLL (30 per 30 days)$0 (Tier 2)DALIRESP[*]$0 (Tier 4)diphenhist capsule 25 mg oral[*]$0 (Tier 4)diphenhydramine hcl capsule 25 mg oral (otc)[*]$0 (Tier 4)diphenhydramine hcl capsule 50 mg oral (otc)MO$0 (Tier 2)diphenhydramine hcl injection[*]$0 (Tier 4)diphenhydramine hcl tablet 25 mg oralMO; QLL (13 per 30 days)$0 (Tier 2)DULERA[*]$0 (Tier 4)ed a-hist tablet 4-10 mg oralMO; QLL (2 per 28 days)$0 (Tier 1)epinephrine injection solution auto-injector 0.15

mg/0.3ml, 0.3 mg/0.3mlMO$0 (Tier 2)EPINEPHRINE PF INJECTION SOLUTION

$0 (Tier 2)epinephrine pf injection solution prefilled syringe

PAR; NE; QLL (270 per 30 days)$0 (Tier 2)ESBRIET ORAL CAPSULEPAR; NE; QLL (270 per 30 days)$0 (Tier 2)ESBRIET ORAL CAPSULEPAR; NE; QLL (270 per 30 days)$0 (Tier 2)ESBRIET ORAL TABLET 267 MGPAR; NE; QLL (270 per 30 days)$0 (Tier 2)ESBRIET ORAL TABLET 267 MGPAR; NE; QLL (90 per 30 days)$0 (Tier 2)ESBRIET ORAL TABLET 801 MGPAR; NE; QLL (90 per 30 days)$0 (Tier 2)ESBRIET ORAL TABLET 801 MG



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[*]$0 (Tier 4)FLONASE ALLERGY RELIEF SUSPENSION 50 MCG/ACT NASAL

MO; QLL (60 per 30 days)$0 (Tier 2)FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ BLIST, 50 MCG/BLIST

MO; QLL (240 per 30 days)$0 (Tier 2)FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/ BLIST

MO; QLL (12 per 30 days)$0 (Tier 2)FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT



MO; QLL (75 per 30 days)$0 (Tier 2)flunisolide nasal solution 25 mcg/act (0.025%)MO$0 (Tier 2)fluticasone propionate external lotionMO; QLL (16 per 30 days)$0 (Tier 2)fluticasone propionate nasal[*]$0 (Tier 4)fluticasone propionate suspension 50 mcg/act

nasal (otc)MO; QLL (60 per 30 days)$0 (Tier 2)fluticasone-salmeterol inhalation aerosol

powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

MO; QLL (60 per 30 days)$0 (Tier 2)fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

MO; QLL (60 per 30 days)$0 (Tier 2)fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

[*]$0 (Tier 4)gnp all day allergy tablet 10 mg oral[*]$0 (Tier 4)gnp allergy capsule 25 mg oral[*]$0 (Tier 4)gnp allergy relief tablet dispersible 10 mg oral[*]$0 (Tier 4)gnp allergy tablet 25 mg oral[*]$0 (Tier 4)gnp childrens allergy liquid 12.5 mg/5ml oral[*]$0 (Tier 4)gnp cold & allergy tablet 4-10 mg oral



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Tên Thuốc

[*]$0 (Tier 4)gnp dayhist allergy tablet 1.34 mg oral[*]$0 (Tier 4)gnp loratadine tablet 10 mg oral[*]$0 (Tier 4)gnp nasal decongestant tablet 30 mg oral[*]$0 (Tier 4)goodsense all day allergy tablet 10 mg oral[*]$0 (Tier 4)guaiatussin ac syrup 100-10 mg/5ml oral[*]$0 (Tier 4)guaifenesin ac syrup 100-10 mg/5ml oral[*]$0 (Tier 4)guaifenesin-codeine solution 100-10 mg/5ml

oral (otc)[*]$0 (Tier 4)hm all day allergy tablet 10 mg oral[*]$0 (Tier 4)hm allergy tablet 25 mg oralPAR; MO$0 (Tier 2)hydroxyzine hcl oral tabletPAR; MO$0 (Tier 2)hydroxyzine pamoate oral capsule 25 mg, 50

mgB/D PAR; MO$0 (Tier 1)ipratropium bromide inhalationMO; QLL (30 per 30 days)$0 (Tier 2)ipratropium bromide nasalB/D PAR; MO; QLL (540 per 30 days)$0 (Tier 2)ipratropium-albuterolPAR; NE; QLL (60 per 30 days)$0 (Tier 2)KALYDECO ORAL TABLETPAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)LETAIRISB/D PAR; MO; QLL (270 per 30 days)$0 (Tier 1)levalbuterol hcl inhalation nebulization solution

0.31 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3mlB/D PAR; MO; QLL (540 per 30 days)$0 (Tier 1)levalbuterol hcl inhalation nebulization solution

0.63 mg/3mlMO; QLL (45 per 30 days)$0 (Tier 2)levalbuterol tartrateMO$0 (Tier 2)levocetirizine dihydrochloride oral tablet[*]$0 (Tier 4)loratadine tablet 10 mg oral[*]$0 (Tier 4)m-clear wc solution 100-6.3 mg/5ml oralMO$0 (Tier 1)metaproterenol sulfate oral syrupMO$0 (Tier 1)montelukast sodium oral[*]$0 (Tier 4)nasal decongestant tablet 30 mg oralPAR; NE; QLL (60 per 30 days)$0 (Tier 2)OFEVPAR; NE; QLL (60 per 30 days)$0 (Tier 2)OFEV



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PAR; NE; QLL (120 per 30 days)$0 (Tier 2)ORKAMBI ORAL TABLET[*]$0 (Tier 4)PEAK AIR PEAK FLOW METER DEVICE[*]$0 (Tier 4)pharbedryl capsule 25 mg oral[*]$0 (Tier 4)pharbedryl capsule 50 mg oralMO$0 (Tier 2)PROAIR HFAMO$0 (Tier 2)PROAIR RESPICLICKPAR; LA; NE$0 (Tier 2)PROLASTIN-C INTRAVENOUS SOLUTIONPAR; MO$0 (Tier 2)promethazine hcl oral tablet[*]$0 (Tier 3)promethazine-codeine solution 6.25-10 mg/5ml

oral[*]$0 (Tier 3)promethazine-codeine syrup 6.25-10 mg/5ml

oral[*]$0 (Tier 3)promethazine-dm syrup 6.25-15 mg/5ml oral[*]$0 (Tier 3)promethazine-phenyleph-codeine syrup 6.25-

5-10 mg/5ml oral[*]$0 (Tier 4)pseudoephedrine hcl tablet 30 mg oral (otc)B/D PAR; NE$0 (Tier 2)PULMOZYMEB/D PAR; NE$0 (Tier 2)PULMOZYME[*]$0 (Tier 4)qc all day allergy tablet 10 mg oral[*]$0 (Tier 4)qc loratadine allergy relief tablet 10 mg oralMO; QLL (11 per 30 days)$0 (Tier 2)QVAR REDIHALER INHALATION AEROSOL

BREATH ACTIVATED 40 MCG/ACTMO; QLL (22 per 30 days)$0 (Tier 2)QVAR REDIHALER INHALATION AEROSOL

BREATH ACTIVATED 80 MCG/ACT[*]$0 (Tier 4)rydex liquid 10-1.33-6.33 mg/5ml oralMO; QLL (60 per 30 days)$0 (Tier 2)SEREVENT DISKUS[*]$0 (Tier 4)siladryl allergy liquid 12.5 mg/5ml oralPAR; NE; QLL (90 per 30 days)$0 (Tier 2)sildenafil citrate oral tablet 20 mg[*]$0 (Tier 4)sm all day allergy tablet 10 mg oral[*]$0 (Tier 4)sm allergy relief capsule 25 mg oral[*]$0 (Tier 4)sm allergy relief liquid 12.5 mg/5ml oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)sm cold & allergy pe tablet 4-10 mg oral[*]$0 (Tier 4)sm loratadine tablet 10 mg oral[*]$0 (Tier 4)sm nasal decongestant max st tablet 30 mg

oralMO; QLL (30 per 30 days)$0 (Tier 2)SPIRIVA HANDIHALERMO; QLL (4 per 30 days)$0 (Tier 2)SPIRIVA RESPIMATMO; QLL (4 per 30 days)$0 (Tier 2)STIOLTO RESPIMAT[*]$0 (Tier 4)sudogest sinus/allergy tablet 4-60 mg oral[*]$0 (Tier 4)sudogest tablet 30 mg oral[*]$0 (Tier 4)sudogest tablet 60 mg oralMO; QLL (2 per 28 days)$0 (Tier 2)SYMJEPIMO$0 (Tier 1)terbutaline sulfate injectionMO$0 (Tier 1)terbutaline sulfate oralMO$0 (Tier 2)theophylline er oral tablet extended release 12

hour 300 mg, 450 mgMO$0 (Tier 2)theophylline er oral tablet extended release 24

hourPAR; LA; NE; QLL (120 per 30 days)$0 (Tier 2)TRACLEER ORAL TABLET SOLUBLEPAR; NE; QLL (270 per 30 days)$0 (Tier 2)VENTAVISMO$0 (Tier 2)VENTOLIN HFA[*]$0 (Tier 4)virtussin a/c solution 100-10 mg/5ml oralMO; QLL (60 per 30 days)$0 (Tier 2)wixela inhubMO; QLL (60 per 30 days)$0 (Tier 2)wixela inhubPAR; LA; NE; QLL (6 per 28 days)$0 (Tier 2)XOLAIR SUBCUTANEOUS SOLUTION

RECONSTITUTEDMO$0 (Tier 1)zafirlukast

SKELETAL MUSCLE RELAXANTS

PAR; MO$0 (Tier 2)carisoprodol oral tablet 350 mgPAR; MO$0 (Tier 2)cyclobenzaprine hcl oralPAR; MO$0 (Tier 2)methocarbamol oralMO$0 (Tier 2)tizanidine hcl oral tablet



Giá Thuốc

(Theo Bậc)

Tên Thuốc

SLEEP DISORDER AGENTS

PAR; MO$0 (Tier 2)doxepin hcl oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg

PAR; MO$0 (Tier 2)doxepin hcl oral concentratePAR; LA; NE; QLL (30 per 30 days)$0 (Tier 2)HETLIOZPAR; MO$0 (Tier 2)modafinil oral tablet 100 mgPAR; MO; QLL (60 per 30 days)$0 (Tier 2)modafinil oral tablet 200 mgMO; QLL (30 per 30 days)$0 (Tier 2)ramelteonMO; QLL (30 per 30 days)$0 (Tier 2)ROZEREMMO; QLL (30 per 30 days)$0 (Tier 2)temazepam oral capsule 15 mg, 30 mgPAR; LA; NE; QLL (540 per 30 days)$0 (Tier 2)XYREMMO; QLL (60 per 30 days)$0 (Tier 2)zaleplon oral capsule 10 mgMO; QLL (30 per 30 days)$0 (Tier 2)zaleplon oral capsule 5 mgPAR; MO; QLL (30 per 30 days)$0 (Tier 2)zolpidem tartrate oral


Danh Mục Thuốc

11ST TIER UNIFINE PENTIPS 29G X 12MM ............................ 7333 day vaginal cream 2 % vaginal .......................... 91Aabacavir sulfate oral solution ......................... 63abacavir sulfate oral tablet ............................. 63abacavir sulfate- lamivudine .................... 63abacavir-lamivudine- zidovudine .................... 63ABELCET ..................... 42ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE ..................... 36ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE ..................... 58ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER ................................. 36ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER ................................. 58abiraterone acetate ...... 46ABRAXANE .................. 46ABREVA CREAM 10 % EXTERNAL ................... 91acamprosate calcium .... 19acarbose oral tablet 100 mg ................................. 73acarbose oral tablet 25 mg ................................. 73

acarbose oral tablet 50 mg ................................. 73ACCU-CHEK AVIVA PLUS STRIP IN VITRO .......... 73ACCU-CHEK COMPACT PLUS STRIP IN VITRO ........................... 73ACCU-CHEK FASTCLIX LANCETS ..................... 73ACCU-CHEK MULTICLIX LANCETS ..................... 73ACCU-CHEK SMARTVIEW STRIP IN VITRO .......... 73ACCU-CHEK SOFT TOUCH LANCETS ....... 73ACCU-CHEK SOFTCLIX LANCETS ..................... 73acebutolol hcl oral ........ 82acetaminophen-codeine #3 .................................. 14acetaminophen-codeine #4 .................................. 14acetaminophen-codeine oral solution ......................... 14acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg ................................. 14acetazolamide er .......... 82acetazolamide oral ....... 82acetazolamide oral ..... 141acetazolamide sodium ... 82acetic acid otic .............. 24acetylcysteine inhalation .................... 145acetylcysteine intravenous ................... 89acid gone suspension 95- 358 mg/15ml oral ........ 112acid gone tablet chewable 160-105 mg oral ......... 112acid reducer maximum strength tablet 20 mg oral .............................. 112

acid reducer tablet 10 mg oral .............................. 112acid reducer tablet 75 mg oral .............................. 112acitretin oral capsule 10 mg ................................. 91acitretin oral capsule 17.5 mg, 25 mg ..................... 91ACNE MEDICATION 10 GEL 10 % EXTERNAL ................... 92ACTHAR ..................... 124ACTHIB ...................... 134ACTIMMUNE .............. 134acyclovir external ointment ........................ 63acyclovir oral ................. 63acyclovir sodium intravenous solution ..... 63ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 (PREFILLED SYRINGE) .................. 134ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF- MCG/0.5 ..................... 134adapalene external gel 0.3 % .................................. 92 adefovir dipivoxil ........... 63ADEMPAS .................. 145adriamycin intravenous solution ......................... 46adriamycin intravenous solution reconstituted 10 mg, 50 mg ..................... 46adrucil ........................... 46ADVAIR DISKUS ........ 145ADVAIR DISKUS ........ 145ADVAIR DISKUS ........ 145ADVAIR HFA .............. 145ADVAIR HFA .............. 145ADVAIR HFA .............. 145

? Nếu quý vị có thắc mắc, vui lòng gọi Anthem Blue Cross Cal MediConnect Plan theo số1-833-214-3606 (TTY: 711), 24 giờ một ngày, 7 ngày một tuần. Cuộc gọi này miễn phí. Để biết thêm thông tin, hãy truy cập vào duals.anthem.com. 153

afeditab cr oral tablet extended release 24 hour 30 mg ............................ 82afeditab cr oral tablet extended release 24 hour 60 mg ............................ 82AFINITOR ..................... 46AFINITOR DISPERZ ... 134AFINITOR ORAL TABLET 2.5 MG ........................ 134afirmelle ...................... 126AFTERA TABLET 1.5 MG ORAL .......................... 126AGAMATRIX ULTRA-THIN LANCETS ..................... 73ak-poly-bac ................. 141ala-cort external cream .......................... 124alaway childrens allergy solution 0.025 % ophthalmic .................. 141alaway solution 0.025 % ophthalmic .................. 141albendazole oral ........... 57albuterol sulfate er ...... 145ALBUTEROL SULFATE HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ ACT ............................ 145albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/ 3ml, 1.25 mg/3ml ........ 145albuterol sulfate inhalation nebulization solution (5 mg/ ml) 0.5%, 2.5 mg/ 0.5ml ........................... 146albuterol sulfate oral .... 146alclometasone dipropionate ................ 124ALDURAZYME ........... 122ALECENSA .................. 46alendronate sodium oral solution ....................... 140alendronate sodium oral tablet 10 mg, 40 mg, 5 mg ............................... 140

alendronate sodium oral tablet 35 mg, 70 mg .... 140alfuzosin hcl er ............ 123ALIMTA ....................... 134ALINIA ORAL SUSPENSION RECONSTITUTED ....... 57ALINIA ORAL TABLET ........................ 57ALIQOPA ...................... 46aliskiren fumarate ......... 82aliskiren fumarate ......... 82all day allergy tablet 10 mg oral .............................. 146all day pain relief tablet 220 mg oral .......................... 21all day relief tablet 220 mg oral ................................ 14allergy childrens liquid 12.5 mg/5ml oral ................. 146allergy relief capsule 25 mg oral .............................. 146allergy relief childrens liquid 12.5 mg/5ml oral ......... 146allergy relief tablet 10 mg oral .............................. 146allergy relief tablet 25 mg oral .............................. 146allergy relief tablet dispersible 10 mg oral .............................. 146allergy tablet 10 mg oral .............................. 146ALLI CAPSULE 60 MG ORAL .......................... 144allopurinol oral .............. 44almacone double strength suspension 400-400-40 mg/ 5ml oral ....................... 112almacone suspension 200- 200-20 mg/5ml oral .... 112alosetron hcl ............... 112ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % .......................... 141alprazolam oral tablet .... 68altavera ....................... 126

aluminum hydroxide gel suspension 320 mg/5ml oral .............................. 112ALUNBRIG ORAL TABLET 180 MG ......................... 46ALUNBRIG ORAL TABLET 30 MG ........................... 46ALUNBRIG ORAL TABLET 90 MG ........................... 46ALUNBRIG ORAL TABLET THERAPY PACK .......... 46alyacen 1/35 ............... 126alyacen 7/7/7 .............. 126amantadine hcl oral ...... 57amantadine hcl oral ...... 63AMBISOME .................. 42AMBRISENTAN .......... 146amcinonide external cream .......................... 124amcinonide external lotion ........................... 124AMCINONIDE EXTERNAL OINTMENT ................. 124amikacin sulfate injection solution 1 gm/4ml, 500 mg/ 2ml ................................ 24amiloride hcl oral .......... 82amiloride- hydrochlorothiazide ...... 82AMINOSYN II INTRAVENOUS SOLUTION 10 %, 15 % ................... 96AMINOSYN-PF ............. 96amiodarone hcl intravenous ................... 82amiodarone hcl oral ...... 83AMITIZA ..................... 112amitriptyline hcl oral ...... 36amlodipine besy-benazepril hcl ................................. 83amlodipine besylate oral ................................ 83amlodipine besylate- valsartan ....................... 83amlodipine- olmesartan .................... 83amlodipine-valsartan- hctz ............................... 83


ammonium lactate external ......................... 92amnesteem ................... 92amoxapine .................... 36amoxicillin oral capsule ......................... 24amoxicillin oral suspension reconstituted ................. 24amoxicillin oral tablet .... 24amoxicillin oral tablet chewable 125 mg, 250 mg ................................. 24amoxicillin-pot clavulanate er .................................. 24amoxicillin-pot clavulanate oral ................................ 24amphetamine- dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg ................................. 89amphetamine- dextroamphetamine oral tablet 30 mg .................. 89amphotericin b intravenous ................... 42ampicillin oral capsule 500 mg ................................. 24ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 2 gm, 250 mg, 500 mg ................................. 24ampicillin sodium intravenous ................... 25ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 3 (2-1) gm ..................... 25ampicillin-sulbactam sodium intravenous ................... 25ANADROL-50 ............. 127anagrelide hcl ............... 80anastrozole oral ............ 46ANORO ELLIPTA ....... 146antacid anti-gas max strength suspension 400- 400-40 mg/5ml oral .... 112

antacid calcium extra strength tablet chewable 750 mg oral ................... 96antacid calcium tablet chewable 500 mg oral ... 96antacid extra strength tablet chewable 750 mg oral .............................. 112antacid fast relief suspension 200-200-20 mg/ 5ml oral ....................... 112antacid maximum strength suspension 400-400-40 mg/ 5ml oral ....................... 112antacid maximum tablet chewable 1000 mg oral .............................. 112antacid plus anti-gas fast act suspension 200-200-20 mg/5ml oral ................. 113antacid plus anti-gas relief suspension 200-200-20 mg/ 5ml oral ....................... 113antacid plus anti-gas relief suspension 400-400-40 mg/ 5ml oral ....................... 113antacid suspension 200- 200-20 mg/5ml oral .... 113antacid tablet chewable 500 mg oral ........................ 113anti-dandruff shampoo 1 % external ......................... 92anti-itch maximum strength cream 1 % external ...... 92antifungal cream 1 % external ......................... 42antifungal cream 2 % external ......................... 92APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE ................ 57apraclonidine hcl ........ 141aprepitant oral capsule 125 mg ................................. 41aprepitant oral capsule 40 mg ................................. 41

aprepitant oral capsule 80 mg ................................. 41apri .............................. 127APRISO ...................... 139aprodine tablet 2.5-60 mg oral .............................. 146APTIOM ........................ 31APTIVUS ORAL CAPSULE ..................... 63APTIVUS ORAL SOLUTION ................... 63aqueous vitamin d liquid 10 mcg/ml oral ................... 96ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG ............... 146aranelle ....................... 127ARCALYST ................. 134aripiprazole oral solution ......................... 36aripiprazole oral solution ......................... 58aripiprazole oral tablet 10 mg ................................. 36aripiprazole oral tablet 10 mg ................................. 58aripiprazole oral tablet 15 mg ................................. 36aripiprazole oral tablet 15 mg ................................. 58aripiprazole oral tablet 2 mg ................................. 36aripiprazole oral tablet 2 mg ................................. 58aripiprazole oral tablet 20 mg, 30 mg ..................... 36aripiprazole oral tablet 20 mg, 30 mg ..................... 58aripiprazole oral tablet 5 mg ................................. 36aripiprazole oral tablet 5 mg ................................. 58aripiprazole oral tablet dispersible 10 mg ......... 36aripiprazole oral tablet dispersible 10 mg ......... 58


aripiprazole oral tablet dispersible 15 mg ......... 36aripiprazole oral tablet dispersible 15 mg ......... 58ARNUITY ELLIPTA .... 146ARRANON .................... 46arsenic trioxide intravenous ................... 46artificial tears solution 1.4 % ophthalmic .................. 141ARZERRA .................... 46ascorbic acid tablet 500 mg oral ................................ 96aspir-low tablet delayed release 81 mg oral ........ 14aspirin 81 tablet delayed release 81 mg oral ........ 14aspirin adult low strength tablet chewable 81 mg oral ................................ 14aspirin ec tablet delayed release 325 mg oral ...... 14aspirin ec tablet delayed release 81 mg oral ........ 14aspirin low dose tablet chewable 81 mg oral .... 14aspirin low dose tablet delayed release 81 mg oral ................................ 14aspirin low strength tablet chewable 81 mg oral .... 14aspirin tablet 325 mg oral ................................ 14aspirin tablet chewable 81 mg oral .......................... 14aspirin tablet delayed release 81 mg oral ........ 14aspirin-dipyridamole er .................................. 80ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML ................................. 74atazanavir sulfate oral capsule 150 mg, 200 mg ................................. 63atazanavir sulfate oral capsule 300 mg ............ 63atenolol oral .................. 83

atenolol- chlorthalidone ............... 83ATGAM ....................... 134athletes foot af cream 1 % external ......................... 42athletes foot spray aerosol 1 % external .................. 42atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg ..................... 89atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg ................................. 89atorvastatin calcium oral ................................ 83atovaquone oral ............ 57atovaquone-proguanil hcl oral tablet 250-100 mg .. 57ATRIPLA ....................... 64atropine sulfate injection solution prefilled syringe 0.25 mg/5ml, 1 mg/ 10ml ............................ 113atropine sulfate injection solution prefilled syringe 0.5 mg/5ml ........................ 113atropine sulfate ophthalmic solution ....................... 141ATROVENT HFA ........ 146AUBAGIO ..................... 89aubra .......................... 127aubra eq ..................... 127aurovela 1.5/30 ........... 127aurovela 1/20 .............. 127aurovela fe 1.5/30 ....... 127aurovela fe 1/20 .......... 127AVASTIN ...................... 46aviane ......................... 127avita .............................. 46avita .............................. 92AVONEX PEN INTRAMUSCULAR AUTO- INJECTOR KIT ............. 89AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT ................................ 89ayuna .......................... 127

azacitidine ..................... 46azathioprine oral ......... 134AZATHIOPRINE SODIUM ..................... 134azelastine hcl nasal solution 0.1 %, 0.15 % ............. 146azelastine hcl ophthalmic .................. 141azithromycin intravenous ................... 25azithromycin oral suspension reconstituted ................. 25azithromycin oral tablet 250 mg (6 pack) ................... 25azithromycin oral tablet 250 mg, 500 mg, 600 mg .... 25AZOPT ........................ 141aztreonam injection solution reconstituted 1 gm ........ 25aztreonam injection solution reconstituted 2 gm ........ 25azurette ....................... 127Bb-1 tablet 100 mg oral ... 96b-1 tablet 250 mg oral ... 96b-12 dots tablet dispersible 500 mcg oral ................. 96b-12 tablet 100 mcg oral ................................ 96b-12 tablet 500 mcg oral ................................ 96b-2 tablet 100 mg oral ... 96b-2 tablet 50 mg oral .... 96b-6 tablet 100 mg oral ... 96b-6 tablet 50 mg oral .... 96bacitra-neomycin- polymyxin-hc ............... 141bacitracin ointment 500 unit/ gm external ................... 25bacitracin ophthalmic .... 25bacitracin zinc ointment 500 unit/gm external (otc) .... 25bacitracin-polymyxin b ophthalmic ointment 500- 10000 unit/gm ............. 141baclofen oral ................. 63balsalazide disodium ... 139


