Lista de medicamentos de Blue Cross Community Centennial › pdf › rx ›...

Lista de medicamentos de Blue Cross Community CentennialSM

enero de 2019

NTENNIALCARE

Este documento contiene información sobre los medicamentos incluidos en esta cobertura.Vigente a partir del: 1 de octubre de 2019

Lista de medicamentos de Blue Cross Community CentennialSM

octubre de 2019

Blue Cross Community Centennial

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

forme parte de la red,• siga las otras normas de su seguro de gastos médicos de

Blue Cross Community Centennial.

Para obtener más información acerca de cómo surtir sus órdenes de medicamentos, por favor revise su Manual del asegurado. También puede comunicarse con Atención al Asegurado de Blue Cross and Blue Shield of New Mexico (BCBSNM) al 1-866-689-1523 (TTY/TDD 711).

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

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

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

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

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

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

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

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

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

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

de esta guía.• Junto al nombre de su medicamento, verá el número de

página en donde puede encontrar la información de la cobertura.

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

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

¿Existe algún límite en mi cobertura?Algunos medicamentos están sujetos a restricciones de edad que se basan en pautas clínicas, del fabricante o de la Administración de Alimentos y Medicamentos (FDA, en inglés). Las restricciones de edad constituyen una medida de seguridad para que los asegurados usen los medicamentos de la manera adecuada. Puede averiguar si su medicamento está sujeto a otras condiciones o límites consultando la lista de

Lista de medicamentos

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medicamentos que comienza en la página 1. La fecha de la última actualización de la lista aparece en la portada. En algunos medicamentos con cobertura, los límites o condiciones agregados pueden incluir:• Autorización previa: Usted o su profesional de la salud

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

– ¿Qué sucede si mi medicamento requiere una autorización previa? ú Comuníquese con Atención al Asegurado de BCBSNM al 1-866-689-1523 (TTY/TDD 711) y pregunte cómo usted o su profesional de la salud pueden enviar una solicitud de autorización previa (excepción).

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

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

– ¿Qué sucede si mi medicamento no tiene cobertura porque supera la cantidad límite? ú Comuníquese con Atención al Asegurado de BCBSNM al 1-866-689-1523 (TTY/TDD 711) y pregunte cómo usted o su profesional de la salud pueden enviar una solicitud de excepción de la cantidad límite.

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

• Terapia escalonada: En algunos casos, Blue Cross Community Centennial requiere que usted pruebe primero ciertos medicamentos antes de que se pueda cubrir otro medicamento. Por ejemplo, si el medicamento A y el medicamento B se usan para tratar su problema médico, es posible que su seguro médico no incluya en su cobertura el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no funciona, su seguro médico incluirá en su

cobertura el medicamento B. Los medicamentos que están sujetos a la terapia escalonada se identifican en la Lista de medicamentos por un “ST” en la columna de “Acciones necesarias, restricciones o límites sobre el uso”.

– ¿Qué sucede si mi medicamento no tiene cobertura ya que no he cumplido con la terapia escalonada? ú Comuníquese con Atención al Asegurado de BCBSNM al 1-866-689-1523 (TTY/TDD 711) y pregunte cómo usted o su profesional de la salud pueden enviar una solicitud de excepción de la terapia escalonada.

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

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

• Límite para surtir opioides: . Todos los opioides están sujetos a un límite de consumo del 90% antes de volver a surtirse. Esto significa que el 90% del medicamento que se surtió originalmente debe utilizarse antes de que se pueda volver a surtir. Si no toma opioides habitualmente, todos los días, se le considera un consumidor reciente de opioides. Los consumidores recientes de opioides están limitados a un suministro de siete días de opioides de liberación inmediata para su primer surtido. Una vez que tengan un historial de consumo de opioides de liberación inmediata, podrá surtir el medicamento por más de siete días. Debe tener un historial de consumo de opioides de liberación inmediata antes de poder surtir opioides de liberación prolongada. Si no tiene un historial de consumo de opioides de liberación inmediata, necesitará obtener autorización previa de BCBSNM para surtir los de liberación extendida. También necesitará obtener una autorización previa de BCBSNM para poder tomar una benzodiazepina y un opioide al mismo tiempo.


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• Programa de surtido diferido de medicamentos oncológicos administrados vía oral: La oncología es el estudio del cáncer. Con los medicamentos oncológicos de administración oral se tratan varios tipos de cáncer. Estos medicamentos son parte importante de muchos planes de tratamiento. Estos medicamentos pueden provocar efectos secundarios que podrían hacer que el médico modifique la dosis o que interrumpa el medicamento por completo. Mientras está en curso el tratamiento, el médico podría realizar cambios al plan de tratamiento hasta que se defina la dosis indicada para usted. Este proceso puede tardar varios meses.

Motivos para la implementación del programa de surtido diferido de medicamentos oncológicos administrados vía oral para pacientes que inician tratamiento por primera vez:

– prevenir expedición de recetas médicas para dosis inadecuadas;

– minimizar el desperdicio de estos medicamentos; – controlar efectos secundarios.

Durante los primeros dos o tres meses del tratamiento, recibirá un surtido de 14 a 15 días del medicamento recetado, dos veces al mes. Después de los primeros dos o tres meses de tratamiento y una vez que se haya definido la dosis adecuada, podría empezar a recibir surtidos de un mes por lo que resta de la terapia. En la lista de medicamentos, cualquier medicamento señalado con las letras “SF” es parte del programa de surtido diferido de medicamentos oncológicos administrados vía oral.

¿Qué sucede si mi medicamento no está incluido en la Lista de medicamentos?Comuníquese con Atención al Asegurado de BCBSNM al 1-866-689-1523 (TTY/TDD 711) y pregunte si su medicamento tiene cobertura. Si Blue Cross Community Centennial no incluye su medicamento, tiene dos opciones:• Puede hablar con su profesional de la salud para decidir si

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

• Si su profesional de la salud considera que otro medicamento no sería adecuado para usted, puede solicitar una autorización previa. “Autorización previa” es pedirle a Blue Cross Community Centennial que haga una excepción y cubra el medicamento para usted. Atención al Asegurado puede ayudarlos a usted y su profesional de la salud a solicitar la excepción. Encontrará el formulario de excepción para la cobertura de medicamentos con receta en MyPrime.com. Los profesionales de la salud pueden enviar los formularios de solicitud de excepción por estos medios:

– fax: 1-877-243-6930; – teléfono: 1-800-285-9426 (TTY/TDD: 711); – sitio web: MyPrime.com o CoverMyMeds.com.

Farmacia de medicamentos especializados (SP, en inglés)Los medicamentos especializados son ciertos medicamentos con receta que se usan para tratar padecimientos complejos y crónicos como el cáncer, la artritis reumatoide y la esclerosis múltiple. Los medicamentos especializados a menudo requieren un manejo especial (como refrigeración durante el envío) y administración (como una inyección o infusión). Los medicamentos especializados requieren de autorización previa antes de que se pueda surtir una receta médica. Se pueden surtir en un suministro hasta de 30 días. Esto debe hacerse por medio de un proveedor de medicamentos especializados que forme parte de la red de Blue Cross Community Centennial. AllianceRx Walgreens Prime es el proveedor de medicamentos especializados preferencial de BCBSNM. La mayoría de estos medicamentos están incluidos en la cobertura para medicamentos y se deben surtir por medio de AllianceRx Walgreens Prime. Los medicamentos especializados incluidos en la cobertura y que no están disponibles en AllianceRx Walgreens Prime se pueden obtener de un proveedor de farmacia de distribución limitada. Estos proveedores son conocidos por los fabricantes farmacéuticos por tener los estándares más altos en experiencia clínica, educación para pacientes, servicio, seguimiento terapéutico y apoyo. Para obtener más información sobre los medicamentos especializados, llame a Atención al Asegurado al 1-866-689-1523 (TTY/TDD 711).

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

peso o aumento de peso;• productos químicos a granel;• medicamentos para el mejoramiento cosmético;• agentes para diagnóstico;• implementación del estudio de eficacia de medicamentos

(DESI, en inglés). Estos son medicamentos que no han demostrado ser seguros ni eficaces;

• medicamentos experimentales y de investigación;


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

• medicamentos para la fertilidad;• medicamentos para anestesia general;• productos opioides contra la tos y el resfrío (se excluyen para

los menores de 18 años);• productos de venta libre que no se incluyan en la lista de

medicamentos de la cobertura;• suministros quirúrgicos/dispositivos médicos.

Los asegurados de Blue Cross Community Centennial que tienen doble cobertura bajo Medicare y Medicaid se darán cuenta que la mayoría de sus medicamentos tendrán cobertura de Medicare. Sin embargo, un número limitado de medicamentos tendrá cobertura de Blue Cross Community Centennial.Estos son algunos ejemplos de dichos medicamentos: • medicamentos para aliviar los síntomas de la tos y el resfrío;• vitaminas y minerales recetados por un médico (por ejemplo,

ácido fólico);• medicamentos de venta libre;• productos de venta libre para dejar de fumar.

Para los medicamentos con cobertura de la Parte B de Medicare, los asegurados de Blue Cross Community Centennial que cuentan con Medicare y Medicaid podrían recibir ayuda de Medicaid para cubrir su coaseguro. Sin embargo, algunos medicamentos únicamente tienen cobertura bajo la Parte B de Medicare si un asegurado tiene un problema médico específico o recibió un tratamiento médico específico. En algunos casos, para poder cubrir el coaseguro de un asegurado, será necesario revisar primero sus antecedentes médicos. Los asegurados deben llamar a Atención al Asegurado al 1-866-689-1523 (TTY/TDD: 711) para completar esta determinación de cobertura.

Artículos y monitores de medición continua de la glucosaBCBSNM ha modificado el proceso para proporcionar artículos y monitores de medición continua de la glucosa. Un monitor de medición continua de la glucosa es un aparato que monitoriza los niveles de azúcar en la sangre durante todo el día. Si a causa de esta modificación el proveedor de equipo médico duradero (DME, en inglés) ya no reúne los requisitos para proporcionarle el aparato y los artículos, deberá obtenerlos a través de otro proveedor de la red. En BCBSNM podremos ayudarlo a buscar otro proveedor. Si se ve afectado por esta modificación, habría recibido una notificación que lo ayudaría con este proceso. BCBSNM informó esta modificación a los profesionales que recetan y a los proveedores de equipo médico duradero de los

asegurados que se vieron afectados. Si necesita ayuda para buscar profesionales médicos o proveedores de la red, llame a Atención al Asegurado al 1-866-689-1523 (TTY: 711).

Para obtener más información Para obtener más detalles sobre la cobertura de medicamentos de su seguro de gastos médicos de Blue Cross Community Centennial, por favor lea su Manual del asegurado y otros materiales de la cobertura médica.Si tiene alguna pregunta, por favor llame a Atención al Asegurado de BCBSNM al: 1-866-689-1523, (TTY/TDD 711). Nuestro horario de atención es de lunes a viernes, de 8:00 a. m. a 5:00 p. m., Hora Montaña.

Asistencia lingüística para la Lista de medicamentosServicios de interpretación Podemos coordinar que alguien le ayude a comunicarse con nosotros en cualquier idioma. Estos servicios son gratuitos. Si su profesional de la salud no habla su idioma, podemos ofrecerle la ayuda de un intérprete. Por favor llame a Atención al Asegurado al 1-866-689-1523 (TTY/TDD 711).

Problemas auditivos y de la vistaPara nuestros asegurados con problemas auditivos, ofrecemos el servicio de TTY/TDD sin ningún cargo. La línea está abierta las 24 horas del día, los siete días de la semana en el 711.

Otros idiomas y formatosPuede obtener este documento en inglés o hablar con alguien acerca de esta información en otros idiomas sin costo alguno. Llame al 1-866-689-1523 (TTY/TDD: 711). La llamada es gratuita. También puede llamar gratis a Atención al Asegurado, para solicitar esta información en otros formatos diferentes como Braille, letra grande y otros formatos. Llame sin costo al: 1-866-689-1523 (TTY/TDD: 711). Nuestro horario de atención es de lunes a viernes, de 8:00 a. m. a 5:00 p. m., Hora Montaña.


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

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

Blue Cross and Blue Shield of New Mexico:

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

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

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

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

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

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

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

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

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

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

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

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

llame al 1-866-689-1523 (TTY/TDD: 711).


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

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

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

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

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

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Medicamento Intervalo de edad elegidoAbilify (aripiprazole)a

2 mg tablet menores de 6 años5 mg tablet menores de 6 años10 mg tablet menores de 6 años15 mg tablet menores de 6 años20 mg tablet menores de 6 años30 mg tablet menores de 6 añosAbilify Discmelt (aripiprazole)a

15 mg orally disintegrating tablet menores de 6 años10 mg orally disintegrating tablet menores de 6 añosClozaril (clozapine)a

25 mg tablet menores de 18 años50 mg tablet menores de 18 años100 mg tablet menores de 18 años200 mg tablet menores de 18 añosFluphenazinea

25 mg/mL decanoate injection menores de 12 añosGeodon (ziprasidone)a

20 mg capsule menores de 10 años40 mg capsule menores de 10 años60 mg capsule menores de 10 años80 mg capsule menores de 10 añosHaldol (haloperidol)a

0.5 mg tablet menores de 5 años1 mg tablet menores de 5 años2 mg tablet menores de 5 años5 mg tablet menores de 5 años10 mg tablet menores de 5 años20 mg tablet menores de 5 años2 mg/mL oral concentrate menores de 18 años50 mg/mL IM injection menores de 18 años100 mg/mL IM injection menores de 18 añosLoxapinea

5 mg capsule menores de 18 años10 mg capsule menores de 18 años25 mg capsule menores de 18 años50 mg capsule menores de 18 añosPerphenazinea

2 mg tablet menores de 12 años4 mg tablet menores de 12 años8 mg tablet menores de 12 años16 mg tablet menores de 12 añosProchlorperazinea

5 mg tablet menores de 2 años10 mg tablet menores de 2 años25 mg suppository menores de 2 añosRisperdal (risperidone)a

1 mg/mL oral solution menores de 5 años

A continuación, se incluye una lista de medicamentos que requieren autorización previa para un grupo de edad específicopara garantizar un uso adecuado.a = medicamento genérico cubierto

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0.25 mg tablet menores de 5 años0.5 mg tablet menores de 5 años1 mg tablet menores de 5 años2 mg tablet menores de 5 años3 mg tablet menores de 5 años4 mg tablet menores de 5 añosRisperdal M-Tab (risperidone)a

0.5 mg orally disintegrating tablet menores de 5 años1 mg orally disintegrating tablet menores de 5 años2 mg orally disintegrating tablet menores de 5 años3 mg orally disintegrating tablet menores de 5 años4 mg orally disintegrating tablet menores de 5 añosRisperidone0.25 mg orally disintegrating tablet menores de 5 añosSeroquel (quetiapine)a

25 mg tablet menores de 10 años50 mg tablet menores de 10 años100 mg tablet menores de 10 años200 mg tablet menores de 10 años300 mg tablet menores de 10 años400 mg tablet menores de 10 añosThioridazinea

10 mg tablet menores de 5 años25 mg tablet menores de 5 años50 mg tablet menores de 5 años100 mg tablet menores de 5 añosThiothixenea

1 mg capsule menores de 12 años2 mg capsule menores de 12 años5 mg capsule menores de 12 años10 mg capsule menores de 12 añosTrifluoperazinea

1 mg tablet menores de 6 años2 mg tablet menores de 6 años5 mg tablet menores de 6 años10 mg tablet menores de 6 añosZyprexa (olanzapine)a

2.5 mg tablet menores de 13 años5 mg tablet menores de 13 años7.5 mg tablet menores de 13 años10 mg tablet menores de 13 años15 mg tablet menores de 13 años20 mg tablet menores de 13 añosZyprexa Zydis (olanzapine)a

5 mg orally disintegrating tablet menores de 13 años10 mg orally disintegrating tablet menores de 13 años15 mg orally disintegrating tablet menores de 13 años20 mg orally disintegrating tablet menores de 13 añosMolindone5mg tablets menores de 12 años10mg tablets menores de 12 años25mg tablets menores de 12 años

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Atralin™ (tretinoin)0.05% gela de 25 años en adelante

Avita® (tretinoin)0.025% creama de 25 años en adelante0.025% gela de 25 años en adelante

Benzamycin (benzoyl peroxide/erythromycin)5%/3% gela de 25 años en adelante

benzoyl peroxide6% foaming clothsa de 25 años en adelante

Cleocin T (clindamycin phosphate)1% gela de 25 años en adelante1% lotiona de 25 años en adelante1% solutiona de 25 años en adelante1% padsa de 25 años en adelante

Clindacin - P (clindamycin phosphate)1% Pledets de 25 años en adelante1% Pads de 25 años en adelante

Differin® (adapalene)0.1% creama de 25 años en adelante

Duac (clindamycin phosphate/benzoyl peroxide)

1.2%/5% gela de 25 años en adelanteerythromycin

2% padsa de 25 años en adelante2% solutiona de 25 años en adelante

Finacea (azelaic acid)15% gel de 25 años en adelante

isotretinoin10 mg capsulea de 25 años en adelante20 mg capsulea de 25 años en adelante30 mg capsulea de 25 años en adelante40 mg capsulea de 25 años en adelante

Klaron (sulfacetamide sodium)10% lotiona de 25 años en adelante

Metrocream (metronidazole)0.75% creama de 25 años en adelante

Metrogel (metronidazole)0.75% gela de 25 años en adelante

Retin-A® (tretinoin)0.025% creama de 25 años en adelante0.05% creama de 25 años en adelante0.1% creama de 25 años en adelante0.01% gela de 25 años en adelante0.025% gela de 25 años en adelante

Tazorac® (tazarotene)0.05% cream de 25 años en adelante0.1% creama de 25 años en adelante0.05% gel de 25 años en adelante0.1% gel de 25 años en adelante

Strattera (atomoxetine)10mg capsules menores de 6 años y mayores de 18 años18mg capsules menores de 6 años y mayores de 18 años

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25mg capsules menores de 6 años y mayores de 18 años40mg capsules menores de 6 años y mayores de 18 años60mg capsules menores de 6 años y mayores de 18 años80mg capsules menores de 6 años y mayores de 18 años100mg capsules menores de 6 años y mayores de 18 años

Adderall (amphetamine/dextroamphetamine)5 mg tableta menores de 6 años y mayores de 18 años7.5 mg tableta menores de 6 años y mayores de 18 años10 mg tableta menores de 6 años y mayores de 18 años12.5 mg tableta menores de 6 años y mayores de 18 años15 mg tableta menores de 6 años y mayores de 18 años20 mg tableta menores de 6 años y mayores de 18 años30 mg tableta menores de 6 años y mayores de 18 añosAdderall XR (amphetamine/dextroamphetamine ER)5 mg capsulea menores de 6 años y mayores de 18 años10 mg capsulea menores de 6 años y mayores de 18 años15 mg capsulea menores de 6 años y mayores de 18 años20 mg capsulea menores de 6 años y mayores de 18 años25 mg capsulea menores de 6 años y mayores de 18 años30 mg capsulea menores de 6 años y mayores de 18 añosConcerta (methylphenidate osmotic ER)a

18 mg tableta menores de 6 años y mayores de 18 años27 mg tableta menores de 6 años y mayores de 18 años36 mg tableta menores de 6 años y mayores de 18 años54 mg tableta menores de 6 años y mayores de 18 añosmethylphenidate ER18 mg tablet menores de 6 años y mayores de 18 años27 mg tablet menores de 6 años y mayores de 18 años36 mg tablet menores de 6 años y mayores de 18 años54 mg tablet menores de 6 años y mayores de 18 añosDexedrine (dextroamphetamine)5 mg tableta menores de 6 años y mayores de 18 años10 mg tableta menores de 6 años y mayores de 18 añosDexedrine Spansule (dextroamphetamine ER)5 mg capsulea menores de 6 años y mayores de 18 años10 mg capsulea menores de 6 años y mayores de 18 años15 mg capsulea menores de 6 años y mayores de 18 añosFocalin (dexmethylphenidate)2.5 mg tableta menores de 6 años y mayores de 18 años5 mg tableta menores de 6 años y mayores de 18 años10 mg tableta menores de 6 años y mayores de 18 añosFocalin XR (dexmethylphenidate ER)5 mg capsulea menores de 6 años y mayores de 18 años10 mg capsulea menores de 6 años y mayores de 18 años15 mg capsulea menores de 6 años y mayores de 18 años20 mg capsulea menores de 6 años y mayores de 18 años30 mg capsulea menores de 6 años y mayores de 18 años40 mg capsulea menores de 6 años y mayores de 18 añosMetadate ER (methylphenidate ER)20 mg tableta menores de 6 años y mayores de 18 añosMetadate CD (methylphenidate ER)10 mg capsulea menores de 6 años y mayores de 18 años

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20 mg capsulea menores de 6 años y mayores de 18 años30 mg capsulea menores de 6 años y mayores de 18 años40 mg capsulea menores de 6 años y mayores de 18 años50 mg capsulea menores de 6 años y mayores de 18 años60 mg capsulea menores de 6 años y mayores de 18 añosMethylin (methylphenidate)5 mg/5 mL solutiona menores de 6 años y mayores de 18 años10 mg/5 mL solutiona menores de 6 años y mayores de 18 añosMethylin (methylphenidate)2.5 mg chewable tableta menores de 6 años y mayores de 18 años5 mg chewable tableta menores de 6 años y mayores de 18 años10 mg chewable tableta menores de 6 años y mayores de 18 añosMethylphenidate ER10 mg tableta menores de 6 años y mayores de 18 años20 mg tableta menores de 6 años y mayores de 18 añosProcentra (dextroamphetamine)5 mg/5 mL oral solutiona menores de 6 años y mayores de 18 años

5 mg tableta menores de 6 años y mayores de 18 años10 mg tableta menores de 6 años y mayores de 18 años20 mg tableta menores de 6 años y mayores de 18 añosRitalin LA (methylphenidate ER)10 mg capsulea menores de 6 años y mayores de 18 años20 mg capsulea menores de 6 años y mayores de 18 años30 mg capsulea menores de 6 años y mayores de 18 años40 mg capsulea menores de 6 años y mayores de 18 añosZenzedi (dextroamphetamine)5 mg tableta menores de 6 años y mayores de 18 años10 mg tableta menores de 6 años y mayores de 18 añosFlovent Diskus® (fluticasone)50 mcg/actuation de 5 años en adelante100 mcg/actuation de 5 años en adelante250 mcg/actuation de 5 años en adelanteFlovent HFA® (fluticasone)44 mcg/actuation de 5 años en adelante110 mcg/actuation de 5 años en adelante220 mcg/actuation de 5 años en adelanteQvar® Redihaler (beclomethasone)40 mcg/actuation de 12 años en adelante80 mcg/actuation de 12 años en adelanteSymbicort® (budesonide and formoterol fumaratedihydrate)80 mcg – 4.5 mcg/actuation de 12 años en adelante160 mcg – 4.5 mcg/actuation de 12 años en adelanteAcetaminophen/codeine120mg-12mg/5mL solution menores de 18 añosButalbital/acetaminophen/caffeine/codeine50mg/325mg/40mg/30mg capsule menores de 18 añosCodeine sulfate30 mg tablet menores de 18 años60 mg tablet menores de 18 añosFiorinal w/Codeine (butalbital/aspirin/caffeine/codeine)

Ritalin (methylphenidate)

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50mg/325mg/40mg/30mg capsule menores de 18 añosTylenol w/Codeine (acetaminophen/codeine)

300mg/15mg tablet menores de 18 años300mg/30mg tablet menores de 18 años300mg/60mg tablet menores de 18 añosUltracet (tramadol/acetaminophen)

37.5mg/325mg tablet menores de 18 añosUltram (tramadol)

50 mg tablet menores de 18 años

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

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Nombre del medicamento

Cuánto le costaráel medicamento de(nivel)

Acciones necesarias,restricciones o límitesen el uso

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

(Augmentin)1

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

es-600)1

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

chew tab 200-28.5 mg2

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

2

dicloxacillin sodium cap 250 mg 1dicloxacillin sodium cap 500 mg 1penicillin v potassium tab 250 mg 1penicillin v potassium tab 500 mg 1

CEPHALOSPORINScefaclor cap 250 mg 1cefaclor cap 500 mg 1cefadroxil cap 500 mg 1cefadroxil for susp 250 mg/5ml 1cefadroxil for susp 500 mg/5ml 1cefadroxil tab 1 gm 1cefdinir cap 300 mg 1

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cefdinir for susp 125 mg/5ml 1cefdinir for susp 250 mg/5ml 1cefixime for susp 100 mg/5ml (Suprax) 1cefixime for susp 200 mg/5ml (Suprax) 1cefprozil for susp 125 mg/5ml 1cefprozil for susp 250 mg/5ml 1cefprozil tab 250 mg 1cefprozil tab 500 mg 1ceftriaxone sodium for inj 250 mg 1ceftriaxone sodium for inj 500 mg 1ceftriaxone sodium for inj 1 gm 1ceftriaxone sodium for inj 2 gm 1cefuroxime axetil tab 250 mg 1cefuroxime axetil tab 500 mg (Ceftin) 1cephalexin cap 250 mg (Keflex) 1cephalexin cap 500 mg (Keflex) 1cephalexin for susp 125 mg/5ml 1cephalexin for susp 250 mg/5ml 1

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

TETRACYCLINESdemeclocycline hcl tab 150 mg 1demeclocycline hcl tab 300 mg 1doxycycline hyclate cap 50 mg 1doxycycline hyclate cap 100 mg (Vibramycin) 1doxycycline hyclate tab delayed release 50 mg (Doryx) 1 PAdoxycycline hyclate tab 20 mg 1doxycycline hyclate tab 100 mg 1

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

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

(Cipro)1

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

AMINOGLYCOSIDESneomycin sulfate tab 500 mg 1paromomycin sulfate cap 250 mg 1TOBRAMYCIN – tobramycin nebu soln 300 mg/5ml 2 PA, QL (56 units/56

days), SPtobramycin nebu soln 300 mg/5ml (Tobi) 2 PA, QL (56 units/56

days), SP

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

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rifampin cap 300 mg (Rifadin) 1

FUNGAL INFECTIONSfluconazole for susp 10 mg/ml (Diflucan) 1 QL (35 mls/30 days)fluconazole for susp 40 mg/ml (Diflucan) 1 QL (35 mls/30 days)fluconazole tab 50 mg (Diflucan) 1 QL (30 tablets/30 days)fluconazole tab 100 mg (Diflucan) 1 QL (30 tablets/30 days)fluconazole tab 150 mg (Diflucan) 1 QL (30 tablets/30 days)fluconazole tab 200 mg (Diflucan) 1 QL (30 tablets/30 days)flucytosine cap 250 mg (Ancobon) 1flucytosine cap 500 mg (Ancobon) 1griseofulvin microsize susp 125 mg/5ml 1griseofulvin microsize tab 500 mg 1griseofulvin ultramicrosize tab 125 mg (Gris-peg) 1griseofulvin ultramicrosize tab 250 mg (Gris-peg) 1itraconazole cap 100 mg (Sporanox) 1 QL (120

capsules/30 days)NOXAFIL – posaconazole susp 40 mg/ml 2 PAnystatin oral powder 1nystatin tab 500000 unit 1posaconazole tab delayed release 100 mg (Noxafil) 1 PAterbinafine hcl tab 250 mg (Lamisil) 1 QL (90 tablets/365 days)voriconazole for susp 40 mg/ml (Vfend) 1 PAvoriconazole tab 50 mg (Vfend) 1 PAvoriconazole tab 200 mg (Vfend) 1 PA

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

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

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ribavirin cap 200 mg (Rebetol) 2 PA, SPribavirin tab 200 mg (Copegus) 2 PA, SPSOFOSBUVIR/VELPATASVIR – sofosbuvir-velpatasvir tab

400-100 mg2 PA, SP

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

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

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

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

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

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

BIKTARVY – bictegravir-emtricitabine-tenofovir af tab50-200-25 mg

2 QL (30 tablets/30 days)

CIMDUO – lamivudine-tenofovir disoproxil fumarate tab300-300 mg


COMPLERA – emtricitabine-rilpivirine-tenofovir df tab200-25-300 mg


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

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

DELSTRIGO – doravirine-lamivudine-tenofovir df tab100-300-300 mg


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DESCOVY – emtricitabine-tenofovir alafenamide fumarate tab200-25 mg


didanosine delayed release capsule 200 mg (Videx ec) 1 QL (30 capsules/30 days)didanosine delayed release capsule 250 mg (Videx ec) 1 QL (30 capsules/30 days)didanosine delayed release capsule 400 mg (Videx ec) 1 QL (30 capsules/30 days)DOVATO – dolutegravir sodium-lamivudine tab 50-300 mg (base

eq)2 QL (30 tablets/30 days)

EDURANT – rilpivirine hcl tab 25 mg (base equivalent) 2 QL (30 tablets/30 days)efavirenz cap 50 mg (Sustiva) 1 QL (90 capsules/30 days)efavirenz cap 200 mg (Sustiva) 1 QL (60 capsules/30 days)efavirenz tab 600 mg (Sustiva) 1 QL (30 tablets/30 days)EMTRIVA – emtricitabine caps 200 mg 2 QL (30 capsules/30 days)EMTRIVA – emtricitabine soln 10 mg/ml 2 QL (720 mls/30 days)EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg (base

equiv)2 QL (30 tablets/30 days)

fosamprenavir calcium tab 700 mg (base equiv) (Lexiva) 1 QL (120 tablets/30 days)FUZEON – enfuvirtide for inj 90 mg 2 QL (1 kit/30 days)GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab

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

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

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

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

equiv)2 QL (180 tablets/30 days)

ISENTRESS – raltegravir potassium chew tab 100 mg (baseequiv)


ISENTRESS HD – raltegravir potassium tab 600 mg (base equiv) 2 QL (60 tablets/30 days)JULUCA – dolutegravir sodium-rilpivirine hcl tab 50-25 mg (base

eq)2 QL (30 tablets/30 days)

KALETRA – lopinavir-ritonavir tab 100-25 mg 2 QL (180 tablets/30 days)KALETRA – lopinavir-ritonavir tab 200-50 mg 2 QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml (Epivir) 1 QL (4 bottles/30 days)lamivudine tab 150 mg (Epivir) 1 QL (30 tablets/30 days)lamivudine tab 300 mg (Epivir) 1 QL (30 tablets/30 days)

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lamivudine-zidovudine tab 150-300 mg (Combivir) 1 QL (60 tablets/30 days)LEXIVA – fosamprenavir calcium susp 50 mg/ml (base equiv) 2 QL (8 bottles/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) (Kaletra) 1 QL (480 mls/30 days)nevirapine susp 50 mg/5ml (Viramune) 1 QL (1200 mls/30 days)nevirapine tab er 24hr 100 mg (Viramune xr) 1 QL (90 tablets/30 days)nevirapine tab er 24hr 400 mg (Viramune xr) 1 QL (30 tablets/30 days)nevirapine tab 200 mg (Viramune) 1 QL (60 tablets/30 days)NORVIR – ritonavir oral soln 80 mg/ml 2 QL (2 bottles/30 days)ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab


PIFELTRO – doravirine tab 100 mg 2 QL (30 tablets/30 days)PREZCOBIX – darunavir-cobicistat tab 800-150 mg 2 QL (30 tablets/30 days)PREZISTA – darunavir ethanolate susp 100 mg/ml (base equiv) 2 QL (2 bottles/30 days)PREZISTA – darunavir ethanolate tab 75 mg (base equiv) 2 QL (300 tablets/30 days)PREZISTA – darunavir ethanolate tab 150 mg (base equiv) 2 QL (180 tablets/30 days)PREZISTA – darunavir ethanolate tab 600 mg (base equiv) 2 QL (60 tablets/30 days)PREZISTA – darunavir ethanolate tab 800 mg (base equiv) 2 QL (30 tablets/30 days)RESCRIPTOR – delavirdine mesylate tab 200 mg 2 QL (180 tablets/30 days)ritonavir tab 100 mg (Norvir) 1 QL (180 tablets/30 days)SELZENTRY – maraviroc tab 150 mg 2 QL (60 tablets/30 days)SELZENTRY – maraviroc tab 300 mg 2 QL (120 tablets/30 days)stavudine cap 15 mg (Zerit) 1 QL (60 capsules/30 days)stavudine cap 20 mg (Zerit) 1 QL (60 capsules/30 days)stavudine cap 30 mg (Zerit) 1 QL (60 capsules/30 days)stavudine cap 40 mg (Zerit) 1 QL (60 capsules/30 days)STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab

150-150-200-300 mg2 QL (30 tablets/30 days)

SUSTIVA – efavirenz tab 600 mg 2 QL (30 tablets/30 days)SUSTIVA – efavirenz cap 50 mg 2 QL (90 capsules/30 days)SUSTIVA – efavirenz cap 200 mg 2 QL (60 capsules/30 days)SYMFI – efavirenz-lamivudine-tenofovir df tab 600-300-300 mg 2 QL (30 tablets/30 days)SYMFI LO – efavirenz-lamivudine-tenofovir df tab


SYMTUZA – darunavir-cobic-emtricitab-tenofov af tab800-150-200-10 mg


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

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TIVICAY – dolutegravir sodium tab 50 mg (base equiv) 2 QL (60 tablets/30 days)TRIUMEQ – abacavir-dolutegravir-lamivudine tab 600-50-300 mg 2 QL (30 tablets/30 days)TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab

100-150 mg2 QL (30 tablets/30 days)

TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab133-200 mg






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

capsules/30 days)zidovudine syrup 10 mg/ml (Retrovir) 1 QL (8 bottles/30 days)zidovudine tab 300 mg 1 QL (60 tablets/30 days)

Influenzaoseltamivir phosphate cap 30 mg (base equiv) (Tamiflu) 1 QL (20 capsules/120

days)oseltamivir phosphate cap 45 mg (base equiv) (Tamiflu) 1 QL (20 capsules/120

days)oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu) 1 QL (20 capsules/120

days)oseltamivir phosphate for susp 6 mg/ml (base equiv) (Tamiflu) 1 QL (360 mls/120 days)RELENZA DISKHALER – zanamivir aero powder breath

activated 5 mg/blister2 QL (40 blisters/120 days)

MALARIAatovaquone-proguanil hcl tab 62.5-25 mg (Malarone) 1 QL (30 tablets/90 days)atovaquone-proguanil hcl tab 250-100 mg (Malarone) 1 QL (30 tablets/90 days)chloroquine phosphate tab 500 mg (Aralen) 1

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DARAPRIM – pyrimethamine tab 25 mg 2 PA, QL (90tablets/30 days)

hydroxychloroquine sulfate tab 200 mg (Plaquenil) 1KRINTAFEL – tafenoquine succinate tab 150 mg (base

equivalent)2

MEFLOQUINE HCL – mefloquine hcl tab 250 mg 2primaquine phosphate tab 26.3 mg (15 mg base) (Primaquine

phosphate)1

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

OTHER ANTI-INFECTIVESALINIA – nitazoxanide tab 500 mg 2 QL (6 tablets/30 days)CAYSTON – aztreonam lysine for inhal soln 75 mg (base

equivalent)2 PA, QL (84 boxes/56

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

(Cleocin pediatric gr)1

dapsone tab 25 mg 1dapsone tab 100 mg 1linezolid for susp 100 mg/5ml (Zyvox) 1 PA, QL (600

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

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

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vancomycin hcl cap 250 mg (base equivalent) (Vancocin hcl) 1XIFAXAN – rifaximin tab 550 mg 2 PA, QL (60

tablets/30 days)ZYVOX – linezolid for susp 100 mg/5ml 2 PA, QL (600

mls/180 days)

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

mcg/0.5ml2

AFLURIA QUADRIVALENT 2019-2020 – influenza virus vac splitquadrivalent susp pref syr 0.25 ml

2

AFLURIA QUADRIVALENT 2019-2020 – influenza virus vac splitquadrivalent susp pref syr 0.5ml

2

AFLURIA QUADRIVALENT 2019-2020 – influenza virus vaccinesplit quadrivalent im inj

2

BOOSTRIX – tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml

2

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

2

ENGERIX-B – hepatitis b vaccine (recombinant) susp 20 mcg/ml 2ENGERIX-B – hepatitis b vaccine (recombinant) 10 mcg/0.5ml 2ENGERIX-B – hepatitis b vaccine (recombinant) 20 mcg/ml 2FLUAD 2019-2020 – influenza vac type a&b surface ant adj susp

pref syr 0.5 ml2

FLUARIX QUADRIVALENT 2019-2020 – influenza virus vac splitquadrivalent susp pref syr 0.5ml

2

FLUBLOK QUADRIVALENT 2019-2020 – influenza vac recombha quad pf soln pref syr 0.5 ml

2

FLUCELVAX QUADRIVALENT 2019-2020 – influenza vac tiss-cult subunt quad susp pref syr 0.5 ml

2

FLUCELVAX QUADRIVALENT 2019-2020 – influenza vac tissue-cultured subunit quadrivalent im susp

2

FLULAVAL QUADRIVALENT 2019-2020 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml

2

FLULAVAL QUADRIVALENT 2019-2020 – influenza virusvaccine split quadrivalent im inj

2

FLUZONE HIGH-DOSE PF 2019-2020 – influenza virus vac splithigh-dose pf susp pref syr 0.5ml

2

FLUZONE QUADRIVALENT 2019-2020 – influenza virus vacsplit quadrivalent susp pref syr 0.25 ml

2

FLUZONE QUADRIVALENT 2019-2020 – influenza virus vacsplit quadrivalent susp pref syr 0.5ml

2

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FLUZONE QUADRIVALENT 2019-2020 – influenza virus vaccinesplit quadrivalent im inj

2

FLUZONE QUADRIVALENT 2019-2020 – influenza virus vaccinesplit quadrivalent inj 0.5 ml

2

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

2

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

2

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

25 mcg/0.5ml2

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

2

PREVNAR 13 – pneumococcal 13-valent conjugate vaccine inj 2RABAVERT – rabies vaccine, pcec for inj 2RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml2

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

2

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

2

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

2 QL (2 vaccines/1 lifetime)

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

unit/0.65ml2 QL (1 vaccine/1 lifetime)

CANCER DRUGSabiraterone acetate tab 250 mg (Zytiga) 2 PA, QL (120 tablets/30

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

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

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

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

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

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

days), SF, SP

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



ALECENSA – alectinib hcl cap 150 mg (base equivalent) 2 PA, QL (240 capsules/30days), SF, SP

ALKERAN – melphalan tab 2 mg 2 SPanastrozole tab 1 mg (Arimidex) 1 90BALVERSA – erdafitinib tab 3 mg 2 PA, QL (84 tablets/28

days), SF, SPBALVERSA – erdafitinib tab 4 mg 2 PA, QL (56 tablets/28

days), SF, SPBALVERSA – erdafitinib tab 5 mg 2 PA, QL (28 tablets/28

days), SF, SPbexarotene cap 75 mg (Targretin) 2 PA, SF, SPbicalutamide tab 50 mg (Casodex) 2 SPBOSULIF – bosutinib tab 100 mg 2 PA, QL (120 tablets/30

