preferred drug list (pdl) - passport · 2019-12-11 · what if my drug is not on the pdl? remember,...

PASS02298

Preferred Drug List (PDL)

List of Covered Drugs

What is the Passport Health Plan Preferred Drug List (PDL)?

The PDL is a list of drugs covered by Passport. To get a drug on our PDL, you must:

• Be a Passport member;

• Need a drug that is medically necessary;

• Get the prescription filled at a Passport Health Plan network pharmacy. A network pharmacy is one that is signed up with Passport; and

• Follow all Passport rules (see limits below).

The PDL is not a complete list of covered drugs by Passport. Some drugs not listed may be covered,

if medically necessary. These drugs may or may not need prior authorization.

How do I find my drug on the PDL?

• You can look for a drug using our Searchable Preferred Drug List on our website at www.passporthealthplan.com.

Are there any limits to the drugs you have been prescribed?

Some covered drugs may have limits on them. This could include:

• Prior Authorization (PA): Prior authorizations help ensure drugs are being prescribed in a safe manner and for appropriate health conditions. Some drugs must be approved before Passport will cover or pay for them. This means your provider will need to get approval before you can have your prescriptions filled. In order for Passport to pay for the drug, you must have prior authorization approval first.

• Step Therapy (ST): Step therapy is when you must first try a certain drug before we will cover the drug your doctor prescribed. Step therapy helps ensure medically sound and cost-effective drugs are prescribed appropriately. For example, if Drug A and Drug B both treat your medical condition, Passport may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Passport will then cover Drug B.

• Quantity Limits (QL): For certain drugs, Passport limits the amount of the drug that they will cover.

These limits are based on FDA recommended dosing guidelines. For example, Passport provides 9

tablets per prescription for sumatriptan succinate tablets. This may be in addition to a standard

one-month supply.

• Too Early to Refill: If you are given a month supply of a drug, Passport will not cover a refill of the

prescription until 30 days has passed.

PASS02298

http://www.passporthealthplan.com/

What if my drug is not on the PDL?

Remember, not all drugs are listed on the PDL. If your drug is not on the PDL, you have 3 options:

1. Work with your pharmacy or provider to find a preferred drug alternative.

2. You can call Member Services at 1-800-578-0603 and ask for a list of similar drugs that are on Passport’s PDL.

3. If a drug is not covered by Passport or it is not listed on our PDL, your doctor can request approval

for it.

Can the PDL change?

Yes. Passport may add or remove drugs from the PDL during the year. To get updated information

about covered drugs, please visit our website at www.passporthealthplan.com or call Member Services

at 1-800-578-0603.

What are generic drugs?

Passport covers both brand name and generic drugs. A generic drug has the same active ingredient as

the brand name drug. This means they work the same and have the same effect. Generic drugs usually

cost less than brand name drugs and are approved by the Food and Drug Administration (FDA). If a

generic drug is available, you must try the generic drug before the brand name drug will be covered.

http://www.passporthealthplan.com/

Nondiscrimination NoticePassport Health Plan DOES: • Follow federal civil rights laws

• Provide free aids and services to people with disabilities such as:- Qualified sign language interpreters- Written information in other formats

(large print, audio, accessible electronic formats)

• Provide free language services to people whose primary language is not English such as: - Qualified interpreters - Information written in

other languages

Passport Health Plan DOES NOT:• Discriminate on the basis of

race, color, national origin, age, disability, sex, health status, need for health services, religion, sexual orientation, or gender identity.

• Exclude people or treat them differently because of race, color, national origin, age, disability, sex, health status, need for health services, religion, sexual orientation, or gender identity.

If you need any of these services listed above, you may contact:

Passport’s Member Services Team 1-800-578-0603Passport’s Care Connectors Team 1-877-903-0082

If you believe Passport has not provided these services or has discriminated against you, you may file a grievance. You can file a grievance by contacting:

Director of Compliance5100 Commerce Crossings Drive, Louisville, KY 40229(502) 212-6767 | Fax: (502) 585-7985 | [email protected]

You may file in person or by mail, fax or email. If you need help filing a grievance, the Director of Compliance can help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights. You can:

• Visit the Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

• Mail to: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

• Call 1-800-368-1019 (TDD 1-800-537-7697)

If you need a complaint form, please visit http://www.hhs.gov/ocr/office/file/index.html

PASS73862 APP_8/23/2017

PASS73862 APP_8/23/2017

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the counter

1

LIST OF COVERED PRESCRIPTION MEDICATIONS Effective 01/01/2020

Drug Name Drug Tier Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS AMPHETAMINES

amphetamine sulfate tab 5 mg 1 QL (90 tabs / 30 days), PA

amphetamine sulfate tab 10 mg 1 QL (90 tabs / 30 days),

PA

amphetamine-dextroamphetamine cap er 24hr 5 mg

1 QL (30 caps / 30 days)

amphetamine-dextroamphetamine cap er

24hr 10 mg


amphetamine-dextroamphetamine cap er

24hr 15 mg








amphetamine-dextroamphetamine tab 5 mg

1 QL (90 tabs / 30 days)

amphetamine-dextroamphetamine tab 7.5 mg




amphetamine-dextroamphetamine tab

12.5 mg


amphetamine-dextroamphetamine tab 15

mg




amphetamine-dextroamphetamine tab 30

mg


dextroamphetamine sulfate cap er 24hr 5 mg






dextroamphetamine sulfate oral solution 5 mg/5ml

1 QL (450 ml / 30 days); For up to age 5 only

dextroamphetamine sulfate tab 5 mg 1 QL (90 tabs / 30 days)

dextroamphetamine sulfate tab 10 mg 1 QL (90 tabs / 30 days)

DYANAVEL XR SUS 2.5MG/ML 3 QL (240 mL / 30 days),

PA


2


VYVANSE CAP 10MG 3 QL (30 caps / 30 days), PA





VYVANSE CAP 60MG 3 QL (30 caps / 30 days),

PA

VYVANSE CAP 70MG 3 QL (30 caps / 30 days),

PA

VYVANSE CHW 10MG 3 QL (30 chews / 30 days), PA

VYVANSE CHW 20MG 3 QL (30 chews / 30

days), PA





zenzedi tab 2.5mg 1 QL (480 tabs / 30 days),

PA zenzedi tab 5mg 1 QL (90 tabs / 30 days),

PA

zenzedi tab 7.5mg 1 QL (240 tabs / 30 days), PA

zenzedi tab 10mg 1 QL (90 tabs / 30 days),

PA

zenzedi tab 15mg 1 QL (120 tabs / 30 days),

PA

zenzedi tab 20mg 1 QL (90 tabs / 30 days), PA

zenzedi tab 30mg 1 QL (60 tabs / 30 days), PA

ANALEPTICS caffeine & sodium benzoate inj 125-125

mg/ml (500 mg/2ml)

1

caffeine citrate inj 60 mg/3ml (10 mg/ml base equiv)

1

caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)

1


3


ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS atomoxetine hcl cap 10 mg (base equiv) 1 QL (30 caps / 30 days),

PA

atomoxetine hcl cap 18 mg (base equiv) 1 QL (60 caps / 30 days), PA

atomoxetine hcl cap 25 mg (base equiv) 1 QL (90 caps / 30 days),

PA





clonidine hcl tab er 12hr 0.1 mg 1 QL (120 tabs / 30 days)

guanfacine hcl tab er 24hr 1 mg (base equiv)








STRATTERA CAP 10MG 3 QL (30 caps / 30 days),

PA

STRATTERA CAP 18MG 3 QL (60 caps / 30 days), PA


PA


PA




PA

HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS WAKIX TAB 4.45MG 3 QL (60 tabs / 30 days),

PA

WAKIX TAB 17.8MG 3 QL (60 tabs / 30 days),

PA

STIMULANTS - MISC. APTENSIO XR CAP 10MG 3 QL (30 caps / 30 days),

ST

APTENSIO XR CAP 15MG 3 QL (30 caps / 30 days), ST


4







armodafinil tab 50 mg 1 QL (30 tabs / 30 days)


armodafinil tab 200 mg 1 QL (30 tabs / 30 days),

ST


DAYTRANA DIS 10MG/9HR 3 QL (30 ptch / 30 days),

PA DAYTRANA DIS 15MG/9HR 3 QL (30 ptch / 30 days),

PA

DAYTRANA DIS 20MG/9HR 3 QL (30 ptch / 30 days), PA

DAYTRANA DIS 30MG/9HR 3 QL (30 ptch / 30 days),

PA dexmethylphenidate hcl cap er 24 hr 5 mg 1 QL (30 caps / 30 days)

dexmethylphenidate hcl cap er 24 hr 10 mg


dexmethylphenidate hcl cap er 24 hr 15

mg



mg





mg






dexmethylphenidate hcl tab 2.5 mg 1 QL (60 tabs / 30 days)

dexmethylphenidate hcl tab 5 mg 1 QL (60 tabs / 30 days)

dexmethylphenidate hcl tab 10 mg 1 QL (60 tabs / 30 days)

methylphenidate hcl cap er 10 mg (cd) 1 QL (30 caps / 30 days)


methylphenidate hcl cap er 24hr 10 mg

(la)


methylphenidate hcl cap er 24hr 20 mg (la)



5










methylphenidate hcl chew tab 2.5 mg 1 QL (90 ea / 30 days)

methylphenidate hcl chew tab 5 mg 1 QL (90 ea / 30 days)

methylphenidate hcl chew tab 10 mg 1 QL (90 ea / 30 days)

methylphenidate hcl soln 5 mg/5ml 1 QL (1800 ml / 30 days)

methylphenidate hcl soln 10 mg/5ml 1 QL (900 ml / 30 days)

methylphenidate hcl tab 5 mg 1 QL (90 tabs / 30 days)



methylphenidate hcl tab er 10 mg 1 QL (90 tabs / 30 days)

methylphenidate hcl tab er 20 mg 1 QL (90 tabs / 30 days)

methylphenidate hcl tab er 24hr 18 mg 1 QL (60 tabs / 30 days)




methylphenidate hcl tab er osmotic release

(osm) 18 mg


methylphenidate hcl tab er osmotic release (osm) 27 mg






modafinil tab 100 mg 1 QL (30 tabs / 30 days), PA

modafinil tab 200 mg 1 QL (60 tabs / 30 days),

PA

QUILLICHEW CHW 20MG ER 3 QL (30 tabs / 30 days),

PA, ST

QUILLICHEW CHW 30MG ER 3 QL (30 tabs / 30 days), PA, ST

QUILLICHEW CHW 40MG ER 3 QL (30 tabs / 30 days),

PA, ST QUILLIVANT SUS 25MG/5ML 3 QL (36 mL / 30 days),

ST

ALLERGENIC EXTRACTS/BIOLOGICALS MISC ALLERGENIC EXTRACTS

ALTERNARIA SOL EXTRACT 2

AMERICAN ELM SOL 2

AMERICAN INJ SYCAMORE 2


6


AMERICAN SOL COCKROAC 2

ASPERGILLUS SOL FUMIGATU 2

AUREOBASIDIU INJ 1:10 2

BAHIA SOL EXTRACT 2

BAYBERRY WAX SOL MYR EXTR 2

BERMUDA SOL GRASS 2

BLACK WALNUT SOL POLL EXT 2

BOX ELDER INJ EXT 1:20 2

CANDIDA SOL ALBICANS 2

CAT HAIR SOL EXTRACT 2

CLADOSPORIUM SOL 20000PNU 2

ENGLISH SOL PLANTAIN 2

HORSE EPITHE INJ 1:10 2

HORSE EPITHE INJ 1:20 2

JOHNSON SOL GRASS 2

JUNE GRASS SOL POLLEN 2

LAMBS SOL QUARTERS 2

MESQUITE SOL EXTRACT 2

MITE SOL EXTRACT 2

MIXED SOL RAGWEED 2

MUGWORT SOL EXTRACT 2

ODACTRA SUB 3 QL (30 tabs / 30 days), PA

ORCHARD GRAS INJ 100000BA 2

PECAN POLLEN SOL EXTRACT 2

PENICILLIUM INJ 1:20 2

PENICILLIUM INJ NOTATUM 2

PERENNIAL INJ RYE GRAS 2

RED BIRCH SOL EXTRACT 2

RED CEDAR SOL EXTRACT 2

RGH PIGWEED SOL EXTRACT 2

RHIZOPUS INJ 1:10 2

RUSS THISTLE SOL EXTRACT 2

SACCHAROMYCE INJ CEREVISI 2

SAGEBRUSH SOL EXTRACT 2

SHAGBARK HCK SOL EXTRACT 2

TIMOTHY GRAS INJ 10000BAU 2

TIMOTHY SOL GRASS 2

VIRGINIA INJ LIVE OAK 2

WHITE ASH INJ EXTRACT 2

WHITE OAK SOL 2

AMEBICIDES AMEBICIDES

SOLOSEC GRA 2GM 3 QL (1 packet / 30 days), PA


7


AMINOGLYCOSIDES AMINOGLYCOSIDES

amikacin sulfate inj 1 gm/4ml (250 mg/ml) 1

amikacin sulfate inj 500 mg/2ml (250

mg/ml)

1

BETHKIS NEB 300/4ML 3 QL (60 ml / 60 days), PA

gentamicin in saline inj 0.8 mg/ml 1

gentamicin in saline inj 1 mg/ml 1

gentamicin in saline inj 1.2 mg/ml 1 PA

gentamicin in saline inj 1.6 mg/ml 1

gentamicin in saline inj 2 mg/ml 1 PA

gentamicin sulfate inj 10 mg/ml 1

gentamicin sulfate inj 40 mg/ml 1

neomycin sulfate tab 500 mg 1

paromomycin sulfate cap 250 mg 1

streptomycin sulfate for inj 1 gm 1 PA

TOBI PODHALR CAP 28MG 2 QL (240 caps / 30 days)

tobramycin nebu soln 300 mg/5ml 1 QL (280 per 56 days)

tobramycin sulfate for inj 1.2 gm 1

tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) (base equiv)

1

tobramycin sulfate inj 2 gm/50ml (40

mg/ml) (base equiv)

1

tobramycin sulfate inj 10 mg/ml (base

equivalent)

1

tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv)

1

ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES

HUMIRA INJ 10/0.1ML 2 QL (2 syringes / 30

days), PA HUMIRA INJ 10MG/0.2 2 QL (2 syringes / 30

days), PA

HUMIRA INJ 20/0.2ML 2 QL (2 syringes / 30 days), PA

HUMIRA INJ 40/0.4ML 2 QL (2 syringes / 30

days), PA HUMIRA KIT 20MG/0.4 2 QL (2 syringes / 30

days), PA

HUMIRA KIT 40MG/0.8 2 QL (2 syringes / 30 days), PA

HUMIRA PEDIA INJ CROHNS 2 QL (2 syringes per

lifetime), PA

HUMIRA PEDIA INJ CROHNS 2 QL (3 syringes per lifetime), PA


8


HUMIRA PEDIA INJ CROHNS 2 QL (6 syringes per lifetime), PA

HUMIRA PEN INJ 40/0.4ML 2 QL (2 syringes / 30 days), PA

HUMIRA PEN INJ 40MG/0.8 2 QL (2 syringes / 30 days), PA

HUMIRA PEN INJ CD/UC/HS 2 QL (6 syringes per lifetime), PA

HUMIRA PEN INJ PS/UV 2 QL (4 syringes per lifetime), PA

HUMIRA PEN KIT CD/UC/HS 2 QL (3 syringes per

lifetime), PA

HUMIRA PEN KIT PS/UV 2 QL (3 syringes per

lifetime), PA

SIMPONI ARIA SOL 50MG/4ML 3 PA

SIMPONI INJ 50/0.5ML 3 PA

SIMPONI INJ 50/0.5ML 3 QL (0.5 ml / 21 days), PA

SIMPONI INJ 100MG/ML 3 PA

SIMPONI INJ 100MG/ML 3 QL (1 syringe / 21 days), PA

ANTIRHEUMATIC - ENZYME INHIBITORS OLUMIANT TAB 2MG 3 QL (30 tabs / 30 days),

PA RINVOQ TAB 15MG ER 3 QL (30 tabs / 30 days),

PA

XELJANZ TAB 5MG 2 QL (60 tabs / 30 days), PA

XELJANZ TAB 10MG 2 QL (60 tabs / 30 days),

PA XELJANZ XR TAB 11MG 2 QL (30 tabs / 30 days),

PA

ANTIRHEUMATIC ANTIMETABOLITES OTREXUP INJ 10MG 3 QL (4 pens / 21 days),

PA

OTREXUP INJ 15MG 3 QL (4 pens / 21 days),

PA OTREXUP INJ 20MG 3 QL (4 pens / 21 days),

PA

OTREXUP INJ 25MG 3 QL (4 pens / 21 days), PA

RASUVO INJ 7.5MG 2 QL (4 pens / 21 days), PA

RASUVO INJ 10MG 2 QL (4 pens / 21 days),

PA



9


RASUVO INJ 15MG 2 QL (4 pens / 21 days), PA





RASUVO INJ 30MG 2 QL (4 pens / 21 days),

PA

INTERLEUKIN-1 BLOCKERS ARCALYST INJ 220MG 2 QL (4 / 30 days), PA

INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA) KINERET INJ 3 QL (30 / 30 days), PA

INTERLEUKIN-1BETA BLOCKERS ILARIS INJ 150MG/ML 2 QL (2 / 30 days), PA

INTERLEUKIN-6 RECEPTOR INHIBITORS ACTEMRA INJ 162/0.9 3 QL (4 syringes / 21

days), PA

KEVZARA INJ 150/1.14 2 QL (2 syringes / 28 days), PA



KEVZARA INJ 200/1.14 2 QL (2 syringes / 30

days), PA

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) all day pain tab 220mg 1 OTC, QL (100 tabs / 30

days)

CALDOLOR INJ 800/8ML 3 PA

celecoxib cap 50 mg 1 ST




diclofenac potassium tab 50 mg 1

diclofenac sodium tab delayed release 25

mg

1

diclofenac sodium tab delayed release 50 mg

1

diclofenac sodium tab delayed release 75 mg

1

diclofenac sodium tab er 24hr 100 mg 1

diclofenac w/ misoprostol tab delayed

release 50-0.2 mg

1 QL (120 tabs / 30 days),

PA


10


diclofenac w/ misoprostol tab delayed release 75-0.2 mg

1 QL (120 tabs / 30 days), PA

etodolac cap 200 mg 1

etodolac cap 300 mg 1

etodolac tab 400 mg 1

etodolac tab 500 mg 1

etodolac tab er 24hr 400 mg 1



flurbiprofen tab 50 mg 1

flurbiprofen tab 100 mg 1

ibuprofen cap 200 mg 1 OTC, QL (100 caps / 30

days)

ibuprofen dro 50/1.25 1 OTC, QL (30 mL / 30 days)

ibuprofen jr chw 100mg 1 OTC, QL (30 tabs / 30

days) ibuprofen susp 100 mg/5ml 1

ibuprofen tab 200 mg 1 OTC, QL (100 tabs / 30 days)

ibuprofen tab 400 mg 1



INDOCIN SUP 50MG 3 ST

indomethacin cap 25 mg 1

indomethacin cap 50 mg 1

indomethacin cap er 75 mg 1 QL (90 caps / 30 days)

ketoprofen cap er 24hr 200 mg 1

ketorolac tromethamine tab 10 mg 1 QL (5 days per fill)

meclofenamate sodium cap 50 mg 1

meclofenamate sodium cap 100 mg 1

mefenamic acid cap 250 mg 1

meloxicam tab 7.5 mg 1

meloxicam tab 15 mg 1

nabumetone tab 500 mg 1

nabumetone tab 750 mg 1

NAPRELAN TAB 750MG CR 3 ST

naproxen dr tab 375mg 1

naproxen dr tab 500mg 1

naproxen sodium cap 220 mg 1 OTC, QL (100 caps / 30

days)

naproxen sodium tab 275 mg 1

naproxen sodium tab 550 mg 1

naproxen sodium tab er 24hr 375 mg

(base equiv)

1

naproxen susp 125 mg/5ml 1


11


naproxen tab 250 mg 1



oxaprozin tab 600 mg 1

piroxicam cap 10 mg 1

piroxicam cap 20 mg 1

sm ibuprofen tab 100mg jr 1 OTC, QL (100 tabs / 30

days)

SPRIX SPR 15.75MG 3 QL (5 / 30 days), ST

sulindac tab 150 mg 1

sulindac tab 200 mg 1

TIVORBEX CAP 20MG 3 QL (90 caps / 30 days),

PA

TIVORBEX CAP 40MG 3 QL (90 caps / 30 days), PA

tolmetin sodium cap 400 mg 1

tolmetin sodium tab 200 mg 1

tolmetin sodium tab 600 mg 1

VIVLODEX CAP 5MG 3 ST

VIVLODEX CAP 10MG 3 ST

PHOSPHODIESTERASE 4 (PDE4) INHIBITORS OTEZLA TAB 10/20/30 3 QL (1 in lifetime), PA

OTEZLA TAB 30MG 3 QL (60 tabs / 30 days),

PA

PYRIMIDINE SYNTHESIS INHIBITORS leflunomide tab 10 mg 1

leflunomide tab 20 mg 1

SELECTIVE COSTIMULATION MODULATORS ORENCIA CLCK INJ 125MG/ML 3 PA

ORENCIA INJ 50/0.4 3 PA

ORENCIA INJ 87.5/0.7 3 PA

ORENCIA INJ 125MG/ML 3 PA

SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL INJ 25/0.5ML 2 QL (8 syringes / 30

days), PA

ENBREL INJ 25MG 2 QL (8 syringes / 30 days), PA

ENBREL INJ 50MG/ML 2 QL (4 syringes / 30

days), PA

ENBREL MINI INJ 50MG/ML 2 QL (4 syringes / 30

days), PA

ENBREL SRCLK INJ 50MG/ML 2 QL (4 syringes / 30 days), PA

ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS

butalbital-acetaminophen tab 50-325 mg 1


12


butalbital-acetaminophen-caffeine cap 50-300-40 mg


butalbital-acetaminophen-caffeine cap 50-325-40 mg


butalbital-acetaminophen-caffeine tab 50-325-40 mg


butalbital-aspirin-caffeine cap 50-325-40 mg

1

duraxin cap 1

migraine tab formula 1 OTC, QL (100 tabs / 30 days)

ANALGESICS OTHER acetaminophen soln 160 mg/5ml 1 OTC, QL (480 mL / 30

days) acetaminophen suppos 650 mg 1 OTC, QL (30 supp / 30

days)

clonidine hcl inj (for epidural infusion) 100 mcg/ml

1

clonidine hcl inj (for epidural infusion) 500 mcg/ml

1

fever reduce sup 120mg 1 OTC, QL (30 supp / 30 days)

FEVERALL INF SUP 80MG 2 OTC

8 hour pain tab 650mg 1 OTC, QL (100 tabs / 30

days)

inf silapap dro 80/0.8ml 1 OTC

little remed liq 160/5ml 1 OTC, QL (480 mL / 30 days)

pain relief sus 160/5ml 1 OTC, QL (480 mL / 30

days) pain relief tab 325mg 1 OTC, QL (100 tabs / 30

days)

pain relief tab 500mg 1 OTC, QL (100 tabs / 30 days)

sm pain rel cap 500mg 1 OTC, QL (100 caps / 30 days)

SALICYLATES aspirin chw 81mg 1 OTC, QL (100 tabs / 30

days)

aspirin low tab 81mg ec 1 OTC, QL (100 tabs / 30 days)

aspirin suppos 300 mg 1 OTC, QL (12 supp / 30 days)

aspirin suppos 600 mg 1 OTC, QL (12 supp / 30

days)

aspirin tab 325 mg 1 OTC, QL (100 tabs / 30 days)


13


aspirin tab delayed release 325 mg 1 OTC, QL (100 tabs / 30 days)

bayer adv tab 500mg 1 OTC, QL (100 tabs / 30 days)

diflunisal tab 500 mg 1

eq aspirin tab 500mg ec 1 OTC, QL (100 tabs / 30

days)

ANALGESICS - OPIOID OPIOID AGONISTS - Additional safety edits may apply

ABSTRAL SUB 100MCG 3 QL (360 tabs / 30 days), ST

ABSTRAL SUB 200MCG 3 QL (180 tabs / 30 days), ST

ABSTRAL SUB 300MCG 3 QL (120 tabs / 30 days),

ST


ST


ST ABSTRAL SUB 800MCG 3 QL (30 tabs / 30 days),

ST

codeine sulf tab 15mg 1 QL (42 tabs / 30 days)



DEMEROL INJ 25MG/0.5 3 ST

DEMEROL INJ 75MG/1.5 3 ST

DEMEROL INJ 75MG/ML 3 ST

DEMEROL INJ 100/2ML 3 ST

EMBEDA CAP 20-0.8MG 3 QL (60 caps / 30 days), PA


EMBEDA CAP 50-2MG 3 QL (60 caps / 30 days), PA


EMBEDA CAP 80-3.2MG 3 QL (60 caps / 30 days),

PA

EMBEDA CAP 100-4MG 3 QL (60 caps / 30 days), PA

fentanyl citrate lozenge on a handle 200

mcg

1 QL (180 lpop / 30 days)

fentanyl citrate lozenge on a handle 400

mcg


fentanyl citrate lozenge on a handle 600 mcg



14








fentanyl citrate pf soln cartridge 100 mcg/2ml

1

fentanyl citrate preservative free (pf) inj 100 mcg/2ml

1

fentanyl citrate preservative free (pf) inj

250 mcg/5ml

1


500 mcg/10ml

1

fentanyl citrate preservative free (pf) inj 1000 mcg/20ml

1


2500 mcg/50ml

1

fentanyl td patch 72hr 12 mcg/hr 1 QL (10 patches / 30 days), PA


fentanyl td patch 72hr 37.5 mcg/hr 1 QL (10 patches / 30 days), PA


fentanyl td patch 72hr 62.5 mcg/hr 1 QL (10 patches / 30

days), PA fentanyl td patch 72hr 75 mcg/hr 1 QL (10 patches / 30

days), PA

fentanyl td patch 72hr 87.5 mcg/hr 1 QL (10 patches / 30 days), PA

fentanyl td patch 72hr 100 mcg/hr 1 QL (10 patches / 30

days), PA

FENTORA TAB 100MCG 3 QL (360 tabs / 30 days),

ST

hydromorphone hcl inj 1 mg/ml 1 PA

hydromorphone hcl inj 2 mg/ml 1

hydromorphone hcl inj 4 mg/ml 1

hydromorphone hcl liqd 1 mg/ml 1 QL (600 mL / 30 days)

hydromorphone hcl preservative free (pf) inj 10 mg/ml

1

hydromorphone hcl tab 2 mg 1 QL (180 tabs / 30 days)



hydromorphone hcl tab er 24hr deter 8 mg 1 QL (120 tabs / 30 days), PA


15


hydromorphone hcl tab er 24hr deter 12 mg






HYSINGLA ER TAB 20 MG 3 QL (180 tabs / 30 days), PA


HYSINGLA ER TAB 40 MG 3 QL (90 tabs / 30 days),

PA


PA



PA


IONSYS PAD 40MCG/AC 3 PA

KADIAN CAP 200MG ER 3 QL (30 caps / 30 days),

PA LAZANDA SPR 100MCG 3 QL (120 sprays / 30

days), ST

LAZANDA SPR 300MCG 3 QL (120 sprays / 30 days), ST

LAZANDA SPR 400MCG 3 QL (120 sprays / 30 days), ST

levorphanol tartrate tab 2 mg 1

meperidine hcl inj 10 mg/ml 1




meperidine hcl oral soln 50 mg/5ml 1 QL (90 mL / 30 days)

meperidine hcl tab 50 mg 1 QL (18 tabs / 30 days)

meperidine hcl tab 100 mg 1 QL (18 tabs / 30 days)

methadone hcl conc 10 mg/ml 1 QL (60 ml / 30 days),

PA methadone hcl soln 5 mg/5ml 1 QL (720 ml / 30 days),

PA

methadone hcl soln 10 mg/5ml 1 QL (360 ml / 30 days), PA

methadone hcl tab 5 mg 1 QL (240 tabs / 30 days),

PA

methadone hcl tab 10 mg 1 QL (240 tabs / 30 days), PA

methadone hcl tab for oral susp 40 mg 1 QL (60 / 30 days), PA


16


morphine sulfate beads cap er 24hr 30 mg 1 QL (120 caps / 30 days), PA





morphine sulfate beads cap er 24hr 120

mg

1 QL (30 caps / 30 days),

PA

morphine sulfate cap er 24hr 10 mg 1 QL (360 caps / 30

days), PA

morphine sulfate cap er 24hr 20 mg 1 QL (180 caps / 30 days), PA

morphine sulfate cap er 24hr 30 mg 1 QL (120 caps / 30

days), PA

morphine sulfate cap er 24hr 40 mg 1


morphine sulfate cap er 24hr 60 mg 1 QL (60 caps / 30 days),

PA morphine sulfate cap er 24hr 80 mg 1 QL (30 caps / 30 days),

PA


morphine sulfate inj 8 mg/ml 1

morphine sulfate inj 10 mg/ml 1

morphine sulfate inj pf 0.5 mg/ml 1 PA

morphine sulfate inj pf 1 mg/ml 1 PA

morphine sulfate oral soln 10 mg/5ml 1 QL (900 mL / 30 days)

morphine sulfate oral soln 20 mg/5ml 1 QL (600 mL / 30 days)

morphine sulfate oral soln 100 mg/5ml (20

mg/ml)

1 QL (120 mL / 30 days),

PA

morphine sulfate suppos 5 mg 1



morphine sulfate tab 15 mg 1 QL (160 tabs / 30 days)

morphine sulfate tab 30 mg 1 QL (80 tabs / 30 days)

morphine sulfate tab er 15 mg 1 QL (240 tabs / 30 days),

PA

morphine sulfate tab er 30 mg 1 QL (120 tabs / 30 days),

PA morphine sulfate tab er 60 mg 1 QL (60 tabs / 30 days),

PA

morphine sulfate tab er 100 mg 1 QL (30 tabs / 30 days), PA


17


morphine sulfate tab er 200 mg 1 QL (30 tabs / 30 days), PA

NUCYNTA ER TAB 50MG 3 QL (180 tabs / 30 days), PA




NUCYNTA ER TAB 250MG 3 QL (30 tabs / 30 days),

PA

NUCYNTA TAB 50MG 3 QL (120 tabs / 30 days),

ST

NUCYNTA TAB 75MG 3 QL (80 tabs / 30 days), ST

NUCYNTA TAB 100MG 3 QL (60 tabs / 30 days),

ST

OXAYDO TAB 5MG 3 QL (180 tabs / 30 days), PA

OXAYDO TAB 7.5MG 3 QL (180 tabs / 30 days), PA

oxycodone hcl cap 5 mg 1 QL (180 caps / 30 days)

oxycodone hcl conc 100 mg/5ml (20

mg/ml)

1 QL (80 mL / 30 days)

oxycodone hcl soln 5 mg/5ml 1 QL (900 mL / 30 days)

oxycodone hcl tab 5 mg 1 QL (180 tabs / 30 days)





oxycodone hcl tab er 12hr deter 10 mg 1 QL (240 tabs / 30 days),

PA


PA

oxycodone hcl tab er 12hr deter 20 mg 1 QL (120 tabs / 30 days), PA


PA oxycodone hcl tab er 12hr deter 40 mg 1 QL (60 tabs / 30 days),

PA



OXYCONTIN TAB 10MG CR 3 QL (240 tabs / 30 days), PA


18







OXYCONTIN TAB 80MG CR 3 QL (30 tabs / 30 days),

PA

oxymorphone hcl tab 5 mg 1 QL (160 tabs / 30 days)

oxymorphone hcl tab 10 mg 1 QL (80 tabs / 30 days)

oxymorphone hcl tab er 12hr 5 mg 1 QL (60 tabs / 30 days), PA

oxymorphone hcl tab er 12hr 7.5 mg 1 QL (60 tabs / 30 days), PA





oxymorphone hcl tab er 12hr 40 mg 1 QL (60 tabs / 30 days),

PA SUBSYS SPR 100MCG 3 QL (120 sprays / 30

days), ST

SUBSYS SPR 200MCG 3 QL (120 sprays / 30 days), ST

SUBSYS SPR 400MCG 3 QL (120 sprays / 30

days), ST SUBSYS SPR 600MCG 3 QL (120 sprays / 30

days), ST

SUBSYS SPR 800MCG 3 QL (120 sprays / 30 days), ST

SUBSYS SPR 1200MCG 3 QL (60 / 30 days), ST

SUBSYS SPR 1600MCG 3 QL (60 / 30 days), ST

sufentanil citrate inj 50 mcg/ml 1 PA

sufentanil citrate inj 100 mcg/2ml (50 mcg/ml)

1 PA

sufentanil citrate inj 250 mcg/5ml (50 mcg/ml)

1 PA

tramadol hcl tab 50 mg 1 QL (180 tabs / 30 days)

tramadol hcl tab er 24hr 100 mg 1 QL (90 tabs / 30 days),

PA


19


tramadol hcl tab er 24hr 200 mg 1 QL (30 tabs / 30 days), PA

tramadol hcl tab er 24hr 300 mg 1 QL (30 tabs / 30 days), PA

tramadol hcl tab er 24hr biphasic release 100 mg






XTAMPZA ER CAP 9MG 3 QL (240 caps / 30

days), PA

XTAMPZA ER CAP 13.5MG 3 QL (150 caps / 30

days), PA

XTAMPZA ER CAP 18MG 3 QL (120 caps / 30 days), PA

XTAMPZA ER CAP 27MG 3 QL (60 caps / 30 days),

PA

XTAMPZA ER CAP 36MG 3 QL (60 caps / 30 days), PA

ZOHYDRO ER CAP 10MG 3 QL (360 caps / 30 days), PA



ZOHYDRO ER CAP 30MG 3 QL (120 caps / 30

days), PA ZOHYDRO ER CAP 40MG 3 QL (90 caps / 30 days),

PA


OPIOID COMBINATIONS - Additional safety edits may apply acetaminophen w/ codeine soln 120-12

mg/5ml

1 QL (2700 ml / 30 days)

acetaminophen w/ codeine tab 300-15 mg 1 QL (390 tabs / 30 days)



acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg


ascomp/cod cap 30mg 1 QL (180 caps / 30 days)

butalbital-acetaminophen-caff w/ cod cap

50-300-40-30 mg


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


endocet tab 2.5-325 1 QL (360 tabs / 30 days)

hydrocodone-acetaminophen soln 7.5-325

mg/15ml

1 QL (90 mL / 30 days)


20


hydrocodone-acetaminophen tab 5-300 mg 1 QL (240 tabs / 30 days)

hydrocodone-acetaminophen tab 5-325 mg 1 QL (240 tabs / 30 days)

hydrocodone-acetaminophen tab 7.5-300 mg


hydrocodone-acetaminophen tab 7.5-325

mg


hydrocodone-acetaminophen tab 10-300

mg


hydrocodone-acetaminophen tab 10-325 mg


hydrocodone-ibuprofen tab 7.5-200 mg 1 QL (50 tabs / 30 days)

ibudone tab 5-200mg 1

ibudone tab 10-200mg 1 QL (50 tabs / 30 days)

LORTAB ELX 10-300MG 3 QL (2025 mL / 30 days), ST

oxycodone w/ acetaminophen soln 5-325

mg/5ml

1 QL (1600 mL / 30 days)

oxycodone w/ acetaminophen tab 5-325

mg


oxycodone w/ acetaminophen tab 7.5-325 mg


oxycodone w/ acetaminophen tab 10-325

mg


oxycodone-aspirin tab 4.8355-325 mg 1 QL (330 tabs / 30 days)

oxycodone-ibuprofen tab 5-400 mg 1 QL (28 tabs / 30 days)

PRIMLEV TAB 5-300MG 3 QL (320 tabs / 30 days), ST

PRIMLEV TAB 7.5-300 3 QL (210 tabs / 30 days), ST

PRIMLEV TAB 10-300MG 3 QL (160 tabs / 30 days), ST

tramadol-acetaminophen tab 37.5-325 mg 1 QL (40 tabs / 30 days)

verdrocet tab 2.5-325 1 QL (360 tabs / 30 days)

OPIOID PARTIAL AGONISTS - Additional safety edits may apply BELBUCA MIS 75MCG 3 QL (90 films / 30 days),

PA

BELBUCA MIS 150MCG 3 QL (90 films / 30 days),

PA


PA


PA

BELBUCA MIS 600MCG 3 QL (90 films / 30 days), PA


PA


21


BELBUCA MIS 900MCG 3 QL (90 films / 30 days), PA

BUNAVAIL MIS 2.1-0.3 3 QL (60 ea / 30 days), PA

BUNAVAIL MIS 4.2-0.7 3 QL (60 ea / 30 days), PA

BUNAVAIL MIS 6.3-1MG 3 QL (30 ea / 30 days), PA

buprenorphine hcl inj 0.3 mg/ml (base equiv)

1 PA

buprenorphine hcl sl tab 2 mg (base equiv) 1 QL (90 tabs / 30 days)

buprenorphine hcl sl tab 8 mg (base equiv) 1 QL (90 tabs / 30 days)

buprenorphine hcl-naloxone hcl sl film 8-2

mg (base equiv)

1 QL (60 ea / 30 days),

PA

buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv)


buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)


buprenorphine td patch weekly 5 mcg/hr 1 PA

buprenorphine td patch weekly 7.5 mcg/hr 1 PA




butorphanol tartrate inj 1 mg/ml 1

butorphanol tartrate inj 2 mg/ml 1 PA

butorphanol tartrate nasal soln 10 mg/ml 1 QL (30 mL / 30 days)

nalbuphine hcl inj 10 mg/ml 1

nalbuphine hcl inj 20 mg/ml 1

pentazocine w/ naloxone tab 50-0.5 mg 1 QL (120 tabs / 30 days),

ST

SUBLOCADE INJ 100/0.5 3 QL (1 syringe / 30 days), PA

SUBLOCADE INJ 300/1.5 3 QL (1 syringe / 30 days), PA

SUBOXONE MIS 2-0.5MG 3 QL (60 ea / 30 days), PA

SUBOXONE MIS 4-1MG 3 QL (60 ea / 30 days), PA

SUBOXONE MIS 8-2MG 3 QL (60 ea / 30 days),

PA SUBOXONE MIS 12-3MG 3 QL (30 ea / 30 days),

PA

ZUBSOLV SUB 0.7-0.18 3 QL (30 ea / 30 days), PA






22



ANDROGENS-ANABOLIC ANDROGENS

ANDRODERM DIS 2MG/24HR 3 QL (30 patches / 30 days), PA

ANDRODERM DIS 4MG/24HR 3 QL (30 patches / 30 days), PA

danazol cap 50 mg 1

danazol cap 100 mg 1

danazol cap 200 mg 1

METHITEST TAB 10MG 2 PA

NATESTO GEL 5.5MG 3 QL (3 tubes / 30 days), PA

STRIANT MIS 30MG 3 QL (60 buccal systems /

30 days), PA TESTONE CIK KIT 200MG/ML 3 PA

testosterone cypionate im inj in oil 100 mg/ml

1

testosterone cypionate im inj in oil 200

mg/ml

1

testosterone enanthate im inj in oil 200

mg/ml

1

testosterone td gel 10mg/act (2%) 1 QL (1 pump / 30 days), PA

testosterone td gel 12.5 mg/act (1%) 1 QL (150 gm / 30 days),

PA testosterone td gel 20.25 mg/1.25gm

(1.62%)

1 QL (37.5 grams / 30

days), PA

testosterone td gel 20.25 mg/act (1.62%) 1 QL (75 grams / 30

days), PA

testosterone td gel 25 mg/2.5gm (1%) 1 QL (150 gm / 30 days), PA

testosterone td gel 40.5 mg/2.5gm (1.62%)

1 QL (75 grams / 30 days), PA

testosterone td gel 50 mg/5gm (1%) 1 QL (150 gm / 30 days), PA

ANORECTAL AGENTS INTRARECTAL STEROIDS

CORTIFOAM AER 90MG 2

hydrocortisone enema 100 mg/60ml 1

UCERIS AER 2MG/ACT 3 PA

RECTAL COMBINATIONS hydrocortisone acetate w/ pramoxine rectal

cream 1-1% 1

PROCORT CRE 3 PA

PROCTOFOAM AER HC 1% 3 PA


23


sm hemorrhoi oin 1 OTC, QL (60 gm / 30 days)

RECTAL STEROIDS hydrocortisone rectal cream 1% 1

hydrocortisone rectal cream 2.5% 1

VASODILATING AGENTS RECTIV OIN 0.4% 2

ANTACIDS ANTACID COMBINATIONS

antacid plus sus anti-gas 1 OTC, QL (360 ml / 30

days)

antacid plus sus gas rel 1 OTC, QL (360 ml / 30

days)

heartburn sus relief 1 OTC

sm antacid chw ex-str 1 OTC, QL (100 tabs / 30 days)

ANTACIDS - BICARBONATE sodium bicarbonate tab 325 mg 1 OTC, QL (100 tabs / 30

days)

sodium bicarbonate tab 650 mg 1 OTC, QL (100 tabs / 30 days)

ANTACIDS - CALCIUM SALTS antacid chw 500mg 1 OTC

antacid chw 750mg 1 OTC, QL (160 tabs / 30

days) calcium carbonate (antacid) tab 648 mg 1 OTC

childrens chw pepto 1 OTC, QL (32 tabs / 30 days)

ANTHELMINTICS ANTHELMINTICS

albendazole tab 200 mg 1

BENZNIDAZOLE TAB 12.5MG 2 QL (60 tabs / year), PA

BENZNIDAZOLE TAB 100MG 2 QL (60 tabs / year), PA

PIN-X CHW 250MG 2 OTC

PINWORM TAB MEDICINE 1 OTC, QL (24 tabs / 30 days); For 12 years of

age and younger

praziquantel tab 600 mg 1 PA

reeses med sus pinworm 1 OTC, QL (240 mL / 30 days)

ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC.

AEMCOLO TAB 194MG 3 QL (12 tabs / 3 days),

PA baciim inj 50000unt 1


24


metronidazole cap 375 mg 1

metronidazole tab 250 mg 1

metronidazole tab 500 mg 1

NEBUPENT INH 300MG 2

PRIMSOL SOL 50MG/5ML 3 PA

tinidazole tab 250 mg 1

tinidazole tab 500 mg 1

trimethoprim tab 100 mg 1

XIFAXAN TAB 200MG 3 QL (9 tabs / 30 days), PA

XIFAXAN TAB 550MG 3 QL (90 tabs / 30 days),

PA

ANTI-INFECTIVE MISC. - COMBINATIONS sulfamethoxazole-trimethoprim susp

200-40 mg/5ml

1

sulfamethoxazole-trimethoprim tab 400-80 mg

1

sulfamethoxazole-trimethoprim tab

800-160 mg

1

ANTIPROTOZOAL AGENTS ALINIA SUS 100/5ML 2

ALINIA TAB 500MG 2 QL (6 tabs / 365 days)

atovaquone susp 750 mg/5ml 1

CARBAPENEMS ertapenem sodium for inj 1 gm (base

equivalent) 1

imipenem-cilastatin intravenous for soln 250 mg

1

imipenem-cilastatin intravenous for soln 500 mg

1

meropenem iv for soln 1 gm 1 PA

meropenem iv for soln 500 mg 1 PA

GLYCOPEPTIDES vancomycin hcl cap 125 mg (base

equivalent) 1

vancomycin hcl cap 250 mg (base equivalent)

1

vancomycin hcl for iv soln 1 gm (base equivalent)

1

vancomycin hcl for iv soln 5 gm (base

equivalent)

1

vancomycin hcl for iv soln 10 gm (base equivalent)

1

vancomycin hcl for iv soln 500 mg (base

equivalent)

1


25


LEPROSTATICS dapsone tab 25 mg 1

dapsone tab 100 mg 1

LINCOSAMIDES CLIN SINGLE KIT USE 3 PA

clindamycin hcl cap 75 mg 1



clindamycin palmitate hcl for soln 75

mg/5ml (base equiv)

1

clindamycin phosphate inj 9 gm/60ml 1

clindamycin phosphate inj 300 mg/2ml 1



lincomycin hcl inj 300 mg/ml 1

MONOBACTAMS aztreonam for inj 1 gm 1

aztreonam for inj 2 gm 1

CAYSTON INH 75MG 2 QL (84 ml / 60 days)

OXAZOLIDINONES linezolid for susp 100 mg/5ml 1 QL (1650 mL / year)

linezolid tab 600 mg 1 QL (56 tabs / year)

SIVEXTRO TAB 200MG 3 QL (6 tabs / 30 days), PA

PLEUROMUTILINS XENLETA TAB 600MG 2 QL (10 tabs / 5 days),

PA

POLYMYXINS colistimethate sod for inj 150 mg (colistin

base activity)

1

polymyxin b sulfate for inj 500000 unit 1

STREPTOGRAMINS SYNERCID INJ 500MG 3 PA

ANTIANGINAL AGENTS ANTIANGINALS-OTHER

RANEXA TAB 500MG 3 PA

RANEXA TAB 1000MG 3 PA

ranolazine tab er 12hr 500 mg 1 PA

ranolazine tab er 12hr 1000 mg 1 PA

NITRATES DILATRATE SR CAP 40MG 3 PA

ISORDIL TAB 40MG 3 PA

isosorbide dinitrate tab 5 mg 1




26



isosorbide dinitrate tab er 40 mg 1

isosorbide mononitrate tab 10 mg 1

isosorbide mononitrate tab 20 mg 1

isosorbide mononitrate tab er 24hr 30 mg 1



NITRO-BID OIN 2% 3 PA

NITRO-DUR DIS 0.3MG/HR 3 PA

NITRO-DUR DIS 0.8MG/HR 3 PA

nitro-time cap 9mg cr 1

nitroglycerin sl tab 0.3 mg 1



nitroglycerin td patch 24hr 0.1 mg/hr 1




nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)

1

NITROMIST AER 400MCG 3 PA

ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC.

buspirone hcl tab 5 mg 1

buspirone hcl tab 7.5 mg 1




hydroxyzine hcl im soln 25 mg/ml 1

hydroxyzine hcl im soln 50 mg/ml 1

hydroxyzine hcl syrup 10 mg/5ml 1

hydroxyzine hcl tab 10 mg 1



hydroxyzine pamoate cap 25 mg 1



meprobamate tab 200 mg 1 PA

meprobamate tab 400 mg 1 PA

BENZODIAZEPINES ALPRAZOLAM CON 1 MG/ML 3 PA

alprazolam orally disintegrating tab 0.5 mg 1

alprazolam orally disintegrating tab 0.25

mg

1

alprazolam orally disintegrating tab 1 mg 1


27


alprazolam orally disintegrating tab 2 mg 1

alprazolam tab 0.5 mg 1

alprazolam tab 0.5mg xr 1

alprazolam tab 0.25 mg 1

alprazolam tab 1 mg 1

alprazolam tab 1mg xr 1

alprazolam tab 2 mg 1



chlordiazepoxide hcl cap 5 mg 1



clorazepate dipotassium tab 3.75 mg 1

clorazepate dipotassium tab 7.5 mg 1

clorazepate dipotassium tab 15 mg 1

diazepam con 5mg/ml 1

diazepam inj 5 mg/ml 1

DIAZEPAM INJ 10MG/2ML 3 PA

diazepam oral soln 1 mg/ml 1

diazepam tab 2 mg 1

diazepam tab 5 mg 1

diazepam tab 10 mg 1

lorazepam conc 2 mg/ml 1

lorazepam inj 2 mg/ml 1 PA

lorazepam inj 4 mg/ml 1 PA

lorazepam tab 0.5 mg 1

lorazepam tab 1 mg 1

lorazepam tab 2 mg 1

oxazepam cap 10 mg 1



ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A

disopyramide phosphate cap 100 mg 1

disopyramide phosphate cap 150 mg 1

NORPACE CAP 100MG CR 3 PA

NORPACE CAP 150MG CR 3 PA

ANTIARRHYTHMICS TYPE I-C flecainide acetate tab 50 mg 1

flecainide acetate tab 100 mg 1

flecainide acetate tab 150 mg 1

propafenone hcl cap er 12hr 225 mg 1



propafenone hcl tab 150 mg 1


28




ANTIARRHYTHMICS TYPE III amiodarone hcl inj 150 mg/3ml (50

mg/ml)

1 PA

amiodarone hcl inj 450 mg/9ml (50 mg/ml)

1

amiodarone hcl inj 900 mg/18ml (50 mg/ml)

1

amiodarone hcl tab 100 mg 1



dofetilide cap 125 mcg (0.125 mg) 1



ibutilide fumarate inj 1 mg/10ml 1

MULTAQ TAB 400MG 3 PA

ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTI-INFLAMMATORY AGENTS

cromolyn sodium soln nebu 20 mg/2ml 1

ANTIASTHMATIC - MONOCLONAL ANTIBODIES XOLAIR INJ 75/0.5 2 QL (6 syringes / 28

days), PA XOLAIR INJ 150MG/ML 2 QL (6 syringes / 28

days), PA

XOLAIR SOL 150MG 2 QL (6 syringes / 28

days), PA

BRONCHODILATORS - ANTICHOLINERGICS ATROVENT HFA AER 17MCG 2

INCRUSE ELPT INH 62.5MCG 2

ipratropium bromide inhal soln 0.02% 1

LONHALA MAGN SOL 25MCG 3 PA

SPIRIVA AER 1.25MCG 3 QL (1 inhaler / 30 days),

PA; PA applies to 18 years of age and older

SPIRIVA CAP HANDIHLR 3 QL (1 box / 30 days), ST

SPIRIVA SPR 2.5MCG 3 QL (1 inhaler / 30 days), PA; PA applies to 18

years of age and older TUDORZA PRES AER 400/ACT 3 ST

YUPELRI SOL 3 QL (30 vials / 30 days), PA

LEUKOTRIENE MODULATORS montelukast sodium chew tab 4 mg (base

equiv) 1 QL (30 tabs / 30 days)


29


montelukast sodium chew tab 5 mg (base equiv)


montelukast sodium oral granules packet 4 mg (base equiv)

1 QL (1 box / 30 days)

montelukast sodium tab 10 mg (base equiv)


zafirlukast tab 10 mg 1

zafirlukast tab 20 mg 1

zileuton tab er 12hr 600 mg 1 PA

ZYFLO TAB 600MG 3 ST

SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS DALIRESP TAB 250MCG 3 QL (30 tabs / 30 days),

PA

DALIRESP TAB 500MCG 3 PA

STEROID INHALANTS ALVESCO AER 80MCG 3 ST

ALVESCO AER 160MCG 3 ST

ARNUITY ELPT INH 50MCG 2 QL (1 inhaler / 30 days)



ASMANEX 14 AER 220MCG 3 QL (1 inhaler / 30 days),

PA

ASMANEX 30 AER 110MCG 3 QL (1 inhaler / 30 days), PA

ASMANEX HFA AER 100 MCG 3 QL (1 inhaler / 30 days),

PA

ASMANEX HFA AER 200 MCG 3 QL (1 inhaler / 30 days), PA

budesonide inhalation susp 0.5 mg/2ml 1 QL (60 ml / 30 days)

budesonide inhalation susp 0.25 mg/2ml 1 QL (60 ml / 30 days)

budesonide inhalation susp 1 mg/2ml 1 QL (60 ml / 30 days)

FLOVENT DISK AER 50MCG 3 ST



FLOVENT HFA AER 44MCG 3 QL (2 inhalers / 30

days), ST

FLOVENT HFA AER 110MCG 3 QL (2 inhalers / 30

days), ST

FLOVENT HFA AER 220MCG 3 QL (2 inhalers / 30 days), ST

PULMICORT INH 90MCG 3 ST

PULMICORT INH 180MCG 3 ST

QVAR REDIHA AER 80MCG 2 QL (1 inhaler / 30 days)

QVAR REDIHAL AER 40MCG 2 QL (1 inhaler / 30 days)

SYMPATHOMIMETICS ADVAIR HFA AER 45/21 3 PA


30


ADVAIR HFA AER 115/21 3 PA

ADVAIR HFA AER 230/21 3 PA

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

1 QL (2 inhalers / 30 days); (generic Proair

HFA)


1 QL (2 inhalers / 30 days); (generic Proventil HFA)


1 QL (2 inhalers / 30 days); (generic Ventolin HFA)

albuterol sulfate soln nebu 0.5% (5 mg/ml) 1

albuterol sulfate soln nebu 0.63 mg/3ml

(base equiv)

1

albuterol sulfate soln nebu 0.083% (2.5

mg/3ml)

1

albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)

1

albuterol sulfate syrup 2 mg/5ml 1

albuterol sulfate tab 2 mg 1

albuterol sulfate tab 4 mg 1

albuterol sulfate tab er 12hr 4 mg 1

albuterol sulfate tab er 12hr 8 mg 1

ANORO ELLIPT AER 62.5-25 3 QL (1 inhaler / 30 days), ST

ARCAPTA CAP 75MCG 3 ST

BEVESPI AER 9-4.8MCG 3 ST

BREO ELLIPTA INH 100-25 2 Covered for 18 years of age and older

BREO ELLIPTA INH 200-25 2 Covered for 18 years of

age and older

BROVANA NEB 15MCG 3 ST

COMBIVENT AER 20-100 2

DULERA AER 100-5MCG 3 ST

DULERA AER 200-5MCG 3 ST

fluticasone-salmeterol aer powder ba

55-14 mcg/act

1

fluticasone-salmeterol aer powder ba 100-50 mcg/dose

1 PA; PA applies to 18 years of age and older

fluticasone-salmeterol aer powder ba

113-14 mcg/act

1

fluticasone-salmeterol aer powder ba 232-14 mcg/act

1






31


ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml

1

isoproterenol hcl inj 0.2 mg/ml 1 PA

levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)

1

levalbuterol hcl soln nebu 0.63 mg/3ml

(base equiv)

1

levalbuterol hcl soln nebu 1.25 mg/3ml

(base equiv)

1

levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv)

1

levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv)

1

metaproterenol sulfate syrup 10 mg/5ml 1

metaproterenol sulfate tab 10 mg 1

metaproterenol sulfate tab 20 mg 1

PERFOROMIST NEB 20MCG 2

PROAIR RESPI AER 3 PA

SEREVENT DIS AER 50MCG 3 ST

STIOLTO AER 2.5-2.5 2 QL (1 inhaler / 30 days)

STRIVERDI AER 2.5MCG 2 QL (1 / 30 days)

SYMBICORT AER 80-4.5 3 ST

SYMBICORT AER 160-4.5 3 ST

terbutaline sulfate inj 1 mg/ml 1

terbutaline sulfate tab 2.5 mg 1

terbutaline sulfate tab 5 mg 1

TRELEGY AER ELLIPTA 2 QL (1 inhaler / 30 days)

UTIBRON CAP NEOHALER 3 ST

wixela inhub aer 100/50 1



XANTHINES aminophylline inj 25 mg/ml 1 PA

ELIXOPHYLLIN ELX 80/15ML 3 PA

THEO-24 CAP 100MG CR 3 ST



THEO-24 CAP 400MG ER 3 ST

theophylline soln 80 mg/15ml 1

theophylline tab er 12hr 200 mg 1






32


ANTICOAGULANTS COUMARIN ANTICOAGULANTS

warfarin sodium tab 1 mg 1


warfarin sodium tab 2.5 mg 1





warfarin sodium tab 7.5 mg 1


DIRECT FACTOR XA INHIBITORS BEVYXXA CAP 40MG 3 QL (86 tabs / 365 days),

PA

BEVYXXA CAP 80MG 3 QL (86 tabs / 365 days), PA

ELIQUIS TAB 2.5MG 2 QL (60 tabs / 30 days)

ELIQUIS TAB 5MG 2 QL (74 tabs / 30 days)

SAVAYSA TAB 15MG 3 QL (30 tabs / 30 days),

ST SAVAYSA TAB 30MG 3 QL (30 tabs / 30 days),

ST

SAVAYSA TAB 60MG 3 QL (30 tabs / 30 days), ST

XARELTO STAR TAB 15/20MG 3 QL (1 kit / year), PA

XARELTO TAB 2.5MG 3 QL (60 tabs / 30 days),

PA

XARELTO TAB 10MG 3 QL (30 tabs / 30 days), PA

XARELTO TAB 15MG 3 QL (42 tabs / 30 days),

PA XARELTO TAB 20MG 3 QL (30 tabs / 30 days),

PA

HEPARINS AND HEPARINOID-LIKE AGENTS enoxaparin sodium inj 30 mg/0.3ml 1 QL (60 syringes / 30

days)

enoxaparin sodium inj 40 mg/0.4ml 1 QL (60 syringes / 30

days) enoxaparin sodium inj 60 mg/0.6ml 1 QL (60 syringes / 30

days)

enoxaparin sodium inj 80 mg/0.8ml 1 QL (60 syringes / 30 days)

enoxaparin sodium inj 100 mg/ml 1 QL (60 syringes / 30 days)

enoxaparin sodium inj 120 mg/0.8ml 1 QL (60 syringes / 30 days)


33


enoxaparin sodium inj 150 mg/ml 1 QL (60 syringes / 30 days)

enoxaparin sodium inj 300 mg/3ml 1 QL (60 syringes / 30 days)

fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml

1 QL (60 syringes / 30 days), PA

fondaparinux sodium subcutaneous inj 5 mg/0.4ml


fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml


fondaparinux sodium subcutaneous inj 10

mg/0.8ml

1 QL (60 syringes / 30

days), PA

FRAGMIN INJ 2500/0.2 3 QL (60 vials / 365

days), PA

FRAGMIN INJ 5000/0.2 3 QL (60 vials / 365 days), PA

FRAGMIN INJ 7500/0.3 3 QL (60 vials / 365

days), PA

FRAGMIN INJ 10000/ML 3 QL (60 vials / 365 days), PA

FRAGMIN INJ 12500UNT 3 QL (60 vials / 365 days), PA



FRAGMIN INJ 95000UNT 3 QL (60 vials / 365

days), PA heparin sodium (porcine) inj 1000 unit/ml 1

heparin sodium (porcine) inj 5000 unit/ml 1



heparin sodium (porcine) pf inj 5000

unit/0.5ml

1

IN VITRO/LOCK ANTICOAGULANTS ACD FORMULA SOL A 2

ANTICOAG CPD SOL 2

ANTICOAGULNT SOL SOD CITR 3 PA

TRICITRASOL CON 2

THROMBIN INHIBITORS IPRIVASK INJ 15MG 3 QL (10 days per 365

days), PA PRADAXA CAP 75MG 3 QL (60 caps / 30 days),

PA

PRADAXA CAP 110MG 3 QL (120 caps / 365 days), PA


34


PRADAXA CAP 150MG 3 QL (60 caps / 30 days), PA

ANTICONVULSANTS AMPA GLUTAMATE RECEPTOR ANTAGONISTS

FYCOMPA TAB 2MG 3 QL (30 tabs / 30 days),

ST


ST FYCOMPA TAB 6MG 3 QL (30 tabs / 30 days),

ST

FYCOMPA TAB 8MG 3 QL (30 tabs / 30 days), ST


ST


ST

ANTICONVULSANTS - BENZODIAZEPINES clobazam suspension 2.5 mg/ml 1 QL (960 mL / 48 days),

PA

clobazam tab 10 mg 1 QL (60 tabs / 30 days),

PA

clobazam tab 20 mg 1 QL (60 tabs / 30 days), PA

clonazepam orally disintegrating tab 0.5 mg

1


1


1

clonazepam orally disintegrating tab 1 mg 1

clonazepam orally disintegrating tab 2 mg 1

clonazepam tab 0.5 mg 1

clonazepam tab 1 mg 1

clonazepam tab 2 mg 1

ANTICONVULSANTS - MISC. APTIOM TAB 200MG 3 QL (30 tabs / 30 days),

ST

APTIOM TAB 400MG 3 QL (30 tabs / 30 days), ST

APTIOM TAB 600MG 3 QL (60 tabs / 30 days),

ST

APTIOM TAB 800MG 3 QL (60 tabs / 30 days), ST

BANZEL SUS 40MG/ML 3 PA

BANZEL TAB 200MG 3 PA

BANZEL TAB 400MG 3 PA

BRIVIACT SOL 10MG/ML 3 QL (2 mL / 30 days), PA


35


BRIVIACT TAB 10MG 3 QL (60 tabs in lifetime), PA

BRIVIACT TAB 25MG 3 QL (60 tabs / 30 days), PA




carbamazepine cap er 12hr 100 mg 1



carbamazepine chew tab 100 mg 1

carbamazepine susp 100 mg/5ml 1

carbamazepine tab 200 mg 1

carbamazepine tab er 12hr 100 mg 1



DIACOMIT CAP 250MG 2 QL (360 caps / 30 days), PA

DIACOMIT CAP 500MG 2 QL (180 caps / 30

days), PA

EPIDIOLEX SOL 100MG/ML 2 PA

gabapentin cap 100 mg 1 QL (1080 caps / 30 days)



gabapentin oral soln 250 mg/5ml 1

gabapentin tab 600 mg 1 QL (180 tabs / 30 days)

gabapentin tab 800 mg 1 QL (120 tabs / 30 days)

LAMICTAL ODT KIT 3 QL (1 box in lifetime),

PA, ST LAMICTAL XR KIT 3 QL (1 box in lifetime),

ST

lamotrigine orally disintegrating tab 25 mg 1 QL (90 tabs / 30 days)

lamotrigine orally disintegrating tab 50 mg 1 QL (90 tabs / 30 days)

lamotrigine orally disintegrating tab 100 mg


lamotrigine orally disintegrating tab 200 mg


lamotrigine tab 25 mg 1

lamotrigine tab 25 mg (35) starter kit 1 QL (1 kit in lifetime), PA

lamotrigine tab 25 mg (42) & 100 mg (7)

starter kit

1 QL (1 kit in lifetime), PA

lamotrigine tab 25 mg (84) & 100 mg (14)

starter kit

1 QL (1 kit in lifetime), PA


36





lamotrigine tab chewable dispersible 5 mg 1

lamotrigine tab chewable dispersible 25 mg 1

lamotrigine tab er 24hr 25 mg 1 QL (90 tabs / 30 days)




lamotrigine tab er 24hr 250 mg 1

lamotrigine tab er 24hr 300 mg 1

levetiracetam inj 500 mg/5ml (100 mg/ml) 1

levetiracetam oral soln 100 mg/ml 1

levetiracetam tab 250 mg 1




levetiracetam tab er 24hr 500 mg 1 QL (180 tabs / 30 days)

levetiracetam tab er 24hr 750 mg 1 QL (120 tabs / 30 days)

oxcarbazepine susp 300 mg/5ml (60 mg/ml)

1

oxcarbazepine tab 150 mg 1



OXTELLAR XR TAB 150MG 3 ST



pregabalin cap 25 mg 1 QL (90 caps / 30 days),

PA

pregabalin cap 50 mg 1 QL (90 caps / 30 days), PA







pregabalin soln 20 mg/ml 1 QL (900 ml / 30 days),

PA primidone tab 50 mg 1

primidone tab 250 mg 1


37


topiramate sprinkle cap 15 mg 1 QL (180 caps / 30 days)

topiramate sprinkle cap 25 mg 1 QL (180 caps / 30 days)

topiramate tab 25 mg 1




TROKENDI XR CAP 25MG 3 QL (30 caps / 30 days),

PA

TROKENDI XR CAP 50MG 3 QL (30 caps / 30 days), PA

TROKENDI XR CAP 100MG 3 QL (30 caps / 30 days),

PA TROKENDI XR CAP 200MG 3 QL (60 caps / 30 days),

PA

VIMPAT SOL 10MG/ML 3 PA

VIMPAT TAB 50MG 3 PA




zonisamide cap 25 mg 1



CARBAMATES felbamate susp 600 mg/5ml 1

felbamate tab 400 mg 1

felbamate tab 600 mg 1

GABA MODULATORS GABITRIL TAB 12MG 2 PA

GABITRIL TAB 16MG 2 PA

SABRIL POW 500MG 3 QL (180 packets / 30

days), PA

tiagabine hcl tab 2 mg 1




vigabatrin powd pack 500 mg 1 QL (180 packets / 30 days), PA

vigabatrin tab 500 mg 1 QL (180 tabs / 30 days),

PA

HYDANTOINS DILANTIN CAP 30MG 3 PA

fosphenytoin sodium inj 100 mg/2ml

(phenytoin equiv)

1

fosphenytoin sodium inj 500 mg/10ml

(phenytoin equiv)

1

PEGANONE TAB 250MG 3 PA


38


phenytoin chew tab 50 mg 1

phenytoin sodium extended cap 100 mg 1



phenytoin sodium inj 50 mg/ml 1

phenytoin susp 125 mg/5ml 1

SUCCINIMIDES CELONTIN CAP 300MG 3 PA

ethosuximide cap 250 mg 1

ethosuximide soln 250 mg/5ml 1

VALPROIC ACID divalproex sodium cap delayed release

sprinkle 125 mg 1

divalproex sodium tab delayed release 125

mg

1

divalproex sodium tab delayed release 250

mg

1

divalproex sodium tab delayed release 500 mg

1

divalproex sodium tab er 24 hr 250 mg 1

divalproex sodium tab er 24 hr 500 mg 1

valproate sodium inj 100 mg/ml 1

valproate sodium oral soln 250 mg/5ml (base equiv)

1

valproic acid cap 250 mg 1

ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)

mirtazapine orally disintegrating tab 15 mg 1



mirtazapine tab 7.5 mg 1

mirtazapine tab 15 mg 1



ANTIDEPRESSANTS - MISC. APLENZIN TAB 174MG 3 ST

APLENZIN TAB 348MG 3 ST

APLENZIN TAB 522MG 3 ST

bupropion hcl tab 75 mg 1

bupropion hcl tab 100 mg 1

bupropion hcl tab er 12hr 100 mg 1






39


bupropion hcl tab er 24hr 450 mg 1 ST

maprotiline hcl tab 25 mg 1



MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM DIS 6MG/24HR 3 QL (30 ea / 30 days), ST

EMSAM DIS 9MG/24HR 3 QL (30 ea / 30 days), ST

EMSAM DIS 12MG/24H 3 QL (30 ea / 30 days), ST

MARPLAN TAB 10MG 3 ST

phenelzine sulfate tab 15 mg 1

tranylcypromine sulfate tab 10 mg 1

N-METHYL-D-ASPARTIC ACID (NMDA) RECEPTOR ANTAGONISTS SPRAVATO SOL 56MG DOS 3 QL (12 dose kits /

month), PA

SPRAVATO SOL 84MG DOS 3 QL (12 dose kits / month), PA

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram hydrobromide oral soln 10

mg/5ml 1

citalopram hydrobromide tab 10 mg (base equiv)






escitalopram oxalate soln 5 mg/5ml (base

equiv)

1 QL (600 mL / 30 days)

escitalopram oxalate tab 5 mg (base

equiv)


escitalopram oxalate tab 10 mg (base equiv)


escitalopram oxalate tab 20 mg (base

equiv)


fluoxetine hcl cap 10 mg 1



fluoxetine hcl cap delayed release 90 mg 1 QL (4 caps / 21 days)

fluoxetine hcl solution 20 mg/5ml 1

fluoxetine hcl tab 10 mg 1 PA

fluoxetine hcl tab 20 mg 1 PA

fluvoxamine maleate cap er 24hr 100 mg 1

fluvoxamine maleate cap er 24hr 150 mg 1

fluvoxamine maleate tab 25 mg 1



paroxetine hcl tab 10 mg 1


40





paroxetine hcl tab er 24hr 12.5 mg 1 QL (30 tabs / 30 days)

paroxetine hcl tab er 24hr 25 mg 1 QL (60 tabs / 30 days)

paroxetine hcl tab er 24hr 37.5 mg 1 QL (60 tabs / 30 days)

PAXIL SUS 10MG/5ML 3 ST

PEXEVA TAB 10MG 3 QL (30 tabs / 30 days), ST




sertraline hcl oral concentrate for solution

20 mg/ml

1

sertraline hcl tab 25 mg 1



SEROTONIN MODULATORS nefazodone hcl tab 50 mg 1 PA

nefazodone hcl tab 100 mg 1 PA




trazodone hcl tab 50 mg 1




TRINTELLIX TAB 5MG 3 QL (30 tabs / 30 days), ST

TRINTELLIX TAB 10MG 3 QL (30 tabs / 30 days),

ST TRINTELLIX TAB 20MG 3 QL (30 tabs / 30 days),

ST

VIIBRYD KIT STARTER 3 QL (1 box in lifetime), ST

VIIBRYD TAB 10MG 3 QL (30 tabs / 30 days),

ST VIIBRYD TAB 20MG 3 QL (30 tabs / 30 days),

ST

VIIBRYD TAB 40MG 3 QL (30 tabs / 30 days), ST

SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) DESVENLAFAX TAB 50MG ER 3 QL (30 tabs / 30 days),

ST


41


DESVENLAFAX TAB 100MG ER 3 QL (30 tabs / 30 days), ST

desvenlafaxine succinate tab er 24hr 25 mg (base equiv)

1 QL (30 tabs / 30 days), ST





desvenlafaxine tab er 24hr 50 mg 1 QL (30 tabs / 30 days), ST

desvenlafaxine tab er 24hr 100 mg 1 QL (30 tabs / 30 days),

ST

duloxetine hcl enteric coated pellets cap 20

mg (base eq)


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


duloxetine hcl enteric coated pellets cap 40

mg (base eq)


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


FETZIMA CAP 20MG 3 QL (30 caps / 30 days), PA



FETZIMA CAP 120MG 3 QL (30 caps / 30 days),

PA FETZIMA CAP TITRATIO 3 QL (1 kit in lifetime), PA

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


venlafaxine hcl cap er 24hr 75 mg (base equivalent)


venlafaxine hcl cap er 24hr 150 mg (base

equivalent)


venlafaxine hcl tab 25 mg (base

equivalent)


venlafaxine hcl tab 37.5 mg (base

equivalent)

1 QL (180 tabs / 30 days),

PA venlafaxine hcl tab 50 mg (base

equivalent)


venlafaxine hcl tab 75 mg (base equivalent)


venlafaxine hcl tab 100 mg (base

equivalent)


venlafaxine hcl tab er 24hr 37.5 mg (base

equivalent)



42


venlafaxine hcl tab er 24hr 75 mg (base equivalent)






TRICYCLIC AGENTS amitriptyline hcl tab 10 mg 1

amitriptyline hcl tab 25 mg 1





amoxapine tab 25 mg 1




clomipramine hcl cap 25 mg 1



desipramine hcl tab 10 mg 1






doxepin hcl cap 10 mg 1






doxepin hcl conc 10 mg/ml 1

imipramine hcl tab 10 mg 1



imipramine pamoate cap 75 mg 1




nortriptyline hcl cap 10 mg 1




nortriptyline hcl soln 10 mg/5ml 1

protriptyline hcl tab 5 mg 1


43


protriptyline hcl tab 10 mg 1

SURMONTIL CAP 25MG 3

SURMONTIL CAP 50MG 3

trimipramine maleate cap 25 mg 1



ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS

acarbose tab 25 mg 1



GLYSET TAB 25MG 1

GLYSET TAB 50MG 1

GLYSET TAB 100MG 1

ANTIDIABETIC - AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG 2 QL (4 pens / 30 days)

SYMLNPEN 120 INJ 1000MCG 2 QL (4 pens / 30 days)

ANTIDIABETIC COMBINATIONS ACTOPLUS MET TAB XR 2

alogliptin-metformin hcl tab 12.5-500 mg 1 ST

alogliptin-metformin hcl tab 12.5-1000 mg 1 ST

alogliptin-pioglitazone tab 12.5-15 mg 1 ST



alogliptin-pioglitazone tab 25-15 mg 1 ST



glipizide-metformin hcl tab 2.5-250 mg 1

glipizide-metformin hcl tab 2.5-500 mg 1

glipizide-metformin hcl tab 5-500 mg 1

glyburide-metformin tab 1.25-250 mg 1

glyburide-metformin tab 2.5-500 mg 1

glyburide-metformin tab 5-500 mg 1

GLYXAMBI TAB 10-5 MG 3 QL (30 tabs / 30 days),

ST

GLYXAMBI TAB 25-5 MG 3 QL (30 tabs / 30 days), ST

INVOKAMET TAB 50-500MG 3 QL (60 tabs / 30 days),

PA

INVOKAMET TAB 50-1000 3 QL (60 tabs / 30 days), PA

INVOKAMET TAB 150-500 3 QL (60 tabs / 30 days),

PA

INVOKAMET TAB 150-1000 3 QL (60 tabs / 30 days), PA


44


INVOKAMET XR TAB 50-500MG 3 QL (60 tabs / 30 days), PA

INVOKAMET XR TAB 50-1000 3 QL (60 tabs / 30 days), PA



JANUMET TAB 50-500MG 3 PA

JANUMET TAB 50-1000 3 PA

JANUMET XR TAB 50-500MG 3 PA

JANUMET XR TAB 50-1000 3 PA

JANUMET XR TAB 100-1000 3 PA

JENTADUETO TAB 2.5-500 3 PA



JENTADUETO TAB XR 3 QL (30 tabs / 30 days), PA

KOMBIGLYZ XR TAB 2.5-1000 3 PA

KOMBIGLYZ XR TAB 5-500MG 3 PA

KOMBIGLYZ XR TAB 5-1000MG 3 PA

pioglitazone hcl-glimepiride tab 30-2 mg 1

pioglitazone hcl-glimepiride tab 30-4 mg 1

pioglitazone hcl-metformin hcl tab 15-500 mg

1

pioglitazone hcl-metformin hcl tab 15-850 mg

1

repaglinide-metformin hcl tab 1-500 mg 1

repaglinide-metformin hcl tab 2-500 mg 1

SEGLUROMET TAB 2.5-500 2 QL (30 tabs / 30 days),

ST

SEGLUROMET TAB 2.5-1000 2 QL (30 tabs / 30 days),

ST SEGLUROMET TAB 7.5-500 2 QL (30 tabs / 30 days),

ST

SEGLUROMET TAB 7.5-1000 2 QL (30 tabs / 30 days), ST

SOLIQUA INJ 100/33 2 QL (30 ml / 30 days), PA

STEGLUJAN TAB 5-100MG 3 QL (30 tabs / 30 days), ST

STEGLUJAN TAB 15-100MG 3 QL (30 tabs / 30 days), ST

SYNJARDY TAB 3 PA

SYNJARDY TAB 5-500MG 3 PA

SYNJARDY TAB 5-1000MG 3 PA

SYNJARDY TAB 12.5-500 3 PA


45


SYNJARDY XR TAB 3 PA

SYNJARDY XR TAB 5-1000MG 3 PA

SYNJARDY XR TAB 10-1000 3 PA

SYNJARDY XR TAB 25-1000 3 PA

XIGDUO XR TAB 5-500MG 3 PA



XIGDUO XR TAB 10-1000 3 PA

XULTOPHY INJ 100/3.6 3 QL (15 pens / 28 days), PA

BIGUANIDES metformin hcl tab 500 mg 1

metformin hcl tab 850 mg 1

metformin hcl tab 1000 mg 1

metformin hcl tab er 24hr 500 mg 1

metformin hcl tab er 24hr 750 mg 1

metformin hcl tab er 24hr modified release

500 mg

3 ST

metformin hcl tab er 24hr modified release

1000 mg

3 ST

metformin hcl tab er 24hr osmotic 500 mg 3 ST

metformin hcl tab er 24hr osmotic 1000 mg

1

RIOMET SOL 2 PA

DIABETIC OTHER GLUCAGEN INJ HYPOKIT 2 QL (2 boxes / 30 days)