BALVERSA ORAL TABLET 3 MG ............................. 46BALVERSA ORAL TABLET 4 MG ............................. 46BALVERSA ORAL TABLET 5 MG ............................. 46balziva ........................ 127banophen capsule 25 mg oral .............................. 146banophen capsule 50 mg oral .............................. 146banophen liquid 12.5 mg/ 5ml oral ....................... 146banophen tablet 25 mg oral .............................. 146BANZEL ORAL SUSPENSION .............. 31BANZEL ORAL TABLET 200 MG ......................... 31BANZEL ORAL TABLET 400 MG ......................... 31BARACLUDE ORAL SOLUTION ................... 64BAVENCIO ................... 46BCG VACCINE ........... 134bekyree ....................... 127BELEODAQ .................. 46benazepril hcl oral ........ 83benazepril- hydrochlorothiazide ...... 83BENDEKA .................... 46BENLYSTA ................. 135benzonatate capsule 100 mg oral ........................ 146benzonatate capsule 200 mg oral ........................ 146benzoyl peroxide gel 10 % external (otc) ................. 92benzoyl peroxide gel 5 % external (otc) ................. 92benzoyl peroxide- erythromycin ................. 92benzphetamine hcl tablet 50 mg oral .......................... 89benztropine mesylate oral ................................ 57beser external lotion ..... 92BESPONSA .................. 46

betamethasone dipropionate aug external cream ............................ 21betamethasone dipropionate aug external cream .......................... 124betamethasone dipropionate aug external lotion ............................. 21betamethasone dipropionate aug external lotion ........................... 124betamethasone dipropionate aug external ointment ........................ 21betamethasone dipropionate aug external ointment ...................... 124betamethasone dipropionate external .... 21betamethasone dipropionate external cream .......................... 124betamethasone dipropionate external lotion ............................. 92betamethasone dipropionate external ointment ...................... 124betamethasone valerate external cream .............. 22betamethasone valerate external cream ............ 124betamethasone valerate external lotion ............... 22betamethasone valerate external lotion ............. 124betamethasone valerate external ointment .......... 22betamethasone valerate external ointment ........ 124BETASERON SUBCUTANEOUS KIT ................................ 89betaxolol hcl ophthalmic .................. 141betaxolol hcl oral .......... 83

bethanechol chloride oral .............................. 123BETIMOL .................... 141bexarotene .................... 46BEXSERO .................. 135bicalutamide ................. 46BICILLIN C-R ................ 25BIKTARVY .................... 64bimatoprost ophthalmic .................. 141bimatoprost ophthalmic .................. 141bisacodyl ec tablet delayed release 5 mg oral ........ 113bisacodyl suppository 10 mg rectal ........................... 113bismatrol maximum strength suspension 525 mg/15ml oral .............................. 113bismatrol suspension 262 mg/15ml oral ............... 113bismatrol tablet chewable 262 mg oral ................. 113bismuth subsalicylate tablet chewable 262 mg oral .............................. 113bisoprolol fumarate ....... 83bisoprolol- hydrochlorothiazide ...... 83bleomycin sulfate .......... 47BLEPHAMIDE S.O.P. .... 22BLEPHAMIDE S.O.P. ......................... 142BLINCYTO .................... 47blisovi fe 1.5/30 ........... 127blisovi fe 1/20 .............. 127BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 (0.5ML SYRINGE) ...... 135BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 , 5-2.5-18.5 LF-MCG/ 0.5 ............................... 135BORTEZOMIB .............. 47bosentan ..................... 146


BOSULIF ORAL TABLET 100 MG ......................... 47BOSULIF ORAL TABLET 400 MG, 500 MG .......... 47BRAFTOVI ORAL CAPSULE 75 MG ......... 47BREO ELLIPTA .......... 146briellyn ........................ 127BRILINTA ..................... 80brimonidine tartrate ophthalmic .................. 142BRIVIACT INTRAVENOUS ............ 31BRIVIACT ORAL SOLUTION ................... 31BRIVIACT ORAL TABLET 10 MG ........................... 31BRIVIACT ORAL TABLET 100 MG, 75 MG ............ 31BRIVIACT ORAL TABLET 25 MG ........................... 31BRIVIACT ORAL TABLET 50 MG ........................... 31bromocriptine mesylate oral ................................ 57bromocriptine mesylate oral .............................. 133budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml .................. 146budesonide inhalation suspension 1 mg/2ml .. 146budesonide oral .......... 113budesonide oral .......... 127budesonide oral .......... 139bumetanide injection .... 83bumetanide oral ............ 83buprenorphine hcl injection ........................ 14buprenorphine hcl sublingual tablet sublingual 2 mg .............................. 14buprenorphine hcl sublingual tablet sublingual 2 mg .............................. 19buprenorphine hcl sublingual tablet sublingual 8 mg .............................. 14

buprenorphine hcl sublingual tablet sublingual 8 mg .............................. 19buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg ...... 19buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg ......... 19bupropion hcl er (smoking det) ............................... 19bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg ................. 36bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg, 200 mg .... 37bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg ................. 37bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg ................. 37bupropion hcl oral tablet 100 mg ................................. 37bupropion hcl oral tablet 75 mg ................................. 37buspirone hcl oral ......... 68busulfan ........................ 47BUSULFEX ................... 47butorphanol tartrate injection solution 1 mg/ ml .................................. 14butorphanol tartrate injection solution 2 mg/ ml .................................. 14butorphanol tartrate nasal ............................. 14BYDUREON BCISE ..... 74BYDUREON SUBCUTANEOUS PEN- INJECTOR .................... 74BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN- INJECTOR .................... 74BYETTA 5 MCG PEN SUBCUTANEOUS

SOLUTION PEN- INJECTOR .................... 74Cc 1000 tablet 1000 mg oral ................................ 96c 250 tablet 250 mg oral ................................ 96c 500 tablet 500 mg oral ................................ 96c-1000 tablet 1000 mg oral ................................ 96c-1000/rose hips tablet 1000 mg oral .......................... 96c-250 tablet 250 mg oral ................................ 96c-500 tablet 500 mg oral ................................ 96c-500/rose hips tablet 500 mg oral .......................... 96cabergoline ................. 133CABOMETYX ............... 47cal-gest antacid tablet chewable 500 mg oral ... 96calamine lotion 8-8 % external ......................... 92calcipotriene external cream ............................ 92calcipotriene external ointment ........................ 92calcipotriene external solution ......................... 92calcitonin (salmon) ..... 140calcitrate tablet 950 mg oral ................................ 96calcitrene ...................... 92calcitriol intravenous solution 1 mcg/ml .......... 97calcitriol oral capsule ... 140calcium + d3 tablet 600-200 mg-unit oral ................... 97calcium 500 + d tablet 500- 125 mg-unit oral ............ 97calcium 500+d tablet 500- 200 mg-unit oral ............ 97calcium 500+d tablet 500- 400 mg-unit oral ............ 97calcium 500/d tablet 500- 200 mg-unit oral ............ 97


calcium 500/d tablet chewable 500-400 mg-unit oral ................................ 97calcium 600 high potency tablet 600 mg oral ......... 97calcium 600 tablet 1500 (600 ca) mg oral ........... 97calcium 600 tablet 600 mg oral ................................ 97calcium 600+d tablet 600- 200 mg-unit oral ............ 97calcium 600+d tablet 600- 400 mg-unit oral ............ 97CALCIUM 600+D TABLET 600-800 MG-UNIT ORAL ............................ 97calcium 600+d3 tablet 600- 400 mg-unit oral ............ 97CALCIUM 600+D3 TABLET 600-800 MG-UNIT ORAL ............................ 97calcium 600/vitamin d tablet 600-400 mg-unit oral .... 97calcium 600/vitamin d3 tablet 600-800 mg-unit oral ................................ 97CALCIUM 600/VITAMIN D3 TABLET 600-800 MG-UNIT ORAL ............................ 97calcium acetate (phos binder) oral capsule .... 123calcium antacid extra strength tablet chewable 750 mg oral ................... 97calcium antacid tablet chewable 500 mg oral ... 97calcium antacid ultra max st tablet chewable 1000 mg oral .............................. 113calcium antacid ultra strength tablet chewable 1000 mg oral ............... 113calcium ascorbate tablet 500 mg oral ................... 97calcium carbonate antacid suspension 1250 mg/5ml oral ................................ 97

calcium carbonate antacid tablet chewable 750 mg oral .............................. 113calcium carbonate tablet 1250 (500 ca) mg oral ... 97calcium carbonate tablet 1500 (600 ca) mg oral ... 97calcium carbonate tablet 600 mg oral ................... 98calcium carbonate-vitamin d tablet 500-400 mg-unit oral ................................ 98calcium carbonate-vitamin d tablet 600-400 mg-unit oral ................................ 98calcium citrate + d tablet 250-200 mg-unit oral .... 98calcium citrate + d tablet 315-200 mg-unit oral .... 98CALCIUM CITRATE + D TABLET 315-200 MG-UNIT ORAL ............................ 98CALCIUM CITRATE + D3 MAXIMUM TABLET 315- 250 MG-UNIT ORAL .... 98calcium citrate tablet 200 mg oral .......................... 98calcium citrate tablet 250 mg oral .......................... 98CALCIUM CITRATE+D3 PETITES TABLET 200-250 MG-UNIT ORAL ........... 98CALCIUM CITRATE+D3 TABLET 315-250 MG-UNIT ORAL ............................ 98calcium citrate-vitamin d tablet 315-200 mg-unit oral ................................ 98CALCIUM CITRATE- VITAMIN D TABLET 315- 250 MG-UNIT ORAL .... 98CALCIUM CITRATE- VITAMIN D3 TABLET 315- 250 MG-UNIT ORAL .... 98calcium high potency tablet 600 mg oral ................... 98CALCIUM HIGH POTENCY/VITAMIN D

TABLET 600-200 MG-UNIT ORAL ............................ 98calcium plus vitamin d3 tablet 600-800 mg-unit oral ................................ 98CALCIUM TABLET CHEWABLE 500-100 MG- UNIT ORAL .................. 98CALCIUM+D3 TABLET 600-800 MG-UNIT ORAL ............................ 98calcium-vitamin d tablet 500-200 mg-unit oral .... 98CALCIUM-VITAMIN D TABLET 600-200 MG-UNIT ORAL ............................ 99calcium-vitamin d tablet 600-400 mg-unit oral .... 99calcium-vitamin d3 tablet 250-125 mg-unit oral .... 99calcium-vitamin d3 tablet 500-400 mg-unit oral .... 99calcium-vitamin d3 tablet 600-400 mg-unit oral .... 99calcium/c/d tablet chewable 500-10-250 mg-mg-unit oral ................................ 99CALQUENCE ............... 47CALTRATE 600+D3 TABLET 600-800 MG-UNIT ORAL ............................ 99camila ......................... 127candesartan cilexetil ..... 83candesartan cilexetil- hctz ............................... 83CAPASTAT SULFATE ..................... 45CAPEX ....................... 125CAPRELSA ORAL TABLET 100 MG ......................... 47CAPRELSA ORAL TABLET 300 MG ......................... 47CARBAGLU .................. 99carbamazepine er oral capsule extended release 12 hour ......................... 71


carbamazepine er oral tablet extended release 12 hour .............................. 31carbamazepine er oral tablet extended release 12 hour 100 mg ................. 71carbamazepine oral ...... 31carbamazepine oral ...... 71carbidopa oral ............... 58carbidopa oral ............... 58carbidopa-levodopa ...... 58carbidopa-levodopa er oral tablet extended release 25- 100 mg, 50-200 mg ...... 58carbidopa-levodopa- entacapone ................... 58carbidopa-levodopa- entacapone ................... 58carbinoxamine maleate oral solution ....................... 146carboplatin intravenous solution ......................... 47CAREONE UNIFINE PENTIPS PLUS 29G X 12MM ............................ 74carisoprodol oral tablet 350 mg ............................... 151carmustine .................... 47carrington antifungal cream 2 % external .................. 42carteolol hcl ................ 142cartia xt ......................... 83carvedilol ...................... 83CAYSTON .................... 25CAYSTON .................. 147caziant ........................ 127cefaclor ......................... 25CEFACLOR ER ............ 25cefadroxil ...................... 25cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 mg .............. 25CEFAZOLIN SODIUM INJECTION SOLUTION RECONSTITUTED 100 GM, 300 GM ......................... 25

cefazolin sodium intravenous solution reconstituted ................. 25CEFAZOLIN SODIUM- DEXTROSE INTRAVENOUS SOLUTION 1-4 GM/50ML-% ........... 25CEFAZOLIN SODIUM- DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1-4 GM- %(50ML) ....................... 25cefdinir .......................... 25cefepime hcl injection .... 25cefoxitin sodium ............ 26CEFOXITIN SODIUM- DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1-4 GM- %(50ML), 2-2.2 GM- %(50ML) ....................... 26cefpodoxime proxetil .... 26cefprozil ........................ 26ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm .................... 26ceftriaxone sodium in dextrose ........................ 26ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg .. 26CEFTRIAXONE SODIUM INJECTION SOLUTION RECONSTITUTED 100 GM ................................ 26ceftriaxone sodium intravenous ................... 26CEFTRIAXONE SODIUM- DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1-3.74 GM-%(50ML), 2-2.22 GM- %(50ML) ....................... 26cefuroxime axetil oral tablet ............................. 26cefuroxime sodium injection solution reconstituted 7.5 gm, 750 mg ................... 26

cefuroxime sodium intravenous solution reconstituted 1.5 gm ..... 26celecoxib oral ................ 14celecoxib oral ................ 22CELONTIN ................... 31cephalexin oral capsule 250 mg, 500 mg ................... 26cephalexin oral suspension reconstituted ................. 26CERDELGA ................ 122CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT ............................. 99cetirizine hcl tablet 10 mg oral .............................. 147CETIRIZINE HCL TABLET 5 MG ORAL ................ 147CHANTIX CONTINUING MONTH PAK ................ 19CHANTIX ORAL TABLET 0.5 MG .......................... 19CHANTIX ORAL TABLET 1 MG ................................ 19CHANTIX STARTING MONTH PAK ................ 19chateal ........................ 127chateal eq ................... 127cheratussin ac syrup 100-10 mg/5ml oral ................. 147childrens aspirin low strength tablet chewable 81 mg oral .......................... 14chloramphenicol sod succinate ...................... 26chlorhexidine gluconate mouth/throat ................. 91chloroquine phosphate oral ................................ 57chlorothiazide oral ........ 83CHLORPROMAZINE HCL INJECTION ................... 58chlorpromazine hcl oral ................................ 41chlorpromazine hcl oral ................................ 58


chlorthalidone oral tablet 25 mg, 50 mg ..................... 83cholestyramine light ...... 83cholestyramine oral ...... 83ciclodan external solution ......................... 92ciclopirox ....................... 42ciclopirox olamine external ......................... 42cilostazol ....................... 80CIMDUO ....................... 64cinacalcet hcl oral tablet 30 mg, 60 mg ................... 140cinacalcet hcl oral tablet 90 mg ............................... 140CINRYZE .................... 135CIPRODEX ................. 145ciprofloxacin hcl ophthalmic .................... 26ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg ................................. 26ciprofloxacin in d5w intravenous solution 200 mg/100ml ...................... 26cisplatin intravenous solution 100 mg/100ml, 200 mg/200ml, 50 mg/ 50ml .............................. 47citalopram hydrobromide oral solution .................. 37citalopram hydrobromide oral tablet 10 mg ........... 37citalopram hydrobromide oral tablet 20 mg ........... 37citalopram hydrobromide oral tablet 40 mg ........... 37cladribine intravenous solution 10 mg/10ml ..... 47claravis ......................... 92clarithromycin er ........... 26clarithromycin oral ........ 26classic prenatal tablet 28- 0.8 mg oral .................... 99clearlax powder oral .... 113clemastine fumarate oral tablet 2.68 mg ............. 147

CLEVER CHOICE COMFORT EZ 29G X 12MM ............................ 74clindacin etz external swab ............................. 92clindacin-p .................... 27clindamycin hcl oral ...... 27clindamycin phosphate external ......................... 27clindamycin phosphate injection solution 300 mg/ 2ml, 600 mg/4ml, 9 gm/ 60ml, 9000 mg/60ml ..... 27clindamycin phosphate vaginal .......................... 27CLINIMIX E/DEXTROSE (2.75/5) ......................... 99CLINIMIX E/DEXTROSE (4.25/10) ....................... 99CLINIMIX E/DEXTROSE (4.25/5) ......................... 99CLINIMIX E/DEXTROSE (5/ 15) ................................ 99CLINIMIX E/DEXTROSE (5/ 20) ................................ 99CLINIMIX/DEXTROSE (4.25/10) ....................... 99CLINIMIX/DEXTROSE (4.25/25) ....................... 99CLINIMIX/DEXTROSE (4.25/5) ......................... 99CLINIMIX/DEXTROSE (5/ 15) ................................ 99CLINIMIX/DEXTROSE (5/ 20) ................................ 99CLINIMIX/DEXTROSE (5/ 25) ................................ 99clobazam oral suspension ................... 31clobazam oral tablet 10 mg ................................. 32clobazam oral tablet 20 mg ................................. 32clobetasol prop emollient base ............................ 125clobetasol propionate e .................................. 125

clobetasol propionate external cream ............ 125clobetasol propionate external solution ......... 125clofarabine .................... 47CLOLAR ....................... 47clomipramine hcl oral .... 37clonazepam oral tablet 0.5 mg ................................. 32clonazepam oral tablet 0.5 mg ................................. 68clonazepam oral tablet 1 mg ................................. 32clonazepam oral tablet 1 mg ................................. 69clonazepam oral tablet 2 mg ................................. 32clonazepam oral tablet 2 mg ................................. 69clonazepam oral tablet dispersible 0.125 mg .... 32clonazepam oral tablet dispersible 0.125 mg .... 69clonazepam oral tablet dispersible 0.25 mg ...... 32clonazepam oral tablet dispersible 0.25 mg ...... 69clonazepam oral tablet dispersible 0.5 mg ........ 32clonazepam oral tablet dispersible 0.5 mg ........ 69clonazepam oral tablet dispersible 1 mg ........... 32clonazepam oral tablet dispersible 1 mg ........... 69clonazepam oral tablet dispersible 2 mg ........... 32clonazepam oral tablet dispersible 2 mg ........... 69clonidine ....................... 83clonidine hcl oral ........... 83clopidogrel bisulfate oral tablet 300 mg ................ 80clopidogrel bisulfate oral tablet 75 mg .................. 80clorazepate dipotassium .................. 32


clorazepate dipotassium .................. 69clotrimazole cream 1 % external (otc) ................. 42clotrimazole cream 1 % vaginal .......................... 42clotrimazole external cream ............................ 42clotrimazole external solution ......................... 42clotrimazole mouth/throat lozenge ......................... 42clotrimazole mouth/throat troche ............................ 91clotrimazole solution 1 % external (otc) ................. 42clotrimazole-betamethasone external cream .............. 92clovique ........................ 99clozapine oral tablet 100 mg ................................. 58clozapine oral tablet 200 mg ................................. 59clozapine oral tablet 25 mg ................................. 59clozapine oral tablet 50 mg ................................. 59clozapine oral tablet dispersible 100 mg ....... 59clozapine oral tablet dispersible 12.5 mg ...... 59clozapine oral tablet dispersible 150 mg ....... 59clozapine oral tablet dispersible 200 mg ....... 59clozapine oral tablet dispersible 25 mg ......... 59colchicine oral ............... 44colchicine-probenecid .... 44COLCRYS .................... 44colestipol hcl ................. 83colistimethate sodium (cba) ............................. 27colistimethate sodium (cba) ............................. 27colocort ....................... 139COLY-MYCIN S .......... 145COMBIGAN ................ 142