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

days), SF, SPBRAFTOVI – encorafenib cap 75 mg 2 PA, QL (180

capsules/30 days), SPCABOMETYX – cabozantinib s-malate tab 20 mg (base

equivalent)2 PA, QL (30 tablets/30

days), SF, SPCABOMETYX – cabozantinib s-malate tab 40 mg (base


days), SF, SPCABOMETYX – cabozantinib s-malate tab 60 mg (base


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

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

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

days), SP

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COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 mg dose)kit

2 PA, QL (1 carton/28days), SF, SP

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg(100 dose) kit


COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg(140 dose) kit


COPIKTRA – duvelisib cap 15 mg 2 PA, QL (56 capsules/28days), SF, SP

COPIKTRA – duvelisib cap 25 mg 2 PA, QL (56 capsules/28days), SF, SP

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

cyclophosphamide cap 25 mg (Cyclophosphamide) 1cyclophosphamide cap 50 mg (Cyclophosphamide) 1DAURISMO – glasdegib maleate tab 25 mg (base equivalent) 2 PA, QL (60 tablets/30

days), SF, SPDAURISMO – glasdegib maleate tab 100 mg (base equivalent) 2 PA, QL (30 tablets/30

days), SF, SPELIGARD – leuprolide acetate for subcutaneous inj kit 7.5 mg 2 SPELIGARD – leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg2 SP

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

2 SP

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

2 SP

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

ERLEADA – apalutamide tab 60 mg 2 PA, QL (120tablets/30 days), SP

erlotinib hcl tab 25 mg (base equivalent) (Tarceva) 2 PA, QL (60 tablets/30days), SF, SP



ETOPOSIDE – etoposide cap 50 mg 2 SPexemestane tab 25 mg (Aromasin) 1 90flutamide cap 125 mg 1

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GILOTRIF – afatinib dimaleate tab 20 mg (base equivalent) 2 PA, QL (30 tablets/30days), SP



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

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

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

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

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

days), SF, SPimatinib mesylate tab 100 mg (base equivalent) (Gleevec) 2 PA, QL (90 tablets/30

days), SF, SPimatinib mesylate tab 400 mg (base equivalent) (Gleevec) 2 PA, QL (60 tablets/30

days), SF, SPINLYTA – axitinib tab 1 mg 2 PA, QL (180 tablets/30

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

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





days), SF, SPKISQALI – ribociclib succinate tab pack 200 mg daily dose 2 PA, QL (63 tablets/28

days), SP

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KISQALI – ribociclib succinate tab pack 400 mg daily dose(200 mg tab)

2 PA, QL (63 tablets/28days), SP

KISQALI – ribociclib succinate tab pack 600 mg daily dose(200 mg tab)


KISQALI FEMARA 200 DOSE – ribociclib 200 mg dose (200 mgtab) & letrozole 2.5 mg tbpk






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

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

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


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


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


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


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


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


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


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

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

days), SPLORBRENA – lorlatinib tab 25 mg 2 PA, QL (90 tablets/30

days), SF, SP

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LORBRENA – lorlatinib tab 100 mg 2 PA, QL (30 tablets/30days), SF, SP

LUPRON DEPOT (1-MONTH) – leuprolide acetate for inj kit3.75 mg

2 PA, SP

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

2 PA, SP

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

2 PA, SP

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

2 PA, SP

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

2 PA, SP

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

2 PA, SP

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

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

LYSODREN – mitotane tab 500 mg 2 PA, SPMATULANE – procarbazine hcl cap 50 mg 2 PA, SPmegestrol acetate susp 40 mg/ml (Megace oral) 1megestrol acetate tab 20 mg 1megestrol acetate tab 40 mg 1MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg (base


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


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

tablets/30 days), SPmercaptopurine tab 50 mg 1methotrexate sodium tab 2.5 mg (base equiv) 1MYLERAN – busulfan tab 2 mg 2 SPNERLYNX – neratinib maleate tab 40 mg (base equivalent) 2 PA, QL (180 tablets/30

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

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

days), SP

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

NINLARO member friendly text – ixazomib citrate cap 2.3 mg(base equivalent)

2 PA, QL (3 capsules/28days), SP

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




PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml) 2 PA, SPRUBRACA – rucaparib camsylate tab 200 mg (base equivalent) 2 PA, QL (120 tablets/30

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

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

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






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

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

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

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

days), SF, SP

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

SYLATRON – peginterferon alfa-2b for inj kit 200 mcg 2 PA, SPSYLATRON – peginterferon alfa-2b for inj kit 300 mcg 2 PA, SPSYLATRON – peginterferon alfa-2b for inj kit 600 mcg 2 PA, SPTABLOID – thioguanine tab 40 mg 2 SPTAFINLAR – dabrafenib mesylate cap 50 mg (base equivalent) 2 PA, QL (120

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

capsules/30 days), SPTALZENNA – talazoparib tosylate cap 0.25 mg (base equivalent) 2 PA, QL (90 capsules/30

days), SF, SPTALZENNA – talazoparib tosylate cap 1 mg (base equivalent) 2 PA, QL (30 capsules/30

days), SF, SPtamoxifen citrate tab 10 mg (base equivalent) 1tamoxifen citrate tab 20 mg (base equivalent) 1TARGRETIN – bexarotene cap 75 mg 2 PA, SF, SPTASIGNA – nilotinib hcl cap 50 mg (base equivalent) 2 PA, QL (120 capsules/30

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

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

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

days), SPtoremifene citrate tab 60 mg (base equivalent) (Fareston) 1 SPtretinoin cap 10 mg 2 PA, SPTYKERB – lapatinib ditosylate tab 250 mg (base equiv) 2 PA, QL (180

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

days), SP

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

VENCLEXTA – venetoclax tab 100 mg 2 PA, QL (180tablets/30 days), SP

VENCLEXTA STARTING PACK – venetoclax tab therapy starterpack 10 & 50 & 100 mg

2 PA, QL (1 pack/180days), SP

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




VITRAKVI – larotrectinib sulfate oral soln 20 mg/ml (baseequivalent)

2 PA, QL (300 mls/30days), SF, SP

VITRAKVI – larotrectinib sulfate cap 25 mg (base equivalent) 2 PA, QL (180 capsules/30days), SF, SP

VITRAKVI – larotrectinib sulfate cap 100 mg (base equivalent) 2 PA, QL (60 capsules/30days), SF, SP

VIZIMPRO – dacomitinib tab 15 mg 2 PA, QL (30 tablets/30days), SF, SP



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

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

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

XOSPATA – gilteritinib fumarate tablet 40 mg (base equivalent) 2 PA, QL (90 tablets/30days), SP

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

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

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

ZOLINZA – vorinostat cap 100 mg 2 PA, QL (120 capsules/30days), SF, SP

ZYKADIA – ceritinib cap 150 mg 2 PA, QL (90 capsules/30days), SF, SP

ZYKADIA – ceritinib tab 150 mg 2 PA, QL (90 tablets/30days), SF, SP

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

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

equivalent)2

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

1

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

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

100 mg2

SOLU-CORTEF – hydrocortisone sodium succinate pf for inj250 mg

2


2


2

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

packets/30 days)testosterone td gel 50 mg/5gm (1%) (Androgel) 1 PA, QL (60

packets/30 days)testosterone td gel 12.5 mg/act (1%) (Androgel pump) 1 PA, QL (4 pump

bottles/30 days)

ESTROGENSCOMBIPATCH – estradiol-norethindrone ace td pttw

0.05-0.14 mg/day2 90

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

2 90

estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella) 1 90estradiol & norethindrone acetate tab 1-0.5 mg (Activella) 1 90estradiol tab 0.5 mg (Estrace) 1 90estradiol tab 1 mg (Estrace) 1 90estradiol tab 2 mg (Estrace) 1 90

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





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

estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)(Climara)

1 QL (4 patches/28days), 90





ESTROGEL – estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump)

2 90

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg(Femhrt low dose)

1 90

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

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

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

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

2

LILETTA – levonorgestrel releasing iud 19.5 mcg/day (52 mgtotal)

2

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

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

PARAGARD INTRAUTERINE COP – copper iud 2 90SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5 mg total) 2 90XULANE – norelgestromin-ethinyl estradiol td ptwk

150-35 mcg/24hr2 QL (3 patches/21

days), 90

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

norethindrone tab 5 mg kit2 PA, SP

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

2 PA, SP

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

2 PA, SP


2 PA, SP

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

2 PA, SP

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

2 PA, SP

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

2 PA, SP

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

2

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

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

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

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

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

days), ST, 90

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

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

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

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


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






ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab25-15 mg






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



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

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

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

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

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

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

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

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

GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj kit 1 mg 2 QL (6 pens/365 days)glyburide tab 1.25 mg 1 QL (60 tablets/30

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

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

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

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

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

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

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

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

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



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

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

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



days), 90STEGLATRO – ertugliflozin l-pyroglutamic acid tab 5 mg (base

equiv)2 QL (60 tablets/30

days), ST

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

2 QL (30 tablets/30days), ST

TRULICITY – dulaglutide soln pen-injector 0.75 mg/0.5ml 2 PA, QL (4 pens/28 days)TRULICITY – dulaglutide soln pen-injector 1.5 mg/0.5ml 2 PA, QL (4 pens/28 days)VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 2 PA, QL (3 pens/30 days)

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

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

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

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

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

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

2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

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

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

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

2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

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


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

2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

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

2 QL (45 mls/30 days), 90

Basal InsulinsBASAGLAR KWIKPEN – insulin glargine soln pen-injector 100


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

GROWTH HORMONEINCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml) 2 PA, SPOMNITROPE – somatropin for inj 5.8 mg 2 PA, SP

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SEROSTIM – somatropin (non-refrigerated) for subcutaneous inj4 mg

2 PA, SP


2 PA, SP


2 PA, SP

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

2 PA, SP

OTHER HORMONES AND RELATED DRUGSACTHAR – corticotropin inj gel 80 unit/ml 2 PA, SPALENDRONATE SODIUM – alendronate sodium tab 5 mg 2 QL (30 tablets/30

days), 90ALENDRONATE SODIUM – alendronate sodium tab 40 mg 2 QL (30 tablets/30 days)alendronate sodium tab 10 mg 1 QL (30 tablets/30

days), 90alendronate sodium tab 35 mg 1 QL (4 tablets/28 days), 90alendronate sodium tab 70 mg (Fosamax) 1 QL (4 tablets/28 days), 90BUPHENYL – sodium phenylbutyrate tab 500 mg 2 PA, SPcabergoline tab 0.5 mg 1calcitonin (salmon) nasal soln 200 unit/act (Miacalcin) 1 90calcitriol cap 0.25 mcg (Rocaltrol) 1 90calcitriol cap 0.5 mcg (Rocaltrol) 1 90calcitriol oral soln 1 mcg/ml (Rocaltrol) 1 90CARBAGLU – carglumic acid tab 200 mg 2 PA, SPcinacalcet hcl tab 30 mg (base equiv) 1 PA, 90cinacalcet hcl tab 60 mg (base equiv) 1 PA, 90cinacalcet hcl tab 90 mg (base equiv) 1 PA, 90CYSTADANE – betaine powder for oral solution 2 PA, QL (180

grams/30 days), 90desmopressin acetate nasal spray soln 0.01% (Ddavp) 1desmopressin acetate nasal spray soln 0.01% (refrigerated) 1desmopressin acetate tab 0.1 mg (Ddavp) 1 90desmopressin acetate tab 0.2 mg (Ddavp) 1 90ETIDRONATE DISODIUM – etidronate disodium tab 200 mg 2ibandronate sodium tab 150 mg (base equivalent) (Boniva) 1 QL (1 tablet/30 days), 90KUVAN – sapropterin dihydrochloride soluble tab 100 mg 2 PA, SPKUVAN – sapropterin dihydrochloride powder packet 100 mg 2 PA, SP

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KUVAN – sapropterin dihydrochloride powder packet 500 mg 2 PA, SPlevocarnitine oral soln 1 gm/10ml (10%) (Carnitor) 1 90levocarnitine tab 330 mg (Carnitor) 1 90LUPRON DEPOT-PED (1-MONTH – leuprolide acetate for inj

pediatric kit 7.5 mg2 PA, SP


2 PA, SP

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

2 PA, SP

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

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

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



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





days), SPSTIMATE – desmopressin acetate nasal soln 1.5 mg/ml 2STRENSIQ – asfotase alfa subcutaneous inj 18 mg/0.45ml 2 PA, SP

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STRENSIQ – asfotase alfa subcutaneous inj 28 mg/0.7ml 2 PA, SPSTRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml 2 PA, SPSTRENSIQ – asfotase alfa subcutaneous inj 80 mg/0.8ml 2 PA, SPTYMLOS – abaloparatide subcutaneous soln pen-injector

3120 mcg/1.56ml2 PA, QL (1 pen/30

days), SPXURIDEN – uridine triacetate oral granules packet 2 gm 2 SP

HEART AND CIRCULATORY DRUGSANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIbenazepril & hydrochlorothiazide tab 5-6.25 mg 1 90benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) 1 90benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct) 1 90benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct) 1 90benazepril hcl tab 5 mg 1 90benazepril hcl tab 10 mg (Lotensin) 1 90benazepril hcl tab 20 mg (Lotensin) 1 90benazepril hcl tab 40 mg (Lotensin) 1 90captopril tab 12.5 mg 1 90captopril tab 25 mg 1 90captopril tab 50 mg 1 90captopril tab 100 mg 1 90CAPTOPRIL/HYDROCHLOROTHIA – captopril &

hydrochlorothiazide tab 25-15 mg2 90

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

2 90


2 90


2 90

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

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

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

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

days), 90

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

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

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

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

1 QL (30 tablets/30days), 90

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


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


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



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



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


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


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


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




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


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


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

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

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metoprolol succinate tab er 24hr 100 mg (tartrate equiv) (Toprolxl)

1 90

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

1 90

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


nadolol tab 20 mg (Corgard) 1 90nadolol tab 40 mg (Corgard) 1 90nadolol tab 80 mg (Corgard) 1 90pindolol tab 5 mg 1 90PROPRANOLOL HCL – propranolol hcl oral soln 20 mg/5ml 2 90PROPRANOLOL HCL – propranolol hcl oral soln 40 mg/5ml 2 90propranolol hcl cap er 24hr 60 mg (Inderal la) 1 90propranolol hcl cap er 24hr 80 mg (Inderal la) 1 90propranolol hcl cap er 24hr 120 mg (Inderal la) 1 90propranolol hcl cap er 24hr 160 mg (Inderal la) 1 90propranolol hcl tab 10 mg 1 90propranolol hcl tab 20 mg 1 90propranolol hcl tab 40 mg 1 90propranolol hcl tab 60 mg 1 90propranolol hcl tab 80 mg 1 90PROPRANOLOL/HYDROCHLOROTH – propranolol &


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

2 90

CALCIUM CHANNEL BLOCKERS AND COMBINATIONSamlodipine besylate tab 2.5 mg (base equivalent) (Norvasc) 1 90amlodipine besylate tab 5 mg (base equivalent) (Norvasc) 1 90amlodipine besylate tab 10 mg (base equivalent) (Norvasc) 1 90amlodipine besylate-benazepril hcl cap 2.5-10 mg 1 90amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel) 1 90amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel) 1 90amlodipine besylate-benazepril hcl cap 5-40 mg 1 90amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel) 1 90

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amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel) 1 90DILT-XR – diltiazem hcl cap er 24hr 120 mg 2 90diltiazem hcl cap er 12hr 60 mg 1 90diltiazem hcl cap er 12hr 90 mg 1 90diltiazem hcl cap er 12hr 120 mg 1 90diltiazem hcl cap er 24hr 180 mg 1 90diltiazem hcl cap er 24hr 240 mg 1 90diltiazem hcl coated beads cap er 24hr 120 mg (Cardizem cd) 1 90diltiazem hcl coated beads cap er 24hr 180 mg (Cardizem cd) 1 90diltiazem hcl coated beads cap er 24hr 240 mg (Cardizem cd) 1 90diltiazem hcl coated beads cap er 24hr 300 mg 1 90diltiazem hcl extended release beads cap er 24hr 120 mg

(Tiazac)1 90

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

1 90


1 90


1 90


1 90


1 90

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

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

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

days), 90felodipine tab er 24hr 2.5 mg 1 90felodipine tab er 24hr 5 mg 1 90felodipine tab er 24hr 10 mg 1 90isradipine cap 2.5 mg 1 90isradipine cap 5 mg 1 90

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nicardipine hcl cap 20 mg 1 90nifedipine cap 10 mg (Procardia) 1 90nifedipine cap 20 mg 1 90nifedipine tab er 24hr 30 mg (Adalat cc) 1 90nifedipine tab er 24hr 60 mg (Adalat cc) 1 90nifedipine tab er 24hr 90 mg (Adalat cc) 1 90nifedipine tab er 24hr osmotic release 30 mg (Procardia xl) 1 90nifedipine tab er 24hr osmotic release 60 mg (Procardia xl) 1 90nifedipine tab er 24hr osmotic release 90 mg (Procardia xl) 1 90nimodipine cap 30 mg 1 90trandolapril-verapamil hcl tab er 2-180 mg (Tarka) 1 90trandolapril-verapamil hcl tab er 2-240 mg (Tarka) 1 90trandolapril-verapamil hcl tab er 4-240 mg (Tarka) 1 90TRANDOLAPRIL/VERAPAMIL HC – trandolapril-verapamil hcl

tab er 1-240 mg2 90

verapamil hcl cap er 24hr 120 mg (Verelan) 1 90verapamil hcl cap er 24hr 180 mg (Verelan) 1 90verapamil hcl cap er 24hr 200 mg (Verelan pm) 1 90verapamil hcl cap er 24hr 240 mg (Verelan) 1 90VERAPAMIL HCL ER – verapamil hcl cap er 24hr 100 mg 2 90VERAPAMIL HCL ER – verapamil hcl cap er 24hr 300 mg 2 90VERAPAMIL HCL SR – verapamil hcl cap er 24hr 360 mg 2 90verapamil hcl tab er 120 mg (Calan sr) 1 90verapamil hcl tab er 180 mg (Calan sr) 1 90verapamil hcl tab er 240 mg (Calan sr) 1 90verapamil hcl tab 40 mg 1 90verapamil hcl tab 80 mg (Calan) 1 90verapamil hcl tab 120 mg (Calan) 1 90

CHEST PAINisosorbide mononitrate tab er 24hr 30 mg 1 90isosorbide mononitrate tab er 24hr 60 mg 1 90isosorbide mononitrate tab er 24hr 120 mg 1 90isosorbide mononitrate tab 10 mg 1 90isosorbide mononitrate tab 20 mg 1 90NITRO-TIME – nitroglycerin cap er 6.5 mg 2 90

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NITRO-TIME – nitroglycerin cap er 9 mg 2 90nitroglycerin cap er 2.5 mg 1 90nitroglycerin sl tab 0.3 mg (Nitrostat) 1nitroglycerin sl tab 0.4 mg (Nitrostat) 1nitroglycerin sl tab 0.6 mg (Nitrostat) 1nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) 1 90nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) 1 90nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) 1 90nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur) 1 90

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

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



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

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

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



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

days), 90

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

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

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

fluvastatin sodium tab er 24 hr 80 mg (base equivalent) (Lescolxl)


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

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






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

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

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

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

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



REPATHA – evolocumab subcutaneous soln prefilled syringe140 mg/ml

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

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

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

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

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

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




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





FLUID RETENTIONacetazolamide cap er 12hr 500 mg (Diamox) 1 90acetazolamide tab 250 mg 1 90amiloride & hydrochlorothiazide tab 5-50 mg 1 90amiloride hcl tab 5 mg 1 90bumetanide tab 0.5 mg (Bumex) 1 90bumetanide tab 1 mg (Bumex) 1 90bumetanide tab 2 mg (Bumex) 1 90CHLOROTHIAZIDE – chlorothiazide tab 250 mg 2 90CHLOROTHIAZIDE – chlorothiazide tab 500 mg 2 90chlorthalidone tab 25 mg 1 90furosemide oral soln 10 mg/ml 1 90furosemide tab 20 mg (Lasix) 1 90furosemide tab 40 mg (Lasix) 1 90furosemide tab 80 mg (Lasix) 1 90

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

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

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QUINIDINE SULFATE – quinidine sulfate tab 300 mg 2 90sotalol hcl (afib/afl) tab 80 mg (Betapace af) 1 90sotalol hcl (afib/afl) tab 120 mg (Betapace af) 1 90sotalol hcl (afib/afl) tab 160 mg (Betapace af) 1 90sotalol hcl tab 80 mg (Betapace) 1 90sotalol hcl tab 120 mg (Betapace) 1 90sotalol hcl tab 160 mg (Betapace) 1 90sotalol hcl tab 240 mg 1 90

OTHER HEART RELATED DRUGSADEMPAS – riociguat tab 0.5 mg 2 PA, QL (90 tablets/30

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

days), SPADEMPAS – riociguat tab 1.5 mg 2 PA, QL (90 tablets/30

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

days), SPADEMPAS – riociguat tab 2.5 mg 2 PA, QL (90 tablets/30

days), SPambrisentan tab 5 mg (Letairis) 2 PA, QL (30 tablets/30

days), SPambrisentan tab 10 mg (Letairis) 2 PA, QL (30 tablets/30

days), SPbosentan tab 62.5 mg (Tracleer) 2 PA, QL (60 tablets/30

days), SPbosentan tab 125 mg (Tracleer) 2 PA, QL (60 tablets/30

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

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




guanfacine hcl tab 1 mg (Tenex) 1 90guanfacine hcl tab 2 mg (Tenex) 1 90hydralazine hcl tab 10 mg 1 90hydralazine hcl tab 25 mg 1 90hydralazine hcl tab 50 mg 1 90hydralazine hcl tab 100 mg 1 90methyldopa tab 250 mg 1 90methyldopa tab 500 mg 1 90midodrine hcl tab 2.5 mg 1midodrine hcl tab 5 mg 1midodrine hcl tab 10 mg 1minoxidil tab 2.5 mg 1 90minoxidil tab 10 mg 1 90phenoxybenzamine hcl cap 10 mg (Dibenzyline) 1prazosin hcl cap 1 mg (Minipress) 1 90prazosin hcl cap 2 mg (Minipress) 1 90prazosin hcl cap 5 mg (Minipress) 1 90sildenafil citrate for suspension 10 mg/ml (Revatio) 2 PA, QL (2 bottles/30

days), SPsildenafil citrate tab 20 mg (Revatio) 1 PA, QL (90 tablets/30

days), SPtadalafil tab 20 mg (pah) (Adcirca) 2 PA, QL (60 tablets/30

days), SPterazosin hcl cap 1 mg (base equivalent) 1 QL (30 capsules/30

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

days), 90terazosin hcl cap 5 mg (base equivalent) 1 QL (30 capsules/30

days), 90

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terazosin hcl cap 10 mg (base equivalent) 1 QL (60 capsules/30days), 90

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

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

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

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

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

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

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

UPTRAVI – selexipag tab 200 mcg 2 PA, QL (140tablets/180 days), SP








ANAPHYLAXISepinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)

(Epipen-jr 2-pak)1 QL (4 pens/1

prescription)epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) (Epipen

2-pak)1 QL (4 pens/1

prescription)

RESPIRATORY AGENTSANTIHISTAMINEScarbinoxamine maleate soln 4 mg/5ml 1

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

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

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

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

promethazine w/ codeine syrup 6.25-10 mg/5ml 1 ME90sodium chloride soln nebu 0.9% 1sodium chloride soln nebu 3% 1sodium chloride soln nebu 7% (Hyper-sal) 1sodium chloride soln nebu 10% 1

ASTHMA/COPDALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr 4 mg 2 90ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr 8 mg 2 90ALBUTEROL SULFATE HFA – albuterol sulfate inhal aero

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

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albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 1 QL (125containers/30 days)

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

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

containers/30 days)albuterol sulfate syrup 2 mg/5ml 1albuterol sulfate tab 2 mg 1albuterol sulfate tab 4 mg 1ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath

activ 50 mcg/act2 QL (30 blisters/30 days)

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

2 QL (30 blisters/30days), 90

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


ATROVENT HFA – ipratropium bromide hfa inhal aerosol17 mcg/act

2 QL (2 inhalers/30days), 90

BEVESPI AEROSPHERE – glycopyrrolate-formoterol fumarateaerosol 9-4.8 mcg/act

2 QL (1 inhaler/30days), 90

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

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

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

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

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

blister2 AL, QL (1 inhaler/30

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

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

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

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

days), 90FLOVENT HFA – fluticasone propionate hfa inhal aero 44 mcg/

act (50/valve)2 AL, QL (1 inhaler/30

days), 90FLOVENT HFA – fluticasone propionate hfa inhal aer 110 mcg/

act (125/valve)2 AL, QL (1 inhaler/30

days), 90

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

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

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






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


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

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

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

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

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

1 QL (30 packets/30days), 90

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

QVAR REDIHALER – beclomethasone diprop hfa breath act inhaer 40 mcg/act

2 AL, QL (1inhaler/30 days)

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

2 AL, QL (2inhalers/30 days)

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


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

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

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

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

terbutaline sulfate tab 2.5 mg 1 90terbutaline sulfate tab 5 mg 1 90THEOCHRON – theophylline tab er 12hr 100 mg 2 90THEOCHRON – theophylline tab er 12hr 200 mg 2 90THEOPHYLLINE ER – theophylline tab er 12hr 450 mg 2 90theophylline soln 80 mg/15ml 1 90

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theophylline tab er 12hr 300 mg 1 90theophylline tab er 24hr 400 mg 1 90theophylline tab er 24hr 600 mg 1 90

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

capsules/30 days), SPKALYDECO – ivacaftor tab 150 mg 2 PA, QL (60 tablets/30

days), SPKALYDECO – ivacaftor packet 25 mg 2 PA, QL (60 packets/30



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

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

days), SPORKAMBI – lumacaftor-ivacaftor tab 100-125 mg 2 PA, QL (120

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

tablets/30 days), SPORKAMBI – lumacaftor-ivacaftor granules packet 100-125 mg 2 PA, QL (60 packets/30

days), SPORKAMBI – lumacaftor-ivacaftor granules packet 150-188 mg 2 PA, QL (60 packets/30

days), SPPULMOZYME – dornase alfa inhal soln 1 mg/ml 2 PA, SPSYMDEKO – tezacaftor-ivacaftor 50-75 mg & ivacaftor 75 mg tab

tbpk2 PA, QL (60 tablets/30

days), SPSYMDEKO – tezacaftor-ivacaftor 100-150 mg & ivacaftor 150 mg

tab tbpk2 PA, QL (60 tablets/30

days), SP

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

pack)1

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

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peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte-flavor packs)

1

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

ULCER/GERDCIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml 2 90dicyclomine hcl cap 10 mg (Bentyl) 1dicyclomine hcl oral soln 10 mg/5ml 1dicyclomine hcl tab 20 mg (Bentyl) 1famotidine for susp 40 mg/5ml (Pepcid) 1 90famotidine tab 20 mg (Pepcid) 1 90famotidine tab 40 mg (Pepcid) 1 90glycopyrrolate tab 1 mg (Robinul) 1glycopyrrolate tab 2 mg (Robinul forte) 1hyoscyamine sulfate elixir 0.125 mg/5ml 1 90hyoscyamine sulfate sl tab 0.125 mg (Levsin/sl) 1 90hyoscyamine sulfate soln 0.125 mg/ml 1 90hyoscyamine sulfate tab disint 0.125 mg (Anaspaz) 1 90hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid) 1 90hyoscyamine sulfate tab 0.125 mg (Levsin) 1 90lansoprazole cap delayed release 15 mg (Prevacid) 1 QL (120 days

supply/365 days)lansoprazole cap delayed release 30 mg (Prevacid) 1 QL (120 days

supply/365 days)methscopolamine bromide tab 2.5 mg (Pamine) 1misoprostol tab 100 mcg (Cytotec) 1 90misoprostol tab 200 mcg (Cytotec) 1 90nizatidine cap 150 mg 1 90nizatidine cap 300 mg 1 90omeprazole cap delayed release 10 mg (Prilosec) 1 QL (120 days

supply/365 days)omeprazole cap delayed release 20 mg (Prilosec) 1 QL (120 days

supply/365 days)omeprazole cap delayed release 40 mg (Prilosec) 1 QL (120 days

supply/365 days)

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

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

rabeprazole sodium ec tab 20 mg (Aciphex) 1 QL (120 dayssupply/365 days)

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

NAUSEA AND VOMITINGaprepitant capsule 40 mg (Emend) 1 QL (2 capsules/30 days)aprepitant capsule 80 mg (Emend) 1 QL (6 capsules/30 days)aprepitant capsule 125 mg (Emend) 1 QL (3 capsules/30 days)meclizine hcl tab 12.5 mg 1meclizine hcl tab 25 mg 1ondansetron hcl oral soln 4 mg/5ml (Zofran) 1 QL (300 mls/30 days)ondansetron hcl tab 4 mg (Zofran) 1 QL (30 tablets/30 days)ondansetron hcl tab 8 mg (Zofran) 1 QL (30 tablets/30 days)ondansetron hcl tab 24 mg 1 QL (1 tablet/30 days)ondansetron orally disintegrating tab 4 mg (Zofran odt) 1 QL (30 tablets/30 days)ondansetron orally disintegrating tab 8 mg (Zofran odt) 1 QL (30 tablets/30 days)trimethobenzamide hcl cap 300 mg (Tigan) 1

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

unit2

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

2

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

2


2


2

SUCRAID – sacrosidase soln 8500 unit/ml 2 PA, QL (1 box/28days), SP

OTHER GASTROINTESTINAL DRUGS

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alosetron hcl tab 0.5 mg (base equiv) (Lotronex) 1 PA, QL (60tablets/30 days)

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

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

(Phoslo)1

calcium acetate (phosphate binder) tab 667 mg (Eliphos) 1CHENODAL – chenodiol tab 250 mg 2 PA, SPCHOLBAM – cholic acid cap 50 mg 2 SPCHOLBAM – cholic acid cap 250 mg 2 SPCIMZIA – certolizumab pegol inj kit 2 x 200 mg/ml 2 PA, QL (2 kits/28

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

days), SPGATTEX – teduglutide (rdna) for inj kit 5 mg 2 PA, SPlactulose (encephalopathy) solution 10 gm/15ml 1 90lanthanum carbonate chew tab 500 mg (elemental) (Fosrenol) 1lanthanum carbonate chew tab 750 mg (elemental) (Fosrenol) 1lanthanum carbonate chew tab 1000 mg (elemental) (Fosrenol) 1mesalamine enema 4 gm 1mesalamine suppos 1000 mg (Canasa) 1mesalamine tab delayed release 800 mg (Asacol hd) 1metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv) 1metoclopramide hcl tab 5 mg (base equivalent) (Reglan) 1metoclopramide hcl tab 10 mg (base equivalent) (Reglan) 1 90sevelamer carbonate packet 0.8 gm (Renvela) 1sevelamer carbonate packet 2.4 gm (Renvela) 1sevelamer carbonate tab 800 mg (Renvela) 1sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs) 1sulfasalazine tab 500 mg (Azulfidine) 1ursodiol cap 300 mg (Actigall) 1 90ursodiol tab 250 mg (Urso 250) 1 90ursodiol tab 500 mg (Urso forte) 1 90

GENITOURINARY DRUGSURINARY TRACT INFECTIONS

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nitrofurantoin macrocrystalline cap 25 mg (Macrodantin) 1nitrofurantoin macrocrystalline cap 50 mg (Macrodantin) 1nitrofurantoin macrocrystalline cap 100 mg (Macrodantin) 1nitrofurantoin monohydrate macrocrystalline cap 100 mg

(Macrobid)1

URINARY TRACT SPASMSbethanechol chloride tab 5 mg (Urecholine) 1bethanechol chloride tab 10 mg (Urecholine) 1bethanechol chloride tab 25 mg (Urecholine) 1bethanechol chloride tab 50 mg (Urecholine) 1darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv)

(Enablex)1 QL (30 tablets/30 days)

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


oxybutynin chloride syrup 5 mg/5ml 1 QL (600 mls/30 days)oxybutynin chloride tab er 24hr 5 mg (Ditropan xl) 1 QL (30 tablets/30 days)oxybutynin chloride tab er 24hr 10 mg (Ditropan xl) 1 QL (60 tablets/30 days)oxybutynin chloride tab er 24hr 15 mg (Ditropan xl) 1 QL (60 tablets/30 days)oxybutynin chloride tab 5 mg 1 QL (120 tablets/30 days)tolterodine tartrate tab 2 mg (Detrol) 1 QL (60 tablets/30 days)trospium chloride cap er 24hr 60 mg 1 QL (30 capsules/30 days)trospium chloride tab 20 mg 1 QL (60 tablets/30 days)

VAGINAL PRODUCTSclindamycin phosphate vaginal cream 2% (Cleocin) 1estradiol vaginal cream 0.1 mg/gm (Estrace) 1estradiol vaginal tab 10 mcg (Vagifem) 1metronidazole vaginal gel 0.75% (Metrogel-vaginal) 1TERCONAZOLE – terconazole vaginal cream 0.8% 2terconazole vaginal cream 0.4% (Terazol 7) 1terconazole vaginal suppos 80 mg 1

OTHER GENITOURINARY DRUGSalfuzosin hcl tab er 24hr 10 mg (Uroxatral) 1 QL (30 tablets/30 days)CYSTAGON – cysteamine bitartrate cap 50 mg 2 PA, SPCYSTAGON – cysteamine bitartrate cap 150 mg 2 PA, SPdutasteride cap 0.5 mg (Avodart) 1 QL (30 capsules/30 days)dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn) 1 QL (30 capsules/30 days)

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finasteride tab 5 mg (Proscar) 1 QL (30 tablets/30 days)phenazopyridine hcl tab 100 mg (Pyridium) 1phenazopyridine hcl tab 200 mg (Pyridium) 1pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml 1potassium citrate & citric acid powder pack 3300-1002 mg 1potassium citrate & citric acid soln 1100-334 mg/5ml 1potassium citrate tab er 5 meq (540 mg) (Urocit-k 5) 1potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10) 1potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15) 1sodium chloride irrigation soln 0.9% 1sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution

modi)1

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

CENTRAL NERVOUS SYSTEM DRUGSANXIETYALPRAZOLAM INTENSOL – alprazolam conc 1 mg/ml 2 QL (180 mls/30 days)alprazolam tab er 24hr 0.5 mg (Xanax xr) 1 QL (30 tablets/30 days)alprazolam tab er 24hr 1 mg (Xanax xr) 1 QL (30 tablets/30 days)alprazolam tab er 24hr 2 mg (Xanax xr) 1 QL (90 tablets/30 days)alprazolam tab er 24hr 3 mg (Xanax xr) 1 QL (60 tablets/30 days)alprazolam tab 0.25 mg (Xanax) 1 QL (120 tablets/30 days)alprazolam tab 0.5 mg (Xanax) 1 QL (120 tablets/30 days)alprazolam tab 1 mg (Xanax) 1 QL (120 tablets/30 days)alprazolam tab 2 mg (Xanax) 1 QL (90 tablets/30 days)buspirone hcl tab 5 mg 1buspirone hcl tab 10 mg 1buspirone hcl tab 15 mg 1buspirone hcl tab 30 mg 1chlordiazepoxide hcl cap 5 mg 1 QL (120

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

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

capsules/30 days)clorazepate dipotassium tab 3.75 mg 1 QL (90 tablets/30 days)clorazepate dipotassium tab 7.5 mg (Tranxene t) 1 QL (90 tablets/30 days)

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clorazepate dipotassium tab 15 mg 1 QL (120 tablets/30 days)DIAZEPAM – diazepam oral soln 1 mg/ml 2 QL (1200 mls/30 days)diazepam conc 5 mg/ml 1 QL (240 mls/30 days)diazepam tab 2 mg (Valium) 1 QL (120 tablets/30 days)diazepam tab 5 mg (Valium) 1 QL (120 tablets/30 days)diazepam tab 10 mg (Valium) 1 QL (120 tablets/30 days)hydroxyzine hcl syrup 10 mg/5ml 1hydroxyzine hcl tab 10 mg 1hydroxyzine hcl tab 25 mg 1hydroxyzine hcl tab 50 mg 1hydroxyzine pamoate cap 25 mg (Vistaril) 1hydroxyzine pamoate cap 50 mg (Vistaril) 1lorazepam conc 2 mg/ml 1 QL (150 mls/30 days)lorazepam tab 0.5 mg (Ativan) 1 QL (90 tablets/30 days)lorazepam tab 1 mg (Ativan) 1 QL (90 tablets/30 days)lorazepam tab 2 mg (Ativan) 1 QL (150 tablets/30 days)

DEPRESSIONamitriptyline hcl tab 10 mg 1amitriptyline hcl tab 25 mg (Elavil) 1amitriptyline hcl tab 50 mg 1amitriptyline hcl tab 75 mg 1amitriptyline hcl tab 100 mg 1amitriptyline hcl tab 150 mg 1APLENZIN – bupropion hbr tab er 24hr 174 mg 2 PA, QL (30

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

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

tablets/30 days)bupropion hcl tab er 12hr 100 mg (Wellbutrin sr) 1 QL (60 tablets/30 days)bupropion hcl tab er 12hr 150 mg (Wellbutrin sr) 1 QL (60 tablets/30 days)bupropion hcl tab er 12hr 200 mg (Wellbutrin sr) 1 QL (60 tablets/30 days)bupropion hcl tab er 24hr 150 mg (Wellbutrin xl) 1 QL (30 tablets/30 days)bupropion hcl tab er 24hr 300 mg (Wellbutrin xl) 1 QL (30 tablets/30 days)bupropion hcl tab 75 mg 1 QL (60 tablets/30 days)

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bupropion hcl tab 100 mg 1 QL (120 tablets/30 days)BUPROPION HYDROCHLORIDE E – bupropion hcl tab er 24hr

450 mg2 PA, QL (30

tablets/30 days)citalopram hydrobromide oral soln 10 mg/5ml 1 QL (600 mls/30 days)citalopram hydrobromide tab 10 mg (base equiv) (Celexa) 1 QL (30 tablets/30 days)citalopram hydrobromide tab 20 mg (base equiv) (Celexa) 1 QL (30 tablets/30 days)citalopram hydrobromide tab 40 mg (base equiv) (Celexa) 1 QL (30 tablets/30 days)desipramine hcl tab 10 mg (Norpramin) 1desipramine hcl tab 25 mg (Norpramin) 1desipramine hcl tab 50 mg 1desipramine hcl tab 75 mg 1desipramine hcl tab 100 mg 1desipramine hcl tab 150 mg 1DOXEPIN HCL – doxepin hcl cap 150 mg 2doxepin hcl cap 10 mg 1doxepin hcl cap 25 mg 1doxepin hcl cap 50 mg 1doxepin hcl cap 75 mg 1doxepin hcl cap 100 mg 1doxepin hcl conc 10 mg/ml 1duloxetine hcl enteric coated pellets cap 20 mg (base eq)