GLUCAGON KIT 1MG 2 QL (2 boxes / 30 days)

glucose drnk liq 15/59ml 1 OTC, QL (118 ml / 30 days)

glucose gel 40% 1 OTC, QL (100 gm / 30

days)

KORLYM TAB 300MG 3

PROGLYCEM SUS 50MG/ML 2

SM GLUCOSE CHW SOUR APP 2 OTC, QL (100 tabs / 30 days)

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS alogliptin benzoate tab 6.25 mg (base

equiv)

1 QL (30 tabs / 30 days),

ST

alogliptin benzoate tab 12.5 mg (base

equiv)


ST

alogliptin benzoate tab 25 mg (base equiv) 1 QL (30 tabs / 30 days), ST

JANUVIA TAB 25MG 3 PA



ONGLYZA TAB 2.5MG 3 PA


46


ONGLYZA TAB 5MG 3 PA

TRADJENTA TAB 5MG 3 PA

INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) ADLYXIN INJ 10/20MCG 3 QL (1 per lifetime), PA

ADLYXIN INJ 20MCG 3 QL (2 pens / 30), PA

BYDUREON BC INJ 2/0.85ML 3 QL (4 syringes / 21 days), PA

BYDUREON INJ 2MG 3 QL (4 syringes / 21 days), PA

BYDUREON PEN INJ 2MG 3 QL (4 syringes / 21 days), PA

BYETTA INJ 5MCG 3 QL (1 pen / 30 days), PA

BYETTA INJ 10MCG 3 QL (1 pen / 30 days), PA

OZEMPIC INJ 2/1.5ML 2 QL (4 pens / 28 days),

ST

TANZEUM INJ 30MG 2 QL (4.5 ml / 30 days), ST

TANZEUM INJ 50MG 2 QL (4.5 ml / 30 days),

ST TRULICITY INJ 0.75/0.5 2 QL (6 pens / 30 days),

ST

TRULICITY INJ 1.5/0.5 2 QL (6 pens / 30 days), ST

VICTOZA INJ 18MG/3ML 2 QL (3 pens / 30 days), ST

INSULIN ADMELOG INJ 100U/ML 2 QL (50 mL / 30 days)

ADMELOG SOLO INJ 100U/ML 2 QL (45 mL / 30 days)

AFREZZA POW 4-8-12 3 QL (1 box (90) / 30 days), ST; (4/8/12 UNIT

pak)

AFREZZA POW 4UNIT 3 QL (1 box (90) / 30

days), ST AFREZZA POW 8 UNIT 3 QL (1 box (90) / 30

days), ST

AFREZZA POW 8-12UNIT 3 QL (1 box (90) / 30 days), ST

AFREZZA POW 12 UNIT 3 QL (1 box (90) / 30 days), ST

APIDRA INJ SOLOSTAR 3 ST

APIDRA INJ U-100 3 ST

BASAGLAR INJ 100UNIT 2 QL (45 ml / 30 days)

HUMALOG INJ 100/ML 3 QL (50 ml / 30 days),

PA HUMALOG KWIK INJ 100/ML 3 QL (45 ml / 30 days),

PA


47


HUMALOG KWIK INJ 200/ML 3 QL (24 ml / 30 days), PA

HUMALOG MIX INJ 50/50 2 QL (50 ml / 30 days)

HUMALOG MIX INJ 50/50KWP 2 QL (45 ml / 30 days)

HUMALOG MIX INJ 75/25KWP 2 QL (45 ml / 30 days)

HUMALOG MIX SUS 75/25 2 QL (50 ml / 30 days)

HUMULIN INJ 70/30 2 OTC, QL (50 ml / 30

days)

HUMULIN INJ 70/30KWP 2 OTC, QL (45 ml / 30 days)

HUMULIN N INJ U-100 2 OTC, QL (50 ml / 30

days)

HUMULIN N INJ U-100KWP 2 OTC, QL (45 ml / 30

days)

HUMULIN R INJ U-100 2 OTC, QL (50 ml / 30 days)

HUMULIN R INJ U-500 2 QL (1 vial / 30 days)

INSULIN LISP INJ 100/ML 3 QL (50 mL / 30 days)

INSULIN LISP INJ 100/ML 3 QL (45 mL / 30 days),

PA

LANTUS INJ 100/ML 3 QL (50 ml / 30 days), ST

LANTUS SOLOS INJ 100/ML 3 QL (45 ml / 30 days),

ST

LEVEMIR INJ 3 QL (50 ml / 30 days), ST

LEVEMIR INJ FLEXTOUC 3 QL (45 ml / 30 days),

ST NOVOLIN INJ 70/30 3 OTC, QL (50 ml / 30

days), ST

NOVOLIN N INJ U-100 3 OTC, QL (50 ml / 30 days), ST

NOVOLIN R INJ U-100 3 OTC, QL (50 ml / 30

days), ST

NOVOLOG INJ 100/ML 3 QL (50 ml / 30 days), ST

NOVOLOG INJ FLEXPEN 3 QL (45 ml / 30 days), ST

NOVOLOG INJ PENFILL 3 QL (45 ml / 30 days), ST

NOVOLOG MIX INJ 70/30 3 QL (50 ml / 30 days), ST

NOVOLOG MIX INJ FLEXPEN 3 QL (45 ml / 30 days), ST

TOUJEO SOLO INJ 300IU/ML 3 QL (9 ml / 30 days), ST

TRESIBA FLEX INJ 100UNIT 2 QL (45 ml / 30 days)

TRESIBA FLEX INJ 200UNIT 2 QL (27 ml / 30 days)

TRESIBA INJ 100UNIT 2 QL (50 mL / 30 days)


48


INSULIN SENSITIZING AGENTS AVANDIA TAB 2MG 3 PA

AVANDIA TAB 4MG 3 PA

pioglitazone hcl tab 15 mg (base equiv) 1



MEGLITINIDE ANALOGUES nateglinide tab 60 mg 1

nateglinide tab 120 mg 1

repaglinide tab 0.5 mg 1

repaglinide tab 1 mg 1

repaglinide tab 2 mg 1

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA TAB 5MG 3 QL (30 tabs / 30 days),

PA

FARXIGA TAB 10MG 3 QL (30 tabs / 30 days), PA

INVOKANA TAB 100MG 3 QL (60 tabs / 30 days), PA

INVOKANA TAB 300MG 3 QL (30 tabs / 30 days), PA

JARDIANCE TAB 10MG 2 QL (60 tabs / 30 days), PA; Covered for

cardiovascular indication JARDIANCE TAB 25MG 2 QL (30 tabs / 30 days),

PA; Covered for

cardiovascular indication STEGLATRO TAB 5MG 2 QL (30 tabs / 30 days),

ST

STEGLATRO TAB 15MG 2 QL (30 tabs / 30 days),

ST

SULFONYLUREAS chlorpropamide tab 100 mg 1

chlorpropamide tab 250 mg 1

glimepiride tab 1 mg 1



glipizide tab 5 mg 1

glipizide tab 10 mg 1

glipizide tab er 24hr 5 mg 1

glipizide tab er 24hr 10 mg 1

glipizide xl tab 2.5mg 1

glyburide micronized tab 1.5 mg 1

glyburide micronized tab 3 mg 1

glyburide micronized tab 6 mg 1

glyburide tab 1.25 mg 1


49


glyburide tab 2.5 mg 1

glyburide tab 5 mg 1

tolazamide tab 250 mg 1

tolazamide tab 500 mg 1

tolbutamide tab 500 mg 1

ANTIDIARRHEAL/PROBIOTIC AGENTS ANTIDIARRHEAL - CHLORIDE CHANNEL ANTAGONISTS

MYTESI TAB 125MG 3 QL (60 tabs / 30 days), PA

ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC. ACIDOPH/PROB TAB FORMULA 3 OTC, PA

floranex tab 1 OTC, QL (100 tabs / 30 days)

FLORASTOR PAK KIDS 2 OTC, QL (60 packets /

30 days); For 12 years of age and younger

PROBIOTIC CAP 2 OTC, PA

probiotic cap gold 1 OTC, QL (100 caps / 30 days)

stomach relf chw 262mg 1 OTC, QL (48 tabs / 30 days)

stomach relf sus 262/15ml 1 OTC, QL (480 mL / 30 days)

stomach relf tab 262mg 1 OTC, QL (40 tabs / 30 days)

ANTIPERISTALTIC AGENTS anti-diarrhe liq 1mg/5ml 1 OTC, QL (240 ml / 30

days)

anti-diarrhe tab 2mg 1 OTC, QL (48 tabs / 30

days)

diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml

1

diphenoxylate w/ atropine tab 2.5-0.025 mg

1

loperamide hcl cap 2 mg 1

MOTOFEN TAB 1-0.025 3 PA

paregoric tincture 2 mg/5ml (morphine

equivalent)

1

ANTIDOTES AND SPECIFIC ANTAGONISTS ANTIDOTE COMBINATIONS

DUODOTE INJ 3 PA

NITHIODOTE KIT 3 PA

ANTIDOTES - CHELATING AGENTS CA-DTPA SOL 1000MG 3 PA

CHEMET CAP 100MG 2

deferasirox tab for oral susp 125 mg 1 PA


50




FERRIPROX SOL 100MG/ML 3 PA

FERRIPROX TAB 500MG 2

FERRIPROX TAB 1000MG 2

JADENU TAB 90MG 3 PA



ZN-DTPA SOL 1000MG 3 PA

ANTIDOTES AND SPECIFIC ANTAGONISTS acetylcysteine inj 200 mg/ml 1 PA

BAL IN OIL INJ 100MG/ML 3 PA

CALCIUM DISO INJ 1GM/5ML 3 PA

deferoxamine mesylate for inj 2 gm 1

deferoxamine mesylate for inj 500 mg 1

DIGIFAB INJ 40MG 3 PA

methylene blue inj 1% 1

PRALIDOXIME INJ 600/2ML 3 PA

SOD NITRITE INJ 30MG/ML 3 PA

sodium thiosulfate inj 25% 1

OPIOID ANTAGONISTS EVZIO INJ 3 QL (2 / 180 days), PA

naloxone hcl inj 0.4 mg/ml 1 QL (2 / 30 days), PA

naloxone hcl inj 4 mg/10ml 1 QL (2 / 30 days), PA

naloxone hcl soln cartridge 0.4 mg/ml 1 QL (2 / 30 days), PA

naloxone hcl soln prefilled syringe 2

mg/2ml

1 QL (2 / 30 days)

naltrexone hcl tab 50 mg 1

NARCAN SPR 2 QL (2 / 30 days); $0

Copay VIVITROL INJ 380MG 3 PA

ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS

granisetron hcl inj 0.1 mg/ml 1 PA

granisetron hcl inj 1 mg/ml 1 PA

granisetron hcl inj 4 mg/4ml (1 mg/ml) 1 PA

granisetron hcl tab 1 mg 1 QL (14 tabs / 30 days)

ondansetron hcl inj 4 mg/2ml (2 mg/ml) 1 PA

ondansetron hcl inj 40 mg/20ml (2 mg/ml) 1 PA

ondansetron hcl oral soln 4 mg/5ml 1

ondansetron hcl tab 4 mg 1 QL (90 tabs / 30 days)



ondansetron orally disintegrating tab 4 mg 1 QL (90 tabs / 30 days)

ondansetron orally disintegrating tab 8 mg 1 QL (90 tabs / 30 days)


51


SANCUSO DIS 3.1MG 3 QL (1 patch / 5 days), PA

ZUPLENZ MIS 4MG 3 ST

ZUPLENZ MIS 8MG 3 ST

ANTIEMETICS - ANTICHOLINERGIC meclizine hcl chew tab 25 mg 1 OTC, QL (30 tabs / 30

days); For 12 years of age and younger

meclizine hcl tab 12.5 mg 1 QL (30 tabs / 30 days)

meclizine hcl tab 25 mg 1 QL (30 tabs / 30 days)

scopolamine td patch 72hr 1 mg/3days 1

TIGAN INJ 100MG/ML 3 ST

trimethobenzamide hcl cap 300 mg 1

ANTIEMETICS - MISCELLANEOUS AKYNZEO CAP 300-0.5 3 QL (2 caps / 30 days),

ST

CESAMET CAP 1MG 3 PA

doxylamine-pyridoxine tab delayed release

10-10 mg


PA

dronabinol cap 2.5 mg 1

dronabinol cap 5 mg 1

dronabinol cap 10 mg 1

SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS aprepitant capsule 40 mg 1 QL (1 cap / 30 days)

aprepitant capsule 80 mg 1 QL (4 caps / 30 days)

aprepitant capsule 125 mg 1 QL (2 caps / 30 days)

aprepitant capsule therapy pack 80 & 125 mg

1 QL (2 paks / 30 days)

EMEND SUS 125MG 2

fosaprepitant dimeglumine for iv infusion

150 mg (base eq)

1

VARUBI TAB 90MG 3 QL (4 tabs / 30 days), ST

ANTIFUNGALS ANTIFUNGALS

AMBISOME INJ 50MG 3 PA

amphotericin b for iv soln 50 mg 1

flucytosine cap 250 mg 1 PA

flucytosine cap 500 mg 1 PA

griseofulvin microsize susp 125 mg/5ml 1

griseofulvin microsize tab 500 mg 1

griseofulvin ultramicrosize tab 125 mg 1

griseofulvin ultramicrosize tab 250 mg 1

nystatin tab 500000 unit 1

terbinafine hcl tab 250 mg 1 QL (30 tabs / 30 days), PA


52


IMIDAZOLE-RELATED ANTIFUNGALS CRESEMBA CAP 186 MG 3 QL (100 days per 365

days), PA

fluconazole for susp 10 mg/ml 1

fluconazole for susp 40 mg/ml 1

fluconazole tab 50 mg 1 QL (10 tabs / 30 days)




itraconazole cap 100 mg 1 QL (60 caps / 30 days)

itraconazole oral soln 10 mg/ml 1 QL (1200 mL / 30 days)

ketoconazole tab 200 mg 1 QL (60 tabs / 30 days)

NOXAFIL SUS 40MG/ML 2

ONMEL TAB 200MG 3 QL (30 tabs / 30 days),

ST

posaconazole tab delayed release 100 mg 1 QL (93 tabs / 30 days), PA

voriconazole for inj 200 mg 1 QL (30 days per 100

days)

voriconazole for susp 40 mg/ml 1 QL (30 days per 100 days)

voriconazole tab 50 mg 1 QL (60 tabs / 30 days)

voriconazole tab 200 mg 1 QL (60 tabs / 30 days)

ANTIHISTAMINES ANTIHISTAMINES - ALKYLAMINES

brompheniramine tannate chew tab 12 mg 1

J-TAN PD DRO 1MG/ML 3 OTC, PA

ANTIHISTAMINES - ETHANOLAMINES allergy cap 25mg 1 OTC, QL (120 caps / 30

days)

allergy relf liq 12.5/5ml 1 OTC, QL (480 mL / 30

days) allergy tab 25mg 1 OTC, QL (120 tabs / 30

days)

carbinoxamine maleate soln 4 mg/5ml 1

carbinoxamine maleate tab 4 mg 1

clemastine fumarate tab 2.68 mg 1

cvs allergy chw 12.5mg 1 OTC, QL (120 tabs / 30

days); For 12 years of

age and younger

diphenhydramine hcl cap 50 mg 1 OTC, QL (120 caps / 30 days)

diphenhydramine hcl elixir 12.5 mg/5ml 1

diphenhydramine hcl inj 50 mg/ml 1

KARBINAL ER SUS 4MG/5ML 3 PA

silphen coug syp 12.5/5ml 1 OTC


53


ANTIHISTAMINES - NON-SEDATING all day allg cap 10mg 1 OTC, QL (30 caps / 30

days)

all day allg tab 10mg 1 OTC, QL (30 tabs / 30 days)

ALLEGRA ALRG TAB 30MG 3 OTC

allergy relf tab 10mg 1 OTC, QL (30 tabs / 30

days)

allergy rlf chw 5mg 1 OTC, QL (30 tabs / 30


cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) 1

cetirizine hcl tab 5 mg 1 OTC, QL (30 tabs / 30 days)

CLARINEX SYP 0.5MG/ML 3 ST

CLARITIN CAP 10MG 2 OTC

desloratadine tab 5 mg 1 PA

desloratadine tab orally disintegrating 2.5 mg

1 PA

desloratadine tab orally disintegrating 5

mg

1 PA

fexofenadine hcl tab 60 mg 1 OTC, QL (60 tabs / 30

days)

fexofenadine hcl tab 180 mg 1 OTC, QL (30 tabs / 30 days)

levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml)

1

levocetirizine dihydrochloride tab 5 mg 1

loratadine chew tab 5 mg 1 OTC, QL (30 tabs / 30 days); For 12 years of age and younger

loratadine chw 5mg 1 OTC, QL (30 tabs / 30 days); For 12 years of

age and younger

loratadine sol 5mg/5ml 1 OTC, QL (240 mL / 30 days)

wal-fex chld sus 30mg/5ml 1 OTC, QL (360 mL / 30 days); For 12 years of

age and younger ZYRTEC ALLGY TAB 10MG 3 OTC, PA

ANTIHISTAMINES - PHENOTHIAZINES promethazine hcl inj 25 mg/ml 1

promethazine hcl inj 50 mg/ml 1

promethazine hcl syrup 6.25 mg/5ml 1

promethazine hcl tab 12.5 mg 1

promethazine hcl tab 25 mg 1

promethazine hcl tab 50 mg 1


54


ANTIHISTAMINES - PIPERIDINES cyproheptadine hcl syrup 2 mg/5ml 1

cyproheptadine hcl tab 4 mg 1

ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS - COMBINATIONS

ezetimibe-simvastatin tab 10-10 mg 1 PA




ANTIHYPERLIPIDEMICS - MISC. KYNAMRO INJ 200MG/ML 3 QL (4 syringes / 21

days), PA

omega-3-acid ethyl esters cap 1 gm 1

triklo cap 1gm 1 PA

VASCEPA CAP 0.5GM 3 ST

VASCEPA CAP 1GM 3 ST

BILE ACID SEQUESTRANTS cholestyramine light powder 4 gm/dose 1

cholestyramine light powder packets 4 gm 1

cholestyramine powder 4 gm/dose 1

cholestyramine powder packets 4 gm 1

colesevelam hcl packet for susp 3.75 gm 1 PA

colesevelam hcl tab 625 mg 1 PA

colestipol hcl granule packets 5 gm 1

colestipol hcl granules 5 gm 1

colestipol hcl tab 1 gm 1

FIBRIC ACID DERIVATIVES fenofibrate tab 40 mg 1

fenofibrate tab 48 mg 1


fenofibrate tab 120 mg 1 PA



fenofibric acid tab 35 mg 1

gemfibrozil tab 600 mg 1

HMG COA REDUCTASE INHIBITORS ALTOPREV TAB 20MG ER 3 ST

ALTOPREV TAB 40MG ER 3 ST

ALTOPREV TAB 60MG ER 3 ST

atorvastatin calcium tab 10 mg (base equivalent)

1

atorvastatin calcium tab 20 mg (base

equivalent)

1


1


55



1

EZALLOR SPR CAP 5MG 2 QL (30 caps / 30 days)




LIVALO TAB 1MG 3 ST

LIVALO TAB 2MG 3 ST

LIVALO TAB 4MG 3 ST

lovastatin tab 10 mg 1



pravastatin sodium tab 10 mg 1




rosuvastatin calcium tab 5 mg 1 ST




simvastatin tab 5 mg 1





INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg 1 PA

MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP)

INHIBITORS JUXTAPID CAP 5MG 2 QL (30 caps / 30 days),

PA

JUXTAPID CAP 10MG 2 QL (30 caps / 30 days),

PA

JUXTAPID CAP 20MG 2 QL (30 caps / 30 days), PA

JUXTAPID CAP 30MG 2 QL (30 caps / 30 days),

PA JUXTAPID CAP 40MG 2 QL (30 caps / 30 days),

PA

JUXTAPID CAP 60MG 2 QL (30 caps / 30 days), PA

NICOTINIC ACID DERIVATIVES niacin tab er 500 mg (antihyperlipidemic) 1

niacin tab er 750 mg (antihyperlipidemic) 1

niacin tab er 1000 mg (antihyperlipidemic) 1

niacor tab 500mg 1


56


PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS PRALUENT INJ 75MG/ML 3 QL (2 syringes / 28

days), PA

PRALUENT INJ 150MG/ML 3 QL (2 syringes / 28 days), PA

REPATHA INJ 140MG/ML 2 QL (2 syringes / 28

days), PA; NDC 72511075001

REPATHA INJ 140MG/ML 3 QL (2 syringes / 28

days), PA REPATHA PUSH INJ 420/3.5 2 QL (1 cartridge / 28

days), PA; NDC 72511077001

REPATHA PUSH INJ 420/3.5 3 QL (1 cartridge / 28 days), PA

REPATHA SURE INJ 140MG/ML 2 QL (2 syringes / 28 days), PA; NDCs

72511076001,

72511076002

REPATHA SURE INJ 140MG/ML 3 QL (2 syringes / 28 days), PA

ANTIHYPERTENSIVES ACE INHIBITORS

benazepril hcl tab 5 mg 1




fosinopril sodium tab 10 mg 1



lisinopril tab 2.5 mg 1

lisinopril tab 5 mg 1





perindopril erbumine tab 2 mg 1



quinapril hcl tab 5 mg 1




ramipril cap 1.25 mg 1

ramipril cap 2.5 mg 1

ramipril cap 5 mg 1


57


ramipril cap 10 mg 1

trandolapril tab 1 mg 1



AGENTS FOR PHEOCHROMOCYTOMA DEMSER CAP 250MG 2

phenoxybenzamine hcl cap 10 mg 1

PHENTOLAMINE INJ 5MG 2

ANGIOTENSIN II RECEPTOR ANTAGONISTS EDARBI TAB 40MG 3 ST

EDARBI TAB 80MG 3 ST

eprosartan mesylate tab 600 mg 1

irbesartan tab 75 mg 1



losartan potassium tab 25 mg 1



valsartan tab 40 mg 1 QL (60 tabs / 30 days)




ANTIADRENERGIC ANTIHYPERTENSIVES clonidine hcl tab 0.1 mg 1

clonidine hcl tab 0.2 mg 1

clonidine hcl tab 0.3 mg 1

clonidine td patch weekly 0.1 mg/24hr 1



doxazosin mesylate tab 1 mg 1




guanfacine hcl tab 1 mg 1

guanfacine hcl tab 2 mg 1

methyldopa tab 250 mg 1

methyldopa tab 500 mg 1

methyldopate hcl inj 250 mg/5ml 1

prazosin hcl cap 1 mg 1



terazosin hcl cap 1 mg (base equivalent) 1





58


ANTIHYPERTENSIVE COMBINATIONS amlodipine besylate-benazepril hcl cap

2.5-10 mg

1

amlodipine besylate-benazepril hcl cap 5-10 mg

1

amlodipine besylate-benazepril hcl cap

5-20 mg

1


1


1


1

amlodipine besylate-olmesartan medoxomil tab 5-20 mg

1 ST

amlodipine besylate-olmesartan medoxomil tab 5-40 mg

1 ST

amlodipine besylate-olmesartan medoxomil

tab 10-20 mg

1 ST

amlodipine besylate-olmesartan medoxomil

tab 10-40 mg

1 ST

amlodipine besylate-valsartan tab 5-160 mg


amlodipine besylate-valsartan tab 5-320

mg


amlodipine besylate-valsartan tab 10-160

mg


amlodipine besylate-valsartan tab 10-320 mg


amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg


amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg


amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg


amlodipine-valsartan-hydrochlorothiazide

tab 10-160-25 mg


amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg


atenolol & chlorthalidone tab 50-25 mg 1

atenolol & chlorthalidone tab 100-25 mg 1

benazepril & hydrochlorothiazide tab

5-6.25 mg

1

benazepril & hydrochlorothiazide tab 10-12.5 mg

1

benazepril & hydrochlorothiazide tab 20-12.5 mg

1


59


benazepril & hydrochlorothiazide tab 20-25 mg

1

bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg

1

bisoprolol & hydrochlorothiazide tab 5-6.25 mg

1

bisoprolol & hydrochlorothiazide tab 10-6.25 mg

1

candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg

1

candesartan cilexetil-hydrochlorothiazide

tab 32-12.5 mg

1

candesartan cilexetil-hydrochlorothiazide

tab 32-25 mg

1

captopril & hydrochlorothiazide tab 25-15 mg

1

captopril & hydrochlorothiazide tab 25-25

mg

1


1


1

EDARBYCLOR TAB 40-12.5 3 ST

EDARBYCLOR TAB 40-25MG 3 ST

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg

1

enalapril maleate & hydrochlorothiazide tab

10-25 mg

1

fosinopril sodium & hydrochlorothiazide tab

10-12.5 mg

1

fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg

1

irbesartan-hydrochlorothiazide tab

150-12.5 mg

1

irbesartan-hydrochlorothiazide tab

300-12.5 mg

1

lisinopril & hydrochlorothiazide tab 10-12.5 mg

1

lisinopril & hydrochlorothiazide tab 20-12.5 mg

1

lisinopril & hydrochlorothiazide tab 20-25

mg

1

losartan potassium & hydrochlorothiazide tab 50-12.5 mg

1

losartan potassium & hydrochlorothiazide

tab 100-12.5 mg

1

losartan potassium & hydrochlorothiazide

tab 100-25 mg

1


60


methyldopa & hydrochlorothiazide tab 250-15 mg

1

methyldopa & hydrochlorothiazide tab 250-25 mg

1

metoprolol & hydrochlorothiazide tab 50-25 mg

1


1


1

moexipril-hydrochlorothiazide tab 7.5-12.5

mg

1

moexipril-hydrochlorothiazide tab 15-12.5

mg

1

moexipril-hydrochlorothiazide tab 15-25 mg

1

olmesartan medoxomil-hydrochlorothiazide

tab 20-12.5 mg

1 ST

olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg

1 ST

olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg

1 ST

olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg

1 ST

olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg

1 ST

olmesartan-amlodipine-hydrochlorothiazide

tab 40-10-12.5 mg

1 ST

olmesartan-amlodipine-hydrochlorothiazide

tab 40-10-25 mg

1 ST

PRESTALIA TAB 3.5-2.5 3 ST

PRESTALIA TAB 7-5MG 3 ST

PRESTALIA TAB 14-10MG 3 ST

propranolol & hydrochlorothiazide tab 40-25 mg

1

propranolol & hydrochlorothiazide tab

80-25 mg

1

quinapril-hydrochlorothiazide tab 10-12.5

mg

1

quinapril-hydrochlorothiazide tab 20-12.5

mg

1

quinapril-hydrochlorothiazide tab 20-25 mg 1

TEKTURNA HCT TAB 150-12.5 3 PA

TEKTURNA HCT TAB 150-25MG 3 PA

TEKTURNA HCT TAB 300-12.5 3 PA

TEKTURNA HCT TAB 300-25MG 3 PA

telmisartan-amlodipine tab 40-5 mg 1



61




telmisartan-hydrochlorothiazide tab 40-12.5 mg

1

telmisartan-hydrochlorothiazide tab

80-12.5 mg

1

telmisartan-hydrochlorothiazide tab 80-25

mg

1

valsartan-hydrochlorothiazide tab 80-12.5 mg

1

valsartan-hydrochlorothiazide tab 160-12.5

mg

1

valsartan-hydrochlorothiazide tab 160-25

mg

1

valsartan-hydrochlorothiazide tab 320-12.5 mg

1

valsartan-hydrochlorothiazide tab 320-25 mg

1

DIRECT RENIN INHIBITORS aliskiren fumarate tab 150 mg (base

equivalent)

1 PA

aliskiren fumarate tab 300 mg (base equivalent)

1 PA

SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) eplerenone tab 25 mg 1

eplerenone tab 50 mg 1

VASODILATORS hydralazine hcl inj 20 mg/ml 1

hydralazine hcl tab 10 mg 1




minoxidil tab 2.5 mg 1

minoxidil tab 10 mg 1

ANTIMALARIALS ANTIMALARIAL COMBINATIONS

atovaquone-proguanil hcl tab 62.5-25 mg 1

atovaquone-proguanil hcl tab 250-100 mg 1

COARTEM TAB 20-120MG 2

ANTIMALARIALS chloroquine phosphate tab 250 mg 1

chloroquine phosphate tab 500 mg 1

DARAPRIM TAB 25MG 3 PA

hydroxychloroquine sulfate tab 200 mg 1

KRINTAFEL TAB 150MG 3 QL (2 tabs / 365 days),

PA


62


mefloquine hcl tab 250 mg 1

PRIMAQUINE TAB 26.3MG 1

quinine sulfate cap 324 mg 1

ANTIMYASTHENIC/CHOLINERGIC AGENTS ANTIMYASTHENIC/CHOLINERGIC AGENTS

FIRDAPSE TAB 10MG 2 QL (240 tabs / 30 days), PA

GUANIDINE TAB 125MG 3 PA

pyridostigmine bromide oral soln 60

mg/5ml

1

pyridostigmine bromide tab 60 mg 1

pyridostigmine bromide tab er 180 mg 1

RUZURGI TAB 10MG 2 QL (240 tabs / 30 days), PA

ANTIMYCOBACTERIAL AGENTS ANTI TB COMBINATIONS

RIFAMATE CAP 3 PA

RIFATER TAB 3 PA

ANTIMYCOBACTERIAL AGENTS CAPASTAT SUL INJ 1GM 3 PA

cycloserine cap 250 mg 1 PA

ethambutol hcl tab 100 mg 1

ethambutol hcl tab 400 mg 1

isoniazid inj 100 mg/ml 1

isoniazid syrup 50 mg/5ml 1

isoniazid tab 100 mg 1

isoniazid tab 300 mg 1

PASER GRA 4GM 3 PA

PRETOMANID TAB 200MG 2 QL (182 tabs / 365

days), PA

PRIFTIN TAB 150MG 2

pyrazinamide tab 500 mg 1

rifabutin cap 150 mg 1

rifampin cap 150 mg 1

rifampin cap 300 mg 1

rifampin for inj 600 mg 1

SIRTURO TAB 100MG 2 QL (188 tabs / 365 days), PA

TRECATOR TAB 250MG 3 PA

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALKYLATING AGENTS

BENDEKA INJ 100/4ML 3 PA

busulfan inj 6 mg/ml 1

BUSULFEX INJ 6MG/ML 2

cisplatin inj 50 mg/50ml (1 mg/ml) 1


63




cyclophosphamide for inj 1 gm 1

cyclophosphamide for inj 2 gm 1

cyclophosphamide for inj 500 mg 1

GLEOSTINE CAP 5MG 2 QL (1 cap / 42 days)

GLEOSTINE CAP 10MG 2 QL (3 caps / 42 days)

GLEOSTINE CAP 40MG 2 QL (2 caps / 42 days)

GLEOSTINE CAP 100MG 2 QL (2 tabs / 42 days)

GLIADEL WAF 7.7MG 3 PA

HEXALEN CAP 50MG 2

IFEX INJ 3GM 3 PA

ifosfamide for inj 1 gm 1 PA

LEUKERAN TAB 2MG 2

melphalan hcl for inj 50 mg (base equiv) 1 PA

melphalan tab 2 mg 1

MYLERAN TAB 2MG 2 QL (120 tabs / 30 days)

temozolomide cap 5 mg 1 QL (15 caps / 28 days), PA





temozolomide cap 250 mg 1 QL (5 caps / 28 days),

PA

thiotepa for inj 15 mg 1 PA

TREANDA INJ 25MG 2 PA

TREANDA INJ 100MG 2 PA

ZANOSAR INJ 1GM 2

ANTIMETABOLITES ALIMTA INJ 100MG 2 PA

ALIMTA INJ 500MG 2 PA

capecitabine tab 150 mg 1 PA

capecitabine tab 500 mg 1 PA

cytarabine inj 20 mg/ml 1

cytarabine inj pf 20 mg/ml 1

cytarabine inj pf 100 mg/ml 1

decitabine for inj 50 mg 1 PA

fludarabine phosphate for inj 50 mg 1

fludarabine phosphate inj 25 mg/ml 1

gemcitabine hcl for inj 1 gm 1 PA

gemcitabine hcl for inj 2 gm 1


64


gemcitabine hcl for inj 200 mg 1 PA

gemcitabine hcl inj 1 gm/26.3ml (38

mg/ml) (base equiv)

1

gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) (base equiv)

1

gemcitabine hcl inj 200 mg/5.26ml (38

mg/ml) (base equiv)

1

mercaptopurine tab 50 mg 1 PA

methotrexate sodium for inj 1 gm 1

methotrexate sodium inj 50 mg/2ml (25 mg/ml)

1

methotrexate sodium inj 250 mg/10ml (25 mg/ml)

1

methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)

1

methotrexate sodium inj pf 250 mg/10ml

(25 mg/ml)

1

methotrexate sodium inj pf 1000 mg/40ml

(25 mg/ml)

1

methotrexate sodium tab 2.5 mg (base equiv)

1

PURIXAN SUS 20MG/ML 2 PA

TABLOID TAB 40MG 2

TREXALL TAB 5MG 2

TREXALL TAB 7.5MG 2

TREXALL TAB 10MG 2

TREXALL TAB 15MG 2

XATMEP SOL 2.5MG/ML 2

ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS AVASTIN INJ 2 PA

AVASTIN INJ 400/16ML 2 PA

ZALTRAP INJ 100/4ML 3 PA

ZALTRAP INJ 200/8ML 3 PA

ANTINEOPLASTIC - ANTIBODIES ARZERRA CON 100/5ML 2 PA

ERBITUX INJ 100MG 2 PA

ERBITUX INJ 200MG 2 PA

HERCEPTIN INJ 150MG 2 PA

HERCEPTIN INJ 440MG 2 PA

KADCYLA INJ 100MG 2 PA

KADCYLA INJ 160MG 2 PA

KEYTRUDA INJ 100MG/4M 3 PA

PERJETA INJ 420/14ML 2 PA

RITUXAN INJ 100MG 2 PA

RITUXAN INJ 500MG 2 PA

VECTIBIX INJ 100MG 2 PA


65


VECTIBIX INJ 400MG 2 PA

YERVOY INJ 50MG 3 PA

YERVOY INJ 200MG 3 PA

ZEVALIN KIT Y-90 2

ANTINEOPLASTIC - BCL-2 INHIBITORS VENCLEXTA TAB 10MG 2 QL (60 tabs / 30 days),

PA

VENCLEXTA TAB 50MG 2 QL (30 tabs / 30 days), PA

VENCLEXTA TAB 100MG 2 QL (120 tabs / 30 days), PA

VENCLEXTA TAB START PK 2 QL (1 box in lifetime), PA

ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS DAURISMO TAB 25MG 2 QL (30 tabs / 30 days),

PA

DAURISMO TAB 100MG 2 QL (30 tabs / 30 days), PA

ERIVEDGE CAP 150MG 2 QL (30 caps / 30 days)

ODOMZO CAP 200MG 2 QL (30 caps / 30 days), PA

ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS abiraterone acetate tab 250 mg 1 QL (120 tabs / 30 days),

PA

anastrozole tab 1 mg 1 QL (30 tabs / 30 days),

PA bicalutamide tab 50 mg 1 QL (30 tabs / 30 days),

PA

DEPO-PROVERA INJ 400/ML 2

ELIGARD INJ 22.5MG 3 QL (1 kit / 90 days), PA

EMCYT CAP 140MG 2

ERLEADA TAB 60MG 2 QL (120 tabs / 30 days),

PA exemestane tab 25 mg 1 QL (30 tabs / 30 days),

PA

FARESTON TAB 60MG 2 QL (30 tabs / 30 days)

flutamide cap 125 mg 1 QL (180 caps / 30 days)

letrozole tab 2.5 mg 1 QL (60 tabs / 30 days), PA

leuprolide acetate inj kit 5 mg/ml 1 QL (2 boxes / 21 days)

LUPRON DEPOT INJ 3.75MG 2 QL (1 box / 21 days), PA

LUPRON DEPOT INJ 7.5MG 2 QL (1 box / 21 days), PA

LUPRON DEPOT INJ 11.25MG 2 QL (1 vial / 90 days), PA

LUPRON DEPOT INJ 22.5MG 2 QL (1 vial / 90 days), PA

LUPRON DEPOT INJ 30MG 2 PA

LUPRON DEPOT INJ 45MG 2 QL (1 kit / 180 days), PA


66


LYSODREN TAB 500MG 2 QL (360 tabs / 30 days)

megestrol acetate susp 40 mg/ml 1 QL (600 mL / 30 days)

megestrol acetate tab 20 mg 1

megestrol acetate tab 40 mg 1

nilutamide tab 150 mg 1 QL (1st fill: 60/30 days, then 30/30)

NUBEQA TAB 300MG 2 QL (120 tabs / 30 days),

PA

SOLTAMOX SOL 10MG/5ML 3 QL (600 mL / 30 days), PA

tamoxifen citrate tab 10 mg (base

equivalent)


tamoxifen citrate tab 20 mg (base

equivalent)


toremifene citrate tab 60 mg (base equivalent)

1 PA

VANTAS KIT 50MG 2 QL (1 box / year), PA

XTANDI CAP 40MG 2 QL (120 caps / 30

days), PA

ZYTIGA TAB 500MG 3 QL (60 tabs / 30 days), PA

ANTINEOPLASTIC - IMMUNOMODULATORS POMALYST CAP 1MG 2 QL (21 caps / 21 days)

POMALYST CAP 2MG 2 QL (21 caps / 21 days)



ANTINEOPLASTIC - XPO1 INHIBITORS XPOVIO PAK 60MG 2 QL (32 tabs / 28 days),

PA

XPOVIO PAK 80MG 2 QL (32 tabs / 28 days),

PA XPOVIO PAK 100MG 2 QL (32 tabs / 28 days),

PA

ANTINEOPLASTIC ANTIBIOTICS dactinomycin for inj 0.5 mg 1 PA

daunorubicin hcl iv soln 20 mg/4ml (base equiv)

1

doxorubicin hcl for inj 10 mg 1

doxorubicin hcl for inj 50 mg 1

doxorubicin hcl inj 2 mg/ml 1

mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml)

1

mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml)

1

mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml)

1


67


ANTINEOPLASTIC COMBINATIONS KISQALI 200 PAK FEMARA 2 QL (91 tabs / 28 days),

PA

KISQALI 400 PAK FEMARA 2 QL (91 tabs / 28 days), PA

KISQALI 600 PAK FEMARA 2 QL (91 tabs / 28 days),

PA

LONSURF TAB 15-6.14 2 PA

LONSURF TAB 20-8.19 2 PA

RITUXAN INJ HYCELA 2 QL (4 vials / 30), PA

ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR DIS TAB 2MG 2 QL (30 tabs / 30 days)

AFINITOR DIS TAB 3MG 2 QL (30 tabs / 30 days)

AFINITOR DIS TAB 5MG 2 QL (30 tabs / 30 days)

AFINITOR TAB 2.5MG 2 QL (30 tabs / 30 days)

AFINITOR TAB 5MG 2 QL (30 tabs / 30 days)

AFINITOR TAB 7.5MG 2 QL (30 tabs / 30 days)

AFINITOR TAB 10MG 2 QL (30 tabs / 30 days)

ALECENSA CAP 150MG 2 QL (240 caps / 30

days), PA ALUNBRIG TAB 30MG 2 QL (180 tabs / 30 days),

PA

BALVERSA TAB 3MG 2 QL (90 tabs / 30 days), PA

BALVERSA TAB 4MG 2 QL (60 tabs / 30 days),

PA BALVERSA TAB 5MG 2 QL (30 tabs / 30 days),

PA

BOSULIF TAB 100MG 2 QL (120 tabs / 30 days)

BOSULIF TAB 500MG 2 QL (30 tabs / 30 days)

BRAFTOVI CAP 50MG 2 QL (180 caps / 30 days), PA

BRAFTOVI CAP 75MG 2 QL (180 caps / 30 days), PA

CABOMETYX TAB 20MG 2 QL (30 tabs / 30 days),

PA

CABOMETYX TAB 40MG 2 QL (30 tabs / 30 days),

PA

CABOMETYX TAB 60MG 2 QL (30 tabs / 30 days), PA

CALQUENCE CAP 100MG 3 QL (60 caps / 30 days),

PA CAPRELSA TAB 100MG 2 QL (60 tabs / 30 days)

CAPRELSA TAB 300MG 2 QL (30 tabs / 30 days)

COMETRIQ KIT 60MG 2 QL (1 box / 21 days), PA




68


COPIKTRA CAP 15MG 2 QL (60 caps / 30 days), PA

COPIKTRA CAP 25MG 2 QL (60 caps / 30 days), PA

COTELLIC TAB 20MG 2 QL (63 tabs / 30 days), PA

erlotinib hcl tab 25 mg (base equivalent) 1 QL (30 tabs / 30 days), PA

erlotinib hcl tab 100 mg (base equivalent) 1 QL (30 tabs / 30 days), PA

erlotinib hcl tab 150 mg (base equivalent) 1 QL (30 tabs / 30 days),

PA

FARYDAK CAP 10MG 2 QL (6 caps / 21 days),

PA

FARYDAK CAP 15MG 2 QL (6 caps / 21 days), PA

FARYDAK CAP 20MG 2 PA

GILOTRIF TAB 20MG 2 QL (30 tabs / 30 days)



IBRANCE CAP 75MG 2 PA



ICLUSIG TAB 15MG 2 QL (60 tabs / 30 days)

ICLUSIG TAB 45MG 2 QL (30 tabs / 30 days)

IDHIFA TAB 50MG 2 QL (30 tabs / 30 days), PA

IDHIFA TAB 100MG 2 QL (30 tabs / 30 days), PA

imatinib mesylate tab 100 mg (base

equivalent)


PA

imatinib mesylate tab 400 mg (base

equivalent)


PA IMBRUVICA CAP 140MG 2 QL (120 caps / 30

days), PA

INLYTA TAB 1MG 2 QL (180 tabs / 30 days)

INLYTA TAB 5MG 2 QL (120 tabs / 30 days)

INREBIC CAP 100MG 2 QL (120 caps / 30

days), PA IRESSA TAB 250MG 2 QL (30 tabs / 30 days)

JAKAFI TAB 5MG 2 QL (60 tabs / 30 days)





KISQALI TAB 200DOSE 2 QL (63 tabs / 28 days),

PA


69


KISQALI TAB 400DOSE 2 QL (63 tabs / 28 days), PA

KISQALI TAB 600DOSE 2 QL (63 tabs / 28 days), PA

KYPROLIS SOL 60MG 3 PA

LENVIMA CAP 8 MG 2 QL (60 caps / 30 days),

PA LENVIMA CAP 10 MG 2 QL (5 caps / 30 days),

PA

LENVIMA CAP 14 MG 2 QL (10 caps / 30 days), PA




LORBRENA TAB 25MG 2 QL (90 tabs / 30 days),

PA

LORBRENA TAB 100MG 2 QL (30 tabs / 30 days), PA

LYNPARZA CAP 50MG 2 QL (480 caps / 30

days), PA LYNPARZA TAB 100MG 2 QL (120 tabs / 30 days),

PA

LYNPARZA TAB 150MG 2 QL (120 tabs / 30 days), PA

MEKINIST TAB 0.5MG 2 QL (90 tabs / 30 days)

MEKINIST TAB 2MG 2 QL (30 tabs / 30 days)

MEKTOVI TAB 15MG 2 QL (180 tabs / 30 days), PA

NERLYNX TAB 40MG 2 QL (180 tabs / 30 days), PA

NEXAVAR TAB 200MG 2 QL (120 tabs / 30 days)

NINLARO CAP 2.3MG 2 QL (3 caps / 28 days), PA

NINLARO CAP 3MG 2 QL (3 caps / 28 days), PA

NINLARO CAP 4MG 2 QL (3 caps / 28 days), PA

PIQRAY 200MG TAB DOSE 2 QL (56 tabs / 28 days), PA

PIQRAY 250MG TAB DOSE 2 QL (56 tabs / 28 days), PA

PIQRAY 300MG TAB DOSE 2 QL (56 tabs / 28 days),

PA ROZLYTREK CAP 100MG 2 QL (30 caps / 30 days),

PA


70


ROZLYTREK CAP 200MG 2 QL (90 caps / 30 days), PA

RUBRACA TAB 200MG 2 QL (120 tabs / 30 days), PA



RYDAPT CAP 25MG 2 QL (224 caps / 28 days), PA

SPRYCEL TAB 20MG 2 QL (30 tabs / 30 days)






STIVARGA TAB 40MG 2 QL (84 tabs / 30 days)

SUTENT CAP 12.5MG 2 QL (30 caps / 30 days)

SUTENT CAP 25MG 2 QL (30 caps / 30 days)

SUTENT CAP 37.5MG 2 QL (30 caps / 30 days)

SUTENT CAP 50MG 2 QL (30 caps / 30 days)

TAFINLAR CAP 50MG 2 QL (120 caps / 30 days)

TAFINLAR CAP 75MG 2 QL (120 caps / 30 days)

TAGRISSO TAB 40MG 2 QL (30 tabs / 30 days), PA

TAGRISSO TAB 80MG 2 QL (30 tabs / 30 days), PA

TALZENNA CAP 0.25MG 2 QL (90 tabs / 30 days), PA

TALZENNA CAP 1MG 2 QL (30 tabs / 30 days),

PA

TASIGNA CAP 150MG 2 QL (120 caps / 30 days)

TASIGNA CAP 200MG 2 QL (120 caps / 30 days)

TIBSOVO TAB 250MG 2 QL (60 tabs / 30 days),

PA

TURALIO CAP 200MG 2 QL (120 caps / 30 days), PA

TYKERB TAB 250MG 2 QL (180 tabs / 30 days), PA

VERZENIO TAB 50MG 2 QL (60 tabs / 30 days), PA





71


VITRAKVI CAP 25MG 2 QL (240 caps / 30 days), PA

VITRAKVI CAP 100MG 2 QL (60 caps / 30 days), PA

VITRAKVI SOL 20MG/ML 2 QL (300 mL / 30 days), PA

VIZIMPRO TAB 15MG 2 QL (30 tabs / 30 days), PA

VIZIMPRO TAB 30MG 2 QL (30 tabs / 30 days), PA

VIZIMPRO TAB 45MG 2 QL (30 tabs / 30 days),

PA

VOTRIENT TAB 200MG 2 QL (120 tabs / 30 days)

XALKORI CAP 200MG 2 QL (60 caps / 30 days)

XALKORI CAP 250MG 2 QL (60 caps / 30 days)

XOSPATA TAB 40MG 2 QL (90 tabs / 30 days),

PA ZEJULA CAP 100MG 2 QL (90 caps / 30 days),

PA

ZELBORAF TAB 240MG 2 QL (240 tabs / 30 days)

ZOLINZA CAP 100MG 2 QL (120 caps / 30 days)

ZYDELIG TAB 100MG 2 QL (60 tabs / 30 days),

PA ZYDELIG TAB 150MG 2 QL (60 tabs / 30 days),

PA

ZYKADIA CAP 150MG 2 QL (90 caps / 30 days), PA

ANTINEOPLASTIC RADIOPHARMACEUTICALS METASTRON INJ 3 PA

ANTINEOPLASTICS MISC. ACTIMMUNE INJ 2MU/0.5 2 PA

bexarotene cap 75 mg 1 PA

dacarbazine for inj 100 mg 1

dacarbazine for inj 200 mg 1

hydroxyurea cap 500 mg 1 PA

INTRON A INJ 18MU 2

INTRON A INJ 25MU 2

MATULANE CAP 50MG 2

NIPENT INJ 10MG 3 PA

PHOTOFRIN INJ 75MG 2

SYLATRON KIT 200MCG 2



SYNRIBO INJ 3.5MG 3 PA

tretinoin cap 10 mg 1


72


CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS dexrazoxane hcl for inj 250 mg (base

equivalent)

1 PA

dexrazoxane hcl for inj 500 mg (base equivalent)

1 PA

ETHYOL INJ 500MG 2 PA

FUSILEV INJ 50MG 2 PA

leucovorin calcium for inj 50 mg 1





leucovorin calcium tab 5 mg 1




levoleucovorin calcium for iv inj 50 mg (base equiv)

1

levoleucovorin calcium inj 175 mg/17.5ml

(base equiv)

1 PA

mesna inj 100 mg/ml 1 PA

MESNEX TAB 400MG 2

MITOTIC INHIBITORS ABRAXANE INJ 100MG 2 PA

docetaxel for inj conc 20 mg/ml 1 PA

docetaxel for inj conc 80 mg/4ml (20

mg/ml)

1 PA

DOCETAXEL INJ 20/0.5ML 3 PA

DOCETAXEL INJ 80MG/2ML 3 PA

etoposide cap 50 mg 1

etoposide inj 1 gm/50ml (20 mg/ml) 1

etoposide inj 100 mg/5ml (20 mg/ml) 1

etoposide inj 500 mg/25ml (20 mg/ml) 1

HALAVEN INJ 1MG/2ML 3 PA

IXEMPRA KIT INJ 15MG 2

IXEMPRA KIT INJ 45MG 2

JEVTANA INJ 60/1.5ML 3 PA

MARQIBO INJ 5MG/31ML 2 PA

paclitaxel iv conc 30 mg/5ml (6 mg/ml) 1

paclitaxel iv conc 100 mg/16.7ml (6

mg/ml)

1



vinblastine sulfate inj 1 mg/ml 1

vinorelbine tartrate inj 10 mg/ml (base

equiv)

1 PA


73


vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv)

1 PA

TOPOISOMERASE I INHIBITORS CAMPTOSAR INJ 300/15ML 3 PA

irinotecan hcl inj 40 mg/2ml (20 mg/ml) 1 PA

irinotecan hcl inj 100 mg/5ml (20 mg/ml) 1 PA

irinotecan hcl inj 500 mg/25ml (20 mg/ml) 1

ANTIPARKINSON AND RELATED THERAPY AGENTS ANTIPARKINSON ADJUVANTS

carbidopa tab 25 mg 1

NOURIANZ TAB 20MG 3 QL (30 tabs / 30 days), PA

NOURIANZ TAB 40MG 3 QL (30 tabs / 30 days), PA

ANTIPARKINSON ANTICHOLINERGICS benztropine mesylate inj 1 mg/ml 1

benztropine mesylate tab 0.5 mg 1

benztropine mesylate tab 1 mg 1

benztropine mesylate tab 2 mg 1

trihexyphenidyl hcl elixir 0.4 mg/ml 1

trihexyphenidyl hcl tab 2 mg 1

trihexyphenidyl hcl tab 5 mg 1

ANTIPARKINSON COMT INHIBITORS entacapone tab 200 mg 1 PA

tolcapone tab 100 mg 1

ANTIPARKINSON DOPAMINERGICS amantadine hcl cap 100 mg 1

amantadine hcl syrup 50 mg/5ml 1

amantadine hcl tab 100 mg 1

APOKYN INJ 10MG/ML 2 QL (30 mL / 30 days)

bromocriptine mesylate cap 5 mg (base

equivalent)

1

bromocriptine mesylate tab 2.5 mg (base equivalent)

1

carbidopa & levodopa orally disintegrating tab 10-100 mg

1


1


1

carbidopa & levodopa tab 10-100 mg 1



carbidopa & levodopa tab er 25-100 mg 1

carbidopa & levodopa tab er 50-200 mg 1


74


carbidopa-levodopa-entacapone tabs 12.5-50-200 mg

1


1

carbidopa-levodopa-entacapone tabs 25-100-200 mg

1


1


1

carbidopa-levodopa-entacapone tabs

50-200-200 mg

1

GOCOVRI CAP 68.5MG 3 QL (60 caps / 30 days),

PA

GOCOVRI CAP 137MG 3 QL (60 caps / 30 days), PA

NEUPRO DIS 1MG/24HR 3 ST






pramipexole dihydrochloride tab 0.5 mg 1




pramipexole dihydrochloride tab 1 mg 1


pramipexole dihydrochloride tab er 24hr

0.75 mg

1 PA

pramipexole dihydrochloride tab er 24hr 0.375 mg

1 PA


1 PA


1 PA

pramipexole dihydrochloride tab er 24hr 3 mg

1 PA

pramipexole dihydrochloride tab er 24hr

4.5 mg

1 PA

ropinirole hydrochloride tab 0.5 mg 1

ropinirole hydrochloride tab 0.25 mg 1

ropinirole hydrochloride tab 1 mg 1






75


ropinirole hydrochloride tab er 24hr 2 mg (base equivalent)

1


1


1


1


1

RYTARY CAP 95MG 3 PA




ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS rasagiline mesylate tab 0.5 mg (base

equiv) 1

rasagiline mesylate tab 1 mg (base equiv) 1

selegiline hcl cap 5 mg 1

selegiline hcl tab 5 mg 1

XADAGO TAB 50MG 3 QL (30 tabs / 30 days), PA

XADAGO TAB 100MG 3 QL (30 tabs / 30 days),

PA ZELAPAR TAB 1.25MG 3 PA

ANTIPSYCHOTICS/ANTIMANIC AGENTS ANTIMANIC AGENTS

lithium carbonate cap 150 mg 1



lithium carbonate tab 300 mg 1

lithium carbonate tab er 300 mg 1

lithium carbonate tab er 450 mg 1

LITHIUM SOL 8MEQ/5ML 3 PA

ANTIPSYCHOTICS - MISC. EQUETRO CAP 100MG 3 ST

EQUETRO CAP 200MG 3 ST

EQUETRO CAP 300MG 3 ST

GEODON INJ 20MG 2 PA

LATUDA TAB 20MG 3 QL (30 tabs / 30 days),

PA

LATUDA TAB 40MG 3 QL (30 tabs / 30 days), PA

LATUDA TAB 60MG 3 QL (30 tabs / 30 days),

PA


76




NUPLAZID CAP 34MG 3 QL (30 caps / 30 days)

NUPLAZID TAB 10MG 3 QL (30 tabs / 30 days)

NUPLAZID TAB 17MG 3 QL (60 tabs / 30 days),

PA

VRAYLAR CAP 1.5-3MG 2 QL (30 caps / 30 days), ST

VRAYLAR CAP 1.5MG 2 QL (30 caps / 30 days),

ST VRAYLAR CAP 3MG 2 QL (30 caps / 30 days),

ST

VRAYLAR CAP 4.5MG 2 QL (30 caps / 30 days), ST

VRAYLAR CAP 6MG 2 QL (30 caps / 30 days), ST

ziprasidone hcl cap 20 mg 1 QL (60 caps / 30 days)




BENZISOXAZOLES FANAPT PAK 3 QL (8 tabs in lifetime),

ST

FANAPT TAB 1MG 3 QL (60 tabs / 30 days), ST




FANAPT TAB 8MG 3 QL (60 tabs / 30 days),

ST FANAPT TAB 10MG 3 QL (60 tabs / 30 days),

ST


INVEGA SUST INJ 39/0.25 2 PA

INVEGA SUST INJ 78/0.5ML 2 PA

INVEGA SUST INJ 117/0.75 2 PA

INVEGA SUST INJ 156MG/ML 2 QL (1 syringe / 21 days), PA

INVEGA SUST INJ 234/1.5 2 QL (1 syringe / 21

days), PA


77


INVEGA TRINZ INJ 273MG 2 QL (1 syringe / 84 days), PA




paliperidone tab er 24hr 1.5 mg 1 QL (30 tabs / 30 days)

paliperidone tab er 24hr 3 mg 1 QL (30 tabs / 30 days)



RISPERDAL INJ 12.5MG 2 QL (2 / 21 days), PA

RISPERDAL INJ 25MG 2 QL (2 / 21 days), PA

RISPERDAL INJ 37.5MG 2 QL (2 / 21 days), PA

RISPERDAL INJ 50MG 2 QL (2 / 21 days), PA

risperidone orally disintegrating tab 0.5 mg 1 QL (60 tabs / 30 days)

risperidone orally disintegrating tab 0.25

mg


risperidone orally disintegrating tab 1 mg 1 QL (60 tabs / 30 days)




risperidone soln 1 mg/ml 1 QL (240 ml / 30 days)

risperidone tab 0.5 mg 1 QL (60 tabs / 30 days)

risperidone tab 0.25 mg 1 QL (60 tabs / 30 days)

risperidone tab 1 mg 1 QL (60 tabs / 30 days)




BUTYROPHENONES haloperidol decanoate im soln 50 mg/ml 1

haloperidol decanoate im soln 100 mg/ml 1

haloperidol lactate inj 5 mg/ml 1

haloperidol lactate oral conc 2 mg/ml 1

haloperidol tab 0.5 mg 1

haloperidol tab 1 mg 1





DIBENZAPINES ADASUVE INH 10MG 3 PA

clozapine orally disintegrating tab 12.5 mg 1 QL (60 tabs / 30 days)

clozapine orally disintegrating tab 25 mg 1 QL (90 tabs / 30 days)



78




clozapine tab 25 mg 1




loxapine succinate cap 5 mg 1




olanzapine for im inj 10 mg 1 QL (30 mL / 30 days)

olanzapine orally disintegrating tab 5 mg 1 QL (30 tabs / 30 days)




olanzapine tab 2.5 mg 1 QL (30 tabs / 30 days)

olanzapine tab 5 mg 1 QL (30 tabs / 30 days)

olanzapine tab 7.5 mg 1 QL (30 tabs / 30 days)




quetiapine fumarate tab 25 mg 1 QL (90 tabs / 30 days)






quetiapine fumarate tab er 24hr 50 mg 1 PA





SAPHRIS SUB 2.5MG 3 QL (60 ea / 30 days), PA

SAPHRIS SUB 5MG 3 QL (60 ea / 30 days), PA

SAPHRIS SUB 10MG 3 QL (60 ea / 30 days), PA

VERSACLOZ SUS 50MG/ML 3 QL (540 ml / 30 days), ST

ZYPREXA RELP INJ 210MG 3 QL (2 vials / 21 days),

PA ZYPREXA RELP INJ 300MG 3 QL (2 vials / 21 days),

PA

ZYPREXA RELP INJ 405MG 3 QL (1 vial / 21 days), PA

PHENOTHIAZINES CHLORPROMAZ INJ 25MG/ML 3 PA

CHLORPROMAZ INJ 50MG/2ML 3 PA

chlorpromazine hcl tab 10 mg 1


79






compro sup 25mg 1 PA

fluphenazine decanoate inj 25 mg/ml 1

fluphenazine hcl elixir 2.5 mg/5ml 1

fluphenazine hcl inj 2.5 mg/ml 1

fluphenazine hcl oral conc 5 mg/ml 1

fluphenazine hcl tab 1 mg 1

fluphenazine hcl tab 2.5 mg 1



perphenazine tab 2 mg 1




prochlorperazine edisylate inj 10 mg/2ml 1

prochlorperazine maleate tab 5 mg (base equivalent)

1

prochlorperazine maleate tab 10 mg (base

equivalent)

1

thioridazine hcl tab 10 mg 1




trifluoperazine hcl tab 1 mg (base equivalent)

1


1


1

trifluoperazine hcl tab 10 mg (base

equivalent)

1

QUINOLINONE DERIVATIVES ABILIFY MAIN INJ 300MG 2 QL (1 vial / 21 days), PA

ABILIFY MAIN INJ 400MG 2 QL (1 vial / 21 days), PA

aripiprazole oral solution 1 mg/ml 1 QL (750 per 30 days)

aripiprazole orally disintegrating tab 10 mg 1 QL (60 tabs / 30 days)

aripiprazole orally disintegrating tab 15 mg 1 QL (60 tabs / 30 days)

aripiprazole tab 2 mg 1 QL (30 tabs / 30 days)







80


ARISTADA INJ 441MG/1. 3 QL (1 / 30 days), PA

ARISTADA INJ 662MG/2 3 QL (1 syringe / 30

days), PA

ARISTADA INJ 882MG/3 3 QL (1 syringe / 30 days), PA

ARISTADA INJ 1064MG 2 QL (1 syringe / 60

days), PA ARISTADA INJ INITIO 2 QL (2.4 in lifetime), PA

REXULTI TAB 0.5MG 3 QL (30 tabs / 30 days), PA

REXULTI TAB 0.25MG 3 QL (30 tabs / 30 days),

PA REXULTI TAB 1MG 3 QL (30 tabs / 30 days),

PA

REXULTI TAB 2MG 3 QL (30 tabs / 30 days), PA



THIOXANTHENES thiothixene cap 1 mg 1

thiothixene cap 2 mg 1



ANTISEPTICS & DISINFECTANTS ANTISEPTIC COMBINATIONS

BUCALSEP SOL 3 PA

BUCALSEP SPR 3 PA

TERSASEPTIC LIQ 3 OTC

ANTISEPTICS & DISINFECTANTS forma-ray sol 20% 1

formaldehyde solution 10% 1 PA

GLUTARALDEHY SOL 25% 2

KERR TRIPLE MIS DYE SWAB 3 OTC, PA

triple dye solution 1 PA

ANTIVIRALS ANTIRETROVIRALS

abacavir sulfate soln 20 mg/ml (base equiv)

1 QL (900 ml / 30 days), PA

abacavir sulfate tab 300 mg (base equiv) 1 QL (30 tabs / 30 days)

abacavir sulfate-lamivudine tab 600-300

mg


abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg



81


APTIVUS CAP 250MG 2 QL (120 caps / 30 days), PA

APTIVUS SOL 2 QL (300 mL / 30 days), PA

atazanavir sulfate cap 150 mg (base equiv) 1 QL (30 caps / 30 days)



ATRIPLA TAB 3 QL (30 tabs / 30 days), PA

BIKTARVY TAB 2 QL (30 tabs / 30 days)

CIMDUO TAB 300-300 2 QL (30 tabs / 30 days)

COMPLERA TAB 2 QL (30 tabs / 30 days)

CRIXIVAN CAP 200MG 2 QL (90 caps / 30 days),

PA

CRIXIVAN CAP 400MG 2 QL (180 caps / 30 days), PA

DELSTRIGO TAB 2 QL (30 tabs / 30 days)

DESCOVY TAB 200/25 2 QL (30 tabs / 30 days)

didanosine delayed release capsule 200 mg 1 QL (60 caps / 30 days)



DOVATO TAB 50-300MG 2 QL (30 tabs / 30 days)

EDURANT TAB 25MG 2 QL (30 tabs / 30 days)

efavirenz cap 50 mg 1 QL (90 caps / 30 days)

efavirenz cap 200 mg 1 QL (60 caps / 30 days)

efavirenz tab 600 mg 1 QL (30 tabs / 30 days)

EMTRIVA CAP 200MG 2 QL (30 caps / 30 days),

PA

EMTRIVA SOL 10MG/ML 2 QL (720 / 30 days), PA

EVOTAZ TAB 300-150 2 QL (30 tabs / 30 days)

fosamprenavir calcium tab 700 mg (base equiv)


FUZEON INJ 90MG 2 QL (60 / 30 days), PA

GENVOYA TAB 2 QL (30 tabs / 30 days)

INTELENCE TAB 25MG 2 QL (60 tabs / 30 days),

PA

INTELENCE TAB 100MG 2 QL (60 tabs / 30 days), PA

INTELENCE TAB 200MG 2 QL (60 tabs / 30 days),

PA

INVIRASE TAB 500MG 2 QL (120 tabs / 30 days),

PA

ISENTRESS CHW 25MG 2 QL (120 ea / 30 days)

ISENTRESS CHW 100MG 2 QL (120 ea / 30 days)

ISENTRESS HD TAB 600MG 2 QL (60 tabs / 30 days)

ISENTRESS POW 100MG 2 QL (60 / 30 days)

ISENTRESS TAB 400MG 2 QL (60 tabs / 30 days)


82


KALETRA TAB 100-25MG 2 QL (60 tabs / 30 days)

KALETRA TAB 200-50MG 2 QL (120 tabs / 30 days)

lamivudine oral soln 10 mg/ml 1 QL (900 ml / 30 days)

lamivudine tab 150 mg 1 QL (60 tabs / 30 days)

lamivudine tab 300 mg 1 QL (30 tabs / 30 days)

lamivudine-zidovudine tab 150-300 mg 1 QL (60 tabs / 30 days)

LEXIVA SUS 50MG/ML 2 QL (1680 ml / 30 days),

PA

lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)

1 QL (390 ml / 30 days)

nevirapine susp 50 mg/5ml 1 QL (1200 mL / 30 days)

nevirapine tab 200 mg 1 QL (60 tabs / 30 days)

nevirapine tab er 24hr 100 mg 1 QL (90 tabs / 30 days),

PA

nevirapine tab er 24hr 400 mg 1 QL (30 tabs / 30 days), PA

NORVIR SOL 80MG/ML 2 QL (480 ml / 30 days)

ODEFSEY TAB 2 QL (30 tabs / 30 days)

PIFELTRO TAB 100MG 2 QL (30 tabs / 30 days)

PREZCOBIX TAB 800-150 2 QL (30 tabs / 30 days)

PREZISTA SUS 100MG/ML 2 QL (240 ml / 30 days)

PREZISTA TAB 75MG 2 QL (60 tabs / 30 days)




RESCRIPTOR TAB 200MG 2 QL (180 tabs / 30 days), PA

REYATAZ POW 50MG 2 QL (240 packs / 30

days)

ritonavir tab 100 mg 1 QL (360 tabs / 30 days)

SELZENTRY SOL 20MG/ML 2 QL (1,840 mL / 30 days), PA

SELZENTRY TAB 25MG 2 QL (120 tabs / 30 days),

PA


PA

SELZENTRY TAB 150MG 2 QL (60 tabs / 30 days), PA


PA stavudine cap 15 mg 1 QL (60 caps / 30 days)

stavudine cap 20 mg 1 QL (60 caps / 30 days)



STRIBILD TAB 2 QL (30 tabs / 30 days)

SYMFI LO TAB 2 QL (30 tabs / 30 days)

SYMFI TAB 2 QL (30 tabs / 30 days)


83


SYMTUZA TAB 3 QL (30 tabs / 30 days), PA

tenofovir disoproxil fumarate tab 300 mg 1 QL (30 tabs / 30 days)

TIVICAY TAB 10MG 2 QL (30 tabs / 30 days)



TRIUMEQ TAB 2 QL (30 tabs / 30 days)

TRUVADA TAB 200-300 2 QL (30 tabs / 30 days)

TYBOST TAB 150MG 2 QL (30 tabs / 30 days)

VIDEX SOL 2GM 2 QL (1200 / 30 days), PA

VIDEX SOL 4GM 2 QL (1200 / 30 days), PA

VIRACEPT TAB 250MG 2 QL (270 tabs / 30 days),

PA

VIRACEPT TAB 625MG 2 QL (120 tabs / 30 days), PA

VIREAD POW 40MG/GM 2 QL (240 / 30 days)

VIREAD TAB 150MG 2 QL (30 tabs / 30 days)



zidovudine cap 100 mg 1 QL (180 caps / 30 days)

zidovudine syrup 10 mg/ml 1 QL (1800 / 30 days)

zidovudine tab 300 mg 1 QL (60 tabs / 30 days), PA

CMV AGENTS ganciclovir sodium for inj 500 mg 1

PREVYMIS TAB 240MG 2 QL (100 tabs / year), PA

PREVYMIS TAB 480MG 2 QL (100 tabs / year), PA

valganciclovir hcl for soln 50 mg/ml (base

equiv)

1

valganciclovir hcl tab 450 mg (base

equivalent)

1

HEPATITIS AGENTS adefovir dipivoxil tab 10 mg 1

BARACLUDE SOL 2

DAKLINZA TAB 30MG 3 QL (30 tabs / 30 days),

PA DAKLINZA TAB 60MG 3 QL (30 tabs / 30 days),

PA

DAKLINZA TAB 90MG 3 QL (30 tabs / 30 days), PA

entecavir tab 0.5 mg 1 QL (30 tabs / 30 days)

entecavir tab 1 mg 1 QL (30 tabs / 30 days)

EPCLUSA TAB 400-100 3 QL (30 tabs / 30 days), PA

EPIVIR HBV SOL 5MG/ML 2


84


HARVONI TAB 90-400MG 3 QL (30 tabs / 30 days), PA

lamivudine tab 100 mg (hbv) 1

MAVYRET TAB 100-40MG 3 QL (84 tabs / 28 days), PA

MODERIBA PAK 800/DAY 3 QL (56 tabs / 30 days),

PA MODERIBA PAK 1200/DAY 3 QL (56 tabs / 30 days),

PA

MODERIBA TAB 600/DAY 3 QL (1 kit / 30 days), PA

MODERIBA TAB 1000/DAY 3 QL (1 kit / 30 days), PA

PEGASYS INJ 2 QL (2 syringes / 30 days), PA

PEGASYS INJ 180MCG/M 2 QL (4 syringes / 30 days), PA

PEGASYS INJ PROCLICK 2 QL (2 syringes / 30

days), PA REBETOL SOL 40MG/ML 3 QL (900 ml / 30 days),

PA

RIBAPAK PAK 800/DAY 2 QL (56 tabs / 30 days), PA

RIBAPAK PAK 1200/DAY 2 QL (56 tabs / 30 days),

PA RIBAPAK TAB 600/DAY 2 QL (1 kit / 30 days), PA

RIBAPAK TAB 600/DAY 2 QL (4 / 30 days), PA

RIBAPAK TAB 1000/DAY 2 QL (1 kit / 30 days), PA

RIBAPAK TAB 1000/DAY 2 QL (4 / 30 days), PA

ribasphere tab 400mg 1 QL (56 tabs / 30 days)

ribasphere tab 600mg 1 QL (56 tabs / 30 days)

ribavirin cap 200 mg 1 QL (180 caps / 30 days)

ribavirin tab 200 mg 1 QL (180 tabs / 30 days)

SOFOS/VELPAT TAB 400-100 1 QL (30 tabs / 30 days),

PA

SOVALDI TAB 400MG 3 QL (30 tabs / 30 days),

PA

TECHNIVIE TAB 3 QL (30 tabs / 30 days), PA

VIEKIRA PAK TAB 3 QL (84 tabs / 30 days),

PA VIEKIRA XR TAB 3 QL (84 tabs / 30 days),

PA

VOSEVI TAB 3 QL (28 tabs / 28 days), PA

ZEPATIER TAB 50-100MG 3 QL (30 tabs / 30 days), PA

HERPES AGENTS acyclovir cap 200 mg 1


85


acyclovir susp 200 mg/5ml 1

acyclovir tab 400 mg 1

acyclovir tab 800 mg 1

famciclovir tab 125 mg 1 QL (21 tabs / 30 days)



SITAVIG TAB 50MG 3 PA

valacyclovir hcl tab 1 gm 1 QL (30 tabs / 30 days)

valacyclovir hcl tab 500 mg 1 QL (42 tabs / 30 days)

INFLUENZA AGENTS oseltamivir phosphate cap 30 mg (base

equiv) 1 QL (10 caps / 180 days)

oseltamivir phosphate cap 45 mg (base equiv)


oseltamivir phosphate cap 75 mg (base equiv)


oseltamivir phosphate for susp 6 mg/ml (base equiv)

1 QL (120 mL / 180 days), PA

RELENZA MIS DISKHALE 2 QL (1 inhaler / 180

days)

rimantadine hydrochloride tab 100 mg 1

XOFLUZA TAB 20MG 2 QL (2 tabs / 365 days)

XOFLUZA TAB 40MG 2 QL (2 tabs / 365 days)

BETA BLOCKERS ALPHA-BETA BLOCKERS

carvedilol tab 3.125 mg 1



carvedilol tab 25 mg 1

labetalol hcl tab 100 mg 1



BETA BLOCKERS CARDIO-SELECTIVE acebutolol hcl cap 200 mg 1

acebutolol hcl cap 400 mg 1

atenolol tab 25 mg 1



betaxolol hcl tab 10 mg 1

betaxolol hcl tab 20 mg 1

bisoprolol fumarate tab 5 mg 1

bisoprolol fumarate tab 10 mg 1

metoprolol succinate tab er 24hr 25 mg

(tartrate equiv)

1

metoprolol succinate tab er 24hr 50 mg

(tartrate equiv)

1


86


metoprolol succinate tab er 24hr 100 mg (tartrate equiv)

1

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

1

metoprolol tartrate tab 25 mg 1




BETA BLOCKERS NON-SELECTIVE HEMANGEOL SOL 4.28/ML 3 PA

propranolol hcl cap er 24hr 60 mg 1




propranolol hcl inj 1 mg/ml 1

propranolol hcl oral soln 20 mg/5ml 1

propranolol hcl oral soln 40 mg/5ml 1

propranolol hcl tab 10 mg 1





sotalol hcl (afib/afl) tab 80 mg 1



SOTALOL HCL INJ 150/10ML 3 PA

sotalol hcl tab 80 mg 1




SOTYLIZE SOL 5MG/ML 3 PA

timolol maleate tab 5 mg 1



CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS

amlodipine besylate tab 2.5 mg (base equivalent)

1

amlodipine besylate tab 5 mg (base equivalent)

1

amlodipine besylate tab 10 mg (base

equivalent)