COMBIVENT RESPIMAT ................. 147COMETRIQ (100 MG DAILY DOSE) ............... 47COMETRIQ (140 MG DAILY DOSE) ............... 47COMETRIQ (60 MG DAILY DOSE) .......................... 47COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 1 ML ...................... 74COMPLERA ................. 64complete allergy medicine capsule 25 mg oral ..... 147compro .......................... 41constulose .................. 113COPIKTRA ................... 47CORLANOR ORAL SOLUTION ................... 83CORLANOR ORAL TABLET ........................ 83cortisone acetate oral .... 22cortisone acetate oral .............................. 125cortisone acetate oral .............................. 139CORTISPORIN-TC ..... 145COTELLIC .................... 47COUMADIN ORAL ....... 80CREON ....................... 122CRIXIVAN ORAL CAPSULE 200 MG ....... 64CRIXIVAN ORAL CAPSULE 400 MG ....... 64cromolyn sodium aerosol solution 5.2 mg/act nasal ........................... 147cromolyn sodium inhalation .................... 147cromolyn sodium ophthalmic .................. 142cromolyn sodium oral .............................. 147cryselle-28 .................. 127cvs antacid kids tablet chewable 750 mg oral .............................. 113

cvs anti-diarrheal suspension 262 mg/15ml oral .............................. 113cvs b-1 tablet 100 mg oral ................................ 99cvs b-12 tablet 500 mcg oral ................................ 99cvs bismuth tablet 262 mg oral .............................. 113cvs bismuth tablet chewable 262 mg oral ................. 113CVS CALCIUM 600 & VITAMIN D3 TABLET 600- 800 MG-UNIT ORAL .... 99CVS CALCIUM 600+D TABLET 600-800 MG-UNIT ORAL ............................ 99CVS CALCIUM CITRATE +D TABLET 315-250 MG- UNIT ORAL ................ 100CVS CALCIUM CITRATE +D3 MINI TABLET 200-250 MG-UNIT ORAL ......... 100cvs chewy not chalky flavor tablet chewable 750 mg oral .............................. 114cvs d3 capsule 10 mcg (400 unit) oral ...................... 100cvs d3 capsule 125 mcg (5000 ut) oral .............. 100cvs d3 capsule 25 mcg (1000 ut) oral .............. 100cvs d3 capsule 50 mcg (2000 ut) oral .............. 100cvs eye wash solution 99.05 % ophthalmic .............. 142cvs gas relief capsule 125 mg oral ........................ 114cvs gas relief extra strength tablet chewable 125 mg oral .............................. 114cvs gas relief ultra strength capsule 180 mg oral .... 114CVS GAUZE STERILE PAD 2"X2" ............................. 74cvs glucose gel 40 % oral ................................ 74


cvs glucose tablet chewable 4 gm oral ....................... 74cvs glucose tablet chewable 4-6 gm-mg oral ............. 74cvs glycerin adult suppository 2 gm rectal ........................... 114cvs glycerin adult suppository 2.1 gm rectal ........................... 114cvs heartburn relief tablet chewable 160-105 mg oral .............................. 114cvs iron tablet 325 (65 fe) mg oral ........................ 100CVS LANCETS MICRO THIN 33G ..................... 74CVS LANCETS THIN 26G ............................... 74CVS LANCETS ULTRA THIN 30G ..................... 74cvs lice killing shampoo 0.33-4 % external ......... 92cvs lice solution kit combination .................. 92cvs magnesium citrate solution 1.745 gm/30ml oral .............................. 114cvs mineral oil enema enema rectal ............... 114cvs mineral oil oil oral .............................. 114cvs nasal mist aerosol solution 0.9 % nasal .... 144cvs stomach relief suspension 525 mg/15ml oral .............................. 114cvs stomach relief tablet chewable 262 mg oral .............................. 114cyanocobalamin solution 1000 mcg/ml injection ...................... 100cyclafem 1/35 ............. 127cyclafem 7/7/7 ............ 127cyclobenzaprine hcl oral .............................. 151

cyclophosphamide oral capsule ......................... 47CYCLOSET .................. 74cyclosporine intravenous ................. 135cyclosporine modified ...................... 135cyclosporine oral capsule ....................... 135cyproheptadine hcl oral tablet ........................... 147CYRAMZA .................... 47cyred ........................... 127cyred eq ...................... 127CYSTADANE .............. 122CYSTAGON ............... 122CYSTARAN ................ 142cytarabine (pf) ............... 47cytarabine injection solution ......................... 47Dd 1000 capsule 25 mcg (1000 ut) oral .............. 100d 400 tablet 10 mcg (400 unit) oral ...................... 100d 5000 capsule 125 mcg (5000 ut) oral .............. 100d 5000 tablet 125 mcg (5000 ut) oral .............. 100d-3-5 capsule 125 mcg (5000 ut) oral .............. 100d-vi-sol liquid 10 mcg/ml oral .............................. 100d2000 ultra strength capsule 50 mcg (2000 ut) oral .............................. 100D3 DOTS TABLET DISPERSIBLE 50 MCG (2000 UT) ORAL ........ 100d3 high potency capsule 25 mcg (1000 ut) oral ...... 100d3 super strength capsule 50 mcg (2000 ut) oral .............................. 100d3-1000 capsule 25 mcg (1000 ut) oral .............. 100d3-1000 tablet 25 mcg (1000 ut) oral .............. 100

dacarbazine intravenous ................... 47dactinomycin ................. 47dalfampridine er ............ 89DALIRESP .................. 147danazol oral ................ 127dantrolene sodium oral ................................ 63dapsone oral ................. 45DAPTACEL INTRAMUSCULAR SUSPENSION 23-15- 5 .................................. 135DAPTOMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG ................................ 27daptomycin intravenous solution reconstituted 500 mg ................................. 27DARAPRIM ................... 57DARZALEX ................... 48dasetta 1/35 ................ 127dasetta 7/7/7 ............... 127daunorubicin hcl intravenous solution 20 mg/ 4ml ................................ 48DAUNORUBICIN HCL INTRAVENOUS SOLUTION 50 MG/10ML ................. 48DAURISMO ORAL TABLET 100 MG ......................... 48DAURISMO ORAL TABLET 25 MG ........................... 48deblitane ..................... 128decadron oral tablet ...... 22decitabine ..................... 48deferasirox oral tablet soluble ........................ 100DELSTRIGO ................. 64delta d3 tablet 10 mcg (400 unit) oral ...................... 100delyla .......................... 128demeclocycline hcl oral ................................ 27DEMSER ...................... 83DENAVIR ...................... 64DEPEN TITRATABS ... 100


DEPEN TITRATABS ... 123DEPEN TITRATABS ... 135DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ ML ............................... 128DESCOVY .................... 64desenex powder 2 % external ......................... 92desipramine hcl oral ..... 37desmopressin ace spray refrig ........................... 126desmopressin acetate injection ...................... 126desmopressin acetate oral .............................. 126desmopressin acetate spray ........................... 126desogestrel-ethinyl estradiol ...................... 128desoximetasone external cream .......................... 125desoximetasone external gel ............................... 125desoximetasone external ointment ...................... 125DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG ................................ 37DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG ................................ 37desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg ............ 37desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg .............. 37desvenlafaxine succinate er oral tablet extended release 24 hour 50 mg .............. 37dex4 glucose tablet chewable 4-6 gm-mg oral ................................ 74

dex4 naturals tablet chewable 4-6 gm-mg oral ................................ 74dex4 pouch pack tablet chewable 4-6 gm-mg oral ................................ 74dex4 quick dissolve glucose tablet chewable 4 gm oral ................................ 74dex4 tablet chewable 4-6 gm-mg oral ................... 74dexamethasone oral elixir .............................. 22dexamethasone oral elixir ............................ 125dexamethasone oral elixir ............................ 139dexamethasone oral solution ......................... 22dexamethasone oral tablet ............................. 22dexamethasone oral tablet ........................... 125dexamethasone oral tablet ........................... 139DEXAMETHASONE SOD PHOSPHATE PF INJECTION SOLUTION ................... 22dexamethasone sodium phosphate injection ...... 22dexamethasone sodium phosphate ophthalmic .................. 142dexrazoxane hcl ........... 48dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 5 mg ................................. 89dextroamphetamine sulfate er oral capsule extended release 24 hour 15 mg .. 89dextroamphetamine sulfate oral tablet 10 mg ........... 89dextroamphetamine sulfate oral tablet 5 mg ............. 90dextrose in lactated ringers ......................... 100

dextrose intravenous solution 10 %, 5 % ...... 100DEXTROSE INTRAVENOUS SOLUTION 20 %, 40 % ................. 100dextrose intravenous solution 250 mg/ml, 30 %, 70 % ........................... 101dextrose intravenous solution 50 % .............. 101DEXTROSE-NACL INTRAVENOUS SOLUTION 10-0.2 % ..................... 101dextrose-nacl intravenous solution 10-0.45 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5- 0.33 %, 5-0.45 %, 5-0.9 % ................................ 101dialyvite vitamin d 5000 capsule 125 mcg (5000 ut) oral .............................. 101diarrhea suspension 262 mg/15ml oral ............... 114DIASTAT ACUDIAL RECTAL GEL 10 MG .... 32DIASTAT ACUDIAL RECTAL GEL 10 MG .... 32DIASTAT ACUDIAL RECTAL GEL 10 MG .... 69DIASTAT ACUDIAL RECTAL GEL 20 MG .... 32DIASTAT ACUDIAL RECTAL GEL 20 MG .... 32DIASTAT ACUDIAL RECTAL GEL 20 MG .... 69DIASTAT PEDIATRIC ... 32DIASTAT PEDIATRIC ... 32DIASTAT PEDIATRIC ... 69diazepam injection ........ 90diazepam intensol ........ 90diazepam oral concentrate ................... 32diazepam oral concentrate ................... 32diazepam oral concentrate ................... 69diazepam oral solution 5 mg/5ml .......................... 32


diazepam oral solution 5 mg/5ml .......................... 32diazepam oral solution 5 mg/5ml .......................... 69diazepam oral tablet 10 mg ................................. 32diazepam oral tablet 10 mg ................................. 32diazepam oral tablet 10 mg ................................. 69diazepam oral tablet 2 mg ................................. 32diazepam oral tablet 2 mg ................................. 32diazepam oral tablet 2 mg ................................. 69diazepam oral tablet 5 mg ................................. 32diazepam oral tablet 5 mg ................................. 32diazepam oral tablet 5 mg ................................. 69diazepam rectal ............ 32diclofenac potassium .... 15diclofenac potassium .... 22diclofenac sodium er .... 15diclofenac sodium er .... 22diclofenac sodium ophthalmic .................. 142diclofenac sodium oral ... 15diclofenac sodium oral ... 22diclofenac sodium transdermal gel 1 % ..... 92dicloxacillin sodium ....... 27dicyclomine hcl oral .... 114didanosine oral capsule delayed release 200 mg ................................. 64didanosine oral capsule delayed release 250 mg, 400 mg .......................... 64diflunisal oral ................. 15diflunisal oral ................. 22digitek oral tablet 125 mcg ............................... 84digitek oral tablet 250 mcg ............................... 84

digox oral tablet 125 mcg ............................... 84digox oral tablet 250 mcg ............................... 84digoxin oral solution ...... 84digoxin oral tablet 125 mcg ............................... 84digoxin oral tablet 250 mcg ............................... 84dihydroergotamine mesylate nasal ............................. 44DILANTIN INFATABS .... 32DILANTIN ORAL CAPSULE ..................... 32dilt-xr ............................. 84diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg ............ 84diltiazem hcl er beads oral capsule extended release 24 hour 360 mg ............ 84diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg .......................... 84diltiazem hcl er coated beads oral capsule extended release 24 hour 360 mg .......................... 84diltiazem hcl er oral capsule extended release 12 hour .............................. 84diltiazem hcl er oral capsule extended release 24 hour 120 mg .......................... 84diltiazem hcl oral ........... 84DIPENTUM ................. 139diphenhist capsule 25 mg oral .............................. 147diphenhydramine hcl capsule 25 mg oral (otc) ............................ 147diphenhydramine hcl capsule 50 mg oral (otc) ............................ 147

diphenhydramine hcl injection ...................... 147diphenhydramine hcl tablet 25 mg oral ................... 147diphenoxylate- atropine ....................... 114DIPHTHERIA-TETANUS TOXOIDS DT .............. 135disulfiram oral ............... 19divalproex sodium er oral tablet extended release 24 hour .............................. 33divalproex sodium er oral tablet extended release 24 hour .............................. 44divalproex sodium er oral tablet extended release 24 hour .............................. 71divalproex sodium oral capsule delayed release sprinkle ......................... 33divalproex sodium oral capsule delayed release sprinkle ......................... 44divalproex sodium oral capsule delayed release sprinkle ......................... 71divalproex sodium oral tablet delayed release ... 33divalproex sodium oral tablet delayed release ... 44divalproex sodium oral tablet delayed release ... 71DOCETAXEL INTRAVENOUS CONCENTRATE 160 MG/ 8ML, 20 MG/ML, 200 MG/ 10ML, 80 MG/4ML ........ 48DOCETAXEL INTRAVENOUS SOLUTION 160 MG/16ML, 20 MG/2ML, 80 MG/8ML ................... 48docu liquid 50 mg/5ml oral .............................. 114docusate sodium capsule 100 mg oral ................. 114docusate sodium liquid 50 mg/5ml oral ................. 114


docusate sodium tablet 100 mg oral ........................ 114docusil capsule 100 mg oral .............................. 114dofetilide ....................... 84dok capsule 100 mg oral .............................. 114dok capsule 250 mg oral .............................. 114donepezil hcl oral tablet 10 mg, 5 mg ....................... 36donepezil hcl oral tablet dispersible .................... 36dorzolamide hcl ophthalmic .................. 142dorzolamide hcl-timolol mal .............................. 142DOVATO ...................... 64doxazosin mesylate oral ................................ 84doxazosin mesylate oral .............................. 123doxepin hcl oral capsule ......................... 37doxepin hcl oral capsule ......................... 69doxepin hcl oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg .......................... 152doxepin hcl oral concentrate ................... 37doxepin hcl oral concentrate ................... 69doxepin hcl oral concentrate ................. 152doxercalciferol oral capsule 0.5 mcg ....................... 101doxercalciferol oral capsule 0.5 mcg ....................... 140doxorubicin hcl intravenous solution ......................... 48doxorubicin hcl liposomal ...................... 48doxy 100 ....................... 27doxycycline hyclate intravenous ................... 27doxycycline hyclate oral capsule ......................... 27

doxycycline hyclate oral capsule ......................... 91doxycycline hyclate oral capsule 50 mg .............. 92doxycycline hyclate oral tablet 100 mg, 20 mg .... 27doxycycline hyclate oral tablet 100 mg, 20 mg .... 91doxycycline monohydrate oral capsule 100 mg, 50 mg ................................. 92doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg ............................ 27doxycycline monohydrate oral tablet 100 mg, 50 mg ................................. 27doxycycline monohydrate oral tablet 100 mg, 50 mg ................................. 93doxycycline monohydrate oral tablet 50 mg ........... 91dronabinol oral capsule 10 mg ................................. 41dronabinol oral capsule 2.5 mg, 5 mg ....................... 41DROPLET PEN NEEDLES 30G X 8 MM ................. 74drospirenone-ethinyl estradiol oral tablet 3-0.03 mg ............................... 128DROXIA ........................ 48ducodyl tablet delayed release 5 mg oral ........ 114DULERA ..................... 147duloxetine hcl oral capsule delayed release particles 20 mg ................................. 37duloxetine hcl oral capsule delayed release particles 20 mg ................................. 69duloxetine hcl oral capsule delayed release particles 20 mg ................................. 90duloxetine hcl oral capsule delayed release particles 30 mg ................................. 37

duloxetine hcl oral capsule delayed release particles 30 mg ................................. 69duloxetine hcl oral capsule delayed release particles 30 mg ................................. 90duloxetine hcl oral capsule delayed release particles 40 mg ................................. 37duloxetine hcl oral capsule delayed release particles 40 mg ................................. 69duloxetine hcl oral capsule delayed release particles 40 mg ................................. 90duloxetine hcl oral capsule delayed release particles 60 mg ................................. 37duloxetine hcl oral capsule delayed release particles 60 mg ................................. 69duloxetine hcl oral capsule delayed release particles 60 mg ................................. 90duramorph .................... 15dutasteride oral ........... 123dutasteride-tamsulosin hcl ............................... 123Ee.e.s. 400 oral tablet ..... 27EASY TOUCH PEN NEEDLES 29G X 12MM ............................ 74EASY TOUCH SAFETY PEN NEEDLES 30G X 8 MM ................................ 74econtra ez tablet 1.5 mg oral .............................. 128ecpirin tablet delayed release 325 mg oral ...... 15ed a-hist tablet 4-10 mg oral .............................. 147EDURANT .................... 64efavirenz oral capsule 200 mg ................................. 64efavirenz oral capsule 50 mg ................................. 64efavirenz oral tablet ...... 64


ELAPRASE ................. 122elinest ......................... 128ELIQUIS ....................... 80ELIQUIS STARTER PACK ............................ 80elite-ob ........................ 101ELITEK ......................... 48ELLA ........................... 128eluryng ........................ 128EMCYT ......................... 48emoquette ................... 128EMPLICITI .................... 48EMSAM ........................ 38EMTRIVA ORAL CAPSULE ..................... 64EMTRIVA ORAL SOLUTION ................... 64enalapril maleate oral .... 84enalapril- hydrochlorothiazide ...... 84ENBREL MINI ............... 15ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/ 0.5ML .......................... 135ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML .. 135ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED ..... 135ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- INJECTOR .................. 135endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg ................................. 15endocet oral tablet 2.5-325 mg ................................. 15enema enema 7-19 gm/ 118ml rectal ................ 114enema mineral oil enema rectal ........................... 114ENGERIX-B INJECTION ................. 135enoxaparin sodium injection ........................ 80

enoxaparin sodium subcutaneous solution 100 mg/ml, 150 mg/ml ......... 80enoxaparin sodium subcutaneous solution 120 mg/0.8ml, 80 mg/ 0.8ml ............................. 80enoxaparin sodium subcutaneous solution 30 mg/0.3ml ....................... 81enoxaparin sodium subcutaneous solution 40 mg/0.4ml ....................... 81enoxaparin sodium subcutaneous solution 60 mg/0.6ml ....................... 81enpresse-28 ................ 128enskyce oral tablet 0.15-30 mg-mcg ....................... 128entacapone ................... 58entecavir ....................... 64ENTRESTO .................. 84enulose ....................... 114EPCLUSA ..................... 64EPCLUSA ..................... 64EPIDIOLEX ................... 33epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 mg/ 0.3ml ........................... 147EPINEPHRINE PF INJECTION SOLUTION ................. 147epinephrine pf injection solution prefilled syringe ........................ 147epirubicin hcl intravenous solution 200 mg/100ml, 50 mg/25ml ........................ 48epitol ............................. 33epitol ............................. 71EPIVIR HBV ORAL SOLUTION ................... 64eplerenone .................... 84eprosartan mesylate ..... 84eq antacid extra strength tablet chewable 750 mg oral .............................. 115

eq antacid ultra strength tablet chewable 1000 mg oral .............................. 115eq calcium 600+d tablet 600-800 mg-unit oral ... 101EQ CALCIUM CITRATE+D TABLET 315-250 MG-UNIT ORAL .......................... 101eq gas relief capsule 125 mg oral ........................ 115eq lice killing max st shampoo 0.33-4 % external ......................... 93eq magnesium citrate solution 1.745 gm/30ml oral .............................. 115eq mineral oil oil oral ... 115eq pink-bismuth tablet chewable 262 mg oral .............................. 115eq stomach relief suspension 262 mg/15ml oral .............................. 115eql b-6 tablet 100 mg oral .............................. 101eql lice killing max st shampoo 0.33-4 % external ......................... 93eql stomach relief suspension 262 mg/15ml oral .............................. 115eql vitamin b-12 tablet 500 mcg oral ...................... 101eql vitamin c tablet 1000 mg oral .............................. 101eql vitamin c tablet 500 mg oral .............................. 101eql vitamin c/rose hips tablet 1000 mg oral ............... 101eql vitamin c/rose hips tablet 500 mg oral ................. 101ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG ................................ 42ERBITUX ...................... 48ergoloid mesylates oral ................................ 36


ERGOMAR ................... 44ergotamine-caffeine ...... 44ERIVEDGE ................... 48ERLEADA ..................... 48erlotinib hcl oral tablet 100 mg, 150 mg ................... 48erlotinib hcl oral tablet 25 mg ................................. 48errin ............................ 128ertapenem sodium ........ 27ERWINAZE INJECTION ................... 48ery ................................. 27ery-tab .......................... 27ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG ................................ 27erythrocin stearate oral tablet 250 mg ................ 27erythromycin base oral tablet delayed release ... 27erythromycin ethylsuccinate oral tablet ...................... 27erythromycin external gel ................................. 28erythromycin external solution ......................... 28erythromycin ophthalmic .................... 28erythromycin stearate oral tablet 250 mg ................ 28ESBRIET ORAL CAPSULE ................... 147ESBRIET ORAL CAPSULE ................... 147ESBRIET ORAL TABLET 267 MG ....................... 147ESBRIET ORAL TABLET 267 MG ....................... 147ESBRIET ORAL TABLET 801 MG ....................... 147ESBRIET ORAL TABLET 801 MG ....................... 147escitalopram oxalate oral solution ......................... 38

escitalopram oxalate oral solution ......................... 69escitalopram oxalate oral tablet 10 mg .................. 38escitalopram oxalate oral tablet 10 mg .................. 69escitalopram oxalate oral tablet 20 mg .................. 38escitalopram oxalate oral tablet 20 mg .................. 69escitalopram oxalate oral tablet 5 mg .................... 38escitalopram oxalate oral tablet 5 mg .................... 69estarylla ...................... 128estradiol oral ............... 128estradiol transdermal patch weekly ......................... 128estradiol vaginal cream .......................... 128ESTRING .................... 128ethambutol hcl oral ....... 45ethosuximide oral ......... 33ethynodiol diac-eth estradiol ...................... 128etodolac oral ................. 15etodolac oral capsule 200 mg ................................. 22etodolac oral tablet ....... 22ETOPOPHOS ............... 48etoposide intravenous solution 1 gm/50ml, 100 mg/ 5ml, 500 mg/25ml ......... 48everolimus .................... 48EVOMELA .................... 49EVOTAZ ....................... 64EXEL COMFORT POINT PEN NEEDLE 29G X 12MM ............................ 75exemestane .................. 49EXJADE ...................... 101EXTAVIA SUBCUTANEOUS KIT ................................ 90EYE STREAM SOLUTION OPHTHALMIC ............ 142ezetimibe ...................... 84

FFABRAZYME .............. 122falmina ........................ 128famciclovir oral tablet 125 mg, 250 mg ................... 64famciclovir oral tablet 500 mg ................................. 64famotidine intravenous solution 20 mg/2ml, 200 mg/ 20ml, 40 mg/4ml ......... 115famotidine oral tablet 20 mg, 40 mg .......................... 115famotidine premixed .... 115famotidine tablet 10 mg oral .............................. 115FANAPT ORAL TABLET 1 MG ................................ 59FANAPT ORAL TABLET 10 MG, 12 MG ................... 59FANAPT ORAL TABLET 2 MG ................................ 59FANAPT ORAL TABLET 4 MG ................................ 59FANAPT ORAL TABLET 6 MG ................................ 59FANAPT ORAL TABLET 8 MG ................................ 59FANAPT TITRATION PACK ............................ 59FANTASY LUBRICATED ............. 144FANTASY LUBRICATED/ SPERMICIDE ............. 144FARYDAK ORAL CAPSULE 10 MG ......... 49FARYDAK ORAL CAPSULE 15 MG, 20 MG ................................ 49FASLODEX INTRAMUSCULAR SOLUTION 250 MG/ 5ML ............................... 49febuxostat ..................... 44felbamate ...................... 33felodipine er .................. 84femynor ....................... 128fenofibrate micronized ... 85


fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg ................................. 85fenofibric acid oral capsule delayed release ............ 85fenoprofen calcium oral tablet ............................. 15fenoprofen calcium oral tablet ............................. 22fentanyl citrate buccal lozenge on a handle ..... 15fentanyl citrate buccal lozenge on a handle ..... 15fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/ hr, 75 mcg/hr ................ 15fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/ hr, 75 mcg/hr ................ 15ferate tablet 240 (27 fe) mg oral .............................. 101ferosul tablet 325 (65 fe) mg oral .............................. 101ferretts tablet 325 (106 fe) mg oral ........................ 101ferrex 150 capsule 150 mg oral .............................. 101ferric x-150 capsule 150 mg oral .............................. 101ferrous gluconate tablet 240 (27 fe) mg oral ............ 101ferrous gluconate tablet 324 (37.5 fe) mg oral ......... 101ferrous gluconate tablet 324 (38 fe) mg oral ............ 101ferrous sulfate tablet 325 (65 fe) mg oral ............ 101ferrous sulfate tablet delayed release 324 (65 fe) mg oral ........................ 102ferrous sulfate tablet delayed release 325 (65 fe) mg oral ........................ 102ferrousul tablet 325 (65 fe) mg oral ........................ 102

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG ................................ 38FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG ............... 38FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 MG ............... 38FETZIMA TITRATION ... 38finasteride oral tablet 5 mg ............................... 123FIRAZYR .................... 135FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG .............................. 133FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG .............................. 133flac .............................. 145flecainide acetate ......... 85FLONASE ALLERGY RELIEF SUSPENSION 50 MCG/ACT NASAL ...... 148FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ BLIST, 50 MCG/ BLIST .......................... 148FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/ BLIST .......................... 148FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT ............ 148FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT ............ 148

FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT ................... 148fluconazole in sodium chloride intravenous solution 200-0.9 mg/100ml- %, 400-0.9 mg/200ml- % .................................. 42 fluconazole oral ............ 42flucytosine oral capsule 250 mg ................................. 42flucytosine oral capsule 500 mg ................................. 42fludarabine phosphate intravenous solution ..... 49fludarabine phosphate intravenous solution reconstituted ................. 49fludrocortisone acetate oral .............................. 125flunisolide nasal solution 25 mcg/act (0.025%) ....... 148fluocinolone acetonide body .............................. 93fluocinolone acetonide external ....................... 125fluocinolone acetonide otic .............................. 125fluocinolone acetonide scalp ........................... 125fluocinonide emulsified base ............................ 125fluocinonide external cream 0.05 % .......................... 93fluocinonide external gel ............................... 125fluocinonide external ointment ...................... 125fluocinonide external solution ....................... 125fluoritab oral tablet chewable 2.2 (1 f) mg ............................... 102fluorometholone ophthalmic .................. 142fluorouracil external cream 5 % ............................... 93


fluorouracil external solution ......................... 93fluorouracil intravenous ................... 49fluoxetine hcl oral capsule 10 mg ............................ 38fluoxetine hcl oral capsule 20 mg ............................ 38fluoxetine hcl oral capsule 40 mg ............................ 38fluoxetine hcl oral solution ......................... 38fluphenazine decanoate injection ........................ 59fluphenazine hcl injection ........................ 59fluphenazine hcl oral .... 59flurbiprofen oral ............. 15flurbiprofen oral ............. 22flurbiprofen sodium ..... 142flutamide ....................... 49fluticasone propionate external ......................... 93fluticasone propionate external ....................... 125fluticasone propionate external lotion ............. 148fluticasone propionate nasal ........................... 148fluticasone propionate suspension 50 mcg/act nasal (otc) ................... 148fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/ dose, 500-50 mcg/ dose ............................ 148fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/ dose, 500-50 mcg/ dose ............................ 148fluticasone-salmeterol inhalation aerosol powder breath activated 100-50

mcg/dose, 250-50 mcg/ dose, 500-50 mcg/ dose ............................ 148fluvoxamine maleate oral tablet 100 mg ................ 38fluvoxamine maleate oral tablet 25 mg .................. 38fluvoxamine maleate oral tablet 50 mg .................. 38folic acid tablet 1 mg oral (otc) ............................ 102folic acid tablet 1 mg oral (rx) .............................. 102folic acid tablet 400 mcg oral .............................. 102folic acid tablet 800 mcg oral .............................. 102FOLOTYN ..................... 49fondaparinux sodium subcutaneous solution 10 mg/0.8ml ....................... 81fondaparinux sodium subcutaneous solution 2.5 mg/0.5ml ....................... 81fondaparinux sodium subcutaneous solution 5 mg/0.4ml ....................... 81fondaparinux sodium subcutaneous solution 7.5 mg/0.6ml ....................... 81FORTEO SUBCUTANEOUS SOLUTION 600 MCG/ 2.4ML .......................... 140fosamprenavir calcium .. 64fosinopril sodium .......... 85fosinopril sodium-hctz .... 85fosphenytoin sodium .... 33FREAMINE III INTRAVENOUS SOLUTION 10 % ........................... 102FULPHILA .................... 81fulvestrant ..................... 49fungoid-d cream 1 % external ......................... 42furosemide injection solution 10 mg/ml ....................... 85

furosemide injection solution 10 mg/ml (4ml syringe) ......................... 85furosemide oral solution 10 mg/ml, 8 mg/ml ............. 85furosemide oral tablet .... 85FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED ....... 64FYCOMPA ORAL SUSPENSION .............. 33FYCOMPA ORAL TABLET 10 MG, 12 MG .............. 33FYCOMPA ORAL TABLET 2 MG ............................. 33FYCOMPA ORAL TABLET 4 MG ............................. 33FYCOMPA ORAL TABLET 6 MG ............................. 33FYCOMPA ORAL TABLET 8 MG ............................. 33Ggabapentin oral capsule 100 mg ................................. 33gabapentin oral capsule 300 mg ................................. 33gabapentin oral capsule 400 mg ................................. 33gabapentin oral solution ......................... 33gabapentin oral tablet 600 mg ................................. 33gabapentin oral tablet 800 mg ................................. 33GAMUNEX-C .............. 135ganciclovir sodium intravenous solution reconstituted ................. 65GARDASIL 9 .............. 135gas relief capsule 180 mg oral .............................. 115gas relief extra strength capsule 125 mg oral .... 115gas relief extra strength tablet chewable 125 mg oral .............................. 115


gas relief tablet chewable 80 mg oral ................... 115gas relief ultra strength capsule 180 mg oral .... 115GAS-X ULTRA STRENGTH CAPSULE 180 MG ORAL .......................... 115GATTEX ..................... 115gavilax powder oral .... 115gavilyte-c .................... 115gavilyte-g .................... 115gavilyte-n with flavor pack ............................ 115GAZYVA ....................... 49GEMCITABINE HCL INTRAVENOUS SOLUTION 1 GM/10ML, 2 GM/ 20ML ............................. 49gemcitabine hcl intravenous solution 1 gm/26.3ml, 2 gm/ 52.6ml, 200 mg/2ml, 200 mg/5.26ml ..................... 49gemcitabine hcl intravenous solution reconstituted 1 gm, 200 mg .......................... 49gemcitabine hcl intravenous solution reconstituted 2 gm ................................. 49gemfibrozil oral ............. 85generlac ...................... 115gengraf oral capsule 100 mg, 25 mg ................... 135gengraf oral solution .... 135gentak ophthalmic ointment ........................ 28gentamicin sulfate external ......................... 28gentamicin sulfate injection ........................ 28gentamicin sulfate ophthalmic solution ....... 28GENVOYA .................... 65GEODON INTRAMUSCULAR ....... 59GEODON INTRAMUSCULAR ....... 71geri-pectate suspension 262 mg/15ml oral ............... 115

GILENYA ORAL CAPSULE 0.25 MG ........................ 38GILENYA ORAL CAPSULE 0.5 MG .......................... 90GILOTRIF ..................... 49glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ ml .................................. 90glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ ml .................................. 90glatopa subcutaneous solution prefilled syringe 20 mg/ml ............................ 90glatopa subcutaneous solution prefilled syringe 40 mg/ml ............................ 90GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG ........................... 49glimepiride oral tablet 1 mg ................................. 75glimepiride oral tablet 2 mg ................................. 75glimepiride oral tablet 4 mg ................................. 75glipizide er oral tablet extended release 24 hour 10 mg ............................ 75glipizide er oral tablet extended release 24 hour 2.5 mg ........................... 75glipizide er oral tablet extended release 24 hour 5 mg ................................. 75glipizide oral tablet 10 mg ................................. 75glipizide oral tablet 5 mg ................................. 75glipizide xl oral tablet extended release 24 hour 10 mg ............................ 75glipizide xl oral tablet extended release 24 hour 2.5 mg ........................... 75

glipizide xl oral tablet extended release 24 hour 5 mg ................................. 75glipizide-metformin hcl oral tablet 2.5-250 mg ......... 75glipizide-metformin hcl oral tablet 2.5-500 mg, 5-500 mg ................................. 75GLOBAL ALCOHOL PREP EASE ............................ 28GLOBAL EASY GLIDE INSULIN SYR 31G X 15/64" 1 ML .............................. 75GLUCAGEN HYPOKIT ...................... 75GLUCAGON EMERGENCY INJECTION KIT ............ 75gluco burst gel 40 % oral ................................ 75glucose tablet chewable 4 gm oral .......................... 75glucose tablet chewable 4- 6 gm-mg oral ................ 75glyburide oral tablet 1.25 mg ................................. 75glyburide oral tablet 2.5 mg ................................. 75glyburide oral tablet 5 mg ................................. 75glycerin (adult) suppository 2 gm rectal .................. 116glycerin (adult) suppository 2.1 gm rectal ............... 116glycolax powder oral .... 116glycopyrrolate injection solution 0.2 mg/ml ...... 116glycopyrrolate oral tablet 1 mg, 2 mg ..................... 116glydo external prefilled syringe .......................... 19gnp acid control 150 max st tablet 150 mg oral ....... 116gnp acid reducer max st tablet 20 mg oral ......... 116gnp acid reducer tablet 75 mg oral ........................ 116


gnp adult aspirin low strength tablet chewable 81 mg oral .......................... 15gnp all day allergy tablet 10 mg oral ........................ 148gnp all day pain relief tablet 220 mg oral ................... 22gnp allergy capsule 25 mg oral .............................. 148gnp allergy relief tablet dispersible 10 mg oral .............................. 148gnp allergy tablet 25 mg oral .............................. 148gnp antacid anti-gas suspension 200-200-20 mg/ 5ml oral ....................... 102gnp antacid extra strength tablet chewable 160-105 mg oral .............................. 116gnp antacid extra strength tablet chewable 750 mg oral .............................. 116gnp antacid tablet chewable 500 mg oral ................. 116gnp antacid ultra strength tablet chewable 1000 mg oral .............................. 116gnp anti-gas capsule 180 mg oral ........................ 116gnp artificial tears solution 5-6 mg/ml ophthalmic .................. 142gnp aspirin low dose tablet delayed release 81 mg oral ................................ 15gnp aspirin tablet 325 mg oral ................................ 15gnp aspirin tablet delayed release 325 mg oral ...... 15gnp athletes foot cream 1 % external ......................... 42gnp bisa-lax tablet delayed release 5 mg oral ........ 116gnp calamine lotion 8-8 % external ......................... 93gnp calcium 500 +d3 tablet 500-600 mg-unit oral ... 102

GNP CALCIUM 600 +D3 TABLET 600-800 MG-UNIT ORAL .......................... 102GNP CALCIUM CITRATE +D3 TABLET 315-250 MG- UNIT ORAL ................ 102gnp calcium tablet 600 mg oral .............................. 102gnp childrens allergy liquid 12.5 mg/5ml oral ......... 148gnp clearlax powder oral .............................. 116gnp clotrimazole 3 cream 2 % vaginal ...................... 93gnp cold & allergy tablet 4- 10 mg oral ................... 148gnp dayhist allergy tablet 1.34 mg oral ................ 149gnp folic acid tablet 400 mcg oral ...................... 102gnp gas relief extra strength capsule 125 mg oral .... 116gnp gas relief extra strength tablet chewable 125 mg oral .............................. 116gnp gas relief tablet chewable 80 mg oral ... 116gnp glucose tablet chewable 4 gm oral ....................... 75gnp glucose tablet chewable 4-6 gm-mg oral ............. 76gnp hydrocortisone cream 0.5 % external ............... 93gnp hydrocortisone max st ointment 1 % external .... 93gnp hydrocortisone plus cream 1 % external ...... 93gnp hydrocortisone/aloe cream 1 % external ...... 93gnp ibuprofen capsule 200 mg oral .......................... 22gnp ibuprofen tablet 200 mg oral ................................ 22gnp iron tablet 200 (65 fe) mg oral ........................ 102gnp lansoprazole capsule delayed release 15 mg oral .............................. 116

gnp laxative tablet delayed release 5 mg oral ........ 116gnp lice treatment liquid 1 % external ..................... 93gnp lice treatment shampoo 0.33-4 % external ......... 93gnp loratadine tablet 10 mg oral .............................. 149gnp lubricating plus eye drops solution 0.5 % ophthalmic .................. 142gnp magnesium citrate solution 1.745 gm/30ml oral .............................. 116gnp miconazole 3 kit 200 & 2 mg-% (9gm) vaginal ... 93gnp miconazole 7 cream 2 % vaginal ...................... 93gnp miconazorb af powder 2 % external .................. 93gnp milk of magnesia suspension 1200 mg/15ml oral .............................. 102gnp motion sickness relief tablet 25 mg oral ........... 41gnp naproxen sodium capsule 220 mg oral ..... 22gnp nasal decongestant tablet 30 mg oral ......... 149gnp niacin tablet 250 mg oral .............................. 102gnp nicotine mini lozenge 2 mg mouth/throat ........... 19gnp nicotine polacrilex gum 2 mg mouth/throat ........ 19gnp nicotine polacrilex gum 4 mg mouth/throat ........ 19gnp nicotine polacrilex lozenge 2 mg mouth/ throat ............................ 20gnp nicotine polacrilex lozenge 4 mg mouth/ throat ............................ 20gnp omeprazole tablet delayed release 20 mg oral .............................. 116gnp pink bismuth tablet 262 mg oral ........................ 116


gnp pink bismuth tablet chewable 262 mg oral .............................. 116gnp prenatal tablet 28-0.8 mg oral ........................ 102gnp quick dissolve glucose tablet chewable 4 gm oral ................................ 76gnp stomach relief suspension 262 mg/15ml oral .............................. 117gnp stool softener capsule 100 mg oral ................. 117gnp stool softener capsule 250 mg oral ................. 117gnp terbinafine hydrochloride cream 1 % external ......................... 43gnp tolnaftate cream 1 % external ......................... 43gnp vitamin c tablet 1000 mg oral ........................ 102gnp vitamin c tablet 250 mg oral .............................. 102gnp vitamin c tablet 500 mg oral .............................. 102gnp vitamin c w/rose hips tablet 500-37 mg oral .. 102gnp vitamin c/rose hips tablet 1000 mg oral ..... 102gnp vitamin d-400 tablet 10 mcg (400 unit) oral ..... 103goodsense all day allergy tablet 10 mg oral ......... 149goodsense artificial tears solution 0.5-0.6 % ophthalmic .................. 142goodsense aspirin tablet 325 mg oral ................... 15goodsense aspirin tablet chewable 81 mg oral .... 15goodsense gas relief tablet chewable 125 mg oral .............................. 117goodsense glucose tablet chewable 4-6 gm-mg oral ................................ 76

goodsense ibuprofen tablet 200 mg oral ................... 22goodsense lubricating eye drop solution 0.5 % ophthalmic .................. 142goodsense nicotine gum 4 mg mouth/throat ........... 20goodsense nicotine lozenge 4 mg mouth/throat ........ 20griseofulvin microsize oral suspension ................... 43griseofulvin ultramicrosize ............... 43guaiatussin ac syrup 100-10 mg/5ml oral ................. 149guaifenesin ac syrup 100-10 mg/5ml oral ................. 149guaifenesin-codeine solution 100-10 mg/5ml oral (otc) ............................ 149guanfacine hcl er .......... 90GUANIDINE HCL ORAL ............................ 45HH-E-B INCONTROL PEN NEEDLES 29G X 12MM ............................ 76hailey 1.5/30 ............... 128HALAVEN ..................... 49halobetasol propionate external cream ............ 125halobetasol propionate external ointment ........ 125haloperidol decanoate intramuscular solution 100 mg/ml 1 ml .................... 59haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml ........... 59haloperidol lactate ........ 59haloperidol oral ............. 59HARVONI ..................... 65HARVONI ORAL TABLET 90-400 MG .................... 65HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ ML 1 ML, 720 EL U/0.5ML 0.5 ML ......................... 135

HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ ML, 720 EL U/0.5ML ... 135healthylax packet oral .............................. 117heartburn antacid ex st tablet chewable 160-105 mg oral .............................. 117heartburn relief max st tablet 150 mg oral ....... 117heartburn relief max st tablet 20 mg oral ......... 117heartburn relief tablet 10 mg oral .............................. 117heather ....................... 128HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 12500-0.45 UT/ 250ML-%, 25000-0.45 UT/ 500ML-% ...................... 81HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 25000-0.45 UT/ 250ML-% ...................... 81HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS SOLUTION 100 UNIT/ML, 25000-5 UT/500ML-% ... 81heparin sod (porcine) in d5w intravenous solution 40-5 unit/ml-% ....................... 81heparin sodium (porcine) injection solution 1000 unit/ ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml ..... 81hepatamine ................. 103HERCEPTIN HYLECTA ..................... 49HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG ................................ 49HETLIOZ .................... 152HIBERIX INJECTION ................. 135hm acid reducer tablet 75 mg oral ........................ 117


hm advanced antacid max st suspension 400-400-40 mg/5ml oral ................. 117hm all day allergy tablet 10 mg oral ........................ 149hm allergy tablet 25 mg oral .............................. 149hm antacid anti-gas ex st suspension 400-400-40 mg/ 5ml oral ....................... 117hm antacid/antigas suspension 200-200-20 mg/ 5ml oral ....................... 117hm aspirin ec low dose tablet delayed release 81 mg oral .......................... 15hm aspirin ec tablet delayed release 325 mg oral ...... 15hm aspirin tablet 325 mg oral ................................ 16hm aspirin tablet chewable 81 mg oral ..................... 16hm calamine lotion 8-8 % external ......................... 93hm calcium antacid ex st tablet chewable 750 mg oral .............................. 117HM CALCIUM CITRATE+D3 PETITE TABLET 200-250 MG-UNIT ORAL .......................... 103HM CALCIUM CITRATE+VITAMIN D TABLET 315-250 MG-UNIT ORAL .......................... 103hm calcium-vitamin d tablet 500-200 mg-unit oral ... 103hm calcium-vitamin d tablet 600-400 mg-unit oral ... 103hm calcium-vitamin d tablet 600-800 mg-unit oral ... 103hm clearlax powder oral .............................. 117hm enema mineral oil enema rectal ............... 117hm eye itch relief solution 0.025 % ophthalmic .... 142

hm famotidine tablet 10 mg oral .............................. 117hm famotidine tablet 20 mg oral .............................. 117hm folic acid tablet 400 mcg oral .............................. 103hm glucose tablet chewable 4-6 gm-mg oral ............. 76hm hydrocortisone plus cream 1 % external ...... 93hm hydrocortisone-aloe max st cream 1 % external .... 93hm ibuprofen capsule 200 mg oral .......................... 22hm ibuprofen ib tablet 200 mg oral .......................... 22hm ibuprofen tablet 200 mg oral ................................ 22hm iron tablet 200 (65 fe) mg oral ........................ 103hm lice killing max st shampoo 0.33-4 % external ......................... 93hm lice treatment liquid 1 % external ......................... 93hm lubricating plus solution 0.5 % ophthalmic ........ 142hm magnesium citrate solution 1.745 gm/30ml oral .............................. 117hm milk of magnesia suspension 1200 mg/15ml oral .............................. 117hm mineral oil oil oral .. 117hm motion relief tablet 25 mg oral .......................... 41hm naproxen sodium capsule 220 mg oral ..... 22hm naproxen sodium tablet 220 mg oral ................... 23hm niacin tablet extended release 250 mg oral .... 103hm nicotine patch 24 hour 14 mg/24hr transdermal ................... 20hm nicotine patch 24 hour 21 mg/24hr transdermal ................... 20

hm nicotine patch 24 hour 7 mg/24hr transdermal ................... 20hm nicotine polacrilex gum 2 mg mouth/throat ........ 20hm nicotine polacrilex gum 4 mg mouth/throat ........ 20hm nicotine polacrilex lozenge 2 mg mouth/ throat ............................ 20hm nicotine polacrilex lozenge 4 mg mouth/ throat ............................ 20hm omeprazole tablet delayed release 20 mg oral .............................. 117hm stomach relief suspension 262 mg/15ml oral .............................. 118hm stomach relief tablet chewable 262 mg oral .............................. 118hm stool softener capsule 100 mg oral ................. 118hm stool softener capsule 250 mg oral ................. 118hm triple antibiotic ointment 3.5-400-5000 external ... 28hm vitamin b1 tablet 100 mg oral .............................. 103hm vitamin b12 tablet 500 mcg oral ...................... 103hm vitamin b6 tablet 100 mg oral .............................. 103hm vitamin c tablet 1000 mg oral .............................. 103hm vitamin c tablet 500 mg oral .............................. 103hm vitamin c/rose hips tablet 500 mg oral ....... 103hm vitamin d3 capsule 50 mcg (2000 ut) oral ...... 103HUMALOG JUNIOR KWIKPEN ..................... 76HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-


INJECTOR 200 UNIT/ ML ................................. 76HUMALOG MIX 50/50 ... 76HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR .................... 76HUMALOG MIX 75/25 ... 76HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR .................... 76HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE ................ 76HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 40 MG/ 0.8ML (6 PACK), 80 MG/ 0.8ML .......................... 136HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/ 0.4ML .......................... 136HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT ........... 136HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/ 0.8ML .......................... 136HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- INJECTOR KIT 80 MG/ 0.8ML .......................... 136HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-

INJECTOR KIT 40 MG/ 0.8ML .......................... 136HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN- INJECTOR KIT 80 MG/ 0.8ML & 40MG/ 0.4ML .......................... 136HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/ 0.2ML, 20 MG/0.2ML, 20 MG/0.4ML ................... 136HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.4ML, 40 MG/ 0.8ML .......................... 136HUMULIN 70/30 ........... 76HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR .................... 76HUMULIN N .................. 76HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR .................... 76HUMULIN R .................. 76HUMULIN R U-500 (CONCENTRATED) ..... 76HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR .................... 76hydralazine hcl injection ........................ 85hydralazine hcl oral ...... 85hydrochlorothiazide oral ................................ 85hydrocod polst-cpm polst er suspension extended release 10-8 mg/5ml oral ................................ 16hydrocodone- acetaminophen oral solution 7.5-325 mg/15ml .......... 16

hydrocodone- acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5- 325 mg .......................... 16hydrocodone-homatropine syrup 5-1.5 mg/5ml oral ................................ 16HYDROCODONE- HOMATROPINE SYRUP 5- 1.5 MG/5ML ORAL ....... 16hydrocodone-homatropine tablet 5-1.5 mg oral ...... 16hydrocodone-ibuprofen oral tablet 5-200 mg, 7.5-200 mg ................................. 16hydrocortisone cream 0.5 % external ......................... 93hydrocortisone cream 1 % external (otc) ................. 94hydrocortisone external cream 1 %, 2.5 % ....... 125hydrocortisone external lotion 2.5 % ................. 125hydrocortisone external ointment 1 %, 2.5 % .... 125hydrocortisone max st cream 1 % external ...... 94hydrocortisone max st/12 moist cream 1 % external ......................... 94hydrocortisone ointment 0.5 % external ..................... 94hydrocortisone ointment 1 % external (otc) ............ 94hydrocortisone oral ..... 125hydrocortisone oral ..... 139hydrocortisone oral tablet 20 mg, 5 mg .................. 23hydrocortisone rectal ... 139hydrocortisone valerate ....................... 125hydrocortisone-acetic acid ............................. 145hydrocortisone-aloe cream 0.5 % external ............... 94hydromet syrup 5-1.5 mg/ 5ml oral ......................... 16


hydromorphone hcl oral tablet ............................. 16hydroxychloroquine sulfate oral ................................ 57hydroxyprogesterone caproate intramuscular solution ......................... 49hydroxyurea oral ........... 49hydroxyzine hcl oral tablet ............................. 41hydroxyzine hcl oral tablet ............................. 69hydroxyzine hcl oral tablet ........................... 149hydroxyzine pamoate oral capsule 25 mg, 50 mg ... 41hydroxyzine pamoate oral capsule 25 mg, 50 mg ... 70hydroxyzine pamoate oral capsule 25 mg, 50 mg ............................... 149HYPERRAB ................ 136HYPERRAB S/D INJECTION SOLUTION 300 UNIT/2ML ................... 136Iibandronate sodium oral .............................. 140IBRANCE ...................... 50ibu ................................. 23ibu oral tablet 600 mg, 800 mg ................................. 16ibu-200 tablet 200 mg oral ................................ 23ibuprofen oral suspension ................... 16ibuprofen oral suspension ................... 23ibuprofen oral tablet 400 mg, 600 mg, 800 mg .... 16ibuprofen oral tablet 400 mg, 600 mg, 800 mg .... 23ibuprofen tablet 200 mg oral ................................ 23icatibant acetate ......... 136ICLUSIG ORAL TABLET 15 MG ................................ 50

ICLUSIG ORAL TABLET 45 MG ................................ 50idarubicin hcl ................. 50IDHIFA ORAL TABLET 100 MG ................................ 50IDHIFA ORAL TABLET 50 MG ................................ 50IFEX INTRAVENOUS SOLUTION RECONSTITUTED 3 GM ................................ 50ifosfamide intravenous solution ......................... 50ifosfamide intravenous solution reconstituted 1 gm ................................. 50IFOSFAMIDE INTRAVENOUS SOLUTION RECONSTITUTED 3 GM ................................ 50ILARIS SUBCUTANEOUS SOLUTION ................... 16ILEVRO ...................... 142imatinib mesylate oral tablet 100 mg .......................... 50imatinib mesylate oral tablet 400 mg .......................... 50IMBRUVICA ORAL CAPSULE 140 MG ....... 50IMBRUVICA ORAL CAPSULE 70 MG ......... 50IMBRUVICA ORAL TABLET 140 MG ......................... 50IMBRUVICA ORAL TABLET 280 MG, 420 MG, 560 MG ................................ 50IMFINZI ......................... 50imipenem-cilastatin ....... 28imipramine hcl oral ....... 38imiquimod external ....... 94IMOGAM RABIES-HT INJECTION SOLUTION 300 UNIT/2ML ................... 136IMOVAX RABIES ....... 136incassia ....................... 128INCRELEX .................. 126indapamide oral ............ 85indomethacin er ............ 16

indomethacin er ............ 23indomethacin oral ......... 16indomethacin oral ......... 23INFANRIX ................... 136INLYTA ORAL TABLET 1 MG ................................ 50INLYTA ORAL TABLET 5 MG ................................ 50INREBIC ....................... 50INSULIN LISPRO (1 UNIT DIAL) ............................ 76INSULIN LISPRO SUBCUTANEOUS SOLUTION ................... 77INSUPEN PEN NEEDLES 29G X 12MM ................ 77INSUPEN ULTRAFIN 29G X 12MM ........................ 77INTELENCE ORAL TABLET 100 MG .......... 65INTELENCE ORAL TABLET 200 MG .......... 65INTELENCE ORAL TABLET 25 MG ............ 65intralipid intravenous emulsion 20 % ............ 103INTRALIPID INTRAVENOUS EMULSION 30 % ....... 103INTRON A INJECTION SOLUTION ................... 65INTRON A INJECTION SOLUTION 6000000 UNIT/ ML ................................. 65INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT ............ 65INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT ............................. 65INTRON A INJECTION SOLUTION RECONSTITUTED 50000000 UNIT ............ 65introvale ...................... 128


INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/ 0.75ML .......................... 59INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 156 MG/ML .. 59INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 234 MG/ 1.5ML ............................ 60INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 39 MG/ 0.25ML .......................... 60INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 78 MG/ 0.5ML ............................ 60INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/ 0.875ML ........................ 60INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 410 MG/ 1.315ML ........................ 60INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 546 MG/ 1.75ML .......................... 60INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 819 MG/ 2.625ML ........................ 60INVIRASE ORAL TABLET ........................ 65IPOL ........................... 136

ipratropium bromide inhalation .................... 149ipratropium bromide nasal ........................... 149ipratropium-albuterol ... 149irbesartan ...................... 85irbesartan- hydrochlorothiazide ...... 85irbesartan- hydrochlorothiazide ...... 85IRESSA ........................ 50irinotecan hcl intravenous solution 100 mg/5ml, 500 mg/25ml ........................ 50irinotecan hcl intravenous solution 40 mg/2ml ....... 50iron (ferrous gluconate) tablet 256 (28 fe) mg oral .............................. 103iron tablet 325 (65 fe) mg oral .............................. 103ISENTRESS HD ........... 65ISENTRESS ORAL PACKET ....................... 65ISENTRESS ORAL TABLET ........................ 65ISENTRESS ORAL TABLET CHEWABLE 100 MG ................................ 65ISENTRESS ORAL TABLET CHEWABLE 25 MG ................................ 65isibloom ...................... 128isoniazid oral ................. 45isopto atropine ............ 142isosorbide dinitrate er .... 85isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg .............................. 85isosorbide mononitrate ................... 85isosorbide mononitrate er .................................. 85isotretinoin oral capsule 10 mg, 20 mg, 30 mg ......... 94isotretinoin oral capsule 40 mg ................................. 94

ISTODAX (OVERFILL) .................. 50itraconazole oral capsule ......................... 43ivermectin oral .............. 57IXEMPRA KIT ............... 50IXIARO ....................... 136JJAKAFI ORAL TABLET 10 MG ................................ 50JAKAFI ORAL TABLET 15 MG ................................ 51JAKAFI ORAL TABLET 20 MG ................................ 51JAKAFI ORAL TABLET 25 MG ................................ 51JAKAFI ORAL TABLET 5 MG ................................ 51jantoven ........................ 81JANUMET ..................... 77JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100- 1000 MG ....................... 77JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50- 1000 MG, 50-500 MG .... 77JANUVIA ORAL TABLET 100 MG ......................... 77JANUVIA ORAL TABLET 25 MG ........................... 77JANUVIA ORAL TABLET 50 MG ........................... 77JARDIANCE ................. 77jencycla ....................... 128JENTADUETO .............. 77JENTADUETO .............. 77JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5- 1000 MG ....................... 77JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5- 1000 MG ....................... 77JENTADUETO XR ORAL TABLET EXTENDED


RELEASE 24 HOUR 5-1000 MG ................................ 77JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG ................................ 77JEVTANA ..................... 51jock itch spray aerosol powder 1 % external ..... 43jolessa ........................ 128juleber ......................... 129JULUCA ........................ 65junel 1.5/30 ................. 129junel 1/20 .................... 129junel fe 1.5/30 ............. 129junel fe 1/20 ................ 129JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG ............................. 85JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG ........................... 85KKADCYLA ..................... 51KALETRA ORAL TABLET 100-25 MG .................... 65KALETRA ORAL TABLET 200-50 MG .................... 65kalliga ......................... 129KALYDECO ORAL TABLET ...................... 149kao-tin capsule 240 mg oral .............................. 118kaopectate extra strength suspension 525 mg/15ml oral .............................. 118kaopectate suspension 262 mg/15ml oral ............... 118kariva .......................... 129kcl in dextrose-nacl intravenous solution 10-5- 0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.45 meq/ l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5- 0.45 meq/l-%-% .......... 103

KCL IN DEXTROSE-NACL INTRAVENOUS SOLUTION 20-5-0.225 MEQ/L-%- % ................................ 104KCL IN DEXTROSE-NACL INTRAVENOUS SOLUTION 40-5-0.9 MEQ/L-%- % ................................ 104KCL-LACTATED RINGERS-D5W .......... 104KEDRAB INJECTION SOLUTION 300 UNIT/ 2ML ............................. 137kelnor 1/35 .................. 129kelnor 1/50 .................. 129KEPIVANCE ................. 51ketoconazole external cream ............................ 43ketoconazole external shampoo 2 % ................ 43ketoconazole oral ......... 43ketorolac tromethamine ophthalmic .................. 142ketotifen fumarate solution 0.025 % ophthalmic (otc) ............................ 142KEYTRUDA INTRAVENOUS SOLUTION ................. 137KHAPZORY .................. 51KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG ............. 38KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG ............... 38KIMONO MICRO THIN PLUS .......................... 144KIMONO SENSATION ............... 144KIMONO SENSATION PLUS .......................... 144KINRIX INTRAMUSCULAR SUSPENSION ............ 137KINRIX INTRAMUSCULAR SUSPENSION INJECTION 0.5 ML ......................... 137

kionex oral suspension ................. 104KISQALI (200 MG DOSE) .......................... 51KISQALI (400 MG DOSE) .......................... 51KISQALI (600 MG DOSE) .......................... 51KISQALI FEMARA (400 MG DOSE) .......................... 51KISQALI FEMARA (600 MG DOSE) .......................... 51KISQALI FEMARA(200 MG DOSE) .......................... 51klor-con 10 .................. 104klor-con 10 .................. 104klor-con m10 ............... 104klor-con m10 ............... 104klor-con m15 ............... 104klor-con m15 ............... 104klor-con m20 ............... 104klor-con m20 ............... 104klor-con oral tablet extended release ........................ 104klor-con oral tablet extended release ........................ 104klor-con sprinkle ......... 104klor-con sprinkle oral capsule extended release 8 meq ............................. 104KORLYM ...................... 77KPN PRENATAL TABLET 0.1 MG ORAL ............. 104kroger glucose tablet chewable 4-6 gm-mg oral ................................ 77KROGER PEN NEEDLES 31G X 8 MM ................. 77kurvelo ........................ 129KUVAN ORAL TABLET SOLUBLE ................... 122KYPROLIS .................... 51Llabetalol hcl intravenous solution ......................... 85labetalol hcl oral ............ 85lactated ringers intravenous ................. 104


lactated ringers irrigation ...................... 104lactulose encephalopathy .......... 118lactulose oral solution ....................... 118lamisil at cream 1 % external ......................... 43lamivudine oral solution ......................... 65lamivudine oral solution ......................... 65lamivudine oral tablet 100 mg ................................. 65lamivudine oral tablet 100 mg ................................. 66lamivudine oral tablet 150 mg ................................. 66lamivudine oral tablet 150 mg ................................. 66lamivudine oral tablet 300 mg ................................. 66lamivudine oral tablet 300 mg ................................. 66lamivudine-zidovudine ... 66lamotrigine oral tablet .... 33lamotrigine oral tablet .... 71lamotrigine oral tablet chewable ...................... 33lamotrigine oral tablet chewable ...................... 71LANCETS ULTRA THIN ............................. 77LANOXIN ORAL TABLET 250 MCG ...................... 86LANOXIN ORAL TABLET 62.5 MCG ..................... 86lansoprazole capsule delayed release 15 mg oral (otc) ............................ 118lansoprazole oral capsule delayed release 15 mg ............................... 118lansoprazole oral capsule delayed release 30 mg ............................... 118LANTUS ....................... 77

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR .................... 77larin 1.5/30 .................. 129larin 1/20 ..................... 129larin fe 1.5/30 .............. 129larin fe 1/20 ................. 129larissia ........................ 129LARTRUVO .................. 51latanoprost ophthalmic .................. 142LATUDA ORAL TABLET 120 MG, 60 MG ............ 60LATUDA ORAL TABLET 20 MG ................................ 60LATUDA ORAL TABLET 40 MG ................................ 60LATUDA ORAL TABLET 80 MG ................................ 60laxative suppository 10 mg rectal ........................... 118leader glucose tablet chewable 4-6 gm-mg oral ................................ 77leader quick dissolve glucose tablet chewable 4 gm oral .......................... 77LEDIPASVIR- SOFOSBUVIR .............. 66leena ........................... 129leflunomide oral .......... 137leflunomide oral .......... 137LENVIMA (10 MG DAILY DOSE) .......................... 51LENVIMA (12 MG DAILY DOSE) .......................... 51LENVIMA (14 MG DAILY DOSE) .......................... 51LENVIMA (18 MG DAILY DOSE) .......................... 51LENVIMA (20 MG DAILY DOSE) .......................... 51LENVIMA (24 MG DAILY DOSE) .......................... 51LENVIMA (4 MG DAILY DOSE) .......................... 51

LENVIMA (8 MG DAILY DOSE) .......................... 51lessina ........................ 129LETAIRIS .................... 149letrozole oral ................. 51leucovorin calcium injection solution 100 mg/10ml .... 51leucovorin calcium injection solution reconstituted .... 51leucovorin calcium oral ................................ 51leucovorin calcium oral ................................ 52LEUKERAN .................. 52leuprolide acetate injection ...................... 133levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml ................ 149levalbuterol hcl inhalation nebulization solution 0.63 mg/3ml ........................ 149levalbuterol tartrate ..... 149LEVEMIR ...................... 78LEVEMIR FLEXTOUCH ................ 78levetiracetam er oral tablet extended release 24 hour 500 mg .......................... 33levetiracetam er oral tablet extended release 24 hour 750 mg .......................... 33LEVETIRACETAM IN NACL INTRAVENOUS SOLUTION 1000 MG/100ML, 1500 MG/ 100ML ........................... 33LEVETIRACETAM IN NACL INTRAVENOUS SOLUTION 500 MG/100ML ............. 33levetiracetam intravenous ................... 34levetiracetam oral ......... 34levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg .......... 133


levo-t oral tablet 25 mcg ............................. 133levobunolol hcl ophthalmic solution 0.5 % ............. 142levocarnitine oral solution ....................... 104LEVOCARNITINE ORAL TABLET ...................... 104levocarnitine sf ............ 104levocetirizine dihydrochloride oral tablet ........................... 149levofloxacin in d5w ....... 28levofloxacin intravenous ................... 28levofloxacin oral tablet ... 28levoleucovorin calcium intravenous solution reconstituted 50 mg ...... 52levonest ...................... 129levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125- 30 mcg ........................ 129levonorgest-eth estrad 91- day oral tablet 0.15-0.03 mg ............................... 129levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg ......... 129levora 0.15/30 (28) ..... 129levorphanol tartrate oral tablet 2 mg .................... 16levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg ........................ 133levothyroxine sodium oral tablet 25 mcg .............. 133levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 50 mcg, 75 mcg, 88 mcg ........................ 133levoxyl oral tablet 25 mcg ............................. 133

LEXIVA ORAL SUSPENSION .............. 66LIBTAYO ...................... 52lice killing maximum strength shampoo 0.33-4 % external ......................... 94lidocaine external ointment ........................ 19lidocaine external patch 5 % .................................. 19 lidocaine hcl (cardiac) pf intravenous solution prefilled syringe 100 mg/ 5ml ................................ 86lidocaine hcl (pf) injection solution 2 % .................. 19lidocaine hcl external solution ......................... 19lidocaine hcl mouth/ throat ............................ 19lidocaine hcl urethral/ mucosal ........................ 19lidocaine viscous hcl ..... 19lidocaine-prilocaine external cream ............................ 19lillow ............................ 129lindane external shampoo ....................... 57linezolid in sodium chloride ......................... 28linezolid intravenous solution 600 mg/ 300ml ............................ 28linezolid oral suspension reconstituted ................. 28linezolid oral tablet ........ 28LINZESS ..................... 118liothyronine sodium oral .............................. 133liquitears solution 1.4 % ophthalmic .................. 143lisinopril oral .................. 86lisinopril- hydrochlorothiazide ...... 86LITHIUM ....................... 71lithium carbonate er ...... 71lithium carbonate oral .... 71

longs glucose tablet chewable 4-6 gm-mg oral ................................ 78LONSURF .................... 52loperamide hcl oral capsule ....................... 118lopinavir-ritonavir .......... 66loratadine tablet 10 mg oral .............................. 149lorazepam intensol ....... 90lorazepam oral concentrate 1 mg/0.5ml .................... 34lorazepam oral concentrate 2 mg/ml ......................... 34lorazepam oral concentrate 2 mg/ml ......................... 70lorazepam oral tablet 0.5 mg, 1 mg ....................... 34lorazepam oral tablet 0.5 mg, 1 mg ....................... 70lorazepam oral tablet 2 mg ................................. 34lorazepam oral tablet 2 mg ................................. 70LORBRENA ORAL TABLET 100 MG ......................... 52LORBRENA ORAL TABLET 25 MG ........................... 52lorcet ............................. 16lorcet hd ........................ 16lorcet plus oral tablet 7.5- 325 mg .......................... 16losartan potassium ....... 86losartan potassium- hctz ............................... 86LOTRIMIN AF CREAM 1 % EXTERNAL ................... 43lovastatin ...................... 86low-ogestrel ................ 129loxapine succinate oral ................................ 60lubricant eye drops pf solution 0.5 % ophthalmic .................. 143LUBRICANT EYE DROPS SOLUTION 0.4-0.3 % OPHTHALMIC ............ 143


lubricant eye drops solution 0.5 % ophthalmic ........ 143lubricating plus eye drops solution 0.5 % ophthalmic .................. 143ludent oral tablet chewable 2.2 (1 f) mg ................. 104LUMIGAN OPHTHALMIC SOLUTION 0.01 % ..... 143LUMIZYME ................. 123LUMOXITI ..................... 52LUPRON DEPOT (1- MONTH) ..................... 133LUPRON DEPOT-PED (1- MONTH) INTRAMUSCULAR KIT 7.5 MG .............................. 133lutera ........................... 129LYNPARZA ORAL TABLET ........................ 52LYSODREN ................ 133lyza ............................. 129Mm-clear wc solution 100-6.3 mg/5ml oral ................. 149M-M-R II INJECTION ... 137mafenide acetate external ......................... 94mag-al plus liquid 200-200- 20 mg/5ml oral ............ 118mag-al plus xs liquid 400- 400-40 mg/5ml oral .... 118magnesium citrate solution 1.745 gm/30ml oral ..... 118magnesium oxide (antacid) capsule 500 mg oral .... 104magnesium sulfate injection solution 50 % .............. 104magnesium sulfate injection solution 50 % (10ml syringe) ....................... 104MAGNESIUM SULFATE INTRAVENOUS SOLUTION 2 GM/50ML, 20 GM/500ML, 4 GM/100ML, 4 GM/50ML, 40 GM/1000ML ........... 105maprotiline hcl oral tablet 25 mg ................................. 38

maprotiline hcl oral tablet 50 mg ................................. 38maprotiline hcl oral tablet 75 mg ................................. 38MARATHON MEDICAL PENTIPS 29G X 12MM ............................ 78marlissa ...................... 129marlissa ...................... 129marlissa ...................... 130MARPLAN .................... 38MARQIBO ..................... 52MATULANE .................. 52meclizine hcl oral tablet ............................. 41meclizine hcl tablet chewable 25 mg oral (otc) .............................. 41meclofenamate sodium oral ................................ 16meclofenamate sodium oral ................................ 23medroxyprogesterone acetate intramuscular .............. 130medroxyprogesterone acetate oral ................. 130mefloquine hcl .............. 57megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml ...................... 130megestrol acetate oral tablet ........................... 130meijer c tablet 500 mg oral .............................. 105meijer glucose tablet chewable 4-6 gm-mg oral ................................ 78MEKINIST ORAL TABLET 0.5 MG .......................... 52MEKINIST ORAL TABLET 2 MG ............................. 52MEKTOVI ..................... 52meloxicam oral tablet .... 16meloxicam oral tablet .... 23melphalan hcl ............... 52memantine hcl er .......... 36

memantine hcl oral solution 10 mg/5ml ..................... 36memantine hcl oral solution 2 mg/ml ......................... 36memantine hcl oral tablet 10 mg ................................. 36memantine hcl oral tablet 5 mg ................................. 36MENACTRA ............... 137MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG .............................. 130MENVEO .................... 137MEPHYTON TABLET 5 MG ORAL .......................... 105mercaptopurine oral .... 137meropenem .................. 28mesalamine er ............ 139mesalamine oral tablet delayed release 1.2 gm ............................... 139mesalamine rectal enema ......................... 139mesalamine rectal suppository ................. 139mesalamine- cleanser ...................... 118mesna ........................... 52MESNEX ORAL ............ 52MESTINON ORAL SOLUTION ................... 45metaproterenol sulfate oral syrup ........................... 149metformin hcl er oral tablet extended release 24 hour 500 mg .......................... 78metformin hcl er oral tablet extended release 24 hour 750 mg .......................... 78metformin hcl oral tablet 1000 mg ........................ 78metformin hcl oral tablet 500 mg ................................. 78metformin hcl oral tablet 850 mg ................................. 78METHADONE HCL INJECTION ................... 16


methadone hcl intensol ......................... 16methadone hcl oral concentrate ................... 16methadone hcl oral solution ......................... 17methadone hcl oral tablet ............................. 17methazolamide oral ...... 86methazolamide oral .... 143methenamine hippurate ....................... 28methimazole oral ........ 134methocarbamol oral .... 151methotrexate oral ....... 137methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml ................. 52methotrexate sodium (pf) injection solution 50 mg/ 2ml .............................. 137methotrexate sodium injection solution 250 mg/ 10ml .............................. 52methotrexate sodium injection solution 50 mg/ 2ml .............................. 137methotrexate sodium injection solution reconstituted ................. 52methoxsalen rapid ........ 94methylphenidate hcl oral tablet ............................. 90methylprednisolone acetate injection suspension 40 mg/ ml .................................. 23METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 80 MG/ ML ................................. 23methylprednisolone oral .............................. 125methylprednisolone oral .............................. 139methylprednisolone oral tablet ............................. 23methylprednisolone sodium succ injection solution

reconstituted 1000 mg, 125 mg, 40 mg ..................... 23metoclopramide hcl injection ...................... 118metoclopramide hcl oral solution 10 mg/10ml, 5 mg/ 5ml .............................. 118metoclopramide hcl oral solution 5 mg/5ml ......... 41metoclopramide hcl oral tablet ............................. 41metoclopramide hcl oral tablet ........................... 118metolazone ................... 86metoprolol succinate er .................................. 86metoprolol tartrate intravenous solution 5 mg/ 5ml ................................ 86metoprolol tartrate intravenous solution cartridge ........................ 86metoprolol tartrate oral ................................ 86metoprolol- hydrochlorothiazide ...... 86metronidazole external cream ............................ 28metronidazole external gel 0.75 % .......................... 28metronidazole external lotion ............................. 28metronidazole in nacl intravenous solution 5-0.79 mg/ml-%, 500-0.79 mg/ 100ml-% ....................... 28METRONIDAZOLE IN NACL INTRAVENOUS SOLUTION 500-0.74 MG/ 100ML-% ...................... 28metronidazole oral ........ 28metronidazole vaginal ... 28mexiletine hcl oral ......... 86mi-acid gas relief tablet chewable 80 mg oral ... 118mi-acid maximum strength suspension 400-400-40 mg/ 5ml oral ....................... 105

mi-acid suspension 200- 200-20 mg/5ml oral .... 105MIACALCIN INJECTION ................. 140miconazole 3 combo pack kit 200 & 2 mg-% (9gm) vaginal .......................... 94miconazole 3 vaginal suppository ................... 43miconazole 7 cream 2 % vaginal .......................... 94miconazole 7 suppository 100 mg vaginal ............. 94miconazole nitrate cream 2 % external ..................... 94miconazole nitrate cream 2 % vaginal ...................... 94microgestin 1.5/30 ...... 130microgestin 1/20 ......... 130microgestin fe 1.5/30 ... 130microgestin fe 1/20 ..... 130midodrine hcl ................ 86miglustat ..................... 123mili .............................. 130milk of magnesia concentrate suspension 2400 mg/10ml oral ...... 105milk of magnesia suspension 1200 mg/15ml oral .............................. 118milk of magnesia suspension 400 mg/5ml oral .............................. 105milk of magnesia suspension 7.75 % oral .............................. 105mineral oil enema rectal ........................... 118mineral oil oil oral ....... 119minitran ......................... 86minocycline hcl oral ...... 29minocycline hcl oral ...... 91minoxidil oral ................. 86mintox maximum strength suspension 400-400-40 mg/ 5ml oral ....................... 105mintox suspension 200-200- 20 mg/5ml oral ............ 119


mirtazapine oral tablet 15 mg ................................. 38mirtazapine oral tablet 30 mg ................................. 38mirtazapine oral tablet 45 mg ................................. 39mirtazapine oral tablet 7.5 mg ................................. 39mirtazapine oral tablet dispersible 15 mg ......... 39mirtazapine oral tablet dispersible 30 mg ......... 39mirtazapine oral tablet dispersible 45 mg ......... 39misoprostol oral .......... 119misoprostol oral tablet 200 mcg ............................. 126mitomycin intravenous solution reconstituted 20 mg, 5 mg ....................... 52mitomycin intravenous solution reconstituted 40 mg ................................. 52mitoxantrone hcl ........... 52modafinil oral tablet 100 mg ............................... 152modafinil oral tablet 200 mg ............................... 152molindone hcl ............... 60mometasone furoate external ....................... 125mondoxyne nl oral capsule 100 mg, 75 mg .............. 29mondoxyne nl oral capsule 100 mg, 75 mg .............. 91mondoxyne nl oral capsule 100 mg, 75 mg .............. 94mono-linyah ................ 130mononessa ................. 130montelukast sodium oral .............................. 149MONUROL ................... 29morgidox oral ................ 29morphine sulfate (concentrate) oral solution 100 mg/5ml ................... 17