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

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

1 QL (90 capsules/30 days)

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

1 QL (60 capsules/30 days)

EMSAM – selegiline td patch 24hr 6 mg/24hr 2 PAEMSAM – selegiline td patch 24hr 9 mg/24hr 2 PAEMSAM – selegiline td patch 24hr 12 mg/24hr 2 PAescitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro) 1 QL (600 mls/30 days)escitalopram oxalate tab 5 mg (base equiv) (Lexapro) 1 QL (30 tablets/30 days)escitalopram oxalate tab 10 mg (base equiv) (Lexapro) 1 QL (30 tablets/30 days)escitalopram oxalate tab 20 mg (base equiv) (Lexapro) 1 QL (30 tablets/30 days)FETZIMA – levomilnacipran hcl cap er 24hr 20 mg (base

equivalent)2 PA, QL (30

capsules/30 days)FETZIMA – levomilnacipran hcl cap er 24hr 40 mg (base

equivalent)2 PA, QL (30

capsules/30 days)

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FETZIMA – levomilnacipran hcl cap er 24hr 80 mg (baseequivalent)

2 PA, QL (30capsules/30 days)

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


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


fluoxetine hcl cap 10 mg (Prozac) 1 QL (30 capsules/30 days)fluoxetine hcl cap 20 mg (Prozac) 1 QL (120

capsules/30 days)fluoxetine hcl cap 40 mg (Prozac) 1 QL (60 capsules/30 days)fluoxetine hcl solution 20 mg/5ml 1 QL (600 mls/30 days)fluoxetine hcl tab 10 mg 1 QL (30 tablets/30 days)fluoxetine hcl tab 20 mg 1 QL (120 tablets/30 days)fluvoxamine maleate tab 25 mg 1 QL (30 tablets/30 days)fluvoxamine maleate tab 50 mg 1 QL (30 tablets/30 days)fluvoxamine maleate tab 100 mg 1 QL (90 tablets/30 days)FORFIVO XL – bupropion hcl tab er 24hr 450 mg 2 PA, QL (30

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

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

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

tablets/30 days)MARPLAN – isocarboxazid tab 10 mg 2 PAmirtazapine tab 15 mg (Remeron) 1 QL (30 tablets/30 days)mirtazapine tab 30 mg (Remeron) 1 QL (30 tablets/30 days)mirtazapine tab 45 mg (Remeron) 1 QL (30 tablets/30 days)nortriptyline hcl cap 10 mg (Pamelor) 1nortriptyline hcl cap 25 mg (Pamelor) 1nortriptyline hcl cap 50 mg (Pamelor) 1nortriptyline hcl cap 75 mg (Pamelor) 1paroxetine hcl tab 10 mg (Paxil) 1 QL (30 tablets/30 days)

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paroxetine hcl tab 20 mg (Paxil) 1 QL (30 tablets/30 days)paroxetine hcl tab 30 mg (Paxil) 1 QL (60 tablets/30 days)paroxetine hcl tab 40 mg (Paxil) 1 QL (30 tablets/30 days)PAXIL – paroxetine hcl oral susp 10 mg/5ml (base equiv) 2 PA, QL (900 mls/30 days)PEXEVA – paroxetine mesylate tab 10 mg (base equiv) 2 PA, QL (30

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



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

xr)1 QL (30 capsules/30 days)

venlafaxine hcl cap er 24hr 75 mg (base equivalent) (Effexor xr) 1 QL (90 capsules/30 days)venlafaxine hcl cap er 24hr 150 mg (base equivalent) (Effexor xr) 1 QL (30 capsules/30 days)venlafaxine hcl tab 25 mg (base equivalent) 1 QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg (base equivalent) 1 QL (90 tablets/30 days)venlafaxine hcl tab 50 mg (base equivalent) 1 QL (90 tablets/30 days)venlafaxine hcl tab 75 mg (base equivalent) 1 QL (90 tablets/30 days)venlafaxine hcl tab 100 mg (base equivalent) 1 QL (90 tablets/30 days)VIIBRYD – vilazodone hcl tab 10 mg 2 PA, QL (30

tablets/30 days)VIIBRYD – vilazodone hcl tab 20 mg 2 PA, QL (30

tablets/30 days)VIIBRYD – vilazodone hcl tab 40 mg 2 PA, QL (30

tablets/30 days)VIIBRYD STARTER PACK – vilazodone hcl tab starter kit 10 (7)

& 20 (23) mg2 PA, QL (30

tablets/180 days)

PSYCHOTIC AND BIPOLAR DISORDERS

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ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 300 mg

2 PA, QL (1syringe/28 days)

ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 400 mg


ABILIFY MAINTENA – aripiprazole im for extended release susp300 mg


ABILIFY MAINTENA – aripiprazole im for extended release susp400 mg


ADASUVE – loxapine aerosol powder breath activated 10 mg 2 PAaripiprazole oral solution 1 mg/ml 1 PA, QL (150 mls/30 days)aripiprazole orally disintegrating tab 10 mg 1 AL, QL (30

tablets/30 days)aripiprazole orally disintegrating tab 15 mg 1 AL, QL (30

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






tablets/30 days)ARISTADA – aripiprazole lauroxil im er susp prefilled syr

441 mg/1.6ml2 PA, QL (1

syringe/28 days)ARISTADA – aripiprazole lauroxil im er susp prefilled syr

662 mg/2.4ml2 PA, QL (1


882 mg/3.2ml2 PA, QL (1


1064 mg/3.9ml2 PA, QL (1

syringe/56 days)ARISTADA INITIO – aripiprazole lauroxil im er susp prefilled syr

675 mg/2.4ml2 PA, QL (1 kit/180 days)

CHLORPROMAZINE HCL – chlorpromazine hcl inj 50 mg/2ml 2 PAchlorpromazine hcl tab 10 mg 1 PA

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chlorpromazine hcl tab 25 mg 1 PAchlorpromazine hcl tab 50 mg 1 PAchlorpromazine hcl tab 100 mg 1 PAchlorpromazine hcl tab 200 mg 1 PACLOZAPINE ODT – clozapine orally disintegrating tab 150 mg 2 PA, QL (60

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

tablets/30 days)clozapine orally disintegrating tab 12.5 mg (Fazaclo) 1 PA, QL (60

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

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

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

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

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

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

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

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





tablets/30 days)

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FANAPT – iloperidone tab 12 mg 2 PA, QL (60tablets/30 days)

FANAPT TITRATION PACK – iloperidone tab 1 mg & 2 mg &4 mg & 6 mg titration pak

2 PA, QL (8tablets/180 days)

FAZACLO – clozapine orally disintegrating tab 150 mg 2 PA, QL (60tablets/30 days)

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

fluphenazine decanoate inj 25 mg/ml 1 ALFLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 mg/5ml 2 PAFLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml 2 PAFLUPHENAZINE HCL – fluphenazine hcl inj 2.5 mg/ml 2 PAFLUPHENAZINE HCL – fluphenazine hcl tab 1 mg 2FLUPHENAZINE HCL – fluphenazine hcl tab 2.5 mg 2FLUPHENAZINE HCL – fluphenazine hcl tab 5 mg 2FLUPHENAZINE HCL – fluphenazine hcl tab 10 mg 2GEODON – ziprasidone mesylate for inj 20 mg (base equivalent) 2 PA, QL (60 vials/30 days)haloperidol decanoate im soln 50 mg/ml (Haldol decanoate 50) 1 ALhaloperidol decanoate im soln 100 mg/ml (Haldol decanoate 100) 1 ALhaloperidol lactate oral conc 2 mg/ml 1 ALhaloperidol tab 0.5 mg 1 ALhaloperidol tab 1 mg 1 ALhaloperidol tab 2 mg 1 ALhaloperidol tab 5 mg 1 ALhaloperidol tab 10 mg 1 ALhaloperidol tab 20 mg 1 ALINVEGA – paliperidone tab er 24hr 1.5 mg 2 PA, QL (30

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



tablets/30 days)INVEGA SUSTENNA – paliperidone palmitate er susp pref syr

39 mg/0.25ml2 PA, QL (1 kit/28 days), 90

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INVEGA SUSTENNA – paliperidone palmitate er susp pref syr78 mg/0.5ml

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


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

INVEGA SUSTENNA – paliperidone palmitate er susp pref syr156 mg/ml

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


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

INVEGA TRINZA – paliperidone palmitate er susp pref syr273 mg/0.875ml

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







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





LITHIUM – lithium oral solution 8 meq/5ml 2 PAlithium carbonate cap 150 mg (Lithium carbonate) 1lithium carbonate cap 300 mg 1lithium carbonate cap 600 mg (Lithium carbonate) 1lithium carbonate tab er 300 mg (Lithobid) 1lithium carbonate tab er 450 mg 1lithium carbonate tab 300 mg 1loxapine succinate cap 5 mg 1 ALloxapine succinate cap 10 mg 1 ALloxapine succinate cap 25 mg 1 ALloxapine succinate cap 50 mg 1 ALMOLINDONE HYDROCHLORIDE – molindone hcl tab 5 mg 2 AL

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MOLINDONE HYDROCHLORIDE – molindone hcl tab 10 mg 2 ALMOLINDONE HYDROCHLORIDE – molindone hcl tab 25 mg 2 ALolanzapine orally disintegrating tab 5 mg (Zyprexa zydis) 1 AL, QL (30

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



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

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

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




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

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



tablets/30 days)perphenazine tab 2 mg 1 ALperphenazine tab 4 mg 1 ALperphenazine tab 8 mg 1 ALperphenazine tab 16 mg 1 ALprochlorperazine maleate tab 5 mg (base equivalent) 1 ALprochlorperazine maleate tab 10 mg (base equivalent) 1 ALprochlorperazine suppos 25 mg 1 AL

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quetiapine fumarate tab er 24hr 50 mg (Seroquel xr) 1 PA, QL (60tablets/30 days)





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






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

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

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




RISPERDAL CONSTA – risperidone microspheres for inj12.5 mg

2 PA, QL (2 vials/28 days)

RISPERDAL CONSTA – risperidone microspheres for inj 25 mg 2 PA, QL (2 vials/28 days)RISPERDAL CONSTA – risperidone microspheres for inj

37.5 mg2 PA, QL (2 vials/28 days)

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RISPERDAL CONSTA – risperidone microspheres for inj 50 mg 2 PA, QL (2 vials/28 days)RISPERIDONE ODT – risperidone orally disintegrating tab

0.25 mg2 AL, QL (60

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

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




tablets/30 days)risperidone soln 1 mg/ml (Risperdal) 1 AL, QL (480 mls/30 days)risperidone tab 0.25 mg (Risperdal) 1 AL, QL (120

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

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




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

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

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

tablets/30 days)thioridazine hcl tab 10 mg 1 ALthioridazine hcl tab 25 mg 1 ALthioridazine hcl tab 50 mg 1 ALthioridazine hcl tab 100 mg 1 ALthiothixene cap 1 mg 1 ALthiothixene cap 2 mg 1 AL

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thiothixene cap 5 mg 1 ALthiothixene cap 10 mg 1 ALtrifluoperazine hcl tab 1 mg (base equivalent) 1 ALtrifluoperazine hcl tab 2 mg (base equivalent) 1 ALtrifluoperazine hcl tab 5 mg (base equivalent) 1 ALtrifluoperazine hcl tab 10 mg (base equivalent) 1 ALVERSACLOZ – clozapine susp 50 mg/ml 2 PA, QL (540 mls/30 days)ziprasidone hcl cap 20 mg (Geodon) 1 AL, QL (60

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



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

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

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

2 PA, QL (2 vials/28 days)

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

2 PA, QL (1 vial/28 days)

SLEEP AIDSestazolam tab 1 mg 1 QL (30 tablets/30 days)estazolam tab 2 mg 1 QL (30 tablets/30 days)eszopiclone tab 1 mg (Lunesta) 1 QL (30 tablets/30 days)eszopiclone tab 2 mg (Lunesta) 1 QL (30 tablets/30 days)eszopiclone tab 3 mg (Lunesta) 1 QL (30 tablets/30 days)phenobarbital elixir 20 mg/5ml 1phenobarbital tab 15 mg 1phenobarbital tab 16.2 mg 1phenobarbital tab 30 mg 1phenobarbital tab 32.4 mg 1phenobarbital tab 60 mg 1phenobarbital tab 64.8 mg 1phenobarbital tab 97.2 mg 1phenobarbital tab 100 mg 1QUAZEPAM – quazepam tab 15 mg 2 QL (30 tablets/30 days)

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temazepam cap 15 mg (Restoril) 1 QL (30 capsules/30 days)temazepam cap 30 mg (Restoril) 1 QL (30 capsules/30 days)zaleplon cap 5 mg (Sonata) 1 QL (30 capsules/30 days)zaleplon cap 10 mg (Sonata) 1 QL (30 capsules/30 days)zolpidem tartrate tab 5 mg (Ambien) 1 QL (30 tablets/30 days)zolpidem tartrate tab 10 mg (Ambien) 1 QL (30 tablets/30 days)

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

capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 10 mg (Adderall

xr)1 AL, QL (30


xr)1 AL, QL (30


xr)1 AL, QL (30


xr)1 AL, QL (30


xr)1 AL, QL (30

capsules/30 days)amphetamine-dextroamphetamine tab 5 mg (Adderall) 1 AL, QL (60

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

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

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




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

tablets/30 days)armodafinil tab 150 mg (Nuvigil) 1 PA, QL (30

tablets/30 days)

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armodafinil tab 200 mg (Nuvigil) 1 PA, QL (30tablets/30 days)

armodafinil tab 250 mg (Nuvigil) 1 PA, QL (30tablets/30 days)

atomoxetine hcl cap 10 mg (base equiv) (Strattera) 1 AL, QL (60capsules/30 days)







caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) 1clonidine hcl tab er 12hr 0.1 mg (Kapvay) 1 QL (120 tablets/30 days)dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin xr) 1 AL, QL (30

capsules/30 days)dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin xr) 1 AL, QL (30





capsules/30 days)dexmethylphenidate hcl tab 2.5 mg (Focalin) 1 AL, QL (60

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

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

tablets/30 days)

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



dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra) 1 AL, QL (1800mls/30 days)

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

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

guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days)guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days)guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days)guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv) 1 QL (30 tablets/30 days)methylphenidate hcl cap er 10 mg (cd) 1 AL, QL (30

capsules/30 days)methylphenidate hcl cap er 20 mg (cd) 1 AL, QL (30





capsules/30 days)methylphenidate hcl cap er 24hr 10 mg (la) (Ritalin la) 1 AL, QL (30




capsules/30 days)methylphenidate hcl chew tab 2.5 mg 1 AL, QL (90

tablets/30 days)

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

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

methylphenidate hcl soln 5 mg/5ml (Methylin) 1 AL, QL (450 mls/30 days)methylphenidate hcl soln 10 mg/5ml (Methylin) 1 AL, QL (900 mls/30 days)methylphenidate hcl tab er 10 mg 1 AL, QL (90

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

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



tablets/30 days)METHYLPHENIDATE HYDROCHLO – methylphenidate hcl tab

er 24hr 18 mg2 AL, QL (30







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

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

tablets/30 days)

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

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

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

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

days), SPAVONEX PEN – interferon beta-1a im auto-injector kit

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

days), SP

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

glatiramer acetate soln prefilled syringe 40 mg/ml (Copaxone) 2 PA, QL (12 syringes/28days), SP

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

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

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

2 QL (180 days/365 days)

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


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


disulfiram tab 250 mg (Antabuse) 1disulfiram tab 500 mg (Antabuse) 1donepezil hydrochloride orally disintegrating tab 5 mg 1 QL (30 tablets/30 days)donepezil hydrochloride orally disintegrating tab 10 mg 1 QL (30 tablets/30 days)donepezil hydrochloride tab 5 mg (Aricept) 1 QL (30 tablets/30 days)donepezil hydrochloride tab 10 mg (Aricept) 1 QL (30 tablets/30 days)GALANTAMINE HYDROBROMIDE – galantamine hydrobromide

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

galantamine hydrobromide cap er 24hr 8 mg (Razadyne er) 1 QL (30 capsules/30 days)galantamine hydrobromide cap er 24hr 16 mg (Razadyne er) 1 QL (30 capsules/30 days)galantamine hydrobromide cap er 24hr 24 mg (Razadyne er) 1 QL (30 capsules/30 days)galantamine hydrobromide tab 4 mg (Razadyne) 1 QL (60 tablets/30 days)galantamine hydrobromide tab 8 mg (Razadyne) 1 QL (60 tablets/30 days)galantamine hydrobromide tab 12 mg (Razadyne) 1 QL (60 tablets/30

days), 90memantine hcl oral solution 2 mg/ml (Namenda) 1 QL (360 mls/30 days), 90memantine hcl tab 5 mg (Namenda) 1 QL (60 tablets/30 days)memantine hcl tab 10 mg (Namenda) 1 QL (60 tablets/30 days)NICOTROL INHALER – nicotine inhaler system 10 mg (4 mg

delivered)2 QL (180 days/365 days)

NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray) 2 QL (180 days/365 days)

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PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptylinetab 2-10 mg

2 PA


2 PA


2 PA


2 PA


2 PA

PIMOZIDE – pimozide tab 1 mg 2PIMOZIDE – pimozide tab 2 mg 2rivastigmine tartrate cap 4.5 mg (base equivalent) 1 QL (60 capsules/30 days)

PAIN RELIEF DRUGSNON-NARCOTIC DRUGSbutalbital-acetaminophen tab 50-325 mg 1 QL (180 tablets/30 days)butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet) 1 QL (180

capsules/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic) 1 QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal) 1 QL (180

capsules/30 days)

NARCOTIC DRUGSacetaminophen w/ codeine soln 120-12 mg/5ml 1 AL, ME90, QL (2700

mls/30 days)acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine) 1 AL, ME90, QL (360

tablets/30 days)acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3) 1 AL, ME90, QL (360

tablets/30 days)acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4) 1 AL, ME90, QL (180

tablets/30 days)ACETAMINOPHEN/CAFFEINE/DI – acetaminophen-caffeine-

dihydrocodeine cap 320.5-30-16 mg2 ME90, QL (300

capsules/30 days)buprenorphine hcl sl tab 2 mg (base equiv) 1 QL (90 tablets/30 days)buprenorphine hcl sl tab 8 mg (base equiv) 1 QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv)

(Suboxone)1 QL (90 films/30 days)

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

1 QL (90 films/30 days)

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buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) 1 QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) 1 QL (90 tablets/30 days)butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg 1 AL, ME90, QL (180

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

codeine #3)1 AL, ME90, QL (180

capsules/30 days)butorphanol tartrate nasal soln 10 mg/ml 1 ME90, QL (2

bottles/30 days)codeine sulfate tab 30 mg (Codeine sulfate) 1 AL, ME90, QL (180

tablets/30 days)fentanyl td patch 72hr 12 mcg/hr (Duragesic) 1 ME90, PA, QL (15

patches/30 days)fentanyl td patch 72hr 25 mcg/hr (Duragesic) 1 ME90, PA, QL (15




patches/30 days)hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet) 1 ME90, QL (3600

mls/30 days)hydrocodone-acetaminophen tab 10-325 mg (Norco) 1 ME90, QL (180

tablets/30 days)hydrocodone-acetaminophen tab 7.5-300 mg (Xodol) 1 ME90, QL (180

tablets/30 days)hydrocodone-acetaminophen tab 5-325 mg (Norco) 1 ME90, QL (360

tablets/30 days)hydrocodone-acetaminophen tab 7.5-325 mg (Norco) 1 ME90, QL (180

tablets/30 days)hydrocodone-acetaminophen tab 10-300 mg (Xodol) 1 ME90, QL (180

tablets/30 days)hydrocodone-ibuprofen tab 5-200 mg (Reprexain) 1 ME90, QL (150

tablets/30 days)

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hydrocodone-ibuprofen tab 7.5-200 mg 1 ME90, QL (150tablets/30 days)

hydromorphone hcl liqd 1 mg/ml (Dilaudid) 1 ME90, QL (1440mls/30 days)

hydromorphone hcl tab 2 mg (Dilaudid) 1 ME90, QL (180tablets/30 days)



methadone hcl conc 10 mg/ml (Methadose) 1 ME90, QL (90mls/30 days)

methadone hcl soln 5 mg/5ml (Methadone hcl) 1 ME90, QL (900mls/30 days)

methadone hcl soln 10 mg/5ml (Methadone hcl) 1 ME90, QL (450mls/30 days)

methadone hcl tab for oral susp 40 mg 1 ME90, QL (90tablets/30 days)

methadone hcl tab 5 mg (Dolophine) 1 ME90, QL (90tablets/30 days)

methadone hcl tab 10 mg (Dolophine) 1 ME90, QL (90tablets/30 days)

MORPHINE SULFATE – morphine sulfate suppos 5 mg 2 ME90MORPHINE SULFATE – morphine sulfate suppos 10 mg 2 ME90MORPHINE SULFATE – morphine sulfate suppos 20 mg 2 ME90MORPHINE SULFATE – morphine sulfate suppos 30 mg 2 ME90morphine sulfate cap er 24hr 100 mg (Kadian) 1 ME90, PA, QL (60

capsules/30 days)MORPHINE SULFATE ER – morphine sulfate beads cap er 24hr

60 mg2 ME90, PA, QL (30


75 mg2 ME90, PA, QL (30


120 mg2 ME90, PA, QL (30

capsules/30 days)morphine sulfate oral soln 10 mg/5ml 1 ME90, QL (2700

mls/30 days)morphine sulfate oral soln 20 mg/5ml 1 ME90, QL (1350

mls/30 days)

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morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 1 ME90, QL (270mls/30 days)

morphine sulfate tab er 15 mg (Ms contin) 1 ME90, PA, QL (90tablets/30 days)





morphine sulfate tab 15 mg (Morphine sulfate) 1 ME90, QL (240tablets/30 days)

morphine sulfate tab 30 mg (Morphine sulfate) 1 ME90, QL (180tablets/30 days)

oxycodone hcl conc 100 mg/5ml (20 mg/ml) 1 ME90, QL (270mls/30 days)

oxycodone hcl soln 5 mg/5ml 1 ME90, QL (5400mls/30 days)

oxycodone hcl tab 5 mg (Roxicodone) 1 ME90, QL (360tablets/30 days)

oxycodone hcl tab 10 mg 1 ME90, QL (180tablets/30 days)


oxycodone hcl tab 20 mg 1 ME90, QL (180tablets/30 days)


oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet) 1 ME90, QL (360tablets/30 days)

oxycodone w/ acetaminophen tab 5-325 mg (Percocet) 1 ME90, QL (360tablets/30 days)

oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet) 1 ME90, QL (240tablets/30 days)

oxycodone w/ acetaminophen tab 10-325 mg (Percocet) 1 ME90, QL (180tablets/30 days)

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OXYCODONE/ASPIRIN – oxycodone-aspirin tab 4.8355-325 mg 2 ME90, QL (360tablets/30 days)

OXYCODONE/IBUPROFEN – oxycodone-ibuprofen tab5-400 mg

2 ME90, QL (120tablets/30 days)

oxymorphone hcl tab 5 mg (Opana) 1 ME90, QL (180tablets/30 days)

oxymorphone hcl tab 10 mg (Opana) 1 ME90, QL (180tablets/30 days)

OXYMORPHONE HYDROCHLORIDE – oxymorphone hcl tab er12hr 5 mg

2 ME90, PA, QL (60tablets/30 days)

OXYMORPHONE HYDROCHLORIDE – oxymorphone hcl tab er12hr 7.5 mg












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


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






tramadol hcl tab 50 mg (Ultram) 1 AL, ME90, QL (240tablets/30 days)

tramadol-acetaminophen tab 37.5-325 mg (Ultracet) 1 AL, ME90, QL (240tablets/30 days)

RHEUMATOID AND OSTEOARTHRITISARCALYST – rilonacept for inj 220 mg 2 PA, QL (4 vials/28

days), SPcelecoxib cap 50 mg (Celebrex) 1 QL (60 capsules/30 days)celecoxib cap 100 mg (Celebrex) 1 QL (60 capsules/30 days)

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celecoxib cap 200 mg (Celebrex) 1 QL (60 capsules/30 days)celecoxib cap 400 mg (Celebrex) 1 QL (30 capsules/30 days)diclofenac potassium tab 50 mg 1 QL (120 tablets/30 days)diclofenac sodium tab delayed release 50 mg 1 QL (120 tablets/30 days)diclofenac sodium tab delayed release 75 mg 1 QL (60 tablets/30 days)diclofenac sodium tab er 24hr 100 mg 1 QL (60 tablets/30 days)ENBREL – etanercept for subcutaneous inj 25 mg 2 PA, QL (8 vials/28

days), SPENBREL – etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml2 PA, QL (4 syringes/28

days), SPENBREL – etanercept subcutaneous soln prefilled syringe

50 mg/ml2 PA, QL (4 syringes/28

days), SPENBREL MINI – etanercept subcutaneous solution cartridge

50 mg/ml2 PA, QL (4 cartridges/28

days), SPENBREL SURECLICK – etanercept subcutaneous solution auto-

injector 50 mg/ml2 PA, QL (4 syringes/28

days), SPflurbiprofen tab 50 mg 1 QL (180 tablets/30 days)flurbiprofen tab 100 mg 1 QL (90 tablets/30 days)HUMIRA – adalimumab prefilled syringe kit 10 mg/0.1ml 2 PA, QL (2 syringes/28

days), SPHUMIRA – adalimumab prefilled syringe kit 10 mg/0.2ml 2 PA, QL (2 syringes/28





days), SPHUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringe

kit 40 mg/0.8ml2 PA, QL (3 syringes/180






kit 80 mg/0.8ml & 40 mg/0.4ml2 PA, QL (2 syringes/180

days), SP

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HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.8ml 2 PA, QL (2 pens/28days), SP

HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.4ml 2 PA, QL (2 pens/28days), SP

HUMIRA PEN-CD/UC/HS START – adalimumab pen-injector kit40 mg/0.8ml

2 PA, QL (6 pens/180days), SP

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

2 PA, QL (1 kit/180days), SP

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

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

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

2 PA, QL (1 kit/180days), SP

ibuprofen susp 100 mg/5ml 1 QL (1000 mls/30 days)ibuprofen tab 400 mg 1 QL (120 tablets/30 days)ibuprofen tab 600 mg 1 QL (150 tablets/30 days)ibuprofen tab 800 mg 1 QL (120 tablets/30 days)indomethacin cap er 75 mg 1 QL (60 capsules/30 days)indomethacin cap 25 mg 1 QL (90 capsules/30 days)indomethacin cap 50 mg 1 QL (60 capsules/30 days)ketorolac tromethamine tab 10 mg 1 QL (20 tablets/30 days)KINERET – anakinra subcutaneous soln prefilled syringe

100 mg/0.67ml2 PA, QL (28 syringes/28

days), SPleflunomide tab 10 mg (Arava) 1leflunomide tab 20 mg (Arava) 1meloxicam tab 7.5 mg (Mobic) 1 QL (60 tablets/30 days)meloxicam tab 15 mg (Mobic) 1 QL (30 tablets/30 days)nabumetone tab 500 mg 1 QL (120 tablets/30 days)nabumetone tab 750 mg 1 QL (60 tablets/30 days)naproxen sodium tab er 24hr 375 mg (base equiv) (Naprelan) 1 QL (120 tablets/30 days)naproxen sodium tab 275 mg 1 QL (150 tablets/30 days)naproxen sodium tab 550 mg (Anaprox ds) 1 QL (90 tablets/30 days)naproxen susp 125 mg/5ml (Naprosyn) 1 PA, QL (1800

mls/30 days)naproxen tab ec 375 mg (Ec-naprosyn) 1 QL (120 tablets/30 days)naproxen tab ec 500 mg (Ec-naprosyn) 1 QL (90 tablets/30 days)naproxen tab 250 mg 1 QL (150 tablets/30 days)

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naproxen tab 375 mg 1 QL (120 tablets/30 days)naproxen tab 500 mg (Naprosyn) 1 QL (90 tablets/30 days)OLUMIANT – baricitinib tab 2 mg 2 PA, QL (30 tablets/30

days), SPORENCIA – abatacept subcutaneous soln prefilled syringe


days), SPORENCIA CLICKJECT – abatacept subcutaneous soln auto-

injector 125 mg/ml2 PA, QL (4 syringes/28

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

30 mg2 PA, QL (55 tablets/180

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

days), SPpiroxicam cap 10 mg (Feldene) 1 QL (60 capsules/30 days)piroxicam cap 20 mg (Feldene) 1 QL (30 capsules/30 days)SIMPONI – golimumab subcutaneous soln auto-injector

50 mg/0.5ml2 PA, QL (1 syringe/28

days), SPSIMPONI – golimumab subcutaneous soln auto-injector 100 mg/

ml2 PA, QL (1 syringe/28

days), SPSIMPONI – golimumab subcutaneous soln prefilled syringe

50 mg/0.5ml2 PA, QL (1 syringe/28

days), SPSIMPONI – golimumab subcutaneous soln prefilled syringe

100 mg/ml2 PA, QL (1 syringe/28

days), SPsulindac tab 150 mg 1 QL (60 tablets/30 days)sulindac tab 200 mg 1 QL (60 tablets/30 days)XELJANZ – tofacitinib citrate tab 5 mg (base equivalent) 2 PA, QL (60 tablets/30

days), SPXELJANZ – tofacitinib citrate tab 10 mg (base equivalent) 2 PA, QL (60 tablets/30

days), SPXELJANZ XR – tofacitinib citrate tab er 24hr 11 mg (base


days), SP

MIGRAINE HEADACHESalmotriptan malate tab 6.25 mg (Axert) 1 QL (18 tablets/30 days)almotriptan malate tab 12.5 mg (Axert) 1 QL (18 tablets/30 days)frovatriptan succinate tab 2.5 mg (base equivalent) (Frova) 1 QL (18 tablets/30 days)IMITREX – sumatriptan nasal spray 5 mg/act 2 QL (12 units/30 days)IMITREX – sumatriptan nasal spray 20 mg/act 2 QL (12 units/30 days)rizatriptan benzoate oral disintegrating tab 5 mg (base eq)

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

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


rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt) 1 QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt) 1 QL (18 tablets/30 days)sumatriptan nasal spray 5 mg/act (Imitrex) 1 QL (12 units/30 days)sumatriptan nasal spray 20 mg/act (Imitrex) 1 QL (12 units/30 days)SUMATRIPTAN SUCCINATE – sumatriptan succinate solution

prefilled syringe 6 mg/0.5ml2 QL (12 doses/30 days)

sumatriptan succinate inj 6 mg/0.5ml (Imitrex) 1 QL (12 vials/30 days)sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex

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

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

1 QL (12 doses/30 days)

sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrexstatdose ref)

1 QL (12 doses/30 days)

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

1 QL (6 packages/30 days)

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

GOUTallopurinol tab 100 mg (Zyloprim) 1allopurinol tab 300 mg (Zyloprim) 1COLCHICINE – colchicine cap 0.6 mg 2colchicine w/ probenecid tab 0.5-500 mg 1MITIGARE – colchicine cap 0.6 mg 2probenecid tab 500 mg 1

NEUROMUSCULAR DRUGSSEIZURESAPTIOM – eslicarbazepine acetate tab 200 mg 2APTIOM – eslicarbazepine acetate tab 400 mg 2APTIOM – eslicarbazepine acetate tab 600 mg 2APTIOM – eslicarbazepine acetate tab 800 mg 2carbamazepine cap er 12hr 100 mg (Carbatrol) 1carbamazepine cap er 12hr 200 mg (Carbatrol) 1carbamazepine cap er 12hr 300 mg (Carbatrol) 1carbamazepine chew tab 100 mg 1

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carbamazepine susp 100 mg/5ml (Tegretol) 1carbamazepine tab er 12hr 100 mg (Tegretol-xr) 1carbamazepine tab er 12hr 200 mg (Tegretol-xr) 1carbamazepine tab er 12hr 400 mg (Tegretol-xr) 1carbamazepine tab 200 mg (Tegretol) 1clonazepam orally disintegrating tab 0.125 mg 1 QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg 1 QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg 1 QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg 1 QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg 1 QL (60 tablets/30 days)clonazepam tab 0.5 mg (Klonopin) 1 QL (90 tablets/30 days)clonazepam tab 1 mg (Klonopin) 1 QL (90 tablets/30 days)clonazepam tab 2 mg (Klonopin) 1 QL (60 tablets/30 days)DILANTIN – phenytoin sodium extended cap 30 mg 2divalproex sodium cap delayed release sprinkle 125 mg

(Depakote sprinkles)1

divalproex sodium tab delayed release 125 mg (Depakote) 1divalproex sodium tab delayed release 250 mg (Depakote) 1divalproex sodium tab delayed release 500 mg (Depakote) 1divalproex sodium tab er 24 hr 250 mg (Depakote er) 1divalproex sodium tab er 24 hr 500 mg (Depakote er) 1ethosuximide cap 250 mg (Zarontin) 1ethosuximide soln 250 mg/5ml (Zarontin) 1felbamate susp 600 mg/5ml (Felbatol) 1felbamate tab 400 mg (Felbatol) 1felbamate tab 600 mg (Felbatol) 1gabapentin cap 100 mg (Neurontin) 1 QL (720

capsules/30 days)gabapentin cap 300 mg (Neurontin) 1 QL (240

capsules/30 days)gabapentin cap 400 mg (Neurontin) 1 QL (180

capsules/30 days)gabapentin oral soln 250 mg/5ml (Neurontin) 1 QL (1500 mls/30 days)gabapentin tab 600 mg (Neurontin) 1 QL (120 tablets/30 days)gabapentin tab 800 mg (Neurontin) 1 QL (90 tablets/30 days)

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

2 PA

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

2 PA

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

2 PA

lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di) 1lamotrigine tab chewable dispersible 25 mg (Lamictal chewable

di)1

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

starter/not)1 PA

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

1 PA

levetiracetam oral soln 100 mg/ml (Keppra) 1levetiracetam tab er 24hr 500 mg (Keppra xr) 1levetiracetam tab er 24hr 750 mg (Keppra xr) 1levetiracetam tab 250 mg (Keppra) 1levetiracetam tab 500 mg (Keppra) 1levetiracetam tab 750 mg (Keppra) 1levetiracetam tab 1000 mg (Keppra) 1oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal) 1oxcarbazepine tab 150 mg (Trileptal) 1oxcarbazepine tab 300 mg (Trileptal) 1oxcarbazepine tab 600 mg (Trileptal) 1OXTELLAR XR – oxcarbazepine tab er 24hr 150 mg 2 PAOXTELLAR XR – oxcarbazepine tab er 24hr 300 mg 2 PA

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OXTELLAR XR – oxcarbazepine tab er 24hr 600 mg 2 PAphenytoin chew tab 50 mg (Dilantin infatabs) 1phenytoin sodium extended cap 100 mg (Dilantin) 1phenytoin sodium extended cap 200 mg (Phenytek) 1phenytoin sodium extended cap 300 mg (Phenytek) 1phenytoin susp 125 mg/5ml (Dilantin-125) 1primidone tab 50 mg (Mysoline) 1primidone tab 250 mg (Mysoline) 1tiagabine hcl tab 2 mg (Gabitril) 1tiagabine hcl tab 4 mg (Gabitril) 1topiramate sprinkle cap 15 mg (Topamax sprinkle) 1topiramate sprinkle cap 25 mg (Topamax sprinkle) 1topiramate tab 25 mg (Topamax) 1topiramate tab 50 mg (Topamax) 1topiramate tab 100 mg (Topamax) 1 90topiramate tab 200 mg (Topamax) 1valproic acid cap 250 mg (Depakene) 1vigabatrin powd pack 500 mg (Sabril) 2 PA, QL (180

packets/30 days), SPvigabatrin tab 500 mg (Sabril) 2 PA, QL (180

tablets/30 days), SPzonisamide cap 25 mg (Zonegran) 1zonisamide cap 50 mg 1zonisamide cap 100 mg (Zonegran) 1

PARKINSON'S DISEASEamantadine hcl cap 100 mg 1amantadine hcl syrup 50 mg/5ml 1benztropine mesylate tab 0.5 mg 1benztropine mesylate tab 1 mg 1benztropine mesylate tab 2 mg 1bromocriptine mesylate cap 5 mg (base equivalent) 1bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel) 1carbidopa & levodopa orally disintegrating tab 10-100 mg 1carbidopa & levodopa orally disintegrating tab 25-100 mg 1carbidopa & levodopa orally disintegrating tab 25-250 mg 1

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carbidopa & levodopa tab er 25-100 mg (Sinemet cr) 1carbidopa & levodopa tab er 50-200 mg (Sinemet cr) 1carbidopa & levodopa tab 10-100 mg (Sinemet) 1carbidopa & levodopa tab 25-100 mg (Sinemet) 1carbidopa & levodopa tab 25-250 mg (Sinemet) 1carbidopa tab 25 mg (Lodosyn) 1entacapone tab 200 mg (Comtan) 1pramipexole dihydrochloride tab er 24hr 2.25 mg (Mirapex er) 1pramipexole dihydrochloride tab 0.125 mg (Mirapex) 1pramipexole dihydrochloride tab 0.25 mg (Mirapex) 1pramipexole dihydrochloride tab 0.5 mg (Mirapex) 1pramipexole dihydrochloride tab 0.75 mg (Mirapex) 1pramipexole dihydrochloride tab 1 mg (Mirapex) 1pramipexole dihydrochloride tab 1.5 mg (Mirapex) 1ropinirole hydrochloride tab 0.25 mg (Requip) 1ropinirole hydrochloride tab 0.5 mg (Requip) 1ropinirole hydrochloride tab 1 mg (Requip) 1ropinirole hydrochloride tab 2 mg (Requip) 1ropinirole hydrochloride tab 3 mg (Requip) 1ropinirole hydrochloride tab 4 mg (Requip) 1ropinirole hydrochloride tab 5 mg (Requip) 1SELEGILINE HCL – selegiline hcl tab 5 mg 2selegiline hcl cap 5 mg (Eldepryl) 1tolcapone tab 100 mg (Tasmar) 1trihexyphenidyl hcl elixir 0.4 mg/ml 1trihexyphenidyl hcl tab 2 mg 1trihexyphenidyl hcl tab 5 mg 1

MUSCLE RELAXANTSbaclofen tab 10 mg 1baclofen tab 20 mg 1carisoprodol tab 250 mg (Soma) 1CHLORZOXAZONE – chlorzoxazone tab 500 mg 2cyclobenzaprine hcl tab 5 mg 1cyclobenzaprine hcl tab 10 mg 1dantrolene sodium cap 25 mg (Dantrium) 1

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dantrolene sodium cap 50 mg (Dantrium) 1dantrolene sodium cap 100 mg 1methocarbamol tab 500 mg (Robaxin) 1methocarbamol tab 750 mg (Robaxin-750) 1orphenadrine citrate tab er 12hr 100 mg 1tizanidine hcl tab 2 mg (base equivalent) 1 QL (180 tablets/30 days)tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) 1 QL (180 tablets/30 days)