1

CARDIZEM LA TAB 120MG 3 ST

CLEVIPREX EMU 50/100ML 3 PA

diltiazem cap 240mg cd 1

diltiazem cap 300mg cd 1


87


diltiazem hcl cap er 12hr 60 mg 1






diltiazem hcl coated beads cap er 24hr 120

mg

1

diltiazem hcl coated beads cap er 24hr 180 mg

1

diltiazem hcl coated beads cap er 24hr 360

mg

1

diltiazem hcl extended release beads cap

er 24hr 120 mg

1

diltiazem hcl extended release beads cap er 24hr 180 mg

1


1


er 24hr 300 mg

1


1


er 24hr 420 mg

1

diltiazem hcl tab 30 mg 1




felodipine tab er 24hr 2.5 mg 1

felodipine tab er 24hr 5 mg 1

felodipine tab er 24hr 10 mg 1

isradipine cap 2.5 mg 1

isradipine cap 5 mg 1

matzim la tab 180mg/24 1





nicardipine hcl cap 20 mg 1

nicardipine hcl cap 30 mg 1

nifedipine cap 10 mg 1 PA

nifedipine cap 20 mg 1 PA

nifedipine tab er 24hr 30 mg 1



nifedipine tab er 24hr osmotic release 30

mg

1


88


nifedipine tab er 24hr osmotic release 60 mg

1

nifedipine tab er 24hr osmotic release 90 mg

1

nimodipine cap 30 mg 1

nisoldipine tab er 24hr 8.5 mg 1

nisoldipine tab er 24hr 17 mg 1


nisoldipine tab er 24hr 25.5 mg 1




NYMALIZE SOL 60/20ML 3 ST

verapamil hcl cap er 24hr 100 mg 1







verapamil hcl tab 40 mg 1



verapamil hcl tab er 120 mg 1



CARDIOTONICS CARDIAC GLYCOSIDES

digitek tab 0.25mg 1

digitek tab 0.125mg 1

digoxin inj 0.25 mg/ml 1

digoxin oral soln 0.05 mg/ml 1

LANOXIN PED INJ 0.1MG/ML 3 PA

LANOXIN TAB 0.0625MG 3 PA

LANOXIN TAB 0.1875MG 3 PA

CARDIOVASCULAR AGENTS - MISC. CARDIOPLEGIC SOLUTIONS

cardioplegic soln 1

CARDIOVASCULAR AGENTS MISC. - COMBINATIONS amlodipine besylate-atorvastatin calcium

tab 2.5-10 mg 1

amlodipine besylate-atorvastatin calcium tab 2.5-20 mg

1

amlodipine besylate-atorvastatin calcium tab 2.5-40 mg

1


89


amlodipine besylate-atorvastatin calcium tab 5-10 mg

1 PA


1


1


1


1

amlodipine besylate-atorvastatin calcium

tab 10-20 mg

1

amlodipine besylate-atorvastatin calcium

tab 10-40 mg

1


1

BIDIL TAB 3 PA

ENTRESTO TAB 24-26MG 3 QL (60 tabs / 30 days),

PA

ENTRESTO TAB 49-51MG 3 QL (60 tabs / 30 days), PA

ENTRESTO TAB 97-103MG 3 QL (60 tabs / 30 days),

PA

PERIPHERAL VASODILATORS papaverine hcl inj 30 mg/ml 1

PROSTAGLANDIN VASODILATORS epoprostenol sodium for inj 0.5 mg 1 PA

epoprostenol sodium for inj 1.5 mg 1 PA

ORENITRAM TAB 0.25MG 3 QL (90 tabs / 30 days), PA


ORENITRAM TAB 1MG 3 QL (120 tabs / 30 days),

PA


ORENITRAM TAB 5MG 3 PA

treprostinil inj soln 20 mg/20ml (1 mg/ml) 1 PA

treprostinil inj soln 50 mg/20ml (2.5 mg/ml)

1 PA

treprostinil inj soln 100 mg/20ml (5

mg/ml)

1 PA

treprostinil inj soln 200 mg/20ml (10

mg/ml)

1 PA

TYVASO START SOL 0.6MG/ML 2 PA

VELETRI INJ 0.5MG 3 PA

VELETRI INJ 1.5MG 3 PA


90


VENTAVIS SOL 10MCG/ML 2 PA

VENTAVIS SOL 20MCG/ML 2 PA

PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR

ANTAGONISTS ambrisentan tab 5 mg 1 QL (30 tabs / 30 days),

PA

ambrisentan tab 10 mg 1 QL (30 tabs / 30 days),

PA

bosentan tab 62.5 mg 1 QL (60 tabs / 30 days),

PA

bosentan tab 125 mg 1 QL (60 tabs / 30 days), PA

OPSUMIT TAB 10MG 2 QL (30 tabs / 30 days), PA

PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS ADCIRCA TAB 20MG 2 QL (60 tabs / 30 days),

PA

sildenafil citrate for suspension 10 mg/ml 1 QL (180 ml / 30 days), PA

sildenafil citrate tab 20 mg 1 QL (90 tabs / 30 days), PA

tadalafil tab 20 mg (pah) 1

PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST UPTRAVI TAB 200/800 3 PA

UPTRAVI TAB 200MCG 3 PA








PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE

STIMULATOR ADEMPAS TAB 0.5MG 2 QL (90 tabs / 30 days),

PA

ADEMPAS TAB 1.5MG 2 QL (90 tabs / 30 days), PA

ADEMPAS TAB 1MG 2 QL (90 tabs / 30 days), PA

ADEMPAS TAB 2.5MG 2 QL (90 tabs / 30 days), PA

ADEMPAS TAB 2MG 2 QL (90 tabs / 30 days), PA


91


SINUS NODE INHIBITORS CORLANOR SOL 5MG/5ML 2 QL (420 ml / 30 days),

PA

CORLANOR TAB 5MG 2 QL (60 tabs / 30 days), PA

CORLANOR TAB 7.5MG 2 QL (60 tabs / 30 days),

PA

TRANSTHYRETIN STABILIZERS VYNDAMAX CAP 61MG 2 QL (120 caps/ 30 days),

PA

VYNDAQEL CAP 20MG 2 QL (30 caps / 30 days), PA

VASOACTIVE NATRIURETIC PEPTIDES NATRECOR INJ 1.5MG 3 PA

CEPHALOSPORINS CEPHALOSPORINS - 1ST GENERATION

cefadroxil cap 500 mg 1

cefadroxil for susp 250 mg/5ml 1

cefadroxil for susp 500 mg/5ml 1

cefadroxil tab 1 gm 1

CEFAZOLIN INJ 100GM 3 PA

CEFAZOLIN INJ 300GM 3 PA

cefazolin sodium for inj 1 gm 1



cefazolin sodium for inj 500 mg 1

cephalexin cap 250 mg 1



cephalexin for susp 125 mg/5ml 1

cephalexin for susp 250 mg/5ml 1

cephalexin tab 250 mg 1

cephalexin tab 500 mg 1

CEPHALOSPORINS - 2ND GENERATION cefaclor cap 250 mg 1

cefaclor cap 500 mg 1

CEFACLOR ER TAB 500MG 3 PA

cefaclor for susp 125 mg/5ml 1



cefotetan disodium for inj 1 gm 1



cefoxitin sodium for inj 10 gm 1

cefprozil for susp 125 mg/5ml 1


92


cefprozil for susp 250 mg/5ml 1

cefprozil tab 250 mg 1

cefprozil tab 500 mg 1

cefuroxime axetil tab 250 mg 1

cefuroxime axetil tab 500 mg 1

cefuroxime sodium for inj 7.5 gm 1

cefuroxime sodium for inj 750 mg 1

CEPHALOSPORINS - 3RD GENERATION cefdinir cap 300 mg 1

cefdinir for susp 125 mg/5ml 1

cefdinir for susp 250 mg/5ml 1

cefditoren pivoxil tab 200 mg (base

equivalent)

1

cefditoren pivoxil tab 400 mg (base

equivalent)

1

cefixime cap 400 mg 1 PA

cefixime for susp 100 mg/5ml 1

cefixime for susp 200 mg/5ml 1

cefotaxime sodium for inj 1 gm 1



cefotaxime sodium for inj 500 mg 1

cefpodoxime proxetil for susp 50 mg/5ml 1

cefpodoxime proxetil for susp 100 mg/5ml 1

cefpodoxime proxetil tab 100 mg 1

cefpodoxime proxetil tab 200 mg 1

ceftazidime for inj 1 gm 1 PA



ceftriaxone sodium for inj 1 gm 1



ceftriaxone sodium for inj 250 mg 1

ceftriaxone sodium for inj 500 mg 1

SUPRAX CHW 100MG 3 PA

SUPRAX CHW 200MG 3 PA

SUPRAX SUS 500/5ML 3 PA

CEPHALOSPORINS - 4TH GENERATION cefepime hcl for inj 1 gm 1

cefepime hcl for inj 2 gm 1

CONTRACEPTIVES COMBINATION CONTRACEPTIVES - ORAL

amethia tab 1 QL (91 tabs / 91 days)

aubra tab 0.1-0.02 1 QL (30 tabs / 30 days)

azurette tab 28 day 1


93


caziant pak 1

chateal tab 0.15/30 1 QL (30 tabs / 30 days)

cyred tab 1 QL (30 tabs / 30 days)

drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg


drospirenone-ethinyl estradiol tab 3-0.03

mg


enpresse-28 tab 1

fayosim tab 1 QL (91 tabs / 91 days)

layolis fe chw 1 QL (30 ea / 30 days)

leena tab 1

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)


LO LOESTRIN TAB 1-10-10 3 PA

low-ogestrel tab 1 QL (30 tabs / 30 days)

microgestin tab 1.5/30 1 QL (30 tabs / 30 days)

microgestin tab 1/20 1 QL (30 tabs / 30 days)

microgestin tab fe1.5/30 1 QL (30 tabs / 30 days)

MINASTRIN 24 CHW FE 3 QL (30 ea / 30 days), PA

mononessa tab 1 QL (30 tabs / 30 days)

NATAZIA TAB 3 PA

necon tab 0.5/35 1 QL (30 tabs / 30 days)

necon tab 1/35 1 QL (30 tabs / 30 days)

necon tab 7/7/7 1

ogestrel tab 1 QL (30 tabs / 30 days)

quasense tab 1 QL (91 tabs / 91 days)

rivelsa tab 1 QL (91 tabs / 91 days)

SAFYRAL TAB 3 QL (30 tabs / 30 days),

PA

tarina fe tab 1/20 1 QL (30 tabs / 30 days)

tilia fe tab 1

trinessa lo tab 1

trinessa tab 1

zenchent tab 1 QL (30 tabs / 30 days)

zovia 1/35e tab 1 QL (30 tabs / 30 days)

COMBINATION CONTRACEPTIVES - TRANSDERMAL xulane dis 150-35 1 QL (3 ea / 30 days)

COMBINATION CONTRACEPTIVES - VAGINAL NUVARING MIS 2 QL (1 ring / 21 days)

EMERGENCY CONTRACEPTIVES ELLA TAB 30MG 3 PA

my way tab 1.5mg 1 OTC

PLAN B TAB 1.5MG 3 OTC, PA

PROGESTIN CONTRACEPTIVES - INJECTABLE DEPO-SQ PROV INJ 104 3 PA


94


medroxyprogesterone acetate im susp 150 mg/ml

1 QL (1 vial / 75 days)

medroxyprogesterone acetate im susp prefilled syr 150 mg/ml

1 QL (1 syringe / 75 days)

PROGESTIN CONTRACEPTIVES - ORAL lyza tab 0.35mg 1

SLYND TAB 4MG 3 PA

CORTICOSTEROIDS GLUCOCORTICOSTEROIDS

ACTIVE INJEC KIT KL-3 3 PA

betamethasone sod phosphate & acetate inj susp 6 (3-3) mg/ml

1

budesonide delayed release particles cap 3 mg

1

budesonide tab er 24hr 9 mg 1 ST

cortisone acetate tab 25 mg 1

DEPO-MEDROL INJ 20MG/ML 3 PA

dexamethasone elixir 0.5 mg/5ml 1

dexamethasone sod phosphate

preservative free inj 10 mg/ml

1

dexamethasone sodium phosphate inj 4

mg/ml

1

dexamethasone sodium phosphate inj 10 mg/ml

1

dexamethasone sodium phosphate inj 20

mg/5ml

1

dexamethasone sodium phosphate inj 100 mg/10ml

1

dexamethasone sodium phosphate inj 120 mg/30ml

1

dexamethasone soln 0.5 mg/5ml 1

dexamethasone tab 0.5 mg 1


dexamethasone tab 1 mg 1





dexamethasone tab therapy pack 1.5 mg

(21)

1 PA

dexamethasone tab therapy pack 1.5 mg (35)

1 PA

dexamethasone tab therapy pack 1.5 mg (51)

1 PA

EMFLAZA TAB 6MG 3 PA




95



hydrocortisone tab 5 mg 1



KENALOG-10 INJ 10MG/ML 3 PA

MEDROL TAB 2MG 3 ST

methylprednisolone acetate inj susp 40

mg/ml

1

methylprednisolone acetate inj susp 80 mg/ml

1

methylprednisolone sod succ for inj 40 mg

(base equiv)

1

methylprednisolone sod succ for inj 125

mg (base equiv)

1

methylprednisolone sod succ for inj 1000 mg (base equiv)

1

methylprednisolone tab 4 mg 1




methylprednisolone tab therapy pack 4 mg

(21)

1

MILLIPRED DP PAK 5MG 3 PA

MILLIPRED TAB 5MG 3 PA

PHYS EZ USE KIT M-PRED 3 PA

prednisolone sod phos orally disintegr tab 10 mg (base eq)

1

prednisolone sod phos orally disintegr tab 15 mg (base eq)

1

prednisolone sod phos orally disintegr tab

30 mg (base eq)

1

prednisolone sod phosph oral soln 6.7

mg/5ml (5 mg/5ml base)

1

prednisolone sod phosphate oral soln 15

mg/5ml (base equiv)

1

prednisolone sodium phosphate oral soln 25 mg/5ml (base eq)

1

prednisolone syrup 15 mg/5ml (usp

solution equivalent)

1

prednisone oral soln 5 mg/5ml 1

prednisone tab 1 mg 1

prednisone tab 2.5 mg 1





prednisone tab therapy pack 5 mg (21) 1


96





RAYOS TAB 1MG 3 ST

RAYOS TAB 2MG 3 ST

RAYOS TAB 5MG 3 ST

SOLU-CORTEF INJ 100MG 3 PA




SOLU-MEDROL INJ 2GM 3 PA

SOLU-MEDROL INJ 500MG 3 PA

triamcinolone acetonide inj susp 40 mg/ml 1 PA

MINERALOCORTICOIDS fludrocortisone acetate tab 0.1 mg 1

COUGH/COLD/ALLERGY ANTITUSSIVES

benzonatate cap 100 mg 1



hydrocodone w/ homatropine syrup 5-1.5 mg/5ml

1

hydrocodone w/ homatropine tab 5-1.5 mg 1

st joseph co syp 7.5/5ml 1 OTC

COUGH/COLD/ALLERGY COMBINATIONS ALDEX GS TAB 30-190MG 2 OTC

allergy d tab 5-120mg 1 OTC, QL (60 tabs / 30

days) allrgy rel-d tab 10-240mg 1 OTC, QL (30 tabs / 30

days)

allrgy rlf-d tab 5-120mg 1 OTC, QL (60 tabs / 30

days)

brotapp liq 1 OTC, QL (480 mL / 30

days)

CARBAPHEN 12 LIQ 3 PA

CARBAPHEN 12 SUS PED 3 PA

CLARINEX-D TAB 2.5-120 3 PA

CODAR D LIQ 30-8/5ML 2 OTC

codar gf liq 200-8/5 1 OTC

cold mult-sy tab daytime 1 OTC, QL (36 tabs / 30

days)

cold/allergy elx children 1 OTC, QL (480 mL / 30 days)

cold/cough elx child 1 OTC, QL (480 mL / 30 days)


97


dibromm chld liq 2.5-1-5 1 OTC, QL (480 mL / 30 days)

DOUBLE-TUSSN LIQ DM 3 OTC, PA

fexofenadine-pseudoephedrine tab er 12hr 60-120 mg

1 OTC, PA

gnp tussin syp cf 1 OTC, QL (480 mL / 30

days) guaiatuss ac syp 100-10/5 1 OTC, QL (240 ml / 30

days)

hydrocod polst-chlorphen polst er susp 10-8 mg/5ml

1

intense coug liq reliever 1 OTC, QL (480 mL / 30 days)

lohist-dm syp 5-2-10mg 1 OTC

MUCINEX CGH GRA 5-100MG 2 OTC, QL (36 packets / 30 days); For 12 years of age and younger

mucus relief liq 5-100mg 1 OTC, QL (480 mL / 30 days)

mucus-dm max tab 60-1200 1 OTC, QL (60 tabs / 30

days)

mucus-dm tab 30-600mg 1 OTC, QL (60 tabs / 30 days)

OBREDON SOL 2.5-200 3 QL (1800 ml / 30 days),

PA promethazine & phenylephrine syrup

6.25-5 mg/5ml

1

promethazine w/ codeine syrup 6.25-10 mg/5ml

1

promethazine-dm syrup 6.25-15 mg/5ml 1

45PSE/400GFN TAB 3 OTC, PA

60PSE/400GFN TAB /20DM 3 OTC, PA

pseudoephed-bromphen-dm syrup 30-2-10

mg/5ml

1

pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml

1 OTC

pyrilamine mal-phenylephrine hcl tann susp 16-5 mg/5ml

1 OTC

q-tapp elx 1-15/5ml 1 OTC, QL (480 mL / 30 days)

RELHIST CHW 3

RESPA C&C IR TAB 3 OTC, PA

ROBITUSSIN LIQ CGH/CLD 3 OTC, PA

ROBITUSSIN LIQ DM MAX 3 OTC, PA

ROBITUSSN DM SYP 3 OTC, PA

rynex pse liq 1 OTC, QL (480 mL / 30 days)

SEMPREX-D CAP 8-60MG 3 PA


98


sinus congst tab /pain dt 1 OTC, QL (24 tabs / 30 days)

supress dm dro 5-50/ml 1 OTC

TRIAMINIC NT MIS COLD/CGH 3 OTC, PA

TRICODE AR LIQ 30-2-8 2 OTC

TRICODE GF LIQ 30-8-200 2 OTC

tussin cf liq 1 OTC, QL (480 mL / 30

days)

tussin cf liq max/m-s 1 OTC, QL (480 mL / 30 days)

tussin dm liq max 1 OTC, QL (480 mL / 30

days)

tussin dm syp 100-10/5 1 OTC, QL (480 mL / 30

days)

TUZISTRA XR SUS 3 PA

VICKS NATURE LIQ COLD/FLU 3 OTC

VICKS NATURE LIQ CONGEST 3 OTC, PA

wal-tap elx cld/alle 1 OTC, QL (480 mL / 30

days)

EXPECTORANTS chest conges tab 400mg 1 OTC, QL (100 tabs / 30

days)

coughtab tab 200mg 1 OTC, QL (100 tabs / 30

days) guaifenesin tab er 12hr 1200 mg 1 OTC, QL (60 tabs / 30

days)

mucus-er tab 600mg 1 OTC, QL (60 tabs / 30 days)

SSKI SOL 1GM/ML 3 PA

tussin chest syp 100/5ml 1 OTC, QL (480 mL / 30

days)

yodefan-nf liq 200-5ml 1 OTC

MISC. RESPIRATORY INHALANTS HYPERSAL NEB 3.5% 3 PA

nebusal neb 3% 1

NEBUSAL NEB 6% 3 PA

sodium chloride soln nebu 0.9% 1

sodium chloride soln nebu 7% 1

sodium chloride soln nebu 10% 1

MUCOLYTICS acetylcysteine inhal soln 10% 1

acetylcysteine inhal soln 20% 1

DERMATOLOGICALS ACNE PRODUCTS - Covered for members through age 18

acne treatme cre 10% 1 OTC; (benzoyl peroxide

10%)


99


adapalene gel 0.1% 1 QL (45 gm / 30 days), PA

BENZOYL PER GEL 2.5% 2 OTC

benzoyl per liq 5% wash 1 OTC, QL (237 / 30 days)

benzoyl per liq 10% wash 1 OTC, QL (227 gm / 30

days)

benzoyl peroxide gel 5% 1 OTC

benzoyl peroxide gel 10% 1 OTC, QL (60 gm / 30 days)

benzoyl peroxide-erythromycin gel 5-3% 1 PA

bpo creamy kit 4% wash 1 OTC

clindacin-p pad 1% 1

clindamycin phosph-benzoyl peroxide

(refrig) gel 1.2 (1)-5%

1 PA

clindamycin phosphate gel 1% 1 PA

clindamycin phosphate lotion 1% 1 PA

clindamycin phosphate soln 1% 1

DIFFERIN GEL 0.1% 1 OTC, QL (45 gm / 30

days)

erythromycin soln 2% 1

isotretinoin cap 10 mg 1 PA




panoxyl wash liq 4% 1 OTC; (benzoyl peroxide 4%)

tretinoin cream 0.1% 1 QL (48 gm / 30 days),

PA

tretinoin cream 0.05% 1 QL (48 gm / 30 days), PA

tretinoin cream 0.025% 1 QL (48 gm / 30 days), PA

tretinoin gel 0.01% 1 QL (48 gm / 30 days), PA

tretinoin gel 0.025% 1 QL (48 gm / 30 days), PA

ANTI-INFLAMMATORY AGENTS - TOPICAL diclofenac epolamine patch 1.3% 1 PA

diclofenac sodium gel 1% 1 QL (200 grams / 30

days)

diclofenac sodium soln 1.5% 1

PENNSAID SOL 2% 3 PA

ANTIBIOTICS - TOPICAL ALTABAX OIN 1% 3 PA

bacitracin oint 500 unit/gm 1 OTC, QL (30 gm / 30 days)

bacitracin zinc oint 500 unit/gm 1 OTC


100


CORTISPORIN CRE 0.5% 3 PA

CORTISPORIN OIN 1% 3 PA

double antib oin 1 OTC, QL (30 gm / 30 days)

gentamicin sulfate cream 0.1% 1

gentamicin sulfate oint 0.1% 1

mupirocin calcium cream 2% 1 QL (15 gm / 30 days),

PA

mupirocin oint 2% 1 QL (132 gm / 30 days)

NEOSPORIN OIN ORIGINAL 3 OTC, PA

triple antib oin 1 OTC, QL (30 gm / 30

days) XEPI CRE 1% 2 QL (1 tube (10 gr) / 30

days)

ANTIFUNGALS - TOPICAL antifungal cre 1% 1 OTC, QL (30 gm / 30

days)

ath foot pow aer 1% 1 OTC, QL (138 mL / 30

days) ciclodan cre 0.77% 1

ciclodan sol 8% 1

ciclopirox gel 0.77% 1

ciclopirox olamine susp 0.77% (base

equiv)

1

ciclopirox shampoo 1% 1

clotrimazole cream 1% 1

clotrimazole soln 1% 1

clotrimazole w/ betamethasone cream

1-0.05%

1

clotrimazole w/ betamethasone lotion

1-0.05%

1

econazole nitrate cream 1% 1

ECOZA AER 1% 3 PA

ERTACZO CRE 2% 3 ST

EXELDERM CRE 1% 3 ST

EXELDERM SOL 1% 3 ST

EXODERM LOT 25-1% 3 PA

JUBLIA SOL 10% 3 QL (12 ml / 30 days), ST

ketoconazole cream 2% 1

ketoconazole shampoo 2% 1

lotrimin af aer 2% 1 OTC

luliconazole cream 1% 1 PA

MENTAX CRE 1% 3 ST

miconazorb pow af 2% 1 OTC, QL (100 gm / 30 days)

naftifine hcl gel 1% 1 PA


101


NAFTIN GEL 2% 3 ST

NIZORAL A-D SHA 1% 2 OTC

nystatin cream 100000 unit/gm 1

nystatin oint 100000 unit/gm 1

nystatin topical powder 100000 unit/gm 1

nystatin-triamcinolone cream 100000-0.1 unit/gm-%

1

nystatin-triamcinolone oint 100000-0.1

unit/gm-%

1

OXISTAT LOT 1% 3 ST

sm antifungl cre 2% 1 OTC, QL (100 gm / 30

days) tetterine oin 2% 1 OTC, QL (100 gm / 30

days)

XOLEGEL GEL 2% 3 ST

ANTIHISTAMINES-TOPICAL benadryl itc gel 2% 1 OTC, QL (120 gm / 30

days)

ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL diclofenac sodium (actinic keratoses) gel

3% 1 QL (100 gm / 30 days)

FLUOROPLEX CRE 1% 3 PA

fluorouracil cream 5% 1

fluorouracil soln 2% 1

fluorouracil soln 5% 1

LEVULAN KERA SOL 20% 3 PA

PICATO GEL 0.05% 3 PA

PICATO GEL 0.015% 3 PA

TARGRETIN GEL 1% 2

TOLAK CRE 4% 3 PA

VALCHLOR GEL 0.016% 2

ANTIPSORIATICS acitretin cap 10 mg 1

acitretin cap 17.5 mg 1

acitretin cap 25 mg 1

calcipotriene cream 0.005% 1 QL (120 grams / 30

days), PA calcipotriene oint 0.005% 1 QL (120 grams / 30

days)

calcipotriene soln 0.005% (50 mcg/ml) 1 QL (60 mL / 30 days)

COSENTYX INJ 150MG/ML 2 QL (2 syringes / 30 days), PA

COSENTYX PEN INJ 300DOSE 2 QL (2 pens / 30 days), PA

ILUMYA SOL 100MG/ML 3 QL (1 syringe / 84 days), PA


102


SILIQ INJ 210/1.5 2 QL (2 syringes / 28 days), PA

SKYRIZI INJ 150DOSE 3 QL (2 syringes / 90 days), PA

SORILUX AER 0.005% 3 ST

STELARA INJ 45MG/0.5 3 PA

STELARA INJ 90MG/ML 3 PA

tazarotene cream 0.1% 1 PA

TAZORAC CRE 0.05% 2 PA

TREMFYA INJ 100MG/ML 3 QL (1 syringe / 56 days), PA

ZITHRANOL SHA 1% 3 PA

ANTISEBORRHEIC PRODUCTS dandruff sha 1% 1 OTC, QL (420 mL / 30

days)

ANTIVIRALS - TOPICAL ABREVA CRE 10% 2 OTC, QL (2 gm / 30

days)

acyclovir cream 5% 1 QL (5 gm / 30 days), PA

acyclovir oint 5% 1 QL (30 gm / 30 days), PA

DENAVIR CRE 1% 3 QL (5 gm / 30 days), ST

docosanol cream 10% 1 OTC

XERESE CRE 5-1% 3 ST

ZOVIRAX OIN 5% 1 QL (30 / 30 days), PA

BURN PRODUCTS ssd cre 1% 1

SULFAMYLON CRE 85MG/GM 2

CAUTERIZING AGENTS arzol silver mis nitr app 1

CORTICOSTEROIDS - TOPICAL ALA SCALP LOT 2% 3 PA

alclometasone dipropionate cream 0.05% 1 QL (120 gm / 30 days)

alclometasone dipropionate oint 0.05% 1 QL (120 gm / 30 days)

amcinonide cream 0.1% 1 QL (120 gm / 30 days)

amcinonide lotion 0.1% 1 QL (120 mL / 30 days)

anti-itch lot 1% 1 OTC, QL (120 mL / 30 days)

betamethasone dipropionate augmented cream 0.05%

1 QL (120 gm / 30 days)

betamethasone dipropionate augmented gel 0.05%

1 QL (120 gm / 30 days)

betamethasone dipropionate augmented lotion 0.05%

1 QL (120 mL / 30 days)

betamethasone dipropionate augmented

oint 0.05%

1 QL (120 gm / 30 days)


103


betamethasone dipropionate cream 0.05% 1 QL (120 gm / 30 days)

betamethasone dipropionate lotion 0.05% 1 QL (120 mL / 30 days)

betamethasone dipropionate oint 0.05% 1 QL (120 gm / 30 days)

betamethasone valerate aerosol foam 0.12%

1

betamethasone valerate cream 0.1% (base

equivalent)

1 QL (120 gm / 30 days)

betamethasone valerate lotion 0.1% (base equivalent)

1 QL (120 mL / 30 days)

betamethasone valerate oint 0.1% (base equivalent)

1 QL (120 gm / 30 days)

calcipotriene-betamethasone dipropionate oint 0.005-0.064%

1 QL (60 grams / 30 days)

CAPEX SHA 0.01% 3 ST

clobetasol e cre 0.05% 1 QL (120 gm / 30 days)

clobetasol propionate cream 0.05% 1 QL (120 gm / 30 days)

clobetasol propionate emulsion foam 0.05%

1 QL (1 can / 30 days)

clobetasol propionate foam 0.05% 1

clobetasol propionate gel 0.05% 1 QL (120 gm / 30 days)

clobetasol propionate lotion 0.05% 1 QL (120 mL / 30 days)

clobetasol propionate oint 0.05% 1 QL (120 gm / 30 days)

clobetasol propionate soln 0.05% 1

clobetasol propionate spray 0.05% 1

clocortolone pivalate cream 0.1% 1 QL (120 gm / 30 days)

clodan sha 0.05% 1

DESONATE GEL 0.05% 3 QL (120 gm / 30 days),

ST

desonide cream 0.05% 1 QL (120 gm / 30 days)

desonide lotion 0.05% 1 QL (120 mL / 30 days)

desonide oint 0.05% 1 QL (120 gm / 30 days)

desoximetasone cream 0.05% 1 QL (120 gm / 30 days)

desoximetasone cream 0.25% 1 QL (120 gm / 30 days)

desoximetasone gel 0.05% 1 QL (120 gm / 30 days)

desoximetasone oint 0.05% 1 QL (120 gm / 30 days)

desoximetasone oint 0.25% 1 QL (120 gm / 30 days)

desoximetasone spray 0.25% 1 PA

ENSTILAR AER 3 ST

EPIFOAM AER 1% 3 PA

fluocinolone acetonide cream 0.01% 1

fluocinolone acetonide cream 0.025% 1 QL (120 gm / 30 days)

fluocinolone acetonide oil 0.01% (body oil) 1

fluocinolone acetonide oil 0.01% (scalp oil) 1

fluocinolone acetonide oint 0.025% 1 QL (120 gm / 30 days)

fluocinolone acetonide soln 0.01% 1

fluocinonide cream 0.1% 1 QL (120 gm / 30 days)


104


fluocinonide cream 0.05% 1 QL (120 gm / 30 days)

fluocinonide emulsified base cream 0.05% 1 QL (120 gm / 30 days)

fluocinonide gel 0.05% 1 QL (120 gm / 30 days)

fluocinonide oint 0.05% 1 QL (120 gm / 30 days)

fluocinonide soln 0.05% 1

fluticasone propionate cream 0.05% 1 QL (120 gm / 30 days)

fluticasone propionate lotion 0.05% 1 QL (120 mL / 30 days)

fluticasone propionate oint 0.005% 1 QL (120 gm / 30 days)

halcinonide cream 0.1% 1 QL (120 gm / 30 days), PA

halobetasol propionate cream 0.05% 1 QL (120 gm / 30 days)

halobetasol propionate oint 0.05% 1 QL (120 gm / 30 days)

HALOG CRE 0.1% 3 QL (120 gm / 30 days), ST

HALOG OIN 0.1% 3 QL (120 gm / 30 days), ST

hydrocort cre 0.5% 1 OTC, QL (60 gm / 30 days)

hydrocort oin 0.5% 1 OTC, QL (60 gm / 30 days)

hydrocortisone butyrate cream 0.1% 1 QL (120 gm / 30 days)

hydrocortisone butyrate hydrophilic lipo base cream 0.1%

1 QL (120 gm / 30 days)

hydrocortisone butyrate oint 0.1% 1 QL (120 gm / 30 days)

hydrocortisone butyrate soln 0.1% 1

hydrocortisone cream 1% 1

hydrocortisone cream 1% 1 OTC, QL (60 gm / 30

days)

hydrocortisone cream 2.5% 1

hydrocortisone lotion 2.5% 1

hydrocortisone oint 2.5% 1

hydrocortisone valerate cream 0.2% 1 QL (120 gm / 30 days)

hydrocortisone valerate oint 0.2% 1 QL (120 gm / 30 days)

mometasone furoate cream 0.1% 1 QL (120 gm / 30 days)

mometasone furoate oint 0.1% 1 QL (120 gm / 30 days)

mometasone furoate solution 0.1% (lotion) 1 QL (120 mL / 30 days)

PANDEL CRE 0.1% 3 QL (120 gm / 30 days),

ST PRAMOSONE CRE 1-1% 3 PA

PRAMOSONE LOT 1% 3 PA

PRAMOSONE LOT 2.5% 3 PA

prednicarbate cream 0.1% 1 QL (120 gm / 30 days)

prednicarbate oint 0.1% 1 QL (120 gm / 30 days)

scalacort lot 2% 1

TACLONEX SUS 3 ST

TEXACORT SOL 2.5% 3 PA


105


triamcinolone acetonide aerosol soln 0.147 mg/gm

1

triamcinolone acetonide cream 0.1% 1



triamcinolone acetonide lotion 0.1% 1

triamcinolone acetonide lotion 0.025% 1

triamcinolone acetonide oint 0.1% 1



TRIANEX OIN 0.05% 3 QL (120 gm / 30 days),

PA VERDESO AER 0.05% 3 ST

ECZEMA AGENTS DUPIXENT INJ 200/1.14 3 QL (2 syringes / 28

days), PA

DUPIXENT INJ 300/2ML 3 PA; QL (4 mL / 28 days, 8 mL allowed first month of therapy)

EMOLLIENT/KERATOLYTIC AGENTS GORDONS UREA OIN 40% 3 PA

LATRIX XM EMU 45% 3 PA

urea cream 47% 1 PA

UREVAZ CRE 44% 3 PA

EMOLLIENTS hyaluronate sodium (emollient) gel 0.2% 1

LAC-HYDRIN LOT 12% 3 OTC, PA

lactic acid (ammonium lactate) cream 12% 1

lactic acid (ammonium lactate) cream 12% 1 OTC, QL (240 gm / 30 days)

lactic acid (ammonium lactate) lotion 12% 1

lactic acid (ammonium lactate) lotion 12% 1 OTC, QL (400 gm / 30 days)

ENZYMES - TOPICAL SANTYL OIN 250/GM 2 QL (60 gm / 90 days),

PA

IMMUNOMODULATING AGENTS - TOPICAL imiquimod cream 3.75% 1 PA

imiquimod cream 5% 1

ZYCLARA PUMP CRE 2.5% 3 PA

IMMUNOSUPPRESSIVE AGENTS - TOPICAL pimecrolimus cream 1% 1 QL (30 grams / 30

days), PA

tacrolimus oint 0.1% 1 QL (30 gm / 30 days), PA


106


tacrolimus oint 0.03% 1 QL (30 gm / 30 days), PA

KERATOLYTIC/ANTIMITOTIC AGENTS BENSAL HP OIN 3 PA

clear away liq 17% 1 OTC, QL (15 mL / 30 days)

CONDYLOX GEL 0.5% 3 PA

PODOCON SOL 25% 3 PA

podofilox soln 0.5% 1

PYROGALL ACD OIN 3 PA

salicylic ac liq 27.5% 1

salicylic acid cream 6% 1

salicylic acid foam 6% 1

salicylic acid gel 6% 1

salicylic acid lotion 6% 1

salicylic acid shampoo 6% 1

LOCAL ANESTHETICS - TOPICAL ANACAINE OIN 3 PA

c-topical sol 4% 1

LDO PLUS GEL 4% 3 PA

lidocaine hcl soln 4% 1

lidocaine hcl urethral/mucosal gel prefilled syringe 2%

1

lidocaine oint 5% 1

lidocaine patch 5% 1 PA

lidocaine-prilocaine cream 2.5-2.5% 1 QL (30 gm / 30 days)

QUTENZA KIT 8% 1-PCH 3 QL (4 boxes / 91 days), PA

MISC. DERMATOLOGICAL PRODUCTS ceramax cre 1

MISC. TOPICAL diaper rash cre 13% 1 OTC, QL (120 gm / 30

days)

diaper rash oin 40% 1 OTC, QL (120 gm / 30 days)

lip balm oin strawber 1 OTC, QL (452 gm / 30 days)

PALOMAR E OIN 2 OTC

YALE CLEANER POW 3 OTC, PA

zinc oxide oin 20% 1 OTC, QL (120 gm / 30

days)

PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL EUCRISA OIN 2% 3 QL (60 gm / 60 days),

PA

ROSACEA AGENTS metronidazole gel 0.75% 1


107


metronidazole gel 1% 1

metronidazole lotion 0.75% 1

NORITATE CRE 1% 3 ST

RHOFADE CRE 1% 3 PA

rosadan cre 0.75% 1

SCABICIDES & PEDICULICIDES bedding spra aer 0.5% 1 OTC, QL (242 gm / 30

days)

crotan lot 10% 1 PA

EURAX CRE 10% 3

lice killing sha 1 OTC, QL (237 mL / 30 days)

lice trtmnt liq 1% 1 OTC, QL (120 / 30 days)

malathion lotion 0.5% 1 QL (59 mL / 30 days),

PA

permethrin cream 5% 1 QL (60 gm / 30 days)

SKLICE LOT 0.5% 3 ST

sm lice lot treatmnt 1 OTC, QL (120 mL / 30

days)

spinosad susp 0.9% 1 QL (240 ml / 30 days)

ULESFIA LOT 5% 3 ST

WOUND CARE PRODUCTS ACTICOAT 7 MIS 1"X24" 3 PA

ACTICOAT 7 MIS 4"X5" 3 PA

ACTICOAT 7 MIS 6"X6" 3 PA

ACTICOAT MIS 5"X5" 3 PA

ALLEVYN AG PAD 3"X3" 3 PA

APLIGRAF MIS 2

ATRAPRO DERM SPR 3 PA

ATRAPRO GEL HYDROGEL 3 PA

BIOSTEP AG MIS 2"X2" 3 PA

BIOSTEP AG MIS 4"X4" 3 PA

BIOSTEP MIS 2"X2" 3 PA

BIOSTEP MIS 4"X4" 3 PA

DERMAGRAFT MIS 3 PA

ENDO DERMAL MIS 5X5 CM 3 PA

ENDO DERMAL MIS 10X12.7 3 PA

HYDROGEL DRE PAD 2"X3" 3 PA

HYDROGEL DRE PAD 4"X5" 3 PA

LUXAMEND CRE 3 PA

OASIS MATRIX MIS 3X7CM 3 PA

OASIS ULTRA MIS 3X3.5CM 3 PA

OASIS ULTRA MIS 5 X 7CM 3 PA

PRUTECT EMU 3 PA

REGRANEX GEL 0.01% 2 QL (45 gm / year)

SILVRSTAT GEL DRESSING 3 PA


108


VENELEX OIN 3 PA

XEROFRM GAUZ MIS 1"X8" 2

XEROFRM PETR PAD 2"X2" 2

DIAGNOSTIC PRODUCTS DIAGNOSTIC DRUGS

GLUCAGEN INJ 1MG 2

DIAGNOSTIC TESTS ACCU-CHEK TES AVIVA PL 2 OTC, QL (210 strips / 30

days), PA

ACCU-CHEK TES COMPACT 2 OTC, QL (210 strips / 30

days), PA

ACCU-CHEK TES GUIDE 2 OTC

ACCU-CHEK TES SMART 2 OTC, QL (210 strips / 30 days), PA

FREESTYLE TES 2 OTC, QL (210 strips / 30

days), PA

FREESTYLE TES INSULINX 2 OTC, QL (210 strips / 30 days), PA

FREESTYLE TES LITE 2 OTC, QL (210 strips / 30 days), PA

FREESTYLE TES PREC NEO 2 OTC, QL (210 strips / 30

days), PA

PRECISION TES XTRA 2 OTC, QL (210 strips / 30 days), PA

DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS DIETARY MANAGEMENT PRODUCTS

l-methylfolate tab 7.5 mg 1 QL (30 tabs / 30 days), PA

l-methylfolate tab 15 mg 1 QL (30 tabs / 30 days), PA

DIGESTIVE AIDS DIGESTIVE ENZYMES

CREON CAP 3000UNIT 2

CREON CAP 6000UNIT 2

CREON CAP 12000UNT 2



PANCREAZE CAP 4200UNIT 3 ST

PANCREAZE CAP 10500UNT 3 ST



PERTZYE CAP 4000UNIT 3 PA

PERTZYE CAP 8000UNIT 3 ST

PERTZYE CAP 16000U 3 ST

PERTZYE CAP 24000U 3 PA

SUCRAID SOL 8500/ML 2 PA


109


VIOKACE TAB 10440 2

VIOKACE TAB 20880 2

ZENPEP CAP 3000UNIT 2

ZENPEP CAP 5000UNIT 2

ZENPEP CAP 10000UNT 2



DIURETICS CARBONIC ANHYDRASE INHIBITORS

acetazolamide cap er 12hr 500 mg 1

acetazolamide sodium for inj 500 mg 1

acetazolamide tab 125 mg 1

acetazolamide tab 250 mg 1

KEVEYIS TAB 50MG 3 QL (120 tabs / 30 days),

PA

methazolamide tab 25 mg 1

methazolamide tab 50 mg 1

DIURETIC COMBINATIONS ALDACTAZIDE TAB 50/50 3 PA

amiloride & hydrochlorothiazide tab 5-50 mg

1

spironolactone & hydrochlorothiazide tab

25-25 mg

1

triamterene & hydrochlorothiazide cap 37.5-25 mg

1

triamterene & hydrochlorothiazide tab

37.5-25 mg

1

triamterene & hydrochlorothiazide tab

75-50 mg

1

LOOP DIURETICS bumetanide tab 0.5 mg 1 PA

bumetanide tab 1 mg 1 PA

bumetanide tab 2 mg 1 PA

ethacrynate sodium for inj 50 mg 1

furosemide inj 10 mg/ml 1

furosemide oral soln 8 mg/ml 1

furosemide oral soln 10 mg/ml 1

furosemide tab 20 mg 1



torsemide tab 5 mg 1





110


POTASSIUM SPARING DIURETICS amiloride hcl tab 5 mg 1

DYRENIUM CAP 50MG 3 PA

DYRENIUM CAP 100MG 3 PA

spironolactone tab 25 mg 1



triamterene cap 50 mg 1 PA

triamterene cap 100 mg 1 PA

THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorothiazide sodium for inj 500 mg 1

chlorothiazide tab 250 mg 1

chlorothiazide tab 500 mg 1

chlorthalidone tab 25 mg 1

chlorthalidone tab 50 mg 1

DIURIL SUS 250/5ML 3 PA; PA applies to 8 years of age and older

hydrochlorothiazide cap 12.5 mg 1

hydrochlorothiazide tab 12.5 mg 1

hydrochlorothiazide tab 25 mg 1

hydrochlorothiazide tab 50 mg 1

indapamide tab 1.25 mg 1

indapamide tab 2.5 mg 1

methyclothiazide tab 5 mg 1

metolazone tab 2.5 mg 1

metolazone tab 5 mg 1

metolazone tab 10 mg 1

ENDOCRINE AND METABOLIC AGENTS - MISC. BONE DENSITY REGULATORS

alendronate sodium oral soln 70 mg/75ml 1 QL (300 ml / 30 days)

alendronate sodium tab 5 mg 1





BINOSTO TAB 70MG 3 ST

calcitonin (salmon) nasal soln 200 unit/act 1

etidronate disodium tab 200 mg 1

etidronate disodium tab 400 mg 1

EVENITY INJ 105MG 3 QL (2 syringes / 30 days; 365 days /

lifetime), PA

FORTEO SOL 600/2.4 3 QL (1 pen / 28 days), PA

FOSAMAX + D TAB 70-2800 3 QL (4 tabs / 30 days), ST


111


FOSAMAX + D TAB 70-5600 3 QL (4 tabs / 30 days), ST

ibandronate sodium tab 150 mg (base equivalent)

1 QL (1 tab / 30 days)

NATPARA INJ 25MCG 3 QL (2 pens / 28 days), PA



NATPARA INJ 100MCG 3 QL (2 pens / 28 days),

PA

PROLIA SOL 60MG/ML 2 QL (1 fill / 180 days), PA

risedronate sodium tab 5 mg 1

risedronate sodium tab 30 mg 1

risedronate sodium tab 35 mg 1 QL (4 tabs / 30 days)

risedronate sodium tab 150 mg 1 QL (1 tab / 30 days)

risedronate sodium tab delayed release 35

mg


TYMLOS INJ 3 QL (1 pen / 30 days), PA

CORTICOTROPIN ACTHAR INJ 80UNIT 3 PA

FERTILITY REGULATORS CHOR GONADOT INJ 10000UNT 3 PA

novarel inj 10000unt 3 PA

PREGNYL INJ 10000UNT 3 PA

GNRH/LHRH ANTAGONISTS ORILISSA TAB 150MG 3 QL (30 tabs / 30 days),

PA

ORILISSA TAB 200MG 3 QL (60 tabs / 30 days), PA

GROWTH HORMONE RELEASING HORMONES (GHRH) EGRIFTA SOL 1MG 2 QL (1 vial (60mg) / 30

days), PA

GROWTH HORMONES GENOTROPIN INJ 0.2MG 3 PA

GENOTROPIN INJ 0.4MG 3 PA







GENOTROPIN INJ 1MG 3 PA




112


HUMATROPE INJ 5MG 3 PA




NORDITROPIN INJ 5/1.5ML 2 PA



NORDITROPIN INJ 30/3ML 2 PA

NUTROPIN AQ INJ 10MG/2ML 3 PA

NUTROPIN AQ INJ 20MG/2ML 3 PA

NUTROPIN AQ INJ NUSPIN 5 3 PA

OMNITROPE INJ 5.8MG 3 PA

OMNITROPE INJ 10/1.5ML 3 PA

SAIZEN INJ 5MG 3 PA

SEROSTIM INJ 4MG 2 PA



ZOMACTON INJ 5MG 3 PA

ZOMACTON INJ 10MG 3 PA

ZORBTIVE INJ 8.8MG 3 PA

HORMONE RECEPTOR MODULATORS OSPHENA TAB 60MG 3 QL (30 tabs / 30 days),

PA raloxifene hcl tab 60 mg 1

INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS) INCRELEX INJ 40MG/4ML 2

LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS LUPR DEP-PED INJ 3M 30MG 2 QL (1 box / 84 days), PA

LUPR DEP-PED INJ 7.5MG 2 QL (1 box / 21 days), PA



LUPR DEP-PED INJ 15MG 2 QL (1 box / 21 days), PA

SYNAREL SOL 2MG/ML 3 QL (40 ml / 30 days), PA

TRIPTODUR SUS 22.5MG 3 QL (1 syringe / 180 days), PA

METABOLIC MODIFIERS ALDURAZYME INJ 2.9MG/5M 2 PA

calcitriol cap 0.5 mcg 1

calcitriol cap 0.25 mcg 1

calcitriol inj 1 mcg/ml 1

calcitriol oral soln 1 mcg/ml 1

CARBAGLU TAB 200MG 2 PA

cinacalcet hcl tab 30 mg (base equiv) 1 QL (60 grams / 30 days), PA


113




CYSTADANE POW 2

doxercalciferol cap 0.5 mcg 1

doxercalciferol cap 1 mcg 1

doxercalciferol cap 2.5 mcg 1

ELAPRASE INJ 6MG/3ML 2 PA

FABRAZYME INJ 5MG 2 PA

FABRAZYME INJ 35MG 2 PA

GALAFOLD CAP 123MG 2 QL (14 caps / 28 days), PA

HECTOROL INJ 2MCG/ML 2

KUVAN POW 100MG 2 PA

KUVAN POW 500MG 2 PA

KUVAN TAB 100MG 2 PA

LUMIZYME INJ 50MG 2 PA

MYALEPT INJ 11.3MG 3 QL (30 syringes / 30 days), PA

NAGLAZYME INJ 1MG/ML 2 PA

nitisinone cap 2 mg 1 PA



ORFADIN CAP 20MG 2 QL (300 caps / 30 days), PA

ORFADIN SUS 4MG/ML 2 PA

PALYNZIQ INJ 2.5/0.5 3 QL (56 syringes / 28

days), PA

PALYNZIQ INJ 10/0.5ML 3 QL (56 syringes / 28 days), PA

PALYNZIQ INJ 20MG/ML 3 QL (56 syringes / 28

days), PA

paricalcitol cap 1 mcg 1



RAVICTI LIQ 1.1GM/ML 3 QL (525 ml / 30 days), PA

RAYALDEE CAP 30MCG 3 ST

REVCOVI INJ 1.6MG/ML 2 PA

sodium phenylbutyrate oral powder 3 gm/teaspoonful

1 PA

sodium phenylbutyrate tab 500 mg 1 PA

STRENSIQ INJ 18/0.45 2 PA

STRENSIQ INJ 28/0.7ML 2 PA

STRENSIQ INJ 40MG/ML 2 PA

STRENSIQ INJ 80/0.8ML 2 PA


114


XURIDEN POW 2GM 3 PA

POSTERIOR PITUITARY HORMONES DDAVP SOL 0.01% 3 PA

desmopressin acetate inj 4 mcg/ml 1

desmopressin acetate nasal spray soln 0.01%

1 PA

desmopressin acetate nasal spray soln

0.01% (refrigerated)

1

desmopressin acetate tab 0.1 mg 1

desmopressin acetate tab 0.2 mg 1

STIMATE SOL 1.5MG/ML 3

PROLACTIN INHIBITORS cabergoline tab 0.5 mg 1

SOMATOSTATIC AGENTS octreotide acetate inj 50 mcg/ml (0.05

mg/ml) 1 PA

octreotide acetate inj 100 mcg/ml (0.1

mg/ml)

1 PA

octreotide acetate inj 500 mcg/ml (0.5 mg/ml)

1 PA

SIGNIFOR INJ 0.3MG/ML 2 QL (60 / 30 days), PA



VASOPRESSIN RECEPTOR ANTAGONISTS JYNARQUE PAK 45-15MG 2 QL (4 boxes / 28 days)

JYNARQUE PAK 60-30MG 2 QL (4 boxes / 28 days)

JYNARQUE PAK 90-30MG 2 QL (4 boxes / 28 days)

SAMSCA TAB 15MG 2 QL (30 tabs / 30 days)

SAMSCA TAB 30MG 2 QL (60 tabs / 30 days)

ESTROGENS ESTROGEN COMBINATIONS

CLIMARA PRO DIS WEEKLY 3 ST

COMBIPATCH DIS 3 QL (8 ea / 28 days), ST

DUAVEE TAB 0.45-20 3 ST

estradiol & norethindrone acetate tab 0.5-0.1 mg

1

estradiol & norethindrone acetate tab 1-0.5 mg

1

fyavolv tab 1-5 1

jevantique l tab 0.5-2.5 1

PREFEST TAB 3 ST

PREMPHASE TAB 3 ST

PREMPRO TAB 3 ST

PREMPRO TAB 0.3-1.5 3 ST

PREMPRO TAB 0.45-1.5 3 ST


115


PREMPRO TAB 0.625-5 3 ST

ESTROGENS DELESTROGEN INJ 10MG/ML 3 PA

DEPO-ESTRADI INJ 5MG/ML 3 PA

DIVIGEL GEL 0.5MG 3 ST

DIVIGEL GEL 0.25MG 3 ST

DIVIGEL GEL 1MG/GM 3 ST

ELESTRIN GEL 0.06% 3 QL (26 gm / 30 days),

ST

estradiol tab 0.5 mg 1

estradiol tab 1 mg 1

estradiol tab 2 mg 1

estradiol td patch twice weekly 0.1 mg/24hr

1 QL (8 ea / 30 days)


1 QL (8 ea / 30 days)


1 QL (8 ea / 30 days)

estradiol td patch twice weekly 0.075

mg/24hr

1 QL (8 ea / 30 days)


1 QL (8 ea / 30 days)

estradiol td patch weekly 0.1 mg/24hr 1 QL (4 ea / 30 days)





estradiol td patch weekly 0.0375 mg/24hr

(37.5 mcg/24hr)

1 QL (4 ea / 30 days)

estradiol valerate im in oil 20 mg/ml 1

estradiol valerate im in oil 40 mg/ml 1

ESTROGEL GEL 3 QL (50 gm / 30 days), ST

estropipate tab 0.75 mg 1

EVAMIST SPR 1.53MG 3 ST

MENEST TAB 0.3MG 2

MENEST TAB 0.625MG 2

MENEST TAB 1.25MG 2

MENOSTAR DIS 14MCG 3 QL (4 ea / 30 days), ST

PREMARIN INJ 25MG 3 PA

PREMARIN TAB 0.3MG 3 ST






116


FLUOROQUINOLONES FLUOROQUINOLONES

BAXDELA TAB 450MG 3 QL (28 tabs / 14 days), PA

CIPRO (5%) SUS 250MG/5 3 PA

ciprofloxacin hcl tab 100 mg (base equiv) 1 QL (60 tabs / 30 days)




ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq)


ciprofloxacin-ciprofloxacin hcl tab er 24hr

1000 mg(base eq)


levofloxacin oral soln 25 mg/ml 1

levofloxacin tab 250 mg 1 QL (30 tabs / 30 days)



moxifloxacin hcl tab 400 mg (base equiv) 1 QL (30 tabs / 30 days)

ofloxacin tab 400 mg 1

GASTROINTESTINAL AGENTS - MISC. 5-HT4 RECEPTOR AGONISTS

MOTEGRITY TAB 1MG 3 QL (30 tabs / 30 days),

PA

MOTEGRITY TAB 2MG 3 QL (30 tabs / 30 days), PA

AGENTS FOR CHRONIC IDIOPATHIC CONSTIPATION (CIC) TRULANCE TAB 3MG 2 QL (30 tabs / 30 days)

ANTIFLATULENTS gas relief cap 125mg 1 OTC, QL (100 caps / 30

days) gas relief cap 180mg 1 OTC, QL (100 caps / 30

days)

gas relief chw 80mg 1 OTC, QL (100 tabs / 30 days)

gas relief dro 40/0.6ml 1 OTC, QL (30 mL / 30

days)

gas relief liq infants 1 OTC, QL (30 mL / 30 days)

sm gas rel chw 125mg 1 OTC, QL (100 tabs / 30 days)

BILE ACID SYNTHESIS DISORDER AGENTS CHOLBAM CAP 50MG 3 PA

CHOLBAM CAP 250MG 3 PA

FARNESOID X RECEPTOR (FXR) AGONISTS OCALIVA TAB 5MG 3 QL (30 tabs / 30 days),

PA


117


OCALIVA TAB 10MG 3 QL (30 tabs / 30 days), PA

GALLSTONE SOLUBILIZING AGENTS CHENODAL TAB 250MG 2

ursodiol cap 300 mg 1

ursodiol tab 250 mg 1

ursodiol tab 500 mg 1

GASTROINTESTINAL ANTIALLERGY AGENTS cromolyn sodium oral conc 100 mg/5ml 1

GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS AMITIZA CAP 8MCG 3 QL (60 caps / 30 days),

PA

AMITIZA CAP 24MCG 3 QL (60 caps / 30 days), PA

GASTROINTESTINAL STIMULANTS METOCLOPRAMI TAB 10MG ODT 3 ST

metoclopramide hcl inj 5 mg/ml (base

equivalent)

1

metoclopramide hcl orally disintegrating

tab 5 mg (base eq)

1

metoclopramide hcl soln 5 mg/5ml (10

mg/10ml) (base equiv)

1

metoclopramide hcl tab 5 mg (base

equivalent)

1

metoclopramide hcl tab 10 mg (base equivalent)

1

INFLAMMATORY BOWEL AGENTS APRISO CAP 0.375GM 3 PA

balsalazide disodium cap 750 mg 1

CIMZIA KIT 3 QL (2 boxes / 30 days),

PA

CIMZIA KIT STARTER 3 QL (1 box in lifetime), PA

CIMZIA PREFL KIT 200MG/ML 3 QL (2 boxes / 30 days), PA

DIPENTUM CAP 250MG 3 ST

GIAZO TAB 1.1GM 3 ST

INFLECTRA INJ 100MG 2 PA

LIALDA TAB 1.2GM 3

mesalamine cap dr 400 mg 1

mesalamine enema 4 gm 1

mesalamine rectal enema 4 gm & cleanser

wipe kit

1

mesalamine suppos 1000 mg 1

mesalamine tab delayed release 1.2 gm 1

mesalamine tab delayed release 800 mg 1


118


PENTASA CAP 250MG CR 3 ST

PENTASA CAP 500MG CR 3 ST

REMICADE INJ 100MG 2 PA

RENFLEXIS INJ 100MG 3 PA

SFROWASA ENE 4GM 3 ST

STELARA INJ 5MG/ML 3 PA

sulfasalazine tab 500 mg 1

sulfasalazine tab delayed release 500 mg 1

INTESTINAL ACIDIFIERS enulose sol 10gm/15 1

IRRITABLE BOWEL SYNDROME (IBS) AGENTS alosetron hcl tab 0.5 mg (base equiv) 1 PA

alosetron hcl tab 1 mg (base equiv) 1 PA

LINZESS CAP 72MCG 2 QL (30 caps / 30 days)



VIBERZI TAB 75MG 3 QL (60 tabs / 30 days), PA

VIBERZI TAB 100MG 3 QL (60 tabs / 30 days),

PA

PERIPHERAL OPIOID RECEPTOR ANTAGONISTS ENTEREG CAP 12MG 3 PA

MOVANTIK TAB 12.5MG 2 QL (30 tabs / 30 days)

MOVANTIK TAB 25MG 2 QL (30 tabs / 30 days)

RELISTOR INJ 8/0.4ML 3 QL (12 syringes / 30 days), PA

RELISTOR INJ 12/0.6ML 3 QL (18 syringes / 30 days), PA

RELISTOR TAB 150MG 3 QL (90 tabs / 30 days), PA

SYMPROIC TAB 0.2MG 3 QL (30 tabs / 30 days),

PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) cap

667 mg (169 mg ca) 1

calcium acetate (phosphate binder) tab 667 mg

1

lanthanum carbonate chew tab 500 mg

(elemental)

1 ST

lanthanum carbonate chew tab 750 mg

(elemental)

1 ST

PHOSLYRA SOL 3 ST

RENVELA POW 0.8GM 3

RENVELA POW 2.4GM 3

RENVELA TAB 800MG 3

sevelamer carbonate packet 0.8 gm 1


119


sevelamer carbonate packet 2.4 gm 1

sevelamer hcl tab 800 mg 1 PA

VELPHORO CHW 500MG 3 ST

SHORT BOWEL SYNDROME (SBS) AGENTS GATTEX KIT 5MG 3 QL (30 boxes / 30

days), PA

TRYPTOPHAN HYDROXYLASE INHIBITORS XERMELO TAB 250MG 2 QL (90 tabs / 30 days),

PA

GENITOURINARY AGENTS - MISCELLANEOUS ALKALINIZERS

ORACIT SOL 3 PA

pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml

1

potassium citrate tab er 5 meq (540 mg) 1



CYSTINOSIS AGENTS CYSTAGON CAP 50MG 2 PA

CYSTAGON CAP 150MG 2 PA

PROCYSBI CAP 25MG 3 QL (900 caps / 30 days), PA

PROCYSBI CAP 75MG 3 QL (900 caps / 30 days), PA

GENITOURINARY IRRIGANTS acetic acid irrigation soln 0.25% 1

argyl saline sol 0.9% 1

neomycin-polymyxin b gu irrigation soln 1

RENACIDIN SOL 2

RESECTISOL SOL 5% 3 PA

SORBITOL SOL 3% IRR 3 PA

SORBITOL SOL 3.3% IRR 3 PA

SORBITOL-MAN SOL 3 PA

INTERSTITIAL CYSTITIS AGENTS ELMIRON CAP 100MG 2

RIMSO-50 SOL 50% 3 PA

PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl tab er 24hr 10 mg 1

CARDURA XL TAB 4MG 3 QL (30 tabs / 30 days),

ST

CARDURA XL TAB 8MG 3 QL (30 tabs / 30 days), ST

dutasteride cap 0.5 mg 1 QL (30 caps / 30 days)

dutasteride-tamsulosin hcl cap 0.5-0.4 mg 1

finasteride tab 5 mg 1


120


silodosin cap 4 mg 1 PA

silodosin cap 8 mg 1 PA

tamsulosin hcl cap 0.4 mg 1

URINARY ANALGESICS phenazopyridine hcl tab 100 mg 1

phenazopyridine hcl tab 200 mg 1

URINARY STONE AGENTS LITHOSTAT TAB 250MG 3 PA

THIOLA EC TAB 100MG 3 PA

THIOLA EC TAB 300MG 3 PA

THIOLA TAB 100MG 3 PA

GOUT AGENTS GOUT AGENT COMBINATIONS

colchicine w/ probenecid tab 0.5-500 mg 1

DUZALLO TAB 200-200 3 QL (30 tabs / 30 days),

ST DUZALLO TAB 200-300 3 QL (30 tabs / 30 days),

ST

GOUT AGENTS allopurinol tab 100 mg 1

allopurinol tab 300 mg 1

colchicine cap 0.6 mg 1 QL (60 caps / 30 days),

PA colchicine tab 0.6 mg 1 QL (60 tabs / 30 days),

PA

febuxostat tab 40 mg 1 QL (30 tabs / 30 days), PA

febuxostat tab 80 mg 1 QL (30 tabs / 30 days),

PA

ZURAMPIC TAB 200MG 3 QL (30 tabs / 30 days), ST

URICOSURICS probenecid tab 500 mg 1

HEMATOLOGICAL AGENTS - MISC. ANTIHEMOPHILIC PRODUCTS

ADVATE INJ 250UNIT 2







ADYNOVATE INJ 250UNIT 3 ST




121




ALPHANATE INJ VWF/HUM 2

ALPHANINE SD INJ 1000UNIT 3 PA

ALPHANINE SD INJ 1500UNIT 3 PA

ALPROLIX INJ 500UNIT 3 PA




BEBULIN INJ 200-1200 2

BENEFIX INJ 250UNIT 2 PA





COAGADEX INJ 250UNIT 3 ST

COAGADEX INJ 500UNIT 3 ST

CORIFACT KIT 2

ELOCTATE INJ 250UNIT 3 PA










FEIBA INJ 2

HELIXATE FS INJ 250UNIT 2





HEMOFIL M INJ 250UNIT 2 ST




HUMATE-P SOL 250-600 2

HUMATE-P SOL 500-1200 2

HUMATE-P SOL 2400UNIT 2

IXINITY INJ 500UNIT 2 PA

IXINITY INJ 1000UNIT 2 PA

IXINITY INJ 1500UNIT 2

KCENTRA KIT 500UNIT 3 PA

KCENTRA KIT 1000UNIT 3 PA


122


KOATE-DVI INJ 250UNIT 2



KOGENATE FS INJ 250UNIT 3 ST





KOVALTRY INJ 250UNIT 2





MONOCLATE-P INJ 1000UNIT 3 ST

MONOCLATE-P INJ 1500UNIT 3 ST

MONONINE INJ 1000UNIT 2 PA

NOVOEIGHT INJ 250UNIT 2





NOVOSEVEN RT INJ 1MG 2




NUWIQ INJ 250UNIT 3 ST




NUWIQ KIT 250UNIT 3 ST




OBIZUR INJ 500 UNIT 3 PA

PROFILNINE INJ 500UNIT 2 PA



RECOMBINATE INJ 2

RECOMBINATE INJ 220-400 2 PA



RIASTAP SOL 1GM 2

RIXUBIS INJ 250 UNIT 3 PA

RIXUBIS INJ 500UNIT 3 PA




123



TRETTEN INJ 2

XYNTHA INJ 250UNIT 2




XYNTHA SOLOF INJ 3000UNIT 2

BRADYKININ B2 RECEPTOR ANTAGONISTS icatibant acetate inj 30 mg/3ml (base

equivalent)


days)

COMPLEMENT INHIBITORS BERINERT INJ 500UNIT 3 PA

CINRYZE SOL 500 UNIT 2 QL (16 per 30 days), PA

HAEGARDA INJ 2000UNIT 2 QL (16 vials / 30 days)

HAEGARDA INJ 3000UNIT 2 QL (16 vials / 30 days)

RUCONEST INJ 2100UNIT 3 PA

SOLIRIS INJ 10MG/ML 2 PA

HEMATAOLOGIC - TYROSINE KINASE INHIBITORS TAVALISSE TAB 100MG 3 QL (60 tabs / 30 days),

PA

TAVALISSE TAB 150MG 3 QL (60 tabs / 30 days),

PA

HEMATORHEOLOGIC AGENTS pentoxifylline tab er 400 mg 1

HEMIN PANHEMATIN INJ 350MG 2

PLASMA EXPANDERS lmd 10%/d5w inj 1

lmd 10%/nacl inj 0.9% 1

PLASMA KALLIKREIN INHIBITORS TAKHZYRO INJ 300/2ML 2 QL (4 vials / 30 days)

PLASMA PROTEINS albumin, human inj 25% 1

alburx inj 5% 1 PA

THROMBAT III INJ 500UNIT 3 PA

THROMBAT III INJ 1000UNIT 3 PA

PLATELET AGGREGATION INHIBITORS anagrelide hcl cap 0.5 mg 1

anagrelide hcl cap 1 mg 1

aspirin-dipyridamole cap er 12hr 25-200

mg


BRILINTA TAB 60MG 3 QL (60 tabs / 30 days), PA

BRILINTA TAB 90MG 3 QL (60 tabs / 30 days),

PA


124


CABLIVI KIT 11MG 2 QL (30 kits / 30 days), PA

cilostazol tab 50 mg 1

cilostazol tab 100 mg 1

clopidogrel bisulfate tab 75 mg (base

equiv)

1

clopidogrel bisulfate tab 300 mg (base

equiv)

1

dipyridamole tab 25 mg 1



DURLAZA CAP 162.5MG 3 QL (30 caps / 30 days),

PA

EFFIENT TAB 5MG 3 QL (30 tabs / 30 days)

EFFIENT TAB 10MG 3 QL (30 tabs / 30 days)

prasugrel hcl tab 5 mg (base equiv) 1 QL (30 tabs / 30 days)

prasugrel hcl tab 10 mg (base equiv) 1 QL (30 tabs / 30 days)

ZONTIVITY TAB 2.08MG 2 QL (30 tabs / 30 days),

PA

PROTAMINE protamine sulfate inj 10 mg/ml 1

THROMBOLYTIC ENZYMES CATHFLO ACTI INJ 2MG 3 PA

HEMATOPOIETIC AGENTS AGENTS FOR GAUCHER DISEASE

CERDELGA CAP 84MG 3 QL (30 caps / 30 days),

PA ELELYSO INJ 200UNIT 2 PA

miglustat cap 100 mg 1

VPRIV INJ 400UNIT 2 PA

AGENTS FOR SICKLE CELL ANEMIA DROXIA CAP 200MG 2

DROXIA CAP 300MG 2

DROXIA CAP 400MG 2

ENDARI POW 5GM 3 QL (180 packets / 30 days), PA

COBALAMINS cyanocobalamin inj 1000 mcg/ml 1

FOLIC ACID/FOLATES folic acid inj 5 mg/ml 1

folic acid tab 1 mg 1 QL (100 tabs / 30 days)

folic acid tab 400 mcg 1 OTC, QL (100 tabs / 30 days)

folic acid tab 800 mcg 1 OTC, QL (100 tabs / 30 days)


125


HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 10MCG 3 PA

ARANESP INJ 25MCG 3 PA








DOPTELET TAB 20MG 3 QL (15 tabs / 5 days)

EPOGEN INJ 2000/ML 3 PA





GRANIX INJ 300/0.5 3 PA

GRANIX INJ 480/0.8 3 PA

LEUKINE INJ 250MCG 2 PA

MIRCERA INJ 100MCG 3 PA

MIRCERA INJ 200MCG 3 PA

MULPLETA TAB 3MG 2 QL (7 tabs / 30 days),

PA

NEULASTA KIT 6MG/0.6M 3 PA

NEUPOGEN INJ 300/0.5 3 PA

NEUPOGEN INJ 300MCG 3 PA

NEUPOGEN INJ 480/0.8 3 PA

NEUPOGEN INJ 480MCG 3 PA

PROCRIT INJ 2000/ML 2 PA






PROMACTA POW 12.5MG 2 QL (30 packets / 30

days), PA

PROMACTA TAB 12.5MG 2 QL (30 tabs / 30 days), PA

PROMACTA TAB 25MG 2 QL (30 tabs / 30 days), PA



ZARXIO INJ 300/0.5 2 PA

ZARXIO INJ 480/0.8 2 PA


126


HEMATOPOIETIC MIXTURES abatron liq 1 OTC

IRON FER-IN-SOL DRO 15MG/ML 2 OTC, PA

ferrous gluconate tab 240 mg (27 mg

elemental fe)

1 OTC, QL (100 tabs / 30

days)

ferrous sulfate elixir 220 mg/5ml (44

mg/5ml elemental fe)

1 OTC, QL (473 mL / 30

days)

ferrous sulfate tab 325 mg (65 mg

elemental fe)

1 OTC, QL (100 tabs / 30

days)

iron supplmt dro 15mg/ml 1 OTC, QL (50 mL / 30 days); For 3 years of age and younger

NOVAFERRUM DRO 15MG/ML 2 OTC, QL (120 mL / 30 days); For 10 years of

age and younger

px iron tab 27mg 1 OTC, QL (100 tabs / 30 days)

sm iron tab 1 OTC

STEM CELL MOBILIZERS MOZOBIL INJ 2 QL (8 syringes / 3

days), PA

HEMOSTATICS HEMOSTATICS - SYSTEMIC

aminocaproic acid inj 250 mg/ml 1

aminocaproic acid oral soln 0.25 gm/ml 1 PA

aminocaproic acid tab 500 mg 1 PA

aminocaproic acid tab 1000 mg 1 PA

tranexamic acid tab 650 mg 1 QL (30 tabs / 21 days)

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS ANTIHISTAMINE HYPNOTICS

diphenhydramine hcl (sleep) tab 50 mg 1 OTC, QL (100 tabs / 30

days)

sleep aid tab 25mg 1 OTC, QL (100 tabs / 30 days)

sleep aid tab 25mg 1 OTC, QL (60 tabs / 30 days)

BARBITURATE HYPNOTICS AMYTAL SOD INJ 500MG 3 PA

BUTISOL SOD TAB 30MG 3 PA

phenobarbital elixir 20 mg/5ml 1

phenobarbital sodium inj 130 mg/ml 1

phenobarbital tab 15 mg 1

phenobarbital tab 16.2 mg 1




127






HYPNOTICS - TRICYCLIC AGENTS SILENOR TAB 3MG 3 PA

SILENOR TAB 6MG 3 PA

NON-BARBITURATE HYPNOTICS EDLUAR SUB 5MG 3 QL (30 ea / 30 days), PA

EDLUAR SUB 10MG 3 QL (30 ea / 30 days), PA

estazolam tab 1 mg 1

estazolam tab 2 mg 1

eszopiclone tab 1 mg 1 QL (30 tabs / 30 days)



midazolam hcl inj 2 mg/2ml (base equivalent)

1 PA


1 PA

midazolam hcl inj 5 mg/ml (base equivalent)

1 PA


1 PA

midazolam hcl inj 10 mg/10ml (base

equivalent)

1

midazolam hcl inj 25 mg/5ml (base

equivalent)

1


1

midazolam hcl syrup 2 mg/ml (base

equivalent)

1 PA

quazepam tab 15 mg 1

temazepam cap 7.5 mg 1

temazepam cap 15 mg 1

temazepam cap 22.5 mg 1

temazepam cap 30 mg 1

triazolam tab 0.25 mg 1

triazolam tab 0.125 mg 1

zaleplon cap 5 mg 1 QL (30 caps / 30 days)

zaleplon cap 10 mg 1 QL (30 caps / 30 days)

zolpidem tartrate tab 5 mg 1 QL (30 tabs / 30 days)

zolpidem tartrate tab 10 mg 1 QL (30 tabs / 30 days)

zolpidem tartrate tab er 6.25 mg 1 QL (30 tabs / 30 days)

zolpidem tartrate tab er 12.5 mg 1 QL (30 tabs / 30 days)

ZOLPIMIST SPR 5MG 3 QL (1 bottle / 30 days), PA


128


OREXIN RECEPTOR ANTAGONISTS BELSOMRA TAB 5MG 3 QL (30 tabs / 30 days),

PA

BELSOMRA TAB 10MG 3 QL (30 tabs / 30 days), PA

BELSOMRA TAB 15MG 3 QL (30 tabs / 30 days),

PA

BELSOMRA TAB 20MG 3 QL (30 tabs / 30 days), PA

SELECTIVE MELATONIN RECEPTOR AGONISTS HETLIOZ CAP 20MG 2 QL (30 caps / 30 days),

PA

ramelteon tab 8 mg 3 QL (30 tabs / 30 days),

PA

LAXATIVES BULK LAXATIVES

EQUALACTIN CHW 625MG 3 OTC

EVAC POW 3 OTC, PA

fiber laxatv tab 625mg 1 OTC

fiber laxtiv cap 0.52gm 1 OTC

fiber select chw gummies 1 OTC

geri-mucil pow 68% 1 OTC

HYDROCIL INS POW 95% 3 OTC

KONSYL DAILY POW 28.3% 2 OTC

KONSYL DAILY POW 100% 3 OTC

KONSYL POW 60.3% 3 OTC

KONSYL POW 60.3% 3 OTC, PA

KONSYL POW 71.67% 3 OTC

METAMUCIL POW 28%ORG 3 OTC

metamucil pow 28.3%org 1 OTC

METAMUCIL POW 55.46% 3 OTC

metamucil pow 58.6%org 1 OTC

METAMUCIL POW 58.12% 3 OTC

METAMUCIL POW 63% 3 OTC

NAT FIBER POW 58.6% 3 OTC

naturl fiber pow 30.9% 1 OTC

qc natural pow vegetabl 1 OTC

sb fib lax pow 30% 1 OTC

sb fib lax pow 33% 1 OTC

sb nat fiber pow 49% 1 OTC

sm fiber lax tab 500mg 1 OTC

sm fiber pow 48.57% 1 OTC

soluble fib pow therapy 1 OTC

total fiber pow 1 OTC

UNIFIBER POW 3 OTC

wal-mucil pow 100% 1 OTC


129


LAXATIVE COMBINATIONS gavilyte-c sol 1

gavilyte-g sol 1

gavilyte-h kit 1

gavilyte-n sol flav pk 1

GOLYTELY SOL 3 ST

MOVIPREP SOL 3 ST

PREPOPIK PAK 3 QL (30 boxes / 30

days), ST

stool softnr tab 8.6-50mg 1 OTC, QL (60 tabs / 30 days)

SUPREP BOWEL SOL PREP KIT 3 PA

LAXATIVES - MISCELLANEOUS constulose sol 10gm/15 1

glycerin ped sup 1.2gm 1 OTC, QL (25 supp / 30 days)

glycerin sup 2gm 1 OTC, QL (25 supp / 30 days)

KRISTALOSE PAK 20GM 3 ST

lactulose pak 10gm 1 PA

MIRALAX POW 3350 NF 3 OTC, PA, ST

polyethylene glycol 3350 oral packet 1

polyethylene glycol 3350 oral powder 1

SALINE LAXATIVES magnesium citrate soln 1 OTC, QL (300 mL / 30

days)

milk of magn sus 1200/15 1 OTC, QL (473 mL / 30 days)

OSMOPREP TAB 1.5GM 3 ST

sodium phosphates - enema 1 OTC, QL (135 mL / 30

days)

STIMULANT LAXATIVES laxative tab 5mg ec 1 OTC, QL (100 tabs / 30

days) senna tab 8.6mg 1 OTC, QL (100 tabs / 30

days)

sennosides syrup 8.8 mg/5ml 1 OTC, QL (240 ml / 30

days) sm laxative sup 10mg 1 OTC, QL (28 supp / 30

days)