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml ... 17morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml ......................... 17MORPHINE SULFATE (PF) INJECTION SOLUTION 10 MG/ML, 4 MG/ML, 8 MG/ ML ................................. 17MORPHINE SULFATE (PF) INTRAVENOUS SOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ ML, 8 MG/ML ................ 17morphine sulfate er oral tablet extended release 100 mg, 200 mg ................... 17morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg ......... 17morphine sulfate intravenous solution 1 mg/ ml .................................. 17morphine sulfate intravenous solution 25 mg/ ml .................................. 17morphine sulfate intravenous solution 50 mg/ ml .................................. 17morphine sulfate oral solution 20 mg/5ml ....... 17morphine sulfate oral solution 20 mg/5ml ....... 17morphine sulfate oral tablet ............................. 17morphine sulfate oral tablet ............................. 17motion-time tablet chewable 25 mg oral ..................... 41MOVANTIK ................. 119MOVIPREP ................. 119moxifloxacin hcl ophthalmic .................... 29moxifloxacin hcl oral ..... 29MOZOBIL ................... 105MULTAQ ....................... 86mupirocin calcium ......... 29mupirocin external ........ 29

mutamycin intravenous solution reconstituted 20 mg, 5 mg ....................... 52mutamycin intravenous solution reconstituted 40 mg ................................. 53mycophenolate mofetil hcl ............................... 137mycophenolate mofetil oral capsule ....................... 137mycophenolate mofetil oral suspension reconstituted ............... 137mycophenolate mofetil oral tablet ........................... 137mycophenolate sodium ........................ 137myferon 150 capsule 150 mg oral ........................ 105MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 4.5 MG ................................ 53myorisan ....................... 94MYRBETRIQ .............. 123Nnabumetone oral .......... 17nabumetone oral .......... 23nadolol oral tablet 20 mg, 40 mg, 80 mg ................ 86nafcillin sodium injection solution reconstituted 1 gm, 2 gm .............................. 29NAFCILLIN SODIUM INJECTION SOLUTION RECONSTITUTED 10 GM ................................ 29nafcillin sodium intravenous solution reconstituted 10 gm ................................. 29nafcillin sodium intravenous solution reconstituted 2 gm ................................. 29NAGLAZYME ............. 123nalbuphine hcl injection solution 10 mg/ml ......... 17nalbuphine hcl injection solution 20 mg/ml ......... 17


naloxone hcl injection solution 0.4 mg/ml, 4 mg/ 10ml .............................. 20naloxone hcl injection solution cartridge .......... 20naloxone hcl injection solution prefilled syringe .......................... 20naltrexone hcl oral ........ 20naltrexone hcl oral ........ 20NAMZARIC ................... 36naproxen dr .................. 17naproxen dr .................. 23naproxen oral tablet ...... 17naproxen oral tablet ...... 23naproxen sodium capsule 220 mg oral ................... 23naproxen sodium oral tablet 275 mg, 550 mg ............ 17naproxen sodium oral tablet 275 mg, 550 mg ............ 23naproxen sodium tablet 220 mg oral .......................... 23NARCAN ...................... 20nasal decongestant tablet 30 mg oral ................... 149nasal mist aerosol solution 0.9 % inhalation .......... 144NATACYN .................... 43nateglinide oral tablet 120 mg ................................. 78nateglinide oral tablet 60 mg ................................. 78NATPARA ................... 140natural c/rose hips tablet 1000 mg oral ............... 105natural vitamin d-3 tablet 125 mcg (5000 ut) oral .............................. 105NAYZILAM .................... 34NAYZILAM .................... 70NEBUPENT .................. 57necon 0.5/35 (28) ....... 130nefazodone hcl oral tablet 100 mg .......................... 39nefazodone hcl oral tablet 150 mg .......................... 39

nefazodone hcl oral tablet 200 mg .......................... 39nefazodone hcl oral tablet 250 mg .......................... 39nefazodone hcl oral tablet 50 mg ............................ 39neo-polycin ................. 143neo-polycin hc ............ 143neomycin sulfate oral .... 29neomycin-bacitracin zn- polymyx ophthalmic ointment 5-400- 10000 .......................... 143neomycin-polymyxin b gu ................................ 123neomycin-polymyxin- dexameth ophthalmic ointment ...................... 143neomycin-polymyxin- dexameth ophthalmic suspension 3.5-10000- 0.1 ............................... 143neomycin-polymyxin- gramicidin ophthalmic solution 1.75-10000- .025 ............................. 143neomycin-polymyxin-hc ophthalmic suspension 3.5- 10000-1 ...................... 143neomycin-polymyxin-hc otic solution 1 % ................ 145neomycin-polymyxin-hc otic suspension ................. 145NERLYNX ..................... 53NEULASTA ONPRO ... 105NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE ..................... 81NEUPRO ...................... 58nevirapine er oral tablet extended release 24 hour 100 mg .......................... 66nevirapine er oral tablet extended release 24 hour 400 mg .......................... 66nevirapine oral suspension ................... 66

nevirapine oral tablet .... 66NEXAVAR .................... 53niacin (antihyperlipidemic) ...... 86niacin er (antihyperlipidemic) ...... 86niacin er capsule extended release 250 mg oral .... 105niacin er capsule extended release 500 mg oral .... 105niacin er tablet extended release 250 mg oral .... 105niacin er tablet extended release 750 mg oral .... 105niacin tablet 100 mg oral .............................. 105niacin tablet 250 mg oral .............................. 105niacin tablet 50 mg oral .............................. 105niacin tablet 500 mg oral .............................. 105niacor ............................ 86nicardipine hcl oral ....... 86nicorelief gum 2 mg mouth/ throat ............................ 20NICORETTE LOZENGE 2 MG MOUTH/THROAT ... 20NICORETTE LOZENGE 4 MG MOUTH/THROAT ... 20NICORETTE MINI LOZENGE 2 MG MOUTH/ THROAT ....................... 20NICORETTE MINI LOZENGE 4 MG MOUTH/ THROAT ....................... 20nicotine kit 21-14-7 mg/24hr transdermal ................... 21nicotine patch 24 hour 14 mg/24hr transdermal (otc) .............................. 21nicotine patch 24 hour 21 mg/24hr transdermal (otc) .............................. 21nicotine patch 24 hour 7 mg/ 24hr transdermal (otc) ... 21nicotine polacrilex gum 2 mg mouth/throat ........... 21


nicotine polacrilex gum 4 mg mouth/throat ........... 21nicotine polacrilex lozenge 2 mg mouth/throat ........ 21nicotine polacrilex lozenge 4 mg mouth/throat ........ 21NICOTROL NS ............. 21nifedical xl oral tablet extended release 24 hour 60 mg ............................ 86nifedipine er .................. 86nifedipine er osmotic release .......................... 87nilutamide ..................... 53nimodipine oral ............. 87NINLARO ...................... 53NIPENT ........................ 53nitisinone .................... 123NITRO-BID ................... 87nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg ................................. 29nitrofurantoin monohyd macro ............................ 29NITROGLYCERIN INTRAVENOUS ............ 87nitroglycerin sublingual ..................... 87nitroglycerin transdermal patch 24 hour ................ 87nora-be ....................... 130NORDITROPIN FLEXPRO ................... 126norethin ace-eth estrad-fe oral tablet 1-20 mg- mcg ............................. 130norethindrone acet-ethinyl est oral tablet .............. 130norethindrone acetate oral .............................. 130norethindrone oral ...... 130norgestim-eth estrad triphasic oral tablet 0.18/ 0.215/0.25 mg-35 mcg ............................. 130norgestimate-eth estradiol oral tablet 0.25-35 mg- mcg ............................. 130

norlyda ........................ 130norlyroc ....................... 130NORMOSOL-M IN D5W ............................ 105NORMOSOL-R ........... 105NORMOSOL-R PH 7.4 ............................... 105NORTHERA ORAL CAPSULE 100 MG ....... 87NORTHERA ORAL CAPSULE 200 MG ....... 87NORTHERA ORAL CAPSULE 300 MG ....... 87nortrel 0.5/35 (28) ....... 130nortrel 1/35 (21) .......... 130nortrel 1/35 (28) .......... 130nortrel 7/7/7 ................ 131nortriptyline hcl oral ...... 39NORVIR ORAL PACKET ....................... 66NORVIR ORAL SOLUTION ................... 66NOXAFIL ORAL SUSPENSION .............. 43NUBEQA ...................... 53NUEDEXTA .................. 90NULOJIX .................... 137NUPLAZID ORAL CAPSULE ..................... 60NUPLAZID ORAL TABLET 10 MG ........................... 60nutrilipid ...................... 105NUVARING ................. 131nyamyc ......................... 43nystatin external ........... 43nystatin mouth/throat .... 43nystatin oral tablet ........ 43nystatin-triamcinolone external cream .............. 94nystop ........................... 43Oocella .......................... 131OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 2 GM/20ML, 2.5 GM/50ML, 25 GM/500ML, 30 GM/ 300ML, 5 GM/100ML ... 137

octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml ........................ 134octreotide acetate injection solution 500 mcg/ml .... 134ODEFSEY .................... 66ODOMZO ..................... 53OFEV ............................ 53OFEV .......................... 149OFEV .......................... 149ofloxacin ophthalmic ..... 29ofloxacin oral tablet 300 mg ............................... 145ofloxacin oral tablet 400 mg ................................. 29ofloxacin otic ................. 29ogestrel ....................... 131okebo oral capsule 75 mg ................................. 29olanzapine intramuscular ................ 60olanzapine intramuscular ................ 71olanzapine oral tablet 10 mg ................................. 60olanzapine oral tablet 10 mg ................................. 71olanzapine oral tablet 15 mg ................................. 60olanzapine oral tablet 15 mg ................................. 71olanzapine oral tablet 2.5 mg ................................. 60olanzapine oral tablet 2.5 mg ................................. 71olanzapine oral tablet 20 mg ................................. 60olanzapine oral tablet 20 mg ................................. 71olanzapine oral tablet 5 mg ................................. 61olanzapine oral tablet 5 mg ................................. 71olanzapine oral tablet 7.5 mg ................................. 61olanzapine oral tablet 7.5 mg ................................. 71


olanzapine oral tablet dispersible 10 mg ......... 61olanzapine oral tablet dispersible 10 mg ......... 71olanzapine oral tablet dispersible 15 mg ......... 61olanzapine oral tablet dispersible 15 mg ......... 71olanzapine oral tablet dispersible 20 mg ......... 61olanzapine oral tablet dispersible 20 mg ......... 71olanzapine oral tablet dispersible 5 mg ........... 61olanzapine oral tablet dispersible 5 mg ........... 71olmesartan-amlodipine- hctz ............................... 87olopatadine hcl ophthalmic .................. 143omega-3 capsule 1000 mg oral .............................. 106omega-3-acid ethyl esters ............................ 87omeprazole oral capsule delayed release .......... 119omeprazole tablet delayed release 20 mg oral ...... 119OMNITROPE .............. 126ondansetron .................. 41ondansetron hcl injection ........................ 41ondansetron hcl oral tablet 24 mg ............................ 41ondansetron hcl oral tablet 4 mg, 8 mg .................... 41ONETOUCH DELICA LANCETS 30G ............. 78ONETOUCH DELICA LANCETS 33G ............. 78ONETOUCH ULTRA BLUE STRIP IN VITRO .......... 78ONETOUCH VERIO STRIP IN VITRO ...................... 78opcicon one-step tablet 1.5 mg oral ........................ 131OPDIVO ........................ 53oralone .......................... 91

ORFADIN ................... 123ORKAMBI ORAL TABLET ...................... 150orsythia ....................... 131oseltamivir phosphate oral ................................ 66oxacillin sodium ............ 29oxaliplatin intravenous solution ......................... 53oxaliplatin intravenous solution reconstituted .... 53oxandrolone oral tablet 10 mg ............................... 131oxandrolone oral tablet 2.5 mg ............................... 131oxaprozin ...................... 17oxaprozin ...................... 23oxcarbazepine .............. 34oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg ..... 123oxybutynin chloride er oral tablet extended release 24 hour 5 mg ................... 123oxybutynin chloride oral syrup ........................... 123oxybutynin chloride oral tablet ........................... 123oxycodone hcl oral capsule ......................... 18oxycodone hcl oral concentrate 10 mg/ 0.5ml ............................. 18oxycodone hcl oral concentrate 100 mg/ 5ml ................................ 18oxycodone hcl oral tablet ............................. 18oxycodone-acetaminophen oral tablet 10-325 mg, 2.5- 325 mg, 5-325 mg, 7.5-325 mg ................................. 18oxycodone-aspirin oral tablet 4.8355-325 mg .... 18oysco 500 tablet 500 mg oral .............................. 106oysco 500+d tablet 500-200 mg-unit oral ................. 106

oyster shell calcium + d tablet 500-200 mg-unit oral .............................. 106oyster shell calcium + d3 tablet 500-400 mg-unit oral .............................. 106oyster shell calcium 250+d tablet 250-125 mg-unit oral .............................. 106oyster shell calcium 500 + d tablet 500-125 mg-unit oral .............................. 106oyster shell calcium 500+d tablet chewable 500-400 mg-unit oral ................. 106oyster shell calcium plus d tablet 500-200 mg-unit oral .............................. 106oyster shell calcium tablet 500 mg oral ................. 106oyster shell calcium/d tablet 250-125 mg-unit oral ... 106oyster shell calcium/d tablet 500-200 mg-unit oral ... 106oyster shell calcium/d3 tablet 500-400 mg-unit oral .............................. 106oyster shell calcium/vitamin d tablet 250-125 mg-unit oral .............................. 106oyster shell calcium/vitamin d tablet 500-200 mg-unit oral .............................. 106oystercal-d tablet 500-400 mg-unit oral ................. 106OZEMPIC (0.25 OR 0.5 MG/DOSE) ................... 78OZEMPIC (1 MG/ DOSE) .......................... 78Ppacerone oral tablet 100 mg, 200 mg, 400 mg .... 87paclitaxel intravenous concentrate 100 mg/16.7ml, 150 mg/25ml, 30 mg/ 5ml ................................ 53


paclitaxel intravenous concentrate 300 mg/ 50ml .............................. 53paliperidone er oral tablet extended release 24 hour 1.5 mg ........................... 61paliperidone er oral tablet extended release 24 hour 3 mg ................................. 61paliperidone er oral tablet extended release 24 hour 6 mg ................................. 61paliperidone er oral tablet extended release 24 hour 9 mg ................................. 61pamidronate disodium intravenous solution 30 mg/ 10ml, 90 mg/10ml ....... 140PAMIDRONATE DISODIUM INTRAVENOUS SOLUTION 6 MG/ML ..................... 141pamidronate disodium intravenous solution reconstituted ............... 141PANRETIN ................... 53pantoprazole sodium intravenous ................. 119pantoprazole sodium oral .............................. 119paricalcitol oral capsule 1 mcg, 2 mcg ................. 141paricalcitol oral capsule 4 mcg ............................. 141paroex ........................... 91paromomycin sulfate oral ................................ 29paroxetine hcl oral tablet 10 mg ................................. 39paroxetine hcl oral tablet 10 mg ................................. 70paroxetine hcl oral tablet 20 mg ................................. 39paroxetine hcl oral tablet 20 mg ................................. 70paroxetine hcl oral tablet 30 mg ................................. 39paroxetine hcl oral tablet 30 mg ................................. 70

paroxetine hcl oral tablet 40 mg ................................. 39paroxetine hcl oral tablet 40 mg ................................. 70PASER ......................... 45PAXIL ORAL SUSPENSION .............. 39PAXIL ORAL SUSPENSION .............. 70PAZEO ....................... 143PC UNIFINE PENTIPS 29G X 12MM ........................ 78PEAK AIR PEAK FLOW METER DEVICE ......... 150PEDIARIX ................... 137PEDVAX HIB INTRAMUSCULAR SUSPENSION ............ 137peg 3350 packet oral ... 119peg 3350 powder oral .............................. 119peg 3350-kcl-na bicarb- nacl ............................. 119peg 3350/ electrolytes ................. 119peg-3350/ electrolytes ................. 119PEGANONE ................. 34PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 180 MCG/ 0.5ML ............................ 66PEGASYS SUBCUTANEOUS SOLUTION ................... 66PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML .................. 66PENICILLIN G POT IN DEXTROSE .................. 29penicillin g potassium .... 29PENICILLIN G PROCAINE ................... 29penicillin g sodium ........ 29penicillin v potassium .... 29PENTACEL ................. 137PENTAM ....................... 57

pentamidine isethionate inhalation ...................... 57pentamidine isethionate injection ........................ 57PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG .............................. 140PENTASA ORAL CAPSULE EXTENDED RELEASE 500 MG .............................. 140pentoxifylline er ............. 87peptic relief tablet chewable 262 mg oral ................. 119pepto-bismol tablet chewable 262 mg oral .............................. 119pepto-bismol to-go tablet chewable 262 mg oral .............................. 119periogard ...................... 91PERJETA ..................... 53permethrin external cream ............................ 57perphenazine oral ......... 41perphenazine oral ......... 61pfizerpen ....................... 30pharbedryl capsule 25 mg oral .............................. 150pharbedryl capsule 50 mg oral .............................. 150PHAZYME ULTRA STRENGTH CAPSULE 180 MG ORAL ................... 119phenelzine sulfate oral .. 39phenobarbital oral elixir .............................. 34phenobarbital oral tablet 100 mg .......................... 34phenobarbital oral tablet 15 mg ................................. 34phenobarbital oral tablet 16.2 mg ......................... 34phenobarbital oral tablet 30 mg ................................. 34phenobarbital oral tablet 32.4 mg ......................... 34phenobarbital oral tablet 60 mg ................................. 34


phenobarbital oral tablet 64.8 mg ......................... 34phenobarbital oral tablet 97.2 mg ......................... 34phentermine hcl capsule 15 mg oral .......................... 90phentermine hcl capsule 30 mg oral .......................... 90phentermine hcl capsule 37.5 mg oral .................. 90phentermine hcl tablet 37.5 mg oral .......................... 90PHENYTEK .................. 34phenytoin oral suspension 125 mg/5ml ................... 34phenytoin oral tablet chewable ...................... 34phenytoin sodium extended ....................... 34phenytoin sodium injection ........................ 34philith .......................... 131PHOSLYRA ................ 123PHOSPHOLINE IODIDE ....................... 143PICATO ........................ 94PIFELTRO .................... 66pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % ................................ 143pilocarpine hcl oral ....... 91pimecrolimus ................ 94pimecrolimus .............. 137pimozide ....................... 61pimtrea ........................ 131pindolol ......................... 87pioglitazone hcl oral tablet 15 mg ............................ 78pioglitazone hcl oral tablet 30 mg ............................ 78pioglitazone hcl oral tablet 45 mg ............................ 78piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm ................................. 30

PIQRAY (200 MG DAILY DOSE) .......................... 53PIQRAY (250 MG DAILY DOSE) .......................... 53PIQRAY (300 MG DAILY DOSE) .......................... 53pirmella 1/35 ............... 131pirmella 7/7/7 .............. 131piroxicam oral ............... 18piroxicam oral ............... 23PLAN B ONE-STEP TABLET 1.5 MG ORAL (OTC) .......................... 131PLASMA-LYTE 148 .... 106pnv-dha ....................... 106podofilox external ......... 94POLIVY ......................... 53poly-iron 150 capsule 150 mg oral ........................ 106polycin ........................ 143polyethylene glycol 3350 oral packet .................. 119polyethylene glycol 3350 oral powder ................. 119polyethylene glycol 3350 packet oral (otc) .......... 119polyethylene glycol 3350 powder oral (otc) ........ 119polymyxin b- trimethoprim ................ 143POMALYST ORAL CAPSULE 1 MG ........... 53POMALYST ORAL CAPSULE 2 MG ........... 53POMALYST ORAL CAPSULE 3 MG, 4 MG ................................ 53portia-28 ..................... 131PORTRAZZA ................ 53potassium chloride crys er ................................ 106potassium chloride er ................................ 106potassium chloride in dextrose intravenous solution 20-5 meq/l-%, 40-5 meq/l-% ...................... 106

potassium chloride in nacl intravenous solution 20-0.45 meq/l-%, 20-0.9 meq/l- % ................................ 107potassium chloride intravenous solution 10 meq/100ml, 2 meq/ml, 20 meq/100ml, 40 meq/ 100ml .......................... 107potassium chloride intravenous solution 10 meq/50ml, 20 meq/ 50ml ............................ 107potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%) .......................... 107potassium citrate er .... 123POTELIGEO ................. 53PRADAXA .................... 81PRALUENT SUBCUTANEOUS SOLUTION AUTO- INJECTOR .................... 87pramipexole dihydrochloride ............. 58prasugrel hcl ................. 81pravastatin sodium ....... 87praziquantel oral ........... 57prazosin hcl oral ........... 87prazosin hcl oral ......... 124prednisolone acetate ophthalmic .................... 23prednisolone acetate ophthalmic .................. 140prednisolone acetate ophthalmic .................. 143prednisolone oral solution ......................... 23prednisolone oral solution ....................... 125prednisolone oral solution ....................... 140PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC .............. 23


PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC ............ 143prednisolone sodium phosphate oral solution 15 mg/5ml, 6.7 (5 base) mg/ 5ml ................................ 24prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml ......... 126prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml ......... 140PREDNISONE INTENSOL .................... 24PREDNISONE INTENSOL .................. 126PREDNISONE INTENSOL .................. 140prednisone oral ............. 24prednisone oral ........... 126prednisone oral solution ....................... 140prednisone oral tablet ........................... 140preferred plus glucose tablet chewable 4-6 gm-mg oral ................................ 78PREFERRED PLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML ................... 78pregabalin oral capsule 100 mg ................................. 34pregabalin oral capsule 150 mg ................................. 34pregabalin oral capsule 200 mg ................................. 34pregabalin oral capsule 225 mg, 300 mg ................... 34pregabalin oral capsule 25 mg ................................. 34pregabalin oral capsule 50 mg ................................. 34pregabalin oral capsule 75 mg ................................. 34pregabalin oral solution ......................... 35PREMARIN ORAL ...... 131

PREMARIN VAGINAL .................... 131PREMASOL INTRAVENOUS SOLUTION 10 % ........................... 107PREMIUM CONDOMS LUBRICATED ............. 144PREMPRO ................. 131prenatal low iron tablet 27- 0.8 mg oral .................. 107prenatal one daily tablet 27- 0.8 mg oral .................. 107prenatal tablet 27-0.8 mg oral (otc) ..................... 107prenatal tablet 28-0.8 mg oral .............................. 107prenatal vitamin and mineral tablet 28-0.8 mg oral ... 107prenatal vitamins tablet 28- 0.8 mg oral .................. 107prevalite ........................ 87previfem ...................... 131PREZCOBIX ................. 66PREZISTA ORAL SUSPENSION .............. 66PREZISTA ORAL TABLET 150 MG ......................... 66PREZISTA ORAL TABLET 600 MG, 800 MG .......... 66PREZISTA ORAL TABLET 75 MG ........................... 66PRIFTIN ........................ 45primaquine phosphate oral ................................ 57primidone oral ............... 35PROAIR HFA .............. 150PROAIR RESPICLICK .............. 150probenecid oral ............. 44procainamide hcl injection ........................ 87prochlorperazine ........... 41prochlorperazine edisylate injection solution 10 mg/2ml, 50 mg/10ml ................... 61prochlorperazine maleate oral ................................ 41

prochlorperazine maleate oral ................................ 61PROCRIT INJECTION SOLUTION 10000 UNIT/ ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ ML ................................. 82PROCRIT INJECTION SOLUTION 20000 UNIT/ ML, 40000 UNIT/ML ..... 82procto-med hc ............. 140procto-pak ................... 126proctosol hc ................ 140proctozone-hc rectal .... 119proctozone-hc rectal .... 126PRODIGY TWIST TOP LANCETS 28G ............. 78progesterone micronized oral .............................. 131PROGLYCEM ............... 78PROGRAF INTRAVENOUS .......... 138PROGRAF ORAL PACKET ..................... 138PROLASTIN-C INTRAVENOUS SOLUTION ................. 150PROLEUKIN ................. 53PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE ................... 141PROMACTA ORAL PACKET ....................... 82PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG ........................... 82PROMACTA ORAL TABLET 50 MG ............ 82promethazine hcl oral tablet ............................. 41promethazine hcl oral tablet ........................... 150promethazine-codeine solution 6.25-10 mg/5ml oral .............................. 150promethazine-codeine syrup 6.25-10 mg/5ml oral .... 150


promethazine-dm syrup 6.25-15 mg/5ml oral .... 150promethazine-phenyleph- codeine syrup 6.25-5-10 mg/5ml oral ................. 150propafenone hcl ............ 87propranolol hcl er .......... 87propranolol hcl intravenous ................... 87propranolol hcl oral ....... 87propylthiouracil oral .... 134PROQUAD SUBCUTANEOUS SUSPENSION RECONSTITUTED ..... 138protriptyline hcl ............. 39provil tablet 200 mg oral ................................ 24pseudoephedrine hcl tablet 30 mg oral (otc) .......... 150PULMOZYME ............. 150PULMOZYME ............. 150pureway-c tablet 500 mg oral .............................. 107PURIXAN ...................... 53px gas relief extra strength capsule 125 mg oral .... 119px gas relief ultra strength capsule 180 mg oral .... 119px glucose tablet chewable 4-6 gm-mg oral ............. 78px stomach relief max st suspension 525 mg/15ml oral .............................. 119px stomach relief suspension 262 mg/15ml oral .............................. 119px stomach relief tablet chewable 262 mg oral .............................. 120pyrazinamide oral ......... 45pyridostigmine bromide oral solution ......................... 45PYRIDOSTIGMINE BROMIDE ORAL TABLET 30 MG ........................... 45pyridostigmine bromide oral tablet 60 mg .................. 45