OTHER NEUROMUSCULAR DRUGSpyridostigmine bromide tab 60 mg (Mestinon) 1riluzole tab 50 mg (Rilutek) 1

SUPPLEMENTSVITAMINScholecalciferol cap 5000 unit 1ergocalciferol cap 50000 unit 1phytonadione tab 5 mg (Mephyton) 1

MULTIVITAMINSb-complex w/ c & folic acid cap 1 mg (Nephrocaps) 1b-complex w/ c & folic acid tab 1b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx) 1b-complex w/ c & folic acid tab 5 mg 1CLASSIC PRENATAL – prenatal vit w/ fe fumarate-fa tab

28-0.8 mg2

CORVITA – multiple vitamins w/ minerals & fa tab 1.25 mg 2CVS PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 2EQL PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab

28-0.8 mg2

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

2

GNP PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2GOODSENSE PRENATAL VITAMI – prenatal vit w/ fe fumarate-

fa tab 28-0.8 mg2

HM PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2KP PRENATAL MULTIVITAMINS – prenatal vit w/ fe fumarate-fa

tab 28-0.8 mg2

M-NATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2M-VIT – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2MULTI PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 2

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multiple vitamins w/ minerals cap 1multiple vitamins w/ minerals tab (Strovite forte) 1NIVA-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2O-CAL FA – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2pediatric multiple vitamin w/ minerals & c drops 45 mg/ml 1pediatric vitamins acd w/ fluoride soln 0.25 mg/ml 1PNV FOLIC ACID + IRON MUL – prenatal vit w/ fe fumarate-fa

tab 27-1 mg2

PNV PRENATAL PLUS MULTIVI – prenatal vit w/ fe fumarate-fatab 27-1 mg

2

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab0.25 mg

2

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab0.5 mg

2

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab1 mg

2

PRE-NATAL FORMULA – prenatal multivitamins & minerals w/iron & fa tab 0.8 mg

2

PRENATAL – prenatal multivitamins & minerals w/iron & fa tab0.8 mg

2

PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 2PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2PRENATAL AND IRON – prenatal multivitamins & minerals w/

iron & fa tab 0.8 mg2

PRENATAL FORTE – prenatal multivitamins & minerals w/iron &fa tab 0.8 mg

2

PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa tab27-0.8 mg

2

PRENATAL MULTI +DHA – prenatal vit w/ fe fum-fa-omega 3 cap27-0.8-228 mg

2

PRENATAL MULTIVITAMIN – prenatal vit w/ fe fumarate-fa tab28-0.8 mg

2

PRENATAL ONE DAILY – prenatal vit w/ fe fumarate-fa tab27-0.8 mg

2

prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 1PRENATAL VITAMIN – prenatal vit w/ fe fumarate-fa tab

27-0.8 mg2

PRENATAL VITAMIN & MINERA – prenatal vit w/ fe fumarate-fatab 28-0.8 mg

2

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PRENATAL VITAMIN/IRON – prenatal vit w/ fe fumarate-fa tab28-0.8 mg

2

PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab28-0.8 mg

2

PRENATAL VITAMINS PLUS LO – prenatal vit w/ fe fumarate-fatab 27-1 mg

2

PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 2PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 2PREPLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2PX PRENATAL MULTIVITAMINS – prenatal vit w/ fe fumarate-fa

tab 28-0.8 mg2

QC PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2RA PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg 2RA PRENATAL FORMULA/FOLIC – prenatal vit w/ fe fumarate-fa

tab 28-0.8 mg2

RIGHT STEP PRENATAL – prenatal vit w/ fe fumarate-fa tab27-0.8 mg

2

SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 2SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 2SM PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab

28-0.8 mg2

speciality vitamin product tab 1TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1 mg 2VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg 2VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1 mg 2VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 2

MINERALS AND ELECTROLYTESEFFERVESCENT POTASSIUM/CH – pot bicarbonate & chloride

effer tab 25 meq2

K-PHOS – potassium phosphate monobasic tab 500 mg 2pot phos monobasic w/sod phos di & monobas tab

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

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

(600 mg)2

potassium chloride microencapsulated crys er tab 10 meq 1

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potassium chloride microencapsulated crys er tab 20 meq 1potassium chloride oral soln 10% (20 meq/15ml) 1potassium chloride oral soln 20% (40 meq/15ml) 1potassium chloride tab er 8 meq (600 mg) 1potassium chloride tab er 10 meq (K-tab) 1SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from 1.1 mg

naf)2

SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from 2.2 mgnaf)

2

sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride) 1sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride) 1sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride) 1sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) 1sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride) 1

OTHER SUPPLEMENTSacetylcysteine cap 600 mg 1amino acids cap 1folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2 mg 1

BLOOD MODIFYING DRUGSBLOOD MODIFYING DRUGSanagrelide hcl cap 0.5 mg (Agrylin) 1anagrelide hcl cap 1 mg 1ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled

syringe 10 mcg/0.4ml2 PA, SP

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

2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP

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

2 PA, SP

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

2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP


2 PA, SP

BRILINTA – ticagrelor tab 60 mg 2 PA, QL (60tablets/30 days)

BRILINTA – ticagrelor tab 90 mg 2 PA, QL (60tablets/30 days)

cilostazol tab 50 mg 1cilostazol tab 100 mg 1clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) 1clopidogrel bisulfate tab 300 mg (base equiv) (Plavix) 1cyanocobalamin inj 1000 mcg/ml 1dipyridamole tab 25 mg 1 90dipyridamole tab 50 mg 1dipyridamole tab 75 mg 1DROXIA – hydroxyurea cap 200 mg 2DROXIA – hydroxyurea cap 300 mg 2DROXIA – hydroxyurea cap 400 mg 2ELIQUIS – apixaban tab 2.5 mg 2 PA, QL (60

tablets/30 days)ELIQUIS – apixaban tab 5 mg 2 PA, QL (74

tablets/30 days)ELIQUIS STARTER PACK – apixaban tab 5 mg 2 PA, QL (74

tablets/180 days)enoxaparin sodium inj 30 mg/0.3ml (Lovenox) 1 QL (30 syringes/365

days)enoxaparin sodium inj 40 mg/0.4ml (Lovenox) 1 QL (30 syringes/365

days)

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enoxaparin sodium inj 60 mg/0.6ml (Lovenox) 1 QL (30 syringes/365days)


enoxaparin sodium inj 100 mg/ml (Lovenox) 1 QL (30 syringes/365days)


enoxaparin sodium inj 150 mg/ml (Lovenox) 1 QL (30 syringes/365days)

fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap(Tandem plus)

1

fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg 1fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg 1ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg 1ferrous fumarate-folic acid tab 324-1 mg 1folic acid tab 1 mg 1folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg 1folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx) 1folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg 1FULPHILA – pegfilgrastim-jmdb soln prefilled syringe 6 mg/0.6ml 2 PA, SPHAEGARDA – c1 esterase inhibitor (human) for subcutaneous inj

2000 unit2 PA, QL (16 vials/28

days), SPHAEGARDA – c1 esterase inhibitor (human) for subcutaneous inj

3000 unit2 PA, QL (8 vials/28

days), SPicatibant acetate inj 30 mg/3ml (base equivalent) (Firazyr) 2 PA, QL (6 syringes/30

days), SPiron combination cap 1iron polysacch complex-vit b12-fa cap 150-0.025-1 mg 1iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg

(Hematron-af)1

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

1

miglustat cap 100 mg (Zavesca) 2 PA, QL (90 capsules/30days), SP

NIVESTYM – filgrastim-aafi soln prefilled syringe 300 mcg/0.5ml 2 PA, SPNIVESTYM – filgrastim-aafi soln prefilled syringe 480 mcg/0.8ml 2 PA, SPNIVESTYM – filgrastim-aafi inj 300 mcg/ml 2 PA, SP

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NIVESTYM – filgrastim-aafi inj 480 mcg/1.6ml (300 mcg/ml) 2 PA, SPpentoxifylline tab er 400 mg 1PROMACTA – eltrombopag olamine powder pack for susp

12.5 mg (base eq)2 PA, QL (30 packets/30

days), SPPROMACTA – eltrombopag olamine tab 12.5 mg (base equiv) 2 PA, QL (30 tablets/30

days), SPPROMACTA – eltrombopag olamine tab 25 mg (base equiv) 2 PA, QL (30 tablets/30



days), SPRETACRIT – epoetin alfa-epbx inj 2000 unit/ml 2 PA, SPRETACRIT – epoetin alfa-epbx inj 3000 unit/ml 2 PA, SPRETACRIT – epoetin alfa-epbx inj 4000 unit/ml 2 PA, SPRETACRIT – epoetin alfa-epbx inj 10000 unit/ml 2 PA, SPRETACRIT – epoetin alfa-epbx inj 40000 unit/ml 2 PA, SPtranexamic acid tab 650 mg (Lysteda) 1warfarin sodium tab 1 mg (Coumadin) 1warfarin sodium tab 2 mg (Coumadin) 1warfarin sodium tab 2.5 mg (Coumadin) 1warfarin sodium tab 3 mg (Coumadin) 1warfarin sodium tab 4 mg (Coumadin) 1warfarin sodium tab 5 mg (Coumadin) 1warfarin sodium tab 6 mg (Coumadin) 1warfarin sodium tab 7.5 mg (Coumadin) 1warfarin sodium tab 10 mg (Coumadin) 1XARELTO – rivaroxaban tab 2.5 mg 2 QL (60 tablets/30 days)XARELTO – rivaroxaban tab 10 mg 2 PA, QL (35

tablets/365 days)XARELTO – rivaroxaban tab 15 mg 2 PA, QL (60

tablets/30 days)XARELTO – rivaroxaban tab 20 mg 2 PA, QL (30

tablets/30 days)XARELTO STARTER PACK – rivaroxaban tab starter therapy

pack 15 mg & 20 mg2 PA, QL (51

tablets/30 days)

TOPICAL PRODUCTS

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EYEAnti-infectivesBACITRACIN – bacitracin ophth oint 500 unit/gm 2bacitracin-polymyxin b ophth oint 1ciprofloxacin hcl ophth soln 0.3% (base equivalent) (Ciloxan) 1erythromycin ophth oint 5 mg/gm 1gentamicin sulfate ophth soln 0.3% 1moxifloxacin hcl ophth soln 0.5% (base equiv) (Vigamox) 1NATACYN – natamycin ophth susp 5% 2neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 1NEOMYCIN/POLYMYXIN/GRAMIC – neomycin-polymy-gramicid

op sol 1.75-10000-0.025mg-unt-mg/ml2

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

(Polytrim)1

sulfacetamide sodium ophth soln 10% (Bleph-10) 1tobramycin ophth soln 0.3% (Tobrex) 1TRIFLURIDINE – trifluridine ophth soln 1% 2

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

phosphate ophth soln 0.1%2

fluorometholone ophth susp 0.1% (Fml liquifilm) 1neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol) 1neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol) 1PREDNISOLONE ACETATE – prednisolone acetate ophth susp

1%2

PREDNISOLONE SODIUM PHOSP – prednisolone sodiumphosphate ophth soln 1%

2

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

2

Glaucomaapraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine) 1betaxolol hcl ophth soln 0.5% 1brimonidine tartrate ophth soln 0.2% 1CARTEOLOL HCL – carteolol hcl ophth soln 1% 2dorzolamide hcl ophth soln 2% (Trusopt) 1

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dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml(Cosopt)

1

latanoprost ophth soln 0.005% (Xalatan) 1 QL (1 bottle/30 days)levobunolol hcl ophth soln 0.5% (Betagan) 1pilocarpine hcl ophth soln 1% (Isopto carpine) 1pilocarpine hcl ophth soln 2% (Isopto carpine) 1pilocarpine hcl ophth soln 4% (Isopto carpine) 1timolol maleate ophth soln 0.25% (Timoptic) 1timolol maleate ophth soln 0.5% (Timoptic) 1

Other Eye ProductsATROPINE SULFATE – atropine sulfate ophth oint 1% 2ATROPINE SULFATE – atropine sulfate ophth soln 1% 2azelastine hcl ophth soln 0.05% 1cromolyn sodium ophth soln 4% 1cyclopentolate hcl ophth soln 0.5% (Cyclogyl) 1cyclopentolate hcl ophth soln 1% (Cyclogyl) 1cyclopentolate hcl ophth soln 2% (Cyclogyl) 1diclofenac sodium ophth soln 0.1% 1epinastine hcl ophth soln 0.05% (Elestat) 1FLURBIPROFEN SODIUM – flurbiprofen sodium ophth soln

0.03%2

homatropine hbr ophth soln 5% 1ISOPTO ATROPINE – atropine sulfate ophth soln 1% 2ketorolac tromethamine ophth soln 0.4% (Acular ls) 1ketorolac tromethamine ophth soln 0.5% (Acular) 1olopatadine hcl ophth soln 0.1% (base equivalent) (Patanol) 1phenylephrine hcl ophth soln 2.5% 1proparacaine hcl ophth soln 0.5% (Alcaine) 1tetracaine hcl ophth soln 0.5% 1

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

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MOUTH AND THROAT (LOCAL)chlorhexidine gluconate soln 0.12% (Peridex) 1clotrimazole troche 10 mg 1lidocaine hcl viscous soln 2% 1nystatin susp 100000 unit/ml 1pilocarpine hcl tab 5 mg (Salagen) 1pilocarpine hcl tab 7.5 mg (Salagen) 1PREVIDENT FLUORIDE – sodium fluoride gel 1.1% (0.5% f) 2PREVIDENT RINSE – sodium fluoride rinse 0.2% 2PREVIDENT 5000 DRY MOUTH – sodium fluoride gel 1.1%

(0.5% f)2

sodium fluoride cream 1.1% (Prevident 5000 plus) 1sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) 1sodium fluoride paste 1.1% (Prevident 5000 boost) 1sodium fluoride rinse 0.2% 1sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000

sensi)1

stannous fluoride gel 0.4% 1triamcinolone acetonide dental paste 0.1% 1

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

SKIN CONDITIONS/PRODUCTSAcneadapalene cream 0.1% (Differin) 1 ALazelaic acid gel 15% (Finacea) 1 ALbenzoyl peroxide cloth 6% 1 ALbenzoyl peroxide-erythromycin gel 5-3% (Benzamycin) 1 ALCLINDACIN ETZ PLEDGETS – clindamycin phosphate swab 1% 2 ALCLINDACIN-P – clindamycin phosphate swab 1% 2 ALclindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5%

(Duac)1 AL

CLINDAMYCIN PHOSPHATE – clindamycin phosphate swab 1% 2 ALclindamycin phosphate gel 1% (Cleocin-t) 1 ALclindamycin phosphate lotion 1% (Cleocin-t) 1 AL

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clindamycin phosphate soln 1% (Cleocin-t) 1 ALerythromycin pads 2% 1 ALerythromycin soln 2% 1 ALisotretinoin cap 10 mg 1 ALisotretinoin cap 20 mg 1 ALisotretinoin cap 30 mg 1 ALisotretinoin cap 40 mg 1 ALmetronidazole cream 0.75% (Metrocream) 1 ALmetronidazole gel 0.75% 1 ALsulfacetamide sodium lotion 10% (acne) (Klaron) 1 ALtazarotene cream 0.1% (Tazorac) 1 ALTAZORAC – tazarotene cream 0.05% 2 ALTAZORAC – tazarotene gel 0.05% 2 ALTAZORAC – tazarotene gel 0.1% 2 ALtretinoin cream 0.025% (Retin-a) 1 ALtretinoin cream 0.05% (Retin-a) 1 ALtretinoin cream 0.1% (Retin-a) 1 ALtretinoin gel 0.01% (Retin-a) 1 ALtretinoin gel 0.025% (Retin-a) 1 ALtretinoin gel 0.05% (Atralin) 1 AL

Anti-infectivesacyclovir oint 5% (Zovirax) 1ciclopirox olamine cream 0.77% (base equiv) (Loprox) 1ciclopirox olamine susp 0.77% (base equiv) 1ciclopirox solution 8% (Penlac Nail Lacquer) 1 PA, QL (6.6 mls/30 days)clotrimazole cream 1% 1clotrimazole soln 1% 1clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone) 1diclofenac sodium gel 1% (Voltaren) 1 QL (200 grams/30 days)gentamicin sulfate oint 0.1% 1ketoconazole cream 2% 1ketoconazole shampoo 2% (Nizoral) 1mupirocin oint 2% 1naftifine hcl cream 2% (Naftin) 1nystatin cream 100000 unit/gm 1

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nystatin oint 100000 unit/gm 1oxiconazole nitrate cream 1% (Oxistat) 1salicylic acid cream 6% 1salicylic acid cream 6% & cleanser liqd kit (Salex cream) 1salicylic acid film forming liquid 27.5% (Virasal) 1salicylic acid foam 6% (Salvax) 1salicylic acid gel 6% (Keralyt) 1SALICYLIC ACID LOTION – salicylic acid lotion 6% & cleanser

liqd kit2

salicylic acid lotion 6% 1salicylic acid shampoo 6% (Salex) 1silver sulfadiazine cream 1% (Silvadene) 1

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

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

betamethasone dipropionate augmented cream 0.05%(Diprolene af)

1 QL (180 grams/90 days)

betamethasone dipropionate augmented lotion 0.05% (Diprolene) 1 QL (180 mls/90 days)betamethasone dipropionate augmented oint 0.05% (Diprolene) 1 QL (180 grams/90 days)betamethasone dipropionate cream 0.05% 1 QL (180 grams/90 days)betamethasone dipropionate lotion 0.05% 1 QL (180 mls/90 days)betamethasone dipropionate oint 0.05% 1 QL (180 grams/90 days)betamethasone valerate cream 0.1% (base equivalent) 1betamethasone valerate lotion 0.1% (base equivalent) 1betamethasone valerate oint 0.1% (base equivalent) 1clobetasol propionate emollient base cream 0.05% (Temovate e) 1clobetasol propionate soln 0.05% (Temovate) 1 QL (180 mls/90 days)desonide cream 0.05% (Desowen) 1desonide oint 0.05% 1desoximetasone cream 0.25% (Topicort) 1 QL (180 grams/90 days)desoximetasone gel 0.05% (Topicort) 1 QL (180 grams/90 days)fluocinolone acetonide cream 0.01% 1fluocinolone acetonide cream 0.025% (Synalar) 1

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fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fssca)

1

fluocinolone acetonide oint 0.025% (Synalar) 1fluocinolone acetonide soln 0.01% (Synalar) 1fluocinonide cream 0.05% 1 QL (180 grams/90 days)fluocinonide emulsified base cream 0.05% 1 QL (180 grams/90 days)fluocinonide gel 0.05% 1 QL (180 grams/90 days)fluocinonide oint 0.05% 1 QL (180 grams/90 days)fluocinonide soln 0.05% 1 QL (180 mls/90 days)flurandrenolide cream 0.05% (Cordran) 1fluticasone propionate cream 0.05% (Cutivate) 1fluticasone propionate oint 0.005% 1halobetasol propionate cream 0.05% (Ultravate) 1 QL (180 grams/90 days)halobetasol propionate oint 0.05% (Ultravate) 1 QL (180 grams/90 days)hydrocortisone butyrate oint 0.1% (Locoid) 1hydrocortisone butyrate soln 0.1% (Locoid) 1hydrocortisone cream 1% 1hydrocortisone cream 2.5% 1hydrocortisone lotion 2.5% 1hydrocortisone oint 1% 1hydrocortisone oint 2.5% 1hydrocortisone valerate cream 0.2% 1hydrocortisone valerate oint 0.2% (Westcort) 1mometasone furoate cream 0.1% (Elocon) 1mometasone furoate oint 0.1% (Elocon) 1 QL (180 grams/90 days)mometasone furoate solution 0.1% (lotion) (Elocon) 1PREDNICARBATE – prednicarbate cream 0.1% 2PREDNICARBATE – prednicarbate oint 0.1% 2triamcinolone acetonide aerosol soln 0.147 mg/gm (Kenalog) 1triamcinolone acetonide cream 0.025% 1triamcinolone acetonide cream 0.1% 1triamcinolone acetonide cream 0.5% 1 QL (180 grams/90 days)triamcinolone acetonide lotion 0.025% 1triamcinolone acetonide lotion 0.1% 1triamcinolone acetonide oint 0.025% 1

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triamcinolone acetonide oint 0.1% 1

Other Skin Productsacitretin cap 10 mg (Soriatane) 1acitretin cap 17.5 mg (Soriatane) 1acitretin cap 25 mg (Soriatane) 1calcipotriene cream 0.005% (Dovonex) 1calcipotriene oint 0.005% 1calcipotriene soln 0.005% (50 mcg/ml) 1CEM-UREA – urea soln 45% 2CERAMAX – dermatological products misc - cream 2COSENTYX – secukinumab subcutaneous soln prefilled syringe


days), SPCOSENTYX – secukinumab subcutaneous soln prefilled syringe

150 mg/ml2 PA, QL (1 syringe/28

days), SPCOSENTYX SENSOREADY PEN – secukinumab subcutaneous

soln auto-injector 150 mg/ml2 PA, QL (2 pens/28

days), SPCOSENTYX SENSOREADY PEN – secukinumab subcutaneous

soln auto-injector 150 mg/ml2 PA, QL (1 pen/28

days), SPCUTTER BACKWOODS – diethyltoluamide (deet) aerosol 2CUTTER SKINSATIONS – diethyltoluamide (deet) liquid 2fluorouracil cream 5% (Efudex) 1 QL (240 grams/180 days)imiquimod cream 5% (Aldara) 1 QL (48 packets/180 days)lidocaine hcl gel 2% 1 QL (120 grams/30 days)lidocaine hcl soln 4% (Xylocaine) 1 QL (120 grams/30 days)lidocaine hcl urethral/mucosal gel 2% 1 QL (120 grams/30 days)lidocaine patch 5% (Lidoderm) 1 PA, QL (90

patches/30 days)lidocaine-prilocaine cream 2.5-2.5% 1 QL (30 grams/60 days)malathion lotion 0.5% (Ovide) 1methoxsalen rapid cap 10 mg (Oxsoralen ultra) 1NATRAPEL 12-HOUR TICK & I – picaridin aerosol 2OFF ACTIVE – diethyltoluamide (deet) aerosol 2OFF DEEP WOODS – diethyltoluamide (deet) aerosol 2OFF DEEP WOODS DRY – diethyltoluamide (deet) aerosol 2OFF SMOOTH & DRY – diethyltoluamide (deet) aerosol 2permethrin cream 5% (Elimite) 1

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podofilox soln 0.5% (Condylox) 1REPEL SPORTSMEN – diethyltoluamide (deet) aerosol 2REPEL SPORTSMEN MAX – diethyltoluamide (deet) aerosol 2SAWYER PREMIUM INSECT REP – picaridin liquid 2selenium sulfide lotion 2.5% 1selenium sulfide shampoo 2.25% 1STELARA – ustekinumab soln prefilled syringe 45 mg/0.5ml 2 PA, QL (1 syringe/84

days), SPSTELARA – ustekinumab soln prefilled syringe 90 mg/ml 2 PA, QL (1 syringe/56

days), SPtacrolimus oint 0.03% (Protopic) 1 QL (60 days

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

supply/120 days), ST

MISCELLANEOUS CATEGORIESDIABETIC SUPPLIESKETOSTIX – acetone (urine) test strip 2ONETOUCH ULTRA BLUE – glucose blood test strip 2 QL (153 strips/30

days), STONETOUCH ULTRA CONTROL – blood glucose calibration -

liquid2

ONETOUCH ULTRA MINI – blood glucose monitoring kit w/device

2 QL (2 systems/365 days)

ONETOUCH ULTRA 2 – blood glucose monitoring kit w/ device 2 QL (2 systems/365 days)ONETOUCH VERIO – blood glucose monitoring kit w/ device 2 QL (2 systems/365 days)ONETOUCH VERIO CONTROL SO – blood glucose calibration -

liquid - high2

ONETOUCH VERIO FLEX BLOOD – blood glucose monitoringkit w/ device


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


ONETOUCH VERIO MID CONTRO – blood glucose calibration -liquid

2

ONETOUCH VERIO TEST STRIP – glucose blood test strip 2 QL (153 strips/30days), ST

INSULIN SYRINGES - TECHLITE AND TRUEPLUS 2 QL (200syringes/30 days)

INUSLIN PEN NEEDLES - TECHLITE AND TRUEPLUS 2 QL (200 insulin penneedles/30 days)

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ONETOUCH DELICA LANCETS E – lancets 2 QL (200 units/30 days)ONETOUCH DELICA LANCETS F – lancets 2 QL (200 units/30 days)ONETOUCH DELICA LANCING D – lancet devices 2ONETOUCH DELICA PLUS LANC – lancet devices 2ONETOUCH SURESOFT LANCING – lancets misc. 2ONETOUCH ULTRASOFT LANCET – lancets 2 QL (200 units/30 days)

RESPIRATORY INHALER-ASSIST DEVICESAEROCHAMBER 2BREATHERITE 2

MISCELLANEOUS DRUGSazathioprine tab 50 mg (Imuran) 1CHEMET – succimer cap 100 mg 2cyclosporine cap 25 mg (Sandimmune) 1cyclosporine cap 100 mg (Sandimmune) 1CYCLOSPORINE MODIFIED – cyclosporine modified cap 50 mg 2cyclosporine modified cap 25 mg (Neoral) 1cyclosporine modified cap 100 mg (Neoral) 1cyclosporine modified oral soln 100 mg/ml (Neoral) 1deferasirox tab for oral susp 125 mg (Exjade) 2 PA, QL (30 tablets/30

days), SPdeferasirox tab for oral susp 250 mg (Exjade) 2 PA, QL (30 tablets/30

days), SPdeferasirox tab for oral susp 500 mg (Exjade) 2 PA, QL (90 tablets/30

days), SPDEPEN TITRATABS – penicillamine tab 250 mg 2 PA, SPFERRIPROX – deferiprone oral soln 100 mg/ml 2 PA, QL (2700

mls/30 days), SPFERRIPROX – deferiprone tab 500 mg 2 PA, QL (540

tablets/30 days), SPFERRIPROX – deferiprone tab 1000 mg 2 PA, QL (270

tablets/30 days)irrigation solution, physiological 1lactated ringer's for irrigation 1mycophenolate mofetil cap 250 mg (Cellcept) 1mycophenolate mofetil for oral susp 200 mg/ml (Cellcept) 1mycophenolate mofetil tab 500 mg (Cellcept) 1

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mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)(Myfortic)

1

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

1

naltrexone hcl tab 50 mg 1NARCAN – naloxone hcl nasal spray 4 mg/0.1ml 2penicillamine cap 250 mg (Cuprimine) 2 PA, SPREVLIMID – lenalidomide caps 2.5 mg 2 PA, QL (30 capsules/30

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





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

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



days), SP

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trientine hcl cap 250 mg (Syprine) 2 PA, QL (240capsules/30 days), SP

VIVITROL – naltrexone for im extended release susp 380 mg 2 QL (1 vial/28 days), SPwater for irrigation, sterile irrigation soln 1ZORTRESS – everolimus tab 0.25 mg 2ZORTRESS – everolimus tab 0.5 mg 2ZORTRESS – everolimus tab 0.75 mg 2ZORTRESS – everolimus tab 1 mg 2

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INDEX

Aabacavir sulfate-lamivudine tab 600-300 mg(Epzicom).......................................................................... 11

abacavir sulfate-lamivudine-zidovudine tab 300-150-300mg (Trizivir)....................................................................... 11

abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen)...... 11abacavir sulfate tab 300 mg (base equiv) (Ziagen)...........11ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 300 mg.................................................................63

ABILIFY MAINTENA – aripiprazole im for er susp prefilledsyringe 400 mg.................................................................63

ABILIFY MAINTENA – aripiprazole im for extendedrelease susp 300 mg........................................................63

ABILIFY MAINTENA – aripiprazole im for extendedrelease susp 400 mg........................................................63

abiraterone acetate tab 250 mg (Zytiga)...........................17acamprosate calcium tab delayed release 333 mg...........75acarbose tab 25 mg (Precose)..........................................29acarbose tab 50 mg (Precose)..........................................29acarbose tab 100 mg (Precose)........................................29acebutolol hcl cap 200 mg (Sectral)..................................39acebutolol hcl cap 400 mg (Sectral)..................................39ACETAMINOPHEN/CAFFEINE/DI – acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg................. 76

acetaminophen w/ codeine soln 120-12 mg/5ml...............76acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine).............................................................................76

acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3)....................................................................... 76

acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4)....................................................................... 76

acetazolamide cap er 12hr 500 mg (Diamox)................... 45acetazolamide tab 250 mg................................................ 45acetic acid otic soln 2%..................................................... 97acetylcysteine cap 600 mg................................................ 92acetylcysteine inhal soln 10%............................................50acetylcysteine inhal soln 20%............................................50acitretin cap 10 mg (Soriatane)....................................... 102acitretin cap 17.5 mg (Soriatane).................................... 102acitretin cap 25 mg (Soriatane)....................................... 102ACTHAR – corticotropin inj gel 80 unit/ml.........................34ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml(2000000 unit/0.5ml).........................................................17

acyclovir cap 200 mg (Zovirax)......................................... 11acyclovir oint 5% (Zovirax)................................................ 99acyclovir susp 200 mg/5ml (Zovirax).................................11acyclovir tab 400 mg (Zovirax).......................................... 11acyclovir tab 800 mg (Zovirax).......................................... 11ADACEL – tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml..........................................................................16

adapalene cream 0.1% (Differin).......................................98ADASUVE – loxapine aerosol powder breath activated 10mg......................................................................................63

adefovir dipivoxil tab 10 mg (Hepsera)..............................10ADEMPAS – riociguat tab 0.5 mg..................................... 47ADEMPAS – riociguat tab 1 mg........................................ 47ADEMPAS – riociguat tab 1.5 mg..................................... 47ADEMPAS – riociguat tab 2 mg........................................ 47ADEMPAS – riociguat tab 2.5 mg..................................... 47ADMELOG – insulin lispro inj 100 unit/ml......................... 32ADMELOG SOLOSTAR – insulin lispro soln pen-injector100 unit/ml........................................................................ 32

AEROCHAMBER..............................................................104AFINITOR DISPERZ – everolimus tab for oral susp 2mg......................................................................................18

AFINITOR DISPERZ – everolimus tab for oral susp 3mg......................................................................................18

AFINITOR DISPERZ – everolimus tab for oral susp 5mg......................................................................................18

AFINITOR – everolimus tab 2.5 mg.................................. 17AFINITOR – everolimus tab 5 mg..................................... 17AFINITOR – everolimus tab 7.5 mg.................................. 17AFINITOR – everolimus tab 10 mg................................... 17AFLURIA QUADRIVALENT 2019-2020 – influenza virusvaccine split quadrivalent im inj.......................................16

AFLURIA QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.25 ml.................... 16

AFLURIA QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.5ml....................... 16

albendazole tab 200 mg (Albenza)....................................15ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr4 mg.................................................................................. 50

ALBUTEROL SULFATE ER – albuterol sulfate tab er 12hr8 mg.................................................................................. 50

ALBUTEROL SULFATE HFA – albuterol sulfate inhal aero108 mcg/act (90mcg base equiv).................................... 50

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..............51albuterol sulfate soln nebu 0.5% (5 mg/ml).......................51albuterol sulfate soln nebu 0.63 mg/3ml (base equiv).......51albuterol sulfate soln nebu 1.25 mg/3ml (base equiv).......51albuterol sulfate syrup 2 mg/5ml....................................... 51albuterol sulfate tab 2 mg..................................................51albuterol sulfate tab 4 mg..................................................51alclometasone dipropionate cream 0.05% (Aclovate).....100alclometasone dipropionate oint 0.05%.......................... 100ALECENSA – alectinib hcl cap 150 mg (baseequivalent).........................................................................18

ALENDRONATE SODIUM – alendronate sodium tab 5mg......................................................................................34

ALENDRONATE SODIUM – alendronate sodium tab 40mg......................................................................................34

alendronate sodium tab 10 mg..........................................34alendronate sodium tab 35 mg..........................................34alendronate sodium tab 70 mg (Fosamax)....................... 34alfuzosin hcl tab er 24hr 10 mg (Uroxatral).......................57ALINIA – nitazoxanide tab 500 mg....................................15ALKERAN – melphalan tab 2 mg......................................18allopurinol tab 100 mg (Zyloprim)......................................84allopurinol tab 300 mg (Zyloprim)......................................84

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almotriptan malate tab 6.25 mg (Axert).............................83almotriptan malate tab 12.5 mg (Axert).............................83ALOGLIPTIN/METFORMIN HCL – alogliptin-metforminhcl tab 12.5-500 mg......................................................... 30

ALOGLIPTIN/METFORMIN HCL – alogliptin-metforminhcl tab 12.5-1000 mg....................................................... 30

ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazonetab 12.5-15 mg................................................................. 30



ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazonetab 25-15 mg.................................................................... 30



ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (baseequiv).................................................................................29

ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (baseequiv).................................................................................29

ALOGLIPTIN – alogliptin benzoate tab 25 mg (baseequiv).................................................................................30

alosetron hcl tab 0.5 mg (base equiv) (Lotronex)............. 56alosetron hcl tab 1 mg (base equiv) (Lotronex)................ 56ALPRAZOLAM INTENSOL – alprazolam conc 1 mg/ml.......................................................................................58

alprazolam tab er 24hr 0.5 mg (Xanax xr)........................ 58alprazolam tab er 24hr 1 mg (Xanax xr)........................... 58alprazolam tab er 24hr 2 mg (Xanax xr)........................... 58alprazolam tab er 24hr 3 mg (Xanax xr)........................... 58alprazolam tab 0.25 mg (Xanax)....................................... 58alprazolam tab 0.5 mg (Xanax)......................................... 58alprazolam tab 1 mg (Xanax)............................................ 58alprazolam tab 2 mg (Xanax)............................................ 58amantadine hcl cap 100 mg.............................................. 87amantadine hcl syrup 50 mg/5ml...................................... 87ambrisentan tab 5 mg (Letairis).........................................47ambrisentan tab 10 mg (Letairis).......................................47amiloride & hydrochlorothiazide tab 5-50 mg....................45amiloride hcl tab 5 mg....................................................... 45amino acids cap................................................................. 92amiodarone hcl tab 200 mg (Cordarone).......................... 46amitriptyline hcl tab 10 mg.................................................59amitriptyline hcl tab 50 mg.................................................59amitriptyline hcl tab 75 mg.................................................59amitriptyline hcl tab 100 mg...............................................59amitriptyline hcl tab 150 mg...............................................59amitriptyline hcl tab 25 mg (Elavil).................................... 59amlodipine besylate-benazepril hcl cap 2.5-10 mg...........40amlodipine besylate-benazepril hcl cap 5-40 mg..............40amlodipine besylate-benazepril hcl cap 5-10 mg(Lotrel)............................................................................... 40

amlodipine besylate-benazepril hcl cap 5-20 mg(Lotrel)............................................................................... 40



amlodipine besylate tab 2.5 mg (base equivalent)(Norvasc)...........................................................................40

amlodipine besylate tab 5 mg (base equivalent)(Norvasc)...........................................................................40

amlodipine besylate tab 10 mg (base equivalent)(Norvasc)...........................................................................40

AMOXICILLIN/CLAVULANATE P – amoxicillin & kclavulanate chew tab 200-28.5 mg....................................7

AMOXICILLIN/CLAVULANATE P – amoxicillin & kclavulanate chew tab 400-57 mg.......................................7

amoxicillin & k clavulanate for susp 200-28.5 mg/5ml........ 7amoxicillin & k clavulanate for susp 400-57 mg/5ml........... 7amoxicillin & k clavulanate for susp 250-62.5 mg/5ml(Augmentin).........................................................................7

amoxicillin & k clavulanate for susp 600-42.9 mg/5ml(Augmentin es-600)............................................................ 7

amoxicillin & k clavulanate tab 250-125 mg........................7amoxicillin & k clavulanate tab 500-125 mg(Augmentin).........................................................................7

amoxicillin & k clavulanate tab 875-125 mg(Augmentin).........................................................................7

AMOXICILLIN – amoxicillin (trihydrate) chew tab 125mg........................................................................................7

AMOXICILLIN – amoxicillin (trihydrate) chew tab 250mg........................................................................................7

amoxicillin (trihydrate) cap 250 mg......................................7amoxicillin (trihydrate) cap 500 mg......................................7amoxicillin (trihydrate) for susp 125 mg/5ml........................7amoxicillin (trihydrate) for susp 200 mg/5ml........................7amoxicillin (trihydrate) for susp 250 mg/5ml........................7amoxicillin (trihydrate) for susp 400 mg/5ml........................7amoxicillin (trihydrate) tab 875 mg...................................... 7amphetamine-dextroamphetamine cap er 24hr 5 mg(Adderall xr)...................................................................... 71

amphetamine-dextroamphetamine cap er 24hr 10 mg(Adderall xr)...................................................................... 71





amphetamine-dextroamphetamine tab 5 mg(Adderall)...........................................................................71

amphetamine-dextroamphetamine tab 7.5 mg(Adderall)...........................................................................71


amphetamine-dextroamphetamine tab 12.5 mg(Adderall)...........................................................................71

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anagrelide hcl cap 1 mg.................................................... 92anagrelide hcl cap 0.5 mg (Agrylin)...................................92anastrozole tab 1 mg (Arimidex)....................................... 18APLENZIN – bupropion hbr tab er 24hr 174 mg...............59APLENZIN – bupropion hbr tab er 24hr 348 mg...............59APLENZIN – bupropion hbr tab er 24hr 522 mg...............59apraclonidine hcl ophth soln 0.5% (base equivalent)(Iopidine)........................................................................... 96

aprepitant capsule 40 mg (Emend)................................... 55aprepitant capsule 80 mg (Emend)................................... 55aprepitant capsule 125 mg (Emend)................................. 55APTIOM – eslicarbazepine acetate tab 200 mg................84APTIOM – eslicarbazepine acetate tab 400 mg................84APTIOM – eslicarbazepine acetate tab 600 mg................84APTIOM – eslicarbazepine acetate tab 800 mg................84APTIVUS – tipranavir cap 250 mg.................................... 11APTIVUS – tipranavir oral soln 100 mg/ml....................... 11ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25mcg/ml...............................................................................93

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40mcg/ml...............................................................................93

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60mcg/ml...............................................................................93

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj100 mcg/ml....................................................................... 93



ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 10 mcg/0.4ml......................................... 92

ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 25 mcg/0.42ml.......................................92







ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 500 mcg/ml............................................ 93

ARCALYST – rilonacept for inj 220 mg.............................80aripiprazole orally disintegrating tab 10 mg.......................63aripiprazole orally disintegrating tab 15 mg.......................63

aripiprazole oral solution 1 mg/ml......................................63aripiprazole tab 2 mg (Abilify)............................................63aripiprazole tab 5 mg (Abilify)............................................63aripiprazole tab 10 mg (Abilify)..........................................63aripiprazole tab 15 mg (Abilify)..........................................63aripiprazole tab 20 mg (Abilify)..........................................63aripiprazole tab 30 mg (Abilify)..........................................63ARISTADA – aripiprazole lauroxil im er susp prefilled syr441 mg/1.6ml....................................................................63