SURFACTANT LAXATIVES docusate cal cap 240mg 1 OTC, QL (60 caps / 30

days)

docusate sodium liquid 150 mg/15ml 1 OTC, QL (240 ml / 30

days)


130


docusate sodium syrup 60 mg/15ml 1 OTC, QL (240 ml / 30 days)

PEDIA-LAX LIQ 50MG 2 OTC

stool softnr cap 100mg 1 OTC, QL (60 caps / 30 days)

stool softnr cap 250mg 1 OTC, QL (60 caps / 30

days)

MACROLIDES AZITHROMYCIN

azithromycin for susp 100 mg/5ml 1

azithromycin for susp 200 mg/5ml 1

azithromycin iv for soln 500 mg 1

azithromycin powd pack for susp 1 gm 1

azithromycin tab 250 mg 1 QL (36 tabs / 30 days)



CLARITHROMYCIN clarithromycin for susp 125 mg/5ml 1

clarithromycin for susp 250 mg/5ml 1

clarithromycin tab 250 mg 1 QL (60 tabs / 30 days)

clarithromycin tab 500 mg 1 QL (60 tabs / 30 days)

clarithromycin tab er 24hr 500 mg 1 QL (30 tabs / 30 days)

ERYTHROMYCINS e.e.s. 400 tab 400mg 1

ery-tab tab 250mg ec 1



ERYPED SUS 400/5ML 2 PA

ERYTHROCIN INJ 500MG 3 PA

erythrocin tab 250mg 1

ERYTHROMYCIN ETHYLSUCCINATE FOR

SUSP 200 MG/5ML

1

erythromycin tab 250 mg 1

erythromycin tab 500 mg 1

erythromycin w/ delayed release particles cap 250 mg

1

FIDAXOMICIN DIFICID TAB 200MG 3 QL (20 tabs / 10 days),

ST

MEDICAL DEVICES AND SUPPLIES BLOOD PRESSURE DEVICES

BP ARM CUFF MIS LARGE 2 OTC

CONCEPTION ASSISTANCE SUPPLIES CONCEPTION KIT 2


131


CONTRACEPTIVES FEMCAP MIS 22MM 2

FEMCAP MIS 26MM 2

FEMCAP MIS 30MM 2

WIDE-SEAL DPR KIT 60 3 PA








DIABETIC SUPPLIES ACCU-CHEK KIT AVIVA PL 2 OTC, QL (1 kit / year)

ACCU-CHEK KIT FASTCLIX 2 OTC

ACCU-CHEK KIT GUIDE 2 OTC, QL (1 kit / year)

ACCU-CHEK KIT MLTICLIX 2 OTC

ACCU-CHEK KIT SOFTCLIX 2 OTC

ACCU-CHEK LIQ ACT/GLUC 2 OTC, QL (4 bottles / 365

days) ACCU-CHEK LIQ SMART 2 OTC, QL (4 bottles / 365

days)

ACCU-CHEK SOL 2 OTC, QL (4 bottles / 365

days)

ACCU-CHEK SOL COMPACT 2 OTC, QL (4 bottles / 365 days)

FREESTYLE KIT SENSOR 2 QL (1 kit / year)

FREESTYLE LIQ CONTROL 2 OTC, QL (4 bottles / 365 days)

FREESTYLE MIS LITE 2 OTC, QL (1 kit / year)

FREESTYLE MIS READER 2 QL (1 kit / year)

GENTLE-LET MIS PLATFORM 2 OTC, QL (210 lancets / 30 days)

LANCETS MIS 2 OTC, QL (210 lancets / 30 days)

LANCING DEVI MIS 2 OTC

PRECISION MIS XTRA 2 OTC, QL (1 kit / year)

ORAL HYGIENE PRODUCTS Q4 ORAL CLEA KIT SYSTEM 3 OTC, PA

PARENTERAL THERAPY SUPPLIES ANESTH NEEDL MIS 22GX2" 2 OTC

AXILLARY NDL MIS 22GX1" 2 OTC

AXILLARY NDL MIS 25GX1" 2 OTC

BD ECLIPSE MIS 1ML/30G 2 OTC

BD ECLIPSE MIS 25GX5/8" 2 OTC


132


BD PEN NEEDL MIS 29GX12.7 2 OTC, QL (200 syringes / 30 days)

BD PEN NEEDL MIS 31GX5MM 2 OTC, QL (200 syringes / 30 days)


BD PEN NEEDL MIS 32GX4MM 2 QL (200 syringes / 30 days)


BD PEN NEEDL MIS 32GX5/32 2 OTC, QL (200 syringes /

30 days)

BD PEN NEEDL MIS 32GX6MM 2 OTC, QL (200 syringes /

30 days)

BD U-500 MIS 31GX6MM 2 QL (200 syringes / 30 days)

5ML CONTROL MIS SANA-LOK 2 OTC

3ML CTRL SYR MIS LL ZONE1 2 OTC

HUBER NEEDLE MIS 20GX1" 2 OTC

HYPO NEEDLE MIS 18GX1" 3

HYPO NEEDLE MIS 19GX1.5" 3




HYPO NEEDLE MIS 23GX1.5" 2 OTC



HYPO NEEDLE MIS 25GX5/8" 3





INFUS SYRING MIS 100ML 2 OTC

INSULIN SYRG MIS 0.3/30G 2 OTC, QL (200 syringes /

30 days)

INSULIN SYRG MIS 0.3/31G 2 OTC, QL (200 syringes / 30 days)



INSULIN SYRG MIS 1ML/25G 2 OTC, QL (200 syringes / 30 days)

INSULIN SYRG MIS 1ML/30G 2 OTC, QL (200 syringes /

30 days)

INSULIN SYRG MIS 1ML/31G 2 OTC, QL (200 syringes /

30 days)


133


3ML LL SYRNG MIS 20GX1" 2 OTC

3ML LL SYRNG MIS 20GX1" 2 OTC, QL (200 syringes /

30 days)

3ML LL SYRNG MIS 21GX1.25 2 OTC

3ML LL SYRNG MIS 22GX1.25 3 OTC

3ML LL SYRNG MIS 22GX3/4" 3 OTC

3ML LL SYRNG MIS 23GX1" 2 OTC, QL (200 syringes /

30 days)

3ML LL SYRNG MIS 25GX1" 2 OTC, QL (200 syringes / 30 days)

3ML LL SYRNG MIS 25GX5/8" 2 OTC, QL (200 syringes /

30 days)

MULIT-DRAW MIS 22GX1.5" 2 OTC

MULTI-DRAW MIS 20GX1.5 2 OTC

MULTI-DRAW MIS 21GX1.5" 2 OTC

NEEDLES MIS 19GX1" 2 OTC

NEEDLES MIS 25GX1.5" 2 OTC

NEEDLES MIS 26X1/2" 2 OTC

NEEDLES MIS 27GX1/2" 2 OTC

SAFETYGLIDE MIS 27GX5/8" 3 OTC

5-6ML SYRING MIS LUER SLP 2 OTC

3ML SYRINGE MIS 20GX1" 3

3ML SYRINGE MIS 20GX1.5" 2

12ML SYRINGE MIS 20GX1.5" 2 OTC



3ML SYRINGE MIS 21GX1" 2 OTC




3ML SYRINGE MIS 22GX1" 3 OTC, PA



3 ML SYRINGE MIS 22X1-1/2 2 OTC






3ML SYRINGE MIS 25GX5/8" 2

1ML SYRINGE MIS 25GX5/8" 2 OTC

1ML SYRINGE MIS 26GX3/8" 2 OTC

30ML SYRINGE MIS GL ZONE1 2 OTC

20ML SYRINGE MIS LL ZONE1 2 OTC

30ML SYRINGE MIS LUER LOC 3

5ML SYRINGE MIS LUER SLP 2 OTC


134


1ML SYRINGE MIS LUER SLP 3

50ML SYRINGE MIS ML ZONE1 2 OTC

3ML SYRINGE MIS REG TIP 3

10-12ML SYRN MIS LUER SLP 2 OTC

1.5 ML SYRNG MIS 22X1-1/2 3 OTC, PA

2ML TB SYRNG MIS LL ZONE1 2 OTC

1ML TB SYRNG MIS LUER SLP 3

TOOMEY SYRIN MIS 70ML 2

VENT NEEDLE MIS 18GX1.5" 2 OTC

YALE NEEDLE MIS 15GX1.5" 3 OTC

YALE NEEDLE MIS 15GX2" 3 OTC

YALE NEEDLE MIS 16GX2" 3 OTC

YALE NEEDLES MIS 13X3-1/2 3 OTC


YALE NEEDLES MIS 17G X 2" 3 OTC















YALE NEEDLES MIS 23GX1/2" 3 OTC


















135







YALE TB SYRN MIS GL 1/4ML 2 OTC

YALE TB SYRN MIS GL 1ML 2 OTC

RESPIRATORY AIDS FACE MASK MIS EARLOOP 3

RESPIRATORY THERAPY SUPPLIES AERCHMBR Z- MIS STAT PLS 2 QL (2 / year for

members under age 18;

1 / yr for 18 years of age and older)

AEROCHAMBER KIT ACTION 3

AIRZONE PEAK MIS FLOW MTR 2 OTC

ASSESS METER MIS FULL RNG 2 OTC

ASSESS METER MIS LOW RANG 2 OTC

ASTHMA CHECK MIS SYSTEM 2 OTC

ASTHMAMENTOR MIS 2 OTC

ASTHMAPACK KIT CHILD 2 OTC

FLEXICHAMBER MIS MASK SM 3 QL (2 / year for members under age 18;

1 / yr for 18 years of

age and older)

INSPIREASE MIS RES BAG 2 QL (2 / year for

members under age 18; 1 / yr for 18 years of

age and older) MICROLIFE MIS PEAK FLO 2 OTC

MINI WRIGHT MIS PFM 3 OTC

MINI WRIGHT MIS PFM 3 OTC, PA

MINI WRIGHT MIS PFM LOW 3 OTC, PA

NASONEB NSL MIS STARTER 2 OTC, PA

PARI LC MIS SPRINT 2

PEAK AIR FLO MIS ADLT/PED 2 OTC

PERSONAL BES MIS FULL RNG 2 OTC

PERSONAL BES MIS LOW RANG 2 OTC

PIKO 1 MIS ELECTRON 2 OTC

POCKET PEAK MIS METER 2 OTC

POCKETPEAK MIS UNIVERSA 3 OTC

SINUSTAR MIS NEBULIZE 2 PA

TRUZONE PEAK MIS FLOW MTR 3 PA

VIOS LC MIS SPRINT 2


136


MIGRAINE PRODUCTS MIGRAINE COMBINATIONS

migergot sup 2/100 1

sumatriptan-naproxen sodium tab 85-500

mg


PA

TREXIMET TAB 10-60MG 3 QL (9 tabs / 30 days), PA

MIGRAINE PRODUCTS dihydroergotamine mesylate nasal spray 4

mg/ml

1 PA

ERGOMAR SUB 2MG 3 PA

MIGRAINE PRODUCTS - MONOCLONAL ANTIBODIES AIMOVIG INJ 70MG/ML 3 QL (1 syringe / 30

days), PA

AIMOVIG INJ 140DOSE 3 QL (1 syringe / 30

days), PA

AIMOVIG INJ 140MG/ML 3 QL (1 syringe / 30 days), PA

AJOVY INJ 225/1.5 3 QL (1 syringe / 30 days), PA

EMGALITY INJ 120MG/ML 3 QL (1 syringe / 30

days), PA

SEROTONIN AGONISTS almotriptan malate tab 6.25 mg 1 QL (6 tabs / 30 days),

PA

almotriptan malate tab 12.5 mg 1 QL (6 tabs / 30 days), PA

eletriptan hydrobromide tab 20 mg (base

equivalent)


eletriptan hydrobromide tab 40 mg (base

equivalent)


frovatriptan succinate tab 2.5 mg (base equivalent)


naratriptan hcl tab 1 mg (base equiv) 1 QL (9 tabs / 30 days)

naratriptan hcl tab 2.5 mg (base equiv) 1 QL (9 tabs / 30 days)

rizatriptan benzoate oral disintegrating tab

5 mg (base eq)


rizatriptan benzoate oral disintegrating tab 10 mg (base eq)


rizatriptan benzoate tab 5 mg (base equivalent)


rizatriptan benzoate tab 10 mg (base equivalent)


sumatriptan nasal spray 5 mg/act 1 QL (1 bottle (6 ml) / 30

days), PA sumatriptan nasal spray 20 mg/act 1 QL (1 bottle (6 ml) / 30

days), PA


137


sumatriptan succinate inj 6 mg/0.5ml 1 QL (4 / 30 days)

sumatriptan succinate solution

auto-injector 4 mg/0.5ml


days)

sumatriptan succinate solution auto-injector 6 mg/0.5ml

1 QL (4 syringes / 30 days)

sumatriptan succinate solution cartridge 4

mg/0.5ml

1 QL (4 cartridges / 30

days) sumatriptan succinate solution cartridge 6

mg/0.5ml

1 QL (4 cartridges / 30

days)

sumatriptan succinate tab 25 mg 1 QL (9 tabs / 30 days)



zolmitriptan orally disintegrating tab 2.5

mg


zolmitriptan orally disintegrating tab 5 mg 1 QL (6 tabs / 30 days)

zolmitriptan tab 2.5 mg 1 QL (6 tabs / 30 days)

zolmitriptan tab 5 mg 1 QL (6 tabs / 30 days)

ZOMIG SPR 2.5MG 3 QL (1 box / 30 days), PA

ZOMIG SPR 5MG 3 QL (1 bottle / 30 days), PA

MINERALS & ELECTROLYTES BICARBONATES

NEUT INJ 4% 3 PA

SOD LACTATE INJ 5MEQ/ML 3 PA

sodium acetate inj 2 meq/ml 1

sodium acetate inj 4 meq/ml 1

sodium bicarbonate iv soln 4.2% 1



CALCIUM calc citr/d3 tab 200-250 1 OTC, QL (100 tabs / 30

days) calc citrate tab +d 1 OTC, QL (100 tabs / 30

days)

calcium 500 tab +d 1 OTC, QL (100 tabs / 30 days)

calcium 600 tab + d 1 OTC, QL (100 tabs / 30

days) calcium 600 tab +d 1 OTC, QL (100 tabs / 30

days)

calcium 600 tab +d3 1 OTC, QL (100 tabs / 30 days)

calcium 600/ tab vit d 1 OTC, QL (100 tabs / 30 days)

calcium carbonate tab 600 mg 1 OTC, QL (100 tabs / 30 days)


138


calcium carbonate tab 1250 mg (500 mg elemental ca)

1 OTC, QL (100 tabs / 30 days)

calcium carbonate tab 1500 mg (600 mg elemental ca)


calcium carbonate-vitamin d tab 250 mg-125 unit






calcium chloride inj 10% 1

CALCIUM CHW GUMMIES 3 OTC

calcium gluconate inj 10% 1

calcium tab 500/d 1 OTC, QL (100 tabs / 30 days)

calcium tab 600mg 1 OTC

oys shell+d tab 250-125 1 OTC, QL (100 tabs / 30 days)

oysco 500+d tab 1 OTC, QL (100 tabs / 30 days)

oyst shell/d tab 500mg 1 OTC, QL (100 tabs / 30 days)

oyster shell calcium tab 500 mg 1 OTC, QL (100 tabs / 30 days)

oyster-cal tab 500mg 1 OTC, QL (100 tabs / 30 days)

RA OYS SHL/D TAB 500MG 1 OTC, QL (100 tabs / 30

days) UPCAL D POW 3 OTC, PA

ELECTROLYTE MIXTURES CERALYTE 70 LIQ 2 OTC, QL (5000 ml / 30

days)

D10W/NACL INJ 0.225% 2

dextrose 2.5% w/ sodium chloride 0.45% 1

dextrose 5% in lactated ringers 1

dextrose 5% w/ sodium chloride 0.2% 1






ELLIOTTS B INJ 3 PA

hyperlyte-cr inj 1 PA

IONOSOL-MB INJ D5W 3 PA

ISOLYTE-P INJ /D5W 3 PA

ISOLYTE-S INJ 3 PA

ISOLYTE-S INJ PH 7.4 3 PA


139


kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj

1


1


1


1


1

kcl 20 meq/l (0.15%) in nacl 0.9% inj 1


kcl 30 meq/l (0.224%) in dextrose 5% &

nacl 0.45% inj

1


1


lactated ringer's solution 1

NORMOSOL -M INJ /D5W 3 PA

NORMOSOL -R INJ 3 PA

NORMOSOL -R INJ /D5W 3 PA

NORMOSOL-R INJ PH 7.4 3 PA

oral electrolyte solution 1 OTC, QL (5000 ml / 30

days)

PLASMA-LYTE INJ -148 3 PA

PLASMA-LYTE INJ -A 3 PA

potassium chloride 20 meq/l (0.15%) in

dextrose 5% inj

1

potassium chloride 40 meq/l (0.3%) in

dextrose 5% inj

1

ringer's solution 1

tpn electrol inj 1 PA

FLUORIDE FLUORABON DRO 3 PA

flura-drops dro 0.25mg f 1 PA

ludent chw 0.5mg f 1

ludent chw 0.25mg f 1

ludent chw 1mg f 1

sodium fluoride soln 0.5 mg/ml f (from 1.1

mg/ml naf)

1

sodium fluoride tab 0.5 mg f (from 1.1 mg

naf)

1

sodium fluoride tab 1 mg f (from 2.2 mg naf)

1

IODINE PRODUCTS iodine solution strong 5% (lugol's) 1


140


MAGNESIUM magdelay tab 64mg 1 OTC

magnesium chloride inj 200 mg/ml 1

magnesium oxide cap 500 mg (elemental mg)

1 OTC, QL (100 caps / 30 days)

magnesium oxide tab 400 mg (240 mg elemental mg)


magnesium oxide tab 500 mg (mg

supplement)

1 OTC, QL (100 tabs / 30

days)

magnesium sulfate inj 50% 1

mgo tab 400mg 1 OTC, QL (100 tabs / 30

days)

MANGANESE manganese chloride inj 0.1 mg/ml 1

PHOSPHATE av-phos 250 tab neutral 1

K-PHOS TAB 2

potassium phosphates inj 15 mm/5ml (phos) 22 meq/5ml (k)

1


1


1

sodium phosphates inj 15 mm/5ml (phos) 20 meq/5ml (na)

1

POTASSIUM EFFER-K TAB 10MEQ 3 PA

EFFER-K TAB 20MEQ 3 PA

klor-con 8 tab 8meq er 1

KLOR-CON M15 TAB 15MEQ ER 3 PA

pot bicarbonate & chloride effer tab 25 meq

1

potassium acetate inj 2 meq/ml 1

potassium bicarbonate effer tab 25 meq 1

potassium chloride cap er 8 meq 1

potassium chloride cap er 10 meq 1

potassium chloride inj 2 meq/ml 1 PA

potassium chloride inj 10 meq/50ml 1





potassium chloride microencapsulated crys

er tab 10 meq

1

potassium chloride microencapsulated crys

er tab 20 meq

1


141


potassium chloride oral soln 10% (20 meq/15ml)

1

potassium chloride oral soln 20% (40 meq/15ml)

1

potassium chloride powder packet 20 meq 1

potassium chloride tab er 10 meq 1

potassium chloride tab er 20 meq (1500

mg)

1

SODIUM sodium chloride inj 2.5 meq/ml (14.6%) 1

sodium chloride iv soln 0.45% 1

sodium chloride iv soln 3% 1

sodium chloride iv soln 4 meq/ml (23.4%) 1

sodium chloride iv soln 5% 1

sodium chloride preservative free (pf) inj 0.9%

1

TRACE MINERALS chromic chloride inj 40 mcg/10ml (4

mcg/ml) (elemental cr)

1

cupric chloride inj 0.4 mg/ml 1

MULTITRACE-4 INJ 2

multitrace-4 inj conc 1

MULTITRACE-4 INJ NEONATAL 3 PA

multitrace-5 inj conc 1

MULTITRACE-5 INJ REGULAR 3 PA

selenious acid inj 40 mcg/ml 1

TRACE ELEM 4 INJ PED 3 PA

ZINC GALZIN CAP 25MG 3 PA

GALZIN CAP 50MG 3 PA

zinc chloride inj 1 mg/ml 1

zinc sulfate inj 1 mg/ml 1

zinc sulfate inj 5 mg/ml 1

MISCELLANEOUS THERAPEUTIC CLASSES CHELATING AGENTS

penicillamine cap 250 mg 1

ENZYMES HYLENEX INJ 150 UNIT 3 PA

VITRASE INJ 200/ML 3 PA

IMMUNOMODULATORS REVLIMID CAP 2.5MG 2 QL (30 caps / 30 days),

PA REVLIMID CAP 5MG 2 QL (30 caps / 30 days),

PA


142


REVLIMID CAP 10MG 2 QL (30 caps / 30 days), PA




THALOMID CAP 50MG 2 QL (30 caps / 30 days), PA

THALOMID CAP 100MG 2 QL (30 caps / 30 days),

PA

THALOMID CAP 150MG 2 QL (60 caps / 30 days),

PA

THALOMID CAP 200MG 2 QL (60 caps / 30 days), PA

IMMUNOSUPPRESSIVE AGENTS ASTAGRAF XL CAP 0.5MG 3 PA

ASTAGRAF XL CAP 1MG 3 PA

ASTAGRAF XL CAP 5MG 3 PA

AZASAN TAB 75 MG 3 PA

AZASAN TAB 100MG 3 PA

azathioprine tab 50 mg 1

cyclosporine cap 25 mg 1

cyclosporine cap 100 mg 1

cyclosporine modified cap 25 mg 1

cyclosporine modified cap 100 mg 1

ENVARSUS XR TAB 0.75MG 3 ST

ENVARSUS XR TAB 1MG 3 ST

ENVARSUS XR TAB 4MG 3 ST

gengraf sol 100mg/ml 1

mycophenolate mofetil cap 250 mg 1

mycophenolate mofetil for oral susp 200 mg/ml

1

mycophenolate mofetil tab 500 mg 1

mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)

1

mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)

1

NULOJIX INJ 250MG 2

PROGRAF INJ 5MG/ML 2

RAPAMUNE SOL 1MG/ML 2

SANDIMMUNE SOL 100MG/ML 3 PA

sirolimus tab 0.5 mg 1

sirolimus tab 1 mg 1

tacrolimus cap 0.5 mg 1

tacrolimus cap 1 mg 1


143


tacrolimus cap 5 mg 1

ZORTRESS TAB 0.5MG 2



IRRIGATION SOLUTIONS argyl saline sol 100ml 1

lactated ringer's for irrigation 1 PA

physiolyte sol 1 PA

ringer's solution for irrigation 1

POTASSIUM REMOVING AGENTS LOKELMA PAK 5GM 3 QL (90 packets / 30

days), PA

LOKELMA PAK 10GM 3 QL (90 packets / 30 days), PA

sodium polystyrene sulfonate powder 1

sodium polystyrene sulfonate rectal susp

30 gm/120ml

1

sps sus 15gm/60 1

PROSTAGLANDINS alprostadil inj 500 mcg/ml 1

SCLEROSING AGENTS ASCLERA INJ 0.5% 3 PA

ASCLERA INJ 1% 3 PA

ETHAMOLIN INJ 5% 3 PA

SOTRADECOL INJ 1% 3 PA

SOTRADECOL INJ 3% 3 PA

VARITHENA AER 10MG/ML 3 PA

SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS BENLYSTA INJ 120MG 2 PA

BENLYSTA INJ 400MG 2 PA

MOUTH/THROAT/DENTAL AGENTS ANESTHETICS TOPICAL ORAL

CEPACOL SORE LOZ COATING 2 OTC

lidocaine hcl viscous soln 2% 1

sore throat loz 15-3.6mg 1 OTC

ANTI-INFECTIVES - THROAT clotrimazole troche 10 mg 1

nystatin susp 100000 unit/ml 1

ORAVIG TAB 50MG 3 QL (14 tabs / 14 days),

ST

ANTISEPTICS - MOUTH/THROAT periogard sol 0.12% 1

DENTAL PRODUCTS cavarest gel 1.1% 1

clinpro 5000 pst 1.1% 1


144


sf 5000 plus cre 1.1% 1

STEROIDS - MOUTH/THROAT/DENTAL triamcinolone acetonide dental paste 0.1% 1

THROAT PRODUCTS - MISC. cevimeline hcl cap 30 mg 1

pilocarpine hcl tab 5 mg 1

pilocarpine hcl tab 7.5 mg 1

MULTIVITAMINS MULTIPLE VITAMINS W/ IRON

sm multiple tab vit/iron 1 OTC, QL (100 tabs / 30

days)

MULTIPLE VITAMINS W/ MINERALS AP-ZEL TAB 3

biocel tab 1

MEGA MULTIVI TAB WOMEN 3 OTC

one daily tab plus iro 1 OTC, QL (100 tabs / 30 days)

MULTIVITAMINS one daily tab 1 OTC, QL (100 tabs / 30

days)

QUINTABS TAB 3 OTC

PED MULTIPLE VITAMINS W/ MINERALS animal shape chw complete 1 OTC, QL (100 tabs / 30

days); For 12 years of

age and younger

FLINTSTONES CHW COMPLETE 3 OTC, PA

FLINTSTONES CHW GUMMIES 3 OTC, PA

healthy kids chw overall 1 OTC, QL (100 tabs / 30 days); For 12 years of age and younger

VITAMAX CHW 3 OTC, PA

vitamax ped dro 1

PED MV W/ IRON MULTI-DELYN LIQ /IRON 3 OTC

MYKIDZ IRON SUS 10MG/2ML 2 OTC

novaferrum dro 1 OTC, QL (50 mL / 30 days); For 3 years of age and younger

POLY-VI-SOL DRO /IRON 2 OTC, QL (50 mL / 30

days) zoo friends chw pls iron 1 OTC, QL (100 tabs / 30


PEDIATRIC MULTIPLE VITAMINS INFUVITE INJ 1 PA


145


POLY-VI-SOL DRO 2 OTC, QL (50 mL / 30 days)

poly-vite dro 1 OTC, QL (50 mL / 30 days); For 3 years of

age and younger

VITACRAVES CHW +OMEGA-3 3 OTC, PA

zoo friends chw extra c 1 OTC

zoo friends chw gummies 1 OTC, QL (100 tabs / 30 days); For 12 years of age and younger

PEDIATRIC VITAMINS bprotected sol tri-vite 1 OTC, QL (50 mL / 30


PRENATAL VITAMINS ATABEX EC TAB 2

BAL-CARE MIS DHA 2

COMPLETE NAT PAK DHA 2

CONCEPT DHA CAP 2

CONCEPT OB CAP 2

DUET DHA 400 MIS 25-1-400 2

DUET DHA MIS BALANCED 2

FOLET DHA PAK 2

FOLET ONE CAP 38-1-225 2

KOSHR PRENAT TAB 30-1MG 2

MARNATAL-F CAP 2

MULTI PRENAT TAB 2 OTC

MYNATAL TAB 2

NATACHEW CHW 2

NATALVIT TAB 75-1MG 2

NESTABS ABC MIS 2

NESTABS DHA PAK 2

NEWGEN TAB 32-1MG 2

NEXA PLUS CAP 2

O-CAL TAB PRENATAL 2

OB COMPLETE CAP PETITE 2

OB COMPLETE TAB 2

OB COMPLETE/ CAP DHA 2

OBSTETRIX EC TAB 2

OBSTETRIX PAK DHA 2

PREFERA OB TAB 2

PREFERAOB CAP ONE 2

PRENATA CHW 29-1MG 2

prenatabs rx tab 1

PRENATAL 19 CHW 29-1MG 2

prenatal 19 chw tab 1


146


prenatal 19 tab 1

PRENATAL 19 TAB 29-1MG 2

PRENATAL TAB 2 OTC

PRENATAL TAB 27-1MG 2

PRENATAL+FE TAB 29-1MG 2

PRENATE AM TAB 1MG 2

PRENATE CAP ENHANCE 2

PRENATE CAP PIXIE 2

PRENATE CAP RESTORE 2

PRENATE CHW 0.6-0.4 2

PRENATE MINI CAP 2

PRENATE TAB ELITE 2

PRETAB TAB 29-1MG 2

PROVIDA DHA CAP 2

PUREFE OB CAP PLUS 2

SELECT-OB CHW 2

TL FOLATE TAB 2

TRICARE PRE CAP 27-1-500 2

trinate tab 1

TRISTART DHA CAP 2

VINATE DHA CAP 27-1.13 2

VINATE M TAB 2

VINATE ONE TAB 2

VIRT NATE TAB 2

VITAFOL-NANO TAB 2

VP-HEME OB TAB 2

SPECIALTY VITAMINS PRODUCTS DIABETIC CAP VITAMIN 3 PA

MUSCULOSKELETAL THERAPY AGENTS CENTRAL MUSCLE RELAXANTS

baclofen tab 10 mg 1

baclofen tab 20 mg 1

carisoprodol tab 250 mg 1 QL (120 tabs / year), ST

carisoprodol tab 350 mg 1 QL (120 tabs / year), ST

chlorzoxazone tab 500 mg 1

cyclobenzaprine hcl cap er 24hr 15 mg 1 PA

cyclobenzaprine hcl cap er 24hr 30 mg 1 PA

cyclobenzaprine hcl tab 5 mg 1

cyclobenzaprine hcl tab 7.5 mg 1

cyclobenzaprine hcl tab 10 mg 1

LORZONE TAB 375MG 3 ST

LORZONE TAB 750MG 3 ST

metaxalone tab 400 mg 1

metaxalone tab 800 mg 1

methocarbamol tab 500 mg 1


147


methocarbamol tab 750 mg 1

orphenadrine citrate inj 30 mg/ml 1

orphenadrine citrate tab er 12hr 100 mg 1

tizanidine hcl tab 2 mg (base equivalent) 1

tizanidine hcl tab 4 mg (base equivalent) 1

DIRECT MUSCLE RELAXANTS dantrolene sodium cap 25 mg 1

dantrolene sodium cap 50 mg 1

dantrolene sodium cap 100 mg 1 PA

MUSCLE RELAXANT COMBINATIONS carisoprodol w/ aspirin & codeine tab

200-325-16 mg 1 PA

carisoprodol w/ aspirin tab 200-325 mg 1 PA

VISCOSUPPLEMENTS EUFLEXXA INJ 10MG/ML 2 PA

GENVISC 850 INJ 25/2.5 2 PA

HYALGAN INJ 20MG/2ML 2 PA

SUPARTZ FX INJ 25/2.5ML 3 PA

NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL AGENTS - MISC.

ayr saline gel nasal 1 OTC, QL (30 mL / 30 days)

nasal moist spr 0.65% 1 OTC, QL (50 mL / 30 days)

nasogel gel 1 OTC, QL (30 mL / 30

days)

saline nasal gel 1 OTC, QL (28.4 gm / 30

days)

NASAL ANTI-INFECTIVES BACTROBAN OIN NASAL 2% 2

NASAL ANTIALLERGY azelastine hcl nasal spray 0.1% (137

mcg/spray)

1

azelastine hcl nasal spray 0.15% (205.5 mcg/spray)

1

cromolyn sodium nasal aerosol soln 5.2

mg/act (4%)

1 OTC, QL (1 bottle / 30

days) olopatadine hcl nasal soln 0.6% 1 QL (1 bottle / 30 days)

NASAL ANTICHOLINERGICS ipratropium bromide nasal soln 0.03% (21

mcg/spray) 1

ipratropium bromide nasal soln 0.06% (42 mcg/spray)

1


148


NASAL STEROIDS budesonide nasal susp 32 mcg/act 1 OTC, QL (1 bottle / 30

days)

fluticasone propionate nasal susp 50 mcg/act

1 QL (1 bottle / 30 days)

mometasone furoate nasal susp 50

mcg/act

1 PA; PA applies to 5

years of age and older

NASACORT ALR SPR 55MCG/AC 3 OTC, PA, ST

triamcinolone acetonide nasal aerosol

suspension 55 mcg/act

1 OTC, QL (1 bottle / 30

days)

SYMPATHOMIMETIC DECONGESTANTS ADRENALIN SOL 1:1000 3 PA

decongestant tab 120mg er 1 OTC, QL (36 tabs / 30 days)

nasal decon syp 30mg/5ml 1 OTC

nasal decong tab 30mg 1 OTC, QL (36 tabs / 30

days)

NEUROMUSCULAR AGENTS ALS AGENTS

riluzole tab 50 mg 1 QL (60 tabs / 30 days)

DEPOLARIZING MUSCLE RELAXANTS succinylcholine chloride inj 20 mg/ml 1 PA

NONDEPOLARIZING MUSCLE RELAXANTS pancuronium bromide inj 1 mg/ml 1

vecuronium bromide for inj 10 mg 1

vecuronium bromide for inj 20 mg 1

NUTRIENTS CARBOHYDRATES

alcohol absolute inj 98% 1 PA

dextrose inj 5% 1

dextrose inj 10% 1 PA

dextrose inj 25% 1

dextrose inj 30% 1

dextrose inj 50% 1

dextrose inj 70% 1

gluco shot liq 1 OTC, QL (118 ml / 30

days)

MISC. NUTRITIONAL SUBSTANCES fish oil cap 435mg 1 OTC, QL (100 caps / 30

days) omega 3 500 cap 500mg 1 OTC, QL (100 caps / 30

days)

omega essent liq basic 1 OTC, QL (200 mL / 30

days) omega-3 fatty acids cap 300 mg 1 OTC, QL (100 caps / 30

days)


149


omega-3 fatty acids cap 1000 mg 1 OTC, QL (100 caps / 30 days)

omega-3 fatty acids cap 1200 mg 1 OTC, QL (100 caps / 30 days)

omega-3 fish chw 113.5mg 1 OTC, QL (100 tabs / 30 days); For 3 years of age and younger

PROTEINS AMINOSYN 7% INJ /LYTES 3 PA

AMINOSYN II INJ 8.5% 3 PA

aminosyn ii inj 8.5/lyte 1 PA

AMINOSYN M INJ 3.5% 3 PA

AMINOSYN-RF INJ 5.2% 3 PA

CLINIMIX E INJ 2.75/D5W 3 PA

CLINIMIX E INJ 2.75/D10 3 PA

CLINIMIX E INJ 4.25/D5W 3 PA



CLINIMIX E INJ 5%/D15W 3 PA



CLINIMIX INJ 2.75/D5W 3 PA

CLINIMIX INJ 4.25/D5W 3 PA

CLINIMIX INJ 4.25/D10 3 PA



CLINIMIX INJ 5%/D15W 3 PA



cysteine hcl inj 50 mg/ml 1

FREAMINE HBC INJ 6.9% 3 PA

FREAMINE III INJ 10% 3 PA

hepatamine sol 8% 1 PA

NEPHRAMINE INJ 5.4% 3 PA

plenamine inj 15% 1 PA

premasol sol 6% 1 PA

PROCALAMINE INJ 3% 3 PA

PROSOL INJ 20% 3 PA

OPHTHALMIC AGENTS ARTIFICIAL TEARS AND LUBRICANTS

artificial sol tears 1 OTC, QL (15 mL / 30

days)

eye drops dro 0.5-0.9% 1 OTC, QL (15 mL / 30

days) LACRISERT MIS 5MG OP 3 PA


150


lubricnt eye dro 0.5% op 1 OTC, QL (1 box / 30 days)

REFRESH CELL GEL 1% OP 3 OTC, QL (32 mL / 30 days)

REFRESH OPTI DRO 0.5-0.9% 2 OTC, PA

REFRESH PLUS DRO 0.5% OP 3 OTC, PA

REFRESH SOL OPTIVE 2 OTC, QL (10 mL / 30

days)

sm dry eye sol relief 1 OTC, QL (15 mL / 30 days)

soothe night oin time 1 OTC, QL (3.5 gm / 30

days) SYSTANE GEL 0.3% 2 OTC

tears pure sol 1 OTC

THERATEARS GEL 1% 3 OTC, PA

THERATEARS SOL 0.25% PF 2 OTC

BETA-BLOCKERS - OPHTHALMIC betaxolol hcl ophth soln 0.5% 1

BETIMOL SOL 0.5% 3 ST

BETIMOL SOL 0.25% 3 ST

BETOPTIC-S SUS 0.25% OP 3 ST

carteolol hcl ophth soln 1% 1

COMBIGAN SOL 0.2/0.5% 3 ST

dorzolamide hcl-timolol maleate ophth sol 22.3-6.8 mg/ml pf

1 ST

dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml

1

levobunolol hcl ophth soln 0.5% 1

metipranolol ophth soln 0.3% 1

timolol maleate ophth gel forming soln

0.5%

1

timolol maleate ophth gel forming soln 0.25%

1

timolol maleate ophth soln 0.5% 1

timolol maleate ophth soln 0.25% 1

TIMOPTIC OCU SOL 0.5% OP 3 ST

TIMOPTIC OCU SOL 0.25% OP 3 ST

CYCLOPLEGIC MYDRIATICS ATROPINE SUL OIN 1% OP 2

atropine sul sol 1% op 1

CYCLOMYDRIL SOL OP 3 PA

cyclopentolate hcl ophth soln 1% 1

cyclopentolate hcl ophth soln 2% 1

homatropine hbr ophth soln 5% 1

phenylephrine hcl ophth soln 2.5% 1

phenylephrine hcl ophth soln 10% 1


151


tropicamide ophth soln 0.5% 1

tropicamide ophth soln 1% 1

MIOTICS MIOCHOL-E SOL 1:100 3 PA

PHOSPHOLINE SOL 0.125%OP 2

OPHTHALMIC ADRENERGIC AGENTS ALPHAGAN P SOL 0.1% 2

apraclonidine hcl ophth soln 0.5% (base equivalent)

1

brimonidine tartrate ophth soln 0.2% 1

brimonidine tartrate ophth soln 0.15% 1

SIMBRINZA SUS 1-0.2% 3 ST

OPHTHALMIC ANTI-INFECTIVES AZASITE SOL 1% 3 ST

bacitracin ophth oint 500 unit/gm 1

BESIVANCE SUS 0.6% 3 ST

BETADINE SOL 5% OP 3 PA

CILOXAN OIN 0.3% OP 3 ST

ciprofloxacin hcl ophth soln 0.3% (base equivalent)

1

gatifloxacin ophth soln 0.5% 1

gentamicin sulfate ophth soln 0.3% 1

levofloxacin ophth soln 0.5% 1

MITOSOL KIT 0.2MG 3 PA

MOXEZA SOL 0.5% 3 ST

moxifloxacin hcl ophth soln 0.5% (base

equiv)

1

NATACYN SUS 5% OP 2

neo-polycin oin op 1

neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml

1

ofloxacin ophth soln 0.3% 1

polycin oin op 1

polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%

1

sulfacetamide sodium ophth oint 10% 1

sulfacetamide sodium ophth soln 10% 1

tobramycin ophth soln 0.3% 1

TOBREX OIN 0.3% OP 3 ST

trifluridine ophth soln 1% 1

VIGAMOX DRO 0.5% 3 ST

ZIRGAN GEL 0.15% 3 ST

OPHTHALMIC INTEGRIN ANTAGONISTS XIIDRA DRO 5% 3 QL (12 / 30 days), PA


152


OPHTHALMIC KINASE INHIBITORS RHOPRESSA SOL 0.02% 3 ST

OPHTHALMIC LOCAL ANESTHETICS AKTEN GEL 3.5% 3 QL (1 ml / year), PA

proparacaine hcl ophth soln 0.5% 1

tetcaine sol 0.5% op 1 PA

OPHTHALMIC NERVE GROWTH FACTORS OXERVATE SOL 20MCG/ML 2 QL (112 mL / 56 days),

PA

OPHTHALMIC STEROIDS ALREX SUS 0.2% 3 PA

BLEPHAMIDE OIN S.O.P. 3 ST

BLEPHAMIDE SUS OP 3 ST

dexamethasone sodium phosphate ophth soln 0.1%

1

DUREZOL EMU 0.05% 3 PA

FLAREX SUS 0.1% OP 3 PA

fluorometholone ophth susp 0.1% 1

FML FORTE SUS 0.25% OP 3 PA

FML OIN 0.1% OP 3 PA

LOTEMAX GEL 0.5% 3 ST

LOTEMAX OIN 0.5% 3 ST

loteprednol etabonate ophth susp 0.5% 1 PA

MAXIDEX SUS 0.1% OP 3 PA

neo-polycin oin hc 1%op 1

neomycin-polymyxin-dexamethasone

ophth oint 0.1%

1

neomycin-polymyxin-dexamethasone ophth susp 0.1%

1

neomycin-polymyxin-hc ophth susp 1

PRED MILD SUS 0.12% OP 2

PRED SOD PHO SOL 1% OP 2

PRED-G S.O.P OIN OP 3 ST

PRED-G SUS OP 3 ST

prednisolone acetate ophth susp 1% 1

sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%

1

TOBRADEX OIN 0.3-0.1% 3 ST

TOBRADEX ST SUS 0.3-0.05 3 ST

tobramycin-dexamethasone ophth susp

0.3-0.1%

1

TRIESENCE INJ 40MG/ML 3 PA

ZYLET SUS 0.5-0.3% 3 PA

OPHTHALMIC SURGICAL AIDS AMVISC INJ 12MG/ML 3 PA


153


AMVISC PLUS INJ 16MG/ML 3 PA

DISCOVISC SOL 3 PA

DUOVISC KIT 0.5/0.55 3 PA

DUOVISC KIT 0.35/0.4 3 PA

GELFILM MIS OP 3 PA

MEMBRANEBLUE SOL 0.15% 3 PA

ocucoat sol 2% op 1

PROVISC INJ 1% 3 PA

VISCOAT SOL 3 PA

VISIONBLUE SOL 0.06% 3 PA

OPHTHALMICS - MISC. ACUVAIL SOL 0.45% 3 QL (30 ml / 365 days),

ST alaway dro 0.025%op 1 OTC, QL (10 ml / 30

days)

ALOCRIL SOL 2% 3 ST

ALOMIDE SOL 0.1% OP 3 ST

azelastine hcl ophth soln 0.05% 1

AZOPT SUS 1% OP 3 ST

bal salt sol op 1

BEPREVE DRO 1.5% 3 ST

bromfenac sodium ophth soln 0.09% (base equiv) (once-daily)

1

cromolyn sodium ophth soln 4% 1

CYSTARAN SOL 0.44% 2 QL (60 ml / 30 days),

PA

diclofenac sodium ophth soln 0.1% 1

dorzolamide hcl ophth soln 2% 1

EMADINE SOL 0.05% OP 3 ST

epinastine hcl ophth soln 0.05% 1

flurbiprofen sodium ophth soln 0.03% 1

ILEVRO DRO 0.3% OP 3 ST

ketorolac tromethamine ophth soln 0.4% 1

ketorolac tromethamine ophth soln 0.5% 1

LASTACAFT SOL 0.25% 3 ST

NEVANAC SUS 0.1% 3 ST

olopatadine hcl ophth soln 0.1% (base equivalent)

1

olopatadine hcl ophth soln 0.2% (base

equivalent)

1

PAZEO DRO 0.7% 3 PA

PROLENSA SOL 0.07% 3 ST

ROSE BENGAL TES 1.3MG 3 OTC

PROSTAGLANDINS - OPHTHALMIC bimatoprost ophth soln 0.03% 1

latanoprost ophth soln 0.005% 1


154


LUMIGAN SOL 0.01% 3 ST

TRAVATAN Z DRO 0.004% 3 ST

VYZULTA SOL 0.024% 3 PA

ZIOPTAN DRO 0.0015% 3 ST

OTIC AGENTS OTIC AGENTS - MISCELLANEOUS

acetic acid otic soln 2% 1

OTIC ANTI-INFECTIVES ciprofloxacin hcl otic soln 0.2% (base

equivalent) 1

ofloxacin otic soln 0.3% 1

OTIC COMBINATIONS CIPRO HC SUS OTIC 3 PA

CIPRODEX SUS 0.3-0.1% 2

COLY-MYCIN S SUS OTIC 3 PA

neomycin-polymyxin-hc otic soln 1% 1

neomycin-polymyxin-hc otic susp 3.5

mg/ml-10000 unit/ml-1%

1

OTIC STEROIDS fluocinolone acetonide (otic) oil 0.01% 1

OXYTOCICS ABORTIFACIENTS/AGENTS FOR CERVICAL RIPENING

CERVIDIL VAG MIS 10MG INS 3 PA

PREPIDIL GEL 0.5MG/3G 3 PA

PROSTIN E2 SUP 20MG 3 PA

OXYTOCICS methergine tab 0.2mg 1

methylergonovine maleate inj 0.2 mg/ml 1 PA

methylergonovine maleate tab 0.2 mg 1

oxytocin inj 10 unit/ml 1

PASSIVE IMMUNIZING AND TREATMENT AGENTS ANTITOXINS-ANTIVENINS

ANASCORP INJ 3 PA

ANTIVENIN KIT LAT MACT 3 PA

CROFAB INJ 3 PA

IMMUNE SERUMS BIVIGAM INJ 10% 3 PA

CARIMUNE NF INJ 6GM 3 PA

CARIMUNE NF INJ 12GM 3 PA

FLEBOGAMMA INJ 5GM/50ML 2 PA

FLEBOGAMMA INJ 10/100ML 2 PA





155


FLEBOGAMMA INJ DIF 5% 2 PA

GAMASTAN S/D INJ 3 PA

GAMMAGARD INJ 1GM/10ML 3 PA

GAMMAGARD INJ 2.5GM/25 3 PA

GAMMAGARD INJ 5GM/50ML 3 PA

GAMMAGARD INJ 10GM/100 3 PA



GAMMAGARD SD INJ 5GM HU 3 PA

GAMMAGARD SD INJ 10GM HU 3 PA

GAMMAPLEX INJ 5% 3 PA

HEPAGAM B INJ 3 PA

HIZENTRA INJ 1GM/5ML 2 PA



HIZENTRA INJ 10/50ML 2 PA

OCTAGAM INJ 1GM 3 PA

OCTAGAM INJ 2.5GM 3 PA

OCTAGAM INJ 2GM/20ML 3 PA


OCTAGAM INJ 5GM/50ML 3 PA

OCTAGAM INJ 10/100ML 3 PA





PRIVIGEN INJ 5 GRAMS 2 PA

PRIVIGEN INJ 10GRAMS 2 PA



RHOPHYLAC INJ 1500/2ML 3 PA

MONOCLONAL ANTIBODIES SYNAGIS INJ 50MG 2 QL (1 vial / 30 days), PA

SYNAGIS INJ 100MG/ML 2 QL (1 vial / 30 days), PA

PASSIVE IMMUNIZING AGENTS - COMBINATIONS HYQVIA INJ 2.5-200 3 PA

HYQVIA INJ 5-400 3 PA




PENICILLINS AMINOPENICILLINS

amoxicillin (trihydrate) cap 250 mg 1

amoxicillin (trihydrate) cap 500 mg 1

amoxicillin (trihydrate) chew tab 125 mg 1


156


amoxicillin (trihydrate) chew tab 250 mg 1

amoxicillin (trihydrate) for susp 125

mg/5ml

1

amoxicillin (trihydrate) for susp 200 mg/5ml

1


mg/5ml

1


mg/5ml

1

amoxicillin (trihydrate) tab 500 mg 1

amoxicillin (trihydrate) tab 875 mg 1

ampicillin cap 500 mg 1

ampicillin sodium for inj 1 gm 1

ampicillin sodium for inj 2 gm 1

ampicillin sodium for inj 125 mg 1



ampicillin sodium for iv soln 10 gm 1

NATURAL PENICILLINS BICILLIN L-A INJ 600000 3 PA

BICILLIN L-A INJ 1200000 3 PA

BICILLIN L-A INJ 2400000 3 PA

PEN G PROC INJ 600000 3

penicillin g potassium for inj 5000000 unit 1

penicillin g potassium for inj 20000000 unit 1

penicillin g sodium for inj 5000000 unit 1

penicillin v potassium for soln 125 mg/5ml 1

penicillin v potassium for soln 250 mg/5ml 1

penicillin v potassium tab 250 mg 1

penicillin v potassium tab 500 mg 1

PENICILLIN COMBINATIONS amoxicillin & k clavulanate chew tab

200-28.5 mg

1

amoxicillin & k clavulanate chew tab 400-57 mg

1

amoxicillin & k clavulanate for susp

200-28.5 mg/5ml

1

amoxicillin & k clavulanate for susp 250-62.5 mg/5ml

1

amoxicillin & k clavulanate for susp 400-57

mg/5ml

1

amoxicillin & k clavulanate for susp

600-42.9 mg/5ml

1

amoxicillin & k clavulanate tab 250-125 mg 1




157


amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg

1

ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm

1

ampicillin & sulbactam sodium for inj 3 (2-1) gm

1

ampicillin & sulbactam sodium for iv soln 15 (10-5) gm

1

AUGMENTIN SUS 125/5ML 3 PA

BICILLIN C-R INJ 900/300 3 PA

BICILLIN C-R INJ 1200000 3 PA

piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm)

1

piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm)

1

piperacillin sod-tazobactam sod for inj 4.5

gm (4-0.5 gm)

1

piperacillin sod-tazobactam sod for inj 40.5

gm (36-4.5 gm)

1

PENICILLINASE-RESISTANT PENICILLINS dicloxacillin sodium cap 250 mg 1

dicloxacillin sodium cap 500 mg 1

nafcillin sodium for inj 1 gm 1

nafcillin sodium for inj 2 gm 1

oxacillin sodium for inj 1 gm (base

equivalent)

1

oxacillin sodium for inj 2 gm (base equivalent)

1

oxacillin sodium for inj 10 gm (base

equivalent)

1

PROGESTINS PROGESTINS

hydroxyprogesterone caproate im in oil

250 mg/ml

1 PA

MAKENA INJ 275MG 2 PA

medroxyprogesterone acetate tab 2.5 mg 1

medroxyprogesterone acetate tab 5 mg 1

medroxyprogesterone acetate tab 10 mg 1

megestrol acetate susp 625 mg/5ml 1

norethindrone acetate tab 5 mg 1

progesterone im in oil 50 mg/ml 1

progesterone micronized cap 100 mg 1

progesterone micronized cap 200 mg 1


158


PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. AGENTS FOR CHEMICAL DEPENDENCY

acamprosate calcium tab delayed release 333 mg

1

disulfiram tab 250 mg 1

disulfiram tab 500 mg 1

LUCEMYRA TAB 0.18MG 3 QL (192 tabs / 14 days),

PA

ANTI-CATAPLECTIC AGENTS XYREM SOL 500MG/ML 2 QL (540 mL / 30 days),

PA

ANTIDEMENTIA AGENTS donepezil hydrochloride orally

disintegrating tab 5 mg 1

donepezil hydrochloride orally

disintegrating tab 10 mg

1

donepezil hydrochloride tab 5 mg 1



galantamine hydrobromide cap er 24hr 8 mg

1


1


1

galantamine hydrobromide oral soln 4

mg/ml

1

galantamine hydrobromide tab 4 mg 1



memantine hcl cap er 24hr 7 mg 1 QL (30 caps / 30 days), PA

memantine hcl cap er 24hr 14 mg 1 QL (30 caps / 30 days),

PA memantine hcl cap er 24hr 21 mg 1 QL (30 caps / 30 days),

PA

memantine hcl cap er 24hr 28 mg 1 QL (30 caps / 30 days),

PA memantine hcl oral solution 2 mg/ml 1

memantine hcl tab 5 mg 1

memantine hcl tab 5 mg (28) & 10 mg (21) titration pak

1

memantine hcl tab 10 mg 1

NAMENDA XR CAP TITRATIO 3 QL (30 caps / 30 days),

ST NAMZARIC CAP 7-10MG 3 QL (30 caps / 30 days),

ST


159


NAMZARIC CAP 14-10MG 3 QL (30 caps / 30 days), ST



rivastigmine tartrate cap 1.5 mg (base equivalent)

1

rivastigmine tartrate cap 3 mg (base equivalent)

1

rivastigmine tartrate cap 4.5 mg (base

equivalent)

1

rivastigmine tartrate cap 6 mg (base

equivalent)

1

rivastigmine td patch 24hr 4.6 mg/24hr 1



COMBINATION PSYCHOTHERAPEUTICS chlordiazepoxide-amitriptyline tab 5-12.5

mg 1

chlordiazepoxide-amitriptyline tab 10-25 mg

1

perphenazine-amitriptyline tab 2-10 mg 1





FIBROMYALGIA AGENTS SAVELLA MIS TITR PAK 2 QL (1 kit in lifetime), PA

SAVELLA TAB 12.5MG 2 QL (60 tabs / 30 days),

PA SAVELLA TAB 25MG 2 QL (60 tabs / 30 days),

PA

SAVELLA TAB 50MG 2 QL (60 tabs / 30 days), PA

SAVELLA TAB 100MG 2 QL (60 tabs / 30 days),

PA

MOVEMENT DISORDER DRUG THERAPY AUSTEDO TAB 6MG 3 QL (60 / 30), PA

AUSTEDO TAB 9MG 3 QL (60 / 30), PA

AUSTEDO TAB 12MG 3 QL (120 / 30), PA

INGREZZA CAP 40MG 3 QL (30 caps / 30), PA

INGREZZA CAP 80MG 3 QL (30 caps / 30), PA

tetrabenazine tab 12.5 mg 1 QL (90 tabs / 30 days)

tetrabenazine tab 25 mg 1 QL (120 tabs / 30 days)


160


MULTIPLE SCLEROSIS AGENTS AUBAGIO TAB 7MG 2 QL (30 tabs / 30 days),

PA

AUBAGIO TAB 14MG 2 QL (30 tabs / 30 days), PA

AVONEX KIT 30MCG 2 QL (4 boxes / 30 days),

PA

AVONEX PEN KIT 30MCG 2 QL (4 boxes / 30 days), PA

AVONEX PREFL KIT 30MCG 2 QL (4 boxes / 30 days), PA

BETASERON INJ 0.3MG 3 QL (15 / 30 days), PA

BETASERON INJ 0.3MG 3 QL (15 boxes / 30

days), PA

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

EXTAVIA INJ 0.3MG 2 QL (15 boxes / 30 days), PA

GILENYA CAP 0.5MG 2 QL (30 caps / 30 days), PA

glatiramer acetate soln prefilled syringe 20 mg/ml


glatiramer acetate soln prefilled syringe 40 mg/ml


glatopa inj 20mg/ml 1 QL (30 syringes / 30

days), PA

MAVENCLAD PAK 10MG (4) 3 QL (16 tabs / 365 days), PA

MAVENCLAD PAK 10MG (5) 3 QL (20 tabs / 365

days), PA


days), PA




days), PA

MAVENCLAD PAK 10MG(4) 3 QL (16 tabs / 365 days), PA



MAVENCLAD PAK 10MG(7) 3 QL (28 tabs / 365

days), PA MAVENCLAD PAK 10MG(8) 3 QL (32 tabs / 365

days), PA


161




MAYZENT TAB 0.25MG 2 QL (112 tabs / 30 days), PA

MAYZENT TAB 2MG 2 QL (30 tabs / 30 days), PA

PLEGRIDY INJ 3 QL (1 / 21 days), PA

PLEGRIDY INJ PEN 3 QL (1 / 21 days), PA

PLEGRIDY INJ STARTER 3 QL (1 box / 21 days), PA

PLEGRIDY PEN INJ STARTER 3 QL (1 box / 21 days), PA

REBIF INJ 22/0.5 2 QL (12 syringes / 30

days), PA

REBIF INJ 44/0.5 2 QL (12 syringes / 30 days), PA

REBIF REBIDO INJ 22/0.5 2 QL (6 syringes / 30 days), PA

REBIF REBIDO INJ 44/0.5 2 QL (6 syringes / 30 days), PA

REBIF REBIDO INJ TITRATN 2 QL (1 box in lifetime), PA

REBIF TITRTN INJ PACK 2 QL (1 box in lifetime), PA

TECFIDERA CAP 120MG 2 QL (60 caps / 30 days), PA

TECFIDERA CAP 240MG 2 QL (60 caps / 30 days),

PA TECFIDERA MIS STARTER 2 QL (1 box in lifetime),

PA

VUMERITY CAP 231MG 3 QL (120 caps / 30 days), PA

POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS GRALISE STAR MIS 300/600 3 QL (1 in lifetime), PA

GRALISE TAB 300MG 3 QL (30 tabs / 30 days), PA

GRALISE TAB 600MG 3 QL (90 tabs / 30 days), PA

PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS fluoxetine hcl (pmdd) cap 10 mg 1

fluoxetine hcl (pmdd) cap 20 mg 1

PSEUDOBULBAR AFFECT (PBA) AGENTS NUEDEXTA CAP 20-10MG 2 QL (60 caps / 30 days),

PA

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. pimozide tab 1 mg 1

pimozide tab 2 mg 1


162


RESTLESS LEG SYNDROME (RLS) AGENTS HORIZANT TAB 300MG ER 2 QL (60 tabs / 30 days),

PA

HORIZANT TAB 600MG ER 2 QL (60 tabs / 30 days), PA

SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab er

12hr 150 mg

1

CHANTIX PAK 0.5& 1MG 2

CHANTIX PAK 1MG 2

CHANTIX TAB 0.5MG 2

nicotine polacrilex gum 2 mg 1 OTC

nicotine polacrilex gum 4 mg 1 OTC

nicotine polacrilex lozenge 2 mg 1 OTC

nicotine polacrilex lozenge 4 mg 1 OTC

NICOTINE SYS KIT TRANSDER 2 OTC

nicotine td patch 24hr 14 mg/24hr 1 OTC

NICOTROL INH 2

NICOTROL NS SPR 10MG/ML 2

sm nicotine dis 7mg/24hr 1 OTC

sm nicotine dis 21mg 1 OTC

TRANSTHYRETIN AMYLOIDOSIS AGENTS TEGSEDI INJ 284/1.5 2 QL (4 syringes / 28

days), PA

VASOMOTOR SYMPTOM AGENTS BRISDELLE CAP 7.5MG 3 QL (30 caps / 30 days),

PA paroxetine mesylate cap 7.5 mg (base

equiv)


PA

RESPIRATORY AGENTS - MISC. ALPHA-PROTEINASE INHIBITOR (HUMAN)

ARALAST NP INJ 500MG 2 PA

ARALAST NP INJ 1000MG 2 PA

GLASSIA INJ 3 PA

CYSTIC FIBROSIS AGENTS KALYDECO PAK 25MG 2 QL (60 packets / 30

days), PA KALYDECO PAK 50MG 2 QL (60 packets / 30

days), PA

KALYDECO PAK 75MG 2 QL (60 packets / 30 days), PA

KALYDECO TAB 150MG 2 QL (60 tabs / 30 days), PA

ORKAMBI GRA 100-125 3 QL (60 packets / 30 days)


163


ORKAMBI GRA 150-188 3 QL (60 packets / 30 days)

ORKAMBI TAB 100-125 3 QL (120 tabs / 30 days), PA

ORKAMBI TAB 200-125 3 QL (120 tabs / 30 days), PA

PULMOZYME SOL 1MG/ML 2 QL (30 pkg / 30 days), PA

SYMDEKO TAB 50-75MG 3 QL (30 tabs / 30 days), PA

SYMDEKO TAB 100-150 3 QL (60 tabs / 30 days),

PA

TRIKAFTA TAB 3 QL (84 tabs / 28 days),

PA

PLEURAL SCLEROSING AGENTS SCLEROSOL AER INTRAPLE 3 PA

STERIL TALC SUS 5GM 3 PA

PULMONARY FIBROSIS AGENTS ESBRIET CAP 267MG 3 QL (270 caps / 30

days), PA

ESBRIET TAB 801MG 3 QL (90 tabs / 30 days), PA

OFEV CAP 100MG 2 QL (60 caps / 30 days), PA

OFEV CAP 150MG 2 QL (60 caps / 30 days),

PA

RESPIRATORY AGENTS - MISC. CUROSURF SUS 120/1.5 3 PA

INFASURF SUS 35MG/ML 3 PA

SURVANTA INH 3 PA

TETRACYCLINES AMINOMETHYLCYCLINES

NUZYRA TAB 150MG 3 QL (30 tabs / 14 days),

PA

TETRACYCLINES demeclocycline hcl tab 150 mg 1

demeclocycline hcl tab 300 mg 1

doxy 100 inj 100mg 1 PA

doxycycline hyclate cap 50 mg 1 PA

doxycycline hyclate cap 100 mg 1 PA

doxycycline hyclate tab 20 mg 1 PA

doxycycline hyclate tab 100 mg 1 PA

doxycycline monohydrate cap 50 mg 1

doxycycline monohydrate cap 100 mg 1

doxycycline monohydrate cap 150 mg 1 PA


164


doxycycline monohydrate for susp 25 mg/5ml

1

doxycycline monohydrate tab 50 mg 1 PA




MINOCIN INJ 100MG 3 PA

minocycline hcl cap 50 mg 1



minocycline hcl tab 50 mg 1



minocycline hcl tab er 24hr 45 mg 1

minocycline hcl tab er 24hr 55 mg 1 PA




minocycline hcl tab er 24hr 105 mg 1 ST



tetracycline hcl cap 250 mg 1

tetracycline hcl cap 500 mg 1

VIBRAMYCIN SYP 50MG/5ML 3 ST

THYROID AGENTS ANTITHYROID AGENTS

methimazole tab 5 mg 1

methimazole tab 10 mg 1

propylthiouracil tab 50 mg 1

THYROID HORMONES ARMOUR THYRO TAB 15MG 2 PA

ARMOUR THYRO TAB 120MG 2




levo-t tab 88mcg 1

levo-t tab 112mcg 1

levo-t tab 137mcg 1

levo-t tab 175mcg 1

levo-t tab 200 mcg 1

levo-t tab 300 mcg 1

levothyroxine sodium tab 25 mcg 1





165




liothyronine sodium tab 5 mcg 1



NATURE THROI TAB 162.5MG 2

NATURE-THROI TAB 16.25MG 2 PA



NATURE-THROI TAB 65MG 2 PA




NATURE-THROI TAB 130MG 2 PA

NATURE-THROI TAB 146.25MG 2

NATURE-THROI TAB 195MG 2



np thyroid tab 15mg 1





SYNTHROID TAB 25MCG 2











thyroid tab 120 mg (2 grain) 1

THYROLAR-1 TAB 60MG 2

THYROLAR-1/2 TAB 30MG 2

THYROLAR-1/4 TAB 15MG 2



TIROSINT CAP 13MCG 3 PA







166







TIROSINT CAP 200 3 PA

WESTHROID TAB 32.5MG 2 PA

WESTHROID TAB 65MG 2 PA

WESTHROID TAB 97.5MG 2 PA

WESTHROID TAB 130MG 2 PA

ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS ANTISPASMODICS

ATROPEN INJ 0.5MG 3 PA

ATROPEN INJ 1MG 3 PA

ATROPEN INJ 2MG 3 PA

atropine sulfate inj 1 mg/ml 1

atropine sulfate inj 8 mg/20ml (0.4 mg/ml) 1

atropine sulfate soln prefill syr 0.25 mg/5ml (0.05 mg/ml)

1

atropine sulfate soln prefill syr 1 mg/10ml (0.1 mg/ml)

1

BELLA/OPIUM SUP 16.2-30 3 PA

BELLA/OPIUM SUP 16.2-60 3 PA

CUVPOSA SOL 1MG/5ML 3 PA

dicyclomine hcl cap 10 mg 1

dicyclomine hcl inj 10 mg/ml 1

dicyclomine hcl oral soln 10 mg/5ml 1

dicyclomine hcl tab 20 mg 1

glycopyrrolate inj 0.2 mg/ml 1

glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) 1

glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) 1

glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) 1

glycopyrrolate tab 1 mg 1

glycopyrrolate tab 2 mg 1

hyoscyamine sulfate tab er 12hr 0.375 mg 1

LEVSIN INJ 0.5MG/ML 3 PA

methscopolamine bromide tab 2.5 mg 1 PA

methscopolamine bromide tab 5 mg 1 PA

propantheline bromide tab 15 mg 1 PA

SYMAX DUOTAB TAB 3 ST

H-2 ANTAGONISTS acid reducer tab 10mg 1 OTC, QL (90 tabs / 30

days)

cimetidine hcl soln 300 mg/5ml 1

cimetidine tab 200 mg 1


167





famotidine for susp 40 mg/5ml 1

famotidine inj 20 mg/2ml 1



famotidine tab 20 mg 1 QL (30 tabs / 30 days)

famotidine tab 40 mg 1

heartbrn rel tab 75mg 1 OTC, QL (60 tabs / 30 days)

nizatidine cap 150 mg 1

nizatidine cap 300 mg 1

nizatidine oral soln 15 mg/ml 1

PEPCID AC CHW MAX ST 3 OTC

ranitidine hcl cap 150 mg 1

ranitidine hcl cap 300 mg 1

ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1

ranitidine hcl tab 150 mg 1

ranitidine hcl tab 300 mg 1

ZANTAC INJ 25MG/ML 3 ST

MISC. ANTI-ULCER CARAFATE SUS 1GM/10ML 3 PA

sucralfate tab 1 gm 1

PROTON PUMP INHIBITORS - Limit of 12 weeks / 365 days ACIPHEX SPR CAP 5MG 3 QL (30 caps / 30 days),

ST

ACIPHEX SPR CAP 10MG 3 QL (30 caps / 30 days), ST

DEXILANT CAP 30MG DR 3 QL (30 caps / 30 days), ST

DEXILANT CAP 60MG DR 3 QL (30 caps / 30 days),

ST

esomeprazole magnesium cap delayed release 20 mg (base eq)

1 QL (30 caps / 30 days), ST

esomeprazole magnesium cap delayed

release 40 mg (base eq)


ST

esomeprazole sodium for intravenous soln 20 mg (base equiv)

1 QL (30 / 30 days)

esomeprazole sodium for intravenous soln

40 mg (base equiv)

1 QL (30 / 30 days)

lansoprazole cap delayed release 15 mg 1 QL (30 caps / 30 days),

ST

lansoprazole cap delayed release 15 mg 1 OTC, QL (30 caps / 30 days), ST

lansoprazole cap delayed release 30 mg 1 QL (30 caps / 30 days),

ST


168


lansoprazole tab delayed release orally disintegrating 15 mg

1 QL (30 tabs / 30 days), ST; ST applies to 12

years of age and older lansoprazole tab delayed release orally

disintegrating 30 mg


ST; ST applies to 12 years of age and older

NEXIUM 24HR CAP 20MG 1 OTC, QL (30 caps / 30 days), ST

NEXIUM GRA 2.5MG DR 3 QL (1 box / 30 days), ST

NEXIUM GRA 5MG DR 3 QL (1 box / 30 days), ST




omeprazole cap delayed release 10 mg 1 QL (60 caps / 30 days)



omeprazole magnesium cap dr 20.6 mg (20 mg base equiv)

1 OTC, QL (30 caps / 30 days)

pantoprazole sodium ec tab 20 mg (base equiv)


pantoprazole sodium ec tab 40 mg (base equiv)


PRILOSEC POW 2.5MG 3 QL (60 packets / 30

days), ST

PRILOSEC POW 10MG 3 QL (60 packets / 30 days), ST

PROTONIX PAK 3 QL (30 packets / 30

days), ST rabeprazole sodium ec tab 20 mg 1 QL (30 tabs / 30 days),

ST

ULCER DRUGS - PROSTAGLANDINS misoprostol tab 100 mcg 1

misoprostol tab 200 mcg 1

ULCER THERAPY COMBINATIONS amoxicillin cap-clarithro tab-lansopraz cap

dr therapy pack 1

dual action chw complete 1 OTC, QL (60 tabs / 30

days)

OMECLAMOX- MIS PAK 3 PA

omeprazole-sodium bicarbonate cap 20-1100 mg



1 OTC, QL (30 caps / 30 days), ST



PYLERA CAP 3 PA


169


URINARY ANTI-INFECTIVES URINARY ANTI-INFECTIVE COMBINATIONS

azuphen mb cap 120mg 1 PA

ur n-c tab 1

uramit mb cap 118mg 1 QL (120 caps / 30 days), PA

urimar-t tab 1

urolet mb tab 1

URINARY ANTI-INFECTIVES methenamine hippurate tab 1 gm 1

methenamine mandelate tab 0.5 gm 1

methenamine mandelate tab 1 gm 1

nitrofurantoin macrocrystalline cap 25 mg 1



nitrofurantoin monohydrate macrocrystalline cap 100 mg

1

nitrofurantoin susp 25 mg/5ml 1 QL (500 ml / 30 days); For 12 years of age and

younger

URINARY ANTISPASMODICS URINARY ANTISPASMODIC - ANTIMUSCARINICS

(ANTICHOLINERGIC) GELNIQUE GEL 10% 3 ST

oxybutynin chloride syrup 5 mg/5ml 1

oxybutynin chloride tab 5 mg 1

oxybutynin chloride tab er 24hr 5 mg 1



OXYTROL DIS 3.9MG/24 3 QL (8 patches / 30 days), PA

OXYTROL/WOMN DIS 3.9MG/24 3 OTC, QL (8 patches / 30

days), PA

solifenacin succinate tab 5 mg 1 PA

solifenacin succinate tab 10 mg 1 PA

tolterodine tartrate cap er 24hr 2 mg 1

tolterodine tartrate cap er 24hr 4 mg 1

tolterodine tartrate tab 1 mg 1

tolterodine tartrate tab 2 mg 1

TOVIAZ TAB 4MG 3 ST

TOVIAZ TAB 8MG 3 ST

trospium chloride cap er 24hr 60 mg 1

trospium chloride tab 20 mg 1


170


URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS MYRBETRIQ TAB 25MG 3 QL (30 tabs / 30 days),

ST

MYRBETRIQ TAB 50MG 3 QL (30 tabs / 30 days), ST

URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS bethanechol chloride tab 5 mg 1

bethanechol chloride tab 10 mg 1



URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS flavoxate hcl tab 100 mg 1

VAGINAL AND RELATED PRODUCTS MISCELLANEOUS VAGINAL PRODUCTS

acetic acid vaginal solution 1 OTC, QL (133 mL / 30 days)

relagard gel 1 PA

VAGINAL ANTI-INFECTIVES AVC CRE 15% 3 PA

CLEOCIN SUP 100MG 3 PA

clindamycin phosphate vaginal cream 2% 1

CLINDESSE CRE 2% 3 PA

clotrimazole cre 1% vag 1 OTC, QL (45 gm / 30 days)

clotrimazole cre 2% 1 OTC, QL (21 gm / 30

days)

3 day vagnal cre 4% 1 OTC, QL (25 gm / 30 days)

GYNAZOLE-1 CRE 2% 3 PA

metronidazole vaginal gel 0.75% 1

miconazole 3 kit combinat 1 OTC, QL (1 kit / 30

days)

miconazole 3 kit combo pk 1 OTC, QL (1 kit / 30 days)

miconazole 3 sup 200mg 1

miconazole 7 cre 2% 1 OTC, QL (45 gm / 30

days)

MONISTAT 3 KIT COMBO PK 3 OTC, PA

NUVESSA GEL 1.3% 3 PA

sm micon 7 sup 100mg 1 OTC, QL (7 supp / 30

days) terconazole vaginal cream 0.4% 1

terconazole vaginal cream 0.8% 1

terconazole vaginal suppos 80 mg 1

VAGINAL ESTROGENS estradiol vaginal cream 0.1 mg/gm 1 PA


171


ESTRING MIS 2MG 3 QL (1 ring / 91 days), ST

FEMRING MIS 0.1MG/24 3 ST

FEMRING MIS 0.05/24H 3 ST

PREMARIN VAG CRE 0.625MG 3 PA

yuvafem tab 10mcg 1

VAGINAL PROGESTINS CRINONE GEL 4% VAG 3 PA

VASOPRESSORS ANAPHYLAXIS THERAPY AGENTS

AUVI-Q INJ 0.1MG 3 QL (4 pens / 180 days), PA

AUVI-Q INJ 0.3MG 3 QL (4 pens / 180 days), PA

AUVI-Q INJ 0.15MG 3 QL (4 pens / 180 days),

PA

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

1 QL (4 pens / 180 days)

epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000)

1 QL (4 pens / 180 days)

EPIPEN-JR INJ 0.15MG 2 QL (4 pens / 180 days)

EPISNAP KIT 3 PA

NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS NORTHERA CAP 100MG 2 QL (540 caps in

lifetime), PA

NORTHERA CAP 200MG 2 QL (180 caps / 30

days), PA NORTHERA CAP 300MG 2 QL (180 caps / 30

days), PA

VASOPRESSORS dobutamine hcl inj 12.5 mg/ml 1

dobutamine inj 1 mg/ml in d5w 1



dopamine hcl inj 40 mg/ml 1



dopamine inj 0.8 mg/ml in d5w 1



ephedrine sulfate inj 50 mg/ml 1

midodrine hcl tab 2.5 mg 1

midodrine hcl tab 5 mg 1

midodrine hcl tab 10 mg 1

PHENYL/NACL INJ 1MG/10ML 2

phenylephrine hcl inj 10 mg/ml 1


172


VITAMINS OIL SOLUBLE VITAMINS

bio-d-mulsio liq 2000unit 1 OTC, QL (30 mL / 30 days)

calcidol dro 8000/ml 1 OTC, QL (60 mL / 30 days)

cholecalciferol cap 10 mcg (400 unit) 1 OTC, QL (100 caps / 30

days) cholecalciferol cap 125 mcg (5000 unit) 1 OTC, QL (100 caps / 30

days)

cholecalciferol oral liquid 10 mcg/ml (400 unit/ml)

1 OTC, QL (200 mL / 30 days); For 3 years of

age and younger

cholecalciferol tab 50 mcg (2000 unit) 1 OTC, QL (100 tabs / 30 days)

d3 cap 1000unit 1 OTC, QL (100 caps / 30

days) d3 super str cap 2000unit 1 OTC, QL (100 caps / 30

days)

d 400 chw 400unit 1 OTC, QL (100 tabs / 30 days); For 12 years of age and younger

d 400 tab 400unit 1 OTC, QL (100 tabs / 30 days)

ergocalciferol cap 1.25 mg (50000 unit) 1

optimal-d cap 50000unt 1 OTC, QL (100 caps / 30 days)

phytonadione inj 1 mg/0.5ml (2 mg/ml) 1 PA

phytonadione inj 10 mg/ml 1

phytonadione tab 5 mg 1

vitamin d3 cap 10000unt 1 OTC, QL (100 caps / 30

days)

vitamin d tab 1000unit 1 OTC, QL (100 tabs / 30 days)

vitamin d-3 tab 5000unit 1 OTC, QL (100 tabs / 30 days)