Qqc 3 day cream 4 % vaginal .......................... 94qc acid controller max st tablet 20 mg oral ......... 120qc acid controller tablet 10 mg oral ........................ 120qc all day allergy tablet 10 mg oral ........................ 150qc antacid suspension 200- 200-20 mg/5ml oral .... 120qc antacid/anti-gas suspension 200-200-20 mg/ 5ml oral ....................... 120qc aspirin low dose tablet chewable 81 mg oral .... 18qc aspirin tablet 325 mg oral ................................ 18qc calamine lotion external ......................... 94qc enteric aspirin tablet delayed release 325 mg oral ................................ 18qc gentle laxative suppository 10 mg rectal ........................... 120qc heartburn antacid tablet chewable 160-105 mg oral .............................. 120qc ibuprofen ib tablet 200 mg oral .......................... 24qc ibuprofen tablet 200 mg oral ................................ 24qc loratadine allergy relief tablet 10 mg oral ......... 150qc magnesium citrate solution 1.745 gm/30ml oral .............................. 120qc miconazole 7 cream 2 % vaginal .......................... 94qc milk of magnesia suspension 400 mg/5ml oral .............................. 120qc mineral oil heavy oil oral .............................. 120qc naproxen sodium tablet 220 mg oral ................... 18

qc tolnaftate cream 1 % external ......................... 43QUADRACEL ............. 138quetiapine fumarate er oral tablet extended release 24 hour 150 mg ................. 39quetiapine fumarate er oral tablet extended release 24 hour 150 mg ................. 61quetiapine fumarate er oral tablet extended release 24 hour 150 mg ................. 71quetiapine fumarate er oral tablet extended release 24 hour 200 mg ................. 39quetiapine fumarate er oral tablet extended release 24 hour 200 mg ................. 61quetiapine fumarate er oral tablet extended release 24 hour 200 mg ................. 72quetiapine fumarate er oral tablet extended release 24 hour 300 mg ................. 39quetiapine fumarate er oral tablet extended release 24 hour 300 mg ................. 61quetiapine fumarate er oral tablet extended release 24 hour 300 mg ................. 72quetiapine fumarate er oral tablet extended release 24 hour 400 mg ................. 39quetiapine fumarate er oral tablet extended release 24 hour 400 mg ................. 61quetiapine fumarate er oral tablet extended release 24 hour 400 mg ................. 72quetiapine fumarate er oral tablet extended release 24 hour 50 mg ................... 39quetiapine fumarate er oral tablet extended release 24 hour 50 mg ................... 61quetiapine fumarate er oral tablet extended release 24 hour 50 mg ................... 72


quetiapine fumarate oral tablet 100 mg ................ 39quetiapine fumarate oral tablet 100 mg ................ 61quetiapine fumarate oral tablet 100 mg ................ 72quetiapine fumarate oral tablet 200 mg ................ 39quetiapine fumarate oral tablet 200 mg ................ 61quetiapine fumarate oral tablet 200 mg ................ 72quetiapine fumarate oral tablet 25 mg .................. 39quetiapine fumarate oral tablet 25 mg .................. 61quetiapine fumarate oral tablet 25 mg .................. 72quetiapine fumarate oral tablet 300 mg ................ 40quetiapine fumarate oral tablet 300 mg ................ 61quetiapine fumarate oral tablet 300 mg ................ 72quetiapine fumarate oral tablet 400 mg ................ 40quetiapine fumarate oral tablet 400 mg ................ 62quetiapine fumarate oral tablet 400 mg ................ 72quetiapine fumarate oral tablet 50 mg .................. 40quetiapine fumarate oral tablet 50 mg .................. 62quetiapine fumarate oral tablet 50 mg .................. 72quinapril hcl .................. 87quinapril- hydrochlorothiazide ...... 87quinidine sulfate oral .... 87QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT ................... 150QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 80 MCG/ACT ................... 150

Rra calcium 600 tablet 600 mg oral ........................ 107RA CALCIUM CIT-VIT D-3 PETITES TABLET 200-250 MG-UNIT ORAL ......... 107ra folic acid tablet 400 mcg oral .............................. 107ra folic acid tablet 800 mcg oral .............................. 107ra gas relief capsule 125 mg oral .............................. 120ra gas relief extra strength tablet chewable 125 mg oral .............................. 120ra glucose tablet chewable 6-4 mg-gm oral ............. 79ra glycerin adult suppository 80.7 % rectal ............... 120ra hi cal tablet 500-200 mg- unit oral ....................... 107ra high potency iron tablet 27 mg oral ................... 107ra iron tablet 325 (65 fe) mg oral .............................. 107ra lice maximum strength shampoo 0.33-4 % external ......................... 94ra magnesium capsule 500 mg oral ........................ 107ra mineral oil oil oral .... 120ra niacin tablet 100 mg oral .............................. 107ra niacin tablet 500 mg oral .............................. 107ra oyster shell calcium/d tablet 500-200 mg-unit oral .............................. 107ra pink bismuth tablet 262 mg oral ........................ 120ra pink bismuth tablet chewable 262 mg oral .............................. 120ra stomach relief max st suspension 525 mg/15ml oral .............................. 120

ra stomach relief suspension 262 mg/15ml oral .............................. 120ra vitamin c tablet 500 mg oral .............................. 107ra vitamin c/rose hips tablet 1000 mg oral ............... 108ra vitamin c/rose hips tablet 500 mg oral ................. 108ra vitamin d-3 capsule 125 mcg (5000 ut) oral ...... 108ra vitamin d-3 capsule 50 mcg (2000 ut) oral ...... 108RABAVERT ................ 138raloxifene hcl .............. 131ramelteon .................... 152ramipril .......................... 87RANEXA ....................... 87ranitidine hcl injection ...................... 120ranitidine hcl oral syrup ........................... 120ranitidine hcl oral tablet 150 mg, 300 mg ................. 120ranitidine hcl tablet 150 mg oral (otc) ..................... 120ranolazine er ................. 87rasagiline mesylate oral ................................ 58RAVICTI ..................... 123reclipsen ..................... 131RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML (1ML SYRINGE) .................. 138RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML ............. 138RECTIV ........................ 88REESES PINWORM MEDICINE SUSPENSION 144 (50 BASE) MG/ML ORAL ............................ 95RELENZA DISKHALER ................. 66RELI-ON INSULIN SYRINGE 29G 0.3 ML .. 79


relion glucose gel 15 gm/ 38gm oral ...................... 79relion glucose tablet chewable 4-6 gm-mg oral ................................ 79RELION PEN NEEDLES 29G X 12MM ................ 79RELISTOR SUBCUTANEOUS SOLUTION 12 MG/ 0.6ML .......................... 120RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML (0.6ML SYRINGE) ...... 120RELISTOR SUBCUTANEOUS SOLUTION 8 MG/ 0.4ML .......................... 121remedy phytoplex antifungal powder 2 % external ..... 95REMICADE ................. 121repaglinide oral tablet 0.5 mg ................................. 79repaglinide oral tablet 1 mg ................................. 79repaglinide oral tablet 2 mg ................................. 79REPATHA ..................... 88REPATHA PUSHTRONEX SYSTEM ....................... 88REPATHA SURECLICK ................. 88RESCRIPTOR ORAL TABLET 200 MG .......... 67RETROVIR INTRAVENOUS ............ 67REVLIMID ORAL CAPSULE 10 MG ......... 54REVLIMID ORAL CAPSULE 15 MG, 25 MG ................................ 54REVLIMID ORAL CAPSULE 2.5 MG, 20 MG ................................ 54REVLIMID ORAL CAPSULE 5 MG ........... 54

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG ................................ 62REXULTI ORAL TABLET 3 MG, 4 MG ..................... 62REYATAZ ORAL PACKET ....................... 67ribavirin oral capsule .... 67ribavirin oral capsule .... 67ribavirin oral tablet 200 mg ................................. 67ribavirin oral tablet 200 mg ................................. 67rid complete lice elimination kit combination .............. 95RIDAURA ................... 138rifabutin ......................... 45rifampin intravenous ..... 45rifampin oral .................. 45RIFATER ...................... 45riluzole .......................... 90rimantadine hcl ............. 67ringers ......................... 108ringers irrigation .......... 108risacal-d tablet 105-81-120 mg-mg-unit oral .......... 108RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG ................... 62RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG ................... 72RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 37.5 MG, 50 MG ................... 62RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 37.5 MG, 50 MG ................... 72risperidone oral solution ......................... 62

risperidone oral solution ......................... 72risperidone oral tablet 0.25 mg ................................. 62risperidone oral tablet 0.25 mg ................................. 72risperidone oral tablet 0.5 mg ................................. 62risperidone oral tablet 0.5 mg ................................. 72risperidone oral tablet 1 mg ................................. 62risperidone oral tablet 1 mg ................................. 72risperidone oral tablet 2 mg ................................. 62risperidone oral tablet 2 mg ................................. 72risperidone oral tablet 3 mg ................................. 62risperidone oral tablet 3 mg ................................. 72risperidone oral tablet 4 mg ................................. 62risperidone oral tablet 4 mg ................................. 72risperidone oral tablet dispersible 0.25 mg ...... 62risperidone oral tablet dispersible 0.25 mg ...... 72risperidone oral tablet dispersible 0.5 mg ........ 62risperidone oral tablet dispersible 0.5 mg ........ 72risperidone oral tablet dispersible 1 mg ........... 62risperidone oral tablet dispersible 1 mg ........... 72risperidone oral tablet dispersible 2 mg ........... 62risperidone oral tablet dispersible 2 mg ........... 72risperidone oral tablet dispersible 3 mg ........... 62risperidone oral tablet dispersible 3 mg ........... 72risperidone oral tablet dispersible 4 mg ........... 62


risperidone oral tablet dispersible 4 mg ........... 73ritonavir ......................... 67RITUXAN HYCELA ...... 54RITUXAN INTRAVENOUS SOLUTION ................... 54rivastigmine .................. 36rivastigmine tartrate ...... 36rizatriptan benzoate ...... 44romidepsin .................... 54ropinirole hcl ................. 58rosadan external cream ............................ 95rosadan external gel ..... 95rosuvastatin calcium ..... 88ROTARIX .................... 138ROTATEQ ORAL SOLUTION ................. 138roweepra ....................... 35roweepra xr oral tablet extended release 24 hour 500 mg .......................... 35roweepra xr oral tablet extended release 24 hour 750 mg .......................... 35ROZEREM .................. 152ROZLYTREK ORAL CAPSULE 100 MG ....... 54ROZLYTREK ORAL CAPSULE 200 MG ....... 54RUBRACA ORAL TABLET 200 MG ......................... 54RUBRACA ORAL TABLET 250 MG, 300 MG .......... 54RYDAPT ....................... 54rydex liquid 10-1.33-6.33 mg/5ml oral ................. 150SSABRIL ORAL PACKET ....................... 35SANTYL ........................ 95SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG ................................ 62SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG ................................ 73

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG ................................ 62SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG ................................ 73SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 5 MG ................................ 62SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 5 MG ................................ 73SAVELLA ORAL TABLET 100 MG ......................... 90SAVELLA ORAL TABLET 12.5 MG ........................ 90SAVELLA ORAL TABLET 25 MG ........................... 91SAVELLA ORAL TABLET 50 MG ........................... 91SAVELLA TITRATION PACK ............................ 91sb antacid anti-gas suspension 200-200-20 mg/ 5ml oral ....................... 121sb aspirin tablet 325 mg oral ................................ 18sb ibuprofen tablet 200 mg oral ................................ 18sb lice killing max st shampoo 0.33-4 % external ......................... 95sb naproxen sodium tablet 220 mg oral ................... 24sb omeprazole tablet delayed release 20 mg oral .............................. 121sb vitamin c tablet 500 mg oral .............................. 108scalpicin maximum strength solution 1 % external .... 95scopolamine ................. 42scopolamine ............... 121selegiline hcl oral .......... 58selenium sulfide external lotion ............................. 95SELZENTRY ORAL SOLUTION ................... 67

SELZENTRY ORAL TABLET 150 MG, 300 MG ................................ 67SELZENTRY ORAL TABLET 25 MG ............ 67SELZENTRY ORAL TABLET 75 MG ............ 67SEREVENT DISKUS ... 150sertraline hcl oral concentrate ................... 40sertraline hcl oral concentrate ................... 70sertraline hcl oral tablet 100 mg ................................. 40sertraline hcl oral tablet 100 mg ................................. 70sertraline hcl oral tablet 25 mg ................................. 40sertraline hcl oral tablet 25 mg ................................. 70sertraline hcl oral tablet 50 mg ................................. 40sertraline hcl oral tablet 50 mg ................................. 70setlakin ....................... 131sevelamer carbonate oral packet 0.8 gm ............. 124sevelamer carbonate oral packet 2.4 gm ............. 124sevelamer carbonate oral tablet ........................... 124sharobel ...................... 131SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML ................ 138SIGNIFOR .................. 134silace liquid 150 mg/15ml oral .............................. 121silace syrup 60 mg/15ml oral .............................. 121siladryl allergy liquid 12.5 mg/5ml oral ................. 150sildenafil citrate oral tablet 20 mg .......................... 150silver sulfadiazine external ......................... 30


SIMBRINZA ................ 143simethicone capsule 125 mg oral ........................ 121simethicone capsule 180 mg oral ........................ 121simethicone tablet chewable 125 mg oral ................. 121simethicone tablet chewable 80 mg oral ................... 121SIMULECT ................. 138simvastatin oral ............. 88sirolimus oral solution ....................... 138sirolimus oral tablet .... 138SIRTURO ..................... 45slow iron tablet extended release 160 (50 fe) mg oral .............................. 108slow release iron tablet extended release 160 (50 fe) mg oral .................. 108sm 3-day vaginal cream 2 % vaginal ...................... 95sm acid reducer max st tablet 20 mg oral ......... 121sm acid reducer tablet 10 mg oral ........................ 121sm acid reducer tablet 75 mg oral ........................ 121sm all day allergy tablet 10 mg oral ........................ 150sm allergy relief capsule 25 mg oral ........................ 150sm allergy relief liquid 12.5 mg/5ml oral ................. 150sm antacid advanced max st suspension 400-400-40 mg/5ml oral ................. 121sm antacid anti-gas suspension 200-200-20 mg/ 5ml oral ....................... 121sm antacid/antigas suspension 200-200-20 mg/ 5ml oral ....................... 108sm antifungal clotrimazole cream 1 % external ...... 43sm antifungal miconazole cream 2 % external ...... 43

sm antifungal tolnaftate cream 1 % external ...... 43sm aspirin adult low strength tablet chewable 81 mg oral .......................... 18sm aspirin adult low strength tablet delayed release 81 mg oral ........ 18sm aspirin ec low strength tablet delayed release 81 mg oral .......................... 18sm aspirin ec tablet delayed release 325 mg oral ...... 18sm aspirin low dose tablet chewable 81 mg oral .... 18sm aspirin tablet 325 mg oral ................................ 18sm athletes foot cream 1 % external ......................... 43sm calcium 600/vitamin d tablet 600-400 mg-unit oral .............................. 108sm calcium antacid ex st tablet chewable 750 mg oral .............................. 121SM CALCIUM CITRATE W/ VIT D3 TABLET 315-250 MG-UNIT ORAL ......... 108SM CALCIUM CITRATE+/ VIT D3 TABLET 315-250 MG-UNIT ORAL ......... 108sm calcium-vitamin d tablet 500-200 mg-unit oral ... 108sm chewable c tablet chewable 500 mg oral .............................. 108sm childrens aspirin tablet chewable 81 mg oral .... 18sm clearlax powder oral .............................. 121sm clotrimazole vaginal cream 1 % vaginal ........ 95sm cold & allergy pe tablet 4-10 mg oral ............... 151sm double antibiotic ointment 500-10000 unit/gm external ......................... 30

sm eye itch relief solution 0.025 % ophthalmic .... 144sm eye wash solution 0.002 % ophthalmic .............. 144sm foaming antacid tablet chewable 80-20 mg oral .............................. 121sm folic acid tablet 400 mcg oral .............................. 108sm gas relief antiflatuent capsule 180 mg oral .... 121sm glucose tablet chewable 4 gm oral ....................... 79sm glucose tablet chewable 4-6 gm-mg oral ............. 79sm hydrocortisone max st ointment 1 % external .... 95sm ibuprofen ib tablet 200 mg oral .......................... 24sm ibuprofen tablet 200 mg oral ................................ 24sm iron slow release tablet extended release 160 (50 fe) mg oral .................. 108sm iron tablet 325 (65 fe) mg oral ........................ 108sm lice killing max strength shampoo 0.33-4 % external ......................... 95sm lice killing shampoo 0.33-4 % external ......... 95sm lice treatment lotion 1 % external ......................... 95sm loratadine tablet 10 mg oral .............................. 151SM LUBRICANT EYE DROPS SOLUTION 0.4-0.3 % OPHTHALMIC ........ 144SM LUBRICATING TEARS SOLUTION 0.4-0.3 % OPHTHALMIC ............ 144sm magnesium citrate solution 1.745 gm/30ml oral .............................. 121sm miconazole 3 kit 200 & 2 mg-% (9gm) vaginal ... 43sm miconazole 7 cream 2 % vaginal ...................... 95


sm miconazole 7 suppository 100 mg vaginal .......................... 43sm milk of magnesia suspension 1200 mg/15ml oral .............................. 121sm mineral oil enema rectal ........................... 121sm motion sickness tablet 25 mg oral ..................... 42sm naproxen sodium tablet 220 mg oral ................... 24sm nasal decongestant max st tablet 30 mg oral ..... 151sm niacin cr tablet extended release 250 mg oral .... 108sm nicotine gum 4 mg mouth/throat ................. 21sm nicotine lozenge 2 mg mouth/throat ................. 21sm nicotine patch 24 hour 14 mg/24hr transdermal ................... 21sm nicotine patch 24 hour 21 mg/24hr transdermal ................... 21sm nicotine patch 24 hour 7 mg/24hr transdermal .... 21sm nicotine polacrilex gum 2 mg mouth/throat ........ 21sm nicotine polacrilex gum 4 mg mouth/throat ........ 21sm nicotine polacrilex lozenge 4 mg mouth/ throat ............................ 21sm omeprazole tablet delayed release 20 mg oral .............................. 122sm oyster shell calcium/vit d3 tablet 500-400 mg-unit oral .............................. 108sm prenatal vitamins tablet 28-0.8 mg oral ............ 108sm stomach relief tablet 262 mg oral ........................ 122sm stomach relief tablet chewable 262 mg oral .............................. 122

sm stool softener capsule 100 mg oral ................. 122sm stool softener capsule 240 mg oral ................. 122sm triple antibiotic ointment 3.5-400-5000 external ... 30sm urinary pain relief tablet 95 mg oral ..................... 18sm vit c/rose hips tablet 1000 mg oral ............... 108sm vitamin b-12 tablet 100 mcg oral ...................... 109sm vitamin b-12 tablet 500 mcg oral ...................... 109sm vitamin b-6 tablet 100 mg oral ........................ 109sm vitamin b1 tablet 100 mg oral .............................. 109sm vitamin c tablet 1000 mg oral .............................. 109sm vitamin c tablet 250 mg oral .............................. 109sm vitamin c tablet 500 mg oral .............................. 109sm vitamin c/rose hips tablet 500 mg oral ................. 109sm vitamin d3 capsule 50 mcg (2000 ut) oral ...... 109sm vitamin d3 tablet 25 mcg (1000 ut) oral .............. 109sm vitamin e capsule 1000 unit oral ....................... 109sm vitamin e capsule 200 unit oral ....................... 109sm vitamin e capsule 400 unit oral ....................... 109SMART SENSE COLOR LANCETS 33G ............. 79smart sense glucose tablet chewable 4-6 gm-mg oral ................................ 79SMART SENSE SUPER THIN LANCETS ............ 79SMART SENSE THIN LANCETS 26G ............. 79sodium chloride (hypertonic) ointment 5 % ophthalmic .................. 144

SODIUM CHLORIDE (HYPERTONIC) OINTMENT 5 % OPHTHALMIC ............ 144sodium chloride (hypertonic) solution 5 % ophthalmic .................. 144sodium chloride injection solution 2.5 meq/ml .... 109sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 % ............................. 109sodium chloride intravenous solution 4 meq/ml ....... 109sodium chloride irrigation solution 0.9 % ............. 109sodium fluoride oral tablet 2.2 (1 f) mg ................. 109sodium fluoride oral tablet chewable 2.2 (1 f) mg ............................... 109sodium phenylbutyrate oral tablet ........................... 123sodium polystyrene sulfonate oral powder ........................ 109sodium polystyrene sulfonate oral suspension ................. 109sodium polystyrene sulfonate rectal ........... 109SOFOSBUVIR- VELPATASVIR ............. 67solifenacin succinate ... 124SOLTAMOX .................. 54SOMATULINE DEPOT ....................... 134SOMAVERT ............... 134soothe & cool inzo antifungal cream 2 % external ......................... 43soothe suspension 262 mg/ 15ml oral ..................... 122soothe tablet 262 mg oral .............................. 122soothe tablet chewable 262 mg oral ........................ 122sorine ............................ 88


sotalol hcl (af) oral tablet 120 mg .......................... 88sotalol hcl (af) oral tablet 160 mg, 80 mg .............. 88sotalol hcl oral ............... 88sotalol hydrochloride oral tablet 120 mg ................ 88sotalol hydrochloride oral tablet 160 mg, 80 mg .... 88SPIRIVA HANDIHALER ............ 151SPIRIVA RESPIMAT ... 151spironolactone oral ....... 88spironolactone-hctz ...... 88SPRAVATO (56 MG DOSE) .......................... 40SPRAVATO (84 MG DOSE) .......................... 40sprintec 28 .................. 131SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG ................. 35SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 750 MG ....... 35SPRYCEL ..................... 54sps .............................. 109sronyx ......................... 131ssd ................................ 30STAMARIL .................. 138stavudine oral capsule 15 mg, 20 mg ..................... 67stavudine oral capsule 30 mg, 40 mg ..................... 67STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/ 0.5ML ............................ 95sterile water for irrigation ...................... 109STIMATE .................... 126stimulant laxative tablet delayed release 5 mg oral .............................. 122STIOLTO RESPIMAT ................. 151

STIVARGA ................... 54stomach relief max st suspension 525 mg/15ml oral .............................. 122stomach relief suspension 262 mg/15ml oral ........ 122stomach relief tablet chewable 262 mg oral .............................. 122stool softener capsule 100 mg oral ........................ 122stool softener capsule 240 mg oral ........................ 122stool softener capsule 250 mg oral ........................ 122streptomycin sulfate intramuscular ................ 30STRIBILD ..................... 67subvenite ...................... 35sucralfate oral tablet .... 122sudogest sinus/allergy tablet 4-60 mg oral ............... 151sudogest tablet 30 mg oral .............................. 151sudogest tablet 60 mg oral .............................. 151sulfacetamide sodium (acne) ........................... 30sulfacetamide sodium ophthalmic solution ....... 30sulfacetamide-prednisolone ophthalmic solution ....... 24sulfacetamide-prednisolone ophthalmic solution ..... 144SULFADIAZINE ORAL ............................ 30sulfamethoxazole- trimethoprim intravenous ................... 30sulfamethoxazole- trimethoprim oral suspension 200-40 mg/ 5ml ................................ 30sulfamethoxazole- trimethoprim oral tablet ............................. 30SULFAMYLON EXTERNAL CREAM ......................... 30

sulfasalazine oral ........ 140sulfazine ....................... 24sulindac oral ................. 18sulindac oral ................. 24sumatriptan nasal ......... 44sumatriptan succinate oral ................................ 44sumatriptan succinate subcutaneous solution auto- injector .......................... 44super calcium 600 + d 400 tablet 600-400 mg-unit oral .............................. 109super calcium 600 + d3 tablet 600-400 mg-unit oral .............................. 109super calcium tablet 600 mg oral .............................. 109SUTENT ORAL CAPSULE 12.5 MG ........................ 54SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG ................................ 54syeda .......................... 131SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG ............................. 54SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG ............................. 67SYMFI ........................... 67SYMFI LO ..................... 67SYMJEPI .................... 151SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN- INJECTOR .................... 79SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- INJECTOR .................... 79SYMPAZAN ORAL FILM 10 MG, 20 MG ................... 35SYMPAZAN ORAL FILM 5 MG ................................ 35SYMTUZA .................... 67