ARISTADA – aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml....................................................................63

ARISTADA – aripiprazole lauroxil im er susp prefilled syr882 mg/3.2ml....................................................................63

ARISTADA – aripiprazole lauroxil im er susp prefilled syr1064 mg/3.9ml..................................................................63

ARISTADA INITIO – aripiprazole lauroxil im er suspprefilled syr 675 mg/2.4ml................................................63

armodafinil tab 50 mg (Nuvigil)..........................................71armodafinil tab 150 mg (Nuvigil)........................................71armodafinil tab 200 mg (Nuvigil)........................................72armodafinil tab 250 mg (Nuvigil)........................................72ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 50 mcg/act....................................................51

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 100 mcg/act..................................................51

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 200 mcg/act..................................................51

atazanavir sulfate cap 150 mg (base equiv) (Reyataz).....11atazanavir sulfate cap 200 mg (base equiv) (Reyataz).....11atazanavir sulfate cap 300 mg (base equiv) (Reyataz).....11atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)......39atenolol & chlorthalidone tab 100-25 mg (Tenoretic100)................................................................................... 39

atenolol tab 25 mg (Tenormin).......................................... 39atenolol tab 50 mg (Tenormin).......................................... 39atenolol tab 100 mg (Tenormin)........................................ 39atomoxetine hcl cap 10 mg (base equiv) (Strattera)......... 72atomoxetine hcl cap 18 mg (base equiv) (Strattera)......... 72atomoxetine hcl cap 25 mg (base equiv) (Strattera)......... 72atomoxetine hcl cap 40 mg (base equiv) (Strattera)......... 72atomoxetine hcl cap 60 mg (base equiv) (Strattera)......... 72atomoxetine hcl cap 80 mg (base equiv) (Strattera)......... 72atomoxetine hcl cap 100 mg (base equiv) (Strattera)....... 72atorvastatin calcium tab 10 mg (base equivalent)(Lipitor).............................................................................. 43

atorvastatin calcium tab 20 mg (base equivalent)(Lipitor).............................................................................. 43



atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)...... 14atovaquone-proguanil hcl tab 250-100 mg (Malarone)..... 14ATRIPLA – efavirenz-emtricitabine-tenofovir df tab600-200-300 mg............................................................... 11

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ATROPINE SULFATE – atropine sulfate ophth oint1%..................................................................................... 97

ATROPINE SULFATE – atropine sulfate ophth soln1%..................................................................................... 97

ATROVENT HFA – ipratropium bromide hfa inhal aerosol17 mcg/act........................................................................ 51

AUBAGIO – teriflunomide tab 7 mg.................................. 74AUBAGIO – teriflunomide tab 14 mg................................ 74AUGMENTED BETAMETHASONE D – betamethasonedipropionate augmented gel 0.05%...............................100

AVONEX – interferon beta-1a im prefilled syringe kit 30mcg/0.5ml..........................................................................74

AVONEX PEN – interferon beta-1a im auto-injector kit 30mcg/0.5ml..........................................................................74

azathioprine tab 50 mg (Imuran)..................................... 104azelaic acid gel 15% (Finacea)......................................... 98azelastine hcl nasal spray 0.1% (137 mcg/spray).............50azelastine hcl ophth soln 0.05%........................................97AZITHROMYCIN – azithromycin powd pack for susp 1gm........................................................................................8

azithromycin for susp 100 mg/5ml (Zithromax)...................8azithromycin for susp 200 mg/5ml (Zithromax)...................8azithromycin tab 250 mg (Zithromax)..................................8azithromycin tab 500 mg (Zithromax)..................................8azithromycin tab 600 mg (Zithromax)..................................8

BBACITRACIN – bacitracin ophth oint 500 unit/gm............ 96bacitracin-polymyxin b ophth oint...................................... 96bacitracin-polymyxin-neomycin-hc ophth oint 1%............. 96baclofen tab 10 mg............................................................ 88baclofen tab 20 mg............................................................ 88balsalazide disodium cap 750 mg (Colazal)......................56BALVERSA – erdafitinib tab 3 mg.....................................18BALVERSA – erdafitinib tab 4 mg.....................................18BALVERSA – erdafitinib tab 5 mg.....................................18BARACLUDE – entecavir oral soln 0.05 mg/ml................ 10BASAGLAR KWIKPEN – insulin glargine soln pen-injector100 unit/ml........................................................................ 33

b-complex w/ c & folic acid cap 1 mg (Nephrocaps)......... 89b-complex w/ c & folic acid tab..........................................89b-complex w/ c & folic acid tab 5 mg................................ 89b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx).......89benazepril & hydrochlorothiazide tab 5-6.25 mg...............36benazepril & hydrochlorothiazide tab 10-12.5 mg(Lotensin hct)....................................................................36

benazepril & hydrochlorothiazide tab 20-12.5 mg(Lotensin hct)....................................................................36

benazepril & hydrochlorothiazide tab 20-25 mg (Lotensinhct).....................................................................................36

benazepril hcl tab 5 mg..................................................... 36benazepril hcl tab 10 mg (Lotensin)..................................36benazepril hcl tab 20 mg (Lotensin)..................................36benazepril hcl tab 40 mg (Lotensin)..................................36BENZNIDAZOLE – benznidazole tab 12.5 mg................. 15BENZNIDAZOLE – benznidazole tab 100 mg.................. 15

benzoyl peroxide cloth 6%.................................................98benzoyl peroxide-erythromycin gel 5-3%(Benzamycin).................................................................... 98

benztropine mesylate tab 0.5 mg...................................... 87benztropine mesylate tab 1 mg......................................... 87benztropine mesylate tab 2 mg......................................... 87betamethasone dipropionate augmented cream 0.05%(Diprolene af)..................................................................100

betamethasone dipropionate augmented lotion 0.05%(Diprolene)...................................................................... 100

betamethasone dipropionate augmented oint 0.05%(Diprolene)...................................................................... 100

betamethasone dipropionate cream 0.05%.....................100betamethasone dipropionate lotion 0.05%......................100betamethasone dipropionate oint 0.05%.........................100betamethasone valerate cream 0.1% (baseequivalent).......................................................................100

betamethasone valerate lotion 0.1% (baseequivalent).......................................................................100

betamethasone valerate oint 0.1% (base equivalent).....100betaxolol hcl ophth soln 0.5%............................................96betaxolol hcl tab 10 mg (Kerlone)..................................... 39betaxolol hcl tab 20 mg (Kerlone)..................................... 39bethanechol chloride tab 5 mg (Urecholine)..................... 57bethanechol chloride tab 10 mg (Urecholine)................... 57bethanechol chloride tab 25 mg (Urecholine)................... 57bethanechol chloride tab 50 mg (Urecholine)................... 57BEVESPI AEROSPHERE – glycopyrrolate-formoterolfumarate aerosol 9-4.8 mcg/act.......................................51

bexarotene cap 75 mg (Targretin)..................................... 18bicalutamide tab 50 mg (Casodex)....................................18BIKTARVY – bictegravir-emtricitabine-tenofovir af tab50-200-25 mg................................................................... 11

bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for solnkit....................................................................................... 53

bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg(Ziac)................................................................................. 39

bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)......39bisoprolol & hydrochlorothiazide tab 10-6.25 mg(Ziac)................................................................................. 39

bisoprolol fumarate tab 5 mg (Zebeta)..............................39bisoprolol fumarate tab 10 mg (Zebeta)............................39BOOSTRIX – tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml.......................................................................16

bosentan tab 62.5 mg (Tracleer)....................................... 47bosentan tab 125 mg (Tracleer)........................................ 47BOSULIF – bosutinib tab 100 mg..................................... 18BOSULIF – bosutinib tab 500 mg..................................... 18BRAFTOVI – encorafenib cap 75 mg................................18BREATHERITE.................................................................104BRILINTA – ticagrelor tab 60 mg...................................... 93BRILINTA – ticagrelor tab 90 mg...................................... 93brimonidine tartrate ophth soln 0.2%.................................96bromocriptine mesylate cap 5 mg (base equivalent).........87bromocriptine mesylate tab 2.5 mg (base equivalent)(Parlodel)...........................................................................87

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budesonide delayed release particles cap 3 mg (Entocortec)......................................................................................26

budesonide inhalation susp 0.25 mg/2ml (Pulmicort)....... 51budesonide inhalation susp 0.5 mg/2ml (Pulmicort)......... 51budesonide inhalation susp 1 mg/2ml (Pulmicort)............ 51bumetanide tab 0.5 mg (Bumex).......................................45bumetanide tab 1 mg (Bumex)..........................................45bumetanide tab 2 mg (Bumex)..........................................45BUPHENYL – sodium phenylbutyrate tab 500 mg............34buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (baseequiv) (Suboxone)............................................................ 76

buprenorphine hcl-naloxone hcl sl film 4-1 mg (baseequiv) (Suboxone)............................................................ 76



buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (baseequiv).................................................................................77

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (baseequiv).................................................................................77

buprenorphine hcl sl tab 2 mg (base equiv)......................76buprenorphine hcl sl tab 8 mg (base equiv)......................76bupropion hcl (smoking deterrent) tab er 12hr 150 mg(Zyban).............................................................................. 75

bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)..............59bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)..............59bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)..............59bupropion hcl tab er 24hr 150 mg (Wellbutrin xl).............. 59bupropion hcl tab er 24hr 300 mg (Wellbutrin xl).............. 59bupropion hcl tab 75 mg....................................................59bupropion hcl tab 100 mg..................................................60BUPROPION HYDROCHLORIDE E – bupropion hcl taber 24hr 450 mg.................................................................60

buspirone hcl tab 5 mg...................................................... 58buspirone hcl tab 10 mg....................................................58buspirone hcl tab 15 mg....................................................58buspirone hcl tab 30 mg....................................................58butalbital-acetaminophen-caffeine cap 50-300-40 mg(Fioricet)............................................................................ 76

butalbital-acetaminophen-caffeine tab 50-325-40 mg(Esgic)............................................................................... 76

butalbital-acetaminophen-caff w/ cod cap 50-325-40-30mg......................................................................................77

butalbital-acetaminophen tab 50-325 mg..........................76butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal).....76butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg(Fiorinal/codeine #3).........................................................77

butorphanol tartrate nasal soln 10 mg/ml..........................77

Ccabergoline tab 0.5 mg...................................................... 34CABOMETYX – cabozantinib s-malate tab 20 mg (baseequivalent).........................................................................18

CABOMETYX – cabozantinib s-malate tab 40 mg (baseequivalent).........................................................................18

CABOMETYX – cabozantinib s-malate tab 60 mg (baseequivalent).........................................................................18

caffeine citrate oral soln 60 mg/3ml (10 mg/ml baseequiv).................................................................................72

calcipotriene cream 0.005% (Dovonex).......................... 102calcipotriene oint 0.005%.................................................102calcipotriene soln 0.005% (50 mcg/ml)........................... 102calcitonin (salmon) nasal soln 200 unit/act (Miacalcin).....34calcitriol cap 0.25 mcg (Rocaltrol)..................................... 34calcitriol cap 0.5 mcg (Rocaltrol)....................................... 34calcitriol oral soln 1 mcg/ml (Rocaltrol)............................. 34calcium acetate (phosphate binder) cap 667 mg (169 mgca) (Phoslo)...................................................................... 56

calcium acetate (phosphate binder) tab 667 mg(Eliphos)............................................................................ 56

CALQUENCE – acalabrutinib cap 100 mg........................18capecitabine tab 150 mg (Xeloda).....................................18capecitabine tab 500 mg (Xeloda).....................................18CAPRELSA – vandetanib tab 100 mg.............................. 18CAPRELSA – vandetanib tab 300 mg.............................. 18CAPTOPRIL/HYDROCHLOROTHIA – captopril &hydrochlorothiazide tab 25-15 mg................................... 36

CAPTOPRIL/HYDROCHLOROTHIA – captopril &hydrochlorothiazide tab 25-25 mg................................... 36



captopril tab 12.5 mg......................................................... 36captopril tab 25 mg............................................................ 36captopril tab 50 mg............................................................ 36captopril tab 100 mg.......................................................... 36CARBAGLU – carglumic acid tab 200 mg........................ 34carbamazepine cap er 12hr 100 mg (Carbatrol)............... 84carbamazepine cap er 12hr 200 mg (Carbatrol)............... 84carbamazepine cap er 12hr 300 mg (Carbatrol)............... 84carbamazepine chew tab 100 mg..................................... 84carbamazepine susp 100 mg/5ml (Tegretol).....................85carbamazepine tab er 12hr 100 mg (Tegretol-xr)..............85carbamazepine tab er 12hr 200 mg (Tegretol-xr)..............85carbamazepine tab er 12hr 400 mg (Tegretol-xr)..............85carbamazepine tab 200 mg (Tegretol).............................. 85carbidopa & levodopa orally disintegrating tab 10-100mg......................................................................................87

carbidopa & levodopa orally disintegrating tab 25-100mg......................................................................................87

carbidopa & levodopa orally disintegrating tab 25-250mg......................................................................................87

carbidopa & levodopa tab er 25-100 mg (Sinemet cr)...... 88carbidopa & levodopa tab er 50-200 mg (Sinemet cr)...... 88carbidopa & levodopa tab 10-100 mg (Sinemet)...............88carbidopa & levodopa tab 25-100 mg (Sinemet)...............88carbidopa & levodopa tab 25-250 mg (Sinemet)...............88carbidopa tab 25 mg (Lodosyn).........................................88carbinoxamine maleate soln 4 mg/5ml..............................49carbinoxamine maleate tab 4 mg...................................... 50

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carisoprodol tab 250 mg (Soma).......................................88CARTEOLOL HCL – carteolol hcl ophth soln 1%............. 96carvedilol tab 3.125 mg (Coreg)........................................39carvedilol tab 6.25 mg (Coreg)..........................................39carvedilol tab 12.5 mg (Coreg)..........................................39carvedilol tab 25 mg (Coreg).............................................39CAYSTON – aztreonam lysine for inhal soln 75 mg (baseequivalent).........................................................................15

cefaclor cap 250 mg............................................................ 7cefaclor cap 500 mg............................................................ 7cefadroxil cap 500 mg..........................................................7cefadroxil for susp 250 mg/5ml........................................... 7cefadroxil for susp 500 mg/5ml........................................... 7cefadroxil tab 1 gm.............................................................. 7cefdinir cap 300 mg............................................................. 7cefdinir for susp 125 mg/5ml............................................... 8cefdinir for susp 250 mg/5ml............................................... 8cefixime for susp 100 mg/5ml (Suprax)...............................8cefixime for susp 200 mg/5ml (Suprax)...............................8cefprozil for susp 125 mg/5ml............................................. 8cefprozil for susp 250 mg/5ml............................................. 8cefprozil tab 250 mg............................................................ 8cefprozil tab 500 mg............................................................ 8ceftriaxone sodium for inj 1 gm........................................... 8ceftriaxone sodium for inj 2 gm........................................... 8ceftriaxone sodium for inj 250 mg....................................... 8ceftriaxone sodium for inj 500 mg....................................... 8cefuroxime axetil tab 250 mg.............................................. 8cefuroxime axetil tab 500 mg (Ceftin)................................. 8celecoxib cap 50 mg (Celebrex)........................................80celecoxib cap 100 mg (Celebrex)......................................80celecoxib cap 200 mg (Celebrex)......................................81celecoxib cap 400 mg (Celebrex)......................................81CEM-UREA – urea soln 45%.......................................... 102cephalexin cap 250 mg (Keflex)..........................................8cephalexin cap 500 mg (Keflex)..........................................8cephalexin for susp 125 mg/5ml..........................................8cephalexin for susp 250 mg/5ml..........................................8CERAMAX – dermatological products misc - cream.......102cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)........................50CHANTIX CONTINUING MONTH – varenicline tartratetab 1 mg (base equiv)......................................................75

CHANTIX STARTING MONTH PA – varenicline tartratetab 0.5 mg x 11 & tab 1 mg x 42 pack............................ 75

CHANTIX – varenicline tartrate tab 0.5 mg (baseequiv).................................................................................75

CHANTIX – varenicline tartrate tab 1 mg (base equiv)..... 75CHEMET – succimer cap 100 mg...................................104CHENODAL – chenodiol tab 250 mg................................56CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide-amitriptyline tab 5-12.5 mg.............................................. 75

CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide-amitriptyline tab 10-25 mg............................................... 75

chlordiazepoxide hcl cap 5 mg..........................................58chlordiazepoxide hcl cap 10 mg........................................58chlordiazepoxide hcl cap 25 mg........................................58

chlorhexidine gluconate soln 0.12% (Peridex).................. 98chloroquine phosphate tab 500 mg (Aralen).....................14CHLOROTHIAZIDE – chlorothiazide tab 250 mg............. 45CHLOROTHIAZIDE – chlorothiazide tab 500 mg............. 45CHLORPROMAZINE HCL – chlorpromazine hcl inj 50mg/2ml...............................................................................63

chlorpromazine hcl tab 10 mg........................................... 63chlorpromazine hcl tab 25 mg........................................... 64chlorpromazine hcl tab 50 mg........................................... 64chlorpromazine hcl tab 100 mg......................................... 64chlorpromazine hcl tab 200 mg......................................... 64chlorthalidone tab 25 mg................................................... 45CHLORZOXAZONE – chlorzoxazone tab 500 mg............88CHOLBAM – cholic acid cap 50 mg..................................56CHOLBAM – cholic acid cap 250 mg................................56cholecalciferol cap 5000 unit............................................. 89cholestyramine light powder 4 gm/dose (Questranlight)...................................................................................43

cholestyramine light powder packets 4 gm....................... 43cholestyramine powder 4 gm/dose (Questran)................. 43cholestyramine powder packets 4 gm (Questran).............43choline fenofibrate cap dr 45 mg (fenofibric acid equiv)(Trilipix)..............................................................................43

ciclopirox olamine cream 0.77% (base equiv)(Loprox).............................................................................99

ciclopirox olamine susp 0.77% (base equiv).....................99ciclopirox solution 8% (Penlac Nail Lacquer)....................99cilostazol tab 50 mg...........................................................93cilostazol tab 100 mg.........................................................93CIMDUO – lamivudine-tenofovir disoproxil fumarate tab300-300 mg.......................................................................11

CIMETIDINE HCL – cimetidine hcl soln 300 mg/5ml........54CIMZIA – certolizumab pegol inj kit 2 x 200 mg/ml...........56CIMZIA STARTER KIT – certolizumab pegol inj kit 6 x 200mg/ml.................................................................................56

cinacalcet hcl tab 30 mg (base equiv)...............................34cinacalcet hcl tab 60 mg (base equiv)...............................34cinacalcet hcl tab 90 mg (base equiv)...............................34ciprofloxacin for oral susp 500 mg/5ml (10%) (10gm/100ml) (Cipro)...............................................................9

ciprofloxacin hcl ophth soln 0.3% (base equivalent)(Ciloxan)............................................................................96

ciprofloxacin hcl tab 750 mg (base equiv)...........................9ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)...............9ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)...............9citalopram hydrobromide oral soln 10 mg/5ml.................. 60citalopram hydrobromide tab 10 mg (base equiv)(Celexa).............................................................................60

citalopram hydrobromide tab 20 mg (base equiv)(Celexa).............................................................................60

citalopram hydrobromide tab 40 mg (base equiv)(Celexa).............................................................................60

clarithromycin tab 250 mg (Biaxin)......................................8clarithromycin tab 500 mg (Biaxin)......................................8CLASSIC PRENATAL – prenatal vit w/ fe fumarate-fa tab28-0.8 mg..........................................................................89

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CLINDACIN ETZ PLEDGETS – clindamycin phosphateswab 1%........................................................................... 98

CLINDACIN-P – clindamycin phosphate swab 1%...........98clindamycin hcl cap 75 mg (Cleocin).................................15clindamycin hcl cap 150 mg (Cleocin)...............................15clindamycin hcl cap 300 mg (Cleocin)...............................15clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)(Cleocin pediatric gr)........................................................ 15

CLINDAMYCIN PHOSPHATE – clindamycin phosphateswab 1%........................................................................... 98

clindamycin phosphate gel 1% (Cleocin-t)........................ 98clindamycin phosphate lotion 1% (Cleocin-t).................... 98clindamycin phosphate soln 1% (Cleocin-t)...................... 99clindamycin phosphate vaginal cream 2% (Cleocin).........57clindamycin phosph-benzoyl peroxide (refrig) gel 1.2(1)-5% (Duac)................................................................... 98

clobetasol propionate emollient base cream 0.05%(Temovate e)...................................................................100

clobetasol propionate soln 0.05% (Temovate)................ 100clonazepam orally disintegrating tab 0.125 mg.................85clonazepam orally disintegrating tab 0.25 mg...................85clonazepam orally disintegrating tab 0.5 mg.....................85clonazepam orally disintegrating tab 1 mg........................85clonazepam orally disintegrating tab 2 mg........................85clonazepam tab 0.5 mg (Klonopin)....................................85clonazepam tab 1 mg (Klonopin).......................................85clonazepam tab 2 mg (Klonopin).......................................85clonidine hcl tab er 12hr 0.1 mg (Kapvay)........................ 72clonidine hcl tab 0.1 mg (Catapres).................................. 47clonidine hcl tab 0.2 mg (Catapres).................................. 47clonidine hcl tab 0.3 mg (Catapres).................................. 47clonidine td patch weekly 0.1 mg/24hr (Catapres-tts-1).................................................................................. 47

clonidine td patch weekly 0.2 mg/24hr (Catapres-tts-2).................................................................................. 47

clonidine td patch weekly 0.3 mg/24hr (Catapres-tts-3).................................................................................. 47

clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)........93clopidogrel bisulfate tab 300 mg (base equiv) (Plavix)......93clorazepate dipotassium tab 3.75 mg................................58clorazepate dipotassium tab 15 mg...................................59clorazepate dipotassium tab 7.5 mg (Tranxene t)............. 58clotrimazole cream 1%.......................................................99clotrimazole soln 1%.......................................................... 99clotrimazole troche 10 mg................................................. 98clotrimazole w/ betamethasone cream 1-0.05%(Lotrisone)......................................................................... 99

CLOZAPINE ODT – clozapine orally disintegrating tab150 mg..............................................................................64

CLOZAPINE ODT – clozapine orally disintegrating tab200 mg..............................................................................64

clozapine orally disintegrating tab 12.5 mg (Fazaclo).......64clozapine orally disintegrating tab 25 mg (Fazaclo)..........64clozapine orally disintegrating tab 100 mg (Fazaclo)........64clozapine tab 50 mg...........................................................64clozapine tab 200 mg.........................................................64

clozapine tab 25 mg (Clozaril)...........................................64clozapine tab 100 mg (Clozaril).........................................64codeine sulfate tab 30 mg (Codeine sulfate).................... 77COLCHICINE – colchicine cap 0.6 mg............................. 84colchicine w/ probenecid tab 0.5-500 mg..........................84colestipol hcl granule packets 5 gm (Colestidflavored)............................................................................ 43

colestipol hcl granules 5 gm (Colestid flavored)................43colestipol hcl tab 1 gm (Colestid)...................................... 43COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.14 mg/day..............................................................27

COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.25 mg/day..............................................................27

COMBIVENT RESPIMAT – ipratropium-albuterol inhalaerosol soln 20-100 mcg/act............................................51

COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60mg dose) kit......................................................................19

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20mg (100 dose) kit............................................................. 19

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20mg (140 dose) kit............................................................. 19

COMPLERA – emtricitabine-rilpivirine-tenofovir df tab200-25-300 mg................................................................. 11

COPIKTRA – duvelisib cap 15 mg....................................19COPIKTRA – duvelisib cap 25 mg....................................19CORTISONE ACETATE – cortisone acetate tab 25mg......................................................................................26

CORVITA – multiple vitamins w/ minerals & fa tab 1.25mg......................................................................................89

COSENTYX – secukinumab subcutaneous soln prefilledsyringe 150 mg/ml..........................................................102

COSENTYX SENSOREADY PEN – secukinumabsubcutaneous soln auto-injector 150 mg/ml..................102

COTELLIC – cobimetinib fumarate tab 20 mg (baseequivalent).........................................................................19

CREON – pancrelipase (lip-prot-amyl) dr cap3000-9500-15000 unit...................................................... 55

CREON – pancrelipase (lip-prot-amyl) dr cap6000-19000-30000 unit.................................................... 55

CREON – pancrelipase (lip-prot-amyl) dr cap12000-38000-60000 unit.................................................. 55

CREON – pancrelipase (lip-prot-amyl) dr cap24000-76000-120000 unit................................................ 55

CREON – pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit.............................................. 55

CRIXIVAN – indinavir sulfate cap 200 mg.........................11CRIXIVAN – indinavir sulfate cap 400 mg.........................11cromolyn sodium ophth soln 4%....................................... 97CUTTER BACKWOODS – diethyltoluamide (deet)aerosol.............................................................................102

CUTTER SKINSATIONS – diethyltoluamide (deet)liquid................................................................................ 102

CVS PRENATAL – prenatal vit w/ fe fumarate-fa tab27-0.8 mg..........................................................................89

cyanocobalamin inj 1000 mcg/ml...................................... 93cyclobenzaprine hcl tab 5 mg............................................88

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cyclobenzaprine hcl tab 10 mg..........................................88cyclopentolate hcl ophth soln 0.5% (Cyclogyl)..................97cyclopentolate hcl ophth soln 1% (Cyclogyl).....................97cyclopentolate hcl ophth soln 2% (Cyclogyl).....................97cyclophosphamide cap 25 mg (Cyclophosphamide).........19cyclophosphamide cap 50 mg (Cyclophosphamide).........19cyclosporine cap 25 mg (Sandimmune)..........................104cyclosporine cap 100 mg (Sandimmune)........................104cyclosporine modified cap 25 mg (Neoral)......................104cyclosporine modified cap 100 mg (Neoral)....................104CYCLOSPORINE MODIFIED – cyclosporine modified cap50 mg..............................................................................104

cyclosporine modified oral soln 100 mg/ml (Neoral)....... 104cyproheptadine hcl syrup 2 mg/5ml...................................50cyproheptadine hcl tab 4 mg............................................. 50CYSTADANE – betaine powder for oral solution.............. 34CYSTAGON – cysteamine bitartrate cap 50 mg............... 57CYSTAGON – cysteamine bitartrate cap 150 mg............. 57

Ddanazol cap 50 mg............................................................ 27danazol cap 100 mg.......................................................... 27danazol cap 200 mg.......................................................... 27dantrolene sodium cap 100 mg.........................................89dantrolene sodium cap 25 mg (Dantrium).........................88dantrolene sodium cap 50 mg (Dantrium).........................89dapsone tab 25 mg............................................................15dapsone tab 100 mg..........................................................15DARAPRIM – pyrimethamine tab 25 mg...........................15darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv)(Enablex)...........................................................................57

darifenacin hydrobromide tab er 24hr 15 mg (base equiv)(Enablex)...........................................................................57

DAURISMO – glasdegib maleate tab 25 mg (baseequivalent).........................................................................19

DAURISMO – glasdegib maleate tab 100 mg (baseequivalent).........................................................................19

deferasirox tab for oral susp 125 mg (Exjade)................ 104deferasirox tab for oral susp 250 mg (Exjade)................ 104deferasirox tab for oral susp 500 mg (Exjade)................ 104DELSTRIGO – doravirine-lamivudine-tenofovir df tab100-300-300 mg............................................................... 11

demeclocycline hcl tab 150 mg........................................... 8demeclocycline hcl tab 300 mg........................................... 8DEPEN TITRATABS – penicillamine tab 250 mg............104DESCOVY – emtricitabine-tenofovir alafenamide fumaratetab 200-25 mg.................................................................. 12

desipramine hcl tab 50 mg................................................ 60desipramine hcl tab 75 mg................................................ 60desipramine hcl tab 100 mg.............................................. 60desipramine hcl tab 150 mg.............................................. 60desipramine hcl tab 10 mg (Norpramin)............................60desipramine hcl tab 25 mg (Norpramin)............................60desloratadine tab 5 mg (Clarinex)..................................... 50desmopressin acetate nasal spray soln 0.01%(Ddavp)..............................................................................34

desmopressin acetate nasal spray soln 0.01%(refrigerated)..................................................................... 34

desmopressin acetate tab 0.1 mg (Ddavp)....................... 34desmopressin acetate tab 0.2 mg (Ddavp)....................... 34desonide cream 0.05% (Desowen)................................. 100desonide oint 0.05%........................................................ 100desoximetasone cream 0.25% (Topicort)........................100desoximetasone gel 0.05% (Topicort)............................. 100DEXAMETHASONE – dexamethasone soln 0.5mg/5ml...............................................................................26

dexamethasone elixir 0.5 mg/5ml......................................26DEXAMETHASONE SODIUM PHOS – dexamethasonesodium phosphate ophth soln 0.1%................................ 96

dexamethasone tab 0.5 mg............................................... 26dexamethasone tab 0.75 mg.............................................26dexamethasone tab 1.5 mg............................................... 26dexamethasone tab 4 mg.................................................. 26dexamethasone tab 6 mg.................................................. 26dexmethylphenidate hcl cap er 24 hr 5 mg (Focalinxr)...................................................................................... 72

dexmethylphenidate hcl cap er 24 hr 10 mg (Focalinxr)...................................................................................... 72





dexmethylphenidate hcl tab 2.5 mg (Focalin)................... 72dexmethylphenidate hcl tab 5 mg (Focalin)...................... 72dexmethylphenidate hcl tab 10 mg (Focalin).................... 72dextroamphetamine sulfate cap er 24hr 5 mg(Dexedrine)....................................................................... 73

dextroamphetamine sulfate cap er 24hr 10 mg(Dexedrine)....................................................................... 73

dextroamphetamine sulfate cap er 24hr 15 mg(Dexedrine)....................................................................... 73

dextroamphetamine sulfate oral solution 5 mg/5ml(Procentra)........................................................................ 73

dextroamphetamine sulfate tab 5 mg................................73dextroamphetamine sulfate tab 10 mg..............................73diazepam conc 5 mg/ml.....................................................59DIAZEPAM – diazepam oral soln 1 mg/ml........................59diazepam tab 2 mg (Valium)..............................................59diazepam tab 5 mg (Valium)..............................................59diazepam tab 10 mg (Valium)............................................59diclofenac potassium tab 50 mg........................................81diclofenac sodium gel 1% (Voltaren).................................99diclofenac sodium ophth soln 0.1%...................................97diclofenac sodium tab delayed release 50 mg..................81diclofenac sodium tab delayed release 75 mg..................81diclofenac sodium tab er 24hr 100 mg..............................81dicloxacillin sodium cap 250 mg..........................................7dicloxacillin sodium cap 500 mg..........................................7

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dicyclomine hcl cap 10 mg (Bentyl)...................................54dicyclomine hcl oral soln 10 mg/5ml................................. 54dicyclomine hcl tab 20 mg (Bentyl)................................... 54didanosine delayed release capsule 200 mg (Videxec)......................................................................................12

didanosine delayed release capsule 250 mg (Videxec)......................................................................................12

didanosine delayed release capsule 400 mg (Videxec)......................................................................................12

DIGOXIN – digoxin oral soln 0.05 mg/ml.......................... 47digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................... 47digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................... 47DILANTIN – phenytoin sodium extended cap 30 mg........85diltiazem hcl cap er 12hr 60 mg........................................41diltiazem hcl cap er 12hr 90 mg........................................41diltiazem hcl cap er 12hr 120 mg......................................41diltiazem hcl cap er 24hr 180 mg......................................41diltiazem hcl cap er 24hr 240 mg......................................41diltiazem hcl coated beads cap er 24hr 300 mg............... 41diltiazem hcl coated beads cap er 24hr 120 mg (Cardizemcd)......................................................................................41

diltiazem hcl coated beads cap er 24hr 180 mg (Cardizemcd)......................................................................................41

diltiazem hcl coated beads cap er 24hr 240 mg (Cardizemcd)......................................................................................41

diltiazem hcl extended release beads cap er 24hr 120 mg(Tiazac)............................................................................. 41






diltiazem hcl tab 90 mg......................................................41diltiazem hcl tab 30 mg (Cardizem)...................................41diltiazem hcl tab 60 mg (Cardizem)...................................41diltiazem hcl tab 120 mg (Cardizem).................................41DILT-XR – diltiazem hcl cap er 24hr 120 mg.................... 41diphenhydramine hcl cap 50 mg....................................... 50diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)...... 54dipyridamole tab 25 mg..................................................... 93dipyridamole tab 50 mg..................................................... 93dipyridamole tab 75 mg..................................................... 93disopyramide phosphate cap 100 mg (Norpace).............. 46disopyramide phosphate cap 150 mg (Norpace).............. 46disulfiram tab 250 mg (Antabuse)..................................... 75disulfiram tab 500 mg (Antabuse)..................................... 75divalproex sodium cap delayed release sprinkle 125 mg(Depakote sprinkles).........................................................85

divalproex sodium tab delayed release 125 mg(Depakote)........................................................................ 85



divalproex sodium tab er 24 hr 250 mg (Depakote er)......85divalproex sodium tab er 24 hr 500 mg (Depakote er)......85dofetilide cap 125 mcg (0.125 mg) (Tikosyn)....................46dofetilide cap 250 mcg (0.25 mg) (Tikosyn)......................46dofetilide cap 500 mcg (0.5 mg) (Tikosyn)........................46donepezil hydrochloride orally disintegrating tab 5 mg..... 75donepezil hydrochloride orally disintegrating tab 10mg......................................................................................75

donepezil hydrochloride tab 5 mg (Aricept).......................75donepezil hydrochloride tab 10 mg (Aricept).....................75dorzolamide hcl ophth soln 2% (Trusopt)..........................96dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt)....................................................................... 97

DOVATO – dolutegravir sodium-lamivudine tab 50-300 mg(base eq)...........................................................................12

doxazosin mesylate tab 1 mg (Cardura)........................... 48doxazosin mesylate tab 2 mg (Cardura)........................... 48doxazosin mesylate tab 4 mg (Cardura)........................... 48doxazosin mesylate tab 8 mg (Cardura)........................... 48doxepin hcl cap 10 mg...................................................... 60doxepin hcl cap 25 mg...................................................... 60doxepin hcl cap 50 mg...................................................... 60doxepin hcl cap 75 mg...................................................... 60doxepin hcl cap 100 mg.................................................... 60doxepin hcl conc 10 mg/ml................................................60DOXEPIN HCL – doxepin hcl cap 150 mg........................60doxycycline hyclate cap 50 mg............................................8doxycycline hyclate cap 100 mg (Vibramycin).................... 8doxycycline hyclate tab delayed release 50 mg (Doryx).....8doxycycline hyclate tab 20 mg............................................ 8doxycycline hyclate tab 100 mg.......................................... 8doxycycline monohydrate cap 50 mg..................................9doxycycline monohydrate cap 100 mg (Monodox)..............9doxycycline monohydrate for susp 25 mg/5ml(Vibramycin)........................................................................ 9

doxycycline monohydrate tab 50 mg (Adoxa).....................9doxycycline monohydrate tab 75 mg (Adoxa).....................9doxycycline monohydrate tab 100 mg (Adoxa pak1/100).................................................................................. 9

DROXIA – hydroxyurea cap 200 mg.................................93DROXIA – hydroxyurea cap 300 mg.................................93DROXIA – hydroxyurea cap 400 mg.................................93duloxetine hcl enteric coated pellets cap 20 mg (base eq)(Cymbalta).........................................................................60

duloxetine hcl enteric coated pellets cap 30 mg (base eq)(Cymbalta).........................................................................60

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

dutasteride cap 0.5 mg (Avodart)...................................... 57dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)............57dyphylline-guaifenesin liqd 100-100 mg/5ml..................... 51

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EEDURANT – rilpivirine hcl tab 25 mg (baseequivalent).........................................................................12

efavirenz cap 50 mg (Sustiva)...........................................12efavirenz cap 200 mg (Sustiva).........................................12efavirenz tab 600 mg (Sustiva)..........................................12EFFERVESCENT POTASSIUM/CH – pot bicarbonate &chloride effer tab 25 meq.................................................91

ELIGARD – leuprolide acetate for subcutaneous inj kit 7.5mg......................................................................................19

ELIGARD – leuprolide acetate (3 month) forsubcutaneous inj kit 22.5mg............................................ 19

ELIGARD – leuprolide acetate (4 month) forsubcutaneous inj kit 30 mg.............................................. 19

ELIGARD – leuprolide acetate (6 month) forsubcutaneous inj kit 45 mg.............................................. 19

ELIQUIS – apixaban tab 2.5 mg....................................... 93ELIQUIS – apixaban tab 5 mg.......................................... 93ELIQUIS STARTER PACK – apixaban tab 5 mg.............. 93ELLA – ulipristal acetate tab 30 mg.................................. 28EMSAM – selegiline td patch 24hr 6 mg/24hr...................60EMSAM – selegiline td patch 24hr 9 mg/24hr...................60EMSAM – selegiline td patch 24hr 12 mg/24hr.................60EMTRIVA – emtricitabine caps 200 mg............................ 12EMTRIVA – emtricitabine soln 10 mg/ml...........................12enalapril maleate & hydrochlorothiazide tab 5-12.5mg......................................................................................36

enalapril maleate & hydrochlorothiazide tab 10-25 mg(Vaseretic)......................................................................... 36

enalapril maleate tab 2.5 mg (Vasotec).............................36enalapril maleate tab 5 mg (Vasotec)............................... 36enalapril maleate tab 10 mg (Vasotec)............................. 36enalapril maleate tab 20 mg (Vasotec)............................. 36ENBREL – etanercept for subcutaneous inj 25 mg...........81ENBREL – etanercept subcutaneous soln prefilled syringe25 mg/0.5ml...................................................................... 81

ENBREL – etanercept subcutaneous soln prefilled syringe50 mg/ml........................................................................... 81

ENBREL MINI – etanercept subcutaneous solutioncartridge 50 mg/ml............................................................81

ENBREL SURECLICK – etanercept subcutaneoussolution auto-injector 50 mg/ml........................................81

ENGERIX-B – hepatitis b vaccine (recombinant) 10mcg/0.5ml..........................................................................16

ENGERIX-B – hepatitis b vaccine (recombinant) 20 mcg/ml.......................................................................................16

ENGERIX-B – hepatitis b vaccine (recombinant) susp 10mcg/0.5ml..........................................................................16