WATER SOLUBLE VITAMINS ascorbic acid inj 500 mg/ml 1

ascorbic acid tab 250 mg 1 OTC

niacin cap er 500 mg 1 OTC, QL (100 caps / 30 days)

niacin tab 250 mg 1 OTC, QL (100 tabs / 30 days)

niacin tab 500 mg 1 OTC, QL (100 tabs / 30 days)

niacin tab er 500 mg 1 OTC, QL (100 tabs / 30 days)


173


pyridoxine hcl tab 25 mg 1 OTC, QL (100 tabs / 30 days)



thiamine hcl inj 100 mg/ml 1

thiamine hcl tab 100 mg 1 OTC, QL (30 tabs / 30

days)

174

Index 1 1.5 ML SYRNG MIS 22X1-1/2............ 134

10-12ML SYRN MIS LUER SLP ........... 134 12ML SYRINGE MIS 20GX1.5 ............ 133 12ML SYRINGE MIS 21GX1.5 ............ 133 1ML SYRINGE MIS 25GX1................. 133

1ML SYRINGE MIS 25GX5/8 ............. 133 1ML SYRINGE MIS 26GX3/8 ............. 133 1ML SYRINGE MIS LUER SLP ............ 134 1ML TB SYRNG MIS LUER SLP........... 134

2 20ML SYRINGE MIS LL ZONE1 .......... 133 2ML TB SYRNG MIS LL ZONE1 .......... 134 3 3 day vagnal cre 4% ........................ 170

3 ML SYRINGE MIS 22X1-1/2 ........... 133 30ML SYRINGE MIS GL ZONE1 ......... 133 30ML SYRINGE MIS LUER LOC .......... 133 3ML CTRL SYR MIS LL ZONE1 ........... 132

3ML LL SYRNG MIS 20GX1 ............... 133 3ML LL SYRNG MIS 21GX1.25........... 133 3ML LL SYRNG MIS 22GX1.25........... 133 3ML LL SYRNG MIS 22GX3/4 ............ 133

3ML LL SYRNG MIS 23GX1 ............... 133 3ML LL SYRNG MIS 25GX1 ............... 133 3ML LL SYRNG MIS 25GX5/8 ............ 133 3ML SYRINGE MIS 20GX1................. 133 3ML SYRINGE MIS 20GX1.5.............. 133

3ML SYRINGE MIS 21GX1................. 133 3ML SYRINGE MIS 21GX1.5.............. 133 3ML SYRINGE MIS 22GX1................. 133 3ML SYRINGE MIS 22GX1.5.............. 133

3ML SYRINGE MIS 23GX1................. 133 3ML SYRINGE MIS 23GX1.5.............. 133 3ML SYRINGE MIS 25GX1................. 133 3ML SYRINGE MIS 25GX5/8 ............. 133

3ML SYRINGE MIS REG TIP .............. 134 4 45PSE/400GFN TAB............................ 97 5 50ML SYRINGE MIS ML ZONE1 ......... 134

5-6ML SYRING MIS LUER SLP ........... 133 5ML CONTROL MIS SANA-LOK .......... 132 5ML SYRINGE MIS LUER SLP ............ 133 6

60PSE/400GFN TAB /20DM................. 97 6ML SYRINGE MIS 20GX1.5.............. 133

6ML SYRINGE MIS 22GX1.5.............. 133 8

8 hour pain tab 650mg ....................... 12 A abacavir sulfate soln 20 mg/ml (base equiv) ................................................ 80

abacavir sulfate tab 300 mg (base equiv).......................................................... 80 abacavir sulfate-lamivudine tab 600-300 mg ..................................................... 80

abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg .......................... 80 abatron liq ....................................... 126 ABILIFY MAIN INJ 300MG ................... 79 ABILIFY MAIN INJ 400MG ................... 79

abiraterone acetate tab 250 mg.......... 65 ABRAXANE INJ 100MG........................ 72 ABREVA CRE 10% ............................ 102 ABSTRAL SUB 100MCG ....................... 13

ABSTRAL SUB 200MCG ....................... 13 ABSTRAL SUB 300MCG ....................... 13 ABSTRAL SUB 400MCG ....................... 13 ABSTRAL SUB 600MCG ....................... 13

ABSTRAL SUB 800MCG ....................... 13 acamprosate calcium tab delayed release 333 mg ............................................ 158 acarbose tab 100 mg.......................... 43 acarbose tab 25 mg ........................... 43

acarbose tab 50 mg ........................... 43 ACCU-CHEK KIT AVIVA PL ................ 131 ACCU-CHEK KIT FASTCLIX ............... 131 ACCU-CHEK KIT GUIDE .................... 131

ACCU-CHEK KIT MLTICLIX ................ 131 ACCU-CHEK KIT SOFTCLIX ............... 131 ACCU-CHEK LIQ ACT/GLUC .............. 131 ACCU-CHEK LIQ SMART.................... 131

ACCU-CHEK SOL .............................. 131 ACCU-CHEK SOL COMPACT .............. 131 ACCU-CHEK TES AVIVA PL................ 108 ACCU-CHEK TES COMPACT ............... 108 ACCU-CHEK TES GUIDE.................... 108

ACCU-CHEK TES SMART ................... 108 ACD FORMULA SOL A ......................... 33 acebutolol hcl cap 200 mg .................. 85 acebutolol hcl cap 400 mg .................. 85

acetaminophen soln 160 mg/5ml ........ 12 acetaminophen suppos 650 mg .......... 12

175

acetaminophen w/ codeine soln 120-12 mg/5ml .............................................. 19 acetaminophen w/ codeine tab 300-15

mg ..................................................... 19 acetaminophen w/ codeine tab 300-30 mg ..................................................... 19 acetaminophen w/ codeine tab 300-60

mg ..................................................... 19 acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg .......................... 19 acetazolamide cap er 12hr 500 mg ... 109

acetazolamide sodium for inj 500 mg 109 acetazolamide tab 125 mg................ 109 acetazolamide tab 250 mg................ 109 acetic acid irrigation soln 0.25% ....... 119 acetic acid otic soln 2% .................... 154

acetic acid vaginal solution ............... 170 acetylcysteine inhal soln 10% ............. 98 acetylcysteine inhal soln 20% ............. 98 acetylcysteine inj 200 mg/ml .............. 50

acid reducer tab 10mg ..................... 166 ACIDOPH/PROB TAB FORMULA ........... 49 ACIPHEX SPR CAP 10MG .................. 167 ACIPHEX SPR CAP 5MG .................... 167

acitretin cap 10 mg .......................... 101 acitretin cap 17.5 mg ....................... 101 acitretin cap 25 mg .......................... 101 acne treatme cre 10% ........................ 98 ACTEMRA INJ 162/0.9 .......................... 9

ACTHAR INJ 80UNIT ......................... 111 ACTICOAT 7 MIS 1 ........................... 107 ACTICOAT 7 MIS 4 ........................... 107 ACTICOAT 7 MIS 6 ........................... 107

ACTICOAT MIS 5 .............................. 107 ACTIMMUNE INJ 2MU/0.5 ................... 71 ACTIVE INJEC KIT KL-3 ...................... 94 ACTOPLUS MET TAB XR ...................... 43

ACUVAIL SOL 0.45% ........................ 153 acyclovir cap 200 mg ......................... 84 acyclovir cream 5% .......................... 102 acyclovir oint 5% ............................. 102 acyclovir susp 200 mg/5ml ................. 85

acyclovir tab 400 mg .......................... 85 acyclovir tab 800 mg .......................... 85 adapalene gel 0.1% ........................... 99 ADASUVE INH 10MG .......................... 77

ADCIRCA TAB 20MG ........................... 90 adefovir dipivoxil tab 10 mg ............... 83

ADEMPAS TAB 0.5MG ......................... 90 ADEMPAS TAB 1.5MG ......................... 90 ADEMPAS TAB 1MG ............................ 90

ADEMPAS TAB 2.5MG ......................... 90 ADEMPAS TAB 2MG ............................ 90 ADLYXIN INJ 10/20MCG ..................... 46 ADLYXIN INJ 20MCG .......................... 46

ADMELOG INJ 100U/ML ...................... 46 ADMELOG SOLO INJ 100U/ML ............ 46 ADRENALIN SOL 1:1000................... 148 ADVAIR HFA AER 115/21.................... 30

ADVAIR HFA AER 230/21.................... 30 ADVAIR HFA AER 45/21...................... 29 ADVATE INJ 1000UNIT ..................... 120 ADVATE INJ 1500UNIT ..................... 120 ADVATE INJ 2000UNIT ..................... 120

ADVATE INJ 250UNIT ....................... 120 ADVATE INJ 3000UNIT ..................... 120 ADVATE INJ 4000UNIT ..................... 120 ADVATE INJ 500UNIT ....................... 120

ADYNOVATE INJ 1000UNIT ............... 120 ADYNOVATE INJ 2000UNIT ............... 121 ADYNOVATE INJ 250UNIT................. 120 ADYNOVATE INJ 3000UNIT ............... 121

ADYNOVATE INJ 500UNIT................. 120 AEMCOLO TAB 194MG ........................ 23 AERCHMBR Z- MIS STAT PLS ............ 135 AEROCHAMBER KIT ACTION ............. 135 AFINITOR DIS TAB 2MG ..................... 67

AFINITOR DIS TAB 3MG ..................... 67 AFINITOR DIS TAB 5MG ..................... 67 AFINITOR TAB 10MG .......................... 67 AFINITOR TAB 2.5MG ......................... 67

AFINITOR TAB 5MG ............................ 67 AFINITOR TAB 7.5MG ......................... 67 AFREZZA POW 12 UNIT ...................... 46 AFREZZA POW 4-8-12 ........................ 46

AFREZZA POW 4UNIT ......................... 46 AFREZZA POW 8 UNIT ........................ 46 AFREZZA POW 8-12UNIT .................... 46 AIMOVIG INJ 140DOSE .................... 136 AIMOVIG INJ 140MG/ML................... 136

AIMOVIG INJ 70MG/ML..................... 136 AIRZONE PEAK MIS FLOW MTR......... 135 AJOVY INJ 225/1.5 ........................... 136 AKTEN GEL 3.5% ............................. 152

AKYNZEO CAP 300-0.5 ....................... 51 ALA SCALP LOT 2% .......................... 102

176

alaway dro 0.025%op ...................... 153 albendazole tab 200 mg ..................... 23 albumin, human inj 25% .................. 123

alburx inj 5% ................................... 123 albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) ........................... 30 albuterol sulfate soln nebu 0.083% (2.5

mg/3ml) ............................................ 30 albuterol sulfate soln nebu 0.5% (5 mg/ml) .............................................. 30 albuterol sulfate soln nebu 0.63 mg/3ml

(base equiv)....................................... 30 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)....................................... 30 albuterol sulfate syrup 2 mg/5ml ........ 30 albuterol sulfate tab 2 mg .................. 30

albuterol sulfate tab 4 mg .................. 30 albuterol sulfate tab er 12hr 4 mg ...... 30 albuterol sulfate tab er 12hr 8 mg ...... 30 alclometasone dipropionate cream 0.05%

........................................................ 102 alclometasone dipropionate oint 0.05%........................................................ 102 alcohol absolute inj 98% .................. 148

ALDACTAZIDE TAB 50/50 ................. 109 ALDEX GS TAB 30-190MG .................. 96 ALDURAZYME INJ 2.9MG/5M ............ 112 ALECENSA CAP 150MG ....................... 67 alendronate sodium oral soln 70

mg/75ml .......................................... 110 alendronate sodium tab 10 mg ......... 110 alendronate sodium tab 35 mg ......... 110 alendronate sodium tab 40 mg ......... 110

alendronate sodium tab 5 mg ........... 110 alendronate sodium tab 70 mg ......... 110 alfuzosin hcl tab er 24hr 10 mg ........ 119 ALIMTA INJ 100MG............................. 63

ALIMTA INJ 500MG............................. 63 ALINIA SUS 100/5ML ......................... 24 ALINIA TAB 500MG ............................ 24 aliskiren fumarate tab 150 mg (base equivalent)......................................... 61

aliskiren fumarate tab 300 mg (base equivalent)......................................... 61 all day allg cap 10mg ......................... 53 all day allg tab 10mg .......................... 53

all day pain tab 220mg ......................... 9 ALLEGRA ALRG TAB 30MG .................. 53

allergy cap 25mg................................ 52 allergy d tab 5-120mg ........................ 96 allergy relf liq 12.5/5ml ...................... 52

allergy relf tab 10mg .......................... 53 allergy rlf chw 5mg............................. 53 allergy tab 25mg ................................ 52 ALLEVYN AG PAD 3........................... 107

allopurinol tab 100 mg ..................... 120 allopurinol tab 300 mg ..................... 120 allrgy rel-d tab 10-240mg .................. 96 allrgy rlf-d tab 5-120mg ..................... 96

almotriptan malate tab 12.5 mg ....... 136 almotriptan malate tab 6.25 mg ....... 136 ALOCRIL SOL 2% ............................. 153 alogliptin benzoate tab 12.5 mg (base equiv) ................................................ 45

alogliptin benzoate tab 25 mg (base equiv) ................................................ 45 alogliptin benzoate tab 6.25 mg (base equiv) ................................................ 45

alogliptin-metformin hcl tab 12.5-1000 mg ..................................................... 43 alogliptin-metformin hcl tab 12.5-500 mg.......................................................... 43

alogliptin-pioglitazone tab 12.5-15 mg 43 alogliptin-pioglitazone tab 12.5-30 mg 43 alogliptin-pioglitazone tab 12.5-45 mg 43 alogliptin-pioglitazone tab 25-15 mg... 43 alogliptin-pioglitazone tab 25-30 mg... 43

alogliptin-pioglitazone tab 25-45 mg... 43 ALOMIDE SOL 0.1% OP .................... 153 alosetron hcl tab 0.5 mg (base equiv)118 alosetron hcl tab 1 mg (base equiv).. 118

ALPHAGAN P SOL 0.1% .................... 151 ALPHANATE INJ VWF/HUM................ 121 ALPHANINE SD INJ 1000UNIT........... 121 ALPHANINE SD INJ 1500UNIT........... 121

ALPRAZOLAM CON 1 MG/ML ............... 26 alprazolam orally disintegrating tab 0.25 mg ..................................................... 26 alprazolam orally disintegrating tab 0.5 mg ..................................................... 26

alprazolam orally disintegrating tab 1 mg.......................................................... 26 alprazolam orally disintegrating tab 2 mg.......................................................... 27

alprazolam tab 0.25 mg ..................... 27 alprazolam tab 0.5 mg ....................... 27

177

alprazolam tab 0.5mg xr .................... 27 alprazolam tab 1 mg .......................... 27 alprazolam tab 1mg xr ....................... 27

alprazolam tab 2 mg .......................... 27 alprazolam tab 2mg xr ....................... 27 alprazolam tab 3mg xr ....................... 27 ALPROLIX INJ 1000UNIT .................. 121

ALPROLIX INJ 2000UNIT .................. 121 ALPROLIX INJ 3000UNIT .................. 121 ALPROLIX INJ 500UNIT .................... 121 alprostadil inj 500 mcg/ml ................ 143

ALREX SUS 0.2% ............................. 152 ALTABAX OIN 1% ............................... 99 ALTERNARIA SOL EXTRACT .................. 5 ALTOPREV TAB 20MG ER .................... 54 ALTOPREV TAB 40MG ER .................... 54

ALTOPREV TAB 60MG ER .................... 54 ALUNBRIG TAB 30MG ......................... 67 ALVESCO AER 160MCG....................... 29 ALVESCO AER 80MCG......................... 29

amantadine hcl cap 100 mg................ 73 amantadine hcl syrup 50 mg/5ml ....... 73 amantadine hcl tab 100 mg ................ 73 AMBISOME INJ 50MG ......................... 51

ambrisentan tab 10 mg ...................... 90 ambrisentan tab 5 mg ........................ 90 amcinonide cream 0.1% ................... 102 amcinonide lotion 0.1% .................... 102 AMERICAN ELM SOL ............................. 5

AMERICAN INJ SYCAMORE ................... 5 AMERICAN SOL COCKROAC .................. 6 amethia tab ....................................... 92 amikacin sulfate inj 1 gm/4ml (250

mg/ml) ................................................ 7 amikacin sulfate inj 500 mg/2ml (250 mg/ml) ................................................ 7 amiloride & hydrochlorothiazide tab 5-50

mg ................................................... 109 amiloride hcl tab 5 mg...................... 110 aminocaproic acid inj 250 mg/ml ...... 126 aminocaproic acid oral soln 0.25 gm/ml........................................................ 126

aminocaproic acid tab 1000 mg ........ 126 aminocaproic acid tab 500 mg .......... 126 aminophylline inj 25 mg/ml ................ 31 AMINOSYN 7% INJ /LYTES ............... 149

AMINOSYN II INJ 8.5% .................... 149 aminosyn ii inj 8.5/lyte ..................... 149

AMINOSYN M INJ 3.5% .................... 149 AMINOSYN-RF INJ 5.2% ................... 149 amiodarone hcl inj 150 mg/3ml (50

mg/ml) .............................................. 28 amiodarone hcl inj 450 mg/9ml (50 mg/ml) .............................................. 28 amiodarone hcl inj 900 mg/18ml (50

mg/ml) .............................................. 28 amiodarone hcl tab 100 mg ................ 28 amiodarone hcl tab 200 mg ................ 28 amiodarone hcl tab 400 mg ................ 28

AMITIZA CAP 24MCG ........................ 117 AMITIZA CAP 8MCG.......................... 117 amitriptyline hcl tab 10 mg................. 42 amitriptyline hcl tab 100 mg ............... 42 amitriptyline hcl tab 150 mg ............... 42

amitriptyline hcl tab 25 mg................. 42 amitriptyline hcl tab 50 mg................. 42 amitriptyline hcl tab 75 mg................. 42 amlodipine besylate tab 10 mg (base

equivalent)......................................... 86 amlodipine besylate tab 2.5 mg (base equivalent)......................................... 86 amlodipine besylate tab 5 mg (base

equivalent)......................................... 86 amlodipine besylate-atorvastatin calcium tab 10-10 mg ..................................... 89 amlodipine besylate-atorvastatin calcium tab 10-20 mg ..................................... 89

amlodipine besylate-atorvastatin calcium tab 10-40 mg ..................................... 89 amlodipine besylate-atorvastatin calcium tab 10-80 mg ..................................... 89

amlodipine besylate-atorvastatin calcium tab 2.5-10 mg .................................... 88 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg .................................... 88

amlodipine besylate-atorvastatin calcium tab 2.5-40 mg .................................... 88 amlodipine besylate-atorvastatin calcium tab 5-10 mg ....................................... 89 amlodipine besylate-atorvastatin calcium

tab 5-20 mg ....................................... 89 amlodipine besylate-atorvastatin calcium tab 5-40 mg ....................................... 89 amlodipine besylate-atorvastatin calcium

tab 5-80 mg ....................................... 89 amlodipine besylate-benazepril hcl cap

178

10-20 mg ........................................... 58 amlodipine besylate-benazepril hcl cap 10-40 mg ........................................... 58

amlodipine besylate-benazepril hcl cap 2.5-10 mg.......................................... 58 amlodipine besylate-benazepril hcl cap 5-10 mg............................................. 58

amlodipine besylate-benazepril hcl cap 5-20 mg............................................. 58 amlodipine besylate-benazepril hcl cap 5-40 mg............................................. 58

amlodipine besylate-olmesartan medoxomil tab 10-20 mg ................... 58 amlodipine besylate-olmesartan medoxomil tab 10-40 mg ................... 58 amlodipine besylate-olmesartan

medoxomil tab 5-20 mg ..................... 58 amlodipine besylate-olmesartan medoxomil tab 5-40 mg ..................... 58 amlodipine besylate-valsartan tab

10-160 mg ......................................... 58 amlodipine besylate-valsartan tab 10-320 mg ......................................... 58 amlodipine besylate-valsartan tab 5-160

mg ..................................................... 58 amlodipine besylate-valsartan tab 5-320 mg ..................................................... 58 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg ........................... 58

amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg .............................. 58 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg .............................. 58

amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg............................. 58 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg................................ 58

amoxapine tab 100 mg....................... 42 amoxapine tab 150 mg....................... 42 amoxapine tab 25 mg ........................ 42 amoxapine tab 50 mg ........................ 42 amoxicillin & k clavulanate chew tab

200-28.5 mg .................................... 156 amoxicillin & k clavulanate chew tab 400-57 mg ....................................... 156 amoxicillin & k clavulanate for susp

200-28.5 mg/5ml ............................. 156 amoxicillin & k clavulanate for susp

250-62.5 mg/5ml ............................. 156 amoxicillin & k clavulanate for susp 400-57 mg/5ml ................................ 156

amoxicillin & k clavulanate for susp 600-42.9 mg/5ml ............................. 156 amoxicillin & k clavulanate tab 250-125 mg ................................................... 156

amoxicillin & k clavulanate tab 500-125 mg ................................................... 156 amoxicillin & k clavulanate tab 875-125 mg ................................................... 156

amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg .................................. 157 amoxicillin (trihydrate) cap 250 mg .. 155 amoxicillin (trihydrate) cap 500 mg .. 155 amoxicillin (trihydrate) chew tab 125 mg

........................................................ 155 amoxicillin (trihydrate) chew tab 250 mg........................................................ 156 amoxicillin (trihydrate) for susp 125

mg/5ml ............................................ 156 amoxicillin (trihydrate) for susp 200 mg/5ml ............................................ 156 amoxicillin (trihydrate) for susp 250

mg/5ml ............................................ 156 amoxicillin (trihydrate) for susp 400 mg/5ml ............................................ 156 amoxicillin (trihydrate) tab 500 mg... 156 amoxicillin (trihydrate) tab 875 mg... 156

amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack ......................... 168 amphetamine sulfate tab 10 mg ........... 1 amphetamine sulfate tab 5 mg ............. 1

amphetamine-dextroamphetamine cap er 24hr 10 mg .......................................... 1 amphetamine-dextroamphetamine cap er 24hr 15 mg .......................................... 1

amphetamine-dextroamphetamine cap er 24hr 20 mg .......................................... 1 amphetamine-dextroamphetamine cap er 24hr 25 mg .......................................... 1 amphetamine-dextroamphetamine cap er

24hr 30 mg .......................................... 1 amphetamine-dextroamphetamine cap er 24hr 5 mg ............................................ 1 amphetamine-dextroamphetamine tab

10 mg .................................................. 1 amphetamine-dextroamphetamine tab

179

12.5 mg ............................................... 1 amphetamine-dextroamphetamine tab 15 mg .................................................. 1

amphetamine-dextroamphetamine tab 20 mg .................................................. 1 amphetamine-dextroamphetamine tab 30 mg .................................................. 1

amphetamine-dextroamphetamine tab 5 mg ....................................................... 1 amphetamine-dextroamphetamine tab 7.5 mg ................................................. 1

amphotericin b for iv soln 50 mg ........ 51 ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm ....................................... 157 ampicillin & sulbactam sodium for inj 3 (2-1) gm .......................................... 157

ampicillin & sulbactam sodium for iv soln 15 (10-5) gm ................................... 157 ampicillin cap 500 mg....................... 156 ampicillin sodium for inj 1 gm ........... 156

ampicillin sodium for inj 125 mg ....... 156 ampicillin sodium for inj 2 gm ........... 156 ampicillin sodium for inj 250 mg ....... 156 ampicillin sodium for inj 500 mg ....... 156

ampicillin sodium for iv soln 10 gm ... 156 AMVISC INJ 12MG/ML ...................... 152 AMVISC PLUS INJ 16MG/ML.............. 153 AMYTAL SOD INJ 500MG .................. 126 ANACAINE OIN ................................. 106

anagrelide hcl cap 0.5 mg ................ 123 anagrelide hcl cap 1 mg ................... 123 ANASCORP INJ ................................. 154 anastrozole tab 1 mg.......................... 65

ANDRODERM DIS 2MG/24HR .............. 22 ANDRODERM DIS 4MG/24HR .............. 22 ANESTH NEEDL MIS 22GX2 .............. 131 animal shape chw complete .............. 144

ANORO ELLIPT AER 62.5-25 ............... 30 antacid chw 500mg ............................ 23 antacid chw 750mg ............................ 23 antacid plus sus anti-gas .................... 23 antacid plus sus gas rel ...................... 23

ANTICOAG CPD SOL ........................... 33 ANTICOAGULNT SOL SOD CITR .......... 33 anti-diarrhe liq 1mg/5ml .................... 49 anti-diarrhe tab 2mg .......................... 49

antifungal cre 1%............................. 100 anti-itch lot 1% ................................ 102

ANTIVENIN KIT LAT MACT ................ 154 APIDRA INJ SOLOSTAR....................... 46 APIDRA INJ U-100 .............................. 46

APLENZIN TAB 174MG ........................ 38 APLENZIN TAB 348MG ........................ 38 APLENZIN TAB 522MG ........................ 38 APLIGRAF MIS .................................. 107

APOKYN INJ 10MG/ML ........................ 73 apraclonidine hcl ophth soln 0.5% (base equivalent)....................................... 151 aprepitant capsule 125 mg ................. 51

aprepitant capsule 40 mg ................... 51 aprepitant capsule 80 mg ................... 51 aprepitant capsule therapy pack 80 & 125 mg .............................................. 51 APRISO CAP 0.375GM ...................... 117

APTENSIO XR CAP 10MG ...................... 3 APTENSIO XR CAP 15MG ...................... 3 APTENSIO XR CAP 20MG ...................... 4 APTENSIO XR CAP 30MG ...................... 4

APTENSIO XR CAP 40MG ...................... 4 APTENSIO XR CAP 50MG ...................... 4 APTENSIO XR CAP 60MG ...................... 4 APTIOM TAB 200MG ........................... 34

APTIOM TAB 400MG ........................... 34 APTIOM TAB 600MG ........................... 34 APTIOM TAB 800MG ........................... 34 APTIVUS CAP 250MG.......................... 81 APTIVUS SOL ..................................... 81

AP-ZEL TAB ...................................... 144 ARALAST NP INJ 1000MG ................. 162 ARALAST NP INJ 500MG ................... 162 ARANESP INJ 100MCG ...................... 125

ARANESP INJ 10MCG........................ 125 ARANESP INJ 150MCG ...................... 125 ARANESP INJ 200MCG ...................... 125 ARANESP INJ 25MCG........................ 125

ARANESP INJ 300MCG ...................... 125 ARANESP INJ 40MCG........................ 125 ARANESP INJ 500MCG ...................... 125 ARANESP INJ 60MCG........................ 125 ARCALYST INJ 220MG .......................... 9

ARCAPTA CAP 75MCG ......................... 30 argyl saline sol 0.9% ........................ 119 argyl saline sol 100ml....................... 143 aripiprazole oral solution 1 mg/ml ...... 79

aripiprazole orally disintegrating tab 10 mg ..................................................... 79

180

aripiprazole orally disintegrating tab 15 mg ..................................................... 79 aripiprazole tab 10 mg ....................... 79

aripiprazole tab 15 mg ....................... 79 aripiprazole tab 2 mg ......................... 79 aripiprazole tab 20 mg ....................... 79 aripiprazole tab 30 mg ....................... 79

aripiprazole tab 5 mg ......................... 79 ARISTADA INJ 1064MG ...................... 80 ARISTADA INJ 441MG/1. .................... 80 ARISTADA INJ 662MG/2 ..................... 80

ARISTADA INJ 882MG/3 ..................... 80 ARISTADA INJ INITIO......................... 80 armodafinil tab 150 mg ........................ 4 armodafinil tab 200 mg ........................ 4 armodafinil tab 250 mg ........................ 4

armodafinil tab 50 mg .......................... 4 ARMOUR THYRO TAB 120MG ............ 164 ARMOUR THYRO TAB 15MG .............. 164 ARMOUR THYRO TAB 180MG ............ 164

ARMOUR THYRO TAB 240MG ............ 164 ARMOUR THYRO TAB 300MG ............ 164 ARNUITY ELPT INH 100MCG ............... 29 ARNUITY ELPT INH 200MCG ............... 29

ARNUITY ELPT INH 50MCG ................. 29 artificial sol tears.............................. 149 ARZERRA CON 100/5ML ..................... 64 arzol silver mis nitr app .................... 102 ASCLERA INJ 0.5%........................... 143

ASCLERA INJ 1%.............................. 143 ascomp/cod cap 30mg........................ 19 ascorbic acid inj 500 mg/ml.............. 172 ascorbic acid tab 250 mg.................. 172

ASMANEX 14 AER 220MCG ................. 29 ASMANEX 30 AER 110MCG ................. 29 ASMANEX HFA AER 100 MCG .............. 29 ASMANEX HFA AER 200 MCG .............. 29

ASPERGILLUS SOL FUMIGATU .............. 6 aspirin chw 81mg ............................... 12 aspirin low tab 81mg ec ..................... 12 aspirin suppos 300 mg ....................... 12 aspirin suppos 600 mg ....................... 12

aspirin tab 325 mg ............................. 12 aspirin tab delayed release 325 mg .... 13 aspirin-dipyridamole cap er 12hr 25-200 mg ................................................... 123

ASSESS METER MIS FULL RNG ......... 135 ASSESS METER MIS LOW RANG ....... 135

ASTAGRAF XL CAP 0.5MG ................. 142 ASTAGRAF XL CAP 1MG .................... 142 ASTAGRAF XL CAP 5MG .................... 142

ASTHMA CHECK MIS SYSTEM ........... 135 ASTHMAMENTOR MIS ....................... 135 ASTHMAPACK KIT CHILD .................. 135 ATABEX EC TAB................................ 145

atazanavir sulfate cap 150 mg (base equiv) ................................................ 81 atazanavir sulfate cap 200 mg (base equiv) ................................................ 81

atazanavir sulfate cap 300 mg (base equiv) ................................................ 81 atenolol & chlorthalidone tab 100-25 mg.......................................................... 58 atenolol & chlorthalidone tab 50-25 mg

.......................................................... 58 atenolol tab 100 mg ........................... 85 atenolol tab 25 mg ............................. 85 atenolol tab 50 mg ............................. 85

ath foot pow aer 1% ........................ 100 atomoxetine hcl cap 10 mg (base equiv)............................................................ 3 atomoxetine hcl cap 100 mg (base

equiv) .................................................. 3 atomoxetine hcl cap 18 mg (base equiv)............................................................ 3 atomoxetine hcl cap 25 mg (base equiv)............................................................ 3

atomoxetine hcl cap 40 mg (base equiv)............................................................ 3 atomoxetine hcl cap 60 mg (base equiv)............................................................ 3

atomoxetine hcl cap 80 mg (base equiv)............................................................ 3 atorvastatin calcium tab 10 mg (base equivalent)......................................... 54

atorvastatin calcium tab 20 mg (base equivalent)......................................... 54 atorvastatin calcium tab 40 mg (base equivalent)......................................... 54 atorvastatin calcium tab 80 mg (base

equivalent)......................................... 55 atovaquone susp 750 mg/5ml ............ 24 atovaquone-proguanil hcl tab 250-100 mg ..................................................... 61

atovaquone-proguanil hcl tab 62.5-25 mg ..................................................... 61

181

ATRAPRO DERM SPR ........................ 107 ATRAPRO GEL HYDROGEL................. 107 ATRIPLA TAB ...................................... 81

ATROPEN INJ 0.5MG......................... 166 ATROPEN INJ 1MG............................ 166 ATROPEN INJ 2MG............................ 166 ATROPINE SUL OIN 1% OP ............... 150

atropine sul sol 1% op...................... 150 atropine sulfate inj 1 mg/ml ............. 166 atropine sulfate inj 8 mg/20ml (0.4 mg/ml) ............................................ 166

atropine sulfate soln prefill syr 0.25 mg/5ml (0.05 mg/ml) ...................... 166 atropine sulfate soln prefill syr 1 mg/10ml (0.1 mg/ml) ...................... 166 ATROVENT HFA AER 17MCG ............... 28

AUBAGIO TAB 14MG......................... 160 AUBAGIO TAB 7MG .......................... 160 aubra tab 0.1-0.02 ............................. 92 AUGMENTIN SUS 125/5ML ............... 157

AUREOBASIDIU INJ 1:10 ...................... 6 AUSTEDO TAB 12MG ........................ 159 AUSTEDO TAB 6MG .......................... 159 AUSTEDO TAB 9MG .......................... 159

AUVI-Q INJ 0.15MG.......................... 171 AUVI-Q INJ 0.1MG............................ 171 AUVI-Q INJ 0.3MG............................ 171 AVANDIA TAB 2MG ............................. 48 AVANDIA TAB 4MG ............................. 48

AVASTIN INJ ...................................... 64 AVASTIN INJ 400/16ML ...................... 64 AVC CRE 15% .................................. 170 AVONEX KIT 30MCG ......................... 160

AVONEX PEN KIT 30MCG .................. 160 AVONEX PREFL KIT 30MCG............... 160 av-phos 250 tab neutral ................... 140 AXILLARY NDL MIS 22GX1................ 131

AXILLARY NDL MIS 25GX1................ 131 ayr saline gel nasal........................... 147 AZASAN TAB 100MG ........................ 142 AZASAN TAB 75 MG ......................... 142 AZASITE SOL 1% ............................. 151

azathioprine tab 50 mg .................... 142 azelastine hcl nasal spray 0.1% (137 mcg/spray) ...................................... 147 azelastine hcl nasal spray 0.15% (205.5

mcg/spray) ...................................... 147 azelastine hcl ophth soln 0.05% ....... 153

azithromycin for susp 100 mg/5ml ... 130 azithromycin for susp 200 mg/5ml ... 130 azithromycin iv for soln 500 mg........ 130

azithromycin powd pack for susp 1 gm........................................................ 130 azithromycin tab 250 mg .................. 130 azithromycin tab 500 mg .................. 130

azithromycin tab 600 mg .................. 130 AZOPT SUS 1% OP ........................... 153 aztreonam for inj 1 gm ....................... 25 aztreonam for inj 2 gm ....................... 25

azuphen mb cap 120mg ................... 169 azurette tab 28 day ............................ 92 B baciim inj 50000unt ........................... 23 bacitracin oint 500 unit/gm ................ 99

bacitracin ophth oint 500 unit/gm ..... 151 bacitracin zinc oint 500 unit/gm.......... 99 baclofen tab 10 mg .......................... 146 baclofen tab 20 mg .......................... 146

BACTROBAN OIN NASAL 2%............. 147 BAHIA SOL EXTRACT ............................ 6 BAL IN OIL INJ 100MG/ML .................. 50 bal salt sol op................................... 153

BAL-CARE MIS DHA .......................... 145 balsalazide disodium cap 750 mg...... 117 BALVERSA TAB 3MG ........................... 67 BALVERSA TAB 4MG ........................... 67 BALVERSA TAB 5MG ........................... 67

BANZEL SUS 40MG/ML ....................... 34 BANZEL TAB 200MG ........................... 34 BANZEL TAB 400MG ........................... 34 BARACLUDE SOL ................................ 83

BASAGLAR INJ 100UNIT ..................... 46 BAXDELA TAB 450MG ....................... 116 BAYBERRY WAX SOL MYR EXTR ............ 6 bayer adv tab 500mg ......................... 13

BD ECLIPSE MIS 1ML/30G ................ 131 BD ECLIPSE MIS 25GX5/8 ................ 131 BD PEN NEEDL MIS 29GX12.7 .......... 132 BD PEN NEEDL MIS 31GX5MM .......... 132 BD PEN NEEDL MIS 31GX8MM .......... 132

BD PEN NEEDL MIS 32GX4MM .......... 132 BD PEN NEEDL MIS 32GX5/32 .......... 132 BD PEN NEEDL MIS 32GX6MM .......... 132 BD U-500 MIS 31GX6MM .................. 132

BEBULIN INJ 200-1200..................... 121 bedding spra aer 0.5% ..................... 107

182

BELBUCA MIS 150MCG ....................... 20 BELBUCA MIS 300MCG ....................... 20 BELBUCA MIS 450MCG ....................... 20

BELBUCA MIS 600MCG ....................... 20 BELBUCA MIS 750MCG ....................... 20 BELBUCA MIS 75MCG ......................... 20 BELBUCA MIS 900MCG ....................... 21

BELLA/OPIUM SUP 16.2-30............... 166 BELLA/OPIUM SUP 16.2-60............... 166 BELSOMRA TAB 10MG ...................... 128 BELSOMRA TAB 15MG ...................... 128

BELSOMRA TAB 20MG ...................... 128 BELSOMRA TAB 5MG ........................ 128 benadryl itc gel 2% .......................... 101 benazepril & hydrochlorothiazide tab 10-12.5 mg ........................................ 58

benazepril & hydrochlorothiazide tab 20-12.5 mg ........................................ 58 benazepril & hydrochlorothiazide tab 20-25 mg ........................................... 59

benazepril & hydrochlorothiazide tab 5-6.25 mg.......................................... 58 benazepril hcl tab 10 mg .................... 56 benazepril hcl tab 20 mg .................... 56

benazepril hcl tab 40 mg .................... 56 benazepril hcl tab 5 mg ...................... 56 BENDEKA INJ 100/4ML ....................... 62 BENEFIX INJ 1000UNIT .................... 121 BENEFIX INJ 2000UNIT .................... 121

BENEFIX INJ 250UNIT ...................... 121 BENEFIX INJ 3000UNIT .................... 121 BENEFIX INJ 500UNIT ...................... 121 BENLYSTA INJ 120MG ...................... 143

BENLYSTA INJ 400MG ...................... 143 BENSAL HP OIN................................ 106 BENZNIDAZOLE TAB 100MG ............... 23 BENZNIDAZOLE TAB 12.5MG .............. 23

benzonatate cap 100 mg .................... 96 benzonatate cap 150 mg .................... 96 benzonatate cap 200 mg .................... 96 BENZOYL PER GEL 2.5% .................... 99 benzoyl per liq 10% wash................... 99

benzoyl per liq 5% wash..................... 99 benzoyl peroxide gel 10% .................. 99 benzoyl peroxide gel 5% .................... 99 benzoyl peroxide-erythromycin gel 5-3%

.......................................................... 99 benztropine mesylate inj 1 mg/ml ...... 73

benztropine mesylate tab 0.5 mg ....... 73 benztropine mesylate tab 1 mg .......... 73 benztropine mesylate tab 2 mg .......... 73

BEPREVE DRO 1.5% ......................... 153 BERINERT INJ 500UNIT .................... 123 BERMUDA SOL GRASS .......................... 6 BESIVANCE SUS 0.6% ..................... 151

BETADINE SOL 5% OP ..................... 151 betamethasone dipropionate augmented cream 0.05% ................................... 102 betamethasone dipropionate augmented

gel 0.05% ........................................ 102 betamethasone dipropionate augmented lotion 0.05% .................................... 102 betamethasone dipropionate augmented oint 0.05% ....................................... 102

betamethasone dipropionate cream 0.05%.............................................. 103 betamethasone dipropionate lotion 0.05%.............................................. 103

betamethasone dipropionate oint 0.05%........................................................ 103 betamethasone sod phosphate & acetate inj susp 6 (3-3) mg/ml ....................... 94

betamethasone valerate aerosol foam 0.12%.............................................. 103 betamethasone valerate cream 0.1% (base equivalent) ............................. 103 betamethasone valerate lotion 0.1%

(base equivalent) ............................. 103 betamethasone valerate oint 0.1% (base equivalent)....................................... 103 BETASERON INJ 0.3MG .................... 160

betaxolol hcl ophth soln 0.5% .......... 150 betaxolol hcl tab 10 mg ...................... 85 betaxolol hcl tab 20 mg ...................... 85 bethanechol chloride tab 10 mg ........ 170

bethanechol chloride tab 25 mg ........ 170 bethanechol chloride tab 5 mg.......... 170 bethanechol chloride tab 50 mg ........ 170 BETHKIS NEB 300/4ML......................... 7 BETIMOL SOL 0.25% ........................ 150

BETIMOL SOL 0.5%.......................... 150 BETOPTIC-S SUS 0.25% OP ............. 150 BEVESPI AER 9-4.8MCG ..................... 30 BEVYXXA CAP 40MG ........................... 32

BEVYXXA CAP 80MG ........................... 32 bexarotene cap 75 mg........................ 71

183

bicalutamide tab 50 mg ...................... 65 BICILLIN C-R INJ 1200000 ............... 157 BICILLIN C-R INJ 900/300................ 157

BICILLIN L-A INJ 1200000................ 156 BICILLIN L-A INJ 2400000................ 156 BICILLIN L-A INJ 600000.................. 156 BIDIL TAB .......................................... 89

BIKTARVY TAB ................................... 81 bimatoprost ophth soln 0.03% ......... 153 BINOSTO TAB 70MG......................... 110 biocel tab ......................................... 144

bio-d-mulsio liq 2000unit.................. 172 BIOSTEP AG MIS 2 ........................... 107 BIOSTEP AG MIS 4 ........................... 107 BIOSTEP MIS 2 ................................ 107 BIOSTEP MIS 4 ................................ 107

bisoprolol & hydrochlorothiazide tab 10-6.25 mg ........................................ 59 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg....................................... 59

bisoprolol & hydrochlorothiazide tab 5-6.25 mg.......................................... 59 bisoprolol fumarate tab 10 mg............ 85 bisoprolol fumarate tab 5 mg.............. 85

BIVIGAM INJ 10% ............................ 154 BLACK WALNUT SOL POLL EXT ............. 6 BLEPHAMIDE OIN S.O.P. .................. 152 BLEPHAMIDE SUS OP ....................... 152 bosentan tab 125 mg ......................... 90

bosentan tab 62.5 mg ........................ 90 BOSULIF TAB 100MG.......................... 67 BOSULIF TAB 500MG.......................... 67 BOX ELDER INJ EXT 1:20 ..................... 6

BP ARM CUFF MIS LARGE ................. 130 bpo creamy kit 4% wash .................... 99 bprotected sol tri-vite ....................... 145 BRAFTOVI CAP 50MG ......................... 67

BRAFTOVI CAP 75MG ......................... 67 BREO ELLIPTA INH 100-25 ................. 30 BREO ELLIPTA INH 200-25 ................. 30 BRILINTA TAB 60MG ........................ 123 BRILINTA TAB 90MG ........................ 123

brimonidine tartrate ophth soln 0.15%........................................................ 151 brimonidine tartrate ophth soln 0.2% 151 BRISDELLE CAP 7.5MG ..................... 162

BRIVIACT SOL 10MG/ML .................... 34 BRIVIACT TAB 100MG ........................ 35

BRIVIACT TAB 10MG .......................... 35 BRIVIACT TAB 25MG .......................... 35 BRIVIACT TAB 50MG .......................... 35

BRIVIACT TAB 75MG .......................... 35 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) ................. 153 bromocriptine mesylate cap 5 mg (base

equivalent)......................................... 73 bromocriptine mesylate tab 2.5 mg (base equivalent)......................................... 73 brompheniramine tannate chew tab 12

mg ..................................................... 52 brotapp liq ......................................... 96 BROVANA NEB 15MCG........................ 30 BUCALSEP SOL................................... 80 BUCALSEP SPR ................................... 80

budesonide delayed release particles cap 3 mg .................................................. 94 budesonide inhalation susp 0.25 mg/2ml.......................................................... 29

budesonide inhalation susp 0.5 mg/2ml.......................................................... 29 budesonide inhalation susp 1 mg/2ml . 29 budesonide nasal susp 32 mcg/act ... 148

budesonide tab er 24hr 9 mg.............. 94 bumetanide tab 0.5 mg .................... 109 bumetanide tab 1 mg ....................... 109 bumetanide tab 2 mg ....................... 109 BUNAVAIL MIS 2.1-0.3 ....................... 21

BUNAVAIL MIS 4.2-0.7 ....................... 21 BUNAVAIL MIS 6.3-1MG ..................... 21 buprenorphine hcl inj 0.3 mg/ml (base equiv) ................................................ 21

buprenorphine hcl sl tab 2 mg (base equiv) ................................................ 21 buprenorphine hcl sl tab 8 mg (base equiv) ................................................ 21

buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv)........................... 21 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv)........................ 21 buprenorphine hcl-naloxone hcl sl tab

8-2 mg (base equiv)........................... 21 buprenorphine td patch weekly 10 mcg/hr ............................................... 21 buprenorphine td patch weekly 15

mcg/hr ............................................... 21 buprenorphine td patch weekly 20

184

mcg/hr ............................................... 21 buprenorphine td patch weekly 5 mcg/hr.......................................................... 21

buprenorphine td patch weekly 7.5 mcg/hr ............................................... 21 bupropion hcl (smoking deterrent) tab er 12hr 150 mg .................................... 162

bupropion hcl tab 100 mg................... 38 bupropion hcl tab 75 mg .................... 38 bupropion hcl tab er 12hr 100 mg ...... 38 bupropion hcl tab er 12hr 150 mg ...... 38

bupropion hcl tab er 12hr 200 mg ...... 38 bupropion hcl tab er 24hr 150 mg ...... 38 bupropion hcl tab er 24hr 300 mg ...... 38 bupropion hcl tab er 24hr 450 mg ...... 39 buspirone hcl tab 10 mg ..................... 26

buspirone hcl tab 15 mg ..................... 26 buspirone hcl tab 30 mg ..................... 26 buspirone hcl tab 5 mg ....................... 26 buspirone hcl tab 7.5 mg .................... 26

busulfan inj 6 mg/ml .......................... 62 BUSULFEX INJ 6MG/ML ...................... 62 butalbital-acetaminophen tab 50-325 mg.......................................................... 11

butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg............................... 19 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg............................... 19 butalbital-acetaminophen-caffeine cap

50-300-40 mg.................................... 12 butalbital-acetaminophen-caffeine cap 50-325-40 mg.................................... 12 butalbital-acetaminophen-caffeine tab

50-325-40 mg.................................... 12 butalbital-aspirin-caffeine cap 50-325-40 mg ..................................................... 12 BUTISOL SOD TAB 30MG.................. 126

butorphanol tartrate inj 1 mg/ml ........ 21 butorphanol tartrate inj 2 mg/ml ........ 21 butorphanol tartrate nasal soln 10 mg/ml.......................................................... 21 BYDUREON BC INJ 2/0.85ML .............. 46

BYDUREON INJ 2MG ........................... 46 BYDUREON PEN INJ 2MG .................... 46 BYETTA INJ 10MCG ............................ 46 BYETTA INJ 5MCG .............................. 46

C cabergoline tab 0.5 mg..................... 114

CABLIVI KIT 11MG ........................... 124 CABOMETYX TAB 20MG ...................... 67 CABOMETYX TAB 40MG ...................... 67

CABOMETYX TAB 60MG ...................... 67 CA-DTPA SOL 1000MG ....................... 49 caffeine & sodium benzoate inj 125-125 mg/ml (500 mg/2ml) ........................... 2

caffeine citrate inj 60 mg/3ml (10 mg/ml base equiv) .......................................... 2 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) ............................... 2

calc citr/d3 tab 200-250 ................... 137 calc citrate tab +d ............................ 137 calcidol dro 8000/ml......................... 172 calcipotriene cream 0.005% ............. 101 calcipotriene oint 0.005% ................. 101

calcipotriene soln 0.005% (50 mcg/ml)........................................................ 101 calcipotriene-betamethasone dipropionate oint 0.005-0.064% ....... 103

calcitonin (salmon) nasal soln 200 unit/act ............................................ 110 calcitriol cap 0.25 mcg...................... 112 calcitriol cap 0.5 mcg ....................... 112

calcitriol inj 1 mcg/ml ....................... 112 calcitriol oral soln 1 mcg/ml.............. 112 calcium 500 tab +d .......................... 137 calcium 600 tab + d ......................... 137 calcium 600 tab +d .......................... 137

calcium 600 tab +d3 ........................ 137 calcium 600/ tab vit d ...................... 137 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) ........................ 118

calcium acetate (phosphate binder) tab 667 mg ............................................ 118 calcium carbonate (antacid) tab 648 mg.......................................................... 23

calcium carbonate tab 1250 mg (500 mg elemental ca) ................................... 138 calcium carbonate tab 1500 mg (600 mg elemental ca) ................................... 138 calcium carbonate tab 600 mg.......... 137

calcium carbonate-vitamin d tab 250 mg-125 unit ..................................... 138 calcium carbonate-vitamin d tab 500 mg-400 unit ..................................... 138

calcium carbonate-vitamin d tab 600 mg-125 unit ..................................... 138

185

calcium chloride inj 10% .................. 138 CALCIUM CHW GUMMIES ................. 138 CALCIUM DISO INJ 1GM/5ML ............. 50

calcium gluconate inj 10%................ 138 calcium tab 500/d ............................ 138 calcium tab 600mg ........................... 138 CALDOLOR INJ 800/8ML ....................... 9

CALQUENCE CAP 100MG .................... 67 CAMPTOSAR INJ 300/15ML................. 73 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg .................................. 59

candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg .................................. 59 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg ..................................... 59 CANDIDA SOL ALBICANS...................... 6

CAPASTAT SUL INJ 1GM ..................... 62 capecitabine tab 150 mg .................... 63 capecitabine tab 500 mg .................... 63 CAPEX SHA 0.01% ........................... 103

CAPRELSA TAB 100MG ....................... 67 CAPRELSA TAB 300MG ....................... 67 captopril & hydrochlorothiazide tab 25-15 mg ..................................................... 59

captopril & hydrochlorothiazide tab 25-25 mg ..................................................... 59 captopril & hydrochlorothiazide tab 50-15 mg ..................................................... 59 captopril & hydrochlorothiazide tab 50-25

mg ..................................................... 59 CARAFATE SUS 1GM/10ML ............... 167 CARBAGLU TAB 200MG .................... 112 carbamazepine cap er 12hr 100 mg .... 35

carbamazepine cap er 12hr 200 mg .... 35 carbamazepine cap er 12hr 300 mg .... 35 carbamazepine chew tab 100 mg........ 35 carbamazepine susp 100 mg/5ml ....... 35

carbamazepine tab 200 mg ................ 35 carbamazepine tab er 12hr 100 mg .... 35 carbamazepine tab er 12hr 200 mg .... 35 carbamazepine tab er 12hr 400 mg .... 35 CARBAPHEN 12 LIQ ............................ 96

CARBAPHEN 12 SUS PED .................... 96 carbidopa & levodopa orally disintegrating tab 10-100 mg ............. 73 carbidopa & levodopa orally

disintegrating tab 25-100 mg ............. 73 carbidopa & levodopa orally

disintegrating tab 25-250 mg ............. 73 carbidopa & levodopa tab 10-100 mg . 73 carbidopa & levodopa tab 25-100 mg . 73

carbidopa & levodopa tab 25-250 mg . 73 carbidopa & levodopa tab er 25-100 mg.......................................................... 73 carbidopa & levodopa tab er 50-200 mg

.......................................................... 73 carbidopa tab 25 mg .......................... 73 carbidopa-levodopa-entacapone tabs 12.5-50-200 mg................................. 74

carbidopa-levodopa-entacapone tabs 18.75-75-200 mg ............................... 74 carbidopa-levodopa-entacapone tabs 25-100-200 mg .................................. 74 carbidopa-levodopa-entacapone tabs

31.25-125-200 mg ............................. 74 carbidopa-levodopa-entacapone tabs 37.5-150-200 mg ............................... 74 carbidopa-levodopa-entacapone tabs

50-200-200 mg .................................. 74 carbinoxamine maleate soln 4 mg/5ml 52 carbinoxamine maleate tab 4 mg........ 52 cardioplegic soln................................. 88

CARDIZEM LA TAB 120MG .................. 86 CARDURA XL TAB 4MG ..................... 119 CARDURA XL TAB 8MG ..................... 119 CARIMUNE NF INJ 12GM................... 154 CARIMUNE NF INJ 6GM .................... 154

carisoprodol tab 250 mg ................... 146 carisoprodol tab 350 mg ................... 146 carisoprodol w/ aspirin & codeine tab 200-325-16 mg ................................ 147

carisoprodol w/ aspirin tab 200-325 mg........................................................ 147 carteolol hcl ophth soln 1% .............. 150 carvedilol tab 12.5 mg........................ 85

carvedilol tab 25 mg........................... 85 carvedilol tab 3.125 mg ...................... 85 carvedilol tab 6.25 mg........................ 85 CAT HAIR SOL EXTRACT ....................... 6 CATHFLO ACTI INJ 2MG.................... 124

cavarest gel 1.1% ............................ 143 CAYSTON INH 75MG........................... 25 caziant pak ........................................ 93 cefaclor cap 250 mg ........................... 91

cefaclor cap 500 mg ........................... 91 CEFACLOR ER TAB 500MG .................. 91

186

cefaclor for susp 125 mg/5ml ............. 91 cefaclor for susp 250 mg/5ml ............. 91 cefaclor for susp 375 mg/5ml ............. 91

cefadroxil cap 500 mg ........................ 91 cefadroxil for susp 250 mg/5ml .......... 91 cefadroxil for susp 500 mg/5ml .......... 91 cefadroxil tab 1 gm ............................ 91

CEFAZOLIN INJ 100GM....................... 91 CEFAZOLIN INJ 300GM....................... 91 cefazolin sodium for inj 1 gm .............. 91 cefazolin sodium for inj 10 gm ............ 91

cefazolin sodium for inj 20 gm ............ 91 cefazolin sodium for inj 500 mg .......... 91 cefdinir cap 300 mg............................ 92 cefdinir for susp 125 mg/5ml .............. 92 cefdinir for susp 250 mg/5ml .............. 92

cefditoren pivoxil tab 200 mg (base equivalent)......................................... 92 cefditoren pivoxil tab 400 mg (base equivalent)......................................... 92

cefepime hcl for inj 1 gm .................... 92 cefepime hcl for inj 2 gm .................... 92 cefixime cap 400 mg .......................... 92 cefixime for susp 100 mg/5ml ............ 92

cefixime for susp 200 mg/5ml ............ 92 cefotaxime sodium for inj 1 gm .......... 92 cefotaxime sodium for inj 10 gm ........ 92 cefotaxime sodium for inj 2 gm .......... 92 cefotaxime sodium for inj 500 mg....... 92

cefotetan disodium for inj 1 gm .......... 91 cefotetan disodium for inj 10 gm ........ 91 cefotetan disodium for inj 2 gm .......... 91 cefoxitin sodium for inj 10 gm ............ 91

cefpodoxime proxetil for susp 100 mg/5ml .............................................. 92 cefpodoxime proxetil for susp 50 mg/5ml.......................................................... 92

cefpodoxime proxetil tab 100 mg........ 92 cefpodoxime proxetil tab 200 mg........ 92 cefprozil for susp 125 mg/5ml ............ 91 cefprozil for susp 250 mg/5ml ............ 92 cefprozil tab 250 mg .......................... 92

cefprozil tab 500 mg .......................... 92 ceftazidime for inj 1 gm ...................... 92 ceftazidime for inj 2 gm ...................... 92 ceftazidime for inj 6 gm ...................... 92

ceftriaxone sodium for inj 1 gm .......... 92 ceftriaxone sodium for inj 10 gm ........ 92

ceftriaxone sodium for inj 2 gm .......... 92 ceftriaxone sodium for inj 250 mg ...... 92 ceftriaxone sodium for inj 500 mg ...... 92

cefuroxime axetil tab 250 mg ............. 92 cefuroxime axetil tab 500 mg ............. 92 cefuroxime sodium for inj 7.5 gm ....... 92 cefuroxime sodium for inj 750 mg ...... 92

celecoxib cap 100 mg ........................... 9 celecoxib cap 200 mg ........................... 9 celecoxib cap 400 mg ........................... 9 celecoxib cap 50 mg ............................. 9

CELONTIN CAP 300MG ....................... 38 CEPACOL SORE LOZ COATING .......... 143 cephalexin cap 250 mg....................... 91 cephalexin cap 500 mg....................... 91 cephalexin cap 750 mg....................... 91

cephalexin for susp 125 mg/5ml ......... 91 cephalexin for susp 250 mg/5ml ......... 91 cephalexin tab 250 mg ....................... 91 cephalexin tab 500 mg ....................... 91

CERALYTE 70 LIQ ............................. 138 ceramax cre ..................................... 106 CERDELGA CAP 84MG....................... 124 CERVIDIL VAG MIS 10MG INS .......... 154

CESAMET CAP 1MG ............................ 51 cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) ............................................ 53 cetirizine hcl tab 5 mg ........................ 53 cevimeline hcl cap 30 mg ................. 144

CHANTIX PAK 0.5& 1MG ................... 162 CHANTIX PAK 1MG ........................... 162 CHANTIX TAB 0.5MG ........................ 162 chateal tab 0.15/30 ............................ 93

CHEMET CAP 100MG .......................... 49 CHENODAL TAB 250MG .................... 117 chest conges tab 400mg..................... 98 childrens chw pepto............................ 23

chlordiazepoxide hcl cap 10 mg .......... 27 chlordiazepoxide hcl cap 25 mg .......... 27 chlordiazepoxide hcl cap 5 mg ............ 27 chlordiazepoxide-amitriptyline tab 10-25 mg ................................................... 159

chlordiazepoxide-amitriptyline tab 5-12.5 mg ................................................... 159 chloroquine phosphate tab 250 mg ..... 61 chloroquine phosphate tab 500 mg ..... 61

chlorothiazide sodium for inj 500 mg 110 chlorothiazide tab 250 mg ................ 110

187

chlorothiazide tab 500 mg ................ 110 CHLORPROMAZ INJ 25MG/ML ............. 78 CHLORPROMAZ INJ 50MG/2ML ........... 78

chlorpromazine hcl tab 10 mg ............ 78 chlorpromazine hcl tab 100 mg........... 79 chlorpromazine hcl tab 200 mg........... 79 chlorpromazine hcl tab 25 mg ............ 79

chlorpromazine hcl tab 50 mg ............ 79 chlorpropamide tab 100 mg................ 48 chlorpropamide tab 250 mg................ 48 chlorthalidone tab 25 mg.................. 110

chlorthalidone tab 50 mg.................. 110 chlorzoxazone tab 500 mg................ 146 CHOLBAM CAP 250MG ...................... 116 CHOLBAM CAP 50MG ........................ 116 cholecalciferol cap 10 mcg (400 unit) 172

cholecalciferol cap 125 mcg (5000 unit)........................................................ 172 cholecalciferol oral liquid 10 mcg/ml (400 unit/ml) ........................................... 172

cholecalciferol tab 50 mcg (2000 unit)........................................................ 172 cholestyramine light powder 4 gm/dose.......................................................... 54

cholestyramine light powder packets 4 gm ..................................................... 54 cholestyramine powder 4 gm/dose ..... 54 cholestyramine powder packets 4 gm . 54 CHOR GONADOT INJ 10000UNT ....... 111

chromic chloride inj 40 mcg/10ml (4 mcg/ml) (elemental cr) .................... 141 ciclodan cre 0.77%........................... 100 ciclodan sol 8% ................................ 100

ciclopirox gel 0.77% ......................... 100 ciclopirox olamine susp 0.77% (base equiv) .............................................. 100 ciclopirox shampoo 1% .................... 100

cilostazol tab 100 mg ....................... 124 cilostazol tab 50 mg ......................... 124 CILOXAN OIN 0.3% OP..................... 151 CIMDUO TAB 300-300 ........................ 81 cimetidine hcl soln 300 mg/5ml ........ 166

cimetidine tab 200 mg...................... 166 cimetidine tab 300 mg...................... 167 cimetidine tab 400 mg...................... 167 cimetidine tab 800 mg...................... 167

CIMZIA KIT ...................................... 117 CIMZIA KIT STARTER ....................... 117

CIMZIA PREFL KIT 200MG/ML........... 117 cinacalcet hcl tab 30 mg (base equiv)112 cinacalcet hcl tab 60 mg (base equiv)113

cinacalcet hcl tab 90 mg (base equiv)113 CINRYZE SOL 500 UNIT.................... 123 CIPRO (5%) SUS 250MG/5 ............... 116 CIPRO HC SUS OTIC......................... 154

CIPRODEX SUS 0.3-0.1% ................. 154 ciprofloxacin hcl ophth soln 0.3% (base equivalent)....................................... 151 ciprofloxacin hcl otic soln 0.2% (base

equivalent)....................................... 154 ciprofloxacin hcl tab 100 mg (base equiv)........................................................ 116 ciprofloxacin hcl tab 250 mg (base equiv)........................................................ 116

ciprofloxacin hcl tab 500 mg (base equiv)........................................................ 116 ciprofloxacin hcl tab 750 mg (base equiv)........................................................ 116

ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq)............................ 116 ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq)............................. 116

cisplatin inj 100 mg/100ml (1 mg/ml) 63 cisplatin inj 200 mg/200ml (1 mg/ml) 63 cisplatin inj 50 mg/50ml (1 mg/ml) .... 62 citalopram hydrobromide oral soln 10 mg/5ml .............................................. 39

citalopram hydrobromide tab 10 mg (base equiv)....................................... 39 citalopram hydrobromide tab 20 mg (base equiv)....................................... 39

citalopram hydrobromide tab 40 mg (base equiv)....................................... 39 CLADOSPORIUM SOL 20000PNU ........... 6 CLARINEX SYP 0.5MG/ML ................... 53

CLARINEX-D TAB 2.5-120................... 96 clarithromycin for susp 125 mg/5ml . 130 clarithromycin for susp 250 mg/5ml . 130 clarithromycin tab 250 mg................ 130 clarithromycin tab 500 mg................ 130

clarithromycin tab er 24hr 500 mg ... 130 CLARITIN CAP 10MG .......................... 53 clear away liq 17% ........................... 106 clemastine fumarate tab 2.68 mg ....... 52

CLEOCIN SUP 100MG ....................... 170 CLEVIPREX EMU 50/100ML ................. 86

188

CLIMARA PRO DIS WEEKLY .............. 114 CLIN SINGLE KIT USE ........................ 25 clindacin-p pad 1%............................. 99

clindamycin hcl cap 150 mg................ 25 clindamycin hcl cap 300 mg................ 25 clindamycin hcl cap 75 mg.................. 25 clindamycin palmitate hcl for soln 75

mg/5ml (base equiv) .......................... 25 clindamycin phosphate gel 1% ........... 99 clindamycin phosphate inj 300 mg/2ml25 clindamycin phosphate inj 600 mg/4ml25

clindamycin phosphate inj 9 gm/60ml. 25 clindamycin phosphate inj 900 mg/6ml25 clindamycin phosphate lotion 1% ....... 99 clindamycin phosphate soln 1% .......... 99 clindamycin phosphate vaginal cream 2%

........................................................ 170 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% ....................... 99 CLINDESSE CRE 2% ......................... 170

CLINIMIX E INJ 2.75/D10 ................. 149 CLINIMIX E INJ 2.75/D5W ................ 149 CLINIMIX E INJ 4.25/D10 ................. 149 CLINIMIX E INJ 4.25/D25 ................. 149

CLINIMIX E INJ 4.25/D5W ................ 149 CLINIMIX E INJ 5%/D15W................ 149 CLINIMIX E INJ 5%/D20W................ 149 CLINIMIX E INJ 5%/D25W................ 149 CLINIMIX INJ 2.75/D5W ................... 149

CLINIMIX INJ 4.25/D10 .................... 149 CLINIMIX INJ 4.25/D20 .................... 149 CLINIMIX INJ 4.25/D25 .................... 149 CLINIMIX INJ 4.25/D5W ................... 149

CLINIMIX INJ 5%/D15W................... 149 CLINIMIX INJ 5%/D20W................... 149 CLINIMIX INJ 5%/D25W................... 149 clinpro 5000 pst 1.1% ...................... 143

clobazam suspension 2.5 mg/ml ......... 34 clobazam tab 10 mg ........................... 34 clobazam tab 20 mg ........................... 34 clobetasol e cre 0.05% ..................... 103 clobetasol propionate cream 0.05% .. 103

clobetasol propionate emulsion foam 0.05%.............................................. 103 clobetasol propionate foam 0.05%.... 103 clobetasol propionate gel 0.05% ....... 103

clobetasol propionate lotion 0.05% ... 103 clobetasol propionate oint 0.05% ..... 103

clobetasol propionate soln 0.05% ..... 103 clobetasol propionate spray 0.05% ... 103 clocortolone pivalate cream 0.1% ..... 103

clodan sha 0.05% ............................ 103 clomipramine hcl cap 25 mg ............... 42 clomipramine hcl cap 50 mg ............... 42 clomipramine hcl cap 75 mg ............... 42

clonazepam orally disintegrating tab 0.125 mg ........................................... 34 clonazepam orally disintegrating tab 0.25 mg ..................................................... 34

clonazepam orally disintegrating tab 0.5 mg ..................................................... 34 clonazepam orally disintegrating tab 1 mg ..................................................... 34 clonazepam orally disintegrating tab 2

mg ..................................................... 34 clonazepam tab 0.5 mg ...................... 34 clonazepam tab 1 mg ......................... 34 clonazepam tab 2 mg ......................... 34

clonidine hcl inj (for epidural infusion) 100 mcg/ml ....................................... 12 clonidine hcl inj (for epidural infusion) 500 mcg/ml ....................................... 12

clonidine hcl tab 0.1 mg ..................... 57 clonidine hcl tab 0.2 mg ..................... 57 clonidine hcl tab 0.3 mg ..................... 57 clonidine hcl tab er 12hr 0.1 mg ........... 3 clonidine td patch weekly 0.1 mg/24hr 57

clonidine td patch weekly 0.2 mg/24hr 57 clonidine td patch weekly 0.3 mg/24hr 57 clopidogrel bisulfate tab 300 mg (base equiv) .............................................. 124

clopidogrel bisulfate tab 75 mg (base equiv) .............................................. 124 clorazepate dipotassium tab 15 mg..... 27 clorazepate dipotassium tab 3.75 mg.. 27

clorazepate dipotassium tab 7.5 mg ... 27 clotrimazole cre 1% vag ................... 170 clotrimazole cre 2%.......................... 170 clotrimazole cream 1% ..................... 100 clotrimazole soln 1% ........................ 100

clotrimazole troche 10 mg ................ 143 clotrimazole w/ betamethasone cream 1-0.05% .......................................... 100 clotrimazole w/ betamethasone lotion

1-0.05% .......................................... 100 clozapine orally disintegrating tab 100

189

mg ..................................................... 77 clozapine orally disintegrating tab 12.5 mg ..................................................... 77

clozapine orally disintegrating tab 150 mg ..................................................... 78 clozapine orally disintegrating tab 200 mg ..................................................... 78

clozapine orally disintegrating tab 25 mg.......................................................... 77 clozapine tab 100 mg ......................... 78 clozapine tab 200 mg ......................... 78

clozapine tab 25 mg ........................... 78 clozapine tab 50 mg ........................... 78 COAGADEX INJ 250UNIT .................. 121 COAGADEX INJ 500UNIT .................. 121 COARTEM TAB 20-120MG ................... 61

CODAR D LIQ 30-8/5ML ..................... 96 codar gf liq 200-8/5 ........................... 96 codeine sulf tab 15mg ........................ 13 codeine sulf tab 30mg ........................ 13

codeine sulf tab 60mg ........................ 13 colchicine cap 0.6 mg ....................... 120 colchicine tab 0.6 mg ....................... 120 colchicine w/ probenecid tab 0.5-500 mg

........................................................ 120 cold mult-sy tab daytime .................... 96 cold/allergy elx children...................... 96 cold/cough elx child............................ 96 colesevelam hcl packet for susp 3.75 gm

.......................................................... 54 colesevelam hcl tab 625 mg ............... 54 colestipol hcl granule packets 5 gm .... 54 colestipol hcl granules 5 gm ............... 54

colestipol hcl tab 1 gm ....................... 54 colistimethate sod for inj 150 mg (colistin base activity) ........................ 25 COLY-MYCIN S SUS OTIC ................. 154

COMBIGAN SOL 0.2/0.5% ................ 150 COMBIPATCH DIS............................. 114 COMBIVENT AER 20-100 .................... 30 COMETRIQ KIT 100MG ....................... 67 COMETRIQ KIT 140MG ....................... 67

COMETRIQ KIT 60MG ......................... 67 COMPLERA TAB .................................. 81 COMPLETE NAT PAK DHA.................. 145 compro sup 25mg .............................. 79

CONCEPT DHA CAP........................... 145 CONCEPT OB CAP ............................. 145

CONCEPTION KIT ............................. 130 CONDYLOX GEL 0.5%....................... 106 constulose sol 10gm/15.................... 129

COPIKTRA CAP 15MG ......................... 68 COPIKTRA CAP 25MG ......................... 68 CORIFACT KIT .................................. 121 CORLANOR SOL 5MG/5ML .................. 91

CORLANOR TAB 5MG .......................... 91 CORLANOR TAB 7.5MG ....................... 91 CORTIFOAM AER 90MG ...................... 22 cortisone acetate tab 25 mg ............... 94

CORTISPORIN CRE 0.5% .................. 100 CORTISPORIN OIN 1% ..................... 100 COSENTYX INJ 150MG/ML ................ 101 COSENTYX PEN INJ 300DOSE ........... 101 COTELLIC TAB 20MG .......................... 68

coughtab tab 200mg .......................... 98 CREON CAP 12000UNT ..................... 108 CREON CAP 24000UNT ..................... 108 CREON CAP 3000UNIT...................... 108

CREON CAP 36000UNT ..................... 108 CREON CAP 6000UNIT...................... 108 CRESEMBA CAP 186 MG ..................... 52 CRINONE GEL 4% VAG ..................... 171

CRIXIVAN CAP 200MG ........................ 81 CRIXIVAN CAP 400MG ........................ 81 CROFAB INJ ..................................... 154 cromolyn sodium nasal aerosol soln 5.2 mg/act (4%) .................................... 147

cromolyn sodium ophth soln 4%....... 153 cromolyn sodium oral conc 100 mg/5ml........................................................ 117 cromolyn sodium soln nebu 20 mg/2ml

.......................................................... 28 crotan lot 10% ................................. 107 c-topical sol 4% ............................... 106 cupric chloride inj 0.4 mg/ml ............ 141

CUROSURF SUS 120/1.5 .................. 163 CUVPOSA SOL 1MG/5ML................... 166 cvs allergy chw 12.5mg ...................... 52 cyanocobalamin inj 1000 mcg/ml ..... 124 cyclobenzaprine hcl cap er 24hr 15 mg

........................................................ 146 cyclobenzaprine hcl cap er 24hr 30 mg........................................................ 146 cyclobenzaprine hcl tab 10 mg.......... 146

cyclobenzaprine hcl tab 5 mg ........... 146 cyclobenzaprine hcl tab 7.5 mg ........ 146

190

CYCLOMYDRIL SOL OP ..................... 150 cyclopentolate hcl ophth soln 1% ..... 150 cyclopentolate hcl ophth soln 2% ..... 150

cyclophosphamide for inj 1 gm ........... 63 cyclophosphamide for inj 2 gm ........... 63 cyclophosphamide for inj 500 mg ....... 63 cycloserine cap 250 mg ...................... 62

cyclosporine cap 100 mg .................. 142 cyclosporine cap 25 mg .................... 142 cyclosporine modified cap 100 mg .... 142 cyclosporine modified cap 25 mg ...... 142

cyproheptadine hcl syrup 2 mg/5ml .... 54 cyproheptadine hcl tab 4 mg .............. 54 cyred tab ........................................... 93 CYSTADANE POW ............................. 113 CYSTAGON CAP 150MG .................... 119

CYSTAGON CAP 50MG ...................... 119 CYSTARAN SOL 0.44% ..................... 153 cysteine hcl inj 50 mg/ml ................. 149 cytarabine inj 20 mg/ml ..................... 63

cytarabine inj pf 100 mg/ml ............... 63 cytarabine inj pf 20 mg/ml ................. 63 D d 400 chw 400unit ........................... 172

d 400 tab 400unit ............................ 172 D10W/NACL INJ 0.225% .................. 138 d3 cap 1000unit ............................... 172 d3 super str cap 2000unit................. 172 dacarbazine for inj 100 mg ................. 71

dacarbazine for inj 200 mg ................. 71 dactinomycin for inj 0.5 mg ................ 66 DAKLINZA TAB 30MG ......................... 83 DAKLINZA TAB 60MG ......................... 83

DAKLINZA TAB 90MG ......................... 83 dalfampridine tab er 12hr 10 mg ...... 160 DALIRESP TAB 250MCG ...................... 29 DALIRESP TAB 500MCG ...................... 29

danazol cap 100 mg ........................... 22 danazol cap 200 mg ........................... 22 danazol cap 50 mg ............................. 22 dandruff sha 1% .............................. 102 dantrolene sodium cap 100 mg......... 147

dantrolene sodium cap 25 mg........... 147 dantrolene sodium cap 50 mg........... 147 dapsone tab 100 mg .......................... 25 dapsone tab 25 mg ............................ 25

DARAPRIM TAB 25MG......................... 61 daunorubicin hcl iv soln 20 mg/4ml (base

equiv) ................................................ 66 DAURISMO TAB 100MG ...................... 65 DAURISMO TAB 25MG ........................ 65

DAYTRANA DIS 10MG/9HR ................... 4 DAYTRANA DIS 15MG/9HR ................... 4 DAYTRANA DIS 20MG/9HR ................... 4 DAYTRANA DIS 30MG/9HR ................... 4

DDAVP SOL 0.01% ........................... 114 decitabine for inj 50 mg ..................... 63 decongestant tab 120mg er .............. 148 deferasirox tab for oral susp 125 mg .. 49

deferasirox tab for oral susp 250 mg .. 50 deferasirox tab for oral susp 500 mg .. 50 deferoxamine mesylate for inj 2 gm ... 50 deferoxamine mesylate for inj 500 mg 50 DELESTROGEN INJ 10MG/ML ............ 115

DELSTRIGO TAB ................................. 81 demeclocycline hcl tab 150 mg ......... 163 demeclocycline hcl tab 300 mg ......... 163 DEMEROL INJ 100/2ML....................... 13

DEMEROL INJ 25MG/0.5 ..................... 13 DEMEROL INJ 75MG/1.5 ..................... 13 DEMEROL INJ 75MG/ML...................... 13 DEMSER CAP 250MG .......................... 57

DENAVIR CRE 1% ............................ 102 DEPO-ESTRADI INJ 5MG/ML ............. 115 DEPO-MEDROL INJ 20MG/ML .............. 94 DEPO-PROVERA INJ 400/ML ............... 65 DEPO-SQ PROV INJ 104 ..................... 93

DERMAGRAFT MIS ............................ 107 DESCOVY TAB 200/25 ........................ 81 desipramine hcl tab 10 mg ................. 42 desipramine hcl tab 100 mg ............... 42

desipramine hcl tab 150 mg ............... 42 desipramine hcl tab 25 mg ................. 42 desipramine hcl tab 50 mg ................. 42 desipramine hcl tab 75 mg ................. 42

desloratadine tab 5 mg....................... 53 desloratadine tab orally disintegrating 2.5 mg ............................................... 53 desloratadine tab orally disintegrating 5 mg ..................................................... 53

desmopressin acetate inj 4 mcg/ml .. 114 desmopressin acetate nasal spray soln 0.01%.............................................. 114 desmopressin acetate nasal spray soln