SYNAGIS .................... 138SYNAREL ................... 134SYNERCID ................... 30SYNJARDY .................. 79SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10- 1000 MG, 12.5-1000 MG, 5-1000 MG .................... 79SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 25- 1000 MG ....................... 79SYNRIBO ..................... 54SYNTHAMIN 17 ......... 110SYNTHROID .............. 133TTABLOID ...................... 54tacrolimus external ....... 95tacrolimus oral capsule 0.5 mg, 1 mg ..................... 138tacrolimus oral capsule 5 mg ............................... 138TAFINLAR .................... 54TAGRISSO ORAL TABLET 40 MG ........................... 54TAGRISSO ORAL TABLET 80 MG ........................... 54TAKE ACTION TABLET 1.5 MG ORAL ................... 131TALZENNA ORAL CAPSULE 0.25 MG ...... 54TALZENNA ORAL CAPSULE 1 MG ........... 54tamoxifen citrate oral .... 54tamsulosin hcl ............. 124TARGRETIN EXTERNAL ................... 54tarina fe 1/20 ............... 131tarina fe 1/20 eq ......... 131TASIGNA ...................... 54TAXOTERE INTRAVENOUS CONCENTRATE 20 MG/ ML, 80 MG/4ML ............ 55tazarotene external ....... 95tazicef injection ............. 30

TAZORAC EXTERNAL CREAM 0.05 % ............ 95TAZORAC EXTERNAL GEL .............................. 95taztia xt ......................... 88TDVAX ........................ 138TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML ............. 55TECENTRIQ INTRAVENOUS SOLUTION 840 MG/14ML ............... 55TECFIDERA ................. 91TECHLITE PEN NEEDLES 29G X 12MM ................ 79TEFLARO ..................... 30TEKTURNA .................. 88telmisartan .................... 88telmisartan-amlodipine oral tablet 80-5 mg ............... 88telmisartan-hctz ............ 88temazepam oral capsule 15 mg, 30 mg ................... 152TEMIXYS ...................... 67temsirolimus ................. 55TENIVAC .................... 138tenofovir disoproxil fumarate ....................... 67tenofovir disoproxil fumarate ....................... 67terazosin hcl oral .......... 88terazosin hcl oral ........ 124terbinafine hcl cream 1 % external ......................... 43terbinafine hcl oral ........ 44terbutaline sulfate injection ...................... 151terbutaline sulfate oral .............................. 151terconazole ................... 44testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml ....... 132testosterone enanthate intramuscular solution ....................... 132

testosterone transdermal gel 20.25 mg/1.25gm (1.62%) ....................... 132testosterone transdermal gel 20.25 mg/act (1.62%), 40.5 mg/2.5gm (1.62%) ....................... 132testosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%) .............. 132tetrabenazine oral tablet 12.5 mg ......................... 91tetrabenazine oral tablet 25 mg ................................. 91tetracycline hcl oral ....... 30TGT CALCIUM + VITAMIN D3 TABLET 600-800 MG- UNIT ORAL ................ 110tgt glucose tablet chewable 4-6 gm-mg oral ............. 79TGT LANCET MICRO THIN 33G ............................... 79TGT LANCET THIN 26G ............................... 79TGT LANCET ULTRA THIN 30G ............................... 79THALOMID ORAL CAPSULE 100 MG, 50 MG ................................ 55THALOMID ORAL CAPSULE 150 MG, 200 MG ................................ 55theophylline er oral tablet extended release 12 hour 300 mg, 450 mg ......... 151theophylline er oral tablet extended release 24 hour ............................ 151thera-d rapid repletion tablet 50 mcg (2000 ut) oral .............................. 110thiamine hcl tablet 100 mg oral .............................. 110thioridazine hcl oral ...... 62thiotepa injection .......... 55thiothixene oral ............. 62THYMOGLOBULIN .... 138tiadylt er ........................ 88


tiagabine hcl ................. 35TIBSOVO ...................... 55TICE BCG ..................... 55tigecycline ..................... 30timolol maleate ophthalmic .................. 144timolol maleate oral ...... 45timolol maleate oral ...... 88tis-u-sol ....................... 110TIVICAY ORAL TABLET 10 MG ................................ 67TIVICAY ORAL TABLET 25 MG, 50 MG ................... 67tizanidine hcl oral tablet ............................. 63tizanidine hcl oral tablet ........................... 151tobramycin inhalation .... 30tobramycin ophthalmic .. 30tobramycin sulfate injection solution ......................... 30tobramycin sulfate injection solution reconstituted .... 30tobramycin- dexamethasone .......... 144tolcapone ...................... 58tolnaftate cream 1 % external ......................... 44tolterodine tartrate ...... 124tolterodine tartrate er ... 124topiramate oral capsule sprinkle ......................... 35topiramate oral capsule sprinkle ......................... 45topiramate oral tablet 100 mg ................................. 35topiramate oral tablet 100 mg ................................. 45topiramate oral tablet 200 mg ................................. 35topiramate oral tablet 200 mg ................................. 45topiramate oral tablet 25 mg ................................. 35topiramate oral tablet 25 mg ................................. 45topiramate oral tablet 50 mg ................................. 35

topiramate oral tablet 50 mg ................................. 45toposar intravenous solution 1 gm/50ml, 100 mg/ 5ml ................................ 55TOPOTECAN HCL INTRAVENOUS SOLUTION ................... 55topotecan hcl intravenous solution reconstituted .... 55toremifene citrate .......... 55torsemide oral ............... 88TOUJEO MAX SOLOSTAR .................. 79TOUJEO SOLOSTAR ... 79TOVIAZ ....................... 124TRACLEER ORAL TABLET SOLUBLE ................... 151TRADJENTA ................ 80tramadol hcl oral ........... 18tramadol- acetaminophen ............. 18trandolapril .................... 88tranexamic acid intravenous solution 1000 mg/ 10ml .............................. 82tranexamic acid oral ..... 82TRANSDERM SCOP (1.5 MG) ............................... 42tranylcypromine sulfate ........................... 40TRAVASOL ................ 110TRAVATAN Z ............. 144travel sickness tablet chewable 25 mg oral .... 42trazodone hcl oral ......... 40TREANDA INTRAVENOUS SOLUTION RECONSTITUTED ....... 55TRECATOR .................. 45TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG .............................. 134TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION

RECONSTITUTED 22.5 MG .............................. 134TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 3.75 MG .............................. 134tretinoin external cream ............................ 55tretinoin external cream ............................ 95tretinoin external gel 0.01 %, 0.025 % ................... 55tretinoin external gel 0.01 %, 0.025 % ................... 95tretinoin oral .................. 55TREXALL .................... 138tri femynor ................... 132tri-estarylla .................. 132tri-linyah ...................... 132tri-mili .......................... 132tri-previfem .................. 132tri-sprintec ................... 132tri-vylibra ..................... 132triamcinolone acetonide external cream ............ 126triamcinolone acetonide external lotion ............. 126triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % ............... 126triamcinolone acetonide injection suspension 40 mg/ ml .................................. 24triamcinolone acetonide mouth/throat ................. 91triamterene-hctz oral capsule 37.5-25 mg ...... 88triamterene-hctz oral tablet ............................. 88triderm external cream 0.1 % ................................ 126triderm external cream 0.5 % .................................. 95 trientine hcl ................. 110trifluoperazine hcl oral ... 63trifluridine ophthalmic .... 67trihexyphenidyl hcl ........ 58


trilyte ........................... 122trimethoprim oral ........... 30trimipramine maleate oral ................................ 40trinessa (28) ................ 132TRINTELLIX ORAL TABLET 10 MG ............ 40TRINTELLIX ORAL TABLET 20 MG ............ 40TRINTELLIX ORAL TABLET 5 MG .............. 40triple antibiotic ointment 3.5- 400-5000 external ........ 30triple antibiotic ointment 5- 400-5000 external ........ 30TRISENOX INTRAVENOUS SOLUTION 12 MG/ 6ML ............................... 55TRIUMEQ ..................... 67trivora (28) .................. 132TROGARZO ................. 68TROPHAMINE ............ 110TRULICITY ................... 80TRUMENBA ............... 138TRUSTEX LUB/RIBBED/ STUDDED .................. 144TRUSTEX LUB/ SPERMICIDE EX ST ... 144TRUSTEX LUB/ SPERMICIDE XL ........ 144TRUSTEX LUBRICATED ............. 144TRUSTEX LUBRICATED EX LARGE .................. 145TRUSTEX LUBRICATED EXTRA ST .................. 145TRUSTEX LUBRICATED/ SPERMICIDE ............. 145TRUSTEX RIA LUB/ SPERMICIDE ............. 145TRUSTEX RIA LUBRICATED ............. 145TRUSTEX-NONOXYNOL- 9/RIB/STUD ................ 145TRUVADA .................... 68tulana .......................... 132

tums ultra 1000 tablet chewable 1000 mg oral .............................. 122TURALIO ...................... 55TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE ................... 138TYBOST ....................... 68TYKERB ....................... 55TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/ 0.5ML .......................... 138TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML (0.5ML SYRINGE) ...... 139TYSABRI ...................... 91UULORIC ........................ 44UNIFINE PENTIPS 30G X 5 MM ............................. 80UNILET COMFORTOUCH LANCET ....................... 80UNILET GP 28 ULTRA THIN ............................. 80UNILET MICRO-THIN 33G ............................... 80UNILET SUPER-THIN 30G ............................... 80UNILET ULTRA-THIN 28G ............................... 80unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg ............................. 133unithroid oral tablet 25 mcg ............................. 133UNIVERSAL 1 LANCETS ULTRA THIN ................ 80up & up glucose tablet chewable 4-6 gm-mg oral ................................ 80UPTRAVI ORAL TABLET ........................ 88

UPTRAVI ORAL TABLET THERAPY PACK .......... 88ursodiol oral ................ 122Vvalacyclovir hcl oral tablet 1 gm ................................. 68valacyclovir hcl oral tablet 500 mg .......................... 68VALCHLOR .................. 55VALCHLOR .................. 95valganciclovir hcl oral tablet ............................. 68valproate sodium intravenous ................... 35valproic acid oral capsule ......................... 35valproic acid oral capsule ......................... 45valproic acid oral capsule ......................... 73valproic acid oral solution ......................... 35valproic acid oral solution ......................... 45valproic acid oral solution ......................... 73valsartan ....................... 88valsartan- hydrochlorothiazide ...... 89VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS SOLUTION 1-5 GM/200ML-%, 500-5 MG/100ML-%, 750-5 MG/ 150ML-% ...................... 31VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1-0.9 GM/ 200ML-%, 500-0.9 MG/ 100ML-%, 750-0.9 MG/ 150ML-% ...................... 31vancomycin hcl intravenous solution reconstituted 1 gm, 10 gm, 5 gm, 500 mg .... 31VANCOMYCIN HCL INTRAVENOUS SOLUTION RECONSTITUTED 1.25 GM, 1.5 GM, 250 MG .... 31


vancomycin hcl intravenous solution reconstituted 750 mg ................................. 31vancomycin hcl oral capsule 125 mg .......................... 31vancomycin hcl oral capsule 250 mg .......................... 31vandazole ..................... 31VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/ 0.5ML 0.5 ML, 50 UNIT/ML 1 ML ............................ 139VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/ 0.5ML, 50 UNIT/ML .... 139VARIVAX .................... 139VARIZIG INTRAMUSCULAR SOLUTION ................. 139VASCEPA ..................... 89vcf vaginal contraceptive foam 12.5 % vaginal .... 132VECAMYL .................... 91VECTIBIX INTRAVENOUS SOLUTION 100 MG/5ML, 400 MG/20ML ............... 55VELCADE INJECTION ................... 55velivet ......................... 132VELPHORO ................ 110VELPHORO ................ 124VEMLIDY ...................... 68VENCLEXTA ORAL TABLET 10 MG ............ 55VENCLEXTA ORAL TABLET 100 MG .......... 56VENCLEXTA ORAL TABLET 50 MG ............ 56VENCLEXTA STARTING PACK ............................ 56venlafaxine hcl er oral capsule extended release 24 hour 150 mg ............ 40venlafaxine hcl er oral capsule extended release 24 hour 150 mg ............ 70

venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg ........... 40venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg ........... 70venlafaxine hcl er oral capsule extended release 24 hour 75 mg .............. 40venlafaxine hcl er oral capsule extended release 24 hour 75 mg .............. 70venlafaxine hcl er oral tablet extended release 24 hour 150 mg .......................... 40venlafaxine hcl er oral tablet extended release 24 hour 150 mg .......................... 70venlafaxine hcl er oral tablet extended release 24 hour 37.5 mg ......................... 40venlafaxine hcl er oral tablet extended release 24 hour 37.5 mg ......................... 70venlafaxine hcl er oral tablet extended release 24 hour 75 mg ............................ 40venlafaxine hcl er oral tablet extended release 24 hour 75 mg ............................ 70venlafaxine hcl oral tablet 100 mg .......................... 40venlafaxine hcl oral tablet 100 mg .......................... 70venlafaxine hcl oral tablet 25 mg ............................ 40venlafaxine hcl oral tablet 25 mg ............................ 70venlafaxine hcl oral tablet 37.5 mg ......................... 40venlafaxine hcl oral tablet 37.5 mg ......................... 70venlafaxine hcl oral tablet 50 mg ............................ 40venlafaxine hcl oral tablet 50 mg ............................ 70venlafaxine hcl oral tablet 75 mg ............................ 40

venlafaxine hcl oral tablet 75 mg ............................ 70VENTAVIS .................. 151VENTOLIN HFA ......... 151verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg .......................... 89verapamil hcl er oral capsule extended release 24 hour 360 mg ............ 89verapamil hcl er oral tablet extended release .......... 89verapamil hcl intravenous ................... 89verapamil hcl oral ......... 89VERSACLOZ ................ 63VERZENIO ................... 56VESICARE ................. 124VICTOZA SUBCUTANEOUS SOLUTION PEN- INJECTOR .................... 80VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 MG ................................ 68VIDEX ORAL SOLUTION RECONSTITUTED 2 GM ................................ 68vienva ......................... 132vigabatrin ...................... 35vigadrone ...................... 35VIIBRYD ORAL TABLET 10 MG ................................ 41VIIBRYD ORAL TABLET 20 MG ................................ 41VIIBRYD ORAL TABLET 40 MG ................................ 41VIMPAT INTRAVENOUS ............ 35VIMPAT ORAL SOLUTION ................... 35VIMPAT ORAL TABLET 100 MG ......................... 35VIMPAT ORAL TABLET 150 MG, 200 MG .......... 35


VIMPAT ORAL TABLET 50 MG ................................ 35vinblastine sulfate intravenous solution ..... 56vincristine sulfate intravenous ................... 56vinorelbine tartrate ........ 56viorele ......................... 132VIRACEPT ORAL TABLET 250 MG ......................... 68VIRACEPT ORAL TABLET 625 MG ......................... 68VIRAZOLE .................... 68VIREAD ORAL POWDER ..................... 68VIREAD ORAL POWDER ..................... 68VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG ................................ 68VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG ................................ 68virtussin a/c solution 100-10 mg/5ml oral ................. 151VITAMIN A PALMITATE TABLET 10000 UNIT ORAL .......................... 110VITAMIN A PALMITATE TABLET 15000 UNIT ORAL .......................... 110vitamin b-1 tablet 100 mg oral .............................. 110vitamin b-1 tablet 250 mg oral .............................. 110vitamin b-1 tablet 50 mg oral .............................. 110vitamin b-12 er tablet extended release 1000 mcg oral .............................. 110vitamin b-12 tablet 100 mcg oral .............................. 110vitamin b-12 tablet 1000 mcg oral ...................... 110vitamin b-12 tablet 250 mcg oral .............................. 110vitamin b-12 tablet 500 mcg oral .............................. 110

vitamin b-2 tablet 100 mg oral .............................. 110vitamin b-2 tablet 25 mg oral .............................. 110vitamin b-2 tablet 50 mg oral .............................. 110vitamin b-6 tablet 100 mg oral .............................. 110vitamin b-6 tablet 50 mg oral .............................. 110vitamin b12 tablet 100 mcg oral .............................. 110vitamin c tablet 1000 mg oral .............................. 110vitamin c tablet 250 mg oral .............................. 111vitamin c tablet 500 mg oral .............................. 111vitamin c-rose hips tablet 1000 mg oral ............... 111vitamin c-rose hips tablet 500 mg oral ................. 111vitamin c/rose hips tablet 500 mg oral ................. 111vitamin d (cholecalciferol) capsule 10 mcg (400 unit) oral .............................. 111vitamin d (cholecalciferol) capsule 25 mcg (1000 ut) oral .............................. 111vitamin d (cholecalciferol) tablet 10 mcg (400 unit) oral .............................. 111vitamin d (cholecalciferol) tablet 25 mcg (1000 ut) oral .............................. 111vitamin d (ergocalciferol) capsule 1.25 mg (50000 ut) oral .............................. 111vitamin d capsule 50 mcg (2000 ut) oral .............. 111vitamin d high potency capsule 25 mcg (1000 ut) oral .............................. 111vitamin d liquid 10 mcg/ml oral .............................. 111vitamin d tablet 25 mcg (1000 ut) oral .............. 111

vitamin d tablet 50 mcg (2000 ut) oral .............. 111vitamin d-3 capsule 25 mcg (1000 ut) oral .............. 111vitamin d2 tablet 10 mcg (400 unit) oral ............. 111vitamin d3 capsule 10 mcg (400 unit) oral ............. 111vitamin d3 capsule 125 mcg (5000 ut) oral .............. 111vitamin d3 capsule 25 mcg (1000 ut) oral .............. 111vitamin d3 capsule 50 mcg (2000 ut) oral .............. 111vitamin d3 maximum strength capsule 125 mcg (5000 ut) oral .............. 111vitamin d3 tablet 10 mcg (400 unit) oral ............. 111vitamin d3 tablet 125 mcg (5000 ut) oral .............. 111vitamin d3 tablet 25 mcg (1000 ut) oral .............. 111vitamin d3 tablet 50 mcg (2000 ut) oral .............. 112vitamin e capsule 100 unit oral .............................. 112vitamin e capsule 1000 unit oral .............................. 112vitamin e capsule 200 unit oral .............................. 112vitamin e capsule 400 unit oral .............................. 112vitamin e water soluble capsule 1000 unit oral .............................. 112VITRAKVI ORAL CAPSULE 100 MG ......................... 56VITRAKVI ORAL CAPSULE 25 MG ........................... 56VITRAKVI ORAL SOLUTION ................... 56VIZIMPRO ORAL TABLET 15 MG ........................... 56VIZIMPRO ORAL TABLET 30 MG, 45 MG .............. 56voriconazole intravenous ................... 44


voriconazole oral suspension reconstituted ................. 44voriconazole oral tablet 200 mg ................................. 44voriconazole oral tablet 50 mg ................................. 44VOSEVI ........................ 68VOTRIENT ................... 56VPRIV ......................... 112VRAYLAR ORAL CAPSULE ..................... 63VRAYLAR ORAL CAPSULE ..................... 73VRAYLAR ORAL CAPSULE THERAPY PACK .......... 63VRAYLAR ORAL CAPSULE THERAPY PACK .......... 73vyfemla ....................... 132vylibra ......................... 132VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 44-100 MG ................................ 56Wwalgreens glucose tablet chewable 4 gm oral ...... 80walgreens glucose tablet chewable 4-6 gm-mg oral ................................ 80warfarin sodium oral ..... 82wera ............................ 132wixela inhub ................ 151wixela inhub ................ 151XXALKORI ...................... 56XARELTO ORAL TABLET 10 MG, 20 MG .............. 82XARELTO ORAL TABLET 15 MG ........................... 82XARELTO ORAL TABLET 2.5 MG .......................... 82XARELTO STARTER PACK ............................ 82XATMEP ..................... 139XELJANZ .................... 139XGEVA ....................... 141XIIDRA ........................ 144

XOFLUZA ..................... 68XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED ..... 151XOSPATA ..................... 56XPOVIO (100 MG ONCE WEEKLY) ..................... 56XPOVIO (60 MG ONCE WEEKLY) ..................... 56XPOVIO (80 MG ONCE WEEKLY) ..................... 56XPOVIO (80 MG TWICE WEEKLY) ..................... 56XTANDI ........................ 56XYREM ....................... 152YYERVOY ....................... 56YF-VAX ....................... 139YONDELIS ................... 56YONSA ......................... 56Zzafirlukast ................... 151zaleplon oral capsule 10 mg ............................... 152zaleplon oral capsule 5 mg ............................... 152ZALTRAP ..................... 56ZANOSAR .................... 56zarah ........................... 132ZARXIO ........................ 82zeasorb-af powder 2 % external ......................... 96ZEJULA ........................ 56ZELBORAF ................... 56zenatane ....................... 96ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000- 79000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT ....... 123zenzedi oral tablet 10 mg ................................. 91zenzedi oral tablet 5 mg ................................. 91

zidovudine oral capsule ......................... 68zidovudine oral syrup .... 68zidovudine oral tablet .... 68ziprasidone hcl oral capsule 20 mg ............................ 63ziprasidone hcl oral capsule 20 mg ............................ 73ziprasidone hcl oral capsule 40 mg ............................ 63ziprasidone hcl oral capsule 40 mg ............................ 73ziprasidone hcl oral capsule 60 mg, 80 mg ................ 63ziprasidone hcl oral capsule 60 mg, 80 mg ................ 73ZIRGAN ........................ 68zoledronic acid intravenous concentrate ................. 141zoledronic acid intravenous solution 4 mg/100ml .... 141ZOLINZA ...................... 44ZOLINZA ...................... 56zolmitriptan oral ............ 45zolpidem tartrate oral ... 152zonisamide oral ............ 36ZORTRESS ................ 139ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED ..... 139zovia 1/35e (28) .......... 132ZULRESSO .................. 91zumandimine .............. 132ZYDELIG ...................... 57ZYKADIA ORAL TABLET ........................ 57ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG ................................ 63ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG ................................ 73


ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION

RECONSTITUTED 300 MG, 405 MG ......................... 63

ZYTIGA ORAL TABLET 500 MG ................................ 57


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Danh mục thuốc này được cập nhật vào ngày 1/28/2020.

Anthem Blue Cross Cal MediConnect Plan là một chương trình bảo hiểm sức khỏe có hợp đồng với cả Medicare và Medi-Cal để cung cấp phúc lợi của cả hai chương trình cho các thành viên.

Anthem Blue Cross là tên thương mại của Blue Cross of California. Anthem Blue Cross và Blue Cross of California Partnership Plan, Inc. là các tổ chức được cấp phép độc lập của Blue Cross Association.

ANTHEM là nhãn hiệu thương mại đã đăng ký của Anthem Insurance Companies, Inc.

H6229_20_107845_T_VN_0002 CMS Approved 09/11/2019ID danh mục thuốc: CM_MMP_20210_v9_2002_1 Phiên bản: v9Đã phát hành 2/1/2020

lacountyduals.anthem.com · los angeles county, ca anthem blue cross cal mediconnect plan...

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