ENGERIX-B – hepatitis b vaccine (recombinant) susp 20mcg/ml...............................................................................16

enoxaparin sodium inj 30 mg/0.3ml (Lovenox)................. 93enoxaparin sodium inj 40 mg/0.4ml (Lovenox)................. 93enoxaparin sodium inj 60 mg/0.6ml (Lovenox)................. 94enoxaparin sodium inj 80 mg/0.8ml (Lovenox)................. 94enoxaparin sodium inj 100 mg/ml (Lovenox).................... 94

enoxaparin sodium inj 120 mg/0.8ml (Lovenox)............... 94enoxaparin sodium inj 150 mg/ml (Lovenox).................... 94entacapone tab 200 mg (Comtan).....................................88entecavir tab 0.5 mg (Baraclude)...................................... 10entecavir tab 1 mg (Baraclude)......................................... 10ENTRESTO – sacubitril-valsartan tab 24-26 mg.............. 41ENTRESTO – sacubitril-valsartan tab 49-51 mg.............. 41ENTRESTO – sacubitril-valsartan tab 97-103 mg............ 41epinastine hcl ophth soln 0.05% (Elestat).........................97epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)(Epipen-jr 2-pak)...............................................................49

epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)(Epipen 2-pak).................................................................. 49

EQL PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...............................................................89

EQUETRO – carbamazepine (antipsychotic) cap er 12hr100 mg..............................................................................64



ergocalciferol cap 50000 unit.............................................89ERIVEDGE – vismodegib cap 150 mg..............................19ERLEADA – apalutamide tab 60 mg.................................19erlotinib hcl tab 25 mg (base equivalent) (Tarceva).......... 19erlotinib hcl tab 100 mg (base equivalent) (Tarceva)........ 19erlotinib hcl tab 150 mg (base equivalent) (Tarceva)........ 19erythromycin ophth oint 5 mg/gm......................................96erythromycin pads 2%....................................................... 99erythromycin soln 2%.........................................................99ESBRIET – pirfenidone cap 267 mg................................. 53escitalopram oxalate soln 5 mg/5ml (base equiv)(Lexapro)...........................................................................60

escitalopram oxalate tab 5 mg (base equiv) (Lexapro).....60escitalopram oxalate tab 10 mg (base equiv)(Lexapro)...........................................................................60

escitalopram oxalate tab 20 mg (base equiv)(Lexapro)...........................................................................60

estazolam tab 1 mg........................................................... 70estazolam tab 2 mg........................................................... 70estradiol & norethindrone acetate tab 0.5-0.1 mg(Activella)...........................................................................27

estradiol & norethindrone acetate tab 1-0.5 mg(Activella)...........................................................................27

estradiol tab 0.5 mg (Estrace)........................................... 27estradiol tab 1 mg (Estrace).............................................. 27estradiol tab 2 mg (Estrace).............................................. 27estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot).................................................................................... 28

estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot).................................................................................... 28



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estradiol td patch weekly 0.025 mg/24hr (Climara)...........28estradiol td patch weekly 0.05 mg/24hr (Climara).............28estradiol td patch weekly 0.06 mg/24hr (Climara).............28estradiol td patch weekly 0.075 mg/24hr (Climara)...........28estradiol td patch weekly 0.1 mg/24hr (Climara)...............28estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)(Climara)............................................................................28

estradiol vaginal cream 0.1 mg/gm (Estrace)....................57estradiol vaginal tab 10 mcg (Vagifem).............................57ESTROGEL – estradiol gel 0.06% (0.75 mg/1.25 gmmetered-dose pump)........................................................ 28

eszopiclone tab 1 mg (Lunesta)........................................ 70eszopiclone tab 2 mg (Lunesta)........................................ 70eszopiclone tab 3 mg (Lunesta)........................................ 70ethambutol hcl tab 100 mg (Myambutol).............................9ethambutol hcl tab 400 mg (Myambutol).............................9ethosuximide cap 250 mg (Zarontin).................................85ethosuximide soln 250 mg/5ml (Zarontin)......................... 85ETIDRONATE DISODIUM – etidronate disodium tab 200mg......................................................................................34

ETOPOSIDE – etoposide cap 50 mg................................19EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg(base equiv)...................................................................... 12

exemestane tab 25 mg (Aromasin)................................... 19EXTAVIA – interferon beta-1b for inj kit 0.3 mg.................75

Ffamciclovir tab 125 mg (Famvir)........................................11famotidine for susp 40 mg/5ml (Pepcid)............................54famotidine tab 20 mg (Pepcid).......................................... 54famotidine tab 40 mg (Pepcid).......................................... 54FANAPT – iloperidone tab 1 mg........................................64FANAPT – iloperidone tab 2 mg........................................64FANAPT – iloperidone tab 4 mg........................................64FANAPT – iloperidone tab 6 mg........................................64FANAPT – iloperidone tab 8 mg........................................64FANAPT – iloperidone tab 10 mg......................................64FANAPT – iloperidone tab 12 mg......................................65FANAPT TITRATION PACK – iloperidone tab 1 mg & 2mg & 4 mg & 6 mg titration pak...................................... 65

FAZACLO – clozapine orally disintegrating tab 150mg......................................................................................65

FAZACLO – clozapine orally disintegrating tab 200mg......................................................................................65

fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1mg......................................................................................94

fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240mg......................................................................................94

fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap(Tandem plus)...................................................................94

felbamate susp 600 mg/5ml (Felbatol)..............................85felbamate tab 400 mg (Felbatol)....................................... 85felbamate tab 600 mg (Felbatol)....................................... 85felodipine tab er 24hr 2.5 mg............................................ 41

felodipine tab er 24hr 5 mg............................................... 41felodipine tab er 24hr 10 mg............................................. 41fenofibrate micronized cap 43 mg..................................... 43fenofibrate micronized cap 67 mg (Lofibra).......................43fenofibrate micronized cap 134 mg (Lofibra).....................43fenofibrate micronized cap 200 mg (Lofibra).....................43fenofibrate tab 54 mg (Lofibra)..........................................44fenofibrate tab 160 mg (Lofibra)........................................44fenofibrate tab 48 mg (Tricor)............................................ 43fenofibrate tab 145 mg (Tricor).......................................... 44fentanyl td patch 72hr 12 mcg/hr (Duragesic)...................77fentanyl td patch 72hr 25 mcg/hr (Duragesic)...................77fentanyl td patch 72hr 50 mcg/hr (Duragesic)...................77fentanyl td patch 72hr 75 mcg/hr (Duragesic)...................77fentanyl td patch 72hr 100 mcg/hr (Duragesic).................77FERRIPROX – deferiprone oral soln 100 mg/ml.............104FERRIPROX – deferiprone tab 500 mg..........................104FERRIPROX – deferiprone tab 1000 mg........................104ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1mg......................................................................................94

ferrous fumarate-folic acid tab 324-1 mg.......................... 94FETZIMA – levomilnacipran hcl cap er 24hr 20 mg (baseequivalent).........................................................................60

FETZIMA – levomilnacipran hcl cap er 24hr 40 mg (baseequivalent).........................................................................60



FETZIMA TITRATION PACK – levomilnacipran hcl cap er24hr 20 & 40 mg therapy pack........................................61

finasteride tab 5 mg (Proscar)...........................................58flecainide acetate tab 50 mg............................................. 46flecainide acetate tab 100 mg........................................... 46flecainide acetate tab 150 mg........................................... 46FLOVENT DISKUS – fluticasone propionate aer pow ba50 mcg/blister................................................................... 51

FLOVENT DISKUS – fluticasone propionate aer pow ba100 mcg/blister................................................................. 51

FLOVENT DISKUS – fluticasone propionate aer pow ba250 mcg/blister................................................................. 51

FLOVENT HFA – fluticasone propionate hfa inhal aer 110mcg/act (125/valve).......................................................... 51

FLOVENT HFA – fluticasone propionate hfa inhal aer 220mcg/act (250/valve).......................................................... 52

FLOVENT HFA – fluticasone propionate hfa inhal aero 44mcg/act (50/valve)............................................................ 51

FLUAD 2019-2020 – influenza vac type a&b surface antadj susp pref syr 0.5 ml................................................... 16

FLUARIX QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.5ml....................... 16

FLUBLOK QUADRIVALENT 2019-2020 – influenza vacrecomb ha quad pf soln pref syr 0.5 ml...........................16

FLUCELVAX QUADRIVALENT 2019-2020 – influenza vactiss-cult subunt quad susp pref syr 0.5 ml.......................16

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FLUCELVAX QUADRIVALENT 2019-2020 – influenza vactissue-cultured subunit quadrivalent im susp.................. 16

fluconazole for susp 10 mg/ml (Diflucan)..........................10fluconazole for susp 40 mg/ml (Diflucan)..........................10fluconazole tab 50 mg (Diflucan).......................................10fluconazole tab 100 mg (Diflucan).....................................10fluconazole tab 150 mg (Diflucan).....................................10fluconazole tab 200 mg (Diflucan).....................................10flucytosine cap 250 mg (Ancobon)....................................10flucytosine cap 500 mg (Ancobon)....................................10fludrocortisone acetate tab 0.1 mg....................................26FLULAVAL QUADRIVALENT 2019-2020 – influenza virusvaccine split quadrivalent im inj.......................................16

FLULAVAL QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.5ml....................... 16

FLUNISOLIDE – flunisolide nasal soln 25 mcg/act(0.025%)............................................................................50

fluocinolone acetonide cream 0.01%.............................. 100fluocinolone acetonide cream 0.025% (Synalar).............100fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs sca).............................................................. 101

fluocinolone acetonide oint 0.025% (Synalar).................101fluocinolone acetonide soln 0.01% (Synalar).................. 101fluocinonide cream 0.05%............................................... 101fluocinonide emulsified base cream 0.05%.....................101fluocinonide gel 0.05%.....................................................101fluocinonide oint 0.05%....................................................101fluocinonide soln 0.05%...................................................101fluorometholone ophth susp 0.1% (Fml liquifilm).............. 96fluorouracil cream 5% (Efudex)....................................... 102fluoxetine hcl cap 10 mg (Prozac).....................................61fluoxetine hcl cap 20 mg (Prozac).....................................61fluoxetine hcl cap 40 mg (Prozac).....................................61fluoxetine hcl solution 20 mg/5ml...................................... 61fluoxetine hcl tab 10 mg.................................................... 61fluoxetine hcl tab 20 mg.................................................... 61fluphenazine decanoate inj 25 mg/ml................................65FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5mg/5ml...............................................................................65

FLUPHENAZINE HCL – fluphenazine hcl inj 2.5 mg/ml.......................................................................................65

FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml.......................................................................................65

FLUPHENAZINE HCL – fluphenazine hcl tab 1 mg..........65FLUPHENAZINE HCL – fluphenazine hcl tab 2.5 mg.......65FLUPHENAZINE HCL – fluphenazine hcl tab 5 mg..........65FLUPHENAZINE HCL – fluphenazine hcl tab 10 mg........65flurandrenolide cream 0.05% (Cordran)..........................101FLURBIPROFEN SODIUM – flurbiprofen sodium ophthsoln 0.03%........................................................................ 97

flurbiprofen tab 50 mg........................................................81flurbiprofen tab 100 mg......................................................81flutamide cap 125 mg........................................................ 19FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 55-14 mcg/act........................ 52

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 113-14 mcg/act...................... 52

FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer powder ba 232-14 mcg/act...................... 52

fluticasone propionate cream 0.05% (Cutivate).............. 101fluticasone propionate nasal susp 50 mcg/act.................. 50fluticasone propionate oint 0.005%................................. 101fluvastatin sodium tab er 24 hr 80 mg (base equivalent)(Lescol xl)..........................................................................44

fluvoxamine maleate tab 25 mg........................................ 61fluvoxamine maleate tab 50 mg........................................ 61fluvoxamine maleate tab 100 mg...................................... 61FLUZONE HIGH-DOSE PF 2019-2020 – influenza virusvac split high-dose pf susp pref syr 0.5ml....................... 16

FLUZONE QUADRIVALENT 2019-2020 – influenza virusvaccine split quadrivalent im inj.......................................17

FLUZONE QUADRIVALENT 2019-2020 – influenza virusvaccine split quadrivalent inj 0.5 ml.................................17

FLUZONE QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.25 ml.................... 16

FLUZONE QUADRIVALENT 2019-2020 – influenza virusvac split quadrivalent susp pref syr 0.5ml....................... 16

FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals &folic acid tab 5 mg............................................................89

folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2 mg.....92folic acid tab 1 mg............................................................. 94folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg..........94folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg.............94folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgardrx)...................................................................................... 94

FORFIVO XL – bupropion hcl tab er 24hr 450 mg............61fosamprenavir calcium tab 700 mg (base equiv)(Lexiva)..............................................................................12

fosinopril sodium & hydrochlorothiazide tab 10-12.5mg......................................................................................36

fosinopril sodium & hydrochlorothiazide tab 20-12.5mg......................................................................................36

fosinopril sodium tab 10 mg.............................................. 36fosinopril sodium tab 20 mg.............................................. 37fosinopril sodium tab 40 mg.............................................. 37frovatriptan succinate tab 2.5 mg (base equivalent)(Frova)...............................................................................83

FULPHILA – pegfilgrastim-jmdb soln prefilled syringe 6mg/0.6ml............................................................................94

furosemide oral soln 10 mg/ml.......................................... 45furosemide tab 20 mg (Lasix)............................................45furosemide tab 40 mg (Lasix)............................................45furosemide tab 80 mg (Lasix)............................................45FUZEON – enfuvirtide for inj 90 mg..................................12

Ggabapentin cap 100 mg (Neurontin)..................................85gabapentin cap 300 mg (Neurontin)..................................85gabapentin cap 400 mg (Neurontin)..................................85gabapentin oral soln 250 mg/5ml (Neurontin)...................85gabapentin tab 600 mg (Neurontin)...................................85

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gabapentin tab 800 mg (Neurontin)...................................85galantamine hydrobromide cap er 24hr 8 mg (Razadyneer)...................................................................................... 75

galantamine hydrobromide cap er 24hr 16 mg (Razadyneer)...................................................................................... 75

galantamine hydrobromide cap er 24hr 24 mg (Razadyneer)...................................................................................... 75

GALANTAMINE HYDROBROMIDE – galantaminehydrobromide oral soln 4 mg/ml...................................... 75

galantamine hydrobromide tab 4 mg (Razadyne).............75galantamine hydrobromide tab 8 mg (Razadyne).............75galantamine hydrobromide tab 12 mg (Razadyne)...........75GATTEX – teduglutide (rdna) for inj kit 5 mg.................... 56gemfibrozil tab 600 mg (Lopid)..........................................44gentamicin sulfate oint 0.1%..............................................99gentamicin sulfate ophth soln 0.3%...................................96GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab150-150-200-10 mg..........................................................12

GEODON – ziprasidone mesylate for inj 20 mg (baseequivalent).........................................................................65

GILOTRIF – afatinib dimaleate tab 20 mg (baseequivalent).........................................................................20



glatiramer acetate soln prefilled syringe 40 mg/ml(Copaxone)....................................................................... 75

glimepiride tab 1 mg (Amaryl)........................................... 30glimepiride tab 2 mg (Amaryl)........................................... 30glimepiride tab 4 mg (Amaryl)........................................... 30glipizide-metformin hcl tab 2.5-250 mg............................. 30glipizide-metformin hcl tab 2.5-500 mg............................. 30glipizide-metformin hcl tab 5-500 mg................................ 31glipizide tab er 24hr 2.5 mg (Glucotrol xl)......................... 30glipizide tab er 24hr 5 mg (Glucotrol xl)............................ 30glipizide tab er 24hr 10 mg (Glucotrol xl).......................... 30glipizide tab 5 mg (Glucotrol).............................................30glipizide tab 10 mg (Glucotrol)...........................................30GLUCAGON EMERGENCY KIT – glucagon (rdna) for injkit 1 mg.............................................................................31

glyburide-metformin tab 1.25-250 mg (Glucovance).........31glyburide-metformin tab 2.5-500 mg (Glucovance)...........31glyburide-metformin tab 5-500 mg (Glucovance)..............31glyburide tab 1.25 mg........................................................ 31glyburide tab 2.5 mg.......................................................... 31glyburide tab 5 mg............................................................. 31glycopyrrolate tab 1 mg (Robinul)..................................... 54glycopyrrolate tab 2 mg (Robinul forte).............................54GNP PRENATAL – prenatal vit w/ fe fumarate-fa tab28-0.8 mg..........................................................................89

GOODSENSE PRENATAL VITAMI – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 89

griseofulvin microsize susp 125 mg/5ml........................... 10griseofulvin microsize tab 500 mg.....................................10griseofulvin ultramicrosize tab 125 mg (Gris-peg).............10

griseofulvin ultramicrosize tab 250 mg (Gris-peg).............10guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv).....73guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv).....73guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv).....73guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv).....73guanfacine hcl tab 1 mg (Tenex).......................................48guanfacine hcl tab 2 mg (Tenex).......................................48

HHAEGARDA – c1 esterase inhibitor (human) forsubcutaneous inj 2000 unit.............................................. 94

HAEGARDA – c1 esterase inhibitor (human) forsubcutaneous inj 3000 unit.............................................. 94

halobetasol propionate cream 0.05% (Ultravate)............101halobetasol propionate oint 0.05% (Ultravate)................ 101haloperidol decanoate im soln 50 mg/ml (Haldoldecanoate 50)...................................................................65

haloperidol decanoate im soln 100 mg/ml (Haldoldecanoate 100).................................................................65

haloperidol lactate oral conc 2 mg/ml................................65haloperidol tab 0.5 mg....................................................... 65haloperidol tab 1 mg.......................................................... 65haloperidol tab 2 mg.......................................................... 65haloperidol tab 5 mg.......................................................... 65haloperidol tab 10 mg........................................................ 65haloperidol tab 20 mg........................................................ 65HEPLISAV-B – hepatitis b vaccine recomb adjuvantedpref syr 20 mcg/0.5ml...................................................... 17

HEPLISAV-B – hepatitis b vaccine recombinantadjuvanted 20 mcg/0.5ml.................................................17

HM PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................89

homatropine hbr ophth soln 5%........................................ 97HUMALOG MIX 75/25 – insulin lispro prot & lispro inj 100unit/ml (75-25)...................................................................32

HUMALOG MIX 50/50 – insulin lispro protamine & lisproinj 100 unit/ml (50-50)...................................................... 32

HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot &lispro sus pen-inj 100 unit/ml (50-50).............................. 32

HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot &lispro sus pen-inj 100 unit/ml (75-25).............................. 32

HUMIRA – adalimumab prefilled syringe kit 10mg/0.1ml............................................................................81






HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 40 mg/0.8ml....................................................81

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HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 80 mg/0.8ml....................................................81

HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 80 mg/0.8ml & 40 mg/0.4ml........................... 81

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.8ml............................................................................82

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.4ml............................................................................82

HUMIRA PEN-CD/UC/HS START – adalimumab pen-injector kit 40 mg/0.8ml....................................................82

HUMIRA PEN-CD/UC/HS START – adalimumab pen-injector kit 80 mg/0.8ml....................................................82

HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit 40 mg/0.8ml....................................................82

HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit 80 mg/0.8ml & 40 mg/0.4ml........................... 82

HUMULIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30)...................................................... 32

HUMULIN 70/30 KWIKPEN – insulin nph & regular susppen-inj 100 unit/ml (70-30)...............................................32

HUMULIN N – insulin nph (human) (isophane) inj 100unit/ml................................................................................32

HUMULIN N KWIKPEN – insulin nph (human) (isophane)susp pen-injector 100 unit/ml...........................................32

HUMULIN R – insulin regular (human) inj 100 unit/ml...... 32HYCAMTIN – topotecan hcl cap 0.25 mg (baseequiv).................................................................................20

HYCAMTIN – topotecan hcl cap 1 mg (base equiv)......... 20hydralazine hcl tab 10 mg................................................. 48hydralazine hcl tab 25 mg................................................. 48hydralazine hcl tab 50 mg................................................. 48hydralazine hcl tab 100 mg............................................... 48hydrochlorothiazide cap 12.5 mg (Microzide)................... 46hydrochlorothiazide tab 12.5 mg....................................... 46hydrochlorothiazide tab 25 mg.......................................... 46hydrochlorothiazide tab 50 mg.......................................... 46hydrocodone-acetaminophen soln 7.5-325 mg/15ml(Hycet)...............................................................................77

hydrocodone-acetaminophen tab 7.5-325 mg (Norco)..... 77hydrocodone-acetaminophen tab 5-325 mg (Norco)........ 77hydrocodone-acetaminophen tab 10-325 mg (Norco)...... 77hydrocodone-acetaminophen tab 7.5-300 mg (Xodol)......77hydrocodone-acetaminophen tab 10-300 mg (Xodol).......77HYDROCODONE BITARTRATE/CH – pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml.............. 50

hydrocodone-ibuprofen tab 7.5-200 mg............................ 78hydrocodone-ibuprofen tab 5-200 mg (Reprexain)........... 77hydrocortisone butyrate oint 0.1% (Locoid).....................101hydrocortisone butyrate soln 0.1% (Locoid)....................101hydrocortisone cream 1%................................................ 101hydrocortisone cream 2.5%............................................. 101hydrocortisone enema 100 mg/60ml (Cortenema)............98hydrocortisone lotion 2.5%.............................................. 101hydrocortisone oint 1%.................................................... 101hydrocortisone oint 2.5%................................................. 101hydrocortisone rectal cream 2.5% (Anusol-hc)................. 98

hydrocortisone rectal cream 1% (Proctocort)....................98hydrocortisone tab 5 mg (Cortef).......................................26hydrocortisone tab 10 mg (Cortef).....................................26hydrocortisone tab 20 mg (Cortef).....................................26hydrocortisone valerate cream 0.2%...............................101hydrocortisone valerate oint 0.2% (Westcort)................. 101hydrocortisone w/ acetic acid otic soln 1-2%.................... 97hydromorphone hcl liqd 1 mg/ml (Dilaudid).......................78hydromorphone hcl tab 2 mg (Dilaudid)............................78hydromorphone hcl tab 4 mg (Dilaudid)............................78hydromorphone hcl tab 8 mg (Dilaudid)............................78hydroxychloroquine sulfate tab 200 mg (Plaquenil).......... 15hydroxyurea cap 500 mg (Hydrea)....................................20hydroxyzine hcl syrup 10 mg/5ml......................................59hydroxyzine hcl tab 10 mg.................................................59hydroxyzine hcl tab 25 mg.................................................59hydroxyzine hcl tab 50 mg.................................................59hydroxyzine pamoate cap 25 mg (Vistaril)........................ 59hydroxyzine pamoate cap 50 mg (Vistaril)........................ 59hyoscyamine sulfate elixir 0.125 mg/5ml.......................... 54hyoscyamine sulfate sl tab 0.125 mg (Levsin/sl)...............54hyoscyamine sulfate soln 0.125 mg/ml............................. 54hyoscyamine sulfate tab disint 0.125 mg (Anaspaz).........54hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid)......... 54hyoscyamine sulfate tab 0.125 mg (Levsin)......................54

Iibandronate sodium tab 150 mg (base equivalent)(Boniva).............................................................................34

IBRANCE – palbociclib cap 75 mg....................................20IBRANCE – palbociclib cap 100 mg..................................20IBRANCE – palbociclib cap 125 mg..................................20ibuprofen susp 100 mg/5ml............................................... 82ibuprofen tab 400 mg.........................................................82ibuprofen tab 600 mg.........................................................82ibuprofen tab 800 mg.........................................................82icatibant acetate inj 30 mg/3ml (base equivalent)(Firazyr).............................................................................94

ICLUSIG – ponatinib hcl tab 15 mg (base equiv)..............20ICLUSIG – ponatinib hcl tab 45 mg (base equiv)..............20imatinib mesylate tab 100 mg (base equivalent)(Gleevec)...........................................................................20

imatinib mesylate tab 400 mg (base equivalent)(Gleevec)...........................................................................20

imipramine hcl tab 10 mg (Tofranil)...................................61imipramine hcl tab 25 mg (Tofranil)...................................61imipramine hcl tab 50 mg (Tofranil)...................................61imiquimod cream 5% (Aldara)......................................... 102IMITREX – sumatriptan nasal spray 5 mg/act...................83IMITREX – sumatriptan nasal spray 20 mg/act.................83IMOVAX RABIES (H.D.C.V.) – rabies virus vaccine, hdcinj....................................................................................... 17

INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)........33INCRUSE ELLIPTA – umeclidinium br aero powd breathact 62.5 mcg/inh (base eq).............................................. 52

indapamide tab 1.25 mg.................................................... 46

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indapamide tab 2.5 mg...................................................... 46indomethacin cap er 75 mg...............................................82indomethacin cap 25 mg................................................... 82indomethacin cap 50 mg................................................... 82INLYTA – axitinib tab 1 mg................................................20INLYTA – axitinib tab 5 mg................................................20INTELENCE – etravirine tab 25 mg.................................. 12INTELENCE – etravirine tab 100 mg................................ 12INTELENCE – etravirine tab 200 mg................................ 12INVEGA – paliperidone tab er 24hr 1.5 mg...................... 65INVEGA – paliperidone tab er 24hr 3 mg......................... 65INVEGA – paliperidone tab er 24hr 6 mg......................... 65INVEGA – paliperidone tab er 24hr 9 mg......................... 65INVEGA SUSTENNA – paliperidone palmitate er susppref syr 39 mg/0.25ml...................................................... 65

INVEGA SUSTENNA – paliperidone palmitate er susppref syr 78 mg/0.5ml........................................................ 66

INVEGA SUSTENNA – paliperidone palmitate er susppref syr 117 mg/0.75ml.................................................... 66

INVEGA SUSTENNA – paliperidone palmitate er susppref syr 156 mg/ml........................................................... 66

INVEGA SUSTENNA – paliperidone palmitate er susppref syr 234 mg/1.5ml...................................................... 66

INVEGA TRINZA – paliperidone palmitate er susp pref syr273 mg/0.875ml................................................................66


INVEGA TRINZA – paliperidone palmitate er susp pref syr546 mg/1.75ml..................................................................66


INVIRASE – saquinavir mesylate tab 500 mg...................12ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml........... 52ipratropium bromide inhal soln 0.02%...............................52ipratropium bromide nasal soln 0.03% (21 mcg/spray).....50ipratropium bromide nasal soln 0.06% (42 mcg/spray).....50irbesartan-hydrochlorothiazide tab 150-12.5 mg(Avalide)............................................................................ 38

irbesartan-hydrochlorothiazide tab 300-12.5 mg(Avalide)............................................................................ 38

irbesartan tab 75 mg (Avapro)...........................................37irbesartan tab 150 mg (Avapro).........................................37irbesartan tab 300 mg (Avapro).........................................38iron combination cap..........................................................94iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg(Hematron-af)....................................................................94

iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg(Corvite 150)..................................................................... 94

iron polysacch complex-vit b12-fa cap 150-0.025-1mg......................................................................................94

irrigation solution, physiological.......................................104ISENTRESS HD – raltegravir potassium tab 600 mg(base equiv)...................................................................... 12

ISENTRESS – raltegravir potassium chew tab 25 mg(base equiv)...................................................................... 12

ISENTRESS – raltegravir potassium chew tab 100 mg(base equiv)...................................................................... 12

ISENTRESS – raltegravir potassium packet for susp 100mg (base equiv)................................................................12

ISENTRESS – raltegravir potassium tab 400 mg (baseequiv).................................................................................12

isoniazid tab 100 mg............................................................9isoniazid tab 300 mg............................................................9ISOPTO ATROPINE – atropine sulfate ophth soln 1%..... 97isosorbide mononitrate tab er 24hr 30 mg........................ 42isosorbide mononitrate tab er 24hr 60 mg........................ 42isosorbide mononitrate tab er 24hr 120 mg...................... 42isosorbide mononitrate tab 10 mg.....................................42isosorbide mononitrate tab 20 mg.....................................42isotretinoin cap 10 mg........................................................99isotretinoin cap 20 mg........................................................99isotretinoin cap 30 mg........................................................99isotretinoin cap 40 mg........................................................99isradipine cap 2.5 mg.........................................................41isradipine cap 5 mg............................................................41itraconazole cap 100 mg (Sporanox)................................ 10ivermectin tab 3 mg (Stromectol)...................................... 15

JJAKAFI – ruxolitinib phosphate tab 5 mg (baseequivalent).........................................................................20

JAKAFI – ruxolitinib phosphate tab 10 mg (baseequivalent).........................................................................20




JULUCA – dolutegravir sodium-rilpivirine hcl tab 50-25 mg(base eq)...........................................................................12

JUXTAPID – lomitapide mesylate cap 5 mg (baseequiv).................................................................................44






KKALETRA – lopinavir-ritonavir tab 100-25 mg.................. 12KALETRA – lopinavir-ritonavir tab 200-50 mg.................. 12KALYDECO – ivacaftor packet 25 mg...............................53KALYDECO – ivacaftor packet 50 mg...............................53KALYDECO – ivacaftor packet 75 mg...............................53KALYDECO – ivacaftor tab 150 mg.................................. 53

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ketoconazole cream 2%.....................................................99ketoconazole shampoo 2% (Nizoral).................................99ketorolac tromethamine ophth soln 0.5% (Acular)............ 97ketorolac tromethamine ophth soln 0.4% (Acular ls).........97ketorolac tromethamine tab 10 mg....................................82KETOSTIX – acetone (urine) test strip............................103KINERET – anakinra subcutaneous soln prefilled syringe100 mg/0.67ml..................................................................82

KISQALI FEMARA 200 DOSE – ribociclib 200 mg dose(200 mg tab) & letrozole 2.5 mg tbpk..............................21



KISQALI – ribociclib succinate tab pack 200 mg dailydose...................................................................................20

KISQALI – ribociclib succinate tab pack 400 mg dailydose (200 mg tab)............................................................21

KISQALI – ribociclib succinate tab pack 600 mg dailydose (200 mg tab)............................................................21

KORLYM – mifepristone tab 300 mg.................................31K-PHOS – potassium phosphate monobasic tab 500mg......................................................................................91

KP PRENATAL MULTIVITAMINS – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 89

KRINTAFEL – tafenoquine succinate tab 150 mg (baseequivalent).........................................................................15

KUVAN – sapropterin dihydrochloride powder packet 100mg......................................................................................34

KUVAN – sapropterin dihydrochloride powder packet 500mg......................................................................................35

KUVAN – sapropterin dihydrochloride soluble tab 100mg......................................................................................34

KYLEENA – levonorgestrel releasing iud 17.5 mcg/day(19.5 mg total).................................................................. 29

Llabetalol hcl tab 100 mg.................................................... 39labetalol hcl tab 200 mg.................................................... 39labetalol hcl tab 300 mg.................................................... 39lactated ringer's for irrigation........................................... 104lactulose (encephalopathy) solution 10 gm/15ml.............. 56lactulose solution 10 gm/15ml........................................... 53LAMICTAL XR – lamotrigine tab er 24hr 25 (14) & 50 mg(14) & 100 mg(7) kit.........................................................86

LAMICTAL XR – lamotrigine tab er 24hr 50 (14) & 100mg(14) & 200 mg(7) kit....................................................86

LAMICTAL XR – lamotrigine tab er 24hr 25 mg (21) & 50mg (7) titration kit............................................................. 86

lamivudine oral soln 10 mg/ml (Epivir).............................. 12lamivudine tab 150 mg (Epivir)..........................................12lamivudine tab 300 mg (Epivir)..........................................12lamivudine tab 100 mg (hbv) (Epivir hbv)......................... 10lamivudine-zidovudine tab 150-300 mg (Combivir)...........13lamotrigine tab chewable dispersible 5 mg (Lamictalchewable di)......................................................................86

lamotrigine tab chewable dispersible 25 mg (Lamictalchewable di)......................................................................86

lamotrigine tab er 24hr 25 mg (Lamictal xr)...................... 86lamotrigine tab er 24hr 50 mg (Lamictal xr)...................... 86lamotrigine tab er 24hr 100 mg (Lamictal xr).................... 86lamotrigine tab er 24hr 200 mg (Lamictal xr).................... 86lamotrigine tab er 24hr 250 mg (Lamictal xr).................... 86lamotrigine tab er 24hr 300 mg (Lamictal xr).................... 86lamotrigine tab 25 mg (42) & 100 mg (7) starter kit(Lamictal starter/not).........................................................86

lamotrigine tab 25 mg (84) & 100 mg (14) starter kit(Lamictal starter/tak).........................................................86

lamotrigine tab 25 mg (Lamictal).......................................86lamotrigine tab 100 mg (Lamictal).....................................86lamotrigine tab 150 mg (Lamictal).....................................86lamotrigine tab 200 mg (Lamictal).....................................86lamotrigine tab 25 mg (35) starter kit (Lamictal starter/tak).....................................................................................86

lansoprazole cap delayed release 15 mg (Prevacid)........ 54lansoprazole cap delayed release 30 mg (Prevacid)........ 54lanthanum carbonate chew tab 500 mg (elemental)(Fosrenol)..........................................................................56

lanthanum carbonate chew tab 750 mg (elemental)(Fosrenol)..........................................................................56

lanthanum carbonate chew tab 1000 mg (elemental)(Fosrenol)..........................................................................56

latanoprost ophth soln 0.005% (Xalatan).......................... 97LATUDA – lurasidone hcl tab 20 mg.................................66LATUDA – lurasidone hcl tab 40 mg.................................66LATUDA – lurasidone hcl tab 60 mg.................................66LATUDA – lurasidone hcl tab 80 mg.................................66LATUDA – lurasidone hcl tab 120 mg...............................66leflunomide tab 10 mg (Arava).......................................... 82leflunomide tab 20 mg (Arava).......................................... 82LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 mg (14 mg daily dose)................................ 21

LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 (2) mg (18 mg daily dose)...........................21

LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapypack 10 (2) & 4 mg (24 mg daily dose)...........................21

LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapypack 10 mg (10 mg daily dose).......................................21

LENVIMA 12MG DAILY DOSE – lenvatinib cap therapypack 4 (3) mg (12 mg daily dose)................................... 21

LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapypack 10 (2) mg (20 mg daily dose)................................. 21

LENVIMA 4 MG DAILY DOSE – lenvatinib cap therapypack 4 mg (4 mg daily dose)...........................................21

LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapypack 4 (2) mg (8 mg daily dose)..................................... 21

letrozole tab 2.5 mg (Femara)...........................................21LEUCOVORIN CALCIUM – leucovorin calcium tab 10mg......................................................................................21

LEUCOVORIN CALCIUM – leucovorin calcium tab 15mg......................................................................................21

leucovorin calcium tab 5 mg..............................................21

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leucovorin calcium tab 25 mg............................................21LEUKERAN – chlorambucil tab 2 mg................................21levetiracetam oral soln 100 mg/ml (Keppra)..................... 86levetiracetam tab er 24hr 500 mg (Keppra xr).................. 86levetiracetam tab er 24hr 750 mg (Keppra xr).................. 86levetiracetam tab 250 mg (Keppra)...................................86levetiracetam tab 500 mg (Keppra)...................................86levetiracetam tab 750 mg (Keppra)...................................86levetiracetam tab 1000 mg (Keppra).................................86levobunolol hcl ophth soln 0.5% (Betagan).......................97levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...........35levocarnitine tab 330 mg (Carnitor)...................................35levocetirizine dihydrochloride tab 5 mg (Xyzal).................50levofloxacin oral soln 25 mg/ml........................................... 9levofloxacin tab 250 mg (Levaquin).....................................9levofloxacin tab 500 mg (Levaquin).....................................9levofloxacin tab 750 mg (Levaquin).....................................9levothyroxine sodium tab 25 mcg (Synthroid)...................33levothyroxine sodium tab 50 mcg (Synthroid)...................33levothyroxine sodium tab 75 mcg (Synthroid)...................33levothyroxine sodium tab 88 mcg (Synthroid)...................33levothyroxine sodium tab 100 mcg (Synthroid).................33levothyroxine sodium tab 112 mcg (Synthroid)................. 33levothyroxine sodium tab 125 mcg (Synthroid).................33levothyroxine sodium tab 137 mcg (Synthroid).................33levothyroxine sodium tab 150 mcg (Synthroid).................33levothyroxine sodium tab 175 mcg (Synthroid).................33levothyroxine sodium tab 200 mcg (Synthroid).................33levothyroxine sodium tab 300 mcg (Synthroid).................33LEXIVA – fosamprenavir calcium susp 50 mg/ml (baseequiv).................................................................................13

lidocaine hcl gel 2%.........................................................102lidocaine hcl soln 4% (Xylocaine)....................................102lidocaine hcl urethral/mucosal gel 2%.............................102lidocaine hcl viscous soln 2%............................................98lidocaine patch 5% (Lidoderm)........................................102lidocaine-prilocaine cream 2.5-2.5%............................... 102LILETTA – levonorgestrel releasing iud 19.5 mcg/day (52mg total)............................................................................29

linezolid for susp 100 mg/5ml (Zyvox)...............................15linezolid tab 600 mg (Zyvox)............................................. 15liothyronine sodium tab 5 mcg (Cytomel)..........................33liothyronine sodium tab 25 mcg (Cytomel)........................33liothyronine sodium tab 50 mcg (Cytomel)........................33lisinopril & hydrochlorothiazide tab 10-12.5 mg(Zestoretic)........................................................................ 37

lisinopril & hydrochlorothiazide tab 20-12.5 mg(Zestoretic)........................................................................ 37

lisinopril & hydrochlorothiazide tab 20-25 mg(Zestoretic)........................................................................ 37

lisinopril tab 5 mg (Prinivil)................................................ 37lisinopril tab 10 mg (Prinivil).............................................. 37lisinopril tab 20 mg (Prinivil).............................................. 37lisinopril tab 2.5 mg (Zestril).............................................. 37lisinopril tab 30 mg (Zestril)............................................... 37lisinopril tab 40 mg (Zestril)............................................... 37

lithium carbonate cap 300 mg........................................... 66lithium carbonate cap 150 mg (Lithium carbonate)...........66lithium carbonate cap 600 mg (Lithium carbonate)...........66lithium carbonate tab er 450 mg........................................66lithium carbonate tab er 300 mg (Lithobid)....................... 66lithium carbonate tab 300 mg............................................66LITHIUM – lithium oral solution 8 meq/5ml....................... 66LONSURF – trifluridine-tipiracil tab 15-6.14 mg................21LONSURF – trifluridine-tipiracil tab 20-8.19 mg................21loperamide hcl cap 2 mg................................................... 54lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)(Kaletra).............................................................................13

lorazepam conc 2 mg/ml................................................... 59lorazepam tab 0.5 mg (Ativan).......................................... 59lorazepam tab 1 mg (Ativan)............................................. 59lorazepam tab 2 mg (Ativan)............................................. 59LORBRENA – lorlatinib tab 25 mg....................................21LORBRENA – lorlatinib tab 100 mg..................................22losartan potassium & hydrochlorothiazide tab 50-12.5 mg(Hyzaar).............................................................................38

losartan potassium & hydrochlorothiazide tab 100-12.5mg (Hyzaar)...................................................................... 38

losartan potassium & hydrochlorothiazide tab 100-25 mg(Hyzaar).............................................................................38

losartan potassium tab 25 mg (Cozaar)............................38losartan potassium tab 50 mg (Cozaar)............................38losartan potassium tab 100 mg (Cozaar)..........................38lovastatin tab 10 mg...........................................................44lovastatin tab 20 mg...........................................................44lovastatin tab 40 mg (Mevacor).........................................44loxapine succinate cap 5 mg.............................................66loxapine succinate cap 10 mg...........................................66loxapine succinate cap 25 mg...........................................66loxapine succinate cap 50 mg...........................................66LUPANETA PACK – leuprolide (1 mon) inj 3.75 mg &norethindrone tab 5 mg kit...............................................29