0.01% (refrigerated) ........................ 114 desmopressin acetate tab 0.1 mg ..... 114

191

desmopressin acetate tab 0.2 mg ..... 114 DESONATE GEL 0.05% ..................... 103 desonide cream 0.05%..................... 103

desonide lotion 0.05%...................... 103 desonide oint 0.05% ........................ 103 desoximetasone cream 0.05%.......... 103 desoximetasone cream 0.25%.......... 103

desoximetasone gel 0.05%............... 103 desoximetasone oint 0.05% ............. 103 desoximetasone oint 0.25% ............. 103 desoximetasone spray 0.25% ........... 103

DESVENLAFAX TAB 100MG ER ............ 41 DESVENLAFAX TAB 50MG ER .............. 40 desvenlafaxine succinate tab er 24hr 100 mg (base equiv) ................................. 41 desvenlafaxine succinate tab er 24hr 25

mg (base equiv) ................................. 41 desvenlafaxine succinate tab er 24hr 50 mg (base equiv) ................................. 41 desvenlafaxine tab er 24hr 100 mg .... 41

desvenlafaxine tab er 24hr 50 mg ...... 41 dexamethasone elixir 0.5 mg/5ml....... 94 dexamethasone sod phosphate preservative free inj 10 mg/ml ........... 94

dexamethasone sodium phosphate inj 10 mg/ml ................................................ 94 dexamethasone sodium phosphate inj 100 mg/10ml ..................................... 94 dexamethasone sodium phosphate inj

120 mg/30ml ..................................... 94 dexamethasone sodium phosphate inj 20 mg/5ml .............................................. 94 dexamethasone sodium phosphate inj 4

mg/ml ................................................ 94 dexamethasone sodium phosphate ophth soln 0.1% ........................................ 152 dexamethasone soln 0.5 mg/5ml ........ 94

dexamethasone tab 0.5 mg ................ 94 dexamethasone tab 0.75 mg .............. 94 dexamethasone tab 1 mg ................... 94 dexamethasone tab 1.5 mg ................ 94 dexamethasone tab 2 mg ................... 94

dexamethasone tab 4 mg ................... 94 dexamethasone tab 6 mg ................... 94 dexamethasone tab therapy pack 1.5 mg (21) ................................................... 94

dexamethasone tab therapy pack 1.5 mg (35) ................................................... 94

dexamethasone tab therapy pack 1.5 mg (51) ................................................... 94 DEXILANT CAP 30MG DR .................. 167

DEXILANT CAP 60MG DR .................. 167 dexmethylphenidate hcl cap er 24 hr 10 mg ....................................................... 4 dexmethylphenidate hcl cap er 24 hr 15

mg ....................................................... 4 dexmethylphenidate hcl cap er 24 hr 20 mg ....................................................... 4 dexmethylphenidate hcl cap er 24 hr 25

mg ....................................................... 4 dexmethylphenidate hcl cap er 24 hr 30 mg ....................................................... 4 dexmethylphenidate hcl cap er 24 hr 35 mg ....................................................... 4

dexmethylphenidate hcl cap er 24 hr 40 mg ....................................................... 4 dexmethylphenidate hcl cap er 24 hr 5 mg ....................................................... 4

dexmethylphenidate hcl tab 10 mg ....... 4 dexmethylphenidate hcl tab 2.5 mg ...... 4 dexmethylphenidate hcl tab 5 mg ......... 4 dexrazoxane hcl for inj 250 mg (base

equivalent)......................................... 72 dexrazoxane hcl for inj 500 mg (base equivalent)......................................... 72 dextroamphetamine sulfate cap er 24hr 10 mg .................................................. 1

dextroamphetamine sulfate cap er 24hr 15 mg .................................................. 1 dextroamphetamine sulfate cap er 24hr 5 mg ....................................................... 1

dextroamphetamine sulfate oral solution 5 mg/5ml ............................................. 1 dextroamphetamine sulfate tab 10 mg . 1 dextroamphetamine sulfate tab 5 mg ... 1

dextrose 10% w/ sodium chloride 0.45%........................................................ 138 dextrose 2.5% w/ sodium chloride 0.45%.............................................. 138 dextrose 5% in lactated ringers ........ 138

dextrose 5% w/ sodium chloride 0.2%........................................................ 138 dextrose 5% w/ sodium chloride 0.225%........................................................ 138

dextrose 5% w/ sodium chloride 0.33%........................................................ 138

192

dextrose 5% w/ sodium chloride 0.45%........................................................ 138 dextrose 5% w/ sodium chloride 0.9%

........................................................ 138 dextrose inj 10%.............................. 148 dextrose inj 25%.............................. 148 dextrose inj 30%.............................. 148

dextrose inj 5%................................ 148 dextrose inj 50%.............................. 148 dextrose inj 70%.............................. 148 DIABETIC CAP VITAMIN.................... 146

DIACOMIT CAP 250MG ....................... 35 DIACOMIT CAP 500MG ....................... 35 diaper rash cre 13% ......................... 106 diaper rash oin 40% ......................... 106 diazepam con 5mg/ml ........................ 27

DIAZEPAM INJ 10MG/2ML................... 27 diazepam inj 5 mg/ml ........................ 27 diazepam oral soln 1 mg/ml ............... 27 diazepam tab 10 mg........................... 27

diazepam tab 2 mg ............................ 27 diazepam tab 5 mg ............................ 27 dibromm chld liq 2.5-1-5 .................... 97 diclofenac epolamine patch 1.3% ....... 99

diclofenac potassium tab 50 mg ........... 9 diclofenac sodium (actinic keratoses) gel 3% .................................................. 101 diclofenac sodium gel 1% ................... 99 diclofenac sodium ophth soln 0.1%... 153

diclofenac sodium soln 1.5% .............. 99 diclofenac sodium tab delayed release 25 mg ....................................................... 9 diclofenac sodium tab delayed release 50

mg ....................................................... 9 diclofenac sodium tab delayed release 75 mg ....................................................... 9 diclofenac sodium tab er 24hr 100 mg .. 9

diclofenac w/ misoprostol tab delayed release 50-0.2 mg ................................ 9 diclofenac w/ misoprostol tab delayed release 75-0.2 mg .............................. 10 dicloxacillin sodium cap 250 mg........ 157

dicloxacillin sodium cap 500 mg........ 157 dicyclomine hcl cap 10 mg................ 166 dicyclomine hcl inj 10 mg/ml ............ 166 dicyclomine hcl oral soln 10 mg/5ml . 166

dicyclomine hcl tab 20 mg ................ 166 didanosine delayed release capsule 200

mg ..................................................... 81 didanosine delayed release capsule 250 mg ..................................................... 81

didanosine delayed release capsule 400 mg ..................................................... 81 DIFFERIN GEL 0.1% ........................... 99 DIFICID TAB 200MG ......................... 130

diflunisal tab 500 mg.......................... 13 DIGIFAB INJ 40MG ............................. 50 digitek tab 0.125mg ........................... 88 digitek tab 0.25mg ............................. 88

digoxin inj 0.25 mg/ml ....................... 88 digoxin oral soln 0.05 mg/ml .............. 88 dihydroergotamine mesylate nasal spray 4 mg/ml ........................................... 136 DILANTIN CAP 30MG .......................... 37

DILATRATE SR CAP 40MG................... 25 diltiazem cap 240mg cd...................... 86 diltiazem cap 300mg cd...................... 86 diltiazem hcl cap er 12hr 120 mg........ 87

diltiazem hcl cap er 12hr 60 mg ......... 87 diltiazem hcl cap er 12hr 90 mg ......... 87 diltiazem hcl cap er 24hr 120 mg........ 87 diltiazem hcl cap er 24hr 180 mg........ 87

diltiazem hcl cap er 24hr 240 mg........ 87 diltiazem hcl coated beads cap er 24hr 120 mg .............................................. 87 diltiazem hcl coated beads cap er 24hr 180 mg .............................................. 87

diltiazem hcl coated beads cap er 24hr 360 mg .............................................. 87 diltiazem hcl extended release beads cap er 24hr 120 mg .................................. 87

diltiazem hcl extended release beads cap er 24hr 180 mg .................................. 87 diltiazem hcl extended release beads cap er 24hr 240 mg .................................. 87

diltiazem hcl extended release beads cap er 24hr 300 mg .................................. 87 diltiazem hcl extended release beads cap er 24hr 360 mg .................................. 87 diltiazem hcl extended release beads cap

er 24hr 420 mg .................................. 87 diltiazem hcl tab 120 mg .................... 87 diltiazem hcl tab 30 mg ...................... 87 diltiazem hcl tab 60 mg ...................... 87

diltiazem hcl tab 90 mg ...................... 87 DIPENTUM CAP 250MG ..................... 117

193

diphenhydramine hcl (sleep) tab 50 mg........................................................ 126 diphenhydramine hcl cap 50 mg ......... 52

diphenhydramine hcl elixir 12.5 mg/5ml.......................................................... 52 diphenhydramine hcl inj 50 mg/ml ..... 52 diphenoxylate w/ atropine liq 2.5-0.025

mg/5ml .............................................. 49 diphenoxylate w/ atropine tab 2.5-0.025 mg ..................................................... 49 dipyridamole tab 25 mg.................... 124

dipyridamole tab 50 mg.................... 124 dipyridamole tab 75 mg.................... 124 DISCOVISC SOL ............................... 153 disopyramide phosphate cap 100 mg .. 27 disopyramide phosphate cap 150 mg .. 27

disulfiram tab 250 mg ...................... 158 disulfiram tab 500 mg ...................... 158 DIURIL SUS 250/5ML ....................... 110 divalproex sodium cap delayed release

sprinkle 125 mg ................................. 38 divalproex sodium tab delayed release 125 mg .............................................. 38 divalproex sodium tab delayed release

250 mg .............................................. 38 divalproex sodium tab delayed release 500 mg .............................................. 38 divalproex sodium tab er 24 hr 250 mg.......................................................... 38

divalproex sodium tab er 24 hr 500 mg.......................................................... 38 DIVIGEL GEL 0.25MG ....................... 115 DIVIGEL GEL 0.5MG ......................... 115

DIVIGEL GEL 1MG/GM ...................... 115 dobutamine hcl inj 12.5 mg/ml ......... 171 dobutamine inj 1 mg/ml in d5w ........ 171 dobutamine inj 2 mg/ml in d5w ........ 171

dobutamine inj 4 mg/ml in d5w ........ 171 docetaxel for inj conc 20 mg/ml ......... 72 docetaxel for inj conc 80 mg/4ml (20 mg/ml) .............................................. 72 DOCETAXEL INJ 20/0.5ML .................. 72

DOCETAXEL INJ 80MG/2ML ................ 72 docosanol cream 10% ...................... 102 docusate cal cap 240mg ................... 129 docusate sodium liquid 150 mg/15ml 129

docusate sodium syrup 60 mg/15ml . 130 dofetilide cap 125 mcg (0.125 mg) ..... 28

dofetilide cap 250 mcg (0.25 mg) ....... 28 dofetilide cap 500 mcg (0.5 mg) ......... 28 donepezil hydrochloride orally

disintegrating tab 10 mg .................. 158 donepezil hydrochloride orally disintegrating tab 5 mg .................... 158 donepezil hydrochloride tab 10 mg ... 158

donepezil hydrochloride tab 23 mg ... 158 donepezil hydrochloride tab 5 mg ..... 158 dopamine hcl inj 160 mg/ml ............. 171 dopamine hcl inj 40 mg/ml ............... 171

dopamine hcl inj 80 mg/ml ............... 171 dopamine inj 0.8 mg/ml in d5w ........ 171 dopamine inj 1.6 mg/ml in d5w ........ 171 dopamine inj 3.2 mg/ml in d5w ........ 171 DOPTELET TAB 20MG ....................... 125

dorzolamide hcl ophth soln 2% ......... 153 dorzolamide hcl-timolol maleate ophth sol 22.3-6.8 mg/ml pf ...................... 150 dorzolamide hcl-timolol maleate ophth

soln 22.3-6.8 mg/ml ........................ 150 double antib oin ............................... 100 DOUBLE-TUSSN LIQ DM ..................... 97 DOVATO TAB 50-300MG ..................... 81

doxazosin mesylate tab 1 mg ............. 57 doxazosin mesylate tab 2 mg ............. 57 doxazosin mesylate tab 4 mg ............. 57 doxazosin mesylate tab 8 mg ............. 57 doxepin hcl cap 10 mg ....................... 42

doxepin hcl cap 100 mg...................... 42 doxepin hcl cap 150 mg...................... 42 doxepin hcl cap 25 mg ....................... 42 doxepin hcl cap 50 mg ....................... 42

doxepin hcl cap 75 mg ....................... 42 doxepin hcl conc 10 mg/ml ................. 42 doxercalciferol cap 0.5 mcg .............. 113 doxercalciferol cap 1 mcg ................. 113

doxercalciferol cap 2.5 mcg .............. 113 doxorubicin hcl for inj 10 mg .............. 66 doxorubicin hcl for inj 50 mg .............. 66 doxorubicin hcl inj 2 mg/ml ................ 66 doxy 100 inj 100mg ......................... 163

doxycycline hyclate cap 100 mg ....... 163 doxycycline hyclate cap 50 mg ......... 163 doxycycline hyclate tab 100 mg ........ 163 doxycycline hyclate tab 20 mg.......... 163

doxycycline monohydrate cap 100 mg........................................................ 163

194

doxycycline monohydrate cap 150 mg........................................................ 163 doxycycline monohydrate cap 50 mg 163

doxycycline monohydrate for susp 25 mg/5ml ............................................ 164 doxycycline monohydrate tab 100 mg164 doxycycline monohydrate tab 150 mg164

doxycycline monohydrate tab 50 mg 164 doxycycline monohydrate tab 75 mg 164 doxylamine-pyridoxine tab delayed release 10-10 mg ............................... 51

dronabinol cap 10 mg......................... 51 dronabinol cap 2.5 mg........................ 51 dronabinol cap 5 mg........................... 51 drospirenone-ethinyl estradiol tab 3-0.03 mg ..................................................... 93

drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg.......................... 93 DROXIA CAP 200MG ......................... 124 DROXIA CAP 300MG ......................... 124

DROXIA CAP 400MG ......................... 124 dual action chw complete ................. 168 DUAVEE TAB 0.45-20 ....................... 114 DUET DHA 400 MIS 25-1-400 ........... 145

DUET DHA MIS BALANCED ............... 145 DULERA AER 100-5MCG ..................... 30 DULERA AER 200-5MCG ..................... 30 duloxetine hcl enteric coated pellets cap 20 mg (base eq) ................................ 41

duloxetine hcl enteric coated pellets cap 30 mg (base eq) ................................ 41 duloxetine hcl enteric coated pellets cap 40 mg (base eq) ................................ 41

duloxetine hcl enteric coated pellets cap 60 mg (base eq) ................................ 41 DUODOTE INJ .................................... 49 DUOVISC KIT 0.35/0.4 ..................... 153

DUOVISC KIT 0.5/0.55 ..................... 153 DUPIXENT INJ 200/1.14 ................... 105 DUPIXENT INJ 300/2ML .................... 105 duraxin cap ........................................ 12 DUREZOL EMU 0.05% ...................... 152

DURLAZA CAP 162.5MG.................... 124 dutasteride cap 0.5 mg .................... 119 dutasteride-tamsulosin hcl cap 0.5-0.4 mg ................................................... 119

DUZALLO TAB 200-200 .................... 120 DUZALLO TAB 200-300 .................... 120

DYANAVEL XR SUS 2.5MG/ML............... 1 DYRENIUM CAP 100MG..................... 110 DYRENIUM CAP 50MG ...................... 110

E e.e.s. 400 tab 400mg ....................... 130 econazole nitrate cream 1% ............. 100 ECOZA AER 1% ................................ 100

EDARBI TAB 40MG ............................. 57 EDARBI TAB 80MG ............................. 57 EDARBYCLOR TAB 40-12.5 ................. 59 EDARBYCLOR TAB 40-25MG ............... 59

EDLUAR SUB 10MG .......................... 127 EDLUAR SUB 5MG ............................ 127 EDURANT TAB 25MG .......................... 81 efavirenz cap 200 mg ......................... 81 efavirenz cap 50 mg ........................... 81

efavirenz tab 600 mg ......................... 81 EFFER-K TAB 10MEQ ........................ 140 EFFER-K TAB 20MEQ ........................ 140 EFFIENT TAB 10MG .......................... 124

EFFIENT TAB 5MG ............................ 124 EGRIFTA SOL 1MG ........................... 111 ELAPRASE INJ 6MG/3ML ................... 113 ELELYSO INJ 200UNIT ...................... 124

ELESTRIN GEL 0.06%....................... 115 eletriptan hydrobromide tab 20 mg (base equivalent)....................................... 136 eletriptan hydrobromide tab 40 mg (base equivalent)....................................... 136

ELIGARD INJ 22.5MG ......................... 65 ELIQUIS TAB 2.5MG ........................... 32 ELIQUIS TAB 5MG .............................. 32 ELIXOPHYLLIN ELX 80/15ML............... 31

ELLA TAB 30MG.................................. 93 ELLIOTTS B INJ ................................ 138 ELMIRON CAP 100MG ....................... 119 ELOCTATE INJ 1000UNIT .................. 121

ELOCTATE INJ 1500UNIT .................. 121 ELOCTATE INJ 2000UNIT .................. 121 ELOCTATE INJ 250UNIT.................... 121 ELOCTATE INJ 3000UNIT .................. 121 ELOCTATE INJ 4000UNIT .................. 121

ELOCTATE INJ 5000UNIT .................. 121 ELOCTATE INJ 500UNIT.................... 121 ELOCTATE INJ 6000UNIT .................. 121 ELOCTATE INJ 750UNIT.................... 121

EMADINE SOL 0.05% OP .................. 153 EMBEDA CAP 100-4MG ....................... 13

195

EMBEDA CAP 20-0.8MG ...................... 13 EMBEDA CAP 30-1.2MG ...................... 13 EMBEDA CAP 50-2MG ......................... 13

EMBEDA CAP 60-2.4MG ...................... 13 EMBEDA CAP 80-3.2MG ...................... 13 EMCYT CAP 140MG ............................. 65 EMEND SUS 125MG ............................ 51

EMFLAZA TAB 18MG ........................... 94 EMFLAZA TAB 30MG ........................... 94 EMFLAZA TAB 36MG ........................... 95 EMFLAZA TAB 6MG ............................. 94

EMGALITY INJ 120MG/ML ................. 136 EMSAM DIS 12MG/24H ....................... 39 EMSAM DIS 6MG/24HR....................... 39 EMSAM DIS 9MG/24HR....................... 39 EMTRIVA CAP 200MG ......................... 81

EMTRIVA SOL 10MG/ML ..................... 81 enalapril maleate & hydrochlorothiazide tab 10-25 mg ..................................... 59 enalapril maleate & hydrochlorothiazide

tab 5-12.5 mg .................................... 59 ENBREL INJ 25/0.5ML ........................ 11 ENBREL INJ 25MG .............................. 11 ENBREL INJ 50MG/ML......................... 11

ENBREL MINI INJ 50MG/ML ................ 11 ENBREL SRCLK INJ 50MG/ML.............. 11 ENDARI POW 5GM ............................ 124 ENDO DERMAL MIS 10X12.7............. 107 ENDO DERMAL MIS 5X5 CM.............. 107

endocet tab 2.5-325 ........................... 19 ENGLISH SOL PLANTAIN....................... 6 enoxaparin sodium inj 100 mg/ml ...... 32 enoxaparin sodium inj 120 mg/0.8ml . 32

enoxaparin sodium inj 150 mg/ml ...... 33 enoxaparin sodium inj 30 mg/0.3ml ... 32 enoxaparin sodium inj 300 mg/3ml .... 33 enoxaparin sodium inj 40 mg/0.4ml ... 32

enoxaparin sodium inj 60 mg/0.6ml ... 32 enoxaparin sodium inj 80 mg/0.8ml ... 32 enpresse-28 tab ................................. 93 ENSTILAR AER ................................. 103 entacapone tab 200 mg...................... 73

entecavir tab 0.5 mg .......................... 83 entecavir tab 1 mg ............................. 83 ENTEREG CAP 12MG......................... 118 ENTRESTO TAB 24-26MG ................... 89

ENTRESTO TAB 49-51MG ................... 89 ENTRESTO TAB 97-103MG.................. 89

enulose sol 10gm/15 ........................ 118 ENVARSUS XR TAB 0.75MG .............. 142 ENVARSUS XR TAB 1MG ................... 142

ENVARSUS XR TAB 4MG ................... 142 EPCLUSA TAB 400-100 ....................... 83 ephedrine sulfate inj 50 mg/ml ......... 171 EPIDIOLEX SOL 100MG/ML ................. 35

EPIFOAM AER 1%............................. 103 epinastine hcl ophth soln 0.05% ....... 153 epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) ........................ 171

epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) .......................... 171 EPIPEN-JR INJ 0.15MG ..................... 171 EPISNAP KIT .................................... 171 EPIVIR HBV SOL 5MG/ML ................... 83

eplerenone tab 25 mg ........................ 61 eplerenone tab 50 mg ........................ 61 EPOGEN INJ 10000/ML ..................... 125 EPOGEN INJ 2000/ML ....................... 125

EPOGEN INJ 20000/ML ..................... 125 EPOGEN INJ 3000/ML ....................... 125 EPOGEN INJ 4000/ML ....................... 125 epoprostenol sodium for inj 0.5 mg .... 89

epoprostenol sodium for inj 1.5 mg .... 89 eprosartan mesylate tab 600 mg ........ 57 eq aspirin tab 500mg ec ..................... 13 EQUALACTIN CHW 625MG ................ 128 EQUETRO CAP 100MG ........................ 75

EQUETRO CAP 200MG ........................ 75 EQUETRO CAP 300MG ........................ 75 ERBITUX INJ 100MG........................... 64 ERBITUX INJ 200MG........................... 64

ergocalciferol cap 1.25 mg (50000 unit)........................................................ 172 ERGOMAR SUB 2MG ......................... 136 ERIVEDGE CAP 150MG ....................... 65

ERLEADA TAB 60MG ........................... 65 erlotinib hcl tab 100 mg (base equivalent)......................................... 68 erlotinib hcl tab 150 mg (base equivalent)......................................... 68

erlotinib hcl tab 25 mg (base equivalent).......................................................... 68 ERTACZO CRE 2% ............................ 100 ertapenem sodium for inj 1 gm (base

equivalent)......................................... 24 ERYPED SUS 400/5ML ...................... 130

196

ery-tab tab 250mg ec....................... 130 ery-tab tab 333mg ec....................... 130 ery-tab tab 500mg ec....................... 130

ERYTHROCIN INJ 500MG .................. 130 erythrocin tab 250mg ....................... 130 ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 200 MG/5ML ........................... 130

erythromycin soln 2% ........................ 99 erythromycin tab 250 mg ................. 130 erythromycin tab 500 mg ................. 130 erythromycin w/ delayed release

particles cap 250 mg ........................ 130 ESBRIET CAP 267MG ........................ 163 ESBRIET TAB 801MG ........................ 163 escitalopram oxalate soln 5 mg/5ml (base equiv)....................................... 39

escitalopram oxalate tab 10 mg (base equiv) ................................................ 39 escitalopram oxalate tab 20 mg (base equiv) ................................................ 39

escitalopram oxalate tab 5 mg (base equiv) ................................................ 39 esomeprazole magnesium cap delayed release 20 mg (base eq)................... 167

esomeprazole magnesium cap delayed release 40 mg (base eq)................... 167 esomeprazole sodium for intravenous soln 20 mg (base equiv) ................... 167 esomeprazole sodium for intravenous

soln 40 mg (base equiv) ................... 167 estazolam tab 1 mg.......................... 127 estazolam tab 2 mg.......................... 127 estradiol & norethindrone acetate tab

0.5-0.1 mg....................................... 114 estradiol & norethindrone acetate tab 1-0.5 mg.......................................... 114 estradiol tab 0.5 mg ......................... 115

estradiol tab 1 mg ............................ 115 estradiol tab 2 mg ............................ 115 estradiol td patch twice weekly 0.025 mg/24hr .......................................... 115 estradiol td patch twice weekly 0.0375

mg/24hr .......................................... 115 estradiol td patch twice weekly 0.05 mg/24hr .......................................... 115 estradiol td patch twice weekly 0.075

mg/24hr .......................................... 115 estradiol td patch twice weekly 0.1

mg/24hr .......................................... 115 estradiol td patch weekly 0.025 mg/24hr........................................................ 115

estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) ................ 115 estradiol td patch weekly 0.05 mg/24hr........................................................ 115

estradiol td patch weekly 0.06 mg/24hr........................................................ 115 estradiol td patch weekly 0.075 mg/24hr........................................................ 115

estradiol td patch weekly 0.1 mg/24hr........................................................ 115 estradiol vaginal cream 0.1 mg/gm .. 170 estradiol valerate im in oil 20 mg/ml 115 estradiol valerate im in oil 40 mg/ml 115

ESTRING MIS 2MG ........................... 171 ESTROGEL GEL................................. 115 estropipate tab 0.75 mg ................... 115 eszopiclone tab 1 mg........................ 127

eszopiclone tab 2 mg........................ 127 eszopiclone tab 3 mg........................ 127 ethacrynate sodium for inj 50 mg ..... 109 ethambutol hcl tab 100 mg................. 62

ethambutol hcl tab 400 mg................. 62 ETHAMOLIN INJ 5% ......................... 143 ethosuximide cap 250 mg................... 38 ethosuximide soln 250 mg/5ml........... 38 ETHYOL INJ 500MG ............................ 72

etidronate disodium tab 200 mg ....... 110 etidronate disodium tab 400 mg ....... 110 etodolac cap 200 mg .......................... 10 etodolac cap 300 mg .......................... 10

etodolac tab 400 mg .......................... 10 etodolac tab 500 mg .......................... 10 etodolac tab er 24hr 400 mg .............. 10 etodolac tab er 24hr 500 mg .............. 10

etodolac tab er 24hr 600 mg .............. 10 etoposide cap 50 mg .......................... 72 etoposide inj 1 gm/50ml (20 mg/ml) .. 72 etoposide inj 100 mg/5ml (20 mg/ml) 72 etoposide inj 500 mg/25ml (20 mg/ml)

.......................................................... 72 EUCRISA OIN 2% ............................. 106 EUFLEXXA INJ 10MG/ML ................... 147 EURAX CRE 10% .............................. 107

EVAC POW ....................................... 128 EVAMIST SPR 1.53MG ...................... 115

197

EVENITY INJ 105MG ......................... 110 EVOTAZ TAB 300-150 ........................ 81 EVZIO INJ .......................................... 50

EXELDERM CRE 1% .......................... 100 EXELDERM SOL 1% .......................... 100 exemestane tab 25 mg....................... 65 EXODERM LOT 25-1% ...................... 100

EXTAVIA INJ 0.3MG.......................... 160 eye drops dro 0.5-0.9% ................... 149 EZALLOR SPR CAP 10MG .................... 55 EZALLOR SPR CAP 20MG .................... 55

EZALLOR SPR CAP 40MG .................... 55 EZALLOR SPR CAP 5MG ...................... 55 ezetimibe tab 10 mg .......................... 55 ezetimibe-simvastatin tab 10-10 mg... 54 ezetimibe-simvastatin tab 10-20 mg... 54

ezetimibe-simvastatin tab 10-40 mg... 54 ezetimibe-simvastatin tab 10-80 mg... 54 F FABRAZYME INJ 35MG...................... 113

FABRAZYME INJ 5MG........................ 113 FACE MASK MIS EARLOOP ................ 135 famciclovir tab 125 mg ....................... 85 famciclovir tab 250 mg ....................... 85

famciclovir tab 500 mg ....................... 85 famotidine for susp 40 mg/5ml ......... 167 famotidine inj 20 mg/2ml ................. 167 famotidine inj 200 mg/20ml ............. 167 famotidine inj 40 mg/4ml ................. 167

famotidine tab 20 mg ....................... 167 famotidine tab 40 mg ....................... 167 FANAPT PAK ....................................... 76 FANAPT TAB 10MG ............................. 76

FANAPT TAB 12MG ............................. 76 FANAPT TAB 1MG ............................... 76 FANAPT TAB 2MG ............................... 76 FANAPT TAB 4MG ............................... 76

FANAPT TAB 6MG ............................... 76 FANAPT TAB 8MG ............................... 76 FARESTON TAB 60MG......................... 65 FARXIGA TAB 10MG ........................... 48 FARXIGA TAB 5MG ............................. 48

FARYDAK CAP 10MG ........................... 68 FARYDAK CAP 15MG ........................... 68 FARYDAK CAP 20MG ........................... 68 fayosim tab ........................................ 93

febuxostat tab 40 mg ....................... 120 febuxostat tab 80 mg ....................... 120

FEIBA INJ......................................... 121 felbamate susp 600 mg/5ml ............... 37 felbamate tab 400 mg ........................ 37

felbamate tab 600 mg ........................ 37 felodipine tab er 24hr 10 mg .............. 87 felodipine tab er 24hr 2.5 mg ............. 87 felodipine tab er 24hr 5 mg ................ 87

FEMCAP MIS 22MM........................... 131 FEMCAP MIS 26MM........................... 131 FEMCAP MIS 30MM........................... 131 FEMRING MIS 0.05/24H ................... 171

FEMRING MIS 0.1MG/24................... 171 fenofibrate tab 120 mg ....................... 54 fenofibrate tab 145 mg ....................... 54 fenofibrate tab 160 mg ....................... 54 fenofibrate tab 40 mg......................... 54

fenofibrate tab 48 mg......................... 54 fenofibrate tab 54 mg......................... 54 fenofibric acid tab 35 mg .................... 54 fentanyl citrate lozenge on a handle 1200

mcg ................................................... 14 fentanyl citrate lozenge on a handle 1600 mcg ................................................... 14 fentanyl citrate lozenge on a handle 200

mcg ................................................... 13 fentanyl citrate lozenge on a handle 400 mcg ................................................... 13 fentanyl citrate lozenge on a handle 600 mcg ................................................... 13

fentanyl citrate lozenge on a handle 800 mcg ................................................... 14 fentanyl citrate pf soln cartridge 100 mcg/2ml ............................................ 14

fentanyl citrate preservative free (pf) inj 100 mcg/2ml ..................................... 14 fentanyl citrate preservative free (pf) inj 1000 mcg/20ml.................................. 14

fentanyl citrate preservative free (pf) inj 250 mcg/5ml ..................................... 14 fentanyl citrate preservative free (pf) inj 2500 mcg/50ml.................................. 14 fentanyl citrate preservative free (pf) inj

500 mcg/10ml.................................... 14 fentanyl td patch 72hr 100 mcg/hr ..... 14 fentanyl td patch 72hr 12 mcg/hr ....... 14 fentanyl td patch 72hr 25 mcg/hr ....... 14

fentanyl td patch 72hr 37.5 mcg/hr .... 14 fentanyl td patch 72hr 50 mcg/hr ....... 14

198

fentanyl td patch 72hr 62.5 mcg/hr .... 14 fentanyl td patch 72hr 75 mcg/hr ....... 14 fentanyl td patch 72hr 87.5 mcg/hr .... 14

FENTORA TAB 100MCG....................... 14 FER-IN-SOL DRO 15MG/ML .............. 126 FERRIPROX SOL 100MG/ML ................ 50 FERRIPROX TAB 1000MG.................... 50

FERRIPROX TAB 500MG...................... 50 ferrous gluconate tab 240 mg (27 mg elemental fe).................................... 126 ferrous sulfate elixir 220 mg/5ml (44

mg/5ml elemental fe)....................... 126 ferrous sulfate tab 325 mg (65 mg elemental fe).................................... 126 FETZIMA CAP 120MG.......................... 41 FETZIMA CAP 20MG............................ 41

FETZIMA CAP 40MG............................ 41 FETZIMA CAP 80MG............................ 41 FETZIMA CAP TITRATIO...................... 41 fever reduce sup 120mg ..................... 12

FEVERALL INF SUP 80MG ................... 12 fexofenadine hcl tab 180 mg .............. 53 fexofenadine hcl tab 60 mg ................ 53 fexofenadine-pseudoephedrine tab er

12hr 60-120 mg ................................. 97 fiber laxatv tab 625mg ..................... 128 fiber laxtiv cap 0.52gm..................... 128 fiber select chw gummies ................. 128 finasteride tab 5 mg ......................... 119

FIRDAPSE TAB 10MG.......................... 62 fish oil cap 435mg ............................ 148 FLAREX SUS 0.1% OP ...................... 152 flavoxate hcl tab 100 mg .................. 170

FLEBOGAMMA INJ 10/100ML ............ 154 FLEBOGAMMA INJ 10/200ML ............ 154 FLEBOGAMMA INJ 20/200ML ............ 154 FLEBOGAMMA INJ 20/400ML ............ 154

FLEBOGAMMA INJ 5GM/50ML ........... 154 FLEBOGAMMA INJ DIF 5% ................ 155 flecainide acetate tab 100 mg............. 27 flecainide acetate tab 150 mg............. 27 flecainide acetate tab 50 mg............... 27

FLEXICHAMBER MIS MASK SM .......... 135 FLINTSTONES CHW COMPLETE ......... 144 FLINTSTONES CHW GUMMIES .......... 144 floranex tab ....................................... 49

FLORASTOR PAK KIDS........................ 49 FLOVENT DISK AER 100MCG .............. 29

FLOVENT DISK AER 250MCG .............. 29 FLOVENT DISK AER 50MCG ................ 29 FLOVENT HFA AER 110MCG ................ 29

FLOVENT HFA AER 220MCG ................ 29 FLOVENT HFA AER 44MCG .................. 29 fluconazole for susp 10 mg/ml ............ 52 fluconazole for susp 40 mg/ml ............ 52

fluconazole tab 100 mg ...................... 52 fluconazole tab 150 mg ...................... 52 fluconazole tab 200 mg ...................... 52 fluconazole tab 50 mg ........................ 52

flucytosine cap 250 mg....................... 51 flucytosine cap 500 mg....................... 51 fludarabine phosphate for inj 50 mg ... 63 fludarabine phosphate inj 25 mg/ml ... 63 fludrocortisone acetate tab 0.1 mg ..... 96

fluocinolone acetonide (otic) oil 0.01%........................................................ 154 fluocinolone acetonide cream 0.01% 103 fluocinolone acetonide cream 0.025%103

fluocinolone acetonide oil 0.01% (body oil) ................................................... 103 fluocinolone acetonide oil 0.01% (scalp oil) ................................................... 103

fluocinolone acetonide oint 0.025% .. 103 fluocinolone acetonide soln 0.01% .... 103 fluocinonide cream 0.05% ................ 104 fluocinonide cream 0.1% .................. 103 fluocinonide emulsified base cream

0.05%.............................................. 104 fluocinonide gel 0.05% ..................... 104 fluocinonide oint 0.05%.................... 104 fluocinonide soln 0.05% ................... 104

FLUORABON DRO ............................. 139 fluorometholone ophth susp 0.1% .... 152 FLUOROPLEX CRE 1% ...................... 101 fluorouracil cream 5% ...................... 101

fluorouracil soln 2% ......................... 101 fluorouracil soln 5% ......................... 101 fluoxetine hcl (pmdd) cap 10 mg ...... 161 fluoxetine hcl (pmdd) cap 20 mg ...... 161 fluoxetine hcl cap 10 mg .................... 39

fluoxetine hcl cap 20 mg .................... 39 fluoxetine hcl cap 40 mg .................... 39 fluoxetine hcl cap delayed release 90 mg.......................................................... 39

fluoxetine hcl solution 20 mg/5ml ....... 39 fluoxetine hcl tab 10 mg ..................... 39

199

fluoxetine hcl tab 20 mg ..................... 39 fluphenazine decanoate inj 25 mg/ml . 79 fluphenazine hcl elixir 2.5 mg/5ml ...... 79

fluphenazine hcl inj 2.5 mg/ml ........... 79 fluphenazine hcl oral conc 5 mg/ml..... 79 fluphenazine hcl tab 1 mg .................. 79 fluphenazine hcl tab 10 mg................. 79

fluphenazine hcl tab 2.5 mg ............... 79 fluphenazine hcl tab 5 mg .................. 79 flura-drops dro 0.25mg f .................. 139 flurbiprofen sodium ophth soln 0.03%

........................................................ 153 flurbiprofen tab 100 mg...................... 10 flurbiprofen tab 50 mg........................ 10 flutamide cap 125 mg......................... 65 fluticasone propionate cream 0.05%. 104

fluticasone propionate lotion 0.05%.. 104 fluticasone propionate nasal susp 50 mcg/act ........................................... 148 fluticasone propionate oint 0.005% .. 104

fluticasone-salmeterol aer powder ba 100-50 mcg/dose ............................... 30 fluticasone-salmeterol aer powder ba 113-14 mcg/act ................................. 30

fluticasone-salmeterol aer powder ba 232-14 mcg/act ................................. 30 fluticasone-salmeterol aer powder ba 250-50 mcg/dose ............................... 30 fluticasone-salmeterol aer powder ba

500-50 mcg/dose ............................... 30 fluticasone-salmeterol aer powder ba 55-14 mcg/act ................................... 30 fluvoxamine maleate cap er 24hr 100 mg

.......................................................... 39 fluvoxamine maleate cap er 24hr 150 mg.......................................................... 39 fluvoxamine maleate tab 100 mg........ 39

fluvoxamine maleate tab 25 mg ......... 39 fluvoxamine maleate tab 50 mg ......... 39 FML FORTE SUS 0.25% OP ............... 152 FML OIN 0.1% OP ............................ 152 FOLET DHA PAK ............................... 145

FOLET ONE CAP 38-1-225 ................ 145 folic acid inj 5 mg/ml........................ 124 folic acid tab 1 mg............................ 124 folic acid tab 400 mcg ...................... 124

folic acid tab 800 mcg ...................... 124 fondaparinux sodium subcutaneous inj

10 mg/0.8ml ...................................... 33 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml ..................................... 33

fondaparinux sodium subcutaneous inj 5 mg/0.4ml ........................................... 33 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml ..................................... 33

formaldehyde solution 10% ................ 80 forma-ray sol 20% ............................. 80 FORTEO SOL 600/2.4 ....................... 110 FOSAMAX + D TAB 70-2800 ............. 110

FOSAMAX + D TAB 70-5600 ............. 111 fosamprenavir calcium tab 700 mg (base equiv) ................................................ 81 fosaprepitant dimeglumine for iv infusion 150 mg (base eq)............................... 51

fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg .................................. 59 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg .................................. 59

fosinopril sodium tab 10 mg ............... 56 fosinopril sodium tab 20 mg ............... 56 fosinopril sodium tab 40 mg ............... 56 fosphenytoin sodium inj 100 mg/2ml

(phenytoin equiv) ............................... 37 fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) ............................... 37 FRAGMIN INJ 10000/ML ..................... 33 FRAGMIN INJ 12500UNT..................... 33

FRAGMIN INJ 15000UNT..................... 33 FRAGMIN INJ 18000UNT..................... 33 FRAGMIN INJ 2500/0.2....................... 33 FRAGMIN INJ 5000/0.2....................... 33

FRAGMIN INJ 7500/0.3....................... 33 FRAGMIN INJ 95000UNT..................... 33 FREAMINE HBC INJ 6.9% ................. 149 FREAMINE III INJ 10% ..................... 149

FREESTYLE KIT SENSOR................... 131 FREESTYLE LIQ CONTROL................. 131 FREESTYLE MIS LITE ........................ 131 FREESTYLE MIS READER .................. 131 FREESTYLE TES ................................ 108

FREESTYLE TES INSULINX ................ 108 FREESTYLE TES LITE ........................ 108 FREESTYLE TES PREC NEO ............... 108 frovatriptan succinate tab 2.5 mg (base

equivalent)....................................... 136 furosemide inj 10 mg/ml .................. 109

200

furosemide oral soln 10 mg/ml ......... 109 furosemide oral soln 8 mg/ml ........... 109 furosemide tab 20 mg ...................... 109

furosemide tab 40 mg ...................... 109 furosemide tab 80 mg ...................... 109 FUSILEV INJ 50MG ............................. 72 FUZEON INJ 90MG ............................. 81

fyavolv tab 1-5................................. 114 FYCOMPA TAB 10MG .......................... 34 FYCOMPA TAB 12MG .......................... 34 FYCOMPA TAB 2MG ............................ 34

FYCOMPA TAB 4MG ............................ 34 FYCOMPA TAB 6MG ............................ 34 FYCOMPA TAB 8MG ............................ 34 G gabapentin cap 100 mg ...................... 35

gabapentin cap 300 mg ...................... 35 gabapentin cap 400 mg ...................... 35 gabapentin oral soln 250 mg/5ml ....... 35 gabapentin tab 600 mg ...................... 35

gabapentin tab 800 mg ...................... 35 GABITRIL TAB 12MG .......................... 37 GABITRIL TAB 16MG .......................... 37 GALAFOLD CAP 123MG ..................... 113

galantamine hydrobromide cap er 24hr 16 mg .............................................. 158 galantamine hydrobromide cap er 24hr 24 mg .............................................. 158 galantamine hydrobromide cap er 24hr 8

mg ................................................... 158 galantamine hydrobromide oral soln 4 mg/ml .............................................. 158 galantamine hydrobromide tab 12 mg158

galantamine hydrobromide tab 4 mg 158 galantamine hydrobromide tab 8 mg 158 GALZIN CAP 25MG ........................... 141 GALZIN CAP 50MG ........................... 141

GAMASTAN S/D INJ .......................... 155 GAMMAGARD INJ 10GM/100............. 155 GAMMAGARD INJ 1GM/10ML ............ 155 GAMMAGARD INJ 2.5GM/25 ............. 155 GAMMAGARD INJ 20GM/200............. 155

GAMMAGARD INJ 30GM/300............. 155 GAMMAGARD INJ 5GM/50ML ............ 155 GAMMAGARD SD INJ 10GM HU ......... 155 GAMMAGARD SD INJ 5GM HU........... 155

GAMMAPLEX INJ 5%......................... 155 ganciclovir sodium for inj 500 mg ....... 83

gas relief cap 125mg ........................ 116 gas relief cap 180mg ........................ 116 gas relief chw 80mg ......................... 116

gas relief dro 40/0.6ml ..................... 116 gas relief liq infants .......................... 116 gatifloxacin ophth soln 0.5% ............ 151 GATTEX KIT 5MG.............................. 119

gavilyte-c sol.................................... 129 gavilyte-g sol ................................... 129 gavilyte-h kit.................................... 129 gavilyte-n sol flav pk ........................ 129

GELFILM MIS OP .............................. 153 GELNIQUE GEL 10% ......................... 169 gemcitabine hcl for inj 1 gm ............... 63 gemcitabine hcl for inj 2 gm ............... 63 gemcitabine hcl for inj 200 mg ........... 64

gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) (base equiv) .......................... 64 gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) (base equiv) .......................... 64

gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) (base equiv) .......................... 64 gemfibrozil tab 600 mg ...................... 54 gengraf sol 100mg/ml ...................... 142

GENOTROPIN INJ 0.2MG .................. 111 GENOTROPIN INJ 0.4MG .................. 111 GENOTROPIN INJ 0.6MG .................. 111 GENOTROPIN INJ 0.8MG .................. 111 GENOTROPIN INJ 1.2MG .................. 111

GENOTROPIN INJ 1.4MG .................. 111 GENOTROPIN INJ 1.6MG .................. 111 GENOTROPIN INJ 1.8MG .................. 111 GENOTROPIN INJ 12MG.................... 111

GENOTROPIN INJ 1MG ..................... 111 GENOTROPIN INJ 2MG ..................... 111 gentamicin in saline inj 0.8 mg/ml ........ 7 gentamicin in saline inj 1 mg/ml ........... 7

gentamicin in saline inj 1.2 mg/ml ........ 7 gentamicin in saline inj 1.6 mg/ml ........ 7 gentamicin in saline inj 2 mg/ml ........... 7 gentamicin sulfate cream 0.1% ........ 100 gentamicin sulfate inj 10 mg/ml ........... 7

gentamicin sulfate inj 40 mg/ml ........... 7 gentamicin sulfate oint 0.1% ............ 100 gentamicin sulfate ophth soln 0.3% .. 151 GENTLE-LET MIS PLATFORM ............. 131

GENVISC 850 INJ 25/2.5 .................. 147 GENVOYA TAB .................................... 81

201

GEODON INJ 20MG ............................ 75 geri-mucil pow 68% ......................... 128 GIAZO TAB 1.1GM ............................ 117

GILENYA CAP 0.5MG ........................ 160 GILOTRIF TAB 20MG .......................... 68 GILOTRIF TAB 30MG .......................... 68 GILOTRIF TAB 40MG .......................... 68

GLASSIA INJ .................................... 162 glatiramer acetate soln prefilled syringe 20 mg/ml ......................................... 160 glatiramer acetate soln prefilled syringe

40 mg/ml ......................................... 160 glatopa inj 20mg/ml ......................... 160 GLEOSTINE CAP 100MG ..................... 63 GLEOSTINE CAP 10MG ....................... 63 GLEOSTINE CAP 40MG ....................... 63

GLEOSTINE CAP 5MG ......................... 63 GLIADEL WAF 7.7MG .......................... 63 glimepiride tab 1 mg .......................... 48 glimepiride tab 2 mg .......................... 48

glimepiride tab 4 mg .......................... 48 glipizide tab 10 mg ............................. 48 glipizide tab 5 mg............................... 48 glipizide tab er 24hr 10 mg................. 48

glipizide tab er 24hr 5 mg .................. 48 glipizide xl tab 2.5mg ......................... 48 glipizide-metformin hcl tab 2.5-250 mg.......................................................... 43 glipizide-metformin hcl tab 2.5-500 mg

.......................................................... 43 glipizide-metformin hcl tab 5-500 mg . 43 GLUCAGEN INJ 1MG ......................... 108 GLUCAGEN INJ HYPOKIT .................... 45

GLUCAGON KIT 1MG .......................... 45 gluco shot liq.................................... 148 glucose drnk liq 15/59ml .................... 45 glucose gel 40%................................. 45

GLUTARALDEHY SOL 25% .................. 80 glyburide micronized tab 1.5 mg ........ 48 glyburide micronized tab 3 mg ........... 48 glyburide micronized tab 6 mg ........... 48 glyburide tab 1.25 mg ........................ 48

glyburide tab 2.5 mg .......................... 49 glyburide tab 5 mg ............................. 49 glyburide-metformin tab 1.25-250 mg 43 glyburide-metformin tab 2.5-500 mg .. 43

glyburide-metformin tab 5-500 mg ..... 43 glycerin ped sup 1.2gm .................... 129

glycerin sup 2gm .............................. 129 glycopyrrolate inj 0.2 mg/ml ............ 166 glycopyrrolate inj 0.4 mg/2ml (0.2

mg/ml) ............................................ 166 glycopyrrolate inj 1 mg/5ml (0.2 mg/ml)........................................................ 166 glycopyrrolate inj 4 mg/20ml (0.2

mg/ml) ............................................ 166 glycopyrrolate tab 1 mg ................... 166 glycopyrrolate tab 2 mg ................... 166 GLYSET TAB 100MG ........................... 43

GLYSET TAB 25MG ............................. 43 GLYSET TAB 50MG ............................. 43 GLYXAMBI TAB 10-5 MG ..................... 43 GLYXAMBI TAB 25-5 MG ..................... 43 gnp tussin syp cf ................................ 97

GOCOVRI CAP 137MG ........................ 74 GOCOVRI CAP 68.5MG ....................... 74 GOLYTELY SOL ................................. 129 GORDONS UREA OIN 40%................ 105

GRALISE STAR MIS 300/600 ............ 161 GRALISE TAB 300MG........................ 161 GRALISE TAB 600MG........................ 161 granisetron hcl inj 0.1 mg/ml ............. 50

granisetron hcl inj 1 mg/ml ................ 50 granisetron hcl inj 4 mg/4ml (1 mg/ml).......................................................... 50 granisetron hcl tab 1 mg .................... 50 GRANIX INJ 300/0.5......................... 125

GRANIX INJ 480/0.8......................... 125 griseofulvin microsize susp 125 mg/5ml.......................................................... 51 griseofulvin microsize tab 500 mg ...... 51

griseofulvin ultramicrosize tab 125 mg 51 griseofulvin ultramicrosize tab 250 mg 51 guaiatuss ac syp 100-10/5 ................. 97 guaifenesin tab er 12hr 1200 mg ........ 98

guanfacine hcl tab 1 mg ..................... 57 guanfacine hcl tab 2 mg ..................... 57 guanfacine hcl tab er 24hr 1 mg (base equiv) .................................................. 3 guanfacine hcl tab er 24hr 2 mg (base

equiv) .................................................. 3 guanfacine hcl tab er 24hr 3 mg (base equiv) .................................................. 3 guanfacine hcl tab er 24hr 4 mg (base

equiv) .................................................. 3 GUANIDINE TAB 125MG ..................... 62

202

GYNAZOLE-1 CRE 2%....................... 170 H HAEGARDA INJ 2000UNIT ................ 123

HAEGARDA INJ 3000UNIT ................ 123 HALAVEN INJ 1MG/2ML ...................... 72 halcinonide cream 0.1% ................... 104 halobetasol propionate cream 0.05% 104

halobetasol propionate oint 0.05% ... 104 HALOG CRE 0.1%............................. 104 HALOG OIN 0.1% ............................. 104 haloperidol decanoate im soln 100 mg/ml

.......................................................... 77 haloperidol decanoate im soln 50 mg/ml.......................................................... 77 haloperidol lactate inj 5 mg/ml ........... 77 haloperidol lactate oral conc 2 mg/ml . 77

haloperidol tab 0.5 mg ....................... 77 haloperidol tab 1 mg .......................... 77 haloperidol tab 10 mg ........................ 77 haloperidol tab 2 mg .......................... 77

haloperidol tab 20 mg ........................ 77 haloperidol tab 5 mg .......................... 77 HARVONI TAB 90-400MG ................... 84 healthy kids chw overall ................... 144

heartbrn rel tab 75mg ...................... 167 heartburn sus relief ............................ 23 HECTOROL INJ 2MCG/ML.................. 113 HELIXATE FS INJ 1000UNIT.............. 121 HELIXATE FS INJ 2000UNIT.............. 121

HELIXATE FS INJ 250UNIT................ 121 HELIXATE FS INJ 3000UNIT.............. 121 HELIXATE FS INJ 500UNIT................ 121 HEMANGEOL SOL 4.28/ML .................. 86

HEMOFIL M INJ 1000UNIT ................ 121 HEMOFIL M INJ 1700UNIT ................ 121 HEMOFIL M INJ 250UNIT .................. 121 HEMOFIL M INJ 500UNIT .................. 121

HEPAGAM B INJ................................ 155 heparin sodium (porcine) inj 1000 unit/ml............................................... 33 heparin sodium (porcine) inj 10000 unit/ml............................................... 33

heparin sodium (porcine) inj 20000 unit/ml............................................... 33 heparin sodium (porcine) inj 5000 unit/ml............................................... 33

heparin sodium (porcine) pf inj 5000 unit/0.5ml .......................................... 33

hepatamine sol 8% .......................... 149 HERCEPTIN INJ 150MG....................... 64 HERCEPTIN INJ 440MG....................... 64

HETLIOZ CAP 20MG.......................... 128 HEXALEN CAP 50MG ........................... 63 HIZENTRA INJ 10/50ML .................... 155 HIZENTRA INJ 1GM/5ML................... 155

HIZENTRA INJ 2GM/10ML ................. 155 HIZENTRA INJ 4GM/20ML ................. 155 homatropine hbr ophth soln 5% ....... 150 HORIZANT TAB 300MG ER ................ 162

HORIZANT TAB 600MG ER ................ 162 HORSE EPITHE INJ 1:10 ....................... 6 HORSE EPITHE INJ 1:20 ....................... 6 HUBER NEEDLE MIS 20GX1 .............. 132 HUMALOG INJ 100/ML ........................ 46

HUMALOG KWIK INJ 100/ML............... 46 HUMALOG KWIK INJ 200/ML............... 47 HUMALOG MIX INJ 50/50 ................... 47 HUMALOG MIX INJ 50/50KWP ............ 47

HUMALOG MIX INJ 75/25KWP ............ 47 HUMALOG MIX SUS 75/25 .................. 47 HUMATE-P SOL 2400UNIT ................ 121 HUMATE-P SOL 250-600................... 121

HUMATE-P SOL 500-1200 ................. 121 HUMATROPE INJ 12MG ..................... 112 HUMATROPE INJ 24MG ..................... 112 HUMATROPE INJ 5MG ....................... 112 HUMATROPE INJ 6MG ....................... 112

HUMIRA INJ 10/0.1ML .......................... 7 HUMIRA INJ 10MG/0.2 ......................... 7 HUMIRA INJ 20/0.2ML .......................... 7 HUMIRA INJ 40/0.4ML .......................... 7

HUMIRA KIT 20MG/0.4 ......................... 7 HUMIRA KIT 40MG/0.8 ......................... 7 HUMIRA PEDIA INJ CROHNS ............. 7, 8 HUMIRA PEN INJ 40/0.4ML ................... 8

HUMIRA PEN INJ 40MG/0.8 .................. 8 HUMIRA PEN INJ CD/UC/HS.................. 8 HUMIRA PEN INJ PS/UV ........................ 8 HUMIRA PEN KIT CD/UC/HS ................. 8 HUMIRA PEN KIT PS/UV ....................... 8

HUMULIN INJ 70/30 ........................... 47 HUMULIN INJ 70/30KWP .................... 47 HUMULIN N INJ U-100........................ 47 HUMULIN N INJ U-100KWP ................. 47

HUMULIN R INJ U-100 ........................ 47 HUMULIN R INJ U-500 ........................ 47

203

HYALGAN INJ 20MG/2ML .................. 147 hyaluronate sodium (emollient) gel 0.2%........................................................ 105

hydralazine hcl inj 20 mg/ml .............. 61 hydralazine hcl tab 10 mg .................. 61 hydralazine hcl tab 100 mg ................ 61 hydralazine hcl tab 25 mg .................. 61

hydralazine hcl tab 50 mg .................. 61 hydrochlorothiazide cap 12.5 mg ...... 110 hydrochlorothiazide tab 12.5 mg ...... 110 hydrochlorothiazide tab 25 mg ......... 110

hydrochlorothiazide tab 50 mg ......... 110 HYDROCIL INS POW 95% ................. 128 hydrocod polst-chlorphen polst er susp 10-8 mg/5ml...................................... 97 hydrocodone w/ homatropine syrup

5-1.5 mg/5ml..................................... 96 hydrocodone w/ homatropine tab 5-1.5 mg ..................................................... 96 hydrocodone-acetaminophen soln

7.5-325 mg/15ml ............................... 19 hydrocodone-acetaminophen tab 10-300 mg ..................................................... 20 hydrocodone-acetaminophen tab 10-325

mg ..................................................... 20 hydrocodone-acetaminophen tab 5-300 mg ..................................................... 20 hydrocodone-acetaminophen tab 5-325 mg ..................................................... 20

hydrocodone-acetaminophen tab 7.5-300 mg ..................................................... 20 hydrocodone-acetaminophen tab 7.5-325 mg ..................................................... 20

hydrocodone-ibuprofen tab 7.5-200 mg.......................................................... 20 hydrocort cre 0.5% .......................... 104 hydrocort oin 0.5% .......................... 104

hydrocortisone acetate w/ pramoxine rectal cream 1-1% ............................. 22 hydrocortisone butyrate cream 0.1% 104 hydrocortisone butyrate hydrophilic lipo base cream 0.1% ............................. 104

hydrocortisone butyrate oint 0.1% ... 104 hydrocortisone butyrate soln 0.1% ... 104 hydrocortisone cream 1%................. 104 hydrocortisone cream 2.5%.............. 104

hydrocortisone enema 100 mg/60ml .. 22 hydrocortisone lotion 2.5%............... 104

hydrocortisone oint 2.5% ................. 104 hydrocortisone rectal cream 1% ......... 23 hydrocortisone rectal cream 2.5% ...... 23

hydrocortisone tab 10 mg................... 95 hydrocortisone tab 20 mg................... 95 hydrocortisone tab 5 mg..................... 95 hydrocortisone valerate cream 0.2% 104

hydrocortisone valerate oint 0.2% .... 104 HYDROGEL DRE PAD 2 ..................... 107 HYDROGEL DRE PAD 4 ..................... 107 hydromorphone hcl inj 1 mg/ml.......... 14

hydromorphone hcl inj 2 mg/ml.......... 14 hydromorphone hcl inj 4 mg/ml.......... 14 hydromorphone hcl liqd 1 mg/ml ........ 14 hydromorphone hcl preservative free (pf) inj 10 mg/ml ...................................... 14

hydromorphone hcl tab 2 mg.............. 14 hydromorphone hcl tab 4 mg.............. 14 hydromorphone hcl tab 8 mg.............. 14 hydromorphone hcl tab er 24hr deter 12

mg ..................................................... 15 hydromorphone hcl tab er 24hr deter 16 mg ..................................................... 15 hydromorphone hcl tab er 24hr deter 32

mg ..................................................... 15 hydromorphone hcl tab er 24hr deter 8 mg ..................................................... 14 hydroxychloroquine sulfate tab 200 mg.......................................................... 61

hydroxyprogesterone caproate im in oil 250 mg/ml ....................................... 157 hydroxyurea cap 500 mg .................... 71 hydroxyzine hcl im soln 25 mg/ml ...... 26

hydroxyzine hcl im soln 50 mg/ml ...... 26 hydroxyzine hcl syrup 10 mg/5ml ....... 26 hydroxyzine hcl tab 10 mg ................. 26 hydroxyzine hcl tab 25 mg ................. 26

hydroxyzine hcl tab 50 mg ................. 26 hydroxyzine pamoate cap 100 mg ...... 26 hydroxyzine pamoate cap 25 mg ........ 26 hydroxyzine pamoate cap 50 mg ........ 26 HYLENEX INJ 150 UNIT .................... 141

hyoscyamine sulfate tab er 12hr 0.375 mg ................................................... 166 hyperlyte-cr inj ................................ 138 HYPERSAL NEB 3.5% ......................... 98

HYPO NEEDLE MIS 18GX1 ................ 132 HYPO NEEDLE MIS 19GX1.5 ............. 132

204

HYPO NEEDLE MIS 21GX1 ................ 132 HYPO NEEDLE MIS 22GX1.5 ............. 132 HYPO NEEDLE MIS 23GX1 ................ 132

HYPO NEEDLE MIS 23GX1.5 ............. 132 HYPO NEEDLE MIS 25GX1 ................ 132 HYPO NEEDLE MIS 25GX1.5 ............. 132 HYPO NEEDLE MIS 25GX5/8 ............. 132

HYPO NEEDLE MIS 26GX1.5 ............. 132 HYPO NEEDLE MIS 26GX1/2 ............. 132 HYPO NEEDLE MIS 27GX1/2 ............. 132 HYPO NEEDLE MIS 30GX3/4 ............. 132

HYQVIA INJ 10-800 .......................... 155 HYQVIA INJ 2.5-200 ......................... 155 HYQVIA INJ 20-1600 ........................ 155 HYQVIA INJ 30-2400 ........................ 155 HYQVIA INJ 5-400 ............................ 155

HYSINGLA ER TAB 100 MG ................. 15 HYSINGLA ER TAB 120 MG ................. 15 HYSINGLA ER TAB 20 MG ................... 15 HYSINGLA ER TAB 30 MG ................... 15

HYSINGLA ER TAB 40 MG ................... 15 HYSINGLA ER TAB 60 MG ................... 15 HYSINGLA ER TAB 80 MG ................... 15 I

ibandronate sodium tab 150 mg (base equivalent)....................................... 111 IBRANCE CAP 100MG ......................... 68 IBRANCE CAP 125MG ......................... 68 IBRANCE CAP 75MG ........................... 68

ibudone tab 10-200mg ....................... 20 ibudone tab 5-200mg ......................... 20 ibuprofen cap 200 mg ........................ 10 ibuprofen dro 50/1.25 ........................ 10

ibuprofen jr chw 100mg ..................... 10 ibuprofen susp 100 mg/5ml ................ 10 ibuprofen tab 200 mg ......................... 10 ibuprofen tab 400 mg ......................... 10

ibuprofen tab 600 mg ......................... 10 ibuprofen tab 800 mg ......................... 10 ibutilide fumarate inj 1 mg/10ml ........ 28 icatibant acetate inj 30 mg/3ml (base equivalent)....................................... 123

ICLUSIG TAB 15MG ............................ 68 ICLUSIG TAB 45MG ............................ 68 IDHIFA TAB 100MG ............................ 68 IDHIFA TAB 50MG .............................. 68

IFEX INJ 3GM ..................................... 63 ifosfamide for inj 1 gm ....................... 63

ILARIS INJ 150MG/ML .......................... 9 ILEVRO DRO 0.3% OP ...................... 153 ILUMYA SOL 100MG/ML .................... 101

imatinib mesylate tab 100 mg (base equivalent)......................................... 68 imatinib mesylate tab 400 mg (base equivalent)......................................... 68

IMBRUVICA CAP 140MG ..................... 68 imipenem-cilastatin intravenous for soln 250 mg .............................................. 24 imipenem-cilastatin intravenous for soln

500 mg .............................................. 24 imipramine hcl tab 10 mg................... 42 imipramine hcl tab 25 mg................... 42 imipramine hcl tab 50 mg................... 42 imipramine pamoate cap 100 mg........ 42

imipramine pamoate cap 125 mg........ 42 imipramine pamoate cap 150 mg........ 42 imipramine pamoate cap 75 mg ......... 42 imiquimod cream 3.75% .................. 105

imiquimod cream 5% ....................... 105 INCRELEX INJ 40MG/4ML ................. 112 INCRUSE ELPT INH 62.5MCG .............. 28 indapamide tab 1.25 mg................... 110

indapamide tab 2.5 mg .................... 110 INDOCIN SUP 50MG ........................... 10 indomethacin cap 25 mg .................... 10 indomethacin cap 50 mg .................... 10 indomethacin cap er 75 mg ................ 10

inf silapap dro 80/0.8ml ..................... 12 INFASURF SUS 35MG/ML.................. 163 INFLECTRA INJ 100MG ..................... 117 INFUS SYRING MIS 100ML ............... 132

INFUVITE INJ ................................... 144 INGREZZA CAP 40MG ....................... 159 INGREZZA CAP 80MG ....................... 159 INLYTA TAB 1MG ................................ 68

INLYTA TAB 5MG ................................ 68 INREBIC CAP 100MG .......................... 68 INSPIREASE MIS RES BAG................ 135 INSULIN LISP INJ 100/ML................... 47 INSULIN SYRG MIS 0.3/30G ............. 132

INSULIN SYRG MIS 0.3/31G ............. 132 INSULIN SYRG MIS 0.5/30G ............. 132 INSULIN SYRG MIS 0.5/31G ............. 132 INSULIN SYRG MIS 1ML/25G ............ 132

INSULIN SYRG MIS 1ML/30G ............ 132 INSULIN SYRG MIS 1ML/31G ............ 132

205

INTELENCE TAB 100MG ...................... 81 INTELENCE TAB 200MG ...................... 81 INTELENCE TAB 25MG ........................ 81

intense coug liq reliever ..................... 97 INTRON A INJ 18MU ........................... 71 INTRON A INJ 25MU ........................... 71 INVEGA SUST INJ 117/0.75................ 76

INVEGA SUST INJ 156MG/ML ............. 76 INVEGA SUST INJ 234/1.5.................. 76 INVEGA SUST INJ 39/0.25.................. 76 INVEGA SUST INJ 78/0.5ML ............... 76

INVEGA TRINZ INJ 273MG.................. 77 INVEGA TRINZ INJ 410MG.................. 77 INVEGA TRINZ INJ 546MG.................. 77 INVEGA TRINZ INJ 819MG.................. 77 INVIRASE TAB 500MG ........................ 81

INVOKAMET TAB 150-1000 ................ 43 INVOKAMET TAB 150-500 .................. 43 INVOKAMET TAB 50-1000 .................. 43 INVOKAMET TAB 50-500MG ............... 43

INVOKAMET XR TAB 150-1000 ........... 44 INVOKAMET XR TAB 150-500 ............. 44 INVOKAMET XR TAB 50-1000 ............. 44 INVOKAMET XR TAB 50-500MG .......... 44

INVOKANA TAB 100MG....................... 48 INVOKANA TAB 300MG....................... 48 iodine solution strong 5% (lugol's) ... 139 IONOSOL-MB INJ D5W ..................... 138 IONSYS PAD 40MCG/AC ..................... 15

ipratropium bromide inhal soln 0.02% 28 ipratropium bromide nasal soln 0.03% (21 mcg/spray) ................................ 147 ipratropium bromide nasal soln 0.06%

(42 mcg/spray) ................................ 147 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml ............................. 31 IPRIVASK INJ 15MG ........................... 33

irbesartan tab 150 mg ........................ 57 irbesartan tab 300 mg ........................ 57 irbesartan tab 75 mg.......................... 57 irbesartan-hydrochlorothiazide tab 150-12.5 mg ...................................... 59

irbesartan-hydrochlorothiazide tab 300-12.5 mg ...................................... 59 IRESSA TAB 250MG............................ 68 irinotecan hcl inj 100 mg/5ml (20

mg/ml) .............................................. 73 irinotecan hcl inj 40 mg/2ml (20 mg/ml)

.......................................................... 73 irinotecan hcl inj 500 mg/25ml (20 mg/ml) .............................................. 73

iron supplmt dro 15mg/ml ................ 126 ISENTRESS CHW 100MG .................... 81 ISENTRESS CHW 25MG ...................... 81 ISENTRESS HD TAB 600MG ................ 81

ISENTRESS POW 100MG .................... 81 ISENTRESS TAB 400MG...................... 81 ISOLYTE-P INJ /D5W ........................ 138 ISOLYTE-S INJ ................................. 138

ISOLYTE-S INJ PH 7.4 ...................... 138 isoniazid inj 100 mg/ml ...................... 62 isoniazid syrup 50 mg/5ml ................. 62 isoniazid tab 100 mg .......................... 62 isoniazid tab 300 mg .......................... 62

isoproterenol hcl inj 0.2 mg/ml ........... 31 ISORDIL TAB 40MG ............................ 25 isosorbide dinitrate tab 10 mg ............ 25 isosorbide dinitrate tab 20 mg ............ 25

isosorbide dinitrate tab 30 mg ............ 26 isosorbide dinitrate tab 5 mg .............. 25 isosorbide dinitrate tab er 40 mg ........ 26 isosorbide mononitrate tab 10 mg ...... 26

isosorbide mononitrate tab 20 mg ...... 26 isosorbide mononitrate tab er 24hr 120 mg ..................................................... 26 isosorbide mononitrate tab er 24hr 30 mg ..................................................... 26

isosorbide mononitrate tab er 24hr 60 mg ..................................................... 26 isotretinoin cap 10 mg ........................ 99 isotretinoin cap 20 mg ........................ 99

isotretinoin cap 30 mg ........................ 99 isotretinoin cap 40 mg ........................ 99 isradipine cap 2.5 mg ......................... 87 isradipine cap 5 mg ............................ 87

itraconazole cap 100 mg..................... 52 itraconazole oral soln 10 mg/ml.......... 52 IXEMPRA KIT INJ 15MG ...................... 72 IXEMPRA KIT INJ 45MG ...................... 72 IXINITY INJ 1000UNIT...................... 121

IXINITY INJ 1500UNIT...................... 121 IXINITY INJ 500UNIT........................ 121 J JADENU TAB 180MG ........................... 50

JADENU TAB 360MG ........................... 50 JADENU TAB 90MG ............................. 50

206

JAKAFI TAB 10MG .............................. 68 JAKAFI TAB 15MG .............................. 68 JAKAFI TAB 20MG .............................. 68

JAKAFI TAB 25MG .............................. 68 JAKAFI TAB 5MG ................................ 68 JANUMET TAB 50-1000....................... 44 JANUMET TAB 50-500MG.................... 44

JANUMET XR TAB 100-1000 ............... 44 JANUMET XR TAB 50-1000 ................. 44 JANUMET XR TAB 50-500MG .............. 44 JANUVIA TAB 100MG .......................... 45

JANUVIA TAB 25MG............................ 45 JANUVIA TAB 50MG............................ 45 JARDIANCE TAB 10MG........................ 48 JARDIANCE TAB 25MG........................ 48 JENTADUETO TAB 2.5-1000................ 44

JENTADUETO TAB 2.5-500.................. 44 JENTADUETO TAB 2.5-850.................. 44 JENTADUETO TAB XR ......................... 44 jevantique l tab 0.5-2.5 .................... 114

JEVTANA INJ 60/1.5ML ....................... 72 JOHNSON SOL GRASS .......................... 6 J-TAN PD DRO 1MG/ML ...................... 52 JUBLIA SOL 10% .............................. 100

JUNE GRASS SOL POLLEN .................... 6 JUXTAPID CAP 10MG .......................... 55 JUXTAPID CAP 20MG .......................... 55 JUXTAPID CAP 30MG .......................... 55 JUXTAPID CAP 40MG .......................... 55

JUXTAPID CAP 5MG ............................ 55 JUXTAPID CAP 60MG .......................... 55 JYNARQUE PAK 45-15MG.................. 114 JYNARQUE PAK 60-30MG.................. 114

JYNARQUE PAK 90-30MG.................. 114 K KADCYLA INJ 100MG .......................... 64 KADCYLA INJ 160MG .......................... 64

KADIAN CAP 200MG ER ...................... 15 KALETRA TAB 100-25MG .................... 82 KALETRA TAB 200-50MG .................... 82 KALYDECO PAK 25MG....................... 162 KALYDECO PAK 50MG....................... 162

KALYDECO PAK 75MG....................... 162 KALYDECO TAB 150MG..................... 162 KARBINAL ER SUS 4MG/5ML .............. 52 KCENTRA KIT 1000UNIT ................... 121

KCENTRA KIT 500UNIT ..................... 121 kcl 10 meq/l (0.075%) in dextrose 5% &

nacl 0.45% inj.................................. 139 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj.................................... 139

kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj.................................. 139 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj.................................. 139

kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.9% inj.................................... 139 kcl 20 meq/l (0.15%) in nacl 0.45% inj........................................................ 139

kcl 20 meq/l (0.15%) in nacl 0.9% inj........................................................ 139 kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj.................................. 139 kcl 40 meq/l (0.3%) in dextrose 5% &

nacl 0.45% inj.................................. 139 kcl 40 meq/l (0.3%) in nacl 0.9% inj 139 KENALOG-10 INJ 10MG/ML................. 95 KERR TRIPLE MIS DYE SWAB.............. 80

ketoconazole cream 2% ................... 100 ketoconazole shampoo 2% ............... 100 ketoconazole tab 200 mg ................... 52 ketoprofen cap er 24hr 200 mg .......... 10

ketorolac tromethamine ophth soln 0.4%........................................................ 153 ketorolac tromethamine ophth soln 0.5%........................................................ 153 ketorolac tromethamine tab 10 mg ..... 10

KEVEYIS TAB 50MG .......................... 109 KEVZARA INJ 150/1.14 ........................ 9 KEVZARA INJ 200/1.14 ........................ 9 KEYTRUDA INJ 100MG/4M .................. 64

KINERET INJ ........................................ 9 KISQALI 200 PAK FEMARA .................. 67 KISQALI 400 PAK FEMARA .................. 67 KISQALI 600 PAK FEMARA .................. 67

KISQALI TAB 200DOSE ...................... 68 KISQALI TAB 400DOSE ...................... 69 KISQALI TAB 600DOSE ...................... 69 klor-con 8 tab 8meq er ..................... 140 KLOR-CON M15 TAB 15MEQ ER ........ 140

KOATE-DVI INJ 1000UNIT ................ 122 KOATE-DVI INJ 250UNIT .................. 122 KOATE-DVI INJ 500UNIT .................. 122 KOGENATE FS INJ 1000UNIT ............ 122

KOGENATE FS INJ 2000UNIT ............ 122 KOGENATE FS INJ 250UNIT .............. 122

207

KOGENATE FS INJ 3000UNIT ............ 122 KOGENATE FS INJ 500UNIT .............. 122 KOMBIGLYZ XR TAB 2.5-1000 ............ 44

KOMBIGLYZ XR TAB 5-1000MG .......... 44 KOMBIGLYZ XR TAB 5-500MG ............ 44 KONSYL DAILY POW 100% ............... 128 KONSYL DAILY POW 28.3% .............. 128

KONSYL POW 60.3% ........................ 128 KONSYL POW 71.67% ...................... 128 KORLYM TAB 300MG .......................... 45 KOSHR PRENAT TAB 30-1MG ............ 145

KOVALTRY INJ 1000UNIT ................. 122 KOVALTRY INJ 2000UNIT ................. 122 KOVALTRY INJ 250UNIT ................... 122 KOVALTRY INJ 3000UNIT ................. 122 KOVALTRY INJ 500UNIT ................... 122

K-PHOS TAB..................................... 140 KRINTAFEL TAB 150MG ...................... 61 KRISTALOSE PAK 20GM.................... 129 KUVAN POW 100MG ......................... 113

KUVAN POW 500MG ......................... 113 KUVAN TAB 100MG .......................... 113 KYNAMRO INJ 200MG/ML ................... 54 KYPROLIS SOL 60MG.......................... 69

L labetalol hcl tab 100 mg ..................... 85 labetalol hcl tab 200 mg ..................... 85 labetalol hcl tab 300 mg ..................... 85 LAC-HYDRIN LOT 12% ..................... 105

LACRISERT MIS 5MG OP................... 149 lactated ringer's for irrigation ........... 143 lactated ringer's solution .................. 139 lactic acid (ammonium lactate) cream

12%................................................. 105 lactic acid (ammonium lactate) lotion 12%................................................. 105 lactulose pak 10gm .......................... 129

LAMBS SOL QUARTERS ........................ 6 LAMICTAL ODT KIT............................. 35 LAMICTAL XR KIT ............................... 35 lamivudine oral soln 10 mg/ml ........... 82 lamivudine tab 100 mg (hbv) ............. 84

lamivudine tab 150 mg....................... 82 lamivudine tab 300 mg....................... 82 lamivudine-zidovudine tab 150-300 mg.......................................................... 82

lamotrigine orally disintegrating tab 100 mg ..................................................... 35

lamotrigine orally disintegrating tab 200 mg ..................................................... 35 lamotrigine orally disintegrating tab 25

mg ..................................................... 35 lamotrigine orally disintegrating tab 50 mg ..................................................... 35 lamotrigine tab 100 mg ...................... 36

lamotrigine tab 150 mg ...................... 36 lamotrigine tab 200 mg ...................... 36 lamotrigine tab 25 mg ........................ 35 lamotrigine tab 25 mg (35) starter kit 35

lamotrigine tab 25 mg (42) & 100 mg (7) starter kit ........................................... 35 lamotrigine tab 25 mg (84) & 100 mg (14) starter kit ................................... 35 lamotrigine tab chewable dispersible 25

mg ..................................................... 36 lamotrigine tab chewable dispersible 5 mg ..................................................... 36 lamotrigine tab er 24hr 100 mg .......... 36

lamotrigine tab er 24hr 200 mg .......... 36 lamotrigine tab er 24hr 25 mg ............ 36 lamotrigine tab er 24hr 250 mg .......... 36 lamotrigine tab er 24hr 300 mg .......... 36

lamotrigine tab er 24hr 50 mg ............ 36 LANCETS MIS ................................... 131 LANCING DEVI MIS .......................... 131 LANOXIN PED INJ 0.1MG/ML .............. 88 LANOXIN TAB 0.0625MG .................... 88