LUPANETA PACK – leuprolide (3 mon) inj 11.25 mg &norethindrone tab 5 mg kit...............................................29

LUPRON DEPOT (1-MONTH) – leuprolide acetate for injkit 3.75 mg........................................................................22

LUPRON DEPOT (1-MONTH) – leuprolide acetate for injkit 7.5 mg..........................................................................22

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3month) for inj kit 11.25 mg............................................... 22

LUPRON DEPOT (3-MONTH) – leuprolide acetate (3month) for inj kit 22.5 mg.................................................22

LUPRON DEPOT (4-MONTH) – leuprolide acetate (4month) for inj kit 30 mg....................................................22

LUPRON DEPOT (6-MONTH) – leuprolide acetate (6month) for inj kit 45 mg....................................................22

LUPRON DEPOT-PED (1-MONTH – leuprolide acetatefor inj pediatric kit 7.5 mg........................................... 29,35

LUPRON DEPOT-PED (1-MONTH – leuprolide acetatefor inj pediatric kit 11.25 mg........................................29,35

LUPRON DEPOT-PED (1-MONTH – leuprolide acetatefor inj pediatric kit 15 mg............................................ 29,35

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LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3month) for inj pediatric kit 11.25 mg................................ 29

LUPRON DEPOT-PED (3-MONTH – leuprolide acetate (3month) for inj pediatric kit 30 mg..................................... 29

LYNPARZA – olaparib tab 100 mg....................................22LYNPARZA – olaparib tab 150 mg....................................22LYSODREN – mitotane tab 500 mg..................................22

Mmalathion lotion 0.5% (Ovide)......................................... 102MAPROTILINE HCL – maprotiline hcl tab 25 mg............. 61MAPROTILINE HCL – maprotiline hcl tab 50 mg............. 61MAPROTILINE HCL – maprotiline hcl tab 75 mg............. 61MARPLAN – isocarboxazid tab 10 mg..............................61MATULANE – procarbazine hcl cap 50 mg.......................22MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg....... 10meclizine hcl tab 12.5 mg..................................................55meclizine hcl tab 25 mg.....................................................55medroxyprogesterone acetate tab 2.5 mg (Provera)........ 28medroxyprogesterone acetate tab 5 mg (Provera)........... 28medroxyprogesterone acetate tab 10 mg (Provera)......... 28MEFLOQUINE HCL – mefloquine hcl tab 250 mg............15megestrol acetate susp 625 mg/5ml (Megace es)............ 28megestrol acetate susp 40 mg/ml (Megace oral)..............22megestrol acetate tab 20 mg.............................................22megestrol acetate tab 40 mg.............................................22MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg(base equivalent).............................................................. 22

MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (baseequivalent).........................................................................22

MEKTOVI – binimetinib tab 15 mg....................................22meloxicam tab 7.5 mg (Mobic).......................................... 82meloxicam tab 15 mg (Mobic)........................................... 82memantine hcl oral solution 2 mg/ml (Namenda)..............75memantine hcl tab 5 mg (Namenda).................................75memantine hcl tab 10 mg (Namenda)...............................75mercaptopurine tab 50 mg.................................................22mesalamine enema 4 gm.................................................. 56mesalamine suppos 1000 mg (Canasa)........................... 56mesalamine tab delayed release 800 mg (Asacol hd)...... 56metformin hcl tab er 24hr 500 mg (Glucophage xr).......... 31metformin hcl tab er 24hr 750 mg (Glucophage xr).......... 31metformin hcl tab 500 mg (Glucophage)...........................31metformin hcl tab 850 mg (Glucophage)...........................31metformin hcl tab 1000 mg (Glucophage).........................31methadone hcl conc 10 mg/ml (Methadose).....................78methadone hcl soln 5 mg/5ml (Methadone hcl)................ 78methadone hcl soln 10 mg/5ml (Methadone hcl).............. 78methadone hcl tab for oral susp 40 mg............................ 78methadone hcl tab 5 mg (Dolophine)................................78methadone hcl tab 10 mg (Dolophine)..............................78methimazole tab 5 mg (Tapazole)..................................... 33methimazole tab 10 mg (Tapazole)................................... 33methocarbamol tab 750 mg (Robaxin-750).......................89methocarbamol tab 500 mg (Robaxin)..............................89methotrexate sodium tab 2.5 mg (base equiv)..................22

methoxsalen rapid cap 10 mg (Oxsoralen ultra)............. 102methscopolamine bromide tab 2.5 mg (Pamine).............. 54methyldopa tab 250 mg..................................................... 48methyldopa tab 500 mg..................................................... 48methylergonovine maleate tab 0.2 mg.............................. 35methylphenidate hcl cap er 24hr 10 mg (la) (Ritalinla).......................................................................................73

methylphenidate hcl cap er 24hr 20 mg (la) (Ritalinla).......................................................................................73



methylphenidate hcl cap er 10 mg (cd).............................73methylphenidate hcl cap er 20 mg (cd).............................73methylphenidate hcl cap er 30 mg (cd).............................73methylphenidate hcl cap er 40 mg (cd).............................73methylphenidate hcl cap er 50 mg (cd).............................73methylphenidate hcl cap er 60 mg (cd).............................73methylphenidate hcl chew tab 2.5 mg...............................73methylphenidate hcl chew tab 5 mg..................................74methylphenidate hcl chew tab 10 mg................................74methylphenidate hcl soln 5 mg/5ml (Methylin)..................74methylphenidate hcl soln 10 mg/5ml (Methylin)................74methylphenidate hcl tab er 10 mg.....................................74methylphenidate hcl tab er 20 mg.....................................74methylphenidate hcl tab 5 mg (Ritalin)..............................74methylphenidate hcl tab 10 mg (Ritalin)............................74methylphenidate hcl tab 20 mg (Ritalin)............................74METHYLPHENIDATE HYDROCHLO – methylphenidatehcl tab er 24hr 18 mg...................................................... 74

METHYLPHENIDATE HYDROCHLO – methylphenidatehcl tab er 24hr 27 mg...................................................... 74



methylprednisolone tab 4 mg (Medrol)..............................26methylprednisolone tab 8 mg (Medrol)..............................26methylprednisolone tab 16 mg (Medrol)............................26methylprednisolone tab 32 mg (Medrol)............................26methylprednisolone tab therapy pack 4 mg (21) (Medroldosepak)............................................................................26

metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (baseequiv).................................................................................56

metoclopramide hcl tab 5 mg (base equivalent)(Reglan).............................................................................56

metoclopramide hcl tab 10 mg (base equivalent)(Reglan).............................................................................56

metolazone tab 2.5 mg...................................................... 46metolazone tab 5 mg......................................................... 46metolazone tab 10 mg....................................................... 46METOPROLOL/HYDROCHLOROTHI – metoprolol &hydrochlorothiazide tab 100-50 mg................................. 40

metoprolol & hydrochlorothiazide tab 50-25 mg(Lopressor hct)..................................................................39

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metoprolol & hydrochlorothiazide tab 100-25 mg(Lopressor hct)..................................................................39

metoprolol succinate tab er 24hr 25 mg (tartrate equiv)(Toprol xl).......................................................................... 39




metoprolol tartrate tab 25 mg............................................ 40metoprolol tartrate tab 50 mg (Lopressor).........................40metoprolol tartrate tab 100 mg (Lopressor).......................40metronidazole cap 375 mg (Flagyl)...................................15metronidazole cream 0.75% (Metrocream).......................99metronidazole gel 0.75%................................................... 99metronidazole tab 250 mg (Flagyl)....................................15metronidazole tab 500 mg (Flagyl)....................................15metronidazole vaginal gel 0.75% (Metrogel-vaginal)........ 57midodrine hcl tab 2.5 mg...................................................48midodrine hcl tab 5 mg...................................................... 48midodrine hcl tab 10 mg....................................................48miglustat cap 100 mg (Zavesca)....................................... 94minocycline hcl cap 50 mg (Minocin).................................. 9minocycline hcl cap 75 mg (Minocin).................................. 9minocycline hcl cap 100 mg (Minocin)................................ 9minoxidil tab 2.5 mg...........................................................48minoxidil tab 10 mg............................................................48MIRENA – levonorgestrel releasing iud 20 mcg/day (52mg total)............................................................................29

mirtazapine tab 15 mg (Remeron).....................................61mirtazapine tab 30 mg (Remeron).....................................61mirtazapine tab 45 mg (Remeron).....................................61misoprostol tab 100 mcg (Cytotec)....................................54misoprostol tab 200 mcg (Cytotec)....................................54MITIGARE – colchicine cap 0.6 mg.................................. 84M-NATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................89

modafinil tab 100 mg (Provigil)..........................................74modafinil tab 200 mg (Provigil)..........................................74moexipril hcl tab 7.5 mg.................................................... 37moexipril hcl tab 15 mg..................................................... 37MOLINDONE HYDROCHLORIDE – molindone hcl tab 5mg......................................................................................66

MOLINDONE HYDROCHLORIDE – molindone hcl tab 10mg......................................................................................67

MOLINDONE HYDROCHLORIDE – molindone hcl tab 25mg......................................................................................67

mometasone furoate cream 0.1% (Elocon).....................101mometasone furoate oint 0.1% (Elocon).........................101mometasone furoate solution 0.1% (lotion) (Elocon)...... 101montelukast sodium chew tab 4 mg (base equiv)(Singulair)..........................................................................52

montelukast sodium chew tab 5 mg (base equiv)(Singulair)..........................................................................52

montelukast sodium oral granules packet 4 mg (baseequiv) (Singulair).............................................................. 52

montelukast sodium tab 10 mg (base equiv)(Singulair)..........................................................................52

morphine sulfate cap er 24hr 100 mg (Kadian).................78MORPHINE SULFATE ER – morphine sulfate beads caper 24hr 60 mg...................................................................78

MORPHINE SULFATE ER – morphine sulfate beads caper 24hr 75 mg...................................................................78

MORPHINE SULFATE ER – morphine sulfate beads caper 24hr 120 mg.................................................................78

MORPHINE SULFATE – morphine sulfate suppos 5mg......................................................................................78




morphine sulfate oral soln 10 mg/5ml............................... 78morphine sulfate oral soln 20 mg/5ml............................... 78morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...........79morphine sulfate tab er 15 mg (Ms contin)....................... 79morphine sulfate tab er 30 mg (Ms contin)....................... 79morphine sulfate tab er 60 mg (Ms contin)....................... 79morphine sulfate tab er 100 mg (Ms contin)..................... 79morphine sulfate tab er 200 mg (Ms contin)..................... 79morphine sulfate tab 15 mg (Morphine sulfate).................79morphine sulfate tab 30 mg (Morphine sulfate).................79moxifloxacin hcl ophth soln 0.5% (base equiv)(Vigamox)..........................................................................96

multiple vitamins w/ minerals cap......................................90multiple vitamins w/ minerals tab (Strovite forte)...............90MULTI PRENATAL – prenatal vit w/ fe fumarate-fa tab27-0.8 mg..........................................................................89

mupirocin oint 2%...............................................................99M-VIT – prenatal vit w/ fe fumarate-fa tab 27-1 mg.......... 89mycophenolate mofetil cap 250 mg (Cellcept)................104mycophenolate mofetil for oral susp 200 mg/ml(Cellcept).........................................................................104

mycophenolate mofetil tab 500 mg (Cellcept).................104mycophenolate sodium tab dr 180 mg (mycophenolic acidequiv) (Myfortic)..............................................................105

mycophenolate sodium tab dr 360 mg (mycophenolic acidequiv) (Myfortic)..............................................................105

MYLERAN – busulfan tab 2 mg........................................ 22

Nnabumetone tab 500 mg....................................................82nabumetone tab 750 mg....................................................82nadolol tab 20 mg (Corgard)............................................. 40nadolol tab 40 mg (Corgard)............................................. 40nadolol tab 80 mg (Corgard)............................................. 40naftifine hcl cream 2% (Naftin).......................................... 99naltrexone hcl tab 50 mg.................................................105

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naproxen sodium tab er 24hr 375 mg (base equiv)(Naprelan)......................................................................... 82

naproxen sodium tab 275 mg............................................82naproxen sodium tab 550 mg (Anaprox ds)......................82naproxen susp 125 mg/5ml (Naprosyn)............................ 82naproxen tab ec 375 mg (Ec-naprosyn)............................82naproxen tab ec 500 mg (Ec-naprosyn)............................82naproxen tab 250 mg.........................................................82naproxen tab 375 mg.........................................................83naproxen tab 500 mg (Naprosyn)......................................83NARCAN – naloxone hcl nasal spray 4 mg/0.1ml...........105NATACYN – natamycin ophth susp 5%............................ 96nateglinide tab 60 mg (Starlix)...........................................31nateglinide tab 120 mg (Starlix).........................................31NATRAPEL 12-HOUR TICK & I – picaridin aerosol........102NEOMYCIN/POLYMYXIN/GRAMIC – neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml.............96

neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000untop oin................................................................................ 96

neomycin-polymyxin-dexamethasone ophth oint 0.1%(Maxitrol)........................................................................... 96

neomycin-polymyxin-dexamethasone ophth susp 0.1%(Maxitrol)........................................................................... 96

neomycin-polymyxin-hc otic soln 1%................................ 97neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%................................................................................ 97

neomycin sulfate tab 500 mg.............................................. 9NERLYNX – neratinib maleate tab 40 mg (baseequivalent).........................................................................22

nevirapine susp 50 mg/5ml (Viramune).............................13nevirapine tab er 24hr 100 mg (Viramune xr)................... 13nevirapine tab er 24hr 400 mg (Viramune xr)................... 13nevirapine tab 200 mg (Viramune)....................................13NEXAVAR – sorafenib tosylate tab 200 mg (baseequivalent).........................................................................22

NEXPLANON – etonogestrel subdermal implant 68mg......................................................................................29

nicardipine hcl cap 20 mg..................................................42NICOTROL INHALER – nicotine inhaler system 10 mg (4mg delivered)....................................................................75

NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray)................................................................................ 75

nifedipine cap 20 mg..........................................................42nifedipine cap 10 mg (Procardia)...................................... 42nifedipine tab er 24hr 30 mg (Adalat cc)...........................42nifedipine tab er 24hr 60 mg (Adalat cc)...........................42nifedipine tab er 24hr 90 mg (Adalat cc)...........................42nifedipine tab er 24hr osmotic release 30 mg (Procardiaxl).......................................................................................42

nifedipine tab er 24hr osmotic release 60 mg (Procardiaxl).......................................................................................42

nifedipine tab er 24hr osmotic release 90 mg (Procardiaxl).......................................................................................42

nimodipine cap 30 mg........................................................42NINLARO – ixazomib citrate cap 3 mg (baseequivalent).........................................................................22

NINLARO – ixazomib citrate cap 4 mg (baseequivalent).........................................................................23

NINLARO – ixazomib citrate cap 2.3 mg (baseequivalent).........................................................................23

nitrofurantoin macrocrystalline cap 25 mg(Macrodantin)....................................................................57



nitrofurantoin monohydrate macrocrystalline cap 100 mg(Macrobid)......................................................................... 57

nitroglycerin cap er 2.5 mg................................................43nitroglycerin sl tab 0.3 mg (Nitrostat)................................ 43nitroglycerin sl tab 0.4 mg (Nitrostat)................................ 43nitroglycerin sl tab 0.6 mg (Nitrostat)................................ 43nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)............... 43nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)............... 43nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)............... 43nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)............... 43NITRO-TIME – nitroglycerin cap er 6.5 mg.......................42NITRO-TIME – nitroglycerin cap er 9 mg..........................43NITYR – nitisinone tab 2 mg............................................. 35NITYR – nitisinone tab 5 mg............................................. 35NITYR – nitisinone tab 10 mg........................................... 35NIVA-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................90

NIVESTYM – filgrastim-aafi inj 300 mcg/ml...................... 94NIVESTYM – filgrastim-aafi inj 480 mcg/1.6ml (300 mcg/ml)......................................................................................95

NIVESTYM – filgrastim-aafi soln prefilled syringe 300mcg/0.5ml..........................................................................94

NIVESTYM – filgrastim-aafi soln prefilled syringe 480mcg/0.8ml..........................................................................94

nizatidine cap 150 mg........................................................54nizatidine cap 300 mg........................................................54norethindrone acetate-ethinyl estradiol tab 1 mg-5mcg....................................................................................28

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5mcg (Femhrt low dose).................................................... 28

norethindrone acetate tab 5 mg (Aygestin).......................28nortriptyline hcl cap 10 mg (Pamelor)............................... 61nortriptyline hcl cap 25 mg (Pamelor)............................... 61nortriptyline hcl cap 50 mg (Pamelor)............................... 61nortriptyline hcl cap 75 mg (Pamelor)............................... 61NORVIR – ritonavir oral soln 80 mg/ml.............................13NOVOLIN 70/30 FLEXPEN – insulin nph & regular susppen-inj 100 unit/ml (70-30)...............................................32

NOVOLIN 70/30 FLEXPEN REL – insulin nph & regularsusp pen-inj 100 unit/ml (70-30)......................................33

NOVOLIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30)...................................................... 32

NOVOLIN 70/30 RELION – insulin nph isophane &regular human inj 100 unit/ml (70-30)............................. 33

NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml.......................................................................................32

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NOVOLIN N RELION – insulin nph (human) (isophane) inj100 unit/ml........................................................................ 32

NOVOLIN R – insulin regular (human) inj 100 unit/ml...... 32NOVOLIN R RELION – insulin regular (human) inj 100unit/ml................................................................................32

NOVOLOG MIX 70/30 – insulin aspart prot & aspart(human) inj 100 unit/ml (70-30)....................................... 33

NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &aspart sus pen-inj 100 unit/ml (70-30).............................33

NOXAFIL – posaconazole susp 40 mg/ml........................ 10NUVARING – etonogestrel-ethinyl estradiol va ring0.120-0.015 mg/24hr........................................................ 29

nystatin cream 100000 unit/gm......................................... 99nystatin oint 100000 unit/gm............................................100nystatin oral powder...........................................................10nystatin susp 100000 unit/ml.............................................98nystatin tab 500000 unit.................................................... 10

OO-CAL FA – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................90

ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab200-25-25 mg................................................................... 13

OFEV – nintedanib esylate cap 100 mg (baseequivalent).........................................................................53

OFEV – nintedanib esylate cap 150 mg (baseequivalent).........................................................................53

OFF ACTIVE – diethyltoluamide (deet) aerosol..............102OFF DEEP WOODS – diethyltoluamide (deet)aerosol.............................................................................102

OFF DEEP WOODS DRY – diethyltoluamide (deet)aerosol.............................................................................102

OFF SMOOTH & DRY – diethyltoluamide (deet)aerosol.............................................................................102

ofloxacin ophth soln 0.3% (Ocuflox)..................................96ofloxacin otic soln 0.3% (Floxin otic).................................97olanzapine orally disintegrating tab 5 mg (Zyprexazydis)................................................................................. 67

olanzapine orally disintegrating tab 10 mg (Zyprexazydis)................................................................................. 67



olanzapine tab 2.5 mg (Zyprexa).......................................67olanzapine tab 5 mg (Zyprexa)..........................................67olanzapine tab 7.5 mg (Zyprexa).......................................67olanzapine tab 10 mg (Zyprexa)........................................67olanzapine tab 15 mg (Zyprexa)........................................67olanzapine tab 20 mg (Zyprexa)........................................67olmesartan medoxomil-hydrochlorothiazide tab 20-12.5mg (Benicar hct)...............................................................38

olmesartan medoxomil-hydrochlorothiazide tab 40-12.5mg (Benicar hct)...............................................................38

olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg(Benicar hct)..................................................................... 38

olmesartan medoxomil tab 5 mg (Benicar)....................... 38olmesartan medoxomil tab 20 mg (Benicar)..................... 38olmesartan medoxomil tab 40 mg (Benicar)..................... 38olopatadine hcl ophth soln 0.1% (base equivalent)(Patanol)............................................................................97

OLUMIANT – baricitinib tab 2 mg..................................... 83omeprazole cap delayed release 10 mg (Prilosec)...........54omeprazole cap delayed release 20 mg (Prilosec)...........54omeprazole cap delayed release 40 mg (Prilosec)...........54OMNITROPE – somatropin for inj 5.8 mg.........................33ondansetron hcl oral soln 4 mg/5ml (Zofran).................... 55ondansetron hcl tab 24 mg................................................55ondansetron hcl tab 4 mg (Zofran)....................................55ondansetron hcl tab 8 mg (Zofran)....................................55ondansetron orally disintegrating tab 4 mg (Zofranodt).................................................................................... 55

ondansetron orally disintegrating tab 8 mg (Zofranodt).................................................................................... 55

ONETOUCH DELICA LANCETS E – lancets................. 104ONETOUCH DELICA LANCETS F – lancets................. 104ONETOUCH DELICA LANCING D – lancet devices...... 104ONETOUCH DELICA PLUS LANC – lancet devices......104ONETOUCH SURESOFT LANCING – lancets misc...... 104ONETOUCH ULTRA 2 – blood glucose monitoring kit w/device.............................................................................. 103

ONETOUCH ULTRA BLUE – glucose blood teststrip..................................................................................103

ONETOUCH ULTRA CONTROL – blood glucosecalibration - liquid........................................................... 103

ONETOUCH ULTRA MINI – blood glucose monitoring kitw/ device.........................................................................103

ONETOUCH ULTRASOFT LANCET – lancets............... 104ONETOUCH VERIO – blood glucose monitoring kit w/device.............................................................................. 103

ONETOUCH VERIO CONTROL SO – blood glucosecalibration - liquid - high.................................................103

ONETOUCH VERIO FLEX BLOOD – blood glucosemonitoring kit w/ device................................................. 103

ONETOUCH VERIO IQ BLOOD G – blood glucosemonitoring kit w/ device................................................. 103

ONETOUCH VERIO MID CONTRO – blood glucosecalibration - liquid........................................................... 103

ONETOUCH VERIO TEST STRIP – glucose blood teststrip..................................................................................103

ORENCIA – abatacept subcutaneous soln prefilledsyringe 125 mg/ml............................................................83

ORENCIA CLICKJECT – abatacept subcutaneous solnauto-injector 125 mg/ml....................................................83

ORKAMBI – lumacaftor-ivacaftor granules packet 100-125mg......................................................................................53

ORKAMBI – lumacaftor-ivacaftor granules packet 150-188mg......................................................................................53

ORKAMBI – lumacaftor-ivacaftor tab 100-125 mg............53ORKAMBI – lumacaftor-ivacaftor tab 200-125 mg............53orphenadrine citrate tab er 12hr 100 mg...........................89

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oseltamivir phosphate cap 30 mg (base equiv)(Tamiflu).............................................................................14



oseltamivir phosphate for susp 6 mg/ml (base equiv)(Tamiflu).............................................................................14

OTEZLA – apremilast tab 30 mg.......................................83OTEZLA – apremilast tab starter therapy pack 10 mg & 20mg & 30 mg......................................................................83

oxcarbazepine susp 300 mg/5ml (60 mg/ml)(Trileptal)........................................................................... 86

oxcarbazepine tab 150 mg (Trileptal)................................86oxcarbazepine tab 300 mg (Trileptal)................................86oxcarbazepine tab 600 mg (Trileptal)................................86oxiconazole nitrate cream 1% (Oxistat).......................... 100OXTELLAR XR – oxcarbazepine tab er 24hr 150 mg.......86OXTELLAR XR – oxcarbazepine tab er 24hr 300 mg.......86OXTELLAR XR – oxcarbazepine tab er 24hr 600 mg.......87oxybutynin chloride syrup 5 mg/5ml..................................57oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)........... 57oxybutynin chloride tab er 24hr 10 mg (Ditropan xl)......... 57oxybutynin chloride tab er 24hr 15 mg (Ditropan xl)......... 57oxybutynin chloride tab 5 mg.............................................57OXYCODONE/ASPIRIN – oxycodone-aspirin tab4.8355-325 mg..................................................................80

OXYCODONE/IBUPROFEN – oxycodone-ibuprofen tab5-400 mg...........................................................................80

oxycodone hcl conc 100 mg/5ml (20 mg/ml).................... 79oxycodone hcl soln 5 mg/5ml............................................79oxycodone hcl tab 10 mg.................................................. 79oxycodone hcl tab 20 mg.................................................. 79oxycodone hcl tab 5 mg (Roxicodone)..............................79oxycodone hcl tab 15 mg (Roxicodone)............................79oxycodone hcl tab 30 mg (Roxicodone)............................79oxycodone w/ acetaminophen tab 2.5-325 mg(Percocet)..........................................................................79

oxycodone w/ acetaminophen tab 5-325 mg(Percocet)..........................................................................79

oxycodone w/ acetaminophen tab 7.5-325 mg(Percocet)..........................................................................79

oxycodone w/ acetaminophen tab 10-325 mg(Percocet)..........................................................................79

oxymorphone hcl tab 5 mg (Opana)..................................80oxymorphone hcl tab 10 mg (Opana)................................80OXYMORPHONE HYDROCHLORIDE – oxymorphone hcltab er 12hr 5 mg.............................................................. 80

OXYMORPHONE HYDROCHLORIDE – oxymorphone hcltab er 12hr 7.5 mg........................................................... 80

OXYMORPHONE HYDROCHLORIDE – oxymorphone hcltab er 12hr 10 mg............................................................ 80





Ppaliperidone tab er 24hr 1.5 mg (Invega)..........................67paliperidone tab er 24hr 3 mg (Invega).............................67paliperidone tab er 24hr 6 mg (Invega).............................67paliperidone tab er 24hr 9 mg (Invega).............................67pantoprazole sodium ec tab 20 mg (base equiv)(Protonix)...........................................................................55

pantoprazole sodium ec tab 40 mg (base equiv)(Protonix)...........................................................................55

PARAGARD INTRAUTERINE COP – copper iud............. 29paromomycin sulfate cap 250 mg....................................... 9paroxetine hcl tab 10 mg (Paxil)........................................61paroxetine hcl tab 20 mg (Paxil)........................................62paroxetine hcl tab 30 mg (Paxil)........................................62paroxetine hcl tab 40 mg (Paxil)........................................62PAXIL – paroxetine hcl oral susp 10 mg/5ml (baseequiv).................................................................................62

pediatric multiple vitamin w/ minerals & c drops 45 mg/ml.......................................................................................90

pediatric vitamins acd w/ fluoride soln 0.25 mg/ml............90peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm(Colyte-flavor packs).........................................................54

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm(Golytely)...........................................................................53

peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack)....................................................................... 53

penicillamine cap 250 mg (Cuprimine)............................105penicillin v potassium tab 250 mg....................................... 7penicillin v potassium tab 500 mg....................................... 7pentoxifylline tab er 400 mg.............................................. 95perindopril erbumine tab 2 mg...........................................37perindopril erbumine tab 4 mg (Aceon).............................37perindopril erbumine tab 8 mg (Aceon).............................37permethrin cream 5% (Elimite)........................................102PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline tab 2-10 mg................................................. 76

PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline tab 2-25 mg................................................. 76




perphenazine tab 2 mg......................................................67perphenazine tab 4 mg......................................................67perphenazine tab 8 mg......................................................67perphenazine tab 16 mg....................................................67PEXEVA – paroxetine mesylate tab 10 mg (baseequiv).................................................................................62

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PEXEVA – paroxetine mesylate tab 20 mg (baseequiv).................................................................................62



phenazopyridine hcl tab 100 mg (Pyridium)......................58phenazopyridine hcl tab 200 mg (Pyridium)......................58phenobarbital elixir 20 mg/5ml...........................................70phenobarbital tab 15 mg....................................................70phenobarbital tab 16.2 mg.................................................70phenobarbital tab 30 mg....................................................70phenobarbital tab 32.4 mg.................................................70phenobarbital tab 60 mg....................................................70phenobarbital tab 64.8 mg.................................................70phenobarbital tab 97.2 mg.................................................70phenobarbital tab 100 mg..................................................70phenoxybenzamine hcl cap 10 mg (Dibenzyline)..............48phenylephrine hcl ophth soln 2.5%................................... 97phenytoin chew tab 50 mg (Dilantin infatabs)................... 87phenytoin sodium extended cap 100 mg (Dilantin)...........87phenytoin sodium extended cap 200 mg (Phenytek)........87phenytoin sodium extended cap 300 mg (Phenytek)........87phenytoin susp 125 mg/5ml (Dilantin-125)........................87phytonadione tab 5 mg (Mephyton)...................................89PIFELTRO – doravirine tab 100 mg.................................. 13pilocarpine hcl ophth soln 1% (Isopto carpine)................. 97pilocarpine hcl ophth soln 2% (Isopto carpine)................. 97pilocarpine hcl ophth soln 4% (Isopto carpine)................. 97pilocarpine hcl tab 5 mg (Salagen)....................................98pilocarpine hcl tab 7.5 mg (Salagen).................................98PIMOZIDE – pimozide tab 1 mg....................................... 76PIMOZIDE – pimozide tab 2 mg....................................... 76pindolol tab 5 mg............................................................... 40pioglitazone hcl tab 15 mg (base equiv) (Actos)............... 31pioglitazone hcl tab 30 mg (base equiv) (Actos)............... 31pioglitazone hcl tab 45 mg (base equiv) (Actos)............... 31piroxicam cap 10 mg (Feldene).........................................83piroxicam cap 20 mg (Feldene).........................................83PNEUMOVAX 23/1 DOSE – pneumococcal vaccinepolyvalent inj 25 mcg/0.5ml............................................. 17

PNEUMOVAX 23 – pneumococcal vaccine polyvalent inj25 mcg/0.5ml.................................................................... 17

PNV FOLIC ACID + IRON MUL – prenatal vit w/ fefumarate-fa tab 27-1 mg.................................................. 90

PNV PRENATAL PLUS MULTIVI – prenatal vit w/ fefumarate-fa tab 27-1 mg.................................................. 90

podofilox soln 0.5% (Condylox).......................................103polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%(Polytrim)...........................................................................96

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasicchew tab 0.25 mg.............................................................90

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasicchew tab 0.5 mg...............................................................90

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasicchew tab 1 mg..................................................................90

POMALYST – pomalidomide cap 1 mg.............................23POMALYST – pomalidomide cap 2 mg.............................23POMALYST – pomalidomide cap 3 mg.............................23POMALYST – pomalidomide cap 4 mg.............................23posaconazole tab delayed release 100 mg (Noxafil)........ 10pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml.......58potassium bicarbonate effer tab 25 meq...........................91potassium chloride cap er 8 meq (Micro-k).......................91potassium chloride cap er 10 meq (Micro-k).....................91POTASSIUM CHLORIDE ER – potassium chloride tab er8 meq (600 mg)................................................................91

potassium chloride microencapsulated crys er tab 10meq....................................................................................91

potassium chloride microencapsulated crys er tab 20meq....................................................................................92

potassium chloride oral soln 10% (20 meq/15ml)............. 92potassium chloride oral soln 20% (40 meq/15ml)............. 92potassium chloride tab er 10 meq (K-tab).........................92potassium chloride tab er 8 meq (600 mg)....................... 92potassium citrate & citric acid powder pack 3300-1002mg......................................................................................58

potassium citrate & citric acid soln 1100-334 mg/5ml....... 58potassium citrate tab er 5 meq (540 mg) (Urocit-k 5)........58potassium citrate tab er 10 meq (1080 mg) (Urocit-k10)..................................................................................... 58

potassium citrate tab er 15 meq (1620 mg) (Urocit-k15)..................................................................................... 58

pot phos monobasic w/sod phos di & monobas tab155-852-130mg (K-phos neutral).....................................91

pramipexole dihydrochloride tab er 24hr 2.25 mg (Mirapexer)...................................................................................... 88

pramipexole dihydrochloride tab 0.125 mg (Mirapex).......88pramipexole dihydrochloride tab 0.25 mg (Mirapex).........88pramipexole dihydrochloride tab 0.5 mg (Mirapex)...........88pramipexole dihydrochloride tab 0.75 mg (Mirapex).........88pramipexole dihydrochloride tab 1 mg (Mirapex)..............88pramipexole dihydrochloride tab 1.5 mg (Mirapex)...........88pravastatin sodium tab 10 mg........................................... 44pravastatin sodium tab 20 mg (Pravachol)........................44pravastatin sodium tab 40 mg (Pravachol)........................44pravastatin sodium tab 80 mg (Pravachol)........................44praziquantel tab 600 mg (Biltricide)...................................15prazosin hcl cap 1 mg (Minipress).................................... 48prazosin hcl cap 2 mg (Minipress).................................... 48prazosin hcl cap 5 mg (Minipress).................................... 48PREDNICARBATE – prednicarbate cream 0.1%............101PREDNICARBATE – prednicarbate oint 0.1%................101PREDNISOLONE ACETATE – prednisolone acetateophth susp 1%..................................................................96

PREDNISOLONE – prednisolone syrup 15 mg/5ml (uspsolution equivalent)...........................................................26

PREDNISOLONE SODIUM PHOSP – prednisolonesodium phosphate ophth soln 1%................................... 96

prednisolone sod phosphate oral soln 15 mg/5ml (baseequiv).................................................................................26

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prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5mlbase) (Pediapred).............................................................26

PREDNISONE – prednisone oral soln 5 mg/5ml.............. 26PREDNISONE – prednisone tab 50 mg............................26prednisone tab 1 mg..........................................................27prednisone tab 2.5 mg.......................................................27prednisone tab 5 mg..........................................................27prednisone tab 10 mg........................................................27prednisone tab 20 mg........................................................27prednisone tab therapy pack 5 mg (21)............................ 27prednisone tab therapy pack 5 mg (48)............................ 27prednisone tab therapy pack 10 mg (21).......................... 27prednisone tab therapy pack 10 mg (48).......................... 27PRENATAL AND IRON – prenatal multivitamins &minerals w/iron & fa tab 0.8 mg.......................................90

PRE-NATAL FORMULA – prenatal multivitamins &minerals w/iron & fa tab 0.8 mg.......................................90

PRENATAL FORTE – prenatal multivitamins & mineralsw/iron & fa tab 0.8 mg..................................................... 90

PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fatab 27-0.8 mg................................................................... 90

PRENATAL MULTI +DHA – prenatal vit w/ fe fum-fa-omega 3 cap 27-0.8-228 mg........................................... 90

PRENATAL MULTIVITAMIN – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...............................................................90

PRENATAL ONE DAILY – prenatal vit w/ fe fumarate-fatab 27-0.8 mg................................................................... 90

PRENATAL – prenatal multivitamins & minerals w/iron &fa tab 0.8 mg.................................................................... 90

PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab29-1 mg.............................................................................91

PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab29-1 mg.............................................................................91

PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8mg......................................................................................90

PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................90

PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................90

PRENATAL VITAMIN/IRON – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...............................................................91

PRENATAL VITAMIN & MINERA – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 90

PRENATAL VITAMIN – prenatal vit w/ fe fumarate-fa tab27-0.8 mg..........................................................................90

PRENATAL VITAMINS PLUS LO – prenatal vit w/ fefumarate-fa tab 27-1 mg.................................................. 91

PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab28-0.8 mg..........................................................................91

prenatal vit w/ fe fumarate-fa tab 28-0.8 mg..................... 90PREPLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................91

PREVIDENT 5000 DRY MOUTH – sodium fluoride gel1.1% (0.5% f)....................................................................98

PREVIDENT FLUORIDE – sodium fluoride gel 1.1%(0.5% f)............................................................................. 98

PREVIDENT RINSE – sodium fluoride rinse 0.2%........... 98PREVNAR 13 – pneumococcal 13-valent conjugatevaccine inj......................................................................... 17

PREZCOBIX – darunavir-cobicistat tab 800-150 mg........13PREZISTA – darunavir ethanolate susp 100 mg/ml (baseequiv).................................................................................13

PREZISTA – darunavir ethanolate tab 75 mg (baseequiv).................................................................................13




PRIFTIN – rifapentine tab 150 mg...................................... 9primaquine phosphate tab 26.3 mg (15 mg base)(Primaquine phosphate)................................................... 15

primidone tab 50 mg (Mysoline)........................................87primidone tab 250 mg (Mysoline)......................................87probenecid tab 500 mg......................................................84prochlorperazine maleate tab 5 mg (base equivalent)......67prochlorperazine maleate tab 10 mg (baseequivalent).........................................................................67

prochlorperazine suppos 25 mg........................................ 67progesterone micronized cap 100 mg (Prometrium).........28progesterone micronized cap 200 mg (Prometrium).........28PROMACTA – eltrombopag olamine powder pack forsusp 12.5 mg (base eq)...................................................95

PROMACTA – eltrombopag olamine tab 12.5 mg (baseequiv).................................................................................95

PROMACTA – eltrombopag olamine tab 25 mg (baseequiv).................................................................................95



promethazine hcl suppos 12.5 mg.................................... 50promethazine hcl suppos 25 mg....................................... 50promethazine hcl syrup 6.25 mg/5ml................................ 50promethazine hcl tab 12.5 mg...........................................50promethazine hcl tab 25 mg..............................................50promethazine hcl tab 50 mg..............................................50promethazine w/ codeine syrup 6.25-10 mg/5ml.............. 50propafenone hcl tab 150 mg..............................................46propafenone hcl tab 300 mg..............................................46propafenone hcl tab 225 mg (Rythmol).............................46proparacaine hcl ophth soln 0.5% (Alcaine)......................97PROPRANOLOL/HYDROCHLOROTH – propranolol &hydrochlorothiazide tab 40-25 mg................................... 40

PROPRANOLOL/HYDROCHLOROTH – propranolol &hydrochlorothiazide tab 80-25 mg................................... 40

propranolol hcl cap er 24hr 60 mg (Inderal la)..................40propranolol hcl cap er 24hr 80 mg (Inderal la)..................40propranolol hcl cap er 24hr 120 mg (Inderal la)................40propranolol hcl cap er 24hr 160 mg (Inderal la)................40

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PROPRANOLOL HCL – propranolol hcl oral soln 20mg/5ml...............................................................................40

PROPRANOLOL HCL – propranolol hcl oral soln 40mg/5ml...............................................................................40

propranolol hcl tab 10 mg..................................................40propranolol hcl tab 20 mg..................................................40propranolol hcl tab 40 mg..................................................40propranolol hcl tab 60 mg..................................................40propranolol hcl tab 80 mg..................................................40propylthiouracil tab 50 mg................................................. 33PULMOZYME – dornase alfa inhal soln 1 mg/ml..............53PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml)......................................................................................23

PX PRENATAL MULTIVITAMINS – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 91

pyrazinamide tab 500 mg.................................................... 9pyridostigmine bromide tab 60 mg (Mestinon)..................89