LANOXIN TAB 0.1875MG .................... 88 lansoprazole cap delayed release 15 mg........................................................ 167 lansoprazole cap delayed release 30 mg

........................................................ 167 lansoprazole tab delayed release orally disintegrating 15 mg ........................ 168 lansoprazole tab delayed release orally

disintegrating 30 mg ........................ 168 lanthanum carbonate chew tab 500 mg (elemental) ...................................... 118 lanthanum carbonate chew tab 750 mg (elemental) ...................................... 118

LANTUS INJ 100/ML ........................... 47 LANTUS SOLOS INJ 100/ML ................ 47 LASTACAFT SOL 0.25% .................... 153 latanoprost ophth soln 0.005%......... 153

LATRIX XM EMU 45% ....................... 105 LATUDA TAB 120MG ........................... 76

208

LATUDA TAB 20MG ............................. 75 LATUDA TAB 40MG ............................. 75 LATUDA TAB 60MG ............................. 75

LATUDA TAB 80MG ............................. 76 laxative tab 5mg ec .......................... 129 layolis fe chw ..................................... 93 LAZANDA SPR 100MCG ...................... 15

LAZANDA SPR 300MCG ...................... 15 LAZANDA SPR 400MCG ...................... 15 LDO PLUS GEL 4% ........................... 106 leena tab............................................ 93

leflunomide tab 10 mg ....................... 11 leflunomide tab 20 mg ....................... 11 LENVIMA CAP 10 MG .......................... 69 LENVIMA CAP 14 MG .......................... 69 LENVIMA CAP 18 MG .......................... 69

LENVIMA CAP 20 MG .......................... 69 LENVIMA CAP 24 MG .......................... 69 LENVIMA CAP 8 MG ............................ 69 letrozole tab 2.5 mg ........................... 65

leucovorin calcium for inj 100 mg ....... 72 leucovorin calcium for inj 200 mg ....... 72 leucovorin calcium for inj 350 mg ....... 72 leucovorin calcium for inj 50 mg ......... 72

leucovorin calcium for inj 500 mg ....... 72 leucovorin calcium tab 10 mg ............. 72 leucovorin calcium tab 15 mg ............. 72 leucovorin calcium tab 25 mg ............. 72 leucovorin calcium tab 5 mg ............... 72

LEUKERAN TAB 2MG........................... 63 LEUKINE INJ 250MCG ....................... 125 leuprolide acetate inj kit 5 mg/ml ....... 65 levalbuterol hcl soln nebu 0.31 mg/3ml

(base equiv)....................................... 31 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)....................................... 31 levalbuterol hcl soln nebu 1.25 mg/3ml

(base equiv)....................................... 31 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) ....................... 31 levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv) ......................... 31

LEVEMIR INJ ...................................... 47 LEVEMIR INJ FLEXTOUC ..................... 47 levetiracetam inj 500 mg/5ml (100 mg/ml) .............................................. 36

levetiracetam oral soln 100 mg/ml ..... 36 levetiracetam tab 1000 mg................. 36

levetiracetam tab 250 mg................... 36 levetiracetam tab 500 mg................... 36 levetiracetam tab 750 mg................... 36

levetiracetam tab er 24hr 500 mg ...... 36 levetiracetam tab er 24hr 750 mg ...... 36 levobunolol hcl ophth soln 0.5% ....... 150 levocetirizine dihydrochloride soln 2.5

mg/5ml (0.5 mg/ml) .......................... 53 levocetirizine dihydrochloride tab 5 mg53 levofloxacin ophth soln 0.5% ............ 151 levofloxacin oral soln 25 mg/ml ........ 116

levofloxacin tab 250 mg ................... 116 levofloxacin tab 500 mg ................... 116 levofloxacin tab 750 mg ................... 116 levoleucovorin calcium for iv inj 50 mg (base equiv)....................................... 72

levoleucovorin calcium inj 175 mg/17.5ml (base equiv) ..................... 72 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) ........................ 93

levorphanol tartrate tab 2 mg ............. 15 levo-t tab 112mcg ............................ 164 levo-t tab 137mcg ............................ 164 levo-t tab 175mcg ............................ 164

levo-t tab 200 mcg ........................... 164 levo-t tab 300 mcg ........................... 164 levo-t tab 88mcg .............................. 164 levothyroxine sodium tab 100 mcg ... 164 levothyroxine sodium tab 125 mcg ... 165

levothyroxine sodium tab 150 mcg ... 165 levothyroxine sodium tab 25 mcg ..... 164 levothyroxine sodium tab 50 mcg ..... 164 levothyroxine sodium tab 75 mcg ..... 164

LEVSIN INJ 0.5MG/ML ...................... 166 LEVULAN KERA SOL 20% ................. 101 LEXIVA SUS 50MG/ML ........................ 82 LIALDA TAB 1.2GM ........................... 117

lice killing sha .................................. 107 lice trtmnt liq 1% ............................. 107 lidocaine hcl soln 4% ........................ 106 lidocaine hcl urethral/mucosal gel prefilled syringe 2% ......................... 106

lidocaine hcl viscous soln 2%............ 143 lidocaine oint 5% ............................. 106 lidocaine patch 5% ........................... 106 lidocaine-prilocaine cream 2.5-2.5%. 106

lincomycin hcl inj 300 mg/ml .............. 25 linezolid for susp 100 mg/5ml............. 25

209

linezolid tab 600 mg ........................... 25 LINZESS CAP 145MCG...................... 118 LINZESS CAP 290MCG...................... 118

LINZESS CAP 72MCG........................ 118 liothyronine sodium tab 25 mcg........ 165 liothyronine sodium tab 5 mcg.......... 165 liothyronine sodium tab 50 mcg........ 165

lip balm oin strawber ........................ 106 lisinopril & hydrochlorothiazide tab 10-12.5 mg ........................................ 59 lisinopril & hydrochlorothiazide tab

20-12.5 mg ........................................ 59 lisinopril & hydrochlorothiazide tab 20-25 mg ..................................................... 59 lisinopril tab 10 mg ............................ 56 lisinopril tab 2.5 mg ........................... 56

lisinopril tab 20 mg ............................ 56 lisinopril tab 30 mg ............................ 56 lisinopril tab 40 mg ............................ 56 lisinopril tab 5 mg .............................. 56

lithium carbonate cap 150 mg ............ 75 lithium carbonate cap 300 mg ............ 75 lithium carbonate cap 600 mg ............ 75 lithium carbonate tab 300 mg............. 75

lithium carbonate tab er 300 mg......... 75 lithium carbonate tab er 450 mg......... 75 LITHIUM SOL 8MEQ/5ML .................... 75 LITHOSTAT TAB 250MG .................... 120 little remed liq 160/5ml ...................... 12

LIVALO TAB 1MG ................................ 55 LIVALO TAB 2MG ................................ 55 LIVALO TAB 4MG ................................ 55 lmd 10%/d5w inj ............................. 123

lmd 10%/nacl inj 0.9% .................... 123 l-methylfolate tab 15 mg .................. 108 l-methylfolate tab 7.5 mg ................. 108 LO LOESTRIN TAB 1-10-10 ................. 93

lohist-dm syp 5-2-10mg ..................... 97 LOKELMA PAK 10GM......................... 143 LOKELMA PAK 5GM........................... 143 LONHALA MAGN SOL 25MCG .............. 28 LONSURF TAB 15-6.14 ....................... 67

LONSURF TAB 20-8.19 ....................... 67 loperamide hcl cap 2 mg .................... 49 lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) ................................... 82

loratadine chew tab 5 mg ................... 53 loratadine chw 5mg ............................ 53

loratadine sol 5mg/5ml ...................... 53 lorazepam conc 2 mg/ml .................... 27 lorazepam inj 2 mg/ml ....................... 27

lorazepam inj 4 mg/ml ....................... 27 lorazepam tab 0.5 mg ........................ 27 lorazepam tab 1 mg ........................... 27 lorazepam tab 2 mg ........................... 27

LORBRENA TAB 100MG....................... 69 LORBRENA TAB 25MG ........................ 69 LORTAB ELX 10-300MG ...................... 20 LORZONE TAB 375MG ...................... 146

LORZONE TAB 750MG ...................... 146 losartan potassium & hydrochlorothiazide tab 100-12.5 mg ................................ 59 losartan potassium & hydrochlorothiazide tab 100-25 mg ................................... 59

losartan potassium & hydrochlorothiazide tab 50-12.5 mg .................................. 59 losartan potassium tab 100 mg .......... 57 losartan potassium tab 25 mg ............ 57

losartan potassium tab 50 mg ............ 57 LOTEMAX GEL 0.5% ......................... 152 LOTEMAX OIN 0.5% ......................... 152 loteprednol etabonate ophth susp 0.5%

........................................................ 152 lotrimin af aer 2% ............................ 100 lovastatin tab 10 mg .......................... 55 lovastatin tab 20 mg .......................... 55 lovastatin tab 40 mg .......................... 55

low-ogestrel tab ................................. 93 loxapine succinate cap 10 mg ............. 78 loxapine succinate cap 25 mg ............. 78 loxapine succinate cap 5 mg ............... 78

loxapine succinate cap 50 mg ............. 78 lubricnt eye dro 0.5% op .................. 150 LUCEMYRA TAB 0.18MG ................... 158 ludent chw 0.25mg f ........................ 139

ludent chw 0.5mg f .......................... 139 ludent chw 1mg f ............................. 139 luliconazole cream 1%...................... 100 LUMIGAN SOL 0.01% ....................... 154 LUMIZYME INJ 50MG ........................ 113

LUPR DEP-PED INJ 11.25MG ............. 112 LUPR DEP-PED INJ 15MG .................. 112 LUPR DEP-PED INJ 3M 30MG ............ 112 LUPR DEP-PED INJ 7.5MG................. 112

LUPRON DEPOT INJ 11.25MG ............. 65 LUPRON DEPOT INJ 22.5MG ............... 65

210

LUPRON DEPOT INJ 3.75MG ............... 65 LUPRON DEPOT INJ 30MG .................. 65 LUPRON DEPOT INJ 45MG .................. 65

LUPRON DEPOT INJ 7.5MG ................. 65 LUXAMEND CRE................................ 107 LYNPARZA CAP 50MG ......................... 69 LYNPARZA TAB 100MG ....................... 69

LYNPARZA TAB 150MG ....................... 69 LYSODREN TAB 500MG ...................... 66 lyza tab 0.35mg ................................. 94 M

magdelay tab 64mg ......................... 140 magnesium chloride inj 200 mg/ml... 140 magnesium citrate soln .................... 129 magnesium oxide cap 500 mg (elemental mg) ................................................. 140

magnesium oxide tab 400 mg (240 mg elemental mg).................................. 140 magnesium oxide tab 500 mg (mg supplement)..................................... 140

magnesium sulfate inj 50% .............. 140 MAKENA INJ 275MG ......................... 157 malathion lotion 0.5% ...................... 107 manganese chloride inj 0.1 mg/ml.... 140

maprotiline hcl tab 25 mg................... 39 maprotiline hcl tab 50 mg................... 39 maprotiline hcl tab 75 mg................... 39 MARNATAL-F CAP ............................. 145 MARPLAN TAB 10MG .......................... 39

MARQIBO INJ 5MG/31ML .................... 72 MATULANE CAP 50MG ........................ 71 matzim la tab 180mg/24 .................... 87 matzim la tab 240mg/24 .................... 87

matzim la tab 300mg/24 .................... 87 matzim la tab 360mg/24 .................... 87 matzim la tab 420mg/24 .................... 87 MAVENCLAD PAK 10MG (4) .............. 160

MAVENCLAD PAK 10MG (5) .............. 160 MAVENCLAD PAK 10MG (6) .............. 160 MAVENCLAD PAK 10MG (7) .............. 160 MAVENCLAD PAK 10MG (8) .............. 160 MAVENCLAD PAK 10MG (9) .............. 160

MAVENCLAD PAK 10MG(10) ............. 161 MAVENCLAD PAK 10MG(4) ............... 160 MAVENCLAD PAK 10MG(5) ............... 160 MAVENCLAD PAK 10MG(6) ............... 160

MAVENCLAD PAK 10MG(7) ............... 160 MAVENCLAD PAK 10MG(8) ............... 160

MAVENCLAD PAK 10MG(9) ............... 161 MAVYRET TAB 100-40MG ................... 84 MAXIDEX SUS 0.1% OP.................... 152

MAYZENT TAB 0.25MG ..................... 161 MAYZENT TAB 2MG .......................... 161 meclizine hcl chew tab 25 mg ............. 51 meclizine hcl tab 12.5 mg................... 51

meclizine hcl tab 25 mg...................... 51 meclofenamate sodium cap 100 mg.... 10 meclofenamate sodium cap 50 mg...... 10 MEDROL TAB 2MG .............................. 95

medroxyprogesterone acetate im susp 150 mg/ml ......................................... 94 medroxyprogesterone acetate im susp prefilled syr 150 mg/ml ...................... 94 medroxyprogesterone acetate tab 10 mg

........................................................ 157 medroxyprogesterone acetate tab 2.5 mg ................................................... 157 medroxyprogesterone acetate tab 5 mg

........................................................ 157 mefenamic acid cap 250 mg ............... 10 mefloquine hcl tab 250 mg ................. 62 MEGA MULTIVI TAB WOMEN ............. 144

megestrol acetate susp 40 mg/ml....... 66 megestrol acetate susp 625 mg/5ml . 157 megestrol acetate tab 20 mg .............. 66 megestrol acetate tab 40 mg .............. 66 MEKINIST TAB 0.5MG......................... 69

MEKINIST TAB 2MG............................ 69 MEKTOVI TAB 15MG ........................... 69 meloxicam tab 15 mg ......................... 10 meloxicam tab 7.5 mg........................ 10

melphalan hcl for inj 50 mg (base equiv).......................................................... 63 melphalan tab 2 mg ........................... 63 memantine hcl cap er 24hr 14 mg .... 158

memantine hcl cap er 24hr 21 mg .... 158 memantine hcl cap er 24hr 28 mg .... 158 memantine hcl cap er 24hr 7 mg ...... 158 memantine hcl oral solution 2 mg/ml 158 memantine hcl tab 10 mg................. 158

memantine hcl tab 5 mg................... 158 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak.............................. 158 MEMBRANEBLUE SOL 0.15% ............ 153

MENEST TAB 0.3MG ......................... 115 MENEST TAB 0.625MG ..................... 115

211

MENEST TAB 1.25MG ....................... 115 MENOSTAR DIS 14MCG .................... 115 MENTAX CRE 1%.............................. 100

meperidine hcl inj 10 mg/ml ............... 15 meperidine hcl inj 100 mg/ml ............. 15 meperidine hcl inj 25 mg/ml ............... 15 meperidine hcl inj 50 mg/ml ............... 15

meperidine hcl oral soln 50 mg/5ml .... 15 meperidine hcl tab 100 mg ................. 15 meperidine hcl tab 50 mg ................... 15 meprobamate tab 200 mg .................. 26

meprobamate tab 400 mg .................. 26 mercaptopurine tab 50 mg ................. 64 meropenem iv for soln 1 gm ............... 24 meropenem iv for soln 500 mg ........... 24 mesalamine cap dr 400 mg .............. 117

mesalamine enema 4 gm ................. 117 mesalamine rectal enema 4 gm & cleanser wipe kit .............................. 117 mesalamine suppos 1000 mg ........... 117

mesalamine tab delayed release 1.2 gm........................................................ 117 mesalamine tab delayed release 800 mg........................................................ 117

mesna inj 100 mg/ml ......................... 72 MESNEX TAB 400MG .......................... 72 MESQUITE SOL EXTRACT ..................... 6 METAMUCIL POW 28%ORG .............. 128 metamucil pow 28.3%org................. 128

METAMUCIL POW 55.46% ................ 128 METAMUCIL POW 58.12% ................ 128 metamucil pow 58.6%org................. 128 METAMUCIL POW 63% ..................... 128

metaproterenol sulfate syrup 10 mg/5ml.......................................................... 31 metaproterenol sulfate tab 10 mg....... 31 metaproterenol sulfate tab 20 mg....... 31

METASTRON INJ ................................. 71 metaxalone tab 400 mg ................... 146 metaxalone tab 800 mg ................... 146 metformin hcl tab 1000 mg ................ 45 metformin hcl tab 500 mg .................. 45

metformin hcl tab 850 mg .................. 45 metformin hcl tab er 24hr 500 mg ...... 45 metformin hcl tab er 24hr 750 mg ...... 45 metformin hcl tab er 24hr modified

release 1000 mg ................................ 45 metformin hcl tab er 24hr modified

release 500 mg .................................. 45 metformin hcl tab er 24hr osmotic 1000 mg ..................................................... 45

metformin hcl tab er 24hr osmotic 500 mg ..................................................... 45 methadone hcl conc 10 mg/ml............ 15 methadone hcl soln 10 mg/5ml .......... 15

methadone hcl soln 5 mg/5ml ............ 15 methadone hcl tab 10 mg................... 15 methadone hcl tab 5 mg..................... 15 methadone hcl tab for oral susp 40 mg15

methazolamide tab 25 mg ................ 109 methazolamide tab 50 mg ................ 109 methenamine hippurate tab 1 gm ..... 169 methenamine mandelate tab 0.5 gm 169 methenamine mandelate tab 1 gm ... 169

methergine tab 0.2mg ...................... 154 methimazole tab 10 mg.................... 164 methimazole tab 5 mg...................... 164 METHITEST TAB 10MG ....................... 22

methocarbamol tab 500 mg.............. 146 methocarbamol tab 750 mg.............. 147 methotrexate sodium for inj 1 gm ...... 64 methotrexate sodium inj 250 mg/10ml

(25 mg/ml) ........................................ 64 methotrexate sodium inj 50 mg/2ml (25 mg/ml) .............................................. 64 methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) ......................... 64

methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) ........................................ 64 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) ........................................ 64

methotrexate sodium tab 2.5 mg (base equiv) ................................................ 64 methscopolamine bromide tab 2.5 mg........................................................ 166

methscopolamine bromide tab 5 mg . 166 methyclothiazide tab 5 mg ............... 110 methyldopa & hydrochlorothiazide tab 250-15 mg ......................................... 60 methyldopa & hydrochlorothiazide tab

250-25 mg ......................................... 60 methyldopa tab 250 mg ..................... 57 methyldopa tab 500 mg ..................... 57 methyldopate hcl inj 250 mg/5ml ....... 57

methylene blue inj 1% ....................... 50 methylergonovine maleate inj 0.2 mg/ml

212

........................................................ 154 methylergonovine maleate tab 0.2 mg........................................................ 154

methylphenidate hcl cap er 10 mg (cd). 4 methylphenidate hcl cap er 20 mg (cd). 4 methylphenidate hcl cap er 24hr 10 mg (la) ...................................................... 4

methylphenidate hcl cap er 24hr 20 mg (la) ...................................................... 4 methylphenidate hcl cap er 24hr 30 mg (la) ...................................................... 5

methylphenidate hcl cap er 24hr 40 mg (la) ...................................................... 5 methylphenidate hcl cap er 30 mg (cd). 5 methylphenidate hcl cap er 40 mg (cd). 5 methylphenidate hcl cap er 50 mg (cd). 5

methylphenidate hcl cap er 60 mg (cd). 5 methylphenidate hcl chew tab 10 mg.... 5 methylphenidate hcl chew tab 2.5 mg .. 5 methylphenidate hcl chew tab 5 mg ..... 5

methylphenidate hcl soln 10 mg/5ml .... 5 methylphenidate hcl soln 5 mg/5ml ...... 5 methylphenidate hcl tab 10 mg ............ 5 methylphenidate hcl tab 20 mg ............ 5

methylphenidate hcl tab 5 mg .............. 5 methylphenidate hcl tab er 10 mg ........ 5 methylphenidate hcl tab er 20 mg ........ 5 methylphenidate hcl tab er 24hr 18 mg 5 methylphenidate hcl tab er 24hr 27 mg 5

methylphenidate hcl tab er 24hr 36 mg 5 methylphenidate hcl tab er 24hr 54 mg 5 methylphenidate hcl tab er osmotic release (osm) 18 mg ............................ 5

methylphenidate hcl tab er osmotic release (osm) 27 mg ............................ 5 methylphenidate hcl tab er osmotic release (osm) 36 mg ............................ 5

methylphenidate hcl tab er osmotic release (osm) 54 mg ............................ 5 methylprednisolone acetate inj susp 40 mg/ml ................................................ 95 methylprednisolone acetate inj susp 80

mg/ml ................................................ 95 methylprednisolone sod succ for inj 1000 mg (base equiv) ................................. 95 methylprednisolone sod succ for inj 125

mg (base equiv) ................................. 95 methylprednisolone sod succ for inj 40

mg (base equiv) ................................. 95 methylprednisolone tab 16 mg ........... 95 methylprednisolone tab 32 mg ........... 95

methylprednisolone tab 4 mg ............. 95 methylprednisolone tab 8 mg ............. 95 methylprednisolone tab therapy pack 4 mg (21) ............................................. 95

metipranolol ophth soln 0.3%........... 150 METOCLOPRAMI TAB 10MG ODT ....... 117 metoclopramide hcl inj 5 mg/ml (base equivalent)....................................... 117

metoclopramide hcl orally disintegrating tab 5 mg (base eq) .......................... 117 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv)..................... 117 metoclopramide hcl tab 10 mg (base

equivalent)....................................... 117 metoclopramide hcl tab 5 mg (base equivalent)....................................... 117 metolazone tab 10 mg...................... 110

metolazone tab 2.5 mg .................... 110 metolazone tab 5 mg ....................... 110 metoprolol & hydrochlorothiazide tab 100-25 mg ......................................... 60

metoprolol & hydrochlorothiazide tab 100-50 mg ......................................... 60 metoprolol & hydrochlorothiazide tab 50-25 mg ........................................... 60 metoprolol succinate tab er 24hr 100 mg

(tartrate equiv) .................................. 86 metoprolol succinate tab er 24hr 200 mg (tartrate equiv) .................................. 86 metoprolol succinate tab er 24hr 25 mg

(tartrate equiv) .................................. 85 metoprolol succinate tab er 24hr 50 mg (tartrate equiv) .................................. 85 metoprolol tartrate tab 100 mg .......... 86

metoprolol tartrate tab 25 mg ............ 86 metoprolol tartrate tab 50 mg ............ 86 metoprolol tartrate tab 75 mg ............ 86 metronidazole cap 375 mg ................. 24 metronidazole gel 0.75%.................. 106

metronidazole gel 1% ...................... 107 metronidazole lotion 0.75%.............. 107 metronidazole tab 250 mg.................. 24 metronidazole tab 500 mg.................. 24

metronidazole vaginal gel 0.75% ...... 170 mgo tab 400mg................................ 140

213

miconazole 3 kit combinat ................ 170 miconazole 3 kit combo pk ............... 170 miconazole 3 sup 200mg .................. 170

miconazole 7 cre 2% ........................ 170 miconazorb pow af 2% ..................... 100 microgestin tab 1.5/30 ....................... 93 microgestin tab 1/20 .......................... 93

microgestin tab fe1.5/30 .................... 93 MICROLIFE MIS PEAK FLO ................ 135 midazolam hcl inj 10 mg/10ml (base equivalent)....................................... 127

midazolam hcl inj 10 mg/2ml (base equivalent)....................................... 127 midazolam hcl inj 2 mg/2ml (base equivalent)....................................... 127 midazolam hcl inj 25 mg/5ml (base

equivalent)....................................... 127 midazolam hcl inj 5 mg/5ml (base equivalent)....................................... 127 midazolam hcl inj 5 mg/ml (base

equivalent)....................................... 127 midazolam hcl inj 50 mg/10ml (base equivalent)....................................... 127 midazolam hcl syrup 2 mg/ml (base

equivalent)....................................... 127 midodrine hcl tab 10 mg................... 171 midodrine hcl tab 2.5 mg ................. 171 midodrine hcl tab 5 mg .................... 171 migergot sup 2/100.......................... 136

miglustat cap 100 mg....................... 124 migraine tab formula .......................... 12 milk of magn sus 1200/15 ................ 129 MILLIPRED DP PAK 5MG ..................... 95

MILLIPRED TAB 5MG .......................... 95 MINASTRIN 24 CHW FE ...................... 93 MINI WRIGHT MIS PFM .................... 135 MINI WRIGHT MIS PFM LOW ............ 135

MINOCIN INJ 100MG ........................ 164 minocycline hcl cap 100 mg.............. 164 minocycline hcl cap 50 mg................ 164 minocycline hcl cap 75 mg................ 164 minocycline hcl tab 100 mg .............. 164

minocycline hcl tab 50 mg ................ 164 minocycline hcl tab 75 mg ................ 164 minocycline hcl tab er 24hr 105 mg .. 164 minocycline hcl tab er 24hr 115 mg .. 164

minocycline hcl tab er 24hr 135 mg .. 164 minocycline hcl tab er 24hr 45 mg .... 164

minocycline hcl tab er 24hr 55 mg .... 164 minocycline hcl tab er 24hr 65 mg .... 164 minocycline hcl tab er 24hr 80 mg .... 164

minocycline hcl tab er 24hr 90 mg .... 164 minoxidil tab 10 mg ........................... 61 minoxidil tab 2.5 mg .......................... 61 MIOCHOL-E SOL 1:100..................... 151

MIRALAX POW 3350 NF .................... 129 MIRCERA INJ 100MCG ...................... 125 MIRCERA INJ 200MCG ...................... 125 mirtazapine orally disintegrating tab 15

mg ..................................................... 38 mirtazapine orally disintegrating tab 30 mg ..................................................... 38 mirtazapine orally disintegrating tab 45 mg ..................................................... 38

mirtazapine tab 15 mg ....................... 38 mirtazapine tab 30 mg ....................... 38 mirtazapine tab 45 mg ....................... 38 mirtazapine tab 7.5 mg ...................... 38

misoprostol tab 100 mcg .................. 168 misoprostol tab 200 mcg .................. 168 MITE SOL EXTRACT .............................. 6 MITOSOL KIT 0.2MG ........................ 151

mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) .............................................. 66 mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) .......................................... 66 mitoxantrone hcl inj conc 30 mg/15ml (2

mg/ml) .............................................. 66 MIXED SOL RAGWEED .......................... 6 modafinil tab 100 mg ........................... 5 modafinil tab 200 mg ........................... 5

MODERIBA PAK 1200/DAY .................. 84 MODERIBA PAK 800/DAY .................... 84 MODERIBA TAB 1000/DAY .................. 84 MODERIBA TAB 600/DAY.................... 84

moexipril-hydrochlorothiazide tab 15-12.5 mg ........................................ 60 moexipril-hydrochlorothiazide tab 15-25 mg ..................................................... 60 moexipril-hydrochlorothiazide tab

7.5-12.5 mg....................................... 60 mometasone furoate cream 0.1%..... 104 mometasone furoate nasal susp 50 mcg/act ........................................... 148

mometasone furoate oint 0.1% ........ 104 mometasone furoate solution 0.1%

214

(lotion)............................................. 104 MONISTAT 3 KIT COMBO PK ............. 170 MONOCLATE-P INJ 1000UNIT ........... 122

MONOCLATE-P INJ 1500UNIT ........... 122 mononessa tab................................... 93 MONONINE INJ 1000UNIT ................ 122 montelukast sodium chew tab 4 mg

(base equiv)....................................... 28 montelukast sodium chew tab 5 mg (base equiv)....................................... 29 montelukast sodium oral granules packet

4 mg (base equiv) .............................. 29 montelukast sodium tab 10 mg (base equiv) ................................................ 29 morphine sulfate beads cap er 24hr 120 mg ..................................................... 16

morphine sulfate beads cap er 24hr 30 mg ..................................................... 16 morphine sulfate beads cap er 24hr 45 mg ..................................................... 16

morphine sulfate beads cap er 24hr 60 mg ..................................................... 16 morphine sulfate beads cap er 24hr 75 mg ..................................................... 16

morphine sulfate beads cap er 24hr 90 mg ..................................................... 16 morphine sulfate cap er 24hr 10 mg ... 16 morphine sulfate cap er 24hr 100 mg . 16 morphine sulfate cap er 24hr 20 mg ... 16

morphine sulfate cap er 24hr 30 mg ... 16 morphine sulfate cap er 24hr 40 mg ... 16 morphine sulfate cap er 24hr 50 mg ... 16 morphine sulfate cap er 24hr 60 mg ... 16

morphine sulfate cap er 24hr 80 mg ... 16 morphine sulfate inj 10 mg/ml............ 16 morphine sulfate inj 8 mg/ml ............. 16 morphine sulfate inj pf 0.5 mg/ml ...... 16

morphine sulfate inj pf 1 mg/ml ......... 16 morphine sulfate oral soln 10 mg/5ml 16 morphine sulfate oral soln 100 mg/5ml (20 mg/ml) ........................................ 16 morphine sulfate oral soln 20 mg/5ml 16

morphine sulfate suppos 10 mg .......... 16 morphine sulfate suppos 20 mg .......... 16 morphine sulfate suppos 5 mg............ 16 morphine sulfate tab 15 mg................ 16

morphine sulfate tab 30 mg................ 16 morphine sulfate tab er 100 mg ......... 16

morphine sulfate tab er 15 mg ........... 16 morphine sulfate tab er 200 mg ......... 17 morphine sulfate tab er 30 mg ........... 16

morphine sulfate tab er 60 mg ........... 16 MOTEGRITY TAB 1MG ....................... 116 MOTEGRITY TAB 2MG ....................... 116 MOTOFEN TAB 1-0.025....................... 49

MOVANTIK TAB 12.5MG ................... 118 MOVANTIK TAB 25MG ...................... 118 MOVIPREP SOL................................. 129 MOXEZA SOL 0.5% .......................... 151

moxifloxacin hcl ophth soln 0.5% (base equiv) .............................................. 151 moxifloxacin hcl tab 400 mg (base equiv)........................................................ 116 MOZOBIL INJ ................................... 126

MUCINEX CGH GRA 5-100MG ............. 97 mucus relief liq 5-100mg .................... 97 mucus-dm max tab 60-1200 .............. 97 mucus-dm tab 30-600mg ................... 97

mucus-er tab 600mg .......................... 98 MUGWORT SOL EXTRACT ..................... 6 MULIT-DRAW MIS 22GX1.5 .............. 133 MULPLETA TAB 3MG ......................... 125

MULTAQ TAB 400MG .......................... 28 MULTI PRENAT TAB .......................... 145 MULTI-DELYN LIQ /IRON .................. 144 MULTI-DRAW MIS 20GX1.5 .............. 133 MULTI-DRAW MIS 21GX1.5 .............. 133

MULTITRACE-4 INJ ........................... 141 multitrace-4 inj conc ........................ 141 MULTITRACE-4 INJ NEONATAL.......... 141 multitrace-5 inj conc ........................ 141

MULTITRACE-5 INJ REGULAR............ 141 mupirocin calcium cream 2%............ 100 mupirocin oint 2% ............................ 100 my way tab 1.5mg ............................. 93

MYALEPT INJ 11.3MG ....................... 113 mycophenolate mofetil cap 250 mg .. 142 mycophenolate mofetil for oral susp 200 mg/ml .............................................. 142 mycophenolate mofetil tab 500 mg... 142

mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) ................ 142 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) ................ 142

MYKIDZ IRON SUS 10MG/2ML .......... 144 MYLERAN TAB 2MG ............................ 63

215

MYNATAL TAB .................................. 145 MYRBETRIQ TAB 25MG ..................... 170 MYRBETRIQ TAB 50MG ..................... 170

MYTESI TAB 125MG............................ 49 N nabumetone tab 500 mg .................... 10 nabumetone tab 750 mg .................... 10

nafcillin sodium for inj 1 gm ............. 157 nafcillin sodium for inj 2 gm ............. 157 naftifine hcl gel 1% .......................... 100 NAFTIN GEL 2% ............................... 101

NAGLAZYME INJ 1MG/ML.................. 113 nalbuphine hcl inj 10 mg/ml ............... 21 nalbuphine hcl inj 20 mg/ml ............... 21 naloxone hcl inj 0.4 mg/ml ................. 50 naloxone hcl inj 4 mg/10ml ................ 50

naloxone hcl soln cartridge 0.4 mg/ml 50 naloxone hcl soln prefilled syringe 2 mg/2ml .............................................. 50 naltrexone hcl tab 50 mg.................... 50

NAMENDA XR CAP TITRATIO ............ 158 NAMZARIC CAP 14-10MG ................. 159 NAMZARIC CAP 21-10MG ................. 159 NAMZARIC CAP 28-10MG ................. 159

NAMZARIC CAP 7-10MG ................... 158 NAPRELAN TAB 750MG CR.................. 10 naproxen dr tab 375mg ...................... 10 naproxen dr tab 500mg ...................... 10 naproxen sodium cap 220 mg............. 10

naproxen sodium tab 275 mg ............. 10 naproxen sodium tab 550 mg ............. 10 naproxen sodium tab er 24hr 375 mg (base equiv)....................................... 10

naproxen susp 125 mg/5ml ................ 10 naproxen tab 250 mg ......................... 11 naproxen tab 375 mg ......................... 11 naproxen tab 500 mg ......................... 11

naratriptan hcl tab 1 mg (base equiv)136 naratriptan hcl tab 2.5 mg (base equiv)........................................................ 136 NARCAN SPR ...................................... 50 NASACORT ALR SPR 55MCG/AC........ 148

nasal decon syp 30mg/5ml ............... 148 nasal decong tab 30mg .................... 148 nasal moist spr 0.65% ..................... 147 nasogel gel....................................... 147

NASONEB NSL MIS STARTER ............ 135 NAT FIBER POW 58.6% .................... 128

NATACHEW CHW .............................. 145 NATACYN SUS 5% OP ...................... 151 NATALVIT TAB 75-1MG..................... 145

NATAZIA TAB ..................................... 93 nateglinide tab 120 mg....................... 48 nateglinide tab 60 mg ........................ 48 NATESTO GEL 5.5MG.......................... 22

NATPARA INJ 100MCG ...................... 111 NATPARA INJ 25MCG ........................ 111 NATPARA INJ 50MCG ........................ 111 NATPARA INJ 75MCG ........................ 111

NATRECOR INJ 1.5MG ........................ 91 NATURE THROI TAB 162.5MG ........... 165 NATURE-THROI TAB 113.75MG......... 165 NATURE-THROI TAB 130MG ............. 165 NATURE-THROI TAB 146.25MG......... 165

NATURE-THROI TAB 16.25MG .......... 165 NATURE-THROI TAB 195MG ............. 165 NATURE-THROI TAB 260MG ............. 165 NATURE-THROI TAB 32.5MG ............ 165

NATURE-THROI TAB 325MG ............. 165 NATURE-THROI TAB 48.75MG .......... 165 NATURE-THROI TAB 65MG ............... 165 NATURE-THROI TAB 81.25MG .......... 165

NATURE-THROI TAB 97.5MG ............ 165 naturl fiber pow 30.9%..................... 128 NEBUPENT INH 300MG ....................... 24 nebusal neb 3% ................................. 98 NEBUSAL NEB 6% .............................. 98

necon tab 0.5/35................................ 93 necon tab 1/35................................... 93 necon tab 7/7/7 ................................. 93 NEEDLES MIS 19GX1........................ 133

NEEDLES MIS 25GX1.5..................... 133 NEEDLES MIS 26X1/2....................... 133 NEEDLES MIS 27GX1/2 .................... 133 nefazodone hcl tab 100 mg ................ 40

nefazodone hcl tab 150 mg ................ 40 nefazodone hcl tab 200 mg ................ 40 nefazodone hcl tab 250 mg ................ 40 nefazodone hcl tab 50 mg .................. 40 neomycin sulfate tab 500 mg ............... 7

neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml ..... 151 neomycin-polymyxin b gu irrigation soln........................................................ 119

neomycin-polymyxin-dexamethasone ophth oint 0.1% ............................... 152

216

neomycin-polymyxin-dexamethasone ophth susp 0.1% .............................. 152 neomycin-polymyxin-hc ophth susp .. 152

neomycin-polymyxin-hc otic soln 1% 154 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ................ 154 neo-polycin oin hc 1%op .................. 152

neo-polycin oin op ............................ 151 NEOSPORIN OIN ORIGINAL .............. 100 NEPHRAMINE INJ 5.4% .................... 149 NERLYNX TAB 40MG ........................... 69

NESTABS ABC MIS ........................... 145 NESTABS DHA PAK ........................... 145 NEULASTA KIT 6MG/0.6M ................. 125 NEUPOGEN INJ 300/0.5.................... 125 NEUPOGEN INJ 300MCG ................... 125

NEUPOGEN INJ 480/0.8.................... 125 NEUPOGEN INJ 480MCG ................... 125 NEUPRO DIS 1MG/24HR ..................... 74 NEUPRO DIS 2MG/24HR ..................... 74

NEUPRO DIS 3MG/24HR ..................... 74 NEUPRO DIS 4MG/24HR ..................... 74 NEUPRO DIS 6MG/24HR ..................... 74 NEUPRO DIS 8MG/24HR ..................... 74

NEUT INJ 4% ................................... 137 NEVANAC SUS 0.1% ........................ 153 nevirapine susp 50 mg/5ml ................ 82 nevirapine tab 200 mg ....................... 82 nevirapine tab er 24hr 100 mg ........... 82

nevirapine tab er 24hr 400 mg ........... 82 NEWGEN TAB 32-1MG ...................... 145 NEXA PLUS CAP................................ 145 NEXAVAR TAB 200MG......................... 69

NEXIUM 24HR CAP 20MG ................. 168 NEXIUM GRA 10MG DR ..................... 168 NEXIUM GRA 2.5MG DR.................... 168 NEXIUM GRA 20MG DR ..................... 168

NEXIUM GRA 40MG DR ..................... 168 NEXIUM GRA 5MG DR....................... 168 niacin cap er 500 mg ........................ 172 niacin tab 250 mg ............................ 172 niacin tab 500 mg ............................ 172

niacin tab er 1000 mg (antihyperlipidemic) ........................... 55 niacin tab er 500 mg ........................ 172 niacin tab er 500 mg (antihyperlipidemic)

.......................................................... 55 niacin tab er 750 mg (antihyperlipidemic)

.......................................................... 55 niacor tab 500mg ............................... 55 nicardipine hcl cap 20 mg ................... 87

nicardipine hcl cap 30 mg ................... 87 nicotine polacrilex gum 2 mg ............ 162 nicotine polacrilex gum 4 mg ............ 162 nicotine polacrilex lozenge 2 mg ....... 162

nicotine polacrilex lozenge 4 mg ....... 162 NICOTINE SYS KIT TRANSDER.......... 162 nicotine td patch 24hr 14 mg/24hr ... 162 NICOTROL INH ................................. 162

NICOTROL NS SPR 10MG/ML ............ 162 nifedipine cap 10 mg .......................... 87 nifedipine cap 20 mg .......................... 87 nifedipine tab er 24hr 30 mg .............. 87 nifedipine tab er 24hr 60 mg .............. 87

nifedipine tab er 24hr 90 mg .............. 87 nifedipine tab er 24hr osmotic release 30 mg ..................................................... 87 nifedipine tab er 24hr osmotic release 60

mg ..................................................... 88 nifedipine tab er 24hr osmotic release 90 mg ..................................................... 88 nilutamide tab 150 mg ....................... 66

nimodipine cap 30 mg ........................ 88 NINLARO CAP 2.3MG .......................... 69 NINLARO CAP 3MG ............................. 69 NINLARO CAP 4MG ............................. 69 NIPENT INJ 10MG............................... 71

nisoldipine tab er 24hr 17 mg ............. 88 nisoldipine tab er 24hr 20 mg ............. 88 nisoldipine tab er 24hr 25.5 mg .......... 88 nisoldipine tab er 24hr 30 mg ............. 88

nisoldipine tab er 24hr 34 mg ............. 88 nisoldipine tab er 24hr 40 mg ............. 88 nisoldipine tab er 24hr 8.5 mg ............ 88 NITHIODOTE KIT ................................ 49

nitisinone cap 10 mg ........................ 113 nitisinone cap 2 mg .......................... 113 nitisinone cap 5 mg .......................... 113 NITRO-BID OIN 2%............................ 26 NITRO-DUR DIS 0.3MG/HR................. 26

NITRO-DUR DIS 0.8MG/HR................. 26 nitrofurantoin macrocrystalline cap 100 mg ................................................... 169 nitrofurantoin macrocrystalline cap 25

mg ................................................... 169 nitrofurantoin macrocrystalline cap 50

217

mg ................................................... 169 nitrofurantoin monohydrate macrocrystalline cap 100 mg ............ 169

nitrofurantoin susp 25 mg/5ml ......... 169 nitroglycerin sl tab 0.3 mg.................. 26 nitroglycerin sl tab 0.4 mg.................. 26 nitroglycerin sl tab 0.6 mg.................. 26

nitroglycerin td patch 24hr 0.1 mg/hr . 26 nitroglycerin td patch 24hr 0.2 mg/hr . 26 nitroglycerin td patch 24hr 0.4 mg/hr . 26 nitroglycerin td patch 24hr 0.6 mg/hr . 26

nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) ........................................ 26 NITROMIST AER 400MCG ................... 26 nitro-time cap 9mg cr......................... 26 nizatidine cap 150 mg ...................... 167

nizatidine cap 300 mg ...................... 167 nizatidine oral soln 15 mg/ml ........... 167 NIZORAL A-D SHA 1% ..................... 101 NORDITROPIN INJ 10/1.5ML ............ 112

NORDITROPIN INJ 15/1.5ML ............ 112 NORDITROPIN INJ 30/3ML ............... 112 NORDITROPIN INJ 5/1.5ML .............. 112 norethindrone acetate tab 5 mg ....... 157

NORITATE CRE 1%........................... 107 NORMOSOL -M INJ /D5W ................. 139 NORMOSOL -R INJ............................ 139 NORMOSOL -R INJ /D5W .................. 139 NORMOSOL-R INJ PH 7.4 ................. 139

NORPACE CAP 100MG CR ................... 27 NORPACE CAP 150MG CR ................... 27 NORTHERA CAP 100MG .................... 171 NORTHERA CAP 200MG .................... 171

NORTHERA CAP 300MG .................... 171 nortriptyline hcl cap 10 mg ................. 42 nortriptyline hcl cap 25 mg ................. 42 nortriptyline hcl cap 50 mg ................. 42

nortriptyline hcl cap 75 mg ................. 42 nortriptyline hcl soln 10 mg/5ml ......... 42 NORVIR SOL 80MG/ML ....................... 82 NOURIANZ TAB 20MG ........................ 73 NOURIANZ TAB 40MG ........................ 73

novaferrum dro ................................ 144 NOVAFERRUM DRO 15MG/ML ........... 126 novarel inj 10000unt ........................ 111 NOVOEIGHT INJ 1000UNIT ............... 122

NOVOEIGHT INJ 1500UNIT ............... 122 NOVOEIGHT INJ 2000UNIT ............... 122

NOVOEIGHT INJ 250UNIT ................. 122 NOVOEIGHT INJ 500UNIT ................. 122 NOVOLIN INJ 70/30 ........................... 47

NOVOLIN N INJ U-100 ........................ 47 NOVOLIN R INJ U-100 ........................ 47 NOVOLOG INJ 100/ML ........................ 47 NOVOLOG INJ FLEXPEN ...................... 47

NOVOLOG INJ PENFILL ....................... 47 NOVOLOG MIX INJ 70/30 ................... 47 NOVOLOG MIX INJ FLEXPEN ............... 47 NOVOSEVEN RT INJ 1MG .................. 122

NOVOSEVEN RT INJ 2MG .................. 122 NOVOSEVEN RT INJ 5MG .................. 122 NOVOSEVEN RT INJ 8MG .................. 122 NOXAFIL SUS 40MG/ML...................... 52 np thyroid tab 120mg....................... 165

np thyroid tab 15mg......................... 165 np thyroid tab 30mg......................... 165 np thyroid tab 60mg......................... 165 np thyroid tab 90mg......................... 165

NUBEQA TAB 300MG .......................... 66 NUCYNTA ER TAB 100MG ................... 17 NUCYNTA ER TAB 150MG ................... 17 NUCYNTA ER TAB 200MG ................... 17

NUCYNTA ER TAB 250MG ................... 17 NUCYNTA ER TAB 50MG ..................... 17 NUCYNTA TAB 100MG ........................ 17 NUCYNTA TAB 50MG .......................... 17 NUCYNTA TAB 75MG .......................... 17

NUEDEXTA CAP 20-10MG ................. 161 NULOJIX INJ 250MG ......................... 142 NUPLAZID CAP 34MG ......................... 76 NUPLAZID TAB 10MG ......................... 76

NUPLAZID TAB 17MG ......................... 76 NUTROPIN AQ INJ 10MG/2ML ........... 112 NUTROPIN AQ INJ 20MG/2ML ........... 112 NUTROPIN AQ INJ NUSPIN 5 ............ 112

NUVARING MIS .................................. 93 NUVESSA GEL 1.3% ......................... 170 NUWIQ INJ 1000UNIT ...................... 122 NUWIQ INJ 2000UNIT ...................... 122 NUWIQ INJ 250UNIT ........................ 122

NUWIQ INJ 500UNIT ........................ 122 NUWIQ KIT 1000UNIT ...................... 122 NUWIQ KIT 2000UNIT ...................... 122 NUWIQ KIT 250UNIT ........................ 122

NUWIQ KIT 500UNIT ........................ 122 NUZYRA TAB 150MG ........................ 163

218

NYMALIZE SOL 60/20ML..................... 88 nystatin cream 100000 unit/gm........ 101 nystatin oint 100000 unit/gm ........... 101

nystatin susp 100000 unit/ml ........... 143 nystatin tab 500000 unit .................... 51 nystatin topical powder 100000 unit/gm........................................................ 101

nystatin-triamcinolone cream 100000-0.1 unit/gm-% .................... 101 nystatin-triamcinolone oint 100000-0.1 unit/gm-% ....................................... 101

O OASIS MATRIX MIS 3X7CM .............. 107 OASIS ULTRA MIS 3X3.5CM ............. 107 OASIS ULTRA MIS 5 X 7CM .............. 107 OB COMPLETE CAP PETITE ............... 145

OB COMPLETE TAB ........................... 145 OB COMPLETE/ CAP DHA .................. 145 OBIZUR INJ 500 UNIT ...................... 122 OBREDON SOL 2.5-200 ...................... 97

OBSTETRIX EC TAB .......................... 145 OBSTETRIX PAK DHA ....................... 145 O-CAL TAB PRENATAL ...................... 145 OCALIVA TAB 10MG ......................... 117

OCALIVA TAB 5MG ........................... 116 OCTAGAM INJ 10/100ML .................. 155 OCTAGAM INJ 10GM......................... 155 OCTAGAM INJ 1GM........................... 155 OCTAGAM INJ 2.5GM........................ 155

OCTAGAM INJ 20/200ML .................. 155 OCTAGAM INJ 25GM......................... 155 OCTAGAM INJ 2GM/20ML ................. 155 OCTAGAM INJ 30/300ML .................. 155

OCTAGAM INJ 5GM........................... 155 OCTAGAM INJ 5GM/50ML ................. 155 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) ............................................ 114

octreotide acetate inj 50 mcg/ml (0.05 mg/ml) ............................................ 114 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) ............................................ 114 ocucoat sol 2% op ............................ 153

ODACTRA SUB ..................................... 6 ODEFSEY TAB..................................... 82 ODOMZO CAP 200MG ......................... 65 OFEV CAP 100MG ............................. 163

OFEV CAP 150MG ............................. 163 ofloxacin ophth soln 0.3% ................ 151

ofloxacin otic soln 0.3% ................... 154 ofloxacin tab 400 mg........................ 116 ogestrel tab........................................ 93

olanzapine for im inj 10 mg ................ 78 olanzapine orally disintegrating tab 10 mg ..................................................... 78 olanzapine orally disintegrating tab 15

mg ..................................................... 78 olanzapine orally disintegrating tab 20 mg ..................................................... 78 olanzapine orally disintegrating tab 5 mg

.......................................................... 78 olanzapine tab 10 mg ......................... 78 olanzapine tab 15 mg ......................... 78 olanzapine tab 2.5 mg ........................ 78 olanzapine tab 20 mg ......................... 78

olanzapine tab 5 mg ........................... 78 olanzapine tab 7.5 mg ........................ 78 olmesartan medoxomil-hydrochlorothiazide tab

20-12.5 mg ........................................ 60 olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg ........................................ 60

olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg ........................................... 60 olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg ........................ 60

olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg ........................... 60 olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg .......................... 60

olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg ............................. 60 olopatadine hcl nasal soln 0.6% ....... 147 olopatadine hcl ophth soln 0.1% (base

equivalent)....................................... 153 olopatadine hcl ophth soln 0.2% (base equivalent)....................................... 153 OLUMIANT TAB 2MG............................. 8 OMECLAMOX- MIS PAK ..................... 168

omega 3 500 cap 500mg .................. 148 omega essent liq basic ..................... 148 omega-3 fatty acids cap 1000 mg..... 149 omega-3 fatty acids cap 1200 mg..... 149

omega-3 fatty acids cap 300 mg....... 148 omega-3 fish chw 113.5mg .............. 149

219

omega-3-acid ethyl esters cap 1 gm ... 54 omeprazole cap delayed release 10 mg........................................................ 168

omeprazole cap delayed release 20 mg........................................................ 168 omeprazole cap delayed release 40 mg........................................................ 168

omeprazole magnesium cap dr 20.6 mg (20 mg base equiv) .......................... 168 omeprazole-sodium bicarbonate cap 20-1100 mg ..................................... 168

omeprazole-sodium bicarbonate cap 40-1100 mg ..................................... 168 OMNITROPE INJ 10/1.5ML ................ 112 OMNITROPE INJ 5.8MG .................... 112 ondansetron hcl inj 4 mg/2ml (2 mg/ml)

.......................................................... 50 ondansetron hcl inj 40 mg/20ml (2 mg/ml) .............................................. 50 ondansetron hcl oral soln 4 mg/5ml.... 50

ondansetron hcl tab 24 mg ................. 50 ondansetron hcl tab 4 mg ................... 50 ondansetron hcl tab 8 mg ................... 50 ondansetron orally disintegrating tab 4

mg ..................................................... 50 ondansetron orally disintegrating tab 8 mg ..................................................... 50 one daily tab .................................... 144 one daily tab plus iro ........................ 144

ONGLYZA TAB 2.5MG ......................... 45 ONGLYZA TAB 5MG ............................ 46 ONMEL TAB 200MG ............................ 52 OPSUMIT TAB 10MG ........................... 90

optimal-d cap 50000unt ................... 172 ORACIT SOL ..................................... 119 oral electrolyte solution .................... 139 ORAVIG TAB 50MG ........................... 143

ORCHARD GRAS INJ 100000BA ............ 6 ORENCIA CLCK INJ 125MG/ML ........... 11 ORENCIA INJ 125MG/ML .................... 11 ORENCIA INJ 50/0.4........................... 11 ORENCIA INJ 87.5/0.7........................ 11

ORENITRAM TAB 0.125MG.................. 89 ORENITRAM TAB 0.25MG.................... 89 ORENITRAM TAB 1MG ........................ 89 ORENITRAM TAB 2.5MG ..................... 89

ORENITRAM TAB 5MG ........................ 89 ORFADIN CAP 20MG ......................... 113

ORFADIN SUS 4MG/ML ..................... 113 ORILISSA TAB 150MG ...................... 111 ORILISSA TAB 200MG ...................... 111

ORKAMBI GRA 100-125 .................... 162 ORKAMBI GRA 150-188 .................... 163 ORKAMBI TAB 100-125 .................... 163 ORKAMBI TAB 200-125 .................... 163

orphenadrine citrate inj 30 mg/ml .... 147 orphenadrine citrate tab er 12hr 100 mg........................................................ 147 oseltamivir phosphate cap 30 mg (base

equiv) ................................................ 85 oseltamivir phosphate cap 45 mg (base equiv) ................................................ 85 oseltamivir phosphate cap 75 mg (base equiv) ................................................ 85

oseltamivir phosphate for susp 6 mg/ml (base equiv)....................................... 85 OSMOPREP TAB 1.5GM ..................... 129 OSPHENA TAB 60MG ........................ 112

OTEZLA TAB 10/20/30 ....................... 11 OTEZLA TAB 30MG ............................. 11 OTREXUP INJ 10MG.............................. 8 OTREXUP INJ 15MG.............................. 8

OTREXUP INJ 20MG.............................. 8 OTREXUP INJ 25MG.............................. 8 oxacillin sodium for inj 1 gm (base equivalent)....................................... 157 oxacillin sodium for inj 10 gm (base

equivalent)....................................... 157 oxacillin sodium for inj 2 gm (base equivalent)....................................... 157 oxaprozin tab 600 mg ........................ 11

OXAYDO TAB 5MG .............................. 17 OXAYDO TAB 7.5MG ........................... 17 oxazepam cap 10 mg ......................... 27 oxazepam cap 15 mg ......................... 27

oxazepam cap 30 mg ......................... 27 oxcarbazepine susp 300 mg/5ml (60 mg/ml) .............................................. 36 oxcarbazepine tab 150 mg ................. 36 oxcarbazepine tab 300 mg ................. 36

oxcarbazepine tab 600 mg ................. 36 OXERVATE SOL 20MCG/ML ............... 152 OXISTAT LOT 1% ............................. 101 OXTELLAR XR TAB 150MG .................. 36

OXTELLAR XR TAB 300MG .................. 36 OXTELLAR XR TAB 600MG .................. 36

220

oxybutynin chloride syrup 5 mg/5ml . 169 oxybutynin chloride tab 5 mg ........... 169 oxybutynin chloride tab er 24hr 10 mg

........................................................ 169 oxybutynin chloride tab er 24hr 15 mg........................................................ 169 oxybutynin chloride tab er 24hr 5 mg 169

oxycodone hcl cap 5 mg ..................... 17 oxycodone hcl conc 100 mg/5ml (20 mg/ml) .............................................. 17 oxycodone hcl soln 5 mg/5ml ............. 17

oxycodone hcl tab 10 mg.................... 17 oxycodone hcl tab 15 mg.................... 17 oxycodone hcl tab 20 mg.................... 17 oxycodone hcl tab 30 mg.................... 17 oxycodone hcl tab 5 mg ..................... 17

oxycodone hcl tab er 12hr deter 10 mg.......................................................... 17 oxycodone hcl tab er 12hr deter 15 mg.......................................................... 17

oxycodone hcl tab er 12hr deter 20 mg.......................................................... 17 oxycodone hcl tab er 12hr deter 30 mg.......................................................... 17

oxycodone hcl tab er 12hr deter 40 mg.......................................................... 17 oxycodone hcl tab er 12hr deter 60 mg.......................................................... 17 oxycodone hcl tab er 12hr deter 80 mg

.......................................................... 17 oxycodone w/ acetaminophen soln 5-325 mg/5ml .............................................. 20 oxycodone w/ acetaminophen tab 10-325

mg ..................................................... 20 oxycodone w/ acetaminophen tab 5-325 mg ..................................................... 20 oxycodone w/ acetaminophen tab

7.5-325 mg ........................................ 20 oxycodone-aspirin tab 4.8355-325 mg 20 oxycodone-ibuprofen tab 5-400 mg .... 20 OXYCONTIN TAB 10MG CR ................. 17 OXYCONTIN TAB 15MG CR ................. 18

OXYCONTIN TAB 20MG CR ................. 18 OXYCONTIN TAB 30MG CR ................. 18 OXYCONTIN TAB 40MG CR ................. 18 OXYCONTIN TAB 60MG CR ................. 18

OXYCONTIN TAB 80MG CR ................. 18 oxymorphone hcl tab 10 mg ............... 18

oxymorphone hcl tab 5 mg ................. 18 oxymorphone hcl tab er 12hr 10 mg ... 18 oxymorphone hcl tab er 12hr 15 mg ... 18

oxymorphone hcl tab er 12hr 20 mg ... 18 oxymorphone hcl tab er 12hr 30 mg ... 18 oxymorphone hcl tab er 12hr 40 mg ... 18 oxymorphone hcl tab er 12hr 5 mg ..... 18

oxymorphone hcl tab er 12hr 7.5 mg .. 18 oxytocin inj 10 unit/ml ..................... 154 OXYTROL DIS 3.9MG/24 ................... 169 OXYTROL/WOMN DIS 3.9MG/24 ....... 169

oys shell+d tab 250-125 .................. 138 oysco 500+d tab .............................. 138 oyst shell/d tab 500mg..................... 138 oyster shell calcium tab 500 mg ....... 138 oyster-cal tab 500mg ....................... 138

OZEMPIC INJ 2/1.5ML ........................ 46 P paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) .............................................. 72

paclitaxel iv conc 150 mg/25ml (6 mg/ml) .............................................. 72 paclitaxel iv conc 30 mg/5ml (6 mg/ml).......................................................... 72

paclitaxel iv conc 300 mg/50ml (6 mg/ml) .............................................. 72 pain relief sus 160/5ml ....................... 12 pain relief tab 325mg ......................... 12 pain relief tab 500mg ......................... 12

paliperidone tab er 24hr 1.5 mg ......... 77 paliperidone tab er 24hr 3 mg ............ 77 paliperidone tab er 24hr 6 mg ............ 77 paliperidone tab er 24hr 9 mg ............ 77

PALOMAR E OIN ............................... 106 PALYNZIQ INJ 10/0.5ML ................... 113 PALYNZIQ INJ 2.5/0.5 ...................... 113 PALYNZIQ INJ 20MG/ML ................... 113

PANCREAZE CAP 10500UNT.............. 108 PANCREAZE CAP 16800UNT.............. 108 PANCREAZE CAP 21000UNT.............. 108 PANCREAZE CAP 4200UNIT .............. 108 pancuronium bromide inj 1 mg/ml .... 148

PANDEL CRE 0.1% ........................... 104 PANHEMATIN INJ 350MG .................. 123 panoxyl wash liq 4% .......................... 99 pantoprazole sodium ec tab 20 mg (base

equiv) .............................................. 168 pantoprazole sodium ec tab 40 mg (base

221

equiv) .............................................. 168 papaverine hcl inj 30 mg/ml ............... 89 paregoric tincture 2 mg/5ml (morphine

equivalent)......................................... 49 PARI LC MIS SPRINT ........................ 135 paricalcitol cap 1 mcg ....................... 113 paricalcitol cap 2 mcg ....................... 113

paricalcitol cap 4 mcg ....................... 113 paromomycin sulfate cap 250 mg ......... 7 paroxetine hcl tab 10 mg.................... 39 paroxetine hcl tab 20 mg.................... 40

paroxetine hcl tab 30 mg.................... 40 paroxetine hcl tab 40 mg.................... 40 paroxetine hcl tab er 24hr 12.5 mg .... 40 paroxetine hcl tab er 24hr 25 mg ....... 40 paroxetine hcl tab er 24hr 37.5 mg .... 40

paroxetine mesylate cap 7.5 mg (base equiv) .............................................. 162 PASER GRA 4GM ................................ 62 PAXIL SUS 10MG/5ML ........................ 40

PAZEO DRO 0.7% ............................ 153 PEAK AIR FLO MIS ADLT/PED ........... 135 PECAN POLLEN SOL EXTRACT ............... 6 PEDIA-LAX LIQ 50MG ....................... 130

PEGANONE TAB 250MG ...................... 37 PEGASYS INJ...................................... 84 PEGASYS INJ 180MCG/M .................... 84 PEGASYS INJ PROCLICK ..................... 84 PEN G PROC INJ 600000 .................. 156

penicillamine cap 250 mg ................. 141 penicillin g potassium for inj 20000000 unit .................................................. 156 penicillin g potassium for inj 5000000

unit .................................................. 156 penicillin g sodium for inj 5000000 unit........................................................ 156 penicillin v potassium for soln 125

mg/5ml ............................................ 156 penicillin v potassium for soln 250 mg/5ml ............................................ 156 penicillin v potassium tab 250 mg..... 156 penicillin v potassium tab 500 mg..... 156

PENICILLIUM INJ 1:20.......................... 6 PENICILLIUM INJ NOTATUM.................. 6 PENNSAID SOL 2% ............................ 99 PENTASA CAP 250MG CR .................. 118

PENTASA CAP 500MG CR .................. 118 pentazocine w/ naloxone tab 50-0.5 mg

.......................................................... 21 pentoxifylline tab er 400 mg ............. 123 PEPCID AC CHW MAX ST .................. 167

PERENNIAL INJ RYE GRAS .................... 6 PERFOROMIST NEB 20MCG................. 31 perindopril erbumine tab 2 mg ........... 56 perindopril erbumine tab 4 mg ........... 56

perindopril erbumine tab 8 mg ........... 56 periogard sol 0.12% ......................... 143 PERJETA INJ 420/14ML....................... 64 permethrin cream 5% ...................... 107

perphenazine tab 16 mg ..................... 79 perphenazine tab 2 mg....................... 79 perphenazine tab 4 mg....................... 79 perphenazine tab 8 mg....................... 79 perphenazine-amitriptyline tab 2-10 mg

........................................................ 159 perphenazine-amitriptyline tab 2-25 mg........................................................ 159 perphenazine-amitriptyline tab 4-10 mg

........................................................ 159 perphenazine-amitriptyline tab 4-25 mg........................................................ 159 perphenazine-amitriptyline tab 4-50 mg

........................................................ 159 PERSONAL BES MIS FULL RNG ......... 135 PERSONAL BES MIS LOW RANG........ 135 PERTZYE CAP 16000U ...................... 108 PERTZYE CAP 24000U ...................... 108

PERTZYE CAP 4000UNIT ................... 108 PERTZYE CAP 8000UNIT ................... 108 PEXEVA TAB 10MG ............................. 40 PEXEVA TAB 20MG ............................. 40

PEXEVA TAB 30MG ............................. 40 PEXEVA TAB 40MG ............................. 40 phenazopyridine hcl tab 100 mg ....... 120 phenazopyridine hcl tab 200 mg ....... 120

phenelzine sulfate tab 15 mg.............. 39 phenobarbital elixir 20 mg/5ml ......... 126 phenobarbital sodium inj 130 mg/ml 126 phenobarbital tab 100 mg ................ 127 phenobarbital tab 15 mg .................. 126

phenobarbital tab 16.2 mg ............... 126 phenobarbital tab 30 mg .................. 126 phenobarbital tab 32.4 mg ............... 126 phenobarbital tab 60 mg .................. 127

phenobarbital tab 64.8 mg ............... 127 phenobarbital tab 97.2 mg ............... 127

222

phenoxybenzamine hcl cap 10 mg ...... 57 PHENTOLAMINE INJ 5MG .................... 57 PHENYL/NACL INJ 1MG/10ML ........... 171

phenylephrine hcl inj 10 mg/ml ........ 171 phenylephrine hcl ophth soln 10% .... 150 phenylephrine hcl ophth soln 2.5% ... 150 phenytoin chew tab 50 mg ................. 38

phenytoin sodium extended cap 100 mg.......................................................... 38 phenytoin sodium extended cap 200 mg.......................................................... 38

phenytoin sodium extended cap 300 mg.......................................................... 38 phenytoin sodium inj 50 mg/ml .......... 38 phenytoin susp 125 mg/5ml ............... 38 PHOSLYRA SOL ................................ 118

PHOSPHOLINE SOL 0.125%OP ......... 151 PHOTOFRIN INJ 75MG ........................ 71 PHYS EZ USE KIT M-PRED .................. 95 physiolyte sol ................................... 143

phytonadione inj 1 mg/0.5ml (2 mg/ml)........................................................ 172 phytonadione inj 10 mg/ml............... 172 phytonadione tab 5 mg .................... 172

PICATO GEL 0.015% ........................ 101 PICATO GEL 0.05% .......................... 101 PIFELTRO TAB 100MG ........................ 82 PIKO 1 MIS ELECTRON ..................... 135 pilocarpine hcl tab 5 mg ................... 144

pilocarpine hcl tab 7.5 mg ................ 144 pimecrolimus cream 1% ................... 105 pimozide tab 1 mg ........................... 161 pimozide tab 2 mg ........................... 161

PINWORM TAB MEDICINE ................... 23 PIN-X CHW 250MG ............................. 23 pioglitazone hcl tab 15 mg (base equiv).......................................................... 48

pioglitazone hcl tab 30 mg (base equiv).......................................................... 48 pioglitazone hcl tab 45 mg (base equiv).......................................................... 48 pioglitazone hcl-glimepiride tab 30-2 mg

.......................................................... 44 pioglitazone hcl-glimepiride tab 30-4 mg.......................................................... 44 pioglitazone hcl-metformin hcl tab

15-500 mg ......................................... 44 pioglitazone hcl-metformin hcl tab

15-850 mg ......................................... 44 piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) ................... 157

piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) ....................... 157 piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) ........................... 157

piperacillin sod-tazobactam sod for inj 40.5 gm (36-4.5 gm) ....................... 157 PIQRAY 200MG TAB DOSE .................. 69 PIQRAY 250MG TAB DOSE .................. 69

PIQRAY 300MG TAB DOSE .................. 69 piroxicam cap 10 mg .......................... 11 piroxicam cap 20 mg .......................... 11 PLAN B TAB 1.5MG ............................. 93 PLASMA-LYTE INJ -148 ..................... 139

PLASMA-LYTE INJ -A ........................ 139 PLEGRIDY INJ .................................. 161 PLEGRIDY INJ PEN ........................... 161 PLEGRIDY INJ STARTER.................... 161

PLEGRIDY PEN INJ STARTER............. 161 plenamine inj 15% ........................... 149 POCKET PEAK MIS METER ................ 135 POCKETPEAK MIS UNIVERSA ............ 135

PODOCON SOL 25% ......................... 106 podofilox soln 0.5%.......................... 106 polycin oin op................................... 151 polyethylene glycol 3350 oral packet 129 polyethylene glycol 3350 oral powder 129

polymyxin b sulfate for inj 500000 unit25 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%......................... 151 POLY-VI-SOL DRO ............................ 145

POLY-VI-SOL DRO /IRON.................. 144 poly-vite dro .................................... 145 POMALYST CAP 1MG........................... 66 POMALYST CAP 2MG........................... 66

POMALYST CAP 3MG........................... 66 POMALYST CAP 4MG........................... 66 posaconazole tab delayed release 100 mg ..................................................... 52 pot & sod citrates w/ cit ac soln

550-500-334 mg/5ml ....................... 119 pot bicarbonate & chloride effer tab 25 meq ................................................. 140 potassium acetate inj 2 meq/ml ....... 140

potassium bicarbonate effer tab 25 meq........................................................ 140

223

potassium chloride 20 meq/l (0.15%) in dextrose 5% inj................................ 139 potassium chloride 40 meq/l (0.3%) in

dextrose 5% inj................................ 139 potassium chloride cap er 10 meq .... 140 potassium chloride cap er 8 meq ...... 140 potassium chloride inj 10 meq/100ml 140

potassium chloride inj 10 meq/50ml . 140 potassium chloride inj 2 meq/ml ....... 140 potassium chloride inj 20 meq/100ml 140 potassium chloride inj 20 meq/50ml . 140

potassium chloride inj 40 meq/100ml 140 potassium chloride microencapsulated crys er tab 10 meq ........................... 140 potassium chloride microencapsulated crys er tab 20 meq ........................... 140

potassium chloride oral soln 10% (20 meq/15ml) ....................................... 141 potassium chloride oral soln 20% (40 meq/15ml) ....................................... 141

potassium chloride powder packet 20 meq ................................................. 141 potassium chloride tab er 10 meq ..... 141 potassium chloride tab er 20 meq (1500

mg) ................................................. 141 potassium citrate tab er 10 meq (1080 mg) ................................................. 119 potassium citrate tab er 15 meq (1620 mg) ................................................. 119

potassium citrate tab er 5 meq (540 mg)........................................................ 119 potassium phosphates inj 15 mm/5ml (phos) 22 meq/5ml (k)..................... 140

potassium phosphates inj 150 mm/50ml (phos) 220 meq/50ml (k) ................. 140 potassium phosphates inj 45 mm/15ml (phos) 66 meq/15ml (k) ................... 140

PRADAXA CAP 110MG......................... 33 PRADAXA CAP 150MG......................... 34 PRADAXA CAP 75MG .......................... 33 PRALIDOXIME INJ 600/2ML ................ 50 PRALUENT INJ 150MG/ML................... 56

PRALUENT INJ 75MG/ML..................... 56 pramipexole dihydrochloride tab 0.125 mg ..................................................... 74 pramipexole dihydrochloride tab 0.25 mg

.......................................................... 74 pramipexole dihydrochloride tab 0.5 mg

.......................................................... 74 pramipexole dihydrochloride tab 0.75 mg.......................................................... 74

pramipexole dihydrochloride tab 1 mg 74 pramipexole dihydrochloride tab 1.5 mg.......................................................... 74 pramipexole dihydrochloride tab er 24hr

0.375 mg ........................................... 74 pramipexole dihydrochloride tab er 24hr 0.75 mg ............................................. 74 pramipexole dihydrochloride tab er 24hr

1.5 mg ............................................... 74 pramipexole dihydrochloride tab er 24hr 2.25 mg ............................................. 74 pramipexole dihydrochloride tab er 24hr 3 mg .................................................. 74

pramipexole dihydrochloride tab er 24hr 4.5 mg ............................................... 74 PRAMOSONE CRE 1-1%.................... 104 PRAMOSONE LOT 1% ....................... 104

PRAMOSONE LOT 2.5% .................... 104 prasugrel hcl tab 10 mg (base equiv) 124 prasugrel hcl tab 5 mg (base equiv) . 124 pravastatin sodium tab 10 mg ............ 55

pravastatin sodium tab 20 mg ............ 55 pravastatin sodium tab 40 mg ............ 55 pravastatin sodium tab 80 mg ............ 55 praziquantel tab 600 mg .................... 23 prazosin hcl cap 1 mg......................... 57

prazosin hcl cap 2 mg......................... 57 prazosin hcl cap 5 mg......................... 57 PRECISION MIS XTRA....................... 131 PRECISION TES XTRA....................... 108

PRED MILD SUS 0.12% OP ............... 152 PRED SOD PHO SOL 1% OP.............. 152 PRED-G S.O.P OIN OP ...................... 152 PRED-G SUS OP ............................... 152

prednicarbate cream 0.1% ............... 104 prednicarbate oint 0.1% ................... 104 prednisolone acetate ophth susp 1% 152 prednisolone sod phos orally disintegr tab 10 mg (base eq)........................... 95

prednisolone sod phos orally disintegr tab 15 mg (base eq)........................... 95 prednisolone sod phos orally disintegr tab 30 mg (base eq)........................... 95

prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) ................... 95

224

prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) .......................... 95 prednisolone sodium phosphate oral soln

25 mg/5ml (base eq) ......................... 95 prednisolone syrup 15 mg/5ml (usp solution equivalent) ............................ 95 prednisone oral soln 5 mg/5ml ........... 95

prednisone tab 1 mg .......................... 95 prednisone tab 10 mg ........................ 95 prednisone tab 2.5 mg ....................... 95 prednisone tab 20 mg ........................ 95

prednisone tab 5 mg .......................... 95 prednisone tab 50 mg ........................ 95 prednisone tab therapy pack 10 mg (21).......................................................... 96 prednisone tab therapy pack 10 mg (48)

.......................................................... 96 prednisone tab therapy pack 5 mg (21).......................................................... 95 prednisone tab therapy pack 5 mg (48)

.......................................................... 96 PREFERA OB TAB.............................. 145 PREFERAOB CAP ONE ....................... 145 PREFEST TAB ................................... 114

pregabalin cap 100 mg ....................... 36 pregabalin cap 150 mg ....................... 36 pregabalin cap 200 mg ....................... 36 pregabalin cap 225 mg ....................... 36 pregabalin cap 25 mg ......................... 36

pregabalin cap 300 mg ....................... 36 pregabalin cap 50 mg ......................... 36 pregabalin cap 75 mg ......................... 36 pregabalin soln 20 mg/ml ................... 36

PREGNYL INJ 10000UNT ................... 111 PREMARIN INJ 25MG ........................ 115 PREMARIN TAB 0.3MG ...................... 115 PREMARIN TAB 0.45MG .................... 115

PREMARIN TAB 0.625MG .................. 115 PREMARIN TAB 0.9MG ...................... 115 PREMARIN TAB 1.25MG .................... 115 PREMARIN VAG CRE 0.625MG .......... 171 premasol sol 6% .............................. 149

PREMPHASE TAB .............................. 114 PREMPRO TAB .................................. 114 PREMPRO TAB 0.3-1.5 ...................... 114 PREMPRO TAB 0.45-1.5 .................... 114

PREMPRO TAB 0.625-5 ..................... 115 PRENATA CHW 29-1MG .................... 145

prenatabs rx tab............................... 145 PRENATAL 19 CHW 29-1MG .............. 145 prenatal 19 chw tab ......................... 145

prenatal 19 tab ................................ 146 PRENATAL 19 TAB 29-1MG ............... 146 PRENATAL TAB ................................. 146 PRENATAL TAB 27-1MG .................... 146

PRENATAL+FE TAB 29-1MG .............. 146 PRENATE AM TAB 1MG ..................... 146 PRENATE CAP ENHANCE ................... 146 PRENATE CAP PIXIE ......................... 146

PRENATE CAP RESTORE ................... 146 PRENATE CHW 0.6-0.4 ..................... 146 PRENATE MINI CAP .......................... 146 PRENATE TAB ELITE ......................... 146 PREPIDIL GEL 0.5MG/3G .................. 154

PREPOPIK PAK ................................. 129 PRESTALIA TAB 14-10MG ................... 60 PRESTALIA TAB 3.5-2.5...................... 60 PRESTALIA TAB 7-5MG ....................... 60

PRETAB TAB 29-1MG ........................ 146 PRETOMANID TAB 200MG................... 62 PREVYMIS TAB 240MG ....................... 83 PREVYMIS TAB 480MG ....................... 83