QQC PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................91

QUAZEPAM – quazepam tab 15 mg................................ 70quetiapine fumarate tab er 24hr 50 mg (Seroquel xr)....... 68quetiapine fumarate tab er 24hr 150 mg (Seroquel xr)..... 68quetiapine fumarate tab er 24hr 200 mg (Seroquel xr)..... 68quetiapine fumarate tab er 24hr 300 mg (Seroquel xr)..... 68quetiapine fumarate tab er 24hr 400 mg (Seroquel xr)..... 68quetiapine fumarate tab 25 mg (Seroquel)........................68quetiapine fumarate tab 50 mg (Seroquel)........................68quetiapine fumarate tab 100 mg (Seroquel)......................68quetiapine fumarate tab 200 mg (Seroquel)......................68quetiapine fumarate tab 300 mg (Seroquel)......................68quetiapine fumarate tab 400 mg (Seroquel)......................68quinapril hcl tab 5 mg (Accupril)........................................37quinapril hcl tab 10 mg (Accupril)......................................37quinapril hcl tab 20 mg (Accupril)......................................37quinapril hcl tab 40 mg (Accupril)......................................37quinapril-hydrochlorothiazide tab 10-12.5 mg(Accuretic)......................................................................... 37

quinapril-hydrochlorothiazide tab 20-12.5 mg(Accuretic)......................................................................... 37

quinapril-hydrochlorothiazide tab 20-25 mg(Accuretic)......................................................................... 37

quinidine gluconate tab er 324 mg....................................46QUINIDINE SULFATE – quinidine sulfate tab 200 mg......46QUINIDINE SULFATE – quinidine sulfate tab 300 mg......47QVAR REDIHALER – beclomethasone diprop hfa breathact inh aer 40 mcg/act..................................................... 52

QVAR REDIHALER – beclomethasone diprop hfa breathact inh aer 80 mcg/act..................................................... 52

RRABAVERT – rabies vaccine, pcec for inj.........................17rabeprazole sodium ec tab 20 mg (Aciphex).................... 55raloxifene hcl tab 60 mg (Evista).......................................35ramipril cap 1.25 mg (Altace)............................................ 37

ramipril cap 2.5 mg (Altace).............................................. 37ramipril cap 5 mg (Altace)................................................. 37ramipril cap 10 mg (Altace)............................................... 37ranitidine hcl syrup 15 mg/ml (75 mg/5ml)........................ 55ranitidine hcl tab 150 mg (Zantac).....................................55ranitidine hcl tab 300 mg (Zantac).....................................55RA PRENATAL FORMULA/FOLIC – prenatal vit w/ fefumarate-fa tab 28-0.8 mg............................................... 91

RA PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8mg......................................................................................91

RAVICTI – glycerol phenylbutyrate liquid 1.1 gm/ml......... 35RECOMBIVAX HB – hepatitis b vaccine (recombinant)susp 5 mcg/0.5ml............................................................. 17

RECOMBIVAX HB – hepatitis b vaccine (recombinant)susp 10 mcg/ml................................................................ 17

RECOMBIVAX HB – hepatitis b vaccine (recombinant)susp 40 mcg/ml................................................................ 17

RELENZA DISKHALER – zanamivir aero powder breathactivated 5 mg/blister....................................................... 14

RELION R – insulin regular (human) inj 100 unit/ml......... 32REPATHA – evolocumab subcutaneous soln prefilledsyringe 140 mg/ml............................................................44

REPATHA PUSHTRONEX SYSTEM – evolocumabsubcutaneous soln cartridge/infusor 420 mg/3.5ml.........45

REPATHA SURECLICK – evolocumab subcutaneous solnauto-injector 140 mg/ml....................................................45

REPEL SPORTSMEN – diethyltoluamide (deet)aerosol.............................................................................103

REPEL SPORTSMEN MAX – diethyltoluamide (deet)aerosol.............................................................................103

RESCRIPTOR – delavirdine mesylate tab 200 mg...........13RETACRIT – epoetin alfa-epbx inj 2000 unit/ml................95RETACRIT – epoetin alfa-epbx inj 3000 unit/ml................95RETACRIT – epoetin alfa-epbx inj 4000 unit/ml................95RETACRIT – epoetin alfa-epbx inj 10000 unit/ml..............95RETACRIT – epoetin alfa-epbx inj 40000 unit/ml..............95REVLIMID – lenalidomide cap 5 mg............................... 105REVLIMID – lenalidomide cap 10 mg............................. 105REVLIMID – lenalidomide cap 15 mg............................. 105REVLIMID – lenalidomide cap 20 mg............................. 105REVLIMID – lenalidomide cap 25 mg............................. 105REVLIMID – lenalidomide caps 2.5 mg.......................... 105REXULTI – brexpiprazole tab 0.25 mg..............................68REXULTI – brexpiprazole tab 0.5 mg................................68REXULTI – brexpiprazole tab 1 mg...................................68REXULTI – brexpiprazole tab 2 mg...................................68REXULTI – brexpiprazole tab 3 mg...................................68REXULTI – brexpiprazole tab 4 mg...................................68ribavirin cap 200 mg (Rebetol).......................................... 11ribavirin tab 200 mg (Copegus).........................................11rifabutin cap 150 mg (Mycobutin)........................................9rifampin cap 150 mg (Rifadin)............................................. 9rifampin cap 300 mg (Rifadin)........................................... 10RIGHT STEP PRENATAL – prenatal vit w/ fe fumarate-fatab 27-0.8 mg................................................................... 91

riluzole tab 50 mg (Rilutek)................................................89

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ringer's solution for irrigation............................................105risedronate sodium tab delayed release 35 mg(Atelvia)............................................................................. 35

RISPERDAL CONSTA – risperidone microspheres for inj12.5 mg.............................................................................68

RISPERDAL CONSTA – risperidone microspheres for inj25 mg................................................................................ 68

RISPERDAL CONSTA – risperidone microspheres for inj37.5 mg.............................................................................68

RISPERDAL CONSTA – risperidone microspheres for inj50 mg................................................................................ 69

RISPERIDONE ODT – risperidone orally disintegratingtab 0.25 mg...................................................................... 69

risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab).................................................................................... 69

risperidone orally disintegrating tab 1 mg (Risperdal m-tab).................................................................................... 69




risperidone soln 1 mg/ml (Risperdal).................................69risperidone tab 0.25 mg (Risperdal)..................................69risperidone tab 0.5 mg (Risperdal)....................................69risperidone tab 1 mg (Risperdal).......................................69risperidone tab 2 mg (Risperdal).......................................69risperidone tab 3 mg (Risperdal).......................................69risperidone tab 4 mg (Risperdal).......................................69ritonavir tab 100 mg (Norvir)..............................................13rivastigmine tartrate cap 4.5 mg (base equivalent)........... 76rizatriptan benzoate oral disintegrating tab 5 mg (base eq)(Maxalt-mlt)....................................................................... 83

rizatriptan benzoate oral disintegrating tab 10 mg (baseeq) (Maxalt-mlt).................................................................84

rizatriptan benzoate tab 5 mg (base equivalent)(Maxalt)............................................................................. 84

rizatriptan benzoate tab 10 mg (base equivalent)(Maxalt)............................................................................. 84

ropinirole hydrochloride tab 0.25 mg (Requip)..................88ropinirole hydrochloride tab 0.5 mg (Requip)....................88ropinirole hydrochloride tab 1 mg (Requip).......................88ropinirole hydrochloride tab 2 mg (Requip).......................88ropinirole hydrochloride tab 3 mg (Requip).......................88ropinirole hydrochloride tab 4 mg (Requip).......................88ropinirole hydrochloride tab 5 mg (Requip).......................88rosuvastatin calcium tab 5 mg (Crestor)........................... 45rosuvastatin calcium tab 10 mg (Crestor)......................... 45rosuvastatin calcium tab 20 mg (Crestor)......................... 45rosuvastatin calcium tab 40 mg (Crestor)......................... 45RUBRACA – rucaparib camsylate tab 200 mg (baseequivalent).........................................................................23

RUBRACA – rucaparib camsylate tab 250 mg (baseequivalent).........................................................................23

RUBRACA – rucaparib camsylate tab 300 mg (baseequivalent).........................................................................23

Ssalicylic acid cream 6%................................................... 100salicylic acid cream 6% & cleanser liqd kit (Salexcream)............................................................................. 100

salicylic acid film forming liquid 27.5% (Virasal)..............100salicylic acid foam 6% (Salvax).......................................100salicylic acid gel 6% (Keralyt)..........................................100salicylic acid lotion 6%.....................................................100SALICYLIC ACID LOTION – salicylic acid lotion 6% &cleanser liqd kit...............................................................100

salicylic acid shampoo 6% (Salex)..................................100SAMSCA – tolvaptan tab 15 mg....................................... 35SAMSCA – tolvaptan tab 30 mg....................................... 35SAPHRIS – asenapine maleate sl tab 2.5 mg (baseequiv).................................................................................69

SAPHRIS – asenapine maleate sl tab 5 mg (baseequiv).................................................................................69

SAPHRIS – asenapine maleate sl tab 10 mg (baseequiv).................................................................................69

SAWYER PREMIUM INSECT REP – picaridin liquid..... 103selegiline hcl cap 5 mg (Eldepryl)..................................... 88SELEGILINE HCL – selegiline hcl tab 5 mg..................... 88selenium sulfide lotion 2.5%............................................103selenium sulfide shampoo 2.25%....................................103SELZENTRY – maraviroc tab 150 mg.............................. 13SELZENTRY – maraviroc tab 300 mg.............................. 13SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1mg......................................................................................91

SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab29-1 mg.............................................................................91

SEROSTIM – somatropin (non-refrigerated) forsubcutaneous inj 4 mg.....................................................34



sertraline hcl oral concentrate for solution 20 mg/ml(Zoloft)............................................................................... 62

sertraline hcl tab 25 mg (Zoloft)........................................ 62sertraline hcl tab 50 mg (Zoloft)........................................ 62sertraline hcl tab 100 mg (Zoloft)...................................... 62sevelamer carbonate packet 0.8 gm (Renvela)................ 56sevelamer carbonate packet 2.4 gm (Renvela)................ 56sevelamer carbonate tab 800 mg (Renvela).....................56SHINGRIX – zoster vac recombinant adjuvanted for im inj50 mcg/0.5ml.................................................................... 17

SIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (baseequiv).................................................................................35



sildenafil citrate for suspension 10 mg/ml (Revatio)..........48

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sildenafil citrate tab 20 mg (Revatio).................................48silver sulfadiazine cream 1% (Silvadene)....................... 100SIMPONI – golimumab subcutaneous soln auto-injector50 mg/0.5ml...................................................................... 83

SIMPONI – golimumab subcutaneous soln auto-injector100 mg/ml......................................................................... 83

SIMPONI – golimumab subcutaneous soln prefilledsyringe 50 mg/0.5ml.........................................................83

SIMPONI – golimumab subcutaneous soln prefilledsyringe 100 mg/ml............................................................83

simvastatin tab 5 mg (Zocor).............................................45simvastatin tab 10 mg (Zocor)...........................................45simvastatin tab 20 mg (Zocor)...........................................45simvastatin tab 40 mg (Zocor)...........................................45simvastatin tab 80 mg (Zocor)...........................................45sirolimus tab 0.5 mg (Rapamune)................................... 105sirolimus tab 1 mg (Rapamune)...................................... 105sirolimus tab 2 mg (Rapamune)...................................... 105SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5mg total)............................................................................29

SM PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fatab 28-0.8 mg................................................................... 91

sodium chloride irrigation soln 0.9%..................................58sodium chloride soln nebu 0.9%....................................... 50sodium chloride soln nebu 3%.......................................... 50sodium chloride soln nebu 10%........................................ 50sodium chloride soln nebu 7% (Hyper-sal)....................... 50sodium citrate & citric acid soln 500-334 mg/5ml (Shohlssolution modi)................................................................... 58

sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)(Luride).............................................................................. 92

sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)(Luride).............................................................................. 92

sodium fluoride chew tab 1 mg f (from 2.2 mg naf)(Luride).............................................................................. 92

sodium fluoride cream 1.1% (Prevident 5000 plus).......... 98sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)......98sodium fluoride paste 1.1% (Prevident 5000 boost)......... 98sodium fluoride-potassium nitrate paste 1.1-5% (Prevident5000 sensi)....................................................................... 98

sodium fluoride rinse 0.2%................................................ 98SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from1.1 mg naf)....................................................................... 92

SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from2.2 mg naf)....................................................................... 92

sodium fluoride soln 0.125 mg/drop f (0.275 mg/dropnaf).................................................................................... 92

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)(Luride).............................................................................. 92

sodium polystyrene sulfonate oral susp 15 gm/60ml...... 105sodium polystyrene sulfonate powder (Kayexalate)........105sodium polystyrene sulfonate rectal susp 30gm/120ml........................................................................ 105

SOFOSBUVIR/VELPATASVIR – sofosbuvir-velpatasvirtab 400-100 mg................................................................ 11

SOLU-CORTEF – hydrocortisone sodium succinate pf forinj 100 mg.........................................................................27



SOLU-CORTEF – hydrocortisone sodium succinate pf forinj 1000 mg.......................................................................27

SOMAVERT – pegvisomant for inj 10 mg (as protein)......35SOMAVERT – pegvisomant for inj 15 mg (as protein)......35SOMAVERT – pegvisomant for inj 20 mg (as protein)......35SOMAVERT – pegvisomant for inj 25 mg (as protein)......35SOMAVERT – pegvisomant for inj 30 mg (as protein)......35sotalol hcl (afib/afl) tab 80 mg (Betapace af).................... 47sotalol hcl (afib/afl) tab 120 mg (Betapace af).................. 47sotalol hcl (afib/afl) tab 160 mg (Betapace af).................. 47sotalol hcl tab 240 mg....................................................... 47sotalol hcl tab 80 mg (Betapace).......................................47sotalol hcl tab 120 mg (Betapace).....................................47sotalol hcl tab 160 mg (Betapace).....................................47speciality vitamin product tab............................................ 91spironolactone & hydrochlorothiazide tab 25-25 mg(Aldactazide)..................................................................... 46

spironolactone tab 25 mg (Aldactone)...............................46spironolactone tab 50 mg (Aldactone)...............................46spironolactone tab 100 mg (Aldactone)............................ 46SPRYCEL – dasatinib tab 20 mg...................................... 23SPRYCEL – dasatinib tab 50 mg...................................... 23SPRYCEL – dasatinib tab 70 mg...................................... 23SPRYCEL – dasatinib tab 80 mg...................................... 23SPRYCEL – dasatinib tab 100 mg.................................... 23SPRYCEL – dasatinib tab 140 mg.................................... 23stannous fluoride gel 0.4%................................................ 98stavudine cap 15 mg (Zerit)...............................................13stavudine cap 20 mg (Zerit)...............................................13stavudine cap 30 mg (Zerit)...............................................13stavudine cap 40 mg (Zerit)...............................................13STEGLATRO – ertugliflozin l-pyroglutamic acid tab 5 mg(base equiv)...................................................................... 31

STEGLATRO – ertugliflozin l-pyroglutamic acid tab 15 mg(base equiv)...................................................................... 32

STELARA – ustekinumab soln prefilled syringe 45mg/0.5ml......................................................................... 103

STELARA – ustekinumab soln prefilled syringe 90 mg/ml.....................................................................................103

STIMATE – desmopressin acetate nasal soln 1.5 mg/ml.......................................................................................35

STIVARGA – regorafenib tab 40 mg................................. 23STRENSIQ – asfotase alfa subcutaneous inj 18mg/0.45ml......................................................................... 35

STRENSIQ – asfotase alfa subcutaneous inj 28mg/0.7ml............................................................................36

STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml.......................................................................................36

STRENSIQ – asfotase alfa subcutaneous inj 80mg/0.8ml............................................................................36

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STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab150-150-200-300 mg........................................................13

STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln2.5 mcg/act (base equiv)................................................. 52

SUBOXONE – buprenorphine hcl-naloxone hcl sl film2-0.5 mg (base equiv)......................................................80

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1mg (base equiv)................................................................80

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2mg (base equiv)................................................................80

SUBOXONE – buprenorphine hcl-naloxone hcl sl film12-3 mg (base equiv).......................................................80

SUCRAID – sacrosidase soln 8500 unit/ml.......................55sucralfate tab 1 gm (Carafate)...........................................55SULFACETAMIDE SODIUM/PRED – sulfacetamidesodium-prednisolone ophth soln 10-0.23(0.25)%............96

sulfacetamide sodium lotion 10% (acne) (Klaron).............99sulfacetamide sodium ophth soln 10% (Bleph-10)............96sulfamethoxazole-trimethoprim susp 200-40 mg/5ml....... 15sulfamethoxazole-trimethoprim tab 400-80 mg(Bactrim)............................................................................15

sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrimds)......................................................................................15

sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)...................................................................................56

sulfasalazine tab 500 mg (Azulfidine)................................56sulindac tab 150 mg...........................................................83sulindac tab 200 mg...........................................................83sumatriptan nasal spray 5 mg/act (Imitrex).......................84sumatriptan nasal spray 20 mg/act (Imitrex).....................84sumatriptan succinate inj 6 mg/0.5ml (Imitrex)..................84sumatriptan succinate solution auto-injector 4 mg/0.5ml(Imitrex statdose sys)....................................................... 84

sumatriptan succinate solution auto-injector 6 mg/0.5ml(Imitrex statdose sys)....................................................... 84

sumatriptan succinate solution cartridge 4 mg/0.5ml(Imitrex statdose ref)........................................................ 84

sumatriptan succinate solution cartridge 6 mg/0.5ml(Imitrex statdose ref)........................................................ 84

SUMATRIPTAN SUCCINATE – sumatriptan succinatesolution prefilled syringe 6 mg/0.5ml............................... 84

sumatriptan succinate tab 25 mg (Imitrex)........................84sumatriptan succinate tab 50 mg (Imitrex)........................84sumatriptan succinate tab 100 mg (Imitrex)......................84SUSTIVA – efavirenz cap 50 mg.......................................13SUSTIVA – efavirenz cap 200 mg.....................................13SUSTIVA – efavirenz tab 600 mg..................................... 13SUTENT – sunitinib malate cap 12.5 mg (baseequivalent).........................................................................23

SUTENT – sunitinib malate cap 25 mg (baseequivalent).........................................................................23

SUTENT – sunitinib malate cap 37.5 mg (baseequivalent).........................................................................23

SUTENT – sunitinib malate cap 50 mg (baseequivalent).........................................................................24

SYLATRON – peginterferon alfa-2b for inj kit 200 mcg.....24

SYLATRON – peginterferon alfa-2b for inj kit 300 mcg.....24SYLATRON – peginterferon alfa-2b for inj kit 600 mcg.....24SYMBICORT – budesonide-formoterol fumarate dihydaerosol 80-4.5 mcg/act.....................................................52

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 160-4.5 mcg/act...................................................52

SYMDEKO – tezacaftor-ivacaftor 50-75 mg & ivacaftor 75mg tab tbpk.......................................................................53

SYMDEKO – tezacaftor-ivacaftor 100-150 mg & ivacaftor150 mg tab tbpk............................................................... 53

SYMFI – efavirenz-lamivudine-tenofovir df tab600-300-300 mg............................................................... 13

SYMFI LO – efavirenz-lamivudine-tenofovir df tab400-300-300 mg............................................................... 13

SYMTUZA – darunavir-cobic-emtricitab-tenofov af tab800-150-200-10 mg..........................................................13

SYNAGIS – palivizumab im soln 50 mg/0.5ml..................17SYNAGIS – palivizumab im soln 100 mg/ml.....................17SYNAREL – nafarelin acetate nasal soln 2 mg/ml (200mcg/act) (base eq)........................................................... 29

TTABLOID – thioguanine tab 40 mg................................... 24tacrolimus cap 0.5 mg (Prograf)......................................105tacrolimus cap 1 mg (Prograf).........................................105tacrolimus cap 5 mg (Prograf).........................................105tacrolimus oint 0.03% (Protopic)......................................103tacrolimus oint 0.1% (Protopic)........................................103tadalafil tab 20 mg (pah) (Adcirca)....................................48TAFINLAR – dabrafenib mesylate cap 50 mg (baseequivalent).........................................................................24

TAFINLAR – dabrafenib mesylate cap 75 mg (baseequivalent).........................................................................24

TALZENNA – talazoparib tosylate cap 0.25 mg (baseequivalent).........................................................................24

TALZENNA – talazoparib tosylate cap 1 mg (baseequivalent).........................................................................24

tamoxifen citrate tab 10 mg (base equivalent).................. 24tamoxifen citrate tab 20 mg (base equivalent).................. 24tamsulosin hcl cap 0.4 mg (Flomax)................................. 58TARGRETIN – bexarotene cap 75 mg..............................24TASIGNA – nilotinib hcl cap 50 mg (base equivalent)...... 24TASIGNA – nilotinib hcl cap 150 mg (baseequivalent).........................................................................24

TASIGNA – nilotinib hcl cap 200 mg (baseequivalent).........................................................................24

tazarotene cream 0.1% (Tazorac)..................................... 99TAZORAC – tazarotene cream 0.05%.............................. 99TAZORAC – tazarotene gel 0.05%................................... 99TAZORAC – tazarotene gel 0.1%..................................... 99TECHLITE PEN NEEDLES 29G..................................... 103temazepam cap 15 mg (Restoril)...................................... 71temazepam cap 30 mg (Restoril)...................................... 71temozolomide cap 5 mg (Temodar)...................................24temozolomide cap 20 mg (Temodar).................................24temozolomide cap 100 mg (Temodar)...............................24

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temozolomide cap 140 mg (Temodar)...............................24temozolomide cap 180 mg (Temodar)...............................24temozolomide cap 250 mg (Temodar)...............................24tenofovir disoproxil fumarate tab 300 mg (Viread)............ 13terazosin hcl cap 1 mg (base equivalent)......................... 48terazosin hcl cap 2 mg (base equivalent)......................... 48terazosin hcl cap 5 mg (base equivalent)......................... 48terazosin hcl cap 10 mg (base equivalent)....................... 49terbinafine hcl tab 250 mg (Lamisil).................................. 10terbutaline sulfate tab 2.5 mg............................................52terbutaline sulfate tab 5 mg...............................................52TERCONAZOLE – terconazole vaginal cream 0.8%........57terconazole vaginal cream 0.4% (Terazol 7).....................57terconazole vaginal suppos 80 mg....................................57testosterone td gel 12.5 mg/act (1%) (Androgelpump)................................................................................ 27

testosterone td gel 25 mg/2.5gm (1%) (Androgel)............ 27testosterone td gel 50 mg/5gm (1%) (Androgel)............... 27tetracaine hcl ophth soln 0.5%.......................................... 97THALOMID – thalidomide cap 50 mg............................. 105THALOMID – thalidomide cap 100 mg........................... 105THALOMID – thalidomide cap 150 mg........................... 105THALOMID – thalidomide cap 200 mg........................... 105THEOCHRON – theophylline tab er 12hr 100 mg............ 52THEOCHRON – theophylline tab er 12hr 200 mg............ 52THEOPHYLLINE ER – theophylline tab er 12hr 450mg......................................................................................52

theophylline soln 80 mg/15ml............................................52theophylline tab er 12hr 300 mg........................................53theophylline tab er 24hr 400 mg........................................53theophylline tab er 24hr 600 mg........................................53thioridazine hcl tab 10 mg................................................. 69thioridazine hcl tab 25 mg................................................. 69thioridazine hcl tab 50 mg................................................. 69thioridazine hcl tab 100 mg............................................... 69thiothixene cap 1 mg..........................................................69thiothixene cap 2 mg..........................................................69thiothixene cap 5 mg..........................................................70thiothixene cap 10 mg........................................................70thyroid tab 30 mg (1/2 grain) (Armour thyroid)..................33thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)...............33thyroid tab 60 mg (1 grain) (Armour thyroid).....................33tiagabine hcl tab 2 mg (Gabitril)........................................ 87tiagabine hcl tab 4 mg (Gabitril)........................................ 87TIBSOVO – ivosidenib tab 250 mg................................... 24timolol maleate ophth soln 0.25% (Timoptic).................... 97timolol maleate ophth soln 0.5% (Timoptic)...................... 97TIVICAY – dolutegravir sodium tab 50 mg (baseequiv).................................................................................14

tizanidine hcl tab 2 mg (base equivalent)..........................89tizanidine hcl tab 4 mg (base equivalent) (Zanaflex).........89tobramycin nebu soln 300 mg/5ml (Tobi)............................ 9tobramycin ophth soln 0.3% (Tobrex)................................96TOBRAMYCIN – tobramycin nebu soln 300 mg/5ml.......... 9tolcapone tab 100 mg (Tasmar)........................................ 88tolterodine tartrate tab 2 mg (Detrol).................................57

topiramate sprinkle cap 15 mg (Topamax sprinkle).......... 87topiramate sprinkle cap 25 mg (Topamax sprinkle).......... 87topiramate tab 25 mg (Topamax)...................................... 87topiramate tab 50 mg (Topamax)...................................... 87topiramate tab 100 mg (Topamax).................................... 87topiramate tab 200 mg (Topamax).................................... 87toremifene citrate tab 60 mg (base equivalent)(Fareston)..........................................................................24

torsemide tab 5 mg............................................................46torsemide tab 100 mg........................................................46torsemide tab 10 mg (Demadex).......................................46torsemide tab 20 mg (Demadex).......................................46TRACLEER – bosentan tab for oral susp 32 mg.............. 49tramadol-acetaminophen tab 37.5-325 mg (Ultracet)....... 80tramadol hcl tab 50 mg (Ultram)........................................80TRANDOLAPRIL/VERAPAMIL HC – trandolapril-verapamil hcl tab er 1-240 mg.........................................42

trandolapril tab 4 mg..........................................................37trandolapril tab 1 mg (Mavik).............................................37trandolapril tab 2 mg (Mavik).............................................37trandolapril-verapamil hcl tab er 2-180 mg (Tarka)........... 42trandolapril-verapamil hcl tab er 2-240 mg (Tarka)........... 42trandolapril-verapamil hcl tab er 4-240 mg (Tarka)........... 42tranexamic acid tab 650 mg (Lysteda).............................. 95trazodone hcl tab 50 mg....................................................62trazodone hcl tab 100 mg..................................................62trazodone hcl tab 150 mg..................................................62tretinoin cap 10 mg............................................................ 24tretinoin cream 0.025% (Retin-a).......................................99tretinoin cream 0.05% (Retin-a).........................................99tretinoin cream 0.1% (Retin-a)...........................................99tretinoin gel 0.05% (Atralin)............................................... 99tretinoin gel 0.01% (Retin-a)..............................................99tretinoin gel 0.025% (Retin-a)............................................99triamcinolone acetonide aerosol soln 0.147 mg/gm(Kenalog).........................................................................101

triamcinolone acetonide cream 0.025%.......................... 101triamcinolone acetonide cream 0.1%.............................. 101triamcinolone acetonide cream 0.5%.............................. 101triamcinolone acetonide dental paste 0.1%...................... 98triamcinolone acetonide lotion 0.025%............................101triamcinolone acetonide lotion 0.1%................................101triamcinolone acetonide nasal aerosol suspension 55mcg/act..............................................................................50

triamcinolone acetonide oint 0.025%.............................. 101triamcinolone acetonide oint 0.1%.................................. 102triamterene & hydrochlorothiazide cap 37.5-25 mg(Dyazide)...........................................................................46

triamterene & hydrochlorothiazide tab 37.5-25 mg(Maxzide-25)..................................................................... 46

triamterene & hydrochlorothiazide tab 75-50 mg(Maxzide)...........................................................................46

TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1 mg.....91trientine hcl cap 250 mg (Syprine).................................. 106trifluoperazine hcl tab 1 mg (base equivalent).................. 70trifluoperazine hcl tab 2 mg (base equivalent).................. 70

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trifluoperazine hcl tab 5 mg (base equivalent).................. 70trifluoperazine hcl tab 10 mg (base equivalent)................ 70TRIFLURIDINE – trifluridine ophth soln 1%......................96trihexyphenidyl hcl elixir 0.4 mg/ml....................................88trihexyphenidyl hcl tab 2 mg..............................................88trihexyphenidyl hcl tab 5 mg..............................................88trimethobenzamide hcl cap 300 mg (Tigan)......................55trimethoprim tab 100 mg....................................................15TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1mg......................................................................................91

TRIUMEQ – abacavir-dolutegravir-lamivudine tab600-50-300 mg................................................................. 14

trospium chloride cap er 24hr 60 mg................................ 57trospium chloride tab 20 mg..............................................57TRUEPLUS INSULIN SYRINGE/.................................... 103TRULICITY – dulaglutide soln pen-injector 0.75mg/0.5ml............................................................................32

TRULICITY – dulaglutide soln pen-injector 1.5mg/0.5ml............................................................................32

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 100-150 mg................................................................ 14




TYBOST – cobicistat tab 150 mg......................................14TYKERB – lapatinib ditosylate tab 250 mg (baseequiv).................................................................................24

TYMLOS – abaloparatide subcutaneous soln pen-injector3120 mcg/1.56ml.............................................................. 36

TYVASO REFILL – treprostinil inhalation solution 0.6 mg/ml.......................................................................................49

TYVASO STARTER – treprostinil inhalation solution 0.6mg/ml.................................................................................49

TYVASO – treprostinil inhalation solution 0.6 mg/ml.........49

UUPTRAVI – selexipag tab 200 mcg...................................49UPTRAVI – selexipag tab 400 mcg...................................49UPTRAVI – selexipag tab 600 mcg...................................49UPTRAVI – selexipag tab 800 mcg...................................49UPTRAVI – selexipag tab 1000 mcg.................................49UPTRAVI – selexipag tab 1200 mcg.................................49UPTRAVI – selexipag tab 1400 mcg.................................49UPTRAVI – selexipag tab 1600 mcg.................................49UPTRAVI – selexipag tab therapy pack 200 mcg (140) &800 mcg (60).................................................................... 49

ursodiol cap 300 mg (Actigall)...........................................56ursodiol tab 250 mg (Urso 250).........................................56ursodiol tab 500 mg (Urso forte)....................................... 56

Vvalacyclovir hcl tab 1 gm (Valtrex).....................................11valacyclovir hcl tab 500 mg (Valtrex).................................11

valganciclovir hcl for soln 50 mg/ml (base equiv)(Valcyte)............................................................................ 10

valganciclovir hcl tab 450 mg (base equivalent)(Valcyte)............................................................................ 10

valproic acid cap 250 mg (Depakene)...............................87valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovanhct).....................................................................................39

valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovanhct).....................................................................................39

valsartan-hydrochlorothiazide tab 160-25 mg (Diovanhct).....................................................................................39

valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovanhct).....................................................................................39

valsartan-hydrochlorothiazide tab 320-25 mg (Diovanhct).....................................................................................39

valsartan tab 40 mg (Diovan)............................................ 38valsartan tab 80 mg (Diovan)............................................ 38valsartan tab 160 mg (Diovan).......................................... 38valsartan tab 320 mg (Diovan).......................................... 38vancomycin hcl cap 125 mg (base equivalent) (Vancocinhcl).....................................................................................15

vancomycin hcl cap 250 mg (base equivalent) (Vancocinhcl).....................................................................................16

VENCLEXTA STARTING PACK – venetoclax tab therapystarter pack 10 & 50 & 100 mg....................................... 25

VENCLEXTA – venetoclax tab 10 mg...............................24VENCLEXTA – venetoclax tab 50 mg...............................25VENCLEXTA – venetoclax tab 100 mg.............................25venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)(Effexor xr)........................................................................ 62

venlafaxine hcl cap er 24hr 75 mg (base equivalent)(Effexor xr)........................................................................ 62

venlafaxine hcl cap er 24hr 150 mg (base equivalent)(Effexor xr)........................................................................ 62

venlafaxine hcl tab 25 mg (base equivalent).....................62venlafaxine hcl tab 37.5 mg (base equivalent)..................62venlafaxine hcl tab 50 mg (base equivalent).....................62venlafaxine hcl tab 75 mg (base equivalent).....................62venlafaxine hcl tab 100 mg (base equivalent)...................62verapamil hcl cap er 24hr 120 mg (Verelan).....................42verapamil hcl cap er 24hr 180 mg (Verelan).....................42verapamil hcl cap er 24hr 240 mg (Verelan).....................42verapamil hcl cap er 24hr 200 mg (Verelan pm)...............42VERAPAMIL HCL ER – verapamil hcl cap er 24hr 100mg......................................................................................42

VERAPAMIL HCL ER – verapamil hcl cap er 24hr 300mg......................................................................................42

VERAPAMIL HCL SR – verapamil hcl cap er 24hr 360mg......................................................................................42

verapamil hcl tab er 120 mg (Calan sr).............................42verapamil hcl tab er 180 mg (Calan sr).............................42verapamil hcl tab er 240 mg (Calan sr).............................42verapamil hcl tab 40 mg.................................................... 42verapamil hcl tab 80 mg (Calan)....................................... 42verapamil hcl tab 120 mg (Calan)..................................... 42VERSACLOZ – clozapine susp 50 mg/ml.........................70

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VERZENIO – abemaciclib tab 50 mg................................25VERZENIO – abemaciclib tab 100 mg..............................25VERZENIO – abemaciclib tab 150 mg..............................25VERZENIO – abemaciclib tab 200 mg..............................25VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml)......................................................................................32

VIDEX – didanosine for soln 2 gm....................................14vigabatrin powd pack 500 mg (Sabril)...............................87vigabatrin tab 500 mg (Sabril)........................................... 87VIIBRYD STARTER PACK – vilazodone hcl tab starter kit10 (7) & 20 (23) mg......................................................... 62

VIIBRYD – vilazodone hcl tab 10 mg................................62VIIBRYD – vilazodone hcl tab 20 mg................................62VIIBRYD – vilazodone hcl tab 40 mg................................62VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1mg......................................................................................91

VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1mg......................................................................................91

VIRACEPT – nelfinavir mesylate tab 250 mg................... 14VIRACEPT – nelfinavir mesylate tab 625 mg................... 14VIREAD – tenofovir disoproxil fumarate oral powder 40mg/gm............................................................................... 14

VIREAD – tenofovir disoproxil fumarate tab 150 mg.........14VIREAD – tenofovir disoproxil fumarate tab 200 mg.........14VIREAD – tenofovir disoproxil fumarate tab 250 mg.........14VIREAD – tenofovir disoproxil fumarate tab 300 mg.........14VITRAKVI – larotrectinib sulfate cap 25 mg (baseequivalent).........................................................................25

VITRAKVI – larotrectinib sulfate cap 100 mg (baseequivalent).........................................................................25

VITRAKVI – larotrectinib sulfate oral soln 20 mg/ml (baseequivalent).........................................................................25

VIVITROL – naltrexone for im extended release susp 380mg....................................................................................106

VIZIMPRO – dacomitinib tab 15 mg..................................25VIZIMPRO – dacomitinib tab 30 mg..................................25VIZIMPRO – dacomitinib tab 45 mg..................................25VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg......................................................................................91

voriconazole for susp 40 mg/ml (Vfend)............................10voriconazole tab 50 mg (Vfend)........................................ 10voriconazole tab 200 mg (Vfend)...................................... 10VOTRIENT – pazopanib hcl tab 200 mg (base equiv)......25

Wwarfarin sodium tab 1 mg (Coumadin)..............................95warfarin sodium tab 2 mg (Coumadin)..............................95warfarin sodium tab 2.5 mg (Coumadin)...........................95warfarin sodium tab 3 mg (Coumadin)..............................95warfarin sodium tab 4 mg (Coumadin)..............................95warfarin sodium tab 5 mg (Coumadin)..............................95warfarin sodium tab 6 mg (Coumadin)..............................95warfarin sodium tab 7.5 mg (Coumadin)...........................95warfarin sodium tab 10 mg (Coumadin)............................95water for irrigation, sterile irrigation soln......................... 106

XXALKORI – crizotinib cap 200 mg.....................................25XALKORI – crizotinib cap 250 mg.....................................25XARELTO – rivaroxaban tab 2.5 mg.................................95XARELTO – rivaroxaban tab 10 mg..................................95XARELTO – rivaroxaban tab 15 mg..................................95XARELTO – rivaroxaban tab 20 mg..................................95XARELTO STARTER PACK – rivaroxaban tab startertherapy pack 15 mg & 20 mg.......................................... 95

XELJANZ – tofacitinib citrate tab 5 mg (baseequivalent).........................................................................83

XELJANZ – tofacitinib citrate tab 10 mg (baseequivalent).........................................................................83

XELJANZ XR – tofacitinib citrate tab er 24hr 11 mg (baseequivalent).........................................................................83

XIFAXAN – rifaximin tab 550 mg.......................................16XOSPATA – gilteritinib fumarate tablet 40 mg (baseequivalent).........................................................................25

XTANDI – enzalutamide cap 40 mg.................................. 25XULANE – norelgestromin-ethinyl estradiol td ptwk150-35 mcg/24hr.............................................................. 29

XURIDEN – uridine triacetate oral granules packet 2gm......................................................................................36

YYONSA – abiraterone acetate tab 125 mg....................... 25

Zzaleplon cap 5 mg (Sonata).............................................. 71zaleplon cap 10 mg (Sonata)............................................ 71ZELBORAF – vemurafenib tab 240 mg............................ 26zidovudine cap 100 mg (Retrovir)..................................... 14zidovudine syrup 10 mg/ml (Retrovir)................................14zidovudine tab 300 mg...................................................... 14ziprasidone hcl cap 20 mg (Geodon)................................ 70ziprasidone hcl cap 40 mg (Geodon)................................ 70ziprasidone hcl cap 60 mg (Geodon)................................ 70ziprasidone hcl cap 80 mg (Geodon)................................ 70ZOLINZA – vorinostat cap 100 mg....................................26zolpidem tartrate tab 5 mg (Ambien).................................71zolpidem tartrate tab 10 mg (Ambien)...............................71zonisamide cap 50 mg.......................................................87zonisamide cap 25 mg (Zonegran)....................................87zonisamide cap 100 mg (Zonegran)..................................87ZORBTIVE – somatropin (non-refrigerated) forsubcutaneous inj 8.8 mg..................................................34

ZORTRESS – everolimus tab 0.25 mg........................... 106ZORTRESS – everolimus tab 0.5 mg............................. 106ZORTRESS – everolimus tab 0.75 mg........................... 106ZORTRESS – everolimus tab 1 mg................................ 106ZOSTAVAX – zoster vaccine live for subcutaneous susp19400 unit/0.65ml............................................................. 17

ZYKADIA – ceritinib cap 150 mg.......................................26ZYKADIA – ceritinib tab 150 mg....................................... 26ZYPREXA RELPREVV – olanzapine pamoate forextended rel im susp 210 mg (base eq)..........................70

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ZYPREXA RELPREVV – olanzapine pamoate forextended rel im susp 300 mg (base eq)..........................70

ZYPREXA RELPREVV – olanzapine pamoate forextended rel im susp 405 mg (base eq)..........................70

ZYTIGA – abiraterone acetate tab 500 mg....................... 26ZYVOX – linezolid for susp 100 mg/5ml........................... 16

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Esos servicios reciben financiamiento parcial del estado de Nuevo México.

Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 479350.1019

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