PREZCOBIX TAB 800-150 ................... 82 PREZISTA SUS 100MG/ML .................. 82 PREZISTA TAB 150MG ........................ 82 PREZISTA TAB 600MG ........................ 82 PREZISTA TAB 75MG .......................... 82

PREZISTA TAB 800MG ........................ 82 PRIFTIN TAB 150MG ........................... 62 PRILOSEC POW 10MG ...................... 168 PRILOSEC POW 2.5MG ..................... 168

PRIMAQUINE TAB 26.3MG .................. 62 primidone tab 250 mg ........................ 36 primidone tab 50 mg .......................... 36 PRIMLEV TAB 10-300MG .................... 20

PRIMLEV TAB 5-300MG ...................... 20 PRIMLEV TAB 7.5-300 ........................ 20 PRIMSOL SOL 50MG/5ML.................... 24 PRIVIGEN INJ 10GRAMS ................... 155 PRIVIGEN INJ 20GRAMS ................... 155

PRIVIGEN INJ 40GRAMS ................... 155 PRIVIGEN INJ 5 GRAMS.................... 155 PROAIR RESPI AER............................. 31 probenecid tab 500 mg..................... 120

PROBIOTIC CAP ................................. 49 probiotic cap gold ............................... 49

225

PROCALAMINE INJ 3% ..................... 149 prochlorperazine edisylate inj 10 mg/2ml.......................................................... 79

prochlorperazine maleate tab 10 mg (base equivalent) ............................... 79 prochlorperazine maleate tab 5 mg (base equivalent)......................................... 79

PROCORT CRE .................................... 22 PROCRIT INJ 10000/ML .................... 125 PROCRIT INJ 2000/ML ...................... 125 PROCRIT INJ 20000/ML .................... 125

PROCRIT INJ 3000/ML ...................... 125 PROCRIT INJ 4000/ML ...................... 125 PROCRIT INJ 40000/ML .................... 125 PROCTOFOAM AER HC 1%.................. 22 PROCYSBI CAP 25MG ....................... 119

PROCYSBI CAP 75MG ....................... 119 PROFILNINE INJ 1000UNIT ............... 122 PROFILNINE INJ 1500UNIT ............... 122 PROFILNINE INJ 500UNIT ................. 122

progesterone im in oil 50 mg/ml ....... 157 progesterone micronized cap 100 mg 157 progesterone micronized cap 200 mg 157 PROGLYCEM SUS 50MG/ML ................ 45

PROGRAF INJ 5MG/ML ...................... 142 PROLENSA SOL 0.07% ..................... 153 PROLIA SOL 60MG/ML ...................... 111 PROMACTA POW 12.5MG .................. 125 PROMACTA TAB 12.5MG ................... 125

PROMACTA TAB 25MG ...................... 125 PROMACTA TAB 50MG ...................... 125 PROMACTA TAB 75MG ...................... 125 promethazine & phenylephrine syrup

6.25-5 mg/5ml................................... 97 promethazine hcl inj 25 mg/ml ........... 53 promethazine hcl inj 50 mg/ml ........... 53 promethazine hcl syrup 6.25 mg/5ml . 53

promethazine hcl tab 12.5 mg ............ 53 promethazine hcl tab 25 mg ............... 53 promethazine hcl tab 50 mg ............... 53 promethazine w/ codeine syrup 6.25-10 mg/5ml .............................................. 97

promethazine-dm syrup 6.25-15 mg/5ml.......................................................... 97 propafenone hcl cap er 12hr 225 mg .. 27 propafenone hcl cap er 12hr 325 mg .. 27

propafenone hcl cap er 12hr 425 mg .. 27 propafenone hcl tab 150 mg ............... 27

propafenone hcl tab 225 mg ............... 28 propafenone hcl tab 300 mg ............... 28 propantheline bromide tab 15 mg ..... 166

proparacaine hcl ophth soln 0.5%..... 152 propranolol & hydrochlorothiazide tab 40-25 mg ........................................... 60 propranolol & hydrochlorothiazide tab

80-25 mg ........................................... 60 propranolol hcl cap er 24hr 120 mg .... 86 propranolol hcl cap er 24hr 160 mg .... 86 propranolol hcl cap er 24hr 60 mg ...... 86

propranolol hcl cap er 24hr 80 mg ...... 86 propranolol hcl inj 1 mg/ml ................ 86 propranolol hcl oral soln 20 mg/5ml ... 86 propranolol hcl oral soln 40 mg/5ml ... 86 propranolol hcl tab 10 mg................... 86

propranolol hcl tab 20 mg................... 86 propranolol hcl tab 40 mg................... 86 propranolol hcl tab 60 mg................... 86 propranolol hcl tab 80 mg................... 86

propylthiouracil tab 50 mg................ 164 PROSOL INJ 20% ............................. 149 PROSTIN E2 SUP 20MG .................... 154 protamine sulfate inj 10 mg/ml ........ 124

PROTONIX PAK................................. 168 protriptyline hcl tab 10 mg ................. 43 protriptyline hcl tab 5 mg ................... 42 PROVIDA DHA CAP ........................... 146 PROVISC INJ 1% .............................. 153

PRUTECT EMU .................................. 107 pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml ................................ 97 PULMICORT INH 180MCG ................... 29

PULMICORT INH 90MCG ..................... 29 PULMOZYME SOL 1MG/ML ................ 163 PUREFE OB CAP PLUS ....................... 146 PURIXAN SUS 20MG/ML ..................... 64

px iron tab 27mg.............................. 126 PYLERA CAP ..................................... 168 pyrazinamide tab 500 mg ................... 62 pyridostigmine bromide oral soln 60 mg/5ml .............................................. 62

pyridostigmine bromide tab 60 mg ..... 62 pyridostigmine bromide tab er 180 mg 62 pyridoxine hcl tab 100 mg ................ 173 pyridoxine hcl tab 25 mg .................. 173

pyridoxine hcl tab 50 mg .................. 173 pyrilamine mal-phenylephrine hcl tann

226

susp 16-5 mg/5ml .............................. 97 PYROGALL ACD OIN ......................... 106 Q

Q4 ORAL CLEA KIT SYSTEM .............. 131 qc natural pow vegetabl ................... 128 q-tapp elx 1-15/5ml ........................... 97 quasense tab...................................... 93

quazepam tab 15 mg ....................... 127 quetiapine fumarate tab 100 mg......... 78 quetiapine fumarate tab 200 mg......... 78 quetiapine fumarate tab 25 mg .......... 78

quetiapine fumarate tab 300 mg......... 78 quetiapine fumarate tab 400 mg......... 78 quetiapine fumarate tab 50 mg .......... 78 quetiapine fumarate tab er 24hr 150 mg.......................................................... 78

quetiapine fumarate tab er 24hr 200 mg.......................................................... 78 quetiapine fumarate tab er 24hr 300 mg.......................................................... 78

quetiapine fumarate tab er 24hr 400 mg.......................................................... 78 quetiapine fumarate tab er 24hr 50 mg.......................................................... 78

QUILLICHEW CHW 20MG ER ................. 5 QUILLICHEW CHW 30MG ER ................. 5 QUILLICHEW CHW 40MG ER ................. 5 QUILLIVANT SUS 25MG/5ML ................ 5 quinapril hcl tab 10 mg....................... 56

quinapril hcl tab 20 mg....................... 56 quinapril hcl tab 40 mg....................... 56 quinapril hcl tab 5 mg ........................ 56 quinapril-hydrochlorothiazide tab 10-12.5

mg ..................................................... 60 quinapril-hydrochlorothiazide tab 20-12.5 mg ..................................................... 60 quinapril-hydrochlorothiazide tab 20-25

mg ..................................................... 60 quinine sulfate cap 324 mg................. 62 QUINTABS TAB................................. 144 QUTENZA KIT 8% 1-PCH .................. 106 QVAR REDIHA AER 80MCG ................. 29

QVAR REDIHAL AER 40MCG................ 29 R RA OYS SHL/D TAB 500MG ............... 138 rabeprazole sodium ec tab 20 mg ..... 168

raloxifene hcl tab 60 mg ................... 112 ramelteon tab 8 mg.......................... 128

ramipril cap 1.25 mg .......................... 56 ramipril cap 10 mg ............................. 57 ramipril cap 2.5 mg ............................ 56

ramipril cap 5 mg ............................... 56 RANEXA TAB 1000MG......................... 25 RANEXA TAB 500MG........................... 25 ranitidine hcl cap 150 mg ................. 167

ranitidine hcl cap 300 mg ................. 167 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) .......................................... 167 ranitidine hcl tab 150 mg.................. 167

ranitidine hcl tab 300 mg.................. 167 ranolazine tab er 12hr 1000 mg ......... 25 ranolazine tab er 12hr 500 mg ........... 25 RAPAMUNE SOL 1MG/ML .................. 142 rasagiline mesylate tab 0.5 mg (base

equiv) ................................................ 75 rasagiline mesylate tab 1 mg (base equiv) ................................................ 75 RASUVO INJ 10MG ............................... 8

RASUVO INJ 12.5MG ............................ 8 RASUVO INJ 15MG ............................... 9 RASUVO INJ 17.5MG ............................ 9 RASUVO INJ 20MG ............................... 9

RASUVO INJ 22.5MG ............................ 9 RASUVO INJ 25MG ............................... 9 RASUVO INJ 30MG ............................... 9 RASUVO INJ 7.5MG .............................. 8 RAVICTI LIQ 1.1GM/ML .................... 113

RAYALDEE CAP 30MCG ..................... 113 RAYOS TAB 1MG ................................ 96 RAYOS TAB 2MG ................................ 96 RAYOS TAB 5MG ................................ 96

REBETOL SOL 40MG/ML ..................... 84 REBIF INJ 22/0.5.............................. 161 REBIF INJ 44/0.5.............................. 161 REBIF REBIDO INJ 22/0.5 ................ 161

REBIF REBIDO INJ 44/0.5 ................ 161 REBIF REBIDO INJ TITRATN ............. 161 REBIF TITRTN INJ PACK ................... 161 RECOMBINATE INJ ........................... 122 RECOMBINATE INJ 220-400 ............. 122

RECOMBINATE INJ 401-800 ............. 122 RECOMBINATE INJ 801-1240............ 122 RECTIV OIN 0.4% .............................. 23 RED BIRCH SOL EXTRACT .................... 6

RED CEDAR SOL EXTRACT .................... 6 reeses med sus pinworm .................... 23

227

REFRESH CELL GEL 1% OP ............... 150 REFRESH OPTI DRO 0.5-0.9% .......... 150 REFRESH PLUS DRO 0.5% OP........... 150

REFRESH SOL OPTIVE ...................... 150 REGRANEX GEL 0.01% ..................... 107 relagard gel...................................... 170 RELENZA MIS DISKHALE .................... 85

RELHIST CHW .................................... 97 RELISTOR INJ 12/0.6ML ................... 118 RELISTOR INJ 8/0.4ML ..................... 118 RELISTOR TAB 150MG...................... 118

REMICADE INJ 100MG ...................... 118 RENACIDIN SOL ............................... 119 RENFLEXIS INJ 100MG ..................... 118 RENVELA POW 0.8GM....................... 118 RENVELA POW 2.4GM....................... 118

RENVELA TAB 800MG ....................... 118 repaglinide tab 0.5 mg ....................... 48 repaglinide tab 1 mg .......................... 48 repaglinide tab 2 mg .......................... 48

repaglinide-metformin hcl tab 1-500 mg.......................................................... 44 repaglinide-metformin hcl tab 2-500 mg.......................................................... 44

REPATHA INJ 140MG/ML .................... 56 REPATHA PUSH INJ 420/3.5 ............... 56 REPATHA SURE INJ 140MG/ML ........... 56 RESCRIPTOR TAB 200MG ................... 82 RESECTISOL SOL 5% ....................... 119

RESPA C&C IR TAB ............................. 97 REVCOVI INJ 1.6MG/ML ................... 113 REVLIMID CAP 10MG ........................ 142 REVLIMID CAP 15MG ........................ 142

REVLIMID CAP 2.5MG ....................... 141 REVLIMID CAP 20MG ........................ 142 REVLIMID CAP 25MG ........................ 142 REVLIMID CAP 5MG .......................... 141

REXULTI TAB 0.25MG ......................... 80 REXULTI TAB 0.5MG ........................... 80 REXULTI TAB 1MG .............................. 80 REXULTI TAB 2MG .............................. 80 REXULTI TAB 3MG .............................. 80

REXULTI TAB 4MG .............................. 80 REYATAZ POW 50MG .......................... 82 RGH PIGWEED SOL EXTRACT ............... 6 RHIZOPUS INJ 1:10 ............................. 6

RHOFADE CRE 1%............................ 107 RHOPHYLAC INJ 1500/2ML ............... 155

RHOPRESSA SOL 0.02% ................... 152 RIASTAP SOL 1GM ........................... 122 RIBAPAK PAK 1200/DAY ..................... 84

RIBAPAK PAK 800/DAY ....................... 84 RIBAPAK TAB 1000/DAY ..................... 84 RIBAPAK TAB 600/DAY ....................... 84 ribasphere tab 400mg ........................ 84

ribasphere tab 600mg ........................ 84 ribavirin cap 200 mg .......................... 84 ribavirin tab 200 mg ........................... 84 rifabutin cap 150 mg .......................... 62

RIFAMATE CAP ................................... 62 rifampin cap 150 mg .......................... 62 rifampin cap 300 mg .......................... 62 rifampin for inj 600 mg ...................... 62 RIFATER TAB...................................... 62

riluzole tab 50 mg ............................ 148 rimantadine hydrochloride tab 100 mg 85 RIMSO-50 SOL 50% ......................... 119 ringer's solution ............................... 139

ringer's solution for irrigation............ 143 RINVOQ TAB 15MG ER ......................... 8 RIOMET SOL ...................................... 45 risedronate sodium tab 150 mg ........ 111

risedronate sodium tab 30 mg .......... 111 risedronate sodium tab 35 mg .......... 111 risedronate sodium tab 5 mg ............ 111 risedronate sodium tab delayed release 35 mg .............................................. 111

RISPERDAL INJ 12.5MG ...................... 77 RISPERDAL INJ 25MG ......................... 77 RISPERDAL INJ 37.5MG ...................... 77 RISPERDAL INJ 50MG ......................... 77

risperidone orally disintegrating tab 0.25 mg ..................................................... 77 risperidone orally disintegrating tab 0.5 mg ..................................................... 77

risperidone orally disintegrating tab 1 mg.......................................................... 77 risperidone orally disintegrating tab 2 mg.......................................................... 77 risperidone orally disintegrating tab 3 mg

.......................................................... 77 risperidone orally disintegrating tab 4 mg.......................................................... 77 risperidone soln 1 mg/ml .................... 77

risperidone tab 0.25 mg ..................... 77 risperidone tab 0.5 mg ....................... 77

228

risperidone tab 1 mg .......................... 77 risperidone tab 2 mg .......................... 77 risperidone tab 3 mg .......................... 77

risperidone tab 4 mg .......................... 77 ritonavir tab 100 mg .......................... 82 RITUXAN INJ 100MG .......................... 64 RITUXAN INJ 500MG .......................... 64

RITUXAN INJ HYCELA ......................... 67 rivastigmine tartrate cap 1.5 mg (base equivalent)....................................... 159 rivastigmine tartrate cap 3 mg (base

equivalent)....................................... 159 rivastigmine tartrate cap 4.5 mg (base equivalent)....................................... 159 rivastigmine tartrate cap 6 mg (base equivalent)....................................... 159

rivastigmine td patch 24hr 13.3 mg/24hr........................................................ 159 rivastigmine td patch 24hr 4.6 mg/24hr........................................................ 159

rivastigmine td patch 24hr 9.5 mg/24hr........................................................ 159 rivelsa tab .......................................... 93 RIXUBIS INJ 1000UNIT .................... 122

RIXUBIS INJ 2000UNIT .................... 122 RIXUBIS INJ 250 UNIT ..................... 122 RIXUBIS INJ 3000UNIT .................... 123 RIXUBIS INJ 500UNIT ...................... 122 rizatriptan benzoate oral disintegrating

tab 10 mg (base eq)......................... 136 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) .......................... 136 rizatriptan benzoate tab 10 mg (base

equivalent)....................................... 136 rizatriptan benzoate tab 5 mg (base equivalent)....................................... 136 ROBITUSSIN LIQ CGH/CLD................. 97

ROBITUSSIN LIQ DM MAX .................. 97 ROBITUSSN DM SYP ........................... 97 ropinirole hydrochloride tab 0.25 mg .. 74 ropinirole hydrochloride tab 0.5 mg .... 74 ropinirole hydrochloride tab 1 mg ....... 74

ropinirole hydrochloride tab 2 mg ....... 74 ropinirole hydrochloride tab 3 mg ....... 74 ropinirole hydrochloride tab 4 mg ....... 74 ropinirole hydrochloride tab 5 mg ....... 74

ropinirole hydrochloride tab er 24hr 12 mg (base equivalent) ......................... 75

ropinirole hydrochloride tab er 24hr 2 mg (base equivalent) ............................... 75 ropinirole hydrochloride tab er 24hr 4 mg

(base equivalent) ............................... 75 ropinirole hydrochloride tab er 24hr 6 mg (base equivalent) ............................... 75 ropinirole hydrochloride tab er 24hr 8 mg

(base equivalent) ............................... 75 rosadan cre 0.75% ........................... 107 ROSE BENGAL TES 1.3MG ................ 153 rosuvastatin calcium tab 10 mg .......... 55

rosuvastatin calcium tab 20 mg .......... 55 rosuvastatin calcium tab 40 mg .......... 55 rosuvastatin calcium tab 5 mg ............ 55 ROZLYTREK CAP 100MG ..................... 69 ROZLYTREK CAP 200MG ..................... 70

RUBRACA TAB 200MG ........................ 70 RUBRACA TAB 250MG ........................ 70 RUBRACA TAB 300MG ........................ 70 RUCONEST INJ 2100UNIT................. 123

RUSS THISTLE SOL EXTRACT ............... 6 RUZURGI TAB 10MG........................... 62 RYDAPT CAP 25MG ............................. 70 rynex pse liq ...................................... 97

RYTARY CAP 145MG ........................... 75 RYTARY CAP 195MG ........................... 75 RYTARY CAP 245MG ........................... 75 RYTARY CAP 95MG ............................. 75 S

SABRIL POW 500MG........................... 37 SACCHAROMYCE INJ CEREVISI............. 6 SAFETYGLIDE MIS 27GX5/8 ............. 133 SAFYRAL TAB ..................................... 93

SAGEBRUSH SOL EXTRACT................... 6 SAIZEN INJ 5MG .............................. 112 salicylic ac liq 27.5% ........................ 106 salicylic acid cream 6% .................... 106

salicylic acid foam 6% ...................... 106 salicylic acid gel 6% ......................... 106 salicylic acid lotion 6% ..................... 106 salicylic acid shampoo 6% ................ 106 saline nasal gel ................................ 147

SAMSCA TAB 15MG .......................... 114 SAMSCA TAB 30MG .......................... 114 SANCUSO DIS 3.1MG ......................... 51 SANDIMMUNE SOL 100MG/ML .......... 142

SANTYL OIN 250/GM ........................ 105 SAPHRIS SUB 10MG ........................... 78

229

SAPHRIS SUB 2.5MG .......................... 78 SAPHRIS SUB 5MG ............................. 78 SAVAYSA TAB 15MG ........................... 32

SAVAYSA TAB 30MG ........................... 32 SAVAYSA TAB 60MG ........................... 32 SAVELLA MIS TITR PAK .................... 159 SAVELLA TAB 100MG........................ 159

SAVELLA TAB 12.5MG ...................... 159 SAVELLA TAB 25MG ......................... 159 SAVELLA TAB 50MG ......................... 159 sb fib lax pow 30%........................... 128

sb fib lax pow 33%........................... 128 sb nat fiber pow 49% ....................... 128 scalacort lot 2% ............................... 104 SCLEROSOL AER INTRAPLE .............. 163 scopolamine td patch 72hr 1 mg/3days

.......................................................... 51 SEGLUROMET TAB 2.5-1000 ............... 44 SEGLUROMET TAB 2.5-500................. 44 SEGLUROMET TAB 7.5-1000 ............... 44

SEGLUROMET TAB 7.5-500................. 44 SELECT-OB CHW .............................. 146 selegiline hcl cap 5 mg ....................... 75 selegiline hcl tab 5 mg........................ 75

selenious acid inj 40 mcg/ml ............ 141 SELZENTRY SOL 20MG/ML.................. 82 SELZENTRY TAB 150MG ..................... 82 SELZENTRY TAB 25MG ....................... 82 SELZENTRY TAB 300MG ..................... 82

SELZENTRY TAB 75MG ....................... 82 SEMPREX-D CAP 8-60MG.................... 97 senna tab 8.6mg .............................. 129 sennosides syrup 8.8 mg/5ml ........... 129

SEREVENT DIS AER 50MCG ................ 31 SEROSTIM INJ 4MG .......................... 112 SEROSTIM INJ 5MG .......................... 112 SEROSTIM INJ 6MG .......................... 112

sertraline hcl oral concentrate for solution 20 mg/ml .............................. 40 sertraline hcl tab 100 mg.................... 40 sertraline hcl tab 25 mg ..................... 40 sertraline hcl tab 50 mg ..................... 40

sevelamer carbonate packet 0.8 gm . 118 sevelamer carbonate packet 2.4 gm . 119 sevelamer hcl tab 800 mg ................ 119 sf 5000 plus cre 1.1% ...................... 144

SFROWASA ENE 4GM ....................... 118 SHAGBARK HCK SOL EXTRACT ............. 6

SIGNIFOR INJ 0.3MG/ML .................. 114 SIGNIFOR INJ 0.6MG/ML .................. 114 SIGNIFOR INJ 0.9MG/ML .................. 114

sildenafil citrate for suspension 10 mg/ml.......................................................... 90 sildenafil citrate tab 20 mg ................. 90 SILENOR TAB 3MG ........................... 127

SILENOR TAB 6MG ........................... 127 SILIQ INJ 210/1.5 ............................ 102 silodosin cap 4 mg............................ 120 silodosin cap 8 mg............................ 120

silphen coug syp 12.5/5ml.................. 52 SILVRSTAT GEL DRESSING .............. 107 SIMBRINZA SUS 1-0.2% .................. 151 SIMPONI ARIA SOL 50MG/4ML ............. 8 SIMPONI INJ 100MG/ML ....................... 8

SIMPONI INJ 50/0.5ML ......................... 8 simvastatin tab 10 mg........................ 55 simvastatin tab 20 mg........................ 55 simvastatin tab 40 mg........................ 55

simvastatin tab 5 mg.......................... 55 simvastatin tab 80 mg........................ 55 sinus congst tab /pain dt .................... 98 SINUSTAR MIS NEBULIZE................. 135

sirolimus tab 0.5 mg ........................ 142 sirolimus tab 1 mg ........................... 142 SIRTURO TAB 100MG ......................... 62 SITAVIG TAB 50MG ............................ 85 SIVEXTRO TAB 200MG ....................... 25

SKLICE LOT 0.5% ............................ 107 SKYRIZI INJ 150DOSE...................... 102 sleep aid tab 25mg........................... 126 SLYND TAB 4MG................................. 94

sm antacid chw ex-str ........................ 23 sm antifungl cre 2% ......................... 101 sm dry eye sol relief ......................... 150 sm fiber lax tab 500mg .................... 128

sm fiber pow 48.57% ....................... 128 sm gas rel chw 125mg ..................... 116 SM GLUCOSE CHW SOUR APP............. 45 sm hemorrhoi oin ............................... 23 sm ibuprofen tab 100mg jr ................. 11

sm iron tab ...................................... 126 sm laxative sup 10mg ...................... 129 sm lice lot treatmnt .......................... 107 sm micon 7 sup 100mg .................... 170

sm multiple tab vit/iron .................... 144 sm nicotine dis 21mg ....................... 162

230

sm nicotine dis 7mg/24hr ................. 162 sm pain rel cap 500mg ....................... 12 SOD LACTATE INJ 5MEQ/ML ............. 137

SOD NITRITE INJ 30MG/ML ................ 50 sodium acetate inj 2 meq/ml ............ 137 sodium acetate inj 4 meq/ml ............ 137 sodium bicarbonate iv soln 4.2% ...... 137

sodium bicarbonate iv soln 7.5% ...... 137 sodium bicarbonate iv soln 8.4% ...... 137 sodium bicarbonate tab 325 mg ......... 23 sodium bicarbonate tab 650 mg ......... 23

sodium chloride inj 2.5 meq/ml (14.6%)........................................................ 141 sodium chloride iv soln 0.45% .......... 141 sodium chloride iv soln 3% ............... 141 sodium chloride iv soln 4 meq/ml

(23.4%) ........................................... 141 sodium chloride iv soln 5% ............... 141 sodium chloride preservative free (pf) inj 0.9% ............................................... 141

sodium chloride soln nebu 0.9% ......... 98 sodium chloride soln nebu 10% .......... 98 sodium chloride soln nebu 7% ............ 98 sodium fluoride soln 0.5 mg/ml f (from

1.1 mg/ml naf)................................. 139 sodium fluoride tab 0.5 mg f (from 1.1 mg naf)............................................ 139 sodium fluoride tab 1 mg f (from 2.2 mg naf) ................................................. 139

sodium phenylbutyrate oral powder 3 gm/teaspoonful ................................ 113 sodium phenylbutyrate tab 500 mg .. 113 sodium phosphates - enema ............. 129

sodium phosphates inj 15 mm/5ml (phos) 20 meq/5ml (na) ................... 140 sodium polystyrene sulfonate powder 143 sodium polystyrene sulfonate rectal susp

30 gm/120ml ................................... 143 sodium thiosulfate inj 25% ................. 50 SOFOS/VELPAT TAB 400-100 ............. 84 solifenacin succinate tab 10 mg ........ 169 solifenacin succinate tab 5 mg .......... 169

SOLIQUA INJ 100/33 .......................... 44 SOLIRIS INJ 10MG/ML...................... 123 SOLOSEC GRA 2GM .............................. 6 SOLTAMOX SOL 10MG/5ML ................ 66

soluble fib pow therapy .................... 128 SOLU-CORTEF INJ 1000MG ................ 96

SOLU-CORTEF INJ 100MG .................. 96 SOLU-CORTEF INJ 250MG .................. 96 SOLU-CORTEF INJ 500MG .................. 96

SOLU-MEDROL INJ 2GM ..................... 96 SOLU-MEDROL INJ 500MG.................. 96 soothe night oin time ....................... 150 SORBITOL SOL 3% IRR .................... 119

SORBITOL SOL 3.3% IRR ................. 119 SORBITOL-MAN SOL......................... 119 sore throat loz 15-3.6mg .................. 143 SORILUX AER 0.005% ...................... 102

sotalol hcl (afib/afl) tab 120 mg.......... 86 sotalol hcl (afib/afl) tab 160 mg.......... 86 sotalol hcl (afib/afl) tab 80 mg ........... 86 SOTALOL HCL INJ 150/10ML .............. 86 sotalol hcl tab 120 mg ........................ 86

sotalol hcl tab 160 mg ........................ 86 sotalol hcl tab 240 mg ........................ 86 sotalol hcl tab 80 mg .......................... 86 SOTRADECOL INJ 1% ....................... 143

SOTRADECOL INJ 3% ....................... 143 SOTYLIZE SOL 5MG/ML ...................... 86 SOVALDI TAB 400MG ......................... 84 spinosad susp 0.9% ......................... 107

SPIRIVA AER 1.25MCG ....................... 28 SPIRIVA CAP HANDIHLR ..................... 28 SPIRIVA SPR 2.5MCG ......................... 28 spironolactone & hydrochlorothiazide tab 25-25 mg ......................................... 109

spironolactone tab 100 mg ............... 110 spironolactone tab 25 mg ................. 110 spironolactone tab 50 mg ................. 110 SPRAVATO SOL 56MG DOS................. 39

SPRAVATO SOL 84MG DOS................. 39 SPRIX SPR 15.75MG ........................... 11 SPRYCEL TAB 100MG.......................... 70 SPRYCEL TAB 140MG.......................... 70

SPRYCEL TAB 20MG ........................... 70 SPRYCEL TAB 50MG ........................... 70 SPRYCEL TAB 70MG ........................... 70 SPRYCEL TAB 80MG ........................... 70 sps sus 15gm/60.............................. 143

ssd cre 1% ....................................... 102 SSKI SOL 1GM/ML.............................. 98 st joseph co syp 7.5/5ml .................... 96 stavudine cap 15 mg .......................... 82

stavudine cap 20 mg .......................... 82 stavudine cap 30 mg .......................... 82

231

stavudine cap 40 mg .......................... 82 STEGLATRO TAB 15MG ....................... 48 STEGLATRO TAB 5MG......................... 48

STEGLUJAN TAB 15-100MG ................ 44 STEGLUJAN TAB 5-100MG .................. 44 STELARA INJ 45MG/0.5 .................... 102 STELARA INJ 5MG/ML....................... 118

STELARA INJ 90MG/ML ..................... 102 STERIL TALC SUS 5GM ..................... 163 STIMATE SOL 1.5MG/ML................... 114 STIOLTO AER 2.5-2.5 ......................... 31

STIVARGA TAB 40MG ......................... 70 stomach relf chw 262mg .................... 49 stomach relf sus 262/15ml ................. 49 stomach relf tab 262mg ..................... 49 stool softnr cap 100mg..................... 130

stool softnr cap 250mg..................... 130 stool softnr tab 8.6-50mg ................. 129 STRATTERA CAP 100MG ....................... 3 STRATTERA CAP 10MG ......................... 3

STRATTERA CAP 18MG ......................... 3 STRATTERA CAP 25MG ......................... 3 STRATTERA CAP 40MG ......................... 3 STRATTERA CAP 60MG ......................... 3

STRATTERA CAP 80MG ......................... 3 STRENSIQ INJ 18/0.45 ..................... 113 STRENSIQ INJ 28/0.7ML................... 113 STRENSIQ INJ 40MG/ML................... 113 STRENSIQ INJ 80/0.8ML................... 113

streptomycin sulfate for inj 1 gm .......... 7 STRIANT MIS 30MG............................ 22 STRIBILD TAB .................................... 82 STRIVERDI AER 2.5MCG ..................... 31

SUBLOCADE INJ 100/0.5 .................... 21 SUBLOCADE INJ 300/1.5 .................... 21 SUBOXONE MIS 12-3MG .................... 21 SUBOXONE MIS 2-0.5MG ................... 21

SUBOXONE MIS 4-1MG ...................... 21 SUBOXONE MIS 8-2MG ...................... 21 SUBSYS SPR 100MCG......................... 18 SUBSYS SPR 1200MCG ....................... 18 SUBSYS SPR 1600MCG ....................... 18

SUBSYS SPR 200MCG......................... 18 SUBSYS SPR 400MCG......................... 18 SUBSYS SPR 600MCG......................... 18 SUBSYS SPR 800MCG......................... 18

succinylcholine chloride inj 20 mg/ml 148 SUCRAID SOL 8500/ML .................... 108

sucralfate tab 1 gm .......................... 167 sufentanil citrate inj 100 mcg/2ml (50 mcg/ml) ............................................. 18

sufentanil citrate inj 250 mcg/5ml (50 mcg/ml) ............................................. 18 sufentanil citrate inj 50 mcg/ml .......... 18 sulfacetamide sodium ophth oint 10%

........................................................ 151 sulfacetamide sodium ophth soln 10%........................................................ 151 sulfacetamide sodium-prednisolone

ophth soln 10-0.23(0.25)% .............. 152 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml .................................. 24 sulfamethoxazole-trimethoprim tab 400-80 mg ......................................... 24

sulfamethoxazole-trimethoprim tab 800-160 mg ....................................... 24 SULFAMYLON CRE 85MG/GM ............ 102 sulfasalazine tab 500 mg .................. 118

sulfasalazine tab delayed release 500 mg........................................................ 118 sulindac tab 150 mg ........................... 11 sulindac tab 200 mg ........................... 11

sumatriptan nasal spray 20 mg/act .. 136 sumatriptan nasal spray 5 mg/act .... 136 sumatriptan succinate inj 6 mg/0.5ml137 sumatriptan succinate solution auto-injector 4 mg/0.5ml ................. 137

sumatriptan succinate solution auto-injector 6 mg/0.5ml ................. 137 sumatriptan succinate solution cartridge 4 mg/0.5ml ...................................... 137

sumatriptan succinate solution cartridge 6 mg/0.5ml ...................................... 137 sumatriptan succinate tab 100 mg .... 137 sumatriptan succinate tab 25 mg...... 137

sumatriptan succinate tab 50 mg...... 137 sumatriptan-naproxen sodium tab 85-500 mg ....................................... 136 SUPARTZ FX INJ 25/2.5ML ............... 147 SUPRAX CHW 100MG ......................... 92

SUPRAX CHW 200MG ......................... 92 SUPRAX SUS 500/5ML ........................ 92 SUPREP BOWEL SOL PREP KIT .......... 129 supress dm dro 5-50/ml ..................... 98

SURMONTIL CAP 25MG....................... 43 SURMONTIL CAP 50MG....................... 43

232

SURVANTA INH ................................ 163 SUTENT CAP 12.5MG .......................... 70 SUTENT CAP 25MG ............................. 70

SUTENT CAP 37.5MG .......................... 70 SUTENT CAP 50MG ............................. 70 SYLATRON KIT 200MCG ..................... 71 SYLATRON KIT 300MCG ..................... 71

SYLATRON KIT 600MCG ..................... 71 SYMAX DUOTAB TAB ........................ 166 SYMBICORT AER 160-4.5 ................... 31 SYMBICORT AER 80-4.5 ..................... 31

SYMDEKO TAB 100-150.................... 163 SYMDEKO TAB 50-75MG................... 163 SYMFI LO TAB .................................... 82 SYMFI TAB ......................................... 82 SYMLINPEN 60 INJ 1000MCG.............. 43

SYMLNPEN 120 INJ 1000MCG ............. 43 SYMPROIC TAB 0.2MG ...................... 118 SYMTUZA TAB .................................... 83 SYNAGIS INJ 100MG/ML................... 155

SYNAGIS INJ 50MG .......................... 155 SYNAREL SOL 2MG/ML ..................... 112 SYNERCID INJ 500MG ........................ 25 SYNJARDY TAB ................................... 44

SYNJARDY TAB 12.5-500 .................... 44 SYNJARDY TAB 5-1000MG .................. 44 SYNJARDY TAB 5-500MG .................... 44 SYNJARDY XR TAB.............................. 45 SYNJARDY XR TAB 10-1000 ................ 45

SYNJARDY XR TAB 25-1000 ................ 45 SYNJARDY XR TAB 5-1000MG ............. 45 SYNRIBO INJ 3.5MG ........................... 71 SYNTHROID TAB 112MCG................. 165

SYNTHROID TAB 125MCG................. 165 SYNTHROID TAB 137MCG................. 165 SYNTHROID TAB 150MCG................. 165 SYNTHROID TAB 175MCG................. 165

SYNTHROID TAB 200MCG................. 165 SYNTHROID TAB 25MCG................... 165 SYNTHROID TAB 300MCG................. 165 SYNTHROID TAB 50MCG................... 165 SYNTHROID TAB 75MCG................... 165

SYNTHROID TAB 88MCG................... 165 SYSTANE GEL 0.3% ......................... 150 T TABLOID TAB 40MG ........................... 64

TACLONEX SUS ................................ 104 tacrolimus cap 0.5 mg ...................... 142

tacrolimus cap 1 mg ......................... 142 tacrolimus cap 5 mg ......................... 143 tacrolimus oint 0.03% ...................... 106

tacrolimus oint 0.1% ........................ 105 tadalafil tab 20 mg (pah).................... 90 TAFINLAR CAP 50MG .......................... 70 TAFINLAR CAP 75MG .......................... 70

TAGRISSO TAB 40MG ......................... 70 TAGRISSO TAB 80MG ......................... 70 TAKHZYRO INJ 300/2ML ................... 123 TALZENNA CAP 0.25MG ...................... 70

TALZENNA CAP 1MG ........................... 70 tamoxifen citrate tab 10 mg (base equivalent)......................................... 66 tamoxifen citrate tab 20 mg (base equivalent)......................................... 66

tamsulosin hcl cap 0.4 mg ................ 120 TANZEUM INJ 30MG ........................... 46 TANZEUM INJ 50MG ........................... 46 TARGRETIN GEL 1% ......................... 101

tarina fe tab 1/20 ............................... 93 TASIGNA CAP 150MG ......................... 70 TASIGNA CAP 200MG ......................... 70 TAVALISSE TAB 100MG .................... 123

TAVALISSE TAB 150MG .................... 123 tazarotene cream 0.1% .................... 102 TAZORAC CRE 0.05% ....................... 102 tears pure sol ................................... 150 TECFIDERA CAP 120MG .................... 161

TECFIDERA CAP 240MG .................... 161 TECFIDERA MIS STARTER................. 161 TECHNIVIE TAB .................................. 84 TEGSEDI INJ 284/1.5 ....................... 162

TEKTURNA HCT TAB 150-12.5 ............ 60 TEKTURNA HCT TAB 150-25MG .......... 60 TEKTURNA HCT TAB 300-12.5 ............ 60 TEKTURNA HCT TAB 300-25MG .......... 60

telmisartan-amlodipine tab 40-10 mg . 60 telmisartan-amlodipine tab 40-5 mg ... 60 telmisartan-amlodipine tab 80-10 mg . 61 telmisartan-amlodipine tab 80-5 mg ... 61 telmisartan-hydrochlorothiazide tab

40-12.5 mg ........................................ 61 telmisartan-hydrochlorothiazide tab 80-12.5 mg ........................................ 61 telmisartan-hydrochlorothiazide tab

80-25 mg ........................................... 61 temazepam cap 15 mg ..................... 127

233

temazepam cap 22.5 mg .................. 127 temazepam cap 30 mg ..................... 127 temazepam cap 7.5 mg .................... 127

temozolomide cap 100 mg.................. 63 temozolomide cap 140 mg.................. 63 temozolomide cap 180 mg.................. 63 temozolomide cap 20 mg ................... 63

temozolomide cap 250 mg.................. 63 temozolomide cap 5 mg ..................... 63 tenofovir disoproxil fumarate tab 300 mg.......................................................... 83

terazosin hcl cap 1 mg (base equivalent).......................................................... 57 terazosin hcl cap 10 mg (base equivalent)......................................... 57 terazosin hcl cap 2 mg (base equivalent)

.......................................................... 57 terazosin hcl cap 5 mg (base equivalent).......................................................... 57 terbinafine hcl tab 250 mg.................. 51

terbutaline sulfate inj 1 mg/ml ........... 31 terbutaline sulfate tab 2.5 mg ............ 31 terbutaline sulfate tab 5 mg ............... 31 terconazole vaginal cream 0.4% ....... 170

terconazole vaginal cream 0.8% ....... 170 terconazole vaginal suppos 80 mg .... 170 TERSASEPTIC LIQ .............................. 80 TESTONE CIK KIT 200MG/ML.............. 22 testosterone cypionate im inj in oil 100

mg/ml ................................................ 22 testosterone cypionate im inj in oil 200 mg/ml ................................................ 22 testosterone enanthate im inj in oil 200

mg/ml ................................................ 22 testosterone td gel 10mg/act (2%)..... 22 testosterone td gel 12.5 mg/act (1%). 22 testosterone td gel 20.25 mg/1.25gm

(1.62%) ............................................. 22 testosterone td gel 20.25 mg/act (1.62%) ............................................. 22 testosterone td gel 25 mg/2.5gm (1%)22 testosterone td gel 40.5 mg/2.5gm

(1.62%) ............................................. 22 testosterone td gel 50 mg/5gm (1%) . 22 tetcaine sol 0.5% op ........................ 152 tetrabenazine tab 12.5 mg ............... 159

tetrabenazine tab 25 mg .................. 159 tetracycline hcl cap 250 mg .............. 164

tetracycline hcl cap 500 mg .............. 164 tetterine oin 2% ............................... 101 TEXACORT SOL 2.5% ....................... 104

THALOMID CAP 100MG..................... 142 THALOMID CAP 150MG..................... 142 THALOMID CAP 200MG..................... 142 THALOMID CAP 50MG....................... 142

THEO-24 CAP 100MG CR .................... 31 THEO-24 CAP 200MG CR .................... 31 THEO-24 CAP 300MG CR .................... 31 THEO-24 CAP 400MG ER .................... 31

theophylline soln 80 mg/15ml ............ 31 theophylline tab er 12hr 200 mg......... 31 theophylline tab er 12hr 300 mg......... 31 theophylline tab er 12hr 450 mg......... 31 theophylline tab er 24hr 400 mg......... 31

theophylline tab er 24hr 600 mg......... 31 THERATEARS GEL 1% ...................... 150 THERATEARS SOL 0.25% PF ............. 150 thiamine hcl inj 100 mg/ml............... 173

thiamine hcl tab 100 mg................... 173 THIOLA EC TAB 100MG .................... 120 THIOLA EC TAB 300MG .................... 120 THIOLA TAB 100MG.......................... 120

thioridazine hcl tab 10 mg .................. 79 thioridazine hcl tab 100 mg ................ 79 thioridazine hcl tab 25 mg .................. 79 thioridazine hcl tab 50 mg .................. 79 thiotepa for inj 15 mg......................... 63

thiothixene cap 1 mg.......................... 80 thiothixene cap 10 mg ........................ 80 thiothixene cap 2 mg.......................... 80 thiothixene cap 5 mg.......................... 80

THROMBAT III INJ 1000UNIT............ 123 THROMBAT III INJ 500UNIT ............. 123 thyroid tab 120 mg (2 grain) ............ 165 THYROLAR-1 TAB 60MG ................... 165

THYROLAR-1/2 TAB 30MG ................ 165 THYROLAR-1/4 TAB 15MG ................ 165 THYROLAR-2 TAB 120MG ................. 165 THYROLAR-3 TAB 180MG ................. 165 tiagabine hcl tab 12 mg ...................... 37

tiagabine hcl tab 16 mg ...................... 37 tiagabine hcl tab 2 mg ........................ 37 tiagabine hcl tab 4 mg ........................ 37 TIBSOVO TAB 250MG ......................... 70

TIGAN INJ 100MG/ML ......................... 51 tilia fe tab .......................................... 93

234

timolol maleate ophth gel forming soln 0.25%.............................................. 150 timolol maleate ophth gel forming soln

0.5% ............................................... 150 timolol maleate ophth soln 0.25% .... 150 timolol maleate ophth soln 0.5% ...... 150 timolol maleate tab 10 mg.................. 86

timolol maleate tab 20 mg.................. 86 timolol maleate tab 5 mg.................... 86 TIMOPTIC OCU SOL 0.25% OP ......... 150 TIMOPTIC OCU SOL 0.5% OP ........... 150

TIMOTHY GRAS INJ 10000BAU ............. 6 TIMOTHY SOL GRASS ........................... 6 tinidazole tab 250 mg......................... 24 tinidazole tab 500 mg......................... 24 TIROSINT CAP 100MCG .................... 165

TIROSINT CAP 112MCG .................... 166 TIROSINT CAP 125MCG .................... 166 TIROSINT CAP 137MCG .................... 166 TIROSINT CAP 13MCG ...................... 165

TIROSINT CAP 150MCG .................... 166 TIROSINT CAP 175MCG .................... 166 TIROSINT CAP 200 ........................... 166 TIROSINT CAP 25MCG ...................... 165

TIROSINT CAP 50MCG ...................... 165 TIROSINT CAP 75MCG ...................... 165 TIROSINT CAP 88MCG ...................... 165 TIVICAY TAB 10MG ............................ 83 TIVICAY TAB 25MG ............................ 83

TIVICAY TAB 50MG ............................ 83 TIVORBEX CAP 20MG ......................... 11 TIVORBEX CAP 40MG ......................... 11 tizanidine hcl tab 2 mg (base equivalent)

........................................................ 147 tizanidine hcl tab 4 mg (base equivalent)........................................................ 147 TL FOLATE TAB ................................ 146

TOBI PODHALR CAP 28MG .................... 7 TOBRADEX OIN 0.3-0.1%................. 152 TOBRADEX ST SUS 0.3-0.05 ............ 152 tobramycin nebu soln 300 mg/5ml ....... 7 tobramycin ophth soln 0.3%............. 151

tobramycin sulfate for inj 1.2 gm .......... 7 tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) (base equiv) ............................ 7 tobramycin sulfate inj 10 mg/ml (base

equivalent)........................................... 7 tobramycin sulfate inj 2 gm/50ml (40

mg/ml) (base equiv) ............................ 7 tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv) ............................ 7

tobramycin-dexamethasone ophth susp 0.3-0.1% ......................................... 152 TOBREX OIN 0.3% OP ...................... 151 TOLAK CRE 4% ................................ 101

tolazamide tab 250 mg....................... 49 tolazamide tab 500 mg....................... 49 tolbutamide tab 500 mg ..................... 49 tolcapone tab 100 mg......................... 73

tolmetin sodium cap 400 mg .............. 11 tolmetin sodium tab 200 mg............... 11 tolmetin sodium tab 600 mg............... 11 tolterodine tartrate cap er 24hr 2 mg 169 tolterodine tartrate cap er 24hr 4 mg 169

tolterodine tartrate tab 1 mg ............ 169 tolterodine tartrate tab 2 mg ............ 169 TOOMEY SYRIN MIS 70ML ................ 134 topiramate sprinkle cap 15 mg ........... 37

topiramate sprinkle cap 25 mg ........... 37 topiramate tab 100 mg....................... 37 topiramate tab 200 mg....................... 37 topiramate tab 25 mg......................... 37

topiramate tab 50 mg......................... 37 toremifene citrate tab 60 mg (base equivalent)......................................... 66 torsemide tab 10 mg ........................ 109 torsemide tab 100 mg ...................... 109

torsemide tab 20 mg ........................ 109 torsemide tab 5 mg .......................... 109 total fiber pow .................................. 128 TOUJEO SOLO INJ 300IU/ML .............. 47

TOVIAZ TAB 4MG ............................. 169 TOVIAZ TAB 8MG ............................. 169 tpn electrol inj .................................. 139 TRACE ELEM 4 INJ PED..................... 141

TRADJENTA TAB 5MG ......................... 46 tramadol hcl tab 50 mg ...................... 18 tramadol hcl tab er 24hr 100 mg ........ 18 tramadol hcl tab er 24hr 200 mg ........ 19 tramadol hcl tab er 24hr 300 mg ........ 19

tramadol hcl tab er 24hr biphasic release 100 mg .............................................. 19 tramadol hcl tab er 24hr biphasic release 200 mg .............................................. 19

tramadol hcl tab er 24hr biphasic release 300 mg .............................................. 19

235

tramadol-acetaminophen tab 37.5-325 mg ..................................................... 20 trandolapril tab 1 mg.......................... 57

trandolapril tab 2 mg.......................... 57 trandolapril tab 4 mg.......................... 57 tranexamic acid tab 650 mg ............. 126 tranylcypromine sulfate tab 10 mg ..... 39

TRAVATAN Z DRO 0.004% ............... 154 trazodone hcl tab 100 mg ................... 40 trazodone hcl tab 150 mg ................... 40 trazodone hcl tab 300 mg ................... 40

trazodone hcl tab 50 mg..................... 40 TREANDA INJ 100MG.......................... 63 TREANDA INJ 25MG ........................... 63 TRECATOR TAB 250MG....................... 62 TRELEGY AER ELLIPTA........................ 31

TREMFYA INJ 100MG/ML................... 102 treprostinil inj soln 100 mg/20ml (5 mg/ml) .............................................. 89 treprostinil inj soln 20 mg/20ml (1

mg/ml) .............................................. 89 treprostinil inj soln 200 mg/20ml (10 mg/ml) .............................................. 89 treprostinil inj soln 50 mg/20ml (2.5

mg/ml) .............................................. 89 TRESIBA FLEX INJ 100UNIT................ 47 TRESIBA FLEX INJ 200UNIT................ 47 TRESIBA INJ 100UNIT ........................ 47 tretinoin cap 10 mg ............................ 71

tretinoin cream 0.025% ..................... 99 tretinoin cream 0.05% ....................... 99 tretinoin cream 0.1% ......................... 99 tretinoin gel 0.01% ............................ 99

tretinoin gel 0.025% .......................... 99 TRETTEN INJ .................................... 123 TREXALL TAB 10MG............................ 64 TREXALL TAB 15MG............................ 64

TREXALL TAB 5MG ............................. 64 TREXALL TAB 7.5MG .......................... 64 TREXIMET TAB 10-60MG .................. 136 triamcinolone acetonide aerosol soln 0.147 mg/gm ................................... 105

triamcinolone acetonide cream 0.025%........................................................ 105 triamcinolone acetonide cream 0.1% 105 triamcinolone acetonide cream 0.5% 105

triamcinolone acetonide dental paste 0.1% ............................................... 144

triamcinolone acetonide inj susp 40 mg/ml ................................................ 96 triamcinolone acetonide lotion 0.025%

........................................................ 105 triamcinolone acetonide lotion 0.1% . 105 triamcinolone acetonide nasal aerosol suspension 55 mcg/act ..................... 148

triamcinolone acetonide oint 0.025% 105 triamcinolone acetonide oint 0.1%.... 105 triamcinolone acetonide oint 0.5%.... 105 TRIAMINIC NT MIS COLD/CGH ........... 98

triamterene & hydrochlorothiazide cap 37.5-25 mg ...................................... 109 triamterene & hydrochlorothiazide tab 37.5-25 mg ...................................... 109 triamterene & hydrochlorothiazide tab

75-50 mg ......................................... 109 triamterene cap 100 mg ................... 110 triamterene cap 50 mg ..................... 110 TRIANEX OIN 0.05% ........................ 105

triazolam tab 0.125 mg .................... 127 triazolam tab 0.25 mg ...................... 127 TRICARE PRE CAP 27-1-500 ............. 146 TRICITRASOL CON ............................. 33

TRICODE AR LIQ 30-2-8 ..................... 98 TRICODE GF LIQ 30-8-200 ................. 98 TRIESENCE INJ 40MG/ML ................. 152 trifluoperazine hcl tab 1 mg (base equivalent)......................................... 79

trifluoperazine hcl tab 10 mg (base equivalent)......................................... 79 trifluoperazine hcl tab 2 mg (base equivalent)......................................... 79

trifluoperazine hcl tab 5 mg (base equivalent)......................................... 79 trifluridine ophth soln 1% ................. 151 trihexyphenidyl hcl elixir 0.4 mg/ml .... 73

trihexyphenidyl hcl tab 2 mg .............. 73 trihexyphenidyl hcl tab 5 mg .............. 73 TRIKAFTA TAB.................................. 163 triklo cap 1gm .................................... 54 trimethobenzamide hcl cap 300 mg .... 51

trimethoprim tab 100 mg ................... 24 trimipramine maleate cap 100 mg ...... 43 trimipramine maleate cap 25 mg ........ 43 trimipramine maleate cap 50 mg ........ 43

trinate tab ........................................ 146 trinessa lo tab .................................... 93

236

trinessa tab ........................................ 93 TRINTELLIX TAB 10MG ....................... 40 TRINTELLIX TAB 20MG ....................... 40

TRINTELLIX TAB 5MG ......................... 40 triple antib oin.................................. 100 triple dye solution .............................. 80 TRIPTODUR SUS 22.5MG .................. 112

TRISTART DHA CAP .......................... 146 TRIUMEQ TAB .................................... 83 TROKENDI XR CAP 100MG.................. 37 TROKENDI XR CAP 200MG.................. 37

TROKENDI XR CAP 25MG.................... 37 TROKENDI XR CAP 50MG.................... 37 tropicamide ophth soln 0.5% ............ 151 tropicamide ophth soln 1% ............... 151 trospium chloride cap er 24hr 60 mg 169

trospium chloride tab 20 mg ............. 169 TRULANCE TAB 3MG......................... 116 TRULICITY INJ 0.75/0.5 ..................... 46 TRULICITY INJ 1.5/0.5 ....................... 46

TRUVADA TAB 200-300 ...................... 83 TRUZONE PEAK MIS FLOW MTR ........ 135 TUDORZA PRES AER 400/ACT............. 28 TURALIO CAP 200MG ......................... 70

tussin cf liq ........................................ 98 tussin cf liq max/m-s.......................... 98 tussin chest syp 100/5ml.................... 98 tussin dm liq max ............................... 98 tussin dm syp 100-10/5 ..................... 98

TUZISTRA XR SUS.............................. 98 TYBOST TAB 150MG ........................... 83 TYKERB TAB 250MG ........................... 70 TYMLOS INJ ..................................... 111

TYVASO START SOL 0.6MG/ML ........... 89 U UCERIS AER 2MG/ACT ........................ 22 ULESFIA LOT 5%.............................. 107

UNIFIBER POW................................. 128 UPCAL D POW .................................. 138 UPTRAVI TAB 1000MCG...................... 90 UPTRAVI TAB 1200MCG...................... 90 UPTRAVI TAB 1400MCG...................... 90

UPTRAVI TAB 1600MCG...................... 90 UPTRAVI TAB 200/800 ....................... 90 UPTRAVI TAB 200MCG........................ 90 UPTRAVI TAB 400MCG........................ 90

UPTRAVI TAB 600MCG........................ 90 UPTRAVI TAB 800MCG........................ 90

ur n-c tab......................................... 169 uramit mb cap 118mg ...................... 169 urea cream 47% .............................. 105

UREVAZ CRE 44% ............................ 105 urimar-t tab ..................................... 169 urolet mb tab ................................... 169 ursodiol cap 300 mg ......................... 117

ursodiol tab 250 mg ......................... 117 ursodiol tab 500 mg ......................... 117 UTIBRON CAP NEOHALER ................... 31 V

valacyclovir hcl tab 1 gm .................... 85 valacyclovir hcl tab 500 mg ................ 85 VALCHLOR GEL 0.016% ................... 101 valganciclovir hcl for soln 50 mg/ml (base equiv)....................................... 83

valganciclovir hcl tab 450 mg (base equivalent)......................................... 83 valproate sodium inj 100 mg/ml ......... 38 valproate sodium oral soln 250 mg/5ml

(base equiv)....................................... 38 valproic acid cap 250 mg .................... 38 valsartan tab 160 mg ......................... 57 valsartan tab 320 mg ......................... 57

valsartan tab 40 mg ........................... 57 valsartan tab 80 mg ........................... 57 valsartan-hydrochlorothiazide tab 160-12.5 mg ...................................... 61 valsartan-hydrochlorothiazide tab 160-25

mg ..................................................... 61 valsartan-hydrochlorothiazide tab 320-12.5 mg ...................................... 61 valsartan-hydrochlorothiazide tab 320-25

mg ..................................................... 61 valsartan-hydrochlorothiazide tab 80-12.5 mg ........................................ 61 vancomycin hcl cap 125 mg (base

equivalent)......................................... 24 vancomycin hcl cap 250 mg (base equivalent)......................................... 24 vancomycin hcl for iv soln 1 gm (base equivalent)......................................... 24

vancomycin hcl for iv soln 10 gm (base equivalent)......................................... 24 vancomycin hcl for iv soln 5 gm (base equivalent)......................................... 24

vancomycin hcl for iv soln 500 mg (base equivalent)......................................... 24

237

VANTAS KIT 50MG ............................. 66 VARITHENA AER 10MG/ML ............... 143 VARUBI TAB 90MG ............................. 51

VASCEPA CAP 0.5GM .......................... 54 VASCEPA CAP 1GM ............................. 54 VECTIBIX INJ 100MG.......................... 64 VECTIBIX INJ 400MG.......................... 65

vecuronium bromide for inj 10 mg .... 148 vecuronium bromide for inj 20 mg .... 148 VELETRI INJ 0.5MG ............................ 89 VELETRI INJ 1.5MG ............................ 89

VELPHORO CHW 500MG ................... 119 VENCLEXTA TAB 100MG ..................... 65 VENCLEXTA TAB 10MG ....................... 65 VENCLEXTA TAB 50MG ....................... 65 VENCLEXTA TAB START PK ................. 65

VENELEX OIN ................................... 108 venlafaxine hcl cap er 24hr 150 mg (base equivalent) ............................... 41 venlafaxine hcl cap er 24hr 37.5 mg

(base equivalent) ............................... 41 venlafaxine hcl cap er 24hr 75 mg (base equivalent)......................................... 41 venlafaxine hcl tab 100 mg (base

equivalent)......................................... 41 venlafaxine hcl tab 25 mg (base equivalent)......................................... 41 venlafaxine hcl tab 37.5 mg (base equivalent)......................................... 41

venlafaxine hcl tab 50 mg (base equivalent)......................................... 41 venlafaxine hcl tab 75 mg (base equivalent)......................................... 41

venlafaxine hcl tab er 24hr 150 mg (base equivalent)......................................... 42 venlafaxine hcl tab er 24hr 225 mg (base equivalent)......................................... 42

venlafaxine hcl tab er 24hr 37.5 mg (base equivalent) ............................... 41 venlafaxine hcl tab er 24hr 75 mg (base equivalent)......................................... 42 VENT NEEDLE MIS 18GX1.5.............. 134

VENTAVIS SOL 10MCG/ML.................. 90 VENTAVIS SOL 20MCG/ML.................. 90 verapamil hcl cap er 24hr 100 mg ...... 88 verapamil hcl cap er 24hr 120 mg ...... 88

verapamil hcl cap er 24hr 180 mg ...... 88 verapamil hcl cap er 24hr 200 mg ...... 88

verapamil hcl cap er 24hr 240 mg ...... 88 verapamil hcl cap er 24hr 300 mg ...... 88 verapamil hcl cap er 24hr 360 mg ...... 88

verapamil hcl tab 120 mg ................... 88 verapamil hcl tab 40 mg ..................... 88 verapamil hcl tab 80 mg ..................... 88 verapamil hcl tab er 120 mg ............... 88

verapamil hcl tab er 180 mg ............... 88 verapamil hcl tab er 240 mg ............... 88 VERDESO AER 0.05% ....................... 105 verdrocet tab 2.5-325 ........................ 20

VERSACLOZ SUS 50MG/ML................. 78 VERZENIO TAB 100MG ....................... 70 VERZENIO TAB 150MG ....................... 70 VERZENIO TAB 200MG ....................... 70 VERZENIO TAB 50MG ......................... 70

VIBERZI TAB 100MG ........................ 118 VIBERZI TAB 75MG .......................... 118 VIBRAMYCIN SYP 50MG/5ML ............ 164 VICKS NATURE LIQ COLD/FLU ............ 98

VICKS NATURE LIQ CONGEST ............ 98 VICTOZA INJ 18MG/3ML ..................... 46 VIDEX SOL 2GM ................................. 83 VIDEX SOL 4GM ................................. 83

VIEKIRA PAK TAB ............................... 84 VIEKIRA XR TAB ................................. 84 vigabatrin powd pack 500 mg ............. 37 vigabatrin tab 500 mg ........................ 37 VIGAMOX DRO 0.5% ........................ 151

VIIBRYD KIT STARTER........................ 40 VIIBRYD TAB 10MG ............................ 40 VIIBRYD TAB 20MG ............................ 40 VIIBRYD TAB 40MG ............................ 40

VIMPAT SOL 10MG/ML........................ 37 VIMPAT TAB 100MG ........................... 37 VIMPAT TAB 150MG ........................... 37 VIMPAT TAB 200MG ........................... 37

VIMPAT TAB 50MG ............................. 37 VINATE DHA CAP 27-1.13................. 146 VINATE M TAB.................................. 146 VINATE ONE TAB.............................. 146 vinblastine sulfate inj 1 mg/ml ........... 72

vinorelbine tartrate inj 10 mg/ml (base equiv) ................................................ 72 vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv) .......................... 73

VIOKACE TAB 10440 ........................ 109 VIOKACE TAB 20880 ........................ 109

238

VIOS LC MIS SPRINT ........................ 135 VIRACEPT TAB 250MG ........................ 83 VIRACEPT TAB 625MG ........................ 83

VIREAD POW 40MG/GM ...................... 83 VIREAD TAB 150MG ........................... 83 VIREAD TAB 200MG ........................... 83 VIREAD TAB 250MG ........................... 83

VIRGINIA INJ LIVE OAK........................ 6 VIRT NATE TAB ................................ 146 VISCOAT SOL ................................... 153 VISIONBLUE SOL 0.06% .................. 153

VITACRAVES CHW +OMEGA-3 .......... 145 VITAFOL-NANO TAB ......................... 146 VITAMAX CHW ................................. 144 vitamax ped dro ............................... 144 vitamin d tab 1000unit ..................... 172

vitamin d3 cap 10000unt.................. 172 vitamin d-3 tab 5000unit .................. 172 VITRAKVI CAP 100MG ........................ 71 VITRAKVI CAP 25MG .......................... 71

VITRAKVI SOL 20MG/ML .................... 71 VITRASE INJ 200/ML ........................ 141 VIVITROL INJ 380MG ......................... 50 VIVLODEX CAP 10MG ......................... 11

VIVLODEX CAP 5MG ........................... 11 VIZIMPRO TAB 15MG ......................... 71 VIZIMPRO TAB 30MG ......................... 71 VIZIMPRO TAB 45MG ......................... 71 voriconazole for inj 200 mg ................ 52

voriconazole for susp 40 mg/ml .......... 52 voriconazole tab 200 mg .................... 52 voriconazole tab 50 mg ...................... 52 VOSEVI TAB ....................................... 84

VOTRIENT TAB 200MG ....................... 71 VP-HEME OB TAB ............................. 146 VPRIV INJ 400UNIT .......................... 124 VRAYLAR CAP 1.5-3MG....................... 76

VRAYLAR CAP 1.5MG .......................... 76 VRAYLAR CAP 3MG ............................. 76 VRAYLAR CAP 4.5MG .......................... 76 VRAYLAR CAP 6MG ............................. 76 VUMERITY CAP 231MG ..................... 161

VYNDAMAX CAP 61MG ........................ 91 VYNDAQEL CAP 20MG ........................ 91 VYVANSE CAP 10MG............................. 2 VYVANSE CAP 20MG............................. 2

VYVANSE CAP 30MG............................. 2 VYVANSE CAP 40MG............................. 2

VYVANSE CAP 50MG............................. 2 VYVANSE CAP 60MG............................. 2 VYVANSE CAP 70MG............................. 2

VYVANSE CHW 10MG ........................... 2 VYVANSE CHW 20MG ........................... 2 VYVANSE CHW 30MG ........................... 2 VYVANSE CHW 40MG ........................... 2

VYVANSE CHW 50MG ........................... 2 VYVANSE CHW 60MG ........................... 2 VYZULTA SOL 0.024% ...................... 154 W

WAKIX TAB 17.8MG ............................. 3 WAKIX TAB 4.45MG ............................. 3 wal-fex chld sus 30mg/5ml................. 53 wal-mucil pow 100% ........................ 128 wal-tap elx cld/alle ............................. 98

warfarin sodium tab 1 mg................... 32 warfarin sodium tab 10 mg................. 32 warfarin sodium tab 2 mg................... 32 warfarin sodium tab 2.5 mg................ 32

warfarin sodium tab 3 mg................... 32 warfarin sodium tab 4 mg................... 32 warfarin sodium tab 5 mg................... 32 warfarin sodium tab 6 mg................... 32

warfarin sodium tab 7.5 mg................ 32 WESTHROID TAB 130MG .................. 166 WESTHROID TAB 32.5MG ................. 166 WESTHROID TAB 65MG .................... 166 WESTHROID TAB 97.5MG ................. 166

WHITE ASH INJ EXTRACT ..................... 6 WHITE OAK SOL................................... 6 WIDE-SEAL DPR KIT 60 .................... 131 WIDE-SEAL DPR KIT 65 .................... 131

WIDE-SEAL DPR KIT 70 .................... 131 WIDE-SEAL DPR KIT 75 .................... 131 WIDE-SEAL DPR KIT 80 .................... 131 WIDE-SEAL DPR KIT 85 .................... 131

WIDE-SEAL DPR KIT 90 .................... 131 WIDE-SEAL DPR KIT 95 .................... 131 wixela inhub aer 100/50 ..................... 31 wixela inhub aer 250/50 ..................... 31 wixela inhub aer 500/50 ..................... 31

X XADAGO TAB 100MG .......................... 75 XADAGO TAB 50MG ............................ 75 XALKORI CAP 200MG ......................... 71

XALKORI CAP 250MG ......................... 71 XARELTO STAR TAB 15/20MG............. 32

239

XARELTO TAB 10MG ........................... 32 XARELTO TAB 15MG ........................... 32 XARELTO TAB 2.5MG .......................... 32

XARELTO TAB 20MG ........................... 32 XATMEP SOL 2.5MG/ML ...................... 64 XELJANZ TAB 10MG.............................. 8 XELJANZ TAB 5MG ............................... 8

XELJANZ XR TAB 11MG ........................ 8 XENLETA TAB 600MG ......................... 25 XEPI CRE 1% ................................... 100 XERESE CRE 5-1% ........................... 102

XERMELO TAB 250MG ...................... 119 XEROFRM GAUZ MIS 1 ..................... 108 XEROFRM PETR PAD 2 ...................... 108 XIFAXAN TAB 200MG.......................... 24 XIFAXAN TAB 550MG.......................... 24

XIGDUO XR TAB 10-1000 ................... 45 XIGDUO XR TAB 10-500MG ................ 45 XIGDUO XR TAB 5-1000MG ................ 45 XIGDUO XR TAB 5-500MG .................. 45

XIIDRA DRO 5%............................... 151 XOFLUZA TAB 20MG ........................... 85 XOFLUZA TAB 40MG ........................... 85 XOLAIR INJ 150MG/ML ....................... 28

XOLAIR INJ 75/0.5 ............................. 28 XOLAIR SOL 150MG ........................... 28 XOLEGEL GEL 2%............................. 101 XOSPATA TAB 40MG........................... 71 XPOVIO PAK 100MG ........................... 66

XPOVIO PAK 60MG ............................. 66 XPOVIO PAK 80MG ............................. 66 XTAMPZA ER CAP 13.5MG .................. 19 XTAMPZA ER CAP 18MG ..................... 19

XTAMPZA ER CAP 27MG ..................... 19 XTAMPZA ER CAP 36MG ..................... 19 XTAMPZA ER CAP 9MG ....................... 19 XTANDI CAP 40MG ............................. 66

xulane dis 150-35 .............................. 93 XULTOPHY INJ 100/3.6....................... 45 XURIDEN POW 2GM.......................... 114 XYNTHA INJ 1000UNIT ..................... 123 XYNTHA INJ 2000UNIT ..................... 123

XYNTHA INJ 250UNIT ....................... 123 XYNTHA INJ 500UNIT ....................... 123 XYNTHA SOLOF INJ 3000UNIT .......... 123 XYREM SOL 500MG/ML ..................... 158

Y YALE CLEANER POW ......................... 106

YALE NEEDLE MIS 15GX1.5 .............. 134 YALE NEEDLE MIS 15GX2 ................. 134 YALE NEEDLE MIS 16GX2 ................. 134

YALE NEEDLES MIS 13X3-1/2 ........... 134 YALE NEEDLES MIS 15X3-1/2 ........... 134 YALE NEEDLES MIS 17G X 2 ............. 134 YALE NEEDLES MIS 18G X 2 ............. 134

YALE NEEDLES MIS 18X1-1/2 ........... 134 YALE NEEDLES MIS 19X1-1/2 ........... 134 YALE NEEDLES MIS 20G X 1 ............. 134 YALE NEEDLES MIS 20G X 2 ............. 134

YALE NEEDLES MIS 20X1-1/2 ........... 134 YALE NEEDLES MIS 21G X 1 ............. 134 YALE NEEDLES MIS 21X1-1/2 ........... 134 YALE NEEDLES MIS 22G X 1 ............. 134 YALE NEEDLES MIS 22G X 2 ............. 134

YALE NEEDLES MIS 22G X 3 ............. 134 YALE NEEDLES MIS 22X1-1/2 ........... 134 YALE NEEDLES MIS 23G X 1 ............. 134 YALE NEEDLES MIS 23G X 2 ............. 134

YALE NEEDLES MIS 23GX1/2 ............ 134 YALE NEEDLES MIS 23X1-1/2 ........... 134 YALE NEEDLES MIS 24G X 1 ............. 134 YALE NEEDLES MIS 24GX1/2 ............ 134

YALE NEEDLES MIS 24GX3/4 ............ 134 YALE NEEDLES MIS 24X1-1/2 ........... 134 YALE NEEDLES MIS 25G X 1 ............. 134 YALE NEEDLES MIS 25GX1/2 ............ 134 YALE NEEDLES MIS 25GX3/8 ............ 134

YALE NEEDLES MIS 25GX5/8 ............ 134 YALE NEEDLES MIS 25X1-1/2 ........... 134 YALE NEEDLES MIS 26G X 1 ............. 134 YALE NEEDLES MIS 26GX1/2 ............ 134

YALE NEEDLES MIS 26GX3/8 ............ 134 YALE NEEDLES MIS 26GX5/8 ............ 134 YALE NEEDLES MIS 26X1-1/2 ........... 134 YALE NEEDLES MIS 27G X 1 ............. 134

YALE NEEDLES MIS 27GX1/2 ............ 135 YALE NEEDLES MIS 27GX1/4 ............ 135 YALE NEEDLES MIS 27GX3/8 ............ 135 YALE NEEDLES MIS 30G X 1 ............. 135 YALE NEEDLES MIS 30X1-1/2 ........... 135

YALE TB SYRN MIS GL 1/4ML............ 135 YALE TB SYRN MIS GL 1ML ............... 135 YERVOY INJ 200MG ............................ 65 YERVOY INJ 50MG .............................. 65

yodefan-nf liq 200-5ml ....................... 98 YUPELRI SOL...................................... 28

240

yuvafem tab 10mcg ......................... 171 Z zafirlukast tab 10 mg ......................... 29

zafirlukast tab 20 mg ......................... 29 zaleplon cap 10 mg .......................... 127 zaleplon cap 5 mg ............................ 127 ZALTRAP INJ 100/4ML ........................ 64

ZALTRAP INJ 200/8ML ........................ 64 ZANOSAR INJ 1GM ............................. 63 ZANTAC INJ 25MG/ML ...................... 167 ZARXIO INJ 300/0.5 ......................... 125

ZARXIO INJ 480/0.8 ......................... 125 ZEJULA CAP 100MG ............................ 71 ZELAPAR TAB 1.25MG ........................ 75 ZELBORAF TAB 240MG ....................... 71 zenchent tab ...................................... 93

ZENPEP CAP 10000UNT .................... 109 ZENPEP CAP 15000UNT .................... 109 ZENPEP CAP 25000UNT .................... 109 ZENPEP CAP 3000UNIT..................... 109

ZENPEP CAP 5000UNIT..................... 109 zenzedi tab 10mg ................................. 2 zenzedi tab 15mg ................................. 2 zenzedi tab 2.5mg................................ 2

zenzedi tab 20mg ................................. 2 zenzedi tab 30mg ................................. 2 zenzedi tab 5mg................................... 2 zenzedi tab 7.5mg................................ 2 ZEPATIER TAB 50-100MG ................... 84

ZEVALIN KIT Y-90 .............................. 65 zidovudine cap 100 mg....................... 83 zidovudine syrup 10 mg/ml ................ 83 zidovudine tab 300 mg ....................... 83

zileuton tab er 12hr 600 mg ............... 29 zinc chloride inj 1 mg/ml .................. 141 zinc oxide oin 20% ........................... 106 zinc sulfate inj 1 mg/ml .................... 141

zinc sulfate inj 5 mg/ml .................... 141 ZIOPTAN DRO 0.0015% ................... 154 ziprasidone hcl cap 20 mg .................. 76 ziprasidone hcl cap 40 mg .................. 76 ziprasidone hcl cap 60 mg .................. 76

ziprasidone hcl cap 80 mg .................. 76 ZIRGAN GEL 0.15%.......................... 151 ZITHRANOL SHA 1% ........................ 102 ZN-DTPA SOL 1000MG ....................... 50

ZOHYDRO ER CAP 10MG..................... 19 ZOHYDRO ER CAP 15MG..................... 19

ZOHYDRO ER CAP 20MG..................... 19 ZOHYDRO ER CAP 30MG..................... 19 ZOHYDRO ER CAP 40MG..................... 19

ZOHYDRO ER CAP 50MG..................... 19 ZOLINZA CAP 100MG ......................... 71 zolmitriptan orally disintegrating tab 2.5 mg ................................................... 137

zolmitriptan orally disintegrating tab 5 mg ................................................... 137 zolmitriptan tab 2.5 mg .................... 137 zolmitriptan tab 5 mg ....................... 137

zolpidem tartrate tab 10 mg ............. 127 zolpidem tartrate tab 5 mg ............... 127 zolpidem tartrate tab er 12.5 mg ...... 127 zolpidem tartrate tab er 6.25 mg ...... 127 ZOLPIMIST SPR 5MG ........................ 127

ZOMACTON INJ 10MG ...................... 112 ZOMACTON INJ 5MG ........................ 112 ZOMIG SPR 2.5MG ........................... 137 ZOMIG SPR 5MG .............................. 137

zonisamide cap 100 mg ...................... 37 zonisamide cap 25 mg ........................ 37 zonisamide cap 50 mg ........................ 37 ZONTIVITY TAB 2.08MG ................... 124

zoo friends chw extra c..................... 145 zoo friends chw gummies ................. 145 zoo friends chw pls iron .................... 144 ZORBTIVE INJ 8.8MG ....................... 112 ZORTRESS TAB 0.25MG ................... 143

ZORTRESS TAB 0.5MG ..................... 143 ZORTRESS TAB 0.75MG ................... 143 zovia 1/35e tab .................................. 93 ZOVIRAX OIN 5%............................. 102

ZUBSOLV SUB 0.7-0.18...................... 21 ZUBSOLV SUB 1.4-0.36...................... 21 ZUBSOLV SUB 11.4-2.9...................... 22 ZUBSOLV SUB 2.9-0.71...................... 21

ZUBSOLV SUB 5.7-1.4........................ 21 ZUBSOLV SUB 8.6-2.1........................ 21 ZUPLENZ MIS 4MG ............................. 51 ZUPLENZ MIS 8MG ............................. 51 ZURAMPIC TAB 200MG ..................... 120

ZYCLARA PUMP CRE 2.5% ................ 105 ZYDELIG TAB 100MG.......................... 71 ZYDELIG TAB 150MG.......................... 71 ZYFLO TAB 600MG ............................. 29

ZYKADIA CAP 150MG ......................... 71 ZYLET SUS 0.5-0.3% ....................... 152

241

ZYPREXA RELP INJ 210MG .................. 78 ZYPREXA RELP INJ 300MG .................. 78 ZYPREXA RELP INJ 405MG .................. 78

ZYRTEC ALLGY TAB 10MG .................. 53 ZYTIGA TAB 500MG............................ 66

preferred drug list (pdl) - passport · 2019-12-11 · what if my drug is not on the pdl? remember,...

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